JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

Recent Articles:

  • Source: National Cancer Institute; Copyright: Daniel Sone; URL:; License: Public Domain (CC0).

    Internet-Based Assessment of Oncology Health Care Professional Learning Style and Optimization of Materials for Web-Based Learning: Controlled Trial With...


    Background: Precision medicine has resulted in increasing complexity in the treatment of cancer. Web-based educational materials can help address the needs of oncology health care professionals seeking to understand up-to-date treatment strategies. Objective: This study aimed to assess learning styles of oncology health care professionals and to determine whether learning style-tailored educational materials lead to enhanced learning. Methods: In all, 21,465 oncology health care professionals were invited by email to participate in the fully automated, parallel group study. Enrollment and follow-up occurred between July 13 and September 7, 2015. Self-enrolled participants took a learning style survey and were assigned to the intervention or control arm using concealed alternating allocation. Participants in the intervention group viewed educational materials consistent with their preferences for learning (reading, listening, and/or watching); participants in the control group viewed educational materials typical of the My Cancer Genome website. Educational materials covered the topic of treatment of metastatic estrogen receptor-positive (ER+) breast cancer using cyclin-dependent kinases 4/6 (CDK4/6) inhibitors. Participant knowledge was assessed immediately before (pretest), immediately after (posttest), and 2 weeks after (follow-up test) review of the educational materials. Study statisticians were blinded to group assignment. Results: A total of 751 participants enrolled in the study. Of these, 367 (48.9%) were allocated to the intervention arm and 384 (51.1%) were allocated to the control arm. Of those allocated to the intervention arm, 256 (69.8%) completed all assessments. Of those allocated to the control arm, 296 (77.1%) completed all assessments. An additional 12 participants were deemed ineligible and one withdrew. Of the 552 participants, 438 (79.3%) self-identified as multimodal learners. The intervention arm showed greater improvement in posttest score compared to the control group (0.4 points or 4.0% more improvement on average; P=.004) and a higher follow-up test score than the control group (0.3 points or 3.3% more improvement on average; P=.02). Conclusions: Although the study demonstrated more learning with learning style-tailored educational materials, the magnitude of increased learning and the largely multimodal learning styles preferred by the study participants lead us to conclude that future content-creation efforts should focus on multimodal educational materials rather than learning style-tailored content.

  • Smartphone monitoring. Source: Ezgi Dogan; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Smartphone-Based Monitoring of Objective and Subjective Data in Affective Disorders: Where Are We and Where Are We Going? Systematic Review


    Background: Electronic mental health interventions for mood disorders have increased rapidly over the past decade, most recently in the form of various systems and apps that are delivered via smartphones. Objective: We aim to provide an overview of studies on smartphone-based systems that combine subjective ratings with objectively measured data for longitudinal monitoring of patients with affective disorders. Specifically, we aim to examine current knowledge on: (1) the feasibility of, and adherence to, such systems; (2) the association of monitored data with mood status; and (3) the effects of monitoring on clinical outcomes. Methods: We systematically searched PubMed, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials for relevant articles published in the last ten years (2007-2017) by applying Boolean search operators with an iterative combination of search terms, which was conducted in February 2017. Additional articles were identified via pearling, author correspondence, selected reference lists, and trial protocols. Results: A total of 3463 unique records were identified. Twenty-nine studies met the inclusion criteria and were included in the review. The majority of articles represented feasibility studies (n=27); two articles reported results from one randomized controlled trial (RCT). In total, six different self-monitoring systems for affective disorders that used subjective mood ratings and objective measurements were included. These objective parameters included physiological data (heart rate variability), behavioral data (phone usage, physical activity, voice features), and context/environmental information (light exposure and location). The included articles contained results regarding feasibility of such systems in affective disorders, showed reasonable accuracy in predicting mood status and mood fluctuations based on the objectively monitored data, and reported observations about the impact of monitoring on clinical state and adherence of patients to the system usage. Conclusions: The included observational studies and RCT substantiate the value of smartphone-based approaches for gathering long-term objective data (aside from self-ratings to monitor clinical symptoms) to predict changes in clinical states, and to investigate causal inferences about state changes in patients with affective disorders. Although promising, a much larger evidence-base is necessary to fully assess the potential and the risks of these approaches. Methodological limitations of the available studies (eg, small sample sizes, variations in the number of observations or monitoring duration, lack of RCT, and heterogeneity of methods) restrict the interpretability of the results. However, a number of study protocols stated ambitions to expand and intensify research in this emerging and promising field.

