JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 4.7 for 2013

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    The Electronic CardioMetabolic Program (eCMP) for Patients With Cardiometabolic Risk: A Randomized Controlled Trial


    Background: Effective lifestyle interventions targeting high-risk adults that are both practical for use in ambulatory care settings and scalable at a population management level are needed. Objective: Our aim was to examine the potential effectiveness, feasibility, and acceptability of delivering an evidence-based Electronic Cardio-Metabolic Program (eCMP) for improving health-related quality of life, improving health behaviors, and reducing cardiometabolic risk factors in ambulatory care high-risk adults. Methods: We conducted a randomized, wait-list controlled trial with 74 adults aged ≥18 years recruited from a large multispecialty health care organization. Inclusion criteria were (1) BMI ≥35 kg/m2 and prediabetes, previous gestational diabetes and/or metabolic syndrome, or (2) BMI ≥30 kg/m2 and type 2 diabetes and/or cardiovascular disease. Participants had a mean age of 59.7 years (SD 11.2), BMI 37.1 kg/m2 (SD 5.4) and were 59.5% female, 82.4% white. Participants were randomized to participate in eCMP immediately (n=37) or 3 months later (n=37). eCMP is a 6-month program utilizing video conferencing, online tools, and pre-recorded didactic videos to deliver evidence-based curricula. Blinded outcome assessments were conducted at 3 and 6 months postbaseline. Data were collected and analyzed between 2014 and 2015. The primary outcome was health-related quality of life. Secondary outcomes included biometric cardiometabolic risk factors (eg, body weight), self-reported diet and physical activity, mental health status, retention, session attendance, and participant satisfaction. Results: Change in quality of life was not significant in both immediate and delayed participants. Both groups significantly lost weight and reduced waist circumference at 6 months, with some cardiometabolic factors trending accordingly. Significant reduction in self-reported anxiety and perceived stress was seen in the immediate intervention group at 6 months. Retention rate was 93% at 3 months and 86% at 6 months post-baseline. Overall eCMP attendance was high with 59.5-83.8% of immediate and delayed intervention participants attending 50% of the virtual stress management and behavioral lifestyle sessions and 37.8-62.2% attending at least 4 out of 7 in-person physical activity sessions. The intervention received high ratings for satisfaction. Conclusions: The technology-assisted eCMP is a feasible and well-accepted intervention and may significantly decrease cardiometabolic risk among high-risk individuals. Trial Registration: NCT02246400; (Archived by WebCite at

  • Health_SQ_by_using_wearables. Image created, sourced and copyright owned by Manal Almalki et al.

    Activity Theory as a Theoretical Framework for Health Self-Quantification: A Systematic Review of Empirical Studies


    Background: Self-quantification (SQ) is a way of working in which, by using tracking tools, people aim to collect, manage, and reflect on personal health data to gain a better understanding of their own body, health behavior, and interaction with the world around them. However, health SQ lacks a formal framework for describing the self-quantifiers’ activities and their contextual components or constructs to pursue these health related goals. Establishing such framework is important because it is the first step to operationalize health SQ fully. This may in turn help to achieve the aims of health professionals and researchers who seek to make or study changes in the self-quantifiers’ health systematically. Objective: The aim of this study was to review studies on health SQ in order to answer the following questions: What are the general features of the work and the particular activities that self-quantifiers perform to achieve their health objectives? What constructs of health SQ have been identified in the scientific literature? How have these studies described such constructs? How would it be possible to model these constructs theoretically to characterize the work of health SQ? Methods: A systematic review of peer-reviewed literature was conducted. A total of 26 empirical studies were included. The content of these studies was thematically analyzed using Activity Theory as an organizing framework. Results: The literature provided varying descriptions of health SQ as data-driven and objective-oriented work mediated by SQ tools. From the literature, we identified two types of SQ work: work on data (ie, data management activities) and work with data (ie, health management activities). Using Activity Theory, these activities could be characterized into 6 constructs: users, tracking tools, health objectives, division of work, community or group setting, and SQ plan and rules. We could not find a reference to any single study that accounted for all these activities and constructs of health SQ activity. Conclusions: A Health Self-Quantification Activity Framework is presented, which shows SQ tool use in context, in relation to the goals, plans, and competence of the user. This makes it easier to analyze issues affecting SQ activity, and thereby makes it more feasible to address them. This review makes two significant contributions to research in this field: it explores health SQ work and its constructs thoroughly and it adapts Activity Theory to describe health SQ activity systematically.

