JP-JMIR Preprints

Pragmatic randomized controlled trial of an internet-based intervention for alcohol use among college students: perceived motivation as a moderating effect

From: Journal of Medical Internet Research

Date Submitted: May 9, 2018

Open Peer Review Period: May 12, 2018 - Jul 7, 2018

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Background: aaa Objective: to evaluate the effectiveness of a web-based personalized normative feedback (PNF) intervention in reducing alcohol use and negative consequences among college students with...

Background: aaa Objective: to evaluate the effectiveness of a web-based personalized normative feedback (PNF) intervention in reducing alcohol use and negative consequences among college students with different motivation levels for receiving the intervention. Methods: : Parallel-group pragmatic randomized controlled trial among college drinkers aged 18 to 30 years from all Brazilian regions. Participants were randomized to a Control (assessment only) or PNF group - 1) drinking profile; 2) normative comparisons; 3) practical costs; 4) alcohol consequences; 5) strategies to decrease risks. Outcomes were: AUDIT scores (primary outcome), the maximum number of drinks, the number of consequences, the frequency of use and number of typical drinks. Motivation for receiving the intervention was assessed with a continuous scale (range=0-10) and students were categorized either as having low motivation (score <3) or being motivated (score ≥3). Students were followed after 1, 3 and 6 months (N=4,460). Generalized mixed models assessed intervention effects via two paradigms: observed cases and attrition models (multiple imputation and pattern-mixture). Results: Regardless of motivation, the PNF reduced typical drinks after 1 and 3 months and maximum drinks after one month (observed and attrition models), compared to the control. When considering motivation, motivated students (N=3,552) receiving PNF reduced the typical drinks after one (b=-0.51, 95CI:-0.76;-0.27, p<0.001), three (b=-0.60, 95CI:-0.91;-0.29, p<0.001) and six months (b=-0.58, 95CI:-0.93;-0.23, p=0.001), compared to control. Attrition models showed that effects were more robust after 1 and 3 months. In contrast, students with low motivation in the PNF group increased their AUDIT score after 6 months. There were no other significant effects. Conclusions: The web-based PNF for alcohol use among college students reduced only alcohol use among students, and motivation for receiving the intervention moderated the intervention effects. The intervention reduced the alcohol use only among motivated students, whereas low motivated students had an increased AUDIT score. Clinical Trial: NCT02058355. https://clinicaltrials.gov/ct2/show/NCT02058355

Acceptability of Computer-Aided Telephone Support for Primary Care Patients with Common Mental Health Conditions

From: JMIR Mental Health

Date Submitted: Feb 26, 2018

Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

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Background: Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitat...

Background: Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitating the development and validation of alternative models of care delivery. Existing evidence supports the acceptability and effectiveness of providing mental health care by telephone. Objective: This analysis assesses patient’s acceptability of computer-aided telephone support delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking. Methods: PARTNERs is a research trial comparing a computer-aided telephone-based intervention to usual care enhanced by periodic assessments in adult primary care patients referred for treatment of depression, anxiety, or at-risk drinking; no part of the study involves in-person contact. For this analysis, the following data were obtained: reasons provided for declining consent; reasons provided for withdrawing from the study; study retention rate; and a thematic analysis of a satisfaction survey upon study completion. Results: During the consent process, 53.7% of 667 patients referred to the study declined to participate, and attributed their refusal to research-related factors (i.e., randomization and time commitment); a further 16.8% declined due to the telephone delivery of the intervention. Among 377 participants who were randomized to the one-year intervention, the overall retention rate was 81.8%. Almost no participants who withdrew from the study identified the telephone components of the study as their reason for withdrawal. Analysis of a qualitative satisfaction survey revealed that 97.4% of comments related to the telephone components were positive, with key reported positive attributes being accessibility, convenience, and privacy. Conclusions: Our results suggest that a computer-aided telephone support is highly acceptable to primary care patients with depression, anxiety, or at-risk drinking. In particular, these patients appreciate its accessibility, flexibility, and privacy. Clinical Trial: Trial registration: ClinicalTrials.gov Identifier: NCT02345122

What the health? Information sources and maternal lifestyle behaviours

From: Journal of Medical Internet Research

Date Submitted: Apr 9, 2018

Open Peer Review Period: Apr 11, 2018 - Jun 6, 2018

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Background: Regular physical activity (PA), adequate gestational weight gain (GWG) and healthy eating are important for the long-term health of both mother and baby. Hence, it is important that women...

Background: Regular physical activity (PA), adequate gestational weight gain (GWG) and healthy eating are important for the long-term health of both mother and baby. Hence, it is important that women receive current and updated advice on these topics, and are encouraged to adopt a healthy lifestyle during pregnancy. Objective: The aim of this study was to investigate the main information sources among pregnant women regarding PA, GWG and nutrition, as well as evaluate how these information sources may affect their health behaviours. Methods: A cross-sectional study design, comprising an electronic questionnaire, was distributed to two antenatal clinics, as well as pregnancy-related online chat forums and social media. Inclusion criteria were ≥ 18 years, ≥ 20 weeks gestation and able to read/write Norwegian. In total, 150 pregnant women answered the questionnaire, which was a mix of 11-point Likert scales, close-ended questions and semi close-ended questions. The relationship between information sources and selected variables, including health behaviours and descriptive variables, were assessed by logistic regression, linear regression or X2 as appropriate (p < 0.05). Results: Mean age (years), gestation week and pre-pregnancy BMI (kg/ m2) were 31.1 (± 4.3), 30.6 (± 5.9) and 24.2 (± 4.2), respectively. More than eight out of ten had received or retrieved information about nutrition (89%) and PA (80%), whereas 54% reported information on GWG. When combining all three lifestyle factors, 38.5% had retrieved information from blogs and Internet forums, and 26.6% from their midwife or family physician. Reporting Internet and media as primary source increased the odds of gaining below the IOM guidelines (P = 0.02), but was also associated with higher compliance with nutritional guidelines (P = 0.03). Family and friends’ advice was significantly associated with gaining above the IOM guidelines (P = 0.03). Otherwise, no other associations were found between information sources and health behaviours. Conclusions: The small number of health professionals giving information, and that about 40% use blogs and Internet forums, highlight the need to address the quality of advice and guide women towards trustworthy sources of information during pregnancy. The association between information sources and PA, GWG and nutrition requires further research.

Design Requirements for a Digital Aid that Supports Adults with Mild Learning Disabilities during Clinical Consultations

From: JMIR Rehabilitation and Assistive Technologies

Date Submitted: Apr 3, 2018

Open Peer Review Period: Apr 4, 2018 - May 30, 2018

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Background: It is widely known that adults with mild learning disabilities (MLDs) face a plethora of inequalities when accessing effective healthcare. One aspect that significantly affects the comple...

Background: It is widely known that adults with mild learning disabilities (MLDs) face a plethora of inequalities when accessing effective healthcare. One aspect that significantly affects the complexity and outcome of primary care is communication. However, patients as well as staff often find it difficult to deliver information in a comprehensible manner, thus leading to a potential misdiagnosis or the individual’s needs remaining unknown. To date, research on how to promote communication within consultations involving adults with mild learning disabilities has largely centered on the development of communication booklets. Objective: This study assessed the potential of using mobile technologies to extract the needs of patients with MLDs and to promote communication during clinical consultations. Due to the lack of similar technologies available, we were interested in obtaining a set of design guidelines from a series of experts in order to shape the development of future technologies. Methods: The study drew on qualitative data and consisted of a 3-stage design process. Firstly, we extracted an initial set of design requirements from a purposive selection of experts in learning disabilities including 4 academics, 3 governmental advisors, 2 General Practitioners and a full-time support worker. We then designed a technology probe using these requirements and subsequently presented it to a subset (n=4) of the aforementioned experts during a round of usability studies. The feedback received was used to update the initial set of requirements extracted during stage 1. Results: A set of guidelines have been produced that may assist in the development of medical applications that target the complex needs of adults with mild learning disabilities. Factors that must be considered during the design process include: the specific health needs of the target population; consumers’ cognitive, motor, auditory and visual abilities; and literacy levels. Furthermore, such technologies should enable customizations to be made to its interface but should restrict patients in changing the content embedded within. Conclusions: The experts involved in the study were optimistic about the potential of embedding mobile technologies within the consultation process. They believe that such technologies could significantly improve communication by displaying information in a form understood by both practitioners and patients. The information provided may also be used by staff to shape the questions presented throughout thus alleviating potential time constraints. The guidelines identified throughout this paper will help to ensure more appropriate technologies are developed in the future.

Online Reputation Management in Radiation Oncology

From: Journal of Medical Internet Research

Date Submitted: Apr 12, 2018

Open Peer Review Period: Apr 13, 2018 - Jun 8, 2018

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Background: Online Reputation Management (ORM) is an emerging practice strategy that emphasizes the systematic and proactive monitoring of online reviews relating to one’s professional reputation. O...

Background: Online Reputation Management (ORM) is an emerging practice strategy that emphasizes the systematic and proactive monitoring of online reviews relating to one’s professional reputation. Objective: We developed this survey project to assess whether radiation oncologists are aware of ORM, and how it is utilized in their practices. We hypothesized that ORM is largely unknown by most practicing radiation oncologists, and that little time is spent actively managing their reputations. Methods: An online survey was submitted to 1,222 radiation oncologists using the Qualtrics research platform. Physician emails were gathered from the American Society for Radiation Oncology (ASTRO) member directory. 85 physicians initiated the survey while 76 physicians completed ≥94% (15/16) of the survey questions and were subsequently used in our analyses. The survey consisted of 15 questions querying practice demographics, patient satisfaction determination, ORM understanding, and activities to address ORM and one question for physicians to opt-in to a $50 Amazon card raffle. The survey data was summarized using a frequency table and data was analyzed using Chi-Square and Fisher’s Exact test. Results: We calculated a 7% (85/1,222) response rate for our survey with a completion rate of 89% (76/85). A majority of respondents (n = 68/76, 89%) endorsed being somewhat or strongly concerned about patient satisfaction (P < .001). However, 58% (n = 44/76) reported spending zero hours per week reviewing or managing their online reputation and 39% (n = 30/76) reported spending <1 hour per week (P < .001). A majority of physicians (n = 43/76, 57%) endorsed no familiarity with ORM (P < .001), and 70% (n = 53/76) did not actively manage their online reputation (P < .001). Although 83% (n = 63/76) of respondents strongly or somewhat believed that patients read online reviews (P < .001), 57% (n = 43/76) of respondents did not check their online reviews (P = .25) and 80% (n = 61/76) endorsed never responding to online reviews (P < .001). 58% (n = 44/76) strongly or somewhat supported the idea of managing their online reputation going forward (P = .0012). Conclusions: ORM is presently under recognized in radiation oncology. Although most practitioners are concerned about patient satisfaction, little effort is directed towards the internet on this matter. ORM offers an area of practice improvement for many practicing radiation oncologists.

Use of Physical Activity Monitoring Devices by Families in Rural Communities

From: JMIR mHealth and uHealth

Date Submitted: Mar 31, 2018

Open Peer Review Period: Apr 3, 2018 - May 29, 2018

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Background: Several studies support the impact of Information Communication Technology-based interventions to promote physical activity among youth [9, 10]. Despite all the studies suggesting benefit...

Background: Several studies support the impact of Information Communication Technology-based interventions to promote physical activity among youth [9, 10]. Despite all the studies suggesting benefits of using technology to promote healthy lifestyles among youth, little is known on how technology can be used by the entire family to encourage healthy behavior that can be sustained over long period of time. Previous studies showed that children and youth rely and are dependent upon decisions and values of their caregivers when it comes to having a healthy lifestyle [11,12]. Thus, the exploration of behavior and attitudes of the entire family are needed. Objective: To explore how the use of physical activity tracking devices (FitBit Zip™) by families in rural communities influence a) participation in physical activity; and b) perception of physical activity. Methods: Eleven families with one to three children of different ages took part in semi-structured group interviews following two weeks of using physical activity tracking devices (FitBit Zip™) as a family. The participants were asked to discuss their experience using the FitBit Zip™ as a family, motivation to be physically active, changes in their pattern of participation in those activities, level of engagement by different family members, and competitiveness with or support of each other. All interviews were voice recorded with the participants’ permission and later transcribed verbatim using pseudonyms. To analyze the data the primary investigator (IS) used open, axial, selective coding techniques. Results: Two themes appeared from the data. Changes in physical activities as a result of using FitBit Zip™ as a family was either absent (lack of interest, already active lifestyle) or minimal (small, naturally occurring changes into everyday life or expanding participation in the activities they were already involved with). However, the participants reported change in attitude and perception of physical activities and healthy lifestyle. As a result of using physical activity tracking devices, the family members reported an increased awareness of their activity level and accountability for being inactive, introduced more conversations about active lifestyle and healthy lifestyle, and changed their view of physical activity to more positive one. Conclusions: While the participation in physical activities as a result of using physical activity tracking devices (FitBit Zip™) by families in rural communities was not significantly changed, the attitude toward participating in physical activity was altered. Considering long term changes in lifestyle, the change in the attitude might have more important impact than the change in the immediate behavior.

Smartphone-Based Telemedicine Practice in Older Chinese Patients with Type 2 Diabetes Mellitus

From: JMIR mHealth and uHealth

Date Submitted: Apr 1, 2018

Open Peer Review Period: Apr 3, 2018 - May 29, 2018

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Background: By reviewing the previous research of telemedicine, we have found out that old diabetic patients have difficulties in using computers, so it is unrealistic for medical teams to communicate...

Background: By reviewing the previous research of telemedicine, we have found out that old diabetic patients have difficulties in using computers, so it is unrealistic for medical teams to communicate with old diabetes patients anytime and anywhere. However, the popularity of smartphones and chatting applications has enabled old people of China to develop skills of chatting on smartphones and become familiar with smartphone operations. Therefore, we have designed an Mobile Health (m-Health) system for diabetics based on smartphones, which greatly streamlined operation interface and functions for maximum automation. In addition, the smartphone-based telemedicine of diabetes has been designed for old people. Objective: To investigate smartphone-based telemedicine applications in the management of older Chinese patients with type 2 diabetes mellitus (T2DM). Variables of interest included efficacy and safety. Methods: A total of 91 older (age>65) patients with T2DM, who presented to our department, were included and randomly assigned to one of two groups. Patients in the intervention group (n=44) were given glucometers capable of data transmission, and received advice pertaining to medications, diet, and exercise via a Mobile Health（m-Health）telemedicine system. Patients assigned to the control group (n=47) presented to traditional outpatient clinics for their medical care and received no other interventions. We followed up patients in both groups at regular 3-month intervals. Results: After 3 months, patients in the intervention group had significant (P<0.05) improvements in postprandial plasma glucose levels. After 6 months, patients in the intervention group exhibited decreasing trends in postprandial plasma glucose and glycosylated hemoglobin (HbA1C) levels compared with the baseline and those in the control group (P<0.05). Conclusions: Smartphone-based telemedicine applications are effective for controlling blood glucose and lowering HbA1C in older Chinese patients with T2DM. Clinical Trial: The ethics committee of the First Affiliated Hospital of Jilin University approved this study, and has been registered at the China Clinical Trial Registration Center with a registration number of ChiCTR1800015214.

Involving (or not) citizens-patients in the development of telehealth services: A qualitative study of experts’ and citizens-patients’ perspectives

From: Journal of Participatory Medicine

Date Submitted: Apr 1, 2018

Open Peer Review Period: Apr 2, 2018 - May 28, 2018

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Background: Decisions regarding telehealth services in Quebec (Canada) have been largely technocratic by nature for the last 15 years, and the involvement of citizen-patients in the development of tel...

Background: Decisions regarding telehealth services in Quebec (Canada) have been largely technocratic by nature for the last 15 years, and the involvement of citizen-patients in the development of telehealth services is virtually non-existent. In view of the societal challenges that telehealth raises, citizen-patient involvement could ensure more balance between evidence from traditional research methodologies and technical experts, and the needs and expectations of populations in decisions about telehealth services. Objective: This study aimed to explore the perception of various stakeholders (decisions-makers, telehealth program and policy managers, clinicians and citizens-patients) regarding the involvement of citizens-patients in the development of telehealth services in Quebec. In particular, we explored its potential advantages, added value, obstacles and challenges it raises for decision-making. Methods: We used a qualitative research approach based on semi-structured individual interviews with a total of 29 key actors. Respondents were identified by the contact network method. Interviews were recorded and transcribed verbatim. A pragmatic content thematic analysis was performed. To increase capacity for interpretation and analysis, we were guided by the principle of data triangulation. Results: Citizen-patient involvement in decision-making is more perceived as a theoretical idea than as a practical reality in healthcare organizations or in the health system. There is very little connection between citizen involvement structures or patient and user groups and telehealth leaders. For the respondents, citizen-patient involvement in telehealth could increase the accountability and transparency of decision-making, and make it more pragmatic within an innovation-driven health system. This involvement could also make citizens-patients ambassadors and promoters of telehealth, and improve the quality and organization of health services while ensuring they are more socially relevant. Challenges and constraints that were reported include the ambiguity of the “citizen-patient”, who should be involved and how, “claimant” citizen-patient, the risk of professionalization of citizen-patient involvement and the gap between decision time vs. time to involve the citizen-patient. Conclusions: This study provides a basis for future research on the potential of involving citizens-patients in telehealth. There is a great need for research on the issue of citizen-patient involvement as an organizational innovation (in terms of decision-making model). Research on the organizational predisposition and preparation for such a change becomes central. More efforts to synthesize and translate knowledge on public participation in decision-making in the health sector, particularly in the field of technology development, are needed. Clinical Trial: Not Applicable

Top-Cited Articles In Medical Professionalism: A Bibliometric Analysis versus Altmetric Scores

From: Journal of Medical Internet Research

Date Submitted: Apr 2, 2018

Open Peer Review Period: Apr 4, 2018 - May 30, 2018

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Background: Citation counts of articles have been used by universities and funding bodies to measure scientific outcomes and assess suitability for grant applications. However, citation counts are not...

Background: Citation counts of articles have been used by universities and funding bodies to measure scientific outcomes and assess suitability for grant applications. However, citation counts are not without limitations. With the rise of social media, altmetric scores may provide an alternative assessment tool. Objective: The aims of this study are to assess the characteristics of highly cited articles in medical professionalism and altmetric scores. Methods: The Web of Science was searched for top-cited articles in medical professionalism, and the characteristics of each article were identified. The altmetric database was searched to identify report for each article. A model to assess the relationship between the number of citations and each of key characteristics as well as altmetric scores were developed. Results: No correlations were found between the number of citations and number of years since publication (p=0.192), number of institutes (p=0.081), number of authors (p=0.270), females in authorship (p=0.15), or number of grants (p=0.384). The altmetric scores varied from zero to 155, total= 806, median=5.0, (IQR=20). Twitter (54%) and Mendeley (62%) were the most popular altmetric resources. No correlation was found between the number of citations and the altmetric scores (p=0.661). The top topics covered were learning and teaching professionalism, curriculum issues, professional and unprofessional behavior, defining and measuring professionalism. Only the number of countries correlated with the number of citations (p= 0.001). The articles were mainly published in Academic Medicine, Journal of the American Medical Association, Journal of General Internal Medicine, and Annals of Internal Medicine. Conclusions: Except for the number of countries involved, no correlation was found between citations and any of the article parameters. Altmetric scores of articles were not significantly correlated with citations. Highly cited articles were produced mainly by the United States, Canada, and the United Kingdom. The study reflects the emerging role of altmetric and social media in the dissemination of research. Future studies should investigate the specific features of highly cited articles and factors that reinforce distribution of research data among scholars and non-scholars. Clinical Trial: Not applicable.

Usability of a store and forward telehealth platform for diagnosis and management of oral mucosal lesions: a cross-sectional study

From: Journal of Medical Internet Research

Date Submitted: Apr 2, 2018

Open Peer Review Period: Apr 4, 2018 - May 30, 2018

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Background: Telediagnosis is a promising tool in situations of limited access to specialty care. Considering that, an oral health telediagnosis platform (EstomatoNet) was created in the state of Rio G...

Background: Telediagnosis is a promising tool in situations of limited access to specialty care. Considering that, an oral health telediagnosis platform (EstomatoNet) was created in the state of Rio Grande do Sul, Brazil. EstomatoNet provides specialist support over a web-based platform to primary care dentists for diagnosis of oral lesions. Objective: To evaluate the usability of EstomatoNet and to identify user perceptions regarding their expectations and difficulties with the system. Methods: Sixteen dentists were selected for the study: 8 were frequent users of EstomatoNet and 8 were residents who had never used the Platform. To assess usability, participants were required to request telediagnosis support for a fictional case provided by the research team. During the process of uploading the information and sending the request, users were asked to “think out loud,” expressing their perceptions. The session was observed by an examiner with remote access to the user's screen (via Skype). After the simulation, users completed the System Usability Scale (SyUS). Results: The mean SyUS score assigned by frequent users was 84.7±6.6, vs. 82.2±9.3 for residents (satisfactory usability: score above 68). The difference between the groups was not statistically significant (Student t test, P = .55). The inexperienced group took longer (347.1s±101.1) to complete the task than frequent users (252.8s±80.3), however the difference between the groups was not statistically significant (Student t test, P = .06). In their subjective evaluation, users suggested the inclusion of a field to add further information on outcomes and resolution of the case and changes in the position of the “Send” button to improve work flow. Conclusions: The present results indicate good usability of EstomatoNet. The Platform seems to meet the needs of users regardless of how experienced they are; nevertheless, a few minor changes in some steps would improve the tool.

Use of on-line or paper surveys by Australian women: a longitudinal study of users, devices and cohort retention

From: Journal of Medical Internet Research

Date Submitted: Apr 2, 2018

Open Peer Review Period: Apr 4, 2018 - May 30, 2018

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Background: There is increasing use of on-line surveys to improve data quality and timeliness, and to reduce costs. While there have been numerous cross-sectional studies comparing responses to on-lin...

Background: There is increasing use of on-line surveys to improve data quality and timeliness, and to reduce costs. While there have been numerous cross-sectional studies comparing responses to on-line or paper surveys, there is little research from a longitudinal perspective. Objective: In the context of the well-established Australian Longitudinal Study on Women’s Health, we examined the patterns of responses to on-line or paper surveys across the first two waves of the study in which both modes were offered. We compared: 1. Differences between women born in 1946-51 and in 1973-78; 2. Types of device used for on-line completion; 3. The socio-demographic, behavioral and health characteristics of women who responded on-line or using mailed paper surveys; 4. Associations between mode of completion of the first survey, and participation and mode of completion in the second survey. Methods: Participants in this study, who had responded to regular mailed surveys since 1996, were offered a choice of completing surveys using paper questionnaires or web-based electronic questionnaires, starting in 2012. Two groups of women were involved: an older cohort born in 1946-51 and aged in their 60s, and a younger cohort born in 1973-78 aged in their 30s when the on-line surveys were first introduced. We compared women who responded on-line on both occasions, women who responded on-line at the first survey and used the paper version of the second survey, women who changed from paper to on-line, and those who used paper for both surveys. Results: Of the 9663 women in their 60s who responded to one or both of the surveys, more than 50% preferred to continue with paper surveys (5290 at the first survey and 5373 at the second survey). If they chose the on-line version most used computers. In contrast, of the 8628 women in their 30s, more than 50% (4835) chose the on-line version at the first survey. While most favored computers to phones or tablets, many did try these alternatives at the subsequent survey. Many women who completed the survey on-line the first time preferred the paper version at the subsequent survey. In fact, for women in their 60s, the number who went from on-line to paper (n=1151) exceeded the number who went from paper to on-line (n=734). The on-line option was more likely to be taken up by better educated and healthier women. In both cohorts, women who completed paper surveys were more likely than on-line completers to become non-respondents at the next survey. Due to the large sample size almost all the differences were statistically significant with P < .001. Conclusions: Despite the cost-saving advantages of on-line compared to paper surveys, paper surveys are likely to appeal to a different population of potential respondents, with different socio-demographic, behavioral and health characteristics and potentially greater attrition from the study. Not offering a paper version is therefore likely to induce bias in the distribution of responses unless weighting for respondent characteristics (relative to the target population) is employed. Therefore, if mixed mode (paper or on-line) options are feasible, they are highly likely to produce more representative results than if only the less costly on-line option is offered.

eHealth program to empower patients in returning to normal activities after colorectal surgical procedures: a mixed method process evaluation alongside a randomized controlled trial

From: Journal of Medical Internet Research

Date Submitted: Apr 3, 2018

Open Peer Review Period: Apr 5, 2018 - May 31, 2018

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Background: Long term recovery takes longer than expected despite improved surgical techniques and Enhanced Recovery After Surgery programs. An eHealth care program (‘ikherstel’) was developed to...

Background: Long term recovery takes longer than expected despite improved surgical techniques and Enhanced Recovery After Surgery programs. An eHealth care program (‘ikherstel’) was developed to partially substitute perioperative care for patients undergoing colorectal surgical procedures. Successfully tested eHealth programs are not always implemented in usual care and it is therefore important to evaluate the process to optimize future implementation. Objective: To evaluate whether the eHealth intervention was executed as planned. Methods: A mixed method process evaluation was carried out alongside a multicenter randomized controlled trial (RCT). This evaluation was performed using the Linnan and Steckler framework for the quantitative part of this study measuring the components reach, dose delivered, dose received, fidelity and participants’ attitudes. Total implementation scores were calculated using the averaging approach, in which the sum of all data points is divided by the number of data points and measured the total adherence to the protocol. For the qualitative part the Unified Theory of Acceptance and Use of Technology framework (UTAUT) was used. The quantitative data was based on participants’ questionnaires, a logistic database, a weblog and participants’ medical files and was obtained by performing semi-structured interviews with participants of the RCT. Results: A total of 151 participants of 340 eligible patients were included in the RCT, of which 73 participants were allocated to the intervention group. Based on the quantitative process data, total implementation scores for the website, mobile application, eConsult and activity tracker of 64%, 63%, 44% and 67% were calculated. Participants in the qualitative part experienced the program as supportive and provided guidance on their recovery process after colorectal surgery. Most frequently mentioned barriers were the limited interaction with and feedback from health care professionals and the lack of tailoring of the convalescence plan in case of a different course of recovery. Conclusions: The intervention needs more interaction with and feedback from health care professionals, and needs more tailored guidance in case of different recovery or treatment courses. To ensure a successful implementation of the program in daily practice, some adjustments are required to optimize the program in a blended care form. Clinical Trial: NTR5686.

The Computerised Life Events and Assessment Record (CLEAR) online measure of life events: reliability, validity and association with depression.

From: JMIR Mental Health

Date Submitted: Apr 3, 2018

Open Peer Review Period: Apr 6, 2018 - Jun 1, 2018

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Background: Background: Given the criticisms of life event (LE) checklists and the costs associated with interviews, LE research requires a sophisticated measure for research and clinical practice. Th...

Background: Background: Given the criticisms of life event (LE) checklists and the costs associated with interviews, LE research requires a sophisticated measure for research and clinical practice. Therefore, the Computerised Life Events and Assessment Record (CLEAR), based on the Life Events and Difficulties Schedule (LEDS), was developed. Objective: To test CLEAR’s reliability, validity, and association with depression. Methods: CLEAR, the General Health Questionnaire, and the List of Threatening Experiences Questionnaire (LTE-Q) was completed by 328 participants (126 students; 202 matched midlife sample: 127 controls, 75 recurrent depression cases). Test-retest reliability over 3-4 weeks was examined, and validity determined by comparing CLEAR with LEDs and LTE-Q. Both CLEAR and LTE-Q were examined in relation to depression. Results: CLEAR demonstrated good test-retest reliability for overall number of events (.89) but only fair reliability for overall agreement of events at both points (.21). Event characteristics for those that agreed had good reliability. Long-term problems (LTPs) showed similar findings. For validity, CLEAR had moderate sensitivity of 59% and specificity of 65% when compared to LEDS on matched events. Associations by category were good e.g. education (.81), work (.70) and health (.59), with high levels of specificity in these domains. CLEAR demonstrated moderate sensitivity (43.1%) and specificity (78.6%) when compared to LTE-Q. CLEAR severe LEs and LTPs were significantly associated with depression (OR = 3.50, 95% CI: 2.10-5.85, P < .001; OR = 3.38, 95% CI: 2.02-5.67, P < .001) whereas LTE-Q events were not (OR=1.06, 95% CI: .43-2.60, P =.90). Conclusions: CLEAR has acceptable reliability and validity and predicts depression. It therefore has great potential for effective use in research and clinical practice identifying stress factors in depression and related disorders.

Correlation analysis among incidence and mortality of cancers and online public attention in China

From: Journal of Medical Internet Research

Date Submitted: May 8, 2018

Open Peer Review Period: May 11, 2018 - Jul 6, 2018

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Background: Cancers pose a serious threat to health of Chinese people, resulting in a immense challenge to public health work. Nowadays, people could get related information not only from medical work...

Background: Cancers pose a serious threat to health of Chinese people, resulting in a immense challenge to public health work. Nowadays, people could get related information not only from medical workers in hospitals, but also retrieve on Internet everywhere in real-time. Online search behaviors can reflect population’s awareness on cancers from a completely new perspective, which could be driven by underlying cancer epidemiology. Objective: The objective of our study was mainly to explore whether there was a correlation among incidence and mortaliy of cancers and online search behaviors. A secondary objective was to predict future incidence and mortality of theses cancers if the correlation was existed. Methods: We used standard Boolean operators to choose search terms of each cancer. We used Spearman’s rank correlation coefficient to validate the correlation among monthly search index values of each cancer type and their monthly incidence and mortality rates. ARIMA model and linear regression model were simultaneously used to predict incidence and mortality of these cancers in future. Results: Monthly search index values statistically significantly correlated with cancer incidence rates in 26 of 28 cancers in China, ( lung cancer: r=.80, P<.001; liver cancer: r=.28, P=.016; stomach cancer: r=.50, P<.001; esophageal cancer: r=.50, P<.001; colorectal cancer: r=.81, P<.001; pancreatic cancer: r=.86, P<.001; breast cancer: r=.56, P<.001; brain and nervous system cancer: r=.63, P<.001; leukemia: r=.75, P<.001; Non-Hodgkin lymphoma: r=.88, P<.001; Hodgkin lymphoma: r=.91, P<.001; cervical cancer: r=.64, P<.001; prostate cancer: r=.67, P<.001; bladder cancer: r=.62, P<.001; gallbladder and biliary tract cancer: r=.88, P<.001; lip and oral cavity cancer: r=.88, P<.001; ovarian cancer: r=.58, P<.001; larynx cancer: r=.82, P<.001; kidney cancer: r=.73, P<.001; squamous-cell carcinoma: r=.94, P<.001; multiple myeloma: r=.84, P<.001; thyroid cancer: r=.77, P<.001; malignant skin melanoma: r=.55, P<.001; mesothelioma: r=.79, P<.001; testicular cancer: r=.57, P<.001; basal-cell carcinoma: r=.83, P<.001). Meanwhile, monthly Baidu search index values statistically significantly correlated with cancer mortality rates in 24 of 27 cancers but not for stomach cancer, esophageal cancer and testicular cancer. Conclusions: Online search behaviors indeed reflect public awareness from a different angle. Research on Internet search behaviors may be an innovative and advance-time tool to monitor and estimate cancer incidence and mortality rates, especially for cancers not included in national registries.

Leveraging Family to Promote Digital Health: Findings from the Pokémon GO Mixed Methods Study of Children and Families

From: JMIR Pediatrics and Parenting

Date Submitted: Apr 9, 2018

Open Peer Review Period: Apr 11, 2018 - Jun 6, 2018

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Background: Pokémon GO illuminated the potential for mobile gaming apps to engage users and promote health. However, much work is needed to fully understand mechanisms through which digitally support...

Background: Pokémon GO illuminated the potential for mobile gaming apps to engage users and promote health. However, much work is needed to fully understand mechanisms through which digitally supported behavior change intervention operate, particularly for children and families. Objective: The goal of the current study was to explore the user-experience and changes in physical activity since playing Pokémon GO from a family perspective and within the greater context of family health. Specifically, factors related to engagement, user trends over time, and health were examined from the perspective of parents, adult caregivers, and children/teen Pokémon GO players. Methods: In January-February 2017, congruent with one of the largest anticipated Pokémon GO updates “Gen 2,” a retrospective pre-post design was used to investigate changes in physical activity in parents and adult caregivers since playing Pokémon GO. Additional descriptive data was collected via a survey that incorporated both closed and open-ended questions from parents and adult caregivers who were impacted by a child/teen that played Pokémon GO. Children/teens who played Pokémon GO were also invited to participate. Results: Self-reported data from 160 adults and 31 children were included in the final analyses (representing 129 adults and 31 parent-child dyads). Gameplay most often occurred between mothers and sons ≤10 years old. “Spending time together” was the most cited reason for gameplay by both adults (76.3%) and children (77.4%), followed by “it helped me go outdoors” (70.1%) for adults and “I am a Pokémon fan” (67.7%) by children. Playing Pokémon GO also helped to satisfy the top three identified family goals: having fun, spending more time/quality time with child, and exercising more. Unique to this population, open-ended responses indicated child gameplay could trigger both positive and negative emotional parent response. Boredom was the most cited reason for app disengagement, while in-app events most contributed to reengagement. For adults, there were significant increases in minutes spent in mild (M=23.36, SD = 66.02; t(97)=3.50, P=.001) and moderate (M=21.76, SD 53.04; t(130)=4.70, P=.000) physical activity per week after playing Pokémon GO. However, dyadic data indicated that child perceptions of parental influence on physical activity most significantly associated with parents who reported weekly strenuous physical activity both before (rs =.514, P=.003) and after (rs =.536, P=.003) Pokémon GO uptake. Conclusions: Pokémon GO transcended traditional understanding of digital health and uniquely reached across generations to engage users. Findings from this study highlight that, for a period of time, Pokémon GO fostered social and physical well-being for children and families through a multifaceted approach.

Prevalence of mineralocorticoid antagonist prescription after ST-elevation myocardial infarction with impaired left ventricular function: a single centre experience.

From: JMIR Cardio

Date Submitted: Apr 4, 2018

Open Peer Review Period: Apr 15, 2018 - Jun 10, 2018

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Background: Evidence suggests long term benefit from angiotensin converting enzyme inhibition (ACE-I) or angiotensin receptor blockade (ARB), beta-adrenoceptor antagonism and mineralocorticoid antagon...

Background: Evidence suggests long term benefit from angiotensin converting enzyme inhibition (ACE-I) or angiotensin receptor blockade (ARB), beta-adrenoceptor antagonism and mineralocorticoid antagonism (MRA) in patients with left ventricular dysfunction After myocardial infarction. However, despite clinical evidence and clearly articulated guidelines, several studies suggest low rates of prescription of some medications like MRA in the target group with post- myocardial infarction left ventricular dysfunction (MI LVD), both in Australia and other countries Objective: To identify the real world medication prescription in ST elevation myocardial infarction (STEMI) patients with impaired left ventricular function Methods: We studied prescription trends in 152 consecutive STEMI patients between August 2013 and December 2016 admitted to a single referral centre who also had a pre-discharge echo that demonstrated at least moderate Left ventricular dysfunction Results: The average age was 63 years. Most patients were male (78%) and the average BMI was 28 (±6). 132 patients [87% (80% - 92%)] were prescribed ACE-I/ARBs, 144 patients received beta-adrenoceptor antagonists (95% [90% - 98%]), 147 patients (97%) received DAPT and 146 patients (95%) received statins post-STEMI. 45 eligible patients (30% [23% - 28%]) received an MRA. Younger patients were more likely to be prescribed an MRA (p = 0.008). The MRA prescribed cohort were younger, 59 versus 64 years, had marginally better renal function with average eGFR 108 vs 91 mL/min/1.73m2 and lower rates of stage ≥III CKD 11 vs 22 (p <0.05) Conclusions: Our study shows a substantial treatment gap, in that a majority of patients with impaired LV dysfunction after STEMI with symptoms of heart failure or diabetes are not receiving medications in the MRA class, despite proven benefit. As such, the root causes of this treatment gap require elucidation in a multi-centre context.

‘Train your Mind’ program: Enhancing Executive Functions among Dutch Elementary School Children: systematic development

From: JMIR Formative Research

Date Submitted: Apr 4, 2018

Open Peer Review Period: Apr 6, 2018 - Jun 1, 2018

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Background: Executive functions are higher cognitive control functions, consisting of inhibitory control, working memory, and cognitive flexibility, and are central to academic performance, and a heal...

Background: Executive functions are higher cognitive control functions, consisting of inhibitory control, working memory, and cognitive flexibility, and are central to academic performance, and a healthy and successful life. While it has been shown that executive functions are trainable, how such improvements translate into everyday behaviors is not yet fully understood. The current project aimed to develop an intervention capable of enhancing executive functions among children aged 9 to 11. Subsequently, we hypothesized these improvements in EFs would lead to improved self-control, emotion-regulation, and attention (timely given the current potential rise in attentional problems); which in turn translate to more healthy behaviors in daily life, specifically physical activity and healthy eating – which is especially interesting given the recent rise in (childhood) obesity. To further stimulate the development of the latter behaviors, personalized tailored feedback was provided in the fourth and final module, eHealth. Objective: The present paper describes (1) what EFs are, why they matter in life, and how they can be trained and (2) the development of the Train your Mind intervention. Methods: The design of this intervention, and the development of the program materials, was guided by the Intervention Mapping framework. Results: A multi-component intervention was composed, including: (1) focused physical exercise (kung fu), (2) cognitive games, (3) socio-emotional development, and (4) eHealth. All four components received positive feedback during pilot-testing in terms of user friendliness (readability, graphics), gameplay (clear instructions, fun), and feasibility (for teachers). Conclusions: The current literature base seems to suggest a multi-modal approach (cognitive, socio-emotional, and physical) may hold promising potential for the purpose of training executive functions, and perhaps even attain the much-desired broad transfer (practical translation into daily life), which, to date, has not been demonstrated before. In sum, encouraging the development of executive functions could yield great benefits in terms of academic performance, (physical and socio-emotional) health, and decreased risks during adolescence. Even though IM could not be applied completely, the overarching framework and various steps, provided guidance in developing and planning the intervention. Clinical Trial: NTR 5804 (Nederlands Trial Register)

Implementing a Web-Based Intervention in HIV Primary Care Clinics: A Pilot Study on the Feasibility of Positive Health Check

From: Journal of Medical Internet Research

Date Submitted: Apr 4, 2018

Open Peer Review Period: Apr 5, 2018 - May 31, 2018

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Background: Web-based interventions can help people living with human immunodeficiency virus (HIV) achieve better clinical outcomes and behaviors, but integrating them into clinical practice remains c...

Background: Web-based interventions can help people living with human immunodeficiency virus (HIV) achieve better clinical outcomes and behaviors, but integrating them into clinical practice remains challenging. Several studies report on the appropriate content for web-based interventions and their outcomes, but there is a gap in understanding the feasibility of implementing these interventions in HIV clinic settings from the clinicians’ perspective. Objective: We examined whether Positive Health Check (PHC)—a web-based, tailored video counseling tool—was acceptable, appropriate, and feasible for HIV primary care clinics to implement. Methods: Four primary care clinics implemented PHC during a 1-month pilot. Nine key clinic staff across clinics who implemented the intervention participated in 54 interviews. We used framework analysis to code the data and identify themes related to implementation outcomes; acceptability, appropriateness, and feasibility. We also analyzed patients’ (n=104) intervention usage metrics to quantify patients’ intervention completion rates (n=68). Results: At the start of implementation, and with increasing frequency as enrollment was opened to more diverse patient groups, clinic staff reported that PHC was an acceptable and appropriate intervention. Stakeholders successfully dedicated space for patients to use the tool, delivered patients’ handouts, and adjusted workflow to facilitate implementation. Clinic staff reported that PHC is feasible to implement in clinic settings, but challenges remained for workflow integration and the best time to administer PHC. Conclusions: To increase implementation effectiveness, we examined implementation outcomes related to the integration of PHC into clinic workflows. Findings from this pilot implementation suggest that PHC can be integrated into clinic workflow systems, but clinicians and researchers need to better understand the role of implementation outcomes to leverage the benefits of tailored web-based interventions for people living with HIV.

TECHsex: Youth Sexual Health and Relationships Online

From: Journal of Medical Internet Research

Date Submitted: Apr 4, 2018

Open Peer Review Period: Apr 6, 2018 - Jun 1, 2018

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Background: According to a 2015 report from PEW Research Center, nearly 24% of teens go online almost constantly and 92% of teens are accessing the internet daily. To explore the sexual health informa...

Background: According to a 2015 report from PEW Research Center, nearly 24% of teens go online almost constantly and 92% of teens are accessing the internet daily. To explore the sexual health information-seeking behaviors and sexual relationship building practices of youth online. In addition, young people also turn to the web for sexual health resources and romantic relationship building. This drastic increase in accessibility and feasibility has changed the way young people are able to access information, build relationships, and socialize. An examination of the unique relationships young people have with their sexual health and relationships online and the implications for adolescent health programs has yet to be fully explored. Objective: Although there is a growing concern for sexually transmitted infections (STIs), human immunodeficiency virus (HIV), and healthy romantic relationships among young people, many programs continue to neglect online spaces as locations for health interventions. Little is known about the online sexual health practices of young people, including digital flirting and online dating. This data provides information relevant to youth sexual health at the emergence of social media tools and online dating, which provides insights into youth behavior and intervention opportunities. Methods: Through January and December 2016, the TECHsex study used a mixed-methods approach to document information-seeking behaviors and sexual health building behaviors of youth online in the US. A national quantitative survey of 1,500 youth and twelve qualitative focus groups (66 youth) were triangulated to understand the experiences and desires of young people as they search for sexual health information online and begin building their sexual relationships through social media, online chat, and online dating. Results: Sixty-two percent of young people throughout the US reported using the internet, most notably Google, as a source for sexual health information. At the same time, respondents most often reported a doctor, nurse, or clinic to be the single most effective way to learn about sexual health (30%). Young people are not only turning to online resources for sexual health information; they are also using the internet to begin sexual relationships with others, including dating, online flirting, and “hooking up”, with 34% of young people reporting the use of online dating apps and 70% having met a partner they met online in real life. Conclusions: While youth are turning to the internet for sexual health information, they are also turning to online spaces to build sexual relationships. Sexual relationship building included online flirting and online dating websites and/or apps. These findings have implications for sexual health, risk, and implementing future programs interested in enhancing youth sexual health. We implore researchers and organizations to consider the relationships young people have to technology for these sexual health purposes and implement these platforms to create successful and youth-centered programs.

Users perceived contribution and usability of mobile health applications and connected objects: patients and health care providers perspectives from an exploratory survey

From: Journal of Medical Internet Research

Date Submitted: Apr 6, 2018

Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

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Background: Technology is nowadays omnipresent. Using New Information and Communications Technologies in the health sector is promising and intended to be beneficial, both for patient disease preventi...

Background: Technology is nowadays omnipresent. Using New Information and Communications Technologies in the health sector is promising and intended to be beneficial, both for patient disease prevention and care. The Lab e-Santé, a French think tank, aims to further advance knowledge of the use and practices of digital health tools, identify obstacles in their use, and issue recommendations. Objective: The Lab e-Santé conducted an exploratory study in order to get preliminary data regarding the appropriation, satisfaction and global use in real life of health applications and connected objects. This initial survey would allow to explore, within MHCs (Multidisciplinary health centers), the usability and the perceived contribution of the tools from both HCPs and patients’ viewpoints and provide preliminary inputs regarding the barriers and the drivers of connected health. Methods: The Lab e-santé recruited a total of 10 facilities from the exhaustive database of French MHCs. HCPs from those MHC were provided with iPads on which the m-health application was installed. They were also provided with three types of connected devices: weighting scales, blood pressure monitors and activity trackers. VirtualSanté and VirtualSanté Pro applications were especially developed for the survey. VirtualSanté allowed to compile all the patient’s data collected from a connected health device, and share these data with the health professional in their dedicated professional application, VirtualSanté Pro. During a 5-month period, participating health professionals were instructed to include patients with chronic diseases, aged 18 years and above, who agreed to participate. Results: This exploratory study addressed the perceived contribution and usability of health technologies from both patients and their HCPs. Our findings as described below suggest that there is a dichotomy between HCPs and patients’ perception about connected health usefulness. HCPs are more confident in a potential contribution of connected health for their patients than the patients themselves. Patients didn’t express any benefit 6 months later and the device became a source of anxiety for some of them. One possible explanation may be the multiple technical issues users faced during the survey including the installation of the applications on non-compatible devices, the initial connection between the object and the application or technical bugs during use. For the same reasons, HCPs found it time-consuming and difficult to integrate in their everyday practice. Conclusions: Today many people are optimistic about the concept of mHealth. However, to use these devices and have high acceptance, both HCPs and patients need to be aware of the existence and usefulness of applications and connected objects then trust them. Tools should be personalized and adaptive, as far as possible, or at least be adapted to the good user profile. The latter should be motivated, properly trained, educated and supported for assuring an appropriate, useful and sustainable use.

Does a Digital Communication Device Facilitate Caregiving to Home-dwelling Frail Older Persons? Results of a Pilot-study in the Netherlands

From: JMIR Aging

Date Submitted: Apr 5, 2018

Open Peer Review Period: Apr 7, 2018 - Jun 2, 2018

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Background: Collaboration among informal and formal caregivers in a mixed care network of home-dwelling elderly may benefit from using a device for digital networked communication (dfDNC). Objective:...

Background: Collaboration among informal and formal caregivers in a mixed care network of home-dwelling elderly may benefit from using a device for digital networked communication (dfDNC). Objective: The study aims to describe and explain differences in the use and evaluation of the dfDNC by members of the care network, and to come up with a list of conditions that facilitate (or restrict) the implementation of a dfDNC by a homecare organization. Methods: A pilot-study collected information on digital communication in seven care networks of clients of a homecare organization in the Netherlands. Semi-structured interviews with four care recipients, seven informal carers (of which three spoke on behalf of the care receiver as well because of receivers’ suffering from dementia) , three district nurses, five auxiliary nurses, and three managers were conducted three times in a period of six months. Additionally we observed relevant workshops initiated by the homecare organization, and studied login data created by the users of the dfDNC. Results: The qualitative data and monthly retrieved quantitative login data revealed three types of digital care networks: Arranging the care network, Discuss the care network and Staying connected network. Differences between network types were attributed to health impairment and digital illiteracy of the care recipients, motivation of informal caregivers, and commitment of formal caregivers. Positively evaluated were the easy availability of up-to-date information, the ability to promote a sense of safety for the carers, and short communication lines in case of complex care situations. Improvement is needed of device functionalities related to issues of privacy. Conclusions: Based on the results, it is concluded that digital communication is beneficial for organizing and discussing the care within a care network. More research is needed to study its impact on care burden of informal carers, on quality of care, and on quality of life of home-dwelling frail older adults.

Designing a digital person-centered self-management support intervention for people with type 2 diabetes

From: Journal of Medical Internet Research

Date Submitted: Apr 5, 2018

Open Peer Review Period: Apr 7, 2018 - Jun 2, 2018

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Background: Self-management is a substantial part of treatment for patients with type-2 diabetes (T2D). Modern digital technology, being small, available and ubiquitous has promising properties that m...

Background: Self-management is a substantial part of treatment for patients with type-2 diabetes (T2D). Modern digital technology, being small, available and ubiquitous has promising properties that might work well in supporting self-management. This study follows the process of designing a digital person-centered self-management support intervention for people with T2D. Objective: The aim of this paper was to explore and describe the preparatory activities and the subsequent choice of digital support for a digital person-centered self-management support intervention for people with T2D treated in primary health care. Methods: A user-centered, mixed-methods approach was used to collect and analyze data from different sources. Results: Results show that the requirements for a digital platform for T2D self-management care is complex and has to be negotiated, often with trade-off relations. It is also shown that the focus on user needs is complicated as nurses’ project organizational and regulatory needs that causes limitations in the design space. Conclusions: A user-centered approach can be useful in identifying goals for design that both show possibilities as highlight challenges and limitations. There are limits in the user-centered approach and thereby we suggest more research to find ways to deal with the nurse-organization perspective. Clinical Trial: This study is a preparatory part of a larger randomized intervention project aimed at designing and implementing person-centred interactive self-management support (iSMS) in primary healthcare in northern Sweden. The overall project has a user-centred design, described in this paper and the project is registered at ClinicalTrials.gov, Identifier NCT03165084.

Implementation of a novel smartphone app (OncoFood) to record and optimize the dietary behavior of oncological patients

From: JMIR Cancer

Date Submitted: Apr 11, 2018

Open Peer Review Period: Apr 12, 2018 - Jun 7, 2018

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Background: Catabolism and tumor-specific therapy lead to a reduced nutrient intake and weight loss in cancer patients. Maintaining a specific individualized diet can be challenging for the patient as...

Background: Catabolism and tumor-specific therapy lead to a reduced nutrient intake and weight loss in cancer patients. Maintaining a specific individualized diet can be challenging for the patient as the nutritional counseling options are limited. The monitoring of nutrient intake and frequent feedback are, however, vital for a successful nutritional therapy as they support the patient’s compliance and realization of dietary therapeutic goals. This study aims at investigating the feasibility and applicability of a novel smartphone application to assess and evaluate dietary behaviors in oncological patients. Objective: This study aims at investigating the feasibility and applicability of a novel smartphone application to assess and evaluate dietary behaviors in oncological patients. Methods: To determine dietary habits and food preferences in oncological patients, initially 1400 nutritional records were evaluated and analyzed. The results provided the basis for creating a nutritional smartphone app. Key requirements for the app included: simple handling, recording the daily intake and a comparison of nutrient-targets and the current status. In total, 39 cancer patients were included in the study. Firstly, all patients received a nutritional anamnesis, a nutritional analysis and nutritional counseling. An individual energy and nutrient aim was defined. The intervention group (n = 12) additionally used the app. Weight and body composition of each group were evaluated after four weeks. Results: The protein intake in the app group was tendentially better opposed to the control group (p = 0.064). In the controls, there was a decrease in macronutrient intake during the study period. The app group achieved a significant weight gain (p = 0.045). Especially the skeletal muscle mass showed a significant increase of in the app group (p = 0.009) compared to the control group. Conclusions: Our study indicates that patients who daily document their dietary habits by using a smartphone app are more likely to reach their nutritional goals than the control patients. Further large-scale studies are needed to confirm these initial findings and to test the applicabilty on a broader basis.

Digital technology in somatic and gene therapy trials of paediatric patients with ocular diseases: a systematic scoping review protocol

From: Journal of Medical Internet Research

Date Submitted: Apr 5, 2018

Open Peer Review Period: Apr 7, 2018 - Jun 2, 2018

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Background: Clinical trials targeting ophthalmic conditions are currently underway and some gene therapies targeting ocular diseases have been proven to be safe and efficacious/present a positive risk...

