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 4.7 for 2013

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  • Photo by cuteimage. Published on 07 February 2014 Stock photo - Image ID: 100234227;

    From Help-Seekers to Influential Users: A Systematic Review of Participation Styles in Online Health Communities


    Background: Understanding how people participate in and contribute to online health communities (OHCs) is useful knowledge in multiple domains. It is helpful for community managers in developing strategies for building community, for organizations in disseminating information about health interventions, and for researchers in understanding the social dynamics of peer support. Objective: We sought to determine if any patterns were apparent in the nature of user participation across online health communities. Methods: The current study involved a systematic review of all studies that have investigated the nature of participation in an online health community and have provided a quantifiable method for categorizing a person based on their participation style. A systematic search yielded 20 papers. Results: Participatory styles were classified as either multidimensional (based on multiple metrics) or unidimensional (based on one metric). With respect to the multidimensional category, a total of 41 different participation styles were identified ranging from Influential Users who were leaders on the board to Topic-Focused Responders who focused on a specific topic and tended to respond to rather than initiate posts. However, there was little overlap in participation styles identified both across OHCs for different health conditions and within OHCs for specific health conditions. Five of the 41 styles emerged in more than one study (Hubs, Authorities, Facilitators, Prime Givers, and Discussants), but the remainder were reported in only one study. The focus of the unidimensional studies was on level of engagement and particularly on high-engaged users. Eight different metrics were used to evaluate level of engagement with the greatest focus on frequency of posts. Conclusions: With the exception of high-engaged users based on high post frequency, the current review found little evidence for consistent participatory styles across different health communities. However, this area of research is in its infancy, with most of the studies included in the review being published in the last 2 years. Nevertheless, the review delivers a nomenclature for OHC participation styles and metrics and discusses important methodological issues that will provide a basis for future comparative research in the area. Further studies are required to systematically investigate a range of participatory styles, to investigate their association with different types of online health communities and to determine the contribution of different participatory styles within and across online health communities.

  • LITE (Librarian Infobutton Tailoring Environment). This image is from the LITE home page (

    Usability and Acceptance of the Librarian Infobutton Tailoring Environment: An Open Access Online Knowledge Capture, Management, and Configuration Tool for...


    Background: The Librarian Infobutton Tailoring Environment (LITE) is a Web-based knowledge capture, management, and configuration tool with which users can build profiles used by OpenInfobutton, an open source infobutton manager, to provide electronic health record users with context-relevant links to online knowledge resources. Objective: We conducted a multipart evaluation study to explore users’ attitudes and acceptance of LITE and to guide future development. Methods: The evaluation consisted of an initial online survey to all LITE users, followed by an observational study of a subset of users in which evaluators’ sessions were recorded while they conducted assigned tasks. The observational study was followed by administration of a modified System Usability Scale (SUS) survey. Results: Fourteen users responded to the survey and indicated good acceptance of LITE with feedback that was mostly positive. Six users participated in the observational study, demonstrating average task completion time of less than 6 minutes and an average SUS score of 72, which is considered good compared with other SUS scores. Conclusions: LITE can be used to fulfill its designated tasks quickly and successfully. Evaluators proposed suggestions for improvements in LITE functionality and user interface.

  • Copyright: The Netherlands Cancer Institute.

    Empowerment of Cancer Survivors Through Information Technology: An Integrative Review


    Background: Patient empowerment may be an effective approach to strengthen the role of cancer survivors and to reduce the burden on health care. However, it is not well conceptualized, notably in oncology. Furthermore, it is unclear to what extent information technology (IT) services can contribute to empowerment of cancer survivors. Objective: We aim to define the conceptual components of patient empowerment of chronic disease patients, especially cancer survivors, and to explore the contribution of existing and new IT services to promote empowerment. Methods: Electronic databases were searched to identify theoretical and empirical articles regarding empowerment. We extracted and synthesized conceptual components of patient empowerment (ie, attributes, antecedents, and consequences) according to the integrated review methodology. We identified recent IT services for cancer survivors by examining systematic reviews and a proposed inventory of new services, and we related their features and effects to the identified components of empowerment. Results: Based on 26 articles, we identified five main attributes of patient empowerment: (1) being autonomous and respected, (2) having knowledge, (3) having psychosocial and behavioral skills, (4) perceiving support from community, family, and friends, and (5) perceiving oneself to be useful. The latter two were specific for the cancer setting. Systematic reviews of IT services and our additional inventory helped us identify five main categories: (1) educational services, including electronic survivorship care plan services, (2) patient-to-patient services, (3) electronic patient-reported outcome (ePRO) services, (4) multicomponent services, and (5) portal services. Potential impact on empowerment included knowledge enhancement and, to a lesser extent, enhancing autonomy and skills. Newly developed services offer promising and exciting opportunities to empower cancer survivors, for instance, by providing tailored advice for supportive or follow-up care based on patients' input. Conclusions: We identified five main components of empowerment and showed that IT services may especially contribute to empowerment by providing knowledge. The components of empowerment could be used to develop IT services for cancer survivors. It is important to take into account patients’ needs, follow up on these needs, and create a service that is attractive and easy to use.

