Journal of Medical Internet Research

The leading peer-reviewed journal for health and healthcare in the Internet age.

JMIR's Thomson Reuter Impact Factor of 4.7 for 2013

Optimising patient preparation and surgical experience using e-health technology

It is expected that with population growth and ageing, the demand for surgical services will escalate. This will place added pressure on a system where identification and management of patient outcomes and processes of care may be lacking. E-health information programs have the potential to support the standardised delivery of surgical care, engage providers and patients, and deliver self-assessment and self-management tools. This paper describes the potential of e-Health programs in overcoming the challenges to providing optimal care across six phases of the surgical journey. Specifically the: 1) challenges to the provision of care from the time a decision is made for surgery, until the point of long-term follow-up; and 2) examples where e-Health programs have, or could, be utilised to improve informed consent processes, pre-operative preparation, admission, immediate post-operative care, discharge planning and rehabilitation and long-term follow-up. Further, the advantages of e-health programs in relation to information gathering and information transfer are summarised, along with the potential challenges to implementing e-Health programs in surgical care and future directions for research in this field. There is a need for rigorous intervention studies to examine the potential role of e-health programs in augmenting patients’ preparation and recovery from surgery, and subsequent impact on patient outcomes and processes of care. Studies examining the role of e-health programs in supporting carers, and strategies to maximise engagement from end-users are also needed.

2015-01-03

As avid JMIR readers know, JMIR has been a pioneer in collecting and using social media metrics long before the term altmetrics became popular. On our Top Articles page we rank all JMIR articles by various metrics, including tweets. By clicking on the "most tweeted - in the last year" tab, readers can rank articles by tweets in the last 12 months (this may also capture articles which were published pre-2014).

Here is a list of our top tweeted articles from 2014:

(the ranking is displayed as tweets for easier tweeting, note that these are not the actual tweets we are counting. The top tweeted article has been tweeted over 300 times)

Top Articles by Twimpact Factor Published in 2014

The ranking of top tweeted articles (as done by many other journals) has one major flaw: It does not take into account time since publication. An article published in December has much less time to accumulate tweetations (citations in a tweet) than an article published in January.

The better way which adjusts for time since publication is to rank the articles by Eysenbach's twimpact factor (tw7), which is the number of tweets accumulated in the first week after its publication. This method was proposed in the seminal article "Can Tweets predict citations?" which also happens to be the most tweeted and most cited (adjusted by age) article of JMIR of all times (note this article is not on the following list, because here we only rank the top articles published in 2014).

  1. Mind the Gap: Social Media Engagement by Public Health Researchers Brett Keller, Alain Labrique, Kriti M Jain, Andrew Pekosz, Orin Levine tw7:164
  2. The Use of Social Networking Sites for Public Health Practice and Research: A Systematic Review Daniel Capurro, Kate Cole, Maria I. Echavarría, Jonathan Joe, Tina Neogi, Anne M Turner tw7:137
  3. The 1% Rule in Four Digital Health Social Networks: An Observational Study Trevor D van Mierlo tw7: 126
  4. Is Biblioleaks Inevitable? Adam G Dunn, Enrico Coiera, Kenneth D Mandl tw7: 117
  5. Social Media: A Review and Tutorial of Applications in Medicine and Health Care Francisco Jose J Grajales III, Samuel Sheps, Kendall Ho, Helen Novak-Lauscher, Gunther Eysenbach tw7:115
  6. Tweeting for and Against Public Health Policy: Response to the Chicago Department of Public Health's Electronic Cigarette Twitter Campaign Jenine K K Harris, Sarah Moreland-Russell, Bechara Choucair, Raed Mansour, Mackenzie Staub, Kendall Simmons tw7: 94
  7. Characterizing the Followers and Tweets of a Marijuana-Focused Twitter Handle Patricia Cavazos-Rehg, Melissa Krauss, Richard Grucza, Laura Bierut tw7: 91
  8. mHealth and Mobile Medical Apps: A Framework to Assess Risk and Promote Safer Use Thomas Lorchan Lewis, Jeremy C Wyatt tw7: 85
  9. How Doctors View and Use Social Media: A National Survey James Harold Brown, Christopher Ryan, Anthony Harris tw7: 68
  10. Massive Open Online Courses on Health and Medicine: Review Tharindu Rekha Rekha Liyanagunawardena, Shirley Ann Williams tw7: 68

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Recent Articles:

  • The Portable Health Clinic System Package.

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    Abstract:

    Background: The prevalence of non-communicable diseases is increasing throughout the world, including developing countries. Objective: The intent was to conduct a study of a preventive medical service in a developing country, combining eHealth checkups and teleconsultation as well as assess stratification rules and the short-term effects of intervention. Methods: We developed an eHealth system that comprises a set of sensor devices in an attaché case, a data transmission system linked to a mobile network, and a data management application. We provided eHealth checkups for the populations of five villages and the employees of five factories/offices in Bangladesh. Individual health condition was automatically categorized into four grades based on international diagnostic standards: green (healthy), yellow (caution), orange (affected), and red (emergent). We provided teleconsultation for orange- and red-grade subjects and we provided teleprescription for these subjects as required. Results: The first checkup was provided to 16,741 subjects. After one year, 2361 subjects participated in the second checkup and the systolic blood pressure of these subjects was significantly decreased from an average of 121 mmHg to an average of 116 mmHg (P<.001). Based on these results, we propose a cost-effective method using a machine learning technique (random forest method) using the medical interview, subject profiles, and checkup results as predictor to avoid costly measurements of blood sugar, to ensure sustainability of the program in developing countries. Conclusions: The results of this study demonstrate the benefits of an eHealth checkup and teleconsultation program as an effective health care system in developing countries.

