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

Developing a mHealth Campaign: Utilizing Principles of Health Communications

Mobile health (mHealth), or the use of mobile devices to improve health, is increasingly used as a powerful campaign tool in health communications. However, there is few peer-reviewed literature outlining how a mHealth campaign can be developed according to established principles of health communications. We outline ten steps to guide campaign development, followed by an exemplar detailing how the steps can be used in an example campaign.


Call for Abstracts is Now Open. Submission Deadline: May 14 at 6pm EST

APRIL 1, 2015, BOSTON, MA -- The Connected Health Symposium, hosted annually by Partners HealthCare, today announced it has established a joint program with JMIR Publications to feature up to 50 poster presentations at this year's Symposium. JMIR Publications is the leading ehealth publisher, with over ten academic journals covering digital health, technology and innovation in health. Its flagship journal, the Journal of Medical Internet Research (JMIR), is the leading publication in the fields of medical informatics, health sciences and services research.

"There is important research being conducted throughout the connected health ecosystem that we can learn from and which deserves recognition. Academics, startups and other innovators will now have a stage to showcase their work at our annual Connected Health Symposium," said Kamal Jethwani, MD, MPH, Senior Director of Connected Health Innovation at Partners HealthCare. "We are very pleased to be working with JMIR Publications, publisher of the largest and most cited journals in ehealth."

As part of this new joint program, JMIR, along with members of the Partners Connected Health Innovation team, will review and select abstracts to be featured in a new poster session at the upcoming Connected Health Symposium. Poster presenters will receive complimentary registration to the Connected Health Symposium. Authors of accepted abstracts will also have an opportunity to submit papers for review and possible publication in JMIR and its sister journals (e.g. JMIR Medical Informatics, JMIR mHealth, JMIR Serious Games, JMIR Rehab, JMIR Mental Health, JMIR Public Health, JMIR Research Protocols and others) at a highly discounted rate.

"The Connected Health Symposium is a destination for discussion, learnings and innovation to advance the adoption and integration of connected health strategies," added Susan Lane, RN, MSN, MBA, Senior Director, Connected Health Operations, Partners HealthCare. "With the addition of this poster session, we are furthering our mission to highlight cutting-edge, novel and scalable programs to over 1,000 attendees at our Symposium, including clinicians, investors, innovators and academicians."

Abstracts must be submitted by May 14, 2015  (6pm EST) at An extended abstract (up to 5 pages) must be also be submitted (template at

For full submission details, please see the call for papers at

“We are thrilled to be involved in selecting the best research submissions for the Connected Health Symposium and to be the official publisher of this conference,” said Gunther Eysenbach, MD, MPH, FACMI, Publisher and Editor-in-Chief of the Journal of Medical Internet Research and its ten sister journals. “The partnership with the Connected Health Symposium is a logical extension of our strategy to partner with the leading knowledge translation initiatives in this field with the ultimate goal to advance ehealth and to expand our unique network of leading researchers in this field.”  

The 12th Annual Connected Health Symposium, being held October 29-30 in Boston, is a change-agent conference that promotes innovative thinking and the application of personal consumer health technologies, with a  focus on trends at the intersection of technology and new models of health care delivery.  Over 1,200 technology leaders, industry execs, Fortune 500 employers, policymakers, clinicians and health plan execs will come together to define the future of care delivery and impact the day-to-day lives of patients.

JMIR Publications
JMIR Publications is the leading ehealth publisher, advancing progress in the health, engineering and social sciences to ultimately help people to live happier and healthier lives using technology. JMIR Publications helps innovators in the health technology space to collaborate and disseminate their innovations, ideas, and research results to the widest possible audience, in a timely manner, adding value to the quality of the work and adhering to the highest ethical and quality standards. We achieve this by using the Internet and the latest available technologies as well as by producing conferences and social media, and other innovative knowledge translation products. We also innovate in the scholarly communication space itself, experimenting with new business models, new models of peer-review and dissemination, and new technologies. Visit

Partners HealthCare Connected Health
Partners is leveraging information technology – cell phones, computers, wearables, sensors and remote health monitoring tools – to deliver quality patient care outside of traditional medical settings. Partners Connected Health programs are also helping providers and patients better manage chronic conditions, maintain health and wellness and improve adherence, engagement and clinical outcomes. The Connected Health team creates and deploys mobile technologies in a number of patient populations and care settings, and is conducting innovative clinical studies to test the effectiveness of mobile health technologies in various clinical applications, including medication adherence, care coordination, chronic disease management, and prevention and wellness.

