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 4.5 for 2015

Recent Articles:

  • Older man at home. Source: Flickr; Copyright: JP Korpi-Vartiainen; URL:; License: Creative Commons Attribution + Noncommercial + ShareAlike (CC-BY-NC-SA).

    Activity Recognition for Persons With Stroke Using Mobile Phone Technology: Toward Improved Performance in a Home Setting


    Background: Smartphones contain sensors that measure movement-related data, making them promising tools for monitoring physical activity after a stroke. Activity recognition (AR) systems are typically trained on movement data from healthy individuals collected in a laboratory setting. However, movement patterns change after a stroke (eg, gait impairment), and activities may be performed differently at home than in a lab. Thus, it is important to validate AR for gait-impaired stroke patients in a home setting for accurate clinical predictions. Objective: In this study, we sought to evaluate AR performance in a home setting for individuals who had suffered a stroke, by using different sets of training activities. Specifically, we compared AR performance for persons with stroke while varying the origin of training data, based on either population (healthy persons or persons with stoke) or environment (laboratory or home setting). Methods: Thirty individuals with stroke and fifteen healthy subjects performed a series of mobility-related activities, either in a laboratory or at home, while wearing a smartphone. A custom-built app collected signals from the phone’s accelerometer, gyroscope, and barometer sensors, and subjects self-labeled the mobility activities. We trained a random forest AR model using either healthy or stroke activity data. Primary measures of AR performance were (1) the mean recall of activities and (2) the misclassification of stationary and ambulatory activities. Results: A classifier trained on stroke activity data performed better than one trained on healthy activity data, improving average recall from 53% to 75%. The healthy-trained classifier performance declined with gait impairment severity, more often misclassifying ambulatory activities as stationary ones. The classifier trained on in-lab activities had a lower average recall for at-home activities (56%) than for in-lab activities collected on a different day (77%). Conclusions: Stroke-based training data is needed for high quality AR among gait-impaired individuals with stroke. Additionally, AR systems for home and community monitoring would likely benefit from including at-home activities in the training data.

  • Hand holding an iPhone with a calendar. Source: Good Free Photos; Copyright: Austin Ban; URL:; License: Public Domain (CC0).

    Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review


    Background: There are an increasing number of mobile apps available for adolescents with mental health problems and an increasing interest in assimilating mobile health (mHealth) into mental health services. Despite the growing number of apps available, the evidence base for their efficacy is unclear. Objective: This review aimed to systematically appraise the available research evidence on the efficacy and acceptability of mobile apps for mental health in children and adolescents younger than 18 years. Methods: The following were systematically searched for relevant publications between January 2008 and July 2016: APA PsychNet, ACM Digital Library, Cochrane Library, Community Care Inform-Children, EMBASE, Google Scholar, PubMed, Scopus, Social Policy and Practice, Web of Science, Journal of Medical Internet Research, Cyberpsychology, Behavior and Social Networking, and OpenGrey. Abstracts were included if they described mental health apps (targeting depression, bipolar disorder, anxiety disorders, self-harm, suicide prevention, conduct disorder, eating disorders and body image issues, schizophrenia, psychosis, and insomnia) for mobile devices and for use by adolescents younger than 18 years. Results: A total of 24 publications met the inclusion criteria. These described 15 apps, two of which were available to download. Two small randomized trials and one case study failed to demonstrate a significant effect of three apps on intended mental health outcomes. Articles that analyzed the content of six apps for children and adolescents that were available to download established that none had undergone any research evaluation. Feasibility outcomes suggest acceptability of apps was good and app usage was moderate. Conclusions: Overall, there is currently insufficient research evidence to support the effectiveness of apps for children, preadolescents, and adolescents with mental health problems. Given the number and pace at which mHealth apps are being released on app stores, methodologically robust research studies evaluating their safety, efficacy, and effectiveness is promptly needed.

  • Source: Flickr; Copyright: Images Money; URL:; License: Creative Commons Attribution (CC-BY).

