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Journal of Medical Internet Research

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


Journal Description

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

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

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

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


Recent Articles:

  • A group of people laughing, drinking, and posting photos (ie, alcohol posts) on social media. Source: Shutterstock; Copyright: Alessandro Biascioli; URL:; License: Licensed by the authors.

    Social Drinking on Social Media: Content Analysis of the Social Aspects of Alcohol-Related Posts on Facebook and Instagram


    Background: Alcohol is often consumed in social contexts. An emerging social context in which alcohol is becoming increasingly apparent is social media. More and more young people display alcohol-related posts on social networking sites such as Facebook and Instagram. Objective: Considering the importance of the social aspects of alcohol consumption and social media use, this study investigated the social content of alcohol posts (ie, the evaluative social context and presence of people) and social processes (ie, the posting of and reactions to posts) involved with alcohol posts on social networking sites. Methods: Participants (N=192; mean age 20.64, SD 4.68 years, 132 women and 54 men) gave researchers access to their Facebook and/or Instagram profiles, and an extensive content analysis of these profiles was conducted. Coders were trained and then coded all screenshotted timelines in terms of evaluative social context, presence of people, and reactions to post. Results: Alcohol posts of youth frequently depict alcohol in a positive social context (425/438, 97.0%) and display people holding drinks (277/412, 67.2%). In addition, alcohol posts were more often placed on participants’ timelines by others (tagging; 238/439, 54.2%) than posted by participants themselves (201/439, 45.8%). Furthermore, it was revealed that such social posts received more likes (mean 35.50, SD 26.39) and comments than nonsocial posts (no people visible; mean 10.34, SD 13.19, P<.001). Conclusions: In terms of content and processes, alcohol posts on social media are social in nature and a part of young people’s everyday social lives. Interventions aiming to decrease alcohol posts should therefore focus on the broad social context of individuals in which posting about alcohol takes place. Potential intervention strategies could involve making young people aware that when they post about social gatherings in which alcohol is visible and tag others, it may have unintended negative consequences and should be avoided.

  • Participant with cardiovascular disease uploading training data from home. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Home-Based Rehabilitation With Telemonitoring Guidance for Patients With Coronary Artery Disease (Short-Term Results of the TRiCH Study): Randomized...


    Background: Cardiac rehabilitation (CR) is an essential part of contemporary coronary heart disease management. However, patients exiting a center-based CR program have difficulty retaining its benefits. Objective: We aimed to evaluate the added benefit of a home-based CR program with telemonitoring guidance on physical fitness in patients with coronary artery disease (CAD) completing a phase II ambulatory CR program and to compare the effectiveness of this program in a prolonged center-based CR intervention by means of a randomized controlled trial. Methods: Between February 2014 and August 2016, 90 CAD patients (unblinded, mean age 61.2 years, SD 7.6; 80/90, 89.0% males; mean height 1.73 m, SD 0.7; mean weight 82.9 kg, SD 13; mean body mass index 27.5 kg/m2, SD 3.4) who successfully completed a 3-month ambulatory CR program were randomly allocated to one of three groups: home-based (30), center-based (30), or control group (30) on a 1:1:1 basis. Home-based patients received a home-based exercise intervention with telemonitoring guidance consisting of weekly emails or phone calls; center-based patients continued the standard in-hospital CR, and control group patients received the usual care including the advice to remain physically active. All the patients underwent cardiopulmonary exercise testing for assessment of their peak oxygen uptake (VO2 P) at baseline and after a 12-week intervention period. Secondary outcomes included physical activity behavior, anthropometric characteristics, traditional cardiovascular risk factors, and quality of life. Results: Following 12 weeks of intervention, the increase in VO2 P was larger in the center-based (P=.03) and home-based (P=.04) groups than in the control group. In addition, oxygen uptake at the first (P-interaction=.03) and second (P-interaction=.03) ventilatory thresholds increased significantly more in the home-based group than in the center-based group. No significant changes were observed in the secondary outcomes. Conclusions: Adding a home-based exercise program with telemonitoring guidance following completion of a phase II ambulatory CR program results in further improvement of physical fitness and is equally as effective as prolonging a center-based CR in patients with CAD. Trial Registration: NCT02047942; (Archived by WebCite at

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

    Evaluation of a Diabetes Self-Management Program: Claims Analysis on Comorbid Illnesses, Health Care Utilization, and Cost


