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Journal of Medical Internet Research

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


Journal Description

The Journal of Medical Internet Research (JMIR), now in its' 20th year, is the pioneering open access eHealth journal, and is the flagship journal of JMIR Publications. It is the leading digital health journal globally, in terms of quality/visibility (Impact Factor 2016: 5.175, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As leading high-impact journal in its' disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

As open access journal we are read by clinicians, allied health professionals, informal caregivers and patients alike and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (e.g. in grant proposals), and for open peer-review purposes. We also invite patients to participate, e.g. as peer-reviewers, and have patient representatives on editorial boards.

Be a widely cited leader in the digitial health revolution and submit your paper today!


Recent Articles:

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

    Web 2.0 Tools in the Prevention of Curable Sexually Transmitted Diseases: Scoping Review


    Background: The internet is now the primary source of information that young people use to get information on issues related to sex, contraception, and sexually transmitted infections. Objective: The goal of the research was to review the scientific literature related to the use of Web 2.0 tools as opposed to other strategies in the prevention of curable sexually transmitted diseases (STDs). Methods: A scoping review was performed on the documentation indexed in the bibliographic databases MEDLINE, Cochrane Library, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Literatura Latinoamericana y del Caribe en Ciencias de la Salud, PsycINFO, Educational Resources Information Center, the databases of Centro Superior de Investigaciones Científicas in Spain, and the Índice Bibliográfico Español de Ciencias de la Salud from the first available date according to the characteristics of each database until April 2017. The equation search was realized by means of the using of descriptors together with the consultation of the fields of title register and summary with free terms. Bibliographies of the selected papers were searched for additional articles. Results: A total of 627 references were retrieved, of which 6 papers were selected after applying the inclusion and exclusion criteria. The STDs studied were chlamydia, gonorrhea, and syphilis. The Web 2.0 tools used were Facebook, Twitter, Instagram, and YouTube. The 6 papers used Web 2.0 in the promotion of STD detection. Conclusions: Web 2.0 tools have demonstrated a positive effect on the promotion of prevention strategies for STDs and can help attract and link youth to campaigns related to sexual health. These tools can be combined with other interventions. In any case, Web 2.0 and especially Facebook have all the potential to become essential instruments for public health.

  • Using fitness trackers and smartwatches to measure physical activity in research. Source: Colourbox; Copyright: Production Perig; URL:; License: Licensed by the authors.

    Using Fitness Trackers and Smartwatches to Measure Physical Activity in Research: Analysis of Consumer Wrist-Worn Wearables


    Background: New fitness trackers and smartwatches are released to the consumer market every year. These devices are equipped with different sensors, algorithms, and accompanying mobile apps. With recent advances in mobile sensor technology, privately collected physical activity data can be used as an addition to existing methods for health data collection in research. Furthermore, data collected from these devices have possible applications in patient diagnostics and treatment. With an increasing number of diverse brands, there is a need for an overview of device sensor support, as well as device applicability in research projects. Objective: The objective of this study was to examine the availability of wrist-worn fitness wearables and analyze availability of relevant fitness sensors from 2011 to 2017. Furthermore, the study was designed to assess brand usage in research projects, compare common brands in terms of developer access to collected health data, and features to consider when deciding which brand to use in future research. Methods: We searched for devices and brand names in six wearable device databases. For each brand, we identified additional devices on official brand websites. The search was limited to wrist-worn fitness wearables with accelerometers, for which we mapped brand, release year, and supported sensors relevant for fitness tracking. In addition, we conducted a Medical Literature Analysis and Retrieval System Online (MEDLINE) and ClinicalTrials search to determine brand usage in research projects. Finally, we investigated developer accessibility to the health data collected by identified brands. Results: We identified 423 unique devices from 132 different brands. Forty-seven percent of brands released only one device. Introduction of new brands peaked in 2014, and the highest number of new devices was introduced in 2015. Sensor support increased every year, and in addition to the accelerometer, a photoplethysmograph, for estimating heart rate, was the most common sensor. Out of the brands currently available, the five most often used in research projects are Fitbit, Garmin, Misfit, Apple, and Polar. Fitbit is used in twice as many validation studies as any other brands and is registered in ClinicalTrials studies 10 times as often as other brands. Conclusions: The wearable landscape is in constant change. New devices and brands are released every year, promising improved measurements and user experience. At the same time, other brands disappear from the consumer market for various reasons. Advances in device quality offer new opportunities for research. However, only a few well-established brands are frequently used in research projects, and even less are thoroughly validated.

  • Source: iStock by Getty Images; Copyright: annebaek; URL:; License: Licensed by the authors.

