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 4.7 for 2013

Lessons Learned from Using Focus Groups to Refine Digital Interventions

There is growing interest in applying novel eHealth approaches for the prevention and management of various health conditions, with the ultimate goal of increasing positive patient outcomes and improving the effectiveness and efficiency of health services delivery. Coupled with the use of innovative approaches is the possibility for adverse outcomes, highlighting the need to strategically refine digital practices prior to implementation with patients. One appropriate method for modification purposes includes focus groups; although a well-established method in qualitative research, there is a lack of guidance regarding the use of focus groups for digital intervention refinement. To address this gap, the purpose of our paper is to highlight several lessons our research team has learned in using focus groups to help refine digital interventions prior to use with patients.


We are pleased to announce our forthcoming new journals, all of which have currently no submission or publication fees, and all of which focus on emerging technologies and patient-centered innovations in specific areas, going beyond Internet/webbased interventions: * JMIR Cancer ( * JMIR Medical Education ( * JMIR Public Health and Surveillance ( We welcome submissions for the inaugural issues of these journals. The following journals have already published articles and are still free of charge to publish in (no submission or publication fees): * JMIR Human Factors ( * JMIR Rehabilitation and Assistive Technologies ( * JMIR Mental Health ( (APF after March 1st, 2015) To submit to these journals, simply append /author to the URLs above (e.g., or submit to the main JMIR journal and use the dropdown-box in step 1 to change the journal name. All journals offer careful copyediting and typesetting of manuscripts, and submission to PubMed and PubMed Central (being new journals it may however take a few month until they appear in PubMed). We are also happy to announce that JMIR Medical Informatics and JMIR Serious Games are now indexed in PubMed.

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Recent Articles:

  • Email icon.

    Patient Use of Email for Health Care Communication Purposes Across 14 European Countries: An Analysis of Users According to Demographic and Health-Related...


    Background: The use of the Internet for health purposes is growing steadily, yet the use of asynchronous communication tools for health care purposes remains undeveloped. The introduction of email as a method of communication in health care has the potential to impact on both patients and health care professionals. Objective: This study aims to describe the characteristics of people who have sent or received an email to or from their doctor, nurse, or health care organization, by country and in relation to demographics, health care resource use, and health status factors. Methods: We conducted a secondary analysis of data (N=14,000) collected from the online Citizens and Information Communication Technology for Health survey, a project undertaken in 2011 by the Institute for Prospective Technology Studies of the European Commission’s Joint Research Centre. The survey was developed to understand and characterize European citizens’ use of information communication technologies for health. Descriptive and statistical analyses of association were used to interpret the data. Results: Denmark reported the highest level of emails sent/received (507/1000, 50.70%). The lowest level reported was by participants in France (187/1000, 18.70%). Men used email communication for health care more than women, as did respondents in the 16-24 age group and those educated to tertiary level or still within the education system. As self-reported health state worsens, the proportion of people reporting having sent or received an email within the context of health care increases. Email use, poor health, multimorbidity, and number of visits to a physician are positively correlated. Conclusions: The use of email communication within the context of European health care is extremely varied. The relationship between high email use, poor health, doctor visits, and multimorbidity is especially pertinent: provision of asynchronous communication for such groups is favored by policymakers. Low reported email use by country may not necessarily reflect low interest in using email for health care: local health policies and technical infrastructures may be significant factors in the delay in implementation of alternative forms of routine health communication.

  • Arthriting website logged-in dashboard (dummy demo testing user).

    Blogging as a Viable Research Methodology for Young People With Arthritis: A Qualitative Study


    Background: The development of services that are responsive to the needs of users is a health policy priority. Finding ways of engaging young people in research to gain insights into their particular experiences, perspectives, and needs is vital but challenging. These data are critical to improving services in ways that meet the needs of young people. Objective: Our aim was to evaluate Web-based blogging as a viable method for understanding the daily experiences and condition management strategies of young people with juvenile arthritis. Methods: To meet the objectives of the study, a qualitative approach was required to gather information on the experiences and perspectives of young people regarding the management of their condition and its daily impact. In collaboration with a group of young people with arthritis, a custom website was developed. This website provided the opportunity for young people (aged 11-19) with arthritis from a United Kingdom pediatric hospital to contribute blogs. It was designed so that young people were free to write about whatever was important to them, but the site also included some structure and prompts to facilitate the writing of blogs. Qualitative analytical procedures were employed, supported by NVivo software. Results: Engagement in the study by young people was variable in terms of their participation rates, frequency of website visits, and the length of their blogs. Young people used the site in different ways, some responding to the website categories and prompts that the team created, while others used it as a diary to record their experiences and thoughts. In line with principles of qualitative inquiry, the data collection was participant-led. Young people were in control of what, how much, and how often they wrote. However, some young people expressed difficulty regarding knowing what they should blog about. For a number of reasons, discussed here, the blogs may also not be fully reflective of experiences and perspectives of the participants. However, the data obtained provided insights into young people’s experiences of living with arthritis and their use of medicines in the context of their daily lives. Conclusions: Web-based research with young people presents opportunities and challenges for researchers. Web-based blogging methodology has the potential to give young people and parents the space and empowerment to express their own ideas and concerns. However, this project suggests that it might not be the best way to engage a large diverse group of young people and might most effectively be combined with other approaches. Despite these limitations, the study provided valuable data about the experience and impact of living with a long-term condition from the perspectives of young people with arthritis.

