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

The effectiveness and acceptability of Computerised Cognitive Behaviour Therapy for anxiety and depression in rural and remote areas: A systematic review

Background: People living in rural and remote areas of Australia experience similar rates of mental health disorders as those who live in metropolitan areas. However, people living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as Cognitive Behaviour Therapy (CBT). Computerised CBT (CCBT) can be used to effectively treat depression and anxiety and may be particularly useful in rural settings where there are a lack of suitably trained practitioners. Objective: To systematically review the evidence regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations. Methods: We searched seven online databases, including Medline, Embase Classic + Embase, PsycInfo, CINAHL, Web of Science, Scopus and the Cochrane Library. We also hand searched reference lists, internet search engines and trial protocols. Two stages of selection were undertaken. In the first, three authors screened citations. Studies were retained if they (1) reported the effectiveness or acceptability of CCBT for depression and/or anxiety disorders; (2) delivered CCBT to people in any location of any age, (3) were peer reviewed; (4) and written in English. NVivo (10), qualitative data analysis software, was then used to run automated text searches for the word “rural”, its synonyms and stemmed words. All studies identified were read in full and included in the study if they measured or meaningfully discussed the effectiveness or acceptability of CCBT among rural participants. Results: A total of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated effectiveness data by location of participant reported that CCBT is equally effective for rural and urban participants. Rural location was found to both positively and negatively predict adherence across studies. CCBT may be more acceptable among rural as compared with urban participants; rural participants are less likely to want more face-to-face contact with a practitioner and find computerised delivery addresses confidentiality concerns. Conclusions: CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Further work is required to confirm these results and determine the most feasible model of CCBT delivery, in partnership with people who live and work in rural and remote communities.

2014-10-04

We are happy to announce the launch of our newly designed responsive website at www.jmir.org and its sister journals. The new stunning design, which features articles cards on the homepage, improved search functionality, easy switching between journals using a drop-down list, altmetrics, improved downloading of bibliographic data into personal reference managers, and other new features, has been in the works for 10 months. "Responsive" means that the website is automatically optimized for different screen sizes and devices, including mobile (change the width of the journal browser to see how this changes the layout).

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  • This is a royalty free image by Ambro (http://www.freedigitalphotos.net/images/CouplesPartners_g216-Elderly_Couple_With_Laptop_p41091.html).

    Which Frail Older Patients Use Online Health Communities and Why? A Mixed Methods Process Evaluation of Use of the Health and Welfare Portal

    Abstract:

    Background: Frail older people often receive fragmented care from multiple providers. According to the literature, there is an urgent need for coordination of care. Online and eHealth tools are increasingly used to improve coordination. However, there are significant barriers to their implementation in frail older people. Objective: Our aim was to (1) evaluate differences in use of a personal online health community (POHC) for frail older people in relation to personal characteristics, and (2) explore barriers and facilitators for use as experienced by older people and their informal caregivers, using the case of the Health and Welfare Information Portal (ZWIP). Methods: This is a mixed methods study. For the quantitative analysis, we used POHC usage information (2 years follow-up) and baseline characteristics of frail older people. For the qualitative analysis, we used semistructured interviews with older people and their informal caregivers. Participants were recruited from 11 family practices in the east of the Netherlands and frail older people over 70 years. The ZWIP intervention is a personal online health community for frail older people, their informal caregivers, and their providers. ZWIP was developed at the Geriatrics Department of Radboud University Medical Center. We collected data on POHC use for 2 years as well as relevant patient characteristics. Interview topics were description of use, reasons for use and non-use, and user profiles. Results: Of 622 frail patients in the intervention group, 290 were connected to ZWIP; 79 used ZWIP regularly (at least monthly). Main predictors for use were having an informal caregiver, having problems with activities of daily living, and having a large number of providers. Family practice level predictors were being located in a village, and whether the family practitioners had previously used electronic consultation and cared for a large percentage of frail older people. From 23 interviews, main reasons for use were perceiving ZWIP to be a good, quick, and easy way of communicating with providers and the presence of active health problems. Important reasons for non-use were lack of computer skills and preferring traditional means of consultation. Conclusions: Only 27.2% (79/290) of frail older enrolled in the POHC intervention used the POHC frequently. For implementation of personal online health communities, older people with active health problems and a sizable number of health care providers should be targeted, and the informal caregiver, if present, should be involved in the implementation process. Clinical Trial: International Standard Randomized Controlled Trial Number (ISRCTN): 11165483; http://www.controlled-trials.com/isrctn/pf/11165483 (Archived by WebCite at http://www.webcitation.org/6U3fZovoU).
  • Youth use online resources for seeking information about mental health. © 2014 Felicia Wetterlin, Institute of Mental Health. All Rights Reserved.

    eMental Health Experiences and Expectations: A Survey of Youths' Web-Based Resource Preferences in Canada

    Abstract:

    Background: Due to the high prevalence of psychological disorders and the lack of access to care among Canadian youth, the development of accessible services is increasingly important. eMental Health is an expanding field that may help to meet this need through the provision of mental health care using technology. Objective: The primary goals of the study are to explore youth experiences with traditional and online mental health resources, and to investigate youth expectations for mental health websites. Methods: A Web-based survey containing quantitative and qualitative questions was delivered to youth aged 17-24 years. Participants were surveyed to evaluate their use of mental health resources as well as their preferences for various components of a potential mental health website. Results: A total of 521 surveys were completed. Most participants (61.6%, 321/521) indicated that they had used the Internet to seek information or help for feelings they were experiencing. If they were going through a difficult time, 82.9% (432/521) of participants were either “somewhat likely” or “very likely” to use an information-based website and 76.8% (400/521) reported that they were either “somewhat unlikely” or “very unlikely” to visit social media websites for information or help-seeking purposes during this time. Most (87.7%, 458/521) participants rated their online privacy as very important. Descriptions of interventions and treatments was the most highly rated feature to have in a mental health-related website, with 91.9% (479/521) of participants regarding it as “important” or “very important”. When presented a select list of existing Canadian mental health-related websites, most participants had not accessed any of the sites. Of the few who had, the Canadian Mental Health Association website was the most accessed website (5.8%, 30/521). Other mental health-related websites were accessed by only 10.9% of the participants (57/521). Conclusions: The findings suggest that despite interest in these tools, current eMental Health resources either do not meet the needs of or are not widely accessed by youth with mental health problems. In order to improve access to these resources for Canadian youth, Web-based platforms should provide information about mental health problems, support for these problems (peer and professional), and information about resources (self-help as well as ability to locate nearby resources), while protecting the privacy of the user. These findings will not only assist in the development of new mental health platforms but may also help improve existing ones.
  • H1N1 Virus. Photo Credit: C. S. Goldsmith and A. Balish, CDC [Public domain], via Wikimedia Commons.

