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

Overcoming Clinical Inertia: A Randomized Clinical Trial of a Telehealth Remote Monitoring Intervention using Paired Glucose Testing in Adults with Type 2 Diabetes

Background: Type 2 diabetes is a worldwide challenge. Research indicates people with diabetes remain at suboptimal glucose control for 2.9 years from patient and provider clinical inertia limiting treatment intensification. Practice guidelines promote structured self-monitoring of blood glucose (SMBG) for informing healthcare providers about glycemic control and providing patient feedback to increase knowledge, self-efficacy, and behavior change. Paired glucose testing—pairs of glucose results obtained before and after a meal, physical activity, or other event— is one method of structured SMBG. However, frequent access to glucose data to interpret values and recommend actions is challenging. A complete feedback loop (CFL)—data collection and interpretation combined with feedback to modify treatment—has been associated with improved outcomes, yet there remains limited integration of SMBG feedback in diabetes management. Incorporating telehealth remote monitoring (RM) and asynchronous electronic health record (EHR) feedback from certified diabetes educators (CDE)—specialists in glucose pattern management—employ the CFL to improve outcomes. Objective: The purpose of this study was to evaluate a telehealth RM intervention using paired glucose testing and asynchronous data analysis in adults with type 2 diabetes. Primary aim was change in A1C—a measure of overall glucose management— between groups after six months. Secondary aims were change in self-reported Summary of Diabetes Self-Care Activities (SDSCA), Diabetes Empowerment Scale (DES), and Diabetes Knowledge Test (DKT). Methods: Methods: A two-group randomized clinical trial was conducted comparing usual care to telehealth RM with paired glucose testing and asynchronous virtual visits. Participants were 30–70 years old, not using insulin with A1C between 7.5%–10.9%. The telehealth RM tablet computer transmitted glucose data and facilitated a CFL to educate participants, analyze actionable glucose data, and provide feedback. Data from paired glucose testing were analyzed asynchronously using computer-assisted pattern analysis and were shared with patients via the EHR weekly. CDEs called participants monthly to discuss paired glucose testing trends and treatment changes. Separate mixed-effects models were used to analyze data. Results: Participants (n=90) were White (64%), mean age of 58 years, body mass index of 34.1 with diabetes for 8.2 years and mean A1C of 8.3%. Both groups lowered A1C with an estimated average decrease of 0.70 percentage points in control and 1.11 percentage points in intervention with a significant group difference of 0.41 percentage points at six months (se = 0.08, t = -2.87, P = .005). Change in medication (se =0.21, t = -3.37, P = .009) was significant on A1C. The treatment group significantly improved SDSCA subscales carbohydrate spacing (P = .04), monitoring glucose (P = .001), and foot care (P = .02). Conclusions: An e-Health model incorporating a CFL with telehealth RM and paired glucose testing with asynchronous data analysis significantly improved A1C compared to control. Clinical Trial: Clinicaltrials.gov identifier NCT01715649

2014-10-04

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  • https://www.youtube.com/watch?v=RBTkpsQiDcM.

    Therapeutic Affordances of Social Media: Emergent Themes From a Global Online Survey of People With Chronic Pain

    Abstract:

    Background: Research continues to present tenuous suggestions that social media is well suited to enhance management of chronic disease and improve health outcomes. Various studies have presented qualitative reports of health outcomes from social media use and have examined discourse and communication themes occurring through different social media. However, there is an absence of published studies examining and unpacking the underlying therapeutic mechanisms driving social media’s effects. Objective: This paper presents a qualitative analysis thoroughly describing what social media therapeutically affords people living with chronic pain who are self-managing their condition. From this therapeutic affordance perspective, we aim to formulate a preliminary conceptual model aimed at better understanding "how" social media can influence patient outcomes. Methods: In total, 218 people with chronic pain (PWCP) completed an online survey, investigating patient-reported outcomes (PROs) from social media use. Supplementary to quantitative data collected, participants were also given the opportunity to provide further open commentary regarding their use of social media as part of chronic pain management; 68/218 unique users (31.2%) chose to provide these free-text responses. Through thematic content analysis, 117 free-text responses regarding 10 types of social media were coded. Quotes were extracted and tabulated based on therapeutic affordances that we had previously identified. Inductive analysis was then performed to code defining language and emergent themes central to describing each affordance. Three investigators examined the responses, developed the coding scheme, and applied the coding to the data. Results: We extracted 155 quotes from 117 free-text responses. The largest source of quotes came from social network site users (78/155, 50.3%). Analysis of component language used to describe the aforementioned affordances and emergent themes resulted in a final revision and renaming of therapeutic affordances: "exploration" (52/155, 33.5% of quotes), "connection" (50/155, 32.3% of quotes), "narration" (33/155, 21.3% of quotes), "adaptation" (13/155, 8.4% of quotes), and "self-presentation" (7/155, 4.5% of quotes). Of the most described affordances, "exploration" was based on a propensity for participants to explain their social media use for information seeking purposes. "Connection" placed greater emphasis on interaction, highlighting themes of "exchanging information" and "mitigating isolation". Responses regarding "narration" highlighted the value of shared experiences and the emotionally cathartic role this plays. Conclusions: Much of the efficacy of social media may be explicable via a closer examination of therapeutic affordances. Particular areas that warrant attention include social media’s ability to filter and guide people to useful information, connect individuals, and share experiences. Further research into a variety of chronic conditions is warranted. Coupled with the results of the present study, a greater theoretical basis detailing how social media may foster health outcomes may lead to an improved evidence base for conducting research and may inform recommendations for social media use in chronic disease management.

