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Latest Submissions Open for Peer Review

JMIR has been a leader in applying openness, participation, collaboration and other "2.0" ideas to scholarly publishing, and since December 2009 offers open peer review articles and preprint server, allowing JMIR users to sign themselves up as peer reviewers for specific articles currently considered by the Journal (in addition to author- and editor-selected reviewers).

Note that this is a not a complete list of submissions as authors can opt-out. The list below shows recently submitted articles where submitting authors have not opted-out of open peer-review and where the editor has not made a decision yet. (Note that this feature is for reviewing specific articles - if you just want to sign up as reviewer (and wait for the editor to contact you if articles match your interests), please sign up as reviewer using your profile).

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Titles/Abstracts of Articles Currently Open for Review:

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 30, 2019
    Open Peer Review Period: May 3, 2019 - Jun 28, 2019

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 30, 2019
    Open Peer Review Period: May 3, 2019 - Jun 28, 2019

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

  • Design, Utilization and Impact of a Novel Clinical Decision Support System for Neuropathic Pain in Primary Care

    From: Journal of Medical Internet Research

    Date Submitted: Apr 30, 2019
    Open Peer Review Period: May 3, 2019 - Jun 28, 2019

    Background: Computerized decision support systems (CDSS) have emerged as an approach to improve compliance of clinicians with clinical practice guidelines (CPG). Research utilizing CDSS has primarily been conducted in clinical contexts with clear diagnostic criteria, such as diabetes and cardiovascular diseases. In contrast, research on CDSS for pain management, and more specifically neuropathic pain (NeP) has been limited. A CDSS for NeP has the potential to enhance patient care as the challenge of diagnosing and treating NEP often leads to tension in clinician-patient relationships Objective: To design and evaluate a clinical decision support system (CDSS) aimed at improving adherence of inter-professional primary care clinicians to clinical practice guidelines (CPG) for managing neuropathic pain (NeP). Methods: Recommendations from Canadian CPGs informed decision pathways. The development of CDSS format and function involved participation of multiple stakeholders and end-users in needs assessment and usability testing. Clinicians, including family medicine physicians, residents, and nurse practitioners, in 3 academic teaching clinics were trained in use of the CDSS. Evaluation over 1 year included measurement of utilization of the CDSS; change in reported awareness, agreement and adoption of CPG recommendations; and change in observed adherence to CPG recommendations. Results: Usability testing of the CDSS was highly successful in the prototype environment. Deployment in the clinical setting was partially complete by the time of the study, with some limitations in planned functionality. The study population had a high level of awareness, agreement and adoption of guideline recommendations prior to implementation of CDSS. Still, there was a small and statistically significant improvement in mean awareness and adoption scores over the year of observation (P=.01 for mean awareness scores at 6 and 12 months compared to baseline; P<0.01 for mean adoption scores at 6 months compared to baseline; P=.01 for mean adoption scores at 12 months). Documenting significant findings related to diagnosis of neuropathic pain increased significantly. Clinicians accessed CPG information more frequently than they utilized data entry functions. Nurse practitioners and first year family medicine trainees had higher utilization than physicians Conclusions: The CDSS was more helpful as a source of knowledge provision and as a training tool, than as dynamic decision support. The process of developing and deploying the CDSS was associated with observed increase in compliance with guideline recommendations.

  • Background: Shared decision-making (SDM) is recognised as a person-centred approach to improving health care quality and outcomes. Few digital interventions to improve SDM have been tested in child and adolescent mental health (CAMH) settings. One such intervention is Power Up, a mobile phone application for young people, which has shown some evidence of promise that young people who received Power Up reported greater levels of SDM. However, parents play a critical role in CAMH care and treatment, but often feel excluded from services. Objective: This protocol is for a pilot trial to determine the feasibility of a large-scale randomised trial to develop and evaluate a web application (called Power Up for Parents or PUfP) to support parents and promote involvement in CAMH decisions. Methods: A two-stage process, consisting of the development stage and pilot testing stage of the initial PUfP prototype will be conducted. At the development stage, a qualitative study with parents and clinicians will be conducted. The interviews will aim to capture the experience of making CAMH decisions, preferences for involvement in SDM, and determine situations within which PUfP can be useful. At the pilot testing stage, (up to 90) parents and their clinicians will be invited to participate in the testing of the prototype. Parents will be randomly allocated to receive the intervention or be part of the control group. This study design will allow us to assess the acceptability and usefulness of PUfP in addition to examining the feasibility of a prospective randomised trial. Clinicians’ perceptions of the prototype and how it has influenced parents' involvement in SDM will also be examined. Results: Recruitment began in January 2019 and is scheduled to last for ten months. Conclusions: The lack of parents’ involvement in CAMH care and treatment can lead to higher rates of dropout from care, and lower adherence to therapeutic interventions. There are significant benefits to be gained globally if digital SDM interventions are adopted by parents and shown to be successful in CAMH settings. Clinical Trial: ISRCTN39238984: Registered 04 July 2018.

  • Implementation of electronic prescription - the physicians’ view

    From: Journal of Medical Internet Research

    Date Submitted: May 1, 2019
    Open Peer Review Period: May 2, 2019 - Jun 27, 2019

    Background: Connected Health is a paradigm shift looking after the individual and community health that is arising all over the world. Applicable in a wide spectrum of care services, including primary care, where electronic prescriptions (e-prescriptions) are a core part of this ecosystem. Electronic prescribing has great potential as it reduces legibility problems associated with handwritten prescriptions, can automatically flag potential interactions, adverse effects improving patient safety and can facilitate operational pharmaceutical management including potentially reducing stock-outs. While e-prescription has been widely adopted, the manner of its’ application and monitoring needs further attention to optimize quality and reduce healthcare costs. Objective: The aim of this study was to investigate the physicians’ opinions about e-prescriptions and how well they manage to use them in the context of different settings. Methods: Using a trusted online survey website, a brief questionnaire comprising of 10-multiple choice questions were sent to physicians through e-mail in thirteen different countries. Results: Ninety-three questionnaires were complete and analysed. The survey showed that implementation of e-prescriptions is feasible. The time for writing e-prescriptions is not shortened comparing to handwritten prescriptions and the support system is not adequate. The prescribers had mostly problems with technical support. The use of e-prescriptions was more difficult for older physicians. Conclusions: To increase its use, prescribers need to be informed how electronic health systems can be beneficial for the easier use of e-prescriptions. Adequate technical support must be provided, and special training for elderly physicians, as they need more time for e-prescribing.

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

    From: JMIR Mental Health

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

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

  • Using iPads to Improve Moods for Older Adults with Dementia and Interactions with their Caregivers

    From: JMIR Aging

    Date Submitted: Apr 30, 2019
    Open Peer Review Period: May 2, 2019 - Jun 27, 2019

    Background: Individuals with Alzheimer’s disease or related dementia (ADRD) represent a significant and growing segment of the older adult (65 years and over) population. Individuals with ADRD are often challenged expressively and may experience difficulties with sharing their feelings or moods. Availability of and easy access to tablets and smart phones facilitates use of information and communication technologies (ICTs) as delivery mechanisms for non-pharmacological interventions, especially for older adults with ADRD. Evidence of the impact of ICTs in different community settings on quality-of-life and mood with older adults and their caregivers is needed for widespread adoption and sustainment of these technologies. Objective: This projects’ research aim was to determine extent of the effects of ICTs (iPad) on positive mood change, and examine effects of study variables on participants’ mood changes and caregivers’ daily activities. Methods: The ICT (iPad) intervention was developed and its impact evaluated in five tablet engagement pilots (2017-2018). The primary outcome was caregiver-assessed participants’ mood (n=1,096) before and after an iPad engagement session using an 8-point mood visual analog scale. Session impact on caregiver daily activities was captured for a sub-sample of participants (n=544). Frequency distributions were computed for each of the study variables, including the degree of patients’ mood changes. χ2 tests of association were calculated to determine the impact of the variables on mood changes for all patients, as well as those being treated in skilled nursing facilities and in-home, and then those that affected caregiver daily activities. Results: iPad interventions substantially improved most patients’ mood. Cumulatively, 51% showed mood improvement while another 41% of patients maintained an already-positive mood resulting from the caregiver engagement session. χ2 analyses demonstrated that positive mood changes resulted from using music (χ2(15) = 93.84, P < .001), using YouTube as the sole app (χ2(6) = 18.38, P=.005), or when cared for in a skilled nursing facility (χ2(6) = 236.36, P < .001) across all participants. Positive improvements in the caregivers’ day occurred for patients with a movement disorder (χ2(2) = 10.04, P=.007), or when socialization was a component of other interventions (χ2(2) = 35.26, P < .001). Conclusions: The study is one of the first to explore the impact of ICTs, in particular tablets such as iPads and apps such as YouTube, to improve mood in older adults and enhance caregiver perceptions about their patient interactions, especially those with ADRD. Importantly, these pilot data substantiate ICTs as part of a person-centered engagement approach, as beneficial alternatives to pharmaceutical interventions for mood enhancement. However, a more comprehensive study that explores the ICT impact on additional quality of life and clinical outcomes is needed to confirm these preliminary findings.

  • Benchmarks of Real-World Objective User Engagement with Mental Health Apps

    From: Journal of Medical Internet Research

    Date Submitted: May 2, 2019
    Open Peer Review Period: May 2, 2019 - May 10, 2019

    Background: Understanding patterns of real-world usage of mental health apps is key to maximizing apps’ potential to increase the public self-management of care. While developer-led studies have published results on the utilization of mental health apps deployed in real-world settings, to the best of our knowledge, no study has systematically examined usage patterns of a large sample of mental health apps relying on independently collected data. Objective: To present real-world objective data on user engagement with popular mental health apps. Methods: A systematic engine search was conducted using Google Play to identify Android apps with 10,000 installs or more, targeting anxiety, depression, or emotional well-being. Coding of apps included primary incorporated techniques and clinical focus. Behavioral data on real-world usage were obtained from a panel that provides aggregated non-personal information on user engagement with mobile apps. Results: Altogether 93 apps met the inclusion criteria (median number of installs = 100,000). The median percentage of daily active users (open rate) was 4.0% with a difference found between trackers (median = 6.3%) and peer-support apps (median=17.0%) in comparison to breathing exercise apps (median = 1.6%; Zs ≥ 3.42, Ps < .001). Among active users, daily minutes of use were significantly higher for mindfulness/meditation (median = 21:28) and peer support (median = 35:05) apps than for apps incorporating other techniques (tracker, breathing exercise, psychoeducation; medians range = 03:32-08:19; Zs ≥ 2.11, Ps < .05). The medians of app 15-day and 30-day retention rates were 3.9% and 3.3%, respectively. On day 30, peer support (median = 8.9%), mindfulness/meditation (median = 4.7%), and tracker apps (median = 6.1%) had significantly higher retention rates than breathing exercise apps (median = 0.0%; Zs ≥ 2.18, Ps ≤ .035). The pattern of daily use presented a descriptive peak toward the evening for apps incorporating most techniques (tracker, psychoeducation, and peer-support) with the exception of mindfulness/meditation, which exhibited two peaks (morning and night). Conclusions: While the number of app installs and daily active minutes of use may seem high, only a small portion of users actually utilize the apps for a long period of time. More studies leveraging different datasets are needed to understand this phenomenon and to better conceptualize our understanding of the ways in which users self-manage their condition in real-world settings.

  • Background: The prevalence of obesity has increased substantially over recent decades and is associated with considerable health inequalities. Although the causes of obesity are complex, key drivers include over-consumption of highly palatable, energy-dense and nutrient-poor foods, which have a profound impact on the composition and function of the gut microbiome. Alterations to the microbiome may play a critical role in obesity by affecting energy extraction from food and subsequent energy metabolism and fat storage. Objective: We report the study protocol and recruitment strategy of the PROMISE (PRedictors linking Obesity and the gut MIcrobiomE) study, which characterises the gut microbiome in two populations with markedly different metabolic disease risk (Pacific and European women) and different body fat profiles (normal and obese). It investigates: (1) the role of gut microbiome composition and functionality in obesity and body fat distribution; and (2) the interactions between dietary intake, eating behaviour, sweet, fat and bitter taste perception, sleep and physical activity, and their impact on the gut microbiome, metabolic and endocrine regulation and body fat profiles. Methods: Healthy Pacific and NZ European women aged between 18 - 45 years from the Auckland region were recruited for this cross-sectional study. Participants were recruited such that half in each group had either a normal weight (BMI 18.5-24.9 kg/m2) or were obese (BMI ≥30 kg/m2). In addition to anthropometric measurements and assessment of the body fat content using dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance analysis (BIA), participants completed sweet, fat and bitter taste perception tests, food records and sleep diaries, and they wore an accelerometer to assess physical activity and sleep. Fasting blood samples were analysed for metabolic biomarkers and endocrine regulators and DNA extracted from faecal samples were analysed by shotgun sequencing on an Illumina HiSeq2500 instrument. Participants completed questionnaires on dietary intake (e.g. 5-day food diaries, food frequency, dietary diversity), eating behaviour (three-factor eating questionnaire), sleep (e.g. sleep quality, chronotype), and physical activity. Data were analysed using descriptive and multivariate regression methods to assess the associations between dietary intake, taste perception, sleep, physical activity, gut microbiome complexity and functionality, and host metabolic and body fat profiles. Results: Of the initial 351 women enrolled, 142 Pacific women and 162 New Zealand European women completed the study protocol. A partnership with a Pacific primary health and social services provider facilitated the recruitment of Pacific women, involving direct contact methods, word-of-mouth and networking within the Pacific communities. New Zealand European women were primarily recruited through online methods and special interest Facebook pages. Conclusions: This cross-sectional study will provide a wealth of data enabling the identification of distinct roles for diet, taste perception, sleep and physical activity in women with different body fat profiles in modifying the gut microbiome and its impact on obesity and metabolic health. It will likely advance our understanding of the aetiology of obesity and will guide future intervention studies involving specific dietary approaches and microbiota-based therapies. Clinical Trial: This trial is registered at www.anzctr.org.au as ACTRN12618000432213.

  • Physical symptoms in tinnitus: an international web-based study

    From: Journal of Medical Internet Research

    Date Submitted: Apr 29, 2019
    Open Peer Review Period: May 2, 2019 - Jun 27, 2019

    Background: Tinnitus, or ringing in the ears, is a phantom perception of sound in the absence of overt acoustic stimulation. Many patients indicate that the perception of their tinnitus is not constant and can vary from moment to moment. This tinnitus fluctuation is one of the diagnostic criteria for somatosensory tinnitus (ST), a tinnitus subtype that is influenced by cervical spine or temporomandibular dysfunctions. Although various factors have been reported to cause fluctuations in tinnitus, such as: stress, anxiety and physical activity. Objective: The aim of this study was twofold: first to investigate the presence of physical symptoms in a large group of participants with tinnitus and second to investigate if these physical symptoms are more frequently present in a subgroup of participants with ST. Methods: An online survey, questioning the presence of physical symptoms in participants with tinnitus was launched on the online forum Tinnitus Talk, managed by Tinnitus Hub. After a general analysis of the physical symptoms, present in our survey population, we further analysed the group op participants who were diagnosed by a physician (n = 1262). This subgroup was divided into two groups, one group diagnosed with ST and another group diagnosed with other types of tinnitus. Results: In total, 6115 participants with a mean age of 54,08 years (SD: 13,8) completed the survey. Physical symptoms were frequently present in our sample of participants with tinnitus: 69% reported some form of neck pain, 7% was diagnosed with temporomandibular disorders, 44,6% indicated they have bruxism and 14 to 23,1% was able to modulate their tinnitus by voluntary movements. ST was diagnosed in 17,7%. Symptoms referring to the known diagnostic criteria were evidently more present in the ST-group than in the non-ST-group. Additionally, participants with ST more often indicated a negative effect of a bad night’s sleep and light intensity exercise. Conclusions: Physical activity and movement (disorders) frequently affect the tinnitus severity. Head-neck related symptoms are more frequently reported in the ST-group, as is the ability to modulate the tinnitus by head or jaw movements. Additionally, participants with ST more often report fluctuations of their tinnitus and reaction to sleeping difficulties and low intensity exercise.

  • Experiences With Virtual Reality Head-Mounted Display Support for Joint Attention: A Usability and Feasibility Pilot of Floreo’s Joint Attention Module

    From: JMIR mHealth and uHealth

    Date Submitted: May 2, 2019
    Open Peer Review Period: May 2, 2019 - May 10, 2019

    Background: Advances in virtual reality (VR) technology offer new opportunities to design supports for the core behaviors associated with autism spectrum disorder (ASD) that promote progress toward optimal outcomes. Floreo has developed a novel mobile VR platform that pairs a user receiving instruction on target skills with an adult monitor. Objective: The primary objective of this pilot was to explore the feasibility of using Floreo’s Joint Attention Module in school-age children with autism in a special education setting. A secondary objective was to explore a novel joint attention measure designed for use with school-aged children, and to observe if there was a suggestion of change in joint attention skills from pre-intervention to post-intervention. Methods: Twelve participants ranging in age from 9 to 16 years received training with the Joint Attention Module for 14 sessions over 5 weeks. Results: No serious side effects were reported, and no participants dropped out of the study due to undesirable side effects. Based on monitor data, 95% of the time participants tolerated the headset, 95% of the time participants seemed to enjoy using Floreo, and 96% of the time the VR experience was reported as valuable. In addition, scoring of the joint attention measure suggested a positive change in participant skills related to total number of interactions, use of eye contact, and initiation of interactions. Conclusions: Study results suggest that Floreo’s Joint Attention Module is safe and well-tolerated by students with ASD, and preliminary data also suggest that use of Floreo is related to improvements in fundamental joint attention skills.

  • Quality of Websites about Long-Acting Reversible Contraception

    From: Journal of Medical Internet Research

    Date Submitted: Apr 29, 2019
    Open Peer Review Period: May 2, 2019 - Jun 27, 2019

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

  • Internet-Based Intervention for Postpartum Depression in China: Formative Research and Design of the “Mommy go” Program

    From: JMIR Research Protocols

    Date Submitted: Apr 28, 2019
    Open Peer Review Period: May 1, 2019 - May 15, 2019

    Background: Postpartum depression (PPD) is a significant public health problem affecting approximately 13% of women. There is strong evidence supporting Internet-based intervention for PPD. The prevalence of PPD can be reduced by early screening the high-risk population of PPD through Internet intervention. To date, however, Web-based interventions have not been used and evaluated specifically for the treatment of PPD in China. Objective: We describe the formative work that contributed to the development of our Internet-based intervention (“Mommy go”) for helping to provide maternal information and emotional support to reduce the risk of PPD, and the design and key components of the program. Methods: The study is based on the method of constructing a health intervention strategy proposed by the multiphase optimization strategy (MOST). Firstly, to select the important components for intervention based on systematic review. Secondly, conducting maternal individualized interviews to understand maternal awareness of PPD, health education needs, and suggestions on “Mommy go”. Thirdly, an Internet intervention strategy for PPD is formed. Then, cooperate with Internet technicians to construct the prototype of “Mommy go”. Finally, using usability test to understand the maternal feedback on the use of “Mommy go” and making appropriate adjustments to the functionality and content of “Mommy go”. Conclusions: An overview of the eventual design, architecture, and key program ingredients of the“Mommy go” provides pregnancy and postnatal maternal and child health care knowledge for pregnant women and systematically assess the health of women during pregnancy and childbirth (including monitoring, intervention, and feedback).

  • Automatically Extracting Disease-Disease Association from Literature with a Large Margin Context-Aware Convolutional Neural Network

    From: JMIR Medical Informatics

    Date Submitted: Apr 26, 2019
    Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

    Background: Research on disease-disease association, like comorbidity and complication, provides important insights into disease treatment and drug discovery, and a large body of literature has been published in the field. However, using current search tools, it is not easy for researchers to retrieve information on the latest disease association findings. For one thing, comorbidity and complication keywords pull up large numbers of PubMed studies. Secondly, disease is not highlighted in search results. Third, disease-disease association (DDA) is not identified, as currently no DDA extraction dataset or tools are available. Objective: Since there are no available disease-disease association extraction (DDAE) datasets or tools, we aim to develop (1) a DDAE dataset and (2) a neural network model for extracting DDAs from literature. Methods: In this study, we formulate DDAE as a supervised machine learning classification problem. To develop the system, we first build a DDAE dataset. We then employ two machine-learning models, support vector machine (SVM) and convolutional neural network (CNN), to extract DDAs. Furthermore, we evaluate the effect of using the output layer as features of the SVM-based model. Finally, we implement large margin context-aware convolutional neural network (LC-CNN) architecture to integrate context features and CNN through the large margin function. Results: Our DDAE dataset consists of 521 PubMed abstracts. Experiment results show that the SVM-based approach achieves an F1-measure of 80.32%, which is higher than the CNN-based approach (73.32%). Using the output layer of CNN as a feature for SVM does not further improve the performance of SVM. However, our LC-CNN achieves the highest F1-measure of 84.18%, and demonstrates combining the hinge loss function of SVM with CNN into a single NN architecture outperforms other approaches. Conclusions: To facilitate the development of text-mining research for DDAE, we develop the first publicly available DDAE dataset consisting of disease mentions, MeSH IDs and relation annotations. We develop different conventional ML models and NN architectures, and evaluate their effects on our DDAE dataset. To further improve DDAE performance, we propose an LC-CNN model for DDAE that outperforms other approaches.

  • Impact of an intensive care information system on the length of stay of surgical ICU patients: an observational study

    From: JMIR Perioperative Medicine

    Date Submitted: Apr 26, 2019
    Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

    Background: The implementation of computerized monitoring and prescription systems has proven to be reliable, to reduce the rate of medical error and to increase the patient care time. It has been suggested that it could also bring a benefit in reducing the length of stay, but this potential benefit has been poorly studied in ICU, with conflicting results. Thus, our objective was to explore the impact of computerization on ICU length of stay. Objective: Explore the impact of computerization on ICU length of stay. Methods: This was a before-after single-centre retrospective observational study. All patients admitted in the surgical ICU of a tertiary care hospital were included, from June 1st, 2015 to June 1st, 2016 for the before period and from August 1st, 2016 to August 1st, 2017 for the after period. The data were extracted from the hospitalization report and included: epidemiological data (age, sex, weight, height and body mass index), reason for ICU admission, severity score at admission, length of stay and mortality in ICU, mortality in hospital, use of life support during the stay and ICU re-admission during the same hospital stay. The consumption of antibiotics, biological analyses and the number of chest x-rays during the stay were also analysed. Results: A total of 1600 patients were included: 839 in the before period and 761 in the after period. Only the severity score SAPS II was significantly higher in the post- computerization period (38 ± 20 vs. 40 ± 21, P<0.05). There was no significant difference in terms of length of stay in ICU (7.0 ± 9.3 days before vs. 7.4 ± 9.9 days after, P = 0.37), ICU mortality rate (16.6% before vs. 16.8% after, P = 0.89), or re-admission rate during the stay (7% before vs. 7.9% after, P = 0.57). Despite less patient in the after group, there was a higher cost and consumption of biological analyses in the post-computerization period (5,416 [5,192-5,956] analyses/month before vs. 6,374 [6,013-6,986] analyses/months after, P = 0.002; and 28,503 [25,531-29,270] €/month before vs. 32,530 [30,222-35,973] €/month after, P = 0.01). There was also a trend towards reduction in the average number of chest x-rays, but this was not significant (0.55 ± 0.39 chest x-rays/day/patient before computerization versus 0.51 ± 0.37 chest x-rays/day/patient after computerization; P=0.054). Conclusions: Implementation of an intensive care information system did not have any impact on reducing the length of stay in our ICU. Our results reinforces the idea that computerized monitoring has few or no impact on ICU length of stay.

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

    From: JMIR mHealth and uHealth

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

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

  • Physical Activity Monitoring in Ischemic Stroke – a Feasibility Study

    From: JMIR mHealth and uHealth

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

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

  • Background: Building a health-care system of justice requires a child-centered care where children and young people, regardless of ability, are allowed to participate in their contact with their healthcare professionals. Implementation of interventions that support children’s participation in healthcare is still rare, and especially so when it comes to children with disabilities. Yet the consequences of insufficient participation are particularly severe for children with disabilities, as their needs for extensive care place greater demands on efficient interaction with professionals. Objective: As part of an overall project focusing on developing and implementing a digital decision support tool to increase participation within pediatric rehabilitation, the aim of this formative study was to explore the experiences of children and young people with disabilities regarding how to achieve participation within the pediatric rehabilitation services. Methods: The formative study has an explorative design, based on a latent qualitative content analysis with an inductive approach. Interviews were conducted with 20 children (6-17 years) and eight young people (19-30 years) with disabilities about their experiences of participation within pediatric rehabilitation services. Results: Three categories emerged reflecting the participants’ possibilities of participation within the pediatric rehabilitation services: to feel involved; to feel independent, and to feel partnership. To feel involved meant being listened to and to being connected; to feel independent meant being admitted and being enabled, and to feel partnership meant being supported and being able to entrust others with the decision-making. Through the overall theme “moving toward empowerment for children in pediatric rehabilitation”, a true feeling of participation can be experienced. Conclusions: The views of children and young people with disabilities are that children within the pediatric rehabilitation services must be given prerequisites for empowerment through being allowed to feel involved, independent, and in partnership, in order to experience true participation within their pediatric rehabilitation services. This finding will become imperative when designing a forthcoming digital decision support tool based on the children’s needs and perspectives.

  • Acceptability and feasibility of a telehealth intervention for STI testing among male couples: Protocol for a Pilot Study

    From: JMIR Research Protocols

    Date Submitted: Apr 24, 2019
    Open Peer Review Period: Apr 30, 2019 - May 14, 2019

    Background: Gay, bisexual, and other men who have sex with men (MSM) are at elevated risk for acquiring sexually transmitted infections (STIs) in the United States (U.S.) especially chlyamida and gonorrhea. While research has indicated main partners may play a central role in STI risk over casual partners, the frequency of STI screening among MSM couples is particularly low. Self-sample collection for chlyamdia and gonorrhea screening has been shown to be highly accurate and at-home STI testing has been shown to be highly acceptable among diverse populations. However, there is little research exploring the feasibility and acceptability of at-home chlyamdia and gonorrhea screening among MSM couples. Our pilot study aims to help evaluate the viability of this screening modality as an intervention tool for MSM couples. Objective: To assess the feasibility and accepatiblity of an at-home chlyamida and gonorrhea sample collection and remote lab testing program among a sample of 50 MSM couples living in the U.S. Methods: This pilot study enrolled 50 MSM couples living in the U.S. ages 18-40 years old who participated in a larger at-home HIV testing randomized controlled trial. Participating couples completed a pre-test instructional video call and then had the option of completing at-home sample collection across three bodily sites (rectal swab, pharyngeal swab, and urine sample) for remote chlyamida and gonorrhea lab testing. For participants who completed any sample collection, they received their results via a post-test video call. All particpants completed an online survey examining satisfaction and acceptability of the home testing process, experience with logistics, willingness to test at home in the future, recent sexual risk behavior, and STI-testing history and linkage to care. A subset of 10 couples completed an in-depth interview about their attitudes towards the sample collection process, different decisions they made while collecting their samples, and their experience accessing treatment for those who received a positive result. Results: Recruitment began in September 2017 and as of March 2019, we enrolled 50 couples. Forty nine of the 50 couples have returned their samples and completed the post-test delivery call. Ten in-depth interviews have been completed and transcribed. Conclusions: Screening MSM couples at-home for chlamydia and gonorrhea and providing video facilitated result delivery may offer a tailored approach to address these increasing STIs. By collecting data on how MSM couples experience at-home STI screening, this project will provide valuable insight into the utility of such a service delivery program to public health interventionists and researchers alike.

