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

Latest Submissions Open for Peer Review

JMIR has been a leader in applying openness, participation, collaboration and other "2.0" ideas to scholarly publishing, and since December 2009 offers open peer review articles, allowing JMIR users to sign themselves up as peer reviewers for specific articles currently considered by the Journal (in addition to author- and editor-selected reviewers).

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Health topics on Facebook groups: content analysis of posts in Multiple Sclerosis communities

    Date Submitted: Feb 16, 2018
    Open Peer Review Period: Feb 17, 2018 - Apr 14, 2018

    Background: Social Network Sites (SNSs) are increasingly being used to exchange health information from patients and practitioners/pharmaceutical companies/research centers. Research contributions have explored the contents discussed online, categorized the topics, and explored their engagement levels. Objective: This research aims at investigating the potential role of Social Networks Site (SNSs) in Healthcare. Specifically it provides a clustering of health information available on SNSs and creates an initial research design that would allow the use of this information to enhance healthcare delivery. In addition, this research aims at testing whether SNSs valid tools for sharing drug related information by patients. Methods: The research is based on a specific chronic disease: Multiple Sclerosis. We searched the SNS Facebook and looked at all existing groups on this condition. The analysis was restricted to public groups for privacy concerns. We created a database by downloading posts from two main groups on which we performed a content analysis and a statistical analysis; this allowed us to discriminate between categories, their engagement level, and type of posts shared. The mean of engagement for each topic was analyzed using one-way ANOVA and followed up by pairwise comparisons using TukeyHSD. Results: On a sample of 7029 posts, initial results show that there are 8 categories of topics that have resonance (percentage of times the topic appears in our sample) with those who post on Facebook: Patient Support (3.09%), Information/Awareness (70.02%), Event Advertising and Petitions (5.19%), Products and Drugs Advertising (0.68%), Fundraising (5.04%), Clinical Trials or Research Studies (0.84%), Drug Discussion (2.05%), and Other (14.14%). Initial analysis shows that “comments” and “likes” (as measures of engagement level) are more frequently used than other measures of engagement. The results show high engagement level (in terms of views, likes, comments, etc.) for Patient support, Information/Awareness. In addition, although Drug Discussion had low resonance it had unexpected highly engagement level which we found worthy of further exploration. Conclusions: SNSs have become important tools for patients and healthcare practitioners to share or seek information. We identify the type of information shared and how the public reacts to it. Our research confirms that the categories of topics discussed in social media related to specific diseases are appropriate as they are similar to the categories observed by other researchers. Additionally, we found other categories such as drug discussion which was unexpected. This and other results of our study enhance our understanding of how contents are disseminated and perceived within a specific disease based community. We conclude that this information has useful implications in the design of prevention campaigns, educational programs, and chronic disease management.

  • Background: For advanced cancer patients in palliative care, a crucial phase is the transition from palliative care in the hospital to the home setting, where 24-7 care is not guaranteed any more. To fill this gap after transition, we are evaluating the feasibility of a physical and social activity tracking system consisting of a FDA approved bracelet (Biovotion Everion MD®) collecting vital data, e.g., heart rate, oxygen saturation etc., and an Android smart-phone (Samsung Galaxy S5) collecting patients’ self-reports of pain and distress as well as acceleration, GPS and phone call statistics data. When study participants are asked, how they are doing in general, a common answer is “There are good days and there are bad days.” Apparently, they order their days into different groups. We argue that these “good” and “bad” days have impact on a patient’s behavior and is therefore visible in the collected activity data. Objective: As a part of the study’s goals, we aim to show the explanatory power of the collected data: the collected data reflect the health status of a patient. Methods: Data is collected over a study period of 12 weeks as part of a feasibility study with an explorative and descriptive study design. Study participants are enrolled from the wards of the Clinic of Radiation-Oncology at the University Hospital Zurich, including the specialized palliative care ward. The data collection chain consists of the patients’ devices, Wi-Fi and internet for secured data upload and a receiving web server. The raw data is preprocessed involving resampling and basic feature extraction. Complex features are extracted using unsupervised machine learning methods, e.g., clustering. Heat maps are used to provide overview visualizations of sensor modalities. Integrated views are generated for multi-modal reconstruction and visualization of patients’ daily routines. Results: Data collection started in March 2017 and already 13 study participants have finished their study participation or had to abort their participation due to health reasons. We collected more than 10000 hours of valid bracelet data and about 410000 GPS positions from the smart-phone. The cohort shows a high variability in live circumstances, e.g., some are still working, and others hardly leave their homes. We give examples of two patients with different courses of disease in order to demonstrate our approach. Conclusions: Our remote monitoring system delivers a large amount of data that allows us to reconstruct the daily routines of the patients showing differences between good and bad days. Clinical Trial: The local Ethics Committee (Kantonale Ethikkommission Zürich) has approved the study protocol; approval number PB_2016-00895.

  • Predicting Concussions Using Data Analytic Approaches

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Background: Sports related concussion forms a major component of all brain injuries occurring in the United States and has a huge detrimental impact on the quality of life and various health outcome. Predicting concussion is an important way to achieve prevention. Understanding concussion likelihood in the context of different data such as demographic, life style and mental health information related injury will support the development of better diagnostics and preventative techniques. Objective: The objective of this study is to predict the concussion occurrence, number of the concussion, and number of the years since the last concussion using the analytical models. Methods: We develop analytic models that are built using disparate data about lifestyle, demographics and medical history. These models that are based on various machine learning algorithms such as K_Nearest Neighbor, Support Vector Machines, Regression, Ensemble models, Artificial Neural Networks, Decision Tree, General Linear Model and Multivariate Adaptive Regression Splines. In this paper the synthetic minority over-sampling (SMOTE) is employed to overcome the data-imbalance problems. Results: The results show that the predictors associated with the cognitive-mental health plays an important role as a predictor of concussions. Findings suggest that Random forest, Artificial Neural Networks and Decision Tree demonstrate superior performance (sensitivity-80, specificity-88, accuracy- 86) over the other analytics approaches. The number of the concussions are best predicted by K_Nearest Neighbor (sensitivity-83, specificity-75, accuracy-80) while Multivariate Adaptive Regression Splines (mean absoluter error - 2.45) and General Linear Model (mean absoluter error - 2.67) outperform the other machine learning methods for predicting the number of the years past from last concussion Conclusions: Using the data derived from a series of easily executable screening test supported with IoT devices and self-reports, comprehensive analytics models to predict concussion occurrence, reoccurrence and duration since last concussion based on their demographic, lifestyle and mental health information can be developed. Such computational models could lead to customized training approaches and improved efforts for concussion prevention and management.

  • Instant Automated Inference of Perceived Mental Stress through Smartphone PPG and Thermal Imaging

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: A smartphone is a promising tool for daily cardiovascular measurement and mental stress monitoring. Photoplethysmography (PPG) and low-cost thermography can be used to create cheap, convenient and mobile systems. However, to achieve robustness, a person has to remain still for several minutes while a measurement is being taken. This is very cumbersome, and limits the usage in applications such producing instant measurements of stress. Objective: We propose to use smartphone-based mobile PPG and thermal imaging to provide a fast binary measure of stress responses to an event using dynamical physiological changes which occur within 20 seconds of the event finishing. Methods: We propose a system that uses a smartphone and its physiological sensors to reliably and continuously measure over a short window of time a person’s blood volume pulse, the time interval between heartbeats (R-R interval) and the 1D thermal signature of the nose tip. 17 healthy participants, involved in a series of stress-inducing mental activities, measured their physiological response to stress in the 20 second-window immediately following each activity. A 10-cm Visual Analogue Scale was used by them to self-report their level of mental stress. As a main labeling strategy, normalized K-means clustering is used to better treat inter-personal differences in ratings. By taking an array of the R-R intervals and thermal directionality as a low-level feature input, we mainly use an artificial neural network to enable the automatic feature learning and the machine learning inference process. To compare the automated inference performance, we also extracted widely used high level features from HRV (e.g., LF/HF ratio) and the thermal signature and input them to a k-nearest neighbor to infer perceived stress levels. Results: First, we tested the physiological measurement reliability. The measured cardiac signals were considered highly reliable (signal goodness probability used, Mean=0.9584, SD=0.0151). The proposed 1D thermal signal processing algorithm effectively minimized the effect of respiratory cycles on detecting the apparent temperature of the nose tip (respiratory signal goodness probability Mean=0.8998 to Mean=0). Second, we tested the 20 seconds instant perceived stress inference performance. The best results were obtained by using automatic feature learning and classification using artificial neural networks rather than using pre-crafted features. The combination of both modalities produced higher accuracy on the binary classification task using 17-fold leave-one-subject-out (LOSO) cross-validation (accuracy: HRV+Thermal: 76.96%; HRV: 60.29%; Thermal: 61.37%). The results are comparable with the state of the art automatic stress recognition methods requiring long term measurements (a minimum of 2 minutes for up to around 80% accuracy from LOSO). Lastly, we explored the impact of different data labeling strategies used in the field on the sensitivity of our inference methods and the need for normalization within individual. Conclusions: Results demonstrate the capability of smartphone biomedical imaging in instant mental stress recognition. Given that this approach does not require long measurements requiring attention and reduced mobility, it is more feasible for mobile mental healthcare solution in the wild.

  • SoTRAACE for active security in Ambient Assisted Living

    Date Submitted: Feb 16, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Ambient Assisted Living (AAL) solutions have been conquering an important place among strategies to promote ageing in place and address the societal challenges of population ageing. AAL is deeply rooted on the computing paradigm of Ambient Intelligence which strongly impacts the technological phenomenon of Internet of Things (IoT), currently covering a plethora of ageing related application areas. The pervasiveness of IoT raise, however, security challenges and require more flexible and better adapted availability and privacy measures. Still, IoT devices and services are frequently described in the literature without any reference to privacy and security issues they may integrate and the few works in the Ambient Assisted Living (AAL) field focus mostly on authentication or physical access control. Objective: This paper describes the SoTRAACE - Socio-Technical Risk-Adaptable Access Control - model, designed to better adapt users’ access control needs to each AAL security context. The model is applied to use cases based on AAL for mental health personas and scenarios. Methods: SoTRAACE architecture takes into account contextual, technological and user’s interaction profiling functionalities to act in each AAL situation/request and perform a quantitative and qualitative risk assessment analysis. The risk analysis supports decision-making on the most secure, private and usable way to access and display information. Results: SoTRAACE unique advantages for improved availability and privacy are discussed in contrast with existing access control models. The model is showcased and discussed within two AAL for mental health use case scenarios. SoTRAACE new and reused components are varied and versatile enough to adapt to different situations and user’s goals, whether these are patient or caregiver oriented. Conclusions: SoTRAACE is an innovative and complete proposal for secure and adaptable access control in AAL or similar environments.

  • Background: Young people who have a parent with a mental illness face elevated risks to their wellbeing. However, they may not have access to appropriate interventions. Online interventions may reach and meet the needs of this at-risk group, yet their preferences regarding the features of this medium are unknown. Objective: This study sought to determine the utility of an online intervention to meet the needs of young people who have a parent with a mental illness, and their perspectives regarding the types of features of such a website. Methods: A systematic, two-round Delphi study was employed to solicit the views of 282 young people aged 16 to 21 years (Round 1 n = 14, Round 2 n = 268), from urban and regional settings in Australia. ‘Regional’ was used to refer to non-urban participants in the study. After first ascertaining whether an online intervention was warranted, an extensive list of online intervention features was identified, including how the site might be facilitated, topics, duration and frequency, and the nature of professional contact. The extent to which young people agreed on the importance of these factors was assessed. Differences and similarities across gender and location were investigated. A mixed method analytic framework was employed using thematic analysis as well as two-way between-groups analysis of covariance controlling for age (ANCOVA) and chi-square test of independence analysis. Results: Both rounds highlighted a strong preference for an online intervention. Consensus was reached for 1) a professionally monitored site; 2) young people and professionals having equal input into the weekly facilitated sessions (e.g., sharing lead role in discussions or deciding on relevant session content); 3) unlimited time access; 4) one-hour, open discussion, weekly sessions over 6 weeks; 5) preferred features for an online intervention; 6) psychoeducation about mental illness; and, 7) considerations for the management of safety violations. There were significant main effects of location type and several of the preferred features for an online intervention for young people who have a parent with a mental illness; however, effect sizes were small to moderate, limiting practical application. Conclusions: Young people aged 16 to 21 years indicated a need for a professionally monitored, psychoeducational, online intervention, with input from professional facilitators and other similar young people, in addition to recommendations to external resources. The findings can be used to inform the development of future online interventions for this highly vulnerable group.

  • Background: Recruitment of highly motivated students for certain clinical practice is considered as an important goal for every medical teacher. It becomes more and more difficult to find out the right and effective teaching way within the extremely fast developing modern education environment full of insufficient and old-fashioned tradition teaching approaches and limited possibilities with patient-hands-on education, especially in Anesthesia and Intensive Care Medicine (AIM). Objective: Our aim was to highlight the importance of using motivation and the application of the modern concept “learning-by-doing” for recruiting the graduates of Medical Faculty of Masaryk University (MFMU) for AIM specialty. Methods: The subject “Individual Student Project” is an obligatory part of the pre-gradual curriculum of MFMU and is mandatory for registration of final exams. Our topic “The development of multimedia educational portal AKUTNE.CZ” has been offered since 2010. The objective was a development of supportive material for Problem-based learning (PBL) / Team-based learning (TBL) lectures aimed at acute medicine. The topic of each algorithm is dealing with AIM issue, but some of them are multidisciplinary. We performed the evaluation focusing on graduates’ choice of profession and specialization in medicine in 2017. Data were reported descriptively. Results: We evaluated 142 students who passed our "Individual Student Project" topic in 2010-2017. During this period, they developed up to 77 electronic Virtual Patients in the form of interactive multimedia algorithms (available at http://www.akutne.cz/index-en.php?pg=education--interactive-algorithms). Out of 139 students of general medicine, 108 students (78%) already graduated, 27 (19%) are still studying (after 12/2017) and 4 (3%) finished their studies unsuccessfully. 37 graduates (34%) work in AIM specialization and 68 (63%) work in other clinical fields of medicine. 3 (3%) graduates currently travel abroad. 57 graduates (53%) chose more-or-less the same specialty after graduation matching the topic of their algorithm. 37 (65%) of these graduates decided for AIM. In the year 2016, there were 41,600 physicians in the Czech Republic. AIM employed 2,207 (5.3%) of them. 525 (23.8%) were trainees without AIM specialization. Approximately one-third of highly motivated students, after completing their studies, selected AIM as their specialization and helped to expand the number of AIM physicians in the Czech Republic. Since 2010, our graduates accounted for 7.1% of all AIM trainees in the Czech Republic. Conclusions: The concept of "learning-by-doing" led to 34% retention of physicians in AIM specialty after graduation. This concept could be considered as an important motivating element of AIM selection after graduation.

  • Consumer Discovery of and Interest in Mental Health Apps: A Survey and Focus Group Study

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: A large number of mental health apps are available directly to consumers through app marketplaces. Little information is known, however, about how consumers search for these apps and which factors influence their uptake, adoption, and long-term use. Objective: The aim of this study was to understand what people look for when they search for mental health apps and aspects and features of those apps that consumers find appealing. Methods: Participants were recruited from a research registry associated with Northwestern University’s Center for Behavioral Intervention Technologies. Most participants (n = 811) completed a survey asking about their use and interest in health and mental health apps. Local participants were also invited to participate in focus groups. A total of 7 focus groups were conducted with 30 participants that collected more detailed information about their use and interest in health and mental health apps. Results: Survey participants commonly found health apps through social media (45.1%, 366/81), personal searches (42.7%, 346/811), or word of mouth (36.9%, 299/811), as opposed to professional sources such as medical providers (24.6%, 200/811). From the focus groups, common themes related to uptake and use of health apps included the importance of personal use prior to adoption, specific features that users found desirable, and trusted sources either developing or promoting the apps. Conclusions: As the number of mental health apps continues to increase it is imperative to better understand the factors that impact people’s adoption and use of such technologies. Our findings indicated that a number of factors – ease of use, aesthetics, individual experience – drove adoption and use and highlighted areas of focus for app developers and disseminators.

  • Understanding the Needs of Mobile Behavioral Sensing Technology for Enhancing University Counseling Services

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Depression is the leading health issue on college campuses in the U.S. The increasing depression prevalence has resulted in record numbers of students seeking mental health services in colleges and universities across the country. Unfortunately, as the primary mental health service provider, university counseling centers are limited in their capacity and efficiency due to time constraints and reliance on student patients’ self-reports. We propose to develop a mobile behavioral sensing platform, named iSee, to enhance the efficiency, accessibility, and scalability of university counseling services. Objective: The purposes of this paper are to 1) validate the usefulness of iSee in improving university counseling services and assisting students’ self-management of their depression conditions, and 2) understand what types of behavioral targets and feedback that need to be delivered via iSee from both clinician and student patients’ perspectives. Methods: We conducted semi-structured interviews with 9 clinicians and 12 depression patients recruited from a counseling center at a large Midwestern university. The interviews lasted from 40-50 minutes and were audio recorded and transcribed. The interview data were analyzed using thematic analysis with an inductive approach. Clinician and student interviews were analyzed separately for comparison. The process of extracting themes involved iterative coding, memo writing, theme revisits and refinement. Results: From the clinician perspective, mobile behavioral sensing technology helps to improve counseling service by providing objective evidence for clinicians and filling gaps in clinician-patient communication. Clinicians suggested providing student patients with their behavioral target data organized around personalized goals. Clinicians recommended delivering therapeutic feedback to student patients based on their behavioral target data, including positive reinforcement, reflection reminder, challenging negative through, and understanding adversity. From the patient perspective, mobile behavioral sensing technology helps to ease continued self-tracking practice. Student patients expressed their need for integrated behavioral target data to understand correlations between behaviors and depression. They also pointed out that they would avoid seeing negative data or feedback that could be depressing. Sometimes, actionable suggestions were preferred to negative feedback. Conclusions: Mobile sensing technology is useful in improving university counseling service and enhancing student patients’ self-management capability. Clinicians and student patients have some diverged opinions on types of behavioral target data and feedback to be provided. Designers are encouraged to consider both clinician and student perspectives and create personalized options to optimize the benefits of mobile sensing technology.

  • Using neural networks with routine health records to identify suicide risk

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Every year approximately 800,000 people die by suicide worldwide, accounting for 1–2 in every 100 deaths. It is always a tragic event with a huge impact on family, friends, community and professionals. Unfortunately, suicide prevention and the development of risk assessment tools have been hindered by the complexity of the underlying mechanisms and the dynamic nature of people’s motivations and intent. Many of those who die by suicide have had contact with health services in the preceding year but identifying those most at risk is a challenge. Objective: To explore the feasibility of using artificial neural networks (ANNs) based on routinely collected electronic health records (EHRs) to support the identification of those at high risk of suicide when in contact with health services. Methods: Using the Secure Anonymised Information Linkage Databank UK, we extracted those who died by suicide between 2001 and 2015 and paired controls. Looking at primary (general practice: GP) and secondary (hospital admissions) EHRs, we built a binary feature vector coding the presence of risk factors at different times before the contact leading to death. Risk factors included: GP contacts and hospital admissions; diagnosis of mental health, injury and poisoning, substance misuse, maltreatment or sleep disorder; and prescription of opiates or psychotropics. We trained simple ANNs to differentiate between cases and controls and interpreted the output score as the estimated suicide risk score. We assessed system performance with 10x10 K-Folds repeated cross-valadiation and studied system performance and behaviour by representing the distribution of estimated risk across cases and controls and the distribution of factors across different estimated risks. Results: We extracted a total of 2,604 suicide cases and 20 paired controls per case. Our system obtained an error rate of 26.78% ± 1.46 (64.57% of sensitivity and 81.86% of specificity). While the distribution of controls was concentrated around estimated risks < 0.5, cases where almost uniformly distributed between 0 and 1. Prescription of psychotropics, depression and anxiety and self-harm increased the estimated risk by ~0.4. At least 95% of those presenting these factors were identified cases. Conclusions: Despite the simplicity of the implemented system, the proposed methodology obtained an accuracy similar to other published methods based on specialized questionnaire generated data. Most of the errors came from the heterogeneity of patterns shown by cases, some of which were identical to those of controls. Prescription of psychotropics, depression and anxiety and self-harm were strongly linked with higher estimated risk scores, followed by hospital admission and long-term drugs and alcohol misuse. Other risk factors such as sleep disorder and maltreatment had more complex effects.

  • Emotion-Recognition Using Smart Watch Sensor Data: Mixed-Design Study

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Research in psychology has shown that the way a person walks reflects that person's current mood (or emotional state). Recent studies have started using smartphones to detect emotional states from movement data. Objective: This study investigates the use of movement sensor data from a smart watch to infer an individual's emotional state. We present our findings on a user study with 50 participants. Methods: The experimental design is a mixed-design study; within-subjects (emotions; happy, sad, neutral) and between-subjects (stimulus type: audio visual "movie clips", audio "music clips"). Each participant experienced both emotions in a single stimulus type. All participants walked 250m while wearing a smart watch on one wrist and a heart rate monitor strap on their chest. They also had to answer a short questionnaire (20 items; PANAS) before and after experiencing each emotion. The heart rate monitor serves as a supplementary information to our data. We performed time-series analysis on the data from the smart watch and a t-test on the questionnaire items to measure the change in emotional state. The heart rate data was analyzed using one-way ANOVA. We extracted features from the time-series using sliding windows and used the features to train and validate classifiers that determine an individual's emotion. Results: We had 50 young adults participate in our study, with 49 included for the affective PANAS questionnaire and all for the feature extraction. Participants reported feeling less negative affect after watching sad videos or after listening to the sad music, P < .006. For the task of emotion recognition using classifiers, our results show that the personal models outperformed personal baselines, and achieve median accuracies higher than 78% for all conditions of the design study for the binary classification of happiness vs sadness. Conclusions: Our findings show that we are able to detect the changes in emotional state with data obtained from the smartwatch as well as behavioral responses. Together with the high accuracies achieved across all users for the classification of happy vs sad emotional states, this is further evidence for the hypothesis that movement sensor data can be used for emotion recognition.

  • System Design and User Perceptions of an Artificially Empathic Conversational Agent

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Conversational agents cannot yet express empathy in nuanced ways that account for the unique circumstances of the user. Agents that possess this faculty could be used to enhance digital mental health interventions. Objective: We sought to design a conversational agent that could express empathic support in ways that might approach, or even match, human capabilities. Another aim was to assess how users might appraise such a system. Methods: Our system used a corpus-based approach to simulate expressed empathy. Responses from an existing pool of online peer support data were appropriated by the agent and presented to the user. Information retrieval techniques and word embeddings were used to select historical responses that best matched a user’s concerns. We collected ratings from 38,366 responses to evaluate the system. Additionally, we conducted a controlled experiment to test whether the alleged source of a response (human or machine) was enough to change how users perceived it. Results: The majority (79.2%) of responses from the system were deemed acceptable by users (N=37,169). However, users significantly preferred the efforts of their peers (P < .001). This effect was maintained in a controlled study (N= 1,284, P = .02), even when the only difference in responses was whether they were framed as coming from a human or a machine. Conclusions: Our system illustrates a novel way for machines to construct nuanced and personalized empathic utterances. However, it had significant limitations and our controlled study results suggest nonhuman agents may always struggle to empathize as convincingly as humans. The ethical implications of empathic agents, as well as their potential iatrogenic effects, are also discussed.

  • Predicting the psycho-physiological effects of pre-selected music– A feasibility Study

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: The use of music therapy in healthcare, including mental health and general wellbeing has become common in many parts of the world, and is usually supported by clinical validation and supervision. In the last decades, research into music therapy and music medicine has advanced rapidly in step with advances in music neuroscience, brain imaging, neuroendocrinology and increasingly easy access to physiological measurements through a new generation of sensors. X-System has developed algorithms predicated upon these developments. These algorithms are intended to model areas and functions of the brain relating to the processing of music, in order to predict the differing neurophysiological effects of different music, and to stream music to achieve desired states of mind and body. X-System has been able to verify these results by both subjective measures and physiological measures including, heart rate and galvanic skin conductance. However, predictions of valence, leading to predictions of mood and emotion, are important for work in mental health but have been difficult to verify physiologically. In this context, Heart Rate Variability (HRV) has proved to be a very promising way forward. Objective: Objectives: This study had two main objectives 1) Understanding the impact of different types of music on heart rate variability as a means of understanding the effects on the subject, and 2) Exploring the potentials of the X-System algorithm to predict psycho-physiological effects of music by comparing the output data to HRV data, and where possible offering validation of existing algorithms Methods: Six participants listened to four such pre-selected pieces (two “happy” and two “sad”, according to internet-sourced popular curations) and one self-selected song in a random order whilst ECG data was recorded continuously throughout. After each song, participants were asked to fill a valence questionnaire. The pre-selected songs were analysed by X-system software to predict the effects of songs on the subjects, and the results were compared to the corresponding HRV data. Results: Results showed that song 4 (happy song), had the largest significant impact on HRV (P=.05), in particular the total power domain where an average increase of 574 ms2 was seen. Promising potential correlations were identified between X-System predictions for both arousal and valence on the one hand and subjective responses of participants on the other. Both arousal and valence, X-System predictions and subjective rankings correlated with HR and HRV rankings for three out of four songs. In tThere were some tentative, identifiable correlations between the X-System predictions, subjective responses and HRV data that suggest that further work should be undertaken, directed towards improving X-System mood predictions and developing treatments for autonomic and mood disorders based on music streaming. Conclusions: There were some tentative, identifiable correlations between the X-System predictions, subjective responses and HRV data that suggest that further work should be undertaken, directed towards improving X-System mood predictions and developing treatments for autonomic and mood disorders based on music streaming.

  • Using smartphone sensor technology for mental health research: Clear obstacles and hidden challenges

    Date Submitted: Feb 16, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Smartphone sensor technology has great potential in providing behavioural markers of mental health. However, this promise has not yet been brought to fruition. Objective: To examine the challenges involved in developing behavioural markers of mental health using smartphone sensor technology. Methods: Both technical challenges and acceptability of passive data collection for mental health research were assessed based on literature review and results from a feasibility study. Socialise, a smartphone app developed at the Black Dog Institute, was used to collect sensor data (Bluetooth, GPS and battery status) and investigate the views and experiences of a group of volunteers (n=32). Results: On average, sensor data was obtained for 55% (Android) and 45% (iOS) of the scheduled scans. Battery life was reduced from 21.3 hours to 18.8 hours when scanning every 5 minutes, a reduction of 2.5 hours or 12%. Despite the limited reduction in battery life, most participants reported that the app had a noticeable effect on their battery. In addition to battery life, the purpose of data collection, trust in the organisation that collects the data, and perceived impact on privacy were identified as the main criteria for acceptability. Conclusions: Based on the findings of the feasibility study and literature review, we recommend a commitment to open science and transparent reporting, and stronger partnerships and communication with users. Sensing technology has the potential to greatly enhance the delivery and impact of mental health care. Realizing this requires all aspects of their use to be rigorously assessed.

  • Patient-Centered Mobile Health Data Management Solution for the German Healthcare System: The DataBox Project

    Date Submitted: Feb 16, 2018
    Open Peer Review Period: Feb 16, 2018 - Feb 26, 2018

    This perspective article describes the DataBox project which offers the perspective of a new health data management solution in Germany. DataBox is initially conceptualized as a repository of individual lung cancer patient data (structured and not structured). The patient is the owner of the data and is able to share his data with different stakeholders. Data is transferred, displayed, and online stored, not archived. In the long run, the project aims at replacing the conventional way of paper- and storage-device-based handling of data for all patients in Germany leading to better organization and availability of data which reduces duplicate diagnostic procedures and treatment errors.

  • Background: One in ten adults globally and 120 million adults in US suffer from chronic pain. Aside from physical detriments chronic pain is closely linked with psychological well-being and there is a prevalence of anxiety, negative affect and in some cases even depressive disorders. In the case of musculoskeletal chronic pain frequent physical activity is beneficial. However, reluctance to engage in physical activity is common due to negative psychological associations (e.g., fear) between movement and pain. It is known that encouragement, increases in self-efficacy and positive beliefs are effective in bolstering adherence to activity. However, given that the majority of time is spent away from personnel who can give such encouragement there is a great need for an automated ubiquitous solution. In this formative study we deploy a smartphone app that generates physical activity recommendations which personalize to an individual’s routine behaviors and ask for small changes to current routine behaviors. The recommendations can be perceived as familiar and easier to do, and therefore likely to be actualized even in the presence of negative beliefs. Objective: MyBehaviorCBP is a smartphone app that uses machine learning on sensor based and self-reported activity tracking to find routine behaviors and automatically generate activity recommendations that are small changes to routine behaviors. In this paper, we report the preliminary efficacy of MyBehaviorCBP based on a pilot trial on individuals with chronic back pain. Methods: A 5-week pilot study was conducted on people with chronic back pain (n=10). After a week of baseline tracking with no recommendations, participants received generic recommendations from an expert for 2 weeks, which served as the control condition. Then, in the next 2 weeks, MyBehaviorCBP recommendations were issued. An exit survey was conducted to compare acceptance towards the different forms of recommendations and future improvements. Results: In the exit survey, 90% (9/10) participant felt positive to about trying the MyBehaviorCBP recommendations, and no participant found the recommendations unhelpful. Several significant differences are observed in outcome measures. e.g., participants found MyBehaviorCBP recommendations easier to adopt compared to generic counterpart (βint=0.42, p<0.005, d=0.25) in a 5-point Likert scale. The MyBehaviorCBP recommendations were actualized more (βint=0.46, p<0.005, d=0.11) with a real terms increase in ~5 minutes of further walking per day (βint=4.9 minutes, p=0.02, d=0.31) compared to generic recommendations. As further improvements, participants wanted push notifications and adaptation for weather or weekend/weekday. Conclusions: In the pilot study, MyBehaviorCBP’s automated approach was found to have positive effects. Specifically, the recommendations were actualized more and they were perceived to be easier to follow. To the best of our knowledge, this is the first time an automated approach has achieved preliminary success to promote physical activity in chronic pain context. Further studies are needed to examine MyBehaviorCBP’s efficacy on a larger cohort and over longer period of time.

  • Background: Online discussion forums allow those in addiction recovery to seek help through text-based messages, including when facing triggers to drink or use drugs. Trained staff (or “moderators”) may participate within these forums in order to offer guidance and support when participants are struggling, but must expend considerable effort to continually review newly posted content. Demands on moderators limit the scalability of evidence-based digital health interventions. Objective: Automated identification of recovery problems could allow for moderators to engage in more timely and efficient ways with participants who are struggling in their recovery. This paper investigates whether natural language processing and supervised machine learning can be applied to successfully flag, in real-time, those discussion forum messages that moderators find most concerning. Methods: Training data came from a trial of a smartphone-based health intervention for individuals in recovery from alcohol use disorder, with human coders labeling discussion forum messages according to whether or not authors mentioned problems in their recovery process. Linguistic features of these messages were extracted via several natural language processing techniques: 1) a Bag-of-Words (BoW) approach 2) the dictionary- based Linguistic Inquiry and Word Count (LIWC) program and 3) a hybrid approach combining the most important features from both BoW and LIWC. These features were applied within binary classifiers leveraging several methods of supervised machine learning: Support Vector Machines, Decision Trees, and Boosted Decision Trees. Classifiers were evaluated in data from a later deployment of the recovery support intervention. Results: To distinguish recovery problem disclosures, the BoW approach relied on domain-specific language including words explicitly linked to substance use (“drink,” “relapse,” “sobriety,” and so on), whereas the LIWC approach relied on language characteristics such as tone, affect, insight, and presence of quantifiers and time references, as well as pronouns. A Boosted Decision Tree classifier, utilizing features from both BoW and LIWC performed best in identifying problems disclosed within the discussion forum, achieving 88% sensitivity and 82% specificity in a separate cohort of patients in recovery. Conclusions: Differences in natural language use can distinguish messages disclosing recovery problems from other message types. Incorporating machine learning models based on language use allows real-time flagging of concerning content such that trained staff may engage more efficiently focus their attention on time-sensitive issues. Clinical Trial: n/a

  • Improving the Efficacy of Cognitive Training for Digital Mental Health Interventions through Avatar Customization

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: The success of Internet-based mental health interventions in practice - i.e., in-the-wild - depends on the uptake and retention of the application and the user's focused attention in the moment of use. Incorporating game-based motivational design into digital interventions delivered in-the-wild has been shown to increase uptake and retention in Internet-based training; however, there are outstanding questions about the potential of game-based motivational strategies to increase engagement with a task in the moment of use, and - as a result - improve intervention efficacy without accompanying increases in treatment exposure. Objective: Designers of Internet-based interventions need to know whether game-based motivational design strategies can increase in-the-moment engagement and thus improve intervention efficacy. We investigate the effects of one motivational design strategy (avatar customization) in an example mental health intervention (computerized cognitive training for attention bias modification). Methods: We assigned 317 participants to either a customized avatar or an assigned avatar condition. After measuring state-anxiety (STAI), we randomly assigned half of the participants in each condition to either an attentional retraining condition (ABMT) or a control condition. After training, participants were exposed to a Negative Mood Induction using images with strong negative valance (IAPS), after which we measured state-anxiety again Results: Avatar customization improved treatment efficacy, evidenced as decreased post-training state-anxiety when controlling for baseline state-anxiety, for those who trained attention bias modification; however, those who did not train experienced decreased resilience to the negative mood induction (F1,252=6.86, P=.009, ηp2=.027). Together these results suggest that customization increased task engagement with the intervention in the moment of use. Avatar customization also increased avatar identification (F5,252=12.46, P<.001, R2=.23), regardless of whether or not participants trained attentional bias (F1,252=.79, P=.378). Avatar identification reduced anxiety after the negative mood induction for participants who underwent training, but increased post-stimulus anxiety for participants who did not undergo training, further suggesting that customization increases engagement in the task (F1,252=6.19, P=.014). The beneficial effect of avatar customization on training was driven by participants who were low in their basic satisfaction of relatedness (F10,248=18.5, P<.001, R2=.43), which is important because these are the participants who are most likely in need of digital interventions for mental health. Conclusions: Our results suggest that applying motivational design can improve the efficacy of attentional retraining, without increasing treatment exposure. Avatar customization is a viable strategy to increase engagement and subsequent training efficacy in a computerized cognitive task.

