JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 5.175 for 2016

Recent Articles:

  • HPV in Young Males (HYM) study website. Source: Image created by the Authors; Copyright: Dorothy Machalek; URL:; License: Creative Commons Attribution (CC-BY).

    Using Facebook to Recruit Young Australian Men Into a Cross-Sectional Human Papillomavirus Study


    Background: Young men can be difficult to engage in health research using traditional methods of recruitment. Social networking sites are increasingly being used to recruit participants into health research, due to their cost effectiveness, overall generalizability, and wide reach. Objective: The aim of this study was to determine the feasibility of using Facebook to recruit young Australian men into a human papillomavirus (HPV) prevalence study. Methods: We recruited male permanent residents of Australia, aged 18 to 35 years, into the HPV in Young Males (HYM) study through targeted advertising placed on Facebook. Consenting participants completed an online questionnaire and provided a self-collected penile swab for HPV DNA detection and genotyping. We compared sociodemographic characteristics of the study population with those of the general Australian male population, based on Australian 2011 census data. Results: Between February 2015 and February 2017, targeted Facebook advertisements reached 1,523,239 men, resulting in 41,811 clicks through to the study website, with 1072 (2.56%) converting to lodgment of an expression of interest. Of these, 681 (63.53%) provided written informed consent and 535 (78.6% of recruited participants) completed all the study requirements. Reasons for participating in the study included altruism, past history of HPV, gaining more knowledge about HPV or the vaccine, working in the health industry, and the monetary compensation. The average advertising cost per completed study participant was Aus $48. Compared with the census population, HYM study participants were more likely to be Australian born (P<.001), be from Victoria (P=.003) or the Australian Capital Territory (P=.004), reside in a major city (P<.001), and have completed undergraduate (P<.001) or postgraduate education (P<.001). HYM study participants were less likely to report being a current smoker (P=.03), but were more likely to identify as bisexual or homosexual (294/529, 55.6%, P<.001), than the general population. Conclusions: Using Facebook is a feasible and efficient strategy for the recruitment of men from across Australia for HPV testing. This method could be used for monitoring the impact of HPV vaccination. Additional targeting may achieve a sample that is broadly demographically representative of the Australian population. Future research should explore how the sexual risk behavior characteristics of populations recruited through Facebook compare with those of traditional recruitment methods.

  • eHealth user and Embodied Conversational Agent. Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Self-Guided Web-Based Interventions: Scoping Review on User Needs and the Potential of Embodied Conversational Agents to Address Them


    Background: Web-based mental health interventions have evolved from innovative prototypes to evidence-based and clinically applied solutions for mental diseases such as depression and anxiety. Open-access, self-guided types of these solutions hold the promise of reaching and treating a large population at a reasonable cost. However, a considerable factor that currently hinders the effectiveness of these self-guided Web-based interventions is the high level of nonadherence. The absence of a human caregiver apparently has a negative effect on user adherence. It is unknown to what extent this human support can be handed over to the technology of the intervention to mitigate this negative effect. Objective: The first objective of this paper was to explore what is known in literature about what support a user needs to stay motivated and engaged in an electronic health (eHealth) intervention that requires repeated use. The second objective was to explore the current potential of embodied conversational agents (ECAs) to provide this support. Methods: This study reviews and interprets the available literature on (1) support within eHealth interventions that require repeated use and (2) the potential of ECAs by means of a scoping review. The rationale for choosing a scoping review is that the subject is broad, diverse, and largely unexplored. Themes for (1) and (2) were proposed based on grounded theory and mapped on each other to find relationships. Results: The results of the first part of this study suggest the presence of user needs that largely remain implicit and unaddressed. These support needs can be categorized as task-related support and emotion-related support. The results of the second part of this study suggest that ECAs are capable of engaging and motivating users of information technology applications in the domains of learning and behavioral change. Longitudinal studies must be conducted to determine under what circumstances ECAs can create and maintain a productive user relationship. Mapping the user needs on the ECAs’ capabilities suggests that different kinds of ECAs may provide different solutions for improving the adherence levels. Conclusions: Autonomous ECAs that do not respond to a user’s expressed emotion in real time but take on empathic roles may be sufficient to motivate users to some extent. It is unclear whether those types of ECAs are competent enough and create sufficient believability among users to address the user’s deeper needs for support and empathy. Responsive ECAs may offer a better solution. However, at present, most of these ECAs have difficulties to assess a user’s emotional state in real time during an open dialogue. By conducting future research with relationship theory–based ECAs, the added value of ECAs toward user needs can be better understood.

  • Source: Pixabay; Copyright: Gerd Altmann; URL:; License: Public Domain (CC0).