Background: Clinical trials targeting ophthalmic conditions are currently underway and some gene therapies targeting ocular diseases have been proven to be safe and efficacious/present a positive risk:benefit; its potential as a therapeutic tool has yet to be fully exploited in clinical ophthalmology. Pharmacogenomics suggests that diseases with similar symptomatic presentations often have varying genetic causes, affecting an individual patient’s response to a specific therapeutic strategy. Gene therapies and somatic cell therapies offer unique therapeutic pathways for ocular diseases and often depend on increased understanding of the genotype-phenotype relationship in disease presentation and progression. While demand for personalised medicine is increasing and the required molecular tools are available, its adoption within paediatric ophthalmology remains to be maximised in the post-genomic era. To address the individual hurdles encountered in the field of genomic-related clinical trials and facilitate the uptake of personalised medicine, we propose to conduct a review that will examine and identify the digital technologies used to facilitate data analysis in somatic and gene therapy trials in paediatric patients with ocular diseases. Objective: To present an outline of HIT/ICT resources used in somatic and gene therapy clinical trials in children with ocular diseases. This review will enable authors to identify challenges and provide recommendations facilitating the uptake of genetic and somatic therapies as therapeutic tools in paediatric ophthalmology. The review will also determine whether conducting a systematic review will be beneficial. Methods: The review will be guided by Arksey/O’Malley’s and Levac’s methodological frameworks. Following the development of Medical Subject Headings (MeSH)/subject headings and keywords, a systematic search of MEDLINE/PubMed, Embase and Scopus will be conducted. Two suitably qualified independent reviewers will determine study eligibility. Following identification of studies, data will be extracted and analysed. Results: Database searches will be initiated in May 2018. We expect to complete the review in August 2018. Conclusions: Based on review findings, the authors will summarise methods used for facilitating IT integration in personalised medicine. Additionally, it will identify further research gaps and determine whether conduction of further reviews will be beneficial. Clinical Trial: Because this is a scoping review protocol, it is ineligible for registration with PROSPERO.

Developing, Implementing, and Evaluating a Multimedia Decision Aid Program to Reform the Informed Consent Process of a Peripherally Inserted Central Venous Catheter Procedure

From: JMIR Formative Research

Date Submitted: Apr 5, 2018

Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

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Background: Informed consent has considerable clinical, ethical, and legal implications for patient safety and liability. Advances in multimedia technology increased the utilization of multimedia pati...

Background: Informed consent has considerable clinical, ethical, and legal implications for patient safety and liability. Advances in multimedia technology increased the utilization of multimedia patient decision aids (PtDA) to supplement the conventional informed consent process. Little information is available about the use of multimedia PtDAs in the consent process for therapeutic invasive procedures such as the peripherally inserted central venous catheter (PICC). Additionally, none of the available studies have designed their multimedia PtDAs based on the patients’ information needs and the Agency for Healthcare Research and Quality (AHRQ’s) comprehensive guide for informed consent. Objective: This paper describes a patient-centered, systematic, multidisciplinary approach to develop, implement, and evaluate an effective multimedia PtDA to reform the informed consent process of a PICC procedure for patients in 10 acute and intensive care units. Methods: The development, implementation, and evaluation processes of the PtDA followed the phases described in the Multimedia Production Framework: preproduction (planning), production (filming), and postproduction (testing and editing). Within this Framework, the Criteria for Judging the Quality of PtDAs developed by the International Collaboration for PtDA Standards were applied. The methodology for improving the informed consent process was guided by the AHRQ’s Making Informed Consent an Informed Choice comprehensive guide, the AHRQ’s Health Literacy Universal Precautions Toolkit Guide, and the AHRQ’s Patient Education Materials Assessment Tool Guide for Audio/Video Materials. Conclusions: PtDAs are recommended tools to supplement the informed consent process of treatment procedures. Well-designed PtDAs can eliminate many limitations of the conventional consent process by ensuring comprehensive, standardized, and easy to comprehend information about therapeutic procedures and treatment options and providing sufficient time for the patients to reflect on the information. To be effective, PtDAs should follow a systematic, patient-centered, evidence-based, and rigorous approach in the development, implementation, and evaluation processes. Including key stakeholders such as leaders, clinicians, and patients is fundamental for the success of PtDAs.

Using the Google Maps to display the pattern of co-author collaborations in JMIR since 1999: A bibliometric study

From: Journal of Medical Internet Research

Date Submitted: Apr 13, 2018

Open Peer Review Period: May 14, 2018 - Jul 9, 2018

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Background: The Google Maps have become increasingly attractive and the disease outbreak has been especially drawn on the Google Maps because of its easy-use characteristic to serve as a spatial repre...

Background: The Google Maps have become increasingly attractive and the disease outbreak has been especially drawn on the Google Maps because of its easy-use characteristic to serve as a spatial representation with coordinates. The use of Google Maps in bibliometric studies is of particular interest in recent years due to the trend of the science evolution that can be known via the visual representations or a dashboard. Objective: The aim is to conduct a systematic evaluation of the literature on the feasibility and applicability of using Google Maps in bibliometrics and to assess the potential benefits and limitations of its application on the topic of co-author collaborations for an academic journal. Methods: The literature was searched for articles published in the Journal of Medical Internet Research (JMIR) since 1999. A total of 2,289 original research articles were extracted from the Medline library. The clusters of author nationalities, the productive authors, and the medical subject headings (MESH) terms were analyzed and distributed on the Google Maps. One-parameter Rasch model of continuous items was performed through cloud computation to examine the aberrant responses of count frequency in paper publications. We applied social network analysis (SNA), the Gini coefficient (GC) and the cluster coefficient(CC) to report study results with visual representations: (i) the trend of author collaboration in JMIR; (ii) the dominant nations and productive authors in JMIR; and (iii) the MESH terms to display the evolution of the journal features. Results: The trend of author collaboration in JMIR is increasing (=0.77) based on the number of authors per article. The mean number of individuals listed as authors in articles is 5.4. The most number of the 1st authors are from the U.S.( 819, 35.78 %), the European Netherlands (225, 9.83%), and the U.K. (199, 8.69%). The top two MESH terms are methods (1,141, 22.39%) and internet (844, 16.56%). The most productive author is Christensen, Helen (Australia) who published 27 articles in JMIR and had a significant network density (CC=0.45, t=7.14). The number of paper publications in nations has a close relation (=0.83) with the national GDP in 2016. Conclusions: There are promising feasibility and applicability of using Google Maps to serve as a spatial representation in bibliometrics or the disease outbreaks in the future. The social network analysis incorporated with the Google Maps provides wide and deep insights into the relationships among entities. The results can provide readers a concept map with the knowledge on the internet to know the JMIR characteristics.

Measuring the quality of mobile applications for the management of pain: a standardised review using the mobile app rating scale (MARS)

From: Journal of Medical Internet Research

Date Submitted: Apr 9, 2018

Open Peer Review Period: Apr 11, 2018 - Jun 6, 2018

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Background: Chronic pain is a major health issue requiring an approach that not only considers medication, but also many other factors included in the Bio-Psycho-Social model of pain. New technologies...

Background: Chronic pain is a major health issue requiring an approach that not only considers medication, but also many other factors included in the Bio-Psycho-Social model of pain. New technologies, such as mobile applications, are tools to address these factors, although in many cases they lack proven quality or are not based on scientific evidence, so it is necessary to review and measure their quality. Objective: The aim is to review and measure the quality of mobile applications for the management of pain using the mobile app rating scale (MARS). Methods: This review included 18 pain related mobile apps from App Store and Android Market. The MARS was administered to measure their quality. We list the scores (of each section and the final score) of every app and we report the mean score (and standard deviation) for an overall vision of the quality of the pain related apps. We compare the section scores between the groups defined according to the tertiles via ANOVA analyses, after checking for normality (Kolmogorov-Smirnov test). Results: The global quality ranged from 1.74 (worst app) to 4.35 (best app). The 18 apps, as a whole, obtained an average score of 3.17 (SD=0.75). The best rated sections were “Functionality” (Mean=3.92;SD=0.72), “Aesthetics” (Mean=3.3;SD=1.05), and “Engagement” (Mean=2.87;SD=1.14), while the worst rated were “App specific” (Mean=2.48;SD=1), “Information” (Mean=2.52;SD=0.82), and “App subjective quality” (Mean=2.68;SD=1.22). The main differences between tertiles were found on “app subjective quality”, “Engagement”, “Aesthetics”, and “App specific”. Conclusions: Current pain related apps are of a certain quality, mainly regarding their technical aspects, although they fail to offer information and have an impact on the user. Most apps are not based on scientific evidence, have not been rigorously tested, and the confidentiality of the information collected is not guaranteed. Future apps would need to improve these aspects and exploit the capabilities of current devices.

Profiles of Participating Healthcare Providers and Their Evaluations of a Statewide Online Education Program for Dissemination of HIV, HCV, and STD Clinical Evidence

From: Journal of Medical Internet Research

Date Submitted: Apr 6, 2018

Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

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Background: Timely and effective dissemination of the latest clinical evidence to healthcare providers is essential for translating biomedical research into routine patient care. Online platforms offe...

Background: Timely and effective dissemination of the latest clinical evidence to healthcare providers is essential for translating biomedical research into routine patient care. Online platforms offer unique opportunities for medical knowledge dissemination. Objective: In this study, we report: (1) the profiles of healthcare providers participating in the New York State HIV-HCV-STD Clinical Education Initiative (CEI) online program; and (2) their evaluations of the CEI online continuing medical education (CME) and continuing nursing education (CNE) courses. Methods: We compiled the professional and personal background information of the clinicians who completed at least one CEI online CME/CNE course. We collected their self-reported program evaluation data with regard to the course content, format, change in knowledge, and impact to clinical practice. Results: We recorded a total of 4,363 completions of 88 online CME/CNE courses by 1,976 unique clinicians during a 12-month study period. The clinicians’ background was much diversified with regard to the demographics, education levels, professional disciplines, practice years, employment settings, caseloads, and clinical services. The evaluation of the CEI online CME/CNE courses was very positive (usefulness/relevant 91.08%, easy comprehension 89.09%, knowledgeable trainer 92.00%, appropriate format 84.35%, knowledge increase 48.52%, intention to use knowledge 85.26%, and plan to change practice 21.98%). Comparison with the reference data indicated that the CEI online program successfully reached out to the primary care communities. Both the younger generation and the senior healthcare providers were attracted to the CEI online program. High quality multimedia resources, flexibility of access, ease of use, and provision of CME/CNE credits contributed to the initial success of the CEI online program. Conclusions: We have successfully characterized a diversified group of clinicians participating in the CEI online program. The evaluation data have demonstrated effective use of online resources to disseminate HIV, HCV, and STD clinical evidence to primary care clinicians.

Step counts of middle-aged and elderly adults for ten months before and after the release of Pokémon GO in Yokohama, Japan

From: Journal of Medical Internet Research

Date Submitted: Apr 30, 2018

Open Peer Review Period: Apr 30, 2018 - Jun 25, 2018

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Background: Smartphones have integrated into our society and are expected to serve as tools to improve health outcomes. In the summer of 2016, Pokémon Go, a location-based augmented reality game for...

Background: Smartphones have integrated into our society and are expected to serve as tools to improve health outcomes. In the summer of 2016, Pokémon Go, a location-based augmented reality game for smartphones, was released and attracted attention from the perspective of health, especially with its potential to increase physical activity (PA). A few studies have compared objectively-measured step counts before and after the release of the game; however, they were conducted over a short study period and evaluated only young people. Objective: Forty-eight players and 192 non-players aged ≥38 years were matched for sex, age group, and PA level; they were respondents to a questionnaire randomly sent to citizens who were given free pedometers by Yokohama city. Their play status was identified through the questionnaire. To investigate the change in step counts before and after the release of Pokémon Go according to play status, two-way repeated measures ANOVA was performed. Step counts one month before the release of the game were compared with those eight months after the release. In addition, subgroup analysis according to sex, age group, PA level, and subjective health status was conducted. Methods: Among citizens who was given a free pedometer by Yokohama City, 48 players and 192 non-players, matched for sex, age group and PA level, were selected. They were aged 38 or older and their play statuses were identified through a questionnaire randomly sent to those citizens. To investigate the change in step counts before and after the release of Pokémon GO by play status, two way repeated measures ANOVA was used. Step counts before the release of 1 month were compared with those after the release of 8 months. In addition to the analysis of all samples, subgroup analysis by sex, age group, PA level and subjective health status were conducted. Results: The mean ages of players and non-players were 56.6 (±9.7) years and 57.3 (±9.6) years, respectively, and the mean of baseline step counts of players and non-players were 7776.5 (±2773.3) and 7947.1 (±2849.2), respectively. There was no significant difference in the age and baseline step counts according to a t-test. In the analysis of all samples, the interaction between play status and time effect was significant for three of eight months after release. In the subgroup analyses, the interaction was significant for five months in men, eight months in the 55–64-year-old group, three months in workers, two months in the active group in PA level, and four months in participants with subjectively good health. The interaction was significant for only one month at most in other subgroups. Conclusions: The present study confirmed a difference in step counts between players and non-players before and after the release of Pokémon GO. According to our analysis, step counts were higher until six months after the release. There was no decrease in the step counts of players even in cold months, despite the decrease in step counts of non-players. In subgroup analyses, players were more likely to be men, aged <55 years, workers, active, and subjectively in good health.

Utilizing Consumer Health Posts to Identify Underlying Factors Associated with Patients’ Attitudes towards Antidepressants

From: Journal of Medical Internet Research

Date Submitted: Apr 7, 2018

Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

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Background: Non-adherence to antidepressants is a major obstacle to antidepressants therapeutic benefits, resulting in a significant burden on individuals and the healthcare system. Several studies sh...

Background: Non-adherence to antidepressants is a major obstacle to antidepressants therapeutic benefits, resulting in a significant burden on individuals and the healthcare system. Several studies showed that non-adherence is weakly associated with personal and clinical variables, but strongly associated with patients’ beliefs and attitudes towards medications. Patients’ drug review posts in online healthcare communities may provide a significant insight into patients’ attitudes towards antidepressants and address the challenges of self-report methods, such as patient recruitment. Objective: The primary objective of this study is to use consumer health posts to identify factors affecting the patient’s attitude towards antidepressant drugs, which in turn, is a strong determinant of treatment non-adherence. Methods: We randomly selected 892 patient drug reviews from the healthcare forum “askapatient.com”. We used the Framework Method to build the analytical framework containing the themes for developing structured data from the qualitative drug reviews. In the next step, four annotators coded the drug reviews at the sentence level using the analytical framework. To test the hypotheses, we first managed missing values using different imputation methods. Then, we used chi-square and ordinal logistic regression to test and model the association between variables and attitude. Results: Analysis of the sample include drug reviews that were posted from February 2001 to February 2016. The majority of the patients (76%; n= 680) were female. Approximately two-thirds of the patients (n=540) were less than 40 years of age. Testing the association between variables and attitude showed that “experience of adverse drug reactions (ADRs)” (x^2= 31.11, P= 2.91e-06), “perceived distress from ADRs” (x^2= 231.6, P= 2.2e-16), “drug effectiveness” (x^2= 548.52, P= 2.2e-16), “complaint about the lack of knowledge” (x^2= 59.36, P= 3.96e-12), “experience of withdrawal” (x^2= 55.63, P= 2.4e-11), and “duration of usage” (F-value= 43.66, P = 6.76e-11) were significantly associated with patients’ attitudes towards antidepressants. While variables “age” (F-value= 0.72, P = 0.4) and “gender” (x^2= 2.7, P= 0.21) were not associated with the patient attitudes. Moreover, modeling the relationship between variables and attitudes showed that “drug effectiveness” and “perceived distress from adverse drug reactions” were the two most significant factors affecting patient attitudes toward antidepressants. Conclusions: Patients self-report experiences of medications in online healthcare communities, can provide a unique insight for identifying underlying factors associated with patients’ perceptions and attitudes towards antidepressants. However, it cannot be used as a replacement for self-report methods due to the lack of information for some of the variables, colloquial language, and the unstructured format of the reports.

Listening to the HysterSisters: Online Conversations about Hysterectomy Recovery

From: Journal of Medical Internet Research

Date Submitted: Apr 7, 2018

Open Peer Review Period: Apr 9, 2018 - Jun 4, 2018

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Background: Despite increased focus on patient-centered care, physicians remain pressured by time constraints. Physicians must optimize perioperative counseling during this limited time. Although pati...

Background: Despite increased focus on patient-centered care, physicians remain pressured by time constraints. Physicians must optimize perioperative counseling during this limited time. Although patients experience major complications infrequently, minor complications are more common and can negatively impact quality of life. These complications may be inadequately addressed during clinical counseling prior to surgery. As a result, less time may be spent discussing common but non-life threatening symptoms. However, these still significantly impact patient quality of life. This creates an information gap that patients attempt to bridge, often through phone calls during the recovery period. Increasingly, patients are turning to social media such as online health communities to seek answers and reassurance. One such community is HysterSisters, which is “dedicated to medical and emotional issues surrounding the hysterectomy experience […], supporting women from diagnosis, to treatment, to recovery.” It offers a unique view into patients’ conversations surrounding hysterectomy and other gynecologic care. Objective: To characterize conversation about hysterectomy recovery as experienced by members of the HysterSisters online community. Methods: A retrospective keyword frequency and survival analysis of the HysterSisters Hysterectomy Recovery forum. Results: Over 1.78 million posts in total were captured from the HysterSisters forum. Among the users who created these posts were 69,950 patients who declared their hysterectomy type and date. Among these posts were also 80,704 threads from the Hysterectomy Recovery board that were posted since 2005 and during the author’s first 12 weeks post-op by 33,311 unique patients who declared hysterectomy type and date. A symptom taxonomy of 8 primary symptom groups was created using a seed list of symptoms generated from a three-gram keyword frequency analysis of these threads. Patient post volumes and distribution of symptom mentions over time reveal key times for potential beneficial symptom-specific patient engagement during recovery. Pain, bleeding and hormones/emotions were the three most mentioned symptom groups and account for over half of all symptom mentions. Minimally invasive hysterectomies were compared against abdominal hysterectomy. There is no significant difference in the proportion of patients who mention pain- and hormone/emotion-related keywords during their recovery across all procedures. As compared to the abdominal hysterectomy group, mentions of bleeding-related keyword mentions were more common in the laparoscopic group, while urinary and intimacy-related keywords were more common in the vaginal hysterectomy group. Nevertheless, the interquartile difference in days for the final mention of these keywords is significantly earlier across all keyword groups for the minimally invasive procedures. Conclusions: Analysis of the HysterSisters Hysterectomy Recovery forum reveals a rich source of information about patient experience and provides novel actionable insights that can improve patient-centered care during the postoperative period.

The development of VegEze: A mobile phone application to increase vegetable consumption in Australian adults.

From: JMIR mHealth and uHealth

Date Submitted: Apr 9, 2018

Open Peer Review Period: Apr 11, 2018 - Jun 6, 2018

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Background: Changing dietary behaviour is difficult and although it is often clear what needs to change, how to action change is more difficult. Mobile phones have characteristics which may support th...

Background: Changing dietary behaviour is difficult and although it is often clear what needs to change, how to action change is more difficult. Mobile phones have characteristics which may support the complexity of changing dietary behaviour. Objective: This paper describes the iterative development process to build and test a mobile app called VegEze that aims to increase vegetable consumption. Methods: In order to upscale, reach target users and create a user-friendly end product, a collaborative research-industry partnership was formed to build the app over a 20-week build phase. The IDEAS framework was used as a scientific basis to guide the development. The Behaviour Change Wheel was also used as a theoretical grounding in combination with other theory-based strategies, such as self-monitoring, social comparison and gamification – which have all been shown to be successful in dietary change or digital health interventions. One consumer survey (n=1068), one usability testing session (n=11), and a pilot efficacy and usability trial (n=283) were conducted to inform the design of the app. The samples for the consumer survey and pilot trial were recruited via email from a database of individuals who had previously expressed an interest in participating in online health-related programs. Results: The target behaviour for the app was defined as “having 3 different types of vegetables at dinner”. The perceived achievability of this target behaviour was high; 93% of respondents felt they were ‘likely’ or ‘very likely’ to be able to regularly achieve the behaviour. App features that users reported to want included recipes and meal ideas (82% of users), functionality to track their intake (62%), and information on how to prepare vegetables. Based on the importance of self-monitoring as a behaviour change technique and its rating by users, the vegetable tracker was a core feature of the app, and was designed to be quick and simple to use and highly applicable to a range of users. Daily feedback messages for logging intake and communicating progress were designed to be engaging and fun using friendly and positive language and emoji icons. Daily and weekly feedback on vegetables consumption was designed to be simple and informative and reinforce monitoring. A creative team were engaged to assist in the branding of the app to ensure it had an identity that reflected the fun and simple nature of the underlying behaviour. The app included 16 behaviour change techniques, most of which were from the goals and planning subsection of the taxonomy. Conclusions: Combining a theoretical framework with an industry perspective and input resulted in an app that was developed in a timely manner while retaining its’ evidence-base and the process of scientific evaluation. VegEze is currently available in the App store, and the overall impact of the VegEze app will be evaluated using the RE-AIM framework in an uncontrolled, quantitative study. Clinical Trial: ACTRN12618000481279

Adverse Effects of eHealth Applications Replacing or Complementing Healthcare Contacts: A Scoping Review

From: Journal of Medical Internet Research

Date Submitted: Apr 14, 2018

Open Peer Review Period: Apr 15, 2018 - Jun 10, 2018

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Background: The use of eHealth has increased tremendously in recent years. eHealth is generally considered to have a positive effect on healthcare quality and to be a promising alternative for face-to...

Background: The use of eHealth has increased tremendously in recent years. eHealth is generally considered to have a positive effect on healthcare quality and to be a promising alternative for face-to-face healthcare contacts. Surprisingly little is known about possible adverse effects of eHealth applications. Objective: We conducted a scoping review on empirical research into adverse effects of eHealth applications that aim to deliver healthcare on a distance. We investigated if adverse effects were reported and the nature and quality of research into these possible adverse effects. Methods: For this scoping review, we followed the five steps of Arksey and O’Malley’s scoping review methodology. We examined the literature between December 2012 and August 2017 in the following databases: PubMed, CINAHL, Web of Science and the Cochrane Library. Each paper was independently screened by at least two authors; differences were resolved through consensus development. Study characteristics were extracted. The methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) lists. Results related to the research question were described and categorized. Results: Our search identified 79 papers that were potentially relevant; 11 studies met our inclusion criteria after screening. These studies differed in many ways and the majority was characterized by small research populations and low study quality. Despite the shortage of solid research, we found some indications of possible adverse effects Conclusions: There is a lack of high-quality empirical research on adverse effects of eHealth applications replacing or complementing face-to-face care. While the development of eHealth applications is ongoing, the knowledge with regard to possible adverse effects is limited. The available research focuses often on efficacy, added value, implementation issues, use and satisfaction, whereas adverse effects are underexposed. A better understanding of possible adverse effects might be a starting point to improve the positive impact of eHealth-based health care delivery.

Change in Waist Circumference with Continuous Use of a Smart Belt: An Observational Study

From: Journal of Medical Internet Research

Date Submitted: Apr 12, 2018

Open Peer Review Period: Apr 13, 2018 - Jun 8, 2018

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Background: Several insurers and health policymakers have exerted effort to prevent and reduce cardiovascular diseases due to obesity. A new concept for conquering obesity has been introduced, and pol...

Background: Several insurers and health policymakers have exerted effort to prevent and reduce cardiovascular diseases due to obesity. A new concept for conquering obesity has been introduced, and policymakers have started adopting new strategies. Objective: This preliminary study aimed at evaluating whether a waist circumference of smart belt users improved. Methods: Preexisting data on waist circumference and self-reported demographics were obtained from the WELT corporation . In the database, 451 male subjects were registered initially; 24 were excluded because of missing data. Demographic and waist circumference data of the subjects were collected. Paired t-test and repeated measurements analysis of variance (ANOVA) were used to identify the change in waist circumference by considering time intervals. In addition, a linear mixed model was used to incorporate all subjects’ waist circumference data at each time point. Results: Compared with the baseline waist circumferences, the waist circumference (inches) decreased significantly at all time points (weeks) (week 4, β=-0.106; week 8, β=-0.300; week 12, β=-0.776; P<.01 ). Although each paired t-test had a different sample size because of loss to follow-up, the differences between baseline and each subsequent week increased. Equal continuous reduction in waist circumference was observed with ANOVA and mixed model analysis (β=-0.056, every week). Conclusions: A smart belt is a newly developed, wearable device that measures real-time steps, sedentary time, and waist circumference. In this study, the smart belt helps users decrease waist circumference after 12 weeks This direct-to-consumer smart health device may contribute toward reducing the risk of non-communicable diseases and controlling the increasing health cost for health insurers. Clinical Trial: None

Assessing the efficacy of an educational smartphone or tablet app with subdivided and interactive content to increase patients’ medical knowledge: A randomized controlled trial

From: Journal of Medical Internet Research

Date Submitted: Apr 13, 2018

Open Peer Review Period: Apr 13, 2018 - Jun 8, 2018

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Background: Modern healthcare focuses on Shared Decision Making (SDM) because of its positive effects on patient satisfaction, therapy compliance, and outcomes. Patients’ knowledge about their illne...

Background: Modern healthcare focuses on Shared Decision Making (SDM) because of its positive effects on patient satisfaction, therapy compliance, and outcomes. Patients’ knowledge about their illness and available treatment options, gained through medical education, is one of the key drivers for SDM. Current patient education relies heavily on medical consultation and is known to be ineffective. Objective: To determine whether providing patients with information in a subdivided, categorized, and interactive manner via an educational app for smartphone or tablet may increase the knowledge of their illness. Methods: A surgeon blinded randomized controlled trial was conducted with 213 patients who were referred to one of the six Dutch hospitals by their general practitioner owing to knee complaints that were indicative of knee osteoarthritis (OA). An interactive app that, in addition to standard care, actively sends informative and pertinent content to patients about their illness on a daily basis by means of push notifications in the week prior to their consultation. The primary outcome was the level of perceived and actual knowledge that patients had about their knee complaints and the relevant treatment options after the intervention. Results: In total 122 patients were enrolled in the control group and 91 in the intervention group. After the intervention, the level of actual knowledge (measured on a 0-36 scale) was 52% higher in the app group (26.4 versus 17.4, P < 0.001). Moreover, within the app group, the level of perceived knowledge (measured on a 0-25 scale) increased by 22% during the week within the app group (from 13.5 to 16.5, P < 0.001), compared to no gain in the control group. Conclusions: Actively offering patients information in a subdivided (per day), categorized (per theme), and interactive (video and quiz questions) manner significantly increases their levels of knowledge (both perceived and actual), compared to standard care educational practices. Clinical Trial: The trial was approved by the regional Medical Ethical Board (Maxima Medisch Centrum, Eindhoven, The Netherlands), reference number N16.130.

Effectiveness of a short web-based film targeting parental knowledge and behavior with respect to the oral health of children

From: Journal of Medical Internet Research

Date Submitted: Apr 10, 2018

Open Peer Review Period: Apr 12, 2018 - Jun 7, 2018

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Background: Children necessarily rely on their parents with respect to oral health routines but parental behavior in this area is not always adequate. Web-based interventions are a promising way of im...

Background: Children necessarily rely on their parents with respect to oral health routines but parental behavior in this area is not always adequate. Web-based interventions are a promising way of improving parental behavior in the area of oral health. Objective: To evaluate the effectiveness of a web-based film about oral health, oral hygiene and dental care targeting parental knowledge and behavior with respect to oral health, directly after exposure and six months later. Methods: We performed a non-blinded quasi-experimental study of the effects of a 8.5 minute web-based film in Dutch, English, Turkish and Moroccan/Berber about the oral health of children. Parents attending well-child clinics in mixed urban and rural areas in the Netherlands were assigned to an intervention (n=88) or control group (n=41). The control group received care as usual. We measured parental knowledge and behavior with respect to oral health before and directly after the intervention and six months later, and assessed differences between the intervention and the control group. Results: Parental knowledge about oral health improved: the mean knowledge score was 93% correct after watching the film in the intervention group by comparison with 59% correct in the control group, Cohen’s d=2.64, and it was still better in the intervention group six months after watching the film. Oral health behavior did not differ between the intervention group and the control group after the intervention. Conclusions: A web-based educational film for parents is an effective way to address specific health topics like oral health and to improve parental knowledge.

Comparison of developers’ and end-users’ perspectives about smoking cessation support through the Crush the Crave app.

From: Journal of Medical Internet Research

Date Submitted: Apr 10, 2018

Open Peer Review Period: Apr 12, 2018 - Jun 7, 2018

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Background: High smoking rates among end-users, combined with their high rates of app use, render this age group as a particularly captive audience for quit smoking apps. There is emerging evidence th...

Background: High smoking rates among end-users, combined with their high rates of app use, render this age group as a particularly captive audience for quit smoking apps. There is emerging evidence that apps are an effective way to support smoking cessation among end-users. How the expectations behind the design of apps align with the needs and preferences of users, and if this differs by gender, is poorly understood, limiting the ability to evaluate and scale these interventions. Objective: The objective of this qualitative case study was to detail how the overall design approach of Crush the Crave (CTC), a quit smoking app that targets end-users, compares with young adult women’s and men’s perspectives and experiences, with consideration for the influence of gender. Methods: Semi-structured interviews were conducted with 15 developers involved in the development of CTC, and 31 young adult CTC users. Data were analyzed inductively to derive thematic findings in relation to the perceived pros and cons of CTC by both developers and end-users. Findings were grouped under four categories 1) technology and platforms utilized for the app, 2) foundation of app content, 3) underlying focus of the app, and 4) look, feel and functionality of the app. Results: 1) Technology and platforms utilized for the app: both developers and end-users agreed that apps aligned with the needs and preferences of young adult smokers. Major limitations with the technology identified by end-users were the frequent “glitches” and requirement for WiFi or data. 2) Foundation of app content: while developers agreed that the strength of CTC was in its strong evidence-base, what mattered to end-users was that the content was packaged in a positive way, focusing on the benefits of quitting versus the consequences of smoking. 3) Underlying focus of the app: that the app entailed an individually-led focus resonated with both developers and end-users, especially young men. 4) Look, feel and functionality of the app: while developers were more positive about the look and feel of the app, end-users did not like the aesthetics of the app because it incited a negative affect. Also, while end-users found it easy to use, they did not find the app intuitive. Finally, end-users thought that, because the app functions were largely based on a user’s quit date versus their ongoing efforts, this often lent to unmeaningful data. Conclusions: The current study findings highlight the importance of understanding multiple perspectives of stakeholders involved in a mobile-based intervention. By gathering the viewpoints of developers and end users, both problematic and effective approaches that underlie development goals were revealed as a means to informing end-users the development, implementation and evaluation of future eHealth interventions.

Message Framing and Exercise Effects in Mobile Fitness Application: Repeated Measure Design and Playtest Experimental Study

From: JMIR mHealth and uHealth

Date Submitted: Apr 11, 2018

Open Peer Review Period: Apr 11, 2018 - Jun 6, 2018

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Background: The ultimate goals of exercise contents in the form of apps are to manage and nurture users’ exercise habits. To promote and maintain their desire for exercise, app developers focus not...

Background: The ultimate goals of exercise contents in the form of apps are to manage and nurture users’ exercise habits. To promote and maintain their desire for exercise, app developers focus not only on the utilization of various media characteristics for fitness apps, but also on the composition and effects of messages that stimulate and reward users’ exercise behaviors. Objective: This study sought to verify differences in user experiences and exercise experiences depending on the message framing provided by a mobile fitness app, based on evaluation of the variables of perceived benefit, exercise interest, exercise flow, and exercise attitude. Methods: The research was designed following the repeated measures design and the playtest method, in which experiments were repeated multiple times for the same group based on the type of message on the fitness app (male 50, female 50). This enabled effective verification of the difference between experimental treatments. Participants were instructed to use two types of fitness app that presented gain or loss messages about exercise outcomes while performing exercises. Thereafter, they were surveyed with a self-administered questionnaire. Results: Users who were exposed to gain-framed messages in the mobile fitness app showed higher perceived benefit, exercise interest, and exercise flow than those who were exposed to loss-framed messages. Furthermore, gain-framed messages also led to a positive attitude toward exercise. Conclusions: The present study is meaningful due to its investigation of the influences and persuasive effects of gain- and loss-framed messages given by a health fitness app. This study, which demonstrated that gain-framed messages enhanced the exercise experiences of users compared to loss-framed messages when persuasive messages were presented through a health functional app, provides a theoretical foundation for health message framing in exercise apps.

Image-Based Mobile System for Dietary Management in an American Cardiology Population: Randomized Controlled Trial to Assess the Efficacy of Dietary Coaching Delivered via Smartphone App versus Traditional Counseling

From: Journal of Medical Internet Research

Date Submitted: Apr 24, 2018

Open Peer Review Period: Apr 24, 2018 - Jun 19, 2018

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Background: Randomized controlled trials conducted in Mediterranean countries have shown that the Mediterranean diet lowers adverse cardiovascular events. In the American population, diet remains the...

Background: Randomized controlled trials conducted in Mediterranean countries have shown that the Mediterranean diet lowers adverse cardiovascular events. In the American population, diet remains the biggest uncontrolled risk factor for cardiovascular disease, and patients with cardiovascular disease require more extensive dietary counseling to reduce their risk of myocardial infarction, stroke and hypertension. Objective: Our study tested the hypothesis that asynchronous dietary counseling supplied through a custom smartphone application results in better adherence to a Mediterranean diet in a non-Mediterranean population compared with traditional standard-of-care counseling. Methods: 100 patients presenting to the cardiology clinic of an academic medical center in Washington D.C. were randomized to either the standard-of-care (SOC) or smartphone app-based (EXP) Mediterranean diet intervention after informed consent and 1 hour of individual face-to-face dietary counseling with a registered dietician. Participants in EXP received a custom smartphone application that reinforced the Mediterranean diet while participants in SOC received two additional sessions of in-person dietary counseling with the registered dietician – 30 minutes at 1 month and 30 minutes at 3 months. Pre-existing knowledge of a Mediterranean diet was measured by the validated Mediterranean Diet Score instrument (MDS). Baseline height, weight, blood pressure and laboratory biomarkers were collected. At 1, 3 and 6 months, participants presented for a follow up appointment to assess compliance to the Mediterranean diet using the MDS, as well as a patient satisfaction survey, blood pressure and weight. Repeat laboratory biomarkers were performed at 3 and 6 months. Results: Enrolled participants had a mean age with standard error of 56.6 ± 1.7 for SOC and 57.2 ± 1.8 for EXP; 65.3% of SOC and 56.9% of EXP were male, and 20.4% of SOC and 35.3% of EXP had coronary artery disease. There were no significant differences between EXP and SOC with respect to blood pressure, lipid parameters, HgbA1C, or CRP. Participants in EXP achieved a significantly greater weight loss on average of 3.3 lbs vs. 3.1 lbs for participants in SOC, p=0.04. Adherence to the Mediterranean diet increased significantly over time for both groups (p<0.001), but there was no significant difference between groups (p=0.69). Similarly, there was no significant difference in diet satisfaction between EXP and SOC, although diet satisfaction increased significantly over time for both groups. The proportion of participants with high Mediterranean diet compliance (defined as MDS ≥ 9) increased significantly over time (p<0.001) – from 18.4 to 57.1% for SOC and 27.5 to 64.7% for EXP – however, there was no significant difference between the groups. Conclusions: Both traditional standard-of-care counseling and smartphone-based counseling were effective in getting participants to adhere to a Mediterranean diet in this US-based study of cardiology patients, and these dietary changes persisted even after counseling had ended. However, neither method was more effective than the other. This study demonstrates that the American cardiology patient can change to and maintain a Mediterranean diet with either traditional or smartphone app-based nutrition counseling.

Predicting rural patients’ use of eHealth through supervised machine learning algorithms: A study on Portable Health Clinic in Bangladesh

From: JMIR mHealth and uHealth

Date Submitted: Apr 12, 2018

Open Peer Review Period: Apr 13, 2018 - Jun 8, 2018

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Background: Predictive analytics through machine learning has been extensively using across industries including eHealth and mHealth for analyzing patient’s health data, predicting diseases, enhanci...

Background: Predictive analytics through machine learning has been extensively using across industries including eHealth and mHealth for analyzing patient’s health data, predicting diseases, enhancing the productivity of technology or devices used for providing healthcare services and so on. However, not enough studies were conducted to predict the usage of eHealth by rural patients in developing countries. Objective: The objective of this study is to predict rural patients’ use of eHealth through supervised machine learning algorithms and propose the best-fitted model after evaluating their performances in terms of predictive accuracy. Methods: Data were collected between June and July 2016 through a field survey with structured questionnaire form 292 randomly selected rural patients in a remote North-Western sub-district of Bangladesh. Four supervised machine learning algorithms namely logistic regression, boosted decision tree, support vector machine, and artificial neural network were chosen for this experiment. A ‘correlation-based feature selection’ technique was applied to include the most relevant but not redundant features into the model. A 10-fold cross-validation technique was applied to reduce bias and over-fitting of the data. Results: Logistic regression outperformed other three algorithms with 85.9% predictive accuracy, 86.4% precision, 90.5% recall, 88.1% F-score, and AUC of 91.5% followed by neural network, decision tree and support vector machine with the accuracy rate of 84.2%, 82.9 %, and 80.4% respectively. Conclusions: The findings of this study are expected to be helpful for eHealth practitioners in selecting appropriate areas to serve and dealing with both under-capacity and over-capacity by predicting the patients’ response in advance with a certain level of accuracy and precision.

Linking Long-Term Care Information Seekers with Providers Through Improved Internet Market Segmentation

From: JMIR Aging

Date Submitted: Apr 12, 2018

Open Peer Review Period: Apr 13, 2018 - Jun 8, 2018

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Background: As the internet has become a primary communication means in the long-term care (LTC) and health care industry, better understanding of market segmentations among LTC consumers is an indisp...

Background: As the internet has become a primary communication means in the long-term care (LTC) and health care industry, better understanding of market segmentations among LTC consumers is an indispensable step to respond to the consumers’ informational needs. Objective: This study was designed to identify underlying market segments of the LTC consumers who seek information online. Methods: Data of the U.S. adult internet users (n = 2,018) were derived from 2010 Pew Internet and America Life Project. Latent class analyses were employed to identify underlying market segments of LTC online information seekers. Results: Online LTC information seekers were classified into two sub-groups – heavy and light online information seekers. One in four heavy online information seekers used the internet for the LTC information while only 2% of the light information seeker did. The heavy information seekers also used the internet to search for all other health information such as a specific disease, treatment and medical facilities significantly more than the light information seekers. The heavy online information seekers were more likely to be younger, female, highly educated, chronic disease patients, caregivers and frequent internet users in general than the light online information seekers. Conclusions: In order to effectively communicate with their consumers, providers who target online LTC information seekers can more carefully align their informational offerings with the specific needs of each subsegment of LTC markets.

Quantifying the relationship between diseases and symptoms using big data

From: Journal of Medical Internet Research

Date Submitted: Apr 12, 2018

Open Peer Review Period: Apr 15, 2018 - Jun 10, 2018

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Background: Crises in endemic transmitted diseases affect humans worldwide, and the symptoms these diseases cause may provide firsthand information about these disorders. Objective: We suggest that ma...

Background: Crises in endemic transmitted diseases affect humans worldwide, and the symptoms these diseases cause may provide firsthand information about these disorders. Objective: We suggest that massive new data sources resulting from human interaction with the Internet may offer a unique perspective on the relationship between illness and symptoms. Methods: By analyzing changes in Google query volumes for search terms related to disease, we find a pattern that may define the relationship between symptoms and disorders. We first retrieved pattern data from Google Trend using the common cold as the primary disease, and sore throat, stuffy nose, sneeze, fever, cough, and headache as symptoms. Pearson’s correlation coefficient was calculated using SPSS to determine the relationship between the symptoms and the disease. Results: Data created since 2013/1/13 was retrieved from Google Trend on a weekly basis. A total of 261 sets of data were calculated to create a high correlation coefficient of 0.925 between the common cold and the stuffy nose symptom. The cough symptom has the second highest correlation coefficient of 0.925, sore throat has a correlation coefficient of 0.853, and fever has a correlation coefficient of 0.626, which was significant at the 0.01 level in a two-tailed test. Conclusions: Data on the relationship between diseases and symptoms often comes from facilities such as government, hospitals, and clinics, where the data is collected through the documentation of physicians and nurses. A conventional study can be limited by the region, the number of patients and the interpretation of the specialist. However, with access to Google Trend’s big data, millions or even billions of data points are accumulated directly from the patient. Another contribution of this study is that the quantified relationship between symptoms and diseases can be used to educate future physicians or even artificial intelligence.

Evidence-based medicine in practice: A two teaching hospital organisational ethnography exploring how evidence is used

From: Journal of Medical Internet Research

Date Submitted: Apr 12, 2018

Open Peer Review Period: Apr 13, 2018 - Jun 8, 2018

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Background: Numerous published articles show that physicians do not follow clinical practice guidelines. However, few studies explore what physicians consider evidence and how they use different forms...

Background: Numerous published articles show that physicians do not follow clinical practice guidelines. However, few studies explore what physicians consider evidence and how they use different forms of evidence in their care decisions. Many of the existing studies on how physicians use evidence occurred before the advent of smart phones and advanced online information retrieval technologies. Objective: It is important to understand how these new technologies influenced the ways that physicians use evidence in their practice. Methods: In this paper, we draw on ethnographic data collected through shadowing internal medicine teams at two teaching hospitals to understand the roles that scientific evidence plays for attending physicians and trainees when caring for patients. Results: Clinical practice guidelines represent just one of several sources of scientific evidence that are used when making care decisions. The majority of scientific evidence was accessed online, often through smart phones. Forms of evidence were used differently depending on the level of experience of the person drawing on the evidence and were often blended together to arrive at shared understandings and approaches to patient care. In applying evidence to care, internal medicine team members are cognizant that scientific evidence is evolving, occasionally of low quality, can make competing claims, and does not cover all clinical problems. In moving from incorporating summaries of scientific evidence to primary sources of scientific evidence into their care decisions, trainees and attending clinicians increasingly add scientific uncertainty to the medical uncertainty that is inherent in their practice. Conclusions: This paper outlines one way that the ethos of evidence-based medicine has been incorporated into the daily work of care. Here multiple online forms of evidence were mixed with other information. This is different from the pathway that is often articulated by health administrators and policy makers whereby clinical practice guideline adherence is equated with practicing evidence-based medicine.

PrEveCOPD: A computer application to predict adverse events in the short-term evolution of patients with exacerbation of COPD

From: Journal of Medical Internet Research

Date Submitted: Apr 13, 2018

Open Peer Review Period: Apr 15, 2018 - Jun 10, 2018

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Background: Chronic obstructive Pulmonary Disease (COPD) is a common chronic disease. Exacerbations of COPD (eCOPD) contribute to worsening of the disease and patient´s evolution. There are some clin...

Background: Chronic obstructive Pulmonary Disease (COPD) is a common chronic disease. Exacerbations of COPD (eCOPD) contribute to worsening of the disease and patient´s evolution. There are some clinical prediction rules that may help to stratify patients with eCOPD by their risk of poor evolution or adverse events. The translation of these clinical prediction rules into computer applications would allow their implementation in clinical practice. Objective: The goal of the study was to create a computer application to predict various outcomes related to adverse events of short-term evolution in eCOPD patients attending an emergency department (ED) based on valid and reliable clinical prediction rules. Methods: A computer application, PrEveCOPD (Prediction of Evolution of patients with eCOPD), was created for prediction of two outcomes related to adverse events: 1) mortality during hospital admission or within a week after the ED visit; and 2) admission to an intensive care unit (ICU) or an intermediate respiratory care unit (IRCU) during the eCOPD episode. The algorithms included in the computer tool were based on clinical prediction rules previously developed and validated within the IRYSS-COPD Study. The app was developed for Windows and Android systems, using Visual Studio 2008 and Eclipse, respectively. Results: The computer application PrEveCOPD implements the prediction models previously developed and validated for two relevant adverse events in the short-term evolution of patients with eCOPD. The application runs into Windows and Android systems and it can be used locally or remotely as a web application. Full description of the clinical prediction rules, as well as the original references, is included in the screen. Input of the predictive variables is controlled for out of range and missing values. Language can be switched between English and Spanish. The application is available for downloading and installing in a computer, as a mobile app or to be used remotely via internet. Conclusions: The PrEveCOPD app shows how clinical prediction rules can be summarized into simple and easy to use tools that allow the estimation of the risk of short-term mortality and ICU or IRCU admission for patients with eCOPD. The app can be used in any computer device, including smartphones or tablets, and it can guide the clinicians to a valid stratification of patients attending the ED with eCOPD.

Development and Feasibility of a Group-Based Online Intervention to Prevent Postpartum Depression

From: JMIR Mental Health

Date Submitted: Apr 30, 2018

Open Peer Review Period: May 2, 2018 - Jun 27, 2018

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Background: Postpartum minor and major depression (PPMD) has a 20% 3-month prevalence rate. The consequences of PPMD are significant for mother, infant, and family. There is a need for interventions t...

Background: Postpartum minor and major depression (PPMD) has a 20% 3-month prevalence rate. The consequences of PPMD are significant for mother, infant, and family. There is a need for interventions that prevent PPMD that are effective and accessible, however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group may create an intervention with the scalability and cost effectiveness of an individual intervention and the better outcomes typically found in supported interventions. Objective: This report describes the development of a peer supported internet intervention to prevent postpartum depression and explore the feasibility and acceptability of this approach. Methods: Clinic based needs assessment and focus groups were used to develop the internet intervention. Once the intervention was developed, women who were 20-28 weeks pregnant with symptoms of depression (PHQ-9 scores of 5-14) but no major depression diagnosis were enrolled in an RCT to compare 8 weeks of a CBT based peer supported internet intervention to an individual internet intervention designed to prevent postpartum depression. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), 4 weeks and 6 weeks postpartum. Results: Twenty-four women completed the RCT. PHQ-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only one woman out of twenty-four (4%) met criteria for PPMD. There was no difference between groups in adherence to the intervention, with an average of 14.55 logins over the course of treatment. Conclusions: Results suggest women were responsive to both peer support and individual internet interventions to prevent postpartum depression and that peer support may be a useful feature to keep participants adherent. Clinical Trial: Clinicaltrials.gov NCT02121015

Predicting Current Hemoglobin A1c Values Among Adults with No Previous Evidence of Hyperglycemia

From: Journal of Medical Internet Research

Date Submitted: Apr 16, 2018

Open Peer Review Period: Apr 18, 2018 - Jun 13, 2018

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Background: Electronic, personalized clinical decision support tools to optimize diabetes screening are lacking. Current screening guidelines are based on simple, categorical rules developed for popul...

Background: Electronic, personalized clinical decision support tools to optimize diabetes screening are lacking. Current screening guidelines are based on simple, categorical rules developed for populations of patients. Although personalized diabetes risk calculators have been created, none are designed to predict current glycemic levels using structured data commonly available in electronic health records (EHRs). Objective: The goal of this project was to create a mathematical equation for predicting the probability of hemoglobin A1c >= 5.7% among patients with no history of hyperglycemia using readily available variables that will allow integration with EHR systems. Methods: This study was conducted on all adult patients who have undergone a glycated hemoglobin test prior to evidence of hyperglycemia or any diabetes related diagnostic code in the EHR. Data was extracted from the Epicare EHR at Wake Forest Baptist Health in Winston-Salem, NC, which included dates between September 2012 and September 2016. Candidate predictor variables were chosen based on theoretical associations with hyperglycemia. Multiple logistic regression was used to model the association between the independent variables and the outcome of hemoglobin A1c >=5.7%. Continuous variables were fit using restricted cubic splines with 3-knots. The model was reduced using Harrell's model approximation method. The reduced model was compared head-to-head with calculators created by Baan (1999) and Griffin (2000). Ten-fold cross-validation was used to calculate the bias-adjusted prediction accuracy of the new model. Statistical analyses were performed in R 3.2.5 using the rms package. Results: The final model contained the following variables in order from most to least importance according to their impact on the discriminating accuracy of the model: age, body mass index, race, random glucose, serum non-High Density Lipoprotein, serum total cholesterol, smoking status, estimated glomerular filtration rate, serum triglycerides, and diagnosis of obesity. The new model achieved a Concordance Statistic of 0.75 which was statistically significantly better than prior models. The model appeared to be well calibrated according to a plot of the predicted probabilities versus the prevalence of the outcome at different probabilities. Conclusions: The personalized prediction model presented in this paper could improve the efficiency of screening initiatives aimed at detecting prediabetes and diabetes.

Factors affecting the reach of messages in a dental twitter network: user popularity, communication pattern and network structure: a cohort study

From: Journal of Medical Internet Research

Date Submitted: Apr 13, 2018

Open Peer Review Period: Apr 15, 2018 - Jun 10, 2018

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Background: Increasing the reach of messages disseminated through twitter promotes the success of twitter-based health education campaigns. Objective: This study aimed to identify factors associated w...

Background: Increasing the reach of messages disseminated through twitter promotes the success of twitter-based health education campaigns. Objective: This study aimed to identify factors associated with reach in a dental twitter network (1) initially and (2) sustainably, at individual and network levels. Methods: We used instructors’ and students’ twitter usernames from a Saudi dental school in 2016-2017, Gephi, social network analysis and social media analytics to calculate user and network metrics. We used content analysis to identify users disseminating oral health information (OHI). The study outcomes were reach at baseline and sustainably over 1.5 years. The explanatory variables were indicators of popularity (number of followers, likes, tweets retweeted by others), communication pattern (number of tweets, retweets, replies, tweeting/ retweeting OHI or not). Multiple logistic regression models were used to investigate associations. Results: Among dental users, 31.8% and 62.9% had reach at baseline and at the end of the study, reaching 749,923 and 37,169 users. At individual level, reach at baseline and sustainably over 1.5 years was associated with the number of followers (OR= 1.003, 95%CI= 1.001, 1.005 and OR= 1.002, 95%CI= 1.0001, 1.003), likes (OR= 1.001, 95%CI= 1.0001, 1.002 and OR= 1.0031, 95%CI= 1.0003, 1.002) and replies (OR= 1.02, 95%CI= 1.005, 1.04 and OR= 1.02, 95%CI= 1.004, 1.03). At network level, users with the least followers, tweets, retweets and replies had the greatest reach. Conclusions: Reach was reduced by time. Factors increasing reach at the user level had different impact at the network level. More than one strategy is needed to maximize reach.

Bridging the Gap: Spanish speaking Hispanic patients’ information preferences during hospitalization

From: Journal of Participatory Medicine

Date Submitted: Apr 13, 2018

Open Peer Review Period: Apr 14, 2018 - Jun 9, 2018

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Background: Self-management of chronic conditions, such as cancer or diabetes, requires coordination of care across multiple care settings. Current patient centered hospital-based care initiatives, in...

Background: Self-management of chronic conditions, such as cancer or diabetes, requires coordination of care across multiple care settings. Current patient centered hospital-based care initiatives, including bedside nursing handoff and multidisciplinary rounds, often retain a focus on provider information exchange and roles but fall short of the goals of participatory medicine, which recognize the right of patients to partner in their own care and take an active role in self-management. Objective: The purpose of this study was to elicit Spanish-speaking Hispanic patients’ perspectives on the exchange and sharing of information during hospitalization. Methods: This exploratory pilot study incorporated a qualitative descriptive approach through the use of Spanish language focus groups, post hospitalization, to determine patient identified information needs during a hospitalization. Results: Participants preferred paper instructions in Spanish. Doctors and nurses were the key information providers and communicated with the participant verbally, usually with the assistance of a translator. The participants expressed a desire to be informed about medications and treatments, including side effects and why there were changes in medications during the hospitalization. They expressed interest in knowing about the progress of their condition and when they could expect to go home. Emotional readiness to receive information about their condition and prognosis was identified as an individual barrier to asking questions and seeking additional information about their condition(s). Conclusions: Overall, participants shared positive experiences with providers during hospitalization and the usefulness of self-care instructions. Language was not recognized as a barrier by any of the participants. Future research on the influence of emotional readiness on timing of medical information is needed.