  • John Snow's pump (http://en.wikipedia.org/wiki/John_Snow_(physician)).

    Automatic Identification of Web-Based Risk Markers for Health Events

    Abstract:

    Background: The escalating cost of global health care is driving the development of new technologies to identify early indicators of an individual’s risk of disease. Traditionally, epidemiologists have identified such risk factors using medical databases and lengthy clinical studies but these are often limited in size and cost and can fail to take full account of diseases where there are social stigmas or to identify transient acute risk factors. Objective: Here we report that Web search engine queries coupled with information on Wikipedia access patterns can be used to infer health events associated with an individual user and automatically generate Web-based risk markers for some of the common medical conditions worldwide, from cardiovascular disease to sexually transmitted infections and mental health conditions, as well as pregnancy. Methods: Using anonymized datasets, we present methods to first distinguish individuals likely to have experienced specific health events, and classify them into distinct categories. We then use the self-controlled case series method to find the incidence of health events in risk periods directly following a user’s search for a query category, and compare to the incidence during other periods for the same individuals. Results: Searches for pet stores were risk markers for allergy. We also identified some possible new risk markers; for example: searching for fast food and theme restaurants was associated with a transient increase in risk of myocardial infarction, suggesting this exposure goes beyond a long-term risk factor but may also act as an acute trigger of myocardial infarction. Dating and adult content websites were risk markers for sexually transmitted infections, such as human immunodeficiency virus (HIV). Conclusions: Web-based methods provide a powerful, low-cost approach to automatically identify risk factors, and support more timely and personalized public health efforts to bring human and economic benefits.

  • Picture Me Smokefree intervention logo and social media branding.

    Picture Me Smokefree: A Qualitative Study Using Social Media and Digital Photography to Engage Young Adults in Tobacco Reduction and Cessation

    Abstract:

    Background: Young adults have high rates of tobacco use compared to other subpopulations, yet there are relatively few tobacco interventions specifically targeted to this group. Picture Me Smokefree is an online tobacco reduction and cessation intervention for young adults that uses digital photography and social networking. Objective: The main goal of the project was to determine the feasibility of engaging young adults in participating in user-driven, online forums intended to provide peer support and motivate critical reflection about tobacco use and cessation among this high-use, hard-to-reach population. A related aim was to explore the influence of gender-related factors on participation, in order to determine the need for online interventions to be tailored to the specific gender preferences reflecting young men and women’s participation styles. Methods: A total of 60 young adults ages 19-24 years who self-identified as current cigarette smokers or who had quit within the last year were recruited from across British Columbia, Canada, and participated in an online photo group on Facebook over a period of 12 consecutive weeks. A variety of data collection methods were used including tracking online activity, a brief online follow-up survey, and qualitative interviews with study participants. Data analysis involved descriptive statistics on recruitment, retention, and participation and qualitative (eg, narrative analysis, synthesis of feedback) feedback about participant engagement. Results: Findings from this study suggest good potential for Facebook as an accessible, low-cost platform for engaging young adults to reflect on the reasons for their tobacco use, the benefits of quitting or reducing, and the best strategies for tobacco reduction. Young adults’ frequent use of mobile phones and other mobile devices to access social networking permitted ease of access and facilitated real-time peer-to-peer support across a diverse group of participants. However, our experience of conducting the study suggests that working with young tobacco users can be accompanied by considerable recruitment, participation, and retention challenges. Our findings also pointed to differences in how young women and men engaged the photo-group intervention that should be considered, bearing in mind that in follow-up interviews participants indicated their preference for a mixed gender and “gender neutral” group format. Conclusions: Tobacco interventions for youth and young adults should be embedded within the existing social networking platforms they access most frequently, rather than designing a stand-alone online prevention or intervention resource. This subpopulation would likely benefit from tobacco reduction interventions that are gender-sensitive rather than gender-specific.

  • Image by Anna Shlyapnikova, licensed under Creative Commons Attribution License 3.0.

    Developing Internet-Based Health Interventions: A Guide for Public Health Researchers and Practitioners

    Abstract:

    Background: Researchers and practitioners interested in developing online health interventions most often rely on Web-based and print resources to guide them through the process of online intervention development. Although useful for understanding many aspects of best practices for website development, missing from these resources are concrete examples of experiences in online intervention development for health apps from the perspective of those conducting online health interventions. Objective: This study aims to serve as a series of case studies in the development of online health interventions to provide insights for researchers and practitioners who are considering technology-based interventional or programmatic approaches. Methods: A convenience sample of six study coordinators and five principal investigators at a large, US-based land grant university were interviewed about the process of developing online interventions in the areas of alcohol policy, adolescent health, medication adherence, and human immunodeficiency virus prevention in transgender persons and in men who have sex with men. Participants were asked questions that broadly addressed each of the four phases of the User-Centered Design Process Map from the US Department of Health and Human Services' Research-Based Web Design & Usability Guidelines. Interviews were audio recorded and transcribed. Qualitative codes were developed using line-by-line open coding for all transcripts, and all transcripts were coded independently by at least 2 authors. Differences among coders were resolved with discussion. Results: We identified the following seven themes: (1) hire a strong (or at least the right) research team, (2) take time to plan before beginning the design process, (3) recognize that vendors and researchers have differing values, objectives, and language, (4) develop a detailed contract, (5) document all decisions and development activities, (6) use a content management system, and (7) allow extra time for testing and debugging your intervention. Each of these areas is discussed in detail, with supporting quotations from principal investigators and study coordinators. Conclusions: The values held by members of each participating organization involved in the development of the online intervention or program, as well as the objectives that are trying to be met with the website, must be considered. These defined values and objectives should prompt an open and explicit discussion about the scope of work, budget, and other needs from the perspectives of each organization. Because of the complexity of developing online interventions, researchers and practitioners should become familiar with the process and how it may differ from the development and implementation of in-person interventions or programs. To assist with this, the intervention team should consider expanding the team to include experts in computer science or learning technologies, as well as taking advantage of institutional resources that will be needed for successful completion of the project. Finally, we describe the tradeoff between funds available for online intervention or program development and the complexity of the project.

