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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:

  • 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.

  • Source: Vandenberg Air Force Base; Copyright: US Air Force (Christian Thomas); URL:; License: Public Domain (CC0).

    Treatment Activity, User Satisfaction, and Experienced Usability of Internet-Based Cognitive Behavioral Therapy for Adults With Depression and Anxiety After...


    Background: Knowledge about user experiences may lead to insights about how to improve treatment activity in Internet-based cognitive behavioral therapy (iCBT) to reduce symptoms of depression and anxiety among people with a somatic disease. There is a need for studies conducted alongside randomized trials, to explore treatment activity and user experiences related to such interventions, especially among people with older age who are recruited in routine care. Objective: The aim of the study was to explore treatment activity, user satisfaction, and usability experiences among patients allocated to treatment in the U-CARE Heart study, a randomized clinical trial of an iCBT intervention for treatment of depression and anxiety following a recent myocardial infarction. Methods: This was a mixed methods study where quantitative and qualitative approaches were used. Patients were recruited consecutively from 25 cardiac clinics in Sweden. The study included 117 patients allocated to 14 weeks of an iCBT intervention in the U-CARE Heart study. Quantitative data about treatment activity and therapist communication were collected through logged user patterns, which were analyzed with descriptive statistics. Qualitative data with regard to positive and negative experiences, and suggestions for improvements concerning the intervention, were collected through semistructured interviews with 21 patients in the treatment arm after follow-up. The interviews were analyzed with qualitative manifest content analysis. Results: Treatment activity was low with regard to number of completed modules (mean 0.76, SD 0.93, range 0-5) and completed assignments (mean 3.09, SD 4.05, range 0-29). Most of the participants initiated the introduction module (113/117, 96.6%), and about half (63/117, 53.9%) of all participants completed the introductory module, but only 18 (15.4%, 18/117) continued to work with any of the remaining 10 modules, and each of the remaining modules was completed by 7 or less of the participants. On average, patients sent less than 2 internal messages to their therapist during the intervention (mean 1.42, SD 2.56, range 0-16). Interviews revealed different preferences with regard to the internet-based portal, the content of the treatment program, and the therapist communication. Aspects related to the personal situation and required skills included unpleasant emotions evoked by the intervention, lack of time, and technical difficulties. Conclusions: Patients with a recent myocardial infarction and symptoms of depression and anxiety showed low treatment activity in this guided iCBT intervention with regard to completed modules, completed assignments, and internal messages sent to their therapist. The findings call attention to the need for researchers to carefully consider the preferences, personal situation, and technical skills of the end users during the development of these interventions. The study indicates several challenges that need to be addressed to improve treatment activity, user satisfaction, and usability in internet-based interventions in this population.

  • Source: JÉSHOOTS; Copyright: Jan Vasek; URL:; License: Licensed by JMIR.

    Detection of Cases of Noncompliance to Drug Treatment in Patient Forum Posts: Topic Model Approach


    Background: Medication nonadherence is a major impediment to the management of many health conditions. A better understanding of the factors underlying noncompliance to treatment may help health professionals to address it. Patients use peer-to-peer virtual communities and social media to share their experiences regarding their treatments and diseases. Using topic models makes it possible to model themes present in a collection of posts, thus to identify cases of noncompliance. Objective: The aim of this study was to detect messages describing patients’ noncompliant behaviors associated with a drug of interest. Thus, the objective was the clustering of posts featuring a homogeneous vocabulary related to nonadherent attitudes. Methods: We focused on escitalopram and aripiprazole used to treat depression and psychotic conditions, respectively. We implemented a probabilistic topic model to identify the topics that occurred in a corpus of messages mentioning these drugs, posted from 2004 to 2013 on three of the most popular French forums. Data were collected using a Web crawler designed by Kappa Santé as part of the Detec’t project to analyze social media for drug safety. Several topics were related to noncompliance to treatment. Results: Starting from a corpus of 3650 posts related to an antidepressant drug (escitalopram) and 2164 posts related to an antipsychotic drug (aripiprazole), the use of latent Dirichlet allocation allowed us to model several themes, including interruptions of treatment and changes in dosage. The topic model approach detected cases of noncompliance behaviors with a recall of 98.5% (272/276) and a precision of 32.6% (272/844). Conclusions: Topic models enabled us to explore patients’ discussions on community websites and to identify posts related with noncompliant behaviors. After a manual review of the messages in the noncompliance topics, we found that noncompliance to treatment was present in 6.17% (276/4469) of the posts.

  • Source: Nellis Air Force Base; Copyright: US Air Force (Rachel Loftis); URL:; License: Public Domain (CC0).