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    Web-based Discussion Forums on Pregnancy Complaints and Maternal Health Literacy in Norway: A Qualitative Study


    Background: The Internet is one of the fastest growing information sources for pregnant women and seems to be used across social and economic strata. However, we still lack knowledge on how interaction in Web-based discussion forums influence maternal health literacy, in terms of how pregnant women access, appraise, and apply information to promote and maintain good health. Objective: The aim of this study was to understand how Web-based discussion forums influence maternal health literacy; hence, we explored the role of interactions in Web-based discussion forums among women who experienced health problems during pregnancy. More specifically, we explored why media-literate women experiencing the medically unexplained condition, pelvic girdle pain (PGP), during pregnancy participated in Web-based discussion forums and how they appraised and applied the information and advice that they gained from the Web-based interaction with other women. Methods: Women were invited to participate in the study via postings on 3 different open websites for pregnant women and mothers. The sample included 11 Norwegian women who participated in open Web-based discussion forums when experiencing PGP in pregnancy. The data were collected using synchronous qualitative email interviews and were analyzed using thematic analysis. Results: In our study sample, interaction in Web-based discussion forums influenced maternal health literacy in terms of increased health-related knowledge and competencies, increased awareness of health promotion and health protection, and increased system navigation. The women appraised and selectively applied information and advice that resonated with their own experiences. For many, the information provided online by other women in the same situation was valued more highly than advice from health professionals. Women reported that they used their knowledge and competency in encounters with health professionals but hesitated to disclose the origin of their knowledge. Those with a high level of education in medicine-related fields raised a concern about the Internet as a source of horror stories and erroneous information and were actively engaged in trying to minimize potential negative effects, by providing biomedical information. Conclusions: The popularity of Web-based discussion forums among pregnant women suggests that this group needs additional sources of information and support to complement traditional consultations with the health professionals. The professionals need to recognize that pregnant women access Web-based discussion forums for support and information to increase their ability to take better health decisions for themselves. This is a potential resource that health professionals may find useful in consultations with pregnant women.

  • eCare_4_eSKC program. Source and copyright: the authors.

    Patient-Reported Safety Events in Chronic Kidney Disease Recorded With an Interactive Voice-Inquiry Dial-Response System: Monthly Report Analysis


    Background: Monitoring patient-reported outcomes (PROs) may improve safety of chronic kidney disease (CKD) patients. Objective: Evaluate the performance of an interactive voice-inquiry dial-response system (IVRDS) in detecting CKD-pertinent adverse safety events outside of the clinical environment and compare the incidence of events using the IVDRS to that detected by paper diary. Methods: This was a 6-month study of Stage III-V CKD patients in the Safe Kidney Care (SKC) study. Participants crossed over from a paper diary to the IVDRS for recording patient-reported safety events defined as symptoms or events attributable to medications or care. The IVDRS was adapted from the SKC paper diary to record event frequency and remediation. Participants were auto-called weekly and permitted to self-initiate calls. Monthly reports were reviewed by two physician adjudicators for their clinical significance. Results: 52 participants were followed over a total of 1384 weeks. 28 out of 52 participants (54%) reported events using the IVDRS versus 8 out of 52 (15%) with the paper diary; hypoglycemia was the most common event for both methods. All IVDRS menu options were selected at least once except for confusion and rash. Events were reported on 121 calls, with 8 calls reporting event remediation by ambulance or emergency room (ER) visit. The event rate with the IVDRS and paper diary, with and without hypoglycemia, was 26.7 versus 4.7 and 18.3 versus 0.8 per 100 person weeks, respectively (P=.002 and P<.001). The frequent users (ie, >10 events) largely differed by method, and event rates excluding the most frequent user of each were 16.9 versus 2.5 per 100 person weeks, respectively (P<.001). Adjudicators found approximately half the 80 reports clinically significant, with about a quarter judged as actionable. Hypoglycemia was often associated with additional reports of fatigue and falling. Participants expressed favorable satisfaction with the IVDRS. Conclusions: Use of the IVDRS among CKD patients reveals a high frequency of clinically significant safety events and has the potential to be used as an important supplement to clinical care for improving patient safety.

  • Image Source: Woman laptop,, Copyright Tina Franklin, Licensed under CC-BY 2.0.

    Readability Analysis of the Package Leaflets for Biological Medicines Available on the Internet Between 2007 and 2013: An Analytical Longitudinal Study