Gender moderates the partial mediation of impulsivity in the relationship between psychiatric distress and problematic online gaming

From: Journal of Medical Internet Research

Date Submitted: Apr 22, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: Research has shown that some individuals can develop problematic patterns of online gaming, leading to significant psychological and interpersonal problems. Psychiatric distress and impuls...

Background: Research has shown that some individuals can develop problematic patterns of online gaming, leading to significant psychological and interpersonal problems. Psychiatric distress and impulsivity has been suggested to contribute to problematic online gaming (POG). Objective: The underlying mediating and/or moderating mechanism of impulsivity as well as gender differences in possible associations between psychiatric distress and POG are largely unknown, which guides this current study Methods: To address this gap, the current study examined relationships between self-reported impulsivity, psychiatric distress, and POG in a sample of matched Hungarian female and male online gamers (n=596, 50% males). Results: Results showed that psychiatric distress directly predicted POG, and impulsivity partially mediated the relationship between psychiatric distress and POG. However, this mediation effect was found only for the impatience subscale. Impulsivity did not moderate the relationship between psychiatric distress and POG. A moderating effect of gender was not found in the direct relationship between psychiatric distress and POG. However, a moderated mediation analysis revealed that impatience mediated the association between psychiatric distress and POG in males, whereas the indirect effect of impatience was not significant in females. Conclusions: Future implications are discussed in light of these results. Clinical Trial: N/a

Bleeding Event Detection in EHR Notes Using CNN Models Enhanced with RNN Autoencoders

From: Journal of Medical Internet Research

Date Submitted: Apr 15, 2018

Open Peer Review Period: Apr 17, 2018 - Jun 12, 2018

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Background: Bleeding events are common and critical which may cause significant morbidity and mortality. Studies show that high incidences of bleeding events are associated with cardiovascular disease...

Background: Bleeding events are common and critical which may cause significant morbidity and mortality. Studies show that high incidences of bleeding events are associated with cardiovascular disease (CVD) patients on anticoagulant therapy. Prompt and accurate detection of bleeding events are essential for preventing serious consequences. As bleeding events are often described in clinical notes, automatic detection of bleeding events from Electronic Health Record (EHR) narratives has the potential to improve drug safety surveillance and pharmacovigilance. Objective: We developed a natural language processing (NLP) system to automatically classify whether an EHR note sentence contains a bleeding event. Methods: We expert-annotated 878 EHR notes (76,577 sentences and 562,630 word tokens) for identifying bleeding events at the sentence-level. This annotated corpus was then used to train and validate our NLP systems. We developed an innovative hybrid CNN and LSTM Autoencoder model (HCLA), which integrates a convolutional neural network architecture (CNN) with a bidirectional Long-short term memory (BiLSTM) autoencoder model to leverage large unlabeled EHR data. Results: HCLA achieved an F-score of 93.79% for identifying whether a sentence contains a bleeding event, surpassing the strong baseline SVM and other CNN models. Conclusions: By incorporating a supervised CNN model with a pre-trained unsupervised BiLSTM Autoencoder, HCLA achieved a high performance in detecting bleeding events.

Healthcare students’ experiences of multi-user virtual environments for collaborative learning in team care delivery: A mixed method study

From: Journal of Medical Internet Research

Date Submitted: Apr 18, 2018

Open Peer Review Period: Apr 20, 2018 - Jun 15, 2018

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Background: There has been a dearth of collaborative learning across tertiary institutions due to challenges in scheduling and geographical locations. Three-dimensional virtual environments are a viab...

Background: There has been a dearth of collaborative learning across tertiary institutions due to challenges in scheduling and geographical locations. Three-dimensional virtual environments are a viable and innovative tool to bring diverse healthcare students to learn together. Objective: The purpose of this study is to describe the development of a multiuser virtual environment and to evaluate healthcare students’ experiences of their collaborative learning in the environment. Methods: A mixed method study design was employed. Participants from six healthcare courses (Medicine, Nursing, Pharmacy, Physiotherapy, Occupational Therapy, and Medical Social Work) were recruited from three institutions to form six interprofessional healthcare teams who participated in interdisciplinary team care via a virtual environment. Four focus groups were conducted with 27 healthcare students after they completed questionnaires to evaluate their perceived usability, the sociability of computer-supported collaborative learning, and senses of presence. Interview transcripts were analyzed using thematic analysis. Results: Four themes emerged from the students’ experiences: “Bringing everyone together” to learn in the virtual platform was perceived as a valuable experience; “Feeling real”, whereby the students felt immersed in their own healthcare profession’s roles; learning in the virtual environment was perceived as “less threatening” compared to face-to-face interactions; and there were some “technical hiccups” related to sound quality and navigation. The participants reported positively on the usability (mean 3.48, SD 0.64) and feasibility (mean 3.39, SD 0.60) of the virtual environment in supporting collaborative learning. With a maximum score of 168, they also perceived a moderately strong sense of presence (mean 107.24, SD 17.78) in the environment. Conclusions: This study provides evidence for the acceptance of a virtual platform for collaborative learning in team care delivery. Given its flexibility, practicality, and scalability, this virtual platform serves as a promising tool for collaborative learning across different healthcare courses and institutions.

Improving EHR Note Comprehension with NoteAid: A Randomized Trial of EHR Note Comprehension Interventions with Crowdsourced Workers

From: Journal of Medical Internet Research

Date Submitted: Apr 27, 2018

Open Peer Review Period: Apr 29, 2018 - Jun 24, 2018

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Background: Patient portals are becoming more common, and with them the ability of patients to access their personal Electronic Health Records (EHRs). EHRs, in particular the free-text EHR notes, ofte...

Background: Patient portals are becoming more common, and with them the ability of patients to access their personal Electronic Health Records (EHRs). EHRs, in particular the free-text EHR notes, often contain medical jargon and terms that are difficult for laypersons to understand. There are many online resources for learning more about particular diseases or conditions, including systems that directly link to lay definitions or educational materials for medical concepts. Objective: Our goal is to determine whether use of one such tool, NoteAid, leads to higher EHR note comprehension ability. Methods: In this work we compare a passive, self-service educational resource (MedlinePlus) with an active resource (NoteAid) where definitions are provided to the user for medical concepts that the system identifies. We use Amazon Mechanical Turk (AMT) to recruit individuals to complete ComprehENotes, a new test of EHR note comprehension. Results: Mean scores for individuals with access to NoteAid are significantly higher than the mean baseline scores, both for raw scores (p=0.008) and estimated ability (p=0.017). Conclusions: In our experiments we show that the active intervention leads to significantly higher scores on the comprehension test as compared to a baseline group with no resources provided. In contrast, there is no significant difference between the group that was provided with the passive intervention and the baseline group. Finally, we analyze the demographics of the individuals who participated in our AMT task and show differences between groups that align with current understanding of health literacy between populations.

Theoretical Predictors of Mindfulness Meditation Mobile App Usage: The Role of Intention and Executive Function

From: JMIR mHealth and uHealth

Date Submitted: Apr 16, 2018

Open Peer Review Period: Apr 18, 2018 - Jun 13, 2018

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Background: Mindfulness meditation has become increasingly popular over the last few years, due in part to the increase in mobile applications incorporating the practice. Although studies have demonst...

Background: Mindfulness meditation has become increasingly popular over the last few years, due in part to the increase in mobile applications incorporating the practice. Although studies have demonstrated the potential of mindfulness meditation to positively impact mental and physical health outcomes, little has been uncovered about what predicts engagement in mindfulness meditation. Understanding the predictors of mindfulness meditation may help practitioners and phone app developers improve intervention strategies and app experience. Objective: The purpose of this study was to use the Theory of Planned Behavior and Temporal Self-Regulation Theory to determine factors predicting mindfulness meditation mobile app use. Methods: The sample consisted of 85 undergraduate students with no prior mindfulness meditation experience. During their first lab visit, participants received a brief training about mindfulness, participated in tasks to measure their executive functioning, and completed a survey to measure Theory of Planned Behavior constructs about mindfulness meditation (beliefs, social norms, perceived behavioral control, and intentions). Over the course of the following two weeks, participants logged the days and minutes that they practiced mindfulness meditation using a phone app. Stepwise regression modeling was used to analyze the data. Results: On average, participants practiced mindfulness on 9.3 days and for 64.3 minutes over the 14 day period. Participant demographic factors did not significantly explain the model variance for number of days practicing mindfulness. In step 2, participant beliefs, social norms, and perceived behavioral control explained model variance for the number of minutes practicing mindfulness, but not for number of days practicing mindfulness. Participant intentions were predictive of the number of minutes (b = 33.87, p = .001) and days (b = 3.17, p < .001) practicing mindfulness. Participant executive functioning did not predict mindfulness meditation practice nor did it moderate the link between intentions and mindfulness meditation practice. Conclusions: These results suggest that the Theory of Planned Behavior is useful in predicting use of mindfulness meditation phone apps, particularly as it pertains to participant beliefs about social norms and their intentions to practice mindfulness. However, given that participant executive functioning was not a predictor or moderator of mindfulness practice, this suggests that Temporal Self-Regulation Theory may be less useful for explaining mindfulness meditation behaviors using phone apps. The results are important for public health professionals, highlighting a need to focus on social norms and intentions to promote mindfulness meditation using phone apps. For psychotherapists and other medical practitioners encouraging mindfulness meditation as a therapy, phone apps may be a particularly effective method to encourage consistency and length of time practicing mindfulness.

The effects of text messaging interventions to improve physical activity and sedentary behaviour in youth: A systematic review

From: JMIR mHealth and uHealth

Date Submitted: Apr 17, 2018

Open Peer Review Period: Apr 19, 2018 - Jun 14, 2018

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Background: The use of text messages (SMS) to change physical activity (PA) and sedentary behaviour (SB) in youth is of interest due to the need for novel, more effective intervention approaches. Prev...

Background: The use of text messages (SMS) to change physical activity (PA) and sedentary behaviour (SB) in youth is of interest due to the need for novel, more effective intervention approaches. Previous reviews have examined a variety of technology-based interventions and their impact on different health behaviours but evidence regarding the impact of just SMS on PA and SB is lacking. Objective: The current systematic review aims to assess the effectiveness of SMS interventions for improving PA and SB in youth. Methods: Authors systematically searched electronic databases from March to November 2017. Citations were sifted using additional reviewers and a qualitative synthesis of eligible studies was conducted using piloted data extraction forms. To be eligible for inclusion, studies had to be of randomised controlled or quasi-experimental design, incorporate SMS, involve adolescents between the ages of 10 and 19 and assess at least one PA or SB outcome. Risk of bias was assessed using the Cochrane Collaboration’s Risk of Bias tool. Results: Thirteen studies reporting on 11 interventions were included in the qualitative synthesis. Studies included interventions that were conducted in schools, online or face-to-face. Studies were of high heterogeneity with regards to study duration, participant characteristics, intervention content and outcome measures. Findings were equivocal with regards to intervention effectiveness for PA and SB. Seven interventions resulted in an improvement for PA and six for SB. All studies were judged to be of high risk of bias for at least one item. Conclusions: Some studies in this review showed promising results for using SMS to improve PA and SB in youth. High heterogeneity of design and outcome measures precluded data pooling and conclusions as to which specific intervention elements are linked to increased effectiveness cannot be drawn. The authors propose incorporating the following elements in future studies: specific focus on desired health behaviour; mixed methods design; include long-term follow-up; include self-monitoring, goal setting and feedback; combine SMS with a mobile app; send 3 or more SMS per week. More rigorous studies are needed to explore the relationship between intervention effectiveness and specific intervention components such as content and delivery.

Continuous Subcutaneous Insulin Infusion and Its Characteristics in Young People with Type 1 Diabetes with Optimal Glucose Control

From: Journal of Medical Internet Research

Date Submitted: Apr 17, 2018

Open Peer Review Period: Apr 19, 2018 - Jun 14, 2018

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Background: Continuous subcutaneous insulin infusion (CSII) is established model for mimicking physiological insulin, which can overcome some of these barriers. CSII therapy is becoming more popular t...

Background: Continuous subcutaneous insulin infusion (CSII) is established model for mimicking physiological insulin, which can overcome some of these barriers. CSII therapy is becoming more popular treatment modality in young people with T1D.Several studies have demonstrated the superiority of CSII over MDI therapy in T1D patients in terms of improved glucose control, the rate of hypoglycemia, dawn phenomenon and glucose variability Objective: To describe Continuous Subcutaneous Insulin Infusion (CSII) characteristics in young people with Type 1 Diabetes (T1D) with optimal glucose control and to describe possible simple CSII settings for fine tuning. Methods: This retrospective study was conducted at University Clinic of Endocrinology, Diabetes and Metabolic Disorders in Skopje. The study enrolled CSII patients with T1D (age 12-25 years) visited our center from January to December 2016. Patient characteristics were collected through the electronic medical record system and CSII characteristics were obtained from 8 weeks reports prior to Hba1c, generated by Carelink Therapy Management Software (Medtronic, Northridge, USA). Results: Ninety-three patients were grouped according age: 12-18 years and 19-25 years. More than 70% of patients achieved HbA1c <7.5% (<58 mmol/mol). Significant difference in basal insulin was found between two age groups. Patients aged 12-18 years had five basal segments, less basal rate in early morning (03-07h) and slight decrease of afternoon basal rate (13-19h), comparing with patients aged 19-25 years with four basal segments, more basal rate in early morning (03-07h) and no decrease of afternoon basal rate (13-19h). Conclusions: Optimal glucose control is achievable in real life conditions among T1D patients on CSII therapy. Bolus wizard, frequent bolusing, multiple basal segments, and close follow up can be determinants for better control. Simple CSII settings as a tool, derived from our data may help clinicians to fine tune T1D patients and achieve optimal glucose control. Clinical Trial: EN16-12

Continuous versus intermittent vital signs monitoring in patients admitted to surgical wards: a cluster-randomised, controlled trial

From: Journal of Medical Internet Research

Date Submitted: Apr 17, 2018

Open Peer Review Period: Apr 19, 2018 - Jun 14, 2018

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Background: Vital signs monitoring is a universal tool for the detection of postoperative complications, but unwell patients can be missed in between traditional observation rounds. New remote monito...

Background: Vital signs monitoring is a universal tool for the detection of postoperative complications, but unwell patients can be missed in between traditional observation rounds. New remote monitoring technologies promise to convey the benefits of continuous monitoring to patients on general wards. Objective: The aim of this study was to evaluate whether continuous remote vital signs monitoring is a practical, acceptable and effective way of monitoring surgical patients. Methods: A prospective, cluster-randomised, parallel-group, controlled study was performed. Patients admitted to two surgical wards at a large tertiary hospital received either continuous and intermittent vital signs monitoring, or intermittent monitoring alone. The primary outcome measure was time to administration of antibiotics in sepsis. Secondary outcome measures included length of hospital stay, 30-day readmission rate, mortality and patient acceptability. Results: 350 patients were recruited between January and June 2017. 140 patients received continuous remote monitoring and 210 received intermittent monitoring alone. On average, patients receiving continuous monitoring were administered antibiotics faster after evidence of sepsis, had a shorter average length of hospital stay and were less likely to require readmission within 30 days of discharge. Wide confidence intervals suggest these differences are not statistically significant. Patients found the monitoring device to be acceptable in terms of comfort and perceived an enhanced sense of safety. Conclusions: Remote continuous vital signs monitoring on surgical wards is practical and acceptable to patients. Large, well-controlled studies in high-risk populations are required to determine if the observed trends translate into a significant benefit for continuous over intermittent monitoring. Clinical Trial: The study was prospectively registered on the ISRCTN registry on 19th December 2016 under registry number ISRCTN60999823; URL: https://doi.org/10.1186/ISRCTN60999823.

Feasibility of Using an Automated Device (iThermonitor) for Continuous Temperature Monitoring in Pediatric Patients

From: JMIR Pediatrics and Parenting

Date Submitted: Apr 17, 2018

Open Peer Review Period: Apr 19, 2018 - Jun 14, 2018

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Background: Fever is an important vital sign and often the first one to be assessed in a sick child. In acutely ill children, caregivers are expected to monitor a child’s body temperature at home af...

Background: Fever is an important vital sign and often the first one to be assessed in a sick child. In acutely ill children, caregivers are expected to monitor a child’s body temperature at home after an initial medical consult. Fever literacy of many caregivers is known to be poor, and coupled with fever phobia, results in unnecessary healthcare utilization. In children with a serious illness, the responsibility of periodically monitoring temperature can add substantially to the already stressful experience of caring for a sick child. Objective: We conducted a pilot study to assess the feasibility of using the iThermonitor, an automated temperature measurement device, for continuous temperature monitoring in post-operative and post-chemotherapy pediatric patients. Methods: We recruited 25 patient-caregiver dyads from the Pediatric Surgery Department at the Massachusetts General Hospital (MGH), and the Pediatric Cancer Centers at the MGH & the Dana Farber Cancer Institute. Enrolled dyads were asked to use the iThermonitor device for continuous temperature monitoring over a 2-week period. Surveys were administered to caregivers at enrollment and at study closeout. Caregivers were also asked to complete a daily event monitoring log. The Generalized Anxiety Disorder-7 item (GAD-7) questionnaire was used to assess caregiver anxiety at enrollment and closeout. Results: 19 participant dyads completed the study. All 19 caregivers reported to have viewed temperature data on the study provided iPad tablet at least once per day, and more than a third did so 6 or more times per day. 74% of participants reported experiencing an out-of-range temperature alert at least once during the study. Majority of caregivers reported that it was easy to learn how to use the device, and that they felt confident about monitoring their child’s temperature with it. Only 21% of caregivers reported concurrently using a device other than the iThermonitor to monitor their child’s temperature during the study. Continuous temperature monitoring was not associated with an increase in caregiver anxiety. Conclusions: The iThermonitor is a highly feasible and easy to use device for continuous temperature monitoring in pediatric oncology and surgery patients. Clinical Trial: ClinicalTrials.gov Identifier: NCT02410252 (March 30, 2015)

Integrated decision support software and data feedback can improve sexual orientation recording, comprehensive sexual health testing and detection of infections among gay and bisexual men attending general practice

From: JMIR Medical Informatics

Date Submitted: Apr 17, 2018

Open Peer Review Period: Apr 18, 2018 - Jun 13, 2018

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Background: Gay and bisexual men are disproportionately affected by HIV and other sexually transmissible infections (STIs) yet opportunities for STI testing of this population are often missed or inco...

Background: Gay and bisexual men are disproportionately affected by HIV and other sexually transmissible infections (STIs) yet opportunities for STI testing of this population are often missed or incomplete in general practice settings. Strategies are needed for improving the uptake and completeness of sexual health testing in this setting. Objective: We evaluated an intervention centred around integrated decision support software and routine data feedback to improve the collection of sexual orientation data and increase sexual health screening among gay and bisexual men attending general practice. Methods: A study using before/after and case/comparison methods was undertaken to assess the interventions impact in seven Australian general practice clinics. The software was introduced in 2012 and used patient records to prompt clinicians to record sexual orientation and, along with pathology testing history, generated prompts when sexual health testing was overdue or incomplete. It also facilitated the routine extraction of clinical data, which was regularly reported to clinicians. We calculated summary rate ratios (SRRs) based on quarterly trends in the 12-month before and 24-month intervention periods and compared those to four comparison clinics that did not receive the intervention. Results: Among 32,276 attending male patients, sexual orientation recording increased 19% (from 47% to 56%) during the intervention period (SRR=1.10, P<0.001). Comprehensive STI testing increased by 89% during the intervention (26-49%; SRR=1.38, P<0.001). While comprehensive testing increased slightly in comparison sites, the increase was comparatively greater in intervention sites (SRR=1.12, P<0.001). There was also an increase in detection of chlamydia and gonorrhoea after the intervention’s introduction, which was not observed in the comparison sites. Conclusions: Integrated decision support software and data feedback were associated with modest increases in sexual orientation recording, comprehensive screening among gay and bisexual men, and the detection of STIs. Decision support software can be utilised to enhance the delivery of sexual health care in general practice. Clinical Trial: N/A

Evaluation of the Quality of Blood Pressure Tracking Applications for the iPhone: Consistency with Home Blood Pressure Measurement Best Practices

From: JMIR mHealth and uHealth

Date Submitted: Apr 18, 2018

Open Peer Review Period: Apr 20, 2018 - Jun 15, 2018

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Background: Blood pressure [BP] tracking apps may aid in hypertension self-management but app quality may be problematic. Objective: To develop a content-dependent rating system and review characteris...

Background: Blood pressure [BP] tracking apps may aid in hypertension self-management but app quality may be problematic. Objective: To develop a content-dependent rating system and review characteristics, tracking features, content-independent quality, and educational comprehensiveness of English language BP tracking apps for the iPhone. Methods: We created a 28-item checklist reflecting overall app quality, and a simplified 2-item checklist to assess consistency with home BP monitoring best practices. We searched the Canadian App Store on June 28th, 2016 using the keywords “hypertension” and “blood pressure.” Two reviewers independently assessed apps according to the standardized template. Apps with educational information were evaluated for comprehensiveness on a 7-point scale, and for consistency with evidence-based guidelines. Higher scores represent better quality and comprehensiveness. We determined if paid apps, educational apps, or those rated ≥4 stars were of higher quality. Results: Of 948 apps screened, 62 met the inclusion criteria. The mean overall quality was 12.2±4.6 and 6 apps (10 %) met BP monitoring best practice criteria. Twelve apps contained educational content (mean comprehensiveness: 2.3±1.6) most commonly, background information on hypertension. Apps with educational content [15.1±3.8 vs. 11.8±4.8 P=0.03] or a ≥4 star rating [17.4±3.6 vs. 12.0±4.6 p= 0.01] had higher overall quality. Conclusions: The included apps had variable quality. When deciding to recommend a specific BP tracking app, we suggest clinicians evaluate if the app allows input of duplicate BP readings for at least 7 days and presents the mean BP value for user specified dates. Greater attention to home BP measurement best practices is required during app development. Clinical Trial: Not Applicable

Perceptions of expertise in food hypersensitivity on social media: An email interview study

From: Journal of Medical Internet Research

Date Submitted: Apr 18, 2018

Open Peer Review Period: Apr 20, 2018 - Jun 15, 2018

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Background: Seeking and sharing information are primary uses of the internet and social media. It is therefore vital to understand the processes individuals go through when engaging with information o...

Background: Seeking and sharing information are primary uses of the internet and social media. It is therefore vital to understand the processes individuals go through when engaging with information on these diverse platforms; especially in areas such as health and risk-related information. One important element of such engagement is evaluating and attributing expertise to others. Objective: The study aimed to explore how meanings around expertise in relation to food allergy/intolerance (food hypersensitivity) were constructed by two groups of social media users; 1) those who use platforms for reasons relating to food hypersensitivity, and 2) those seen as experts by this community. Methods: Email interviews were conducted with food hypersensitive adults (n = 4), parents of food hypersensitive children (n = 4), and perceived experts in food hypersensitivity on social media (n = 5). Data were analysed thematically using Braun and Clarke’s approach. Results: The thematic analysis demonstrated that judging expertise on social media is a complex and multi-faceted process. Users might be judged as expert through their professional background, or their experience living with food hypersensitivities. How users behave on social media, and the traces of their online activity can influence how others will see them. Such considerations are both measured and moderated through the social media community itself. Findings highlighted how social media often acts as a supportive information tool following a diagnosis, but this also raised concerns if patients cannot access suitable vetted information. Conclusions: This work has implications for understanding how users perceive expertise on social media in relation to a health concern, and how information assessments are made during management of risks. Findings will prove beneficial to both medical and organisational stakeholders involved in the support of those living with life-changing conditions, such as food hypersensitivities.

Adaptation and implementation of a multinational eHealth intervention for people with cancer: Reflections from the field

From: JMIR Cancer

Date Submitted: Apr 18, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: An international shift in healthcare has seen an increasing focus on personalised, technology-enabled, in-home health interventions (eHealth interventions) that aim to improve patient outc...

Background: An international shift in healthcare has seen an increasing focus on personalised, technology-enabled, in-home health interventions (eHealth interventions) that aim to improve patient outcomes and patient-clinician communication. When tested on an international scale, the development and effectiveness of such interventions are dependent on collaborative work conducted by multidisciplinary teams to address a number of methodological and implementation considerations. Objective: To describe the processes undertaken in the preparation of an international, multi-centre randomised controlled trial that tested an eHealth intervention to enhance management of chemotherapy toxicity in people with cancer receiving adjuvant chemotherapy, via use of a mobile-phone, remote-monitoring symptom management system versus standard hospital care. Methods: Prospective, mixed-methods, involving consecutive, iterative stages of collaborative research work. Results: Testing across multiple European sites identified areas where the technology needed to be adapted, both clinically and technologically, in order to meet the diverse needs of the users within a European context prior to initiation of the RCT. Conclusions: Adapting and implementing this international, multicentre intervention required close attention to diverse considerations and unique challenges, primarily time and communication. Success was dependent on collaborative work among academics, technology industry, patients, and clinicians as well as a rigorous and iterative methodological approach to research.

Patient Perspectives on the Challenges and Responsibilities of Living with Chronic Inflammatory Diseases

From: Journal of Participatory Medicine

Date Submitted: Apr 18, 2018

Open Peer Review Period: Apr 19, 2018 - Jun 14, 2018

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Background: Collectively, chronic inflammatory diseases take a great toll on individuals and society in terms of participation restrictions, quality of life, and economic costs. Although many qualitat...

Background: Collectively, chronic inflammatory diseases take a great toll on individuals and society in terms of participation restrictions, quality of life, and economic costs. Although many qualitative studies have reported patients’ experiences and challenges living with inflammatory diseases, they are sometimes criticized as non-transferable due to small and highly specific samples. Larger-scale studies could verify patient perspectives across a broader sample and examine similarities in the patient experience across different types of inflammatory diseases. Objective: To identify the significant consequences of inflammatory arthritis, psoriasis, and inflammatory bowel diseases on daily life and explore commonalities across diseases. Methods: A cross-sectional online survey was designed by patient research partners and distributed by representatives of patient organizations via their social media channels and a newspaper story. One open-ended item asked about burdens and responsibilities experienced in daily life. Informed by narrative traditions in qualitative health research, we applied an iterative content analysis to participants’ written accounts in response to this item. This approach is an example of a study conceived, conducted, and interpreted with patients as research partners. Results: 636 Canadians submitted surveys, median age band 55-64 years, 80% women. 540 wrote substantive responses to the open-ended item. Four main narratives were identified: (1) daily life disrupted; (2) socio-economic vulnerabilities; (3) stresses around visible, invisible, and hiding disabilities; and (4) actions aimed at staying positive. Ways in which participants experienced social stigma, pain and fatigue, balancing responsibilities, and worries about the future appeared throughout all four narratives. Conclusions: People living with chronic inflammatory diseases affecting joints, skin, and digestive tract report important gaps between health, social, and economic support systems that create barriers to finding the services they need to sustain their health. Regardless of diagnosis, they report similar experiences navigating the consequences of lifelong conditions which has implications for policy makers. There is a need for outcomes measures in research and service delivery to address patient priorities, and for programs to fill gaps created by the artificial administrative separation of health services, social services, and income assistance.

Effectiveness of a technology-based supportive educational parenting program on parental outcomes in Singapore: A randomized controlled trial

From: Journal of Medical Internet Research

Date Submitted: Apr 19, 2018

Open Peer Review Period: Apr 20, 2018 - Jun 15, 2018

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Background: Transition to parenthood can be stressful to new parents in Singapore, especially with the lack of continuity of care from healthcare professionals during the postpartum period. Short hosp...

Background: Transition to parenthood can be stressful to new parents in Singapore, especially with the lack of continuity of care from healthcare professionals during the postpartum period. Short hospital stays limit the availability of support and time parents need to be well-equipped with parenting and infant care skills. Poor parental adjustment may in turn lead to negative parental outcomes and adversely affect the child’s development. Therefore, for the family’s future wellbeing and in order to facilitate smoother transition to parenthood, there is a need for easily accessible technology-based educational programs that can support parents during this crucial perinatal period. Objective: To examine the effectiveness of a technology-based supportive educational parenting program (SEPP) on parenting outcomes during the perinatal period. Methods: A randomized controlled pretest-posttest experimental study design was used. The study recruited 236 patients (118 couples) from an antenatal ward of a tertiary hospital. Eligible parents were randomly assigned to the intervention group (n = 118) or the control group (n = 118). The SEPP is based on Bandura’s self-efficacy theory and Bowlby’s theory of attachment. Components of the intervention include two telephone-based education sessions and a mobile-health application follow-up for one month. Outcome measures including parental bonding, parental self-efficacy, perceived social support, parenting satisfaction, postnatal depression, and anxiety were measured using reliable and valid instruments. Data were collected over 12 months (December 2016 to December 2017) at four timepoints: during pregnancy (third trimester), immediately postpartum, one month postpartum, and three months postpartum. A linear mixed methods analysis was used to compare the percentage change of all outcome variables. Results: The intervention group had statistically significant improvements for parental bonding [P < 0.001, 95%CI -4.78 – -3.90], parental self-efficacy [P < 0.001, 95% CI: 1.94 – 2.79], social support [P < 0.001, 95% CI: 2.78 – 3.47], parenting satisfaction [P < 0.001, 95% CI: 3.14 – 3.83], postnatal depression [P < 0.001, 95% CI: -3.93 – -3.15], and postnatal anxiety [P < 0.001, 95% CI: -3.65 – -2.85] at one month and three months postpartum compared to the control group. A cessation of the intervention at one month postpartum showed a decline in all parental outcomes. Conclusions: The technology-based SEPP is effective in improving parental bonding, parental self-efficacy, perceived social support, parental satisfaction, and parental bonding. Hence, nurses and midwives should incorporate it with existing hands-on parent-craft classes and routine care. Further studies should investigate the long-term effectiveness (beyond three months) of this program on parental outcomes. Clinical Trial: ISRCTN48536064

Detection of Cerebrovascular Disease with Mobile Application

From: JMIR mHealth and uHealth

Date Submitted: Apr 19, 2018

Open Peer Review Period: Apr 20, 2018 - Jun 15, 2018

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Background: The prevalence of cerebrovascular disease has gradually increased to become the second leading cause of death in the world. Magnetic resonance angiography (MRA) evaluates the intracranial...

Background: The prevalence of cerebrovascular disease has gradually increased to become the second leading cause of death in the world. Magnetic resonance angiography (MRA) evaluates the intracranial vessels without requiring invasive procedures. Objective: This study provides a novel anatomy cerebrovascular disease detection platform for mobile devices with Android systems that could be applied in the treatment of cerebrovascular disease, medical prevention, and health care. Methods: The system proposed herein can transfer information of a text, DICOM images, and the 3D cerebrovascular model from the server to the client. The platform design structure can be divided into five layers. The platform server was based on an event-driven mechanism and used an HTTP protocol to achieve faster and more effective data transmission. In addition, the client used a Model View Controller(MVC) model for platform development. Results: This study investigated the reliability and effectiveness of the platform and examined user-related questions. Forty students who represented common users and 21 doctors who represented professional users participated in the experiment. The results indicated that both common and professional users were satisfied with the platform usage. Conclusions: The experimental results implied that the platform could be a useful tool for detecting cerebrovascular disease and that it could be integrated into existing diagnosis methods and treatments. Furthermore, the platform could be extended to the detection of other diseases such as respiratory and cardiovascular diseases. Clinical Trial: ChiCTR-OCH-12002508

Evaluation of experience with the Jawbone UP2 activity tracker in an exercise program after breast cancer treatment

From: Journal of Medical Internet Research

Date Submitted: Apr 20, 2018

Open Peer Review Period: Apr 21, 2018 - Jun 16, 2018

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Background: There is growing evidence that physical activity is related to a better prognosis after a breast cancer diagnosis, whereas sedentary behavior is associated with worse outcomes. It is there...

Background: There is growing evidence that physical activity is related to a better prognosis after a breast cancer diagnosis, whereas sedentary behavior is associated with worse outcomes. It is therefore important to stimulate physical activity and reduce sedentary time among breast cancer patients. Activity trackers offer a new opportunity for interventions directed at stimulating physical activity behavior change. Objective: This study explored the experience of breast cancer patients who used an activity tracker in addition to a supervised exercise intervention in the randomized UMBRELLA Fit trial. Methods: Ten patients with breast cancer who completed cancer treatment participated in semi-structured in-depth interviews about their experience with and suggestions for improvements for the Jawbone UP2 activity tracker. Results: The activity tracker motivated women to be physically active and created more awareness of their (sedentary) lifestyles. The women indicated that the automatically generated advice (received via the UP app) lacked individualization and was not applicable to their personal situations (i.e., having been treated for cancer). Furthermore, women felt that the daily step goal was one-dimensional and they preferred to incorporate other physical activity goals. The activity tracker’s inability to measure strength exercises was a noted shortcoming. Finally, women valued personal feedback about the activity tracker from the physiotherapist. Conclusions: Wearing an activity tracker raised lifestyle awareness in breast cancer patients. The women also reported additional needs not addressed by the system. Potential improvements include a more realistic total daily physical activity representation, personalized advice, and personalized goals.

Investigating the Dynamics of Health Agency Response and Public Engagement during Public Health Emergency: A Case Study of CDC Tweeting Pattern during 2016 Zika Epidemic in the U.S.

From: JMIR Public Health and Surveillance

Date Submitted: May 10, 2018

Open Peer Review Period: May 21, 2018 - Jun 4, 2018

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Background: Social media have been increasingly adopted by health agencies and professionals to disseminate information, interact with public, and understand public opinion. Among them, the Centers fo...

Background: Social media have been increasingly adopted by health agencies and professionals to disseminate information, interact with public, and understand public opinion. Among them, the Centers for Disease Control and Prevention (CDC) is arguably one of the first government health agencies to adopt social media during health emergencies and crisis. It had been active on Twitter during the 2016 Zika epidemic that caused 5,168 domestic cases in the United States. Objective: This study aims to quantify the temporal variabilities in CDC’s tweeting activities over the course of Zika epidemic, public engagement in these CDC-initiated tweets (i.e., retweets and replies), and Zika case counts. It then compares the patterns of these three sets of data to identify the discrepancy and consistency among actual domestic Zika case counts, CDC response on Twitter, and public engagement in this topic. Methods: All of the CDC-initiated tweets published in 2016 with corresponding retweets and replies were collected from 67 CDC-associated Twitter accounts. Both univariate (ARIMA model) and multivariate time series analyses (CCF, mutual Shannon information entropy, ARIMAX model, Granger test) were performed in each quarter of 2016 for domestic Zika case counts, CDC tweeting activities, and public engagement in the CDC-initiated tweets. Results: CDC sent out more than 84% of its Zika tweets in the first quarter of 2016 when Zika case counts were low in the 50 U.S. states and territories. While Zika case counts increased dramatically in the second and the third quarters, CDC efforts on Twitter plunged. Time series of public engagement in the CDC-initiated tweets generally differed among quarters and from that of original CDC tweets based on ARIMA model parameters. Original CDC tweets and public engagement both had highest mutual information with Zika case counts in the 2nd quarter. Public engagement in the original CDC tweets was also substantially influenced by and preceded actual Zika epidemic. Conclusions: There were substantial discrepancies among CDC’s original tweets regarding Zika, public engagement in these tweets, and actual Zika epidemic. The patterns of these discrepancies also varied between different quarters in 2016. We discovered that although CDC was very effective in early warning of Zika in the first quarter of 2016, it failed to respond in a timely manner on Twitter during the rest of the Zika epidemic. Public engagement in CDC’s original tweets served as a more prominent predictor of actual Zika epidemic than number of CDC’s original tweets later in the year.

Accuracy of Wearables During a Continuous and Ecologically Valid 24-Hour Period That Approximates Actual Consumer Device Use Conditions Within an Individual.

From: Journal of Medical Internet Research

Date Submitted: Apr 19, 2018

Open Peer Review Period: Apr 21, 2018 - Jun 16, 2018

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Background: Wrist-worn smart watches and fitness monitors (i.e., wearables) have become widely adopted by consumers and are gaining increased attention from researchers for their potential contributio...

Background: Wrist-worn smart watches and fitness monitors (i.e., wearables) have become widely adopted by consumers and are gaining increased attention from researchers for their potential contribution to digital measurement of health in a scalable, and ecologically valid way. Various studies have begun to examine the accuracy of these devices in controlled laboratory settings (e.g., treadmill, stationary bike), yet no studies to date have investigated the accuracy of wearables during a continuous and ecologically valid 24-hour period that approximates actual consumer device use conditions. Objective: The goal of the present study was to determine the accuracy of two popular wearable devices, the Apple Watch 3 and Fitbit Charge 2, to assess heart rate accuracy as compared to the gold-standard reference method for real-world settings, an ambulatory electrocardiogram (ECG). Data was collected across five daily conditions, including sitting, walking, running, daily activities (e.g., cleaning, chores, work transitions), and sleeping. Methods: One participant, (BN; 29-year-old Caucasian male) completed a 24-hour ecologically valid protocol by wearing two of the most popular wrist wearable devices (Apple Watch 3 and Fitbit Charge 2). In addition, an ambulatory ECG (Vrije Universiteit Ambulatory Monitoring System) was used as the reference method during a normal day, which resulted in the collection of 102,740 individual heart beats. A single subject design was used to keep all variables constant except for wearable devices. Accuracy of these devices compared to the gold-standard ECG was assessed using percent error, Bland-Altman analyses, and concordance class correlation to assess agreement between devices. Results: The Apple Watch 3 and Fitbit Charge 2 were generally highly accurate across the overall 24-hour condition. Specifically, the Apple Watch 3 had a mean difference of -1.80 bpm, a mean error percent of -2.25%, and a mean agreement of 95% when compared to the ECG across 24 hours. The Fitbit Charge 2 had a mean difference of -3.47 bpm, a mean error of -4.25%, and a mean agreement of 91% when compared to the ECG across 24 hours. These findings varied by condition. Conclusions: The Apple Watch 3 and the Fitbit Charge 2 provided acceptable heart rate accuracy overall across a 24 hour continuous and ecologically valid period as compared to the gold-standard ECG, although during some conditions and devices error rose past the 5% acceptable error rate and some individual measurements were significantly erratic. Overall, these devices appear to be useful for implementing as ambulatory measures of cardiac activity in research studies, especially those where the specific advantages of these methods (e.g., scalability, low participant burden) are particularly suited to the population or research question.

“It's not just technology, it's people”: A Conceptual Model of Shared Health Informatics for chronic illness

From: Journal of Medical Internet Research

Date Submitted: Apr 19, 2018

Open Peer Review Period: Apr 21, 2018 - Jun 16, 2018

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Background: Chronic illness is a substantial public health burden and the day-to-day work of a person with chronic illness is central to illness management. However, although management programs are a...

Background: Chronic illness is a substantial public health burden and the day-to-day work of a person with chronic illness is central to illness management. However, although management programs are available to train people to manage their chronic illnesses, those programs rarely provide people with sufficient guidance on implementing fine-grained management strategies. This lack of guidance transfers much of the burden of day-to-day management practices to people with chronic illness. Objective: To decrease the management burden many people have created technological solutions, but we claim that to be maximally effective and tailored to people’s needs, those solutions need to be informed by a model that integrate patient work and self-management frameworks with personal health informatics models. We see an opportunity to improve personal health informatics models to (1) incorporate the ongoing nature of management work, and (2) append a social dimension to more accurately depict the context of illness management. Methods: We used qualitative methods to analyze the chronic illness management practices of 63 people through the lenses of self-management and informatics frameworks. Results: Analysis results are distilled into a new Conceptual Model of Shared Health Informatics. We describe the people and work involved in chronic illness management and contribute a Conceptual Model of Shared Health Informatics depicting the process of chronic illness management in a social context. Conclusions: Through insight into management work provided by our Conceptual Model of Shared Health Informatics, technology designers and implementers can improve the quality of chronic illness management tools to ensure confident and capable management of chronic illness.

Online Health Information Seeking and eHealth Literacy among Primary Care Patients: a Cross-sectional Survey in Hong Kong

From: Journal of Medical Internet Research

Date Submitted: Apr 23, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: Online health information seeking by patients was shown to affect medical consultations and patient-doctor relationships. An up-to-date picture of patients’ online health information see...

Background: Online health information seeking by patients was shown to affect medical consultations and patient-doctor relationships. An up-to-date picture of patients’ online health information seeking behaviors can inform and prepare frontline healthcare professionals to collaborate, facilitate or empower patients to access and manage health information online. Objective: This study explores the prevalence, patterns, and predictors of online health information seeking behaviors among primary care patients in Hong Kong, and the associations between online health information seeking and eHealth literacy. Methods: Patients attending a university primary care clinic in Hong Kong were asked to complete a questionnaire survey on their demographic backgrounds; health status; frequency and pattern of online health information seeking; contents, sources, and reasons of online health information seeking, and their eHealth literacy. eHealth literacy was measured by the validated eHealth Literacy Scale (eHEALS). Independent-samples t-tests were performed to examine the association between eHealth literacy and respondent characteristics, and between eHealth literacy and source of online health information. A hierarchical multiple regression analysis explored various demographics and behavioral predictors to online health information seeking. Results: 97.3% (1162/1194) respondents used the Internet, of which 87.4% (1016/1162) had used the Internet to find health information. Most respondents (66.0%, 665/1008) searched once monthly or more. Few (26.7%, 271/1016) asked their doctor about health information found online, but most doctors (56.1%, 152/271) showed little or no interest at all. The most sought topic was symptom (81.6%, 829/1016), the top reason was noticing new symptoms or change in health (70.1%, 712/1016), the most popular source is online encyclopedia (70.0%, 711/1016), and the top reason for choosing a source was convenience (55.4%, 563/1016). Hierarchical multiple regression identified eHEALS score, fair or poor self-rated health, senior job rank, having chronic medical condition, and using the Internet daily or more as significant predictors to online health information seeking. Respondents choosing authoritative websites for health information were associated with higher eHEALS score. Conclusions: OHIS is prevalent among primary care patients in Hong Kong, but only a minority shared the information with doctors. Higher eHealth literacy was associated with using authoritative websites. Doctors should recognize, facilitate and empower patients for OHIS.

Characterizing tweet volume and content about common health conditions across Pennsylvania

From: Journal of Medical Internet Research

Date Submitted: Apr 20, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: Tweets can provide broad, real time perspectives about health and medical diagnoses that can inform disease surveillance in geographic regions. Less is known however about how much individ...

Background: Tweets can provide broad, real time perspectives about health and medical diagnoses that can inform disease surveillance in geographic regions. Less is known however about how much individuals post about common health conditions or what they post about. Objective: We sought to collect and analyze tweets from one state about high prevalence health conditions and characterize tweet volume and content. Methods: We collected 408,296,620 tweets originating in Pennsylvania from 2012-2015 and compared the prevalence of 14 common diseases to the frequency of disease mentions on Twitter. We identified and corrected bias induced due to variance in disease term specificity and used the machine learning approach of differential language analysis to determine the content (words and themes) most highly correlated with each disease. Results: Common disease terms were included in 226,802 tweets. Posts about breast cancer (22.5% messages, 2.4% prevalence) and diabetes (23.1% messages, 17.2% prevalence) were overrepresented on Twitter relative to disease prevalence, while hypertension (9.9% messages, 36.3% prevalence), COPD (0.9% messages, 8.5% prevalence), and heart disease (7.8% messages, 19.4% prevalence) were underrepresented. The content of messages also varied by disease. Personal experience messages accounted for 12% of prostate cancer tweets and 24% of asthma tweets. Awareness themed tweets were more often about breast cancer (23%) than asthma (6%). Tweets about risk factors were more often about heart disease (10%) than lymphoma (2%). Conclusions: Twitter provides a window into the online visibility of diseases and how the volume of online content about diseases varies by condition. Further, the potential value in tweets is in the rich content they provide about individuals’ perspective about diseases (e.g. personal experiences, awareness, risk factors) that are not otherwise easily captured through traditional surveys or administrative data.

A multi-centre pragmatic randomized controlled trial of a web-based mental health platform in individuals seeking specialized mental health care services

From: Journal of Medical Internet Research

Date Submitted: Apr 20, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: Web-based self-directed mental health applications are rapidly emerging as a solution to health service gaps and unmet needs for information and support. Objective: The aim of this study w...

Background: Web-based self-directed mental health applications are rapidly emerging as a solution to health service gaps and unmet needs for information and support. Objective: The aim of this study was to determine if a multi-component web-based moderated mental health application could benefit individuals with mental health symptoms severe enough to warrant specialized mental health care. Methods: A multi-centre, pragmatic randomized controlled trial was conducted across several outpatient mental health programs affiliated with 3 hospital programs in Ontario, Canada. Individuals referred to or receiving treatment, 16 years of age or older, with access to the internet and an email address, and having the ability to navigate a web-based mental health application were eligible. 812 participants were randomized 2:1 to receive immediate (ITG) or delayed (DTG) access for 3 months to the Big White WallTM, a web-based multi-component mental health intervention based in the United Kingdom and New Zealand. The primary outcome was total score on the Recovery Assessment Scale, revised (RAS-r) measuring mental health recovery. Secondary outcomes were total scores on the Patient Health Questionnaire-9 item (PHQ-9), the Generalized Anxiety Disorder Questionnaire-7 item (GAD-7), the EQ-5D-5L, and the Community Integration Questionnaire (CIQ). An exploratory analysis examined the association between actual BWW use (categorized into quartiles) and outcomes among study completers. Results: Intervention participants achieved small, statistically significant increases in adjusted RAS-r score (4.97 points, 95% CI 2.90 to 7.05), and decreases in PHQ-9 score (-1.83 points, 95% CI -2.85 to -0.82) and GAD-7 score (-1.55 points, 95% CI -2.42 to -0.70). Follow-up was achieved for 446 (55%) at 3 months; 48% of ITG participants, and 69% of DTG participants. Only 58% of ITG participants logged on more than once. Some higher BWW user groups had significantly greater improvements in PHQ-9 and GAD-7 relative to the lowest use group. Conclusions: The web-based application may be beneficial, however, many participants did not engage in an ongoing way. This has implications for patient selection and engagement as well as delivery and funding structures for similar web-based interventions. Clinical Trial: Clinicaltrials.gov NCT02896894. Registered on 31 August 2016 (retrospectively registered). https://clinicaltrials.gov/ct2/show/NCT02896894

Virtual Reality Clinical Research: Promises and Challenges

From: JMIR Serious Games

Date Submitted: Apr 21, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Virtual Reality (VR) therapy has been explored as a therapeutic approach in a number of medical applications, where three dimensional virtual environments can be explored in real time. Some significan...

Virtual Reality (VR) therapy has been explored as a therapeutic approach in a number of medical applications, where three dimensional virtual environments can be explored in real time. Some significant successes have been claimed. A number of studies have asserted positive outcome for patients using VR for clinical conditions such as anxiety disorders, addictions, phobias, post-traumatic stress disorder, eating disorders, stroke rehabilitation, and pain management. Nevertheless, the implementation of clinical VR research outside of the laboratory presents many clinical challenges. This paper explores some of the key issues in implementing clinical VR research including theoretical ambiguity and immaturity, a lack of technical standards, problems of media vs. medium, practical in-vivo issues and costs. It is argued that careful attention to addressing these issues in research design and pilot studies are needed, in order to make clinical VR research more rigorous and meaningful.

Development of an Educational Program to Increase Patient Involvement in a Healthcare Patient Portal: A Quality Improvement Project

From: JMIR Medical Informatics

Date Submitted: Apr 20, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: Efforts in the United States to improve patient engagement and communication with health care providers have led to the creation of the meaningful use program. [1] The Centers for Medicare...

Background: Efforts in the United States to improve patient engagement and communication with health care providers have led to the creation of the meaningful use program. [1] The Centers for Medicare and Medicaid Services have created a three-stage process to encourage the adoption and use of electronic health records (EHR). Benefits of EHR use include the ability to provide accurate, up-to-date, legible, and complete information about patients at the point of care. One important component of EHR is the patient portal. Patient portals provide 24-hour access to portions of a patient medical record as well as a secure pathway to send messages to providers, ask for refills of medications, and schedule appointments. Objective: To assess if patients who have not used the patient portal will engage in using the portal after an in-office orientation on how to access and the benefits of using the patient portal. Methods: A quality improvement project was performed using a convenience sample of 60 participants who were scheduled for an appointment in an outpatient cardiology office and had not accessed the patient portal in the past 12 months. The participants were given a survey regarding their computer and internet access as well as their level of comfort using a computer. Each participant was assisted in creating a username and password as well as a security question and answer. The participant then accessed the portal and navigated through the portal with the guidance of the nurse practitioner. They also sent a message via the portal to the provider they were assigned to that day. Each participant was given a pamphlet and a printed power point to reinforce what they had learned. After two months, the nurse practitioner accessed the portal to determine if the enrolled participants had accessed the portal. The reasons for access and frequency were recorded. If there was no access, the participant was called by the nurse practitioner to determine the reason they had not accessed the portal. Results: Of the 60 participants, 54% were women, 46% men, 93% were Caucasian. Fifty-six point seven accessed the portal from home. Reasons for access included: 85% reviewed labs, 53% reviewed messages sent to them from the office and 23% sent messages to the office. Twenty-four participants did not access the portal. Of those participants, 33% stated that they had no clear reason to access the portal, 25% stated that they forgot their login information and 17% stated they no interest in the portal. Conclusions: Patient portals are a useful tool for communication between patients and their providers. Providing an in-office orientation to the portal increased patient access to the portal.

Piloting and Evaluation of Text-Based Illness Monitoring for Detection of Novel Influenza A Virus Infections during an Influenza A(H3N2)v Virus Outbreak in Michigan, 2016

From: JMIR Public Health and Surveillance

Date Submitted: May 11, 2018

Open Peer Review Period: May 21, 2018 - Jun 4, 2018

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Background: Rapid reporting of human infections with novel influenza A viruses accelerates detection of viruses with pandemic potential and implementation of effective public health responses. After d...

Background: Rapid reporting of human infections with novel influenza A viruses accelerates detection of viruses with pandemic potential and implementation of effective public health responses. After detection of human infections with influenza A(H3N2) variant viruses (“H3N2v”) associated with agricultural fairs during August of 2016, the Michigan Department of Health and Human Services worked with Centers for Disease Control and Prevention (CDC) to identify infections with variant influenza viruses using a text-based illness monitoring system. Objective: To enhance detections of influenza infections using text-based monitoring and evaluate the feasibility and acceptability of the system for use in future outbreaks of novel influenza viruses. Methods: During an outbreak of H3N2v virus infections among agricultural fair attendees, we deployed text-illness monitoring (TIM) to conduct active illness surveillance among households of youth who exhibited swine at fairs. We selected fairs with suspected H3N2v virus infections and fairs without suspect infections that met predefined criteria. Eligible respondents were identified and recruited through email outreach and/or on-site meetings at fairs. During and for 10 days after selected fairs, enrolled households received daily, automated text-messages inquiring about illness; reports of illness were investigated by local health departments. To understand the feasibility and acceptability of the system, we monitored enrollment and trends in participation and distributed a web-based survey to households of exhibitors from 5 fairs. Results: Among an estimated 500 households with a member who exhibited swine at one of 9 selected fairs, representatives of 87 (17%) households were enrolled, representing 392 household members. For fairs that were ongoing when TIM was deployed, the number of respondents peaked at 56 on the third day of the fair and then steadily declined throughout the rest of the monitoring period; 26 (30%) of 87 household representatives responded through the end of the 10-day monitoring period. We detected 2 H3N2v virus infections using TIM, which represents 17% (2/12) of all H3N2v virus infections detected during this outbreak in Michigan. Of the 70 survey respondents, 16 (23%) had participated in TIM. Of those, 73% (11/15) participated because it was recommended by fair coordinators and 80% (11/15) said they would participate again. Conclusions: Using a text-message system, we were able to monitor a large number of individuals and households for illness and detected H3N2v virus infections through active surveillance. Text-based illness monitoring systems are useful to detect novel influenza virus infections when active monitoring is deemed necessary. Participant retention and testing of persons reporting illness are critical elements for system improvement.

