JMIR Publications

Journal of Medical Internet Research

The leading peer-reviewed journal for digital medicine, and health & healthcare in the Internet age.

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

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  • Source: Fotolia; Copyright: skyNext; URL:; License: Licensed by the authors.

    Web-Based Aftercare for Women With Bulimia Nervosa Following Inpatient Treatment: Randomized Controlled Efficacy Trial


    Background: Relapse rates in bulimia nervosa (BN) are high even after successful treatment, but patients often hesitate to take up further treatment. An easily accessible program might help maintain treatment gains. Encouraged by the effects of Web-based eating disorder prevention programs, we developed a manualized, Web-based aftercare program (IN@) for women with BN following inpatient treatment. Objective: The objective of this study was to determine the efficacy of the web-based guided, 9-month, cognitive-behavioral aftercare program IN@ for women with BN following inpatient treatment. Methods: We conducted a randomized controlled efficacy trial in 253 women with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) BN and compared the results of IN@ with treatment as usual (TAU). Assessments were carried out at hospital admission (T0), hospital discharge/baseline (T1), postintervention (T2; 9 months after baseline), 9-month follow-up (T3; 18 months after baseline). The primary outcome, abstinence from binge eating and compensatory behaviors during the 2 months preceding T2, was analyzed by intention to treat, using logistic regression analyses. Frequencies of binge eating and vomiting episodes, and episodes of all compensatory behaviors were analyzed using mixed effects models. Results: At T2, data from 167 women were available. There were no significant differences in abstinence rates between the TAU group (n=24, 18.9%) and the IN@ group (n=27, 21.4%; odds ratio, OR=1.29; P=.44). The frequency of vomiting episodes in the IN@ group was significantly (46%) lower than in the TAU group (P=.003). Moderator analyses revealed that both at T2 and T3, women of the intervention group who still reported binge eating and compensatory behaviors after inpatient treatment benefited from IN@, whereas women who were already abstinent after the inpatient treatment did not (P=.004; P=.002). Additional treatment utilization was high in both groups between baseline and follow-up. Conclusions: Overall, data from this study suggest moderate effects of IN@. High rates of outpatient treatment utilization after inpatient treatment may have obscured potential intervention effects on abstinence. An aftercare intervention might be more beneficial as part of a stepped-care approach. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 08870215; (Archived by WebCite at

  • 15 years of non-smoking vs. 15 years of smoking one pack a day (right). Source: The Authors; Copyright: Titus Josef Brinker; URL:; License: Creative Commons Attribution (CC-BY).

    A Dermatologist's Ammunition in the War Against Smoking: A Photoaging App


    This viewpoint reviews the perspectives for dermatology as a specialty to go beyond the substantial impact of smoking on skin disease and leverage the impact of skin changes on a person's self-concept and behavior in the design of effective interventions for smoking prevention and cessation.

  • MyPersonality Project website (montage). Source: myPersonality Project Website /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Computerized Adaptive Testing Provides Reliable and Efficient Depression Measurement Using the CES-D Scale


    Background: The Center for Epidemiologic Studies Depression Scale (CES-D) is a measure of depressive symptomatology which is widely used internationally. Though previous attempts were made to shorten the CES-D scale, few have attempted to develop a Computerized Adaptive Test (CAT) version for the CES-D. Objective: The aim of this study was to provide evidence on the efficiency and accuracy of the CES-D when administered using CAT using an American sample group. Methods: We obtained a sample of 2060 responses to the CESD-D from US participants using the myPersonality application. The average age of participants was 26 years (range 19-77). We randomly split the sample into two groups to evaluate and validate the psychometric models. We used evaluation group data (n=1018) to assess dimensionality with both confirmatory factor and Mokken analysis. We conducted further psychometric assessments using item response theory (IRT), including assessments of item and scale fit to Samejima’s graded response model (GRM), local dependency and differential item functioning. We subsequently conducted two CAT simulations to evaluate the CES-D CAT using the validation group (n=1042). Results: Initial CFA results indicated a poor fit to the model and Mokken analysis revealed 3 items which did not conform to the same dimension as the rest of the items. We removed the 3 items and fit the remaining 17 items to GRM. We found no evidence of differential item functioning (DIF) between age and gender groups. Estimates of the level of CES-D trait score provided by the simulated CAT algorithm and the original CES-D trait score derived from original scale were correlated highly. The second CAT simulation conducted using real participant data demonstrated higher precision at the higher levels of depression spectrum. Conclusions: Depression assessments using the CES-D CAT can be more accurate and efficient than those made using the fixed-length assessment.

