JMIR Publications

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 4.5 for 2015

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    An Integrated Process and Outcome Evaluation of a Web-Based Communication Tool for Patients With Malignant Lymphoma: Randomized Controlled Trial


    Background: The complex nature of the medical dialogue and the often emotional context in cancer care present challenges to health care professionals (HCPs) and patients. Patients are increasingly expected to be informed participants and to be able to make conscious decisions, which they often find very difficult. In an attempt to support patients with malignant lymphoma in clinical communication, we developed a stand-alone, Web-based intervention called “PatientTIME.” The development of PatientTIME was based on a participatory intervention mapping framework. Its primary aim is to boost patients’ self-efficacy in patient-professional communication (ie, their confidence when interacting with their HCP). Patients can use this intervention before their hospital visit to prepare for their clinical consultation. PatientTIME is fully automated and use is patient-initiated. Objective: The aim of this study was to evaluate if and in what way patients benefit from PatientTIME and if it enhances their confidence in clinical communication. Methods: The intervention was evaluated in a closed randomized controlled trial with continuous recruitment (using online and offline methods to reach potential participants) and data collection. In accordance with the Medical Research Council guidance, we started with a process evaluation. Subsequently, an outcome evaluation was performed focusing on the patients’ perceived confidence in communication with their HCP, measured with the validated PEPPI questionnaire at baseline and at 3 months after participation. Process and outcome data were obtained through Web-based questionnaires, log files (automatically generated files mapping the interactions between program and users), and a logbook (comprising a record of actions and interactions kept by the researchers). Participants were not blinded. A total of 146 patients registered online, of whom 97 gave their informed consent and were assigned at random to the control group (N=34) or 1 of the 2 intervention groups (N=63). Ultimately 87/97 (90%) of these patients actually participated in the study, producing 87 datasets for analysis. Results: More than half of the intervention group patients reported that the intervention helped them prepare for a clinical consultation; it created awareness about the importance of communication and reinforced their existing communication skills. In the postvisit test, the control group showed a small, nonsignificant improvement in perceived communication efficacy. The intervention group showed a significant improvement in perceived efficacy. However, the interaction effect was not significant, indicating that the improvement solely as a result of the intervention may not be significant. Conclusions: A considerable number of patients reported that PatientTIME did provide support. We found a trend indicating that in the long run, patients with access to PatientTIME scored better on the perceived efficacy scale than patients without access. However, at this stage we cannot conclude that PatientTIME improves patients’ confidence when interacting with HCPs. ClinicalTrial: Netherlands National Trial Register (NTR): 3779; (archived by WebCite at

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    First-Stage Development and Validation of a Web-Based Automated Dietary Modeling Tool: Using Constraint Optimization Techniques to Streamline Food Group and...


    Background: Standardizing the background diet of participants during a dietary randomized controlled trial is vital to trial outcomes. For this process, dietary modeling based on food groups and their target servings is employed via a dietary prescription before an intervention, often using a manual process. Partial automation has employed the use of linear programming. Validity of the modeling approach is critical to allow trial outcomes to be translated to practice. Objective: This paper describes the first-stage development of a tool to automatically perform dietary modeling using food group and macronutrient requirements as a test case. The Dietary Modeling Tool (DMT) was then compared with existing approaches to dietary modeling (manual and partially automated), which were previously available to dietitians working within a dietary intervention trial. Methods: Constraint optimization techniques were implemented to determine whether nonlinear constraints are best suited to the development of the automated dietary modeling tool using food composition and food consumption data. Dietary models were produced and compared with a manual Microsoft Excel calculator, a partially automated Excel Solver approach, and the automated DMT that was developed. Results: The web-based DMT was produced using nonlinear constraint optimization, incorporating estimated energy requirement calculations, nutrition guidance systems, and the flexibility to amend food group targets for individuals. Percentage differences between modeling tools revealed similar results for the macronutrients. Polyunsaturated fatty acids and monounsaturated fatty acids showed greater variation between tools (practically equating to a 2-teaspoon difference), although it was not considered clinically significant when the whole diet, as opposed to targeted nutrients or energy requirements, were being addressed. Conclusions: Automated modeling tools can streamline the modeling process for dietary intervention trials ensuring consistency of the background diets, although appropriate constraints must be used in their development to achieve desired results. The DMT was found to be a valid automated tool producing similar results to tools with less automation. The results of this study suggest interchangeability of the modeling approaches used, although implementation should reflect the requirements of the dietary intervention trial in which it is used.

