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

Recent Articles:

  • App-based prevention teaser. Image sourced and copyright owned by authors Copyright Titus J. Brinker et al.

    Photoaging Mobile Apps in School-Based Tobacco Prevention: The Mirroring Approach


    Background: Most smokers start smoking during their early adolescence, often with the idea that smoking is glamorous. Adolescent smoking can best be prevented through health education at schools. Interventions that take advantage of the broad availability of mobile phones as well as adolescents’ interest in their appearance may be a novel way to improve prevention. Objective: In this first pilot study, we aimed to use mobile phone technology in accordance with the theory of planned behavior to improve school-based tobacco prevention. Methods: We used a free photoaging mobile phone app (“Smokerface”) in three German secondary schools via a novel method called mirroring. The students’ altered three-dimensional selfies on mobile phones or tablets were “mirrored” via a projector in front of their whole grade. Using an anonymous questionnaire, we then measured on a 5-point Likert scale the perceptions of the intervention among 125 students of both genders (average age 12.75 years). Results: A majority of the students perceived the intervention as fun (77/125, 61.6%), claimed that the intervention motivated them not to smoke (79/125, 63.2%), and stated that they learned new benefits of non-smoking (81/125, 64.8%). Only a minority of students disagreed or fully disagreed that they learned new benefits of non-smoking (16/125, 12.8%) or that they were themselves motivated not to smoke (18/125, 14.4%). Conclusions: We have presented a novel method to integrate photoaging in school-based tobacco prevention that affects student peer groups and considers the predictors of smoking in accordance with the theory of planned behavior.

  • Creating and maintaining good health. Image created and copyright owned by Authors Anjali Gopalan et al.

    Health-Specific Information and Communication Technology Use and Its Relationship to Obesity in High-Poverty, Urban Communities: Analysis of a...


    Background: More than 35% of American adults are obese. For African American and Hispanic adults, as well as individuals residing in poorer or more racially segregated urban neighborhoods, the likelihood of obesity is even higher. Information and communication technologies (ICTs) may substitute for or complement community-based resources for weight management. However, little is currently known about health-specific ICT use among urban-dwelling people with obesity. Objective: We describe health-specific ICT use and its relationship to measured obesity among adults in high-poverty urban communities. Methods: Using data collected between November 2012 and July 2013 from a population-based probability sample of urban-dwelling African American and Hispanic adults residing on the South Side of Chicago, we described patterns of ICT use in relation to measured obesity defined by a body mass index (BMI) of ≥30 kg/m2. Among those with BMI≥30 kg/m2, we also assessed the association between health-specific ICT use and diagnosed versus undiagnosed obesity as well as differences in health-specific ICT use by self-reported comorbidities, including diabetes and hypertension. Results: The survey response rate was 44.6% (267 completed surveys/598.4 eligible or likely eligible individuals); 53.2% were African American and 34.6% were Hispanic. More than 35% of the population reported an annual income of less than US $25,000. The population prevalence of measured obesity was 50.2%. People with measured obesity (BMI≥30 kg/m2) were more likely to report both general (81.5% vs 67.0%, P=.04) and health-specific (61.1% vs 41.2%, P=.01) ICT use. In contrast, among those with measured obesity, being told of this diagnosis by a physician was not associated with increased health-specific ICT use. People with measured obesity alone had higher rates of health-specific use than those with comorbid hypertension and/or diabetes diagnoses (77.1% vs 60.7% vs 47.4%, P=.04). Conclusions: In conclusion, ICT-based health resources may be particularly useful for people in high-poverty urban communities with isolated measured obesity, a population that is at high risk for poor health outcomes.

  • Correlation coefficients between Google Flu Trends and influenza-related emergency department visits for individual cities over the total time series (2005-2011). Correlations range from .672 (yellow) to .925 (red).