  • eHealth-interop: an Interoperability Platform developed for Mental Care Integration

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: The electronic exchange of health-related data can support different professionals and services to act in more coordinated and transparent manner and make the management of health services networks more efficient. Although mental health care is one of the areas that can benefit from a secure health information exchange, since it usually involves long-term and multi professional care, there are few published studies on this topic, particularly in low and middle income countries. Objective: The design, implementation and evaluation of an eHealth platform that allows the technical and informational support of a Brazilian regional network of mental health care. This solution enables the health information exchange, improve data quality and identify and monitor patients over time and in different services. Methods: The proposed platform is based on client-server architecture to be deployed in the web following a web-services communication model. The interoperability information model was based on international and Brazilian health standards. To test platform usage, we have utilized the case of the mental health care network of the XIII Regional Health Department of the São Paulo state, Brazil. Data were extracted from five different sources, involving 26 municipalities: national demographic data, data from primary health care, data from requests for psychiatric hospitalizations performed by community services, and data obtained with psychiatric hospitals about hospitalizations. Data quality metrics such as accuracy and completeness were evaluated to test the proposed solution. Results: The eHealth-Interop integration platform was designed, developed and tested. It contains a built-in terminology server and a record linkage module to support patient's identification and deduplication. The proposed interoperability environment was able to integrate information in the mental health care network case with the support of five international and national terminologies. In total, 27353 records containing demographic and clinical data were integrated into eHealth-Interop. Of all these records, 34% (9547) were identified as patients who were present in more than 1 data source with different levels of accuracy and completeness . In general, it was possible to achieve an improvement of 18,4% in completeness and 1,1% in syntactic accuracy over the test data set after integration and deduplication. Conclusions: The proposed platform established an eHealth solution to fill the gap in the availability and quality of information within a network of health services, in order to improve the continuity of care and the health services management. It has been successfully applied in the context of mental health care and is flexible to be tested in other areas of care.

  • Background: Most people with mental health disorders fail to receive timely access to adequate care. Digital technology has the potential to drive a sea change in the psychosocial treatment of mental health problems, especially in minority populations that have known barriers to accessing and utilizing traditional treatment approaches. Objective: The objective of the present study was to compare recruitment, engagement, and treatment outcomes between a sample of depressed Spanish-speaking Hispanic/Latino individuals compared to a cohort of depressed English speakers using 3 different self-guided mobile apps (iPST (based on evidence-based therapeutic principles from problem-solving therapy [PST]); Project: Evolution™ (EVO; a cognitive training app based on cognitive neuroscience principles); and Health Tips (health information app that served as an information control)). Methods: Participants were recruited for this randomized controlled trial using social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 646 English-speaking and 437 Spanish-speaking adults (≥18 years old) with mild to moderate depression as determined by a 9-item Patient Health Questionnaire (PHQ-9) score ≥5 or an endorsement of impaired functioning. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale). Engagement in the study was assessed based on the number of times participants completed active surveys. Results: We screened 4,502 participants and enrolled 1,083 participants from throughout the US over 6 months. The majority of the participants were recruited via posts on craigslist.org, with significant participant acquisition costs present when recruiting Spanish speakers ($31/ participant) compared to English speakers ($1.46/participant). Long-term engagement surfaced as a key issue with Spanish speaking participants, as these individuals dropped out two weeks earlier than their English counterparts. Furthermore, while no significant difference between Spanish- and English speakers were observed for treatment remission, Spanish-speakers consistently reported higher depression symptoms compared to their English speaking counterparts. Conclusions: Our findings suggest that fully remote mobile-based studies can attract a diverse participant pool including people from lower socioeconomic backgrounds (in this case Hispanic/Latinos). However, keeping participants engaged in this type of ‘low-touch’ research study remains challenging. Further research including user-centered approaches are needed to understand the culturally adequate incentive levels, notification strategies and effective mobile content formatting to enhance the recruitment and retention of minority populations. Clinical Trial: Clinicaltrials.gov Identifier: NCT01808976

  • User Experience of CBT Apps for Depression: An Analysis of App Functionality and User Reviews

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 16, 2018 - Apr 13, 2018

    Background: Hundreds of mental health apps are available to the general public. With increasing pressures on healthcare systems they offer a potential way for people to support their mental health and wellbeing. However, while many are highly rated by users, few are evidence-based. Equally, our understanding of what makes apps engaging and valuable to users is limited. Objective: The aim of this paper was to analyse functionality and user opinions of apps purporting to support Cognitive Behavioural Therapy (CBT) for depression and to explore key factors that have impact on user experience and support engagement. Methods: We systematically identified apps described as being based on CBT for depression. We then conducted two studies. In the first, we analysed the therapeutic functionality of apps. This partially replicated existing work on apps' fidelity to CBT theory, but we also extended prior work by examining features designed to support user engagement. Engagement features found in CBT apps for depression were compared with those found in a larger group of apps that support mental wellbeing in a more general sense. Our second study involved a more detailed examination of user experience, through a thematic analysis of publicly available user reviews of CBT apps for depression. Results: We identified 31 apps that purport to be based on CBT for depression. Functionality analysis (Study 1) showed that they offered an eclectic mix of features, including many not based on CBT practice. CBT apps used less varied engagement features compared to 253 other mental wellbeing apps. The analysis of 1,287 user reviews of CBT apps for depression (Study 2) showed that apps are used in a wide range of contexts, both replacing and augmenting therapy, and allowing users to take active role in supporting their mental health and wellbeing. Users, including health professionals, valued and used apps that incorporated both core CBT and non-CBT elements, but concerns were also expressed regarding the unsupervised use of apps. Positivity was seen as important to engagement, e.g. in the context of automatic thoughts, users express a preference to capture not just negative, but also positive ones. Privacy, security and trust were crucial to the user experience. Conclusions: CBT apps for depression need to do a better job of incorporating evidence-based CBT elements. Equally, a positive user experience is dependent on other design factors, including consideration of varying contexts of use. App designers should be able to clearly identify the therapeutic basis of their apps, but they should also draw on evidence-based strategies to support a positive and engaging user experience. The most effective apps are likely to strike a balance between evidence-based CBT strategies and evidence-based design strategies, including the possibility of eclectic therapeutic techniques.

  • Background: Although cognitive behavioral therapy sleep treatments have been shown to be safe, effective, and associated with durable improvements in patients presenting with insomnia (CBTI), they have not been used to promote healthy sleep in military populations that include active duty service members (ADSM), veterans, and the clinicians who serve them. This population’s need for CBTI treatments might be best met through the use of interactive Resilience Enhancing Sleep Tactics (iREST), an application developed as a form of just-in-time adaptive intervention (JITAI). Drawing from existing BBTI contexts, iREST could offer ADSM and veterans a more efficacious form of CBTI by dynamically adapting both the assessment and intervention in response to each user’s highly individualized context. Objective: This paper seeks to perform a clinical feasibility study that assesses the JITAI application—the iREST app—for delivering behavioral insomnia treatment in a military population. The outcomes are then compared with results from a traditional (in person) behavioral treatment. Methods: In this feasibility study, ADSM and Veterans between the ages of 18 and 60 were recruited and subjected to a set of eligibility and exclusion criteria through a set of surveys, questionnaires, and interviews. Once selected, participants followed the BBTI intervention through the iREST app for 4-6 weeks. The Insomnia Severity Index (ISI) was used as the primary sleep outcome metric; overall sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and the PSQI Addendum for PTSD (PSQIA). Results: 22 individuals were included in the clinical feasibility study and 19 (86.36%) completed the post-treatment/follow-up assessment. There were no statistically significant demographic differences between participants in the current study (iREST) and the traditional BBTI study. The chi-squared values for response and remission were found to be = 0.34, >0.05 and < 0.91, >0.05 respectively, suggesting that no significant difference exists between the rates in the current trial and the previous BBTI-MV. Pre and post-intervention tests show statistically significant improvement in primary and secondary outcomes, e.g., the mean reduction on the ISI = 10.16, t (18) = 7.40, < 0.01. While a mixed model ANOVA with time functioning as a within-subject variable detected only a main effect of time (F(1,34) = 87.39, < 0.01) further suggests that JITAI was equally as effective as in-person intervention. Conclusions: The iREST intervention was shown to be non-inferior compared to the traditional approach. In fact, the preliminary results showed that the remission and response-to-treatment were slightly better compared to traditional intervention. This finding suggests that JITAI is a feasible approach in behavioral treatments for insomnia and other sleep problems.

  • Data-driven learning in high-resolution activity sampling from depressed patients with bipolar disorder

    Date Submitted: Feb 14, 2018
    Open Peer Review Period: Feb 15, 2018 - Apr 12, 2018

    Background: Behavioral Activation (BA) is a pen and paper-based therapy form for treating depression. The patient registers their activity hourly, and together with the therapist, they agree on a plan to change behavior. However, with the limited clinical personnel, and a growing patient population, new methods are needed to advance BA. Objective: The objectives of this paper were to 1) automatically identify behavioral patterns through statistical analysis of the paper-based activity schedules, and 2) determine whether it is feasible to move the BA therapy format to a digital solution. Methods: We collected activity schedules from seven patients, covering in total 2,480 hours of self-reported activities. A pleasure score, on a 1-10 rating scale, was reported for each activity. The activities were digitalized into seven activity categories, and statistical analyses were conducted. Results: Across all patients, movement-related activities were associated with the highest pleasure score followed by social activities. On an individual level, through a non-parametric Wilcoxon Signed-Rank test, one patient had a statistically significant larger amount of spare time activities when feeling bad (z = -2.045, p = .041). Through a within-subject ANCOVA, the patients were found to have a better day than the previous, if that previous day followed their diurnal rhythm (ρ = .265, p = .0288). Furthermore, a second-order trend indicated that two hours of daily social activity was the optimal for the patients (β2 = -0.08, t(63) = -1.22, p = .23). Conclusions: The data-driven statistical approach was able to find patterns within the behavioral traits that could help to assist, the therapist in a future application.

  • Background: Many mental disorders are mostly preceded by a prodromal phase consisting of various attenuated and unspecific symptoms and functional impairment. Electronic Health Records (EHR) are generally used to capture these symptoms during medical consultation. Internet-based and mobile technologies provide the opportunity to monitor symptoms emerging in patients’ environment using ecological momentary assessment techniques to support preventative therapeutic decision making. Objective: We assessed the clinical acceptability of a web-based application designed to collect medical data during appointments and provide EMA features. Methods: Clinicians at four community psychiatry departments were recruited to participate. They used the application to assess patients and to collect data after viewing a video of a young patient’s emerging psychiatric consultation. They were then asked to answer a short anonymous self-administered questionnaire that evaluated their experience, the acceptability of the application, and their habit of using new technologies. Results: Of 24 practitioners solicited, 88% agreed to participate. Most of them were between 25 and 45 years old, and greater age was not associated with poorer acceptability. Most of the practitioners regularly use new technologies, and 90% connect daily to the internet, with 67% connecting three times a day or more. However, only 50% report feeling comfortable with computers. 86% (n=18) of the clinicians would recommend the tool to their colleagues and 67% consider that a daily use would be interesting. Most of the clinicians (76%) found the interface easy to use and useful. However, several clinicians regret the lack of readability (38%) and point out the necessity of improving ergonomy (19%) in particular to facilitate browsing through various subsections. Part of them (24%) are concerned about the storage of medical datas and most of them (52%) seem to be uncomfortable with this. Conclusions: In this study we describe the first step of the development of a web application combining an EHR and ecological momentary assessment (EMA) features. This online tool offers the possibility to assess patients and to integrate medical data easily into face to face conditions. The acceptability of this application supports the feasibility of its broader implementation. This app could help to standardize assessment and to build up a strong database. Used in conjunction with robust data mining analytic techniques, such a database would allow exploration of risk factors, patterns of symptom evolution, and identification of distinct risk subgroups.

  • Automatic detection of emotions in depressed patients and healthy subjects: a mobile application study

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 15, 2018 - Apr 12, 2018

    Background: Improving the recognition and management of momentary emotion is crucial for mental health, both in depressed patients and in normal population. Objective: The objective of this study is to examine the performance of a mobile phone system regarding the detection of real-time emotion. Methods: A mobile phone application, iHOPE, was developed for detecting emotion. A Bayesian network with 15 nodes was used for inferring momentary emotion based on contextual factors and smartphone use patterns. Five patients with major depressive disorder and seven normal participants were recruited. Participants used the Circumplex model to label their daily emotions for 8 consecutive weeks, which were used for model training and validation. Results: Depressed patients spent 77% more time with smartphone than healthy subjects. In comparison with accuracy of 25% by random guessing, our detection algorithm achieved an accuracy of 54% in all participants, as demonstrated by 10-fold cross validation. Predictive accuracy was better in patients than in healthy subjects. In depressed patients, using data 180 minutes prior to emotion tags achieved the best performance, whereas for healthy subjects, the optimal time window was 30 minutes. We also find that using more recent data (i.e. the past 2 weeks vs. the first 2 weeks or all data) resulted in better performance. The contribution of individual variable on predictive accuracy demonstrated significant inter-subject variability. Conclusions: The findings here suggest that, both in depressed patients and in healthy subjects, it is possible to infer momentary emotion with individualized detection algorithm, while identifying personal attributes to improve emotional awareness and design intervention.

  • Background: Medication non-adherence is a major problem in healthcare, imposing poor clinical outcomes and a heavy financial burden on all stakeholders. Current methods of adherence assessment are severely limited: they are applied only periodically, do not relate to actual pill intake and suffer from patient bias due to errors, misunderstanding or intentional non-adherence. ReX is an innovative drug management system designed to address poor patient adherence and enhance patient engagement with their therapy. ReX controls and tracks pills from the point of packaging right through to the patient’s mouth. ReX generates robust, real-time adherence data. Interactive communication with the system enables patients to report outcomes, complete surveys and receive messages and instructions. ReX includes a reusable Drug Dispensing Unit, disposable Cassette containing pills and a cloud-based, data portal. Objective: The objectives of this study were to evaluate: 1) ReX safety 2) acceptance and usability of ReX innovative technology 3) efficacy of ReX in (a) providing pills according to the dose regimen; (b) managing reminders and adherence data; (c) enhancing adherence rates compared to standard of care. Methods: ReX system components and operation are demonstrated. The ReX system safety, usability and efficacy were evaluated in two human-factor, non-clinical, feasibility studies. Human subjects used ReX for administration of pill-shaped Tic Tac sweets, according to a pre-programmed dose regimen. The first study, comprising 59 subjects aged 18-92 evaluated ReX use and administration of 2 pill intakes. The second study was a self-controlled, “walk around” study, comprising 40 subjects, aged 18-90. Subjects took pills at home, for 4 days each via the device (ReX test) or from standard packaging (Control test). Results: The first study confirmed the usability and acceptance of the ReX novel approach to pill dispensing. All subjects (100%) successfully managed 2 pill intakes. 81% of subjects rated the ReX device as easy to use. The second “walk around” study confirmed the safety, usability and efficacy of the ReX system. Overall adherence rate in the ReX test was 21% higher than in the Control test (P<0.0001, Confidence=95%). Real-time, personalized reminders, provided in the event of delay in pill intake, contributed to 18% of doses taken during the ReX test (P<0.0001, Confidence=95%). 87% of subjects found the ReX system easy to use and felt comfortable using it for their medications. Conclusions: ReX’s novel “Tracking to the Mouth” technology was found to be safe, feasible and effective for oral medication therapy.

  • Facebook Ads to Recruit Military Veterans: Reaching Those At-Risk for Psychiatric Disorders and Suicidal Ideation

    Date Submitted: Feb 14, 2018
    Open Peer Review Period: Feb 15, 2018 - Apr 12, 2018

    Background: Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans. Objective: This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health. Methods: Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, survey completion, and cost per survey completed. Results: Advertisements produced 827,918 impressions, 9,527 clicks, and 587 survey completions. Lack of enrollment in VA health care (33%) and positive screens for current mental health problems were common, including PTSD (52%), problematic drinking (51%), major depression (28%), and suicidality (22%). Half of survey participants (n=285) were recruited with just 2 of the 15 ads, which showed soldiers marching tied to an “incentive” or “sharing” headline. These two ads were also the most cost effective, at $4.88 and $5.90 per participant, respectively. Among veterans with current suicidal ideation, the survey-taking image resulted in higher survey completion than the soldiers marching image (p=0.007). Conclusions: Facebook ads are effective in rapidly and inexpensively reaching military veterans, including those at-risk for mental health problems and suicidality, and those not receiving VA healthcare. Ad image and headlines may help optimize effectiveness of ads for specific subgroups.

  • Trajectories of 12-month usage patterns for two smoking cessation websites: Exploring how users engage over time

    Date Submitted: Feb 15, 2018
    Open Peer Review Period: Feb 15, 2018 - Feb 24, 2018

    Background: Little is known about how individuals engage with e-health interventions over time and whether this engagement predicts health outcomes. Objective: Using the example of a specific type of e-health intervention (i.e., websites for smoking cessation), the objectives were to determine: (1) distinct groups of login trajectories over a 12-month period, (2) their association with smoking cessation, and (3) baseline user characteristics that predict trajectory group membership. Methods: Functional clustering analysis of 365 consecutive days of login data from both arms of a large (N = 2637) randomized trial of two website interventions for smoking cessation (WebQuit.org and Smokefree.gov), with a primary outcome of 30-day point prevalence smoking abstinence at 12-months. Analyses were conducted for each website separately. Results: Three distinct trajectory groups emerged for each website. For WebQuit.org, participants were clustered into three groups: “one-week users” (55% of the sample), “five-week users” (32%), and “fifty-two week users” (13%). Compared to the one-week users, the five and fifty-two week users had 57% higher odds (OR = 1.57; 95% CI = 1.13-2.17 p = .007) and 124% higher odds (OR= 2.24; 95% CI = 1.45-3.43; p < .001), respectively, of being abstinent at 12 months. Smokefree.gov users were clustered into three groups: “one-week users” (49% of the sample), “four-week users” (30%), and “five-week users” (21%). Compared to the one-week users, five-week users (but not four-week users, p = .99) had 48% higher odds (OR = 1.48; 95% CI = 1.05-2.07; p = .02) of being abstinent at 12 months. In general, the WebQuit intervention had a greater number of weekly logins within each of the three trajectory groups as compared to those of the Smokefree intervention. Baseline characteristics associated with trajectory group membership varied between websites. Conclusions: One-week and four-week usage of websites may be two common patterns of how people engage in e-health interventions. The very wide duration of the third and longest pattern (five vs fifty-two weeks) may depend on the content and structure of the e-health intervention, but tended to be predictive of the main outcome of higher odds of quitting smoking—especially for the WebQuit intervention. Strategies to engage e-health intervention users at the end of one-week, four-weeks, five-weeks, and beyond would be worthwhile to test. Clinical Trial: Clinical Trials.gov Registration Number: NCT01812278

  • Background: Self-guided internet-based cognitive-behavioral therapies (iCBTs) may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT. Objective: We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore their effects on study outcomes, and compare the frequency of use of these criteria to their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample towards those with a less complex clinical profile, thus inflating treatment outcomes. Methods: We coded the inclusion and exclusion criteria from the 16 studies of a recently-published meta-analysis of self-guided iCBT that was the product of systematic literature searches in PubMed, Medline, PsycINFO, and Embase. We conducted a meta-regression analysis to test the effect of the different commonly-used psychiatric entry criteria used on the treatment-control differences. Additionally, we compared the frequency with which the exclusion criteria were used in the self-guided iCBT studies to the frequency of their use in studies of face-to-face psychotherapy (k = 16) and antidepressants (k = 170). Results: A trend in the data (p = 0.05) suggested that self-guided iCBT studies were more likely (25%) to exclude patients with severe depressive symptoms than antidepressant (8%) studies, though they were no more likely to use this criterion than face-to-face psychotherapy studies (38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were less likely to exclude patients on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes. Conclusions: A conservative interpretation of the current findings is that the patient population sampled in literature on self-guided iCBT is comparable to that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided CBT may sample from a more heterogeneous, representative, and severely ill patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies.

  • Background: Internet- and mobile-based interventions (IMIs) are effective in the treatment of chronic pain. However, little is known about the willingness to engage in IMIs and how uptake of such interventions can be improved. Objective: The aim of this study is to identify people’s (1) acceptance, (2) uptake and (3) adherence (primary outcomes) with regard to an IMI for chronic pain and the influence of an information video as an acceptance facilitating intervention (AFI). Methods: In this randomized controlled trial with parallel design, we invited 489 individuals with chronic pain to participate in an online survey assessing acceptance towards IMIs with the offer to receive an unguided IMI for chronic pain after completion. Two versions of the online survey (with or without the AFI) were randomly sent to two groups of N=245 (with AFI) and N=244 (without AFI). Participants who completed the online survey with or without the AFI entered the intervention group (IG) or the control group (CG), respectively. In the survey, the individuals’ acceptance of pain IMIs, measured with a 4-item scale (sum score ranging from 4 to 20), predictors of acceptance, sociodemographic and pain-related variables, as well as physical and emotional functioning were assessed. Uptake rates (login to the IMI) and adherence (number of completed modules) of the intervention was assessed 4 months after intervention access. In order to examine which factors influence acceptance, uptake rate and adherence in IMIs, we conducted additional exploratory subgroup analyses. Results: 57 (IG) and 58 (CG) participants in each group completed the survey and were considered in the analyses. The groups did not differ with regard to acceptance, uptake rate and adherence (Bonferroni adjusted P>.016). Most participants reported a moderate (62%) to high (35%) acceptance, with 3% showing low acceptance (IG: M=14.60, SD=2.79; CG: M= 14.08, SD= 2.10). 68% (IG) and 62% (CG) have logged in in the intervention. In IG and CG, an average of M=1.23 (SD=1.57) and M=1.32 (SD=2.00) modules were completed, respectively. Conclusions: The informational video was not effective with regard to acceptance, uptake rate and adherence. Despite of the high acceptance, uptake rate was only moderate, and adherence was remarkably low. The present study shows that acceptance can be much higher in a sample participating in an IMI efficacy trial than in the target population in routine health care settings. Thus, future research should not only focus on acceptance and uptake facilitating interventions, but also on ways to influence adherence. Further research should be conducted within routine health care settings with more representative samples of the target population. Clinical Trial: Is study is linked to an outcome evaluation study with the German Clinical Trial Registration (DRKS): DRKS00006183

  • Wrist-worn optical heart rate monitors; valid validations? Methodological shortcomings

    Date Submitted: Feb 13, 2018
    Open Peer Review Period: Feb 14, 2018 - Apr 11, 2018

    Wearable sensor technology could have an important role for clinical research and in delivering healthcare. Accordingly, such technology should undergo rigorous evaluation prior to market launch and their performance should be supported by evidence-based marketing claims. Many studies have been published validating wrist-worn photoplethysmography (PPG)-based heart rate monitoring devices, but their contrasting results question the utility of this technology. The reason why many validations did not provide conclusive evidence of the validity of wrist-worn PPG-based heart rate monitoring devices is mostly methodological. The validation strategy should consider the nature of data provided by both the investigational and reference devices. There should be uniformity in the statistical analyses employed in these validation studies. The investigators should always test the technology in the population of interest. Device industries as well as the scientific community are in need of standards for the validation of new wearable sensor technology.

  • Enhancing perceptions of control in depressed and non-depressed volunteers using a mobile phone intervention

    Date Submitted: Feb 14, 2018
    Open Peer Review Period: Feb 14, 2018 - Apr 11, 2018

    Background: Perceived control is strongly linked to healthy outcomes, mental healthiness and psychological wellbeing. This is particularly important when people have little control over things that are happening to them. Perceived control studies have been performed extensively in laboratory settings and show that perceived control can be enhanced by experimental manipulations. Although these studies suggest that it may be possible to improve people’s mental health by increasing their perceived control, to-date there is very little evidence to suggest that perceived control can also be influenced in the real world. Objective: The first aim of this study was to test for evidence of a link between non-control situations and psychological wellbeing in the real world using a mobile phone application. The second and arguably more important aim of the study was to test whether a simple instructional intervention on the nature of alternative causes would enhance people’s perceptions of their own control in these non-control situations. Methods: We implemented a behavioral action-outcome contingency judgment task using a mobile phone application. An opportunity sample of 106 healthy volunteers scoring low (N = 56, no depression) or high (N = 50, mild depression) on a depression scale participated. They were given no control over the occurrence of a low or high frequency stimulus that was embedded in everyday phone interactions during a typical day lasting eight-hours. The intervention involved instructions that either described a consistent alternative cause against which to assess their own control, or dynamic alternative causes of the outcome. Throughout the day, participants rated their own control over the stimulus using a quantitative judgment scale. Results: Participants with no evidence of depression overestimated their control, whereas those who were most depressed were also more accurate in their control ratings. Instructions given to all participants about the nature of alternative causes significantly affected the pattern of perceived control ratings. Instructions describing discrete alternative causes enhanced perceived control for all participants; whereas dynamic alternative causes were linked to less perceived control. Conclusions: Perceptions of external causes are important to perceived control and can be used to enhance people’s perceptions. Theoretically motivated interventions can be used to enhance perceived control using mobile phone applications. This is the first study to do so in a real world setting.

  • How do primary care patients use mobile apps to manage their depressive symptoms? A qualitative study

    Date Submitted: Feb 14, 2018
    Open Peer Review Period: Feb 14, 2018 - Apr 11, 2018

    Background: Mobile applications (apps) are emerging as tools with the potential to revolutionise the treatment of mental health conditions such as depression. At the forefront of community health sector, general practitioners (GPs) are in a unique position to guide the integration of technology and depression management, however little is currently known about how primary care patients with depressive symptoms are currently using apps. Objective: The aim of this study was to explore the natural patterns of mobile app use amongst patients with depressive symptoms, in order to facilitate understanding of the potential role for mobile apps in primary care depression management. Methods: Semi-structured phone interviews were conducted with participants with symptoms of depression recruited from primary care practices in Victoria, Australia. Interviews explored current depression management strategies and the use of mobile apps (if any). Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was iteratively conducted using QSR NVivo 11 Pro to identify emergent themes. Results: A total of 16 participants aged between 20 to 58 years took part in the interviews, with 11 reporting the use of at least one mobile app to manage depressive symptoms and 5 reporting no app use. A variety of apps were described including relaxation, mindfulness, cognitive, exercise, gaming, social media and wellbeing apps to aid with depressive symptoms. There were two main patterns of app use with four subtypes: frequent (skills acquisition, social connectedness) and sporadic (inquisitive trials, safety netting). Major factors that influenced app use included accessibility and personal compatibility. Conclusions: Mobile apps are being utilised for self-management of depressive symptoms by primary care patients. This study provided insight into the natural patterns and perspectives of app use, which enhances understanding of how GPs may integrate this technology into their toolbox for the management of depression.

  • Background: Physical activity (PA) is a potentially effective treatment for depression and depressive relapse. However, promoting PA in people with depression is challenging. Interventions informed by theory and evidence are therefore needed to support people with depression to become more physically active. eMotion is a web-based intervention combining behavioral activation (BA) and PA promotion for people in the community with symptoms of depression. Objective: The objectives were to assess the feasibility and acceptability of delivering eMotion to people with depression in the community, and to explore outcomes. Methods: Participants with elevated depressive symptoms (≥10 PHQ-8) were recruited from the community through a variety of methods (e.g. social media) and randomized to eMotion or a waiting list control group for eight weeks. eMotion is an administratively supported weekly modular programme aiming to help people use key behavior change techniques (e.g., graded tasks, action planning and self-monitoring) to re-engage in routine, pleasurable or necessary activities, with a focus on physical activities. Feasibility data was collected which included: recruitment and trial retention rates, the fidelity of intervention delivery, receipt and enactment, and the acceptability of the intervention and data collection procedures. Data was collected for the primary (depression) and secondary outcomes (e.g. anxiety, PA, fidelity and client satisfaction) at baseline and two months post randomization using self-reported online questionnaires and accelerometers. Fidelity of delivery (logins, modules accessed, time spent) was tracked using web usage statistics. Exploratory analyses were conducted on the primary and secondary outcomes. Results: Of the 183 people who made contact, 62 were recruited and randomized with a mean PHQ-8 score of 14.6 (SD = 3.2). Of those randomized, 52 provided accelerometer recorded PA data at baseline which showed a baseline median of 35.8 (IQR = 0.0 to 98.6) minutes of MVPA (in 10-minute bouts) per week, with only seven people (13%) achieving NICE guideline levels (150 minutes of MVPA per week). 81% of participants provided follow up data for the primary outcome (PHQ-8), but only 42% provided follow up accelerometer data. Within the intervention group, the median number of logins, modules accessed and total minutes spent on eMotion was 3 (IQR = 2.0 to 8.0), 3 (IQR = 2.0 to 5.0) and 41.3 (IQR = 18.9 to 90.4) respectively. Acceptability was mixed. Exploratory data showed that PHQ-8 levels were reduced more for the intervention group than the control group at two months post randomization (Adjusted Mean Difference: -3.6 (95% CI: -6.1 to -1.1). Conclusions: It is feasible to deliver eMotion in UK communities to inactive populations. eMotion has the potential to be effective and is ready for testing in a full-scale trial. Further work is needed to improve engagement with both the intervention and data collection procedures. Clinical Trial: ClinicalTrials.gov NC-T03084055

  • Background: Clinical trials often experience challenges with recruitment and retention. Little is known concerning general attitudes and preferences towards trial design and willingness to participate among parents of children treated for cancer. Further, willingness to participate in internet-administered psychological interventions is also unknown. As such, this study examined attitudes and preferences of the population regarding study procedures for a hypothetical trial of an internet-administered psychological intervention. Further, differences in response rate between modes of study invitation, and willingness to enage in internet-administered interventions were examined. Objective: The primary objective was to examine attitudes and preferences towards participating in an internet-administrated psychological intervention, and the secondary objective was to examine the response rates and help seeking behaviors among parents of children treated for cancer. Methods: A cross-sectional online survey with parents of children who had completed cancer treatment. An online survey examined self-reported emotional distress; prior help-seeking and receipt of psychological support; past research participation; attitudes towards research; preferences concerning recruitment procedures and attitudes towards different types of trial design. Results: Of 350 parents invited, 32% (n=112) completed the survey, with no difference in response rate between mode of study invitation (χ2 = 0.58, P = .45). The majority reported past emotional distress (71.4%). Parents reported high (50%) or somewhat high trust in research (45.5%) and the majority would accept internet-administered psychological support if offered. Parents reported a preference for postal study invitation letters (76.8%), sent by a researcher (75.0%) with additional study information provided online via text (72.3%) and video (58.9%). Overall, parents reported acceptability for trials utilising a waiting list control, active alternative treatment control, or a patient-preference design. Conclusions: Parents of children treated for cancer appear willing to participate in trials examining internet-administered psychological support. Findings will inform the design of a feasibility trial examining internet-administered psychological support for the population.

  • Touching Force-Sensitive Screens Reveal Emotions

    Date Submitted: Feb 12, 2018
    Open Peer Review Period: Feb 13, 2018 - Apr 10, 2018

    Background: Emotions impact our mental health: they influence our perception, affect our physical strength and interfere with our reason. Emotions modulate our face, voice and movements. When emotions are expressed through the voice or face, they are difficult to measure with current emotion detection technologies; In real life, cameras and microphones are not often used in the same frequency and conditions of a lab setting where the emotion detection algorithms perform well: emotions are thus not detected accurately or as often as needed. Because emotions modulate our movements and users already touch their smartphones thousands of times a day, we have an opportunity to explore expressive touches and recognize emotions. Objective: In this study, we ask two questions: 1) If emotions modulate our touches, will human be able to recognize emotions by only looking at an expressive touch? 2) Can we teach machines how to accurately recognize users’ emotions from their touches on force-sensitive screens? Methods: We are interested in 8 emotions: Anger, Awe, Desire, Fear, Hate, Grief, Laugh, Love and No-Emotion. We recruited 117 volunteers: 15 were good imagers, emotionally aware subjects and part of Group A, the other 102 subjects were part of Group B. We conducted two experiments. In the first, we video-recorded, for few seconds, the expressive touches of Group A and we asked Group B to guess the emotion of every expressive touch. In the second experiment, we trained Group A to express every emotion on a force-sensitive smartphone; we collected hundreds of thousands of touches and applied feature selection and machine learning techniques to detect emotions from the coordinates of subjects’ finger touches, amount of force and skin area, all as functions of time. Results: In the first experiment, Group B was able to successfully recognize all emotions (and no emotion) with a high 83.2% accuracy: 50% of them were 100% correct and 24.4% were 66.7% correct. In the second experiment, we achieved a high 91.1% classification accuracy in detecting all emotions (and no emotion) from 9 spatiotemporal features of Group A touches. Conclusions: Emotions modulate our touches on force-sensitive screens; human have a natural ability to recognize other people’ emotions by watching pre-recorded videos of their expressive touches; machines can learn the same emotion recognition ability and do better than human if they are allowed to continue learning on new data. It is possible to enable force-sensitive screens to recognize users’ emotions and share this emotional insight with users, to increase their emotional awareness as well as with researchers, to design better technologies for well-being.