    Expert Coaching in Weight Loss: Retrospective Analysis


    Background: Providing coaches as part of a weight management program is a common practice to increase participant engagement and weight loss success. Understanding coach and participant interactions and how these interactions impact weight loss success needs to be further explored for coaching best practices. Objective: The purpose of this study was to analyze the coach and participant interaction in a 6-month weight loss intervention administered by Retrofit, a personalized weight management and Web-based disease prevention solution. The study specifically examined the association between different methods of coach-participant interaction and weight loss and tried to understand the level of coaching impact on weight loss outcome. Methods: A retrospective analysis was performed using 1432 participants enrolled from 2011 to 2016 in the Retrofit weight loss program. Participants were males and females aged 18 years or older with a baseline body mass index of ≥25 kg/m², who also provided at least one weight measurement beyond baseline. First, a detailed analysis of different coach-participant interaction was performed using both intent-to-treat and completer populations. Next, a multiple regression analysis was performed using all measures associated with coach-participant interactions involving expert coaching sessions, live weekly expert-led Web-based classes, and electronic messaging and feedback. Finally, 3 significant predictors (P<.001) were analyzed in depth to reveal the impact on weight loss outcome. Results: Participants in the Retrofit weight loss program lost a mean 5.14% (SE 0.14) of their baseline weight, with 44% (SE 0.01) of participants losing at least 5% of their baseline weight. Multiple regression model (R2=.158, P<.001) identified the following top 3 measures as significant predictors of weight loss at 6 months: expert coaching session attendance (P<.001), live weekly Web-based class attendance (P<.001), and food log feedback days per week (P<.001). Attending 80% of expert coaching sessions, attending 60% of live weekly Web-based classes, and receiving a minimum of 1 food log feedback day per week were associated with clinically significant weight loss. Conclusions: Participant’s one-on-one expert coaching session attendance, live weekly expert-led interactive Web-based class attendance, and the number of food log feedback days per week from expert coach were significant predictors of weight loss in a 6-month intervention.

  • Source: Pixabay; Copyright: Roland Mey; URL:; License: Public Domain (CC0).

    Evolution of Electronic Cigarette Brands From 2013-2014 to 2016-2017: Analysis of Brand Websites


    Background: The electronic cigarette (e-cigarette) industry has grown in size and organizational complexity in recent years, most notably with the entry of major tobacco companies in 2012 and the proliferation of vape shops. Many brands maintain retail websites that present e-cigarette marketing claims and sell directly to consumers. Understanding of the evolving composition of different types of e-cigarette brand websites is currently underdeveloped. Objective: This paper presents how e-cigarette brand websites surveyed in 2013-2014 evolved by 2016-2017, and how the websites run by different types of e-cigarette producers currently differ. Methods: In 2016-2017, we revisited 466 e-cigarette brand websites surveyed in 2013-2014, 288 of which were extant, and identified 145 new English-language websites. We compared product designs, marketing claims, and age-based warnings presented by types of e-cigarette producers: major tobacco companies, independent vape shops, and independent internet-only companies. Results: Among the 433 websites examined in 2016-2017, 12 were owned by major tobacco companies, 162 operated a physical vape shop, and 259 were internet-only operations. Closed-system product designs were sold by 83% (10/12) of tobacco-owned brands. In comparison, 29.0% (47/162, P<.001) of vape shop and 55.2% (143/259, P=.06) of internet-only brands sold closed-system designs. Compared with vape shop and internet-only brands, tobacco-owned brands offered a smaller set of product models (P values <.001) and a narrower range of flavors (P values <.01), with greater emphasis on the traditional combustible cigarette flavors of tobacco and menthol (P values <.001). Tobacco-owned brands also offered a narrower range of nicotine options than the vape shops (P=.002) and were less likely to offer nicotine-free e-liquid compared with internet-only and vape shop brands (P values <.001). Finally, 83% (10/12) of tobacco-owned brand websites featured age verification pop-up windows. In comparison, only 50.2% (130/259) of internet-only brands (P=.01) and 60.5% (98/162) of vape shop brands (P=.06) featured age verification windows. Websites surveyed in both 2013-2014 and 2016-2017 became more likely to sell open-system mods (P<.001) and sold an increased number of product models (P<.001), flavors (P<.001), and nicotine options (P<.001). Prevalence of several types of claims decreased significantly, including indirect claims regarding smoking cessation (P<.001), claims regarding e-cigarettes as healthier (P<.001), less expensive (P<.001), and usable in more places (P<.001) compared with combustible cigarettes. Conclusions: The number of e-cigarette brands has not appeared to increase since 2014, even as website messaging evolved, with brands owned by tobacco companies and vape shops pulling in opposite directions. Brands owned by tobacco companies offered a limited range of e-cigarette products, whereas brands owned by vape shops emphasized a panoply of flavor and nicotine options. Furthermore, the Food and Drug Administration’s regulatory action may influence the types of e-cigarette products offered and the market shares of various companies.

  • Twitter collage. Source: JMIR Publications; License: Creative Commons Attribution (CC-BY).