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

    Ontology-Based Approach to Social Data Sentiment Analysis: Detection of Adolescent Depression Signals


    Background: Social networking services (SNSs) contain abundant information about the feelings, thoughts, interests, and patterns of behavior of adolescents that can be obtained by analyzing SNS postings. An ontology that expresses the shared concepts and their relationships in a specific field could be used as a semantic framework for social media data analytics. Objective: The aim of this study was to refine an adolescent depression ontology and terminology as a framework for analyzing social media data and to evaluate description logics between classes and the applicability of this ontology to sentiment analysis. Methods: The domain and scope of the ontology were defined using competency questions. The concepts constituting the ontology and terminology were collected from clinical practice guidelines, the literature, and social media postings on adolescent depression. Class concepts, their hierarchy, and the relationships among class concepts were defined. An internal structure of the ontology was designed using the entity-attribute-value (EAV) triplet data model, and superclasses of the ontology were aligned with the upper ontology. Description logics between classes were evaluated by mapping concepts extracted from the answers to frequently asked questions (FAQs) onto the ontology concepts derived from description logic queries. The applicability of the ontology was validated by examining the representability of 1358 sentiment phrases using the ontology EAV model and conducting sentiment analyses of social media data using ontology class concepts. Results: We developed an adolescent depression ontology that comprised 443 classes and 60 relationships among the classes; the terminology comprised 1682 synonyms of the 443 classes. In the description logics test, no error in relationships between classes was found, and about 89% (55/62) of the concepts cited in the answers to FAQs mapped onto the ontology class. Regarding applicability, the EAV triplet models of the ontology class represented about 91.4% of the sentiment phrases included in the sentiment dictionary. In the sentiment analyses, “academic stresses” and “suicide” contributed negatively to the sentiment of adolescent depression. Conclusions: The ontology and terminology developed in this study provide a semantic foundation for analyzing social media data on adolescent depression. To be useful in social media data analysis, the ontology, especially the terminology, needs to be updated constantly to reflect rapidly changing terms used by adolescents in social media postings. In addition, more attributes and value sets reflecting depression-related sentiments should be added to the ontology.

  • The nurse-moderated online mothers’ group section of the intervention website (montage). Source: Women's and Children's Health Network /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Nurse-Moderated Internet-Based Support for New Mothers: Non-Inferiority, Randomized Controlled Trial


    Background: Internet-based interventions moderated by community nurses have the potential to improve support offered to new mothers, many of whom now make extensive use of the Internet to obtain information about infant care. However, evidence from population-based randomized controlled trials is lacking. Objective: The aim of this study was to test the non-inferiority of outcomes for mothers and infants who received a clinic-based postnatal health check plus nurse-moderated, Internet-based group support when infants were aged 1-7 months as compared with outcomes for those who received standard care consisting of postnatal home-based support provided by a community nurse. Methods: The design of the study was a pragmatic, preference, non-inferiority randomized control trial. Participants were recruited from mothers contacted for their postnatal health check, which is offered to all mothers in South Australia. Mothers were assigned either (1) on the basis of their preference to clinic+Internet or home-based support groups (n=328), or (2) randomly assigned to clinic+Internet or home-based groups if they declared no strong preference (n=491). The overall response rate was 44.8% (819/1827). The primary outcome was parenting self-competence, as measured by the Parenting Stress Index (PSI) Competence subscale, and the Karitane Parenting Confidence Scale scores. Secondary outcome measures included PSI Isolation, Interpersonal Support Evaluation List–Short Form, Maternal Support Scale, Ages and Stages Questionnaire–Social-Emotional and MacArthur Communicative Development Inventory (MCDI) scores. Assessments were completed offline via self-assessment questionnaires at enrolment (mean child age=4.1 weeks, SD 1.3) and again when infants were aged 9, 15, and 21 months. Results: Generalized estimating equations adjusting for post-randomization baseline imbalances showed that differences in outcomes between mothers in the clinic+Internet and home-based support groups did not exceed the pre-specified margin of inferiority (0.25 of a SD) on any outcome measure at any follow-up assessment, with the exception of MCDI scores assessing children’s language development at 21 months for randomized mothers, and PSI Isolation scores at 9 months for preference mothers. Conclusion: Maternal and child outcomes from a clinic-based postnatal health check plus nurse-moderated Internet-based support were not inferior to those achieved by a universal home-based postnatal support program. Postnatal maternal and infant support using the Internet is a promising alternative to home-based universal support programs. Trial Registration: Australian New Zealand Clinical Trials Registry Number (ANZCTR): ACTRN12613000204741; (Archived by WebCite at

  • Source: Wikimedia Commons; Copyright: William M Benson; URL:; License: Public Domain (CC0).

    Evaluating a Web-Based Coaching Program Using Electronic Health Records for Patients With Chronic Obstructive Pulmonary Disease in China: Randomized...