    Cumulative Query Method for Influenza Surveillance Using Search Engine Data

    Abstract:

    Background: Internet search queries have become an important data source in syndromic surveillance system. However, there is currently no syndromic surveillance system using Internet search query data in South Korea. Objectives: The objective of this study was to examine correlations between our cumulative query method and national influenza surveillance data. Methods: Our study was based on the local search engine, Daum (approximately 25% market share), and influenza-like illness (ILI) data from the Korea Centers for Disease Control and Prevention. A quota sampling survey was conducted with 200 participants to obtain popular queries. We divided the study period into two sets: Set 1 (the 2009/10 epidemiological year for development set 1 and 2010/11 for validation set 1) and Set 2 (2010/11 for development Set 2 and 2011/12 for validation Set 2). Pearson’s correlation coefficients were calculated between the Daum data and the ILI data for the development set. We selected the combined queries for which the correlation coefficients were .7 or higher and listed them in descending order. Then, we created a cumulative query method n representing the number of cumulative combined queries in descending order of the correlation coefficient. Results: In validation set 1, 13 cumulative query methods were applied, and 8 had higher correlation coefficients (min=.916, max=.943) than that of the highest single combined query. Further, 11 of 13 cumulative query methods had an r value of ≥.7, but 4 of 13 combined queries had an r value of ≥.7. In validation set 2, 8 of 15 cumulative query methods showed higher correlation coefficients (min=.975, max=.987) than that of the highest single combined query. All 15 cumulative query methods had an r value of ≥.7, but 6 of 15 combined queries had an r value of ≥.7. Conclusions: Cumulative query method showed relatively higher correlation with national influenza surveillance data than combined queries in the development and validation set.
  • (cc) Mishra et al. CC-BY-SA-2.0, please cite as (http://www.jmir.org/article/viewFile/3788/1/48423).

    Recruitment via the Internet and Social Networking Sites: The 1989-1995 Cohort of the Australian Longitudinal Study on Women’s Health

    Abstract:

    Background: Faced with the challenge of recruiting young adults for health studies, researchers have increasingly turned to the Internet and social networking sites, such as Facebook, as part of their recruitment strategy. As yet, few large-scale studies are available that report on the characteristics and representativeness of the sample obtained from such recruitment methods. Objective: The intent of the study was to describe the sociodemographic and health characteristics of a national sample of young Australian women recruited mainly through the Internet and social networking sites and to discuss the representativeness of their sociodemographic, health, and lifestyle characteristics relative to the population. Methods: A cohort of 17,069 women (born between 1989 and 1995) was recruited in 2012-13 for the Australian Longitudinal Study on Women’s Health. Sociodemographic characteristics (percentages, means, and 95% confidence intervals) from the online survey data were compared with women aged 18-23 years from the 2011 Australian Census. Sample data were compared by age and education level with data from the 2011-13 Australian Health Survey (AHS). Results: Compared to the Australian Census data, study participants were broadly representative in terms of geographical distribution across Australia, marital status (95.62%, 16,321/17,069) were never married), and age distribution. A higher percentage had attained university (22.52%, 3844/17,069) and trade/certificate/diploma qualifications (25.94%, 4428/17,069) compared with this age group of women in the national population (9.4% and 21.7% respectively). Among study participants, 22.05% (3721/16,877) were not in paid employment with 35.18% (5931/16,857) studying 16 or more hours a week. A higher percentage of study participants rated their health in the online survey as fair or poor (rather than good, very good, or excellent) compared with those participating in face-to-face interviews in the AHS (18.77%, 3203/17,069 vs 10.1%). A higher percentage of study participants were current smokers (21.78%, 3718/17,069 vs 16.4%) and physically active (59.30%, 10,089/17,014 were classified as sufficiently active vs 48.3%) but alcohol consumption was lower (59.58%, 9865/16,558 reported drinking alcohol at least once per month vs 65.9% in the AHS). Using self-reported height and weight to determine body mass index (BMI, kg/m2), 34.80% (5901/16,956) of the cohort were classified as overweight or obese (BMI of 25 or more), compared with 33.6% respectively using measured height and weight in the AHS. Conclusions: Findings indicated that using the Internet and social networking sites for an online survey represent a feasible recruitment strategy for a national cohort of young women and result in a broadly representative sample of the Australian population.
  • Image courtesy of Witthaya Phonsawat at FreeDigitalPhotos.net.

    Exploring the Relationship Between Changes in Weight and Utterances in an Online Weight Loss Forum: A Content and Correlational Analysis Study

    Abstract:

    Background: There is increasing interest in the use of online forums as a component of eHealth weight loss interventions. Although the research is mixed on the utility of online forums in general, results suggest that there is promise to this, particularly if the systems can be designed well to support healthful interactions that foster weight loss and continued engagement. Objective: The purpose of this study was to examine the relationship between the styles of utterances individuals make on an online weight loss forum and week-to-week fluctuations in weight. This analysis was conducted to generate hypotheses on possible strategies that could be used to improve the overall design of online support groups to facilitate more healthful interactions. Methods: A convenience sample of individuals using an online weight loss forum (N=4132) included data both on online forum use and weight check-in data. All interactions were coded utilizing the Linguistic Inquiry and Word Count (LIWC) system. Mixed model analyses were conducted to examine the relationship between these LIWC variables and weight over time. Results: Results suggested that increased use of past-tense verbs (P=.05) and motion (P=.02) were associated with lower weekly weights whereas increased use of conjunctions (eg, and, but, whereas; P=.001) and exclusion words (eg, but, without, exclude; P=.07) were both associated with higher weight during the weeks when these utterances were used more. Conclusions: These results provide some insights on the styles of interactions that appear to be associated with weight fluctuations. Future work should explore the stability of these findings and also explore possibilities for fostering these types of interactions more explicitly within online weight loss forums.
  • (cc) Hsu et al. CC-BY-SA-2.0, please cite as (http://www.jmir.org/article/viewFile/3542/1/49303).

    The Effect of Individual Factors on Health Behaviors Among College Students: The Mediating Effects of eHealth Literacy

    Abstract:

    Background: College students’ health behavior is a topic that deserves attention. Individual factors and eHealth literacy may affect an individual’s health behaviors. The integrative model of eHealth use (IMeHU) provides a parsimonious account of the connections among the digital divide, health care disparities, and the unequal distribution and use of communication technologies. However, few studies have explored the associations among individual factors, eHealth literacy, and health behaviors, and IMeHU has not been empirically investigated. Objective: This study examines the associations among individual factors, eHealth literacy, and health behaviors using IMeHU. Methods: The Health Behavior Scale is a 12-item instrument developed to measure college students’ eating, exercise, and sleep behaviors. The eHealth Literacy Scale is a 12-item instrument designed to measure college students’ functional, interactive, and critical eHealth literacy. A nationally representative sample of 525 valid college students in Taiwan was surveyed. A questionnaire was administered to collect background information about participants’ health status, degree of health concern, major, and the frequency with which they engaged in health-related discussions. This study used Amos 6.0 to conduct a confirmatory factor analysis to identify the best measurement models for the eHealth Literacy Scale and the Health Behavior Scale. We then conducted a multiple regression analysis to examine the associations among individual factors, eHealth literacy, and health behaviors. Additionally, causal steps approach was used to explore indirect (mediating) effects and Sobel tests were used to test the significance of the mediating effects. Results: The study found that perceptions of better health status (t520=2.14-6.12, P<.001-.03) and greater concern for health (t520=2.58-6.95, P<.001-.003) influenced college students’ development of 3 dimensions of eHealth literacy and adoption of healthy eating, exercise, and sleep behaviors. Moreover, eHealth literacy played an intermediary role in the association between individual factors and health behaviors (Sobel test=2.09-2.72, P<.001-.03). Specifically, higher levels of critical eHealth literacy promoted students’ health status and their practice of multiple positive health behaviors, including eating, exercise, and sleep behaviors. Conclusions: Because this study showed that eHealth literacy mediates the association between individual factors and health behaviors, schools should aim to enhance students’ eHealth literacy and promote their health behaviors to help them achieve high levels of critical eHealth literacy. Although some of the study’s hypotheses were not supported in this study, the factors that influence health behaviors are complex and interdependent. Therefore, a follow-up study should be conducted to further explore how these factors influence one another.
  • View of MHV home page after login.