Partners HealthCare
Partners HealthCare is an integrated health system founded by Brigham and Women’s Hospital and Massachusetts General Hospital.  In addition to its two academic medical centers, the Partners system includes community and specialty hospitals, a managed care organization, community health centers, a physician network, home health and long-term care services, and other health care entities. Partners HealthCare is committed to patient care, research, teaching, and service to the community. Partners is one of the nation’s leading biomedical research organizations and a principal teaching affiliate of Harvard Medical School.  Partners HealthCare is a non-profit organization. Visit


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    Review and Evaluation of Online Tobacco Dependence Treatment Training Programs for Health Care Practitioners


    Background: Training health care professionals is associated with increased capacity to deliver evidence-based smoking cessation interventions and increased quit rates among their patients. Online training programs hold promise to provide training but questions remain regarding the quality and usability of available programs. Objective: The aim was to assess the quality of English-language online courses in tobacco dependence treatment using a validated instrument. Methods: An environmental scan was conducted using the Google search engine to identify available online tobacco dependence treatment courses. The identified courses were then evaluated using the Peer Review Rubric for Online Learning, which was selected based on its ability to evaluate instructional design. It also has clear and concise criteria descriptions to ensure uniformity of evaluations by trained experts. Results: A total of 39 courses were identified, of which 24 unique courses were assessed based on their accessibility and functionality during the period of evaluation. Overall, the course ratings indicated that 17 of 24 courses evaluated failed to meet minimal quality standards and none of the courses evaluated could be ranked as superior. However, many excelled in providing effective navigation, course rationale, and content. Many were weak in the use of instructional design elements, such as teaching effectiveness, learning strategies, instructor’s role, and assessment and evaluation. Evaluation results and suggestions for improvement were shared with course administrators. Conclusions: Based on the courses evaluated in this review, course developers are encouraged to employ best practices in instructional design, such as cohesiveness of material, linearity of design, practice exercises, problem solving, and ongoing evaluation to improve existing courses and in the design of new online learning opportunities.

  • Possible thumbnail image for journal's table of contents.
Author Dr. CR Neary
Copyright Dr. CR Neary
No URL as photographer is family member so it's kindly reproduced with his permission.

    Validity of Internet-Based Longitudinal Study Data: The Elephant in the Virtual Room


    Background: Internet-based data collection relies on well-designed and validated questionnaires. The theory behind designing and validating questionnaires is well described, but few practical examples of how to approach validation are available in the literature. Objective: We aimed to validate data collected in an ongoing Internet-based longitudinal health study through direct visits to participants and recall of their health records. We demonstrate that despite extensive pre-planning, social desirability can still affect data in unexpected ways and that anticipation of poor quality data may be confounded by positive validation. Methods: Dogslife is a large-scale, Web-based longitudinal study of canine health, in which owners of Labrador Retrievers were recruited and questioned at regular intervals about the lifestyle and health of their dogs using an Internet-based questionnaire. The Dogslife questionnaire predominantly consists of closed-answer questions. In our work, two separate validation methodologies were used: (1) direct interviews with 43 participants during visits to their households and (2) comparison of owner-entered health reports with 139 historical health records. Results: Our results indicate that user-derived measures should not be regarded as a single category; instead, each measurement should be considered separately as each presents its own challenge to participants. We recommend trying to ascertain the extent of recall decay within a study and, if necessary, using this to guide data collection timepoints and analyses. Finally, we recommend that multiple methods of communication facilitate validation studies and aid cohort engagement. Conclusions: Our study highlighted how the theory underpinning online questionnaire design and validation translates into practical data issues when applied to Internet-based studies. Validation should be regarded as an extension of questionnaire design, and that validation work should commence as soon as sufficient data are available. We believe that validation is a crucial step and hope our suggested guidelines will help facilitate validation of other Internet-based cohort studies.

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    A New Method for Assessing Content Validity in Model-Based Creation and Iteration of eHealth Interventions


    Background: The advent of eHealth interventions to address psychological concerns and health behaviors has created new opportunities, including the ability to optimize the effectiveness of intervention activities and then deliver these activities consistently to a large number of individuals in need. Given that eHealth interventions grounded in a well-delineated theoretical model for change are more likely to be effective and that eHealth interventions can be costly to develop, assuring the match of final intervention content and activities to the underlying model is a key step. We propose to apply the concept of “content validity” as a crucial checkpoint to evaluate the extent to which proposed intervention activities in an eHealth intervention program are valid (eg, relevant and likely to be effective) for the specific mechanism of change that each is intended to target and the intended target population for the intervention. Objective: The aims of this paper are to define content validity as it applies to model-based eHealth intervention development, to present a feasible method for assessing content validity in this context, and to describe the implementation of this new method during the development of a Web-based intervention for children. Methods: We designed a practical 5-step method for assessing content validity in eHealth interventions that includes defining key intervention targets, delineating intervention activity-target pairings, identifying experts and using a survey tool to gather expert ratings of the relevance of each activity to its intended target, its likely effectiveness in achieving the intended target, and its appropriateness with a specific intended audience, and then using quantitative and qualitative results to identify intervention activities that may need modification. We applied this method during our development of the Coping Coach Web-based intervention for school-age children. Results: In the evaluation of Coping Coach content validity, 15 experts from five countries rated each of 15 intervention activity-target pairings. Based on quantitative indices, content validity was excellent for relevance and good for likely effectiveness and age-appropriateness. Two intervention activities had item-level indicators that suggested the need for further review and potential revision by the development team. Conclusions: This project demonstrated that assessment of content validity can be straightforward and feasible to implement and that results of this assessment provide useful information for ongoing development and iterations of new eHealth interventions, complementing other sources of information (eg, user feedback, effectiveness evaluations). This approach can be utilized at one or more points during the development process to guide ongoing optimization of eHealth interventions.