  • The devilSPARC app Home Screen. Image sourced and copyright held by authors Meg Bruening et al.

    A Mobile Ecological Momentary Assessment Tool (devilSPARC) for Nutrition and Physical Activity Behaviors in College Students: A Validation Study


    Background: The majority of nutrition and physical activity assessments methods commonly used in scientific research are subject to recall and social desirability biases, which result in over- or under-reporting of behaviors. Real-time mobile-based ecological momentary assessments (mEMAs) may result in decreased measurement biases and minimize participant burden. Objective: The aim was to examine the validity of a mEMA methodology to assess dietary and physical activity levels compared to 24-hour dietary recalls and accelerometers. Methods: This study was a pilot test of the SPARC (Social impact of Physical Activity and nutRition in College) study, which aimed to determine the mechanism by which friendship networks impact weight-related behaviors among young people. An mEMA app, devilSPARC, was developed to assess weight-related behaviors in real time. A diverse sample of 109 freshmen and community mentors attending a large southwestern university downloaded the devilSPARC mEMA app onto their personal mobile phones. Participants were prompted randomly eight times per day over the course of 4 days to complete mEMAs. During the same 4-day period, participants completed up to three 24-hour dietary recalls and/or 4 days of accelerometry. Self-reported mEMA responses were compared to 24-hour dietary recalls and accelerometry measures using comparison statistics, such as match rate, sensitivity and specificity, and mixed model odds ratios, adjusted for within-person correlation among repeated measurements. Results: At the day level, total dietary intake data reported through the mEMA app reflected eating choices also captured by the 24-hour recall. Entrées had the lowest match rate, and fruits and vegetables had the highest match rate. Widening the window of aggregation of 24-hour dietary recall data on either side of the mEMA response resulted in increased specificity and decreased sensitivity. For physical activity behaviors, levels of activity reported through mEMA differed for sedentary versus non-sedentary activity at the day level as measured by accelerometers. Conclusions: The devilSPARC mEMA app is valid for assessing eating behaviors and the presence of sedentary activity at the day level. This mEMA may be useful in studies examining real-time weight-related behaviors.

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    Web-Based Interventions for Chronic Back Pain: A Systematic Review


    Background: Chronic low back pain is one of the most common presenting complaints to a physician’s office. Treatment is often challenging and recovery depends on various factors, often resulting in significant investments of time and resources. Objective: The aim of this review is to determine which Web-based interventions aimed at chronic low back pain are of benefit to patients. Methods: Randomized controlled trials (RCTs) studying Web-based interventions directed at adults with chronic low back pain were included. Retrospective studies, narrative reviews, nonrandomized trials, and observational studies were excluded. Electronic databases and bibliographies were searched. Results: In total, nine unique RCTs were identified (total participants=1796). The number of patients randomized in each trial ranged from 51 to 580. Four trials studied online cognitive behavioral therapy (CBT) and five trials studied other Web-based interventions with interactive features. Empowerment/control was improved in six studies. Use of CBT was associated with reduced catastrophization among patients. Mixed results were reported with regards to reduction in pain levels and disability, although some studies showed promise in reducing disability in the short term. One study that measured health care utilization reported reduced utilization with the use of moderated email discussion. Conclusions: Limited data are available regarding effective Web-based interventions to improve outcomes for patients with chronic low back pain. Nine RCTs with small sample sizes were identified in this review. Online CBT appears to show some promise in terms of reducing catastrophization and improving patient attitudes. Further research in this area with larger-scale studies focusing on appropriate outcomes appears to be a priority.