  • Development and Validation of the German Version of the Mobile Application Rating Scale (MARS-G)

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 24, 2019
    Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

    Background: Evidence for the efficacy of mobile health applications (MHA) to foster healthy behavior, to prevent the onset of disease, to manage and cure disease as well as to assist with rehabilitation is rapidly growing. However, most mobile health apps lack efficacy data, and user star ratings in app stores are limited in their objectivity. Objective: Systematic assessments are highly needed to make pro and cons of MHA use transparent and to develop quality standards. The mobile application rating scale (MARS) is such an assessment tool, but it’s not available in German yet. This study addresses that gap. Methods: The original 19-item version of the mobile app rating scale (MARS) was forward and backward translated twice, resulting in the MARS-German (MARS-G). App description items were extended (e.g. methodological background, data handling, etc.). 104 MHA were rated twice by eight independent bilingual researchers with the German and English MARS version. The internal consistency, validity and reliability of both scales were assessed. Mokken scale analysis was used to investigate the scalability of the overall scores. Results: The retranslation did not result in differences. The properties of the MARS-G are comparable to the original English version of the scale. Internal consistency is good for all subscales: Omega ranged from .72 to .91. Correlations between the scales of the German and English version reached from r=.93 to r=.98. Scalability of MARS (H=.50) and MARS-G are (H=.48) good. Conclusions: The MARS-G is a reliable and valid tool for experts and stakeholders to assess the quality of health apps in German speaking populations. Using the overall score gives a reliable quality estimation. Further studies are needed to assess the factorial structure of MARS and MARS-German. Clinical Trial: Not needed is a translation of a questionnaire, no participants involved

  • User Experience Investigation of Seven Mobile EEG Devices

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 24, 2019
    Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 26, 2019
    Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 25, 2019
    Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 25, 2019
    Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

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

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

    From: Journal of Medical Internet Research

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

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

  • Impact of the iMHere Mobile Health System on Bladder Management and Mood Outcomes in Spinal Cord Injury: A Randomized Controlled Trial

    From: Journal of Medical Internet Research

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

    Background: Individuals with Spinal Cord Injury (SCI) are at risk for several medical complications, such as urinary tract infections (UTIs) and pressure injuries that could potentially be mitigated through improved self-management techniques. The Interactive Mobile Health and Rehabilitation (iMHere) mobile health system was developed for individuals with disabilities to support self-management. Objective: The main objective of this study was to determine if the use of iMHere would be associated with improved health and psychosocial outcomes over a 9-month period. A secondary objective was to determine the average amount of staff support needed to manage the system. Methods: Thirty-eight participants with spinal cord injury (SCI) were randomized into either the intervention group who used the iMHere system and received standard care, or the control group who received standard care without any technology intervention. Participants in the intervention group were trained to use the app and followed for 9 months. Health outcomes were recorded for the year prior to entry into the study, and during the 9 months of the study. Participants completed surveys at baseline and every three months to measure psychosocial outcomes. Results: The intervention group had a statistically significant reduction in urinary tract infections (0.47 events per person, p = 0.034, Number needed to treat= 2.11) and mood symptoms (p = 0.047). The intervention group also had a non-significant trend toward a reduction in 6 other medical outcomes. No changes were seen in other measures. Approximately 34 minutes per participant per month were needed on average to manage the system and provide technical support through this mobile health system. Conclusions: The use of the iMHere mobile health platform may be a valuable tool in the prevention of UTIs or reductions in depressive symptoms. Given these findings, there exists potential for scalability of this platform for larger populations. Clinical Trial: ClinicalTrials.gov, registration # NCT02592291

  • Background: Extended criteria donors (ECD) are widely utilized due to organ shortage, but they may increase the risk of graft dysfunction and of poorer outcomes. Hypothermic oxygenated perfusion (HOPE) is a recent organ preservation strategy for marginal kidney and liver grafts, allowing to redirect anaerobic metabolism to aerobic metabolism under hypothermic conditions and to protect grafts from oxidative species-related damage; these mechanisms may potentially improve graft function and survival. Objective: With the present study we will evaluate the benefit of end-ischemic HOPE on ECD grafts (livers and kidneys) as compared to static cold storage (SCS). The aim of the study will be demonstrating the ability of HOPE to improve graft function and post-operative outcomes of ECD kidney and liver recipients. Methods: This is an open-label, randomized single center clinical trial with the aim of comparing HOPE vs. SCS in ECD kidney and liver transplantation. In the study protocol - approved by ethics committee - 220 patients (110 liver recipients and 110 kidney recipients) will be enrolled. Livers and kidneys assigned to HOPE will be perfused by machine perfusion with cold Belzer solution (4°-10°C) and with continuous oxygenation (partial pressure of oxygen = 500-600 mmHg). In the control group, livers and kidneys undergoing SCS will be steeped in Celsior or University of Wisconsin Belzer solutions and stored in ice. Using the same perfusion machine for both liver and kidney grafts, organs will be perfused from the start of the back-table procedure until implantation, without increasing cold ischemia time (CIT). For each group we will evaluate clinical outcomes, graft function tests and histologic findings, as well as perfusate and the number of allocated organs. Publication of the results may be assumed starting from 2021. Results: The study is ongoing, and recruitment of participants will continue until December 2019. Conclusions: It is expected that the use of adequate organ preservation techniques may improve the post-transplant outcome without to compromise the graft function and survival increasing the donor organ pool. If proven effective, this method could be implemented in general practice. Clinical Trial: ClinicalTrials.gov NCT03837197; https://clinicaltrials.gov/ct2/show/NCT03837197?term=NCT03837197&rank=1 (Archived by WebCite® at http://www.webcitation.org/76fSutT3R)

  • Back to the Future: Achieving Health Equity through Health Informatics and Digital Health

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 27, 2019
    Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

    The rapid proliferation of health informatics and digital health innovations has revolutionized clinical and research practices. There is no doubt that these fields will continue to have accelerated growth and a substantial impact on population health. However, there are legitimate concerns about how these promising technological advances can lead to unintended consequences of perpetuating or even creating health and healthcare disparities for under-resourced populations. To mitigate this potential pitfall, it is imperative for the health informatics and digital health scientific communities to understand the challenges faced by disadvantaged groups inclusive of racial/ethnic minorities which hinder their achievement of ideal health. This report presents illustrative exemplars of sociotechnical, mobile health (mHealth) interventions designed with community members to address health inequities using community-engaged research approaches. We strongly encourage researchers and innovators to integrate community engagement into the development of data-driven, modernized solutions to meet the needs of every sector of society in order to truly achieve health equity for all.

  • Background: The influence of social networks and its effect on the self-image of young people has been studied previously. These technologies not only produce a bad self-image or a decrease in self-esteem but also produce changes in personality, especially among young people. Nonetheless, these technologies have been also used as effective health interventions in order to prevent health issues. Objective: This study aims to determine the influence of social networks on female college students, in terms of body satisfaction, self-perception, eating disorders, social networks addiction and biological factors, 2D:4D. And, secondly, to develop an interactive web application to prevent eating disorders and to promote healthy lifestyles. Methods: The data was obtained from a survey made of EAT-26, ARS, CIPE-a, ESTE II y BSQ surveys and photographs from students of biology, nursing and education. The relationship between quantitative variables was studied using Pearson’s correlation coefficient. The web platform was developed with CakePHP 3.5 as a framework, additionally the base language was PHP and HTML, combined with MySQL, CSS, Javascript and Jquery. Results: The results focused on women’s self-image and eating disorders have shown how these variables have a correlation with environmental and mental factors, such as self-esteem, stereotypes or SNS use and 2D:4D ratio. The other result was the development of a multilingual web platform accessible from any device. Conclusions: The findings presented in this study suggest that experiences of body dissatisfaction and desire to achieve the thin-ideal appear to be universal among college women. The platform has been created as an intervention to improve and integrate all levels of prevention and promotion of health, especially for women and people recovering from an eating disorder.

  • Cyberchondria Information Clinic: Internet's Impact on your Health

    From: Journal of Medical Internet Research

    Date Submitted: Apr 26, 2019
    Open Peer Review Period: Apr 27, 2019 - Jun 22, 2019

    Over half of Americans report looking up health-related questions on the internet, including questions regarding their own ailments. The internet, in its vastness of information, provides a platform for patients to understand how to seek help and understand their condition. In most cases, this search for knowledge serves as a starting point to gather evidence that leads to a doctor’s appointment. However, in some cases, the person looking for information ends up tangled in an information web that perpetuates anxiety and further searches, without leading to a doctor’s appointment. The Internet can provide helpful and useful information; however, it can also be a tool for self-misdiagnosis. Said person craves the instant gratification the Internet provides when ‘googling’ – something one does not receive when having to wait for a doctor’s appointment or test results. Nevertheless, the Internet gives that instant response we demand in those moments of desperation. Cyberchondria, a term that has entered the medical lexicon in the 21st century after the advent of the internet, refers to the unfounded escalation of people’s concerns about their symptomatology based on search results and literature online. ‘Cyberchondriacs’ experience mistrust of medical experts, compulsion, reassurance seeking, and excessiveness. Their excessive online research about health can also be associated with unnecessary medical expenses, which primarily arise from anxiety, increased psychological distress, and worry. This vicious cycle of searching information and trying to explain current ailments derives into a quest for associating symptoms to diseases and further experiencing the other symptoms of said disease. This psychiatric disorder, known as somatization, was first introduced to the DSM-III in the 1980s. Somatization is a psycho-biological disorder where physical symptoms occur without any palpable organic cause. It is a disorder that has been renamed, discounted, and misdiagnosed from the beginning of the DSMs. Somatization triggers span many mental, emotional, and cultural aspects of human life. Our environment and social experiences can lay the blueprint for disorders to develop over time; an idea that is widely accepted for underlying psychiatric disorders such as depression and anxiety. The research is going in the right direction by exploring brain regions but needs to be expanded on from a sociocultural perspective. In this work, we explore the relationship between somatization disorder and the condition known as cyberchondria. First, we provide a background on each of the disorders, including their history and psychological perspective. Second, we proceed to explain the relationship between the two disorders, followed by a discussion on how this relationship has been studied in the scientific literature. Thirdly, we explain the problem that the relationship between these two disorders creates in society. Lastly, we propose a set of intervention aids and helpful resource prototypes that aim at resolving the problem. The proposed solutions ranged from a site-specific clinic teaching about cyberchondria to a digital design-coded chrome extension available to the public.

  • Awareness of radiation doses and risks among radiology residents, fellows, specialists, consultants and technologists in Jeddah, Saudi Arabia: Cross-Sectional Study.

    From: Interactive Journal of Medical Research

    Date Submitted: Apr 20, 2019
    Open Peer Review Period: Apr 25, 2019 - Jun 20, 2019

    Background: Radiology now plays a major role to diagnose, monitoring, and management of several diseases; numerous diagnostic and interventional radiology procedures involve exposure to ionizing radiation. Radiology now plays a major role to diagnose, monitoring, and management of several diseases; numerous diagnostic and interventional radiology procedures involve exposure to ionizing radiation. Objective: This study aimed to discover and compare the awareness level of radiation doses, protection issues, and risks among radiology staff in Jeddah hospitals. Methods: A cross-sectional survey containing 25 questions on personal information and various aspects of radiation exposure doses and risks was designed using an online survey tool and the link was emailed to all radiology staff in eight tertiary hospitals in Jeddah. The authors were excluded from the study. A P-value of < .05 was used to identify statistical significance. All analyses were performed using SPSS, version 21. Results: Out of 156 participants the majority 151 (96.8%) had poor knowledge score, where the mean scores were 2.4±1.3 for doses knowledge, 2.1±1.1for cancer risks knowledge, 2.3±0.6 for general information, and 6.7±1.9 for the total score. Only 34.6% of the participants were aware of the dosage of a single-view chest x-ray, and 9.0% chose the right answer for the approximate effective dose received by a patient in a two-view. 42.9% were able to know the correct dose of CT abdomen single phase. There is a significant underestimation of cancer risk of CT studies especially for CT abdomen where only 23.7% knew the right risk. A p-value of <0.05 was used to identify statistical significance. No significant difference of knowledge score was detected regarding gender (P =.2) or work position (P=.66). Conclusions: Our survey results show considerable inadequate knowledge in all groups without exception. We recommended a conscientious effort to deliver more solid education and obtain more knowledge in these matters and providing periodic training courses to teach how to minimize the dose of radiation and to avoid risk related. Clinical Trial: not applicable

  • Determinants of the intention to use teledermatology: evidence from dermatologist and primary care physicians

    From: JMIR Dermatology

    Date Submitted: Apr 20, 2019
    Open Peer Review Period: Apr 25, 2019 - Jun 20, 2019

    Background: Teledermatology (TD) consists on the application of information and communication technologies (ICTs) for the care of skin diseases. The studies on TD indicate that it seems to be effective in diagnosing early malignant pathologies such as melanoma, and in reducing the waiting lists by prioritizing the urgent pathology. Despite these advantages, the implementation of TD is still low in many areas. Previously, most studies have focused on analysing the results of TD use. However, to fully understand TD it is necessary to consider the determinants of its use Objective: This study analyses the determinants of the intentions of medical professionals to use TD in their healtcare institution. Methods: A survey that targeted a total population of 743 medical professionals from a healthcare institution in Spain was used. The study simple was formed by 223 doctors (39% were dermatologists and 61% primary care physicians). Using an extended Technology Acceptance Model and microdata for the 223 physicians, the user's ICT profile (clusters analysis) and a binary logistic regression analysis were carried out. Results: This analysis showed the presence of three clusters in the sample with respect to the use of technology (Cluster 1: advanced use of ICTs, Cluster 2: moderate use of ICTs, Cluster 3: scarce use of ICTs). The analysis performed confirmed the model's goodness-of-fit, which allowed 69 percent of the variable's variance to be explained. The outcomes revealed that the factors that were most important when implanting a TD system were: user's ICT profile, system efficiency and preference of the subjects involved (p <0.005). The quality of the assistance, the difficulties due to the use of technology (information security and confidentiality) or the interest of the administration were not decisive factors for the implementation of TD. Subsequently, we performed a logistic regression separating the samples between primary care doctors and dermatologists. For the former, the determining factors were the ICT profile and the efficiency of the system; while between dermatologists only the preference of each of the individual seem to be determining. Conclusions: The use of TD should be accompanied by a comprehensive program of validation and evaluation. These results show that there is a difference between determinants of the implementation of TD according to the subjects involved. Therefore, it is essential to perform studies prior to the implementation of a TD system, to identify and to influence the aforementioned predictive factors

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

    From: JMIR Medical Informatics

    Date Submitted: Apr 24, 2019
    Open Peer Review Period: Apr 25, 2019 - Jun 20, 2019

    Background: Long-term care for patients with chronic diseases poses a huge challenge in primary care. Deficits exist especially regarding monitoring and structured follow up. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists. Objective: The aim was to develop an evidence based standardized generic template, which improves monitoring of patients with chronic conditions in primary care by means of an EMR. Methods: Five highly prevalent chronic diseases were chosen: Diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure and osteoarthritis. Previously, a systematic literature review has been performed, resulting in an evidence based structured set of indicators. These indicators were now evaluated, by means of an adapted Delphi procedure concerning usability in practice, and 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. Conclusions: Our generic template can improve the care for patients with chronic diseases by means of an EMR in primary care, since for the first time it systematically summarizes the existing scientific evidence for the standardized long-term monitoring of chronic conditions, and was implemented into a user friendly and clinically sensible layout.

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 20, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

  • Analyzing Demographic Impact on Online Physician Ratings

    From: Journal of Medical Internet Research

    Date Submitted: Apr 21, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

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

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 19, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

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

    From: Journal of Medical Internet Research

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

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

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

  • Impact of intelligent family physician optimized coordination model On Primary Hypertension Patients in a Beijing Community

    From: JMIR Medical Informatics

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

    Background: In order to address the challenges of chronic diseases, Beijing Municipal Government promoted intelligent family physician optimized collaborative model ( IFOC ) schema, which is poised to implement the patient-centered healthcare model, supported by intelligent chronic disease management system. The Fangzhuang community health service center is a National Demonstration Community Health Service Center in China, laid emphasis on the patient-centered model service, initiated, piloted and promoted IFOC schema optimize management of chronic diseases. Objective: To explore the effect of an intelligent family physician optimized collaborative model on selected hypertension patients of Fangzhuang Community in Beijing. Methods: This retrospective study used de-identified data of hypertension patients from the database of Fangzhuang community health service center. A comparative study pre- and post-implementation of IFOC for 2 years was performed to evaluate standardized management rate of blood pressure (BP), BP values, BP control rate, lifestyle changes and blood lipid levels. Continuous variables and categorical variables were analyzed using paired t-test and χ2 test, respectively. Results: A total of 6929 hypertension cases met inclusion/exclusion criteria. Compared with the pre-index period, standardized management rate increased from 34.4% to 67.4% in the post-index period (p < 0.001). SBP decreased from 144.10 mmHg to 141.38 mmHg (p < 0.001). BP control rate of the high-risk patients and overall BP control rate enhanced from 35.2% to 48.8%, from 44.7% to 49.9% , respectively (both p < 0.001). BMI decreased from 25.31 kg/m² to 24.65 kg/m².Exercise frequency increased from 2.83 times/week to 5.39 times/week; exercise duration increased from 20.03 min/d to 31.93 min/d; salt intake decreased from 9.56 g/d to 6.81 g/d; amount of cigarette smoking decreased from 11.31/d to 7.16 /d (all p < 0.005). TC decreased from 5.36 mmol/L to 4.65 mmol/L, LDL-C decreased from 3.35 mmol/L to 3.07 mmol/L (both p< 0.001), TG decreased from 1.79 mmol/L to 1.66 mmol/L (p= 0.021). Conclusions: IFOC is an effective model in the management of hypertension and should be promoted and popularized by the Community Health Service Center in China as well as in other developing countries.

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

    From: Journal of Medical Internet Research

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

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

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

    From: JMIR mHealth and uHealth

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

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

  • User-Driven Guidelines for Technology-Enabled Culinary Nutrition Education Program to Support Engaged Overweight and Obese Adolescents

    From: Journal of Medical Internet Research

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

    Background: Childhood overweight and obesity are major health challenges in the US. One of the recommendations to combat obesity is to maintain a healthy diet, which is often best supported by eating home cooked meals to control cooking methods, ingredients, and portions. Diet control through home cooking is challenged due to the decline of culinary skills in the population and a paucity of effective culinary nutrition education programs (CNE). Providing technology-enabled CNE (CNE-tech) to overweight and obese adolescents can equip them with life skills that can assist them in the future. Such skills can facilitate saving money, eating healthier, and creating social environments. In addition, CNE builds cooking confidence and food literacy that in turn can build adolescent self-efficacy, particularly towards managing their health behaviors. Objective: In this study, we aim to inform functionalities, design requirements, and the context of use for CNE-tech that could enhance overweight and obese adolescents’ healthy food literacy, cooking confidence, and general self-efficacy regarding self-management to ultimately, promote healthy lifestyle management. Methods: The design science study was completed in two distinct phases engaging overweight and obese adolescents, parents of overweight and obese adolescents, and providers that treat adolescents with these conditions. Phase 2, our primary source of data, involved user-centered design methods including: a) early stage prototype usability analysis, b) semi-structured interviews with 70 overweight or obese adolescents engaged in a healthy behavior program and c) semi-structured interviews with 10 healthcare providers. Data was analyzed using a constant comparison method to identify functionalities, design requirements, and inform the context of use of CNE-tech. Results: Data revealed specific desired functionalities for the CNE-tech related to cooking skill building, populated healthy recipes database, suggesting healthy alternatives, supports to construct a healthy plate, and the ability to share healthy recipes and cooking accomplishments. Moreover, adolescents provided design requirements pertaining to presentation (e.g., vivid colors, semi-realistic images, cooking sounds), use of multimedia, and gaming. Data further revealed contextual factors, such as shared experiences with family members and enhanced continued use. Conclusions: We demonstrate the potentiality of creating CNE-tech that could effectively lead to better self-care and induce sustainable behavioral change as it facilitates skill building, self-efficacy, and a pathway that enables overweight and obese adolescents to influence cooking habits in their family home and future dwellings. Our CNE-tech proposed solution aligns with the goals of overweight and obese adolescents and also reflects existing theories about behavioral change.

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

    From: JMIR Medical Education

    Date Submitted: Apr 17, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

  • Nutritional assessment in childhood cancer survivors: SCCSS-Nutrition study protocol

    From: JMIR Research Protocols

    Date Submitted: Apr 17, 2019
    Open Peer Review Period: Apr 23, 2019 - May 7, 2019

    Background: Childhood cancer survivors (CCSs) are at high risk of developing adverse late health effects. Poor nutritional intake may contribute to this risk, but information about dietary intake is limited. Objective: This study will assess dietary intake of CCSs and compare two dietary assessment tools: a self-reported food frequency questionnaire (FFQ), and dietary measurements from urine spot samples. Methods: In the Swiss Childhood Cancer Survivor Study, we assessed dietary intake of CCSs via a validated FFQ. To a subset of CCSs from the French-speaking region of Switzerland, we sent a urine spot collection kit to analyse urinary sodium, potassium, urea, urate, creatinine, and phosphate content. We will compare the FFQ with the urine spot analyses to quantify the intake of different nutrients in CCSs. Data collection took place between March 2016 and March 2018. Results: We contacted 1599 CCSs of whom 919 (57%) returned an FFQ. We excluded 11 CCSs who were pregnant or were breastfeeding, 35 CCSs with missing dietary data, and 71 CCSs who had unreliable FFQ data, resulting in 802 CCSs available for FFQ analyses. To a subset of 197 CCSs in French-speaking Switzerland we sent a urine spot collection kit, and 111 (56%) returned a urine sample. We expect to have the results from analyses of these samples in mid-2019. Conclusions: The SCCSS-Nutrition study has collected in-depth dietary data that will allow us to assess dietary intake and quality and compare two dietary assessment tools. This study will contribute to the current knowledge of nutrition among CCSs and is a step towards surveillance guidelines and targeted nutritional recommendations for CCSs in Switzerland. Clinical Trial: ClinicalTrials.gov identifier SCCSS: NCT03297034

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 20, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 17, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 16, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

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

    From: JMIR mHealth and uHealth

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

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

  • EHealth interventions to improve adherence to antiretroviral therapy in people living with HIV: A systematic review and meta-analysis

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 16, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

    Background: EHealth is increasingly used for the self-management and service delivery of acquired immune deficiency syndrome (AIDS) related diseases. However, the benefits of eHealth to antiretroviral therapy (ART) adherence in people living with HIV (PLWH) have not been investigated. Objective: The purpose of this study was to explore the effectiveness of eHealth interventions on improving ART adherence of PLWH. The effectiveness of different interventions and study characteristics were also assessed. Methods: Under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement from the Cochrane Collaboration guidelines, we systematically searched MEDLINE (via PubMed), Embase, the Cochrane Central Register of Controlled Trials and three conference abstract databases. Articles published in English that used randomized controlled trials to assess eHealth interventions to improve ART adherence of PLWH were identified. Two authors independently screened the studies, extracted the data, and assessed the study quality. Disagreements were resolved through discussions with a third author. We extracted the study characteristics, participant characteristics, intervention characteristics, and outcome measure. The Cochrane risk-of-bias tool was used to assess the risk of bias and study quality. Odds ratios (OR) and Cohen’s d effect sizes were calculated using a random-effects model. We also performed subgroup and sensitivity analyses to define any sources of heterogeneity. Results: The database searches identified 3941 articles. A total of 19 studies encompassing 21 trials were included after 154 full-text articles were assessed. The trials included 3937 participants (mean age: 35 years; 47.16% (1857 of 3937) females). The median study duration was 36 weeks. Short Message Service (SMS) was the most commonly used intervention. In the meta-analysis, eHealth interventions significantly improved the ART adherence of PLWH (OR, 1.59; 95% CI, 1.10 to 2.29; P = 0.013). The effectiveness of eHealth was sensitive to sample size (Q, 5.56; P, 0.02) and study duration (Q, 8.89; P, 0.003), but it could not be explained by other moderators. The meta-analysis result was robust in terms of sensitivity analyses. Conclusions: EHealth interventions are an effective method to increase ART adherence of PLWH. We found that eHealth was particularly effective in studies with small sample sizes performed over a short duration. Further verification of the effectiveness of eHealth are now required in studies with larger sample sizes and of longer duration.

  • Needs and barriers of medication taking self-efficacy among post-stroke patients: a qualitative study

    From: JMIR Nursing

    Date Submitted: Apr 15, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

    Background: Stroke is one of the top ten leading diseases with high mortality and morbidity rate globally. There is an incomplete understanding of various types of self-efficacy involved in recurrent stroke prevention, and one of them is medication taking self-efficacy. Objective: Therefore the present study explores its fundamental needs and barriers. Methods: We report here findings from in-depth individual interviews with ten post-stroke patients from the Outpatient and Inpatient Neurology clinic, Hospital Kuala Lumpur. Results: Two key themes were identified, 1) self-efficacy in understanding recurrent stroke and its preventative treatment and 2) self-efficacy in taking prescribed medication. The discussion was focused on eliciting the needs and barriers related to medication taking self-efficacy. Conclusions: The study findings were consistent with several health behavioral concepts and constructs, indicating the importance of understanding needs and overcoming barriers to improve quality of life of post-stroke patients. We anticipate that, the results would be into consideration for future patient education intervention. Clinical Trial: The design and conduct of the study approvals have been granted by the Malaysian Medical Research and Ethics Committee – MREC (NMRR ID-15-851-24737) in July 2015.

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

    From: JMIR Diabetes

    Date Submitted: Apr 15, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

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

    From: JMIR Pediatrics and Parenting

    Date Submitted: Apr 11, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

  • Background: The number of people living with and beyond a cancer diagnosis has increased, however survivors may experience long-term side-effects from treatment that can impact on physical fitness and cardiovascular health. Lifestyle interventions enhance outcomes after cancer treatment but innovations and technology are needed to provide consistency and scalability. Interventions to support exercise and dietary modification in secondary care settings have been limited by the lack of personalisation, clinician time and resources. Community pharmacies are well positioned to provide lifestyle advice for people with cancer and long-term conditions. This study is the first to develop a tailored lifestyle intervention using a computer algorithm to enable community pharmacists to provide personalised advice for cancer patients. Objective: To create a computer-based algorithm to support community pharmacists to deliver a tailored lifestyle intervention for men during and after treatment for prostate cancer. Methods: An observational study was conducted at two UK centres involving 83 men with prostate cancer who were 3-36 months’ post-diagnosis. Physical fitness, strength and cardiovascular health were assessed. Qualitative interviews were undertaken with 20 participants to understand their interpretation of the assessment and analysed using a framework analysis. These data were used to inform our computer-based algorithm and lifestyle prescriptions. Results: Physical fitness varied across participants. Limb strength was categorised with upper body strength low for 40% of men compared to their age (40 out of 83) and lower limb strength (44 of 83) 53% of men were low in comparison to age normative values. The Siconolfi step test provided classification of cardiopulmonary fitness with 26.5% (22 of 83) men unable to complete level 1 with very low physical fitness and 41% (34 of 83) of men moderate completing stage 2 of the test. Cardiovascular risk was categorised as high (>20% QRISK2) in 41% of men contributed to by the number of men who had a high hip to waist ratio 72 of 83 men (86.7%) indicating abdominal fat. Three emergent themes from the qualitative analysis highlighted different perceptions of the physical assessment experience. The algorithm provided a clear pathway for decision making, that it was safe and effective to enable community pharmacists to prescribe tailored lifestyle advice for men with prostate cancer. Conclusions: We have developed a computer algorithm that uses simple, safe and validated assessments to provide tailored lifestyle advice which addresses specific areas of cardiovascular risk, strength and physical fitness in men with prostate cancer. It generates a real-time lifestyle prescription at the point of care and has been integrated into the software platform used by pharmacies in the UK. The algorithm was integrated into the software platform used by pharmacies within the UK. Clinical Trial: The study was approved by the UK National Research Ethics Service REC 14/LO/0495 IRAS project ID 148309.

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

    From: JMIR Biomedical Engineering

    Date Submitted: Apr 15, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

  • Expedited safety reporting to sponsors with the implementation of an alert system for clinical trial management at an academic medical center

    From: Journal of Medical Internet Research

    Date Submitted: Apr 13, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

    Background: Early detection or awareness of adverse event (AE) occurrence during clinical trials is essential to ensure patient safety. Although clinical trials take advantage of innovative strategies, clinical designs, and state of the art technologies to evaluate efficacy and safety, early awareness of AE occurrences by investigators still needs to be systematically improved. Objective: This study aimed to build a system to promptly informs investigators when clinical trial participants make unscheduled visits to the emergency room or other departments within or hospital. Methods: We developed an “Adverse Event Awareness System (AEAS)” to facilitate early awareness of AE occurrence at the site level. The AEAS system makes investigators and study coordinators aware of AE occurrences promptly by sending automatic text messages when study participants make unscheduled visits to the emergency department or other clinics at our center. We established the AEAS system in July 2015 in the clinical trial management system. We compared the AE reporting timeline data of 305 AE occurrences from 74 clinical trials pre-initiative (December 2014-July 2015) and post-initiative (June 2015-July 2016). Results: The timeline for alerting investigators of an unscheduled patient visit (onset) was significantly shorten (Mean day: 4.222 + 13.217 vs. 0.787 + 2.247, P = 0.006). With post initiative, overall safety reporting timeline (from the onset to reporting time) was expedited significantly, from 5.435 to 1.180 days (P = <.001). Comparison of reporting time by clinical trial phase, in Phase 1, the average date for awareness to reporting and onset to reporting decreased statistically significantly from 1.04 to 0.45 and from 2.20 to 0.96, respectively. Low-risk trails (Level 1) greatly shortened the meantime in onset to awareness step, from 14.363 to 1.058 days (P =.01). Relatively, high-risk trials (Level 3) were shown a small decline in three AE report indicators (Mean days: 2.19 vs. 0.61, P = .51; SD: 10.28 vs. 1.37). Conclusions: The improvement of safety reporting timelines were most prominent in phase 4 or low-risk level trials. These findings suggest that an information technology driven automatic alert system effectively improves safety reporting timelines, which may enhance patient safety.

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 22, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 22, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

  • Recruiting ambulatory oncology practices and lessons learned

    From: Journal of Medical Internet Research

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

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

  • Evaluation of the universal prevention program Klasse2000 in fourth grade primary school children: Study protocol for a propensity score matching approach

    From: JMIR Research Protocols

    Date Submitted: Apr 15, 2019
    Open Peer Review Period: Apr 23, 2019 - May 7, 2019

    Abstract Background: Klasse2000 is the most widely adopted school-based prevention program in Germany. It addresses health promotion as well as addiction and violence prevention in primary schools. As a universal prevention program, it has reached more than 1.4 million German children in the past 25 years. Methods: The effectiveness of Klasse2000 will be evaluated with a large representative survey among students. Students who have participated in the prevention program (intervention group - IG) will be compared to students who did not participate (control group CG). The comparison will cover the following outcome domains: well-being, self-esteem, emotion regulation, food habits, behavioral problems as well as the school and classroom atmosphere. Furthermore, victimization as well as perpetration regarding bullying, alcohol consumption, smoking and media consumption are assessed. To control for potential group differences the treatment effects will be estimated using propensity score matching. (PSM). PSM matches students from the IG and the CG based on an identical propensity score (PS) or a PS that does not differ by more than a previously defined distance. The treatment effect will then be estimated in the matched sample taking the matching process into account. Discussion: The results regarding the effectiveness of the Klasse2000 prevention program will form an empirical basis for legitimizing universal prevention programs as well as for planning future prevention approaches. Trial Registration: German Clinical Trial Registration DRKS-ID, ID: DRKS00014332. Registered on March 22nd, 2018; version 1

  • Background: Online information resources and support have been demonstrated to positively influence the wellbeing of people diagnosed with cancer. This has been explored in past literature for more common cancers, however for rare cancers, such as Neuroendocrine tumours (NETs), there are little to no support or resources available. Despite relatively good prognoses, the quality of life (QoL) of patients with NETs is significantly lower compared to samples of mixed cancer patients and the general population. Patients with NETs also typically report unclear and difficult pathways of disease management and treatment. There is a vital need to improve the availability of disease-specific information for this patient group and provide supportive care that is tailored to the unique needs of the NET patient population. Objective: The aims of this study are to better understand the outcomes and experiences of patients diagnosed with NETs and to develop and pilot test a nurse-led online and phone-based intervention that will provide tailored supportive care targeted to NET subgroups (functioning versus non-functioning). Methods: This is a multi site cohort with three phases, incorporating both quantitative and qualitative data collection. Phase one is a mixed-methods prospective cohort study of NETs patients identifying differences in patient experiences and priority of needs between NET sub-groups. Phase two utilises results from phase one to develop an online and nurse-led phone-based intervention. Phase three is to pilot test and evaluate the intervention’s acceptability, appropriateness and feasibility. Results: Currently the project is progressing through Phase one and has completed recruitment. A total of 138 participants have been recruited to the study. To date patient reported outcome data from 123 participants at baseline and 87 at 6-month follow-up has been collected. Of these, qualitative data from semi-structured interviews from 35 participants has also been obtained. Phase two and Phase three of the project is yet to be completed. Conclusions: Limited research for patients with NETs suggests QoL and patient experiences are significantly impaired compared to the general population. Furthermore, past research has failed to delineate how the clinical variability between those with functioning and non-functioning NETs impacts on patient supportive care needs. This study will improve on the availability of disease-specific information as well as informing the design of a nurse-led online and phone-based supportive care intervention tailored for the unique needs of the NET patient population. Clinical Trial: Ethics approval was obtained from the Human research Ethics Committee of Peter MacCallum Cancer Centre (project number 16/08L), Human research ethics committee of the Northern Sydney Local Health District in NSW (project number RESP/16/73) and The Human research ethics committee of the central Adelaide Local Health Network in SA (project number Q20160901). Results will be widely disseminated to the funding body, oncology conferences and meetings and through peer-reviewed publications.

