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 4.7 for 2013

Recent Articles:

  • Stressless.
Credit: Image taken by Michael Mehring in Paracas/Peru. Dr Mehring holds the image copyright.

    Effects of a Web-Based Intervention for Stress Reduction in Primary Care: A Cluster Randomized Controlled Trial


    Background: Preliminary findings suggest that Web-based interventions may be effective in achieving significant stress reduction. To date, there are no findings available for primary care patients. This is the first study that investigates a Web-based intervention for stress reduction in primary care. Objective: The aim was to examine the short-term effectiveness of a fully automated Web-based coaching program regarding stress reduction in a primary care setting. Methods: The study was an unblinded cluster randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily text message reminders, and weekly feedback through the Internet. All components of the program were fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was change in the Perceived Stress Questionnaire (PSQ) over 12 weeks. Results: A total of 93 participants (40 in intervention group, 53 in control group) were recruited into the study. For 25 participants from the intervention group and 49 participants from the control group, PSQ scores at baseline and 12 weeks were available. In the intention-to-treat analysis, the PSQ score decreased by mean 8.2 (SD 12.7) in the intervention group and by mean 12.6 (SD 14.7) in the control group. There was no significant difference identified between the groups (mean difference –4.5, 95% CI –10.2 to 1.3, P=.13). Conclusions: This trial could not show that the tested Web-based intervention was effective for reducing stress compared to usual care. The limited statistical power and the high dropout rate may have reduced the study’s ability to detect significant differences between the groups. Further randomized controlled trials are needed with larger populations to investigate the long-term outcome as well as the contents of usual primary care. Trial Registration: German Clinical Trials Register DRKS00003067; (Archived by WebCite at


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No attribution required.

    Examining the Relationship Between Past Orientation and US Suicide Rates: An Analysis Using Big Data-Driven Google Search Queries


    Background: Internet search query data reflect the attitudes of the users, using which we can measure the past orientation to commit suicide. Examinations of past orientation often highlight certain predispositions of attitude, many of which can be suicide risk factors. Objective: To investigate the relationship between past orientation and suicide rate by examining Google search queries. Methods: We measured the past orientation using Google search query data by comparing the search volumes of the past year and those of the future year, across the 50 US states and the District of Columbia during the period from 2004 to 2012. We constructed a panel dataset with independent variables as control variables; we then undertook an analysis using multiple ordinary least squares regression and methods that leverage the Akaike information criterion and the Bayesian information criterion. Results: It was found that past orientation had a positive relationship with the suicide rate (P≤.001) and that it improves the goodness-of-fit of the model regarding the suicide rate. Unemployment rate (P≤.001 in Models 3 and 4), Gini coefficient (P≤.001), and population growth rate (P≤.001) had a positive relationship with the suicide rate, whereas the gross state product (P≤.001) showed a negative relationship with the suicide rate. Conclusions: We empirically identified the positive relationship between the suicide rate and past orientation, which was measured by big data-driven Google search query.

  • Examples of text messages participants can opt to receive (left) and reward notifications on the main website (right).

    Effectiveness of an Activity Tracker- and Internet-Based Adaptive Walking Program for Adults: A Randomized Controlled Trial


    Background: The benefits of physical activity are well documented, but scalable programs to promote activity are needed. Interventions that assign tailored and dynamically adjusting goals could effect significant increases in physical activity but have not yet been implemented at scale. Objective: Our aim was to examine the effectiveness of an open access, Internet-based walking program that assigns daily step goals tailored to each participant. Methods: A two-arm, pragmatic randomized controlled trial compared the intervention to no treatment. Participants were recruited from a workplace setting and randomized to a no-treatment control (n=133) or to treatment (n=132). Treatment participants received a free wireless activity tracker and enrolled in the walking program, Walkadoo. Assessments were fully automated: activity tracker recorded primary outcomes (steps) without intervention by the participant or investigators. The two arms were compared on change in steps per day from baseline to follow-up (after 6 weeks of treatment) using a two-tailed independent samples t test. Results: Participants (N=265) were 66.0% (175/265) female with an average age of 39.9 years. Over half of the participants (142/265, 53.6%) were sedentary (<5000 steps/day) and 44.9% (119/265) were low to somewhat active (5000-9999 steps/day). The intervention group significantly increased their steps by 970 steps/day over control (P<.001), with treatment effects observed in sedentary (P=.04) and low-to-somewhat active (P=.004) participants alike. Conclusions: The program is effective in increasing daily steps. Participants benefited from the program regardless of their initial activity level. A tailored, adaptive approach using wireless activity trackers is realistically implementable and scalable. Trial Registration: NCT02229409, (Archived by WebCite at