    Pharma Websites and “Professionals-Only” Information: The Implications for Patient Trust and Autonomy


    Background: Access to information is critical to a patient’s valid exercise of autonomy. One increasingly important source of medical information is the Internet. Individuals often turn to drug company (“pharma”) websites to look for drug information. Objective: The objective of this study was to determine whether there is information on pharma websites that is embargoed: Is there information that is hidden from the patient unless she attests to being a health care provider? We discuss the implications of our findings for health care ethics. Methods: We reviewed a convenience sample of 40 pharma websites for “professionals-only” areas and determined whether access to those areas was restricted, requiring attestation that the user is a health care professional in the United States. Results: Of the 40 websites reviewed, 38 had information that was labeled for health care professionals-only. Of these, 24 required the user to certify their status as a health care provider before they were able to access this “hidden” information. Conclusions: Many pharma websites include information in a “professionals-only” section. Of these, the majority require attestation that the user is a health care professional before they can access the information. This leaves patients with two bad choices: (1) not accessing the information or (2) lying about being a health care professional. Both of these outcomes are unacceptable. In the first instance, the patient’s access to information is limited, potentially impairing their health and their ability to make reasonable and well-informed decisions. In the second instance, they may be induced to lie in a medical setting. “Teaching” patients to lie may have adverse consequences for the provider-patient relationship.

  • Source:; Copyright: Ambro; URL:; License: Creative Commons Attribution (CC-BY).

    Diversity in Older Adults’ Use of the Internet: Identifying Subgroups Through Latent Class Analysis


    Background: As for all individuals, the Internet is important in the everyday life of older adults. Research on older adults’ use of the Internet has merely focused on users versus nonusers and consequences of Internet use and nonuse. Older adults are a heterogeneous group, which may implicate that their use of the Internet is diverse as well. Older adults can use the Internet for different activities, and this usage can be of influence on benefits the Internet can have for them. Objective: The aim of this paper was to describe the diversity or heterogeneity in the activities for which older adults use the Internet and determine whether diversity is related to social or health-related variables. Methods: We used data of a national representative Internet panel in the Netherlands. Panel members aged 65 years and older and who have access to and use the Internet were selected (N=1418). We conducted a latent class analysis based on the Internet activities that panel members reported to spend time on. Second, we described the identified clusters with descriptive statistics and compared the clusters using analysis of variance (ANOVA) and chi-square tests. Results: Four clusters were distinguished. Cluster 1 was labeled as the “practical users” (36.88%, n=523). These respondents mainly used the Internet for practical and financial purposes such as searching for information, comparing products, and banking. Respondents in Cluster 2, the “minimizers” (32.23%, n=457), reported lowest frequency on most Internet activities, are older (mean age 73 years), and spent the smallest time on the Internet. Cluster 3 was labeled as the “maximizers” (17.77%, n=252); these respondents used the Internet for various activities, spent most time on the Internet, and were relatively younger (mean age below 70 years). Respondents in Cluster 4, the “social users,” mainly used the Internet for social and leisure-related activities such as gaming and social network sites. The identified clusters significantly differed in age (P<.001, ω2=0.07), time spent on the Internet (P<.001, ω2=0.12), and frequency of downloading apps (P<.001, ω2=0.14), with medium to large effect sizes. Social and health-related variables were significantly different between the clusters, except social and emotional loneliness. However, effect sizes were small. The minimizers scored significantly lower on psychological well-being, instrumental activities of daily living (iADL), and experienced health compared with the practical users and maximizers. Conclusions: Older adults are a diverse group in terms of their activities on the Internet. This underlines the importance to look beyond use versus nonuse when studying older adults’ Internet use. The clusters we have identified in this study can help tailor the development and deployment of eHealth intervention to specific segments of the older population.

  • Picture of a woman using a tablet. Source: iStock by Getty Images; Copyright: julief514; URL:; License: Licensed by the authors.

    Development of Trust in an Online Breast Cancer Forum: A Qualitative Study


    Background: Online health forums provide peer support for a range of medical conditions including life-threatening and terminal illnesses. Trust is an important component of peer-to-peer support, although relatively little is known about how trust forms within online health forums. Objective: The aim of this paper is to examine how trust develops and influences sharing among users of an online breast cancer forum. Methods: An interpretive qualitative approach was adopted. Data were collected from forum posts from 135 threads on 9 boards on the UK charity, Breast Cancer Care (BCC). Semistructured interviews were conducted with 14 BCC forum users. Both datasets were analyzed thematically using Braun and Clarke’s approach and combined to triangulate analysis. Results: Trust operates in 3 dimensions, structural, relational, and temporal, and these intersect with each other and do not operate in isolation. The structural dimension relates to how the affordances and formal rules of the site affected trust. The relational dimension refers to how trust was necessarily experienced in interactions with other forum users: it emerged within relationships and was a social phenomenon. The temporal dimension relates to how trust changed over time and was influenced by the length of time users spent on the forum. Conclusions: Trust is a process that changes over time and which is influenced by structural features of the forum, as well as informal but collectively understood relational interactions among forum users. The study provides a better understanding of how the intersecting structural, relational, and temporal aspects that support the development of trust facilitate sharing in online environments. These findings will help organizations developing online health forums.

