Latest Submissions Open for Peer Review

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Using Beta-Version Mobile Health Technology for Team-Based Care Management to Support Stroke Prevention: A Qualitative Analysis

    Date Submitted: Dec 5, 2016
    Open Peer Review Period: Dec 7, 2016 - Feb 1, 2017

    Background: Beta versions of health information technology tools are needed in service delivery models with health care and community partnerships to confirm the key components and assess the performance of the tools and impact on users. Using an open-source mobile platform, we developed a care management technology (CMT) for an intervention called Secondary Stroke Prevention by Uniting Community and Chronic Care Model Teams Early to End Disparities (SUCCEED) that is being tested in a randomized controlled trial. In the SUCCEED intervention, community health workers (CHWs) work collaboratively with care managers (CMs) in the health care system to empower recent stroke survivors to eat healthy foods, engage in physical activity, and use medications that can lower the risk of another stroke. The CMT was expected to facilitate achieving the target health outcome of reduced stroke risk by enhancing both the efficiency and effectiveness of the healthcare team. Objective: The primary objective was to describe the SUCCEED CMT and investigate CM and CHW perceptions of the CMT’s usefulness for team-based care management. Methods: We performed in-depth analysis of interviews conducted with all users of the beta-version SUCCEED CMT, namely two CMs and three CHWs. They were asked to demonstrate and describe their perceptions of the CMT’s ease of use and usefulness for completing predefined key care management activities. They were also probed about their general perceptions of the CMT’s information quality, ease of use, usefulness, and impact on CM and CHW roles. Interview transcripts were coded using a priori codes. Coded excerpts were grouped into broader themes and then related in a conceptual model of how the CMT facilitated care management. We also conducted a survey with 14 patients to obtain their perspective on CHW tablet use during CHW-patient interactions. Results: Overall, CMs and CHWs expressed that the CMT was useful. It helped them keep track of patient interactions and plan their work to ensure patients received the minimum set of interactions. The CMT guided CMs in developing care plans and allowed them to share the care plans with CHWs. For CHWs, the tool enabled electronic collection of clinical assessment data and provided decision support. It also tracked patients’ risk factor values and allowed CHWs to access these values in the field. Long loading times and downtimes due to outages were the most significant challenges encountered. Additional issues included the inability to link to educational materials outside of the platform or generate graphics of risk factor values over time, the extensive use of free-text responses, lengthy forms, and manual data transfer from the electronic medical record. Despite these challenges, patients overall did not perceive the tablet interfering with CHW-patient interactions. Conclusions: Our findings suggest useful functionalities of CMTs supporting health care and community partners in collaborative chronic care management. However, usability issues need to be addressed during the development process. The SUCCEED CMT is an initial step toward the development of effective health information technology tools to support collaborative, team-based models of care and will need to be modified as the evidence base grows. Future research should assess the CMT’s effects on team performance.

  • A proposal for an anonymisation matrix for the secondary use of Big Data for research

    Date Submitted: Dec 6, 2016
    Open Peer Review Period: Dec 7, 2016 - Feb 1, 2017

    Background: The current law on anonymisation sets the same standard across all situations, which poses a problem for biomedical research. Objective: We propose a matrix for setting different standards which is responsive to the context and public expectations. Methods: The law and ethics applicable to anonymisation were reviewed. The social science on public attitudes and research on technical methods of anonymisation were applied to formulate a matrix. Results: The matrix adjusts anonymisation standards according to the sensitivity of the data and the safety of the place, people and projects involved. Conclusions: Conclusion: The matrix offers a tool for context-specific standards for anonymisation for data research.

  • Whiplash syndrome reloaded: digital echoes of whiplash syndrome inside the Europeans internet´s search-engine context

    Date Submitted: Nov 27, 2016
    Open Peer Review Period: Dec 2, 2016 - Jan 27, 2017

    Background: In many Western countries, after a motor vehicle collision, those involved seek health care for the assessment of injuries and for insurance documentation purposes. In contrast, in many less wealthy countries, there may be limited access to care, and no insurance or compensation system. Objective: The purpose of this study was to investigate the global pattern of evolving internet usage in countries with and without insurance and the corresponding compensation systems for whiplash injury. Methods: We used internet search engine analytics via Google Trends to study the health information-seeking behavior concerning whiplash injury at national population levels in Europe. Results: We found that the search for “whiplash” is strikingly and consistently often associated with the search for “compensation” in countries or cultures with a tort system. Frequent or traumatic painful injuries, diseases or disorders such as arthritis, headache, radius and hip fracture, depressive disorders, and fibromyalgia were not associated similarly with searches on "compensation". Conclusions: In this study, we present evidence from the evolving viewpoint of naturalistic internet search engine analytics that the expectations for receiving compensation may influence internet search behavior in relation to whiplash injury.

  • ‘Am I normal?’ Patients with lymphoma wish to compare their own quality of life and symptom scores with those of others of same age and sex

    Date Submitted: Dec 1, 2016
    Open Peer Review Period: Dec 2, 2016 - Jan 27, 2017

    Background: Providing feedback to patients on their health-related quality of life (HRQoL) and symptoms can help patients in monitoring their functioning and symptoms and may help empower them. Objective: This study investigates whether patients with lymphoma wish to receive feedback, including the option to compare their scores to the scores of others, and how this feedback is evaluated. Methods: Sixty-four patients participating in a lymphoma cohort who were eligible for a follow-up questionnaire were invited and given an option to receive patient-reported outcomes (PRO) feedback. Patients completed questions about HRQoL and symptoms. PRO feedback was provided via bar-charts. Results: Forty-five of 64 invited patients participated (response=70%) and 36 patients (80%) wished to receive PRO feedback. The vast majority (34/36=94%) compared their scores to a lymphoma reference cohort, and 64% (23/36) to a normative population without cancer. All patients wished to receive feedback on their HRQoL and 81-92% on their functioning, fatigue, neuropathy, anxiety and depressive feelings. Ninety-seven percent reviewed the PRO feedback as useful, with reassurance and knowledge about own functioning in relation to what is ‘normal’ as most frequently mentioned arguments. Conclusions: Patients reported the comparison of their scores to a lymphoma reference cohort as most valuable. Research should demonstrate if PRO feedback could increase empowerment and possibly improve HRQoL.

  • Methods for Coding Tobacco-Related Twitter Data: A Systematic Review

    Date Submitted: Nov 30, 2016
    Open Peer Review Period: Nov 30, 2016 - Jan 25, 2017

    Background: As Twitter has grown in popularity to 313 million monthly active users, researchers have increasingly been using it as a data source for tobacco-related research. Objective: The objective of this systematic review was to assess the methodological approaches of categorically coded tobacco Twitter data and make recommendations for future studies. Methods: Data sources included PsychInfo, Web of Science, PubMed, ABI/INFORM, Communication Source, and Tobacco Regulatory Science. Searches were limited to peer reviewed journals in English from January 2006 to July 2016. The initial search identified 274 articles using a Twitter keyword and a tobacco keyword. One coder reviewed all abstracts and identified 27 articles that met the following inclusion criteria: 1) original research; 2) focused on tobacco or a tobacco product; 3) analyzed Twitter data; and 4) coded Twitter data categorically. One coder extracted data collection and coding methods. Results: The most common type of Twitter data analyzed was e-cigarettes, followed by specific tobacco campaigns. The most prevalent data sources were Gnip and Twitter’s Streaming Application Programming Interface (API). The primary methods of coding were hand-coding and machine-learning. The articles predominantly coded for relevance, sentiment, theme, user/account, and location of user. Conclusions: Standards for data collection and coding should be developed to be able to more easily compare and replicate tobacco-related Twitter results. Additional recommendations include: sample Twitter’s databases multiple times, make a distinction between message attitude and emotional tone for sentiment, code images and URLs, and analyze user profiles. Being relatively novel and widely used among adolescents and Black and Hispanic individuals, Twitter could provide a rich source of tobacco surveillance data among vulnerable populations.