  • Volume of Wikipedia articles if stacked on a bookshelf.

    Wikipedia and Medicine: Quantifying Readership, Editors, and the Significance of Natural Language


    Background: Wikipedia is a collaboratively edited encyclopedia. One of the most popular websites on the Internet, it is known to be a frequently used source of health care information by both professionals and the lay public. Objective: This paper quantifies the production and consumption of Wikipedia’s medical content along 4 dimensions. First, we measured the amount of medical content in both articles and bytes and, second, the citations that supported that content. Third, we analyzed the medical readership against that of other health care websites between Wikipedia’s natural language editions and its relationship with disease prevalence. Fourth, we surveyed the quantity/characteristics of Wikipedia’s medical contributors, including year-over-year participation trends and editor demographics. Methods: Using a well-defined categorization infrastructure, we identified medically pertinent English-language Wikipedia articles and links to their foreign language equivalents. With these, Wikipedia can be queried to produce metadata and full texts for entire article histories. Wikipedia also makes available hourly reports that aggregate reader traffic at per-article granularity. An online survey was used to determine the background of contributors. Standard mining and visualization techniques (eg, aggregation queries, cumulative distribution functions, and/or correlation metrics) were applied to each of these datasets. Analysis focused on year-end 2013, but historical data permitted some longitudinal analysis. Results: Wikipedia’s medical content (at the end of 2013) was made up of more than 155,000 articles and 1 billion bytes of text across more than 255 languages. This content was supported by more than 950,000 references. Content was viewed more than 4.88 billion times in 2013. This makes it one of if not the most viewed medical resource(s) globally. The core editor community numbered less than 300 and declined over the past 5 years. The members of this community were half health care providers and 85.5% (100/117) had a university education. Conclusions: Although Wikipedia has a considerable volume of multilingual medical content that is extensively read and well-referenced, the core group of editors that contribute and maintain that content is small and shrinking in size.

  • Purchased from Dollar Photo Club.

    Emergency Physicians’ Views of Direct Notification of Laboratory and Radiology Results to Patients Using the Internet: A Multisite Survey


    Background: Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital’s electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians’ opinions. Objective: The aim was to explore emergency physicians’ current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. Methods: A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. Results: The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). Conclusions: Although patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

  • Dialogue window.

    Effectiveness of a Web-Based Tailored Interactive Health Communication Application for Patients With Type 2 Diabetes or Chronic Low Back Pain: Randomized...


    Background: The prevalence of chronic diseases such as type 2 diabetes and chronic low back pain is rising. Patient empowerment is a key strategy in the management of chronic diseases. Patient empowerment can be fostered by Web-based interactive health communication applications (IHCAs) that combine health information with decision support, social support, and/or behavioral change support. Tailoring the content and tone of IHCAs to the needs of individual patients might improve their effectiveness. Objective: The main objective was to test the effectiveness of a Web-based, tailored, fully automated IHCA for patients with type 2 diabetes or chronic low back pain against a standard website with identical content without tailoring (control condition) on patients’ knowledge and empowerment. Methods: We performed a blinded randomized trial with a parallel design. In the intervention group, the content was delivered in dialogue form, tailored to relevant patient characteristics. In the control group, the sections of the text were presented in a content tree without any tailoring. Participants were recruited online and offline and were blinded to their group assignments. Measurements were taken at baseline (t0), directly after the first visit (t1), and at 3-month follow-up (t2). The primary hypothesis was that the tailored IHCA would have larger effects on knowledge and patient empowerment (primary outcomes) than the control website. The secondary outcomes were decisional conflict and preparation for decision making. All measurements were conducted by online self-report questionnaires. Intention-to-treat (ITT) and available cases (AC) analyses were performed for all outcomes. Results: A total of 561 users agreed to participate in the study. Of these, 179 (31.9%) had type 2 diabetes and 382 (68.1%) had chronic low back pain. Usage was significantly higher in the tailored system (mean 51.2 minutes) than in the control system (mean 37.6 minutes; P<.001). Three months after system use, 52.4% of the sample was retained. There was no significant intervention effect in the ITT analysis. In the AC analysis, participants using the tailored system displayed significantly more knowledge at t1 (P=.02) and more emotional well-being (subscale of empowerment) at t2 (P=.009). The estimated mean difference between the groups was 3.9 (95% CI 0.5-7.3) points for knowledge and 25.4 (95% CI 6.3-44.5) points for emotional well-being on a 0-100 points scale. Conclusions: The primary analysis did not support the study hypothesis. However, content tailoring and interactivity may increase knowledge and reduce health-related negative effects in persons who use IHCAs. There were no main effects of the intervention on other dimensions of patient empowerment or decision-related outcomes. This might be due to our tailored IHCA being, at its core, an educational intervention offering health information in a personalized, empathic fashion that merely additionally provides decision support. Tailoring and interactivity may not make a difference with regard to these outcomes. Trial Registration: International Clinical Trials Registry: DRKS00003322; (Archived by WebCite at