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    Older Cancer Patients’ User Experiences With Web-Based Health Information Tools: A Think-Aloud Study


    Background: Health information is increasingly presented on the Internet. Several Web design guidelines for older Web users have been proposed; however, these guidelines are often not applied in website development. Furthermore, although we know that older individuals use the Internet to search for health information, we lack knowledge on how they use and evaluate Web-based health information. Objective: This study evaluates user experiences with existing Web-based health information tools among older (≥ 65 years) cancer patients and survivors and their partners. The aim was to gain insight into usability issues and the perceived usefulness of cancer-related Web-based health information tools. Methods: We conducted video-recorded think-aloud observations for 7 Web-based health information tools, specifically 3 websites providing cancer-related information, 3 Web-based question prompt lists (QPLs), and 1 values clarification tool, with colorectal cancer patients or survivors (n=15) and their partners (n=8) (median age: 73; interquartile range 70-79). Participants were asked to think aloud while performing search, evaluation, and application tasks using the Web-based health information tools. Results: Overall, participants perceived Web-based health information tools as highly useful and indicated a willingness to use such tools. However, they experienced problems in terms of usability and perceived usefulness due to difficulties in using navigational elements, shortcomings in the layout, a lack of instructions on how to use the tools, difficulties with comprehensibility, and a large amount of variety in terms of the preferred amount of information. Although participants frequently commented that it was easy for them to find requested information, we observed that the large majority of the participants were not able to find it. Conclusions: Overall, older cancer patients appreciate and are able to use cancer information websites. However, this study shows the importance of maintaining awareness of age-related problems such as cognitive and functional decline and navigation difficulties with this target group in mind. The results of this study can be used to design usable and useful Web-based health information tools for older (cancer) patients.

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    Behavioral Analysis of Visitors to a Medical Institution’s Website Using Markov Chain Monte Carlo Methods


    Background: Consistent with the “attention, interest, desire, memory, action” (AIDMA) model of consumer behavior, patients collect information about available medical institutions using the Internet to select information for their particular needs. Studies of consumer behavior may be found in areas other than medical institution websites. Such research uses Web access logs for visitor search behavior. At this time, research applying the patient searching behavior model to medical institution website visitors is lacking. Objective: We have developed a hospital website search behavior model using a Bayesian approach to clarify the behavior of medical institution website visitors and determine the probability of their visits, classified by search keyword. Methods: We used the website data access log of a clinic of internal medicine and gastroenterology in the Sapporo suburbs, collecting data from January 1 through June 31, 2011. The contents of the 6 website pages included the following: home, news, content introduction for medical examinations, mammography screening, holiday person-on-duty information, and other. The search keywords we identified as best expressing website visitor needs were listed as the top 4 headings from the access log: clinic name, clinic name + regional name, clinic name + medical examination, and mammography screening. Using the search keywords as the explaining variable, we built a binomial probit model that allows inspection of the contents of each purpose variable. Using this model, we determined a beta value and generated a posterior distribution. We performed the simulation using Markov Chain Monte Carlo methods with a noninformation prior distribution for this model and determined the visit probability classified by keyword for each category. Results: In the case of the keyword “clinic name,” the visit probability to the website, repeated visit to the website, and contents page for medical examination was positive. In the case of the keyword “clinic name and regional name,” the probability for a repeated visit to the website and the mammography screening page was negative. In the case of the keyword “clinic name + medical examination,” the visit probability to the website was positive, and the visit probability to the information page was negative. When visitors referred to the keywords “mammography screening,” the visit probability to the mammography screening page was positive (95% highest posterior density interval = 3.38-26.66). Conclusions: Further analysis for not only the clinic website but also various other medical institution websites is necessary to build a general inspection model for medical institution websites; we want to consider this in future research. Additionally, we hope to use the results obtained in this study as a prior distribution for future work to conduct higher-precision analysis.

  • Mother looking for health information on the Internet with her daughter

Source: CC0 Public Domain.