  • Background: Digital technology has the potential to transform how patients engage with mental health services. There is promising evidence regards feasibility, acceptability and efficacy of digital systems in psychosis. However, research to date has largely ignored patients’ perspectives of these systems. Objective: We explored early psychosis patients’ subjective views of mobile technology in the mental health setting. Methods: Qualitative framework analysis on data from 21 semi-structured interviews with patients registered with early intervention for psychosis teams. Robust measures were taken to develop a stable framework, including member-checking, triangulation of analysis, independent verification of themes, and consensus meetings. Results: Four themes were established a priori: acceptability of technology in mental health; technology can increase access to, and augment, mental health support; barriers to adopting digital solutions; data protection, privacy and security of information. Two themes were generated a posteriori: digital interventions as an adjunct to, or replacement for, usual care; empowerment, control and choice. Conclusions: In the first study of its kind, early psychosis patients reported digital tools were an acceptable and accessible method for mental health support. Digital tools could enhance access to care by extending the reach of services to one’s natural environment, facilitating honest communication. Digital systems were viewed as progressive, modern and relevant. Potentially de-stigmatising, they can overcome access barriers patients face within traditional service settings. Digital tools facilitate empowerment, affording patients meaningful choice and the opportunity to take active control of their healthcare. Concerns were expressed about the management of data security, safety and risk information. Clinical Trial: NA

  • Predicting Social Anxiety from GPS Traces of College Students

    Date Submitted: Feb 12, 2018
    Open Peer Review Period: Feb 12, 2018 - Apr 9, 2018

    Background: Social anxiety is highly prevalent among college students. Current methodologies for detecting symptoms are based on client self-report in traditional clinical settings. Self-report is subject to recall bias while visiting a clinic requires a high level of motivation. Assessment methods that use passively collected data hold promise for detecting social anxiety symptoms and supplementing self-report measures. Continuously collected location data may provide a fine-grained and ecologically valid way to assess social anxiety in situ. Objective: The current study examines the feasibility of leveraging non-invasive mobile sensing technology to passively assess college students' social anxiety symptom level. Specifically, we explore the different relationships between mobility and social anxiety to build a predictive model that assesses social anxiety from passively generated Global Positioning System (GPS) data. Methods: 228 undergraduate participants were recruited from a Southeast American university. Social anxiety symptoms were assessed using self-report instruments at a baseline laboratory session. An app installed on people’s personal mobile phones passively sensed data from the GPS sensor for two weeks. The proposed framework supports longitudinal, dynamic tracking of college students to evaluate the relationship between their social anxiety and movement patterns in the college campus environment. We first extracted several mobility features: (1) cumulative staying time in each different location, (2) the distribution of visits over time, (3) the entropy of locations, and (4) the frequency of transitions between locations. Next, we studied the correlation between these features and participants' social anxiety scores to enhance understanding of how students' social anxiety levels are associated with their mobility. Finally, we used a neural network-based prediction method to predict social anxiety symptoms from the extracted daily mobility features. Results: Several mobility features correlate with social anxiety level. Location entropy is negatively associated with social anxiety (r=-0.67 during weekdays and r=-0.51 during weekends). More (vs. less) socially anxious students were found to avoid public areas and engage in less leisure activities during evenings and weekends, choosing instead to spend more time at home after school (4pm-12am). Our prediction method based on extracted mobility features from GPS trajectories successfully classified participants as high or low socially anxious with an accuracy of 85% and predicted their social anxiety score (on a scale of 0 to 80) with a root-mean-square error of 7.06. Conclusions: Results indicate that extracting and analyzing mobility features may help to reveal how social anxiety symptoms manifest in the daily lives of college students. Given the ubiquity of mobile phones in our society, understanding how to leverage passively sensed data has strong potential to address the growing needs for mental health monitoring and treatment.

  • How is “hearing loss” and “hearing aid(s)” represented in the United States newspaper media?

    Date Submitted: Feb 7, 2018
    Open Peer Review Period: Feb 12, 2018 - Apr 9, 2018

    Background: News media plays an important role in formulating peoples knowledge and opinions about various aspects including health. Objective: The current study explored how “hearing loss” and “hearing aid(s)” are represented in United States newspaper media. Methods: A cross-sectional study design was selected to analyze publicly available newspaper media data. The data sets were generated from the database, the U.S. Major Dailies by ProQuest by searching the key words for newspapers published during 1990-2017. Cluster analysis (i.e., text pattern analysis) and Chi square tests were performed using Iramuteq software. Results: The hearing loss data set had 1,527 texts (i.e., articles). The cluster analysis resulted in seven clusters, which were named as: (1) causes and consequences (26.1%); (2) early identification and diagnosis (9%); (3) health promotion and prevention (22.1%); (4) recreational noise exposure (10.4%); (5) prevalence (14.3%); (6) research and development (12.4%); and (7) cognitive hearing science (5.6%). The hearing aid(s) data set had 2,667 texts. The cluster analysis resulted in eight clusters, which were named as: (1) signal processing (20.2%); (2) insurance (8.9%); (3) prevalence (12.4%); (4) research and development (5.4%); (5) activities and relation (16.2%); (6) environment (13.8%); (7) innovation (12%); and (8) wireless and connectivity (11.1%). Time series analysis of clusters in both “hearing loss” and “hearing aid(s)” data sets indicated that the change in pattern of information presented in newspaper media during 1990-2016 (e.g., cluster 7 focusing on cognitive hearing science in hearing loss data set emerging only since the year 2012 and growing rapidly). Conclusions: The text pattern analysis showed that the U.S. newspaper media focuses on a range of issues when considering “hearing loss” and “hearing aid(s),” and the pattern or trends change over time. The study results can be helpful for hearing healthcare professionals to understand what presuppositions society in general may have as the media has the ability to influence societal perception and opinions.

  • Background: The U.S. National Cancer Institute (NCI) developed software to collect symptomatic adverse events directly from patients participating in cancer clinical trials. This software administers surveys to patients using items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) via web-based or automated telephone interfaces, and enables management of survey administration and the resultant data by professionals (clinicians and research associates). Objective: The purpose of this study was to iteratively evaluate and improve the usability of the PRO-CTCAE software in both patients and professional users. Methods: Heuristic evaluation of software functionality was followed by semi-scripted, think-aloud protocols in sequential rounds of usability testing among patients, clinicians, and research associates. Patient testing was conducted both in clinic and remotely (i.e., from home) for both the web and telephone interfaces. Software was refined between rounds and retested. Results: Heuristic evaluation identified functionality problems and deviations from best practices across 10 standardized categories, which informed initial software improvement. Subsequently, user-based testing was conducted among 169 patients with cancer (54% female, 67% white, 26% high school education or less, 19% with limited computer experience, 18% older than 65), and 47 professionals (26% physicians, 26% nurses, 49% research associates) at three cancer centers in two rounds of usability testing. Software modifications between rounds addressed identified issues, including difficulty using radio buttons, absence of survey progress indicators, and login problems (for patients); and scheduling of patient surveys (for professionals). Following modifications, there were improvements in task performance for both patients and professional users. Conclusions: Software modifications, informed by rigorous assessment, rendered a usable system which is now in use in multiple NCI-sponsored multicenter cancer clinical trials. Clinical Trial: ClinicalTrials.gov Identifier: NCT01031641

  • Mobile Phone, Computer, and Internet Use among Older Homeless Adults: Results from the HOPE HOME Study

    Date Submitted: Feb 12, 2018
    Open Peer Review Period: Feb 12, 2018 - Apr 9, 2018

    Background: The median age of single homeless adults is approximately 50. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression and substance use disorders. Access to mobile phones and the Internet could help lower barriers to social support, social services and medical care, yet little is known about access to and use of these by older homeless adults. Objective: We describe access to and use of mobile phones, computers, and the Internet among a cohort of 350 homeless adults over age 50. Methods: We recruited 350 participants who were homeless and >50 in Oakland, CA. We interviewed participants at 6-month intervals about health status, residential history, social support, substance use, depressive symptomology and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about Internet and mobile technology use. We assessed participants’ comfort with and use of multiple functions associated with these technologies. Results: Of the 343 participants alive at the 6-month follow-up, 300 (87.5%) completed the mobile phone and Internet questionnaire. The median age of participants was 57.5 (IQR 54-61). Two-hundred and twenty four (74.7%) were male and 243 (81.0%) were Black. Approximately one-quarter (73; 24.3%) of participants had cognitive impairment. Most (217; 72.3%) participants currently owned or had access to a mobile phone. Of those, most had basic, rather than smartphones (89; 32.1%) and did not hold annual contracts (261; 94.2%). Just over half (164; 55%) had ever accessed the Internet. Participants used phones and the Internet to communicate with medical personnel (179; 64.6%), search for housing and employment 85 (85; 30.7%), and to contact family (228; 82.3%). Those with mobile phone access at the time of the interview were significantly more likely to have regained housing (P < .001) and significantly less likely to be cognitively impaired (P-value = .04). Conclusions: Older homeless adults could benefit from portable Internet and phone access, yet participants had a lower prevalence of smartphone and Internet access than adults over 65 in the general public or low-income adults. Participants faced barriers to mobile phone and Internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.

  • Background: Transmedia storytelling was useful to attract symptomatic English-speaking Latina women to engage in discussions of the highly stigmatized topics of depression and anxiety in a pilot study. Accessibility to transmedia via the Internet using personal devices, such as smart phones, provides a discreet way to access not only a story, but also affiliated symptom management resources and referral information for services. Participant attraction to transmedia or other technological applications needs to be coupled with engagement over time but engagement hinges on the ability of participants to relate to the main character of the storyline. Human centered design of applications aiming to improve mental health and well-being are likely to be enhanced by the inclusion of a lead character who is considered dynamic, compelling, and relatable by the target group of users, thereby deepening and lengthening engagement. Objective: To examine participants' perceptions of the lead character of the story, interviews were done with 28 English Speaking Latinas (target group) with elevated symptoms of depression or anxiety who participated in an Internet accessible transmedia story-telling intervention. Development of this character during the creation of the media was informed by de-identified research data from previous studies with members of the target group. Critique of the character from a panel of therapists who had experience working with the target group informed editing, as did input from women of the target group. Methods: All interviews were done via telephone, audio recorded, and transcribed. Data analysis was guided by Grounded Theory methodology. Results: Participants embraced the main character, Catalina, related to her as a person with an emotional life and a temporal reality, and reported that they learned from her. After having engaged with the media, they desired more episodes that featured her and her life. Grounded Theory analysis led to the development of one category (She "just felt so real": relating to Catalina as a real person with a past, present, and future) with four properties. Properties included (1) relating emotionally to Catalina's vulnerability, (2) recognizing shared experiences, (3) needing to support others while simultaneously lacking self-support, and (4) using Catalina as a spring board for imagining alternative futures. Participants found that Catalina's efforts to pursue mental health treatment were meaningful and led them to compare themselves to her and consider how they might pursue treatment themselves. Conclusions: When creating a story-based mental health intervention to be delivered through an application of technology regardless of type, careful development of the main character is valuable. Theoretical guidance, previous de-identified data from the target group, critique from key stakeholders and members of the target group, and preliminary testing are likely to enhance the main character's relatability and appropriateness, which can increase sustained engagement.

  • Internet of Things Buttons for Real-time Notifications in Hospital Operations

    Date Submitted: Feb 8, 2018
    Open Peer Review Period: Feb 10, 2018 - Apr 7, 2018

    Hospital staff frequently perform the same process hundreds to thousands of times a day. Customizable Internet of Things (IoT) buttons can send automatic, reliable, real-time notifications when pressed and have the potential to automate some of these repetitive tasks. In addition, IoT buttons generate logs of triggered events that can be used for future process improvement. Although IoT buttons have been successful commercially, little has been reported on their application in hospital systems. We discuss potential hospital applications categorized by the intended user group (patient or hospital staff) and location of use (within hospital and outside hospital). In addition, we examine key technological considerations, including network connectivity, security, and button management systems. In order to meaningfully deploy IoT buttons in a hospital system, we propose an implementation framework grounded in the Plan-Do-Study-Act method. Overall, IoT buttons have significant promise; future rigorous evaluation is needed to determine the impact of IoT buttons in real-world healthcare settings.

  • Background: Although 90% of older Korean adults have at least one chronic disease, most self-management interventions are clinic-based, delivered through face-to-face education, and highly focused on disease information only in South Korea. Therefore, older Koreans living in the community continue to seek an adjunct to manage chronic disease by themselves and expect mobile health (mHealth) to meet their healthcare needs in daily life. Objective: This feasibility study (1) developed an mHealth protocol to empower older adults to manage their chronic diseases at home, (2) examined the feasibility of the mHealth intervention using mobile tablets and applications (apps), and (3) discussed contextual and methodological challenges when applying an mHealth intervention for older Koreans with chronic diseases. Methods: The mHealth intervention protocol was developed based on the eHealth Enhanced Chronic Care Model. Our mHealth intervention included four phases. Phase 1 included mobile tablet training and standardized technology training with guidebooks, demonstrations, and guided practice. Phase 2 included standardized information for disease management retrieved from both governmental and professional healthcare organizations. Phase 3 included training to use the pre-selected high-quality mHealth apps to consider types of individuals’ chronic disease. Phase 4 included encouragement to practice self-selected mHealth apps based on their individual needs. Quantitatively descriptive and qualitative content analyses of user evaluation were completed to assess feasibility and user acceptance. Results: Among the 27 older adults, 25 completed mHealth training for 4 weeks. The attrition rate was 7.4% (2/27), due to time conflicts, emotional distress, and/or family discouragement. The men required little or no time for Phase 1, while the women seemed to depend on the interventionists for Phase 3. At least 4 weeks with weekly meetings were required to complete training of the mHealth intervention. Sex, educational level, and previous experience using smartphones were associated with learning speed, confidence, and competence. Conclusions: A highly person-centered approach is required to implement mHealth interventions for older adults. Self-management of chronic diseases via mHealth requires careful consideration regarding the complex nature of human behavior, emotional response, and family influence; therefore, integrating a theoretical-clinical-technical approach is necessary for successful implementation and higher effectiveness among older adults.

  • Background: In an e-health context, combining traditional structured clinical assessment methods and routine electronic health based data capture may be a reliable method to build a dynamic clinical decision support system (CDSS) in suicide prevention. Our objective was to describe the data mining module of a web-based CDSS and to identify suicide repetition risk in a sample of suicide attempters. A database of 2802 suicide attempters has been analysed. Clustering methods were used to identify groups of similar patients while regression trees are applied to estimate the number of suicide attempts among these patients. Three groups of patients are identified by clustering methods. Relevant risk factors explaining the number of suicide attempts are highlighted by regression trees. Data mining techniques can help to identify different groups of patients at risk of suicide reattempt. Objective: Our objective was to describe the data mining module of a web-based CDSS and to identify suicide repetition risk in a sample of suicide attempters. Methods: A database of 2802 suicide attempters has been analysed. Clustering methods were used to identify groups of similar patients while regression trees are applied to estimate the number of suicide attempts among these patients. Results: Three groups of patients are identified by clustering methods. Relevant risk factors explaining the number of suicide attempts are highlighted by regression trees. Data mining techniques can help to identify different groups of patients at risk of suicide reattempt. Conclusions: These results can be combined with web-based and smartphone based data to improve dynamic decision making for clinicians.

  • Background: Despite a proliferation of patient-facing mobile apps for mental disorders, there is little literature guiding efforts to incorporate mobile tools into clinical care delivery and integrate patient-generated data into care processes for patients with complex psychiatric disorders. Objective: We sought to gain an understanding of how to incorporate a patient-provider mobile health platform to support the delivery of integrated primary care-based mental health services (Collaborative Care) to rural patients with post-traumatic stress disorder and/or bipolar disorder. Methods: Using the Principles for Digital Development as a framework, we describe our experience designing, developing, and deploying a patient-facing smartphone application that integrates with a clinical patient registry to support Collaborative Care. We extracted mobile metadata to describe the early adoption and use of the system, and report preliminary results from an in-app patient feedback survey that includes a System Usability Scale. Results: Each of the nine Principles for Digital Development is illustrated with examples. The first 10 patients to use the smartphone app have completed symptom measures on average every 14 days over an average period of 20 weeks. The mean System Usability Scale score at week 8 among four patients who completed this measure was 91.9. We present lessons learned about the technical and training requirements for integration into practice that can inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions. Conclusions: Adhering to the Principles for Digital Development, we created and deployed a mobile health system to support Collaborative Care for patients with complex psychiatric conditions in rural health centers. Preliminary data among the initial users support high system usability and show promise for sustained use. Based on our experience, we propose five additional principles to extend this framework and inform future efforts to incorporate health technologies to improve care for patients with psychiatric conditions: Design for Public Health Impact, Add Value for All Users, Test the Product and the Process, Acknowledge Disruption, and Anticipate Variability. Clinical Trial: NCT: 02738944

  • Characterizing public opinions towards diseases by mining news media data

    Date Submitted: Feb 8, 2018
    Open Peer Review Period: Feb 8, 2018 - Apr 5, 2018

    Background: Society always has limited resources to expend on health care, or anything else. What are the unmet medical needs? How to allocate limited resources to maximize health and welfare of the people? These challenging questions might be re-examined systematically on a much larger scale, leveraging the latest advancement in information technology and data science. Objective: We expanded our previous work by investigating news media data to uncover the popularity of different diseases and medical conditions, together with their sentiments and topics in news articles over two decades. We were motivated to do so since news media plays a significant role in politics and affects the public policy making. Methods: We analyzed over 4.6 million news articles from Reuters media during the periods of 1996-1997, 2008-2009 and 2016-2017, using summary statistics, sentiment analysis, and topic modeling. Summary statistics illustrated the popularity of various diseases and medical conditions during the last two decades. Sentiment analysis and topic modeling helped us automatically detect the sentiments of news articles (i.e., positive versus negative) and topics (i.e., a series of keywords) associated with each disease over time. Results: The percentages of news articles mentioning diseases and medical conditions were 0.44%, 0.56% and 0.80% in the three time periods, suggesting that news media, or the public has gradually increased its interests in medicine since 1996. Certain diseases such as other malignant neoplasm (35%), other infectious disease (18%) and influenza (12%) represented the most covered diseases. 235 diseases and medical conditions (98.3%) were found to have neutral or negative sentiments in the news articles. Using topic modeling, we identified meaningful topics on these diseases and medical conditions. For instance, the smoking theme appeared in the news articles on other malignant neoplasm only during 1996-1997. The topic phrases HIV and Zika virus were linked to other infectious diseases during 1996-1997 and 2016-2017, respectively. Conclusions: The multi-dimensional analysis of news media data allows the discovery of focus, sentiments and topics of news media in terms of diseases and medical conditions. These discoveries could shed light on unmet medical needs and research priorities for future and provide guidance for the decision-making in public policy.

  • Cybersecurity in Hospitals: a Systematic, Organizational Perspective

    Date Submitted: Feb 7, 2018
    Open Peer Review Period: Feb 8, 2018 - Apr 5, 2018

    Background: Cybersecurity incidents are a growing threat to the healthcare industry in general and hospitals in particular. The healthcare industry has lagged behind other industries in protecting its main stakeholder (i.e., patients), and now hospitals must invest considerable capital and effort in protecting their systems. However, this is easier said than done, because hospitals are extraordinarily technology-saturated, complex organizations with high endpoint complexity, internal politics, and regulatory pressures. Objective: The purpose of this study was to develop a systematic and organizational perspective for studying: 1) the dynamics of cybersecurity capability development at hospitals; and 2) how these internal organizational dynamics interact to form a system of hospital cybersecurity in the U.S. Methods: We conducted interviews with hospital CIOs, CISOs, and healthcare cybersecurity experts, analyzed the interview data, and developed a system dynamics model that unravels the mechanisms by which hospitals build cybersecurity capabilities. We then use simulation analysis to examine how changes to variables within the model affect the likelihood of successful cyber-attacks across both individual hospitals and a system of hospitals. Results: From the interviews, we discover several key variables that hospitals use to reduce the likelihood of cyber-criminal activity, including internal stakeholder alignment, pressures to improve cybersecurity capabilities, and endpoint complexity. Our simulation results show that the variable with the most dramatic impact on reducing cyber-attack at hospitals is endpoint complexity, followed by internal stakeholder alignment. While resource availability was important in fueling efforts to close cybersecurity capability gaps, low levels of resources could be compensated against by setting a high target level of cybersecurity. Furthermore, high variabilities in resource availability and endpoint complexity across a system of hospitals made the whole system more vulnerable to cyber-attacks. Conclusions: In order to enhance cybersecurity capabilities at hospitals, the main focus of CIOs and CISOs should be on reducing endpoint complexity and improving internal stakeholder alignment. In a large system of hospitals, if variabilities in endpoint complexity and resource availability are reduced, then the whole system is made less vulnerable. This provides some support to decisions made by smaller hospitals to outsource information security functions to larger organizations, and suggests that policies should raise the target floor of capabilities to a point that reduces the variability across the entire healthcare system. This study assists health care leaders to better understand the range of outcomes resulting from strategic decisions of cybersecurity capability development, so that they can better reduce the vulnerabilities that hospitals have today.

  • Using Abstract Animations as an Innovative Technology-Based Approach to Measuring Pain in Adults

    Date Submitted: Feb 7, 2018
    Open Peer Review Period: Feb 7, 2018 - Apr 4, 2018

    Background: Pain is the most common medical symptom requiring care, yet the current methods for assessing pain are sorely inadequate. Pain assessment tools either take too long to complete for point of care use or are too simplistic to capture the dynamic pain experience. Objective: To address this, we developed Painimation, a novel tool that uses graphic visualizations and animations instead of words or numeric scales to assess pain quality, intensity, and course. This study examines the utility of abstract animations as a measure of pain. Methods: Painimation was evaluated in a chronic pain medicine clinic. Eligible patients were receiving treatment for pain and reported pain more days than not for at least 3 months. Using a tablet computer, participating patients completed the Painimation instrument, the McGill Pain Questionnaire (MPQ), and the PainDETECT questionnaire for neuropathic symptoms. Results: Participants (N = 207), completed Painimation and indicated it was useful for describing their pain (mean=4.04/5 on a usefulness scale), and 154 out of 196 participants (79%) agreed or strongly agreed that they would use Painimation to communicate with their providers. Animations selected corresponded with pain adjectives endorsed on the MPQ. Further, selection of the electrifying animation was associated with self-reported neuropathic pain (r=.16, P=.03), similar to the association between neuropathic pain and PainDETECT (r=.17, P=.03). Painimation was associated with PainDETECT (r=.35, P<.001). Conclusions: Using animations may be a faster and more patient-centered method for assessing pain and is not limited by age, literacy level, or language; however, more data are needed to assess the validity of this approach. Painimation needs testing in a more homogenous pain population to validate animations as a pain assessment method.

  • Diet and Multiple Sclerosis: Systematic Review of Online Recommendations

    Date Submitted: Feb 6, 2018
    Open Peer Review Period: Feb 7, 2018 - Apr 4, 2018

    Background: There is currently no scientific evidence supporting the use of specific diets in the management of Multiple Sclerosis(MS), the strongest dietary associations are observed with vitamin D and omega-3 fatty acid supplementation. Despite this, there are many websites that provide advice or suggestions about using various dietary approaches to control symptoms or disease progression. Objective: To assess the dietary advice for the symptomatic management of MS available on the internet. Methods: The study was a systematic review of webpages that provided dietary advice for the management of multiple sclerosis. Webpages were selected from an internet search conducted in November 2016, using Google, Yahoo and Bing search engines, and the search term 'ms diet'. The first two pages of results from each search engine were included for initial assessment. Duplicates were removed. Data extracted from websites included specific advice relating to diet and its rationale, the citation of supporting scientific literature and authorship information. Results: Thirty-two webpages were included in the final assessment. The webpages made specific recommendations regarding dietary patterns and/or individual foods to help manage MS. The most common dietary pattern advised on these webpages were the low fat, high fibre balanced diet, followed by the low saturated fat, near vegetarian Swank diet, and the Paleo diet. The main categories of individual foods/nutrients suggested for addition to the diet were: Supplements (especially omega 3 and vitamin D); Fruits; Vegetables and Lean protein. In contrast, the most commonly recommended for removal were saturated fats; dairy; gluten-containing grains and refined sugar. These recommendations were often accompanied by rationale relating to how the particular food/nutrient may affect the development, prevalence and/or symptoms of MS, however, very little of this information is supported by the current scientific evidence between diet and MS. Conclusions: There is a wide variety of dietary advice, in some cases contradictory advice, offered online. In most cases this advice is the result of peoples’ individual experiences and has not been scientifically tested.

  • Background: The 7-item Game Addiction Scale (GAS) has been validated under standard confirmatory factor analysis and has good psychometric properties. Whether this scale satisfies the necessary conditions for consideration by item response theory (IRT) modeling is unknown. However, section 3 of the DSM-5 recently proposed criteria to define Internet gaming disorder (IGD) to promote research on this possible condition. Objective: We aimed to (1) to analyze the GAS scale in the context of IRT (graded-response) modeling; (2) investigate differential item functioning (DIF), a feature of IRT modeling, in 2 subsamples; and (3) contribute to the ongoing (IGD) debate related to the validity of the DSM-5 criteria, using the GAS scale items as a proxy. Methods: Two large representative samples of Swiss men (3320 French speaking and 2670 German speaking) were assessed with the GAS. Results: All items had high discrimination parameters. Relapse, conflict, withdrawal, and problems (loss of interests) were the GAS items endorsed more frequently in more severe IGD stages, whereas items related to tolerance, salience (preoccupation), and mood modification (escape) were endorsed more widely among the participants (including in less severe IGD stages). Several DIF effects were found but were classified as negligible. Conclusions: The results of the analyses support the notion that an IRT approach is recommended for GAS and that this scale is also a reliable instrument for measuring game addiction. Clinical Trial: Not applicable

  • Background: Adaptive coping behaviours can improve wellbeing for young people experiencing life stressors while maladaptive coping can increase vulnerability to mental health problems in youth and into adulthood. Given that young people are keen users of digital resources, they could potentially benefit from the use of digital technology tools if the latter could help enhance their coping skills and overcome barriers in help-seeking behaviours. However, while there is relatively limited evidence in support of the efficacy of current digital technology tools in improving wellbeing, little is known about the current and desired digital technology use for self-management of wellbeing among young people in the general population. Objective: The first research question of the present study involved exploring how young people currently use digital technology in order to self-manage their wellbeing. The second research question looked into what young people desire from digital technology tools for the management of their wellbeing. Methods: Young people aged 12-18 were recruited from the general community to take part in semi-structured interviews. Data from the interviews were transcribed and analysed using inductive thematic analysis. Results: Fourteen participants were recruited, with a mean age of 14.6 (3/14 female). None of the participants reported using any digital tools specifically designed to manage wellbeing. However, the two themes emerging with regard to the first research question showed that young people use digital technology to destress and manage their mood, mainly through games, music and videos. Regarding the second research question, themes overall indicated that young people were keen on using such tools and were centred around the content and features of an ideal tool. The 3 themes relative to the content indicated that young people wanted a tool that immerses them in a stress-free environment, is uplifting and directs them to resources based on their needs. The 3 feature-based themes suggested that young people wanted the tool to be flexible, to enable engagement with others but to also be sensitive to privacy. Conclusions: The young people did not report engaging with digital technology specialised to improve wellbeing but instead used media already accessed in their daily lives. As a result, the variety of coping strategies reported was limited to the digital resources used for recreational and social purposes. Less adaptive strategies included distraction techniques whilst more adaptive coping reflected emotion regulation efforts and active support seeking. These same coping strategies were also desired in an ideal tool which would nonetheless have to be more flexible and more interactive but at the same time more sensitive to privacy. The present study contributes to the scarce research into young people’s preferred use of digital technology tools for the purposes of self-management of wellbeing.

  • Older people negotiating independence and safety in everyday life using technology. A qualitative study

    Date Submitted: Feb 6, 2018
    Open Peer Review Period: Feb 7, 2018 - Apr 4, 2018

    Background: Due to demographic changes, there is a demand for technology innovations in caring services. To understand the complexity of technology innovations in caring practices we need a knowledge base of the complex and diverse experiences of people interacting with established technologies. Objective: This article addresses the research gap in relation to understanding the micro context are of co-producing when technologies are integrated into caring practices. Public service research describes a potential co-production of services by utilising user-experiences, by exploiting concepts from Science and Technology Studies offers us tools to explore what really happens when different actors utilise technology when co-producing caring practices. Methods: Participant observations and 22 interviews with actors utilising the social alarm were conducted employing the Critical Incident Technique. A stepwise deductive-inductive analysis was then performed. Results: The results reveal how co-production assumes different meanings according to how actors utilise the technology, perform bricolages and optimise practice thus co-creating independent and safe living. Conclusions: Caring services are always co-produced between the actors involved. By utilising aspects of Science and Technology Studies this article provides an integrative model for exploring technology in use in caring practices. The model provides tools to unpack and articulate the process of co-producing services. Moreover, how technology innovation changes the dynamics between the actors and rearranges caring practices. Additionally, it opens up for unexpected results and bricolages as an integrated part of technology innovations.

  • Background: Acute Lymphoblastic Leukemia (ALL) is the most common childhood malignancy. Caring for children with ALL is challenging for parents. A mHealth supportive care intervention was developed to meet parents’ needs. Objective: To evaluate the effectiveness of this mHealth supportive care intervention on emotional distress, social support, care burden, uncertainty, quality of life and knowledge. Methods: A quasi-experimental study was conducted form June 2015 to January 2016. In total, 101 parents were enrolled in the study, with 50 in the observation group and 51 in the intervention group. Parents in the observation group received the standard health education and were observed for 3 months. Parents in the intervention group received the mHealth supportive care intervention, in addition to the standard health education. Data of parents’ social support, anxiety, depression, care burden, uncertainty in illness, quality of life, their existing knowledge of ALL and care, and knowledge need were collected before and after the 3-month study period in both groups. For the intervention group, parents’ experience of receiving the intervention was also collected through individual interviews. Results: Forty three parents in the observation group and 49 parents in the intervention group completed the study. Results found that the intervention reduced parents’ anxiety (P=0.030) and uncertainty in illness (P=0.007), improved parents’ social function (P=0.014), increased parents’ knowledge of ALL and care (P=0.000), and decreased their need for knowledge (P=0.000). Qualitative results showed that parents were satisfied with the intervention and their role in the caregiving process. Conclusions: The mHealth intervention in supporting parents of children with ALL is effective. This study is informative for other future studies on providing mHealth supportive care for parents of children with cancer.

  • Background: Placebo effects and their underpinning mechanisms are increasingly well-understood. However, this is poorly communicated to participants in placebo-controlled trials. For valid informed consent, participants should be informed about the potential benefits and risks of participating in placebo-controlled trials. Existing information leaflets often fail to describe potential benefits and/or adverse effects associated with placebo allocation. This study tested the effects of a new website designed to inform patients, “the Power of Placebos” (PoP). PoP was designed using qualitative methods in combination with theory and evidence-based approaches to ensure it was engaging, informative, and addressed patients’ concerns. Objective: To test the effects of PoP, compared to a control website, on people’s knowledge about placebo and ability to make an informed choice about taking part in a placebo-controlled trial. Methods: 350 adults with back pain recruited from 26 GP practices in southern England were randomly assigned to PoP (which presented scientifically accurate information about placebo effects in an engaging way), or a control website (based on existing information leaflets from UK trials). Participants completed pre- and post-intervention measures of knowledge about placebo effects, and pre-intervention measures of attitudes towards and intentions to participate in a placebo-controlled trial. The two primary outcomes were (1) knowledge and (2) informed choice to take part in a placebo-controlled trial (computed from knowledge, attitudes, and intentions). Results: After viewing PoP, participants had significantly greater knowledge about placebos (M=8.28, SD=1.76) than participants who viewed the control (M=5.60, SD=2.24), F(1, 329)=273.821, P<.001, η2 = .346. Participants who viewed PoP were 3.16 times more likely than those who viewed the control to make an informed choice about placebos χ2 (1) = 36.524, P<.001. Conclusions: PoP could be used to improve knowledge about placebo effects. After further testing in clinical trial settings it could support informed consent in placebo-controlled trials. Well-developed web-based resources for informed consent may improve the ethical conduct of clinical research.

  • Background: Since medical research based on big data has become more common, community’s interest and effort to analyze a large amount of semi-structured or unstructured text data, such as examination reports, has rapidly increased. However, these large-scale text data are often not readily applicable to analysis due to typographical errors, inconsistencies, or data entry problems. Therefore, an efficient data cleaning process is required to ensure the veracity of such data. Objective: We proposed an efficient data cleaning process for large-scale medical text data, which employs text clustering methods and value-converting technique, and evaluated its performance with medical examination text data. Methods: The proposed data cleaning process consists of text clustering and value-merging. In the text clustering step, we suggested to use key collision and nearest neighbor methods in a complementary manner. Words (called as values) in the same cluster would be expected as a correct value and its wrong representations. In the value-converting step, wrong values for each identified cluster would be converted into their correct value. We applied this data cleaning process to 574,266 stool examination reports produced for parasite analysis at Samsung Medical Center from 1995 to 2015. The performance of the proposed process was examined and compared with data cleaning processes based on a single clustering method. We used OpenRefine 2.7, an open source application that provides various text clustering methods and an efficient user interface for value-converting with common-value suggestion. Results: A total of 1,167,104 words in stool examination reports were surveyed. In the data cleaning process, we discovered 30 correct words and 45 patterns of typographical errors and duplicates. We observed high correction rates for words with typographical errors (98.61%) and typographical error patterns (97.78%). The resulting data accuracy was nearly 100% based on the number of total words. Conclusions: Our data cleaning process based on the combinatorial use of key collision and nearest neighbor methods provides an efficient cleaning of large-scale text data, and hence improves data accuracy.

  • Comparing approaches to mobile depression assessment for measurement-based care

    Date Submitted: Feb 5, 2018
    Open Peer Review Period: Feb 5, 2018 - Apr 2, 2018

    Background: To inform measurement-based care, practice guidelines suggest routine symptom monitoring, often weekly or monthly. Increasingly, patient-provider contacts occur remotely (e.g., by telephone, online portals), and mobile health tools can now monitor mood daily or more frequently. However, the reliability and utility of daily mood ratings is unclear. Objective: We examined the association between a daily depressive symptom measure and the PHQ-9, the most widely adopted depression self-report measure, and compared how well these two assessment methods predict patient outcomes. Methods: 547 individuals completed smartphone-based measures including the PHQ-2 modified for daily administration, the PHQ-9, and the Sheehan Disability Scale. Multilevel factor analyses evaluated the reliability of latent mood based on the PHQ-2 (for repeated measures) between Weeks 2 to 4 and its correlation with the PHQ-9 at Week 4. Regression models predicted Week 8 depressive symptoms and disability ratings with daily PHQ-2 and with PHQ-9. Results: The daily PHQ-2 and the PHQ-9 are highly reliable (range: 0.80-0.88) and highly correlated (r = 0.80). Findings were robust across demographic groups (age, gender, ethnic minority status). Daily PHQ-2 and PHQ-9 were comparable in predicting Week 8 disability and were independent predictors of Week 8 depressive symptoms and disability, though the unique contribution of the PHQ-2 was small in magnitude. Conclusions: Daily completion of the PHQ-2 is a reasonable proxy for the PHQ-9 and is comparable to the PHQ-9 in predicting future outcomes. Mobile assessment methods offer researchers and clinicians reliable and valid new methods for depression assessment that may be leveraged for measurement-based depression care. Clinical Trial: ClinicalTrials.gov NCT00540865

  • Background: Patient falls are a major problem in hospitals. The development of a Patient-Centered Fall Prevention Toolkit, Fall TIPS (Tailoring Interventions for Patient Safety), reduced falls by 25% in acute care hospitals by leveraging health information technology to complete the three-step fall prevention process: 1) conduct fall risk assessments 2) develop tailored fall prevention plans with the evidence-based interventions and 3) consistently implement the plan. We learned that Fall TIPS was most effective when patients and family were engaged in all three steps of the fall prevention process. Over the past decade our team developed three Fall TIPS modalities: the original EHR version, a laminated paper version that uses color to provide clinical decision support linking patient-specific risk factors to the interventions, and a bedside display version that automatically populates the bedside monitor with the patient’s fall prevention plan based on clinical documentation in the electronic health record. The relative effectiveness of each Fall TIPS modality for engaging patients and family in the three-step fall prevention process was unknown. Objective: The purpose of this study is to examine if the Fall TIPS modality impacts patient engagement in the three-step fall prevention process and thus Fall TIPS efficacy. Methods: To assess patient engagement in the three-step fall prevention process, random audits were conducted with the question: “Does the patient/family member know their fall prevention plan?” Audits were also conducted to measure adherence, defined by the presence of the Fall TIPS poster at the bedside. Champions from three hospitals reported data from April-June 2017 on six Neurology and seven Medical units. Peer-to-peer feedback to reiterate the best practice for patient engagement was central to data collection. Results: 1209 audits were submitted for the patient engagement measure and 1401 for presence of the Fall TIPS poster at the bedside. All units reached 80% adherence for both measures. Some units maintained high levels of patient engagement and adherence with the poster protocol. Others showed improvement over time, reaching clinically significant adherence (>80%) by the final month of data collection. Conclusions: Each Fall TIPS modality effectively facilitates patient engagement in the three-step fall prevention process, suggesting all three can be used to integrate evidence-based fall prevention practices into clinical workflow. The three Fall TIPS modalities may prove an effective strategy for spread, allowing diverse institutions to choose the modality the fits with the organizational culture and health information technology infrastructure.