  • This is the feature image for my paper (Image from:

    The Association Between Online Health Information–Seeking Behaviors and Health Behaviors Among Hispanics in New York City: A Community-Based...


    Background: Hispanics are the fastest-growing minority group in the United States and they suffer from a disproportionate burden of chronic diseases. Studies have shown that online health information has the potential to affect health behaviors and influence management of chronic disease for a significant proportion of the population, but little research has focused on Hispanics. Objective: The specific aim of this descriptive, cross-sectional study was to examine the association between online health information–seeking behaviors and health behaviors (physical activity, fruit and vegetable consumption, alcohol use, and hypertension medication adherence) among Hispanics. Methods: Data were collected from a convenience sample (N=2680) of Hispanics living in northern Manhattan by bilingual community health workers in a face-to-face interview and analyzed using linear and ordinal logistic regression. Variable selection and statistical analyses were guided by the Integrative Model of eHealth Use. Results: Only 7.38% (198/2680) of the sample reported online health information–seeking behaviors. Levels of moderate physical activity and fruit, vegetable, and alcohol consumption were low. Among individuals taking hypertension medication (n=825), adherence was reported as high by approximately one-third (30.9%, 255/825) of the sample. Controlling for demographic, situational, and literacy variables, online health information–seeking behaviors were significantly associated with fruit (β=0.35, 95% CI 0.08-0.62, P=.01) and vegetable (β=0.36, 95% CI 0.06-0.65, P=.02) consumption and physical activity (β=3.73, 95% CI 1.99-5.46, P<.001), but not alcohol consumption or hypertension medication adherence. In the regression models, literacy factors, which were used as control variables, were associated with 3 health behaviors: social networking site membership (used to measure one dimension of computer literacy) was associated with fruit consumption (β=0.23, 95% CI 0.05-0.42, P=.02), health literacy was associated with alcohol consumption (β=0.44, 95% CI 0.24-0.63, P<.001), and hypertension medication adherence (β=–0.32, 95% CI –0.62 to –0.03, P=.03). Models explained only a small amount of the variance in health behaviors. Conclusions: Given the promising, although modest, associations between online health information–seeking behaviors and some health behaviors, efforts are needed to improve Hispanics’ ability to access and understand health information and to enhance the availability of online health information that is suitable in terms of language, readability level, and cultural relevance.

  • Doctor-patient communication in an online forum. Image created by authors who hold the copyright.

    Impact of Scientific Versus Emotional Wording of Patient Questions on Doctor-Patient Communication in an Internet Forum: A Randomized Controlled Experiment...