    Google Flu Trends Spatial Variability Validated Against Emergency Department Influenza-Related Visits


    Background: Influenza is a deadly and costly public health problem. Variations in its seasonal patterns cause dangerous surges in emergency department (ED) patient volume. Google Flu Trends (GFT) can provide faster influenza surveillance information than traditional CDC methods, potentially leading to improved public health preparedness. GFT has been found to correlate well with reported influenza and to improve influenza prediction models. However, previous validation studies have focused on isolated clinical locations. Objective: The purpose of the study was to measure GFT surveillance effectiveness by correlating GFT with influenza-related ED visits in 19 US cities across seven influenza seasons, and to explore which city characteristics lead to better or worse GFT effectiveness. Methods: Using Healthcare Cost and Utilization Project data, we collected weekly counts of ED visits for all patients with diagnosis (International Statistical Classification of Diseases 9) codes for influenza-related visits from 2005-2011 in 19 different US cities. We measured the correlation between weekly volume of GFT searches and influenza-related ED visits (ie, GFT ED surveillance effectiveness) per city. We evaluated the relationship between 15 publically available city indicators (11 sociodemographic, two health care utilization, and two climate) and GFT surveillance effectiveness using univariate linear regression. Results: Correlation between city-level GFT and influenza-related ED visits had a median of .84, ranging from .67 to .93 across 19 cities. Temporal variability was observed, with median correlation ranging from .78 in 2009 to .94 in 2005. City indicators significantly associated (P<.10) with improved GFT surveillance include higher proportion of female population, higher proportion with Medicare coverage, higher ED visits per capita, and lower socioeconomic status. Conclusions: GFT is strongly correlated with ED influenza-related visits at the city level, but unexplained variation over geographic location and time limits its utility as standalone surveillance. GFT is likely most useful as an early signal used in conjunction with other more comprehensive surveillance techniques. City indicators associated with improved GFT surveillance provide some insight into the variability of GFT effectiveness. For example, populations with lower socioeconomic status may have a greater tendency to initially turn to the Internet for health questions, thus leading to increased GFT effectiveness. GFT has the potential to provide valuable information to ED providers for patient care and to administrators for ED surge preparedness.

  • Visual analogy of resuming the quit attempt after a lapse; original from the program. Image sourced, created and copyright owned by authors Marianne T. S. Holter et al.

    How a Fully Automated eHealth Program Simulates Three Therapeutic Processes: A Case Study


    Background: eHealth programs may be better understood by breaking down the components of one particular program and discussing its potential for interactivity and tailoring in regard to concepts from face-to-face counseling. In the search for the efficacious elements within eHealth programs, it is important to understand how a program using lapse management may simultaneously support working alliance, internalization of motivation, and behavior maintenance. These processes have been applied to fully automated eHealth programs individually. However, given their significance in face-to-face counseling, it may be important to simulate the processes simultaneously in interactive, tailored programs. Objective: We propose a theoretical model for how fully automated behavior change eHealth programs may be more effective by simulating a therapist’s support of a working alliance, internalization of motivation, and managing lapses. Methods: We show how the model is derived from theory and its application to Endre, a fully automated smoking cessation program that engages the user in several “counseling sessions” about quitting. A descriptive case study based on tools from the intervention mapping protocol shows how each therapeutic process is simulated. Results: The program supports the user’s working alliance through alliance factors, the nonembodied relational agent Endre and computerized motivational interviewing. Computerized motivational interviewing also supports internalized motivation to quit, whereas a lapse management component responds to lapses. The description operationalizes working alliance, internalization of motivation, and managing lapses, in terms of eHealth support of smoking cessation. Conclusions: A program may simulate working alliance, internalization of motivation, and lapse management through interactivity and individual tailoring, potentially making fully automated eHealth behavior change programs more effective.

  • Source:; CC0 Public Domain.

    Does a Mobile Phone Depression-Screening App Motivate Mobile Phone Users With High Depressive Symptoms to Seek a Health Care Professional’s Help?


    Background: The objective of disease screening is to encourage high-risk subjects to seek health care diagnosis and treatment. Mobile phone apps can effectively screen mental health conditions, including depression. However, it is not known how effective such screening methods are in motivating users to discuss the obtained results of such apps with health care professionals. Does a mobile phone depression-screening app motivate users with high depressive symptoms to seek health care professional advice? This study aimed to address this question. Method: This was a single-cohort, prospective, observational study of a free mobile phone depression app developed in English and released on Apple’s App Store. Apple App Store users (aged 18 or above) in 5 countries, that is, Australia, Canada, New Zealand (NZ), the United Kingdom (UK), and the United States (US), were recruited directly via the app’s download page. The participants then completed the Patient Health Questionnaire (PHQ-9), and their depression screening score was displayed to them. If their score was 11 or above and they had never been diagnosed with depression before, they were advised to take their results to their health care professional. They were to follow up after 1 month. Results: A group of 2538 participants from the 5 countries completed PHQ-9 depression screening with the app. Of them, 322 participants were found to have high depressive symptoms and had never been diagnosed with depression, and received advice to discuss their results with health care professionals. About 74% of those completed the follow-up; approximately 38% of these self-reported consulting their health care professionals about their depression score. Only positive attitude toward depression as a real disease was associated with increased follow-up response rate (odds ratio (OR) 3.2, CI 1.38-8.29). Conclusions: A mobile phone depression-screening app motivated some users to seek a depression diagnosis. However, further study should investigate how other app users use the screening results provided by such apps.