Effects of a Mindfulness-Meditation App on Subjective Well-Being: An Active Randomized Controlled Trial and Experience Sampling Study

From: Journal of Medical Internet Research

Date Submitted: Apr 20, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: Mindfulness training (MT) includes a variety of contemplative practices aimed at promoting intentional awareness of experience, coupled with attitudes of non-judgment and curiosity. Follow...

Background: Mindfulness training (MT) includes a variety of contemplative practices aimed at promoting intentional awareness of experience, coupled with attitudes of non-judgment and curiosity. Following the success of 8-week, manualized, group interventions, MT has been implemented in a variety of modalities, including smartphone applications that seek to replicate the success of group interventions. However, while smartphone apps are scalable and accessible to a wider swath of population, their benefits remain largely untested. Objective: The present study investigated a newly developed MT application called Wildflowers, which was co-developed with the lab for use in mindfulness research. It was hypothesized that MT through this application would improve subjective well-being, attentional control, and interoceptive integration, albeit with weaker effects than those published in the group intervention literature. Methods: Undergraduate students completed 3-weeks of MT with Wildflowers (n = 45), or 3-weeks of mathematical problem-solving training with a game called 2048 (n = 41). State training effects were assessed through pre- and post-session ratings of current mood, stress level, and heart rate. Trait training effects were assessed through pre- and post-intervention questionnaires canvassing subjective well-being, and behavioural task measures of attentional control and interoceptive integration. State and trait training data were analyzed in a multilevel model, using emergent latent factors (acceptance, awareness, openness) to summarize the trait questionnaire battery. Results: Analyses revealed both state and trait effects specific to MT; participants engaging in MT demonstrated improved mood (r = 0.14) and a reduction of stress (r = -0.13) immediately after each training session compared to before the training session, and decreased post-session stress over 3-weeks (r = -0.08). Additionally, MT relative to math training resulted in greater improvements in attentional control (r = -0.24). Interestingly, both groups demonstrated increased subjective ratings of awareness (r = 0.28) and acceptance (r = 0.23) from pre- to post-intervention, with greater changes in acceptance for the MT group trending (r = 0.21). Conclusions: MT using a smartphone app may provide immediate effects on mood and stress while also providing long-term benefits for attentional control. Although further investigation is warranted, there is evidence that with continued usage, MT via a smartphone app may provide long-term benefits in changing how one relates to their inner and outer experiences. Clinical Trial: This study was not registered at ClinicalTrials.gov, but the study protocol matches that of the REB approval acquired prior to the study trial.

Effects of a theta/SMR neurofeedback training protocol on measures of impulsivity, drug craving and substance abuse in forensic psychiatric patients with substance abuse: a randomized controlled trial

From: JMIR Mental Health

Date Submitted: Apr 24, 2018

Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

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Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination...

Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination of psychiatric disorders and SUD increases the risk of future violence. Chronic substance abuse can lead to a structural state of disinhibition, resulting in more drug taking and eventually loss of control over drug intake. When treating SUD, it is crucial to address high levels of impulsivity and lack of inhibitory control. Objective: The current study set out to investigate the effects of a theta/Sensorimotor rhythm (SMR) neurofeedback training protocol on levels of impulsivity, levels of drug craving and actual drug intake in a population of forensic psychiatric patients with a diagnosis of SUD. Methods: 21 participants received 20 sessions of SMR/theta neurofeedback training in combination with treatment as usual (TAU). Results were compared to 21 participants who received TAU only. Results: SMR magnitude showed a significant (P = .02) increase post-training for patients in the neurofeedback training group, whereas theta magnitude did not change (P >.05). Levels of drug craving as well as scores on the ‘motor’ subscale of the BIS-11 decreased equally for patients in the neurofeedback training group and the TAU group. Other measures of impulsivity, as well as drug intake, did not change post-treatment (P > .05). Therefore, neurofeedback + TAU was not more effective than TAU only. Conclusions: The current study demonstrated evidence that forensic psychiatric patients are able to increase SMR magnitude over the course of neurofeedback training. However, at the group level, the increase in SMR activity was not related to any of the included impulsivity or drug craving measures. Further research should focus on which patients will be able to benefit from neurofeedback training at an early stage of the employed training sessions. Clinical Trial: Dutch National Trial Register NTR5386; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5386 (Archived by WebCite at http://www.webcitation.org/6nXLQuoLl)

Daily Smartphone Overdependence Screening Model using Support Vector Machine

From: Journal of Medical Internet Research

Date Submitted: Apr 23, 2018

Open Peer Review Period: Apr 23, 2018 - Jun 18, 2018

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Background: Smartphone overdependence has caused many social problems. To overcome these problems, it is necessary to screen and identify smartphone overdependence before it becomes a serious issue. O...

Background: Smartphone overdependence has caused many social problems. To overcome these problems, it is necessary to screen and identify smartphone overdependence before it becomes a serious issue. Objective: We aimed to developed a daily smartphone overdependence screening model using a Support Vector Machine (SVM). Methods: We used smartphone application usage time and frequency data from 224 participants whose ages ranged from their 20s to their 40s. We classified the participants into two groups the smartphone usage control group (SUC) and the smartphone usage disorder addiction group (SUD) using the Korean Smartphone Addiction Proneness Scale (K-SAPS) for Adults. We built a 3-dimensional tensor as the input of machine learning training. This study used the SVM to develop a daily smartphone overdependence screening model. We compared the model performance between the SVM, the Artificial Neural Network(ANN) and the Logistic Regression. Results: We identified the frequency of smartphone application usage, age, and marital status as the dominant features of screening smartphone overdependence. Using these features as the inputs of the SVM machine learning model showed a 90% of accuracy for the smartphone overdependence screening. Conclusions: We developed a SVM model, which is a tool for self-control of smartphone daily usage. As a pre-testing tool before visiting a mental health clinic. The SVM model is a powerful analysis method for smartphone overdependence screening. Notably, psychiatry studies have used the SVM when identifying a psychiatric disease. We suggest using the SVM model for smartphone overdependence screening as a smartphone application or intervention system for smartphone dependency management.

Consumers’ Gender Difference in Communicating with Doctors on Social Media: Survey Study

From: JMIR mHealth and uHealth

Date Submitted: Apr 23, 2018

Open Peer Review Period: Apr 24, 2018 - Jun 19, 2018

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Background: Social media is becoming more and more important for communication between doctors and consumers. However, little is known about the effect of doctor-consumer communication on consumers’...

Background: Social media is becoming more and more important for communication between doctors and consumers. However, little is known about the effect of doctor-consumer communication on consumers’ health information seeking intention. Meanwhile, gender difference in the effect of doctor-consumer communication has not been studied well. Objective: The purpose of this study is to investigate how doctor-consumer communication on social media affects consumers’ health information seeking intention and whether this association is moderated by gender. Methods: Based on professional-client interaction theory and social role theory, we propose that doctor-consumer communication can be divided into instrumental and affective communication. These two types of communication influence consumers’ health information seeking intention through trust towards doctors. We also argue that the relationship between doctor-consumer communication and trust towards doctors could be moderated by gender. To validate our proposed research model, we employed the survey method and developed corresponding measurement instruments for constructs in our research model. 352 valid answers were collected from consumers who have experience of communicating with doctors on social media. To analyze the data, partial least square was performed. Results: Trust towards doctors was found to influence consumers’ health information seeking intention significantly (t=16.881, P<0.001), while both instrumental (t=6.083, P<0.001) and affective communication (t=5.745, P<0.001) between doctors and consumers on social media influence trust towards doctors significantly. Towards the moderation effect of gender, the effect of both instrumental (t=12.87, P<0.001) and affective communication (t=7.3, P<0.001) on trust towards doctors is greater for females than for males. Conclusions: This study not only demonstrates the effect of doctor-consumer communication on social media on consumers’ health information seeking intention, but also uncovers the role of gender in the impact of doctor-consumer communication. To consider the different genders in doctor-consumer communication on social media, we can understand the effect of doctor-consumer communication on social media on consumers’ health information seeking behavior better and deeper.

Impact of Activity Monitors on Quantification of Physical Activity - A Systematic Review & Meta-Analysis

From: Interactive Journal of Medical Research

Date Submitted: Apr 26, 2018

Open Peer Review Period: Apr 27, 2018 - Jun 22, 2018

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Background: Utilization of several research and consumer grade activity monitors for quantification of Physical Activity has created an uncertainty due to imprecise measurement. Objective: The aim of...

Background: Utilization of several research and consumer grade activity monitors for quantification of Physical Activity has created an uncertainty due to imprecise measurement. Objective: The aim of this analysis was to determine the impact of different activity monitors for quantifying PA among the sedentary population for accurate measurement of EE, MET and Temporospatial parameters of Gait Methods: 8 databases were searched from 2010 till present out of which only 16 articles were selected for qualitative (n=9) and quantitative (n=7) analysis. Accelerometers with sedentary lifestyle population was selected with TSPs, EE, MET, 6MWT as outcome measures. Quality assessment was conducted using Tool for assessing risk of bias considering Cochrane Collaboration. Accelerometers were categorized into a) actigraphy, b) activPAL c) mixed accelerometers, d) New generation accelerometers Results: Out of 105 studies only 16 studies (2542 participants) met the inclusion criteria. The result obtained from the quantitative analysis of study shows that activPAL had more validity than any of the other accelerometers for the quantification of the Physical Activity in free living environment for sedentary behavior with the pooled effect of 0.966 under fixed effect model followed by new generation accelerometers 0.771, mixed accelerometers 0.71 and actiGraph older generation 0.682. Conclusions: Evidences presented in the paper reveals that a paradigm shift has been seen from subjective measurement approach to objective measurement due to availability of several types of accelerometers. activPAL has found to effective in quantification of PA during life style behaviors

Baby Boomer Perceptions of Diabetes Online Community Credibility, Social Capital, Help and Harm is Similar to Younger Adults

From: JMIR Aging

Date Submitted: Apr 25, 2018

Open Peer Review Period: Apr 26, 2018 - Jun 21, 2018

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Background: Background: The use of online health communities such as the diabetes online community (DOC) is growing. Individuals who engage in the diabetes online community (DOC) are able to interact...

Background: Background: The use of online health communities such as the diabetes online community (DOC) is growing. Individuals who engage in the diabetes online community (DOC) are able to interact with peers who have the same medical condition. It is not known if older adults are perceiving the DOC differently than younger adults. Objective: Objective: The purpose of this study was two-fold: 1) to describe social capital, perceived source credibility, help and harm among DOC users, and 2) to examine differences in social capital, perceived source credibility, help and harm among baby boomer (born between 1946 and 1964) and younger adult (born between 1965-1996) DOC users. Methods: Methods: This study represents a subset of participants from a larger study of DOC users. Adults with diabetes were recruited from the DOC to participate in a cross-sectional survey. Baby boomer and younger adult demographics, eHealth use (reasons to join the DOC, DOC intensity, DOC engagement, internet social capital, and help or harm from the DOC), source credibility, health-related quality of life, and diabetes self-care were collected. We examined relationships between variables and examined differences between baby boomers and younger adults. Results: Results: Baby boomers (N=76) and younger adult counterparts (N=102) participated in this study. Participants scored their diabetes healthcare team (M=33.5, SD=8) significantly higher than the DOC (M=32, SD=6.4) with regard to competence (p<.05) and trustworthiness (diabetes healthcare team, M=36.3, SD=7.1; DOC M=33.6, SD=6.2; p<.001). High bonding and bridging social capital correlated with high DOC intensity (r=.629, p<.001 and r=.676, p<.001 and respectively) and high DOC engagement (r=.474, p<.01 and r=.507, p=<.01 and respectively). The greater majority (69.8%) reported the DOC as being helpful and 1.8% reported the DOC had caused minor harm. Baby boomers perceive DOC credibility, social capital, help and harm similarly to their younger adult counterparts. Conclusions: Conclusions: Baby boomers are using and perceiving the DOC similarly to younger adults. DOC users find the DOC to be credible, however, scored their healthcare team higher with regards to competence and trustworthiness. The DOC is beneficial with low risk and may augment current diabetes care.

Mobile Device Use among Rural, Low-Income Families and the Feasibility of an App to Encourage Preschooler’s Physical Activity: A Qualitative Study

From: JMIR Formative Research

Date Submitted: Apr 24, 2018

Open Peer Review Period: Apr 24, 2018 - Jun 19, 2018

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Background: As mobile devices are becoming ubiquitous, technology-based interventions provide a promising strategy to positively influence health behaviors of families with young children. However, qu...

Background: As mobile devices are becoming ubiquitous, technology-based interventions provide a promising strategy to positively influence health behaviors of families with young children. However, questions remain about the feasibility and acceptability of intervention delivery via mobile apps in low-income, rural settings and among families with preschoolers. Objective: The aims of this study were to understand the content and context of preschooler’s mobile device; explore parent beliefs on this topic, including the acceptability of intervention delivery via mobile devices; and to test a prototype of an app to encourage preschoolers’ physical activity with both parents and children. Methods: Parents (n=29) were recruited from five preschool centers in eastern, rural Colorado to complete a semi-structured telephone interview regarding preschooler’s mobile device use. A second sample of parents (n=31) were recruited from the same preschool centers to view the app prototype independently and provide feedback. A third sample of preschool children (n=24) were videotaped using the app in small groups to measure engagement and record their responses to the app. Results: Five key content areas emerged from the telephone interviews: 1) mobile devices are an important part of families’ everyday routines and parents have parameters governing their use; 2) parents often use mobile devices as a tool for behavior management; 3) parents clearly distinguish between mobile device use for learning vs entertainment; 4) parents have an overarching desire for balance in regards to their child’s mobile device use; and 5) parents were generally supportive of the idea of using mobile apps for intervention delivery. From the app prototype testing with parents, participants reacted positively to the app and felt that it would be useful in a variety of situations. Testing with preschoolers showed the children were highly engaged with the app and on average, moved actively for 74% of the movement time, or just over 2 minutes, each time they used the app. Conclusions: Mobile devices are already integrated into most families’ daily routines and appear to be an acceptable method of intervention delivery in low-income, rural, Colorado families. The physical activity app represents an innovative way to reach these families and, with further improvements based on participant feedback, will provide children a unique opportunity to practice key movement skills.

Technology-based alcohol interventions in primary care: A systematic review

From: Journal of Medical Internet Research

Date Submitted: Apr 23, 2018

Open Peer Review Period: Apr 24, 2018 - Jun 19, 2018

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Background: Primary care settings are uniquely positioned to reach individuals at-risk of alcohol use disorder through technology-delivered behavioral health interventions. Despite emerging effectiven...

Background: Primary care settings are uniquely positioned to reach individuals at-risk of alcohol use disorder through technology-delivered behavioral health interventions. Despite emerging effectiveness data, few efforts have been made to summarize the collective findings from these delivery approaches. Objective: The purpose of this study was to review recent literature on the use of technology to deliver, enhance, or support the implementation of alcohol-related interventions in primary care. We focused on addressing questions related to (1) categorization and target, (2) descriptive characteristics and context of delivery, (3) reported efficacy, and (4) factors influencing efficacy. Methods: We conducted a comprehensive search and systematic review of completed studies at the intersection of primary care, technology, and alcohol-related problems published from January 2000 to May 2015 within EBSCO databases, ProQuest Dissertations, and Cochrane Reviews. Of 1498 initial records, 35 were included and coded independently by two investigators. Results: Studies on technology-based alcohol interventions in primary care have increased four-fold between the years of 2000-2005 and 2010-2015. Of the 35 studies, 23 (66%) were randomized controlled trials. Further, as a proxy for study quality, studies were rated on risk of bias and found to be low risk/high quality (n=15), moderate risk (n=13), and high risk/low quality (n=7). Approximately two-thirds (68%) of studies reported reduced drinking or harm in all primary and secondary efficacy outcomes. Furthermore, 38% of studies reported that at least half of the primary and secondary efficacy outcomes of the technology-based interventions were superior to treatment as usual. High efficacy was associated with provider involvement and the reported use of an implementation strategy to deliver the technology-based intervention. Conclusions: Our systematic review highlights a pattern of rapid growth in the use and evaluation of technology-based alcohol interventions in primary care. While these interventions appear largely beneficial in primary care, outcomes may be enhanced by provider involvement and implementation strategy use. This review enables better understanding of the typologies and efficacy of these interventions and informs recommendations for those developing and implementing technology-based alcohol interventions in primary care settings.

Health Information Technologies in the Support Systems of Pregnant Women and their Caregivers: A Mixed Methods Study

From: Journal of Medical Internet Research

Date Submitted: Apr 24, 2018

Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

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Background: The quality and quantity of families’ support systems during pregnancy can affect maternal and fetal outcomes. The support systems of expecting families can include many elements, such a...

Background: The quality and quantity of families’ support systems during pregnancy can affect maternal and fetal outcomes. The support systems of expecting families can include many elements, such as family members, friends, and work or community groups. Emerging health information technologies such as social media, Internet websites, and mobile apps provide new resources for pregnant families to augment their support systems and to fill information gaps. Objective: This study sought to determine the number and nature of the components of the support systems of pregnant women and their caregivers, and the role of health information technologies in these support systems. We examined the differences between pregnant women’s support systems and those of their caregivers and the associations between support system composition and stress levels. Methods: We enrolled pregnant women and caregivers from an advanced maternal fetal and group prenatal care clinics. Participants completed surveys assessing sociodemographic characteristics, health literacy, numeracy, and stress levels, and they were asked to draw a picture of their support system. Support system elements were extracted from drawings, categorized by type (i.e., individual persons, groups, technologies, and other), and summarized for pregnant women and caregivers. Participant characteristics and support system elements were compared using Pearson Chi-square test for categorical variables and Wilcoxon ranked sum test for continuous variables. Associations between support system characteristics and stress levels were measured with Spearman correlation coefficient. Results: The study enrolled 100 participants: 71 pregnant women and 29 caregivers. The support systems of pregnant women were significantly larger than those of caregivers, with an average of 7.4 components for pregnant women and 5.4 components for caregivers (P=0.003). For all participants, the most commonly reported support system elements were individual persons (60.3% of support systems), followed by people groups (19.3%), technologies (16.2%), and other resources (4.2%). Pregnant women’s and caregivers’ technology preferences within their support systems differed: pregnant women more often identified informational websites, apps, and social media as parts of their support systems, whereas caregivers more frequently reported general Internet search engines. The size and components of these support systems were not associated with levels of stress. Conclusions: This study is one of the first demonstrating that technologies comprise a substantial portion of the support systems of pregnant women and their caregivers. Pregnant women more frequently reported specific medical information websites as part of their support system, whereas caregivers more often reported general Internet search engines. Although social support is important for maternal and fetal health outcomes, no associations among stress, support system size, and support system components were found in this study. As health information technologies continue to evolve and their adoption increases, their role in patient and caregiver support systems and their effects should be further explored.

Economic evaluation of an internet-based stress-management intervention alongside an RCT

From: Journal of Medical Internet Research

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: Work-related stress is widespread among employees and associated with high costs for the society. Internet-based stress management interventions (iSMI) are effective in reducing such stres...

Background: Work-related stress is widespread among employees and associated with high costs for the society. Internet-based stress management interventions (iSMI) are effective in reducing such stress. However, evidence for their cost-effectiveness is scant. Objective: The aim of the study was to evaluate the cost-effectiveness (CEA) and cost-utility (CUA) of a guided iSMI with mobile support for employees. Methods: A sample of 264 employees with elevated symptoms of perceived stress (Perceived Stress Scale, PSS-10 ≥ 22) was assigned to either the iSMI or to a waitlist control condition (WLC) with unrestricted access to treatment as usual. Participants were recruited in 2013, followed through 2014, and data analyzed in 2017. The iSMI consisted of 7 sessions plus one booster session and was based on problem-solving and emotion regulation techniques. Costs were measured from the societal perspective, in-cluding all direct and indirect medical and non-medical costs. Costs were related to symp-tomatic remission in the CEA and to gains in quality adjusted life years (QALYs) in the CUA. Statistical uncertainty was handled using bootstrapping (N=5000). Results: At a willingness-to-pay (WTP) ceiling of €0 for becoming free of self-perceived stress symptoms, there was a 70% probability of the intervention being more cost-effective than WLC. This rose to 85% and 93% when society is willing to pay €1000 and €2000 achieving symptomatic remission, respectively. The CUA yielded a 76% probability of the interven-tion being more cost-effective than WLC at a conservative WTP threshold of €20,000 ($25,800) per QALY gained. Conclusions: From the societal perspective, offering iSMI to stressed employees has an acceptable likeli-hood of being cost-effective compared to WLC. Clinical Trial: German Clinical Trials Register (DRKS): 00004749; http://drks-neu.uniklinik-freiburg.de/ drks_web/setLocale_EN.do (Archived by WebCite at http://www.webcitation.org/6e8rl98nl )

A Novel Insight into the Challenges of Diagnosing Cervical Spondylotic Myelopathy using Online Symptom Checkers

From: Journal of Medical Internet Research

Date Submitted: Apr 25, 2018

Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

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Background: Cervical Spondylotic Myelopathy (CSM) is a common debilitating condition resulting from degeneration of the cervical spine. Whilst decompressive surgery can halt disease progression, exist...

Background: Cervical Spondylotic Myelopathy (CSM) is a common debilitating condition resulting from degeneration of the cervical spine. Whilst decompressive surgery can halt disease progression, existing spinal cord damage is often permanent, leaving patients with lifelong disability. Treatment within 6 months improves the likelihood of recovery, yet most patients wait over 2 years for a diagnosis. The majority of delays occur initially, before and within primary care, mainly due to a lack of recognition. Symptom checkers are widely used by patients before medical consultation and can be useful for preliminary triage and diagnosis. Lack of recognition of CSM by symptom checkers may contribute to the delay in diagnosis. Objective: The present study sought to investigate whether online symptom checkers are able to recognise relevant symptoms of CSM, to characterise the CSM differential returned, and to evaluate the diagnostic performance of its recognised symptoms. Methods: Textbook CSM symptoms were pooled from leading review articles. These symptoms were entered into the algorithms used by the top 20 symptom checker websites (N=4) (Google Search). The most widely cited symptom checker, WebMD, was used to characterise the differential diagnosis for CSM symptoms. Results: 31 textbook CSM symptoms were identified, of which 14 (45%) listed CSM as a differential and 3 (10%) placed CSM in the top third of the differential. The mean differential rank for motor symptoms was significantly better than for arthritic symptoms (P = .0093) and the average differential rank for all symptoms (P = .048). The symptom checker WebMD performed best at recognising CSM, placing it nearer the top of the differential list (average rank of 5.6) than both Healthline (rank of 12.9, P = .015) and Healthtools.AARP (rank of 15.5, P = .0014). On WebMD, only one combination of symptoms resulted in CSM as the primary differential: neck, shoulder and arm pain with hand weakness. 151 differential diagnoses for CSM symptoms were recorded on WebMD. Multiple sclerosis and peripheral neuropathy were the most common differentials, shortlisted for 52% and 32% of CSM symptoms respectively. Conclusions: CSM symptoms perform poorly in online symptom checkers and lead to a large differential of many other common conditions. Whilst a diagnosis becomes more likely as the number of symptoms increases, this will not support much needed earlier diagnosis. Symptom checkers remain an attractive concept with potential. Further research is required to support their optimisation.

Quantifying Impact of Validation and Testing on FHIR Standards Compliance

From: Journal of Medical Internet Research

Date Submitted: Apr 24, 2018

Open Peer Review Period: Apr 25, 2018 - Jun 20, 2018

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Background: There is wide recognition that the lack of health data interoperability has significant impacts. Traditionally health data standards are complex, and test-driven methods played important r...

Background: There is wide recognition that the lack of health data interoperability has significant impacts. Traditionally health data standards are complex, and test-driven methods played important roles in achieving interoperability. HL7 FHIR may be a technical solution that aligns with policy, but systems need to be validated and tested. Objective: Our objective is to explore the question of whether or not the regular use of validation and testing tools improves server compliance with the HL7 FHIR specification. Methods: We used two independent validation and testing tools, Crucible and Touchstone, and analyzed the usage and result data to determine their impact on server compliance with the HL7 FHIR specification. Results: The use of validation and testing tools such as Crucible and Touchstone are strongly correlated with increased compliance, and “practice makes perfect.” Additional data analysis reveals trends over time with respect to vendors, use-cases, and FHIR versions. Conclusions: Validation and testing tools can aid in the transition to an interoperable health care infrastructure. Developers that use testing and validation tools tend to produce more compliant FHIR implementations. When it comes to health data interoperability, “practice makes perfect.”

A systematic review of online systems for patients to report and manage the side effects of cancer treatment

From: Journal of Medical Internet Research

Date Submitted: Apr 25, 2018

Open Peer Review Period: Apr 26, 2018 - Jun 21, 2018

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Background: There has been a dramatic increase in the development of electronic systems to support cancer patients to report and manage side effects of treatment from home. Systems vary in features th...

Background: There has been a dramatic increase in the development of electronic systems to support cancer patients to report and manage side effects of treatment from home. Systems vary in features that they offer to patients which may impact on how patients engage with them, and subsequently on the benefit that may be derived in terms of patient centred outcomes. Objective: This review aimed to 1) Describe the features and functions of existing electronic symptom reporting systems (e.g. symptom monitoring, tailored self-management advice etc.) 2) Explore which features may be associated with patient engagement and patient-centred outcomes. Methods: The review was registered with PROSPERO and followed guidelines from the Centre for Reviews and Dissemination. Primary searches were undertaken of MEDLINE, EMBASE, PsychInfo, Web of Science, Cochrane Central Register of Controlled Trials and the Health Technology Assessment databases. Secondary searches were undertaken by screening reference lists and citations. Two researchers applied broad inclusion criteria to identify and select relevant records. Data was extracted and summarised using Microsoft Excel. In order to meet the aims, study selection, data extraction and data synthesis evolved into two stages. Stage 1: Identifying and characterising available systems and Stage 2: Summarising data on patient engagement and patient centred outcomes. Results: 77 publications were identified relating to 41 distinct systems. Stage 1: All publications were included (n=77). Features identified which supported clinicians and care were: facility for health professionals to remotely access and monitor patient reported data (58%) and function to send alerts to health professionals for severe symptoms (41%). Features which supported patients were: facility for patients to monitor/review their symptom reports over time (e.g. graphs) (46%), general patient information about cancer treatment and side-effects (41%), tailored automated patient advice on symptom management (29%), feature for patients to communicate with the healthcare team (15%) and a forum for patients to communicate with one another (10%). Stage 2: Only publications which included some data on patient engagement and/or patient-centred outcomes were included (n=29). A lack of consistency between studies in how engagement was defined, measured or reported and a wide range of methods chosen to evaluate systems meant we couldn’t compare across studies or make conclusions on relationships with system features. Conclusions: Electronic systems have the potential to support patients to manage side effects of cancer treatment with some evidence to suggest a positive effect on patient centred outcomes. However, comparison across studies is difficult due to the wide range of assessment tools used. There is a need to develop guidelines for assessing and reporting engagement with systems, and a set of core outcomes for evaluation. We hope that this review will contribute to the field by the introduction of a taxonomy for characterising system features.

Internet-based interventions for carers of individuals with psychiatric and neurological disorders and brain injury: A systematic review

From: Journal of Medical Internet Research

Date Submitted: Apr 26, 2018

Open Peer Review Period: Apr 27, 2018 - Jun 22, 2018

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Background: Non-professional caregivers who provide support to an individual with a psychiatric or neurological disorder will often themselves experience symptoms of stress, anxiety, and low mood, and...

Background: Non-professional caregivers who provide support to an individual with a psychiatric or neurological disorder will often themselves experience symptoms of stress, anxiety, and low mood, and perceive that they receive little support. Internet-based interventions have previously been found to be effective in the treatment and prevention of a range of mental health difficulties. Objective: The current review seeks to investigate the status of existing internet-based interventions for informal carers of people with psychiatric and neurological disorders or traumatic brain injury, establishing the degree to which they improve carer mental health. Methods: A systematic literature search was conducted in October 2017 using the Embase (1974 – present), Ovid MEDLINE (1946 – present), PsychARTICLES, PsychINFO (1806 – present) and Global Health (1973 – present) databases, via the Ovid Technologies database. Search terms included carer, caregiver, online, technology, web-based, interactive, intervention, and evaluation. Studies selected for inclusion in this review met the following predetermined criteria: (i) delivering an intervention aimed primarily at informal (non-professional) caregivers; of (ii) individuals with psychiatric disorders, stroke, dementia, or brain injury; (iii) the intervention delivered to the caregivers was primarily internet-based; (iv) the study reported a pre- and post- quantitative measure of caregiver depression, anxiety, stress, burden, or quality of life; (v) appearing in a peer-reviewed journal; and (vi) accessible in English. Results: A total of 39 studies were identified for inclusion through the detailed search strategy. The search was conducted and data information extracted independently by two researchers. Studies were found to vary greatly with regards to both methodological quality, and reported efficacy/effectiveness of the intervention on measures relating to caregiver mental health, however, the majority of studies did report that one or more measures relating to carer mental health was found to improve following receipt of a relevant intervention. Conclusions: Studies investigating internet-based interventions for carers of individuals with psychiatric and neurological difficulties and brain injury show some evidence in support of the effectiveness of internet-based interventions, and additionally, that such interventions are likely to be found acceptable by the caring population. The evidence currently available within this field is of varying quality, and has some methodological shortcomings. Further research in this area is required to establish how specific components, such as the structure and interactivity of the intervention, may contribute to the overall efficacy of the intervention with regards to carer mental health, and how this frequently underserved population can best be supported.

Towards standardized monitoring of patients with chronic diseases in primary care using electronic medical records.

From: JMIR mHealth and uHealth

Date Submitted: May 6, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: Long-term care for patients with chronic diseases poses a huge challenge. Deficits exist especially regarding monitoring and structured follow up. Appropriate Electronic medical records (E...

Background: Long-term care for patients with chronic diseases poses a huge challenge. Deficits exist especially regarding monitoring and structured follow up. Appropriate Electronic medical records (EMR) could support this, but so far, no generic templates exist. Objective: The aim was to develop an evidence based standardized generic template, which improves monitoring of patients with chronic conditions by means of an EMR. Methods: Five highly prevalent chronic diseases were chosen: Diabetes mellitus type 2, arterial hypertension, asthma, osteoarthritis and chronic heart failure. In a first step, a systematic literature review was performed searching for indicators that monitor each chronic condition or studies that address the topic “monitoring”. The resulting indicators were then evaluated by means of an adapted Delphi procedure and in a second step summarized into a user-friendly layout. Results: This multi-step procedure resulted in a monitoring tool consisting of condensed sets of indicators, divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and set procedures to facilitate disease management. An additional tab contains information on non-disease specific indicators, as for example allergies and vital signs. Our study further shows that the term “monitoring”, in terms of disease management and long-time care of patients, is not widely spread. Conclusions: Our generic template can improve the care for patients with chronic diseases, since for the first time it systematically summarizes the existing scientific evidence for the standardized long-term monitoring of chronic conditions by means of an EMR in general practice.

AO Patient Outcomes Center (AOPOC) — Design, Implementation, and Evaluation of a Software Application for Collection of Patient-Reported Outcome Measures in Orthopedic Outpatient Clinics

From: Journal of Medical Internet Research

Date Submitted: Apr 25, 2018

Open Peer Review Period: Apr 26, 2018 - Jun 21, 2018

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Background: Patient-reported outcomes (PROs) are increasingly utilized in routine orthopedic clinical care. Computer adaptive tests (CATs) from the Patient-Reported Outcomes Measurement Information Sy...

Background: Patient-reported outcomes (PROs) are increasingly utilized in routine orthopedic clinical care. Computer adaptive tests (CATs) from the Patient-Reported Outcomes Measurement Information System (PROMIS) offer brief and precise assessment that is well suited for collection within busy clinical environments. However, software applications that support the administration and scoring of CATs, immediate access to PRO scores, and minimize clinician burden are not widely available. Objective: Our objective was to design, implement, and test the feasibility and usability of a web-based system for collecting CATs in orthopedic clinics. Methods: AO Patient Outcomes Center (AOPOC) was subjected to two rounds of testing. Alpha testing was conducted in 3 orthopedic clinics to evaluate ease of use and feasibility of integration in clinics. Patients completed an assessment of PROMIS CATs and a usability survey. Clinicians participated in a brief semi-structured interview. Beta phase testing evaluated system performance through load testing and usability of the updated version of AOPOC. In both rounds of testing, user satisfaction, bugs, change requests, and performance of PROMIS CATs were captured. Results: Patient feedback supported the ease of use in completing an assessment in AOPOC. Across both phases of testing, clinicians rated AOPOC as easy to use, but noted difficulties in integrating a web-based software application within their clinics. PROMIS CATs performed well; the default assessment of 2 CATs was completed quickly (mean=9.5 items) with a satisfactory range of measurement. Conclusions: AOPOC was demonstrated to be an easy to learn and easy to use software application for patients and clinicians that can be integrated into orthopedic clinical care. The workflow disruption in integrating any type of PRO collection must be addressed if patients’ voices are to be better integrated in clinical care.

Impacts of Integrating Gamified Surgery Educational Technologies in Healthcare

From: JMIR Serious Games

Date Submitted: Apr 25, 2018

Open Peer Review Period: Apr 26, 2018 - Jun 21, 2018

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Recently, prominent technological entities have explored whether gamified simulation, which is the integration of game mechanics into a virtually-induced simulation, can be a plausible solution to the...

Recently, prominent technological entities have explored whether gamified simulation, which is the integration of game mechanics into a virtually-induced simulation, can be a plausible solution to the dilemma of “not enough experience” in psychomotor-dependent training for surgical residents. Existing Virtual-Reality Simulators, among others, are venturing into the arena via combining the dexterity of robotic surgery technologies and the sophisticated animated 3D Graphics environment. Emerging technologies that incorporate surgeon educators as active agents in developing these solutions will prove to be a much more usable and accepted an alternative to the traditional approach of passive observation to surgical procedures. Gamified training can be considered as a low-cost option once the dexterity training and cognitive load needed for analyzing surgical procedures are in optimal coherence. This could lead to an enhanced evidence-based care with measurable performance agents of quality surgical training and residents’ competency in future research.

Expertise modulates the student’s perception of pain from a self-perspective

From: Journal of Medical Internet Research

Date Submitted: May 16, 2018

Open Peer Review Period: May 17, 2018 - Jul 12, 2018

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Background: FMRI studies show that medical doctors suppress the pain matrix when they view painful actions executed on others. But how do doctors perceive pain from a self-perspective? Objective: We h...

Background: FMRI studies show that medical doctors suppress the pain matrix when they view painful actions executed on others. But how do doctors perceive pain from a self-perspective? Objective: We hypothesize that virtual dental treatment from a self-perspective may induce brain activity in pain related areas in controls while this is less the case for dental students. We expect that dental students learn to control the motoric aspects of pain during their education because it is a prerequisite for manual treatment. Methods: In this fMRI study, neural correlates of pain perception from a self-perspective in a sample of 20 dental students and 20 age matched controls were investigated trough classic general linear model analysis and in house classification methods. All subjects viewed video clips presenting a dental treatment from the first‐person perspective. Dental students and naïve controls exhibited similar anxiety levels for invasive stimuli. Results: Invasive dentistry scenes evoked less affective component of pain in dental students compared to naïve controls. Reduced affective pain perception went along with suppressed brain activity in pain matrix areas including insula, anterior cingulate cortex and basal ganglia. Furthermore, a substantial reduction of brain activity was observed in motor related areas in particular the supplementary motor area, premotor cortex and basal ganglia (p<0.001, k=156). Within this context a classifier analysis based on neural activity in the nucleus lentiformis (p<0.0005 with k=125) could identify dental students and controls on the individual subject level in 85 percent of the cases (sensitivity = 90.0%; specificity = 80.0%). Conclusions: We speculate that dentistry students learn to control motoric aspects of pain during their education because it is a prerequisite for professional manual treatment of patients. We discuss that a specific set of learning mechanism might affect perceived self-efficacy of dental students, which in turn might reduce their affective component of pain perception.

The perceptions of Midwives, Obstetricians, and recently delivered Mothers to remote monitoring for prenatal care

From: Journal of Medical Internet Research

Date Submitted: Apr 26, 2018

Open Peer Review Period: Apr 27, 2018 - Jun 22, 2018

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Background: There have been few studies on remote monitoring (RM) in midwifery. These studies were mostly performed several decades ago, and no recent studies have investigated the perceptions to or e...

Background: There have been few studies on remote monitoring (RM) in midwifery. These studies were mostly performed several decades ago, and no recent studies have investigated the perceptions to or experiences of new technologies. The Pregnancy Remote Monitoring (PREMOM) study, which started in January 2015 in Ziekenhuis Oost-Limburg (Genk, Belgium), enrolled pregnant women at increased risk of developing gestational hypertensive disorders (GHD). Women enrolled in PREMOM underwent conventional prenatal follow-up, which was complemented with RM. Objective: We sought to investigate the perceptions and experiences of mothers, midwives, and obstetricians to the RM approach used in the PREMOM study. Methods: We developed specific questionnaires for the mothers, midwives, and obstetricians. The questionnaires comprised five domains: ‘prior knowledge and experience of RM’, ‘reactions to abnormal values’, ‘privacy’, ‘quality and patient safety’, and ‘financial aspects’. The caregivers were also questioned about which issues they consider important when implementing RM. A five-point Likert scale was used to provide objective scores. Results: Ninety-one participants completed the questionnaires, including 47/92 (51.08%) mothers, 35/52 (67.30%) midwives, and 9/14 (64.29%) obstetricians. The mothers, midwives, and obstetricians reported positive experiences and perceptions to RM. Overall, 29/35 (82.85%) midwives and 7/9 (77.78%) obstetricians had no or little prior experience with this technology. After working for 1 year with RM, 28/35 (80.00%) midwives and 6/9 (66.67%) obstetricians felt that this technology is an important component in the prenatal monitoring of high-risk pregnancies and that it had a positive contribution to the care of pregnant women. They support a further roll-out of RM in Belgium, but caregivers need additional training on RM devices and the pathological aspects of GHD. Nearly three-quarters of the mothers who participated in the PREMOM study (34/47, 72.34%) did not report any problems with taking the measurements at the required times. Almost half of the mothers (19/47, 40.43%) wanted to be contacted within 3–12 hours after abnormal values, preferably by telephone. Nearly all of the mothers (41/47, 87.24%) did not have any problems with regularly sharing their health data with their gynaecologist. Finally, most of the mothers (39/47, 82.97%) reported that RM gave them a feeling of security throughout their pregnancy. Conclusions: Although the majority of midwives and obstetricians had no or very little experience with RM before enrolling in the PREMOM study after one year, they reported that RM is an important component in the follow-up of high-risk pregnancies and would recommend it to their colleagues and pregnant patients.

Development and field evaluation of the INTER-ACT app, inter-pregnancy coaching for a healthy future to reduce risks in a consecutive pregnancy

From: Journal of Medical Internet Research

Date Submitted: Apr 26, 2018

Open Peer Review Period: Apr 27, 2018 - Jun 22, 2018

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Background: Background: The inter-pregnancy period is an important window of opportunity to prevent gestational weight retention and associated risks in the next pregnancy. Despite an overwhelming nu...

Background: Background: The inter-pregnancy period is an important window of opportunity to prevent gestational weight retention and associated risks in the next pregnancy. Despite an overwhelming number of available health apps, targeted and validated applications supporting a healthy lifestyle in women during both pregnancy and postpartum are lacking. Objective: Objective: The aim of this paper is to describe the process of development and pilot testing of the INTER-ACT app. The INTER-ACT app is part of an inter-pregnancy coaching module targeting women with excessive gestational weight gain. These women are followed up to the end of the next pregnancy in order to reduce the risk for maternal and childbirth complications. Methods: Methods: a mixed methods design was used to identify needs of healthcare providers and end users (pregnant and postnatal women) before designing the app. This was based on 15 semi-structured interviews with midwives (n=5), GP’s (n=4), gynecologists (n=3) and dieticians (n=3), two focus groups with midwives, a survey in 43 healthcare providers and 50 pregnant women as well as on iterative discussions within our research group and two professional organizations. The app user interface was designed by user experience researchers and evaluated in a pilot study including 9 women. Results: Results: From the healthcare providers’ perspective, a mobile app can enhance a healthy lifestyle in pregnant women provided that the app can be combined with face-to-face coaching without increasing administrative workload. Pregnant women preferred a graphic display of weight evolution in the app and weekly notifications and support messages, based on their own preset goals. In the user evaluation study, mothers reported that the INTER-ACT app increased their awareness about their own behavior. In comparison with commercially available health apps mothers explicitly valued the combination of the INTER-ACT app with face-to-face contact. This finding aligns with healthcare providers’ perspectives. Conclusions: Conclusions: We report on the development and evaluation process of an application to promote a healthy lifestyle in a very specific female population. These pregnant and postpartum women specifically valued the INTER-ACT app because it was offered in combination with face-to-face contact with a caregiver.

Effect of a mobile phone intervention on quitting smoking in a young adult population of smokers: results from a randomized controlled trial

From: Journal of Medical Internet Research

Date Submitted: Apr 27, 2018

Open Peer Review Period: Apr 27, 2018 - Jun 22, 2018

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Background: Digital mobile technology presents a promising medium for reaching young adults with smoking cessation interventions because they are the heaviest users of this technology. Objective: The...

Background: Digital mobile technology presents a promising medium for reaching young adults with smoking cessation interventions because they are the heaviest users of this technology. Objective: The primary aim of this trial was to determine the efficacy of an evidence-informed smartphone app for smoking cessation, Crush the Crave (CTC), on reducing smoking prevalence among young adult smokers in comparison to an evidence-informed self-help guide On the Road to Quitting (OnRQ). Methods: A parallel, double-blind randomized controlled trial (RCT) with two arms was conducted in Canada to evaluate CTC. In total, 1599 young adult smokers (19 to 29 years old) intending to quit smoking in the next 30 days were randomized to receive CTC or the control condition OnRQ for a period of 6 months. The primary outcome measure was self-reported continuous abstinence at the 6 month follow-up. Results: Overall follow-up rates were 55.5% and 58.3% at 3 and 6 months respectively. Forty-five percent of participants (n=725) completed baseline, 3 and 6 month follow-up. Intention-to-treat (last observation carried forward) continuous abstinence (n=1,599) at 6 months was not significantly different at 7.8% for CTC vs. 9.2% for OnRQ (OR = 0.83, 95% CI = 0.59-1.18). Similarly, 30-day point prevalence abstinence at 6 months was not significantly different at 14.4% and 16.9% for CTC and OnRQ respectively (OR = 0.82, 95% CI = 0.63-1.08); however, these rates of abstinence are favourable compared to unassisted 30-day quit rates of 11.5% among young adults. Secondary measures of quit attempts and the number of cigarettes smoked per day at 6 month follow-up did not reveal any significant differences between groups. For those who completed 6 month follow-up, 85.1% of young adult smokers downloaded CTC as compared to 81.8% of OnRQ, χ2 (1,N = 845) = 1.64, p =.23. Further, OnRQ participants reported significantly higher levels of overall satisfaction (M=3.3, SD=1.1 versus M=2.6, SD=1.3, t(644)=6.87, p < .0001) and perceived helpfulness (M=5.8, SD = 2.4 versus M=4.3, SD = 2.6, t(657)=8.0, p < .0001) as compared to CTC participants. Conclusions: CTC was feasible for delivering cessation support but was not superior to a self-help guide in helping motivated young adults to quit smoking. CTC will benefit from further formative research. Digital mobile technology smoking cessation interventions may serve as useful alternatives to traditional self-care guides due to the wide-spread availability of mobile technology. Clinical Trial: ClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150

Context-sensitive ecological momentary assessment: Application of user-centered design for improving user satisfaction and engagement during self-report

From: Journal of Medical Internet Research

Date Submitted: May 1, 2018

Open Peer Review Period: May 2, 2018 - Jun 27, 2018

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Background: Ecological Momentary Assessment (EMA) can be a useful tool for collecting real time behavioral data in studies of health and health behavior. However, EMA administered through mobile techn...

Background: Ecological Momentary Assessment (EMA) can be a useful tool for collecting real time behavioral data in studies of health and health behavior. However, EMA administered through mobile technology can be burdensome and it tends to suffer from suboptimal user engagement, particularly in low health literacy populations. Objective: To report a case study involving the design and evaluation of a mobile EMA tool that supports context-sensitive EMA reporting of location and social situations accompanying eating and sedentary behavior. Methods: An iterative, user-centered design process with obese, middle-aged women seeking care in a safety-net health system was used to identify the preferred format of self-report measures, and the look, feel and interaction of the mobile EMA tool. A single arm feasibility field trial with 21 participants receiving 12 prompts each day for momentary self-reports over a 4-week period (336 total prompts per participant) was used to determine user satisfaction with interface quality and user engagement, operationalized as response rate. A second trial among 38 different participants randomized to receive or not a feature designed to improve engagement was conducted. Results: The feasibility trial results showed high interface satisfaction and engagement, with an average response rate of 50% over 4 weeks. Qualitative feedback pointed to the need for auditory alerts. We settled on three alerts at 10-minute intervals to accompany each EMA reporting prompt. The second trial testing this feature showed a statistically significant increase in response rate among participants randomized to receive repeat auditory alerts versus those not (60% vs 40%). Conclusions: This paper reviews the design research and a set of design constraints that may be considered in the creation of mobile EMA interfaces personalized to users’ preferences. Novel aspects of the study include the involvement of low health literacy adults in design research, the capture of data on time, place, and social context of eating and sedentary behavior, and reporting prompts tailored to an individual’s location and schedule. Clinical Trial: NCT03083964

Context-aware systems for chronic disease patients: A scoping review

From: Journal of Medical Internet Research

Date Submitted: Apr 27, 2018

Open Peer Review Period: Apr 27, 2018 - Jun 22, 2018

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Background: Context-aware systems, also known as context-sensitive systems, are computing applications designed to capture, interpret, and use contextual information and provide adaptive services acco...

Background: Context-aware systems, also known as context-sensitive systems, are computing applications designed to capture, interpret, and use contextual information and provide adaptive services according to the current context of use. Context-aware systems have the potential to support patients with chronic conditions, yet little is known about how such systems have been utilized to facilitate patient work. Objective: To characterize the different tasks and contexts in which context-aware systems for patient work were used, as well as to assess any existing evidence about the impact of such systems on health-related process or outcome measures. Methods: Six databases (Medline, Embase, CINAHL, ACM Digital, Web of Science and Scopus) were scanned using a predefined search strategy. Studies were included in the review if they: focused on patients with chronic conditions; involved the use of a context-aware system to support patients’ health-related activities; and reported the evaluation of the systems by the users. Studies were screened by independent reviewers, and a narrative synthesis of included studies was conducted. Results: The database search retrieved 1478 citations; 6 papers were included, all published from 2009 onwards. The majority of the papers were quasi-experimental and involved pilot and usability testing with a small number of users; there were no randomized controlled trials (RCTs) to evaluate the efficacy of a context-aware system. In the included studies, context was captured using sensors or self-reports, sometimes involving both. Most studies used a combination of sensor technology and mobile applications to deliver personalized feedback. Three studies examined the impact of interventions on health-related measures, showing positive results. Conclusions: The use of context-aware systems to support patient work is an emerging area of research. RCTs are needed to evaluate the effectiveness of effectiveness of context-aware systems in improving patient work, self-management practices, and health outcomes in chronic disease patients. Clinical Trial: N/A

Experience with the use of a virtual social network on Facebook for Brazilian patients with gestational trophoblastic disease - a netnography study

From: Journal of Medical Internet Research

Date Submitted: Apr 26, 2018

Open Peer Review Period: Apr 27, 2018 - Jun 22, 2018

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Background: Gestational trophoblastic disease (GTD) encompasses complete and partial moles, uncommon pregnancies with the potential to evolve to a malignant disease, the gestational trophoblastic neop...

Background: Gestational trophoblastic disease (GTD) encompasses complete and partial moles, uncommon pregnancies with the potential to evolve to a malignant disease, the gestational trophoblastic neoplasia (GTN). While highly curable, the pre-malignant nature of molar pregnancies worries patients, leading them to seek information on the internet. A Facebook page headed by Brazilian specialized physicians in GTD was created in 2013 to provide online support for GTD patients. Objective: To describe the netnography of Brazilian patients with gestational trophoblastic disease (GTD) on Facebook® (FBGTD) and to evaluate whether experiences differed whether they received care in a Brazilian trophoblastic disease reference center (BRC) or elsewhere. Methods: This was a cross-sectional study using a survey of G Suit Google Platform and a netnographic analysis of interactions among patients with GTD members of FBGTD, invited to answer a survey from March 6th to October 5th, 2017. Results: The survey was answered by 356 Brazilian GTD patients: 176 reference center patients (RCP) treated at a BRC and 180 non-reference center patients (NRCP) treated elsewhere. Comparing the groups, RCP felt safer and more confident at the time of diagnosis of GTD (P = 0.001), and they utilized FBGTD through referral by health assistants (P < 0.001), whereas NRCP discovered FBGTD on search sites and pages (P < 0.001). NRCP had higher educational level (P = 0.009), were on FBGTD ≥ 6 months (P = 0.026), reported more frequently (P = 0.007) that what most negatively affected them at the time of diagnosis was the fact that doctors did not explain about GTD and had more doubts about GTD treatment (P = 0.013), and were unlikely to use hormonal contraception (P < 0.001). Most patients accessed the internet preferentially from home and using cell phones (89%). Almost all patients (98%) declared that they felt safe reading the guidelines posted by FBGTD physicians. Conclusions: This netnographic analysis of GTD patients on FBGTD shows that an online doctor-patient relationship can supplement the care for women with GTD. This resource is particularly valuable for women being cared for outside of established reference centers.

Mobile Health Interventions for Self-control of Unhealthy Alcohol Use: A Systematic Review

From: Journal of Medical Internet Research

Date Submitted: Apr 29, 2018

Open Peer Review Period: Apr 30, 2018 - Jun 25, 2018

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Background: Unhealthy alcohol use (UAU) is one of the major causes of preventable morbidity, mortality and associated behavioral risks worldwide. Although mobile health (mHealth) interventions can pro...

