JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 4.5 for 2015

Recent Articles:

  • Mother looking for health information on the Internet with her daughter

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    Modelling and Predicting eHealth Usage in Europe: A Multidimensional Approach From an Online Survey of 13,000 European Union Internet Users


    Background: More advanced methods and models are needed to evaluate the participation of patients and citizens in the shared health care model that eHealth proposes. Objective: The goal of our study was to design and evaluate a predictive multidimensional model of eHealth usage. Methods: We used 2011 survey data from a sample of 13,000 European citizens aged 16–74 years who had used the Internet in the previous 3 months. We proposed and tested an eHealth usage composite indicator through 2-stage structural equation modelling with latent variables and measurement errors. Logistic regression (odds ratios, ORs) to model the predictors of eHealth usage was calculated using health status and sociodemographic independent variables. Results: The dimensions with more explanatory power of eHealth usage were health Internet attitudes, information health Internet usage, empowerment of health Internet users, and the usefulness of health Internet usage. Some 52.39% (6811/13,000) of European Internet users’ eHealth usage was more intensive (greater than the mean). Users with long-term health problems or illnesses (OR 1.20, 95% CI 1.12–1.29) or receiving long-term treatment (OR 1.11, 95% CI 1.03–1.20), having family members with long-term health problems or illnesses (OR 1.44, 95% CI 1.34–1.55), or undertaking care activities for other people (OR 1.58, 95% CI 1.40–1.77) had a high propensity toward intensive eHealth usage. Sociodemographic predictors showed that Internet users who were female (OR 1.23, 95% CI 1.14–1.31), aged 25–54 years (OR 1.12, 95% CI 1.05–1.21), living in larger households (3 members: OR 1.25, 95% CI 1.15–1.36; 5 members: OR 1.13, 95% CI 0.97–1.28; ≥6 members: OR 1.31, 95% CI 1.10–1.57), had more children <16 years of age (1 child: OR 1.29, 95% CI 1.18–1.14; 2 children: OR 1.05, 95% CI 0.94–1.17; 4 children: OR 1.35, 95% CI 0.88–2.08), and had more family members >65 years of age (1 member: OR 1.33, 95% CI 1.18–1.50; ≥4 members: OR 1.82, 95% CI 0.54–6.03) had a greater propensity toward intensive eHealth usage. Likewise, users residing in densely populated areas, such as cities and large towns (OR 1.17, 95% CI 1.09–1.25), also had a greater propensity toward intensive eHealth usage. Educational levels presented an inverted U shape in relation to intensive eHealth usage, with greater propensities among those with a secondary education (OR 1.08, 95% CI 1.01–1.16). Finally, occupational categories and net monthly income data suggest a higher propensity among the employed or self-employed (OR 1.07, 95% CI 0.99–1.15) and among the minimum wage stratum, earning ≤€1000 per month (OR 1.66, 95% CI 1.48–1.87). Conclusions: We provide new evidence of inequalities that explain intensive eHealth usage. The results highlight the need to develop more specific eHealth practices to address different realities.

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    Health Care Applicability of a Patient-Centric Web Portal for Patients’ Medication Experience


    Background: With the advent of the patient-centered care paradigm, it is important to examine what patients’ reports of medication experience (PROME) mean to patient care. PROME available through a Web portal provide information on medication treatment options and outcomes from the patient’s perspective. Patients who find certain PROME compelling are likely to mention them at their physician visit, triggering a discussion between the patient and the physician. However, no studies have examined PROME’s potential applicability to patient care. Objective: This study aimed to examine older (≥50 years) adults’ perceptions of the health care applicability of a hypothetical PROME Web portal. Specifically, this study investigated whether PROME would facilitate patient-physician communication, and identified the preferred reporting items and the trusted sponsors of such a PROME Web portal. Methods: We used a cross-sectional, self-administered, 5-point Likert scale survey to examine participants’ perceptions of a hypothetical PROME Web portal that compared PROME for 5 common antihypertensive medications. Between August and December 2013, we recruited 300 members of 7 seniors’ centers in a metropolitan area of a southeastern state of the United States to participate in the survey. Results: An overwhelming majority of study participants (243/300, 81.0%) had a favorable perception of PROME’s health care applicability. They were mostly positive that PROME would facilitate patient-physician communication, except for the perception that physicians would be upset by the mention of PROME (n=133, 44.3%). Further, 85.7% (n=257) of participants considered the PROME information trustworthy, and 72.0% (n=216) were willing to participate by reporting their own medication experiences. Study participants wanted the PROME Web portal to report the number of reviews, star ratings, and individual comments concerning different medication attributes such as side effects (224/809, 27.7%), cost (168/809, 20.8%), and effectiveness (153/809, 18.9%). Finally, the PROME Web portal sponsorship was important to participants, with the most trusted sponsor being academic institutions (120/400, 30.0%). Conclusions: PROME, if well compiled through Web portals, have the potential to facilitate patient-physician communication.