  • (cc) Domnich et al. CC-BY-SA-2.0, please cite as (

    Uncontrolled Web-Based Administration of Surveys on Factual Health-Related Knowledge: A Randomized Study of Untimed Versus Timed Quizzing


    Background: Health knowledge and literacy are among the main determinants of health. Assessment of these issues via Web-based surveys is growing continuously. Research has suggested that approximately one-fifth of respondents submit cribbed answers, or cheat, on factual knowledge items, which may lead to measurement error. However, little is known about methods of discouraging cheating in Web-based surveys on health knowledge. Objective: This study aimed at exploring the usefulness of imposing a survey time limit to prevent help-seeking and cheating. Methods: On the basis of sample size estimation, 94 undergraduate students were randomly assigned in a 1:1 ratio to complete a Web-based survey on nutrition knowledge, with or without a time limit of 15 minutes (30 seconds per item); the topic of nutrition was chosen because of its particular relevance to public health. The questionnaire consisted of two parts. The first was the validated consumer-oriented nutrition knowledge scale (CoNKS) consisting of 20 true/false items; the second was an ad hoc questionnaire (AHQ) containing 10 questions that would be very difficult for people without health care qualifications to answer correctly. It therefore aimed at measuring cribbing and not nutrition knowledge. AHQ items were somewhat encyclopedic and amenable to Web searching, while CoNKS items had more complex wording, so that simple copying/pasting of a question in a search string would not produce an immediate correct answer. Results: A total of 72 of the 94 subjects started the survey. Dropout rates were similar in both groups (11%, 4/35 and 14%, 5/37 in the untimed and timed groups, respectively). Most participants completed the survey from portable devices, such as mobile phones and tablets. To complete the survey, participants in the untimed group took a median 2.3 minutes longer than those in the timed group; the effect size was small (Cohen’s r=.29). Subjects in the untimed group scored significantly higher on CoNKS (mean difference of 1.2 points, P=.008) and the effect size was medium (Cohen’s d=0.67). By contrast, no significant between-group difference in AHQ scores was documented. Unexpectedly high AHQ scores were recorded in 23% (7/31) and 19% (6/32) untimed and timed respondents, respectively, very probably owing to “e-cheating”. Conclusions: Cribbing answers to health knowledge items in researcher-uncontrolled conditions is likely to lead to overestimation of people’s knowledge; this should be considered during the design and implementation of Web-based surveys. Setting a time limit alone may not completely prevent cheating, as some cheats may be very fast in Web searching. More complex and contextualized wording of items and checking for the “findability” properties of items before implementing a Web-based health knowledge survey may discourage help-seeking, thus reducing measurement error. Studies with larger sample sizes and diverse populations are needed to confirm our results.

  • The Prevent Online Diabetes Prevention Program.
(c) Sepah et al.

    Long-Term Outcomes of a Web-Based Diabetes Prevention Program: 2-Year Results of a Single-Arm Longitudinal Study


    Background: Digital therapeutics are evidence-based behavioral treatments delivered online that can increase accessibility and effectiveness of health care. However, few studies have examined long-term clinical outcomes of digital therapeutics. Objective: The objective of this study was to conduct a 2-year follow-up on participants in the Internet-based Prevent diabetes prevention program pilot study, specifically examining the effects on body weight and A1c, which are risk factors for diabetes development. Methods: A quasi-experimental research design was used, including a single-arm pre- and post-intervention assessment of outcomes. Participants underwent a 16-week weight loss intervention and an ongoing weight maintenance intervention. As part of the program, participants received a wireless scale, which was used to collect body weight data on an ongoing basis. Participants also received A1c test kits at baseline, 0.5 year, 1 year, and 2-year time points. Results: Participants previously diagnosed with prediabetes (n=220) were originally enrolled in the pilot study. A subset of participants (n=187) met Centers for Disease Control and Prevention (CDC) criteria for starting the program (starters), and a further subset (n=155) met CDC criteria for completing the program (completers) and were both included in analyses. Program starters lost an average of 4.7% (SD 0.4) of baseline body weight after 1 year and 4.2% (SD 0.8) after 2 years, and reduced A1c by mean 0.38% (SD 0.07) after 1 year and 0.43% (SD 0.08) after 2 years. Program completers lost mean 4.9% (SD 0.5) of baseline body weight after 1 year and 4.3% (SD 0.8) after 2 years, and reduced A1c by 0.40% (SD 0.07) after 1 year and 0.46% (SD 0.08) after 2 years. For both groups, neither 2-year weight loss nor A1c results were significantly different from 1-year results. Conclusions: Users of the Prevent program experienced significant reductions in body weight and A1c that are maintained after 2 years. Contrary to the expected progression from prediabetes to diabetes over time, average A1c levels continued to show an average regression from within the prediabetic range (5.7%-6.4%) initially to the normal range (<5.7%) after 2 years. Further investigation is warranted to test digital therapeutics as a scalable solution to address national diabetes and cardiovascular disease prevention efforts.