  • Image source and copyright: the authors Christiane et al.

    “The Record is Our Work Tool!”—Physicians’ Framing of a Patient Portal in Sweden


    Background: Uppsala County in Sweden launched an eHealth patient portal in 2012, which allows patients to access their medical records over the Internet. However, the launch of the portal was critically debated in the media. The professionals were strongly skeptical, and one reason was possible negative effects on their work environment. This study hence investigates the assumptions and perspectives of physicians to understand their framing of the patient portal in relation to their work environment. Objective: The study uses the concept of technological frames to examine how physicians in different specialties make sense of the patient portal in relation to their work environment. Methods: A total of 12 semistructured interviews were conducted with physicians from different specialties. Interviews were transcribed and translated. A theoretically informed thematic analysis was performed. Results: The thematic analysis revealed 4 main themes: work tool, process, workload, and control. Physicians perceive medical records as their work tool, written for communication within health care only. Considering effects on work environment, the physicians held a negative attitude and expected changes, which would affect their work processes in a negative way. Especially the fact that patients might read their test results before the physician was seen as possibly harmful for patients and as an interference with their established work practices. They expected the occurrence of misunderstandings and needs for additional explanations, which would consequently increase their workload. Other perceptions were that the portal would increase controlling and monitoring of physicians and increase or create a feeling of mistrust from patients. Regarding benefits for the patients, most of the physicians believe there is only little value in the patient portal and that patients would mostly be worried and misunderstand the information provided. Conclusions: Supported by the study, we conclude: (1) The transfer of a paper-based health care process where patients read on paper into a digital process challenges current work practices and has consequences for the work environment. Mostly, this is explained by the changing positions between the physicians and the patient: the latter can drive the process, which reduces the physicians’ ability to guide the patient. (2) The physicians’ experiences were expressed as worries: patients would not understand the content of the record and become unnecessarily anxious from misunderstandings. The concerns are to some extent based on a generalized view of patients, which might disregard those, who already actively participate in health care. This study hence reveals a need to provide physicians with information about the values for patients from using patient portals. (3) A change of work practices may be beneficial to increase patient participation, but such changes should preferably be designed and discussed with physicians. However, the strong resistance from the physicians made this challenging when launching the patient portal.

  • Image Source: Doctor greating patient, copyright Vic,,
Licensed under Creative Commons Attribution cc-by 2.0

    Changing Mental Health and Positive Psychological Well-Being Using Ecological Momentary Interventions: A Systematic Review and Meta-analysis


    Background: Mental health problems are highly prevalent, and there is need for the self-management of (mental) health. Ecological momentary interventions (EMIs) can be used to deliver interventions in the daily life of individuals using mobile devices. Objectives: The aim of this study was to systematically assess and meta-analyze the effect of EMI on 3 highly prevalent mental health outcomes (anxiety, depression, and perceived stress) and positive psychological outcomes (eg, acceptance). Methods: PsycINFO and Web of Science were searched for relevant publications, and the last search was done in September 2015. Three concepts were used to find publications: (1) mental health, (2) mobile phones, and (3) interventions. A total of 33 studies (using either a within- or between-subject design) including 43 samples that received an EMI were identified (n=1301), and relevant study characteristics were coded using a standardized form. Quality assessment was done with the Cochrane Collaboration tool. Results: Most of the EMIs focused on a clinical sample, used an active intervention (that offered exercises), and in over half of the studies, additional support by a mental health professional (MHP) was given. The EMI lasted on average 7.48 weeks (SD=6.46), with 2.80 training episodes per day (SD=2.12) and 108.25 total training episodes (SD=123.00). Overall, 27 studies were included in the meta-analysis, and after removing 6 outliers, a medium effect was found on mental health in the within-subject analyses (n=1008), with g=0.57 and 95% CI (0.45-0.70). This effect did not differ as function of outcome type (ie, anxiety, depression, perceived stress, acceptance, relaxation, and quality of life). The only moderator for which the effect varied significantly was additional support by an MHP (MHP-supported EMI, g=0.73, 95% CI: 0.57-0.88; stand-alone EMI, g=0.45, 95% CI: 0.22-0.69; stand-alone EMI with access to care as usual, g=0.38, 95% CI: 0.11-0.64). In the between-subject studies, 13 studies were included, and a small to medium effect was found (g=0.40, 95% CI: 0.22-0.57). Yet, these between-subject analyses were at risk for publication bias and were not suited for moderator analyses. Furthermore, the overall quality of the studies was relatively low. Conclusions: Results showed that there was a small to medium effect of EMIs on mental health and positive psychological well-being and that the effect was not different between outcome types. Moreover, the effect was larger with additional support by an MHP. Future randomized controlled trials are needed to further strengthen the results and to determine potential moderator variables. Overall, EMIs offer great potential for providing easy and cost-effective interventions to improve mental health and increase positive psychological well-being.

