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 4.5 for 2015

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  • Laptop with user's hands. Source: Pixabay; Copyright: Unsplash; URL:; License: Public Domain (CC0).

    Digital Support Interventions for the Self-Management of Low Back Pain: A Systematic Review


    Background: Low back pain (LBP) is a common cause of disability and is ranked as the most burdensome health condition globally. Self-management, including components on increased knowledge, monitoring of symptoms, and physical activity, are consistently recommended in clinical guidelines as cost-effective strategies for LBP management and there is increasing interest in the potential role of digital health. Objective: The study aimed to synthesize and critically appraise published evidence concerning the use of interactive digital interventions to support self-management of LBP. The following specific questions were examined: (1) What are the key components of digital self-management interventions for LBP, including theoretical underpinnings? (2) What outcome measures have been used in randomized trials of digital self-management interventions in LBP and what effect, if any, did the intervention have on these? and (3) What specific characteristics or components, if any, of interventions appear to be associated with beneficial outcomes? Methods: Bibliographic databases searched from 2000 to March 2016 included Medline, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER and TRoPHI, Social Science Citation Index, and Science Citation Index. Reference and citation searching was also undertaken. Search strategy combined the following concepts: (1) back pain, (2) digital intervention, and (3) self-management. Only randomized controlled trial (RCT) protocols or completed RCTs involving adults with LBP published in peer-reviewed journals were included. Two reviewers independently screened titles and abstracts, full-text articles, extracted data, and assessed risk of bias using Cochrane risk of bias tool. An independent third reviewer adjudicated on disagreements. Data were synthesized narratively. Results: Of the total 7014 references identified, 11 were included, describing 9 studies: 6 completed RCTs and 3 protocols for future RCTs. The completed RCTs included a total of 2706 participants (range of 114-1343 participants per study) and varied considerably in the nature and delivery of the interventions, the duration/definition of LBP, the outcomes measured, and the effectiveness of the interventions. Participants were generally white, middle aged, and in 5 of 6 RCT reports, the majority were female and most reported educational level as time at college or higher. Only one study reported between-group differences in favor of the digital intervention. There was considerable variation in the extent of reporting the characteristics, components, and theories underpinning each intervention. None of the studies showed evidence of harm. Conclusions: The literature is extremely heterogeneous, making it difficult to understand what might work best, for whom, and in what circumstances. Participants were predominantly female, white, well educated, and middle aged, and thus the wider applicability of digital self-management interventions remains uncertain. No information on cost-effectiveness was reported. The evidence base for interactive digital interventions to support patient self-management of LBP remains weak.

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

    More Than a Text Message: Dismantling Digital Triggers to Curate Behavior Change in Patient-Centered Health Interventions


    Digital triggers such as text messages, emails, and push alerts are designed to focus an individual on a desired goal by prompting an internal or external reaction at the appropriate time. Triggers therefore have an essential role in engaging individuals with digital interventions delivered outside of traditional health care settings, where other events in daily lives and fluctuating motivation to engage in effortful behavior exist. There is an emerging body of literature examining the use of digital triggers for short-term action and longer-term behavior change. However, little attention has been given to understanding the components of digital triggers. Using tailoring as an overarching framework, we separated digital triggers into 5 primary components: (1) who (sender), (2) how (stimulus type, delivery medium, heterogeneity), (3) when (delivered), (4) how much (frequency, intensity), and (5) what (trigger’s target, trigger’s structure, trigger’s narrative). We highlighted key considerations when tailoring each component and the pitfalls of ignoring common mistakes, such as alert fatigue and habituation. As evidenced throughout the paper, there is a broad literature base from which to draw when tailoring triggers to curate behavior change in health interventions. More research is needed, however, to examine differences in efficacy based on component tailoring, to best use triggers to facilitate behavior change over time, and to keep individuals engaged in physical and mental health behavior change efforts. Dismantling digital triggers into their component parts and reassembling them according to the gestalt of one’s change goals is the first step in this development work.

