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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:

  • Feasibility, Acceptability, and Potential Efficacy of a Web-Based Physical Activity Intervention for Latina Adolescents: Niñas Saludables

    Date Submitted: Oct 17, 2017
    Open Peer Review Period: Oct 18, 2017 - Dec 13, 2017

    Background: Physical activity is markedly low in Latina adolescents, yet few physical activity interventions have been attempted in this population. Web-based interventions can incorporate theory-based components, be appealing to adolescents, and have potential for low cost dissemination. Objective: We sought to assess the feasibility, acceptability, and potential efficacy of a web-based physical activity intervention for Latina adolescents in a single-arm pilot trial. Methods: Twenty-one Latina adolescents (age 12-18) who were underactive (<90 minutes/week) participated in a 12-week theory-informed web-based physical activity intervention. Web content was individually tailored based on responses to monthly questionnaires. Feasibility was measured by recruitment, retention, and adherence/engagement, and acceptability was measured by satisfaction. Physical activity was measured at baseline and follow-up using the 7-Day Physical Activity Recall (PAR) Interview and accelerometers. Results: Baseline activity as measured by the 7-Day PAR and accelerometers was 24.7(26.11) and 24.8(38.3) minutes/week, respectively. At 12 weeks, 19 participants (90.5%) returned. Adherence and engagement with materials was low, and 72% of participants indicated they were satisfied with the intervention. Activity at 12 weeks increased by 58.8(11.33) minutes/week measured by the 7-Day PAR (p<0.001). Accelerometer-measured activity did not increase. Activities reported at follow-up were more varied than at baseline, including some measured poorly by accelerometers (e.g. biking, swimming). Participants suggested simplifying the website and incorporating other technologies. Conclusions: Good retention and increases in self-reported activity suggest a promising approach to delivering a physical activity intervention to Latina adolescents. Incorporating other technologies, such as smartphone apps, could make the intervention more engaging, acceptable and effective.

  • Validation of a Novel EHR Patient Portal Advance Care Planning Delivery System

    Date Submitted: Oct 17, 2017
    Open Peer Review Period: Oct 18, 2017 - Dec 13, 2017

    Background: Advanced Care Planning (ACP) allows patients to articulate their future care preferences should they no longer be able to make decisions on their own. Early ACP in outpatient settings provides benefits such as less aggressive care and fewer hospitalizations. Yet, ACP remains rarely delivered due to barriers like provider time constraints and communication complexity. Novel methods, like patient portals, can provide a unique opportunity to conduct ACP pre-visit planning for outpatient care. Objective: Our intervention tested a pre-visit ACP questionnaire sent via secure Electronic Health Record (EHR)-linked patient portal in a real world clinical setting to determine its impact on frequency and quality of ACP. Methods: We conducted a pragmatic trial in 2 sister clinical sites (with similar baseline ACP workflows) with site randomization to electronic pre-visit ACP planning and usual care over a 3-month study period. Baseline chart review at both sites was conducted 1 month prior. 200 patients received intervention and 219 usual care. Chart review was conducted at 1 week and 1 month post-visit to determine the presence and quality of ACP documentation. Results: Intervention patients had a 27% increase in documentation rates and 25.4% higher quality scores compared to usual care. Individuals between 50-60 years of age and active portal users (>10 messages in one year) saw documentation rates increase by 37% and 33.5% respectively at the intervention site. Conclusions: Sending patients a pre-visit questionnaire on their future care preferences yielded improvement in quality and presence of ACP documentation, with highest improvement in active patient portal users and patients aged 50-60. Targeted pre-visit patient portal ACP delivery in these populations can potentially improve the quality of care in these populations.

  • Well beyond a reminder tool: applying the Behaviour Change Wheel to evaluate how an interactive two-way mHealth intervention improves medication adherence

    Date Submitted: Oct 17, 2017
    Open Peer Review Period: Oct 18, 2017 - Dec 13, 2017

    Background: Medication adherence is an important, but highly complex set of behaviours, which for life-threatening and infectious diseases like HIV carry critical consequences for individual and public health. There is growing evidence that mobile phone text messaging interventions (‘mHealth’) connecting providers with patients positively impact medication adherence, particularly ‘two-way’ engagement platforms that require bidirectional communication versus ‘one-way’, in which responses aren’t mandatory. However, mechanisms of action have not been well defined. The Behaviour Change Wheel (BCW) is a comprehensive framework for behaviour change that includes an all-encompassing model of behaviour known as ‘COM-B’ (Capability Opportunity Motivation – Behaviour) and complemented by a taxonomy of behaviour change techniques. Evaluating mHealth interventions for medication adherence using these tools could provide useful insights that may contribute to optimizing their integration into the health care system and successful scaling-up. Objective: We aim to help address the current knowledge gap regarding how two-way mHealth interventions for medication adherence may work by applying the BCW to characterize WelTel: an interactive digital health outreach platform with robust evidence for improving adherence to antiretroviral therapy (ART). Methods: To characterize how WelTel may promote medication adherence, we applied the BCW in order to systematically (1) generate a ‘behavioural diagnosis’ through mapping known ART adherence barriers onto the COM-B model of behaviour; (2) specify the behaviour change techniques (BCTs) that WelTel delivers; (3) link identified BCTs to corresponding intervention functions of the BCW; and (4) connect these BCTs and interventions functions to respective COM-B influences on behaviour in order to determine potential mechanisms of action. Results: Our evaluation of WelTel using the BCW suggests that most of its impact is delivered primarily through its personalized communication component, in which eight different BCTs were identified and linked with five intervention functions (environmental restructuring, enablement, education, persuasion, training). Its mechanisms of action in promoting ART adherence may involve addressing all COM-B influences on behaviour (physical and psychological capability, physical and social opportunity, reflective and automatic motivation). Conclusions: Systematically unpacking the potential active ingredients of effective interventions facilitates the creation and implementation of more parsimonious, tailored and targeted approaches. Evaluating WelTel using the BCW has provided valuable insights into how and why such interactive two-way mHealth interventions may produce greater impact than one-way in addressing both non-intentional and intentional forms of non-adherence. The application of the BCW for evidence synthesis across mHealth interventions targeting various conditions would contribute to strengthening the knowledge base regarding how they may work to impact medication adherence behaviour.

  • Are Turkish University Students Text-Message Dependent?Validity and Reliability of Turkish Self-Perception of Text-Message Dependency Scale

    Date Submitted: Oct 17, 2017
    Open Peer Review Period: Oct 18, 2017 - Dec 13, 2017

    Background: Text messaging is a fast and efficient means of communication among people. Text messaging (especially via SMS, Facebook, Twitter, Whatsapp) is quite common in developed and developing countries. Objective: We aimed to do validity and reliability of Self-perception of Text-message Dependency Scale among Turkish university students and show their text-message dependency level Methods: Between January 2016 and March 2016, Self-perception of Text-message Dependency Scale were administered to 221 students selected with a simple random selection method, from the Faculty of Social Sciences of Çankırı Karatekin University along with a sociodemographic data form. Internal reliability coefficient (Chronbach α), Pearson correlation analysis, confirmatory factor analysis, and goodness of fit indexes were calculated. P<0.05 is considered significant. Results: The mean age of the participants was 21 ± 1.72. The Internal Consistency Coefficient of the self-perception of text-message dependency scale was found to be Cronbach α 0.85. GFI=1, CFI=1, NFI=1, RMSEA=0,000. The total item correlation (rit) is between 0.329 and 0.663, indicating that the construct validity is strong.The theoretical model proposed by Igarashi et al. consists of 3 latent variables (factors) that are influenced by extroversion and neuroticism: 1) excessive use of messaging, 2) relationship maintenance, and 3) emotional reactions (5). These factors have an impact on the psychological or behavioral patterns by affecting the frequency of message writing. Conclusions: In our study, the internal reliability and goodness of fit indexes values were similar to the original study inciting that the Message Dependence Perception Scale can reliably be used in Turkey.

  • Zika Virus and Sexual Transmission: A Twitter-Based Study

    Date Submitted: Oct 17, 2017
    Open Peer Review Period: Oct 18, 2017 - Dec 13, 2017

    Background: Zika virus emerged in Latin America in 2015, leading the WHO to declare the epidemic a public health emergency of international concern. Although it is primarily a vector-borne disease, sexual transmission is also possible and has been emphasized in public health recommendations and media coverage. Hence, sexual transmission of Zika may provide important insights into how the public perceive Zika and how health information is shared in social media. Objective: This is an exploratory qualitative research study that aims at describing the discourses around sexual transmission of Zika virus on Twitter during the beginning of the public health emergency of international concern. We also aim to analyze the relationship between information shared in traditional media and Twitter. Methods: We retrieved tweets and linked URLs that contained references to sexual transmission of Zika posted from January 1, 2016, to March 1, 2016. We restricted our search to tweets in English, French, Portuguese, and Spanish. We manually categorized the content of the tweets posted during peaks of Twitter activity and accessed the websites linked to the tweets in order to identify major themes in the textual and graphic content of these websites. Results: We retrieved 37,992 tweets (18,912 in English, 13,799 in Spanish, 3,280 in Portuguese, and 2,001 in French) and three peaks of Twitter activity (February 5, 24, and 27, 2016). The first peak was seen only in Portuguese (412 tweets) and followed the discovery of live Zika particles in saliva. Most tweets had humorous content (55.3%) or were disseminating information (32.0%), and only 19.6% contained an embedded URL. The second peak was seen in English, French, and Spanish (5,514 tweets total) and was associated with the investigation of 14 cases of sexual transmission of Zika in the US. Tweets were emotionally neutral and served the purpose of disseminating information (>94%). The third peak, in all languages (5,182 tweets total), followed the identification of a case of sexually-transmitted Zika in France. Again, tweets were emotionally neutral and disseminated information (>93%). Across all peaks, URLs contained in the tweets contained content predominantly produced by traditional media outlets and represented a technicized speech; Images in these tweets depicted the public health response of the epidemic and emphasized mosquitoes (57.8%), public health authorities (19.0%), and laboratory settings (16.0%). Images of the victims of Zika were not common (16.6%). Conclusions: Early in the Zika epidemic, tweets that mentioned sexual transmission of the disease were predominantly driven by traditional media, and largely reproduced the technical discourse of international news agencies. The technical discourse de-politicizes the health crisis created by Zika virus in a moment when a heated debate about reproductive justice and abortion was taking place in Latin America.

  • Home-but not Alone- mobile-health application based postnatal educational programme: A descriptive qualitative study

    Date Submitted: Oct 16, 2017
    Open Peer Review Period: Oct 17, 2017 - Dec 12, 2017

    Background: Postnatal period poses numerous challenges for new parents. Various educational programmes are available to support new parents during this stressful period. However, the usefulness of educational programmes needs to be evaluated to ascertain their credibility. Objective: The aim of this descriptive qualitative study is to explore the views of parents to new-born with regard to the content and delivery of a mobile-health application based postnatal educational programme. Methods: A qualitative semi-structured interview guide was used to collect data from the 17 participants who belonged to the intervention group of a randomised controlled trail. The intervention, a four-week-long access to a mobile-health application based educational programme, was evaluated. The interviews were carried out in English and at the participants’ homes. Thematic analysis was used to analyse the data. Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to report the findings. Results: The interviews revealed four main themes: (1) positive features of the mobile-health application, (2) advice from the midwife, (3) experiences gained from using the mobile-health application, and (4) recommendations for the future. The participants evaluated the educational programme to be a good source of information that was tailored to the local context. The different modes of delivery, including audio and video, accentuated the accessibility of information. The parents evaluated that the facilitator of the featured communication platform, a midwife, provided trustworthy advice. Belonging to a virtual community beyond the hospital gave parents the confidence that they were not alone and were supported by other parents and healthcare professionals. Conclusions: The mobile-health application based educational programme effectively supported a multi-ethnic sample of parents during the postnatal period. This signals its potential to be implemented in a wider community of parents in the postnatal period. The effectiveness of the educational programme is a testament of the potential benefits in using telemedicine among new parents postnatally. Resources can also be dedicated towards extending the duration of access to the application beyond one month, and to develop relevant content for parents across the perinatal period. Clinical Trial: ISRCTN99092313

  • Role of Social Media in Diabetes Management in the Middle East Region: A Systematic Review

    Date Submitted: Oct 16, 2017
    Open Peer Review Period: Oct 17, 2017 - Dec 12, 2017

    Abstract Background: The objective of the study was to evaluate the impact of social networking interventions in the improvement of diabetes management and health outcomes in patients with diabetes in the Middle East. Methods: We identified peer-reviewed articles from PubMed (1990-2017) and Google Scholar (1990-2017) using various combinations of predefined terms and search criteria. The main inclusion criteria consisted of the use of social networking applications on mobile phones as the primary intervention. Outcomes were grouped according to study design, type of diabetes, category of technological intervention, location and sample size. Results: In this review, we included 5 articles, evaluating the use of social media tools in the management of diabetes in the Middle East. In most studies, the acceptance rate for the use of social networking to optimize the management of diabetes was relatively high. Diabetes-specific management tools such as the SANAD and DIAR system helped collect patient information and lower HbA1c levels, respectively. Conclusion: The evaluated studies further demonstrate the potential of social network applications being adopted in regions in the Middle East to improve the management of diabetes. Future studies consisting of larger sample sizes spanning across multiple regions will provide further insight regarding the use of social network media for improving patient outcomes.

  • Qualitative exploration of patient and health professional requirements for an e-health behavioural change intervention to self-manage cardiovascular disease.

    Date Submitted: Oct 16, 2017
    Open Peer Review Period: Oct 17, 2017 - Dec 12, 2017

    Background: Cardiovascular diseases (CVD) are a leading cause of premature death worldwide. International guidelines recommend routine delivery of all phases of cardiac rehabilitation (CR). Uptake of traditional cardiac rehabilitation remains suboptimal, as attendance at formal hospital-based CR programmes is low, with community-based CR rates and individual long-term exercise maintenance even lower. Home-based CR programs have been shown to be equally effective in clinical and health-related quality of life outcomes, and yet are not readily available. Objective: Given the potential that home-based CR programs have it is important to explore how to appropriately design any such intervention in conjunction with key stakeholders. The aim of the current study was to engage with individuals with cardiovascular disease and other professionals within the health eco-system to 1) understand the personal, social and physical factors that inhibit or promote their capacity to engage with physical activity and 2) explore their technology competencies, needs and wants in relation to an eHealth intervention. Methods: Fifty-four semi-structured interviews were conducted across two countries. Interviews were audiotaped, transcribed verbatim, and analysed using thematic analysis and further mapped onto the COM-B model for future intervention design. Results: Key recommendations included collection of patient data and use of measurements, harnessing hospital based social connections, and advice to utilize a patient-centered approach with personalization and tailoring to facilitate optimal engagement. Barriers to the implementation of PATHway were also explored specifically in relation to physical capability and safety as well as technology readiness. Conclusions: In summary, a multi-faceted, personalisable intervention with an inclusively designed interface was deemed desirable for use among CVD patients both by end-users and key stakeholders. In depth understanding of core needs of the population can aid intervention development and acceptability.

  • A computer-based Driving in Dementia Decision Tool with mail support: A cluster randomized controlled trial

    Date Submitted: Oct 16, 2017
    Open Peer Review Period: Oct 17, 2017 - Dec 12, 2017

    Background: Physicians often find significant challenges in assessing automobile driving in persons with mild cognitive impairment and mild dementia, and deciding when to report to transportation administrators. Care must be taken to balance the safety of patients and other road users with potential negative effects of issuing such reports. Objective: To assess whether a Driving in Dementia Decision Tool (DD-DT) increased appropriate reporting of patients with mild dementia or mild cognitive impairment (MCI) to transportation administrators. Methods: Design: Parallel-group cluster non-blinded randomized controlled trial of a multifaceted knowledge translation intervention. The intervention included a computer-based decision support system, activated by the physician-user, which provides a recommendation about whether to report patients with mild dementia or MCI to transportation administrators, based on an algorithm derived from earlier work. The intervention also included a mailed educational package and web-based specialized reporting forms. Specialists and family physicians with expertise in dementia or care of the elderly were stratified by sex and randomized to either use the DD-DT or a control version of the tool that required identical data input as the intervention group, but instead generated a generic reminder about the reporting legislation in Ontario, Canada. The trial ran from Sept 9, 2014 to Jan 29, 2016, and the primary outcome was the number of reports made to the transportation administrators concordant with the algorithm. Results: Sixty-nine participating physicians were randomized, and 36 of these used the DD-DT; 20 of the 35 randomized to the intervention group used the DD-DT with 114 patients, and 16 of the 34 randomized to the control group used it with 103 patients. The proportion of all assessed patients reported to the transportation administrators concordant with the DD-DT recommendation did not differ between the intervention and the control groups (50% vs. 49%; Z=-0.19, P = .85). Two variables predicted algorithm-based reporting: caregiver concern (OR 5.8, 95% CI 2.5-13.6, P <.001) and abnormal clock drawing (OR 6.1, 95% CI 3.1-11.8, P <.001). Conclusions: Based on this quantitative analysis, in-office abnormal clock drawing and expressions of concern about driving from caregivers substantially influence physicians to report patients with mild dementia or MCI to transportation administrators, but the DD-DT tool itself did not increase such reports among these expert physicians. Clinical Trial: NCT02036099

  • Real-time Antiretroviral Therapy Adherence Interventions are Acceptable and Feasible in Rural Uganda: Mixed Methods Findings from a Pilot Randomized Controlled Trial

    Date Submitted: Oct 15, 2017
    Open Peer Review Period: Oct 16, 2017 - Dec 11, 2017

    Background: Wireless electronic adherence monitors can detect antiretroviral therapy (ART) adherence lapses and trigger interventions in real time, thus potentially avoiding unnecessary HIV viremia. Evidence about the acceptability and feasibility of these monitors and associated interventions, however, is limited. Objective: To assess the acceptability and feasibility of real-time adherence monitoring linked to short message service (SMS) reminders and notifications to support adherence amongst individuals living with HIV who are taking ART in rural southwestern Uganda. Methods: Sixty-three individuals living with HIV who are initiating ART were enrolled in a pilot randomized controlled trial exploring the effects of SMS plus real-time adherence monitoring on ART adherence. Participants received a real-time adherence monitor and were randomized to one of the following study arms: (1) scheduled SMS, (2) SMS triggered by missed or delayed doses, or (3) no SMS. SMS notifications were also sent to forty-five patient-identified social supporters for sustained adherence lapses. Qualitative interviews were performed to assess acceptability of this technology. An inductive, content analytic approach framed by the Unified Theory of Acceptance and Use of Technology model was used to analyze qualitative data. Quantitative feasibility data, including device functionality and SMS tracking data, were recorded and summarized descriptively. Results: Participants reported that real-time monitoring intervention linked to SMS reminders and notifications are generally acceptable. The key acceptability factor was perceived usefulness; participants perceived both the monitoring enabled through the device and the SMS reminders as helpful for medication adherence. The intervention was found to be technically feasible as data was obtained from most participants as expected most of the time. Potential feasibility challenges included the impact of the technology on confidentiality, shared phone ownership, usability skills, and availability of electricity. Conclusions: Real-time adherence monitoring integrated with SMS reminders and social support notifications is an acceptable and feasible intervention in a resource limited country. Additional studies are needed in diverse contexts. Clinical Trial: NCT01957865

  • Effectiveness of new media interventions on glycemic control in patients with type 2 diabetes: a meta-analysis of randomized controlled trials

    Date Submitted: Oct 14, 2017
    Open Peer Review Period: Oct 16, 2017 - Dec 11, 2017

    Background: New media has become a hot area of research for several years. Given its rapid development and increasing coverage worldwide, new media seems to offer a promising option to ameliorate huge burdens brought by type 2 diabetes mellitus. However, studies conducted by different researchers came out with contradictory results on new media’s effect in glycemic control. Objective: This meta-analysis aims to summarize currently available evidence and evaluate the overall impact of new media interventions on glycemic management of type 2 diabetic patients. Methods: A systematic literature search was performed in Pubmed, ScienceDirect and Web of Science. Randomized controlled trials that used glycosylated hemoglobin values as the outcome measure of glycemic control were considered. Risk of bias and publication bias were evaluated. Results: Of the 471 articles, 28 were included in meta-analysis and results indicated that compared with usual care, new media interventions significantly reduced HbA1c levels with a pooled weighted mean difference of -0.314% (95% CI [-0.39, -0.24], P < .001). Subgroup analyses revealed that intervention duration > 3 months and ≤ 6 months yielded optimal performance (WMD -0.47%, 95% CI [-0.63, -0.30], P < .001). Web-based interventions were substantially superior to mobile-based interventions in glycemic control (mobile only: WMD -0.23%, 95% CI [-0.40, -0.06], P = .009; web only: WMD -0.51%, 95% CI [-0.68, -0.34], P < .001). Furthermore, interventions with automated feedbacks had advantages over interventions with factitious feedbacks and studies with online educational contents were more effective in glycemic control. Assessment revealed low risk of bias. Conclusions: In conclusion, utilization of new media interventions is beneficial to patients with type 2 diabetes and taking full advantage of new media may substantially reduce the incidence of complications and improve quality of life. Clinical Trial: This meta-analysis was registered at PROSPERO and the registration number is CRD42017058032.

