JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 4.5 for 2015

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  • Pharmacy personnel deliver medical prescriptions electronically. Image source: License:Creative Commons Attribution 2.0 Generic.

    Professional Use of Social Media by Pharmacists: A Qualitative Study


    Background: Social media is frequently used by consumers and health care professionals; however, our knowledge about its use in a professional capacity by pharmacists is limited. Objective: Our aim was to investigate the professional use of social media by pharmacists. Methods: In-depth semistructured interviews were conducted with practicing pharmacists (N=31) from nine countries. Interviews were recorded, transcribed verbatim, and thematically analyzed. Results: Wikipedia, YouTube, and Facebook were the main social media platforms used. Professional use of social media included networking with peers, discussion of health and professional topics, accessing and sharing health and professional information, job searching, and professional promotion. Wikipedia was the participants’ first choice when seeking information about unfamiliar topics, or topics that were difficult to search for. Very few pharmacy-related contributions to Wikipedia were reported. YouTube, a video-sharing platform, was used for self-education. University lectures, “how-to” footage, and professionally made videos were commonly watched. No professional contribution was made to YouTube. Facebook, a general social networking site, was used for professional networking, promotion of achievements, and job advertisements. It also afforded engagement in professional discussions and information sharing among peers. Conclusions: Participants used social media in a professional capacity, specifically for accessing and sharing health and professional information among peers. Pharmacists, as medicines experts, should take a leading role in contributing to health information dissemination in these user-friendly virtual environments, to reach not only other health care professionals but also health consumers.

  • Experience of HIV. Image sourced and copyright owned by authors Ian Down et al.

    Australian Gay Men Describe the Details of Their HIV Infection Through a Cross-Sectional Web-Based Survey


    Background: With emerging opportunities for preventing human immunodeficiency virus (HIV) transmission, it remains important to identify those at greatest risk of infection and to describe and understand the contexts in which transmissions occur. Some gay and bisexual men with recently diagnosed HIV infection are initially unable to identify high-risk behaviors that would explain their HIV infection. We explored whether Web-based data collection could assist them in identifying the circumstances of their infection. Objective: To assess the capacity of a Web-based survey to collect reliable self-report data on the event to which gay and bisexual men ascribe their HIV infection. Methods: The HIV Seroconversion Study included a Web-based survey of gay and bisexual men with recently diagnosed HIV infection in Australia. Participants were asked if they could identify and describe the event they believe led to their infection. Men were also asked about their sexual and other risk practices during the 6 months before their diagnosis. Results: Most (403/506, 79.6%) gay and bisexual men with newly diagnosed HIV infection were able to identify and describe the circumstances that likely led to their infection. Among those who were initially unable to identify possible exposure events, many could nonetheless provide sensible information that ostensibly explained their seroconversion. Free-text responses allowed men to provide more detailed and contextual information, whereas questions about the totality of their sexual behavior before diagnosis provided opportunities for men to describe their sexual risk behavior in general. Overall, 84.0% indicated having engaged in condomless anal intercourse before their HIV diagnosis, including 71.8% in the receptive position. Conclusions: This study demonstrates the effectiveness of using Internet-based technologies to capture sensitive information about the circumstances in which HIV infection occurs among gay and bisexual men. By providing a range of opportunities for relaying experience, this research reveals some of the complexity in how individuals come to understand and explain their HIV infection. These findings may assist in obtaining detailed sexual history in the clinical setting.

  • Example visual display from CHART personalized feedback. Image sourced by authors and copyright owned and permitted by  UNC Lineberger Comprehensive Cancer Center’s CHAI Core.