  • This is a royalty free image by basketman (

    Insights Into the Impact of Online Physician Reviews on Patients’ Decision Making: Randomized Experiment


    Background: Physician-rating websites combine public reporting with social networking and offer an attractive means by which users can provide feedback on their physician and obtain information about other patients’ satisfaction and experiences. However, research on how users evaluate information on these portals is still scarce and only little knowledge is available about the potential influence of physician reviews on a patient’s choice. Objective: Starting from the perspective of prospective patients, this paper sets out to explore how certain characteristics of physician reviews affect the evaluation of the review and users’ attitudes toward the rated physician. We propose a model that relates review style and review number to constructs of review acceptance and check it with a Web-based experiment. Methods: We employed a randomized 2x2 between-subject, factorial experiment manipulating the style of a physician review (factual vs emotional) and the number of reviews for a certain physician (low vs high) to test our hypotheses. A total of 168 participants were presented with a Web-based questionnaire containing a short description of a dentist search scenario and the manipulated reviews for a fictitious dental physician. To investigate the proposed hypotheses, we carried out moderated regression analyses and a moderated mediation analysis using the PROCESS macro 2.11 for SPSS version 22. Results: Our analyses indicated that a higher number of reviews resulted in a more positive attitude toward the rated physician. The results of the regression model for attitude toward the physician suggest a positive main effect of the number of reviews (mean [low] 3.73, standard error [SE] 0.13, mean [high] 4.15, SE 0.13). We also observed an interaction effect with the style of the review—if the physician received only a few reviews, fact-oriented reviews (mean 4.09, SE 0.19) induced a more favorable attitude toward the physician compared to emotional reviews (mean 3.44, SE 0.19), but there was no such effect when the physician received many reviews. Furthermore, we found that review style also affected the perceived expertise of the reviewer. Fact-oriented reviews (mean 3.90, SE 0.13) lead to a higher perception of reviewer expertise compared to emotional reviews (mean 3.19, SE 0.13). However, this did not transfer to the attitude toward the physician. A similar effect of review style and number on the perceived credibility of the review was observed. While no differences between emotional and factual style were found if the physician received many reviews, a low number of reviews received lead to a significant difference in the perceived credibility, indicating that emotional reviews were rated less positively (mean 3.52, SE 0.18) compared to fact-oriented reviews (mean 4.15, SE 0.17). Our analyses also showed that perceived credibility of the review fully mediated the observed interaction effect on attitude toward the physician. Conclusions: Physician-rating websites are an interesting new source of information about the quality of health care from the patient’s perspective. This paper makes a unique contribution to an understudied area of research by providing some insights into how people evaluate online reviews of individual doctors. Information attributes, such as review style and review number, have an impact on the evaluation of the review and on the patient’s attitude toward the rated doctor. Further research is necessary to improve our understanding of the influence of such rating sites on the patient's choice of a physician.

  • Example of a 3D virtual environment streamed via the Internet directly onto the learner’s computer (ie, Web based) where the user can freely walk around and interact with the environment—authors’ project in collaboration with Clemson University, SC, USA.

    3D Immersive Patient Simulators and Their Impact on Learning Success: A Thematic Review


    Background: Immersive patient simulators (IPSs) combine the simulation of virtual patients with a three-dimensional (3D) environment and, thus, allow an illusionary immersion into a synthetic world, similar to computer games. Playful learning in a 3D environment is motivating and allows repetitive training and internalization of medical workflows (ie, procedural knowledge) without compromising real patients. The impact of this innovative educational concept on learning success requires review of feasibility and validity. Objective: It was the aim of this paper to conduct a survey of all immersive patient simulators currently available. In addition, we address the question of whether the use of these simulators has an impact on knowledge gain by summarizing the existing validation studies. Methods: A systematic literature search via PubMed was performed using predefined inclusion criteria (ie, virtual worlds, focus on education of medical students, validation testing) to identify all available simulators. Validation testing was defined as the primary end point. Results: There are currently 13 immersive patient simulators available. Of these, 9 are Web-based simulators and represent feasibility studies. None of these simulators are used routinely for student education. The workstation-based simulators are commercially driven and show a higher quality in terms of graphical quality and/or data content. Out of the studies, 1 showed a positive correlation between simulated content and real content (ie, content validity). There was a positive correlation between the outcome of simulator training and alternative training methods (ie, concordance validity), and a positive coherence between measured outcome and future professional attitude and performance (ie, predictive validity). Conclusions: IPSs can promote learning and consolidation of procedural knowledge. The use of immersive patient simulators is still marginal, and technical and educational approaches are heterogeneous. Academic-driven IPSs could possibly enhance the content quality, improve the validity level, and make this educational concept accessible to all medical students.

  • Image source: Istockphoto, (c) gbrundin.

    Exploring Women’s Beliefs and Perceptions About Healthy Eating Blogs: A Qualitative Study