    Background: Medical expert forums on the Internet play an increasing role in patient counseling. Therefore, it is important to understand how doctor-patient communication is influenced in such forums both by features of the patients or advice seekers, as expressed in their forum queries, and by characteristics of the medical experts involved. Objective: In this experimental study, we aimed to examine in what way (1) the particular wording of patient queries and (2) medical experts’ therapeutic health concepts (for example, beliefs around adhering to a distinctly scientific understanding of diagnosis and treatment and a clear focus on evidence-based medicine) impact communication behavior of the medical experts in an Internet forum. Methods: Advanced medical students (in their ninth semester of medical training) were recruited as participants. Participation in the online forum was part of a communication training embedded in a gynecology course. We first measured their biomedical therapeutic health concept (hereinafter called “biomedical concept”). Then they participated in an online forum where they answered fictitious patient queries about mammography screening that either included scientific or emotional wording in a between-group design. We analyzed participants’ replies with regard to the following dimensions: their use of scientific or emotional wording, the amount of communicated information, and their attempt to build a positive doctor-patient relationship. Results: This study was carried out with 117 medical students (73 women, 41 men, 3 did not indicate their sex). We found evidence that both the wording of patient queries and the participants’ biomedical concept influenced participants’ response behavior. They answered emotional patient queries in a more emotional way (mean 0.92, SD 1.02) than scientific patient queries (mean 0.26, SD 0.55; t74=3.48, P<.001, d=0.81). We also found a significant interaction effect between participants’ use of scientific or emotional wording and type of patient query (F2,74=10.29, P<.01, partial η2=0.12) indicating that participants used scientific wording independently of the type of patient query, whereas they used emotional wording particularly when replying to emotional patient queries. In addition, the more pronounced the medical experts’ biomedical concept was, the more scientifically (adjusted β=.20; F1,75=2.95, P=.045) and the less emotionally (adjusted β=–.22; F1,74=3.66, P=.03) they replied to patient queries. Finally, we found that participants’ biomedical concept predicted their engagement in relationship building (adjusted β=–.26): The more pronounced their biomedical concept was, the less they attempted to build a positive doctor-patient relationship (F1,74=5.39, P=.02). Conclusions: Communication training for medical experts could aim to address this issue of recognizing patients’ communication styles and needs in certain situations in order to teach medical experts how to take those aspects adequately into account. In addition, communication training should also make medical experts aware of their individual therapeutic health concepts and the consequential implications in communication situations.

  • The eHealth portal in use. Photo by Kai T.Dragland/NTNU.

    The Impact of an eHealth Portal on Health Care Professionals’ Interaction with Patients: Qualitative Study


    Background: People who undergo weight loss surgery require a comprehensive treatment program to achieve successful outcomes. eHealth solutions, such as secure online portals, create new opportunities for improved health care delivery and care, but depend on the organizational delivery systems and on the health care professionals providing it. So far, these have received limited attention and the overall adoption of eHealth solutions remains low. In this study, a secure eHealth portal was implemented in a bariatric surgery clinic and offered to their patients. During the study period of 6 months, 60 patients and 5 health care professionals had access. The portal included patient information, self-management tools, and communication features for online dialog with peers and health care providers at the bariatric surgery clinic. Objective: The aim of this study was to characterize and assess the impact of an eHealth portal on health care professionals’ interaction with patients in bariatric surgery. Methods: This qualitative case study involved a field study consisting of contextual interviews at the clinic involving observing and speaking with personnel in their actual work environment. Semi-structured in-depth interviews were conducted with health care professionals who interacted with patients through the portal. Analysis of the collected material was done inductively using thematic analysis. Results: The analysis revealed two main dimensions of using an eHealth portal in bariatric surgery: the transparency it represents and the responsibility that follows by providing it. The professionals reported the eHealth portal as (1) a source of information, (2) a gateway to approach and facilitate the patients, (3) a medium for irrevocable postings, (4) a channel that exposes responsibility and competence, and (5) a tool in the clinic. Conclusions: By providing an eHealth portal to patients in a bariatric surgery program, health care professionals can observe patients’ writings and revelations thereby capturing patient challenges and acting and implementing measures. Interacting with patients through the portal can prevent dropouts and deterioration of patients’ health. However, professionals report on organizational challenges and personal constraints related to communicating with patients in writing online. Further development of guidelines and education of health care professionals about how to handle, prioritize, communicate, and facilitate patients online is required in addition to increased attention to the organizational infrastructures and incentives for enabling such solutions in health care.

  • Screenshot of NPS MedicineWise Facebook advertising the Pharmacist Hour service.

    Provision of a Medicines Information Service to Consumers on Facebook: An Australian Case Study


