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

Design and multi-country validation of SMS for an mHealth, behavioral change, randomized clinical trial on primary prevention of progression to hypertension

Background: Mobile health (mHealth) has been posited to contribute to reduction in health gaps, showing fast and wide spread into developing countries. This growth demands understanding of and preparedness for local cultural contexts. Objective: To describe the design and validation of text messages (SMS) to be used for an mHealth behavioral change intervention to prevent hypertension in three Latin American countries: Argentina, Guatemala, and Peru. Methods: An initial set of 64 SMS were designed to promote healthy lifestyles among individuals in different stages of behavior change, addressing four key domains: salt and sodium intake, fruit and vegetable intake, consumption of high fat and sugar foods, and physical activity. The 64 SMS were organized in nine subsets for field validation. In each country, 36 people, half of them male, were recruited. Four participants per country evaluated each subset of SMS, which had between 6 and 8 SMS of different key domains and stages of change. Understanding and appeal of each SMS was assessed using a 7-item questionnaire. Understanding and appeal ratings were used to reach a final set of 56 SMS. Results: Overall, each of the 64 SMS received a total of 12 evaluations (4 per country). The majority of evaluations, 96.7% of a total of 767, revealed an adequate understanding of the key idea contained in the SMS. On a scale from 0-10, the average appeal score was 8.7 points (range 4-10 points). Based on their low scores, eight SMS per country were discarded. Once the final set of 56 SMS was identified, and based on feedback obtained in the field, wording and content of some SMS was improved: 9 SMS in Argentina, 8 SMS in Guatemala and 16 SMS in Peru. Most SMS selected for the final set (49/56) were the same in all countries, except for small wording differences. Conclusions: The final set of SMS produced had very high rates of understanding and appeal in three different Latin American countries. This study highlights the importance of developing and validating a package of simple preventative SMS, grounded on evidence and theory, across three different Latin American countries with active engagement of end-users.

2014-10-04

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Recent Articles:

  • Tablet, Web-Based, or Paper Questionnaires for Measuring Anxiety in Patients Suspected of Breast Cancer: Patients' Preferences and Quality of Collected Data

    Abstract:

    Background: Electronic applications are increasingly being used in hospitals for numerous purposes. Objective: Our aim was to assess differences in the characteristics of patients who choose paper versus electronic questionnaires and to evaluate the data quality of both approaches. Methods: Between October 2012 and June 2013, 136 patients participated in a study on diagnosis-induced stress and anxiety. Patients were asked to fill out questionnaires at six different moments during the diagnostic phase. They were given the opportunity to fill out the questionnaires on paper or electronically (a combination of tablet and Web-based questionnaires). Demographic characteristics and completeness of returned data were compared between groups. Results: Nearly two-thirds of patients (88/136, 64.7%) chose to fill out the questionnaires on paper, and just over a third (48/136, 35.3%) preferred the electronic option. Patients choosing electronic questionnaires were significantly younger (mean 47.3 years vs mean 53.5 in the paper group, P=.01) and higher educated (P=.004). There was significantly more missing information (ie, at least one question not answered) in the paper group during the diagnostic day compared to the electronic group (using a tablet) (28/88 vs 1/48, P<.001). However, in the week after the diagnostic day, missing information was significantly higher in the electronic group (Web-based questionnaires) compared to the paper group (41/48 vs 38/88, P<.001). Conclusions: Younger patients and patients with a higher level of education have a preference towards filling out questionnaires electronically. In the hospital, a tablet is an excellent medium for patients to fill out questionnaires with very little missing information. However, for filling out questionnaires at home, paper questionnaires resulted in a better response than Web-based questionnaires.
  • Rapid Grading of Fundus Photographs for Diabetic Retinopathy Using Crowdsourcing

    Abstract:

    Background: Screening for diabetic retinopathy is both effective and cost-effective, but rates of screening compliance remain suboptimal. As screening improves, new methods to deal with screening data may help reduce the human resource needs. Crowdsourcing has been used in many contexts to harness distributed human intelligence for the completion of small tasks including image categorization. Objective: Our goal was to develop and validate a novel method for fundus photograph grading. Methods: An interface for fundus photo classification was developed for the Amazon Mechanical Turk crowdsourcing platform. We posted 19 expert-graded images for grading by Turkers, with 10 repetitions per photo for an initial proof-of-concept (Phase I). Turkers were paid US $0.10 per image. In Phase II, one prototypical image from each of the four grading categories received 500 unique Turker interpretations. Fifty draws of 1-50 Turkers were then used to estimate the variance in accuracy derived from randomly drawn samples of increasing crowd size to determine the minimum number of Turkers needed to produce valid results. In Phase III, the interface was modified to attempt to improve Turker grading. Results: Across 230 grading instances in the normal versus abnormal arm of Phase I, 187 images (81.3%) were correctly classified by Turkers. Average time to grade each image was 25 seconds, including time to review training images. With the addition of grading categories, time to grade each image increased and percentage of images graded correctly decreased. In Phase II, area under the curve (AUC) of the receiver-operator characteristic (ROC) indicated that sensitivity and specificity were maximized after 7 graders for ratings of normal versus abnormal (AUC=0.98) but was significantly reduced (AUC=0.63) when Turkers were asked to specify the level of severity. With improvements to the interface in Phase III, correctly classified images by the mean Turker grade in four-category grading increased to a maximum of 52.6% (10/19 images) from 26.3% (5/19 images). Throughout all trials, 100% sensitivity for normal versus abnormal was maintained. Conclusions: With minimal training, the Amazon Mechanical Turk workforce can rapidly and correctly categorize fundus photos of diabetic patients as normal or abnormal, though further refinement of the methodology is needed to improve Turker ratings of the degree of retinopathy. Images were interpreted for a total cost of US $1.10 per eye. Crowdsourcing may offer a novel and inexpensive means to reduce the skilled grader burden and increase screening for diabetic retinopathy.
  • Evaluating the Interactive Web-Based Program, Activate Your Heart, for Cardiac Rehabilitation Patients: A Pilot Study

