We are scheduled to perform a server upgrade on Thursday, November 30, 2017 between 4 and 6 PM Eastern Time.

Please refrain from submitting support requests related to server downtime during this window.

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

Latest Submissions Open for Peer Review

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

For a complete list of all submissions across all JMIR journals as well as partner journals, see JMIR Preprints

Note that this is a not a complete list of submissions as authors can opt-out. The list below shows recently submitted articles where submitting authors have not opted-out of open peer-review and where the editor has not made a decision yet. (Note that this feature is for reviewing specific articles - if you just want to sign up as reviewer (and wait for the editor to contact you if articles match your interests), please sign up as reviewer using your profile).

To assign yourself to an article as reviewer, you must have a user account on this site (if you don't have one, register for a free account here) and be logged in (please verify that your email address in your profile is correct).

Add yourself as a peer reviewer to any article by clicking the '+Peer-review Me!+' link under each article. Full instructions on how to complete your review will be sent to you via email shortly after. Do not sign up as peer-reviewer if you have any conflicts of interest (note that we will treat any attempts by authors to sign up as reviewer under a false identity as scientific misconduct and reserve the right to promptly reject the article and inform the host institution).

We now reward completed peer-reviews (all rounds must be completed) with 90 Karma points which can be used as credits towards your own submissions. In addition, you receive karma points at the time of self-assignment, and additional bonus points for nominating other reviewers as well as for excellent reviews. Conditions apply, see Karma Description for details. Note that assigning yourself as reviewer and not delivering a review will lead to negative karma points.

The standard turnaround time for reviews is currently 2 weeks, and the general aim is to give constructive feedback to the authors and/or to prevent publication of uninteresting or fatally flawed articles. Reviewers will be acknowledged by name if the article is published, but remain anonymous if the article is declined.

The abstracts on this page are unpublished studies - please do not cite them (yet). If you wish to cite them/wish to see them published, write your opinion in the form of a peer-review!

Tip: Include the RSS feed of the JMIR submissions on this page on your homepage, blog, or desktop RSS reader to stay informed about current submissions!

JMIR Submissions under Open Peer Review

↑ Grab this Headline Animator

If you follow us on Twitter, we will also announce new submissions under open peer-review there.

Titles/Abstracts of Articles Currently Open for Review:

  • Background: Medical coding is essential for standardized communication and integration of clinical data. The Unified Medical Language System by the National Library of Medicine is the largest clinical terminology system for medical coders and natural language processing tools. However, abundance of ambiguous codes leads to low rates of uniform coding among different coders. Objective: To measure uniform coding among different medical experts in terms of inter-rater reliability (IR) and analyze the effect on IR by using an expert-based online code suggestion system. Methods: A quasi-experimental study was conducted. Six medical experts coded 602 medical items from structured quality assurance forms (QA) or free-text eligibility criteria (EC) of 20 different clinical trials. Medical item content was selected based on mortality-leading diseases according to WHO data. The intervention consisted of using a semi-automatic code suggestion tool that is linked to a European information infrastructure providing a large medical text corpus of more than 300,000 medical form items with expert-assigned semantic codes. Krippendorff’s alpha (Kalpha) with bootstrap analysis was used for IR analysis and coding times were measured before and after intervention. Results: The intervention improved IR in structured QA form items (from Kalpha= 0.50, 95%-CI [0.43-0.57] to Kalpha = 0.62 [0.55-0.69]) and free-text eligibility criteria (from Kalpha = 0.19 [0.14-0.24] to Kalpha = 0.43 [0.37-0.50]) while preserving or slightly reducing mean coding time per item for all six coders. Regardless of intervention, pre-coordination and structured items were associated with significant higher IR, but the proportion of items that were pre-coordinated significantly increased after intervention (EC: Odds ratio: 4.92 [2.78 - 8.72]; QA: Odds ratio: 1.96 [1.19-3.25]). Conclusions: Use of an online information infrastructure improved IR towards moderate or even substantial inter coder agreement. Pre-coordination and use of structured vs. free-text data elements are key drivers for higher IR.

  • MISSION COPD: Outcomes from a Multidisciplinary, Vertically Integrated Care Clinic

    Date Submitted: Dec 13, 2017
    Open Peer Review Period: Dec 13, 2017 - Feb 7, 2018

    COPD is the second leading cause of death in the UK and accounts for 1.7% of bed days in acute hospitals. An estimated 2/3 patients with COPD remain undiagnosed. MISSION COPD aimed to proactively identify patients from primary care who were undiagnosed or uncontrolled and deliver a comprehensive integrated multidisciplinary clinic to address the needs of this complex group to improve diagnosis, personalise therapy and empower patients to self manage. This clinic was led by a Respiratory Specialist team from Portsmouth Hospitals NHS trust working with five Primary Care surgeries in Wessex. 108 patients were seen, with 98 consenting to be followed up for research. Diagnoses were changed in 14 patients and 32 new diagnoses were made. Reductions were seen across all aspects of unscheduled care compared to each participants use in the 12 months prior: emergency GP visits (3.37-0.79 per patient, p=<0.01), exacerbations (2.64-0.56 per patient, p=0.01), out-of-hours calls (0.16-0.05 per patient, p=0.423), hospital admissions (0.49-0.12 per patient, p=0.48). Improvements were seen in quality of life and symptom scores in addition to patient activation (PAM) and patient reported confidence. This pilot has demonstrated the MISSION model may be an effective way to provide comprehensive gold-standard care that is valued by patients and promotes integration across sectors.

  • Background: The use of social media has risen tremendously over the past decade with usage rates spanning from 5% American adults in 2005 up to 69% in 2016. A 2011 survey of 4,033 clinicians found that 65% physicians use social media for professional purposes. In order to remain relevant in today’s digital society, Medical Information departments must continue to assess new digital channels and evolve their medical information services to meet the changing needs of their customers. Objective: To evaluate the impact and feasibility of using social media as a channel to respond to unsolicited medical requests from Healthcare Professionals (HCP RUR) directed toward the pharmaceutical industry. Methods: Three pilots were conducted from November 2016 to June 2017 during three professional congresses: the 2016 American College of Rheumatology (ACR) Annual Meeting, the 2017 American Society of Clinical Oncology (ASCO) Annual Meeting, and the 2017 American Headache Society (AHS) Annual Scientific Meeting. For each social media account, an identified Community Manager (CM) monitored the incoming account feed for proper triaging of posts. When an unsolicited medical request appeared, the CM routed the question to the Tier One Medical Information Contact Center (MICC) agents to respond. The following metrics were collected: total number of unsolicited requests directed to MICC agents, total number of unsolicited requests that required escalation to Tier Two Medical Information Associates (MIAs), total number of unsolicited requests that were confirmed US HCPs, total number of unsolicited requests received after hours, and total number of unsolicited requests that were redirected to a different channel. Results: Nine unsolicited medical requests were received during the three pilots with request numbers ranging from two to four requests per pilot. One was from a confirmed US HCP that required escalation to the Tier Two MIAs. A majority of requests (seven out of nine) came in after scheduled monitoring hours with many requests appearing to be from potential consumers. Four requests were redirected to the MICC phone number. The Marketing accounts received more unsolicited medical requests than the Corporate accounts (seven versus two, respectively), and the three Twitter accounts saw more overall engagement (ie, medical requests and other general engagement) than the LinkedIn account. Conclusions: A limited number of medical questions were asked by HCPs using social media during the three pilots. New innovative MICC channels often take time to build awareness. Thus, continued channel awareness is needed to fully understand the channel’s true impact. Since consumers currently make up a majority of the engagement, companies should look into creating a combined consumer and HCP RUR strategy to provide better customer experience to all customers.

  • Do Online Health Information Bubbles Exist? An Analysis of Personalized Google Search Results

    Date Submitted: Dec 12, 2017
    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: There is considerable debate focusing on the consequences of online health information, which is generally related to issues such as information quality and the necessary literacy to identify such information. However, the availability of information is a prerequisite to provoke positive outcomes. Search engines inherently prioritize information. In this study, we consider the nature of the health information that is prioritized by Google. Moreover, we consider the potential occurrence of health filter bubbles, due to algorithmic personalization. Such bubbles could restrict the availability of high-quality information, and amplify user self-confirmation. Objective: The aim of this study was to examine the nature of the information sources that are retained as results to a standardized set of health-related Google search queries and to inquire the way in which these search results reflect personalization. Methods: We harvested the personal search results of 380 Google users on 16 standardized health-related search queries. In addition, we conducted a survey measuring socio-demographic and health behavior variables. To define the nature of the collected search results we undertook a content analysis of the collected search queries, coding entries for type of website, revenue model, information authorship, and source materials. Results: An initial Latent Class Analysis (LCA) of the unique search results, based on type of website, revenue model, information authorship, and source materials showed four clusters of information types: commercial health news (33%), health goods and services (30%), user contributions (21%), and health advocacy (16%). To identify personalization, we conducted a subsequent LCA of the entire set of search results per participant. Five patterns emerge, significantly differing for the information they are composed of (i.e., 11 to 41% difference). Still, tests of covariates did not reveal any significant relations (p < .05) with user characteristics (i.e., participants’ gender, age, perception of current health, frequency of searching for online health information, and the age of their Google accounts). Conclusions: The results indicate that the overall majority of health information is commercial in nature, and often lacks proper information on authorship and source materials. Moreover, we find mild evidence for the personalization of health information. However, we were unable to isolate potential grounds for this personalization. Clinical Trial: We received ethical clearance from the Social and Societal Ethics Committee (SMEC) at the KU Leuven (https://admin.kuleuven.be/raden/en/smec). The clearance is registered as G-2016 01 449.

  • The Burden of a Remote Trial in a Nursing Home Setting; A Qualitative Study

    Date Submitted: Dec 12, 2017
    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: Despite an ageing population, older adults are typically under recruited in clinical trials, often due to the perceived burden of participation, particularly travel associated with clinic visits. Conducting a clinical trial remotely presents an opportunity to leverage mobile and wearable technologies in order to bring the research to the patient. However, the burden associated with shifting clinical research to a remote site requires exploration. While a remote trial holds the potential to reduce patient burden, the extent to which this shifts burden to other stakeholders needs to be investigated. Objective: The aim of this study is to explore the burden of a remote trial in a nursing home setting for both staff and residents involved. Methods: Using the results generated from a grounded analysis of qualitative data, this study explores and characterizes the burden of a remote trial conducted in a nursing home in Dublin, Ireland. It captures the lived experience for staff and residents and examines the relationship between the burden and value of participation. At the end of the trial, a total of 6 residents and 8 members of staff participated in semi-structured interviews (n=14). They reviewed the data generated by the devices and reflected upon their experience of taking part. Results: Staff reported extensive burden in fulfilling their roles and responsibilities to support the activities of the trial. Among staff, we found 8 key characteristics of burden (1) comprehension, (2) time, (3) communication, (4) emotional load, (5) cognitive load, (6) research engagement, (7) logistical burden and (8) product accountability. Residents reported comparatively less burden. Amongst residents, we found only 4 key characteristics of burden (1) comprehension (2) adherence (3) emotional load (4) personal space. Conclusions: A remote trial in a nursing home setting has the potential to minimise burden for residents and enable inclusive participation. However, it arguably creates extensive burden for staff, particularly where they have a role to play in locally supporting and maintaining technology as part of data collection. Future research should examine how to measure and minimise the burden of data collection.

  • Background: Simulator-based teaching for coronary angiography (CA) is a seductive educational tool for medical students to improve knowledge and skills. Its pedagogical impact has not been fully evaluated yet. Objective: The aim of this study was to compare traditional face-to-face teaching with a simulator-based teaching. Methods: 118 students, in their 4th to 6th year of medical school, were prospectively randomized in two groups: a control teaching group (n=59, CONT group) and a simulator (Mentice AB, Sweden) group (n=59, SIM group). CONT group received a PowerPoint-based course whereas SIM group received a simulator-based course including exactly the same information in an interactive environment. After the course, students were evaluated by 40 multiple choice questions (maximum of 100 points (pts)), including questions on coronary anatomy (part1), angiographic projections (part2) and real case interpretations (part3). Results: Student characteristics were identical in both groups: 52.5% were female; age was 22.6±1.4 years. 35.6% were in their 4th year, 35.6% in 5th year and 28.8% in 6th year. SIM students scored higher than CONT students irrespective of age and year of medical school (59.5±10.8 vs. 43.7±11.3pts,p<0.00001) for all parts of the evaluation (part1: 36.9±6.6 vs. 29.6±6.9pts,p<0.00001; part2: 5.9±3.0 vs. 3.1±2.8pts,p<0.00001; and part3: 16.8±6.9 vs. 10.9±6.5pts,p<0.00001). Student satisfaction was also higher in SIM group than in CONT group (98% vs. 75% p<0.0001). Conclusions: This trial suggests that simulator-based teaching in CA significantly improves students' knowledge in coronary anatomy and angiography projections, as well as clinical and decision-making competences. These results should encourage further evaluation of simulator-based teaching in other branches of medicine.

  • Extrahepatic Autoimmune Diseases are Prevalent in Autoimmune Hepatitis Patients and their First-Degree Relatives

    Date Submitted: Dec 11, 2017
    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: Concurrent autoimmune illnesses contribute to increased medical burden and reduced quality of life in those with autoimmune hepatitis (AIH). The frequency of coexisting autoimmune conditions among North American AIH patients and their families remains incomplete. Challenges associated with disease capture in the electronic medical record, high study costs, and geographic spread of patients are formidable barriers to understanding the extent of concurrent autoimmune conditions in these groups. Objective: We aimed to examine the frequency of extra-hepatic autoimmune disorders (EHAD) among AIH cases and healthy controls as well as their first-degree relatives using social networking sites (SNS). Methods: We developed a 53-question survey detailing history of autoimmune diseases. A survey link was posted at routine intervals within specific online cohorts on SNS. Healthy controls, without self-reported autoimmune liver disease, were recruited from Amazon’s Mechanical Turk. Continuous variables were summarized using medians and P-values obtained with the Wilcoxon rank sum test. Categorical variables were compared using the Chi-squared test. Results: Cases (n = 306) were more likely than controls (n = 1,162) to be older (median: 49 years vs 33 years), female (93% vs 82%), and have an EHAD (42% vs 19%) (p=0.001). The most frequent EHADs among cases were thyroid disease (16%), Sjögren’s syndrome (9%), Raynaud’s (7%), and psoriasis (5%). 56% of cases and 36% of controls reported at least one first-degree relative (FDR) with history of EHAD (p=0.001). Cases had significantly higher risk of EHAD compared to controls after adjustment for age, sex, race, and BMI (OR: 2.46, CI:1.8-3.3, p=0.001). Conclusions: Patients with AIH report higher prevalence of co-existent extrahepatic autoimmune disorders compared to healthy controls, and their first-degree relatives are also more likely to have autoimmune disorders. Clinical Trial: n/a

  • Background: The insertion of fixed orthodontic appliances increases the risk of dental caries, particularly in adolescents. Caries can be prevented by performing good oral-health behavior. To support adolescents with fixed orthodontic appliances in promoting oral-health behavior, we therefore developed a mobile-health (mHealth) intervention, the WhiteTeeth application (app). Objective: To describe the systematic development of a theory and evidence-based mHealth intervention, WhiteTeeth app, for promoting oral-health behavior. Methods: For systematic development of the intervention, we used Intervention Mapping (IM), an intervention-planning guide. In this manuscript we present the results of the first five steps of IM: (1) problem analysis, (2) program outcomes and objectives, (3) program design, (4) program production, and (5) program implementation plan. Results: On the basis of the problem analysis (step 1), we identified fluoride use and the control of dental plaque levels (e.g., tooth brushing and proxy brush usage) as target behaviors for preventing caries. After defining specific program objectives based on these target behaviors (step 2), we translated selected theoretical methods, such as prompting self-monitoring and reinforcing implementation intentions, into practical strategies (step 3). The results of steps 1 – 3 were used to design a mHealth app, the WhiteTeeth app, which was piloted with the target group for acceptability and usability (step 4). To prepare for the adoption and implementation of the intervention, several meetings with adolescents and dental professionals were organized (step 5). Conclusions: This article is a comprehensive description of the systematic development and design of the WhiteTeeth app. It responds to recent calls for improved reporting on the process of intervention development.

  • Background: Computerized cognitive-behavioral therapy (cCBT) was developed to make treatment for Social anxiety disorder (SAD) patients more easily available. Objective: The present article aims to evaluate the efficacy of cCBT on SAD and investigate the important features of cCBT for effective and safe self-guided interventions. Methods: The present study employs a systematic review and meta-analysis to measure the efficacy of computerized interventions for SAD. Results: Based on 30 studies, we systematically reviewed and described computerized cognitive-behavioral therapy (cCBT) studies on SAD, with attention to the literature characteristics, therapists’ support, intervention modules, drop-out rates, satisfaction rates, and limitations. Furthermore, the current research used a meta-analysis of RCTs to assess the efficacy of cCBT for SAD. For this purpose, 18 articles were included. Random-effects model showed that cCBT treatments for SAD had a greater effect size than waiting-list conditions (g = .96 [95% CI, .55 - 1.37], k = 14, z = 4.57, P < .001), but the Trial Sequential Analysis (TSA) indicated the current evidence was insufficient to be regarded as conclusive. Compared to other treatment conditions (such as traditional CBT), cCBT showed an equal efficacy (g = .17 [95% CI, -.004 - .39], k = 5, z = 1.91, P = .056). Moreover, when comparing the cCBT group with the waiting-list group, the subgroup analysis also found that the effect size of cCBT for SAD was larger in two conditions. Firstly, the treatment efficacy of cCBT on SAD with therapist support was higher than that without therapist support (Q = 7.91, P =.005). Secondly, the effect size of cCBT on SAD for the general population (recruited from mass media) was significantly larger than that for specific population (referred from therapists) (Q = 5.04, P = .025). Conclusions: cCBT is an efficacious treatment for SAD that could play a role in SAD treatment beyond traditional psychological interventions. An option could be to implement cCBT before the regular SAD treatment, which might function as an initial self-help intervention for stepped care in situations when participants need to wait for a long time to get the traditional therapy treatment.

  • Is a Mobile Personal Health Record Effective Tool for Managing Patient-Generated Health Data?

    Date Submitted: Dec 11, 2017
    Open Peer Review Period: Dec 11, 2017 - Dec 21, 2017

    Background: Mobile health applications and personal health records (PHRs) are considered essential tools to ensure patient engagement. Mobile PHR (mPHR) can be a platform to integrate patient-generated health data (PGHD) and patient medical information. Objective: An mPHR developed by a tertiary hospital in South Korea was used from Dec 2010 to Dec 2015. Patients could manage their own health data through the mPHR. By analyzing five years’ PGHD, we wanted to evaluate how PGHD were managed and find out issues in PGHD management based on actual usage data. Additionally, we analyzed how to improve patient engagement through the mPHR by analyzing the actively used services and long-term usage patterns. Methods: Five years’ log data were gathered from a backup mobile server. Users who entered PGHDs were selected and then variables regarding usage of the mPHR and PGHDs were gathered. PGHDs included body weight (WT), blood pressure (BP), blood sugar test (BST), 10-year risk of cardiovascular disease (CVD), metabolic syndrome score (META), medication schedule, and insulin. Users were divided based on the presence of patient ID. Factors related to continuous use (for at least 28 days or more in WT, BP, BST and for at least 180 days or more in CVD and META) were analyzed according to the presence of patient ID and patient characteristics for the users with patient ID. PGHD entry counts and proportion of continuous users for each PGHD were compared by user type. Results: Total number of users were 18,265 (with patient ID: 16,729, 91.59%)with 3,620 users having entered WT, followed by BP (1625), BST (1374), CVD (764), META (685), insulin (72), and medication (62). Most users (from 66.89% to 72.30%) entered PGHD just one time, only less than 1% of users used it for more than 4 years. Input of WT, BP, BST, CVD, and META tended to increase. In BST and BP, users without patient id were significantly higher in continuous use of PGHD than users with patient ID (p <.001, and p = 0.030, respectively). Continuous use of PGHD in health management (BP, BST, and WT) was statistically significant among older individuals and men (p <.001, <.001, respectively). Overall chronic disease and continuous use of PGHD were not statistically related (p = 0.076), but diabetes (p < 0.001), and cerebrovascular diseases (p = 0.020) were significant. In risk management (CVD and META), there was no significant association. Conclusions: Though a small portion of users managed PGHD continuously through the mPHR, we found potency of the mPHR as a proper tool for a platform to integrate PGHD and medical information. Further evaluations for clinical application of PGHD, feedback for user interface, and connection with wearable devices are needed.

  • Background: Treatment of hyperglycemia in women with gestational diabetes (GDM) is associated with improved maternal and neonatal outcomes and requires intensive clinical input. This is currently achieved by hospital clinic attendance every 2-4 weeks with limited opportunity for intervention between these visits. Objective: We conducted a randomised controlled trial to determine whether the use of a smartphone-based real-time blood glucose management system to manage women with GDM remotely was as effective in controlling blood glucose as standard care through clinic attendance. Methods: Women with an abnormal oral glucose tolerance test before 34 completed weeks of gestation were individually randomized to a smartphone-based blood glucose management solution (GDm-health, the intervention) or routine clinic care. The primary outcome was change in mean blood glucose in each group from recruitment to delivery, calculated with adjustments made for number of blood glucose measurements, proportion of preprandial and postprandial readings, baseline characteristics and length of time in the study. Results: 203 women were randomised. BG data was available for 98 intervention and 85 control women. There was no significant difference in rate of change of BG: -0.16 mmol/L in the intervention and -0.14 mmol/L in the control group per 28 days, (p=0.78). Women using the intervention had higher satisfaction with care (p=0.05). Preterm birth was less common in the intervention group: 5.0% versus 12.7%, OR 0.36 (0.12, 1.01). There were fewer caesarean sections compared with vaginal deliveries in the intervention group (27%) versus control group (46%) p=0.005. Other glycaemic, maternal and neonatal outcomes were similar in both groups. The median time from recruitment to delivery was similar; 54 and 49 days in the intervention and control group, respectively (p=0.23). However there were significantly more BG readings in the intevenion group: mean (SD) 3.8 (1.80) and 2.63 (1.71) readings per day in the intevenion and control group, respectively (p=<0.0001). There was no significant difference in direct healthcare costs between the two groups, with a mean cost difference of the intervention group compared to control : -£1,044 (95% CI -£2,186 to £99). There were no unexpected adverse outcomes. Conclusions: Remote BG monitoring in women with GDM is safe. We demonstrated superior data capture using GDm-health. Whilst glycaemic control, maternal and neonatal outcomes were similar, women preferred this model of care. Further studies are required to explore whether digital health solutions can promote desired self-mangament lifestyle behaviours and dietetic adherence, and influence maternal and neonatal outcomes. Digital BG monitoring may provide a scalable, practical method to address the growing burden of GDM around the world. Clinical Trial: Clinical Trials registration NCT01916694

  • Patients’ experiences of blended Group Therapy for Depression: Fit and Implications for the Group Setting.