    Background: Social networking sites (SNSs) have changed the way people communicate. They may also change the way people seek health advice. Objective: This study describes the provision of a medicines information service on Facebook to individual consumers. It aimed to discuss the pros and cons, and inform health and pharmacy stakeholders and researchers about the opportunities and challenges of providing such a service. Methods: We adopted an exploratory approach using a case study method. Results: NPS MedicineWise, an independent, not-for-profit Australian organization, runs a public question-and-answer service on Facebook, dubbed Pharmacist Hour. Consumers following the organization’s Facebook page are invited to post medication-related questions often with a suggested health topic. A wide range of questions and comments are posted related to medication usage. The pharmacist answers the queries, providing evidence-based medicines information and using consumer-friendly language, during the specific 1-hour period. The most popular questions in the past 12 months were related to adverse effects, treatment options for conditions, and drug interactions. The service had a mean number of engagements (defined as a like or share of the Pharmacy Hour post) of 38 (SD 19) people and a mean 5 (SD 3) questions per session. Conclusions: The Pharmacist Hour Facebook service addresses the medicines information needs of consumers and indirectly promotes other appropriate and relevant NPS MedicineWise products and services to further assist consumers. The service offers a new medium for a quality use of medicines organization committed to promoting awareness about the correct and safe use of medicines in Australia.

  • Feature image for homepage.
Created by author.

    Measuring Use of Health-Related Support on the Internet: Development of the Health Online Support Questionnaire (HOSQ)


    Background: Social support plays an important role for the perceived health in people with health problems and chronic diseases. Provision of different kinds of support during the disease trajectory is crucial for many people. Online support is ubiquitous and represents a promising modality for people with chronic diseases. There are no existing instruments that measure various aspects of online support. Objective: The objective of this study was to create a generic questionnaire regarding health-related support online that can be applied to people with various health problems and illnesses. Additionally, we wanted to test the questionnaire in a cancer population to assess its adequacy in the context of severe disease. Methods: Initial items for the Health Online Support Questionnaire (HOSQ) were inspired by sociologist James House regarding social support. An exploratory factor analysis was conducted in healthy persons or with minor health problems (n=243) on 31 initial items. The scale was reduced to 18 items and the internal consistency and reliability of the scale was examined along with content validity. Further validation was conducted by a confirmatory analysis on the 18-item scale in a cancer population (n=215). In addition, data on demographics, health problems experienced, and Internet use were collected. Results: The exploratory factor analysis on the final 18-item scale resulted in 2 factors. After scrutinizing the content, these factors were labeled “reading” and “interacting” and they demonstrated good internal consistency (Cronbach alphas .88 and .77, respectively). The factors were confirmed in the cancer population. The response pattern revealed expected differences both between the interaction and reading scales and according to age, gender, education, and health problems thereby supporting the validity of the HOSQ. Conclusions: The HOSQ may be a reliable and valid instrument for measuring the use of online support for people with health problems, but the results ought to be replicated in more studies to confirm the results for different diagnoses. If the results of this study are corroborated by future studies, the HOSQ may be used as a basis for the development of different forms of support on the Internet.

  • Google Trends and Dementia (image created by authors who hold the copyright).

    Forecasting the Incidence of Dementia and Dementia-Related Outpatient Visits With Google Trends: Evidence From Taiwan


    Background: Google Trends has demonstrated the capability to both monitor and predict epidemic outbreaks. The connection between Internet searches for dementia information and dementia incidence and dementia-related outpatient visits remains unknown. Objective: This study aimed to determine whether Google Trends could provide insight into trends in dementia incidence and related outpatient visits in Taiwan. We investigated and validated the local search terms that would be the best predictors of new dementia cases and outpatient visits. We further evaluated the nowcasting (ie, forecasting the present) and forecasting effects of Google Trends search trends for new dementia cases and outpatient visits. The long-term goal is to develop a surveillance system to help early detection and interventions for dementia in Taiwan. Methods: This study collected (1) dementia data from Taiwan’s National Health Insurance Research Database and (2) local Internet search data from Google Trends, both from January 2009 to December 2011. We investigated and validated search terms that would be the best predictors of new dementia cases and outpatient visits. We then evaluated both the nowcasting and the forecasting effects of Google Trends search trends through cross-correlation analysis of the dementia incidence and outpatient visit data with the Google Trends data. Results: The search term “dementia + Alzheimer’s disease” demonstrated a 3-month lead effect for new dementia cases and a 6-month lead effect for outpatient visits (r=.503, P=.002; r=.431, P=.009, respectively). When gender was included in the analysis, the search term “dementia” showed 6-month predictive power for new female dementia cases (r=.520, P=.001), but only a nowcasting effect for male cases (r=.430, P=.009). The search term “neurology” demonstrated a 3-month leading effect for new dementia cases (r=.433, P=.008), for new male dementia cases (r=.434, P=.008), and for outpatient visits (r=.613, P<.001). Conclusions: Google Trends established a plausible relationship between search terms and new dementia cases and dementia-related outpatient visits in Taiwan. This data may allow the health care system in Taiwan to prepare for upcoming outpatient and dementia screening visits. In addition, the validated search term results can be used to provide caregivers with caregiving-related health, skills, and social welfare information by embedding dementia-related search keywords in relevant online articles.

