JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 4.5 for 2015

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  • Source:; CC license, Attribution jcomp/Freepik, modified using (CC0 Public Domain).

    Electronic Quality of Life Assessment Using Computer-Adaptive Testing


    Background: Quality of life (QoL) questionnaires are desirable for clinical practice but can be time-consuming to administer and interpret, making their widespread adoption difficult. Objective: Our aim was to assess the performance of the World Health Organization Quality of Life (WHOQOL)-100 questionnaire as four item banks to facilitate adaptive testing using simulated computer adaptive tests (CATs) for physical, psychological, social, and environmental QoL. Methods: We used data from the UK WHOQOL-100 questionnaire (N=320) to calibrate item banks using item response theory, which included psychometric assessments of differential item functioning, local dependency, unidimensionality, and reliability. We simulated CATs to assess the number of items administered before prespecified levels of reliability was met. Results: The item banks (40 items) all displayed good model fit (P>.01) and were unidimensional (fewer than 5% of t tests significant), reliable (Person Separation Index>.70), and free from differential item functioning (no significant analysis of variance interaction) or local dependency (residual correlations < +.20). When matched for reliability, the item banks were between 45% and 75% shorter than paper-based WHOQOL measures. Across the four domains, a high standard of reliability (alpha>.90) could be gained with a median of 9 items. Conclusions: Using CAT, simulated assessments were as reliable as paper-based forms of the WHOQOL with a fraction of the number of items. These properties suggest that these item banks are suitable for computerized adaptive assessment. These item banks have the potential for international development using existing alternative language versions of the WHOQOL items.

  • ER. Image created and copyright owned by authors Lauren Stephanie Chernick et al.

    Adolescent Female Text Messaging Preferences to Prevent Pregnancy After an Emergency Department Visit: A Qualitative Analysis


    Background: Over 15 million adolescents use the emergency department (ED) each year in the United States. Adolescent females who use the ED for medical care have been found to be at high risk for unintended pregnancy. Given that adolescents represent the largest users of text messaging and are receptive to receiving text messages related to their sexual health, the ED visit represents an opportunity for intervention. Objective: The aim of this qualitative study was to explore interest in and preferences for the content, frequency, and timing of an ED-based text message intervention to prevent pregnancy for adolescent females. Methods: We conducted semistructured, open-ended interviews in one urban ED in the United States with adolescent females aged 14-19 years. Eligible subjects were adolescents who were sexually active in the past 3 months, presented to the ED for a reproductive health complaint, owned a mobile phone, and did not use effective contraception. Using an interview guide, enrollment continued until saturation of key themes. The investigators designed sample text messages using the Health Beliefs Model and participants viewed these on a mobile phone. The team recorded, transcribed, and coded interviews based on thematic analysis using the qualitative analysis software NVivo and Excel. Results: Participants (n=14) were predominantly Hispanic (13/14; 93%), insured (13/14; 93%), ED users in the past year (12/14; 86%), and frequent text users (10/14; 71% had sent or received >30 texts per day). All were interested in receiving text messages from the ED about pregnancy prevention, favoring messages that were “brief,” “professional,” and “nonaccusatory.” Respondents favored texts with links to websites, repeated information regarding places to receive “confidential” care, and focused information on contraception options and misconceptions. Preferences for text message frequency varied from daily to monthly, with random hours of delivery to maintain “surprise.” No participant feared that text messages would violate her privacy. Conclusions: Adolescent female patients at high pregnancy risk are interested in ED-based pregnancy prevention provided by texting. Understanding preferences for the content, frequency, and timing of messages can guide in designing future interventions in the ED.