    Background: An estimated 30.3 million Americans have diabetes mellitus. The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to improve the quality of life for people who either have or are at risk for diabetes mellitus, and hence, lower the personal and national economic burden of this debilitating chronic disease. Diabetes self-management education interventions are a primary focus of this initiative. Objective: The aim of this study was to evaluate the impact of the Better Choices Better Health Diabetes (BCBH-D) self-management program on comorbid illness related to diabetes mellitus, health care utilization, and cost. Methods: A propensity score matched two-group, pre-post design was used for this study. Retrospective administrative medical and pharmacy claims data from the HealthCore Integrated Research Environment were used for outcome variables. The intervention cohort included diabetes mellitus patients who were recruited to a diabetes self-management program. Control cohort subjects were identified from the HealthCore Integrated Research Environment by at least two diabetes-associated claims (International Classification of Diseases-Ninth Revision, ICD-9 250.xx) within 2 years before the program launch date (October 1, 2011-September 30, 2013) but did not participate in BCBH-D. Controls were matched to cases in a 3:1 propensity score match. Outcome measures included pre- and postintervention all-cause and diabetes-related utilization and costs. Cost outcomes are reported as least squares means. Repeated measures analyses (generalized estimating equation approach) were conducted for utilization, comorbid conditions, and costs. Results: The program participants who were identified in HealthCore Integrated Research Environment claims (N=558) were matched to a control cohort of 1669 patients. Following the intervention, the self-management cohort experienced significant reductions for diabetes mellitus–associated comorbid conditions, with the postintervention disease burden being significantly lower (mean 1.6 [SD 1.6]) compared with the control cohort (mean 2.1 [SD 1.7]; P=.001). Postintervention all-cause utilization was decreased in the intervention cohort compared with controls with −40/1000 emergency department visits vs +70/1000; P=.004 and −5780 outpatient visits per 1000 vs −290/1000; P=.001. Unadjusted total all-cause medical cost was decreased by US $2207 in the intervention cohort compared with a US $338 decrease in the controls; P=.001. After adjustment for other variables through structural equation analysis, the direct effect of the BCBH-D was –US $815 (P=.049). Conclusions: Patients in the BCBH-D program experienced reduced all-cause health care utilization and costs. Direct cost savings were US $815. Although encouraging, given the complexity of the patient population, further study is needed to cross-validate the results.

  • Sharing suicidal ideation online. Source: iStock by Getty Images; Copyright: Sinicakover; URL:; License: Licensed by the authors.

    Detecting Suicidal Ideation on Forums: Proof-of-Concept Study


    Background: In 2016, 44,965 people in the United States died by suicide. It is common to see people with suicidal ideation seek help or leave suicide notes on social media before attempting suicide. Many prefer to express their feelings with longer passages on forums such as Reddit and blogs. Because these expressive posts follow regular language patterns, potential suicide attempts can be prevented by detecting suicidal posts as they are written. Objective: This study aims to build a classifier that differentiates suicidal and nonsuicidal forum posts via text mining methods applied on post titles and bodies. Methods: A total of 508,398 Reddit posts longer than 100 characters and posted between 2008 and 2016 on SuicideWatch, Depression, Anxiety, and ShowerThoughts subreddits were downloaded from the publicly available Reddit dataset. Of these, 10,785 posts were randomly selected and 785 were manually annotated as suicidal or nonsuicidal. Features were extracted using term frequency-inverse document frequency, linguistic inquiry and word count, and sentiment analysis on post titles and bodies. Logistic regression, random forest, and support vector machine (SVM) classification algorithms were applied on resulting corpus and prediction performance is evaluated. Results: The logistic regression and SVM classifiers correctly identified suicidality of posts with 80% to 92% accuracy and F1 score, respectively, depending on different data compositions closely followed by random forest, compared to baseline ZeroR algorithm achieving 50% accuracy and 66% F1 score. Conclusions: This study demonstrated that it is possible to detect people with suicidal ideation on online forums with high accuracy. The logistic regression classifier in this study can potentially be embedded on blogs and forums to make the decision to offer real-time online counseling in case a suicidal post is being written.

  • Health care provider using Google Glass face-mounted technology. Source: Image created by the Authors; Copyright: Sandra Odenheimer; URL:; License: Creative Commons Attribution (CC-BY).

    Patient Acceptance of Remote Scribing Powered by Google Glass in Outpatient Dermatology: Cross-Sectional Study