  • Screenshots from the myFitnessCompanion app.

    Bringing Health and Fitness Data Together for Connected Health Care: Mobile Apps as Enablers of Interoperability


    Background: A transformation is underway regarding how we deal with our health. Mobile devices make it possible to have continuous access to personal health information. Wearable devices, such as Fitbit and Apple’s smartwatch, can collect data continuously and provide insights into our health and fitness. However, lack of interoperability and the presence of data silos prevent users and health professionals from getting an integrated view of health and fitness data. To provide better health outcomes, a complete picture is needed which combines informal health and fitness data collected by the user together with official health records collected by health professionals. Mobile apps are well positioned to play an important role in the aggregation since they can tap into these official and informal health and data silos. Objective: The objective of this paper is to demonstrate that a mobile app can be used to aggregate health and fitness data and can enable interoperability. It discusses various technical interoperability challenges encountered while integrating data into one place. Methods: For 8 years, we have worked with third-party partners, including wearable device manufacturers, electronic health record providers, and app developers, to connect an Android app to their (wearable) devices, back-end servers, and systems. Results: The result of this research is a health and fitness app called myFitnessCompanion, which enables users to aggregate their data in one place. Over 6000 users use the app worldwide to aggregate their health and fitness data. It demonstrates that mobile apps can be used to enable interoperability. Challenges encountered in the research process included the different wireless protocols and standards used to communicate with wireless devices, the diversity of security and authorization protocols used to be able to exchange data with servers, and lack of standards usage, such as Health Level Seven, for medical information exchange. Conclusions: By limiting the negative effects of health data silos, mobile apps can offer a better holistic view of health and fitness data. Data can then be analyzed to offer better and more personalized advice and care.

  •; By watcharakun, published on 03 October 2012 Stock Photo - image ID: 100104792.

    Using the Consolidated Framework for Implementation Research to Identify Barriers and Facilitators for the Implementation of an Internet-Based...


    Background: Although there is growing evidence of the positive effects of Internet-based patient-provider communication (IPPC) services for both patients and health care providers, their implementation into clinical practice continues to be a challenge. Objective: The 3 aims of this study were to (1) identify and compare barriers and facilitators influencing the implementation of an IPPC service in 5 hospital units using the Consolidated Framework for Implementation Research (CFIR), (2) assess the ability of the different constructs of CFIR to distinguish between high and low implementation success, and (3) compare our findings with those from other studies that used the CFIR to discriminate between high and low implementation success. Methods: This study was based on individual interviews with 10 nurses, 6 physicians, and 1 nutritionist who had used the IPPC to answer messages from patients. Results: Of the 36 CFIR constructs, 28 were addressed in the interviews, of which 12 distinguished between high and low implementation units. Most of the distinguishing constructs were related to the inner setting domain of CFIR, indicating that institutional factors were particularly important for successful implementation. Health care providers’ beliefs in the intervention as useful for themselves and their patients as well as the implementation process itself were also important. A comparison of constructs across ours and 2 other studies that also used the CFIR to discriminate between high and low implementation success showed that 24 CFIR constructs distinguished between high and low implementation units in at least 1 study; 11 constructs distinguished in 2 studies. However, only 2 constructs (patient need and resources and available resources) distinguished consistently between high and low implementation units in all 3 studies. Conclusions: The CFIR is a helpful framework for illuminating barriers and facilitators influencing IPPC implementation. However, CFIR’s strength of being broad and comprehensive also limits its usefulness as an implementation framework because it does not discriminate between the relative importance of its many constructs for implementation success. This is the first study to identify which CFIR constructs are the most promising to distinguish between high and low implementation success across settings and interventions. Findings from this study can contribute to the refinement of CFIR toward a more succinct and parsimonious framework for planning and evaluation of the implementation of clinical interventions. ClinicalTrial: NCT00971139; (Archived by WebCite at

  • ALICE screenshot.

