JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

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  • Source: Flickr; Copyright: faungg's photos; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Social Media–Promoted Weight Loss Among an Occupational Population: Cohort Study Using a WeChat Mobile Phone App-Based Campaign


    Background: Being overweight and obese are major risk factors for noncommunicable diseases such as cardiovascular diseases. The prevalence of overweight and obesity is high throughout the world and these issues are very serious in the Shunyi District in China. As mobile technologies have rapidly developed, mobile apps such as WeChat are well accepted and have the potential to improve health behaviors. Objective: This study aims to evaluate the effectiveness of a mobile app (WeChat) as an intervention on weight loss behavior. Methods: This study was conducted among an occupational population from August 2015 to February 2016 in the Shunyi District of Beijing. Before the intervention, the Shunyi District Government released an official document for weight loss to all 134 government agencies and enterprises in Shunyi District. Participants willing to use our official WeChat account were enrolled in a WeChat group and received 6 months of interventions for weight loss; those who were not willing to use the account were in a control group given routine publicity on weight loss. Results: In total, 15,310 occupational participants including 3467 participants (22.65%) in the control group and 11,843 participants (77.35%) in the WeChat group were enrolled. Participants in the WeChat group lost more weight (mean 2.09, SD 3.43 kg) than people in the control group (mean 1.78, SD 2.96 kg), and the difference in mean weight loss between the two groups for males was significant based on the stratification of age and educational level. To control for confounding factors and to explore the effects of WeChat on weight loss, the propensity score method with a multinominal logistic regression was utilized. For males, this showed that the WeChat group (with both active and inactive subgroups) had a higher probability of maintaining weight, weight loss from 1 to 2 kg, or weight loss more than 2 kg than the control group. However, the control group had higher probability of weight loss from 0 to 1 kg. Being active in WeChat was likely to be associated with weight loss. The more active participants were in the weight loss program via WeChat, the more weight they lost. Conclusions: The weight loss intervention campaign based on an official WeChat account focused on an occupation-based population in Shunyi District was effective for males. The more active male participants were in using WeChat, the more weight they lost. There might be no effect or there may even be a negative effect on weight loss for females. Future research should focus on how to improve adherence to the WeChat weight loss interventions, to improve and refine the WeChat content such as developing a variety of materials to attract interest, and to protect personal privacy, especially for females.

  • Simulation of a mobile phone design and text features (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Veterans’ Preferences for Exchanging Information Using Veterans Affairs Health Information Technologies: Focus Group Results and Modeling Simulations


    Background: The Department of Veterans Affairs (VA) has multiple health information technology (HIT) resources for veterans to support their health care management. These include a patient portal, VetLink Kiosks, mobile apps, and telehealth services. The veteran patient population has a variety of needs and preferences that can inform current VA HIT redesign efforts to meet consumer needs. Objective: This study aimed to describe veterans’ experiences using the current VA HIT and identify their vision for the future of an integrated VA HIT system. Methods: Two rounds of focus group interviews were conducted with a single cohort of 47 veterans and one female caregiver recruited from Bedford, Massachusetts, and Tampa, Florida. Focus group interviews included simulation modeling activities and a self-administered survey. This study also used an expert panel group to provide data and input throughout the study process. High-fidelity, interactive simulations were created and used to facilitate collection of qualitative data. The simulations were developed based on system requirements, data collected through operational efforts, and participants' reported preferences for using VA HIT. Pairwise comparison activities of HIT resources were conducted with both focus groups and the expert panel. Rapid iterative content analysis was used to analyze qualitative data. Descriptive statistics summarized quantitative data. Results: Data themes included (1) current use of VA HIT, (2) non-VA HIT use, and (3) preferences for future use of VA HIT. Data indicated that, although the Secure Messaging feature was often preferred, a full range of HIT options are needed. These data were then used to develop veteran-driven simulations that illustrate user needs and expectations when using a HIT system and services to access VA health care services. Conclusions: Patient participant redesign processes present critical opportunities for creating a human-centered design. Veterans value virtual health care options and prefer standardized, integrated, and synchronized user-friendly interface designs.