    Pregnant Women Sharing Pregnancy-Related Information on Facebook: Web-Based Survey Study

    Authors List:


    Background: Research indicates expectant and new mothers use the Internet, specifically social media, to gain information and support during the transition to parenthood. Although parents regularly share information about and photos of their child or children on Facebook, researchers have neither explored the use of Facebook to share pregnancy-related information nor investigated factors that influence such sharing. Objective: The aim of this study was to address a gap in the literature by exploring the use of Facebook by pregnant women. Specifically, the study examined the use of Facebook to share pregnancy-related information, as well as any association between prenatal attachment and the aforementioned aspects of sharing pregnancy-related information on Facebook. Methods: Pregnant women who were at least 18 years of age were recruited for participation in the study through posts and paid advertisements on Facebook and posts to professional organization listservs. Individuals interested in participating were directed to a secure Web-based survey system where they completed the consent form and the survey that focused on their current pregnancy. Participants completed the Maternal Antenatal Attachment Scale and answered questions that assessed how often they shared pregnancy-related information on Facebook, who they shared it with, why they shared it, and what they shared. Results: A total of 117 pregnant women completed the survey. Descriptive statistics indicated that the pregnancy announcement was most commonly shared (75/108, 69.4%), with most women sharing pregnancy-related information on Facebook less than monthly (52/117, 44.4%) with only family and friends (90/116, 77.6% and 91/116, 78.4%, respectively) and for the purpose of involving others or sharing the experience (62/107, 57.9%). Correlation and regression analyses showed that prenatal attachment, in general, was positively and significantly related to all aspects of sharing pregnancy-related information at the P<.05 level, with the exception of sharing because of expectations. Quality of attachment, which involves the positive feelings the woman has about her unborn child, was significantly associated with sharing to involve others or share the pregnancy (t8,93=2.654 , P=.009). In contrast, after controlling for other variables, the strength or preoccupation component of prenatal attachment was significantly associated with frequency of sharing (t8,100=2.554 , P=.01), number to types of information shared (t8,97=2.605 , P=.01), number of groups with whom shared (t8,99=3.467, P=.001), and sharing to get advice (χ28=5.339 , P=.02). Conclusions: Pregnant women in this study used Facebook for a variety of reasons, demonstrating the use of the social media platform during pregnancy for supportive and informational purposes. Overall, the results of this study are likely to be useful to professionals who are seeking alternative methods for providing intervention, information, and support to pregnant women via social media in our technology-driven society.

  • Source: Freepik; Copyright: Freepik; URL:; License: Licensed by JMIR.

    Just-in-Time Feedback in Diet and Physical Activity Interventions: Systematic Review and Practical Design Framework


    Background: The integration of body-worn sensors with mobile devices presents a tremendous opportunity to improve just-in-time behavioral interventions by enhancing bidirectional communication between investigators and their participants. This approach can be used to deliver supportive feedback at critical moments to optimize the attainment of health behavior goals. Objective: The goals of this systematic review were to summarize data on the content characteristics of feedback messaging used in diet and physical activity (PA) interventions and to develop a practical framework for designing just-in-time feedback for behavioral interventions. Methods: Interventions that included just-in-time feedback on PA, sedentary behavior, or dietary intake were eligible for inclusion. Feedback content and efficacy data were synthesized descriptively. Results: The review included 31 studies (15/31, 48%, targeting PA or sedentary behavior only; 13/31, 42%, targeting diet and PA; and 3/31, 10%, targeting diet only). All studies used just-in-time feedback, 30 (97%, 30/31) used personalized feedback, and 24 (78%, 24/31) used goal-oriented feedback, but only 5 (16%, 5/31) used actionable feedback. Of the 9 studies that tested the efficacy of providing feedback to promote behavior change, 4 reported significant improvements in health behavior. In 3 of these 4 studies, feedback was continuously available, goal-oriented, or actionable. Conclusions: Feedback that was continuously available, personalized, and actionable relative to a known behavioral objective was prominent in intervention studies with significant behavior change outcomes. Future research should determine whether all or some of these characteristics are needed to optimize the effect of feedback in just-in-time interventions.

  • A user of Overcome Social Anxiety listens as a clinical psychologist explains important elements of cognitive behavioral therapy through a voice recording. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Evaluating a Web-Based Social Anxiety Intervention Among University Students: Randomized Controlled Trial


    Background: Treatment rates for social anxiety, a prevalent and potentially debilitating condition, remain among the lowest of all major mental disorders today. Although computer-delivered interventions are well poised to surmount key barriers to the treatment of social anxiety, most are only marginally effective when delivered as stand-alone treatments. A new, Web-based cognitive behavioral therapy (CBT) intervention called Overcome Social Anxiety was recently created to address the limitations of prior computer-delivered interventions. Users of Overcome Social Anxiety are self-directed through various CBT modules incorporating cognitive restructuring and behavioral experiments. The intervention is personalized to each user’s symptoms, and automatic email reminders and time limits are used to encourage adherence. Objective: The purpose of this study was to conduct a randomized controlled trial to investigate the effectiveness of Overcome Social Anxiety in reducing social anxiety symptoms in a nonclinical sample of university students. As a secondary aim, we also investigated whether Overcome Social Anxiety would increase life satisfaction in this sample. Methods: Following eligibility screening, participants were randomly assigned to a treatment condition or a wait-list control condition. Only those assigned to the treatment condition were given access to Overcome Social Anxiety; they were asked to complete the program within 4 months. The social interaction anxiety scale (SIAS), the fear of negative evaluation scale (FNE), and the quality of life enjoyment and satisfaction questionnaire—short form (Q-LES-Q-SF) were administered to participants from both conditions during baseline and 4-month follow-up lab visits. Results: Over the course of the study, participants assigned to the treatment condition experienced a significant reduction in social anxiety (SIAS: P<.001, Cohen d=0.72; FNE: P<.001, Cohen d=0.82), whereas those assigned to the control condition did not (SIAS: P=.13, Cohen d=0.26; FNE: P=.40, Cohen d=0.14). Additionally, a direct comparison of the average change in social anxiety in the 2 conditions over the course of the study showed that those assigned to the treatment condition experienced significantly more improvement than those assigned to the control condition (SIAS: P=.03, Cohen d=0.56; FNE: P=.001, Cohen d=0.97). Although participants assigned to the treatment condition experienced a slight increase in life satisfaction, as measured by Q-LES-Q-SF scores, and those assigned to the control condition experienced a slight decrease, these changes were not statistically significant (treatment: P=.35, Cohen d=−0.18; control: P=.30, Cohen d=0.18). Conclusions: Our findings indicate that Overcome Social Anxiety is an effective intervention for treating symptoms of social anxiety and that it may have further utility in serving as a model for the development of new interventions. Additionally, our findings provide evidence that contemporary Web-based interventions can be sophisticated enough to benefit users even when delivered as stand-alone treatments, suggesting that further opportunities likely exist for the development of other Web-based mental health interventions. Trial Registration: NCT02792127; (Archived by WebCite at