  • Making Emergency Care in Rural Areas Fit for Future: Protocol for multi-method and multi-perspective longitudinal analysis and control group study

    From: JMIR Research Protocols

    Date Submitted: Apr 12, 2019
    Open Peer Review Period: Apr 23, 2019 - May 7, 2019

    Background: The German Emergency Medical Services is a two-tiered system with paramedic staffed ambulances as primary response supported by pre-hospital emergency doctors for life-threatening conditions. As in all European health care systems, German medical practitioners are in short supply whilst the demand for timely emergency medical care is constantly growing. In rural areas, this has led to critical delays in the provision of emergency medical care. In particular, in cases of cardiac arrest, time is of essence [1], because with each minute passing, the chance of survival with good neurological outcome decreases. Objective: The project follows four main objectives: 1) Reducing the therapy-free interval through widespread reinforcement of resuscitation skills and motivating the public to provide help (called bystander-CPR), (2) fast, professional first aid in addition to rescue services through alarming trained first aiders via smartphone, (3) faster and higher availability of emergency physicians through introducing the tele-emergency physician (TEP) system, and (4) enhanced emergency care through improving the cooperation between statutory health insurance on-call medical services (German: Kassenärztlicher Bereitschaftsdienst) and emergency medical services. Methods: The implementation of the project is evaluated through a tripartite prospective and intervention study: (1) in medical evaluation, the influences of various project measures on quality of care are assessed using multiple methods. (2) The economic evaluation mainly focuses on the valuation of inputs and outcomes of the different measures while considering various relevant indicators. (3) As part of the scientific work and organizational evaluation important work- and occupational-related parameters but also network and regional indexes are assessed. Results: The project was started in 2017 and enrollment will be completed in 2020. The pre-analysis phase recently finished. Conclusions: Overall, the implementation of the project entails the realignment of emergency medicine in rural areas and the enhancement of quality of medical emergency care in the long-term. It is expected to lead to a measurable increase in medical laypersons’ individual motivation to provide resuscitation, to strengthen resuscitation skills as well as much more frequently provided first aid through medical laypersons. Furthermore, the project is intended to decrease the therapy-free interval in cases of cardiac arrest by dispatching first aiders via smartphones. As demonstrated by previous projects in urban regions, the TEP system has already proven a higher availability and quality of emergency call-outs in regular health care. A closer interrelation of emergency practices of statutory health insurance physicians with the rescue service is expected to lead to a better coordination of rescue and on-call services. Clinical Trial: Ethikkomission (ethics comission) an der Universität Greifswald BB 111/17 http://www2.medizin.uni-greifswald.de/ethik/

  • Interest of SMS contact on medical safety for outpatient surgery: Retrospective Study

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 11, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

    Background: Outpatient surgery is one of major challenge for the care offer development. Establishing the communication with the patient before surgery and for the follow-up is part of a successful medical management in outpatient surgery. During this communication with phone call, pre-operatives’ rules are repeated. Short Message Services (SMS) seems an interesting alternative. Objective: The objective of this study was to evaluate the impact of pre and post-operative SMS on medical safety in outpatient surgery. Methods: We conducted a retrospective, monocentric, observational study. The design of the study was a before-after schema within the adult ambulatory surgery unit of Rouen University Hospital. During the first phase all the patient were called the day before surgery and postoperative period by one off the nurses of the unit. The patient was reminded the preoperative instructions and time of arrival at the hospital. After surgery, the patient was given post-operative advices and pain was evaluated. After instauration of the SMS platform, on the day before surgery the patient and day +1 and +7 after postoperative period received the same instruction by SMS. The primary endpoint was the rate of conversion to full time hospitalization. The secondary’s end points were, defining the causes of hospitalization (medical, surgical, organizational) and the cost of each systems. Results: During a 16 months period we included 4388 patients, 2160 patients before the SMS (7 months) and 2228 patients during the SMS phase (9 months). The use of SMS significantly decreased the rate of conversion to full time hospitalization from 1.20% (n= 26) to 0.36% (n= 8) (p=0,001). Causes of hospitalization were mainly medical (56%), followed by surgical (30%), and organizational (14%). We estimated the cost of the SMS to half off the cost of a phone calls information’s and follow-up. Conclusions: This retrospective work suggests that SMS reminder decreases the rate of conversion to full time hospitalization and so could improve the safety of outpatient surgery. SMS also decreases by two the cost of patient information. Clinical Trial: E2019-11, Non-Interventional Research Committee based at Rouen University Hospital, Rouen, France

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 17, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

  • Weight-loss after stroke: A randomized controlled trial protocol for an intensive lifestyle intervention (GLB-CVA).

    From: JMIR Research Protocols

    Date Submitted: Apr 10, 2019
    Open Peer Review Period: Apr 23, 2019 - May 7, 2019

    Background: Weight gain can be a consequence of stroke, or cerebrovascular accident (CVA), due to impaired mobility, behavioral and emotional disorder, and sensory losses. Weight gain increases the patient’s risk of recurrent stroke and chronic diseases such as diabetes, metabolic syndrome, pulmonary and heart disease. Approaches to weight loss in this population are lacking, yet necessary, due to the unique physiological and cognitive needs of persons post stroke. Evidence demonstrates that intensive behavioral therapy interventions that address both physical activity and diet offer the greatest potential for weight-loss. The Group Lifestyle Balance (GLB) intervention is a twelve-month, evidence-based weight-loss program that has been used extensively with the general population, but not with people post stroke. We modified the program to meet the needs of people who have a stroke (GLB-CVA). Objective: This current randomized control trial (RCT) examines the efficacy of the GLB-CVA on weight and secondary outcomes compared to a waitlist controlled group. Methods: This RCT will enroll and randomize 64 patients over an eighteen-month period. Results: N/A Conclusions: It is anticipated the findings from this RCT will contribute to the evidence base regarding weight-loss strategies for people living with stroke. Clinical Trial: NCT03873467

  • Background: Vedolizumab has been shown to induce clinical remission in patients with active UC. Treatment with anti-integrin vedolizumab leads to clinical remission in 16.9% and clinical response in 47.1% of cases after 6 weeks. In clinical practice, however, no decision to discontinue or continue vedolizumab therapy is made until 14 weeks at the earliest. Objective: The aim of this study is to develop an algorithm for optimizing vedolizumab administration in patients with moderate to severe Ulcerative colitis (UC) by calculating the probability of clinical response in Week 14 based on data from Week 6. Methods: The study is designed as a prospective, single-arm, multicentric, non-interventional observational study with no interim analyses and a sample size of 35 evaluable patients. Results: Enrollment started in August 2018 and was still open at the date of submission. The study is expected to finish in September 2020. Conclusions: The early identification of patients who are responding to an integrin antibody is therapeutically beneficial. At the same time, patients who are not responding can be identified earlier. The development of a therapeutic algorithm for identifying patients as responders or non-responders can thus help prescribing physicians to both: avoid ineffective treatments and adjust dosages when necessary. This in turn promotes a higher degree of treatment tolerance and patient safety in the case of the anti-Integrin antibody Vedolizumab administration. Clinical Trial: German Clinical Trials Register, Deutsches Register Klinischer Studien DRKS00014249; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014249

  • A Survey of Heart Failure Patient Interest in mHealth Applications for Self-Care

    From: JMIR mHealth and uHealth

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

    Background: Heart failure (HF) is a serious public health concern that afflicts millions of individuals in the United States (US). Development of behaviors that promote HF self-care may be imperative to reduce complications and to avoid hospital readmissions. Mobile health (mHealth) solutions, such as Fitbit activity trackers and smartphone applications, could potentially help to promote self-care through remote tracking and issuing reminders. Objective: The objective of this study was to ascertain HF patients’ interest in a smartphone application to assist them in managing their treatment and symptoms, and to determine factors that influence their interest in such an application. Methods: In the clinic waiting room on the day of their outpatient clinic appointments, 50 HF patients participated in a self-administered survey. The survey consisted of 139 questions from previously published, institutional review board-approved questionnaires. The survey measured patients’ interest in and experience using technology, as well as their function, HF symptoms, and HF self-care behaviors. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was among the 11 questionnaires and was used to measure the HF patients’ health-related quality of life (HRQOL) through patient-reported outcomes (PROs). Results: Patients were 64.5 years of age on average, women 32.0%, and New York Heart Association (NYHA) Class II or higher 91.1%. Greater than 60% of the survey participants expressed interest in several potential features of a smartphone application designed for HF patients. Participant age correlated negatively with interest in tracking, tips, and reminders in multivariate regression analysis (p < 0.05). In contrast, MLHFQ scores (worse health status) produced positive correlations with these interests (p < 0.05). Conclusions: The majority of HF patients showed interest in activity tracking, HF symptom management tips, and reminder features of a smartphone application. Desirable features and an understanding of factors that influence patient interest in a smartphone application for HF self-care may allow researchers to address common concerns and to develop applications that demonstrate the potential benefits of mobile technology.

  • The Impact of War in Yemen on Under One Year Children Immunization Coverage

    From: JMIR Public Health and Surveillance

    Date Submitted: Apr 20, 2019
    Open Peer Review Period: Apr 23, 2019 - May 7, 2019

    Background: The war that was started in 2015 have crippled the capacity of the Yemeni National Health System and left only 45% of health facilities functioning. Therefore, Yemen faced increasing vaccine preventable diseases (VPD) outbreaks and may become a high risk polio importation area for the country and the whole Eastern Mediterranean Region.. Purpose: to determine the immunization coverage rate among Yemeni children under one year during 2012- 2015 . Methods: Data on vaccination coverage for the 2012-2015 was obtained from the National Expand Programme for Immunization (EPI). The vaccination coverage was calculated at national and governorate levels through dividing number of the actually vaccinated children by the estimated under one year children population. Finding: there is an increase from 2012 to 2014 in the national coverage with Penta 3 and measles, the coverage was still below the national target (≥ 90%). Furthermore, the 2015 witnessed marked drop in national coverage compared to 2014 for measles and BCG but slight drop in coverage by Penta 3. Such drop was more marked at the governorates that witness armed confrontations e.g. Taiz governorate showed drop in Penta 3 coverage in 2015 and Sa`dah. On the other sides, governorates didn’t witness armed confirmations showed increase in coverage e.g. Rima showed increase in Penta 3 coverage from 87% to 106% for the same period. Conclusions: The analysis shows the marked negative impact of the 2015 war on immunization coverage especially in the governorates that witness armed confrontations that may put Yemen at more risk for polio importation and VPD outbreaks. Besides the ongoing struggles to stop the Yemeni war, more innovative vaccine delivery/provision and increasing demands strategies are needed especially in governorates with confrontations.

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

    From: Journal of Medical Internet Research

    Date Submitted: Apr 15, 2019
    Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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

  • Gaming my way to recovery: Review protocol to understand how to integrate video game technologies into youth mental health services

    From: JMIR Research Protocols

    Date Submitted: Apr 10, 2019
    Open Peer Review Period: Apr 23, 2019 - May 7, 2019

    Background: Video games are played by millions of adolescents and young adults around the world, and are one of the technologies used by youth who are accessing mental health services. Youth with mental health problems strongly endorse the use of technology, for example, Apps and online platforms, for receiving information; supporting their treatment journey (eg, decision-making tools); and to facilitate their recovery. There is a growing body of literature that explores the advantages of playing video games in promoting better attention, memory, managing emotions; promoting behavior change; and, supporting mental illness treatment (eg, anxiety, depression, PTSD). Concurrently, the field of research focuses on the negative impact of video games describing potential harms related to aggression, addiction, and depression. To promote clarity on this matter, there is a demand for a knowledge synthesis that can offer recommendations on how video games can be safely and effectively adopted and integrated into existing youth mental health services. Objective: Using a stepped care conceptual framework, this knowledge synthesis aims to understand where, when, how, and for what purpose video game technologies can best be implemented into youth services for mental health and substance misuse, and if it is appropriate to do so. Assessing current knowledge on video game technology and intervention has the potential to support youth mental health services transformation. Methods: Using Arksey and O’Malley’s methodology, we are conducting a scoping review, which aims to systematically map the primary sources of evidence, types of evidence, quality of the evidence, key concepts, models, and gaps in the research on a specific topic area. Results: This review on video game technologies will help mental health providers and policymakers to access evidence-based knowledge to assess the potential and risks of these interventions, and, if appropriate, effectively promote its implementation in youth mental health services to support assessment, and treatment. Conclusions: Video game technologies hold the promise of being learning machines because of their ability to build on pedagogical principles (eg, experiential learning; active engagement of the learners). They can employ unique features for facilitating learning processes, as well as opening up new modalities to increase knowledge, improve coping strategies and skills, and, overall provide treatment to youth, support caregivers, and providers.

  • Communicating health science to the public in the digital and social media ecosystem: A scoping review and a proposed typology of strategies used by scientists

    From: JMIR Public Health and Surveillance

    Date Submitted: Apr 18, 2019
    Open Peer Review Period: Apr 23, 2019 - May 7, 2019

    Background: The public’s understanding of health science can be influential in a wide range of areas related to public health, including policy-making and self-care. Through the digital and social media ecosystem, health scientists play a growing role in health science communication (HSC) to the public. Objective: This review aimed to: 1) synthesize the literature on HSC by health scientists in the digital and social media ecosystem; 2) describe the HSC strategies and communication channels used. Methods: This scoping review was based on the Joanna Briggs Institute Methodological Framework. A systematic search was performed in 6 databases (January 2000—April 2018). Screening, full-text review, data charting and critical appraisal were performed independently by two review authors. Data regarding included studies and communication channels was synthesized descriptively. The typology of HSC strategies was developed using a qualitative and inductive method of data synthesis. Results: Among 960 identified articles, 18 met inclusion criteria. Six publications were scored good quality (31.58%), 9 were scored moderate quality (47.37%), and 3 were scored low quality (15.79%). Overall, 75 HSC strategies used by health scientists were identified. These were grouped into 9 types: content, credibility, engagement, intention, linguistics, planification, presentation, social exchange, and statistics. Five types of communication channels were identified: social networking platforms (e.g., Twitter), content-sharing platforms (e.g., YouTube), digital research communities (e.g., ResearchGate), personal blogs and websites, and social news aggregation and discussion platforms (e.g., Reddit). Conclusions: Few empirical works have been conducted on HSC by health scientists in the digital and social media ecosystem. Evidence suggests multiple types of HSC strategies are used concurrently. Future studies should examine the appropriateness and effectiveness of HSC strategies for improving public health-related outcomes, and identify the barriers, facilitators and ethical considerations inherent to the involvement of health scientists in the digital and social media ecosystem.

  • Practices and Attitudes Towards Patient E-Communication and Social Media Use Amongst Neurology Providers

    From: Interactive Journal of Medical Research

    Date Submitted: Apr 12, 2019
    Open Peer Review Period: Apr 20, 2019 - Jun 15, 2019

    Background: E-communication is increasingly being utilized in healthcare but there is limited research investigating the practices and attitudes of providers towards the use of these tools in professional settings. Objective: To assess the experiences, attitudes, and practices of neurology healthcare providers, regarding e-communication contact with patients and social media (SM) use. Methods: Two surveys assessing patient e-communication and SM use were disseminated by e-mail to subscribers of NeuroSens, an online educational platform. Results: 67% and 27% of respondents completely opposed patient contact to their personal mobile and e-mail respectively, while the remaining respondents believed propriety was situation-dependent. Respondents tolerant to patient contact were more likely to have been contacted for urgent matters in the past. Most respondents (54%) used at least one of the main SM networks, and 76% denied having posted inappropriate content. The majority of respondents (74%) were unfamiliar with any SM policy within their practicing institution and the vast majority (98%) agreed clinical institutions need to establish updated e-communication policies. Conclusions: Neurology healthcare providers demonstrate conservative practices and perceptions of SM use and patient e-communication, despite limited institutional guidance. With the continued growth of e-communications tools, there is a strong need to for clinical institutions to establish policies to support the use of these applications within healthcare.

  • Development and initial randomized controlled test of an interactive mobile phone app for increasing fruit and vegetable knowledge and intakes

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 13, 2019
    Open Peer Review Period: Apr 17, 2019 - Jun 12, 2019

    Background: Fruit and vegetable (FV) consumption is important for health, but many individuals fail to consume adequate FV for health benefits. While many individuals are aware of current FV consumption recommendations, research suggests that adherence to these recommendations is hampered by low knowledge and confusion surrounding the details of the recommendations. Objective: This paper reports the development and details of a pilot randomized controlled trial for a novel interactive mobile phone application (app) for addressing low knowledge of the UK 5 a day FV recommendations. Methods: First, the requirements for the app were elicited and defined by researchers and potential end-users, and prioritised using the MoSCoW method. Then a prototype smart phone app was designed and developed using an agile approach. The prototype app was then tested in a randomized controlled pilot trial, for impacts on FV knowledge and FV intake, where users also provided qualitative feedback. In this trial, volunteers were randomized to either receive (N=50) or not receive the app (N=44) for two or four weeks, and FV knowledge, FV intakes, and FV behaviour were assessed at study start and study end. App usage and feedback was also investigated. Lastly, a final version of the app was developed to incorporate the findings from this pilot test. Results: Low knowledge of the FV recommendations centred around portion sizes and the need for variety, and an interactive mobile phone app was considered a suitable tool for improving knowledge in a practical manner, that would be available both at time of consumption and outside of these times. The pilot test revealed improved FV behaviour in volunteers who received the app for two weeks compared to baseline, and suggestions of increased FV intakes, but improvements in FV knowledge were found in both groups, and no improvements in FV intake were found in formal measures. App usage was also low and feedback suggested a desire for reminder notifications and a value from increased awareness of low FV intakes. Improvements in the final version of the app include a message to increase awareness of low intakes and an option to add notifications to increase use. Conclusions: A novel interactive mobile phone app was successfully developed based on requirements, and when tested in a pilot randomized controlled trial, this app was found to have some impacts on FV outcomes. While benefits from the app were small, app usage was also low, and feedback from those testing the app offered useful insights to improve engagement. A final version of the app has now been developed and requires full testing. Clinical Trial: www.clinicaltrials.gov (ID NCT02779491).

  • Connected Health: A Systematic Mapping Study

    From: Journal of Medical Internet Research

    Date Submitted: Apr 15, 2019
    Open Peer Review Period: Apr 17, 2019 - Jun 12, 2019

    Background: This paper examines the development of the Connected Health research landscape with a view on providing a historical perspective on existing Connected Health research. Connected Health has become a rapidly growing research field as our healthcare system is facing pressured to become more proactive and patient centred. Objective: We aimed to identify the extent and coverage of the current body of knowledge in Connected Health. With this, we want to identify which topics have drawn the attention of Connected health researchers, and if there are gaps or interdisciplinary opportunities for further research. Methods: We used a systematic mapping study that combines scientific contributions from research on medicine, business, computer science and engineering. We analyse the papers with seven classification criteria, publication source, publication year, research types, empirical types, contribution types research topic and the condition studied in the paper. Results: Altogether, our search resulted in 208 papers which were analysed by a multidisciplinary group of researchers. Our results indicate a slow start for Connected Health research but a more recent steady upswing since 2013. The majority of papers proposed healthcare solutions (37%) or evaluated Connected Health approaches (23%). Case studies (28%) and experiments (26%) were the most popular forms of scientific validation employed. Diabetes, cancer, multiple sclerosis, and heart conditions are among the most prevalent conditions studied. Conclusions: We conclude that Connected Health research seems to be an established field of research, which has been growing strongly during the last five years. There seems to be more focus on technology driven research with a strong contribution from medicine, but business aspects of Connected health are not as much studied.

  • Usability of a psychotherapeutic interactive gaming tool used in facial emotion recognition for people with schizophrenia

    From: JMIR Mental Health

    Date Submitted: Apr 11, 2019
    Open Peer Review Period: Apr 15, 2019 - Jun 10, 2019

    Background: Emotional Recognition (ER) is one of the areas most affected in people with schizophrenia. However, there are no software tools available for the assessment of ER. The interactive software program ‘Feeling Master’ (a cartoon facial recognition tool) was developed to investigate the deficit in facial emotion recognition (FER) with a sample of patients with schizophrenia in a pilot project framework. Objective: The aim of the study was to test the usability of ‘Feeling Master’ as a psychotherapeutic interactive gaming tool for the assessment of emotional recognition in people with schizophrenia compared with healthy people, and the relationship between FER, attributional style and theory of mind. Methods: Nineteen individuals with schizophrenia and 17 healthy control (HC) subjects completed the ‘Feeling Master’ including five emotions (happiness, sadness, anger, fear, and surprise). Regarding the group with schizophrenia they were evaluated with the Personal and Situational Attribution Questionnaire (IPSAQ) and the Hinting Task (Theory of Mind) to evaluate social cognition. Results: Patients with schizophrenia showed impairments in emotion recognition and they remained slower than the HC in the recognition of each emotion (P<.001). Regarding the impairment in the recognition of each emotion we only found a trend toward significance in error rates on fear discrimination (P=.07). And the correlations between correct response on the ‘Feeling Master’ and the hinting task showed significant values in the correlation of surprise and theory of mind (P=.046). Conclusions: In conclusion, the study puts forward the usability of the ‘Feeling Master’ in FER for people with schizophrenia. These findings lend support to the notion that difficulties in emotion recognition are more prevalent in people with schizophrenia, and that these are associated with impairment in ToM, suggesting the potential utility of the FER in the rehabilitation of people with schizophrenia.

  • Title: Hacking 9-1-1: infrastructure vulnerabilities and attack vectors

    From: Journal of Medical Internet Research

    Date Submitted: Apr 14, 2019
    Open Peer Review Period: Apr 14, 2019 - Jun 9, 2019

    Background: 9-1-1 call centers are a critical component of prehospital care: they accept emergency calls, dispatch field responders such as EMS units, and provide callers with emergency medical instructions prior to their arrival. Objective: We aim to describe the technical structure of the 9-1-1 call taking system and describe its vulnerabilities that could lead to compromised patient care. Methods: 9-1-1 calls answered from mobile phones and land lines use a variety of technologies to provide information about caller location and other information. These interconnected technologies create potential cyber vulnerabilities. Results: A variety of attacks could be carried out on 9-1-1 infrastructure to various ends. Attackers could target individuals, groups, or entire municipalities. These attacks could result in anything from a nuisance, to increased loss of life in a physical attack, to worse overall outcomes due to delays in care for time sensitive conditions. Conclusions: Evolving 9-1-1 systems are increasingly connected and dependent on network technology. As implications of cybersecurity vulnerabilities loom large, future research should examine methods of hardening the 9-1-1 system against attack.

  • Barriers and enablers for successful implementation of the eHealth service Sisom for improved child participation in pediatric care - a multi-center study

    From: Journal of Medical Internet Research

    Date Submitted: Apr 8, 2019
    Open Peer Review Period: Apr 12, 2019 - Jun 7, 2019

    Background: Children’s participation in healthcare is one of the most important components in the management of their disease. eHealth services that are adapted to the needs of children have the potential for restructuring how children and professionals work together. We have developed the digital interactive assessment and communication tool, Sisom, to give children between 6-12 years “a voice" in their own healthcare. However, the implementation of eHealth services such as Sisom in daily practice in pediatric healthcare is rarely investigated. Objective: The purpose of this study was to explore the process of implementing Sisom for children in pediatric care in Sweden. More specifically, to (1) evaluate whether the implementation strategy was conducted as planned; (2) understand the barriers and facilitators of the implementation strategy in pediatric care settings; (3) gain insight into how professionals work with the specific intervention; and (4) gain insight into the usefulness and effects of the intervention from the professionals’ perspectives. Methods: A process evaluation design was used to study the implementation of Sisom at four pediatric care centers in Sweden. An extensive amount of qualitative and quantitative data was collected before, during and after the intervention through self-report checklists, memos and interviews with professionals. In total, 46 children, age 6- 13 years, participated. The children used Sisom at two occasions during 6 months. When they have used Sisom, a printed report forms the basis for a forthcoming dialogue between professionals, children and their parents. Results: To our knowledge, this is the first implementation study of an eHealth communication tool aimed at strengthening children’s participation in pediatric healthcare. Key factors for successful implementation were alignment of the solution with the values and goals of the organization, healthcare professionals’ beliefs in the usefulness and usability of the solution and healthcare professionals’ willingness to change their professional roles guided by the solution. Conclusions: The results from the study shows that it is possible to restructure healthcare delivery towards a child-centered approach if there is a willingness and preparedness in the organization to implement an eHealth solution with the aim of restructuring the way of working with children’s participation.

  • Integrating Health technologies in Health Services for Syrian Refugees in Lebanon: a Qualitative study

    From: Journal of Medical Internet Research

    Date Submitted: Apr 8, 2019
    Open Peer Review Period: Apr 12, 2019 - Jun 7, 2019

    Background: Lebanon currently hosts around one million Syrian refugees. There has been an increasing interest in integrating eHealth and mHealth technologies into the provision of primary healthcare to refugees and Lebanese citizens. Objective: We aimed to gain a deeper understanding of the potential for technology integration in primary healthcare provision in the context of the protracted Syrian refugee crisis in Lebanon. Methods: A total of 18 face-to-face semi structured interviews were conducted with key informants (n=8) and healthcare providers (n=10) involved in the provision of health care to the Syrian refugee population in Lebanon. Interviews were audio recorded and directly translated and transcribed from Arabic to English. Thematic Analysis was conducted. Results: Study participants indicated that varying resources, primarily time and the availability of technologies, at primary healthcare clinics, to be one of the main challenges for integrating technologies for the provision of healthcare services for refugees. This challenge is compounded by refugees being viewed by participants as a mobile population thus making primary healthcare clinics less willing to invest in refugee health technologies. Lastly, participants’ perceptions of refugees’ technological capabilities and motivations regarding their health concerns were found to be challenges that need addressing for the successful integration of refugee health technologies. Conclusions: Our findings indicate that in the context of integrating technology into the provision of healthcare for refugees in a low or middle income country, such as Lebanon, some barriers for technology integration related to the availability of resources are common with those found elsewhere. However, we identified participants’ perceptions of refugees’ capabilities to be a challenge specific to the context of this refugee crisis. These perceptions needs addressing when considering refugee health technologies. This could be done by: a)increasing the visibility of refugee capabilities, and; b) configuring refugee health technologies so that they may create spaces in which refugees are empowered within the healthcare system and can work towards debunking the negative perceptions surfaced in this study.

  • A Research Roadmap: Connected Health as enabler of Cancer Patient Support

    From: Journal of Medical Internet Research

    Date Submitted: Apr 12, 2019
    Open Peer Review Period: Apr 12, 2019 - Jun 7, 2019

    Sustained improvements in cancer care in recent years have resulted in increased numbers of people living with and beyond cancer, and increased attention being placed on improving quality of life for those living with and beyond cancer. Connected Health provides the foundations for the transformation of cancer care into a patient-centric model focused to provide personalised support to the unique needs of each patient. It creates an opportunity to overcome barriers of health care support among patients diagnosed with chronic conditions. This paper provides an overview of important areas for the creation of a new connected health paradigm in cancer care. It discusses the capabilities of mobile and wearable technologies and device systems to advance a multidisciplinary and inclusive approach for cancer patients for mental wellbeing, physical activity, and rehabilitation. Several examples already show that there is an enthusiasm to strengthen the possibilities offered by Connected Health in persuasive & pervasive technology in cancer care. Developments harnessing the internet of things, personalization, and artificial intelligence help to monitor and assess the health status of cancer patients. Furthermore, this paper analyses the Data Infrastructure Ecosystem the Connected Health economy ecosystem, and its associated barriers. Interoperability is essential when developing Connected Health solutions which integrate with health systems and electronic health records. Business growth in mHealth exponential, making it both an attractive and challenging market. As a conclusion, there is a need for user-centered and multi-disciplinary standards of practice to the design, development, evaluation, and implementation of Connected Health interventions in cancer care to ensure their acceptability, practicality, effectiveness, affordability, safety, and equity.

  • Online Health Information Seeking Among Kuwait University Students

    From: JMIR Formative Research

    Date Submitted: Apr 9, 2019
    Open Peer Review Period: Apr 11, 2019 - Jun 6, 2019

    Background: Background: Due to the revolution in technology, the internet has become an important aspect in the lives of people. Modern technology is enabling people from different educational levels to use the internet for several purposes, one of which is health information seeking. Recently, online health information has become more popular among patients all over the world, as well as the general public. Objective: Objectives: This study aims to investigate the use of online health resources among undergraduate students in Kuwait University. Methods: Methods: The study employed a cross-sectional design with students selected from eight faculties of Kuwait University, four of which are Literature and four are Science faculties. Data was collected using structured questionnaires, and analysis was done using chi-square test and binary logistic regression to determine the factors associated with seeking health information online. Results: Results: The sample size obtained was 1132 with a response rate of 90.3%. Overall, the prevalence of students seeking online health information was 86.2%. The most significant factors associated with seeking health information online were age, gender, faculty, year of study, primary source of internet, and level of experience with internet use. Ninety percent of students who are more than 21 years old, used online health information compared to 83% of those who are 18 years old. Also, Female students showed a higher prevalence (88.8%) of online health information seeking than males (77.8%). All the differences found in the study were significant (P value < 0.05). Conclusions: Conclusion: The study concluded that a large number of people use the internet for seeking health information online. Socio-demographic factors have a significant association to online health information seeking. Therefore, education has to be provided by the doctors to the public about the websites that the people can trust.

