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Journal of Medical Internet Research

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


Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2016: 5.175, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As leading high-impact journal in its' disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

As open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (eg, in grant proposals), and for open peer-review purposes. We also invite patients to participate (eg, as peer-reviewers) and have patient representatives on editorial boards.

Be a widely cited leader in the digitial health revolution and submit your paper today!


Recent Articles:

  • Pokemon GO family. Source: Image created by the Authors; Copyright: Ben V Ma; URL:; License: Creative Commons Attribution (CC-BY).

    Pokémon GO and Physical Activity in Asia: Multilevel Study


    Background: Physical activity has long been considered as an important component of a healthy lifestyle. Although many efforts have been made to promote physical activity, there is no effective global intervention for physical activity promotion. Some researchers have suggested that Pokémon GO, a location-based augmented reality game, was associated with a short-term increase in players’ physical activity on a global scale, but the details are far from clear. Objective: The objective of our study was to study the relationship between Pokémon GO use and players’ physical activity and how the relationship varies across players with different physical activity levels. Methods: We conducted a field study in Hong Kong to investigate if Pokémon GO use was associated with physical activity. Pokémon GO players were asked to report their demographics through a survey; data on their Pokémon GO behaviors and daily walking and running distances were collected from their mobile phones. Participants (n=210) were Hong Kong residents, aged 13 to 65 years, who played Pokémon GO using iPhone 5 or 6 series in 5 selected types of built environment. We measured the participants’ average daily walking and running distances over a period of 35 days, from 14 days before to 21 days after game installation. Multilevel modeling was used to identify and examine the predictors (including Pokémon GO behaviors, weather, demographics, and built environment) of the relationship between Pokémon GO use and daily walking and running distances. Results: The average daily walking and running distances increased by 18.1% (0.96 km, approximately 1200 steps) in the 21 days after the participants installed Pokémon GO compared with the average distances over the 14 days before installation (P<.001). However, this association attenuated over time and was estimated to disappear 24 days after game installation. Multilevel models indicated that Pokémon GO had a stronger and more lasting association among the less physically active players compared with the physically active ones (P<.001). Playing Pokémon GO in green space had a significant positive relationship with daily walking and running distances (P=.03). Moreover, our results showed that whether Pokémon GO was played, the number of days played, weather (total rainfall, bright sunshine, mean air temperature, and mean wind speed), and demographics (age, gender, income, education, and body mass index) were associated with daily walking and running distances. Conclusions: Pokémon GO was associated with a short-term increase in the players’ daily walking and running distances; this association was especially strong among less physically active participants. Pokémon GO can build new links between humans and green space and encourage people to engage in physical activity. Our results show that location-based augmented reality games, such as Pokémon GO, have the potential to be a global public health intervention tool.

  • Source: Unsplash; Copyright: Eaters Collective; URL:; License: Licensed by JMIR.

    What People “Like”: Analysis of Social Media Strategies Used by Food Industry Brands, Lifestyle Brands, and Health Promotion Organizations on Facebook...


    Background: Health campaigns have struggled to gain traction with young adults using social media, even though more than 80% of young adults are using social media at least once per day. Many food industry and lifestyle brands have been successful in achieving high levels of user engagement and promoting their messages; therefore, there may be lessons to be learned by examining the successful strategies commercial brands employ. Objective: This study aims to identify and quantify social media strategies used by the food industry and lifestyle brands, and health promotion organizations across the social networking sites Facebook and Instagram. Methods: The six most engaging posts from the 10 most popular food industry and lifestyle brands and six health promotion organizations were included in this study. A coding framework was developed to categorize social media strategies, and engagement metrics were collected. Exploratory linear regression models were used to examine associations between strategies used and interactions on Facebook and Instagram. Results: Posts from Facebook (143/227, 63.0%) and Instagram (84/227, 37.0%) were included. Photos (64%) and videos (34%) were used to enhance most posts. Different strategies were most effective for Facebook and Instagram. Strategies associated with higher Facebook interactions included links to purchasable items (beta=0.81, 95% CI 0.50 to 1.13, P<.001) featuring body image messages compared with food content (beta=1.96, 95% CI 1.29 to 2.64, P<.001), and where the content induced positive emotions (beta=0.31, 95% CI 0.04 to 0.57, P=.02). Facebook interactions were negatively associated with using pop culture (beta=–0.67, 95% CI –0.99 to –0.34, P<.001), storytelling (beta=–0.86, 95% CI –1.29 to –0.43, P<.001) or visually appealing graphics (beta=–0.53, 95% CI –0.78 to –0.28, P<.001) in their posts compared with other strategies. Posting relatable content was negatively associated with interactions on Facebook (beta=–0.29, 95% CI –0.53 to –0.06, P=.01), but positively associated on Instagram (beta=0.50, 95% CI 0.05 to 0.95, P=.03). Instagram interactions were negatively associated with weight loss (beta=–1.45, 95% CI –2.69 to –0.21, P=.02) and other content (beta=–0.81, 95% CI –1.57 to –.06, P=.04) compared with food content. Conclusions: Health promotion professionals and organizations can improve engagement using positive messaging and tailoring posts appropriate for different social media channels.