    Abstract:

    Background: Conventional cardiac rehabilitation (CR) programs are traditionally based on time-constrained, structured, group-based programs, usually set in hospitals or leisure centers. Uptake for CR remains poor, despite the ongoing evidence demonstrating its benefits. Additional alternative forms of CR are needed. An Internet-based approach may offer an alternative mode of delivering CR that may improve overall uptake. Activate Your Heart (AYH) is a Web-based CR program that has been designed to support individuals with coronary heart disease (CHD). Objective: The aim of this pilot study was to observe the outcome for participants following the AYH program. Methods: We conducted a prospective observational trial, recruiting low-risk patients with CHD. Measures of exercise, exercise capacity, using the Incremental Shuttle Walk Test (ISWT), dietary habits, and psychosocial well-being were conducted by a CR specialist at baseline and at 8 weeks following the Web-based intervention. Results: We recruited 41 participants; 33 completed the program. We documented significant improvements in the ISWT distance (mean change 49.69 meters, SD 68.8, P<.001), and Quality of Life (QOL) (mean change 0.28, SD 0.4, P<.001). Dietary habits improved with an increased proportion of patients consuming at least 5 portions of fruit and vegetables per day, (22 [71%] to 29 [94%] P=.01) and an increased proportion of patients consuming at least 2 portions of oily fish per week (14 [45%] to 21 [68%], P=.01). We did not detect changes in anxiety and depression scores or exercise behavior. Conclusions: We observed important improvements in exercise capacity, QOL, and dietary habits in a group of participants following a Web-based CR program. The program may offer an alternative approach to CR. A mobile version has been developed and we need to conduct further trials to establish its value compared to supervised CR.
  • Comorbidity Structure of Psychological Disorders in the Online e-PASS Data as Predictors of Psychosocial Adjustment Measures: Psychological Distress,...

    Abstract:

    Background: A relative newcomer to the field of psychology, e-mental health has been gaining momentum and has been given considerable research attention. Although several aspects of e-mental health have been studied, 1 aspect has yet to receive attention: the structure of comorbidity of psychological disorders and their relationships with measures of psychosocial adjustment including suicidal ideation in online samples. Objective: This exploratory study attempted to identify the structure of comorbidity of 21 psychological disorders assessed by an automated online electronic psychological assessment screening system (e-PASS). The resulting comorbidity factor scores were then used to assess the association between comorbidity factor scores and measures of psychosocial adjustments (ie, psychological distress, suicidal ideation, adequate social support, self-confidence in dealing with mental health issues, and quality of life). Methods: A total of 13,414 participants were assessed using a complex online algorithm that resulted in primary and secondary Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) diagnoses for 21 psychological disorders on dimensional severity scales. The scores on these severity scales were used in a principal component analysis (PCA) and the resulting comorbidity factor scores were related to 4 measures of psychosocial adjustments. Results: A PCA based on 17 of the 21 psychological disorders resulted in a 4-factor model of comorbidity: anxiety-depression consisting of all anxiety disorders, major depressive episode (MDE), and insomnia; substance abuse consisting of alcohol and drug abuse and dependency; body image–eating consisting of eating disorders, body dysmorphic disorder, and obsessive-compulsive disorders; depression–sleep problems consisting of MDE, insomnia, and hypersomnia. All comorbidity factor scores were significantly associated with psychosocial measures of adjustment (P<.001). They were positively related to psychological distress and suicidal ideation, but negatively related to adequate social support, self-confidence, and quality of life. Conclusions: This exploratory study identified 4 comorbidity factors in the e-PASS data and these factor scores significantly predicted 5 psychosocial adjustment measures. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN121611000704998; http://www.anzctr.org.au/trial_view.aspx?ID=336143 (Archived by WebCite at http://www.webcitation.org/618r3wvOG).
  • Beyond Traditional Advertisements: Leveraging Facebook’s Social Structures for Research Recruitment

    Abstract:

    Background: Obtaining access to a demographically and geographically diverse sample for health-related research can be costly and time consuming. Previous studies have reported mixed results regarding the potential of using social media-based advertisements to overcome these challenges. Objective: Our aim was to develop and assess the feasibility, benefits, and challenges of recruiting for research studies related to consumer health information technology (IT) by leveraging the social structures embedded in the social networking platform, Facebook. Methods: Two recruitment strategies that involved direct communication with existing Facebook groups and pages were developed and implemented in two distinct populations. The first recruitment strategy involved posting a survey link directly to consenting groups and pages and was used to recruit Filipino-Americans to a study assessing the perceptions, use of, and preferences for consumer health IT. This study took place between August and December 2013. The second recruitment strategy targeted individuals with type 2 diabetes and involved creating a study-related Facebook group and asking administrators of other groups and pages to publicize our group to their members. Group members were then directly invited to participate in an online pre-study survey. This portion of a larger study to understand existing health management practices as a foundation for consumer health IT design took place between May and June 2014. In executing both recruitment strategies, efforts were made to establish trust and transparency. Recruitment rate, cost, content of interaction, and characteristics of the sample obtained were used to assess the recruitment methods. Results: The two recruitment methods yielded 87 and 79 complete responses, respectively. The first recruitment method yielded a rate of study completion proportionate to that of the rate of posts made, whereas recruitment successes of the second recruitment method seemed to follow directly from the actions of a subset of administrators. Excluding personnel time, the first recruitment method resulted in no direct costs, and the second recruitment method resulted in a total direct cost of US $118.17. Messages, posts, and comments received using both recruitment strategies reflected ten themes, including appreciation, assistance, clarification, concerns, encouragement, health information, interest, promotion, solicitations, and support. Both recruitment methods produced mixed results regarding sample representativeness with respect to characteristics such as gender, race, and ethnicity. Conclusions: The results of the study demonstrate that leveraging the social structures of Facebook for health-related research was feasible for obtaining small samples appropriate for qualitative research but not for obtaining large samples needed for quantitative research. The content of interactions with members of the target population prompted ethical deliberations concerning suitable target communities and appropriate boundaries between researchers and participants. Widespread replication of this method would benefit from a broad discussion among researchers, social media users, social media companies, and experts in research ethics to address appropriate protocols for such interactions.
  • Patients’ Continuing Use of an Online Health Record: A Quantitative Evaluation of 14,000 Patient Years of Access Data

    Abstract:

    Background: Online access to all or part of their health records is widely demanded by patients and, where provided in form of patient portals, has been substantially used by at least subgroups of patients, particularly those with chronic disease. However, little is reported regarding the longer-term patient use of patient-accessible electronic health record services, which is important in allocating resources. Renal PatientView (RPV) is an established system that gives patients with chronic kidney disease access to live test results and information about their condition and treatment. It is available in most UK renal units with up to 75% of particular patient groups registered in some centers. We have analyzed patient use out to 4 years and investigated factors associated with more persistent use. Objective: Our aim was to investigate RPV use by patients over time from initial registration in order to understand which patients choose to access RPV and the endurance of its appeal for different patient groups. Methods: We analyzed an anonymized extract of the database underlying RPV containing information on patient registration and events including patient access and the arrival of new blood test results or letters that patients might wish to view. Results: At the time of the extract, there were 11,352 patients registered on RPV for 0-42 months (median 17). More than half of registrants became persistent users, logging in a median of 2.0 times each month over post-registration intervals of up to 42 months (median 18.9). Provision of assistance with first logon was strongly associated with becoming a persistent user, even at 3 years. Logons by persistent users occurred around the time of consultations/tests, strongly suggestive of patient engagement. While indices indicative of greater deprivation were the strongest determinants of non-participation, they had negligible influence on drop-out rates among established users. Conclusions: In this mature patient portal system, a large proportion of patients made regular use of their online health records over protracted periods. The patterns and timing of use indicate strong patient interest in detailed information such as recent test results and clinic letters. Supporting patients through the first steps of establishing access to their online records is associated with much higher rates of long-term use of RPV and likely would increase use of other electronic health records provided for patients with chronic disease.
  • Diabetes Patients' Experiences With the Implementation of Insulin Therapy and Their Perceptions of Computer-Assisted Self-Management Systems for Insulin Therapy

    Abstract:

    Background: Computer-assisted decision support is an emerging modality to assist patients with type 2 diabetes mellitus (T2DM) in insulin self-titration (ie, self-adjusting insulin dose according to daily blood glucose levels). Computer-assisted insulin self-titration systems mainly focus on helping patients overcome barriers related to the cognitive components of insulin titration. Yet other (eg, psychological or physical) barriers could still impede effective use of such systems. Objective: Our primary aim was to identify experiences with and barriers to self-monitoring of blood glucose, insulin injection, and insulin titration among patients with T2DM. Our research team developed a computer-assisted insulin self-titration system, called PANDIT. The secondary aim of this study was to evaluate patients’ perceptions of computer-assisted insulin self-titration. We included patients who used PANDIT in a 4-week pilot study as well as patients who had never used such a system. Methods: In-depth, semi-structured interviews were conducted individually with patients on insulin therapy who were randomly recruited from a university hospital and surrounding general practices in the Netherlands. The interviews were transcribed verbatim and analyzed qualitatively. To classify the textual remarks, we created a codebook during the analysis, in a bottom-up and iterative fashion. To support examination of the final coded data, we used three theories from the field of health psychology and the integrated model of user satisfaction and technology acceptance by Wixom and Todd. Results: When starting insulin therapy, some patients feared a lifelong commitment to insulin therapy and disease progression. Also, many barriers arose when implementing insulin therapy (eg, some patients were embarrassed to inject insulin in public). Furthermore, patients had difficulties increasing the insulin dose because they fear hypoglycemia, they associate higher insulin doses with disease progression, and some were ignorant of treatment targets. Patients who never used a computer-assisted insulin self-titration system felt they had enough knowledge to know when their insulin should be adjusted, but still believed that the system advice would be useful to confirm their reasoning. Furthermore, the time and effort saved with automated insulin advice was considered an advantage. Patients who had used PANDIT found the system useful if their glycemic regulation improved. Nevertheless, for some patients, the absence of personal contact with their caregiver was a drawback. While guidelines state that adjustment of basal insulin dose based on fasting plasma glucose values is sufficient, both patients who had and those who had not used PANDIT felt that such a system should take more patient data into consideration, such as lifestyle and diet factors. Conclusions: Patients encounter multiple obstacles when implementing insulin therapy. Computer-assisted insulin self-titration can increase patient awareness of treatment targets and increase their confidence in self-adjusting the insulin dose. Nevertheless, some barriers may still exist when using computer-assisted titration systems and these systems could also introduce new barriers.
  • Understanding Usage of a Hybrid Website and Smartphone App for Weight Management: A Mixed-Methods Study

    Abstract:

    Background: Advancements in mobile phone technology offer huge potential for enhancing the timely delivery of health behavior change interventions. The development of smartphone-based health interventions (apps) is a rapidly growing field of research, yet there have been few longitudinal examinations of how people experience and use these apps within their day-to-day routines, particularly within the context of a hybrid Web- and app-based intervention. Objective: This study used an in-depth mixed-methods design to examine individual variation in (1) impact on self-reported goal engagement (ie, motivation, self-efficacy, awareness, effort, achievement) of access to a weight management app (POWeR Tracker) when provided alongside a Web-based weight management intervention (POWeR) and (2) usage and views of POWeR Tracker. Methods: Thirteen adults were provided access to POWeR and were monitored over a 4-week period. Access to POWeR Tracker was provided in 2 alternate weeks (ie, weeks 1 and 3 or weeks 2 and 4). Participants’ goal engagement was measured daily via self-report. Mixed effects models were used to examine change in goal engagement between the weeks when POWeR Tracker was and was not available and whether the extent of change in goal engagement varied between individual participants. Usage of POWeR and POWeR Tracker was automatically recorded for each participant. Telephone interviews were conducted and analyzed using inductive thematic analysis to further explore participants’ experiences using POWeR and POWeR Tracker. Results: Access to POWeR Tracker was associated with a significant increase in participants’ awareness of their eating (β1=0.31, P=.04) and physical activity goals (β1=0.28, P=.03). The level of increase varied between individual participants. Usage data showed that participants used the POWeR website for similar amounts of time during the weeks when POWeR Tracker was (mean 29 minutes, SD 31 minutes) and was not available (mean 27 minutes, SD 33 minutes). POWeR Tracker was mostly accessed in short bursts (mean 3 minutes, SD 2 minutes) during convenient moments or moments when participants deemed the intervention content most relevant. The qualitative data indicated that nearly all participants agreed that it was more convenient to access information on-the-go via their mobiles compared to a computer. However, participants varied in their views and usage of the Web- versus app-based components and the informational versus tracking tools provided by POWeR Tracker. Conclusions: This study provides evidence that smartphones have the potential to improve individuals’ engagement with their health-related goals when used as a supplement to an existing online intervention. The perceived convenience of mobile access to information does not appear to deter use of Web-based interventions or strengthen the impact of app access on goal engagement. A mixed-methods design enabled exploration of individual variation in daily usage of the app-based tools.
  • Supporting Health Care Professionals to Improve the Processes of Shared Decision Making and Self-Management in a Web-Based Intervention: Randomized...

    Abstract:

    Background: Research to assess the effect of interventions to improve the processes of shared decision making and self-management directed at health care professionals is limited. Using the protocol of Intervention Mapping, a Web-based intervention directed at health care professionals was developed to complement and optimize health services in patient-centered care. Objective: The objective of the Web-based intervention was to increase health care professionals’ intention and encouraging behavior toward patient self-management, following cardiovascular risk management guidelines. Methods: A randomized controlled trial was used to assess the effect of a theory-based intervention, using a pre-test and post-test design. The intervention website consisted of a module to help improve professionals’ behavior, a module to increase patients’ intention and risk-reduction behavior toward cardiovascular risk, and a parallel module with a support system for the health care professionals. Health care professionals (n=69) were recruited online and randomly allocated to the intervention group (n=26) or (waiting list) control group (n=43), and invited their patients to participate. The outcome was improved professional behavior toward health education, and was self-assessed through questionnaires based on the Theory of Planned Behavior. Social-cognitive determinants, intention and behavior were measured pre-intervention and at 1-year follow-up. Results: The module to improve professionals’ behavior was used by 45% (19/42) of the health care professionals in the intervention group. The module to support the health professional in encouraging behavior toward patients was used by 48% (20/42). The module to improve patients’ risk-reduction behavior was provided to 44% (24/54) of patients. In 1 of every 5 patients, the guideline for cardiovascular risk management was used. The Web-based intervention was poorly used. In the intervention group, no differences in social-cognitive determinants, intention and behavior were found for health care professionals, compared with the control group. We narrowed the intervention group and no significant differences were found in intention and behavior, except for barriers. Results showed a significant overall difference in barriers between the intervention and the control group (F1=4.128, P=.02). Conclusions: The intervention was used by less than half of the participants and did not improve health care professionals’ and patients’ cardiovascular risk-reduction behavior. The website was not used intensively because of time and organizational constraints. Professionals in the intervention group experienced higher levels of barriers to encouraging patients, than professionals in the control group. No improvements were detected in the processes of shared decision making and patient self-management. Although participant education level was relatively high and the intervention was pre-tested, it is possible that the way the information was presented could be the reason for low participation and high dropout. Further research embedded in professionals’ regular consultations with patients is required with specific emphasis on the processes of dissemination and implementation of innovations in patient-centered care. Clinical Trial: Netherlands Trial Register Number (NTR): NTR2584; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2584 (Archived by WebCite at http://www.webcitation.org/6STirC66r).
  • A Case Study of the New York City 2012-2013 Influenza Season With Daily Geocoded Twitter Data From Temporal and Spatiotemporal Perspectives

    Abstract:

    Background: Twitter has shown some usefulness in predicting influenza cases on a weekly basis in multiple countries and on different geographic scales. Recently, Broniatowski and colleagues suggested Twitter’s relevance at the city-level for New York City. Here, we look to dive deeper into the case of New York City by analyzing daily Twitter data from temporal and spatiotemporal perspectives. Also, through manual coding of all tweets, we look to gain qualitative insights that can help direct future automated searches. Objective: The intent of the study was first to validate the temporal predictive strength of daily Twitter data for influenza-like illness emergency department (ILI-ED) visits during the New York City 2012-2013 influenza season against other available and established datasets (Google search query, or GSQ), and second, to examine the spatial distribution and the spread of geocoded tweets as proxies for potential cases. Methods: From the Twitter Streaming API, 2972 tweets were collected in the New York City region matching the keywords “flu”, “influenza”, “gripe”, and “high fever”. The tweets were categorized according to the scheme developed by Lamb et al. A new fourth category was added as an evaluator guess for the probability of the subject(s) being sick to account for strength of confidence in the validity of the statement. Temporal correlations were made for tweets against daily ILI-ED visits and daily GSQ volume. The best models were used for linear regression for forecasting ILI visits. A weighted, retrospective Poisson model with SaTScan software (n=1484), and vector map were used for spatiotemporal analysis. Results: Infection-related tweets (R=.763) correlated better than GSQ time series (R=.683) for the same keywords and had a lower mean average percent error (8.4 vs 11.8) for ILI-ED visit prediction in January, the most volatile month of flu. SaTScan identified primary outbreak cluster of high-probability infection tweets with a 2.74 relative risk ratio compared to medium-probability infection tweets at P=.001 in Northern Brooklyn, in a radius that includes Barclay’s Center and the Atlantic Avenue Terminal. Conclusions: While others have looked at weekly regional tweets, this study is the first to stress test Twitter for daily city-level data for New York City. Extraction of personal testimonies of infection-related tweets suggests Twitter’s strength both qualitatively and quantitatively for ILI-ED prediction compared to alternative daily datasets mixed with awareness-based data such as GSQ. Additionally, granular Twitter data provide important spatiotemporal insights. A tweet vector-map may be useful for visualization of city-level spread when local gold standard data are otherwise unavailable.
  • Use of Mobile Phone Text Message Reminders in Health Care Services: A Narrative Literature Review

    Abstract:

    Background: Mobile text messages are a widely recognized communication method in societies, as the global penetration of the technology approaches 100% worldwide. Systematic knowledge is still lacking on how the mobile telephone text messaging (short message service, SMS) has been used in health care services. Objective: This study aims to review the literature on the use of mobile phone text message reminders in health care. Methods: We conducted a systematic literature review of studies on mobile telephone text message reminders. The data sources used were PubMed (MEDLINE), CINAHL, Proquest Databases/ PsycINFO, EMBASE, Cochrane Library, Scopus, and hand searching since 2003. Studies reporting the use of SMS intended to remind patients in health services were included. Given the heterogeneity in the studies, descriptive characteristics, purpose of the study, response rates, description of the intervention, dose and timing, instruments, outcome measures, and outcome data from the studies were synthesized using a narrative approach. Results: From 911 initial citations, 60 studies were included in the review. The studies reported a variety of use for SMS. Mobile telephone text message reminders were used as the only intervention in 73% (44/60) of the studies, and in 27% (16/60) of the remaining studies, SMS was connected to another comprehensive health intervention system. SMS reminders were sent to different patient groups: patients with HIV/AIDS (15%, 9/60) and diabetes (13%, 8/60) being the most common groups. The response rates of the studies varied from 22-100%. Typically, the text message reminders were sent daily. The time before the specific intervention to be rendered varied from 10 minutes (eg, medication taken) to 2 weeks (eg, scheduled appointment). A wide range of different evaluation methods and outcomes were used to assess the impact of SMS varying from existing databases (eg, attendance rate based on medical records), questionnaires, and physiological measures. About three quarters of the studies (77%, 46/60) reported improved outcomes: adherence to medication or to treatment reportedly improved in 40% (24/60) of the studies, appointment attendance in 18% (11/60) of the studies, and non-attendance rates decreased in 18% (11/60) of the studies. Other positive impacts were decreased amount of missed medication doses, more positive attitudes towards medication, and reductions in treatment interruptions. Conclusions: We can conclude that although SMS reminders are used with different patient groups in health care, SMS is less systematically studied with randomized controlled trial study design. Although the amount of evidence for SMS application recommendations is still limited, having 77% (46/60) of the studies showing improved outcomes may indicate its use in health care settings. However, more well-conducted SMS studies are still needed.
  • Tweeting for and Against Public Health Policy: Response to the Chicago Department of Public Health's Electronic Cigarette Twitter Campaign