  • Screenshot of the eBalance Web-based app.

    The Impact of a Web-Based App (eBalance) in Promoting Healthy Lifestyles: Randomized Controlled Trial


    Background: The use of Web-based apps to promote a healthy lifestyle is increasing, although most of these programs were not assessed using suitable epidemiological methods. We evaluated the effectiveness of a newly developed Web-based app in promoting a healthy lifestyle and educating adults on such lifestyles. We also analyzed predictors for success in acquiring and maintaining a healthy lifestyle. Objective: Our aim was to compare people receiving a new Web-based app with people who got an introductory lecture alone on healthy lifestyle, weight change, nutritional knowledge, and physical activity, and to identify predictors of success for maintaining a healthy lifestyle. Methods: Subjects were recruited from the community and were randomized into intervention and control groups. The intervention subjects received access to the app without any face-to-face support; the control subjects continued their standard lifestyle. Measurements were taken by the researcher at baseline and after 14 weeks and included weight and waist circumference. Nutritional knowledge, diet quality, and physical activity duration were obtained using online questionnaires. The new Web-based app was developed based on current US Department of Agriculture and Israel Ministry of Health recommendations for healthy lifestyle. The app provides tools for monitoring diet and physical activity while instructing and encouraging healthy diet and physical activity. Results: Out of 99 subjects who were randomized into app and control groups, 85 participants (86%) completed the study, 56 in the intervention and 29 in the control group. The mean age was 47.9 (SD 12.3) years, and mean Body Mass Index was 26.2 (SD 3.9). Among the intervention group only, frequency of app use was 2.7 (SD 1.9) days/week. The mean change in physical activity was 63 (SD 20.8) minutes in the app group and -30 (SD 27.5) minutes in the control group (P=.02). The mean weight change was -1.44 (SD 0.4) kg in the app group and -0.128 (SD 0.36) kg in the control group (P=.03). Knowledge score increased significantly in the app group, 76 (SD 7.5) to 79 (SD 8.7) at the end of the study (P=.04) compared with the control group. Diet quality score also increased significantly at the end of the study, from 67 (SD 9.8) to 71 (SD 7.6; P<.001) in contrast to the control group. Success score (represents the success in maintaining healthy lifestyle) was higher among the app group (68%) compared with 36% in the control group (P<.001). The app frequency of use was significantly related to a higher success score (P<.001). Conclusions: We showed a positive impact of a newly developed Web-based app on lifestyle indicators during an intervention of 14 weeks. These results are promising in the app’s potential to promote a healthy lifestyle, although larger and longer duration studies are needed to achieve more definitive conclusions. Trial Registration: number: NCT01913496; (Archived by WebCite at

  • Image courtesy of [imagerymajestic] at

    Advantages and Disadvantages of Educational Email Alerts for Family Physicians: Viewpoint


    Background: Electronic knowledge resources constitute an important channel for accredited Continuing Medical Education (CME) activities. However, email usage for educational purposes is controversial. On the one hand, family physicians become aware of new information, confirm what they already know, and obtain reassurance by reading educational email alerts. Email alerts can also encourage physicians to search Web-based resources. On the other hand, technical difficulties and privacy issues are common obstacles. Objective: The purpose of this discussion paper, informed by a literature review and a small qualitative study, was to understand family physicians’ knowledge, attitudes, and behavior in regard to email in general and educational emails in particular, and to explore the advantages and disadvantages of educational email alerts. In addition, we documented participants’ suggestions to improve email alert services for CME. Methods: We conducted a qualitative descriptive study using the “Knowledge, Attitude, Behavior” model. We conducted semi-structured face-to-face interviews with 15 family physicians. We analyzed the collected data using inductive-deductive thematic qualitative data analysis. Results: All 15 participants scanned and prioritized their email, and 13 of them checked their email daily. Participants mentioned (1) advantages of educational email alerts such as saving time, convenience and valid information, and (2) disadvantages such as an overwhelming number of emails and irrelevance. They offered suggestions to improve educational email. Conclusions: The advantages of email alerts seem to compensate for their disadvantages. Suggestions proposed by family physicians can help to improve educational email alerts.