  • Screenshot of the survey in recruitment video.

    Patient-Reported Outcomes and Therapeutic Affordances of Social Media: Findings From a Global Online Survey of People With Chronic Pain

    Abstract:

    Background: Patient-reported outcomes (PROs) from social media use in chronic disease management continue to emerge. While many published articles suggest the potential for social media is positive, there is a lack of robust examination into mediating mechanisms that might help explain social media’s therapeutic value. This study presents findings from a global online survey of people with chronic pain (PWCP) to better understand how they use social media as part of self-management. Objective: Our aim is to improve understanding of the various health outcomes reported by PWCP by paying close attention to therapeutic affordances of social media. We wish to examine if demographics of participants underpin health outcomes and whether the concept of therapeutic affordances explains links between social media use and PROs. The goal is for this to help tailor future recommendations for use of social media to meet individuals’ health needs and improve clinical practice of social media use. Methods: A total of 231 PWCP took part in a global online survey investigating PROs from social media use. Recruited through various chronic disease entities and social networks, participants provided information on demographics, health/pain status, social media use, therapeutic affordances, and PROs from use. Quantitative analysis was performed on the data using descriptive statistics, cross-tabulation, and cluster analysis. Results: The total dataset represented 218 completed surveys. The majority of participants were university educated (67.0%, 146/218) and female (83.9%, 183/218). More than half (58.7%, 128/218) were married/partnered and not working for pay (75.9%, 88/116 of these due to ill health). Fibromyalgia (46.6%, 55/118) and arthritis (27.1%, 32/118) were the most commonly reported conditions causing pain. Participants showed a clear affinity for social network site use (90.0%, 189/210), followed by discussion forums and blogs. PROs were consistent, suggesting that social media positively impact psychological, social, and cognitive health. Analysis also highlighted two strong correlations linking platform used and health outcomes (particularly psychological, social, and cognitive) to (1) the narrative affordance of social media and (2) frequency of use of the platforms. Conclusions: Results did not uncover definitive demographics or characteristics of PWCP for which health outcomes are impacted. However, findings corroborate literature within this domain suggesting that there is a typical profile of people who use social media for health and that social media are more suited to particular health outcomes. Exploration of the relationship between social media’s therapeutic affordances and health outcomes, in particular the narration affordance, warrants further attention by patients and clinicians.

  • Virtual patients on the Semantic Web.

    Virtual Patients on the Semantic Web: A Proof-of-Application Study

    Abstract:

    Background: Virtual patients are interactive computer simulations that are increasingly used as learning activities in modern health care education, especially in teaching clinical decision making. A key challenge is how to retrieve and repurpose virtual patients as unique types of educational resources between different platforms because of the lack of standardized content-retrieving and repurposing mechanisms. Semantic Web technologies provide the capability, through structured information, for easy retrieval, reuse, repurposing, and exchange of virtual patients between different systems. Objective: An attempt to address this challenge has been made through the mEducator Best Practice Network, which provisioned frameworks for the discovery, retrieval, sharing, and reuse of medical educational resources. We have extended the OpenLabyrinth virtual patient authoring and deployment platform to facilitate the repurposing and retrieval of existing virtual patient material. Methods: A standalone Web distribution and Web interface, which contains an extension for the OpenLabyrinth virtual patient authoring system, was implemented. This extension was designed to semantically annotate virtual patients to facilitate intelligent searches, complex queries, and easy exchange between institutions. The OpenLabyrinth extension enables OpenLabyrinth authors to integrate and share virtual patient case metadata within the mEducator3.0 network. Evaluation included 3 successive steps: (1) expert reviews; (2) evaluation of the ability of health care professionals and medical students to create, share, and exchange virtual patients through specific scenarios in extended OpenLabyrinth (OLabX); and (3) evaluation of the repurposed learning objects that emerged from the procedure. Results: We evaluated 30 repurposed virtual patient cases. The evaluation, with a total of 98 participants, demonstrated the system’s main strength: the core repurposing capacity. The extensive metadata schema presentation facilitated user exploration and filtering of resources. Usability weaknesses were primarily related to standard computer applications’ ease of use provisions. Most evaluators provided positive feedback regarding educational experiences on both content and system usability. Evaluation results replicated across several independent evaluation events. Conclusions: The OpenLabyrinth extension, as part of the semantic mEducator3.0 approach, is a virtual patient sharing approach that builds on a collection of Semantic Web services and federates existing sources of clinical and educational data. It is an effective sharing tool for virtual patients and has been merged into the next version of the app (OpenLabyrinth 3.3). Such tool extensions may enhance the medical education arsenal with capacities of creating simulation/game-based learning episodes, massive open online courses, curricular transformations, and a future robust infrastructure for enabling mobile learning.