    Background: The ubiquitous use of electronic health records (EHRs) during medical office visits using a computer monitor and keyboard can be distracting and can disrupt patient-health care provider (HCP) nonverbal eye contact cues, which are integral to effective communication. Provider use of a remote medical scribe with face-mounted technology (FMT), such as Google Glass, may preserve patient-HCP communication dynamics in health care settings by allowing providers to maintain direct eye contact with their patients while still having access to the patient’s relevant EHR information. The medical scribe is able to chart patient encounters in real-time working in an offsite location, document the visit directly into EHR, and free HCP to focus only on the patient. Objective: The purpose of this study was to examine patient perceptions of their interactions with an HCP who used FMT with a remote medical scribe during office visits. This includes an examination of any association between patient privacy and trust in their HCP when FMT is used in the medical office setting. Methods: For this descriptive, cross-sectional study, a convenience sample of patients was recruited from an outpatient dermatology clinic in Northern California. Participants provided demographic data and completed a 12-item questionnaire to assess their familiarity, comfort, privacy, and perceptions following routine office visits with an HCP where FMT was used to document the clinical encounter. Data were analyzed using appropriate descriptive and inferential statistics. Results: Over half of the 170 study participants were female (102/170, 59.4%), 60.0% were Caucasian (102/170), 24.1% were Asian (41/170), and 88.8% were college-educated (151/170). Age ranged between 18 and 90 years (mean 50.5, SD 17.4). The majority of participants (118/170, 69.4%) were familiar with FMT, not concerned with privacy issues (132/170, 77.6%), and stated that the use of FMT did not affect their trust in their HCP (139/170, 81.8%). Moreover, participants comfortable with the use of FMT were less likely to be concerned about privacy (P<.001) and participants who trusted their HCP were less likely to be concerned about their HCP using Google Glass (P<.009). Almost one-third of them self-identified as early technology adopters (49/170, 28.8%) and 87% (148/170) preferred their HCP using FMT if it delivered better care. Conclusions: Our study findings support the patient acceptance of Google Glass use for outpatient dermatology visits. Future research should explore the use of FMT in other areas of health care and strive to include a socioeconomically diverse patient population in study samples.

  • Woman using a Web-based tailored smoking cessation intervention. Source: Maxpixel; Copyright: Maxpixel; URL:; License: Public Domain (CC0).

    The Effectiveness of Web-Based Tailored Smoking Cessation Interventions on the Quitting Process (Project Quit): Secondary Analysis of a Randomized Controlled...


    Background: Project Quit was a randomized Web-based smoking cessation trial designed and conducted by researchers from the University of Michigan, where its primary outcome was the 7-day point prevalence. One drawback of such an outcome is that it only focuses on smoking behavior over a very short duration, rather than the quitting process over the entire study period. Objective: The aim of this study was to consider the number of quit attempts during the 6-month study period as an alternative outcome, which would better reflect the quitting process. We aimed to find out whether tailored interventions (high vs low) are better in reducing the number of quit attempts for specific subgroups of smokers. Methods: To identify interactions between intervention components of smoking cessation and individual smoker characteristics, we employed Poisson regression to analyze the number of quit attempts. This approach allowed us to construct data-driven, personalized interventions. Results: A negative effect of the number of cigarettes smoked per day (P=.03) and a positive effect of education (P=.03) on the number of quit attempts were detected from the baseline covariates (n=792). Thus, for every 10 extra cigarettes smoked per day, there was a 5.84% decrease in the expected number of quit attempts. Highly educated participants had a 15.49% increase in their expected number of quit attempts compared with their low-educated counterparts. A negative interaction between intervention component story and smoker’s education was also detected (P=.03), suggesting that a high-tailored story given to highly educated people results in 13.50% decrease in the number of quit attempts compared with a low-tailored story. Conclusions: A highly individually tailored story is significantly more effective for smokers with a low level of education. This is consistent with prior findings from Project Quit based on the 7-day point prevalence.

  • Source: / Pixabay; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Teledermatology Scale-Up Framework and Roadmap for Sustainable Scaling: Evidence-Based Development


    Background: The objectives of South Africa’s electronic health (eHealth) strategy recognize the value proposition that telemedicine practices hold for rural and urban referrals, but a lack of accepted and formalized scale-up has impeded realization of benefits. While both synchronous and asynchronous teledermatology exist, these remain localized and not scaled-up. Skin pathology is often the first sign of an HIV/AIDS infection, which remains a major cause of morbidity and mortality in South Africa. It is essential to replace the current inefficient dermatology referral process with a swift, organized, and efficacious one. Objective: The objective of this study is to present an evidenced-based teledermatology scale-up framework (TDSF) and implementation roadmap (TDSF-IR). Methods: A qualitative method with a design science research process model was used which consisted of 5 phases: (1) Awareness, which confirmed the need for an evidence-based TDSF and supporting TDSF-IR; (2) Suggestion, where a proposal was delivered on how to develop a TDSF and TDSF-IR; (3) Development, where we identified recommended design requirements and used these to identify and critique existing teledermatology or related scale-up frameworks; (4) Evaluation and validation, where we assessed outputs of the development phase against the design requirements and validated by confirming the veracity of the TDSF and TDSF-IR (validation involved 4 key senior teledermatology stakeholders using a questionnaire with a 5-point Likert scale); and (5) Conclusion, where validation results were used to finalize and communicate the TDSF and TDSF-IR to users. Results: The study identified 5 TDSF components: eHealth building blocks, eHealth strategic objectives and budget, scale-up continuum periods, scale-up drivers, and scale-up phases. In addition, 36 subcomponents were identified. Each was further characterized and described to enable design of the final evidence-based TDSF. An implementation roadmap (TDSF-IR) was also prepared as a guide for an implementer with step-by-step instructions for application of the TDSF. For the validation study of the TDSF and supporting TDSF-IR, 4 purposively selected key senior teledermatology management stakeholders were asked if they found it useful as a guide to assist the South African public health system with teledermatology scale-up. The mean (SD) of Likert-scale rating was 4.0 (0.53) where 4=Agree and 33 of 36 responses were either agree or strongly agree. Conclusions: This study developed a TDSF and supporting roadmap (TDSF-IR) that are evidence-based. The proposed approach and described tools could be adapted to assist with ensuring scale-up and sustainability for other eHealth practices in other locations.