    Date Submitted: Dec 9, 2017
    Open Peer Review Period: Dec 11, 2017 - Feb 5, 2018

    Background: Blended group therapy (bGT) combines group sessions with internet- and app-based treatment modules. Consequently, bGT widens the choice of interventional strategies within Internet Interventions at reasonable costs. This is the first qualitative study on bGT. Objective: This study investigates the user-centred feasibility of bGT, with special emphasis on the fit and dynamic interplay between face-to-face and internet-based components of group therapy. Methods: A total of 22 patients, with a variety of experiences from two different bGT interventions, were interviewed following a semi-structured interview guide. In-depth interviews were analysed by three trained psychologists, using thematic analysis and a rule-guided online program (QCAmap). The transcript of the interviews (113 555 words) was condensed to 1081 coded units, with subsequent extraction of 16 themes. Results: Technology was described as a treatment facilitator and motivator, increasing the salience and consolidation of cognitive behavioural therapy materials, and resulting in in- and intersession alignment to the treatment. Additionally, patients value the option of intimate online self-disclosure (via lateral patient-to-therapist communication) and therapists are provided with tools for between-session monitoring and reinforcement of exercising. In this context, group phenomena seem to back up therapists’ efforts to increase treatment engagement. Negative effects regarded the possible dissonance due to non-compliance with online tasks and the constriction of in-session group interaction. Lastly, issues of tailoring and structure seem to meet different preconditions compared to individual therapy. Conclusions: bGT constitutes a structured and proactive approach to work with depression and the integration of both modalities initiates a beneficial interplay. Results confirm the user-centred value of bGT and provide a first insight into bGT’s role in fostering relevant active treatment factors. However, potential negative effects should be considered carefully. Clinical Trial: DRKS00010894; DRKS00010888

  • Patient factors affecting the use of Twitter for psychiatric consultation in Saudi Arabia

    Date Submitted: Dec 9, 2017
    Open Peer Review Period: Dec 11, 2017 - Feb 5, 2018

    Background: Despite the increasing prevalence of mental disorders in the Kingdom of Saudi Arabia, discussing the issue of psychiatric conditions are still avoided. In recent studies, it is indicated that social media is increasingly being used clinically for various purposes such as consultation, solicitation of expert opinions, and social support. Objective: The purpose of this study is to explore how demographic variables, satisfaction, and e-health literacy affect Twitter usage with respect to psychiatric consultation. Methods: This study included a quantitative cross-sectional analysis conducted in Saudi Arabia between February 9 and March 2, 2015. The study population, recruited using convenience sampling, consisted of Twitter users who had sought psychiatric consultation through Twitter. The study included users that had received at least one psychiatric consultation on Twitter, were living in Saudi Arabia, and possessed the ability to speak and understand Arabic. An online questionnaire was posted on the Twitter accounts of psychiatrists who practice in Saudi Arabia. Measurements of interest were user socio-demographic factors, satisfaction, e-health literacy, Twitter usage for health purposes or psychiatric consultation, and whether the specific Twitter consultation solved their problem. Results: Among all participants, (88/155; 56.8%) used Twitter to seek medical or health advice, in general, while (52/155; 33.5%) reported using Twitter to seek psychiatric advice specifically. The Twitter users who reported psychiatric consultation were predominately female (45/53; 86.5%), with a low financial income level (35/52, 69.2%). E-health literacy did not differ between those who were using Twitter for psychiatric consultation and those who were using it for other purposes. The majority of participants reported that Twitter consultation solved their problem and that they were satisfied with the consultation. Conclusions: Being female was a significant factor for Twitter-based psychiatric consultation in Saudi Arabia, whereas other demographic factors such as age, marital status, education level, income, and nationality were not as significant.

  • Background: Smartphone diet-tracking applications may help individuals lose weight, manage chronic conditions, and understand dietary patterns, however, the ease of use and capabilities of these apps have not been well studied. Objective: The aim of this study was to review the usability of current iOS and Android diet-tracking apps, the degree to which app features align with behavior change constructs, and to assess variations between apps in nutrient coding. Methods: The top seven diet-tracking apps were identified from the iOS iTunes and Android Play online stores, downloaded and used over a 2-week period. Each app was independently scored using the System of Usability Scale (SUS), and features were compared to the domains in an integrated behavior change theory framework: the Theoretical Domains Framework (TDF). A 3-day food diary was completed using each app to evaluate their differences in nutrient data against the USDA reference. Results: Of the apps that were reviewed, LifeSum scored the highest average SUS score of 89.2, while MyDietCoach scored the lowest of 46.7. There were some variations in features noted between Android and iOS versions of the same apps, mainly for MyDietCoach, which affected SUS scoring. App features varied considerably, yet all of the apps had features consistent with Beliefs about Capabilities, and thus have the potential to promote self-efficacy by helping individuals track their diet and progress towards goals. None of the apps allowed for tracking of emotional factors that may be associated with diet patterns. The presence of behavior change domain features tended to be weakly correlated with greater usability (R2 ranging from 0 to 0.396). The exception to this was features related to the Reinforcement domain, which were correlated with less usability. Comparing the apps to the USDA reference for a 3-day diet, the average differences was 1.4 % for calories, 1.0 % for carbohydrates, 10.4% for protein, and -6.5% for fat. Conclusions: Diet tracking apps score well in usability, utilize a variety of behavior change constructs, and accurately code calories and carbohydrates, allowing them to play a potential role in dietary intervention studies.

  • Background: Alcohol use is a major social and public health issue in Australia, with an estimated cost to the community of $30 billion per annum. Until recently, a major barrier in addressing this significant public health issue is the fact that the majority of individuals with alcohol use disorders are not receiving treatment. Objective: To assess whether alcohol consumption changes as a result of participation in Hello Sunday Morning (HSM), an online forum discussing experiences in abstaining from alcohol. Methods: The study reports on HSM participants who signed up for a three-month period of abstinence from November 2009 to November 2016. The sample was made up of 1,917 participants (63.7% female, 36.3% male). Main outcome measures were AUDIT scores, mood, program engagement metrics and slip-ups. Results: Individuals engaged in the HSM program reported a significant decrease in alcohol consumption, moving from harmful, high-risk or dependent drinking levels to risky or almost low-risk levels, four months following program commencement (p < .001). This reduction in risk was maintained seven months following program commencement. Furthermore, those who engaged in the program more (as defined by more sign-in’s, blogs posted, check-ins completed, engagement with the community through likes and following), had lower alcohol consumption. Lastly, those who experienced more slip ups had lower alcohol consumption. Conclusions: Participation in an online forum can support long-term behaviour change in individuals wishing to change their drinking behaviour. This has promising implications for future models of alcohol reduction treatment, as online forums are anonymous, accessible and cost-effective alternative or adjunct to treatment-as-usual. Further research is needed into the specific mechanisms of change within an online supportive community, as well as the role of specific mood states in predicting risky drinking behaviour.

  • The Social Media Landscape of China’s Tertiary Referral Hospitals: An Observation of the Best 705 Hospitals

    Date Submitted: Dec 8, 2017
    Open Peer Review Period: Dec 9, 2017 - Feb 3, 2018

    Background: Social media has penetrated all walks of life. Chinese Healthcare Institutions are increasingly utilizing social media to connect with their patients for better health service delivery. Current research has focused heavily on the use of social media in developed countries, with few exploring its usage in the context of developing countries, such as China. This study examines China’s best hospitals, as recognized by The National Health and Family Planning Commission (NHFPC) of the People’s Republic of China, mapping out the landscape of current social media usage by hospitals when engaging with patients. Objective: This study aims to examine China’s best hospitals, as recognized by The National Health and Family Planning Commission (NHFPC) of the People’s Republic of China, and to map out the landscape of current social media usage by hospitals when engaging with patients. Methods: We examined the best 705 hospitals in China, collecting and analyzing their usage of popular Chinese social media applications, Sina Weibo and WeChat. Specific data included: (1) hospital characteristics (i.e. established time, number of beds, hospital type, regions/localities) and (2) status of social media usage on two of the most popular local social media platforms in China (i.e. initiated time, number of followers and number of tweets or posts). We further used a logistic regression model to test the association between hospital characteristics and social media adoption. Results: A total of 537 (76.17%) tertiary-referral hospitals have created official accounts on either Sina Weibo or WeChat. Of these, WeChat is more popular than Sina Weibo. In addition, our study suggests that larger and newer hospitals with greater resources are more likely to adopt social media, while hospital type and affiliation to universities are not significant predictors of social media adoption among hospitals. Conclusions: Our study demonstrated that hospitals are more inclined to use WeChat. The move by hospitals from Sina Weibo to WeChat means that patients are seen to be not satisfied by mere communication and now place more value on health services delivery. For the future, a long journey still lies ahead for hospitals in running their official social media accounts.

  • Background: Background: Obesity is a high prevalent condition with important health implications throughout the world. Face-to-face interventions to treat obesity demand a large number of human resources and time both by the health system and for patients. In this context, the internet is an attractive tool for delivering weight loss programs. Users´ anonymity, 24 hour-access and the possibility of reaching a large number of patients and also remote areas are reasons for this. Objective: Objectives: We aimed to investigate the effectiveness of web-based-only (no hybrid or mixed) interventions on weight loss and lifestyle habits changes in individuals with overweight/obesity. Methods: Methods: We searched Pubmed/Medline, SciELO, Lilacs, PsychNet, Web of Science up to February, 2017, and references of previous reviews for randomized trials that compared web-based-only to offline interventions for weight and lifestyle habits changes in adults with overweight/obesity. Random effects meta-analysis and meta-regression were performed for mean weight changes. We rated the quality of evidence using GRADE. Results: Results: Among the 3811 articles retrieved, nine were selected. Mean weight and BMI changes were not different between web-based and offline interventions (-1.06 kg; 95% CI -2.75 to 0.63, and -0.04 kg/m2; 95% CI -0.73 to 0.04, respectively). Compared to offline interventions, web-based-only interventions led to a greater (<6 months follow-up) weight loss in the short-term (-2.14 kg; 95% CI -2.71 to -1.56), but not in the long-term (-0.70 kg; 95% CI -4.47 to 3.07). Web-based interventions were also superior to no specific interventions (-3.03 kg; 95% CI -3.55 to -2.51). We rated the quality of evidence as moderate due to high attrition rates and heterogeneity, mainly (79%) attributable to control group differences. Conclusions: Conclusion: Moderate quality evidence showed that web-based interventions lead to greater short-term weight loss than offline interventions in overweight/obese adults. There was not any difference in weight loss between these two types of intervention in the long-term. High attrition rates suggest that engagement is a major issue in web interventions.

  • Background: Inadequacies in mental healthcare coverage remain an enormous problem in the United States. Barriers to care include geographical and financial limitations, and a scarcity of accessible mental healthcare professionals. Use of a mobile application may improve early access to healthcare for individuals who may benefit from tools to reduce stress as well as improve management of anxiety and depression. It is unknown how self-directed use of a mental health mobile application improves coping skills and its effects on self-reported depression and anxiety. Objective: The objective of this study was to evaluate self-directed engagement of the mobile application Sinasprite and how use can impact self-reported confidence in coping skills, and depression and anxiety severity. Methods: This retrospective longitudinal study involved users who were recruited via clinician referral and self-referral through social media and news media. Questionnaires were utilized to record demographic, medical and prescription medication histories. Mental health status was assessed via Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder Item 7- (GAD-7) and the Coping Self-Efficacy Scale (CSE) questionnaires. Mobile use data were provided by the application development team. Individuals with verifiable usage data and at least one completed questionnaire at six weeks of use were included. Mann-Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman Rho test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed at baseline and again six weeks after via Wilcoxon signed-rank test. A mixed effects repeated measures regression model assessed the main effects of time, concomitant counseling and psychotropic prescription medication use on mental health status. Results: Thirty-four users were eligible for the analysis. Users were more commonly female, Caucasian, and college educated. At baseline, 35% of respondents reported use of individual/group counseling and 38% reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. After six weeks of engagement statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (p<0.001), GAD-7(p= 0.002), and CSE (p= 0.011) questionnaire scores. A strong, positive correlation between improvement in the GAD-7 and CSE questionnaire scores (r= 0.581 p= 0.007, n= 20) was observed. The mixed effects repeated measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (p< 0.001), GAD-7 (0.007) and CSE (p= 0.003) questionnaire scores while controlling for concomitant therapies. Conclusions: This six-week retrospective study showed that self-directed use of a mental health-related mobile application, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.

  • Background: Self-monitoring is a cornerstone of behavioral lifestyle interventions for obesity and type 2 diabetes mellitus (T2DM). Previous studies found that mobile technology has potential to improve adherence to self-monitoring and patient outcomes. However, no study has tested the use of a smartphone to facilitate self-monitoring in low-literate overweight or obese adults with T2DM living in the underserved community. Objective: To examine the feasibility of and compare preliminary efficacy of a behavioral lifestyle intervention using smart phone or paper-based self-monitoring of multiple behaviors on weight loss and glycemic control in a sample of overweight or obese adults with T2DM living in underserved communities Methods: We conducted a randomized controlled trial to examine the feasibility and preliminary efficacy of a behavioral lifestyle intervention among underserved individuals. A total of 26 overweight or obese patients with T2DM were recruited from an underserved minority community health center in Houston, TX. They were randomly assigned to one of the three groups: 1) behavior intervention with smart phone based self-monitoring, 2) Behavior intervention with paper diary based self-monitoring, and 3) Usual care group. Both the mobile and paper groups received a total of 11 group sessions in a 6-month intervention. The mobile group received an android-based smart phone with two applications loaded to help them record their diet, physical activity, weight, and blood glucose, along with a connected glucometer, while the paper group used paper diaries for these recordings. Treatment fidelity was assessed using a checklist for each intervention session. Primary outcomes of the study included % weight loss and glycolated hemoglobin (HbA1c) changes over 6 months of the study. Results: We had 96% retention rate at 6 months. The sample is predominantly African Americans with an average age of 56.4 years and BMI of 29.6. Participants lost an average of 2.73% (mobile group), 0.13% (paper group) weight at 6 months, while the control group had an average .49% weight gain. Their HbA1c changed from 8% to 7 % in mobile group, 10% to 9% in paper group, and maintained at 9% for the control group. We found a significant difference on HbA1c at 6 months among the 3 groups (P=.01). We did not find statistical significance on % weight loss (P=.20) and HbA1c changes (P=.44) among the 3 groups overtime, however, we found a large effect size of .40 for weight loss and a medium effect size of .28 for glycemic control. Conclusions: Delivering a simplified behavioral lifestyle intervention using mHealth-based self-monitoring in an underserved community is feasible and acceptable, and shows higher preliminary efficacy, as compared to paper-based self-monitoring. A full-scale randomized controlled trial is needed to confirm the findings in this pilot study. Clinical Trial: Clinicaltrials.gov NCT02858648; https://clinicaltrials.gov/ct2/show/NCT02858648

  • Background: Efforts to translate evidence-based weight loss interventions, such as the Diabetes Prevention Program (DPP), to low-income, postpartum women are limited by poor intervention attendance and high attrition rates. Strategies that improve engagement and retention in this population are needed to maximize the reach of evidence-based weight loss interventions Objective: To adapt a DPP-based weight loss intervention (Fresh Start) for Facebook delivery and to evaluate its feasibility among low-income postpartum women. Methods: This study comprised of three single group pilot studies where feasibility outcomes iteratively informed changes from one pilot to the next. We paralleled the in-person program to Facebook delivery by translating the protocol to a content library to be delivered in a Facebook feed with additional input from lifestyle coaches. Low-income postpartum women were recruited from Women, Infants, and Children (WIC) clinics in Worcester, MA. Participants were enrolled into a 16-week weight loss intervention delivered via Facebook. During the first eight weeks, Facebook intervention posts were delivered two times per day with additional posts from coaches. For the following 8 weeks, posts were delivered once per day without additional coaching. Outcome measures were collected at baseline and 16-week follow-up and included changes in weight as well as feasibility outcomes including retention, engagement (defined by likes, comments, and posts), and acceptability. Results: Pilot 1 (n = 27) had a retention rate of 89% and 62% engaged in the group during the 8-week coached phase. Mean weight loss was 2.6 pounds (SD = 8.64) and 75% reported being satisfied with the program. Pilot 2 (n = 24) had a retention rate of 83% and 55.2% engaged in the group during the 8-week coached phase. Mean weight loss was 2.5 pounds (SD = 9.23) and 80% were satisfied with the program. Pilot 3 (n = 16) had a retention rate of 88% and 67% engaged in the group during the 8-week coached phased. Mean weight loss was 7.0 pounds (SD = 11.6) and 64.3% were satisfied with the program. Conclusions: Findings demonstrated that a Facebook-delivered intervention was acceptable and could be feasibly delivered to the low-income, postpartum women. Future research is needed to evaluate the efficacy of a Facebook-delivered weight loss intervention.

  • Background: People with Type 2 Diabetes (T2DM) and Microalbuminuria are at significantly increased risk of Cardiovascular (CV) mortality and morbidity. Recent audit data shows that most of these patients do not achieve evidence based treatment targets for CV risk factors including blood pressure, cholesterol and HbA1c. Individualised interventions have shown success at reducing mortality and morbidity but implementation has been hampered by scarce resources available within primary care. The GP Prompt study is testing a healthcare professional technology driven intervention aiming to improve the management of patients of T2DM and MA Objective: To describe the trial design and baseline characteristics of individuals participating in a targeted, multifactorial intervention in a high risk, multi-ethnic population with type 2 diabetes (T2DM) and microalbuminuria (MA) delivered by health care professionals in a community based setting Methods: A complex, multifaceted intervention comprising a software ‘prompt’ with an evidence based treatment algorithm installed on GP computer systems alerting healthcare professionals to eligible study individuals not meeting tight CV risk factor targets, healthcare professional education, clinician email support, three monthly feedback and dissemination of performance data illustrating proportion of individuals meeting risk factor targets, practice based mean CV risk factor targets and prescribing patterns. Primary outcome is proportion of eligible participants meeting tight CV risk factor targets including systolic and diastolic blood pressure (<130/80mmHg) and total cholesterol (<3.5mmol/l) at 24 months. Secondary outcomes include proportion of individuals with HbA1c <58mmol/mol(7.5%), change in medication prescribing, changes in MA and renal function (eGFR), incidence of major adverse CV events and mortality, and coding for microalbuminuria in patient records. Cost-effectiveness of the intervention will be assessed Results: Among 2721 eligible study individuals, mean (SD) age was 62.9 (10.0), duration of diabetes 10.46 (7.22) years. Mean (SD) HbA1c was 59.3 (17.4) mmol/mol, systolic and diastolic BP (mmHg) was 134.3 (14.6) and 76.1 (9.5) mmHg, respectively and total cholesterol was 4.1 (0.98) mmol/l. Overall, 131 (4.8%) of study individuals achieved all three ‘tight’ CV risk factor targets. CV risk factor burden increased two-fold in those with GFR < 60 compared to those with GFR ≥ 60 ml/min/1.73m2. Prevalence of MA was 22.8%. In total, 1076 (39.5%) individuals were coded for microalbuminuria or proteinuria on their primary care medical record. Conclusions: The GP Prompt study is the largest UK primary care-based, technology driven, randomised controlled trial to support intensive intervention in high risk group of multi-ethnic individuals with T2DM and MA. This paper provides contemporary estimates for prevalent cardiovascular disease and adherence to evidence based cardiovascular risk factor targets at baseline in a population with T2DM and MA. The main trial results, including cost effectiveness data will be submitted for publication in early 2018 Clinical Trial: Trial registration: ISRCTN number: 14918517 Registration Date: 9/5/15

  • Background: In the last few decades, mobile technology has been widely employed in healthcare service field in order to improve the accessibility and quality of health services. Thereby mobile health (mHealth) emerged at the right time and was paid increasing attention by scientific researchers with a rapid increase in the related literature. Objective: The purpose of this article is to analyze research status and publication outputs in mHealth field in order to uncover in depth collaboration characteristics and topic burst of international mHealth research. Methods: The authors collected literature during the past 20 years, indexed by Thomson Reuters Web of Science Core Collection (WoSCC). Various statistical techniques and bibliometric measures, including publication growth analysis, journal distribution, subject distribution, and collaboration network analysis at the author, institution and country collaboration level, had been employed. The temporal visualization map of burst terms was drawn, and the co-occurrence matrix of these burst terms was analyzed by hierarchical cluster analysis and social network analysis. Results: A total 2,704 bibliographic records on mHealth were collected. The earliest article on mHealth was published in 1997. And the number of articles has risen continually since then. The output on mHealth was published in 1,008 journals. The publication output on mHealth was distributed in 162 subject categories. The total number of authors on mHealth research is 10,895, 21.3% (2,318) of which is first author. However, only 141 (1.3%) authors have just published one article. The total collaborative degree of author was 4.42, and the collaborative degree of authors per year is on the rise in general. The core authors group basically forms. Nevertheless, the collaboration of core author is not tight and stable. The publications on mHealth are distributed among 3,040 research institutions. University Michigan ranks the top one on most publications, but less collaboration among institutions exits. Scholars from 111 countries have contributed on mHealth research. The USA is the most productive country and plays an irreplaceable leading role in the collaboration network of mHealth research. However, the country collaboration is relatively scarce. There are 5,543 different keywords in all 2,704 articles, and the number of keyword frequency obeys power law distribution. The temporal bar graph clearly presents overall topic evolutionary process over time. There are 12 important research directions identified, which are in the imbalanced development. Moreover, the density of the network was 0.007, a relatively low level. These 12 topics basically locate in four different areas, namely patient engagement and patient intervention, health monitoring and self care, mobile device and mobile computing, and security and privacy. Conclusions: This study provides important insights into the collaboration status, topic burst and trends on mHealth research, which might provide a potential guide for the future research.

  • Effectiveness of a Digital Therapeutic in Adults with Type 2 Diabetes: A Pilot Study

    Date Submitted: Dec 7, 2017
    Open Peer Review Period: Dec 8, 2017 - Dec 18, 2017

    Background: Intensive lifestyle change can treat and even reverse type 2 diabetes. Digital therapeutics have the potential to deliver lifestyle as medicine for diabetes at scale. Objective: This 12-week pilot study investigates the effects of a novel digital therapeutic on Hemoglobin A1c (HbA1c) and diabetes medication use. Methods: Adults with type 2 diabetes and a smartphone were recruited throughout the United States using Facebook advertisements. The intervention aim was to effect a sustainable shift to a plant-based dietary pattern and regular exercise by advancing culinary literacy and lifestyle skill acquisition. The intervention was delivered by an app paired with specialized human support, also delivered digitally. Health coaching was provided every 2 weeks by telephone, and a clinical team was available for participants requiring additional support. Participants self-reported current medications and HbA1c at the beginning and end of the 12-week program. Self-efficacy related to managing diabetes and maintaining dietary changes was assessed via survey. Engagement was recorded automatically through the app. Results: We enrolled 118 participants with a baseline HbA1c > 6.5%. Participants were 81.4% female, resided in 38 U.S. states, with a mean age of 50.7 years (SD 9.4), baseline Body Mass Index (BMI) of 38.1 kg/m2 (SD 8.8) and baseline HbA1c of 8.1% (SD 1.6). At 12-weeks, 86.2% (n=94) of participants were still using the app. Mean change in HbA1c was -0.8% (n=97, SD 1.3, P <.001) for those reporting end-study data; and, for participants with a baseline HbA1c >7.0% who did not change medications mid-study, HbA1c change was -1.1% (n=65, SD 1.4, P < .001). The proportion of participants with an end-study HbA1c < 6.5% was 22.7% (n=22). After completion of the intervention, 16.5% (n=16) of participants reported a decrease in diabetic medication while 8.3% (n=8) reported an increase. 56.7% (n=55) of participants achieved a composite outcome of reducing HbA1c, reducing diabetic medication use or both. 91.8% (n=90) reported greater confidence in their ability to manage their diabetes compared to before the program, and 90.8% (n=89) reported greater confidence in their ability to maintain a healthy dietary pattern. Participants engaged with the app an average of 4.3 times per day. We observed a significantly greater decrease in HbA1c amongst participants in the highest tertile of app engagement compared to those in the lowest tertile of app engagement (P = .03). Conclusions: The FareWell digital therapeutic produced clinically meaningful reductions in HbA1c. Greater glycemic control was observed with increasing app engagement. Engagement and retention were both high in this widely distributed sample. Clinical Trial: Trial registered on ClinicalTrials.gov, id: NCT03369626, https://clinicaltrials.gov/

  • Background: Poor online health information can easily turn into misinformation, reinforcing pre-existing inaccurate beliefs in people and leading them to dangerous behaviors, especially in controversial topics such as Complementary and Alternative Medicine (CAM). Objective: In this study, we analyze a sample of web pages about CAM issues to: identify and categorize the different kinds of falsehoods, explore the relationships between the various types of falsehood, estimate the risk of running into deceptive information, and observe the differences among the experts’ and layperson’s information assessment. Methods: We performed a cross-sectional observational study to assess the quality of the sample with respect to falsehood types. We investigated the possible association between unfounded statements and correct information. Expert scholars and a layperson evaluated sentences with scientific content and results of the formers and the latter were compared too. Results: We analyzed 16 web pages and 1356 sentences. 714 (82%) were unfounded statements. There were 260 (71%) incorrect scientific statements overall, and they directly related to the risk of “unfounded” information (OR=13.90 for “incorrect” versus “correct” scientific statements; 95%CI:1.81-107.02; P=.01). In the 73 statements considered “incorrect” by experts, the layperson responded properly 43 times (59%). Conclusions: Health misinformation can severely affect people’s behavior. This study can help professionals to interpret deceptive online information about controversial issues and improve their health information and communication services.

