JMIR Publications

Journal of Medical Internet Research

The leading peer-reviewed journal for health and healthcare in the Internet age.

JMIR's Thomson Reuter Impact Factor of 4.5 for 2015

Recent Articles:

  • BACRA. Image source and copyright owned by the authors Irene et al.

    Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents


    Background: Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. Objective: The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. Methods: The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA’s design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. Results: BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). Conclusions: BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use.

  • A medical officer explains an x-ray to the patient. Source: Copyright: Rhoda Baer. License: Public Domain.

    Using Foreign Virtual Patients With Medical Students in Germany: Are Cultural Differences Evident and Do They Impede Learning?


    Background: Learning with virtual patients (VPs) is considered useful in medical education for fostering clinical reasoning. As the authoring of VPs is highly demanding, an international exchange of cases might be desirable. However, cultural differences in foreign VPs might hamper learning success. Objective: We investigated the need for support for using VPs from the United States at a German university, with respect to language and cultural differences. Our goal was to better understand potential implementation barriers of a intercultural VP exchange. Methods: Two VPs were presented to 30 German medical students featuring a cultural background different from German standards with respect to diagnostic and therapeutic procedures, ethical aspects, role models, and language (as identified by a cultural adaptation framework). Participants were assigned to two groups: 14 students were advised to complete the cases without further instructions (basic group), and 16 students received written explanatory supplemental information specifically with regard to cultural differences (supplement group). Using a 6-point scale (6=strongly agree), we analyzed the results of an integrated assessment of learning success as well as an evaluation of cases by the students on usefulness for learning and potential issues regarding the language and cultural background. Results: The German students found it motivating to work with cases written in English (6-point scale, 4.5 points). The clinical relevance of the VPs was clearly recognized (6 points), and the foreign language was considered a minor problem in this context (3 points). The results of the integrated learning assessment were similar in both groups (basic 53% [SD 4] vs supplement 52% [SD 4] correct answers, P=.32). However, students using the supplemental material more readily realized culturally different diagnostic and therapeutic strategies (basic 4 vs supplement 5 points, P=.39) and were less affirmative when asked about the transferability of cases to a German context (basic 5 vs supplement 3 points, P=.048). Conclusions: German students found English VPs to be highly clinically relevant, and they rated language problems much lower than they rated motivation to work on cases in English. This should encourage the intercultural exchange of VPs. The provision of supplemental explanatory material facilitates the recognition of cultural differences and might help prevent unexpected learning effects.

  • 9/11 Veterans. Image created and permission granted by James Greene, SFC (Ret.), Vermont Army National Guard.

    Post-9/11 Veterans and Their Partners Improve Mental Health Outcomes with a Self-directed Mobile and Web-based Wellness Training Program: A Randomized...


    Background: Veterans with history of deployment in the Global War on Terror face significant and ongoing challenges with high prevalences of adverse psychological, physical, spiritual, and family impacts. Together, these challenges contribute to an emerging public health crisis likely to extend well into the future. Innovative approaches are needed that reach veterans and their family members with strategies they can employ over time in their daily lives to promote improved adjustment and well-being. Objective: The objective of this study was to evaluate effects of use of a Web-based, self-directed program of instruction in mind- and body-based wellness skills to be employed by Global War on Terror veterans and their significant relationship partners on mental health and wellness outcomes associated with postdeployment readjustment. Methods: We recruited 160 veteran-partner dyads in 4 regions of the United States (San Diego, CA; Dallas, TX; Fayetteville, NC; and New York, NY) through publicity by the Iraq and Afghanistan Veterans of America to its membership. Dyads were randomly allocated to 1 of 4 study arms: Mission Reconnect (MR) program alone, MR plus the Prevention and Relationship Enhancement Program (PREP) for Strong Bonds weekend program for military couples, PREP alone, and waitlist control. We administered a battery of standardized and investigator-generated instruments assessing mental health outcomes at baseline, 8 weeks, and 16 weeks. Dyads in the MR arms were provided Web-based and mobile app video and audio instruction in a set of mindfulness-related stress reduction and contemplative practices, as well as partner massage for reciprocal use. All participants provided weekly reports on frequency and duration of self-care practices for the first 8 weeks, and at 16 weeks. Results: During the first 8-week reporting period, veterans and partners assigned to MR arms used some aspect of the program a mean of 20 times per week, totaling nearly 2.5 hours per week, with only modest declines in use at 16 weeks. Significant improvements were seen at 8 and 16 weeks in measures of posttraumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to MR arms. In addition, significant reductions in self-reported levels of pain, tension, irritability, anxiety, and depression were associated with use of partner massage. Conclusions: Both veterans and partners were able to learn and make sustained use of a range of wellness practices taught in the MR program. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. Use of the MR program appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among post-9/11 veterans and their partners. Trial Registration: NCT01680419; (Archived by WebCite at