  • Source: Pixabay; Copyright: Pexels; URL:; License: Public Domain (CC0).

    Dissemination of a Web-Based Tool for Supporting Health Insurance Plan Decisions (Show Me Health Plans): Cross-Sectional Observational Study


    Background: The rate of uninsured people has decreased dramatically since the Affordable Care Act was passed. To make an informed decision, consumers need assistance to understand the advantages and disadvantages of health insurance plans. The Show Me Health Plans Web-based decision support tool was developed to improve the quality of health insurance selection. In response to the promising effectiveness of Show Me Health Plans in a randomized controlled trial (RCT) and the growing need for Web-based health insurance decision support, the study team used expert recommendations for dissemination and implementation, engaged external stakeholders, and made the Show Me Health Plans tool available to the public. Objective: The purpose of this study was to implement the public dissemination of the Show Me Health Plans tool in the state of Missouri and to evaluate its impact compared to the RCT. Methods: This study used a cross-sectional observational design. Dissemination phase users were compared with users in the RCT study across the same outcome measures. Time spent using the Show Me Health Plans tool, knowledge, importance rating of 9 health insurance features, and intended plan choice match with algorithm predictions were examined. Results: During the dissemination phase (November 2016 to January 2017), 10,180 individuals visited the SMHP website, and the 1069 users who stayed on the tool for more than one second were included in our analyses. Dissemination phase users were more likely to live outside St. Louis City or County (P<.001), were less likely to be below the federal poverty level (P<.001), and had a higher income (P=.03). Overall, Show Me Health Plans users from St. Louis City or County spent more time on the Show Me Health Plans tool than those from other Missouri counties (P=.04); this association was not observed in the RCT. Total time spent on the tool was not correlated with knowledge scores, which were associated with lower poverty levels (P=.009). The users from the RCT phase were more likely to select an insurance plan that matched the tool’s recommendations (P<.001) compared with the dissemination phase users. Conclusions: The study suggests that a higher income population may be more likely to seek information and online help when making a health insurance plan decision. We found that Show Me Health Plans users in the dissemination phase were more selective in the information they reviewed. This study illustrates one way of disseminating and implementing an empirically tested Web-based decision aid tool. Distributing Web-based tools is feasible and may attract a large number of potential users, educate them on basic health insurance information, and make recommendations based on personal information and preference. However, using Web-based tools may differ according to the demographics of the general public compared to research study participants.

  • Source: US Air Force; Copyright: Stacey Geiger; URL:; License: Public Domain (CC0).

    The Burden of a Remote Trial in a Nursing Home Setting: Qualitative Study


    Background: Despite an aging population, older adults are typically underrecruited in clinical trials, often because of the perceived burden associated with participation, particularly travel associated with clinic visits. Conducting a clinical trial remotely presents an opportunity to leverage mobile and wearable technologies to bring the research to the patient. However, the burden associated with shifting clinical research to a remote site requires exploration. While a remote trial may reduce patient burden, the extent to which this shifts burden on the other stakeholders needs to be investigated. Objective: The aim of this study was to explore the burden associated with a remote trial in a nursing home setting on both staff and residents. Methods: Using results from a grounded analysis of qualitative data, this study explored and characterized the burden associated with a remote trial conducted in a nursing home in Dublin, Ireland. A total of 11 residents were recruited to participate in this trial (mean age: 80 years; age range: 67-93 years). To support research activities, we also recruited 10 nursing home staff members, including health care assistants, an activities co-ordinator, and senior nurses. This study captured the lived experience of this remote trial among staff and residents and explored the burden associated with participation. At the end of the trial, a total of 6 residents and 8 members of staff participated in semistructured interviews (n=14). They reviewed clinical data generated by mobile and wearable devices and reflected upon their trial-related experiences. Results: Staff reported extensive burden in fulfilling their roles and responsibilities to support activities of the trial. Among staff, we found eight key characteristics of burden: (1) comprehension, (2) time, (3) communication, (4) emotional load, (5) cognitive load, (6) research engagement, (7) logistical burden, and (8) product accountability. Residents reported comparatively less burden. Among residents, we found only four key characteristics of burden: (1) comprehension, (2) adherence, (3) emotional load, and (4) personal space. Conclusions: A remote trial in a nursing home setting can minimize the burden on residents and enable inclusive participation. However, it arguably creates additional burden on staff, particularly where they have a role to play in locally supporting and maintaining technology as part of data collection. Future research should examine how to measure and minimize the burden associated with data collection in remote trials.