  • Care coordinator using a Web-based electronic health record tailored to support implementation of care coordination using the Wraparound process. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Impact of a Web-Based Electronic Health Record on Behavioral Health Service Delivery for Children and Adolescents: Randomized Controlled Trial


    Background: Electronic health records (EHRs) have been widely proposed as a mechanism for improving health care quality. However, rigorous research on the impact of EHR systems on behavioral health service delivery is scant, especially for children and adolescents. Objective: The current study evaluated the usability of an EHR developed to support the implementation of the Wraparound care coordination model for children and youth with complex behavioral health needs, and impact of the EHR on service processes, fidelity, and proximal outcomes. Methods: Thirty-four Wraparound facilitators working in two programs in two states were randomized to either use the new EHR (19/34, 56%) or to continue to implement Wraparound services as usual (SAU) using paper-based documentation (15/34, 44%). Key functions of the EHR included standard fields such as youth and family information, diagnoses, assessment data, and progress notes. In addition, there was the maintenance of a coordinated plan of care, progress measurement on strategies and services, communication among team members, and reporting on services, expenditures, and outcomes. All children and youth referred to services for eight months (N=211) were eligible for the study. After excluding those who were ineligible (69/211, 33%) and who declined to participate (59/211, 28%), a total of 83/211 (39%) children and youth were enrolled in the study with 49/211 (23%) in the EHR condition and 34/211 (16%) in the SAU condition. Facilitators serving these youth and families and their supervisors completed measures of EHR usability and appropriateness, supervision processes and activities, work satisfaction, and use of and attitudes toward standardized assessments. Data from facilitators were collected by web survey and, where necessary, by phone interviews. Parents and caregivers completed measures via phone interviews. Related to fidelity and quality of behavioral health care, including Wraparound team climate, working alliance with providers, fidelity to the Wraparound model, and satisfaction with services. Results: EHR-assigned facilitators from both sites demonstrated the robust use of the system. Facilitators in the EHR group reported spending significantly more time reviewing client progress (P=.03) in supervision, and less time overall sending reminders to youth/families (P=.04). A trend toward less time on administrative tasks (P=.098) in supervision was also found. Facilitators in both groups reported significantly increased use of measurement-based care strategies overall, which may reflect cross-group contamination (given that randomization of staff to the EHR occurred within agencies and supervisors supervised both types of staff). Although not significant at P<.05, there was a trend (P=.10) toward caregivers in the EHR group reporting poorer shared agreement on tasks on the measure of working alliance with providers. No other significant between-group differences were found. Conclusions: Results support the proposal that use of EHR systems can promote the use of client progress data and promote efficiency; however, there was little evidence of any impact (positive or negative) on overall service quality, fidelity, or client satisfaction. The field of children’s behavioral health services would benefit from additional research on EHR systems using designs that include larger sample sizes and longer follow-up periods. Trial Registration: NCT02421874; (Archived by WebCite at

  • The okdoc homepage (montage). Source: / The Authors; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Content, Quality, and Assessment Tools of Physician-Rating Websites in 12 Countries: Quantitative Analysis


    Background: Websites on which users can rate their physician are becoming increasingly popular, but little is known about the website quality, the information content, and the tools they offer users to assess physicians. This study assesses these aspects on physician-rating websites in German- and English-speaking countries. Objective: The objective of this study was to collect information on websites with a physician rating or review tool in 12 countries in terms of metadata, website quality (transparency, privacy and freedom of speech of physicians and patients, check mechanisms for appropriateness and accuracy of reviews, and ease of page navigation), professional information about the physician, rating scales and tools, as well as traffic rank. Methods: A systematic Web search based on a set of predefined keywords was conducted on Google, Bing, and Yahoo in August 2016. A final sample of 143 physician-rating websites was analyzed and coded for metadata, quality, information content, and the physician-rating tools. Results: The majority of websites were registered in the United States (40/143) or Germany (25/143). The vast majority were commercially owned (120/143, 83.9%), and 69.9% (100/143) displayed some form of physician advertisement. Overall, information content (mean 9.95/25) as well as quality were low (mean 18.67/47). Websites registered in the United Kingdom obtained the highest quality scores (mean 26.50/47), followed by Australian websites (mean 21.50/47). In terms of rating tools, physician-rating websites were most frequently asking users to score overall performance, punctuality, or wait time in practice. Conclusions: This study evidences that websites that provide physician rating should improve and communicate their quality standards, especially in terms of physician and user protection, as well as transparency. In addition, given that quality standards on physician-rating websites are low overall, the development of transparent guidelines is required. Furthermore, attention should be paid to the financial goals that the majority of physician-rating websites, especially the ones that are commercially owned, pursue.

  • Source: iStock by Getty Images; Copyright: julief514; URL:; License: Licensed by the authors.