    Evaluating Patient Perspectives of Provider Professionalism on Twitter in an Academic Obstetrics and Gynecology Clinic: Patient Survey


    Background: One-third of Americans use social media websites as a source of health care information. Twitter, a microblogging site that allows users to place 280-character posts—or tweets—on the Web, is emerging as an important social media platform for health care. However, most guidelines on medical professionalism on social media are based on expert opinion. Objective: This study sought to examine if provider Twitter profiles with educational tweets were viewed as more professional than profiles with personal tweets or a mixture of the two, and to determine the impact of provider gender on perceptions of professionalism in an academic obstetrics and gynecology clinic. Methods: This study randomized obstetrics and gynecology patients at the University of Michigan Von Voigtlander Clinic to view one of six medical provider Twitter profiles, which differed in provider gender and the nature of tweets. Each participant answered 10 questions about their perception of the provider’s professionalism based on the Twitter profile content. Results: The provider profiles with educational tweets alone received higher mean professionalism scores than profiles with personal tweets. Specifically, the female and male provider profiles with exclusively educational tweets had the highest and second highest overall mean professionalism ratings at 4.24 and 3.85, respectively. In addition, the female provider profiles received higher mean professionalism ratings than male provider profiles with the same content. The female profile with mixed content received a mean professionalism rating of 3.38 compared to 3.24 for the male mixed-content profile, and the female profile with only personal content received a mean professionalism rating of 3.68 compared to 2.68 for the exclusively personal male provider profile. Conclusions: This study showed that in our obstetrics and gynecology clinic, patients perceived providers with educational profiles as more professional than those with a mixture of educational and personal tweets or only personal tweets. It also showed that our patient population perceived the female provider with educational tweets to be the most professional. This study will help inform the development of evidence-based guidelines for social media use in medicine as it adds to the growing body of literature examining professionalism and social media.

  • Example of a crowdsourcing contest organized to solicit videos promoting condom use in China (montage). Source: SESH China /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Ethical Concerns of and Risk Mitigation Strategies for Crowdsourcing Contests and Innovation Challenges: Scoping Review


    Background: Crowdsourcing contests (also called innovation challenges, innovation contests, and inducement prize contests) can be used to solicit multisectoral feedback on health programs and design public health campaigns. They consist of organizing a steering committee, soliciting contributions, engaging the community, judging contributions, recognizing a subset of contributors, and sharing with the community. Objective: This scoping review describes crowdsourcing contests by stage, examines ethical problems at each stage, and proposes potential ways of mitigating risk. Methods: Our analysis was anchored in the specific example of a crowdsourcing contest that our team organized to solicit videos promoting condom use in China. The purpose of this contest was to create compelling 1-min videos to promote condom use. We used a scoping review to examine the existing ethical literature on crowdsourcing to help identify and frame ethical concerns at each stage. Results: Crowdsourcing has a group of individuals solve a problem and then share the solution with the public. Crowdsourcing contests provide an opportunity for community engagement at each stage: organizing, soliciting, promoting, judging, recognizing, and sharing. Crowdsourcing poses several ethical concerns: organizing—potential for excluding community voices; soliciting—potential for overly narrow participation; promoting—potential for divulging confidential information; judging—potential for biased evaluation; recognizing—potential for insufficient recognition of the finalist; and sharing—potential for the solution to not be implemented or widely disseminated. Conclusions: Crowdsourcing contests can be effective and engaging public health tools but also introduce potential ethical problems. We present methods for the responsible conduct of crowdsourcing contests.

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

    Internet-Based Cognitive Behavioral Therapy for Symptoms of Depression and Anxiety Among Patients With a Recent Myocardial Infarction: The U-CARE Heart...


    Background: Symptoms of depression and anxiety are common after a myocardial infarction (MI). Internet-based cognitive behavioral therapy (iCBT) has shown good results in other patient groups. Objective: The aim of this study was to evaluate the effectiveness of an iCBT treatment to reduce self-reported symptoms of depression and anxiety among patients with a recent MI. Methods: In total, 3928 patients were screened for eligibility in 25 Swedish hospitals. Of these, 239 patients (33.5%, 80/239 women, mean age 60 years) with a recent MI and symptoms of depression or anxiety were randomly allocated to a therapist-guided, 14-week iCBT treatment (n=117), or treatment as usual (TAU; n=122). The iCBT treatment was designed for post-MI patients. The primary outcome was the total score of the Hospital Anxiety and Depression Scale (HADS) 14 weeks post baseline, assessed over the internet. Treatment effect was evaluated according to the intention-to-treat principle, with multiple imputations. For the main analysis, a pooled treatment effect was estimated, controlling for age, sex, and baseline HADS. Results: There was a reduction in HADS scores over time in the total study sample (mean delta=−5.1, P<.001) but no difference between the study groups at follow-up (beta=−0.47, 95% CI −1.95 to 1.00, P=.53). Treatment adherence was low. A total of 46.2% (54/117) of the iCBT group did not complete the introductory module. Conclusions: iCBT treatment for an MI population did not result in lower levels of symptoms of depression or anxiety compared with TAU. Low treatment adherence might have influenced the result. Trial Registration: NCT01504191; (Archived at Webcite at

