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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    Use and Appreciation of a Tailored Self-Management eHealth Intervention for Early Cancer Survivors: Process Evaluation of a Randomized Controlled Trial


    Background: A fully automated computer-tailored Web-based self-management intervention, Kanker Nazorg Wijzer (KNW [Cancer Aftercare Guide]), was developed to support early cancer survivors to adequately cope with psychosocial complaints and to promote a healthy lifestyle. The KNW self-management training modules target the following topics: return to work, fatigue, anxiety and depression, relationships, physical activity, diet, and smoking cessation. Participants were guided to relevant modules by personalized module referral advice that was based on participants’ current complaints and identified needs. Objective: The aim of this study was to evaluate the adherence to the module referral advice, examine the KNW module use and its predictors, and describe the appreciation of the KNW and its predictors. Additionally, we explored predictors of personal relevance. Methods: From the respondents (N=231; mean age 55.6, SD 11.5; 79.2% female [183/231]), 98.3% (227/231) were referred to one or more KNW modules (mean 2.9, SD 1.5), and 85.7% (198/231) of participants visited at least one module (mean 2.1, SD 1.6). Significant positive associations were found between the referral to specific modules (range 1-7) and the use of corresponding modules. The likelihoods of visiting modules were higher when respondents were referred to those modules by the module referral advice. Predictors of visiting a higher number of modules were a higher number of referrals by the module referral advice (β=.136, P=.009), and having a partner was significantly related with a lower number of modules used (β=-.256, P=.044). Overall appreciation was high (mean 7.5, SD 1.2; scale 1-10) and was significantly predicted by a higher perceived personal relevance (β=.623, P=.000). None of the demographic and cancer-related characteristics significantly predicted the perceived personal relevance. Results: The KNW in general and more specifically the KNW modules were well used and highly appreciated by early cancer survivors. Results indicated that the module referral advice might be a meaningful intervention component to guide the users in following a preferred selection of modules. These results indicate that the fully automated Web-based KNW provides personal relevant and valuable information and support for early cancer survivors. Therefore, this intervention can complement usual cancer aftercare and may serve as a first step in a stepped-care approach. Conclusions: The KNW in general and more specifically the KNW modules were well used and highly appreciated by early cancer survivors. Indications were found that the module referral advice might be a meaningful intervention component to guide the users in following a preferred selection of modules. These results indicate that the fully automated Web-based KNW provides personal relevant and valuable information and support for early cancer survivors. Therefore, this intervention can complement usual cancer aftercare and may serve as a first step in a stepped-care approach. Trial Registration: Nederlands Trial Register: NTR3375; (Archived by WebCite at

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    An Evaluation and Ranking of Children’s Hospital Websites in the United States


    Background: Children’s hospitals are faced with the rising need for technological innovation. Their prospective health care consumers, who increasingly depend on the Web and social media for communication and consumer engagement, drive this need. As patients and family members navigate the Web presence of hospitals, it is important for these specialized organizations to present themselves and their services efficiently. Objective: The purpose of this study was to evaluate the website content of children’s hospitals in order to identify opportunities to improve website design and create benchmarks to judge improvement. Methods: All websites associated with a children’s hospital were identified using a census list of all children’s hospitals in the United States. In March of 2014, each website and its social media were evaluated using a Web crawler that provided a 5-dimensional assessment that included website accessibility, marketing, content, technology, and usability. The 5-dimensional assessment was scored on a scale ranging from 0 to 10 with positive findings rated higher on the scale. Websites were ranked by individual dimensions as well as according to their average ranking across all dimensions. Results: Mean scores of 153 websites ranged from 5.05 to 8.23 across all 5 dimensions. Results revealed that no website scored a perfect 10 on any dimension and that room exists for meaningful improvement. Conclusions: Study findings allow for the establishment of baseline benchmarks for tracking future website and social media improvements and display the need for enhanced Web-based consumer engagement for children’s hospitals.