  • The impact of Small Private Online Course as a new approach in teaching oncology

    Date Submitted: Oct 16, 2017
    Open Peer Review Period: Oct 16, 2017 - Oct 24, 2017

    Background: The complexity of medical care in oncology with the multidisciplinary management of patients is not optimal due to a lack of effective communication and misinformation. Objective: The educational objective was to build a new teaching method to improve cancer treatment and management by emphasizing the link between hospital and city. Methods: We developed a SPOC (small private online courses) over 2 sessions with the participation of 22 professionals from public and private institutions. Each session lasted for 6 weeks including 6 topics: individual health care plans, cancer surgery, ionizing radiation, anti-cancer drug treatments, clinical research and oncological supportive care. We targeted audience working on cancer. This SPOC chose an active teaching method with a collaborative and multidisciplinary learning. A final exam test was suggested for each session. We evaluated the satisfaction rate by means of a questionnaire and the success of this SPOC by its completion, success and commitment rate. Results: Among 1574 participants, 446 filled the evaluation form. The majority of the participants was aged between 31 and 45 years. There were 56 nurses, 103 pharmacists, 26 from the medical corpus, 53 participants from patient’s associations, 28 health teachers and 13 health students. Among the participants, 24.7% had an independent medical activity, 38.5% worked in a public institution and 36.8% in a private institution. 86% thought they learnt new information, 90.8% felt their expectations were met, 90.4% considered this formation had a positive impact on their professional practice. The completion rate was 35.5%, the success rate was 71.5% and the commitment rate was 64.7%. Conclusions: This SPOC showed the positive interest on the management of patients suffering from cancer. This digital learning is a new and very attractive concept to integrate in our teaching. It offered an optimal propagation of information and it met the students’ expectations. Clinical Trial: NA

  • Fat Stigma Goes Viral on the Internet: A Systemic Assessment of YouTube Comments Attacking Overweight Men and Women

    Date Submitted: Oct 14, 2017
    Open Peer Review Period: Oct 14, 2017 - Dec 9, 2017

    Background: On social media including YouTube, a plethora of anonymous verbal attacks against overweight individuals are made and go viral. These comments often accompany negative, misogynist or derogatory words, which stigmatize the targeted obese individuals. These verbal attacks can cause depressions in obese individuals, which can subsequently promote unhealthy eating behavior (i.e., binge eating) and further weight-gains. To develop an intervention policy and strategies that tackle the anonymous, online verbal attacks, a thorough understanding of what the comments spell out is necessary. Objective: The present study aimed to examine how anonymous users verbally attack or defend overweight individuals in terms of four themes: 1) topic of verbal attack (i.e., what aspect of overweight individuals are verbally attacked), 2) genders of commenters and targeted overweight individuals, 3) intensity of derogation depending on the targeted gender (i.e., the number of swear words used within comments), 4) gender of overweight models in the YouTube videos. Methods: This study content-analyzed YouTube comments which discuss overweight individuals or groups from two videos, titled “Fat Girl Tinder Date” and “Fat Guy Tinder Date.” These two videos were released approximately three weeks prior to the beginning of this study. Thus, these two videos provided an ideal empirical setting (i.e., natural experiment) since these two videos provide the same stories except the gender of the main character. Thus, these two “twin” videos provide avenue through which to analyze discussions of obesity as they organically occurred in a contemporary setting. Three-hundred and twenty comments were sampled from these two videos and analyzed based on an instrument developed for this study. Results: The primary results are four-fold. First, overweight women are attacked for their capacities (e.g, laziness, maturity, etc.) while overweight men are attacked for their hetero-social skills (e.g., rudeness, annoyance, etc.). Second, the majority of commenters who attacked overweight women are male. Third, overweight women receive more swear words than men when targeted. Fourth, the gender of the model in the video attracts the aggressive comments against overweight people made by the commenters of the opposite gender. Conclusions: Our data elucidate a worrying situation where the online world is filled with disinhibited aggressive messages against overweight individuals. More importantly, the patterns of these verbal aggression differ depending on the gender of the overweight model in the YouTube videos. Thus, gender-tailored effective intervention strategies that specifically tackles Internet users’ verbal aggression against these three traits needed to be developed.

  • Technology and Social Media Use among Patients Enrolled in Outpatient Addiction Treatment Programs

    Date Submitted: Oct 13, 2017
    Open Peer Review Period: Oct 14, 2017 - Dec 9, 2017

    Background: Substance use disorder research and practice have not yet taken advantage of emerging changes in communication patterns. While internet and social media use is widespread in the general population, little is known about how these mediums are used in substance use disorder treatment. Objective: This paper aims to provide data on patients with substance use disorders prevalence of smartphone ownership, patterns of use of multiple digital platforms (social media, internet, computer, and mobile applications), and interest in the use of these platforms to monitor personal recovery. Methods: We conducted a cross-sectional survey of patients in four intensive outpatient substance use disorder treatment facilities in Philadelphia, PA, USA. Logistic regressions were used to examine associations among variables. Results: Survey participants (N= 259) were mostly male (73%), African American (63%), with annual incomes < $10,000 (62%), and averaged 39 years of age. The vast majority of participants (94%) owned a cellphone and about 64% owned a smartphone, of whom 80% accessed the internet mainly through their smartphone. There were no significant differences in age, gender, ethnicity or SES by computer usage, internet usage, number of times participants changed their phone, type of cellphone contract, or whether participants had unlimited calling plans. The sample was grouped into 3 age groups (Millennials, Generation Xers and Baby Boomers. The rates of having a social media account differed across these three age groups with significant differences between Baby Boomers and both GenXers and Millennials (p<0.0001 in each case). Among participants with a social media account (73.6%), most (76%) reported using it daily and nearly all (98%) used Facebook. Nearly half of participants (47%) reported viewing content on social media that triggered substance cravings and an equal percentage reported being exposed to recovery information on social media. There was a significant difference in rates of reporting viewing recovery information on social media across the three age groups with Baby Boomers reporting higher rates than Millennials (p<0.001). The majority of respondents (70%) said they would prefer to use a relapse prevention app on their phone or receive SMS relapse prevention text messages (72%) and 49% expressed an interest in receiving support by allowing social media accounts to be monitored as a relapse prevention technique. Conclusions: This is the first and largest study to date examining the online behavior and preferences regarding technology-based substance use disorder treatment interventions in a population of patients enrolled in community outpatient treatment programs. Patients were generally receptive to using relapse prevention apps and text messaging interventions and a substantial proportion support social media surveillance tools. The design of technology-based interventions remains a challenge, however, as many participants have monthly telephone plans, which may limit continuity, and most do not have a smartphone. Clinical Trial: N/A

  • The Role of Person-Generated Health Data in Simulated Rehabilitation for Stroke: A Literature Review

    Date Submitted: Oct 13, 2017
    Open Peer Review Period: Oct 14, 2017 - Dec 9, 2017

    Background: Person- or patient-generated health data (PGHD) are health, wellness and clinical data that people generate, record and analyse for themselves. There is potential for PGHD to improve the efficiency and effectiveness of simulated rehabilitation technologies for stroke. Objective: This review attempts to understand to what extent Kinect-based Stroke Rehabilitation Systems (K-SRS) have utilised PGHD, and to what benefit. Methods: The review is conducted in two parts. Part 1 is an overview of PGHD-related content in existing systematic literature reviews of K-SRS. Part 2 reviews original research papers with a specific focus on PGHD utilisation. Results: Part 1 showed that previous reviews focused on technical effectiveness of K-SRS, with some attention on clinical effectiveness. None of those reviews reported on home-based implementation, nor on PGHD utilisation. Part 2 showed that there is a gap in understanding how PGHD utilisation may affect patients using K-SRS, as well as a lack of patient participation in the design of such systems. Conclusions: This paper calls specifically for further studies of K-SRS - and more generally for studies of technologies that allow patients to generate their own health data - to pay more attention to how patients’ own use of their data may influence their care processes and outcomes. Future studies which trial the effectiveness of K-SRS outside the clinic should also explore how patients and carers use PGHD in home rehabilitation programs.

  • Attitudes towards e-Mental health services in a community sample of adults: Predictors of preferences and intentions

    Date Submitted: Oct 12, 2017
    Open Peer Review Period: Oct 13, 2017 - Dec 8, 2017

    Background: Despite evidence that e-Mental health services are effective, consumer preferences still appear to be in favor of face-to-face services. However, the Theory of Planned Behavior suggests that cognitive intentions are more proximal to behavior and thus may have a more direct influence on service use. Investigating individual characteristics that influence both preferences and intentions to use e-Mental health services is important for better understanding factors that might impede or facilitate use of these services. Objective: This study explores predictors of preferences and intentions to access e-Mental health services relative to face-to-face services. Five domains were investigated (demographics, technology factors, personality, psychopathology, and beliefs), identified from previous studies and informed by the Internet Interventions model. We expected that more participants would report intentions to use e-Mental health services relative to reported preferences for this type of support, and that these five domains would be significantly associated with both intentions and preferences towards online services. Methods: A mixed sample of 308 community members and university students were recruited through social media and the host institution in Australia. Ages ranged between 17 and 68 years, and 82.5% were female. Respondents completed an online survey. Chi-square analysis and t-tests were used to explore group differences, and logistic regression models were employed to explore factors predicting preferences and intentions. Results: Most respondents (85.7%) preferred face-to-face services over e-Mental health services. Relative to preferences, a larger proportion of respondents (39.6%) endorsed intentions to use e-Mental health services if experiencing mental health difficulties in the future. In terms of the five predictor domains, 95% confidence intervals of odds ratios derived from bootstrapped standard errors suggested prior experience with online services significantly predicted intentions to use self-help (95% CI: 2.08 – 16.24) and therapist-assisted (95% CI: 1.71 – 11.90) online services in future. Being older predicted increased intentions to use therapist-assisted online services in future (95% CI: 1.01 – 1.06), as did more confidence using computers and the internet (95% CI: 1.06 – 2.69). Technology confidence was also found to predict greater preference for online services versus face-to-face options (95% CI: 1.24 – 4.82), while higher doctor-related locus of control (95% CI: 0.76 – 0.95) and extraversion (95% CI: 0.88 – 1.00) were predictive of lower likelihood of preferring online services relative to face-to-face. Conclusions: Despite generally low reported preferences towards e-Mental health services, intentions to access these services are higher, raising the question of how to best encourage translation of intentions into behavior (i.e. actual use of programs). Strategies designed to ease people into new internet-based mental health programs (to enhance confidence and familiarity) may be important for increasing the likelihood that they will return to such programs later.

  • Feasibility study of a novel intelligent two-way communication system for remote heart failure medication uptitration: the CARDIOCOACH study

    Date Submitted: Oct 11, 2017
    Open Peer Review Period: Oct 13, 2017 - Dec 8, 2017

    Background: ESC guidelines for the treatment of heart failure (HF) prescribe uptitration of angiotensin converting enzyme inhibitors (ACE-I) and β-blockers to the maximum tolerated evidence-based dose. Although HF prognosis can drastically improve when correctly implementing these guidelines, studies showed that they are insufficiently implemented in clinical practice. Objective: The aim was to verify whether the addition of the CardioCoach follow-up tool to the usual care is feasible and safe to use and adds in the efficient implementation of guideline recommendations for β-blocker and ACE-I. Methods: 25 HF patients were randomly assigned to either the usual care (n=10) or CardioCoach intervention group (n=15) and followed for six months. The CardioCoach follow-up tool is a two-way communication platform with decision support algorithms for semi-automatic remote medication uptitration. Remote monitoring sensors automatically transmit patients' blood pressure, heart rate and weight on a daily basis. Results: Patients’ satisfaction and compliance for medication intake (93%) and vital sign measurements (95%) were excellent. However, the amount of technical issues was large, with 831 phone contacts (median 41 (IQR 32-65) in total. The semi-automatic remote uptitration was safe, as there were no adverse events and no false positive uptitration proposals. Although, no significant differences were found between both groups, a higher number of patients was on guideline-recommended medication dose in both groups compared to literature. Conclusions: The CardioCoach follow-up tool for remote uptitration is feasible and safe to use and showed to be efficient in facilitating information exchange between care actors, with high patient satisfaction and compliance. Clinical Trial: Clinicaltrials.gov, NCT03294811, https://clinicaltrials.gov/ct2/show/NCT03294811?term=cardiocoach&rank=1

  • Fitspiration on social media: a qualitative study exploring young people’s experiences of following healthy lifestyle material

    Date Submitted: Oct 10, 2017
    Open Peer Review Period: Oct 11, 2017 - Dec 6, 2017

    Background: Social media use has become ubiquitous in the lives of many people, especially young adults. A popular recent trend emerging on social media is that of posting and following ‘Fitspirational’ content - material that purports to motivate and showcase healthy lifestyle habits, particularly relating to exercise and diet. There is very limited existing literature on how engaging with this type of content influences people’s psychological and physical heath. Initial studies have focused on concerns over potential negative effects on psychological wellbeing including body image, self-esteem and eating disorders. Objective: We aimed to address a gap in the literature for exploratory research on this topic from the perspective of users. We used a qualitative approach to explore how people experience viewing Fitspiration on social media including why and how they engage with this material and how they perceive that it affects their thoughts, emotions, behaviour and health. Methods: We recruited 20 young adults (14 females, 6 males, aged 18-25) who self-declared themselves to be Fitspiration followers to participate in either focus groups or individual interviews. We asked detailed, open-ended questions about their motivations for following Fitspiration, experiences of viewing this content and its perceived impact. We used inductive thematic analysis to derive themes that represented common and salient features of the data set. Results: Four main themes were developed: 1) A tool with the potential to support healthy living, 2) Unrealistic, untrustworthy content, 3) Negative effects on emotional wellbeing, and 4) Vulnerability and protective factors. Following Fitspirational posts on social media can provide young people with knowledge and motivation that may support healthy lifestyle behaviours. However, a range of harms also appeared to arise from Fitspiration viewing ranging from minor annoyances and frustrations to more meaningful negative effects on psychological & physical health. These negative effects seemed to persist despite individuals acknowledging that the material can be unrealistic, and believing that they are personally equipped to minimise harms to themselves. Conclusions: This study suggests that Fitspiration on social media can be attractive and compelling for young people but appears to bring about negative as well as positive effects. Future research should aim to confirm the scale and intensity of positive and negative effects and investigate ways of harnessing desirable outcomes and minimising undesirable outcomes.

  • Online Consumer Ratings of Healthcare Providers Differ Across Specialties: A Tool to Calculate Specialty-Specific Rankings

    Date Submitted: Oct 10, 2017
    Open Peer Review Period: Oct 11, 2017 - Dec 6, 2017

    Background: Healthcare consumers are increasingly using online ratings to select providers, but interpretation of ratings is difficult due to the lack of established benchmarks for scoring. Objective: To determine whether distributions of consumer ratings differ across specialties and to provide specialty-specific data to assist consumers and clinicians in interpreting ratings Methods: We sampled 212,933 healthcare providers rated on the Healthgrades consumer ratings website, representing 29 medical specialties (n=128,678), 15 surgical specialties (n=72,531), and 6 allied health professions (n=11,724). We created boxplots depicting distributions and tested the normality of overall patient satisfaction scores. We then determined specialty-specific percentile rank for scores across groupings of specialties and individual specialties. Results: Allied health providers had higher median overall satisfaction scores (4.5, IQR 4.0, 5.0) than physicians in medical specialties (4.0, IQR 3.3, 4.5) and surgical specialties (4.2, IQR 3.6, 4.6) (p<.001). Overall satisfaction scores were highly left skewed for all specialties but skewness was greatest among allied health providers (-1.23, 95% CI -1.280, -1.181), followed by surgical (-0.77, 95% CI -0.787, -0.755) and medical specialties (-0.64 95% CI -0.648, -0.628). Percentile ranks for overall satisfaction scores varied across groupings of specialties and individual specialties; percentile ranks for scores of 2 (0.7%, 3%, 0.8%), 3 (6%, 17%, 8%), 4 (23%, 50%, 37%), and 5 (64%, 90%, 87%) differed for allied health, medical, and surgical specialties, respectively. Conclusions: Online consumer ratings of healthcare providers are highly left skewed, fall within narrow ranges, and differ by specialty, which precludes meaningful interpretation by healthcare consumers. Specialty-specific percentile ranks may help consumers more meaningfully assess online physician ratings.

  • Employees’ perspectives on the facilitators and barriers to engaging with digital mental health in the workplace: a qualitative study

    Date Submitted: Oct 9, 2017
    Open Peer Review Period: Oct 11, 2017 - Dec 6, 2017

    Background: Prevalence rates of work related stress, depression and anxiety are high, resulting in reduced productivity and increased absenteeism. There is evidence that these conditions can be successfully treated in the workplace but take-up of psychological treatments amongst workers is low. Digital mental health interventions delivered in the workplace may be one way to address this imbalance, but while there is evidence that digital mental health is effective at treating stress, depression and anxiety in the workplace, uptake of and engagement with these interventions remains a concern. Additionally, there is little research on the appropriateness of the workplace for delivering these interventions, or on what the facilitators and barriers to engagement with digital mental health interventions in an occupational setting might be. Objective: The aim of this research was to get a better understanding of the facilitators and barriers to engaging with digital mental health interventions in the workplace. Methods: Semi-structured interviews were held with 18 participants who had access to an occupational digital mental health intervention as part of a randomised controlled trial. The interviews were transcribed and thematic analysis was used to develop an understanding of the data. Results: Digital mental health interventions were described by interviewees as convenient, flexible and anonymous; these attributes were seen as being both facilitators and barriers to engagement in a workplace setting. Convenience and flexibility could increase the opportunities to engage with digital mental health, but in a workplace setting they could also result in difficulty prioritising time and ensuring a temporal and spatial separation between work and therapy. The anonymity of the Internet could encourage use, but that benefit may be lost for people who work in open plan offices. Other facilitators to engagement included interactive and interesting content and design features such as progress trackers and reminders to login. The main barrier to engagement was the lack of time. The perfect digital mental health intervention was described as a website that combined a short interactive course that was accessed alongside time-unlimited information and advice that was regularly updated and could be dipped in and out of. Participants also wanted access to e-coaching support. Conclusions: Occupational digital mental health interventions may have an important role in delivering healthcare support to employees. Although the advantages of digital mental health interventions are clear, they do not always fully translate to interventions delivered in an occupational setting and further work is required to identify ways of minimising potential barriers to access and engagement. Clinical Trial: This is a qualitative study

  • A tailored web-based parenting intervention to prevent adolescent depression and anxiety problems: Post-intervention findings from a randomized controlled trial

    Date Submitted: Oct 9, 2017
    Open Peer Review Period: Oct 11, 2017 - Oct 19, 2017