  • Description of the Emergence of a Health Care Online Community of Practice: Using a Netnographic Framework for Twitter Hashtag Analytics

    Date Submitted: Nov 29, 2016
    Open Peer Review Period: Nov 30, 2016 - Jan 25, 2017

    Background: The advent of social media as an educational tool is based on the assumption that online communities of practice (CoP) emerge from these interactions. These communities offer an open digital space and flat role hierarchy for information sharing and provide a strong group identity, rapid flow of information, content curation, and knowledge translation. To date, no evidence verifies the existence of online CoP. Objective: We aimed to demonstrate the emergence of a online CoP through the study of social media interactions of the Free Open Access Medical education movement. Methods: We examined the social media activity in Twitter by analyzing the network centrality metrics of tweets with the #FOAMed hashtag and compared them with previously validated criteria to determine whether it was a true community of practice. Results: The centrality analytics of the FOAMed community showed marked concordance with all aspects of a general community of practice (in terms of community, domain, and practice), as well as with the specific traits of a health care community, including interdependence, community-based interactions, social control common purpose, flat hierarchy, and network-based and concrete achievement. Conclusions: This study showed the emergence of online CoP focused on education and based on social media interactions. These communities result in significant knowledge translation and practice change for their participants. Clinical Trial: N/A

  • Sexual Health and the Internet: A Cross-Sectional Study on Online Preferences amongst Adolescents

    Date Submitted: Nov 29, 2016
    Open Peer Review Period: Nov 30, 2016 - Jan 25, 2017

    Background: The internet is widely used by adolescents for sexual health information and bears the potential to increase knowledge and positively affect behavior. Objective: The objective of this study is to assess students’ preferences when looking for sexual health information online. Methods: We conducted a cross-sectional survey amongst 9th-grade students in a convenience sample of 13 secondary schools in Berlin, Germany. During a regular school period, participants were requested to rate the importance they attribute to nine aspects of sexual health websites in a paper-based questionnaire. Bivariate and multivariable analyses were used to assess awareness and preferences by gender, age, migrant background and school type. Results: Out of 1,190 eligible students, 1,177 (98.9%) students with a mean age of 14.6 years participated (SD = .67), 52.5% were male and 52.9% had at least one parent born abroad. Participant numbers were spread equally across the three types of secondary schools in Berlin. Website aspects most frequently cited as important were easily comprehensible wording (88.3%), clear information layout (80.6%) and reliability of the website’s publisher (79.2%), whilst the visual style of a website was deemed important by the lowest number of students (35.1%). Demographic differences were particularly visible in how important respondents found publisher reliability: the odds ratio from multivariable regression for male students to select this item was .50 (reference=female, Confidence Interval (CI) .37; .69). The odds ratio for students with migrant background was .64 (reference=no migrant background, CI .50;.81) and .49 for students of the most academic set of schools (reference=least academic, CI .25;.97). Conclusions: Students prefer easily understandable online resources. Setting up sexual health websites according to the explicit preferences of the target audience might encourage usage, especially by those subpopulations less likely to critically assess information validity: Male adolescents, children of immigrants and the academically disadvantaged.

  • COPD self-management with web-based platforms: high level of integration in integrated disease management leads to higher usage in the e-Vita COPD study

    Date Submitted: Nov 24, 2016
    Open Peer Review Period: Nov 28, 2016 - Jan 23, 2017

    Background: Worldwide nearly 3 million people die from chronic obstructive pulmonary disease (COPD) every year. Integrated disease management (IDM) improves disease-specific quality of life and exercise capacity for people with COPD, but can also reduce hospital admissions and hospital days. Self-management of COPD through eHealth interventions has shown to be an effective method to improve the quality and efficiency of IDM. Objective: Our study, e-Vita COPD, compares different levels of integration of web-based self-management platforms in IDM in 3 primary care settings. The main aim of this study is to analyze the factors that successfully promote the use of a self-management platform for COPD patients. Methods: We investigated different implementation methods of two platforms using a parallel cohort design. The design included three different levels of integration in IDM (group 1, 2 and 3) and randomization of two levels of personal assistance for patients (group A high assistance and B no assistance). Every visit to the platforms e-Vita and Zorgdraad was tracked objectively by collecting log data (sessions and services). The amount of use and user's patterns were analyzed. Baseline characteristics were extracted from the log files, i.e. age, gender, education level, scores on the Clinical COPD Questionnaire (CCQ) and on 3 questionnaires. Multiple regression analyses were used to evaluate the care group, integration in IDM (high, medium, non) and personal assistance for the participants (high vs. low assistance) as determinants for the usage. We analyzed the educational level and self-efficacy level (GSES) as independent variables to predict the usage of the platform. A correction was made for age and gender. Results: Of the 702 invited COPD patients, 215 (31%) registered to a platform. 82 patients participated in group 1 (high integration IDM); 36 patients in group 1A (personal assistance), 46 in group 1B (low assistance). 96 patients participated in group 2 (medium integration IDM); 44 in group 2A (telephone assistance) and 52 in group 2B (low assistance). 37 patients participated in group 3 (no integration IDM). 107 users visited the platform at least once in the 15-month period. The mean (SD) number of sessions differed between the three groups 1, 2 and 3 (10.5 (SD 1.3); 8.8 (SD 1.4) and 3.7 (SD 1.8) respectively, p=0.011). The mean (SD) number of sessions differed between high assistance group 1A & 2A and low assistance group 1B & 2B; (11.8 (SD 1.3); 6.7 (SD 1.4) respectively, p=0.012). No association was found between the educational level and the usage and between the GSES and the usage. Conclusions: Use of a self-management platform is higher when the platform is an integrated part of IDM, with adequate personal assistance about how to use the platform. An implementation setup with blended care, will likely lead to increased use of the online program. Future research should provide additional insights into the preferences of different patient groups. Clinical Trial: NTR4098 (31072013)

  • Exercise Intensities: The Accuracy of Self-monitoring Heart Rate and Physical Activity Wearable Devices

    Date Submitted: Nov 24, 2016
    Open Peer Review Period: Nov 26, 2016 - Jan 21, 2017

    Background: Physical activity tracking wearables have emerged as an increasingly popular method for consumers to assess their daily activity and calories expended. However, it is unknown if these wearables are valid at different levels of exercise intensity. Objective: To examine heart rate (HR) and energy expenditure (EE) validity of three popular wrist-worn activity monitors at different exercise intensities. Methods: 62 participants (36 females, 46.8% non-white) wore the Apple Watch (AW), Fitbit Charge HR (FCHR) and Garmin Forerunner 225 (GF). Validity was assessed by 2 criterion devices: HR chest strap and a metabolic cart. Participants completed a 10-min seated baseline; separate 4-min stages of light, moderate and vigorous-intensity treadmill exercises; and a 10-min seated recovery. Data from devices were compared to each criterion via two-way RM-ANOVA and Bland-Altman analysis. Differences were expressed in mean absolute percentage error values (MAPE). Results: AW – HR MAPE between 1.14-6.70%. HR not significantly different at the start (p = .13), baseline (p = .76) or vigorous intensity (p = .84). Lower HR readings during light (p < .05), moderate (p < .01) and recovery (p < .01). EE MAPE between 14.07-210.84%. Measured higher EE at all stages (p < .01). FCHR – HR MAPE between 2.38-16.99%. HR not significantly different at start (p = .43) or moderate intensity (p = .34). Lower HR readings during baseline, vigorous and recovery (p < .001) and higher HR in light (p < .001). EE MAPE between 16.85-84.98%. Measured higher EE at baseline (p < .05), light (p < .001) and moderate (p < .001). GF – HR MAPE between 7.87-24.38%. HR not significantly different at vigorous intensity (p = .35). Measured higher HR readings start, baseline, light, moderate (p < .001) and recovery (p < .05). EE MAPE between 30.77-155.05%. Measured higher EE at all stages (p < .001). Conclusions: This study provides one of the first validation assessments for the Fitbit Charge HR, Apple Watch and Garmin Forerunner 225. An advantage and novel approach of the study is the examination of HR and EE at specific PA intensities. Establishing validity of wearables is of particular interest as these devices are being used in weight loss interventions and could impact findings. Future research should investigate why differences between exercise intensities and the devices exist.

  • Ethics and Privacy Implications of Using the Internet and Social Media to Recruit Participants for Health Research: A Privacy-by-Design Framework for Online Recruitment

    Date Submitted: Nov 22, 2016
    Open Peer Review Period: Nov 25, 2016 - Jan 20, 2017

    Introduction: The Internet, and in particular social media, offer promising ways to improve the reach, efficiency and effectiveness of recruitment efforts at a reasonable cost, but raise unique ethical dilemmas. We describe how we used social media to recruit cancer patients for a research study, ethical issues we encountered, and the strategies we developed to address them. Drawing on the principles of Privacy by Design (PbD), a globally recognized standard for privacy protection, we offer a PbD framework for online research recruitment. Case: A focus group study on the dietary behaviors of cancer patients and their families, and the role of web-based dietary self-management tools. Using an established blog on our hospital website, we proposed publishing a recruitment post and sharing the link on our Twitter and Facebook pages. The Research Ethics Board (REB) raised concern about the privacy risks associated with our recruitment strategy: by clicking on a recruitment post, an individual could inadvertently disclose personal health information to third party companies engaged in tracking online behavior. Discussion: Ethical guidelines recommend a proportionate approach to ethics assessment, which advocates for risk mitigation strategies that are proportional to the magnitude and probability of risks. We include a critical reflection of the perceptions of potential risks associated with our social media recruitment strategy and the appropriateness of our risk mitigation. Conclusion: Researchers, REBs, ethicists, students, and potential study participants are often unaware of the privacy risks of social media research recruitment and there is no official guidance. Our PbD framework for online recruitment is a resource for these wide audiences.