    Impact of Game-Inspired Infographics on User Engagement and Information Processing in an eHealth Program


    Background: Online interventions providing individual health behavior assessment should deliver feedback in a way that is both understandable and engaging. This study focused on the potential for infographics inspired by the aesthetics of game design to contribute to these goals. Objective: We conducted formative research to test game-inspired infographics against more traditional displays (eg, text-only, column chart) for conveying a behavioral goal and an individual’s behavior relative to the goal. We explored the extent to which the display type would influence levels of engagement and information processing. Methods: Between-participants experiments compared game-inspired infographics with traditional formats in terms of outcomes related to information processing (eg, comprehension, cognitive load) and engagement (eg, attitudes toward the information, emotional tone). We randomly assigned participants (N=1162) to an experiment in 1 of 6 modules (tobacco use, alcohol use, vegetable consumption, fruit consumption, physical activity, and weight management). Results: In the tobacco module, a game-inspired format (scorecard) was compared with text-only; there were no differences in attitudes and emotional tone, but the scorecard outperformed text-only on comprehension (P=.004) and decreased cognitive load (P=.006). For the other behaviors, we tested 2 game-inspired formats (scorecard, progress bar) and a traditional column chart; there were no differences in comprehension, but the progress bar outperformed the other formats on attitudes and emotional tone (P<.001 for all contrasts). Conclusions: Across modules, a game-inspired infographic showed potential to outperform a traditional format for some study outcomes while not underperforming on other outcomes. Overall, findings support the use of game-inspired infographics in behavioral assessment feedback to enhance comprehension and engagement, which may lead to greater behavior change.

  • Survey. Image sourced and copyright owned by authors Valéry Risson et al.

    Linked Patient-Reported Outcomes Data From Patients With Multiple Sclerosis Recruited on an Open Internet Platform to Health Care Claims Databases Identifies...


    Background: An enormous amount of information relevant to public health is being generated directly by online communities. Objective: To explore the feasibility of creating a dataset that links patient-reported outcomes data, from a Web-based survey of US patients with multiple sclerosis (MS) recruited on open Internet platforms, to health care utilization information from health care claims databases. The dataset was generated by linkage analysis to a broader MS population in the United States using both pharmacy and medical claims data sources. Methods: US Facebook users with an interest in MS were alerted to a patient-reported survey by targeted advertisements. Eligibility criteria were diagnosis of MS by a specialist (primary progressive, relapsing-remitting, or secondary progressive), ≥12-month history of disease, age 18-65 years, and commercial health insurance. Participants completed a questionnaire including data on demographic and disease characteristics, current and earlier therapies, relapses, disability, health-related quality of life, and employment status and productivity. A unique anonymous profile was generated for each survey respondent. Each anonymous profile was linked to a number of medical and pharmacy claims datasets in the United States. Linkage rates were assessed and survey respondents’ representativeness was evaluated based on differences in the distribution of characteristics between the linked survey population and the general MS population in the claims databases. Results: The advertisement was placed on 1,063,973 Facebook users’ pages generating 68,674 clicks, 3719 survey attempts, and 651 successfully completed surveys, of which 440 could be linked to any of the claims databases for 2014 or 2015 (67.6% linkage rate). Overall, no significant differences were found between patients who were linked and not linked for educational status, ethnicity, current or prior disease-modifying therapy (DMT) treatment, or presence of a relapse in the last 12 months. The frequencies of the most common MS symptoms did not differ significantly between linked patients and the general MS population in the databases. Linked patients were slightly younger and less likely to be men than those who were not linkable. Conclusions: Linking patient-reported outcomes data, from a Web-based survey of US patients with MS recruited on open Internet platforms, to health care utilization information from claims databases may enable rapid generation of a large population of representative patients with MS suitable for outcomes analysis.

  • Woman using laptop. Image source: License: CC0 License.

    Can Facebook Be Used for Research? Experiences Using Facebook to Recruit Pregnant Women for a Randomized Controlled Trial