  • A physician engaged in a pre-op consultation.
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    Positive Clinical Outcomes Are Synergistic With Positive Educational Outcomes When Using Telehealth Consulting in General Practice: A Mixed-Methods Study


    Background: The use of telehealth technology to enable real-time consultations between patients and specialist services (to whom travel may be an impediment to the patient’s care) has recently been encouraged in Australia through financial incentives. However, the uptake has been both fragmented and inconsistent. The potential benefits for patients include access to a broader range of specialist referral services, cost and time saving, and more rapid access to specialist services and a continuum of care through the triangulation of interaction between patient, primary health care providers (general practitioners and nurses), and specialists. Enhanced broadband connectivity and higher-grade encryption present an opportunity to trial the use of telehealth consulting as an intrinsic element of medical education for both medical students and doctors-in-training within rural practices and Aboriginal Medical Services. Objective: This paper discusses the reported, and varied, benefits of telehealth consulting arising from a multisite trial in New South Wales, Australia. The purpose of this study is to encourage the use of selected telehealth consultations between patients in a primary care setting with a specialist service as an integral aspect of medical education. Methods: The trial closely followed the protocol developed for this complex and multiaspect intervention. This paper discuses one aspect of the research protocol—using telehealth consultations for medical education—in detail. Results: Qualitative and quantitative analyses were conducted. In the quantitative analysis, free-text comments were made on aspects of Telehealth Consulting for the patient, concerning the quality of the interactions, and the time and cost saving, and also on the leaning opportunities. Students commented that their involvement enhanced their learning. All respondents agreed or strongly agreed that that the interpersonal aspects were satisfactory, with some brief comments supporting their views. In the analysis of the qualitative data, five themes emerged from the analyses concerning the educational benefits of Telehealth Consulting for different levels of learners, while three themes were identified concerning clinical benefits. Conclusions: The results demonstrated strong synergies between the learning derived from the telehealth consulting and the clinical benefits to the patient and clinicians involved.

  • Gene-based feedback and change in physical activity. This image was created by Cyril (author) using materials made available according to the Creative Commons Attribution license 3.0.

    Changes in Physical Activity Following a Genetic-Based Internet-Delivered Personalized Intervention: Randomized Controlled Trial (Food4Me)


    Background: There is evidence that physical activity (PA) can attenuate the influence of the fat mass- and obesity-associated (FTO) genotype on the risk to develop obesity. However, whether providing personalized information on FTO genotype leads to changes in PA is unknown. Objective: The purpose of this study was to determine if disclosing FTO risk had an impact on change in PA following a 6-month intervention. Methods: The single nucleotide polymorphism (SNP) rs9939609 in the FTO gene was genotyped in 1279 participants of the Food4Me study, a four-arm, Web-based randomized controlled trial (RCT) in 7 European countries on the effects of personalized advice on nutrition and PA. PA was measured objectively using a TracmorD accelerometer and was self-reported using the Baecke questionnaire at baseline and 6 months. Differences in baseline PA variables between risk (AA and AT genotypes) and nonrisk (TT genotype) carriers were tested using multiple linear regression. Impact of FTO risk disclosure on PA change at 6 months was assessed among participants with inadequate PA, by including an interaction term in the model: disclosure (yes/no) × FTO risk (yes/no). Results: At baseline, data on PA were available for 874 and 405 participants with the risk and nonrisk FTO genotypes, respectively. There were no significant differences in objectively measured or self-reported baseline PA between risk and nonrisk carriers. A total of 807 (72.05%) of the participants out of 1120 in the personalized groups were encouraged to increase PA at baseline. Knowledge of FTO risk had no impact on PA in either risk or nonrisk carriers after the 6-month intervention. Attrition was higher in nonrisk participants for whom genotype was disclosed (P=.01) compared with their at-risk counterparts. Conclusions: No association between baseline PA and FTO risk genotype was observed. There was no added benefit of disclosing FTO risk on changes in PA in this personalized intervention. Further RCT studies are warranted to confirm whether disclosure of nonrisk genetic test results has adverse effects on engagement in behavior change. Trial Registration: NCT01530139; (Archived by WebCite at:

  • Image Source: Stockphoto by Rocketclips, licensed from Fotolia

    What Predicts Patients’ Willingness to Undergo Online Treatment and Pay for Online Treatment? Results from a Web-Based Survey to Investigate the Changing...