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    Effectiveness of mHealth Interventions Targeting Health Care Workers to Improve Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review


    Background: Low- and middle-income countries (LMICs) face the highest burden of maternal and neonatal deaths. Concurrently, they have the lowest number of physicians. Innovative methods such as the exchange of health-related information using mobile devices (mHealth) may support health care workers in the provision of antenatal, delivery, and postnatal care to improve maternal and neonatal outcomes in LMICs. Objective: We conducted a systematic review evaluating the effectiveness of mHealth interventions targeting health care workers to improve maternal and neonatal outcomes in LMIC. Methods: The Cochrane Library, PubMed, EMBASE, Global Health Library, and Popline were searched using predetermined search and indexing terms. Quality assessment was performed using an adapted Cochrane Risk of Bias Tool. A strength, weakness, opportunity, and threat analysis was performed for each included paper. Results: A total of 19 studies were included for this systematic review, 10 intervention and 9 descriptive studies. mHealth interventions were used as communication, data collection, or educational tool by health care providers primarily at the community level in the provision of antenatal, delivery, and postnatal care. Interventions were used to track pregnant women to improve antenatal and delivery care, as well as facilitate referrals. None of the studies directly assessed the effect of mHealth on maternal and neonatal mortality. Challenges of mHealth interventions to assist health care workers consisted mainly of technical problems, such as mobile network coverage, internet access, electricity access, and maintenance of mobile phones. Conclusions: mHealth interventions targeting health care workers have the potential to improve maternal and neonatal health services in LMICs. However, there is a gap in the knowledge whether mHealth interventions directly affect maternal and neonatal outcomes and future research should employ experimental designs with relevant outcome measures to address this gap.

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    Evaluation of a Web-Based E-Learning Platform for Brief Motivational Interviewing by Nurses in Cardiovascular Care: A Pilot Study


    Background: Brief motivational interviewing (MI) can contribute to reductions in morbidity and mortality related to coronary artery disease, through health behavior change. Brief MI, unlike more intensive interventions, was proposed to meet the needs of clinicians with little spare time. While the provision of face-to-face brief MI training on a large scale is complicated, Web-based e-learning is promising because of the flexibility it offers. Objective: The primary objective of this pilot study was to examine the feasibility and acceptability of a Web-based e-learning platform for brief MI (MOTIV@CŒUR), which was evaluated by nurses in cardiovascular care. The secondary objective was to assess the preliminary effect of the training on nurses’ perceived brief MI skills and self-reported clinical use of brief MI. Methods: We conducted a single-group, pre-post pilot study involving nurses working in a coronary care unit to evaluate MOTIV@CŒUR, which is a Web-based e-learning platform for brief MI, consisting of two sessions lasting 30 and 20 minutes. MOTIV@CŒUR covers 4 real-life clinical situations through role-modeling videos showing nurse-client interactions. A brief introduction to MI is followed by role playing, during which a nurse practitioner evaluates clients’ motivation to change and intervenes according to the principles of brief MI. The clinical situations target smoking, medication adherence, physical activity, and diet. Nurses were asked to complete both Web-based training sessions asynchronously within 20 days, which allowed assessment of the feasibility of the intervention. Data regarding acceptability and preliminary effects (perceived skills in brief MI, and self-reported clinical use of conviction and confidence interventions) were self-assessed through Web-based questionnaires 30 days (±5 days) after the first session. Results: We enrolled 27 women and 4 men (mean age 37, SD 9 years) in March 2016. Of the 31 participants, 24 (77%, 95% CI 63%–91%) completed both sessions in ≤20 days. At 30 days, 28 of the 31 participants (90%) had completed at least one session. The training was rated as highly acceptable, with the highest scores observed for information quality (mean 6.26, SD 0.60; scale 0–7), perceived ease of use (mean 6.16, SD 0.78; scale 0–7), and system quality (mean 6.15, SD 0.58; scale 0–7). Posttraining scores for self-reported clinical use of confidence interventions were higher than pretraining scores (mean 34.72, SD 6.29 vs mean 31.48, SD 6.75, respectively; P=.03; scale 10–50). Other results were nonsignificant. Conclusions: Brief MI training using a Web-based e-learning platform including role-modeling videos is both feasible and acceptable according to cardiovascular care nurses. Further research is required to evaluate the e-learning platform in a randomized controlled trial. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 16510888; (Archived by WebCite at

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    Efficacy of Internet-Based Self-Monitoring Interventions on Maternal and Neonatal Outcomes in Perinatal Diabetic Women: A Systematic Review and Meta-Analysis