  • Background: Until recently, treatment options were limited for patients with acute myeloid leukemia and myelodysplastic syndrome (AML/MDS) who are ineligible for intensive chemotherapy. Due to rapid progression of the condition, it is difficult to capture what is most important to patients when making treatment decisions. Patients’ needs can be better addressed by gaining a deeper understanding of their perspectives, which is valuable in the decision-making process. The Food and Drug Administration (FDA) recently encouraged the use of social media as a tool to gain insight on patients’ perspectives regarding symptoms experienced and the impacts of their disease. Objective: To use disease-specific social media posts by patients with AML/MDS who are ineligible for intensive chemotherapy and their caregivers to capture factors that are most important to this population, and to provide current evidence to inform and characterize these perspectives. Methods: Posts by patients with AML/MDS and their caregivers were extracted from publicly available discussions on three large AML/MDS-specific sites. These posts were manually reviewed to only include patients who are ineligible for intensive chemotherapy. A total of 1,443 posts from 220 AML patients/caregivers and 2,733 posts from 127 MDS patients/caregivers met the study inclusion criteria. A qualitative data analysis (QDA) of a sample of 85 patients/caregivers’ posts was conducted to identify themes, and a targeted QDA of posts from 79 users focused on treatment decision discussions. Posts were manually reviewed, and relevant text segments were coded and grouped into categories and overall themes. Results: A total of 86% (73 of 85) of users included in the overall QDA had relevant information about the key objectives. The most commonly discussed treatment experience theme was the humanistic burden of AML/MDS in terms of emotional/physical impact and impact on family (86% of users), followed by treatment decisions (56%) and unmet needs (50%). In the QDA of treatment decisions, 60 posts from 45 users contained relevant information. Patients commonly reported the desire to reach specific milestones including birthdays and weddings. They wished for a better quality of life over quantity of life, did not want the risk of suffering from side effects, and expressed a clear preference to be at home rather than in a hospital or care home. Conclusions: This study was a novel application of disease-specific social media. It highlighted experiences in the current treatment of AML/MDS including information gaps, patient/caregiver uncertainty, and the importance of understanding patient/caregiver goals and opinions. A clear finding from this research was the importance of reaching certain personal life goals and being at home with family and friends. The analysis showed that patients/caregivers face additional challenges that include humanistic impacts and a lack of information regarding treatment options.

  • The Evaluation of Pulmonary Rehabilitation in Virtual Reality for Chronic Obstructive Pulmonary Disease Patients

    From: Journal of Medical Internet Research

    Date Submitted: Apr 6, 2019
    Open Peer Review Period: Apr 10, 2019 - Jun 5, 2019

    Background: Uptake of traditional pulmonary rehabilitation classes from Chronic Obstructive Pulmonary Disease (COPD) patients is poor due to personal factors preventing accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation and Virtual Reality (VR) could be the promising technology for COPD patients to access services remotely. Objective: This study aims to investigate whether VR improves COPD patients compliance with pulmonary rehabilitation, particularly vulnerable patient group (MRC four or five), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programmes. Methods: Eight-week patient trial using an innovative VR pulmonary rehabilitation programme. Purposive sample of ten COPD patients graded MRC four or five registered at a selected healthcare centre and a hospital in Cumbria, UK. Both qualitative (focus groups and interviews) and quantitative (self-report patient surveys) data were gathered. The five self-report surveys included the Patient Activation Measure (PAM), Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-9), Short Physical Performance Battery (SPPB), and the Edmonton Frail Scale (EFS). Patients set a short-term goal and a long-term goal prior to the trial which included physical measures such as walking speed, walking distance, mobility, and strength. Results: From the qualitative data, eleven themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further supports the qualitative findings by revealing significant improvements in all physical measures. Conclusions: Overall, this study demonstrates how remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing this service to COPD patients at scale. Clinical Trial: n/a

  • Investigating the Use of mHealth Interventions in Vulnerable Populations for Cardiovascular Disease Management – Scoping Review

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 4, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: Cardiovascular disease (CVD) has grown to become one of the leading causes of mortality worldwide. The advancements of CVD-related treatments have led to a decline in CVD prevalence amongst individuals in high income countries (HICs). However, these improvements do not reflect the state of individuals in low-and-middle-income countries (LMICs) and vulnerable subgroup populations in HIC’s, like the Indigenous. To help minimize the health disparities in these populations, technology-based interventions have been offered as a potential solution, but there is concern regarding if they will be effective, or even needed, as these tools have been designed for use in HICs, Objective: The objective of this study was to explore how mobile health (mHealth) interventions currently assist individuals in Indigenous communities and LMICs with CVD management. Methods: A scoping review guided by the methods outlined by Arksey and O’Malley was conducted. A comprehensive search was completed by two reviewers in five electronic databases using keywords related to mobile health, cardiovascular disease, self-care, Indigenous communities and LMICs. Studies were screened over two rounds and critically reviewed using a descriptive-analytical narrative method. Descriptive data was categorized into thematic groups reflecting the major findings related to the study objective. Results: We identified a total of 11 original articles and 11 review papers that met the criteria for this scoping review. The majority of the studies included a telemonitoring and SMS related feature associated with the intervention. The use of SMS was the most common approach to effectively promote disease management amongst individuals in both LMICs and Indigenous communities. However, customizing for cultural considerations within the design of the intervention was highlighted as a pivotal component to encourage CVD management. Specifically, individuals emphasized that the inclusion of collaborative partnerships with community members would strengthen the effectiveness of the intervention, by ensuring it is designed with the appropriate context. Conclusions: Technology-based interventions used within Indigenous communities and LMICs has shown its potential to assist individuals with managing their condition. Although the literature available regarding this topic is limited, this review outlines key components to promote the effective use of these tools in the context of these vulnerable populations.

  • Technology adoption in Australian healthcare environments: Nurses as stakeholders

    From: JMIR Nursing

    Date Submitted: Apr 5, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: The 2017 Australian Digital Health Agency National Digital Health Strategy (ADHA Strategy) is based on the underlying assumption that digital technology in healthcare environments is ubiquitous. The ADHA Strategy views health professionals, especially nurses, as grappling with the complexity of installing and using digital technologies to facilitate personalized and sustainable person-centered care. Yet ironically the 2018 debate over how to enrol Australians into the national electronic health record and its alteration from an opt-in to opt-out model heightened public and professional concern over what constituted a ‘safe, seamless and secure’ health information system. What can be termed a ‘digital technology paradox’ has emerged where, although it is widely acknowledged there are benefits from deploying and using digital technology in the workplace, the perception of risk renders it unavailable or inaccessible at point of care. The inability of nurses to legitimately access and use mobile technology is impeding the diffusion of digital technology in Australian healthcare environments and undermining the 2017 ADHA Strategy. Objective: This study explored the nature and scope of usability of mobile technology at point of care, in order to understand how current governance structures impacted on access and use of digital technology from an organization perspective. Methods: Individual semi-structured interviews were conducted with representatives from professional nursing organizations. Ten interview questions focused on factors that impacted the use of mobile technology for learning at point of care. Seven national organizations and 52 Coalition of National Nursing and Midwifery Organizations members were invited to participate. Interviews were recorded and transcribed verbatim. Data analysis was systematic and organized, consisting of trial coding, and member checking was undertaken to ensure rigour. A codebook was developed to provide a framework for analysis to identify the key themes latent in the transcibed data. Nurses as stakeholders emerged as a key theme. Results: Four female and two male senior members of ther nursing profession were interviewed. Each interview lasted between 17 and 54 minutes which related to knowledge of the particiant regarding the topic of interest and their availability. Two sub-themes coded as ‘ways of thinking’ and ‘ways of acting’ emerged from the open codes. Participants provided examples of the factors that impacted the capacity of nurses to adopt digital technology from an emic perspective. There were contributing factors that related to actions including workarounds; attentiveness; and experiences. Nurses also indicated there were attitudes and influences that impacted thinking regarding access and use of mobile technology at point of care. Conclusions: Nurse are inadequately prepared for the digital future that has now arrived in healthcare environments. Nurses do not perceive they are leaders in decision making regarding digital technology adoption, nor are they able to facilitate digital literacy or model digital professionalism.

  • Automated outlier Identification for Validation (AIV) of Stroke Outcomes Using Multiple Large Repositories

    From: JMIR Medical Informatics

    Date Submitted: Apr 5, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: Introduction: Researchers commonly use the Modified Rankin Scale (mRS) and the Barthel Index (BI) to assess a patient’s clinical outcome after stroke. These are potential targets in machine learning models for stroke outcome prediction. Objective: The objective of this study was to evaluate density-based outlier detection methods on mRS and BI assessments. Methods: We trained three density-based outlier detection methods including density-based spatial clustering of applications (DBSCAN), hierarchical DBSCAN (HDBSCAN) and local outlier factor (LOF) based on data obtained from a nationwide prospective stroke registry in Taiwan. The testing of each method was done by using four different NINDS stroke datasets. Results: The DBSCAN achieved a high performance across all mRS values (the highest average accuracy was 99.2±0.7 at mRS-4 and the lowest average accuracy was 92.0±4.6 at mRS-3). The LOF also achieved similar performance but the HDBSCAN needs further improvement. Conclusions: The evaluation results showed that promising density-based outlier detection methods are promising for validation of stroke outcome measures during the study data clean up processes to improve completion of clinical data for increased data quality and research analyses.

  • Temporal Pattern Detection to Predict Adverse Events in Critical Care: A Case Study with Acute Kidney Injury

    From: Journal of Medical Internet Research

    Date Submitted: Apr 4, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: More than 20% of patients admitted to the intensive care unit (ICU) develop an adverse event (AE) increasing the risk of further complications and mortality. Despite substantial research on AE prediction, no previous study has leveraged patients’ temporal data to extract features using their structural temporal patterns, i.e. trends. Objective: To improve AE prediction methods by using structural temporal pattern detection for patients admitted to the ICU by extracting features from their temporal pattern data to capture global and local temporal trends and to demonstrate these improvements in the detection of Acute Kidney Injury (AKI). Methods: Using the MIMIC dataset, we extracted both global and local trends using structural pattern detection methods to predict AKI. Classifiers were built using state-of-the-art models; the optimal classifier was selected for comparisons with previous approaches. The classifier with structural pattern detection features was compared with two baseline classifiers that used different temporal feature extraction approaches: (i) symbolic temporal pattern detection, which is the most common approach for multivariate time series classification; and (ii) the last recorded value before the prediction point, which is the most common approach to extract temporal data in the AKI prediction literature. Moreover, we assessed the individual contribution of global and local trends. Classifier performance was measured in terms of accuracy (primary outcome), area under the curve (AUC), and F-measure. Results: Random Forest was the best classifier using structural temporal pattern detection. The accuracy of the classifier with local and global trend features was significantly higher than when using symbolic temporal pattern detection and last recorded value (81.3% vs. 70.6% vs. 58.1%; p<0.001). Excluding local or global features reduced the accuracy to 74.4% or 78.1% respectively (p<0.001). Conclusions: We demonstrated that using features obtained from structural temporal pattern detection the onset of AKI prediction in ICU patients was predicted significantly better than with previous approaches. The proposed method of combining both local and global trends is a generalizable approach to predict adverse events in critical care that may be used to help clinicians intervene in a timely manner to prevent or mitigate adverse events.

  • Occupational health needs and predicted well-being in office workers undergoing online-health promotion training: Cross-sectional study

    From: Journal of Medical Internet Research

    Date Submitted: Apr 5, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: Office workers face workplace health issues, including stress and back pain, resulting in considerable costs to businesses and health care systems. Workplace health promotion attempts to prevent these health issues, and the Internet can be used to deliver workplace health promotion interventions to office workers. Data was provided by fitbase GmbH, a German company which specializes in workplace health promotion via the Internet (online-health). The online-health intervention allowed workers to focus on different health categories by using information modules (reading health information) and/or completing practical exercises (guided, interactive health tutorials). Objective: This study aimed to identify the extent to which office workers have health issues related to the workplace, assess whether office workers who differ in their health focus also differ in their improved well-being, and whether completing practical exercises influences improved well-being more than reading information modules. Methods: fitbase GmbH collected data for the period of February 2016 to May 2017 from health insurance employees undergoing online-health training in Hamburg, Germany. The data consisted of a needs assessment examining health issues faced by office workers, a wellness questionnaire regarding one’s perception of the online-health intervention, and activity logs of information modules and practical exercises completed. Through logistic regression, we determined associations between improved well-being from online-health training and differences in a worker’s health focus and a worker’s preferred intervention method. Results: Nearly half of the office workers chronically had back pain (1532 of 3354) and felt tense or irritated (1680 of 3348). Over four-fifths (645 of 766) of the office workers indicated that the online-health training improved their well-being (P<0.001). Office workers who preferred practical exercises compared to information modules had 2.2 times greater odds of reporting improved well-being from the online-health intervention (P=0.01; 95% CI, 1.20-4.11). Office workers with a back health focus within practical exercises had higher odds of improved well-being compared to other health foci. Office workers focused on back pain practical exercises had 3.1 times, 2.3 times, 3.1 times, and 3.4 times the odds of having their well-being improved from the online-health intervention compared to those focused in stress management, mindfulness, stress management/mindfulness, and eye health (P<0.001, P=0.02, P=0.005, P =0.003, respectively). For those who preferred information modules, no particular health focus predicted improved well-being. Conclusions: Office workers frequently report having back pain and stress. A focus on online-health training via practical exercises and back health exercises predict an improvement in office workers’ reported well-being.

  • “I Feel That Everybody’s Around Me”: Family Separation and the Impact of ICTs on the Mental Health of Refugee Families in the United States

    From: Journal of Medical Internet Research

    Date Submitted: Apr 3, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: Conflicts around the world have resulted in a record high number of refugees. Family separation is a critical factor that impacts refugee mental health. Thus, it is important to explore refugees’ ability to maintain contact with family members across the globe and the ways in which they attempt to do so. It is increasingly common for refugees to use Information and Communication Technologies (ICTs), which include mobile phones, the internet, and social media sites like Facebook, Whatsapp, Skype, and Viber, for these purposes. Objective: With uses and gratification theory as a framework, this study explores refugees’ perceptions of the impact of communication through ICTs on their mental health and logistical issues that affect their access to ICTs in the United States. Methods: We used a constructivist grounded theory approach to analyze in-depth interviews of 290 adult refugee participants from different countries. Results: Analyses showed that communication through ICTs had differing impacts on the mental health of refugee participants. ICTs, as channels of communication between separated families, were a major source of emotional and mental well-being for a large number of refugee participants. However, some participants relayed that the communication process with separated family members through digital technology was mentally and emotionally difficult. Several participants noted logistical and financial barriers in communicating with their families through ICTs. Conclusions: These findings are important in elucidating aspects of user agency and environmental constraints in uses and gratification theory, and in providing insight for researchers and practitioners involved in efforts related to migration and mental health.

  • One-year outcomes of a therapist-supported, smartphone-based intervention for elevated symptoms of depression and anxiety

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 5, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: Depression is one of the most common mental health disorders and severely impacts physical, psychological and social functioning. To address access barriers to care, we developed Ascend - a smartphone-delivered, therapist-supported, 8-week intervention based on several evidence-based psychological treatments for depression and anxiety. Objective: A feasibility study reported that Ascend is associated with a post-intervention reduction in depression symptoms among 102 adults with elevated depression. Here, we examined whether Ascend is also associated with a reduction in symptoms of anxiety, and critically, whether reductions in symptoms of depression and anxiety are maintained up to 12 months post-intervention. Methods: We examined whether the previously-reported, end-of-treatment improvements among 102 adults with elevated symptoms of depression extended up to 12 months post-treatment for depression symptoms (measured by the Patient Health Questionnaire [PHQ-9]), and up to 6 months post-treatment for anxiety symptoms (added to the intervention later, and measured by the Generalized Anxiety Disorder scale [GAD-7]). We used linear mixed effects models with Tukey contrasts to compare time-points, and report intention-to-treat statistics with a sensitivity analysis. Results: The intervention was associated with reductions in symptoms of depression that were maintained 12 months after the program (6.67 reduction in PHQ-9, 95% CI 5.59 to 7.75, P < 0.001; Hedges’ g = 1.14 [0.78 to 1.49]). 60% of participants with PHQ-9 scores above the cut-off for major depression at baseline (PHQ ≥ 10) reported clinically significant improvement at 12-month follow-up (at least 50% reduction in PHQ-9 score and post-program score < 10). Participants also reported reductions in symptoms of anxiety that were maintained for at least 6 months after the program (4.26 reduction in GAD-7, 95% CI 3.14 to 5.38, P < 0.001; Hedges’ g = 0.91 [0.54 to 1.28]). Conclusions: There is limited evidence regarding whether outcomes associated with smartphone-based interventions for common mental health problems are maintained post-treatment. Participants enrolled in Ascend experienced clinically significant reductions in symptoms of depression and anxiety that were maintained for up to one year after the intervention. Future randomized trials are warranted to test Ascend as a scalable solution to the treatment of depression and/or anxiety.

  • Click by Click Molecular Docking for non-bioinformaticians using Chimera 1.12

    From: JMIR Bioinformatics and Biotechnology

    Date Submitted: Apr 3, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    In the field of drug discovery, many methods of molecular modeling have been employed to study the complex biological and chemical systems. Experimental strategies are integrated with computational approaches in the identification, characterization and development of novel drugs and compounds. Molecular Docking is the approach in the modern drug design that explores the confirmation of ligand within the binding site of the macromolecule. To date many software’s and tools for Docking have been employed. AutoDock Vina (in UCSF Chimera) is one of the computationally fast and accurate software employed in Docking. In this paper, a sequential demonstration of molecular Docking of ligand Fisetin with the target protein Akt has been provided, using AutoDock Vina in UCSF Chimera 1.12. The first step involves the target protein ID retrieval from PDB, the second step is to visualize the structure of protein in UCSF Chimera, the third step is to prepare the target protein for Docking, the fourth step is preparing the ligand for docking, the fifth step is the Docking of ligand and the target protein as Mol.2 files in Chimera using AutoDock Vina and the final step is the interpretation and analysis of Docking results. By following the guidelines and the steps used in this paper, the researchers who have no previous background in bioinformatics research can perform computational Docking in a more user-friendly and easy manner.

  • Assessing mobile phone digital literacy and engagement in user-centered design in a diverse, safety-net population

    From: Journal of Medical Internet Research

    Date Submitted: Apr 5, 2019
    Open Peer Review Period: Apr 8, 2019 - Jun 3, 2019

    Background: Healthcare systems are rapidly deploying digital tools with the goal of improving chronic disease management, yet few studies evaluate their usability by vulnerable populations. To understand barriers to lower rates of app use among vulnerable populations, we employed user-centered design (UCD) methods in the development of a new text messaging app. Objective: We describe variations in engagement in design process, focusing specifically on limited health literacy (LHL), limited English proficiency (LEP), and limited digital literacy (LDL). Methods: We conducted 20 in-depth semi-structured interviews with primary care patients at a public healthcare system in San Francisco. We used open-ended discussions and cardsorting tasks to seek input about mobile phones and text messaging. We used open coding to categorize patterns of mobile phone use and to evaluate engagement in the cardsorting process. We examined qualitative differences in engagement by examining the extensiveness of participant feedback on existing and novel text messaging content. We calculated the proportion of patients providing extensive feedback on existing and novel content, overall and by health literacy, English proficiency, and digital literacy. Results: Participants were 59 (+/-8) years old; 65% were female, 90% were non-white, 80% had LHL, 65% had LEP. All had depression and 70% had diabetes. Most participants had smartphones (18/20) and regularly used text messaging (15/20), but 70% reported having difficulty, such as inability to type, physical disability, and low literacy. We identified 10 participants as specifically having LDL; 7 of these participants had LEP and all 10 had LHL. Half of participants required a modification of the cardsorting activity due to not understanding it or not being able to read the cards in the allotted time. The proportion of participants who gave extensive feedback on existing content was lower in participants with limited versus adequate English proficiency (30% vs 70%), limited versus adequate health literacy (44% vs 75%), and limited versus adequate digital literacy (40% vs 60%); none of these differences were statistically significant. When examining the proportion of patients who gave extensive feedback for novel messaging content, those with LHL were less engaged than those with adequate health literacy (50% vs 100%); there were no statistical differences by any subgroup. Conclusions: Despite widespread mobile phone use, digital literacy barriers are common among vulnerable populations. Engagement in the cardsorting activity varied among participants, and appeared to lower among those with LHL, LEP, and LDL. This suggests that researchers employing traditional UCD methods should routinely measure these communication domains among their end user samples. Future work is needed to replicate our findings in larger samples, but augmentation of cardsorting with direct observation and audiovisual cues may be more productive in eliciting feedback for those with communication barriers.

  • Your Patient Has a New Health App? Start with its Data Source

    From: Journal of Participatory Medicine

    Date Submitted: Apr 5, 2019
    Open Peer Review Period: Apr 7, 2019 - Jun 2, 2019

    Recent regulatory and technological advances have enabled a new era of health apps, which are controlled by patients and contain valuable health information. These health apps will be numerous and use novel interfaces that appeal to patients, but will likely be unfamiliar to practitioners. We posit that understanding the origin of the health data is the most meaningful and versatile way for physicians to understand and effectively use these apps in patient care. This will allow providers to better support patients and encourage patient engagement in their own care.

  • Usage and Acceptability of the ibobbly app: A pilot trial for suicide prevention in Aboriginal and Torres Strait Islander youth.

    From: JMIR Mental Health

    Date Submitted: Apr 6, 2019
    Open Peer Review Period: Apr 6, 2019 - Jun 1, 2019

    The proliferation of mental health apps purporting to target and improve psychological wellbeing is ever-growing yet also concerning: few apps have been rigorously evaluated and the safety of most of them has not been determined. Over 10000 self-help apps exist but the majority are not used much after being downloaded. Gathering and analysing usage data and the acceptability of apps is critical to inform consumers, researchers and app developers. This paper presents pilot usage and acceptability data from the ibobbly suicide prevention app, an app distributed through a randomised controlled trial. Aboriginal and Torres Strait Islander participants from the Kimberley region of Western Australia completed a survey measuring their technology use in general (n=13) and data on their experiences and views of the ibobbly app were also collected in semi-structured interviews (n=13) and thematically analysed. Finally, engagement with the app, such as the number of completed sessions and time spent on various acceptance-based therapeutic activities were analysed (n=18). Regression analysis indicate that app use improved psychological outcomes although only minimally and effects were not significant. However, results of the thematic analysis indicate that the ibobbly app was deemed effective, acceptable and culturally appropriate by those interviewed.

  • New Mobile App Increases Well-Being and Reduces Stress in Working Women Compared to an Active Control App: a Randomized Controlled Trial

    From: Journal of Medical Internet Research

    Date Submitted: Apr 5, 2019
    Open Peer Review Period: Apr 5, 2019 - May 31, 2019

    Background: Background: Although the availability and use of mobile mental-health apps has grown exponentially in recent years, little data are available regarding their efficacy. Objective: Objective: To evaluate the effectiveness of an app developed to promote stress management and well-being among working women compared with a control app. Methods: Methods: Female employees at a private hospital were invited to participate in the study via mailing lists and intranet ads. A total of 653 individuals self-enrolled through the website. Eligible participants were randomized between Control (n = 240) and Intervention (n = 250) groups. The well-being mobile app provides an 8-week program with 4 classes per week (including a brief theoretical portion and a 15-minute guided practice). The active-control app also provided 4 assessments per week that encouraged participants to observe their mental disposition. We also used the app to conduct online questionnaires (PSS-10 and WHO-5) and ask specific questions before, during and after the intervention to assess subjective levels of stress and well-being at those time-points. Both applications were fully automated without any human involvement. Outcomes from the control and intervention conditions at the three time-points were analysed using a Repeated Measures Analysis of Variance (ANOVA). Results: Results: Among the randomized participants (n = 490), 185 participants were excluded at the 4-week follow-up and another 79 at the 8-week follow-up due to noncompliance with the experimental protocol. Participants who did not complete t4 and t8 assessments were equally distributed between groups [t4: CG = 34.6% and IG = 40.8%; P = .156; t8: CG = 29,9% and IG = 21,6%; P = .098]. Both groups showed a significant increase in general well-being as a function of time [F(2, 426) = 5.27, P = .006], but only the intervention group presented a significant increase in work-related well-being [F(2, 426) = 8.92, P < .001], as well as a significant reduction in work-related and overall stress [F(2, 426) = 5.50, P = .004 and F(2, 426) = 8.59, P < .001, respectively]. Conclusions: Conclusion: The well-being mobile app was effective in reducing employee stress and improving well-being. Clinical Trial: Trial Registration: ClinicalTrials.gov NCT02637414

  • A Pilot Study to Assess the Compliance and Impact on Weight of Kurbo, a Pediatric Centered Weight Loss App

    From: JMIR Pediatrics and Parenting

    Date Submitted: Apr 2, 2019
    Open Peer Review Period: Apr 5, 2019 - May 31, 2019

    Background: The national prevalence of adolescent obesity has increased from 5% to 21% over the last five decades. Lifestyle modification continues to be the cornerstone of treatment for obesity and its comorbidities, and a number of digital tools have been developed as adjuncts to foster weight and BMI decrease. Apps targeting the pediatric population are few and none to date have been validated with scientific studies assessing their feasibility and outcomes. Objective: The purpose of this pilot study is to establish compliance and feasibility of Kurbo, a pediatric-centered weight loss app, as an adjunct to our pediatric weight management clinic. Methods: Kurbo utilizes games and activities to educate children about healthy eating and exercise. Kurbo also includes the option of personalized weekly feedback with a learning coach that covers basic nutrition education, behavior modification tools, and action plans to reach weekly food and exercise goals. Subjects were primarily English speaking, aged 10 through 17 years old, with regular access to a smart device, and who were seen at Baystate Children’s Hospital outpatient weight management clinic. Participants were randomized to receive the Kurbo app or Kurbo plus a learning coach in addition to standard of care. Subjects were seen monthly by the dietitian or physician, where BMI was determined, and questionnaires assessing use of the app were answered. Results: Twenty-seven subjects were enrolled; 13 in the Kurbo group and 14 in the Kurbo plus learning coach group. Compliance overall was poor, with only 15% of subjects completing the required follow-up visits and approximately 7% and 4% of subjects self-reporting > 75% compliance with food or exercise tracking, respectively. A small increase in compliance was noted in app collected versus self-reported data. Conclusions: Future studies might look into enrolling more motivated patients who might utilize the app more and have better outcomes. Clinical Trial: ClinicalTrials.gov NCT02880254; https://clinicaltrials.gov/ct2/show/NCT02880254 (Archived by WebCite® at http://www.webcitation.org/74jU3ATSJ)

  • Background: Telemedical approaches can contribute to the stabilization of rehabilitation success regardless of location and time. Objective: Aim of the study was to investigate a specific three-month interactive telemedical movement therapy with regard to effectiveness in function and return to work compared to usual aftercare. Methods: From 08/2016 to 12/2017, 111 patients (54.9±6.8 years, 54.3% female) with hip or knee replacement were enrolled in the randomized controlled trial. At discharge from inpatient rehabilitation and after three months, the distance in the 6-minute-walk-test was assessed as the primary endpoint. Other functional parameters, health related quality of life, pain and return to work were secondary endpoints. Results: Patients of the intervention group performed telerehabilitation 55.0±9.2 min per week. The adherence was high with over 75% until the 7th week of the 3-month intervention phase. Almost all of the patients and therapists used the communication offers. Both groups increased the distance in the 6-minute-walk-test (intervention group Δ88.3±57.7m, control group Δ79.6±48.7m, p=0.951). Improvements in other functional parameters as well as in quality of life and pain were achieved in both groups. The higher proportion of working patients in the intervention group is of particular note (64.6% vs. 46.2%, p=0.014). Conclusions: The effect of the investigated telerehabilitation in patients after knee or hip replacement was equivalent to usual aftercare in terms of functional testing, quality of life and pain. Since a significantly higher return to work rate could be achieved, this therapy seems to be a promising supplement to established aftercare. Clinical Trial: The study was registered in the German Register of Clinical Trials (ID DRKS00010009)

  • Do the effects of a self-guided Internet-based intervention for depression wear off when repeated? Results of a randomized-controlled trial (RCT)

    From: Journal of Medical Internet Research

    Date Submitted: Apr 2, 2019
    Open Peer Review Period: Apr 5, 2019 - May 31, 2019

    Background: Self-guided Internet-based interventions have several advantages over guided interventions and generally are effective in treating psychiatric symptoms. Objective: We investigated whether the use of a new self-guided Internet-based intervention (MOOD) would lead to a significant reduction in depressive symptoms compared to a care-as-usual (CAU) control group in a sample of individuals with depressive symptoms, most of whom had already used a different self-guided Internet-based intervention in a previous trial. Methods: A total of 125 individuals were randomized to the intervention condition (MOOD) and received access to the intervention for a period of six weeks or to a CAU group. After six weeks, all participants were invited to take part in the post assessment. The Beck Depression Inventory-II (BDI-II) served as the primary outcome. Results: Both intention-to-treat as well as per-protocol analyses indicated that the depressive symptomatology decreased in both conditions but showed no advantage for those who had used MOOD. Subsequent moderation analyses suggested that those individuals who had less experience with psychotherapy benefitted to a greater extent compared to those with more experience. Conclusions: Self-guided Internet-based interventions are deemed a suitable first-step approach to the treatment of depression. Yet, our results indicate that they are more efficacious in those with less psychotherapy experience. Clinical Trial: ClinicalTrials. gov NCT03795480, https://clinicaltrials.gov/ct2/show/NCT03795480

  • Health-Related Internet Use among Men with Prostate Cancer in Canada: A Cancer Registry Population Survey

    From: Journal of Medical Internet Research

    Date Submitted: Apr 2, 2019
    Open Peer Review Period: Apr 5, 2019 - May 31, 2019

    Background: After a prostate cancer diagnosis, men want information about their disease and treatment options. The Internet offers a convenient means to deliver health information to prostate cancer patients. However, there are concerns about the use of the Internet among this largely senior population. Objective: To determine the patterns and factors associated with the use of the Internet as a source of health information among Canadian men with prostate cancer and the information and features wanted in a website. Methods: Population surveys were conducted in four Canadian provinces in 2014-15. Data analyses included descriptive, bivariable and multivariable analyses. Pearson’s chi square and univariable regression were used to examine associations between independent variables and health-related Internet use. Factors associated with health-related Internet use were analyzed using multivariable logistic regression. Results: 1362 patients responded across provinces. Mean age of respondents was 69 years (SD=8.2). 82% (n=1071) were Internet users and 71% (n=910) used the Internet daily. 65% (n=784) used the Internet as a source of prostate cancer information, and 40% (n=521) were confident using Internet information to make health decisions. Men who used the Internet for prostate cancer information were more likely to be active information seekers (OR 4.6, 95% CI 2.6-8.3), to be confident using information from the Internet to make health decisions (OR 3.6, 95% CI 2.3-5.6), to have broadband Internet (OR 1.8, 95% CI 1.2-2.7), and to have more unmet supportive care needs (OR 1.05, 95%CI 1.0-1.1). Top features wanted in a website, reported by more than 50% of respondents were: a library (n=893;63%), tools to support treatment decision making (n=815;58%) and tools to help navigate the prostate cancer journey (n=698; 50%). Top three topics of information wanted in such a website were: treatment options (n=916; 65%), disease progression (n=904; 64%) and how to manage side effects (n=858; 61%) Conclusions: Over two-thirds of Canadian prostate cancer patients surveyed use the Internet as a source of health information about prostate cancer, but over half did not feel confident in using information from the Internet to make health decisions. Being an active information seeker, having confidence in using information from the Internet to make health decisions, having broadband Internet, and having more unmet supportive care needs were significantly associated with health-related Internet use. Future work should examine eHealth literacy interventions as a means to boost men’s confidence in using information from the Internet, and design websites that include information and features that help men navigate the prostate cancer journey and support treatment decision making and management of side effects.