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    Parent-Focused Childhood and Adolescent Overweight and Obesity eHealth Interventions: A Systematic Review and Meta-Analysis


    Background: Effective broad-reach interventions to reduce childhood obesity are needed, but there is currently little consensus on the most effective approach. Parental involvement in interventions appears to be important. The use of eHealth modalities in interventions also seems to be promising. To our knowledge, there have been no previous reviews that have specifically investigated the effectiveness of parent-focused eHealth obesity interventions, a gap that this systematic review and meta-analysis intends to address. Objective: The objective of this study was to review the evidence for body mass index (BMI)/BMI z-score improvements in eHealth overweight and obesity randomized controlled trials for children and adolescents, where parents or carers were an agent of change. Methods: A systematic review and meta-analysis was conducted, which conforms to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Seven databases were searched for the period January 1995 to April 2015. Primary outcome measures were BMI and/or BMI z-score at baseline and post-intervention. Secondary outcomes included diet, physical activity, and screen time. Interventions were included if they targeted parents of children and adolescents aged 0-18 years of age and used an eHealth medium such as the Internet, interactive voice response (IVR), email, social media, telemedicine, or e-learning. Results: Eight studies were included, involving 1487 parent and child or adolescent dyads. A total of 3 studies were obesity prevention trials, and 5 were obesity treatment trials. None of the studies found a statistically significant difference in BMI or BMI z-score between the intervention and control groups at post-intervention, and a meta-analysis demonstrated no significant difference in the effects of parent-focused eHealth obesity interventions compared with a control on BMI/BMI z-score (Standardized Mean Difference −0.15, 95% CI −0.45 to 0.16, Z=0.94, P=.35). Four of seven studies that reported on dietary outcomes demonstrated significant improvements in at least 1 dietary measurement, and 1 of 6 studies that reported on physical activity outcomes demonstrated significant improvements compared with the control. The quality of the interventions was generally not high; therefore, these results should be interpreted with caution. Conclusion: It is recommended that larger, longer duration, high-quality parent-focused eHealth studies are conducted, which transform successful components from face-to-face interventions into an eHealth format and target younger age groups in particular. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRD42015019837; (Archived by WebCite at

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    Investigating the Potential Contribution of Patient Rating Sites to Hospital Supervision: Exploratory Results From an Interview Study in the Netherlands


    Background: Over the last decades, the patient perspective on health care quality has been unconditionally integrated into quality management. For several years now, patient rating sites have been rapidly gaining attention. These offer a new approach toward hearing the patient’s perspective on the quality of health care. Objective: The aim of our study was to explore whether and how patient reviews of hospitals, as reported on rating sites, have the potential to contribute to health care inspector’s daily supervision of hospital care. Methods: Given the unexplored nature of the topic, an interview study among hospital inspectors was designed in the Netherlands. We performed 2 rounds of interviews with 10 senior inspectors, addressing their use and their judgment on the relevance of review data from a rating site. Results: All 10 Dutch senior hospital inspectors participated in this research. The inspectors initially showed some reluctance to use the major patient rating site in their daily supervision. This was mainly because of objections such as worries about how representative they are, subjectivity, and doubts about the relevance of patient reviews for supervision. However, confrontation with, and assessment of, negative reviews by the inspectors resulted in 23% of the reviews being deemed relevant for risk identification. Most inspectors were cautiously positive about the contribution of the reviews to their risk identification. Conclusions: Patient rating sites may be of value to the risk-based supervision of hospital care carried out by the Health Care Inspectorate. Health care inspectors do have several objections against the use of patient rating sites for daily supervision. However, when they are presented with texts of negative reviews from a hospital under their supervision, it appears that most inspectors consider it as an additional source of information to detect poor quality of care. Still, it should always be accompanied and verified by other quality and safety indicators. More research on the value and usability of patient rating sites in daily hospital supervision and other health settings is needed.