  • Background: Digital interventions show promise in reducing problematic cannabis use. However, little is known about effect moderators in such interventions. The therapist-guided Internet intervention “Quit the Shit” (QTS) provides 50 days of chat-based (synchronous) and time-lagged (asynchronous) counselling. Objective: In the study, we examined whether the effectiveness of QTS is reduced by shortening the program or removing chat-based counselling option. Methods: Purely web-based randomized controlled non-inferiority trial using a two-factorial design (factor 1: real time-counselling via text-chat: yes vs. no; factor 2: intervention duration: 50 days vs. 28 days). Participants were recruited online on the QTS-website. Follow-ups were conducted 3, 6 and 12 months after randomization. Primary outcomes were cannabis use days, quantity and use events during the past 30 days using a Timeline Followback procedure. Secondary outcomes were cannabis dependency (SDS), treatment satisfaction (CSQ-8) and working alliance (WAI-sr). Results: 534 participants were included in the trial. Follow-up rates were 47.2% after 3 months, 38.2% after 6 months and 25.3% after 12 months. The lower bounds of the CIs for all between-group effect sizes are well within the non-inferiority margin of d=0.21, pointing to non-inferiority in both factors and for all outcomes. Provision of chat-based counselling was significantly associated with higher treatment satisfaction (P=.001, d=0.33) and stronger working alliance (P=.01, d=0.36). However, these results are also within the predefined range of non-inferiority. Conclusions: The reduction of program length and the waiver of synchronous communication have no meaningful impact on the effectiveness of “Quit the Shit”. It therefore seems tenable to abbreviate the program and to offer a self-guided start into QTS. Due to its positive impact on treatment satisfaction and working alliance, chat-based counselling nevertheless should be provided in QTS. Clinical Trial: ISRCTN99818059; http://www.isrctn.com/ISRCTN99818059 (Archived by WebCite at http://www.webcitation.org/6uVDeJjfD)

  • Background: Functional abdominal pain disorders (FAPDs) are a set of chronic abdominal pain conditions, which are highly prevalent in the pediatric population and are associated with significant morbidity. Of the various treatment modalities, psychological therapies like guided imagery therapy are the most effective. However, access to therapists is a significant barrier to their use. Consequently, interest is increasing in providing these therapies remotely (e.g., online, telephone). Objective: Given the need for increasing access to psychological treatments for FAPDs, we conducted a mixed methods study to assess whether affected pediatric patients and their parents would be interested in utilizing guided imagery therapy sessions delivered remotely via mobile application (app) to treat abdominal pain. Methods: Children ages 7 to 12 years old with a pediatric Rome III defined FAPD and their parent were recruited from primary care ambulatory clinics. Parents completed our modified Technology Acceptance Model Questionnaire to characterize our participants’ personal factors and behavioral intention to use a guided imagery therapy mobile app for FAPDs. Parents and children also participated in separate in-person interviews to assess interest in the proposed app. Results: Fifteen mother/child dyads participated. Children were 33% Hispanic and 73% were diagnosed with irritable bowel syndrome. Dyads were from homes of diverse socioeconomic status. The TAM Questionnaire indicated that mothers had a positive attitude toward using an app designed to treat their children’s FAPD. Behavioral intention to use such an app was also high. Qualitative findings confirmed mothers’ interest in a guided imagery mobile app. Mothers advocated for an image or interactive visual component on the mobile device to keep their child’s attention while the guided imagery therapy session audio is played; liked the idea of incorporating background sounds into the therapy sessions; thought reminder notifications built within such an app would be helpful; and most thought the best time for their child to listen to the sessions would be in the evening or before bed. Qualitative findings indicated that the children were also interested in a mobile app to treat their FAPD. They identified multiple topics (e.g., sports-related activities) that would be of interest for the guided imagery therapy sessions. Conclusions: The concept of a mobile app that remotely delivers guided imagery therapy sessions to treat pediatric patients with FAPDs appears to be acceptable to parents and children.

  • Reliability of web information about palliative care

    Date Submitted: Dec 5, 2017
    Open Peer Review Period: Dec 5, 2017 - Jan 30, 2018

    Background: Patients and their families are able to easily obtain information about palliative care online nowadays. However, there are concerns that some information is inaccurate or has not been updated for a long time. Objective: The purpose of this study is to elucidate various problems with palliative care and medical information obtained from the web. Methods: We evaluated the top 50 palliative care websites that appeared in the Google Japan and Google USA search results using DISCERN or LIDA instruments. Results: We found that Japanese websites were given a lower evaluation on reliability compared with US websites. Conclusions: Our study suggested that there was not enough information provided on the websites to assess their reliability.

  • Background: The contents of classical communication media and new Internet social media reflect the interests of society. Barriers and a lack of attention for mental diseases have been previously observed. Objective: To measure the relevance given by the main American social communication media (ASCM) to psychiatric information and the interest generated in their Twitter followers. Methods: We investigated the tweets generated about mental health conditions and disease by 15 main United States of America (USA) general communication media from January 2007 to December 2016. Our study strategy focused on identifying several psychiatric terms of main interest. The number of retweets generated by the selected tweets was also investigated. For a control, we used tweets generated about the main causes of death in the USA, the main chronic neurological degenerative diseases and infection by the human immunodeficiency virus (HIV). Results: In total, 13,119 tweets sent by the ASCM about mental health disorders show a heterogeneous distribution with preferential accumulation in a reduced number of conditions. Suicide and gender dysphoria accumulated half of the number of sent tweets. Variability in the number of tweets related to each control disease was also found (5,998). The number of tweets sent regarding each different psychiatric or organic disease analyzed was significantly correlated with the number of retweets generated by followers (1,030,974 and 424,813 responses to metal health disorders and organic diseases, respectively). However, the probability of a tweet being retweeted was statistically different between the conditions and diseases analyzed. Furthermore, the retweeted/tweet ratio was significantly higher in psychiatric diseases than in the control organic diseases (OR=1.11 [1.07- 1.14], p<0.001). Conclusions: According to the use of Twitter, the ASCM and the general public demonstrate a preferential interest for psychiatric diseases. The heterogeneous weight given by the ASCM to the different mental health disorders and conditions is reflected in the response of Twitter followers.

  • Design Sprint and Usability Testing of a Patient-facing, Diabetes Dashboard Embedded in a Patient Web Portal

    Date Submitted: Dec 4, 2017
    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Health apps and web-based interventions designed for patients with diabetes offer novel and scalable approaches to engaging patients and improving outcomes. However, careful attention to the design and usability of these apps and web-based interventions is essential to reduce barriers to engagement and maximize use. Objective: We aimed to design a patient-facing, diabetes dashboard that addresses users’ needs, incorporates recommended strategies for increasing user engagement, and is satisfying to use. Methods: We applied the 5-day Design Sprint methodology developed by GV (Alphabet Inc., Mountain View, CA) to create our initial dashboard prototype. We identified recommended strategies from the literature for using patient-facing technologies to activate patients and designed dashboard functionality to match each strategy. We then conducted a mixed-methods, task-based usability assessment of dashboard prototypes with individual patients. Measures included validated metrics of task performance on five common and standardized tasks, semi-structured interviews, and a validated usability satisfaction questionnaire. After each round of usability testing, the dashboard prototype was revised in response to usability findings prior to the next round of testing until the majority of participants successfully completed tasks, expressed high satisfaction, and identified no new usability concerns (i.e., stop criterion met). Results: The sample (N=14) was composed of five patients in round 1, three patients in round 2, and six patients in round 3 at which point we reached our stop criterion. Participants’ mean age was 63 (range: 45 - 78), 57% were female, and 50% were Caucasian. Our Design Sprint yielded an initial patient-facing diabetes dashboard prototype that displayed and summarized five measures of patients’ diabetes health status (e.g., Hgb A1C). The dashboard used graphics to visualize and summarize health data and reinforce understanding, incorporated motivational strategies (e.g., social comparisons and gamification), and provided educational resources and secure-messaging capability. Greater than 80% of participants were able to successfully complete all five tasks using the final prototype. Interviews revealed usability concerns with design, efficiency of use, content and terminology which led to improvements. Overall satisfaction (0=worst, 7=best) significantly improved from the initial to the final prototype (mean±SD, 5.8±0.4 vs. 6.7±0.5, P=0.02). Conclusions: Our results demonstrate the utility of Design Sprint methodology paired with mixed-methods, task-based usability testing to efficiently and effectively design of a patient-facing, web-based diabetes dashboard that is satisfying for patients to use.

  • Background: Chronic disease is the leading cause of morbidity and mortality worldwide. The primary health care setting is an effective avenue for the management and prevention of chronic disease, and dietitians working in this setting assist the management of chronic disease modifiable risk factors. However, healthcare professionals report challenges in providing care in this setting, due to time and financial constraints. Information technology offers the potential to improve health care quality, safety, efficiency and cost-efficiency, but there is limited understanding of dietitians’ application of technology in this setting. Objective: This study explored the perceptions of primary care dietitians about using information technology in their workplace. Methods: Twenty Australian primary care dietitians were recruited for semi-structured telephone interviews. Interview questions aimed to gain an understanding of dietitians’ perceptions about sharing patient outcomes through a national database, and the benefits, disadvantages, feasibility and barriers of using information technology. Interviews were audio-recorded, transcribed verbatim and thematically analysed for emerging themes and sub-themes. The technologies used by participants were collated by name and researched for their key attributes. Results: Four distinct themes emerged from the data (i) information technology improving efficiency of practice tasks, (ii) experiencing barriers to using information technology in practice, (iii) information technology enhancing outcomes through education and monitoring, and (iv) information technology for sharing information with others. Participants identified several advantages and disadvantages with using technology, and expressed a willingness to share patient outcomes using an online database. Conclusions: This study suggests that information technology is perceived to have benefits to dietitians and patients in primary health care. However, to achieve the optimal benefit, support is required to overcome barriers to better integrate information technology into practice. Further development of patient management systems and standardized online data collection systems is needed to support better usage by dietitians.

  • A Mobile Game for Patients with Breast Cancer: Randomized Controlled Trial

    Date Submitted: Dec 4, 2017
    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Although video gaming has been associated with many negative health consequences, it was hypothesized that a mobile online game would help to increase compliance with cytotoxic chemotherapy and decrease the incidence of chemotherapy side effects in patients with breast cancer. Objective: The potential efficiency of video games to help side effects and improve life quality and life span for metastatic breast cancer patients needs to be demonstrated. Methods: A total of 76 patients with metastatic breast cancer agreed to participate in an education-controlled trial of mobile game healthcare management. All participants were randomly assigned to a chemotherapy+mobile game play group (mobile game group) or a chemotherapy+education group (education group) at a 1:1 ratio. This study was designed as a 3-week prospective trial. Results: The mobile game group showed increased drug adherence scores and game playing time compared to the education group. The mobile game group also reported decreased personal total physical side effects (χ2=8.87, p<0.01), including fatigue (χ2=6.26, p=0.02), numbness of hand or foot (χ2<1.0, p<0.01), stomatitis (χ2<1.0, p<0.01), and hair loss (χ2<1.0, p<0.01) compared to the education group. In addition, the mobile game group also reported decreased severity of physical side effects including (F=12.37, p<0.01), decreased appetite (F=9.33, p<0.01), numbness in the hand or foot (F<1.0, p<0.01), stomatitis (F<1.0, p<0.01), and hair loss (F<1.0, p<0.01) compared to the patients in the education group. Over the course of 3 weeks, the education group showed greater decreases in scores for quality of life (QoL) compared to the mobile game group. Conclusions: Our findings indicate improved drug compliance, QoL and decreased prevalence rates for physical side effects when using a mobile game for breast cancer patients. These results suggest that the mobile game, ILOVEBREAST, may be helpful in the management of breast cancer. Clinical Trial: Clinicaltrials.gov Identifier NCT03205969

  • Background: Obsessive Compulsive Disorder (OCD) is a highly disabling psychological disorder with a chronic course if left untreated. Cognitive-behavioral therapy (CBT) has been shown to be an effective treatment, but access to face-to-face CBT is not always possible. Internet-based CBT (iCBT) has become an increasingly viable option. However, no study has compared iCBT to an analogous control condition using a Randomized Controlled Trial (RCT). Objective: A two-armed RCT was used to compare a therapist-assisted 12-module iCBT to an analogous active attention control condition (Internet-based standard progressive relaxation training, iPRT) in adult OCD. Methods: In total, 179 participants (117 females; 65.7%) were randomized (stratified by gender) into iCBT or iPRT. The iCBT intervention included psychoeducation, mood and behavioral management, exposure and response prevention (ERP), cognitive therapy and relapse prevention; the iPRT intervention included psychoeducation, and relaxation techniques as a way of managing OCD-related anxiety but did not incorporate ERP or other CBT elements. Both treatments included audiovisual content, case stories, demonstrations of techniques, downloadable audio content and worksheets, and expert commentary. All participants received one weekly email, with a maximum 15-minute preparation time per client from a remote therapist trained in e-therapy. Emails aimed to monitor progress, review homework, provide support and encouragement, and assist in individualizing the treatment. Participants were assessed for baseline and post-treatment OCD severity with the telephone-administered clinician-rated Yale-Brown Obsessive-Compulsive Scale (YBOCS) and other measures by assessors who were blinded to treatment condition allocation. Results: No pre-treatment differences were found between the two conditions. Intention-to-treat analysis (ITT) revealed significant pre-post improvements in OCD symptom severity for both conditions (P < .001). However, relative to iPRT, iCBT showed significantly greater symptom severity improvement (P = .001); Cohen’s d for iCBT was 1.05 (95% confidence interval: 0.72, 1.37), whereas for iPRT it was 0.48 (95% confidence interval: 0.22, 073). The iCBT condition was also superior in regards to reliable improvement (49% vs 29.1%; P = .04) and clinically significant pre-post-treatment changes (33.3% vs 10.9%; P = .005). Furthermore, those undertaking iCBT post completion of iPRT showed further significant symptom amelioration (P < .001), although the sequential treatment was no more efficacious than the iCBT alone (P = .63). Conclusions: This study is the first to compare an online therapist-assisted CBT program (iCBT) for OCD to an analogous active attention control condition using Internet-based progressive relaxation training (iPRT). The current findings demonstrate the large magnitude efficacy of iCBT for OCD; interestingly, the analogous active attention control (iPRT) was also moderately efficacious, albeit significantly less so than the iCBT intervention. The findings are compared to previous Internet-based and face-to-face CBT treatment programs for OCD. Future directions for technology-enhanced programs for the treatment of OCD are outlined. Clinical Trial: ACTRN12611000321943

  • Background: Project Quit was a randomized web-based smoking cessation trial conducted by researchers from the University of Michigan, and was designed with the seven-day point prevalence as the primary outcome. One drawback of the point prevalence outcome is that it only focuses on the smoking behavior in a very short time window, rather than looking at the quitting process over the entire study period. Objective: In the current article, we consider an alternative outcome, namely, the number of quit attempts during the 6-month study period, that better reflects the quitting process. We aim to find out if tailored interventions are better suited to specific subgroups of smokers, in terms of the number of quit attempts outcome. Methods: We employ Poisson regression to analyze the number of quit attempts data, in order to identify interactions between the smoking cessation intervention components and individual smoker characteristics, thereby allowing us to find out data-driven, personalized interventions. Results: Among the baseline covariates, a negative effect of the number of cigarretes smoked per day (P=0.029) and a positive effect of education (P=0.026) are detected. Thus, for every 10 extra cigarettes smoked per day, there is a 5.84% decrease in the expected number of quit attempts; and 15.49% increase in the expected number of quit attempts for highly-educated participants as compared to low-educated participants. More interestingly, a negative interaction between the intervention component story and smoker’s education is detected (P=0.034), suggesting that giving a highly-tailored story to a highly educated person results in a 13.50% decrease in the number of quit attempts compared to a low-tailored story. Conclusions: We conclude that highly individually tailored level of story is significantly more effective for smokers with low level of education. This is consistent with prior analysis of the Project Quit data with the point prevalence outcome.

  • Cost- analysis of prenatal remote monitoring of women with gestational hypertensive diseases

    Date Submitted: Dec 2, 2017
    Open Peer Review Period: Dec 3, 2017 - Jan 28, 2018

    Background: Remote monitoring (RM) in obstetrics is relatively new; its effectiveness for both mother and child has been shown in some trials. However, few studies evaluated the economic impact of RM compared to conventional care (CC), and no cost-analysis of a RM prenatal follow-up program for women diagnosed with gestational hypertensive diseases has been published today. Objective: The aim of this study was to assess the costs of RM versus CC, relative to reported benefits. Methods: Patient data from the reported Pregnancy Remote Monitoring (PREMOM) study was used. Health care costs were calculated from patient-specific hospital bills of Ziekenhuis Oost Limburg (Genk Belgium) in 2015. Cost comparison was made from three perspectives: the Belgian national health care system (HCS), which combines costs for the National Institution for Insurance of Disease and Disability (RIZIV), and costs for individual patients. The calculations were made for four major domains: prenatal follow-up, prenatal admission to the hospital, maternal and neonatal care at and after delivery, and total amount of costs. A simulation exercise is made in which is calculated how much can be demanded to RIZIV for funding the RM service. Results: A total of 140 pregnancies were included, of which 43 RM (30.71%) and 97 CC (69.29%) received. From the three perspectives, there were no differences in costs for prenatal follow-up. Compared to CC, RM patients had 34.51% less HCS and 41.72% les RIZIV costs for labs (€0.00 ± €55.34 vs. €38.28 ± € 44.08, P < 0.01; and €21.09 ± €27.94 vs. €36.19 ± €41.36 , P < 0.01 respectively) and a reduction of 47.16% in HCS and 48.19% in RIZIV costs for neonatal care (€989.66 ± €3020.22 vs. €1872.92 ± €5058.31, P < 0.01; and €872.97 ± €2761.64 vs. €1684.86 ± €4702.20, P < 0.01). HCS costs for medication were 1.92% lower in RM than in CC (€209.22 ± €213.32 vs. €231.32 ± 67.09, P = 0.02), but were 0.69% higher for RIZIV (€122.60 ± €92.02 vs. €121.78 ± €20.77; P < 0.01). Overall HCS costs for RM were €4233.31 ± €3463.31 pp and €4973.69 ± €5219.00 pp for CC (P = 0.82), which means a reduction of €740.38 (14.89%) pp, with savings mainly for RIZIV of €848.97 pp (23.18%; €2797.42 ± €2905.18 vs. €3646.39 ± €4878.47, P = 0.19). When an additional fee of €525.07/month/pregnant woman for funding RM costs is owned, RM is acceptable in their costs for HCS, RIZIV and individual patients. Conclusions: In the current organization of Belgian health care, a RM prenatal follow-up of women with GHD is cost-saving for the global health care system, mainly via savings for the insurance institution RIZIV. Clinical Trial: /

  • Background: Parents of children with a chronic kidney disease (CDK) experience high levels of stress in daily management of their child’s disease. Although parents want continuously accessible support and information, online support programs are lacking. Therefore, e-Powered Parents (e-PP) was developed: an online program consisting of: 1) medical information, 2) an interactive part, and 3) four training modules (stress management, setting limits, communication and coping). Prior to a large scale evaluation, a feasibility study was conducted consisting of an effect study and process evaluation. Objective: 1) To identify outcomes measures most likely to capture potential benefit, 2) to evaluate potential effectiveness and effect size, and 3) to evaluate recruitment, reach, dose received and context. Methods: A mixed methods feasibility study with a two-armed wait-list randomized controlled trial (RCT) was conducted. Prior to baseline, parents (n=146) were randomly allocated to group 1 or group 2. After completing the baseline questionnaire, parents in group 1 got access to e-PP, and group 2 received usual care. At six month follow-up (T1), parents in group 2 got access to e-PP as well. After one year, an extra measurement (T2) evaluated the effect of long-term exposure. Outcomes were: the child’s quality of life (CVS), parental stress (PIP) and fatigue (MFI), self-efficacy in communication with health professionals (PEPPI) and parental perceptions of family management (FaMM). Floor and ceiling effects and percentage of parents showing no change in scores were calculated. Linear mixed models were used to evaluate potential effectiveness and effect sizes using intention to treat and per protocol analysis. Recruitment, reach, dose received and context were evaluated in the process evaluation, using a questionnaire send to the parents, login data, and a focus group interview with healthcare professionals. Results: At T1 (n=86) and T2 (n=51) no significant effects were found on any of the five outcomes. The PEPPI showed ceiling effects and high percentages of parents showing no change between the measurement times. The information and interactive part of the intervention were used by 84% of the parents in group 1 and 49% of the parents in group 2. Information pages were visited most frequently. 85% of the parents logged in at the training platform, 31% actually used the training modules. Conclusions: No significant effect on one of the outcomes was found. This could possibly be explained by the minimum use of the intervention and parents’ heterogeneity. For continued participation, a tailored intervention is recommended and further studies are necessary to find out if and how online programs could be used to support parents in the management of their child’s CKD. Clinical Trial: Dutch Trial Registration: NTR4808; www.trialregister.nl

  • A Thematic Analysis of U.S. Hospitals’ Posts on Facebook

    Date Submitted: Dec 1, 2017
    Open Peer Review Period: Dec 3, 2017 - Jan 28, 2018

    Background: While healthcare organizations such as hospitals and clinics have widely embraced social media as a means to educate the community on health topics and increase patient loyalty and satisfaction, little is known about the content that these organizations actually share when using social media channels. Objective: This study aimed to explore the types of content that U.S. hospitals post on their Facebook pages and how hospitals’ Facebook activities differ with regard to content types. Methods: We collected and thematically analyzed more than 1,700 Facebook posts made over a three-month period by seventeen U.S. hospitals. During the first phase, the two researchers coded a set of 159 posts and created an initial thematic web of content. During the second phase, the researchers coded the remaining posts and then revised, refined, and validated the initial web of content accordingly. Coding consensus was achieved on 1184 of the 1548 analyzable sampled posts (76.49%). Results: We identified a list of thirteen unique health social media post themes and classified those themes into three thematic groups that included announcing, sharing, and recognizing activities. The most frequently used theme was sharing health information, which appeared in more than 35% of the posts analyzed. Such posts sought to provide health tips and advice to community members. Recognizing special days and recognizing employees were the second and third most frequently used themes, respectively, with 14.95% and 11.82% of the posts containing those themes. The frequency of these themes were surprising in that the content was geared more toward stakeholders internal to the organization, while most prior literature has focused on social media as a tool to connect with external stakeholders. In addition, we found that many of the posts involved more than one theme and selected sets of themes co-occurred frequently. For example, 25% of the posts recognizing special days also included content to share health information and nearly 38% of the posts announcing research activities also included content to share health information. Finally, we found that hospitals were in some ways similar and in some other ways different in terms of the themes that they predominantly used in their Facebook posts. Conclusions: Using Facebook is an inexpensive, yet effective way for healthcare organizations to educate people on health and wellness topics and to communicate different types of information and news to the public audience. Hospitals and clinics that are expanding their social media activities or are starting to embark on social media strategies can use the results of this study to better formulate their activities on Facebook.

  • Background: Although most physicians in a medical setting have to deliver bad news, the skills of delivering bad news to patients have been given insufficient attention. Delivering bad news is a complex communication task that includes verbal and non-verbal skills, the ability to recognise and respond to patients’ emotions and the importance of considering the patient environment such as culture and social level. How bad news is delivered can have consequences that may affect patients sometimes definitively. Objective: The goal of the project was to develop an online formative self-assessment tool for physicians to practice delivering bad news so as to minimize the deleterious effects of a poor way of disclosing bad news about a disease, whatever the disease. Methods: BReaking bAD NEws Tool (BRADNET) items were developed by using a review of the existing protocols and recommendations for delivering bad news and patient–physician communication assessment instruments and semi-structured interviews with patients and physicians. From this step, the themes were selected and then pooled before consensus on a good practices communication framework list. Items were then created from this list. To ensure that physicians found the BRADNET acceptable, understandable and relevant to their condition, the tool was refined by a working group of clinicians familiar with delivering bad news. The think-aloud approach was then used to explore the impact of the items and messages and why and how these messages could change physicians’ relations with patients or how to deliver bad news. Finally, formative self-assessment sessions were constructed according to a double perspective of progression: a chronological progression of the disclosure of the bad news and the growing difficulty of items (difficulty concerning the expected level of self-reflection). Results: The good practices communication framework list consisted of 70 specific issues in breaking bad news pooled in 8 main domains: opening, preparing for the delivering bad news consultation, communication techniques, consultation content, attention, physician emotional management, shared decision making and relationship between the physician and the medical team. Following the construction of the items from this list, the items were extensively refined to make it more useful to the target audience. The BRADNET contains 71 items, each including a question, response options and a corresponding message. These 71 items were divided into 8 domains and assessed with 12 self-assessment sessions. Conclusions: The self-assessed training tool is Web-based. Its objective is to create a “space” for reflection. It contains items leading to self-reflection and messages introducing recommended communication behaviors. The interest in our approach lies in providing a distance-learning self-assessment tool that is not expensive and is more manageable and less time-consuming for physicians with often overwhelming schedules.