  • Cultural Safety in Indigenous Research: Wise Practices for e-Health RCTs from the DREAM-GLOBAL Evaluation

    From: Journal of Medical Internet Research

    Date Submitted: Apr 1, 2019
    Open Peer Review Period: Apr 5, 2019 - May 31, 2019

    Background: There is a paucity of controlled clinical trial data based on research with Indigenous peoples. A lack of data specific to Indigenous peoples, will mean that new therapeutic methods such as those involving eHealth will be extrapolated to these groups based on research with other populations. Appropriate, ethical, and culturally safe research can be undertaken with Indigenous communities but requires attention to good research practices. Literature on how to involve Indigenous people in the development and evaluation of eHealth /mHealth applications in order to respond to the needs of Indigenous patients, providers and communities is still scarce, although the need for community-based participatory research (CBPR) to develop culturally safe technologies is emerging as an essential focus in Indigenous eHealth research. To be effective, researchers must first gain an in-depth understanding of Indigenous determinants of health including the harmful consequences of colonialism. Second, researchers need to learn how colonialism affects the research process. The challenge then for eHealth researchers is to braid Indigenous ethical values with the requirements of good research methodologies into a culturally safe research protocol. Objective: A recent systematic review showed that Indigenous people are underrepresented in randomized controlled trials (RCTs), primarily due to a lack of attention to providing space for Indigenous perspectives within the study frameworks of RCTs. Given the lack of guidelines for conducting RCTs with Indigenous communities, we conducted an analysis of our large evaluation data set collected in the DREAM-GLOBAL trial. With over five years engaging with Indigenous communities, our goal from this analysis is to identify wise practices for culturally safe, collaborative eHealth and RCT research with Indigenous communities. Methods: We thematically analyzed survey responses and qualitative interview/focus group data that we collected over 5 years in six Indigenous communities in Canada during the evaluation of the clinical trial DREAM-GLOBAL. We established themes that reflect culturally safe approaches to research and then developed wise practices for culturally safe research in pragmatic eHealth research. Results: Based on our analysis, successful eHealth research in collaboration with Indigenous communities requires a focus on cultural safety during (1) building and (2) maintaining a respectful research relationship, (3) communication and support, (4) co-design of the innovation, (5) task-shifting. Finally, we recognized that reflecting on mistakes and lessons learned or areas for improvement supports learning and cultural safety. Conclusions: Based on evaluation data collected over 5 years of the DREAM-GLOBAL RCT, we found that there are important cultural safety considerations in Indigenous eHealth Research. Building on the perspectives of Indigenous staff and patients we gleaned wise practices for RCTs in Indigenous communities. Clinical Trial: ClinicalTrials.gov NCT02111226; https://clinicaltrials.gov/ct2/show/NCT02111226 (Archived by WebCite at http://www.webcitation.org/6oxfHXege)

  • Acceptability of Self-regulation Theory based mHealth Behaviorial Intervention for Older Adults with Type 2 Diabetes and Obesity

    From: JMIR Diabetes

    Date Submitted: Apr 1, 2019
    Open Peer Review Period: Apr 5, 2019 - May 31, 2019

    Background: Mobile health (mHealth) is routinely used in younger adults with diabetes for weight loss. However, it is not known if older adult can use mHealth successfully in making lifestyle changes. Objective: The aim of the study was to examine the acceptability of a self-regulation theory-based mHealth behaviorial intervention for older adults with type 2 diabetes and obesity. Methods: This was a one-group intervention study. Participants received an 8-week self-regulation theory-based intervention consisting of 5 group sessions. They also used the Lose It! App for daily self-monitoring of food intake, a Fitbit, Bluetooth-enabled glucose meters, and weighing scales. At the end of the 8-week intervention, participants were asked to continue use of these devices for daily self-monitoring for 4 more weeks, without additional group sessions. Results: The sample (N=9) was White (88.9%) and female (44.4%), with mean 76.4±6.0 years of age (range: 69-89), 15.7±2.0 years of education, 33.3±3.1 kg/m2 for BMI and 7.4%±0.8 for HbA1c. Mild cognitive impairment was observed in 44.4% of sample. Over the 84 days of self-monitoring, the mean % days of using the Lose It!, Fitbit, blood glucose meter, and scale were 82.7±17.6, 85.2±19.7, 65.3±30.1, and 53.0±34.5, respectively. The mean percent weight loss from baseline was 4.92%±0.25. The dose of oral hypoglycemic agents or insulin was reduced in 55.6% of participants. Conclusions: Older adults are able to use mHealth to improve their lifestyle behaviors and clinical outcomes. Clinical Trial: NCT03398590

  • Patient Recommendations to Improve Implementation and Engagement with Portals in Acute Care: a hospital-based, mixed-methods study

    From: Journal of Medical Internet Research

    Date Submitted: Apr 2, 2019
    Open Peer Review Period: Apr 5, 2019 - May 31, 2019

    Background: Inpatient implementation of portals to the Electronic Health Record lags behind outpatient settings and the literature on patient preferences for engagement with portals in the hospital is limited. Objective: We sought to understand patient-reported barriers and facilitators to engagement during an episode of acute care using mixed methods with a large, diverse sample of hospitalized patients. Methods: We utilized a mixed-methods approach to explore patient experiences using the portal during hospitalization. All patients received a tablet with brief tutorial, pre/post-use surveys, and completed in-person, semi-structured interviews. Qualitative data were coded using thematic analysis to iteratively develop 18 codes which were integrated into 3 themes framed as patient recommendations to hospitals to improve engagement with the portal during acute care. Themes from this qualitative data guided our approach to analysis of quantitative data. Results: We enrolled 97 participants: 53 (55%) women, 44 (45%) non-white, average age 48 (19-81), average length of hospitalization was 6.4 days. Forty-seven (48%) had an active portal account, 59 (57%) owned a smartphone, and 79 (81%) accessed the internet daily. Three overarching themes emerged from qualitative analysis of interviews with these patients during their hospital stay: 1) Hospitals should provide both access to a device and Bring-Your-Own-Device (BYOD) platform to access the portal; 2) Hospitals should provide an orientation both on how to use the device and how to use the portal; 3) Hospitals should ensure portal content is up-to-date and easy to understand. Conclusions: Patients independently and consistently identified basic needs for device and portal access, education, and usability. Hospitals should prioritize these areas to enable successful implementation of inpatient portals to promote greater patient engagement during acute care. Clinical Trial: NCT01970852

  • Can Digital Access Reduce Cognitive Decline: Longitudinal Evidence from Chinese Mid-aged and Elderly Population

    From: Journal of Medical Internet Research

    Date Submitted: Mar 30, 2019
    Open Peer Review Period: Apr 3, 2019 - May 29, 2019

    Background: Cognitive decline is a major risk factor for disability and death, and may serve as a precursor of dementia. Digital device can provide a platform of cognitively stimulating activities which might help to slow cognitive decline in the process of normal aging. Objective: This longitudinal study aimed to examine the independent protective factors of desktop and cellphone ownership against cognitive decline in mid-life and older adulthood and to examine the combined effect of desktop and cellphone ownership on the same outcome. Methods: Data from China Health and Retirement Longitudinal Studies cohort with 13457 community-dwelling adults aged 45 years or above in 2011-2012, followed for 4 years, with baseline measurement and two two-year follow-ups. Cognitive function was tested in baseline and two follow-up visits. A global cognition z-score was calculated based on two domains: word recall, mental intactness. The key independent variables were defined as whether one had desktops with internet connection at home and whether one had a cellphone. A additional categorical variable of three values was constructed as 0 (no desktop or cellphone), 1 (desktop or cellphone alone), and 2 (desktop and cellphone both). Mixed-effects regression was adjusted for demographic and health behavior as well as health condition risk factors. Results: Adjusted for demographic and health behavior as well as health condition risk factors, desktop/cellphone ownership were independently associated with decreased subsequent cognitive decline over the four-year period. Participants without desktop at home had adjusted cognitive decline of -0.16 (95% CI -0.18 to -0.15) standard deviations, while participants with desktop at home had adjusted cognitive decline of -0.10 (95% CI -0.14 to -0.07) standard deviations (difference of -0.06 standard deviations, p = .003). A similar pattern of significantly protective association of 0.06 (95% CI 0.03 to 0.10, p < .001) standard deviations between cellphone ownership and cognitive function was observed over the four-year period. Additionally, a larger longitudinal protective association on cognitive decline was observed among those with multiple digital devices, although the 95% CIs for the coefficients overlapped with those with single digital device alone. Conclusions: Findings from this study underscored the importance of digital devices as platforms for cognitively stimulating activities to delay the cognitive decline. Future studies focusing on use of digital devices are warranted to investigate their longitudinal protective factors against cognitive decline at mid- and later life. Clinical Trial: Digital Access

  • Stress among resident doctors in Jordanian teaching hospitals

    From: JMIR Public Health and Surveillance

    Date Submitted: Apr 2, 2019
    Open Peer Review Period: Apr 2, 2019 - May 28, 2019

    Background: Residents doctors in Jordanian hospitals are involved in many clinical and non-clinical tasks that might expose them to various stress factors. High stress and burnout have the potential to negatively impact upon work performance and patient care, including medication errors, suboptimal care, clinical errors and patient dissatisfaction. Objective: This study aimed to determine the perceived stress among resident doctors in Jordanian hospitals and its associated risk factors Methods: : A cross-sectional study was conducted among residents in Jordanian hospitals. A cluster sample of five hospitals with residency programs was selected from different health sectors. All residents who were working in the selected hospitals were invited to participate in this study during the period April- July 2017. A total of 555 residents (response rate was 84 %) agreed to participate in this study. The perceived stress scale (PSS) was used for assessment. Results: A total of 398 male and 157 female residents were included in this study. The mean PSS score in this study was 21.6. About 6.7% of the residents had hypertension, 2.7% had diabetes, 3.2% had heart-diseases, and 8.5% were anemic. The majority of respondents complained of back pain 42%, and 29% complained of insomnia. Stress was associated with higher workload, sleep deprivation, and dissatisfaction with the relationships with colleagues, income and the program. In multivariate analysis, the following were significantly associated with stress: female gender, dissatisfaction with working environment, and facing work-related stressors. Conclusions: The majority of resident doctors in Jordanian hospitals suffer from stress. Stress management programs during residency and improving working environment are strongly recommended.

  • Capturing at-home health and care information for Children with Medical Complexity using voice-interactive technologies

    From: Journal of Medical Internet Research

    Date Submitted: Mar 29, 2019
    Open Peer Review Period: Apr 1, 2019 - May 27, 2019

    Digital health tools and technologies continue transforming the healthcare system. However, there is a recognition of the unmet needs on health information capture and care coordination at home for children with medical complexity (CMC). Typically, families of CMC spend significant amounts of time not only providing hands-on medical care within the home setting but also coordinating activities among multiple providers and caregivers. Here, a multidisciplinary team of stakeholders discusses the value of health information generated at home, how technologies can facilitate care coordination, and challenges of technology adoption from a patient-centered perspective. This team has identified voice interactive technologies to potentially transform care coordination for CMC. Furthermore, it provides recommendations on how to leverage them for the targeted patient population.

  • How remote, smart, and precise healthcare can be met through connected health? A qualitative study.

    From: Journal of Medical Internet Research

    Date Submitted: Mar 29, 2019
    Open Peer Review Period: Apr 1, 2019 - May 27, 2019

    Background: As our society is progressively ageing and the impact of this is felt worldwide, research into connected health (CH) is becoming essential. CH is accelerating future healthcare to be more proactive, preventive, and targeted. Not only has great value been shown in the management of chronic diseases (CDs), but tremendous progress is also demonstrated in applications preventing CDs which create a huge burden to society. CD is a promising solution to ageing-associated disease and societal challenges, although barriers still need to be overcome. Objective: To identify how healthcare can be managed in more comprehensive ways: remote, smart, and precise. Methods: A qualitative approach was used based on 60 multi-stage, semi-structured stakeholder interviews to explore the unknown and obtain insights. Results: The interviews enabled the authors to develop a stakeholder classification and interaction diagram. These stakeholders sequentially interacted to provide technology-based content to end-users. Three innovation strategies [12] are discussed to reflect the manner in which remote, smart, and precise healthcare can be met through the CH platform. Conclusions: The findings indicated that innovation strategies will be beneficial to leverage the required resources for the implementation of CH. Moreover, continually revisiting business models is essential, given the ongoing technology changes across CH stakeholder groupings. Trends toward remote, smart, and precise healthcare shape what individuals expect from products and services, providing firms unique opportunities for growth. As long as suitable strategies are applied to reflect how people perceive the world around them, these will inspire implementations for strategic success.

  • Internet-based HIV self-testing program to increase HIV testing uptake for men who have sex with men in Brazil

    From: Journal of Medical Internet Research

    Date Submitted: Mar 27, 2019
    Open Peer Review Period: Apr 1, 2019 - May 27, 2019

    Background: Approximately 30% of people living with HIV worldwide are estimated to be unaware of their infection. HIV self-testing (HIVST) is a strategy recommended by the World Health Organization which increases access to and uptake of testing among key populations who are at high risk for HIV infection. Objective: To describe the development and feasibility of a free, anonymous, Internet-based HIV self-testing (HIVST) strategy designed for men who have sex with men (MSM) in Curitiba, Brazil (E-testing). Methods: The project was developed under the scope of the “A Hora é Agora” (Time is now) program. Individuals aiming to request an HIVST package (2 tests each) answered an anonymous 5-minute questionnaire regarding inclusion criteria and sexual risk behavior. Eligible individuals could receive one package every 6 months for free. Website analytics, response to online questionnaires, packages distribution, and return of test results were monitored via a platform-integrated system. Results: Between February 2015 and January 2016, the website documented 17,786 unique visitors with 3,218 provided complete answers to the online questionnaires. Most individuals self-reported being white (77%), young (median age was 25 years, interquartile range 22-31), educated (87.3% complete secondary education or more), and had previously tested for HIV (62.5%). Overall, 2,526 HIVST packages were delivered; of those, 542 (21.4%) reported a result online or by mail (23 reactive and 11 invalid). During the study period, 37 individuals reporting to have used E-testing visited the pre-specified health facility for confirmatory testing (30 positive; 7 negative). Conclusions: E-testing proved highly feasible and acceptable in this study, thus supporting scale-up to additional MSM population centers in Brazil.

  • The intervening role of mHealth apps in postpartum obesity and mental health

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 27, 2019
    Open Peer Review Period: Apr 1, 2019 - May 27, 2019

    Background: The development of mHealth (mobile health) has changed people’s routines of improving self-management. Nonetheless, the effectiveness of the apps depends on the frequency of use. Objective: This paper introduces a new framework of fitness apps associated with obesity modeling by using structural equation modeling (SEM) and examining data of postpartum women through moderation analysis. Fitness mHealth apps are considered the moderator in the research framework. Methods: Online questionnaires were sent to Malaysian postpartum women within one year after pregnancy and 468 completed questionnaires were returned. The frequency of mHealth fitness app use was categorized into four groups: daily, weekly, rarely and never. Therefore, four models were considered for the final analysis. Results: According to the output, every model has a different structure in terms of significance and coefficients. The R-squared obtained for the “daily” model (0.82) is the highest, followed by the “weekly” (0.79), “rarely” (0.66) and “never use” (0.59) models. This infers that 82% of mental health variation is related to the demographics, lifestyle, healthy and unhealthy food intake and BMI of daily fitness app users. In addition, the impact of BMI on mental health in every model is significant with a negative coefficient, which implies that users with high BMI have less mental health issues. Meanwhile, the factor loading analysis indicates that the screen time (0.89) and physical activity (0.81) indicators are the two highest coefficients in the lifestyle variable. This result is subsequently equivalent to the daily and weekly fitness app users who choose to consume more healthy food and thus have a lower BMI. Conclusions: This paper proves that Malaysian postpartum women who use fitness apps as part of their daily life are more disciplined and such applications have significant effects on obesity and mental health. However, for never or weekly users, the statistical analysis shows there is no proof of the effectiveness of self-management activities that affected on obesity and mental health. Therefore, the frequency of fitness app use acts as a moderator in postpartum obesity and mental health modeling.

  • Promoting Social Connection and Deepen Relations in Older People: Design of Media Parcels towards facilitating Time-based Media Sharing

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 29, 2019
    Open Peer Review Period: Apr 1, 2019 - May 27, 2019

    Background: Being socially connected is related to well-being in older age. The use of social media helps people to stay connected despite physical proximity. However, some older people are resistant to mainstream social networking technology which they see as shallow compared to face-to-face contact. Objective: In this paper, we report the design and evaluation of a novel social networking system called Media Parcels, specifically designed to deepen relationships over a fixed period within a small group of users. The system uses a time-based dialogue running on a network of smartphones or tablets, to elicit and re-distribute ‘media parcels’ in distinct phases between users. Methods: Two trials of the system in both the UK and Brazil were conducted with family and friendship groups respectively. Results: The findings show strong engagement with the system and positive social effects for both deepening and developing relationships over a short space of time. Conclusions: The Media Parcels system was an effective approach to promote media sharing of emotional content for the elderly population. Clinical Trial: It was not a clinical trial.

  • Why do data users say healthcare data is difficult to utilize? A cross-sectional survey study

    From: Journal of Medical Internet Research

    Date Submitted: Mar 28, 2019
    Open Peer Review Period: Apr 1, 2019 - May 27, 2019

    Background: There has been significant effort in attempting to utilize healthcare data; however, laws that protect patients’ privacy have restricted data utilization because healthcare data contains sensitive information. Thus, discussions on privacy laws are now focusing on the active utilization of healthcare data beyond protection. However, current literature does not clarify the obstacles that make data usage and de-identification processes difficult or elaborate on users’ needs for data linking from practical perspectives. Objective: The objective of this study is to investigate 1) the current status of data utilization by each medical area, 2) institutional efforts and difficulties in de-identification processes and, 3) users’ data linking needs. Methods: We conducted a cross-sectional online survey. In order to recruit people who have used healthcare data, we publicized the promotion campaign and sent official documents to an academic society encouraging participation in the online survey. Results: In total, 128 participants responded to the online survey, and 10 participants were excluded for either inconsistent responses or lack of demand for healthcare data. Finally, 118 participants’ responses were analyzed. The majority of participants work in general hospitals or universities (62/118, 52.5%; 51/118, 43.2% multiple). More than half of all participants responded that they have a need for clinical data (82/118, 69.5%) and public data (76/118, 64.4 %). Furthermore, 85.6% of respondents conducted de-identification measures when using data, and they considered rigid social culture as an obstacle for de-identification (28/101, 27.7%). In addition, they require data linking (98/118, 83.1%), and they noted deregulation and data standardization to allow access to healthcare data linking (33/98, 33.7%; 38/98, 38.8%). There are not significant differences in the proportion of responded data needs and linking in groups that used healthcare data for either data demand for public purposes and commercial purposes. Conclusions: This study provides a cross-sectional view from a practical, users-oriented perspective on the kinds of data users want to utilize, efforts and difficulties in de-identification processes, and the needs for data linking. Most users want to use clinical and public data; most participants conduct de-identification processes and express a desire to conduct data linking. Our study confirmed that they noted regulation as a primary obstacle whether their purpose is commercial or public. A legal system based on both data utilization and data protection needs is required.

  • PATHway-I: Feasibility, acceptability and clinical effectiveness of a technology enabled cardiac rehabilitation platform. A randomized controlled trial.

    From: Journal of Medical Internet Research

    Date Submitted: Apr 1, 2019
    Open Peer Review Period: Apr 1, 2019 - May 27, 2019

    Background: Cardiac rehabilitation (CR) is highly effective as secondary prevention for cardiovascular diseases (CVD). Uptake of CR remains suboptimal (30% of eligible patients) and long-term adherence to a physically active (PA) lifestyle is even lower. Innovative strategies are needed to counteract this phenomenon. Objective: We developed the PATHway system (Physical Activity Towards Health) to provide a comprehensive, remotely monitored home-based CR program for CVD patients. The PATHway-I study aimed to investigate its feasibility and clinical efficacy during phase III CR. Methods: Participants were randomized on a 1:1 basis to the PATHway intervention group (PW) or usual care control group (UC) in a Single-blind, multicenter, randomized controlled pilot trial. Outcomes were assessed at completion of phase II CR and six months follow-up. The primary outcome was PA (Actigraph GT9X link). Secondary outcomes included measures of physical fitness, modifiable cardiovascular risk factors, endothelial function, intima-media thickness of the common carotid artery and quality of life. System usability and patients' experiences were evaluated only in PW. A mixed-model ANOVA with Bonferroni adjustment was used to analyze between-group effects over time. Missing values were handled by means of an intention-to-treat analysis. Statistical significance was set at a two-sided alpha level of 0.05. Data are reported as mean ± SD. Results: A convenience sample of 120 CVD patients (61.4 ± 13.5 years, 22 women) was included. The PATHway system was deployed in the homes of 60 participants. System use decreased over time and system usability was average with a score of 65.7 ± 19.7 (range 5-100). Moderate to vigorous intensity PA increased in PW (PW: 127 ± 58 min to 141 ± 69 min, UC: 146 ± 66 min to 143 ± 71 min; p-interaction=0.039), while diastolic blood pressure (PW: 79 ± 11 to 79 ± 10 mmHg, UC: 78 ± 9 to 83 ± 10 mmHg; p-interaction=0.004) and cardiovascular risk score remained constant, but deteriorated in UC (PW: 15.9 ± 10.4 to 15.5 ± 10.5%, UC: 14.5 ± 9.7 to 15.7 ± 10.9%; p-interaction=0.004). Conclusions: This pilot study demonstrated the feasibility and acceptability of a technology-enabled, remotely monitored, home-based CR program. Although clinical effectiveness was demonstrated, several challenges were identified that could influence adoption of PATHway. Clinical Trial: This trial was registered at www.clinicaltrials.gov: NCT02717806

  • Barriers and Facilitators to the Implementation of eHealth Services: A Systematic Literature Analysis

    From: Journal of Medical Internet Research

    Date Submitted: Mar 29, 2019
    Open Peer Review Period: Mar 31, 2019 - May 26, 2019

    Background: The field of eHealth has a history of more than twenty years. During that time many different eHealth services were developed. Factors influencing the adoption of such services were, however, seldomly the main focus of analyses. For this reason, organizations adopting and implementing eHealth services seem not to be fully aware of barriers and facilitators influencing the integration of eHealth services into routine care. Objective: The objective of this work is twofold (a) to provide a comprehensive list of relevant barriers to be considered, and (b) a list of facilitators or success factors to help in planning and implementing successful eHealth services. Methods: For this study a twofold approach was applied. On the one hand, we gathered experts’ current opinions on facilitators and barriers in implementing eHealth services via expert discussions at two health informatics conferences held in Europe. On the other hand, we conducted a systematic literature analysis concerning the barriers and facilitators for the implementation of eHealth services. Finally, we merged the results of the expert discussions with the ones of the systematic literature analysis. Results: Both expert discussions identified 15 barriers and 31 facilitators, whereas 76 barriers and 268 facilitators were found in 38 articles published from twelve different countries. The combination of both sources resulted in 77 barriers and 292 facilitators for the adoption and implementation of eHealth services. Conclusions: This work contributes a comprehensive list of barriers and facilitators for the implementation and adoption of eHealth services. Addressing barriers early and leveraging facilitators during the implementation can help creating eHealth services that better meet the needs of its users and provide higher benefits for patients and caregivers. Clinical Trial: No trial has been performed.

  • Design and validation of a software for the diagnosis of sarcopenia in community-dwelling elders

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 26, 2019
    Open Peer Review Period: Mar 29, 2019 - May 24, 2019

    Background: The usual diagnosis of sarcopenia requires a Dual-Energy X-Ray Absorptiometry (DXA) exam, whose accessibility in primary care is scarce in Latin American countries. Objective: To design and validate a software for mobile devices (Android, IOS) and computer-based on an adapted version of the diagnostic algorithm of sarcopenia proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). Methods: The follow-up of 430 community-dwelling Chilean participants 60 years and older was conducted; these individuals were beneficiaries of public health centers (mean±SD: 68.2±4.9years) and were included in the HTSMayor and Alexandros cohorts designed to study sarcopenia. The software was designed according to an adapted version of the algorithm proposed by the EWGSOP and was divided into four phases: longitudinal validation of diagnostic algorithm of sarcopenia, alpha version, beta version and release version. The software estimates appendicular muscle mass (ASM) using an anthropometric equation or DXA measurements with Chilean cut-off points. The predictive validation of the algorithm was estimated, comparing functional limitations (one activity of daily living; and/or two instrumental activities of daily living, and/or three mobility limitations) and falls at follow-up in non-sarcopenic and sarcopenic subjects at baseline, using logistic models. Results: After 2078.42 person-years of 4.82 years (median) of follow-up, 37 new cases of sarcopenia (10% approximately) were identified (incidence density rate=1.78 per 100 persons-years). ASM estimated with the anthropometric equation showed a high sensitivity and specificity compared with those estimated by DXA measurements, yielding a concordance of 0.933. The diagnostic algorithm of sarcopenia considered in the software with the equation showed a high sensitivity (81.3%) and specificity (95.1%) when compared with DXA (reference standard). Non-sarcopenic subjects (in baseline) showed better physical performance (after approximately 5 years) than sarcopenic adults. Loss of functionality is greater in sarcopenic adults (adjusted OR=5.6) than in non-sarcopenic adults. Similar results were observed in falls (adjusted OR=2.2) and osteoporosis (adjusted OR=2.8) is higher in persons with sarcopenia than robust adults. In beta and release test the measurements and results were completed in mean time of 10 and 11 minutes, respectively. Conclusions: We obtained a validated software for the diagnosis of sarcopenia in Chilean elders that can be used on a mobile device or a computer with a good sensitivity and specificity, thus allowing for the development of programs for the prevention, delay or reversal of this disease.

  • Using an electronic clinical-decision support system in primary care to assess inappropriate polypharmacy in the young-elderly with multimorbidity.

    From: Journal of Medical Internet Research

    Date Submitted: Mar 25, 2019
    Open Peer Review Period: Mar 29, 2019 - May 24, 2019

    Background: Multimorbidity is a global health problem that is usually associated with polypharmacy, which increases the risk of potentially inappropriate prescribing (PIP). PIP entails higher hospitalization rates, mortality, and usage of services provided by the health system. There are tools to improve prescription and decrease PIP, such as explicit criteria that can be applied in an automatized manner. Objective: The aim of this study was to describe the prevalence of PIP in primary care consultations in the population aged 65–75 years with multimorbidity and polypharmacy, detected by an electronic clinical-decision support system (ECDSS) following the 2015 criteria by the AGS Beers and the European Screening Tool of Older Person’s Prescription and Screening Tool to Alert doctors to the Right Treatment (STOPP/START). Methods: Observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 75 years, with multimorbidity (≥ 3 diseases) and polypharmacy (≥ 5 medications), who had visited their primary care doctor at least once over the last year at one of the 38 healthcare centers participating in the Multi-PAP trial. Socio-demographic data, clinical and pharmacological-treatment variables, and PIP, as detected by one ECDSS, were recorded. A multivariate logistic regression model with robust estimators was built to assess factors affecting PIP according to the STOPP criteria. Results: PIP was detected in 57.0% of patients according to the STOPP (338/593, CI 95%: 53–61) and 72.8% according to the Beers criteria (432/593, CI 95%: 69.3–76.4), whereas 42.8% met some of the START criteria (254/593, CI 95%: 38.9–46.8). The most frequently detected PIP using the STOPP version 2 was benzodiazepines intake for more than four weeks (217/593, 36.6%) and the prolonged use of a proton-pump inhibitors (269/593, 45.4%) with the Beers 2015. Being a woman (OR=1.43, CI 95%: 1.01–2.01; p=0.04), taking a greater number of medicines (OR=1.25, CI 95%: 1.14–1.37; p<0.001), working in the primary-sector (OR=1.91, CI 95%: 1.25–2.93; p=0.003), and being prescribed with drugs for the central nervous system (OR=3.75 CI 95%: 2.45-5.76; p<0.001) were related to a higher frequency of PIP. Conclusions: There is a high prevalence of PIP in primary care as detected by an ECDSS in community-dwelling young-elderly with comorbidity and polypharmacy. The specific PIP criteria defined by this study are consistent with the current literature. This ECDSS can be useful for supervising prescriptions in primary healthcare consultations. Clinical Trial: NCT02866799

  • “Spirits I have conjured no longer pay me heed.” Does health literacy induct a critical reading of physician reviews?