  • Collect Your Happiness: A Case Study of Using Positive Psychology Principles in Technology Design

    Date Submitted: Feb 5, 2018
    Open Peer Review Period: Feb 5, 2018 - Apr 2, 2018

    Background: More and more of our daily activities depend on smartphones and applications. Thus, an increasing number of studies are interested in whether interactive applications can be used to improve happiness of individuals. Objective: The study aimed to develop and test a digital application designed for happiness. Methods: This paper presents an application called Collect Your Happiness (CYH) that is based on some positive psychology principles. It can not only enhance people’s happiness by collecting their daily happy moments, but provide small tasks to improve their happiness levels. A cross-cultural measurement between the Chinese and Dutch was conducted to evaluate the efficacy of this intervention by SHS, SWLS, PGWBI, and MAAS. In addition, collected moments were coded based on Selig- man’s PERMA model to analyze the cultural differences. Results: Results show that CYH can help people from both countries improve their happiness. The Chinese tended to find their happiness in relationships (R) with their friends and family, however, the Dutch tended to search for meaning (M) and engagement (E) in their lives. Conclusions: In this paper, we developed an application that provided recording positive things, reminders for the past happy moments and tasks for users to gain happiness. The CYH successfully enhance the happiness of the cross-cultural users for four weeks. We also explored the difference of happiness between the Dutch and the Chinese based on Seligman’s PERMA model, and established a multimedia database of happiness for future research. Despite some limitations, most users found the application helpful to improve their happiness. By directly measuring subjective and multidimensional perspectives of happiness, there is potential to more successfully promote people’s happiness. Overall, our study not only complement existing positive psychological interventions that enhance human happiness, but it also suggests novel ways of applying positive psychology principles in the future technology design.

  • Rethinking the Meaning of Cloud Computing for Healthcare: a Taxonomic Perspective

    Date Submitted: Feb 5, 2018
    Open Peer Review Period: Feb 5, 2018 - Apr 2, 2018

    Background: Cloud computing (CC) is an innovative paradigm that provides users on-demand access to a shared pool of configurable computing resources, such as servers, storage, and applications. Researchers claim that IT services delivered via the CC paradigm (i.e. cloud computing services (CCSs)) provide major benefits for healthcare. However, due to a mismatch between our conceptual understanding of CC for healthcare and the actual phenomenon in practice, the meaningful use of CC for the healthcare industry cannot always be ensured. Although some studies have tried to conceptualize CC or interpret this phenomenon for healthcare settings, they mainly rely on the interpretation of CC in a common context or are heavily based on a general understanding of traditional health IT artefacts, leading to an insufficient or unspecific conceptual understanding of CC for healthcare. Objective: We aim to generate insights into the concept of CC for health IT research. We propose a taxonomy that can serve as a fundamental mechanism for organizing knowledge about CCSs in healthcare organizations to gain a deepened, specific understanding of CC in healthcare. With the taxonomy, we focus on conceptualizing the relevant properties of CC for service delivery to healthcare and highlighting their specific meanings for healthcare. Methods: We employed a two-stage approach to develop a taxonomy of CCSs for healthcare organizations. We conducted a systematic literature review and 24 semi-structured expert interviews in stage 1, drawing on data from theory and practice. In stage 2, we applied a systematic approach and relied on data from stage 1 to develop and evaluate the taxonomy using 14 iterations. Results: Our taxonomy is composed of eight dimensions and 28 characteristics that are relevant for CCSs in healthcare organizations. By applying the taxonomy to classify existing CCSs identified from the literature and expert interviews, which also serves as a part of the taxonomy, we identify seven specificities of CC in healthcare. Theses specificities challenge what we have learned about CC in general contexts or in traditional health IT from the previous literature. The summarized specificities suggest research opportunities with exemplary research questions for future health IT research on CC. Conclusions: By relying on perspectives from a taxonomy for CCSs for healthcare organizations, this study provides a solid conceptual cornerstone for CC in healthcare. Moreover, the identified specificities of CC and the related future research opportunities will serve as a valuable roadmap to facilitate more research into CC in healthcare.

  • Background: Regular physical activity is associated with reduced risk of chronic illnesses. Despite various types of successful physical activity interventions, maintenance of activity over the long term is extremely challenging. Objective: The aims of this paper are to 1) describe physical activity engagement post intervention, 2) identify motivational profiles using natural language processing (NLP) and clustering techniques in a sample of women who completed the physical activity intervention, and 3) compare sociodemographic and clinical data among these identified cluster groups. Methods: In this cross-sectional analysis, 204 out of 210 women who completed a 12-month study exit telephone interview in the mobile phone based physical activity education (mPED) study were examined. Subjects in the Control, Regular, and Plus groups returned the study accelerometer and stopped accessing the study app (if any) at 9-month (last) research office visit. Physical engagement and motivational profiles were assessed by both closed and open-ended questions, such as “Since your 9-month study visit, has you physical activity been more, less, or about the same (compared to the first 9 months of the study)?” and “What motivates you the most to be physically active?,” NLP and cluster analysis were used to classify motivational profiles. Descriptive statistics were used to compare participants’ baseline characteristics among identified groups. Results: Approximately a half of the two intervention groups (Regular and Plus) reported still wearing a accelerometer and engaging in brisk walking as they were directed during the intervention phases. These numbers in the two intervention groups were much higher than the control group (overall P values = .005 and = .003, respectively). Three clusters were identified through NLP and named as the Weight Loss group (n=19), the Illness Prevention group (n=138), and the Health Promotion group (n=46). The Weight Loss group was significantly younger than the Illness Prevention and Health Promotion groups (overall P < .001). The Illness Prevention group had a larger number of Caucasians as compared to the Weight Loss group (P = .001), which was mostly composed of those who identified as African American, Hispanic, or mixed race (P =.008, P = .006, respectively). Additionally, the Health Promotion group tended to have lower BMI scores compared to the Illness Prevention group (overall P =.024). However, there was no difference in the baseline moderate to vigorous intensity activity level among the three groups (overall p > .05). Conclusions: The findings could be relevant to tailoring a physical activity maintenance intervention. Furthermore, the findings from NLP and cluster analysis are useful methods to analyze short free text to differentiate motivational profiles. As more sophisticated NL tools are developed in the near future, the potential of NLP application in behavioral research will broaden. Clinical Trial: ClinicalTrials.gov NCT01280812

  • Manifesting Its Ugly Roots: Text Mining Mental Health Literature and College Students

    Date Submitted: Feb 4, 2018
    Open Peer Review Period: Feb 5, 2018 - Apr 2, 2018

    Background: See details below. Objective: We explore mental health among college students using a corpus of reports and news articles. Mental health issues and concerns among this population have been on the rise, and understanding what themes are in current news and literature reports can better enable higher education institutions to provide health services to its students. Methods: We used SAS Text Miner to analyze 165 references (from 2010 to 2015) focused on mental health among college students. Key clusters (or themes) were identified to show the topics that were most significant to the topic. Results: The final cluster analysis yielded four themes in students’ mental health experiences in higher education. Much of the literature focuses on student services via campus counseling centers, and issues of race/ethnicity emerged as a critical factor in the information seeking behaviors among this population. Although the results indicated four major clusters, the notion of victimization suggest that there is potentially a disconnection between theory and practice. While colleges and universities explore innovative methods to address mental health needs, legal and ethical issues continue to challenge institutions, and stigma plays a critical role among students. Conclusions: While cluster analysis identified that institutions (in some cases) are devoting more and innovative resources to help with students who experience mental health concerns, there is a need to focus on proactive approaches to mitigate the causes of mental health and the aftermath of a negative experience. Such strategies can potentially influence how students navigate their health information seeking. Clinical Trial: N/A

  • Background: The benefits of e-health support for dementia caregivers are increasingly recognised. Reaching early-stage dementia caregivers could prevent high levels of burden and psychological problems in the later stages. Objective: The current study evaluates the effectiveness of the blended care self-management program "Partner in Balance" (PiB) compared to a control group. Methods: A single-blind randomized controlled trial with 81 family caregivers of community-dwelling people with (very) mild dementia was conducted. Participants were randomly assigned to either the 8-week blended care self-management program PiB (N=41) or a waiting-list control group (N=40) receiving usual care (low-frequent counselling). PiB combines face-to-face coaching with tailored web-based modules. Data were collected at baseline and after 8 weeks in writing by an independent research assistant who was unknown to the allocation of the treatment. Primary proximal outcome included self-efficacy (CSES), primary distal outcome symptoms of depression (CES-D). Secondary outcomes included mastery (PMS), quality of life (ICECAP-O), and psychological complaints (anxiety (HADS-A) and perceived stress (PSS)). Results: A significant increase in favor of the intervention group was demonstrated for self-efficacy (care management P=0.002, service use P=0.001), mastery (P=0.001), and quality of life (P=0.032). Effect sizes were medium for quality of life (d=0.58) to high for self-efficacy (d=0.85 and d=0.94, respectively) and mastery (d=0.94). No significant differences between the groups were found on depressive symptoms, anxiety and perceived stress. Conclusions: This study evaluated the first blended care intervention for caregivers of people with early-stage dementia and demonstrated a significant improvement in self-efficacy, mastery and quality of life after receiving the "Partner in Balance" intervention, compared to a waiting-list control group receiving care as usual. Contrary to our expectations, the intervention did not decrease symptoms of depression and anxiety and perceived stress. However, levels of psychological complaints were relatively low in the study sample. Future studies including long-term follow up could clarify if an increase in self-efficacy results in a decrease or prevention of increased stress and depression in the long run. To conclude, the program "Partner in Balance" can provide accessible preventative care to future generations of early-stage dementia caregivers. Clinical Trial: Dutch Trial Register (NTR): NTR4748; http://www.trialregister.nl (Archived by WebCite at http://www.webcitation.org/6vSb2t9Mg)

  • Background: Oral antineoplastic agents (OAA) are high risk drugs used in a fragile population. Due to their characteristics and increase in recent years, e-health 2.0 is positioned as a useful tool to track real time pharmacotherapy. Objective: To design the functional requirements of a mobile app based on the needs of the onco-hematological patient receiving oral antineoplastic agents. The app integrates relevant information on treatment and enables patients to play an active role in the management of their disease. Methods: We performed a prospective observational study to analyze the features of patients receiving OAA. We then performed a descriptive study of apps that were specific to cancer patients in order to identify the main points that could be improved. Results: We designed an app (e-OncoHealth®) with the following components: - Agenda: Daily patient activity. - Treatment: Current medication, with information on dose, unit of measure, and frequency. The package insert can be accessed through an icon. - Auto-control: general status, blood pressure, weight, and adverse effects (AEs). The patient can record these values at regular intervals, except for AEs, which are registered as they occur. Instructions on the management of the AEs are structured using decision trees. - Messages: Bidirectional communication channel via which both patients and pharmacist can contact each other as necessary. - Education: The patient has a self-care guide associated with his/her treatment and links to web pages of interest. All the data are sent automatically to the pharmacist for real-time monitoring in such a way as to enable continuous home monitoring. Conclusions: e-OncoHealth® is a tool that can improve the care of patients receiving OAAs. After analysis of the features of these patients, we designed an ad hoc tool that facilitates treatment.

  • Background: Hello Sunday Morning (HSM) is a self-guided health promotion website with the aim to improve drinking culture. Members are encouraged to sign up for a three-month period of alcohol abstention, and record and track their progress and goals. Objective: This study employed Self-Determination Theory (SDT) to examine the nature of goals subscribed by HSM users to test the extent to which intrinsic goal pursuit was linked to lower alcohol dependency risk and higher engagement with the HSM website. Methods: HSM users (N=2,216; 65% female; aged 18 to 79) completed the World Health Organisation’s Alcohol Use Disorders Identification Test (WHO-AUDIT, which measures alcohol dependence risk level) at sign up, and four and six months after sign up. The website also had a goals-subscription feature that allowed participants to share their goals. Two independent raters classified the goals according to a coding system we devised based on SDT, which proposes that intrinsic goals (e.g. growth, relationships, community and health) better promote positive outcomes than extrinsic goals (e.g. wealth, fame and image). Results: Although there was substantial (~47%) attrition of HSM users from sign up to six months, the attrition rate could not be attributed to alcohol dependency risk because people in different WHO-AUDIT risk zones were equally likely to be missing at four and six months after sign up. SDT-driven coding of goals yielded the following categories: wealth and image (extrinsic goals); relationships, personal growth, community engagement, and physical health (intrinsic goals); and alcohol use related goals (which were hard to classify as either extrinsic or intrinsic). Alcohol dependence risk level correlated positively with goals related to money (r = 0.16), personal growth (r = 0.17), relationships (r = 0.10) and alcohol use (r = 0.25). Website engagement correlated negatively with alcohol dependence risk level (r = 0.10) and positively with relationship (r = 0.10) and community goals (r = 0.12). Conclusions: HSM users with higher alcohol dependence risk tended to engage with the website less, but to the extent that they did, they tended to subscribe to goals related to alcohol use and improving their personal growth, relationships and finances. In line with SDT, engagement with goals – particularly the intrinsic goals of connecting with close-others and the broader community – related to increased website engagement. Internet-based tools intended to promote healthy behaviours in users may be effective in engaging their users if the users’ experience on the website supports the pursuit of intrinsic goals.

  • Validation of an online clinical staging model for use in an early intervention youth Mental Health eClinic

    Date Submitted: Feb 1, 2018
    Open Peer Review Period: Feb 3, 2018 - Mar 31, 2018

    Background: Globally, there is increasing recognition that new strategies are required to reduce the disability due to common mental health problems. As 75% of mental health and substance misuse disorders emerge during the teenage or early adulthood years, these strategies need to be readily accessible to young people. When considering how to provide such services at scale, e-health technologies show promise in augmenting traditional clinic-based services. Objective: The aim of this study was to assess the effectiveness and accuracy of an online assessment of clinical staging for use in a prototypic Internet-based early intervention youth mental health service system, known as the Mental Health eClinic. Methods: An online version of clinical staging for early intervention youth mental health services, was compared directly with clinician assessments within two Sydney-based primary care service hubs (headspace Camperdown and Campbelltown). Two hundred and four (N=204) young people were recruited in the study. Eligible participants completed both face-to-face and online assessments which were randomly allocated and counterbalanced at a one-to-three ratio. These assessments were: (1) a traditional 45 to 60-minute headspace face-to-face assessment performed by a Youth Access Clinician; and (2) a self-report online survey followed by an online 'video-visit' assessment with a clinician taking approximately 15 minutes. All assessments were completed within a two-week timeframe from initial presentation. Results: Of the 72 participants who completed the study, 72% were female and the mean age was 20.4 years. Sixty eight percent (49/72) of the participants were recruited from headspace Camperdown and the remaining 32% (23/72) from headspace Campbelltown. Inter-rater agreement of participants' clinical stages, as determined after the face-to-face assessment and after the online assessment, demonstrated fair agreement (κ=0.39, P<0.001), with concordance in 68% of cases (49/72). In 26% of cases, the face-to-face assessment appeared to downrate the lifetime history of mental health problems. By contrast, the online evaluation placed greater weight on past history of mental health disorders (P=0.001), as well as any previous suicide planning (P=0.002) and current substance misuse (P=0.03). Conclusions: The online application of clinical staging presents a technologically-advanced and clinically-efficient method for determining key clinical service parameters. It has the potential to be adapted to varied settings in which young people are connecting with traditional clinical services and assist to provide optimal care. Clinical Trial: The University of Sydney's Human Research Ethics Committee approved the study (Protocol No. 2014/689).

  • A Systematic Review of Internet-Delivered Early Interventions for Individuals Exposed to Traumatic Events

    Date Submitted: Feb 2, 2018
    Open Peer Review Period: Feb 3, 2018 - Mar 31, 2018

    Background: Over 75% of individuals are exposed to a traumatic event, and a substantial minority will go on to experience mental health problems that can be chronic and pernicious in their lifetime. Early interventions show promise for preventing posttrauma psychopathology; yet, face-to-face intervention can be costly and there are many barriers to accessing this format of care. Objective: This paper systematically reviewed studies of Internet-delivered early interventions for trauma-exposed individuals. Methods: A literature search was conducted in PsycINFO and Pubmed/Medline for papers published between 1991 and 2017. Papers were included if the following criteria were met: 1) an Internet-based intervention was described and applied to individuals exposed to a traumatic event; 2) The authors stated that the intervention was intended to be applied early posttrauma exposure or as a preventive intervention; and 3) data on mental health symptoms at pre-and post- intervention were described (regardless of whether these were primary outcomes). Methodological quality of included studies was assessed using the Downs and Blacks Checklist. Results: The interventions in the seven studies identified were categorized as “selected” (i.e., delivered to an entire sample following trauma regardless of psychopathology symptoms), or “indicated” (i.e., delivered to those endorsing some level of posttraumatic distress). Selected interventions did not produce significant symptom improvement compared with treatment-as-usual or no intervention control groups. However, indicated interventions yielded significant improvements over other active control conditions on mental health outcomes. Conclusions: Consistent with the notion that many experience natural recovery posttrauma, results imply that indicated early Internet-delivered interventions hold the most promise in future prevention efforts. More studies that use rigorous methods and clearly defined outcomes are needed to evaluate the efficacy of early Internet-delivered interventions. Moreover, basic research on risk and resilience factors following trauma exposure is necessary to inform indicated Internet-delivered interventions.

  • Background: Internet-delivered exercise, education, and pain coping skills training is effective for people with knee osteoarthritis (OA), yet it is not clear whether this treatment is better suited to particular sub-groups of patients. Objective: To explore demographic and clinical moderators of the effect of an internet-delivered intervention on changes in pain and physical function in people with knee OA. Methods: Exploratory analysis of data from 148 people with knee osteoarthritis who participated in a randomised controlled trial comparing internet-delivered exercise, education, and pain-coping skills training to internet-delivered education alone. Primary outcomes were changes in knee pain while walking (11-point Numeric Rating Scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index function subscale) at three and nine months. Separate regression models were fit with moderator variables (age, gender, expectations of outcomes, self-efficacy (pain), education, employment status, pain catastrophising, body mass index) and study group as covariates, including an interaction between the two. Results: Participants in the intervention group who were currently employed had significantly greater reductions in pain at three months than similar participants in the control group (mean (95% confidence interval) between-group difference: 2.38 NRS units (1.52,3.23), interaction P=0.02). Additionally, within the intervention group pain at three months reduced by 0.53 units for each unit increase in baseline self-efficacy for managing pain (95% CI: 0.28,0.78) while within the control group the effect of a unit increase in self-efficacy was 0.11 (95% CI: -0.13, 0.35, interaction P=0.02). Conclusions: Internet-delivered education, exercise, and pain coping skills training appears to be effective for a range of patients, with no evidence of moderation of the effect across gender, educational level, expectation of treatment outcome or across age, BMI, or tendency to catastrophise pain. People who were employed and had higher self-efficacy at baseline experienced greater improvements in pain in the short-term, but not the long-term. Findings support the long- and short-term effectiveness of internet-delivered care for a wide range of people with knee OA. Clinical Trial: N/A

  • Background: Digital consulting e.g. email, text and skype is increasingly offered to young people accessing specialist care for long term conditions. No patient reported outcome measures (PROM) have been evaluated for assessing outcomes of digital consulting. Systematic and scoping reviews, alongside patient involvement revealed two candidate PROMs for this purpose, the Patient Activation Measure (PAM) and the Physician’s Humanistic Behaviours Questionnaire (PHBQ). PAM measures knowledge, beliefs and skills that enable people to manage their long term condition. The PHBQ measures the extent to which behaviours that are important to patients in their physician-patient interactions are present. Objective: To explore i) whether the PAM and the PHBQ elicit important outcomes of digital consulting ii) whether the PROMs can isolate the digital consultation component of care. Methods: Participants were drawn from five clinics providing specialist NHS care to 16-24yrs olds with long term health conditions participating in the wider LYNC study. Fourteen people were convenience sampled and consented to have a cognitive interview in this sub-study. Seven participants were young people with either inflammatory bowel disease, cystic fibrosis or cancer. Seven clinicians were clinical psychologist, two nurses, three consultants and a community youth worker practising in Cancer, Diabetes, Cystic Fibrosis and Liver disease. Cognitive interviews were transcribed and analysed and a spread sheet recorded participants’ PROM item appraisals. Illustrative quotes were extracted verbatim from the interviews for all participants. Results: Young people found 10 of the PAM 13 items to be relevant to digital consulting and fewer of the additional PAM 22 items. They were only able to provide a spontaneous examples of digital consulting for 50% of the 22 items. Four of the 6 clinicians appraised 12 of the PAM 13 items and 19 of the PAM 22 items to be relevant to evaluating digital consulting and articulated operationalisation of the items with reference to their own digital consulting practice with greater ease than the young people. Appraising the PHBQ, in 14 of the 25 items (56%) 2/3rds of young people’s appraisals offered digital consulting examples with ease suggesting that the young people can detect and discern humanistic clinician behaviours via digital as well as face to face communication channels. Seventeen of the 25 items (68%) were appraised as relevant by the young people. This finding was mirrored in the clinician appraisals. Both young people and clinicians found the research task complex. Young participants required considerably more researcher prompting to illicit examples related to digital consulting rather than their face to face care. Conclusions: The PAM and the PHBQ have satisfactory face and content validity for evaluating digital consulting to warrant proceeding to psychometric evaluation. Completion instructions require revision to differentiate between digital and face to face consultations.

  • Artificial Intelligence in Disease Diagnosis and Medical Treatment

    Date Submitted: Feb 1, 2018
    Open Peer Review Period: Feb 2, 2018 - Mar 30, 2018

    Artificial intelligence (AI) has been widely used in medical field, facilitating the development of medical services. This passage illustrates basic principles of AI application in medicine, summarizes some outstanding achievements of such application and discusses its merits and drawbacks. The passage is also an attempt to look into the future of AI in medical field.

  • Mobilizing mHealth data collection in older adults: Challenges and opportunities

    Date Submitted: Feb 1, 2018
    Open Peer Review Period: Feb 1, 2018 - Mar 29, 2018

    Worldwide, there is an unprecedented and ongoing expansion of both the (i) proportion of older adults in society, and (ii) innovations in digital technology. Within the next three decades the number of older adults (aged 65 years and above) will outnumber children (aged 15 and younger). This shift in the population age structure has myriad implications for healthcare, as increasing numbers of individuals requiring care put greater demands on already heavily burdened healthcare systems. In order to address these challenges, we must look to innovative ways of studying the processes of aging. The breadth, depth, and granularity of information available through technology-driven data collection and analysis mechanisms has the potential to improve our capacity to research, understand, and address the implications of an aging population. However, whilst there is also great opportunity in harnessing these technologies, there are equally as many challenges. Notably, older adults may experience the first-level digital divide, i.e. lack of access to technologies, and/or the second-level digital divide, i.e. lack of use/skill. In order to harness the numerous benefits of these innovative research methods and techniques, we must first engage older adults in a meaningful way and adjust the framework of traditional mHealth smart devices for the unique physiological and psychological characteristics of the aging populace. Through an informed approach to the development of technologies with older adults in mind, the hope is that we can leverage these innovations to increase the quality and quantity of life experienced by the growing population of older adults.

  • Background: Perinatal morbidity and mortality are significant public health issues with enduring impact on the health and wellbeing of women and their families. Millions of pregnant women now download and use mobile applications (“apps”) to access, store and share health information, but little is known about the consequences; investigation of their impact on perinatal health outcomes is particularly topical. Objective: To determine the effects of mobile app interventions during pregnancy on influencing healthy maternal behaviour and improving perinatal health outcomes. Methods: PubMed, Embase, The Cochrane Library, CINAHL, WHO Global Health Library, POPLINE and CABI Global Health were searched with no date or language restrictions. Randomised and non-randomised studies were included if they reported perinatal health outcomes of interventions targeting pregnant women, using mobile apps compared with other communication modalities or with standard care. The primary outcome measure was change in maternal behaviours (as defined by trial authors), by intervention goals. Two reviewers independently extracted data using standardized forms. Results: Four randomised controlled trials (RCTs) involving 456 participants were included. All studies targeted participants in early pregnancy; however, wide variation was evident in participant characteristics, intervention and study outcomes measures. Three trials were based in hospital settings, comparing women using mobile apps with routine antenatal care. One community-based trial gave all participants a device to promote physical activity; the intervention arm were also given a mobile app. All studies reported data for the primary outcome measure, describing some benefit from the intervention compared with controls; but few statistically significant primary or secondary outcomes were reported. Due to insufficient data, the planned meta-analysis and subgroup analyses were not performed. Conclusions: Due to limited numbers, heterogeneity of interventions, comparators and outcome measures, no firm conclusions can be drawn on the effects of mobile application interventions during pregnancy on maternal knowledge, behaviour change, and perinatal health outcomes. As millions of women utilise mobile apps during pregnancy, rigorous studies are essential for healthcare and maternity care providers to optimally design, implement and evaluate interventions. Clinical Trial: PROSPERO CRD number 42016037344

  • Background: A chronic somatic condition, such as rheumatoid arthritis (RA), can significantly reduce health related quality of life due to psychological, social and physical consequences. Cognitive behavioural therapy can aid in improving outcomes for patients, for example in terms of disease trajectory, health care utilization, and workplace disability of patients. In recent years internet-based cognitive behavioural therapy has been proposed as an effective and efficient way to offer cognitive behavioural therapy and further implementation. However, little research has been conducted to support this proposition. Objective: To stimulate the implementation of effective treatment strategies for improving health-related quality of life (HRQoL) of patients with rheumatoid arthritis (RA), cost-benefit ratios are required to inform stake-holders. A cost-effectiveness study from a societal perspective was conducted alongside a randomized controlled trial on a tailored and therapist-guided internet-based cognitive behavioural intervention (ICBT) for patients with elevated levels of distress, as an addition to usual care alone. Methods: Data were collected at baseline/pre-intervention, 6 months/post-intervention, and three-monthly thereafter during one year follow-up. Effects were measured in quality-adjusted life years (QALYs) and costs from a societal perspective including healthcare sector costs (including healthcare use, medication, and intervention costs), patient travel costs for healthcare use, and costs associated with loss of labor. Results: The intervention improved quality of life compared to usual care alone (Δ QALYs= 0.059), but also led to higher costs (Δ= € 4.211,44), which reduced substantially when medication costs were left out of the equation (Δ= € 1.862,72). Most (93%) of the simulated ICERS were in the north-east quadrant, suggesting a high probability that the intervention is effective in improving HRQoL, but at a greater monetary cost for society compared to usual care alone. Conclusions: A tailored and guided ICBT intervention as an addition to usual care for patients with RA with heightened distress was effective in gaining quality of life. Consequently, implementation of the ICBT into standard healthcare for patients with RA is recommended, yet further study into cost reductions in this population is warranted. Clinical Trial: National trial registry number:NTR2100

  • Attachment Style, Impulsivity, Sexual Desire, Mood, and Addictive Cybersex

    Date Submitted: Feb 1, 2018
    Open Peer Review Period: Feb 1, 2018 - Mar 29, 2018

    Background: Rising concerns have been reported related to problematic cybersex or cybersex addiction. Objective: The aim of this study was to assess potential links between cybersex addiction and several psychological and psychopathological factors, including sexual desire, mood, self-esteem, attachment style, and impulsivity, by taking into account the age, sex, and sexual orientation of cybersex users. Methods: An online survey was conducted in which participants were assessed for sociodemographic variables and with the following instruments: Compulsive Internet Use Scale adapted for cybersex use, Sexual Desire Inventory, Short Depression-Happiness Scale, Self-Esteem Scale, and UPPS-P scale for impulsivity. Attachment style was assessed with the Experiences in Close Relationships-Revised questionnaire (Anxiety and Avoidance subscales). Results: A sample of 145 subjects completed the study. Cybersex addictive use was associated with male gender, depressive mood, higher levels of sexual desire, and avoidant attachment style, but not with impulsivity Conclusions: Addictive cybersex use is a function of avoidant attachment, sexual desire, and depressive mood. Clinical Trial: Not a trial

  • Information and communication technologies access and use among an urban community sample of Black women

    Date Submitted: Feb 1, 2018
    Open Peer Review Period: Feb 1, 2018 - Mar 29, 2018

    Background: Information and communication technologies (ICT) offer potential for delivering healthcare interventions to medically underserved populations. However, most studies on ICT use and acceptability for health education and interventions have been conducted in clinical settings. Objective: The aim of this study was to examine access to and use of cell phone and computers as well as acceptability of ICT to deliver behavioral health information among a community sample of urban, predominately Black women. Methods: Participants (N=220) were recruited from hair salons and social service centers and completed audio-computer assisted self-interviews. Results: The majority (96%) reported at least weekly cell phone use, of which 89% used smartphones; 62% reported at least weekly computer use. Fifty-two percent and 39% used cell phones or computers, respectively, to access health and/or safety information weekly or more frequently. Approximately half reported interest in receiving information about stress management (51% - 56%) or alcohol and health (45 - 46%) via ICT. Smartphone ownership was associated with younger age (OR: 0.92, CI: 0.87-0.97) and employment (OR: 5.12, CI: 1.05-24.95). Accessing health and safety information weekly by phone was associated with younger age (OR: 0.96, CI: 0.94-0.99) and inversely associated with higher income (OR: 0.42, CI: 0.20-0.92). Conclusions: Our findings suggest that ICT use, particularly smartphone use, is pervasive among Black women in urban nonclinical settings and that ICT is an acceptable modality for delivering health information to this population. Further exploration of the acceptability, feasibility, and effectiveness of using ICT to disseminate behavioral health education and intervention is warranted. Clinical Trial: NA

  • Background: Cancer patients receiving chemotherapy have high symptom needs that can negatively impact quality of life and healthcare utilization. Chemotherapy-related toxicities usually occur between ambulatory visits to the oncology clinic and result in high rates of unplanned acute care visits, likely reflecting of suboptimal management of these toxicities. Objective: To design a prototype tool to facilitate remote management of chemotherapy-related toxicities to address this gap in care. Methods: User needs were assessed using a participatory, user-centered design methodology that included ethnographic interviews and focus groups, then analyzed using thematic analysis. Participants included oncology patients, caregivers, and health care providers (HCPs) including medical oncologists, oncology nurses, primary care physicians and pharmacists. Overarching themes informed development of a web-based prototype, which was further refined over 2 rounds of usability testing with end-users. Results: Overarching themes were derived from needs assessments which included 14 patients, 1 caregiver, and 12 HCPs. Themes common to both patients and HCPs included: gaps and barriers in current systems, need for decision aids, improved communication and options in care delivery, secure access to credible, timely information, and integration into existing systems. Additionally, patients identified missed opportunities, care not meeting their needs, feeling overwhelmed and anxious, and wanting to be more empowered. HCPs identified accountability for patient management as an issue. These themes informed development of a web-based prototype (“bridges”), which included toxicity tracking, self-management advice, and HCP communication functionalities. Usability testing with 11 patients and 11 HCPs was generally positive; however, identified challenges included tool integration into existing workflows, need for standardized toxicity self-management advice, issues of privacy and consent, and patient-tailored information. Conclusions: A web-based tool integrating just-in-time self-management advice and HCP support into routine care may address gaps in systems for managing chemotherapy-related toxicities but attention needs to be paid to implementation issues.

  • Reliability of an ePRO Tool of FACT-B for Measuring Health-Related Quality of Life in Breast Cancer Patients

    Date Submitted: Jan 31, 2018
    Open Peer Review Period: Feb 1, 2018 - Mar 29, 2018

    Background: The most frequent malignant disease in women is breast cancer. In the metastatic setting, quality of life is the primary therapeutic goal and systematic treatment has only limited effect on survival rates; therefore, the concept of Health-related Quality of Life (HRQoL) and measurement of Patient Reported Outcomes (PRO) is gaining more and more importance in the therapy setting of diseases such as breast cancer. One of the frequently used questionnaires for measuring HRQoL in breast cancer patients is the Functional Assessment of Cancer Therapy - Breast (FACT-B). Currently, paper-based surveys still predominate as only a few reliable and validated electronic-based questionnaires are available. EPRO tools of the FACT-B questionnaire with proven reliability are missing so far. Objective: The aim of this study was to analyze the reliability of tablet-based measurement of FACT-B in German language in adjuvant (curative) and metastatic breast cancer patients. Methods: Paper- and tablet-based questionnaires were completed by a total of 106 female adjuvant and metastatic breast cancer patients, recruited as part of the ePROCOM and PEPPER study. All patients were required to complete the electronically based (ePRO) and paper-based version of the FACT-B. A frequency analysis was performed to determine descriptive sociodemographic characteristics. Both dimensions of reliability [parallel forms reliability (Wilcoxon test) and test of internal consistency (Spearman’s rho)] and agreement rates for single items, Kendall’s tau for each subscale and total score were analyzed. Results: High correlations were shown for both dimensions of reliability (parallel forms reliability and internal consistency) in the patient’s response behavior between paper-based and electronically based questionnaires. Regarding the reliability test of parallel forms no significant differences were found in 35 of 37 single items, while significant correlations in the test for consistency were found in all 37 single items, in all 5 sum individual item subscale scores, as well as in total FACT B score. Conclusions: The ePRO version of the FACT-B questionnaire is reliable for breast cancer patients in both the adjuvant and metastatic setting, showing highly significant correlations with the paper-based version in almost all questions all subscales and the total score.