  • Senior using phone. Image source: License: CC0 Public Domain.

    The Inclusion of Ethnic Minority Patients and the Role of Language in Telehealth Trials for Type 2 Diabetes: A Systematic Review


    Background: Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and prevent secondary complications. However, trials designed to test the effectiveness of telehealth interventions may underrecruit or exclude ethnic minority patients, with language a potential barrier to recruitment. The underrepresentation of minorities in trials limits the external validity of the findings for this key patient demographic. Objective: This systematic review examines (1) the research reporting practices and prevalence of ethnic minority patients included in telehealth randomized controlled trials (RCTs) targeting type 2 diabetes and the trial characteristics associated with recruiting a high proportion of minority patients, and (2) the proportion of included RCTs that report using English language proficiency as a patient screening criterion and how and why they do so. Methods: Telehealth RCTs published in refereed journals targeting type 2 diabetes as a primary condition for adults in Western majority English-speaking countries were included. Ethnically targeted RCTs were excluded from the main review, but were included in a post hoc subgroup analysis. Abstract and full-text screening, risk of bias assessment, and data extraction were independently conducted by two reviewers. Results: Of 3358 records identified in the search, 79 articles comprising 58 RCTs were included. Nearly two-thirds of the RCTs (38/58) reported on the ethnic composition of participants, with a median proportion of 23.5% patients (range 0%-97.7%). Fourteen studies (24%) that included at least 30% minority patients were all US-based, predominantly recruited from urban areas, and described the target population as underserved, financially deprived, or uninsured. Eight of these 14 studies (57%) offered intervention materials in a language other than English or employed bilingual staff. Half of all identified RCTs (29/58) included language proficiency as a participant-screening criterion. Language proficiency was operationalized using nonstandardized measures (eg, having sufficient “verbal fluency”), with only three studies providing reasons for excluding patients on language grounds. Conclusions: There was considerable variability across studies in the inclusion of ethnic minority patients in RCTs, with higher participation rates in countries with legislation to mandate their inclusion (eg, United States) than in those without such legislation (eg, United Kingdom). Less than 25% of the RCTs recruited a sizeable proportion of ethnic minorities, which raises concerns about external validity. The lack of objective measures or common procedures for assessing language proficiency across trials implies that language-related eligibility decisions are often based on trial recruiters’ impressionistic judgments, which could be subject to bias. The variability and inconsistent reporting on ethnicity and other socioeconomic factors in descriptions of research participants could be more specifically emphasized in trial reporting guidelines to promote best practice. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRD42015024899; (Archived by WebCite at

  • Balance It icon. Image sourced and copyright owned by author Pepijn van Empelen (TNO).

    Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors (“Balance It”): A Pilot Study


    Background: Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of “Balance It,” a serious self-regulation game intervention targeting students’ overweight-related behaviors: dietary intake and physical activity (PA). Objective: We aimed to pilot the effects of Balance It on secondary vocational education students’ dietary intake and PA. Methods: In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8% (145/231) were female, and 26.8% (62/231) had a non-Dutch background. Body mass index (BMI kg/m2) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants. Results: After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6% (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users’ snack consumption decreased more strongly (active users: mean change=–0.20; control group: mean change=–0.08; beta=–0.36, P=.01, R2 change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=–0.12; beta=1.58, P=.02, R2 change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R2 change=.04) and action control (active users: mean change=0.63; control group: mean change=–0.05; beta=1.25, P=.001, R2 change=.08) in terms of unhealthy eating. Conclusions: The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6%). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight.

  • Pharmacy personnel deliver medical prescriptions electronically. Image source: License:Creative Commons Attribution 2.0 Generic.

    Professional Use of Social Media by Pharmacists: A Qualitative Study


    Background: Social media is frequently used by consumers and health care professionals; however, our knowledge about its use in a professional capacity by pharmacists is limited. Objective: Our aim was to investigate the professional use of social media by pharmacists. Methods: In-depth semistructured interviews were conducted with practicing pharmacists (N=31) from nine countries. Interviews were recorded, transcribed verbatim, and thematically analyzed. Results: Wikipedia, YouTube, and Facebook were the main social media platforms used. Professional use of social media included networking with peers, discussion of health and professional topics, accessing and sharing health and professional information, job searching, and professional promotion. Wikipedia was the participants’ first choice when seeking information about unfamiliar topics, or topics that were difficult to search for. Very few pharmacy-related contributions to Wikipedia were reported. YouTube, a video-sharing platform, was used for self-education. University lectures, “how-to” footage, and professionally made videos were commonly watched. No professional contribution was made to YouTube. Facebook, a general social networking site, was used for professional networking, promotion of achievements, and job advertisements. It also afforded engagement in professional discussions and information sharing among peers. Conclusions: Participants used social media in a professional capacity, specifically for accessing and sharing health and professional information among peers. Pharmacists, as medicines experts, should take a leading role in contributing to health information dissemination in these user-friendly virtual environments, to reach not only other health care professionals but also health consumers.

  • Experience of HIV. Image sourced and copyright owned by authors Ian Down et al.

    Australian Gay Men Describe the Details of Their HIV Infection Through a Cross-Sectional Web-Based Survey


    Background: With emerging opportunities for preventing human immunodeficiency virus (HIV) transmission, it remains important to identify those at greatest risk of infection and to describe and understand the contexts in which transmissions occur. Some gay and bisexual men with recently diagnosed HIV infection are initially unable to identify high-risk behaviors that would explain their HIV infection. We explored whether Web-based data collection could assist them in identifying the circumstances of their infection. Objective: To assess the capacity of a Web-based survey to collect reliable self-report data on the event to which gay and bisexual men ascribe their HIV infection. Methods: The HIV Seroconversion Study included a Web-based survey of gay and bisexual men with recently diagnosed HIV infection in Australia. Participants were asked if they could identify and describe the event they believe led to their infection. Men were also asked about their sexual and other risk practices during the 6 months before their diagnosis. Results: Most (403/506, 79.6%) gay and bisexual men with newly diagnosed HIV infection were able to identify and describe the circumstances that likely led to their infection. Among those who were initially unable to identify possible exposure events, many could nonetheless provide sensible information that ostensibly explained their seroconversion. Free-text responses allowed men to provide more detailed and contextual information, whereas questions about the totality of their sexual behavior before diagnosis provided opportunities for men to describe their sexual risk behavior in general. Overall, 84.0% indicated having engaged in condomless anal intercourse before their HIV diagnosis, including 71.8% in the receptive position. Conclusions: This study demonstrates the effectiveness of using Internet-based technologies to capture sensitive information about the circumstances in which HIV infection occurs among gay and bisexual men. By providing a range of opportunities for relaying experience, this research reveals some of the complexity in how individuals come to understand and explain their HIV infection. These findings may assist in obtaining detailed sexual history in the clinical setting.