  • What motivates young adults to talk about physical activity on social network sites?

    Date Submitted: Nov 20, 2016
    Open Peer Review Period: Nov 24, 2016 - Jan 19, 2017

    Background: Electronic word-of-mouth on social network sites has been used successfully in marketing. In social marketing, electronic word-of-mouth about products of health behaviors on SNSs has the potential to be more effective and reach more young adults than health education through traditional mass media. However little is known about what motivates people to actively initiate electronic word-of-mouth about health behaviors on their personal pages/profiles on social network sites where electronic word-of-mouth can reach all their contacts on social network sites. Objective: This study filled the gap by applying a marketing theoretical model to explore the factors associated with electronic word-of-mouth on social network sites about leisure-time physical activity. Methods: A web survey link was sent to undergraduate students at a Midwestern university and 439 completed the survey. Results: Results suggested emotional engagement with leisure-time physical activity (i.e., affective involvement in leisure-time physical activity) predicted providing leisure-time physical activity opinions or information on social network sites. Social network sites users who felt closer to their contacts on social network sites were more likely to provide and seek leisure-time physical activity opinions and information. People who provided leisure-time physical activity opinions and information were more likely to seek opinions and information. People who forwarded leisure-time physical activity information about leisure-time physical activity were more likely to chat about leisure-time physical activity information. Conclusions: This study shed light on the application of the electronic word-of-mouth theoretical framework in promoting health behaviors. The findings can also guide the development of future social marketing interventions using social network sites to promote leisure-time physical activity.

  • Using Feedback to Promote Physical Activity: The Role of the Feedback Sign

    Date Submitted: Nov 21, 2016
    Open Peer Review Period: Nov 24, 2016 - Jan 19, 2017

    Background: Providing feedback is a technique to facilitate behavior change that is widely used in health interventions. One important characteristic of feedback is the feedback sign, i.e. whether the feedback signals success or failure. Despite its widespread use, the effect of the feedback sign has so far not been examined with regard to health behavior change and the underlying theoretical mechanisms are unclear. Objective: To examine the effect of the feedback sign in a health behavior change intervention. Methods: Data from N = 1623 participants of a six-month physical activity intervention was used. Participants received five feedback emails over the course of the intervention. Feedback was either positive or negative depending on the participants’ physical activity. In two separate analyses, monthly comparisons of step counts were used to evaluate the feedback effect. Results: Results indicate a small but substantial main effect of the feedback sign on behavior change (r = .25; r = .21). Negative feedback was followed by an increase and positive feedback was followed by a decrease of step counts. Conclusions: Our study illustrates that feedback can have detrimental effects on behavior and should therefore be implemented with high diligence. Theoretical and practical implications as well as limitations of the study are discussed.

  • Randomised controlled trial to assess feasibility and acceptability of web-based enhanced relapse prevention for bipolar disorder (ERPonline)

    Date Submitted: Nov 17, 2016
    Open Peer Review Period: Nov 21, 2016 - Jan 16, 2017

    Background: Interventions that teach people with Bipolar Disorder (BD) to recognise and respond to early warning signs of relapse are NICE recommended but implementation in clinical practice is poor. Objective: This study tests the feasibility and acceptability of an online trial to evaluate an online enhanced relapse prevention intervention (ERPonline), and reports preliminary evidence of effectiveness. Methods: Single blind, parallel primarily online randomised controlled trial (n=96) over 48 weeks comparing ERPonline plus usual treatment to waitlist (WL) control for people with BD recruited through national health services, voluntary organisations, and media. Randomisation was independent, minimised on number of previous episodes (<8,8-20,21+). Primary outcomes were feasibility and acceptability assessed by rates of study recruitment and retention, levels of intervention use, adverse events and participant feedback. Process and clinical outcomes were assessed by telephone and online and compared using linear models with intention-to-treat analysis. Results: Two hundred and eighty people registered interest online, from which ninety-six met inclusion criteria, consented and were randomised (49 to WL, 47 to ERPonline) over seventeen months, with 80% retention in telephone and online follow up, except week 48 online (76%). Acceptability was high for both ERPonline and trial methods. Qualitative data highlighted the importance of the relationship users have with online interventions and how this is created as an extension of the relationship with the humans perceived as offering and supporting its use. Access to ERPonline was associated with: a more positive model of bipolar disorder at 24 (10.70 (0.90-20.5 95%CIs)) and 48 weeks (13.1 (2.44-23.93 95%CIs)); increased monitoring of early warning signs of depression at 48 weeks (-1.39 (-2.61, -.163 95%CIs)) and of (hypo)mania at 24 (-1.72 (-2.98, -0.47 95%CIs)) and 48 weeks (-1.61 (-2.92, -0.30 95%CIs)), compared to WL. There was no evidence of impact of ERPonline on clinical outcomes or medication adherence, but relapse rates across both arms were very low (15%) and the sample remained high functioning throughout. One person died by suicide prior to randomisation. Five people in ERPonline and six in WL control reported ideas of suicide or self-harm during the study. None were deemed study related by an independent Trial Steering Committee. Conclusions: ERPonline offers a cheap accessible option for people seeking ongoing support following successful treatment. However, given high functioning and low relapse rates in this study, testing clinical effectiveness for this population would require very large sample sizes. Building in human support to use ERPonline should be considered. Clinical Trial: ISRCTN56908625

  • The impact of social processes in online health communities on patient empowerment in relationship with the physician: Emergence of functional and dysfunctional empowerment

    Date Submitted: Nov 17, 2016
    Open Peer Review Period: Nov 21, 2016 - Jan 16, 2017

    Background: Substantial research has demonstrated the importance of online health communities (OHCs) for patient empowerment, but little is known about the impact of social processes in OHCs on the patient-physician relationship. Patient empowerment also occurs in relationship with the physician, but studies of OHC disregard this or measure phenomena with single item, rendering it impossible to establish psychometric properties. The question also remains about the nature and consequences of this empowerment as it might be based on limited validity of some information in OHCs. Objective: The main purpose of this study was to examine the impact of social processes in OHCs (information exchange with users and medical experts, social support, finding meaning and self-expressing) on functional and dysfunctional patient empowerment in relationship with the physician (PERP). This impact is investigated by taking into account interactions with e-health literacy and physician's paternalism. Methods: The study undertakes a quasi-experimental design on a simple random sample of 25.000 registered users of the most popular general online health community in Slovenia. The final sample size consisted of 591 regular users of the studied OHC, who visited a physician at least once in the last 2 years. Variables with multi-item measurement were tested with exploratory and confirmatory factor analytical procedures. Functional and dysfunctional PERP was predicted with a series of OLS regression analyses with interactions included. Results: Factor analyses of PERP revealed 5-factor structure with acceptable fit (RMSEA=.06, SRMR=.06, CFI=.9). The main results show that functional self-efficacy is positively predicted by information exchange with experts (β=.12, P=.02), information exchange with users (β=.12, P=.05), giving social support (β=.12, P=.02), but negatively with receiving of social support (β=-.21, P<.001). Functional control is also predicted by information exchange with experts (β=.16, P=.005). Dysfunctional aspects of empowerment are also dependent on social processes in OHC. Dysfunctional control and competence are inhibited by information exchange with experts (β=-.12, P=.03), but stimulated by receiving social support (β=.11, P=.05), while dysfunctional self-efficacy is inhibited by self-expressing (β=-.12, P=.05). Perceived paternalism of physician and e-health literacy are important control and moderating variables. Most notably, process of finding meaning will likely lead to development of dysfunctional competences and control if physician is perceived as paternalistic (β=-14, P=.03). On the other hand under condition of high e-health literacy, process of finding meaning will inhibit development of dysfunctional competences and control (β=-.17, P=.01). Conclusions: Social processes in OHCs do not have a uniform impact on PERP and this impact is moderated by E-health literacy and physician’s paternalism. Exchanging information with health professionals in OHCs is most important factor for stimulating functional and diminishing dysfunctional PERP. Social support in OHCs plays an ambiguous role, often making patients behave in a strategic, uncooperative way toward physicians.

  • Understanding health information seeking online; who, when, and why: a qualitative study in Hong Kong.