    Background: Self-monitoring using the Internet offers new opportunities to engage perinatal diabetic women in self-management to reduce maternal and neonatal complications. Objective: This review aims to synthesize the best available evidence to evaluate the efficacy of Internet-based self-monitoring interventions in improving maternal and neonatal outcomes among perinatal diabetic women. Methods: The review was conducted using Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsyINFO, Scopus, and ProQuest Dissertations and Theses to search for English-language research studies without any year limitation. A risk of bias table was used to assess methodological quality. Meta-analysis was performed with RevMan software. Cochran Q and I2 tests were used to assess heterogeneity. The overall effect was assessed using z tests at P<.05. Of the 438 studies identified through electronic searches and reference lists, nine experimental studies from 10 publications were selected. Results: Half of the selected studies showed low risk of bias and comprised 852 perinatal diabetic women in six countries. The meta-analysis revealed that Internet-based self-monitoring interventions significantly decreased the level of maternal glycated hemoglobin A1c (z=2.23, P=.03) compared to usual care among perinatal diabetic women at postintervention. Moreover, Internet-based self-monitoring interventions significantly decreased the cesarean delivery rate (z=2.23, P=.03) compared to usual care among the mixed group at postintervention. Conclusions: This review shows neonatal or other maternal outcomes are similar between Internet-based self-monitoring interventions and usual diabetes care among perinatal diabetic women. The long-term effects of the intervention must be confirmed in future studies using randomized controlled trials and follow-up data.

  • Image Source: Verona Cycling, copyright, Tejvan Pettinger., Licensed under Creative Commons Attribution cc-by 2.0

    Web-Based Video-Coaching to Assist an Automated Computer-Tailored Physical Activity Intervention for Inactive Adults: A Randomized Controlled Trial


    Background: Web-based physical activity interventions that apply computer tailoring have shown to improve engagement and behavioral outcomes but provide limited accountability and social support for participants. It is unknown how video calls with a behavioral expert in a Web-based intervention will be received and whether they improve the effectiveness of computer-tailored advice. Objective: The purpose of this study was to determine the feasibility and effectiveness of brief video-based coaching in addition to fully automated computer-tailored advice in a Web-based physical activity intervention for inactive adults. Methods: Participants were assigned to one of the three groups: (1) tailoring + video-coaching where participants received an 8-week computer-tailored Web-based physical activity intervention (“My Activity Coach”) including 4 10-minute coaching sessions with a behavioral expert using a Web-based video-calling program (eg, Skype; n=52); (2) tailoring-only where participants received the same intervention without the coaching sessions (n=54); and (3) a waitlist control group (n=45). Demographics were measured at baseline, intervention satisfaction at week 9, and physical activity at baseline, week 9, and 6 months by Web-based self-report surveys. Feasibility was analyzed by comparing intervention groups on retention, adherence, engagement, and satisfaction using t tests and chi-square tests. Effectiveness was assessed using linear mixed models to compare physical activity changes between groups. Results: A total of 23 tailoring + video-coaching participants, 30 tailoring-only participants, and 30 control participants completed the postintervention survey (83/151, 55.0% retention). A low percentage of tailoring + video-coaching completers participated in the coaching calls (11/23, 48%). However, the majority of those who participated in the video calls were satisfied with them (5/8, 71%) and had improved intervention adherence (9/11, 82% completed 3 or 4 modules vs 18/42, 43%, P=.01) and engagement (110 minutes spent on the website vs 78 minutes, P=.02) compared with other participants. There were no overall retention, adherence, engagement, and satisfaction differences between tailoring + video-coaching and tailoring-only participants. At 9 weeks, physical activity increased from baseline to postintervention in all groups (tailoring + video-coaching: +150 minutes/week; tailoring only: +123 minutes/week; waitlist control: +34 minutes/week). The increase was significantly higher in the tailoring + video-coaching group compared with the control group (P=.01). No significant difference was found between intervention groups and no significant between-group differences were found for physical activity change at 6 months. Conclusions: Only small improvements were observed when video-coaching was added to computer-tailored advice in a Web-based physical activity intervention. However, combined Web-based video-coaching and computer-tailored advice was effective in comparison with a control group. More research is needed to determine whether Web-based coaching is more effective than stand-alone computer-tailored advice. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12614000339651; (Archived by WebCite at

  • Gamla Stan metro station in Stockholm, Sweden. Image Source: Mats Halldin 31 March 2007 (UTC) - Own work, licensed under CC BY-SA 3.0,

    The Effect of Tailored Web-Based Feedback and Optional Telephone Coaching on Health Improvements: A Randomized Intervention Among Employees in the Transport...