    Background: The package leaflet included in the packaging of all medicinal products plays an important role in the transmission of medicine-related information to patients. Therefore, in 2009, the European Commission published readability guidelines to try to ensure that the information contained in the package leaflet is understood by patients. Objective: The main objective of this study was to calculate and compare the readability levels and length (number of words) of the package leaflets for biological medicines in 2007, 2010, and 2013. Methods: The sample of this study included 36 biological medicine package leaflets that were downloaded from the European Medicines Agency website in three different years: 2007, 2010, and 2013. The readability of the selected package leaflets was obtained using the following readability formulas: SMOG grade, Flesch-Kincaid grade level, and Szigriszt’s perspicuity index. The length (number of words) of the package leaflets was also measured. Afterwards, the relationship between these quantitative variables (three readability indexes and length) and categorical (or qualitative) variables were analyzed. The categorical variables were the year when the package leaflet was downloaded, the package leaflet section, type of medicine, year of authorization of biological medicine, and marketing authorization holder. Results: The readability values of all the package leaflets exceeded the sixth-grade reading level, which is the recommended value for health-related written materials. No statistically significant differences were found between the three years of study in the readability indexes, although differences were observed in the case of the length (P=.002), which increased over the study period. When the relationship between readability indexes and length and the other variables was analyzed, statistically significant differences were found between package leaflet sections (P<.001) and between the groups of medicine only with regard to the length over the three studied years (P=.002 in 2007, P=.007 in 2010, P=.009 in 2013). Linear correlation was observed between the readability indexes (SMOG grade and Flesch-Kincaid grade level: r2=.92; SMOG grade and Szigriszt’s perspicuity index: r2=.81; Flesch-Kincaid grade level and Szigriszt’s perspicuity index: r2=.95), but not between the readability indexes and the length (length and SMOG grade: r2=.05; length and Flesch-Kincaid grade level: r2=.03; length and Szigriszt’s perspicuity index: r2=.02). Conclusions: There was no improvement in the readability of the package leaflets studied between 2007 and 2013 despite the European Commission’s 2009 guideline on the readability of package leaflets. The results obtained from the different readability formulas coincided from a qualitative point of view. Efforts to improve the readability of package leaflets for biological medicines are required to promote the understandability and accessibility of this online health information by patients and thereby contribute to the appropriate use of medicines and medicine safety.

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    Effectiveness of a Web-Based Screening and Fully Automated Brief Motivational Intervention for Adolescent Substance Use: A Randomized Controlled Trial


    Background: Mid-to-late adolescence is a critical period for initiation of alcohol and drug problems, which can be reduced by targeted brief motivational interventions. Web-based brief interventions have advantages in terms of acceptability and accessibility and have shown significant reductions of substance use among college students. However, the evidence is sparse among adolescents with at-risk use of alcohol and other drugs. Objective: This study evaluated the effectiveness of a targeted and fully automated Web-based brief motivational intervention with no face-to-face components on substance use among adolescents screened for at-risk substance use in four European countries. Methods: In an open-access, purely Web-based randomized controlled trial, a convenience sample of adolescents aged 16-18 years from Sweden, Germany, Belgium, and the Czech Republic was recruited using online and offline methods and screened online for at-risk substance use using the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening instrument. Participants were randomized to a single session brief motivational intervention group or an assessment-only control group but not blinded. Primary outcome was differences in past month drinking measured by a self-reported AUDIT-C-based index score for drinking frequency, quantity, and frequency of binge drinking with measures collected online at baseline and after 3 months. Secondary outcomes were the AUDIT-C-based separate drinking indicators, illegal drug use, and polydrug use. All outcome analyses were conducted with and without Expectation Maximization (EM) imputation of missing follow-up data. Results: In total, 2673 adolescents were screened and 1449 (54.2%) participants were randomized to the intervention or control group. After 3 months, 211 adolescents (14.5%) provided follow-up data. Compared to the control group, results from linear mixed models revealed significant reductions in self-reported past-month drinking in favor of the intervention group in both the non-imputed (P=.010) and the EM-imputed sample (P=.022). Secondary analyses revealed a significant effect on drinking frequency (P=.037) and frequency of binge drinking (P=.044) in the non-imputation-based analyses and drinking quantity (P=.021) when missing data were imputed. Analyses for illegal drug use and polydrug use revealed no significant differences between the study groups (Ps>.05). Conclusions: Although the study is limited by a large drop-out, significant between-group effects for alcohol use indicate that targeted brief motivational intervention in a fully automated Web-based format can be effective to reduce drinking and lessen existing substance use service barriers for at-risk drinking European adolescents. Trial Registration: International Standard Randomized Controlled Trial Registry: ISRCTN95538913; (Archived by WebCite at

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    Medical Tourism and Telemedicine: A New Frontier of an Old Business

    Authors List:


    In October 2015, the “Chinese American Physicians E-Hospital” celebrated its “grand opening” online. All physicians affiliated with this E-Hospital are bilingual Chinese American physicians, who provide services ranging from initial teleconsulting to international transfer and treatment in the United States. Such telemedicine platform for medical tourism not only saves the patients from the hassles of identifying and connecting with an appropriate health service provider but also minimizes the language and cultural barriers. As a growing number of patients from middle- and low-income countries travel to the United States (US) for medical care, we face promising opportunities as well as mounting challenges. The Centers for Disease Control (CDC) in the US has guidance for Americans seeking care overseas, but is not available for international patients seeking care in US. This article opens a dialogue on the challenges associated with flourishing medical tourism and telemedicine, including quality assessment, risk communication, ethical guidelines, and legal concerns.