  • Image of the educative intervention. Source and copyright: the authors.

    Decreased Body Mass Index in Schoolchildren After Yearlong Information Sessions With Parents Reinforced With Web and Mobile Phone Resources: Community Trial


    Background: The obesity pandemic has now reached children, and households should change their lifestyles to prevent it. Objective: The objective was to assess the effect of a comprehensive intervention on body mass index z-score (BMIZ) in schoolchildren. Methods: A yearlong study was conducted at 4 elementary schools in Mexico City. Intervention group (IG) and control group (CG) were split equally between governmental and private schools. Three educational in-person parents and children sessions were held at 2-month intervals to promote healthy eating habits and exercise. To reinforce the information, a website provided extensive discussion on a new topic every 2 weeks, including school snack menus and tools to calculate body mass index in children and adults. Text messages were sent to parents’ mobile phones reinforcing the information provided. The IG contained 226 children and CG 181 children. We measured their weight and height and calculated BMIZ at 0, 6, and 12 months. Results: The CG children showed a change of +0.06 (95% CI 0.01, 0.11) and +0.05 (95% CI 0.01, 0.10) in their BMIZ at 6 and 12 months, respectively. The BMIZ of IG children decreased by -0.13 (95% CI -0.19 to -0.06) and -0.10 (95% CI -0.16 to -0.03), respectively, and the effect was greater in children with obesity. Conclusions: The comprehensive intervention tested had beneficial effects, preserved the BMIZ of normal weight children, and reduced the BMIZ of children with obesity.

  • Image source: Pixabay, CC0 Public Domain.

    Technology-Based Innovations to Foster Personalized Healthy Lifestyles and Well-Being: A Targeted Review


    Background: New community-based arrangements and novel technologies can empower individuals to be active participants in their health maintenance, enabling people to control and self-regulate their health and wellness and make better health- and lifestyle-related decisions. Mobile sensing technology and health systems responsive to individual profiles combined with cloud computing can expand innovation for new types of interoperable services that are consumer-oriented and community-based. This could fuel a paradigm shift in the way health care can be, or should be, provided and received, while lessening the burden on exhausted health and social care systems. Objective: Our goal is to identify and discuss the main scientific and engineering challenges that need to be successfully addressed in delivering state-of-the-art, ubiquitous eHealth and mHealth services, including citizen-centered wellness management services, and reposition their role and potential within a broader context of diverse sociotechnical drivers, agents, and stakeholders. Methods: We review the state-of-the-art relevant to the development and implementation of eHealth and mHealth services in critical domains. We identify and discuss scientific, engineering, and implementation-related challenges that need to be overcome to move research, development, and the market forward. Results: Several important advances have been identified in the fields of systems for personalized health monitoring, such as smartphone platforms and intelligent ubiquitous services. Sensors embedded in smartphones and clothes are making the unobtrusive recognition of physical activity, behavior, and lifestyle possible, and thus the deployment of platforms for health assistance and citizen empowerment. Similarly, significant advances are observed in the domain of infrastructure supporting services. Still, many technical problems remain to be solved, combined with no less challenging issues related to security, privacy, trust, and organizational dynamics. Conclusions: Delivering innovative ubiquitous eHealth and mHealth services, including citizen-centered wellness and lifestyle management services, goes well beyond the development of technical solutions. For the large-scale information and communication technology-supported adoption of healthier lifestyles to take place, crucial innovations are needed in the process of making and deploying usable empowering end-user services that are trusted and user-acceptable. Such innovations require multidomain, multilevel, transdisciplinary work, grounded in theory but driven by citizens’ and health care professionals’ needs, expectations, and capabilities and matched by business ability to bring innovation to the market.