  • U-CARE team group photo. Source: The authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Fifteen Challenges in Establishing a Multidisciplinary Research Program on eHealth Research in a University Setting: A Case Study


    Background: U-CARE is a multidisciplinary eHealth research program that involves the disciplines of caring science, clinical psychology, health economics, information systems, and medical science. It was set up from scratch in a university setting in 2010, funded by a governmental initiative. While establishing the research program, many challenges were faced. Systematic documentation of experiences from establishing new research environments is scarce. Objective: The aim of this paper was to describe the challenges of establishing a publicly funded multidisciplinary eHealth research environment. Methods: Researchers involved in developing the research program U-CARE identified challenges in the formal documentation and by reflecting on their experience of developing the program. The authors discussed the content and organization of challenges into themes until consensus was reached. Results: The authors identified 15 major challenges, some general to establishing a new research environment and some specific for multidisciplinary eHealth programs. The challenges were organized into 6 themes: Organization, Communication, Implementation, Legislation, Software development, and Multidisciplinarity. Conclusions: Several challenges were faced during the development of the program and several accomplishments were made. By sharing our experience, we hope to help other research groups embarking on a similar journey to be prepared for some of the challenges they are likely to face on their way.

  • Source: Image created by the authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Evaluating the Social Media Performance of Hospitals in Spain: A Longitudinal and Comparative Study


    Background: Social media is changing the way in which citizens and health professionals communicate. Previous studies have assessed the use of Health 2.0 by hospitals, showing clear evidence of growth in recent years. In order to understand if this happens in Spain, it is necessary to assess the performance of health care institutions on the Internet social media using quantitative indicators. Objectives: The study aimed to analyze how hospitals in Spain perform on the Internet and social media networks by determining quantitative indicators in 3 different dimensions: presence, use, and impact and assess these indicators on the 3 most commonly used social media - Facebook, Twitter, YouTube. Further, we aimed to find out if there was a difference between private and public hospitals in their use of the aforementioned social networks. Methods: The evolution of presence, use, and impact metrics is studied over the period 2011- 2015. The population studied accounts for all the hospitals listed in the National Hospitals Catalog (NHC). The percentage of hospitals having Facebook, Twitter, and YouTube profiles has been used to show the presence and evolution of hospitals on social media during this time. Usage was assessed by analyzing the content published on each social network. Impact evaluation was measured by analyzing the trend of subscribers for each social network. Statistical analysis was performed using a lognormal transformation and also using a nonparametric distribution, with the aim of comparing t student and Wilcoxon independence tests for the observed variables. Results: From the 787 hospitals identified, 69.9% (550/787) had an institutional webpage and 34.2% (269/787) had at least one profile in one of the social networks (Facebook, Twitter, and YouTube) in December 2015. Hospitals’ Internet presence has increased by more than 450.0% (787/172) and social media presence has increased ten times since 2011. Twitter is the preferred social network for public hospitals, whereas private hospitals showed better performance on Facebook and YouTube. The two-sided Wilcoxon test and t student test at a CI of 95% show that the use of Twitter distribution is higher (P<.001) for private and public hospitals in Spain, whereas other variables show a nonsignificant different distribution. Conclusions: The Internet presence of Spanish hospitals is high; however, their presence on the 3 main social networks is still not as high compared to that of hospitals in the United States and Western Europe. Public hospitals are found to be more active on Twitter, whereas private hospitals show better performance on Facebook and YouTube. This study suggests that hospitals, both public and private, should devote more effort to and be more aware of social media, with a clear strategy as to how they can foment new relationships with patients and citizens.

  • Source: Pixabay; Copyright: USA-Reiseblogger; URL:; License: Public Domain (CC0).