  • Background: Caring for someone with dementia is one of the most challenging caring roles. The need for support for family caregivers has been recognised for some time, but is often still lacking. With an ageing population there is growing demand on health and social care services, and the population is increasingly looking to the internet for information and support. Objective: This review aimed to: 1) Identify the key components of existing internet-based interventions designed to support family caregivers of people with dementia 2) Develop an understanding of which components are most valued by caregivers 3) Consider the evidence of effectiveness of internet-based interventions designed to support family caregivers of people with dementia Methods: A systematic search was conducted of online databases in May 2017. Reference lists were searched and citations tracked. All study designs were included. A narrative synthesis approach was adopted with thematic analysis and tabulation as tools. Results: 2035 studies were identified and 37 were included. The interventions varied in the number and types of components, duration and dose, and in the outcomes used to measure effectiveness. The interventions focussed on: 1) contact with health or social care providers; 2) peer interaction; 3) provision of information; 4) decision support and 5) psychological support. The overall quality of the studies was low, making interpretation and generalizability of the effectiveness findings difficult. However, the majority of studies suggested that interventions may be beneficial to family caregiver well-being, including positive impacts on depression, anxiety and burden. Particular benefit came from psychological support provided online, where several small randomised controlled trials suggested improvements in caregiver mental health. Provision of information online was most beneficial when tailored specifically for the individual and used as part of a multi-component intervention. Peer support provided in online groups was appreciated by most participants and showed positive effects on stress. Finally, online contact with a professional was appreciated by caregivers, who valued the easy access to personalised practical advice and emotional support, leading to a reduction in burden and strain. Conclusions: Although mixed, the results indicate a positive response for the use of internet-based interventions by caregivers. More high quality studies are required to identify the effectiveness of internet interventions aimed at supporting family caregivers, with particular focus on meeting the needs of caregivers during the different stages of dementia. Clinical Trial: N/A

  • Background: Electronic methods are increasingly being used to manage health-related data amongst general and sporting populations. Collection of such data permits analysis of injury and illness trends, improves early detection of health problems and provides evidence to inform prevention strategies. Athlete self-report monitoring (ASRM) via online systems have been successfully employed across a range of team sports to monitor health. Australian combat athletes train across the country without dedicated national medical/sports science teams to monitor and advocate for their health. Employing an internet-based ASRM system may provide an avenue to increase visibility of health problems experienced by combat athletes, and deliver key information to stakeholders about where prevention programs can be targeted. Objective: The objectives of this study were to: 1) Investigate the uptake and engagement with two online ASRM tools across a cohort of Australian combat athletes, 2) Document the type and severity of injuries/illnesses sustained by these athletes, and 3) Compare the strengths/limitations of two different injuries/illness definitions. Methods: Twenty-six athletes from four Olympic combat sports (boxing, judo, taekwondo and wrestling) were approached to complete two online ASRM tools, one daily and one weekly. Engagement with the ASRM tools was measured and health problems (injuries and illnesses) collected by the tools were coded using OSICS version 10.1 and ICP 2. Multilevel mixed effects Poisson regression was utilised to assess engagement across the study period and the effect of personal contact made on the reporting. Results: Despite over 160 contacts, athlete engagement with online tools was poor with only 13% compliance across the 12 week period. No taekwondo or wrestling athletes were compliant. Communication with athletes did not influence their long term behaviour and those that were compliant at the beginning of the study were more likely to be compliant throughout. Despite low engagement, high numbers of injuries/illness were recorded across 11 athletes: 22 unique injuries, 8 unique illnesses, 30 recurrent injuries and two recurrent illnesses. The most frequent injuries were to the knee in boxing (n=41) and thigh in judo (n=9). Judo players experienced more severe, but less frequent, injuries than did boxers yet sustained more illnesses. Athletes were continued to train irrespective of health problems in 97% of cases. Conclusions: Amongst athletes who reported injuries, many reported multiple conditions. Athletes were not highly engaged with the online ASRM tools despite ample feedback and reminders. Contact was beneficial athletes who had previously entered data but did not change the behaviour of non-compliant athletes. Results indicate that there may be a need for staff within the sports organisations drive implementation. By utilising the information gathered from online monitoring to inform daily training, engagement and subsequent data quality can be enhanced all whilst increasing coach/staff oversight of combat athlete health.

  • Investigating the relationship between media coverage and vaccination uptake in Denmark

    Date Submitted: Dec 1, 2017
    Open Peer Review Period: Dec 2, 2017 - Jan 27, 2018

    Background: Understanding the influence of media coverage upon vaccination activity is a potential resource for timely vaccination surveillance and similarly, might be an important factor when designing outreach campaigns. The necessity and safety of the measles, mumps and rubella (MMR) vaccine has been debated for many years, making it a suitable candidate for studying the interplay between media and vaccinations. Objective: Study the relationship between media coverage, incidence of measles, and vaccination activity of the MMR vaccine in Denmark. Methods: The cross-correlations between media coverage (1,622 articles), vaccination activity (2 million individual registrations), and incidence of measles are analyzed for the period 1997-2014. All 1,622 news media articles are annotated as being pro-vaccination, anti-vaccination, or of neutral stance. Results: The majority of anti-vaccination media coverage (65% of total anti-vaccination coverage) is observed in the period 1997-2004, immediately prior to and following the 1998 publication of the falsely claimed link between autism and the MMR vaccine. For the period 1998-2004 we observe a statistically significant positive correlation between the first MMR vaccine (targeting children aged 15 months), and pro-vaccination coverage (r=.49, P=.004), and between the first MMR vaccine and neutral media coverage (r=.45, P=.003). For the first MMR vaccine during the full period 1997-2014, we observe a statistically significant positive correlation with the measles incidence (r=.31, P=.005) with a lag of one month, indicating an increase in vaccinations following measles outbreaks. Looking at the whole period, 1997-2014, we observe no significant correlations between vaccination activity and media coverage. Conclusions: While there is no correlation between vaccination uptake and media coverage for the full period 1997-2014, there is a statistically significant positive correlation between pro-vaccination and neutral media coverage and vaccination activity for the period following the falsely claimed link between autism and the MMR vaccine, in 1998-2004. The fact that a correlation was only observed during a period of controversy suggests that people are more susceptible to media influence when presented with diverging opinions. Additionally, this correlation was only observed for the first MMR vaccine, indicating that the influence of media is stronger on parents when they are deciding on the first vaccine of their children, than on the subsequent vaccines.

  • An Account of how Attention to Usability and Lifestyle Issues may Contribute to Protocols for Clinical Trials of Medical Devices

    Date Submitted: Nov 30, 2017
    Open Peer Review Period: Nov 30, 2017 - Jan 25, 2018

    Objectives: Within the field of medicine attempts have been made to establish the efficacy of new treatments with medical devises by double blind randomized clinical trials. Very precise protocols have been developed for this purpose. However, experience has shown that conducting clinical trials on medical devices may be fraught with trouble often because of the difficulty of establishing a valid sham procedure. This paper makes a contribution by showing how one may formulate protocols for clinical trials of medical devices that rely on a pragmatic approach, which includes an interest in usability and lifestyle issues, rather than a sham procedure. Our case in point is a protocol for a clinical trial, conducted by the authors, of a new kind of treatment of epilepsy with a medical device. Methods: This paper makes a methodological contribution relevant for the formulation of protocols for clinical trials of medical devises in cases where a sham devise is not practical. Results: In the paper, we make three major points: (1) abandoning basing a clinical trial of a medical device on a sham procedure, involves making choices as to the formulation of a pragmatic alternative, (2) shifting to a pragmatic evaluation based on data on for example continued use, may involve generating data on usability and lifestyle issues. Understanding to what degree noncompliance is due to usability or lifestyle issues requires attention to the design of suitable instruments for data generation, and (3) the successful formulation of a protocol for a clinical trial of a medical device (where sham is not an option) relies on a case report form (CRF) that facilitates the separation of data on the (somatic) efficacy of the treatment from data on usability and lifestyle issues. Conclusion: Digital devices play an important role in medicine today and in the future. This paper makes a contribution by showing how one may formulate protocols for clinical trials of medical devices that do not rely on a sham procedure. The approach is based on a pragmatic approach, the generating data on usability and lifestyle issues connected to the use of the devise, and the separation of these issues from the evaluation of the efficacy of the active component of the treatment.

  • Background: Parents seek online communities to verify their suspicions of autism spectrum disorder (ASD) markers in their child. Automated tools support human decisions in many domains hence could potentially support concerned parents. Objective: Our goal was to test the feasibility of assessing ASD risk from online parental concerns, using automated text analysis tools and minimal standard questioning. Methods: Participants were 115 parents with concerns regarding their child’s social-communication development. Children were 16-30 months old, and 57% had a family history of ASD. Parents reported their concerns online, and completed an ASD specific screener, the Modified Checklist for Autism in Toddlers-Revised, with Follow-Up (M-CHAT-R/F) and a broad developmental screener, the Ages and Stages Questionnaire (ASQ). An algorithm predicted ASD risk using a combination of the parent's text and a single screening question, selected by the algorithm to enhance prediction accuracy. Results: Screening measures identified 58-88% of children at risk for ASD. Children with a family history of ASD were 3 times more likely to show ASD risk on screening measures. The prediction of a child’s risk on the ASQ or M-CHAT-R was significantly more accurate when predicted from text combined with an M-CHAT-R question selected (automatically) than from the text alone. The frequently automatically selected M-CHAT-R questions that predicted risk were: following a point, make-believe play, and concern about deafness. Conclusions: The internet can be harnessed to pre-screen for ASD using parental concerns by administering a few standardized screening questions to augment this process.

  • Engaging Men in Prenatal Health via eHealth: Findings from a National Survey

    Date Submitted: Nov 29, 2017
    Open Peer Review Period: Nov 29, 2017 - Jan 24, 2018

    Background: Pregnancy outcomes in the U.S. rank among the worst of countries with a developed healthcare system. While traditional prenatal health primarily focuses on women, promising findings have emerged in international research that suggest the potential of including men in prenatal health interventions in the U.S. eHealth applications present a promising avenue to reach new and expectant fathers with crucial parenting knowledge and healthy, supportive behaviors. Objective: To explore the perceived role of men in prenatal health, the potential use of e-health promotion, and participant-suggested ways of improving a prenatal health application designed for new and expectant fathers. Methods: A nationally-representative sample of adult males (N=962) was recruited through an online panel. The sample had an average age of 30.2 (SD=6.3) and included both fathers (413/962, 42.9%) and non-fathers (549/962, 57.1%). Nearly 12% (115/962) of participants had a partner who was pregnant at the time of the survey. Results: Despite perceived barriers such as time constraints, financial burdens, and an unclear role, men believe it is important to be involved in pregnancy health. The majority of participants (770/944, 81.6%) found the site to contain useful and interesting information. Most substantially, results indicate that more than three quarters (738/962, 76.7%) of the sample said they would share the site with others who would benefit from the information. Participants recommended the addition of interactive modules, such as a financial planning tool and videos, to make the site stronger. Conclusions: We explored the use of targeted eHealth to introduce men to prenatal education. Results indicate men are favorable to this intervention. Additional refinement should include interactive tools further engage men in this important issue. Reaching men at the prenatal phase is an early ‘teachable moment’ – where new/expectant fathers are open to information on how to help their partners have a healthy pregnancy and promote the health of their unborn children. Findings will further inform best practices for engaging men in pregnancy, which is crucial for improving maternal and child health outcomes in the U.S.

  • Background: In 2012, Region Uppsala was the first county council in Sweden to introduce patient accessible electronic health records (PAEHRs). By summer 2016 all but four out of 21 county councils had given citizens the possibility to access their medical information online. Numerous studies on the effect of PAEHRs on the work environment of healthcare professionals have been carried out, but up until now no extensive studies have been carried out regarding the patient’s experiences with using PAEHRs. Objective: The aim of the study was to investigate patients’ experiences of accessing their online electronic health records through the Swedish national patient portal. In this paper, the focus is on describing user characteristics, usage, and attitudes towards the system. Methods: A national patient survey was designed, based on an earlier interview and survey studies with patients and healthcare professionals. Data was collected during a five months period, June-October 2016. The survey was made available online on the login page to the patient accessible electronic health record system (Journalen) in Sweden. Patients from all county councils in Sweden could reach the survey. Results: 2587 users answered the survey. Two participants were excluded from the analysis, since they had only received care in a county council which did not yet show any information in Journalen. The results show that the majority of the users are women (67%) and there is a clear indication that a large amount of the users work or have worked within healthcare. Most users use Journalen infrequently (72%) and the main reason for use is to get an overview of one’s health status. Furthermore, lab results was shown to be the most important type of information to have access to. The majority of the respondents (69%) want access to new information within a day. A vast majority of the users are positive towards Journalen; 87% strongly agree and 8% agree to the statement “Getting access to Journalen is good for me”. Conclusions: The respondents provide several important reasons for why they use Journalen and why it is important for them to be able to access information in this way - several relate to patient empowerment, involvement, and security. Also considering the overall positive attitude, we can conclude that Journalen - and most probably other similar systems as well - fill important needs for patients. It is clear that patients appreciate the possibilities that Journalen gives.

  • Background: Morbid obesity (body mass index >40) has increased worldwide. The only long-term effective treatment for morbid obesity is bariatric surgery, with Roux-en-Y gastric bypass (RYGB) being the most commonly used, typically resulting in about 25% weight loss. Previous research shows that patients often have unrealistic expectations of surgery. The Internet is now the most widely-used source of healthcare information, and studies show that most RYGB patients have accessed information about the procedure online and wish to come into contact with others who have had the surgery. It has also been shown that many patients have unrealistic expectations about the surgery, despite being given accurate information by healthcare staff. Objective: The aim of the present study was to describe shared values, feelings, and thoughts among forum posters visiting a web-based forum for those considering and/or undergoing bariatric surgery. Methods: The study was conducted as a cross-sectional observation study using qualitative contents analysis. The material consisted of an online discussion forum thread about bariatric surgery, with 498 posts. These were copied into a separate document, read and re-read in a familiarization process. Data was then coded into meaningful sections and grouped into categories, illustrated with suitable excerpts. Results: The following categories emerged from the analysis: a new life - anticipating dramatic changes of body and mind; b) negotiating the system and playing the waiting game; c) a means to an end - managing the pre-operative diet; and d) managing the attitudes of others. The results showed that many posters described the process of bariatric surgery as a journey, riddled with roadblocks, setbacks and trials, but also with joy and great expectations of a new and better life. They struggled with the pre-operative weight loss diet, and many feared negative comments from their surroundings, but the posters provided constant emotional support, information and encouragement to each other in the discussion forum. Conclusions: The results show that the process of making a decision to undergo surgery, and navigating the healthcare system, the preoperative preparations and the reactions of friends and family, can be seen as a journey. As such, it is a process wraught with roadblocks, setbacks and struggles, during which the forum posters provide practical, emotional and social support for each other. Professionals who encounter this group should be aware of their need for support throughout the process, and investigate the possibility of both pre- and postoperative support groups, either online or face-to-face.

  • The value of RFID in Quality Management of the Blood Transfusion Chain in an Academic Hospital Setting

    Date Submitted: Nov 27, 2017
    Open Peer Review Period: Nov 28, 2017 - Jan 23, 2018

    Background: A complex process like the blood transfusion chain could benefit from modern technologies like RFID. RFID could for example play an important role in generating logistic and temperature data of blood products, which are important in assessing the quality of the logistic process of blood transfusions and the product itself. Objective: The aim of this study is to evaluate whether location, time-stamp and temperature data generated in real-time by an active RFID system containing temperature sensors attached to Red Blood Cell products (RBCs), can be used to assess the compliance of the management of RBCs to 4intra-hospital European and Dutch guidelines prescribing logistic and temperature constraints in an academic hospital setting. Methods: A RFID infrastructure supported the tracking and tracing of 243 tagged RBCs in a clinical setting inside the hospital at the Blood Transfusion Laboratory (BTL), the Operating Room (OR) complex and the Intensive Care Unit (ICU) within the Academic Medical Center (AMC), a large academic hospital in Amsterdam, The Netherlands. The compliance of the management of 182 out of the 243 tagged RBCs could be assessed on their adherence to the following guidelines on intra-hospital storage, transport and distribution: (1) RBCs must be preserved within an environment with a temperature between 2°C and 6°C; (2) RBCs have to be transfused within 1 hour after they have left a validated cooling system; (3) RBCs that have reached a temperature above 10°C must not be restored or must be transfused within 24 hours, or else be destroyed; (4) Unused RBCs are to be returned to the blood transfusion laboratory within 24 hours after they left the transfusion laboratory. Results: In total 4 blood products (4 in 182 compliant; 2%) complied to all applicable guidelines. Fifteen blood products (15 in 182 not compliant to 1 out of several guidelines; 8%) were not compliant to one of the guidelines of either 2 or 3 relevant guidelines; Finally 148 blood products (in 182 not compliant to 2 guidelines; 81%) were not compliant to 2 out of 3 relevant guidelines. Conclusions: The results point out the possibilities of using RFID technology to assess the quality of the blood transfusion chain itself inside a hospital setting in reference to intra-hospital guidelines concerning the storage, transport and distribution conditions of RBCs. This study shows the potentials of RFID in identifying potential bottlenecks in hospital organizations’ processes by use of objective data which are to be tackled in process redesign efforts. The effect of these efforts can subsequently be evaluated by the use of RFID again. As such, RFID can play a significant role in optimization of the quality of the blood transfusion chain

  • Background: Field hockey is associated with a risk for musculoskeletal injuries, especially in the lower extremities. At present time, no measures focussing on the prevention of lower extremity injuries exist in the Netherlands. Consequently, a scientific research project has been initiated in the Netherlands aimed at developing and implementing an evidence-based intervention to prevent the occurrence of lower extremity injuries among young and adult recreational field hockey players. Objective: This article describes: (i) the systematic development of the intervention; and (ii) the assessment of its feasibility in terms of relevancy, suitability, satisfaction and usability. Methods: The intervention was developed according to the first four steps of the Intervention Mapping and Knowledge Transfer Scheme processes, namely: needs assessment; objective and target groups; content selection; development. Subsequently, a quasi-experimental research (one-group post-test design) was conducted among 35 young field hockey players and seven coaches. Participants were asked to use the intervention for three weeks and the degrees of relevancy, suitability, satisfaction and usability of the intervention were assessed by means of a questionnaire and a group interview. Results: First, the needs assessment conducted among the main actors within recreational field hockey revealed that an injury prevention intervention was needed, ideally delivered through videos via an application for smartphone/tablet or website. Second, the objective and target groups of the intervention were defined, namely to prevent or reduce the occurrence of lower extremity injuries among both young and adult recreational field hockey players. Third, preventive measures and strategies (e.g. core stability, strength, coordination) were selected in order to accomplish a decrease in injury incidence. Last, the ‘Warming-Up Hockey’ intervention ‘was developed, consisting of a warm-up programme (16 minutes) delivered by coaches including more than 50 unique exercises. The relevancy, satisfaction and usability of ‘Warming-Up Hockey’ were positively evaluated. Group interviews revealed especially that the warm-up programme in its current form was not suitable as a pre-match warm-up. Conclusions: The feasibility of ‘Warming-Up Hockey’ was positively assessed by players and coaches. In accordance with the feasibility study, the duration of the intervention was reduced to 12 minutes, while a match-specific warm-up was developed. ‘Warming-Up Hockey’ was made available through an application for smartphone/tablet and a website. Prior to its nationwide implementation, the effectiveness of the intervention on injury reduction among field hockey players should be conducted.

  • Background: Osteoarthritis of the knee is the most common cause for disability and limited mobility in the elderly with considerable individual suffering and high direct and indirect disease related costs. Non-surgical interventions such as exercise, enhanced physical activity and self-management have shown beneficial effects in terms of pain reduction as well as improvement of physical function and quality of life, for many access to these treatments is limited due to lack of mobility or adequate health care facilities. Therefore home therapy is strongly recommended, however adherence to these programs is low. Patients report lack of motivation, feedback and personal interaction as the main barriers to home therapy adherence. To overcome these barriers, eHealth is seen as a promising opportunity. eHealth technology such as mobile apps or web-based programs offer tailored instructions, allow monitoring of progress and interaction with fellow patients, therapists and medical personnel. While beneficial effects have been shown in the literature for other chronic diseases such as chronic pain, cardiovascular disease and diabetes, a systematic literature review on the efficacy of eHealth interventions for patients with osteoarthritis of knee is missing so far. Objective: To compare the efficacy of eHealth interventions to no or other interventions regarding pain, physical function and health related quality of life (QoL) Methods: Medline, CENTRAL, CINAHL and PEDro were systematically searched using the keywords osteoarthritis knee, eHealth and exercise. An inverse variance random-effects meta-analysis was carried out pooling standardized mean differences of individual studies. The Cochrane tool was used to assess risk of bias in individual studies and the quality of evidence across studies was evaluated following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: The literature search yielded a total of 648 results. After screening of titles, abstracts and full-texts, seven RCTs were included. Pooling the data of individual studies demonstrated beneficial short-term (pain SMD -0.31, 95% CI -0.58 to -0.04, low quality; QoL SMD 0.24, 95% CI 0.05 to 0.43, moderate quality) and long-term effects (pain -0.30, 95% CI -0.07 to -0.53, moderate quality; physical function 0.41, 95% CI 0.17 to 0.64, high quality; QoL SMD 0.27, 95% CI 0.06 to 0.47, high quality). Conclusions: eHealth supported exercise interventions resulted in less pain, improved physical function and health-related quality of life compared to no or other interventions, however these improvements were small (SMD<0.5) and may not make a meaningful difference for individual patients. Low adherence is seen as one limiting factor of eHealth interventions. Future research should focus on participatory development of eHealth technology integrating evidence-based principles of exercise science and ways of increasing patient motivation and adherence. Clinical Trial: Review Registration: PROSPERO 2017 CRD42017072079

  • Background: Barriers to attending cardiac rehabilitation (CR), including cultural and linguistic differences, may be addressed by recent technological developments. However, the feasibility of using these approaches in diverse language patients is yet to be determined. Objective: This study aims, 1) To determine the comparative use of mobile technologies and features, as well as confidence in utilization across patients speaking different languages at home(English, Mandarin, and a language other than English and Mandarin [other]), who were eligible for CR; and 2) To examine the sociodemographic correlates of mobile technology/ feature use, including language spoken at home in these three groups. Methods: This is a Descriptive, case matched, comparative study. Age and gender-matched patients speaking English, Mandarin and other languages (n = 30/group) eligible for CR were surveyed for their mobile technology and mobile feature use. Results Results: Participants were 66.7± 13 (n=90, range 46-95) years old, 53.3% (n=48) male. The majority (n=82, 91.1%) used at least one technology device, with 74.4% (n=67) using Internet accessible devices, the most common being smartphones (n=57, 63.3%), computers/laptops (n=46, 51.1%) and tablets (n=28, 31.1%). More English-speaking participants used computer than Mandarin or “other” language speaking participants (P= 0.003 and 0.017), and were more confident in doing so compared to Mandarin-speaking participants (P=0.003). More Mandarin-speaking participants used smartphones compared with “other” language speaking participants (P=0.027). Most commonly used mobile features were voice calls (n=77, 93.9%), text message (n=54, 65.9%), Internet browsing (n=39, 47.6%), email (n=36, 43.9%), Skype / Facetime (Wechat / QQ) (n=35, 42.7%). Less Mandarin-speaking participants used email (P=0.001) and social media (P=0.007) than English-speaking participants. Speaking Mandarin was independently associated with using smartphone, computer and email (OR: 7.238 P=0.027, OR: 0.12 P=0.007, and OR: 0.089 P=0.006), and speaking “other” language was independently associated with computer use (OR: 0.223 P=0.046). Conclusions: Mobile technology is highly accepted by cardiac rehabilitation patients, including non-English speaking patients and may offer a potential solution for supporting patients from diverse language backgrounds.