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

    Novel Interventions and Assessments Using Patient Portals in Adolescent Research: Confidential Survey Study


    Background: While adolescents can receive confidential health care without parental or guardian notification, they are rarely asked about their experiences and opinions regarding their care because participation in research often requires parental consent. Anonymous research with adolescents via confidential patient portals may ameliorate this research gap. Objective: Because use of a confidential online adolescent patient portal is high at our academic institution, we hypothesized that adolescents would also respond to survey-based research via the portal, especially if asked anonymously and without parental consent. We used a clinical scenario of needing to better understanding adolescent and young adults’ views about their health and health care, including information on a long-acting reversible contraceptive (LARC) to test if and how they will use a portal for research. Methods: Upon receiving Institutional Review Board approval, we sent 2 portal-based surveys about confidential services to 2 groups of females, ages 14 to 25 years, who had attended an adolescent clinic in the past 3 years. This clinic mostly serves Medicaid recipients (80%) and is racially and ethnically diverse with half of patients identifying as African American and roughly 10% Hispanic. The control group was a random sample of female patients who never received a LARC (n=150) and the intervention group included all female adolescents who had received a LARC from the same clinic (n=107). This second sample was manually cross-checked to confirm they had an office visit for this reason. Consenting for themselves, the control group received an email through the patient portal with a link and a request to perform an assessment. The survey for the control group included items assessing health literacy and health communication preferences. The survey for the intervention group included health literacy items as well as items to assess their opinions and perceptions regarding LARCs. We tracked click-through rates and opened messages; each participant received 4 reminders. Results: While only 3 participants fully completed either survey, email read rates (29/107 [27.1%] of LARC recipients and 39/150 [26.0%] of controls) were encouraging. Additionally, of those who opened the messages, almost twice as many of the LARC recipients (10/107 [9.3%]) read through the entire survey, while less than half read the entire survey as compared to those who received the survey asking about health literacy and health care preferences (6/150 [4.0%]). Conclusions: The methodology of using adolescent portals for online surveys provides a new avenue for research even though the study did not yield sufficient participation to understand these adolescents’ preferences. Future studies need to test if a different survey topic would engage adolescents or if other methods like text-based reminders would improve participation.

  • Tech workers doing paper prototyping on a whiteboard with sticky notes. Source: Shutterstock Inc; Copyright: REDPIXEL.PL; URL:; License: Licensed by the authors.

    Information Architecture of Web-Based Interventions to Improve Health Outcomes: Systematic Review


    Background: The rise in usage of and access to new technologies in recent years has led to a growth in digital health behavior change interventions. As the shift to digital platforms continues to grow, it is increasingly important to consider how the field of information architecture (IA) can inform the development of digital health interventions. IA is the way in which digital content is organized and displayed, which strongly impacts users’ ability to find and use content. While many information architecture best practices exist, there is a lack of empirical evidence on the role it plays in influencing behavior change and health outcomes. Objective: Our aim was to conduct a systematic review synthesizing the existing literature on website information architecture and its effect on health outcomes, behavioral outcomes, and website engagement. Methods: To identify all existing information architecture and health behavior literature, we searched articles published in English in the following databases (no date restrictions imposed): ACM Digital Library, CINAHL, Cochrane Library, Google Scholar, Ebsco, and PubMed. The search terms used included information terms (eg, information architecture, interaction design, persuasive design), behavior terms (eg, health behavior, behavioral intervention, ehealth), and health terms (eg, smoking, physical activity, diabetes). The search results were reviewed to determine if they met the inclusion and exclusion criteria created to identify empirical research that studied the effect of IA on health outcomes, behavioral outcomes, or website engagement. Articles that met inclusion criteria were assessed for study quality. Then, data from the articles were extracted using a priori categories established by 3 reviewers. However, the limited health outcome data gathered from the studies precluded a meta-analysis. Results: The initial literature search yielded 685 results, which was narrowed down to three publications that examined the effect of information architecture on health outcomes, behavioral outcomes, or website engagement. One publication studied the isolated impact of information architecture on outcomes of interest (ie, website use and engagement; health-related knowledge, attitudes, and beliefs; and health behaviors), while the other two publications studied the impact of information architecture, website features (eg, interactivity, email prompts, and forums), and tailored content on these outcomes. The paper that investigated IA exclusively found that a tunnel IA improved site engagement and behavior knowledge, but it decreased users’ perceived efficiency. The first study that did not isolate IA found that the enhanced site condition improved site usage but not the amount of content viewed. The second study that did not isolate IA found that a tailored site condition improved site usage, behavior knowledge, and some behavior outcomes. Conclusions: No clear conclusion can be made about the relationship between IA and health outcomes, given limited evidence in the peer-reviewed literature connecting IA to behavioral outcomes and website engagement. Only one study reviewed solely manipulated IA, and we therefore recommend improving the scientific evidence base such that additional empirical studies investigate the impact of IA in isolation. Moreover, information from the gray literature and expert opinion might be identified and added to the evidence base, in order to lay the groundwork for hypothesis generation to improve empirical evidence on information architecture and health and behavior outcomes.