    Background: Lifestyle-related health problems are an important health concern in the transport service industry. Web- and telephone-based interventions could be suitable for this target group requiring tailored approaches. Objective: To evaluate the effect of tailored Web-based health feedback and optional telephone coaching to improve lifestyle factors (body mass index—BMI, dietary intake, physical activity, stress, sleep, tobacco and alcohol consumption, disease history, self-perceived health, and motivation to change health habits), in comparison to no health feedback or telephone coaching. Methods: Overall, 3,876 employees in the Swedish transport services were emailed a Web-based questionnaire. They were randomized into: control group (group A, 498 of 1238 answered, 40.23%), or intervention Web (group B, 482 of 1305 answered, 36.93%), or intervention Web + telephone (group C, 493 of 1333 answered, 36.98%). All groups received an identical questionnaire, only the interventions differed. Group B received tailored Web-based health feedback, and group C received tailored Web-based health feedback + optional telephone coaching if the participants’ reported health habits did not meet the national guidelines, or if they expressed motivation to change health habits. The Web-based feedback was fully automated. Telephone coaching was performed by trained health counselors. Nine months later, all participants received a follow-up questionnaire and intervention Web + telephone. Descriptive statistics, the chi-square test, analysis of variance, and generalized estimating equation (GEE) models were used. Results: Overall, 981 of 1473 (66.60%) employees participated at baseline (men: 66.7%, mean age: 44 years, mean BMI: 26.4 kg/m2) and follow-up. No significant differences were found in reported health habits between the 3 groups over time. However, significant changes were found in motivation to change. The intervention groups reported higher motivation to improve dietary habits (144 of 301 participants, 47.8%, and 165 of 324 participants, 50.9%, for groups B and C, respectively) and physical activity habits (181 of 301 participants, 60.1%, and 207 of 324 participants, 63.9%, for B and C, respectively) compared with the control group A (122 of 356 participants, 34.3%, for diet and 177 of 356 participants, 49.7%, for physical activity). At follow-up, the intervention groups had significantly decreased motivation (group B: P<.001 for change in diet; P<.001 for change in physical activity; group C: P=.007 for change in diet; P<.001 for change in physical activity), whereas the control group reported significantly increased motivation to change diet and physical activity (P<.001 for change in diet; P<.001 for change in physical activity). Conclusion: Tailored Web-based health feedback and the offering of optional telephone coaching did not have a positive health effect on employees in the transport services. However, our findings suggest an increased short-term motivation to change health behaviors related to diet and physical activity among those receiving tailored Web-based health feedback.

  • Identification of malaria on a virtual microscope delivered over the Internet.
Image created by authors.

    Web-Based Virtual Microscopy of Digitized Blood Slides for Malaria Diagnosis: An Effective Tool for Skills Assessment in Different Countries and Environments


    Background: Morphological examination of blood films remains the reference standard for malaria diagnosis. Supporting the skills required to make an accurate morphological diagnosis is therefore essential. However, providing support across different countries and environments is a substantial challenge. Objective: This paper reports a scheme supplying digital slides of malaria-infected blood within an Internet-based virtual microscope environment to users with different access to training and computing facilities. The feasibility of the approach was established, allowing users to test, record, and compare their own performance with that of other users. Methods: From Giemsa stained thick and thin blood films, 56 large high-resolution digital slides were prepared, using high-quality image capture and 63x oil-immersion objective lens. The individual images were combined using the photomerge function of Adobe Photoshop and then adjusted to ensure resolution and reproduction of essential diagnostic features. Web delivery employed the Digital Slidebox platform allowing digital microscope viewing facilities and image annotation with data gathering from participants. Results: Engagement was high with images viewed by 38 participants in five countries in a range of environments and a mean completion rate of 42/56 cases. The rate of parasite detection was 78% and accuracy of species identification was 53%, which was comparable with results of similar studies using glass slides. Data collection allowed users to compare performance with other users over time or for each individual case. Conclusions: Overall, these results demonstrate that users worldwide can effectively engage with the system in a range of environments, with the potential to enhance personal performance through education, external quality assessment, and personal professional development, especially in regions where educational resources are difficult to access.

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    Mechanisms of Communicating Health Information Through Facebook: Implications for Consumer Health Information Technology Design