  • Example visual display from CHART personalized feedback. Image sourced by authors and copyright owned and permitted by  UNC Lineberger Comprehensive Cancer Center’s CHAI Core.

    Impact of Game-Inspired Infographics on User Engagement and Information Processing in an eHealth Program


    Background: Online interventions providing individual health behavior assessment should deliver feedback in a way that is both understandable and engaging. This study focused on the potential for infographics inspired by the aesthetics of game design to contribute to these goals. Objective: We conducted formative research to test game-inspired infographics against more traditional displays (eg, text-only, column chart) for conveying a behavioral goal and an individual’s behavior relative to the goal. We explored the extent to which the display type would influence levels of engagement and information processing. Methods: Between-participants experiments compared game-inspired infographics with traditional formats in terms of outcomes related to information processing (eg, comprehension, cognitive load) and engagement (eg, attitudes toward the information, emotional tone). We randomly assigned participants (N=1162) to an experiment in 1 of 6 modules (tobacco use, alcohol use, vegetable consumption, fruit consumption, physical activity, and weight management). Results: In the tobacco module, a game-inspired format (scorecard) was compared with text-only; there were no differences in attitudes and emotional tone, but the scorecard outperformed text-only on comprehension (P=.004) and decreased cognitive load (P=.006). For the other behaviors, we tested 2 game-inspired formats (scorecard, progress bar) and a traditional column chart; there were no differences in comprehension, but the progress bar outperformed the other formats on attitudes and emotional tone (P<.001 for all contrasts). Conclusions: Across modules, a game-inspired infographic showed potential to outperform a traditional format for some study outcomes while not underperforming on other outcomes. Overall, findings support the use of game-inspired infographics in behavioral assessment feedback to enhance comprehension and engagement, which may lead to greater behavior change.

  • Survey. Image sourced and copyright owned by authors Valéry Risson et al.

    Linked Patient-Reported Outcomes Data From Patients With Multiple Sclerosis Recruited on an Open Internet Platform to Health Care Claims Databases Identifies...


    Background: An enormous amount of information relevant to public health is being generated directly by online communities. Objective: To explore the feasibility of creating a dataset that links patient-reported outcomes data, from a Web-based survey of US patients with multiple sclerosis (MS) recruited on open Internet platforms, to health care utilization information from health care claims databases. The dataset was generated by linkage analysis to a broader MS population in the United States using both pharmacy and medical claims data sources. Methods: US Facebook users with an interest in MS were alerted to a patient-reported survey by targeted advertisements. Eligibility criteria were diagnosis of MS by a specialist (primary progressive, relapsing-remitting, or secondary progressive), ≥12-month history of disease, age 18-65 years, and commercial health insurance. Participants completed a questionnaire including data on demographic and disease characteristics, current and earlier therapies, relapses, disability, health-related quality of life, and employment status and productivity. A unique anonymous profile was generated for each survey respondent. Each anonymous profile was linked to a number of medical and pharmacy claims datasets in the United States. Linkage rates were assessed and survey respondents’ representativeness was evaluated based on differences in the distribution of characteristics between the linked survey population and the general MS population in the claims databases. Results: The advertisement was placed on 1,063,973 Facebook users’ pages generating 68,674 clicks, 3719 survey attempts, and 651 successfully completed surveys, of which 440 could be linked to any of the claims databases for 2014 or 2015 (67.6% linkage rate). Overall, no significant differences were found between patients who were linked and not linked for educational status, ethnicity, current or prior disease-modifying therapy (DMT) treatment, or presence of a relapse in the last 12 months. The frequencies of the most common MS symptoms did not differ significantly between linked patients and the general MS population in the databases. Linked patients were slightly younger and less likely to be men than those who were not linkable. Conclusions: Linking patient-reported outcomes data, from a Web-based survey of US patients with MS recruited on open Internet platforms, to health care utilization information from claims databases may enable rapid generation of a large population of representative patients with MS suitable for outcomes analysis.