    Sharing and Empathy in Digital Spaces: Qualitative Study of Online Health Forums for Breast Cancer and Motor Neuron Disease (Amyotrophic Lateral Sclerosis)


    Background: The availability of an increasing number of online health forums has altered the experience of living with a health condition, as more people are now able to connect and support one another. Empathy is an important component of peer-to-peer support, although little is known about how empathy develops and operates within online health forums. Objective: The aim of this paper is to explore how empathy develops and operates within two online health forums for differing health conditions: breast cancer and motor neuron disease (MND), also known as amyotrophic lateral sclerosis. Methods: This qualitative study analyzed data from two sources: interviews with forum users and downloaded forum posts. Data were collected from two online health forums provided by UK charities: Breast Cancer Care and the Motor Neurone Disease Association. We analyzed 84 threads from the breast cancer forum and 52 from the MND forum. Threads were purposively sampled to reflect varied experiences (eg, illness stages, topics of conversation, and user characteristics). Semistructured interviews were conducted with 14 Breast Cancer Care forum users and five users of the MND forum. All datasets were analyzed thematically using Braun and Clarke’s six-phase approach and combined to triangulate the analysis. Results: We found that empathy develops and operates through shared experiences and connections. The development of empathy begins outside the forum with experiences of illness onset and diagnosis, creating emotional and informational needs. Users came to the forum and found their experiences and needs were shared and understood by others, setting the empathetic tone and supportive ethos of the forum. The forum was viewed as both a useful and meaningful space in which they could share experiences, information, and emotions, and receive empathetic support within a supportive and warm atmosphere. Empathy operated through connections formed within this humane space based on similarity, relationships, and shared feelings. Users felt a need to connect to users who they felt were like themselves (eg, people sharing the same specific diagnosis). They formed relationships with other users. They connected based on the emotional understanding of ill health. Within these connections, empathic communication flourished. Conclusions: Empathy develops and operates within shared experiences and connections, enabled by structural possibilities provided by the forums giving users the opportunity and means to interact within public, restricted, and more private spaces, as well as within groups and in one-to-one exchanges. The atmosphere and feeling of both sites and perceived audiences were important facilitators of empathy, with users sharing a perception of virtual communities of caring and supportive people. Our findings are of value to organizations hosting health forums and to health professionals signposting patients to additional sources of support.

  • Older adult use of internet. Source: iStock by Getty Images; Copyright: kinemero; URL:; License: Licensed by the authors.

    Internet-Based Interventions Aimed at Supporting Family Caregivers of People With Dementia: Systematic Review


    Background: Caring for someone with dementia is one of the most challenging caring roles. The need for support for family caregivers has been recognized for some time but is often still lacking. With an aging population, demand on health and social care services is growing, and the population is increasingly looking to the internet for information and support. Objective: In this review, we aimed to (1) identify the key components of existing internet-based interventions designed to support family caregivers of people with dementia, (2) develop an understanding of which components are most valued by caregivers, and (3) consider the evidence of effectiveness of internet-based interventions designed to support family caregivers of people with dementia. Methods: We conducted a systematic search of online databases in April 2018. We searched reference lists and tracked citations. All study designs were included. We adopted a narrative synthesis approach with thematic analysis and tabulation as tools. Results: We identified 2325 studies, of which we included 40. The interventions varied in the number and types of components, duration and dose, and outcomes used to measure effectiveness. The interventions focused on (1) contact with health or social care providers, (2) peer interaction, (3) provision of information, (4) decision support, and (5) psychological support. The overall quality of the studies was low, making interpretation and generalizability of the effectiveness findings difficult. However, most studies suggested that interventions may be beneficial to family caregiver well-being, including positive impacts on depression, anxiety, and burden. Particular benefit came from psychological support provided online, where several small randomized controlled trials suggested improvements in caregiver mental health. Provision of information online was most beneficial when tailored specifically for the individual and used as part of a multicomponent intervention. Peer support provided in online groups was appreciated by most participants and showed positive effects on stress. Finally, online contact with a professional was appreciated by caregivers, who valued easy access to personalized practical advice and emotional support, leading to a reduction in burden and strain. Conclusions: Although mixed, the results indicate a positive response for the use of internet-based interventions by caregivers. More high-quality studies are required to identify the effectiveness of internet interventions aimed at supporting family caregivers, with particular focus on meeting the needs of caregivers during the different stages of dementia.

  • Source: Flickr; Copyright: Silvia Storti; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    Detecting Recovery Problems Just in Time: Application of Automated Linguistic Analysis and Supervised Machine Learning to an Online Substance Abuse Forum