    Background: Chronic diseases are the leading cause of death (63%) worldwide. A key behavioral risk factor is unhealthy eating. New strategies must be identified and evaluated to improve dietary habits. Social media, such as blogs, represent a unique opportunity for improving knowledge translation in health care through interactive communication between health consumers and health professionals. Despite the proliferation of food and lifestyle blogs, no research has been devoted to understanding potential blog readers’ perceptions of healthy eating blogs written by dietitians. Objective: To identify women’s salient beliefs and perceptions regarding the use of healthy eating blogs written by dietitians promoting the improvement of their dietary habits. Methods: We conducted a qualitative study with female Internet users living in the Quebec City, QC, area with suboptimal dietary habits. First, the women explored 4 existing healthy eating blogs written in French by qualified dietitians. At a focus group 2-4 weeks later, they were asked to discuss their experience and perceptions. Focus group participants were grouped by age (18-34, 35-54, and 55-75 years) and by their use of social media (users/nonusers). Using a questionnaire based on the Theory of Planned Behavior, participants were asked to identify salient beliefs underlying their attitudes (advantages/disadvantages), subjective norms (what people important to them would think), and perceptions of control (facilitators/barriers) regarding the use of a healthy eating blog written by a dietitian to improve dietary habits. Discussion groups were audiotaped, transcribed verbatim, coded, and a deductive content analysis was performed independently by 2 individuals using the NVivo software (version 10). Results: All participants (N=33) were Caucasian women aged between 22 to 73 year. Main advantages perceived of using healthy eating blogs written by a dietitian were that they provided useful recipe ideas, improved lifestyle, were a credible source of information, and allowed interaction with a dietitian. Disadvantages included increased time spent on the Internet and guilt if recommendations were not followed. Important people who would approve were family, colleagues, and friends. Important people who could disapprove were family and doctors. Main facilitators were visually attractive blogs, receiving an email notification about new posts, and finding new information on the blog. Main barriers were too much text, advertising on the blog, and lack of time. Conclusions: The women in this study valued the credibility of healthy eating blogs written by dietitians and the contact with dietitians they provided. Identifying salient beliefs underlying women’s perceptions of using such blogs provides an empirically supported basis for the design of knowledge translation interventions to help prevent chronic diseases.

  • An example of online community and extracted quality factors for hospitals.

    Identifying Key Hospital Service Quality Factors in Online Health Communities


    Background: The volume of health-related user-created content, especially hospital-related questions and answers in online health communities, has rapidly increased. Patients and caregivers participate in online community activities to share their experiences, exchange information, and ask about recommended or discredited hospitals. However, there is little research on how to identify hospital service quality automatically from the online communities. In the past, in-depth analysis of hospitals has used random sampling surveys. However, such surveys are becoming impractical owing to the rapidly increasing volume of online data and the diverse analysis requirements of related stakeholders. Objective: As a solution for utilizing large-scale health-related information, we propose a novel approach to identify hospital service quality factors and overtime trends automatically from online health communities, especially hospital-related questions and answers. Methods: We defined social media–based key quality factors for hospitals. In addition, we developed text mining techniques to detect such factors that frequently occur in online health communities. After detecting these factors that represent qualitative aspects of hospitals, we applied a sentiment analysis to recognize the types of recommendations in messages posted within online health communities. Korea’s two biggest online portals were used to test the effectiveness of detection of social media–based key quality factors for hospitals. Results: To evaluate the proposed text mining techniques, we performed manual evaluations on the extraction and classification results, such as hospital name, service quality factors, and recommendation types using a random sample of messages (ie, 5.44% (9450/173,748) of the total messages). Service quality factor detection and hospital name extraction achieved average F1 scores of 91% and 78%, respectively. In terms of recommendation classification, performance (ie, precision) is 78% on average. Extraction and classification performance still has room for improvement, but the extraction results are applicable to more detailed analysis. Further analysis of the extracted information reveals that there are differences in the details of social media–based key quality factors for hospitals according to the regions in Korea, and the patterns of change seem to accurately reflect social events (eg, influenza epidemics). Conclusions: These findings could be used to provide timely information to caregivers, hospital officials, and medical officials for health care policies.

  • Online gaming. (cc) Király et al. CC-BY-SA-2.0, please cite as (

    The Mediating Effect of Gaming Motivation Between Psychiatric Symptoms and Problematic Online Gaming: An Online Survey


    Background: The rapid expansion of online video gaming as a leisure time activity has led to the appearance of problematic online gaming (POG). According to the literature, POG is associated with different psychiatric symptoms (eg, depression, anxiety) and with specific gaming motives (ie, escape, achievement). Based on studies of alcohol use that suggest a mediator role of drinking motives between distal influences (eg, trauma symptoms) and drinking problems, this study examined the assumption that there is an indirect link between psychiatric distress and POG via the mediation of gaming motives. Furthermore, it was also assumed that there was a moderator effect of gender and game type preference based on the important role gender plays in POG and the structural differences between different game types. Objective: This study had two aims. The first aim was to test the mediating role of online gaming motives between psychiatric symptoms and problematic use of online games. The second aim was to test the moderator effect of gender and game type preference in this mediation model. Methods: An online survey was conducted on a sample of online gamers (N=3186; age: mean 21.1, SD 5.9 years; male: 2859/3186, 89.74%). The Brief Symptom Inventory (BSI), the Motives for Online Gaming Questionnaire (MOGQ), and the Problematic Online Gaming Questionnaire (POGQ) were administered to assess general psychiatric distress, online gaming motives, and problematic online game use, respectively. Structural regression analyses within structural equation modeling were used to test the proposed mediation models and multigroup analyses were used to test gender and game type differences to determine possible moderating effects. Results: The mediation models fitted the data adequately. The Global Severity Index (GSI) of the BSI indicated that the level of psychiatric distress had a significant positive direct effect (standardized effect=.35, P<.001) and a significant indirect (mediating) effect on POG (standardized effect=.194, P<.001) via 2 gaming motives: escape (standardized effect=.139, P<.001) and competition (standardized effect=.046, P<.001). The comparison of the 2 main gamer types showed no significant differences in the model. However, when comparing male and female players it was found that women had (1) slightly higher escape scores (on a 5-point Likert scale: mean 2.28, SD 1.14) than men (mean 1.87, SD 0.97) and (2) a stronger association between the escape motive and problematic online gaming (standardized effect size=.64, P<.001) than men (standardized effect size=.20, P=.001). Conclusions: The results suggest that psychiatric distress is both directly and indirectly (via escape and competition motives) negatively associated with POG. Therefore, the exploration of psychiatric symptoms and gaming motives of POG can be helpful in the preparation of prevention and treatment programs.

