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

Serious Games for Healthcare: Online Framework, Applications and Evaluation Case Studies

Background: Integrating serious games for Health has been proposed through a unified framework expanding current Health informatics. Healthcare from this perspective includes care for persons with physical, mental or developmental limitations. Objective: The main objective is to suggest an online framework to configure, monitor and analyze the results of health intervention therapy based games using different media. Methods: The technology offers various possibilities to interact with the game through tools such as iPad, Kinect, Wii or robots. All of them communicated through internet and the information stored in the cloud. Results: Having all the data in the cloud allows, not only have the updated tracking of the patient, also to update the treatment based on the combination of appropriate games for every stage of the disease. To do this, biofeedback information is included. Conclusions: The main benefit remains to be that Games can provide an improved lifestyle and a more friendly approach to health diagnostics and therapies when possible.


Call for Abstracts is Now Open. Submission Deadline: May 14 at 6pm EST

APRIL 1, 2015, BOSTON, MA -- The Connected Health Symposium, hosted annually by Partners HealthCare, today announced it has established a joint program with JMIR Publications to feature up to 50 poster presentations at this year's Symposium. JMIR Publications is the leading ehealth publisher, with over ten academic journals covering digital health, technology and innovation in health. Its flagship journal, the Journal of Medical Internet Research (JMIR), is the leading publication in the fields of medical informatics, health sciences and services research.

"There is important research being conducted throughout the connected health ecosystem that we can learn from and which deserves recognition. Academics, startups and other innovators will now have a stage to showcase their work at our annual Connected Health Symposium," said Kamal Jethwani, MD, MPH, Senior Director of Connected Health Innovation at Partners HealthCare. "We are very pleased to be working with JMIR Publications, publisher of the largest and most cited journals in ehealth."

As part of this new joint program, JMIR, along with members of the Partners Connected Health Innovation team, will review and select abstracts to be featured in a new poster session at the upcoming Connected Health Symposium. Poster presenters will receive complimentary registration to the Connected Health Symposium. Authors of accepted abstracts will also have an opportunity to submit papers for review and possible publication in JMIR and its sister journals (e.g. JMIR Medical Informatics, JMIR mHealth, JMIR Serious Games, JMIR Rehab, JMIR Mental Health, JMIR Public Health, JMIR Research Protocols and others) at a highly discounted rate.

"The Connected Health Symposium is a destination for discussion, learnings and innovation to advance the adoption and integration of connected health strategies," added Susan Lane, RN, MSN, MBA, Senior Director, Connected Health Operations, Partners HealthCare. "With the addition of this poster session, we are furthering our mission to highlight cutting-edge, novel and scalable programs to over 1,000 attendees at our Symposium, including clinicians, investors, innovators and academicians."

Abstracts must be submitted by May 14, 2015  (6pm EST) at An extended abstract (up to 5 pages) must be also be submitted (template at

For full submission details, please see the call for papers at

“We are thrilled to be involved in selecting the best research submissions for the Connected Health Symposium and to be the official publisher of this conference,” said Gunther Eysenbach, MD, MPH, FACMI, Publisher and Editor-in-Chief of the Journal of Medical Internet Research and its ten sister journals. “The partnership with the Connected Health Symposium is a logical extension of our strategy to partner with the leading knowledge translation initiatives in this field with the ultimate goal to advance ehealth and to expand our unique network of leading researchers in this field.”  

The 12th Annual Connected Health Symposium, being held October 29-30 in Boston, is a change-agent conference that promotes innovative thinking and the application of personal consumer health technologies, with a  focus on trends at the intersection of technology and new models of health care delivery.  Over 1,200 technology leaders, industry execs, Fortune 500 employers, policymakers, clinicians and health plan execs will come together to define the future of care delivery and impact the day-to-day lives of patients.

JMIR Publications
JMIR Publications is the leading ehealth publisher, advancing progress in the health, engineering and social sciences to ultimately help people to live happier and healthier lives using technology. JMIR Publications helps innovators in the health technology space to collaborate and disseminate their innovations, ideas, and research results to the widest possible audience, in a timely manner, adding value to the quality of the work and adhering to the highest ethical and quality standards. We achieve this by using the Internet and the latest available technologies as well as by producing conferences and social media, and other innovative knowledge translation products. We also innovate in the scholarly communication space itself, experimenting with new business models, new models of peer-review and dissemination, and new technologies. Visit

Partners HealthCare Connected Health
Partners is leveraging information technology – cell phones, computers, wearables, sensors and remote health monitoring tools – to deliver quality patient care outside of traditional medical settings. Partners Connected Health programs are also helping providers and patients better manage chronic conditions, maintain health and wellness and improve adherence, engagement and clinical outcomes. The Connected Health team creates and deploys mobile technologies in a number of patient populations and care settings, and is conducting innovative clinical studies to test the effectiveness of mobile health technologies in various clinical applications, including medication adherence, care coordination, chronic disease management, and prevention and wellness.