  • Visual Behavior Analysis Between Neuro-typical Children and Children with Autism Spectrum Disorder

    Date Submitted: Jan 30, 2018
    Open Peer Review Period: Feb 1, 2018 - Mar 29, 2018

    Autism Spectrum Disorder (ASD) is a complex and diverse neuro-developmental condition. Little research has been done globally which is not commensurate with the multifariousness of ASD and in developing countries like Bangladesh, such fields of research are almost void. This research investigates the visual behavior of 24 neuro-typical children and 24 children with ASD in smooth pursuit and saccadic eye movement. The smooth pursuit experiment contained animations of objects moving horizontally across the screen and the saccadic tests contained animations of predictable and non-predictable saccades. To attain the gaze data, Tobii EyeX Controller was used and the data was processed and analyzed in MATLAB. Significant differences in results were found in the two areas of investigation. Children with ASD were found to have higher saccadic latency, lower accuracy in smooth pursuit and an overall poorer performance in these basic visual tests compared to their control counterparts. Fundamental eye movements are connected to the sensory- motor processing of the brain and such behavior might be the product of flawed cerebellum and motor functions of the brain. To fully understand this, further eye-tracking, neuroimaging, and behavioral studies should be done in integration.

  • Background: Changing population demographics and technology developments have resulted in growing interest in the potential of consumer facing digital health. In the UK a £37 million, national digital health programme ‘delivering assisted living lifestyles at scale’ (dallas), aimed to deploy such technologies at scale. However, little is known about how consumers ‘value’ such digital health opportunities. Objective: This study aims to explore consumer perspectives on the potential value of digital health technologies, particularly mobile health (mHealth) to promote wellbeing by examining their “willingness to pay” (WTP) for such health solutions. Methods: Contingent valuation (CV) study involving a UK-wide survey which asked participants to report open-ended absolute and marginal WTP or willingness-to-accept (WTA) for the gain/loss of a hypothetical mHealth app, ‘healthy connections’. Results: In 2015, a UK-representative cohort (n=1697) and a ‘dallas-like’ (representative of communities participating in the wider dallas intervention) cohort (n=305) were surveyed. This study identified positive absolute and marginal WTP valuations of the app across both cohorts (absolute WTP, UK-representative £196, dallas-like £162; marginal WTP UK-representative £160, dallas-like £151). Among both cohorts there was a high prevalence of zeros for both the WTP (UK-representative 28%; dallas-like 31%) and marginal WTP (UK-representative 29%; dallas-like 32%). In both cohorts, better general health, previous amount spent on health apps (UK-representative, 0.64 95% CI 0.27, 1.01; dallas-like, 1.27 95% CI 0.32, 2.23) and age had a significant (p>0.05) association with WTP (UK-representative, -0.1 95% CI -0.02, -0.01; dallas-like, -0.02 95% CI -0.03, -0.01), with younger participants willing to pay more for the app. In the UK-representative cohort, higher WTP was positively associated with income up to £30,000 (0.21, 95% CI 0.14, 0.4) and increased spending on existing phone and internet services (0.52 95% CI 0.30, 0.74). Amount spent on existing health apps was shown to be a positive indicator of WTP across cohorts, although the effect was marginal (UK-representative, 0.01 95% CI 0.01, 0.01; dallas-like, 0.01 95% CI 0.01, 0.02). Conclusions: This paper demonstrates consumers value mHealth solutions that promote wellbeing, social connectivity and healthcare control but it is not universally embraced. For mHealth to achieve its potential applications need to be tailored to the needs of the user and a better understanding of how type of digital device may impact on mHealth usage. A key challenge is how to engage people with long term conditions to encourage uptake of mHealth apps. This novel application of WTP in a digital health context demonstrates that there is an economic argument for investing in upskilling the population to promote access and expedite uptake and utilisation of such digital health and wellbeing apps.

  • Spurring up research through a collaborative platform: Seintinelles

    Date Submitted: Jan 30, 2018
    Open Peer Review Period: Feb 1, 2018 - Mar 29, 2018

    Background: Cancer research participation today is unfortunately not optimally effective. Only a few citizens of the population in France are involved in clinical trials. The participation of a wide number of people in cancer research is crucial to increase speed and optimize quality in cancer research. Objective: In order to remove this barrier and connect the public with researchers a national online platform called Seintinelles has been created in 2014. Methods: Participants subscribed voluntarily to a website and were afterwards recruited by email for studies suitable to their baseline profile. Participants were given the possibility to register for the newsletter or to participate in social events. Once a researcher needed volunteers the participants in the database received an email with the terms and criteria of the study and interested participants could give their permission to be included. Results: Currently more than 20.504 participants, healthy people and people with a specific cancer type, with a mean age of 46 years old and spread out all over France, have subscribed to the website Seintinelles. The main cancer type that is represented is breast cancer (5962 participants), followed by colorectal cancer (136 participants) and lung cancer (78 participants). A group of researchers (n: 277) contributed to successfully match patients with the appropriate studies 10 studies have been successfully conducted and 7 are currently ongoing. Conclusions: Seintinelles successfully started a national online platform in 2014 that connects researchers and citizens of France in order to improve the efficacy of cancer research. Within 2 years time the website has been able to recruit 20.504 citizens eligible to participate in important nation-wide cancer studies. Seinitelles has shown to be an effective way to speed up cancer research. The future goal is to expand the platform and involve up to 50.000 patients and 10 yearly studies by 2018.

  • Background: Mobile technologies have great potential to promote an active lifestyle in lower educated working young adults, an under-researched target group at higher risk of low activity levels. Objective: This study aimed to examine the effect and process evaluation of the newly developed evidence- and theory-based smartphone application (app), ‘Active Coach’, on objectively measured total daily physical activity (PA), self-reported context-specific PA, and self-reported psychosocial variables among lower educated working young adults. Methods: Lower educated working young adults (n=130) participated in a 2-group cluster randomized controlled trial assessing outcomes at baseline, post-test (baseline+9weeks) and follow-up (post-test+3months). Intervention participants (n=60) used the Active Coach app (9 weeks) combined with a Fitbit activity tracker. Personal goals, practical tips and educational facts were provided to encourage PA. The control group received print-based generic PA information. Both groups wore accelerometers to objectively measure PA and individual interviews were conducted to assess psychosocial variables and context-specific PA. Intervention participants were also asked process evaluation questions. Generalized linear mixed models and descriptive statistics were applied. Results: No significant intervention effects were found for objectively measured PA, self-reported PA and self-reported psychosocial variables (all p>0.05). Intervention participants evaluated the Active Coach app and the combined use with the Fitbit wearable as self-explanatory (70.6%), user-friendly (78.4%) and interesting (66.7%). Throughout the intervention, frequency decreased of viewing graphical displays in the app (p<0.001), reading the tips, facts and goals (p<0.05) and wearing the Fitbit wearable (p<0.001). Few intervention participants found the tips and facts motivating (24.4%), used them to be physically active (19.6%) and thought they were tailored to their lifestyle (17.1%). Conclusions: The lack of significant intervention effects might be due to low continuous user engagement. Advice/feedback that was not perceived as tailored enough and the difficulty to compete with many popular commercial apps on young people’s smartphones may be responsible for a decrease in engagement. A stand-alone app does not seem sufficient to promote an active lifestyle among lower educated working young adults, therefore multi-component interventions (using both technological and human support), as well as using context-specific sensing to provide tailored advice might be needed in this population. Clinical Trial: NCT02948803 (Clinicaltrials.gov)

  • Background: While people in Taiwan receive highly accessible, affordable medical care, patients’ knowledge and awareness of their medication information and personal healthcare needs are limited. Mobile health (mHealth) Apps have recently demonstrated the potential to engage and empower people to improve their own health. Although availability of health-related Apps is increasing, the adoption rate in Taiwan is exceptionally low, due mainly to Western culture-based design that is challenging for non-English-speaking individuals. To our knowledge, no mHealth App is available in Taiwan that is culturally tailored for Mandarin-speaking users and that applies a patient-centered approach to self-manage medication and health. Objective: The purpose of this study was to design and deploy a culturally competent mHealth system that could be easily integrated into clinical practice in Taiwan, and to evaluate its efficacy in empowering Mandarin-speaking patients to self-manage their medication and health information. Methods: A mHealth information system and mobile App were designed based on clinical needs assessment and to operate within the present care workflow in Taiwan. To promote the best patient experience, a novel quick response (QR) code scheme was developed into the current prescription process to enable highly efficient, mobile-offline registration of personal medication information, including dosage, frequency, photo, side effects, and warnings, through a mobile App. The App also supports notifications for drug utilization, refills, and symptom checks. Patients were encouraged to record medication use, symptoms and self-assessment in the App during their treatment period. Evaluation of the novel mHealth system was conducted from August 2016 to December 2016 among Mandarin-speaking patients at MacKay Memorial Hospital, Taipei, Taiwan. Population data and App usage statistics were analyzed. Results: During the five-month implementation period, a total of 25,909 users downloaded the App with an overall 7-day retention rate of 15.4% (± 3.9) and younger adults (25-44 years old) as well as male are predominant population. Patients’ feedback on App usability, design, QR code system as drug input method, medication reminders and linking family/friends into care networks was generally positive. Physicians showed great interest in utilizing patient-generated data in their care process, and the positive medication adherence rate was the most highly-valued component of this system. Conclusions: This pilot study demonstrated efficacy of the novel mHealth approach for individualized medication and health management in Taiwan. The mHealth system optimizes personalized care, including patient-generated data such as medication utilization. The population scale of the mHealth system may help hospital administrations and health authorities with continuous quality improvement and policy development.

  • Identifying types of clinical entities from Chinese electronic health records

    Date Submitted: Jan 30, 2018
    Open Peer Review Period: Jan 30, 2018 - Mar 27, 2018

    Background: Electronic health records (EHR) is an important data resource for clinical studies and applications. Physicians or clinicians describe patients’ disorders or treatment procedures using free texts in EHR. The narrative information play an important role in patient treatment and clinical research. However, it is challenging to made machine understand the clinical narratives. Objective: This study aimed to automatically identify Chinese clinical entities from free texts in EHR, and make machine semantically understand diagnosis, test, body part, symptom, treatment and, etc. Methods: Two machine learning (ML) models, conditional random fields (CRF) method and bidirectional LSTM-CRF, were applied to recognize clinical entities from Chinese EHR data. For training the CRF-based model, we selected features as bag of Chinese characters, part-of-speech (POS) tags, character types and the position of characters. For the bidirectional LSTM-CRF-based model, character embeddings and segmentation information were used as features. In addition, we used a dictionary-based approach as the baseline for performance evaluation purpose. Results: To validate our methods, we used the benchmark data set with human annotated Chinese electronic health records, released by CCKS 2017 CNER challenge task. The result showed that our methods were able to automatically identify types of Chinese clinical entities such as diagnosis, test, symptom body part and treatment in one-round running. The identification overall performance of CRF and bidirectional LSTM-CRF achieved Precision of 0.9203 and 0.9112, Recall of 0.8709 and 0.8974, F1 score of 0.8949 and 0.9043 respectively. The result also indicated that our methods performed well on recognizing each type of clinical entities, in which the “symptom” type achieved the best with F1 score over 0.96. Conclusions: In this study, we developed two computational methods to simultaneously identify types of Chinese clinical entities from free texts in EHRs. Via training, it can effectively identify various types of clinical entities (e.g., symptom and treatment) with high accuracy. This study contributed to translating human-readable health information into machine-readable one.

  • Background: Remote management is partially replacing routine follow-up in patients implanted with cardiac implantable electronic devices. While it reduces clinical staff time compared to standard in-office follow-up, new definition of roles and responsibilities may be needed to review remote transmissions in an effective, efficient and timely manner. If the remote triage may be outsourced is still unclear. Objective: The aim of this healthcare quality improvememt project was to assess if outsourcing the triage of cardiac implantable devices (CIEDs) remote follow-up is safe, effective and efficient to manage clinical and technical events and can improve resource utilization. Methods: Patients (N=153) with implanted CIEDs were followed up for 8 months. An external remote monitoring center (ERMC) composed of nurses and physicians reviewed remote transmissions daily following a specific remote monitoring (RM) protocol. A benchmarking phase with the standard RM management, where patients transmissions were managed directly by the hospital staff, was performed as a term of comparison. Results: A total of 654 transmissions were recorded in the RM system and managed by the ERMC team within 2 working days, showing a significant time reduction compared with standard RM management (100% vs 11% respectively within 2 days, p<0.001). 84% of the transmissions did not include a prioritized event and did not require escalation to the hospital clinician. High-priority was assigned to 15 (2.3%) transmissions, which were communicated to the hospital team by email within 1 working day. Non-urgent device status events occurred in 88 cases and were communicated to the hospital within 2 working days. Overall, 10 (9.7%) transmissions were followed by a hospitalization. Conclusions: The outsourcing of RM management to an ERMC safely provides efficacy and efficiency gains in patients care compared with a standard in hospital management. Moreover the externalization of RM management could be a key tool to save dedicated staff and facility time with possible positive economic impact. Clinical Trial: Clinicaltrials.gov NCT01007474, http://clinicaltrials.gov/ct2/show/NCT01007474)

  • Exploring measurement, levels and predictors of adherence to a blended smoking cessation treatment

    Date Submitted: Jan 29, 2018
    Open Peer Review Period: Jan 30, 2018 - Mar 27, 2018

    Background: Blended face-to-face and web-based treatment is a promising way to deliver cognitive behavioral therapy. Since adherence has been shown to be a measure for treatment's acceptability and a determinant for treatment's effectiveness, this study explored adherence to a new blended smoking cessation treatment (BSCT). Objective: This study aimed (1) to develop an adequate method to measure adherence to BSCT; (2) to define an adequate degree of adherence to be used as a threshold for being adherent; (3) to estimate adherence to BSCT; and (4) to explore possible predictors of adherence to BSCT. Methods: Patients' (n=75) data were analyzed to trace adherence to BSCT delivered at an outpatient smoking cessation clinic. (1) In total, 18 patient activities were selected to measure adherence and the degree of adherence per patient was compared to the quitting success. (2) The minimum degree of adherence of the patients who reported abstinence was examined to define a threshold for the detection of adherent patients. (3) The number of adherent patients was calculated for each of the 18 selected activities; the degree of adherence over the course of the treatment was displayed; and the number of patients that were adherent was analyzed. (4) The relationship between adherence and 33 person,- smoking and health-related characteristics was examined. Results: (1) The method for measuring adherence was found to be adequate, as adherence to BSCT correlated with self-reported abstinence (P=.03). (2) Patients reporting abstinence, adhered to at least 61% of BSCT. (3) Adherence declined over the course of the treatment; the percentage of adherent patients per treatment activity ranged from 82% at treatment start and 11% to 19% in the final third of BSCT; applying a 61% threshold, 18% of the patients were classified as adherent. (4) Marital status and social modelling were the best independent predictors of adherence. Patients having a partner had 11-times higher odds of being adherent (OR=11.3; CI: 1.33-98.99; P=.03). For social modeling - graded from 0 (=partner and friends are not smoking) to 8 (=both partner and nearly all friends are smoking) - each unit increase was associated with 28% lower odds of being adherent (OR=0.72; CI: 0.55-0.94; P=.02). Conclusions: The current study is the first study exploring adherence to a blended face-to-face and web-based treatment (BSCT) based on a substantial group of patients. It revealed a rather low adherence rate to BSCT: applying a 61% threshold for adherence, only 18% of the patients were classified as adherent. The method for measuring adherence to BSCT could be considered to be adequate, because the expected dose-response relationship between adherence and quitting could be verified. Furthermore, this study revealed that marital status and social modelling were independent predictors of adherence. Clinical Trial: Nederlands Trial Register, NTR5113, http://www.trialregister.nl

  • Assessment of Google Glass for Photographic documentation in veterinary forensic pathology

    Date Submitted: Jan 29, 2018
    Open Peer Review Period: Jan 30, 2018 - Mar 27, 2018

    Background: Google Glass is head-mounted device designed in the shape of a pair of eyeglasses equipped with 5.0 Mpx integrated camera and capable to take pictures with simple voice commands Objective: The aim of the study was to determine if Google Glass is fit for Veterinary forensics pathology purposes. Methods: A total of 16 forensic necropsies of 2 different species (8 dogs and 8 cats) were performed by 2 pathologists; Google Glass was used for photographic report in 8 cases (4 dogs and 4 cats) and a reflex camera Nikon D3200 for the other 8 cases. For each necropsy, we evaluated 1) the difference in mean duration between necropsies conduced with google glass and DSLR camera, 2) the loss of battery power of the devices 2) the usability aspects and 3) the quality of the Photographic documentation obtained using Google Glass compared with a DSLR camera. As reguard the quality images assessment, the pictures taken by both devices were collected in 3 groups and evaluated by 3 forensic pathologists using a 5-point score system. The parameters assessed were: overall color settings, region of interest and sharpness. T student test was used to assess the difference in ratings among the quality of the pictures taken by both devices. ANOVA test was used to test differences among the groups. Results: We found a significant reduction in the necropsies execution time conduced with the Google Glass with respect to the reflex group (p<0.01). But, on the other hand, the former drained the battery very quickly. Furthemore, the images taken by Google Glass received significantly lower ratings than those acquired by reflex camera for all 3 parameter assessed (P<0.01). In particular, the images of the Group A (external appearance of the animals) taken by glass received mean ratings of 3,23±0.43, 3,28±0.46 and 3,42±0.50 for region of interest, sharpness, and overall color settings respectively. Furthermore, the images of the Group B (pictures of the organs) received mean ratings of 3,10±0.44, 3,40±0.50 and 3,20±0.52. The lowest ratings were observed in the pictures of group C (small anatomical detail) with mean of 2,38±0.49 for region of interest, 3,19±0.40 for sharpness and 2,71±0.56 for overall color settings. Conclusions: These findings suggested that Glass was usable in veterinary forensic pathology but the image quality was lower if compared to a reflex camera. In particular, the average-good images quality of the group A and B seemed adequate for forensic photographic documentation purpose. However, in this step of development, the low pictures quality of the group C due to the low camera resolution and absence of photografic zoom suggested that the Glass device was not suitable for taking pictures of small anatomical details or close-up of the injuries

  • Design, Development and Usability Testing of a Stress Management Application Intervention for Cancer Survivors

    Date Submitted: Jan 29, 2018
    Open Peer Review Period: Jan 30, 2018 - Mar 27, 2018

    Background: Distress is prevalent in cancer survivors. Stress management interventions can reduce distress and improve quality of life for cancer patients, but many people with cancer are unfortunately not offered or able to attend such in-person stress management interventions. Objective: The present study sought to develop an evidence-based stress management intervention for patients living with cancer that can be delivered electronically, with wide reach and dissemination. This paper describes the design and development process of a technology based stress management intervention for cancer survivors, including the exploration phase, intervention content development, iterative software development (including design, development and formative evaluation of low- and high-level prototypes) and security and privacy considerations. Methods: Design and development processes were iterative and performed in close collaboration with key stakeholders, including male and female cancer survivors (n=17) representing a wide age range (31-81 years) and cancer diagnoses, healthy volunteers (n=7), healthcare providers (n=8) including psychosocial oncology experts, and eHealth experts (n=8) including IT design and developers. To ensure user involvement in each phase various user-centered design and service design methods were included, including interviews, usability testing and think aloud processes. Intervention content was developed by stress management experts, based on well-known cognitive-behavioral stress management strategies and adjusted to electronic format through multiple iterations with stakeholders. Privacy and security issues were considered throughout. Results: The design and development process identified a variety of stakeholder requirements. Cancer survivors preferred stress management through a mobile application (app) rather than through a personal computer (PC) and identified usefulness, easy access, user friendliness, use of easily understandable language and many brief sections rather than longer ones as important components of the intervention. These requirements were also supported by recommendations from health care providers and eHealth experts. The final intervention was named StressProffen and the hospital Privacy and Security Protection Committee was part of the final intervention approval to also ensure anchoring in the hospital organization. Conclusions: Interventions, even evidence-based, have little impact if not actively used. This study illustrates how user-centered design and service design can be applied to identify and incorporate essential stakeholder aspects in the entire design and development process. In combination with evidence-based concepts this process facilitated development of a stress management intervention truly designed for the end users, in this case cancer survivors. Clinical Trial: Clinical trial.gov NCT02939612

  • Background: The elderly HIV patient population not only presents more comorbidity and poly-medication, but also suffers from stigmatization on behalf of society and lack of social support, where new technologies can now play a role towards enhancing the empowerment of these patients. Objective: To encourage a greater knowledge about the infection, promote patient treatment adherence and offer them the possibility of anonymously establishing contact between them and their peers. Methods: A series of clinical and psychosocial parameters were studied in 30 HIV-infected patients of over 60 years of age. 15 of them were randomized to use an app and 15 were the control group. All tests were repeated after 6 months. Results: The median age of patients was 66,5 years old, with an 11-year period suffering from HIV infection. 29 of them had an undetectable viral load and CD4 nadir was 194 cel/micromole. Median number of comorbidity diseases was 2. 11 of them lived with their parents and 19 lived alone. They spent an average of 5 hours a day sitting down and 56,7% of them referred high physical activity. They scored 4 out of 5 for general quality of life perception. 80% presented high adherence to their treatment and average number of concomitant medication was 5. In the 6-minute walking test (6MWT) they covered a distance of 400 meters and 3 of them desaturated during the test. The 15 patients made frequent use of the app with 2407 sessions and an average of 7 minutes and 56 seconds time of use with a total of 13143 screen views. During the 6 months of the trial, 3 non-AIDS events took place. There were no significant modifications to BMI, blood pressure measurements, lipid profile or panel or immuno-virology information data. Neither was there any significant modification in the distance covered in the 6MWT or of the desaturation percentage. There wasn´t any differences in the questionnaire scores for perception of quality of life either, or for confessed physical activity or ART and non-ART treatment adherence. Conclusions: Significant differences between studied parameters were not objectified in these patients, although this trial has a small sample size and only a brief follow-up period is considered. However, patients did make a frequent use of the app, making this a possible method of intervention to be proposed in future subsequent studies

  • Background: The integration and mining of multiple post market surveillance data sources provide the healthcare industry with a unique opportunity to become more proactive in responding to potential product quality defects. However, many challenges exist in collecting, accessing, analyzing and interpreting data sets with uncertainty and high background noises. This is in particular the case when monitoring product performance {it via} customer complaints, which is the common methodology used in the in vitro diagnostic industry. Objective: The aim of this study is therefore to integrate data collected by in vitro diagnostic analyzers used in the the healthcare industry to measure various assays, with a customer database in order to predict the causes of customer complaints. Methods: Quality control (QC) results of five selected in vitro diagnostic assays were combined with the corresponding customer complaints of each of the assay over a 90-day period. We defined a set of features used to train two classifiers, one based on decision trees, and the other based on adaptive boosting. Results: A cross-validation analysis shows that, for some assays, classification error rates close to zero can be achieved with adaptive boosting in predicting customer complaints and the potential cause of the complaint. Performance can be further improved by shortening / modulating the training period when the volume of complaints increases. Conclusions: This novel approach to predicting customer complaints based on product QC data may allow the diagnostic industry to proactively identify potential product quality issues, and fix these before receiving customer complaints. This represents a new step in the direction of using "big data" towards product quality improvement. Clinical Trial: N/A

  • Background: Disease-related malnutrition is a common challenge among hospitalized patients. There seems to be a lack of an effective system to follow-up nutritional treatment of patients at nutritional risk. We identify a need for a more standardized system to prevent and treat disease-related malnutrition. Objective: To develop a dietary assessment application for tablets for use in a hospital setting. Further, to evaluate the app’s ability to measure individual intake of energy, protein, and liquids, foods, and beverages, among hospitalized patients for two days. We also aimed to measure the patients’ experiences using the application. Methods: We have developed the “MyFood” application, consisting of three modules; 1) Collection of information about the patient, 2) Dietary assessment function, and 3) Evaluation of recorded intake compared to individual needs. We used observations from digital photography of the meals, combined with partial weighing of the meal components, as a reference method to evaluate the app’s dietary assessment system for two days. Differences in the intake estimations of energy, protein, liquid, and food and beverage items, between MyFood and the photograph method, were analyzed on both group and individual level. Results: Thirty-two patients hospitalized at Oslo University Hospital were included in the study. The data collection period ran from March to May 2017. About half of the patients had ≥ 90% agreement in total for energy, protein, and liquid intake, both recording days. The dinner meal was the meal with the lowest percent agreement between the methods. MyFood overestimated the patients’ intake of bread and cereals and underestimated fruit consumption. The agreement between the methods increased from day 1 to day 2 for bread and cereals, spreads, egg, yogurt, soup, hot dishes, and desserts. Ninety percent of the participants reported that MyFood was easy to use, and 97% found the app easy to navigate in. Conclusions: We have developed the MyFood application as a tool to follow up hospitalized patients at nutritional risk. The recorded intake of energy, protein, and liquids in MyFood showed good agreement with the reference method for the majority of the participants. The application’s ability to estimate intake within food groups was good, except for bread and cereals which were overestimated, and fruits which were underestimated in MyFood. The app was well accepted among the study participant and has the potential to be a dietary assessment tool for use among patients in clinical practice.

  • Informal Caregivers’ Experiences and Perceptions of an Online Peer Support Network: A Mixed-Methods Study

    Date Submitted: Jan 26, 2018
    Open Peer Review Period: Jan 27, 2018 - Mar 24, 2018

    Background: Online peer support interventions have shown promise in reducing social isolation and social support deficits among informal caregivers, but little research has examined how caregivers use and perceive these interventions. Objective: The current study examined utilization and perceptions of an internet social support intervention for informal caregivers of wounded, ill, and injured U.S. military service members and veterans. Methods: The current study was a mixed-methods study that used quantitative survey data and qualitative data from focus groups and interviews with informal caregivers enrolled in an online peer support intervention to explore their use and perceptions of the intervention. The intervention was delivered via a website that featured interest groups organized around specific topics, webinars, webchats, and messaging functionality and was moderated by professionally-trained peers. Results: Survey findings (N = 217) indicated that caregivers used the site infrequently, with 60.7% (n = 128) visiting the site once a month or less, and passively, with a minority (n = 32, 22.2%) of users (i.e., those who had visited the site at least once during the past three months, N = 144) posting comments or links to the network. Nonetheless, most users (n = 121, 84.0%) endorsed moderate or greater satisfaction with the site on the survey, and focus group and interview participants reported benefiting sufficiently from passive use of the site (e.g., reading posts). Quantitative and qualitative findings suggested that users viewed the site primarily as a source of informational support: Among 63.2% (n = 91) of users who completed the survey, the most commonly-reported network-related activity was obtaining information from the network’s resource library, and focus group and interview participants viewed the network primarily as an informational resource. Focus group and interview participants expressed an unmet need for emotional support and the desire for a more “personal touch” in the forms of more active engagement with other caregivers in the online network and the creation of local, in-person support groups for caregivers. Conclusions: These findings suggest that online peer support interventions may lend themselves better to the provision of informational (vs. emotional) support and may need to be supplemented by in-person peer support groups to better meet caregivers’ needs for emotional support.

  • Predicting Caller Type Using Call Log Data from a Mental Health and Wellbeing Helpline

    Date Submitted: Jan 25, 2018
    Open Peer Review Period: Jan 26, 2018 - Mar 23, 2018

    Background: The paper presents an analysis of call data records pertaining to a telephone helpline in Ireland, for those seeking mental health and wellbeing support and for those who are in a suicidal crisis. Objective: Our aim was to examine if rule sets generated from decision tree classification, trained using features derived from a caller's several initial calls could be used to predict the type of caller they would become. Methods: Machine learning techniques were applied to the call log data and five distinct patterns of caller behaviors were revealed, each impacting the helpline capacity in different ways. Results: The main findings from the paper indicate that a statistically significant model (p<0.001) for predicting caller type from call log data obtained from the first eight calls is possible. This indicates an association between caller behavior exhibited in the first number of calls and their behavior over the lifetime of using the service. Conclusions: These data-driven findings contribute to advanced workload forecasting for operational management of the telephony-based helpline and informs the literature on helpline caller behavior generally.

  • Acceptability and Usability of iPrevent®, a Web-Based Tool for Assessment and Management of Breast Cancer Risk.

    Date Submitted: Jan 25, 2018
    Open Peer Review Period: Jan 25, 2018 - Mar 22, 2018

    Background: iPrevent® estimates breast cancer (BC) risk and provides tailored risk management information. Objective: This study assessed the usability and acceptability of the iPrevent® prototype. Methods: Clinicians were eligible if they worked in primary care, breast surgical or genetics clinics. Female patients were eligible if aged 18-70 years with no personal cancer history. Clinicians were first familiarised with iPrevent® using hypothetical paper-based cases, then actor scenarios and then subsequently used iPrevent® with their patients. Clinicians and patients completed the System Usability Scale (SUS) and an Acceptability questionnaire 2 weeks after using iPrevent®, and patients also completed measures of BC worry, anxiety, risk perception and knowledge pre- and 2 weeks post-iPrevent®. Data were summarised using descriptive statistics. Results: 20 clinicians and 43 patients participated. Usability was above average (SUS score >68) for most clinicians (68%) and patients (76%). Most clinicians (89%) and patients (89%) reported that the amount of information provided by iPrevent® was about right and most (95% and 98% respectively) would recommend iPrevent® to others, although 10 (53%) clinicians and 10 (27%) patients said it was too long. Exploratory analyses suggested iPrevent® could improve risk perception, decrease frequency of breast cancer worry and enhance breast cancer prevention knowledge without changing state anxiety. Conclusions: The iPrevent® prototype demonstrated good usability and acceptability. Because concerns about length could be a barrier to implementation, data entry has been abbreviated in the publically available version of iPrevent® which can be found at www.petermac.org/iprevent.

  • Presence of Hospitals on Facebook: Nationwide Survey in Taiwan

    Date Submitted: Jan 25, 2018
    Open Peer Review Period: Jan 25, 2018 - Mar 22, 2018

    Background: Social media advertising has grown increasingly influential in recent years. Because Facebook has the most active users worldwide, many hospitals in Taiwan have created official Facebook fan pages to enhance their reputations and provide services to more patients. Objective: The aim of this study was to present an overview of official Facebook fan pages of hospitals in Taiwan. Methods: All 417 hospitals were surveyed about their use of Facebook fan pages in December 2017. The last update time, posts in the past 30 days, number of “Likes”, and other features were analyzed and stratified according to the accreditation statuses of the hospitals. Results: In Taiwan, only 51.1% (n = 213) of the hospitals had an official Facebook fan page. Among these hospitals, 71.8% (n = 153) had updated their pages in the past 30 days, although 89.2% (n= 190) provided online interactions. The most common contents of posts were activity photos (80.8%), health education (66.7%), upcoming events (64.7%), and related news links (63.8%). Academic medical centers tended to have more “Likes” than regional and local community hospitals (on average 5947.4, 2644.8, and 1548.0, respectively). Conclusions: In spite of the popularity of Facebook among the general population, most hospitals in Taiwan do not seem to make good use of this kind of social media. The reasons for the use and nonuse of Facebook on the part of both hospitals and patients deserve further investigation.

  • Background: Internet based interventions are becoming an alternative of treatment aimed to support behavioral changes and several advantages over traditional treatments are reported. New ways of delivering an intervention may result in new challenges regarding monitoring of treatment fidelity which is essential to ensure internal and external validity. Despite of the importance of the theme, only few studies in this field are reported. Objective: To examine treatment fidelity of a smartphone delivered intervention based on Acceptance and Commitment Therapy (ACT) with e-diaries and written situational feedback for persons with Diabetes Mellitus type 2 (DMT2), the recommendations from the Behavior Change Consortium (BCC) established by The National Institutes of Health (NHI) were applied. To analyze fidelity, they recommend five areas to be investigated; design of study, provider training, delivery of treatment, receipt of treatment, and enactment of treatment. In this study these areas were examined based on the analysis of therapists’ adherence to the treatment protocol and participants’ and therapists’ experience with the intervention. Methods: To investigate the therapists’ adherence to the treatment protocol 251 written feedback messages were divided in text segments and qualitative thematic analyses were done to examine how ACT and other therapeutic processes were used in the feedback by the therapists. For the therapists’ and participants’ experience analysis, participants answered a self-reported questionnaire and participated in two interviews. The therapists spontaneously reported their experiences to the researcher responsible for the project. Results: The results show high therapists’ adherence to the treatment protocol. All ACT processes were found in the coded text segments of the feedback in addition to communication and motivation strategies. For 336 (46% of a total possible) text segments coded independently by two researchers, the inter-rater reliability measured by Cohen’s kappa, was 0.845. The evaluation of participants’ and therapists’ experience with the intervention was positive. The proportion adherence to treatment fidelity strategies recommended by NHI BCC was 0.95. Conclusions: Based on the level of therapists’ adherence to ACT-principles and participants’ and therapists’ experience with the intervention, the five areas of treatment fidelity recommended by NHI BCC were analyzed indicating a high level of treatment fidelity. These results ensure an appropriate level of internal and external validity of the study and reliable intervention results and facilitate a precise replication of this intervention concept. A reliable assessment of therapists’ adherence to the smartphone delivered intervention based on ACT was possible due to the coding scheme developed in a previous study. Internet-delivered psychological interventions to support people with chronic conditions are increasingly common. This study supports the results from the previous study which indicated that ACT can reliably be delivered in a written web-based format. Clinical Trial: NCT01297049

  • Background: The Carrot Rewards application (‘app’) was developed as part of an innovative public-private partnership to reward Canadians with loyalty points (exchangeable for retail goods, travel rewards and groceries) for engaging in healthy behaviors, such as walking. Objective: The purpose of this study was to examine whether very small incentives tied to daily step goal achievement (assessed by built-in smartphone accelerometers) could increase physical activity in two Canadian provinces, British Columbia (BC) and Newfoundland and Labrador (NL). Methods: A 12-week quasi-experimental (single group pre/post) study was conducted with 32,229 participants enrolled in the Carrot Rewards walking program (June 13th - July 10th 2016). During the two-week baseline (or 'run-in') period, mean steps/day were calculated for each participant. Thereafter, participants earned incentives ($0.04 CAD) every day they reached their personalized daily step goal (i.e. baseline mean + 1,000 steps = level of first daily step goal). Participants earned additional points (worth $0.40 CAD) for meeting their step goal 10+ non-consecutive times in a 14-day period (called a "Step Up Challenge"). Upon meeting the 10-day contingency, participants could increase their daily goal by 500 steps, with the objective of gradually increasing the number of steps participants take each day by 3,000. The primary study outcome was mean steps/day (by week), and was analyzed using linear mixed effects models. Results: Of the 32,229 participants, the mean age was 33.7 (SD=11.6) years and 66.11% (21,306/32,229) were female. The mean step count at baseline was 6,511.22 steps per day. Just over half of users (50.69%, 16,336/32,229) were categorized as "sedentary", accumulating less than 5,000 daily steps at baseline. Results from the mixed-effects models revealed statistically significant increases in mean daily step counts when comparing baseline with each study week (P<.001). Compared to baseline, participants walked 115.70 more steps (95% CI: 74.59,156.81; P<.001) at Week 12. Users classified as "high engagers" (48.13%; 15,511/32,229) in BC and NL walked 738.70 (95% CI: 673.81, 803.54; P<.001) and 346.00 (95% CI: 239.26, 452.74; P<.001) more steps, respectively. Among sedentary, high-engagers (21.08%; 7,022/32,229) an average increase of 1,224.66 steps per day (95% CI: 1160.69, 1288.63; P<.001) was observed. Effect sizes were modest. Conclusions: Providing very small but immediate rewards for personalized daily step goal achievement encouraged physical activity on a population-scale, especially for sedentary individuals and individuals who engaged more with the program. Positive effects in both BC and NL provide evidence of replicability.