    Health-Seeking Influence Reflected by Online Health-Related Messages Received on Social Media: Cross-Sectional Survey


    Background: Major social networking platforms, such as Facebook, WhatsApp, and Twitter, have become popular means through which people share health-related information, irrespective of whether messages disseminated through these channels are authentic. Objective: This study aims to describe the demographic characteristics of patients that may demonstrate their attitudes toward medical information shared on social media networks. Second, we address how information found through social media affects the way people deal with their health. Third, we examine whether patients initiate or alter/discontinue their medications based on information derived from social media. Methods: We conducted a cross-sectional survey between April and June 2015 on patients attending outpatient clinics at King Abdulaziz University, Jeddah, Saudi Arabia. Patients who used social media (Facebook, WhatsApp, and Twitter) were included. We designed a questionnaire with closed-ended and multiple-choice questions to assess the type of social media platforms patients used and whether information received on these platforms influenced their health care decisions. We used chi-square test to establish the relationship between categorical variables. Results: Of the 442 patients who filled in the questionnaires, 401 used Facebook, WhatsApp, or Twitter. The majority of respondents (89.8%, 397/442) used WhatsApp, followed by Facebook (58.6%, 259/442) and Twitter (42.3%, 187/442). In most cases, respondents received health-related messages from WhatsApp and approximately 42.6% (171/401) reported ever stopping treatment as advised on a social media platform. A significantly higher proportion of patients without heart disease (P=.001) and obese persons (P=.01) checked the authenticity of information received on social media. Social media messages influenced decision making among patients without heart disease (P=.04). Respondents without heart disease (P=.001) and obese persons (P=.01) were more likely to discuss health-related information received on social media channels with a health care professional. A significant proportion of WhatsApp users reported that health-related information received on this platform influenced decisions regarding their family’s health care (P=.001). Respondents’ decisions regarding family health care were more likely to be influenced when they used two or all three types of platforms (P=.003). Conclusions: Health education in the digital era needs to be accurate, evidence-based, and regulated. As technologies continue to evolve, we must be equipped to face the challenges it brings with it.

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

    Patient Health Record Systems Scope and Functionalities: Literature Review and Future Directions


    Background: A new generation of user-centric information systems is emerging in health care as patient health record (PHR) systems. These systems create a platform supporting the new vision of health services that empowers patients and enables patient-provider communication, with the goal of improving health outcomes and reducing costs. This evolution has generated new sets of data and capabilities, providing opportunities and challenges at the user, system, and industry levels. Objective: The objective of our study was to assess PHR data types and functionalities through a review of the literature to inform the health care informatics community, and to provide recommendations for PHR design, research, and practice. Methods: We conducted a review of the literature to assess PHR data types and functionalities. We searched PubMed, Embase, and MEDLINE databases from 1966 to 2015 for studies of PHRs, resulting in 1822 articles, from which we selected a total of 106 articles for a detailed review of PHR data content. Results: We present several key findings related to the scope and functionalities in PHR systems. We also present a functional taxonomy and chronological analysis of PHR data types and functionalities, to improve understanding and provide insights for future directions. Functional taxonomy analysis of the extracted data revealed the presence of new PHR data sources such as tracking devices and data types such as time-series data. Chronological data analysis showed an evolution of PHR system functionalities over time, from simple data access to data modification and, more recently, automated assessment, prediction, and recommendation. Conclusions: Efforts are needed to improve (1) PHR data quality through patient-centered user interface design and standardized patient-generated data guidelines, (2) data integrity through consolidation of various types and sources, (3) PHR functionality through application of new data analytics methods, and (4) metrics to evaluate clinical outcomes associated with automated PHR system use, and costs associated with PHR data storage and analytics.

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

    Reducing Symptom Distress in Patients With Advanced Cancer Using an e-Alert System for Caregivers: Pooled Analysis of Two Randomized Clinical Trials


    Background: Symptom distress in patients toward the end of life can change rapidly. Family caregivers have the potential to help patients manage those symptoms, as well as their own stress, if they are equipped with the proper resources. Electronic health (eHealth) systems may be able to provide those resources. Very sick patients may not be able to use such systems themselves to report their symptoms but family caregivers could. Objective: The aim of this paper was to assess the effects on cancer patient symptom distress of an eHealth system that alerts clinicians to significant changes in the patient’s symptoms, as reported by a family caregiver. Methods: A pooled analysis from two randomized clinical trials (NCT00214162 and NCT00365963) compared outcomes at 12 months for two unblinded groups: a control group (Comprehensive Health Enhancement Support System [CHESS]-Only) that gave caregivers access to CHESS, an online support system, and an experimental group (CHESS+CR [Clinician Report]), which also had CHESS but with a CR that automatically alerted clinicians if symptoms exceeded a predetermined threshold of severity. Participants were dyads (n=235) of patients with advanced lung, breast, or prostate cancer and their respective family caregivers from 5 oncology clinics in the United States of America. The proportion of improved patient threshold symptoms was compared between groups using area-under-the-curve analysis and binomial proportion tests. The proportion of threshold symptoms out of all reported symptoms was also examined. Results: When severe caregiver-reported symptoms were shared with clinicians, the symptoms were more likely to be subsequently reported as improved than when the symptoms were not shared with clinicians (P<.001). Fewer symptom reports were completed in the group of caregivers whose reports went to clinicians than in the CHESS-Only group (P<.001), perhaps because caregivers, knowing their reports might be sent to a doctor, feared they might be bothering the clinician. Conclusions: This study suggests that an eHealth system designed for caregivers that alerts clinicians to worrisome changes in patient health status may lead to reduced patient distress. Trial Registration: NCT00214162; (Archived by WebCite at and NCT00365963; (Archived by WebCite at