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

    Virtual Visits and Patient-Centered Care: Results of a Patient Survey and Observational Study


    Background: Virtual visits are clinical interactions in health care that do not involve the patient and provider being in the same room at the same time. The use of virtual visits is growing rapidly in health care. Some health systems are integrating virtual visits into primary care as a complement to existing modes of care, in part reflecting a growing focus on patient-centered care. There is, however, limited empirical evidence about how patients view this new form of care and how it affects overall health system use. Objective: Descriptive objectives were to assess users and providers of virtual visits, including the reasons patients give for use. The analytic objective was to assess empirically the influence of virtual visits on overall primary care use and costs, including whether virtual care is with a known or a new primary care physician. Methods: The study took place in British Columbia, Canada, where virtual visits have been publicly funded since October 2012. A survey of patients who used virtual visits and an observational study of users and nonusers of virtual visits were conducted. Comparison groups included two groups: (1) all other BC residents, and (2) a group matched (3:1) to the cohort. The first virtual visit was used as the intervention and the main outcome measures were total primary care visits and costs. Results: During 2013-2014, there were 7286 virtual visit encounters, involving 5441 patients and 144 physicians. Younger patients and physicians were more likely to use and provide virtual visits (P<.001), with no differences by sex. Older and sicker patients were more likely to see a known provider, whereas the lowest socioeconomic groups were the least likely (P<.001). The survey of 399 virtual visit patients indicated that virtual visits were liked by patients, with 372 (93.2%) of respondents saying their virtual visit was of high quality and 364 (91.2%) reporting their virtual visit was “very” or “somewhat” helpful to resolve their health issue. Segmented regression analysis and the corresponding regression parameter estimates suggested virtual visits appear to have the potential to decrease primary care costs by approximately Can $4 per quarter (Can –$3.79, P=.12), but that benefit is most associated with seeing a known provider (Can –$8.68, P<.001). Conclusions: Virtual visits may be one means of making the health system more patient-centered, but careful attention needs to be paid to how these services are integrated into existing health care delivery systems.

  • Source: Image created by author and; Copyright: Matthew Davis; URL:; License: Public Domain (CC0).

    Public Response to Obamacare on Twitter


    Background: The Affordable Care Act (ACA), often called “Obamacare,” is a controversial law that has been implemented gradually since its enactment in 2010. Polls have consistently shown that public opinion of the ACA is quite negative. Objective: The aim of our study was to examine the extent to which Twitter data can be used to measure public opinion of the ACA over time. Methods: We prospectively collected a 10% random sample of daily tweets (approximately 52 million since July 2011) using Twitter’s streaming application programming interface (API) from July 10, 2011 to July 31, 2015. Using a list of key terms and ACA-specific hashtags, we identified tweets about the ACA and examined the overall volume of tweets about the ACA in relation to key ACA events. We applied standard text sentiment analysis to assign each ACA tweet a measure of positivity or negativity and compared overall sentiment from Twitter with results from the Kaiser Family Foundation health tracking poll. Results: Public opinion on Twitter (measured via sentiment analysis) was slightly more favorable than public opinion measured by the Kaiser poll (approximately 50% vs 40%, respectively) but trends over time in both favorable and unfavorable views were similar in both sources. The Twitter-based measures of opinion as well as the Kaiser poll changed very little over time: correlation coefficients for favorable and unfavorable public opinion were .43 and .37, respectively. However, we found substantial spikes in the volume of ACA-related tweets in response to key events in the law’s implementation, such as the first open enrollment period in October 2013 and the Supreme Court decision in June 2012. Conclusions: Twitter may be useful for tracking public opinion of health care reform as it appears to be comparable with conventional polling results. Moreover, in contrast with conventional polling, the overall amount of tweets also provides a potential indication of public interest of a particular issue at any point in time.

  • Vet checking his prescription using the myhealthevet web portal. Source: US Department of Veterans Affairs; Copyright: US Department of Veterans Affairs; URL:; License: Public Domain (CC0).