  • Background: Traditional clinical surveillance relied on the results from clinical trials, and observational studies of administrative databases. However, these studies not only require a lot of valuable resources but also faced a very long time lag. Objective: To illustrate a practical application of the National Taiwan University Hospital Clinical Surveillance System (NCSS) in the identification of patients with an osteoporotic fracture, and provide a high reusability infrastructure for a computerized workflow that capture of relevant longitudinal clinical data and make those data repositories be reuse. Methods: The NCSS integrates electronic medical records in the National Taiwan University Hospital (NTUH) with a data warehouse, and is equipped with a user-friendly interface. The NCSS was developed using professional insight from multidisciplinary experts including clinical practitioners, epidemiologists, and biomedical engineers. The practical example identifying the unmet treatment needs for patients encountering major osteoporotic fractures described herein was mainly achieved by adopting the computerized workflow in the NCSS. Results: We developed the infrastructure of the NCSS, including an integrated data warehouse and an automatic surveillance workflow. By applying the NCSS, we efficiently identified 2,193 patients who newly diagnosed with a hip or vertebral fracture between 2010 and 2014 at NTUH. By adopting the filter function, we identified 1,808 (82.4%) patients who continued their follow-up at NTUH, and 464 (21.2%) patients who were prescribed anti-osteoporosis medications, within 3 and 12 months post index fracture, respectively. Conclusions: The NCSS systems can integrate the workflow of cohort identification to accelerate the survey process of clinically relevant problems and provide decision support in the daily practice of clinical physicians, thereby making the benefit of evidence-based medicine a reality.

  • Digital transformation of the health care sector: What kind of disruption is underway?

    Date Submitted: Nov 26, 2017
    Open Peer Review Period: Nov 27, 2017 - Jan 22, 2018

    Background: Digital innovation, introduced across many industries, is a strong force of transformation. Some industries have seen faster transformation, whereas the health care sector only recently came into focus. A context where “digital corporations” move into health care, payers strive to keep rising costs at bay and longer-living patients desire continuously improved quality of care, points to a digital and value based transformation with drastic implications for the health care sector. Objective: We tried to operationalize the discussion within the health care sector around digital and disruptive innovation to identify what type of technological enablers, business models as well as value networks seem to be emerging in different groups of innovators with respect to their digital transformational efforts. Methods: Through Forbes 2000- and the CBinsights data base we identified 100 leading technology, life science and start-up companies active in the health care sector. Further analysis identified projects from these companies within a digital context that were subsequently evaluated using the criteria: delivery of patient value, presence of a comprehensive and distinctive underlying business model, solutions provided and the customer needs addressed. Results: Our methodological approach recorded more than 400 projects and collaborations. We identified patterns that show, established corporations rely more on incremental innovation that supports their current business models, while start-ups engage their flexibility to explore new market segments with notable transformations of established business models. Thereby, start-ups offer higher promises of disruptive innovation. Additionally, start-ups offer more diversified value propositions addressing broader areas of the health care sector. Conclusions: Digital transformation is an opportunity to accelerate health care performance by lowering cost and improving quality of care. At an economic scale on the one hand existing business models can be strengthened as well as disruptive innovation models enabled. Corporations should look for collaborations with start-up companies to keep investment costs at bay and off the balance sheet. At the same time, the regulatory knowledge of established corporations might help start-ups to kick off digital disruption in the health care sector.

  • Designing a portal to patient-centered care? Let’s start with the patient. A cross-sectional survey.

    Date Submitted: Nov 26, 2017
    Open Peer Review Period: Nov 27, 2017 - Jan 22, 2018

    Background: In recent literature, Patient Portals are considered as important tools for the delivery of patient-centered care. Yet, it is not clear how patients would conceptualize a Patient Portal and which health information needs they have when doing so. Objective: 1) to investigate health information needs, expectations and attitudes towards a Patient Portal. 2) to assess if determinants such as patient characteristics, health literacy and empowerment status can predict two different variables, namely the importance people attribute to obtaining health information when using a Patient Portal and the expectations concerning personal healthcare when using a Patient Portal. Methods: A cross-sectional survey was performed in the Flemish population on what patients prefer to know about their digital health data and on their expectations and attitudes towards using a patient portal to access their Electronic Health Record. People were invited to participate in the survey through newsletters, social media and magazines. We used a validated questionnaire including demographics, health characteristics, health literacy, patient empowerment and patient portal characteristics. Results: We received 433 completed surveys. The health information needs included features such as being notified when one’s health changes (93.7%, 371/396), being notified when physical parameters rise to dangerous levels (93.7%, 370/395), to see connections between one’s symptoms/diseases/biological parameters (85.2%, 339/398), to view the evolution of one’s health in function of time (84.5%, 333/394) and to view information about the expected effect of treatment (88.4%, 349/395). Almost 90% (369/412) of respondents were interested in using a Patient Portal. Determinants of patients’ attachment to obtaining health information on a Patient Portal were 1) age between 45 and 54 years (P = .047); 2) neutral (P = .030) or interested attitude (P = .008) towards shared decision-making; 3) commitment to question the physicians’ decisions (P = .030). (R2 = .122) Determinants of patients’ expectations on improved healthcare by accessing a Patient Portal were 1) lower education level (P = .040); 2) neutral (P = .030) or interested attitude (P = .008) towards shared decision-making; 3) problems in understanding health information (P = .037). (R2 = .106) Conclusions: The interest in using a Patient Portal is considerable in Flanders. People report they would like to receive alerts or some form of communication from a Patient Portal in case they need to take action to manage their health. Determinants such as education, attached importance to shared decision-making, difficulties in finding relevant health information and the attached importance to questioning the decisions of physicians need to be taken into account in the design of a Patient Portal.

  • Background: Type 2 Diabetes Mellitus is one of the commonest long-term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. While the existing evidence suggested that uptake of self-management education was low, the development of internet-based technology might improve the situation. Objective: To establish the cost-effectiveness of a web-based self-management programme for people with type 2 Diabetes (HeLP-Diabetes) compared to usual care. Methods: An incremental cost-effectiveness analysis was conducted, from a National Health Service and personal and social services perspective, based on data collected from a multi-centre, two-arm individually randomised controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomised to either usual care plus HeLP-Diabetes, an interactive, theoretically-informed web-based self-management programme, or to usual care plus access to a comparator website containing basic information only. The participants’ intervention costs and wider health care resource use were collected as well as two health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to deal with the missing data. Results: In total, 374 participants were randomised, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios (ICERs) of £58 (-£268 to £742) per unit improvement on PAID scale and £5,550 (-£15,515 to £59,275) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and higher uncertainty with ICERs of £116 (95% CI -£1,299 to £1,690) per unit improvement on PAID scale and £18,500 (95%CI -£203,949 to £190,267) per QALY. The cost-effectiveness acceptability curve showed an 87% probability of cost-effectiveness at £20,000 per QALY willingness-to-pay threshold. The one-way sensitivity analyses estimated 363 users would be needed to use the intervention for it to become less costly than usual care. Conclusions: Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of £20,000 to £30,000 per QALY by National Institute of Health and Care Excellence. Clinical Trial: ISRCTN02123133

  • Affordances for Crush the Crave, a mobile app for quitting smoking among young adults.

    Date Submitted: Nov 23, 2017
    Open Peer Review Period: Nov 25, 2017 - Jan 20, 2018

    Background: Smartphone apps have emerged as a promising way to reach young adult smokers given their high smartphone ownership rates, and openness to receiving cessation support via digital technologies. While emerging evidence indicates that quit smoking apps are an effective way to reduce smoking among young adults, lacking is formative evaluative research that captures the perspectives of end-users. Objective: The objective of this study was to contribute insights toward understanding how young adults interact with the Crush the Crave (CTC app), and how this interaction shapes young adults’ smoking cessation experiences and practices, with consideration for the influence of gender. Methods: Semi-structured interviews were conducted with 31 young adult CTC users. Guided by sociomateriality theory and an affordances approach, data were inductively analyzed to derive thematic findings in relation to the impacts of CTC on quit efforts, and to expose the underlying affordances (mechanisms) that lend to these outcomes. Findings were grouped according to the 4 design components of CTC: credibility, social support, task support and dialogue support. Results: The credibility component of CTC played an important role in harnessing the trust of young adults because it afforded them promise in relation to its potential effectiveness in assisting them with quitting smoking. Affordances of the social support component lent to various user practices and experiences that rendered this aspect as the weakest component in supporting quit efforts. While most functions situated in the task and dialogue support components were found to be helpful, there were a few affordances in CTC that resulted in negative experiences, notably weaning from smoking. Gender-related influences were also evident. For example, young men preferred to control and self-manage their quitting and, therefore, did not engage with functions that afforded journaling or reminding to stay on track. Women, by contrast were more likely to benefit from these affordances. Conclusions: An affordances approach is productive for gaining an in-depth understanding of how mobile apps interact with users to lend to particular outcomes. The study findings have implications for developing and improving apps for helping young adults quit smoking, as well as apps that target other health behaviours. Productive affordances may also serve as a beginning framework for leveraging apps for smoking cessation.

  • The development of a smart screening device for primary health care

    Date Submitted: Nov 24, 2017
    Open Peer Review Period: Nov 24, 2017 - Jan 19, 2018

    Background: Adequate recognition of mental health problems is prerequisite for successful treatment. Though most people tend to consult their general practitioner first when they experience mental health problems, general practices are not very well equipped to screen for various forms of psychopathology and determining patients’ need for treatment. Objective: In this paper, the development and characteristics of a computerized adaptive test battery build to facilitate triage in primary care settings is described, and first results of implementation are reported. Methods: A bottom-up approach was implemented during development in which regular meetings were organized with general practitioners and mental health assistants. During implementation, users were requested to appraise clients’ ranking on the domains to be tested as well as the treatment level anticipated before test administration. Results: The result is CATja, an online computerized adaptive test battery that can be used by caregivers to screen their clients on several psychopathology domains and on two positive psychology domains. Agreements for clients’ domain scores were mostly between .40-.50, and for treatment level advised .65. Conclusions: By using CATja, caregivers can efficiently generate profiles of their clients’ strengths and weaknesses on which decisions about treatment type and care level may be based. Further validation research is needed.

  • Background: Radium-223 dichloride, under the brand name Xofigo was approved by Health Canada in December 2013 for the treatment of castration-resistant prostate cancer with symptomatic bone metastases and no visceral metastatic disease. The disease-specific Functional Assessment of Cancer-Therapy Prostate (FACT-P) questionnaire is a 27-item questionnaire that assess patients function over the past 7 days and was used in this study for the evaluation of the quality of life experienced over six treatments. Objective: The aim of this study was to assess the improvement of the FACT-P quality of life scores in CRPC patients over successive treatments using an electronic data collection tool while providing real-time analysis in a Canadian population. Methods: This study targeted patients (n=72) across two large teaching hospitals in one metropolitan area. Statistical analysis software (SPSS) was used to analyze the data. Results: A total of 72 patients completed the survey but 9 patients were excluded due to missing treatment details therefore, this left 63 patients with a total number of 6 treatments for analysis. The overall score changed from a total score 72.9 (Treatment 1) to 77.2 (Treatment 6) with the highest being 78.7 (Treatment 5) which was not Significant (p Value = 0.997). Physical well-being parameter, the patients were most affected by “I have nausea” and “I am bothered by side effects of the treatment”, which had an average score of 2.8 and 2.5, respectively (Somewhat). Social/family well-being, “emotional support, support from friends, family acceptance, family communication, close to partner and satisfied with sex life” all were given a high rating ranging from 3.9 to 4.4 (Quite a bit). However, “I feel close to my friends” was given the lowest rating of 1.8 (A little bit). Emotional well being, “losing hope” was given the highest rating of 3.8 (Quite a bit) and gradually increased over successive treatments and then plateaus in treatments 4, 5 and 6. In contrast, “I feel sad, satisfied with coping, I feel nervous, worry about dying and worry about getting worse” were all given a low rating of 1.8 (A little bit). Functional-well being, “I have accepted my illness, sleeping well and enjoy fun” were all given a high rating of ranging from 3.6 to 4.0 (Quite a bit). In contrast, “I am able to work, work fulfilling, enjoy life and qualify of life” were all given a lower rating ranging from 2.7 to 3.2 (Somewhat). Conclusions: Results of this study demonstrate that radium therapy is the most effective in the functional well-being portion of the FACT-P questionnaire, which increases over time with each treatment. Future directions include applying this questionnaire over a wider population across Canada and in other countries around the world. Clinical Trial: NA

  • Abstract: Identifying the key influence factors of mobile health care adoption is a key issue. We established an evaluation index system for consumer adoption and verified the effectiveness of our model by using a DDANPMV model. This model comprises three parts: (1) the decision making trial and evaluation laboratory (DEMATEL) technique, which is used to establish an influence network relationship map at both the “dimensions” and “criteria” levels; (2) a DEMATEL-based analytic network process (ANP; DANP), which determines the interrelationships and influential weights among the criteria; and (3) a modified VlseKriterijumska Optimizacija I Kompromisno Resenje (VIKOR) method, which applies the influence weights obtained through DANP to performance gaps regarding consumer perception. VIKOR thereby evaluates and improves performance gaps with the aims of satisfying consumer needs, achieving continuous improvement, and enabling sustainable product development. The main innovation of this method is the construction of the DDANPMV model, which integrates the DEMATEL, DANP, and modified VIKOR approaches to examine consumers’ adoption of mobile health care. This method was developed to not only help decision-makers evaluate alternative mobile health care and determine the best option but also use to identify and improve the performance gap of alternative products with the goal of satisfying the aspirations of consumers. Four types of mobile health care products were analyzed. The results indicate that social norms, product image, and consumer trust are three key factors in consumer adoption. This finding can guide product improvement strategies for decision-makers and illustrates the effectiveness of this modified VIKOR method.

  • Background: Given the widespread availability of screening and monitoring Apps for mental health problems, providing tailored feedback may encourage people at high risk to seek help to manage their symptoms. While Apps typically provide personal score feedback only, feedback types that are user-friendly and increase personal relevance may encourage further help-seeking. Objective: The aim of this study is to compare the immediate effects of normative and humour-driven feedback based on online mental health help-seeking and to explore predictors that encourage help-seeking. Methods: An online sample of 549 adults were recruited using social media advertisements. Participants downloaded a smartphone App which allowed them to screen their mental wellbeing through completing standardised measures on Symptoms (K6), Wellbeing (WHO Five Wellbeing Index), and Resilience (Brief Resilience Scale). Participants were randomised to receiving normative feedback that compared their scores to a reference group or humour-driven feedback that presented their scores in an engaging fashion. Those who scored in the moderate or poor ranges in any measure were encouraged to seek further help by clicking on a link to an external online resource. Results: There was no significant difference of feedback type on online help-seeking for all the measures. A larger proportion of participants from the Wellbeing measure (62%) clicked on the links than the Resilience (26%) or Symptoms (35%) measures. There were no significant demographic factors associated with help-seeking for the Resilience or Wellbeing measures. Participants with previous poor mental health were less likely than those without such history to click on the external help-seeking link in the Symptoms measure (p=.003, OR=0.83). Conclusions: Normative and humour-driven feedback were no different in encouraging immediate online help-seeking. Limitations included lack of personal score control group, limited measures of predictors and other forms of help-seeking. Further investigation into factors that affect help-seeking after personal feedback is needed. Clinical Trial: ACTRN12616000707460

  • User-experience of Patients with Telehealth: Complementing a Clinical Trial with Human-Computer Interaction

    Date Submitted: Nov 23, 2017
    Open Peer Review Period: Nov 23, 2017 - Jan 18, 2018

    Background: The use of telehealth to monitor patients from home is on the rise. A telehealth technology is evaluated in a clinical trial with measures of health outcomes and cost effectiveness. However, what happens between a technology and the patients are not investigated during a clinical trial −the telehealth technology remains as a “black box”. Meanwhile three decades of research in the discipline of Human-Computer Interaction (HCI) presents design, implementation and evaluation of technologies with a primary emphasis on users. HCI research exposed the importance of user-experience (UX) as an essential part of technology development and evaluation. Objective: This research investigates Type 2 Diabetes (T2D) patients’ experiences of a telehealth in-home monitoring technology through HCI approach. How HCI could complement future telehealth clinical trials for patient-centred design and evaluation is also explored. Methods: We adopted an ethnographic philosophy to conduct a contextual inquiry due to time-limitations and semi-structured interviews of nine T2D patients. We defined the method as Clinical User-experience Evaluation (CUE). The patients were enrolled in a telehealth clinical trial of T2D. However, this research is an independent HCI study, conducted by information technologists and health researchers for a patient-centred evaluation of telehealth. Results: Key analytical findings depicted that patients value the benefits of in-home monitoring but the current device did not possess all functionalities that patients want. Results contain patients’ experiences and emotions while using the device, patients’ perceived benefits of the device, and domestication of the device in their homes. Further analysis showed the influence of the device on patients’ awareness, family involvement, and design implications for telehealth T2D. Conclusions: CUE could complement the telehealth clinical trial and uncovered knowledges about T2D patients’ experiences, future design implications and importance of understanding patients in telehealth.

  • Background: The Internet offers major opportunities in supporting mental healthcare and a variety of online mental and behavioral health services have been developed. Yet despite growing evidence for the effectiveness of these services, its acceptance and use in clinical practice remains low. So far, the current literature still lacks a structured insight into the experienced drivers and barriers to the adoption of online treatment from the perspective of clinical psychologists. Objective: The aim of the current study was to gain an in-depth understanding of the drivers and barriers for psychologists in adopting online psychological treatment tools, and to arrive at a conceptual model that helps us understand how these drivers and barriers affect technology acceptance and use. Methods: The study adopted a qualitative descriptive approach consisting of in-depth semi-structured interviews with clinical psychologists working in the Netherlands (N = 12). Based on the findings, a model was constructed, which was then examined through a communicative validation. Methods: The study adopted a qualitative descriptive approach consisting of in-depth semi-structured interviews with clinical psychologists working in the Netherlands (N = 12). Based on the findings, a model was constructed, which was then examined through a communicative validation. Results: In general, a key driver for psychologists to adopt online counseling is the belief and experience that it can be beneficial to them or their clients. Perceived advantages that are novel to literature include the acceleration of the treatment process, increased intimacy of the therapeutic relationship, and new treatment possibilities due to online counseling. More importantly, a relation was found between the extent to which psychologists have adopted online counseling, and the particular drivers and barriers they experience. This differentiation is incorporated in the Levels of Adoption of Online Treatment (LAOT) model, which we developed to provide a structured representation of the factors that influence the adoption of online treatment. From the LAOT model it can be inferred that interventions to increase adoption should be tailored to the practitioners’ personal level of adoption of online treatment. Conclusions: The study finds that the nature and importance of the various drivers and barriers perceived by psychologists are dependent on the extent to which they have adopted online treatment. The LAOT model facilitates further research on the process of adopting online psychological treatment, which will subsequently enable targeted recommendations with respect to technology, training and clinical practice, in order to ensure that mental healthcare professionals as well as their clients will benefit optimally from the current (and future) range of available online treatment options in mental healthcare.

  • The Interactive Child Distress Screener: Development and Preliminary Feasibility Testing

    Date Submitted: Nov 21, 2017
    Open Peer Review Period: Nov 22, 2017 - Jan 17, 2018

    Background: Early identification of child emotional and behavioral concerns is essential for the prevention of mental health problems, however, few suitable child-report screening measures are available. Digital tools offer an exciting opportunity for obtaining clinical information from the child’s perspective. Objective: This paper describes the initial development and pilot testing of the Interactive Child Distress Screener (ICDS). The ICDS is a web-based screening instrument for the early identification of emotional and behavioral problems in children aged between 5 and 12 years. Methods: This paper utilized a mixed-methods approach to a) develop and refine item content using an expert review process (Study 1) and b) develop and refine prototype animations and app interface using co-design with child users (Study 2). Study 1 involved an iterative process comprised of four steps: 1) initial development of target constructs, 2) preliminary content validation (face validity, item importance and suitability for animation) from an expert panel of researchers and psychologists (N = 9), 3) item refinement, and 4) follow-up validation with the same expert panel. Study 2 also comprised four steps: 1) development of prototype animations, 2) development of the app interface and response format, 3) child interviews to determine feasibility and obtain feedback, and 4) refinement of animations and interface. Cognitive interviews were conducted with 18 children aged between 4 and 12 years who tested three prototype animated items. Children were asked to describe the target behavior, how well the animations captured the intended behavior, and provide suggestions for improvement. Their ability to understand the wording of instructions was also assessed, as well as the general acceptability of character and sound design. Results: In Study 1, a revised list of 15 constructs was generated from the first and second round of expert feedback. These were rated highly in terms of importance (M = 6.32/7, SD = 0.42) and perceived compatibility of items (M = 6.41/7, SD = 0.45). In Study 2, overall feedback regarding the character design and sounds was positive. Children’s ability to understand intended behaviors varied according to target items, and feedback highlighted key objectives for improvements, such as adding contextual cues or improving character detail. These design changes were incorporated through an iterative process, with examples presented. Conclusions: The ICDS has potential to obtain clinical information from the child’s perspective that may otherwise be overlooked. If effective, the ICDS will provide a quick, engaging and easy-to-use screener that can be utilized in routine care settings. This project highlights the importance of involving expert review and user co-design in the development of digital assessments for children. Clinical Trial: n/a

  • Telehealth Nursing Effectiveness in Stroke Patients

    Date Submitted: Nov 21, 2017
    Open Peer Review Period: Nov 21, 2017 - Jan 16, 2018

    Background: Stroke care requires immediate assessment and treatment, to reduce the risk of death and disability. Many patients do not receive timely interventions due to lack of immediate health care expertise and specialist services.Therefore better collaboration, communication and coperation between the health care providers and the stroke patients is needed. Telehealth enabling interventions with stroke patients and nurses are considered to improve medical outcomes. Objective: The primary objective of this review is to analyze the effectiveness of telestroke nursing interventions .A further focus is laid on the themes and findings extracted from these papers. This review was aimed to address the broad research question in mind, which is as follows: Does telehealth enabling interventions involving stroke patients and nurses improve medical outcomes? Methods: A systemic review design was conducted using the Preferred Reporting Items of Systemic Reviews Meta-Analyses (PRISMA) guidelines. A comprehensive and systemic search was undertaken using PubMed/ Medline as well as EMBASE electronic databases .The search strategy included the Medical Subject Headings (MeSH) terms; “telehealth” “telemedicine” “nursing” and “stroke”. Article selection was done through a process of removing duplicates, analyzing the title and abstract, and then reviewing the full text of the article. Results: The query results were evaluated and narrowed down to 37 articles. Studies suggest that telestroke along with the proper health care providers input and nursing support can help in providing enhanced stroke diagnosis, and improve long-term outcomes. . Four of the selected articles were pertaining to telehealth nursing management and education for stroke patients(10%, n=4), two articles were about the benefits of telestroke for speedy discharge and recovery(5.4%, n=2), seven were about telehealth nursing education and care for stroke patients as well as caregivers(18.92%, n=7), two covered the topic of a stroke-specific, care coordination home telehealth (CCHT) program (5.4%,n=2), two were related to acceptance of telestroke by caregivers in home setting(5.4%, n=2), five articles emphasized how telehealth and such techniques help in savings and decrease stroke patient cost( 13.5%,n=5), seven more papers discussed how telemedicine is considered along with other strategies to manage stroke(18.92%, n=7), six papers described the methods in which acute ischemic stroke is managed in emergency medicine with telehealth and related techniques(16.27%,n=6) and two articles covered how telehealth helps in diagnosis of stroke(5.4%, n=2). Conclusions: The review of the papers overall highlight a positive role of telehealth nursing towards stroke patient care. More data collection and statistical analysis is needed to validate and address the research question. Technological breakthroughs have contributed tremendously toward stroke care of patients, leading us to believe that telestroke along with the proper health care providers input and nursing support can help in providing enhanced stroke diagnosis, increased tissue plasminogen activator administration and improved long-term outcomes.

  • Privacy-Preserving Harmonization of Contextual Embeddings From Different Sources

    Date Submitted: Nov 20, 2017
    Open Peer Review Period: Nov 21, 2017 - Jan 16, 2018

    Background: Data sharing has been a big challenge in biomedical informatics due to privacy concerns. Contextual embedding models have demonstrated very strong representative capability to describe medical concepts (and their context), and they have shown promise as an alternative way to support deep learning applications without the need to disclose original data. However, contextual embedding models acquired from individual hospitals cannot be directly combined because their embedding spaces are different and naive pooling renders combined embeddings useless. Objective: We present a novel approach to address these issues to promote sharing representation without sharing data. We can build a global model from representations learned from local private data without sacrificing privacy and synchronize information from multiple sources. Methods: We propose a methodology that harmonizes different local contextual embeddings into a global model. We use Word2Vec to generate contextual embeddings from each source and Procrustes to fuse different vector models into one common space by using a list of corresponding pairs as anchor points. With harmonized embeddings, we performed prediction analysis. Results: We used sequential medical events extracted from the Medical Information Mart for Intensive Care III database to evaluate the proposed methodology in predicting the next likely diagnosis of a new patient using either structured data or unstructured data. Under different experimental scenarios, we confirmed that the global model built from harmonized local models achieves more accurate prediction than local models and global model built from naive pooling. Conclusions: Such aggregation of local models using our unique harmonization can serve as the proxy for a global model, combining information from a wide range of institutions and information sources. It allows information unique to a certain hospital to become available to other sites, increasing the fluidity of information flow in health care.