    Modelling and Predicting eHealth Usage in Europe: A Multidimensional Approach From an Online Survey of 13,000 European Union Internet Users


    Background: More advanced methods and models are needed to evaluate the participation of patients and citizens in the shared health care model that eHealth proposes. Objective: The goal of our study was to design and evaluate a predictive multidimensional model of eHealth usage. Methods: We used 2011 survey data from a sample of 13,000 European citizens aged 16–74 years who had used the Internet in the previous 3 months. We proposed and tested an eHealth usage composite indicator through 2-stage structural equation modelling with latent variables and measurement errors. Logistic regression (odds ratios, ORs) to model the predictors of eHealth usage was calculated using health status and sociodemographic independent variables. Results: The dimensions with more explanatory power of eHealth usage were health Internet attitudes, information health Internet usage, empowerment of health Internet users, and the usefulness of health Internet usage. Some 52.39% (6811/13,000) of European Internet users’ eHealth usage was more intensive (greater than the mean). Users with long-term health problems or illnesses (OR 1.20, 95% CI 1.12–1.29) or receiving long-term treatment (OR 1.11, 95% CI 1.03–1.20), having family members with long-term health problems or illnesses (OR 1.44, 95% CI 1.34–1.55), or undertaking care activities for other people (OR 1.58, 95% CI 1.40–1.77) had a high propensity toward intensive eHealth usage. Sociodemographic predictors showed that Internet users who were female (OR 1.23, 95% CI 1.14–1.31), aged 25–54 years (OR 1.12, 95% CI 1.05–1.21), living in larger households (3 members: OR 1.25, 95% CI 1.15–1.36; 5 members: OR 1.13, 95% CI 0.97–1.28; ≥6 members: OR 1.31, 95% CI 1.10–1.57), had more children <16 years of age (1 child: OR 1.29, 95% CI 1.18–1.14; 2 children: OR 1.05, 95% CI 0.94–1.17; 4 children: OR 1.35, 95% CI 0.88–2.08), and had more family members >65 years of age (1 member: OR 1.33, 95% CI 1.18–1.50; ≥4 members: OR 1.82, 95% CI 0.54–6.03) had a greater propensity toward intensive eHealth usage. Likewise, users residing in densely populated areas, such as cities and large towns (OR 1.17, 95% CI 1.09–1.25), also had a greater propensity toward intensive eHealth usage. Educational levels presented an inverted U shape in relation to intensive eHealth usage, with greater propensities among those with a secondary education (OR 1.08, 95% CI 1.01–1.16). Finally, occupational categories and net monthly income data suggest a higher propensity among the employed or self-employed (OR 1.07, 95% CI 0.99–1.15) and among the minimum wage stratum, earning ≤€1000 per month (OR 1.66, 95% CI 1.48–1.87). Conclusions: We provide new evidence of inequalities that explain intensive eHealth usage. The results highlight the need to develop more specific eHealth practices to address different realities.

  • Image Source: Halfway, copyright Rory MacLeod,, Licensed under Creative Commons Attribution cc-by 2.0

    Health Care Applicability of a Patient-Centric Web Portal for Patients’ Medication Experience


    Background: With the advent of the patient-centered care paradigm, it is important to examine what patients’ reports of medication experience (PROME) mean to patient care. PROME available through a Web portal provide information on medication treatment options and outcomes from the patient’s perspective. Patients who find certain PROME compelling are likely to mention them at their physician visit, triggering a discussion between the patient and the physician. However, no studies have examined PROME’s potential applicability to patient care. Objective: This study aimed to examine older (≥50 years) adults’ perceptions of the health care applicability of a hypothetical PROME Web portal. Specifically, this study investigated whether PROME would facilitate patient-physician communication, and identified the preferred reporting items and the trusted sponsors of such a PROME Web portal. Methods: We used a cross-sectional, self-administered, 5-point Likert scale survey to examine participants’ perceptions of a hypothetical PROME Web portal that compared PROME for 5 common antihypertensive medications. Between August and December 2013, we recruited 300 members of 7 seniors’ centers in a metropolitan area of a southeastern state of the United States to participate in the survey. Results: An overwhelming majority of study participants (243/300, 81.0%) had a favorable perception of PROME’s health care applicability. They were mostly positive that PROME would facilitate patient-physician communication, except for the perception that physicians would be upset by the mention of PROME (n=133, 44.3%). Further, 85.7% (n=257) of participants considered the PROME information trustworthy, and 72.0% (n=216) were willing to participate by reporting their own medication experiences. Study participants wanted the PROME Web portal to report the number of reviews, star ratings, and individual comments concerning different medication attributes such as side effects (224/809, 27.7%), cost (168/809, 20.8%), and effectiveness (153/809, 18.9%). Finally, the PROME Web portal sponsorship was important to participants, with the most trusted sponsor being academic institutions (120/400, 30.0%). Conclusions: PROME, if well compiled through Web portals, have the potential to facilitate patient-physician communication.