    Prioritizing Measures of Digital Patient Engagement: A Delphi Expert Panel Study


    Background: Establishing a validated scale of patient engagement through use of information technology (ie, digital patient engagement) is the first step to understanding its role in health and health care quality, outcomes, and efficient implementation by health care providers and systems. Objective: The aim of this study was to develop and prioritize measures of digital patient engagement based on patients’ use of the US Department of Veterans Affairs (VA)’s MyHealtheVet (MHV) portal, focusing on the MHV/Blue Button and Secure Messaging functions. Methods: We aligned two models from the information systems and organizational behavior literatures to create a theory-based model of digital patient engagement. On the basis of this model, we conducted ten key informant interviews to identify potential measures from existing VA studies and consolidated the measures. We then conducted three rounds of modified Delphi rating by 12 national eHealth experts via Web-based surveys to prioritize the measures. Results: All 12 experts completed the study’s three rounds of modified Delphi ratings, resulting in two sets of final candidate measures representing digital patient engagement for Secure Messaging (58 measures) and MHV/Blue Button (71 measures). These measure sets map to Donabedian’s three types of quality measures: (1) antecedents (eg, patient demographics); (2) processes (eg, a novel measure of Web-based care quality); and (3) outcomes (eg, patient engagement). Conclusions: This national expert panel study using a modified Delphi technique prioritized candidate measures to assess digital patient engagement through patients’ use of VA’s My HealtheVet portal. The process yielded two robust measures sets prepared for future piloting and validation in surveys among Veterans.

  • Older man at home. Source: Flickr; Copyright: JP Korpi-Vartiainen; URL:; License: Creative Commons Attribution + Noncommercial + ShareAlike (CC-BY-NC-SA).

    Activity Recognition for Persons With Stroke Using Mobile Phone Technology: Toward Improved Performance in a Home Setting


    Background: Smartphones contain sensors that measure movement-related data, making them promising tools for monitoring physical activity after a stroke. Activity recognition (AR) systems are typically trained on movement data from healthy individuals collected in a laboratory setting. However, movement patterns change after a stroke (eg, gait impairment), and activities may be performed differently at home than in a lab. Thus, it is important to validate AR for gait-impaired stroke patients in a home setting for accurate clinical predictions. Objective: In this study, we sought to evaluate AR performance in a home setting for individuals who had suffered a stroke, by using different sets of training activities. Specifically, we compared AR performance for persons with stroke while varying the origin of training data, based on either population (healthy persons or persons with stoke) or environment (laboratory or home setting). Methods: Thirty individuals with stroke and fifteen healthy subjects performed a series of mobility-related activities, either in a laboratory or at home, while wearing a smartphone. A custom-built app collected signals from the phone’s accelerometer, gyroscope, and barometer sensors, and subjects self-labeled the mobility activities. We trained a random forest AR model using either healthy or stroke activity data. Primary measures of AR performance were (1) the mean recall of activities and (2) the misclassification of stationary and ambulatory activities. Results: A classifier trained on stroke activity data performed better than one trained on healthy activity data, improving average recall from 53% to 75%. The healthy-trained classifier performance declined with gait impairment severity, more often misclassifying ambulatory activities as stationary ones. The classifier trained on in-lab activities had a lower average recall for at-home activities (56%) than for in-lab activities collected on a different day (77%). Conclusions: Stroke-based training data is needed for high quality AR among gait-impaired individuals with stroke. Additionally, AR systems for home and community monitoring would likely benefit from including at-home activities in the training data.

  • Hand holding an iPhone with a calendar. Source: Good Free Photos; Copyright: Austin Ban; URL:; License: Public Domain (CC0).

    Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review


    Background: There are an increasing number of mobile apps available for adolescents with mental health problems and an increasing interest in assimilating mobile health (mHealth) into mental health services. Despite the growing number of apps available, the evidence base for their efficacy is unclear. Objective: This review aimed to systematically appraise the available research evidence on the efficacy and acceptability of mobile apps for mental health in children and adolescents younger than 18 years. Methods: The following were systematically searched for relevant publications between January 2008 and July 2016: APA PsychNet, ACM Digital Library, Cochrane Library, Community Care Inform-Children, EMBASE, Google Scholar, PubMed, Scopus, Social Policy and Practice, Web of Science, Journal of Medical Internet Research, Cyberpsychology, Behavior and Social Networking, and OpenGrey. Abstracts were included if they described mental health apps (targeting depression, bipolar disorder, anxiety disorders, self-harm, suicide prevention, conduct disorder, eating disorders and body image issues, schizophrenia, psychosis, and insomnia) for mobile devices and for use by adolescents younger than 18 years. Results: A total of 24 publications met the inclusion criteria. These described 15 apps, two of which were available to download. Two small randomized trials and one case study failed to demonstrate a significant effect of three apps on intended mental health outcomes. Articles that analyzed the content of six apps for children and adolescents that were available to download established that none had undergone any research evaluation. Feasibility outcomes suggest acceptability of apps was good and app usage was moderate. Conclusions: Overall, there is currently insufficient research evidence to support the effectiveness of apps for children, preadolescents, and adolescents with mental health problems. Given the number and pace at which mHealth apps are being released on app stores, methodologically robust research studies evaluating their safety, efficacy, and effectiveness is promptly needed.

  • Source: Flickr; Copyright: Images Money; URL:; License: Creative Commons Attribution (CC-BY).

    Pharma Websites and “Professionals-Only” Information: The Implications for Patient Trust and Autonomy


    Background: Access to information is critical to a patient’s valid exercise of autonomy. One increasingly important source of medical information is the Internet. Individuals often turn to drug company (“pharma”) websites to look for drug information. Objective: The objective of this study was to determine whether there is information on pharma websites that is embargoed: Is there information that is hidden from the patient unless she attests to being a health care provider? We discuss the implications of our findings for health care ethics. Methods: We reviewed a convenience sample of 40 pharma websites for “professionals-only” areas and determined whether access to those areas was restricted, requiring attestation that the user is a health care professional in the United States. Results: Of the 40 websites reviewed, 38 had information that was labeled for health care professionals-only. Of these, 24 required the user to certify their status as a health care provider before they were able to access this “hidden” information. Conclusions: Many pharma websites include information in a “professionals-only” section. Of these, the majority require attestation that the user is a health care professional before they can access the information. This leaves patients with two bad choices: (1) not accessing the information or (2) lying about being a health care professional. Both of these outcomes are unacceptable. In the first instance, the patient’s access to information is limited, potentially impairing their health and their ability to make reasonable and well-informed decisions. In the second instance, they may be induced to lie in a medical setting. “Teaching” patients to lie may have adverse consequences for the provider-patient relationship.

  • Source:; Copyright: Ambro; URL:; License: Creative Commons Attribution (CC-BY).

    Diversity in Older Adults’ Use of the Internet: Identifying Subgroups Through Latent Class Analysis


    Background: As for all individuals, the Internet is important in the everyday life of older adults. Research on older adults’ use of the Internet has merely focused on users versus nonusers and consequences of Internet use and nonuse. Older adults are a heterogeneous group, which may implicate that their use of the Internet is diverse as well. Older adults can use the Internet for different activities, and this usage can be of influence on benefits the Internet can have for them. Objective: The aim of this paper was to describe the diversity or heterogeneity in the activities for which older adults use the Internet and determine whether diversity is related to social or health-related variables. Methods: We used data of a national representative Internet panel in the Netherlands. Panel members aged 65 years and older and who have access to and use the Internet were selected (N=1418). We conducted a latent class analysis based on the Internet activities that panel members reported to spend time on. Second, we described the identified clusters with descriptive statistics and compared the clusters using analysis of variance (ANOVA) and chi-square tests. Results: Four clusters were distinguished. Cluster 1 was labeled as the “practical users” (36.88%, n=523). These respondents mainly used the Internet for practical and financial purposes such as searching for information, comparing products, and banking. Respondents in Cluster 2, the “minimizers” (32.23%, n=457), reported lowest frequency on most Internet activities, are older (mean age 73 years), and spent the smallest time on the Internet. Cluster 3 was labeled as the “maximizers” (17.77%, n=252); these respondents used the Internet for various activities, spent most time on the Internet, and were relatively younger (mean age below 70 years). Respondents in Cluster 4, the “social users,” mainly used the Internet for social and leisure-related activities such as gaming and social network sites. The identified clusters significantly differed in age (P<.001, ω2=0.07), time spent on the Internet (P<.001, ω2=0.12), and frequency of downloading apps (P<.001, ω2=0.14), with medium to large effect sizes. Social and health-related variables were significantly different between the clusters, except social and emotional loneliness. However, effect sizes were small. The minimizers scored significantly lower on psychological well-being, instrumental activities of daily living (iADL), and experienced health compared with the practical users and maximizers. Conclusions: Older adults are a diverse group in terms of their activities on the Internet. This underlines the importance to look beyond use versus nonuse when studying older adults’ Internet use. The clusters we have identified in this study can help tailor the development and deployment of eHealth intervention to specific segments of the older population.