Partners HealthCare
Partners HealthCare is an integrated health system founded by Brigham and Women’s Hospital and Massachusetts General Hospital.  In addition to its two academic medical centers, the Partners system includes community and specialty hospitals, a managed care organization, community health centers, a physician network, home health and long-term care services, and other health care entities. Partners HealthCare is committed to patient care, research, teaching, and service to the community. Partners is one of the nation’s leading biomedical research organizations and a principal teaching affiliate of Harvard Medical School.  Partners HealthCare is a non-profit organization. Visit


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    Online and Offline Recruitment of Young Women for a Longitudinal Health Survey: Findings From the Australian Longitudinal Study on Women’s Health 1989-95...


    Background: In 2012, we set out to recruit a cohort of at least 10,000 women aged 18-23 from across Australia. With recent research demonstrating the inadequacy of traditional approaches to recruiting women in this age group, we elected to conduct open recruiting. Objective: Our aim was to report on the overall success of open recruiting and to evaluate the relative success of a variety of recruitment methods in terms of numbers and demographics. Methods: We used referrals, Facebook, formal advertising, and incentives in order to recruit the cohort. Results: In all, 17,069 women were recruited for the longitudinal online survey, from 54,685 initiated surveys. Of these women, most (69.94%, n=11,799) who joined the longitudinal cohort were recruited via Facebook, 12.72% (n=2145) via the fashion promotion, 7.02% (n=1184) by referral, 4.9% (n=831) via other Web activities, and 5.4% (n=910) via traditional media. Conclusions: Facebook was by far the most successful strategy, enrolling a cohort of women with a similar profile to the population of Australian women in terms of age, area of residence, and relationship status. Women recruited via fashion promotion were the least representative. All strategies underrepresented less educated women—a finding that is consistent with more traditional means of recruiting. In conclusion, flexibility in recruitment design, embracing new and traditional media, adopting a dynamic responsive approach, and monitoring the results of recruiting in terms of sample composition and number recruited led to the successful establishment of a new cohort.

  • This is a royalty free image by Stuart Miles (

    Sources of Traffic and Visitors’ Preferences Regarding Online Public Reports of Quality: Web Analytics and Online Survey Results


    Background: In the context of the Affordable Care Act, there is extensive emphasis on making provider quality transparent and publicly available. Online public reports of quality exist, but little is known about how visitors find reports or about their purpose in visiting. Objective: To address this gap, we gathered website analytics data from a national group of online public reports of hospital or physician quality and surveyed real-time visitors to those websites. Methods: Websites were recruited from a national group of online public reports of hospital or physician quality. Analytics data were gathered from each website: number of unique visitors, method of arrival for each unique visitor, and search terms resulting in visits. Depending on the website, a survey invitation was launched for unique visitors on landing pages or on pages with quality information. Survey topics included type of respondent (eg, consumer, health care professional), purpose of visit, areas of interest, website experience, and demographics. Results: There were 116,657 unique visitors to the 18 participating websites (1440 unique visitors/month per website), with most unique visitors arriving through search (63.95%, 74,606/116,657). Websites with a higher percent of traffic from search engines garnered more unique visitors (P=.001). The most common search terms were for individual hospitals (23.25%, 27,122/74,606) and website names (19.43%, 22,672/74,606); medical condition terms were uncommon (0.81%, 605/74,606). Survey view rate was 42.48% (49,560/116,657 invited) resulting in 1755 respondents (participation rate=3.6%). There were substantial proportions of consumer (48.43%, 850/1755) and health care professional respondents (31.39%, 551/1755). Across websites, proportions of consumer (21%-71%) and health care professional respondents (16%-48%) varied. Consumers were frequently interested in using the information to choose providers or assess the quality of their provider (52.7%, 225/427); the majority of those choosing a provider reported that they had used the information to do so (78%, 40/51). Health care professional (26.6%, 115/443) and consumer (20.8%, 92/442) respondents wanted cost information and consumers wanted patient narrative comments (31.5%, 139/442) on the public reports. Health care professional respondents rated the experience on the reports higher than consumers did (mean 7.2, SD 2.2 vs mean 6.2, SD 2.7; scale 0-10; P<.001). Conclusions: Report sponsors interested in increasing the influence of their reports could consider using techniques to improve search engine traffic, providing cost information and patient comments, and improving the website experience for both consumers and health care professionals.

  • Image source: US Department of Agriculture - licensed under cc-by-nd .

    Childcare Service Centers’ Preferences and Intentions to Use a Web-Based Program to Implement Healthy Eating and Physical Activity Policies and Practices:...