  • Business woman. Image sourced and purchased by authors. Image source:

    Exploring the Relationship Between Online Social Network Site Usage and the Impact on Quality of Life for Older and Younger Users: An Interaction Analysis


    Background: Analyzing content generated by users of social network sites has been shown to be beneficial across a number of disciplines. Such analysis has revealed the precise behavior of users that details their distinct patterns of engagement. An issue is evident whereby without direct engagement with end users, the reasoning for anomalies can only be the subject of conjecture. Furthermore, the impact of engaging in social network sites on quality of life is an area which has received little attention. Of particular interest is the impact of online social networking on older users, which is a demographic that is specifically vulnerable to social isolation. A review of the literature reveals a lack of knowledge concerning the impact of these technologies on such users and even less is known regarding how this impact varies across different demographics. Objective: The objective of our study was to analyze user interactions and to survey the attitudes of social network users directly, capturing data in four key areas: (1) functional usage, (2) behavioral patterns, (3) technology, and (4) quality of life. Methods: An online survey was constructed, comprising 32 questions. Each question directly related to a research question. Respondents were recruited through a variety of methods including email campaigns, Facebook advertisements, and promotion from related organizations. Results: In total, data was collected from 919 users containing 446 younger and 473 older users. In comparison to younger users, a greater proportion of older users (289/473, 61.1% older vs 218/446, 48.9% younger) (P<.001) stated that Facebook had either a positive or huge impact on their quality of life. Furthermore, a greater percentage of older users strongly agreed that Facebook strengthened their relationship with other people (64/473, 13.5% older vs 40/446, 9.0%younger) (P=.02). In comparison to younger users, a greater proportion of older users had more positive emotions—classified as slightly better or very good—during their engagement with Facebook (186/473, 39.3% older vs 120/446, 26.9% younger) (P<.001). Conclusions: The results reveal that despite engaging at considerably lower rates with significantly fewer connections, older users gain a greater quality-of-life benefit. Results disclose how both cohorts vary in their use, interactions, and rationale for engaging with Facebook.

  • BACRA. Image source and copyright owned by the authors Irene et al.

    Design and Testing of BACRA, a Web-Based Tool for Middle Managers at Health Care Facilities to Lead the Search for Solutions to Patient Safety Incidents


    Background: Lack of time, lack of familiarity with root cause analysis, or suspicion that the reporting may result in negative consequences hinder involvement in the analysis of safety incidents and the search for preventive actions that can improve patient safety. Objective: The aim was develop a tool that enables hospitals and primary care professionals to immediately analyze the causes of incidents and to propose and implement measures intended to prevent their recurrence. Methods: The design of the Web-based tool (BACRA) considered research on the barriers for reporting, review of incident analysis tools, and the experience of eight managers from the field of patient safety. BACRA’s design was improved in successive versions (BACRA v1.1 and BACRA v1.2) based on feedback from 86 middle managers. BACRA v1.1 was used by 13 frontline professionals to analyze incidents of safety; 59 professionals used BACRA v1.2 and assessed the respective usefulness and ease of use of both versions. Results: BACRA contains seven tabs that guide the user through the process of analyzing a safety incident and proposing preventive actions for similar future incidents. BACRA does not identify the person completing each analysis since the password introduced to hide said analysis only is linked to the information concerning the incident and not to any personal data. The tool was used by 72 professionals from hospitals and primary care centers. BACRA v1.2 was assessed more favorably than BACRA v1.1, both in terms of its usefulness (z=2.2, P=.03) and its ease of use (z=3.0, P=.003). Conclusions: BACRA helps to analyze incidents of safety and to propose preventive actions. BACRA guarantees anonymity of the analysis and reduces the reluctance of professionals to carry out this task. BACRA is useful and easy to use.

  • A medical officer explains an x-ray to the patient. Source: Copyright: Rhoda Baer. License: Public Domain.

    Using Foreign Virtual Patients With Medical Students in Germany: Are Cultural Differences Evident and Do They Impede Learning?