  • Picture of a woman using a tablet. Source: iStock by Getty Images; Copyright: julief514; URL:; License: Licensed by the authors.

    Development of Trust in an Online Breast Cancer Forum: A Qualitative Study


    Background: Online health forums provide peer support for a range of medical conditions including life-threatening and terminal illnesses. Trust is an important component of peer-to-peer support, although relatively little is known about how trust forms within online health forums. Objective: The aim of this paper is to examine how trust develops and influences sharing among users of an online breast cancer forum. Methods: An interpretive qualitative approach was adopted. Data were collected from forum posts from 135 threads on 9 boards on the UK charity, Breast Cancer Care (BCC). Semistructured interviews were conducted with 14 BCC forum users. Both datasets were analyzed thematically using Braun and Clarke’s approach and combined to triangulate analysis. Results: Trust operates in 3 dimensions, structural, relational, and temporal, and these intersect with each other and do not operate in isolation. The structural dimension relates to how the affordances and formal rules of the site affected trust. The relational dimension refers to how trust was necessarily experienced in interactions with other forum users: it emerged within relationships and was a social phenomenon. The temporal dimension relates to how trust changed over time and was influenced by the length of time users spent on the forum. Conclusions: Trust is a process that changes over time and which is influenced by structural features of the forum, as well as informal but collectively understood relational interactions among forum users. The study provides a better understanding of how the intersecting structural, relational, and temporal aspects that support the development of trust facilitate sharing in online environments. These findings will help organizations developing online health forums.

  • U-CARE team group photo. Source: The authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Fifteen Challenges in Establishing a Multidisciplinary Research Program on eHealth Research in a University Setting: A Case Study


    Background: U-CARE is a multidisciplinary eHealth research program that involves the disciplines of caring science, clinical psychology, health economics, information systems, and medical science. It was set up from scratch in a university setting in 2010, funded by a governmental initiative. While establishing the research program, many challenges were faced. Systematic documentation of experiences from establishing new research environments is scarce. Objective: The aim of this paper was to describe the challenges of establishing a publicly funded multidisciplinary eHealth research environment. Methods: Researchers involved in developing the research program U-CARE identified challenges in the formal documentation and by reflecting on their experience of developing the program. The authors discussed the content and organization of challenges into themes until consensus was reached. Results: The authors identified 15 major challenges, some general to establishing a new research environment and some specific for multidisciplinary eHealth programs. The challenges were organized into 6 themes: Organization, Communication, Implementation, Legislation, Software development, and Multidisciplinarity. Conclusions: Several challenges were faced during the development of the program and several accomplishments were made. By sharing our experience, we hope to help other research groups embarking on a similar journey to be prepared for some of the challenges they are likely to face on their way.

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

    Evaluating the Social Media Performance of Hospitals in Spain: A Longitudinal and Comparative Study