  • Applications of Space Technologies to Global Health: A Scoping Review

    Date Submitted: Nov 20, 2017
    Open Peer Review Period: Nov 21, 2017 - Jan 16, 2018

    Background: Space technology has an impact on many domains of activity on earth, including in the field of global health. With the recent adoption of the United Nations’ (UN) Sustainable Development Goals, which highlight the interdependence and possible synergies of different domains, it is useful to better characterize the relationship between space technology and global health. Objective: To identify the applications of space technologies to global health, the key stakeholders in the field as well as the gaps and challenges. Methods: We used a scoping review methodology, including a literature review and the involvement of stakeholders via self-administered questionnaires. A distinct search on several search engines was conducted for each of the four key technological domains that were previously identified by the UN Office for Outer Space Affair’s expert group on space and global health (domain A: remote sensing, B: global navigation satellite systems, C: satellite communication and D: human space flights). Themes in which space technologies are of benefit to global health were extracted. Key stakeholders as well as gaps, challenges and perspectives were identified. Results: 222 sources were included for domain A, 82 sources for domain B, 144 sources for domain C and 31 sources for domain D. 3 questionnaires out of 16 sent were answered. Global Navigation Satellite Systems (GNSS) and Global Information Systems were used for the study and forecasting of communicable and non-communicable diseases; Satellite communication and GNSS for disaster response; Satellite communication for telemedicine and tele-education; GNSS for autonomy improvement; access to healthcare, as well as for safe and efficient transportation. Various researches and technologies developed for inhabited space flights have been adapted for terrestrial use. Conclusions: Although numerous examples of space technology applications to global health exist, improved awareness, training and collaboration of the research community is needed.

  • Background: Parenting a child through cancer is a distressing experience and a subgroup of parents report negative long-term psychological consequences years after treatment completion. However, there is a lack of evidence-based psychological interventions for parents who experience distress in relation to a child’s cancer disease after end of treatment. Objective: To develop an internet-administered, guided, CBT based, psychological, self-help intervention (ENGAGE) for parents of children previously treated for cancer, and identify acceptable procedures for future feasibility and efficacy studies testing and evaluating the intervention. Methods: Participatory Action Research (PAR) methodology was used. The study included face-to-face workshops and related online exercises. Six parents (four mothers, two fathers) of children previously treated for cancer were involved as parent research partners (PRPs). Two clinical psychologists were involved as expert research partners (ERPs). Research partners and research group members worked collaboratively throughout the study. Data were analysed iteratively using written summaries of the workshops and online exercises parallel to data collection. Results: A 10-week, internet-administered, guided, CBT based, psychological, self-help intervention (ENGAGE) was developed in collaboration with PRPs and ERPs. The content of the intervention, mode and frequency of e-therapist support and individualised approach for feedback were modified based on research partner input. Shared solutions were reached regarding the type and timing of support from an e-therapist, duration and timing of intervention, and the removal of “unnecessary” support functions. Preferences for study procedures in future studies testing and evaluating the intervention were discussed, but consensus was not reached. Conclusions: The PAR process contributed to the further development of an internet-administered, guided, CBT based, psychological self-help intervention (ENGAGE) for parents of children previously treated for cancer and identified areas for further study regarding acceptable procedures for future studies testing and evaluating the intervention. To the best of our knowledge this study is the first use of a PAR approach to develop a psychological intervention for parents of children previously treated for cancer and to identify acceptable study procedures. Involvement of parents with lived experience was vital in the development of a potentially relevant and acceptable intervention for this population.

  • Background: Tobacco public education campaigns are focusing increasingly on hard-to-reach (HTR) populations at higher risk for smoking (eg, lesbian, gay, bisexual, and/or transgender [LGBT] young adults), prompting campaign content creators and evaluators to develop marketing and participant recruitment strategies to reach HTR populations in virtual and physical spaces where they frequently spend time. Objective: This study describes 2 novel recruitment strategies and compares characteristics of participants recruited via these strategies for FDA’s This Free Life campaign evaluation targeting LGBT young adults. Methods: We recruited LGBT adults aged 18–24 in 24 designated market areas in the United States via Facebook and Instagram ads (N= 1,709, mean age= 20.94, SD= 1.94) or intercept in LGBT social venues (N= 2,348, mean age= 21.98, SD= 1.69) for the baseline evaluation survey. Covariates related to recruitment strategy were age, race/ethnicity, LGBT identity, education, pride event attendance, and alcohol, cigarette, and social media use. Results: Lesbian/gay women (aOR= 1.88, P< .001), bisexual men and women (aOR= 1.46, P= .001), gender minorities (aOR= 1.68, P< .001), and other sexual minorities (aOR= 2.48, P< .001) were more likely than gay men to be recruited via social media (than intercept). Hispanic (aOR= 0.73, P= .001) and other/multiracial, non-Hispanic participants (aOR= .70, P= .006) were less likely than white, non-Hispanic participants to be recruited via social media. As age increased, odds of recruitment via social media decreased (aOR= .76, P< .001). Participants with some college (aOR= 1.27, P= .03) were more likely than those with a college degree to be recruited via social media. Participants reporting alcohol use in the past 30 days were less likely to be recruited via social media (aOR= 0.33, P< .001). Participants who reported past-year pride event attendance were more likely to be recruited via social media (aOR= 1.31, P= .02) as well as those who used Facebook at least once a day (aOR= 1.43, P= .002). Participants who reported using Instagram at least once a day were less likely to be recruited via social media (aOR= .73, P< .001). Social media recruitment was faster and more cost effective than intercept but had greater data quality issues—a larger percentage of social media respondents were lost due to duplicate and low quality responses (8.4%) compared to intercept respondents lost to interviewer misrepresentation (.3%) (P< .001). Conclusions: Social media provided access to important LGBT subpopulations (bisexual and gender and other sexual minority) and a more diverse LGBT sample when combined with intercept. Social media methods have more data quality issues but are faster and less expensive than intercept. Recruiting HTR populations via novel, audience-tailored strategies enabled recruitment of one of the largest known LGBT young adult samples, suggesting the promise of these methods for accessing HTR populations.

  • Background: Women with breast cancer undergoing chemotherapy have frequently reported unmet supportive care needs. Easily accessible and innovative support is lacking. Mobile applications (apps) provide a promising platform to provide supportive care where women with breast cancer can acquire knowledge and interact with peers or health care professionals when and where needed. Objective: The purpose of this trial was to determine the effectiveness of an app-based Breast Cancer e-Support (BCS) program to address women’s self-efficacy, social support, symptom distress, quality of life, and anxiety and depression. Secondary objectives included exploring the association between women’s health outcomes and the BCS usage data. Methods: A multi-center, single-blinded, randomized controlled trial was used. One hundred and fourteen women with breast cancer, who were commencing chemotherapy and were able to use mobile phone to access internet, were recruited in the clinics from two university affiliated hospitals in China. Women were randomized into either intervention group (n=57) receiving BCS plus care as usual (CAU) or control group (n=57) receiving CAU alone. The health care team and RA collecting data were blinded to the women’s group allocation. Bandura’s self-efficacy theory and the social exchange theory guided the development of the BCS program, which has four components: 1) a Learning forum; 2) a Discussion forum; 3) an Ask-the-Expert forum; and 4) a Personal Stories forum. Moderated by an experienced health care professional, the BCS program supported women for 12 weeks covering 4 cycles of chemotherapy. Health outcomes were self-assessed through paper questionnaires in clinics at baseline before randomization (T0), after 3 (T1) and 6 months (T2) of follow-ups. Results: Fifty-five participants in the intervention group and 49 in the control group completed the follow-up assessments (response rate: 91.2%). During the 12-week intervention, the login frequency ranged from 0 to 774 times (medium: 11; interquartile range: 5~27), and the total usage duration ranged from 0 to 9371 minutes (medium: 100; interquartile range: 27~279). Repeated measures MANCOVA (Intention-to-treat) found that BCS+CAU participants had significant improvement at 3 month regarding self-efficacy (21.05; 95% Cl: 1.87 to 40.22; P=0.03; d=0.53), symptom interference (-0.73; 95% Cl: -1.35 to -0.11; P=0.02; d=-0.51), and QoL (6.64; 95% Cl: 0.77 to 12.50; P=0.027, d=0.46), but not regarding social support, symptom severity, anxiety and depression compared to CAU participants. These beneficial effects were not sustained at 6 months. Spearman's rank-order correlation showed that the BCS usage duration was positively correlated with self-efficacy (r=.290, P=.032), social support (r=.320, P=.017), and QoL (r=.273, P=.044) at 3 months. Conclusions: The BCS program demonstrated its potential as an effective and easily accessible intervention to promote women’s self-efficacy, symptom interference, and QoL during chemotherapy. Clinical Trial: ACTRN: ACTRN12616000639426, Registered 17 May, 2016. http://www.ANZCTR.org.au/ACTRN12616000639426.aspx. Archived at: http://www.webcitation.org/6v1n9hGZq

  • Women’s Perceptions on a Mobile Application of Breast Cancer e-Support Program: The process evaluation

    Date Submitted: Nov 19, 2017
    Open Peer Review Period: Nov 20, 2017 - Jan 15, 2018

    Background: Women with breast cancer undergoing chemotherapy experience difficulty in accessing to adequate cancer care in China. Mobile applications (apps) have the potential to provide easily accessible support for these women. However, there remains a paucity of Randomized Controlled Trials (RCTs) to evaluate the effectiveness of the app-based program targeting specifically at women with breast cancer undergoing chemotherapy. Moreover, women’s perceptions and experiences related to using and interacting within the app-based program have rarely been reported. Therefore, an app-based Breast Cancer e-Support (BCS) program was developed and evaluated using a randomized controlled trial (RCT). The BCS program was based on the incorporation of Bandura’s self-efficacy and social exchange theory. The BCS program lasted for 12 weeks covering four cycles of chemotherapy and had four components: 1) a Learning forum; 2) a Discussion forum; 3) an Ask-the-Expert forum; and 4) a Personal Stories forum. Objective: As a part of the RCT, this study aimed to explore the participants’ perception of BCS program, the strengths and weaknesses of the BCS program, as well as their suggestions on improvement of the intervention. Methods: A descriptive qualitative study was employed. Thirteen women with breast cancer from two university affiliated hospitals in P. R. China, who were randomly allocated to the BCS program in the RCT, were interviewed from November 2016 to February 2017. Purposive sampling were used on the basis of women’s scores of self-efficacy after the completion of the intervention. Inductive content analysis was used to analyze the transcript, allowing the categories and themes to flow from the data. Results: The qualitative interviews revealed that the participants perceived the BCS program to be helpful in enhancing knowledge, improving confidence level, and promoting emotional well-being. Women also identified access to tailored advice from experts and convenience as the benefits of the BCS program. Physical/psychological health status, stigma related with breast cancer, and app instability were mentioned as the challenges to BCS engagement. Suggestions for BCS improvement included adding message reminders to prompt instant communication and search engine to locate information quickly, supplementing more interesting and practical knowledge, updating the information more often, and quickening the responses to women’s questions. The participants recommended the BCS program to be incorporated as routine care to support women during chemotherapy. Conclusions: This study demonstrates the potential of the BCS program to support women during chemotherapy. Future app-based interventions should apply family-centred approach and provide more support on stigma associated with the disease to encourage the app engagement. Suggestions of improvement regarding the design, content, and operation of the app-based intervention should be addressed in future studies. It is promising to incorporate the BCS program into routine care to generalize the benefits. Clinical Trial: ACTRN: ACTRN12616000639426, Registered 17 May, 2016. http://www.ANZCTR.org.au/ACTRN12616000639426.aspx. Archived at: http://www.webcitation.org/6v1n9hGZq

  • Support or subversion? – The reasons that medical students use online discussion forums.

    Date Submitted: Nov 19, 2017
    Open Peer Review Period: Nov 19, 2017 - Jan 14, 2018

    Background: Internet use has increased enormously over the last several decades. One popular use of the Internet is to engage with online discussion forums to discuss and seek advice from others. These forums form a safe and often anonymous place to carry out various discussions and are understandably popular amongst young adults who typically have concerns and questions they feel unable to discuss openly. Such forums are therefore commonly used amongst medical students in the UK, as they provide a safe, non-judgemental environment. Medical students are usually self- directed and eager to learn as they generally seek groups of colleagues to study together with and contact tutors to improve their learning. Online forums provide another method for peer learning which is not constrained by the availability of others and may allow less confident learners to engage. Research also shows that students who do not participate as much in class due to being more introverted or lacking confidence or prior knowledge tend to contribute more actively on online forums. Objective: This study was conducted to explore the types of engagement medical students in the UK have with such forums. This will help identify areas of education, advice and support that may be required by medical students. Methods: ‘Thestudentroom’ online forum was found to be the most popularly used by medical students in the UK. Data and associated responses were extracted from its sub-forum ‘Current Medical Students and Doctors.’ Each month had on average, approximately 20 to 30 posts. Due to the high number of posts, the first 6 posts per month, from 2015 were extracted and analysed in this project. Posts were coded thematically in textual form by the student author. The idea of this thematic coding was to identify the best fit coding categories under which any discussion post can suitably fit. A second researcher then validated a proportion of the data coding. Results: In total 72 threads with 420 lines of individual text response were extracted for analysis. Codes were grouped into relevant broad categories and four themes emerged: study advice, career advice, health issues and personal & professional support. Validation of feelings and emotional support were additional over-arching factors that emerged throughout. Conclusions: This study identified four main areas of discussion and suggests where additional advice from medical schools may be needed. It also highlighted important roles anonymous forums play, in allowing students to seek opinion, personal and study support in the competitive environment of a medical school and obtain validation and reassurance about decisions. Forums appear to have benefitted students hence, medical schools should encourage their students to engage in such forums in a professional manner.

  • Background: Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and to facilitate adherence to chronic disease management. However, there is also lack of studies on differences in preference for using information exchange technologies between chronic and non-chronic disease patients and factors affecting these differences. Objective: The purpose of this paper is to understand preferences and interests in use of technology for information exchange among a nationally representative sample of adults with and without chronic disease conditions and to assess whether these preferences differ according to varying demographic variables. Methods: We utilized data from the 2021 and 2014 iteration of the Health Information National Trends Study (HINTS, N=7307). We modeled negative responses using multiple logistic regressions adjusting for relevant covariates to identify independent factors associated with lowers odds of using health information technology and therefore identify targets for awareness. Analyses were weighted for the US population and adjusted for the sociodemographic variables of age, gender, race and US census region. Results: Analysis included 7,307 participants (weighted population 230,993,888) and 3,529 participants of this sample (weighted population of 90,748,995) reported CVD, diabetes, or hypertension. In the unadjusted models, individuals with Diabetes/CVD/Hypertension were more likely to report using email to exchange medical information with their provider (Odds Ratio [OR] 1.431; 95% Confidence Interval [95% CI] 1.113, 1.838) and less likely to not use any of the technology in health information exchange (OR 0.778; 95% CI 0.618, 0.979). In unadjusted model, additional significant odds ratio values are observed. However, after adjustment, all relationships regarding use and interest in exchanging information with the provider were no longer significant. As a next step, we looked at adjusted odds ratios for demographic variables. Individuals above 65 years old (OR 2.32; 95% CI 1.55, 3.49) and Hispanics (OR 1.95; 95% CI 1.26, 3.01) were less likely to report using email to exchange medical information with their provider. Minorities were less likely to indicate they had no interest in exchanging general health tips with a provider electronically ((Hispanics OR 0.55; 95% CI 0.34, 0.88), (Non-Hispanic Blacks OR 0.36; 95% CI 0.23, 0.56), (Asians OR 0.33; 95% CI 0.16-0.70)). Conclusions: Health information technology related interventions; particularly design of m-health technologies should focus more on demographic factors including race, age and region than chronic disease status to increase likelihood of use. Future research is needed to understand and explore more patient friendly use and design of m-health applications which can be utilized by variety of age, race or education/ health literacy groups efficiently to further bridge the gap in communication between patients and their provider.

  • Background: Poor bone health in adolescent and young females is a growing concern. Given the widespread use of smartphones in this population, mobile health (mHealth) interventions may help improve lifestyle behaviours related to bone health in young women. Objective: To determine the effectiveness and feasibility of a mHealth intervention called “Tap4Bone” in improving lifestyle behaviours associated with the risk of osteoporosis in young women. Methods: The mHealth intervention comprised the use of mobile phone apps, short messaging service (SMS) and web emails to encourage lifestyle behaviour changes. The education group received osteoporosis prevention education leaflets. Changes in bone-health-related lifestyle behaviours namely, exercise, smoking and calcium intake were assessed. Users’ experiences and acceptance of the app were collected through focus group interviews. Results: A total of 35 were randomised to either the smartphone (intervention n =18) or education (control n = 17) group. All participants from the mHealth intervention group started taking calcium supplements after commencing the study, compared to fewer in the education control group (100.0% vs 44.4%, P < .001). Though there were trends towards improvement in sports activity and smoking behaviours in the mHealth intervention group, compared to the education group, these were not statistically significant. Approximately 70% of the sample said they would use a mobile phone app in future to improve their bone health. Conclusions: The Tap4Bone mHealth intervention was widely accepted by users and more effective than traditional education at encouraging calcium supplement intake to support bone health in young women.

  • How might digital technology augment chronic illness management among Black men? A commentary.

    Date Submitted: Nov 16, 2017
    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Health disparities associated with chronic illness experiences of Black men demonstrate widespread systematic failures to meet an urgent need. Well-established social and behavioral determinants that have led to health disparities among Black men, include racism, discrimination, and stress. While advocacy work that includes community-engagement and tailoring health promotion strategies have shown local impact, evidence shows the gaps are increasing. We suspect that failure to reduce current disparities may be due to conventional public health interventions and programs; therefore, we submit that innovative interventions, ones that embrace digital technologies and their ability to harness naturally occurring social networks within groups, like Black men, have particular importance and deserve attention. This commentary characterizes the current literature on chronic illness among Black men as well as health interventions that use digital technology, to build a case for expanding research in this area to reduce the overwhelming burden of chronic illness among Black men.

  • Background: In type 1 diabetes, qualitative studies indicate that visibility of diabetes supplies, self-care, and hypoglycaemia symptoms are associated with stigma and suboptimal management. This may be particularly salient in youth who face concurrent challenges such as establishing autonomy and vocational choices. Objective: To estimate stigma prevalence in youth (14-24 years) with type 1 diabetes and associations with glycemic control. Methods: Participants, recruited largely through social media, were asked to complete an online survey and mail in capillary blood samples for A1C measurement. The primary definition of stigma required endorsement of one or more of three stigma-specific items of the Barriers to Diabetes Adherence questionnaire. These addressed avoidance of diabetes management with friends present, difficulty telling others about diabetes diagnosis, and embarrassment in performing diabetes care with others present. Poor glycemic control was defined as A1C >9% (i.e., >75 mmol/mol; measured value when available, else self-report) and/or ≥1 severe hypoglycemic episode in the previous year (reported requiring assistance from someone else during the episode). Stigma prevalence was computed (95% confidence intervals, CI) and associations with glycemic control evaluated (multivariate logistic regression models). Results: Among the 380 respondents, stigma prevalence was 65.5% (95% CI 60.7-70.3). Stigma was associated with a two-fold higher odds of poor glycemic control overall (OR 2.25, 95% CI 1.33-3.80; adjusted for age, sex, type of treatment). There were specific associations with both A1C >9% (75 mmol/mol; OR 3.05, 95% CI 1.36-6.86) and severe hypoglycemia in the previous year (OR 1.86, 95% CI 1.05-3.31). Conclusions: There is a high prevalence of stigma in youth with type 1 diabetes that is associated with both high A1C and severe hypoglycemia. Targeted strategies to address stigma are needed. Clinical Trial: linicalTrials.gov NCT02796248

  • Use of a smartphone for the early detection of melanoma: A systematic review.

    Date Submitted: Nov 15, 2017
    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Background: The early diagnosis of melanoma is associated with a decreased mortality. The smartphone, with its applications and the possibility of sending photographs to a dermatologist, could improve melanoma screening. Objective: The aim of our review was to report evidence on 1) the diagnostic performance of smartphone applications and store-and-forward teledermatology via a smartphone in the early detection of melanoma; 2) the impact on the patient’s medical care course; and 3) the feasibility criteria (focusing on the modalities of picture taking, transfer of data, and time to get a reply). Methods: We conducted a systematic search of PubMed for the period from January 1, 2007, (launch of the first smartphone) to November 1, 2017, according to the PRISMA guidelines. Results: Of the thirty-one articles included, fourteen concentrated on store-and-forward teledermatology, and thirteen studied the diagnostic performance of applications. Store-and-forward teledermatology opens several new perspectives: it accelerates the care course (less than 10 days vs 80 days), and its sensitivity is higher than that of application algorithms. However, the concordance between the conclusion of a teledermatologist and the conclusion of a dermatologist who conducts a face-to-face examination depended on the study (k=0.2 to 0.84; median k=0.6). The use of a dermoscope may improve the concordance (k=0.29 to 0.87; median k=0.74). Regarding smartphone applications, the major concerns are their low sensitivity, which ranges from 7% to 90% (median 64%), the lack of assessment in clinical practice conditions, and the lack of assessment in primary care populations. In this literature review, up to 20% of the photographs transmitted were of insufficient quality. The modalities of picture taking and encryption of the data were only partially reported. Conclusions: The use of teledermatology could improve access to a dermatology consultation by optimizing the care course. Our review confirmed the absence of evidence of the safety and efficacy of smartphone medical apps. Further research is required to determine quality criteria, as there was major variability among the studies.

  • Measuring engagement in e- & mHealth behaviour change interventions: a methodological overview

    Date Submitted: Nov 15, 2017
    Open Peer Review Period: Nov 15, 2017 - Jan 10, 2018

    Background: Effective engagement in e -& mHealth behaviour change interventions is important for intervention effectiveness and efficacy. Detailed definitions and conceptual models of engagement help to improve our understanding of engagement. However, to test the hypotheses generated by these models we first need to know how to measure engagement in a valid and reliable way. Objective: This paper provides a comprehensive overview of engagement measurement options that can be employed in e- & mHealth behaviour change interventions. Methods: Measures (n = 120) identified in systematic reviews of engagement research, as well as those utilised in studies known to the authors were extracted and critically reviewed. Results: A wide range of methods to measure engagement were identified, including qualitative measures, self-report questionnaires, ecological momentary assessments, system usage data, sensor data, social media data and psychophysiological measures. Each measurement method is reviewed, and examples are provided to illustrate possible use in e-&mHealth behaviour change research. Recommendations for future research are provided, based on the limitations of current methods and the heavy reliance on system usage data as the sole assessment of engagement in research thus far. The use of mixed methods to assess engagement components related to interest, attention and affect, aThis paper provides a comprehensive overview of measurement methods for user engagement in e- & mHealth behaviour change interviews. We anticipate that the results from our study will help to advance the field of e- & mHealth and behaviour change by facilitating the use of a wider range of engagement measurements and their thoughtful application to the study of engagement and its antecedents. s well as the behaviour change process are encouraged. Conclusions: This paper provides a comprehensive overview of measurement methods for user engagement in e- & mHealth behaviour change interviews. We anticipate that the results from our study will help to advance the field of e- & mHealth and behaviour change by facilitating the use of a wider range of engagement measurements and their thoughtful application to the study of engagement and its antecedents.

  • Patient developed NPPE in recovery room

    Date Submitted: Nov 15, 2017
    Open Peer Review Period: Nov 15, 2017 - Jan 10, 2018

    Postoperative pulmonary edema is a rare life threatening complication associated with general anesthesia. Laryngospasm leads to forced inspiration generating large amount of negative intrathoracic pressure leading to negative pressure pulmonary edema. It usually develops immediately after extubation . This is a rare case report where patient developed NPPE in recovery room. In this paper we report a young fit adult who developed NPPE after an uneventful appendectomy in the post-operative period. The aim of this paper is to highlight the dramatic presentation of this rare condition in post-operative period and to remind that it can be lethal if immediate remedial steps are not taken. The anesthetist and paramedical staff in recovery room should be well aware of this condition.