    Background: Learning with virtual patients (VPs) is considered useful in medical education for fostering clinical reasoning. As the authoring of VPs is highly demanding, an international exchange of cases might be desirable. However, cultural differences in foreign VPs might hamper learning success. Objective: We investigated the need for support for using VPs from the United States at a German university, with respect to language and cultural differences. Our goal was to better understand potential implementation barriers of a intercultural VP exchange. Methods: Two VPs were presented to 30 German medical students featuring a cultural background different from German standards with respect to diagnostic and therapeutic procedures, ethical aspects, role models, and language (as identified by a cultural adaptation framework). Participants were assigned to two groups: 14 students were advised to complete the cases without further instructions (basic group), and 16 students received written explanatory supplemental information specifically with regard to cultural differences (supplement group). Using a 6-point scale (6=strongly agree), we analyzed the results of an integrated assessment of learning success as well as an evaluation of cases by the students on usefulness for learning and potential issues regarding the language and cultural background. Results: The German students found it motivating to work with cases written in English (6-point scale, 4.5 points). The clinical relevance of the VPs was clearly recognized (6 points), and the foreign language was considered a minor problem in this context (3 points). The results of the integrated learning assessment were similar in both groups (basic 53% [SD 4] vs supplement 52% [SD 4] correct answers, P=.32). However, students using the supplemental material more readily realized culturally different diagnostic and therapeutic strategies (basic 4 vs supplement 5 points, P=.39) and were less affirmative when asked about the transferability of cases to a German context (basic 5 vs supplement 3 points, P=.048). Conclusions: German students found English VPs to be highly clinically relevant, and they rated language problems much lower than they rated motivation to work on cases in English. This should encourage the intercultural exchange of VPs. The provision of supplemental explanatory material facilitates the recognition of cultural differences and might help prevent unexpected learning effects.

  • 9/11 Veterans. Image created and permission granted by James Greene, SFC (Ret.), Vermont Army National Guard.

    Post-9/11 Veterans and Their Partners Improve Mental Health Outcomes with a Self-directed Mobile and Web-based Wellness Training Program: A Randomized...


    Background: Veterans with history of deployment in the Global War on Terror face significant and ongoing challenges with high prevalences of adverse psychological, physical, spiritual, and family impacts. Together, these challenges contribute to an emerging public health crisis likely to extend well into the future. Innovative approaches are needed that reach veterans and their family members with strategies they can employ over time in their daily lives to promote improved adjustment and well-being. Objective: The objective of this study was to evaluate effects of use of a Web-based, self-directed program of instruction in mind- and body-based wellness skills to be employed by Global War on Terror veterans and their significant relationship partners on mental health and wellness outcomes associated with postdeployment readjustment. Methods: We recruited 160 veteran-partner dyads in 4 regions of the United States (San Diego, CA; Dallas, TX; Fayetteville, NC; and New York, NY) through publicity by the Iraq and Afghanistan Veterans of America to its membership. Dyads were randomly allocated to 1 of 4 study arms: Mission Reconnect (MR) program alone, MR plus the Prevention and Relationship Enhancement Program (PREP) for Strong Bonds weekend program for military couples, PREP alone, and waitlist control. We administered a battery of standardized and investigator-generated instruments assessing mental health outcomes at baseline, 8 weeks, and 16 weeks. Dyads in the MR arms were provided Web-based and mobile app video and audio instruction in a set of mindfulness-related stress reduction and contemplative practices, as well as partner massage for reciprocal use. All participants provided weekly reports on frequency and duration of self-care practices for the first 8 weeks, and at 16 weeks. Results: During the first 8-week reporting period, veterans and partners assigned to MR arms used some aspect of the program a mean of 20 times per week, totaling nearly 2.5 hours per week, with only modest declines in use at 16 weeks. Significant improvements were seen at 8 and 16 weeks in measures of posttraumatic stress disorder, depression, sleep quality, perceived stress, resilience, self-compassion, and pain for participants assigned to MR arms. In addition, significant reductions in self-reported levels of pain, tension, irritability, anxiety, and depression were associated with use of partner massage. Conclusions: Both veterans and partners were able to learn and make sustained use of a range of wellness practices taught in the MR program. Home-based, self-directed interventions may be of particular service to veterans who are distant from, averse to, or prohibited by schedule from using professional services. Leveraging the partner relationship may enhance sustained use of self-directed interventions for this population. Use of the MR program appears to be an accessible, low-cost approach that supports well-being and reduces multiple symptoms among post-9/11 veterans and their partners. Trial Registration: NCT01680419; (Archived by WebCite at

  • Senior using phone. Image source: License: CC0 Public Domain.