  • Image Source: AGC Photo Girls Enjoy Lunch, copyright U.S. Department of Agriculture,, Licensed under Creative Commons Attribution cc-by 2.0

    Parent-Focused Childhood and Adolescent Overweight and Obesity eHealth Interventions: A Systematic Review and Meta-Analysis


    Background: Effective broad-reach interventions to reduce childhood obesity are needed, but there is currently little consensus on the most effective approach. Parental involvement in interventions appears to be important. The use of eHealth modalities in interventions also seems to be promising. To our knowledge, there have been no previous reviews that have specifically investigated the effectiveness of parent-focused eHealth obesity interventions, a gap that this systematic review and meta-analysis intends to address. Objective: The objective of this study was to review the evidence for body mass index (BMI)/BMI z-score improvements in eHealth overweight and obesity randomized controlled trials for children and adolescents, where parents or carers were an agent of change. Methods: A systematic review and meta-analysis was conducted, which conforms to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Seven databases were searched for the period January 1995 to April 2015. Primary outcome measures were BMI and/or BMI z-score at baseline and post-intervention. Secondary outcomes included diet, physical activity, and screen time. Interventions were included if they targeted parents of children and adolescents aged 0-18 years of age and used an eHealth medium such as the Internet, interactive voice response (IVR), email, social media, telemedicine, or e-learning. Results: Eight studies were included, involving 1487 parent and child or adolescent dyads. A total of 3 studies were obesity prevention trials, and 5 were obesity treatment trials. None of the studies found a statistically significant difference in BMI or BMI z-score between the intervention and control groups at post-intervention, and a meta-analysis demonstrated no significant difference in the effects of parent-focused eHealth obesity interventions compared with a control on BMI/BMI z-score (Standardized Mean Difference −0.15, 95% CI −0.45 to 0.16, Z=0.94, P=.35). Four of seven studies that reported on dietary outcomes demonstrated significant improvements in at least 1 dietary measurement, and 1 of 6 studies that reported on physical activity outcomes demonstrated significant improvements compared with the control. The quality of the interventions was generally not high; therefore, these results should be interpreted with caution. Conclusion: It is recommended that larger, longer duration, high-quality parent-focused eHealth studies are conducted, which transform successful components from face-to-face interventions into an eHealth format and target younger age groups in particular. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRD42015019837; (Archived by WebCite at

  • Source and copyright: the authors;, license to use under creative commons.

    Investigating the Potential Contribution of Patient Rating Sites to Hospital Supervision: Exploratory Results From an Interview Study in the Netherlands


    Background: Over the last decades, the patient perspective on health care quality has been unconditionally integrated into quality management. For several years now, patient rating sites have been rapidly gaining attention. These offer a new approach toward hearing the patient’s perspective on the quality of health care. Objective: The aim of our study was to explore whether and how patient reviews of hospitals, as reported on rating sites, have the potential to contribute to health care inspector’s daily supervision of hospital care. Methods: Given the unexplored nature of the topic, an interview study among hospital inspectors was designed in the Netherlands. We performed 2 rounds of interviews with 10 senior inspectors, addressing their use and their judgment on the relevance of review data from a rating site. Results: All 10 Dutch senior hospital inspectors participated in this research. The inspectors initially showed some reluctance to use the major patient rating site in their daily supervision. This was mainly because of objections such as worries about how representative they are, subjectivity, and doubts about the relevance of patient reviews for supervision. However, confrontation with, and assessment of, negative reviews by the inspectors resulted in 23% of the reviews being deemed relevant for risk identification. Most inspectors were cautiously positive about the contribution of the reviews to their risk identification. Conclusions: Patient rating sites may be of value to the risk-based supervision of hospital care carried out by the Health Care Inspectorate. Health care inspectors do have several objections against the use of patient rating sites for daily supervision. However, when they are presented with texts of negative reviews from a hospital under their supervision, it appears that most inspectors consider it as an additional source of information to detect poor quality of care. Still, it should always be accompanied and verified by other quality and safety indicators. More research on the value and usability of patient rating sites in daily hospital supervision and other health settings is needed.