    Background: Substantial research has focused on patients’ health information–seeking behavior on the Internet, but little is known about the variables that may predict patients’ willingness to undergo online treatment and willingness to pay additionally for online treatment. Objective: This study analyzed sociodemographic variables, psychosocial variables, and variables of Internet usage to predict willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the general practitioner (GP). Methods: An online survey of 1006 randomly selected German patients was conducted. The sample was drawn from an e-panel maintained by GfK HealthCare. Missing values were imputed; 958 usable questionnaires were analyzed. Variables with multi-item measurement were factor analyzed. Willingness to undergo online treatment and willingness to pay additionally for online treatment offered by the GP were predicted using 2 multiple regression models. Results: Exploratory factor analyses revealed that the disposition of patients’ personality to engage in information-searching behavior on the Internet was unidimensional. Exploratory factor analysis with the variables measuring the motives for Internet usage led to 2 separate factors: perceived usefulness (PU) of the Internet for health-related information searching and social motives for information searching on the Internet. Sociodemographic variables did not serve as significant predictors for willingness to undergo online treatment offered by the GP, whereas PU (B=.092, P=.08), willingness to communicate with the GP more often in the future (B=.495, P<.001), health-related information–seeking personality (B=.369, P<.001), actual use of online communication with the GP (B=.198, P<.001), and social motive (B=.178, P=.002) were significant predictors. Age, gender, satisfaction with the GP, social motive, and trust in the GP had no significant impact on the willingness to pay additionally for online treatment, but it was predicted by health-related information–seeking personality (B=.127, P=.07), PU (B=–.098, P=.09), willingness to undergo online treatment (B=.391, P<.001), actual use of online communication with the GP (B=.192, P=.001), highest education level (B=.178, P<.001), monthly household net income (B=.115, P=.01), and willingness to communicate with the GP online more often in the future (B=.076, P=.03). Conclusions: Age, gender, and trust in the GP were not significant predictors for either willingness to undergo online treatment or to pay additionally for online treatment. Willingness to undergo online treatment was partly determined by the actual use of online communication with the GP, willingness to communicate online with the GP, health information–seeking personality, and social motivation for such behavior. Willingness to pay extra for online treatment was influenced by the monthly household net income category and education level. The results of this study are useful for online health care providers and physicians who are considering offering online treatments as a viable number of patients would appreciate the possibility of undergoing an online treatment offered by their GP.

  • Start window alcohol game. The image was created by the authors A.Jander, R. Crutzen, L. Mercken, and H. de Vries in cooperation with Goal043. For reuse of the image, please contact the author A.Jander for permission.

    Effects of a Web-Based Computer-Tailored Game to Reduce Binge Drinking Among Dutch Adolescents: A Cluster Randomized Controlled Trial


    Background: Binge drinking among Dutch adolescents is among the highest in Europe. Few interventions so far have focused on adolescents aged 15 to 19 years. Because binge drinking increases significantly during those years, it is important to develop binge drinking prevention programs for this group. Web-based computer-tailored interventions can be an effective tool for reducing this behavior in adolescents. Embedding the computer-tailored intervention in a serious game may make it more attractive to adolescents. Objective: The aim was to assess whether a Web-based computer-tailored intervention is effective in reducing binge drinking in Dutch adolescents aged 15 to 19 years. Secondary outcomes were reduction in excessive drinking and overall consumption during the previous week. Personal characteristics associated with program adherence were also investigated. Methods: A cluster randomized controlled trial was conducted among 34 Dutch schools. Each school was randomized into either an experimental (n=1622) or a control (n=1027) condition. Baseline assessment took place in January and February 2014. At baseline, demographic variables and alcohol use were assessed. Follow-up assessment of alcohol use took place 4 months later (May and June 2014). After the baseline assessment, participants in the experimental condition started with the intervention consisting of a game about alcohol in which computer-tailored feedback regarding motivational characteristics was embedded. Participants in the control condition only received the baseline questionnaire. Both groups received the 4-month follow-up questionnaire. Effects of the intervention were assessed using logistic regression mixed models analyses for binge and excessive drinking and linear regression mixed models analyses for weekly consumption. Factors associated with intervention adherence in the experimental condition were explored by means of a linear regression model. Results: In total, 2649 adolescents participated in the baseline assessment. At follow-up, 824 (31.11%) adolescents returned. The intervention was effective in reducing binge drinking among adolescents aged 15 years (P=.03) and those aged 16 years when they participated in at least 2 intervention sessions (P=.04). Interaction effects between excessive drinking and educational level (P=.08) and between weekly consumption and age (P=.09) were found; however, in-depth analyses revealed no significant subgroup effects for both interaction effects. Additional analyses revealed that prolonged use of the intervention was associated with stronger effects for binge drinking. Yet, overall adherence to the intervention was low. Analyses revealed that being Protestant, female, younger, a nonbinge drinker, and having a higher educational background were associated with adherence. Conclusions: The intervention was effective for adolescents aged 15 and 16 years concerning binge drinking. Prevention messages may be more effective for those at the start of their drinking career, whereas other methods may be needed for those with a longer history of alcohol consumption. Despite using game elements, intervention completion was low. Trial Registration: Dutch Trial Register: NTR4048; (Archived by WebCite® at

  • Social media communication/analysis.
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By Doesn't say [CC0], via Wikimedia Commons.