Background: Unhealthy alcohol use (UAU) is one of the major causes of preventable morbidity, mortality and associated behavioral risks worldwide. Although mobile health (mHealth) interventions can provide consumers with an effective means for self-control of UAU in a timely, ubiquitous, and cost-effective manner, to date, there is a lack of evidence about the health outcomes of these interventions. The components of these interventions are also unclear. Objective: To systematically review and synthesize the research evidence about the health outcomes of mHealth interventions for self-control of UAU and to explore the common components of these interventions. Methods: We systematically searched four electronic interdisciplinary databases: Scopus, PubMed (PMC), CINAHL Plus with full text and MEDLINE with full text. Search terms and MeSH headings, “mHealth”, “text message”, “self-control”, “self-regulation”, “alcohol*” were used individually or in combination to identify peer-reviewed publications in English from 2007 to 2017. We screened titles and abstracts, and assessed full-text articles as per inclusion and exclusion criteria. Data were extracted from the included articles according to CONSORT-EHEALTH checklist (V.1.6.1) by two authors independently. Data quality was assessed by the Mixed Methods Appraisal Tool. Data synthesis and analyses were conducted following the procedures for qualitative content analysis. Statistical testing was also conducted to test differences among groups of studies. Results: Twenty publications were included in the review. In fourteen studies (70%), mHealth interventions brought significant positive outcomes in improving participants’ health as measured by behavioral indicators (n=13), physiological indicators (n=1) and cognitive indicators (n=1). No significant health outcome was reported in the other five studies (25%). Surprisingly, a significant negative outcome was reported for the male participants in the intervention arm in one study (5%), but no change was found for the female participants. Five common components reported in mHealth interventions for consumer self-control of UAU were context, theoretical base, delivery mode, content and implementation procedure. The health outcomes were similar regardless of types of UAU, deployment setting, with or without non-mobile co-intervention and with or without theory. Conclusions: The major change brought by mHealth interventions for consumer self-control of UAU appeared to be improving behavior. There is still a lack of sound evidence on the effects of these interventions in improving the physiological and cognitive outcomes. More robust trials are needed to validate the short- and long-term health benefits and the contributing factors of mHealth interventions.

A Randomized Clinical Trial of a Novel Clinician Orchestrated Virtual Reality Platform for Distraction during Pediatric Intravenous Procedures in Children with Hemophilia

From: Journal of Medical Internet Research

Date Submitted: May 1, 2018

Open Peer Review Period: May 5, 2018 - Jun 30, 2018

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Background: Introduction : Needles are frequently required for routine medical procedures. Children with severe hemophilia can have hundreds of IV procedures per year. Fear of needle related procedure...

Background: Introduction : Needles are frequently required for routine medical procedures. Children with severe hemophilia can have hundreds of IV procedures per year. Fear of needle related procedures can cause avoidance of future health care. Virtual reality (VR) has shown promise as a distraction technique during procedures, but barriers to commercially available VR platforms have prevented widespread use. Objective: Objective : We hypothesized that we could create a VR platform that would be customized for pediatric hemophilia care, clinician orchestrated and feasible to use for distraction during intravenous (IV) procedures performed as a part of complex healthcare. Methods: Methods: We created a custom VR platform that consisted of a wireless, adjustable, disposable headset and a suite of VR games that could be orchestrated remotely. The platform was customized for a pediatric hemophilia population. Orchestration was performed by a hemophilia nurse observing the procedure. The primary endpoint of the trial was to assess feasibility of VR versus Standard-of-care (SOC) distraction during a planned IV procedure in the course of a comprehensive hemophilia clinic visit. Feasibility and usability of the platform was assessed in a single-center, randomized clinical trial from June through December 2016. Participants were children with hemophilia age 6 to 18 years. After informed consent 25 patients enrolled and were randomized. Each subject, 1 caregiver and 1 hemophilia nurse orchestrator assessed degree of pre-procedural nervousness/anxiety with an anchored, combined modified Visual Analog (VAS)/FACES scale prior to the IV procedure. Each participant then underwent a timed IV procedure with either VR or SOC distraction. Each rater assessed the distraction methods using a VAS/FACES scale at the completion of the IV procedure with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers and nurses were also asked to rate how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, the Mann-Whitney test was used. Results: Results: 25 children were enrolled and 24 were included in the primary analysis. The median procedure time was 10 minutes in the VR group (range 1-31 minutes) and was comparable to 9 minutes (range: 3-20 minutes) in the SOC arm (p=0. 764). Patients in both VR and SOC arms reported a positive influence of distraction on procedural anxiety and pain. Eighty percent of the children, caregivers and nurses reported that they would like to use VR for future procedures. No adverse events were experienced in either arm. Conclusions: Conclusion: We demonstrated that an orchestrated, VR environment could be integrated and used during pediatric hemophilia care during IV interventions without adversely disrupting clinic flow. This platform has the potential to improve the patient experience during medical procedures. Clinical Trial: Clinical Trials.gov NCT03507582

Identification of Key Influence Factors of Consumers’ Intention towards Mobile Health Care Promotion Based on a DDANPMV Model

From: JMIR mHealth and uHealth

Date Submitted: Apr 29, 2018

Open Peer Review Period: Apr 30, 2018 - Jun 25, 2018

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Identifying the key influence factors of mobile health care adoption and improving alternative mobile health services continuously can help ordinary consumers (especially vulnerable populations) use e...

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

Transition education for young adults with type 1 diabetes: Feasibility of a group telehealth intervention

From: Journal of Medical Internet Research

Date Submitted: Apr 30, 2018

Open Peer Review Period: Apr 30, 2018 - Jun 25, 2018

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Background: Young adults with type 1 diabetes (T1D) experience a decline in glycemic outcomes and gaps in clinical care. A diabetes education and support program designed for young adults was delivere...

Background: Young adults with type 1 diabetes (T1D) experience a decline in glycemic outcomes and gaps in clinical care. A diabetes education and support program designed for young adults was delivered via group videoconference and mobile web. Objective: To assess the feasibility, acceptability, and preliminary efficacy of the program as measured by attendance and web page views, satisfaction, and pre-/post intervention psychosocial outcomes respectively. Methods: Young adults ages 18-25 years were recruited to attend five 30-minute group diabetes education videoconferences during an 8-week time period. Videoconferences included an expert presentation followed by a moderated group discussion. Within 48 hours of each videoconference, participants were sent a link to more information on the study website. Feasibility was assessed using data on videoconference attendance and web page views. Acceptability was assessed via satisfaction survey completed at the conclusion of the study. Descriptive statistics were generated. Preliminary efficacy was assessed via survey as changes in diabetes-specific self-efficacy and diabetes distress. Pre- and post-intervention data were compared using paired samples t-tests. Results: Twenty young adults (mean age=19.2 years, SD=1.1), attended an average of 5.1 (SD=1.0) videoconferences equivalent to 153 minutes (SD=30.6) of diabetes education per participant during an 8-week period. Average participant satisfaction scores were 62.2 (SD=2.6) out of a possible 65 points. A total of 102 links sent via text/email resulted in 504 web page views. There was no statistically significant difference in pre- and post-intervention diabetes-specific self-efficacy or diabetes related distress. Conclusions: Delivery of diabetes education via group videoconference with mobile web follow up is feasible and acceptable to young adults with T1D. This model of care delivery has the potential to improve attendance, social support, and patient-reported satisfaction. Further research is required to establish effect on long-term psychosocial and glycemic outcomes.

Creating engaging health promotion campaigns on social media: observations and lessons from Fitbit and Garmin

From: Journal of Medical Internet Research

Date Submitted: Apr 30, 2018

Open Peer Review Period: Apr 30, 2018 - Jun 25, 2018

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Background: The popularity and reach of social media make it an ideal delivery platform for interventions targeting health behaviours, such as physical inactivity. Research has identified a dose-respo...

Background: The popularity and reach of social media make it an ideal delivery platform for interventions targeting health behaviours, such as physical inactivity. Research has identified a dose-response relationship whereby greater engagement and exposure are positively associated with intervention effects, hence enhancing engagement will maximise the potential of these interventions. Objective: This study examined the social media activity of successful commercial activity tracker brands to understand which creative devices they use in their communication to engage current and potential users, which platforms attract the most engagement, and which creative devices prompted the most engagement. Methods: Posts (n=509) made by Fitbit and Garmin on Facebook, Twitter and Instagram over a 3-month period were coded for the presence of creative devices. User engagement in terms of the total number of likes, comments or shares per post was recorded. Results: Posts (n=509) made by Fitbit and Garmin on Facebook, Twitter and Instagram over a 3-month period were coded for the presence of creative devices. User engagement in terms of the total number of likes, comments or shares per post was recorded. Conclusions: Future work should prioritise Instagram as a delivery platform and incorporate principles of market segmentation, or tailoring. Health messages on social media should be clear, refreshed regularly, incorporate inspirational messages and imagery and be focussed on tangible end products of health to maximise engagement and therefore the potential of this approach for positive behaviour change.

Young people’s knowledge about antibiotics and vaccinations and increasing it through gaming: a mixed methods study using e-Bug

From: JMIR Serious Games

Date Submitted: Apr 30, 2018

Open Peer Review Period: Apr 30, 2018 - Jun 25, 2018

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Background: e-Bug, led by Public Health England, educates young people about important topics; microbes, infection prevention and antibiotics. Body Busters and Stop the Spread are two new e-Bug educat...

Background: e-Bug, led by Public Health England, educates young people about important topics; microbes, infection prevention and antibiotics. Body Busters and Stop the Spread are two new e-Bug educational games. Objective: To determine student baseline knowledge, views on the games and knowledge improvement. Methods: Students in five UK educational provisions were observed playing two e-Bug games. Before and after knowledge and evaluation questionnaires and student focus groups were completed. Results: 123 junior and 350 senior students completed questionnaires. Vaccination baseline knowledge was high. Knowledge increased significantly around antibiotic use, appropriate sneezing behaviours, and vaccinations. 26 student focus groups were conducted. Body Busters was “engaging” and “enjoyable”; whereas Stop the Spread was “fast paced” and “challenging” but increased vaccination and health behaviour intentions. Conclusions: e-Bug games are an effective learning tool for students to increase knowledge around microbes, infection prevention and antibiotics. Game suggested improvements should help increase enjoyment.

How patient reported outcome measures from heiQ, HLQ and SF-36 can be used to follow people with COPD in an ehealth based 24/7 service, the ‘Epital Care Model’

From: Journal of Medical Internet Research

Date Submitted: May 2, 2018

Open Peer Review Period: May 5, 2018 - Jun 30, 2018

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Background: Individuals diagnosed with chronic obstructive pulmonary disease (COPD) live with the burden of progressive life-threatening condition that is often accompanied by anxiety and depression....

Background: Individuals diagnosed with chronic obstructive pulmonary disease (COPD) live with the burden of progressive life-threatening condition that is often accompanied by anxiety and depression. The severity of the condition is usually considered from a clinical perspective, and characterized according to the GOLD classification of severity that focuses on increasing symptoms and exacerbations (A through D) whereas information about perceived health or ability to manage the condition are rarely objectively included. Objective: To evaluate three patient-reported outcome measurements (PROMs) to understand how these can be used to report on individuals living with COPD supported by an innovative digitally assisted solution – the Epital, that aims to increase patient’s understanding and management of their condition to improve their wellbeing. Methods: A total of 93 individuals with COPD were enrolled. At entry and after six and twelve months, heiQ, HLQ and SF-36 PROMs were collected. The scores of the 19 PROM dimensions were related to COPD severity i.e. GOLD risk factor group, pulmonary function at entry and number of exacerbations over a three month period. Results: Only three dimensions showed significant differences between GOLD risk factor groups; heiQ3. Emotional distress (D and C, p<0.05), heiQ5. Constructive attitudes and approaches (D and C, p<0.01) and SF36 Physical health (D and A, p<0.001; D and B p<0.01), indicating more distress, poorer attitudes and poorer health status with increasing severity. heiQ3. Emotional distress was higher in group C than the other groups indicating less distress for this group. A similar pattern was seen in the SF36 Mental health score. As expected, pulmonary function (FEV1) was negatively associated with the severity of the condition (GOLD risk factor group) FEV1 was associated with increased heiQ2. Positive and active engagement in life (p<0.05), decreased heiQ3. Emotional distress (p<0.05), increased heiQ5. Constructive attitudes and approaches (p<0.001), increased heiQ8. Health service navigation (p<0.05), and also increased in SF36 Physical health (p<0.001). Furthermore, there was a negative association between FEV1 and HLQ 3. Actively managing my health (p<0.05). Only HLQ 8. Ability to find good health information was independently associated with reduced number of contacts over three months. After six months we observed an increase of heiQ 6. Skills and technical acquisition and a reduction in in heiQ 3. Emotional distress. The latter effect persisted after twelve months as did heiQ 4. Self-monitoring and insight had also increased. HLQ 3. Actively managing my health decreased after six and twelve months. Conclusions: The examined PROMs provides health professionals with new insights into individual’s ability to understand and manage their condition. In contrast to the Gold severity index, the PROMs did not predict number of contacts to a 24/7 available response and coordination center.

Crossing the digital divide in online self-management support: analysis of usage data from HeLP-Diabetes.

From: Journal of Medical Internet Research

Date Submitted: May 1, 2018

Open Peer Review Period: May 2, 2018 - Jun 27, 2018

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Background: Digital health is increasingly recognised as a cost-effective means to support patient self-care. However there are concerns about whether the “digital divide”, defined as the gap betw...

Background: Digital health is increasingly recognised as a cost-effective means to support patient self-care. However there are concerns about whether the “digital divide”, defined as the gap between those who do and do not make regular use of digital technologies will lead to increased health inequalities. Access to the internet, computer literacy, motivation to use digital health interventions, and fears about internet security are barriers to use of digital health interventions. Some of these barriers disproportionately affect people of older age, black or minority ethnic background, and low socioeconomic status. HeLP-Diabetes, a theoretically informed online self-management programme for adults with type 2 diabetes, was developed to meet the needs of people from a wide demographic background. Objective: The aim of the study was to determine whether there was evidence of a digital divide when HeLP-Diabetes was integrated into routine care, by comparing the characteristics of people who registered for the programme against the target population (people with type 2 diabetes in inner London); comparing the characteristics of people who registered for the programme and used it with those who did not use it; and comparing sections of the website visited by different demographic groups. Methods: A retrospective analysis of data on the use of HeLP-Diabetes in routine clinical practice in four inner London CCGs was undertaken. Data were collected from patients who registered for the programme as an NHS service. Data on gender, age, ethnicity and educational attainment were collected at registration, and data on webpage visits (user identification number, and date, time and page visited) were collected automatically by software on the server side of the website. Results: The characteristics of people who registered for the programme were found to reflect those of the target population. The mean age was 58 years (SD=30), over 50.0% were from black and minority ethnic backgrounds, and nearly a third (29.8%) had no qualifications beyond school leaving age. There was no association between demographic characteristics and use of the programme, apart from weak evidence of less use by the mixed ethnicity group. There was no evidence of differential use of the programme by any demographic group, apart from weak evidence for people with degrees and school leavers being more likely to use the “Living and working with diabetes” (p=0.03) and “Treating diabetes” (p=0.04) sections of the website. Conclusions: This study is one of the first to provide evidence that a digital health intervention can be integrated into routine health services without widening health inequalities. The relative success of the intervention may be attributed to integration into routine health care, and careful design with extensive user input and consideration of literacy levels. Developers of digital health interventions need to acknowledge barriers to access and use, and collect data on the demographic profile of users, in order to address inequalities. Clinical Trial: N/A

Evaluation of Clinical Effect in Routine Secondary Care of Guided Internet Based CBT for Adult Depression and Anxiety: An Observational Study

From: Journal of Medical Internet Research

Date Submitted: May 1, 2018

Open Peer Review Period: May 2, 2018 - Jun 27, 2018

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Background: Internet-based cognitive behavioural therapy (iCBT) is a promising new treatment format for depression and anxiety. However, it is important to establish whether results can be transferred...

Background: Internet-based cognitive behavioural therapy (iCBT) is a promising new treatment format for depression and anxiety. However, it is important to establish whether results can be transferred into routine care before implementing it on a large scale. While ample studies have demonstrated its efficacy under controlled conditions, fewer studies have investigated its effectiveness in routine care. Furthermore, the picture is blurred, with treatment effects in routine care ranging from none to very large. Objective: The objective of the present study was to evaluate the clinical effectiveness of iCBT for depression and anxiety in routine secondary care. Methods: A retrospective cohort design was used analysing N=203 patients treated for either depression or anxiety in a dedicated iCBT clinic in secondary care in Denmark. Patients were measured before commencing treatment and subsequently weekly. Baseline and last observation were used as pre- and post-intervention time points. Outcome measures were the Patient Health Questionnaire-9 and the Generalised Anxiety Disorder-7 scale for the two diagnoses respectively. Primary analyses were conducted using a linear mixed-effects model. Secondary analyses were conducted using baseline characteristics as predictors (gender, age, highest level of education, occupational status, marital status, psychotropic medication use, consumption of alcohol and leisure drugs). Additionally, logistic regressions were performed to predict non-completion of treatment. Results: The primary analyses revealed large and significant reductions in symptomatic levels of depression (ß=-6.27, SE=0.83, p<.001, d=1.0) and anxiety (ß=-3.78, SE=0.43, p<.001, d=1.1). In all, 62% and 40%, respectively, completed depression and anxiety treatment. Baseline severity of primary disorder was associated with higher treatment gains, which for anxiety patients also predicted higher risk of non-completion. Higher baseline severity of comorbid disorder increased risk of non-completion for both disorders. Being unemployed predicted higher risk of non-completion for depression OR=7.50, CI=1.40 – 59.25, p=.028. Time spend with the program predicted a slight increase in improvement for depressed patients ß=-0.03 SE=0.01, p=.012, but not for anxiety patients. Conclusions: The results support the hypothesis that iCBT can be an effective treatment when implemented in routine secondary care, in line with previous cohort studies conducted by similar clinics. The results are even comparable to within-group results found in efficacy and effectiveness studies. Non-completion rates of 38% for depressed patients and 60% for anxiety patients resemble those observed in psychotherapy in general but were higher than those seen in similar clinics. Multiple factors predicted outcome and non-completion. However, all predictor effects were statistically relatively weak. The main results of the present investigation are important findings, since depression and anxiety are costly and debilitating disorders that are vastly under-treated. These findings support that ICBT may be able to help bridge this gap between the need for treatment and its provision.

Measuring the Impact of an Open Online Prescribing Data Analysis Service on Clinical Practice: a Cohort Study in NHS England Data

From: Journal of Medical Internet Research

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: OpenPrescribing is a freely accessible service that enables any user to view and analyse NHS primary care prescribing data at the level of individual practices. This tool is intended to im...

Background: OpenPrescribing is a freely accessible service that enables any user to view and analyse NHS primary care prescribing data at the level of individual practices. This tool is intended to improve the quality, safety, and cost-effectiveness of prescribing. Objective: We set out to measure the impact of OpenPrescribing being viewed on subsequent prescribing. Methods: Having pre-registered our protocol and code, we measured three different metrics of prescribing quality (mean percentile across 34 existing OpenPrescribing quality measures, available “price-per-unit” savings, and total “low-priority prescribing” spend) to see if they changed after CCG and practice pages were viewed. We also measured whether practices whose data were viewed on OpenPrescribing differed in prescribing, prior to viewing, to those who were not. We used fixed effects and between effects linear panel regression, to isolate change over time and differences between practices respectively. We adjusted for month of prescribing in the fixed effects model, to remove underlying trends in outcome measures. Results: We found a reduction in available price-per-unit savings for both practices and CCGs after their pages were viewed. The saving was greater at the practice level (-£40.42 per thousand patients per month, 95% confidence interval -54.04 to -26.01) than at CCG level (-£14.70 per thousand patients per month, 95% confidence interval -25.56 to -3.84). We estimate a total saving since launch of £243k at practice level and £1.47m at CCG level between the feature launch and end of follow-up (August to November 2017) among practices viewed. If the observed savings from practices viewed were extrapolated to all practices, this would generate £26.8m in annual savings for the NHS, approximately 20% of the total possible savings from this method. The other two measures were not different after CCGs/practices were viewed. Practices which were viewed had worse prescribing quality scores overall, prior to viewing. Conclusions: We found a clinically significant positive impact from use of OpenPrescribing, specifically for the class of savings opportunities that can only be identified by using this tool. We also show that it is possible to conduct a robust analysis of the impact of such an online service on clinical practice.

Evaluating Mobile Health Application on Customized Dietary Recording for Young Adults and Elders Using Randomized Trials

From: JMIR mHealth and uHealth

Date Submitted: May 3, 2018

Open Peer Review Period: May 7, 2018 - Jul 2, 2018

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Background: The role of individual-tailored dietary recording in mobile phone health applications has become increasingly important in management of self-healthcare and population-based preventive ser...

Background: The role of individual-tailored dietary recording in mobile phone health applications has become increasingly important in management of self-healthcare and population-based preventive service. The development such mobile applications for user-centered designing is still challengeable and requires further scientific evidence. Objective: This study aims to conduct the randomized trial to assess the accuracy and efficiency of the two prototypes for dietary recoding utilization, including designs of SCT (self-chosen tab) and AEL (autonomous exhaustive list) for individual dietary intakes. Methods: We first present an innovative combinatorial concept for dietary recording to account for dish variation. The SCT features with choosing each food ingredient to synthesize an individual dish, while the AEL provides one selection from a comprehensive list of dish items. The concept includes commercial available choices that allow users to more accurately account for their individual food selection. The two mobile applications were implemented for further head-to-head parallel randomized trial evaluation. Young adults (n = 70) and older adults (n=35) were recruited and randomized into two groups for accuracy and response time evaluation based on 12 types of food items in use of the developed SCT and AEL respectively. Results: Using the trial based on SCT (53 participants) and AEL groups (52 participants), the two prototypes were found to be highly effective on accuracy (above 98%). SCT was found to be more timely efficient, requiring significantly less time for input of 11 of the 12 items (p<0.05). SCT users occasionally neglected to select food attributes, an issue which did not occur in AEL. Conclusions: Our study contributes through the scientific evaluation of the transformation step into prototype development to demonstrate that SCT has a better opportunity in effectiveness and efficiency. The combinatorial concept offers potential for dietary recording and planning which can account for high food item variability. Our findings on prototype development of diversified dietary recording provide design consideration and user interaction for related further application development and improvement. Clinical Trial: ISRCTN86142301 https://doi.org/10.1186/ISRCTN86142301

Usability evaluation of a mobile phone- based system for remote monitoring and management of chemotherapy-related side effects in Canadian cancer patients

From: Journal of Medical Internet Research

Date Submitted: May 3, 2018

Open Peer Review Period: May 7, 2018 - Jul 2, 2018

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Background: Most chemotherapy is administered in the outpatient setting; therefore, patients are required to manage related side effects at home without direct support from health professionals. The...

Background: Most chemotherapy is administered in the outpatient setting; therefore, patients are required to manage related side effects at home without direct support from health professionals. The Advanced Symptom Management System (ASyMS) has been developed to facilitate the remote monitoring and management of chemotherapy-related toxicity in patients with cancer, using standardized patient-reported outcomes (PRO) questionnaires. Objective: Our goal was to evaluate usability of this mobile phone-based technology from the perspective of Canadian cancer patients receiving chemotherapy where the objectives were to elicit their views, experiences and satisfaction with ASyMS and identify existing design, functionality, and usability issues. Methods: A mixed-method approach to data collection with user-based testing, think aloud technique, semi-structured interviews, and short answer questionnaires was used with 10 cancer patients. Patients attended usability testing sessions at the Centre for Global eHealth Innovation, UHN. Participants performed specific tasks on the ASyMS device. The test was video recorded and each task was timed during the test. After the usability sessions, patients completed the post-test questionnaire and participated in a semi-structured interview. Thematic analysis was used to code and categorize the identified issues according to the type and frequency of occurrence. Also, a set of variables related to the participant’s performance including the number of errors each participant made, requests for help, the time taken to complete the task, participant feedback, and reviewing the videos was used to identify a list of usability issues. Results: The thematic analysis generated three over-arching themes: (1) ASyMS user- friendliness, (2) Usefulness of the ASyMS (content quality & richness), and (3) Intention to use. Results from the post-test questionnaire indicate that 80% of participants (n=8) had great motivation to use the ASyMS, 70% (n=7) had positive perceptions of the successful use of the ASyMS, and all (n=10) had positive attitude towards using the ASyMS in future. Most identified design and functionality issues are related to the navigation of the ASyMS, using more advanced and attractive design with better functionality and features. Conclusions: The ASyMS has shown positive perceptions by patients; however, evaluation of the ASyMS through a trial is needed. Clinical Trial: N/A

Processing of Electronic Medical Record for Health Services Research in Academic Medical Centre: Methods and Validation

From: JMIR Medical Informatics

Date Submitted: May 2, 2018

Open Peer Review Period: May 5, 2018 - Jun 30, 2018

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Background: Electronic medical records (EMRs) contain a wealth of information that can support data-driven decision making in healthcare policy design and service planning. Although research using EMR...

Background: Electronic medical records (EMRs) contain a wealth of information that can support data-driven decision making in healthcare policy design and service planning. Although research using EMRs has become increasingly prevalent, challenges such as coding inconsistency, data validity and lack of suitable measures in important domains still hinder the progress. Objective: Our objective is to design a structured way to process records in administrative EMR systems for health services research and assess validity in selected areas. Methods: Based on a local hospital EMR system in Singapore, we developed a structured framework for EMR data processing, including standardization and phenotyping of diagnosis codes, construction of cohort with multi-level views, and generation of variables and proxy measures to supplement primary data. Disease complexity was estimated by Charlson Comorbidity Index (CCI) and Polypharmacy Score (PPS), while socioeconomic status (SES) was estimated by housing type. Validity of modified diagnosis codes and derived measures were investigated. Results: Visit level (N=7,778,761) and patient level records (n=549,109) were generated. Diagnosis codes were standardized to ICD-9-CM with a mapping rate of 97.5%. 97.4% of the ICD-9-CM codes were phenotyped successfully using Clinical Classification Software (CCS). Diagnosis codes that underwent modification (truncation or zero-addition) in standardization and phenotyping procedures had the modification validated by physicians, with validity rates of more than 90%. Disease complexity measures (CCI and PPS) and SES were found to be valid and robust after a correlation analysis and a multivariate regression analysis. CCI and PPS were correlated with each other, and positively correlated with healthcare utilization measures. Larger housing type was associated with lower government subsidies received, suggesting association with lower SES. Profile of constructed cohorts showed differences in disease prevalence, disease complexity and hospital utilization was found in those aged above 65 and those below. Conclusions: The framework proposed in this study would be useful for other researchers working with EMR data for health services research. Further analyses would be needed to better understand differences observed in the cohorts.

ICUTogether a web based recovery program for intensive care survivors: a randomized controlled trial protocol

From: Journal of Medical Internet Research

Date Submitted: May 2, 2018

Open Peer Review Period: May 5, 2018 - Jun 30, 2018

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Background: Those who experience a critical illness/event requiring admission to an intensive care unit frequently experience physical and psychological complications as a direct result of their criti...

Background: Those who experience a critical illness/event requiring admission to an intensive care unit frequently experience physical and psychological complications as a direct result of their critical illness/event and intensive care unit experience. Complications, if left untreated, can affect the quality of life of survivors and impact upon health care resources. Explorations of potential interventions to reduce the negative impact of an intensive care unit experience have failed to establish an evidence based intervention. Objective: The aim of this study is to evaluate the impact of a web based intensive care recovery program on the mental well-being of intensive care survivors and to determine if it is a cost effective approach. Methods: One hundred and sixty-two patients that survived an intensive care unit experience will be recruited and randomized into one of two groups. The intervention group will receive access to the web based intensive care recovery program, ICUTogether, two weeks after discharge (n=81) and the control group will receive usual care (n=81). Mental well-being will be measured using the Hospital Anxiety and Depression Scale, The Impact of Events Scale-Revised and the EQ-5D at three time points (2 weeks, 6 months and 12 months post discharge). Analysis will be conducted on an intention to treat basis using regression modelling. Covariates will include baseline outcome measures, study allocation (intervention or control), age, gender, length of intensive care unit stay, Apache III score, level of family support and hospital readmissions. Participants’ evaluation of the mobile website will be sought at 12 months post discharge. A cost utility analysis conducted at 12 months from a societal perspective will consider costs incurred by individuals as well as health care providers. Discussion: This study will evaluate a novel intervention in a group of intensive care unit survivors. The findings from this study will inform a larger study and the wider debate about an appropriate intervention in this population. Trial Registration: Australian New Zealand Clinical Trial Registry: ACTRN12618000252213

Effect of a Mobile Application on Preoperative Patient Preparation for Major Ambulatory Surgery: Protocol for a Randomized Clinical Trial

From: JMIR Research Protocols

Date Submitted: May 11, 2018

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

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Background: Inadequate preoperative patient preparation causes organizational, economic, and emotional problems in patients and professionals. In a context of increasing healthcare burdens, introducin...

Background: Inadequate preoperative patient preparation causes organizational, economic, and emotional problems in patients and professionals. In a context of increasing healthcare burdens, introducing innovative tools based on mobile Health Apps can have a significant effect on healthcare systems. Objective: To evaluate the effectiveness of the Listeo+ mobile Health App as a tool for improving adherence to preoperative recommendations in major ambulatory surgery (MAS) versus standard of care (SoC). Methods: A multicenter, randomized, open-label clinical trial that compares SoC to the additional use of Listeo+, a specific mobile Health App for MAS preoperative patient monitoring, is being conducted. The study will include patients aged ≥18 years with surgical indication for MAS who meet the necessary technological and connectivity requirements. Patients in the control group will receive written preoperative recommendations, and those in the intervention group will additionally use the Listeo+ mobile Health App. There will be a competitive recruitment of 790 patients during six months in four hospitals of Andalusia (Spain) that belong to the National Health System. The main efficacy variable is adherence to preoperative recommendations. Secondary variables include the rate of cancellations, associated resource consumption, and perceived usability and utility with Listeo+ by participants of the intervention group. Results: The technological development of Listeo+ and the integration and interoperability of the information systems was completed in September 2017. Subsequently, simulation tests were performed with Listeo+, and a pilot study was initiated with real patients that concluded successfully in October 2017. Patient recruitment began in December 2017 in the four participating centers. After an intermediate analysis performed six months after the start of the recruitment phase, it is expected that the phases of data collection, data cleaning, and final data analysis will be completed in June 2018. Conclusions: Progress in the integration and interoperability of information systems represents a major step forward in the field of mobile health (mHealth).

Neurological Disorders in Central Spain, second survey (NEDICES-2): Pilot study, difficulties and findings

From: JMIR Research Protocols

Date Submitted: May 2, 2018

Open Peer Review Period: May 24, 2018 - Jun 7, 2018

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Background: NEDICES (Neurological Disorders in Central Spain) was a prospective population-based epidemiological survey of elderly subjects with few laboratory data. For this reason, a NEDICES-2 surve...

Background: NEDICES (Neurological Disorders in Central Spain) was a prospective population-based epidemiological survey of elderly subjects with few laboratory data. For this reason, a NEDICES-2 survey with analogous aims was designed to collect data from approximately 8,000 participants selected from the Spanish National Health System and to establish an associated biobank. Objective: To assess all aspects of the planned NEDICES-2 survey using a selection of the entire population in several study areas (rural and urban). Methods: The pilot study applied the same clinical methods of the original NEDICES, while adding procedures to establish bio-banks (blood, urine, saliva and nails). Results: 569 study participants were enrolled (198 from hospitals and 371 from the study areas). Of these, 310 completed all study procedures (questionnaires and the neurological evaluation). Only 3.8% of the target population refused to participate. A few primary care physicians from some areas were unable to participate, which led to reconfiguration of study areas included. Also, the central biobank needed to be supplemented by local biobanks at local Spanish National Health System hospitals. Conclusions: This study shows that complex population surveys, such as NEDICES-2, require a pilot study to evaluate the procedures. The main NEDICES-2 field survey is currently underway.

Estimating Determinants of Attrition in Online Eating Disorder Community: An Instrumental Variables Approach

From: Journal of Medical Internet Research

Date Submitted: May 6, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: The use of social media as key health-information source has increased steadily among people affected by eating disorders. Intensive research has examined characteristics of individuals en...

Background: The use of social media as key health-information source has increased steadily among people affected by eating disorders. Intensive research has examined characteristics of individuals engaging in online communities, while little is known about discontinuation of engagement and the phenomenon of participants dropping out of these communities. Objective: This study aims to investigate characteristics of dropout behaviors among eating disordered individuals on Twitter and to estimate the causal effects of personal emotions and social networks on dropout behaviors. Methods: Using a snowball sampling method, we collected a set of individuals who self-identified with eating disorders in their Twitter profile descriptions, as well as their tweets and social networks, leading to 241,243,043 tweets from 208,063 users. Individuals’ emotions are measured from their language use in tweets using an automatic sentiment analysis tool, and network centralities are measured from users’ following networks. Dropout statuses of users are observed in a follow-up period 1.5 years later (from Feb. 11, 2016 to Aug. 17, 2017). Linear and survival regression instrumental variables models are used to estimate the effects of emotions and network centrality on dropout behaviors. An individual’s attributes are instrumented with the attributes of the individual’s followees (i.e., people who are followed by the individual). Results: Eating disordered users have relatively short periods of activity on Twitter, with one half of our sample dropping out at 6 months after account creation. Active users show more negative emotions and higher network centralities than dropped-out users. Active users tend to connect to other active users, while dropped-out users tend to cluster together. Estimation results suggest that users’ emotions and network centralities have causal effects on their dropout behaviors on Twitter. More specifically, users with positive emotions are more likely to drop out and have shorter-lasting periods of activity online than users with negative emotions, while central users in a social network have longer-lasting participation than peripheral users. Findings on users’ tweeting interests further show that users who attempt to recover from eating disorders are more likely to drop out than those who promote eating disorders as a lifestyle choice. Conclusions: Presence in online communities is strongly determined by individual’s emotions and social networks, suggesting that studies analyzing and trying to draw condition and population characteristics through online health communities are likely to be biased. Future research needs to examine in more detail the links between individual characteristics and participation patterns if better understanding of the entire population is to be achieved. At the same time, such attrition dynamics need to be acknowledged and controlled for when designing online interventions so as to accurately capture their intended populations.

Barriers and Opportunities to Use Wearable Devices to Increase Physical Activity Among Veterans: A Qualitative Study

From: JMIR mHealth and uHealth

Date Submitted: May 2, 2018

Open Peer Review Period: May 7, 2018 - Jul 2, 2018

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Background: Few studies have examined the use of wearable devices among the veteran population. Objective: To evaluate veterans’ perceptions of and experiences with wearable devices and identify pot...

Background: Few studies have examined the use of wearable devices among the veteran population. Objective: To evaluate veterans’ perceptions of and experiences with wearable devices and identify potential barriers and opportunities to using such devices to increase physical activity levels in this population. Methods: Veterans able to ambulate with or without assistance completed surveys about their mobile technology use and physical activity levels. They were then given the option of using a wearable device to monitor their activity levels. Follow-up telephone interviews were conducted after 2 months. Results: 16 veterans were enrolled in this study, and all 16 agreed to take home and use the wearable device to monitor their activity levels. At follow-up, 90.9% (10/11) were still using the device daily. Veterans identified both opportunities and barriers to incorporating these devices into interventions to increase physical activity. Conclusions: Veterans engaged in using wearable devices at high rates.

Investigating Efficacy and Feasibility of a Multi-Modal Digital Psychotherapy Platform for Adult Depression

From: JMIR mHealth and uHealth

Date Submitted: May 2, 2018

Open Peer Review Period: May 7, 2018 - Jul 2, 2018

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Background: Although psychotherapy is one of the most efficacious treatments for depression, limited accessibility to trained providers significantly limits access to care. Many digital platforms seek...

Background: Although psychotherapy is one of the most efficacious treatments for depression, limited accessibility to trained providers significantly limits access to care. Many digital platforms seeking to provide these services using digital modalities (e.g. video, text, chat) have been developed in an attempt to overcome this obstacle. However, use of these modalities individually poses barriers to intervention access and acceptability. Multi-modal platforms, comprising those that allow users to select from a number of available modalities, may provide a solution to these concerns. Objective: We investigated the efficacy and feasibility of a multi-modal digital psychotherapy platform, also examining differential responses to intervention by gender, physical status, and health status, plus the ways in which prior exposure to traditional face-to-face psychotherapy affected response to multi-modal digital psychotherapy. Finally, we examined the dose-effect relations. Methods: Data was collected from a total of 318 active users of BetterHelp, a multi-modal digital psychotherapy platform. Information on physical status, health status, and prior exposure to psychotherapy was obtained using self-report measures. Symptom change was measured using the PHQ-9 at Time 1 (time of enrollment) and Time 2 (3 months after enrollment). Intervention dosage was measured as the sum of individual therapist-user interactions across modalities. Results: Depression symptom severity significantly reduced after use of the multi-modal digital psychotherapy intervention (P < .001). Individuals without prior traditional psychotherapy experience revealed increased improvement after intervention (P = .006). We found no significant dose-response of therapy, nor significant differences in outcomes across gender, financial status, or physical health status. Conclusions: Users of BetterHelp experienced significantly reduced depression symptom severity after engaging with the platform. Findings suggest that this intervention is equally effective across gender, financial status, and physical health status, and particularly effective for individuals without a history of psychotherapy. Taken together results of the study suggest that multi-modal digital psychotherapy is a potentially efficacious treatment for adult depression; experimental trials are needed. Implications for treatment delivery are discussed.

Physician Use of Electronic Health Records: Factors Associated with Provider Reported Satisfaction and Perceived Patient Impact

From: Journal of Medical Internet Research

Date Submitted: May 2, 2018

Open Peer Review Period: May 5, 2018 - Jun 30, 2018

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Background: The effect electronic health record (EHR) implementation has on physician satisfaction and patient care remains unclear. A better understanding of physicians’ perceptions of EHR’s and...

Background: The effect electronic health record (EHR) implementation has on physician satisfaction and patient care remains unclear. A better understanding of physicians’ perceptions of EHR’s and factors that influence those perceptions is needed to improve the physician and patient experience when using EHR’s. Objective: The objective of this study was to determine provider and clinical practice factors associated with physicians’ EHR satisfaction and perception of patient impact. Methods: We surveyed a random sample of physicians, including residents and fellows, at a quaternary care academic hospital from February to March 2016. The survey assessed provider demographics, clinical practice factors, and overall EHR experience. The primary outcomes assessed were providers’ satisfaction and the providers’ perception of impact to patient care. Responses on the satisfaction and patient impact questions were recorded on a continuous scale initially anchored at neutral (scale range 0-100 with 0 defined as extremely negatively and 100 as extremely positively). Independent variables assessed included demographic and clinical practice factors including perceived efficiency in using the EHR. One-way analysis of variance or the Kruskal-Wallis Test was used for bivariate comparisons and linear regression was used for multivariable modeling. Results: 111 of 157 physicians (71%) completed the survey. 51% of the respondents were attending physicians, and of those, 72% reported a > 50% clinical FTE and half reported supervising residents >50% of the time. 36% of the respondents were primary care practitioners and previous EHR experience was evenly distributed. 13% of the total sample were EHR super users. Responses to how our current EHR affects satisfaction were rated above the neutral survey anchor point (mean=58, std. dev 22) as were their perceptions as to how the EHR impacts the patient (mean=61, std. dev 18). In bivariate comparisons, only physician age, clinical role (resident, fellow, or attending), and perceived efficiency were associated with EHR satisfaction. In the linear regression models, physicians with higher reported perceived efficiency reported higher overall satisfaction and patient impact after controlling for other variables in the model. Conclusions: Physician satisfaction with EHRs and their perception of its impact on clinical care were generally positive but physician characteristics, greater age and attending physician, were associated with worse EHR satisfaction. Perceived efficiency is the factor most associated with physicians’ satisfaction with EHRs when controlling for other factors. Understanding physician perceptions of EHRs may allow targeting of technology resources to ensure efficiency and satisfaction with EHR system use during clinical care.

Protocol: Innovate Dementia 2.0: a user-driven living lab for assistive technology to support people living at home with dementia.

From: JMIR Research Protocols

Date Submitted: May 13, 2018

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

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Background: As there is currently no cure for dementia, there is an urgent need to look at alternative ways to support people with dementia (PWD) and their informal caregivers. Carefully designed inte...

Background: As there is currently no cure for dementia, there is an urgent need to look at alternative ways to support people with dementia (PWD) and their informal caregivers. Carefully designed interventions can answer the unmet needs of both PWD and their informal caregivers in the community. However, existing products, systems and services are often too complex or unsuitable. Objective: To stimulate person-centered innovations for PWD and their informal caregivers. Methods: A user-driven living lab design is used to structurally explore the needs of PWD and their informal caregivers over time and to develop co-created based innovations which are tested and evaluated in real life situations. All informal caregivers will complete questionnaires at three time points: at baseline, one year and two years after they start participating. Outcomes include neuropsychiatric symptoms, cognitive decline, independence in activities of daily living, safety and caregiver burden. Focus groups which meet on a monthly basis identify the needs of the PWD and their informal caregivers and provide feedback to the stakeholders. In the context field studies participants have the opportunity to actually test the products at home and to provide feedback. Results: The longitudinal quantitative data obtained from the questionnaires will be explored using both multilevel and multivariate regression analyses. The qualitative data obtained from the interviews, the focus groups and the context field studies will be analyzed using descriptive statistics and frequencies. Conclusions: The overall aim of Innovate Dementia (ID) 2.0 is to facilitate person-centered innovations developed for PWD and their informal caregivers at all stages as the dementia progresses. This should lead to newly designed concepts which are more able to answer the unmet needs of PWD and their caregivers.

Enhancing Privacy Controls for Patients via a Selective Authentic EHR Exchange Service – Perspectives by Medical Professionals and Patients

From: Journal of Medical Internet Research

Date Submitted: May 3, 2018

Open Peer Review Period: May 7, 2018 - Jul 2, 2018

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Background: Patients’ privacy is regarded as essential for the patient-doctor relationship. One example for a privacy-enhancing technology for user-controlled data minimization on content level is a...

Background: Patients’ privacy is regarded as essential for the patient-doctor relationship. One example for a privacy-enhancing technology for user-controlled data minimization on content level is a redactable signature. It enables users to redact personal information from signed documents while preserving the validity of the signature and thus the authenticity of the document. In this paper, we present end users’ evaluations of a Selective Authentic EHR Exchange Service (SAE-service) in an eHealth use-case. In the use-case scenario, patients are given control to redact specified information fields in their electronic health records, which were signed by their doctors with a redactable signature and transferred to them into a cloud platform. They can then selectively disclose the remaining information in the EHR, which still bears the valid digital signature, to third parties of their choice. Objective: To explore the perceptions, attitudes and mental models concerning the SAE-service of both medical professionals and patients with different backgrounds. Another objective is to elicit usability requirements for this service based on our analysis. Methods: We chose empirical qualitative methods to address our research objective. Designs of mock-ups for the service were used as part of our User-centered Design approach in our studies with test participants from Germany and Sweden. Thirteen individual walk-throughs/interviews were conducted with medical staff to investigate the EHR signers’ perspectives. Moreover, five group walk-throughs in focus groups sessions with (N= 32) prospective patients with different technical knowledge to investigate redactor’s perspective of EHR data redaction control were used. Results: Our study participants showed to have correct mental models in regard to the redaction process. Users with some technical models lacked trust in the validity of the doctor’s signature on the redacted documents. Main results to be considered are the requirements concerning the accountability of the patients’ redactions and the design of redaction templates for guidance and control. Conclusions: For the SAE-service to be means for enhancing patient control and privacy, the diverse usability and trust factors of different user groups should be considered.

Online Peer-to-Peer Mentoring Support for Youth with Hemophilia: A Qualitative Needs Assessment

From: JMIR Pediatrics and Parenting

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: To support adolescents through transition from pediatrics to adult care, health care providers and families help teens to gain knowledge and develop self-management skills. Peer mentoring...

Background: To support adolescents through transition from pediatrics to adult care, health care providers and families help teens to gain knowledge and develop self-management skills. Peer mentoring can provide meaningful support and has been associated with improved health outcomes in other chronic conditions. Peer mentoring is an appealing way to provide support, but it is imperative to consider this unique group’s needs to ensure its success. Objective: To identify the peer mentoring wants and needs of youth with hemophilia in order to guide the development of a new program. Methods: A qualitative study interviewed a convenience sample of youth with hemophilia from two Canadian hemophilia treatment centers. Two iterative cycles of audio-recorded semi-structured individual interviews were conducted. Descriptive statistics and content analyses were used to organize data into categories that reflected emerging themes. Results: Twenty-three participants were recruited between the ages of 12 to 20 years (average age =14.91 ± 2.57). When asked about program design, participants weighed the importance of flexibility in delivery (e.g. online, in-person, texting), content (e.g. structured vs. unstructured), frequency of sessions, and length of the program. Participants identified some potential challenges such as scheduling issues, comfort level of disease discussion, and discordant mentor-mentee personality types. The program was viewed as a positive medium for connecting peers with hemophilia. Conclusions: Adolescents with hemophilia expressed interest in a peer mentoring program and provided valuable insight that will be applied in the development of a peer mentoring program for youth with hemophilia.

Effect of a web-based versus face to face lifestyle intervention on perceived benefits and barriers to exercise in midlife women: A three arm equivalency study.

From: Journal of Medical Internet Research

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: Noncommunicable diseases (NCD) account for more than 18 million deaths in women annually, with many of these deaths being attributed to modifiable risk factors like physical inactivity. Wo...

Background: Noncommunicable diseases (NCD) account for more than 18 million deaths in women annually, with many of these deaths being attributed to modifiable risk factors like physical inactivity. Women perceive a range of benefits and barriers to exercise, however, there is little evidence about the effect of different lifestyle intervention delivery modes on perceptions of exercise. Objective: This study compares the effect of a multiple health behavior change intervention called the Women’s Wellness Program or WWP. This intervention was delivered in three different modes on perceived exercise benefits, perceived exercise barriers, and actual physical activity and exercise in midlife women. Methods: Women aged 45 to 65 years were recruited via the study website. Women were assigned in blocks to three different treatment groups (A. online independent; B. face-to-face with nurse consultations, and; C. online with virtual nurse consultations). All participants received the 12 week intervention that utilises principles from social-cognitive theory to provide a structured guide to promote healthy lifestyle behaviours with an emphasis on regular exercise and healthy eating. Data were collected using self-report online questionnaire at baseline (T1) and post intervention (T2) including perceived exercise benefits and barriers (EBBS) and exercise and physical activity (SPA). Data analysis examined both within and between groups changes over time. Results: Participants in this study (n = 225) had a mean age of 50.9 years ± 5.9 and most were married or living with a partner (83.3%, n = 185). Attrition was 30.2% with 157 participants completing the final questionnaire. Women in all intervention groups reported a significant increase in positive perceptions of exercise (p < .05); a significant increase in exercise and overall physical activity (p > .01), with moderate to large effect sizes noted for overall physical activity (d = .5 - .87). Participants receiving support from registered nurses in the face to face and online groups, had a greater magnitude of change in benefits perceptions and physical activity compared to the online independent group. There was no significant change in exercise barriers perceptions within or between groups over time. Conclusions: Results of this study suggest the multiple health behaviour change intervention can be effective in increasing exercise benefits perceptions, overall physical activity and exercise in midlife women. While web-based programs are cost effective, flexible and can be delivered remotely, providing a range of options including face to face group delivery and personalised e-health coaching from registered nurses, has potential to enhance participant engagement and motivation. Clinical Trial: ANZCTR: ACTRN12616001189415

Implementations of Virtual Reality for Anxiety-related Disorders: A Systematic Review

From: JMIR Serious Games

Date Submitted: May 9, 2018

Open Peer Review Period: May 12, 2018 - Jul 7, 2018

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Background: While traditional forms of therapy for anxiety-related disorders (e.g.: cognitive-behavioural therapy) have been effective, there have been longstanding issues with these therapies that la...

Background: While traditional forms of therapy for anxiety-related disorders (e.g.: cognitive-behavioural therapy) have been effective, there have been longstanding issues with these therapies that largely centre around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (e.g.: weather, bystander behaviour), or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for VR exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems should improve to provide the best care possible. Objective: The aim of this review was to establish the efficacy of virtual reality-based treatment for anxiety-related disorders, as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems. Methods: A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published prior to 31-August-2017 within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated. Results: A total of 49 studies met the inclusion criteria from an initial pool of 2,419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET to various forms of CBT (e.g.: in-vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favour of VRET despite the VR technology’s limitations. Conclusions: Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve in order to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world.

Supporting Systematic Assessment of Digital Interventions: A Framework for Analysing and Measuring Usage and Engagement Data (AMUsED)

From: Journal of Medical Internet Research

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Introduction: Trials of digital behavior change interventions (DBCIs) can yield extensive, in-depth usage data, yet usage analyses tend to focus on broad descriptive summaries of how an intervention h...

Introduction: Trials of digital behavior change interventions (DBCIs) can yield extensive, in-depth usage data, yet usage analyses tend to focus on broad descriptive summaries of how an intervention has been used by the whole sample. This paper proposes a novel framework to guide systematic, fine-grained usage analyses that better enables understanding of how an intervention works, when and for whom. Framework description: The framework comprises three stages to assist: 1) familiarisation with the intervention and its relationship to the captured data; 2) identification of meaningful measures of usage and specifying research questions to guide systematic analyses of usage data; 3) preparation of datasheets, and consideration of available analytical methods with which to examine the data. Framework application: The framework can be applied to inform data capture during the development of a DBCI and/or in the analysis of data after the completion of an evaluation trial. We will demonstrate how the framework shaped preparation and aided efficient data capture for a DBCI to lower transmission of cold and flu viruses in the home, and informed a systematic in-depth analysis of usage data collected from a separate DBCI designed to promote self-management of colds and flu. Conclusions: The AMUsED framework guides systematic and efficient in-depth usage analyses that will support standardized reporting with transparent and replicable findings. These detailed findings will also enable examination of what constitutes effective engagement with particular interventions.

Systematic Review of Augmented Reality in Healthcare

From: JMIR mHealth and uHealth

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: Augmented Reality (AR) offers a new way to approach Education in Medicine, planning a Surgery or treating Patients suffering from fear of small animals. Objective: This Review paper offers...

Background: Augmented Reality (AR) offers a new way to approach Education in Medicine, planning a Surgery or treating Patients suffering from fear of small animals. Objective: This Review paper offers an overview of the development of Applications in the objective AR with a medical use case within the time range from 03/2012 to 06/2017. Methods: In total 1068 publications from PubMed of the last five years have been manually analyzed and categorized based upon a pre-defined taxonomy. 689 publications have been excluded, i.e. due to wrong classification or unavailable technical data. The remaining 267 publications were original research on AR and 68 reviews from medical subfields. An assessment of the maturity of projects has been applied to the remaining publications using Technology Readiness Levels (TRL). To provide a comprehensible process of inclusion and exclusion the authors followed the PRISMA statement. Results: The results show an increasing trend in publications on AR used in health care. There is no relevant number of clinical trials on the effect of AR in healthcare. Domains that make use of displays and other technologies seem to be more researched than other medical fields. The TRL showed that AR technology is following a rough bell curve around the levels 4-7. Current AR technology is more often applied in treatment scenarios then in training. Conclusions: This work discusses the applicability and future development of mixed reality technologies such as wearable computers and AR devices. The field of AR is well researched, and there is a positive trend, but it is in an early stage in medicine and not widely adopted in clinical practice. It still lacks clinical studies proving the effectiveness of applied AR technologies.