  • Image Source: Gettyimages.

    Ethical Issues in Using Twitter for Public Health Surveillance and Research: Developing a Taxonomy of Ethical Concepts From the Research Literature

    Authors List:

    Abstract:

    Background: The rise of social media and microblogging platforms in recent years, in conjunction with the development of techniques for the processing and analysis of “big data”, has provided significant opportunities for public health surveillance using user-generated content. However, relatively little attention has been focused on developing ethically appropriate approaches to working with these new data sources. Objective: Based on a review of the literature, this study seeks to develop a taxonomy of public health surveillance-related ethical concepts that emerge when using Twitter data, with a view to: (1) explicitly identifying a set of potential ethical issues and concerns that may arise when researchers work with Twitter data, and (2) providing a starting point for the formation of a set of best practices for public health surveillance through the development of an empirically derived taxonomy of ethical concepts. Methods: We searched Medline, Compendex, PsycINFO, and the Philosopher’s Index using a set of keywords selected to identify Twitter-related research papers that reference ethical concepts. Our initial set of queries identified 342 references across the four bibliographic databases. We screened titles and abstracts of these references using our inclusion/exclusion criteria, eliminating duplicates and unavailable papers, until 49 references remained. We then read the full text of these 49 articles and discarded 36, resulting in a final inclusion set of 13 articles. Ethical concepts were then identified in each of these 13 articles. Finally, based on a close reading of the text, a taxonomy of ethical concepts was constructed based on ethical concepts discovered in the papers. Results: From these 13 articles, we iteratively generated a taxonomy of ethical concepts consisting of 10 top level categories: privacy, informed consent, ethical theory, institutional review board (IRB)/regulation, traditional research vs Twitter research, geographical information, researcher lurking, economic value of personal information, medical exceptionalism, and benefit of identifying socially harmful medical conditions. Conclusions: In summary, based on a review of the literature, we present a provisional taxonomy of public health surveillance-related ethical concepts that emerge when using Twitter data.

  • (cc) Fradgley et al. CC-BY-SA-2.0, please cite as http://www.jmir.org/article/viewFile/3545/1/49404. This image is of a participant navigating the Web-based survey using a touchscreen tablet device.

    Consumer Participation in Quality Improvements for Chronic Disease Care: Development and Evaluation of an Interactive Patient-Centered Survey to Identify...

    Abstract:

    Background: With increasing attention given to the quality of chronic disease care, a measurement approach that empowers consumers to participate in improving quality of care and enables health services to systematically introduce patient-centered initiatives is needed. A Web-based survey with complex adaptive questioning and interactive survey items would allow consumers to easily identify and prioritize detailed service initiatives. Objective: The aim was to develop and test a Web-based survey capable of identifying and prioritizing patient-centered initiatives in chronic disease outpatient services. Testing included (1) test-retest reliability, (2) patient-perceived acceptability of the survey content and delivery mode, and (3) average completion time, completion rates, and Flesch-Kincaid reading score. Methods: In Phase I, the Web-based Consumer Preferences Survey was developed based on a structured literature review and iterative feedback from expert groups of service providers and consumers. The touchscreen survey contained 23 general initiatives, 110 specific initiatives available through adaptive questioning, and a relative prioritization exercise. In Phase II, a pilot study was conducted within 4 outpatient clinics to evaluate the reliability properties, patient-perceived acceptability, and feasibility of the survey. Eligible participants were approached to complete the survey while waiting for an appointment or receiving intravenous therapy. The age and gender of nonconsenters was estimated to ascertain consent bias. Participants with a subsequent appointment within 14 days were asked to complete the survey for a second time. Results: A total of 741 of 1042 individuals consented to participate (71.11% consent), 529 of 741 completed all survey content (78.9% completion), and 39 of 68 completed the test-retest component. Substantial or moderate reliability (Cohen’s kappa>0.4) was reported for 16 of 20 general initiatives with observed percentage agreement ranging from 82.1%-100.0%. The majority of participants indicated the Web-based survey was easy to complete (97.9%, 531/543) and comprehensive (93.1%, 505/543). Participants also reported the interactive relative prioritization exercise was easy to complete (97.0%, 189/195) and helped them to decide which initiatives were of most importance (84.6%, 165/195). Average completion time was 8.54 minutes (SD 3.91) and the Flesch-Kincaid reading level was 6.8. Overall, 84.6% (447/529) of participants indicated a willingness to complete a similar survey again. Conclusions: The Web-based Consumer Preferences Survey is sufficiently reliable and highly acceptable to patients. Based on completion times and reading level, this tool could be integrated in routine clinical practice and allows consumers to easily participate in quality evaluation. Results provide a comprehensive list of patient-prioritized initiatives for patients with major chronic conditions and delivers practice-ready evidence to guide improvements in patient-centered care.

  • PainCoach screenshot.

    Retaining Critical Therapeutic Elements of Behavioral Interventions Translated For Delivery via the Internet: Recommendations and an Example Using Pain...

    Abstract:

    Evidence supporting the efficacy of behavioral interventions based on principles of cognitive behavioral therapies has spurred interest in translating these interventions for delivery via the Internet. However, the benefits of this dissemination method cannot be realized unless the translated interventions are as effective as possible. We describe a challenge that must be overcome to ensure this occurs—Internet interventions must retain therapeutic components and processes underlying the success of face-to-face interventions on which they are based. These components and processes vary in the ease with which they can be translated to the online environment. Moreover, some are subtle and may be overlooked, despite being recognized as essential to the success of face-to-face interventions. We provide preliminary guidance for retaining critical therapeutic components and processes in the translation process, using Pain Coping Skills Training for osteoarthritis pain to illustrate methods. Directions for future research are also discussed.

  • Virtual Reality Interior Design Application for Occupational Therapy.

    Occupational Therapists’ Views on Using a Virtual Reality Interior Design Application Within the Pre-Discharge Home Visit Process

    Abstract:

    Background: A key role of Occupational Therapists (OTs) is to carry out pre-discharge home visits (PHV) and propose appropriate adaptations to the home environment in order to enable patients to function independently after hospital discharge. However, research shows that more than 50% of specialist equipment installed as part of home adaptations is not used by patients. A key reason for this is that decisions about home adaptations are often made without adequate collaboration and consultation with the patient. Consequently, there is an urgent need to seek out new and innovative uses of technology to facilitate patient/practitioner collaboration, engagement, and shared decision making in the PHV process. Virtual reality interior design applications (VRIDAs) primarily allow users to simulate the home environment and visualize changes prior to implementing them. Customized VRIDAs, which also model specialist occupational therapy equipment, could become a valuable tool to facilitate improved patient/practitioner collaboration, if developed effectively and integrated into the PHV process. Objective: The intent of the study was to explore the perceptions of OTs with regard to using VRIDAs as an assistive tool within the PHV process. Methods: Task-oriented interactive usability sessions, utilizing the think-aloud protocol and subsequent semi-structured interviews were carried out with seven OTs who possessed significant experience across a range of clinical settings. Template analysis was carried out on the think-aloud and interview data. Analysis was both inductive and driven by theory, centering around the parameters that impact upon the acceptance, adoption, and use of this technology in practice as indicated by the Technology Acceptance Model (TAM). Results: OTs’ perceptions were identified relating to three core themes: (1) perceived usefulness (PU), (2) perceived ease of use (PEoU), and (3) actual use (AU). Regarding PU, OTs believed VRIDAs had promising potential to increase understanding, enrich communication and patient involvement, and improve patient/practitioner shared understanding. However, it was unlikely that VRIDAs would be suitable for use with cognitively impaired patients. For PEoU, all OTs were able to use the software and complete the tasks successfully; however, participants noted numerous specialist equipment items that could be added to the furniture library. AU perceptions were positive regarding use of the application across a range of clinical settings including children/young adults, long-term conditions, neurology, older adults, and social services. However, some “fine tuning” may be necessary if the application is to be optimally used in practice. Conclusions: Participants perceived the use of VRIDAs in practice would enhance levels of patient/practitioner collaboration and provide a much needed mechanism via which patients are empowered to become more equal partners in decisions made about their care. Further research is needed to explore patient perceptions of VRIDAs, to make necessary customizations accordingly, and to explore deployment of the application in a collaborative patient/practitioner-based context.