    In Pursuit of Theoretical Ground in Behavior Change Support Systems: Analysis of Peer-to-Peer Communication in a Health-Related Online Community


    Background: Research studies involving health-related online communities have focused on examining network structure to understand mechanisms underlying behavior change. Content analysis of the messages exchanged in these communities has been limited to the “social support” perspective. However, existing behavior change theories suggest that message content plays a prominent role reflecting several sociocognitive factors that affect an individual’s efforts to make a lifestyle change. An understanding of these factors is imperative to identify and harness the mechanisms of behavior change in the Health 2.0 era. Objective: The objective of this work is two-fold: (1) to harness digital communication data to capture essential meaning of communication and factors affecting a desired behavior change, and (2) to understand the applicability of existing behavior change theories to characterize peer-to-peer communication in online platforms. Methods: In this paper, we describe grounded theory–based qualitative analysis of digital communication in QuitNet, an online community promoting smoking cessation. A database of 16,492 de-identified public messages from 1456 users from March 1-April 30, 2007, was used in our study. We analyzed 795 messages using grounded theory techniques to ensure thematic saturation. This analysis enabled identification of key concepts contained in the messages exchanged by QuitNet members, allowing us to understand the sociobehavioral intricacies underlying an individual’s efforts to cease smoking in a group setting. We further ascertained the relevance of the identified themes to theoretical constructs in existing behavior change theories (eg, Health Belief Model) and theoretically linked techniques of behavior change taxonomy. Results: We identified 43 different concepts, which were then grouped under 12 themes based on analysis of 795 messages. Examples of concepts include “sleepiness,” “pledge,” “patch,” “spouse,” and “slip.” Examples of themes include “traditions,” “social support,” “obstacles,” “relapse,” and “cravings.” Results indicate that themes consisting of member-generated strategies such as “virtual bonfires” and “pledges” were related to the highest number of theoretical constructs from the existing behavior change theories. In addition, results indicate that the member-generated communication content supports sociocognitive constructs from more than one behavior change model, unlike the majority of the existing theory-driven interventions. Conclusions: With the onset of mobile phones and ubiquitous Internet connectivity, online social network data reflect the intricacies of human health behavior as experienced by health consumers in real time. This study offers methodological insights for qualitative investigations that examine the various kinds of behavioral constructs prevalent in the messages exchanged among users of online communities. Theoretically, this study establishes the manifestation of existing behavior change theories in QuitNet-like online health communities. Pragmatically, it sets the stage for real-time, data-driven sociobehavioral interventions promoting healthy lifestyle modifications by allowing us to understand the emergent user needs to sustain a desired behavior change.

  • Real-time videoconferencing (RVC). Image copyright: Study Authors.

    Utilizing Remote Real-Time Videoconferencing to Expand Access to Cancer Genetic Services in Community Practices: A Multicenter Feasibility Study


    Background: Videoconferencing has been used to expand medical services to low-access populations and could increase access to genetic services at community sites where in-person visits with genetic providers are not available. Objective: To evaluate the feasibility of, patient feedback of, and cognitive and affective responses to remote two-way videoconferencing (RVC) telegenetic services at multiple sociodemographically diverse community practices without access to genetic providers. Methods: Patients at 3 community sites in 2 US states outside the host center completed RVC pretest (visit 1, V1) and post-test (visit 2, V2) genetic counseling for cancer susceptibility. Surveys evaluated patient experiences, knowledge, satisfaction with telegenetic and cancer genetics services, anxiety, depression, and cancer worry. Results: A total of 82 out of 100 (82.0%) approached patients consented to RVC services. A total of 61 out of 82 patients (74%) completed pretest counseling and 41 out of 61 (67%) proceeded with testing and post-test counseling. A total of 4 out of 41 (10%) mutation carriers were identified: BRCA2, MSH2, and PMS2. Patients reported many advantages (eg, lower travel burden and convenience) and few disadvantages to RVC telegenetic services. Most patients reported feeling comfortable with the video camera—post-V1: 52/57 (91%); post-V2: 39/41 (95%)—and that their privacy was respected—post-V1: 56/57 (98%); post-V2: 40/41 (98%); however, some reported concerns that RVC might increase the risk of a confidentiality breach of their health information—post-V1: 14/57 (25%); post-V2: 12/41 (29%). While the majority of patients reported having no trouble seeing or hearing the genetic counselor—post-V1: 47/57 (82%); post-V2: 39/41 (95%)—51 out of 98 (52%) patients reported technical difficulties. Nonetheless, all patients reported being satisfied with genetic services. Compared to baseline, knowledge increased significantly after pretest counseling (+1.11 mean score, P=.005); satisfaction with telegenetic (+1.74 mean score, P=.02) and genetic services (+2.22 mean score, P=.001) increased after post-test counseling. General anxiety and depression decreased after pretest (-0.97 mean anxiety score, P=.003; -0.37 mean depression score, P=.046) and post-test counseling (-1.13 mean anxiety score, P=.003; -0.75 mean depression score, P=.01); state anxiety and cancer-specific worry did not significantly increase. Conclusions: Remote videoconferencing telegenetic services are feasible, identify genetic carriers in community practices, and are associated with high patient satisfaction and favorable cognitive and affective outcomes, suggesting an innovative delivery model for further study to improve access to genetic providers and services. Potential barriers to dissemination include technology costs, unclear billing and reimbursement, and state requirements for provider licensure.