    Abstract:

    Background: In January 2014, the Chicago City Council scheduled a vote on local regulation of electronic cigarettes as tobacco products. One week prior to the vote, the Chicago Department of Public Health (CDPH) released a series of messages about electronic cigarettes (e-cigarettes) through its Twitter account. Shortly after the messages, or tweets, were released, the department’s Twitter account became the target of a “Twitter bomb” by Twitter users sending more than 600 tweets in one week against the proposed regulation. Objective: The purpose of our study was to examine the messages and tweet patterns in the social media response to the CDPH e-cigarette campaign. Methods: We collected all tweets mentioning the CDPH in the week between the e-cigarette campaign and the vote on the new local e-cigarette policy. We conducted a content analysis of the tweets, used descriptive statistics to examine characteristics of involved Twitter users, and used network visualization and descriptive statistics to identify Twitter users prominent in the conversation. Results: Of the 683 tweets mentioning CDPH during the week, 609 (89.2%) were anti-policy. More than half of anti-policy tweets were about use of electronic cigarettes for cessation as a healthier alternative to combustible cigarettes (358/609, 58.8%). Just over one-third of anti-policy tweets asserted that the health department was lying or disseminating propaganda (224/609, 36.8%). Approximately 14% (96/683, 14.1%) of the tweets used an account or included elements consistent with “astroturfing”—a strategy employed to promote a false sense of consensus around an idea. Few Twitter users were from the Chicago area; Twitter users from Chicago were significantly more likely than expected to tweet in support of the policy. Conclusions: Our findings may assist public health organizations to anticipate, recognize, and respond to coordinated social media campaigns.

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  • Design and multi-country validation of SMS for an mHealth, behavioral change, randomized clinical trial on primary prevention of progression to hypertension

    Date Submitted: Oct 31, 2014

    Open Peer Review Period: Oct 31, 2014 - Dec 26, 2014

    Background: Mobile health (mHealth) has been posited to contribute to reduction in health gaps, showing fast and wide spread into developing countries. This growth demands understanding of and prepare...

    Background: Mobile health (mHealth) has been posited to contribute to reduction in health gaps, showing fast and wide spread into developing countries. This growth demands understanding of and preparedness for local cultural contexts. Objective: To describe the design and validation of text messages (SMS) to be used for an mHealth behavioral change intervention to prevent hypertension in three Latin American countries: Argentina, Guatemala, and Peru. Methods: An initial set of 64 SMS were designed to promote healthy lifestyles among individuals in different stages of behavior change, addressing four key domains: salt and sodium intake, fruit and vegetable intake, consumption of high fat and sugar foods, and physical activity. The 64 SMS were organized in nine subsets for field validation. In each country, 36 people, half of them male, were recruited. Four participants per country evaluated each subset of SMS, which had between 6 and 8 SMS of different key domains and stages of change. Understanding and appeal of each SMS was assessed using a 7-item questionnaire. Understanding and appeal ratings were used to reach a final set of 56 SMS. Results: Overall, each of the 64 SMS received a total of 12 evaluations (4 per country). The majority of evaluations, 96.7% of a total of 767, revealed an adequate understanding of the key idea contained in the SMS. On a scale from 0-10, the average appeal score was 8.7 points (range 4-10 points). Based on their low scores, eight SMS per country were discarded. Once the final set of 56 SMS was identified, and based on feedback obtained in the field, wording and content of some SMS was improved: 9 SMS in Argentina, 8 SMS in Guatemala and 16 SMS in Peru. Most SMS selected for the final set (49/56) were the same in all countries, except for small wording differences. Conclusions: The final set of SMS produced had very high rates of understanding and appeal in three different Latin American countries. This study highlights the importance of developing and validating a package of simple preventative SMS, grounded on evidence and theory, across three different Latin American countries with active engagement of end-users.