    Web-Based Immersive Virtual Patient Simulators: Positive Effect on Clinical Reasoning in Medical Education


    Background: Clinical reasoning is based on the declarative and procedural knowledge of workflows in clinical medicine. Educational approaches such as problem-based learning or mannequin simulators support learning of procedural knowledge. Immersive patient simulators (IPSs) go one step further as they allow an illusionary immersion into a synthetic world. Students can freely navigate an avatar through a three-dimensional environment, interact with the virtual surroundings, and treat virtual patients. By playful learning with IPS, medical workflows can be repetitively trained and internalized. As there are only a few university-driven IPS with a profound amount of medical knowledge available, we developed a university-based IPS framework. Our simulator is free to use and combines a high degree of immersion with in-depth medical content. By adding disease-specific content modules, the simulator framework can be expanded depending on the curricular demands. However, these new educational tools compete with the traditional teaching Objective: It was our aim to develop an educational content module that teaches clinical and therapeutic workflows in surgical oncology. Furthermore, we wanted to examine how the use of this module affects student performance. Methods: The new module was based on the declarative and procedural learning targets of the official German medical examination regulations. The module was added to our custom-made IPS named ALICE (Artificial Learning Interface for Clinical Education). ALICE was evaluated on 62 third-year students. Results: Students showed a high degree of motivation when using the simulator as most of them had fun using it. ALICE showed positive impact on clinical reasoning as there was a significant improvement in determining the correct therapy after using the simulator. ALICE positively impacted the rise in declarative knowledge as there was improvement in answering multiple-choice questions before and after simulator use. Conclusions: ALICE has a positive effect on knowledge gain and raises students’ motivation. It is a suitable tool for supporting clinical education in the blended learning context.

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  • Examining e-loyalty in an online sexual health promotion intervention

    Date Submitted: Nov 29, 2015

    Open Peer Review Period: Nov 30, 2015 - Jan 25, 2016

    Background: Online sexual health resources are typically evaluated in terms of their efficacy. Information is lacking about how sexual health promotion websites are perceived and used. It is essential...

    Background: Online sexual health resources are typically evaluated in terms of their efficacy. Information is lacking about how sexual health promotion websites are perceived and used. It is essential to understand website use to address challenges with adherence and attrition to online health interventions. An existing theoretical framework for examining loyalty to eHealth interventions has been not yet been applied in the context of sexual health promotion, nor has the association between e-loyalty and intended intervention efficacy outcomes been investigated. Objective: This study investigated users’ loyalty towards a sexual health website (i.e. e-loyalty), measured user perceptions of the website, and measured the association between e-loyalty and perceived knowledge increase and intent to change behaviour. Methods: Over four months, website users (clients and healthcare providers) participated in an open, online, cross-sectional survey about their user experiences that measured e-loyalty, user perceptions and intended website efficacy outcomes. Relationships between user perceptions and e-loyalty were investigated using structural equation modeling (SEM). Associations between e-loyalty and website efficacy outcomes were tested using Spearman’s correlation. Results: A total of 173 participants completed user perception questions and were included in the analysis. E-loyalty was high for both clients and providers, and was significantly correlated with perceived knowledge increase (rho=0.30, p<0.001), clients’ intent to have safer sex (rho=0.24, p=0.01), and clients’ intent to get tested for sexually transmitted infections (rho=0.37, p<0.001). The SEM showed that trustworthiness, overall experience, active trust and effectiveness were directly related to e-loyalty. Finding the website ‘easy to understand’ was significantly related to active trust (i.e. participants’ willingness to act upon information presented on the website). Conclusions: E-loyalty may be related to the efficacy of this website in improving sexual health; e-loyalty was significantly associated with all three intended knowledge and behavioural outcomes. To increase e-loyalty, trustworthiness and active trust are important user perceptions to deliberately engender. Our findings indicate that the understandability of a website contributes to active trust, highlighting the importance of considering eHealth literacy in designing health promotion websites. Our study confirms the relevance of e-loyalty as an outcome for evaluating the antecedents of the use and efficacy of online public health interventions across disciplines by adapting and validating an existing e-loyalty framework to the field of sexual health promotion. Our findings suggest that e-loyalty is positively associated with measures of website efficacy including increased knowledge and intent to change behavior. Longitudinal research with larger samples could further investigate the relationships between e-loyalty, website understandability, and outcomes of online health interventions, and determine how the manipulation of website characteristics may impact user perceptions and e-loyalty.