  • Photo credit: laura pasquini via ttps://  / CC BY-NC-SA.

    Adapting Behavioral Interventions for Social Media Delivery


    Patients are increasingly using online social networks (ie, social media) to connect with other patients and health care professionals—a trend called peer-to-peer health care. Because online social networks provide a means for health care professionals to communicate with patients, and for patients to communicate with each other, an opportunity exists to use social media as a modality to deliver behavioral interventions. Social media-delivered behavioral interventions have the potential to reduce the expense of behavioral interventions by eliminating visits, as well as increase our access to patients by becoming embedded in their social media feeds. Trials of online social network-delivered behavioral interventions have shown promise, but much is unknown about intervention development and methodology. In this paper, we discuss the process by which investigators can translate behavioral interventions for social media delivery. We present a model that describes the steps and decision points in this process, including the necessary training and reporting requirements. We also discuss issues pertinent to social media-delivered interventions, including cost, scalability, and privacy. Finally, we identify areas of research that are needed to optimize this emerging behavioral intervention modality.

  • Photo credit: svenwerk via FlickR  / CC BY-NC-ND.

    The Effect of Information Communication Technology Interventions on Reducing Social Isolation in the Elderly: A Systematic Review


    Background: The aging of the population is an inexorable change that challenges governments and societies in every developed country. Based on clinical and empirical data, social isolation is found to be prevalent among elderly people, and it has negative consequences on the elderly’s psychological and physical health. Targeting social isolation has become a focus area for policy and practice. Evidence indicates that contemporary information and communication technologies (ICT) have the potential to prevent or reduce the social isolation of elderly people via various mechanisms. Objective: This systematic review explored the effects of ICT interventions on reducing social isolation of the elderly. Methods: Relevant electronic databases (PsycINFO, PubMed, MEDLINE, EBSCO, SSCI, Communication Studies: a SAGE Full-Text Collection, Communication & Mass Media Complete, Association for Computing Machinery (ACM) Digital Library, and IEEE Xplore) were systematically searched using a unified strategy to identify quantitative and qualitative studies on the effectiveness of ICT-mediated social isolation interventions for elderly people published in English between 2002 and 2015. Narrative synthesis was performed to interpret the results of the identified studies, and their quality was also appraised. Results: Twenty-five publications were included in the review. Four of them were evaluated as rigorous research. Most studies measured the effectiveness of ICT by measuring specific dimensions rather than social isolation in general. ICT use was consistently found to affect social support, social connectedness, and social isolation in general positively. The results for loneliness were inconclusive. Even though most were positive, some studies found a nonsignificant or negative impact. More importantly, the positive effect of ICT use on social connectedness and social support seemed to be short-term and did not last for more than six months after the intervention. The results for self-esteem and control over one’s life were consistent but generally nonsignificant. ICT was found to alleviate the elderly’s social isolation through four mechanisms: connecting to the outside world, gaining social support, engaging in activities of interests, and boosting self-confidence. Conclusions: More well-designed studies that contain a minimum risk of research bias are needed to draw conclusions on the effectiveness of ICT interventions for elderly people in reducing their perceived social isolation as a multidimensional concept. The results of this review suggest that ICT could be an effective tool to tackle social isolation among the elderly. However, it is not suitable for every senior alike. Future research should identify who among elderly people can most benefit from ICT use in reducing social isolation. Research on other types of ICT (eg, mobile phone–based instant messaging apps) should be conducted to promote understanding and practice of ICT-based social-isolation interventions for elderly people.

  • © Sebastian Molkenbur, Leuphana University Lueneburg, Germany.