  • The 10,000 Steps website landing page.(montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Effectiveness of a Web 2.0 Intervention to Increase Physical Activity in Real-World Settings: Randomized Ecological Trial


    Background: The translation of Web-based physical activity intervention research into the real world is lacking and becoming increasingly important. Objective: To compare usage and effectiveness, in real-world settings, of a traditional Web 1.0 Web-based physical activity intervention, providing limited interactivity, to a Web 2.0 Web-based physical activity intervention that includes interactive features, such as social networking (ie, status updates, online “friends,” and personalized profile pages), blogs, and Google Maps mash-ups. Methods: Adults spontaneously signing up for the freely available 10,000 Steps website were randomized to the 10,000 Steps website (Web 1.0) or the newly developed WALK 2.0 website (Web 2.0). Physical activity (Active Australia Survey), quality of life (RAND 36), and body mass index (BMI) were assessed at baseline, 3 months, and 12 months. Website usage was measured continuously. Analyses of covariance were used to assess change over time in continuous outcome measures. Multiple imputation was used to deal with missing data. Results: A total of 1328 participants completed baseline assessments. Only 3-month outcomes (224 completers) were analyzed due to high attrition at 12 months (77 completers). Web 2.0 group participants increased physical activity by 92.8 minutes per week more than those in the Web 1.0 group (95% CI 28.8-156.8; P=.005); their BMI values also decreased more (–1.03 kg/m2, 95% CI –1.65 to -0.41; P=.001). For quality of life, only the physical functioning domain score significantly improved more in the Web 2.0 group (3.6, 95% CI 1.7-5.5; P<.001). The time between the first and last visit to the website (3.57 vs 2.22 weeks; P<.001) and the mean number of days the website was visited (9.02 vs 5.71 days; P=.002) were significantly greater in the Web 2.0 group compared to the Web 1.0 group. The difference in time-to-nonusage attrition was not statistically significant between groups (Hazard Ratio=0.97, 95% CI 0.86-1.09; P=.59). Only 21.99% (292/1328) of participants (n=292 summed for both groups) were still using either website after 2 weeks and 6.55% (87/1328) were using either website after 10 weeks. Conclusions: The website that provided more interactive and social features was more effective in improving physical activity in real-world conditions. While the Web 2.0 website was visited significantly more, both groups nevertheless displayed high nonusage attrition and low intervention engagement. More research is needed to examine the external validity and generalizability of Web-based physical activity interventions. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12611000253909; /Trial/Registration/TrialReview.aspx?id=336588&isReview=true (Archived by WebCite at 2HxD)

  • Source: Pixabay; Copyright: Concord90; URL:; License: Public Domain (CC0).