  • User accessing secure messaging through the Veterans Health Administration’s personal health record portal, My HealtheVet. Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Patient Centeredness in Electronic Communication: Evaluation of Patient-to-Health Care Team Secure Messaging


    Background: As information and communication technology is becoming more widely implemented across health care organizations, patient-provider email or asynchronous electronic secure messaging has the potential to support patient-centered communication. Within the medical home model of the Veterans Health Administration (VA), secure messaging is envisioned as a means to enhance access and strengthen the relationships between veterans and their health care team members. However, despite previous studies that have examined the content of electronic messages exchanged between patients and health care providers, less research has focused on the socioemotional aspects of the communication enacted through those messages. Objective: Recognizing the potential of secure messaging to facilitate the goals of patient-centered care, the objectives of this analysis were to not only understand why patients and health care team members exchange secure messages but also to examine the socioemotional tone engendered in these messages. Methods: We conducted a cross-sectional coding evaluation of a corpus of secure messages exchanged between patients and health care team members over 6 months at 8 VA facilities. We identified patients whose medical records showed secure messaging threads containing at least 2 messages and compiled a random sample of these threads. Drawing on previous literature regarding the analysis of asynchronous, patient-provider electronic communication, we developed a coding scheme comprising a series of a priori patient and health care team member codes. Three team members tested the scheme on a subset of the messages and then independently coded the sample of messaging threads. Results: Of the 711 messages coded from the 384 messaging threads, 52.5% (373/711) were sent by patients and 47.5% (338/711) by health care team members. Patient and health care team member messages included logistical content (82.6%, 308/373 vs 89.1%, 301/338), were neutral in tone (70.2%, 262/373 vs 82.0%, 277/338), and respectful in nature (25.7%, 96/373 vs 33.4%, 113/338). Secure messages from health care team members sometimes appeared hurried (25.4%, 86/338) but also displayed friendliness or warmth (18.9%, 64/338) and reassurance or encouragement (18.6%, 63/338). Most patient messages involved either providing or seeking information; however, the majority of health care team member messages involved information provision in response to patient questions. Conclusions: This evaluation is an important step toward understanding the content and socioemotional tone that is part of the secure messaging exchanges between patients and health care team members. Our findings were encouraging; however, there are opportunities for improvement. As health care organizations seek to supplement traditional encounters with virtual care, they must reexamine their use of secure messaging, including the patient centeredness of the communication, and the potential for more proactive use by health care team members.

  • Consumers can comment on their health care experiences using physician ratings websites. Source: Pixnio; Copyright: James Gathany, Judy Schmidt, USCDCP; URL:; License: Public Domain (CC0).

    Scope, Breadth, and Differences in Online Physician Ratings Related to Geography, Specialty, and Year: Observational Retrospective Study


    Background: Physician ratings websites have emerged as a novel forum for consumers to comment on their health care experiences. Little is known about such ratings in Canada. Objective: We investigated the scope and trends for specialty, geographic region, and time for online physician ratings in Canada using a national data source from the country’s leading physician-rating website. Methods: This observational retrospective study used online ratings data from Canadian physicians (January 2005-September 2013; N=640,603). For specialty, province, and year of rating, we assessed whether physicians were likely to be rated favorably by using the proportion of ratings greater than the overall median rating. Results: In total, 57,412 unique physicians had 640,603 individual ratings. Overall, ratings were positive (mean 3.9, SD 1.3). On average, each physician had 11.2 (SD 10.1) ratings. By comparing specialties with Canadian Institute of Health Information physician population numbers over our study period, we inferred that certain specialties (obstetrics and gynecology, family practice, surgery, and dermatology) were more commonly rated, whereas others (pathology, radiology, genetics, and anesthesia) were less represented. Ratings varied by specialty; cardiac surgery, nephrology, genetics, and radiology were more likely to be rated in the top 50th percentile, whereas addiction medicine, dermatology, neurology, and psychiatry were more often rated in the lower 50th percentile of ratings. Regarding geographic practice location, ratings were more likely to be favorable for physicians practicing in eastern provinces compared with western and central Canada. Regarding year, the absolute number of ratings peaked in 2007 before stabilizing and decreasing by 2013. Moreover, ratings were most likely to be positive in 2007 and again in 2013. Conclusions: Physician-rating websites are a relatively novel source of provider-level patient satisfaction and are a valuable source of the patient experience. It is important to understand the breadth and scope of such ratings, particularly regarding specialty, geographic practice location, and changes over time.

  • Click and collect. Source: SH:24; Copyright: Glyn Parry; URL:; License: Public Domain (CC0).