  • eHealth Literacy and Use of Web 2.0 for Health Information among Internet Users Over the Age of 50

    Date Submitted: Oct 29, 2014

    Open Peer Review Period: Oct 29, 2014 - Nov 8, 2014

    Background: Older adults are in the early stages of adopting more advanced digital devices and online participatory platforms (i.e. Web 2.0) to search for health information. Therefore, it is importan...

    Background: Older adults are in the early stages of adopting more advanced digital devices and online participatory platforms (i.e. Web 2.0) to search for health information. Therefore, it is important to understand how socio-demographic and technological factors affect eHealth literacy and the use of Web 2.0 for health information among older adults. Objective: To examine associations between socio-demographic variables, electronic device use, perceived health status, eHealth literacy, and use of Web 2.0 for health information among Internet users over the age of 50. Methods: Older adults (n=283, M=67.46 years, SD=9.98 years) were randomly selected to participate in a cross-sectional, telephone survey. Multiple linear and logistic regression analyses were conducted to determine associations between socio-demographic variables, electronic device use, perceived health status, scores on the eHealth literacy scale (eHEALS), and self-reported use/non-use of Web 2.0 for health information. Mann-Whitney U tests determined whether use of Web 2.0 for health information was associated with higher eHealth literacy. Results: Over half of respondents (n=124, 59%) reported using one electronic device to search for health information, while 41% (n=86) reported use of two or more devices. Almost 90% of older Web 2.0 users (n=90) reported using popular social media sites such as Facebook and Twitter. Total scores on the eHEALS ranged from 11 to 40 (Mdn=30, IQR=27-33). Younger age (b = -.104), more education (b = .476), and use of more electronic devices (b = 1.258) were significantly associated with greater eHealth literacy (R2 = .172, R2adj = .139, F (9,229) = 5.277, P<.001). Web 2.0 users had significantly greater eHealth literacy (Mdn = 31, n =101) than non-Web 2.0 users (Mdn = 29, n=182), U = 7001.5, z = -3.330, p = .001, r = -.20. Female older adults were nearly three times more likely than males to use Web 2.0 for health information (OR= 2.632, Wald= 8.088, df =1, P=.004). More education also predicted greater use of Web 2.0 for health information, with college graduates (OR= 2.570, Wald= 3.861, df =1, P=.049) or post graduates (OR= 7.105, Wald= 4.278, df =1, P=.04) nearly 2 to 7 times more likely than non-high school graduates to use Web 2.0. Respondents reporting use of one electronic device information (OR= 3.68, Wald= 8.857, df =1, P=.003) or two or more electronic devices (OR= 6.063, Wald= 15.93, df =1, P=.001) were between three and six times more likely to use Web 2.0 for health information when compared to respondents not reporting any electronic device use. Conclusions: Among older adults, various demographic factors were associated with eHealth literacy and use of Web 2.0 for health information. In particular, use of Web 2.0 for health information was associated with higher eHealth literacy in older adults.

  • Comparative And Cost Effectiveness Of Telemedicine Versus Telephone Counseling For Smoking Cessation

    Date Submitted: Oct 27, 2014

    Open Peer Review Period: Oct 28, 2014 - Dec 23, 2014

    Background: In rural America cigarette smoking is prevalent and healthcare providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services...

    Background: In rural America cigarette smoking is prevalent and healthcare providers lack the time and resources to help smokers quit. Telephone quitlines are important avenues for cessation services in rural America, but they are poorly integrated with local health care resources. Objective: To compare the comparative effectiveness, and cost effectiveness, of two models for delivering expert tobacco treatment at a distance: Telemedicine counseling that was integrated into smokers’ primary care clinics (Integrated Telemedicine—ITM) versus telephone counseling, similar to telephone quitline counseling, delivered to smokers in their homes (Phone). Methods: Smokers (n=566) were recruited offline from 20 primary care and safety net clinics across Kansas. They were randomly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling. Patients in ITM received real-time video counseling, similar to Skype, delivered by computer/webcams in clinic exam rooms. Three full-time equivalent trained counselors delivered the counseling. The counseling duration and content was the same in both groups and was available in Spanish or English. Both groups also received identical materials and assistance in selecting and obtaining cessation medications. The primary outcome was verified 7-day point prevalence smoking abstinence at month 12, using an intent to treat analysis. Results: There were no significant baseline differences between groups, and the trial achieved 88% follow up at 12 months. Verified abstinence at 12 months did not significantly differ between ITM or Phone (9.8% vs 12%, p=.406). Phone participants completed somewhat more counseling sessions than ITM (2.6 vs 2.4), however, participants in ITM used significantly more cessation medications than Phone (55.9% vs 46.1%, p=0.03). Compared to Phone participants, ITM participants were significantly more likely to recommend the program to a family member or friend (p=0.0075). From the combined provider + participant (societal) perspective, Phone was less costly than ITM ($81.61 versus $166.04). The cost difference was mainly due to the time and mileage costs incurred by participants, who had to travel to clinics for ITM sessions. From the provider perspective, counseling costs were similar between ITM ($45.46) and Phone ($49.58). Provider costs were strongly influenced by how the clinic space for delivering ITM was valued. Conclusions: ITM was as effective as telephone counseling for helping rural patients quit smoking. ITM increased utilization of cessation pharmacotherapy and produced higher participant satisfaction, but Phone counseling was significantly less expensive. Future interventions could combine elements of both approaches to optimize pharmacotherapy utilization, counseling adherence, and satisfaction. Such an approach could commence with a clinic office visit for pharmacotherapy guidance, and continue with real-time video counseling delivered via smart phones to flexibly deliver behavioral support to patients where they most need it—in their homes and communities. Clinical Trial: Clinical Trials Registration: NCT00843505