    Background: Consumer health information technology (IT) solutions are designed to support patient health management and have the ability to facilitate patients’ health information communication with their social networks. However, there is a need for consumer health IT solutions to align with patients’ health management preferences for increased adoption of the technology. It may be possible to gain an understanding of patients’ needs for consumer health IT supporting their health information communication with social networks by explicating how they have adopted and adapted social networking sites, such as Facebook, for this purpose. Objective: Our aim was to characterize patients’ use of all communication mechanisms within Facebook for health information communication to provide insight into how consumer health IT solutions may be better designed to meet patients’ communication needs and preferences. Methods: This study analyzed data about Facebook communication mechanisms use from a larger, three-phase, sequential, mixed-methods study. We report here on the results of the study’s first phase: qualitative interviews (N=25). Participants were over 18, used Facebook, were residents or citizens of the United States, spoke English, and had a diagnosis consistent with type 2 diabetes. Participants were recruited through Facebook groups and pages. Participant interviews were conducted via Skype or telephone between July and September 2014. Data analysis was grounded in qualitative content analysis and the initial coding framework was informed by the findings of a previous study. Results: Participants’ rationales for the use or disuse of a particular Facebook mechanism to communicate health information reflected six broad themes: (1) characteristics and circumstances of the person, (2) characteristics and circumstances of the relationship, (3) structure and composition of the social network, (4) content of the information, (5) communication purpose, and (6) attributes of the technology. Conclusions: The results of this study showed that participants consider multiple factors when choosing a Facebook mechanism for health information communication. Factors included what information they intended to share, what they were trying to accomplish, attributes of technology, and attributes and communication practices of their social networks. There is a need for consumer health IT that allows for a range of choices to suit the intersectionality of participants’ rationales. Technology that better meets patients’ needs may lead to better self-management of health conditions, and therefore, improve overall health outcomes.

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    Frequent Surfing on Social Health Networks is Associated With Increased Knowledge and Patient Health Activation


    Background: The advent of the Internet has driven a technological revolution that has changed our lives. As part of this phenomenon, social networks have attained a prominent role in health care. A variety of medical services is provided over the Internet, including home monitoring, interactive communications between the patient and service providers, and social support, among others. This study emphasizes some of the practical implications of Web-based health social networks for patients and for health care systems. Objective: The objective of this study was to assess how participation in a social network among individuals with a chronic condition contributed to patient activation, based on the Patient Activation Measure (PAM). Methods: A prospective, cross-sectional survey with a retrospective component was conducted. Data were collected from Camoni, a Hebrew-language Web-based social health network, participants in the diabetes mellitus, pain, hypertension, and depression/anxiety forums, during November 2012 to 2013. Experienced users (enrolled at least 6 months) and newly enrolled received similar versions of the same questionnaire including sociodemographics and PAM. Results: Among 686 participants, 154 of 337 experienced and 123 of 349 newly enrolled completed the questionnaire. Positive correlations (P<.05) were found between frequency and duration of site visits and patient activation, social relationships, and chronic disease knowledge. Men surfed longer than women (χ²3=10.104, P<.05). Experienced users with diabetes surfed more than those with other illnesses and had significantly higher PAM scores (mean, M=69.3, standard deviation, SD=19.1, PAM level 4; Z=−4.197, P<.001) than new users (M=62.8, SD=18.7, PAM level 3). Disease knowledge directly predicted PAM for all users (β=.26 and .21, respectively). Frequency and duration of social health network use were correlated with increased knowledge about a chronic disease. Experienced surfers had higher PAM than newly enrolled, suggesting that continued site use may contribute to increased activation. Conclusions: Web-based social health networks offer an opportunity to expand patient knowledge and increase involvement in personal health, thereby increasing patient activation. Further studies are needed to examine these changes on other aspects of chronic illnesses such as quality of life and costs.

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    Spanish-Language Consumer Health Information Technology Interventions: A Systematic Review


    Background: As consumer health information technology (IT) becomes more thoroughly integrated into patient care, it is critical that these tools are appropriate for the diverse patient populations whom they are intended to serve. Cultural differences associated with ethnicity are one aspect of diversity that may play a role in user-technology interactions. Objective: Our aim was to evaluate the current scope of consumer health IT interventions targeted to the US Spanish-speaking Latino population and to characterize these interventions in terms of technological attributes, health domains, cultural tailoring, and evaluation metrics. Methods: A narrative synthesis was conducted of existing Spanish-language consumer health IT interventions indexed within health and computer science databases. Database searches were limited to English-language articles published between January 1990 and September 2015. Studies were included if they detailed an assessment of a patient-centered electronic technology intervention targeting health within the US Spanish-speaking Latino population. Included studies were required to have a majority Latino population sample. The following were extracted from articles: first author’s last name, publication year, population characteristics, journal domain, health domain, technology platform and functionality, available languages of intervention, US region, cultural tailoring, intervention delivery location, study design, and evaluation metrics. Results: We included 42 studies in the review. Most of the studies were published between 2009 and 2015 and had a majority percentage of female study participants. The mean age of participants ranged from 15 to 68. Interventions most commonly focused on urban population centers and within the western region of the United States. Of articles specifying a technology domain, computer was found to be most common; however, a fairly even distribution across all technologies was noted. Cancer, diabetes, and child, infant, or maternal health were the most common health domains targeted by consumer health IT interventions. More than half of the interventions were culturally tailored. The most frequently used evaluation metric was behavior/attitude change, followed by usability and knowledge retention. Conclusions: This study characterizes the existing body of research exploring consumer health IT interventions for the US Spanish-speaking Latino population. In doing so, it reveals three primary needs within the field. First, while the increase in studies targeting the Latino population in the last decade is a promising advancement, future research is needed that focuses on Latino subpopulations previously overlooked. Second, preliminary steps have been taken to culturally tailor consumer health IT interventions for the US Spanish-speaking Latino population; however, focus must expand beyond intervention content. Finally, the field should work to promote long-term evaluation of technology efficacy, moving beyond intermediary measures toward measures of health outcomes.