    Web-Based Activity Within a Sexual Health Economy: Observational Study


    Background: Regular testing for sexually transmitted infections (STIs) is important to maintain sexual health. Self-sampling kits ordered online and delivered in the post may increase access, convenience, and cost-effectiveness. Sexual health economies may target limited resources more effectively by signposting users toward Web-based or face-to-face services according to clinical need. Objective: The aim of this paper was to investigate the impact of two interventions on testing activity across a whole sexual health economy: (1) the introduction of open access Web-based STI testing services and (2) a clinic policy of triage and signpost online where users without symptoms who attended clinics for STI testing were supported to access the Web-based service instead. Methods: Data on attendances at all specialist public sexual health providers in an inner-London area were collated into a single database. Each record included information on user demographics, service type accessed, and clinical activity provided, including test results. Clinical activity was categorized as a simple STI test (could be done in a clinic or online), a complex visit (requiring face-to-face consultation), or other. Results: Introduction of Web-based services increased total testing activity across the whole sexual health economy by 18.47% (from 36,373 to 43,091 in the same 6-month period—2014-2015 and 2015-2016), suggesting unmet need for testing in the area. Triage and signposting shifted activity out of the clinic onto the Web-based service, with simple STI testing in the clinic decreasing from 16.90% (920/5443) to 12.25% (511/4172) of total activity, P<.001, and complex activity in the clinic increasing from 69.15% (3764/5443) to 74.86% (3123/4172) of total activity, P<.001. This intervention created a new population of online users with different demographic and clinical profiles from those who use Web-based services spontaneously. Some triage and signposted users (29.62%, 375/1266) did not complete the Web-based testing process, suggesting the potential for missed diagnoses. Conclusions: This evaluation shows that users can effectively be transitioned from face-to-face to Web-based services and that this introduces a new population to Web-based service use and changes the focus of clinic-based activity. Further development is underway to optimize the triage and signposting process to support test completion.

  • Social media use among patients enrolled in outpatient addiction treatment programs. Source: Pexels; Copyright: Fancycrave; URL:; License: Public Domain (CC0).

    Technology and Social Media Use Among Patients Enrolled in Outpatient Addiction Treatment Programs: Cross-Sectional Survey Study


    Background: Substance use disorder research and practice have not yet taken advantage of emerging changes in communication patterns. While internet and social media use is widespread in the general population, little is known about how these mediums are used in substance use disorder treatment. Objective: The aims of this paper were to provide data on patients' with substance use disorders mobile phone ownership rates, usage patterns on multiple digital platforms (social media, internet, computer, and mobile apps), and their interest in the use of these platforms to monitor personal recovery. Methods: We conducted a cross-sectional survey of patients in 4 intensive outpatient substance use disorder treatment facilities in Philadelphia, PA, USA. Logistic regressions were used to examine associations among variables. Results: Survey participants (N=259) were mostly male (72.9%, 188/259), African American (62.9%, 163/259), with annual incomes less than US $10,000 (62.5%, 161/259), and averaged 39 (SD 12.24) years of age. The vast majority of participants (93.8%, 243/259) owned a mobile phone and about 64.1% (166/259) owned a mobile phone with app capabilities, of which 85.1% (207/243) accessed the internet mainly through their mobile phone. There were no significant differences in age, gender, ethnicity, or socio-economic status by computer usage, internet usage, number of times participants changed their phone, type of mobile phone contract, or whether participants had unlimited calling plans. The sample was grouped into 3 age groups (Millennials, Generation Xers, and Baby Boomers). The rates of having a social media account differed across these 3 age groups with significant differences between Baby Boomers and both Generation Xers and Millennials (P<.001 in each case). Among participants with a social media account (73.6%, 190/259), most (76.1%, 144/190) reported using it daily and nearly all (98.2%, 186/190) used Facebook. Nearly half of participants (47.4%, 90/190) reported viewing content on social media that triggered substance cravings and an equal percentage reported being exposed to recovery information on social media. There was a significant difference in rates of reporting viewing recovery information on social media across the 3 age groups with Baby Boomers reporting higher rates than Millennials (P<.001). The majority of respondents (70.1%, 181/259) said they would prefer to use a relapse prevention app on their phone or receive SMS (short message service) relapse prevention text messages (72.3%, 186/259), and nearly half (49.1%, 127/259) expressed an interest in receiving support by allowing social media accounts to be monitored as a relapse prevention technique. Conclusions: To our knowledge, this is the first and largest study examining the online behavior and preferences regarding technology-based substance use disorder treatment interventions in a population of patients enrolled in community outpatient treatment programs. Patients were generally receptive to using relapse prevention apps and text messaging interventions and a substantial proportion supported social media surveillance tools. However, the design of technology-based interventions remains as many participants have monthly telephone plans which may limit continuity.

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  • Veterans' Perspectives on Fitbit Use in Treatment for Posttraumatic Stress Disorder: An Interview Study

    Date Submitted: Mar 15, 2018

    Open Peer Review Period: Mar 16, 2018 - May 11, 2018

    Background: The increase in availability of patient data through consumer health wearable devices and smartphone sensors provides opportunities for mental health treatment beyond traditional self-repo...