    Tailored Web-Based Interventions for Pain: Systematic Review and Meta-Analysis


    Background: Efforts have multiplied in the past decade to underline the importance of pain management. For both acute and chronic pain management, various barriers generate considerable treatment accessibility issues, thereby providing an opportunity for alternative intervention formats to be implemented. Several systematic reviews on Web-based interventions with a large emphasis on chronic pain and cognitive behavioral therapy have been recently conducted to explore the influence of these interventions on pain management However, to our knowledge, the specific contribution of tailored Web-based interventions for pain management has not been described and their effect on pain has not been evaluated. Objective: The primary aim of this systematic review was to answer the following research question: What is the effect of tailored Web-based pain management interventions for adults on pain intensity compared with usual care, face-to-face interventions, and standardized Web-based interventions? A secondary aim was to examine the effects of these interventions on physical and psychological functions. Methods: We conducted a systematic review of articles published from January 2000 to December 2015. We used the DerSimonian-Laird random effects models with 95% confidence intervals to calculate effect estimates for all analyses. We calculated standardized mean differences from extracted means and standard deviations, as outcome variables were measured on different continuous scales. We evaluated 5 different outcomes: pain intensity (primary outcome), pain-related disability, anxiety, depression, and pain catastrophizing. We assessed effects according to 3 time intervals: short term (<1 month), medium term (1-6 months), and long term (6-12 months). Results: After full-text review, we excluded 31 articles, resulting in 17 eligible studies. Only 1 study concerned acute pain and was removed from the meta-analysis, resulting in 16 studies available for quantitative assessment. Compared with standard care or a waiting list, tailored Web-based intervention showed benefits immediately after, with small effect sizes (<0.40) for pain intensity (10 randomized controlled trials [RCTs], n=1310, P=.003) and pain-related disability (6 RCTs, n=953, P<.001). No other improvements were observed at follow-up in the medium and long terms. Compared with the active control group, no improvements were found for the primary outcome (pain intensity) or any of the outcomes except for a small effect size on pain catastrophizing (2 RCTs, n=333, P<.001) immediately after the intervention. Conclusions: Tailored Web-based interventions did not prove to be more efficacious than standardized Web-based interventions in terms of pain intensity, pain-related disability, anxiety, and depression. An interesting finding was that some efficacy was shown on pain catastrophizing compared with active control interventions. Considering the diversity of approaches used in tailored Web-based interventions for chronic pain management, their efficacy is yet to be explored. Moreover, their contribution to acute pain management is embryonic. Trial Registration: International prospective register of systematic reviews (PROSPERO): CRD42015027669; (Archived by WebCite at http://www.

  • Smartphone. Source: Shutterstock; Copyright:; URL:; License: Purchased for use from Shutterstock.

    Is Connected Health Contributing to a Healthier Population?


    Connected health tools, including mobile phones, incorporate various functions that capture events, direct actions, and make informed decisions based on complex sources of data. Connected health, a term recently proposed by some academics and industry, refers to the development, testing, and integration of smart technology tools into health care. Through these means, connected health creates interconnectivity across various environments, profoundly changing the way we learn, self-regulate, and communicate with one another. In health care, mobile phones enable more precise diagnostics, personalized health recommendations that enhance patient experiences and outcomes while containing health care costs. However, for connected health to achieve its full potential, issues must be addressed pertaining to active engagement in use, privacy, security, and quality, as well as the development of evidence-based guidelines. This commentary discusses these key challenges and explores the promise of connected health, specifically eHealth and mHealth. Anchored within the context of cancer, the authors’ area of expertise, the ideas put forward can readily be applied to other health-related disciplines.

  • Source: Pexels; Copyright: Chevanon Photography; URL:; License: Public Domain (CC0).

    Performance of a Mobile Phone App-Based Participatory Syndromic Surveillance System for Acute Febrile Illness and Acute Gastroenteritis in Rural Guatemala


    Background: With their increasing availability in resource-limited settings, mobile phones may provide an important tool for participatory syndromic surveillance, in which users provide symptom data directly into a centralized database. Objective: We studied the performance of a mobile phone app-based participatory syndromic surveillance system for collecting syndromic data (acute febrile illness and acute gastroenteritis) to detect dengue virus and norovirus on a cohort of children living in a low-resource and rural area of Guatemala. Methods: Randomized households were provided with a mobile phone and asked to submit weekly reports using a symptom diary app (Vigilant-e). Participants reporting acute febrile illness or acute gastroenteritis answered additional questions using a decision-tree algorithm and were subsequently visited at home by a study nurse who performed a second interview and collected samples for dengue virus if confirmed acute febrile illness and norovirus if acute gastroenteritis. We analyzed risk factors associated with decreased self-reporting of syndromic data using the Vigilant-e app and evaluated strategies to improve self-reporting. We also assessed agreement between self-report and nurse-collected data obtained during home visits. Results: From April 2015 to June 2016, 469 children in 207 households provided 471 person-years of observation. Mean weekly symptom reporting rate was 78% (range 58%-89%). Households with a poor (<70%) weekly reporting rate using the Vigilant-e app during the first 25 weeks of observation (n=57) had a greater number of children (mean 2.8, SD 1.5 vs mean 2.5, SD 1.3; risk ratio [RR] 1.2, 95% CI 1.1-1.4), were less likely to have used mobile phones for text messaging at study enrollment (61%, 35/57 vs 76.7%, 115/150; RR 0.6, 95% CI 0.4-0.9), and were less likely to access care at the local public clinic (35%, 20/57 vs 67.3%, 101/150; RR 0.4, 95% CI 0.2-0.6). Parents of female enrolled participants were more likely to have low response rate (57.1%, 84/147 vs 43.8%, 141/322; RR 1.4, 95% CI 1.1-1.9). Several external factors (cellular tower collapse, contentious elections) were associated with periods of decreased reporting. Poor response rate (<70%) was associated with lower case reporting of acute gastroenteritis, norovirus-associated acute gastroenteritis, acute febrile illness, and dengue virus-associated acute febrile illness (P<.001). Parent-reported syndromic data on the Vigilant-e app demonstrated agreement with nurse-collected data for fever (kappa=.57, P<.001), vomiting (kappa=.63, P<.001), and diarrhea (kappa=.61, P<.001), with decreased agreement as the time interval between parental report and nurse home visit increased (<1 day: kappa=.65-.70; ≥2 days: kappa=.08-.29). Conclusions: In a resource-limited area of rural Guatemala, a mobile phone app-based participatory syndromic surveillance system demonstrated a high reporting rate and good agreement between parental reported data and nurse-reported data during home visits. Several household-level and external factors were associated with decreased syndromic reporting. Poor reporting rate was associated with decreased syndromic and pathogen-specific case ascertainment.