  • Image source: (c) Ken Banks,, licensed under cc-by 2.0.

    Potential Reach of mHealth Versus Traditional Mass Media for Prevention of Chronic Diseases: Evidence From a Nationally Representative Survey in a...


    Background: Public radio and television announcements have a long tradition in public health education. With the global rise of computer and mobile device ownership, short message service (SMS) and email-based health services (mHealth) are promising new tools for health promotion. Objective: Our objectives were to examine 1) self-reported exposure to programs related to noncommunicable diseases (NCDs) on national public television and radio during the 12 months preceding the survey (2013–2014), 2) current ownership of a mobile phone, smartphone, computer, or tablet, and use of the Internet, and 3) willingness of individuals to receive SMS or emails with information on health, with a focus on distribution of these variables across different demographic, socioeconomic status (SES), and NCD risk groups. Methods: We obtained data in a population survey of 1240 participants aged 25–64 years conducted in 2013–2014 in the Seychelles, a rapidly developing small island state in the African region. We administered a structured questionnaire and measured NCD risk factors. Univariate and multivariate analyses explored the relationships between outcomes and sociodemographic variables. Results: Of 1240 participants, 1037 (83.62%) reported exposure to NCD-related programs on public television, while a lower proportion of 740 adults (59.67%), reported exposure via public radio (P <.001). Exposure to NCD-related programs on public television was associated with older age (P <.001) and female sex (P <.001), but not with SES, while exposure to NCD-related programs on public radio was associated with older age (P <.001) and lower SES (P <.001). A total of 1156 (93.22%) owned a mobile phone and ownership was positively associated with female sex (P <.001), younger age (P <.001), and higher SES (P <.001). Only 396 adults (31.93%) owned a smartphone and 244 adults (19.67%) used their smartphone to access the Internet. A total of 1048 adults (84.51%) reported willingness to receive health-related SMS, which was positively associated with female sex (P <.001), younger age (P <.001), and higher SES (P <.001). Controlling for SES, exposure to NCD-related programs on public television or radio and willingness to receive health-related SMS were not independently associated with a person’s NCD risk. Conclusions: Broadcasting health programs through traditional mass media (national public radio and television) reached the majority of the population under study, including older adults and those in lower socioeconomic groups. With a high penetration of mobile phones and willingness to receive health-related SMS, mHealth presents an opportunity for health programs, especially when targeted SMS messages are intended for younger adults and those in higher socioeconomic groups. By contrast, due to reduced Internet access, email-based programs had a more limited reach for health promotion programs. These findings emphasize the different reach of interventions using SMS or email versus traditional mass media, according to demographic and socioeconomic categories, for health education programs in a developing country.

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    Preexposure Prophylaxis Modality Preferences Among Men Who Have Sex With Men and Use Social Media in the United States


    Background: Preexposure prophylaxis (PrEP) is available as a daily pill for preventing infection with the human immunodeficiency virus (HIV). Innovative methods of administering PrEP systemically or topically are being discussed and developed. Objective: The objective of our study was to assess attitudes toward different experimental modalities of PrEP administration. Methods: From April to July 2015, we recruited 1106 HIV-negative men who have sex with men through online social media advertisements and surveyed them about their likelihood of using different PrEP modalities. Participants responded to 5-point Likert-scale items indicating how likely they were to use each of the following PrEP modalities: a daily oral pill, on-demand pills, periodic injection, penile gel (either before or after intercourse), rectal gel (before/after), and rectal suppository (before/after). We used Wilcoxon signed rank tests to determine whether the stated likelihood of using any modality differed from daily oral PrEP. Related items were combined to assess differences in likelihood of use based on tissue or time of administration. Participants also ranked their interest in using each modality, and we used the modified Borda count method to determine consensual rankings. Results: Most participants indicated they would be somewhat likely or very likely to use PrEP as an on-demand pill (685/1105, 61.99%), daily oral pill (528/1036, 50.97%), injection (575/1091, 52.70%), or penile gel (438/755, 58.01% before intercourse; 408/751, 54.33% after). The stated likelihoods of using on-demand pills (median score 4) and of using a penile gel before intercourse (median 4) were both higher than that of using a daily oral pill (median 4, P<.001 and P=.001, respectively). Compared with a daily oral pill, participants reported a significantly lower likelihood of using any of the 4 rectal modalities (Wilcoxon signed rank test, all P<.001). On 10-point Likert scales created by combining application methods, the reported likelihood of using a penile gel (median 7) was higher than that of using a rectal gel (median 6, P<.001), which was higher than the likelihood of using a rectal suppository (median 6, P<.001). The modified Borda count ranked on-demand pills as the most preferred modality. There was no difference in likelihood of use of PrEP (gel or suppository) before or after intercourse. Conclusions: Participants typically prefer systemic PrEP and are less likely to use a modality that is administered rectally. Although most of these modalities are seen as favorable or neutral, attitudes may change as information about efficacy and application becomes available. Further data on modality preference across risk groups will better inform PrEP development.