  • Background: African Americans experience a high prevalence of obesity and its associated comorbidities, including diabetes. Church-based interventions have been shown to be effective in decreasing weight in this population. mHealth interventions have the ability to address two needs for obesity treatment in this community, including enhancing weight loss and providing wide dissemination. Objective: To assess the feasibility and efficacy of a church-based weight loss intervention that incorporated mHealth technology. Methods: Eight churches (n = 97) were randomly assigned to the intervention or delayed-intervention condition. Participants were recruited through their respective church. Volunteer church members were trained by study staff to deliver the 10-session, 6-month intervention. Participants in the intervention attended group sessions and received automated text messages designed to reinforce behavioral strategies. Participants in the delayed intervention received text messages related to health conditions relevant for African Americans. Measures of body composition, blood pressure, blood glucose, and cholesterol were taken. Results: Ninety-seven African American adults (mean age = 56.0 (10.3) years; 91.8% female; mean BMI = 38.6 (6.4) kg/m2) were successfully recruited into the study and attended churches that were randomized into the intervention (n = 68) or delayed intervention (n = 29) condition. Seventy-two (74.2%) of these individuals (69.1% intervention; 86.2% delayed intervention) completed the 6-month assessment. The average attendance was 55%. There was a significant difference in weight loss (p = 0.041) between participants in the intervention (-1.5 kg (0.5)) and control (0.11 kg (0.6)) groups. There was a marginally significant difference (p = 0.067) in percent body fat (-0.4% (0.8) v 1.4% (0.5)) between the intervention and control groups, respectively. Greater number of text messages sent was positively associated with percent body fat loss (r = -0.26, p = 0.026). The participants reported high satisfaction with the text messages. Conclusions: Automated text messages were well-received by the participants, suggesting that more enhanced mHealth technologies are a viable avenue for interventions targeting African Americans. Clinical Trial: The study is registered in clinicaltrials.gov [NCT02863887].

  • Background: Telecoaching approaches can enhance physical activity (PA) in patients with COPD. However, effectiveness is likely to be influenced by intervention specific characteristics. Objective: To assess the fidelity, feasibility, acceptability and appropriateness of a complex PA telecoaching intervention from both patient and coach perspectives and link these to the effectiveness of the intervention. Methods: We conducted a mixed methods study based on the intervention group (n=171) included in an (effective) 12-week PA telecoaching intervention. This semi-automated telecoaching intervention consisted of a stepcounter and a smartphone application. 1) Fidelity was assessed via adherence with smartphone and stepcounter which was derived from application data. 2) Acceptability and appropriateness of the intervention were evaluated by a project-tailored user-experience questionnaire. 3) Intervention feasibility was investigated via analyzing duration and frequency of every contact between the coach and the patient. 4) Fidelity and feasibility were linked to objectively measured change in PA. Results: 1) Fidelity: Patients wore the step counter for a median [p25-p75] 6.3 [5.9-6.8] days/week, which did not change over time (p=0.98). The smartphone interface was used less frequently and adherence of all daily tasks decreased significantly over time (p<0.001). 2) Acceptability and appropriateness: The intervention was well accepted with 89.3% (142/159) of patients indicating that they enjoyed taking part. Patients who completed the intervention (93.0%, 159/171) rated the usefulness of the step counter (10 [8-10] out of 10) and the contacts with the coach (9 [7 to 10] out of 10) as the most crucial parts of the intervention. 3) Intervention feasibility: The total contact time per patient was 50 [30-95] minutes, accumulated during 6 [4-9] contacts. 4) Association with the effectiveness of intervention: Patients needing more contact time had a smaller increase in PA: mean ± SD Δ step count 193±2375 steps/day, 907±2306 steps/day and 1489±2310 steps/day in high, medium and low contact time tertiles respectively; p-for-trend=0.01). Adherence with the different components of the intervention per se was not associated with change in step count in the total group (p=0.63). Conclusions: The 12 weeks semi-automated PA telecoaching intervention was well accepted and feasible for patients with COPD and their coaches. Adherence with the step counter was excellent, while adherence with the smartphone tasks was lower and decreased over time. Over the 12 weeks of coaching, patients required a median of 50 minutes of contact time with the coaches. Patients with more need for contact experienced less PA benefits. The primary treatment goal of these patients should shift from promoting PA towards directing them into more supervised programs (e.g. pulmonary rehabilitation). Clinical Trial: NCT02158065 (clinicaltrials.gov)

  • Background: Gamification is a promising strategy to increase engagement and effectiveness of online mental health interventions by enhancing motivation. However, as most studies focus on the longer term effects of gamification (e.g. effectiveness or adherence at the end of the intervention period), there is limited insight in how gamification may enhance motivation. Research implies that gamification has a direct impact at the time of use of the intervention which changes the experience of the users and thereby motivated users. However, it is unclear what this direct impact of gamification might be and how it can be measured. Objective: The goal of this study was to explore the direct impact of gamification in terms of creating a positive and meaningful experience and thereby gain more insight how gamification may enhance motivation. Methods: A pilot (n=20) and a real-life (n=76) randomized between-groups experiment has been carried out where participants used a gamified or non-gamified version of the same online wellbeing intervention in a single session. Participants (64% female, mean age 23 years) were asked to use the intervention in one session for research purposes. Gamification elements included a map as visualization of the different lessons, a virtual guide and badges. Afterwards, positive emotions, enjoyment, involvement, flow, overall satisfaction and usability were measured. Results: The pilot experiment showed no differences between the gamified and non-gamified intervention. However, in the real-life experiment, participants in the gamified intervention scored higher on involvement (P = .023), flow (P = .049) and the emotions ‘interest’ (P = .033) and ‘inspiration’ (P = .009). Conclusions: When participants used the intervention in a real-life setting, the gamified intervention seemed to create a more meaningful experience for its users, but not necessarily a more positive experience. However, this impact was only seen in this real-life setting. Concluding, we cannot say that gamification ‘works’, but that the design of an intervention, in this case gamification, can have an impact on how participants experience the intervention. The design may make the intervention more meaningful and relevant to the participants, but it may well be that this design needs to be different for different people in different settings. Future research should investigate how to match the design of an intervention to the setting, motivation and preferences of participants.

  • Prevalence, Features, and Subtypes of Asthma and COPD Overlap (ACO) Patients in the US

    Date Submitted: Jan 24, 2018
    Open Peer Review Period: Jan 25, 2018 - Mar 22, 2018

    Background: Although asthma and chronic obstructive pulmonary disease (COPD) are clinically distinct diseases, they represent biologically diverse and overlapping clinical entities. Asthma–COPD overlap (ACO) is characterized by persistent airflow limitation consistent with COPD, together with several distinguishing features of asthma. Better characterization and more accurate diagnosis will help in in the management of ACO, and in the development of better preventive public health strategies to decrease the impact of this clinical entity. Objective: To describe patient characteristics and estimate prevalence, healthcare utilization and costs of asthma-chronic obstructive pulmonary disease overlap (ACO) using claims-based diagnoses confirmed with medical record information. Methods: Eligible patients were commercial US health plan enrolees, ≥40 years; had asthma, COPD, or ACO; ≥3 prescription fills for asthma/COPD medications; and ≥2 spirometry tests. Records for a random sample of 5,000 patients with ACO were reviewed to validate claims-based diagnoses. Results: Estimated ACO prevalence was 6% among 183,521 study patients. In claims-based cohorts, comorbidity burden for ACO was greater vs asthma but similar to COPD cohorts. Medication utilization was higher in ACO vs asthma and COPD. Mean total healthcare costs were significantly higher for ACO vs asthma but similar to COPD. In confirmed diagnoses cohorts, mean total healthcare costs (medical plus pharmacy) were lower for ACO vs COPD but similar to asthma ($20,035, P=.56). Smoking history was higher in ACO (88%) vs asthma cohorts (55%), but similar to COPD (81%). Conclusions: ACO had more comorbidities, medication utilization, and costs than patients with asthma or COPD but differences were not seen after confirmation with medical records.

  • Background: Guiding and monitoring postoperative recovery and resumption of activities are usually not provided to patients after discharge from the hospital. Therefore a perioperative eHealth intervention ('ikherstel'-intervention or ‘I recover’-intervention) was developed to empower gynecological patients during the perioperative period. This eHealth intervention requires a need for further development for patients who will undergo various types of general surgical and gynecological procedures. Objective: To further develop the ‘ikherstel’ eHealth intervention to fit a broader patient population. Methods: The Intervention Mapping protocol was used to guide further development of the ‘ikherstel’-intervention. Firstly, patients’ needs were identified using i) the information of a process evaluation of the earlier performed ‘ikherstel’-study; ii) a review of the literature; iii) a survey study; and iv) focus group discussions among stakeholders. Next, program and change-objectives were defined. Thirdly, behavior change theories and practical tools were selected for the intervention program. Finally, an implementation and evaluation plan was developed. Results: The outcome for an effective eHealth intervention tool for patients recovering from abdominal general surgical and gynecological procedures was redefined as ‘achieving earlier recovery including return to normal activities and work’. The Attitude-Social influence-self-Efficacy model was used as a theoretical framework to transform personal and external determinants into change-objectives of personal behavior. The knowledge gathered in the needs assessment and using the theoretical framework in the preparatory steps of the Intervention Mapping protocol resulted in additional tools. A mobile application, an activity tracker and an eConsult will be incorporated in the further developed eHealth intervention. This intervention will be evaluated in a multicenter single blinded randomized controlled trial with 18 departments in 11 participating hospitals in the Netherlands. Conclusions: The Intervention Mapping protocol provided a systematic, transparent and valuable framework for the further development and evaluation of the 'ikherstel'-intervention. Clinical Trial: NTR5686.

  • Background: Background: The use of web/smartphone-based applications for tracking of health indicators has increased greatly. However, provider perceptions of consumer grade devices has not been widely explored. Objective: Objective: The purpose of this study was to determine primary care physicians’ and advance practice registered nurses’ (APRNs) perceptions of consumer-grade sensor devices and Web/smartphone-based applications (apps) that allow patients to track physical activity, diet, and sleep. Methods: Methods: We conducted a cross-sectional mailed survey with a random sample of 300 primary care physicians and 300 APRNs from Michigan. Provider use and recommendation of these types of technologies, and perceptions of benefits and barriers to patient use for physical activity, diet, and sleep tracking, were key outcomes assessed. Results: Results: The majority of the respondents (n=189, response rate = 33.6%) were APRNs (56.6%). Almost half of the sample (49.2%) owned or used behavioral tracking technologies. Providers found these technologies to be helpful in clinical encounters, they trusted the data, perceived their patients to be interested in them and did not have concerns over the privacy of the data. However, the providers did perceive patient barriers to using these technologies. Additionally, those that owned or used these technologies were up to 6.5 times more likely to recommend them to their patients. Conclusions: Conclusions: Our study demonstrates that many providers perceived benefits for their patients to use these technologies, including improved communication. Providers’ concerns included their patients’ access and the usability of these technologies. Providers who encountered data from these technologies during patient visits generally perceive this to be helpful. We additionally discuss the barriers perceived by the providers and offer suggestions and future research to realize the potential benefits to using these data in clinical encounters.

  • What’s Being Used, and Who’s Using it? Barriers to the Adoption of Smartphone Patient Experience Surveys

    Date Submitted: Jan 24, 2018
    Open Peer Review Period: Jan 25, 2018 - Mar 22, 2018

    Background: Smartphones are positioned to transform the way healthcare services gather patient experience data through advanced survey applications, which we call SmartSurveys. In comparison to traditional methods of survey data capture, smartphone sensing applications have the capacity to elicit multi-dimensional, in-situ user experience data in real-time with unprecedented detail, responsiveness, and accuracy. Objective: To explore the context and circumstances under which patients are willing to use their smartphones to share data on their service experiences. Methods: We conducted in-person, semi-structured interviews (N=24) with smartphone owners in order to capture their experiences, perceptions and attitudes towards SmartSurveys Results: Analysis examining perceived risk revealed few barriers to use, however a subsequent thematic analysis revealed major barriers to adoption: the identity of recipients, reliability of the communication channel, and potential for loss of agency. The results demonstrate that the classical dimensions of perceived risk raised minimal concerns for participating smartphone users. Instead, they considered the doctor-patient relationship, reliability of the communication channel, and the risk of losing information agency as determinants for SmartSurveys use. Conclusions: Based on these findings, we provide recommendations for the design of SmartSurveys in practice, and suggest a need for privacy design tools for voluntary, health-related technologies.

  • Background: Geosocial networking (GSN) applications (apps) have made sexual partner-seeking easier for MSM, raising both challenges and opportunities for HIV/STI prevention and research. Most studies on MSM GSN app use have been conducted in large urban areas, despite research indicating that similar patterns of online- and app-based sex-seeking occur among MSM in rural and mid-sized cities. Objective: To examine the spatial distribution of GSN app usage and characterize areas with increasing numbers of partner-seeking MSM in a mid-sized city in the South. Methods: Data collection points (n=62) were spaced in two-mile increments along nine routes (112 miles) covering the county encompassing the city. At each point, staff logged into three different GSN apps to record the number of GSN app users within a one-mile radius. Data were collected separately during daytime (8am - 5pm) and nighttime (8pm - 12am) hours. Empirical Bayesian kriging was used to create a raster estimating the number of app users throughout the county. Raster values were summarized for each of the county's 208 Census block groups and used as the outcome measure (i.e., GSN app usage). Negative binomial regression and Wilcoxon signed rank sum tests were used to examine Census block group variables (i.e., median income, median age, etc.) associated with GSN app usage and temporal differences in app usage, respectively. Results: The number of GSN app users within a 1-mile radius of the data collection points ranged from 0-36 during daytime hours and 0-39 during nighttime hours. In adjusted analyses, Census block group median income and percent Hispanic ethnicity were negatively associated with GSN app usage for all three GSN apps and during daytime and nighttime hours. Population density and the presence of businesses were positively associated with GSN app usage for all three GSN apps and during daytime and nighttime hours. Conclusions: In this mid-sized city, GSN app usage was highest in areas that were more population-dense, lower income, and had more businesses. This research is an example of how GSN apps’ geospatial capabilities can be used to better understand patterns of virtual partner-seeking among MSM.

  • Background: Most food in the UK is purchased in supermarkets and many of these purchases are routinely tracked through supermarket loyalty card data. Using such data may be an effective way to develop remote public health interventions and to measure objectively their effectiveness at changing food purchasing behaviour. Objective: The FLICC study is a pilot randomised controlled trial of a digital behaviour change intervention that incorporates tailored feedback of previous purchases of ready meals and pizzas based on traffic light labelling. The control group received web-based information on traffic light labelling. This pilot trial aimed to collect data on recruitment and retention rates and to provide estimates of effect sizes for the primary outcome (healthiness of ready meals and pizzas purchased) to inform a larger trial. Methods: Participants were recruited via email from a list of loyalty card holders held by the participating supermarket. All food and drink purchases for the participants for the six months prior to recruitment, during the six week intervention period and during a twelve week wash out period were transferred to the research team by the participating supermarket. Healthiness of ready meal and pizzas was measured using a pre-developed scale based solely on the traffic light colours on the foods. Questionnaires were completed at recruitment, end of intervention and end of wash out to estimate the effect of the intervention on variables that mediate behaviour change (e.g. belief and intention formation). Results: We recruited 496 participants from an initial email to 50,000 people. Only 3 people withdrew from the study and purchase data were received for all other participants. 208 participants completed all three questionnaires. There was no difference in the healthiness of purchased ready meals and pizzas between the intervention and control arms either during the intervention period (P = 0.315) or at wash-out (P = 0.594). Conclusions: Whilst the FLICC study did not find evidence of an impact of the intervention on food purchasing behaviour, the unique methods used in this pilot trial are informative for future studies that plan to use supermarket loyalty card data in collaboration with supermarket partners. The experience of the trial showcases the possibilities and challenges associated with the use of loyalty card data in public health research. Clinical Trial: ISRCTN19316955

  • Optimizing gestational weight gain with the Eating4Two Smartphone App: A randomized control trial protocol

    Date Submitted: Jan 23, 2018
    Open Peer Review Period: Jan 25, 2018 - Mar 22, 2018

    Background: Background: Approximately 50% of women gain excessive weight in pregnancy. Optimizing gestational weight gain (GWG) is important for the short and long-term health of the childbearing woman and her baby. Despite this, there is no recommendation for routine weighing in pregnancy, and weight is a topic that many maternity care providers avoid. Resource intensive interventions have mainly targeted overweight and obese women with variable results. Few studies have examined the way that socio-economic status might influence the effectiveness or acceptability of an intervention to participants. Given the scale of the problem of maternal weight gain, maternity services will be unlikely to sustain resource intensive interventions, therefore innovative strategies are required to assist women to manage weight gain in pregnancy. Objective: The aim of this paper is to detail a protocol for a study into the use of a smartphone “App” to prevent excess GWG. Methods: This randomized controlled trial will randomize 1330 women to control or intervention groups in three regions representing different socioeconomic status. The intervention group will be provided with access to the “Eating4Two” smartphone App which provides nutrition and dietary information specifically tailored for pregnancy, advice on food serving sizes and a graph that illustrates women’s weight change in relation to the range recommended by the Institute of Medicine (IOM). Women will be encouraged to use the App to prompt conversations with their maternity care providers about weight gain in pregnancy. The control group will receive routine antenatal care. The primary aim of the trial is to examine the effectiveness of the “Eating4Two” smartphone App in assisting women of all BMI categories to optimize GWG. Secondary aims include childbirth outcomes for women in both groups, comparing their satisfaction with antenatal care and examining the way that relative advantage and disadvantage might influence engagement with and acceptability of the intervention. Results: Feasibility testing highlighted the inadequacy of the original recruitment strategy and the need to provide the App in both major platforms (Android and iOS). Smartphone technology may offer an effective alternative to resource intensive strategies for assisting women to optimize weight gain in pregnancy. Conclusions: Smartphone technology may offer an effective alternative to resource intensive strategies for assisting women to optimize weight gain in pregnancy. Clinical Trial: ACTRN12617000169347 (Australian and New Zealand Clinical Trials Registry). Registered 1/02/2017.

  • Background: Current practice guidelines emphasize the use of physical activity as the first-line treatment of knee osteoarthritis (OA); however, up to 90% of people with OA are inactive. Objective: To assess the efficacy of a technology-enabled counselling intervention for improving physical activity in people with either a physician confirmed diagnosis of knee OA, or having passed two validated criteria for early OA Methods: We conducted a proof-of-concept randomized controlled trial (RCT). The Immediate Group received a brief education session by a physical therapist (PT), a Fitbit® FlexTM, and 4 bi-weekly phone calls for activity counselling. The Delayed Group received the same intervention two months later. Participants were assessed at baseline (T0), and the end of 2 months (T1), 4 months (T2), and 6 months (T3). Outcomes included: 1) mean time on moderate/vigorous physical activity [MVPA >3 METS (3+), primary outcome]; 2) mean time on MVPA >4 METS (4+); 3) mean daily steps; 4) mean time on sedentary activities; 5) Knee Injury and OA Outcome Score (KOOS); 6) Partners in Health Scale. Mixed effects repeated measures analysis of variance was used to assess 5 planned contrasts of changes in outcome measures over measurement periods. The 5 contrasts were: 1) Immediate T1–T0 vs. Delayed T1–T0; 2) Delayed T2–T1 vs. Delayed T1–T0; 3) Average of Contrast 1 and Contrast 2; 4) Immediate T1–T0 vs. Delayed T2–T1; 5) Average of Immediate T2–T1 and Delayed T3–T2. The first three contrasts estimate the between-group effects. The latter two contrasts estimate the effect of the 2-month intervention delay on outcomes. Results: We recruited 61 participants (Immediate: n=30; Delayed: n=31). Both groups were similar in age (Immediate: 61.3 (SD 9.4) years; Delayed: 62.1 (8.5) years] and body mass index [Immediate: 29.2 (5.5); Delayed: 29.2 (4.8)]. Contrast analyses revealed significant between-group effects in MVPA 3+ (Contrast 1 coefficient: 26.6, 95% CI 4.0, 49.1, p=0.02; Contrast 3 coefficient: 26.0, 95% CI 3.1, 49.0, p=0.03), daily steps (Contrast 1 coefficient: 1,699.2, 95% CI 349.0, 3,049.4, p=0.02; Contrast 2 coefficient: 1,601.8, 95% CI 38.7, 3,164.9, p=0.045; Contrast 3 coefficient: 1,650.5, 95% CI 332.3, 2,968.7; p=0.02); KOOS Activity of Daily Living (ADL) subscale (Contrast 1 coefficient: 6.9, 95% CI 0.1, 13.7, p=0.047; Contrast 3 coefficient: 7.2, 95% CI 0.8, 13.6, p=0.03), and KOOS Quality of Life (QOL) subscale (Contrast 1 coefficient: 7.4, 95% CI 0.0, 14.7, p=0.049; Contrast 3 coefficient: 7.3, 95% CI 0.1, 14.6, p=0.048). We found no significant effect in any outcome measures due to the 2-month delay of the intervention. Conclusions: Our counselling program improved MVPA 3+, daily steps, ADL and QOL in people with knee OA. The finding is important since an active lifestyle is an important component of successful self-management. Clinical Trial: NCT02315664

  • Background: Assessment of the wheelchair and seating needs of people with complex disabilities requires health professionals to have advanced training and experience, creating difficulties in accessing such specialist services for wheelchair users living outside of metropolitan areas. Use of telehealth technologies to enable remote assessment has been suggested as one way to improve accessibility to specialist assessment and reduce the cost of services, however no synthesis of this research is currently available to guide practice or research development. Objective: This scoping review synthesizes research to date on the effects and processes of telehealth enabled wheelchair and seating assessment and the perceptions of wheelchair users and healthcare providers of this mode of service delivery. Methods: A systematic search and scoping review of peer-reviewed publications and theses was undertaken. Five databases were searched including CINAHL, Embase, Medline, Psychinfo and Scopus followed by hand searching of reference lists and forward citations. Data extraction and synthesis was organised around each research objective. Results: From an initial identification of 1801 publications, 9 studies published in 13 documents met the inclusion criteria. Study quality and study design varied considerably. The effect of telehealth compared to in-person assessment was insignificant in all studies that compared effectiveness (n=2) in relation to wheelchair-user and assessor rated variables. Telehealth assessment improved accessibility for some wheelchair users (n=1). However the process of telehealth that was applied to wheelchair assessment was inadequately described in all studies. Qualitative studies (n= 2) revealed that wheelchair-users appraised telehealth wheelchair assessment more positively than assessors. Non-specialist, assisting assessors appraised telehealth assessment more positively than specialist assessors. It appeared that each stakeholder group appraised telehealth based on different criteria including accessibility, professional supportiveness and technical accuracy. No studies examined funder views. Conclusions: Preliminary research suggests telehealth wheelchair assessment may be as effective as in-person assessment. Furthermore, this approach is viewed favorably by wheelchair users and non-specialist assessors, while expert assessors have some hesitations. The literature to date has not provided adequate descriptions of the process undertaken during remote wheelchair assessment. The process of remote wheelchair assessment requires clarification to further understandings of how telehealth can be used for greatest effect in this area.

  • Server-focused security assessment of mHealth apps for popular mobile platforms

    Date Submitted: Jan 22, 2018
    Open Peer Review Period: Jan 22, 2018 - Mar 19, 2018

    Background: The importance of mobile apps is growing. Independently from the technologies used, mobile apps bring more and more functionality into the hands of users. In the health context, mobile apps play an important role providing information and services to patients, offering healthcare professionals with ways to monitor vital parameters or offer remote consultations to patients. Because of the inherent importance of confidentiality in the realm of healthcare, security is (or should be) a major concern for users and developers of mobile apps. Objective: The objectives of this study were as follows: (1) identification of relevant security concerns on the server side of mobile apps, (2) testing a subset of mobile apps regarding their vulnerability to those concerns, and (3) comparing the servers used by mHealth apps with servers used in all domains. Methods: Server-Security characteristics relevant to the security of mHealth apps were assessed, presented, and discussed. To evaluate servers, appropriate tools were discussed and selected. For the tests apps from the Android and iOS app stores were selected, tested and the results evaluated. Results: The 40 apps tested communicated with a total of 76 backend servers, 13% received non-A rating by SSL Labs. A chi-square test was conducted against the general number of servers receiving such ratings from SSL Pulse. It was found that tested servers from mHealth apps received significantly fewer non-A ratings (P < 0.001). A total of 8 apps (26%) of 31 (corrected for overlap between iOS and Android) were found using at least one server that received a non-A rating, endangering confidentiality, authenticity of the server and integrity of the data displayed. It was also found that a majority of apps used ad, tracking, or external content provider servers. Out of 31 unique apps, 19 (61%) used servers that received a non-A rating for servers facilitating such services. Conclusions: The results show, that while servers in the mHealth domain perform significantly better regarding their security, there are still severe problems with the configuration of some servers. The most severe problems observed can expose patient communication with healthcare professionals, be exploited to display false or harmful information to the user or used to send data to an app facilitating further damage on the device.

  • Trigger tool based automated adverse event detection in electronic health records: a systematic review

    Date Submitted: Jan 22, 2018
    Open Peer Review Period: Jan 22, 2018 - Mar 19, 2018

    Background: Adverse events (AEs) in healthcare entail substantial burdens to healthcare systems, institutions, and patients. Retrospective trigger tools are often manually applied to detect AEs, although automated approaches using electronic health records (EHRs) may offer real-time AE detection, allowing timely corrective interventions. Objective: This systematic review aimed to describe current study methods and challenges regarding the use of automatic trigger tool-based AE detection methods in EHRs. In addition, we aimed to appraise the applied studies’ designs and to synthesize estimates of AE prevalence and diagnostic test accuracy (DTA) of automatic detection methods, using manual trigger tool as a reference standard. Methods: PubMed, Embase, CINAHL, and the Cochrane Library were queried. We included observational studies applying trigger tools in acute care settings, and excluded studies using non-hospital and outpatient settings. Eligible articles were divided into DTA studies and prevalence studies. We derived the study prevalence and estimates for the positive predictive value (PPV). We assessed bias risks and applicability concerns using QUADAS-2 for DTA studies and an in-house developed tool for prevalence studies. Results: Eleven studies met all criteria: two concerned DTA, nine prevalence. We judged several studies to be at high bias risks for their automated detection method, definition of outcomes, and type of statistical analyses. Across all the eleven studies, AE prevalence ranged from 0 to 17.9%, with a median of 0.8%. The PPV of all triggers to detect AEs ranged from 0% to 100% across studies, with a median of 40%. Some triggers had wide ranging PPV values: 1) in six studies, hypoglycaemia had a PPV ranging from 15.8% to 60%; 2) in five studies, naloxone had a PPV from 20% to 91%; 3) in four studies, flumazenil had a PPV ranging from 38.9% to 83.3%; and 4) in four studies, protamine had a PPV ranging from 0% to 60%. We were unable to determine the AE prevalence, PPV, preventability, and severity in 40.4%, 10.5%, 71.1%, and 68.4% of the studies, respectively. These studies did not report the overall number of records analysed, triggers, or AEs; or the studies did not conduct the analysis. Conclusions: We observed broad inter-study variation in reported AE prevalence and PPV. The lack of sufficiently described methods led to difficulties regarding interpretation. To improve quality, we see the need for a set of recommendations to endorse optimal use of research designs and adequate reporting of future AE detection studies.

  • Perceived Attitudes About Substance Use in Anonymous Social Media Posts Near College Campuses

    Date Submitted: Jan 21, 2018
    Open Peer Review Period: Jan 22, 2018 - Mar 19, 2018

    Background: Substance use is a major issue for adolescents and young adults, particularly college students. With the importance of peer influence, as well as the ubiquitous use of social media among these age groups, it is important to assess what about substance use is discussed on social media. One particular mobile application (Yik Yak) allowed users to post anonymously to nearby persons, often in areas with close proximity to major colleges and universities. Objective: The current study describes social media discussions that occurred near college campuses and involved substances. The authors hypothesized that posts about one’s own substance use would display a more positive attitude toward the substance mentioned, compared to posts about other’s use. Methods: Four hundred and ninety-three posts about drugs and alcohol on Yik Yak were reviewed and coded for their content, as well as the poster’s attitude about the substance. Results: Alcohol (226/493; 45.8%), marijuana (206/493; 41.8%), and tobacco (67/493; 13%) were the most frequently mentioned substances. Posts about use (442/493) were generally positive toward the substance mentioned (262/442; 59.3%), unless the post was about abstinence. Additionally, posts that commented on the substance use of others tended to be less positive (18/92; 19.6% positive) compared to posts about one’s own use (132/202; 65.3% positive). Conclusions: This study provides a description of anonymous discussions on or near college campuses about drugs and alcohol, which serves as an example of data that can be examined from social media sites for further research and prevention campaigns.

  • Background: Primary care needs to be patient-centred, integrated and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing problem of polypharmacy, there is increasing attention on how and when medication-related decisions should be coordinated across multi-disciplinary care teams. Improved knowledge on how integrated EHRs can support interprofessional shared decision-making for medication therapy management is necessary to continue to improve patient care. Objective: This objective of this study was to examine how physicians and pharmacists understand and communicate patient-focused medication information with each other and how this knowledge can influence the design of electronic health records. Methods: This study is part of a broader cross-Canada study between patients and health care providers around how health-related decisions are made and communicated. We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Semi-structured interviews were conducted with physician and pharmacists. A modified version of the Multidisciplinary Framework Method was used to analyze the data. Results: Data was collected at 19 pharmacies and 9 medical clinics and we identified six main themes from 34 health care professionals. Interprofessional Shared Decision Making was not occurring and clinicians made decisions based on their understanding of the patient. Physicians and pharmacists reported indirect Communication, incomplete Information specifically missing insight into indication and adherence, and misaligned Processes of Care further compounded by electronic health records not designed to facilitate collaboration. Scope of Practice examined professional and workplace boundaries for pharmacists and physicians that were internally and externally imposed. Physicians decided on the degree of the Physician/Pharmacist Relationship which was often predicated by co-location. Conclusions: When managing medications, there was limited communication and collaboration between primary care providers and pharmacists. Pharmacists were missing key information around reason for use, and physicians required accurate information around adherence. EHRs are a potential tool to help clinicians communicate information to resolve this issue. EHRs need to be designed to facilitate interprofessional medication management, so that pharmacists and physicians move beyond task-based work toward a collaborative approach Clinical Trial: n/a

  • Background: Peer-to-peer online support groups and the discussion forums in these groups can help patients by providing opportunities for increasing their empowerment. Most previous research on online empowerment and online social support uses qualitative methods, or questionnaires to gain insight into the dynamics of online empowerment processes. Objective: The overall goal of this study was to analyze the presence of the empowering processes in the online communication of people affected by cancer, using text mining techniques. Use of these relatively new methods enable to study social processes such as empowerment on large scale and with unsolicited data, avoiding unintended biases caused by research tools. Methods: The sample consisted of 5534 messages in 1708 threads by 2071 by users of a forum for cancer patients and their relatives. Supervised and unsupervised text mining techniques were used to explore the online communication of the users. Supervised text mining techniques were applied to operationalize empowerment: a random subsample of 2051 messages in the forum was manually labeled with five empowerment processes (sharing narrative, asking a question, providing information, emotional support, reference to information), using a coding scheme based on knowledge from previous research. Machine learning classifiers (Linear Support Vector Classification and Logistic regression) were then trained on the content of the messages with their manually assigned labels and the remainder of the sample was automatically labeled with empowerment processes using the generated model. For the unsupervised part, the messages in the sample were automatically labeled with categories from the Linguistic Inquiry and Word Count (LIWC). Subsequently, the supervised and unsupervised data were studied in conjunction. Empowerment was studied in relation to the intensity of online participation in relation to the LIWC categories. Results: The precision of the automatic labeling was 85.6%, which was considered to be sufficient for automatically labeling the complete corpus and doing further analyses on the labeled data. 62.9% of the messages contained a narrative, 23.8% a question, and 27.5% informational support. Emotional support and references to external sources were less frequent. Users with more posts more often referred to an external source, provided informational support, and emotional support (Kendall τ > 0.2, p < 0.001) and less often shared narratives (Kendall τ = -0.297, p < 0.001). A number of LIWC categories are significant predictors for the empowerment processes. Words expressing assent (‘ok’, ‘yes’) and emotional processes (expressions of feelings) are significant positive predictors for emotional support (p = 0.002). Conclusions: Empowerment processes are associated with intensity of online use. The relation between linguistic analyses and empowerment processes indicates that empowerment processes can be identified from the occurrences of specific linguistic cues.