  • Source: Pexels; Copyright: Lukas; URL:; License: Public Domain (CC0).

    Public Awareness and Use of German Physician Ratings Websites: Cross-Sectional Survey of Four North German Cities


    Background: Physician rating websites (PRWs) allow patients to rate, comment, and discuss physicians’ quality. The ability of PRWs to influence patient decision making and health care quality is dependent, in part, on sufficient awareness and usage of PRWs. However, previous studies have found relatively low levels of awareness and usage of PRWs, which has raised concerns about the representativeness and validity of information on PRWs. Objective: The objectives of this study were to examine (1) participants’ awareness, use, and contribution of ratings on PRWs and how this compares with other rating websites; (2) factors that predict awareness, use, and contribution of ratings on PRWs; and (3) participants’ attitudes toward PRWs in relation to selecting a physician. Methods: A mailed cross-sectional survey was sent to a random sample (N=1542) from four North German cities (Nordhorn, Hildesheim, Bremen, and Hamburg) between April and July 2016. Survey questions explored respondents’ awareness, use, and contribution of ratings on rating websites for service (physicians, hospitals, and hotels and restaurants) and products (media and technical) in general and the role of PRWs when searching for a new physician. Results: A total of 280 completed surveys were returned (280/1542, 18.16% response rate), with the following findings: (1) Overall, 72.5% (200/276) of respondents were aware of PRWs. Of the respondents who were aware of PRWs, 43.6% (86/197) had used PRWs. Of the respondents who had used PRWs, 23% (19/83) had rated physicians at least once. Awareness, use, and contribution of ratings on PRWs were significantly lower in comparison with all other rating websites, except for hospital rating websites. (2) Except for the impact of responders’ gender and marital status on the awareness of PRWs and responders’ age on the use of PRWs, no other predictors had a relevant impact. (3) Whereas 31.8% (85/267) of the respondents reported that PRWs were a very important or somewhat important information source when searching for a new physician, respondents significantly more often reported that family, friends and colleagues (259/277, 93.5%), other physicians (219/274, 79.9%), and practice websites (108/266, 40.6%) were important information sources. Conclusions: Whereas awareness of German PRWs appears to have substantially increased, the use of PRWs and contribution of ratings remains relatively low. Further research is needed to examine the reasons why only a few patients are rating physicians. However, given the information inequality between provider and consumer will always be higher for consumers using the services of physicians, it is possible that people will always rely more on interpersonal recommendations than impersonal public information before selecting a physician.

  • Functional magnetic resonance imaging. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    Brain Activation in Response to Personalized Behavioral and Physiological Feedback From Self-Monitoring Technology: Pilot Study


    Background: The recent surge in commercially available wearable technology has allowed real-time self-monitoring of behavior (eg, physical activity) and physiology (eg, glucose levels). However, there is limited neuroimaging work (ie, functional magnetic resonance imaging [fMRI]) to identify how people’s brains respond to receiving this personalized health feedback and how this impacts subsequent behavior. Objective: Identify regions of the brain activated and examine associations between activation and behavior. Methods: This was a pilot study to assess physical activity, sedentary time, and glucose levels over 14 days in 33 adults (aged 30 to 60 years). Extracted accelerometry, inclinometry, and interstitial glucose data informed the construction of personalized feedback messages (eg, average number of steps per day). These messages were subsequently presented visually to participants during fMRI. Participant physical activity levels and sedentary time were assessed again for 8 days following exposure to this personalized feedback. Results: Independent tests identified significant activations within the prefrontal cortex in response to glucose feedback compared with behavioral feedback (P<.001). Reductions in mean sedentary time (589.0 vs 560.0 minutes per day, P=.014) were observed. Activation in the subgyral area had a moderate correlation with minutes of moderate-to-vigorous physical activity (r=0.392, P=.043). Conclusion: Presenting personalized glucose feedback resulted in significantly more brain activation when compared with behavior. Participants reduced time spent sedentary at follow-up. Research on deploying behavioral and physiological feedback warrants further investigation.