    Date Submitted: Nov 16, 2016
    Open Peer Review Period: Nov 18, 2016 - Jan 13, 2017

    Background: The Internet has become an established source for health information. The number of individuals using the Internet to search for health information, ranging from healthy lifestyle advices to treatment and diseases, continues to grow. Scholars have emphasized the need to give greater voice and influence to health consumers. Hong Kong being one of the most technologically advanced and connected cities in the world, has one of the highest Internet penetration in the world. Given the dearth of research in an Asian context, Hong Kong is an excellent platform to study individuals’ perceptions (e.g., benefits and limitations on seeking health information online, and how the information is used) on health information seeking. Objective: To study individuals’ perceptions on health information seeking and to document their online information seeking behaviours. Methods: Five focus groups (n=49) were conducted during November 2015 to January 2016 with individuals across different age groups (18 or above). Focus group contents were audiotaped, transcribed, and analyzed using thematic analysis techniques. Results: Older (55+ years old) and less educated respondents were less likely to use the Internet to search for health information. Among individuals who obtained health information online, regardless of the severity of the health issue, the Internet was always the first source for information. Limited doctor consultation time and barriers to accessing professional health services were the main reasons for using the Internet. Convenience and coverage, were regarded as the main advantages, while credibility and trustworthiness of health information were noted as limitations. The use of online health information varied among individuals, hence the implications on the doctor-patient relationship were mixed. Conclusions: The prevalent and increasing use of Internet for health information seeking suggests the need for health care professionals to understand how it can be optimally utilized to improve health outcomes. Strategies for communicating and disseminating credible health information in a form that users can understand and use are essential. Because of the rapid technological and related behavioural changes, online health information seeking and its effects need to be closely monitored.

  • Objective Attention Deficit Hyperactivity Disorder Assessment using a Kinectized Continuous Performance Test

    Date Submitted: Nov 13, 2016
    Open Peer Review Period: Nov 14, 2016 - Jan 9, 2017

    Background: One of the major challenges in mental medical care is to find out new instruments for an accurate and objective attention deficit hyperactivity disorder (ADHD) diagnosis. Early ADHD identification and prompt treatment are essential to avoid the negative effects associated to this mental condition. Objective: To develop a novel ADHD assessment instrument based on Microsoft Kinect which identifies ADHD cardinal symptoms in order to provide a more accurate evaluation. Methods: A group of 10 children, aged 8 to 12 years (10.8±1.48; Male 50%) from the Child and Adolescent Psychiatry Unit of the Department of Psychiatry at Fundación Jiménez Díaz Hospital (Madrid, Spain), were included in this study. Children were required to meet DSM-5 criteria of ADHD diagnosis. One of the parents or guardians of the children filled the Spanish version of the Strengths and Weaknesses of ADHD Symptoms and Normal Behaviors Rating Scale (SWAN) used in clinical practice. Each child conducted a kinectized continuous performance test in which the reaction time (RT), the commission errors, and the time required to complete the reaction (CT) were calculated. The correlations of the three predictors, obtained using Kinect methodology, with respect to the scores of the SWAN scale were calculated. Results: The RT achieved a correlation of 0.08, -0.30 and -0.04 with respect to the inattention, hyperactivity and impulsivity factors of the SWAN scale. The correlations of the commission error with respect to these three factors were -0.16, 0.35 and 0.33, respectively. Regarding the CT, the correlations with the three factors of the SWAN scale were 0.27,-0.05, -0.01. Conclusions: Our findings show a relation between the kinectized version of the CPT and ADHD symptomatology assessed through parental report. Results points out the importance of future research on the development of objective measures for the diagnosis of ADHD among children and adolescents.

  • Real-time Mobile Device-Based Electronic Data Capture System (mEDC) in Research: Experience in a Pharmaceutical Clinical Trial

    Date Submitted: Nov 9, 2016
    Open Peer Review Period: Nov 14, 2016 - Jan 9, 2017

    Background: Mobile device-based electronic data capture (mEDC) systems are becoming increasingly popular nowadays, which could help users conduct data collection and project management in clinical trials. Objective: This study aimed to evaluate the feasibility of the mEDC for data collection and management in a multicenter, randomized pharmaceutical clinical trial. Methods: We developed the mEDC to support the THAT trial comparing the efficacy of telmisartan and hydrochlorothiazide monotherapy in high sodium intake patients with mild to moderate hypertension. To ensure compliance with regulatory requirements, the design of the mEDC was based on three guidelines focusing on EDC systems for randomized controlled clinical trials. Semi-structured interviews were conducted to evaluate the feasibility of the mEDC. Nvivo 9.0 was applied to analyze records of interviews, and a thematic framework method was used to obtain outcomes. Results: With support of the mEDC, 1333 patients were recruited, of whom 1037 successfully completed all visits during 2 months. Across all visits, the average time needed for 141 questions per patient was 53 minutes. Overall, 24 doctors, 53 patients, 1 clinical research associate, 1 project manager, and 1 data manager were involved in the qualitative evaluation. All the interviewees reported being satisfied with the mEDC, and expressed their expectation for using the mEDC in the future. The average satisfaction score was 9.2 (scale, 0–10). Conclusions: The mEDC was a feasible tool to implement the THAT trial, and has the potential to be applied in other pharmaceutical clinical trials in the future.

  • Development of a theory- based online intervention for post-treatment cancer survivors

    Date Submitted: Nov 14, 2016
    Open Peer Review Period: Nov 14, 2016 - Jan 9, 2017

    Background: Cancer-related fatigue (CrF) is the most common and disruptive symptom experienced by cancer survivors. This paper describes the development of a theory-based, interactive web-based intervention designed to facilitate self-management and enhance coping with CrF following cancer treatment. Objective: This paper outlines the process and method of development of the intervention. The content and principles used in the development process are described, while also clarifying hypothesised causal mechanisms Methods: In this paper, we outline the process of establishing a therapeutic approach based on theory and an extensive review of the literature. We describe the design of the content of the intervention, and of the website features. the initial usability testing of the website. The aim is to outline the rationale, decision-making processes, methods, and findings which led to the development of an online intervention to be tested in a feasibility trial Results: The co-creation of the intervention with the experts and service users allowed the design team to ensure that an acceptable intervention was developed. This evidence-based online programme is the first intervention of its kind based on self-regulation model theory, with the primary aim of targeting the representations of fatigue and enhancing self-management of CrF specifically. Conclusions: This research sought to integrate psychological theory, existing evidence of effective interventions, empirically derived principles of web design, and the views of potential users into the systematic planning and design of the intervention of an easy to use website for cancer survivors Clinical Trial: ISRCTN55763085

  • ComMove: Designing Guided In-Car Mindful Movement Interventions for Commuters

    Date Submitted: Nov 12, 2016
    Open Peer Review Period: Nov 12, 2016 - Jan 7, 2017

    Background: The daily commute could be an opportune moment to teach drivers to use movement or breath towards improving their mental health. While driving safety is paramount, mindful exercise might help commuters to decrease the effects of daily stress while staying alert. Increasing vehicle automation may present new opportunities but also new challenges. Objective: This paper aims to describe the design space for mindful movement interventions for commuters. We use qualitative analysis of simulated driving experiences in combination with simple movement-based commands to generate guidelines for design and research in this topic. Methods: We performed a semi-structured viability assessment in which drivers (N= 12) were given simple instructions to complete a series of basic movements, breathing exercises, and visualization techniques while engaged in either a simple or complex simulated urban driving task, using autonomous and manual driving modes. We also designed and evaluated a set of vibrotactile patterns from the car seat that cue users to perform these movements. We report a spectrum of obvious and less obvious individual emotional and cognitive reactions to the movements and the vibrotactile cues. Results: We report a summary of individual emotional and cognitive reactions to the movements and the vibrotactile cues. Based on our assessment, we suggest the best situations within a drive to perform movement-based interventions; we describe movements and exercises that may interfere with driving and those that are complementary with driving; identify the movements that are conducive towards “soothing,” and we evaluate vibrotactile stimuli that could trigger or guide such movements and exercises. We discuss key design elements such as the driving modality, system customization, social perception influence in users, and the role of prior awareness of mindful techniques in the adoption of new movement-based techniques. Conclusions: These findings provide insight into which movements to recommend when to encourage mindful movements while commuting, and how best to communicate the moves using non-invasive haptic cues.