    Web-Based and Mobile Stress Management Intervention for Employees: A Randomized Controlled Trial


    Background: Work-related stress is highly prevalent among employees and is associated with adverse mental health consequences. Web-based interventions offer the opportunity to deliver effective solutions on a large scale; however, the evidence is limited and the results conflicting. Objective: This randomized controlled trial evaluated the efficacy of guided Web- and mobile-based stress management training for employees. Methods: A total of 264 employees with elevated symptoms of stress (Perceived Stress Scale-10, PSS-10≥22) were recruited from the general working population and randomly assigned to an Internet-based stress management intervention (iSMI) or waitlist control group. The intervention (GET.ON Stress) was based on Lazarus’s transactional model of stress, consisted of seven sessions, and applied both well-established problem solving and more recently developed emotion regulation strategies. Participants also had the opportunity to request automatic text messages on their mobile phone along with the iSMI. Participants received written feedback on every completed session from an e-coach. The primary outcome was perceived stress (PSS-10). Web-based self-report assessments for both groups were scheduled at baseline, 7 weeks, and 6 months. At 12 months, an extended follow-up was carried out for the iSMI group only. Results: An intention-to-treat analysis of covariance revealed significantly large effect differences between iSMI and waitlist control groups for perceived stress at posttest (F1,261=58.08, P<.001; Cohen’s d=0.83) and at the 6-month follow-up (F1,261=80.17, P<.001; Cohen’s d=1.02). The effects in the iSMI group were maintained at 12-month follow-up. Conclusions: This Web- and mobile-based intervention has proven effective in reducing stress in employees in the long term. Internet-based stress management interventions should be further pursued as a valuable alternative to face-to-face interventions. Trial Registration: German Clinical Trials Register (DRKS): 00004749; drks_web/ (Archived by WebCite at

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

    Date Submitted: Feb 12, 2016

    Open Peer Review Period: Feb 13, 2016 - Apr 9, 2016

    Background: Mental health problems are highly prevalent and there is need for the self-management of (mental) health. Ecological Momentary Interventions (EMI) can be used to deliver interventions in t...

    Background: Mental health problems are highly prevalent and there is need for the self-management of (mental) health. Ecological Momentary Interventions (EMI) can be used to deliver interventions in the daily life of individuals using mobile devices. Objective: The aim of the current study was to systematically assess and meta-analyze the effect of EMI on three highly prevalent mental health outcomes (anxiety, depression and perceived stress) and positive psychological outcomes (e.g., 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. Thirty-three studies 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: The majority 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). Twenty-seven studies were included in the meta-analysis, and after removing six 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 (i.e., anxiety, depression, perceived stress, acceptance and relaxation). The only moderator for which the effect varied significantly was additional support by a MHP (MHP supported EMI, g = 0.73, 95% CI [0.57; 0.88]; stand-alone EMI, g = .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 psychological well-being and that the effect was not different between outcome types. Moreover, the effect was larger with additional support by a 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 psychological well-being.

  • What makes people persist with online psychological intervention for insomnia: A qualitative study of treatment completers

    Date Submitted: Feb 12, 2016

    Open Peer Review Period: Feb 13, 2016 - Apr 9, 2016

    Background: Computerized cognitive behavioural therapy (cCBT) has a growing evidence base, but it is less clear what factors may limit acceptability, feasibility and the translation of the effects see...

    Background: Computerized cognitive behavioural therapy (cCBT) has a growing evidence base, but it is less clear what factors may limit acceptability, feasibility and the translation of the effects seen in trials. In reality many such programs will be used as adjunctive treatment to face to face therapies. Objective: The purpose of this study was to use mixed methods to explore the use of a cCBT program for insomnia amongst depressed patients in a psychiatric clinic and evaluate barriers and facilitators to the implementation of adjunctive cCBT alongside clinical care. Methods: The qualitative arm of the study was conducted using face-to-face or telephone interviews with participants who had participated in a clinical trial of a cCBT program for insomnia used as an adjunctive treatment in a psychiatric clinical setting. In line with the grounded theory approach, a semi-structured interview guide was utilised with new thematic questions being formulated during the transcription and data analysis, as well as being added to the interview schedule. Data from all 40 study participants who completed the 12 week intervention was also collected in the post-intervention online survey. Results: Two themes, consistent with non-adjunctive cCBT implementation, emerged (1) reasons to commence, and expectations prior to commencing the program related to intrinsic motivators, (2) motivators and barriers to continue with the program in relation to the program structure and content. In this clinical setting the support of the clinician in completing the unsupported program was highlighted, as was the need for the program and clinical treatment to be co-ordinated. Conclusions: The use of a normally unsupported cCBT program as an adjunctive treatment can be aided by the clinician’s approach. Care needs to be taken to ensure the messages and interventions given by the program and the clinician are coordinated if the use of the program is to be optimised. Clinical Trial: Australian and New Zealand Clinical Trials Registry ACTRN12612000985​886.