    Background: Recruitment is often a difficult and costly part of any human research study. Social media and other emerging means of mass communication hold promise as means to complement traditional strategies used for recruiting participants because they can reach a large number of people in a short amount of time. With the ability to target a specified audience, paid Facebook advertisements have potential to reach future research participants of a specific demographic. This paper describes the experiences of a randomized controlled trial in Edmonton, Alberta, attempting to recruit healthy pregnant women between 8 and 20 weeks’ gestation for participation in a prenatal study. Various traditional recruitment approaches, in addition to paid Facebook advertisements were trialed. Objective: To evaluate the effectiveness of paid advertisements on Facebook as a platform for recruiting pregnant women to a randomized controlled trial in comparison with traditional recruitment approaches. Methods: Recruitment using traditional approaches occurred for 7 months, whereas Facebook advertisements ran for a total of 26 days. Interested women were prompted to contact the study staff for a screening call to determine study eligibility. Costs associated with each recruitment approach were recorded and used to calculate the cost to recruit eligible participants. Performance of Facebook advertisements was monitored using Facebook Ads Manager. Results: Of the 115 women included, 39.1% (n=45) of the women who contacted study staff heard about the study through Facebook, whereas 60.9% (n=70) of them heard about it through traditional recruitment approaches. During the 215 days (~7 months) that the traditional approaches were used, the average rate of interest was 0.3 (0.2) women/day, whereas the 26 days of Facebook advertisements resulted in an average rate of interest of 2.8 (1.7) women/day. Facebook advertisements cost Can $506.91 with a cost per eligible participant of Cad $20.28. In comparison, the traditional approaches cost Cad $1087, with approximately Cad $24.15 per eligible participant. Demographic characteristics of women were similar between the 2 recruitment methods except that women recruited using Facebook were significantly earlier in their pregnancy than those recruited using traditional approaches (P<.03). Conclusions: Paid Facebook advertisements hold promise as a platform for reaching pregnant women. The relative ease of placing an advertisement, the comparable cost per participant recruited, and the dramatically improved recruitment rates in comparison with traditional approaches highlight the importance of combining novel and traditional recruitment approaches to recruit women for pregnancy-related studies. Trial Registration: NCT02711644; (Archived by WebCite at

  • Web search. Image source: License: CC0 Public Domain.

    Impact of Predicting Health Care Utilization Via Web Search Behavior: A Data-Driven Analysis


    Background: By recent estimates, the steady rise in health care costs has deprived more than 45 million Americans of health care services and has encouraged health care providers to better understand the key drivers of health care utilization from a population health management perspective. Prior studies suggest the feasibility of mining population-level patterns of health care resource utilization from observational analysis of Internet search logs; however, the utility of the endeavor to the various stakeholders in a health ecosystem remains unclear. Objective: The aim was to carry out a closed-loop evaluation of the utility of health care use predictions using the conversion rates of advertisements that were displayed to the predicted future utilizers as a surrogate. The statistical models to predict the probability of user’s future visit to a medical facility were built using effective predictors of health care resource utilization, extracted from a deidentified dataset of geotagged mobile Internet search logs representing searches made by users of the Baidu search engine between March 2015 and May 2015. Methods: We inferred presence within the geofence of a medical facility from location and duration information from users’ search logs and putatively assigned medical facility visit labels to qualifying search logs. We constructed a matrix of general, semantic, and location-based features from search logs of users that had 42 or more search days preceding a medical facility visit as well as from search logs of users that had no medical visits and trained statistical learners for predicting future medical visits. We then carried out a closed-loop evaluation of the utility of health care use predictions using the show conversion rates of advertisements displayed to the predicted future utilizers. In the context of behaviorally targeted advertising, wherein health care providers are interested in minimizing their cost per conversion, the association between show conversion rate and predicted utilization score, served as a surrogate measure of the model’s utility. Results: We obtained the highest area under the curve (0.796) in medical visit prediction with our random forests model and daywise features. Ablating feature categories one at a time showed that the model performance worsened the most when location features were dropped. An online evaluation in which advertisements were served to users who had a high predicted probability of a future medical visit showed a 3.96% increase in the show conversion rate. Conclusions: Results from our experiments done in a research setting suggest that it is possible to accurately predict future patient visits from geotagged mobile search logs. Results from the offline and online experiments on the utility of health utilization predictions suggest that such prediction can have utility for health care providers.

  • FitBit. Image sourced and copyright owned by authors.