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

    An International Study on the Determinants of Poor Sleep Amongst 15,000 Users of Connected Devices


    Background: Sleep is a modifiable lifestyle factor that can be a target for efficient intervention studies to improve the quality of life and decrease the risk or burden of some chronic conditions. Knowing the profiles of individuals with poor sleep patterns is therefore a prerequisite. Wearable devices have recently opened new areas in medical research as potential efficient tools to measure lifestyle factors such as sleep quantity and quality. Objectives: The goal of our research is to identify the determinants of poor sleep based on data from a large population of users of connected devices. Methods: We analyzed data from 15,839 individuals (13,658 males and 2181 females) considered highly connected customers having purchased and used at least 3 connected devices from the consumer electronics company Withings (now Nokia). Total and deep sleep durations as well as the ratio of deep/total sleep as a proxy of sleep quality were analyzed in association with available data on age, sex, weight, heart rate, steps, and diastolic and systolic blood pressures. Results: With respect to the deep/total sleep duration ratio used as a proxy of sleep quality, we have observed that those at risk of having a poor ratio (≤0.40) were more frequently males (odds ratio [OR]female vs male=0.45, 95% CI 0.38-0.54), younger individuals (OR>60 years vs 18-30 years=0.47, 95% CI 0.35-0.63), and those with elevated heart rate (OR>78 bpm vs ≤61 bpm=1.18, 95% CI 1.04-1.34) and high systolic blood pressure (OR>133 mm Hg vs ≤116 mm Hg=1.22, 95% CI 1.04-1.43). A direct association with weight was observed for total sleep duration exclusively. Conclusions: Wearables can provide useful information to target individuals at risk of poor sleep. Future alert or mobile phone notification systems based on poor sleep determinants measured with wearables could be tested in intervention studies to evaluate the benefits.

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

    Web-Based Information on the Treatment of Tobacco Dependence for Oral Health Professionals: Analysis of English-Written Websites


    Background: Studies have been conducted on the content and quality of Web-based information for patients who are interested in smoking cessation advice and for health care practitioners regarding the content of e-learning programs about tobacco cessation. However, to the best of our knowledge, there is no such information about the quality of Web-based learning resources regarding smoking cessation dedicated to oral health professionals. Objective: The aim of this study was to identify and evaluate the quality of the content of webpages providing information about smoking cessation for oral health care professionals. Methods: Websites were identified using Google and Health on Net (HON) search engines using the terms: smoking cessation OR quit smoking OR stop smoking OR 3As OR 5As OR tobacco counselling AND dentistry OR dental clinic OR dentist OR dental hygienist OR oral health professionals. The first 100 consecutive results of the 2 search engines were considered for the study. Quality assessment was rated using the DISCERN questionnaire, the Journal of the American Medical Association (JAMA) benchmarks, and the HON seal. In addition, smoking cessation content on each site was assessed using an abbreviated version of the Smoke Treatment Scale (STS-C) and the Smoking Treatment Scale-Rating (STS-R). To assess legibility of the selected websites, the Flesch Reading Ease (FRES) and the Flesch-Kinkaid Reading Grade Level (FKRGL) were used. Websites were also classified into multimedia and nonmultimedia and friendly and nonfriendly usability. Results: Of the first 200 sites selected (100 of Google and 100 of HON), only 11 met the inclusion criteria and mainly belonged to governmental institutions (n=8), with the others being prepared by Professional Associations (n=2) and nonprofit organizations (n=1). Only 3 were exclusively dedicated to smoking cessation. The average score obtained with the DISCERN was 3.0, and the average score in the FKRGL and FRES was 13.31 (standard deviation, SD 3.34) and 40.73 (SD 15.46), respectively. Of the 11 websites evaluated, none achieved all the four JAMA benchmarks. The mean score of STS-R among all the websites was 2.81 (SD 0.95) out of 5. A significant strong positive correlation was obtained between the DISCERN mean values and the STS-R (R=.89, P=.01). Conclusions: The mean quality of webpages with information for oral health care professionals about smoking cessation is low and displayed a high heterogeneity. These webpages are also difficult to read and often lack multimedia resources, which further limits their usefulness.

  • SoSu-liv app (montage). Source: Mobile Fitness A/S /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Experiences From a Web- and App-Based Workplace Health Promotion Intervention Among Employees in the Social and Health Care Sector Based on Use-Data and...