    Background: Chronic obstructive pulmonary disease (COPD) is now the fourth leading cause of death in the world, and it continues to increase in developing countries. The World Health Organization expects COPD to be the third most common cause of death in the world by 2020. Effective and continuous postdischarge care can help patients to maintain good health. The use of electronic health records (EHRs) as an element of community health care is new technology in China. Objective: The aim of this study was to develop and evaluate a Web-based coaching program using EHRs for physical function and health-related quality of life for patients with COPD in China. Methods: A randomized controlled trial was conducted from 2008 to 2015 at two hospitals. The control group received routine care and the intervention group received routine care with the addition of the Web-based coaching program using EHRs. These were used to manage patients’ demographic and clinical variables, publish relevant information, and have communication between patients and health care providers. Participants were not blinded to group assignment. The effects of the intervention were evaluated by lung function, including percent of forced expiratory volume in 1 second (FEV1%), percent of forced vital capacity (FVC%), peak expiratory flow (PEF), maximum midexpiratory flow; St George’s Respiratory Questionnaire (SGRQ); Modified Medical Research Council Dyspnea Scale (MMRC); and 6-Minute Walk Test (6MWT). Data were collected before the program, and at 1, 3, 6, and 12 months after the program. Results: Of the 130 participants, 120 (92.3%) completed the 12-month follow-up program. There were statistically significant differences in lung function (FEV1%: F1,4=5.47, P=.002; FVC%: F1,4=3.06, P=.02; PEF: F1,4=12.49, P<.001), the total score of SGRQ (F1,4=23.30, P<.001), symptoms of SGRQ (F1,4=12.38, P<.001), the activity of SGRQ (F1,4=8.35, P<.001), the impact of SGRQ (F1,4=12.26, P<.001), MMRC (F1,4=47.94, P<.001), and 6MWT (F1,4=35.54, P<.001) between the two groups with the variation of time tendency. Conclusions: The Web-based coaching program using EHRs in China appears to be useful for patients with COPD when they are discharged from hospital into the community. It promotes the sharing of patients’ medical information by hospital and community nurses, and achieves dynamic management and follow-up analysis for patients’ disease. In addition, this program can postpone the decreasing rate of lung function, improve quality of life, decrease dyspnea, and increase physical capacity.

  • The Dutch MS Study website. Source: Image created by the authors; Copyright: Ingrid Kremer; URL:; License: Creative Commons Attribution (CC-BY).

    Adherence to Web-Based Self-Assessments in Long-Term Direct-to-Patient Research: Two-Year Study of Multiple Sclerosis Patients


    Background: Direct-to-patient research via Web-based questionnaires is increasingly being used. Missed data or delayed reporting of data may negatively affect the quality of study results. It is insufficiently known to what degree patients adhere to agreed self-assessment schedule over the long term and whether questionnaires are filled out in a timely manner. Objective: The objective of this study was to investigate patients’ adherence to a self-assessment schedule with low-frequency long questionnaires versus that with a high-frequency short questionnaire. Methods: In this study, the 36-item MS Impact Profile (MSIP) questionnaire measured (perceived) disabilities and the 54-item MS Quality of Life-54 (MSQoL-54) questionnaire measured health-related quality of life at 6-month intervals. Additionally, the 2-item Medication and Adherence (MA) questionnaire documented medication and adherence to disease-modifying medication every month. An experienced MS nurse assessed the Expanded Disability Status Scale (EDSS) score via phone. For both the self-assessment schedules, we calculated the percentage of patients who had completed all the questionnaires in the first 2 years (completion adherence), the percentage of patients who completed all the questionnaires within set time frames (interval adherence), the relationship between adherence and the EDSS score, and the timing of EDSS assessment. Results: Of the 331 patients who enrolled themselves, 301 patients completed at least one questionnaire. At month six (M6), M12, M18, and M24, the MSIP was completed by 83.4% (251/301), 71.8% (216/301), 68.1% (205/301), and 58.5% (176/301) of the patients, respectively; the MSQoL-54 by 82.1% (247/301), 71.8% (216/301), 66.8% (201/301), and 57.1% (172/301), respectively; and the MA questionnaire by 80.1% (241/301), 70.4% (212/301), 62.1% (187/301), and 53.5% (161/301), respectively. For the MSIP, 56.8% (171/301) of the patients were 2-year completion adherent; 55.5% (167/301) and 53.5% (161/301) of the patients were completion adherent for the MSQoL-54 and MA questionnaires, respectively. Whereas 85.5% (142/166) of the patients were interval adherent for the MSIP and MSQoL-54, 25.5% (41/161) were interval adherent for the MA questionnaire, with 73.9% (119/161) exceeding the maximum MA monthly interassessment interval. Completion adherence for the monthly short MA questionnaire was higher in patients with moderately high disability (EDSS 5.0-5.5) than for those with no or minimal disability (EDSS 0-2.5) (OR 5.47, 95% CI 1.08-27.69; P=.040). Completion adherence was also higher in patients with EDSS assessment within 6 months after baseline than in those with later assessment (OR 1.810, 95% CI 0.999-3.280; P=.050). Conclusions: The 2-year completion adherence to Web-based self-assessments did not differ between the low-frequency long questionnaires and a high-frequency short questionnaire, but the interval adherence was substantially higher for the low-frequency long questionnaires. Personal contact with a member of the research team regarding a clinically relevant professional-reported outcome early in the study might positively affect the long-term completion adherence in direct-to-patient studies.

  • Source: Flickr; Copyright: Senado Federal; URL:; License: Creative Commons Attribution (CC-BY).