    From: Journal of Medical Internet Research

    Date Submitted: Mar 25, 2019
    Open Peer Review Period: Mar 29, 2019 - May 24, 2019

    Physician rating websites (PRWs) are an innovation born of the potentials of the Internet, but also boosted very much by the longstanding policy of improving and encouraging in patient participation in medical decision-making. A mismatch is feared between patients’ motivation to participate and the capabilities of doing so well, captured in the study by subjective and objective health literacy. PRWs are a device people are motivated to use both actively and passively, and in fact do, although their objective capabilities are insufficient, at least as far as their participation extends to judge the medical performance and qualification of physicians. An experiment was conducted that traced the moderating impact of health literacy on the effect of favorable and unfavorable worded appraisals of a physician’s medical competence on subsequent patient selection of a physician. Results show reviews of a physician’s competence and medical skill affected participants’ choice of a physician and their attitude to the physicians involved. Results disappoint hopes that persons with high objective health literacy will receive physician reviews with more distance, more critically and will be more loth to draw any conclusions for their own decisions.

  • Potential of Blockchain technology for Health Information Exchange (HIE): an experimental study from patients’ perspectives

    From: Journal of Medical Internet Research

    Date Submitted: Mar 28, 2019
    Open Peer Review Period: Mar 29, 2019 - May 24, 2019

    Background: Nowadays, a number of mechanisms and tools are being used by healthcare organizations and physicians to electronically exchange personal health information of patients. The main objectives of different methods of Health Information Exchange (HIE) are to reduce healthcare costs, minimize medical errors, and improve the coordination of inter-organizational information exchange transactions across healthcare entities. The main challenges associated with the common HIE systems is the privacy concerns, security risks, low visibility of system transparency, and lack of patient control. Blockchain technology, based on its special characteristics, is likely to disrupt the current information exchange models utilized in the healthcare industry. Objective: Little is also known about patients’ attitudes and perceptions toward the implementation of Blockchain-enabled HIE networks and it is still not clear if patients (as one of the main HIE stakeholders) are likely to opt-in to the applications of this technology in HIE initiatives. Thus, this study is aimed at exploring the core value of Blockchain technology in the healthcare industry from healthcare consumers. Methods: To recognize the potential applications of Blockchain technology in healthcare practices, we designed sixteen information exchange scenarios for controlled online experiments. Totally, 2013 respondents participated in the online experiments that described information exchange conditions characterized by four exchange mechanisms (i.e., direct, look-up, patient-centered, and Blockchain), two types of health information (i.e., sensitive vs. non-sensitive), and privacy policy transparency (weak vs. strong). Results: The findings show that there are significant differences in patients’ perceptions of various exchange mechanisms with regards to patient privacy concern, trust in competency and integrity, opt-in intention, and willingness to share information. Interestingly, participants hold favorable attitude toward Blockchain-based exchange mechanisms for privacy protection, coordination, and information exchange purposes. This study proposes the potentials and limitations of a Blockchain-based attempt in the HIE context. Conclusions: The results of this research should be of interest to both academics and practitioners. The findings propose potential limitations of a Blochchain-based HIE that should be addressed by healthcare organizations to exchange personal health information in a secure and private manner. This work can contribute to the research in the Blochchain area and enrich the literature on the use of Blockchain in HIE efforts. Practitioners can also identify how to leverage the benefit of Blochchain to promote HIE initiatives nationwide.

  • The Concordance Study between IBM Watson for Oncology and Multidisciplinary Team in Clinical Decision-making of Gastric Cancer and the Prognostic Implication

    From: Journal of Medical Internet Research

    Date Submitted: Mar 24, 2019
    Open Peer Review Period: Mar 27, 2019 - May 22, 2019

    Background: With the increasingly abundant of cancer treatment, the emergence of multidisciplinary team (MDT) will provide patients with personalized treatment options. In recent years, artificial intelligence has developed rapidly in the medical field. And there is a tendency to replace traditional diagnosis and treatment gradually. IBM Watson for Oncology (WFO) has been proven in breast cancer and lung cancer, but the research on gastric cancer is rarely so far. Objective: Compared the concordance of WFO with that of MDT, and we try to investigate the patients' prognosis between them. Methods: This study retrospectively analyzed the eligible cases (N=235) of MDT with gastric cancer who received the corresponding treatment and obtained follow-up. Then doctors input the information of all cases into WFO manually, and the results was compared with the treatment programs by MDT. If the treatment program of MDT is classified as “recommended” or “considered”, we define the results as concordant. All patients were divided into concordant group and non-concordant group according to whether the treatment program of WFO and MDT were concordant. The prognostic analysis of the two groups was analyzed. Results: The overall concordance of WFO and MDT was 54.5% (128/235) in all 235 cases included in the study. Subgroup analysis found that patients with human epidermal growth factor receptor 2 (HER2)-positive were less likely to be concordant than patients with HER2-negative (P=0.019). Age, Eastern Cooperative Oncology Group performance status, differentiation type and clinical stage was not found to affect concordance. In all patients, the survival time of concordant patients were significantly better than that of non-concordant patients (P<0.001). Multivariate analysis revealed that consistency was an independent prognostic factor of overall survival in patients with gastric cancer (HR=0.312, 95% CI: 0.187-0.521). Conclusions: Treatment recommendations made by WFO and MDT were mostly concordant for gastric cancer cases. If they can include the local treatment programs, the concordance will be significantly improved. The HER2 status of gastric cancer have a significant effect on concordance. Generally speaking, patients with concordant treatment programs had quite better survival than non-concordant patients.

  • SALT-C: Standardization Algorithm for Categorical Laboratory Tests for Clinical Big Data Research

    From: Journal of Medical Internet Research

    Date Submitted: Mar 24, 2019
    Open Peer Review Period: Mar 27, 2019 - May 22, 2019

    Background: Data standardization is essential in electronic health records (EHRs) for both clinical practice and retrospective research. However, it is still not easy to standardize EHR data because of nonidentical duplicates, typographical errors, or inconsistencies. To overcome this drawback, standardization efforts have been undertaken for collecting data in a standardized format as well as for curating the stored data in EHRs. To perform clinical big data research, the stored data in EHR should be standardized, starting from laboratory results, given their importance. However, most of the previous efforts have been based on labor-intensive manual methods. Objective: We aimed to develop an automatic standardization method for eliminating the noises of categorical laboratory data, grouping, and mapping of cleaned data using standard terminology. Methods: We developed a method called Standardization Algorithm for Laboratory Test–Categorical result (SALT-C) that can process categorical laboratory data, such as “pos +,” “250 4+ (urinalysis results),” and “reddish (urinalysis color results).” SALT-C consists of five steps. First, it applies data cleaning rules to categorical laboratory data. Second, it categorizes the cleaned data into five predefined groups (urine color, urine dipstick, blood type, presence finding, and pathogenesis tests). Third, all data in each group are vectorized. Fourth, similarity is calculated between the vectors of data and those of each value in the predefined value sets. Finally, the value closest to the data is assigned. The source code of SALT-C can be downloaded via https://github.com/rpmina/SALT_C. Results: The performance of SALT-C was validated using 59,213,696 data points (167,938 unique values) generated over 23 years from a tertiary hospital. Apart from the data whose original meaning could not be interpreted correctly (e.g., “**” and “_^”), SALT-C mapped unique raw data to the correct reference value for each group with accuracy of 97.62% (urine color tests), 97.54% (urine dipstick tests), 94.64% (blood type tests), 99.68% (presence finding tests), and 99.61% (pathogenesis tests). Conclusions: The proposed SALT-C successfully standardized the categorical laboratory test results with high reliability. SALT-C can be beneficial for clinical big data research by reducing laborious manual standardization efforts.

  • Do daily fluctuations in psychological and app-related variables predict engagement with an alcohol reduction app? A series of N-of-1 studies

    From: Journal of Medical Internet Research

    Date Submitted: Mar 22, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: Previous studies have identified psychological and smartphone app-related predictors of engagement with alcohol reduction apps at a group level. However, strategies to promote engagement need to be effective at the individual level. Evidence as to whether group-level predictors of engagement are also predictive for individuals is lacking. Objective: This study aimed to examine whether daily fluctuations in: i) the receipt of a reminder, ii) motivation to reduce alcohol, iii) perceived usefulness of the app, iv) alcohol consumption, and v) perceived lack of time predicted within-person variability in the frequency and amount of engagement with an alcohol reduction app. Methods: A series of observational N-of-1 studies were conducted. The predictor variables were measured twice daily for 28 days via Ecological Momentary Assessments. The outcome variables were measured through automated recordings of participants’ app screen views. Nine London-based adults who drank alcohol excessively and were willing to set a reduction goal took part. Each participant’s dataset was analysed separately using Generalised Additive Mixed Models to derive incidence rate ratios (IRRs) for the within-person associations of the predictor and outcome variables. Debriefing interviews, analysed using thematic analysis, were used to contextualise the findings. Results: Predictors of the frequency and amount of engagement differed between individuals, and for the variables ‘perceived usefulness of the app’ and ‘perceived lack of time’, the direction of associations also differed between individuals. The most consistent predictors of within-person variability in the frequency of engagement were the receipt of a daily reminder (IRRs = 1.80-3.88, P’s < .05) and perceived usefulness of the app (IRRs = 0.82-1.42, P’s < .05). The most consistent predictors of within-person variability in the amount of engagement were motivation to reduce alcohol (IRRs = 1.67-3.45, P’s < .05) and perceived usefulness of the app (IRRs = 0.52-137.32, P’s < .05). Conclusions: The utility of the selected psychological and app-related variables in predicting the frequency and amount of engagement with an alcohol reduction app differed at the individual level. This highlights that key within-person associations may be masked in group-level designs and suggests that different strategies to promote engagement may be required for different individuals. Clinical Trial: osf.io/zn79m

  • Common Data Elements of patients with acute coronary syndrome (ACS)

    From: JMIR Medical Informatics

    Date Submitted: Mar 22, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: Standardization in clinical documentation can increase efficiency, save time and resources. Objective: The objectives of this work are to compare documentation forms for acute coronary syndrome (ACS), check for standardization and generate a list of the most common data elements using semantic form annotation with Unified Medical Language System (UMLS). Methods: 86 sources from registries, studies, risk scores, quality assurance, official guidelines and routine documentation of four hospitals in Germany were semantically annotated. This allowed for automatic comparison of concept frequencies and generation of a list of most common concepts. 3.710 forms items were semantically annotated using 842 unique UMLS concepts. Results: Half of all medical concept occurrences are covered by 60 unique concepts, which suggests the existence of a core data set of relevant concepts. Overlap percentages between forms are relatively low, hinting at inconsistent documentation structures and lack of standardization. Conclusions: This analysis shows a lack of standardized and semantically enriched documentation for patients with ACS. Efforts made by official institutions like the ESC have not yet been fully implemented. Utilizing a standardized and annotated core data set of the most important data concepts could make export and automatic re-use of data easier. The generated list of common data elements is an exemplary implementation suggestion of the concepts to use in a standardized approach.

  • Quality of pregnancy dating and obstetric interventions: a retrospective database analysis

    From: JMIR Pediatrics and Parenting

    Date Submitted: Mar 23, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: The timing of gestation is critical information to make timely decisions and provide obstetric care. Objective: To analyse the association between the quality of gestational age (GA) information and obstetric interventions during birth. Secondarily, to assess obstetric outcomes and the agreement between obstetricians and paediatricians who independently estimate GA Methods: Hospital-based cohort study with 2,113 births. Groups of newborns with ultrasound-based GA estimated at <14 weeks (very-adequate GA) or at ≤20 weeks (adequate GA) were compared with the group without antenatal ultrasound or with ultrasound-based GA estimated at >20 weeks (inadequate GA). A univariate analysis was used to associate outcomes among the interest groups. Paired analyses compared GA recorded by the obstetrician or paediatrician. Results: Better quality of GA estimates at birth were associated with a higher rate of interventions for pregnancy interruption and improved obstetric outcomes. The chance of non-spontaneous delivery and oxytocin augmentation was higher in very-adequate-GA and adequate-GA groups, as compared to the inadequate-GA group: OR=1.64 (1.35 – 1.98 95%CI) and OR=1.58 (1.31 – 1.90 95%CI); OR=1.41 (1.09 – 1.82 95%CI) and 1.34 (1.04 – 1.72 95%CI), respectively. Caesarean rates (40.8% vs 37.1%, p=0.121, and 40.1% vs 37.1%, p=0.195) and forceps (3.6% vs 2.6%, p=0.236, and 3.2% vs 2.6%, p=0.474) were similar between such groups of comparisons. Moreover, maternal blood transfusion after birth was more frequent in the inadequate-GA group than in the other groups (3.1% vs 1.5%, p=0.020, and 3.1% vs 1.7%, p=0.048), and neonatal intensive-care-unit admission was more frequent in the inadequate-GA group than in the other groups, excluding major foetal malformations (18.1% vs 13.2%, p=0.008, and 18.1% vs 13.3%, p=0.010). Disagreement between paediatricians or obstetricians regarding the GA estimate impacted the rate of small-for-gestational-age newborns (14.5% vs 15.4%, respectively, p=0.037). Conclusions: The credibility of GA retrieved at birth can be an influential factor in timely obstetric interventions in labour management and NICU admissions.

  • The Quantified Reconnaissance Marine Training Study

    From: Journal of Medical Internet Research

    Date Submitted: Mar 22, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: Service members volunteer for training and selection to serve in elite and specialized United States military units. Training is often psychologically and physically intense and is associated with high attrition rates. There is a need to graduate more service members without degrading performance standards. However, the mental and physical factors that predict success or failure in training are unknown, and thus it is difficult to target interventions. Objective: We sought to continuously quantify the mental and physical status of trainees of an elite United States military unit to identify novel predictors of success or failure in successive training classes performed on land and in water. Methods: Three consecutive classes of Marines and Sailors entering the first 25-day class of a specialized training course were provided with an Apple iPhone and Watch and a specially-designed mobile application. Baseline personality assessments and continuous daily measures of mental status, physical pain, heart rate, activity, sleep, hydration and nutrition were collected from the application and Watch data. Results: A total of 121 trainees were enrolled (100% male, age 22±4 years) and 64 (56%) successfully graduated (completed the course). Most training withdrawals (23%) occurred by day 7 (5.5± 3.4 days, range 1-22 days). Neither performance on physical training standards, such as hikes or aquatic training, or continuous measures of heart rate, work output, hydration, nutrition and sleep duration continuously predicted course completion. Throughout the 25-day course, trainees’ mean daily heart rate and work output was 112 ± 30 bpm (range 30-120 bpm), 10,510 ± 7,742 steps (range 1-34,978) and 1767.32 ± 64.46 Calories (range, 1-9133). Extraversion and positive affect personality traits and daily psychological profiles were associated with course completion; key psychological factors could predict withdrawals 1-2 days in advance (P=0.009). Conclusions: It is possible to gather accurate and continuous mental and physical status data during elite military training. Early predictors of trainee withdrawal can be identified that can provide an opportunity for intervention.

  • Real-World Use of Do-it-Yourself Artificial Pancreas Systems in Children and Adolescents: Self-Reported Clinical Outcomes

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 21, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: Patient-driven initiatives have made uptake of Do-it-Yourself Artificial Pancreas Systems (DIYAPS) increasingly popular amongst people with diabetes of all ages. Observational studies show improvements in glycemic control and quality of life amongst adults. However, there remains a lack of research examining experiences of children and adolescents with DIYAPS in everyday life and their social context. Objective: This study assesses self-reported clinical outcomes of the pediatric population using DIYAPS in real-world use. Methods: An online survey was distributed to caregivers, assessing HbA1c and Time in Range (TIR) before and after, and problems during DIYAPS use. Results: 209 caregivers from 21 countries responded. Children were 47.4% female with a median age of 10y; a mean diabetes duration of 5.1y ±3.9 and 10.3m ±10.0 experience with DIYAPS. Clinical outcomes improved significantly, including HbA1c (from 6.91% ±0.88 to 6.27% ±0.67; P<.001) and TIR (from 64.2% ±15.94 to 80.68% ±9.26; P<.001). Conclusions: Improved glycemic outcomes were found across all pediatric age groups including adolescents and very young children. These findings are in line with clinical trial results from commercially developed closed-loop systems. Clinical Trial: The study was approved by the Charité ethics committee (EA2/140/18).

  • Is Health Literacy Associated with Health-Related Information Seeking Behavior Using Technology?

    From: Journal of Medical Internet Research

    Date Submitted: Mar 22, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: None. Objective: To investigate health-related information-seeking using the Internet and its relationship with health literacy, access to technology, and socio-demographic characteristics. Methods: Data come from 614 adults in Minnesota who answered a survey on health literacy, access to technology, and health-related information-seeking Internet use. We used a cross-sectional, multivariate regression design to assess the relationship between health-related information-seeking on the Internet and health literacy and access to technology, controlling for socio-demographic characteristics. Results: Better health literacy and greater access to technological devices were both associated with more health-related information-seeking behavior on the Internet, after adjusting for all other socio-demographic characteristics. Possession of a graduate degree, female gender, poor health, participation in social groups, and having an annual health exam were all associated with online health-related information-seeking as well. Conclusions: Higher health literacy and better access to technology are associated with more online health-related information-seeking. Online health-related information-seeking also varies by socio-demographic characteristics. Practice Implications: Access to online health-related information is not uniformly distributed throughout the population, which may exacerbate disparities in health and healthcare. Research, policy, and practice attention are needed to address disparities in access to health information, as well as to ensure the quality of that information.

  • Has the YouTube Generation Crossed The Line: A Prospective Study Evaluating the Identification of Informed Consent to post patient videos on social media

    From: Journal of Medical Internet Research

    Date Submitted: Mar 20, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: the American Medical Association regulations state that any clinical image taken for public education forms part of the patients’ records. Hence a patient’s informed consent is required to collect, share and distribute his or her image. Patients must be informed of the intended use of the clinical image and the intended audience as part of the informed consent Objectives: to determine whether a random selection of videos containing footage of real patients on YouTube identify the presence of informed consent to post the video on social media Design: A prospective evaluation of the first 125 videos on YouTube, with the search criteria “central line insertion” by 2 separate researchers Setting: Video content on YouTube Participants: Posters of footage containing real patient procedures Interventions: All posters were contacted to clarify the status of consent to both film and disseminate the video on social media. A period of 2 months was provided to respond to initial contact. Furthermore, YouTube were contacted to clarify company policy Primary and Secondary Outcome Measures: The primary outcome was to determine if videos on YouTube were amended to include details of consent at 2 months post-contact. The secondary outcome was a response to the initial email at 2 months Results: 143 videos were compiled. 41 videos contained footage of patient procedures. 41/41 videos were of indeterminate consent status. 23/41 contained identifiable patient footage. 3/41 posters responded to initial contact. 0/41 amended the video to document consent status. Response from YouTube is pending Conclusion: There are videos on social media, containing footage of patients undergoing medical procedures, without any verification of informed consent. While this study investigated a small sample of available videos, the problem appears more ubiquitous, and should be studied more extensively

  • Evidence-based Best Practices and Use of Behavior Change Theories in Breast Cancer Apps: A Systematic Analysis

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 20, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: Mobile phone applications (‘apps’) designed for the prevention and management of breast cancer have the potential to extend current healthcare efforts. Theoretically-designed mHealth breast cancer interventions have shown success in achieving positive behavior change. However, little is known about the theoretical underpinnings of breast cancer apps available to the general public. Objective: Given that theories may strengthen mHealth interventions, the aim of this study was to identify breast cancer apps designed to support behavior change and disease management, to assess the extent to which they address content along the cancer-care continuum and contain theory-based constructs, and the degree to which user-rating is related to theory-based design. Methods: Using a criteria-based screening process, we searched two major app stores for breast cancer apps designed to promote behavior change. Apps were coded for content along the cancer-care continuum and analyzed for behavior change theories. A correlation analysis was used to examine the relationship between apps’ user ratings and use of behavior change theories. Results: The search resulted in a total of 302 apps, of which 108 were identified as including breast cancer content. Only 30 (10%) apps met inclusion criteria for supporting behavior change and were further analyzed. These apps were disproportionally focused on behaviors to enhance early detection, particularly self-exams, whereas only a few apps supported care management, treatment, and post-treatment behaviors. In regard to theories, the majority of apps customized content to users (63%), established a health-behavior link (70%), and provided instructions on how to change behavior (80%). Fifteen apps (50%) prompted intention formation, while less than half included goal setting (30%) and goal reviewing (23%). Most apps did not provide information on peer behavior (23%) or allowed for social comparison (20%). None of the apps mobilized social norms (0%). Only half of all apps had user ratings, and the results of the Pearson r correlation suggested that there was a significant positive correlation between user ratings and use of theories at .422 (p = .022). The analysis of behavioral theories used in apps reveals significant shortcomings in apps’ use of goal setting and social influence features. Conclusions: Our findings indicate that commercially-available breast cancer apps have not yet fully realized their potential to promote behavior change, with only a minority of apps focusing on behavior change, and even fewer including theoretical design to support behavior along the cancer continuum. These shortcomings are likely limiting apps’ effectiveness in improving public health. More attention needs to be paid to the involvement of users and professionals in app development and adherence to theories and best practices on the cancer continuum in the design of mHealth apps to provide individuals with the support they need along the cancer-care continuum.

  • Exploring ‘why’ members belong to an intensive care virtual community using online asynchronous focus groups and key informant interviews

    From: Journal of Medical Internet Research

    Date Submitted: Mar 20, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: Clinical practice variation that result in poor patient outcomes remains a pressing problem for healthcare organizations. Some evidence suggests that a key factor may be ineffective internal and professional networks that limit knowledge exchange between healthcare professionals. Virtual communities (VC) have the potential to overcome professional and organisational barriers and facilitate knowledge flow. Objective: To explore why healthcare professionals belong to an exemplar VC, ICUConnect. The specific research objectives were to: 1) understand why members join and remain a member; 2) identify what purpose the VC serves in in their professional lives; 3) identify how a member uses the VC; and 4) identify how members used the knowledge or resources shared on the VC. Methods: A qualitative design, underpinned by Pragmatism, was used to collect data from three asynchronous online focus groups and four key informant interviews with participants allocated to a group based on their posting behaviors during the previous two years - between September 1, 2012 and August 31, 2014: 1) frequent (more than five times); 2) low (five times or less); and 3) non-posters. A novel approach to focus group moderation, based on principles of traditional focus groups, and e-moderating was developed. Thematic analysis was undertaken, applying the Diffusion of Innovations theory as the theoretical lens. NCapture was used to extract data from the online focus groups and NVIVO was used to manage all data. A research diary and audit trail were maintained. Results: There were 27 participants: seven frequent posters, 13 low posters, and seven non-posters. All participants displayed an external orientation with the majority using other social media, however, listservs were perceived to be superior in terms of professional compatibility and complexity. The main theme was ‘Intensive care professionals are members of ICUConnect because by being a member of a broader community they have access to credible best-practice knowledge’. The VC facilitated access to all professionals caring for the critically ill and was characterized by a positive and collegial online culture. The knowledge found was credible because it was extensive, and because the VC was moderated and sponsored by a government agency. This enabled members to benchmark and improve their unit practices, and keep up to date. Conclusions: This group of healthcare professionals made a strategic decision to be members of ICUConnect, as they understood that to provide up-to-date clinical practices, they needed to network with colleagues in other facilities. This demonstrated that a closed speciality-specific VC can create a broad heterogeneous professional network, overcoming current ineffective networks that adversely impact on knowledge exchange and creation in local practice settings. To address clinical practice variation healthcare organizations can leverage low cost social media technologies to improve inter-professional and – organizational networks. Clinical Trial: not applicable

  • Background: Electronic screening and brief intervention (eSBI) has demonstrated some effectiveness in reducing harmful alcohol consumption. However, a challenge remains as to how to sufficiently engage users with app and online based eSBI, as trials demonstrate low engagement rates. Young adults are an under-identified harmful drinking population who prefer eSBI delivered alcohol interventions. Engagement has been associated with improved clinical outcomes in the digital behaviour change literature. Therefore, identifying novel methods to engage users is warranted to improve the effectiveness of app-based eSBI interventions. Objective: (i) To conduct a Randomised Controlled Trial (RCT) to determine whether eSBI plus novel Engagement Promoting Strategies (EPS) compared to eSBI only was associated with higher levels of user engagement in an app targeting harmful drinking in young adults (ii) To examine the relationship between the inclusion of EPS and changes in harmful alcohol consumption and, (iii) To determine the relationship between participants who engaged and those who did not engage with the app and change in AUDIT-C score. Methods: An app called ‘BRANCH’ was developed, including EPS of tailoring, social features, in-app reminders and gamification. A two-arm RCT examined whether participants in the eSBI plus EPS arm (intervention) logged into BRANCH more times than the eSBI only arm (control). Participants were young adults (>=18 years old and <=30 years old) who drank alcohol at a harmful level (scored >=7 on the AUDIT-C), and lived in the UK. The primary outcome was number of logins at 28 days. Secondary outcomes included AUDIT-C at six months and engagement measured by treatment compliance (logged in > 1). Results: The addition of EPS to eSBI in an app targeting harmful drinking in young adults did not result in increased use, measured by number of logins compared, to the same app including only eSBI components 28 days post randomisation (P=.60). Users of the eSBI plus EPS app did not show a significant reduction in harmful drinking score as measured by the AUDIT-C score compared to users of the eSBI only app at 6-month post randomisation (P=.17). App engagers (logged in > 1) did not show a significant reduction in harmful drinking compared to non-engagers (logged in once) (P=.58). Conclusions: An eSBI app optimised with tailored, social and gamification features did not promote increased usage compared to eSBI only. Engagement with eSBI in young adults continues to be a barrier for designing effective eSBI apps. The associations between EPS, engagement rates and drinking outcomes remain unclear. The low engagement rates with some eSBI apps may be leading to a lack of exposure to the active behaviour change components, resulting in limited effects. Clinical Trial: ISRCTN: 70980706

  • A randomized controlled trial of an intervention delivered by app instant messaging to increase acceptability and use of effective contraception among young women in Bolivia

    From: Journal of Medical Internet Research

    Date Submitted: Mar 21, 2019
    Open Peer Review Period: Mar 26, 2019 - May 21, 2019

    Background: Unintended pregnancy is associated with poorer health outcomes for both women and their children. Fulfilling unmet need for contraception is essential in avoiding unintended pregnancies. Although the most effective methods of contraception are available in Bolivia, unmet need among women aged 15-19 is estimated to be 38% (2008) and the adolescent fertility rate is 71 per 1,000 women (2016). Mobile phones are a popular mode by which to deliver health behaviour support. The London School of Hygiene & Tropical Medicine and the Centro de Investigación, Educación y Servicios in Bolivia developed a contraceptive behavioural intervention for young Bolivian women delivered by mobile phone. The intervention development was guided by behavioural science and consists of short instant messages sent through an app over four months. Objective: The objective of this trial was to evaluate the effect of the intervention on young Bolivian women’s use of and attitudes towards the effective contraceptive methods available in Bolivia (oral contraceptive pills, intrauterine devices, injectables, implants and the patch). Methods: This was a parallel group, individually randomised superiority trial with a 1:1 allocation ratio. Women were eligible if they were aged 16-24, owned a personal Android mobile phone, lived in La Paz or El Alto, reported an unmet need for contraception (i.e. are sexually active, not on effective contraception and want to avoid a pregnancy) and could read Spanish. The target sample size was 1310 participants. Participants allocated to the intervention arm had access to an app with standard family planning information plus intervention messages. Participants allocated to the control arm had access to the same app plus control messages. Co-primary outcomes were use of effective contraception and acceptability of at least one method of effective contraception at four months. Secondary outcomes were use of effective contraception during the study, acceptability of the individual methods, service uptake, unintended pregnancy and abortion. Process outcomes included knowledge, perceived norms, personal agency and intention. Outcomes were analyzed using logistic and linear regression. We also asked participants if they experienced physical violence since joining the study. Results: 640 participants were enrolled and 67% (n= 429) contributed follow-up data for the co-primary outcome, use of effective contraception. There was no evidence that use differed between the groups (33% in the control arm vs 37% in the intervention arm, adjusted OR 1.19, 95% CI 0.80-1.77, p = 0.40). There was a borderline significant effect regarding the acceptability outcome (63% in the control arm vs 72% in the intervention arm; adjusted OR 1.49, 95% CI 0.98-2.28, p = 0.06). There were no statistically significant differences in any of the secondary or process outcomes. Intervention dose received was low. In the control group, 3% reported experiencing physical violence compared to 2% in the intervention group (Fisher’s exact test p=0.75). Conclusions: This trial was unable to provide definitive conclusions regarding the effect of the intervention on use and acceptability of effective contraception due to under recruitment. While we cannot strongly recommend implementation, the results suggest that it would be safe and may increase acceptability of effective contraception if the intervention messages were offered alongside the download of the app. Clinical Trial: ClinicalTrials.gov Identifier NCT02905526

  • An Assessment of Facebook Advertising for Recruiting a Representative Sample of a Canadian Adult Population for a Health Survey

    From: Journal of Medical Internet Research

    Date Submitted: Mar 22, 2019
    Open Peer Review Period: Mar 25, 2019 - May 20, 2019

    Background: Facebook has shown promise as an economical means of recruiting participants for health research. However, few studies have evaluated this recruitment method in Canada, fewer still targeting older adults, and, to our knowledge, none specifically in Newfoundland and Labrador (NL). Objective: To assess Facebook advertising as an economical means of recruiting a representative sample of adults ages 35 to 74 in NL for a cross-sectional health survey. Methods: Facebook advertising was used to recruit for an online survey on cancer awareness and prevention during April-May 2018; during recruitment, additional ads were targeted to increase representation of demographics that we identified as being underrepresented in our sample. Sociodemographic and health characteristics of the study sample were compared to distributions of the underlying population to determine representativeness. Cramer’s V indicates the magnitude of the difference between the sample and population distributions, interpreted as small (Cramer’s V = 0.10), medium (0.30), and large (0.50). Sample characteristics were considered representative if there was no statistically significant difference in distributions (chi-square P > .01) or if V ≤ 0.10, and practically representative if 0.10 < V ≤ 0.20. Cost per recruit of Facebook advertising was compared to a quote for a random digit dialling (RDD)-recruited postal survey to determine if this method was economical. Results: Facebook advertising is feasible and economical for survey research, reaching 34,012 people, of which 2,067 clicked on the ad, for a final sample size of 1048 people at $2.18 CAD per recruit, versus the quoted $23,316.05 CAD for 400 recruits ($35.52 CAD per recruit) via RDD. The sample was representative of rural/urban geography (P = 0.021, V = 0.073), practically representative of age (P = .003, V = 0.145) and income (P < .001, V = 0.188), and over-representative of women (P < .001, V = 0.507) and higher levels of education (P < .001, V = 0.488). The sample was representative of the proportion of people with a regular healthcare provider (P = 0.938, V = 0.025) and diabetes prevalence (P = .002, V = 0.096), and practically representative of smoking status (P < .001, V = 0.14), body mass index (P < .001, V = 0.135), and having had a colonoscopy or sigmoidoscopy (P < .001, V = 0.124). The sample was not representative of arthritis prevalence (P < .001, V = 0.573), perceived health (P < .001, V = 0.384), or time since last seasonal flu shot (P < .001, V = 0.449). Conclusions: Facebook advertising offers an easy, rapid, and economical means to recruit a partially representative (representative or practically representative of eight of the thirteen characteristics studied) sample of middle-aged and older adults for health survey research. As Facebook uses a non-random targeting algorithm, caution is warranted in its applications for certain types of research.