  • Source: Skitterphoto; Copyright: Rudy van der Veen; URL:; License: Public Domain (CC0).

    A Fully Automated Web-Based Program Improves Lifestyle Habits and HbA1c in Patients With Type 2 Diabetes and Abdominal Obesity: Randomized Trial of Patient...


    Background: The prevalence of abdominal obesity and type 2 diabetes mellitus (T2DM) is a public health challenge. New solutions need to be developed to help patients implement lifestyle changes. Objective: The objective of the study was to evaluate a fully automated Web-based intervention designed to help users improve their dietary habits and increase their physical activity. Methods: The Accompagnement Nutritionnel de l’Obésité et du Diabète par E-coaching (ANODE) study was a 16-week, 1:1 parallel-arm, open-label randomized clinical trial. Patients with T2DM and abdominal obesity (n=120, aged 18-75 years) were recruited. Patients in the intervention arm (n=60) had access to a fully automated program (ANODE) to improve their lifestyle. Patients were asked to log on at least once per week. Human contact was limited to hotline support in cases of technical issues. The dietetic tool provided personalized menus and a shopping list for the day or the week. Stepwise physical activity was prescribed. The control arm (n=60) received general nutritional advice. The primary outcome was the change of the dietary score (International Diet Quality Index; DQI-I) between baseline and the end of the study. Secondary endpoints included changes in body weight, waist circumference, hemoglobin A1c (HbA1c) and measured maximum oxygen consumption (VO2 max). Results: The mean age of the participants was 57 years (standard deviation [SD] 9), mean body mass index was 33 kg/m² (SD 4), mean HbA1c was 7.2% (SD 1.1), and 66.7% (80/120) of participants were women. Using an intention-to-treat analysis, the DQI-I score (54.0, SD 5.7 in the ANODE arm; 52.8, SD 6.2 in the control arm; P=.28) increased significantly in the ANODE arm compared to the control arm (+4.55, SD 5.91 vs -1.68, SD 5.18; between arms P<.001). Body weight, waist circumference, and HbA1c changes improved significantly in the intervention. Conclusions: Among patients with T2DM and abdominal obesity, the use of a fully automated Web-based program resulted in a significant improvement in dietary habits and favorable clinical and laboratory changes. The sustainability of these effects remains to be determined. Trial Registration: NCT02343107; (Archived by WebCite at

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  • Support or subversion? – The reasons that medical students use online discussion forums.

    Date Submitted: Nov 19, 2017

    Open Peer Review Period: Nov 19, 2017 - Jan 14, 2018

    Background: Internet use has increased enormously over the last several decades. One popular use of the Internet is to engage with online discussion forums to discuss and seek advice from others. Thes...

    Background: Internet use has increased enormously over the last several decades. One popular use of the Internet is to engage with online discussion forums to discuss and seek advice from others. These forums form a safe and often anonymous place to carry out various discussions and are understandably popular amongst young adults who typically have concerns and questions they feel unable to discuss openly. Such forums are therefore commonly used amongst medical students in the UK, as they provide a safe, non-judgemental environment. Medical students are usually self- directed and eager to learn as they generally seek groups of colleagues to study together with and contact tutors to improve their learning. Online forums provide another method for peer learning which is not constrained by the availability of others and may allow less confident learners to engage. Research also shows that students who do not participate as much in class due to being more introverted or lacking confidence or prior knowledge tend to contribute more actively on online forums. Objective: This study was conducted to explore the types of engagement medical students in the UK have with such forums. This will help identify areas of education, advice and support that may be required by medical students. Methods: ‘Thestudentroom’ online forum was found to be the most popularly used by medical students in the UK. Data and associated responses were extracted from its sub-forum ‘Current Medical Students and Doctors.’ Each month had on average, approximately 20 to 30 posts. Due to the high number of posts, the first 6 posts per month, from 2015 were extracted and analysed in this project. Posts were coded thematically in textual form by the student author. The idea of this thematic coding was to identify the best fit coding categories under which any discussion post can suitably fit. A second researcher then validated a proportion of the data coding. Results: In total 72 threads with 420 lines of individual text response were extracted for analysis. Codes were grouped into relevant broad categories and four themes emerged: study advice, career advice, health issues and personal & professional support. Validation of feelings and emotional support were additional over-arching factors that emerged throughout. Conclusions: This study identified four main areas of discussion and suggests where additional advice from medical schools may be needed. It also highlighted important roles anonymous forums play, in allowing students to seek opinion, personal and study support in the competitive environment of a medical school and obtain validation and reassurance about decisions. Forums appear to have benefitted students hence, medical schools should encourage their students to engage in such forums in a professional manner.