  • Screen-shot from the Online workshop.

    Benefits of Diabetes Self-Management for Health Plan Members: A 6-Month Translation Study


    Background: Diabetes self-management education has been shown to be effective in controlled trials. However, few programs that meet American Association of Diabetes Educators standards have been translated into widespread practice. Objective: This study examined the translation of the evidence-based Better Choices, Better Health-Diabetes program in both Internet and face-to-face versions. Methods: We administered the Internet program nationally in the United States (n=1010). We conducted face-to-face workshops in Atlanta, Georgia; Indianapolis, Indiana; and St. Louis, Missouri (n=232). Self-report questionnaires collected health indicator, health behavior, and health care utilization measures. Questionnaires were administered on the Web or by mail. We determined hemoglobin A1c (HbA1c) from blood samples collected via mailed kits. Paired t tests determined whether changes between baseline and 6 months differed significantly from no change. Subgroup analyses determined whether participants with specific conditions benefited (high HbA1c, depression, hypoglycemia, nonadherence to medication taking, and no aerobic exercise). We calculated the percentage of participants with improvements of at least 0.4 effect size in at least one of the 5 above measures. Results: Of the 1242 participants, 884 provided 6-month follow-up questionnaires. There were statistically significant improvements in 6 of 7 health indicators (including HbA1c) and in 7 of 7 behaviors. For each of the 5 conditions, there were significant improvements among those with the condition (effect sizes 0.59–1.1). A total of 662 (75.0%) of study participants improved at least 0.4 effect size in at least one criterion, and 327 (37.1%) improved in 2 or more. Conclusions: The Diabetes Self-Management Program, offered in two modes, was successfully disseminated to a heterogeneous national population of members of either insured or administered health plans. Participants had small but significant benefits in multiple measures. The program appears effective in improving diabetes management.

  • LetThemKNow. Image sourced and copyright owned by Authors Rebecca J Guy et al.

    Evaluation of Chlamydia Partner Notification Practices and Use of the “Let Them Know” Website by Family Planning Clinicians in Australia: Cross-Sectional...


    Background: Chlamydia, caused by Chlamydia trachomatis, is the most common reportable infection in many developed countries. Testing, treatment, and partner notification (PN) are key strategies for chlamydia control. In 2008 the Let Them Know (LTK) PN website was established, which provided means for people to send anonymous PN messages by text messaging (short message service, SMS), email, or letter. Objective: We evaluated PN practices among Australian family planning clinicians following chlamydia diagnosis and assessed how often clinicians refer their patients to the LTK website. Methods: A mixed methods approach included a Web-based cross-sectional survey of Australian family planning clinicians to examine PN attitudes and practices and focus groups to explore the context of LTK website use. Results: Between May 2012 and June 2012, all clinicians from 29 different family planning services (n=212) were invited to complete the survey, and 164 participated (response rate=77.4%); of the clinicians, 96.3% (158/164) were females, 56.1% (92/164) nurses, and 43.9% (72/164) doctors. More than half (62.2%, 92/148) agreed that PN was primarily the client's responsibility; however, 93.2% (138/148) agreed it was the clinician's responsibility to support the client in informing their partners by providing information or access to resources. Almost half (49.4%, 76/154) of the clinicians said that they always or usually referred clients to the LTK website, with variation across clinics in Australian states and territories (0%-77%). Eleven focus groups among 70 clinicians at 11 family planning services found that the LTK website had been integrated into routine practice; that it was particularly useful for clients who found it difficult to contact partners; and that the LTK letters and fact sheets were useful. However, many clinicians were not aware of the website and noted a lack of internal clinic training about LTK. Conclusions: The LTK website has become an important PN tool for family planning clinicians. The variation in referral of patients to the LTK website and lack of awareness among some clinicians suggest further promotion of the website, PN training, and clinic protocols are warranted.