  • Matching openEHR specifications and General Data Protection Regulation requirements

    Date Submitted: Jan 15, 2018
    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: The concerns about privacy and personal data protection resulted in reforms of the existing legislation in European Union (EU). The General Data Protection Regulation (GDPR) aims to reform the existing directive on the topic of personal data protection of the European Union citizens, with a strong emphasis on more control of the citizens over their data and in the establishment of rules for the processing of personal data. OpenEHR is a standard that embodies many principles of interoperable and secure software for electronic health records, and has been advocated as the best approach for the development of HIS. Objective: This work aims to understand to what extent the openEHR standard can help in the compliance to the GDPR requirements. Methods: A list of requirements for a Hospital Information Systems (HIS) to support the compliance with GDPR, and also a list of the openEHR specifications were made. The requirements were categorized and compared with the specifications by specialists on openEHR and GDPR. Results: 53 GDPR requirements, and 8 openEHR specification items were identified. The openEHR specifications matched 32% (n=17) GDPR requirements. All the openEHR specifications were aligned with GDPR requirements. Conclusions: This work reinforces the openEHR initial claim, showing that openEHR has a good fit also when privacy and data protection are incorporated by design in the system development. By using an openEHR based EHR the institutions are closer to becoming compliant with GDPR while safeguarding the medical data.

  • Clinical Cybersecurity Training Through Novel High Fidelity Simulations

    Date Submitted: Jan 15, 2018
    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: Cybersecurity risks in healthcare systems have traditionally been measured in data breaches of protected health information but compromised medical devices and critical medical infrastructure raises questions about the risks of disrupted patient care. The increasing prevalence of these connected medical devices and systems implies that these risks are growing. Objective: This paper details the development and execution of three novel high fidelity clinical simulations designed to teach clinicians to recognize, treat, and prevent patient harm from vulnerable medical devices. Methods: Clinical simulations were developed which incorporated patient care scenarios with hacked medical devices based on previously researched security vulnerabilities. Results: Clinician participants universally failed to recognize the etiology of their patient’s pathology as being the result of a compromised device. Conclusions: Simulation can be a useful tool in educating clinicians in this new, critically important patient safety space.

  • A Survey of Privacy-Preserving Techniques for Reuse of Distributed Health Data

    Date Submitted: Jan 15, 2018
    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: Large amounts of detailed electronic health data are being collected. Reuse of these data has enormous potential for scientific discoveries that enables the improvement of healthcare systems’ effectiveness, efficiency, and quality of care. However, health data reuse should protect the privacy interests of the stakeholders (i.e., patients and healthcare providers) and promote public good through research. This is particularly challenging when the data are distributed across several data custodians. Objective: This paper aims to give an overall overview of existing privacy-preserving techniques for distributed data reuse and their practical applications. Methods: We searched for review papers that are focused on privacy-preserving techniques for different stages of distributed data reuse, such as creating dataset that satisfy a given criteria, analyzing the dataset, and releasing statistical results. We analyzed the identified techniques in terms of privacy, data utility, efficiency, and scalability. Practical uses of the techniques are also discussed when there is actual use. Results: Several privacy-preserving data reuse techniques have been identified. The techniques are developed for different stages of distributed data reuse based on de-identification, secure multi-party computation (SMC), or a combination of these two building blocks. Different combinations of the techniques need to be applied for the whole stages of distributed data reuse. Some of the surveyed techniques protect the privacy of data custodians in addition to individuals. The main challenge for de-identification based data reuse techniques is making a balance between utility and privacy. Whereas, efficiency and scalability are the main challenges for SMC based techniques. Conclusions: Enormous progress has been made towards making privacy-preserving reuse of distributed data possible. However, there are only few practical uses of the available techniques. the problem of distributed data reuse also requires governance, legal, and ethical frameworks, as well as the technical solutions. It is not clear whether consent, data-use agreement, and ethics review are required for practical uses of the techniques.

  • Background: If purposefully designed, patient information can support patients in making well-founded decisions about their care. The study was initiated to improve the online information about whiplash injuries at the patient information portal of the Swedish government. Objective: The aim is to describe how patients and relatives perceive the national online information about whiplash injuries. Methods: Five interviews were made with patients (n = 10) who had had a whiplash injury and with relatives (n = 3) of such patients. Interviews were held, until no more categories appeared and we estimated that saturation was reached. The interviews were taped, transcribed verbatim and analysed by means of conventional content analysis. Results: Two themes emerged from the latent content analysis: on the one hand, a confidence and trust in the public health care system (hereinafter health care), and on the other, a disappointment with health care encounters. Conclusions: We found that taking part of the online information had caused distress to most of the study participants because of discrepancy between the sender’s authority and deficient information. The online information on whiplash injuries may greatly impact patients’ care decisions as well as their physical, mental and social wellbeing. We would recommend that patient information about whiplash injuries is made highly informative, with less emphasis on psychology and a patient wide perspective on pathophysiology, prognosis and treatment.

  • Background: Despite being an important cardiovascular risk factor, hypertension (HT) has low control levels worldwide. Computerized clinical decision support systems (CDSS) might be effective in reducing blood pressure, with a potential impact in reducing cardiovascular risk. Objective: To evaluate the feasibility and usability of a CDSS, named TeleHAS, in the care of patients with HT in the context of primary care setting in a middle income country, as well as the physician’s satisfaction with its use. Methods: The TeleHAS application consists of a platform integrating clinical and laboratory data of a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of HT and cardiovascular risk. Ten family physicians of different primary care units in Montes Claros city, Brazil, were randomly selected to use the application for the care of hypertensive patients for 6 months. After 3 months, the feasibility and usability of the CDSS in the routine care of the health teams was evaluated through standardized questionnaire and semi-structured interviews. After 6 months, another questionnaire and semi-structured interviews were applied to test the satisfaction of the physicians with the application. Results: Throughout the study, clinicians registered 535 patients with HT, at an average of 1.24 consultations per patient. Women accounted for 80% of participant doctors, median age 31.5 years (interquartile range 27-59 years). As for feasibility, 100% of medical users claimed it is possible to use the application in the primary care setting and for 80% of them it is easy to incorporate its use in the daily routine and home visits. Nevertheless, 70% of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated the TeleHAS as good (80% of users), with easy filling blanks and friendly interface (100%) and with the potential to improve patients’ treatment (100%). Ninety percent of physicians had access to new knowledge about cardiovascular risk and HT through the application recommendations and found it useful to promote prevention and optimize treatment. Conclusions: In this study, a CDSS developed to assist the management of patients with HT was applicable in the context of primary health care setting in a middle income country, with good user’s satisfaction and potential to improve adherence to evidence-based practices.

  • The Complexity of Mental Health App Privacy Policies: A Potential Barrier to Privacy

    Date Submitted: Jan 17, 2018
    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: In 2017, the Indian Supreme Court ruled that privacy is a fundamental right of every citizen. While smartphone apps have the potential to help people with non-communicable diseases, they often contain complex privacy policies which consumers may not understand. This complexity may impede consumers’ ability to make decisions regarding privacy, a critical issue due to the stigma of mental illness. Objective: Our objective is to determine whether mental health apps have more complex privacy policies than diabetes apps. Methods: The study utilizes privacy policies extracted from apps. Apps pertained to diabetes or mental health, and were of Indian origin. Privacy policy reading complexity was compared between the two types of apps using a series of fifteen readability measures. The universe of applicable apps on the Google Play store, as viewed between May and June 2017, was considered. The measures of readability were compared using Chi-square tests. Results: No significant difference was found between the privacy policy readability of the diabetes apps versus the mental health apps for each of the measures considered. As the mean Flesch-Kincaid Grade Level was 13.9 for diabetes apps and 13.6 for mental health apps, the mean policy was written at a college level. Privacy policies in the 25th percentile of complexity were also written at a college level for both types of apps. Conclusions: Privacy policy complexity may be a barrier for informed decision making. Clinical Trial: NA

  • Background: The development and evaluation of digital interventions aimed at preventing or treating substance use related problems and disorders is a rapidly growing field. Previous reviews of such interventions reveal a large and complex picture with regard to targeted users, utilization, and efficacy. Objective: The objective of this review is to investigate the feasibilty and effects of the subset of digital interventions developed specifically for digital platforms, that are focused on supporting people in recovery from Substance Use Disorders, helping them to achieve their substance use goals, and to develop a more satisfying life situation. This group of interventions has not been targeted in prior reviews. Methods: The review is based on a systematic search in Pubmed, Embase, PsychInfo and Cochrane Library. Of the 1142 identified papers, 714 were first excluded as obviously not relevant. Of the remaining papers, 21 were found to be previous reviews, 269 was on interventions aimed at reducing hazardous alcohol or cannabis use and 94 was on digitized versions of treatment interventions that were not developed originally for digital platforms. The remaining 44 papers were all read in full and systematically scored by both authors. Results: The 44 papers cover 29 unique interventions, of which 34 have been published after 2013. Based on the number of features or modules, the interventions were categorized as simple or complex. Eleven of the 19 simple interventions and six of the 10 complex interventions had been studied with quantitative controlled methodologies. Fourteen of the 19 simple interventions were integrated in other treatment or support systems, mainly delivered as smartphone apps, while six of the ten complex interventions were designed as “stand alone” interventions, most often delivered on a platform combining desktop/web and smartphone technologies. The interventions were generally easy to implement, but the implementation of the complex interventions was found to be more dependent on sustained organizational support. 70-90% of the participants found the interventions to be useful and easy to use. The rates of sustained use were also generally high, except for simple interventions with an open internet-based recruitment and some information and education modules of the complex interventions. Across all interventions, slightly more than half (55%) of the studies with control groups generated positive findings on one or more substance use outcomes, with 54% of the interventions also found to be efficacious in one or more studies. In the positive studies, effects were typically in the small to moderate range, with a few studies yielding larger effects. Due to stronger control conditions, simple interventions were less likely to produce positive effects. Conclusions: The digital interventions included in this review are in general feasible but are not consistently effective in helping people in recovery from SUD reduce their substance use or achieving other recovery goals.

  • Background: Inflammatory bowel disease (IBD) affects many patients of reproductive age. Most IBD medications are safe to use during pregnancy and breastfeeding, but despite this, observational studies note that women, particularly those with Crohn’s Disease, have higher rates of voluntary childlessness due to concerns surrounding medication side effects, passing the disease to their offspring, fear of infertility and advice given by treating physician. Moreover, many women perceive medications to be unsafe during pregnancy. We employ social listening of online forums and social media to explore how patients with IBD understand, discuss, and act on the perceived risks and benefits associated with taking IBD medications during pregnancy and breastfeeding. Objective: The objective of this study was to gain a more thorough understanding of how individuals taking IBD medications during key reproductive periods make decisions about their medications to inform clinical practice. Having a better understanding about why patients stop or refuse to take certain medications during key reproductive periods may allow clinicians to address specific beliefs and attitudes during office visits. Methods: We collected posts from 3,000 social media sites posted over a 3-year period and analyzed posts using qualitative content analysis. After an initial read-through of the posts, we created a preliminary codebook using inductive methods and grounded the codes in the data. We created new codes as we continued to code the data and iteratively coded the posts, re-coding all posts with new codes as we constructed them. We then organized the codes into larger categories. Results: We identified 7 main themes in 1818 social media posts. Patients used social media to (1) seek advice about medication use related to reproductive health (N = 253, 14%); (2) express beliefs about the safety of IBD therapies (N = 135, 7%); (3) discuss personal experiences with medication use (N = 304, 17%); and (4) articulate fears and anxieties about the safety of IBD therapies (N = 210, 12%). Patients also discussed their (5) physician-patient relationships, (N=57, 3%), (6) concerns around infertility and IBD medications, (N = 316, 18%) and (7) IBD symptoms during and after pregnancy and breastfeeding periods (N = 206, 11%). Conclusions: Beliefs around medication safety play an important role in whether patients with IBD decide to take medications during pregnancy and breastfeeding. Increased provider education and better patient decision-making tools may help patients better understand the risks and benefits of medication use during pregnancy and breastfeeding.

  • Background: Background: Perfectionism can become a debilitating condition that may negatively impact functioning in multiple areas, including mental health. Prior research has indicated that Internet-based Cognitive Behavior Therapy (ICBT) can be beneficial, but few studies have included follow-up data. Objective: Objective: The current study explored the long-term benefits of ICBT with guided self-help, delivered as two separate randomized controlled trials conducted in Sweden and the United Kingdom (UK). Methods: Method: In total, 120 participants randomized to ICBT were included in both intention-to-treat and completer analyses, n = 78 (Swedish trial) and n = 62 (UK trial). Primary outcome measure was the Frost Multidimensional Perfectionism Scale, subscale Concern over Mistakes (FMPS CM). Secondary outcome measures varied between the trials and consisted of the Clinical Perfectionism Questionnaire (CPQ; both trials), the Patient Health Questionnaire – 9 Items (PHQ-9; Swedish trial), the Generalized Anxiety Disorder – 7 Items (GAD-7; Swedish trial), and the Depression Anxiety and Stress Scale – 21 Items (DASS-21; UK trial). Follow-up occurred after six months for the UK trial, and twelve months for the Swedish trial. Results: Results: Analysis of Covariance revealed a significant difference between pre-treatment and follow-up in both cases. Intention-to-treat within-group effect sizes Cohen’s d were 1.21 (Swedish trial), 95% Confidence Interval (CI) [0.86, 1.54], and 1.24 (UK trial), 95% CI [0.85, 1.62] for the FMPS CM. Furthermore, 29 (59.2%; Swedish trial) and 15 (42.9%; UK trial) of the participants met criteria for recovery on the FMPS CM. Significant improvements were also found for the CPQ, 1.32 (Swedish trial), 95% CI [0.97, 1.66], and 1.49 (UK trial), 95% CI [1.09, 1.88], the PHQ-9, 0.60, 95% CI [0.28, 0.92], the GAD-7, 0.67, 95% CI [0.34, 0.99], and the DASS-21, 0.50 [0.13, 0.85]. Conclusions: Conclusions: The results are promising for the use of ICBT as a way of targeting perfectionism, but the findings need to be replicated and include a comparison condition.

  • Show Me Health Plans: Dissemination of a Web-based Decision Aid for Health Insurance Plan Decisions

    Date Submitted: Jan 17, 2018
    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: The rate of uninsured has decreased dramatically since the passage of the Affordable Care Act. To make an informed decision, consumers need assistance to understand the advantages and disadvantages of health insurance plans and select a suitable plan. The Show Me Health Plans (SMHP) web-based decision support tool was developed to improve health insurance decision quality. In response to the promising effectiveness of SMHP in a randomized controlled trial (RCT) and the growing need for web-based health insurance decision support, the study team used expert recommendations for dissemination and implementation processes, engaged external stakeholders, and released the SMHP tool so that it was available to the general public. Objective: The purpose of this study was to examine public dissemination of the web-based SMHP tool in the state of Missouri, and to evaluate the impact of SMHP in its dissemination phase compared to the RCT. Methods: This study used a cross-sectional observational design. Dissemination phase users were compared with users in the RCT study across the same outcome measures. Time spent using SMHP tool, knowledge, importance rating of 9 health insurance features, and intended plan choice match with algorithm predictions were examined. Results: During the dissemination phase between November, 2016 and January, 2017, 10,180 users visited the SMHP tool. 1,069 users were included in analyses. Dissemination phase users were more likely to live outside St. Louis City or County (p < 0.001), were less likely to be below the federal poverty level (p<0.0001), and had a higher income (p=0.03). Tool users from St. Louis City or County had higher overall time spent on the SMHP tool than those from other Missouri counties (p=0.04); this association was not observed in the RCT. Total time spent on the tool was not correlated with knowledge scores. Knowledge was associated lower poverty levels (p=0.009). The users in RCT phase were more likely to select an insurance plan that match the tool’s algorithm recommendations (p <0.001) compared with the dissemination phase users. Conclusions: The study suggests that a higher income population may be more likely to seek information and online help when making a health insurance plan decision, and that tool users in the dissemination phase were more selective in the information they reviewed. This study provides an example of ways to disseminate and implement an empirically tested web-based decision aid tool. Disseminating web-based tools is feasible and may attract a large number of potential users, educate them on basic health insurance information, and make recommendations based on personal information and preference. However, those in the general public may differ in their demographics and use of web-based tools compared to participants in a research trial.

  • Effects of the Digital Transformation: Disturbances and Limitations Using Video Visits in Outpatient Care

    Date Submitted: Jan 17, 2018
    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilities. The study investigates effects of digital transformation, in this case how video visits in outpatient care change work processes and introduces new tasks, in order to further improve the concept of video visits. Objective: Through real-time, social interactional features of preparing for and conducting video visits, the study examines clinicians’ perceived limitations and disturbances, and how the conditions between patients and clinicians may change when using video visits instead of face-to-face meetings in outpatient care. Methods: Qualitative methods have been used including 14 observations of video visits at two different clinics and 14 followup interviews with clinicians. Transcriptions of interviews and field notes were thematically analysed, discussed and synthesised into themes. Results: Disturbances and limitations related to the technology were related to time; a flexibility to schedule the meeting unbound of place, frustrations when the other part was late for the scheduled meeting, and that more experienced users of video visits usually waited longer before logging in. They were also related to sound; problems getting the sound to work satisfactory during the video visits, and problems with the image. Disturbances and limitations related to the surroundings were related to both the patient’s and the clinician’s environment; the principle of video technology in itself may affect the experience and the content of the consultation, and the surrounding chosen changes the conditions for and reduces the participants’ field of view. Conclusions: We could see 1) a transformation of roles and responsibilities when turning from face-to-face meetings to video visits, 2) that video visits add new circumstances, with a risk of introducing disturbances and limitations, that in turn affects the content of the meeting, 3) that avoiding negative disturbances during a video visit, requires a sensibility from the clinician’s side as well as a trust in the patient’s judgement, 4) that both expected and unexpected disturbances and limitations during a video visit affect the clinician’s behaviour, feelings, the content of the meeting and how the clinician’s relate to the different components of the concept, and 5) that there is a change of roles introduced when conducting video visits, e.g., the clinician taking the first line support if both (s)he and the patient encounter problems with the technology.

  • Building a community knowledge commons for learning networks: The Learning Exchange

    Date Submitted: Jan 17, 2018
    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Learning Networks are distributed learning health systems that enable collaboration, at scale, to improve health and healthcare. A key requirement for such networks is having a way to create and share information and knowledge in furtherance of the work of the community. Objective: We describe a Learning Exchange - a bespoke, scalable knowledge management and exchange platform initially built and tested for improving pediatric inflammatory bowel disease outcomes in the ImproveCareNow (ICN) Network - and assess evidence of its acceptability, feasibility, and utility in facilitating creation and sharing of information in furtherance of the work of the community and as a model for other communities. Methods: The process of designing, prototyping and pilot testing utilized a combination of interaction design, quality improvement, and co-production methodologies in an iterative process. Results: The Learn Exchange has over 1000 users and supported sharing of resources across all care centers in ICN. Users reported that the Learning Exchange has facilitated their work and resulted in increased ability to find resources relevant to local information needs. Conclusions: The Learning Exchange is acceptable, feasible and useful as a knowledge management and exchange platform in service of the work of ICN. Experience with the ICN Learning Exchange suggests that the design principles are extensible to other chronic care Learning Networks.

  • Is the Patient Suited or Not? Clinicians’ Selection Criteria for Video Visits in OutPatient Care

    Date Submitted: Jan 17, 2018
    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilities. The study investigates effects of digital transformation, in this case how video visits in outpatient care change work processes and introduces new tasks. Objective: Through real-time, social interactional features of preparing for and conducting video visits, the study examines which patients the clinicians considered as suitable for video visits and why, in order to increase the value of these visits for further improvement of the concept video visits. Methods: Qualitative methods have been used including 14 observations of video visits at two different clinics and 14 follow-up interviews with clinicians. Transcriptions of interviews and field notes were thematically analysed, discussed and synthesised into themes. Results: From the interviews, 25 different arguments for selecting a specific patient/relative for video visits were identified. Analysing interviews and field notes also reviled not expressed reasons that played a part in the selection process. The expressed arguments, as well as the implicit reasons, of why a patient was given the opportunity of video visits, can be understood as selection criteria for helping clinicians in their decision of whom to offer video visits or not. The criteria identified in the collected data were divided into the three categories: The patient has the right conditions, Needs to practically facilitate the treatment, and Enabling the content of the treatment. Conclusions: Not all patients undergoing treatment programs should be offered video visits. When selecting patients it is important to consider if the patient has the right conditions, if there are needs to practically facilitate the treatment, and if there is a need to enable the content of the treatment. A set of criteria to be used in the selection process and a method for how and when to involve the patient in the decision is recommended to be developed.

  • mHealth Functionalities for HIV Care: Results from a Co-Design Process across Five European Clinical Sites

    Date Submitted: Jan 16, 2018
    Open Peer Review Period: Jan 16, 2018 - Mar 13, 2018

    Background: Despite advances in testing and treatment, HIV incidence rates within European countries are at best stable or else increasing. mHealth technology has been advocated to increase quality and cost-effectiveness of health services while dealing with growing patient numbers. However, studies suggested that mHealth applications are rarely adopted and often considered of low quality by users. Only a few studies (conducted in the US) have involved people living with HIV (PLWH) in the design of mHealth. Objective: The goal of this study was to facilitate a co-design process among PLWH and clinicians across five clinical sites in the European Union to inform the development of an mHealth platform to be integrated into clinical care pathways. We aimed to (1) elicit experiences of living with HIV and of working in HIV care, (2) identify mHealth functionalities that are considered useful for HIV care, and (3) identify potential benefits as well as concerns about mHealth. Methods: Between January and June 2016, 14 co-design workshops and 22 semi-structured interviews were conducted, involving 97 PLWH and 65 clinicians. Data were analysed thematically and iteratively, drawing on grounded theory techniques. Results: Findings were established into three thematic clusters: (1) ‘Approaching the mHealth platform’, (2) ‘Imagining the mHealth Platform’, and (3) ‘Anticipating the mHealth Platform’s Implications’. Co-design participants approached the mHealth platform with pre-existing concerns arising from their experiences of receiving or providing care. PLWH particularly addressed issues of stigma and questioned how mHealth could enable them to manage their HIV. Clinicians problematized the compatibility of mHealth with existing IT systems and questioned which patients should be targeted by mHealth. Imagining the potential of mHealth for HIV care, co-design participants suggested ‘medical functionalities’ (accessing test results, managing medicines and appointments, and digital communication channels), ‘social functionalities’ (peer-support network, international travel, etc.), and ‘general features’ (security and privacy, credibility, language, etc.). Co-design participants also anticipated potential implications of mHealth for self-management and the provision of care. Conclusions: Our approach to co-design enabled us to facilitate early engagement in the mHealth platform enabling patient and clinician feedback to become embedded in the development process at a pre-prototype phase. Although the technologies in question were not yet present, understanding how users approach, imagine and anticipate technology formed an important source of knowledge and proved highly significant within the technology design and development process. Clinical Trial: -

  • Background: Adolescent and young adult (AYA) oncology and hematology is a developing field of medicine, focusing on a population that faces many challenges throughout medical treatment and beyond. Mobile health (mHealth) interventions provide exciting new opportunities for improvement of health-related quality of life (HRQoL) in AYA cancer patients. Many smartphone applications (apps) are currently available for AYAs with cancer; however, very few apps for AYAs with cancer have been designed with direct input from AYAs themselves or have demonstrated their effectiveness and benefit. Objective: The objective of this project was to develop the prototype of a smartphone app for AYAs with cancer through the process of co-creation, with the active input of AYA who have received treatment for cancer directly impacting content and design. Methods: Patients were recruited from a population of Danish AYAs who had received treatment for cancer between the ages of 15-29. The co-creation process was completed over the course of three workshops and intermittent ad hoc meetings, where the recruited AYAs worked in coordination with a nurse, a doctor, and two representatives from a digital agency and app developer. During each workshop, participants prioritized their goals for the app. After new app content was developed, feedback was requested from the participants, and changes were made accordingly. This iterative process continued until consensus on final product features and design were achieved. Healthcare professionals provided minimal input, and primarily performed observational roles in the workshops, with direct interaction limited to introducing the project and explaining measurement features of the app in development. Results: Three key features to be included in the prototype app were identified from the co-creation workshops: 1) a community forum, 2) an information library, and 3) a symptom and side effect tracking tool. Bright, warm colors were selected for the app by the participating AYAs. The final prototype will be launched for pilot testing and implementation testing in February of 2018. Conclusions: The process of co-creation is user-involved process that can create an end-product that is useful and customized for the target population. This process, as such, is a beneficial process to utilize when addressing the specific needs of AYAs with cancer. The results of the here described app prototype will be evaluated in more detail in the near future. However, this description of the co-creation process in app development can be utilized for the creation of other mHealth interventions.

  • Theory-based digital interventions to improve asthma self-management outcomes: a systematic review

    Date Submitted: Jan 15, 2018
    Open Peer Review Period: Jan 15, 2018 - Mar 12, 2018

    Background: Asthma is a chronic disease that requires effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how, and to what extent, theory has been applied, which theoretical models could potentially improve asthma self-management, and which components of these models are most effective. Objective: To examine the use and application of theories in the development of digital interventions to enhance asthma self-management, and to evaluate whether these interventions are effective in eliciting behaviour change and improving clinical outcomes and quality of life. Methods: Electronic databases (The Cochrane Library, MEDLINE, EMBASE and PsycINFO) were searched systematically using pre-determined terms and inclusion criteria. Additional studies were identified by scanning reference lists of relevant studies. Two researchers screened titles and abstracts and a third researcher resolved discrepancies. Full-text review was undertaken for relevant studies. Studies meeting inclusion criteria were assessed for risk of bias using The Cochrane Collaboration tool. The review was conducted in accordance with the PRISMA statement. Interventions were coded as fully or partly digital, and in terms of the type of digital platform used and the theory of model applied. The Theory Coding Scheme (TCS) was used to establish: the extent to which each intervention had applied theory, which theoretical constructs or behavioural determinants had been addressed, the involvement of the target group with the development of the intervention, if, and how, interventions were tailored, and if participants’ selection had been based on assessment of need. The impact of the interventions on behavioural and clinical outcomes and healthcare utilisation was described using narrative synthesis. Results: Sixteen studies evaluating 15 different digital interventions were selected for this review. The most commonly cited theories/models included Social Cognitive Theory, the Health Belief Model and the Common-Sense Model of Self-Regulation. The 3 studies that applied theory to an extent of ≥50% of the different uses of theory, as assessed by the TCS, showed a significant positive effect (P<0.05) of the intervention on all measured behavioural and clinical outcomes, but from those that incorporated <50% of the different uses of theory, only 2% of 13 studies showed such an effect. Conclusions: Theory-based digital interventions can be effective at improving clinical outcomes and self-management behaviour. Most studies lack detail on the theoretical constructs and how they have been applied to the design of the intervention, or selection of participants. A systematic approach to the use of theory to guide the design, selection and application of intervention techniques is needed. Clinical Trial: N/A

  • Background: The Roland Morris Disability Scale (RMDQ), Visual Analogue Scale of pain intensity (VAS) and Numerical Rating Scale (NRS) are three of the four most commonly used outcome measures in trials of interventions for low back pain. Their validity in paper form is well-established. Few data are available on the metric properties of electronic counterparts. Objective: To establish responsiveness, minimal important change (MIC) thresholds, reliability, and minimal detectable change (MDC95) for electronic (e) versions of the RMDQ, VAS, and NRS as delivered via iOS app, Android app, and web app. Methods: We recruited people with back pain who visited osteopaths. We invited participants to complete the eRMDQ, eVAS, and eNRS at baseline, one-week, and six-weeks, along with a health transition question (TQ) at one and six weeks. Data from participants with self-reported recovery were used in responsiveness and MIC analyses, using Receiver Operator Characteristic curves with the TQ as the external criterion. Data from self-reported stable patients were used for analyses of reliability (ICC agreement) and minimal detectable change (MDC95). Results: We included 442 participants. At one and then six-weeks, ROC AUCs were 0.69 (95%CI 0.59 to 0.80) then 0.67 (0.46 to 0.87) for the eRMDQ; 0.69 (0.58 to 0.80) then 0.74 (0.53 to 0.95) for the eVAS; and 0.73 (0.66 to 0.80) then 0.81 (0.69 to 0.92) for the eNRS. Associated MIC thresholds were estimated as 1 then 2, 13 then 7, and 2 then 1 points, respectively. Over one-week in stable and ‘about the same’ participants ICCs were 0.87 and 0.84 for the eRMDQ, with MDC95 of 4 and 5; 0.31 and 0.61 for the eVAS with MDC95 of 39 and 34; and 0.52 to 0.67 with MDC95 of 4 and 3 for the eNRS. Conclusions: The eRMDQ was reliable with borderline adequate responsiveness. The eNRS was responsive with borderline reliability. While the eVAS had adequate responsiveness it did not have an attractive reliability profile. Thus, the eNRS might be preferred over the eVAS for measuring pain intensity. The observed electronic outcome measures’ metric properties are within the range of values reported in the literature for their paper counterparts and are adequate for measuring within a back pain population. Clinical Trial: N/A

  • Background: Evaluating the quality of mHealth apps for weight loss and weight management is important to understand whether these can be used for obesity prevention and treatment. Recent reviews call for more research on multi-dimensional aspects of app quality, especially involving end-users, as there are already many expert reviews on this domain. However, no quantitative study has investigated how lay persons see popular apps for weight management and how they perceive different dimensions of app quality. Objective: To explore how lay persons evaluate the quality of six free weight management apps (MyDietCoach, SparkPeople, Lark, MyFitnessPal, MyPlate, MyDietDiary), which achieved the highest quality ratings in a related and recent expert review. Methods: A user-centered study was conducted with 36 employees of a Lebanese university. Participants enrolled in the study on a rolling basis between October 2016 and March 2017. Participants were randomly assigned an app to use for two weeks. App quality was evaluated at the end of the trial period using the Mobile App Rating Scale (user version, uMARS). uMARS assesses the dimensions of ‘engagement’, ‘functionality’, ‘aesthetics’, ‘information’, and ‘subjective quality’ on 5-point scales. Internal consistency and inter-rater agreement were examined. The associations between uMARS scores and background characteristics were also explored using non-parametric tests. Analyses were completed in November 2017. Results: Overall, the six apps were of moderately good quality (Md uMARS score=3.6, IQR=0.3). The highest total uMARS scores were achieved by Lark (M=4.0, SD=0.5) and MyPlate (M=3.8, SD=0.4), which also achieved the highest subjective quality scores (Lark: M=3.3, SD=1.4; MyPlate: M=3.3, SD=0.8). ‘Functionality’ was the highest-rating domain (Md=3.9, IQR=0.3), followed by ‘aesthetics’ (Md=3.7, IQR=0.5), ‘information’ (Md=3.7, IQR=0.1), and ‘engagement’ (Md=3.3, IQR=0.2). ‘Subjective quality’ was judged low (Md=2.5, IQR=0.9). Overall, ‘subjective quality’ was strongly and positively related (p<0.001) with total uMARS score (rho=0.75), ‘engagement’ (rho=0.68), ‘information’ and ‘aesthetics’ (rho=0.60), but not ‘functionality’ (rho=0.40, p=0.02). Higher ‘engagement’ scores were reported among healthy (p=.003) and obese individuals (p=.034), who also showed higher total uMARS (p=.038), and ‘subjective quality’ (p=.047) scores. Conclusions: Even if the apps were considered highly functional, they were relatively weak in engagement and subjective quality scores, which indicate a low propensity of using the apps in the future. As engagement was the sub-domain most strongly associated with subjective quality, app developers and researchers should focus on creating apps that are engaging, holding constant the functionality, aesthetics, and information quality. The tested apps (in particular Lark and MyPlate) were perceived as more engaging and of higher quality among healthy, obese individuals, making them a promising mode of delivery for self-directed interventions promoting weight control among the sampled population or in similar and comparable settings. Clinical Trial: None.

  • Background: Physical activity benefits older adults by protecting against morbidity and mortality. Wearable activity trackers (WATs) offer the opportunity to increase physical activity through continuous monitoring. We explore the nuances of WAT use and adoption among older adults using the transtheoretical model (TTM) of behavior change. Objective: We investigate older adults’ perceptions and uses of WATs in different stages of WAT adoption. Methods: Data for the research come from 10 focus groups. The first set of focus groups was with participants who had never used WATs. These focus groups included a WAT trial. Other focus groups (without the trial) were conducted with short-term, long-term, and former WAT users. Results: Older adults in different WAT use stages liked and wished for different WAT features, with long-term users being the most diverse and sophisticated users of WATs. Long-term users had developed a habit of WAT use while other participants needed to employ various encouragement strategies. Social support, with the focus on collaboration, was the primary motivator for long-term users, while short-term and former users focused on competition, and non-users engaged in vicarious WAT use experiences. Finally, long-term users were more likely to see benefits of WATs while other participants focused on obstacles related to WAT use. Conclusions: WATs may be an effective technology to encourage physical activity among older adults. Yet, WATs alone are not likely to be successful in changing behavior. Tailored approaches based on the TTM stage of change as well as motivations, facilitators, and specific WAT characteristics that are important for older adults will ensure successful long-term use. Clinical Trial: NA

  • Background: Background: Online social networks are a powerful communicative element whose use is increasingly widespread. Persons in a extreme social exclusion like persons experiencing homelessness (IEH) can be beneficiated of the positive elements of communication and relationship associated with social network sites. Objective: Objective: This study suggests the comparison of a Facebook training course and an office software course and their effect on psychological well being in a group of IEH. Methods: Methods: Experimental and longitudinal study was designed. A sample of IEH were assigned to the Facebook group or the office software group randomly and their social skills, Self-Esteem, Self-Efficacy and Life Satisfaction were measured on four occasions: pre test, at the end of the training course, one month later and three months later. A mixed ANOVA of repeated measures (2x4) was performed. Results: Results: A total of 92 IEH participated in the study. The number of cases in which the 4 observations were completed was 71 (35 in the intervention group and 36 in the control group). The mixed ANOVA of repeated-measures and the multiple regression analysis indicated a significant increase of the four analyzed parameters, more significant in social skills and Self-Esteem. The critical level associated to the interaction Time*Program were significant in all variables and levels. Therefore, the scores in the 4 analyzed constructs were not equal according to the program carried out throughout the work. The effect size associated to the interaction Time*Program in the scores of social skills was large (Eta2 = .32), in the self-esteem and selt-efficacy scores it was medium, (Eta2 = .13) and in satisfaction with life scores it was small (Eta2 = .09). The results of the adjustment of the different models of multiple linear regression indicate that the number of hours devoted weekly to the use of Facebook was a predictor of the increase in the scores of social skills (B = 3.43, r2 = .405) and self-esteem (B = .382). Age (B = .175) and self-efficacy (B = .09) were also variables which with independence and in equal conditions predicted the self-esteem (r2 = .29). Finally, self-esteem (B = .69) was also a predictor variable of the increase of satisfaction with life (r2 = .195). Conclusions: Conclusion: These findings suggest that Facebook could be a key element in homeless psychological wellbeing and socialization.