    Background: Online discussion forums allow those in addiction recovery to seek help through text-based messages, including when facing triggers to drink or use drugs. Trained staff (or “moderators”) may participate within these forums to offer guidance and support when participants are struggling but must expend considerable effort to continually review new content. Demands on moderators limit the scalability of evidence-based digital health interventions. Objective: Automated identification of recovery problems could allow moderators to engage in more timely and efficient ways with participants who are struggling. This paper aimed to investigate whether computational linguistics and supervised machine learning can be applied to successfully flag, in real time, those discussion forum messages that moderators find most concerning. Methods: Training data came from a trial of a mobile phone-based health intervention for individuals in recovery from alcohol use disorder, with human coders labeling discussion forum messages according to whether or not authors mentioned problems in their recovery process. Linguistic features of these messages were extracted via several computational techniques: (1) a Bag-of-Words approach, (2) the dictionary-based Linguistic Inquiry and Word Count program, and (3) a hybrid approach combining the most important features from both Bag-of-Words and Linguistic Inquiry and Word Count. These features were applied within binary classifiers leveraging several methods of supervised machine learning: support vector machines, decision trees, and boosted decision trees. Classifiers were evaluated in data from a later deployment of the recovery support intervention. Results: To distinguish recovery problem disclosures, the Bag-of-Words approach relied on domain-specific language, including words explicitly linked to substance use and mental health (“drink,” “relapse,” “depression,” and so on), whereas the Linguistic Inquiry and Word Count approach relied on language characteristics such as tone, affect, insight, and presence of quantifiers and time references, as well as pronouns. A boosted decision tree classifier, utilizing features from both Bag-of-Words and Linguistic Inquiry and Word Count performed best in identifying problems disclosed within the discussion forum, achieving 88% sensitivity and 82% specificity in a separate cohort of patients in recovery. Conclusions: Differences in language use can distinguish messages disclosing recovery problems from other message types. Incorporating machine learning models based on language use allows real-time flagging of concerning content such that trained staff may engage more efficiently and focus their attention on time-sensitive issues.

  • Source:; Copyright: snowing; URL:; License: Licensed by JMIR.

    Discovery of and Interest in Health Apps Among Those With Mental Health Needs: Survey and Focus Group Study


    Background: A large number of health apps are available directly to consumers through app marketplaces. Little information is known, however, about how consumers search for these apps and which factors influence their uptake, adoption, and long-term use. Objective: The aim of this study was to understand what people look for when they search for health apps and the aspects and features of those apps that consumers find appealing. Methods: Participants were recruited from Northwestern University’s Center for Behavioral Intervention Technologies’ research registry of individuals with mental health needs. Most participants (n=811) completed a survey asking about their use and interest in health and mental health apps. Local participants were also invited to participate in focus groups. A total of 7 focus groups were conducted with 30 participants that collected more detailed information about their use and interest in health and mental health apps. Results: Survey participants commonly found health apps through social media (45.1%, 366/811), personal searches (42.7%, 346/811), or word of mouth (36.9%, 299/811), as opposed to professional sources such as medical providers (24.6%, 200/811). From the focus groups, common themes related to uptake and use of health apps included the importance of personal use before adoption, specific features that users found desirable, and trusted sources either developing or promoting the apps. Conclusions: As the number of mental health and health apps continue to increase, it is imperative to better understand the factors that impact people’s adoption and use of such technologies. Our findings indicated that a number of factors—ease of use, aesthetics, and individual experience—drove adoption and use and highlighted areas of focus for app developers and disseminators.

  • Pregnant woman discussing IBD concerns with physician. Source: Shutterstock Inc; Copyright: VGstockstudio; URL:; License: Licensed by the authors.

    Reproductive Health and Medication Concerns for Patients With Inflammatory Bowel Disease: Thematic and Quantitative Analysis Using Social Listening


    Background: Inflammatory bowel disease (IBD) affects many individuals of reproductive age. Most IBD medications are safe to use during pregnancy and breastfeeding; however, observational studies find that women with IBD have higher rates of voluntary childlessness due to fears about medication use during pregnancy. Understanding why and how individuals with IBD make decisions about medication adherence during important reproductive periods can help clinicians address patient fears about medication use. Objective: The objective of this study was to gain a more thorough understanding of how individuals taking IBD medications during key reproductive periods make decisions about their medication use. Methods: We collected posts from 3000 social media sites posted over a 3-year period and analyzed the posts using qualitative descriptive content analysis. The first level of analysis, open coding, identified individual concepts present in the social media posts. We subsequently created a codebook from significant or frequently occurring codes in the data. After creating the codebook, we reviewed the data and coded using our focused codes. We organized the focused codes into larger thematic categories. Results: We identified 7 main themes in 1818 social media posts. Individuals used social media to (1) seek advice about medication use related to reproductive health (13.92%, 252/1818); (2) express beliefs about the safety of IBD therapies (7.43%, 135/1818); (3) discuss personal experiences with medication use (16.72%, 304/1818); (4) articulate fears and anxieties about the safety of IBD therapies (11.55%, 210/1818); (5) discuss physician-patient relationships (3.14%, 57/1818); (6) address concerns around conception, infertility, and IBD medications (17.38%, 316/1818); and (7) talk about IBD symptoms during and after pregnancy and breastfeeding periods (11.33%, 206/1818). Conclusions: Beliefs around medication safety play an important role in whether individuals with IBD decide to take medications during pregnancy and breastfeeding. Having a better understanding about why patients stop or refuse to take certain medications during key reproductive periods may allow clinicians to address specific beliefs and attitudes during office visits.