    Accuracy of a Wrist-Worn Wearable Device for Monitoring Heart Rates in Hospital Inpatients: A Prospective Observational Study


    Background: As the sensing capabilities of wearable devices improve, there is increasing interest in their application in medical settings. Capabilities such as heart rate monitoring may be useful in hospitalized patients as a means of enhancing routine monitoring or as part of an early warning system to detect clinical deterioration. Objective: To evaluate the accuracy of heart rate monitoring by a personal fitness tracker (PFT) among hospital inpatients. Methods: We conducted a prospective observational study of 50 stable patients in the intensive care unit who each completed 24 hours of heart rate monitoring using a wrist-worn PFT. Accuracy of heart rate recordings was compared with gold standard measurements derived from continuous electrocardiographic (cECG) monitoring. The accuracy of heart rates measured by pulse oximetry (Spo2.R) was also measured as a positive control. Results: On a per-patient basis, PFT-derived heart rate values were slightly lower than those derived from cECG monitoring (average bias of −1.14 beats per minute [bpm], with limits of agreement of 24 bpm). By comparison, Spo2.R recordings produced more accurate values (average bias of +0.15 bpm, limits of agreement of 13 bpm, P<.001 as compared with PFT). Personal fitness tracker device performance was significantly better in patients in sinus rhythm than in those who were not (average bias −0.99 bpm vs −5.02 bpm, P=.02). Conclusions: Personal fitness tracker–derived heart rates were slightly lower than those derived from cECG monitoring in real-world testing and not as accurate as Spo2.R-derived heart rates. Performance was worse among patients who were not in sinus rhythm. Further clinical evaluation is indicated to see if PFTs can augment early warning systems in hospitals. Trial Registration: NCT02527408; (Archived by WebCite at

  • Patient complaining about the service. Image source URL:]. Image purchased by authors.

    Do Health Care Providers Use Online Patient Ratings to Improve the Quality of Care? Results From an Online-Based Cross-Sectional Study


    Background: Physician-rating websites have become a popular tool to create more transparency about the quality of health care providers. So far, it remains unknown whether online-based rating websites have the potential to contribute to a better standard of care. Objective: Our goal was to examine which health care providers use online rating websites and for what purposes, and whether health care providers use online patient ratings to improve patient care. Methods: We conducted an online-based cross-sectional study by surveying 2360 physicians and other health care providers (September 2015). In addition to descriptive statistics, we performed multilevel logistic regression models to ascertain the effects of providers’ demographics as well as report card-related variables on the likelihood that providers implement measures to improve patient care. Results: Overall, more than half of the responding providers surveyed (54.66%, 1290/2360) used online ratings to derive measures to improve patient care (implemented measures: mean 3.06, SD 2.29). Ophthalmologists (68%, 40/59) and gynecologists (65.4%, 123/188) were most likely to implement any measures. The most widely implemented quality measures were related to communication with patients (28.77%, 679/2360), the appointment scheduling process (23.60%, 557/2360), and office workflow (21.23%, 501/2360). Scaled-survey results had a greater impact on deriving measures than narrative comments. Multilevel logistic regression models revealed medical specialty, the frequency of report card use, and the appraisal of the trustworthiness of scaled-survey ratings to be significantly associated predictors for implementing measures to improve patient care because of online ratings. Conclusions: Our results suggest that online ratings displayed on physician-rating websites have an impact on patient care. Despite the limitations of our study and unintended consequences of physician-rating websites, they still may have the potential to improve patient care.

  • Source and copyright: the authors, License to use under CC.

    Incentive and Reminder Strategies to Improve Response Rate for Internet-Based Physician Surveys: A Randomized Experiment


    Background: Most research on how to enhance response rates in physician surveys has been done using paper surveys. Uncertainties remain regarding how to enhance response rates in Internet-based surveys. Objective: To evaluate the impact of a low-cost nonmonetary incentive and paper mail reminders (formal letter and postcard) on response rates in Internet-based physician surveys. Methods: We executed a factorial-design randomized experiment while conducting a nationally representative Internet-based physician survey. We invited 3966 physicians (randomly selected from a commercial database of all licensed US physicians) via email to complete an Internet-based survey. We used 2 randomly assigned email messages: one message offered a book upon survey completion, whereas the other did not mention the book but was otherwise identical. All nonrespondents received several email reminders. Some physicians were further assigned at random to receive 1 reminder via paper mail (either a postcard or a letter) or no paper reminder. The primary outcome of this study was the survey response rate. Results: Of the 3966 physicians who were invited, 451 (11.4%) responded to at least one survey question and 336 (8.5%) completed the entire survey. Of those who were offered a book, 345/2973 (11.6%) responded compared with 106/993 (10.7%) who were not offered a book (odds ratio 1.10, 95% CI 0.87-1.38, P=.42). Regarding the paper mail reminder, 168/1572 (10.7%) letter recipients, 148/1561 (9.5%) postcard recipients, and 69/767 (9.0%) email-only recipients responded (P=.35). The response rate for those receiving letters or postcards was similar (odds ratio 1.14, 95% CI 0.91-1.44, P=.26). Conclusions: Offering a modest nonmonetary incentive and sending a paper reminder did not improve survey response rate. Further research on how to enhance response rates in Internet-based physician surveys is needed.