  • Blood pressure monitor. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Personalized Hypertension Management Using Patient-Generated Health Data Integrated With Electronic Health Records (EMPOWER-H): Six-Month Pre-Post Study


    Background: EMPOWER-H (Engaging and Motivating Patients Online With Enhanced Resources-Hypertension) is a personalized-care model facilitating engagement in hypertension self-management utilizing an interactive Web-based disease management system integrated with the electronic health record. The model is designed to support timely patient-provider interaction by incorporating decision support technology to individualize care and provide personalized feedback for patients with chronic disease. Central to this process were patient-generated health data, including blood pressure (BP), weight, and lifestyle behaviors, which were uploaded using a smartphone. Objective: The aim of this study was to evaluate the program among patients within primary care already under management for hypertension and with uncontrolled BP. Methods: Using a 6-month pre-post design, outcome measures included office-measured and home-monitored BP, office-measured weight, intervention contacts, diet, physical activity, smoking, knowledge, and health-related quality of life. Results: At 6 months, 55.9% of participants (N=149) achieved office BP goals (<140/90 mm Hg; P<.001) and 86.0% achieved clinically meaningful reduction in office BP (reduction in systolic BP [SBP] ≥5 mm Hg or diastolic BP [DBP] ≥3 mm Hg). At baseline, 25.2% of participants met home BP goals (<135/85 mm Hg), and this percentage significantly increased to 71.4% (P<.001) at 6 months. EMPOWER-H also significantly reduced both office and home SBP and DBP, decreased office-measured weight and consumption of high-salt and high-fat foods (all P<.005), and increased intake of fruit and vegetables, minutes of aerobic exercise, and hypertension knowledge (all P<.05). Patients with higher home BP upload frequencies had significantly higher odds of achieving home BP goals. Patients receiving more total intervention, behavioral, pharmaceutical contacts had significantly lower odds of achieving home BP goals but higher improvements in office BP (all P<.05). Conclusions: EMPOWER-H significantly improved participants’ office-measured and home-monitored BP, weight, and lifestyle behaviors, suggesting that technologically enabled BP home-monitoring, with structured use of patient-generated health data and a personalized care-plan facilitating patient engagement, can support effective clinical management. The experience gained in this study provides support for the feasibility and value of using carefully managed patient-generated health data in the day-to-day clinical management of patients with chronic conditions. A large-scale, real-world study to evaluate sustained effectiveness, cost-effectiveness, and scalability is warranted.

  • Source: Shutterstock; Copyright: And-One; URL:; License: Licensed by JMIR.

    Components and Outcomes of Internet-Based Interventions for Caregivers of Older Adults: Systematic Review


    Background: When trying to access interventions to improve their well-being and quality of life, family caregivers face many challenges. Internet-based interventions provide new and accessible opportunities to remotely support them and can contribute to reducing their burden. However, little is known about the link existing between the components, the use of behavior change techniques, and the outcomes of these Internet-based interventions. Objective: This study aimed to provide an update on the best available evidence about the efficacy of Internet-based interventions for caregivers of older adults. Specifically, the components and the use of behavior change techniques and how they impact on the efficacy of the intervention were sought. Methods: A systematic review searched primary source studies published between 2000 and 2015. Included studies were scored with a high level of evidence by independent raters using the GRADE criteria and reported caregiver-specific outcomes about interventions delivered through the Internet for caregivers of people aged 50 years and older. A narrative synthesis identified intervention components (eg, content, multimedia use, interactive online activities, and provision of support), behavior change techniques, and caregiver outcomes (eg, effects on stressors, mediators, and psychological health). The risk of bias within the included studies was assessed. Results: A total of 2338 articles were screened and 12 studies describing 10 Internet-based interventions were identified. Seven of these interventions led to statistically significant improvements in caregiver outcomes (eg, reducing depression or anxiety, n=4). These efficacious interventions used interactive components, such as online exercises and homework (n=4) or questionnaires on health status (n=2) and five of them incorporated remote human support, either by professionals or peers. The most frequently used behavior change techniques included in efficacious interventions were provision of social support (n=6) and combinations of instructions to guide behavior change and barrier identification (n=5). The design and aim of the included studies did not permit determining exactly which component and/or behavior change technique was more efficacious in producing positive outcomes in caregivers. The risk for selection bias was low for all the studies, and low to high for performance, detection, and attrition biases. Conclusions: In sum, Internet-based interventions that incorporate professional and social support, and provide instructions to change behavior and problem solve in an interactive manner appear to lead to positive outcomes in caregivers. Studies isolating the specific effect of components are needed to improve our understanding of the underlying mechanism of action.