    Background: Social media is changing the way in which citizens and health professionals communicate. Previous studies have assessed the use of Health 2.0 by hospitals, showing clear evidence of growth in recent years. In order to understand if this happens in Spain, it is necessary to assess the performance of health care institutions on the Internet social media using quantitative indicators. Objectives: The study aimed to analyze how hospitals in Spain perform on the Internet and social media networks by determining quantitative indicators in 3 different dimensions: presence, use, and impact and assess these indicators on the 3 most commonly used social media - Facebook, Twitter, YouTube. Further, we aimed to find out if there was a difference between private and public hospitals in their use of the aforementioned social networks. Methods: The evolution of presence, use, and impact metrics is studied over the period 2011- 2015. The population studied accounts for all the hospitals listed in the National Hospitals Catalog (NHC). The percentage of hospitals having Facebook, Twitter, and YouTube profiles has been used to show the presence and evolution of hospitals on social media during this time. Usage was assessed by analyzing the content published on each social network. Impact evaluation was measured by analyzing the trend of subscribers for each social network. Statistical analysis was performed using a lognormal transformation and also using a nonparametric distribution, with the aim of comparing t student and Wilcoxon independence tests for the observed variables. Results: From the 787 hospitals identified, 69.9% (550/787) had an institutional webpage and 34.2% (269/787) had at least one profile in one of the social networks (Facebook, Twitter, and YouTube) in December 2015. Hospitals’ Internet presence has increased by more than 450.0% (787/172) and social media presence has increased ten times since 2011. Twitter is the preferred social network for public hospitals, whereas private hospitals showed better performance on Facebook and YouTube. The two-sided Wilcoxon test and t student test at a CI of 95% show that the use of Twitter distribution is higher (P<.001) for private and public hospitals in Spain, whereas other variables show a nonsignificant different distribution. Conclusions: The Internet presence of Spanish hospitals is high; however, their presence on the 3 main social networks is still not as high compared to that of hospitals in the United States and Western Europe. Public hospitals are found to be more active on Twitter, whereas private hospitals show better performance on Facebook and YouTube. This study suggests that hospitals, both public and private, should devote more effort to and be more aware of social media, with a clear strategy as to how they can foment new relationships with patients and citizens.

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  • Needle in a haystack: A comparison of online survey recruitment platforms for hard-to-reach populations

    Date Submitted: May 26, 2017

    Open Peer Review Period: May 26, 2017 - Jul 21, 2017

    Background: Smoking during pregnancy is the leading cause of infant mortality and pregnancy complications. Effective smoking cessation programs can significantly reduce the negative health outcomes as...

    Background: Smoking during pregnancy is the leading cause of infant mortality and pregnancy complications. Effective smoking cessation programs can significantly reduce the negative health outcomes associated with smoking while pregnant. This population, however, is difficult to recruit due to the social stigma surrounding the issue. Objective: To determine the feasibility of recruiting a hard-to-reach population of pregnant smokers using four different online platforms. Additionally, we aimed to describe the populations of participants available on each of the channels. Methods: A screener and survey were distributed online through Qualtrics Panel, Soapbox Sample, Reddit, and Amazon Mechanical Turk (mTurk). Descriptive statistics were used to summarize results of each recruitment channel, including eligibility yield, quality yield, income, race, age, and gestational age. Results: Of the 3,848 participants screened for eligibility across all four online platforms, 308 were eligible and completed the survey. Amazon mTurk yielded the least amount of completed responses (n=9), 93% of which passed several quality metrics verifying pregnancy and smoking status. Qualtrics Panel yielded 14 completed responses, 0.87% of which passed the quality screening. Soapbox Sample produced 107 completed surveys, 51.02% of which were found to be quality responses. Advertising through Reddit produced the highest completion rate (n=178) but only 29% of those surveys passed the quality metrics. Conclusions: Although each platform successfully recruited pregnant smokers, the results varied in quality, cost, and percentage of complete responses. Moving forward, investigators should pay careful attention to the percentage yield and cost of online recruitment channels to maximize internal and external validity.

  • Systematic adaptation of an eHealth intervention to promote physical activity and social network of single, chronically impaired older adults

    Date Submitted: May 24, 2017

    Open Peer Review Period: May 26, 2017 - Jul 21, 2017

    Background: Especially for single older adults with chronic diseases, physical inactivity and a poor social network are regarded as serious threats to their health and independence. The Active Plus in...

