JMIR Publications

Journal of Medical Internet Research

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

JMIR's Thomson Reuter Impact Factor of 4.7 for 2013

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    Positive Clinical Outcomes Are Synergistic With Positive Educational Outcomes When Using Telehealth Consulting in General Practice: A Mixed-Methods Study


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

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

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


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

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


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

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

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


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

  • Social media communication/analysis.
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    In Pursuit of Theoretical Ground in Behavior Change Support Systems: Analysis of Peer-to-Peer Communication in a Health-Related Online Community


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

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

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


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

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

    Adapting Behavioral Interventions for Social Media Delivery


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

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

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


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

  • © Sebastian Molkenbur, Leuphana University Lueneburg, Germany.

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


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

  • By Jerry Berger [CC BY-SA 4.0 (], via Wikimedia Commons


    Features of Computer-Based Decision Aids: Systematic Review, Thematic Synthesis, and Meta-Analyses


    Background: Patient information and education, such as decision aids, are gradually moving toward online, computer-based environments. Considerable research has been conducted to guide content and presentation of decision aids. However, given the relatively new shift to computer-based support, little attention has been given to how multimedia and interactivity can improve upon paper-based decision aids. Objective: The first objective of this review was to summarize published literature into a proposed classification of features that have been integrated into computer-based decision aids. Building on this classification, the second objective was to assess whether integration of specific features was associated with higher-quality decision making. Methods: Relevant studies were located by searching MEDLINE, Embase, CINAHL, and CENTRAL databases. The review identified studies that evaluated computer-based decision aids for adults faced with preference-sensitive medical decisions and reported quality of decision-making outcomes. A thematic synthesis was conducted to develop the classification of features. Subsequently, meta-analyses were conducted based on standardized mean differences (SMD) from randomized controlled trials (RCTs) that reported knowledge or decisional conflict. Further subgroup analyses compared pooled SMDs for decision aids that incorporated a specific feature to other computer-based decision aids that did not incorporate the feature, to assess whether specific features improved quality of decision making. Results: Of 3541 unique publications, 58 studies met the target criteria and were included in the thematic synthesis. The synthesis identified six features: content control, tailoring, patient narratives, explicit values clarification, feedback, and social support. A subset of 26 RCTs from the thematic synthesis was used to conduct the meta-analyses. As expected, computer-based decision aids performed better than usual care or alternative aids; however, some features performed better than others. Integration of content control improved quality of decision making (SMD 0.59 vs 0.23 for knowledge; SMD 0.39 vs 0.29 for decisional conflict). In contrast, tailoring reduced quality of decision making (SMD 0.40 vs 0.71 for knowledge; SMD 0.25 vs 0.52 for decisional conflict). Similarly, patient narratives also reduced quality of decision making (SMD 0.43 vs 0.65 for knowledge; SMD 0.17 vs 0.46 for decisional conflict). Results were varied for different types of explicit values clarification, feedback, and social support. Conclusions: Integration of media rich or interactive features into computer-based decision aids can improve quality of preference-sensitive decision making. However, this is an emerging field with limited evidence to guide use. The systematic review and thematic synthesis identified features that have been integrated into available computer-based decision aids, in an effort to facilitate reporting of these features and to promote integration of such features into decision aids. The meta-analyses and associated subgroup analyses provide preliminary evidence to support integration of specific features into future decision aids. Further research can focus on clarifying independent contributions of specific features through experimental designs and refining the designs of features to improve effectiveness.

  • Feature image for homepage (This image was developed by the e-Health Technology Program at the MD Anderson Cancer Center.).

    Impact of a Mobile Phone Intervention to Reduce Sedentary Behavior in a Community Sample of Adults: A Quasi-Experimental Evaluation


    Background: Greater time spent sedentary is linked with increased risk of breast, colorectal, ovarian, endometrial, and prostate cancers. Given steadily increasing rates of mobile phone ownership, mobile phone interventions may have the potential to broadly influence sedentary behavior across settings. Objective: The purpose of this study was to examine the short-term impact of a mobile phone intervention that targeted sedentary time in a diverse community sample. Methods: Adults participated in a quasi-experimental evaluation of a mobile phone intervention designed to reduce sedentary time through prompts to interrupt periods of sitting. Participants carried mobile phones and wore accelerometers for 7 consecutive days. Intervention participants additionally received mobile phone prompts during self-reported sitting and information about the negative health impact of prolonged sedentariness. The study was conducted from December 2012 to November 2013 in Dallas, Texas. Linear mixed model regression analyses were conducted to evaluate the influence of the intervention on daily accelerometer-determined estimates of sedentary and active time. Results: Participants (N=215) were predominantly female (67.9%, 146/215) and nonwhite (black: 50.7%, 109/215; Latino: 12.1%, 26/215; other: 5.6%, 12/215). Analyses revealed that participants who received the mobile phone intervention had significantly fewer daily minutes of sedentary time (B=–22.09, P=.045) and more daily active minutes (B=23.01, P=.04) than control participants. Conclusions: A simple mobile phone intervention was associated with engaging in less sedentary time and more physical activity. Findings underscore the potential impact of mobile phone interventions to positively influence sedentary behavior and physical activity.