  • PlayForward: Elm City Stories characters (montage). Source: play2PREVENT Lab /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Video Game Intervention for Sexual Risk Reduction in Minority Adolescents: Randomized Controlled Trial


    Background: Human immunodeficiency virus (HIV) disproportionately impacts minority youth. Interventions to decrease HIV sexual risk are needed. Objective: We hypothesized that an engaging theory-based digital health intervention in the form of an interactive video game would improve sexual health outcomes in adolescents. Methods: Participants aged 11 to 14 years from 12 community afterschool, school, and summer programs were randomized 1:1 to play up to 16 hours of an experimental video game or control video games over 6 weeks. Assessments were conducted at 6 weeks and at 3, 6, and 12 months. Primary outcome was delay of initiation of vaginal/anal intercourse. Secondary outcomes included sexual health attitudes, knowledge, and intentions. We examined outcomes by gender and age. Results: A total of 333 participants were randomized to play the intervention (n=166) or control games (n=167): 295 (88.6%) were racial/ethnic minorities, 177 (53.2%) were boys, and the mean age was 12.9 (1.1) years. At 12 months, for the 258 (84.6%) participants with available data, 94.6% (122/129) in the intervention group versus 95.4% (123/129) in the control group delayed initiation of intercourse (relative risk=0.99, 95% CI 0.94-1.05, P=.77). Over 12 months, the intervention group demonstrated improved sexual health attitudes overall compared to the control group (least squares means [LS means] difference 0.37, 95% CI 0.01-0.72, P=.04). This improvement was observed in boys (LS means difference 0.67, P=.008), but not girls (LS means difference 0.06, P=.81), and in younger (LS means difference 0.71, P=.005), but not older participants (LS means difference 0.03, P=.92). The intervention group also demonstrated increased sexual health knowledge overall (LS means difference 1.13, 95% CI 0.64-1.61, P<.001), in girls (LS means difference 1.16, P=.001), boys (LS means difference 1.10, P=.001), younger (LS means difference 1.18, P=.001), and older (LS means difference=1.08, P=.002) participants. There were no differences in intentions to delay the initiation of intercourse between the two groups (LS means difference 0.10, P=.56). Conclusions: An interactive video game intervention improves sexual health attitudes and knowledge in minority adolescents for at least 12 months. Trial Registration: NCT01666496; (Archived by WebCite at

  • Source:; Copyright: Photo-Mix; URL:; License: Public Domain (CC0).

    Cardiac Patients’ Experiences and Perceptions of Social Media: Mixed-Methods Study


    Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults provides an opportunity to reach patients who are eligible for cardiac rehabilitation but unable to attend traditional face-to-face groups. However, there is a paucity of research on cardiac patients’ experiences and perspectives on using social media to support their health. Objective: The aim of this study was to describe cardiac rehabilitation patients’ experiences in using social media in general and their perspective on using social media, particularly Facebook, to support their cardiac health and secondary prevention efforts. Methods: A mixed-methods study was undertaken among cardiac rehabilitation patients in both urban and rural areas. First, this study included a survey (n=284) on social media use and capability. Second, six focus group interviews were conducted with current Facebook users (n=18) to elucidate Facebook experience and perspectives. Results: Social media use was low (28.0%, 79/282) but more common in participants who were under 70 years of age, employed, and had completed high school. Social media users accessed Web-based information on general health issues (65%, 51/79), medications (56%, 44/79), and heart health (43%, 34/79). Participants were motivated to invest time in using Facebook for “keeping in touch” with family and friends and to be informed by expert cardiac health professionals and fellow cardiac participants if given the opportunity. It appeared that participants who had a higher level of Facebook capability (understanding of features and the consequences of their use and efficiency in use) spent more time on Facebook and reported higher levels of “liking,” commenting, or sharing posts. Furthermore, higher Facebook capability appeared to increase a participants’ willingness to participate in a cardiac Facebook support group. More capable users were more receptive to the use of Facebook for cardiac rehabilitation and more likely to express interest in providing peer support. Recommended features for a cardiac rehabilitation Facebook group included a closed group, expert cardiac professional involvement, provision of cardiac health information, and ensuring trustworthiness of the group. Conclusions: Cardiac health professionals have an opportunity to capitalize on cardiac patients’ motivations and social media, mostly Facebook, as well as the capability for supporting cardiac rehabilitation and secondary prevention. Participants’ favored purposeful time spent on Facebook and their cardiac health provides such a purpose for a Facebook intervention. The study results will inform the development of a Facebook intervention for secondary prevention of cardiovascular disease.