    Development and Use of Health-Related Technologies in Indigenous Communities: Critical Review


    Background: Older Indigenous adults encounter multiple challenges as their age intersects with health inequities. Research suggests that a majority of older Indigenous adults prefer to age in place, and they will need culturally safe assistive technologies to do so. Objective: The aim of this critical review was to examine literature concerning use, adaptation, and development of assistive technologies for health purposes by Indigenous peoples. Methods: Working within Indigenous research methodologies and from a decolonizing approach, searches of peer-reviewed academic and gray literature dated to February 2016 were conducted using keywords related to assistive technology and Indigenous peoples. Sources were reviewed and coded thematically. Results: Of the 34 sources captured, only 2 concerned technology specifically for older Indigenous adults. Studies detailing technology with Indigenous populations of all ages originated primarily from Canada (n=12), Australia (n=10), and the United States (n=9) and were coded to four themes: meaningful user involvement and community-based processes in development, the digital divide, Indigenous innovation in technology, and health technology needs as holistic and interdependent. Conclusions: A key finding is the necessity of meaningful user involvement in technology development, especially in communities struggling with the digital divide. In spite of, or perhaps because of this divide, Indigenous communities are enthusiastically adapting mobile technologies to suit their needs in creative, culturally specific ways. This enthusiasm and creativity, coupled with the extensive experience many Indigenous communities have with telehealth technologies, presents opportunity for meaningful, culturally safe development processes.

  • Source:; Copyright: Vichaya Kiatying-Angsulee; URL:; License: Licensed by the authors.

    Adolescents’ Perspectives on Personalized E-Feedback in the Context of Health Risk Behavior Screening for Primary Care: Qualitative Study


    Background: Electronic health screening tools for primary care present an opportunity to go beyond data collection to provide education and feedback to adolescents in order to motivate behavior change. However, there is limited research to guide feedback message development. Objective: The aim of this study was to explore youth perceptions of and preferences for receiving personalized feedback for multiple health risk behaviors and reinforcement for health promoting behaviors from an electronic health screening tool for primary care settings, using qualitative methodology. Methods: In total, 31 adolescents aged 13-18 years completed the screening tool, received the electronic feedback, and subsequently participated in individual, semistructured, qualitative interviews lasting approximately 60 min. Participants were queried about their overall impressions of the tool, perceptions regarding various types of feedback messages, and additional features that would help motivate health behavior change. Using thematic analysis, interview transcripts were coded to identify common themes expressed across participants. Results: Overall, the tool was well-received by participants who perceived it as a way to enhance—but not replace—their interactions with providers. They appreciated receiving nonjudgmental feedback from the tool and responded positively to information regarding the consequences of behaviors, comparisons with peer norms and health guidelines, tips for behavior change, and reinforcement of healthy choices. A small but noteworthy minority of participants dismissed the peer norms as not real or relevant and national guidelines as not valid or reasonable. When prompted for possible adaptations to the tool, adolescents expressed interest in receiving follow-up information, setting health-related goals, tracking their behaviors over time, and communicating with providers electronically between appointments. Conclusions: Adolescents in this qualitative study desired feedback that validates their healthy behavior choices and supports them as independent decision makers by neutrally presenting health information, facilitating goal setting, and offering ongoing technological supports.

  • Source: The Authors; Copyright: Leanwer; URL:; License: Creative Commons Attribution (CC-BY).

    Social Media Engagement and HIV Testing Among Men Who Have Sex With Men in China: A Nationwide Cross-Sectional Survey


    Background: Many interventions find that social media engagement with health promotion materials can translate into behavioral changes. However, only a few studies have examined the ways in which specific actions on various social media platforms are correlated with health behaviors. Objective: The objective of this study was to examine the association between social media use and HIV testing behaviors among Chinese men who have sex with men (MSM). Methods: In July 2016, a Web-based survey was conducted to recruit MSM in 8 Chinese cities through Blued (Blue City Holdings Ltd.), the world’s largest gay mobile phone app. Data on sociodemographic variables, social media use platforms and behaviors, sexual behaviors, and HIV testing histories were collected. HIV testing–related social media use was defined as having ever engaged with HIV testing content on social media, which was further divided into observing (ie, receiving), endorsing (eg, liking and sharing), and contributing (eg, posting or commenting on HIV testing materials). Confirmatory factor analysis (CFA) was conducted to determine the best division of HIV testing–related social media use. Univariate and multivariable logistic regressions were used to examine the association between HIV testing–related social media use and HIV testing behaviors. Results: A total of 2105 individuals participated in the survey. Among them, 46.75% (984) were under the age of 24 years, 35.43% (746) had high school education or less, and 47.74% (587) had condomless sex in the last 3 months. More than half of the respondents (58.14%, 1224/2105) reported HIV testing–related social media use. Additionally, HIV testing–related social media use, especially on multifunctional platforms such as WeChat, was found to be associated with recent HIV testing (adjusted odds ratio [aOR] 2.32, 95% CI 1.66-3.24). Contributing on social media was correlated with recent HIV testing (aOR 2.10, 95% CI 1.40-3.16), but neither observing (aOR 0.66, 95% CI 0.38-1.15) nor endorsing (aOR 1.29, 95% CI 0.88-1.90) were correlated. Conclusions: Our data suggest that social media use, particularly on multifunctional platforms such as WeChat and with contributing behaviors, is correlated with HIV testing among MSM in China. Campaigns that promote active participant contribution on social media beyond passive observation and endorsement of promotional materials are needed. This study has implications for the design and implementation of social media interventions to promote HIV testing.