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

    Total Knee Replacement and the Effect of Technology on Cocreation for Improved Outcomes and Delivery: Qualitative Multi-Stakeholder Study


    Background: The growth in patient-centered care delivery combined with the rising costs of health care have perhaps not unsurprisingly been matched by a proliferation of patient-centered technology. This paper takes a multistakeholder approach to explore how digital technology can support the cocreation of value between patients and their care teams in the delivery of total knee replacement (TKR) surgery, an increasingly common procedure to return mobility and relieve pain for people suffering from osteoarthritis. Objective: The aim of this study was to investigate communications and interactions between patients and care teams in the delivery of TKR to identify opportunities for digital technology to add value to TKR health care service by enhancing the cocreation of value. Methods: A multistakeholder qualitative study of user needs was conducted with Australian stakeholders (N=34): surgeons (n=12), physiotherapists (n=3), patients (n=11), and general practitioners (n=8). Data from focus groups and interviews were recorded, transcribed, and analyzed using thematic analysis. Results: Encounters between patients and their care teams are information-rich but time-poor. Results showed seven different stages of the TKR journey that starts with referral to a surgeon and ends with a postoperative review at 12 months. Each stage of the journey has different information and communication challenges that can be enhanced by digital technology. Opportunities for digital technology include improved waiting list management, supporting and reinforcing patient retention and recall of information, motivating and supporting rehabilitation, improving patient preparation for hospital stay, and reducing risks and anxiety associated with postoperative wound care. Conclusions: Digital technology can add value to patients’ care team communications by enhancing information flow, assisting patient recall and retention of information, improving accessibility and portability of information, tailoring information to individual needs, and by providing patients with tools to engage in their own health care management. For care teams, digital technology can add value through early detection of postoperative complications, proactive surveillance of health data for postoperative patients and patients on waiting lists, higher compliance with rehabilitation programs, and reduced length of stay. Digital technology has the potential to improve patient satisfaction and outcomes, as well as potentially reduce hospital length of stay and the burden of disease associated with postoperative morbidity.

  • Source: Gratisography; Copyright: Gratisography; URL:; License: Licensed by JMIR.

    Social Media as a Catalyst for Policy Action and Social Change for Health and Well-Being: Viewpoint

    Authors List:


    This viewpoint paper argues that policy interventions can benefit from the continued use of social media analytics, which can serve as an important complement to traditional social science data collection and analysis. Efforts to improve well-being should provide an opportunity to explore these areas more deeply, and encourage the efforts of those conducting national and local data collection on health to incorporate more of these emerging data sources. Social media remains a relatively untapped source of information to catalyze policy action and social change. However, the diversity of social media platforms and available analysis techniques provides multiple ways to offer insight for policy making and decision making. For instance, social media content can provide timely information about the impact of policy interventions. Social media location information can inform where to deploy resources or disseminate public messaging. Network analysis of social media connections can reveal underserved populations who may be disconnected from public services. Machine learning can help recognize important patterns for disease surveillance or to model population sentiment. To fully realize these potential policy uses, limitations to social media data will need to be overcome, including data reliability and validity, and potential privacy risks. Traditional data collection may not fully capture the upstream factors and systemic relationships that influence health and well-being. Policy actions and social change efforts, such as the Robert Wood Johnson Foundation’s effort to advance a culture of health, which are intended to drive change in a network of upstream health drivers, will need to incorporate a broad range of behavioral information, such as health attitudes or physical activity levels. Applying innovative techniques to emerging data has the potential to extract insight from unstructured data or fuse disparate sources of data, such as linking health attitudes that are expressed to health behaviors or broader health and well-being outcomes.

  • The phone screen displays a text message reading, “What was your fasting blood sugar this morning?”. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Transition of a Text-Based Insulin Titration Program From a Randomized Controlled Trial Into Real-World Settings: Implementation Study