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    Social Annotation Valence: The Impact on Online Informed Consent Beliefs and Behavior


    Background: Social media, mobile and wearable technology, and connected devices have significantly expanded the opportunities for conducting biomedical research online. Electronic consent to collecting such data, however, poses new challenges when contrasted to traditional consent processes. It reduces the participant-researcher dialogue but provides an opportunity for the consent deliberation process to move from solitary to social settings. In this research, we propose that social annotations, embedded in the consent form, can help prospective participants deliberate on the research and the organization behind it in ways that traditional consent forms cannot. Furthermore, we examine the role of the comments’ valence on prospective participants’ beliefs and behavior. Objective: This study focuses specifically on the influence of annotations’ valence on participants’ perceptions and behaviors surrounding online consent for biomedical research. We hope to shed light on how social annotation can be incorporated into digitally mediated consent forms responsibly and effectively. Methods: In this controlled between-subjects experiment, participants were presented with an online consent form for a personal genomics study that contained social annotations embedded in its margins. Individuals were randomly assigned to view the consent form with positive-, negative-, or mixed-valence comments beside the text of the consent form. We compared participants’ perceptions of being informed and having understood the material, their trust in the organization seeking the consent, and their actual consent across conditions. Results: We find that comment valence has a marginally significant main effect on participants’ perception of being informed (F2=2.40, P=.07); specifically, participants in the positive condition (mean 4.17, SD 0.94) felt less informed than those in the mixed condition (mean 4.50, SD 0.69, P=.09). Comment valence also had a marginal main effect on the extent to which participants reported trusting the organization (F2=2.566, P=.08). Participants in the negative condition (mean 3.59, SD 1.14) were marginally less trusting than participants exposed to the positive condition (mean 4.02, SD 0.90, P=.06). Finally, we found that consent rate did not differ across comment valence conditions; however, participants who spent less time studying the consent form were more likely to consent when they were exposed to positive-valence comments. Conclusions: This work explores the effects of adding a computer-mediated social dimension, which inherently contains human emotions and opinions, to the consent deliberation process. We proposed that augmenting the consent deliberation process to incorporate multiple voices can enable individuals to capitalize on the knowledge of others, which brings to light questions, problems, and concerns they may not have considered on their own. We found that consent forms containing positive valence annotations are likely to lead participants to feel less informed and simultaneously more trusting of the organization seeking consent. In certain cases where participants spent little time considering the content of the consent form, participants exposed to positive valence annotations were even more likely to consent to the study. We suggest that these findings represent important considerations for the design of future electronic informed consent mechanisms.

  •; CCBY2.0, Attribution: Joe The Goat Farmer; modified.

    How Affiliation Disclosure and Control Over User-Generated Comments Affects Consumer Health Knowledge and Behavior: A Randomized Controlled Experiment of...


    Background: More people are seeking health information online than ever before and pharmaceutical companies are increasingly marketing their drugs through social media. Objective: The aim was to examine two major concerns related to online direct-to-consumer pharmaceutical advertising: (1) how disclosing an affiliation with a pharmaceutical company affects how people respond to drug information produced by both health organizations and online commenters, and (2) how knowledge that health organizations control the display of user-generated comments affects consumer health knowledge and behavior. Methods: We conducted a 2×2×2 between-subjects experiment (N=674). All participants viewed an infographic posted to Facebook by a health organization about a prescription allergy drug. Across conditions, the infographic varied in the degree to which the health organization and commenters appeared to be affiliated with a drug manufacturer, and the display of user-generated comments appeared to be controlled. Results: Affiliation disclosure statements on a health organization’s Facebook post increased perceptions of an organization-drug manufacturer connection, which reduced trust in the organization (point estimate –0.45, 95% CI –0.69 to –0.24) and other users who posted comments about the drug (point estimate –0.44, 95% CI –0.68 to –0.22). Furthermore, increased perceptions of an organization-manufacturer connection reduced the likelihood that people would recommend the drug to important others (point estimate –0.35, 95% CI –0.59 to –0.15), and share the drug post with others on Facebook (point estimate –0.37, 95% CI –0.64 to –0.16). An affiliation cue next to the commenters' names increased perceptions that the commenters were affiliated with the drug manufacturer, which reduced trust in the comments (point estimate –0.81, 95% CI –1.04 to –0.59), the organization that made the post (point estimate –0.68, 95% CI –0.90 to –0.49), the likelihood of participants recommending the drug (point estimate –0.61, 95% CI –0.82 to –0.43), and sharing the post with others on Facebook (point estimate –0.63, 95% CI –0.87 to –0.43). Cues indicating that a health organization removed user-generated comments from a post increased perceptions that the drug manufacturer influenced the display of the comments, which negatively affected trust in the comments (point estimate –0.35, 95% CI –0.53 to –0.20), the organization (point estimate –0.31, 95% CI –0.47 to –0.17), the likelihood of recommending the drug (point estimate –0.26, 95% CI –0.41 to –0.14), and the likelihood of sharing the post with others on Facebook (point estimate –0.28, 95% CI –0.45 to –0.15). (All estimates are unstandardized indirect effects and 95% bias-corrected bootstrap confidence intervals.) Conclusions: Concern over pharmaceutical companies hiding their affiliations and strategically controlling user-generated comments is well founded; these practices can greatly affect not only how viewers evaluate drug information online, but also how likely they are to propagate the information throughout their online and offline social networks.