  • Graph of reduced pain-related tweet corpus. Each term contained within corpus is represented by a point; point size corresponds to the total degree centrality of the associated term. The color of each point indicates membership to a modularity community. Whenever a term is associated with another term within a given tweet, the 2 points are connected by a line, or edge; edge width corresponds to the frequency of association between the 2 connected terms.

    The Painful Tweet: Text, Sentiment, and Community Structure Analyses of Tweets Pertaining to Pain


    Background: Despite the widespread popularity of social media, little is known about the extent or context of pain-related posts by users of those media. Objective: The aim was to examine the type, context, and dissemination of pain-related tweets. Methods: We used content analysis of pain-related tweets from 50 cities to unobtrusively explore the meanings and patterns of communications about pain. Content was examined by location and time of day, as well as within the context of online social networks. Results: The most common terms published in conjunction with the term “pain” included feel (n=1504), don’t (n=702), and love (n=649). The proportion of tweets with positive sentiment ranged from 13% in Manila to 56% in Los Angeles, CA, with a median of 29% across cities. Temporally, the proportion of tweets with positive sentiment ranged from 24% at 1600 to 38% at 2400, with a median of 32%. The Twitter-based social networks pertaining to pain exhibited greater sparsity and lower connectedness than did those social networks pertaining to common terms such as apple, Manchester United, and Obama. The number of word clusters in proportion to node count was greater for emotion terms such as tired (0.45), happy (0.43), and sad (0.4) when compared with objective terms such as apple (0.26), Manchester United (0.14), and Obama (0.25). Conclusions: Taken together, our results suggest that pain-related tweets carry special characteristics reflecting unique content and their communication among tweeters. Further work will explore how geopolitical events and seasonal changes affect tweeters’ perceptions of pain and how such perceptions may affect therapies for pain.

  • (cc) Al-Durra et al, CC-BY-SA-2.0, please cite as (

    The Use of Behavior Change Theory in Internet-Based Asthma Self-Management Interventions: A Systematic Review


    Background: The high prevalence rate of asthma represents a major societal burden. Advancements in information technology continue to affect the delivery of patient care in all areas of medicine. Internet-based solutions, social media, and mobile technology could address some of the problems associated with increasing asthma prevalence. Objective: This review evaluates Internet-based asthma interventions that were published between 2004 and October 2014 with respect to the use of behavioral change theoretical frameworks, applied clinical guidelines, and assessment tools. Methods: The search term (Asthma AND [Online or Internet or Mobile or Application or eHealth or App]) was applied to six bibliographic databases (Ovid MEDLINE, PubMed, BioMed Central, ProQuest Computing, Web of Knowledge, and ACM Digital Library) including only English-language articles published between 2004 and October 2014. In total, 3932 articles matched the priori search terms and were reviewed by the primary reviewer based on their titles, index terms, and abstracts. The matching articles were then screened by the primary reviewer for inclusion or exclusion based on their abstract, study type, and intervention objectives with respect to the full set of priori inclusion and exclusion criteria; 331 duplicates were identified and removed. A total of 85 articles were included for in-depth review and the remaining 3516 articles were excluded. The primary and secondary reviewer independently reviewed the complete content of the 85 included articles to identify the applied behavioral change theories, clinical guidelines, and assessment tools. Findings and any disagreement between reviewers were resolved by in-depth discussion and through a consolidation process for each of the included articles. Results: The reviewers identified 17 out of 85 interventions (20%) where at least one model, framework, and/or construct of a behavioral change theory were applied. The review identified six clinical guidelines that were applied across 30 of the 85 interventions (35%) as well as a total of 21 assessment tools that were applied across 32 of the 85 interventions (38%). Conclusions: The findings of this literature review indicate that the majority of published Internet-based interventions do not use any documented behavioral change theory, clinical guidelines, and/or assessment tools to inform their design. Further, it was found that the application of clinical guidelines and assessment tools were more salient across the reviewed interventions. A consequence, as such, is that many Internet-based asthma interventions are designed in an ad hoc manner, without the use of any notable evidence-based theoretical frameworks, clinical guidelines, and/or assessment tools.

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  • Developing a mHealth Campaign: Utilizing Principles of Health Communications

    Date Submitted: Apr 16, 2015

    Open Peer Review Period: Apr 17, 2015 - Jun 12, 2015

    Mobile health (mHealth), or the use of mobile devices to improve health, is increasingly used as a powerful campaign tool in health communications. However, there is few peer-reviewed literature outli...