  • Source: The Authors /; Copyright: The Authors; URL:; License: Licensed by the authors.

    Comparing Approaches to Mobile Depression Assessment for Measurement-Based Care: Prospective Study


    Background: To inform measurement-based care, practice guidelines suggest routine symptom monitoring, often on a weekly or monthly basis. Increasingly, patient-provider contacts occur remotely (eg, by telephone and Web-based portals), and mobile health tools can now monitor depressed mood daily or more frequently. However, the reliability and utility of daily ratings are unclear. Objective: This study aimed to examine the association between a daily depressive symptom measure and the Patient Health Questionnaire-9 (PHQ-9), the most widely adopted depression self-report measure, and compare how well these 2 assessment methods predict patient outcomes. Methods: A total of 547 individuals completed smartphone-based measures, including the Patient Health Questionnaire-2 (PHQ-2) modified for daily administration, the PHQ-9, and the Sheehan Disability Scale. Multilevel factor analyses evaluated the reliability of latent depression based on the PHQ-2 (for repeated measures) between weeks 2 and 4 and its correlation with the PHQ-9 at week 4. Regression models predicted week 8 depressive symptoms and disability ratings with daily PHQ-2 and PHQ-9. Results: The daily PHQ-2 and PHQ-9 are highly reliable (range: 0.80-0.88) and highly correlated (r=.80). Findings were robust across demographic groups (age, gender, and ethnic minority status). Daily PHQ-2 and PHQ-9 were comparable in predicting week 8 disability and were independent predictors of week 8 depressive symptoms and disability, though the unique contribution of the PHQ-2 was small in magnitude. Conclusions: Daily completion of the PHQ-2 is a reasonable proxy for the PHQ-9 and is comparable to the PHQ-9 in predicting future outcomes. Mobile assessment methods offer researchers and clinicians reliable and valid new methods for depression assessment that may be leveraged for measurement-based depression care.

  • Source: Placeit; Copyright: The Authors; URL:; License: Licensed by the authors.

    Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled...


    Background: Prevalent co-occurring poor diet and physical inactivity convey chronic disease risk to the population. Large magnitude behavior change can improve behaviors to recommended levels, but multiple behavior change interventions produce small, poorly maintained effects. Objective: The Make Better Choices 2 trial tested whether a multicomponent intervention integrating mHealth, modest incentives, and remote coaching could sustainably improve diet and activity. Methods: Between 2012 and 2014, the 9-month randomized controlled trial enrolled 212 Chicago area adults with low fruit and vegetable and high saturated fat intakes, low moderate to vigorous physical activity (MVPA) and high sedentary leisure screen time. Participants were recruited by advertisements to an open-access website, screened, and randomly assigned to either of two active interventions targeting MVPA simultaneously with, or sequentially after other diet and activity targets (N=84 per intervention) or a stress and sleep contact control intervention (N=44). They used a smartphone app and accelerometer to track targeted behaviors and received personalized remote coaching from trained paraprofessionals. Perfect behavioral adherence was rewarded with an incentive of US $5 per week for 12 weeks. Diet and activity behaviors were measured at baseline, 3, 6, and 9 months; primary outcome was 9-month diet and activity composite improvement. Results: Both simultaneous and sequential interventions produced large, sustained improvements exceeding control (P<.001), and brought all diet and activity behaviors to guideline levels. At 9 months, the interventions increased fruits and vegetables by 6.5 servings per day (95% CI 6.1-6.8), increased MVPA by 24.7 minutes per day (95% CI 20.0-29.5), decreased sedentary leisure by 170.5 minutes per day (95% CI –183.5 to –157.5), and decreased saturated fat intake by 3.6% (95% CI –4.1 to –3.1). Retention through 9-month follow-up was 82.1%. Self-monitoring decreased from 96.3% of days at baseline to 72.3% at 3 months, 63.5% at 6 months, and 54.6% at 9 months (P<.001). Neither attrition nor decline in self-monitoring differed across intervention groups. Conclusions: Multicomponent mHealth diet and activity intervention involving connected coaching and modest initial performance incentives holds potential to reduce chronic disease risk. Trial Registration: NCT01249989; (Archived by WebCite at

  • Source: Freepik; Copyright: Yanalya; URL:; License: Licensed by JMIR.

    Severely Burdened Individuals Do Not Need to Be Excluded From Internet-Based and Mobile-Based Stress Management: Effect Modifiers of Treatment Outcomes From...