  • Source: The Authors; Copyright:; URL:; License: Licensed by the authors.

    Blending Face-to-Face and Internet-Based Interventions for the Treatment of Mental Disorders in Adults: Systematic Review


    Background: Many studies have provided evidence for the effectiveness of Internet-based stand-alone interventions for mental disorders. A newer form of intervention combines the strengths of face-to-face (f2f) and Internet approaches (blended interventions). Objective: The aim of this review was to provide an overview of (1) the different formats of blended treatments for adults, (2) the stage of treatment in which these are applied, (3) their objective in combining face-to-face and Internet-based approaches, and (4) their effectiveness. Methods: Studies on blended concepts were identified through systematic searches in the MEDLINE, PsycINFO, Cochrane, and PubMed databases. Keywords included terms indicating face-to-face interventions (“inpatient,” “outpatient,” “face-to-face,” or “residential treatment”), which were combined with terms indicating Internet treatment (“internet,” “online,” or “web”) and terms indicating mental disorders (“mental health,” “depression,” “anxiety,” or “substance abuse”). We focused on three of the most common mental disorders (depression, anxiety, and substance abuse). Results: We identified 64 publications describing 44 studies, 27 of which were randomized controlled trials (RCTs). Results suggest that, compared with stand-alone face-to-face therapy, blended therapy may save clinician time, lead to lower dropout rates and greater abstinence rates of patients with substance abuse, or help maintain initially achieved changes within psychotherapy in the long-term effects of inpatient therapy. However, there is a lack of comparative outcome studies investigating the superiority of the outcomes of blended treatments in comparison with classic face-to-face or Internet-based treatments, as well as of studies identifying the optimal ratio of face-to-face and Internet sessions. Conclusions: Several studies have shown that, for common mental health disorders, blended interventions are feasible and can be more effective compared with no treatment controls. However, more RCTs on effectiveness and cost-effectiveness of blended treatments, especially compared with nonblended treatments are necessary.

  • PiiA application of the EORTC QLQ-C30 questionnaire for 4-point-scale questions in German (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Reliability of an e-PRO Tool of EORTC QLQ-C30 for Measurement of Health-Related Quality of Life in Patients With Breast Cancer: Prospective Randomized Trial


    Background: Breast cancer represents the most common malignant disease in women worldwide. As currently systematic palliative treatment only has a limited effect on survival rates, the concept of health-related quality of life (HRQoL) is gaining more and more importance in the therapy setting of metastatic breast cancer. One of the major patient-reported outcomes (PROs) for measuring HRQoL in patients with breast cancer is provided by the European Organization for Research and Treatment of Cancer (EORTC). Currently, paper-based surveys still predominate, as only a few reliable and validated electronic-based questionnaires are available. Facing the possibilities associated with evolving digitalization in medicine, validation of electronic versions of well-established PRO is essential in order to contribute to comprehensive and holistic oncological care and to ensure high quality in cancer research. Objective: The aim of this study was to analyze the reliability of a tablet-based measuring application for EORTC QLQ-C30 in German language in patients with adjuvant and (curative) metastatic breast cancer. Methods: Paper- and tablet-based questionnaires were completed by a total of 106 female patients with adjuvant and metastatic breast cancer recruited as part of the e-PROCOM study. All patients were required to complete the electronic- (e-PRO) and paper-based versions of the HRQoL EORTC QLQ-C30 questionnaire. A frequency analysis was performed to determine descriptive sociodemographic characteristics. Both dimensions of reliability (parallel forms reliability [Wilcoxon test] and test of internal consistency [Spearman rho and agreement rates for single items, Pearson correlation and Kendall tau for each scale]) were analyzed. Results: High correlations were shown for both dimensions of reliability (parallel forms reliability and internal consistency) in the patient’s response behavior between paper- and electronic-based questionnaires. Regarding the test of parallel forms reliability, no significant differences were found in 27 of 30 single items and in 14 of 15 scales, whereas a statistically significant correlation in the test of consistency was found in all 30 single items and all 15 scales. Conclusions: The evaluated e-PRO version of the EORTC QLQ-C30 is reliable for patients with both adjuvant and metastatic breast cancer, showing a high correlation in almost all questions (and in many scales). Thus, we conclude that the validated paper-based PRO assessment and the e-PRO tool are equally valid. However, the reliability should also be analyzed in other prospective trials to ensure that usability is reliable in all patient groups. Trial Registration: NCT03132506; (Archived by WebCite at

  • Source: Pixabay; Copyright: Free-Photos; URL:; License: Public Domain (CC0).