  • YouTube video screenshot. Source: Use of image in accordance with YouTube fair use policy (

    Tracking Dabbing Using Search Query Surveillance: A Case Study in the United States


    Background: Dabbing is an emerging method of marijuana ingestion. However, little is known about dabbing owing to limited surveillance data on dabbing. Objective: The aim of the study was to analyze Google search data to assess the scope and breadth of information seeking on dabbing. Methods: Google Trends data about dabbing and related topics (eg, electronic nicotine delivery system [ENDS], also known as e-cigarettes) in the United States between January 2004 and December 2015 were collected by using relevant search terms such as “dab rig.” The correlation between dabbing (including topics: dab and hash oil) and ENDS (including topics: vaping and e-cigarette) searches, the regional distribution of dabbing searches, and the impact of cannabis legalization policies on geographical location in 2015 were analyzed. Results: Searches regarding dabbing increased in the United States over time, with 1,526,280 estimated searches during 2015. Searches for dab and vaping have very similar temporal patterns, where the Pearson correlation coefficient (PCC) is .992 (P<.001). Similar phenomena were also obtained in searches for hash oil and e-cigarette, in which the corresponding PCC is .931 (P<.001). Dabbing information was searched more in some western states than other regions. The average dabbing searches were significantly higher in the states with medical and recreational marijuana legalization than in the states with only medical marijuana legalization (P=.02) or the states without medical and recreational marijuana legalization (P=.01). Conclusions: Public interest in dabbing is increasing in the United States. There are close associations between dabbing and ENDS searches. The findings suggest greater popularity of dabs in the states that legalized medical and recreational marijuana use. This study proposes a novel and timely way of cannabis surveillance, and these findings can help enhance the understanding of the popularity of dabbing and provide insights for future research and informed policy making on dabbing.

  • Growing healthy app created by the authors. Image sourced and copyright owned by authors.

    A Comparison of Recruitment Methods for an mHealth Intervention Targeting Mothers: Lessons from the Growing Healthy Program


    Background: Mobile health (mHealth) programs hold great promise for increasing the reach of public health interventions. However, mHealth is a relatively new field of research, presenting unique challenges for researchers. A key challenge is understanding the relative effectiveness and cost of various methods of recruitment to mHealth programs. Objective: The objectives of this study were to (1) compare the effectiveness of various methods of recruitment to an mHealth intervention targeting healthy infant feeding practices, and (2) explore factors influencing practitioner referral to the intervention. Methods: The Growing healthy study used a quasi-experimental design with an mHealth intervention group and a concurrent nonrandomized comparison group. Eligibility criteria included: expectant parents (>30 weeks of gestation) or parents with an infant <3 months old, ability to read and understand English, own a mobile phone, ≥18 years old, and living in Australia. Recruitment to the mHealth program consisted of: (1) practitioner-led recruitment through Maternal and Child Health nurses, midwives, and nurses in general practice; (2) face-to-face recruitment by researchers; and (3) online recruitment. Participants’ baseline surveys provided information regarding how participants heard about the study, and their sociodemographic details. Costs per participant recruited were calculated by taking into account direct advertising costs and researcher time/travel costs. Practitioner feedback relating to the recruitment process was obtained through a follow-up survey and qualitative interviews. Results: A total of 300 participants were recruited to the mHealth intervention. The cost per participant recruited was lowest for online recruitment (AUD $14) and highest for practice nurse recruitment (AUD $586). Just over half of the intervention group (50.3%, 151/300) were recruited online over a 22-week period compared to practitioner recruitment (29.3%, 88/300 over 46 weeks) and face-to-face recruitment by researchers (7.3%, 22/300 over 18 weeks). No significant differences were observed in participant sociodemographic characteristics between recruitment methods, with the exception that practitioner/face-to-face recruitment resulted in a higher proportion of first-time parents (68% versus 48%, P=.002). Less than half of the practitioners surveyed reported referring to the program often or most of the time. Key barriers to practitioner referral included lack of time, difficulty remembering to refer, staff changes, lack of parental engagement, and practitioner difficulty in accessing the app. Conclusions: Online recruitment using parenting-related Facebook pages was the most cost effective and timely method of recruitment to an mHealth intervention targeting parents of young infants. Consideration needs to be given to addressing practitioner barriers to referral, to further explore if this can be a viable method of recruitment.