  • Image Source: Cinderella's Using WiFi. Image sourced and Copyright owned by David Goehring. Licensed under Creative Commons Attribution cc-by 2.0

    Participation in an Intensive Longitudinal Study with Weekly Web Surveys Over 2.5 Years


    Background: Technological advances have made it easier for researchers to collect more frequent longitudinal data from survey respondents via personal computers, smartphones, and other mobile devices. Although technology has led to an increase in data-intensive longitudinal studies, little is known about attrition from such studies or the differences between respondents who complete frequently administered surveys in a timely manner, and respondents who do not. Objective: We examined respondent characteristics and behaviors associated with continued and on-time participation in a population-based intensive longitudinal study, using weekly web-based survey interviews over an extended period. Methods: We analyzed data from the Relationship Dynamics and Social Life study, an intensive longitudinal study that collected weekly web-based survey interviews for 2.5 years from 1003 18- and 19-year-olds to investigate factors shaping the dynamics of their sexual behavior, contraceptive use, and pregnancies. Results: Ordinary least squares and logistic regression analyses showed background respondent characteristics measured at baseline were associated with the number of days respondents remained enrolled in the study, the number of interviews they completed, and the odds that they were late completing interviews. In addition, we found that changes in pregnancy-related behaviors reported in the weekly interviews were associated with late completion of interviews. Specifically, after controlling for sociodemographic, personality, contact information, and prior experience variables, we found that weekly reports such as starting to have sex (odds ratio [OR] 1.17, 95% CI 1.03-1.32, P=.01), getting a new partner (OR 1.76, 95% CI 1.53-2.03, P<.001), stopping the use of contraception (OR 1.28, 95% CI 1.10-1.49, P=.001), and having a new pregnancy (OR 5.57, 95% CI 4.26-7.29, P<.001) were significantly associated with late survey completion. However, young women who reported changes in pregnancy-related behaviors also had lower levels of study attrition, and completed more interviews overall, than did their counterparts. Conclusions: We found that measures of participation in a longitudinal study with weekly web surveys varied not only by respondent characteristics, but also by behaviors measured across the surveys. Our analyses suggest that respondents who experience the behaviors measured by the study may maintain higher participation levels than respondents who do not experience those behaviors.

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  • A Multimedia Child Developmental Screening Checklist-Design and Validation

    Date Submitted: Jun 26, 2016

    Open Peer Review Period: Jun 26, 2016 - Aug 21, 2016

    Background: Identifying disability early in life confers long-term benefits for children. To detect those who need help early, judicious use of practical and reliable standardized screening tools is o...

    Background: Identifying disability early in life confers long-term benefits for children. To detect those who need help early, judicious use of practical and reliable standardized screening tools is of great importance. Objective: This study intended to construct the multimedia version child development checklists, and investigate the measurement equivalence of this multimedia version to the original text-based paper-and-pencil version. Methods: In order to develop the multimedia version of the Taipei City Child Development Screening tool, Second Version (Taipei II), a team of experts created illustrations, translations, and dubbing of the original checklists. The developmental process lasted approximately 10 months. The developmental screening test was administered to a total of 390 primary caregivers of children aged between 4 months and 6 years. Results: Psychometric testing revealed excellent agreement between the paper and multimedia versions. Good to excellent reliabilities were demonstrated for all age groups for both the cross-mode similarity (ICCmode range = 0.85-0.96) and test–retest reliability (r = 0.93). Regarding usability, 98% of the participants preferred the multimedia version because of its dynamic illustrations and explanatory dubbing. Conclusions: The multimedia tool produced essentially equivalent results to the paper-and-pencil tool, in addition to numerous advantages. It can facilitate active participation and promote early screening of target populations. Clinical Trial: NCT02359591

  • LGBT health-care disparities in Multiple Sclerosis: a cross-sectional web-based study in Italy

    Date Submitted: Jun 25, 2016

    Open Peer Review Period: Jun 25, 2016 - Aug 20, 2016

    Background: Lesbian, gay, bisexual and transgender (LGBT) patients might experience unique difficulties and barriers to treatment of chronic diseases related to their sexual orientation. Objective: To...

    Background: Lesbian, gay, bisexual and transgender (LGBT) patients might experience unique difficulties and barriers to treatment of chronic diseases related to their sexual orientation. Objective: To investigate health-care disparities experienced by LGBT patients with multiple sclerosis (MS). Methods: We conducted a survey on an Italian social-network ( for MS patients, by using standardized multiple-choice questions. The survey investigated: socio-demographic factors, lifestyle habits, MS-related health status and LGBT specific issues (e.g. friendliness to their sexual orientation or homophobic behaviors from the staff of their MS Center). Results: LGBT patients were associated with a smaller number of psychological consultations, compared to heterosexuals (Coeff.=-0.449; p<0.001; 95%CI=-0.682--0.217). LGBT patients were more likely to change MS Center, compared to heterosexuals (OR=2.064; p=0.046; 95%CI=1.011-4.212). The number of MS Center changes was associated with MS Center friendliness (p=0.037; rho=-0.229) and with the occurrence of homophobic behaviors (p=0.036; rho=0.234). Conclusions: LGBT MS patients more frequently changed MS Center and had a reduced use of psychological services, compared to heterosexuals. The attitude towards LGBT MS patients might affect resource utilizations and, possibly, LGBTs’ health status.