    Background: Although internet-based and mobile-based stress management interventions (iSMIs) may be a promising strategy to reach employees suffering from high chronic stress, it remains unknown whether participants with high symptom severity of depression or anxiety also benefit from iSMIs or should be excluded. Objective: This study aimed to evaluate the efficacy of iSMIs in subgroups with high symptom severity and to test whether baseline symptom severity moderates treatment outcome. Methods: Data from three randomized controlled trials (N=791) were pooled to identify effect modifiers and to evaluate efficacy in subgroups with different levels of initial symptom severity. The outcomes perceived stress (Perceived Stress Scale, PSS), depression severity (Center for Epidemiological Depression Scale, CES-D), and anxiety (Hospital Anxiety and Depression Scale, HADS) symptom severity were assessed at baseline, 7-week postassessment, and 6-month follow-up. Potential moderators were tested in predicting differences in the change of outcome in multiple moderation analyses. Simple slope analyses evaluated efficacy of the iSMI comparing the intervention group with the waitlist control group in subgroups with low, moderate, and severe initial symptomology based on means and SDs of the study population. In addition, subgroups with clinical values of depression (CES-D≥16) and anxiety (HADS≥8) at baseline were explored, and response rates (RRs; 50% symptom reduction) and symptom-free (SF) status (CES-D<16, HADS<8) were reported. Results: Individuals with high stress (PSS≥30), depression (CES-D≥33), anxiety (HADS≥15), and emotional exhaustion (MBI≥5.6) benefited significantly from the intervention with great reductions of stress (dpost=0.86-1.16, dFU=0.93-1.35), depression (dpost=0.69-1.08, dFU=0.91-1.19), and anxiety (dpost=0.79-1.19, dFU=1.06-1.21), and effects were sustained at 6-month follow-up. Symptom severity moderated treatment outcomes, as individuals with higher symptom severity at baseline benefited significantly more from the intervention than individuals with lower symptom severity. Furthermore, 82.9% (656/791) of individuals had clinical depression values at baseline, of which significantly more individuals in the intervention group reached at least 50% symptom reduction or fell under clinical cut-off (RR: 29.2%, 93/318; SF: 39.6%, 126/318) compared with the waitlist control group (RR: 8.0%, 27/338; SF: 18.6%, 63/338) at postassessment. Significantly more individuals with clinical anxiety values at baseline (HADS≥8, 85.3%, 675/791) in the intervention group achieved at least 50% symptom reduction or fell under clinical cut-off (RR: 27.7%, 94/339; SF: 39.8%, 135/339) compared with the WLC (RR: 4.8%, 16/336; SF: 15.5%, 52/336). Conclusions: Highly burdened individuals benefit greatly from iSMIs and therefore should not be excluded from participation. Stress management may be a valid entry point to reach highly burdened individuals who otherwise may not seek treatment. Trial Registration: 1) German Clinical Trials Register DRKS00005112; (Archived by WebCite at; 2) German Clinical Trials Register DRKS00005384; DRKS00005384 (Archived by WebCite at; and 3) German Clinical Trials Register DRKS00004749; (Archived by WebCite at

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  • Telemedicine in remote orthopaedic consultations is cost-effective. A randomised controlled trial

    Date Submitted: Jun 19, 2018

    Open Peer Review Period: Jun 23, 2018 - Aug 18, 2018

    Background: Telemedicine consultations using realtime videoconferencing has the potential to improve access and quality of care, avoid patient travels and reduce healthcare costs. Objective: The aim o...

    Background: Telemedicine consultations using realtime videoconferencing has the potential to improve access and quality of care, avoid patient travels and reduce healthcare costs. Objective: The aim of this study was to examine the cost-effectiveness of an orthopaedic videoconferencing service between the University Hospital of North-Norway and a regional medical centre in a remote community located 148 km away. Methods: An economic evaluation based on a randomised controlled trial of 389 patients (557 consultations) referred to the hospital for an orthopaedic outpatient consultation was conducted 5 years after the intervention ended. Patients randomised to the intervention group received video-assisted remote orthopaedic consultations (n=302 consultations). Patient randomised to the control group received standard care in outpatient consultation at the hospital (n=257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as Quality Adjusted Life Years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts and consultation records. These were valued using externally collected data on unit costs and QALY-weights. An extended sensitivity analysis was conducted to address the robustness of the results. Results: This study shows that using videoconferencing for orthopaedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceed 158 per year. For a total workload of 300 consultations per year the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultation needed to break even was 193. Conclusions: The number of patients visiting the remote medical centre were much larger than the break even numbers. Thus, the telemedicine service investigated here is cost-effective, both from a societal and a health sector perspective. Clinical Trial: identifier: NCT00616837. Due to organisational delays, the trial was registered on 22 January 2008. The specified study start date in is November 2007.

  • Applying an affordances framework to social media intervention approaches

    Date Submitted: Jun 20, 2018

    Open Peer Review Period: Jun 23, 2018 - Aug 18, 2018

    Social media interventions are a growing area of internet research, particularly for adolescent health. Researchers developing social media intervention approaches face the task of selecting a social...