  • Courtesy of the Centers for Disease Control and Prevention, 2013 Tips From Former Smokers(tm) campaign.

    Does Digital Video Advertising Increase Population-Level Reach of Multimedia Campaigns? Evidence From the 2013 Tips From Former Smokers Campaign


    Background: Federal and state public health agencies in the United States are increasingly using digital advertising and social media to promote messages from broader multimedia campaigns. However, little evidence exists on population-level campaign awareness and relative cost efficiencies of digital advertising in the context of a comprehensive public health education campaign. Objective: Our objective was to compare the impact of increased doses of digital video and television advertising from the 2013 Tips From Former Smokers (Tips) campaign on overall campaign awareness at the population level. We also compared the relative cost efficiencies across these media platforms. Methods: We used data from a large national online survey of approximately 15,000 US smokers conducted in 2013 immediately after the conclusion of the 2013 Tips campaign. These data were used to compare the effects of variation in media dose of digital video and television advertising on population-level awareness of the Tips campaign. We implemented higher doses of digital video among selected media markets and randomly selected other markets to receive similar higher doses of television ads. Multivariate logistic regressions estimated the odds of overall campaign awareness via digital or television format as a function of higher-dose media in each market area. All statistical tests used the .05 threshold for statistical significance and the .10 level for marginal nonsignificance. We used adjusted advertising costs for the additional doses of digital and television advertising to compare the cost efficiencies of digital and television advertising on the basis of costs per percentage point of population awareness generated. Results: Higher-dose digital video advertising was associated with 94% increased odds of awareness of any ad online relative to standard-dose markets (P<.001). Higher-dose digital advertising was associated with a marginally nonsignificant increase (46%) in overall campaign awareness regardless of media format (P=.09). Higher-dose television advertising was associated with 81% increased odds of overall ad awareness regardless of media format (P<.001). Increased doses of television advertising were also associated with significantly higher odds of awareness of any ad on television (P<.001) and online (P=.04). The adjusted cost of each additional percentage point of population-level reach generated by higher doses of advertising was approximately US $440,000 for digital advertising and US $1 million for television advertising. Conclusions: Television advertising generated relatively higher levels of overall campaign awareness. However, digital video was relatively more cost efficient for generating awareness. These results suggest that digital video may be used as a cost-efficient complement to traditional advertising modes (eg, television), but digital video should not replace television given the relatively smaller audience size of digital video viewers.

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  • Attachment style and Internet addiction

    Date Submitted: Sep 25, 2016

    Open Peer Review Period: Sep 25, 2016 - Nov 20, 2016

    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Overall, the estimated prevalence of computer game and Internet addiction is between 3 and...

    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Overall, the estimated prevalence of computer game and Internet addiction is between 3 and 5%. Considering the fact that there is ample evidence for the relationship between attachment style and substance abuse, it stands to reason that attachment theory can also make an important contribution to the understanding of the pathogenesis of Internet addiction. Accordingly, the aim of this study was to examine people’s tendency toward pathological Internet usage in relation to their attachment style. Method: An online survey was conducted. Sociodemographic data, attachment style (Bielefeld questionnaire partnership expectations), symptoms of Internet addiction (scale for online addiction for adults), used Internet services and online relationship motives (Cyper relationship motive Scale) were assessed. In order to confirm the findings, a study using the Rorschach test was also conducted. Results: In total N = 245 subjects were recruited. Participants with insecure attachment style showed a higher tendency to pathological Internet usage compared to securely-attached participants. An ambivalent attachment style was particularly associated with pathological Internet usage. Escapist and social-compensatory motives played an important role for insecurely attached subjects. However, there were no significant effects with respect to online services and applications used. Results of the analysis of the Rorschach protocol with N = 16 subjects corroborated these results. Users with pathological Internet use frequently showed signs of infantile relationship structures in the context of social groups. This refers to the results of the online survey, in which interpersonal relationships were the result of an insecure attachment style. Conclusions: In summary, pathological Internet use was a function of insecure attachment and limited interpersonal relationships.