    Background: An increasing number of Web- and app-based tools for health promotion are being developed at the moment. The ambition is generally to reach out to a larger part of the population and to help users improve their lifestyle and develop healthier habits, and thereby improve their health status. However, the positive effects are generally modest. To understand why the effects are modest, further investigation into the participants’ experiences and the social aspects of using Web- and app-based health promotion tools is needed. Objective: The objectives of this study were to investigate the motivation behind taking part in and using a Web- and app-based health promotion tool (SoSu-life) at the workplace and to explore the participants’ experiences with using the tool. Methods: Qualitative interviews with 26 participants who participated in a 38-week randomized controlled trial of a workplace Web- and app-based tool for health promotion were conducted. Data were supplemented with tracking the frequency of use. The basic features of the tool investigated in the trial were self-reporting of diet and exercise, personalized feedback, suggestions for activities and programs, practical tips and tricks, and a series of social features designed to support and build interactions among the participants at the workplace. Results: The respondents reported typically one of the two reasons for signing up to participate in the study: either a personal wish to attain some health benefits or the more social reason that participants did not want to miss out on the social interaction with colleagues. Peer pressure from colleagues had made some participants to sign up even though they did not believe they had an unhealthy behavior. Of the total of 355 participants in the intervention group, 203 (57.2%) left the intervention before it ended. Of the remaining participants, most did not use the tool after the competition at the end of the initial 16-week period. The actual number of active users of the tool throughout the whole intervention period was low; however, the participants reported that lifestyle habits became a topic of conversation. Conclusions: A tool that addresses group interactions at workplaces appears to initiate peer pressure, which helped recruitment for participation. However, active participation was low. A social change was indicated, allowing for more interaction among colleagues around healthy lifestyle issues. Future and more long-term studies are needed to determine whether such social changes could lead to sustained improvements of health.

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

    Effectiveness of Two Web-Based Interventions for Chronic Cancer-Related Fatigue Compared to an Active Control Condition: Results of the “Fitter na...


    Background: Approximately one third of all patients who have been successfully treated for cancer suffer from chronic cancer-related fatigue (CCRF). Effective and easily accessible interventions are needed for these patients. Objective: The current paper reports on the results of a 3-armed randomized controlled trial investigating the clinical effectiveness of two different guided Web-based interventions for reducing CCRF compared to an active control condition. Methods: Severely fatigued cancer survivors were recruited via online and offline channels, and self-registered on an open-access website. After eligibility checks, 167 participants were randomized via an embedded automated randomization function into: (1) physiotherapist-guided Ambulant Activity Feedback (AAF) therapy encompassing the use of an accelerometer (n=62); (2) psychologist-guided Web-based mindfulness-based cognitive therapy (eMBCT; n=55); or (3) an unguided active control condition receiving psycho-educational emails (n=50). All interventions lasted nine weeks. Fatigue severity was self-assessed using the Checklist Individual Strength - Fatigue Severity subscale (primary outcome) six times from baseline (T0b) to six months (T2). Mental health was self-assessed three times using the Hospital Anxiety and Depression Scale and Positive and Negative Affect Schedule (secondary outcome). Treatment dropout was investigated. Results: Multiple group latent growth curve analysis, corrected for individual time between assessments, showed that fatigue severity decreased significantly more in the AAF and eMBCT groups compared to the psycho-educational group. The analyses were checked by a researcher who was blind to allocation. Clinically relevant changes in fatigue severity were observed in 66% (41/62) of patients in AAF, 49% (27/55) of patients in eMBCT, and 12% (6/50) of patients in psycho-education. Dropout was 18% (11/62) in AAF, mainly due to technical problems and poor usability of the accelerometer, and 38% (21/55) in eMBCT, mainly due to the perceived high intensity of the program. Conclusions: Both the AAF and eMBCT interventions are effective for managing fatigue severity compared to receiving psycho-educational emails. Trial Registration: NTR3483; (Archived by WebCite at

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    What Clinical Information Is Valuable to Doctors Using Mobile Electronic Medical Records and When?