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    Exploring the Utility of Web-Based Social Media Advertising to Recruit Adult Heavy-Drinking Smokers for Treatment


    Background: Identifying novel ways to recruit smokers for treatment studies is important. In particular, certain subgroups of adult smokers, such as heavy-drinking smokers, are at increased risk for serious medical problems and are less likely to try quitting smoking, so drawing this hard-to-reach population into treatment is important for improving health outcomes. Objective: This study examined the utility of Facebook advertisements to recruit smokers and heavy-drinking smokers for treatment research and evaluated smoking and alcohol use and current treatment goals among those who responded to the Web-based survey. Methods: Using Facebook’s advertising program, 3 separate advertisements ran for 2 months targeting smokers who were thinking about quitting. Advertisements were shown to adult (at least 18 years of age), English-speaking Facebook users in the greater New Haven, Connecticut, area. Participants were invited to complete a Web-based survey to determine initial eligibility for a smoking cessation research study. Results: Advertisements generated 1781 clicks and 272 valid, completed surveys in 2 months, with one advertisement generating the most interest. Facebook advertising was highly cost-effective, averaging $0.27 per click, $1.76 per completed survey, and $4.37 per participant meeting initial screening eligibility. On average, those who completed the Web-based survey were 36.8 (SD 10.4) years old, and 65.8% (179/272) were female. Advertisements were successful in reaching smokers; all respondents reported daily smoking (mean 16.2 [SD 7.0] cigarettes per day). The majority of smokers (254/272, 93.4%) were interested in changing their smoking behavior immediately. Many smokers (161/272, 59.2%) also reported heavy alcohol consumption at least once a month. Among smokers interested in reducing their alcohol use, more were heavy drinkers (45/56, 80.4%) compared to non-heavy drinkers (11/56, 19.6%; χ2[1,N=272]=13.0, P<.001). Of those who met initial screening eligibility from the Web-based survey, 12.7% (14/110) attended an in-person follow-up appointment. Conclusions: Social media advertisements designed to target smokers were cost-effective and successful for reaching adult smokers interested in treatment. Additionally, recruiting for smokers reached those who also drink alcohol heavily, many of whom were interested in changing this behavior as well. However, additional social media strategies may be needed to engage individuals into treatment after completion of Web-based screening surveys.

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    Applying Multiple Methods to Comprehensively Evaluate a Patient Portal’s Effectiveness to Convey Information to Patients


    Background: Patient portals have yet to achieve their full potential for enhancing health communication and improving health outcomes. Although the Patient Protection and Affordable Care Act in the United States mandates the utilization of patient portals, and usage continues to rise, their impact has not been as profound as anticipated. Objective: The objective of our case study was to evaluate how well portals convey information to patients. To demonstrate how multiple methodologies could be used to evaluate and improve the design of patient-centered portals, we conducted an in-depth evaluation of an exemplar patient-centered portal designed to promote preventive care to consumers. Methods: We used 31 critical incident patient interviews, 2 clinician focus groups, and a thematic content analysis to understand patients’ and clinicians’ perspectives, as well as theoretical understandings of the portal’s use. Results: We gathered over 140 critical incidents, 71.8% (102/142) negative and 28.2% (40/142) positive. Positive incident categories were (1) instant medical information access, (2) clear health information, and (3) patient vigilance. Negative incident categories were (1) standardized content, (2) desire for direct communication, (3) website functionality, and (4) difficulty interpreting laboratory data. Thematic analysis of the portal’s immediacy resulted in high scores in the attributes enhances understanding (18/23, 78%), personalization (18/24, 75%), and motivates behavior (17/24, 71%), but low levels of interactivity (7/24, 29%) and engagement (2/24, 8%). Two overarching themes emerged to guide portal refinements: (1) communication can be improved with directness and interactivity and (2) perceived personalization must be greater to engage patients. Conclusions: Results suggest that simple modifications, such as increased interactivity and personalized messages, can make portals customized, robust, easily accessible, and trusted information sources.

  • Image Source: Communication, copyright Anne Worner,, CC-BY 2.0.