    Harnessing Facebook for Smoking Reduction and Cessation Interventions: Facebook User Engagement and Social Support Predict Smoking Reduction


    Background: Social media technologies offer a novel opportunity for scalable health interventions that can facilitate user engagement and social support, which in turn may reinforce positive processes for behavior change. Objective: By using principles from health communication and social support literature, we implemented a Facebook group–based intervention that targeted smoking reduction and cessation. This study hypothesized that participants’ engagement with and perceived social support from our Facebook group intervention would predict smoking reduction. Methods: We recruited 16 regular smokers who live in the United States and who were motivated in quitting smoking at screening. We promoted message exposure as well as engagement and social support systems throughout the intervention. For message exposure, we posted prevalidated, antismoking messages (such as national antismoking campaigns) on our smoking reduction and cessation Facebook group. For engagement and social support systems, we delivered a high degree of engagement and social support systems during the second and third week of the intervention and a low degree of engagement and social support systems during the first and fourth week. A total of six surveys were conducted via Amazon Mechanical Turk (MTurk) at baseline on a weekly basis and at a 2-week follow-up. Results: Of the total 16 participants, most were female (n=13, 81%), white (n=15, 94%), and between 25 and 50 years of age (mean 34.75, SD 8.15). There was no study attrition throughout the 6-time-point baseline, weekly, and follow-up surveys. We generated Facebook engagement and social support composite scores (mean 19.19, SD 24.35) by combining the number of likes each participant received and the number of comments or wall posts each participant posted on our smoking reduction and cessation Facebook group during the intervention period. The primary outcome was smoking reduction in the past 7 days measured at baseline and at the two-week follow-up. Compared with the baseline, participants reported smoking an average of 60.56 fewer cigarettes per week (SD 38.83) at the follow-up, and 4 participants out of 16 (25%) reported 7-day point prevalence smoking abstinence at the follow-up. Adjusted linear regression models revealed that a one-unit increase in the Facebook engagement and social support composite scores predicted a 0.56-unit decrease in cigarettes smoked per week (standard error =.24, P=.04, 95% CI 0.024-1.09) when baseline readiness to quit, gender, and baseline smoking status were controlled (F4, 11=8.85, P=.002). Conclusions: This study is the first Facebook group–based intervention that systemically implemented health communication strategies and engagement and social support systems to promote smoking reduction and cessation. Our findings imply that receiving one like or posting on the Facebook-based intervention platform predicted smoking approximately one less cigarette in the past 7 days, and that interventions should facilitate user interactions to foster user engagement and social support.

  • Simulated users using an early prototype of the Concussion or Brain Bleed app. Source: Image created by the authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Patient-Centered Decision Support: Formative Usability Evaluation of Integrated Clinical Decision Support With a Patient Decision Aid for Minor Head Injury...


    Background: The Canadian Computed Tomography (CT) Head Rule, a clinical decision rule designed to safely reduce imaging in minor head injury, has been rigorously validated and implemented, and yet expected decreases in CT were unsuccessful. Recent work has identified empathic care as a key component in decreasing CT overuse. Health information technology can hinder the clinician-patient relationship. Patient-centered decision tools to support the clinician-patient relationship are needed to promote evidence-based decisions. Objective: Our objective is to formatively evaluate an electronic tool that not only helps clinicians at the bedside to determine the need for CT use based on the Canadian CT Head Rule but also promotes evidence-based conversations between patients and clinicians regarding patient-specific risk and patients’ specific concerns. Methods: User-centered design with practice-based and participatory decision aid development was used to design, develop, and evaluate patient-centered decision support regarding CT use in minor head injury in the emergency department. User experience and user interface (UX/UI) development involved successive iterations with incremental refinement in 4 phases: (1) initial prototype development, (2) usability assessment, (3) field testing, and (4) beta testing. This qualitative approach involved input from patients, emergency care clinicians, health services researchers, designers, and clinical informaticists at every stage. Results: The Concussion or Brain Bleed app is the product of 16 successive iterative revisions in accordance with UX/UI industry design standards. This useful and usable final product integrates clinical decision support with a patient decision aid. It promotes shared use by emergency clinicians and patients at the point of care within the emergency department context. This tablet computer app facilitates evidence-based conversations regarding CT in minor head injury. It is adaptable to individual clinician practice styles. The resultant tool includes a patient injury evaluator based on the Canadian CT Head Rule and provides patient specific risks using pictographs with natural frequencies and cues for discussion about patient concerns. Conclusions: This tool was designed to align evidence-based practices about CT in minor head injury patients. It establishes trust, empowers active participation, and addresses patient concerns and uncertainty about their condition. We hypothesize that, when implemented, the Concussion or Brain Bleed app will support—not hinder—the clinician-patient relationship, safely reduce CT use, and improve the patient experience of care.