  • Tight Control In Rheumatoid Arthritis: Validation Of An Electronic Device. Paper Versus Electronic Questionnaires.

    Date Submitted: Feb 11, 2016

    Open Peer Review Period: Feb 13, 2016 - Apr 9, 2016

    Background: Rheumatoid Arthritis (RA), defined as an inflammatory chronic joint disease, causes structural problems to the human body and impaired quality of life. The disease activity is a crucial pa...

    Background: Rheumatoid Arthritis (RA), defined as an inflammatory chronic joint disease, causes structural problems to the human body and impaired quality of life. The disease activity is a crucial parameter for patients with recent-onset RA. Objective: The aim of this study is to evaluate the level of agreement between the electronic and paper answers provided at the same questionnaires. Methods: This is a prospective, randomized, crossover study. A tablet-based software that enables the acquisition and management of clinical data has been developed. The level of agreement between electronic and paper responses was estimated with the Intraclass Correlation Coefficient (ICC), expressed with 95% confidence interval. A Bland Altman Plot was used to graphically confirm and visualize the concordance degree. Results: One hundred and eighty-five patients with diagnosis of rheumatoid arthritis were invited to participate the study. All of them completed the questionnaire, both on paper and on electronic versions. For all the evaluated items, the intra-rater degree of agreement between the responses given with paper and electronic format was found excellent (ICC > 0.75, P<.001). The Bland Altman Plots confirmed the same results. Conclusions: The study demonstrates that patients are able to correctly use electronic devices and they prefer this way of self-assessment evaluation rather than paper version. This should not be surprising, as mobile technologies are turning into everyday tool for the Italian population and healthcare makes no exception. Furthermore, two methods of evaluations provide the same and reliable results, with no significant difference.

  • Methods of using real-time social media technologies to monitor levels of perceived stress and emotional state in college students

    Date Submitted: Feb 9, 2016

    Open Peer Review Period: Feb 13, 2016 - Apr 9, 2016

    Background: Background: College can be stressful for many freshmen as they cope with a variety of stressors. Excess stress can negatively affect both psychological and physical health. Thus, there is...

    Background: Background: College can be stressful for many freshmen as they cope with a variety of stressors. Excess stress can negatively affect both psychological and physical health. Thus, there is a need to find innovative and cost-effective strategies to help identify those students experiencing high levels of stress to receive appropriate treatment. Social media use has been rapidly growing and recent studies have reported that data from these technologies can be used for public health surveillance. Currently, no studies have examined whether Twitter data can be used to monitor stress level and emotional state among college students. Objective: Objective: The primary objective was to study whether students’ perceived levels of stress were associated with the sentiment and emotions of their tweets. The secondary objective was to explore whether students’ emotional state was associated with the sentiment and emotions of their tweets. Methods: Methods We recruited 181 first year freshman students at University of California Los Angeles between the ages of 18-20 years. All participants were asked to complete a questionnaire that assessed their demographic characteristics, levels of stress and emotional state for the past 7 days. All questionnaires were completed within a 48-hour period. All tweets posted by the participants from that week (November 2nd to 8th) were mined and manually categorized based on their sentiment (positive, negative, neutral) and emotion (anger, fear, love, joy) expressed. Ordinal regressions were used to assess whether weekly levels of stress and emotional states were associated with percent of positive, neutral, negative, anger, fear, love or happiness tweets. Results: Results 121 participants completed the survey and were included in our analysis. A total of 1879 tweets were analyzed. A higher level of weekly stress was significantly associated with greater percentage of negative sentiment tweets (β±SE: 1.7±0.7; P=0.02), tweets containing sadness (β±SE: 2.4±0.9; P=0.01) and tweets containing love and hope (β±SE: 3.6±1.4; P=0.01). Greater level of anger was negatively associated with percent of positive sentiment (β±SE: -1.6±0.8; P=0.05) and tweets related to the emotions of joy (β±SE: -2.2±0.9; P=0.02). Greater level of fear was positively associated with percent of negative sentiment (β±SE: 1.67±0.7; P=0.012, particularly a greater proportion of sadness tweets (β±SE: 2.4±0.8; P=0.01). Participants that reported a greater level of love showed a smaller percentage of negative sentiment tweets (β±SE: -1.3 ±0.7; P=0.05). Emotions of joy were positively associated with percent of tweets related to the emotion of joy (β±SE: -1.8 ±0.8; P=0.02) and negatively associated with percent of negative sentiment tweets (β±SE: -1.7 ±0.7; P=0.02) and tweets related to the emotion of sadness (β±SE:-2.8 ±0.8; P=0.01). Conclusions: Conclusions The results suggest that sentiment and emotions expressed in the tweets has the potential to provide real-time monitoring of stress level and emotional well being in college students.