    Background: The Mobile Insulin Titration Intervention (MITI) program helps patients with type 2 diabetes find their correct basal insulin dose without in-person care. Requiring only basic cell phone technology (text messages and phone calls), MITI is highly accessible to patients receiving care in safety-net settings. MITI was shown in a randomized controlled trial (RCT) to be efficacious at a New York City (NYC) safety-net clinic where patients often have challenges coming for in-person care. In 2016, MITI was implemented as usual care at Bellevue Hospital (the site of the original RCT) and at Gouverneur Health (a second NYC safety-net clinic) under 2 different staffing models. Objective: This implementation study examined MITI’s transition into real-world settings. To understand MITI’s flexibility, generalizability, and acceptability among patients and providers, we evaluated whether MITI continued to produce positive outcomes in expanded underserved populations, outside of an RCT setting. Methods: Patients enrolled in MITI received weekday text messages asking for their fasting blood glucose (FBG) values and a weekly titration call. The goal was for patients to reach their optimal insulin dose (OID), defined either as the dose of once-daily basal insulin required to achieve either an FBG of 80-130 mg/dL (4.4-7.2 mmol/L) or as the reaching of the maximum dose of 50 units. After 12 weeks, if OID was not reached, the patients were asked to return to the clinic for in-person care and titration. MITI program outcomes, clinical outcomes, process outcomes, and patient satisfaction were assessed. Results: MITI was successful at both sites, each with a different staffing model. Providers referred 170 patients to the program—129 of whom (75.9%, 129/170) were eligible. Of these, 113 (87.6%, 113/129) enrolled. Moreover, 84.1% (95/113) of patients reached their OID, and they did so in an average of 24 days. Clinical outcomes show that mean FBG levels fell from 209 mg/dL (11.6 mmol/L) to 141 mg/dL (7.8 mmol/L), P<.001. HbA1c levels fell from 11.4% (101 mmol/mol) to 10.0% (86 mmol/mol), P<.001. Process outcomes show that 90.1% of MITI’s text message prompts received a response, nurses connected with patients 81.9% of weeks to provide titration instructions, and 85% of attending physicians made at least one referral to the MITI program. Satisfaction surveys showed that most patients felt comfortable sharing information over text and felt the texts reminded them to take their insulin, check their sugar, and make healthy food choices. Conclusions: This implementation study showed MITI to have continued success after transitioning from an RCT program into real-world settings. MITI showed itself to be flexible and generalizable as it easily fits into a second site staffed by general medical clinic–registered nurses and remained acceptable to patients and staff who had high levels of engagement with the program.

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

    Digital Gaming for Improving the Functioning of People With Traumatic Brain Injury: Randomized Clinical Feasibility Study


    Background: Traumatic brain injury (TBI) is a major health problem that often requires intensive and long-term rehabilitation. Objective: The aim of this study was to determine whether rehabilitative digital gaming facilitates cognitive functioning and general well-being in people with TBI. Methods: A total of 90 Finnish-speaking adults with TBI (18-65 years) were recruited from an outpatient neuroscience clinic. The participants were randomly allocated to one of the three groups: a rehabilitation gaming group (n=29, intervention), an entertainment gaming group (n=29, active control), or a passive control group (n=32). The gaming groups were instructed to engage in gaming for a minimum of 30 min per day for 8 weeks. Primary and secondary outcomes were measured at three time points: before the intervention, after the intervention, and 3 months following the intervention. The primary outcome was cognitive status measured by processing speed and visuomotor tasks (The Trail Making Test; Wechsler Adult Intelligence Scale-Fourth Edition, WAIS-IV, symbol search, coding, and cancellation tasks). Secondary outcomes were attention and executive functions (Simon task), working memory (WAIS-IV digit span and Paced Auditory Serial Addition Test, PASAT), depression (Patient Health Questionnaire-9), self-efficacy (General Self-efficacy Scale), and executive functions (Behavior Rating Inventory of Executive Function-Adult Version). Feasibility information was assessed (acceptability, measurement instruments filled, dropouts, adherence, usability, satisfaction, and possible future use). Cognitive measurements were conducted in face-to-face interviews by trained psychologists, and questionnaires were self-administered. Results: The effects of rehabilitation gaming did not significantly differ from the effects of entertainment gaming or being in a passive control group. For primary outcomes and PASAT tests, the participants in all three groups showed overall improvement in test scores across the three measurement points. However, depression scores increased significantly between baseline and after 8 weeks and between baseline and after 3 months in the rehabilitative gaming group. No differences were found in patients’ self-efficacy between the three measuring points in any of the groups. Participants did use the games (rehabilitation group: 93%, 27/29; entertainment group 100%, 29/29). Games were seen as a usable intervention (rehabilitation group: 70%, 14/29; entertainment group: 83%, 20/29). The rehabilitation group was less satisfied with the gaming intervention (68%, 13/29 vs 83%, 20/29), but they were more willing to use the game after the intervention period (76%, 16/29 vs 63%, 15/29). Total time spent on gaming during the intervention period was low (15.22 hour rehabilitation gaming group, 19.22 hour entertainment gaming group). Conclusions: We did not find differences between the groups in improvement in the outcome measures. The improvements in test performance by all three groups may reflect rehearsal effects. Entertainment gaming had elements that could be considered when rehabilitative games are designed for, implemented in, and assessed in larger clinical trials for persons with TBI. Trial Registration: NCT02425527; (Archived by WebCite at

  • A mobile app for diabetes self-management. Source: Flickr; Copyright: Philips Communications; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    A Mobile App to Improve Self-Management of Individuals With Type 2 Diabetes: Qualitative Realist Evaluation