  • Woman using laptop. Image source: License: CC0 License.

    Can Facebook Be Used for Research? Experiences Using Facebook to Recruit Pregnant Women for a Randomized Controlled Trial


    Background: Recruitment is often a difficult and costly part of any human research study. Social media and other emerging means of mass communication hold promise as means to complement traditional strategies used for recruiting participants because they can reach a large number of people in a short amount of time. With the ability to target a specified audience, paid Facebook advertisements have potential to reach future research participants of a specific demographic. This paper describes the experiences of a randomized controlled trial in Edmonton, Alberta, attempting to recruit healthy pregnant women between 8 and 20 weeks’ gestation for participation in a prenatal study. Various traditional recruitment approaches, in addition to paid Facebook advertisements were trialed. Objective: To evaluate the effectiveness of paid advertisements on Facebook as a platform for recruiting pregnant women to a randomized controlled trial in comparison with traditional recruitment approaches. Methods: Recruitment using traditional approaches occurred for 7 months, whereas Facebook advertisements ran for a total of 26 days. Interested women were prompted to contact the study staff for a screening call to determine study eligibility. Costs associated with each recruitment approach were recorded and used to calculate the cost to recruit eligible participants. Performance of Facebook advertisements was monitored using Facebook Ads Manager. Results: Of the 115 women included, 39.1% (n=45) of the women who contacted study staff heard about the study through Facebook, whereas 60.9% (n=70) of them heard about it through traditional recruitment approaches. During the 215 days (~7 months) that the traditional approaches were used, the average rate of interest was 0.3 (0.2) women/day, whereas the 26 days of Facebook advertisements resulted in an average rate of interest of 2.8 (1.7) women/day. Facebook advertisements cost Can $506.91 with a cost per eligible participant of Cad $20.28. In comparison, the traditional approaches cost Cad $1087, with approximately Cad $24.15 per eligible participant. Demographic characteristics of women were similar between the 2 recruitment methods except that women recruited using Facebook were significantly earlier in their pregnancy than those recruited using traditional approaches (P<.03). Conclusions: Paid Facebook advertisements hold promise as a platform for reaching pregnant women. The relative ease of placing an advertisement, the comparable cost per participant recruited, and the dramatically improved recruitment rates in comparison with traditional approaches highlight the importance of combining novel and traditional recruitment approaches to recruit women for pregnancy-related studies. Trial Registration: NCT02711644; (Archived by WebCite at

  • Web search. Image source: License: CC0 Public Domain.

    Impact of Predicting Health Care Utilization Via Web Search Behavior: A Data-Driven Analysis


    Background: By recent estimates, the steady rise in health care costs has deprived more than 45 million Americans of health care services and has encouraged health care providers to better understand the key drivers of health care utilization from a population health management perspective. Prior studies suggest the feasibility of mining population-level patterns of health care resource utilization from observational analysis of Internet search logs; however, the utility of the endeavor to the various stakeholders in a health ecosystem remains unclear. Objective: The aim was to carry out a closed-loop evaluation of the utility of health care use predictions using the conversion rates of advertisements that were displayed to the predicted future utilizers as a surrogate. The statistical models to predict the probability of user’s future visit to a medical facility were built using effective predictors of health care resource utilization, extracted from a deidentified dataset of geotagged mobile Internet search logs representing searches made by users of the Baidu search engine between March 2015 and May 2015. Methods: We inferred presence within the geofence of a medical facility from location and duration information from users’ search logs and putatively assigned medical facility visit labels to qualifying search logs. We constructed a matrix of general, semantic, and location-based features from search logs of users that had 42 or more search days preceding a medical facility visit as well as from search logs of users that had no medical visits and trained statistical learners for predicting future medical visits. We then carried out a closed-loop evaluation of the utility of health care use predictions using the show conversion rates of advertisements displayed to the predicted future utilizers. In the context of behaviorally targeted advertising, wherein health care providers are interested in minimizing their cost per conversion, the association between show conversion rate and predicted utilization score, served as a surrogate measure of the model’s utility. Results: We obtained the highest area under the curve (0.796) in medical visit prediction with our random forests model and daywise features. Ablating feature categories one at a time showed that the model performance worsened the most when location features were dropped. An online evaluation in which advertisements were served to users who had a high predicted probability of a future medical visit showed a 3.96% increase in the show conversion rate. Conclusions: Results from our experiments done in a research setting suggest that it is possible to accurately predict future patient visits from geotagged mobile search logs. Results from the offline and online experiments on the utility of health utilization predictions suggest that such prediction can have utility for health care providers.