  • Towards a Mixed Methods Research Approach to Content Analysis in The Digital Age: The Combined Content Analysis Model and its Applications to Healthcare Twitter Feeds

    Date Submitted: Nov 28, 2015

    Open Peer Review Period: Nov 29, 2015 - Dec 7, 2015

    Background: Twitter’s 140-character microblog posts are increasingly used to access information, and facilitate discussions among healthcare professionals and between patients with chronic condition...

    Background: Twitter’s 140-character microblog posts are increasingly used to access information, and facilitate discussions among healthcare professionals and between patients with chronic conditions and their caregivers. Recently, some efforts have emerged to investigate the content of healthcare-related posts on Twitter. This marks a new area for researchers to investigate and apply content analysis (CA). In current research initiatives, quantitative and qualitative Twitter data are often combined, and there are no clear guidelines for researchers to follow when conducting and/or evaluating Twitter-driven content. Objective: The aim of this study is to evaluate 18 studies on healthcare and social media that used Twitter feeds as a primary source of data, and CA as an analysis technique. The evaluation of these studies is based on a narrative review of previous methodological studies and textbooks, to determine criteria and main features of quantitative and/or qualitative CA. The key features of CA and mixed methods research designs are then used to propose the combined content analysis (CCA) model as a solid research framework for designing, conducting, and/or evaluating investigations of Twitter-driven content. Methods: A PubMed search was conducted to collect studies published between 2010 and 2014 that used CA to analyze healthcare-related tweets. The PubMed search and reference list checks of selected papers identified 21 articles. Three articles were excluded and 18 were included for further analysis. Results: Results suggest that the methodology used in these studies is not purely quantitative or qualitative, and the mixed methods design is not explicitly chosen for data collection and analysis. A solid research framework is needed for researchers who intend to analyze Twitter data through the use of CA. Conclusions: We propose the CCA model as a useful framework that provides a straightforward approach to guide Twitter-driven studies and that adds rigor to healthcare social media investigations. Suggestions for the use of the CCA model in eldercare-related contexts are provided for future research.

  • OCD Treatment Online: Preliminary results of the OCD? Not Me! self-guided iCBT program for young people with OCD

    Date Submitted: Nov 22, 2015

    Open Peer Review Period: Nov 24, 2015 - Jan 19, 2016

    Background: The development and evaluation of e-mental health interventions provides a potential solution for current limitations in the acceptability, availability and accessibility of mental health...

    Background: The development and evaluation of e-mental health interventions provides a potential solution for current limitations in the acceptability, availability and accessibility of mental health care for young people with obsessive-compulsive disorder (OCD). This study is the first of its kind to report on the effectiveness of fully-automated online treatment for young people (12-18 years) with OCD. Objective: We aimed to conduct a preliminary evaluation of the effectiveness of the OCD? Not Me! program for reducing OCD-related psychopathology in young people (12-18 years). This program is an eight-stage, fully-automated online cognitive behavioural treatment for OCD. Methods: The current data were taken from a parent study in which an open trial design is being used to evaluate the effectiveness of the OCD? Not Me! program. Participants were required to have at least subclinical levels of OCD to be offered the online program. Participants with moderate-high suicide/self-harm risk, or symptoms of eating disorder or psychosis were not offered the program. OCD symptoms and severity were measured at pre- and post-test, and at the beginning of each stage of the program. Data were analysed with generalized linear mixed models (GLMM). Results: A total of 334 people were screened for inclusion in the study, with 132 participants aged 12-18 years providing data for the final analysis. Participants showed significant reductions in OCD symptoms (P < .001) and severity (P < .001) between pre- and post-test. Conclusions: These preliminary results suggest that fully-automated iCBT holds promise as way of increasing access to treatment for young people with OCD, however further research needs to be conducted to replicate the results and to determine the feasibility of the program. Clinical Trial: The trial was registered on 8 February 2013 with the Australian New Zealand Clinical Trials Registry (ACTRN12613000152729).

  • Electronic Adherence Monitoring in a High Utilizing Pediatric Asthma Cohort: A Feasibility Study

    Date Submitted: Nov 21, 2015

    Open Peer Review Period: Nov 21, 2015 - Jan 16, 2016

    Background: Inner-city, minority children with asthma have highest rates of morbidity and death from asthma and the lowest rates of asthma controller medication adherence. A number of recent electroni...