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    The Importance of Debiasing Social Media Data to Better Understand E-Cigarette-Related Attitudes and Behaviors



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  • Redirecting behavioural cues using technology: Is there a role for the use of social media in conjunction with activity trackers?

    Date Submitted: Aug 18, 2016

    Open Peer Review Period: Aug 23, 2016 - Oct 18, 2016

    Recent work by Cole-Lewis and colleagues explored the use of health promotion tools within social media to better understand complex network analyses. However, there is a lack of evidence on the use o...

    Recent work by Cole-Lewis and colleagues explored the use of health promotion tools within social media to better understand complex network analyses. However, there is a lack of evidence on the use of social media and activity trackers in conjunction to augment health behaviours. This is a novel strategy and we propose its use in combating the growing obesity epidemic.

  • Supervised machine learning algorithms can classify open-text feedback of doctor performance with human-level accuracy

    Date Submitted: Aug 23, 2016

    Open Peer Review Period: Aug 23, 2016 - Oct 18, 2016

    Background: Machine learning techniques may be an efficient and effective way to classify open text reports on doctor’s activity for the purposes of quality assurance, safety, and continuing profess...

    Background: Machine learning techniques may be an efficient and effective way to classify open text reports on doctor’s activity for the purposes of quality assurance, safety, and continuing professional development. Objective: To evaluate the accuracy of machine learning algorithms trained to classify open-text reports of doctor performance and to assess the potential for classifications to signal differences in doctors’ professional performance in the UK. Methods: We used 1636 open-text comments (34,283 words) relating to the performance of 548 doctors collected from a survey of clinician’s colleagues using the GMC Colleague Questionnaire. We coded comments into five global themes (innovation, interpersonal skills, popularity, professionalism, and respect) using a qualitative framework. We trained machine learning algorithms to classify doctors and assessed their performance using several training samples. We evaluated doctor performance using the GMC Colleague Questionnaire (GMC-CQ) and compared scores between doctors with different classifications using t-tests. Results: Individual algorithm performance was high (range F=0.80 to 0.85). Inter-rater agreement between the algorithms and the human coder was highest for codes relating to ‘popular’ (recall =.97), ‘innovator’ (recall =.98), and ‘respected’ (recall =.87) codes and was lower for the ‘interpersonal’ (recall =.80) and ‘professional’ (recall =.82) codes. Four-fold cross-validation demonstrated similar performance in each analysis. When combined into an ensemble of multiple algorithms, mean human-computer inter-rater agreement was .87. Doctors who were classified as ‘respected’, ‘professional’, and ‘interpersonal’ had higher scores on the GMC Colleague Questionnaire compared to doctors who were not classified (P<.05). Scores did not vary between doctors who were rated as popular or innovative and those who were not rated at all (P>.05). Conclusions: Machine learning algorithms can classify open-text feedback of doctor performance into multiple themes derived by human raters with high performance. Colleague open-text comments that signal respect, professionalism, and being interpersonal may be key indicators of doctor’s performance.

  • A smarter pathway for delivering cue exposure therapy? The design and development of a smartphone application targeting alcohol use disorder.

    Date Submitted: Aug 19, 2016

    Open Peer Review Period: Aug 19, 2016 - Oct 14, 2016

    Background: While the number of alcohol-related treatments in app stores is proliferating, none of them are based on a psychological framework and supported by empirical evidence. Cue exposure treatme...