    Background: There has been a lack of understanding on what types of specific clinical information are most valuable for doctors to access through mobile-based electronic medical records (m-EMRs) and when they access such information. Furthermore, it has not been clearly discussed why the value of such information is high. Objective: The goal of this study was to investigate the types of clinical information that are most valuable to doctors to access through an m-EMR and when such information is accessed. Methods: Since 2010, an m-EMR has been used in a tertiary hospital in Seoul, South Korea. The usage logs of the m-EMR by doctors were gathered from March to December 2015. Descriptive analyses were conducted to explore the overall usage patterns of the m-EMR. To assess the value of the clinical information provided, the usage patterns of both the m-EMR and a hospital information system (HIS) were compared on an hourly basis. The peak usage times of the m-EMR were defined as continuous intervals having normalized usage values that are greater than 0.5. The usage logs were processed as an indicator representing specific clinical information using factor analysis. Random intercept logistic regression was used to explore the type of clinical information that is frequently accessed during the peak usage times. Results: A total of 524,929 usage logs from 653 doctors (229 professors, 161 fellows, and 263 residents; mean age: 37.55 years; males: 415 [63.6%]) were analyzed. The highest average number of m-EMR usage logs (897) was by medical residents, whereas the lowest (292) was by surgical residents. The usage amount for three menus, namely inpatient list (47,096), lab results (38,508), and investigation list (25,336), accounted for 60.1% of the peak time usage. The HIS was used most frequently during regular hours (9:00 AM to 5:00 PM). The peak usage time of the m-EMR was early in the morning (6:00 AM to 10:00 AM), and the use of the m-EMR from early evening (5:00 PM) to midnight was higher than during regular business hours. Four factors representing the types of clinical information were extracted through factor analysis. Factors related to patient investigation status and patient conditions were associated with the peak usage times of the m-EMR (P<.01). Conclusions: Access to information regarding patient investigation status and patient conditions is crucial for decision making during morning activities, including ward rounds. The m-EMRs allow doctors to maintain the continuity of their clinical information regardless of the time and location constraints. Thus, m-EMRs will best evolve in a manner that enhances the accessibility of clinical information helpful to the decision-making process under such constraints.

  • Watching clinical illustration during online training. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Using the Internet to Train Therapists: Randomized Comparison of Two Scalable Methods


    Background: One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise. Objective: The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects. Methods: Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training. Results: A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being –0.06 (95% Cl –1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl –1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference –0.70, 95% CI –1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92). Conclusions: Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.

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

    Reduction in Fall Rate in Dementia Managed Care Through Video Incident Review: Pilot Study


    Background: Falls of individuals with dementia are frequent, dangerous, and costly. Early detection and access to the history of a fall is crucial for efficient care and secondary prevention in cognitively impaired individuals. However, most falls remain unwitnessed events. Furthermore, understanding why and how a fall occurred is a challenge. Video capture and secure transmission of real-world falls thus stands as a promising assistive tool. Objective: The objective of this study was to analyze how continuous video monitoring and review of falls of individuals with dementia can support better quality of care. Methods: A pilot observational study (July-September 2016) was carried out in a Californian memory care facility. Falls were video-captured (24×7), thanks to 43 wall-mounted cameras (deployed in all common areas and in 10 out of 40 private bedrooms of consenting residents and families). Video review was provided to facility staff, thanks to a customized mobile device app. The outcome measures were the count of residents’ falls happening in the video-covered areas, the acceptability of video recording, the analysis of video review, and video replay possibilities for care practice. Results: Over 3 months, 16 falls were video-captured. A drop in fall rate was observed in the last month of the study. Acceptability was good. Video review enabled screening for the severity of falls and fall-related injuries. Video replay enabled identifying cognitive-behavioral deficiencies and environmental circumstances contributing to the fall. This allowed for secondary prevention in high-risk multi-faller individuals and for updated facility care policies regarding a safer living environment for all residents. Conclusions: Video monitoring offers high potential to support conventional care in memory care facilities.

  • My Health eVet website (montage). Source: US Department of Veterans Affairs /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    The Association of Patient Factors, Digital Access, and Online Behavior on Sustained Patient Portal Use: A Prospective Cohort of Enrolled Users