    Background: The increasing use of Web-based solutions for health prevention and promotion presents opportunities to improve self-management and adherence to guideline-based therapy for individuals with type 2 diabetes (T2DM). Despite promising preliminary evidence, many users stop using Web-based solutions due to the burden of data entry, hidden costs, loss of interest, and a lack of comprehensive features. Evaluations tend to focus on effectiveness or impact and fail to evaluate the nuanced variables that may interact to contribute to outcome success (or failure). Objective: This study aimed to evaluate a Web-based solution for improving self-management in T2DM to identify key combinations of contextual variables and mechanisms of action that explain for whom the solution worked best and in what circumstances. Methods: A qualitative realist evaluation was conducted with one-on-one, semistructured telephonic interviews completed at baseline, and again toward the end of the intervention period (3 months). Topics included participants’ experiences of using the Web-based solution, barriers and facilitators of self-management, and barriers and facilitators to effective use. Transcripts were analyzed using thematic analysis strategies, after which the key themes were used to develop statements of the relationships between the key contextual factors, mechanisms of action, and impact on the primary outcome (glycated hemoglobin, HbA1c). Results: Twenty-six interviews (14 baseline, 12 follow-up) were completed with 16 participants with T2DM, and the following 3 key groups emerged: the easiest fit, the best fit, and those who failed to activate. Self-efficacy and willingness to engage with the solution facilitated improvement in HbA1c, whereas competing priorities and psychosocial issues created barriers to engagement. Individuals with high baseline self-efficacy who were motivated, took ownership for their actions, and prioritized diabetes management were early and eager adopters of the app and recorded improvements in HbA1c over the intervention period. Individuals with moderate baseline self-efficacy and no competing priorities, who identified gaps in understanding of how their actions influence their health, were slow to adopt use but recorded the greatest improvements in HbA1c. The final group had low baseline self-efficacy and identified a range of psychosocial issues and competing priorities. These participants were uncertain of the benefits of using a Web-based solution to support self-management, ultimately resulting in minimal engagement and no improvement in HbA1c. Conclusions: Self-efficacy, competing priorities, previous behavior change, and beliefs about Web-based solutions interact to determine engagement and impact on the clinical outcomes. Considering the balance of these patient characteristics is likely to help health care providers identify individuals who are apt to benefit from a Web-based solution to support self-management of T2DM. Web-based solutions could be modified to incorporate the existing screening measures to identify individuals who are at risk of suboptimal adherence to inform the provision of additional support(s) as needed.

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    Open Peer Review Period: Mar 22, 2018 - May 17, 2018

    Background: The past decades depression prevention and early intervention has become a top priority within the Netherlands, however, there is still considerable room for improvement. To this extent, w...

    Background: The past decades depression prevention and early intervention has become a top priority within the Netherlands, however, there is still considerable room for improvement. To this extent, web-based complaint-directed mini-interventions (CDMIs) were developed. These brief and low-threshold interventions focus on psychological stress, sleep problems, and worry, because these complaints are highly prevalent, are demonstrably associated with depression and have a substantial economic impact. Objective: Aim of the current economic evaluation is to examine the added value of web-based unguided self-help CDMIs as compared to a wait-listed control group with unrestricted access to usual care both from a societal and healthcare perspective. Methods: This health economic evaluation was embedded in a randomized controlled trial. The study entailed two-arms in which three web-based CMDIs were compared to a no-intervention waiting-list control group (control group received intervention at three months follow-up). Measurements were conducted at baseline, and at three- and six-months follow-up. Primary outcome of the study was response rate on depressive symptomatology as measured by the Inventory of Depressive Symptomatology Self-Report (IDS-SR). Change in quality of life was estimated by calculating effect sizes (Cohens’ d) for individual pre- and post-treatment IDS-SR scores. Incremental cost-effectiveness ratios (ICERs) were calculated using bootstraps (5000 times) of seemingly unrelated regression equations and cost-effectiveness acceptability curves were constructed for the costs per QALY gained. Results: In total, 329 participants were included in the study of which 165 randomized to the CDMI group. At three months follow-up the responder rate was 13.9% in the CDMI group and 7.3% in the control group. Participants in the CDMI group gained 0.15 QALY at three months follow-up compared to baseline, whereas participants in the control group gained 0.03 QALY at three months follow-up. Average total costs per patient during 3 months follow-up were €2,094 for the CDMI group and €2,230 for the control group (excluding baseline costs). Bootstrapped SURE models resulted in a dominant ICER (i.e. less costs and a higher responder rate) for the CDMI group compared to the control group at three months follow-up. The same result was found for the costs per QALY gained. Various sensitivity analyses attested to the robustness of the findings of the main analysis. Conclusions: This study demonstrated that brief and low-threshold web-based unguided self-help CDMIs have the potential to be a cost-effective addition to usual care for adults with mild-to-moderate depressive symptoms. The CDMIs were shown to improve health status while at the same time reduced healthcare costs of participants and hence dominates the care as usual control condition. As intervention costs are relatively low, and Internet is nowadays readily available in the Western world, we believe the CDMIs can be easily implemented on a large scale. Clinical Trial: Netherlands Trial Register (NTR): NTR4612; (Archived by WebCite at

  • Mobile applications for management of tinnitus: users’ survey, quality assessment and content analysis

    Date Submitted: Mar 21, 2018

    Open Peer Review Period: Mar 21, 2018 - May 16, 2018

    Background: Tinnitus is the perception of a sound without any outside source. It affects 6 million people in the UK. Sound therapy is a core component of many tinnitus management programmes. Potential...