  • Costs and Cost-Effectiveness of a Web-Based Physical Activity Intervention for Spanish Speaking Latinas

    Date Submitted: Jun 22, 2016

    Open Peer Review Period: Jun 22, 2016 - Aug 17, 2016

    Background: Latinas report particularly low levels of physical activity (PA), and suffer from greater rates of lifestyle-related conditions such as obesity and diabetes. Interventions are needed that...

    Background: Latinas report particularly low levels of physical activity (PA), and suffer from greater rates of lifestyle-related conditions such as obesity and diabetes. Interventions are needed that can increase physical activity in this growing population in a large-scale, cost-effective manner. Web-based interventions may have potential given the increase in Internet use among Latinos and the scalability of web-based programs. Objective: To examine the costs and cost-effectiveness of a web-based Spanish language PA intervention for Latinas compared to a contact control. Methods: Healthy adult Latinas (N=205) were recruited from the community and randomly assigned to receive a Spanish language web-based individually-tailored PA intervention (Intervention), or were given access to a website with content on wellness topics other than PA (Control). PA was measured by 7-Day Physical Activity Recall Interview and ActiGraph accelerometer at baseline, 6 months (post-intervention) and 12 months (maintenance phase). Costs were estimated from a payer perspective and included all features necessary to implement the intervention in a community setting, including staff time (wage, benefits and overhead), materials, hardware, website hosting, and routine website maintenance. Results: At 6 months, the cost of the Intervention and Control groups were $17/month and $8/month, respectively. These fell to $12 and $6 at 12 months. Linear interpolation showed Intervention participants increased their PA by 1362 total minutes at six months (523 by accelerometer) compared to 715 minutes in Controls (186 by accelerometer). At six months, each minute increase in PA for the Intervention cost $0.08 ($0.20 by accelerometer), compared to $0.07 in Controls ($0.26 by accelerometer). Incremental costs per minute increase associated with the intervention were $0.08 at six months and $0.04 at 12 months ($0.16 and $0.08 by accelerometer, respectively). Sensitivity analyses showed variations in staffing costs or intervention effectiveness yielded only modest changes in incremental costs. Conclusions: While the web-based PA intervention was more expensive than the wellness control, both were quite low cost compared to face-to-face or mail-delivered interventions. Cost-effectiveness ranged markedly based on physical activity measure, and was similar between the two conditions. Overall, the web-based intervention was effective and low cost, suggesting a promising channel for increasing PA on a large scale in this at-risk population. Clinical Trial: NCT01834287

  • Happy, a Smartphone-based Intervention to Promote Cancer Prevention Behaviors: Usability and Feasibility Study

    Date Submitted: Jun 22, 2016

    Open Peer Review Period: Jun 22, 2016 - Aug 17, 2016

    Background: Estimates predict that more than half of all cancers are due to inadequate lifestyle choices. Smartphones can be successfully used to support the behavior change needed to prevent cancer....

    Background: Estimates predict that more than half of all cancers are due to inadequate lifestyle choices. Smartphones can be successfully used to support the behavior change needed to prevent cancer. Objective: The purpose of this study was to field-test Happy, a smartphone app designed to promote cancer prevention behaviors, based on tailored-messages deliver. Methods: Thirty-two participants downloaded and used the app for 28 consecutive days (4 weeks). At the end of this period, they all answered to an online questionnaire and ten of them were interviewed. Usability, feasibility, message receptivity, and perceived impact of the app were assessed. Results: Compliance with cancer prevention guidelines was lower than expected. Happy was considered simple, intuitive and easy to use. Messages sent by the app were considered easy to understand, providing good advices and meaningful information that grabbed reader’s attention. Participants also considered that Happy might be an effective way to promote cancer prevention. Behavioral data collected during the trial showed an increase in several cancer prevention behaviors and a significant increase in the overall cancer prevention level, 7 points in average (P=.031). Conclusions: This study showed the viability of designing and implementing smartphone-based interventions to promote cancer prevention behaviors. The results suggest that Happy is usable and might help users change their behavior, making healthier choices, thus reducing their personal risk of developing cancer.