    The Inclusion of Ethnic Minority Patients and the Role of Language in Telehealth Trials for Type 2 Diabetes: A Systematic Review


    Background: Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and prevent secondary complications. However, trials designed to test the effectiveness of telehealth interventions may underrecruit or exclude ethnic minority patients, with language a potential barrier to recruitment. The underrepresentation of minorities in trials limits the external validity of the findings for this key patient demographic. Objective: This systematic review examines (1) the research reporting practices and prevalence of ethnic minority patients included in telehealth randomized controlled trials (RCTs) targeting type 2 diabetes and the trial characteristics associated with recruiting a high proportion of minority patients, and (2) the proportion of included RCTs that report using English language proficiency as a patient screening criterion and how and why they do so. Methods: Telehealth RCTs published in refereed journals targeting type 2 diabetes as a primary condition for adults in Western majority English-speaking countries were included. Ethnically targeted RCTs were excluded from the main review, but were included in a post hoc subgroup analysis. Abstract and full-text screening, risk of bias assessment, and data extraction were independently conducted by two reviewers. Results: Of 3358 records identified in the search, 79 articles comprising 58 RCTs were included. Nearly two-thirds of the RCTs (38/58) reported on the ethnic composition of participants, with a median proportion of 23.5% patients (range 0%-97.7%). Fourteen studies (24%) that included at least 30% minority patients were all US-based, predominantly recruited from urban areas, and described the target population as underserved, financially deprived, or uninsured. Eight of these 14 studies (57%) offered intervention materials in a language other than English or employed bilingual staff. Half of all identified RCTs (29/58) included language proficiency as a participant-screening criterion. Language proficiency was operationalized using nonstandardized measures (eg, having sufficient “verbal fluency”), with only three studies providing reasons for excluding patients on language grounds. Conclusions: There was considerable variability across studies in the inclusion of ethnic minority patients in RCTs, with higher participation rates in countries with legislation to mandate their inclusion (eg, United States) than in those without such legislation (eg, United Kingdom). Less than 25% of the RCTs recruited a sizeable proportion of ethnic minorities, which raises concerns about external validity. The lack of objective measures or common procedures for assessing language proficiency across trials implies that language-related eligibility decisions are often based on trial recruiters’ impressionistic judgments, which could be subject to bias. The variability and inconsistent reporting on ethnicity and other socioeconomic factors in descriptions of research participants could be more specifically emphasized in trial reporting guidelines to promote best practice. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRD42015024899; (Archived by WebCite at

  • Balance It icon. Image sourced and copyright owned by author Pepijn van Empelen (TNO).

    Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors (“Balance It”): A Pilot Study


    Background: Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of “Balance It,” a serious self-regulation game intervention targeting students’ overweight-related behaviors: dietary intake and physical activity (PA). Objective: We aimed to pilot the effects of Balance It on secondary vocational education students’ dietary intake and PA. Methods: In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8% (145/231) were female, and 26.8% (62/231) had a non-Dutch background. Body mass index (BMI kg/m2) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants. Results: After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6% (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users’ snack consumption decreased more strongly (active users: mean change=–0.20; control group: mean change=–0.08; beta=–0.36, P=.01, R2 change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=–0.12; beta=1.58, P=.02, R2 change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R2 change=.04) and action control (active users: mean change=0.63; control group: mean change=–0.05; beta=1.25, P=.001, R2 change=.08) in terms of unhealthy eating. Conclusions: The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6%). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight.

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

    Professional Use of Social Media by Pharmacists: A Qualitative Study


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

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

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


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

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

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


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

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

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


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

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  • Effect of caffeine on attention and alertness measured in a home-setting, using web-based cognition tests

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: Background: There is an increasing interest among nutritional researchers to perform life style and nutritional intervention studies in a home setting instead of testing subjects in a clin...