    Background: Especially for single older adults with chronic diseases, physical inactivity and a poor social network are regarded as serious threats to their health and independence. The Active Plus intervention is a totally automated computer tailored eHealth intervention that has been proven effective to promote physical activity in the general population of older adults aged over 50. Objective: The aim of the present study is to report on the methods and results of the systematic adaptation of Active Plus to the narrower target population of single people over the age of 65 who have one or more chronic diseases, as this target population may encounter specific challenges regarding physical activity and social network. Methods: The Intervention Mapping Protocol is used to systematically adapt the existing intervention to optimally suit the new target population. A literature study is performed, and quantitative and qualitative data is derived from health care professionals (by questionnaires (n = 10)) and the target population (by focus group interviews (n = 14)), and systematically integrated into the adapted intervention. Results: Since the health problems and the targeted behaviour are largely the same in the original and adapted intervention, the performance objectives (i.e. the behaviour that the target population has to perform to reach the overall program objective) are not changed. As found in the literature study and in data derived from health professionals and the target population, the relative importance and operationalization of the relevant psychosocial determinants related to these objectives are different from the original intervention, resulting in a refinement of the change objectives (i.e. the intervention objectives specific for this intervention) to optimally fit the target population. This refinement - based on data derived from the target population - also resulted in changes in the practical applications, program components, intervention materials and in the evaluation- and implementation strategy. Conclusions: The present study demonstrates that the adaptation of an existing intervention is an intensive process in which adopting the Intervention Mapping protocol is an invaluable tool. The study provides a broad insight in adapting interventions aimed at single older adults with a chronic disease. It is concluded that even when the new target population is a sizable segment of the original target population, the adapted intervention still needs considerable changes to optimally fit the needs and situational differences of the narrower target population. Clinical Trial: Not applicable as this article does not report on the results of an intervention.

  • The Use of Mobile Health Applications in OB-GYN-Embedded Psychiatric Care

    Date Submitted: May 26, 2017

    Open Peer Review Period: May 26, 2017 - Jun 3, 2017

    This paper explores the potential benefits of the use of mobile health (“mHealth”) applications in OB-GYN-embedded psychiatric clinics in the United States. First, we highlight the increasing tren...

    This paper explores the potential benefits of the use of mobile health (“mHealth”) applications in OB-GYN-embedded psychiatric clinics in the United States. First, we highlight the increasing trend of integrating mental health care within the OB-GYN context. Second, we provide examples of successful uses of mHealth in the global health context, and highlight the dearth of available research in the United States. Finally, we provide a summary of the shortcomings of currently available applications, and describe the upcoming trial of a novel application currently underway at the Mother and Child Wellness Center, Boston Medical Center. To

  • Cardiac patients’ experiences and perceptions of social media: a mixed methods study

    Date Submitted: May 22, 2017

    Open Peer Review Period: May 24, 2017 - Jul 19, 2017

    Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults prov...

    Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults provides an opportunity to reach patients eligible for cardiac rehabilitation but who are unable to attend traditional face-to-face groups. However, there is a paucity of research on cardiac patient’s experiences and perspectives on using social media to support their health. Objective: This study aims to describe cardiac rehabilitation patient’s experiences in using social media in general and their perspective on using social media to support their cardiac health and secondary prevention efforts. Methods: A mixed methods study was undertaken among cardiac rehabilitation patients in both urban and rural areas which comprised a survey (n = 284) on social media use and six focus group interviews with current social media users (n = 18) to elucidate social media experience and perspectives. Results: Social media use was common (28%; 79/282) particularly in patients who were under 70 years of age, employed and had completed high school. Social media users accessed online information on general health issues (65%; 51/79), medications (56%; 44/79) and heart health (43%; 34/79). Patients were motivated to invest time in using social media for ‘keeping in touch’ with family and friends, and to be informed by expert cardiac health professionals and fellow cardiac patients if given the opportunity. Social media capability (understanding of features and the consequences of their use and efficiency in use) appears to influence the frequency and degree of engagement of social media use and the willingness to participate in a cardiac social media group. More capable users were more receptive to the use of social media for cardiac rehabilitation and more likely to express interest in providing peer support. Recommended features for a cardiac rehabilitation social media group using a Facebook platform included a closed group, expert cardiac professional involvement, provision of cardiac health information and ensuring trustworthiness of the group. Conclusions: Cardiac health professionals have an opportunity to capitalise on cardiac patients’ motivations and social media capability for supporting cardiac rehabilitation and secondary prevention. Patients’ favoured purposeful time spent on social media, and their cardiac health provides such a purpose for a social media intervention. The study results will inform the development of a social media intervention for secondary prevention of cardiovascular disease.