    Personal Health Record Reach in the Veterans Health Administration: A Cross-Sectional Analysis

    Abstract:

    Background: My HealtheVet (MHV) is the personal health record and patient portal developed by the United States Veterans Health Administration (VA). While millions of American veterans have registered for MHV, little is known about how a patient’s health status may affect adoption and use of the personal health record. Objective: Our aim was to characterize the reach of the VA personal health record by clinical condition. Methods: This was a cross-sectional analysis of all veterans nationwide with at least one inpatient admission or two outpatient visits between April 2010 and March 2012. We compared adoption (registration, authentication, opt-in to use secure messaging) and use (prescription refill and secure messaging) of MHV in April 2012 across 18 specific clinical conditions prevalent in and of high priority to the VA. We calculated predicted probabilities of adoption by condition using multivariable logistic regression models adjusting for sociodemographics, comorbidities, and clustering of patients within facilities. Results: Among 6,012,875 veterans, 6.20% were women, 61.45% were Caucasian, and 26.31% resided in rural areas. The mean age was 63.3 years. Nationwide, 18.64% had registered for MHV, 11.06% refilled prescriptions via MHV, and 1.91% used secure messaging with their clinical providers. Results from the multivariable regression suggest that patients with HIV, hyperlipidemia, and spinal cord injury had the highest predicted probabilities of adoption, whereas those with schizophrenia/schizoaffective disorder, alcohol or drug abuse, and stroke had the lowest. Variation was observed across diagnoses in actual (unadjusted) adoption and use, with registration rates ranging from 29.19% of patients with traumatic brain injury to 14.18% of those with schizophrenia/schizoaffective disorder. Some of the variation in actual reach can be explained by facility-level differences in MHV adoption and by differences in patients’ sociodemographic characteristics (eg, age, race, income) by diagnosis. Conclusions: In this phase of early adoption, opportunities are being missed for those with specific medical conditions that require intensive treatment and self-management, which could be greatly supported by functions of a tethered personal health record.
  • Image from HD Around the Globe campaign featuring models wearing the campaign T-shirt.

    Analysis of a Parent-Initiated Social Media Campaign for Hirschsprung’s Disease

    Abstract:

    Background: Social media can be particularly useful for patients or families affected by rare conditions by allowing individuals to form online communities across the world. Objective: Our aim in this study was to conduct a descriptive and quantitative analysis of the use of a social media community for Hirschsprung’s Disease (HD). Methods: In July 2011, a mother of a child with HD launched the “Shit Happens” campaign. The campaign uses social media (blogs, Twitter, and Facebook) to engage other families affected by HD. Internet analytics including Google Analytics and Facebook Insights were used to evaluate the reach and responsiveness of this campaign. Results: On the day the HD campaign was launched, 387 people viewed the blog “Roo’s Journey”. Blog views have now exceeded 5400 views from 37 countries. The Facebook page extends to 46 countries, has an average post reach of 298 users, 1414 “likes”, and an overall reach of 131,032 users. The campaign has 135 Twitter followers and 344 tweets at the time of writing. The most common question posted on the Facebook page is related to treatment for extreme diaper rash. Responsiveness assessment demonstrated that within 2 hours of posting, a question could receive 143 views and 20 responses, increasing to 30 responses after 5 hours. Conclusions: Social media networks are well suited to discussion, support, and advocacy for health-related conditions and can be especially important in connecting families affected by rare conditions. The HD campaign demonstrates the reach and responsiveness of a community that primarily relies on social media to connect families affected by HD. Although responsive, this community is currently lacking consistent access to evidence-based guidance for their common concerns. We will explore innovative consumer-researcher partnerships to offer a solution in future research.
  • Introducing the telemonitoring application to a patient participating in the Heart at Home study.

    Use of Home Telemonitoring to Support Multidisciplinary Care of Heart Failure Patients in Finland: Randomized Controlled Trial

    Abstract:

    Background: Heart failure (HF) patients suffer from frequent and repeated hospitalizations, causing a substantial economic burden on society. Hospitalizations can be reduced considerably by better compliance with self-care. Home telemonitoring has the potential to boost patients’ compliance with self-care, although the results are still contradictory. Objective: A randomized controlled trial was conducted in order to study whether the multidisciplinary care of heart failure patients promoted with telemonitoring leads to decreased HF-related hospitalization. Methods: HF patients were eligible whose left ventricular ejection fraction was lower than 35%, NYHA functional class ≥2, and who needed regular follow-up. Patients in the telemonitoring group (n=47) measured their body weight, blood pressure, and pulse and answered symptom-related questions on a weekly basis, reporting their values to the heart failure nurse using a mobile phone app. The heart failure nurse followed the status of patients weekly and if necessary contacted the patient. The primary outcome was the number of HF-related hospital days. Control patients (n=47) received multidisciplinary treatment according to standard practices. Patients’ clinical status, use of health care resources, adherence, and user experience from the patients’ and the health care professionals’ perspective were studied. Results: Adherence, calculated as a proportion of weekly submitted self-measurements, was close to 90%. No difference was found in the number of HF-related hospital days (incidence rate ratio [IRR]=0.812, P=.351), which was the primary outcome. The intervention group used more health care resources: they paid an increased number of visits to the nurse (IRR=1.73, P<.001), spent more time at the nurse reception (mean difference of 48.7 minutes, P<.001), and there was a greater number of telephone contacts between the nurse and intervention patients (IRR=3.82, P<.001 for nurse-induced contacts and IRR=1.63, P=.049 for patient-induced contacts). There were no statistically significant differences in patients’ clinical health status or in their self-care behavior. The technology received excellent feedback from the patient and professional side with a high adherence rate throughout the study. Conclusions: Home telemonitoring did not reduce the number of patients’ HF-related hospital days and did not improve the patients’ clinical condition. Patients in the telemonitoring group contacted the Cardiology Outpatient Clinic more frequently, and on this way increased the use of health care resources. Clinical Trial: Clinicaltrials.gov NCT01759368; http://clinicaltrials.gov/show/NCT01759368 (Archived by WebCite at http://www.webcitation.org/6UFxiCk8Z).
  • 'Alcheringa Spirit’ an Australian limestone sculpture displayed in the foyer of the ATSIC Commission in Sydney was created by Australian Aboriginal artist Mundara Koorang. Image source:

    Social Media and Mobile Apps for Health Promotion in Australian Indigenous Populations: Scoping Review

    Abstract:

    Background: Health promotion organizations are increasingly embracing social media technologies to engage end users in a more interactive way and to widely disseminate their messages with the aim of improving health outcomes. However, such technologies are still in their early stages of development and, thus, evidence of their efficacy is limited. Objective: The study aimed to provide a current overview of the evidence surrounding consumer-use social media and mobile software apps for health promotion interventions, with a particular focus on the Australian context and on health promotion targeted toward an Indigenous audience. Specifically, our research questions were: (1) What is the peer-reviewed evidence of benefit for social media and mobile technologies used in health promotion, intervention, self-management, and health service delivery, with regard to smoking cessation, sexual health, and otitis media? and (2) What social media and mobile software have been used in Indigenous-focused health promotion interventions in Australia with respect to smoking cessation, sexual health, or otitis media, and what is the evidence of their effectiveness and benefit? Methods: We conducted a scoping study of peer-reviewed evidence for the effectiveness of social media and mobile technologies in health promotion (globally) with respect to smoking cessation, sexual health, and otitis media. A scoping review was also conducted for Australian uses of social media to reach Indigenous Australians and mobile apps produced by Australian health bodies, again with respect to these three areas. Results: The review identified 17 intervention studies and seven systematic reviews that met inclusion criteria, which showed limited evidence of benefit from these interventions. We also found five Australian projects with significant social media health components targeting the Indigenous Australian population for health promotion purposes, and four mobile software apps that met inclusion criteria. No evidence of benefit was found for these projects. Conclusions: Although social media technologies have the unique capacity to reach Indigenous Australians as well as other underserved populations because of their wide and instant disseminability, evidence of their capacity to do so is limited. Current interventions are neither evidence-based nor widely adopted. Health promotion organizations need to gain a more thorough understanding of their technologies, who engages with them, why they engage with them, and how, in order to be able to create successful social media projects.
  • Interactive whiteboard.

    Educational Technologies in Problem-Based Learning in Health Sciences Education: A Systematic Review

    Abstract:

    Background: As a modern pedagogical philosophy, problem-based learning (PBL) is increasingly being recognized as a major research area in student learning and pedagogical innovation in health sciences education. A new area of research interest has been the role of emerging educational technologies in PBL. Although this field is growing, no systematic reviews of studies of the usage and effects of educational technologies in PBL in health sciences education have been conducted to date. Objective: The aim of this paper is to review new and emerging educational technologies in problem-based curricula, with a specific focus on 3 cognate clinical disciplines: medicine, dentistry, and speech and hearing sciences. Analysis of the studies reviewed focused on the effects of educational technologies in PBL contexts while addressing the particular issue of scaffolding of student learning. Methods: A comprehensive computerized database search of full-text articles published in English from 1996 to 2014 was carried out using 3 databases: ProQuest, Scopus, and EBSCOhost. Eligibility criteria for selection of studies for review were also determined in light of the population, intervention, comparison, and outcomes (PICO) guidelines. The population was limited to postsecondary education, specifically in dentistry, medicine, and speech and hearing sciences, in which PBL was the key educational pedagogy and curriculum design. Three types of educational technologies were identified as interventions used to support student inquiry: learning software and digital learning objects; interactive whiteboards (IWBs) and plasma screens; and learning management systems (LMSs). Results: Of 470 studies, 28 were selected for analysis. Most studies examined the effects of learning software and digital learning objects (n=20) with integration of IWB (n=5) and LMS (n=3) for PBL receiving relatively less attention. The educational technologies examined in these studies were seen as potentially fit for problem-based health sciences education. Positive outcomes for student learning included providing rich, authentic problems and/or case contexts for learning; supporting student development of medical expertise through the accessing and structuring of expert knowledge and skills; making disciplinary thinking and strategies explicit; providing a platform to elicit articulation, collaboration, and reflection; and reducing perceived cognitive load. Limitations included cumbersome scenarios, infrastructure requirements, and the need for staff and student support in light of the technological demands of new affordances. Conclusions: This literature review demonstrates the generally positive effect of educational technologies in PBL. Further research into the various applications of educational technology in PBL curricula is needed to fully realize its potential to enhance problem-based approaches in health sciences education.
  • Animated conversational agent interface.

    Automated Indexing of Internet Stories for Health Behavior Change: Weight Loss Attitude Pilot Study

    Abstract:

    Background: Automated health behavior change interventions show promise, but suffer from high attrition and disuse. The Internet abounds with thousands of personal narrative accounts of health behavior change that could not only provide useful information and motivation for others who are also trying to change, but an endless source of novel, entertaining stories that may keep participants more engaged than messages authored by interventionists. Objective: Given a collection of relevant personal health behavior change stories gathered from the Internet, the aim of this study was to develop and evaluate an automated indexing algorithm that could select the best possible story to provide to a user to have the greatest possible impact on their attitudes toward changing a targeted health behavior, in this case weight loss. Methods: An indexing algorithm was developed using features informed by theories from behavioral medicine together with text classification and machine learning techniques. The algorithm was trained using a crowdsourced dataset, then evaluated in a 2×2 between-subjects randomized pilot study. One factor compared the effects of participants reading 2 indexed stories vs 2 randomly selected stories, whereas the second factor compared the medium used to tell the stories: text or animated conversational agent. Outcome measures included changes in self-efficacy and decisional balance for weight loss before and after the stories were read. Results: Participants were recruited from a crowdsourcing website (N=103; 53.4%, 55/103 female; mean age 35, SD 10.8 years; 65.0%, 67/103 precontemplation; 19.4%, 20/103 contemplation for weight loss). Participants who read indexed stories exhibited a significantly greater increase in self-efficacy for weight loss compared to the control group (F1,107=5.5, P=.02). There were no significant effects of indexing on change in decisional balance (F1,97=0.05, P=.83) and no significant effects of medium on change in self-efficacy (F1,107=0.04, P=.84) or decisional balance (F1,97=0.78, P=.38). Conclusions: Personal stories of health behavior change can be harvested from the Internet and used directly and automatically in interventions to affect participant attitudes, such as self-efficacy for changing behavior. Such approaches have the potential to provide highly tailored interventions that maximize engagement and retention with minimal intervention development effort.

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  • The effectiveness and acceptability of Computerised Cognitive Behaviour Therapy for anxiety and depression in rural and remote areas: A systematic review

    Date Submitted: Dec 14, 2014

    Open Peer Review Period: Dec 16, 2014 - Feb 10, 2015

    Background: People living in rural and remote areas of Australia experience similar rates of mental health disorders as those who live in metropolitan areas. However, people living in rural and remote...