  • A systematic review of telemedicine utilization in caregivers of cancer patients

    Date Submitted: Jan 10, 2018
    Open Peer Review Period: Jan 13, 2018 - Mar 10, 2018

    Background: Recent decades have seen a growing number of published studies and systematic reviews examining different telehealth interventions targeting patients and their effects on patients’ wellbeing and quality of life. However, there is a less definite picture on telemedicine tools aimed at the family members and caregivers of adult cancer patients. Objective: This systematic review aims to provide a more complete framework regarding carers’ telemedicine tools implemented in all phases of cancer care, to identify what are the main considered outcomes, to analyse the role of telehealth and the usability and feasibility trends in supporting the patient’s carers. Methods: A literature search was systematically conducted in the following databases: Web of Science, Cochrane Library, PubMed, Scopus, CINAHL, Embase, Google Scholar, and Ovid PsychINFO. Inclusion criteria were the use of English language, publication on peer-reviewed journals, the description of a telehealth implemented intervention, the focus on caregivers of adult cancer patients at any stage of the disease. The study selection was conducted up to November 2017. Included papers were critically appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and quality of evidence was graded by outcome using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system. Results: Twenty-four studies were included in the final selection. In 21 out of 24 studies the patient-caregiver dyad was analysed, and the study population dealt with different types of cancer at different stages. Included studies considered the caregiver’s condition both from an individual and a relational point of view. Along with psychosocial variables, some papers monitored engagement and user satisfaction regarding web-based platforms or telehealth interventions. All studies reported significant improvements in some of the investigated areas, but they often showed small effect sizes. Different telehealth intervention formats were adopted: web-based platform, and telephone calls. Some of the included studies referred to the same project, but on samples with different cancer diagnoses or with new versions of already-developed interventions. Conclusions: Reported outcomes seem to suggest that we are in an exploratory phase. There is still a need of more detailed and targeted research hypotheses. Clarifying caregiver’s needs related to telehealth tools and better defining outcome measures may allow to obtain more significant results.

  • Background: Many patients undergoing treatment for head and neck cancer (HNC) experience significant swallowing difficulties, and there is some evidence that swallowing exercises may improve outcomes, including quality of life. This feasibility study developed an evidence-based, practical Swallowing Intervention Package (SiP) for patients undergoing chemo-radiotherapy (CRT) for HNC. As part of the study, an electronic version of SiP (e-SiP) was concurrently developed to support patients to self-manage during treatment. This paper reports on the e-SiP component of this work. Objective: To develop and conduct preliminary evaluation of an electronic support system (e-SiP) for patients undergoing CRT for head and neck cancer. Methods: The study involved health professionals and patients who were undergoing CRT for head and neck cancer. The scoping stage of e-SiP development involved investigated the potential usefulness of e-SiP, exploring how e-SiP would look and feel and what content would be appropriate to provide. Patient and carer focus groups and a health professionals’ consensus day were used as a means of data gathering around potential e-SiP content. A repeat focus group looked at an outline version of e-SIP and informed the next stage of its development around requirements for tool. This was followed by further development and a testing stage of e-SiP involved the coding of a prototype which was then evaluated using a series of steering group meetings, semi-structured interviews with both patients and health care professionals, and analysis of e-SiP log data. Results: Feedback from focus groups and health professional interviews was very positive and it was felt e-SiP use would support and encourage patients in conducting their swallowing exercises. However, of the ten patients offered e-SIP, only two opted to use it. For these patients, aspects of the e-SIP application were considered useful, in particular the ease of keeping a diary of exercises performed. Interviews with users and non-users suggested significant barriers to its use. Most significantly the lack of flexibility of platform on which e-SiP could be accessed appeared a dominant factor in deterring e-SiP use. Conclusions: Results suggest a need for further research to be conducted around the implementation of e-SiP. This involves evaluating how e-SiP can be better integrated into usual care, and through patient training and staff engagement, can be seen as a beneficial tool to help support patients in conducting swallowing exercises.

  • Background: Gout is a form of chronic arthritis caused by elevated serum uric acid (SUA) and culminates in painful gout attacks. Effective uric acid-lowering therapies exist, however adherence is low. This is partly due to the lack of support for patients to self-manage their disease. Mobile health applications (apps) have been used in self-management of chronic conditions. However, not all are developed with patients, limiting their effectiveness. Objective: This study aimed to design an effective gout self-management app by collecting feedback from gout patients. Methods: Two mixed-methods studies were conducted. In Study 1, researchers developed a short educational video and written materials about gout management, designed to be embedded into an app. Six interviews and one focus group were held with gout patients to gather feedback on these materials. Usability testing in Study 2 involved additional gout patients using a pilot version of Healthy.me Gout, a gout self-management app, for two weeks. Following the trial, patients participated in an interview about their experiences using the app. Results: Patients viewed the gout educational material positively, appreciating the combined use of video, text and images. Patients were receptive to using a mobile app to self-manage their gout. Feedback about Healthy.me Gout was generally positive, with patients reporting that the tracking and diary features were most useful. Patients also provided suggestions for improving the app and educational materials. Conclusions: These studies involved patients in the development of a gout self-management app. Patients provided insight to improve the app’s presentation and usability, and general lessons on useful features for chronic disease apps. Gout patients enjoyed tracking their SUA concentrations and gout attack triggers. These capabilities can be translated to self-management apps for chronic diseases that require monitoring of pathological values, medication adherence and/or symptoms. Future health app design should integrate patient input and be developed iteratively to address concerns identified by patients.

  • Assessing the Quality of Websites Relating to Complementary and Integrative Health: A Review of Five Domains

    Date Submitted: Jan 9, 2018
    Open Peer Review Period: Jan 11, 2018 - Mar 8, 2018

    Background: In recent years, we have seen both an increase in the utilization of complementary and integrative health (CIH) care, and an increase in information-seeking behavior focused on complementary and integrative health. Thus, understanding the quality of CIH information that is available on the Internet is an imperative. Though there have been a limited number of studies that have evaluated the quality of websites providing information about specific CIH-related topics, a broad evaluation of CIH websites has yet to be conducted. Objective: This study was designed to fill that gap. We set out to perform an assessment of website quality in five CIH domains: acupuncture, homeopathy, massage, reiki and yoga. Our research had three main aims: 1) to evaluate the quality of these websites; 2) to evaluate characteristics of websites which may affect readers’ perceptions of websites, specifically message content, structural features, and presentation style; and 3) to investigate the extent to which harms, benefits and purposes of use are stated on websites. Methods: This study employed a systematic search strategy to identify websites in each of the target domains to be evaluated. The websites were then classified by type, and a set of checklists focusing on quality, message content, structural features, and presentation style were used to evaluate the websites. Lastly, we performed content analysis to identify harms, benefits, and perceived purposes of use. Results: There were similarities across domains in terms of their overall quality and their message content. Across all domains, a high proportion of websites received a score of 2 on ownership, currency, interactivity and navigability. Scores were more variable with respect to authorship, balanced presentation of information and the use of sources of information. However, there were differences in terms of their structural features and presentation style. Acupuncture and reiki sites tended to include more external links, and yoga, fewer. The presence of physical locations was more common among homeopathy and massage websites. Additionally, there was variation across domains in the extent to which the websites contained domain-specific terminology. Websites tended to provide a large list of potential benefits, while reporting of harms was scarce. Conclusions: There is a need to emphasize inclusion of authorship attribution, balanced presentation of information, and source attribution in online CIH information. There is also a need to better understand how individuals may interact with CIH websites, and to develop tools to assist people to interpret the CIH-related information that they encounter.

  • Background: Use of the Internet within a healthcare context offers possibilities, not only to provide information, but also to establish support online. Internet Support Groups (ISGs) are often used by patients with cancer or depression, offering potentials and advantages not provided by face-to-face support. Use of an ISG could be beneficial in patients undergoing lumbar spine fusion (LSF), accommodating isolation after surgery, providing a sense of social life, and contributing to the overall health-related quality of life providing peer support. However, research indicates that LSF patients are often not Internet users, as they often belong to the low-income group, have low education, and are of older age. However, knowledge of LSF patients' use of ISG is limited. Objective: This study describes and analyses the use of an ISG in Danish patients undergoing instrumented LSF due to degenerative spine disorders. Methods: A prospective, randomized controlled trial of 114 patients, half of whom were randomized to receive access to an ISG and half to a control group with no access. This study is a prospective cohort where the population comprised those patients randomized to access the ISG (n=57). Sociodemographic characteristics (gender, age, marital status, employment status, and level of education) and information on psychological wellbeing (symptom of anxiety and depression) were obtained at baseline, 1-5 weeks prior to surgery, and the use of the ISG was registered from baseline until 3 months after surgery. Results: Eight participants were excluded. Thus, 49 participants comprised the study population, with a mean age of 53 years (range 29-77), 57% female, 84% not living alone, 70% unemployed, and the majority (69%) had secondary education as their highest education. Approximately one-third of the participants had symptoms of depression (33%), and one-third had symptoms of anxiety (31%), half of these overlapped, having both anxiety and depression. A total of 43 of the 49 participants (88%) took the opportunity to access the ISG. We found no correlations between sociodemographic data and the degree to which participants accessed the ISG. Women were more prone to be active users (P=0.04) and more often contributed with posts to the ISG. Finally, participants who were active users and contributed with posts or comments had more interactions (P<0.001) and pageviews (P<0.001). Conclusions: Sociodemographic characteristics were not predictors of ISG use in this study. However, accessibility, the ability to try using the ISG, perceived usefulness of the ISG, and motivation seem to be important facilitators of the use of an ISG website. In addition, we found that women were more prone to be active users of the ISG. Clinical Trial: Data management and security were approved by the Danish Data protection agency (J.no. 2014-41-3583) and the trial was registered at Clinical Trials.gov (record NCT02615483).

  • Background: Women undergoing pelvic examination for cervical cancer screening can experience periprocedural anxiety. Objective: Our aim was to assess the anxiety level experienced by women undergoing visual inspection with acetic acid and lugol iodine (VIA/VILI) examination, with or without watching the procedure on a digital screen. Methods: This prospective study took place at the Dschang District Hospital, Cameroon. HPV-positive women, aged 30-49 years old, were recruited in a cervical cancer screening campaign and invited to participate to the study during the 12-months follow-up control visit, including VIA/VILI examination. Before the procedure, participants were randomized with a 1:1 ratio in a control group (CG) who underwent a pelvic examination in the usual practice and were verbally informed and an intervention group (IG), where participants were verbally informed and watched the procedure live on a digital screen. Women’s anxiety was assessed before and immediately after the exam, using Spielberg’s State Anxiety Inventory (STAI). A two-sided Student t-test and Mann-Whitney Wilcoxon test were used to compare the mean STAI score for each question before and after VIA/VILI. Results: A total of 118 women were included in the study (CG: 60, IG: 58). The mean age was 39.1 (±5.2) years. The mean STAI baseline scores before the exam were similar between the two groups (CG: 33.6±10.9, IG: 36.4±11.8, P = .17). The STAI score after pelvic examination was significantly reduced for both groups (CG: 29.3±11.2, IG: 28.5±12.0). Overall, the difference of the STAI score between before and after the pelvic examination was similar for the two groups (IG: 7.9±14.3, CG: 4.2±9.0, P=.1). However, women’s emotional state, such as “I feel secure” and “I feel strained”, were improved in IG as compared to CG (P=.01). Conclusions: Watching live VIA/VILI procedure improved the emotional state but did not reduce the periprocedural anxiety. Further larger studies should assess women's satisfaction with watching their pelvic examination in real time to determine if this procedure should be include in VIA/VILI routine practice. Clinical Trial: clinicaltrials.gov, NCT02945111.

  • Economic impact of digital consulting on young people with long-term conditions: a mixed -methods approach

    Date Submitted: Jan 9, 2018
    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Since 2000, health professionals are starting to use email, text and other digital methods to consult with their patients in a timely manner. There is lack of evidence regarding the economic impact of digital consulting in the UK National Healthcare System (NHS). Objective: This study aims to estimate the direct costs associated with digital consulting as an adjunct to routine care at 18 clinics serving young people with longterm conditions. Methods: This study uses both quantitative and qualitative approaches. Semi-structured Interviews were conducted with 173 clinical team members on the impacts of digital consulting. A structured questionnaire was developed and used for health professionals across 18 sites in the UK to collect data on time and other resources used for Digital consulting. A follow-up semi-structured interview was conducted with a single senior clinician at each site to clarify the mechanisms through which Digital consulting use might lead to outcomes relevant to economic evaluation. We used the 2 part model to see the association between the time spent on Digital consulting and the job role of staff, type of clinic, and the average length of the working hours using digital consulting. Results: Staff time is the key driver of digital consulting related costs and consultant status was a significant negative predictor of time spent on this activity. Staff time spent per day digitally consulting varied widely (median 45 minutes, IQR 0-120 minutes). Time spent by consultants, nurses, physiotherapist and psychologists were 28, 120, 120, 34 minutes, respectively. Nurses, physiotherapists, and psychologists consulted digitally more than consultants by 95, 55, and 32 minutes per day, respectively. The highest total clinic cost per month was £9560 and lowest was £161. Four potential economic benefits for the NHS were identified qualitatively by health professionals: serious adverse events, patient wellbeing, waiting list length and staff workload. We did not find evidence to suggest that the clinical condition was associated with digital consulting use. Conclusions: Nurses were the greatest users of digital consulting with the greatest costs associated with their time. Teams appear to use an efficient triage system with the most expensive members digitally consulting less than lower paid team members. Staff report concerns regarding time spent digitally consulting which implies that direct costs increase. There remain considerable gaps in evidence related to cost-effectiveness of digital consulting but this study has highlighted important cost-related outcomes for assessment in future cost-effectiveness trials of digital consulting.

  • Background: Patient and public involvement in health research is important to produce relevant and impactful results. Objective: To prioritize and summarize Hirschsprung’s Disease (HD)-related information needs among caregivers of children with HD and their pediatric surgeons through partnership with a parent-initiated social media campaign. Methods: We conducted an online survey with the two stakeholder groups to identify information needs. The caregiver survey was conducted through a global online community and the surgeon survey was distributed to members of the Canadian Association of Paediatric Surgeons (CAPS). We conducted a literature review to identify evidence on the prioritized topics. Results: Eighty-nine individuals completed the caregiver survey, and 52 pediatric surgeons completed survey distributed through CAPS. Only 20% of caregivers reported being very satisfied or satisfied with current HD-related resources. A final prioritized list of information needs included: i) bowel management, ii) nutrition and growth, iii) infection, iv) perianal irritation, v) gastrointestinal pain, vi) surgical diagnostics, and vii) surgical complications. Eighty-seven studies were included in the literature review: eight reviews, two randomized controlled trials, 74 cohort studies and three practice guidelines. Two priority issues identified by caregivers had only a single study that met inclusion criteria while one topic had none. Conclusions: With caregiver and surgeon input, we identified seven information priority areas related to HD. A review on the literature of the priorities found little evidence to support the development of high-quality guidelines. More research is necessary to meet the information needs related to HD as identified by stakeholders.

  • Background: Experimental and epidemiologic studies have shown that circadian clocks disruption can play an important role in the development of cancer and metabolic diseases. The cellular clocks outside the brain are effectively coordinated by the body temperature rhythm. We hypothesized that concurrent measurements of body temperature and rest-activity rhythms would assess circadian clocks coordination in individual patients, thus enabling the integration of biological rhythms into precision medicine. Objective: The study aimed at the real-time demonstration of large inter-subject differences in the circadian clocks of people during their daily routine, using a mobile e-Health platform. Such critical step further aimed at the integration of circadian rhythm disorders diagnosis and treatments into precision e-medicine. Methods: Non-invasive real-time measurements of rest-activity and chest temperature rhythms were recorded during the subject’s daily life, using a dedicated new mobile e-health platform (PiCADo). It involved a chest sensor that jointly measured accelerations, 3D-orientation and skin surface temperature every 1-5 min, and relayed them out to a mobile gateway via Bluetooth-Low-Energy. The gateway tele-transmitted all stored data to a server via GPRS every 24 h. The technical capabilities of PiCADo were validated in 55 healthy subjects and 12 cancer patients, whose rhythms were e-monitored during their daily routine for 3-30 days. Spectral analyses enabled to compute rhythm parameters values, with their 90% confidence limits, and their dynamics in each subject. Results: All the individuals displayed a dominant circadian rhythm in activity with maxima occurring from 12:09 to 20:25. This was not the case for the dominant temperature period, which clustered around 24 h for 51 subjects (76.1%), and around 12 h for 13 others (19.4%). Statistically significant sex- and age- related differences in circadian coordination were identified in the non-cancerous subjects, based upon the range of variations in temperature rhythm amplitudes, maxima (acrophases), and phase relations with rest-activity. The circadian acrophase of chest temperature was located at night for the majority of people, but it occurred at daytime for 26% of the non-cancerous people and 33.3% of the cancer patients, hence supporting important inter-subject differences in circadian coordination. Sex, age and cancer significantly impacted on circadian coordination. Conclusions: Complementing rest-activity with chest temperature circadian e-monitoring revealed striking inter-subject differences regarding human circadian clocks coordination and timing during daily routine. To further delineate the clinical importance of such finding, the PiCADo platform is currently applied for both the assessment of health effects resulting from atypical work schedules, and the identification of the key determinants of circadian disruption in cancer patients.

  • Background: Mood disorders are common and associated with significant morbidity and mortality. Better tools are needed for their diagnosis and treatment. Deeper phenotypic understanding of these disorders is integral to development of these tools. This study is the first effort to use passively collected, mobile phone keyboard activity to build deep digital phenotypes. Objective: To demonstrate the feasibility of using passively collected keyboard dynamic metadata to infer mood states Methods: Within subject design of eight weeks, subjects were provided a mobile phone loaded with a customized keyboard which passively collected keystroke metadata. Subjects were administered the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) weekly. Linear mixed-effects models were created to predict HDRS and YMRS scores (total keystrokes n= 626,641, weekly average 9,791 ± 7,861; total accelerometer readings n= 6,660,890, weekly average 104,076 ± 68,912). Results: A statistically significant mixed-effects regression model for the prediction of HDRS-17 item scores was created: conditional R²=0.63, P=0.014. A mixed-effects regression model for YMRS scores showed the variance accounted for by random effect was zero, and so a simple linear regression model was created: R²=0.34, P=0.0011. Multiple significant variables were demonstrated for each measure. Conclusions: Mood states in bipolar disorder are correlated with specific changes in mobile phone usage. The creation of these models provides evidence for the feasibility of using passively collected keyboard metadata to detect and monitor mood disturbances.

  • Diabetes mellitus is a major chronic disease burden and healthcare challenge in the Kingdom of Saudi Arabia. The Kingdom has one of the highest diabetes prevalence levels globally. This high prevalence levels in the Kingdom is compounded with increasing economic health burden resulting from the diabetes related complications and their treatment costs. The development of m-health system and implementation strategies tailored for Saudi patients and healthcare system is important and timely to alleviate some of these healthcare and economic burdens. However, these strategies face a myriad of economic, human, social and cultural barriers that hinder the progress in this important area of healthcare delivery. The Kingdom has one of highest penetration of smart phone, Internet and social networking users in the Gulf area. Yet, this popularity is not translated appropriately to tangible mobile health (m-Health) solutions for diabetes care and self management. Also, to date no relevant m-Health policy and implementation strategy or initiative exists within the different healthcare sectors within the Kingdom. The digital savvy society and patient population is well poised to embrace these digital health solutions. However, the adoption of m-Health in the Kingdom remains low and lacks the support of the decisions makers and healthcare providers. In this paper, a perspective of mobile health for diabetes self management in the Kingdom of Saudi Arabia is presented. An overview of the current status of m-Health for diabetes self management and the clinical evidence of the work in this area within the Kingdom is also presented. A small survey study to identify the implementations barriers of m-health for diabetes care in the Kingdom and the relevant solutions is also presented and discussed with future recommendations and further work in this area.

  • Feasibility of a digital patient-led hospital checklist to enhance safety in cataract surgery

    Date Submitted: Jan 1, 2018
    Open Peer Review Period: Jan 4, 2018 - Mar 1, 2018

    Background: Surgery is a high-risk area for iatrogenic patient harm. Correct and sufficient communication and information during the surgical process has been reported as one of the root causes of preventing patient harm. Information technology may substantially contribute to engaging patients in this process. Objective: To determine the feasibility of a digital patient-led checklist for cataract surgery, we evaluate the experiences of patients and nurses who have used this novel tool with a focus on use, appreciation and impact. Methods: A multidisciplinary team including cataract surgeons, nursing, pharmacy and administrative representatives developed a 19-item digital patient-led checklist for cataract patients who undergo surgery in an ambulatory setting. This ‘EYEpad’ checklist was distributed to patients and their companion during their hospital visit via an application on a tablet. It contained necessary information the patient should have received before or during the surgical preparation (8 items), before anaesthesia (2 items), and before discharge (9 items). Patients and their companions were invited to actively tick on the EYEpad the information they received or was discussed. Our qualitative research design included semi-structured individual interviews with patients and a focus group with the nurses involved. The transcripts were analysed by two independent coders using both deductive and inductive coding. Results: All but one of the 17 patients included used the EYEpad, whether or not assisted by their companion (mostly their partner). In most cases, the checklist was completed by the companion. Most patients were positive about the usability of the EYEpad. Yet, for the majority of the patients it was not clear why they received the checklist. Only four of them indicated that they understood that the EYEpad meant to validate if there was sufficient and correct information discussed or checked by the nurses. Although most nurses agreed that the EYEpad was easy to use and could be a useful tool to improve patient participation in improving safety, they felt that not all elderly patients are willing or capable of using it and that it interfered with the existing surgical process. They also anticipated to spend more time explaining the purpose and use of the EYEpad. Conclusions: Our study shows that a digital patient-led checklist is a potentially valid way to increase patient participation in improving safety, even in this group of elderly patients. It also illustrates the crucial role that nurses play in the implementation diffusion of technological innovations. Increased patient participation will only improve safety when both health care workers and patients feel empowered to share responsibility and balance power. Clinical Trial: Ethical approval was obtained from the ethics committee of the University of Twente (ECT number: 13196).

  • Background: Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drive effort to improve approaches, strategies, and delivery modes. It is unknown to what extent and in what respect serious gaming during regular outpatient rehabilitation can contribute to health outcomes. Objective: Study objectives are: to determine the effect of additional serious gaming on 1) physical and/or emotional functioning in general, 2) particular outcome domains, and 3) patient global impressions of change, general health, and functioning; and to determine 4) dependency of serious gaming effects on adherence. Methods: A naturalistic quasi-experiment with embedded qualitative methods was conducted. Intervention group patients received an additional guided (mindfulness based) serious gaming intervention (‘LAKA’) during week 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semi-structured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to estimate a group effect on outcome change between week 8 and 16 in 4 primary outcomes simultaneously: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Secondly, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (i.e. global impression of change, general health, functioning, and treatment satisfaction) were compared between groups by means of independent t-tests. Fourth, subgroups by levels of adherence were established from log-data. Influences of observed confounding factors were considered throughout analyses. Results: Out of 329 eligible patients, 156 intervention group and 119 control group patients (N=275) with mostly chronic back pain and concomitant psychosocial problems participated in the study. By 119 patients, the game was played for 75% or more. First, standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of treatment for the intervention group than for the control group (β=-.119, SE=.046, P=.009). Second, the intervention group showed a greater outcome change in depressive mood (b=-2.748, SE=1.072, P=.011), but not in ‘insufficiency’ or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant. Conclusions: Present findings suggest a small favorable average effect across relevant health outcomes such as depressive mood. Further research and development are required to determine when and how serious games could be applied cost-effectively in therapy, in order to increase perceptibly relevant effects on recovery and to know for which patients, and why. Clinical Trial: www.trialregister.nl NTR6020

  • Background: Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact with these solutions. There has been less attention focused on understanding the mechanisms and factors associated with the usability and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. Objective: In this context, a study was undertaken to assess and understand the usability and scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences. Methods: This study used a qualitative design with semi-structured interviews and a thematic analysis approach. Twenty-five stakeholders (six patients and three caregivers; six healthcare providers; two vendors; and eight health system decision makers) participated in this study. Results: The following three primary mechanisms emerged to influence the usability of the virtual care solution: 1) receiving hands-on training and ongoing communication from a supportive team; 2) adapting to meet user needs and embedding into workflow, and 3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: 1) co-design locally, embed into the daily workflow, and deploy over time and 2) share the benefits and build the case. Conclusions: Study findings can be used by key stakeholders in their future efforts to enhance usability and scalability of virtual care solutions for chronic disease management.

  • Facebook Intervention for Young Onset Melanoma Patients and their Family Members: A Pilot and Feasibility Study

    Date Submitted: Dec 26, 2017
    Open Peer Review Period: Dec 26, 2017 - Feb 20, 2018

    Background: Despite their elevated melanoma risk, young onset melanoma patients and their families engage in low rates of skin cancer surveillance and sun protection. Interventions that improve their skin cancer surveillance (total cutaneous exam or TCE and skin self-exam or SSE) and prevention (sun protection) practices would likely have an impact on skin cancer morbidity and mortality, but none exist. Objective: To examine the development, feasibility, and preliminary impact of a family-focused Facebook intervention to increase SSE and sun protection. Methods: Forty-eight young onset melanoma patients and 40 family members completed measures of knowledge, beliefs, and total cutaneous exam, skin self-exam, and sun protection behaviors before and one month after joining a “secret” (i.e., private) Facebook group. Intervention content consisted of daily postings about skin cancer, skin cancer risk factors, total cutaneous exams, skin self- exams, and sun protection. Results: Patient and family member participation rates differed by recruitment setting, with acceptance rates ranging from 24.6% to 39% among families recruited from a cancer center setting and 12.7% to 61.5% among families recruited from a state registry. Among the five consecutive groups conducted, engagement, as measured by comments and likes in response to postings, increased across the groups. Post-group evaluations suggested that 69% reported that they learned something new from the content and 73% reported that group helped them learn how better sun protection, skin self-exams and exams by a doctor would benefit their family (rating > 5 on a 7-point scale). Preliminary analyses indicated increases in sun protection, SSE, TCE intentions, knowledge, sun protection benefits, SSE benefits, perceived benefits to one’s family for regular skin exams and sun protection, support for family member engagement in regular sun protection and regular SSE. Conclusions: A family-focused Facebook intervention shows promise as an feasible and efficacious method to increase sun protection and skin cancer surveillance.

  • Background: The long-term management of cardiometabolic diseases, such as type 2 diabetes and hypertension, is complex and can be facilitated by supporting patient-directed behavioral changes. The concurrent application of wireless technology and personalized text messages (PTMs) based on behavioral economics in managing cardiometabolic diseases although promising, has not been studied. Objective: The aim of this pilot study was to evaluate the feasibility and acceptability of the concurrent application of wireless home blood pressure (BP) monitoring (as an example of “automatic hovering”) and PTMs (as an example of “nudging”) targeting pharmacotherapy and lifestyle habits in patients with type 2 diabetes and/or hypertension. Methods: The Wireless technology and Behavioral Economics to Engage Patients with cardiometabolic disease (WiBEEP) study was a single-arm, open-label, 7-week long pilot study in 12 patients (age 58.5 y) with access to a mobile phone. The study took place at Tufts Medical Center (Boston, MA) between March and September 2017. All patients received PTMs; nine patients received wireless home BP monitoring. At baseline, patients completed questionnaires to learn about their health goals and to assess medication adherence; at the end of week 7, all participants completed questionnaires to evaluate the feasibility and acceptability of the intervention and assess for medication adherence. Hemoglobin A1c was ascertained from data collected during routine clinical care in 7 patients. Results: The majority of patients reported the texts messages to be easy to understand (88%), appropriate in frequency (71%) and language (88%). All patients reported BP monitoring to be useful. Mean arterial pressure was lower at the end-of-study compared to baseline (-3.4 mmHg [95% CI, -5 to -1.8]. Mean change in HbA1c was -0.31% [95% CI, -0.56 to -0.06]. Conclusions: Among patients with type 2 diabetes and/or hypertension the combination of wireless BP monitoring and lifestyle-focused text messaging was feasible and acceptable. Larger studies will determine the long-term effectiveness of such an approach.

  • The Chinese adaptation of Smartphone Addiction Scale-Short version in Hong Kong adults: a population study

    Date Submitted: Dec 24, 2017
    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Background: Problematic mobile phone use (PMPU) is an emerging but under-studied public health issue. Extremely limited is known on the pattern of PMPU at the population level. A valid and reliable measure of PMPU that permit cross-cultural comparisons is needed for further studies. Objective: To evaluate the psychometric properties of Chinese Smartphone Addiction Scale-Short version (SAS-SV) as a measure of PMPU and examined its sociodemographic and health behavior correlates in Chinese general adults in Hong Kong, where the proportion of smartphone user was the second highest globally. Methods: The psychometric properties of the Chinese SAS-SV were assessed in a territory-wide, probability-based telephone survey of 3211 Hong Kong general adults aged ≥ 18 years (mean 43.3 years, 45.3% men). The sample was randomly split into 2 subsamples for exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). One-week test-retest reliability was evaluated in a random subset of 100 subjects. SAS-SV cut-off scores of ≥ 31 for males and ≥ 33 for females were used to determine the prevalence of PMPU. Multivariable linear regression calculated the regression coefficients (b) of SAS-SV score in relation to sociodemographic factors, health behaviors and chronic disease status. Data were weighted by age, sex and education attainment distributions of the Hong Kong general population. Results: EFA revealed an unifactorial structure for the Chinese SAS-SV (92.9% variance explained), which was replicated by a CFA. Internal consistency (Cronbach’s alpha = 0.844) and one-week test-retest reliability were satisfactory (intraclass correlation = 0.76, P < .001). The prevalence of PMPU was 38.5% (95% confidence interval [CI] 36.9%-40.2%). Female sex, younger age, being married/ co-habitated or divorced/ separated (vs unmarried), and lower education level were associated with a higher SAS-SV score (all P < .05). After controlling for sociodemographic factors and mutual adjustment, higher SAS-SV scores were observed in subjects who currently smoke (vs never smoker; b = 1.48, 95% CI 0.19, 2.78), drink alcohol weekly or more (vs never drinker; b = 1.50, 95% CI 0.18, 2.83), and were physically inactive (P for trend = 0.019). Conclusions: Chinese SAS-SV is a valid and reliable psychometric for assessing PMPU, which was associated with sociodemographic and health behavioral risk factors in Hong Kong adults. Further research on the health consequences of prevalent PMPU in Chinese is warranted.

  • Risk knowledge of people with relapsing-remitting multiple sclerosis – results of an international survey

    Date Submitted: Dec 23, 2017
    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Background: Adequate risk knowledge of people with Multiple Sclerosis (pwMS) is a prerequisite for informed choices in medical encounters. Previous work showed that MS risk knowledge is low among pwMS and role preferences are different in Italy and Germany. Objective: We investigated the level of risk knowledge and role preferences in 8 countries and assessed putative variables associated with risk knowledge. Methods: An online-survey was performed based on the Risk knowledge questionnaire for people with relapsing-remitting MS (RIKNO 2.0), the electronic Control Preference Scale (eCPS), and other patient questionnaires. Results: Of 1939 participants from Germany, Italy, the Netherlands, Serbia, Spain and Turkey, 986 (51%) completed the RIKNO 2.0, with a mean of 41% correct answers. There were less than 50 participants in the UK and Estonia and data were not analysed. Risk knowledge differed across countries (P < .001). Variables significantly associated with higher risk knowledge were higher education (P < .001), previous experience with disease modifying drugs (P = .001), correct answer to a medical data interpretation question (P < .001), while higher fear for wheelchair dependency was negatively associated to risk knowledge (P = .001). Conclusions: MS risk knowledge was overall low and differed across participating countries. These data indicate that information is an unmet need of most pwMS. Clinical Trial: Not applicable.

  • Background: The cost of workplace injuries and illnesses impacts significantly on overall healthcare costs and is a significant annual economic burden in the United States. Within the dangerous occupational sector of Agricultural, Fishing, and Forestry, injury surveillance is limited and the annual economic burden of injuries not well known. Many farm owners in the Upper Midwest have expanded operations and taken on the role of manager and employer; yet they receive little training in injury prevention, farm safety, or workers’ compensation programs and processes. Clinicians play a key role in return to work of injured and ill farmers and farm workers, though little to no formal training is offered in medical school. Objective: This project aimed to develop a prototype application designed to assist clinicians in returning to injured workers to light-duty job assignments with their current employer. Methods: Semi-structured interviews with farmers and farm workers from the Upper Midwest, coupled with English- and Spanish-speaking farm worker focus groups advised the development team from conception through an iterative design and development project. Results: A total of 35 farm workers participated in five focus groups comprising three Spanish-speaking and two English-speaking groups. The initial interviews and worker focus groups guided an iterative design and development cycle. Guidance impacted everything from workflows and button placement to output sheets that offer specific light-duty farm work recommendations for the injured worker to discuss with his/her employer. Additionally, eight farmers were interviewed in the final year of the 5-year project to further explore barriers of adoption regarding the use of mHealth (mobile health). Conclusions: Development of a complex prototype intended to impact patient care is a significant undertaking. Reinventing a paper-based process to eventually integrate with an electronic health record or a private company’s human resource system requires substantial stakeholder input from each facet including patients, employers, and clinical care teams. The prototype is available for testing, and further research is needed in the form of clinical trials to assess effectiveness of the process and the software’s impact in return-to-work of injured and ill workers. Farmers are increasingly adopting new technology from smartphone apps to autonomous, self-driving equipment capable of capturing enormous amounts of operational data. There is significant financial incentive to return injured workers to a light duty job, limiting work time loss. It is unlikely that clinicians would face barriers amongst farmers in adopting return-to-work technology. However, there is little incentive for clinicians to adopt the technology. Without seamless integration into the clinical electronic health record workflow, it is unlikely that individual physicians would consistently leverage such a system at the point-of-care. Clinical Trial: Not a clinical trial; not applicable.