  • Facebook page of a cigarette brand (indexed under

    Exploring How the Tobacco Industry Presents and Promotes Itself in Social Media

    Abstract:

    Background: The commercial potential of social media is utilized by tobacco manufacturers and vendors for tobacco promotion online. However, the prevalence and promotional strategies of pro-tobacco content in social media are still not widely understood. Objective: The goal of this study was to reveal what is presented by the tobacco industry, and how it promotes itself, on social media sites. Methods: The top 70 popular cigarette brands are divided into two groups according to their retail prices: group H (brands with high retail prices) and group L (brands with low retail prices). Three comprehensive searches were conducted on Facebook, Wikipedia, and YouTube respectively using the top 70 popular cigarette brands as keywords. We identified tobacco-related content including history and culture, product features, health warnings, home page of cigarette brands, and Web-based tobacco shops. Furthermore, we examined the promotional strategies utilized in social media. Results: According to the data collected from March 3, 2014 to March 10, 2014, 43 of the 70 representative cigarette brands had created 238 Facebook fan pages, 46 cigarette brands were identified in Wikipedia, and there were over 120,000 pro-tobacco videos on YouTube, associated with 61 cigarette brands. The main content presented on the three social media websites differs significantly. Wikipedia focuses on history and culture (67%, 32/48; P<.001). Facebook mainly covers history and culture (37%, 16/43; P<.001) and major products (35%, 15/43), while YouTube focuses on the features of major tobacco products (79%, 48/61; P=.04) and information about Web-based shops (49%, 30/61; P=.004). Concerning the content presented by groups H and L, there is no significant difference between the two groups. With regard to the promotional strategies used, sales promotions exist extensively in social media. Sales promotion is more prevalent on YouTube than on the other two sites (64%, 39/61 vs 35%, 15/43; P=.004). Generally, the sale promotions of higher-cost brands in social media are more prevalent than those of lower-cost brands (55%, 16/29 vs 7%, 1/14; P<.001 for Facebook; 78%, 28/36 vs 44%, 11/25; P=.005 for YouTube). Conclusions: The prevalence of cigarette brands in social media allows more pro-tobacco information to be accessed by online users. This dilemma indicates that corresponding regulations should be established to prevent tobacco promotion in social media.

  • (cc) Raatz et al. CC-BY-SA-2.0, please cite as (http://www.jmir.org/article/viewFile/3744/1/51932). Diet Record Keeping.

    Validity of Electronic Diet Recording Nutrient Estimates Compared to Dietitian Analysis of Diet Records: Randomized Controlled Trial

    Abstract:

    Background: Dietary intake assessment with diet records (DR) is a standard research and practice tool in nutrition. Manual entry and analysis of DR is time-consuming and expensive. New electronic tools for diet entry by clients and research participants may reduce the cost and effort of nutrient intake estimation. Objective: To determine the validity of electronic diet recording, we compared responses to 3-day DR kept by Tap & Track software for the Apple iPod Touch and records kept on the Nutrihand website to DR coded and analyzed by a research dietitian into a customized US Department of Agriculture (USDA) nutrient analysis program, entitled GRAND (Grand Forks Research Analysis of Nutrient Data). Methods: Adult participants (n=19) enrolled in a crossover-designed clinical trial. During each of two washout periods, participants kept a written 3-day DR. In addition, they were randomly assigned to enter their DR in a Web-based dietary analysis program (Nutrihand) or a handheld electronic device (Tap & Track). They completed an additional 3-day DR and the alternate electronic diet recording methods during the second washout. Entries resulted in 228 daily diet records or 12 for each of 19 participants. Means of nutrient intake were calculated for each method. Concordance of the intake estimates were determined by Bland-Altman plots. Coefficients of determination (R2) were calculated for each comparison to assess the strength of the linear relationship between methods. Results: No significant differences were observed between the mean nutrient values for energy, carbohydrate, protein, fat, saturated fatty acids, total fiber, or sodium between the recorded DR analyzed in GRAND and either Nutrihand or Tap & Track, or for total sugars comparing GRAND and Tap & Track. Reported values for total sugars were significantly reduced (P<.05) comparing Nutrihand to GRAND. Coefficients of determination (R2) for Nutrihand and Tap & Track compared to DR entries into GRAND, respectively, were energy .56, .01; carbohydrate .58, .08; total fiber .65, .37; sugar .78, .41; protein .44, .03; fat .36, .03; saturated fatty acids .23, .03; sodium .20, .00; and for Nutrihand only for cholesterol .88; vitamin A .02; vitamin C .37; calcium .05; and iron .77. Bland-Altman analysis demonstrates high variability in individual responses for both electronic capture programs with higher 95% limits of agreement for dietary intake recorded on Tap & Track. Conclusions: In comparison to dietitian-entered 3-day DR, electronic methods resulted in no significant difference in mean nutrient estimates but exhibited larger variability, particularly the Tap & Track program. However, electronic DR provided mean estimates of energy, macronutrients, and some micronutrients, which approximated those of the dietitian-analyzed DR and may be appropriate for dietary monitoring of groups. Electronic diet assessment methods have the potential to reduce the cost and burden of DR analysis for nutrition research and clinical practice. Trial Registration: Clinicaltrials.gov NCT01183520; http://clinicaltrials.gov/ct2/show/NCT01183520 (Archived by WebCite at http://www.webcitation.org/6VSdYznKX).