  • Source: Image created by the authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Smart Toy to Enhance the Decision-Making Process at Children’s Psychomotor Delay Screenings: A Pilot Study


    Background: EDUCERE (“Ubiquitous Detection Ecosystem to Care and Early Stimulation for Children with Developmental Disorders”) is an ecosystem for ubiquitous detection, care, and early stimulation of children with developmental disorders. The objectives of this Spanish government-funded research and development project are to investigate, develop, and evaluate innovative solutions to detect changes in psychomotor development through the natural interaction of children with toys and everyday objects, and perform stimulation and early attention activities in real environments such as home and school. Thirty multidisciplinary professionals and three nursery schools worked in the EDUCERE project between 2014 and 2017 and they obtained satisfactory results. Related to EDUCERE, we found studies based on providing networks of connected smart objects and the interaction between toys and social networks. Objective: This research includes the design, implementation, and validation of an EDUCERE smart toy aimed to automatically detect delays in psychomotor development. The results from initial tests led to enhancing the effectiveness of the original design and deployment. The smart toy, based on stackable cubes, has a data collector module and a smart system for detection of developmental delays, called the EDUCERE developmental delay screening system (DDSS). Methods: The pilot study involved 65 toddlers aged between 23 and 37 months (mean=29.02, SD 3.81) who built a tower with five stackable cubes, designed by following the EDUCERE smart toy model. As toddlers made the tower, sensors in the cubes sent data to a collector module through a wireless connection. All trials were video-recorded for further analysis by child development experts. After watching the videos, experts scored the performance of the trials to compare and fine-tune the interpretation of the data automatically gathered by the toy-embedded sensors. Results: Judges were highly reliable in an interrater agreement analysis (intraclass correlation 0.961, 95% CI 0.937-0.967), suggesting that the process was successful to separate different levels of performance. A factor analysis of collected data showed that three factors, trembling, speed, and accuracy, accounted for 76.79% of the total variance, but only two of them were predictors of performance in a regression analysis: accuracy (P=.001) and speed (P=.002). The other factor, trembling (P=.79), did not have a significant effect on this dependent variable. Conclusions: The EDUCERE DDSS is ready to use the regression equation obtained for the dependent variable “performance” as an algorithm for the automatic detection of psychomotor developmental delays. The results of the factor analysis are valuable to simplify the design of the smart toy by taking into account only the significant variables in the collector module. The fine-tuning of the toy process module will be carried out by following the specifications resulting from the analysis of the data to improve the efficiency and effectiveness of the product.

  • Codesign with children of a Swedish high-fidelity prototype of the digital peer support (DPS) tablet app “Give Me a Break”. Source: Image created by the authors; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Effects of Using Child Personas in the Development of a Digital Peer Support Service for Childhood Cancer Survivors


    Background: Peer support services have the potential to support children who survive cancer by handling the physical, mental, and social challenges associated with survival and return to everyday life. Involving the children themselves in the design process allows for adapting services to authentic user behaviors and goals. As there are several challenges that put critical requirements on a user-centered design process, we developed a design method based on personas adapted to the particular needs of children that promotes health and handles a sensitive design context. Objective: The purpose of this study was to evaluate the effects of using child personas in the development of a digital peer support service for childhood cancer survivors. Methods: The user group’s needs and behaviors were characterized based on cohort data and literature, focus group interviews with childhood cancer survivors (n=15, 8-12 years), stakeholder interviews with health care professionals and parents (n=13), user interviews, and observations. Data were interpreted and explained together with childhood cancer survivors (n=5) in three explorative design workshops and a validation workshop with children (n=7). Results: We present findings and insights on how to codesign child personas in the context of developing digital peer support services with childhood cancer survivors. The work resulted in three primary personas that model the behaviors, attitudes, and goals of three user archetypes tailored for developing health-promoting services in this particular use context. Additionally, we also report on the effects of using these personas in the design of a digital peer support service called Give Me a Break. Conclusions: By applying our progressive steps of data collection and analysis, we arrive at authentic child-personas that were successfully used to design and develop health-promoting services for children in vulnerable life stages. The child-personas serve as effective collaboration and communication aids for both internal and external purposes.