    User Acceptance of Computerized Cognitive Behavioral Therapy for Depression: Systematic Review


    Background: Computerized cognitive behavioral therapy (cCBT) has been proven to be effective in depression care. Moreover, cCBT packages are becoming increasingly popular. A central aspect concerning the take-up and success of any treatment is its user acceptance. Objective: The aim of this study was to update and expand on earlier work on user acceptance of cCBT for depression. Methods: This paper systematically reviewed quantitative and qualitative studies regarding the user acceptance of cCBT for depression. The initial search was conducted in January 2016 and involved the following databases: Web of Science, PubMed, the Cochrane Library, and PsycINFO. Studies were retained if they described the explicit examination of the user acceptance, experiences, or satisfaction related to a cCBT intervention, if they reported depression as a primary outcome, and if they were published in German or English from July 2007 onward. Results: A total of 1736 studies were identified, of which 29 studies were eligible for review. User acceptance was operationalized and analyzed very heterogeneously. Eight studies reported a very high level of acceptance, 17 indicated a high level of acceptance, and one study showed a moderate level of acceptance. Two qualitative studies considered the positive and negative aspects concerning the user acceptance of cCBT. However, a substantial proportion of reviewed studies revealed several methodical shortcomings. Conclusions: In general, people experience cCBT for depression as predominantly positive, which supports the potential role of these innovative treatments. However, methodological challenges do exist in terms of defining user acceptance, clear operationalization of concepts, and measurement.

  • Source: Pixabay; Copyright: StartupStockPhotos; URL:; License: Public Domain (CC0).

    Putting the Focus Back on the Patient: How Privacy Concerns Affect Personal Health Information Sharing Intentions


    Background: Health care providers are driven by greater participation and systemic cost savings irrespective of benefits to individual patients derived from sharing Personal Health Information (PHI). Protecting PHI is a critical issue in the sharing of health care information systems; yet, there is very little literature examining the topic of sharing PHI electronically. A good overview of the regulatory, privacy, and societal barriers to sharing PHI can be found in the 2009 Health Information Technology for Economic and Clinical Health Act. Objective: This study investigated the factors that influence individuals’ intentions to share their PHI electronically with health care providers, creating an understanding of how we can represent a patient’s interests more accurately in sharing settings, instead of treating patients like predetermined subjects. Unlike privacy concern and trust, patient activation is a stable trait that is not subject to change in the short term and, thus, is a useful factor in predicting sharing behavior. We apply the extended privacy model in the health information sharing context and adapt this model to include patient activation and issue involvement to predict individuals’ intentions. Methods: This was a survey-based study with 1600+ participants using the Health Information National Trends Survey (HINTS) data to validate a model through various statistical techniques. The research method included an assessment of both the measurement and structural models with post hoc analysis. Results: We find that privacy concern has the most influence on individuals’ intentions to share. Patient activation, issue involvement, and patient-physician relationship are significant predictors of sharing intention. We contribute to theory by introducing patient activation and issue involvement as proxies for personal interest factors in the health care context. Conclusions: Overall, this study found that although patients are open to sharing their PHI, they still have concerns over the privacy of their PHI during the sharing process. It is paramount to address this factor to increase information flow and identify how patients can assure that their privacy is protected. The outcome of this study is a set of recommendations for motivating the sharing of PHI. The goal of this research is to increase the health profile of the patients by integrating the testing and diagnoses of various doctors across health care providers and, thus, bring patients closer to the physicians.

  • A young woman shows off her flu shot after receiving vaccine at a local drug store. Source: Wikimedia Commons; Copyright: Whoisjohngalt; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Enhancing Seasonal Influenza Surveillance: Topic Analysis of Widely Used Medicinal Drugs Using Twitter Data