    Background: While the number of alcohol-related treatments in app stores is proliferating, none of them are based on a psychological framework and supported by empirical evidence. Cue exposure treatment (CET) with urge-specific coping skills (USCS) is often used in Danish treatment settings. It is an evidence-based psychological approach that focuses on promoting `confrontation with alcohol cues’ as a means of reducing urges and the likelihood of relapse. Objective: This paper describes the design and development of a CET-based smartphone application; an innovative delivery pathway for treating alcohol use disorder (AUD). Methods: The treatment is based on Monty and co-workers’ manual for CET with USCS (2002). It was created by a multidisciplinary team of psychiatrists, psychologists, engineers and graphic designers as well as patients with AUD. A database was developed for the purpose of registering and monitoring training activities. A final version of the CET app and database was developed after several user tests. Results: The final version of the CET app includes: an introduction, 4 sessions featuring USCS, 8 alcohol exposure videos promoting the use of one of the USCS, and a results component providing an overview of training activities and potential progress. Real-time urges are measured before, during and after exposure to alcohol cues and are registered in the app together with other training activity variables. Data packages are continuously sent in encrypted form to an external database, and will be merged with other data (in an internal database) in the future. Conclusions: The CET smartphone app is currently being tested in a large-scale, randomized controlled trial with the aim of clarifying whether it can be classified as an evidence-based treatment solution. The app has the potential to augment the reach of psychological treatment for AUD. Clinical Trial: ID: NCT02298751 Registration date: 6 November 2014

  • Disease monitoring and health campaign evaluation using Internet search activities for HIV/AIDS, stroke, colorectal cancer and marijuana use in Canada: A Retrospective Observational Study

    Date Submitted: Aug 16, 2016

    Open Peer Review Period: Aug 16, 2016 - Oct 11, 2016

    Background: Infodemiology can offer practical and feasible health research applications through the practice of studying information available on the Internet. Google Trends provides publically access...

    Background: Infodemiology can offer practical and feasible health research applications through the practice of studying information available on the Internet. Google Trends provides publically accessible information regarding search behaviours in a population, which may be studied and used for health campaign evaluation and disease monitoring. Additional studies examining the use and effectiveness of Google Trends for these purposes remain warranted. Objective: The study explored the use of infodemiology in the context of health campaign evaluation and chronic disease monitoring. It was hypothesized that following a launch of the campaign, there would be an increase in information seeking behaviour on the Internet. Secondly, increasing and decreasing disease patterns in a population would be associated with the Internet search activity trends. This study examined four different diseases: HIV, stroke, colorectal cancer and marijuana use. Methods: Using Google Trends, relative search volume data were collected throughout the period of February 2004 to January 2015. Campaign information and disease statistics were obtained from governmental publications. Search activity trends were graphed and assessed with disease trends and the campaign interval. Pearson product correlation statistics and joinpoint methodology analyses were used to determine significance. Results: Disease patterns and online activity across all four diseases were significantly correlated: HIV (r=0.36, p<0.001), stroke (r=0.40, p<0.001), colorectal cancer (r= -0.41, p<0.001) and substance use (r=0.64, p<0.001). Visual inspection and the joinpoint analysis showed significant correlations for the campaigns on colorectal cancer and substance use in stimulating online search activity. No significant correlations were observed for the campaigns on stroke and HIV regarding Internet search activity. Conclusions: The use of infoveillance shows promises as an alternative and inexpensive solution to disease surveillance and health campaign evaluation. Further research is needed to understand Google Trends as a valid and reliable tool for health research.

  • Comparison of ecological momentary assessment versus direct measurement of e-cigarette use with a Bluetooth-enabled e-cigarette: a pilot study

    Date Submitted: Aug 15, 2016

    Open Peer Review Period: Aug 16, 2016 - Oct 11, 2016

    Background: Background: Assessing the frequency and intensity of e-cigarette use presents special challenges beyond those posed by cigarette use. Accurate measurement of puff counts, the duration of a...