    Background: Overweight and obesity is a significant public health problem that impacts a large number of children globally. Supporting childcare centers to deliver healthy eating and physical activity-promoting policies and practices is a recommended strategy for obesity prevention, given that such services provide access to a substantial proportion of children during a key developmental period. Electronic Web-based interventions represent a novel way to support childcare service providers to implement such policies and practices. Objective: This study aimed to assess: (1) childcare centers’ current use of technology, (2) factors associated with intention to use electronic Web-based interventions, and (3) Web-based features that managers rated as useful to support staff with implementing healthy eating and physical activity-promoting policies and practices. Methods: A computer-assisted telephone interview (CATI) was conducted with service managers from long day care centers and preschools. The CATI assessed the following: (1) childcare center characteristics, (2) childcare centers’ use of electronic devices, (3) intention to use a hypothetical electronic Web-based program—assessed using the Technology Acceptance Model (TAM) with ratings between 1 (strongly disagree) and 7 (strongly agree), and (4) features rated as useful to include in a Web-based program. Results: Overall, 214 service centers out of 277 (77.3%) consented to participate. All service centers except 2 reported using computers (212/214, 99.1%), whereas 40.2% (86/214) used portable tablets. A total of 71.9% (151/210) of childcare service managers reported a score of 6 or more for intention to use a hypothetical electronic Web-based program. In a multivariable logistic regression analysis, intention to use the program was significantly associated with perceived ease of use (P=.002, odds ratio [OR] 3.9, 95% CI 1.6-9.2) and perceived usefulness (P<.001, OR 28,95% CI 8.0-95.2). Features reported by service managers as useful or very useful for a Web-based program included decision-support tools to support staff with menu planning (117/129, 90.7%), links to relevant resources (212/212, 100%), updated information on guidelines (208/212, 98.1%), and feedback regarding childcare center performance in relation to other childcare centers (212/212, 100%). Conclusions: Childcare service managers reported high intention to use a Web-based program and identified several useful features to support staff to implement healthy eating and physical activity policies and practices. Further descriptive and intervention research examining the development and use of such a program to support childcare centers with the implementation of healthy eating and physical activity-promoting policies and practices is warranted.

  • Copyright cc-by the authors.

    Access to Care and Use of the Internet to Search for Health Information: Results From the US National Health Interview Survey


    Background: The insurance mandate of the Affordable Care Act has increased the number of people with health coverage in the United States. There is speculation that this increase in the number of insured could make accessing health care services more difficult. Those who are unable to access care in a timely manner may use the Internet to search for information needed to answer their health questions. Objective: The aim was to determine whether difficulty accessing health care services for reasons unrelated to insurance coverage is associated with increased use of the Internet to obtain health information. Methods: Survey data from 32,139 adults in the 2011 National Health Interview Study (NHIS) were used in this study. The exposure for this analysis was reporting difficulty accessing health care services or delaying getting care for a reason unrelated to insurance status. To define this exposure, we examined 8 questions that asked whether different access problems occurred during the previous 12 months. The outcome for this analysis, health information technology (HIT) use, was captured by examining 2 questions that asked survey respondents if they used an online health chat room or searched the Internet to obtain health information in the previous 12 months. Several multinomial logistic regressions estimating the odds of using HIT for each reported access difficulty were conducted to accomplish the study objective. Results: Of a survey population of 32,139 adults, more than 15.90% (n=5109) reported experiencing at least one access to care barrier, whereas 3.63% (1168/32,139) reported using online health chat rooms and 43.55% (13,997/32,139) reported searching the Internet for health information. Adults who reported difficulty accessing health care services for reasons unrelated to their health insurance coverage had greater odds of using the Internet to obtain health information. Those who reported delaying getting care because they could not get an appointment soon enough (OR 2.2, 95% CI 1.9-2.5), were told the doctor would not accept them as a new patient or accept their insurance (OR 2.1, 95% CI 1.7-2.5 and OR 2.1, 95% CI 1.7-2.5, respectively), or because the doctor’s office was not open when they could go (OR 2.2, 95% CI 1.9-2.7) had more than twice the odds of using the Internet to obtain health information compared to those who did not report such access difficulties. Conclusions: People experiencing trouble accessing health care services for reasons unrelated to their insurance status are more likely to report using the Internet to obtain health information. Improving the accuracy and reliability of health information resources that are publicly available online could help those who are searching for information due to trouble accessing health care services.

  • Screenshot of Breaking The Ice website.

    Six-Month Outcomes of a Web-Based Intervention for Users of Amphetamine-Type Stimulants: Randomized Controlled Trial


    Background: The use of amphetamine-type stimulants (ATS) places a large burden on health services. Objective: The aim was to evaluate the effectiveness of a self-guided Web-based intervention (“breakingtheice”) for ATS users over 6 months via a free-to-access site. Methods: We conducted a randomized trial comparing a waitlist control with a fully automated intervention containing 3 modules derived from cognitive behavioral therapy and motivation enhancement. The main outcome was self-reported ATS use in the past 3 months assessed at 3- and 6-month follow-ups using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Secondary outcomes were help-seeking intentions (general help-seeking questionnaire), actual help seeking (actual help-seeking questionnaire), psychological distress (Kessler 10), polydrug use (ASSIST), quality of life (European Health Interview Survey), days out of role, and readiness to change. Follow-up data were evaluated using an intention-to-treat (ITT) analysis with a group by time interaction. Results: We randomized 160 people (intervention: n=81; control: n=79). At 6 months, 38 of 81 (47%) intervention and 41 of 79 (52%) control participants provided data. ATS scores significantly declined for both groups, but the interaction effect was not significant. There were significant ITT time by group interactions for actual help seeking (rate ratio [RR] 2.16; d=0.45) and help-seeking intentions (RR 1.17; d=0.32), with help seeking increasing for the intervention group and declining for the control group. There were also significant interactions for days completely (RR 0.50) and partially (RR 0.74) out of role favoring the intervention group. However, 37% (30/81) of the intervention group did not complete even 1 module. Conclusions: This self-guided Web-based intervention encouraged help seeking associated with ATS use and reduced days out of role, but it did not reduce ATS use. Thus, this program provides a means of engaging with some sections of a difficult-to-reach group to encourage treatment, but a substantial minority remained disengaged. Trial Registration: Australian and New Zealand Clinical Trials Registry: ACTRN12611000947909; (Archived by WebCite at

  • Screenshot of the Virtual Supermarket.