  • Remote and real-time medical tracking of circadian clocks in people during their daily routine. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Relevance of a Mobile Internet Platform for Capturing Inter- and Intrasubject Variabilities in Circadian Coordination During Daily Routine: Pilot Study


    Background: Experimental and epidemiologic studies have shown that circadian clocks’ disruption can play an important role in the development of cancer and metabolic diseases. The cellular clocks outside the brain are effectively coordinated by the body temperature rhythm. We hypothesized that concurrent measurements of body temperature and rest-activity rhythms would assess circadian clocks coordination in individual patients, thus enabling the integration of biological rhythms into precision medicine. Objective: The objective was to evaluate the circadian clocks’ coordination in healthy subjects and patients through simultaneous measurements of rest-activity and body temperature rhythms. Methods: Noninvasive real-time measurements of rest-activity and chest temperature rhythms were recorded during the subject’s daily life, using a dedicated new mobile electronic health platform (PiCADo). It involved a chest sensor that jointly measured accelerations, 3D orientation, and skin surface temperature every 1-5 min and relayed them out to a mobile gateway via Bluetooth Low Energy. The gateway tele-transmitted all stored data to a server via General Packet Radio Service every 24 hours. The technical capabilities of PiCADo were validated in 55 healthy subjects and 12 cancer patients, whose rhythms were e-monitored during their daily routine for 3-30 days. Spectral analyses enabled to compute rhythm parameters values, with their 90% confidence limits, and their dynamics in each subject. Results: All the individuals displayed a dominant circadian rhythm in activity with maxima occurring from 12:09 to 20:25. This was not the case for the dominant temperature period, which clustered around 24 hours for 51 out of 67 subjects (76%), and around 12 hours for 13 others (19%). Statistically significant sex- and age-related differences in circadian coordination were identified in the noncancerous subjects, based upon the range of variations in temperature rhythm amplitudes, maxima (acrophases), and phase relations with rest-activity. The circadian acrophase of chest temperature was located at night for the majority of people, but it occurred at daytime for 26% (14/55) of the noncancerous people and 33% (4/12) of the cancer patients, thus supporting important intersubject differences in circadian coordination. Sex, age, and cancer significantly impacted the circadian coordination of both rhythms, based on their phase relationships. Conclusions: Complementing rest-activity with chest temperature circadian e-monitoring revealed striking intersubject differences regarding human circadian clocks’ coordination and timing during daily routine. To further delineate the clinical importance of such finding, the PiCADo platform is currently applied for both the assessment of health effects resulting from atypical work schedules and the identification of the key determinants of circadian disruption in cancer patients.

  • Multinational training-trainees from 33 different countries. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Increasing the Availability of Psychological Treatments: A Multinational Study of a Scalable Method for Training Therapists


    Background: One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. A highly scalable form of Web-centered therapist training, undertaken without external support, has recently been shown to have promise in promoting therapist competence. Objective: The aim of this study was to conduct an evaluation of the acceptability and effectiveness of a scalable independent form of Web-centered training in a multinational sample of therapists and investigate the characteristics of those most likely to benefit. Methods: A cohort of eligible therapists was recruited internationally and offered access to Web-centered training in enhanced cognitive behavioral therapy, a multicomponent, evidence-based, psychological treatment for any form of eating disorder. No external support was provided during training. Therapist competence was assessed using a validated competence measure before training and after 20 weeks. Results: A total of 806 therapists from 33 different countries expressed interest in the study, and 765 (94.9%) completed a pretraining assessment. The median number of training modules completed was 15 out of a possible 18 (interquartile range, IQR: 4-18), and 87.9% (531/604) reported that they treated at least one patient during training as recommended. Median pretraining competence score was 7 (IQR: 5-10, range: 0-19; N=765), and following training, it was 12 (IQR: 9-15, range: 0-20; N=577). The expected change in competence scores from pretraining to posttraining was 3.5 (95% CI 3.1-3.8; P<.001). After training, 52% (300/574) of therapists with complete competence data met or exceeded the competence threshold, and 45% (95% CI 41-50) of those who had not met this threshold before training did so after training. Compliance with training predicted both an increase in competence scores and meeting or exceeding the competence threshold. Expected change in competence score increased for each extra training module completed (0.19, 95% CI 0.13-0.25), and those who treated a suitable patient during training had an expected change in competence score 1.2 (95% CI 0.4-2.1) points higher than those who did not. Similarly, there was an association between meeting the competence threshold after training and the number of modules completed (odds ratio, OR=1.11, 95% CI 1.07-1.15), and treating at least one patient during training was associated with competence after training (OR=2.2, 95% CI 1.2-4.1). Conclusions: Independent Web-centered training can successfully train large numbers of therapists dispersed across a wide geographical area. This finding is of importance because the availability of a highly scalable method of training potentially increases the number of people who might receive effective psychological treatments.

  • Patient with type 2 diabetes using the intervention website (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Cost-Effectiveness of Facilitated Access to a Self-Management Website, Compared to Usual Care, for Patients With Type 2 Diabetes (HeLP-Diabetes): Randomized...