  • Anxiety online screenshot.

    Multiple Comorbidities of 21 Psychological Disorders and Relationships With Psychosocial Variables: A Study of the Online Assessment and Diagnostic System...


    Background: While research in the area of e-mental health has received considerable attention over the last decade, there are still many areas that have not been addressed. One such area is the comorbidity of psychological disorders in a Web-based sample using online assessment and diagnostic tools, and the relationships between comorbidities and psychosocial variables. Objective: We aimed to identify comorbidities of psychological disorders of an online sample using an online diagnostic tool. Based on diagnoses made by an automated online assessment and diagnostic system administered to a large group of online participants, multiple comorbidities (co-occurrences) of 21 psychological disorders for males and females were identified. We examined the relationships between dyadic comorbidities of anxiety and depressive disorders and the psychosocial variables sex, age, suicidal ideation, social support, and quality of life. Methods: An online complex algorithm based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision, was used to assign primary and secondary diagnoses of 21 psychological disorders to 12,665 online participants. The frequency of co-occurrences of psychological disorders for males and females were calculated for all disorders. A series of hierarchical loglinear analyses were performed to examine the relationships between the dyadic comorbidities of depression and various anxiety disorders and the variables suicidal ideation, social support, quality of life, sex, and age. Results: A 21-by-21 frequency of co-occurrences of psychological disorders matrix revealed the presence of multiple significant dyadic comorbidities for males and females. Also, for those with some of the dyadic depression and the anxiety disorders, the odds for having suicidal ideation, reporting inadequate social support, and poorer quality of life increased for those with two-disorder comorbidity than for those with only one of the same two disorders. Conclusions: Comorbidities of several psychological disorders using an online assessment tool within a Web-based population were similar to those found in face-to-face clinics using traditional assessment tools. Results provided support for the transdiagnostic approaches and confirmed the positive relationship between comorbidity and suicidal ideation, the negative relationship between comorbidity and social support, and the negative relationship comorbidity and quality of life. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; (Archived by WebCite at

  • This image is from the public domain (

    The Contribution of Online Peer-to-Peer Communication Among Patients With Adrenal Disease to Patient-Centered Care


    Background: Addison’s disease and Cushing’s syndrome are rare. The Dutch Adrenal Society offers an online forum for Dutch adrenal patients to meet and communicate. However, little is known about the added value such a forum has for the delivery of patient-centered care. Objective: Our aim was to analyze the purposes of online patient-to-patient forum conversations, within the context of patient-centered care. Methods: For this study a consecutive sample of 300 questions (“threads”) from the past 3.5 years was selected from the forum. The content of these patient-driven questions was analyzed based on the dimensions of patient-centeredness of the Picker Institute. This analysis was performed using ATLAS.ti. Results: From the 390 questions analyzed, 80.8% (N=315) were intended to gain more information about the disease, the treatment, and to verify if other patients had similar complaints. To a much lesser extent (38/390, 9.7%), questions expressed a call for emotional support. Patients answered primarily by giving practical tips to fellow patients and to share their own experiences. Conclusions: On an online patient forum for Cushing’s syndrome and Addison’s disease, patients appear to primarily gain knowledge and, to a lesser extent, emotional support from their peers. This experience-based knowledge has become a very important information source. As such, patients can make a substantial contribution to the creation of patient-centered care if this knowledge is integrated into the care provided by health care professionals.

  • Thumbnail photo. (C) PATH, 2014.

    Impact of mHealth Chronic Disease Management on Treatment Adherence and Patient Outcomes: A Systematic Review


    Background: Adherence to chronic disease management is critical to achieving improved health outcomes, quality of life, and cost-effective health care. As the burden of chronic diseases continues to grow globally, so does the impact of non-adherence. Mobile technologies are increasingly being used in health care and public health practice (mHealth) for patient communication, monitoring, and education, and to facilitate adherence to chronic diseases management. Objective: We conducted a systematic review of the literature to evaluate the effectiveness of mHealth in supporting the adherence of patients to chronic diseases management (“mAdherence”), and the usability, feasibility, and acceptability of mAdherence tools and platforms in chronic disease management among patients and health care providers. Methods: We searched PubMed, Embase, and EBSCO databases for studies that assessed the role of mAdherence in chronic disease management of diabetes mellitus, cardiovascular disease, and chronic lung diseases from 1980 through May 2014. Outcomes of interest included effect of mHealth on patient adherence to chronic diseases management, disease-specific clinical outcomes after intervention, and the usability, feasibility, and acceptability of mAdherence tools and platforms in chronic disease management among target end-users. Results: In all, 107 articles met all inclusion criteria. Short message service was the most commonly used mAdherence tool in 40.2% (43/107) of studies. Usability, feasibility, and acceptability or patient preferences for mAdherence interventions were assessed in 57.9% (62/107) of studies and found to be generally high. A total of 27 studies employed randomized controlled trial (RCT) methods to assess impact on adherence behaviors, and significant improvements were observed in 15 of those studies (56%). Of the 41 RCTs that measured effects on disease-specific clinical outcomes, significant improvements between groups were reported in 16 studies (39%). Conclusions: There is potential for mHealth tools to better facilitate adherence to chronic disease management, but the evidence supporting its current effectiveness is mixed. Further research should focus on understanding and improving how mHealth tools can overcome specific barriers to adherence.