    Using a 3D Virtual Supermarket to Measure Food Purchase Behavior: A Validation Study


    Background: There is increasing recognition that supermarkets are an important environment for health-promoting interventions such as fiscal food policies or front-of-pack nutrition labeling. However, due to the complexities of undertaking such research in the real world, well-designed randomized controlled trials on these kinds of interventions are lacking. The Virtual Supermarket is a 3-dimensional computerized research environment designed to enable experimental studies in a supermarket setting without the complexity or costs normally associated with undertaking such research. Objective: The primary objective was to validate the Virtual Supermarket by comparing virtual and real-life food purchasing behavior. A secondary objective was to obtain participant feedback on perceived sense of “presence” (the subjective experience of being in one place or environment even if physically located in another) in the Virtual Supermarket. Methods: Eligible main household shoppers (New Zealand adults aged ≥18 years) were asked to conduct 3 shopping occasions in the Virtual Supermarket over 3 consecutive weeks, complete the validated Presence Questionnaire Items Stems, and collect their real supermarket grocery till receipts for that same period. Proportional expenditure (NZ$) and the proportion of products purchased over 18 major food groups were compared between the virtual and real supermarkets. Data were analyzed using repeated measures mixed models. Results: A total of 123 participants consented to take part in the study. In total, 69.9% (86/123) completed 1 shop in the Virtual Supermarket, 64.2% (79/123) completed 2 shops, 60.2% (74/123) completed 3 shops, and 48.8% (60/123) returned their real supermarket till receipts. The 4 food groups with the highest relative expenditures were the same for the virtual and real supermarkets: fresh fruit and vegetables (virtual estimate: 14.3%; real: 17.4%), bread and bakery (virtual: 10.0%; real: 8.2%), dairy (virtual: 19.1%; real: 12.6%), and meat and fish (virtual: 16.5%; real: 16.8%). Significant differences in proportional expenditures were observed for 6 food groups, with largest differences (virtual – real) for dairy (in expenditure 6.5%, P<.001; in items 2.2%, P=.04) and fresh fruit and vegetables (in expenditure: –3.1%, P=.04; in items: 5.9%, P=.002). There was no trend of overspending in the Virtual Supermarket and participants experienced a medium-to-high presence (88%, 73/83 scored medium; 8%, 7/83 scored high). Conclusions: Shopping patterns in the Virtual Supermarket were comparable to those in real life. Overall, the Virtual Supermarket is a valid tool to measure food purchasing behavior. Nevertheless, it is important to improve the functionality of some food categories, in particular fruit and vegetables and dairy. The results of this validation will assist in making further improvements to the software and with optimization of the internal and external validity of this innovative methodology.

  • Screenshot of the audiovisual material in which an older patient is presenting information in conversational style.

    The Effect of Modality and Narration Style on Recall of Online Health Information: Results From a Web-Based Experiment


    Background: Older adults are increasingly using the Internet for health information; however, they are often not able to correctly recall Web-based information (eHealth information). Recall of information is crucial for optimal health outcomes, such as adequate disease management and adherence to medical regimes. Combining effective message strategies may help to improve recall of eHealth information among older adults. Presenting information in an audiovisual format using conversational narration style is expected to optimize recall of information compared to other combinations of modality and narration style. Objective: The aim of this paper is to investigate the effect of modality and narration style on recall of health information, and whether there are differences between younger and older adults. Methods: We conducted a Web-based experiment using a 2 (modality: written vs audiovisual information) by 2 (narration style: formal vs conversational style) between-subjects design (N=440). Age was assessed in the questionnaire and included as a factor: younger (<65 years) versus older (≥65 years) age. Participants were randomly assigned to one of four experimental webpages where information about lung cancer treatment was presented. A Web-based questionnaire assessed recall of eHealth information. Results: Audiovisual modality (vs written modality) was found to increase recall of information in both younger and older adults (P=.04). Although conversational narration style (vs formal narration style) did not increase recall of information (P=.17), a synergistic effect between modality and narration style was revealed: combining audiovisual information with conversational style outperformed combining written information with formal style (P=.01), as well as written information with conversational style (P=.045). This finding suggests that conversational style especially increases recall of information when presented audiovisually. This combination of modality and narration style improved recall of information among both younger and older adults. Conclusions: We conclude that combining audiovisual information with conversational style is the best way to present eHealth information to younger and older adults. Even though older adults did not proportionally recall more when audiovisual information was combined with conversational style than younger adults, this study reveals interesting implications for improving eHealth information that is effective for both younger and older adults.

  • Screenshot of @iurojc Twitter page, as an example of a Twitter-based journal club.