    Background: People living in rural and remote areas of Australia experience similar rates of mental health disorders as those who live in metropolitan areas. However, people living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as Cognitive Behaviour Therapy (CBT). Computerised CBT (CCBT) can be used to effectively treat depression and anxiety and may be particularly useful in rural settings where there are a lack of suitably trained practitioners. Objective: To systematically review the evidence regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations. Methods: We searched seven online databases, including Medline, Embase Classic + Embase, PsycInfo, CINAHL, Web of Science, Scopus and the Cochrane Library. We also hand searched reference lists, internet search engines and trial protocols. Two stages of selection were undertaken. In the first, three authors screened citations. Studies were retained if they (1) reported the effectiveness or acceptability of CCBT for depression and/or anxiety disorders; (2) delivered CCBT to people in any location of any age, (3) were peer reviewed; (4) and written in English. NVivo (10), qualitative data analysis software, was then used to run automated text searches for the word “rural”, its synonyms and stemmed words. All studies identified were read in full and included in the study if they measured or meaningfully discussed the effectiveness or acceptability of CCBT among rural participants. Results: A total of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated effectiveness data by location of participant reported that CCBT is equally effective for rural and urban participants. Rural location was found to both positively and negatively predict adherence across studies. CCBT may be more acceptable among rural as compared with urban participants; rural participants are less likely to want more face-to-face contact with a practitioner and find computerised delivery addresses confidentiality concerns. Conclusions: CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Further work is required to confirm these results and determine the most feasible model of CCBT delivery, in partnership with people who live and work in rural and remote communities.

  • TOWARDS A TAXONOMY OF DESIGN ELEMENTS FOR SERIOUS GAMES FOR MENTAL HEALTH

    Date Submitted: Dec 10, 2014

    Open Peer Review Period: Dec 11, 2014 - Dec 20, 2014

    Background: Internet interventions for improving health and wellbeing have the potential to reach many people and fill gaps in service provision. Uptake and adherence has generally been disappointing...

    Background: Internet interventions for improving health and wellbeing have the potential to reach many people and fill gaps in service provision. Uptake and adherence has generally been disappointing. ‘Serious Gaming’ interfaces provide opportunities to optimise user adherence and impact. Health interventions to promote behaviour change which are based in theory and evidence and tailored to psychological constructs have been found to be more effective. Defining the design elements which engage the user and help them to meet their goals may contribute to better informed Serious Games. Objective: To elucidate design elements important from user perspectives within a hypothesized framework comprising the three constructs of Self Determination Theory and four stakeholder groups involved in Serious Game design. Methods: We analysed data from five studies, linking user perceptions of Autonomy, Competence and Relatedness to the features of the Serous Game SPARX which supported user perceptions. The design elements important from a user-centred perspective within this framework were identified.We analysed data from five studies, linking user perceptions of Autonomy, Competence and Relatedness to the features of the Serous Game SPARX which supported user perceptions. The design elements important from a user-centred perspective within this framework were identified. Results: User perceptions mapped well to the framework which may assist developers to understand the context of user needs. By further mapping these elements against the constructs of SDT we were also able to propose a sound theoretical base for the model. The framework and model can be used to deliberately incorporate Serious Game design elements which support a user’s sense of autonomy, competence, and relatedness; key constructs which have been found to mediate motivation at all stages of the change process. Conclusions: This study’s method allowed for the articulation of design elements in a Serious Game from a user-centred perspective within a coherent overarching framework. The resulting model can be built upon and inform developers, ensuring programs support significant user-centred requirements. Involving users in program design remains an imperative if Serious Games are to be fit for purpose.

  • Internet addiction through the phase of adolescence

    Date Submitted: Dec 10, 2014

    Open Peer Review Period: Dec 10, 2014 - Feb 4, 2015

    Background: Adolescence can be defined as the period between puberty and adulthood, usually between the ages of 11 and 18 years. Events during this period have a great influence on a person's developm...