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    Follow #eHealth2011: Measuring the Role and Effectiveness of Online and Social Media in Increasing the Outreach of a Scientific Conference


    Background: Social media promotion is increasingly adopted by organizers of industry and academic events; however, the success of social media strategies is rarely questioned or the real impact scientifically analyzed. Objective: We propose a framework that defines and analyses the impact, outreach, and effectiveness of social media for event promotion and research dissemination to participants of a scientific event as well as to the virtual audience through the Web. Methods: Online communication channels Twitter, Facebook, Flickr, and a Liveblog were trialed and their impact measured on outreach during five phases of an eHealth conference: the setup, active and last-minute promotion phases before the conference, the actual event, and after the conference. Results: Planned outreach through online channels and social media before and during the event reached an audience several magnitudes larger in size than would have been possible using traditional means. In the particular case of eHealth 2011, the outreach using traditional means would have been 74 attendees plus 23 extra as sold proceedings and the number of downloaded articles from the online proceedings (4107 until October 2013). The audience for the conference reached via online channels and social media was estimated at more than 5300 in total during the event. The role of Twitter for promotion before the event was complemented by an increased usage of the website and Facebook during the event followed by a sharp increase of views of posters on Flickr after the event. Conclusions: Although our case study is focused on a particular audience around eHealth 2011, our framework provides a template for redefining “audience” and outreach of events, merging traditional physical and virtual communities and providing an outline on how these could be successfully reached in clearly defined event phases.

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    Possible Biases of Researchers’ Attitudes Toward Video Games: Publication Trends Analysis of the Medical Literature (1980–2013)


    Background: The study of video games is expanding, and so is the debate regarding their possible positive and deleterious effects. As controversies continue, several researchers have expressed their concerns about substantial biases existing in the field, which might lead to the creation of a skewed picture, both in the professional and in the lay literature. However, no study has tried to examine this issue quantitatively. Objective: The objective of our study was to examine possible systematic biases in the literature, by analyzing the publication trends of the medical and life sciences literature regarding video games. Methods: We performed a complete and systematic PubMed search up to December 31, 2013. We assessed all 1927 articles deemed relevant for their attitude toward video games according to the focus, hypothesis, and authors’ interpretation of the study results, using a 3-category outcome (positive, negative, and neutral). We assessed the prevalence of different attitudes for possible association with year of publication, location of researchers, academic discipline, methodological research, and centrality of the publishing journals. Results: The attitude toward video games presented in publications varied by year of publication, location, academic discipline, and methodological research applied (P<.001 for all). Moreover, representation of different attitudes differed according to centrality of the journals, as measured by their impact factor (P<.001). Conclusions: The results suggest that context, whether scientific or social, is related to researchers’ attitudes toward video games. Readers, both lay and professional, should weigh these contextual variables when interpreting studies’ results, in light of the possible bias they carry. The results also support a need for a more balanced, open-minded approach toward video games, as it is likely that this complex phenomenon carries novel opportunities as well as new hazards.

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    Associations of eHealth Literacy With Health Behavior Among Adult Internet Users


    Background: In the rapidly developing use of the Internet in society, eHealth literacy—having the skills to utilize health information on the Internet—has become an important prerequisite for promoting healthy behavior. However, little is known about whether eHealth literacy is associated with health behavior in a representative sample of adult Internet users. Objective: The aim of this study was to examine the association between eHealth literacy and general health behavior (cigarette smoking, physical exercise, alcohol consumption, sleeping hours, eating breakfast, eating between meals, and balanced nutrition) among adult Internet users in Japan. Methods: The participants were recruited among registrants of a Japanese Internet research service company and asked to answer a cross-sectional Internet-based survey in 2012. The potential respondents (N=10,178) were randomly and blindly invited via email from the registrants in accordance with the set sample size and other attributes. eHealth literacy was assessed using the Japanese version of the eHealth Literacy Scale. The self-reported health behaviors investigated included never smoking cigarettes, physical exercise, alcohol consumption, sleeping hours, eating breakfast, not eating between meals, and balanced nutrition. We obtained details of sociodemographic attributes (sex, age, marital status, educational attainment, and household income level) and frequency of conducting Internet searches. To determine the association of each health behavior with eHealth literacy, we performed a logistic regression analysis; we adjusted for sociodemographic attributes and frequency of Internet searching as well as for other health behaviors that were statistically significant with respect to eHealth literacy in univariate analyses. Results: We analyzed the data of 2115 adults (response rate: 24.04%, 2142/10,178; male: 49.74%, 1052/2115; age: mean 39.7, SD 10.9 years) who responded to the survey. Logistic regression analysis showed that individuals with high eHealth literacy were significantly more likely to exhibit the good health behaviors of physical exercise (adjusted odds ratio [AOR] 1.377, 95% CI 1.131-1.678) and eating a balanced diet (AOR 1.572, 95% CI 1.274-1.940) than individuals with low eHealth literacy. Conclusions: We found that some health behaviors, including exercise and balanced nutrition, were independently associated with eHealth literacy among Japanese adult Internet users.