  • Designing patient-centered text messaging interventions for increasing physical activity among participants with Type II Diabetes: Qualitative results from the Text to Move intervention

    Date Submitted: Sep 21, 2016

    Open Peer Review Period: Sep 22, 2016 - Nov 17, 2016

    Background: The Text to Move (TTM) study was a six-month 2-parallel group randomized controlled trial of individuals with type II diabetes (T2DM) to increase physical activity, measured by a pedometer...

    Background: The Text to Move (TTM) study was a six-month 2-parallel group randomized controlled trial of individuals with type II diabetes (T2DM) to increase physical activity, measured by a pedometer. The intervention arm received twice daily text messages for 6 months that were tailored to the participant’s stage of behavior change as defined by the Transtheoretical Model of Behavior Change. Objective: The purpose of this follow-up study was to collect feedback from participants in the TTM program and explore their views on text messaging as a health promotion tool. Categorizing the perceived barriers and facilitators to the TTM program will help inform the design of future technology-based studies to maximize participant engagement. Methods: We assessed participants’ attitudes regarding their experience with text messaging, focusing on perceived barriers and facilitators, through two focus groups and telephone interviews. All interviews were audio-recorded, transcribed verbatim, coded and analyzed using a grounded theory approach. Results: The response rate was 67.4% (31/46 participants). The average age was 51 and 61% were male. The majority of individuals were English speakers and married, had completed at least 12th grade and approximately half of all participants were employed full-time. Overall, participants were satisfied with the TTM program and recalled the text messages as educational, informational, and motivational. Program involvement increased the sense of connection with their healthcare center. The wearing of pedometers and daily step count information served as motivational reminders and created a sense of accountability through the sentinel effect. However, there was frustration concerning the automation of the text message program, including the repetitiveness, predictability of text time delivery, and lack of customization and interactivity of text message content. Participants recommended personalization of texting content and frequency as well as more contact time with personnel for a stronger sense of support, including greater surveillance and feedback based on their own results and comparison to other participants. Conclusions: Participants in a theory-based text messaging intervention identified key facilitators and barriers to program efficacy that should be incorporated into future texting interventions to optimize participant satisfaction and outcomes. Clinical Trial:

  • Does usage of an e-health intervention reduce the risk of excessive gestational weight gain?

    Date Submitted: Sep 13, 2016

    Open Peer Review Period: Sep 13, 2016 - Nov 8, 2016

    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Online interventions have the potential for delivering innovative, interactive excess...

    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Online interventions have the potential for delivering innovative, interactive excessive GWG prevention to large numbers of people. Objective: This study creates a novel measure of online intervention usage patterns and examines whether online intervention usage is associated with reduced risk of excessive GWG. Methods: The online intervention was theory based and emphasized the active ingredients of weight gain tracking and behavioral goal-setting and self-monitoring. One-thousand three hundred and thirty-five (898 intervention and 437 control) relatively diverse and healthy pregnant women were randomly assigned to the intervention arms or control arm. Usage patterns were examined for both intervention and control arm participants using Latent Class Analysis. A modified Poisson regression approach was used to estimate the relative risk of excessive total or weekly GWG for women with different usage patterns. Results: Five usage patterns best characterized the usage of the intervention arm participants. Three usage patterns best characterized control arm participants’ usage. Control arm usage patterns were not associated with excessive GWG, whereas intervention arm usage patterns were associated with excessive GWG. Conclusions: The control and intervention arm usage pattern characterization is a unique methodological contribution to process evaluations for self-directed, online interventions. Clinical Trial: NCT01331564,,

  • The Sugarsquare study: a multicenter randomized controlled feasibility trial concerning a web-based patient portal for parents of a child with type 1 diabetes

    Date Submitted: Sep 10, 2016

    Open Peer Review Period: Sep 11, 2016 - Nov 6, 2016

    Background: Raising a child with type 1 diabetes (T1D) faces parents with the task of combining the demands of the disease-management with everyday parenting, which is associated with increased levels...