  • Long-Term Effects of An Internet-Mediated Pedometer-Based Walking Program in COPD: A Randomized Controlled Trial

    Date Submitted: Feb 9, 2016

    Open Peer Review Period: Feb 13, 2016 - Apr 9, 2016

    Background: Regular physical activity (PA) is recommended for persons with chronic obstructive pulmonary disease (COPD). Novel interventions that promote PA and sustain long-term adherence to PA are n...

    Background: Regular physical activity (PA) is recommended for persons with chronic obstructive pulmonary disease (COPD). Novel interventions that promote PA and sustain long-term adherence to PA are needed. Objective: We examined the effects of an Internet-mediated, pedometer-based walking intervention, called Taking Healthy Steps, at 12 months. Methods: Veterans with COPD (n=239) were randomized in a 2:1 ratio to: intervention or wait-list control. During the first 4 months of the intervention, participants were instructed to wear the pedometer every day, upload daily step counts at least once a week, and provided access to a website with four key components: individualized goal-setting; iterative feedback; educational and motivational content; and an online community forum. During the following 8-month maintenance phase, participants continued to wear the pedometer, upload step-counts, receive feedback and goals, and had access to the online forum; they no longer received new educational content. Participants randomized to the wait-list control group were instructed to wear the pedometer, log into the website to upload step-count data at least monthly, and report all adverse events; they received no instructions about PA or exercise and were not assigned step-count goals. The primary outcome was health-related quality of life, assessed by the St. George’s Respiratory Questionnaire Total Score (SGRQ-TS), and the secondary outcome was daily step count. Linear mixed-effect models assessed the effect of intervention over time. Within the intervention group, we assessed engagement with the web-based intervention using the number of logins to the website and a structured questionnaire that queried aspects of engagement with the intervention, including participants’ ease of finding time to log in to the website, knowledge of step-count goals, and use of the various website components. Results: Subjects were 94% male (223 out of 238), with mean age 67±9 years. At 12 months, there were no significant between-group differences in SGRQ-TS or daily step count. Between-group difference in daily step count was maximal and statistically significant at month 4, but approached zero in months 8 to 12. Within the intervention group, daily step counts peaked at 2 months and then decreased over time. Average number of logins to the website also significantly decreased over the months of study: 6.8 at month 1, 4.2 at month 9 and 3.0 at month 12 (P < .001). Responses to questions assessing participants’ engagement with the intervention were not significantly different at 12 months compared to 4 months. Conclusions: An Internet-mediated, pedometer-based PA intervention, although efficacious at 4 months, does not maintain improvements in HRQL and daily step counts at 12 months. Waning engagement with the website by the intervention group was observed. Future efforts should focus on improving the long-term efficacy of PA interventions and promoting behavior change to sustain engagement in PA. Clinical Trial: Clinical NCT01102777

  • Achieving consensus for the design and delivery of an online intervention to support midwives in work-related psychological distress: Results from a Delphi Study

    Date Submitted: Feb 8, 2016

    Open Peer Review Period: Feb 13, 2016 - Apr 9, 2016

    Background: Some midwives are known to experience psychological distress. An online intervention may be one option midwives may engage with in pursuit of effective support. However, the priorities for...

    Background: Some midwives are known to experience psychological distress. An online intervention may be one option midwives may engage with in pursuit of effective support. However, the priorities for the development of an online intervention to effectively support midwives in work-related psychological distress have yet to be explored. Objective: The objective of this study was to explore what should be prioritised in the development of an online intervention to support midwives in work-related psychological distress with an expert panel. Methods: A two round online Delphi study was conducted. This study invited both qualitative and quantitative data from a variety of experts recruited via a scoping literature search and social media channels. Results: 185 experts were invited to participate in this Delphi study. 66 (35.7%) of participants invited to contribute completed Round 1. 44 (66.6%) of those who contributed to this first round went on to complete Round 2. Of the 20 questions posed during Round 1, 11 items achieved consensus and 9 did not. Of the 19 questions posed within a second round of questioning, 7 statements achieved consensus and 12 did not. 1604 free text responses were collected and categorised into 2446 separate sentiments, creating a total of 442 themes. Overall, it was agreed that online interventions to effectively support midwives in work-related psychological distress, should make confidentiality and anonymity a high priority, along with mobile 24-hour access, effective moderation, an online discussion forum, and a plethora of legal, educational and therapeutic components. It was also agreed that midwives should be offered a simple user assessment to identify those midwives deemed to be at risk of causing and/or enduring harm, and direct them to appropriate support. Conclusions: This study has identified priorities for the development of online interventions to effectively support midwives in work-related psychological distress. The impact of any future intervention of this type will be optimised by augmenting the development process in line with these findings.