    Globalization of Continuing Professional Development by Journal Clubs via Microblogging: A Systematic Review


    Background: Journal clubs are an essential tool in promoting clinical evidence-based medical education to all medical and allied health professionals. Twitter represents a public, microblogging forum that can facilitate traditional journal club requirements, while also reaching a global audience, and participation for discussion with study authors and colleagues. Objective: The aim of the current study was to evaluate the current state of social media–facilitated journal clubs, specifically Twitter, as an example of continuing professional development. Methods: A systematic review of literature databases (Medline, Embase, CINAHL, Web of Science, ERIC via ProQuest) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of Twitter, the followers of identified journal clubs, and Symplur was also performed. Demographic and monthly tweet data were extracted from Twitter and Symplur. All manuscripts related to Twitter-based journal clubs were included. Statistical analyses were performed in MS Excel and STATA. Results: From a total of 469 citations, 11 manuscripts were included and referred to five Twitter-based journal clubs (#ALiEMJC, #BlueJC, #ebnjc, #urojc, #meded). A Twitter-based journal club search yielded 34 potential hashtags/accounts, of which 24 were included in the final analysis. The median duration of activity was 11.75 (interquartile range [IQR] 19.9, SD 10.9) months, with 7 now inactive. The median number of followers and participants was 374 (IQR 574) and 157 (IQR 272), respectively. An overall increasing establishment of active Twitter-based journal clubs was observed, resulting in an exponential increase in total cumulative tweets (R2=.98), and tweets per month (R2=.72). Cumulative tweets for specific journal clubs increased linearly, with @ADC_JC, @EBNursingBMJ, @igsjc, @iurojc, and @NephJC, and showing greatest rate of change, as well as total impressions per month since establishment. An average of two tweets per month was estimated for the majority of participants, while the “Top 10” tweeters for @iurojc showed a significantly lower contribution to overall tweets for each month (P<.005). A linearly increasing impression:tweet ratio was observed for the top five journal clubs. Conclusions: Twitter-based journal clubs are free, time-efficient, and publicly accessible means to facilitate international discussions regarding clinically important evidence-based research.

  • Connected Cardiac Care Program. (cc) Agboola et al, CC-BY-SA-2.0, please cite as (

    Heart Failure Remote Monitoring: Evidence From the Retrospective Evaluation of a Real-World Remote Monitoring Program


    Background: Given the magnitude of increasing heart failure mortality, multidisciplinary approaches, in the form of disease management programs and other integrative models of care, are recommended to optimize treatment outcomes. Remote monitoring, either as structured telephone support or telemonitoring or a combination of both, is fast becoming an integral part of many disease management programs. However, studies reporting on the evaluation of real-world heart failure remote monitoring programs are scarce. Objective: This study aims to evaluate the effect of a heart failure telemonitoring program, Connected Cardiac Care Program (CCCP), on hospitalization and mortality in a retrospective database review of medical records of patients with heart failure receiving care at the Massachusetts General Hospital. Methods: Patients enrolled in the CCCP heart failure monitoring program at the Massachusetts General Hospital were matched 1:1 with usual care patients. Control patients received care from similar clinical settings as CCCP patients and were identified from a large clinical data registry. The primary endpoint was all-cause mortality and hospitalizations assessed during the 4-month program duration. Secondary outcomes included hospitalization and mortality rates (obtained by following up on patients over an additional 8 months after program completion for a total duration of 1 year), risk for multiple hospitalizations and length of stay. The Cox proportional hazard model, stratified on the matched pairs, was used to assess primary outcomes. Results: A total of 348 patients were included in the time-to-event analyses. The baseline rates of hospitalizations prior to program enrollment did not differ significantly by group. Compared with controls, hospitalization rates decreased within the first 30 days of program enrollment: hazard ratio (HR)=0.52, 95% CI 0.31-0.86, P=.01). The differential effect on hospitalization rates remained consistent until the end of the 4-month program (HR=0.74, 95% CI 0.54-1.02, P=.06). The program was also associated with lower mortality rates at the end of the 4-month program: relative risk (RR)=0.33, 95% 0.11-0.97, P=.04). Additional 8-months follow-up following program completion did not show residual beneficial effects of the CCCP program on mortality (HR=0.64, 95% 0.34-1.21, P=.17) or hospitalizations (HR=1.12, 95% 0.90-1.41, P=.31). Conclusions: CCCP was associated with significantly lower hospitalization rates up to 90 days and significantly lower mortality rates over 120 days of the program. However, these effects did not persist beyond the 120-day program duration.

  • Screenshot of the Survey banner advertisement.

    A Mixed-Methods Study on the Acceptability of Using eHealth for HIV Prevention and Sexual Health Care Among Men Who Have Sex With Men in China