    Background: Depression and anxiety disorders in young people are a global health concern. Parents have an important role in reducing the risk of these disorders in their adolescents, but cost-effective, evidence-based interventions for parents that can be widely disseminated are lacking. Objective: The aim of this study was to examine the post-intervention effects of the Partners in Parenting program (PiP) on parenting risk and protective factors for adolescent depression and anxiety, and on adolescent depression and anxiety symptoms. Methods: A 2-arm randomized controlled trial was conducted with 359 parent-adolescent dyads, recruited primarily through schools across Australia. Parents and adolescents completed online measures of parenting and adolescent symptoms at baseline and 3 months later (post-intervention). Parents in the intervention condition received PiP, a tailored web-based parenting intervention designed following Persuasive Systems Design principles to target parenting factors associated with adolescents’ risk for depression and anxiety problems. PiP comprises a tailored feedback report highlighting each parent’s strengths and areas for improvement, followed by a set of interactive online modules (up to nine) that is specifically recommended for the parent, based on individually identified areas for improvement. Parents in the active control condition received a standardized package of five online factsheets about adolescent development and wellbeing. Parents in both conditions received a 5-minute weekly call to encourage progress through their allocated program to completion. Both programs were delivered weekly via the trial website. The primary outcome measure at post-intervention was parent-reported changes in parenting risk and protective factors for adolescent depression and anxiety, measured using the Parenting to Reduce Adolescent Depression and Anxiety Scale (PRADAS). Secondary outcome measures were the adolescent-report PRADAS, the parent- and child-report Short Mood and Feelings Questionnaire (depressive symptoms), and parent- and child-report Spence Children’s Anxiety Scale (anxiety symptoms). Results: Parents in the intervention condition completed a mean of 73.7% of their intended personalized PiP program. 318 parents (88.6%) and 308 adolescents (92.8%) completed the post-intervention assessment. Attrition was handled using mixed-model repeated-measures ANOVA. As hypothesized, we found a significant condition-by-time interaction on the PRADAS, with a medium effect size, Cohen’s d = 0.57, [95% CI: 0.34, 0.79]. No significant differences between conditions were found at post-intervention on any of the secondary outcome measures, with adolescent depressive (parent-report only) and anxiety (both parent- and adolescent-report) symptoms decreasing significantly from baseline to post-intervention in both conditions. Conclusions: The fully-automated Partners in Parenting intervention showed promising short-term effects on parenting behaviors that are associated with adolescents’ risk for depression and anxiety. Longer-term follow-up is required to ascertain whether these effects translate into reduced adolescent depression and anxiety problems. The intervention may be useful as a low-cost universal public health program to increase parenting practices believed to benefit adolescents’ mental health. Clinical Trial: ANZCTR.org.au ACTRN12615000328572 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368274 (Archived by WebCite® at http://www.webcitation.org/6qgsZ3Aqj)

  • Perceived Threat and Internet Use Predict Intentions to Get Bowel Cancer Screening (Colonoscopy): A Longitudinal Questionnaire Study

    Date Submitted: Oct 9, 2017
    Open Peer Review Period: Oct 11, 2017 - Dec 6, 2017

    Background: Many people use the Internet for health-related information search, which is known to help regulate their emotional state. However, not much is known yet about how online information search together with negative emotional states (i.e., threat of cancer diagnosis) relate to preventive medical treatment decisions (i.e., colonoscopy intentions). Objective: The present study investigated how frequency of health-related Internet use together with perceived threat of a possible (bowel) cancer diagnosis influence intentions to get a colonoscopy. Previous research has shown that people who experience threat preferentially process positive information in an attempt to downregulate the aversive emotional state. The Internet can facilitate this regulatory strategy through allowing self-directed, unrestricted and thus biased information search. In the context of threat regarding a possible bowel cancer diagnosis, feelings of threat can still be effectively reduced through cancer screening (i.e., colonoscopy). We, therefore, predict that in that particular context, feelings of threat should be related to stronger colonoscopy intentions, and that this relationship should be enhanced for people who use the Internet often. Methods: A longitudinal questionnaire study was conducted among healthy participants who were approaching or just entering the bowel cancer risk group (45 – 55 years old). Perceived threat of a possible (bowel) cancer diagnosis, frequency of health-related Internet use and intentions to have a colonoscopy were assessed at two time points (6-month time lag between the two measurement points T1 and T2). Multiple regression analyses were conducted to test whether threat and Internet use at T1 together predicted colonoscopy intentions at T2. Results: In line with our predictions, we found that threat of a possible (bowel) cancer diagnosis interacted with frequency of Internet use (both T1) to predict colonoscopy intentions (T2; B = .23, SE = .09, P = .01). For people who used the Internet relatively often (+ 1SD) the positive relationship between threat and colonoscopy intentions was significantly stronger (B = .56, SE = .15, P < .001) compared to participants who used the Internet less often (- 1 SD; B = .17, SE = .09, P = .07). This relationship was unique to online (vs. offline) information search and independent of objective risk factors (e.g., BMI, smoking). Conclusions: The results of the present study suggest that health-related Internet use can facilitate emotion-regulatory processes. People who feel threatened by a possible (bowel) cancer diagnosis reported stronger colonoscopy intentions, especially when they used the Internet often. We propose that this is because people who experience threat are more likely to search for and process information that allows them to downregulate their aversive emotional state. In the present case of (bowel) cancer prevention, the most effective way to reduce threat is to get screened.

  • Patient Continuance Use towards Online Healthcare Communities: Web Mining of Patient-Doctor Communication

    Date Submitted: Oct 7, 2017
    Open Peer Review Period: Oct 9, 2017 - Dec 4, 2017

    Background: In practice, OHCs have passed the adoption stage to reach the diffusion phase of development. In this phase, patients equipped with knowledge regarding the issues involved in healthcare are capable of switching among different communities to maximize their OHC activities. OHCs employ doctors to answer patient questions, and high quality doctors are more likely to be consulted by patients. Therefore, one important question that must be addressed is which factors drive patients to sustain ongoing relationships with OHCs, in which communication occurs between doctors and patients. However, this important question has only received limited scholarly attention. Objective: The purpose of this study is to identify factors drive patients to sustain ongoing relationships with online healthcare communities (OHCs), in which communication occurs between doctors and patients, integrating the information system success model (ISSM) and OHC features. Methods: A web spider is employed to download and extract data from the most authoritative Chinese OHC in which communication occurs between doctors and patients. The time span analyzed in our study was the period from January 2017 to March 2017. Finally, a sample of 469 valid anonymous patients with 9667 posts were obtained, which is equal to 469 respondents in survey research. Then a combination of web mining and structural equation modeling (SEM) is conducted to test the research hypotheses. Results: The results show that research framework for integrating the ISSM and OHC features contributes to our understanding about the roles of constructs that drive patients to sustain ongoing relationships with OHCs. (1) Social support, information quality, and service quality exert significant direct effects on perceived usefulness and patient satisfaction. (2) Regarding the influences of perceived usefulness and patient satisfaction, both have significant effects on continuance useuse of OHC patients. In addition, the effects of social support, information quality and service quality on patient satisfaction are mediated by perceived usefulness. (3) Overall, these results suggest that by increasing social support, informational quality and service quality may improve the perceived usefulness and patient satisfaction of OHCs, which could in turn foster the continuance use of OHC patients. (4) Unexpectedly, individual literacy has no influence on perceived usefulness and satisfaction of OHC patients. Conclusions: First, this study enriches the literature on the continuance use of OHC, in which communication occurs between doctors and patients, using an empirical approach. The study complements previous analyses of OHCs with a new perspective that reflects the intricacies of human health behavior at individual, community, and social levels. Second, a web spider is a data collection method that enables us to acquire objective data relatively easily and frequently, thereby overcoming a major limitation of survey techniques. Additionally, the method develops an appropriate metric for constructs. Third, this study not only reveals how to use web mining to evaluate the success of OHCs but also provides a foundation for future research in the information systems field, which is increasingly turning its attention to web mining.

  • Usage Patterns Associated with a Mobile Application in Patients Prescribed a Smoking Cessation Medicine

    Date Submitted: Oct 6, 2017
    Open Peer Review Period: Oct 9, 2017 - Dec 4, 2017

    Background: Cigarette smoking is the leading preventable cause of death and is responsible for more than 480,000 deaths per year in the United States (US). Smoking cessation is challenging for many patients. Regardless of available treatment options, most quit attempts are unaided and it takes multiple attempts before a patient is successful. With the ever-increasing use of smartphones, mobile applications (apps) hold promise in supporting cessation efforts. The current study evaluates the ease of use and user satisfaction with the Pfizer Meds app to support smoking cessation among patients prescribed varenicline (Chantix®). Objective: Study participants included varenicline users who downloaded and used the app on their personal smartphone. The main objective was to report mobile app download frequency and usage details and to describe the participant-reported satisfaction with and usefulness of the application over the 14-week follow-up study period. Methods: Adults 18 years or older who had been prescribed varenicline were identified from the ESI pharmacy claims database. After meeting privacy restrictions, subjects were sent an invitation letter and second reminder letter with instructions on how to download the Pfizer Meds mobile application. Participants received a push notification to complete a smart phone-enabled survey regarding the utility of the application 12 weeks after downloading the application. Descriptive statistics summarized socio-demographics, use of varenicline, and details of use and satisfaction with the mobile application. Results: Of the 38,129 varenicline users who were sent invitation letters, 1,281 participants (3.4%) downloaded the Pfizer Meds application. Of the 1,032 with demographic and other data, 585 (56.7%) were females and 446 (43.2%) were males; mean age was 46.4 years (Standard Deviation [SD] 10.8). The mean number of app sessions per participant was 4.0 (SD 6.8). The end-of-study survey was completed by 131 survey respondents (10.2%); a large proportion (117/131; 89.3%) reported being extremely, very, or moderately satisfied with the app. A total of 97 survey respondents (97/131; 74.0%) reported setting up a quit date in the application. Of those, 74 (74/97; 76.3%) reported quitting on their quit date. Conclusions: Positive patient engagement was observed in this study based on app download and usage. This study quantified how the Pfizer Meds app performed in an observational real world data setting. The findings demonstrate the willingness of participants to set a quit date and use the app for support in medication adherence, refill reminders, and information regarding how to take the medication. This study provides real world evidence of the contribution apps can make to the continued encouragement of smokers to improve their health by smoking cessation.

  • Increasing reasoning awareness: A video analysis of students' two-party virtual patient interactions

    Date Submitted: Oct 8, 2017
    Open Peer Review Period: Oct 9, 2017 - Dec 4, 2017

    Background: Patient cases are often used in learning activities for medical students to train clinical reasoning. The computerized virtual patient (VP) cases allow for a stepwise exploration of cases and, thereby, stimulate active learning. In terms of reasoning, peer settings during VP sessions are believed to have benefits, but have received scant attention in literature. Objective: The objective of this study is to scrutinize the two-party virtual patient setting in terms of clinical reasoning. Methods: An in-depth exploration of dyad students’ pairwise interactions in VP sessions was performed by using video-observation. Two VP sessions, one-hour each, were video-recorded and transcribed in full. The transcriptions were analyzed using thematic analysis and short video-clips were selected for subsequent collaborative analysis in relation to clinical reasoning and clinical aspects. Results: Four categories of interactions were identified: (i) Task-related dialogue, in which students negotiated a shared understanding of the task and strategies for information gathering. (ii) Case-related insights and perspectives were gained, and the students consolidated and applied pre-existing biomedical knowledge into a clinical setting. (iii) Clinical reasoning interactions were made explicit. In these, hypotheses were followed up and clinical examples were used. The researchers observed interactions not only between students and the VP, but also (iv) interactions with other resources, such as a textbook. The interactions are discussed in relation to theories of clinical reasoning and peer learning. Conclusions: The dyad virtual patient setting corresponds to activities promoting analytic clinical reasoning. The peer setting, access to different resources and time to pursue different lines of reasoning seem to be valuable components promoting students’ clinical reasoning in this setting.

  • Online assessment of the usual diet: a validity and reproducibility study of a new short food frequency questionnaire in an adult population

    Date Submitted: Oct 5, 2017
    Open Peer Review Period: Oct 5, 2017 - Nov 30, 2017

    Background: Available dietary questionnaires to assess the habitual diet are timely, costly, or not adapted to the modern diet; thus there is a need to develop a short food frequency e-Questionnaire (SFFeQ) adapted to Western countries diets, to properly estimate energy and macronutrient intakes and rank individuals according to food and nutrient intakes. Objective: The aim of the study was to evaluate the validity and reproducibility of a 30-minute and 44-item SFFeQ in a sample of adults from the general population. Methods: A sample of French adults was recruited through social media and an advertising campaign. A total of 223 volunteers completed the SFFeQ twice, at a one-year interval, and were included in the reproducibility study. During that interval, 92 participants also completed three to six 24-hour recalls and were included in the validity study. Main nutrient and dietary intakes were computed. The level of agreement between the two methods was evaluated for nutrient and food group intakes using classification into quintiles of daily intake, correlation coefficients and Bland-Altman plots. Results: Regarding validity, correlation coefficients ranged from 0.09 to 0.88 (unadjusted correlation coefficients, median: 0.48) and 0.02 to 0.68 (de-attenuated and energy adjusted correlation coefficients, median: 0.50) for food group and nutrient intakes, respectively. The median proportion of subjects classified into the same or adjacent quintile was 73% and 66% for food and nutrient intakes, respectively. Bland-Altman plots showed good agreement across the range of intakes. Regarding reproducibility, intraclass correlation coefficients ranged from 0.33 to 0.72 (median: 0.60) and 0.55 to 0.73 (median: 0.64), for food and nutrient intakes, respectively. Conclusions: The SFFeQ showed acceptable validity and reproducibility in a sample of adults. It appears valid to rank individuals based on their food and nutrient intakes. The SFFeQ is a promising and low-cost tool that can now be used in large-scale online epidemiological studies or in clinical routine and could be integrated in evidence-based smartphone apps for assessing diet components.

  • Lessons learned from a Living Lab on broad adoption of eHealth in primary healthcare

    Date Submitted: Oct 4, 2017
    Open Peer Review Period: Oct 5, 2017 - Nov 30, 2017

    eHealth solutions are considered to relieve current and future pressure on the sustainability of primary healthcare systems. However, evidence of the effectiveness of eHealth in daily practice is absent. Furthermore, eHealth solutions are often not implemented structurally after a pilot phase, even if successful during this phase. Although many studies on barriers and facilitators were published in recent years, including theoretical models on implementation of innovations, eHealth implementation still progresses only slowly. To further unravel the slow implementation process in primary healthcare and accelerate the implementation of eHealth, a three-year Living Lab project was set up in the Netherlands, resulting in in-depth information on the development and adoption of eHealth. In the Living Lab, called eLabEL, patients, healthcare professionals, small- and medium-sized enterprises (SMEs) and research institutes collaborated to select and integrate fully mature eHealth technologies for implementation in primary healthcare. Seven primary healthcare centres, ten SMEs, and four research institutes participated. Reflective and process-based notes from all meetings of the project partners, interview data and data of focus groups were analysed systematically using four theoretical models to study the adoption of eHealth in primary care. The results showed that large-scaled implementation of eHealth depends on the effort of and interaction and collaboration among four groups of stakeholders: patients, healthcare professionals, enterprises, and those responsible for healthcare policy (healthcare insurers and policy makers). These stakeholders are all acting within their own contexts and with their own values and expectations. In the eLabEL project we experienced that patients reported expected benefits regarding the use of eHealth for self-management purposes, and healthcare professionals stressed the potential benefits of eHealth and were interested in using eHealth to distinguish themselves from other care organisations. In addition, eHealth entrepreneurs valued the intensive collaboration among SME’s as they were not big enough to enter the healthcare market on their own and valued the collaboration with research institutes. Furthermore, healthcare insurers and policymakers shared the ambition and need for the development and implementation of an integrated eHealth infrastructure. However, we learned that for optimal and sustainable use of eHealth, patients should be actively involved, primary healthcare professionals need to be reinforced in their management, entrepreneurs should work closely with healthcare professionals and patients, and the government needs to focus on new healthcare models stimulating innovations. Only when all these parties act together, starting in local communities with a small range of eHealth tools, the potential of eHealth will be enforced.

  • Parents’ experiences of caring for their child at the time of discharge after cardiac surgery and during the post-discharge period: qualitative study using an on-line forum

    Date Submitted: Oct 4, 2017
    Open Peer Review Period: Oct 5, 2017 - Nov 30, 2017

    Background: Congenital heart disease is the most common class of birth defects and includes a broad spectrum of severity from relatively minor to extremely complex.  Improvements in surgery and intensive care have resulted in increasing numbers of infants with the most complex lesions surviving to hospital discharge after surgery but there remain concerns about out of hospital mortality, variability in how services are provided at the time of discharge and beyond and difficulties experienced by some families in accessing care.  Objective: As part of a mixed-methods programme of research we wanted to elicit parental experiences of caring for a child with congenital heart disease after discharge following cardiac surgery and to collect information to inform interviews for a subsequent stage of the project. Methods: A closed online discussion group was set up via the main Facebook page of the Children’s Heart Federation, a national charity offering support to children with heart disease and their families. The discussion group was advertised through the charity’s webpage and interested participants were directed to the charity's Facebook page from where they could access the closed Facebook group and respond to questions posted. The Children’s Heart Federation moderated the forum and the research team provided questions to be posted on the forum.  Responses were collated into a single transcript and subjected to thematic analysis. Results: The forum was open for four months and 91 participants (mean age 35 years; range 23-58 years; 89 female; 89 parents, 2 grandparents) submitted demographic information and were given access to the closed forum group.  A common experience of isolation emerged from the data with descriptons of how that isolation was experienced (physical, social, knowledge) and its psychological impact, together with the factors that made that worse or better.  Woven through this theme was the notion that parents developed expertise over time.   Conclusions: Use of an on-line forum provided a means of eliciting a large number of parents’ experiences of caring for their child after discharge from hospital following cardiac surgery.  Parents engaged with the forum and were able to articulate what went well and what went less well, together with sharing their stories and supporting each other through doing so.  Some parents clearly found participating in the forum a positive experience in itself, demonstrating the potential of social media as a mechanism for providing support and reducing isolation. Information gained from the forum was used to shape questions for interviews with parents in a subsequent phase of the study. Furthermore, the themes identified in the on-line forum have contributed to identifying ways of improving the provision of care and support for parents of high risk babies following discharge after cardiac surgery.

  • Mobile Spirometry: A case report of effective screening for COPD in a rural area

    Date Submitted: Oct 3, 2017
    Open Peer Review Period: Oct 5, 2017 - Nov 30, 2017

    Chronic Obstructive Pulmonary Disease (COPD) is a multidimensional debilitating disease that affects nearly 210 million individuals and is classified as the fifth leading cause of death worldwide. Despite advancements in management, the disease is still frequently underdiagnosed and undertreated [1]. To identify patients at risk for COPD, spirometry is used as a basis for diagnosis [2]. Despite initiation of federal COPD outreach programs, the cost endured directly or indirectly to a patient remains high. According to the ERS, the annual costs of healthcare and lost productivity due to COPD are estimated as €48.4 billion, of which €23.3 billion constitute direct costs and €25.1 indirect costs [3]. The average annual cost per case for COPD in the EU is € 2104 (direct - €1013; indirect - €1091) [3]. In late-diagnosis of COPD, direct medical costs were higher by an average of $3,671 per patient in 2 years and $2,489 in one year prior to initial diagnosis of COPD compared to controls [4]. We investigated the effects associated with using MySpiroo, with a dedicated mobile application in a medical screening event, conducted for inhabitants of Przezmark, a village in Pomorskie province in northern Poland, with minimal access to healthcare nearby.

  • An exercise intervention to unravel the mechanisms underlying insulin resistance in a cohort of black South African women: Protocol for a randomized controlled trial

    Date Submitted: Oct 3, 2017
    Open Peer Review Period: Oct 5, 2017 - Nov 30, 2017

    Background: The pathogenesis of type 2 diabetes (T2D) in black African women is complex and differs to that of their white counterparts. However, earlier studies have been cross-sectional and provide little insight into the causal pathways. Exercise training is consistently used as a model to examine the mechanisms underlying insulin resistance and risk for T2D. Objective: To examine the mechanisms underlying the changes in insulin sensitivity and secretion in response to a 12-week exercise intervention in obese black South African (SA) women. Methods: Forty-five obese (BMI 30-40 kg/m2) black SA women were randomized into a control (n=22) or experimental (exercise; n=23) group. The exercise group completed 12 weeks of supervised combined aerobic and resistance training (40-60 min, 4 days/week), while the control group maintained their typical physical activity patterns, and both groups were requested not to change their dietary patterns. Prior to and following the 12-week intervention period, insulin sensitivity and secretion (frequently sampled intravenous glucose tolerance test), and its primary and secondary determinants, were measured. Dietary intake, sleep quality and quantity, physical activity and sedentary behaviors were measured every four weeks. Results: The final sample included 20 exercise and 15 control participants. Baseline socio-demographics, cardiorespiratory fitness, anthropometry, cardio-metabolic risk factors, physical activity and diet did not differ between the groups (p>0.05). Conclusions: We describe a research protocol for an exercise intervention to understand the mechanisms underlying insulin sensitivity and secretion in obese black SA women. We aim to identify causal pathways underlying the high prevalence of insulin resistance and risk for T2D in black SA women, targeting specific areas for therapeutic intervention.  Clinical Trial: The trial has not been registered.