  • https://www.youtube.com/watch?v=DungzgrI_8U.

    Earned Media and Public Engagement With CDC’s "Tips From Former Smokers" Campaign: An Analysis of Online News and Blog Coverage

    Abstract:

    Background: In March 2012, the US Centers for Disease Control and Prevention (CDC) launched the first-ever paid national tobacco education campaign. At a cost of US $54 million, “Tips from Former Smokers” (Tips) ran for 3 months across multiple media, depicting the suffering experienced by smokers and their families in graphic detail. The potential impact and reach of the Tips campaign was not limited to that achieved through paid media placements. It was also potentially extended through “earned media”, including news and blog coverage of the campaign. Such coverage can shape public understanding of and facilitate public engagement with key health issues. Objective: To better understand the contribution of earned media to the public’s engagement with health issues in the current news media environment, we examined the online “earned media” and public engagement generated by one national public health campaign. Methods: We constructed a purposive sample of online media coverage of the CDC’s 2012 Tips from Former Smokers television campaign, focusing on 14 influential and politically diverse US news outlets and policy-focused blogs. We identified relevant content by combining campaign and website-specific keywords for 4 months around the campaign release. Each story was coded for content, inclusion of multimedia, and measures of audience engagement. Results: The search yielded 36 stories mentioning Tips, of which 27 were focused on the campaign. Story content between pieces was strikingly similar, with most stories highlighting the same points about the campaign’s content, cost, and potential impact. We saw notable evidence of audience engagement; stories focused on Tips generated 9547 comments, 8891 Facebook “likes”, 1027 tweets, and 505 story URL shares on Facebook. Audience engagement varied by story and site, as did the valence and relevance of associated audience comments. Comments were most oppositional on CNN and most supportive on Yahoo. Comment coding revealed approximately equal levels of opposition and support overall. We identified four common arguments among oppositional comments: government intrusion on personal behaviors, problematic allocation of governmental spending, questionable science, and challenges regarding campaign efficacy. Supportive comments tended to convey personal stories and emotions. Conclusions: The Tips campaign received limited coverage on either online news or blog sources, but the limited number of stories generated engagement among online audiences. In addition to the content and volume of blog and news coverage, audience comments and websites’ mechanisms for sharing stories via social media are likely to determine the influence of online earned media. In order to facilitate meaningful evaluation of public health campaigns within the rapidly advancing media environment, there is a need for the public health community to build consensus regarding collection and assessment of engagement data.

  • Partial screenshot of the study website.

    Short- and Medium-Term Efficacy of a Web-Based Computer-Tailored Nutrition Education Intervention for Adults Including Cognitive and Environmental Feedback:...

    Abstract:

    Background: Web-based, computer-tailored nutrition education interventions can be effective in modifying self-reported dietary behaviors. Traditional computer-tailored programs primarily targeted individual cognitions (knowledge, awareness, attitude, self-efficacy). Tailoring on additional variables such as self-regulation processes and environmental-level factors (the home food environment arrangement and perception of availability and prices of healthy food products in supermarkets) may improve efficacy and effect sizes (ES) of Web-based computer-tailored nutrition education interventions. Objective: This study evaluated the short- and medium-term efficacy and educational differences in efficacy of a cognitive and environmental feedback version of a Web-based computer-tailored nutrition education intervention on self-reported fruit, vegetable, high-energy snack, and saturated fat intake compared to generic nutrition information in the total sample and among participants who did not comply with dietary guidelines (the risk groups). Methods: A randomized controlled trial was conducted with a basic (tailored intervention targeting individual cognition and self-regulation processes; n=456), plus (basic intervention additionally targeting environmental-level factors; n=459), and control (generic nutrition information; n=434) group. Participants were recruited from the general population and randomly assigned to a study group. Self-reported fruit, vegetable, high-energy snack, and saturated fat intake were assessed at baseline and at 1- (T1) and 4-months (T2) postintervention using online questionnaires. Linear mixed model analyses examined group differences in change over time. Educational differences were examined with group×time×education interaction terms. Results: In the total sample, the basic (T1: ES=–0.30; T2: ES=–0.18) and plus intervention groups (T1: ES=–0.29; T2: ES=–0.27) had larger decreases in high-energy snack intake than the control group. The basic version resulted in a larger decrease in saturated fat intake than the control intervention (T1: ES=–0.19; T2: ES=–0.17). In the risk groups, the basic version caused larger decreases in fat (T1: ES=–0.28; T2: ES=–0.28) and high-energy snack intake (T1: ES=–0.34; T2: ES=–0.20) than the control intervention. The plus version resulted in a larger increase in fruit (T1: ES=0.25; T2: ES=0.37) and a larger decrease in high-energy snack intake (T1: ES=–0.38; T2: ES=–0.32) than the control intervention. For high-energy snack intake, educational differences were found. Stratified analyses showed that the plus version was most effective for high-educated participants. Conclusions: Both intervention versions were more effective in improving some of the self-reported dietary behaviors than generic nutrition information, especially in the risk groups, among both higher- and lower-educated participants. For fruit intake, only the plus version was more effective than providing generic nutrition information. Although feasible, incorporating environmental-level information is time-consuming. Therefore, the basic version may be more feasible for further implementation, although inclusion of feedback on the arrangement of the home food environment and on availability and prices may be considered for fruit and, for high-educated people, for high-energy snack intake. Trial Registration: Netherlands Trial Registry NTR3396; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3396 (Archived by WebCite at http://www.webcitation.org/6VNZbdL6w).