  • Source: Flickr; Copyright: Daniel Horacio Agostini; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Youth Oriented Activity Trackers: Comprehensive Laboratory- and Field-Based Validation


    Background: Commercial activity trackers are growing in popularity among adults and some are beginning to be marketed to children. There is, however, a paucity of independent research examining the validity of these devices to detect physical activity of different intensity levels. Objectives: The purpose of this study was to determine the validity of the output from 3 commercial youth-oriented activity trackers in 3 phases: (1) orbital shaker, (2) structured indoor activities, and (3) 4 days of free-living activity. Methods: Four units of each activity tracker (Movband [MB], Sqord [SQ], and Zamzee [ZZ]) were tested in an orbital shaker for 5-minutes at three frequencies (1.3, 1.9, and 2.5 Hz). Participants for Phase 2 (N=14) and Phase 3 (N=16) were 6-12 year old children (50% male). For Phase 2, participants completed 9 structured activities while wearing each tracker, the ActiGraph GT3X+ (AG) research accelerometer, and a portable indirect calorimetry system to assess energy expenditure (EE). For Phase 3, participants wore all 4 devices for 4 consecutive days. Correlation coefficients, linear models, and non-parametric statistics evaluated the criterion and construct validity of the activity tracker output. Results: Output from all devices was significantly associated with oscillation frequency (r=.92-.99). During Phase 2, MB and ZZ only differentiated sedentary from light intensity (P<.01), whereas the SQ significantly differentiated among all intensity categories (all comparisons P<.01), similar to AG and EE. During Phase 3, AG counts were significantly associated with activity tracker output (r=.76, .86, and .59 for the MB, SQ, and ZZ, respectively). Conclusions: Across study phases, the SQ demonstrated stronger validity than the MB and ZZ. The validity of youth-oriented activity trackers may directly impact their effectiveness as behavior modification tools, demonstrating a need for more research on such devices.

  • Wikipedia pages related to autoimmune disorders (montage). Source: The Authors / Freepik; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Readability of Wikipedia Pages on Autoimmune Disorders: Systematic Quantitative Assessment


    Background: In the era of new information and communication technologies, the Internet is being increasingly accessed for health-related information. Indeed, recently published patient surveys of people with autoimmune disorders confirmed that the Internet was reported as one of the most important health information sources. Wikipedia, a free online encyclopedia launched in 2001, is generally one of the most visited websites worldwide and is often consulted for health-related information. Objective: The main objective of this investigation was to quantitatively assess whether the Wikipedia pages related to autoimmune disorders can be easily accessed by patients and their families, in terms of readability. Methods: We obtained and downloaded a list of autoimmune disorders from the American Autoimmune Related Diseases Association (AARDA) website. We analyzed Wikipedia articles for their overall level of readability with 6 different quantitative readability scales: (1) the Flesch Reading Ease, (2) the Gunning Fog Index, (3) the Coleman-Liau Index, (4) the Flesch-Kincaid Grade Level, (5) the Automated Readability Index (ARI), and (6) the Simple Measure of Gobbledygook (SMOG). Further, we investigated the correlation between readability and clinical, pathological, and epidemiological parameters. Moreover, each Wikipedia analysis was assessed according to its content, breaking down the readability indices by main topic of each part (namely, pathogenesis, treatment, diagnosis, and prognosis plus a section containing paragraphs not falling into any of the previous categories). Results: We retrieved 134 diseases from the AARDA website. The Flesch Reading Ease yielded a mean score of 24.34 (SD 10.73), indicating that the sites were very difficult to read and best understood by university graduates, while mean Gunning Fog Index and ARI scores were 16.87 (SD 2.03) and 14.06 (SD 2.12), respectively. The Coleman-Liau Index and the Flesch-Kincaid Grade Level yielded mean scores of 14.48 (SD 1.57) and 14.86 (1.95), respectively, while the mean SMOG score was 15.38 (SD 1.37). All the readability indices confirmed that the sites were suitable for a university graduate reading level. We found no correlation between readability and clinical, pathological, and epidemiological parameters. Differences among the different sections of the Wikipedia pages were statistically significant. Conclusions: Wikipedia pages related to autoimmune disorders are characterized by a low level of readability. The onus is, therefore, on physicians and health authorities to improve the health literacy skills of patients and their families and to create, together with patients themselves, disease-specific readable sites, disseminating highly accessible health-related online information, in terms of both clarity and conciseness.

  • Source:; Copyright: blackzheep; URL:; License: Licensed by the authors.