  • How do patients with major depression use and benefit from smartphone CBT? Content analyses of completed cognitive and behavioral skills exercises with Kokoro-app

    Date Submitted: Oct 3, 2017
    Open Peer Review Period: Oct 4, 2017 - Nov 29, 2017

    Background: A strong and growing body of evidence has demonstrated effectiveness of cognitive-behavior therapy (CBT), either face-to-face in person or as self-help via internet, for depression. However CBT is a complex intervention consisting of several putatively effective components and how each component may or may not contribute to the overall effectiveness of CBT is poorly understood. Objective: To investigate how the users of smartphone CBT use and benefit from various components of the program. Methods: This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated effectiveness of adjunctive use of smartphone CBT (Kokoro-app) over antidepressant pharmacotherapy alone among patients with drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40, J Med Internet Res doi:10.2196/jmir.8602). Kokoro-app comprises three cognitive-behavioral skills of self-monitoring, behavioral activation and cognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the program and completing each worksheet were uploaded onto Kokoro-web which each patient could use for self-check. We examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at the median of change in depression severity. Results: 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0 (SD=1.4) out of 8 sessions of the program; it took them 10.8 (4.2) days to complete one session, during which they spent 62 (96) minutes on the app. There were no statistically significant differences in the number of sessions completed, time spent for the program or the number of completed self-monitoring worksheets between the beneficiaries and the non-beneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, and also filled in more cognitive restructuring worksheets than the latter. Activities such as “Test-drive a new car,” “Go to a coffee shop after lunch,” or “Call up an old friend” were found to be particularly rewarding. All cognitive-restructuring strategies were found to significantly decrease the distress level, with “What would be your advice to a friend who has a similar problem?” found more helpful than some other strategies. Conclusions: The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of mobile health in general. Clinical Trial: Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000015984

  • Assessing therapeutic alliance in the context of m-health interventions for mental health problems

    Date Submitted: Oct 4, 2017
    Open Peer Review Period: Oct 4, 2017 - Nov 29, 2017

    Background: There are a variety of digital health interventions (DHIs) in the form of smartphone apps, with a growing proportion of these aimed at improving mental health. This is an important development, enabling people access to support as and when needed without having to overcome the stigma many people experience in accessing routine mental health services. If we are to evaluate m-health apps and advance scientific understanding in this field, we also need tools to help us understand in what ways m-health interventions are or are not effective. The concept of therapeutic alliance (TA), a measure of the quality of the relationship between a healthcare provider and a service user, is a key factor in explaining the effects of face-to-face mental health interventions. To date, the concept of TA in relation to m-health interventions has received little attention. Objective: This study presents the first attempt to: i) explore service users’ views of the concept of ‘relationship’ within m-health mental health interventions; and ii) adapt a well validated face-to-face measure of TA, the Agnew Relationship Measure (ARM), for use with m-health interventions. Methods: Our methodology involved three stages. In stage one, we interviewed nine mental health service users about the concept of TA in the context of a DHI and derived key themes from interview transcripts using thematic analysis. In stage two, we used a combination of rating scales and open-ended questions and elicited views from fourteen service users and ten mental health staff about the content and face validity of a version of the ARM which replaced the word ‘therapist’ with the word ‘app’. In stage three, we used the findings from stages one and two to adapt the measure with the support of a decision-making algorithm about which items to drop, retain or adapt. Results: Findings suggest that service users do identify relationship concepts when thinking about m-health interventions, including forming a bond with an app and the ability to be open with an app. However, there were key differences between relationships with health professionals and relationships with apps, such as apps not being as tailored and responsive to each person’s unique needs and apps not being capable of portraying uniquely human-like qualities such as friendliness, collaboration and agreement. Conclusions: We present an m-health version of the ARM, the m-ARM, which has good face and content validity. We encourage researchers to include this easy to use administer tool in DHI studies to develop further data about its psychometric properties and advance our understanding of the efficacy of m-health interventions and the TA in the context of DHIs.

  • Using information and communication technologies and digital health services for self-management support: perceptions of persons with type 2 diabetes treated in Swedish primary health care – A Qualitative Study

    Date Submitted: Oct 2, 2017
    Open Peer Review Period: Oct 4, 2017 - Nov 29, 2017

    Background: Digital health services are increasing rapidly worldwide. Strategies to involve patient in self-monitoring of type 2 diabetes (T2D) on a daily basis is of crucial importance and there is a need to optimize the delivery of care, such as self-management support. Digitalised solutions have the potential to modify and personalise the way in which people use primary health services, both by increasing access to information and providing other forms of support at a distance. This study is part of a larger project aimed at implementing person-centred interactive self-management support (iSMS) in primary health care. Objective: The aim of this study was to describe perceptions of using information and communication technologies (ICT) and digital health services for self-management support among people with type 2 diabetes treated in Swedish primary healthcare. Methods: This is a report from a qualitative study, based on interviews analysed using content analysis conducted among people diagnosed with T2D. Results: Findings suggest that the participants had mixed feelings regarding the use of digital health services for self-management support. They experienced potentials such as increased involvement, empowerment, and safety, as well as concerns such as ambiguity and uncertainty. Conclusions: Digital health services for self-management are easily accessible and have the potential to reach a wide population. However, targeted training to increase digital skills is required and personalised devices must be adapted and become more person-centred to improve patients´ involvement in their own care.

  • To share or not to share? Examining perspectives on privacy, trust, and data sharing in web-based and mobile research among a large nationwide sample of men who have sex with men

    Date Submitted: Sep 28, 2017
    Open Peer Review Period: Oct 2, 2017 - Nov 27, 2017

    Background: Research is increasingly relying on online and mobile technologies, and this is particularly true among historically hard-to-reach populations such as gay, bisexual, and other men who have sex with men (GBMSM). Despite this, very little empirical data have been published on participant perspectives about issues such as privacy, trust, and data sharing. Objective: Data from an online sample of 11,032 GBMSM in the United States were analyzed to examine trust and perspectives on privacy and data sharing within online and mobile research. Methods: Participants were recruited via a social networking site or sexual networking app to complete an anonymous online survey. We conducted a series of repeated measures analyses adjusted for between-person factors to examine differences in: (1) trust for guarding personal information across different venues (e.g., online research conducted by a university, an online search engine); (2) privacy concerns about twelve different types by data activity (i.e., collection by app owners, anonymous selling to third parties, and anonymous sharing with researchers); and (3) willingness to share twelve different types of data with researchers. Due to the large sample size, we primarily report measures of effect size as evidence of clinical significance. Results: Online research was rated highest with regards to trust and was different from online and mobile technology companies, such as app owners and search engines, by magnitudes of effect that were moderate (partial-η2 = 0.06) to large (partial-η2 = 0.11). Responding separately about twelve different types of data, participants expressed more concerns regarding anonymously selling data to third-party partners (Mdn = 7.6) and fewer concerns about the data being collected by the app owners (Mdn = 5.8) or shared anonymously with researchers (Mdn = 4.6); differences were small-to-moderate in size (partial-η2 = 0.01, partal-η2 = 0.03). Participants were most willing to share public profile information (e.g., age) with researchers and least willing to share device usage information (e.g., other apps installed); the comparisons were small-to-moderate in size (partial-η2 = 0.03). Conclusions: Participants reported high levels of trust in online and mobile research, which is noteworthy given recent high profile cases of corporate and government data security breaches. Researchers and ethical boards should keep up with technological shifts to maintain the ability to guard privacy and confidentiality and maintain trust. Relatedly, there was substantial variability in privacy concerns about and willingness to share different types of data, suggesting the need to gain consent for data sharing on a specific rather than broad basis. Finally, we saw evidence of a privacy paradox whereby participants expressed privacy concerns about the very types of data-related activities they have likely already permitted via the terms of the apps and sites they use regularly.

  • A systematic and integrated Review of Studies that Evaluate Technology Enhanced Programmes for Healthcare Professionals

    Date Submitted: Sep 29, 2017
    Open Peer Review Period: Oct 2, 2017 - Nov 27, 2017

    Background: Background: Technology enhanced learning (TEL) programmes are increasingly seen as the way in which education for healthcare professionals can be transformed giving access to effective ongoing learning and training even where time or geographical barriers exist. Given the increasing emphasis on this mode of educational support for healthcare practitioners it is vital that we can effectively evaluate and measure impact to ensure that TEL programmes are effective and fit for purpose. This paper examines the existing evidence base for the evaluation of technology enhanced learning programmes for healthcare professionals. Objective: We aimed to undertake a systematic review of the literature relating to evaluation of technology enhanced learning programmes for healthcare professionals and critically appraise the quality of the studies. Methods: This review employed specific search criteria to identify research studies that included evaluation of technology enhanced learning for healthcare professionals. The databases searched included Medline Ovid, CINAHL Plus Advanced, ASSIA, ZETOC, IEE, AMED, ERIC (January 2006 – January 2017). An additional hand search for relevant articles from reference lists was undertaken. Each of the studies identified was critically appraised for quality using the Crowe Critical Appraisal Tool. This produced a percentage total score for each study across specified categories. A proportion of the studies were independently assessed by an additional two reviewers. Results: The review identified 21 studies that met the inclusion criteria. The studies included scored totals across 8 categories within a range of 37% and 97.5 % and average score of 68 %. A number of common themes were identified in relation to the most common types of TEL evaluation evident in the literature and the type of information reported within TEL evaluation studies. Conclusions: Relatively few studies have examined effective evaluation of TEL education for healthcare professionals. Studies often fail to provide sufficient detail to support transferability or direct future TEL healthcare education programmes.

  • A web application to involve patients in the medication reconciliation process: a user-centered usability and usefulness study

    Date Submitted: Sep 29, 2017
    Open Peer Review Period: Sep 29, 2017 - Nov 24, 2017

    Background: Medication discrepancies consist of unexplained differences between medication lists at different transition points of care; they are a threat to patient safety. These discrepancies can be solved through medication reconciliation (MedRec), a complex and time-consuming process. Several approaches to optimizing MedRec have been encouraged, including the development of information technology (IT) tools and patient engagement. The SEAMPAT project aims to develop a MedRec IT platform based on two applications (one for the patient, the “patient app”, the other for healthcare professionals), which were developed using a three-iteration user-centered design. The patient app presents the patient with a medication list compiled from different medication resources. Objective: To evaluate the usability and usefulness of the third iteration of the patient app, from the perspective of different categories of users, with the aims of making recommendations for wider use and informing further research. Methods: We performed a four-month user-centered observational study. After a kick-off session, patients, identified through purposive sampling, were invited to use the patient app at home, to update their medication lists whenever required. Quantitative and qualitative data were collected at different time points to evaluate three dimensions of usability (efficiency, satisfaction, and effectiveness), as well as usefulness. Participants completed two questionnaires on satisfaction and usefulness (including the system usability scale, SUS) at the kick-off and the end of the study. Effectiveness was assessed by measuring the completeness and correctness (i.e. medication discrepancies) of the final medication list generated by the patient application. Qualitative data were collected from observations at different time points and from semi-structured interviews at the end of the study. Results: Forty-eight patients agreed to participate and 42 completed the study, of whom 32 connected at least once to the application at home. Sixty-nine percent of patients considered the patient app to be acceptable (SUS Score ≥ 70) and perceived usefulness was high. The medication list was complete for a quarter of the patients and there was a median of two discrepancies per patient. The main causes were technology-related. The qualitative data enabled the identification of several barriers and, thus, of approaches to optimizing usability and usefulness. These relate to both functional (e.g. access, on-screen display, additional functionalities) and non-functional aspects (e.g. patient awareness, concordance between patient and physician) of the application. For future adoption of the tool, it will be important to address these issues. Conclusions: Our findings highlight the importance and value of user-centered usability testing of a patient application implemented in “real-world” conditions. We believe our study also underlines the need to take patients’ points of view into consideration. To achieve adoption and sustained use by patients, the patient app should meet patients’ needs while also efficiently improving the quality of MedRec.

  • Self-swabbing for virological confirmation of influenza like illness (ILI) amongst an internet based cohort in the UK, 2014-5

    Date Submitted: Sep 29, 2017
    Open Peer Review Period: Sep 29, 2017 - Nov 24, 2017

    Background: Routine influenza surveillance, based on laboratory confirmation of viral infection often fails to estimate a true burden of influenza like illness (ILI) in the community due to the fact that those suffering from ILI often manage their own symptoms, without visiting a health professional. Internet based surveillance can complement this traditional health-service-based surveillance by measuring symptoms and health behaviour of a population with minimal time delay. Flusurvey, the UK’s largest crowd-sourced platform for surveillance of influenza, collects routine data on over 6,000 voluntary participants and offers real-time estimates of ILI circulation. However, one criticism of this method of surveillance is that it is only able to assess ILI, rather than virologically confirmed influenza. Objective: We designed a pilot to see if it was feasible to ask individuals from the Flusurvey platform to perform a self-swabbing task, and to assess whether they were able to collect samples with a suitable viral content to be able to identify an influenza virus in the laboratory. Methods: Virological swabbing kits were sent to pilot participants, who then monitored their ILI symptoms over the influenza season (2014-5) through the Flusurvey platform. If they reported ILI, they were asked to undertake the self-swabbing exercise, and return the swabs to Public Health England (PHE) laboratory for multiplex PCR testing. Results: The results showed that samples from 18/51 people who reported ILI tested positive for a virological confirmed infection through multiplex PCR testing. Conclusions: This demonstrated proof of concept that it is possible to apply self-swabbing for virological laboratory testing to an online cohort study. This pilot does not have significant numbers to validate whether Flusurvey surveillance does reflect influenza infection in the community, but it highlights that the methodology is feasible and self-swabbing could be expanded to larger online surveillance activities, such as during the initial stages of a pandemic to understand community transmission or to better assess inter-seasonal activity.

  • Perspectives of nurses toward Telehealth Efficacy and Quality of Health Care

    Date Submitted: Sep 28, 2017
    Open Peer Review Period: Sep 29, 2017 - Nov 24, 2017

    Background: Telehealth nursing, or the delivery, management, and coordination of nursing care services, provided via telecommunications technology, is one of the methods of delivering health care to patients in the USA. It is important to assess the service quality of the involved medical fields as well as the telehealth nursing process .The role of telehealth nursing and related technology toward patient care needs to be justified and established. Objective: The primary objective of this study is to examine whether telehealth technology impacts the perceived level of internal service quality, delivered by nurses, within a telehealth organization. To address this research goal, the notion of telehealth nursing service quality is empirically tested and validated with a survey instrument. Methods: Data was collected based on interview questions inquiring about facilitators and inhibitors to telehealth nursing service quality (TNSQ). A survey to measure telehealth nursing service quality based on the SERVQUAL instrument was completed by adjusting descriptions of the original instrument to suit the context. Follow up interviews were conducted to validate questions on the revised instrument. Results: The findings of this survey research were positive, based on mean differences between expectations and perceptions of telehealth nursing service quality. This indicates satisfaction with TNSQ and also indicates that quality of the service is higher than what the respondents expect. The Wilcoxon signed-ranks test using the p-value for the test, which is 0.35, did not show a statistically significant change between the median differences of perception and expectation. The total number of respondents was 13. Results indicate that overall perceived service quality is a positive value (0.05332).This means the perceptions of the level of service, is slightly higher than what they expect, indicating there is satisfaction with telehealth nursing service quality. Conclusions: The responses to the interview questions and data gathered from the survey showed overall satisfaction with TNSQ. The SERVQUAL instrument was a good framework to assess TNSQ. In a nutshell, the study highlighted how the telehealth process provides daily monitoring of patient health, leading to the benefits of immediate feedback for patients, family, and caregivers as well as convenience of scheduling.

  • Electronic collection of multilingual patient reported outcomes across Europe

    Date Submitted: Sep 28, 2017
    Open Peer Review Period: Sep 29, 2017 - Nov 24, 2017

    Background: The interoperability between information systems in healthcare is still an issue despite of the large number of institutions seeking solutions. One of the most commonly accepted ones is the use of standards. Patient reported outcomes (PROs), information provided directly by the patient, improve patient diagnosis and treatment, and their translations may be used to treat international patients. Electronic systems and especially mobile devices provide a great opportunity for the collection of PROs. These systems are normally study oriented and therefore single language, not scalable and not interoperable. Objective: To demonstrate the feasibility of an open standard based electronic PRO system in a multilingual and multi-centre context. Methods: MoPat was developed using Java 8 and jQuery Mobile 1.4.5. The system was evaluated in the context of the European dermatology project “PruNet”, which aimed to unify the assessment of itch in routine dermatological care in Europe. Clinicians and patients participating in the PruNet study were interviewed and the user acceptance of MoPat was assessed. Results: MoPat’s initial implementation was enhanced with multilingual capabilities and is now able to perform surveys in several languages and collect the results in a single one. 26 clinicians and 495 patients from 8 European clinical centres participated in a satisfaction survey, resulting in a high acceptance of the system by both groups. The age of the patients not willing to further use MoPat was, in average, considerably higher than the ones willing to use the system. Conclusions: This study represents the first use of an electronic PRO system for the collection of multilingual PROs in an international multi-centre setting. MoPat has been evaluated by both clinicians and patients in the context of a European dermatological study resulting in a high user acceptance. The system will be further developed in order to include new features such as patient’s follow up outside of the clinical setting.

  • Self-harm and cyberbullying: a systematic review of the association between cyberbullying and self-harm and suicidal behaviours in children and young people

    Date Submitted: Sep 29, 2017
    Open Peer Review Period: Sep 29, 2017 - Nov 24, 2017

    Background: Given concerns about bullying via electronic communication in children and young people and its possible contribution to self-harm (SH) we have reviewed the evidence for associations between cyberbullying involvement and SH or suicidal behaviours (such as suicidal ideation, suicide plans and suicide attempts) in children and young people. Objective: The aim of this study was to systematically review the current evidence examining the association between cyberbullying involvement as victim and/or perpetrator and SH and suicidal behaviours in children and young people (under 25-years), and where possible, to meta-analyse data on the associations. Methods: An electronic literature search was conducted for all studies published between 01/01/1996 and 03/02/2017 across sources including Medline, Cochrane, and PsycINFO. Articles were included if the study examined any association between cyberbullying involvement and SH or suicidal behaviours and reported empirical data in a sample under 25-years of age. Quality of included papers was assessed and data extracted. Meta-analyses of data were conducted. Results: Thirty-one eligible articles from 24 independent studies were included covering a population of 155,471 children and young people. Twenty-five articles (20 independent studies, n = 115,056) identified associations (negative influences) between cybervictimisation and SH/suicidal behaviours or between perpetrating cyberbullying and suicidal behaviours. Three additional articles, in which the cyberbullying, SH or suicidal behaviours measures had been combined with other measures (such as traditional bullying and mental health problems), also showed negative influences (n = 44,526). Three articles showed no significant associations (n = 4,733). Meta-analyses, producing odds ratios (OR) as a summary measure of effect size (e.g. ratio of the odds of cybervictims who have experienced SH versus non-victims who have experienced SH) showed that, compared with non-victims, those who have experienced cybervictimisation were: 2·35 [1·65, 3·34] times as likely to SH; 2·10 [1·73, 2·55] times as likely to exhibit suicidal behaviours; 2·57 [1·69, 3·90] times more likely to attempt suicide; and 2·15 [1·70, 2·71] times more likely to have suicidal thoughts. Cyberbullying perpetrators were 1·21 [1·02, 1·44] times more likely to exhibit suicidal behaviours and 1·23 [1·10, 1·37] times more likely to experience suicidal ideation than non-perpetrators. Conclusions: Victims of cyberbullying are at a greater risk than non-victims of both SH and suicidal behaviours. To a lesser extent, perpetrators of cyberbullying are at risk of suicidal behaviours and suicidal ideation when compared to non-perpetrators. Policymakers and schools should prioritise the inclusion of cyberbullying involvement in programmes to prevent traditional bullying. Type of cyberbullying involvement, frequency, and gender should be assessed in future studies.