  • Internet and adolescents: use and access, behavior, cyberbullying and grooming. Results of an investigative whole city survey.

    Date Submitted: Jun 21, 2016

    Open Peer Review Period: Jun 21, 2016 - Aug 16, 2016

    Background: According to the Digital Agenda for Europe, the way children use Internet and mobile technologies changed dramatically in the past years. Objective: This study aims to break down the modal...

    Background: According to the Digital Agenda for Europe, the way children use Internet and mobile technologies changed dramatically in the past years. Objective: This study aims to break down the modalities of access and use of the Internet by teenagers to assess risks and risky behaviours and to provide scientific data to evaluate and counsel safe use of the Internet and new technologies by teenagers. Methods: The study was conducted under the program “Strategies for a better internet for children” started in May 2012 by the European Commission. It represents the main result of the project launched by Telecom Italia “Anche io ho qualcosa da dire” (I too have something to say) thanks to which many of contributions were collected and used to develop a survey. The questionnaire was structured in 45 questions, covering three macro areas of interest and it was approved by the Department Board at UMG’s School of Medicine. After authorization from the regional high school authority, it was administered to all 1534 students (aged 13 to 19) in the city of Catanzaro, Italy. Results: The data has been broken down into three main groups: describing education and access to the Internet, methods of use and social networking and finally perception and evaluation of risk and risky behaviours. Among noteworthy results in the first group we can mention that the average age of first contact with information technologies was around 9 years old. Moreover, 79% of the interviewed students reported the access to a smartphone or a tablet. Among the results of the second group we find that the most used social networks were Facebook (85%), Youtube (61%), and Google+ (52%). 72% of the interviewed teenagers use their name and surname on social networks. 40% of them knew all their Facebook contacts personally. Among the results of the third group we find that 7,7% of the interviewed teenagers have uploaded pictures or movies that they feel ashamed of. 27% have received invitations from people they met on the Internet to meet in real life, and 8,4% have accepted such invitations. Conclusions: The results offer a breakdown of the teenagers’ use of the Internet, focusing on how teenagers learn to use and access it considering factors such as parental coaching, schooling or self-education. It describes how they approach and interact with social networks, and how they perceive risks and/or risky behaviours in a virtual environment. Information technology must be seen as an instrument and not as a hindrance. For this to happen parental guidance, schooling, and medical counseling are needed for a sound evolution of the child in this critical stage of development.

  • WhatsApp Messenger as an Adjunctive Tool for Medical Internet: A Review

    Date Submitted: Jun 17, 2016

    Open Peer Review Period: Jun 17, 2016 - Aug 12, 2016

    Background: The advent of medical internet has allowed physicians to deliver medical treatment to patients from a distance. Mobile applications such as WhatsApp Messenger, an instant messaging service...

    Background: The advent of medical internet has allowed physicians to deliver medical treatment to patients from a distance. Mobile applications such as WhatsApp Messenger, an instant messaging service, came as a novel concept in all fields of medicine. The use of instant messaging services has been shown to improve communication within medical teams by providing means for quick teleconsultation, information sharing, and starting treatment as soon as possible. Objective: The aim of the current study was to perform a comprehensive systematic review of present literature on the use of the WhatsApp Messenger application as an adjunctive healthcare tool. Methods: Searches were performed in PubMed, Embase, and the Cochrane Library using the term whatsapp* in articles published before January 2016. A bibliography of all relevant original articles that used the WhatsApp Messenger application was created. The impact and the indications of WhatsApp Messenger are discussed in order to understand the extent to which this application currently functions an adjunctive tool for telemedicine. Results: The database search identified a total of 30 studies in which the term whatsapp* was used. Each article’s list of references was evaluated item by item. After review articles, letters to the editor, and low-quality studies were excluded, a total of 10 studies were found to be eligible for inclusion. Of these studies, nine had been published in the English language and one had been published in Spanish. Conclusions: The pooled data presents compelling evidence that the WhatsApp Messenger application is a promising system, whether used as a communication tool between healthcare professionals, as a means of communication between healthcare professionals and the general public, or as a learning tool for providing healthcare information to professionals or to the general population. However, high-quality and properly evaluated research is needed, as are improvements in descriptions of the methodology and the study processes. These improvements will allow WhatsApp Messenger to be categorically defined as an effective telemedicine tool in many different fields of healthcare.