    Ecological Momentary Assessment of Physical Activity: Validation Study


    Background: Ecological momentary assessment (EMA) may elicit physical activity (PA) estimates that are less prone to bias than traditional self-report measures while providing context. Objectives: The objective of this study was to examine the convergent validity of EMA-assessed PA compared with accelerometry. Methods: The participants self-reported their PA using International Physical Activity Questionnaire (IPAQ) and Behavioral Risk Factor Surveillance System (BRFSS) and wore an accelerometer while completing daily EMAs (delivered through the mobile phone) for 7 days. Weekly summary estimates included sedentary time and moderate-, vigorous-, and moderate-to vigorous-intensity physical activity (MVPA). Spearman coefficients and Lin’s concordance correlation coefficients (LCC) examined the linear association and agreement for EMA and the questionnaires as compared with accelerometry. Results: Participants were aged 43.3 (SD 13.1) years, 51.7% (123/238) were African American, 74.8% (178/238) were overweight or obese, and 63.0% (150/238) were low income. The linear associations of EMA and traditional self-reports with accelerometer estimates were statistically significant (P<.05) for sedentary time (EMA: ρ=.16), moderate-intensity PA (EMA: ρ=.29; BRFSS: ρ=.17; IPAQ: ρ=.24), and MVPA (EMA: ρ=.31; BRFSS: ρ=.17; IPAQ: ρ=.20). Only EMA estimates of PA were statistically significant compared with accelerometer for agreement. Conclusions: The mobile EMA showed better correlation and agreement to accelerometer estimates than traditional self-report methods. These findings suggest that mobile EMA may be a practical alternative to accelerometers to assess PA in free-living settings.

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  • Enhancing Outcomes of Non-Communicable Diseases Care in Rural Settings and Refugee Camps: Could Low-cost mHealth Interventions Make a Difference?

    Date Submitted: Jul 24, 2017

    Open Peer Review Period: Jul 24, 2017 - Sep 18, 2017

    Background: Rural areas and refugee camps are characterized by poor access of patients to needed NCD-related health services, including diabetes and hypertension. Employing low-cost innovative eHealth...

    Background: Rural areas and refugee camps are characterized by poor access of patients to needed NCD-related health services, including diabetes and hypertension. Employing low-cost innovative eHealth interventions such as mobile health (mHealth) may help improve NCDs prevention and control among disadvantaged populations through delivering NCD-targeted care. Objective: Assess the effect of employing low-cost mHealth tools on the accessibility to health services and health outcomes of individuals with NCDs residing in rural areas and refugee camps in Lebanon. Methods: This is a randomized control trial study in which centers were allocated randomly into control and intervention sites. The effect of an employed mHealth intervention is assessed through selected quality indicators (QIs) examined in both control and intervention groups. Sixteen primary healthcare centers (8 controls, 8 interventions) located in rural areas and Palestinian refugee camps across Lebanon were included in this study. Data on diabetic and hypertensive patients- 1433 in the intervention groups and 926 in the control groups was extracted from patient files in the pre and post intervention periods. The intervention entailed weekly SMS messages including medical information, importance of compliance and reminders of appointments/ regular physician follow-up. QIs included results of Blood Pressure (BP), Glycosylated hemoglobin (HbA1c), smoking status, and dates of last visit for HbA1c testing, eye check-up, and foot exam. Descriptive analysis of baseline characteristics of participants, bivariate analysis, logistic regression, and linear regression were conducted using SPSS. Statistical significance was set at p-value of 0.05. Results: Bivariate analysis of QIs indicated that the intervention group had a significant increase in BP control (p= 0.03), as well as a significant decrease in the mean Systolic Blood Pressure (SBP) (p=0.02), mean HbA1c (p<0.01) and in the proportion of HbA1c poor control (p=0.02). Separate regression models controlling for age, gender, and setting, showed a 28% increase in the odds of BP control (p=0.05) and a 38% decrease in the odds of HbA1c poor control (p=0.04) among the intervention group in the post-test period. Females were at a lower odds of HbA1c poor control (p=0.01) and age was statistically associated with annual HbA1c testing (p<0.01). Regression models for mean SBP, mean Diastolic Blood Pressure, and mean HbA1c showed that a mean decrease in HbA1c of 0.87% (p<0.01) pre-test to post-test period was observed among the intervention group. Patients in rural areas belonging to the intervention group had a lower HbA1c score as compared to those in refugee camps (p<0.01). Conclusions: This study underlines the importance of employing integrative approaches of diseases prevention and control in which existing NCD programs in underserved communities (i.e. rural and refugee camps settings) can be coupled with innovative, low-cost approaches such as mHealth to provide an effective and amplified effect of traditional NCD-targeted care, that can be reflected by improved clinical outcomes among the population.

  • Reliability and Validity of the Telephone-Based eHealth Literacy Scale: Evidence from Data Collected among Older Adults

    Date Submitted: Jul 21, 2017

    Open Peer Review Period: Jul 21, 2017 - Sep 15, 2017

    Background: Only a handful of studies have examined reliability and validity evidence of scores produced by the 8-item eHealth literacy Scale (eHEALS) among older adults. Older adults are generally mo...