    Background: The increase in availability of patient data through consumer health wearable devices and smartphone sensors provides opportunities for mental health treatment beyond traditional self-report measurements. Previous studies have suggested that wearables can be effectively used to benefit the physical health of people with mental health issues but little research has explored the integration of wearable devices into mental health care. As such, early research is still necessary to address factors that might impact that integration including patient's motivations to use wearables and its subsequent data. Objective: We sought to gain an understanding of patients' motivations to use or not to use wearables devices during intensive treatment program for posttraumatic stress disorder (PTSD). During this treatment, they received a complementary Fitbit. We investigated the following research questions: How did the veterans in the intensive treatment program use their Fitbit? What are contributing motivators for the use and non-use of the Fitbit? Methods: We conducted semi-structured interviews with 13 veterans who completed an intensive treatment program for PTSD. We transcribed and analyzed interviews using thematic analysis. Results: We identified three major motivations for veterans to use the Fitbit during their time in the program: increase self-awareness, support social interactions, and give back to other veterans. We also identified three major reasons certain features of the Fitbit were not used: lack of clarity around the purpose of the Fitbit, lack of meaning in the Fitbit data, and challenges in the veteran-provider relationship. Conclusions: In order to integrate wearable data into mental health treatment programs, it is important to understand the patient perspectives and motivations. We also discuss how the military culture and PTSD may have contributed to our participant's behaviors and attitudes towards Fitbit usage. We conclude with possible approaches for integrating PGD into mental health treatment settings that may address the challenges we identified.

  • Differences in emotional and pain-related language in tweets about dentists and medical doctors: Text-analysis of Twitter content

    Date Submitted: Mar 16, 2018

    Open Peer Review Period: Mar 16, 2018 - May 11, 2018

    Background: Social media provides people with easy ways to communicate their attitudes and feelings to a wide audience. Many people unfortunately have negative associations and feelings about dental t...

    Background: Social media provides people with easy ways to communicate their attitudes and feelings to a wide audience. Many people unfortunately have negative associations and feelings about dental treatment due to former painful experiences. Former research indicates that there might exist a pervasive and negative occupational stereotype related to dentists, and that this stereotype is expressed in many different venues, including in movies and in literature. Objective: This study investigates the language used in relation to dentists and medical doctors in the social media channel Twitter. The purpose is to compare the professions concerning the use of emotional words and pain-related words, which might underlie the pervasive negative stereotype identified in relation to dentists. We hypothesize that (A) tweets about dentists will have more negative emotion words than tweets about medical doctors, and that (B) pain related words are used more frequently in tweets about dentists than medical doctors. Methods: Twitter content (“tweets”) about dentists and medical doctors were collected scanning the keywords “dentist” and “doctor” using the Twitter API 140Dev. Word content of the selected tweets were analysed using the Linguistic Inquiry and Word Count software. The research hypotheses were investigated using non-parametric Wilcoxon-Mann-Whitney tests. Results: Over 2.3 million tweets were collected in total, of which about 1/3 contained the word “dentist” and about 2/3 contained the word “doctor”. Hypothesis A was supported as there were a higher proportion of negative words used in tweets about dentists than in tweets about medical doctors; W = 634925.00, p < .001. Similarly, tests showed a difference in proportions of anger words (W = 582087.00, p < .001), anxiety words (W = 660532.00, p < .001), and sadness words (W = 617011.00, p < .001), with higher proportions in tweets about dentists than tweets about doctors. Also, Hypothesis B was supported as there were a higher proportion of pain related words used in tweets about dentists than about doctors; W = 590139.00, p < .001. Conclusions: The results from this study support the existence of a negative stereotype for dentists among Twitter-users. The impact of expression of this stereotype on Twitter needs to be further explored with other study designs.

  • Sudden Infant Death Syndrome and Safe Sleep on Twitter: Public Perceptions and Opinions to Guide Health Promotion

    Date Submitted: Mar 16, 2018

    Open Peer Review Period: Mar 16, 2018 - May 11, 2018

    Background: In the United States, sudden infant death syndrome (SIDS) is the leading cause of death in infants aged 1 month to 1 year. Approximately 3,500 infants die from SIDS and sleep-related reaso...