  • Source:; Attribution: Dooder -; Creative commons licensed; modified.

    Social Annotation Valence: The Impact on Online Informed Consent Beliefs and Behavior


    Background: Social media, mobile and wearable technology, and connected devices have significantly expanded the opportunities for conducting biomedical research online. Electronic consent to collecting such data, however, poses new challenges when contrasted to traditional consent processes. It reduces the participant-researcher dialogue but provides an opportunity for the consent deliberation process to move from solitary to social settings. In this research, we propose that social annotations, embedded in the consent form, can help prospective participants deliberate on the research and the organization behind it in ways that traditional consent forms cannot. Furthermore, we examine the role of the comments’ valence on prospective participants’ beliefs and behavior. Objective: This study focuses specifically on the influence of annotations’ valence on participants’ perceptions and behaviors surrounding online consent for biomedical research. We hope to shed light on how social annotation can be incorporated into digitally mediated consent forms responsibly and effectively. Methods: In this controlled between-subjects experiment, participants were presented with an online consent form for a personal genomics study that contained social annotations embedded in its margins. Individuals were randomly assigned to view the consent form with positive-, negative-, or mixed-valence comments beside the text of the consent form. We compared participants’ perceptions of being informed and having understood the material, their trust in the organization seeking the consent, and their actual consent across conditions. Results: We find that comment valence has a marginally significant main effect on participants’ perception of being informed (F2=2.40, P=.07); specifically, participants in the positive condition (mean 4.17, SD 0.94) felt less informed than those in the mixed condition (mean 4.50, SD 0.69, P=.09). Comment valence also had a marginal main effect on the extent to which participants reported trusting the organization (F2=2.566, P=.08). Participants in the negative condition (mean 3.59, SD 1.14) were marginally less trusting than participants exposed to the positive condition (mean 4.02, SD 0.90, P=.06). Finally, we found that consent rate did not differ across comment valence conditions; however, participants who spent less time studying the consent form were more likely to consent when they were exposed to positive-valence comments. Conclusions: This work explores the effects of adding a computer-mediated social dimension, which inherently contains human emotions and opinions, to the consent deliberation process. We proposed that augmenting the consent deliberation process to incorporate multiple voices can enable individuals to capitalize on the knowledge of others, which brings to light questions, problems, and concerns they may not have considered on their own. We found that consent forms containing positive valence annotations are likely to lead participants to feel less informed and simultaneously more trusting of the organization seeking consent. In certain cases where participants spent little time considering the content of the consent form, participants exposed to positive valence annotations were even more likely to consent to the study. We suggest that these findings represent important considerations for the design of future electronic informed consent mechanisms.

  •; CCBY2.0, Attribution: Joe The Goat Farmer; modified.

    How Affiliation Disclosure and Control Over User-Generated Comments Affects Consumer Health Knowledge and Behavior: A Randomized Controlled Experiment of...