    Background: As electronic health records and computerized workflows expand, there are unprecedented opportunities to digitally connect with patients using secure portals. To realize the value of patient portals, initial reach across populations will need to be demonstrated, as well as sustained usage over time. Objective: The study aim was to identify patient factors associated with short-term and long-term portal usage after patients registered to access all portal functions. Methods: We prospectively followed a cohort of patients at a large Department of Veterans Affairs (VA) health care facility who recently completed identity proofing to use the VA patient portal. Information collected at baseline encompassed patient factors potentially associated with portal usage, including: demographics, Internet access and use, health literacy, patient activation, and self-reported health conditions. The primary outcome was the frequency of portal log-ins during 6-month and 18-month time intervals after study enrollment. Results: A total of 270 study participants were followed prospectively. Almost all participants (260/268, 97.0%) reported going online, typically at home (248/268, 92.5%). At 6 months, 84.1% (227/270) of participants had visited the portal, with some variation in usage across demographic and health-related subgroups. There were no significant differences in portal log-ins by age, gender, education, marital status, race/ethnicity, distance to a VA facility, or patient activation measure. Significantly higher portal usage was seen among participants using high-speed broadband at home, greater self-reported ability using the Internet, and routinely going online. By 18 months, 91% participants had logged in to the portal, and no significant associations were found between usage and demographics, health status, or patient activation. When examining portal activity between 6 and 18 months, patients who were infrequent or high portal users remained in those categories, respectively. Conclusions: Short-term and long-term portal usage was associated with having broadband at home, high self-rated ability when using the Internet, and overall online behavior. Digital inclusion, or ready access to the Internet and digital skills, appears to be a social determinant in patient exposure to portal services.

  • Patient education center (montage). Source: Mayo Clinic /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Recommending Education Materials for Diabetic Questions Using Information Retrieval Approaches


    Background: Self-management is crucial to diabetes care and providing expert-vetted content for answering patients’ questions is crucial in facilitating patient self-management. Objective: The aim is to investigate the use of information retrieval techniques in recommending patient education materials for diabetic questions of patients. Methods: We compared two retrieval algorithms, one based on Latent Dirichlet Allocation topic modeling (topic modeling-based model) and one based on semantic group (semantic group-based model), with the baseline retrieval models, vector space model (VSM), in recommending diabetic patient education materials to diabetic questions posted on the TuDiabetes forum. The evaluation was based on a gold standard dataset consisting of 50 randomly selected diabetic questions where the relevancy of diabetic education materials to the questions was manually assigned by two experts. The performance was assessed using precision of top-ranked documents. Results: We retrieved 7510 diabetic questions on the forum and 144 diabetic patient educational materials from the patient education database at Mayo Clinic. The mapping rate of words in each corpus mapped to the Unified Medical Language System (UMLS) was significantly different (P<.001). The topic modeling-based model outperformed the other retrieval algorithms. For example, for the top-retrieved document, the precision of the topic modeling-based, semantic group-based, and VSM models was 67.0%, 62.8%, and 54.3%, respectively. Conclusions: This study demonstrated that topic modeling can mitigate the vocabulary difference and it achieved the best performance in recommending education materials for answering patients’ questions. One direction for future work is to assess the generalizability of our findings and to extend our study to other disease areas, other patient education material resources, and online forums.

  • Inform Study website (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Factors Associated With Engagement With a Web-Based Lifestyle Intervention Following Provision of Coronary Heart Disease Risk: Mixed Methods Study


    Background: Web-based interventions provide the opportunity to combine the tailored approach of face-to-face interventions with the scalability and cost-effectiveness of public health interventions. This potential is often limited by low engagement. A number of studies have described the characteristics of individuals who engage more in Web-based interventions but few have explored the reasons for these variations. Objective: We aimed to explore individual-level factors associated with different degrees of engagement with a Web-based behavior change intervention following provision of coronary heart disease (CHD) risk information, and the barriers and facilitators to engagement. Methods: This study involved the secondary analysis of data from the Information and Risk Modification Trial, a randomized controlled trial of a Web-based lifestyle intervention alone, or alongside information on estimated CHD risk. The intervention consisted of three interactive sessions, each lasting up to 60 minutes, delivered at monthly intervals. Participants were characterized as high engagers if they completed all three sessions. Thematic analysis of qualitative data from interviews with 37 participants was combined with quantitative data on usage of the Web-based intervention using a mixed-methods matrix, and data on the views of the intervention itself were analyzed across all participants. Results: Thirteen participants were characterized as low engagers and 24 as high engagers. There was no difference in age (P=.75), gender (P=.95), or level of risk (P=.65) between the groups. Low engagement was more often associated with: (1) reporting a negative emotional reaction in response to the risk score (P=.029), (2) perceiving that the intervention did not provide any new lifestyle information (P=.011), and (3) being less likely to have reported feeling an obligation to complete the intervention as part of the study (P=.019). The mixed-methods matrix suggested that there was also an association between low engagement and less success with previous behavior change attempts, but the statistical evidence for this association was weak (P=.16). No associations were seen between engagement and barriers or facilitators to health behavior change, or comments about the design of the intervention itself. The most commonly cited barriers related to issues with access to the intervention itself: either difficulties remembering the link to the site or passwords, a perceived lack of flexibility within the website, or lack of time. Facilitators included the nonjudgmental presentation of lifestyle information, the use of simple language, and the personalized nature of the intervention. Conclusions: This study shows that the level of engagement with a Web-based intervention following provision of CHD risk information is not influenced by the level of risk but by the individual’s response to the risk information, their past experiences of behavior change, the extent to which they consider the lifestyle information helpful, and whether they felt obliged to complete the intervention as part of a research study. A number of facilitators and barriers to Web-based interventions were also identified, which should inform future interventions.