  • Internet-based Mindfulness Program.

    Enhancing Web-Based Mindfulness Training for Mental Health Promotion With the Health Action Process Approach: Randomized Controlled Trial

    Abstract:

    Background: With increasing evidence demonstrating the effectiveness of Web-based interventions and mindfulness-based training in improving health, delivering mindfulness training online is an attractive proposition. Objective: The aim of this study was to evaluate the efficacy of two Internet-based interventions (basic mindfulness and Health Action Process Approach enhanced mindfulness) with waitlist control. Health Action Process Approach (HAPA) principles were used to enhance participants’ efficacy and planning. Methods: Participants were recruited online and offline among local universities; 321 university students and staff were randomly assigned to three conditions. The basic and HAPA-enhanced groups completed the 8-week fully automated mindfulness training online. All participants (including control) were asked to complete an online questionnaire pre-program, post-program, and at 3-month follow-up. Results: Significant group by time interaction effect was found. The HAPA-enhanced group showed significantly higher levels of mindfulness from pre-intervention to post-intervention, and such improvement was sustained at follow-up. Both the basic and HAPA-enhanced mindfulness groups showed better mental well-being from pre-intervention to post-intervention, and improvement was sustained at 3-month follow-up. Conclusions: Online mindfulness training can improve mental health. An online platform is a viable medium to implement and disseminate evidence-based interventions and is a highly scalable approach to reach the general public. Clinical Trial: Chinese Clinical Trial Registry (ChiCTR): ChiCTR-TRC-12002954; http://www.chictr.org/en/proj/show.aspx?proj=3904 (Archived by WebCite at http://www.webcitation.org/6VCdG09pA).

  • SF28 Homescreen.

    A Mobile App to Aid Smoking Cessation: Preliminary Evaluation of SmokeFree28

    Abstract:

    Background: Little is known about the effectiveness of mobile apps in aiding smoking cessation or their validity for automated collection of data on smoking cessation outcomes. Objective: We conducted a preliminary evaluation of SF28 (SF28 is the name of the app, short for SmokeFree28)—an app aimed at helping smokers to be smoke-free for 28 days. Methods: Data on sociodemographic characteristics, smoking history, number of logins, and abstinence at each login were uploaded to a server from SF28 between August 2012 and August 2013. Users were included if they were aged 16 years or over, smoked cigarettes at the time of registration, had set a quit date, and used the app at least once on or after their quit date. Their characteristics were compared with data from a representative sample of smokers trying to stop smoking in England. The percentage of users recording 28 days of abstinence was compared with a value of 15% estimated for unaided quitting. Correlations were assessed between recorded abstinence for 28 days and well-established abstinence predictors. Results: A total of 1170 users met the inclusion criteria. Compared with smokers trying to quit in England, they had higher consumption, and were younger, more likely to be female, and had a non-manual rather than manual occupation. In total, 18.9% (95% CI 16.7-21.1) were recorded as being abstinent from smoking for 28 days or longer. The mean number of logins was 8.5 (SD 9.0). The proportion recording abstinence for 28 days or longer was higher in users who were older, in a non-manual occupation, and in those using a smoking cessation medication. Conclusions: The recorded 28-day abstinence rates from the mobile app, SF28, suggest that it may help some smokers to stop smoking. Further evaluation by means of a randomized trial appears to be warranted.

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  • Optimising patient preparation and surgical experience using e-health technology

    Date Submitted: Jan 25, 2015

    Open Peer Review Period: Jan 26, 2015 - Mar 23, 2015

    It is expected that with population growth and ageing, the demand for surgical services will escalate. This will place added pressure on a system where identification and management of patient outcome...

    It is expected that with population growth and ageing, the demand for surgical services will escalate. This will place added pressure on a system where identification and management of patient outcomes and processes of care may be lacking. E-health information programs have the potential to support the standardised delivery of surgical care, engage providers and patients, and deliver self-assessment and self-management tools. This paper describes the potential of e-Health programs in overcoming the challenges to providing optimal care across six phases of the surgical journey. Specifically the: 1) challenges to the provision of care from the time a decision is made for surgery, until the point of long-term follow-up; and 2) examples where e-Health programs have, or could, be utilised to improve informed consent processes, pre-operative preparation, admission, immediate post-operative care, discharge planning and rehabilitation and long-term follow-up. Further, the advantages of e-health programs in relation to information gathering and information transfer are summarised, along with the potential challenges to implementing e-Health programs in surgical care and future directions for research in this field. There is a need for rigorous intervention studies to examine the potential role of e-health programs in augmenting patients’ preparation and recovery from surgery, and subsequent impact on patient outcomes and processes of care. Studies examining the role of e-health programs in supporting carers, and strategies to maximise engagement from end-users are also needed.

  • Development, Feasibility and Acceptability of the ‘Space from Heart Disease’ Intervention for People Cardiovascular Disease and Distress: a mixed methods study.

    Date Submitted: Jan 23, 2015

    Open Peer Review Period: Jan 23, 2015 - Mar 20, 2015

    Background: Poor self-management of symptoms and psychological distress leads to worse outcomes and excess health service use in cardiovascular disease (CVD). Online delivered therapy is effective, bu...