  • Twitter search results for

    Twitter Sentiment Predicts Affordable Care Act Marketplace Enrollment


    Background: Traditional metrics of the impact of the Affordable Care Act (ACA) and health insurance marketplaces in the United States include public opinion polls and marketplace enrollment, which are published with a lag of weeks to months. In this rapidly changing environment, a real-time barometer of public opinion with a mechanism to identify emerging issues would be valuable. Objective: We sought to evaluate Twitter’s role as a real-time barometer of public sentiment on the ACA and to determine if Twitter sentiment (the positivity or negativity of tweets) could be predictive of state-level marketplace enrollment. Methods: We retrospectively collected 977,303 ACA-related tweets in March 2014 and then tested a correlation of Twitter sentiment with marketplace enrollment by state. Results: A 0.10 increase in the sentiment score was associated with an 8.7% increase in enrollment at the state level (95% CI 1.32-16.13; P=.02), a correlation that remained significant when adjusting for state Medicaid expansion (P=.02) or use of a state-based marketplace (P=.03). Conclusions: This correlation indicates Twitter’s potential as a real-time monitoring strategy for future marketplace enrollment periods; marketplaces could systematically track Twitter sentiment to more rapidly identify enrollment changes and potentially emerging issues. As a repository of free and accessible consumer-generated opinions, this study reveals a novel role for Twitter in the health policy landscape.

  • Tweet2Quit Project, Source: Accessed: 2015-02-19. (Archived by WebCite® at

    Development of a Twitter-Based Intervention for Smoking Cessation that Encourages High-Quality Social Media Interactions via Automessages


    Background: The medical field seeks to use social media to deliver health interventions, for example, to provide low-cost, self-directed, online self-help groups. However, engagement in online groups is often low and the informational content may be poor. Objective: The specific study aims were to explore if sending automessages to online self-help groups encouraged engagement and to see if overall or specific types of engagement related to abstinence. Methods: We conducted a Stage I Early Therapy Development Trial of a novel social media intervention for smoking cessation called Tweet2Quit that was delivered online over closed, 20-person quit-smoking groups on Twitter in 100 days. Social media such as Twitter traditionally involves non-directed peer-to-peer exchanges, but our hybrid social media intervention sought to increase and direct such exchanges by sending out two types of autocommunications daily: (1) an “automessage” that encouraged group discussion on an evidence-based cessation-related or community-building topic, and (2) individualized “autofeedback” to each participant on their past 24-hour tweeting. The intervention was purposefully designed without an expert group facilitator and with full automation to ensure low cost, easy implementation, and broad scalability. This purely Web-based trial examined two online quit-smoking groups with 20 members each. Participants were adult smokers who were interested in quitting and were recruited using Google AdWords. Participants’ tweets were counted and content coded, distinguishing between responses to the intervention’s automessages and spontaneous tweets. In addition, smoking abstinence was assessed at 7 days, 30 days, and 60 days post quit date. Statistical models assessed how tweeting related to abstinence. Results: Combining the two groups, 78% (31/40) of the members sent at least one tweet; and on average, each member sent 72 tweets during the 100-day period. The automessage-suggested discussion topics and participants’ responses to those daily automessages were related in terms of their content (r=.75, P=.012). Responses to automessages contributed 22.78% (653/2867) of the total tweets; 77.22% (2214/2867) were spontaneous. Overall tweeting related only marginally to abstinence (OR 1.03, P=.086). However, specific tweet content related to abstinence including tweets about setting of a quit date or use of nicotine patches (OR 1.52, P=.024), countering of roadblocks to quitting (OR 1.76, P=.008) and expressions of confidence about quitting (OR 1.71, SE 0.42, P=.032). Questionable, that is, non-evidence-based, information about quitting did not relate to abstinence (OR 1.12, P=.278). Conclusions: A hybrid social media intervention that combines traditional online social support with daily automessages appears to hold promise for smoking cessation. This hybrid approach capitalizes on social media’s spontaneous real-time peer-to-peer exchanges but supplements this with daily automessages that group members respond to, bolstering and sustaining the social network and directing the information content. Highly engaging, this approach should be studied further. Trial Registration: NCT01602536; (Archived by WebCite at

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  • Lessons Learned from Using Focus Groups to Refine Digital Interventions

    Date Submitted: Mar 5, 2015

    Open Peer Review Period: Mar 6, 2015 - May 1, 2015

    There is growing interest in applying novel eHealth approaches for the prevention and management of various health conditions, with the ultimate goal of increasing positive patient outcomes and improv...