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

    Attachment Style and Internet Addiction: An Online Survey


    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Considering the fact that there is ample evidence for the relationship between attachment style and substance abuse, it stands to reason that attachment theory can also make an important contribution to the understanding of the pathogenesis of Internet addiction. Objective: The aim of this study was to examine people’s tendency toward pathological Internet usage in relation to their attachment style. Methods: An online survey was conducted. Sociodemographic data, attachment style (Bielefeld questionnaire partnership expectations), symptoms of Internet addiction (scale for online addiction for adults), used Web-based services, and online relationship motives (Cyber Relationship Motive Scale, CRMS-D) were assessed. In order to confirm the findings, a study using the Rorschach test was also conducted. Results: In total, 245 subjects were recruited. Participants with insecure attachment style showed a higher tendency to pathological Internet usage compared with securely attached participants. An ambivalent attachment style was particularly associated with pathological Internet usage. Escapist and social-compensatory motives played an important role for insecurely attached subjects. However, there were no significant effects with respect to Web-based services and apps used. Results of the analysis of the Rorschach protocol with 16 subjects corroborated these results. Users with pathological Internet use frequently showed signs of infantile relationship structures in the context of social groups. This refers to the results of the Web-based survey, in which interpersonal relationships were the result of an insecure attachment style. Conclusions: Pathological Internet use was a function of insecure attachment and limited interpersonal relationships.

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Latest Submissions Open for Peer-Review:

View All Open Peer Review Articles
  • Cardiac patients’ experiences and perceptions of social media: a mixed methods study

    Date Submitted: May 22, 2017

    Open Peer Review Period: May 24, 2017 - Jul 19, 2017

    Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults prov...

    Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults provides an opportunity to reach patients eligible for cardiac rehabilitation but who are unable to attend traditional face-to-face groups. However, there is a paucity of research on cardiac patient’s experiences and perspectives on using social media to support their health. Objective: This study aims to describe cardiac rehabilitation patient’s experiences in using social media in general and their perspective on using social media to support their cardiac health and secondary prevention efforts. Methods: A mixed methods study was undertaken among cardiac rehabilitation patients in both urban and rural areas which comprised a survey (n = 284) on social media use and six focus group interviews with current social media users (n = 18) to elucidate social media experience and perspectives. Results: Social media use was common (28%; 79/282) particularly in patients who were under 70 years of age, employed and had completed high school. Social media users accessed online information on general health issues (65%; 51/79), medications (56%; 44/79) and heart health (43%; 34/79). Patients were motivated to invest time in using social media for ‘keeping in touch’ with family and friends, and to be informed by expert cardiac health professionals and fellow cardiac patients if given the opportunity. Social media capability (understanding of features and the consequences of their use and efficiency in use) appears to influence the frequency and degree of engagement of social media use and the willingness to participate in a cardiac social media group. More capable users were more receptive to the use of social media for cardiac rehabilitation and more likely to express interest in providing peer support. Recommended features for a cardiac rehabilitation social media group using a Facebook platform included a closed group, expert cardiac professional involvement, provision of cardiac health information and ensuring trustworthiness of the group. Conclusions: Cardiac health professionals have an opportunity to capitalise on cardiac patients’ motivations and social media capability for supporting cardiac rehabilitation and secondary prevention. Patients’ favoured purposeful time spent on social media, and their cardiac health provides such a purpose for a social media intervention. The study results will inform the development of a social media intervention for secondary prevention of cardiovascular disease.

  • The effects of the daily PM2.5 concentration on the public awareness of lung cancer risk in China: Evidence from the Internet big data platform

    Date Submitted: May 23, 2017

    Open Peer Review Period: May 23, 2017 - May 31, 2017

    Background: In October 2013, the International Agency for Research on Cancer (IARC) classified the particulate matter from outdoor air pollution as a Class 1 carcinogen and declared that the particula...