    Background: Adolescence can be defined as the period between puberty and adulthood, usually between the ages of 11 and 18 years. Events during this period have a great influence on a person's development and can determine their attitudes and behavior in later life [1]. The latest research has shown that adolescence can be divided into several stages; early, middle and late. Later on we can consider the post-adolescent phase [2]. One of the most important functions of adolescence is to develop one’s own perceptions of sexuality, without conflict with oneself and always acting within acceptable moral standards. The easing of parental authority helps to guide the individual through new and independent relationships, reducing dependence on peer groups thus helping to find one's own identity. [3] Teenagers are often in conflict with authority and the cultural and moral norms of society, so certain developmental effects can trigger a series of defense mechanisms [2]. For all age groups, from school age to adulthood, the most dominating and uncontrollable emotion is sorrow, which can lead to depression, discouragement and loneliness. These emotions are central to most experiences of depression. These symptoms usually increase with age for females who generally demonstrate a higher degree than males. During the developmental stages of adolescence there is an increased danger of crises, often accompanied by mood changes, periods of anxiety and depressive behavior which adolescents attempt to fight through withdrawal, avoidance of overly emphasized social contact, aggressive reactions and addictive behavior [4], [5] . Adolescents are exceptionally vulnerable during this period and because of their receptive age can become drawn to the Internet as a release. This can, in time, lead to a type of addiction. Adolescents are especially attracted to new and technological methods of communication which offer interaction with others and at the same time give them anonymity and an impression of belonging to a community as well as social acceptability. The Internet is a global network which connects millions of people throughout the world, enabling users to exchange information and, importantly, this information is available at any time and any place [6]. In a very short time the Internet has become the most popular and sophisticated medium for influencing the needs of children and young persons [7]. Access to information is unlimited and it can be a source of amusement as well as a generator of new interests [8]. However the Internet can also represent new and unknown threats. Simple and uncontrolled information access and the anonymity that goes with it can endanger the moral development of the young. The Internet can generate negative attitudes, aggressive feelings and insensitivity to unethical behavior due to the fact that there is no direct contact between individuals. Factors which can lead to addictive attitudes towards the Internet are depression, loneliness, intimacy, simplicity, availability of approach, anonymity, high level of curiosity paired with strong pressures from ones surroundings. Addiction is often the result of social crises, lack of self-confidence, a need to conform, boredom and the availability of interesting and amusing pastimes [8]. The concept of addictions to particular behaviors or substances has been known for centuries, as have the psychological effects these have. Regardless of extensive knowledge about such tendencies, they do not appear to diminish; on the contrary, these traits seem to be increasingly attractive to some and often become compulsive [9]. Persons addicted to Internet use have been noticed to have three to five psychiatric disturbances. The most common of these are social phobias, ADD/ADHD, insomnia, behavioral disorders, anxiety, and compulsive attitudes to gambling and other social pastimes [10]. Anxiety issues often affect problem children and adolescents and during this period there is a distinct tendency towards symptoms of depression. Recent research by Nalwa & Anand points to the fact that the Internet gives students numerous advantages for learning due to the wide access to literature, e-learning, courses etc. However, frequent access to the many unimportant web sites such as those for chat, games etc. can easily cause addiction which could have negative results on their health and standards of learning. Children often abandon traditional pastimes and replace them with time spent surfing the Internet. This can lead to late bed time with the subsequent loss of peaceful sleep. Often life is considered boring without the Internet which can lead to a strong feeling of loneliness [11]. The purpose of this paper is to observe the psycho social effects of Internet addiction during adolescence. Since the early and middle stages of adolescence are crucial for emotional development, the research dealt with them in particular. Adolescents need time to solve identity crises, affirm their attitudes, and establish social links and professional aims. Emotional regulators represent an important mechanism through which the child’s own characteristics, as well as those of its surroundings, influence the child’s ability to adapt. It is during this period of adjustment that adolescents are open to the various addictive temptations that the Internet presents. J.J. Gross defines emotional regulation as the process through which individuals influence which emotions they have, when they have them, and how they experience and express them [12]. In general we can conclude that emotional control helps a person to coordinate expressive feelings with those of the environment (the regulation behavior) and also to protect themselves from uncomfortable feelings. These feelings do not restrain, detract or inhibit normal functioning (the regulation of emotional experience) [13]. Adolescents tend to be more involved with risky behavior and can indulge in addictive practices in order to more easily cope with anxiety, frustration and failure. Objective: Due to the lack of scientific proof it is difficult to ascertain in which stages do adolescents use the Internet and to what purposes. It is also hard to establish how does the virtual model of life preferred by the Internet addicts influence psycho social functioning and the quality of life. Since Internet addicts spend most of their time surfing in front of the computer the goal was to establish for which purposes do they most often use the Internet. The goal was also to note whether there are differences between the Croatian, Polish and Finnish adolescents with regards to the purpose of Internet use as well as any possible differences with respect to gender. Hypothesis H1- There is an influence, a correlation between the purpose of Internet use and the age, and the interaction of the two, on the level of addiction to the Internet. Methods: Participants are defined as students who attend regular school, age 11- 18 years old. The schools that participated in this research are Poljisani Split Viska 12 and „ Blatine-Skrape“ Krzice 2 Split elementary school as well as First Grammar school Teslina 10 21000 Split and Third Grammar school Matice Hrvatske 11 21000 Split. From Finland the following schools were chosen: Raunistulan koulu, Teräsrautelan koulu / Suikkilan yksikkö, Talinkorventie 16, 20320 Turkish, Finland, Turun suomalaisen yhteiskoulun lukio, Kauppiaskatu 17, FINE-20100 Turkish. From Poland the following schools participated: Szkoła Podstawowa them. Powstancow Wielkopolskich to the ul. More painfully 2 88-170 Pakość ; Gimnazjum them. Ewerysta Estkowskiego to the ul. Szkolna 44 88-170 Pakość. Research was carried out with permissions of the ministries in charge of education in Croatia, Poland and Finland, ethical commissions of the schools and with consent of the participants themselves. The schools were issued an invitation to participate with assurances of the complete respect of the privacy of individual students with the informed consent of the students and their parents or guardians. The questionnaire was developed in Google documents format and sent to schools in an electronic form along with instructions and contact information of the researchers. The title page instructed the participants to fill the questionnaires out fully and truthfully. They were informed that participation is anonymous and voluntary, that the data will be used for research purposes only and general and particular importance of the research was pointed out to them. Furthermore, they were notified as to the type and duration of the procedures used and they were informed of the confidentiality of the data gathered and the protection of privacy of the participants. The participants were free to refuse participation or to quit at any time without explanation. Having been notified of all the particulars, they proceeded to fill out the questionnaires. Method of research Survey consists of three parts. A standardized procedure of double translation was applied to each part for each country/language. General information Demographic parameters used in the research include: • Age • Gender (1-female ; 2-male) • Country of residence • Purpose of Internet use Participants were asked to appraise whether they use the Internet more often for amusement or educational purposes. Internet addiction questionnaire Internet addiction will be assessed using Young’s (1996) IAT (Internet Addiction Test), also known as YIAS (Young’s Internet Addiction Scale). IAT contains twenty questions based on the criteria for pathological gambling. These questions reflect typical addictive behavior. Widiyanto and McMurran report that the scale reflects six dimensions of Internet addiction: salient preoccupation, overuse of the Internet, neglecting work responsibilities, expectation, lack of self-control and neglecting social life. The authors have found that the factors of saliency and overuse are in connection with a more intensive use while neglecting work is only correlated with age and negatively. The conclusion drawn by the authors is that IAT “does measure some of the key aspects of Internet addiction”. [14]. Level of addiction was graded on a scale, ranging from 20 to 100. 20-49 – Normal 50-79 – Moderate addiction 80-100 – Serious addiction Each question can score up to 5 points (1 very rarely, 2 rarely, 3 often, 4 very often, 5 always). The scale demonstrates excellent internal consistency with the alpha coefficient of 0.93 in the current studies. Results: 1078 adolescents from Croatia, Poland and Finland participated in the research. The representative sample of n = 1078 comprised of roughly an equal number of participants of both genders: 534 males and 525 females (for 19 of them the gender was unknown). The age varied between 11 and 18, the average age being 14.9 with the average discrepancy of 1.92 years which is a small dispersion (with the variance coefficient of only 13%). Participants were predominantly fifteen year olds so both the median and mode values are 15 years. The structure of the participants sample is shown in Graph 1 with regard to their gender, age, country and the purpose of Internet use. Graph 1: Structure of polled adolescents with regard to gender, age, orgin and purpose of internet use ( in percentages) The predominant purpose of Internet use with the 1078 participants is entertainment (84%) with school/work far behind at 16%. Using the chi-square test a correlation was established between the purpose of Internet use and gender and the purpose of Internet use and nationality (country of residence) as can be observed in the following contingency tables (Table 1 and Table 2) used in these tests. Table 1: Number of interviewed adolescents according to gender and purpose Internet use( n=1078) The values of chi-square test computed using Table 1 (χ2 = 11,285; df = 1; N = 1042; p = 0.001) point to the conclusion that there is a statistically significant link (p = 0.001) between gender and the purpose of Internet use. What is this link? Female participants use the Internet for school or work related purposes (20%) much more than their male counterparts (12%). However, if the analyses of this correlation between gender and the purpose of Internet use are carried out separately for each country the results are