    Background: Type 2 diabetes mellitus is one of the most common long-term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. While the existing evidence suggested that uptake of self-management education was low, the development of internet-based technology might improve the situation. Objective: To establish the cost-effectiveness of a Web-based self-management program for people with type 2 diabetes (HeLP-Diabetes) compared to usual care. Methods: An incremental cost-effectiveness analysis was conducted, from a National Health Service and personal and social services perspective, based on data collected from a multi-center, two-arm individually randomized controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomized to either usual care plus HeLP-Diabetes, an interactive, theoretically-informed Web-based self-management program, or to usual care plus access to a comparator website containing basic information only. The participants’ intervention costs and wider health care resource use were collected as well as two health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to handle the missing data. Results: In total, 374 participants were randomized, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios of £58 (95% CI –411 to 587) per unit improvement on PAID scale and £5550 (95% CI –21,077 to 52,356) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and higher uncertainty with incremental cost-effectiveness ratios of £116 (95% CI –1299 to 1690) per unit improvement on PAID scale and £18,500 (95% CI –203,949 to 190,267) per QALY. The cost-effectiveness acceptability curve showed an 87% probability of cost-effectiveness at £20,000 per QALY willingness-to-pay threshold. The one-way sensitivity analyses estimated 363 users would be needed to use the intervention for it to become less costly than usual care. Conclusions: Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of £20,000 to £30,000 per QALY by National Institute of Health and Care Excellence. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 02123133; (Archived by WebCite at

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  • Disclosure of child maltreatment to a text messaging-based crisis service

    Date Submitted: Jun 15, 2018

    Open Peer Review Period: Jun 16, 2018 - Aug 11, 2018

    Background: Disclosure is a difficult but important process for victims of child maltreatment. There is limited research on child maltreatment disclosure, but Young people have been reluctant to discl...

    Background: Disclosure is a difficult but important process for victims of child maltreatment. There is limited research on child maltreatment disclosure, but Young people have been reluctant to disclose victimization to adults, but short message service (SMS) crisis services may represent one novel method of engaging young people around sensitive topics. Objective: The purpose of this study was to determine characteristics of child maltreatment disclosure to Crisis Text Line (CTL), a SMS-based crisis service. Methods: We conducted a content analysis of all conversations (n = 244) that resulted in a mandatory report by CTL between October 2015 and July 2017. We coded characteristics of the disclosure process, including the reason for initial contact, phrase used to disclose abuse, perpetrator, type of abuse, and length of victimization. After identifying terms used by young people to disclose child abuse, we randomly selected and analyzed 50 conversations using those terms to determine if use of the terms differed between conversations that did and did not result in mandatory report. Results: Parents were the most common perpetrator. Physical abuse was the most common form of abuse discussed in the initial abuse disclosure (n = 106), followed by psychological abuse (n = 83), sexual abuse (n = 38), and neglect (n = 15). More than half of texters discussed abuse or other significant family issues in the first message. “Abuse”, other definite language (e.g., rape, molested), or an explicit description of the experience was common in disclosures. Conclusions: Early disclosure, combined with explicit language, may suggest at least a portion of young victims are actively seeking safe ways to talk about their experiences, rather than incidentally sharing experiences while seeking support for other issues. SMS may be a valuable way to engage with young people around sensitive topics, but these approaches will require careful consideration in their development, implementation, and evaluation to ensure a positive experience for young people.

  • A Web-based exercise intervention for effective complementary treatment of patients with NAFLD - First results of the HELP-Study

    Date Submitted: Jun 13, 2018

    Open Peer Review Period: Jun 16, 2018 - Aug 11, 2018

    Background: Physical inactivity is a major risk factor for non-alcoholic fatty liver disease (NAFLD). Improvement of cardiorespiratory fitness (CRF) by exercise based prevention interventions is a rec...

    Background: Physical inactivity is a major risk factor for non-alcoholic fatty liver disease (NAFLD). Improvement of cardiorespiratory fitness (CRF) by exercise based prevention interventions is a recommended complementary treatment for NAFLD. Enabling patients to achieve minimally effective physical activity recommendations to improve CRF, typically requires high personal and financial expenses in face-to-face settings. Here we designed an eHealth approach for patients with NAFLD to overcome typical intrinsic and extrinsic barriers for the improvement of CRF (HELP-Study). Objective: We assessed the effectiveness of an 8-week tailored Web-based exercise intervention for the improvement of CRF, expressed as VO2peak, in patients with histologically confirmed NAFLD. Methods: In a 24-month period, 44 patients were enrolled into an 8-week prospective, single-arm study. After a medical examination and performance diagnostics, a sports therapist introduced the patients to a Web-based platform for individualized training support. Regular individual patient feedback, was used to systematically adapt the weekly exercise schedule. This enabled to monitor and warrant patient adherence to strength and endurance training and to optimize the step-wise progressive exercise load. Exercise progression was based on an a priori algorithm taking the subjective rate for both, perceived exhaustion and general physical discomfort into account. VO2peak was assessed at baseline and at the end of the study by spiroergometry. Results: Forty-three patients completed the intervention with no adverse events reported. VO2peak significantly increased 8.5 % by 2.4 ml/kg/min (95% CI: 1.48 - 3.27, P < .0001) accompanied by a 1.0 kg (95% CI: 0.33 – 1.58, P = .004) body weight reduction and a 1.3 kg (95% CI: 0.27 – 2.27, P = .01) body fat mass reduction. In an exploratory analysis step-wise logistic regression analysis revealed low body fat and low VO2peak at baseline as well as the total minutes of endurance training during the intervention as main contributors to a positive change in VO2peak. Our predictive model indicated that the average NAFLD patient needed 223 min for stabilization of VO2peak, while 628 min were required to achieve average improvement in VO2peak. However, in patients with a roughly 20 % higher than average VO2peak these 628 min were only sufficient to stabilize VO2peak and a more than 40 % lower than average fat mass would be required for such subjects with high VO2peak to achieve an average outcome. Conclusions: Here we show for the first time that patients with NAFLD can be effectively supported by a Web-based approach enabling similar increases in VO2peak as face-to-face interventions. Patients with low body fat and low VO2peak turned out to profit the most from our intervention. In terms of future treatment strategies, this implies that NAFLD patients with high body fat may particularly benefit from body fat reduction by a sharp nutritional intervention in first place thus enabling a more effective exercise intervention, subsequently. Clinical Trial: NCT02526732