    The Effectiveness of Self-Management Mobile Phone and Tablet Apps in Long-term Condition Management: A Systematic Review


    Background: Long-term conditions and their concomitant management place considerable pressure on patients, communities, and health care systems worldwide. International clinical guidelines on the majority of long-term conditions recommend the inclusion of self-management programs in routine management. Self-management programs have been associated with improved health outcomes; however, the successful and sustainable transfer of research programs into clinical practice has been inconsistent. Recent developments in mobile technology, such as mobile phone and tablet computer apps, could help in developing a platform for the delivery of self-management interventions that are adaptable, of low cost, and easily accessible. Objective: We conducted a systematic review to assess the effectiveness of mobile phone and tablet apps in self-management of key symptoms of long-term conditions. Methods: We searched PubMed, Embase, EBSCO databases, the Cochrane Library, and The Joanna Briggs Institute Library for randomized controlled trials that assessed the effectiveness of mobile phone and tablet apps in self-management of diabetes mellitus, cardiovascular disease, and chronic lung diseases from 2005–2016. We searched registers of current and ongoing trials, as well as the gray literature. We then checked the reference lists of all primary studies and review papers for additional references. The last search was run in February 2016. Results: Of the 9 papers we reviewed, 6 of the interventions demonstrated a statistically significant improvement in the primary measure of clinical outcome. Where the intervention comprised an app only, 3 studies demonstrated a statistically significant improvement. Interventions to address diabetes mellitus (5/9) were the most common, followed by chronic lung disease (3/9) and cardiovascular disease (1/9). A total of 3 studies included multiple intervention groups using permutations of an intervention involving an app. The duration of the intervention ranged from 6 weeks to 1 year, and final follow-up data ranged from 3 months to 1 year. Sample size ranged from 48 to 288 participants. Conclusions: The evidence indicates the potential of apps in improving symptom management through self-management interventions. The use of apps in mHealth has the potential to improve health outcomes among those living with chronic diseases through enhanced symptom control. Further innovation, optimization, and rigorous research around the potential of apps in mHealth technology will move the field toward the reality of improved health care delivery and outcomes.

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  • Which Doctor to Trust: A Recommender System for Identifying the Right Doctors

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jun 2, 2016

    Background: In the field of medical/health informatics, it is critical to identify key opinion leaders (KOLs) on different diseases. KOLs refer to the people who have the ability in influencing public...

    Background: In the field of medical/health informatics, it is critical to identify key opinion leaders (KOLs) on different diseases. KOLs refer to the people who have the ability in influencing public opinions on the subject matter for which the opinion leaders have the authority. This is important for both health industry and patients. However, no study has tried to solve this issue systematically. Objective: We aim to develop a recommender system for identifying KOLs for any specific disease with the methods of healthcare data mining methods. Methods: In this paper, an unsupervised aggregation approach is exploited for integrating these ranking features to find the right doctors who have the reputation as KOLs on different diseases. Furthermore, we introduce the design, implementation, and deployment details of the recommender system. In this system, the professional footprints of doctors, such as articles in scientific journals, presentation activities, patient advocacy, and media exposure, are collected and used as ranking features for KOL identification. Results: We collect and exploit a large amount of public information (as much as 3,657,797 medical journal articles) related to almost all doctors (as much as 2, 381, 750 doctors) in China, including their profiles, academic publications, funding, etc. Comparative experiments have been done on the datasets and demonstrate that the proposed system outperforms several benchmark systems with similar purpose with a significant margin. Moreover, a case study is performed in real-world system to verify the reasonableness of our proposed method. Conclusions: The results suggest that doctor profile and academic publication are useful data sources for identifying key opinion leaders in the field of medical/health informatics. Moreover, the recommender system has been deployed and applied the data service for a recommender system of NetEase. Patients could obtain authority ranking lists of doctors with this system. Clinical Trial: As this was a research on method and application of doctor recommendation, no patients were involved and no intervention was performed, thus trial was not registered.

  • A feasibility study piloting a randomised controlled trial of computerised Cognitive Behavioural Therapy to treat emotional distress after stroke.

    Date Submitted: May 23, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: Depression and anxiety are common complications following stroke. Symptoms may be treatable with psychological therapy but there is little evidence-base. Aims: To investigate the accept...

    Background: Depression and anxiety are common complications following stroke. Symptoms may be treatable with psychological therapy but there is little evidence-base. Aims: To investigate the acceptability and feasibility of computerised Cognitive Behavioural Therapy (cCBT) to treat symptoms of depression and anxiety in the context of using Randomised Controlled Trial methodology as means of piloting assessment of efficacy. Method: Of 133 people screened for symptoms of depression and anxiety following stroke, 28 were cluster randomised in blocks with an allocation ratio 2:1 to cCBT (n=19) or an active comparator (n=9). Qualitative and quantitative feedback was sought on the acceptability and feasibility of the interventions, alongside measuring levels of depression, anxiety and activities of daily living (ADLs) before, after and three-months post treatment. Results: Overall, our protocol design is reasonable; both interventions were considered appropriate, accessible and useful (ranging from 50-87.5%), and participants tolerated randomisation. Drop-out rates were in line with similar trials, with only a small proportion of participants (n=3) discontinuing due to potential adverse effects. Adaptations were required to the protocol for recruiting people who are further post-stroke, and future studies may wish to control for those receiving medical interventions for mood. Descriptive statistics of the proposed outcome measures are reported and qualitative feedback about the cCBT intervention is discussed. Conclusions: A pragmatic approach is required to deliver online interventions to accommodate individual needs. We report on a protocol that should inform the development of a full RCT for testing the efficacy of cCBT for people with long-term neurological conditions; a potentially promising way of improving accessibility of psychological support.