different: Table 2: Correlation between gander and purpose of Internet use for each country This statistically significant link is present with Croatian participants (χ2 = 26,811; df = 1; N = 476; p < 0,001) and it is not present with the Finnish and Polish ones (p > 0,05). Therefore, the Croatian participants have importantly contributed to the conclusion that there is a statistically significant correlation between gender and the purpose of Internet use (in all three countries). Table 3: Number of interviwed adolescents according to country and purpose Internet use (N=534) The values of chi-square test computed using Table 3 (χ2= 27,274; df = 2; N = 1058; p < 0,001) point to the conclusion that there is a statistically highly significant correlation between the country and the purpose of Internet use (p < 0,001). For example, the use of Internet for school/work is less in Croatia (16%) than in Poland (24%) with Finland in the last place at only 8%. There is a statistically significant correlation (χ2 = 19,742; df = 6; N = 919; p = 0,003) between age and the level of Internet addiction. Using the contingency table (Table 3) it is possible to calculate that the percentage of moderate and serious addicts grows simultaneously with the participants’ age: youngest (11-12) – 6% slightly older (13-14) – 12% older (15-16) – 19% the oldest (17-18) – drops down to 13% The results show a correlation between age and Internet addiction (χ2= 13,512; df = 3; N = 919; p = 0,004). This correlation can be further broken down by gender, country and the purpose of Internet use. According to gender the adolescents can be categorized as male or female and we can calculate a separate chi-square test for each of these sub-sections in order to ascertain the correlation between the age of adolescents and Internet addiction. This result will show us whether it is the male or the female demographic which contributes to the correlation between age and Internet addiction. The same can be done with the remaining two independent variables – country and the purpose of Internet use. For reasons of exactitude of tests the Internet addiction is expressed on only two levels: normal addiction and moderate and serious addiction. Table 4: Correlation between age and Internet addiction So, the males (p = 0,001) and those adolescents who have used the Internet mostly for entertainment purposes (p = 0,038) have mostly contributed to the correlation between the age of adolescents and Internet addiction. Using correlation analysis, the age was considered as being a continuous independent variable and the Internet addiction as dependent ordinal variable. Non-parametric method was used to calculate the Spearman’s coefficient of correlation of 0,08 for N = 1033 and with p = 0,011. It can be concluded that the correlation between the age of adolescents and Internet addiction is weak, positive and statistically significant. Two-factor variance analysis was carried out using the following variables: Dependent quantitative variable = Internet addiction (expressed in points). This variable was formed as a sum of answers to the twenty questions on Internet use. First independent categorical variable = purpose of Internet use (factor 1) with two modalities: school/work and entertainment. Second independent categorical variable = age group (factor 2) with four modalities: 11-12, 13-14, 15-16, 17-18. This model of two-factor variance analysis is meant to provide answers to the following three questions: • Is there a statistically significant influence of the purpose of Internet use on the level of Internet addiction (disregarding the age of participants)? • Is there a statistically significant influence of the age of participants on the level of Internet addiction (disregarding the purpose of Internet use)? • Is there a statistically significant interaction between the purpose of Internet use and the age of the participants regarding the level of Internet addiction? In describing the analysis data obtained through the described model, the Levene test of variance equality has to be mentioned first, as it has established that variances are not homogenous (p < 0,001) for the analyzed sample of participants. The p values obtained in the ANOVA table enable us to answer the three questions: • There is no statistically significant influence of the purpose of Internet use on the level of Internet addiction (disregarding the age of participants), as p = 0,215, that is p > 0,05. • There is a statistically important influence of the age of participants on the level of Internet addiction (disregarding the purpose of Internet use), as p < 0,001. • There is a statistically significant interaction between the purpose of Internet use and age regarding the level of Internet addiction (p = 0,001). Comparing the eight mean values between themselves we are able to conclude where this level of Internet addiction is at its lowest and where at its highest: 11-12 y.o. school/work 32,5 Entertainment 32,8 13-14 y.o. school/work 34,8 Entertainment 38,2 15-16 y.o. school/work 46,5 Entertainment 39,3 17-18 y.o. school/work 38,2 Entertainment 35,9 The lowest level of Internet addiction is noted with the youngest who use the Internet for school (32,5). The adolescents between the ages of 15 and 16 who also use the Internet for school have the highest. Single factor variance analysis (F test) was used to compare the average values of Internet addiction in adolescents of different ages. These average values (points calculated on the basis of the answers to the twenty questions in the questionnaire) according to age groups are: 11-12 y.o. – 32,4 13-14 y.o. – 37,6 15-16 y.o. – 40,6 17-18 y.o. – 36,4 The average score overall was 37,8. There is a statistically significant difference between the four averages (F = 14,461 with df = 3 and N = 919), as p < 0,001. Graphically, these are represented as follows: Graph 2: compare the average values of Internet addiction in adolescents of diferent ages Discussion 1078 adolescents aged 11 – 18 from Croatia, Poland and Finland participated in the research. The goal of this research was to investigate the existence of differences between the adolescents in Croatia, Poland and Finland with regard to the purpose of Internet use and also to establish whether there are differences between the genders regarding the purpose of Internet use. The basic purpose of Internet use among the 1078 participants is predominantly entertainment (84%), with only 16% using the Internet for school/work. Female participants use the Internet for school/work significantly more (20%) than their male counterparts (12%). Croatian participants (16%) use the Internet for school much less than the Polish ones (24%), while the Finnish participants use it the least (just 8%). Lenhart & Madden got similar results in their research; male adolescents in America use functional and entertainment activities on the Internet much more than the girls who use it for educational and social activities to a much higher degree [15]. Furthermore, similar data was also obtained by Lin & Tsai. They concluded that Taiwanese boys use the Internet to elevate their mood levels, while Taiwanese girls possess a more practical view of the Internet [16]. Programs and activities on the Internet offer the younger generations new dimensions of social activities, so the use of Internet can expand and reinforce the connection with friends and colleagues [17] Tsai and Lin noticed that some adolescents were so preoccupied with activities on the Internet that they were displaying signs of addiction [16]. In accordance with the correlations of risky forms of behavior and the developmental stages of adolescence, the following hypothesis was accepted: different stages of adolescence show a different percentage of Internet addicts. This means that there is a correlation between the age of adolescents and Internet addiction and it is weak, positive and statistically significant (χ2= 13,512; df = 3; N = 919; p = 0,004). The percentage of moderate and serious addicts grows with age: - Youngest (11-12 y.o.) – 6% - Slightly older (13-14) – 12% - Older (15-16) – 19% - Oldest (17-18) – drops down to 13% The greatest contributors to this correlation are males (p = 0,001) and those adolescents who use the Internet predominately for entertainment (p = 0,038). Adolescents aged 15 – 16 demonstrate the highest degree of addiction, possibly because at this age they achieve a greater level of independence. Their free time and social activities are less controlled by their parents. Online communication has a strong influence on the developmental stages of adolescence. Adolescents share their experience through new forms of communication; they seek their own position within a group and report their friends as being a great source of social support, even greater than their parents [18]. A two-factor variance analysis was carried out, utilizing the following variables: Dependent quantitative variable “Internet addiction” and factor 1, “the purpose of Internet use” with two modalities: school/work and entertainment. The second, independent categorical variable, “age group” had four modalities: 11-12, 13-14, 15-16 and 17-18. Regarding the analyzed sample of participants: There is no statistically significant influence of the purpose of Internet use on the level of Internet addiction while there is a statistically significant influence of age of participants on the level of Internet addiction. There is a statistically significant interaction between the purpose of Internet use and age with regard to the level of Internet addiction (p = 0,001). Comparing the eight mean values between themselves we established that the lowest level of addiction occurs with the youngest group (11-12 y.o.) who use the Internet for school (32,5). They are also the ones who use the Internet for entertainment the least (32,8). The highest level of Internet addiction occurs with the 15-16 y.o. adolescents. Their purpose of use of the Internet for school is the highest (46,5) of the age groups, as is their use for the purposes of entertainment (39,3). Those aged 13-14 use the Internet more for entertainment (38,2) and less for school (34,2). The 17-18 y.o. group uses Internet at the percentage of 38,2 for school/work and 35,9 for entertainment. Single factor variance analysis (F test) was used to compare average values of Internet addiction in adolescents of different ages. These averages were calculated on the basis of answers given to the twenty questions in the questionnaire and are: 11 – 12 y.o. – 32,4 13 – 14 y.o. – 37,6 15 – 16 y.o. – 40,6 17 – 18 z.o. – 36,4 The average overall score was 37,8 and there is a statistically significant difference between the four averages (F = 14,461 with df = 3 and N = 919), as p < 0,001. Conclusions: The basic purpose of Internet use among the 1078 participants is entertainment (84%), the secondary school/work (16%). 20% of female adolescents use the internet for school/work, which is significantly more than the males (12%). Croatian participants (16%) use the Internet for school/work significantly less than the Polish ones (24%) and the Finnish participants use it for school/work the least (only 8%). Percentage of moderate and serious Internet addicts grows with age. Most addicts are to be found in the middle stage of adolescence, in the 15 – 16 age group. Furthermore, the purpose of Internet use has no effect on the level of Internet addiction whereas the age is a significant predictor of the level of Internet addiction as is the interaction between the purpose of Internet use and age which also influences the level of Internet addiction. After comparing the eight mean values between themselves we learned that the lowest level of Internet addiction is found among the youngest group (11-12) that uses the Internet for school (32,5). They also have the lowest rate of Internet use for entertainment (32,8). The highest level of Internet addiction is to be found in the 15 – 16 group. This group has the highest rate of Internet use for school (46,5), but also for entertainment (39,3). 13 – 14 y.o. adolescents use Internet for school at the percentage of 38,2 and for entertainment at 34,2. The numbers for 17 – 18 y.o. group are 38,2 for school/work and 35,9 for entertainment.