  • Factors influencing online survey response for a longitudinal cohort of young women born 1989-95

    Date Submitted: Jun 13, 2018

    Open Peer Review Period: Jun 16, 2018 - Aug 11, 2018

    Background: With health research practices shifting towards rapid recruitment of samples through the use of online approaches, little is known about the impact of these recruitment methods on continue...

    Background: With health research practices shifting towards rapid recruitment of samples through the use of online approaches, little is known about the impact of these recruitment methods on continued participation in cohort studies. Objective: Report on the retention of a cohort of young women who were recruited using an open recruitment strategy. Methods: Women from the 1989-95 cohort of the Australian Longitudinal Study on Women’s Health, recruited in 2012-13 were followed up annually via online surveys in 2014, 2015 and 2016. Prevalence ratios for survey response were calculated using log-binomial model with generalised estimating equations with demographic, health-related and recruitment method characteristics examined as explanatory factors. Results: Of the 17,012 women who completed the baseline survey, approximately two-thirds completed the second survey, and just over half completed surveys 3 and 4, respectively. Women demonstrated transient patterns of responding with only 38% of women completing all four surveys. While retention of young women was associated with age, education, health status and health behaviours, method of recruitment was a key determinant of study participation in the multivariate model. Although women were more likely to be recruited into the cohort via social media (e.g. Facebook), retention over time was higher for women recruited through traditional media and referral approaches. Conclusions: A balance must be obtained between achieving representativeness, achieving rapid cohort recruitment and mitigating the pitfalls of attrition based on recruitment method in the new era of cohort studies, where traditional recruitment methods are no longer exclusively viable options.

  • Enabling my independence – users’ experiences of an app-based treatment for stress urinary incontinence

    Date Submitted: Jun 14, 2018

    Open Peer Review Period: Jun 16, 2018 - Aug 11, 2018

    Background: Stress urinary incontinence (SUI) affects 10–39% of women. First-line treatment consists of lifestyle interventions and pelvic floor muscle training (PFMT), which can be performed superv...

    Background: Stress urinary incontinence (SUI) affects 10–39% of women. First-line treatment consists of lifestyle interventions and pelvic floor muscle training (PFMT), which can be performed supervised or unsupervised. Health apps are increasing in number and can be used to improve adherence to treatments. We developed the Tät® app, which provides a 3-month treatment program with a focus on PFMT for women with SUI. The app treatment was evaluated in a randomized controlled trial (RCT), which demonstrated efficacy regarding incontinence symptoms and quality of life. In this qualitative interview study, we investigated participant experiences of the app-based treatment. Objective: To explore women’s experiences of using an app-based treatment program for SUI. Methods: A qualitative study based on telephone interviews with 15 selected women, with a mean age of 47, who had used the app in the previous RCT. A semi-structured interview guide with open-ended questions was used, and the interviews were transcribed verbatim. Data were analyzed according to Grounded Theory. Results: The results were grouped into three categories: “Something new!”, “Keeping motivation up!”, and “Good enough?” A core category, “Enabling my independence”, was identified. The participants appreciated having a new and modern way to access a treatment program for SUI. The use of new technology seemed to make incontinence treatment feel more prioritized and less embarrassing. The closeness to their smartphone and app features like reminders and visual graphs helped to support and motivate the women to carry through the PFMT. The participants felt confident that they could perform the treatment program on their own, even though they expressed some uncertainty about whether they were doing the pelvic floor muscle contractions correctly. They experienced that the app-based treatment increased their self-confidence and enabled them to take responsibility for their treatment. Conclusions: Using the app-based treatment program for SUI empowered the women and helped them self-manage their incontinence treatment. They appreciated the app as a new tool supporting their motivation to carry through a somewhat challenging PFMT program.

  • Utilization of Electronic Medical Records and Biomedical Literature to Support Rare Disease Diagnosis

    Date Submitted: Jun 15, 2018

    Open Peer Review Period: Jun 16, 2018 - Jun 25, 2018

    Background: In the United States, rare diseases are defined as those affecting fewer than 200,000 patients at any given time. Patients with rare diseases are frequently either misdiagnosed or left und...