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  • The Mediating Effect of Internet Addiction in the Relationship between Individualism and Cyberbullying

    Date Submitted: Oct 22, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Among a variety of dynamics that may have an effect in Internet-related behaviors, cultural orientation is particularly important. Previous studies suggest that individualism is a strong d...

    Background: Among a variety of dynamics that may have an effect in Internet-related behaviors, cultural orientation is particularly important. Previous studies suggest that individualism is a strong determinant of aggressive behavior. In addition, findings suggest that vertical individualism may lead to the development of more tolerance for addiction and aggression. Objective: The study aimed to test whether vertical individualism has significant positive effects on cyberbullying and Internet addiction and whether horizontal individualism has significant negative effects on cyberbullying and Internet addiction. A theoretical model was specified to test the relationships among vertical versus horizontal individualism, cyberbullying, and Internet addiction. Methods: A total of 665 college students were selected using convenience sampling method and willingly participated in the study. Participants’ ages ranged from 17 years old to 19 years old (mean age=17.94, SD=1.12). Of the group, 462 were women (69.5 %) and 203 were men (30.5%). Study majors represented are mathematics (n=113, 17%), science (n=102, 15.3%), instructional technology (n=99, 14.9%), psychology (n=98, 14.7%), and others (n=253, 38.1%). Self-report instruments were used to measure vertical/horizontal individualism, cyberbullying, and Internet addiction. Results: Results show significant positive effect of vertical individualism (.10) and significant negative effect of horizontal individualism (-.12) on cyberbullying. In addition, the direct effect of vertical individualism on Internet addiction was significant (.28) but the direct effect of horizontal individualism was not (-.05). Finally, Internet addiction had a significant direct effect on cyberbullying (.39) as well as an intervening effect in the relationship between vertical individualism and cyberbullying. Results also indicate significant gender differences in cultural patterns and Internet addiction. Conclusions: Points raised in the current study should be valuable to researchers and taken into account by practitioners who design and implement prevention or treatment programs in dealing with Internet addiction or cyberbullying.

  • A topic model approach to detect cases of non compliance to treatment in social media

    Date Submitted: Oct 22, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Medication non-adherence is a major impediment to the management of many health conditions. A better understanding of the factors underlying non compliance to treatment may help health pro...

    Background: Medication non-adherence is a major impediment to the management of many health conditions. A better understanding of the factors underlying non compliance to treatment may help health professionals to address it. Patients use social media to share their experiences regarding their treatments and their diseases. Using topic models makes it possible to model themes present in a collection of posts, thus to identify cases of non-compliance. Objective: Our study aims to detect messages describing patients' non-compliant behaviors. They are associated with a drug of interest. Thus, our objective is the clustering of posts featuring a homogeneous vocabulary related to non-adherent attitudes. Methods: We implemented a probabilistic topic model in order to identify the topics that occurred in a corpus of online messages posted between 2004 and 2013 on three of the most popular French forums. Data were collected using a Web Crawler designed by Kappa Santé as part of the Detec’t project to analyze social media for drug safety. Several topics were related to non-compliance to treatment. Results: Starting from a corpus of 3 650 posts related to an antidepressant drug, (escitalopram), and 2,164 posts related to an antipsychotic drug (aripiprazole), the use of latent Dirichlet allocation allowed us to model several themes including interruptions of treatment and changes in dosage. The topic model approach detected cases of non compliance behaviors with a recall of 98.5% and a precision of 32.6%. Conclusions: Topic models enabled us to explore patients’ discussions on community websites and to identify posts related with non-compliant behaviors. After a manual review of the messages in the non-compliance topics, we found that non-compliance to treatment was present in almost 6% of the posts.