Increasing Need for an eHealth Impact Framework for Africa

From: Journal of Medical Internet Research

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: Efforts by African countries to improve healthcare and citizens’ health within challenging resource limitations put considerable pressure on investment decisions. eHealth is believed to...

Background: Efforts by African countries to improve healthcare and citizens’ health within challenging resource limitations put considerable pressure on investment decisions. eHealth is believed to have potential to strengthen health systems and is now seen by some entities as a determinant of health, yet its impact is not well estimated in advance or measured after implementation. This is an obstacle to the effective allocation of healthcare resources and limits national and regional abilities to develop eHealth and realise its potential in health systems transformation. Objective: A broad conceptual framework for appraising eHealth impact could help selection of the best course of action by informing individual steps, including: identification of promising initiatives, choosing between eHealth options, motivating for financing, managing implementation, preparing for obsolescence, analysing achievements, and promoting sustainability. Such insight could help strengthen and transform healthcare, provide benchmarks for oversight and Monitoring and Evaluation (M&E), and improve individual and population health. Such frameworks exist, but do not address the needs of African countries. Methods: Desktop literature review to explore African countries’ eHealth context and the need for an eHealth economic appraisal framework. Results: Unique aspects of Africa’s health context are elucidated, particularly relating to resource constraints and health strengthening priorities. The influence of these aspects on eHealth development, and how to address factors such as affordability, value for money and risk, are highlighted. Key eHealth appraisal terms are clarified. Conclusions: The paper presents the role of eHealth impact appraisal in appraising eHealth options for African countries and describes aspects critical for an eHealth impact framework for Africa.

Data leakage in health outcomes prediction with machine learning

From: Journal of Medical Internet Research

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Evidence-based evaluation of eHealth interventions: A systematic literature review

From: Journal of Medical Internet Research

Date Submitted: May 7, 2018

Open Peer Review Period: May 11, 2018 - Jul 6, 2018

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Background: Until now, the use of technology in healthcare is driven mostly by the assumptions about the benefits of eHealth rather than the evidence of it. It is noticeable that the magnitude of evid...

Background: Until now, the use of technology in healthcare is driven mostly by the assumptions about the benefits of eHealth rather than the evidence of it. It is noticeable that the magnitude of evidence of effectiveness and efficiency of eHealth is not proportionate to the number of interventions that are regularly conducted. Reliable evidence generated through comprehensive evaluation of eHealth interventions may accelerate the growth of eHealth for long-term successful implementation and help to experience the benefits of eHealth in an enhanced way. Objective: The objective of this article was to understand how the evidence of effectiveness and efficiency of eHealth can be generated through evaluation. Hence, we aim to discern, (1) the phases of eHealth intervention as depicted by eHealth literature, (2) the aspects of eHealth intervention that are supposed to be evaluated according to eHealth literature, (3) how empirical studies about eHealth are evaluated, and (4) how evidence can be generated while evaluating eHealth interventions. Methods: A systematic literature review was conducted to explore the evaluation methods for eHealth interventions. PRISMA guidelines were followed. We searched Google Scholar and Scopus for the published articles that addressed the evaluation of eHealth or described an eHealth intervention study. A qualitative analysis of the selected articles was conducted in several steps. Results: We identified two distinct branches of conceptual framework that discussed the evaluation of eHealth interventions. The first branch identified evaluation as one of the phases of the intervention. The other phases identified through the literature review included design, pre-testing, pilot study, pragmatic trial, and post-intervention. The second branch provided the aspects of evaluation during intervention including clinical, human/social, organizational, technological, cost, ethical/legal, and transferability. The analysis of the empirical studies revealed that evaluation varied greatly and it may not be plausible to employ a standard evaluation procedure. Lastly, we proposed a conceptual model based on our findings that shows how the evidence of effectiveness and efficiency can gradually and reliably be built by evaluating specific aspects during specific intervention phases. Conclusions: The importance of evidence in eHealth has not been discussed as rigorously as have the diverse research approaches and evaluation frameworks. Further research directed towards evidence-based evaluation can not only improve the quality of intervention studies, but also facilitate successful long-term implementation of eHealth in general. We conclude that the development of more robust and comprehensive eHealth intervention studies or an improved validation of evaluation methods could ease the transferability of results among similar studies. Thus, the resources can be used to supplementary research in eHealth.

The validity of smart devices to measure physical activity in daily life

From: JMIR mHealth and uHealth

Date Submitted: May 4, 2018

Open Peer Review Period: May 5, 2018 - Jun 30, 2018

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Background: Wearables for monitoring physical activity are increasingly popular. These devices are not only used by consumers to monitor their own levels of PA, but also by reseachers to track the beh...

Background: Wearables for monitoring physical activity are increasingly popular. These devices are not only used by consumers to monitor their own levels of PA, but also by reseachers to track the behavior of large samples. Consequently, it is important to explore how accurately physical activity can be tracked via these devices. Objective: The aim of this study was therefore to investigate concurrent validity of three Android Wear smartwatches (Polar M600, Huawei Watch, Asus Zenwatch3) and the Fitbit Charge with an ActiGraph accelerometer for measuring steps and MVPA (moderate-to-vigorous physical activity) on both a day and 15 min level. Methods: A free-living protocol was used in which 36 adults engaged in usual daily activities over 2 days while wearing two different wearables on the same wrist of the preferred hand and an ActiGraph GT3X+ accelerometer on the hip. Validity was evaluated on both levels by comparing each wearable with the ActiGraph GT3X+ accelerometer, using correlations and Bland-Altman plots in SPSS 24.0. Results: On a day level, all devices showed strong correlations (Spearman r: 0.757-0.892) and good agreement (ICC: 0.695-0.885) for measuring steps, but moderate correlations (Spearman r: 0.557-0.577) and low agreement (ICC: 0.377-0.660) for measuring MVPA. Bland-Altman revealed a systematic overestimation of the wearables for measuring steps, but a variation between over- and under-counting of MVPA. On a 15-minute level, all devices showed strong correlations (Spearman r: 0.752-0.917) and good agreement (ICC: 0.792-0.887) for measuring steps, but weak correlations (Spearman r: 0.116-0.208) and low agreement (ICC: 0.461-0.577) for measuring MVPA. Bland-Altman revealed a systematic underestimation of the wearables for both steps and MVPA. Conclusions: In sum, all four consumer-level devices can be considered accurate step counters in free-living conditions. This study, however, provides evidence of systematic bias for all devices in measurement of MVPA. The results on a 15-minute level also indicate that these devices are not sufficiently accurate to provide correct real-time feedback.

Feasibility and conceptualization of an e-mental health treatment for depression in older adults.

From: JMIR Aging

Date Submitted: May 4, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: In older adults depression is one of the most common mental disorders. Unfortunately, depression in older adults is often not being recognized. Objective: The aim of this study was to iden...

Background: In older adults depression is one of the most common mental disorders. Unfortunately, depression in older adults is often not being recognized. Objective: The aim of this study was to identify how online applications can recognize and help treat depression in older adults. Methods: Focus groups were realized with mental health care expert (N = 8). An online survey with N = 56 older adults suffering from depression was carried out. Qualitative interviews were conducted with N = 2 individuals. Results: Results of the focus groups highlighted that there is a need for a collaborative care platform for depression in old age. Findings from the online study showed that younger participants (50 to 64 years) used electronic media more often than older participants (65 years and older). The interviews point in a comparable direction. Conclusions: Overall, an e-mental health treatment for depression in older adults would be well accepted. They should be developed, evaluated and in case of evidence for their effectiveness integrated in everyday clinic.

Usability and acceptability of a home blood pressure telemonitoring device in community dwelling seniors with hypertension: A qualitative study

From: Journal of Medical Internet Research

Date Submitted: May 9, 2018

Open Peer Review Period: May 12, 2018 - Jul 7, 2018

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Background: Hypertension is a major cause of cardiovascular disease in older individuals. To ensure that blood pressure (BP) levels are in the optimal range, accurate BP monitoring is required. Contem...

Background: Hypertension is a major cause of cardiovascular disease in older individuals. To ensure that blood pressure (BP) levels are in the optimal range, accurate BP monitoring is required. Contemporary hypertension clinical practice guidelines strongly endorse use of home BP measurement as a preferred method of BP monitoring for individuals with hypertension. The benefits of home BP monitoring may be optimized when measurements are telemonitored to care providers; however, this may be challenging for older individuals with less technological capabilities. Objective: The purpose of this qualitative study was to examine usability and acceptability of a home BP telemonitoring system with seniors. Methods: A qualitative descriptive study was conducted. Following a 1-week period of device use, an individual, semi-structured interview was conducted. Interview audio recordings were anonymized, de-identified, and transcribed verbatim. Thematic analysis was conducted on interview transcripts. Results: Seven seniors participated in usability testing of the home BP telemonitoring system. Participants were female (n=4) and male (n=3) with a mean age of 86 years (range 70 – 95 years). Overall, eight main themes were identified from the interviews: 1) positive features of the device; 2) difficulties or problems with device; 3) device was simple to use; 4) comments about wireless capability and components; 5) would recommend device to someone else; 6) would use device in future; 7) suggestions for improving the device; and, 8) assistance to use device. Additional sub-themes were also identified. Conclusions: Overall, the home blood pressure telemonitoring device had very good usability and acceptability with community dwelling seniors with hypertension. To enhance long-term use, a few improvements were noted that may mitigate some of the relatively minor challenges encountered by the target population.

From problem to solution: A guide on architecture, design and evaluation of an injury surveillance and workload monitoring app for cricket

From: JMIR mHealth and uHealth

Date Submitted: May 11, 2018

Open Peer Review Period: May 14, 2018 - Jul 9, 2018

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Background: Mobile apps are a cost effective tool for monitoring health conditions, however their role in monitoring cricket related injuries in unexplored. Objective: The aims of this study are to pr...

Background: Mobile apps are a cost effective tool for monitoring health conditions, however their role in monitoring cricket related injuries in unexplored. Objective: The aims of this study are to present a method for the development of a mobile app on injury surveillance and workload monitoring in cricket, and to evaluate the feedback from its users on functionality, utility and design of the app. Methods: TeamDoc mobile App for Android and Apple smartphones was developed using three languages C++, Qt Modeling Language (QML) and JavaScript. For server-side connectivity, PHP: Hypertext Preprocessor (PHP) was used as it is a commonly-used cross-platform language. PHP includes components that interacts with popular Database Management Systems (DBMSs), allowing for secure interaction with databases on a server-level. Evaluation of the app was done by administrating the validated user version of Mobile Application Rating Scale (uMARS). Results: TeamDoc is the first complimentary, standalone mobile app that records cricket injuries through a smartphone. It can also record cricketing workloads, which are known risk factors for injury. The App can be used without the need of supplementary computer devices for synchronization, and showed satisfactory user ratings (3.6/5) on the uMARS, showing its acceptability by cricketers. Conclusions: Electronic injury surveillance systems have been shown to improve data collection during competitive sport. Therefore, TeamDoc may assist in improving injury reporting and may also act as a monitoring system for coaching staff to adjust individual training workloads. The methods described in this paper provide a template to researchers to develop similar Apps for other sports.

Cyberchondria - Use of online health services in hypochondriacs compared to non-hypochondriacs.

From: Journal of Medical Internet Research

Date Submitted: May 5, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: An increasing number of people consult physicians because of worrying information found online. Cyberchondria refers to the phenomenon of health anxiety due to online health information. O...

Background: An increasing number of people consult physicians because of worrying information found online. Cyberchondria refers to the phenomenon of health anxiety due to online health information. Objective: The present study aimed at examining Internet usage patterns of participants with and without symptoms of hypochondria and their impact on health anxiety as well as behavior. Methods: An online survey was conducted. Demographic data, health-related Internet use and general health behavior were assessed. The illness attitude scale was used to record symptoms of hypochondria. Results: The final sample consisted of N = 471 participants. More than 40% of participants showed at least some symptoms of hypochondria. As expected subjects with symptoms of hypochondria used the Internet more frequently for health related purposes and also frequented more various services than non-hypochondriacs. Most online health services were rated as more reliable by hypochondriacs. Reactions to online research such as doctor hopping or ordering non-prescribed medicine online were considered more likely by participants with hypochondria. Conclusions: Results contradict a substitution thesis, whereby users turn to online research as a result of a lack of alternatives, but rather show that intensive users of health-related services seem to consult them on- as well as offline.

Long-term Effects of Telemonitoring on Healthcare Usage in Patients with Heart Failure or COPD

From: Journal of Medical Internet Research

Date Submitted: May 17, 2018

Open Peer Review Period: May 23, 2018 - Jul 18, 2018

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Objective The aim of this study was to evaluate the effectiveness of home telemonitoring in reducing healthcare usage and costs in patients with heart failure or chronic obstructive pulmonary disease...

Objective The aim of this study was to evaluate the effectiveness of home telemonitoring in reducing healthcare usage and costs in patients with heart failure or chronic obstructive pulmonary disease (COPD). Design The study was a retrospective observational study with a pre-post research design and a follow-up duration of up to 3 years, based on hospital data collected in the period 2012-2016. Setting Data was collected at the Slingeland Hospital in Doetinchem, The Netherlands. Participants In 2012 the Slingeland Hospital in The Netherlands started a telemonitoring program for patients with COPD or heart failure as part of their usual care. Patients were eligible for the telemonitoring program if they were in an advanced disease stage (New York Heart Association (NYHA) functional class 3 or 4; COPD gold stage 3 or 4), received treatment for their condition by a cardiologist or pulmonary specialist at the Slingeland Hospital, were proficient in Dutch and capable of providing informed consent. Exclusion criteria were absence of the cognitive, physical or logistical ability required to fully participate in the program. Hundred seventy-seven patients with heart failure and 83 patients with COPD enrolled the program between 2012 and 2016. Intervention Using a touchscreen, participants with heart failure recorded their weight (daily), blood pressure and heart rate (once a week) through connected instruments, and completed a questionnaire about their symptoms (once a week). Symptoms in patients with COPD were monitored via the Clinical COPD Questionnaire (CCQ), which participants were asked to complete twice per week. All home registrations were sent via a telemonitoring application (cVitals, FocusCura, Driebergen-Rijssenburg) on the iPad to a medical service center were a trained nurse monitored the data and contacted the patient by video chat or a specialised nurse in the hospital in case of abnormal results, such as deviations from a preset threshold or alterations in symptom score. Outcome measures The primary outcome was the number of hospitalisations; the secondary outcomes were total number of hospitalisation days and healthcare costs during the follow-up period. Generalised Estimating Equations were applied to account for repeated measurements, adjusting for sex, age and length of follow-up. Results In heart failure patients (N=177), after initiation of home telemonitoring both the number of hospitalisations and the total number of hospitalisation days significantly decreased (incidence rate ratio of 0.35 (95% CI: 0.26-0.48) and 0.35 (95% CI: 0.24-0.51), respectively), as did the total healthcare costs (exp(B) = 0.11 (95% CI: 0.08-0.17)), all p < 0.001. In COPD patients (N=83) neither the number of hospitalisations nor the number of hospitalisation days changed compared to the pre-intervention period. However, the average healthcare costs were about 54% lower in COPD patients after the start of the home telemonitoring intervention (exp(B) = 0.46, 95% CI 0.25-0.84, p = 0.011). Conclusion Integrated telemonitoring significantly reduced the number of hospital admissions and days spent in hospital in patients with heart failure, but not in patients with COPD. Importantly, in both patients with heart failure and COPD the intervention substantially reduced the total healthcare costs.

An evaluation of a Massive Open Online Course (MOOC) about data science for continuing education in healthcare

From: Journal of Medical Internet Research

Date Submitted: May 6, 2018

Open Peer Review Period: May 9, 2018 - Jul 4, 2018

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Background: Evaluation of Massive Open Online Courses (MOOCs) is a necessary practice for appraising their application and analyzing their performance and benefits. Imperial College London in collabor...

Background: Evaluation of Massive Open Online Courses (MOOCs) is a necessary practice for appraising their application and analyzing their performance and benefits. Imperial College London in collaboration with Health iQ offered a 5-week MOOC Data Science Essentials: Real World Evidence. Objective: This study was conducted to evaluate the MOOC: Data Science Essentials: Real World Evidence, concerning its impact on learners knowledge, skills and attitudes and on the use of data science in healthcare. The aim of the evaluation was to investigate the success of the MOOC's objectives regarding ‘reach' about intended audience and social networks, ‘efficacy' about knowledge/skill gain skill and attrition, and adoption and sustainability of social networks for continual learning in this emerging field. Methods: The study design was a mixed-method evaluation drawing on semi-structured interviews of 2 learners transcribed and analysed using Braun and Clark's method for thematic coding. A Kirkpatrick evaluation was completed on two interview participants who could be assessed at all four levels of evaluation. Results: While the MOOC improved learners' knowledge of the topic, it could be improved regarding increasing communication and networking between learners. Participants reported increased knowledge but no change in skills and attitudes in the workplace after taking the MOOC. Lack of resources in the workplace and the change to a different workplace, which changed participant's responsibilities were barriers identified by not experiencing a change in skills and attitudes as a result of taking the MOOC. Conclusions: The are two reasons that may explain why the MOOC while improving participants’ learning, was not able to change participants’ attitudes and use of data science in the workplace. Since the MOOC offered was about a brand-new topic (Real World Evidence) that requires the availability of specific resources, participants were not able to apply the learning since these resources were still not available in the workplace. Also, having a job that requires a different set of skills than the ones taught in the MOOC was another reason that prevented a participant from applying the learning from the MOOC. Understanding the MOOC learners’ experience, learning level and influence on behaviour change can potentially improve future MOOCs to become more effective for learning and changing behaviour. Clinical Trial: The evaluation received ethical approval from the Imperial College Education Ethics Review Process (EERP).

Priovi, an EHealth Programm for Patients with Borderline Personality Disorder to support individual face-to-face schema therapy– Pilot Study

From: JMIR Mental Health

Date Submitted: May 6, 2018

Open Peer Review Period: May 7, 2018 - Jul 2, 2018

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Background: EHealth programs have hardly been investigated yet for people with borderline personality disorder (BPD). However this might be very promising given both the high economic and health-relat...

Background: EHealth programs have hardly been investigated yet for people with borderline personality disorder (BPD). However this might be very promising given both the high economic and health-related burden as well as high need for treatment in this patient group. Development and use of eHealth applications for BPD are complicated by (1) safety issues due to frequent aversive and dangerous behaviors of these patients, (2) their tendency to drop out of any type of treatment, relationship or activity, (3) long treatment duration and accordingly need for comparably long and complex eHealth interventions. Objective: We piloted the program priovi in 14 patients with BPD. Priovi was offered to support individual face-to-face schema therapy to assess whether it is feasible, safe, and potentially helpful. Methods: Priovi is a schema therapy based self-help program for patients with BPD, designed to be used over 6-12 months. The patients used priovi over a period of 12 months in addition to their individual face-to-face schema therapy. BPD symptom severity was assessed with self-reported and interview-based measures. Qualitative interviews were conducted to understand the patient’s experience with the program in more detail and to detect barriers to feasibility and safety. Results: BPD symptoms improved over one year with high effect size (Cohen’s d 1.0). Patients receiving BPD treatment for the first time improved more than chronic patients with prior treatments. Qualitative data showed that patients generally liked the program. They were well able to build up a functional relationship with priovi. Some exercises provoked mild anxiety, however no serious threads to safety could be detected. Conclusions: Priovi is a potentially helpful and safe tool to support individual schema therapy. The next step should be a larger randomized-controlled study Clinical Trial: German Clinical Trials Register DRKS-ID: DRKS00011538

Technology users’ experiences of remote rehabilitation as part of counseling planning: a qualitative study

From: Journal of Medical Internet Research

Date Submitted: May 8, 2018

Open Peer Review Period: May 11, 2018 - Jul 6, 2018

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Background: Even though technology is becoming increasingly common in rehabilitation programs, insufficient data is available of rehabilitees’ perceptions and experiences as yet. Therefore, it is im...

Background: Even though technology is becoming increasingly common in rehabilitation programs, insufficient data is available of rehabilitees’ perceptions and experiences as yet. Therefore, it is important to understand their abilities to use technology for remote rehabilitation. Objective: This is a qualitative study on technology experiences of persons affected by cardiovascular disease assessed before remote rehabilitation. The aim of the study was to explore rehabilitees’ experience with technology before 12 months remote rehabilitation. Methods: Qualitative interviews were conducted with 39 rehabilitees in four focus groups. The participants were aged 34−77 years (average 54.8 years) and male 74%, had coronary artery disease (CAD), and were undergoing treatment in a rehabilitation center. The interviews were conducted between September 2015 and November 2016. Data was analyzed using Glaser’s mode of the grounded theory approach. Results: The result of the study is an “identifying the e-usage” category, which relates to rehabilitees identifying their usage of information and communication technologies (ICT) (e-usage) in the process of behavior change. The category formed into four subcategories which define the rehabilitees’ technology experience. These categories are: feeling outsider, being uninterested, reflecting benefit, and enthusiastic using. All rehabilitees expected remote technology should to be simple, flexible, and easy to use and learn. The results reflecting their technology experience can be utilize in e-rehabilitation programs. Rehabilitees who feel outsiders and are not interested in technology need face-to-face communication for a major part of rehabilitation, while rehabilitees who reflect benefit and are enthusiastic about using technology need incrementally less face-to-face interaction and feel that web-based coaching provides sufficient support for rehabilitation. Conclusions: The findings show that persons affected by heart disease have had different experiences with technology and expectations of counseling, while all rehabilitees expected technology to be easy to use and their experiences to be smooth and problem-free. The results can also be used more widely in different contexts of social and health care for the planning of, and training in, remote rehabilitation counseling and education. Clinical Trial: Trial registration: ISRCTN Registry: ISRCTN61225589.

A Study of Web Page Understandability for Consumer Health Search

From: Journal of Medical Internet Research

Date Submitted: May 7, 2018

Open Peer Review Period: May 11, 2018 - Jul 6, 2018

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Background: Understandability plays a key role in ensuring that people accessing health information are capable of gaining insights that can assist them with their health concerns and choices. The acc...

Background: Understandability plays a key role in ensuring that people accessing health information are capable of gaining insights that can assist them with their health concerns and choices. The access to unclear or misleading information has been shown to negatively impact on the health decisions of the general public. Objective: We investigated methods to estimate the understandability of health Web pages and used these to improve the retrieval of information for people seeking health advice on the Web. Methods: Our investigation considered methods to automatically estimate the understandability of health information in Web pages, and it provided a thorough evaluation of these methods using human assessments as well as an analysis of pre-processing factors affecting understandability estimations, and associated pitfalls. Furthermore, lessons learnt for estimating Web page understandability were applied to the construction of retrieval methods with specific attention to retrieving information understandable by the general public. Results: We found that machine learning techniques were more suitable to estimate health Web page understandability than traditional readability formulae, which are often used as guidelines and benchmarking by health information providers on the Web (larger difference found for Pearson correlation of .602 using Gradient Boosting regressor compared to .438 using SMOG Index with CLEF 2015 collection). Learning to rank effectively exploited these estimates to provide the general public with more understandable search results (H_RBP^* reached 29.20, 22% higher than a BM25 baseline and 13% higher than the best system at CLEF 2016, both P≤.001). Conclusions: The findings reported in this article are important for specialised search services tailored to support the general public in seeking health advice on the Web, as they document and empirically validate state-of-the-art techniques and settings for this domain application. Clinical Trial: Not required.

The use of augmented reality in a serious game to motivate oral hygiene practices among children and toddlers: a research protocol

From: JMIR Research Protocols

Date Submitted: May 10, 2018

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

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Background: New technologies invariably open up possibilities towards new forms of action, of interaction, and of knowledge acquirement, something extremely relevant in the health education field. How...

Background: New technologies invariably open up possibilities towards new forms of action, of interaction, and of knowledge acquirement, something extremely relevant in the health education field. However, a protocol is needed for new digital means towards the use of an immersive interactive interface, both ludic and educational, regarding oral health with a preventive focus on health maintenance and a healthy development of the child, by means of Augmented Reality, activated by the user interaction with the projection. Objective: Development of an immersive virtual environment protocol using Augmented Reality for the improvement of the quality of teaching, in the fields of science and youth odontological health, making available modern content and interfaces, in order to point out paths for the evolution of technological resources in teaching and learning; i.e., a concrete tool for the universalization of knowledge and digital inclusion. Methods: A qualitative study will be conducted in order to define a research protocol for the development of a serious game that uses augmented reality techniques in order to disseminate oral health knowledge among children at school age, and its training as to the correct execution of teeth brushing techniques. During the first phase of the study, a template analysis will be conducted to identify barriers and facilitators in each scenario. Then, during the second phase, the computational process, the gestural, graphic elements and cognitive processes involved in the development of the research protocol of the interactive panel will be analyzed and delineated. In a posterior phase, after the implementation of the system, an analysis of the product efficacy will be conducted, by means of usability tests conducted with the target audience. Results: This article presents the development protocol of the instructional immersive interactive environment, using projection and computational resources. Conclusions: It is hoped that these protocols contribute to the prevention of buccal problems afflicting the population, by means of the diffusion of scientific knowledge of the aforementioned fields in the school environment, and that its replication is done by the students themselves, assuming the role of multipliers of this knowledge with the community.

Approaches to improve the surveillance, monitoring, and management of noncommunicable diseases among HIV-infected persons

From: JMIR Public Health and Surveillance

Date Submitted: May 7, 2018

Open Peer Review Period: May 23, 2018 - Jun 6, 2018

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Low- and middle-income countries (LIMCs) are undergoing an ‘epidemiological transition’, in which the burden of non-communicable diseases (NCDs) is rising and mortality will shift from infectious...

Low- and middle-income countries (LIMCs) are undergoing an ‘epidemiological transition’, in which the burden of non-communicable diseases (NCDs) is rising and mortality will shift from infectious diseases to NCDs. Specifically, cardiovascular disease, diabetes, renal diseases, chronic respiratory diseases, and cancer are becoming more prevalent. In some regions, particularly sub-Saharan Africa, the dual HIV and NCD epidemics will pose challenges as joint burden will have adverse effects on quality of life and will likely increase global inequities. Given the austere clinical infrastructure in many LMICs, innovative models of care delivery are needed to provide comprehensive care in resource-limited settings. Improved data collection and surveillance of NCDs among HIV-infected persons in LMICs are necessary to inform integrated NCD-HIV prevention, care, and treatment models that are effective across a range of geographic settings. These efforts will preserve the considerable investments that have been made to prevent lives lost to HIV, promote healthy aging of PLHIV, and contribute to meeting United Nations Sustainable Development Goals.

Development of a smartphone application for informal carers of people with cancer: processes and learnings

From: JMIR mHealth and uHealth

Date Submitted: May 8, 2018

Open Peer Review Period: May 12, 2018 - Jul 7, 2018

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Background: There are few support systems available to informal carers who provide care to cancer patients. Smartphone applications have the capacity to reach large audiences and can provide informati...

Background: There are few support systems available to informal carers who provide care to cancer patients. Smartphone applications have the capacity to reach large audiences and can provide information and support at a time convenient to carers. Objective: To describe the process of developing and designing a smartphone application prototype for carers of adults with cancer involving focus groups and interviews with present and past carers, to understand their information and supportive care needs. Carers' willingness to use a smartphone application as part of an information and support mechanism was also explored. Methods: Carers were recruited from a public hospital, a private hospital and a carer organisation and participated in either a focus group or phone interview. Carers answered questions about: their caregiving experience, supportive care needs and items to include in an application to address needs identified. Based on carers' feedback a smartphone app was designed and tested. Beta testing was conducted using a convenience sample of participants who completed scenarios to inform the application's design, functionality and usability. Scenarios were timed and marked as complete or incomplete. Participants completed a questionnaire about the useability of the app. Beta testing occurred in two stages: a paper-based version of the app and an app-based test using participants' preferred device. Alpha testing was completed internally to ensure the functionality of the app. Results: 33 carers participated in phone interviews and 12 in focus groups, their average age was 55 (SD 14) and 60% were female. Carers noted that smartphone technology may improve their ability to seek information and support in managing their own health as well as the care needs of the person with cancer. Carers requested a variety of resources including information, support services and features such as reminders, notepads and calendars. Paper-based testing: Participants were aged <30 (30%), 30-49 (30%) and 50+ (40%) and 60% were male. Participants found the app user-friendly and pleasing in appearance. Navigation was unclear within three of the headings. Headings and contents were reorganised to improve useability. App-based testing: Participants were aged <30 (20%), 30-49 (30%) and 50+ (50%) and 50% were male. Participants reported the app user-friendly and easy to navigate. The majority (60%) of participants were unable to create a shortcut icon to add the app to the home screen of their phone. Video instructions were created to assist with downloading and navigation for those with less confidence in using apps. Google Analytics was modified to provide accurate usage data. Conclusions: Carers require information and support during the caring period. The Carer Guide Application was created to assist them during their time of caring. Further testing is required to assess how carers will receive and use the app on a day-to-day basis.

Emotion in Motion: A gamified approach for the modification of attentional bias.

From: JMIR Serious Games

Date Submitted: May 8, 2018

Open Peer Review Period: May 8, 2018 - Jul 3, 2018

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Background: Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting this attentional bias makes a causal contribut...

Background: Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting this attentional bias makes a causal contribution to anxiety vulnerability. Recent years have seen an increase in the use of attentional bias modification (ABM) procedures to modify patterns of attentional bias, however often this change in bias is not successfully achieved. Objective: The current study presents a novel ABM procedure, Emotion-in-Motion, requiring individuals to engage in patterns of attentional scanning and tracking within a gamified complex and dynamic environment. We aimed to examine the capacity of this novel procedure, as compared to the traditional prWe administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed prior to and following this stressor.obe-based ABM procedure, to produce a change in attentional bias and result in a change in anxiety vulnerability. Methods: We administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed prior to and following this stressor. Results: Whereas the conventional ABM task failed to induce differential patterns of attentional bias or affect anxiety vulnerability, the Emotion-in-Motion training did induce a group difference in attentional bias (P = .003, Cohen’s d = 0.87), and differentially affected anxiety vulnerability (P = .032, Cohen’s d = 0.60). Conclusions: Our novel, gamified Emotion-in-Motion ABM task appears more effective in modifying patterns of attentional bias and anxiety vulnerability. Candidate mechanisms contributing to these findings are discussed, including the increased stimulus complexity, dynamic nature of the stimulus presentation, and enriched performance feedback.

Evaluation of Electronic and Paper Pen Data Capturing Tools for Data Quality in a Public Health Survey in a Health and Demographic Surveillance Site, Ethiopia: A randomized controlled crossover Healthcare IT-Evaluation

From: JMIR mHealth and uHealth

Date Submitted: May 8, 2018

Open Peer Review Period: May 11, 2018 - Jul 6, 2018

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Background: Periodic demographic health surveillance and surveys are the main sources of health information in developing countries. Conducting survey in requires extensive use of paper-pen and manual...

Background: Periodic demographic health surveillance and surveys are the main sources of health information in developing countries. Conducting survey in requires extensive use of paper-pen and manual work and lengthy processes to generate the required information. Despite the rise of popularity in using electronic data collection systems to alleviate the problems, sufficient evidence is not available to support the use of electronic data capture tools in interviewer administered data collection processes. Objective: The purpose of this study was to compare data quality parameters in the data collected using mobile electronic and standard paper-based data capture tools in one of health and demographic surveillance sites in northwest Ethiopia. Methods: A randomized controlled crossover Healthcare IT-Evaluation was conducted from May 10 to June 3rd, 2016 in demographic and surveillance site. Twelve interview administrator, as two individuals in six groups (one with a tablet computer and the other with paper-based questionnaire), were assigned in the six towns of the surveillance premises. Data collectors switch data collection method based on computer generated random order. Data was cleaned using Mysql program and transferred to SPSS and R statistical software for analysis. Descriptive and mixed ordinal logistic analyses employed. The qualitative interview audio record was transcribed, and the usability of this open data kit (ODK) based system was assessed using system usability scale (SUS) and interview mapping in the isometric dialogue principles for system usability. Results: From the submitted 1,251 complete records/questionnaires in each tools, 42 % (522) of the paper and pen data capture (PPDC) and 29 % (285) of the electronic data capture (EDC) tool questionnaires had one or more types of data quality errors. The overall error rates were 1.67% and 0.6% for PPDC and EDC respectively. The chances of more errors on PPDC tool were multiplied by 1.015 for each additional question in the interview compared to EDC. The SUS score of the data collectors was 85.6. In qualitative data response mapping, EDC had more positive suitability of task responses with few error tolerance characteristics. Conclusions: EDC possessed significantly better data quality and efficient compared with PPDC, explained in fewer errors, instant data submission, and easy handling. The EDC proved to be a usable data collection tool in the rural study setting. The consistent power source and decent internet connection, standby technical support, and security assurance for the device users suggested by the data collectors before full-fledged the implementation of the system.

Stop this waste of people, animals and money

From: JMIR Serious Games

Date Submitted: May 8, 2018

Open Peer Review Period: May 11, 2018 - Jul 6, 2018

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Background: Entities that have become known as ‘predatory’ journals and publishers are permeating the world of scholarly publishing, yet little is known about the papers they publish Objective: T...

Background: Entities that have become known as ‘predatory’ journals and publishers are permeating the world of scholarly publishing, yet little is known about the papers they publish Objective: This work looks at journals that fail to meet the expected best practice publishing standards. These journals, often called ‘predatory’, are thought to prioritize profits earned from publishing articles over the quality of the articles they publish. In this study we examined nearly 200 journals thought to be predatory Methods: We examined a cross-section of 1907 human and animal biomedical studies, recording their study designs, epidemiological and reporting characteristics. In our sample more than two million humans and over eight thousand animals were included in predatory publications Results: Only 40% of studies report having ethics approval. Of the 17% of articles reporting their funding source, the US National Institutes of Health was most frequently named. Corresponding authors were most often from India (511/1907, 26.8%) and the US (288/1907, 15.1%). The reporting quality of work reported in our sample was poor and worse than contemporaneous samples from the legitimate literature. Many studies were missing key methodological details and findings. Conclusions: Our results raise important ethical concerns since research in predatory journals is difficult to identify and not indexed in scientifically curated biomedical databases. Funders and academic institutions need to develop explicit policies to drive grantees and prospective authors away from these entities.

The oncology patient and eHealth. How can new eHealth technologies be applied to cancer patient care?

From: Journal of Medical Internet Research

Date Submitted: May 9, 2018

Open Peer Review Period: May 12, 2018 - Jul 7, 2018

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Background: Information and communication technologies (ICTs) in oncology can revolutionize the medical care of cancer patients. ICTs can promote patient’s empowerment and real-time disease monitori...

Background: Information and communication technologies (ICTs) in oncology can revolutionize the medical care of cancer patients. ICTs can promote patient’s empowerment and real-time disease monitoring. There is limited information about the impact of ICTs in cancer patients of ICTs in this patient group or indeed their level of interest in using these tools for greater management of their condition. Objective: We aimed to understand the ICT usage profile in hematology–oncology patients, to identify their needs, and to determine their level of interest in these technologies as a means of managing their disease. Methods: A 28-item questionnaire was drawn up by a multidisciplinary team including pharmacists and oncologists. The questions were organized into three blocks. A: socio-demographic characteristics; B: use of ICTs when searching for health-related information; and C: usage preferences for health apps. Hematology–oncology patients receiving treatment between May and July 2017 were included. A paper copy of the questionnaire was handed to patients in the Day Hospital or the Pharmaceutical Care Consultancy in Pharmacy Services. Results: A total of 650 questionnaires were handed out, with a participation of 94% (611/650). Patient socio-demographic characteristics: Mean age was 57.8 years-old [19–91]. Of participants, 61.9% (378/611) were women, 40.7% (249/611) had a university education, and 45.1% (276/611) of patients reported their overall state of health to be good. Use of ICTs when searching for health-related information: 87.1% (532/611) of subjects were interested in being informed about health-related matters. Of all subjects, 75.5% (532/611) sought information from health professionals and 61.3% (375/611) on the Internet. Of these, 71.2% (436/611) searched through Google and 21.9% (134/611) by means of social networks. Before going to their doctor’s appointment, 21.8% (133/611) of patients looked up information about their disease and/or treatment on the Internet. This access to the internet rose to 51% after their first medical appointment with their oncologist, up to 50.9% (311/611) of participants referred to the Internet. Usage preferences for health apps: 82.7% (505/611) had a smartphone, while 20.3% (124/611) had a health app installed. Some 81.5% (498/611) would use an app if their health professional recommended it to them, but 39.6% (242/611) were not willed to pay for it. Conclusions: The hematology–oncology patients showed a great deal of interest in searching for health-related information by means of ICTs, especially using smartphones and apps. The issues that drew the most interest in terms of apps were appointment management, advice on disease management, and communication with health professionals. Free access to these features and the recommendation by a health professional are important factors when it comes to their use. Therefore, the health care provider is a key element in the recommendation of ICTs, providing their knowledge and experience concerning their correct usage.

Advantages and disadvantages of online and blended therapy: Attitudes towards both interventions amongst licensed psychotherapists in Austria

From: Journal of Medical Internet Research

Date Submitted: May 9, 2018

Open Peer Review Period: May 12, 2018 - Jul 7, 2018

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Background: Online and blended (face-to-face plus online) interventions for common mental health disorders are gaining in significance. However, many licensed psychotherapists still have guarded attit...

Background: Online and blended (face-to-face plus online) interventions for common mental health disorders are gaining in significance. However, many licensed psychotherapists still have guarded attitudes towards technology-aided formats, hindering dissemination efforts. Objective: This study provides a first therapist-centered evaluation of online and blended therapy and aims at identifying commonalities and differences in attitudes towards both formats. It further tests the impact of a short video clip on expressed attitudes. Methods: In total, 95 Austrian psychotherapists were contacted and surveyed via their listed occupational e-mail address. An eight-minute informational video clip was followed by two randomized survey blocks, assessing therapists’ attitudes towards online and blended therapy. Results: The sample resembled all assessed properties of Austrian psychotherapists (age, theoretical orientation, and region). Therapists did not hold a uniform overall preference. Instead, both intervention approaches’ advantages were perceived equally neutral (t(94)= 1.89, p= .063; d= 0.11), whereas online interventions were associated with more disadvantages and risks (t(94)= 9.86, p<.001; d= 0.81). The short informational clip did not excerpt any detectable effect on therapist views (r(95)= -.109 , p= 0.295). Personal use of modern technologies had a medium effect on given ratings and cognitive behavioral therapists tended to have more open-minded views than other therapists. Conclusions: This study is the first to directly compare attitudes towards online and blended therapy on a fine-grained level. Positive expectations play a pivotal role in the dissemination of new technologies, but unexperienced therapists seem to lack knowledge on how to benefit from technology-aided treatments. In order to speed up implementation, this aspects need to be addressed in the development of new interventions. Further, the preference of blended treatments over online interventions seems to relate to avoidance of risks. While this study is likely to represent therapist attitudes in countries with less advanced eHealth services, therapists’ attitudes in more developed countries might present differently.

Reminder use to improve service referral use among participants in a community engagement program

From: Journal of Medical Internet Research

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Recent research on health care delivery has shown that mobile based interventions are effective in bringing behavior change among clinical populations. Mobile phone-based interventions are...

Background: Recent research on health care delivery has shown that mobile based interventions are effective in bringing behavior change among clinical populations. Mobile phone-based interventions are considered to be convenient and economical to the provider and non-invasive and hence acceptable to the receiver. Studies have also shown that personalized text message reminders are more acceptable and effective than automated mass messages. However, despite the increasing literature on mobile phone-based interventions (mHealth) contributing to improvement in health care, there is a dearth of information on the use of reminders for social and medical service referrals provided to nonclinical populations by community-engagement programs. Objective: This pilot study aimed to apply mobile phone-based interventions to improve the utilization rates of medical and social service referrals provided to community members by Community Health Workers (CHW’s) through HealthStreet – a community engagement initiative at the University of Florida (UF). Methods: 300 eligible HealthStreet members were randomly assigned to CALLSONLY, TEXTONLY, CALLS+TEXT reminder intervention groups. Reminders were sent based on their assignment on the 15th and 45th day after the baseline assessment reminding them to utilize the medical and/or social referrals that were provided by the community health workers based on their expressed need during the baseline assessment. A telephonic follow up was done on the 30th and 60th day to assess the rate of utilization of the referrals. Further, a telephone based brief satisfaction survey was also administered to all participants on the 60th day follow up call. Results: Out of 290 participants, 201 (69.3%) successfully completed the 30-day HealthStreet follow up and 149 (51.4%) participants successfully completed the 60-day HealthStreet follow up. At the 30-day follow up, 52 of the 201 respondents reported the use of at least one referral and there were no differences for utilization by contact status. At the 60-day follow up, 69 of the 149 participants reported utilizing at least one referral; there were no differences for this group either. Conclusions: Findings from this study did not find any significant difference in the rate of service referral utilization between participants who received different types of reminders. The absence of a significant difference between the two groups may be because of the smaller sample size of the study.

A novel approach to evaluating mobile smartphone screen time: feasibility and preliminary findings

From: Journal of Medical Internet Research

Date Submitted: May 20, 2018

Open Peer Review Period: May 21, 2018 - Jul 16, 2018

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Background: Increasingly high levels of smartphone ownership and use pose the potential for addictive behaviors and negative health outcomes, particularly among younger populations. Previous methodolo...

Background: Increasingly high levels of smartphone ownership and use pose the potential for addictive behaviors and negative health outcomes, particularly among younger populations. Previous methodologies to understand mobile screen time have relied on self-report survey or ecological momentary assessment (EMA). Self-report is subject to bias and unreliability, while EMA can be burdensome to participants. New methodology is needed to advance the understanding of mobile screen time. Objective: The objective of this study was to test the feasibility of a novel methodology to record and evaluate mobile smartphone screen time and use: Battery Use Screenshot (BUS). Methods: The Battery Use Screenshot (BUS) approach, defined for this study as uploading a mobile phone screenshot of a specific page within a smartphone, was utilized within an online cross-sectional survey of adolescents aged 12 to 15 years old through the survey platform Qualtrics. Participants were asked to provide a screenshot of their battery use page, a feature within smartphones, to upload within the online survey. Feasibility was assessed by smartphone ownership and response rate to BUS upload request. Data availability was evaluated as applications (apps) per BUS, completeness of data within screenshot, and five most used applications based on battery use percentage. Results: Among those surveyed, 309 (26.7%) indicated ownership of their smartphone. A total of 105 screenshots were evaluated. For data availability, screenshots contained an average of 10.2 (SD=2.0) apps per screenshot and over half (55%) had complete data available. The most common apps included safari and home/lock screen. Conclusions: Findings describe BUS as a novel approach for real-time data collection focused on mobile smartphone screen time among young adolescents. Though feasibility showed some challenges in upload capacity of young teens, data availability was generally strong across this large data set. This data from screenshots have the potential to provide key insights into precise mobile smartphone screen use and time spent per mobile application. Future studies could explore the use of the BUS methodology to correlate mobile smartphone screen time with health outcomes.

Easier and faster is not always better: A grounded theory of the Impact of a large-scale, system transformation on the clinical work of emergency medicine nurses and physicians

From: JMIR Human Factors

Date Submitted: May 17, 2018

Open Peer Review Period: May 19, 2018 - Jun 2, 2018

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Background: The effectiveness of Lean Thinking as a quality improvement method for healthcare has been contested due, in part, to our limited contextual understanding of how it affects the working con...

Background: The effectiveness of Lean Thinking as a quality improvement method for healthcare has been contested due, in part, to our limited contextual understanding of how it affects the working conditions, and clinical workflow, of nurses and physicians. While there are some initial indications, arising from prevalence surveys and interviews, that Lean may intensify work performed within medical environments, the evidence base about Lean healthcare still requires more detailed descriptions of the changes that were actually introduced to individuals’ clinical workflow and ways that these changes impacted healthcare professionals. Objective: The objectives of this study were to explore the ways in which a Lean intervention may enhance or disrupt the clinical work of emergency medicine nurses and physicians and within what context(s). Methods: We employed a realist grounded theory approach to explore the clinical work of nurses and physicians practicing in two emergency medicine departments from a single teaching hospital in Canada. The hospital has 1,000 beds with 163,000 emergency department visits annually. In response to its poor wait times, in 2013, both sites began a large-scale, Lean-driven, system transformation of their practice environments. Semi-structured, in-person interviews were iteratively conducted with healthcare professionals from July to December 2017. As the interviews proceeded, information from their transcripts was coded into categories and was compared to existing codes. With the repeated review of transcripts and our evolving coding, we organized categories into themes and our data collection continued to theoretical sufficiency. Results: Interviews were conducted with 15 emergency medicine nurses and 5 physicians. Eighteen of these individuals had practiced emergency medicine for a minimum of 10 years. Within our results, we first describe the physical practice environment and patient care processes that existed before-and-after the Lean intervention and then we present our grounded theory about how these working environments impacted our participants. Our grounded theory involved three themes: 1) Organization of our clinical work, 2) Pushed pace in the front cell, and 3) The toll this all takes on us. While the intervention was supposed to make the emergency departments work easier, faster and better, the participants in our study indicated that the changes made had the opposite impact. Nurses and physicians described ways in which the reconfigured emergency departments disrupted their established practice routines and resulted in the intensification of their work. Participants also identified indications of deskilling of nurses’ work and how the new, push-forward model of patient care undertaken with the Lean intervention had detrimental impacts on their physical, cognitive, and emotional well-being. Conclusions: To our knowledge, this is the first study to describe the impact of Lean healthcare on the working conditions, and actual work, of emergency medicine nurses and physicians. We theorize that rather than support healthcare professionals in their management of the complexities that characterize emergency medicine, the physical and process-based changes introduced by the Lean intervention acted to further complicate their working environment. Our research has illuminated some unintended consequences associated with accelerating patient flow on the clinical workflow and perceived well-being of healthcare professionals. Based on our findings, we identify some areas for reconsideration by the departments and put forward ideas for future research.

Applying social network analysis to the pattern of international author collaboration on the topic of skin cancer

From: JMIR Dermatology

Date Submitted: May 9, 2018

Open Peer Review Period: May 12, 2018 - Jul 7, 2018

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Background: Google Maps and social network analysis (SNA) are cutting edge methods and technologies that provide an insight into the big data and data analytics for readers to understand the pattern o...

Background: Google Maps and social network analysis (SNA) are cutting edge methods and technologies that provide an insight into the big data and data analytics for readers to understand the pattern of phenomena we concern. Dominant nations in the long term are from the U.S. and Europe in science. Whether the trend has been changed, particularly on the topic of dermatology and cancer, requires studying and visual analytics using Google maps and SNA. Objective: To apply SNA to the pattern of international author collaborations on the topic of dermatology and cancer using data from Medline and to visualize the results on the Google Maps. Methods: We obtained 44,411 abstracts on April 12, 2018, from Medline based on the keywords of dermatology and cancer since 1950. The author names, countries/areas, and journals were recorded. We disclosed following features: (1) nation distribution for 1st author’s and most popular journals; (2) four stages’ pattern of international author collaborations on Google Maps with two types of displays(by continents and clusters), (3) network density used for evaluating the trend change of the international author collaborations and Kendall’s coefficient (W) used for determining the concordance to the trend; (4) the number of paper publications is association with the country’s gross domestic product (GDP). We programmed Microsoft Excel VBA routines to extract data from Medline. Google Maps and SNA Pajek software were performed to display the graphical representations. Results: We found that (1) the most number of papers on the topic of dermatology and cancer are from the U.S.(13,805, 34.34%), Germany(4,261,10.60%), and Japan( 4,042, 10.05%); (2)both patterns of international author collaborations (by continents and clusters) display on Google Maps with an easy-to-read feature for readers; (3) Kendall’s coefficient shows a significant concordance (W=0.91, =16.4, d.f.=3, p<0.001) in author collaboration trend across four classified stages over the years;(4) the correlation coefficient between the number of paper publications and the country’s GDP is 0.74(t=11.46). Conclusions: Social network analysis provides wide and deep insight into the relationships with the pattern of international author collaborations among nations. The results can provide readers with knowledge and concept maps for understanding the trend of paper publications on the topic of dermatology and cancer.

Detecting potential adverse drug reactions using a deep neural network model

From: Journal of Medical Internet Research

Date Submitted: May 10, 2018

Open Peer Review Period: May 14, 2018 - Jul 9, 2018

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Background: Adverse drug reactions (ADRs) are common and they are the underlying cause of over a million serious injuries and deaths each year. The most familiar method to detect ADRs is relying on sp...

Background: Adverse drug reactions (ADRs) are common and they are the underlying cause of over a million serious injuries and deaths each year. The most familiar method to detect ADRs is relying on spontaneous reports. Unfortunately, the low reporting rate of spontaneous reports is a serious limitation of pharmacovigilance. Objective: Our objective was to identify a method to detect potential ADRs of drugs automatically using a deep neural network (DNN). Methods: We designed a DNN model that utilizes the chemical, biological, and biomedical information of drugs to detect ADRs. This model aimed to fulfil two main purposes, identifying the potential ADRs of drugs and predicting the possible ADRs of a new drug. For improving the detection performance, we distributed representations of the target drugs in a vector space to capture the drug relationships by using the word embedding approach to process amounts of biomedical literature. Moreover, we built a mapping function to address new drugs that do not appear in the dataset. Results: We predicted the ADRs of drugs recorded up to 2012, by using the drug information and the ADRs reported up to 2009. There were contained 746 drugs and 232 new drugs which only recorded in 2012 with 1,325 ADRs. The experimental results showed that the overall performance of our model with mean average precision (MAP) at top-10 is achieved 0.523 for ADR prediction on the dataset. Conclusions: Our model was effective in identifying the potential ADRs of a drug and the possible ADRs of a new drug. Most importantly, it can detect potential ADRs irrespective of whether they have been reported in the past.

Access to Resources in the Community (ARC) through Navigation – A Feasibility Study Protocol

From: JMIR Research Protocols

Date Submitted: May 11, 2018

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

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Background: Community based health and social resources can help individuals with complex health and social needs. However, there is often a discontinuation of patient care between primary care practi...

Background: Community based health and social resources can help individuals with complex health and social needs. However, there is often a discontinuation of patient care between primary care practices and community resources due to: a lack of physician or patient awareness of available resources; the presence of social barriers; the paucity of means to facilitate patients’ trajectory along the continuum of care; and more broadly, to the difficulties implementing organizational changes in primary care practices already busy providing health care services. Navigation services – where a person is tasked with helping connect patients to community resources – can strengthen continuity of care for patients. The implementation and study of the navigators’ impact is complex and warrants further investigation. Objective: Assess whether the ARC Model is feasible, including its potential to achieve its intended outcomes, and the viability of the evaluation approach. Methods: Describe the protocol of a single arm, prospective, explanatory mixed methods, pre-post design feasibility study, focusing on primary care practice settings with vulnerable populations. Participants include primary care providers, and patients. Results: Enrollment is closed with 82 patients. Navigation services have ended for 69 patients. Conclusions: Multilayered complex issues contribute to a high risk of failing to sustainably implement navigation services, thwarting randomized control trials’ effectiveness at assessing their impact. Undertaking a feasibility study from a conceptually clear and methodologically solid protocol will inform on the acceptability, ease of implementation, quality of integration, practicality and adaptation needs prior to initiating a randomized control trial. Clinical Trial: ClinicalTrials.gov, NCT03105635. Registered 10 April 2017

Walking In A Robotic Exoskeleton Does Not Mimic Natural Gait

From: JMIR Rehabilitation and Assistive Technologies

Date Submitted: May 10, 2018

Open Peer Review Period: May 14, 2018 - Jul 9, 2018

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Background: Robotic exoskeleton devices enable individuals with lower extremity weakness to stand up and walk over ground with a full-weight bearing and reciprocal gait. Limited information is availab...