    Background: Tinnitus is the perception of a sound without any outside source. It affects 6 million people in the UK. Sound therapy is a core component of many tinnitus management programmes. Potential mechanisms of benefit include making tinnitus less noticeable, habituation, distracting attention from tinnitus, relaxation, and promoting neuroplastic changes within the brain. In recent years there has been a substantial increase in the use of mobile technology. This provided an additional medium via which people with tinnitus can access different tinnitus management options including sound therapy. Objective: The purpose of this study was to: 1) generate the list of apps that people use for management of their tinnitus; 2) explore reasons for apps use and non-use; 3) perform quality assessment of the most cited apps; 4) perform content analysis to explore and describe options and management techniques available in the most cited apps. Methods: An online survey consisting of 33 open and closed questions captured: i) demographic information about respondents, information about tinnitus, hearing loss; ii) mobile apps specific questions asked about the motivation to use an app to manage tinnitus, the apps which respondents used for managing tinnitus, important factors when choosing an app, devices used to access apps, reasons for not using apps. The quality of the most cited apps listed by respondents was assessed using the Mobile Apps Rating Scale (MARS) Content and features of the most cited apps were analysed. Results: Data from 643 respondents were analysed. The majority of respondents (75%) had never used an app for management of tinnitus mainly due to lack of awareness (79%). The list of the 55 apps that people use for the management of their tinnitus was generated. These included apps which were developed specifically for the management of tinnitus, however the majority of cited apps were developed for other problems (e.g. sleep, depression/anxiety, relaxation). Quality assessment of the 18 most popular apps, using MARS resulted in a range of mean scores from 1.6 to 4.2 (out of 5). In line with the current model of tinnitus management, sound was the main focus of the majority of the apps. Other components included relaxation exercises, elements of cognitive behaviour therapy, information and education and hypnosis. Conclusions: People use apps for the management of their tinnitus, however this was done mostly as a self-help option without conjunction with management provided by hearing healthcare professionals. Further research should consider the place for apps in the tinnitus management (standalone self-management intervention vs part of the management by a hearing professional). As the content of the apps varies in respect to sound options, information and management strategies it seems that the choice of the best management app should be guided by individual patient needs and preferences.

  • Patient Experiences Using a Self-Monitoring App in Eating Disorder Treatment: Findings from a Qualitative Study

    Date Submitted: Mar 21, 2018

    Open Peer Review Period: Mar 21, 2018 - May 16, 2018

    Background: The Recovery Record smartphone app is a self-monitoring tool for individuals recovering from an eating disorder. Unlike traditional pen-and-paper meal diaries, which are often used in trad...

    Background: The Recovery Record smartphone app is a self-monitoring tool for individuals recovering from an eating disorder. Unlike traditional pen-and-paper meal diaries, which are often used in traditional eating disorder treatment, the app holds novel features, such as meal reminders, affirmations, and patient-clinician in-app linkage allowing for clinicians to continuously monitor patients' app data. Objective: To explore patients' experiences with using Recovery Record as part of eating disorder treatment. Methods: A total of 41 patients from a Danish eating disorder treatment facility were included. All 41 patients were part of participant observations, and 26 were interviewed. Data were generated and analyzed concurrently, applying the inductive methodology of Interpretive Description. Results: The patients' experiences with Recovery Record depended on its app features, the impact of these app features on patients, and patients' specific app usage. This patient-app interaction affected and was affected by changeable contexts making patients' experiences dynamic. Furthermore, the patient-app interaction affected patients' placement of specific Recovery Record app features along a continuum from supportive to obstructive of individual everyday life activities, including the eating disorder treatment. Conclusions: To achieve optimal usage of Recovery Record, we recommend a patient-clinician collaboration including the individual patient's preferences regarding app usage as well as the clinician's professional judgment on the appropriate course of treatment. Thus, ongoing discussions between patients and clinicians are needed in relation to which Recovery Record app features are supportive, when taking patients' individual treatment needs, everyday life activities, and preferences into account. Consequently, the supportive app features may be applied further, while primarily obstructive app features may be avoided.

  • An Online Hand Exercise Intervention for Adults with Rheumatoid Arthritis (mySARAH): Design, Development, and Usability Testing.

    Date Submitted: Mar 21, 2018

    Open Peer Review Period: Mar 21, 2018 - May 16, 2018

    Background: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme is a tailored, progressive 12-week exercise programme for people with hand problems due to rheumatoi...

    Background: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme is a tailored, progressive 12-week exercise programme for people with hand problems due to rheumatoid arthritis. The programme was shown to be clinically and cost-effective in a large clinical trial and is recommended by the UK National Institute for Health and Care Excellence (NICE) guidelines for rheumatoid arthritis in adults. Objective: We have developed an online version of the SARAH programme (mySARAH) to make the SARAH programme widely accessible to people with rheumatoid arthritis. The purposes of this study were to develop mySARAH and to evaluate and address its usability issues. Methods: We developed mySARAH using a three-step process and gaining feedback from patient contributors. After initial development, mySARAH was tested in two iterative usability cycles in nine participants using a simplified think-aloud protocol and self-reported questionnaires. We also evaluated if participants executed the SARAH exercises correctly after watching the exercise videos included on the website. Results: A preliminary version of mySARAH consisting of six sessions over a 12-week period and delivered via text, exercise videos, images, exercise plan form, exercise diaries, and links to additional information on rheumatoid arthritis was developed. Five participants (1 male; 4 females; median age 64 years) and four participants (four females; median age 64.5 years) took part in the first and second usability testing cycles respectively. Usability issues identified from Cycle 1 such as having a navigation tutorial video and individualised feedback on pain levels were addressed prior to Cycle 2. The need for more instructions to complete the mySARAH patient forms was identified in Cycle 2 and was rectified. Self-reports from both cycles indicated that participants found the programme useful and easy to use and were confident in performing the SARAH exercises themselves. Eight of the nine participants correctly demonstrated all the exercises. Conclusions: mySARAH is the first online hand exercise intervention for people with rheumatoid arthritis. We actively involved target users in the development and usability evaluation and ensured mySARAH met their needs and preferences.