  • Evaluating the effectiveness of real-time patient experience feedback: a systematic review

    Date Submitted: Sep 28, 2017
    Open Peer Review Period: Sep 29, 2017 - Nov 24, 2017

    Background: One of the essential elements of a strategic approach to improving patents’ experience is to measure and report on patients’ experiences in real-time, to assess progress and identify new opportunities for improving performance. Real-time feedback (RTF) is increasingly being collected or collated using digital technology, however, there remains a gap in the literature with regard to the effectiveness of these digital real-time feedback modes. Objective: The aim of this review was to assess the effectiveness of real-time patient experience feedback. Methods: The following databases were systematically searched to identify articles which used digital systems to collect, collate or disseminate RTF: the Cochrane Librbary, Global Health, Health Management Information Consortium, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL. Google Scholar and Grey Literature was also utilised. Studies were assessed on their effectiveness using a Digital Maturity Framework, based on four domains; capacity/resource, usage, interoperability and impact. A total score of four indicated the highest level of digital maturity. Results: Of the 13 eligible studies, none had digital systems that were deemed to be of the highest level of maturity. Three (23.1%) studies achieved a score of 3, three (23.1%) a score of 2, three (23.1%) a score of 1, and four (30.7%) achieved a score of 0. Seven (53.8%) studies demonstrated capacity/resource, and 8 (61.5%) demonstrated impact. No articles demonstrated interoperability in their digital systems. Implementation of digital systems showed acceptable response rates and positive views from patients and staff. Conclusions: Digitally enabled RTF has been chronically under-reviewed. Given the potential benefits, healthcare services should be mindful of the need to ensure digital maturity when implementing RTF. As failure to deliver across the digital maturity continuum may lead to ineffective RTF thwarting improvement efforts.

  • A Neuroimaging Web Services Interface Design as a Cyber Physical System for Medical Imaging and Data Management in Brain Research

    Date Submitted: Sep 28, 2017
    Open Peer Review Period: Sep 28, 2017 - Nov 23, 2017

    Background: Structural and functional brain images are generated as essential elements for medical experts to study brain anatomy, learn about the different functions of the brain in its normal and pathology states, provide diagnosis and prevention measures, and tailor treatment plans that are subject specific. These images are typically visually inspected by experts in the field and stored as part of patient’s medical histories. In order to analyze images without any bias, they must be first converted to numeric values representing volumes, surfaces, direction of water movement in the brain, brain activity maps, etc. Many software packages are available to process the images, but they are complex and difficult to use for non-computer experts. The software packages are also hardware intensive, requiring specialized servers. The results obtained after processing varies depending on the native operating system used and its associated software libraries; data processed in one system cannot typically be combined with data on another system. Objective: Neuroimaging Web Services Interface (NWSI) is a series of processing pipelines that is designed to store, process, and share neuroimaging and clinical data, aimed at fulfilling the need of the neuroimaging community for a common platform to process and store their neuroimaging data. Methods: NWSI was developed based on Drupal 7, with feedback from experts in the field of Alzheimer’s disease and Epilepsy. The repository accepts raw images, such as MRI, PET, DTI, and fMRI. The images are processed using existing and custom software packages. The output is then stored as image files, tabulated files, and MySQL data tables. The system, made up of a series of interconnected servers, is password protected, and is securely accessible through a HIPPA compliant web interface from anywhere in the world. The webserver allows (1) visualization of results by embedding interactive visual analysis of multi-faceted neuroimaging data, and (2) downloading tabulated data results for further processing. Several forms are also available on the interface to capture demographic and clinical data (e.g., diagnoses and neuropsychological test scores). Results: The system has been piloted using data and researchers from the 1Florida Alzheimer’s disease Research Center (ADRC), Baptist Health South Florida, and Nicklaus Children's Hospital. All results were obtained using our processing servers in order to maintain data validity and consistency. The design is responsive and scalable. The processing pipeline starts from a FreeSurfer reconstruction of T1-weighted MRI images. The FreeSurfer and regional Standardized Uptake Value ratio (SUVR) calculations have been validated using ADNI input images and results are posted at LONI (Laboratory of Neuro Imaging) data archive. Conclusions: To our knowledge there is no validated web-based system offering all the services that NWSI offers. The intent of NWSI is to create a tool for clinicians and researchers with keen interest on multimodal neuroimaging but who do not necessarily have the time and/or the required expertise in image processing, computing, and data management resources.

  • Validity of wireless sensors in measuring surface electromyography and skin temperature: Basis for a novel preventive headache treatment

    Date Submitted: Sep 28, 2017
    Open Peer Review Period: Sep 28, 2017 - Nov 23, 2017

    Background: The use of wearables and mobile phone applications in medicine is gaining attention. Biofeedback has the potential to exploit the recent advances in mobile health (mHealth), for the treatment of headaches. Objective: The aim of this study was to assess the validity of selected wireless wearable health monitoring sensors (WHMS) for measuring surface electromyography (SEMG) and peripheral skin temperature in combination with a mobile-phone application. This proof of concept will form the basis for developing innovative mHealth delivery of biofeedback treatment among young persons with primary headache. Methods: Sensors fulfilling the following predefined criteria were identified: wireless, small size, low weight, low cost, and simple to use. These sensors were connected to an application and used by 20 healthy volunteers. Validity was assessed through the agreement with simultaneous control measurements made with stationary neurophysiological equipment. The main variables were: (1) trapezius muscle tension during different degrees of voluntary contraction and (2) voluntary increase in finger temperature. Data were statistically analyzed using Bland-Altman plots, intra-class correlation coefficient (ICC), and concordance correlation coefficient (CCC). Results: The application was programmed to receive data from the wireless sensors, process them, and feed them back to the user through a simple interface. Excellent agreement was found for the temperature sensor, regarding increase in temperature (CCC, 0.90; 95% coefficient interval [CI], 0.83–0.97). Excellent to fair agreement was found for the SEMG sensor. The ICC for the average of three repetitions during four different target levels ranged from 0.58 to 0.81. The wireless sensor showed consistency in muscle tension change during moderate muscle activity. Electrocardiography artifacts were avoided through right-sided use of the SEMG sensors. Participants evaluated the setup as usable and tolerable. Conclusions: This study confirmed the validity of wireless WHMS connected to a smartphone for monitoring neurophysiological parameters of relevance for biofeedback therapy.

  • Title: Patient reported measures for person-centred coordinated care: a comparative domain map and online compendium for supporting policy development and implementation.

    Date Submitted: Sep 28, 2017
    Open Peer Review Period: Sep 28, 2017 - Nov 23, 2017

    Background: Patient Reported Measure (PRM) questionnaires were originally used in research to measure outcomes of intervention studies. They have now evolved into a diverse family of tools measuring a range of constructs including quality of life (QoL) and experiences of care. Current health and social care policy increasingly advocates their use for embedding the patient voice into service redesign through new models of care such as Person Centred Coordinated Care (P3C). If chosen carefully and used efficiently, these tools can help improve care delivery through a variety of novel ways, including system-level feedback for healthcare management and commissioning. Support and guidance on how to use these tools would be critical to achieve these goals. Objective: To develop evidence based guidance and support for the use of P3C-PRMs in health and social care policy through: 1) identification of PRMs that can be used to enhance the development of P3C; 2) mapping P3C-PRMs against an existing model of domains of P3C; and 3) integration and organisation of the information in a user-friendly online database. Methods: A pragmatic approach was used for the systematic identification of candidate P3C-PRMs, which aimed at balancing comprehensiveness and feasibility. This utilised a number of resources, including existing compendiums, published and grey literature (using a flexible search strategy) and stakeholder engagement (which included guidance for relevant clinical areas). A subset of those candidate measures (meeting pre-specified eligibility criteria) were then mapped against a theoretical model of P3C, facilitating classification of the construct being measured and the subsequent generation of shortlists for: 1) generic P3C measures, 2) specific aspects of P3C (e.g. “communication” or “decision making”), in addition to 3) condition specific measures (e.g. diabetes, cancer, stroke etc.) in priority areas as highlighted by stakeholders. Results: In total, 328 P3C-PRMs were identified, which were used to populate a freely available online database (“the compendium”). 63 of these P3C-PRMs met eligibility criteria for shortlisting and were classified according to their measurement constructs and mapped against the theoretical P3C model. We identified tools with the best coverage of P3C, thereby providing evidence of their content validity as outcome measures for new models of care. Transitions and medications were two areas currently poorly covered by existing measures All the information is currently available at a user-friendly online portal (p3c.org.uk), which includes all relevant information on each measure such as the constructs targeted, links to relevant literature, item lists of the mapped measures, in addition to shortlists according to relevant constructs. Conclusions: A detailed compendium of P3C-PRMs has been developed using a pragmatic systematic approach supported by stakeholder engagement. Our user-friendly suite of tools is designed to act as a portal to the world of PRMs for P3C, and have utility for a broad audience, including (but not limited to) healthcare commissioners, managers, and researchers.

  • Web-based versus usual care and other formats of decision aids to support prostate cancer screening decision: systematic review and meta-analysis

    Date Submitted: Sep 27, 2017
    Open Peer Review Period: Sep 28, 2017 - Nov 23, 2017

    Background: Prostate cancer is a leading cause of cancer among men. Screening for prostate cancer is a controversial issue. Thus, many experts in the field have defended the use of shared decision making using validated decision aids, which can be presented in different formats (written, multimedia, web). Recent studies have concluded that decision aids improve knowledge and reduce decisional conflict. Objective: This meta-analysis aimed to investigate the impact of using web-based decision aids to support men's prostate cancer screening decisions in comparison with usual care and other formats of decision aids. Methods: Pubmed, CINAHL, PsychINFO, and Cochrane Database of Systematic Reviews databases up until November 2016 were searched. The review identified randomised controlled trials, which assessed web-based decision aids for men making a prostate cancer screening decision and reported quality of decision-making outcomes. Two reviewers independently screened citations for inclusion criteria, extracted data, and assessed risk of bias. Using a random-effects model, meta-analyses were conducted pooling results using mean differences (MD), standardized mean differences (SMD), and relative risks (RR). Results: Of 2406 unique citations, seven randomised controlled trials met the inclusion criteria. For risk of bias, selective outcome reporting and partipant/personnel blinding were mostly rated as unclear due to inadequate reporting. Based on seven items, two studies had high risk of bias for one item. Compared to the usual care, web-based decision aids increased knowledge (SMD 0.46; 95% confidence interval [CI] 0.18‒0.75), reduced decisional conflict (MD -7.07%; 95% CI -9.44 ‒ [-]4.71), and reduced the practitioner control role in the decision-making process (RR 0.50; 95% CI 0.31‒0.81). Web-based decision aid compared to printed decision aids yielded no differences in knowledge, decisional conflict, and participation in decision or screening behaviours. Compared to video decision aids, web-based decision aids showed lower average knowledge scores (SMD -0.50; 95% CI -0.88‒[-]0.12) and a slight decrease in prostate-specific antigen (PSA) screening (RR 1.12; 95% CI 1.01‒1.25). Conclusions: According to the present analysis, web-based decision aids performed similarly to alternative formats (printed, video) for the assessed decision-quality outcomes. The low cost, readiness, availability, and anonymity of the worldwide web can be an advantage for increasing access to decision aids that support prostate cancer screening decision among men.

  • Effect on the metabolic biomarkers in schoolchildren, after a comprehensive intervention using electronic media and in-person sessions, to change lifestyles: Community Trial

    Date Submitted: Sep 27, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    Background: Obesity is a chronic low-intensity state of inflammation with metabolic alterations that acquired during childhood, lead to severe illness in adult age. Encouraging healthy eating habits and physical activity is the basis for preventing and treating obesity and its complications. Objective: To evaluate how a comprehensive intervention promoting healthy eating habits and physical activities in schools affects children’s metabolic biomarkers. Methods: Out of four Mexico City primary schools in this study, two participated in a 12-month intervention (IG) and the other two were control groups (CG). The intervention had two components: 1) Parents/schoolchildren attended in-person educational sessions promoting healthy eating and physical activity habits and were provided printed information; 2) parents were able to seek information through a Web site; they also received brief, weekly phone texts. Anthropometric measurements and fasting blood samples were taken from both groups of children at baseline and again after 12 months. Results: Regardless of each child's nutritional status at the beginning of the study, the intervention improved metabolic parameters; the IG showed a negative effect on glucose concentrations (-1.83; CI 95% -3.06 to -0.60), LDL-C (-2.59; CI 95% -5.12 to -0.06), insulin (-0.84; CI 95% -1.31 to -0.37) and HOMA-IR (-0.21; CI 95% -0.32 to -0.09) in comparison to the CG. HOMA-IR improved in children who had higher than baseline BMI z-scores. Conclusions: Intervention through multiple components promoting healthier eating and physical activity habits improved the metabolic parameters of the children in the study after one year, regardless of their nutritional status.

  • How is “tinnitus” is represented in the United Sates newspaper media and social media?

    Date Submitted: Sep 27, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    Background: When people with health conditions start to manage their health issues, one aspect that determines what they do with the information involves what they obtain through various sources (e.g., news media, social media, health professionals, friends and family). The information they gather helps form their opinions, and will also to some degree influence their attitudes towards managing the condition. Objective: The current study was aimed at understanding how “tinnitus” is represented in the United Sates newspaper media and in social media (specifically Facebook pages) using text pattern analysis. Methods: This was a cross-sectional study based upon secondary analyses of publicly available data. The two data sets (i.e., text corpuses) analyzed in this study were generated from: (1) U.S. newspaper media during 1980-2017 (downloaded from the database U.S. Major Dailies by ProQuest); and (2) Facebook pages during 2010-2016. The text corpuses were analyzed using the Iramuteq software using cluster analysis and Chi square tests. Results: The newspaper data set had 432 texts (i.e., articles). The cluster analysis resulted in five clusters, which were named as follows: (1) brain stimulation (26.2%); (2) symptoms (13.5%); (3) coping (19.8%); (4) social support (24.2%); and (5) treatment innovation (16.4%). A time series analysis of clusters indicated a change in the pattern of information presented in newspaper media during 1980-2017 (e.g., more emphasis on cluster 5, focusing on treatment inventions). The Facebook data set had 1,569 texts. The cluster analysis resulted in five clusters, which were named as: (1) diagnosis (21.9%); (2) cause (4.1%); (3) research and development (13.6%); (4) social support (18.8%); (5) challenges (11.1%); (6) symptoms (21.4%); and (7) coping (9.2%). A time series analysis of clusters indicated no change in information presented in Facebook pages on tinnitus during 2011-2016. Conclusions: The study highlights the specific aspects about tinnitus that the U.S. newspaper media and social media (i.e., Facebook pages) focuses on, and also how these aspects change over time. These findings can help clinicians to better understand the presupposition that tinnitus patients have, and may also help clinicians in tailoring specific messages during clinical consultations and rehabilitation. More importantly, the findings can help public health experts and health communication experts in tailoring health information about tinnitus in order to promote self-management, as well as assisting in appropriate choices of treatment for tinnitus sufferers. Clinical Trial: NA

  • Assessing Unmet Information Needs of Breast Cancer Survivors using Text Classification and Retrieval

    Date Submitted: Sep 27, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    Background: Patient education materials given to breast cancer survivors may not be a good fit for their information needs. Needs may change over time, be forgotten, or be misreported, for a variety of reasons. An automated content analysis of survivors' postings to online health forums can identify expressed information needs over a span of time and be repeated regularly at low cost. Identifying these unmet needs can guide improvements to existing education materials and the creation of new resources. Objective: The primary goals of this project are to assess the unmet information needs of breast cancer survivors from their own perspectives and to identify gaps between information needs and current education materials. Methods: This approach employs computational methods for content modeling and supervised text classification to data from online health forums to identify explicit and implicit requests for health-related information. Potential gaps between needs and education materials are identified using techniques from information retrieval. Results: We provide a new taxonomy for the classification of sentences in online health forum data. 260 postings from two online health forums were selected, yielding 4179 sentences for coding. After annotation of data and training alternative one-versus-others classifiers, a random forest-based approach achieved F1 scores from 66% (Other, dataset2) to 90% (Medical, dataset1) on the primary information types. 136 expressions of need were used to generate queries to indexed education materials. Upon examination of the best two pages retrieved for each query, 12% of queries were found to have relevant content by all coders, and 33% were judged to have relevant content by at least one. Conclusions: Text from online health forums can be analyzed effectively using automated methods. Our analysis confirms that breast cancer survivors have many information needs that are not covered by the written documents they typically receive, as our results suggest that at most a third of breast cancer survivors’ questions would be addressed by the materials currently provided to them.

  • Towards impactful collaborations on Computing and Mental Health

    Date Submitted: Sep 26, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    We describe an initiative to bring mental health researchers, computer scientists, human-computer interaction researchers and other communities together to address the challenges of the global mental health epidemic. Two face-to-face events and one special issue of the Journal of Medical Internet Research were organized. The works presented in these events and publication reflect key current state of the art research in this interdisciplinary collaboration. A summary description of the special issue articles is presented and contextualized in order to present a picture of the most recent research. In addition, we describe a series of collaborative activities held during the 2nd Symposium and where the community identified five challenges and their possible solutions.

  • Estimation of Symptom Severity During Chemotherapy From Passively Sensed Data: An Exploratory Study

    Date Submitted: Sep 26, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    Background: Physical and psychological symptoms are common during chemotherapy for cancer, and real-time monitoring of these symptoms can improve patient outcomes. Sensors embedded in smartphones and wearable activity trackers could be potentially useful in monitoring symptoms passively, with minimal patient burden. Objective: The goal of this study was to explore whether passively sensed smartphone and Fitbit data could be used to estimate daily symptom burden during chemotherapy. Methods: A total of 14 patients undergoing chemotherapy for gastrointestinal cancer participated in the 4-week study. Participants carried an Android phone and wore a Fitbit Charge HR device for the duration of the study and also completed daily severity ratings of 12 common symptoms. Symptom severity ratings were summed to create a total symptom burden score for each day, and ratings were centered on individual patient means and categorized into low, average, and high symptom burden days. Results: Across 295 days of data with both symptom and sensor data, a number of smartphone and Fitbit features were correlated with patient-reported symptom burden scores. Using a classifier to estimate symptom burden, we achieved an accuracy of 88.1% for our population model. The subset of features with the best accuracy included sedentary behavior as the most frequent activity, fewer minutes in light physical activity, less variable and average acceleration of the phone, and longer screen-on time/interactions with apps on the phone. Accuracy of individual models ranged from 78.1-100%, and subsets of relevant features varied across participants. Conclusions: Passive sensor data, including smartphone accelerometer and usage and Fitbit-assessed activity and sleep, were strongly related to daily symptom burden during chemotherapy. These findings highlight opportunities for long-term monitoring of cancer patients during chemotherapy with minimal patient burden as well as real-time adaptive interventions aimed at early management of worsening or severe symptoms.

  • Evolution on Cognitive Rehabilitation after Stroke: from Traditional Techniques to Smart and Personalised ICT Home-based Systems

    Date Submitted: Sep 27, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    Background: Neurological patients after stroke usually present cognitive deficits which impose a dependency in their daily living. These deficits mainly affect the performance of some daily activities which can be dangerous if no supervision is provided. For that reason, stroke patients need long-term processes for their cognitive rehabilitation. Considering that classical techniques are focused on acting as a guide, teaching by repetition and they depend on the help of therapists, big efforts are being made to improve current methodologies and get benefits from e-health and web-based architectures to implement ICT systems that achieve reliable, personalized and home-based platforms to increase efficiency and level of attractiveness for patients and carers. Objective: The goal of this work is to provide a wide swept in the practices implemented for the assessment of stroke patients and cognitive rehabilitation. The article puts together traditional methods and the most recent personalised platforms based on ICT technologies and even Internet of Things in order to show the evolution and improvements in the field of cognitive rehabilitation. Methods: A literature review has been distributed to a multidisciplinary team of researchers from engineering, psychology and sport science fields. The systematic review has been focused on scientific published research, other European projects and the most current innovative large-scale initiatives in the area. 3,469 results were managed from the Web of Science, 284 articles from JMIR Publications were obtained and finally, 15 research European projects from CORDIS during the last fifteen years were reviewed for classification and selection regarding their relevance. Results: The analysis of evolution on the techniques gave evidence on the improvements in the implementation of traditional techniques. In that sense, 7 relevant studies on the screening of stroke patients have been presented with 6 additional methods for the analysis of kinematics and 9 works on the execution of goal-oriented activities. Meanwhile, the classical methods to provide cognitive rehabilitation have been classified in the 5 main techniques implemented. Finally, the review has finalised with the selection of 8 different ICT-based approaches found in scientific-technical articles; 9 European projects funded by the European Commission that offer e-health architectures; and other large-scale activities such as smart houses and the initiative City4Age. Conclusions: Stroke is one of the main causes that most negatively affect countries in the socio-economic aspect. The design of new ICT-based systems should provide 4 main features for an efficient and personalised cognitive rehabilitation: support in the execution of complex daily tasks, automatic error detection, home-based performance, and accessibility. Only 33% of the European projects presented fulfilled those requirements at the same time. For this reason, current and future large-scale initiatives focused on e-health and smart environments try to solve this situation by providing more complete and sophisticated platforms.