    Background: In October 2013, the International Agency for Research on Cancer (IARC) classified the particulate matter from outdoor air pollution as a Class 1 carcinogen and declared that the particulate matter could cause lung cancer. PM2.5 pollution is becoming a serious public health concern in urban cities of China. It is essential to emphasize the importance of the awareness and knowledge of modifiable risk factors of lung cancer for prevention. Objective: To explore the public awareness of the association of PM2.5 with lung cancer risk in China by analyzing the relationship between the daily PM2.5 concentration and the searches for the term “lung cancer” via the Internet big data platform. Methods: We collected the daily PM2.5 concentration data and the daily Baidu index data in 31 Chinese capital cities between January 1, 2014 and December 31, 2016. We used the Spearman correlation analysis to explore the correlations between the daily Baidu Index for the term “lung cancer” and the daily average PM2.5 concentration. Granger causality test was used to analyze the causal relationship between the two time series variables. Results: In 23 of 31 cities, the pairwise correlation coefficients, by Spearman’s Rho, between the daily Baidu Index for the term “lung cancer” and the daily average PM2.5 concentration, were positive and statistically significant (p<0.05). However, the correlation between the daily Baidu Index for the term “lung cancer” and the daily average PM2.5 concentration was poor (All r2s<0.1). The results of Granger causality test illustrated that there was no unidirectional causality running from the daily PM2.5 concentration to the daily Baidu index for the term “lung cancer” statistically significant at the 5% level for each city. Conclusions: In conclusion, the daily average PM2.5 concentration has a weak positive impact on the daily search interest for the term of “lung cancer” via Baidu search engine. Well-designed awareness campaigns are needed to enhance the general public awareness of the association of PM2.5 with lung cancer risk, and to lead the public to seek more information about PM2.5 and its hazards, and to cope with their environment and its risks correctly.

  • Methods for Co-Designing a Collaborative Chronic Care Network (C3N)

    Date Submitted: May 20, 2017

    Open Peer Review Period: May 21, 2017 - Jul 16, 2017

    Background: Learning Health Systems (LHSs) are seen as a means to accelerate outcomes, improve care delivery, and further clinical research, yet few such systems exist. Objective: We describe the proc...

    Background: Learning Health Systems (LHSs) are seen as a means to accelerate outcomes, improve care delivery, and further clinical research, yet few such systems exist. Objective: We describe the process of co-designing, with all relevant stakeholders, an approach for creating a collaborative chronic care network (C3N), a peer-produced networked LHS. Methods: The setting was ImproveCareNow, an improvement network for pediatric inflammatory bowel disease. In collaboration with patients and families, clinicians, researchers, social scientists, technologists, and designers, C3N leaders used a modified idealized design process to develop a design for a C3N. Results: Over 100 people participated in the design process, which resulted in: a) an overall “concept design” for the ImproveCareNow C3N, b) a logic model for bringing about this system, and c) thirteen potential innovations likely to increase awareness and agency, make it easier to collect and share information, and to enhance collaboration – that could be tested collectively to bring about the C3N. Conclusions: Our current healthcare system fails to deliver necessary results and incremental system improvements are not enough. We demonstrate methods that resulted in a design that has the potential to transform the chronic care system. Our experience suggests that employing structured co-design processes in collaboration with all relevant stakeholders can result in a potentially transformative design for the chronic care delivery system.

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

    Date Submitted: May 19, 2017

    Open Peer Review Period: May 21, 2017 - Jul 16, 2017

    Background: A new generation of user-centric information systems is emerging in healthcare as Patient Health Record systems. These systems create a platform supporting the new vision of health service...

    Background: A new generation of user-centric information systems is emerging in healthcare as Patient Health Record 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: To assess patient health records (PHR) data through a review of the literature, to inform the healthcare informatics community and provide recommendations for PHR design, research and practice. Methods: In this paper we review the literature to identify challenges associated with the development PHR systems. We survey PubMed, Embase and Medline databases from 1966 to 2015 for studies of personal health records resulting in 1822 articles, from which we select a total of 106 articles for a detailed review of PHR data content. We present several key findings related to the scope and functionalities in current PHR systems. We also present a functional taxonomy and chronological analyses of PHR data types and functionalities. Based on the evolution of prior PHR systems, we develop a maturity model for evaluation of multi-organizational systems such as PHR systems and identify implications on future health information systems research; improving understanding and providing insights for future directions. Results: 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 revealed an evolution of PHR systems’ functionalities over time from simple data access, to data modification, and more recently automated assessment, prediction and recommendation. Conclusions: Efforts are needed to improve PHR 1) 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) functionality through application of new data analytics methods and 4) metrics to evaluate clinical outcomes associated with automated PHR systems’ use, and cost associated with PHR data storage and analytics.