    Background: Human immunodeficiency virus (HIV) infection disproportionately affects men who have sex with men (MSM). Over half of all HIV-positive MSM in China may not know their HIV status. Mobile phones and Web interventions (eHealth) are underutilized resources that show promise for supporting HIV education, testing, and linkage to care. Objective: This mixed-methods study among MSM in China assessed technology utilization and eHealth acceptability for sexual health care. Methods: We conducted in-depth interviews and an online survey. Qualitative analyses informed the development of the Internet survey, which was administered through two popular MSM websites. Bivariate and multivariate analysis assessed characteristics of MSM interested in eHealth for sexual health care. Results: The qualitative sample included MSM across a range of ages, education, marital status, sexuality, and HIV testing experience. Qualitative findings included the importance of the Internet as the primary source of information about sexual health, HIV and other sexually transmitted diseases (STDs), use of the Internet to enable HIV testing opportunities by facilitating connections with both the gay community and health care providers, and mixed perceptions regarding the confidentiality of eHealth tools for sexual health. Among the Internet sample (N=1342), the average age was 30.6 years old, 82.81% (1098/1342) were single, and 53.42% (711/1331) had completed college. In the past 3 months, 38.66% (382/988) had condomless sex and 60.53% (805/1330) self-reported having ever tested for HIV. The majority of men owned computers (94.14%, 1220/1296) and mobile phones (92.32%, 1239/1342), which many had used to search for HIV/STD information and testing sites. In multivariate analysis, interest in using computers or mobile phones to support their sexual health care was associated with being a student, prior use of computers or mobile phones to search for general health information, prior use of computers or mobile phones to search for HIV/STD information, and confidentiality concerns. Conclusions: MSM in this sample had high utilization of technology and interest in eHealth despite confidentiality concerns. Future eHealth interventions can thoughtfully and creatively address these concerns as a priority for successful implementation.

  • Word cloud generated from a sample of posts that are high on informational or emotional support or both.

    Eliciting and Receiving Online Support: Using Computer-Aided Content Analysis to Examine the Dynamics of Online Social Support


    Background: Although many people with serious diseases participate in online support communities, little research has investigated how participants elicit and provide social support on these sites. Objective: The first goal was to propose and test a model of the dynamic process through which participants in online support communities elicit and provide emotional and informational support. The second was to demonstrate the value of computer coding of conversational data using machine learning techniques (1) by replicating results derived from human-coded data about how people elicit support and (2) by answering questions that are intractable with small samples of human-coded data, namely how exposure to different types of social support predicts continued participation in online support communities. The third was to provide a detailed description of these machine learning techniques to enable other researchers to perform large-scale data analysis in these communities. Methods: Communication among approximately 90,000 registered users of an online cancer support community was analyzed. The corpus comprised 1,562,459 messages organized into 68,158 discussion threads. Amazon Mechanical Turk workers coded (1) 1000 thread-starting messages on 5 attributes (positive and negative emotional self-disclosure, positive and negative informational self-disclosure, questions) and (2) 1000 replies on emotional and informational support. Their judgments were used to train machine learning models that automatically estimated the amount of these 7 attributes in the messages. Across attributes, the average Pearson correlation between human-based judgments and computer-based judgments was .65. Results: Part 1 used human-coded data to investigate relationships between (1) 4 kinds of self-disclosure and question asking in thread-starting posts and (2) the amount of emotional and informational support in the first reply. Self-disclosure about negative emotions (beta=.24, P<.001), negative events (beta=.25, P<.001), and positive events (beta=.10, P=.02) increased emotional support. However, asking questions depressed emotional support (beta=–.21, P<.001). In contrast, asking questions increased informational support (beta=.38, P<.001), whereas positive informational self-disclosure depressed it (beta=–.09, P=.003). Self-disclosure led to the perception of emotional needs, which elicited emotional support, whereas asking questions led to the perception of informational needs, which elicited informational support. Part 2 used machine-coded data to replicate these results. Part 3 analyzed the machine-coded data and showed that exposure to more emotional support predicted staying in the group longer 33% (hazard ratio=0.67, P<.001), whereas exposure to more informational support predicted leaving the group sooner (hazard ratio=1.05, P<.001). Conclusions: Self-disclosure is effective in eliciting emotional support, whereas question asking is effective in eliciting informational support. Moreover, perceptions that people desire particular kinds of support influence the support they receive. Finally, the type of support people receive affects the likelihood of their staying in or leaving the group. These results demonstrate the utility of machine learning methods for investigating the dynamics of social support exchange in online support communities.

  • Actual statistics compared with predicted values for obesity, 2010 BRFSS. Darker colors represent higher prevalence. Light gray indicates missing data. (cc-by) the authors.

    A New Source of Data for Public Health Surveillance: Facebook Likes


    Background: Investigation into personal health has become focused on conditions at an increasingly local level, while response rates have declined and complicated the process of collecting data at an individual level. Simultaneously, social media data have exploded in availability and have been shown to correlate with the prevalence of certain health conditions. Objective: Facebook likes may be a source of digital data that can complement traditional public health surveillance systems and provide data at a local level. We explored the use of Facebook likes as potential predictors of health outcomes and their behavioral determinants. Methods: We performed principal components and regression analyses to examine the predictive qualities of Facebook likes with regard to mortality, diseases, and lifestyle behaviors in 214 counties across the United States and 61 of 67 counties in Florida. These results were compared with those obtainable from a demographic model. Health data were obtained from both the 2010 and 2011 Behavioral Risk Factor Surveillance System (BRFSS) and mortality data were obtained from the National Vital Statistics System. Results: Facebook likes added significant value in predicting most examined health outcomes and behaviors even when controlling for age, race, and socioeconomic status, with model fit improvements (adjusted R2) of an average of 58% across models for 13 different health-related metrics over basic sociodemographic models. Small area data were not available in sufficient abundance to test the accuracy of the model in estimating health conditions in less populated markets, but initial analysis using data from Florida showed a strong model fit for obesity data (adjusted R2=.77). Conclusions: Facebook likes provide estimates for examined health outcomes and health behaviors that are comparable to those obtained from the BRFSS. Online sources may provide more reliable, timely, and cost-effective county-level data than that obtainable from traditional public health surveillance systems as well as serve as an adjunct to those systems.