  • Implementation of a Confidential Helpline for Men having Sex with Men in India

    Date Submitted: Oct 27, 2014

    Open Peer Review Period: Oct 27, 2014 - Dec 22, 2014

    Background: In India, men who have sex with men (MSM) are often abused and face physical violence and harassment from police and the general society. Many MSM may not openly disclose their sexual iden...

    Background: In India, men who have sex with men (MSM) are often abused and face physical violence and harassment from police and the general society. Many MSM may not openly disclose their sexual identity, especially if they are married and have families. Due to pervasive stigma and discrimination, HIV prevention programs are unable to reach many MSM effectively. Objective: The purpose of this paper is to describe the design, operations, and monitoring of the Sahaay helpline, a mHealth intervention for MSM population of India. Methods: We established the “Sahaay” mHealth intervention in 2013, a MSM-dedicated helpline whose main goal was to increase access to comprehensive, community-based HIV prevention services and improve HIV/STI-related knowledge, attitudes and behaviors of MSM in three states of India (Chhattisgarh, Delhi, and Maharashtra). The helpline provided a 24x7 confidential and easy to use interactive voice response system (IVRS) to callers. IVRS function was monitored through an online dashboard of indicators. The system also provided real-time reporting on callers and services provided. Results: The helpline received more than 100,000 calls during the first nine months of operation. Many MSM clients reported increased self-esteem in dealing with their sexual identity and disclosing the same with their family and spouse; and an increase in HIV/AIDS risk-reduction behaviors like consistent condom use and HIV testing. Conclusions: National HIV/AIDS prevention interventions for MSM in India may wish to consider scale-up of this helpline service across the country. The helpline may serve as an important mechanism for accessing hard-to-reach MSM, and thus improving HIV prevention programing.

  • A Privacy Preservation Model for Health-Related Social Networking Sites

    Date Submitted: Oct 25, 2014

    Open Peer Review Period: Oct 27, 2014 - Dec 22, 2014

    The increasing use of health-related social network sites (SNSs) has resulted in a growing number of individuals posting personal health information online. These sites may disclose users’ health in...

    The increasing use of health-related social network sites (SNSs) has resulted in a growing number of individuals posting personal health information online. These sites may disclose users’ health information to many different individuals and organizations, yet the revelation of personal health information to unauthorized individuals or entities brings a concomitant concern of greater risk for loss of privacy among users. This paper analyzes the privacy and security characteristics of leading health-related SNSs. We present a threat model and identify the principal threats to users. Building on threat analysis and modeling, we develop a privacy preservation model that incorporates individual self-protection and privacy-by-design approaches and use it to develop principles and countermeasures which can protect privacy on health-related SNSs.

  • Strategy of Robotic Surgeons as Early Adopters of a Medical Innovation to Exert Public Influence Through Twitter

    Date Submitted: Oct 25, 2014

    Open Peer Review Period: Oct 27, 2014 - Dec 22, 2014

    Background: Twitter is gaining growing popularity as an innovative social media platform for communication and as a potential tool to influence the public in medical matters. Urologists are increasing...

    Background: Twitter is gaining growing popularity as an innovative social media platform for communication and as a potential tool to influence the public in medical matters. Urologists are increasingly incorporating this part of the blogosphere into their professional activities and thus belong to the vanguard. The type of urologist and the strategies employed to exert public influence through Twitter have not yet been identified. Objective: To examine whether robotic surgeons (RSs), as early adopters of a medical innovation, use Twitter more influentially than other urologists (OUs), and to assess their strategies. Methods: A tweet and profile analysis of Twitter users at the 28th Annual Congress of the European Association of Urology was performed. Physicians using Twitter were divided into RSs and OUs. The primary goal was to compare the public influence of RSs and OUs by assessing Twitter Follower/Following Ratio, Retweet Rank and Percentile. The secondary goal was to investigate the Twitter strategies of RSs and OUs by comparing their tweets and profiles. Results: RSs had a significantly higher Twitter Follower/Following Ratio (2.1 ± 1.1) and Retweet Rank percentile (91.4 % ± 2.4 %) than OUs (1.5 ± 1.2 and 88.5 % ± 3.8 %, respectively). RSs used original tweet content more often than OUs (69.4% and 53.8%, respectively) and their tweets contained more links than those of OUs (19.8% vs. 12.5%). The use of links in profiles was also more frequent for RSs (78.3%) than for OUs (31.9%). Conclusions: RSs had a higher public influence on Twitter than OUs. The strategy for successful Twitter use at the 28th Annual Congress of the European Association of Urology revealed posting of original tweets and links in tweets and profiles. Social media merit the attention of healthcare professionals and organizations and might optimize patient-centred care in the future.