    Background: Only a handful of studies have examined reliability and validity evidence of scores produced by the 8-item eHealth literacy Scale (eHEALS) among older adults. Older adults are generally more comfortable responding to survey items when asked by a real person rather than by completing self-administered paper-and-pencil or online questionnaires. However, no studies have explored the psychometrics of this scale when administered to older adults over the telephone. Objective: Examine the reliability and internal structure of eHEALS data collected from older adults over the age of 50 responding to items over the telephone. Methods: Respondents completed eHEALS as part of a cross-sectional landline telephone survey. Exploratory structural equation modeling (E-SEM) analyses examined model fit of eHEALS scores with 1-, 2-, and 3-factor structures. Subsequent analyses based on the Partial Credit Model (PCM) explored the internal structure of eHEALS data. Results: Compared to 1- and 2-factor models, the 3-factor eHEALS structure showed the best global E-SEM model fit indices (RMSEA=0.07; CFI=1.0; TLI=1.0). Nonetheless, the 3 factors were highly correlated (r = 0.36 - 0.65). Item analyses revealed that eHEALS items 2 through 5 were over-fit to a minor degree (mean square infit/outfit values < 1.0; t-statistics < -2.0), but the internal structure of Likert scale response options functioned as expected. Over-fitting eHEALS items (2-5) displayed a similar degree of information for respondents at similar points on the latent continuum. Test information curves suggested that eHEALS may capture more information about older adults at the higher-end of the latent continuum (i.e., those with high eHealth literacy), as compared to those at the lower end of the continuum (i.e., those with low eHealth literacy). Item reliability (value=.92) and item separation (value=11.31) estimates indicated that eHEALS responses were reliable and stable. Conclusions: Results support administering eHEALS over the telephone when surveying older adults regarding their use of the Internet for health information. eHEALS scores best captured 3-factors (or subscales) to measure eHealth literacy in older adults; however, statistically significant correlations between these 3 factors suggest an overarching unidimensional structure with three underlying dimensions. As older adults continue to use the Internet more frequently to find and evaluate health information, it will be important to modify the original eHEALS to adequately measure societal shifts in online health information seeking among aging populations.

  • An Efficient Automated Classification Approach for Free-text Medical Narratives using Word Embedding and Convolutional Neural Networks

    Date Submitted: Jul 20, 2017

    Open Peer Review Period: Jul 21, 2017 - Sep 15, 2017

    Background: Automated disease code classification using free-text medical information is important for public health surveillance. However, traditional natural language processing (NLP) pipelines are...

    Background: Automated disease code classification using free-text medical information is important for public health surveillance. However, traditional natural language processing (NLP) pipelines are limited, so a method combining word embedding with a convolutional neural network (CNN) is proposed. Objective: We conducted a classification task identifying chapter-level ICD-10-CM diagnosis codes in discharge notes and compared the performance of traditional pipelines (NLP + supervised machine learning models) with that of word embedding combined with a CNN. Methods: Two classification methods are presented: (1) some features (terms, n-gram phrases, and SNOMED CT categories) are extracted from discharge notes and used to train a set of supervised machine learning models (support vector machine, random forests, and gradient boosting machine); (2) a feature matrix is built by a pre-trained word embedding model and used to train a CNN. These methods were used to identify the chapter-level ICD-10-CM diagnosis codes in a set of discharge notes. An evaluation was conducted using 103,390 discharge notes covering patients hospitalized from June 1, 2015 to January 31, 2017 in the Tri-Service General Hospital. The receiver operating characteristic curve was used as an evaluation measure, and the area under the curve (AUC) was taken as a global measure of effectiveness. Results: In five-fold cross-validation tests, our method had a higher testing accuracy (a mean AUC of 0.9696) than traditional NLP-based approaches (a mean AUC of 0.8183–0.9571). A real-world simulation that split the training sample and testing sample by date verified this result (a mean AUC of 0.9645 using the proposed method). Further analysis showed that the convolutional layers of the CNN effectively identified a large number of keywords and automatically extracted enough concepts to predict the diagnosis codes. Conclusions: Word embedding combined with a CNN shows outstanding performance compared with traditional methods, and it needs hardly any data pre-processing. This shows that future studies will not be limited by incomplete dictionaries. A large amount of unstructured information from free-text medical writing will be extracted by automated approaches in the future, and we believe that the healthcare field is about to enter the age of big data.

  • Use of social network services for communication among health professionals: a systematic review

    Date Submitted: Jul 20, 2017

    Open Peer Review Period: Jul 20, 2017 - Sep 14, 2017

    Background: Social network services (SNSs) are subject to tremendous exploitation in health communication. Although much research has been done investigating the roles of SNSs in linking patients and...

    Background: Social network services (SNSs) are subject to tremendous exploitation in health communication. Although much research has been done investigating the roles of SNSs in linking patients and health professionals, there is a lack of evidence on their uses, benefits and limitations in connecting health professionals. Objective: This review aimed to examine the utilization of SNSs for communication among health professionals in (1) frontline clinical practice, (2) professional networks and (3) education and training, so as to identify areas for future health communication research. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of the literature published in the last ten years (1 January 2007–1 March 2017) was performed in March 2017, using the following electronic databases: Medline via OvidSP, Embase, CINAHL Complete and InfoSci Journals. The searches were performed using the following defined search terms: ‘social media’ OR ‘social network’ OR ‘social network site’ OR ‘Facebook’ OR ‘Twitter’ OR ‘Linkedin’ OR ‘Instagram’ OR ‘Weibo’ OR ‘Whatsapp’ OR ‘Telegram’ OR ‘WeChat’ AND ‘health’ OR ‘health profession’. Results: A total of 32 studies were included in this review. They were exploratory in nature, and the majority utilized surveys, interviews and content analysis. The most reported SNSs were Twitter, Facebook, WhatsApp Messenger and LinkedIn. All retrieved studies stated that SNSs enhanced effective communication and information sharing. In clinical practice, SNSs were used for supporting operations, making referrals, and disseminating guidelines. They were beneficial in network building and professional collaboration. SNSs were novel tools to enhance educational interactions among peers, students, instructors and preceptors. Yet, the application of SNSs for professional communication came with restraints in technical knowledge and techniques. Concerns regarding data protection, privacy and liability should be addressed by proper institutional policy and training. Conclusions: SNSs create a new dimension in communication among health professionals. Expanding professional networks, disseminating multimedia information and producing positive learning experiences are the benefits observed. The evolving use of SNSs necessitates that health professionals match the pace of development. Further robust research such as randomized controlled trials is required to explore the full potential and relative effectiveness of SNSs in professional communication.