    Social media interventions are a growing area of internet research, particularly for adolescent health. Researchers developing social media intervention approaches face the task of selecting a social media platform for their intervention. In this paper, we present the theoretical framework of affordances to help guide social media platform selection for intervention research. We first describe methodological approaches to incorporating common affordances into intervention design, followed by four examples of intervention design applying the affordance framework. A scientific approach for the selection of the appropriate social media platform for a given intervention is an important research priority to advance the field of internet research.

  • An eighteen-month prospective cohort study examining the effect of using geosocial networking applications on the HIV incidence rate among men who have sex with men in Shenyang, China

    Date Submitted: Jun 19, 2018

    Open Peer Review Period: Jun 21, 2018 - Aug 16, 2018

    Background: Men who have sex with men (MSM) frequently seek partners through geosocial networking applications (GSN-APPs). However, it is unclear whether GSN-APPs use is associated with the increase i...

    Background: Men who have sex with men (MSM) frequently seek partners through geosocial networking applications (GSN-APPs). However, it is unclear whether GSN-APPs use is associated with the increase in HIV (human immunodeficiency virus) incidence among MSM. Objective: To clarify the characteristics of GSN-APPs users, and to determine the association and putative mechanisms between GSN-APPs use behavior and HIV incidence. Methods: We conducted an eighteen-month prospective cohort study of MSM in Shenyang, China, and the participants were surveyed every three months from March 2015 to December 2016. An in-person interview collected information on socio-demographics, GSN-APPs use, recreational drug use, and sexual behaviors. In addition, blood was drawn to test for HIV and syphilis. We used a multivariable Cox regression model to determine possible predictors for increased HIV incidence. Results: Of the enrolled 686 HIV-negative MSM, 431 (62.8%) were GSN-APPs users. Compared to GSN-APPs nonusers, GSN-APPs users were younger, had an earlier age of sexual debut, and in the past three months, were more likely to have used recreational drugs, more likely to have had 5 or more casual partners (CPs), more likely to have had group sex with males, and more likely to have had condomless anal intercourse (CAI) with male steady partners (SPs). In addition, 59.4% (256/431) of the GSN-APPs users were willing to accept HIV/AIDS (acquired immunodeficiency syndrome) prevention information push services through GSN-APPs. In total, 19 MSM seroconverted to HIV during the follow-up period; the HIV incidence density rate was 8.1 (95% confidence interval (CI): 4.7-12.9)/100 person-years (PY) among GSN-APPs users and 2.2 (95% CI: 0.4-6.2)/100 PY among nonusers (P=.02). New HIV infections were independently associated with ever using GSN-APPs to seek male sexual partners (P=.04), and in the past three months, using recreational drugs (P=.048), having group sex with males (P=.01), and having CAI with male CPs (P=.02). Conclusions: GSN-APPs use is associated with higher HIV incidence, and may be mediated through recreational drug use and having multiple CPs. Researchers must develop an intervention propagated through GSN-APPs to reach this high-risk population in order to mitigate the HIV epidemic in the MSM community.

  • eStEPs – A eHealth Strategy for Elderly Patients

    Date Submitted: Jun 21, 2018

    Open Peer Review Period: Jun 21, 2018 - Aug 16, 2018

    Background: Routine practice in oncology increasingly relies on electronic Patient Reported Outcome (ePRO) measures. Elderly and less tech‐savvy patients often experience difficulties regarding elec...

    Background: Routine practice in oncology increasingly relies on electronic Patient Reported Outcome (ePRO) measures. Elderly and less tech‐savvy patients often experience difficulties regarding electronic questionnaires. Hence, innovative strategies have to be developed to overcome their uncertainty and inexperience in computer usage. Objective: The first objective of this paper is to analyze the status quo of elderly patients regarding their internet usage, technical handling and future interest in internet-based therapy support, by focusing on septuagenarians and older patients who have already participated in a previous survey on breast cancer. The second objective is to examine the required adaptions within the CANKADO eHealth platform to meet the needs of elderly patients. The modifications were based on the results of unstructured interviews conducted with myeloma patients who actively used CANKADO for at least two months. Methods: The eHealth Strategy for Elderly Patients (eStEPs) is a module inside the open online platform CANKADO ( In the first stage, 124 patients aged 70 years and older were interviewed regarding their internet use and technical equipment. In the second stage, 30 patients with multiple myeloma actively used CANKADO supplementary to their therapy. These patients were treated in eight centers. During the project term of at least two months, all participating Health Care Professionals HCPs and patients were regularly questioned in open interviews on their eHealth practice. Results: The first phase showed a high penetration of internet usage in patients above 70 years: 51% of all surveyed patients had a computer with internet access at home while 36% used the internet every day. In the course of the second phase, 30 patients, 12 nurses and 7 physicians took part in My–eStEPs. Evaluation of the recorded statements led to three significant modifications in CANKADO: The implementation of a simplified login procedure, the possibility of dynamic content adjustment and the development of a simulation mode where HCPs can switch to the patient’s interface to show and explain the application to the patient. Conclusions: To successfully establish eHealth methods among elderly patients, it is important to understand their needs and adapt the services to their requirements. Moreover, a close cooperation between HCPs and their patients is an essential demand during the initial period.