    Background: Background: There is an increasing interest among nutritional researchers to perform life style and nutritional intervention studies in a home setting instead of testing subjects in a clinical unit. The term used in other disciplines is ‘ecological validity’ stressing a realistic situation. This becomes more and more feasible since devices and self-tests that enable such studies are more commonly available. Here we present such a study, in which we reproduced the effect of caffeine on attention and alertness in an at-home setting. Objective: Objective: The study is aimed to reproduce the effect of caffeine on attention and alertness using a web-based study environment of subjects at home performing different online cognition tests. Methods: Study design: The study is designed as a randomized, placebo-controlled, double blind, cross-over study. Methods: Subjects were provided with coffee sachets (two with and two without caffeine). They were also provided with a written instruction of the test days. Healthy volunteers consumed a cup of coffee after an overnight fast. Coffee was prepared from a sachet containing either regular coffee or decaf coffee. Each intervention was repeated once. Before and one hour after coffee consumption subjects performed online cognitive performance tests at home which measured alertness and attention, established by three computerized tests provided by Quantified Mind. Each test was performed for five minutes. Results: The recruitment via internet was fast and efficient. Within two weeks about 100 subjects applied of whom 70 were eligible. Of these, 53 completed all four test sessions, indicating that they were able to perform the do it yourself tests at home correctly. The Go-NoGo cognition test performed at home showed the same significant improvement in performance with caffeine as found in controlled studies in a metabolic ward. Conclusions: The study showed that the effects of caffeine consumption on a cognition test in an at-home setting revealed similar results as in a controlled setting. The Go-NoGo test applied showed improved results after caffeine intake, similar as seen in clinical trials. This type of study thus is a fast, reliable, economical and easy way to demonstrate effectiveness of a supplement and is rapidly becoming a viable alternative for the classical RCT to evaluate life style and nutritional interventions. Clinical Trial: Registration of the study was done at (NCT 02061982).

  • The Impact of Internet Health Information on the Physiotherapist-Patient Relationship: the Case of the Lebanese Community.

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: With the evolution of the internet and communication media, endless information are made available for all individuals, most of the time free of charge. The health care field seems to be o...

    Background: With the evolution of the internet and communication media, endless information are made available for all individuals, most of the time free of charge. The health care field seems to be of high interest for patients who surf the net for pathology definitions, symptoms, treatments and medications mostly before visiting a health practitioner. No matter the quantity of information found on the internet, the quality and credibility of this information is sometimes questionable, leading to undesirable health outcomes or resulting in inappropriate requests for clinical interventions. Few researches on physiotherapy were generally conducted and almost none in Lebanon and none targeted specifically the impact of internet use for medical information research. Objective: This research attempts to examine the effect of searching for health related information by patients over the internet on the physiotherapist-patient relationship, exploring particularly how the online medical information can affect the physiotherapist-patient relationship and the patients’ acceptance of the physiotherapist’s medical approach. Methods: This research adopts a positivist and deductive approach, based on similar studies conducted in the context of other health care specialties. A questionnaire-based survey was sent using communication media to a representative sample population and data was computerized and analyzed using SPSS program to be able to analyze the results and accept or reject H1 and H2. Results: According to the order of physiotherapist in Lebanon2, 1935 physiotherapists are currently registered at the order and working within the Lebanon territory. Our sample is 92 physiotherapists, chosen from those registered at the OPTL, distributed in Lebanon, using an acceptable error of 10% and a confidence level of 95%. Eighty six percent of the physiotherapists valued the recent increase of health information on the internet. Eighty percent found the time to discuss that information with their patients. Seventy three percent believed that the latter positively affects the physiotherapist-patient relationship and eighty one percent said that it positively engages patients in the treatment plan. For H1, 32% of the variation in the physiotherapist-patient relationship was caused by seeking health information on the internet, and in H2: 27.2% of the variation in the acceptance of the physiotherapist’s medical plan was caused by seeking health information on the internet. Conclusions: This study is the first of its kind in the physiotherapy field in general and in Lebanon specifically, aiming to explore the impact of the medical information research on the internet and how it affects the physiotherapist-patient relationship. This study can help raising PTs awareness on how to use appropriate skills to assist their patients in facing information overflow and achieving good health outcomes.