    There is growing interest in applying novel eHealth approaches for the prevention and management of various health conditions, with the ultimate goal of increasing positive patient outcomes and improving the effectiveness and efficiency of health services delivery. Coupled with the use of innovative approaches is the possibility for adverse outcomes, highlighting the need to strategically refine digital practices prior to implementation with patients. One appropriate method for modification purposes includes focus groups; although a well-established method in qualitative research, there is a lack of guidance regarding the use of focus groups for digital intervention refinement. To address this gap, the purpose of our paper is to highlight several lessons our research team has learned in using focus groups to help refine digital interventions prior to use with patients.

  • Assessing E-cigarette Related Tweets for Sentiment and Content Using Supervised Machine Learning

    Date Submitted: Mar 5, 2015

    Open Peer Review Period: Mar 6, 2015 - Mar 12, 2015

    Background: E-cigarettes continue to be growing topic among social media users, especially Twitter. The ability to analyze conversations about e-cigarettes in real-time can provide important insight i...

    Background: E-cigarettes continue to be growing topic among social media users, especially Twitter. The ability to analyze conversations about e-cigarettes in real-time can provide important insight into the trends in the public’s knowledge, attitudes, and beliefs surrounding e-cigarettes, and subsequently guide public health interventions. Objective: To establish a supervised machine learning algorithm to build predictive classification models that assess Twitter data for a range of e-cigarette-related factors. Methods: Manual content analysis was conducted for 17,098 tweets. These tweets were coded for five categories: E-cigarette relevance, sentiment, user description, genre, and theme. Machine learning classification models were then built for each of these five categories, and word groupings (n-grams) were used to define the feature space for each classifier. Results: Predictive performance scores for classification models indicated that the models correctly labeled the tweets with the appropriate variables between 68% and 99% of the time, and the percentage of maximum possible improvement over a random baseline that was achieved by the classification models ranged from 42% to 81%. Classifiers with the highest performance scores that also achieved the highest percentage of the maximum possible improvement over a random baseline were Policy/Government (Performance: 0.94; % Improvement: 81%), Relevance (Performance: 0.94; % Improvement: 75%), Advertisement or Promotion (Performance: 0.89; % Improvement: 73%), and Marketing (Performance: 0.91; % Improvement: 73%). The most appropriate word-grouping unit (n-gram) was 1 for the majority of classifiers. Performance continues to marginally increase with the size of the training dataset of manually annotated data, but eventually levels off; even at low dataset sizes of 4,000 observations, performance characteristics are fairly sound. Conclusions: Social media outlets like Twitter can uncover real-time snapshots of personal sentiment, knowledge, attitudes, and behavior that is not as accessible, at this scale, through any other off-line platform. Using the vast data available through social media presents an opportunity for social science and public health methodologies to utilize computational methodologies to enhance and extend research and practice. This study was successful in automating a complex 5-category manual content analysis of e-cigarette-related content on Twitter using machine learning techniques. The study details machine learning model specifications that provided the best accuracy for data related to e-cigarettes, as well as a replicable methodology to allow extension of these methods to additional topics.

  • A Tele-surveillance System with Automatic ECG Interpretation based on Support Vector Machine and Rule-based Processing

    Date Submitted: Mar 4, 2015

    Open Peer Review Period: Mar 4, 2015 - Apr 29, 2015

    Background: Telehealthcare is a global trend affecting clinical practice around the world. To mitigate the loading of health professionals and provide a ubiquitous healthcare, a comprehensive surveill...