  • Estimating Skin Cancer Risk: Evaluating Mobile Computer-Adaptive Testing


    Background: Response burden is a major detriment to questionnaire completion rates. Computer adaptive testing may offer advantages over non-adaptive testing, including reduction of numbers of items required for precise measurement. Objective: Our aim was to compare the efficiency of non-adaptive (NAT) and computer adaptive testing (CAT) facilitated by Partial Credit Model (PCM)-derived calibration to estimate skin cancer risk. Methods: We used a random sample from a population-based Australian cohort study of skin cancer risk (N=43,794). All 30 items of the skin cancer risk scale were calibrated with the Rasch PCM. A total of 1000 cases generated following a normal distribution (mean [SD] 0 [1]) were simulated using three Rasch models with three fixed-item (dichotomous, rating scale, and partial credit) scenarios, respectively. We calculated the comparative efficiency and precision of CAT and NAT (shortening of questionnaire length and the count difference number ratio less than 5% using independent t tests). Results: We found that use of CAT led to smaller person standard error of the estimated measure than NAT, with substantially higher efficiency but no loss of precision, reducing response burden by 48%, 66%, and 66% for dichotomous, Rating Scale Model, and PCM models, respectively. Conclusions: CAT-based administrations of the skin cancer risk scale could substantially reduce participant burden without compromising measurement precision. A mobile computer adaptive test was developed to help people efficiently assess their skin cancer risk.

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  • Can We Foster a Culture of Peer Support and Promote Mental Health in Adolescence Using a Web-Based Application? A Control Group Study

    Date Submitted: Feb 3, 2016

    Open Peer Review Period: Feb 6, 2016 - Apr 2, 2016

    Background: Adolescence with its many transitions is a vulnerable period for the development of mental illnesses. Establishing effective mental health promotion programs for this age group is a challe...

    Background: Adolescence with its many transitions is a vulnerable period for the development of mental illnesses. Establishing effective mental health promotion programs for this age group is a challenge but crucial to societal health. Programs need to take into account the specific developmental tasks that adolescents face. Considering peer influence and fostering adolescent autonomy strivings is essential. Moreover, program participation needs to be compelling to young people. Their affinity to new technologies offers unprecedented opportunities in this respect. Objective: This companion project built on these premises and developed an application (the companion app) to foster a positive peer culture among adolescents and thereby strengthen social support and reduce stress. Methods: In a control group study design, a group of employed (n = 546) and unemployed (n = 76) adolescents had access to the companion app during 10 months. The companion app was developed as a web-based app giving adolescents access to a peer mentoring system and interactive, health-relevant content. The intervention was evaluated using a combined quantitative and qualitative approach. Linear mixed effect models were used to analyze changes in chronic stress levels and users’ perception of social support. Monthly feedback on the app and qualitative interviews at the end of the study allowed for an in-depth exploration of the adolescents’ perception of the intervention. Results: Adolescents in the intervention group did not use the companion app consistently. The intervention had no effects on chronic stress levels and perception of social support. Adolescents reported endorsing the concept of the app and in particular the implementation of a mentoring system. However, the immediate benefit of using the app did not seem obvious to the majority of them. Also, some participants reported that there had not been enough activity by other users on the app and that this had made the app less attractive to them. Conclusions: The companion project implemented a theory-driven and innovative approach to mental health promotion in adolescence, taking into account the specificities of this developmental phase. Among other things, insufficient external encouragement and the short duration of the study may have contributed to the lacking commitment of the adolescents to this intervention. Further research is needed on how to best take advantage of new technologies to promote mental health in adolescence.

  • Feasibility and Limitations of Vaccine 2d Barcoding Using Mobile Devices

    Date Submitted: Feb 2, 2016

    Open Peer Review Period: Feb 6, 2016 - Apr 2, 2016

    Background: 2d barcoding has the potential to enhance documentation of vaccine encounters at the point of care. However, this is currently limited to environments equipped with dedicated barcode scann...