  • Background: mHealth (mobile health) applications can offer a number of benefits for users, representing a feasible and acceptable means of administering health interventions, such as Cognitive Behavioural Therapy (CBT). CBT is commonly used in the treatment of mental health conditions, where it has a strong evidence base, suggesting that it represents an effective method to elicit health behaviour change. Importantly, CBT has shown to be effective in smoking cessation, whereby smoking-related costs to the NHS were estimated to be £2.6bn in 2015. Whilst the evidence base for computerised CBT in mental health is strong, there is limited literature on its use in smoking cessation. This, combined with the cost-effectiveness of mHealth interventions, advocates a need for research into the effectiveness of CBT-based smoking cessation applications. Objective: The objective of this study is to investigate the impact of two mHealth applications, one CBT-based application, Quit Genius (QG), and one non-CBT-based application, NHS SmokeFree (SF), in promoting positive behaviour change with respect to smoking cessation. Methods: A qualitative short-term longitudinal study was conducted, using a sample of 29 smokers allocated to one of the two applications, QG or SF. Each user underwent two one-to-one semi-structured interviews, one week apart. From the primary data collected, thematic analysis was carried out and themes were identified. Results: Results indicated that QG generally led to a perceptional change in participants’ smoking behaviour and increased confidence in their ability to quit, thus eliciting greater effects than SF on their positive behaviour change, after one week of use. A greater proportion of participants using QG compared to SF reported smoking fewer cigarettes per day (QG 53% vs SF 14%, p<.05). QG participants were similarly more likely to recommend the application compared to SF (73% vs 36%, p<.05) and participants stated a higher likelihood to continue using QG compared to SF (67% vs 36%, p <.05). Conclusions: The findings support the use of CBT in the context of mHealth applications as an effective smoking cessation tool. mHealth applications must be well-developed, preferably with an underlying behavioural change mechanism, to promote positive health behaviour change. Digital CBT thus has the potential to become a powerful tool in overcoming current healthcare challenges. Future research is required to focus on the effect of greater personalisation on measures of behavioural change, and on understanding the psychological barriers to the adoption of new mHealth solutions.

  • Public Perception Analysis of Tweets during the 2015 Measles Outbreak Using a Neural Network Model

    Date Submitted: Nov 14, 2017
    Open Peer Review Period: Nov 14, 2017 - Jan 9, 2018

    Background: Timely understanding of public perceptions allows public health agencies to provide up-to-date responses to health crises such as infectious diseases outbreaks. Social media such as Twitter provides an unprecedented way for the prompt assessment of the large-scale public response. Objective: This study has two aims: 1) to develop a scheme for a comprehensive public perception analysis of a measles outbreak from Twitter data; 2) to demonstrate the superiority of the neural network-based approach (compared with conventional machine-learning methods) on measles outbreak-related tweets classification tasks with a relatively small and highly unbalanced gold standard training set. Methods: We first designed a comprehensive scheme for the analysis of public perception of measles based on tweets, including three dimensions: Discussion themes, Emotions expressed, and Attitude toward vaccination. All 1,154,156 tweets containing the word “measles” posted between December 1st, 2014 and April 30th, 2015 were purchased and downloaded from DiscoverText.com. Two expert annotators curated a gold standard of 1,151 (approximately 1% of all the tweets) tweets based on the three-dimensional scheme. Next, a tweet classification system based convolutional neural network (CNN) was developed. We compared the performance of the CNN model to that of four conventional machine-learning models. We also compared the performances of two word embeddings: (1) Stanford GloVe embedding trained on billions of tweets in general domain and (2) measles-specific embedding trained on our 1 million measles related tweets. Results: Cohen’s Kappa inter-coder reliability values for the annotation were: 0.781, 0.723, and 0.796 on three dimensions. Class distributions in the gold standard were highly unbalanced for all dimensions. The CNN model with measles-specific embedding and Stanford GloVe embedding performed significantly better on all classification tasks than K-nearest Neighbors, Naïve Bayes, Support Vector Machines, or Random Forest. Detailed comparison between Support Vector Machines and CNN model with two tweet embeddings showed that the major contributor to the overall superiority of the CNN models is the significant improvement on recall, especially for those classes with low occurrence. The CNN model with Stanford GloVe embedding achieved the best performance overall, while the CNN model with measles-specific tweet embedding achieved better performance for some classes with lower abundance. Conclusions: Compared to conventional machine-learning methods, our CNN models showed superiority on measles related tweet classification tasks with a relatively small and highly unbalanced gold standard. Our proposed scheme and neural network based tweets classification system could be used for the analysis of tweets about other infectious diseases such as influenza and Ebola.

  • Background: Women significantly decrease their activity levels in the transition to motherhood. Digital health technologies are low cost, scalable, and can provide an effective delivery mechanism for behavior change. This is the first study that examines the use of videoconferencing and mobile apps to create exercise groups for mothers. Objective: We tested the feasibility, acceptability, and effectiveness of an individually adaptive and socially supportive physical activity intervention incorporating videoconferencing and mobile apps in mothers. Methods: The Moms Online Video Exercise (MOVE) Study was an 8-week, two-armed, web-based randomized trial comparing the effectiveness of a group exercise intervention to a waitlist control. Healthy mothers with at least one child under age 12 were recruited online, through Facebook and email listservs. Intervention participants joined exercise groups using videoconferencing (Google Hangouts) every weekday morning and exercised together in real time guided by exercise mobile apps (e.g. Nike+, Sworkit, etc.) of their choosing. Waitlist control participants had access to the list of recommended mobile apps and an invitation to join an exercise group after an 8-week period. The main outcomes assessed were self-reported moderate, vigorous, and moderate-to-vigorous physical activity (MVPA) minutes per week in aggregate and stratified by whether women met Centers for Disease Control and Prevention (CDC) guidelines for sufficient aerobic activity at baseline. Outcomes were measured through self-assessed online questionnaires at baseline and 8 weeks. Results: The intervention was effective at increasing exercise for inactive women, and proved to be feasible and acceptable to all participants. 64 women were randomized, 30 to intervention and 34 to control. Women attended 2.8 sessions per week. There was a strong, but not statistically significant, trend toward increasing moderate and vigorous minutes of physical activity for all women. As hypothesized, women in the pre-specified strata who were inactive at baseline (n=51) significantly increased their activity by an average of 56 MVPA minutes per week more in the intervention group (95% CI: 10.8, 100.7, P=.02). A corresponding statistically significant net increase of 21 (95% CI: 5.2, 36.8, P=.01) minutes of vigorous activity drove the difference in increased MVPA minutes for this stratum of inactive women. Inactive women in the intervention group reported promising reductions in depression, a statistically significant net decrease in their depression score, -4.1 (95% CI: -7.3, -0.8, P=.02).  Conclusions: We found that a group exercise intervention using videoconferencing and mobile apps was a feasible and acceptable way to deliver a physical activity intervention to mothers with young children. The intervention significantly increased physical activity in inactive mothers. Further studies are needed to better establish how long these changes in physical activity can be maintained and whether these findings can be reproduced in a more diverse population. Clinical Trial: ClinicalTrials.gov NCT02805140

  • Remote patient monitoring and telemedicine in neonatal and pediatric settings: A scoping literature review

    Date Submitted: Nov 13, 2017
    Open Peer Review Period: Nov 13, 2017 - Jan 8, 2018

    Background: Telemedicine and telehealth solutions are emerging rapidly in healthcare, and have the potential to decrease costs for insurers, providers and patients in various settings. Pediatric populations that require specialty care, are disadvantaged socially or economically, or have chronic health conditions will greatly benefit from results of studies utilizing telemedicine technologies. This paper examines the emerging trends within pediatric populations as part of a systematic literature review and provides a scoping review of the type, extent, and quantity of research available. Objective: This paper aims to examine the role of remote patient monitoring and telemedicine in neonatal and pediatric settings. Findings can be used to identify strengths, weaknesses, and gaps in the field. The identification of gaps will allow for interventions or research to improve healthcare quality and costs. Methods: A systematic literature review is being conducted in order to gather an adequate amount of relevant research for telehealth in pediatric populations. The fields of remote patient monitoring and telemedicine are not yet very well established by the healthcare services sector and definitions vary across healthcare systems, and thus the terms are not always defined similarly throughout the literature. Three databases were scoped for information for this specific review, and 56 articles are included so far Results: Three major telemedicine trends emerged from the review of 45 relevant papers: remote patient monitoring, teleconsultation, and monitoring patients within the hospital, but without contact, thus decreasing likelihood of infection or other adverse health effects. Conclusions: While the current telemedicine approaches show promise, limited conditions studied and small sample sizes affect generalizability, therefore warranting further research. The information presented can inform healthcare providers of the most widely implemented, studied, and effective forms of telemedicine for patients and their families, and the telemedicine initiatives that are most cost efficient for health systems. While the focus of this review is to summarize some telehealth applications in pediatrics, there are also research studies presented which can inform providers of the importance of data sharing of remote monitoring data between hospitals. Further reports will be developed to inform health systems as the systematic literature review continues.

  • Background: Targeting sedentary time post-exacerbation may be more relevant than targeting structured exercise for individuals with COPD. Focussing interventions on sitting less and moving more after an exacerbation may act as a stepping stone to increase uptake to pulmonary rehabilitation. Objective: To conduct a randomised trial examining trial feasibility and the acceptability of an education and self-monitoring intervention using wearable technology to reduce sedentary behaviour for individuals with COPD admitted to hospital for an acute exacerbation. Methods: Participants were recruited and randomised in-hospital into three groups with the intervention lasting two weeks post-discharge. The Education group received verbal and written information about reducing their time spent sitting face-to-face with a study researcher. The Education+Feedback group received the same education component along with real-time feedback on their sitting time, stand-ups and steps at home through a waist-worn inclinometer linked to a smart device application. Patients were shown how to use the technology by the same study researcher. The inclinometer also provided vibration prompts to encourage movement at patient defined intervals of time. Patients and healthcare professionals involved in COPD exacerbation care were interviewed to investigate trial feasibility and acceptability of trial design and methods. Main quantitative outcomes of trial feasibility were eligibility, uptake and retention, and for acceptability, were behavioural responses to the vibration prompts. Results: 111 patients were approached with 33 patients recruited (11 Control, 10 Education and 12 Education+Feedback). Retention at two-week follow-up was 51.5% (6 Control, 3 Education and 8 Education+Feedback). No study-related adverse events occurred. Collectively, patients responded to 106 out of 325 vibration prompts from the waist-worn inclinometer (33%). 41% of responses occurred within 5 minutes of the prompt with patients standing for 1.4±0.8 minutes and walking for 0.4±0.3 minutes (21±11 steps). Interviews indicated that being unwell and overwhelmed after an exacerbation was the main reason for not engaging with the intervention. Healthcare staff considered reducing sedentary behaviour potentially attractive for patients but suggested starting the intervention as an inpatient. Conclusions: Whilst the data support that it was feasible to conduct the trial, modifications are needed to improve participant retention. The intervention was acceptable to most patients and healthcare professionals. Clinical Trial: ISRCTN 13790881. Registration date: 30-Oct-2015. Enrolment of first participant date: 05-Feb-2016.

  • Background: Although internet-based mobile-supported stress management interventions (iSMIs) may be a promising strategy to reach employees suffering from high chronic stress, it remains unknown whether participants with high symptom severity of depression or anxiety also profit, or should be excluded from iSMIs. Objective: The study aimed to evaluate the efficacy of iSMIs in subgroups with high symptom severity. Methods: Data from three randomized controlled trials (RCTs; N=791) were pooled to identify effect modifiers, and to evaluate efficacy in subgroups with different levels of initial symptom severity. The outcomes perceived stress (PSS), depressive (CES-D) and anxiety (HADS) symptom severity were assessed at baseline, 7-week post-treatment, and 6-month follow-up. In multiple moderation analyses (MMAs) potential moderators were tested in predicting differences in change of outcome. Through simple slope analyses efficacy of the iSMI was compared in subgroups with low, moderate and severe initial symptomology based on means and standard deviations of the study population. Results: Individuals with high stress (PSS≥30), depression (CES-D≥33), anxiety (HADS≥15) and emotional exhaustion (MBI≥5.6) profited significantly from the intervention with great reductions of stress (dpost=[0.86-1.16], dFU=[0.93-1.35]), depression (dpost=[0.69-1.08], dFU=[0.91-1.19]), and anxiety (dpost=[0.79-1.19], dFU=[1.06-1.21]), and effects were sustained at 6-month follow-up. Symptom severity moderated treatment outcomes, as individuals with higher symptom severity at baseline profited significantly more from the intervention than individuals with lower symptom severity. Conclusions: Highly burdened individuals benefit greatly from iSMIs and should, therefore, not be excluded from participation. Clinical Trial: German clinical trial registry DRKS00005112, DRKS00005384, DRKS00004749 (https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_DE.do)

  • Understanding Users’ ENDS Vaping Experience from Social Media Using Sentiment Opinion Summarization Techniques

    Date Submitted: Nov 10, 2017
    Open Peer Review Period: Nov 11, 2017 - Jan 6, 2018

    Background: E-liquid is one of the main components in electronic nicotine delivery systems (ENDS), it is possible that ENDS review comments could serve as an early warning on use patterns, and even function to serve as an indicator of problems or adverse events pertaining to the use of specific e-liquids – much like the types of responses that are tracked by the Food and Drug Administration (FDA) regarding medications. Objective: This paper aims to understand users’ vaping experience using sentiment opinion summarization techniques, which can help characterize how consumers, ENDS vendors, and others think about specific e-liquids and their characteristic (e.g. flavor, throat hit, vapor production, etc.). Methods: We collected e-liquid reviews on JuiceDB from June 26, 2013 to May 16, 2017 by using its public application programming interface (API), which is the world’s largest independent e-liquid and vape juice resource. The dataset contains 25449 reviews for 8039 e-liquid products, 5956 users and 1567 businesses; each review is accompanied by user information, business information, an overall rating and a set of four aspect ratings of an e-liquid, each on a scale of 1-5: flavor accuracy, throat hit, value and cloud production; each user includes user name, user type, description, etc. An Iterative Dichotomiser 3 (ID3) based influential aspect analysis model is proposed to learn the key elements that have impacts on using e-liquid, then, fine-grained sentiment analysis is employed to mine opinions on various aspects of the vaping experience related to e-liquid. Results: We found that (1) 67.50%(17177/25449) of the reviews were positive and 12.50%(3180/25449) of the reviews were negative, which indicates that users generally hold positive attitude towards e-liquid products. Among the nine flavors, fruity and sweet were the top 2 most popular flavors with the most positive, negative and total number of reviews, nutty and coffee were top 2 flavors with the least positive, negative and total number of reviews; (2) flavor accuracy and value were the two most important aspects influence users sentiments toward e-liquid products; (3) users are satisfied with fruity flavors since the flavors taste great, sweet, nice, good, amazing, and strong, the price/value is good, great, reasonable, the throat hit is strong, good, nice and perfect, meanwhile, weird, sour, bad, weak, and disappointing tastes make users dislike the flavor, some users complain that the price is steep and expensive, the quality is bad, the throat hit is harsh; (4) at the product level, among 1009 products labeled as rich flavor, 72.35% of the products were positive, among 432 products labeled as spiced flavor, 20.14% of the products were negative, rich and spiced flavors were the categories whose percentage of positive products and negative products was the largest. Slevin, ‘nana Cream and Unicorn Milk ranked top 3 in 8039 products; (5) at the user level, top 3 user categories with the most reviews were Unverified user, Verified user, and Trusted user, Business owner and Verified user had higher scores on products; (6) at the business level, top 5 most polular businesses were Mt.Baker Vapor, The Vapor Chef, Adirondack Vapor, Blue Dot Vapors, and Carpe Diem Vapor. And 14.1% of reviews were discussing the products provided by these popular businesses. The mined data-driven findings can help regulatory authorities automatically monitor e-liquid product information across the platforms and largely improving work efficiency. These findings can help distinguish e-liquid characteristics that impact use or lack of use of specific e-liquids in particular e-liquids. Conclusions: It is the first study to provide an effective mechanism to analyze users’ ENDS vaping experience based on sentiment opinion summarization techniques. Sentiment trend and opinions for aspect, product, and business can be found using our method, which is of great importance to monitor e-liquid products across the platforms and largely improving work efficiency of management department.

  • Background: There are multiple strategies but no gold standards for self-monitoring diet, physical activity (PA), and perceived stress. Although self-monitoring is a core element of self-management and behavior change, the success of mHealth behavioral tools is dependent on validity and reliability, which is lacking in evidence. African-American and Latina mothers in the United States are high priority populations for applications addressing diet, PA, and stress because mothers typically increase body mass index (BMI) for several years after childbirth and the risks of obesity and its’ sequelae diseases are elevated among minority populations. Objective: This pilot study examined inter-method reliability and concurrent validity of smartphone-based self-monitoring by ecological momentary assessments (EMA) and daily-diaries for diet, stress, and PA compared to brief recall measures, anthropometric bio-measures and bloodspot biomarkers. Methods: A purposive sample (n=42) of primarily African-American (39%) and Latina (44%) mothers (about one-third normal weight, overweight, or obese) was assigned AndroidTM smartphones with the Ohmage application to self-monitor diet, perceived stress, and PA over six months. Participants were assessed at 3- and 6-month follow-ups. Recall measures included brief food frequency screeners, PA assessments adapted from NHANES, and the PSM-9 stress measure. Anthropometric bio-measures included BMI, body fat, waist circumference, and blood pressure (BP). Bloodspot assays for Ebstein-Barr Virus (EBV) and C-Reactive Protein (CRP) were used as biomarkers of systemic load and stress. EMA and daily diary questions assessed perceived quality and quantity of meals, perceived stress levels, and moderate, vigorous, and light PA. Units of analysis were follow-up assessments (n=29 to n=45 depending on domain) nested in participants (N=29 with sufficient data for analyses). Correlations, R2 statistics, and multivariate linear regressions assessed strength of associations between variables. Results: Almost all participants (93%) completed the study. Inter-method reliability between smartphone EMA/diary reports and their corresponding recall reports was highest for stress and diet, with correlations ranging from .27 to .52 (with p<.05), but was unexpectedly low for PA with no significant associations. Concurrent validity was demonstrated for diet EMA/diary reports with systolic BP (r = -.32), CRP (r = -.34), and moderate and vigorous PA recalls (r = .35 to .48), suggesting co-variation between healthy diet and PA behaviors. Stress EMA/diary reports were not associated with EBV and CRP biomarkers. Moderate and vigorous PA diary reports were negatively associated with BMI and body fat (r = -.35 to -.44, p<.05). Conclusions: Brief smartphone EMA may be valid and reliable for long-term self-monitoring of diet, stress, and PA. Lack of inter-method reliability for PA measures is consistent with prior research. More research is needed on the efficacy of smartphone self-monitoring for self-management and behavior change support.

  • Effective Facebook Advertising Strategies for Large-Scale Online RCT Recruitment

    Date Submitted: Nov 8, 2017
    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Targeted Facebook advertising can be an effective strategy to recruit participants for a large-scale online study. Facebook advertising is useful for reaching people in a wide geographic area, matching a specific demographic profile. It can also target people who would be unlikely to search for the information and would thus not be accessible via Google AdWords. It is especially useful when it is desirable not to raise awareness of the study in a demographic group that would be ineligible for the study. This paper describes the use of Facebook advertising to recruit and enroll 1,145 women over a 15-month period for a randomized clinical trial to teach support skills to female partners of male smokeless tobacco users. This tutorial shares our study team’s experiences, “lessons learned,” and recommendations to help researchers to design Facebook advertising campaigns. Topics covered include designing the study infrastructure to optimize recruitment and enrollment tracking, creating a Facebook presence via a “fan page,” designing ads that attract potential participants while meeting Facebook’s strict requirements, and planning and managing an advertising campaign that accommodates the rapid rate of diminishing returns for each ad.

  • The impact of low back pain clinical trials measured by the Altmetric score: an analysis of 200 articles

    Date Submitted: Nov 8, 2017
    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: There is interest from authors and publishers in sharing the results of their studies over the internet in order to increase their readership. In this way, articles tend to be discussed and the impact of these articles tends to be increased. In order to measure this type of impact a new score (named Altmetric) was created. Altmetric aims to understand the individual impact of each article through the attention attracted online. Objective: The primary objective of this study was to analyze potential factors related with with the publishing journal and the publishing trial that could be associated with Altmetric scores on a random sample of low back pain randomised controlled trials. The secondary objective of this study was to describe the characteristics of these trials and their Altmetric scores. Methods: We searched for all low back pain randomised controlled trials indexed on the Physiotherapy Evidence Database (www.pedro.org.au) published between 2010 and 2015. A total of 200 articles were randomly selected. We extracted data related to the publishing trial, the publishing journal, methodological quality of the trials (measured by the 0-10 item PEDro scale) and total and individual scores of Altmetric mentioned and Altmetric reader. Multivariate regression models and descriptive statistics were used to present statistical analysis. Results: A total of four variables were associated with Altmetric mentioned score: impact factor (β= 3.4 points), number of years since publication (β= -4.9), number of citations divided by years since publication (β= 5.2 points) and descriptive title (β= -29.4 points). Only one independent variable was associated with Altmetric reader score: number of citations divided by years since publication (β= 10.1 points, 95% CI (7.74 to 12.46)). Descriptive statistics showed that the majority of articles were published in English, with a descriptive title and published in open access journals endorsing the CONSORT statement. Conclusions: Researchers should preferrably select high impact factor journals for submission and use declarative or interrogative titles, as these factors are likely to increase the visibility of their studies in social media.

  • A Study of Calorie Estimation in Pictures of Food

    Date Submitted: Nov 8, 2017
    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: Software to accurately estimate food calories from still images could help users and health professionals more efficiently identify dietary patterns and food choices associated with health and health risks. However, calorie estimation from images is difficult, and no publicly available software can do so accurately while minimizing the burden associated with data collection and analysis. Objective: The aim of this study is to determine the accuracy of crowdsourced annotations of calorie content in food images, and to identify and quantify sources of bias and noise as a function of respondent characteristics and food qualities (e.g., energy density). Methods: We invited adult social media users to provide calorie estimates for 20 food images (for which ground truth calorie data were known) using a custom-built webpage that administers an online quiz. The images were selected to provide a range of food types and energy density. Participants optionally provided age range, gender, and their height and weight. Additionally, five nutrition experts provided annotations for the same data to form a basis of comparison. We examined estimate accuracy on the basis of expertise, demographic data, and food qualities using linear mixed effects models with participant and image index as random variables. We also analyzed the advantage of aggregating nonexpert estimates. Results: 2028 respondents agreed to participate in the study (males: 770 [38%], mean body mass index: 27.5). Average accuracy was 5 out of 20 correct guesses, where “correct” was defined as a number within 20% of the ground truth. Even a small crowd of 10 individuals achieved an accuracy of 7, exceeding the average individual's and expert annotator’s accuracy of 5. Women were more accurate than men (P<.001), and younger people were more accurate than older people (P<.001). The calorie content of energy-dense foods was overestimated (P=.024). Participants did not perform better when images contained reference objects (such as credit cards) for scale. Conclusions: Our findings provide new information about the way we process food information, which can inform the design of future calorie-estimation applications.

  • A structured review of health information on firefighter websites

    Date Submitted: Nov 8, 2017
    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: Since firefighters have high health risks, access to health information specific to their needs is essential. Objective: To search and catalogue the information resources available on Canadian firefighter websites. The intention was to focus on gaps in online resources available to firefighters to guide electronic resource creation and future research. Methods: A search of health resources on Canadian firefighter (union, employer) websites was conducted on Google (July 2017). Data was extracted and collated to describe the nature of the resources in terms of their health focus and format. Results: From the total (n=313) number of websites reviewed, 41 websites contained health information, totalling 128 resources on firefighter mental (46%), physical (34%), and work health (20%). Resources were most dense on the international/national websites (13 resources/website) and least dense on local websites (1 resource/7 websites). General mental health (34%), post-traumatic stress disorder (24%), and suicide (24%) were the most prevalent topics in mental health resources, while half (49%) of all physical health resources were on cancer. Ontario, Québec, and British Columbia were key contributors, accounting for 81% of resources found on the provincial/local level. No resources from Northern Canada were found. Musculoskeletal health was not mentioned in any resources identified. Conclusions: While pockets of excellent information to support firefighter health are available, there are substantial gaps and a clear lack of coordination of resources, since the focus of health information is highly variable across firefighter websites. Quality evaluation and coordination of resources are needed to advance firefighter health.