    Background: In the United States, sudden infant death syndrome (SIDS) is the leading cause of death in infants aged 1 month to 1 year. Approximately 3,500 infants die from SIDS and sleep-related reasons on a yearly basis. Unintentional sleep-related deaths and bed sharing, a known risk factor for SIDS, are on the rise. Furthermore, ethnic disparities exist among those most affected by SIDS. Despite public health campaigns, infant mortality persists. Given the popularity of social media, understanding social media conversations around SIDS and safe sleep may provide the medical and public health communities with the information needed to spread, reinforce, or counteract false information regarding SIDS and safe sleep. Objective: The purpose of this project was to study the social media conversation around SIDS to understand possible influences and guide health promotion efforts, public health research, and enable health professionals to engage in directed communication regarding this topic. Methods: This study used textual analytics to identify topics and extract meanings contained in unstructured textual data. Twitter messages were captured during the months of September, October, and November of 2017. Tweets and retweets were collected using NUVI software in conjunction with Twitter’s Search API using the keywords: "sids", "infant death syndrome", "sudden infant death syndrome”, and "safe sleep." This returned a total of 41,358 messages, which were analyzed using text-mining and social media monitoring software. Results: Multiple themes were identified, including: recommendations for safe sleep to prevent SIDS, safe sleep devices, the potential causes of SIDS, and how breastfeeding reduces SIDS. Compared to the months of September and November, October (Pregnancy and Infant Loss Awareness Month) demonstrated personal and specific stories of infant loss. The top influencers were news organizations, universities, and health-related organizations. Conclusions: This study offers valuable information regarding the public’s perception and opinions regarding SIDS and safe sleep. It highlights the contradicting information the public is exposed to regarding SIDS and the continued controversy of vaccines. This analysis also emphasizes the lack of public health organizations’ presence on Twitter compared to the influence of universities and news media organizations. It also demonstrates the prevalence of safe sleep products that are embedded in safe sleep messaging. These findings can assist providers in speaking about relevant topics when engaging in conversation about the prevention of SIDS and the promotion of safe sleep. Further, public health agencies and advocates should utilize social media and Twitter to better communicate accurate health information as well as continue to combat the spread of false information.

  • Developing Brief Message Content for Interventions Delivered Via Mobile Devices to Improve Medication Adherence in People with Type 2 Diabetes Mellitus: A Rapid Systematic Review

    Date Submitted: Mar 16, 2018

    Open Peer Review Period: Mar 16, 2018 - May 11, 2018

    Background: Current interventions to support patients with medication adherence are generally resource-intensive and ineffective. Brief messages, such as those delivered via short message service (SMS...

    Background: Current interventions to support patients with medication adherence are generally resource-intensive and ineffective. Brief messages, such as those delivered via short message service (SMS) systems, are increasingly used in digital health interventions to support adherence because they can be delivered on a wide-scale and at low cost. The content of messages is a crucial intervention feature for promoting behaviour change, but it is often unclear what the rationale is for chosen wording or any underlying mechanisms targeted for behavioural change. There is little guidance for developing and optimising brief message content for use in mobile-device delivered interventions. Objective: (1) To identify theoretical constructs (i.e. the targets that interventions aim to change) and behavioural strategies (i.e. features of intervention content) found to be associated with medication adherence in patients with type 2 diabetes. Additionally, (2) to map these onto a standard taxonomy for behaviour change techniques (BCTs) i.e. ‘active ingredients’ of interventions used to promote behavioural change, to produce an evidence-based set of approaches that have shown promise of improving adherence in previous studies and which could be further tested in digital-health interventions. Methods: A rapid systematic review of existing relevant systematic reviews was conducted. Medline and PsycINFO databases were searched from inception to 10th April 2017. Inclusion criteria: (A) systematic reviews of quantitative data if the studies reviewed (i) identified predictors of or correlates with medication adherence and/or evaluated medication adherence-enhancing interventions and (ii) included adult participants taking medication to manage a chronic physical health condition; and (B) systematic reviews of qualitative studies of experiences of medication adherence for adult participants with type 2 diabetes. Data were extracted on review characteristics and BCTs, theoretical constructs or behavioural strategies associated with improved medication adherence. Constructs and strategies were mapped onto the BCT v1 taxonomy. Results: A total of 1701 articles were identified; 25 systematic reviews (19 quantitative reviews, 3 qualitative reviews and 3 mixed-method reviews) were included. 21 theoretical constructs (e.g. self-efficacy) and 18 behavioural strategies (e.g. habit analysis) were identified in the included reviews. In total, 46 BCTs were identified as being related to medication adherence (e.g. habit formation, prompts/cues, information about health consequences). Conclusions: We have identified 46 promising BCTs related to medication adherence, upon which the content of brief messages delivered through mobile devices to improve adherence could be based. By using explicit systematic review methods and linking our findings to a standardised taxonomy of BCTs, we have described a novel approach for the development of SMS message content. Future brief message interventions that aim to support medication adherence could incorporate the BCTs identified in this review.

  • Development of a multidimensional tool to measure individuals’ health technology readiness - The Readiness and enablement index for Health technology (READHY)

    Date Submitted: Mar 15, 2018

    Open Peer Review Period: Mar 16, 2018 - May 11, 2018

    Background: The increasing digitalization of healthcare services with enhanced access to fast internet connections along with wide use of smartphones offers the opportunity to get health advice or tre...