  • Using fitness trackers and smart watches to measure physical activity in research. A review of consumer wrist worn wearables.

    Date Submitted: Nov 17, 2017

    Open Peer Review Period: Nov 18, 2017 - Nov 25, 2017

    Background: New fitness trackers and smart watches are released to the consumer market every year. These devices are equipped with different sensors, algorithms, and accompanying mobile applications....

    Background: New fitness trackers and smart watches are released to the consumer market every year. These devices are equipped with different sensors, algorithms, and accompanying mobile applications. With recent advances in mobile sensor technology, privately collected physical activity data can be used as an addition to existing methods for health data collection in research. Furthermore, data collected from these devices have possible applications in patient diagnostics and treatment. With an increasing number of diverse brands, there is a need for an overview of device sensor support, as well as device applicability in research projects. Objective: The objective of this review is to examine the availability of wrist-worn fitness wearables and analyze availability of relevant fitness sensors from 2011 to 2017. Furthermore, the review is designed to assess brand usage in research projects, compare common brands in terms of developer access to collected health data, and features to consider when deciding which brand to use in future research. Methods: We searched for devices and brand names in six wearable device databases. For each brand, we identified additional devices on official brand web sites. The search was limited to wrist-worn fitness wearables with accelerometers, for which we mapped brand, release year and supported sensors relevant for fitness tracking. In addition, we conducted a MEDLINE and search to determine brand usage in research projects. Finally, we reviewed developer accessibility to the health data collected by identified brands. Results: We identified 423 unique devices from 132 different brands. Forty-three percent of brands released only one device. Introduction of new brands peaked in 2014, and the highest number of new devices was introduced in 2015. Sensor support increased every year and, in addition to the accelerometer, a photoplethysmograph, for estimating heart rate, was the most common sensor. Out of the brands currently available, the five most often used in research projects are Fitbit, Garmin, Misfit, Apple and Polar. Fitbit is used in twice as many validation studies as any other brands, and is registered in ten times as often as other brands. Conclusions: The wearable landscape is in constant change. New devices and brands are released every year, promising improved measurements and user experience. At the same time, other brands disappear from the consumer marked for various reasons. Advances in device quality offer new opportunities for researches. However, only a few well-established brands are frequently used in research projects, and even less has been thoroughly validated.

  • Preferences for Health Information Technologies among U.S. Adults: Findings from the Health Information National Trends Survey

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 17, 2017 - Jan 12, 2018

    Background: Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and to facilitate adherence to chronic disease ma...

    Background: Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and to facilitate adherence to chronic disease management. However, there is also lack of studies on differences in preference for using information exchange technologies between chronic and non-chronic disease patients and factors affecting these differences. Objective: The purpose of this paper is to understand preferences and interests in use of technology for information exchange among a nationally representative sample of adults with and without chronic disease conditions and to assess whether these preferences differ according to varying demographic variables. Methods: We utilized data from the 2021 and 2014 iteration of the Health Information National Trends Study (HINTS, N=7307). We modeled negative responses using multiple logistic regressions adjusting for relevant covariates to identify independent factors associated with lowers odds of using health information technology and therefore identify targets for awareness. Analyses were weighted for the US population and adjusted for the sociodemographic variables of age, gender, race and US census region. Results: Analysis included 7,307 participants (weighted population 230,993,888) and 3,529 participants of this sample (weighted population of 90,748,995) reported CVD, diabetes, or hypertension. In the unadjusted models, individuals with Diabetes/CVD/Hypertension were more likely to report using email to exchange medical information with their provider (Odds Ratio [OR] 1.431; 95% Confidence Interval [95% CI] 1.113, 1.838) and less likely to not use any of the technology in health information exchange (OR 0.778; 95% CI 0.618, 0.979). In unadjusted model, additional significant odds ratio values are observed. However, after adjustment, all relationships regarding use and interest in exchanging information with the provider were no longer significant. As a next step, we looked at adjusted odds ratios for demographic variables. Individuals above 65 years old (OR 2.32; 95% CI 1.55, 3.49) and Hispanics (OR 1.95; 95% CI 1.26, 3.01) were less likely to report using email to exchange medical information with their provider. Minorities were less likely to indicate they had no interest in exchanging general health tips with a provider electronically ((Hispanics OR 0.55; 95% CI 0.34, 0.88), (Non-Hispanic Blacks OR 0.36; 95% CI 0.23, 0.56), (Asians OR 0.33; 95% CI 0.16-0.70)). Conclusions: Health information technology related interventions; particularly design of m-health technologies should focus more on demographic factors including race, age and region than chronic disease status to increase likelihood of use. Future research is needed to understand and explore more patient friendly use and design of m-health applications which can be utilized by variety of age, race or education/ health literacy groups efficiently to further bridge the gap in communication between patients and their provider.