  • Telemonitoring Blood Pressure In Kidney Disease: A Feasibility Study - Oxford Heart And Renal Protection Study-1 (OX HARP-1)

    Date Submitted: Jun 18, 2018

    Open Peer Review Period: Jun 21, 2018 - Aug 16, 2018

    Background: Blood pressure (BP) is a key modifiable risk factor for patients with CKD, with current guidelines recommending strict control to reduce the risk of both progression of CKD and cardiovascu...

    Background: Blood pressure (BP) is a key modifiable risk factor for patients with CKD, with current guidelines recommending strict control to reduce the risk of both progression of CKD and cardiovascular disease. Trials of BP lowering require multiple visits to achieve target BP which increases the costs of such trials, and in routine care BP measured in clinic may not accurately reflect usual BP. Objective: We sought to assess whether a telemonitoring system for BP (using a Bluetooth-enable BP machine which could transmit BP measurements to a tablet device which had a bespoke app to guide measurement of BP and collect questionnaire data) was acceptable to patients with CKD, and whether patients would provide sufficient BP readings to assess variability and guide treatment. Methods: 25 participants with CKD were trained to use the telemonitoring equipment, asked to record BP daily for 30 days, attend a study visit, and then record BP on alternate days for the next 60 days. They were also offered a wrist-worn applanation tonometry device (BPro) which measures BP every 15 minutes over a 24 hour period. Participants were given questionnaires at the one-month and three-month time points, derived from the System Usability Scale and Technology Acceptance Model. Results: Mean age was 58 (SD 11) years and mean eGFR was 36 (SD 13) mL/min/1.73m2. 52% of participants provided >90% of expected data and 72% provided >80% expected data. The usability of the telemonitoring system was rated highly with mean scores of 84.9/100 (SE 2.8) after 30 days and 84.2/100 (SE 4.1) after 90 days. The coefficient of variation (CV) for variability of telemonitoring systolic BP was 8.9%, compared to 7.9% for the BPro device (and 9.0% over one year in a recently completed trial with identical eligibility criteria), indicating that most variation in BP is short-term. Conclusions: Telemonitoring is acceptable to patients with CKD and provides sufficient data to inform titration of antihypertensive therapies in either a randomized trial setting (comparing different targets BPs) or routine clinical practice. Such methods could be employed in both scenarios and reduce costs currently associated with such activities. Clinical Trial: ISRCTN13725286

  • Internet Access and Hypertension Management among the Elderly Population: A Nationally Representative Cross-Sectional Survey in China

    Date Submitted: Jun 17, 2018

    Open Peer Review Period: Jun 20, 2018 - Aug 15, 2018

    Background: Hypertension is a rapidly growing epidemic in China. Yet it remains inadequately controlled, especially in rural areas. Internet has shown potential for better health management in differe...

    Background: Hypertension is a rapidly growing epidemic in China. Yet it remains inadequately controlled, especially in rural areas. Internet has shown potential for better health management in different settings; however, few studies have investigated its role in hypertension management in China. Objective: Our study aimed to examine the association between Internet access and hypertension awareness, treatment and control among elderly Chinese adults, and to investigate whether the association between Internet access and hypertension management differed between those lived in urban areas and those lived in rural areas. Methods: Data were obtained from the nationally representative survey of the China Health and Retirement Longitudinal Study in 2011. Hypertension was defined as (i) an average systolic blood pressure of ≥ 140 mm Hg, and/or an average diastolic blood pressure of ≥ 90 mm Hg; and/or (ii) currently taking antihypertensive medications. Outcome assessed included hypertension awareness, treatment and control. The key independent variable was defined as whether one had Internet access at home. Multivariate logistic regressions were performed for each of the three outcomes. Results: Among 5135 hypertensive respondents (62.4 ± 9.9 years; 45.8% men), 12·9% had Internet access at home. Compared to those had no Internet access, Internet access was positively associated with hypertension awareness (odds ratio, 1.36 [1.07–1.73]) and treatment (odds ratio, 1.38 [1.09–1.75], but not control (odds ratio, 1.19 [0.90–1.58]). Internet access reduced urban-rural disparity in hypertension awareness by 9.6 percentage points (P = 0.02), treatment by 8.3 percentage points (P = 0.05), but not in control. In addition, the moderating effect of Internet access on urban-rural disparities in hypertension management was larger among females. The decreased urban-rural disparities were primarily driven by that Internet access improved the management level in rural areas. Conclusions: Strategies for reducing the disparities in hypertension management and overall disease burden of hypertension among elderly population should consider Internet as a platform.