  • SOLVD-TEEN: Findings from Smartphone- and OnLine-usage-based eValuation for Depression (SOLVD) Study in Adolescents. Can we predict depressive symptoms with parental input?

    From: Journal of Medical Internet Research

    Date Submitted: Mar 19, 2019
    Open Peer Review Period: Mar 22, 2019 - May 17, 2019

    Background: Depression carries significant financial, medical and emotional burden on modern society. Various proof of concept studies have highlighted how apps can link dynamic activity changes to fluctuations in smartphone usage in adult patients with major depressive disorder. The application of such apps to adolescents remains a more challenging field. Objective: This study aims to investigate whether smartphone applications are useful in evaluating and monitoring depression symptoms in a clinically depressed adolescent population compared to gold-standard clinical psychometric instruments (PHQ-9, HAM-D and HAM-A). Methods: The authors recruited 13 families with adolescent patients diagnosed with major depressive disorder with or without comorbid anxiety disorder. Over an eight-week period, daily self-reported moods and smartphone sensor data were collected by the SOLVD App. The evaluations of teens’ parents were also collected. Baseline depression and anxiety symptoms were measured biweekly using PHQ-9, HAM-D, and HAM-A. Results: The authors observed a significant correlation between the self-evaluated mood averaged over a 2-week period and the biweekly psychometric scores (0.45≤|r|≤0.63, all P < .05). The daily steps taken, SMS frequency and average call duration were also highly correlated with clinical scores (0.44≤|r|≤0.72, all P < .05). By combining self-evaluations and smartphone sensor data of the teens, the authors could predict the PHQ-9 score with an accuracy of 74.8%. When including the evaluations from the teens’ parents, the prediction accuracy could be further increased to 79.2%. Conclusions: Smartphone apps such as SOLVD represent a useful way to monitor depressive symptoms in clinically depressed adolescents, and correlate well with current gold-standard psychometric instruments. This is a first-of-its-kind study that was conducted on the adolescent population, and it included inputs from both the teens and their parents as observers. The results are preliminary because of small sample size and the authors plan to expand the study to a larger population. Clinical Trial: N/A

  • Background: Digital games may become beneficial for older adults, by offering cognitive stimulation. However, due to unfamiliarity with the medium of digital games, game learning and retention could become too stressful to be motivating. We propose a model-driven quantitative approach to game evaluation, based on the theory of Stress Appraisal and Coping (Lazarus & Folkman, 1984) according to which individual differences in perception of and coping with new challenge would manifest quantifiable physiological signals. Objective: We aim to investigate the impact of Appraisal and cognitive reserve on stress response to different genres of computer games. Methods: 35 older adults filled a game assessment survey and were invited to participate in a 3-arms crossover laboratory experiment involving playing three brain-beneficial games, Brain training, CarRacing, and exergaming. Appraisal was measured based on pre- and post game surveys, and cognitive reserve from Montreal Cognitive Assessment (MOCA). Stress was estimated from cortisol (4 samples), stress-sensitive cognitive tests (Stroop + Picture encode/delayed recall), and continuous recording of electrodermal activity, temperature, heart rate and heart rate variability, using a light wristband (E4). Generalized Estimating Equations were used to test the effect of Session, and Group x Session x Activity on stress metrics. Results: Eighteen volunteers (71±4.5 years, 12 women), with high education (16.8 ± 3.5 year), low perceived stress (8.7± 4, out of 40) and generally positive attitude towards games participated. Those who participated in the experiment had a generally more positive attitude towards games. The Exergame session induced the strongest post-game physiological and cognitive responses, suggesting that it was more stressful than brain training and car racing games, which showed a generally similar patterns). The low-MOCA (mean±std=24.62 ±1.41) had a generally less positive attitude towards playing (both before and after experiments), and significantly higher EDA and HR during Brain Games, as well as higher (but not statistically significant) cortisol levels during exergame. Conclusions: Physiological biomarkers are sensitive to detecting game-related experiential differences that relate to individual variations in appraisal of the games and their cognitive reserves. To apply mixed method research to the game design cycle is an important consideration for developing efficacious Serious Games. We illustrate that perceptual differences in game evaluation can be objectively assessed. More work is needed to illustrate the mediating effect of initial stress on game-learning and on long term benefits of using gamified health interventions.

  • Internet-based asthma education program in combination with presence education increases asthma knowledge more than conventional presence education: results of a randomized controlled trial

    From: Journal of Medical Internet Research

    Date Submitted: Mar 18, 2019
    Open Peer Review Period: Mar 21, 2019 - May 16, 2019

    Background: Asthma education programs (AEP) in combination with keeping an asthma diary and usage of an asthma action plan to foster self-management is associated with reduced hospitalization, disability and mortality. However, only few patients are participating in presence educational programs which might be due to time constraints, organizational reasons, and low physiological or psychological strains. Internet-based educational programs might help to increase participation rates. Objective: We developed an electronic AEP (eAEP) conform with accreditation criteria for presence AEPs (pAEPs) and compared the effectiveness of eAEP and pAEP for knowledge gain regarding asthma self-management. Methods: The study was a two-armed, single-centre, randomized controlled trial performed between 17th July and 11th October 2018 in a pulmonary rehabilitation in-patient clinic. Due to safety reasons, patients of the eAEP group were obliged to participate in the presence education after finalization of the eAEP. Asthma knowledge was determined with the Asthma Knowledge Test (AKT) comprising 54 items. The total sum score ranges from 0 to 54 points, with higher scoring indicating better knowledge. Group differences were calculated with linear regression adjusting for age, gender, years since asthma diagnosis and AKT baseline values. Results: In the intervention group, AKT scores increased from 41.57 (standard deviation 5.63) at baseline to 45.82 (3.84) after completion of the eAEP, and again after completion of the pAEP to 47.20 (3.78) (both increases p<0.001). In the control group the scores increased from 41.73 (4.74) at baseline to 45.72 (3.65) after completion of the pAEP (p<0.001). The knowledge gain was similar between the eAEP and pAEP group after completion of the corresponding educational sessions (p=0.881). However, knowledge gain was significantly higher in the eAEP group after participating in the obligatory pAEP group compared to the patients solely participating in the pAEP group (p=0.020). Personal comments highlighted the possibility to use the eAEP for looking up facts about asthma medication and management, or to use it for in-depth learning after pAEP. Conclusions: eAEP might lead to similar knowledge gain as pAEP. Thus, an internet-based approach to reach patients for asthma education might be valuable to compensate for the educational deficits of a large amount of patients with asthma. Future studies have to examine optimal ways how to implement eAEPs within clinical settings or primary care, under consideration of the necessity to combine it with regular review, active engagement and training of patients. Clinical Trial: German Register of Clinical Trials; number DRKS00015078.

  • The impacts of perceived transparency of privacy policy and trust in providers on building trust in Health Information Exchange (HIE)

    From: Journal of Medical Internet Research

    Date Submitted: Mar 18, 2019
    Open Peer Review Period: Mar 21, 2019 - May 16, 2019

    Background: In the context of exchange technologies, such as Health Information Exchanges (HIEs), existing technology acceptance theories should be expanded to consider not only the cognitive beliefs resulting in adoption behavior, but also the affect provoked by the sharing nature of the technology. Objective: This work uses a trust-centered model to study HIEs adoption. Based on the Theory of Reasoned Action (TRA), the technology adoption literature, and the trust transfer mechanism, we theoretically explain and empirically test the impacts of perceived transparency of privacy policy and trust in healthcare providers on cognitive trust and emotional trust in an HIE. Moreover, we analyze the effects of cognitive trust and emotional trust on the intention to opt in to the HIE and willingness to disclose health information. Methods: An online survey was conducted using data from individuals who were aware of HIE through experiences with a (or multiple) provider participating in a HIE network. Results: SEM analysis results provide empirical support for the proposed model. Our findings indicate that when patients trust in healthcare providers and they know more about HIE security measures, HIE sharing procedures, and privacy terms, then they feel more in control, more assured, and less at risk. Moreover, trust in providers has a significant moderating effect on building trust in HIE efforts. Results also show that patient trust in HIE may take the forms of opt-in intentions to HIE and patients’ willingness to disclose health information which are exchanged through the HIE. Conclusions: The results of this research should be of interest to both academics and practitioners. The findings provide an in-depth dimensions of HIE privacy policy that should be addressed by healthcare organizations to exchange personal health information in a secure and private manner.This work can contribute to trust transfer theory and enrich the literature on HIE efforts. Practitioners can also identify how to leverage the benefit of patients’ trust and trust transfer process to promote HIE initiatives nationwide.

  • A hybrid depressive mood analysis model to detect blogger depression tendency from web posts

    From: Journal of Medical Internet Research

    Date Submitted: Mar 18, 2019
    Open Peer Review Period: Mar 21, 2019 - May 16, 2019

    n recent years, reports of suicide have continuously increased because of people suffering from tremendous pressure or depression. Depression is listed as the third highest health issue from the World Health Organization. They also predict that depression will become the second highest issue by 2020. This kind of mental illness is difficult to diagnose and detect. In our previous works, we proposed a Negative Emotion Evaluation (NEE) model and an Event-Driven Depression Tendency Warning (EDDTW) model to early detect depressive moods. In this work, we combine the previous models to propose a Hybrid Depressive Mood Analysis (HDMA) model to predict the depression from web posts. The experimental results show that our proposed hybrid depressive mood analysis model obtains over 70% precision.

  • The Adoption of Electronic Patient Record Sharing Pilot Project: A Cross-Sectional Survey

    From: Journal of Medical Internet Research

    Date Submitted: Mar 18, 2019
    Open Peer Review Period: Mar 21, 2019 - May 16, 2019

    Background: The Public Private Interface-electronic Patient Record (PPI-ePR) system was implemented as a new electronic platform to facilitate collaboration between the public and private sectors in Hong Kong. However, its barriers to participate and benefits have not hitherto been comprehensively assessed. Objective: This study aims to evaluate the awareness, acceptance, perceived benefits, and obstacles to participation among private doctors and general public. Methods: From December 2012 to January 2013, 2,435 telephone interviews were performed by trained interviewers to survey random-selected patients who were enrolled or not enrolled in the PPI-ePR system. At the meantime, self-administered surveys were sent by post to 10,285 registered doctors in Hong Kong. The questionnaires for both patients and doctors contain questions on subjects’ awareness, acceptance and perceptions to PPI-ePR, perceived benefits and obstacles of participating in the programme, reasons for not using the system after enrolling, as well as perceived areas for service improvement of the system. Results: Over 53% of enrolled patients believed that the PPI-ePR system would improve healthcare quality by “reducing duplicate tests and treatments”, while over 76% of enrolled doctors emphasized “timely access to patients’ medical records” as the biggest benefit of their enrolment. Among non-enrolled patients, unawareness of the project was among the most popular obstacle of enrolling the PPI-ePR system (40%). Regarding non-enrolled doctors, the complicated registration process hinder them from participating in the programme the most (48%). Establishing of user-friendly interface (71.5%), and open rights for patients to access their own medical records (63.7%) were among the most widely underlined factors to attract non-enrollees’ participation of the programme. Conclusions: This study comprehensively assessed the popularity, perceived benefits and hindering factors of enrolling the PPI-ePR system in Hong Kong. Lack of awareness, as well as fear of the complex registration procedures, was the most common reason of individuals’ absence in the program, calling for more frequent and effective promotions of the program. Even for enrolled users, simplified and user-friendly interface with more functions must be developed to improve their activity.

  • Differential Diagnosis Assessment in Ambulatory Care with an Automated Medical History-Taking Device: A Pilot Randomized Study

    From: Journal of Medical Internet Research

    Date Submitted: Mar 17, 2019
    Open Peer Review Period: Mar 20, 2019 - May 15, 2019

    Background: Automated medical history-taking devices (AMHTD) are emerging tools with the potential to increase the quality of medical consultations by providing physicians with an exhaustive, high-quality, standardized anamnesis and differential diagnosis (DD). Objective: This study aims to assess the effectiveness of an AMHTD to obtain an accurate DD in an outpatient service. Methods: We conducted a pilot, randomized controlled trial including 59 patients presenting to an emergency outpatient unit and suffering from various conditions affecting the limbs, the back and the chest wall. Resident physicians were randomized into two groups, one assisted by the AMHTD and one without access to the device. For each patient, physicians were asked to establish an exhaustive DD based on the anamnesis and clinical examination. In the intervention group, residents read the AMHTD report before performing the anamnesis. In both groups, the senior physician had to establish a DD, considered as the gold standard, independent of the resident’s opinion and the AMHTD report. Results: Physicians in the intervention group (n=29) had more years of clinical practice compared to the control group (n=30) (mean: 4.3 ± 2 vs. 5.5 ± 2, respectively; P=.03). There were also 16.1% more DDs in the intervention group (mean: 75.3 ± 26% vs. 59.2 ± 31%, respectively; P=.01). Subgroup analysis showed a between-group difference of 3.3% for low complexity cases (1-2 DDs possible) in favor of the AHMTD, 31.1% for intermediate complexity (3 DDs), and 23.7% for high complexity (4-5 DDs). The AMHTD was able to determine 72.6 ± 30% of the correct DDs. Patient satisfaction was good (4.3/5) and 26/29 patients (90%) estimated being able to accurately describe their symptomatology. In eight of 29 cases (28%), the residents considered that the AMHTD helped DD establishment. Conclusions: The AMHTD allowed physicians to make more accurate DD, particularly in complex cases where the diagnosis is not evident. This could be explained not only by the ability of the AMHTD to make the right diagnoses, but also by the exhaustive anamnesis provideApproved by the Medical Ethics Committee of Geneva University Hospitals (REQ-2017-00878).d. Clinical Trial: Approved by the Medical Ethics Committee of Geneva University Hospitals (REQ-2017-00878).

  • Automatically applying a credibility appraisal tool to track vaccination-related communications shared on social media

    From: Journal of Medical Internet Research

    Date Submitted: Mar 17, 2019
    Open Peer Review Period: Mar 20, 2019 - May 15, 2019

    Background: Tools used to appraise the credibility of health information are time-consuming to apply and require context-specific expertise, limiting their use for quickly identifying and mitigating the spread of misinformation as it emerges. Our aim was to estimate the proportion of vaccination-related posts on Twitter are likely to be misinformation, and how unevenly exposure to misinformation was distributed among Twitter users. Methods: Sampling from 144,878 vaccination-related web pages shared on Twitter between January 2017 and March 2018, we used a seven-point checklist adapted from two validated tools to appraise the credibility of a small subset of 474. These were used to train several classifiers (random forest, support vector machines, and a recurrent neural network with transfer learning), using the text from a web page to predict whether the information satisfies each of the seven criteria. Results: Applying the best performing classifier to the 144,878 web pages, we found that 14.4% of relevant posts to text-based communications were linked to webpages of low credibility and made up 9.2% of all potential vaccination-related exposures. However, the 100 most popular links to misinformation were potentially seen by between 2 million and 80 million Twitter users, and for a substantial sub-population of Twitter users engaging with vaccination-related information, links to misinformation appear to dominate the vaccination-related information to which they were exposed. Conclusions: We proposed a new method for automatically appraising the credibility of webpages based on a combination of validated checklist tools. The results suggest that an automatic credibility appraisal tool can be used to find populations at higher risk of exposure to misinformation or applied proactively to add friction to the sharing of low credibility vaccination information.

  • Development of a mobile app for a resource limited setting to guide the grading and management of drug-induced hearing loss for patients with DR-TB

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 16, 2019
    Open Peer Review Period: Mar 19, 2019 - May 14, 2019

    Background: Tuberculosis, affecting millions of people worldwide, is treated with medication including aminoglycosides and polypeptides. Generally, individuals respond differently to medication as a result of their genetic inheritance. These differences in genetic inheritance can result in the under- or over-dosing of medication, which may affect the efficacy, or in the case of aminoglycosides and polypeptides used in the treatment of all forms of tuberculosis (TB), result in ototoxicity. When ototoxicity is detected physicians should adjust dosages to minimize further ototoxicity and hearing loss, yet there are no suitable grading systems to define ‘significant’ hearing loss. Objective: The aim was to develop a standardized grading system by making use of an eHealth system to ensure a user-friendly method to interpret hearing test results, calculate significant hearing loss and provide recommendations with regards to dosage adjustments and management. It further aimed to establish the sensitivity of newly developed grading scale. Methods: This grading system was developed in South Africa based on data that was obtained from an audiology and pharmacokinetic study in Drug-Resistant Tuberculosis (DR-TB) patients at two DR-TB units at state run hospitals. This feasibility study employed a prospective, cross-sectional, exploratory, descriptive and case series research design, with a total of 22 participants. Participants underwent audiological and pharmacological assessments at baseline and every two weeks for the first three months of treatment. Various professionals (8 in total) were subsequently involved in the development of the eHealth system, including a software engineer, four audiologists, a pharmacist, medical doctor and a nurse. The application underwent 14 modifications which involved data storage, ease of usability, grades and the risk factor checklist. Results: An ototoxicity grading system within a mobile application for use by doctors, nurses and audiologists was developed for patients with DR-TB. The purpose of this user-friendly ototoxicity calculator, ‘OtoCalc™’ is to: i) assist health professionals in assessing patients for ototoxicity; ii) establish the clinical significance of ototoxicity, by calculating the grade of hearing loss; iii) monitor the progression of hearing loss; and iv) enable systematic referral and management of patients according to their needs. Conclusions: This newly developed system is more sensitive for ototoxicity in DR-TB patients when compared to the existing grading methods. This application needs to be trialed in a larger sample to establish the data security, user-ease and suitability within this population.

  • ’I Hit Onederland Today!!!’: Learning About Factors Contributed to Weight Loss via Online Discussions

    From: Journal of Medical Internet Research

    Date Submitted: Mar 15, 2019
    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: Maintaining a healthy weight can low the risk of developing many health issues, including type II diabetes, high blood pressures and certain types of cancers. Online social media platforms are popular for people to seek and share their weight loss experiences, which provides opportunities to learn about weight loss behaviors. Objective: To discover the topics conveyed in online discussions on weight loss and investigate the extent to which the factors disclosed in these discussions are associated with weight loss. Methods: We collected posts that were published before January 13, 2018 in r/loseit subreddit, an online discussion board for people to discuss weight loss related topics. We focused on users who mentioned their start weight, current weight and goal weight within at least 30 days. We applied a topic modeling technique to obtain the main themes that were discussed in this subreddit. We further applied trend analysis to discover the temporal trend of topic prevalence. In order to gain insights into the detailed potential factors that were related to weight loss, we applied hierarchical clustering to obtain word semantic clusters. Finally, we applied regression model to learn the association between topics, word semantic clusters and weight loss reported in this subreddit. The predictors that were statistically significant at a level of 0.05 were reported. Results: Our data consisted of 477,904 posts that were published by 7,660 users within a period of 7 years. We found that the number of posts published in this forum raised rapidly after 2016. Through applying Latent Dirichlet Allocation, we identified 25 topics that were mainly discussed in online forums, including drinking, calories, exercises, family members, and lifestyles. Our regression analysis showed that the start weight (=0.823, P<0.001), live days (=0.017, P=0.009), and the number of votes (=0.263, P=0.016) received by a user were positively associated with weight loss. Further, our findings suggested that exercises (e.g., mentions of workout clothes, =0.145, P<0.001) and nutrition (=0.120, P<0.001) were the most effective factors that were associated with weight loss. Users who had higher weight loss might be motivated by the negative emotions (=-0.098, P<0.001) that they experienced in social activities before starting the journey of weight loss. By contrast, we found that users who mentioned vacations (=-0.108, P=0.005), payments (=-0.112, P=0.001) and supermarkets (=-0.060, P=0.008) tended to experience relatively lower weight loss. Further, mentions of family members (=-0.031, P=0.033) and employment status (=-0.041, P=0.033) were also found to be negatively associated with weight loss. Conclusions: Our findings indicated that what people disclosed in online discussion contains many factors that were statistically significant with respect to their weight loss. Our study contributed to the evidence that online personal health data can be effectively applied to learn about health-related behaviors.

  • Preferences for user experiences in digital smartphone mental health applications: implications for design in adolescents.

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 13, 2019
    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: Mental health digital applications hold promise to provide scalable solutions to individual self-care, education, and illness prevention. However, a common problem with mental health apps is that they lack engaging user interfaces and experiences, often resulting in high attrition. While guidelines for new digital interventions in adults have begun to examine engagement, there is a paucity of evidence in how to best address digital interventions in adolescents. As adolescence is a period of great transition and can lead to a vulnerability to mental illness in later life, understanding how best to engage this population is crucial. Objective: In this study we sought to gather qualitative evidence in a sample of adolescents in the UK about their experience of a mental health app. Methods: We used the COREQ guidelines for reporting qualitative data. Adolescents were asked to use the app for a week and were then interviewed using a semi-structured questionnaire. Results: Authors developed five themes from the data that were important in whether the app was perceived to be useful and effective: User Experience/User Interface such as loading screens and portrait mode, specific Location and Frequency of app access, Effectiveness of the app for mental health goals, Content, e.g. games and meditation, and the Reasons for Use , i.e. what participants’ goals were before using the app. Conclusions: In convergence with previous research, we suggest these aspects of app development should be considered crucial in future apps aimed at preventing and supporting mental illness. Clinical Trial: TCYP171110

  • Content analysis of a Facebook page used to support individuals who have been affected by methamphetamine

    From: Journal of Medical Internet Research

    Date Submitted: Mar 14, 2019
    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: Methamphetamine is an illicit and addictive psychostimulant that remains a significant cause of economic burden in Australia. Social media is increasingly being used by non-government organisations and health services to encourage the growth of social support networks amongst people with health-related issues. Several studies have investigated the utility of social media in providing social support to groups of people with health-related issues. However, limited research exists exploring how people affected by methamphetamine use social media for social support. Objective: The present study aimed to determine the types of support being sought by people affected by methamphetamine when accessing a Facebook support page. Methods: 2000 unique posts were coded using content analysis. Results: Emotional support was found to be the most offered support type (42.1%), followed by esteem support (40.4%) and informational support (24.2%), with network support (2.3%) and tangible support (1.7%) being the least offered support types. Conclusions: The present study demonstrates that online social support groups can be effective in challenging stigma by encouraging people affected by methamphetamine to connect with each other and talk about their struggles. This in turn represents an important step towards successful rehabilitation.

  • Use of a Smartphone Application for Weight Loss versus a Paper-Based Dietary Diary in Overweight Adults: A Randomized Trial

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 15, 2019
    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: There is increasing evidence that mobile health (mHealth) tools have value in dietary monitoring and assessment. Objective: This study aims to evaluate the effectiveness of a mobile dietary self-monitoring application (app) for weight loss versus a paper-based diary among adults with a body mass index (BMI) of 23 kg/m2 or above. Methods: A total of 33 men and 17 women aged 18-39 years participated in a six-week randomized trial. We randomly assigned participants to one of two groups: (A) Smartphone app group (n=25) or (B) paper-based diary group (n=25). The smartphone app group recorded foods and dietary supplements that they consumed and received immediate dietary feedback using ‘Well-D’, a fully-automated dietary self-monitoring app developed by our team. The paper-diary group was instructed to record foods or supplements that they consumed using the self-recorded diary. The primary outcomes were weight, BMI, waist circumference, body fat mass and skeletal muscle mass. We also examined changes in nutrient intakes including energy, carbohydrate, protein, fat, dietary fiber, vitamins, and minerals using 3-day 24-hour recalls (24HR) across time at pre- and post-intervention. Differences in changes between the two groups were analyzed using the independent t-test or Wilcoxon Mann-Whitney test. All of the data were analyzed by the intent to treat analysis. Results: The numbers of days recorded (mean ± SD) was 18.5 ± 14.1 for the app group and 15.5 ± 10.1 for the paper-based diary group. The differences in changes of weight, BMI and waist circumference were not significantly different between the app group and paper-based diary group (p=0.33, 0.34, and 0.70, respectively). Similarly, changes in body fat mass or skeletal muscle mass did not differ between the two groups (p=0.71 and 0.054, respectively). Although energy intake was reduced in both groups, there was no statistical difference in change of energy intake between the two groups (p=0.98). Conclusions: There were no differences in changes of anthropometric measures and nutrient intakes between the app group and the paper-based diary group. Both mobile dietary self-monitoring app and paper-based diary may be useful for improving anthropometric measures. Clinical Trial: KCT, KCT0003170; https://cris.nih.go.kr/cris/search/search_result_st01_en.jsp?seq=11642

  • A three-arm quasi-experimental evaluation comparing social and communication apps, telephone, and usual care for improving diabetes self-management

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 15, 2019
    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: There are many technology-assisted innovations used to address disease management. However, most of them are not broadly used by older adults due to their cost. Besides, disease management through the technology-assisted innovations does not compared with other interventions. Objective: This study tested the employment of a widely and freely used social and communication app for helping older diabetes patients manage their distress and glycemic control. It also compared the effectiveness with two other methods, including telephone and conventional health education, and to determine which sub-group experiences the most effects within each intervention. Methods: Type 2 diabetes patients aged ≥50 were recruited from Southern Taiwan (N=231) and were allocated to different 3-month interventions. Results: Participants in the mobile-based group had a significant reduction in hemoglobin A1C as compared with the telephone-based and usual care groups (mean change=-0.4, 0.1, 0.03, respectively, P=0.02). Diabetes-specific distress reduced to a greater extent in the mobile-based group as compared to the other two groups (mean change=-5.16, -3.49, and -2.44, respectively, P=0.02). Subgroup analyses further revealed that the effects on reducing blood glucose level and diabetes-related distress in the social and communication app group was especially evident in those with lower distress scores and those who aged less than 60 years or with higher educational levels, respectively. Conclusions: Findings from this study inform a more flexible use of social and communication apps in patient education and counselling. Clinical Trial: This study was approved by the Institution Review Board (IRB) of National Cheng Kung University Hospital in Taiwan (No. A-ER- 102-425). This study is identical with what the IRB assessed when providing approval before the trial started.

  • Studies of computerized cognitive training with healthy older adults from 2016-2018 do not adequately control for placebo effects: a systematic review

    From: JMIR Serious Games

    Date Submitted: Mar 15, 2019
    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: Computerized cognitive training has been proposed as a potential solution to age-related cognitive decline. However, published findings from evaluation studies of cognitive training games, including from meta-studies and systematic reviews, provide evidence both for and against transferability from trained tasks to untrained cognitive ability. There continues to be no consensus on this issue from the scientific community. A number of researchers have proposed that the number of results supporting the efficacy of cognitive training may be inflated due to placebo effects. Boot et al. [1] (2013) suggest that placebo effects need to be better controlled by using an active control and measuring participant expectations for improvement on outcome measures. Objective: This review examines placebo control methodology for recent evaluation studies of computerized cognitive training programs with older adult subjects, specifically looking for use of active control and measurement of expectations. Methods: Data sources: PubMed. Study eligibility criteria: Studies of computerized cognitive training published between 2016 and 2018. Participants and interventions: Evaluation studies of computerized cognitive training with older adult subjects (age 50+). Study appraisal and synthesis methods: Methods sections of studies were searched for (1) control type (active or passive) and sub-type (active: active-ingredient or similar-form; passive: no-contact or passive-task); (2) if expectations were measured: how were they measured, and whether they were used in analysis; (3) whether researchers acknowledged lack of active control and lack of expectation measurement as limitations (where appropriate). Results: Results: 4 of 19 (~21%) of eligible studies measured expectations. 9 of 19 (~47%) included an active control condition, all of which were of the similar-form type. The majority (10 studies, or ~53%) used only a passive control. 9 of these studies found results supporting efficacy of cognitive training, 5 of which were for far transfer effects. Conclusions: Conclusions: 47% of reviewed studies had poor placebo control, yet still published results supporting the effectiveness of cognitive training programs. 5 of these positive results were for far transfer effects, which form the basis for broad claims by cognitive training game makers about the scientific validity of their product. For a minimum level of placebo control, future evaluation studies should use a similar-form active control and administer a questionnaire to participants at the end of the training period about their own perceptions of improvement. Researchers are encouraged to think of more methods for the valid measure of expectations at other time points in the training.