    Background: Uptake of medicinal drugs (preventive or treatment) is among the approaches used to control disease outbreaks, and therefore, it is of vital importance to be aware of the counts or frequencies of most commonly used drugs and trending topics about these drugs from consumers for successful implementation of control measures. Traditional survey methods would have accomplished this study, but they are too costly in terms of resources needed, and they are subject to social desirability bias for topics discovery. Hence, there is a need to use alternative efficient means such as Twitter data and machine learning (ML) techniques. Objective: Using Twitter data, the aim of the study was to (1) provide a methodological extension for efficiently extracting widely consumed drugs during seasonal influenza and (2) extract topics from the tweets of these drugs and to infer how the insights provided by these topics can enhance seasonal influenza surveillance. Methods: From tweets collected during the 2012-13 flu season, we first identified tweets with mentions of drugs and then constructed an ML classifier using dependency words as features. The classifier was used to extract tweets that evidenced consumption of drugs, out of which we identified the mostly consumed drugs. Finally, we extracted trending topics from each of these widely used drugs’ tweets using latent Dirichlet allocation (LDA). Results: Our proposed classifier obtained an F1 score of 0.82, which significantly outperformed the two benchmark classifiers (ie, P<.001 with the lexicon-based and P=.048 with the 1-gram term frequency [TF]). The classifier extracted 40,428 tweets that evidenced consumption of drugs out of 50,828 tweets with mentions of drugs. The most widely consumed drugs were influenza virus vaccines that had around 76.95% (31,111/40,428) share of the total; other notable drugs were Theraflu, DayQuil, NyQuil, vitamins, acetaminophen, and oseltamivir. The topics of each of these drugs exhibited common themes or experiences from people who have consumed these drugs. Among these were the enabling and deterrent factors to influenza drugs uptake, which are keys to mitigating the severity of seasonal influenza outbreaks. Conclusions: The study results showed the feasibility of using tweets of widely consumed drugs to enhance seasonal influenza surveillance in lieu of the traditional or conventional surveillance approaches. Public health officials and other stakeholders can benefit from the findings of this study, especially in enhancing strategies for mitigating the severity of seasonal influenza outbreaks. The proposed methods can be extended to the outbreaks of other diseases.

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  • Web-Based Patient Education in Orthopaedics: A Systematic Review

    Date Submitted: Sep 21, 2017

    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: Orthopaedic patients frequently use the Internet to find health information. Patient education that is distributed online may form an easy-accessible, time- and cost-effective alternative...

    Background: Orthopaedic patients frequently use the Internet to find health information. Patient education that is distributed online may form an easy-accessible, time- and cost-effective alternative to patient education delivered through traditional channels, such as one-on-one consultations or booklets. However, no systematic evidence for the comparative effectiveness of web-based educational interventions exists. Objective: The objective of this systematic review was to examine the effects of web-based patient education interventions for adult orthopaedic patients and to compare its effectiveness to generic health information websites and traditional forms of patient education. Methods: CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsycINFO, PUBMED, ScienceDirect, Scopus and Web of Science were searched covering the period 1995-2016. Peer-reviewed English and Dutch studies were included if they delivered patient education via the Internet to the adult orthopaedic patient population, and assessed its effects in a controlled or observational trial. Results: A total of 10 trials reported in 14 studies involving 4172 patients were identified. Nine trials provided evidence for increased patients’ knowledge after web-based patient education. Seven trials reported increased satisfaction and good evaluations of web-based patient education. No compelling evidence exists for an effect of web-based patient education on anxiety, health attitudes and behaviour, or clinical outcomes. Conclusions: Web-based patient education may be offered as a time- and cost-effective alternative to current educational interventions when the objective is to improve patients’ knowledge and satisfaction. However, these findings may not be representative for the whole orthopaedic patient population as most reviewed trials included considerably younger, higher-educated, and internet-savvy participants only.

  • Development and Formative Evaluation of a Smartphone Application for Smoking Cessation: Crush the Crave

    Date Submitted: Sep 21, 2017

    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: Emerging evidence supports the use of smartphone apps for smoking cessation. However, there remains a paucity of research describing the design and development processes of mobile health (...

    Background: Emerging evidence supports the use of smartphone apps for smoking cessation. However, there remains a paucity of research describing the design and development processes of mobile health (mHealth) interventions, leaving unanswered questions about how to productively leverage apps for quitting smoking. Objective: This paper describes the process of developing the Crush the Crave (CTC) app for smoking cessation and the results of a formative evaluation of app usage behaviour, as part of a broader program of research that seeks to establish the effectiveness of the CTC app. Methods: The Spiral Technology Action Research (STAR) five-cycle model (listen, plan, do, act, and study) was employed to guide development, implementation, and dissemination of CTC. The approach to development and formative evaluation included focus groups with young adult smokers (n=78), analysis of the content of existing apps, two sessions with content experts, and google analytics to assess user behaviour during a 12-month pilot. Results: LISTEN – focus groups revealed young adult smoker preferences of 1) Positive reinforcement, 2) Personalization, 3) Social support, 4) Quit support, 5) Tracking the behaviour, and 6) Tracking quit benefits. PLAN – Informed by evidence for smoking cessation, young adult preferences, and an assessment of popular cessation apps, content experts produced a mind map and a storyboard describing app content and structure. DO – Focus groups with young adult smokers provided feedback on the first version of the app with opinions on content and suggestions for improvement such as providing alerts, distractions from craving, and improvements to the organization of help information for quitting. ACT – CTC App refinements were made and app content was organized using the four key design components of credibility, task support, dialogue support and social support. CTC was launched April 2013 and piloted from the period July 2013 to June 2014 where 1,987 Android users had 18,567 sessions resulting in 59,384 page views and 89.6% of users returning within the same day to use CTC. STUDY – A pragmatic randomized controlled trial of CTC was launched August 2014 to demonstrate that including mHealth technology as a population-based intervention can help young adult smokers to quit. Conclusions: CTC is one of the first smoking cessation apps designed to meet the needs of young adult smokers. The development was informed by the inclusion of young adults in the design and the systematic application of multiple stakeholder input, scientific evidence, and theory. The STAR model approach was followed from the beginning of intervention development, which should facilitate optimization of mHealth interventions in the future.