  • Illustrative photo of the intervention. Picture taken by the developers of WebChoice at Centre for Shared Decision Making and Collaborative Care Research. Licensed under Creative Commons Attribution (please cite the JMIR article).

    Comparing Effects in Regular Practice of E-Communication and Web-Based Self-Management Support Among Breast Cancer Patients: Preliminary Results From a...

    Abstract:

    Background: While Web-based interventions have been shown to assist a wide range of patients successfully in managing their illness, few studies have examined the relative contribution of different Web-based components to improve outcomes. Further efficacy trials are needed to test the effects of Web support when offered as a part of routine care. Objective: Our aim was to compare in regular care the effects of (1) an Internet-based patient provider communication service (IPPC), (2) WebChoice, a Web-based illness management system for breast cancer patients (IPPC included), and (3) usual care on symptom distress, anxiety, depression, (primary outcomes), and self-efficacy (secondary outcome). This study reports preliminary findings from 6 months’ follow-up data in a 12-month trial. Methods: We recruited 167 patients recently diagnosed with breast cancer and undergoing treatment from three Norwegian hospitals. The nurse-administered IPPC allowed patients to send secure e-messages to and receive e-messages from health care personnel at the hospital where they were treated. In addition to the IPPC, WebChoice contains components for symptom monitoring, tailored information and self-management support, a diary, and communication with other patients. A total of 20 care providers (11 nurses, 6 physicians, and 3 social workers) were trained to answer questions from patients. Outcomes were measured with questionnaires at study entry and at study months 2, 4, and 6. Linear mixed models for repeated measures were fitted to compare effects on outcomes over time. Results: Patients were randomly assigned to the WebChoice group (n=64), the IPPC group (n=45), or the usual care group (n=58). Response rates to questionnaires were 73.7% (123/167) at 2 months, 65.9 (110/167) at 4 months, and 62.3% (104/167) at 6 months. Attrition was similar in all study groups. Among those with access to WebChoice, 64% (41/64) logged on more than once and 39% (25/64) sent e-messages to care providers. In the IPPC group, 40% (18/45) sent e-messages. Linear mixed models analyses revealed that the WebChoice group reported significantly lower symptom distress (mean difference 0.16, 95% CI 0.06-0.25, P=.001), anxiety (mean difference 0.79, 95% CI 0.09-1.49, P=.03), and depression (mean difference 0.79, 95% CI 0.09-1.49, P=.03) compared with the usual care group. The IPPC group reported significant lower depression scores compared with the usual care group (mean difference 0.69, 95% CI 0.05-1.32, P=.03), but no differences were observed for symptom distress or anxiety. No significant differences in self-efficacy were found among the study groups. Conclusions: In spite of practice variations and moderate use of the interventions, our results suggest that offering Web support as part of regular care can be a powerful tool to help patients manage their illness. Our finding that a nurse-administered IPPC alone can significantly reduce depression is particularly promising. However, the multicomponent intervention WebChoice had additional positive effects. Trial Registration: Clinicaltrials.gov:NCT00971009; http://clinicaltrials.gov/show/NCT00971009 (Archived by WebCite at http://www.webcitation.org/6USKezP0Y).

  • 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.

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  • Overcoming Clinical Inertia: A Randomized Clinical Trial of a Telehealth Remote Monitoring Intervention using Paired Glucose Testing in Adults with Type 2 Diabetes

    Date Submitted: Dec 22, 2014

    Open Peer Review Period: Dec 22, 2014 - Feb 16, 2015

    Background: Type 2 diabetes is a worldwide challenge. Research indicates people with diabetes remain at suboptimal glucose control for 2.9 years from patient and provider clinical inertia limiting tr...