    Background: More people are seeking health information online than ever before and pharmaceutical companies are increasingly marketing their drugs through social media. Objective: The aim was to examine two major concerns related to online direct-to-consumer pharmaceutical advertising: (1) how disclosing an affiliation with a pharmaceutical company affects how people respond to drug information produced by both health organizations and online commenters, and (2) how knowledge that health organizations control the display of user-generated comments affects consumer health knowledge and behavior. Methods: We conducted a 2×2×2 between-subjects experiment (N=674). All participants viewed an infographic posted to Facebook by a health organization about a prescription allergy drug. Across conditions, the infographic varied in the degree to which the health organization and commenters appeared to be affiliated with a drug manufacturer, and the display of user-generated comments appeared to be controlled. Results: Affiliation disclosure statements on a health organization’s Facebook post increased perceptions of an organization-drug manufacturer connection, which reduced trust in the organization (point estimate –0.45, 95% CI –0.69 to –0.24) and other users who posted comments about the drug (point estimate –0.44, 95% CI –0.68 to –0.22). Furthermore, increased perceptions of an organization-manufacturer connection reduced the likelihood that people would recommend the drug to important others (point estimate –0.35, 95% CI –0.59 to –0.15), and share the drug post with others on Facebook (point estimate –0.37, 95% CI –0.64 to –0.16). An affiliation cue next to the commenters' names increased perceptions that the commenters were affiliated with the drug manufacturer, which reduced trust in the comments (point estimate –0.81, 95% CI –1.04 to –0.59), the organization that made the post (point estimate –0.68, 95% CI –0.90 to –0.49), the likelihood of participants recommending the drug (point estimate –0.61, 95% CI –0.82 to –0.43), and sharing the post with others on Facebook (point estimate –0.63, 95% CI –0.87 to –0.43). Cues indicating that a health organization removed user-generated comments from a post increased perceptions that the drug manufacturer influenced the display of the comments, which negatively affected trust in the comments (point estimate –0.35, 95% CI –0.53 to –0.20), the organization (point estimate –0.31, 95% CI –0.47 to –0.17), the likelihood of recommending the drug (point estimate –0.26, 95% CI –0.41 to –0.14), and the likelihood of sharing the post with others on Facebook (point estimate –0.28, 95% CI –0.45 to –0.15). (All estimates are unstandardized indirect effects and 95% bias-corrected bootstrap confidence intervals.) Conclusions: Concern over pharmaceutical companies hiding their affiliations and strategically controlling user-generated comments is well founded; these practices can greatly affect not only how viewers evaluate drug information online, but also how likely they are to propagate the information throughout their online and offline social networks.

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    Open Peer Review Period: Jul 29, 2016 - Sep 23, 2016

    Background: Many markets have traditionally been dominated by a few best-selling products, and this is also the case for the health care industry. However, we do not know whether the market will be mo...

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    Fundamental quality, safety, and cost problems have not been resolved by the increasing digitization of healthcare. This digitization has progressed alongside the presence of a persistent divide betwe...

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    Open Peer Review Period: Jul 28, 2016 - Aug 5, 2016

    Background: Work on pharmacovigilance systems using texts from PubMed and Twitter is vast, and even if there is a large number of available corpora from these two data sources these corpora target dif...

    Background: Work on pharmacovigilance systems using texts from PubMed and Twitter is vast, and even if there is a large number of available corpora from these two data sources these corpora target different elements and use different annotation guidelines, and to date there is no comparable set of documents from both Twitter and PubMed annotated in the same manner. Objective: This study aims to provide a comparable corpus of texts from PubMed and Twitter that can be used to study drug reports from these two sources of information allowing researchers in the area of pharmacovigilance to perform experiments to better understand the similarities and differences between drug reports in Twitter and PubMed. Methods: We produced a corpus of Twitter messages and PubMed sentences that contain mentions to drugs, chosen from a closed set of drug names, as well as for diseases and symptoms related to the intake of these drugs. All the sentences from Twitter and PubMed were selected using the same strategy, and annotated at entity-level by the same experts (pharmacists) using the same set of guidelines. Results: We provide the resulting annotations for the entities and relations mentioned in 1000 tweets and 1000 PubMed sentences as well as for a number of attributes for the annotated entities. The set of drugs we included in the study covers 30 different drugs used in other pharmacovigilance studies providing a balanced number of mentions. The inter annotator agreement between the two pharmacists was perfect for drugs (96.11% in Twitter and 92.00% in PubMed), while diseases and symptoms categories obtained substantial inter annotator agreement in both Twitter (67.85% and 65.50%, respectively) and PubMed (73.01% for diseases and 66.64% for symptoms). We also present our strategy for resolving a number of disagreements which resulted in noticeable improvements in the inter annotator agreement scores in both PubMed and Twitter. Additionally, we provide the annotation guidelines and the tools that can be used to obtain the raw tweets and to preprocess the sentences from both Twitter and PubMed to allow the reuse of our annotations. Conclusions: We present a corpus that is unique in its characteristics as this is the first corpus for pharmacovigilance curated from Twitter messages and PubMed sentences using the same data selection and annotation strategies. We believe this corpus will be of particular interest for researchers willing to compare results from pharmacovigilance systems (e.g. classifiers and named entity recognition systems) when using data from Twitter and from PubMed. We hope that given the comprehensive set of drug names and the annotated entities and relations this corpus becomes a standard resource to compare results from different pharmacovigilance studies.