  • The effects of the daily PM2.5 concentration on the public awareness of lung cancer risk in China: Evidence from the Internet big data platform

    Date Submitted: May 23, 2017

    Open Peer Review Period: May 23, 2017 - May 31, 2017

    Background: In October 2013, the International Agency for Research on Cancer (IARC) classified the particulate matter from outdoor air pollution as a Class 1 carcinogen and declared that the particula...

    Background: In October 2013, the International Agency for Research on Cancer (IARC) classified the particulate matter from outdoor air pollution as a Class 1 carcinogen and declared that the particulate matter could cause lung cancer. PM2.5 pollution is becoming a serious public health concern in urban cities of China. It is essential to emphasize the importance of the awareness and knowledge of modifiable risk factors of lung cancer for prevention. Objective: To explore the public awareness of the association of PM2.5 with lung cancer risk in China by analyzing the relationship between the daily PM2.5 concentration and the searches for the term “lung cancer” via the Internet big data platform. Methods: We collected the daily PM2.5 concentration data and the daily Baidu index data in 31 Chinese capital cities between January 1, 2014 and December 31, 2016. We used the Spearman correlation analysis to explore the correlations between the daily Baidu Index for the term “lung cancer” and the daily average PM2.5 concentration. Granger causality test was used to analyze the causal relationship between the two time series variables. Results: In 23 of 31 cities, the pairwise correlation coefficients, by Spearman’s Rho, between the daily Baidu Index for the term “lung cancer” and the daily average PM2.5 concentration, were positive and statistically significant (p<0.05). However, the correlation between the daily Baidu Index for the term “lung cancer” and the daily average PM2.5 concentration was poor (All r2s<0.1). The results of Granger causality test illustrated that there was no unidirectional causality running from the daily PM2.5 concentration to the daily Baidu index for the term “lung cancer” statistically significant at the 5% level for each city. Conclusions: In conclusion, the daily average PM2.5 concentration has a weak positive impact on the daily search interest for the term of “lung cancer” via Baidu search engine. Well-designed awareness campaigns are needed to enhance the general public awareness of the association of PM2.5 with lung cancer risk, and to lead the public to seek more information about PM2.5 and its hazards, and to cope with their environment and its risks correctly.

  • Methods for Co-Designing a Collaborative Chronic Care Network (C3N)

    Date Submitted: May 20, 2017

    Open Peer Review Period: May 21, 2017 - Jul 16, 2017

    Background: Learning Health Systems (LHSs) are seen as a means to accelerate outcomes, improve care delivery, and further clinical research, yet few such systems exist. Objective: We describe the proc...

    Background: Learning Health Systems (LHSs) are seen as a means to accelerate outcomes, improve care delivery, and further clinical research, yet few such systems exist. Objective: We describe the process of co-designing, with all relevant stakeholders, an approach for creating a collaborative chronic care network (C3N), a peer-produced networked LHS. Methods: The setting was ImproveCareNow, an improvement network for pediatric inflammatory bowel disease. In collaboration with patients and families, clinicians, researchers, social scientists, technologists, and designers, C3N leaders used a modified idealized design process to develop a design for a C3N. Results: Over 100 people participated in the design process, which resulted in: a) an overall “concept design” for the ImproveCareNow C3N, b) a logic model for bringing about this system, and c) thirteen potential innovations likely to increase awareness and agency, make it easier to collect and share information, and to enhance collaboration – that could be tested collectively to bring about the C3N. Conclusions: Our current healthcare system fails to deliver necessary results and incremental system improvements are not enough. We demonstrate methods that resulted in a design that has the potential to transform the chronic care system. Our experience suggests that employing structured co-design processes in collaboration with all relevant stakeholders can result in a potentially transformative design for the chronic care delivery system.