    Mobile health (mHealth), or the use of mobile devices to improve health, is increasingly used as a powerful campaign tool in health communications. However, there is few peer-reviewed literature outlining how a mHealth campaign can be developed according to established principles of health communications. We outline ten steps to guide campaign development, followed by an exemplar detailing how the steps can be used in an example campaign.

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    Open Peer Review Period: Apr 17, 2015 - Jun 12, 2015

    Background: Social media is an appealing recruitment strategy for scientific data collection compared to traditional methods. Researchers can conduct surveys studies using Twitter by including a link...

    Background: Social media is an appealing recruitment strategy for scientific data collection compared to traditional methods. Researchers can conduct surveys studies using Twitter by including a link to an online survey. However, a paucity of research currently exists to guide researchers on how to best employ an online survey study using Twitter. Objective: The purpose of this paper is to describe the use of two different Twitter strategies in recruiting participants for an online survey study. Methods: The first strategy targeted high profile twitter accounts (High profile), i.e. those in a prominent position to attract attention or publicity, and the second strategy targeted low profile accounts (Low profile). Potential reach and actual reach for the different strategies were calculated, as well as the time of day, and day of week that received the most retweets. Results: The high profile strategy had a higher potential reach than the low profile strategy (difference 2430802 followers), but the low profile strategy had a higher actual reach (difference 73960 followers). Both stratagies received a large proportion (between 59%-69%) of retweets on Tuesday, Wednesday and Thursday during the average week, with Thursday being the most active day. Mornings, between 06h00-11h59 received the most retweets. Conclusions: Based on this study, Twitter recruitment strategies for scientific data collection through on-line surveys should target both high and low profile accounts.

  • Smartphones in Parkinson’s research and treatment: ethical guidelines and future directions

    Date Submitted: Apr 15, 2015

    Open Peer Review Period: Apr 17, 2015 - Jun 12, 2015

    Smartphones and other remote monitoring devices, collectively referred to as mHealth, promise to transform the treatment of a range of movement disorders, such as Parkinson’s disease. The ability to...

    Smartphones and other remote monitoring devices, collectively referred to as mHealth, promise to transform the treatment of a range of movement disorders, such as Parkinson’s disease. The ability to easily collect vast arrays of personal data over long periods of time will give clinicians and researchers unique insights into disease treatment and progression. These capabilities also pose new ethical challenges that neurologists and other health care professionals will need to manage if this promise is to be realised with minimal risk of harm. These include: privacy protection when anonymity is not always possible, minimisation of third party uses of mHealth data, informing patients of complex risks when obtaining consent, managing data in ways that maximise benefit while minimising the potential for disclosure to third parties, careful communication of clinically relevant information gleaned via mHealth technologies, and rigorous evaluation and regulation of mHealth products before widespread use. These challenges will be best met through early and ongoing engagement with people with Parkinson’s disease and other relevant stakeholders.

  • Pattern of dietary self monitoring using a smartphone application and weight loss

    Date Submitted: Apr 14, 2015

    Open Peer Review Period: Apr 17, 2015 - Jun 12, 2015

    Background: Obesity is a major global public health issue due to its association with a number of serious chronic illnesses and its high economic burden to healthcare providers. Self monitoring of die...

    Background: Obesity is a major global public health issue due to its association with a number of serious chronic illnesses and its high economic burden to healthcare providers. Self monitoring of diet has been consistently linked to weight loss. However, there is limited evidence about how frequently individuals need to monitor their diet for optimal weight loss. Objective: The aim of this paper is to describe app usage frequency and pattern in the smartphone arm of a previously conducted randomised controlled trial. The relationship between frequency and pattern of electronic dietary self monitoring and weight loss has also been investigated. Methods: A randomised pilot trial comparing 3 methods of self monitoring (smartphone app, paper diary, web-based) has been previously conducted. Trial duration was 6 months. The smartphone app ‘My Meal Mate’ (MMM) features an electronic food diary and encourages users to self monitor their dietary intake. All food consumption data is automatically uploaded with a time and date stamp. Post-hoc regression analysis of app usage patterns was undertaken in the MMM group (n=43, 77% female, 100% white ethnic origin, mean age 41 (SD: 9) years, mean BMI: 34 (SD: 4) kg/m2) in order to explore the relationship between frequency and pattern of electronic dietary self monitoring and weight loss. Baseline characteristics of participants were also investigated to identify any potential predictors of dietary self monitoring. Results: Regression analysis showed that those in the highest ‘frequency of use’ category (recorded ≥129 days on the smartphone app) had a −6.4kg (95% CI; −10.0, −2.9) lower follow up weight (adjusted for baseline weight) than those in the lowest ‘frequency of use’ category (recorded ≤42 days) (p<0.01). Long term intermittent monitoring over 6 months appeared to facilitate greater mean weight loss than other patterns of electronic self-monitoring (i.e. monitoring over the short or moderate term and stopping and consistently monitoring over consecutive days). Participant characteristics such as age, baseline weight, gender, ethnicity, conscientiousness and consideration of future consequences were not statistically associated with extent of self monitoring. Conclusions: The results of this post-hoc exploratory analysis indicate that duration and frequency of app use is associated with improved weight loss but further research is required to identify whether there are participant characteristics which would reliably predict those who are most likely to regularly self monitor their diet. Clinical Trial: NCT01744535; (Archived by WebCite at

  • Use and uptake of eHealth in general practice: a cross-sectional survey and focus group study among health care users and general practitioners

    Date Submitted: Apr 15, 2015

    Open Peer Review Period: Apr 17, 2015 - Jun 12, 2015

    Background: Policymakers promote the use of eHealth to widen access to health care services and to improve the quality and safety of care. Nevertheless, the enthusiasm among policymakers for eHealth d...