  • Internet-based cognitive behaviour therapy for stress, anxiety and depressive symptoms among perinatal women: A systematic review and meta-analysis

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: A growing number of meta-analyses have supported the application of Internet-based cognitive behaviour therapy (iCBT) for psychological disorders across different populations, but relative...

    Background: A growing number of meta-analyses have supported the application of Internet-based cognitive behaviour therapy (iCBT) for psychological disorders across different populations, but relatively few meta-analyses have concentrated on perinatal women. Objective: This meta-analysis evaluated the efficacy of iCBT in improving stress, anxiety and depressive symptoms among perinatal women. Methods: Ten electronic databases were used to search for published and unpublished trials. Cochrane Collaboration’s tool for assessing risk of bias was utilised to measure methodological quality. Meta-analysis was performed using RevMan software. Among the 789 studies identified, nine randomised controlled trials were selected, involving 1,626 participants across seven countries. Results: More than half (63%) of the selected studies had a low risk of bias with no to moderate heterogeneity. Results revealed that iCBT significantly improved stress (d = 0.70, n = 6), anxiety (d = 0.32, n = 7) and depressive symptoms (d = 0.63, n = 8,) of the intervention group compared to those of the control group at post-intervention. Significant subgroup differences according to different control conditions and supportive types were found on stress symptoms. Conclusions: This review revealed that iCBT significantly improve stress, anxiety, and depressive symptoms among perinatal women with small to medium effects. Future effectiveness studies should establish the essential components, format and approach of iCBT with optimal levels of human support to maximize a long-term effect.

  • Non-participation in Videoconferencing-based Treatment for Alcohol Use Disorder

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: We recently conducted an effectiveness study randomized controlled pilot trial concerning videoconferencing-based treatment for alcohol use disorder (AUD). In short, the aim was to test if...

    Background: We recently conducted an effectiveness study randomized controlled pilot trial concerning videoconferencing-based treatment for alcohol use disorder (AUD). In short, the aim was to test if optional videoconferencing increases adherence and effect in treatment for AUD. Due to a lower patient- and participation rate than anticipated arose the opportunity and need to examine why the patients declined to participate in the effectiveness study. Objective: To examine non-participants’ barriers against participating in an effectiveness study randomized controlled pilot trial and to examine differences between participants and non-participants. Objective: To examine non-participants’ barriers against participating in an effectiveness study randomized controlled pilot trial and to examine differences between participants and non-participants. Methods: The design of this study was mixed methods; an analysis of barriers against participating using an anonymous questionnaire filled out by non-participants, and a comparative analysis of participants and non-participants using data from a clinical database. Results: 43 non-participants filled out the questionnaire. Two categories were derived: scientific barriers, which were barriers against the scientific study in general, and technical barriers, which were barriers against using a laptop and/or videoconferencing in specific. 6 patients stated scientific barriers: of these, 6 patients declined to participate in a research project, and 1 patient also declined to participate in a randomization. 27 patients stated technical barriers: of these, 22 patients declined to use videoconferencing, 12 declined to learn how to use a laptop, and 13 declined to spend time learning it. Non-participants who had technical barriers to participating in the study were older, more often female and part of the work force than those who did not have technical barriers. 13 patients elaborated on technical barriers. 9 patients found it impersonal, preferred personal contact, and would rather attend face-to-face treatment at the clinic. There were no significant differences between participants and non-participants according to socio-demographics, alcohol measures, and composite scores. Conclusions: Patients’ barriers against participating in the effectiveness study were mainly concerned with the technology. They declined to participate because they refused to receive treatment via videoconferencing. Clinical Trial: The regional health research ethics committee system in Southern Denmark, S-20110052

  • Techniques for Improving Communication of Emotional Content in Text-only Online Therapeutic Communications – A Systematic Review

    Date Submitted: Sep 30, 2016

    Open Peer Review Period: Sep 30, 2016 - Nov 25, 2016

    Background: Online typed exchanges are increasingly used by professionals to provide emotional support to patients. Although some empirical evidence exists to suggest that various strategies may be us...