  • Can Gaming Increase Antibiotic Awareness in Children? A Mixed Methods Approach

    Date Submitted: Jul 28, 2016

    Open Peer Review Period: Jul 28, 2016 - Sep 22, 2016

    Background: e-Bug is a pan-European educational resource for junior and senior school children that contains activities covering prudent antibiotic use and the spread, treatment, and prevention of inf...

    Background: e-Bug is a pan-European educational resource for junior and senior school children that contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home. Objective: The aim of this study was to appraise young people’s opinions of three antibiotic games on the e-Bug student website by exploring children’s views and suggestions for improvements, and analysing change in awareness about the learning outcomes. The three games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses. Methods: A mixed methodological approach was undertaken. 153 pupils aged 9-11 in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe awareness questions, before and after playing three e-Bug games for a total of 15 minutes each. The after questionnaire also contained open-ended and Likert scale questions. In addition, six focus groups with 48 students and think-aloud sessions with four students who had all played the games were performed. Results: The questionnaire data showed a significant increase in awareness for 2 out of 7 questions, while all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections, and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game 'Body Busters' was the most popular game, closely followed by ‘Doctor Doctor’, with 'Microbe Mania' being the least popular. Conclusions: The conclusions of this study show that two of the e-Bug antibiotic educational games are valuable. The ‘Body Busters’ game effectively increased antibiotic awareness in children and had the greatest flow and enjoyment for children. The ‘Doctor Doctor’ game also resulted in increased knowledge, but was less enjoyable. The ‘Microbe Mania’ game had neither flow nor knowledge gain and therefore needs much modification and review. These games, especially the ‘Body Busters’ and ‘Doctor Doctor’ games should be promoted to schools and families. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games.

  • The Internet as a Source of Health Information – the Results of a Polish Survey Study

    Date Submitted: Jul 28, 2016

    Open Peer Review Period: Jul 28, 2016 - Sep 22, 2016

    Background: The popularisation of Internet access has made it one of the basic sources of information (in this article, the term “Internet” is understood as different kinds of: websites, blogs, so...

    Background: The popularisation of Internet access has made it one of the basic sources of information (in this article, the term “Internet” is understood as different kinds of: websites, blogs, social networking sites, such as: Facebook, Twitter, etc.; text messages, including: email, skype, other instant messengers; discussion forums). This relates also to health and its correlates. Objective: The main objective of the study was to evaluate the scale of the phenomenon of using the Internet to look for health information in Poland. The aim of the study was also to evaluate the influence of information about health published in the network on the behaviour of internet users. Methods: A questionnaire-based survey (face-to-face interview) was carried out among a representative group of 1000 inhabitants of Poland aged 15 years and older. Results: Among the 1000 respondents surveyed in this study, 670 (67%) declared using the Internet, more than half of which (53.7%) reported seeking, among others, health information. The most commonly sought information included: diet and healthy eating (33.3%), a particular medication or dietary supplement (its effect, dosage, side effects) (28.9%), reviews of doctors (26.7%), and how other people coped with similar health problems (25.3%). More than 53% of Internet health information seekers were driven by curiosity, 46.4% by the ease and speed of finding information, 32.5% by the opportunity of finding a lot of independent reviews in one place, and 29.7% by no extra costs. Conclusions: The importance of the Internet as a source of information about health is constantly increasing. Our study presents that in Poland, women, younger, well-educated, living in big cities, especially often look for health information on the web. However most people have limited trust in the data derived from that source. The influence of information about health published in the network on people's behaviour could be less than is commonly believed.