    Background: Telehealthcare is a global trend affecting clinical practice around the world. To mitigate the loading of health professionals and provide a ubiquitous healthcare, a comprehensive surveillance system with value-added services based on information technologies must be established. Objective: We conducted this study to describe our proposed tele-surveillance system designed for monitoring and classifying ECG signals and evaluate the performance of ECG classification. Methods: We established a tele-surveillance system with an automatic ECG interpretation mechanism. The system included: (1) automatic ECG signal transmission via telecommunication; (2) ECG signal processing, including noise elimination, peak estimation, and feature extraction; (3) automatic ECG interpretation based on the Support Vector Machine classifier and rule-based processing; (4) displaying ECG signals and their analyzing results. We analyzed 213,420 ECG signals that were diagnosed by cardiologists as the gold standard to verify the classification performance. Results: In the clinical ECG database from the Telehealthcare Center of NTUH, the experimental results showed that the ECG classifier yielded a specificity value of 96.661% for normal rhythm detection, a sensitivity value of 98.502% for disease recognition, and an accuracy value of 81.168% for noise detection, respectively. For the detection performance of specific diseases, the recognition model mainly generated the sensitivity values of 92.697% in Atrial Fibrillation, 89.104% in Pacemaker rhythm, 88.600% in Atrial Premature Contraction, 72.978% in T-wave Inversion, 62.213% in Atrial Flutter, and 62.569% in First-degree Atrio-Ventricular Block, respectively. Conclusions: Via connected telehealthcare devices, the tele-surveillance system, and the automatic ECG interpretation system, the mechanism is intentionally designed for continuous decision-making support and is reliable enough to reduce the need of face-to-face diagnosis. With this value-added service, the system could widely assist physicians and other health professionals for decision-making in clinical practice. The system will be very helpful for the patient who suffers from the cardiac disease but is inconvenient to go to the hospital very often.

  • A novel system for supporting autism diagnosis using home videos: Iterative development and evaluation of system design

    Date Submitted: Mar 4, 2015

    Open Peer Review Period: Mar 4, 2015 - Apr 29, 2015

    Background: Observing behavior in the natural environment is valuable to obtain an accurate and comprehensive assessment of a child’s behavior, but in practice it is limited to in-clinic observation...

    Background: Observing behavior in the natural environment is valuable to obtain an accurate and comprehensive assessment of a child’s behavior, but in practice it is limited to in-clinic observation [1,2,3]. Research shows significant time lag between when parents first become concerned and when the child is finally diagnosed with autism [4,5,6]. This lag can delay early interventions that have been shown to improve developmental outcomes [1,7,8,9,10]. Objective: To develop and evaluate the design of an asynchronous system that allows parents to easily collect clinically valid in-home videos of their child’s behavior and supports diagnosticians in completing diagnostic assessment of autism. Methods: First, interviews were conducted with 11 clinicians and 6 families to solicit feedback from stakeholders about the system concept. Next, the system was iteratively designed, informed by experiences of families using it in a controlled experimental home-like setting and a participatory design process involving domain experts. Finally, in-field evaluation of the system design was conducted with five families of children (four with previous autism diagnosis, one typically developing) and three diagnosticians. For each family two diagnosticians, blind to the child’s previous diagnostic status, independently completed an autism diagnosis via our system. We compared the outcome of the assessment between the two diagnosticians, and between each diagnostician and the child’s previous diagnostic status. Results: The system that resulted through the iterative design process includes: 1) NODA SmartCapture, a smartphone-based application for parents to record prescribed video evidence at home; and 2) NODA Connect, a web portal for diagnosticians to direct in-home video collection, access developmental history and conduct an assessment by linking evidence of behaviors tagged in the videos to DSM criteria. Applying clinical judgment, the diagnostician concludes a diagnostic outcome. During field evaluation, without prior training, parents easily (average rating of 4 on a five-point scale) used the system to record video evidence. Across all in-home video evidence recorded during field evaluation, 96% were judged as clinically useful, for performing an autism diagnosis. For four children (3 autism, 1 typically developing), both diagnosticians independently arrived at the correct diagnostic status (autism v. typical). Overall, in 91% of assessments (10 out of 11) via NODA Connect, diagnosticians confidently (average rating 4.5 on a five-point scale) concluded a diagnostic outcome that matched with the child’s previous diagnostic status. Conclusions: The in-field evaluation demonstrated that the system’s design enabled parents to easily record clinically valid evidence of their child’s behavior, and diagnosticians to complete a diagnostic assessment. These results shed light on the potential for appropriately designed telehealth technology to support clinical assessments using in-home video captured by families. This assessment model can be readily generalized to other conditions where direct observation of behavior plays a central role in the assessment process.

  • Swab2know: Results of an HIV-testing strategy using oral fluid samples and online communication of test results for MSM in Belgium.

    Date Submitted: Feb 27, 2015

    Open Peer Review Period: Feb 27, 2015 - Apr 24, 2015

    Background: As HIV remains a public health concern, increased testing among those at risk for HIV-acquisition is important. Men who have sex with men (MSM) are the most important group for targeted HI...