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    Influence of Intensified Supervision by Health Care Inspectorates on Online Patient Ratings of Hospitals: A Multilevel Study of More Than 43,000 Online Ratings


    Background: In the Netherlands, hospitals with quality or safety issues are put under intensified supervision by the Dutch Health Care Inspectorate, which involves frequent announced and unannounced site visits and other measures. Patient rating sites are an upcoming phenomenon in health care. Patient reviews might be influenced by perceived quality including the media coverage of health care providers when the health care inspectorate imposes intensified supervision, but no data are available to show how these are related. Objective: The aim of this study was to investigate whether and how being under intensified supervision of the health care inspectorate influences online patient ratings of hospitals. Methods: We performed a longitudinal study using data from the patient rating site Zorgkaart Nederland, from January 1, 2010 to December 31, 2015. We compared data of 7 hospitals under intensified supervision with a control group of 28 hospitals. The dataset contained 43,856 ratings. We performed a multilevel logistic regression analysis to account for clustering of ratings within hospitals. Fixed effects in our analysis were hospital type, time, and the period of intensified supervision. Random effect was the hospital. The outcome variable was the dichotomized rating score. Results: The period of intensified supervision was associated with a low rating score for the hospitals compared with control group hospitals; both 1 year before intensified supervision (odds ratio, OR, 1.67, 95% CI 1.06-2.63) and 1 year after (OR 1.79, 95% CI 1.14-2.81) the differences are significant. For all periods, the odds on a low rating score for hospitals under intensified supervision are higher than for the control group hospitals, corrected for time. Time is also associated with low rating scores, with decreasing ORs over time since 2010. Conclusions: Hospitals that are confronted with intensified supervision by the health care inspectorate have lower ratings on patient rating sites. The scores are independent of the period: before, during, or just after the intervention by the health care inspectorate. Health care inspectorates might learn from these results because they indicate that the inspectorate identifies the same hospitals as “at risk” as the patients rate as underperformers.

  • The alarm pendant. Image sourced and copyright owned by author Randi Stokke.

    The Personal Emergency Response System as a Technology Innovation in Primary Health Care Services: An Integrative Review

    Authors List:


    Background: Most western countries are experiencing greater pressure on community care services due to increased life expectancy and changes in policy toward prioritizing independent living. This has led to a demand for change and innovation in caring practices with an expected increased use of technology. Despite numerous attempts, it has proven surprisingly difficult to implement and adopt technological innovations. The main established technological innovation in home care services for older people is the personal emergency response system (PERS), which is widely adopted and used throughout most western countries aiming to support “aging safely in place.” Objective: This integrative review examines how research literature describes use of the PERS focusing on the users’ perspective, thus exploring how different actors experience the technology in use and how it affects the complex interactions between multiple actors in caring practices. Methods: The review presents an overview of the body of research on this well-established telecare solution, indicating what is important for different actors in regard to accepting and using this technology in community care services. An integrative review, recognized by a systematic search in major databases followed by a review process, was conducted. Results: The search resulted in 33 included studies describing different actors’ experiences with the PERS in use. The overall focus was on the end users’ experiences and the consequences of having and using the alarm, and how the technology changes caring practices and interactions between the actors. Conclusions: The PERS contributes to safety and independent living for users of the alarm, but there are also unforeseen consequences and possible improvements in the device and the integrated service. This rather simple and well-established telecare technology in use interacts with the actors involved, creating changes in daily living and even affecting their identities. This review argues for an approach to telecare in which the complexity of practice is accounted for and shows how the plug-and-play expectations producers tend to generate is a simplification of the reality. This calls for a recognition that place and actors matter, as does a sensitivity to technology as an integrated part of complex caring practices.