    Background: 2d barcoding has the potential to enhance documentation of vaccine encounters at the point of care. However, this is currently limited to environments equipped with dedicated barcode scanners and compatible record systems. Mobile devices may present a cost effective alternative to leverage 2d vaccine vial barcodes and improve vaccine product specific information residing in digital health records. Objective: Mobile devices have the potential to capture product specific information from 2d vaccine vial barcodes. We sought to examine the feasibility, performance, and potential limitations of scanning 2d barcodes on vaccine vials using four different smartphones. Methods: A unique barcode scanning application was developed for Android and iOS operating systems. The impact of four variables on the scan success rate, data accuracy, and time to scan were examined: barcode size, curvature, fading and ambient lighting conditions. Two experimenters performed four trials ten times each amounting to a total of 2160 barcode scan attempts. Results: 1832(84.8%) attempts scanned successfully. Of those, zero produced incorrect data. 5mm barcodes were the slowest to scan, although only by 0.5 seconds on average. Barcodes up to 50% fading had a 100% success rate, but success rate deteriorated beyond 60% fading. Curved barcodes took longer to scan compared to flat but success rate deterioration was only observed at a vial diameter of 10mm. Light conditions did not impact success rate or scan time between 500 and 20 lux. Conditions below 20 lux impeded the device’s ability to scan successfully. Variability in scan time was observed across devices in all trials performed. Conclusions: 2d vaccine barcoding is possible using mobile devices and is successful under the majority of conditions examined. Manufacturers utilizing 2d barcodes should take into consideration the impact of factors which limit scan success rates. Future studies should evaluate the impact of mobile barcoding on workflow and vaccine administrator acceptance.

  • Google Flu Trends Spatial Variability Validated against Emergency Department Influenza-related Visits

    Date Submitted: Jan 30, 2016

    Open Peer Review Period: Jan 31, 2016 - Mar 27, 2016

    Background: Influenza is a deadly and costly public health problem. Variations in its seasonal patterns cause dangerous surges in Emergency Department (ED) patient volume. Google Flu Trends (GFT) can...

    Background: Influenza is a deadly and costly public health problem. Variations in its seasonal patterns cause dangerous surges in Emergency Department (ED) patient volume. Google Flu Trends (GFT) can provide faster influenza surveillance information than traditional CDC methods, potentially leading to improved public health preparedness. GFT has been found to correlate well with reported influenza and to improve influenza prediction models. However, previous validation studies have focused on isolated clinical locations. Objective: To measure GFT surveillance effectiveness by correlating GFT with influenza-related ED visits in 19 United States (US) cities across seven influenza seasons. To explore which city characteristics lead to better or worse GFT effectiveness. Methods: Using Healthcare Cost and Utilization Project data, we collected weekly counts of ED visits for all patients with diagnosis (ICD-9) codes for influenza-related visits from 2005 to 2011 in 19 different US cities. We measured the correlation between weekly volume of GFT searches and influenza-related ED visits (i.e., GFT ED surveillance effectiveness) per city. We evaluated the relationship between 15 publically-available city indicators (11 sociodemographic, 2 healthcare utilization, and 2 climate) and GFT surveillance effectiveness using univariate linear regression. Results: Correlation between city-level GFT and influenza-related ED visits had a median of 0.84, ranging from 0.67 to 0.93 across 19 cities. Temporal variability was observed, with median correlation ranging from 0.78 in 2009 to 0.94 in 2005. City indicators significantly associated (P <0.10) with improved GFT surveillance include higher proportion of population female, higher proportion with Medicare coverage, higher ED visits per capita, and lower socio-economic status. Conclusions: GFT is strongly correlated with ED influenza-related visits at the city level, but unexplained variation over geographic location and time limits its utility as standalone surveillance. GFT is likely most useful as an early signal used in conjunction with other more comprehensive surveillance techniques. City indicators associated with improved GFT surveillance provide some insight into the variability of GFT effectiveness. For example, populations with lower socio-economic status may have a greater tendency to initially turn to the internet for health questions, thus leading to increased GFT effectiveness. GFT has the potential to provide valuable information to ED providers for patient care and to administrators for ED surge preparedness.

  • Decreased BMI z-score in school children after year-long information sessions with parents reinforced with web and mobile phone resources

    Date Submitted: Jan 29, 2016

    Open Peer Review Period: Jan 30, 2016 - Mar 26, 2016

    Background: The obesity pandemic has now reached children and households should change their lifestyles to prevent it. Objective: The objective was to assess the effect of a comprehensive intervention...