  • Experiences of Adults with Type 1 Diabetes Using Glucose Sensor-Based Mobile Technology for Glycemic Variability: A Qualitative Study

    From: JMIR Diabetes

    Date Submitted: Mar 15, 2019
    Open Peer Review Period: Mar 18, 2019 - May 13, 2019

    Background: Adults with type 1 diabetes (PWDs) face challenging self-management regimens including monitoring their glucose values multiple times a day to assist with achieving glycemic targets and reduce the risk of long-term diabetes complications. Recent advances in diabetes technology have reportedly improved glycemia, but little is known about how PWDs utilize mobile technology to make positive changes in their diabetes self-management. Objective: This qualitative study explored PWDs’ experiences using “Sugar Sleuth,” a glucose sensor-based mobile app and web-based reporting system integrated with the FreeStyle Libre glucose monitor that provides feedback about glycemic variability. Methods: We used a qualitative descriptive research design and conducted semi-structured interviews with 10 PWDs (baseline A1c 8.0% ± 0.4; 60% male, 52±16 years old, T1D duration 31±14 years, 40% insulin pump) following a 14-week intervention during which they received clinical support and used “Sugar Sleuth” to review glucose data. Audio-recorded interviews were transcribed, coded, and analyzed using thematic analysis and NVivo 11. Results: Four main themes emerged from the data. Participants perceived “Sugar Sleuth” as an Empowering Tool that served to inform lifestyle choices and diabetes self-management tasks, promoted pre-emptive self-care actions, and improved discussions with clinicians. They also described “Sugar Sleuth” as providing a Source of Psychosocial Support and offering relief from worry, reducing glycemic uncertainty and supporting positive feelings about everyday life with diabetes. Participants varied in their Approaches to Glycemic Data: 40% described using “Sugar Sleuth” to review data, understand glycemic cause and effect, and plan for future self-care. On the other hand, 60% described focusing only on the feedback from immediate numbers and trend arrows, receiving benefit from this information but feeling reluctant to review past data. Finally, only two participants voiced Concerns about Use of “Sugar Sleuth”; they perceived the app as sometimes too demanding of information or as not attuned to the socio-economic backgrounds of PWDs from diverse populations. Conclusions: Results suggest that “Sugar Sleuth” can be an effective educational tool to enhance both patient-clinician collaboration and diabetes self-management. Findings also highlight the importance of exploring psychosocial and socio-economic factors that may advance the understanding of PWDs’ individual differences when using glycemic technology and may promote the development of customized mobile tools to improve diabetes self-management.

  • Novel Machine Learning Method for Prediction Using Times Series Data: Initial Application to Prediction of On Road Exam Outcomes from Virtual Driving Test Data

    From: Journal of Medical Internet Research

    Date Submitted: Mar 12, 2019
    Open Peer Review Period: Mar 15, 2019 - May 10, 2019

    Background: A large midwestern state commissioned a virtual driving test (VDT) to assess safe driving skills preparedness before the on-road license examination (ORE). Since July, 2017, a pilot deployment of the VDT in state licensing centers (VDT pilot) has collected both VDT and ORE data from new license applicants with an aim to create a scoring algorithm. Objective: Leveraging data collected from the VDT pilot, this study aimed to develop and conduct an initial evaluation of a novel machine learning-based classifier using limited domain knowledge and minimal feature engineering to predict applicant pass/fail on the ORE. Such methods, if proven useful, could be applicable to classification of other time series data collected within medical and other settings. Methods: We analyzed an initial dataset comprised of 4,308 drivers who completed both the VDT and the ORE; where 1,096 (25.4%) drivers went on to fail the ORE. We studied two different approaches to constructing feature sets to use as input to machine learning (ML) algorithms: the standard method of reducing the time series data to a set of manually defined variables that summarize driving behavior, and a novel approach using time series clustering. We then fed these representations into different ML algorithms to compare their ability to predict a driver’s ORE outcome. Results: The new method using time series clustering performed similarly compared to the standard method in terms of overall accuracy (0.761 vs. 0.762) and AUC (0.656 vs. 0.682). However, the time series clustering slightly outperformed the standard method in differentially predicting failure versus passing the ORE: those predicted to fail were three times more likely to fail the ORE than those predicted to pass (novel clustering method yields a risk ratio of 3.07 [95% CI: 2.75, 3.43]); standard variables method, 2.68 [95% CI: 2.41, 2.99]. Also, the time series clustering method with logistic regression produced the lowest ratio of false alarms (0.27). Conclusions: Our results provide initial evidence that the clustering method has utility for feature construction in classification tasks involving time series data when resources are limited to create multiple, domain-relevant variables

  • Pilot and Feasibility Test of a Mobile Health-Supported Intervention for Stopping Hypertension

    From: JMIR Formative Research

    Date Submitted: Mar 12, 2019
    Open Peer Review Period: Mar 15, 2019 - May 10, 2019

    Background: The seminal Dietary Approaches to Stopping Hypertension (DASH) study demonstrated the effectiveness of diet to control hypertension, however, effective implementation and dissemination of its principles have been limited. Objective: We hypothesize that a smartphone version of the DASH diet that uses automatic data collection, social networks, and “in-the-moment” feedback will be an effective medium for the delivery of DASH. Methods: We conducted a single arm pilot study from August 2015 - August 2016 with a pre-post evaluation design to evaluate the feasibility and preliminary efficacy of a smartphone version of DASH incorporating human health-coaching. Results: Seventeen patients participated; they had a mean age of 59 years (SD 6) and 60% were women. Engagement was high: out of 90 days, the mean number of logged blood pressures was 63 (SD 46), recorded weights was 52 (SD 45), and recorded steps was 55 (SD 36). 73% of coaching phone calls were completed. The mean number of servings documented per patient for the dietary assessment was 709 (SD 541), and patients set a mean number of 5 (SD 2) goals. Mean systolic and diastolic blood pressure, heart rate, weight, body mass index; or steps did not significantly change over time. Conclusions: Successful lifestyle change interventions require substantial patient motivation, engagement, and access to experts. Our study was underpowered to evaluate for change in clinical outcomes; however, the high engagement of DASH mobile suggests that the “in-the-moment” delivery of DASH mobile may be a way to integrate and sustain behavioral change in HTN management. Future implementations of DASH can include integrated calendars, alarms, social networks, GPS or other smartphone tools to allow the delivery of behavioral feedback and education to the specific to the user’s behavior.

  • Background: Precision medicine (PM) is a growing area of interest in cancer care. Although the terms ‘precision medicine’ and ‘personalized medicine’ are used interchangeably, the former may be new both to cancer patients and the general population. Most previous studies evaluated peoples’ attitudes towards genetic testing as a part of personalized medicine and included a single stakeholder, either patients or the general population. Few studies have evaluated cancer patients’ knowledge and perception regarding PM. Objective: To evaluate cancer patients’ awareness, knowledge, as well as perceived benefits and barriers regarding PM, and their willingness to participate in a national registry for PM, in comparison to those of the general population. Methods: We conducted a cross-sectional survey on 1,500 consecutive cancer patients enrolled at two university-based cancer hospitals in Seoul, Korea; 1,500 people who were representative of the Korean population were enrolled as controls. Multivariable logistic regression was conducted to identify the factors associated with a willingness to participate in a national registry for PM. Results: : In the total population, 20.0% of the cancer patients had heard of PM and 35.1% were able to accurately define it. Cancer patients were three times likelier to express a willingness to participate in a national registry for PM than the general population (95% confidence interval [CI], 2.47-3.61). Participants who had heard of PM (cancer patients: adjusted odds ratio (aOR) = 1.40, 95% CI, 1.00-1.95; general population: aOR = 2.04, 95% CI, 1.62-2.56) and who had a more positive perception of the PM-related benefits (cancer patients: aOR = 2.48, 95% CI, 1.88-3.27; general population: aOR = 1.34, 95% CI, 1.05-1.71) were likelier to be willing to participate in a national registry for PM. Conclusions: While PM is gaining importance in clinical settings, a majority of cancer patients are not well-informed about it. Nevertheless, the patients in our study perceived PM as being associated with various benefits and showed a willingness to participate in a national registry for PM. Considerable efforts need to be taken to educate the public and advocate participation in studies on PM

  • Public Perception and Misconceptions about Chemotherapy as a Cancer Treatment: Analysis of Arabic Twitter Content

    From: Journal of Medical Internet Research

    Date Submitted: Mar 12, 2019
    Open Peer Review Period: Mar 15, 2019 - May 10, 2019

    Background: Even though chemotherapy has been first introduced for cancer treatment more than 60 years ago, the public understanding and acceptance of it might be in doubt. Objective: This study aimed to assess the public perception and misconceptions that have been shared on Twitter regarding chemotherapy as a cancer treatment. Methods: All tweets containing any of the representative set keywords and written between 1st of May to 31st of October 2017 were retrieved. A manual content analysis to identify categories of users, general themes of tweets and the common misconceptions was carried out. A chi-square test for independence with adjusted residuals was used to assess for significant associations between the categories of users and themes of the tweets. Results: A total of 402,157 tweets were retrieved. Out of that, we excluded 309,602 retweets, and 62,651 irrelevant tweets. Therefore, 29,904 tweets were included in the final analysis. ‘General users’ were the majority (86.2%) followed by ‘cancer patients’ relatives and friends’ (6.4%). Tweets fell into nine themes where ‘prayers and wishes’ was the most common theme (67.8%), followed by ‘misconceptions’ (7%). There was a highly significant association between the category of user and the themes of tweets (X2 (40) = 16904.45, P-value <0.0001). Conclusions: Our findings add to previous studies that showed Twitter as a valuable opportunity to assess public perception and misconceptions about various health-related topics. Most of the tweets in our sample delivered supportive messages for the patients undergoing chemotherapy which suggests a possible role for the Twitter as a support mechanism for those patients. Misconceptions were also the second most prevalent theme. Our exploratory analysis should help physicians and organizations tailor future educational efforts to address these areas of misconception.

  • ICT Systems to Tackle Barriers to Breastfeeding: A Systematic Literature Review

    From: Journal of Medical Internet Research

    Date Submitted: Mar 11, 2019
    Open Peer Review Period: Mar 14, 2019 - May 9, 2019

    Background: Breastfeeding has many benefits for newborns, mothers, and wider society. WHO recommends mothers to feed newborns exclusively with breastmilk for the first six months after birth but breastfeeding rates in many countries fail to align with the recommendations due to various barriers. Breastfeeding success is associated with a number of determinants, such as self-efficacy, intention to breastfeed, and attitudes toward breastfeeding. Information and Communication Technology (ICT) has been leveraged to support breastfeeding by means of improving knowledge or providing practical supports in different maternal stages. Prior reviews have examined the effectiveness and credibility of interventions although a thorough analysis of technology design and other quality attributes is not yet done. Objective: This review aims to provide a comprehensive overview of existing ICT-based interventions to support breastfeeding by investigating their goals, technology design, validation process, clinical effectiveness, quality attributes and their impact on breastfeeding determinants. Methods: A systematic review was conducted in accordance with PRISMA guidelines in the following libraries: PubMed, Science Direct, ACM and IEEE. Results: Thirty-five papers discussing 30 interventions were included. The main goals of these interventions were organized to four categories: 1) breastfeeding education (n=12), 2) breastfeeding promotion (n=8), 3) communication support (n=6), and 4) daily practical support (n=4). Thirteen of the interventions target mothers in the postnatal period. Web technologies (n=11) and smartphone applications (n=6) have been the most frequently used technology platforms to provide breastfeeding support. The interventions were validated with different methods: 12 user studies concerned usability and user experience, and 18 clinical validation studies focused on the effects of the interventions on breastfeeding determinants; five papers did not report their results. Conclusions: This review shows that most of the interventions support breastfeeding by means of breastfeeding education. Web and smartphone are the two popular platforms to deploy the interventions due to their ubiquitous nature. Our results have indicated that the duration of exclusive breastfeeding and other breastfeeding determinants were rarely improved although some interventions succeeded in improving breastfeeding knowledge. Relevant stakeholders like partners were generally excluded from the interventions, and very few interventions included usability, user experience, and user satisfaction evaluations in addition to their clinical validation studies.

  • Integrating self-management needs and theory to implement a web-based self-management tool for people with Type 1 diabetes using an insulin pump

    From: Journal of Medical Internet Research

    Date Submitted: Mar 11, 2019
    Open Peer Review Period: Mar 14, 2019 - May 9, 2019

    Background: Type 1 diabetes (T1D) is an autoimmune disease requiring intensive self-management (SM). An insulin pump (a new health technology) is designed to better support personal T1D management but at the same time exacerbates the complexity and requirements of SM. Research shows that people with diabetes are likely to benefit from navigating and connecting to local means of social-support and resources from online interventions which offer flexible, innovative and accessible SM. However, questions remain as to which behaviour change mechanisms within such resources benefit patients most and how to foster engagement with and endorsement of SM interventions from both patients and healthcare professionals (HCPs). Objective: The aim of this study was to evaluate the perspectives and experiences of people with T1D using an insulin pump and specialist HCPs pertaining to a web-based social network (SN) intervention to support SM and determine what behaviour change characteristics and strategies are required. Methods: Focus Groups with insulin pump users (N=19) and specialist HCPs (N=20) in 6 NHS Trusts across the South of England examined the barriers and enablers to incorporating and self-managing an insulin pump. Analysis was undertaken using the Behaviour Change Wheel and Theoretical Domains Framework followed by a taxonomy of Behaviour Change Techniques (BCTs) to identify the contents of and strategies for implementation of a complex health intervention. Results: Four themes represent the SM perspectives and experiences of stakeholders: (1). A desire for access to tailored and appropriate resources and information - the support and information required for successful SM is situational, contextual and varies according to time and life circumstances and so needs to be tailored and appropriate; (2). Specific social-support preferences - taking away isolation, providing shared learnings and practical tips, but limitations included the fear of judgement from others and self-pity from peers; (3). The environmental context: Capacity and knowledge of pump clinic HCPs - HCPs acknowledge patient’s need for holistic support but lack confidence in providing it; and (4). Professional responsibility: “Risks and dangers” – HCPs are bombarded with “risks and dangers” around SM support for patients and question whether it fits into their role. BCTs were identified to address these issues. Conclusions: The use of a behavioural theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers to and enablers of self-managing T1D with an insulin pump. A web-based SN intervention appears to offer additional forms of SM support while complimenting NHS services. However in order for intervention implementation, HCP apprehensions about responsibility when signposting to outside agencies or support would need to be addressed, and opportunistic features added where pump users could actively engage with other people living with T1D.

  • Using the Extended Parallel Process Model to Examine the Nature and Impact of Breast Cancer Prevention Information in Mobile Social Media

    From: JMIR mHealth and uHealth

    Date Submitted: Mar 11, 2019
    Open Peer Review Period: Mar 14, 2019 - May 9, 2019

    This study aims to examine the nature and impact of health information in mobile social media. Specifically, we investigate how the levels of threat and efficacy of breast cancer prevention information affect individuals’ engagement with the information, such as readings and likes. Breast cancer prevention articles posted on a Chinese mobile social media platform (i.e. WeChat SA) from 1st January to 31st December, 2017 were extracted using the Python Web Crawler. We used content analysis and ANCOVA to analyze our data. The results revealed that breast cancer prevention information on WeChat SA was well designed. Moreover, the level of threat and efficacy of breast cancer prevention information significantly affected the number of readings and likes.

  • Background: Globally, cardiovascular disease is the leading cause of death. Cardiovascular mortality can be decreased by participation in cardiac rehabilitation. Researchers are exploring the use of mHealth technology in cardiac rehabilitation. Objective: The aim of this systematic review is to examine the effectiveness of randomized controlled trials that use a mHealth intervention as a part of an outpatient and/or home-based cardiac rehabilitation program on improving physical activity and physical fitness outcomes. Methods: For this systematic review, mHealth interventions were limited to text messaging, mobile apps, and use of a mobile phone network for data transmission, used to deliver cardiac rehabilitation program. Using six databases, the search strategy included published English language studies through 2016. Data was extracted independently by two reviewers, and then synthesized. Results: The initial search yielded 149 articles, of which 15 articles that represented nine studies met inclusion criteria. Articles were published from 2010 to 2016 and came from two continents. The majority (84%) of participants were male. Generally, the participant mean age was late 50s to early 60s. Text messaging was the most frequently used intervention. The results of the physical activity and physical fitness findings were mixed. Effect sizes for intervention as measured by the 6-minute walk test ranged from 0.46 to 0.58 and peak VO2 ranged from 0.03 to 1.35. Conclusions: Globally, use of mHealth in outpatient and/or home-based cardiac rehabilitation is being studied with greater attention. However, these studies are limited by geography, gender, and age. Therefore, further research in the area of cardiac rehabilitation and mHealth is recommended, especially in developing countries, among women, and older adults.

  • Microlearning in Health Professions Education: Scoping Review

    From: JMIR Medical Education

    Date Submitted: Mar 12, 2019
    Open Peer Review Period: Mar 13, 2019 - May 8, 2019

    Background: Microlearning, the acquisition of knowledge or skills in the form of small units, is endorsed by health professions educators as a means of facilitating student learning, training, and continuing education, but it is difficult to define in terms of its features and outcomes. Objective: The goal of this review was to conduct a systematic search of the literature on microlearning in health professions education to identify key concepts, characterize microlearning as an educational strategy, and evaluate pedagogical outcomes experienced by health professions students. Methods: A scoping review was performed in 2018 using the bibliographic databases PubMed (MEDLINE), CINAHL, Education Resources Information Center, Embase, PsycINFO, Education Full Text (H.W. Wilson), and ProQuest Dissertations & Theses Global. A combination of keywords and subject headings related to microlearning, e-learning, or just-in-time learning combined with health professions education were used. No date limits were placed on the search, but inclusion was limited to materials published in English. Pedagogical outcomes were evaluated on the basis of the four-level Kirkpatrick’s model. Results: A total of 3,096 references were retrieved, of which 17 articles were selected after applying the inclusion and exclusion criteria. Articles that met the criteria were published between 2011 and 2018, and their authors were from a range of countries including the United States, China, India, Australia, Canada, Iran, Netherlands, Taiwan, and the United Kingdom. The 17 studies reviewed included various health-related disciplines, such as medicine, nursing, pharmacy, dentistry, and allied health. While microlearning appeared in a variety of subject areas, different technologies, such as podcast, short messaging service, microblogging, and social networking service, were also used. Based on Buchem and Hamelmann’s 10 microlearning concepts, each study satisfied at least 40% of the characteristics while all studies featured concepts of maximum time spent less than 15 minutes as well as content aggregation. According to our assessment of each article using the Kirkpatrick's model, 16 (94%) assessed student reactions to the microlearning (level 1); 14 (82%) evaluated knowledge or skill acquisition (level 2); 5 (29%) measured the effect of the microlearning on student behavior (level 3), and no studies were found at the highest level. Conclusions: Microlearning as an educational strategy has demonstrated a positive effect on the knowledge and confidence of health professions students in performing procedures, retaining medication knowledge, studying, and engaging in collaborative learning. However, downsides to mirolearning include pedagogical discomfort, technology inequalities, and privacy concerns. Future research should look at higher-level outcomes including benefits to patients or practice changes. The findings of this scoping review will inform education researchers, faculty, and academic administrators on the application of microlearning, pinpoint gaps in the literature, and help identify opportunities for instructional designers and subject matter experts to improve course content in didactic and clinical settings.

  • Determinants of Instagram Use: A Cross-sectional Questionnaire Study

    From: Journal of Medical Internet Research

    Date Submitted: Mar 12, 2019
    Open Peer Review Period: Mar 13, 2019 - May 8, 2019

    Background: Instagram counts over one billion users, yet the determinants behind its use, its addiction potential and relation to well-being are poorly understood. Objective: Our goal is to (1) investigate the demographic and socio-cognitive determinants of (low, medium and high) Instagram use, (2) the prevalence of Instagram addiction, (3) the relation between Instagram use, self-esteem and life satisfaction and (4) examine how these factors (1-3) explain Instagram usage intensity. Methods: A total of 237 participants (18-35 years) filled in an online questionnaire based on self-constructed scales measuring Instagram/social networking use and determinants of Instagram use, a short version of Young’s Internet Addiction Test, the Rosenberg Self-esteem scale and the Satisfaction with life scale. The data was analyzed with one-way ANOVAs, multiple regression analysis and Pearson’s correlations. Results: The model of the linear regression explained 41.2% of the variance of Instagram use in minutes, F(22, 214)=6.82, P<.001. Variance was mostly explained by social influence (β=.23, P<.001), perceived susceptibility to intensive use (β=.34, P<.001) and female sex (β=-.11, P=.047). Self-efficacy (r=0.48, P<.001), attitude pro (.45, P<.001), attitude con (r=0.33, P<.001) and social influence (r=0.36, P<.001) correlated moderately to largely with Instagram use in minutes. Age (r=-0.21, P=.001) and intention (r=0.16, P=.01) showed smaller effects, while self-esteem and life satisfaction showed no associations with Instagram use. In this study, 7.2% (N=14) participants classified as Instagram addicts while 37.5% (N=89) felt at substantial risk of using Instagram more than two hours daily. Time spent on Instagram daily was related to preferred Instagram functions and medium and high users used Instagram more passively than low ones. Conclusions: Instagram use was shown to be especially pronounced among younger females with lower self-efficacy that held strong positive and negative attitudes towards Instagram. Moreover, passive use patterns, higher social influence and perceived susceptibility towards Instagram promoted Instagram use. While many users experienced drawbacks of Instagram use in isolated areas like distraction at work or overthinking one’s self-presentation, addiction prevalence was low and no relation between Instagram use and self-esteem or life satisfaction was found. Female sex, perceived susceptibility to intensive use and social influence explained variances in daily Instagram use in minutes the best.

  • #Pugua: An Instagram-based study to understand betel nut use culture in Micronesia

    From: Journal of Medical Internet Research

    Date Submitted: Mar 7, 2019
    Open Peer Review Period: Mar 12, 2019 - May 7, 2019

    Background: A 2012 WHO report recognizes betel nut use as an urgent public health threat faced by the Western Pacific region. Yet, compared to other addictive substances, little is known about how the use of betel nut is depicted on social media platforms. Objective: The purpose of the study explores and documents the ways that betel nut is portrayed on the photo-sharing site Instagram. The analysis focuses on the hashtag #pugua, which refers to the local term for betel nut on Guam and other parts of Micronesia. Methods: A mixed-method approach applied social media data analytics and content analysis to 284 Instagram posts tagged #pugua. Frequency analysis of word count, likes and comments, and content themes were conducted for each Instagram post. Results: Text analysis of 242 relevant Instagram posts revealed consistent themes around Chamorro culture and language. Visual content analysis of Instagram found seven overall content themes with the majority of Instagram posts referencing the betel nut or tree and aspects of its consumption and use. Local culture related to Guam and the Pacific Islands emerged as a second important theme. Conclusions: The visual nature of Instagram reflects the cultural and island life in Guam. Our findings demonstrate the complex social context that ties #pugua to its audience and cultural message. Findings from this study may guide Western Pacific health efforts toward the development and implementation of effective health promotion and behavioral change using social media.

  • Integration of Hospital Room Hospitality Features onto Patient-Controlled Tablet Computers

    From: Journal of Medical Internet Research

    Date Submitted: Mar 8, 2019
    Open Peer Review Period: Mar 12, 2019 - May 7, 2019

    Background: Patient portals tethered to electronic heatlh records can improve patient experience, activation, and outcomes. However, adoption of inpatient portals have been challenging. One way to potentially increase inpatient portal usage is to integrate it with a room control app found on a common tablet computer. Objective: To perform a retrospective analysis of patient usage of a room control app found on tablet computers in patient rooms of our new inpatient tower. Methods: We identified all patients who were admitted for >24 hours to our new inpatient tower over a 90-day period. We then identified patients who used the room control app at least one time during their admission. We linked this data to patient demographics (including age, sex, and race) and admitting service. We then performed univariable and multivariable logistic regression to assess patterns of room control app usage. Results: A total of 3,411 patients were admitted over the course of study period and 2,242 (65.7%) used the room control app during their hospitalization. Compared to white patients, other/mixed/unknown race and Asian/Hawaiian/Pacific Islanders/American Indian race were significantly associated with increased use of the room control app in multivariable analysis. Increasing age was significantly associated with increased usage of the room control app. Usage of the room control app also varied by admitting services. Compared to general medicine, bone marrow transplant and general surgery patients had increased usage of the room control app. Conversely, critical care, medical specialty, neurology, surgical subspecialty, and obstetrics/gynecology were all associated with decreased usage of the room control app. Conclusions: Integrating room controls with inpatient portals offer a potential strategy to increase patient utilization of inpatient portals. Contrary to common belief, older patients may utilize tablet-enabled room controls just as often, if not more often, than younger patients. Certain admitting services, such as neurology and surgical subspecialties, may have had lower usage rates due to accessibility issues. Our study allows hospitals to tailor support for specific patient populations to increase room control app usage.

  • The epidemiology of email addresses. Security and ethical considerations for the communication between hospitals and patients raised by the study of emails’ domain names

    From: Journal of Medical Internet Research

    Date Submitted: Mar 12, 2019
    Open Peer Review Period: Mar 12, 2019 - May 7, 2019

    Background: Healthcare professionals are caught between the wish of patients to speed up health-related communication via emails and the need of protecting health information. The inconsistency between these two aspects is a part of the privacy paradox. Objective: The aim is to analyze the privacy breach risks associated with the use of emails of patients. Methods: Between 2000 and November of 2018, 971,822 patients of the European Hospital Georges Pompidou (HEGP) were included in the clinical information system. Results: The HEGP has collected 41,004 patient email addresses (4.2% of the total population of patients), from which 37,779 associated with known email providers, 31,005 email addresses associated with Google, Microsoft, Orange and Yahoo, 2,878 to professional emails addresses and 347 email addresses to personalized domain names. Conclusions: Patients’ emails expose them to a privacy breach. We recommend a very restrictive use of the emails for health communication.

  • mHealth coaching on nutrition and lifestyle behaviors for subfertile couples using the Smarter Pregnancy program: a model-based cost-effectiveness analysis

    From: Journal of Medical Internet Research

    Date Submitted: Mar 6, 2019
    Open Peer Review Period: Mar 11, 2019 - May 6, 2019

    Background: The healthcare costs for reproductive care have substantially increased by the use of in vitro fertilization (IVF) treatment. The mHealth coaching program Smarter Pregnancy is an effective intervention to improve nutrition and lifestyle behaviors and pregnancy rates in (sub)fertile couples, including those who undergo IVF treatment. Therefore, we hypothesize that this mHealth program also reduces healthcare costs associated with IVF treatment. Objective: To evaluate the cost-effectiveness of the mHealth coaching program Smarter Pregnancy versus usual care in women of subfertile couples who start their first IVF cycle. Methods: This model-based cost-effectiveness analysis was performed on data from couples undergoing IVF treatment at the Erasmus MC, University Medical Center Rotterdam. A decision tree model was used to assess the incremental cost-effectiveness ratio (ICER) of ongoing pregnancies and costs of use of the mHealth program versus usual care. A probabilistic sensitivity analysis was performed to consider the uncertainty surrounding the point estimates of the input parameters. Results: Based on our model, including 793 subfertile women undergoing IVF treatment, the use of the mHealth program resulted in 86 additional pregnancies and saved €270,000 compared to usual care after two IVF cycles, with an ICER of -€3,050 (95%CI -3,960;-540) per additional pregnancy. The largest cost saving was caused by the avoided IVF treatment costs. Sensitivity analyses showed that the mHealth program needs to increase the ongoing pregnancy rate with at least 51% after two IVF cycles in order to be cost saving. Conclusions: The mHealth coaching program Smarter Pregnancy is potentially cost-saving for subfertile couples preceding their first IVF treatment. Implementation of this mHealth program in routine preconception care for subfertile couples should be seriously considered given the relatively low costs and promising cost-effectiveness estimates. Clinical Trial: Dutch Trial Registration: NTR1450

  • Building a Semantic Health Data Warehouse: Evaluation of a search tool in Clinical trials

    From: Journal of Medical Internet Research

    Date Submitted: Mar 5, 2019
    Open Peer Review Period: Mar 8, 2019 - May 3, 2019

    Background: The huge amount of clinical, administrative and demographic data recorded and maintained by hospitals can be consistently aggregated into Health Data Warehouses (HDWs) with a uniform data model. In 2017, Rouen University Hospital (RUH) initiated the design of a Semantic Health Data Warehouse (SHDW) enabling both semantic description and retrieval of health information. Objective: Our objectives were: first, to present a proof of concept of this SHDW, based on the data of 250,000 patients from RUH and second, to assess its ability to assist health professionals to select patients in a clinical trials context. Methods: The SHDW relies on three distinct semantic layers: (a) a Terminology and Ontology (T&O) portal, (b) a Semantic Annotator and (c) a Semantic Search Engine and a Not Only SQL (NoSQL) layer to enhance data access performances. The system adopts an entity-centered vision which contrasts with the usually patient-centered vision adopted by existing systems such as Informatics for Integrating Biology and the Bedside (i2b2). This vision notably provides generic search capabilities able to express data requirements in terms of the whole set of interconnected conceptual entities that compose health information. We assessed the ability of the system to assist the search for 95 inclusion and exclusion criteria originating from five randomly chosen Clinical Trials from RUH. Results: The system succeeded in fully automating 39.19% of the criteria and was efficiently used as a pre-screening tool for 72.97% of them. Conclusions: The semantic aspect of the system combined with its generic entity-centered vision enables the processing of a large range of clinical questions. However, an important part of health information remains in Clinical Narratives and we are currently investigating novel approaches (deep learning) to enhance the semantic annotation of those unstructured data.

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

    From: JMIR Preprints

    Date Submitted: Oct 7, 2018
    Open Peer Review Period: Dec 30, 2018 - Dec 15, 2019

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