  • CARE+ Spanish computer-based counseling tool. Image sourced by authors and copyright held by Resource Online.  (

    Linguistic and Cultural Adaptation of a Computer-Based Counseling Program (CARE+ Spanish) to Support HIV Treatment Adherence and Risk Reduction for People...


    Background: Human immunodeficiency virus (HIV) disease in the United States disproportionately affects minorities, including Latinos. Barriers including language are associated with lower antiretroviral therapy (ART) adherence seen among Latinos, yet ART and interventions for clinic visit adherence are rarely developed or delivered in Spanish. Objective: The aim was to adapt a computer-based counseling tool, demonstrated to reduce HIV-1 viral load and sexual risk transmission in a population of English-speaking adults, for use during routine clinical visits for an HIV-positive Spanish-speaking population (CARE+ Spanish); the Technology Acceptance Model (TAM) was the theoretical framework guiding program development. Methods: A longitudinal randomized controlled trial was conducted from June 4, 2010 to March 29, 2012. Participants were recruited from a comprehensive HIV treatment center comprising three clinics in New York City. Eligibility criteria were (1) adults (age ≥18 years), (2) Latino birth or ancestry, (3) speaks Spanish (mono- or multilingual), and (4) on antiretrovirals. Linear and generalized mixed linear effects models were used to analyze primary outcomes, which included ART adherence, sexual transmission risk behaviors, and HIV-1 viral loads. Exit interviews were offered to purposively selected intervention participants to explore cultural acceptability of the tool among participants, and focus groups explored the acceptability and system efficiency issues among clinic providers, using the TAM framework. Results: A total of 494 Spanish-speaking HIV clinic attendees were enrolled and randomly assigned to the intervention (arm A: n=253) or risk assessment-only control (arm B, n=241) group and followed up at 3-month intervals for one year. Gender distribution was 296 (68.4%) male, 110 (25.4%) female, and 10 (2.3%) transgender. By study end, 433 of 494 (87.7%) participants were retained. Although intervention participants had reduced viral loads, increased ART adherence and decreased sexual transmission risk behaviors over time, these findings were not statistically significant. We also conducted 61 qualitative exit interviews with participants and two focus groups with a total of 16 providers. Conclusions: A computer-based counseling tool grounded in the TAM theoretical model and delivered in Spanish was acceptable and feasible to implement in a high-volume HIV clinic setting. It was able to provide evidence-based, linguistically appropriate ART adherence support without requiring additional staff time, bilingual status, or translation services. We found that language preferences and cultural acceptability of a computer-based counseling tool exist on a continuum in our urban Spanish-speaking population. Theoretical frameworks of technology’s usefulness for behavioral modification need further exploration in other languages and cultures. Trial Registration: NCT01013935; (Archived by WebCite at

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  • Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme

    Date Submitted: Jul 22, 2016

    Open Peer Review Period: Jul 22, 2016 - Sep 16, 2016

    Background: Diabetes self-management involves adherence to good daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers ha...

    Background: Diabetes self-management involves adherence to good daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption. Objective: This systematic review seeks to identify and classify barriers to adoption of remote systems for management of type 2 diabetes. Methods: Six electronic databases, MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier), were searched for articles published from 2010 to 2015. The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of two to review and extract data from identified papers. Information collected included study characteristics, outcomes, drop-out rates, technologies used, and barriers identified. Results: Fifty-three publications on 42 studies met the specified criteria. Lack of data accuracy due to input bias (n=13/42, 31%), limitations on scalability (n=10/42, 24%), and technology illiteracy (n=10/42, 24%) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations while limitations on scalability was more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. Forty-one percent of identified barrier instances impeded patient engagement, which is manifest in the large drop-out rates cited (up to 57%). Conclusions: The barriers identified represent major challenges in the design of remote health systems for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high drop-out rates, and new interventions are needed to identify and assist those at greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financially sustainability.

  • Technologies to support community-dwelling persons with dementia: an INTERDEM position paper on issues regarding development, usability, (cost)effectiveness, implementation and ethics

    Date Submitted: Jul 20, 2016

    Open Peer Review Period: Jul 21, 2016 - Sep 15, 2016

    Background: With the expected growing number of people with dementia, providing timely, adequate and affordable care and support is challenging. Assistive and health technologies may be a valuable con...