  • FitBit. Image sourced and copyright owned by authors.

    Accuracy of a Wrist-Worn Wearable Device for Monitoring Heart Rates in Hospital Inpatients: A Prospective Observational Study


    Background: As the sensing capabilities of wearable devices improve, there is increasing interest in their application in medical settings. Capabilities such as heart rate monitoring may be useful in hospitalized patients as a means of enhancing routine monitoring or as part of an early warning system to detect clinical deterioration. Objective: To evaluate the accuracy of heart rate monitoring by a personal fitness tracker (PFT) among hospital inpatients. Methods: We conducted a prospective observational study of 50 stable patients in the intensive care unit who each completed 24 hours of heart rate monitoring using a wrist-worn PFT. Accuracy of heart rate recordings was compared with gold standard measurements derived from continuous electrocardiographic (cECG) monitoring. The accuracy of heart rates measured by pulse oximetry (Spo2.R) was also measured as a positive control. Results: On a per-patient basis, PFT-derived heart rate values were slightly lower than those derived from cECG monitoring (average bias of −1.14 beats per minute [bpm], with limits of agreement of 24 bpm). By comparison, Spo2.R recordings produced more accurate values (average bias of +0.15 bpm, limits of agreement of 13 bpm, P<.001 as compared with PFT). Personal fitness tracker device performance was significantly better in patients in sinus rhythm than in those who were not (average bias −0.99 bpm vs −5.02 bpm, P=.02). Conclusions: Personal fitness tracker–derived heart rates were slightly lower than those derived from cECG monitoring in real-world testing and not as accurate as Spo2.R-derived heart rates. Performance was worse among patients who were not in sinus rhythm. Further clinical evaluation is indicated to see if PFTs can augment early warning systems in hospitals. Trial Registration: NCT02527408; (Archived by WebCite at

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  • Telehealth interventions to support self-management of long-term conditions: a systematic meta-review of diabetes, heart failure, asthma, chronic obstructive pulmonary disease and cancer.

    Date Submitted: Sep 26, 2016

    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. This meta-review synthesises evidence for te...

    Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. This meta-review synthesises evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Objective: The objectives of this review were a) to assess the impact of telehealth interventions to support self-management on disease control and healthcare utilisation, and b) to identify components of telehealth support and their impact on disease control and the process of self-management. Methods: We performed a meta-review (a systematic review of systematic reviews) of randomised controlled trials (RCTs) of telehealth interventions to support self-management in six exemplar long-term conditions. Seven databases were searched from January 2000 to May 2016 and studies screened against eligibility criteria. Reviews were weighted by quality (R-AMSTAR), size and relevance). Results were combined in a narrative synthesis and using Harvest Plots. Results: Fifty-three systematic reviews, comprising 232 unique RCTs, were included. Reviews concerned diabetes (type 1 (n=6), type 2 (n=11), mixed (n=19)), heart failure (n=9), asthma (n=7), COPD (n=7) and cancer (n=3). Findings varied between and within disease areas. The highest weighted reviews showed blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycaemic control in type-2, but not type-1, diabetes; telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure; but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multi-faceted interventions were associated with greater improvements in diabetes, heart failure and asthma. Conclusions: While not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth represents a safe option for delivery for self-management support, particularly in conditions such as heart failure and type 2 diabetes where the evidence base is more developed. Larger scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.