    Background: The increasing digitalization of healthcare services with enhanced access to fast internet connections along with wide use of smartphones offers the opportunity to get health advice or treatment remotely. As a service provider, it is important to consider how consumers can take full advantage of available services and how this can create an enabling environment. However, it is important to consider the digital context and the attributes of current and future users such as their readiness, i.e. knowledge, skills and attitudes, including trust and motivation. Objective: To evaluate how a combination of the e-Health Literacy Questionnaire (eHLQ) with selected dimensions from the Health Education Impact Questionnaire (heiQ) and the Health Literacy Questionnaire (HLQ) can be used together as one instrument to characterize an individual’s level of health technology readiness and explore how the generated data can be used to create health technology readiness profiles of potential users of health technologies and digital health services. Methods: The instrument as well as sociodemographic questions was administered to a population of 305 citizens with a recent cancer diagnosis referred to rehabilitation in a setting that plans to introduce various technologies to assist the individuals. Properties of the READHY instrument were evaluated using confirmatory factor analysis (CFA), convergent and discriminant validity analysis and exploratory factor analysis (EFA). To identify different health technology readiness profiles in the population, the data were further analyzed using hierarchical and k-means cluster analysis. Results: The CFA found a suitable fit for the 13 factors with only one cross loading of one item between two dimensions. The convergent and discriminant validity analysis revealed many factor correlations suggesting that, in this population, a more parsimonious model might be achieved. EFA pointed to five to six constructs based on aggregates of the existing dimensions. The results were not satisfactory, so an eight-factor CFA was performed resulting in a good fit with only one item cross loading between two dimensions. Cluster analysis showed that data from the READHY instrument can be clustered to create meaningful health technology readiness profiles of users. Conclusions: The 13 dimensions from heiQ, HLQ and eHLQ can be used in combination to describe user’s health technology readiness level and degree of enablement. Further studies in other populations are needed to understand whether the associations between dimensions are consistent and if the number of dimensions can be reduced.

  • Impact of a Web-Based Electronic Health Record on Quality and Fidelity of Behavioral Health Services for Children and Adolescents with Serious Emotional and Behavioral Disorders: A Randomized Controlled Trial

    Date Submitted: Mar 16, 2018

    Open Peer Review Period: Mar 16, 2018 - Mar 28, 2018

    Background: Electronic health records (EHR) have been widely proposed as a mechanism for improving health care quality. However, rigorous research on the impact of EHR on behavioral health service del...

    Background: Electronic health records (EHR) have been widely proposed as a mechanism for improving health care quality. However, rigorous research on the impact of EHR on behavioral health service delivery is scant, especially for children and adolescents. Objective: The current study evaluated usability of an EHR developed to support implementation of the Wraparound care coordination model for youth with complex behavioral health needs, and impact of the EHR on service processes, fidelity, and proximal outcomes. Methods: Thirty-four Wraparound facilitators working in two programs in two states were randomized to either use the new EHR (n=19) or continue to implement Wraparound services as usual (SAU) using paper-based documentation (n=15). Assignment was unblended due to facilitators working in the same organizations. Key functions of the EHR included standard fields such as youth and family information, diagnoses, assessment data, and progress notes; as well as maintenance of a coordinated plan of care; progress measurement on strategies and services; communication among team members; and reporting on services, expenditures, and outcomes. All youth referred to services for 8 months (N=211) were eligible for the study. After excluding those who were ineligible (n=69) and who declined to participate (n=59), n=83 youth were enrolled in the study: n=49 in the EHR condition and n=34 in the SAU condition. Facilitators serving these youth and families and their supervisors completed measures of EHR usability and appropriateness, supervision processes and activities, work satisfaction, and use of and attitudes toward standardized assessments. Parents and caregivers completed measures related to fidelity and quality of behavioral health care, including Wraparound team climate, working alliance with providers, fidelity to the Wraparound model, and satisfaction with services. Results: EHR-assigned facilitators from both sites demonstrated robust use of the system. Facilitators in the EHR group reported spending significantly more time reviewing client progress (P = .03) in supervision, and less time overall sending reminders to youth/families (P = .04). A trend toward less time on administrative tasks (P = .098) in supervision was also found. Facilitators in both groups reported significantly increased use of measurement-based care strategies overall, which may reflect cross-group contamination (given that randomization of staff to the EHR occurred within agencies and supervisors supervised both types of staff). Although not significant at P < .05, there was a trend (P = .10) toward caregivers in the EHR group reporting poorer working alliance on one subscale focused on shared agreement on tasks. No other significant between-group differences were found. Conclusions: Results support the proposal that use of EHR systems can promote use of client progress data and promote efficiency; however, there was little evidence of any impact (positive or negative) on overall service quality, fidelity, or client satisfaction. The field of children’s behavioral health services would benefit from additional research on EHR systems using designs that include larger sample sizes and longer follow-up periods. Clinical Trial: NCT02421874,