  • How the “Understanding Research Evidence” web-based video series from the National Collaborating Centre for Methods and Tools contributes to public health capacity to practice evidence-informed decision making: A mixed-methods evaluation

    Date Submitted: Nov 8, 2016
    Open Peer Review Period: Nov 9, 2016 - Jan 4, 2017

    Background: The National Collaborating Centre for Methods and Tools (NCCMT) offers workshops and webinars to public health professionals to build capacity for evidence-informed public health. Despite positive feedback for NCCMT workshops and resources, NCCMT users found key terms used in research papers difficult to understand. The Understanding Research Evidence (URE) videos use plain language, cartoon visuals, and public health examples to explain complex research concepts. The videos are posted on the NCCMT website and on the NCCMT’s YouTube channel. Objective: An evaluation was conducted to examine public health professionals’ experience with the first four videos in the URE web-based video series to explain how the videos affected their professional practice. A mixed-methods approach was used to examine the delivery mode and the content of the videos. Specifically, the evaluation explored: 1) whether the videos were effective at increasing knowledge on the four video topics, 2) public health professionals’ satisfaction with the videos, and 3) how public health professionals applied the knowledge gained from the videos in their work. Methods: A three-part evaluation was conducted to determine the effectiveness of the first four URE videos. The evaluation included an online survey, telephone interviews, and pretest/posttests to evaluate public health professionals experience with the videos, and how the videos affected their public health work. Participants were invited to participate in this evaluation through various public health open-access e-mail lists, through informational flyers and posters at the Canadian Public Health Association conference, and through targeted recruitment to NCCMT’s network. Results: In the online surveys (n=46), participants achieved higher scores on the knowledge assessment questions from watching the odds ratio (P=.036), confidence interval (P=.036), and clinical significance (P=.049) videos but not the forest plot (P=.118) video, compared to participants who had not watched the videos. The pretest/posttest (n=124) demonstrated that participants had a better understanding of forest plots (P=.00) and confidence intervals (P=.00) after watching the videos. Due to small sample size numbers, there was insufficient pretest/posttest data to conduct meaningful analyses on the clinical significance and odds ratio videos. Telephone interview participants (n=18) thought the videos’ use of animation, narration, and plain-language was appropriate for people with different levels of understanding and learning styles. Participants felt that, by increasing their understanding of research evidence, they could develop better interventions and design evaluations to measure the impact of public health initiatives. Conclusions: Overall, the results of the evaluation showed that watching the videos resulted in an increase in knowledge, and participants had an overall positive experience with the URE videos. With increased competence in using the best available evidence, professionals are empowered to contribute to decisions that can improve health outcomes of communities.

  • There are few high quality apps for people with rheumatoid arthritis to monitor their disease activity: a review of apps for best practice and quality

    Date Submitted: Nov 6, 2016
    Open Peer Review Period: Nov 9, 2016 - Jan 4, 2017

    Background: Rheumatoid arthritis (RA) is a chronic inflammatory arthritis requiring long-term treatment with regular monitoring by a rheumatologist to achieve good health outcomes. Since people with RA may wish to monitor their own disease activity with a smartphone application (app), it is important to understand the functions and quality of apps for this purpose. Objective: To assess the features and quality of apps to assist people to monitor their RA disease activity by: 1. Summarizing the available apps, particularly the instruments used for measurement of RA disease activity; 2. Comparing the app features with American College of Rheumatology/European League against Rheumatism (ACR/EULAR) guidelines for monitoring of RA disease activity; and 3. Rating app quality with the Mobile Application Rating Scale. Methods: Systematic searches of the New Zealand iTunes and Google Play app stores were used to identify all apps for monitoring of RA disease activity that could be used by people with RA. The apps were described both by key meta-data and the app functionality. App adherence with recommendations for monitoring of RA disease activity in clinical practice was evaluated by identifying if apps included calculation of a validated composite disease activity measure and recorded results for future retrieval. App quality was assessed by two independent reviewers using the Mobile App Rating Scale (MARS). Results: The search identified 721 apps in the Google Play store and 216 in the iTunes store, of which 19 unique apps met criteria for inclusion (eight from both app stores, eight iTunes and three Google play) Fourteen apps included at least one validated instrument measuring RA disease activity. Eight of eleven apps that allowed users to enter a joint count used the standard 28 swollen and tender joint count. Eight apps included at least one ACR/EULAR recommended RA composite disease activity (CDA) measure. Ten apps included data storage and retrieval. Only one app, Arthritis Power, included both a RA CDA measure and tracked data but this app did not include the standard 28 tender and swollen joint count. The median MARS score for apps was 3.41/5. Of the five apps which scored ≥4/5 on the MARS rating, only one included a CDA score endorsed by ACR/EULAR but this app did not have a data tracking function. Conclusions: This review found a lack of high quality apps for longitudinal assessment of RA disease activity. Current apps fall into two categories: simple calculators for rheumatologists, or data tracking tools for people with RA. The latter do not uniformly collect data using validated instruments or composite disease activity measures. There is a need for appropriate, high quality apps for use by rheumatologists and patients together in co-management of RA. Clinical Trial: Not applicable

  • InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial with Primary Care Physicians

    Date Submitted: Nov 4, 2016
    Open Peer Review Period: Nov 8, 2016 - Jan 3, 2017

    Background: Most patients with diabetes mellitus (DM) are followed by primary care physicians, who often lack knowledge or confidence to prescribe insulin properly. This contributes to clinical inertia and poor glycemic control. Effectiveness of traditional continuing medical education (CME) to solve that is limited, so new approaches are required. Electronic games are a good option, since they can be very effective and easily disseminated. Objective: To assess applicability, user acceptance, and educational effectiveness of InsuOnline, an electronic serious game for medical education on insulin therapy for DM, compared to a traditional CME activity. Methods: Primary care physicians (PCPs) from South of Brazil were invited by phone or email to participate in an unblinded randomized controlled trial, and randomly allocated to play the game InsuOnLine, installed as an app in their own computers, in the time of their choice, with minimal or no external guidance, or to participate in a traditional CME session, composed by onsite lectures and cases discussion. Both interventions had the same content and duration (~4 hours). Applicability was assessed by how many subjects completed the assigned intervention in each group. Insulin-prescribing competence (factual knowledge, problem-solving skills, and attitudes) was self-assessed through a questionnaire applied before, immediately after, and 3 months after the interventions. Acceptance of the intervention (satisfaction and perceived importance for clinical practice) was also assessed immediately after, and 3 months after the interventions, respectively. Results: Subjects characteristics were similar between groups (mean age 38, 51% male). In game group, 69 of 88 (78%) completed the intervention, compared to 65 of 73 (89%) in control group, with no diference in applicability. Percentage of right answers in the competence subscale, which was 52% at baseline in both groups, significantly improved immediately after both interventions: to 92% in the game group, and to 85% in control (P<.001). After 3 months, it remained significantly higher than at baseline in both groups (80% in game, and 76% in control; P<.001). Absolute increase in competence score was better with the game (40%) than with traditional CME (34%; P=.01). Insulin-related attitudes were more affected by the game (significant improvement in 5 out of 9 items) than in control group (2 out of 9). Both interventions were very well accepted, with most subjects rating them as “fun/pleasant”, “useful” and “practice-changing”. Conclusions: The game InsuOnLine was applicable, very well accepted, and extremely effective for medical education on insulin therapy. In view of its flexibility and easy dissemination, it is an excellent option for large-scale CME, potentially helping to reduce clinical inertia and to improve quality of care for DM patients. Clinical Trial: NCT01759953.

  • Directional and non-directional peer support in online mental health forums for young people

    Date Submitted: Oct 30, 2016
    Open Peer Review Period: Nov 3, 2016 - Dec 29, 2016

    Background: The internet has the potential to help young people by reducing the stigma associated with mental health and enabling young people to access services and professionals who they may not otherwise access. Online support can empower young people, help them develop new online friendships, share personal experiences, communicate with others who understand, provide information and emotional support and most importantly help them feel less alone and normalise their experiences in the world. Objective: The aim of the research was to gain an understanding of how young people use an online forum for emotional and mental health issues. Specifically, the project examined what the young people discuss and how they seek support on the forum (objective 1). Further it looked at how the young service users responded to posts in order to gain an understanding of how young people provided each other with peer to peer support (objective 2). Methods: Kooth is an online counselling service for young people aged 11-25 experiencing emotional and mental health problems. It is based in the UK and provides support that is anonymous, confidential and free at the point of delivery. Kooth provided the researchers with all the online forum posts between a two year period which resulted in a data set of 622 initial posts and 3,657 initial posts with responses. Thematic analysis was employed to elicit key themes from the data set. Results: The findings support the literature that online forums provide young people with both informational and emotional support around a wide array of topics. The findings from this large data set also reveal that this informational and/or emotional support can be viewed as directive or non-directive. The non-directive approach refers to when young people provide others with support by sharing their own experiences. These posts do not include explicit advice to act in a particular way but the sharing process is hoped to be of use to the poster. The directive approach, in contrast, involves individuals making an explicit suggestion of what they believe the poster should do. Conclusions: This study adds to the research exploring what young people discuss within online forums and provides insights into how these communications take place. Further, it highlights the challenge that organisations may encounter in mediating support that is multidimensional in nature (informational-emotional, directive-non-directive).