    Background: Poor self-management of symptoms and psychological distress leads to worse outcomes and excess health service use in cardiovascular disease (CVD). Online delivered therapy is effective, but generic interventions lack relevance for people with specific long term conditions, such as Cardiovascular Disease (CVD). Objective: To develop a comprehensive online CVD specific intervention to improve both self-management and well-being and to test acceptability and feasibility. Methods: Informed by the MRC guidance for the development of complex interventions, we adapted an existing evidence based generic intervention for depression and anxiety for people with CVD. Content was informed by a literature review of existing resources and trial evidence and the findings of a focus group study. Think aloud usability testing was conducted to identify improvements to design and content. Acceptability and feasibility were tested in a cross-sectional study. Results: Focus group participants (n=10) agreed that no existing resource met all their needs. Improvements such as ‘collapse and expand’ features were added based on findings that participants’ information needs varied and specific information such as detecting heart attacks and when to seek help was added. Think aloud testing (n=2) led to changes in font size and design changes around navigation. All participants of the cross sectional study (n=10) were able to access and use the intervention. Reported satisfaction was good, although the intervention was perceived to lack relevance for people without co-morbid psychological distress. Conclusions: We have developed an evidence based, theory informed, user-led online intervention for improving self-management and well-being in CVD. The use of multiple evaluation tests informed improvements to content and usability. Preliminary acceptability and feasibility has been demonstrated. The ‘Space from Heart Disease’ intervention is now ready to be tested for effectiveness. This work has also identified that people with CVD symptoms and co-morbid distress would be the most appropriate sample for a future randomized controlled trial to evaluate its effectiveness.

  • How the fit of physicians’ communication style to patients’ needs influences patients’ attitude change and decision-making in a simulated online consultation

    Date Submitted: Jan 22, 2015

    Open Peer Review Period: Jan 23, 2015 - Mar 20, 2015

    Background: Patients come to a medical consultation with typical needs, and physicians require adequate communication skills in order to address these needs effectively. It is largely unclear, however...

    Background: Patients come to a medical consultation with typical needs, and physicians require adequate communication skills in order to address these needs effectively. It is largely unclear, however, to what extent patients’ attitudes toward a medical procedure or their resulting decisions are influenced by a physician’s communication that ignores or explicitly takes these needs into account. Objective: This experimental study tested how a patient’s salient needs and a doctor’s communication style influenced a patient’s attitude toward mammography screening and the decision whether or not to participate in this procedure. Methods: One hundred women (age range 20-47 years, mean 25.22, SD 4.71) participated in an interactive role play of an online consultation. During the consultation a fictitious, program-controlled physician provided information about advantages and disadvantages of mammography screening. The physician either merely communicated factual medical information or made additional comments utilizing a communication style oriented toward patients’ typical needs for clarity and well-being. Orthogonal to this experimental treatment, participants’ personal needs for clarity and for well-being were either made salient before or after the consultation with a needs questionnaire. We also measured all participants’ attitudes toward mammography screening and their hypothetical decisions whether or not to participate before and after the experiment. Results: As assumed, the participants expressed strong needs for clarity (mean 4.57, SD 0.42) and for well-being (mean 4.21, SD 0.54 on 5-point Likert scales respectively). Making these needs salient or not revealed significant interaction effects with the physician’s communication style regarding patient’s attitude change, F(1, 92)=7.23, P=.009, η2=.073, and decision making, F(1, 92)=4.43, P=.038, η2=.046. Those participants whose needs were made salient before the consultation responded to the physician’s communication style, while participants without salient needs did not: When the physician utilized a need-oriented communication style, those participants with salient needs had a more positive attitude toward mammography after the consultation than before (mean 0.13, SD 0.54), while they changed their attitude in a negative direction when confronted with a purely fact-oriented communication style (mean -0.35, SD 0.80). The same applied to decision modification (need-oriented: mean 0.10, SD 0.99; fact-oriented: mean -0.30, SD 0.88). Conclusions: The findings underline the importance of communicating in a need-oriented style with patients who are aware of their personal needs. Ignoring the needs of those patients appears to be particularly disadvantageous. So physicians’ sensitivity for their patients’ currently relevant needs is essential.

  • Usability and acceptability of ASSESS MS: a system to support the assessment of motor dysfunction in Multiple Sclerosis using depth-sensing computer vision

    Date Submitted: Jan 23, 2015

    Open Peer Review Period: Jan 23, 2015 - Mar 20, 2015

    Background: Sensor-based recordings of human movements are becoming increasingly important for the assessment of motor symptoms in neurological disorders beyond rehabilitative purposes. ASSESS MS is a...