    Background: With the expected growing number of people with dementia, providing timely, adequate and affordable care and support is challenging. Assistive and health technologies may be a valuable contribution in dementia care, but new challenges may emerge. Objective: To review the state of the art of technologies for people with dementia in three fields of technologies: 1) managing everyday life, 2) pleasurable and meaningful activities, and 3) health care technologies to support dementia care provision. And to identify challenges and calls for action. Methods: Reviews of literature in the three fields of technologies regarding issues on development, usability, (cost)effectiveness, implementation and ethics. Results: Results showed that: persons with dementia want to be included in development of technologies, little research is performed on usability of assistive technologies, various benefits are reported but mainly based on low quality studies, various barriers are found to implementation of technologies in dementia care and ethical issues were addressed by researchers but often not studied. Many challenges remain. These are: including the target group more often in development, performing more high quality studies on usability and (cost)effectiveness, having access to high quality data on existing technologies to enable adequate implementation of technologies in dementia care and to ensure that ethical issues are considered an important topic for researchers to include in their evaluation of assistive technologies. Conclusions: Based on the results of the state of the art, various actions are recommended for development, usability, evaluation, implementation and ethics of assistive and health technologies across Europe. Examples are to ensure that unnecessary replication of technology development that is provenly unhelpful or ineffective does not occur and to better focus on how technological services succeed in addressing individual needs of persons with dementia, as the population is heterogeneous and many face co-morbid conditions. Furthermore, it is suggested to have these recommendations implemented in national and international calls for funding and assistive technology research programmes in the coming decade. In practice, policy makers, care insurers and care providers together with technology enterprises and researchers should prepare strategies for the implementation of assistive technologies in different care settings, to ensure that next generations of people with dementia are enabled to actually utilize the developed technologies in an affordable way and that they can all benefit from it Clinical Trial: NO clinical trial

  • Self-monitoring utilization patterns among individuals in an incentivized program for healthy behaviors

    Date Submitted: Jul 20, 2016

    Open Peer Review Period: Jul 21, 2016 - Jul 28, 2016

    Background: The advent of digital technology has enabled individuals to track meaningful biometric data about oneself. This novel capability has spurred non-traditional health care organizations to de...

    Background: The advent of digital technology has enabled individuals to track meaningful biometric data about oneself. This novel capability has spurred non-traditional health care organizations to develop systems that aid users in managing their health. One of the most prolific systems is Walgreens’ Balance Rewards for healthy choices™ (BRhc™) program, an incentivized, online self-monitoring program. Objective: This study was performed to evaluate health data self-tracking characteristics of individuals enrolled in the Walgreens BRhc™ program, including the impact of manual versus automatic data entries through a supported device or application. Methods: We obtained activity tracking data from total of 455,341 BRhc™ users during the 2014 calendar year. Upon identifying users with sufficient follow-up data, we explored temporal trends in user participation. Results: Thirty-four percent of users quit participating after a single entry of an activity. Among users who tracked at least two activities on different dates, the median length of participating was 8 weeks, with an average of 5.8 activities entered per week. Furthermore, users who participated for at least 20 weeks (28.3% of users) consistently entered 8 to 9 activities per week. Majority of users (77%) recorded activities through manual data entry alone. However, individuals who entered activities automatically through supported devices or apps participated roughly four times longer than their manual activity-entering counterparts (average 20 and 5 weeks, respectively; P<.001). Conclusions: This study provides insights into the utilization patterns of individuals participating in an incentivized, online self-monitoring program. Our results suggest automated health tracking could significantly improve long-term health self-management and engagement.

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

    Date Submitted: Jul 20, 2016

    Open Peer Review Period: Jul 20, 2016 - Sep 14, 2016

    Background: Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and...