  • Health-Related Internet Use by Informal Caregivers of Children and Adolescents: An Integrative Literature Review

    Date Submitted: Dec 9, 2014

    Open Peer Review Period: Dec 10, 2014 - Feb 4, 2015

    Background: Internet-based health resources can support caregivers who are caring for children or adolescents with health care needs. However, few studies discriminate caregivers’ needs from those o...

    Background: Internet-based health resources can support caregivers who are caring for children or adolescents with health care needs. However, few studies discriminate caregivers’ needs from those of their care recipients or from those caring for adults. Objective: This study aims to review the literature of health-related Internet use (HRIU) among caregivers of children and adolescents. Methods: Fourteen studies were selected from literature searches conducted in six electronic databases: PubMed, Cochrane, CINAHL, PsycINFO, ERIC, and EMBASE. All databases were searched in recent 10-year, peer-reviewed publications. Search terms consisted of “health-related Internet use,” “eHealth,” “Internet use for health-related purpose,” “web-based resource,” and “online resources,” combined with informal caregiver of “child,” “adolescent,” “student,” “youth,” and “teen.” The specific ages of the children and adolescents receiving care were limited to younger than 21years old. Their caregivers were defined as persons who provided unpaid care or assistance to a child or an adolescent with health problems. Results: Among 14 empirical studies, the majority of child or adolescent caregivers were parents of children who were experiencing a wide range of medical and situational issues. Quantitative studies (86%, 12/14) reported prevalence and predictors of HRIU, while mixed methods and qualitative studies (14%, 2/14) investigated caregivers’ perceptions of helpful HRIU and barriers of use. The prevalence of HRIU varied (11%-90%) dependent upon how HRIU was operationalized and measured. Disease-specific information was used for decision making about treatment, while social support via a virtual community and emailing communication were used for caregivers’ emotional support needs. Compared to adult caregivers, caregivers of children uniquely sought age-specific information for child development and health promotion, such as parenting. A digital divide was identified in minority and lower educated caregivers with limited Internet access. Most studies had methodological challenges resulting from convenience sampling, cross-sectional surveys, lack of theoretical frameworks, and no clear definitions of HRIU. Conclusions: This study provides an important understanding of how family members use Internet-based information and support systems during child caregiving. Health care providers and policy makers should integrate family needs into their current practices and policies. Further rigorous research is required to design efficient and effective nursing interventions.

  • Doctors and the Etiquette of Mobile Device Use in Trauma and Orthopaedics

    Date Submitted: Dec 9, 2014

    Open Peer Review Period: Dec 10, 2014 - Feb 4, 2015

    Background: The etiquette surrounding the use of smartphones and mobile devices has been previously identified as a barrier to use in an educational context. Objective: To investigate the influence of...

    Background: The etiquette surrounding the use of smartphones and mobile devices has been previously identified as a barrier to use in an educational context. Objective: To investigate the influence of mobile device use on patient and staff opinions in the Trauma and Orthopaedics department at a teaching hospital in Wales. Methods: A survey of patients at the bedside and staff in their work environment was undertaken. Data included age, frequency of observed use and suspected main reason for use and whether doctors’ use of a mobile device positively or negatively influenced their opinion of them as a professional and as a person. Results: 59 patients and 35 staff responded. The modal age range was 40 to 54 years. Most patients (78%) never see doctors using mobile devices in the workplace, compared with 3% of staff. The main reason for use was thought to be ‘communicating with colleagues’ (48%) followed by ‘internet use/applications for work reasons’ (40%). Approximately 40% of patients' opinions of doctors were positively influenced by device use, compared with 80% of staff. This difference between patient and staff opinions was statistically significant for both professional (p=<.001) and personal (p=.002) opinions. Conclusions: Patients are likely to have a negative opinion of doctors using mobile devices. This can be balanced by the more positive opinions of colleagues. We would advise doctors to remember ‘mobiquette’ around patients.

  • The use of behavior change theory in Internet-based Asthma Self-Management Interventions: A systematic review

    Date Submitted: Dec 8, 2014

    Open Peer Review Period: Dec 10, 2014 - Dec 18, 2014

    Background: The high prevalence rate of asthma, the aging population, and increasing cost of healthcare services, represents a major societal burden. Advancements in the information technology continu...

    Background: The high prevalence rate of asthma, the aging population, and increasing cost of healthcare services, represents a major societal burden. Advancements in the information technology continue to affect the delivery of patient care in all areas of medicine. Internet-based online solutions, social media, and mobile technology could address some of the problems associated with the increasing asthma prevalence. Objective: This review evaluates internet-based asthma interventions over the past decade (2004 through October 2014) with respect to the use of behavioral change theoretical frameworks and applied clinical guidelines. Methods: The search term (Asthma AND (Online or Internet or mobile or Application or eHealth or App)) was applied to five bibliographic databases (MEDLINE (OVID), PubMed, BioMed Central, ProQuest Computing, and Web of Knowledge) including only English articles published between 2004 and October 2014. In total, 3927 articles matched the priori search terms and were reviewed by the primary reviewer based on their titles, index terms, and abstracts. The matching articles were then screened by the primary reviewer for inclusion or exclusion based on their abstract, study type, and intervention objectives with respect to the full set of priori inclusion and exclusion criteria. 331 duplicates were identified and removed. A total of 84 were included for in-depth review and the remaining 3512 articles were excluded. The primary and secondary reviewer independently reviewed the complete content of the 84 included articles to identify the applied behavioral change theories and clinical guidelines. Findings and any disagreement between reviewers were resolved by in-depth discussion and through a consolidation process for each of the included articles. Results: The reviewers have identified 16 out of 84 interventions (19%) where at least one model, framework and/or construct of a behavioral change theory has been applied. The review identified 46 out of 84 interventions (55%) where at least one documented clinical guideline and/or tool was applied. Conclusions: The findings of this literature review indicate that the majority of published internet-based interventions do not use any documented behavioral change theory to inform their design. Further, it was found that the application of clinical guidelines and assessment tools were more salient across the reviewed interventions. A consequence as such, is that many internet-based asthma interventions are designed in an ad hoc manner, without the use of any notable evidence-based theoretical frameworks.