    Background: Sensor-based recordings of human movements are becoming increasingly important for the assessment of motor symptoms in neurological disorders beyond rehabilitative purposes. ASSESS MS is a movement recording and analysis system being developed to automate the classification of motor dysfunction in patients with multiple sclerosis using depth-sensing computer vision. It aims to provide a more consistent and finer-grained measurement of motor dysfunction than currently possible. Objective: To test the usability and acceptability of ASSESS MS with health professionals and patients with multiple sclerosis. Methods: A prospective, mixed-methods study was carried out at three centres. After a one-hour training session, a convenience sample of 12 health professionals (6 neurologists and 6 nurses) used ASSESS MS to capture recordings of standardized movements performed by 51 volunteer patients. Metrics for effectiveness, efficiency and acceptability were defined and used to analyse data captured by ASSESS MS, video-recordings of each examination, feedback questionnaires and follow-up interviews. Results: All health professionals were able to complete recordings using ASSESS MS, achieving high levels of standardisation on three out of four metrics (movement performance, lateral positioning, and clear camera view but not distance positioning). Results were unaffected by patients’ level of physical or cognitive disability. ASSESS MS was perceived as easy to use by both patients and health professionals with high scores on the Likert-scale questions and positive interview commentary. ASSESS MS was highly acceptable to patients on all dimensions considered, including attitudes to future use, interaction (with health professionals) and overall perceptions of ASSESS MS. Health professionals also accepted ASSESS MS, but with greater ambivalence arising from the need to alter patient interaction styles. There was little variation in results across participating centers, and no differences between neurologists and nurses. Conclusions: In typical clinical settings, ASSESS MS is usable and acceptable to both patients and health professionals, generating data of a quality suitable for clinical analysis. An iterative design process appears to have been successful in accounting for factors that permit ASSESS MS to be used by a range of health professionals in new settings with minimal training. The study shows the potential of shifting ubiquitous sensing technologies from research into the clinic through a design approach that gives appropriate attention to the clinic environment.

  • Exposure to ‘Exergames’ increases older adults’ perception of the usefulness of technology for improving health and physical activity: A pilot study.

    Date Submitted: Jan 22, 2015

    Open Peer Review Period: Jan 22, 2015 - Mar 19, 2015

    Background: High rates of sedentary behaviours in older adults lead to poor health outcomes however new technologies, namely exercise-based videogames (exergames), may provide ways of stimulating upta...

    Background: High rates of sedentary behaviours in older adults lead to poor health outcomes however new technologies, namely exercise-based videogames (exergames), may provide ways of stimulating uptake and ongoing participation in physical activities. Older adults’ perception of the use of technology to improve health is not known. . Objective: The study aimed to determine use and perceptions of technology prior to and after using an exergame Methods: Twenty-four healthy participants aged between 55 and 82 years (70±6 years) volunteered to engage with an exergame which focussed on postural balance (Yourshape Fitness Evolved 2012, UbiSoft) over five weeks. Focus groups determined habitual use of technology and the participant’s perceptions of technology to assist with health and physical activity. Surveys were developed to quantitatively measure these perceptions and were administered pre and post intervention. Rates of game participation and enjoyment were also recorded. Results: After the intervention there was an increased awareness that technology (in the form of exergames) can assist with improving physical activity and are useful. High levels of enjoyment and participation rates were recorded. Conclusions: Participation in a balance focussed exergame improved older adults’ perception of the use of technology for improving several health outcomes. Technology, in the form of enjoyable exergames, may be useful for improving participation in physical activity that is relevant for older adults.

  • A new App for at-home cognitive training: description and pilot study on people with multiple sclerosis.

    Date Submitted: Jan 22, 2015

    Open Peer Review Period: Jan 22, 2015 - Mar 19, 2015

    Background: Cognitive impairment is common in people with neurological diseases, severely affecting their social and professional life. It has been shown that intensive and personalized cognitive reha...

    Background: Cognitive impairment is common in people with neurological diseases, severely affecting their social and professional life. It has been shown that intensive and personalized cognitive rehabilitation (CR) based on working memory (WM) exercises produces positive effects on the cognitive status improvement of healthy and cognitive impaired subjects. To date research should be addressed to develop new tools providing low cost and effective interventions. Technologies, in particular portable devices, would help promote accessible, at home and self-managed CR interventions, remotely supervised by the care team. Objective: To develop an App for mobile devices allowing at home self-administration of intensive and personalized CR intervention based on WM exercises and to test usability and effectiveness of the system on cognitive impaired patients with multiple sclerosis (PwMS), identified as likely users due to the young age of disease onset. Methods: The developed system included sections for personal data input and management, for WM exercises setting and for CR intervention configuration, the database, routines for data processing and routines implementing adaptive working load algorithms. To date, 3 WM exercises are implemented. 12 cognitive impaired PwMS (age=45.92±8.77 years; EDSS=3.50±1.86) were submitted to a 8-week at home intervention administered by the App, scheduled in 5 daily sessions a week, 30 minutes a session. Usability of the system was investigated by means of a questionnaire administered to patients at the end of the 8-week treatment and the percentage of days of completed training on the total amount of the 8 weeks was calculated to assess adherence to treatment. Effectiveness of the intervention was evaluated assessing patients' cognitive functions at baseline and after the training by the following tests: Symbol Digit Modalities Test (SDMT), 3 seconds Paced Auditory Serial Additional Test (PASAT-3), and Spatial Recall Test (SPART). Results: PwMS adherence to treatment was of 84%. The 91.67% of PwMS understood the instructions given; 100% felt independent to use the App at home; 66.67% found the exercises interesting; 75.0% found the exercises useful and was motivated to use the App again; moreover, during the exercises execution, PwMS felt high level of motivation to well perform (3.08/4) and rather low levels of stress (2.0/4), boredom (2.0/4) and amusement (1.83/4). Paired t-test analysis showed significant difference between the evaluation sessions before and after the intervention in SDMT, PASAT-3 and SPART (P<.001). Conclusions: The App was very well received by PwMS, who referred high usability of the system and motivation to use it again. The App seems effective in improving cognitive dysfunctions in PwMS, suggesting its use also for other neurological diseases. New releases of the App might be useful to add new WM exercises, enhance amusement perceived and promote internet communication procedures for data transfer fostering remote control of the intervention.