    Background: The obesity pandemic has now reached children and households should change their lifestyles to prevent it. Objective: The objective was to assess the effect of a comprehensive intervention on body mass index z-score (BMIZ) in school children. Methods: Four elementary schools in Mexico City, two governmental and two private, were engaged. The intervention was implemented in two schools, one governmental and one private (intervention group, IG); the others two schools were controls (CG). The intervention lasted for a school year. Three educational parent/child sessions were held at two-month intervals to promote healthy eating habits and exercise. To reinforce the information, a website provided extensive discussion on a new topic every 15 days, menus about school snacks, and tool for assessing BMI in children and adults. Text messages were sent to parents’ mobile phones. IG contained 226 children and CG 181 children. We measured their weight and height and BMIZ at 0, 6, and 12 months. Results: The CG children showed a change of +0.06 (95% CI 0.01 to 0.11) and +0.05 (95% CI 0.01 to 0.10) in their BMIZ at 6 and 12 months, respectively. The IG children decreased their BMIZ by -0.13 (95% CI -0.19 to -0.06) and -0.10 (95% CI -0.16 to -0.03), respectively, and the effect was greater in children with obesity. Conclusions: The comprehensive intervention tested had beneficial effects, preserved the BMIZ of eutrophic children and reduced the BMIZ of children with obesity.

  • Supporting knowledge and medical decisions in the digital age: a psychological point of view

    Date Submitted: Jan 26, 2016

    Open Peer Review Period: Jan 28, 2016 - Mar 24, 2016

    The process of web information searching is a crucial point in our digital age. We would like to suggest a critical thinking about the role and the use of internet and web search engines. Doctors and...

    The process of web information searching is a crucial point in our digital age. We would like to suggest a critical thinking about the role and the use of internet and web search engines. Doctors and Health operators should consider seriously how to support their patients into web navigation and they should consider which skills are required to assist them in an appropriate way.

  • The effect of guided web-based cognitive behavioral therapy on patients with depressive symptoms and heart failure- A randomized controlled trial

    Date Submitted: Jan 26, 2016

    Open Peer Review Period: Jan 28, 2016 - Mar 24, 2016

    Background: Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategie...

    Background: Depressive symptoms, and the associated coexistence of symptoms of anxiety and decreased quality of life (QoL), are common in patients with heart failure (HF). However, treatment strategies for depressive symptoms in patients with HF still remain to be established. Internet-based cognitive behavioral therapy (ICBT) as guided self-help CBT programs have shown good effects in the treatment of depression. Until now ICBT has not previously been evaluated in patients with HF with depressive symptoms. Objective: The aims of this study were to: (I) evaluate the effect of a nine-week guided ICBT program on depressive symptoms in patients with HF; (II) to assess factors associated with the change in depressive symptoms; and (III) to investigate the effect of the ICBT program on cardiac anxiety and QoL. Methods: Fifty participants were included and randomized into two treatment arms: ICBT or an online moderated discussion forum (DF). The Patient Health Questionnaire -9 (PHQ-9) was used to measure depressive symptoms, the Cardiac Anxiety Questionnaire (CAQ) was used to measure cardiac-related anxiety, and the Minnesota Living with Heart Failure questionnaire (MLHF) was used to measure QoL. Data (self-reported) were collected at baseline and at the nine-week follow-up. Intention to treat analysis was used, and missing data was imputed by the expectation-maximization method. T-tests was used for within group differences and relationships were analyzed by Pearson’s r or Tau-b. Between group differences were determined by analysis of covariance (ANCOVA) with control for baseline score and regression to the mean. Results: In the ICBT group (n=25), depressive symptoms improved significantly (M=10.8 vs. M=8.6, P=.02). Also cardiac anxiety in the subscale of fear decreased significantly (M=1.55 vs. M=1.35, P=.04) between baseline and the follow up in the ICBT-group. QoL improved in the ICBT group by 6 points in the total score and 2.4 points in the physical factor , but this was not significant (P=.09 and P=.12). In the DF group (n=25) no significant change in the level of depressive symptoms was found (M =10.6 SD=5.0, vs. M=9.8 SD=4.3, P=.36). There were no significant differences in the change in depressive symptoms between the DF- and the ICBT- group, nor in cardiac related anxiety or in QoL. In the ICBT group, the number of logins to the web-portal correlated significantly with improvement in depressive symptoms (P=.02), whereas higher age (P=.01) and male sex (P=.048) were associated with less change in depressive symptoms. Conclusions: Guided ICBT adapted for persons with HF and depressive symptoms can potentially reduce depressive symptoms, cardiac anxiety and increase QoL, but is not statistically superior to participation in an online discussion forum. Clinical Trial: NCT01681771.