  • Promoting psychological wellbeing at work by reducing stress and improving sleep: results from a mixed methods analysis

    Date Submitted: Sep 26, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    Background: Workplace programs designed to improve the health and psychological wellbeing of employees are becoming more popular. However, there are mixed reports regarding the effectiveness of such programs and little analysis of what makes these programs effective. Objective: This evaluation of a particularly broad, team-based, digital health and wellbeing program uses mixed methods to identify the elements of the program that promote the psychological wellbeing of employees and the characteristics of the participants best served by this program. Methods: Participants in the Virgin Pulse Global Challenge (VPGC) program during the period May-September 2016 were studied. Self-reported stress, sleep quality, productivity and psychological wellbeing data were collected both pre- and post-program. Participant experience data was also collected through an additional survey released after program completion (n=18,674). Text mining of the participant experience data and machine learning methods were used to identify which factors drove successful outcomes. Results: Results for the participants who completed all three of the surveys (8%) indicate that the VPGC program was effective (p<.001) for improving psychological wellbeing (2 = 0.372), sleep quality (2 = 0.298), work-related stress (2 = 0.226) and productivity (2 = 0.109). For the participants who completed only the first two surveys the results were still significant but not as strong. After pre-program psychological wellbeing, improvement in productivity was the most important predictor of post-program psychological wellbeing (2 = 0.245), followed by improvements in sleep (2 = 0.226) and stress (2 = 0.206). Improved colleague connections were less important (2 = 0.114). The Physical Activity module increased the odds of an improvement in connections with colleagues by 38% on average (95% CI 22%, 56%). However, this module was less important for improvements in stress, sleep, productivity and psychological wellbeing than any of the three other program modules (namely, Nutrition, Sleep, and Balance). Text-mining methods were used to identify 25 key topics from participant descriptions of the VPGC program and regression tree models incorporating these topics provided a contextual view of how the program modules and features drove improvements in psychological wellbeing, stress, sleep and productivity. However, there was some indication that the tracking of steps in the Physical Activity module of the program was proving a distraction. In addition, it was found that the effect of the program was not as beneficial for those who showed less engagement with the program in that they failed to complete the participant experience survey. Conclusions: The results suggest that the VPGC program improves stress, sleep, productivity and psychological wellbeing. The complementary use of both qualitative and quantitative survey data in a mixed methods analysis provided rich information that will inform the development of this and other programs designed to improve employee health. Clinical Trial: n.a.

  • A bibliometric analysis of physical activity, sedentary behavior and diet related e- & mHealth research

    Date Submitted: Sep 26, 2017
    Open Peer Review Period: Sep 27, 2017 - Nov 22, 2017

    Background: e- & mHealth approaches to address low physical activity levels, sedentary behavior and unhealthy diets have received significant research attention. However, attempts to systematically map the entirety of the research field are lacking. This gap can be filled with a bibliometric study, where publication-specific data such as citations, journals, authors and keywords are used to provide a systematic overview of a specific field. Such analyses will help researchers better position their work. Objective: To use bibliometric data to provide an overview of the e- & mHealth research field related to physical activity, sedentary behavior and diet. Methods: The Web of Science (WoS) Core Collection was searched to retrieve all, and highly-cited (as defined by WoS), physical activity, sedentary behavior and diet e- & mHealth research papers published in English between January 2000 and 31 December 2016. Retrieved titles were screened for eligibility, using the abstract and full-text where needed. We described publication trends over time; journals, authors and countries of eligible papers; as well as their keywords and subject categories. Citations of eligible papers were compared to those expected based on published data. Additionally, we identified and described “highly-cited papers” of the field (i.e. top ranked 1%). Results: The search identified 4805 hits, of which 1712 (including 42 highly-cited papers) were included in the analyses. Publication output increased on average 26% per year since 2000 with 51% of papers being published between 2014 and 2016. Overall and throughout the years, e- & mHealth papers related to physical activity, sedentary behavior and diet received more citations than expected compared to papers in the same WoS subject categories. The Journal of Medical Internet Research published most papers in the field (n=164, 9.6% of total papers). Papers predominantly originated from high-income countries (96.1%) with the United States being the most prolific country (48.8% of all papers). Most articles were trials, and studied physical activity. Beginning in 2013, research on "Generation 2" technologies (e.g., smartphones, apps, wearables) sharply increased, while research on "Generation 1" (e.g., text messages) technologies increased at a reduced pace. Reviews accounted for 20 of the 42 highly-cited papers (n=19 systematic reviews). Social media, smartphone apps and wearable activity trackers used to encourage physical activity, less sedentary behavior and/or healthy eating were the focus of 14 highly-cited papers. Conclusions: This study highlighted the rapid growth of the e- & mHealth physical activity, sedentary behavior and diet research field, emphasized the sizeable contribution of research from high-income countries and pointed to the increased research interest in "Generation 2" technologies. It is expected that the field will grow and diversify further, and that reviews and research on most recent technologies will continue to strongly impact the field.

  • Designing for Clinical Change: Creating an Intervention to Implement New Statin Guidelines in a Primary Care Clinic

    Date Submitted: Sep 25, 2017
    Open Peer Review Period: Sep 25, 2017 - Nov 20, 2017

    Background: Recent clinical practice guidelines from major national organizations, including a joint United States Department of Veterans Affairs and Department of Defense (VA/DoD) committee, have substantially changed recommendations for the use of the cholesterol-lowering statin medications after years of relative stability. Because statin medications are among the most commonly prescribed treatments in the United States, any change to their use may have significant implications for patients and providers alike. Prior research has shown that effective implementation interventions should be both user-centered and specifically chosen to address identified barriers. Objective: To identify potential determinants of provider uptake of the new statin guidelines and to use that information to tailor a coordinated and streamlined local quality improvement intervention focused on statin prescribing. Methods: We employed user-centered design principles to guide the development and testing of a multi-component guideline implementation intervention to improve statin prescribing. This paper describes the intervention development process whereby semi-structured qualitative interviews with providers were conducted to 1) illuminate the values, workflows, and subjective needs and preferences of providers and 2) elicit feedback on intervention prototypes developed to align with and support the use of the VA/DoD guidelines. Our aim was to use this information to design a local quality improvement intervention focused on statin prescribing that was tailored to the needs of primary care providers at our facility. Cabana’s Clinical Practice Guidelines Framework for Improvement and Nielsen’s Usability Heuristics were used to guide the analysis of data obtained in the intervention development process. Results: Semi-structured qualitative interviews were conducted with 15 primary care Patient Aligned Care Team (PACT) professionals (13 physicians and two clinical pharmacists) at a single VA medical center (VAMC). Findings highlight that providers were generally comfortable with the paradigm shift to risk-based guidelines, but less clear on the need for the VA/DoD guidelines in specific. Providers preferred a clinical decision support tool that helped them calculate patient risk and guide their care without limiting autonomy. They were less comfortable with risk communication and performance measurement systems that do not account for shared decision making. When possible, we incorporated their recommendations into the intervention. Conclusions: By combining qualitative methods and user-centered design principles, we were able to inform the design of a multicomponent guideline implementation intervention to better address the needs and preferences of providers, including clear and direct language, logical decision prompts including an option to dismiss a clinical decision support tool, and logical ordering of feedback information. Additionally, this process allowed us to identify future design considerations for quality improvement interventions.

  • A Theory-Based Web Survey on Psychosocial Factors in Health Professionals’ Intention to Use a Decision Aid for Down Syndrome Screening

    Date Submitted: Sep 25, 2017
    Open Peer Review Period: Sep 25, 2017 - Nov 20, 2017

    Background: Health professionals are expected to engage pregnant women in decisions about prenatal screening tests for Down syndrome. The use of patient decision aids fosters shared decision making, but they are rarely used in this context. Objective: We sought to identify factors influencing health professionals’ intention to use a DA during a prenatal visit for decisions about Down syndrome screening. Methods: We conducted cross-sectional quantitative study using a theory-based survey of midwives, family physicians and obstetricians/gynecologists in the province of Quebec (Canada) using a web panel. From December 18th, 2015 to October 4th, 2016, we recruited health professionals. Eligibility criteria were: a) involved in prenatal care; b) family physicians, midwives, obstetrician-gynecologists or interns in these professions; and c) working in the province of Quebec. Participants watched a video depicting the use of a DA during a prenatal consultation with a health professional, a pregnant woman and her partner, and then answered a questionnaire based on an extended version of the Theory of Planned Behavior (TPB). The questionnaire assessed eight psychosocial constructs (attitude, anticipated regret, subjective norm, self-identity, moral norm, descriptive norm, self-efficacy and perceived control), seven related sets of behavioral beliefs (advantages, disadvantages, emotions, sources of encouragement or discouragement, incentives, facilitators and barriers) as well as sociodemographic data. We performed descriptive, bivariate, and multiple linear regression analyses to identify the factors influencing professionals’ intention to use a DA. Results: Among 330 health professionals who completed the survey, 310 met the inclusion criteria: 171 family physicians (55%), 105 obstetrician-gynecologists (34%), and 34 midwives (11%). Of these, 251 were female (81%) and the mean age of participants was 39.6 ± 11.5 years. In decreasing order of importance, socio-cognitive factors influencing participants’ intention to use a DA for Down syndrome prenatal screening were: 1) self-identity (β=0.325, P<0.0001), 2) attitude (β=0.297, P<0.0001), 3) moral norm (β=0.288, P<0.0001), 4) descriptive norm (β=0.166, P<0.0001), and 5) anticipated regret (β=0.099, P=0.0026). Underlying attitudinal beliefs of participating health professionals significantly related to intention were that the use of a DA (i) would promote decision making (β = 0.117, 95% CI 0.043, 0.190), (ii) would reassure health professionals (β = 0.100, 95% CI 0.024, 0.175), and (iii) might require more time than planned for the consultation (β = -0.077, 95% CI -0.124, -0.031). Conclusions: Implementation interventions targeting the use of a DA among health professionals for prenatal screening for Down syndrome should include strategies to remind them: a) that this would be expected from someone in their societal role, b) the favorable emotions they will experience from using it, c) that it is likely would be compatible with their moral values, d) that other health professionals use it and that they may regret not using it.

  • Characteristics of Brazilian MSM using apps for sexual encounters: awareness of prevention strategies and willingness to use PrEP

    Date Submitted: Sep 23, 2017
    Open Peer Review Period: Sep 25, 2017 - Nov 20, 2017

    Background: Geosocial networking (GSN) smartphone applications (apps) are becoming the main venue for sexual encounters among Brazilian men who have sex with men (MSM). To address the increased HIV incidence in this population, pre-exposure prophylaxis (PrEP) was recently implemented in the Brazilian public health system (SUS) in the context of combined HIV prevention. Objective: This study aimed to describe the characteristics of MSM using GSN apps for sexual encounters, their awareness of prevention strategies and willingness to use PrEP. Methods: Online cross-sectional study conducted in ten Brazilian state capitals from July 1st to July 31st, 2016. The questionnaire was programmed on SurveyGizmo® and advertised in two GSN apps used by MSM to find sexual partners (Hornet and Grindr). Inclusion criteria were ≥18 years-old, cisgender men and HIV negative. Eligible individuals answered questions on demographics, behavior, and knowledge, preferences and willingness to use PrEP, non-occupational post-exposure prophylaxis (nPEP), HIV self-testing (HIVST) and condoms. Logistic regression models were used to assess factors associated with daily oral PrEP willingness. Results: During the study period, 8885 individuals provided consent and started the questionnaire. Of these, 2063 (23.22%) were ineligible, 6822 (76.78%) initiated, and 5065 (57.00%) completed the entire questionnaire and were included in the present analysis. Median age was 30 years (IQR: 25-36), most self-declared as MSM (4991, 98.54%), white (3194, 63.06%), middle income (2148, 42.41%) and had 12 or more years of schooling (3106, 61.36%). The majority of MSM (3363, 66.41%) scored ≥10 points (high risk) on The HIV Incidence Risk for MSM scale, but only 1,083 (21.39%) had a low perceived likelihood of getting HIV in the next year. Daily use of apps for sex was reported by 1798 (35.58%). Most MSM (4488, 85.43%) reported ever testing for HIV and 464 (9.16%) used nPEP in the previous year. PrEP, nPEP and HIVST awareness was reported by 2932 (57.89%), 2907 (57.39%) and 1346 (26.57%), respectively. Half of responders (2653, 52.38%) were willing to use daily oral PrEP, and this was associated with higher number of male sexual partners (adjusted odds ratio [AOR] 1.26,95%CI1.09-1.47), condomless receptive anal intercourse (AOR 1.27, 95%CI1.12-1.44), daily use of apps for sexual encounters (AOR 1.48, 95%CI1.17-1.87), high and unknown perceived likelihood of getting HIV in the next year (AOR 1.72, 95%CI1.47-2.02 and AOR 1.39, 95%CI1.13-1.70), STI diagnosis (AOR 1.25, 95%CI1.03-1.51), PrEP awareness (AOR 1.48, 95%CI1.30-1.70) and not willing to use condoms (AOR 1.16, 95%CI1.00-1.33). Conclusions: Our results evidenced high-risk scores in the studied population suggesting the value for PrEP use. Moreover, those presenting sexual risky behaviors were more willing to use PrEP. Nonetheless, only 58% had heard about this prevention strategy. Efforts to increase awareness of new prevention strategies are needed, and mobile health tools are a promising strategy to reach MSM.

  • The co-production of a theory-based digital resource for unpaid carers: the Care Companion

    Date Submitted: Sep 23, 2017
    Open Peer Review Period: Sep 25, 2017 - Nov 20, 2017

    Background: Family and other unpaid carers are crucial to supporting the growing population of older people that are living outside residential care with frailty and co-morbidities. The burden associated with caring affects carers’ wellbeing, so limiting the sustainability of such care. There is a need for accessible, flexible and responsive interventions that promote carers’ coping and resilience, and so support maintenance of the health, wellbeing and independence of the cared for person. Objective: This study aimed to co-produce a digital program for carers to support effective use of information and other online resources. Its overlapping stages comprised: understanding the ways in which online interventions may address challenges faced by carers; identifying target behaviours for the intervention; identifying intervention components; and developing the intervention prototype. Methods: The study was informed by person-based theories of co-production, and involved substantial patient and public involvement together with input from a range of key stakeholders. It drew on the Behaviour Change Wheel framework to support a systematic focus on behavioural issues relevant to caring. It comprised scoping literature reviews, interviews and focus groups with carers and organisational stakeholders, and an agile, lean approach to IT development. Qualitative data was analysed using a thematic approach. Results: Four behavioural challenges were identified: burden of care lack of knowledge, self-efficacy and lack of time. Local health and social care services for carers were only being accessed by a minority of carers. Carers appreciated the potential value of online resources, but described difficulty identifying reliable information at times of need. Key aspects of behaviour change relevant to addressing these challenges were education (increasing knowledge and understanding), enablement (increasing means and reducing barriers for undertaking caring roles) and persuasion (changing beliefs and encouraging action towards active use of the intervention). In collaboration with carers, this was used to define requirements for the program. A resources library was created to link to websites, online guidance, video and other material that addressed condition-specific and generic information. Each resource was classified according to a taxonomy itemising over 30 different sub-categories of need under the headings Care Needs (of the cared-for person), General information and advice, and Sustaining the Carer. In addition, features, such as a journal and mood monitor, were incorporated to address other enablement challenges. The need for proactive, personalised prompts emerged; the program regularly prompts the carer to re-visit and update their profile which, together with their previous use of the intervention, drives notifications about resources and actions that may be of value. Conclusions: The “person-based” approach has allowed an in-depth understanding of the biopsychosocial context of carers to inform the production of an engaging, relevant, applicable and feasible online intervention. User acceptance and feasibility testing is currently underway.

  • Web-Based Patient Education in Orthopaedics: A Systematic Review

    Date Submitted: Sep 21, 2017
    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: Orthopaedic patients frequently use the Internet to find health information. Patient education that is distributed online may form an easy-accessible, time- and cost-effective alternative to patient education delivered through traditional channels, such as one-on-one consultations or booklets. However, no systematic evidence for the comparative effectiveness of web-based educational interventions exists. Objective: The objective of this systematic review was to examine the effects of web-based patient education interventions for adult orthopaedic patients and to compare its effectiveness to generic health information websites and traditional forms of patient education. Methods: CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsycINFO, PUBMED, ScienceDirect, Scopus and Web of Science were searched covering the period 1995-2016. Peer-reviewed English and Dutch studies were included if they delivered patient education via the Internet to the adult orthopaedic patient population, and assessed its effects in a controlled or observational trial. Results: A total of 10 trials reported in 14 studies involving 4172 patients were identified. Nine trials provided evidence for increased patients’ knowledge after web-based patient education. Seven trials reported increased satisfaction and good evaluations of web-based patient education. No compelling evidence exists for an effect of web-based patient education on anxiety, health attitudes and behaviour, or clinical outcomes. Conclusions: Web-based patient education may be offered as a time- and cost-effective alternative to current educational interventions when the objective is to improve patients’ knowledge and satisfaction. However, these findings may not be representative for the whole orthopaedic patient population as most reviewed trials included considerably younger, higher-educated, and internet-savvy participants only.

  • Development and Formative Evaluation of a Smartphone Application for Smoking Cessation: Crush the Crave

    Date Submitted: Sep 21, 2017
    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: Emerging evidence supports the use of smartphone apps for smoking cessation. However, there remains a paucity of research describing the design and development processes of mobile health (mHealth) interventions, leaving unanswered questions about how to productively leverage apps for quitting smoking. Objective: This paper describes the process of developing the Crush the Crave (CTC) app for smoking cessation and the results of a formative evaluation of app usage behaviour, as part of a broader program of research that seeks to establish the effectiveness of the CTC app. Methods: The Spiral Technology Action Research (STAR) five-cycle model (listen, plan, do, act, and study) was employed to guide development, implementation, and dissemination of CTC. The approach to development and formative evaluation included focus groups with young adult smokers (n=78), analysis of the content of existing apps, two sessions with content experts, and google analytics to assess user behaviour during a 12-month pilot. Results: LISTEN – focus groups revealed young adult smoker preferences of 1) Positive reinforcement, 2) Personalization, 3) Social support, 4) Quit support, 5) Tracking the behaviour, and 6) Tracking quit benefits. PLAN – Informed by evidence for smoking cessation, young adult preferences, and an assessment of popular cessation apps, content experts produced a mind map and a storyboard describing app content and structure. DO – Focus groups with young adult smokers provided feedback on the first version of the app with opinions on content and suggestions for improvement such as providing alerts, distractions from craving, and improvements to the organization of help information for quitting. ACT – CTC App refinements were made and app content was organized using the four key design components of credibility, task support, dialogue support and social support. CTC was launched April 2013 and piloted from the period July 2013 to June 2014 where 1,987 Android users had 18,567 sessions resulting in 59,384 page views and 89.6% of users returning within the same day to use CTC. STUDY – A pragmatic randomized controlled trial of CTC was launched August 2014 to demonstrate that including mHealth technology as a population-based intervention can help young adult smokers to quit. Conclusions: CTC is one of the first smoking cessation apps designed to meet the needs of young adult smokers. The development was informed by the inclusion of young adults in the design and the systematic application of multiple stakeholder input, scientific evidence, and theory. The STAR model approach was followed from the beginning of intervention development, which should facilitate optimization of mHealth interventions in the future.

  • The effectiveness of healthcare information technologies: An empirical evaluation of trust, security beliefs, and privacy as determinants of healthcare outcomes.