  • Comparing Crowdsourcing and Friendsourcing: a Social Media Based Feasibility Study to Support Alzheimer’s Disease Caregivers

    Date Submitted: Oct 30, 2016
    Open Peer Review Period: Nov 3, 2016 - Dec 29, 2016

    Background: In the United States, over 15 million informal caregivers provide unpaid care to people with Alzheimer’s disease (AD). Compared to others in their age group, AD caregivers suffer from higher rates of stress, medical and psychiatric illness. Psychosocial interventions improve the health of caregivers. However, constraints of time, distance and availability inhibit the utilization of these services. Newer online technologies such as social media, online groups, friendsourcing and crowdsourcing, present alternative methods of delivering support. However, limited work has been done in this area with caregivers. Objective: The primary aim of this study was to determine the feasibility of innovating peer support group work delivered through social media with friendsourcing. A Facebook app provided support to AD caregivers through collecting friendsourced answers to caregiving questions from participants’ social networks. The study’s secondary aim descriptively compared friendsourced answers to crowdsourced answers. Methods: This feasibility study recruited AD caregivers online to participate in a 6 week long asynchronous, online, closed group on Facebook, where caregivers received support through moderator prompts, group member interactions and friendsourced answers to caregiving questions. Participants were surveyed and interviewed before and after the online group to assess their needs, views on technology and experience with the intervention. Caregiving questions were pushed automatically to the participants’ Facebook Newsfeed, allowing participants’ Facebook friends to see and post answers to the caregiving questions (Friendsourced answers). Two of these caregiving questions were pushed to crowdsource workers through the Amazon Mechanical Turk platform. Characteristics of these crowdsourced answers were descriptively compared with the friendsourced answers. Results: Six AD caregivers completed the initial online survey and semi-structured phone interview. Four of these six participants agreed to participate in the online Facebook closed group activity portion of the study. Friendsourcing and crowdsourcing answers to caregiving questions had similar rates of acceptability as rated by content experts, 90% and 100% respectively. Rates of emotional support and informational support for both groups of answers appeared to trend with the type of support emphasized in the caregiving question (emotional vs. informational support question). Friendsourced answers included more shared experiences (67%) than crowdsourced answers (9%). Conclusions: An asynchronous, online, closed group on Facebook was found to be generally acceptable as a means to deliver support to caregivers of people with AD. Both friendsourced and crowdsourced answers may be an acceptable way to provide informational and emotional support to caregivers of people with AD. Friendsourced answers demonstrated higher rates of shared experiences.

  • ‘Click for Closer Care’: A Content Analysis of Community Pharmacy Websites in Four Countries

    Date Submitted: Oct 30, 2016
    Open Peer Review Period: Nov 3, 2016 - Dec 29, 2016

    Background: Community pharmacies are undeniably taking up an increasingly extended role in health care provision nowadays, and this is leading to –potentially controversial- combinations of clinical and commercial services hitherto unprecedented in professional health care. However it is unknown to which extent this development manifests on the Internet. Objective: To fill the void of knowledge about clinical and commercial services presented on the websites of licensed community pharmacies nowadays. Methods: A content analysis of clinical and commercial services present in a random sample of 200 licensed community pharmacy websites from Great Britain, the Netherlands, the Canadian provinces British Columbia and Manitoba, and the Australian states New South Wales and Western Australia. Results: The top-5 specific services mentioned on the community pharmacy websites were cosmetic products (62.7%), medication refill request options (62.0%), over-the-counter medicine (57.5%), complementary and alternative medicine (53.5%), and home medical aids (49.0%) respectively. On average 72.5% of the community pharmacy websites across the four countries included combinations of clinical and commercial services. Combinations of clinical and commercial services were more often present on chain pharmacy websites (82.8%) than single pharmacy websites (47.2%) (P < .001), and most often on the Canadian community pharmacy websites, followed by the Australian, British, and Dutch pharmacy websites respectively (P < .05). Further, more than half of the pharmacies’ homepages contained combinations of clinical and commercial images (54.0%), and almost half of the homepage menus contained combinations of clinical and commercial items (49.5%). The latter were again more common on chain pharmacy than single pharmacy websites (P < .001), with significant differences between countries (P < .001). Conclusions: A considerable share of the websites of licensed community pharmacies in Great Britain, the Netherlands, Canada, and Australia nowadays combine a clinical offer with commercial services. Previous research into combinations of commercial and professional services suggests that such combinations may lead to increased interest in commercial services that may be unnecessary or inappropriate to patients’ health.

  • Communicating Research Findings: as a Case Study

    Date Submitted: Oct 28, 2016
    Open Peer Review Period: Nov 1, 2016 - Dec 27, 2016

    Background: The disconnect between academic research and what is reported in the mainstream media suggests the need to connect journalists, policy makers, and the public with the best available evidence on high profile health policy topics. While well positioned to provide this evidence, approximately half of researchers do not engage with the media; fewer than half promote their research through social media. was created in Canada in 2011 to overcome obstacles faced by researchers and the media in accurately communicating health policy-related evidence. Objective: To describe and highlight the factors underlying a uniquely successful Canadian effort,, to widely disseminate important research results. The importance of a balanced effort building on both new and traditional media is emphasized. Methods: This case-study of describes a mechanism to engage both academics and the media to improve health policy reporting. We review the methods used by to gain credibility with the media and to adapt academic writing to better communicate evidence, while responding to the ever-changing needs of media outlets. Internet analytics highlight the growing reach of Key examples demonstrate the potential impact of communicating research through the media. Results: engages academics and the media to improve health policy reporting primarily through supporting the development of evidence-based op-eds (a commentary placed opposite the editorial page). Once accepted by traditional print and new media outlets, uses social media (e.g., Facebook, Twitter, Reddit and LinkedIn) to further promote the spread and uptake of the evidence-based messages. To date, a pan-Canadian network of over 80 academics and strong relationships with key media outlets have been developed. Between 2011 and 2016, has helped to get op-eds written by academic experts published over 1,650 times in major Canadian media outlets and over 1,150 more times in smaller community papers (a total of > 2,800 publications). Other communications initiatives include media backgrounders, posters and infographics, podcasts, eBooks, webinars and conferences. Examples of evidence uptake by governments and policy makers at both provincial and federal levels demonstrate impact. Conclusions: has developed a successful method for overcoming tensions between academics and the media in order to improve health policy reporting. The network’s niche product pushes evidence-based knowledge using traditional, new media and social media. Academics are given a powerful opportunity to have their research understood and used by patients, the public and policy makers.

  • Characterising Measurements in Health Self Quantification: A Tools Review Study

    Date Submitted: Oct 27, 2016
    Open Peer Review Period: Oct 27, 2016 - Dec 22, 2016

    Background: Background: The use of wearable devices for health self-quantification (SQ) introduces new ways of thinking about one’s body and how to achieve the desired health outcomes. Measures related to heart rate, respiratory volume, skin temperature, blood volume pulse, sleep, mood, blood pressure, food consumed, quality of surrounding air – anything from mental, emotional, and physical to social and environmental aspects of daily life can be acquired, quantified, and aggregated in a holistic way that has never been possible before. However, health SQ lacks a formal common language or taxonomy for describing these measurements. Establishing such taxonomy is important because it enables systematic investigations which are needed to improve the use of wearable devices in health self-care, and contributes to provide evidence of sufficient quality to determine whether and how health SQ is a worthwhile healthcare paradigm. Objective: Objectives: This study aims to investigate a sample of wearable devices in order to build and test a taxonomy of measurements in health SQ. This is called the Classification of Data and Activity in Self-Quantification Systems (CDA-SQS). Methods: Methods: A sample of seven health SQ devices/services was selected to be examined in detail: 1) Zeo Sleep Manager, 2) Fitbit Ultra, 3) Fitlinxx Actipressure, 4) iBGStar, 5) Sensaris Senspod, 6) 23andMe, 7) uBiome. Open coding technique was followed to find all the themes that are related to our research aim. Results: Results: This study helped to distinguish between three types of measurements in health SQ: body structures and functions, body actions and activities, and around body. The CDA-SQS classification should be applicable to studying health SQ among people whatever their health objectives, health status and conditions are. Conclusions: Conclusion: CDA-SQS is a critical contribution to a much more consistent way of studying health SQ. It can be coupled to external taxonomies of tools, and models that describe the users’ health self-care activities and behaviours to facilitate a more rigorous analysis. This in turn may help in stratifying people into groups based on their health related measurements, wearable devices, health activities, etc. and ultimately enable the development of better personalised health interventions.

  • Linguistic Markers of Depression Severity Level: An Exploratory Study

    Date Submitted: Oct 26, 2016
    Open Peer Review Period: Oct 27, 2016 - Dec 22, 2016

    Background: Depression is a serious illness that affects millions of people globally. It is frequently undetected and commonly misdiagnosed. An objective marker of depression has the potential to dramatically improve current diagnostic approaches. Due to the ubiquity of smart phones and the popularity of social media, text is now a common form of communication, which could be very useful in monitoring linguistic patterns that might be indicative of symptoms of depression. Objective: The objective of this study was to explore the potential of using natural language processing and machine learning to automatically identify depression symptom severity. Methods: This study used the Distress Analysis Interview Corpus (DAIC), a multimodal collection of semi-structured clinical interviews. The interviews simulate the standard protocols for identifying people with major depression. The corpus contains audio and video recordings of participant interviews (N=688). In addition to manual transcriptions, automatic speech recognition (ASR) was performed to generate transcripts of the interviews. Semantic and syntactic linguistic features were extracted from the transcripts and then used to train linear regression models. Results: Using linguistic markers, we successfully train speaker-independent regression models that were able to predict depression severity (MAE=4.42, RMSE=5.06). We find a number of semantic and syntactic features to be significantly correlated with depression score (P<.001), including but not limited to: first person singular pronouns, words related to affective processes, word length, unique number of part-of-speech tags, attributes related to the syntactic dependency tree representation, and semantic coherence. Conclusions: Features extracted from unconstrained speech provided useful linguistics markers that were strongly related to depression. In addition, regression models trained with linguistic features were able to successfully predict depression level. These findings suggest that natural language processing and machine learning approaches offer numerous clinical opportunities, including an unobtrusive automatic assessment of depression severity, which could be used ubiquitously.