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  • Serious Games for Healthcare: Online Framework, Applications and Evaluation Case Studies

    Date Submitted: Apr 23, 2015

    Open Peer Review Period: Apr 25, 2015 - Jun 20, 2015

    Background: Integrating serious games for Health has been proposed through a unified framework expanding current Health informatics. Healthcare from this perspective includes care for persons with phy...

    Background: Integrating serious games for Health has been proposed through a unified framework expanding current Health informatics. Healthcare from this perspective includes care for persons with physical, mental or developmental limitations. Objective: The main objective is to suggest an online framework to configure, monitor and analyze the results of health intervention therapy based games using different media. Methods: The technology offers various possibilities to interact with the game through tools such as iPad, Kinect, Wii or robots. All of them communicated through internet and the information stored in the cloud. Results: Having all the data in the cloud allows, not only have the updated tracking of the patient, also to update the treatment based on the combination of appropriate games for every stage of the disease. To do this, biofeedback information is included. Conclusions: The main benefit remains to be that Games can provide an improved lifestyle and a more friendly approach to health diagnostics and therapies when possible.

  • Smoking cessation intervention on Facebook: Which content generates the best engagement?

    Date Submitted: Apr 24, 2015

    Open Peer Review Period: Apr 25, 2015 - Jun 20, 2015

    Background: Social media offer great opportunity to deliver smoking cessation treatment to young adults, but previous online and social media interventions targeting health behavior change have strugg...

    Background: Social media offer great opportunity to deliver smoking cessation treatment to young adults, but previous online and social media interventions targeting health behavior change have struggled with low participant engagement. We examined engagement generated by content based on the Transtheoretical Model of Behavior Change (TTM) in a motivationally tailored smoking cessation intervention on Facebook. Objective: This study aimed to identify which intervention content based on the TTM generated the highest engagement among participants in pre-action stages of change (Precontemplation, Contemplation, Preparation). Methods: Participants (N=79, 20% female, Mean age = 20.8) were assessed for readiness to quit smoking and assigned to one of 7 secret Facebook groups tailored to their stage of change. Daily postings to the groups based on the TTM were made by research staff over 3 months. Engagement was operationalized as the number of participant comments to each post. TTM theory-based predictors of number of comments were analyzed, stratified by baseline stage of change, using zero-inflated negative binomial regression. Results: A total of 512 TTM-based posts generated 630 individual comments. In Precontemplation and Contemplation groups, Decisional Balance posts generated above average engagement (p=.01 and p<.001). In Contemplation groups, Dramatic Relief and Self-Liberation posts resulted in below average engagement (p=.01 and p=.005). In Preparation groups, Consciousness Raising generated above average engagement (p=.009). Participant engagement decreased over time and differed between groups within Precontemplation and Contemplation stages, but was independent of day of the week and time of day the content was posted to the groups. No participant baseline characteristics significantly predicted engagement. Conclusions: Participants not ready to quit in the next 30 days (in Precontemplation or Contemplation) engaged most when prompted to think about the pros and cons of behavior change, while those in the Preparation stage engaged most when posts increased awareness about smoking. Findings support tailoring intervention to readiness to quit and suggest intervention targets that may be most effective through social media.

  • Evaluating the hip range of motion using the goniometer, the Nintendo Wiimote and video tracking method

    Date Submitted: Apr 22, 2015

    Open Peer Review Period: Apr 25, 2015 - Jun 20, 2015

    Background: The range of motion (ROM) of the hip joint is an important clinical parameter used in diagnosing femoroacetabular impingement (FAI). Early detection of FAI helps people avoid the developme...

    Background: The range of motion (ROM) of the hip joint is an important clinical parameter used in diagnosing femoroacetabular impingement (FAI). Early detection of FAI helps people avoid the development of osteoarthritis. The goniometer is the most common method employed to measure the joint angles. However it has several limitations, as to allowing the clinician to analyse the ROM at the gate, and track the hip joint during walking or maximum squat. Motion capture devices traditionally used to analyzing the patient’s gait, and assess the condition of the joints and bones are accurate but requiring significant logistical and financial investment. The Nintendo Wiimote, used typically in games has found its way in medical applications such as rehabilitation interventions and shows promise. This is the first study of its kind to evaluate the goniometer, a bespoke Wiimote system and marker-based Motion Capture (MoCap) to measure ROM. Objective: To develop and assess a reliable, validated, easy but scientifically sound method to measure ROM. Methods: This study has used three methods, namely a high-spec marker-based MoCap system (Vicon), a markerless MoCap system (bespoke Wiimote system) and the conventional goniometer to examine the range of motion of 20 subject volunteers. This is the first study of its kind to evaluate goniometer and Wiimote with MoCap to measure ROM. Results: The intraclass correlation coefficient (ICC) of the three methods is higher than 0.8 which shows that the reliability of all methods is adequate. The validity of the marker-based MoCap system and the bespoke Wiimote system is the same and furthermore, it is sufficient to be used in clinical assessment. The marker-based MoCap system has slightly higher reliability and validity compare to the bespoke Wiimote system but the latter is an easier to deploy, low-cost and portable method of measurement. The limitations of this study was to use non FAI volunteers. Conclusions: As a result, the Wiimote can be used instead of the goniometer in clinical usage. The Wiimote is easy to use, portable, reliable, and accurate and also enables surgeons to have a free hand in order to avoid pelvic rotation and errors.