  • Quantifying app store dynamics: longitudinal tracking of mental health apps

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: For many mental health conditions, mobile health apps offer the ability to deliver information, support, and intervention outside the clinical setting. However, there are difficulties with...

    Background: For many mental health conditions, mobile health apps offer the ability to deliver information, support, and intervention outside the clinical setting. However, there are difficulties with the use of a commercial app store to distribute healthcare resources, including turnover of apps, irrelevance of apps, and discordance with evidence-based practice. Objective: The primary aim of this study was to quantify the longevity and rate of turnover of mental health apps within the Android and iOS app stores. The secondary aim was to quantify the proportion of apps which are clinically relevant, and assess whether the longevity of these apps differ from non-clinically relevant apps. The third aim was to establish the proportion of clinically relevant apps which include claims of clinical effectiveness. Additional sub-group analyses were performed using additional data from the app store including search result ranking, user ratings, and number of downloads. Methods: The Google Play and iTunes app stores were searched each day over a nine-month period for apps related to depression, bipolar disorder, and suicide. Additional app-specific searches were performed if an app no longer appeared within the main search results. The time period for 50% of search results to change was calculated, along with the time period for 50% of the apps to no longer be downloadable. App store descriptions were manually screened for clinical relevance and claims of effectiveness. Results: On the Android platform, 50% of the search results changed after 130 days (depression), 195 days (bipolar disorder), and 115 days (suicide). Search results were more stable on iOS, with 50% of the search results remaining at the end of the study period. Approximately 75% of Android and 90% of iOS apps were still available to download at the end of the study. Only 35% of apps were identified as being clinically relevant, of which nine (2.6%) claimed clinical effectiveness. Only three included a full citation to a published study. Conclusions: The mental health app environment is volatile, with a clinically-relevant apps for depression becoming unavailable to download every 2.9 days. This poses challenges for consumers and clinicians seeking relevant and long-term apps, as well as researchers seeking to evaluate the evidence base for publicly available apps. Clinical Trial: n/a

  • “I always vet things”: Navigating privacy and the presentation of self on health discussion boards amongst individuals with long term conditions

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: The ethics of research into online communities is a long debated issue, with many researchers arguing that open access discussion groups are publically accessible data and do not require i...

    Background: The ethics of research into online communities is a long debated issue, with many researchers arguing that open access discussion groups are publically accessible data and do not require informed consent from participants for their use in research purposes. However, it has been suggested that there is a discrepancy between the perceived and actual privacy of user-generated online content by community members. Objective: There has been very little research regarding how privacy is experienced and enacted online. This study aims to address this gap by qualitatively exploring the expectations of privacy on internet forums among individuals with long term conditions. Methods: Semi-structured interviews were conducted with 20 participants with ME/CFS and 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups. Results: The findings indicate that privacy online is a nebulous concept. Rather than individuals drawing a clear-cut distinction between what they would and would not be comfortable sharing online, it was evident that these situations were contextually dependent and related to a number of unique and individual factors. Conclusions: Interviewees were seen to carefully manage how they presented themselves on forums, filtering and selecting the information that they shared about themselves in order to develop and maintain a particular online persona, while maintaining and preserving an acceptable level of privacy.

  • The Effectiveness of an On-line Training Program for Improving Fire Knowledge of Healthcare Workers: A Randomized Controlled Trial

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: Fire disaster in hospitals can cause serious consequences. However, due to the busy schedule of healthcare workers, fire drills in hospitals are often difficult to achieve high attendance...