  • Acceptability and feasibility of using mobile technology to improve bone-related lifestyle risk factors in young women with low bone mineral density: a pilot study

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 17, 2017 - Jan 12, 2018

    Background: Poor bone health in adolescent and young females is a growing concern. Given the widespread use of smartphones in this population, mobile health (mHealth) interventions may help improve li...

    Background: Poor bone health in adolescent and young females is a growing concern. Given the widespread use of smartphones in this population, mobile health (mHealth) interventions may help improve lifestyle behaviours related to bone health in young women. Objective: To determine the effectiveness and feasibility of a mHealth intervention called “Tap4Bone” in improving lifestyle behaviours associated with the risk of osteoporosis in young women. Methods: The mHealth intervention comprised the use of mobile phone apps, short messaging service (SMS) and web emails to encourage lifestyle behaviour changes. The education group received osteoporosis prevention education leaflets. Changes in bone-health-related lifestyle behaviours namely, exercise, smoking and calcium intake were assessed. Users’ experiences and acceptance of the app were collected through focus group interviews. Results: A total of 35 were randomised to either the smartphone (intervention n =18) or education (control n = 17) group. All participants from the mHealth intervention group started taking calcium supplements after commencing the study, compared to fewer in the education control group (100.0% vs 44.4%, P < .001). Though there were trends towards improvement in sports activity and smoking behaviours in the mHealth intervention group, compared to the education group, these were not statistically significant. Approximately 70% of the sample said they would use a mobile phone app in future to improve their bone health. Conclusions: The Tap4Bone mHealth intervention was widely accepted by users and more effective than traditional education at encouraging calcium supplement intake to support bone health in young women.

  • How might digital technology augment chronic illness management among Black men? A commentary.

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Health disparities associated with chronic illness experiences of Black men demonstrate widespread systematic failures to meet an urgent need. Well-established social and behavioral determinants that...

    Health disparities associated with chronic illness experiences of Black men demonstrate widespread systematic failures to meet an urgent need. Well-established social and behavioral determinants that have led to health disparities among Black men, include racism, discrimination, and stress. While advocacy work that includes community-engagement and tailoring health promotion strategies have shown local impact, evidence shows the gaps are increasing. We suspect that failure to reduce current disparities may be due to conventional public health interventions and programs; therefore, we submit that innovative interventions, ones that embrace digital technologies and their ability to harness naturally occurring social networks within groups, like Black men, have particular importance and deserve attention. This commentary characterizes the current literature on chronic illness among Black men as well as health interventions that use digital technology, to build a case for expanding research in this area to reduce the overwhelming burden of chronic illness among Black men.

  • Stigma and its association with glycemic control and hypoglycemia in adolescents and young adults with type 1 diabetes, a cross-sectional study

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Background: In type 1 diabetes, qualitative studies indicate that visibility of diabetes supplies, self-care, and hypoglycaemia symptoms are associated with stigma and suboptimal management. This may...

    Background: In type 1 diabetes, qualitative studies indicate that visibility of diabetes supplies, self-care, and hypoglycaemia symptoms are associated with stigma and suboptimal management. This may be particularly salient in youth who face concurrent challenges such as establishing autonomy and vocational choices. Objective: To estimate stigma prevalence in youth (14-24 years) with type 1 diabetes and associations with glycemic control. Methods: Participants, recruited largely through social media, were asked to complete an online survey and mail in capillary blood samples for A1C measurement. The primary definition of stigma required endorsement of one or more of three stigma-specific items of the Barriers to Diabetes Adherence questionnaire. These addressed avoidance of diabetes management with friends present, difficulty telling others about diabetes diagnosis, and embarrassment in performing diabetes care with others present. Poor glycemic control was defined as A1C >9% (i.e., >75 mmol/mol; measured value when available, else self-report) and/or ≥1 severe hypoglycemic episode in the previous year (reported requiring assistance from someone else during the episode). Stigma prevalence was computed (95% confidence intervals, CI) and associations with glycemic control evaluated (multivariate logistic regression models). Results: Among the 380 respondents, stigma prevalence was 65.5% (95% CI 60.7-70.3). Stigma was associated with a two-fold higher odds of poor glycemic control overall (OR 2.25, 95% CI 1.33-3.80; adjusted for age, sex, type of treatment). There were specific associations with both A1C >9% (75 mmol/mol; OR 3.05, 95% CI 1.36-6.86) and severe hypoglycemia in the previous year (OR 1.86, 95% CI 1.05-3.31). Conclusions: There is a high prevalence of stigma in youth with type 1 diabetes that is associated with both high A1C and severe hypoglycemia. Targeted strategies to address stigma are needed. Clinical Trial: NCT02796248