    Background: In the United States, rare diseases are defined as those affecting fewer than 200,000 patients at any given time. Patients with rare diseases are frequently either misdiagnosed or left undiagnosed, possibly due in part to a lack of knowledge or experience with the rare disease on the part of care providers. With an exponentially growing volume of electronically accessible medical data, a large volume of information on thousands of rare diseases and their potentially associated diagnostic information is buried in electronic medical records (EMRs) and medical literature. Objective: We hypothesize that patients’ phenotypic information available within these heterogeneous resources (e.g., electronic medical records and biomedical literature) can be leveraged to accelerate disease diagnosis. In this study, we aimed to leverage information contained in heterogeneous datasets to assist rare disease diagnosis. Methods: In a previous study, we proposed utilizing a collaborative filtering recommendation system enriched with natural language processing and semantic techniques to assist rare disease diagnosis based on phenotypic characterizations derived solely from EMR data. In this study, in order to further investigate the performance of collaborative filtering on heterogeneous datasets, we studied EMR data generated at Mayo Clinic as well as published article abstracts retrieved from the Semantic MEDLINE Database. Specifically, in this study, we applied Tanimoto coefficient similarity, overlap coefficient similarity, Fager & McGowan coefficient similarity, and log likelihood ratio similarity with K nearest neighbor and threshold based patient neighbor algorithms on various combinations of datasets. Results: We evaluated different approaches to this problem using characterizations derived from various combinations of EMR data and literature, as well as with solely EMR data. We extracted 12.8 million EMRs from the Mayo Clinic unstructured patient cohort generated between 2010 through 2015 and retrieved all article abstracts from the semi-structured Semantic MEDLINE Database that were published through the end of 2016. We applied a collaborative filtering model and compared the performance generated by different metrics. Log likelihood ratio similarity combined with K nearest neighbor on heterogeneous datasets showed the optimal performance in patient recommendation with PRAUC 0.475 (string match), 0.511 (SNOMED match), and 0.752 (GARD match). Log likelihood ratio similarity also performed the best with mean average precision 0.465 (string match), 0.5 (SNOMED match), and 0.749 (GARD match). Performance of rare disease prediction was also demonstrated by using the optimal algorithm. Macro-average F-measure for string, SNOMED-CT, and GARD match were 0.32, 0.42, and 0.63, respectively. Conclusions: This study demonstrated potential utilization of heterogeneous datasets in a collaborative filtering model to support rare disease diagnosis. In addition to phenotypic-based analysis, in the future, we plan to resolve the heterogeneity issue and reduce miscommunication between EMR and literature by mining genotypic information to establish a comprehensive disease-phenotype-gene network for rare disease diagnosis.

  • Toward Open Recordings: The prevalence of recording clinic visits for patients' personal use in the U.S.

    Date Submitted: Jun 15, 2018

    Open Peer Review Period: Jun 16, 2018 - Jun 25, 2018

    Background: A handful of clinics in the U.S. routinely offer patients audio or video recordings of their clinic visits. While interest in the practice of clinic visit recording has increased, to date...

    Background: A handful of clinics in the U.S. routinely offer patients audio or video recordings of their clinic visits. While interest in the practice of clinic visit recording has increased, to date there is no data on the prevalence of recording in clinical practice in the U.S. Objective: Our objectives were to 1) determine the prevalence of sharing audio-recorded clinic visits for patients’ personal use in the U.S., 2) assess the attitudes of clinicians and the public toward recording, and 3) identify whether or not policies exist to guide recording practices in 49 of the largest health systems in the U.S. Methods: Two parallel cross-sectional surveys were administered in July 2017 to Internet Panels of U.S. based clinicians (SERMO Panel) and the U.S. public (Qualtrics Panel). To ensure a diverse range of perspectives, we set quotas to capture clinicians from eight specialties. Quotas were also applied to the public survey based on U.S. Census data (gender, race, ethnicity and language other than English spoken at home) to approximate views among U.S. adults. Forty-nine of the largest health systems (by clinician number) in the U.S. were contacted by email and telephone to determine the existence, or absence, of policies to guide audio-recordings of clinic visits for patients’ personal use. Multiple logistic regression models were used to determine factors associated with recording. Results: A total of 456 clinicians and 524 public respondents completed surveys. Approximately 28% of clinicians reported that they had recorded a clinic visit for patients’ personal use, while 18% of the public reported doing so, including 3% who recorded visits without the clinician’s permission. Of the 327 clinicians who had not recorded a clinic visit, 50% would be willing to do so in the future, while 66% of the public would be willing to record in the future. Clinician specialty was associated with prior recording: oncology, OR=5.1 (95% CI 1.9 to 14.9; P=0.002) and physical rehabilitation OR=3.9 (95% CI 1.4 to 11.6; P=0.01). Public respondents who were male, OR=2.11 (95% CI 1.26 to 3.61; P=0.005), younger age, OR=0.73 for a 10-year increase in age (95% CI 0.60 to 0.89; P=0.002); or spoke a language other than English at home, OR=1.99 (95% CI 1.09 to 3.59; P=0.02) were more likely to have recorded a clinic visit. None of the large health systems we contacted reported a dedicated policy, however 2 of the 49 health systems did report an existing policy that would cover the recording of clinic visits for patient use. Perceived benefits of recording included improved patient understanding and recall. Privacy and medico-legal concerns were raised. Conclusions: U.S. clinicians and public are taking the lead on recording clinic visits, while health systems seem to be lagging. Policy guidance from health systems and further examination of the impact of recordings, positive or negative, on the delivery of care and patients’ behavioral and health-related outcomes is urgently required.