    Date Submitted: Sep 21, 2017
    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: The diffusion of health information technologies (HITs) within the healthcare sector continues to grow. However, there is no theory explaining how HITs success influences patient care outcomes. And the increase in data breaches, HITs success now hinges on the effectiveness of data protection solutions. Yet still, empirical research has only addressed privacy concerns, with little regard for other factors of information assurance. Objective: We study the effectiveness of HITs using the DeLone and McLean IS Success Model (DMISSM)1. We examine the role of information assurance constructs (i.e., information privacy and security beliefs, and trust in health information) as measures of HIT effectiveness. We also investigate the relationships between information assurance and three aspects of system success; electronic medical record (EMR) use, patients’ attitudes towards health information exchange (HIE), and patient care quality. Methods: Using structural equation modeling, we analyze data from a sample of 3,677 cancer patients. We used R software and the Lavaan package to test the hypothesized relationships. Results: Our extension of the DMISSM1 to healthcare was supported. We found that increased privacy concerns reduce the frequency of EMR use, positive attitudes towards HIE, and perceptions of patient care quality. Also, information security beliefs increase EMR use and the positive attitudes towards HIE. Trust in health information had a positive association with attitudes towards HIE, and patient care quality. Trust in health information had no direct effect on EMR use; however, it had an indirect relationship through information privacy concerns. Conclusions: Information trust and information security safeguards increase perceptions of patient care quality. Information privacy concerns reduce EMR use by patients, patients’ positive attitudes towards HIE exchange, and overall patient care quality. Healthcare organizations are encouraged to implement security safeguards for increasing trust and EMR use, reducing privacy concerns, and consequently increasing patient care quality.

  • Worker preferences for a mental health App in male-dominated industries: A Participatory Study

    Date Submitted: Sep 20, 2017
    Open Peer Review Period: Sep 23, 2017 - Nov 18, 2017

    Background: Men are less likely to seek help for mental health problems possibly due to stigma imposed by cultural masculine norms. These tendencies may be amplified within male-dominated workplaces such as the emergency services, or transport industries. Mobile apps present a promising way to provide access to mental health support. However, little is known about the kinds of technologies men would be willing to engage with in their workplace, and no App can work if people do not engage with it. Objective: The goal of this participatory user research study was to explore the perceptions, preferences, and ideas of workers in male-dominated workplaces in order to define requirements for a mental health app that would be engaging and effective at improving psychological well-being. Methods: Workers from male-dominated workplaces in rural, suburban, and urban locations, took part in participatory workshops designed to elicit their perspectives and preferences for mental health support and the design of an app for mental health. Participants generated a number of artifacts (including draft screen designs and promotional material) designed to reify their perceptions, tacit knowledge, and ideas. Results: A total of 60 workers aged 26-65 years (92% male) from male-dominated workplaces in rural (27%), suburban (23%) and urban (50%) locations participated in one of six workshops resulting in 49 unique feature ideas and 81 participant-generated artifacts. Thematic analysis resulted in a set of feature, language, and style preferences, as well as characteristics considered important by participants for a mental health app. The term “mental health” was highly stigmatized and disliked by participants. Tools including a mood tracker, self-assessment and “mood boost” tool were highly valued and App characteristics such as the brevity of interactions, minimal on-screen text and a solutions-oriented approach were considered essential by participants. Conclusions: Future mental health smartphone applications targeting workers in male-dominated workplaces need to balance the preferences of users with the demands of evidence-based intervention. In addition to informing the development of mental health apps for workers in male-dominated industries, these findings may also provide insights towards mental health technologies for men more generally, and for others in high-stigma environments.

  • Making Friends with Doctors in Social Media: The Effect of Doctor-Consumer Interaction on Healthy Behaviors

    Date Submitted: Sep 21, 2017
    Open Peer Review Period: Sep 22, 2017 - Nov 17, 2017

    Background: Background: Both doctors and consumers have engaged in using social media for health purpose. Social media change traditional one-to-one communication way between doctors and patients to many-to-many communication way between doctors and consumers. However, little is known about the effect of doctor-consumer interaction on consumers’ healthy behaviors. Objective: The purpose of this study is to investigate how doctor-consumer interaction in social media affects consumers’ healthy behaviors. Methods: Based on professional-client interaction theory and social cognitive theory, we propose that doctor-consumer interaction can be divided into instrumental interaction and affective interaction. These two types of interaction influence consumers’ healthy behaviors through declarative knowledge, self-efficacy and outcome expectancy. To validate our proposed research model, we employed the survey method and developed corresponding measurement instruments for constructs in our research model. 352 valid answers were collected and partial least square was performed to analyze the data. Results: Instrumental doctor-consumer interaction was found to influence consumers’ declarative knowledge (t=5.763, P <0.001), self-efficacy (t=4.891,P<0.001) and outcome expectancy (t=7.554, P <0.001) significantly, while affective doctor-consumer interaction also impacted consumers’ declarative knowledge (t=4.025, P <0.001), self-efficacy (t=4.775, P <0.001) and outcome expectancy (t=4.855, P <0.001). Meanwhile, consumers’ declarative knowledge (t=3.838, P <0.001), self-efficacy (t=3.824, P <0.001) and outcome expectancy (t=2.985, P <0.01) all significantly affected consumers’ healthy behaviors. Our mediation analysis showed that consumers’ declarative knowledge, self-efficacy and outcome expectancy partially mediated the effect of instrumental interaction on healthy behaviors, while the three mediators fully mediated the effect of affective interaction on healthy behaviors. Conclusions: Compared with many intentional intervention programs, doctor-consumer interaction can be treated as natural cost-effective intervention to promote consumers’ healthy behaviors. Meanwhile, both instrumental and affective interaction should be highlighted for the best interaction results. Declarative knowledge, self-efficacy and outcome expectancy are working mechanisms of doctor-consumer interaction.

  • Evaluation of a smartphone-based intervention to increase parents’ knowledge about the MMR vaccination and their psychological empowerment: A mixed method approach.

    Date Submitted: Sep 20, 2017
    Open Peer Review Period: Sep 21, 2017 - Nov 16, 2017

    Background: There is mixed evidence on the effectiveness of vaccination-related interventions. A major limitation of most interventions is that they lack a rigorous evaluative assessment which is partly due to the fact that, over the last two decades, randomized controlled trials have been increasingly considered as the only proof of the effectiveness of an intervention and, consequently, as the most important instrument in deciding whether to adopt an intervention or not. Objective: The aim of this study is to evaluate two smartphone-based interventions aimed at increasing parents’ knowledge of the MMR vaccination (through elements of gamification) and their psychological empowerment (through the use of narratives), respectively. The two interventions were part of a randomized controlled trial. Methods: We conducted two studies with the RCT participants: an online survey aimed at assessing their rating of the tool regarding a number of qualities, such as usability and usefulness, and qualitative telephone interviews to explore participants’ experiences with the application. Results: The results of the survey showed that participants receiving the knowledge intervention (alone or together with the empowerment one) liked the app significantly better compared to the group that only received the empowerment intervention. Parents receiving the empowerment intervention complained that they did not receive useful information but were only invited to make an informed, autonomous MMR vaccination decision. Conclusions: The results suggest that empowering efforts should always be accompanied by the provision of factual information. Using a narrative format that promotes parents’ identification can be an appropriate strategy, but it should be employed together with the presentation of more points of views and notions regarding, for instance, the risks and benefits of the vaccination at the same time.

  • Barriers and facilitators to patient portal implementation from an organizational perspective: a qualitative study

    Date Submitted: Sep 20, 2017
    Open Peer Review Period: Sep 21, 2017 - Nov 16, 2017

    Background: Patient portals can contribute to patient-centered care and are defined as “an online gateway for patients to gather and share information mostly provided by one health institution”. The number of patient portals is rising and while portals can have positive effects, its implementation has major impact on the providing health care institutions. Little is known about the organizational factors affecting successful implementation. Knowledge of the specific barriers and facilitators of different stakeholders may be useful for future implementations. Objective: The objective of this study is to identify the barriers and facilitators of patient portal implementation among different stakeholders within the hospital organization. Methods: Purposive sampling was used to select hospitals of different classes. Two university medical centers (UMCs), 3 mid-size hospitals and 2 general hospitals were included. Per hospital three stakeholders were interviewed: 1) medical professionals, 2) managers, and 3) IT employees. Semi-structured interviews were conducted using the model of Grol and Wensing, which describes barriers and facilitators of change in health care practice at six levels: 1) Innovation, 2) Individual professional, 3) Patient, 4) Social Context, 5) Organizational Context, 6) Economic Context. Two researchers independently selected and coded quotes by using this model. Additional factors related to technical and portal characteristics were added by using the model of McGinn et al developed for implementation of electronic health records. Results: In total, we identified 382 quotes and 34 factors. Twenty-five factors were common for all stakeholder groups including 16 barriers and 12 facilitators. Positive factors related to ‘advantage in practice’ were mentioned most frequently, followed by positive ‘attitude’ and ‘motivation to change’. The main barriers were ‘resources’ (eg lack of staff), ‘opinion of colleagues’ (eg negative beliefs) and ‘privacy and security’ (eg strict regulations). Similarities as well as differences were found between stakeholder groups and hospital classes. For example, medical professionals and IT employees considered 'resources' as an essential barrier. However, their perspectives differed regarding 'opinion of colleagues' as this was a major barrier for medical professionals (eg clinicians’ negative attitude), but a facilitator for IT employees (eg implementation can drive a positive change). Conclusions: The model of Grol and Wensing proved to be useful in elicitation and classification of barriers and facilitators to portal implementation. Nevertheless, technical and factors related to portal characteristics (eg 'privacy and security') were missing, and were added from the McGinn model. Barriers and facilitators occurred at various levels and differed between hospital classes and stakeholder groups on several factors (eg 'opinion of colleagues' and 'cost issues'). This underscores the added value of involving multiple stakeholders in portal implementations. The identified set of barriers and facilitators may be useful to make strategic and efficient implementation plans.

  • Is Social Media a Venue for Help-Seeking? Results from a Clinical Sample of Military Veterans with Depression

    Date Submitted: Sep 20, 2017
    Open Peer Review Period: Sep 21, 2017 - Nov 16, 2017

    Background: The media has devoted significant attention to anecdotes of individuals who post messages on Facebook prior to suicide. However, it is unclear to what extent social media is perceived as a source of help, or how it compares to other sources of potential support for mental health problems. Objective: The objective was to evaluate the degree to which adults with depression use social media for help-seeking, in comparison to other more traditional sources of help. Methods: Cross-sectional self-report survey of 270 adult military veterans with probable major depression. Help-seeking intentions were measured with a modified General Help-Seeking Questionnaire. Facebook users and non-users were compared via t-tests, chi-square, and mixed effects regression models. Associations between types of help-seeking were examined using mixed effects models. Results: The majority of participants were users of social media, primarily Facebook (n=162). Mean overall help-seeking intentions were similar between Facebook users and non-users, even after adjustment for potential confounders. Facebook users were very unlikely to turn to Facebook as a venue for support when experiencing either emotional problems or suicidal thoughts. Compared to help-seeking intentions for Facebook, help-seeking intentions for formal (e.g., psychologists), informal (e.g. friends), or phone help lines sources of support were significantly higher. Results did not substantially change when examining participants who were frequent or active users of Facebook. Conclusions: In its current form, a social media platform such as Facebook is not seen as a venue for seeking help for emotional problems or suicidality among people with major depression in the United States.

  • Implications of patient portal transparency in oncology: Experiences of patients, oncologists and medical informaticists

    Date Submitted: Sep 18, 2017
    Open Peer Review Period: Sep 20, 2017 - Nov 15, 2017

    Background: Providing patients with unrestricted access to their electronic medical records through patient portals has impacted patient-provider communication and patients’ personal health knowledge. However, little is known about how patient portals are used in oncology. Objective: We aimed to understand attitudes of the portal’s adoption for oncology and to identify the advantages and disadvantages of using the portal to communicate and view medical information. Methods: In depth semi-structured interviews were conducted with 60 participants: 35 patients, 13 oncologists and 12 medical informaticists. Interviews were recorded, transcribed and thematically analyzed to identify critical incidents and general attitudes encountered by participants. Results: Two primary themes were discovered: 1) implementation practices influence attitudes, in which the decision-making and execution process of introducing portals throughout the hospital did not include the input of oncologists. Lack of oncologists’ involvement led to a lack of knowledge about portal functionality, such as not knowing the time period when test results would be disclosed to patients; 2) perceptions of portals as communication tools varies by user type, meaning that each participant group (patients, oncologists, and medical informaticists) had varied opinions about how the portal should be used to transmit and receive information. Oncologists and medical informaticists had difficulty understanding one another’s culture and communication processes in their fields, while patients had preferences for how they would like to receive communication, but it largely depended upon the type of test being disclosed. Conclusions: The majority of patients (54%) who participated in this study viewed lab results or scan reports via the portal before being contacted by a clinician. Most were relatively comfortable with this manner of disclosure, but still preferred face-to-face or telephone communication. Findings from this study indicate that portal education is needed for both patients and oncologists, especially when portals are implemented across entire health systems since highly specialized areas of medicine may have unique needs and uses. Patient portals in oncology can potentially alter the way diagnoses are delivered and how patients and oncologists communicate. Therefore, communication about the portal should be established during initial consultations so patients can decide whether they want to be informed in such a manner.

  • Personal Healthcare Management: Assessing the Relationship With Chronic Disease Prevalence

    Date Submitted: Sep 19, 2017
    Open Peer Review Period: Sep 20, 2017 - Nov 15, 2017

    Background: The use of personal healthcare management (PHM) is increasing rapidly within the U.S. due to implementation of health technology across the healthcare continuum and increased regulatory requirements for healthcare professionals and organizations promoting the use of PHM, particularly the use of messaging, online scheduling, and online requests for prescription renewals. Limited research has been conducted comparing PHM use across groups based upon chronic condition. Objective: The purpose of this research is to describe the overall utilization of PHM and compare individual characteristics associated with PHM in groups with no reported chronic conditions, with one chronic condition and with two or more such conditions. Methods: Datasets drawn from the National Health Interview Series were analyzed using multiple logistic regression to determine the level of PHM use in relation to demographic, socioeconomic, or health-related factors. Data from 47,814 individuals were analyzed using logistic regression. Results: Approximately 12 percent of respondents reported using PHM, but higher rates of use were reported by individuals with higher levels of education and income. The overall rate of PHM remained stable between 2009 and 2014, despite increased focus on the promotion of patient engagement initiatives. Demographic factors predictive of PHM use were younger, non-Hispanic, and people who lived in the western region of the United States were the most likely to use PHM. There were also differences in PHM use based upon socioeconomic factors. Respondents with college level education were over 2.5 times more likely to use PHM than respondents without college level education. Health related factors were also predictive of PHM use. Individuals with health insurance and a usual place for healthcare were more likely to use PHM than individuals with no health insurance and no usual place for healthcare. Individuals reporting a single chronic condition or multiple chronic conditions reported slightly higher levels of PHM use than individuals reporting no chronic condition. Individuals with no chronic conditions who did not experience barriers to accessing healthcare were more likely to use PHM than individuals with one or more chronic conditions. Conclusions: The findings of this study illustrated the disparities in PHM use based upon a number of chronic conditions, and that multiple factors influence the use of PHM, including economics and education. These findings provide evidence of the challenge associated with engaging patients through the use of electronic health information as the healthcare industry continues to evolve.

  • Integrative analysis of the canonical TGFβ-Smad signaling pathway in breast cancer

    Date Submitted: Sep 15, 2017
    Open Peer Review Period: Sep 17, 2017 - Nov 12, 2017

    Background: Breast cancer deaths are mainly attributed to metastasis, while epithelial to mesenchymal transition (EMT) plays a pivotal role in promoting cancer cell metastasis. EMT is activated by various stimuli, resulting in different therapeutic responses. The TGFβ signaling pathway is a canonical driver of EMT, and many molecular drugs are developed to target this pathway. However, the alternations of this pathway in BC remain elusive. Objective: The aim of this study was to investigate the relationship between the canonical TGFβ-Smad signaling pathway and breast cancer pathogenesis. Methods: Herein, we investigated the mutational, transcriptional, epigenetic and post-transcriptional alternations of 14 core members in this pathway through bioinformatics approach by analyses of 56,496 BC patients from various public databases, including COSMIC, Oncomine, DiseaseMeth and Starbase. A protein-protein interaction network was derived from Cytoscape software. Associations of these selected members with relapse free survival (RFS), overall survival (OS), distant metastases free survival (DMFS) and post progression survival (PPS) were performed using the Kaplan-Meier plotter online tool. Results: Our integrated analyses revealed that Smad4 was the most frequently mutated member of the TGFβ-Smad pathway in BC with a mutation frequency of 0.85% (30/3537). The expression levels of TGFβ1, TGFβ3, Smad1, Smad2 and Smad7 were significantly higher, whereas TGFβ2, ALK1, ALK2, ALK5, TGFβR2, Smad3, Smad4, Smad5 and Smad6 were downregulated in BC compared with normal subjects (P<0.001). Evaluation of epigenetic alteration identified that the promoters of ALK1 (P=0.000e+00), ALK2 (P=2.22e-16) and ALK5 (P=1.625e-12) were hypermethylated in 1,274 BC samples. In contrast, Smad2 (P=6.56e-04) was significantly hypomethylated in BC. Although all 14 members had potential diagnostic significances with different prediction power (AUC ranging from 0.788 to 1.00) in various subtypes of BC, only TGFβ3 could predict RFS (HR=0.69, 95% CI [0.62-0.77]), OS (HR=0.69, 95% CI [0.56-0.86]), DMFS (HR=0.8, 95% CI [0.66-0.97]) and PPS (HR=0.76, 95% CI [0.6-0.97]) for patients with BC in an independent manner. Additionally, 11 out of 14 members were associated with RFS in luminal A BC. Conclusions: Our results indicated that TGFβ-Smad pathway core members could serve as novel diagnostic and prognostic biomarkers in BC.

  • Assessing Information Quality in Online Health Social Networks - An Exploratory Investigation of Diabetes-Related Threads

    Date Submitted: Sep 13, 2017
    Open Peer Review Period: Sep 16, 2017 - Nov 11, 2017

    Background: The number of people turning to online health social networks for health-related information continues to grow. While online support is an important benefit that patients derive from using such forums, patients also seek answers to questions relating to topics such as medication, treatment, and diagnosis. Many prior studies confirm that the health related information available on the Internet and in online health social networks is suspect. Incorrect responses to questions by patients could adversely impact patient safety if patients heed such advice. Objective: The goal of this exploratory study is to investigate the factors that are associated with information quality in online health social networks. These factors can then be used for predicting, monitoring, and warning patients about the extent of misinformation contained in threads in online healthcare social networks. Methods: This quantitative study is based on the analysis of 2,586 posts from 152 threads relating to diabetes mellitus. The data were extracted from a popular online health social network site (OHSNS), and three family medicine board certified physicians evaluated the clinical quality of responses for each thread. Partial least squares (PLS) regression was used to examine the factors. Only threads relating to questions seeking answers regarding medication, diagnosis, and treatment were included in the study. This study excludes threads purely seeking emotional support. Results: Our findings show that the clinical quality of the response is positively associated with the quality of the thread question (completeness P < .001, readability P = .09), the extent of user’s experience with the disease (P = .004), the sentiment within the thread (P = .001), and the proportion of responders with Type-1 diabetes (P < .001). Counter intuitively, the study also found that the quality of the response is negatively associated with the responder’s social network-related measures (likability (P= .001), tenure (P = .003), and activity (P = .047)). The findings suggest that traditional social media measures, such as responders’ “likes”, might mislead users. Conclusions: The results of this exploratory study help to identify factors (also referred to as cues) associated with the response quality of threads in OHSNS. The factors identified in this study could be utilized for developing indicators of information quality to improve patient safety.

  • Team Resilience Training in the Workplace: An E-Learning Adaptation, Measurement Model, and Two Pilot Studies

    Date Submitted: Sep 13, 2017
    Open Peer Review Period: Sep 16, 2017 - Nov 11, 2017

    Two exploratory and quasi-experimental pilot studies were designed to address four shortcomings in the study of workplace resilience interventions. There is a need: to promote social or team resilience; to condense generally longer class-room training into a brief e-learning format; to use known guides for making e-learning programs effective, and for more theoretical precision in designing programs and assessing outcomes. The authors took an established evidence-based program (Team Resilience) and modified it based on these needs. A measurement model distinguishes outcomes that are more proximal (perceptions that the program improved resilience) and more distal (dispositional resilience). Seven hypotheses are advanced to test the model and program efficacy. Two samples (ns = 118, 181) of engineering firms received the online training and provided immediate reactions in a post-test only design. The second sample also included a control condition (n = 201). Findings generally support the model and program efficacy. For example, workplace resilience was greater in the intervention than control group. Other findings suggest social dissemination effects, equal outcomes for employees at different stress levels, and greater benefit for females.