  • mHealth interventions for health system strengthening in China: a Systematic Review

    Date Submitted: Oct 26, 2016
    Open Peer Review Period: Oct 26, 2016 - Dec 21, 2016

    Background: With rapidly expanding infrastructure in China, mobile technology has been deemed to have the potential to revolutionise healthcare delivery. There is particular promise for mHealth to positively influence health system reform, and confront the new challenges of chronic diseases. Objective: To systematically review existing mHealth initiatives in China, to characterise them and examine the extent to which mHealth contributes towards the health system strengthening in China. Also to identify gaps in mHealth development and evaluation. Methods: Systematically review of the literature from English and Chinese electronic database and trial registries, including PubMed, EMBASE, Cochrane, China National Knowledge of Infrastructure, and WHO International Clinical Trials Registry Platform. We used the English keywords of mHealth, eHealth, telemedicine, telehealth, mobile phone, cell phone, text messaging, and China, as well as their corresponding Chinese keywords. All articles using mobile technology for healthcare management were included in the study. Results: 1,704 articles were found using the search terms. and eventually 72 were included. Overall, few high quality interventions were identified. Most interventions were found to be insufficient in scope, and their evaluation was of inadequate rigour to generate scalable solutions and provide reliable evidence of effectiveness. Most interventions focused on text messaging for consumer education and behaviour change. There were a limited number of interventions that addressed health information management, health workforce issues, use of medicines and technologies, or leadership and governance from a health system perspective. Conclusions: We provide four recommendations for future mHealth interventions in China that include the need for the development, evaluation and trials examining integrated mHealth interventions in effort to guide the development of future mHealth interventions, target disadvantaged populations with mHealth interventions, and generate appropriate evidence for scalable and sustainable models of care.

  • The feasibility and acceptability of a web-based alcohol management intervention in community sports clubs: a cross sectional study

    Date Submitted: Oct 20, 2016
    Open Peer Review Period: Oct 21, 2016 - Dec 16, 2016

    Background: The implementation of comprehensive alcohol management strategies can reduce excessive alcohol use and reduce the risk of alcohol related harm at sporting venues. Supporting sports venues to implement alcohol management strategies via the web may represent an effective and efficient means of reducing harm caused by alcohol in this setting. However, the feasibility and acceptability of such an approach is unknown. Objective: This study aimed to identify: (1) current access to and use of the web and electronic devices by sports clubs; (2) perceived usefulness, ease of use, and intention to use a web-based program to support implementation of alcohol management practices in sports clubs; (3) factors associated with intention to use such a web-based support program; and (4) the specific features of such a program that sports clubs would find useful. Methods: A cross-sectional survey was conducted with club administrators of community football clubs in the state of New South Wales, Australia. Perceived usefulness, ease of use and behavioural intention to use a hypothetical web-based alcohol management support program was assessed using the validated Technology Acceptance Model (TAM) instrument. Associations between intention to use a web-based program and club characteristics as well as perceived ease of use and usefulness was tested using Fisher’s exact test and represented using relative risk for high intention to use the program. Results: Of the 73 football clubs that were approached to participate in the study, 63 consented to participate, 46 were eligible and completed the survey. All participants reported having access to the web and 98% reported current use of electronic devices (e.g. computers, iPads/tablets, smartphones, laptops, televisions and smartboards). Mean scores (out of a possible 7) for the TAM constructs were high for: intention to use (Mean: 6.25, SD: 0.87), perceived ease of use (Mean: 6.00, SD: 0.99), and perceived usefulness (mean: 6.17, SD: 0.85). Intention to use the web-based alcohol management program was significantly associated with perceived ease of use (P=.02, RR: 1.4, CI: 1.0-2.9), perceived usefulness (P=.03, RR: 1.5, CI: 1.0-6.8) and club size (P=.02, RR: 0.8 CI: 0.5-0.9). The most useful features of such a program included the perceived ability to complete program requirements within users own time, complete program accreditation assessment and monitoring online, develop tailored action plans and receive email reminders and prompts to complete action. Conclusions: A web-based alcohol management approach to support sports clubs in the implementation of recommended alcohol management practices appears both feasible and acceptable. Future research should aim to determine if such intended use leads to actual use and club implementation of alcohol management practices. Clinical Trial: NA

  • An Inter-hospital 12-Lead Electrocardiography Teleconsultation System and Mobile Application Based on Users’ Experiences

    Date Submitted: Oct 20, 2016
    Open Peer Review Period: Oct 21, 2016 - Dec 16, 2016

    Background: More and more hospitals have formed hospital alliance to share medical resources with one another in Taiwan. Consequently, the need for developing a safe and convenient inter-hospital 12-lead electrocardiography (ECG) and tele-consultation system arises. Objective: The major goal of this study is to develop a safe and effective mobile application (App) and ECG system to deliver inter-hospital 12-lead ECG tele-consultation. Methods: The design of this APP and system was based on the experiences of cardiologists as users and human factor consideration so to minimize misuse, misdiagnosis, and violation of patients’ privacy. In addition, this technology facilitated the interoperability of 12-lead ECG across hospitals, which integrates heterogeneous 12-lead ECG from different hospitals and various mobile phones of consulting cardiologists. Notably, the use of role-based certificates enhanced the safety of ECG delivery on internet. This App was evaluated by two senior cardiologists as with credible usability. Results: This technology allowed the practice of 12-lead ECG tele-consultation easier and more convenient. It also helped clinicians give proper diagnosis and disposition more efficiently based on more comprehensive ECG reports and consultation. Conclusions: In summary, this App can be applied easily in clinical settings and greatly improves the efficiency and quality of medical services.

  • What predicts online health information seeking behaviour among Egyptian adults? A cross-sectional study.

    Date Submitted: Oct 21, 2016
    Open Peer Review Period: Oct 21, 2016 - Dec 16, 2016

    Background: Over the last decade, the Internet has become an important source of health-related information for a wide range of people worldwide. However, little is known about who accesses this source of information among Egyptian users. Objective: To identify personal characteristics of Egyptian online health information (OHI) seekers and their association with health information seeking behaviour. Methods: This cross-sectional study was conducted from June to October 2015. An online questionnaire was sent to Egyptian users of a popular health information website aged ≥ 18 years or older (N = 1400). The study questionnaire included: (1) demographic characteristics, (2) general health status, and (3) health information seeking behaviour which included: frequency of use, different topics sought, and self reported impact of obtained OHI on health behaviours. Data were analysed using descriptive statistics and multiple regression analysis. Results: A total of 490 respondents completed the electronic questionnaire with response rate equivalent to 35.0 % . Of the participants; 57.1% were females, 63.4% had a university level qualification, and 37.1 % had a chronic health problem. The results of the multiple regression analysis showed that 31.0% (F= 9.94, P < 0.05) of variance in frequency of using OHI can be predicted by personal characteristics. Participants who sought for OHI were more likely to be female, younger age, higher education levels, and good self-reported general health. Conclusions: Our results provide insights into Internet use and health information–seeking behaviours of the Egyptian internet users. This will contribute to better recognize their needs, highlight improvements of internet health information availability and provide tools to navigate to the highest-quality health information to Egyptian OHI users.