    Background: Raising a child with type 1 diabetes (T1D) faces parents with the task of combining the demands of the disease-management with everyday parenting, which is associated with increased levels of distress. To support parents, a web-based patient portal Sugarsquare was developed, delivering online parent-professional communication, peer support and disease information. Objective: The first aim of this study was to assess the feasibility of conducting a multicenter, randomized controlled trial concerning Sugarsquare in a population of parents of a child with T1D. The second aim was to assess the feasibility of implementing Sugarsquare in clinical practice. Methods: Hundred and five parents of 105 children with T1D under the age of 13 participated in a 6-month multicenter randomized controlled feasibility trial and were randomly assigned to an experimental (usual care + Sugarsquare) or a control group (usual care). Attrition rates and user statistics were gathered throughout the study-period for feasibility of the trial and the implementation. To determine potential efficacy of Sugarsquare, parenting stress (PSI-SF) was assessed at baseline (T0) and after six months (T1). Results: Enrollment refusal rate (58%), baseline attrition rate (25%) and post-randomization attrition rate during follow-up (26%) were all average. User statistics in the experimental group showed high practicability, integration in all users, moderate acceptability and demand in parents and high acceptability and demand in healthcare professionals. Reporting higher levels of parenting stress at baseline was related to higher frequency of logging in by parents (ρ=.282, p=.030) on Sugarsquare and higher parents’ number of page views (ρ=.304, p=.019). No significant differences in change in parenting stress between experimental and control group were found (F=.49, p=.49). Conclusions: Conducting a trial concerning an Internet intervention in a population of parents of a child with T1D can be considered feasible. Implementing Sugarsquare in clinical practice was found to be partly feasible, given the moderate demand and acceptability in parent users and lack of potential efficacy. Parents who reported higher levels of parenting stress used Sugarsquare more often. Although usage did not lead to a decrease in parenting stress, results indicate that online provision of care is suitable for parents of a child with T1D, who are in need for additional support. Future research should clarify whether incorporating targeted interventions in Sugarsquare will lead to less psychosocial problems. Factors potentially contributing to successful implementation are suggested. Clinical Trial: The study described in this paper is registered under NTR3643 (Dutch Trial Register).

  • Remote monitoring of patients with heart failure: An overview of Systematic Reviews

    Date Submitted: Sep 8, 2016

    Open Peer Review Period: Sep 9, 2016 - Nov 4, 2016

    Background: Many systematic reviews exist on Remote Patient Monitoring (RPM) interventions to improve clinical outcomes and psychological wellbeing of patients with heart failure (HF). However, resear...

    Background: Many systematic reviews exist on Remote Patient Monitoring (RPM) interventions to improve clinical outcomes and psychological wellbeing of patients with heart failure (HF). However, research is broadly distributed from simple telephone based to highly technology based interventions. The scope and focus of such evidence also vary widely, creating challenges for clinicians who seek information on the effect of RPM interventions. Objective: The aim of this article is to investigate the effects of RPM interventions on the health outcomes of HF patients by synthesising review-level evidence. Methods: We searched CINAHL, PubMed, EMBASE and the Cochrane Electronic Library from 2005 to 2015.We screened reviews based on relevance to RPM interventions using criteria developed for this overview. Using the standardised forms, we extracted information from systematic reviews. Independent authors screened, selected and assessed reviews for methodological quality. We used standardised language to summarise results across reviews and provide final statements about intervention effectiveness. Results: 19 systematic reviews met our inclusion criteria. Reviews consisted of RPM with diverse interventions such as tele-monitoring, home telehealth, mobile phone based monitoring and video conferencing. All cause and HF mortality were the most frequently-reported outcomes, but others such as quality of life, rehospitalisation, emergency visits and length of stay were also reported. Self-care and knowledge were less commonly identified. Conclusions: Tele-monitoring and home telehealth appear generally effective to improve HF rehospitalisation and to reduce mortality. Other interventions including the use of mobile phone and videoconferencing require further investigation.