  • Student Evaluation of a Distance Learning Module Using The Sigu Questionnaire

    Date Submitted: Sep 26, 2016

    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Infectious diseases remain a public health concern in Brazil. To achieve success in this process and to implement surveillance and public policy action, it is necessary to have health prof...

    Background: Infectious diseases remain a public health concern in Brazil. To achieve success in this process and to implement surveillance and public policy action, it is necessary to have health professionals that are highly trained and updated with the latest skills. The Brazilian government, through the Open University of SUS (UNA-SUS), in partnership with public universities in several states, offers specialization courses, further training and extension courses with free access, in the distance learning (DE) modality. In order to assess the DE courses offered by the institution, UNA-SUS/UFMA created the SIGU questionnaire, a subsystem that facilitates the processing and interpretation of data that is collected when students assess course’s modules. Objective: This study aimed to analyze students’ perceptions regarding didactic and pedagogical aspects related to the content and activities, educational resources, and tutoring in the Communicable Disease module in two distance learning (DE) postgraduate courses at UNA-SUS/UFMA. Methods: The authors analyzed a sample of 319 students, enrolled in two Postgraduate in Family Health classes (class of 2013 and 2014), and two Postgraduate Classes in Primary Care (two classes of 2014), who had completed the Communicable Diseases module and responded to evaluation questions through the SIGU questionnaire, an auxiliary system for processing and interpreting assessments of distance education modules offered by UNA-SUS/UFMA. By way of a statistical analysis, evaluation variables were dichotomized into either a positive outcome (“great” and “good”) or a negative outcome (“bad” and “insufficient”). Data were analyzed using SPSS (Version 18); the significance level was set at 5% (P < .05). Results: After analyzing the data, the authors observed that 99% of the students evaluated the module positively. With regard to the evaluation of the content and activities developed in the module, 53% (169), 43.6% (139), and 3.4% (11) of students evaluated the item workload of the course educational units as great, good, and bad, respectively. The highest rated item was tutor performance, with a rating of “great” from 229 (71.8%) of the students. Conclusions: Overall, the results contributed to the improvement of DE courses offered by UNA-SUS/UFMA from the perspectives of controlling dropout rates and the development of public health services offered in Brazil.

  • Attachment style and Internet addiction

    Date Submitted: Sep 25, 2016

    Open Peer Review Period: Sep 25, 2016 - Nov 20, 2016

    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Overall, the estimated prevalence of computer game and Internet addiction is between 3 and...

    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Overall, the estimated prevalence of computer game and Internet addiction is between 3 and 5%. Considering the fact that there is ample evidence for the relationship between attachment style and substance abuse, it stands to reason that attachment theory can also make an important contribution to the understanding of the pathogenesis of Internet addiction. Accordingly, the aim of this study was to examine people’s tendency toward pathological Internet usage in relation to their attachment style. Method: An online survey was conducted. Sociodemographic data, attachment style (Bielefeld questionnaire partnership expectations), symptoms of Internet addiction (scale for online addiction for adults), used Internet services and online relationship motives (Cyper relationship motive Scale) were assessed. In order to confirm the findings, a study using the Rorschach test was also conducted. Results: In total N = 245 subjects were recruited. Participants with insecure attachment style showed a higher tendency to pathological Internet usage compared to securely-attached participants. An ambivalent attachment style was particularly associated with pathological Internet usage. Escapist and social-compensatory motives played an important role for insecurely attached subjects. However, there were no significant effects with respect to online services and applications used. Results of the analysis of the Rorschach protocol with N = 16 subjects corroborated these results. Users with pathological Internet use frequently showed signs of infantile relationship structures in the context of social groups. This refers to the results of the online survey, in which interpersonal relationships were the result of an insecure attachment style. Conclusions: In summary, pathological Internet use was a function of insecure attachment and limited interpersonal relationships.