    Background: Background: Assessing the frequency and intensity of e-cigarette use presents special challenges beyond those posed by cigarette use. Accurate measurement of puff counts, the duration of an e-cigarette puff, and the stability of these measures is the basis for estimating the behavioral and health effects of e-cigarette use. Objective: Objective: The purpose of this pilot study was to: 1) examine the feasibility of capturing e-cigarette puff behavior via ecological momentary assessment (EMA) by comparing daily EMA self-reported e-cigarette puff counts to objective puff data from a Bluetooth-enabled e-cigarette device; and, 2) to examine the feasibility and acceptability of using a second-generation e-cigarette among adult smokers. A secondary objective was to demonstrate the utility of e-cigarette EMA data for understanding the e-cigarette trial period, including examining the interaction between e-cigarette and cigarette consumption. Methods: Methods: Five adult smokers were enrolled in a 3-week longitudinal parent study assessing how e-cigarette use affects cigarette use among e-cigarette naïve smokers. Using a text message-based EMA system, participants reported cigarette smoking for one week, followed by cigarette smoking and e-cigarette puffs for two weeks. Participants were also given a Bluetooth-enabled e-cigarette (“Smokio”) that passively collected puff counts and puff duration. Comparisons between mean reports of Smokio (device report) and EMA (self-report) use were evaluated using paired t-tests. Correlation and agreement between device- and self-reports were evaluated using Pearson correlation and the concordance correlation coefficient (CCC), respectively. Results: Results: Five African American participants, 4 men and 1 woman, with a mean age of 38.8 years (SD=13.8) completed the study, resulting in 5,180 observations (device report) of e-cigarette use. At baseline, participants reported smoking for an average of 14.4 years (SD=8.5) and consumed a mean of 9 cigarettes per day (CPD; SD=3.5); 4 smoked within 30 minutes of waking. At the 30-day follow-up, CPD decreased to 1.8 (SD=2.3), 4 participants reported past 7-day e-cigarette use, and 1 participant reported no cigarette smoking in the past 7 days. Over 2 weeks of e-cigarette use, participants took an average of 1,074 e-cigarette puffs (SD=779.0) per person as captured by the device reports. Each participant took a mean of 75.0 puffs (SD=58.8) per day, with each puff lasting an average of 3.6 seconds (SD=2.4). Device reports captured an average of 33.3 more puffs per person per day (SD=47.8) than the self-reported e-cigarette puffs. In 87% of days, participants underestimated the number of puffs they had taken on the Smokio. There was significant moderate correlation (r = 0.47, p=0.0001) but poor agreement (pc=0.31, 95% CI: 0.15, 0.46) between the device- and self-reported data. Conclusions: Conclusions: EMA is a feasible method for collecting e-cigarette puff data; however, a Bluetooth-enabled device captured significantly more e-cigarette use and allowed for examination of puff duration in addition to puff counts.

  • What drives young Vietnamese to use M-health innovations? An insight into the patterns of smartphone usage and user preferences of mobile applications

    Date Submitted: Aug 12, 2016

    Open Peer Review Period: Aug 12, 2016 - Oct 7, 2016

    Background: Low and Middle - income countries, such as Vietnam, are becoming more connected to the Internet. In addition, aside to the increased penetration and proliferation of Internet services, th...

    Background: Low and Middle - income countries, such as Vietnam, are becoming more connected to the Internet. In addition, aside to the increased penetration and proliferation of Internet services, there has also been an eight times increment in the absolute number of mobile subscriptions in this period. There has been prior research looking at the attitudes of the general population towards smartphone and smartphone applications, as well as how smartphone have helped in terms of self-management of medical disorders Objective: With the increased penetration of Internet and smartphone devices in countries like Vietnam, it is the aim and objective of this current research article to look into the patterns of usage of smartphone applications as well as the preferences with regards to the functionalities of smartphone based applications. Methods: In order to achieve the study objectives, an online cross-sectional study was conducted from August 2015 to October 2015 in Vietnam. The Vietnam Authority of HIV/AIDS Control provided the ethical approval for the current research project. Response-driven sampling technique (RDS) was utilized in the recruitment of participants. The online questionnaire was programmed and implemented using Google Form. The web-based questionnaire that was conceptualized included the following parts: a) Baseline demographics; b) Smartphone usage pattern; c) Attitudes towards existing Smartphone applications and d) Preferences for a smartphone application. Chi-squared, t-test and ANOVA were used to explore the differences of satisfaction among characteristics. A p-value of less than 0.05 was set as the level of statistical significance. Results: A cumulative total of 380 individuals completed the web-based questionnaires, out of which 35.0% (n=133) were males. The vast majority of the participants were between the age groups of 18 to 22 years old, amounting to 77.6% of the entire sample. The vast majority of the participants (54.2%) rated themselves as being intermediate in terms of their proficiency with regards to their knowledge of utilization of a smartphone device. A similar percentage of the participants preferred to download applications for disease prevention (11.1%), as compared to applications for beauty counseling, nutrition counseling and disease treatment, with65.8% of the participants perceiving these applications to be very useful and 52.7% of the participants reported that they were very satisfied with the existing mobile health applications that were available. The vast majority of the participants would prefer applications that they could download and run directly from their smartphone. With regards to the contents of the applications, they would prefer there to be a balance between visuals as well as text-based information and participants also indicated that it is crucial for smartphone applications to have sharing functionalities, for them to share information onto their own personal social networks. Conclusions: An understanding of the attitudes and user preferences with regards to smartphone applications is essential in the conceptualization and development of appropriate smartphone interventions targeting youths and young adults.