  • Users, uses and effects of social media in dietetic practice: a scoping review of the quantitative and qualitative evidence

    Date Submitted: Oct 20, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Social media are increasingly used by registered dietitians (RDs) as they represent novel tools to improve knowledge translation and exchange in nutrition. However, a thorough understandin...

    Background: Social media are increasingly used by registered dietitians (RDs) as they represent novel tools to improve knowledge translation and exchange in nutrition. However, a thorough understanding of social media in dietetic practice is utterly lacking. Objective: Using a scoping review methodology, we aimed to map and summarize the evidence about the users, uses and effects of social media in dietetic practice to identify gaps in the literature and inform future research. Methods: Stages for conducting the scoping review included: (1) identifying the research question; (2) identifying relevant studies through an explicit sensitive search strategy; (3) selecting eligible studies; (4) charting the data; and (5) collating, summarizing and reporting results for dissemination. Last, (6) knowledge users (RDs working for dietetic professional associations and public health organizations) were involved in each review stage in order to generate usable and practical findings. Results: Of the 47 included studies, 34 were intervention studies, 4 were descriptive studies, 2 were content analysis studies and 7 were expert opinion articles in dietetics practice. Discussion forums were the most frequent social media tool evaluated (n=19), followed by blogs (n=13) and social networking sites (n=10). Most studies targeted overweight and obese or healthy users, with adult populations being most studied. Social media tools were mostly used to deliver multi-component behavior change interventions for weight management. Among intervention studies using a control group with no exposition to social media, we identified positive, neutral and mixed effects of social media for outcomes related to users’ health behaviors and status (e.g. dietary intakes and body weight), participation rates, and professional knowledge. Factors associated with the characteristics of the specific social media, such as ease of use, a design for quick access to desired information and concurrent reminders of use, were perceived as the main facilitators to the use of social media in dietetic practice, followed to a lesser extent by interactions with an RD and social support from fellow users. Barriers to social media use were mostly related to complicated access to the site and time issues. Conclusions: Research on social media in dietetic practice is at its infancy, but it is growing fast. So far, this field of research has targeted few social media platforms, most of which were assessed in multiple-component interventions for weight management among overweight or obese adults. Trials isolating the effects and mechanisms of action of specific social media tools are needed to draw clear conclusions regarding the effectiveness of those tools to support dietetic practice. Future studies should address barriers and facilitators related to the use of social media written by RDs, and how to make these tools useful for RDs to reach health consumers to improve health through diet. Clinical Trial: None

  • Uncovering a role for electronic personal health records (PHRs) in reducing disparities in sexually transmitted infection rates: A mixed-methods study among students at a predominantly Black university

    Date Submitted: Oct 21, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Young Black adults continue to bear an overwhelming proportion of the United States sexually transmitted infection (STI) burden, including HIV. Several studies on web- and mobile-based (mH...

    Background: Young Black adults continue to bear an overwhelming proportion of the United States sexually transmitted infection (STI) burden, including HIV. Several studies on web- and mobile-based (mHealth) STI interventions have been conducted and are currently ongoing that focus on improving outcomes related to testing, risk communication, reducing stigma, increasing condom use, and improving adherence to biomedical prevention and treatment among men who have sex with men (MSM), substance using, and adolescent populations. The Electronic Sexual Health Information Notification and Education (eSHINE) Study was an exploratory mixed-methods study among students at a historically Black university, exploring perceptions on facilitating STI testing conversations with partners using electronic personal health records (PHRs). Objective: The purpose of this paper is to use eSHINE Study results to describe perceived impacts of PHRs on facilitating risk discussion events. Methods: Focus groups and individual in-depth interviews were conducted on a qualitative research sample (n=35) to explore attitudes and practices related to talking with partners about STI testing and of incorporating PHRs into dyadic discussion events. An online survey was developed to measure qualitative findings on a larger sample of Black students (n=354) and to determine whether any significant differences exist between male and female participants. Results: Multiple contextual barriers were described that inhibit the utility of PHRs for facilitating discussions about STI testing and test results with partners. PHRs were believed to facilitate participants’ ability to initiate conversations and confidence in STI screening information shared by partners. With PHR access, the proportion of online survey participants who reported willingness to discuss STI testing within dyadic partnerships prior to sex increased from 40.4% to 61.0%. Conclusions: Findings suggest that subpopulations of young Black adults having access to PHR may improve both motivation and personal agency for initiating dyadic talks about STI testing. This study builds on mHealth interventions research to suggest that PHRs also offer promise as a STI prevention strategy to reduce health disparities. Future eSHINE Study analyses will determine factors associated with willingness to utilize PHR for delivery of STI results as well as willingness to utilize these results to facilitate risk discussions. Clinical Trial: N/A