  • Getting to the Root of Reinvestment - An fNIRS study in Dentistry using Virtual Reality Haptic Simulation

    Date Submitted: May 15, 2017

    Open Peer Review Period: May 18, 2017 - Jul 13, 2017

    Background: Personality has been identified as a factor that influences learning in healthcare. Movement specific reinvestment is a dimension of personality that has been shown to influence psychomoto...

    Background: Personality has been identified as a factor that influences learning in healthcare. Movement specific reinvestment is a dimension of personality that has been shown to influence psychomotor learning because it has a central role in conscious control of movements. Currently, there is little evidence considering the relationship between movement specific reinvestment and working memory in terms of functional brain activation of the dorsolateral prefrontal cortex (DLPFC) during motor skill performance. Objective: This study used functional near infrared spectroscopy (fNIRS) to examine the research gap between movement specific reinvestment and working memory using undergraduate dental students performing dental virtual reality (VR) psychomotor tasks. Methods: The propensity for movement specific reinvestment was assessed in 24 dental students, who completed two dental tasks (clinical, non-clinical) on a VR haptic simulator. Portable fNIRS equipment was used to assess oxygen demands in the left and right DLPFC hemispheres during performance. Results: Students with a high propensity for movement specific reinvestment displayed significantly greater oxyhaemoglobin demands in and area associated with working memory during the non-clinical task (Spearman correlation, rs = -0.49, p = 0.033). Conclusions: This small-scale study suggests that neurophysiological differences are evident between high and low reinvesters during a dental VR task in terms of oxyhaemoglobin demands in an area associated with working memory. The results contribute to understanding the neurological processes underpinning conscious control of movements and may assist in the design of individualized training plans for psychomotor skills.

  • Development and Validation of a Functional Behavioural Assessment Ontology to Support Behavioural Health Interventions

    Date Submitted: May 15, 2017

    Open Peer Review Period: May 18, 2017 - Jul 13, 2017

    Background: In the cognitive behavioural approach, Functional Behavioural Assessment is one of the most effective methods to identify the variables that determine a problem behaviour. In this context,...

    Background: In the cognitive behavioural approach, Functional Behavioural Assessment is one of the most effective methods to identify the variables that determine a problem behaviour. In this context, the use of modern technologies can encourage the collection and sharing of behavioural patterns, effective intervention strategies, and statistical evidences about antecedents and consequences of clusters of problem behaviours, encouraging the designing of function-based interventions. Objective: The paper describes the development and validation process used to design a specific Functional Behavioural Assessment Ontology (FBA-Ontology). The FBA-Ontology is a semantic representation of the variables that intervene in a behavioral observation process, facilitating the systematic collection of behavioral data, the consequential planning of treatment strategies and, indirectly, the scientific improvement in this field of study. Methods: The ontology has been developed deducing concepts and relationships of the ontology from a golden standard and then performing a machine-based validation and a human-based assessment to validate the Functional Behavioural Assessment Ontology. These validation and verification processes were aimed to verify how much the ontology is conceptually well founded and semantically and syntactically correct. Results: The Pellet reasoner checked the logical consistency and the integrity of classes and properties defined in the ontology, not detecting any violation of constraints in the ontology definition. In order to assess whether the ontology definition is coherent with the knowledge domain or not, a human evaluation of the ontology were performed asking 84 people to fill in a questionnaire composed by 13 questions assessing concepts, relations between concepts, and concepts’ attributes. The response rate for the survey was 34.52%. The domain experts confirmed that the concepts, the attributes, and the relationships between concepts defined in the FBA-Ontology are valid and well represent the Functional Behavioural Assessment process. Conclusions: The new ontology developed could be a useful tool to design new evidence-based systems in the Behavioral Interventions practices, encouraging the link with other Linked Open Data datasets and repositories to provide users with new models of e-health focused on the management of problem behaviours. Therefore, new researches and efforts are needed to develop and implement innovative strategies to improve the poor reproducibility and translatability of basic research findings in the field of behavioural assessment.