  • Using a Refined Process Evaluation Model to Assess an Online Organ Donation Educational Intervention

    Date Submitted: Jul 19, 2017

    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public...

    Background: The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public commitment to organ donation through the broad reach of web-based, behavioral interventions. Implementing Internet interventions, however, presents some challenges, including preventing fraudulent respondents and ensuring intervention uptake. While web-based organ donation interventions have increased in recent years, process evaluation models fit for web-based interventions are lacking. Objective: This study outlines a refined process evaluation model adapted for online settings and used to assess the implementation of an online intervention aimed to increase organ donation among African Americans. Methods: We used a randomized pretest-posttest control design to assess the effectiveness of the intervention website, which addressed barriers to organ donation through corresponding videos. Eligible participants were African American adult residents of Georgia who were not registered on the state donor registry. Drawing from previously developed process constructs, we adapted reach (the extent to which the target population was recruited into the study), recruitment (online mechanism used to recruit participants), dose received (intervention uptake) and context (how the online setting influenced study implementation) for Internet settings, and used the adapted model to assess the implementation of our online intervention. Results: Reach: 1,415 individuals completed the eligibility screener; 948 (67.0%) were determined eligible, of which 918 (96.8%) completed the study. After eliminating duplicate entries (n=17), those who did not initiate the post-test (n=21) and those with an invalid ZIP code (n=108), 772 valid entries remained. Per the IP address analysis, only 23 of the 772 valid entries (3.8%) respondents were within Georgia, and only 17 of those were considered unique entries and could be considered for analyses. Recruitment: 517 of the 772 valid entries (67.0%) of participants were recruited from an online recruiter. Dose received: No videos from the intervention website were watched in their entirety, and the average viewing duration was 17 seconds over the minimum. Context: Context analysis provided us with valuable insights into factors in the Internet environment that may have affected study implementation. Although only active for a brief period of time, the advertisement may have contributed the largest volume of fraudulent responses. Conclusions: We determined fraud and low uptake to be serious threats to this study and further confirmed the importance of conducting a process evaluation to identify such threats. We suggest checking participants’ IP addresses prior to study initiation, selecting software that allows for automatic duplicate protection and tightening minimum requirements for intervention uptake. Further research is needed to understand how process evaluation models can be used to monitor implementation of online studies.

  • Security and Privacy Concerns Regarding Genetic Data in Mobile Health Record Systems: An Empirical Study from Turkey

    Date Submitted: Jul 19, 2017

    Open Peer Review Period: Jul 19, 2017 - Sep 13, 2017

    Background: In today’s health services, it has become a necessity to keep patients’ health data in electronic format. There are many theories and considerable research on the design of electronic...

    Background: In today’s health services, it has become a necessity to keep patients’ health data in electronic format. There are many theories and considerable research on the design of electronic health record applications. As the use of genetic testing, and applications of bioinformatics is increasing in healthcare, genetic and genomic information needs to be included within these systems. Objective: In this study, we carried out a descriptive survey with 174 participants to acquire their views on the privacy and the security of mobile health record systems and inclusion of their genetic data in these systems. Methods: An online survey and an on-site survey in the two genetic diagnostic centers were conducted to reach patients or relatives of patients that had undergone genetic testing. Descriptive statistics is used to summarize the data. Results: Nearly half of the participants or their relatives (48.9%) had undergone genetic testing. Doctors are the only profession group that people trust for the privacy of their health and genetic information (61.2%); however, people chose to limit even their doctor’s access to their genetic/medical records (52.5%). Majority of the respondents (94%) prefer to keep full access right option only for themselves. The regulations and security measurements are suggested in the questionnaire are found to be acceptable by the majority of the respondents. A significant amount of participants had bad experiences and prejudices about electronic health records: 9.7 % of respondents’ medical records were used or released without their consents, 15.1 % stated that they had avoided being tested because of violation risks, and 3.5 % asked their doctors to enter a less embarrassing health status into their records. Also our analysis showed that participants attribute special importance to their genetic records, as significantly more participants stated that storing genetic records in a mobile system is more risky compared to other health records (P=.00). Conclusions: People have various negative experiences and there are plenty of information disclosure events in the media; hence people have concerns about the privacy and security of their health and genetic data. The results of our survey showed that people would like to see security measurements and regulations to protect their privacy, before they start to use any application to keep track of their health/genetic data. They also would like to have sole control on these applications. Personal Health Record (PHR) applications offers solutions to the data management problem as an electronic system, since they enable the users to have full control over their records.