  • The effectiveness of healthcare information technologies: An empirical evaluation of trust, security beliefs, and privacy as determinants of healthcare outcomes.

    Date Submitted: Sep 21, 2017

    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: The diffusion of health information technologies (HITs) within the healthcare sector continues to grow. However, there is no theory explaining how HITs success influences patient care outc...

    Background: The diffusion of health information technologies (HITs) within the healthcare sector continues to grow. However, there is no theory explaining how HITs success influences patient care outcomes. And the increase in data breaches, HITs success now hinges on the effectiveness of data protection solutions. Yet still, empirical research has only addressed privacy concerns, with little regard for other factors of information assurance. Objective: We study the effectiveness of HITs using the DeLone and McLean IS Success Model (DMISSM)1. We examine the role of information assurance constructs (i.e., information privacy and security beliefs, and trust in health information) as measures of HIT effectiveness. We also investigate the relationships between information assurance and three aspects of system success; electronic medical record (EMR) use, patients’ attitudes towards health information exchange (HIE), and patient care quality. Methods: Using structural equation modeling, we analyze data from a sample of 3,677 cancer patients. We used R software and the Lavaan package to test the hypothesized relationships. Results: Our extension of the DMISSM1 to healthcare was supported. We found that increased privacy concerns reduce the frequency of EMR use, positive attitudes towards HIE, and perceptions of patient care quality. Also, information security beliefs increase EMR use and the positive attitudes towards HIE. Trust in health information had a positive association with attitudes towards HIE, and patient care quality. Trust in health information had no direct effect on EMR use; however, it had an indirect relationship through information privacy concerns. Conclusions: Information trust and information security safeguards increase perceptions of patient care quality. Information privacy concerns reduce EMR use by patients, patients’ positive attitudes towards HIE exchange, and overall patient care quality. Healthcare organizations are encouraged to implement security safeguards for increasing trust and EMR use, reducing privacy concerns, and consequently increasing patient care quality.

  • Worker preferences for a mental health App in male-dominated industries: A Participatory Study

    Date Submitted: Sep 20, 2017

    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: Men are less likely to seek help for mental health problems possibly due to stigma imposed by cultural masculine norms. These tendencies may be amplified within male-dominated workplaces s...

    Background: Men are less likely to seek help for mental health problems possibly due to stigma imposed by cultural masculine norms. These tendencies may be amplified within male-dominated workplaces such as the emergency services, or transport industries. Mobile apps present a promising way to provide access to mental health support. However, little is known about the kinds of technologies men would be willing to engage with in their workplace, and no App can work if people do not engage with it. Objective: The goal of this participatory user research study was to explore the perceptions, preferences, and ideas of workers in male-dominated workplaces in order to define requirements for a mental health app that would be engaging and effective at improving psychological well-being. Methods: Workers from male-dominated workplaces in rural, suburban, and urban locations, took part in participatory workshops designed to elicit their perspectives and preferences for mental health support and the design of an app for mental health. Participants generated a number of artifacts (including draft screen designs and promotional material) designed to reify their perceptions, tacit knowledge, and ideas. Results: A total of 60 workers aged 26-65 years (92% male) from male-dominated workplaces in rural (27%), suburban (23%) and urban (50%) locations participated in one of six workshops resulting in 49 unique feature ideas and 81 participant-generated artifacts. Thematic analysis resulted in a set of feature, language, and style preferences, as well as characteristics considered important by participants for a mental health app. The term “mental health” was highly stigmatized and disliked by participants. Tools including a mood tracker, self-assessment and “mood boost” tool were highly valued and App characteristics such as the brevity of interactions, minimal on-screen text and a solutions-oriented approach were considered essential by participants. Conclusions: Future mental health smartphone applications targeting workers in male-dominated workplaces need to balance the preferences of users with the demands of evidence-based intervention. In addition to informing the development of mental health apps for workers in male-dominated industries, these findings may also provide insights towards mental health technologies for men more generally, and for others in high-stigma environments.