Background: Robotic exoskeleton devices enable individuals with lower extremity weakness to stand up and walk over ground with a full-weight bearing and reciprocal gait. Limited information is available on how an exoskeleton robotic affects gait characteristics. Objective: The purpose of this study was to examine whether wearing a robotic exoskeleton affects temporospatial parameters, kinematics, and muscle activity during gait. Methods: Fifteen healthy adults (age: 26.2±8.3 years, 6 men, 9 women) completed the study. Each participant performed walking under two conditions, with and without wearing a robotic exoskeleton (EKSO). A 10-camera motion analysis system synchronized with 6 force plates and a surface electromyographic (EMG) system captured temporospatial and kinematic gait parameters and lower extremity muscle activity. Five walking trials were collected for each condition and included for data analysis. Results: Differences were observed between the two conditions in temporospatial gait parameters of speed, stride length, and double limb support time. When wearing EKSO, hip and ankle range of motion were reduced and knee range of motion increased during the stance phase. However, during swing phase, knee and ankle range of motion were reduced when wearing exoskeleton bionic suit. EMG activity decreased bilaterally in the stance phase for all muscle groups of the lower extremities, and in the swing phase for the distal muscle groups (tibialis anterior and soleus) as well as left medial hamstrings when participants were wearing EKSO. Conclusions: Wearing EKSO altered temporospatial gait parameters, lower extremity kinematics and muscle activity during gait in healthy adults. EKSO appears to promote a type of gait that is disparate from normal gait in first time users. More research is needed to determine the impact on gait training with EKSO in people with gait impairments.

Continuous Glucose Monitoring in the Real-World: Photosurveillance of #Dexcom on Instagram

From: JMIR Public Health and Surveillance

Date Submitted: May 10, 2018

Open Peer Review Period: May 21, 2018 - Jun 4, 2018

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Background: Individuals with diabetes are using social media as a method to share and gather information about their health via the diabetes online community. Infoveillance is one methodological appro...

Background: Individuals with diabetes are using social media as a method to share and gather information about their health via the diabetes online community. Infoveillance is one methodological approach to examine healthcare trends. Infoveillance, however, while very effective in identifying many real-world health trends, may miss opportunities which use photographs as primary sources for data. We propose a new methodology, photosurveillance, in which photographs are analyzed to examine real-world trends. Objective: The purpose of this research is to 1) assess the use of photosurveillance as a research method to examine real-world trends in diabetes, and 2) report on real-world use of continuous glucose monitoring on Instagram. Methods: This exploratory mixed method study examined all photographs posted on Instagram identified with the hashtag, #dexcom, over a 2-month period. Photographs were coded by CGM location on the body. Original posts and corresponding comments were textually coded for length of CGM wear and CGM failure and analyzed for emerging themes. Results: 2923 photographs were manually screened, 12.1% (N=353) depicted a photograph with a CGM site location. The majority (64%, n=225) of the photographs showed a CGM site in an off-label location, while 26.2% where in an FDA approved location (abdomen), and 10.2% (n=36) were in unidentifiable locations There were no significant differences in the number of likes or comments based on FDA approval. Four themes emerged from the analysis of original posts (N-353) and corresponding comments (N=2364): 1) endorsement of CGM as providing a sense of wellbeing, 2) reciprocating encouragement and support, and 3) life hacks to optimize CGM use, and 4) sharing and learning about off-label CGM activity. Conclusions: Our results indicate that individuals successfully used CGM in off-label locations with greater frequency than the abdomen, with no indication of sensor failure, although these photographs only capture a snapshot in time. There were instances in which sensors were worn beyond the FDA-approved 7-days, however, they represented the minority in this study.

Online-Delivered Multi-Media Training Materials for the Self-Collection of Dried Blood Spots

From: JMIR Formative Research

Date Submitted: May 10, 2018

Open Peer Review Period: May 14, 2018 - Jul 9, 2018

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Background: Dried blood spots (DBS) have been increasingly used in biomedical research as an objective measure for variables that are typically plagued by self-report, such as smoking status. The deve...

Background: Dried blood spots (DBS) have been increasingly used in biomedical research as an objective measure for variables that are typically plagued by self-report, such as smoking status. The development of training materials for the self-collection of DBS that can be delivered online would allow for broader use of this methodology. Objective: The goal of this project was to develop and evaluate multi-media training materials delivered online to allow for the remote self-collection of DBS. Methods: We recruited participants via Facebook for two studies. In Study 1, we evaluated the feasibility and acceptability of our newly developed DBS training materials. In Study 2, we examined the feasibility of implementing this protocol within a larger online study. Results: In Study 1 participants (n=115) were, on average, 26.1±6.4 years of age. Participants who used the training materials produced useable samples (96% collected DBS were useable). Self-collection of DBS also was feasible as 98% of participants were willing to collect DBS again. In Study 2, assessing implementation, our response rate was 25% (41/164) with non-responders significantly younger than responders were (22.0±0.4 years vs. 20.3±0.2 years, P<.001) and 92% of DBS were useable by the lab. Conclusions: Overall, while the protocol is acceptable, feasible, and produced useable samples, additional work is needed to improve response rates.

Improving Understanding of Test Results by Substituting (Not Adding) Goal Ranges: Experimental Study

From: Journal of Medical Internet Research

Date Submitted: May 15, 2018

Open Peer Review Period: May 17, 2018 - Jul 12, 2018

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Background: Most displays of laboratory test results include a standard reference range. For some patients (e.g. those with chronic conditions), however, achieving a result within the standard range m...

Background: Most displays of laboratory test results include a standard reference range. For some patients (e.g. those with chronic conditions), however, achieving a result within the standard range may be unachievable, inappropriate, or even harmful. Objective: To test the impact of including clinically-appropriate goal ranges outside the standard range in visual displays of laboratory test results. Methods: Participants (N=6776) from a demographically diverse online panel viewed hypothetical hemoglobin A1c test results (either A1c=6.2% or =8.2%) as part of a type 2 diabetes management scenario. Test result visual displays included either (1) standard range (4.5%-5.7%) only, (2) a goal range (6.5%-7.5%) added to standard range or (3) goal range only in one of three display formats: (a) table, (b) a simple, two-colored number line (simple line), or (c) a number line with diagnostic categories indicated via colored blocks (block line). Primary outcome measures were comprehension of and negative reactions to test results. Results: While goal range information did not influence understanding of A1c=8.2% results, goal range only displays produced higher levels of comprehension and decreased negative reactions to A1c=6.2% test results compared to the no goal range and goal range added conditions. Goal range information was less helpful in the block line condition versus other formats. Conclusions: Replacing the standard range with a clinically-appropriate goal range could help patients better understand how their test results relate to their personal targets.

Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS): A Protocol for Monitoring the Control of Sexually Transmissible Infections and Blood Borne Viruses

From: JMIR Research Protocols

Date Submitted: May 11, 2018

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

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Background: New biomedical prevention interventions make the control or elimination of some blood -borne viruses (BBVs) and sexually transmissible infections (STIs) increasingly feasible. In response,...

Background: New biomedical prevention interventions make the control or elimination of some blood -borne viruses (BBVs) and sexually transmissible infections (STIs) increasingly feasible. In response, the World Health Organization and governments around the world have established elimination targets and associated timelines. Objective: This paper describes ACCESS (Australian Collaboration for Coordinated Enhanced Sentinel Surveillance), a national surveillance network designed to monitor public health and evaluate the impact of strategies aimed at controlling BBVs and STIs in Australia. Methods: ACCESS is a sentinel surveillance system comprising health services and pathology laboratories in each of the eight Australian jurisdictions. Sites that provide significant testing or management of BBVs and/or STIs or see populations with particular risks for these infections (‘priority populations’) are included in the network. ACCESS is based on regular and automated extraction of de-identified patient data using specialised software called GRHANITE™, which creates a unique and anonymous identifier from individual patient details. This identifier allows anonymous linkage between and within participating sites, creating a national cohort that allows the evaluation of clinical and public health interventions and related research. Results: As of March 2018, 104 health services (sexual health clinics, general practice clinics, drug and alcohol services, community-led testing services, and hospital outpatient clinics) and 17 pathology laboratories (private and public) were participating in ACCESS. Between 2009 and 2017, ACCESS captured data from 1,171,658 individual patients who attended a participating health service at least once, comprising a total of 7,992,241 consultations. Conclusions: ACCESS is a unique system with the ability to track efforts to control STIs and BBVs – including through the calculation of powerful epidemiological indicators – by identifying response gaps and facilitating the evaluation of programs and interventions. By anonymously linking patients between and within services and over time, ACCESS has exciting potential as a research and evaluation platform.

Data Driven Blood Glucose Pattern Classification and Anomalies Detection: Machine Learning Applications in Type 1 Diabetes

From: Journal of Medical Internet Research

Date Submitted: May 11, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

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Background: Diabetes mellitus is a chronic metabolic disorder that results in abnormal blood glucose regulations. Blood glucose level (BG) is preferably maintained close to normality through self-mana...

Background: Diabetes mellitus is a chronic metabolic disorder that results in abnormal blood glucose regulations. Blood glucose level (BG) is preferably maintained close to normality through self-management practices, which involves actively tracking BG levels and taking proper actions including adjusting diet and insulin medications. It is obvious that a tight BG control could sometimes results in out of range levels, i.e., hyper- or hypoglycemia episodes. Factors such as carbohydrate intake, stress and infections could result in hyperglycemia episodes. BG anomalies could be defined as any undesirable reading either due to a precisely known (normal cause variation) or unknown reason (special cause variation) to the patient. Even if the advancement in self-management applications and diabetes monitoring technologies have made things easier, the challenge of BG anomalies remains to be managed by the patient her-/himself. There are increasingly more technological developments in the direction of personalized decision systems and BG event alarms to provide an alert and decision support to the patient for these challenges. Techniques like detection of glycemic variability, hypoglycemia, and hyperglycemia in particular and blood glucose anomalies in general are central to the development of these diabetes technologies. The ubiquitous nature and widespread use of mobile health applications (mHealth apps), sensors and wearables and other point of care (POC) devices for self-monitoring and management purposes have made possible the generation of automated and continuous diabetes related data, which brought an opportunity for the introduction of machine learning applications for an intelligent and improved systems, capable of solving complex tasks within a dynamic knowledge and environment.Recently, machine learning applications have been widely introduced within the diabetes research in general and BG anomalies detection in particular. However, irrespective of their expanding and increasing popularity, there is lack of updated reviews that materialize the current trends in modelling options and strategies in BG anomalies detection within the context of personalized decision support systems and BG alarm events applications in type 1 diabetes. Objective: The objective of this review is to identify, assess and analyze the state of the art machine learning strategies and its hybrid systems focusing on blood glucose anomalies classification and detection including glycemic variability, hyperglycemia, and hypoglycemia in type 1 diabetes, which are important constituents for optimal diabetes self-management. The review covers machine learning approaches pertinent to personalized decision support systems and BG alarm events applications. Methods: A rigorous literature was conducted between September 1 and October 1, 2017, through various online databases including Google scholar, PubMed, ScienceDirect and others. Peer reviewed journals and articles were considered. Relevant articles were first identified by reviewing the title, keywords, and abstracts as a preliminary filter with our selection criteria, and then reviewed the full text articles that fulfilled the inclusion criteria. Information from the selected literature was extracted based on some predefined categories, which were based on previous research and further elaborated through brainstorming. Results: The initial hit was vetted using the title, abstract, and keywords, and retrieved a total of 467 papers (DBLP Computer Science (17), Diabetes Technology and Therapeutics (23), Google scholar (150), IEEE (211), Journal of Diabetes Science and Technology (21), PubMed Medlin (19), ScienceDirect (26)) (see Figure 3 below). After removing duplicates from the list, 389 records remained. Then, we did an independent assessment of the articles and screening based on the inclusion and exclusion criteria, which eliminated another 210 papers, leaving 179 relevant papers. After a full-text assessment, 45 articles were left (hyperglycemia = 5, glycemic variability = 3, hypoglycemia = 37), which were critically analyzed. The inter-rater agreement was measured using Cohen Kappa test, and disagreements were resolved through discussion. Conclusions: Despite the complexity of blood glucose dynamics, there are many attempts to capture hypoglycemia, hyperglycemia incidences and the extent of an individual’s glycemic variability using different approaches. Recently, due to the ubiquitous nature of self-management mHealth apps, sensors and wearables has paved the way for the continuous accumulation of self-collected health data, which in turn contributed for the widespread research of machine learning applications. The state of the art indicates that various classes of machine learning have been developed and tested in different BG pattern classification and anomalies detection tasks. These class includes feed forward artificial neural network, hybrid systems, support vector machine (SVM), decision tree, genetic algorithm, adaptive neural fuzzy inference system (ANFIS), nonlinear auto-regressive network with exogenous inputs (NARX), and nonlinear auto-regressive network (NAR), Gaussian process regression, deep belief network, and Bayesian neural network (BNN). These techniques have explored various kinds of input parameters such as blood glucose (BG), heart rate, QT interval, insulin, diet, physical activity, galvanic response, and skin impedance. Most of the identified studies used a theoretical threshold either suggest by physician or various concerned bodies like the American diabetes association. However, the problem with this kind of approaches is that the specified threshold may vary from patient to patient and also some patients might feel no symptoms. Therefore, such models should consider the difference among patients and also track its temporal change overtime. Moreover, the studies should also give more emphasis on the time lag (TL) and the various types of inputs used. Generally, we foresee these developments might encourage researchers to further develop and test these systems on a large-scale basis.

Electronic Health Record Portal Adoption- A New Integrated Model Approach

From: Journal of Medical Internet Research

Date Submitted: May 13, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

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Background: The future of health care delivery is becoming more patient focused and EHR portals are getting more attention from worldwide governments that consider this technology as valuable asset fo...

Background: The future of health care delivery is becoming more patient focused and EHR portals are getting more attention from worldwide governments that consider this technology as valuable asset for the future sustainability of the national healthcare systems. Overall this makes the adoption of EHR Portals an important field to study. Objective: The goal of this study is to understand the factors that drive individuals to adopt EHR portals. Methods: We applied a new adoption model that combines three different theories, extended Unified Theory of Acceptance and Use of Technology (UTAUT2), Health Belief Model (HBM) and the Diffusion of Innovation (DOI), all of the three with relevant contributions for the understanding of EHR Portals. To test the research model, we used the partial least squares (PLS) causal modelling approach. We executed a national survey based on randomly generated mobile phone numbers. We collected 139 questionnaires. Results: Performance expectancy (β = .203; t = 2.699), compatibility (β = .530; t = 6.189) and habit (β =.251; t =2.660) have a statistically significant impact in behaviour intention (R2= 76.0%). Habit (β = .378; t =3.821), self-perception (β = .233; t = 2.971) and behaviour intention (β =.263; t =2.379) have a statistically significant impact in use behaviour (R2= 61.8%). Additionally, behaviour intention (β =.747; t =10.737) has a statistically significant impact in intention to recommend (R2= 69.0%), results demonstrability (β =.403 ; t =2.888 ) and compatibility (β =.337; t =2.243) have a statistically significant impact in effort expectancy (R2= 48.3%), and compatibility (β =.594 ; t = 6.141) in performance expectancy (R2= 42.7%). Conclusions: Our research model yields very good results, with relevant R2 in the most important dependent variables that help explain the adoption of EHR Portals, behaviour intention and use behaviour.

Patient-centric portable health record exchange: A feasibility study

From: JMIR mHealth and uHealth

Date Submitted: May 11, 2018

Open Peer Review Period: May 14, 2018 - Jul 9, 2018

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Background: Patient medical records contain important information for healthcare professionals to make the right decisions that provide efficient care and optimize quality patient outcomes. Electroni...

Background: Patient medical records contain important information for healthcare professionals to make the right decisions that provide efficient care and optimize quality patient outcomes. Electronic health record (EHR) systems are now the standard to document patient health information. However, the exchange of patient protected health information remains a challenge due to the lack of connectivity across hundreds of different EHR systems. Objective: The aim of the study is to describe the implementation of a secure and EHR-agnostic portable patient medical record technology, and to describe initial user experiences. Methods: We developed the VYRTY solution, a HIPPA compliant and secure medical record card and reader that allows for user authentication, patient authentication, data capture, data storage, and documentation sharing that works with any EHR system. Storage of all patient medical records is encrypted on the VYRTY card allowing safe patient transportation of medical records. Physician activation was phased in over the first 5 months of the one-year pilot. Patient enrollment was voluntary and was complete within 8 months from start of the pilot. Physicians uploaded medical record documents from their EHR by using the print function. Patients that were referred shared their VYRTY card with the receiving physician for downloading of medical records. The exchange of medical records was recorded by the VYRTY system and personal interviews were conducted and recorded to assess user experience. Results: One hundred and ninety-four patients participated out of 200 enrolled, while 23 physicians actively participated out of 45 enrolled. Patients utilized their VYRTY cards 49% of the time, and physicians downloaded documents 51% of the time during the 1-year pilot period. Participating physicians found VYRTY easy to use and their patients were very satisfied with the convenient portability of their medical records. Conclusions: VYRTY was implemented successfully and found to be easy to use by physicians and patients. Using the VYRTY system gave patients their own medical records to share with other providers, which effectively solved the problem of exchanging health information between different EHR systems.

Disrupted Care: eHealth engagement as a response to negative healthcare experiences

From: Journal of Medical Internet Research

Date Submitted: May 14, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

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Background: EHealth provides individuals with new means of accessing health information and communicating with providers through online channels. Prior evidence suggests that patients turn to eHealth...

Background: EHealth provides individuals with new means of accessing health information and communicating with providers through online channels. Prior evidence suggests that patients turn to eHealth to look for information online when they receive care that is low in patient centeredness. However, it is not clear how other problems with the healthcare delivery system motivate use of eHealth, how these problems relate to different kinds of eHealth activities, and who is most likely to turn to eHealth when they receive low quality care. Objective: We sought to determine (1) how two types of negative care experiences, low patient centeredness and care coordination problems, motivated use of different kinds of eHealth activities, and (2) whether highly educated individuals, who may find these tools easier to use, are more or less likely to make use of eHealth following negative experiences than less educated individuals. Methods: Using nationally representative data from the 2017 Health Information National Trends Survey (HINTS), we first used factor analysis to group 25 different eHealth activities into categories based on the correlation between respondents’ reports of their usage. We then used multivariate negative binomial generalized linear model regressions to determine whether negative healthcare experiences predicted greater use of these resulting categories. Finally, we stratified our sample based on educational attainment to test whether associations between healthcare experiences and eHealth use differed across groups. Results: Factor analysis suggested eHealth activities divide into two categories: provider-facing (e.g. facilitating communication with providers) and independent (e.g. patient-driven information seeking, communication with non-providers). Negative care experiences were not associated with provider-facing eHealth activity in the overall population or among highly educated respondents (P’s>.05), but respondents with lower education that had experienced problems with care coordination used somewhat more provider-facing eHealth (P=.07). Regarding independent eHealth activity, individuals engaged in more of these activities if they had experienced problems with either care coordination (P=.01) or patient centered communication (P=.01). Furthermore, while care coordination problems predicted independent eHealth activity across education levels (P=.01 for high education, P=.07 for low education), the relationship between low perceived patient centeredness and independent activity was constrained to individuals with lower levels of education (P=.02). Conclusions: Our findings indicate that individuals turn to eHealth activities--especially those that are independent of healthcare providers--when they experience problems with their healthcare. People with lower levels of education seem especially inclined to use eHealth in response to negative healthcare experiences. To maximize the potential for eHealth to meet the needs of all patients, and especially those traditionally underserved by the healthcare system, additional work should ensure eHealth resources are accessible and usable for all members of the population.

A Study to Identify Key Topics Bearing Negative Sentiment on Twitter Concerning the 2015/2016 Zika Epidemic

From: JMIR Public Health and Surveillance

Date Submitted: May 13, 2018

Open Peer Review Period: May 21, 2018 - Jun 4, 2018

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Background: In order to understand public sentiment regarding the Zika virus, social media can be leveraged to understand how positive, negative, and neutral sentiments are expressed in society. Speci...

Background: In order to understand public sentiment regarding the Zika virus, social media can be leveraged to understand how positive, negative, and neutral sentiments are expressed in society. Specifically, understanding the characteristics of negative sentiment could help inform federal disease control agencies’ efforts to disseminate relevant information to the public about Zika related issues. Objective: The purpose of this study was to analyze public sentiment concerning Zika using posts on Twitter and determine the qualitative characteristics of positive, negative and neutral sentiments expressed. Methods: Machine learning techniques and algorithms were used to analyze the sentiment of tweets concerning Zika. A supervised machine learning classifier was built to classify tweets into three sentiment categories: positive, neutral, and negative. Tweets in each category were then examined using a topic modeling approach in order to determine the main topics for each category, with focus on the negative category. Results: A total of 5,303 tweets were manually annotated and used to train multiple classifiers. These performed moderately well (F1 score = 0.69, 0.68) with text-based feature extraction. All 48,734 tweets were then categorized into the sentiment categories. Ten topics for each sentiment category were identified using topic modeling with a focus on the negative sentiment category. Conclusions: Our study demonstrates how sentiment expressed within discussions of epidemics on Twitter can be discovered. This allows public health officials to understand public sentiment regarding an epidemic and enables them to address specific elements of negative sentiment in real-time. Our negative sentiment classifier was able to identify tweets concerning Zika with three broad themes: neural defects, Zika abnormalities, and reports and findings. These broad themes were based on domain expertise and from topics discussed in journals such as MMWR and Vaccine. Since the majority of topics in the negative sentiment category concerned symptoms, officials should focus on spreading information about prevention and treatment research.

Planning, implementation and process evaluation of a Short Message Service intervention for improving infant feeding practices in Shanghai, China

From: JMIR mHealth and uHealth

Date Submitted: May 13, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

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Background: Although m-health has been widely applied in healthcare services, few studies have reported detailed process of the development and implementation of Short Message Service (SMS) interventi...

Background: Although m-health has been widely applied in healthcare services, few studies have reported detailed process of the development and implementation of Short Message Service (SMS) intervention. Objective: Our study aims to demonstrate the process and lessons learnt of a community-based SMS intervention for improving infant feeding in Shanghai, China. Methods: The intervention included planning and development, implementation, and process evaluation. A three-phase process was adopted during planning and development: a formative study with expectant and new mothers to explore the barriers of appropriate infant feeding practices; a baseline questionnaire survey to understand potential intervention approaches; and development of the SMS message bank. The SMS intervention was delivered via a computer-based platform. Process evaluation was conducted through field records and qualitative interviews with participating mothers. Results: The study found that the SMS intervention was feasible and well received by mothers because of its easy and flexible access. The message frequency was thought to be appropriate and contents were anticipatory and trustworthy. Some mothers had high expectations for timely response to inquiries. Occasionally messages were not delivered due to unstable telecommunication transmission. Mothers suggested that messages could be more personalized. Conclusions: The study demonstrates the feasibility and value of SMS intervention in filling gaps in delivering healthcare services and promoting healthy infant feeding practices in settings where personal contact is limited.

Using Passive Smartphone Sensing for improved Risk Stratification of patients with Depression and Diabetes

From: Journal of Medical Internet Research

Date Submitted: May 14, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

This manuscript needs more reviewers
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Background: Research studies are establishing the use of smartphone-sensing to measure mental well-being. Smartphone sensor information captures behavioral patterns and its analysis helps reveal well...

Background: Research studies are establishing the use of smartphone-sensing to measure mental well-being. Smartphone sensor information captures behavioral patterns and its analysis helps reveal well-being changes. Depression in diabetes goes highly under-diagnosed and under-reported. The comorbidity has been associated with increased mortality and worse clinical outcomes; including poor glycemic control and poor self-management. Clinical only intervention has been found to have very modest effect on diabetes management among people with depression. Smartphone technologies could play a significant role in complementing co-morbid care. Objective: To present an approach to risk-stratify people with diabetes based on symptoms of depression detected using smartphone-sensing information. Methods: A cross-sectional observational study (Project SHADO- Analyzing Social and Health Attributes through Daily Digital Observation) was conducted on 47 participants with diabetes. The study smartphone-sensing app passively collected data regarding activity, mobility, sleep and communication from each participant. Self-reported symptoms of depression (using validated Patient Health Questionnaire- 9) was collected once every 2 weeks from all participants. A descriptive analysis was performed to understand the representation of the participants. A univariate analysis was performed on each derived sensing variable to compare behavioral changes between depression states- those with self-reported major depression (PHQ-9 > 9) and those with none (PHQ-9 <= 9). A classification predictive modeling, using supervised machine-learning methods, was explored using derived sensing variables as input to construct and compare classifiers that could risk-stratify people with diabetes based on symptoms of depression. Results: A noticeably high prevalence of self-reported depression (30 out of 47 participants, ~65%) was found among the participants. Low correlation was found between self-reported depression state and each of the 53 derived sensing variables. Between depression states, a significant difference was found for average activity rates (day time) among participant-day instances with symptoms of major depression (M=16.06, SD=14.90) and those with none (M=18.79, SD=16.72); P= .005. For average number of people called, a significant difference was found between participant-day instances with symptoms of major depression (M=5.08, SD=3.83) and those with none (M=8.59, SD=7.05); P < .001. These results suggest that participants with diabetes and symptoms of major depression exhibited lower activity through the day and maintained contact with fewer people. Using all the derived sensing variables, the XGBoost machine-learning classifier provided the best performance with an average cross-validation accuracy of 79.07% (95% CI: 74%, 84%) and test accuracy of 81.05% to classify symptoms of depression. Conclusions: Participants with diabetes and self-reported symptoms of major depression were observed to show lower levels of social contact and lower activity levels during the day. While findings must be reproduced in a broader RCT, the study shows promise in use of predictive modeling for early detection of symptoms of depression in people with diabetes using smartphone-sensing information.

WhatsApp embedded in routine service delivery for smoking cessation: Effects on success rates in a randomized controlled study

From: Journal of Medical Internet Research

Date Submitted: May 14, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

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Background: The demand for smoking cessation services has risen in Turkey, as those planning to quit, reached 35% in 2012. For quitting efforts, communication technologies are used widespread globally...

Background: The demand for smoking cessation services has risen in Turkey, as those planning to quit, reached 35% in 2012. For quitting efforts, communication technologies are used widespread globally, yet service integration is rare. Objective: This study aims to assess the effect of a WhatsApp application embedded in the cessation service delivery, on success rate. Methods: Randomized controlled intervention study was conducted with 132 volunteers, followed up at Ege University Hospital, Smoking Cessation Clinic, March-July 2017. Intervention content based on Transtheoretic Model, was prepared and 60 WhatsApp messages were delivered to participants for 3 months, with 6 months follow up. Initial interview and follow up forms consisting sociodemographics, smoking status, medical condition and treatment, were used. The success rate at 1st and 3rd months were assessed by point-prevalence. Intention-to-treat analysis was used. As secondary outcomes; number of follow-ups, change in weight and continuity of medication were evaluated. Results: Success rate at 1st month was 65.9% for intervention group and 40.9% in control group; for the 3rd month it was 50.0% and 30.7%, consecutively. Being in the intervention group increased success rate by 3.50 (1.30-9.44) times in the 1st 2.50 (1.08-6.40) times in the 3rd and 2.31 (1.03- 5.16) times 6th month. The intervention was the only parameter effective in the two follow-up periods; all other factors were eliminated after adjustment for the intervention. As secondary outcomes, in the intervention group, number of follow-ups and face to face follow-ups increased for the 1st and 3rd months and continuity of medication was higher at 3rd month. Conclusions: WhatsApp support embedded in cessation service delivery increases the success rate and has favorable effects on follow-up. Moreover, the equalizing effect of the intervention in terms of socioeconomic differences, positively contributes to the elimination of inequalities for successful smoking cessation in disadvantaged groups.

The Reality of the Use of Virtual Reality in Patients with Eating Disorders

From: Journal of Medical Internet Research

Date Submitted: May 14, 2018

Open Peer Review Period: May 17, 2018 - Jul 12, 2018

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Four phases for user-centered digital development: Integrating academic and industry approaches to health information technology

From: Journal of Medical Internet Research

Date Submitted: May 14, 2018

Open Peer Review Period: May 17, 2018 - Jul 12, 2018

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Background: Design thinking and human-centered design approaches have become increasingly common in the healthcare literature, particularly in relation to health information technology (HIT), as a pat...

Background: Design thinking and human-centered design approaches have become increasingly common in the healthcare literature, particularly in relation to health information technology (HIT), as a pathway toward the development of usable, diffusible tools and processes. There is a need in academic medical centers tasked with digital innovation for a comprehensive process model to guide development that incorporates current industry trends including design thinking and the lean and agile approaches to digital development. Objective: To describe the foundations and phases of our model for user centered HIT development. Methods: Based on our experience, we established an integrated approach and rigorous process for HIT development that leverages design thinking, lean and agile strategies in a pragmatic way while preserving methodological integrity in support of academic research goals. Results: A four phased pragmatic process model for user-centered digital development in HIT. Conclusions: The culmination of diverse innovation projects, this model for user-centered HIT development represents a multi-phased, high fidelity process for making more creative, flexible, efficient and effective tools. This model is a critical step in building a rigorous approach to HIT design that incorporates a multidisciplinary, pragmatic perspective, combined with academic research practices and state of the art approaches to digital product development to meet the unique needs of healthcare.

A Practical Do-It-Yourself Recruitment Framework for Concurrent eHealth Clinical Trials: A Simple Architecture – Part 1

From: Journal of Medical Internet Research

Date Submitted: May 14, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

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Background: The ability to identify, screen, and enroll potential research participants in an efficient and timely manner is crucial to the success of clinical trials. In the age of the internet, rese...

Background: The ability to identify, screen, and enroll potential research participants in an efficient and timely manner is crucial to the success of clinical trials. In the age of the internet, researchers can be confronted with large numbers of people contacting the program, overwhelming study staff and frustrating potential participants. Objective: This article describes a “do-it-yourself” recruitment support framework (DIY-RSF), using tools readily available in many academic research settings, to support remote participant recruitment, pre-screening, enrollment, and management across multiple concurrent eHealth clinical trials. Methods: This work was conducted in an academic research center focused on developing and evaluating behavioral intervention technologies. A needs assessment consisting of unstructured individual and group interviews was conducted to identify barriers to recruitment and important features for the new system. Results: We describe a practical and adaptable recruitment management architecture that used readily available software, such as REDCap and standard statistical software (e.g. SAS, R), to create an automated recruitment framework that supported prescreening potential participants, consent to join a research registry, triaging for management of multiple trials, capture of eligibility information for each phase of a recruitment pipeline, and staff management tools including monitoring of participant flow and task assignment/reassignment features. The DIY-RSF was launched in July 2015. As of July 2017, the DIY-RSF has supported the successful recruitment efforts for eight trials, producing 14,557 participant records in the Referral Tracking database and 5,337participants in the center research registry. The DIY-RSF has allowed for more efficient use of staff time and more rapid processing of potential applicants. Conclusions: Using tools already supported at many academic institutions, we describe the architecture and utilization of an adaptable referral management framework to support recruitment for multiple concurrent clinical trials. The DIY-RSF can serve as a guide for leveraging common technologies to improve clinical trial recruitment procedures.

A Practical Do-It-Yourself Recruitment Framework for Concurrent eHealth Clinical Trials: Identification of Efficient and Cost-Effective Methods for Decision Making - Part 2

From: Journal of Medical Internet Research

Date Submitted: May 14, 2018

Open Peer Review Period: May 15, 2018 - Jul 10, 2018

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Background: The ability to successfully recruit participants for eHealth clinical trials is largely dependent on the use of efficient and effective recruitment strategies. Determining which types of r...

Background: The ability to successfully recruit participants for eHealth clinical trials is largely dependent on the use of efficient and effective recruitment strategies. Determining which types of recruitment strategies to use presents a challenge for many researchers. Objective: This article presents an analysis of the time-efficiency and cost-effectiveness of recruitment strategies for eHealth clinical trials and describes a framework for cost-effective trial recruitment. Methods: Participants were recruited for one of 5 eHealth trials of interventions for common mental health conditions. A multi-pronged recruitment approach was used, including digital (e.g., social media, Craigslist), research registry-based, print (e.g. flyers, posters on public transportation), clinic-based (e.g., a general internal medicine clinic within an academic medical center, a large nonprofit healthcare organization), a market research recruitment firm, and traditional media strategies (e.g., newspaper and television coverage in response to press releases). The time costs and fees for each recruitment method were calculated and the participant yield on recruitment costs was calculated by dividing the number of enrolled participants by the total cost for each method. Results: A total of 777 participants were enrolled in one of the trials. Digital recruitment strategies yielded the largest number of participants across the 5 clinical trials and represented 34% of the total enrolled participants. Registry-based recruitment strategies were in second place by enrolling 28% of the total enrolled participants across trials. Research registry-based recruitment had a relatively high conversion rate from potential participants who contacted our center to being screened to being enrolled, and it was also the most cost-effective for enrolling participants in this set of clinical trials with a total cost per person enrolled at $8.99. Conclusions: Based on these results, a framework is proposed for participant recruitment. To make decisions on initiating and maintaining different types of recruitment strategies, the resources available and requirements of the research study (or studies) need to be carefully examined.

The unmet needs of caregivers of stroke survivors: A review of the content of YouTube videos

From: Journal of Medical Internet Research

Date Submitted: May 15, 2018

Open Peer Review Period: May 17, 2018 - Jul 12, 2018

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Background: Content produced by caregivers of stroke survivors on online video sharing platforms such as YouTube may be a good source of knowledge regarding caregivers’ unmet needs and caregiving ex...

Background: Content produced by caregivers of stroke survivors on online video sharing platforms such as YouTube may be a good source of knowledge regarding caregivers’ unmet needs and caregiving experiences. Objective: We aimed to examine content, quantity and quality of YouTube videos that specifically target and discuss the needs and concerns of caregivers of stroke survivors. Methods: YouTube was systematically searched using six select search strings. The first 20 videos retrieved from each search string were screened against the eligibility criteria and included if they were: developed by either adult caregivers of stroke survivors and focused on caregivers’ needs and concerns; or professional organisations and depicted first-hand testimonials of the needs and concerns of caregivers of stroke survivors. A pre-determined coding schedule was used to report the rate of unmet needs in each video: (1) Impact of Caregiving on Daily Activities; (2) Relationship; (3) Emotional and Psychological; (4) Comprehensive Stroke care; (5) Information; and (6) Spirituality. General video characteristics were also reported. Results: Of the 132 videos screened, 26 individual videos were included in the analysis. Most videos were developed in the USA (61.5%) and featured spouses of stroke survivors (65.47%). The most common types of videos were video blogs (vlogs) in which the main content featured the caregiver(s) diarising their daily thoughts and feelings (n=16, 48.5%). In total, 291 unmet needs were reported by caregivers of stroke survivors, with an average of 11.2 unmet needs per video. The most common unmet needs domain was ‘Impact of Caregiving on Daily Activities’ which made up 44% of the unmet needs reported. The most frequently reported sub-category was ‘Financial Impact’, appearing 24 times in 26 videos (92.3%). Conclusions: Content produced by caregivers of stroke survivors on YouTube may be used as a tool for caregivers to provide and receive support through online communication. YouTube videos offer insight into the unmet needs of caregivers of stroke survivors across countries and healthcare systems, and may be used as an additional resource for stroke services to disseminate health information and support to caregivers. Further research is needed to investigate other online platforms to address the unmet needs of caregivers of stroke survivors.

Understanding Care Navigation by Older Adults with Multimorbidity: A Mixed–Methods Study Using Social Network Analysis and Framework Analysis

From: JMIR Aging

Date Submitted: May 15, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: Health and social care systems were designed to be used primarily by people with single and acute diseases. However, a growing number of older adults are diagnosed with multiple long-term...

Background: Health and social care systems were designed to be used primarily by people with single and acute diseases. However, a growing number of older adults are diagnosed with multiple long-term health conditions (LTCs). The process of navigating the intricacies of health and social care systems in order to receive appropriate care presents significant challenges for older people living with multiple LTCs, which in turn can negatively influence their well-being and quality of life. Objective: The long-term goal of this work is to design technology to assist people with LTCs in navigating health and social care systems. In order to do so, we must first understand how older people living with LTCs currently engage with and navigate their care networks. There is no published research that describes and analyses the structure of formal and informal care networks of older adults with multiple LTCs, the frequency of interactions with each type of care service, and the problems that typically arise in these interactions. Methods: A mixed-methods study was carried out. Sixty-two participants, all aged 55 years or over, living in England, with two or more LTCs, were recruited and completed a social network analysis (SNA) questionnaire. Semi-structured interviews were conducted with roughly a 10% subsample of the questionnaire sample; four women and three men. On average, interviewees were aged 70 years old and had four LTCs. Results: Personal care networks (PCNs) were complex and adapted to each individual. The task of building, and subsequently navigating, one’s PCN rested mainly on patients’ shoulders. It was frequently the patients’ task to bridge and connect the different parts of the system. The major factor leading to a satisfying navigation experience was found to be patients’ assertive, determined and proactive approaches. Smooth communication and interaction between different parts of the care system were found to lead to more satisfying navigation experiences. Conclusions: Technology to support care navigation for older adults with multiple LTCs needs to support patients in managing complex health and social care systems by effectively integrating management of multiple conditions and facilitating communication between multiple stakeholders, while also offering flexibility to adapt to individual situations. Since quality of care seems to be dependent on determination and ability of patient, this leads to uneven care. Those with less determination, and less organization skills experience worse care. Technology must aim to fulfil these coordination functions, to ensure care is equitable across those who need it, not just those who ask loudest.

A comparative study on the psychometric properties of a paper v.s. app administered resilience scale in Scottish youth.

From: JMIR mHealth and uHealth

Date Submitted: May 15, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: Adequately measuring resilience is important in order to support young people and children who are accessing support through social work or educational settings. A widely accepted measure...

Background: Adequately measuring resilience is important in order to support young people and children who are accessing support through social work or educational settings. A widely accepted measure of youth resilience has been developed by Ungar and Liebenberg which has been shown to work within vulnerable youth [1]. While the measure is completed by the young person on paper, it has been designed to be worked through with a teacher or social worker should further clarification be required. However, this method is time consuming and when faced with large assessment needs can be overwhelming for schools and practitioners. The current study assesses app software with a built-in avatar who can guide the young person through the assessment and its interpretation. Objective: The primary objective is to compare the reliability and psychometric properties of a mobile software app to a paper version of the Child and Youth Resilience measure (CYRM-28). Second, the study will assess the use of the CYRM-28 in a Scottish youth population (11-18 years). Methods: Following focus groups and discussion with teachers, social workers and young people an avatar was developed by a software company and integrated into an android smartphone app designed to ask questions via the text-to-voice engine built into the device. Seven-hundred and fourteen students from 2 schools in North East Scotland completed either a paper version or app version of the CYRM-28. A cross-sectional design was used and students completed their allocated version twice with a two-week period in between each testing. All participants could request clarification either from a guidance teacher (paper version) or from the in-built software glossary (app version). Results: Test and retest correlations reported that the app was significantly better performing than the paper version. Paper (r(303)=.76, P<.001, 95%CI [.78, .89]); App (r(413)=.84, P<.001, 95%CI [.77, .85]). Fisher’s r to z transformation found the difference in the correlations to be statistically significant, Z=-2.97, P <.01. Similarly, Cronbach’s alpha in the app condition was very strong (28 items; α=.92) as was the paper version (28 items; α=.87). Fisher’s r to z transformation found the difference in the correlations to be statistically significant, Z=-3.69, P <.01. A Confirmatory Factor Analysis[2] supported the three-factor solution (individual, relational and contextual) and reported a good model fit (χ2 (15, N= 541) = 27.6, P=0.24) ). Conclusions: Alex, an avatar with an integrated voice guide, increased reliability when measuring resilience compared to a paper version with teacher assistance. The CFA reports similar structure using the avatar when compared against the original validation.

Effect of a Multimedia Patient Decision Aid to Supplement the Informed Consent Process of a Peripherally Inserted Central Venous Catheter Procedure: Part 2

From: JMIR Medical Informatics

Date Submitted: May 15, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: Informed consent is a complex process to help patients engage in care processes and reach the best treatment decisions. There are many limitations to the conventional consent process that...

Background: Informed consent is a complex process to help patients engage in care processes and reach the best treatment decisions. There are many limitations to the conventional consent process that is based on oral discussion of information related to treatment procedures by the healthcare provider. A conclusive body of research supports the effectiveness of multimedia patient decision aids (PtDAs) in the consent process in terms of patient satisfaction, increased knowledge about the procedure, reduced anxiety level, and higher engagement in the decision-making. little information is available about the effectiveness of multimedia PtDAs in the consent process of invasive therapeutic procedures such as the peripherally inserted central venous catheter or PICC. Objective: This study examined the effectiveness of a multimedia PtDA to supplement the consent process of the PICC for patients in 10 acute and intensive care units in terms of knowledge recall, knowledge retention, satisfaction with the consent process, and satisfaction with the multimedia PtDA. Methods: This is a pre-post study that included 130 patients for whom a PICC was ordered. Patients in the control group (N= 65) received the conventional consent process for the PICC, while patients in the intervention group (N= 65) received the multimedia PtDA to support the consent process of a PICC. All patients were surveys for knowledge recall and retention about the procedure and satisfaction with the consent process. Patients in the intervention group were also surveyed for their satisfaction with the multimedia PtDA. Results: In comparison to the control group, the intervention group scored around 2 points higher on knowledge recall (t = 4.9, P = .0001) and knowledge retention (t = 4.8, P = .0001). All patients in the intervention group were highly satisfied with the multimedia PtDA with a mean score above 4.5 out of 5 on all items. Items with the highest mean scores were related to the effect of the multimedia PtDA on knowledge retention (mean=4.9, SD=0.2), patient readiness (mean=4.8, SD= 0.5), and complete understanding of procedure complications (mean=4.8, SD= 0.4) and patient role in maintaining the safety of the PICC (mean=4.8, SD= 0.5). Patients in the two groups were highly satisfied with the consent process. However, 10 (out of 65) patients in the control group (15%) reported the followings were omitted from the discussion: patient and provider role in the safety of the PICC, other treatment options, and common side effects. Two of the patients also commented that they were not ready to engage in the discussion. Conclusions: Multimedia PtDA is an effective standardized, structured, self-paced learning tool to supplement the consent process of the PICC and improve patient satisfaction with the process, knowledge recall, and knowledge retention.

Original Paper: Informing Young Adults about the Risks of Using Electronic Cigarettes: A Pilot Study of an Informational Mobile Phone Text Messaging Program

From: JMIR mHealth and uHealth

Date Submitted: May 15, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: Young adults are rapidly adopting electronic cigarette (e-cigarette) use. E-cigarettes’ popularity among young people can be attributed to heavy industry advertising and misleading healt...

Background: Young adults are rapidly adopting electronic cigarette (e-cigarette) use. E-cigarettes’ popularity among young people can be attributed to heavy industry advertising and misleading health claims. Data indicate young e-cigarette users who never used conventional cigarettes are now progressing toward smoking combustible cigarettes. Literature documents the influence of text messaging as a delivery mode to support participants in behavioral interventions. Communicating e-cigarette risks via text messaging has not been tested. Objective: This pilot study assessed the impact of exposure to text messages on e-cigarette knowledge and risk perception outcomes. Methods: A 2-group randomized pretest and posttest study was conducted among young men and women recruited from vocational training programs. Personal phones were used to receive messages and 95 racially and ethnically diverse participants completed a pretest and posttest. Fifty percent were randomized to either receive gain- or loss-framed messages that integrated the latest scientific findings about e-cigarettes. All messages used wording suitable for audiences with low health literacy. Knowledge and risk perceptions about e-cigarettes and tobacco use were assessed pretest and posttest after message exposure. Results: The mean age of participants was 20.8 (SD = 1.7). At pretest, approximately 10.5% of the (n=10/95) participants were current e-cigarette users, and 27.4% (n=26/95) used a variety of tobacco products. Participants randomized to gain-framed messages reported a statistically significant higher risk perception for using e-cigarettes at posttest than those who received loss-framed messages (P = .018). After message exposure there was no change in use of e-cigarettes or other tobacco products. Conclusions: Young adults were informed that e-cigarette use may lead to addiction to nicotine and other consequences. Delivery of effective text messages such as those tested in this pilot can assist young consumers to evaluate and make decisions about e-cigarettes and other evolving tobacco products. Clinical Trial: This was a pilot study and not a clinical trial, thus the project was not registered.

Time series visualizations for daily diary reports of health behaviors: a case study of mobile phone-based reports of stress, physical activity, and diet quality in mostly ethnic minority mothers

From: Journal of Medical Internet Research

Date Submitted: May 16, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: Health behavior (HB) patterns reported through daily diary data are important to understand and intervene upon at the individual level for N-of-1 trials and related study designs. Analyses...

Background: Health behavior (HB) patterns reported through daily diary data are important to understand and intervene upon at the individual level for N-of-1 trials and related study designs. Analyses often utilize regressions that evaluate aggregate effects across individuals. Furthermore, standard analyses target single outcomes. There is often interest in relationships between multiple outcomes, such as stress and HB. Objective: This article illustrates how individuals’ daily reports of stress and HB (time series) can be explored using visualization tools. Methods: Secondary analysis was conducted on six months of daily diary reports of stress and HB (physical activity and diet quality) from mostly ethnic minority mothers who pilot tested a self-monitoring mobile health app. Time series with minimal missing data from 14 of 44 mothers were analyzed. Correlations between stress and HB within each time series were reported as a preliminary step. Stress and HB time series patterns were visualized by plotting moving averages and time points where mean shifts in the data occurred (changepoints). Results: Median correlation was small and negative for associations of stress with physical activity (r = -0.14) and with diet quality (r = -0.083). Moving averages and changepoints for stress and HB were aligned for some participants, but not others. A third subset of participants exhibited little variation in stress and HB reports. Conclusions: Median correlations corroborated prior findings. Time series visualizations highlighted variations in stress and HB across individuals and time that are difficult to capture through correlations and regression-based summary measures.

Impact of Patient Crowdvotes Aggregated Service Diversity on Doctors’ Service Sales in Online Health Community: a Retrospective Study

From: Journal of Medical Internet Research

Date Submitted: May 16, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: An increasing number of people visit online health communities to esquire health information with doctors. In the online health community (OHC), patient crowds tended to label and vote the...

Background: An increasing number of people visit online health communities to esquire health information with doctors. In the online health community (OHC), patient crowds tended to label and vote the doctors’ specialties with encountered disease. Understanding how patients’ online labels can help us understand the service diversity for patients in online health communities and provide constructive suggestions for doctors serving more patients online. Objective: Our goal was to understand: (1) what kind of patterns are the labels of patient crowdvotes aggregated service diversity, including encountered disease labels and online votes, in a OHC? (2) wheather the patient crowdvotes aggregated service diversity make doctors’ service sales difference in OHC? (3) how can managers in OHC perform to improve doctors’ service sales with the feedback of crowdvotes aggregated service diversity? Methods: We designed a retrospective study with data collected from the largest OHC (Good Doctor website) in China. We first used descriptive statistics to investigate the patient crowdvotes aggregated service diversity. Then a multiple log-linear relationship was adapted to investigate the main and the interaction impact of service diversity on doctors’ service sales. Results: Our sample consists of 9,841 doctors from 1,255 different hospitals widely distributed in China. 18,997,018 patients had been serviced by these doctors since they became members of the study OHC. 704,467 votes of doctors’ clinical specialties were labeled by patient crowds in recent two years (Aug.26, 2015-Aug. 25, 2017). Gini coefficient of serviced patients is very high, 0.626, followed by the volume of votes (0.562). Based on the regression model, we found that the coefficients of the control variables, doctor review rating and clinic title, were 0.810(0.041), and 1.735 (0.027), respectively. For the breadth of voted specialties, volume of votes and degree of voted diversity, the standardized coefficient of the main effect were 0.309 (0.038), 0.745 (0.014) and 0.073 (0.018), respectively. All of the estimates are statistically significant at a 0.1% level. Conclusions: Our study provided empirical evidence that the patterns of both the labels of patient crowdvotes aggregated service diversity and doctors’ service sales were of inequality (as illustrated in Lorenz curves) in the distribution of its size of serviced patients in a OHC. Patient crowds’ online labels also leaded to differences in the doctors’ service sales online. The treads of the doctors’ service sales kept increasing as the patient crowdvotes aggregated service diversity increased. Finally, our findings suggested that the higher breadth of voted specialties and degree of voted diversity displayed a greater service sales with a higher review rating, deploying less inequality of Doctors’ service sales.

Development of a UV index sensor-based portable device with the EUVB ratio of natural light

From: JMIR mHealth and uHealth

Date Submitted: May 16, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: Ultraviolet (UV) rays are electromagnetic waves that account for about 5% of the solar light, and when overexposed, they pose malevolent effects on the human skin and health. However, with...

Background: Ultraviolet (UV) rays are electromagnetic waves that account for about 5% of the solar light, and when overexposed, they pose malevolent effects on the human skin and health. However, with recent reports on the beneficial effects of some wavelength bands of UV rays, people’s interest in UV information has increased. This has resulted in requiring, not just simple information such as the amount of UV or UV index (UVI), but detailed UV information that directly affects health, such as EUVB(Erythemally weighted UVB). However, calculating EUVB, which can be done by applying the erythemal weighted function on the intensity value in wavelength, requires specialized optical measurement devices, which cannot be easily accessed by the general public; furthermore, public institutions UV information services do not offer EUVB information for individuals. Objective: Therefore, the present study proposes a UVI sensor-based portable device, with which the general public can have easy access to UV-related information. Methods: The proposed device comprises a UVI sensor that can measure the intensity of erythemal UV radiation, a BLE module that supports communication, and a MCU for key operations. In addition, it applies the ratio of EUVB by month/time, resulting from the actual analysis of natural light to calculate the EUVB and provides the amount of UVI and EUVB to check if they meet conditions required for outdoor activities through the device and smartphone applications. Results: The applicability of the proposed device was verified by the measurement performance comparison test with the standard device, a spectrometer (CAS 140 CT), which showed an average error of 0.06 for UVI and 0.0017 W/m2. Conclusions: The proposed device’s offering of UV-related information such as UVI and EUVB to user is expected to prevent potential damage due to the exposure to UV and to support healthy outdoor activities.

A Qualitative Evaluation of Mothers’ Perceptions of a Technology-Based Supportive Educational Parenting Programme

From: Journal of Medical Internet Research

Date Submitted: May 16, 2018

Open Peer Review Period: May 18, 2018 - Jul 13, 2018

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Background: Transitioning into parenthood can be stressful as parents struggle to cope with new parenting responsibilities. Although perinatal care in hospitals aims to improve parental outcomes, ther...