  • Beyond use versus non-use: identifying subgroups based on older adults’ activities on the Internet

    Date Submitted: Oct 20, 2016
    Open Peer Review Period: Oct 20, 2016 - Dec 15, 2016

    Background: As for all individuals, the Internet is essential in everyday life of older adults. Research on older adults’ use of the Internet has merely focused on users versus non-users, and consequences of Internet use and non-use. Older adults are a heterogeneous group, which may implicate that their use of the Internet is diverse as well. Older adults can use the Internet for different activities, and this usage can be of influence on benefits the Internet can have for older adults. Objective: The aim of this paper is to describe the diversity or heterogeneity in the activities for which older adults use the Internet, and to determine whether diversity is related to social or health related variables. Methods: We used data of a national representative Internet panel in the Netherlands. Panel members aged 65 years and older and who have access and make use of the Internet were selected (n=1418, 88.18% of the total sample were Internet users). We conducted a latent class analysis based upon the Internet activities that panel members reported to spend time on. Second, we described the identified clusters with descriptive statistics, and compared the clusters using ANOVA and chi-square tests. Results: Four clusters were distinguished. Cluster 1 was labelled as the ‘practical users’ (36.88%, n=523). These respondents mainly used the Internet for practical and financial purposes such as searching for information, comparing products, and banking. Respondents in cluster 2 ‘the minimizers’ (32.23%, n=457), reported the lowest frequency on most Internet activities, are older and spent the smallest time on the Internet. Cluster 3 was labelled as ‘the maximizers’ (17.77%, n=252): these respondents used the Internet for various activities, spent the most time on the Internet and were younger. Respondents in cluster 4 ‘the social users’ mainly used the Internet for social and leisure related activities, such as gaming and social network sites. The identified clusters were significantly different in age (P<.001, ω2=.07), time spent on the Internet (P<.001, ω2=.12), frequency of downloading apps (P<.001, ω2=.14) with medium to large effect sizes. Social and health related variables were significantly different between the clusters, except social and emotional loneliness. However, effect sizes were small. The minimizers scored significantly lower on psychological well-being, iADL and experienced health compared with the practical users and maximizers. Conclusions: Older adults are a diverse group concerning their activities on the Internet. This underlines the importance to look beyond use versus non-use when studying older adults Internet use. The clusters we have identified in this study can help tailor the development and deployment of eHealth intervention to specific segments of the older population.

  • Nurse-moderated Internet-based Support for New Mothers: A Non-inferiority, Randomised Controlled Trial

    Date Submitted: Oct 19, 2016
    Open Peer Review Period: Oct 19, 2016 - Dec 14, 2016

    Background: Internet-based interventions moderated by community nurses have the potential to improve support offered to new mothers, many of whom now make extensive use of the internet to obtain information about infant care. However, evidence from population-based randomised controlled trials is lacking. Objective: The aim of this study was to test the non-inferiority of outcomes for mothers and infants who received a clinic-based postnatal health check plus nurse-moderated, internet-based-group support when infants were aged 1-7 months as compared to outcomes for those who received standard care consisting of postnatal home-based support provided by a community nurse. Methods: The design of the study was a pragmatic, preference, non-inferiority randomised control trial. Participants were recruited from mothers contacted for their postnatal health check, which is offered to all mothers in South Australia. Mothers were assigned either: 1) on the basis of their preference to clinic+internet or home-based support groups (n=328), or 2) randomly assigned to clinic+internet or home-based groups if they declared no strong preference (n=491). The overall response rate was 45%. Primary outcomes were Parenting Stress Index (PSI) Confidence and Karitane Parenting Confidence Scale scores. Secondary outcomes were PSI Isolation, Interpersonal Support Evaluation List – Short Form, Maternal Support Scale, Ages and Stages Questionnaire – Social-Emotional and MacArthur Communicative Development Inventory (MCDI) scores. Assessments were completed offline via self-assessment questionnaires at enrolment, (mean child age = 4.1 weeks, SD = 1.3) and again when infants were aged 9, 15 and 21 months. Results: Generalised estimating equations adjusting for post-randomisation baseline imbalances showed that differences in outcomes between mothers in the clinic+internet and home-based support groups did not exceed the pre-specified margin of inferiority (0.25 SD) on any outcome measure at any follow-up assessment, with the exception of MCDI scores assessing children’s language development at 21 months for randomised mothers, and PSI Isolation scores at 9 months for preference mothers. Conclusions: Maternal and child outcomes from a clinic-based postnatal health check plus nurse-moderated internet-based support were not inferior to those achieved by a universal home-based postnatal support program. Postnatal maternal and infant support using the internet is a promising alternative to home-based universal support programs. Clinical Trial: Australian New Zealand Clinical Trials Registry ACTRN12613000204741

  • Motivational determinants of exergame participation for older people in Assisted Living facilities: a mixed methods study.

    Date Submitted: Oct 18, 2016
    Open Peer Review Period: Oct 18, 2016 - Dec 13, 2016

    Background: Exergames (exercise based videogames) as a mode of delivering strength and balance exercise for older people are growing in popularity with the emergence of new Kinect based technologies, however little is known about the factors affecting their uptake and use with older people. Objective: The aim of this study is to determine the factors that may influence the motivation of older people to use exergames to improve their physical function and reduce fall risk. Methods: Mixed methods were employed in which fourteen semi-structured interviews were conducted with older people (n=12, aged 59-91 years) from two supportive housing facilities in the North West of the UK who participated in a 6 week trial of the exergames, one manager and one physiotherapist; 81 hours of observation and Technology Acceptance Model questionnaires were conducted. Results: The findings suggest that the participants were intrinsically motivated to participate in the exergames due to the enjoyment experienced when playing the exergames and perceived improvements of their physical and mental health and/or social confidence. The social interaction provided in this study was an important extrinsic motivator which increased the intrinsic motivation to adhere to the exergame programme. Conclusions: The findings of this study suggest that exergames may be a promising tool for delivering falls prevention exercises and increasing adherence to exercise in older people. Understanding the motivation of older people to use exergames may assist in the process of implementation.

  • Hierarchical Medical System Based on Mobile Internet: A New Strategic Choice of Healthcare Service

    Date Submitted: Oct 13, 2016
    Open Peer Review Period: Oct 13, 2016 - Dec 8, 2016

    China is setting up a hierarchical medical system to solve the problems of imbalanced resource allocation in healthcare and unreasonable patient flow. The development of Mobile Internet technology provides a new perspective for the establishment of hierarchical medical system. This article opens a dialogue on the challenges associated with the innovation model of hierarchical medical system based on Mobile Internet, including the model’s aim and realization approach.

  • Navigating Ethics in Mobile and Digital Health Research: Introducing the CORE Platform as a New Online Tool for Researchers and IRBs

    Date Submitted: Oct 13, 2016
    Open Peer Review Period: Oct 13, 2016 - Dec 8, 2016

    Background: NA / Perspective Objective: NA / Perspective Methods: NA / Perspective Results: NA / Perspective Conclusions: NA / Perspective Clinical Trial: NA / Perspective

  • Studying Acute Coronary Syndrome Care-Seeking Behavior through the World Wide Web: Experiences, Lessons and Assessments

    Date Submitted: Oct 11, 2016
    Open Peer Review Period: Oct 12, 2016 - Dec 7, 2016

    Background: This study details the experiences, lessons and assessments of conducting a national study of acute coronary syndrome, or heart attack, care-seeking behavior in the United States utilizing the World Wide Web. The Yale Heart Study was funded by the National Heart, Lung and Blood Institute of the National Institutes of Health and conducted at Yale University. Objective: The Yale Heart Study was designed to study the care-seeking behavior of individuals experiencing an acute coronary syndrome [ACS]event. The use of the internet was a means by which a more representative sample of ACS patients could be obtained to increase our understanding of their care-seeking behaviors and to ultimately develop interventions to facilitate care-seeking. Methods: An internet based survey was designed and built to capture the ACS experiences of study participants. It was designed to be easily downloaded, navigated and uploaded so as to minimize study participant difficulties. The Yale Heart Study was IRB approved and required one hour or less to complete. A key feature of the study instrument was its algorithmic design which allowed a self-tailored survey for each participant depending on their care-seeking experiences. To guide our sampling we constructed a quota sample based on age, sex and race derived from the NHANES study. Using this sampling technique we needed to recruit 2314 participants. The national sample obtained for the Yale Heart Study was recruited primarily by internet ads placed on Google, Facebook, AOL and Yahoo/Bing. Among other recruitment methods used, flyers and posters were also displayed at public libraries, senior and rehabilitation centers, and internet chatrooms. African-American participants were over-sampled to ensure their representation. Results: The Yale Heart Study needed to recruit 2314 participants to provide a representative sample of individuals who experienced an ACS event based on our quotas. The number of study participants who registered to participate was 2381. The number of usable interviews was 1154. To obtain our final study sample over the course of 2 years and 5 months, we ran 279,834,651 internet ads, had 124,795 clicks to the Yale Heart Study website and emailed all public libraries in the United States, having an email address, our flyers and posters. We failed miserably to obtain a useful African-American sample of participants. Only 33 African-Americans participated out of the 388 needed for our sample. Conclusions: In general it is possible to collect a nationally representative sample of ACS patients using the recruitment methods of the Yale Heart Study. Difficulties arise in being able to bring potential participants to your website and in being able to effectively over-sample known and emerging difficult to reach subgroups. We experienced several sources of delay in executing the study causing extensive periods of non-recruitment. Since the study was one of the first to be launched it was met with some resistance. Using the internet to collect data is less expensive than interviewing, but in some instances the quality of the data is diminished somewhat in not being able to assist the participant or ask the question in a different manner to solicit the needed information. Clinical Trial: Trial Registration: NCT01407146