    Background: Type 2 diabetes is a worldwide challenge. Research indicates people with diabetes remain at suboptimal glucose control for 2.9 years from patient and provider clinical inertia limiting treatment intensification. Practice guidelines promote structured self-monitoring of blood glucose (SMBG) for informing healthcare providers about glycemic control and providing patient feedback to increase knowledge, self-efficacy, and behavior change. Paired glucose testing—pairs of glucose results obtained before and after a meal, physical activity, or other event— is one method of structured SMBG. However, frequent access to glucose data to interpret values and recommend actions is challenging. A complete feedback loop (CFL)—data collection and interpretation combined with feedback to modify treatment—has been associated with improved outcomes, yet there remains limited integration of SMBG feedback in diabetes management. Incorporating telehealth remote monitoring (RM) and asynchronous electronic health record (EHR) feedback from certified diabetes educators (CDE)—specialists in glucose pattern management—employ the CFL to improve outcomes. Objective: The purpose of this study was to evaluate a telehealth RM intervention using paired glucose testing and asynchronous data analysis in adults with type 2 diabetes. Primary aim was change in A1C—a measure of overall glucose management— between groups after six months. Secondary aims were change in self-reported Summary of Diabetes Self-Care Activities (SDSCA), Diabetes Empowerment Scale (DES), and Diabetes Knowledge Test (DKT). Methods: Methods: A two-group randomized clinical trial was conducted comparing usual care to telehealth RM with paired glucose testing and asynchronous virtual visits. Participants were 30–70 years old, not using insulin with A1C between 7.5%–10.9%. The telehealth RM tablet computer transmitted glucose data and facilitated a CFL to educate participants, analyze actionable glucose data, and provide feedback. Data from paired glucose testing were analyzed asynchronously using computer-assisted pattern analysis and were shared with patients via the EHR weekly. CDEs called participants monthly to discuss paired glucose testing trends and treatment changes. Separate mixed-effects models were used to analyze data. Results: Participants (n=90) were White (64%), mean age of 58 years, body mass index of 34.1 with diabetes for 8.2 years and mean A1C of 8.3%. Both groups lowered A1C with an estimated average decrease of 0.70 percentage points in control and 1.11 percentage points in intervention with a significant group difference of 0.41 percentage points at six months (se = 0.08, t = -2.87, P = .005). Change in medication (se =0.21, t = -3.37, P = .009) was significant on A1C. The treatment group significantly improved SDSCA subscales carbohydrate spacing (P = .04), monitoring glucose (P = .001), and foot care (P = .02). Conclusions: An e-Health model incorporating a CFL with telehealth RM and paired glucose testing with asynchronous data analysis significantly improved A1C compared to control. Clinical Trial: Clinicaltrials.gov identifier NCT01715649

  • 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.

  • 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.

  • Disease profiling for computerized peer-support of Ménière's disease

    Date Submitted: Dec 5, 2014

    Open Peer Review Period: Dec 5, 2014 - Jan 30, 2015

    Background: Peer-support is an emerging form of person driven active health care. Chronic conditions such as Ménière's disease need continuing rehabilitation and support that is beyond the scope of...

    Background: Peer-support is an emerging form of person driven active health care. Chronic conditions such as Ménière's disease need continuing rehabilitation and support that is beyond the scope of routine clinical medical practice. Hence, peer-support programs can be helpful in supplementing some of the rehabilitation aspects. Objective: The aim of this study was to design a computerized data collection system for peer-support of Menière’s disease that is capable in profiling the subject for the diagnosis and in assisting in problem solving. Methods: The expert program comprises several data entries focusing on symptoms, activity limitations, participation restrictions, quality of life, attitude and personality trait, and evaluation of disease specific impact. Data was collected from 740 members of the Finnish Ménière's Federation and utilized in constructing and evaluation of the program. Results: The program verifies the diagnosis of a person by using an expert system and the inference engine selects 50 cases with matched symptom severity by using the nearest neighboring algorithm. These are then used as a reference group to compare with person’s attitude, sense of coherence and anxiety. The program provides feedback for the person and uses this information to guide the person through the problem solving processes. Conclusions: This computer based peer-support program is the first example of an advanced computer oriented approach using artificial intelligence both in the disease profiling and in the person complaint profiling for hearing loss, tinnitus and vertigo.