  • Prevalence of Depression in Medical Students at the Lebanese University and its Correlation with Facebook Relevance:

    Date Submitted: Apr 17, 2015

    Open Peer Review Period: Apr 21, 2015 - Jun 16, 2015

    Background: The prevalence of major depression is particularly high in medical students affecting around one third of this population. Moreover, online social media and in particular Facebook (fb) is...

    Background: The prevalence of major depression is particularly high in medical students affecting around one third of this population. Moreover, online social media and in particular Facebook (fb) is becoming an intrinsic part in the life of a growing proportion of individuals worldwide. Objective: Our primary objective is to identify the prevalence of depression in medical students at the Lebanese University Faculty of Medicine (unique state university in Lebanon) and its correlation with the utilization of the interactive features of fb. Methods: Students of the Lebanese University Faculty of Medicine were assessed for: (1) depression and (2) fb activity. To screen for major depression we used the PHQ-9 scale. As for fb activity we developed the Facebook Resorting Questionnaire (FbRQ), which measures the degree of fb resorting. Results: Three hundred and sixty five (76%) out of 480 students participated in the survey. Twenty four were excluded hence 341 students were finally included. Current depression was reported in 117 students (34.31%) with a (2.25:1) female to male ratio; 81 out of 195 females (41.5%) versus 36 out of 146 males (24.6%). Moreover, 41 depressed students resorted to fb (35%) compared to 73 non-depressed students (32.5%). There was a strong correlation between depression and fb- resorting (P= .001) and depressed users resorted more to fb than the non- depressed. Conclusions: This study showed that depression was highly prevalent among students of the Faculty of Medicine at the Lebanese University. Moreover fb may be a promising helpful psychological tool for optimizing the management of depression. Our study brought to bear further questions that now prompt further observation and scrutiny to know more about the high rates of depression in this student population more so in this part of the world and to the growing role of social media.

  • Meaningful Use: Experiences from the Field and Future Opportunities

    Date Submitted: Apr 19, 2015

    Open Peer Review Period: Apr 20, 2015 - Jun 15, 2015

    Background: With the aim of improving health care processes through health information technology (HIT), the U.S. government has promulgated requirements for “meaningful use” (MU) of electronic he...

    Background: With the aim of improving health care processes through health information technology (HIT), the U.S. government has promulgated requirements for “meaningful use” (MU) of electronic health records (EHRs) as a condition for providers receiving financial incentives for the adoption and use of these systems. Considerable uncertainty remains as to the impact of these requirements on the effective application of EHR systems. Objective: The Agency for Healthcare Research and Quality (AHRQ)-sponsored Centers for Education and Research in Therapeutics (CERTs) critically examined the impact of the MU policy relating to the use of medications, and jointly developed recommendations to help inform future HIT policy. Methods: We gathered perspectives from a wide range of stakeholders who had experience with MU requirements, including academicians, practitioners, policy makers from different health care organizations including and beyond the CERTs. Specific issues and recommendations were discussed and agreed upon as a group. Results: Stakeholders’ knowledge and experiences from implementing MU requirements fell into six domains: (1) accuracy of medication lists and medication reconciliation, (2) problem list accuracy and the shift in HIT priorities, (3) accuracy of allergy lists and allergy-related standards development, (4) support of safer and effective prescribing for children, (5) considerations for rural communities, and (6) general issues with achieving MU. Standards are needed to better facilitate the exchange of data elements between health care settings. Several organizations felt that their pre-occupation with fulfilling MU requirements stifled innovation. Greater emphasis should be placed on local HIT configurations that better address population health care needs. Conclusions: While MU has stimulated adoption of EHRs, its effects on quality and safety remain uncertain. Stakeholders felt that MU requirements should be more flexible, and recognize that integrated models may achieve information-sharing goals in alternate ways. Future certification rules and requirements should enhance EHR functionalities critical for safer prescribing of medications in children. Clinical Trial: Not applicable

  • Developing a mHealth Campaign: Utilizing Principles of Health Communications

    Date Submitted: Apr 16, 2015

    Open Peer Review Period: Apr 17, 2015 - Jun 12, 2015

    Mobile health (mHealth), or the use of mobile devices to improve health, is increasingly used as a powerful campaign tool in health communications. However, there is few peer-reviewed literature outli...

    Mobile health (mHealth), or the use of mobile devices to improve health, is increasingly used as a powerful campaign tool in health communications. However, there is few peer-reviewed literature outlining how a mHealth campaign can be developed according to established principles of health communications. We outline ten steps to guide campaign development, followed by an exemplar detailing how the steps can be used in an example campaign.