    Background: Policymakers promote the use of eHealth to widen access to health care services and to improve the quality and safety of care. Nevertheless, the enthusiasm among policymakers for eHealth does not match its uptake and use. eHealth is defined in this study as ‘health services delivered or enhanced through the internet and related information and communication technologies’. Objective: The objective of this study is to investigate 1) the current use of eHealth in the Netherlands by GPs, and 2) the perceived positive effects and barriers from the perspective of general practitioners (GPs) and health care users. Based on Rogers’ theoretical model of adoption of innovations, we refer to the five stages of the adoption process: 1) knowledge 2) persuasion 3) decision 4) implementation 5) rejection or confirmation of the innovation. We use this model to identify the stage at which the GPs and health care users in our study are positioned. Methods: A cross sectional survey of a sample of Dutch General Practitioners (GPs) and members of the Dutch Health Care Consumer Panel was conducted in April 2014. A pre-structured questionnaire was completed by 171 GPs (response 12%) and by 754 health care users (response 50%). In addition, two focus groups were conducted: one group with GPs (eight participants) and one with health care users (ten participants). Results: Generally, GPs have a positive attitude to using eHealth in their general practice. Nonetheless, 80% of the GPs perceive barriers, especially concerning its innovation (e.g. insufficient reliable, secure systems) and the socio-political context (e.g. lack of financial compensation for the time spent on implementation). According to Rogers' model, most GPs in this study are at the ‘persuasion-stage”: they are actively exploring the possibilities of using eHealth and are becoming convinced of the value of the innovation. Health care users are generally not aware of eHealth-services offered by their GP. In terms of Rogers’ model of adoption, most health care users are at the stage of seeking ‘knowledge’ (awareness). One in five (21%) health care users perceives barriers to the use of e-Health. These include concerns about the safety of health information obtained via the internet (67%) and about privacy aspects (56%). Conclusions: GPs and health care users have generally positive attitudes towards eHealth, which is a prerequisite for the uptake of eHealth. But, general practitioners in particular, perceive barriers to using eHealth, and consider the implementation of eHealth to be complex. It will take some time before these issues are resolved and therefore until eHealth is fully adopted. Clinical Trial: None.

  • m-Health lifestyle program with telephone support (TXT2BFiT) prevents unhealthy weight gain in young adults: 12-week efficacy outcomes of a randomised controlled trial

    Date Submitted: Apr 14, 2015

    Open Peer Review Period: Apr 14, 2015 - Apr 22, 2015

    Background: Weight gained in young adulthood often persists throughout later life with associated chronic disease risk. Despite this, current population prevention strategies are not specifically desi...

    Background: Weight gained in young adulthood often persists throughout later life with associated chronic disease risk. Despite this, current population prevention strategies are not specifically designed for young adults. Objective: We designed and assessed the efficacy of an m-Health prevention program, TXT2BFiT, in preventing excess weight gain and improving dietary and physical activity behaviours in young adults at increased risk of obesity and unhealthy lifestyle choices. Methods: A two-arm parallel-group, randomised controlled trial was conducted. Subjects and analysing researchers were blinded. Two-hundred fifty 18 to 35 year olds at high risk of weight-gain; body mass index (BMI) 23.0-24.9 kg m-2 with ≥ 2 kg gain in previous 12-months; or BMI 25.0-31.9 kg m-2 were randomised to intervention or control. In the 12-week trial, the intervention (I) received eight text messages weekly based on the Transtheoretical Model of behaviour change, one email weekly, five personalized coaching calls, diet booklet and access to resources and Smartphone applications on a website. Controls (C) received only four text messages and printed dietary and physical activity guidelines. Measured body weight and height were collected at baseline and 12-weeks. Outcomes were assessed via online surveys at baseline and 12-weeks including self-reported weight, dietary and physical activity measures. Results: Two hundred fourteen (110 I; 104 C) completed the 12-week trial. Ten participants (8.0%; 10 I; 0 C) dropped out and 26 (10.4%; 5 I; 21 C) participants did not complete post intervention online surveys. Adherence to coaching calls and delivery of text messages was over 95%. At 12-weeks the intervention group were 2.2 kg (95% CI 0.8 to 3.6) lighter than controls (P=0.005) and consumed more vegetables (P=0.009), less sugary soft drinks (P = 0.002) and less energy-dense take-out meals (P=0.0014) and increased total physical activity (P=0.05) and total physical activity days (P=0.003). Conclusions: The TXT2BFiT low-intensity intervention was successful in preventing weight gain with modest weight-loss and improvement in lifestyle behaviours among overweight young adults. The short-term success shows potential for translation into a community-based program. Clinical Trial: The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12612000924853).