  • Designing patient-centered text messaging interventions for increasing physical activity among participants with Type II Diabetes: Qualitative results from the Text to Move intervention

    Date Submitted: Sep 21, 2016

    Open Peer Review Period: Sep 22, 2016 - Nov 17, 2016

    Background: The Text to Move (TTM) study was a six-month 2-parallel group randomized controlled trial of individuals with type II diabetes (T2DM) to increase physical activity, measured by a pedometer...

    Background: The Text to Move (TTM) study was a six-month 2-parallel group randomized controlled trial of individuals with type II diabetes (T2DM) to increase physical activity, measured by a pedometer. The intervention arm received twice daily text messages for 6 months that were tailored to the participant’s stage of behavior change as defined by the Transtheoretical Model of Behavior Change. Objective: The purpose of this follow-up study was to collect feedback from participants in the TTM program and explore their views on text messaging as a health promotion tool. Categorizing the perceived barriers and facilitators to the TTM program will help inform the design of future technology-based studies to maximize participant engagement. Methods: We assessed participants’ attitudes regarding their experience with text messaging, focusing on perceived barriers and facilitators, through two focus groups and telephone interviews. All interviews were audio-recorded, transcribed verbatim, coded and analyzed using a grounded theory approach. Results: The response rate was 67.4% (31/46 participants). The average age was 51 and 61% were male. The majority of individuals were English speakers and married, had completed at least 12th grade and approximately half of all participants were employed full-time. Overall, participants were satisfied with the TTM program and recalled the text messages as educational, informational, and motivational. Program involvement increased the sense of connection with their healthcare center. The wearing of pedometers and daily step count information served as motivational reminders and created a sense of accountability through the sentinel effect. However, there was frustration concerning the automation of the text message program, including the repetitiveness, predictability of text time delivery, and lack of customization and interactivity of text message content. Participants recommended personalization of texting content and frequency as well as more contact time with personnel for a stronger sense of support, including greater surveillance and feedback based on their own results and comparison to other participants. Conclusions: Participants in a theory-based text messaging intervention identified key facilitators and barriers to program efficacy that should be incorporated into future texting interventions to optimize participant satisfaction and outcomes. Clinical Trial:

  • Does usage of an e-health intervention reduce the risk of excessive gestational weight gain?

    Date Submitted: Sep 13, 2016

    Open Peer Review Period: Sep 13, 2016 - Nov 8, 2016

    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Online interventions have the potential for delivering innovative, interactive excess...

    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Online interventions have the potential for delivering innovative, interactive excessive GWG prevention to large numbers of people. Objective: This study creates a novel measure of online intervention usage patterns and examines whether online intervention usage is associated with reduced risk of excessive GWG. Methods: The online intervention was theory based and emphasized the active ingredients of weight gain tracking and behavioral goal-setting and self-monitoring. One-thousand three hundred and thirty-five (898 intervention and 437 control) relatively diverse and healthy pregnant women were randomly assigned to the intervention arms or control arm. Usage patterns were examined for both intervention and control arm participants using Latent Class Analysis. A modified Poisson regression approach was used to estimate the relative risk of excessive total or weekly GWG for women with different usage patterns. Results: Five usage patterns best characterized the usage of the intervention arm participants. Three usage patterns best characterized control arm participants’ usage. Control arm usage patterns were not associated with excessive GWG, whereas intervention arm usage patterns were associated with excessive GWG. Conclusions: The control and intervention arm usage pattern characterization is a unique methodological contribution to process evaluations for self-directed, online interventions. Clinical Trial: NCT01331564,,