  • Making Friends with Doctors in Social Media: The Effect of Doctor-Consumer Interaction on Healthy Behaviors

    Date Submitted: Sep 21, 2017

    Open Peer Review Period: Sep 22, 2017 - Nov 17, 2017

    Background: Background: Both doctors and consumers have engaged in using social media for health purpose. Social media change traditional one-to-one communication way between doctors and patients to m...

    Background: Background: Both doctors and consumers have engaged in using social media for health purpose. Social media change traditional one-to-one communication way between doctors and patients to many-to-many communication way between doctors and consumers. However, little is known about the effect of doctor-consumer interaction on consumers’ healthy behaviors. Objective: The purpose of this study is to investigate how doctor-consumer interaction in social media affects consumers’ healthy behaviors. Methods: Based on professional-client interaction theory and social cognitive theory, we propose that doctor-consumer interaction can be divided into instrumental interaction and affective interaction. These two types of interaction influence consumers’ healthy behaviors through declarative knowledge, self-efficacy and outcome expectancy. To validate our proposed research model, we employed the survey method and developed corresponding measurement instruments for constructs in our research model. 352 valid answers were collected and partial least square was performed to analyze the data. Results: Instrumental doctor-consumer interaction was found to influence consumers’ declarative knowledge (t=5.763, P <0.001), self-efficacy (t=4.891,P<0.001) and outcome expectancy (t=7.554, P <0.001) significantly, while affective doctor-consumer interaction also impacted consumers’ declarative knowledge (t=4.025, P <0.001), self-efficacy (t=4.775, P <0.001) and outcome expectancy (t=4.855, P <0.001). Meanwhile, consumers’ declarative knowledge (t=3.838, P <0.001), self-efficacy (t=3.824, P <0.001) and outcome expectancy (t=2.985, P <0.01) all significantly affected consumers’ healthy behaviors. Our mediation analysis showed that consumers’ declarative knowledge, self-efficacy and outcome expectancy partially mediated the effect of instrumental interaction on healthy behaviors, while the three mediators fully mediated the effect of affective interaction on healthy behaviors. Conclusions: Compared with many intentional intervention programs, doctor-consumer interaction can be treated as natural cost-effective intervention to promote consumers’ healthy behaviors. Meanwhile, both instrumental and affective interaction should be highlighted for the best interaction results. Declarative knowledge, self-efficacy and outcome expectancy are working mechanisms of doctor-consumer interaction.

  • Systematic review of studies on mHealth interventions for maternal and child health

    Date Submitted: Sep 20, 2017

    Open Peer Review Period: Sep 21, 2017 - Nov 16, 2017

    Background: The application of mHealth technology in reproductive, maternal, newborn and child health (RMNCH) is increasing worldwide. However, best practice and the most effective mHealth interventio...

    Background: The application of mHealth technology in reproductive, maternal, newborn and child health (RMNCH) is increasing worldwide. However, best practice and the most effective mHealth interventions have not been reviewed systematically. Objective: A systematic review and meta-analysis on studies of mHealth interventions for RMNCH around the world were conducted to investigate their characteristics as well as features and effectiveness of mHealth interventions. Methods: Studies of mHealth interventions for RMNCH between January 2011 and December 2016 were retrieved from six databases (PubMed, EMBASE, Global Health, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, and Wanfang Data Knowledge Service Medium). Comparable studies were included in a random-effects meta-analysis for both exclusive breastfeeding (EBF) and antenatal checks (ANC). Descriptive analysis were conducted for mHealth studies with for a range of study design. Results: Analysis of 245 studies were included, including 51 RCTs. Results showed that there are increasing numbers of studies on mHealth interventions for RMNCH. Although two meta-analysis, one with two RCTs on EBF (OR 2.03, 95% CI 1.34–3.08, I2=25%) and the other with three RCTs on ANC (OR 1.43, 95% CI 1.13–1.79, I2=78%), showed that mHealth interventions are more effective than usual care, almost half (43.1%) of RCTs showed negative or unclear results on mHealth interventions. Functions described in mHealth interventions were diverse and the health stages covered were broad, but single function/single stage appeared to be dominant among mHealth interventions compared with multiple functions/stages. Conclusions: More rigorous evaluations are needed to draw consistent conclusions, and to analyse mHealth products with multiple functions, especially those popular in the Application markets.