    Background: As HIV remains a public health concern, increased testing among those at risk for HIV-acquisition is important. Men who have sex with men (MSM) are the most important group for targeted HIV-testing in Europe. Several new strategies are developed and implemented to increase HIV-testing uptake in this group, among them the “Swab2know” project. Objective: In this project, we aim to facilitate testing uptake by offering free oral fluid test during outreach activities in MSM settings or online ordering sampling kits, and communicating test results via a secured website. Methods: Sample collection happened via outreach and online sampling among MSM. Test results were communicated through a secured website. HIV-test was executed in the laboratory. Each reactive sample needed to be confirmed using state-of-the-art confirmation procedures on a blood sample. Close follow-up of participants who didn’t pick up their result, or those with a reactive result, was included in the protocol. Participants were asked to provide feedback on the methodology using a short survey. Results: During 17 months, 1071 tests were executed on samples collected among 898 men. Over half of the samples (n=553; 51.6%) was collected during 23 outreach sessions. During an 8 months period, 430 samples (40.2%) were collected from online sampling. Additionally, 88 samples (8.2%) were collected by 2 partner organizations using the methodology during face-to-face consultations with MSM, and male sex workers. Results of 983 (91.8%) tests have been collected from the website. The pickup rate was higher among participants who ordered their kit online (421; 98.6%), compared to those participating during outreach activities (559; 87.2%; P<.001). MSM participating during outreach activities were more likely to have never been tested before (17.3% vs. 10.0%; P=.001), and reported more sexual partners in the 6 months prior to the participation in the project (7.18 vs. 3.23; P<.001). Ninety-two percent of the test results were checked. Twenty participants (2.2%) were confirmed HIV-positive, and linked to care. Twenty-eight participants (2.6%) with a weak reactive result could not be confirmed, and are thereby classified as ‘false reactive’ results. Most of the 388 (39.5%) obtained post-test surveys were very positive. The vast majority (371; 95.6%) was very satisfied, while 17 (4.4%) reported mixed feelings. Conclusions: Despite a high yield, and a considerable number of false reactive results, satisfaction was high among participants. The project helped us to reach the target population, both in numbers of tests executed, as in newly diagnosed HIV infections. Further operationalization should be considered in the accuracy of the test, the functionalities of the website, including an online counseling tool, and study the cost-effectiveness of the methodology.

  • How do young adults rate behavior change techniques applied in smartphone apps that promote physical activity? A cross-sectional survey

    Date Submitted: Feb 27, 2015

    Open Peer Review Period: Feb 27, 2015 - Apr 24, 2015

    Background: Interventions delivered through new technology devices, including smartphone apps, seem an effective method to reach young adults. Previous research indicates that self-efficacy and social...

    Background: Interventions delivered through new technology devices, including smartphone apps, seem an effective method to reach young adults. Previous research indicates that self-efficacy and social support for physical activity and self-regulation behavior change techniques (BCT), such as goal setting, feedback, and self-monitoring, are important for promoting physical activity; however, how the target population rates such BCTs applied to physical activity is unknown. Objective: This study aims to explore young adults’ opinions regarding BCTs applied in smartphone physical activity apps by rating these BCTs that include self-regulation techniques, and to examine the associations between personality characteristics and ratings of BCTs applied in physical activity apps. Methods: We conducted a cross-sectional online survey among healthy 18-30 year old adults (N=179). Data on participants’ gender, age, height, weight, current education level, living situation, smartphone use, personality traits, exercise self-efficacy, exercise self-identity, total physical activity level, and whether participants met the Dutch physical activity guidelines were collected. Items for rating BCTs applied in physical activity apps were selected from a hierarchical taxonomy for BCTs and were clustered into three BCT categories, according to factor analysis: “goal setting and goal reviewing,” “feedback and self-monitoring,” and “social support and social comparison.” Results: Most participants were female (N=146) and highly educated (N=169). In general, we observed high ratings of BCTs aimed to increase “goal setting and goal reviewing” and “feedback and self-monitoring,” but not for BCTs addressing “social support and social comparison.” Significant associations were observed between the personality characteristic “agreeableness” and more positive ratings of BCTs addressing “goal setting and goal reviewing” (OR = 1.6, 95%CI 1.06 – 2.41), the personality characteristic “neuroticism” and BCTs addressing “feedback and self-monitoring” (OR = 0.76, 95%CI 0.58 – 1.00), and exercise self-efficacy and a high rating of BCTs addressing “feedback and self-monitoring” (OR = 1.06, 95%CI 1.02 – 1.11). No associations were observed between personality characteristics (i.e. personality, exercise self-efficacy, exercise self-identity) and participants’ ratings of BCTs addressing “social support and social comparison.” Conclusions: Young Dutch adults rate self-regulation techniques as most positive and techniques addressing social support as less positive in smartphone apps that aim to promote physical activity. Such ratings of BCTs differ according to personality traits and exercise self-efficacy. Future research should focus on what behavior change techniques are effective in app-based interventions to increase physical activity behavior.