    Background: Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and prevent secondary complications. However, trials designed to test the effectiveness of telehealth interventions may under-recruit or exclude ethnic minority patients, with language a potential barrier to recruitment. The underrepresentation of minorities in trials limits the external validity of the findings for this key patient demographic. Objective: This systematic review examines (1) the research reporting practices and prevalence of ethnic minority patients included in telehealth randomized controlled trials (RCTs) targeting type 2 diabetes, as well as the trial characteristics associated with recruiting a high proportion of minority patients, and (2) the proportion of included RCTs that report using English language proficiency as a patient screening criterion and how and why they do so. Methods: Telehealth RCTs published in refereed journals targeting type 2 diabetes as a primary condition for adults in Western majority English speaking countries were included. Ethnically-targeted RCTs were excluded from the main review but included in a post-hoc subgroup analysis. Abstract and full-text screening, risk of bias assessment, and data extraction were independently conducted by two reviewers. Results: Of 3358 records identified in the search, 79 articles comprising 58 RCTs were included. Nearly two-thirds of the RCTs (38/58) reported on the ethnic composition of participants, with a median proportion of 23.5% patients (range: 0%-97.7%). Fourteen studies (24%) that included at least 30% minority patients were all US-based, predominantly recruited from urban areas, and described the target population as underserved, financially deprived, or uninsured. Seven of these 14 studies (50%) offered intervention materials in a language other than English or employed bilingual staff. Half of all identified RCTs (29/58) included language proficiency as a participant screening criterion. Language proficiency was operationalized using non-standardized measures (e.g., having sufficient “verbal fluency”), with only three studies providing reasons for excluding patients on language grounds. Conclusions: There was considerable variability across studies in the inclusion of ethnic minority patients in RCTs, with higher participation rates in countries with legislation to mandate their inclusion (e.g., US) than in those without such legislation (e.g., UK). Less than 25% of the RCTs recruited a sizeable proportion of ethnic minorities, which raises concerns about external validity. The lack of objective measures or common procedures for assessing language proficiency across trials implies that language-related eligibility decisions are often based on trial recruiters’ impressionistic judgments, which could be subject to bias. The variability and inconsistent reporting on ethnicity and other socioeconomic factors in descriptions of research participants could be more specifically emphasized in trial reporting guidelines to promote best practice. Clinical Trial: PROSPERO International Prospective Register of Systematic Reviews: CRD42015024899

  • Datathons and software to promote reproducible research

    Date Submitted: Jul 17, 2016

    Open Peer Review Period: Jul 18, 2016 - Sep 12, 2016

    Background: Datathons facilitate collaboration between clinicians, statisticians, and data scientists in order to answer important clinical questions. Previous datathons have resulted in numerous publ...

    Background: Datathons facilitate collaboration between clinicians, statisticians, and data scientists in order to answer important clinical questions. Previous datathons have resulted in numerous publications of interest to the critical care community and serve as a viable model for interdisciplinary collaboration. In the most recent datathon, participants were provided with open-source software called Chatto that was created by members of our group. Results: This suite of tools fulfills two purposes: (1) facilitation of interdisciplinary teamwork through archiving and version control of datasets, analytical code, and team discussions; and (2) advancement of research reproducibility by functioning post-publication as an online environment in which independent investigators can rerun or modify analyses with relative ease. Conclusions: With the introduction of Chatto, we hope to solve a variety of challenges presented by collaborative data mining projects while improving research reproducibility.

  • The Physical Activity Tracker Testing in Youth (P.A.T.T.Y) Study: Content analysis and Children’s Perceptions

    Date Submitted: Jul 15, 2016

    Open Peer Review Period: Jul 15, 2016 - Sep 9, 2016

    Background: Activity trackers are widely used by adults and several models are now marketed for childre Objective: The purposes of this study were to: 1) perform a content analysis of behavioral chang...

    Background: Activity trackers are widely used by adults and several models are now marketed for childre Objective: The purposes of this study were to: 1) perform a content analysis of behavioral change techniques (BCTs) used by three commercially available youth-oriented activity trackers; 2) obtain feedback describing children’s perception of these devices and the associated websites. Methods: A content analysis recorded the presence of 36 possible BCTs for the MovBand™, Sqord™ and Zamzee™ activity trackers (MB, SQ, and ZZ, respectively). In addition, 16 participants (age: 8.6±1.6 y, 50% female) received all three trackers and oriented to the devices and websites. Participants were instructed to wear the trackers on 4 consecutive days and spend ≥10 min/d on each website. A cognitive interview and survey were administered when the participant returned the devices. Qualitative data analysis was used to analyze the content of the cognitive interviews. Chi square analyses were used to determine differences in behavioral monitoring and social interaction features between websites. Results: The MB, SQ, and ZZ devices/websites included 8, 15 and 14 of the possible 36 BCTs, respectively. All of the websites had a behavioral monitoring feature (charts for tracking activity) but the percentage of participants indicating that they “liked” those features varied by website (MB: 50%, SQ: 38%, ZZ: 69%). Two websites (SQ and ZZ) included an “avatar” the user could create to represent themselves on the website. Participants reported that they “liked” creating and changing their avatar (SQ: 75%, ZZ: 94%), which was supported by the qualitative analyses of the cognitive interviews. Most participants (75%) indicated that they would want to wear the devices more if their friends were wearing a tracker. No significant differences were observed between SQ and ZZ devices in regards to liking or use of social support interaction features (P=0.21-0.37) Conclusions: The websites contained several BCTs consistent with previously identified strategies. Children “liked” the social aspects of the websites more than the activity tracking features. Developers of commercial activity trackers for youth may benefit from considering a theoretical perspective during the website design process.