  • User preferences and persona design for an mHealth intervention to support adherence to cardiovascular disease medication in Singapore.

    Date Submitted: Mar 21, 2018

    Open Peer Review Period: Mar 21, 2018 - May 16, 2018

    Background: The use of mHealth has gained popularity globally including for use in variety of health interventions, particularly through SMS. However, there are challenges to the use of mHealth, parti...

    Background: The use of mHealth has gained popularity globally including for use in variety of health interventions, particularly through SMS. However, there are challenges to the use of mHealth, particularly amongst older users who have a large heterogeneity in usability and accessibility barriers when using technology. In order to better understand and conceptualise the diversity of users and give insight into their particular needs, we turned to persona creation. Personas are user archetypes created through data generated from mixed-methods inquiry with actual target users. Personas are an appropriate yet largely underutilised component of current mHealth research. Methods: Leveraging on data from a mixed methods study conducted in Singapore with an ethnically diverse population including Chinese, Malay and Indian participants, we used a proforma to analyse data from the qualitative component (n=20 in-depth interviews) and quantitative component (n=100 interviewer guided surveys). We then identified key characteristics including technology use and preferences as well as adherence factors to synthesize five personas reflective of persons over the age of 40 years old with atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk factors such as hypertension, in Singapore. Results: We present five personas typologized as 1) The Quiet Analog, 2) The Busy Grandparent, 3) The Socializer, 4) The Newly Diagnosed and 5) The Hard-to-Reach. We report on four key characteristics - health care access, medication adherence, mobile phone technology usage (ownership, access and utilization) and interest in mHealth. Finally, we provide insights into how these personas may be used in the design and implementation of an mHealth intervention. Our work demonstrates how mixed methods data can create biopsychosocial personas which can be used to explore and address the diversity in behaviours, preferences and needs in user groups. Conclusion: With wider adoption of mHealth, it is important that we consider user-centered design techniques, and design thinking in order to create meaningful, patient centered interventions for adherence to medications. Future research in this area should include greater exploration of how these five personas can be used to better understand how and when is best to deliver mHealth interventions in Singapore and beyond.

  • Measuring eHealth Literacy Across the Lifespan: Are We Comparing Apples and Oranges?

    Date Submitted: Mar 21, 2018

    Open Peer Review Period: Mar 21, 2018 - Mar 31, 2018

    Background: Electronic health (eHealth) is engrained in the healthcare experience to engage patients across the lifespan. eHealth accessibility and optimization is influenced by lifespan development,...

    Background: Electronic health (eHealth) is engrained in the healthcare experience to engage patients across the lifespan. eHealth accessibility and optimization is influenced by lifespan development, as older adults experience greater challenges in accessing and using eHealth compared to their younger counterparts. The eHealth Literacy Scale (eHEALS) is the most popular measure to assess patients’ confidence in locating, understanding, evaluating, and acting upon online health information. Currently, however, it is unknown if eHEALS measurement properties support empirical comparisons across the lifespan. Objective: The purpose of this study was to examine the structure of eHEALS scores and the degree of measurement invariance by age among a sample of United States (US) adults. Methods: A Qualtrics panel (N = 830) completed the online survey. The sample was categorized into younger (18-48) and middle-to-older (49-84) age groups. Multi-group exploratory structural equation modeling was conducted to identify and confirm the number of underlying eHEALS factors. A structural equation modeling approach was also conducted to explore the degree of configural (number of factors and items on each factor), pattern (factor loading equivalence), and unique (item measurement error equivalence) measurement invariance between age groups. In the best-fitted 3-factor model, independent t-tests were conducted to examine age group differences in average responses. Results: Young (18-48 years old; N = 411) and old (49-84 years old; N = 419) adults completed the survey. A 3-factor model had the best fit (RMSEA = .06; CFI = .99; TLI = .98), as compared to the 1-factor, 2-factor, and 4-factor models. These 3-factors included eHealth Information Awareness (2 items), Information Seeking (2 Items), and Information and Evaluation (4 items). Pattern invariance was supported with acceptable model fit (RMSEA = .06; ΔX2 = p > .05; ΔCFI = 0). Compared with younger adults, older adults had less confidence in eHealth resource awareness (p < .001), information seeking skills (p < .01), and ability to evaluate and act upon online health information (p < .001). Conclusions: Evidence for measurement invariance across the lifespan is supported by this study. The eHEALS can be used to uniquely assess, monitor, and evaluate self-efficacy of Internet users’ eHealth information awareness, information seeking skills, and evaluation/action abilities. This finding will allow health researchers and practitioners identify the eHealth deficits experienced by their respondents, so that timely and relevant trainings can be recommended. Future research is needed to extend the number of eHEALS items to capture the social nature of eHealth and to meet gold standard expectations for factor representation (i.e., 3 items).