Background: Transitioning into parenthood can be stressful as parents struggle to cope with new parenting responsibilities. Although perinatal care in hospitals aims to improve parental outcomes, there is a general consensus that it is suboptimal and insufficient. Therefore, many studies have designed intervention methods to supplement support for parents during this stressful period. However, studies often focus on parental outcomes as indicators of intervention success and effectiveness. Studies evaluating participants’ experiences and feedback are limited. Objective: To examine the experiences and perceptions of participants who participated in the supportive education parenting program intervention study. Methods: A qualitative semi-structured interview was conducted with 16 mothers (6 control and 10 intervention) from a randomized controlled trial. The supportive education parenting programme included two phone-based perinatal educational sessions, a phone-based educational session after childbirth, and a one-month postpartum access to a mobile-health application. The interviews were approximately 30 to 60 minutes long, were audiotaped and transcribed verbatim, and analysed using thematic analysis. Study findings were reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. Results: Three main themes evaluating mothers’ experiences and perceptions were generated: 1) changed perspective towards parenthood, 2) journey from pregnancy to after birth, and 3) a way forward. Mothers from the intervention group mostly had a good perinatal experience with sufficient support received, which alleviated their emotional wellbeing and increased parenting involvement. Mothers in the control group, although satisfied with the hospital care received, were more stressed and shared a need for professional advice and extra support. Apart from technical enhancements, mothers also requested extended social support during early pregnancy up to one year postpartum, taking into consideration Asian cultural practices. Conclusions: Mothers who received the intervention were overall satisfied with the support provided by the technology-based supportive educational parenting program. The success of the educational programme in this study highlights the need for supplementing standard care in hospitals with technology-based educational programmes. Future research should include fathers’ perceptions to attain an in-depth understanding of overall participants’ experiences and needs in the future development of supportive and educational programs. Clinical Trial: ISRCTN48536064

Creating, implementing and evaluating an app that uses sports, videogames, and gamification to improve young men’s mental health and wellbeing

From: JMIR Research Protocols

Date Submitted: May 17, 2018

Open Peer Review Period: May 19, 2018 - Jun 2, 2018

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Background: Young men have different mental health needs to young women, who make up the primary audience of digital mental health interventions. An app (MindMax) incorporating sport (Australian Footb...

Background: Young men have different mental health needs to young women, who make up the primary audience of digital mental health interventions. An app (MindMax) incorporating sport (Australian Football League; AFL), videogames, and gamification was developed in an effort to address this issue. Objective: This protocol outlines the research and development process of MindMax. Methods: These include: 1) six participatory design workshops with young people aged 16 to 35 years; 2) 15 user experience testing interviews at three separate time points to iteratively assess and improve the app; and 3) a naturalistic trial, tracking users across multiple time points to evaluate the app. Results: Preliminary results suggest a preference for an action-based approach and a strong preference for a personalised experience. A naturalistic longitudinal trial (baseline N=441) concluded in May 2018. Conclusions: In basing itself strongly within the AFL and videogaming subcultures, MindMax aims to tackle mental health help-seeking barriers for men, and to provide psychoeducation on strategies to increase mental wellbeing. A successful implementation would indicate that generalising this approach to other traditional sporting codes and even competitive videogaming leagues (esports) would be fruitful.

Are we delaying the inevitable? Maintaining lifestyle changes six months after the ‘Get Healthy, Stay Healthy’ extended contact intervention

From: JMIR mHealth and uHealth

Date Submitted: May 17, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Extended intervention contact after an initial, intensive intervention is becoming accepted as best practice in behavioral weight control interventions. What is not clear is whether extend...

Background: Extended intervention contact after an initial, intensive intervention is becoming accepted as best practice in behavioral weight control interventions. What is not clear is whether extended contact mitigates weight regain in the longer-term, or whether it simply delays weight regain until after the extended intervention contact ceases. Objective: To evaluate maintenance following the Get Healthy, Stay Healthy (GHSH) extended contact intervention, by comparing: the intervention and control group averages at 12 months (the traditional comparison of maintained intervention effects); the intervention and control group averages over the first six months of non-contact (a novel approach which directly compares the relapse effects between groups over the same duration of time); and, the individual participant changes over the first six months of non-contact (to explore the extent to which the group average is reflective of directions of changes for individuals). Methods: Clients completing the Get Healthy Service (GHS) lifestyle telephone coaching program were randomised to receive extended contact via tailored text messages (GHSH, n=114) or standard care (no additional contact, n=114) and were assessed at baseline (following completion of GHS), six months (following completion of GHSH) and 12 months (no-contact maintenance follow-up). At all three assessments participants self-reported their body weight, waist circumference, physical activity (walking, moderate and vigorous sessions/week) and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks per day, takeaway meals per week; Fat, Fiber and Total indices from the Fat and Fiber Behavior Questionnaire). Moderate-vigorous physical activity (MVPA) was also assessed via accelerometry. Results: Retention over the 12-month trial was high (93%, 211/228). Participants had a mean (±standard deviation) age of 53.4±12.3 years and baseline BMI of 29.2±5.9 kg/m2. The between-group differences detected at 6 months were still present and statistically significant at 12 months for body weight (-1.33kg (-2.61, -0.05)) and accelerometer-assessed MVPA (24.9 minutes/week (5.8, 44.0)). None of the other outcomes were significantly favoured compared to the control group at 12 months. Changes over their first six months of non-contact for the GHSH group were significantly better than the control group in terms of accelerometer-measured MVPA and self-reported moderate activity (other differences between the groups were all non-significant). In addition to the maintenance seen in the group averages, most intervention participants had maintained their behavioral outcomes during the first six months of non-contact. Conclusions: The GHSH participants were better off relative to where they were initially, and relative to their counterparts not receiving extended contact in terms of MVPA. However, based on the between group difference in bodyweight over the first six months of non-contact, GHSH does appear to simply delay the ‘inevitable’ weight regain. However, this delay in weight regain, coupled with sustained improvements in MVPA, has public health benefit.

Coping strategies and social support in a mobile phone “chat” application designed to support smoking cessation

From: Journal of Medical Internet Research

Date Submitted: May 24, 2018

Open Peer Review Period: May 25, 2018 - Jul 20, 2018

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Background: Smoking is one of the most significant factors contributing to low life expectancy, health inequalities, and illness at the worldwide sacle. Smoking cessation attempts benefit from social...

Background: Smoking is one of the most significant factors contributing to low life expectancy, health inequalities, and illness at the worldwide sacle. Smoking cessation attempts benefit from social support. Mobile phones have changed the way we communicate through the use of freely available message-oriented applications. Mobile application-based interventions for smoking cessation programs can provide interactive, supportive, and individually tailored interventions. Objective: To describe the emotions, coping strategies, beliefs, values, and cognitive evaluations of smokers who are in the process of quitting, and to analyze online social support provided through the analysis of messages posted to a chat function integrated into a mobile application (app). Methods: Descriptive qualitative research. Informants were smokers who participated in the chat of Tobbstop. The technique to generate information was documentary through messages collected from September 2014 through June 2016, specifically designed to support a smoking cessation intervention. A thematic content analysis of the messages applied two models: the Lazarus model to assess participant experiences and perceptions and the Cutrona model to evaluate online social support. Results: During the study period, 11,788 text messages were posted to the chat by 101 users. The most frequent messages offered information and emotional support, and all of the basic emotions were reported in the chat. The three most frequent coping strategies identified were: increased physical activity, different types of treatment such as nicotine replacement, and humor. Beliefs included the inevitability of weight gain and the notion that not using any type of medications is better for smoking cessation. Health and family were the values more frequently described, followed by freedom. A smoke-free environment was perceived as important to successful smoking cessation. The social support group that was developed with the app offered mainly emotional and informational support. Conclusions: Our analysis suggests that a chat integrated into a mobile application focused on supporting smoking cessation provides a useful tool for smokers who are in the process of quitting, by offering social support and a space to share concerns, information, or strategies. Clinical Trial: Trial Registration NCT01734421 https://clinicaltrials.gov/ct2/show/NCT01734421?term=NCT01734421&rank=1

Clinical adoption of mobile technology to support self-management of pediatric cystic fibrosis in Sweden: A qualitative case study

From: JMIR Pediatrics and Parenting

Date Submitted: May 17, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Mobile health technologies have potential to improve self-management and care coordination of pediatric chronic diseases requiring complex care, such as cystic fibrosis. Barriers to implem...

Background: Mobile health technologies have potential to improve self-management and care coordination of pediatric chronic diseases requiring complex care, such as cystic fibrosis. Barriers to implementation have included a lack of support and infrastructure to use mHealth in the clinical microsystem. Coproducing mHealth technology with patients, clinicians, and designers may increase the likelihood of successful integration in the clinical setting. Objective: This study explored the development, adoption and integration of a new, coproduced mHealth platform (Genia) for the management of pediatric cystic fibrosis in Sweden. Methods: A retrospective, qualitative case study approach was used. The case was defined as the process of introducing and using Genia at the Pediatric Cystic Fibrosis Center at Skåne University Hospital in Lund, Sweden. Data sources included interviews, presentations, meeting notes, and other archival documents created between 2014-2017. To be included, data sources must have described or reflected upon the Genia adoption process. Iterative content analysis of data source materials was conducted by two qualitatively trained researchers to derive themes characterizing the mHealth clinical adoption process. Results: Four core themes characterized successful clinical integration of Genia at Lund: a cultural readiness to use mHealth; the use of weekly huddles to foster momentum and rapid iteration; engagement in incremental “Genia Talk” to motivate patient adoption; and a co-design approach toward pediatric chronic care. Conclusions: Principles of quality improvement, relational coordination, user-centered design, and coproduction facilitate the integration of mHealth technology into clinical care systems for pediatric CF care. Clinical Trial: Not applicable

How Confidence in Prior Attitudes, Social Tag Popularity, and Source Credibility Shape Confirmation Bias: A Randomized Controlled Web-Based Study about Attitudes towards Antidepressants and Psychotherapy in a Representative German Sample

From: Journal of Medical Internet Research

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: In health-related, web-based information search, people should choose objectively correct information, but they are often misguided by confirmation bias–the tendency to select and evalua...

Background: In health-related, web-based information search, people should choose objectively correct information, but they are often misguided by confirmation bias–the tendency to select and evaluate information in line with their prior attitudes. They are also misguided by dubious information, not taking source credibility into account properly. Objective: We test whether people are prone to confirmation bias in mental health-related information search, particularly (1) if high confidence worsens confirmation bias, (2) if social tags are an appropriate interface to circumvent the influence of prior attitudes, and (3) if people successfully distinguish high and low source credibility. Moreover, we describe attitudes towards the efficacy of the treatment of depression with antidepressants and psychotherapy. Methods: 520 participants of a representative sample of the German population were recruited on an online platform of a panel company. 250 (48%) completed the fully automated, randomized, controlled web-based study, which was accessible online from November 14th to November 18th 2014, until at least 250 participants completed the survey. Participants provided prior attitudes about antidepressants and psychotherapy. We manipulated (1) confidence by having participants recall situations in which they were confident or doubtful. Next, participants searched for blog posts about the treatment of depression, with social tag clouds differing in (2) tag popularity–either psychotherapy or antidepressant tags were more popular. Finally, we manipulated (3) source credibility with banners indicating high or low expertise of the tagging community, and we measured tag- and blog post selection, and treatment efficacy ratings after navigation. Results: We observed a tendency to rate psychotherapy (mean = 5.24, SD = 1.10) as more effective than antidepressants (mean = 4.61, SD = 1.19; t(225) = 9.71, P < .001, d = .56.). Tag popularity predicted the proportion of selected antidepressant tags (beta = 0.44, SE = .11, P < .001), and blog posts (beta = 0.46, SE = .11, P < .001). We could not replicate the confidence manipulation (t(224) < 1, P = .78). Participants did not attend to source credibility on banners (t(224) = 1.67, P = .10). When confidence was low (-1 SD), participants selected more blog posts consistent with prior attitudes (beta = -0.26, SE = 0.05, P < .001). Moreover, when confidence was low (-1 SD) and source credibility was high (+1 SD), the efficacy ratings of attitude consistent treatments increased (beta = 0.34, SE = 0.13, P = .01). Conclusions: We found correlational support for defense motivation account underlying confirmation bias in the mental health-related search context. That is, participants did not tend to select objectively correct, but information that supported their prior attitudes.

Person-Centered, Technology Enhanced Care Model For Managing Chronic Conditions: Development and Implementation

From: Journal of Medical Internet Research

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes...

Background: Caring for individuals with chronic conditions is labor intensive, requiring ongoing appointments, treatments, and support. The growing number of individuals with chronic conditions makes this current support model unsustainably burdensome on health care systems globally. Mobile health (mHealth) technologies are increasingly being used throughout health care to facilitate communication, track disease, and provide educational support to patients. Such technologies show promise, yet they are not being utilized to their full extent within US health care systems. Objective: The purpose of this study was to examine the utilization of staff and costs of a remote monitoring care model in persons with and without a chronic condition. Methods: At Dartmouth-Hitchcock Health, 2,894 employees volunteered to monitor their health, transmit data for analysis, and communicate digitally with a care team. Volunteers received Bluetooth-connected consumer-grade devices that were paired to a smartphone application that facilitated digital communication with nursing and health behavior change staff. Health data were collected, automatically analyzed, and generated behavioral support communications based on those analyses. Care support staff were automatically alerted according to purpose-developed algorithms. In a subgroup of participants and matched controls, we used difference-in-difference techniques to examine changes in per-capita expenditures. Results: Participants averaged 41 years of age; 73% (n = 2,104) were female and 13% (n = 376) had at least one chronic condition. On average, each month, participants submitted 23 vital sign measurements, engaged in 1.96 conversations, and received 0.25 automated messages. Persons with chronic conditions accounted for 40% of all staff conversations, with higher per-capita conversation rates for all shifts compared to those without chronic conditions (P<.001). Additionally, persons with chronic conditions engaged nursing staff more than those without chronic conditions (1.40 & 0.19 per-capita conversations, respectively, P<.001). When compared to the same period in the prior year, per-capita healthcare expenditures for persons with chronic conditions dropped by 15% (P=.06) more than did those for matched controls. Conclusions: The technology-based chronic condition management care model was frequently used and demonstrated the potential for cost savings among participants with chronic conditions. While further studies are necessary, this model appears to be a promising solution to efficiently provide patients with personalized care, when and where they need it.

Rationale and Design of the Hispanic Secondary Stroke Prevention Initiative: A Community Health Worker Intervention among Latino Patients at Risk of Recurrent Stroke

From: JMIR Research Protocols

Date Submitted: May 17, 2018

Open Peer Review Period: May 22, 2018 - Jun 5, 2018

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Background: Hispanic-Latino populations face a disproportionate stroke burden, and are less likely to have sufficient control over stroke risk factors in comparison to other ethnic populations. A prom...

Background: Hispanic-Latino populations face a disproportionate stroke burden, and are less likely to have sufficient control over stroke risk factors in comparison to other ethnic populations. A promising approach to improving chronic health outcomes has been the use of Community Health Workers (CHWs) Objective: This study aims to evaluate their effectiveness in a randomized controlled trial setting Methods: The Hispanic Secondary Stroke Prevention Initiative is an Randomized Clinical Trial of 300 Latinos from South Florida whom have experienced a stroke within the last 5 years. Participants randomized into the CHW intervention arm receive health education and assistance with healthcare navigation and social services through home visits and phone calls. Results: Outcomes at 12 months include changes in systolic blood pressure, LDL, HbA1c, and medication adherence. Conclusions: HiSSPI is one of the first RTCs to examine CHW-facilitated stroke prevention and will provide rigorous evidence on the impact of CHWs on secondary stroke risk factors among Latinos having had a stroke. Clinical Trial: ClinicalTrials.gov: NCT02251834

Social connection and online engagement: Insights from users of a mental health online forum.

From: Journal of Medical Internet Research

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Over the past two decades, online forums for mental health support have emerged as an important tool for improving mental health and wellbeing. There has been important research which anal...

Background: Over the past two decades, online forums for mental health support have emerged as an important tool for improving mental health and wellbeing. There has been important research which analyses the content of forum posts, studies on how and why individuals engage with forums, and how extensively forums are used. However, we still lack insights into key questions on the effectiveness of medical and health Internet tools, how they are experienced by their users, and how they might be best configured and deployed – especially in rural and remote settings, outside major cities and towns. Objective: The aim of our study was to study the dynamics, benefits, and challenges of a peer-to-peer mental health online forum, from a user perspective. In particular, to better explore and understand user perspectives on connection, engagement, and support offered in such forums, information and advice they gained, and what issues they encountered. We studied both consumer and carer experiences of the forums. Methods: In order to understand the experience of forum users, we devised a qualitative study utilising semi-structured interviews with 17 participants (12 women, 5 men). Data were transcribed, coded, and analysed via key themes. Results: The study found that participants: experienced considerable social and geographical isolation which the forums helped to address; sought out the forums as a way to find social connection that was lacking in their everyday lives; used the forums to both find and provide information and practical advice. Conclusions: The study confirms that online peer support provides a critical, ongoing role in providing social connection for mental health consumers. In addition, the research shows forums also provide crucial information and advice for many in this study, especially those living in rural and remote areas. Key to the success of this online forum was careful configuration of moderation, deployment of professional support and advice.

Identification of Primary Medication Concerns regarding Thyroid Hormone Replacement Therapy from Online Patient Medication Reviews

From: Journal of Medical Internet Research

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Patients with hypothyroidism report poor health-related quality of life despite having undergone thyroid hormone replacement therapy (THRT). Understanding patient concerns regarding levoth...

Background: Patients with hypothyroidism report poor health-related quality of life despite having undergone thyroid hormone replacement therapy (THRT). Understanding patient concerns regarding levothyroxine can help improve the treatment outcomes of thyroid hormone replacement therapy. Objective: This study aimed to (1) identify the distinctive themes in patient concerns regarding THRT; to (2) determine whether patients have unique primary medication concerns specific to demographics, and to (3) determine the predictability of primary medication concerns on patient treatment satisfaction. Methods: We collected patient reviews from WebMD (1,037 reviews about generic levothyroxine and 1,075 reviews about the brand version) posted between September 1, 2007 and January 30, 2017. We used natural language processing (NLP) to identify the themes of medication concerns. Multiple regression analyses were conducted in order to examine the predictability of the primary medication concerns on patient treatment satisfaction. Results: NLP of the patient reviews of levothyroxine posted on a social networking site produced six distinctive themes of patient medication concerns related to levothyroxine treatment: ‘How to take the drug,’ ‘treatment initiation,’ ‘dose adjustment,’ ‘symptoms of pain,’ ‘generic substitutability’ and ‘appearance.’ Patients had different primary medication concerns unique to their gender, age, and treatment duration. Furthermore, treatment satisfaction on levothyroxine depended on what primary medication concerns the patient had. Conclusions: NLP of text content available on social networks could identify different themes of patient medication concerns that can be incorporated into tailored medication counseling to improve patient treatment satisfaction.

An evaluation of the effectiveness of the modalities used to deliver eHealth interventions for Chronic Pain: A systematic review with network meta-analysis.

From: Journal of Medical Internet Research

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: eHealth is the use of information and communication technology in the context of healthcare and health research. Recently, there has been a rise in the number of eHealth modalities and the...

Background: eHealth is the use of information and communication technology in the context of healthcare and health research. Recently, there has been a rise in the number of eHealth modalities and the frequency in which they are used to deliver technology-assisted self-management interventions for people living with chronic pain. However, there has been little or no research directly comparing these eHealth modalities. Objective: The aim of the current systematic review with a network meta-analysis is to directly compare the effectiveness of eHealth modalities in the context of chronic pain. Methods: Randomised controlled trials (N>20 per arm) that investigated technologically delivered interventions for adults with chronic pain were included. Data were extracted on pain severity, psychological distress and HRQoL, and the risk of bias was assessed. Studies were classified by their primary mode of delivery. Pair-wise meta-analyses were undertaken and a network meta-analysis was conducted to generate indirect comparisons of modalities for reducing pain severity. Results: The search returned 18,470 studies with 18,349 excluded (duplicates [2,310]; title and abstract [16,039]). Of the remaining papers, 30 studies with 4,595 randomised participants were included in the review. Rankings tentatively indicate that telephone supported interventions are the most effective, with a 46% chance that telephone intervention was the best modality, followed by studies delivered via interactive voice response, internet and virtual reality. Conclusions: This current systematic review with a network meta-analysis generated comparisons between previously un-compared technological modalities to determine which delivered the most effective interventions for the reduction of pain severity in chronic pain patients. There are limitations with this review; in particular, the underrepresented nature of some eHealth modalities included in the analysis. However, in the event that the review is regularly updated a clear ranking of eHealth modalities for the reduction of pain severity will emerge. Clinical Trial: PROSPERO: Registration database number: CRD42016035595

Can Watson for Oncology replace oncologists: A comparative study between Watson for Oncology and our multidisciplinary tumor board

From: Journal of Medical Internet Research

Date Submitted: May 21, 2018

Open Peer Review Period: May 23, 2018 - Jul 18, 2018

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Background: Artificial intelligence（AI）is developing quickly in the medical field, which gives convenience to both medical staff and patients. The AI CDSS Watson for Oncology (WFO) is an outstandi...

Background: Artificial intelligence（AI）is developing quickly in the medical field, which gives convenience to both medical staff and patients. The AI CDSS Watson for Oncology (WFO) is an outstanding representative of AI in medical field, it can give prompt treatment recommendations to cancer patients, just as an excellent oncologist. It is more and more widely used in China, but there is no report about whether it suits Chinese patients. Here we report a retrospective study about the consistency of WFO's recommendations and commendations of the same patient given by our multi-disciplinary team board（MDT） at our center on lung cancer patients’ treatment. Objective: Our objective was to explore practicability of the WFO to the lung cancer cases in China and how to make it more suitable for Chinese patients with lung cancer. Methods: We selected all the lung cancer patients who were hospitalized and received antitumor treatment in the 2nd Xiangya hospital cancer center for the first time from September to December in 2017. WFO gave treatment recommendations to all qualified cases. If our actual therapeutic regimen (which was given by our MDT) was “recommended” or “for consideration” in WFO, we thought it was of consistency, if it was “not recommended” or WFO didn’t have this option, we thought it was of no consistency. Blind second round reviews were made by our MDT to reassess the incongruent cases. Results: WFO didn’t support 18% of all the cases (n=182). Of the 149 cases (82%) supported, 66% were consistent with our MDT recommendations. Subgroup analysis showed that pathological type and staging had a significant effect on consistency (p=0.004, p=0, respectively). Age, gender, whether there was gene mutation or not had no effect on consistency. In 81% of the inconsistent cases, our MDT gave two treatments with Chinese characteristics , which were different from recommendations given by WFO but were also with excellent effect. If WFO can bring the two alternative treatments into the recommended or considered range, the overall consistency can be elevated from 66% to 93%. Conclusions: In China, the majority of the treatment recommendations of WFO are consistent with the recommendation of the expert group, but there is still a relative high proportion of cases which are not supported by WFO. WFO cannot substitute our oncologists currently. As doctors’ assistant, it can improve the efficiency of our work, and it needs to learn local characteristics of patients to become a better assistant. Clinical Trial: none

Use of video consultations for patients with hematological diseases from a patient perspective

From: JMIR mHealth and uHealth

Date Submitted: May 22, 2018

Open Peer Review Period: May 25, 2018 - Jul 20, 2018

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Background: The need for use of telemedicine in the future is expected to increase in the coming years. There is furthermore a lack of evidence about the use of video consultations for hematological p...

Background: The need for use of telemedicine in the future is expected to increase in the coming years. There is furthermore a lack of evidence about the use of video consultations for hematological patients and how the use of video consultations is experienced from the patient’s perspective. Objective: This study aimed to identify patients’ experiences with the use of video consultations in place of face-to-face consultations, what it means to the patient to save the travel time, and how the roles between patients and healthcare professionals are experienced when using video consultation. Methods: The study was designed as an exploratory and qualitative study. Data were collected through participant observations and semi-structured interviews, and analyzed in a post-phenomenological framework. Results: The data analysis revealed three categories: “Intimacy is not about physical presence”, “Handling technology” and “Technology increases the freedom that the patients desire”. Conclusions: This study shows what is important for the patients in terms of seeing the healthcare professionals through a screen. It was found that intimacy can be mediated through a screen and physical presence is not as important to the patient as other things. Also the fact how important it is for the patients to have a choice of their own – to be involved in the planning of their own course of treatment. The patients valued the freedom, and they acted as active patients, taking responsibility for their own course of treatment, and they experienced that the technology gave them the possibility of feeling free and active, despite their illness. Clinical Trial: Danish Data Protection Agency (2012-58-0018)

Management of Anticoagulation in the Peri-Procedural Period: Uptake and Utilization of the MAPPP App

From: JMIR mHealth and uHealth

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Anticoagulants are major contributors to preventable adverse drug events, and their optimal management in the peri-procedural period is particularly challenging. Traditional methods of dis...

Background: Anticoagulants are major contributors to preventable adverse drug events, and their optimal management in the peri-procedural period is particularly challenging. Traditional methods of disseminating clinical guidelines and tools cannot keep pace with the rapid expansion of available therapeutic agents, approved indications for use, and published medical evidence, so a mobile application, Management of Anticoagulation in the Peri-Procedural Period (MAPPP), was developed and disseminated to provide clinicians with guidance reflecting the most current medical evidence. Objective: To assess the global, national, and state-level acquisition of a mobile app since its initial release and characterize individual episodes of use based on drug selection, procedural bleeding risk, and patient thromboembolic risk. Methods: Data was extracted from a mobile app usage tracker (Google Analytics) to characterize new users and completed episodes temporally (by calendar quarter) and geographically (globally, nationally, and in the targeted US state of New York) for the period from April 1, 2016, through September 30, 2017. Results: The app was acquired by 2,866 new users in the measurement period, and users completed nearly 10,000 individual episodes of use. Acquisition and utilization spanned 51 countries globally, predominantly in the United States and particularly in New York State. Warfarin and rivaroxaban were the most frequently selected drugs, and completed episodes most frequently included the selection of the high bleeding risk (49.06%) and high thromboembolic risk categories (45.17%). Conclusions: The MAPPP app is a successful means of disseminating current guidance on peri-procedural anticoagulant use, as indicated by broad global uptake and upward trends in utilization. Limitations in access to provider and patient-specific data preclude objective evaluation of the clinical impact of the app. An ongoing study incorporating app logic into electronic health record systems at participant health systems will provide a more definitive evaluation of the clinical impact of the app logic.

Families on Track: Feasibility and engagement with a digital weight loss intervention for parents of children being treated for obesity.

From: Journal of Medical Internet Research

Date Submitted: May 18, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: The prevalence of childhood obesity continues to increase, and clinic-based treatment options have failed to demonstrate effectiveness. One of the strongest predictors of child weight is p...

Background: The prevalence of childhood obesity continues to increase, and clinic-based treatment options have failed to demonstrate effectiveness. One of the strongest predictors of child weight is parent weight. Parental treatment for weight loss may indirectly reduce obesity in the child. We have previously demonstrated the effectiveness among adults of a fully-automated, evidence-based digital weight loss intervention (Track). However, it is unknown if it is feasible to deliver such a treatment directly to parents with obesity who bring their child with obesity to a weight management clinic for treatment. Objective: To evaluate the feasibility of and engagement with a digital weight loss intervention to parents of children receiving treatment for obesity. Methods: We conducted a 6-month pre-post feasibility trial among parents/guardians and their children aged 4-16 years presenting for tertiary-care obesity treatment. Along with the standard family-based treatment protocol, parents received a 6-month digital weight loss intervention, which included weekly monitoring of personalized behavior change goals via mobile technologies. We examined levels of engagement by tracking completed weeks of self-monitoring and feasibility by assessing change in weight. Results: Participants (n=48) were on average 39 years old, mostly female (82%), non-Hispanic Black (51%) and had obesity (75%). Over a quarter had a yearly household income of less than $25,000 and about a third had the equivalent of a high school education. Children were on average 10 years old and had a BMI of 29.8. The median percent of weeks participants tracked their behaviors was 77% (IQR 6.3 to 100) (18.5/24 total weeks). The median number of attempts via phone or text required to complete one tracking week was 3.3 (IQR 2.6 to 4.9). Nearly half (48%) had high levels of engagement, completing 19 (80%) or more weeks of tracking. Of the 26 participants with weights at 6 months (81% self-reported) there was a median 2.44kg (IQR -6.5 to 1.0) decrease in weight. Conclusions: It is feasible to deliver an evidence-based digital weight loss intervention to parents/guardians whose children are enrolled in a weight management program. Given the feasibility of this approach, future studies should investigate the effectiveness of digital weight loss interventions for parents on child weight and health outcomes.

Efficacy of smartphone application-based pulmonary rehabilitation in chemotherapy-treated patients with advanced lung cancer: a pilot study

From: Journal of Medical Internet Research

Date Submitted: May 19, 2018

Open Peer Review Period: May 19, 2018 - Jul 14, 2018

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Background: Advanced lung cancer patients often have chronic lung disease with reduced exercise capacities and various symptoms leading to altered quality of life (QoL). No studies have assessed pulmo...

Background: Advanced lung cancer patients often have chronic lung disease with reduced exercise capacities and various symptoms leading to altered quality of life (QoL). No studies have assessed pulmonary rehabilitation (PR) employing a mobile application and an Internet of Things device in advanced lung cancer patients undergoing chemotherapy. Objective: We determined the feasibility and efficacy of a smartphone application-based PR on exercise capacity, symptom management, and QoL in these patients. Methods: A total of 100 patients were recruited in a prospective, single-arm intervention study using smartphone application-based PR program for 12 weeks. Exercise capacity (6-minute walking distance, 6MWD), QoL, symptom scale scores, and distress indexes were investigated. Results: Ninety patients completed the PR program. The most common cause of dropout was hospitalization due to cancer progression. After PR, there was significant improvement in the 6MWD; 380.1 ± 74.1 m at baseline, 429.1 ± 58.6 m at 6-weeks (P < .001), and 448.1 ± 50.0 m at 12-weeks (P < .001). However, the dyspnea scale score showed no significant improvement in the patients overall, but there was a trend for improvement in those with a stable tumor response (P = .065). Role (P = .02), emotional (P < .001), and social functioning (P = .002) scale scores showed significant improvement after PR. Symptom scale scores for fatigue (P < .001), anorexia (P = .047), and diarrhea (P = .01) also showed significant improvement. There was significant improvement in depression (P = .048) and anxiety (P = .01), while there was no significant change in QoL (P = .063) and severity of pain (P = .24). Conclusions: Smartphone application-based PR represents an effective and feasible program to improve exercise capacity, and to manage symptoms and distress in patients with advanced lung cancer, undergoing chemotherapy.

Privacy of mHealth Systems: A national survey on user perspectives

From: JMIR mHealth and uHealth

Date Submitted: May 21, 2018

Open Peer Review Period: May 21, 2018 - Jul 16, 2018

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Background: Personal electronic health devices, such as fitness trackers, heart rate monitors, blood glucose meters, blood pressure monitors and stress level meters, and related smartphone-based healt...

Background: Personal electronic health devices, such as fitness trackers, heart rate monitors, blood glucose meters, blood pressure monitors and stress level meters, and related smartphone-based health applications are increasing in usage and popularity. These Internet-based medical technologies, which this paper refers to as mHealth systems, may be prescribed by a healthcare professional or purchased over-the-counter and make it easier for an individual to collect, access and monitor information relevant to their own health and well-being. However, as with many Internet-based technologies, and especially so with sensitive, personal health information, privacy is a significant concern. Actual or a perceived risk of privacy intrusions may delay the wider adoption of mHealth systems and even generate mistrust that reduces their long-term effectiveness. This paper contributes to the understanding of users’ perspectives on information privacy in mHealth systems. Objective: To gain an understanding of current usage patterns and how important users perceive privacy, we have conducted a national survey in Australia. Understanding consumers’ preferences and expectations provide directions for developers, lawmakers and researchers in creating an improved mHealth ecosystem. Methods: As part of the National Social Survey by Population Research Laboratory of CQUniversity, participants who were 18 years or older were randomly selected from across Australia for telephone interviews. The participants were asked 10 questions about usage and privacy of mobile health systems. The collected data was tabulated, cleaned and analysed using SPSS and the resultant data set contained 1,225 cases with a total of 187 variables for each case. Results: The survey reveals users of mHealth systems have a strong desire for privacy, e.g. more than 80% rate privacy important or very important and more than 60% think no personal information should be released to developers. The survey also shows around 70% of users never or rarely review privacy policies, and that they perceive the significant potential impact of intrusions, including increased health insurance costs, embarrassment and financial loss. Conclusions: While the survey results show users desire privacy and have low trust of telecommunications and IT organisations, this conflicts with the technical design of mHealth systems: in many cases application developers, device manufacturers and telecommunication companies may have access to sensitive health information. The lack of standardization and guidelines for data processing by mHealth systems, as well as ineffectiveness of privacy policies, need to be addressed to avoid users’ confusion and potential invasions of privacy. Clinical Trial: This research is undertaken as part of our CQUniversity Population Research Grant Scheme (PRGS). NSS-2016 received approval by the Human Ethics Research Review Panel at CQUniversity before administration to the general public. Project: H14/09-203, NATIONAL SOCIAL SURVEY 2016.

Personalization in Physical Activity Interventions: A Systematic Review of the Literature

From: JMIR mHealth and uHealth

Date Submitted: May 21, 2018

Open Peer Review Period: May 21, 2018 - Jul 16, 2018

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Background: Fitness devices have spurred the development of applications that not only monitor physical activity (PA) but also aim to motivate users, through interventions, to increase their PA. Perso...

Background: Fitness devices have spurred the development of applications that not only monitor physical activity (PA) but also aim to motivate users, through interventions, to increase their PA. Personalization in the interventions is essential as the target users are diverse with respect to their activity levels, requirements, preferences, and behavior. Objective: This review aims to: 1) identify different kinds of personalization in interventions for promoting PA; 2) identify user models used for providing personalization; and 3) identify gaps in the current literature and suggest future research directions. Methods: A systematic review was undertaken using the PRISMA guidelines. PsycINFO, PubMed and Web of Science databases were searched. The main inclusion criteria were: 1) studies that aimed to promote PA among target users as (at least one of) their objectives; 2) studies that had user personalization, with the intention of promoting PA (e.g., activity recommendations or motivational messages); 3) studies that described user models for personalization. Results: The literature search resulted in 28 eligible studies. Of these, 68% (19 studies) focused solely on increasing PA, while the remaining studies had other objectives, like healthcare (18%), weight loss (7%), rehabilitation (7%). The reviewed studies provide personalization in six categories related to recommendation and feedback: goal recommendation, activity recommendation, fitness partner recommendation, educational content, motivational content, and intervention timing. With respect to the mode of generation, interventions were found to be manual, semi-automated, or automatic. Of these, the automatic systems were either knowledge-based or data-driven or both. User models in the studies were constructed with parameters from five categories: PA profile, demographics, medical data, behavior change technique (BCT) parameters, and contextual information. Only 15 of the eligible studies evaluated the interventions and 67% of these 15 concluded that the interventions to increase PA are more effective when they are personalized. Conclusions: This systematic review investigates personalization of interventions, in the form of recommendations or feedback for increasing PA. Based on the review and gaps identified, research directions for improving the efficacy of personalized interventions are proposed. First, data-driven prediction techniques can facilitate effective personalization of automated and semi-automated interventions. Second, use of BCTs in automated interventions, and in combinations with PA guidelines, are yet to be explored and preliminary studies in this direction are promising. Third, systems with automated interventions also need to be suitably adapted to serve specific needs of patients with clinical conditions. Fourth, previous user models focus on single metric evaluations of PA instead of a, potentially more effective, holistic and multidimensional view. Fifth, with the widespread adoption of activity monitoring devices and smartphones, personalized and dynamic user models can be created using the available user data, including the user’s social profile. Finally, the long-term effects of such interventions need to be evaluated rigorously.

Multi-center, observational, prospective study of endotracheal intubation among the critically ill: HEModynamic and AIRway (HEMAIR) management protocol

From: JMIR Research Protocols

Date Submitted: May 21, 2018

Open Peer Review Period: May 21, 2018 - Jun 4, 2018

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Background: Endotracheal intubation can occur in up to 60% of critically ill patients. Despite the frequency with which endotracheal intubation may occur, the current practice is largely unknown. Th...

Background: Endotracheal intubation can occur in up to 60% of critically ill patients. Despite the frequency with which endotracheal intubation may occur, the current practice is largely unknown. This is relevant as advances in airway equipment, i.e., video laryngoscopes, have become more prevalent leading to possible improvement of care delivered during this process. In addition to new devices, a greater emphasis on airway plans and choices in sedation have evolved, although the influence on patient morbidity and mortality is largely unknown. Thus, through a multi-center prospective study, our aim was to derive and validate prediction models for immediate airway and hemodynamic complications of intensive care unit intubations. Objective: The overall goal of this multi-center prospective study is to arrive at a prediction model for both immediate airway and hemodynamic complications thus allowing critical care physicians to be better prepared to address these occurrences and improve the quality of care delivered to the critically ill. Methods: A multi-center, observational, prospective study of adult critically ill patients admitted to both medical and surgical intensive care units at participating sites throughout 8 health and human services regions of the country for which endotracheal intubation was needed was conducted. A steering committee composed of both anesthesia and pulmonary critical care physicians proposed a core set of data variables as a data collection form to be used within the multiple intensive care units across the country during the time of intubation. The data collection form consisted of two basic components, focusing 1- on airway management and 2- on hemodynamic management. The form was generated using RedCap and distributed to the participating centers. Quality checks on the dataset was performed several times from each center to arrive at less than 10% missing values for each data variable and subsequently entered into a database. The primary outcomes will focus on both derivation and validation of airway and hemodynamic models to predict immediate airway and hemodynamic complications of intensive care unit intubations. Results: With these procedures and requirements in place, the rights and welfare of subjects were not adversely affected by study participation or the waiver of consent/authorization. This multi-center, prospective trial will be among the first to include a large diverse patient population from across the United States with a large sample size. The potential benefits would include deriving and validating prediction models for immediate severe complications regarding airway and hemodynamic management surrounding intubations among the critically ill. Conclusions: With this information, it is our hope that the clinician will have a tool to predict which patients will become unstable during this procedure so as to adjust treatment plans allowing improved quality of care delivered during this procedure. This prospective observational trial is even more important as post-intubation hypotension/hemodynamic derangement is noted by some to occur at a fairly high rate leading to possibly increased risk of mortality. Clinical Trial: Clinicaltrials.gov identifier NCT02508948 (07/21/2015)

Publicly available, interactive Option GridTM patient decision aid shifts user preferences about the PSA test, increases knowledge and reduces decisional conflict

From: Journal of Medical Internet Research

Date Submitted: May 21, 2018

Open Peer Review Period: May 21, 2018 - Jul 16, 2018

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Background: Randomized trials of web-based decision aids for prostate specific antigen (PSA) testing indicate that these interventions improve knowledge and reduce decisional conflict. However, we do...

Background: Randomized trials of web-based decision aids for prostate specific antigen (PSA) testing indicate that these interventions improve knowledge and reduce decisional conflict. However, we do not know about these tools’ impact on people who spontaneously use a PSA testing patient decision aid on the internet. Objective: 1) Determine the impact of publicly available web-based PSA Option Grid patient decision aids on preference shift, knowledge, and decisional conflict; 2) identify which frequently asked questions (FAQs) are associated with preference shift; 3) explore the possible relationships between these outcomes. Methods: Data were collected between January 1, 2016 and December 30, 2017. Users who accessed the online, interactive PSA Option Grid were provided with three options – have a PSA test, no PSA test, unsure. Users first declared their initial preference, completed five knowledge questions, and a four-item (yes or no) validated decisional conflict scale (SURE). Next, users were presented with ten FAQs and asked to identify their preference for each question based on the information provided. At the end, users declared their final preference and completed the same knowledge and decisional conflict questions. Paired sample t-tests were employed to compare before-and-after knowledge and decisional conflict scores. A multinomial regression analysis was conducted to determine which FAQs were associated with a shift in screening preference. Results: Of the 467 people who accessed the PSA Option Grid, 186 (40%) completed the interactive journey and associated surveys. After excluding 22 female users, we analyzed 164 responses. At completion, users shifted their preference to ‘not having the PSA test’ (26% vs 71%; P <.01), had higher levels of knowledge (68% vs 89%, P < .01), and lower decisional conflict (57% vs 11%, P < .01). Three FAQs were associated with preference shift: What does the test involve? If my PSA level is high, what are the chances that I have prostate cancer? What are the risks? No relationships were present between knowledge, decisional conflict, and preference shift. Conclusions: Unprompted use of the interactive PSA Option Grid leads to preference shift, increased knowledge, and reduced decisional conflict which confirms the ability of these tools to influence decision-making, even when used outside clinical encounters.

Codesign of a mobile app to provide evidence-based information about crystal methamphetamine (‘ice’) to the community.

From: JMIR mHealth and uHealth

Date Submitted: May 21, 2018

Open Peer Review Period: May 25, 2018 - Jul 20, 2018

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Background: There is evidence of increasing harms and community concern related to the drug crystal methamphetamine (‘ice’), yet there is a lack of easily accessible, evidence-based information fo...

Background: There is evidence of increasing harms and community concern related to the drug crystal methamphetamine (‘ice’), yet there is a lack of easily accessible, evidence-based information for community members affected by its use and no evidence-based mobile applications (apps) specifically focused on crystal methamphetamine. Objective: To describe the codesign and beta-testing of a mobile app to provide evidence-based, up-to-date information about crystal methamphetamine to the general community. Methods: A mobile app about crystal methamphetamine was developed in 2017. The development process involved multiple stakeholders (n=12) including; technology and drug and alcohol experts, researchers, app developers, a consumer expert with lived experience, and community members. Beta-testing was conducted with end users (Australian community members; n=34), largely recruited via the web through Facebook advertising. Participants were invited to use a beta version of the app and provide feedback about the content, visual appeal, usability, engagement, features and functions. Participants were also asked about their perceptions of the app’s influence on awareness, understanding, and help-seeking behaviour related to crystal methamphetamine, and about their knowledge about crystal methamphetamine pre and post using the app. Results: The vast majority of participants reported the app was likely to increase awareness and understanding and encourage help-seeking. The app received positive ratings overall and was well received. Specifically, participants responded positively to the high quality of the information provided, usability and visual appeal. Areas suggested for improvement included; reducing the amount of text, increasing engagement, removing a profile picture, and improving navigation through the addition of a ‘back’ button. Suggested improvements were incorporated prior to the apps public release. There was also a trend to indicate that use of the app resulted in increased perceived knowledge about crystal methamphetamine. Conclusions: The Cracks in the Ice mobile app provides evidence-based information about the drug crystal methamphetamine for the general community. The app is regularly updated, available via the web and offline and was developed in collaboration with experts and end-users. Initial results indicate it is easy to use and acceptable to the target group.

Perspectives on acceptance and use of an mHealth intervention for the prevention of atherosclerotic cardiovascular disease in Singapore: A mixed methods study

From: JMIR mHealth and uHealth

Date Submitted: May 21, 2018

Open Peer Review Period: May 24, 2018 - Jul 19, 2018

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Background: Cardiovascular disease, including atherosclerotic cardiovascular disease (ASCVD), is a growing public health threat globally and many individuals remain undiagnosed, untreated and uncontro...

Background: Cardiovascular disease, including atherosclerotic cardiovascular disease (ASCVD), is a growing public health threat globally and many individuals remain undiagnosed, untreated and uncontrolled. Simultaneously, mobile health (mHealth) interventions using short messaging service (SMS) have gained popularity globally. There is an opportunity for innovative approaches such as mHealth to encourage and enable adherence to medications for ASCVD and its risk factors. Objective: This study seeks to understand mobile technology acceptance, use and facilitating conditions amongst the study population ahead of the design of an mHealth intervention. Methods: Using data from a mixed methods study conducted in Singapore we conducted a cross-sectional survey with 100 participants and in-depth semi-structured interviews with 20 patients. All participants were over the age of 40 with ASCVD and/or its risk factors. Interviews were conducted in English and Mandarin and if needed translated to English. QSR Nvivo 11 was used for analyses. Results: Participants reported their perspectives on technology use and preferences, including low or sporadic mobile phone use and usability concerns including small screen and text size, amongst others; the benefit of previous mHealth use in creating a favourable opinion of SMS for health information; trust in both the source of mHealth SMS, as well as trust in treatment, the formation of habits and fear of sequelae or death for facilitating intention to use an mHealth intervention and adhere to medication. We also highlight a case which underscored the importance of the period after diagnosis in habit forming as an opportunity for an mHealth intervention. Conclusions: We identify factors relating to technology use, as well as factors impacting adherence to medications, that influence a patient’s intention to use an mHealth intervention, as well as enable or inhibit their intention to adopt such an intervention. As mHealth becomes increasingly used for the management of chronic conditions, it is important that mHealth interventions are contextually appropriate and consider the breadth of factors influencing patient uptake and use.

Electronic Consultation Services Worldwide: An Environmental Scan

From: Journal of Medical Internet Research

Date Submitted: May 22, 2018

Open Peer Review Period: May 25, 2018 - Jul 20, 2018

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Background: Excessive wait times for specialist care pose a serious concern for many patients, leading to duplication of tests, patient anxiety, and poorer health outcomes. In response to this issue,...

Background: Excessive wait times for specialist care pose a serious concern for many patients, leading to duplication of tests, patient anxiety, and poorer health outcomes. In response to this issue, many healthcare systems have begun implementing technological innovations designed to improve the referral-consultation process. Among these services is electronic consultation (eConsult), which connects primary care providers and specialists via a secure platform to facilitate discussion of patients’ care. Objective: In this article, we examine the different eConsult services available worldwide and compare the strategies, barriers, and successes of their implementation in different healthcare contexts worldwide. Methods: We conducted an environmental scan comprised of three stages: a literature review, a grey literature search, and targeted, semi-structured key informant interviews. We searched Medline and EMBASE (literature review) and Google (grey literature search). Upon completing the searches, we generated a list of potential interview candidates from among the stakeholders identified. Potential participants included researchers, physicians, and decision-makers. Maximum variation sampling was employed to ensure sufficient breadth of participant experience. We conducted semi-structured interviews by telephone using an interview guide based on the RE-AIM framework. Analyses of transcripts were conducted using a thematic synthesis approach. Results: A total of 53 services emerged from the published and grey literature. Respondents from 10 services participated in telephone interviews. Four major themes emerged from the analysis: service structure, benefits of eConsult, implementation challenges, and implementation enablers. Conclusions: eConsult services have emerged in a variety of countries and health system contexts worldwide. Despite differences in structure, platform, and delivery of their services, respondents described similar barriers and enablers to implementation and growth, and reported improved access and high levels of satisfaction.

Repeated automated mobile text reminders for follow-up of positive fecal occult blood tests: Do they work?

From: JMIR mHealth and uHealth

Date Submitted: May 23, 2018

Open Peer Review Period: May 25, 2018 - Jul 20, 2018

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Background: Fecal occult blood tests are recommended by the US Preventive Services Task Force as a screening method for colorectal cancer, but they are only effective if positive results are followed...

Background: Fecal occult blood tests are recommended by the US Preventive Services Task Force as a screening method for colorectal cancer, but they are only effective if positive results are followed by colonoscopy. Surprisingly, a large proportion of patients with a positive result do not follow this recommendation. Objective: To examine the effectiveness of a short message service in increasing adherence to colonoscopy follow-up after a positive Fecal occult blood test. Methods: This randomized controlled trial was conducted with patients who had positive colorectal cancer screening results. Randomization was stratified by residential district and socioeconomic status. Subjects in the control group (n = 232) received routine care that included an alert to the physician regarding the positive Fecal occult blood test result. The intervention group (n = 238) received routine care and three short message service reminders to visit their primary care physician. Adherence to colonoscopy was measured 120 days from the positive result. Physicians of the study patients completed an attitude survey regarding FOBT as a screening test for colorectal cancer. The intervention and control groups were compared using chi-squared for discrete variables. Logistic regression was used to calculate odds ratios and 95% confidence intervals for performing colonoscopy within 120 days, adjusting for potential confounders of age, gender, socioeconomic status, district, ethnicity, intervention group and physician's attitude. Results: Patients in the intervention group had significantly better adherence to colonoscopy within 120 days of a positive Fecal occult blood test than the control group did (70% vs. 47%, P<.0001). After adjusting for all potential confounders, the likelihood of having a colonoscopy was 2.5 times higher in the intervention group than in the control group (P=.001). Conclusions: A short message service reminder is an effective, simple and inexpensive method for improving adherence among patients with positive colorectal screening results. This type of intervention could also be evaluated for other types of screening tests. Clinical Trial: This study was approved by the Meuhedet Institutional Review Board on May 20, 2015 (IRB; trial reference number: 02-20-05-15). ClinicalTrials.gov Identifier: NCT02534142. Submitted on August 27, 2015. https://clinicaltrials.gov/ct2/show/NCT02534142.

Frequency and attitudes of patients purchasing medications online: Hungarian cross-sectional study - Can we profile consumers turning to the Internet pharmacy market?

From: Journal of Medical Internet Research

Date Submitted: May 23, 2018

Open Peer Review Period: May 24, 2018 - Jun 2, 2018

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Background: During the past two decades Internet has become an accepted way to purchase products and services. Apparently, buying medications online is no exception. Beside it’s benefits several pat...

Background: During the past two decades Internet has become an accepted way to purchase products and services. Apparently, buying medications online is no exception. Beside it’s benefits several patient safety risks are linked to the purchase of medicines outside the traditional supply chain. Although ten thousands of Internet pharmacies are accessible on the web, the actual size of the market is unknown. Further, limited data is available on the use of Internet pharmacies, the number and attitude of people obtaining medications and other health products from the Internet. Objective: The authors aimed to gather information on the frequency and attitudes of patients purchasing medications online in a nationally representative sample of outpatients. Attitudes towards main supply chain channels, perceived benefits and disadvantages influencing online medication purchase are evaluated. Methods: A cross sectional explorative study using a personally administered survey was conducted in a representative sample of Hungarian outpatients in 2018. Results: A total of 1055 outpatients completed the survey (response rate 77.2%). Mean age was 45 years and 43.2% reported to have chronic health conditions. Majority (82.7%) of the respondents were aware of that medications can be obtained online, but only 4.17% (n=44) used the Internet for medication purchase previously. Attitudes towards the different pharmaceutical supply chain retail channels showed significant differences (p<0,01), respondents accepted retail pharmacy units as the most appropriate source of medications while rejected Internet pharmacies. Respondents were asked to evaluate nine statements regarding the potential benefits and disadvantages about the online medicine purchase, and based on the computed relative attitude rate there is a weak still significant tendency toward rejection (p<0,01). Correspondence of demographic factors, internet usage behavior and prospective online drug purchase attitude was evaluated. Respondents who use the internet more and purchase goods online will more likely to buy medications online. Further, younger age and higher educational level will determine the medication purchase behavior. Conclusions: Reasonable number of patients will purchase medications on the Internet in the near future. As illegitimate actors dominate the global online pharmacy market, there is an increased risk of patients buying products from illegal actors. Consequently, improved patient-provider communication and promotion campaigns are needed to inform the public on the safe use of Internet pharmacies, as these initiatives can directly prevent patient safety threats.

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