    Background: Inner-city, minority children with asthma have highest rates of morbidity and death from asthma and the lowest rates of asthma controller medication adherence. A number of recent electronic medication monitoring interventions demonstrated dramatic improvements in adherence in lower risk populations. The feasibility and acceptability of such an intervention in the highest risk children with asthma has not been studied. Objective: Our objective was to assess feasibility and acceptability of a community health worker delivered, electronic adherence monitoring intervention among the highest utilizers of acute asthma care in an inner city practice. Methods: This was a prospective cohort pilot study of targeting the 50 children with the highest frequency of asthma-related emergency department and hospital care within a local managed care Medicaid plan. The 3-month intervention included motivational interviewing, electronic monitoring of controller and rescue inhaler use, and outreach by a community health worker for predefined medication alerts. Acceptability was measured using a modified Technology Acceptability Model and changes in asthma control using the Asthma Control Test (ACT). A classification framework was developed to describe different patterns of medication use. Results: We enrolled fourteen non-Hispanic Black children with a mean age of 3.5. Subjects averaged 7.8 emergency or hospital visits in the year preceding enrollment. All subjects initiated use of the electronic devices, however, no modem signal was transmitted for 5/14 subjects after a mean of 45 days. All (100%) of the caregivers who completed the final study visit viewed the electronic monitoring device favorably and would recommend it to friends and 56% believed the device helped to improve asthma control. ACT scores improved by a mean of 2.7 points (P=0.05) over the 3-month intervention. We observed three distinct patterns of controller use; four patients demonstrated sustained use, 5 patients had periodic use, and 5 patients lapsed within two weeks. Conclusions: High utilizer, minority families with asthma found a community health worker delivered, electronic adherence intervention acceptable. Feasibility concerns, such as recruitment, data transmission failure and lost devices, should be carefully considered when designing interventions in this setting. High asthma care utilizers demonstrated three qualitatively different patterns of controller use.

  • Frugal innovation and personalized health technology

    Date Submitted: Nov 19, 2015

    Open Peer Review Period: Nov 19, 2015 - Jan 14, 2016

    Personalised health technologies – devices like wearables, smartwatches, and mobile health applications – enable users to quantify their health behaviors. Despite their potential to advance health...

    Personalised health technologies – devices like wearables, smartwatches, and mobile health applications – enable users to quantify their health behaviors. Despite their potential to advance health for all populations, personalised health technologies are used largely by the healthy and wealthy. They remain unaffordable, inaccessible, and largely unusable for marginalized populations who often have the greatest health needs. The creation of personalised health technologies using a frugal innovation mindset combined with stakeholder collaboration among the public and private sectors are proposed as strategies to ensure the disruptive technology advantages all populations.

  • A Data-Driven Approach to Characterizing the (Perceived) Newsworthiness of Health Science Articles

    Date Submitted: Nov 18, 2015

    Open Peer Review Period: Nov 19, 2015 - Jan 14, 2016

    Background: Health science findings are primarily disseminated through manuscript publications, and are then communicated to the public by the news media. Journalists and communication staff members s...

    Background: Health science findings are primarily disseminated through manuscript publications, and are then communicated to the public by the news media. Journalists and communication staff members select which articles receive coverage and thus public attention. Objective: This study aims to identify attributes of published health science articles that correlate with (1) journal editor issuance of press releases and (2) mainstream media coverage. Methods: We constructed four novel datasets to identify factors that correlate with press release issuance and media coverage. These corpora include thousands of published articles, subsets of which received a press release or mainstream media coverage. We used statistical machine learning methods to identify correlations between words in the science abstracts and press release issuance and media coverage. Further, we used topic modeling-based machine learning approach to uncover latent topics predictive of perceived newsworthiness in each of the datasets. Results: Both press release issuance for and media coverage of health science articles are predictable from corresponding journal article content. For the former task, we achieved average AUCs of 0.666 and 0.822 on two separate datasets, with size 3024 and 10760. For the latter task, models realized mean AUCs of 0.591 and 0.783 on two datasets, with size 422 and 28910. We reported most predictive words and topics for press release or news coverage. Conclusions: We have presented a novel data-driven characterization of content that renders health science "news-worthy". The analysis provides new insights into the news coverage selection process.