  • How healthcare professionals evaluate a digital intervention to improve medication adherence: a qualitative exploratory study

    Date Submitted: Sep 12, 2017
    Open Peer Review Period: Sep 13, 2017 - Nov 8, 2017

    Background: For many chronic diseases, medication non-adherence poses a serious and hard-to-tackle problem. eHealth applications that foster patient engagement and shared decision making may be a novel approach to improve medication adherence. Objective: The aim of this study was to investigate the perspective of healthcare professionals regarding a new developed digital application, aimed to improve medication adherence. Familial hypercholesterolemia (FH) was chosen as a case example. Methods: A web-based prototype of the eHealth application (called ‘MIK’) was co-designed with patients and healthcare professionals. After user tests with patients we performed semi-structured interviews and user tests with 12 physicians from six different hospitals to examine how the functionalities offered by ‘MIK’ could assist physicians in their consultation and how they could be integrated in daily clinical practice. Qualitative thematic analysis was used to identify themes that covered physicians’ evaluations. Results: Three themes were identified based on the interview data; 1) Perceived impact on patient-physician collaboration; 2) Perceived impact on patient’s understanding and self-management regarding medication adherence; 3) Perceived impact on clinical decisions and workflow. Conclusions: The eHealth application ‘MIK’ seems to have the potential to improve the consultation between patient and physician in terms of collaboration and patient engagement. The impact of eHealth applications, based on the concept of shared decision making, on improving medication taking behavior and clinical outcomes is yet to be evaluated. Insights will be useful for further development of eHealth applications aimed at improving self-management by means of patient engagement and shared decision making.

  • Just in time information and feedback (JITIF) on antibiotics use for village doctors in rural Anhui, China: A randomize controlled trial

    Date Submitted: Sep 8, 2017
    Open Peer Review Period: Sep 11, 2017 - Nov 6, 2017

    Background: Excessive antibiotics use is very common worldwide especially in rural China and various measures have been used in curbing the problem but showed only marginal effects. Objective: This study tested an innovative intervention which provided just in time information and feedback (JITIF) to village doctors on care of common infectious diseases. Methods: The “information” component of JITIF consisted of a set of theory or evidence- based ingredients including operation guideline, public commitment, and takeaway information; while the “feedback” component tells each participating doctor about his/her performance scores and percentages of antibiotic prescriptions. These ingredients were incorporated together in a synergetic way via a web-based aid (WBA). Evaluation of JITIF adopted a randomized controlled trial (RCT) design involving 24 village clinics randomized into equal control and intervention arms. Measures used included changes between baseline and endpoint (1 year after baseline) in terms of: percentages of patients with symptomatic respiratory or gastrointestinal tract infections (RTIs/GTIs) being prescribed antibiotics; delivery of essential service procedures; patients’ beliefs and knowledge about antibiotics and infection prevention. Two researchers worked as a group in collecting the data at each site clinic. One performed non-participative observation of the service process; while the other, structured exit interview about patients beliefs and knowledge. Data analysis consisted mainly: a) descriptive estimations of beliefs/knowledge, practice of indicative procedures and use of antibiotics at baseline and endpoint and for intervention and control groups; and b) Chi-square tests for the differences between these groups. Results: A total of 1048 patients completed the evaluation, including 532 at baseline (intervention=269, control=263) and 516 at endpoint (intervention=262, control=254). Patients diagnosed with RTIs and GTIs accounted for 407(76.5%) and 125(23.5%) respectively at baseline and 417(80.8%) and 99(19.2%) at endpoint. JITIF resulted in substantial improvement in delivery of essential service procedures (2.6% to 24.8% at baseline on both arms and at endpoint on the control arm versus 88.5% to 95.0% at endpoint on the intervention arm, P<0.05), beliefs favoring rational antibiotics use (11.5% to 39.8% at baseline on both arms and at endpoint on the control arm versus 19.8% to 62.6% at endpoint on the intervention arm, P<0.05) and knowledge about side-effects of antibiotics (35.7% on the control arm versus 73.7% on the intervention arm, p<0.05), measures for managing/preventing RTIs (39.1% versus 66.7%, p<0.05), and measures for managing/preventing GTIs (46.8% versus 69.2%, p<0.05). It also reduced antibiotics prescription (from 88.8% to 62.3%, p<0.05) and this decrease was consistent for RTIs (87.1% versus 64.3%, p<0.05) and GTIs (94.7% versus 52.4%, p<0.05). Conclusions: JITIF is effective in controlling antibiotics prescription at least in the short term, and may provide a low-cost and sustainable solution to the widespread excessive use of antibiotic in rural China. Clinical Trial: Not applicable

  • A smartphone app (BlueIce) for young people (aged 12-17) who self-harm: An Open Phase 1 Trial

    Date Submitted: Sep 8, 2017
    Open Peer Review Period: Sep 11, 2017 - Nov 6, 2017

    Background: Recent years have seen a significant increase in the availability of smart phone apps for mental health problems. Despite their proliferation few have been specifically developed for young people and almost none have been subject to any form of evaluation. Objective: Our aim was to undertake a preliminary evaluation of a mobile app (BlueIce), co-produced with young people, designed to help young people manage distress and urges to self-harm. We explored app acceptability and safety as well as changes in self-harm and pre-post changes on standardized measures of depression, anxiety and behaviour. Methods: We undertook an open trial where we recruited young people aged 12 to 17 attending specialist child and adolescent mental health services (CAMHS) who were currently, or had a history of self-harm. Eligible participants were assessed at baseline and then given BlueIce. They were assessed 2 weeks later (post familiarisation) and again at 12 weeks (post-use). Standardised measures of depression, anxiety and general behaviour were completed alongside self-reports of self-harm, app helpfulness and safety. Results: Of the 54 young people assessed for eligibility, 44 began the study and completed baseline assessments. Post-familiarization interviews were conducted with 40 participants and 33 completed post-use assessments. BlueIce was highly acceptable to clinicians and young people. There were no adverse events during the course of the study and young people did not feel that BlueIce increased their urge to self-harm. Almost three-quarters of those who had recently self-harmed reported reductions in self-harm after using BlueIce for 12 weeks. There was a significant difference on symptoms of depression (P =.043) and on symptoms of anxiety (P =.001) at post-use compared to baseline. There was no statistically significant change in behaviour other than on the emotional sub-scale of the SDQ (P =.007). Conclusions: Although our study has limitations our findings are encouraging and suggest that BlueIce, used alongside a traditional CAMHS face to face intervention, can help young people manage their emotional distress and urges to self-harm. Clinical Trial: N/A

  • Associations of eHealth Literacy with Health Services Utilization among College Students

    Date Submitted: Sep 7, 2017
    Open Peer Review Period: Sep 9, 2017 - Nov 4, 2017

    Background: eHealth literacy has become an important topic in the health field and related fields. Studies have found that individuals with higher eHealth literacy are more likely to use preventive care services and to have effective interactions with their physician. In addition, previous studies have shown that there is a gender difference in the utilization of physician access and outpatient services. Nevertheless, few studies have explored the associations among gender, eHealth literacy, and various determinants of health services utilization among college students. Moreover, there is a lack of studies that focus on the three levels of eHealth literacy as predictors of health services utilization. Objective: To investigate the associations among gender, eHealth literacy, and health services utilization. Methods: The eHealth Literacy Scale is a 12-item instrument designed to measure college students’ functional, interactive, and critical eHealth literacy. The Health Services Utilization Scale is a 10-item instrument developed to measure four dimensions of health services utilization by college students. A nationally representative sample of 489 valid college students in Taiwan was surveyed. We then conducted a multiple regression analysis to examine the associations among gender, eHealth literacy, and health services utilization. Results: The study found that being female negatively predicted the purpose dimension of health services utilization (t484=-2.85, P<0.01). Moreover, critical (t484=2.98-4.23, P<0.01) and interactive eHealth literacy (t484=2.43-2.89, P<0.05) predicted 3 of the health services utilization dimensions, and functional eHealth literacy predicted only the purpose dimension (t484=-2.63, P<0.01). Conclusions: This study found that participants with high interactive and critical eHealth literacy are more likely to utilize various determinants of health services. Moreover, it found that participants with low functional or high interactive eHealth literacy might have a short time interval for visiting a doctor and that females are less likely to seek preventive, illness-related and custodial care

  • The effects of a guided computer-based health information search on hypertensive seniors’ decision self-efficacy levels: a quasi-experimental design.

    Date Submitted: Sep 6, 2017
    Open Peer Review Period: Sep 8, 2017 - Nov 3, 2017

    Background: Patients’ engagement in healthcare decision making is constituted by at least two behaviors: health information seeking and active involvement in medical decisions. Previous research reported that older adults desire a lot of information but want to participate in decision making to a lesser degree. However, there is only limited evidence on the effect of health information preference and consultation on seniors’ perceived confidence in making an informed choice (i.e., decision self-efficacy). Objective: The goal of this study was to contribute to a better understanding of the role desire for health information has for older patients. More specifically, it tested whether decision self-efficacy increases as a function of information consultation. Additionally, the study allowed insights into the sources senior patients prefer to consult. Methods: A sample of 101 senior citizens (aged 60 or older) with a high blood pressure condition in the Italian-speaking part of Switzerland answered a questionnaire before and after an informational intervention was applied. The intervention consisted of offering additional information on hypertension from five different sources and of providing the information the participant desired. Preference for receiving this information was the major independent variable. The main outcome measure was decision self-efficacy (assessed at baseline and posttest). Analyses of co-variance were conducted to detect differences between and within who desired additional hypertensive related contents (intervention group) and ‘information avoidant’ profiles (control group). Results: Healthcare professionals firmly remain the preferred and most trusted source of health information for senior patients. The second most consulted source was the Internet. However, among the total sample the Internet obtained the lowest credibility score. A significant increase in decision self-efficacy occurred to seniors consulting further information compared to avoidant profiles (F(1,93) = 28.25; P<.001). Conclusions: Engaging in a guided computer-based health information consultation is a helpful activity to ultimately increase hypertensive senior patients’ perceived confidence in making treatment decisions.

  • Using Mobile Health Gamification to Facilitate Cognitive-Behavioral Therapy Skills Practice in Child Anxiety Treatment

    Date Submitted: Sep 5, 2017
    Open Peer Review Period: Sep 6, 2017 - Nov 1, 2017

    Background: Cognitive Behavioral Therapy (CBT) is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40-50%) do not show a significant reduction in symptoms and/or full recovery from primary anxiety diagnoses. Children may fail to improve because they do not fully understand or apply the skills learned in the clinic to their daily lives. Homework is routinely assigned in CBT with the goal of generalizing skills beyond the therapy session in clinic. Many children however, are likely to struggle with homework completion. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of CBT skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve CBT efficacy by delivering more engaging and interactive strategies to facilitate CBT skills practice in everyday lives (in vivo). Objective: The goal of this project was to redesign an existing mHealth system called SmartCAT so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project sought to evaluate the utility of SmartCAT in open clinical trial, and also to assess the effectiveness of gamification in improving user engagement and retention throughout post-treatment. Methods: We redesigned our existing SmartCAT system consisting of a smartphone app and an integrated clinician portal. The app contains: (1) a series of interactive activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use CBT skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure techniques, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used the portal connected to the app to setup required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to Brief CBT (BCBT) in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at post-treatment with the existing version of SmartCAT without gamification. Results: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 minutes on the app (SD=64.18) completing 13.00 activities between each therapy session (SD=12.61). At the .10 significance level, the app usage of the gamified system (Median=68.00) was higher than that of the existing version (Median=37.00), U=76.00, P<.01. The amount of time spent on the gamified system (Median=173.15) was significantly different from that of the existing version (Median=120.73), U=173.00, P=.06. Conclusions: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving BCBT treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment, and thus has the potential to increase involvement in full-length treatment.

  • Using Reddit to recruit hard-to-reach study populations

    Date Submitted: Aug 29, 2017
    Open Peer Review Period: Aug 30, 2017 - Oct 25, 2017

    Background: Social media websites (e.g., Facebook and Twitter) have been used to recruit hard-to-reach populations for research. One hard-to-reach population is women who are refused reproductive health care due to a provider’s moral or ethical beliefs. Objective: To test methods for recruiting a hard-to-reach population into qualitative research via Reddit, a social news aggregation and discussion site. Methods: We employed two recruitment methods: 1) recruitment posts on applicable subreddits (pages dedicated to specific topics) and 2) private messaging Reddit users who had previously posted about being denied this care. Results: For the first approach, we posted recruitment messages 13 times on 6 subreddits at various times during a five-month interval. This method yielded no interviews. For the second approach, we used key words in Reddit’s search function, which revealed posts from 13 potentially-eligible women. After messaging the women, three completed the interview. Conclusions: Social media websites (e.g., Facebook and Twitter) have been used to recruit hard-to-reach populations for research. One hard-to-reach population is women who are refused reproductive health care due to a provider’s moral or ethical beliefs.

  • Usage of a Digital Health Workplace Intervention based on Socioeconomic Environment and Race: Is there a Digital Divide?

    Date Submitted: Aug 28, 2017
    Open Peer Review Period: Aug 29, 2017 - Oct 24, 2017

    Background: Digital health tools have been associated with improvement of cardiovascular (CVD) risk factors and outcomes; however, the differential use of these technologies among various ethnic and economic classes in not well known. Objective: To identify the effect of socioeconomic environment of usage of a digital health intervention. Methods: We analyzed usage of a previously-validated workplace digital health tool in association with a change in intermediate markers of CVD over the course of one year in 26,188 participants of a work health program across 81 organizations in 42 states between 2011 and 2014. Baseline demographic data for participants included age, sex, race, home zip code, weight, height, blood pressure, glucose, lipids, and HbA1c which was then obtained in 90 day increments for up to one year. Using publicly available data from the American Community Survey, we obtained the median income for each zip code as a marker for socioeconomic status via median household income. DHI usage was analyzed based on socioeconomic status as well as age, gender, and race. Results: The cohort was found to represent a wide sample of socioeconomic environments from a median income of $11,000 to $171,000. As a whole, doubling of income was associated with 7.6% increase in log-in frequency. However, there were marked differences between races. Blacks showed a 40.5% increase and Hispanics showed a 57.8% increase in use with a doubling of income, compared to 3% for Caucasians. Conclusions: The current study demonstrated that socioeconomic data confirms no relevant relationship between socioeconomic environment and DHI usage for Whites. However, a strong relationship is present for Black and Hispanic cohorts. Thus, socioeconomic environment plays a prominent role only in minority groups that represent a high-risk group for cardiovascular disease. This identifies a need for digital health applications that are effective in these high risk groups. Clinical Trial: Retrospective analysis, no trial number

  • Preferences for online information material for low back pain – a semi-structured interview study of people consulting general practice (Part of the ADVIN Back Trial)

    Date Submitted: Aug 25, 2017
    Open Peer Review Period: Aug 27, 2017 - Oct 22, 2017

    Background: Information on self-management, including addressing people’s fears and concerns, are core aspects of managing patients with low back pain (LBP). Web applications with patient information may be used to extend the consultation and encourage self-management outside of the consultation room. It is, however, important to identify the end users’ needs and preferences in order to maximise acceptance. Objective: The aim of this study was to identify preferences for the content, design, and functionality of a web application with evidence-based information and advice for people with LBP. Methods: This is a phenomenological qualitative study. Adults who had consulted their general practitioner because of LBP within the past 14 days were included. Each participated in a semi-structured interview, which was audiotaped and transcribed for text condensation. Interviews were conducted at the participant’s home by two interviewers. Participants also completed a questionnaire with information about age, gender, Internet usage, interest in searching new knowledge, LBP-related function, and pain. Results: We conducted fifteen 45-minute interviews. Participants had a median age of 40 (range, 22-68) years and reported a median disability of 7 points (range, 0-18) using the 23-item Roland Morris Disability Questionnaire. Participants reported that online information should be easy to find and easy to read, should not be overloaded with information, and should be easily overviewed. They found existing online information confusing, often difficult to comprehend, and not relevant for them, and they questioned the motives driving most hosting companies/organisations. The Patient Handbook, a Danish government-funded website that provides information to Danes about health, was mentioned as a trustworthy site and a preferred site when searching online for information and advice regarding LBP. Conclusions: This study identified important issues to consider when developing and supplementing existing general practice treatment with online information and advice to patients with LBP. Development of a web application should consider patient input, and developers should carefully address the following domains: readability, customisation, design, credibility, and usability.

  • My Doctor Sister, My Nutrition Sister: Feasibility, acceptability and compliance with an integrated package of nutrition counselling and unconditional cash transfers on a mobile platform to improve maternal and child nutrition

    Date Submitted: Aug 25, 2017
    Open Peer Review Period: Aug 27, 2017 - Oct 22, 2017

    Background: Inappropriate feeding practices, inadequate nutrition knowledge and insufficient access to food are major risk factors for maternal and child under nutrition. There is evidence to suggest that the combination of cash transfer and nutrition education improves child growth. However, it will require cost effective delivery platform to achieve the complete coverage of these interventions in the population Objective: This study aims to assess feasibility, acceptability and the compliance of an intervention package of voice messaging, direct counselling, and un-conditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of the child’s life. Methods: We conducted a mixed method pilot study. We recruited 340 women. The women were either pregnant or lactating. The intervention consisted of an unconditional cash transfer combined with nutrition counselling both delivered on a mobile platform. The participants received BDT 787 per month and were given a mobile phone. The nutrition message and counselling were delivered by voice message and conversations with a counsellor from a call centre. We carried out cross sectional surveys at base line and end line, focus group discussion and in-depth interviews with participants and their family members. Results: The poor rural women were interested both in voice messages and direct counselling. Most women reported that they had no problem in operating the mobile phones and listen to the voice messages. There were also able to interact freely with the counsellor. Charging of the mobile handsets posed some challenges. Less than 50% households had electricity at home. However almost all families, which did not have electricity at home were able to find a solution. They either charged their mobiles at their neighbour’s house or at a market place. No major barriers were identified with the use of mobile banking for cash transfers. Regarding the use of cash, our study reported that one of the highest priorities for poor families was purchasing food. Conclusions: The use of mobile platform for cash transfer and nutrition counselling is a feasible and acceptable strategy and has the potential to be used in large-scale programs to improve maternal and child nutrition.

  • Needs and perspectives of patients with asthma and chronic obstructive pulmonary disease on patient web portals: a focus group study

    Date Submitted: Aug 24, 2017
    Open Peer Review Period: Aug 24, 2017 - Oct 19, 2017

    Background: As accessibility to the internet has increased in society, many healthcare organizations have developed patient web portals. These portals can provide a range of self-management options to improve patient access. However, the available evidence suggests that they are used inefficiently and that they do not benefit patients with low health literacy. Asthma and chronic obstructive pulmonary disease (COPD) are common chronic diseases that require ongoing self-management. Moreover, patients with COPD are typically older and have lower health literacy. Objective: We aimed to obtain and present an overview of patients’ perspectives of patient web portals to facilitate the development of a portal that better meets the needs of patients with asthma and COPD. Methods: We performed a focus group study using semi-structured interviews in three patient groups from the north of the Netherlands who were recruited through the Dutch Lung Foundation. Each group met three times for two hours each, with one week between meetings. Data were analyzed with coding software and patient descriptors were analyzed with nonparametric tests. The consolidated criteria for reporting qualitative research were followed when conducting the study. Results: We included 29 patients (55% male, mean age 65 years) with large variation in internet experience: some patients hardly used the internet, whereas others were daily uses. In general, patients were positive about having access to a patient web portal, considering access to personal medical records to be the most important option, though only after discussion with their physician. A medication overview was also considered a useful option. It was expressed that communication between healthcare professionals could be improved if patients could use the patient web portal to share information with their healthcare professionals. However, participants were worried about the language and usability of portals, so it was recommended that language should be adapted to the patient level. Another concern was that disease monitoring through online questionnaire use would only be useful if the results were discussed with healthcare professionals. Conclusions: Participants were positive about patient web portals and considered them a logical step. Today, most patients tend to be better educated and to have internet access, while also being more assertive and better informed about their disease. A patient web portal could support these patients. Our participants also provided practical suggestions for implementation in current and future patient web portal developments. The next step will be to develop a portal based on these recommendations and to assess whether it meets the needs of patients and healthcare providers. Clinical Trial: According to the medical ethics committee of the University Medical Center Groningen, this study did not fall under the Medical Research Involving Human Subjects Act.