    Background: Online typed exchanges are increasingly used by professionals to provide emotional support to patients. Although some empirical evidence exists to suggest that various strategies may be used to convey emotion during online typed exchanges, there has been no critical review of these data. Objective: The objective of this review was to identify the techniques used to convey emotion in written or typed online communication and assess the empirical evidence regarding impact on communication and psychological outcomes. Methods: An electronic search of databases including Medline, CINAHL, PsycINFO, Embase and the Cochrane Library was conducted to identify literature published between 1990 and 2015. Searches were also conducted using Google Scholar, manual searching of reference lists of identified articles and manual searching of tables of contents for selected relevant journals. Data extraction and coding were completed by two reviewers. Publications were assessed against the eligibility criteria and excluded if they: were duplicates; were not published in English; were published before 1990; referenced animal/non-human subjects; did not describe original research; were not journal articles; or did not empirically test the effect of one or more non-verbal communication techniques (for instance smilies, emoticons, emotional bracketing, voice accentuation, trailers (ellipsis) and pseudowords) as part of online, web-based or typed communication on communication-related variables including: message interpretation, social presence, the nature of the interaction (e.g. therapeutic alliance), consumer perceptions of the interaction (e.g. participant satisfaction), or psychological outcomes including depression, anxiety and distress. Results: A total of 4617 unique publications were identified. Of these, four publications met the eligibility criteria and were included in a narrative synthesis. All four studies addressed the effect of smilies or emoticons on participant responses, message interpretation or social presence of the writer. It was found that smilies and emoticons were able to convey a limited amount of emotion. No studies addressed other techniques for conveying emotion in written communication. No studies addressed the effects of any techniques on the nature of the interaction (e.g. therapeutic alliance), consumer perceptions of the interaction (e.g. participant satisfaction) or psychological outcomes (depression, anxiety or distress). Conclusions: There is a need for greater empirical attention to the effects of the various proposed techniques for conveying emotion in online or typed communications in order to inform health service providers regarding best-practice online communication skills.

  • Telehealth interventions to support self-management of long-term conditions: a systematic meta-review of diabetes, heart failure, asthma, chronic obstructive pulmonary disease and cancer.

    Date Submitted: Sep 26, 2016

    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. This meta-review synthesises evidence for te...

    Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. This meta-review synthesises evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Objective: The objectives of this review were a) to assess the impact of telehealth interventions to support self-management on disease control and healthcare utilisation, and b) to identify components of telehealth support and their impact on disease control and the process of self-management. Methods: We performed a meta-review (a systematic review of systematic reviews) of randomised controlled trials (RCTs) of telehealth interventions to support self-management in six exemplar long-term conditions. Seven databases were searched from January 2000 to May 2016 and studies screened against eligibility criteria. Reviews were weighted by quality (R-AMSTAR), size and relevance). Results were combined in a narrative synthesis and using Harvest Plots. Results: Fifty-three systematic reviews, comprising 232 unique RCTs, were included. Reviews concerned diabetes (type 1 (n=6), type 2 (n=11), mixed (n=19)), heart failure (n=9), asthma (n=7), COPD (n=7) and cancer (n=3). Findings varied between and within disease areas. The highest weighted reviews showed blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycaemic control in type-2, but not type-1, diabetes; telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure; but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multi-faceted interventions were associated with greater improvements in diabetes, heart failure and asthma. Conclusions: While not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth represents a safe option for delivery for self-management support, particularly in conditions such as heart failure and type 2 diabetes where the evidence base is more developed. Larger scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.