    Background: Fire disaster in hospitals can cause serious consequences. However, due to the busy schedule of healthcare workers, fire drills in hospitals are often difficult to achieve high attendance rate. Objective: We carried out and examined the effectiveness of an on-line fire knowledge training for healthcare workers in China. Methods: 128 participants were recruited between December 2014 to March 2015 by convenient sampling from five public hospitals in Chengdu, Kunming, Jingzhou, and Fuzhou in China. We built a webpage which includes the informed consent, pre-test questionnaire, video training, and post-test questionnaire. After completing the pre-test questionnaire, participants will be randomly assigned in 1:1 ratio by the webpage to watch one of the two videos. Those in the intervention group were watching a 14-min video showing the basic response to a hospital fire and patient evacuation methods, while those in the control group were watching a 6-min video introducing volcanic disasters. A questionnaire consisted of 45 items on fire knowledge was implemented before and after the video watching. The fire knowledge items can be further divided into two subscales, the first one consists of 25 items on generic knowledge of fire response, including prevention and disposal and the second one consists of 20 items on hospital-specific knowledge related to dealing with a hospital fire and selecting equipment under a fire emergency in a hospital. One point was awarded for each correct answer and no point was awarded for each wrong answer. Results: Half of the participants (n=64, 50%) was randomized into intervention group and the remaining 64 (50%) was randomized into control group. All of them complete the pre-test and pro-test questionnaire. For generic fire knowledge, those in the intervention group improved significantly (from 16.16 to 20.44, P < 0.001) while those in the control group decreased significantly (from 15.27 to 13.70, P = 0.03). For hospital-specific fire knowledge, those in the intervention group (from 10.75 to 11.33, P = 0.15) and the control group (from 10.38 to 10.16, P = 0.54) had insignificant change. For total score, those in the intervention group improved significantly (from 26.91 to 31.77, P < 0.001) while those in the control group decreased insignificantly (from 25.64 to 23.86, P = 0.07). After the intervention, the difference between intervention group and control group of all the three fire knowledge scores were significant (all Ps < 0.05). Conclusions: To conclude, on-line fire training program by watching educational video can effectively improve healthcare workers’ knowledge of fire prevention and evacuation. Clinical Trial: NCT02438150;

  • Young people, Adult worries: a randomised controlled feasibility study of the internet-based self-support method “Feel the ViBe” for adolescents and young adults exposed to family violence.

    Date Submitted: May 20, 2016

    Open Peer Review Period: May 20, 2016 - Jul 15, 2016

    Background: Children growing up in families where violence occurs are (almost) always exposed to this violence with severe consequences for physical, emotional and behavioural development. Peer suppor...

    Background: Children growing up in families where violence occurs are (almost) always exposed to this violence with severe consequences for physical, emotional and behavioural development. Peer support is recognized effective to change behaviour and the internet considered most suitable as mode of delivery. Objective: RCT and feasibility of the internet-based self-support method “Feel the ViBe (FtV)”, choosing efficacy, demand, acceptability, implementation, and practicality as focus. Feasibility studies aim to fully understand strengths and weaknesses of a new intervention, evaluating both efficacy and effectiveness. Methods: Adolescents and young adults aged 12-25 exposed to family violence, were randomized in an intervention group (access to FtV + usual care), and a control group (minimally enhanced usual care) after they self-registered themselves for participation. Between June 2012 and July 2014, participants completed the Impact of Event Scale and the Depression and Anxiety subscales of the Symptom CheckList-90R every 6 weeks. The Web Evaluation Questionnaire was completed after twelve weeks. All questionnaires were self-assessed, without face-to-face components. During the whole study period, quantitative usage data was collected using Google analytics and CMS logs and data files. UNIANOVA, Mixed Model analysis and Paired sample t-tests were used to compare groups. Feasibility measures were used to structurally address the findings. Results: 31 out of 46 participants in the Intervention group and 26 out of 47 participants in the Control group started FtV. After receiving full access 24 users used FtV for 24 weeks or longer, reporting a mean online time of 2.83 with a mean online session time of 36 minutes. Acceptability was good: FtV was rated a mean 7.47 (1-10 Likert scale) with a helpfulness score of 3.16 (1-5 Likert scale). All participants felt safe. 17 participants (I n=8, C n=9) completed all questionnaires. IES outcomes showed no significant differences between groups. Mixed model analysis showed significant differences between groups on the SCL-90 DEP (p=0.041) and ANX (p=0.049) subscales between six and twelve weeks after participation started. UNIANOVA showed no significant differences. Pre-post test paired sample t-tests for the SCL-90 DEP (p=0.034) and SCL-90 ANX (p=0.046) subscales showed significant improvements after twelve weeks. General knowledge of regular healthcare was low, but after twelve weeks, two thirds of the intervention participants started regular healthcare. Conclusions: FtV functions best as a first step for adolescents and young adults in an early stage of change and shows promising results. Preset goals for FtV have been met. No changes on the IES were found. SCL-90 DEP and ANX show promising results, however, the calculated sample size was not reached (n=18). FtV can be easily implemented without extensive resources. FtV should be implemented in the field of public healthcare or national governmental care. Clinical Trial: This randomized feasibility study is conducted in the Netherlands, registered in The Netherlands National Trial Register (NTR) and assigned the trial ID NTR3692.