  • Long-Term Effectiveness of a Smartphone Application for Improving Healthy Lifestyles in general population in Primary Care: A Randomized Controlled Trial (EVIDENT II study)

    Date Submitted: Oct 21, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Information and communication technologies are currently one of the supporting elements that may contribute to improving health and changing lifestyles. Objective: To evaluate the long-ter...

    Background: Information and communication technologies are currently one of the supporting elements that may contribute to improving health and changing lifestyles. Objective: To evaluate the long-term effectiveness of adding an app to standardized counselling in order to increase physical activity (PA) and adherence to the Mediterranean diet (MD) and to analyze the effects of app adherence in lifestyles changes. Methods: Randomized, multicenter clinical trial with 12 month-follow up, including 833 participants, recruited by random sampling in six primary Spanish care centers (415 versus 418). Interventions: Counseling on PA and MD was given to both groups by a nurse research. The counseling+app group (IG) received additional training in the use of an app that was designed to promote MD and PA over a 3-month period. Main Outcomes and Measures: PA by accelerometer and the 7-day Physical Activity Recall (PAR) questionnaire and adherence to the MD by an adherence screener questionnaire. We considered adherence to the app to be high when it was used for >60 days. Results: The mean age was 51 years (SD 12) in the IG and 52.3 (SD 12.0) in the counseling only group (CG); females predominated in both groups (60.0% and 64.1%, respectively). PA by accelerometer declined in both groups at 12 months (p for tendency in moderate-vigorous PA [MVPA]=0.146).The subgroup of IG with high app adherence had better behavior than the low adherence subgroup (p for tendency in MVPA=0.001). The PA analyzed by 7-day PAR did not show changes at 12 months in any of the groups (p for tendency=0.245). In MD, an increase in adherence was observed in both groups at 12 months with no differences between them (p for tendency=0.465). In these two cases the group with high app adherence also had better behavior although without reaching significance for the tendency (p >0.05). Conclusions: In subjects with high app adherence, better results in healthy lifestyle improvements were observed. Overall, however, no differences were found between the IG group and CG in PA increase and adherence to the MD in the long-term. Clinical Trial: Clinical Identifier: NCT02016014 (

  • Changes in anxiety following participation in BRAVE Self-Help: an open-access online Cognitive-Behaviour Therapy Program for anxiety

    Date Submitted: Oct 19, 2017

    Open Peer Review Period: Oct 21, 2017 - Dec 16, 2017

    Background: Internet-based CBT (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but has not yet been examined when disseminated as a public health int...

    Background: Internet-based CBT (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but has not yet been examined when disseminated as a public health intervention. If effective, iCBT programs may offer promise as a first-step, low-intensity intervention that can be easily accessed by young people. Objective: The aim of this study was to examine changes in anxiety severity in young people enrolling in a publicly available online, self-help iCBT program (BRAVE Self-Help). Methods: This study conducted an open trial, involving the analysis of data collected from 1094 children and adolescents aged 7-17 years who presented with elevated anxiety at baseline and commenced the program during the data collection period. The iCBT program was delivered through an open-access portal with no professional support. Anxiety severity was assessed via scores on the Children’s Anxiety Scale, 8-item (CAS-8) at four time points; baseline, Session 4, Session 7 and Session 10. Results: Statistically significant reductions in anxiety were evident across all time points for both children and adolescents. For users who completed 6 or more sessions, there was an average 4-point improvement in CAS-8 scores (d=0.87 for children, d=0.81 for adolescents) indicative of a moderate to large effect size. For participants who completed 9 sessions, 58.3% (95 out of 163) achieved clinically meaningful, and 54.6% (89 out of 163) achieved statistically reliable reductions in anxiety. Conclusions: Substantial and meaningful reductions in anxiety symptoms were achieved by many children and adolescents taking part in a completely open-access and self-directed iCBT program. Online self-help CBT may offer an effective and viable first step for service delivery with children and adolescents with anxiety. Clinical Trial: n/a