  • Background: The Internet has become a major means of acquiring health information due to the increasing demand for health information and the development of the Internet. However, Internet health information is of mixed quality and may therefore significantly affects health-related behaviour and decisions. The trust of patients in their physicians may potentially change because of health information obtained from the Internet, thereby affecting their compliance to medical diagnoses and treatment. Hence, it is significant to discuss the relationship between Internet health information and patient compliance from the perspective of trust. Objective: This study aimed to discuss the relationship between Internet health information and patient compliance from the dimensions of quality and source through theoretical principle (i.e. cognition- and affect-based trust) and empirical study. Methods: An online survey involving 375 participants from 28 cities in China was conducted to assess the research model, which included two independent variables (i.e. Internet health information quality and source of Internet health information), two mediator variables (i.e. cognition- and affect-based trust) and one dependent variable (i.e. patient compliance). All variables were measured using multiple-item scales from previously validated instruments. The scales’ reliability and validity were analysed, demographic analysis was performed and hypotheses were tested using structural equation modelling (SEM). Results: The questionnaire response was 89.6%, and the reliability and validity was acceptable (Cronbach’s α = .950 > .700, KMO = .907 > .700, P < .001). This study indicated that the quality and source of Internet health information impacted cognition- and affect-based trust, consequently, patient compliance. In addition, Internet health information source also directly affected patient compliance, and the Internet health information quality was more important than the source of information. Furthermore, cognition- and affect-based trust had significant positive impacts on patient compliance, and cognition-based trust had a significant impact on affect-based trust. Unexpectedly, a nonsignificant relationship between source of Internet health information and affect-based trust was found. Conclusions: The Internet health information quality plays a more important role than the source of information in impacting patient trust, consequently, patient compliance. Therefore, patient compliance should be improved by strengthening the management of Internet health information quality and urging physicians to focus on health websites, and acquire health information from these websites to understand the information accessed by patients and enrich their knowledge structure to show their specialization and reliability in their interaction with patients. Cognition- and affect-based trust directly impact patient compliance. Therefore, physicians can communicate with patients through health websites to allow patients to acquire health information from physicians online and establish cognition-based trust in advance. Furthermore, physicians should focus on providing care and respect for patients and foster a safe atmosphere in which patients can express themselves sufficiently.

  • Background: The online, evidence-informed BeUpstandingTM Champion Toolkit was developed to provide employers (via a “train the champion approach”) with the resources and support to address reducing prolonged sitting within their own desk-based workplace. As part of a five-phase research-to-dissemination process this study reports on the evaluation of the beta (test) version of this toolkit (Phase 2). Objective: To evaluate: 1) implementation of the toolkit by workplace champions; and, 2) impact of the toolkit on: sitting (primary outcome), standing, and moving; use of activity-promoting strategies; knowledge and attitudes; and, indicators of health and work performance. Methods: An implementation study using a pre-post design was conducted in seven desk-based workplaces in Australia (September 2015 to May 2016), with work teams (one per workplace) purposively recruited to ensure representation across a range of sectors (white-/blue-collar), organisational sizes (small/medium/large), and locations (metropolitan/regional). All staff within participating teams were invited to participate in the relevant toolkit activities. Implementation outcomes (time commitment required by champions and toolkit activities completed) were collected from each champion via telephone interviews. Changes in impact outcomes, measured via an online questionnaire completed by employees at baseline and three months post implementation, were assessed using mixed models, correcting for clustering. Results: Champions reported a 30-60 min/week time commitment to the toolkit activities. All teams formed a wellbeing committee and sent the staff surveys at both time points, while most champions held a staff consultation workshop (6/7), identified team-level strategies within that workshop (5/7); used the communication resources provided within the toolkit (emails, posters; 6/7); and, completed the action plan (5/7). In total, 315 employees (52%) participated in at least one survey and 97 completed both surveys. At follow-up, there was a significant (P<0.05) reduction in self-reported workplace sitting time compared to baseline (-6.3%, 95%CI -10.1% to -2.5%; n=85) equating to ≈30 min/workday. Significant benefits were also observed for use of activity-promoting strategies, with small, non-significant changes observed for knowledge and attitudes, and indicators of health and work performance. Conclusions: The beta version of the BeUpstanding Champion Toolkit was feasible to implement and effective at reducing self-reported workplace sitting across a broad range of desk-based workplaces. The next phase (Phase 3) will build on these learnings to optimise the toolkit for wider-scale implementation and longer-term evaluation.

  • Background: Despite their potential benefits many eHealth innovations studied in major studies fail to integrate into organizational routines and implementation of these innovations remains problematic. Objective: The purpose of this study was to describe health care professionals’ self-identified perceived barriers and facilitators for the implementation of a web-based portal to monitor asthmatic children online as a substitution for routine outpatient care. Also, we assessed patient (and/or their parents) satisfaction with this eHealth innovation. Methods: Between April and November 2015, 76 healthcare professionals were recruited to participate. During a period of six months, participants received three questionnaires to identify factors that facilitate or impede the use of this eHealth innovation. Questionnaires for patients (and/or parents) were sent once after a period of 6 months. Results: perceived barriers included concerns about the lack of structural financial reimbursement for online monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of web-based portal use on clinician workload and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals towards eHealth, the possibility to tailor care to the individual patient (so-called ‘personalized eHealth’) and to easily deliver care according to current guidelines by using the virtual asthma clinic (VAC) and long-term profit and efficiency. Conclusions: Implementation of an eHealth innovation is complex, dynamic and influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context and economic and political context. Understanding and defining the barriers and facilitators that influence the context appears to be important for successful implementation and sustainability of eHealth innovations.

  • Background: Altering the approach to medical recommendations delivery could enhance patient adherence. Text-message reminders, in interrogative form are effective and inexpensive in enhancing colorectal cancer (CRC) screening. Objective: To examine responses to text-message reminders and associate responses with senders' characteristics and subsequent screening. Methods: Prospective cohort intervention. Text-message reminders to undergo colorectal cancer (CRC) screening, randomized into interrogative and declarative phrasing, sent to non-adherent women and men (40,000), aged 50 to 74, at CRC average-risk. Recipients’ responses were analyzed by message type and recipients’ characteristics; for content, the latter predicting subsequent CRC screening per program database. Results: Interrogative text-message reminders elicited 1475 (8.4%) responses; declarative ones elicited 146 responses. Text-message respondents screened significantly more than non-respondents six months following the reminders (25.8% vs. 8.8%, χ2=420.7, P<0.0001); a year later (21.7% vs.12.4%, χ2=98.6, P<0.0001); two years later (14.2% vs.10.5%, χ2=19.2, P<0.0001). Text-message responses were grouped: position towards CRC screening and intention to screen. Positions towards CRC screening were positive (81.7%); 67.1% intended to undergo Fecal Occult Blood Test. In a multivariable logistic regression among text-message respondents, screening at six months was significantly predicted by older age, past sporadic screening and intentions; gender was non-predictive. Conclusions: Interrogative text-message reminders reached previously uninvolved sectors in the CRC target population: men, sporadic-screenees, and the 'never-tested' before. This novel application resulted in a population-level, incremental enhanced screening. Asking patients about their future health-behavior enhanced cancer screening, and is relevant for enhancing other health-behaviors, in preventive medicine and in clinical settings.

  • Quantitative Content Analysis of Mobile Applications for Caregivers of Older Adults

    Date Submitted: Nov 6, 2017
    Open Peer Review Period: Nov 7, 2017 - Jan 2, 2018

    Background: Informal caregivers of older adults provide critical support for their loved ones but are subject to negative health outcomes because of burden and stress. Interventions to provide information and resources as well as social and emotional support reduce burden. Mobile applications featuring access to information, assistance with scheduling, and other features can automate support functions inexpensively and conveniently and reach a greater proportion of caregivers than otherwise possible. Objective: The aim was to identify mobile applications geared towards caregivers of older adults, catalog features, and suggest best practices for adoption based on empirical findings of beneficial interventions in the caregiving literature. Methods: Search for applications focused on those for caregivers of older adults in Google Play and iTunes, compiling their features, and identifying features reflecting categories of support identified in successful intervention studies to negative caregiver outcomes. Intervention research indicates that provision of information and resources, assistance in practical problem solving, coordinating care among multiple caregivers, and emotional support reduce caregiver burden. Results: Despite approximately over 200,000 mobile health­-related applications, availability of mobile applications for caregivers is relatively sparse with 44 apps as of October 2017. Applications generally addressed specific categories of support, including information and resources, family communication, and/or caregiver­-recipient interactions. Few applications were comprehensive, with only 18% (8 apps) with features that addressed three or more categories. Few applications provided specific stress reduction exercises for caregivers, important for reducing burden. Conclusions: Mobile applications have the potential to provide resources, just­-in­-time information for problem solving, and stress reduction strategies for caregivers. Many applications offer functions that have been shown to reduce burden and improve health outcomes in caregivers, but few provide emotional support. Using an evidence­-based practice approach, mobile applications for caregivers can provide multiple beneficial support functions. Applications can serve a much larger proportion of this highly underserved population in their mobile form than more traditional means, improving their health and quality of life.

  • Applying Persuasive Design Techniques to Change Data Entry Behaviour in Primary Care

    Date Submitted: Nov 4, 2017
    Open Peer Review Period: Nov 6, 2017 - Jan 1, 2018

    Background: Persuasive design (PD) is an approach that seeks to change the behaviours of users by using design and social influence. In primary care, clinician behaviours and attitudes are important precursors to structured data entry, and there is an impact on overall data quality. This research hypothesizes that PD could change data entry behaviours in clinicians and improve data quality. Objective: Our objective was to use PD principles to change clinician data-entry behaviours in a primary care environment and to increase data quality within a registry system. Methods: We performed a detailed systems analysis of the data-entry task by using cognitive work analysis (CWA). We used the results of this analysis with the Persuasive Systems Design (PSD) framework to describe the persuasion context. We identified several PD principles to be introduced in a new summary screen, which became part of the data entry workflow. As part of our experimental design, we defined three data quality measures (same-day entry, record completeness, and data validity) to measure changes in data quality and entry behaviour. We measured the impacts of the new screen with a paired pre/post t-test and generated XmR charts to contextualize the results. Results: 53 users were shown the new screen during their data entry over the course of 10 weeks. Based on a pre-post analysis, the new summary screen successfully encouraged users to enter more of their data on the same day as their encounter. The percentage of same-day entries increased by 10.34% (P < 0.001). During the first month of the new screen, users compensated by sacrificing aspects of data completeness, before returning to normal in the second month. Improvements to record validity were marginal over the study period (P = 0.045). Statistical process control techniques allowed us to study the XmR charts to contextualize our results and understand trends throughout the study period. Conclusions: By conducting a detailed systems analysis and introducing new PD elements into a data entry system, we demonstrated it was possible to change data-entry behavior and influence data quality in a reporting system. The results show that using PD concepts may be effective at influencing data entry behaviours in clinicians. There may be opportunities to continue improving this approach, and further work is required to perfect and test additional designs. Persuasive design is a viable approach to encourage clinician user change and could support better data capture in the field of medical informatics.

  • Background: eHealth tools are becoming increasingly popular for helping patients self-manage chronic conditions. Little research has examined the effect of ehealth tools for patient self-reporting on medication management. This review aims to determine whether ehealth tools featuring patient self-reporting of symptoms, adverse effects and drug therapy problems are effective at prompting medication changes and improving patient outcomes. Objective: The primary objective is to determine how patient self-reporting of symptoms and adverse effects via ehealth tools influences medication use and changes made to medications. Secondary objectives are to investigate how patient use of ehealth tools influences identification of adverse events, patient self-management of disease and self-efficacy, medication use behaviour, medication reconciliation and recommendations for drug changes, changes in patient signs and symptoms, health services utilization, quality of life, and patient satisfaction with health care. Methods: MEDLINE, EMBASE and CINAHL were searched from Jan 1, 2000 through to January 4, 2016. References were also searched. Title, abstract and full text review, as well as data abstraction and risk of bias assessment were performed in duplicate. Due to high heterogeneity, results were not meta-analyzed, and instead presented as a narrative synthesis. Results: 13 studies, including 10 randomized controlled trials (RCTs) and 3 single-arm cohort studies were included, from which 10 unique ehealth tools were identified. Here six of seven RCTs found improvement in patient symptoms following ehealth tool use, especially in adolescent asthma patients. Four of six RCTs reported that ehealth tools may have potential to initiate changes to medications based on patient self-reports. Two of four RCTs showed that ehealth tools may improve patient self-efficacy and self-management of chronic disease. Little or no evidence was found to support the effectiveness of ehealth tools at improving medication recommendations and reconciliation by clinicians, medication-use behaviour, health service utilization, quality of life, or patient satisfaction. eHealth tools with multifaceted functionalities and those allowing direct patient-provider communication may be more effective at improving patient self-management and self-efficacy. Conclusions: Initial evidence showing ehealth tools may improve patient symptoms and lead to medication changes is promising. Patients generally found ehealth tools useful in improving communication with health care providers. Implementation issues such as poor patient engagement and poor clinician workflow integration were identified. More high-quality research is needed to explore how ehealth tools can be used to effectively manage use of medications to improve patient outcomes.

  • Mapping of crowdsourcing in health: a systematic review

    Date Submitted: Nov 2, 2017
    Open Peer Review Period: Nov 3, 2017 - Dec 29, 2017

    Background: Crowdsourcing involves obtaining ideas, needed services, or content by soliciting online contributions from a crowd. The four types of crowdsourced tasks (problem solving, data processing, surveillance/monitoring and surveying) can be applied in the three categories of health (promotion, research and care). Objective: We aimed to map the different applications of crowdsourcing in health in order to assess the fields of health that are using crowdsourcing and the crowdsourced tasks used. We also describe the logistics of crowdsourcing and the characteristics of crowd workers. Methods: MEDLINE, EMBASE and ClinicalTrials.gov were searched for available reports from inception to March 30th, 2016 with no restriction on language or publication status. Results: We identified 202 relevant studies that used crowdsourcing, including 9 randomized controlled trials, only one with results posted at ClinicalTrials.gov. Crowdsourcing was used in health promotion (45%), research (36%) and care (19%). The four most frequent areas of application were public health (33%), psychiatry (16%), surgery (11%) and oncology (7%). Half of the reports (49%, n=99) referred to data processing, 35% (n=70) surveying, 10% (n=21) surveillance/monitoring and 6% (n=12) problem solving. Labor-market platforms (e.g., Amazon Mechanical Turk) were used in most studies (94%). The crowd workers’ characteristics were poorly reported and crowdsourcing logistics were missing from two thirds of reports. When reported, the median size of the crowd was 424 [Q1-Q3: 167-802]; crowd workers’ median age was 34 years [32-36] and 55% were men. Crowd workers were mainly recruited nationally, particularly in the United States. For many studies (59%), previous experience in crowdsourcing was required, and passing a qualification test or training was seldom needed (about 12% of studies). For half of the studies, monetary incentives were mentioned, mainly less than 1 USD. The time needed to perform the task was mostly less than 10 min (59% of studies). Data-quality validation was used in 54 studies (27%), mainly by attention-check questions or by replicating the task with several crowd workers. Conclusions: Our results illustrate the increasing use of crowdsourcing for the three areas of health. However, the description of crowdsourcing logistics and crowd workers’ characteristics is frequently missing in study reports. Clinical Trial: We uploaded a pre-specified protocol to a publicly accessible institutional Website (http://www.clinicalepidemio.fr/protocols/).

  • Background: Tenosynovial Giant Cell Tumor(TGCT) is a rare, benign lesion affecting the synovial lining of joints, bursae and tendon sheaths. It is generally characterized as a locally aggressive and often recurring tumor. A distinction is made between localized- and diffuse-type. The impact of TGCT on daily living is currently ill described. Objective: This crowdsourcing study evaluates impact of TGCT on physical function, daily activities, societal participation(work, sports and hobbies) and overall quality of life from a patient perspective. Secondary aim is to define risk factors for deteriorated outcome in TGCT. Methods: Crowdsourcing was used to obtain big data. In a timeframe of six months, TGCT patients were invited to complete an online questionnaire by advertising on the largest known TGCT Facebook-community, ‘PVNS is Pants!!’. The questionnaire, mainly multiple-choice, comprised self-constructed questions on patient- and tumor characteristics, treatments, medical history, TGCT-symptoms, employment and sports, as well as the Visual Analogue Scale(VAS) worst pain and stiffness, the PROMIS-physical functioning(PF) questionnaire, the Short-Form(SF)-12 and the EuroQoL(EQ-5D-5L). To confirm disease presence and TGCT-type, patients were requested to share histological- or radiological-proof. Unpaired t-tests and chi-squared tests were used to compare groups with and without proof of TGCT and define determinants for daily living. Results: 337 Questionnaires(32% with disease confirmation), originating from 30 countries, were completed. Median age at diagnosis was 33(IQR25-42)years, majority was female(80%), diffuse-TGCT(70%) and affected lower extremities: knee(71%), hip(10%). In 299 lower extremity TGCT-patients, recurrence-rate was 36% and 70% in localized- and diffuse-type, respectively. For both types, pain and swelling decreased after treatment, but stiffness worsened and range of motion decreased. Due to TGCT, 13% of localized- and 11% of diffuse-type was unable to (fully)perform their employment and 58% of localized- and 64% of diffuse-type was unable to practice sport-activities. Compared with general population, all patients showed lower PROMIS-PF T-score, SF-12 PCS- and MCS-scores and EQ5D-5L utility-score. The decrease in PROMIS-PF, SF-12 PCS and EQ-5D-5L score was considered clinically relevant, according to estimated Minimal Important Difference(MID). In comparing localized- and diffuse-TGCT, diffuse-type scored almost 0.5 standard-deviation lower for PROMIS-PF(P<.001) and 5% lower for EQ-5D-5L(P.03). In localized-TGCT, recurrent disease and ≥2surgeries negatively influenced scores of VAS-pain/stiffness, SF-12 PCS-score and EQ-5D-5L(P<0.05). In diffuse-type, recurrence resulted in lower score for VAS-pain/stiffness, PROMIS-PF, SF-12 MCS-score and EQ-5D-5L(P<0.05). In both types, patients with treatment ≤1year ago had significantly lower SF-12 PCS-score. Conclusions: TGCT has huge impact on daily living in a relatively young and working population. Patients with diffuse-type, recurrent disease and ≥2surgeries represent lowest functional and quality-of-life outcomes. Physicians and other relevant health care providers(e.g. physiotherapists) should be aware that TGCT patients frequently continue to experience declined health-related quality of life and physical function and often remain limited in daily activities, sports and employment, even after treatment(s).

  • Designing an Intensive Care Unit Visualization Dashboard: An Integrative Literature Review

    Date Submitted: Nov 1, 2017
    Open Peer Review Period: Nov 1, 2017 - Dec 27, 2017

    Background: Intensive Care Units (ICUs) in the United States admit more than 5.7 million people each year. The ICU level of care helps people with life-threatening illness or injuries and involves close, constant attention by a team of specially-trained health care providers. Delay between condition onset and implementation of necessary interventions can dramatically impact the prognosis of patients with life-threatening diagnoses. Evidence supports a connection between information overload and medical errors. A tool that improves display and retrieval of key clinical information has great potential to benefit patient outcomes. The purpose of this review is to synthesize research on the use of visualization dashboards in health care. Objective: The purpose of conducting this literature review is to synthesize previous research on the use of visualization dashboards. A review of the existing literature on this subject can be used to identify gaps in prior research and to inform further research efforts on this topic. Ultimately, this evidence can be used to guide the development, testing, and implementation of a new solution to optimize the visualization of clinical information, reduce clinician cognitive overload, and improve patient outcomes. Methods: Articles were included if they addressed the development, testing, implementation, or use of a visualization dashboard solution in a health care setting. An initial search was conducted of literature on dashboards only in the intensive care unit setting, but there were not many articles found that met the inclusion criteria. A secondary follow-up search was conducted to broaden the results to any health care setting. The initial and follow-up searches returned a total of 17 articles that were analyzed for this literature review. Results: Visualization dashboard solutions decrease time spent on data gathering, difficulty of data gathering process, cognitive load, time to task completion, errors, and improve situation awareness, compliance with evidence-based safety guidelines, usability, and navigation. Conclusions: Researchers can build on the findings, strengths, and limitations of the work identified in this literature review to bolster development, testing, and implementation of novel visualization dashboard solutions. Due to the relatively few studies conducted in this area, there is plenty of room for researchers to test their solutions and add significantly to the field of knowledge on this subject.

  • Background: Electronic Medical Record systems hold the promise of accurate, real time access to patient healthcare data. This review evaluated the usability of EMR systems implemented in sub-Saharan Africa (SSA) based on a usability evaluation criteria developed by the Healthcare Information and Management Systems Society (HIMSS). Objective: To evaluate electronic medical record system implementations in sub-Saharan Africa against a well defined evaluation methodology and assess their usability based on a defined set of metrics. To identify the extent to which usability has been an enabling or hindering factor in the implementation of electronic medical record systems in sub-Saharan Africa. To identify approaches for incorporating usability in new EMR system implementations to facilitate successful system adoption and use. Methods: 5 key metrics for evaluating EMR system usability were developed based on the methodology proposed by HIMSS. These include efficiency, effectiveness, ease of learning, cognitive load and user satisfaction. A five point rating system was developed for the review. EMR systems in 20 reviewed publications were scored based on this rating system. It awarded 5 points per metric to any EMR system that was identified as excellent, 4 points for good, 3 points for fair, 2 points for poor and 1 point for bad. Additionally the effectiveness of each system carried a maximum weighted score of 30, efficiency 25, ease of learning 20, user satisfaction 15 and cognitive load 10. The percentage scores for each metric were then computed from these weighted scores from which the final overall usability score was derived. Results: In contributing to the usability of implemented EMR systems, ease of learning obtained the highest percentage score of 67% of the publications reviewed followed closely by user satisfaction which obtained a percentage score of 66%. Effectiveness and efficiency obtained similar percentage scores of 65%. Cognitive load obtained the lowest percentage score of 59%. The overall usability score for all systems was calculated to be 64%. Conclusions: The usability of electronic medical record systems implemented in sub-Saharan Africa has been only fair with ease of learning and user satisfaction being the biggest positive contributors to this rating. Effectiveness and efficiency have been third joint contributors in positively influencing the usability of EMR implemented systems. Cognitive load has impeded EMR system usability in in sub-Saharan Africa and hasn’t been given adequate attention by EMR system designers.

  • Background: An estimated 30.3 million Americans have diabetes mellitus (DM). The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to improve the quality-of-life for people who either have, or are at risk, for DM and, hence, lower the personal and national economic burden of this debilitating chronic disease. Diabetes self-management education interventions are a primary focus of this initiative. Objective: To evaluate the impact of the Better Choices Better Health Diabetes (BCBH-D) self-management program on comorbid illness related to DM, healthcare utilization, and cost. Methods: A propensity score matched, two-group, pre-post design was used for this study. Retrospective administrative medical and pharmacy claims data from the HealthCore Integrated Research Environment (HIRE) were used for outcome variables. The Intervention cohort included DM patients who were recruited to a diabetes self-management program offered both on-line and via in-person workshops. Control cohort subjects were identified from the HIRE by at least two diabetes associated claims (ICD-9 250.xx) within two years prior to the program launch date (10/01/2011-09/30/2013), and received usual care but did not participate in BCBH-D. Controls were matched to cases in a 3:1 propensity score match. Outcome measures included pre- and post-intervention all-cause and diabetes-related utilization and costs recorded in the HIRE claims database. Cost outcomes are reported as least squares means. Repeated measures analyses (Generalized Estimating Equation approach) were conducted for utilization, comorbid conditions, and costs. Results: The program participants who were identified in HIRE claims (N=558) were matched to a Control Cohort of 1,669 patients. Following the intervention, the self-management cohort experienced significant reductions in claims for DM associated comorbid conditions, with the post-intervention disease burden being significantly lower (mean 1.78 (SD=1.6)) compared to the Control cohort (mean 2.13 (SD=1.73)); P=.001. Post-intervention all-cause utilization was decreased in the Intervention cohort compared to controls with -40/1000 Emergency department visits vs +70/1000; P=.004 and -2,790 outpatient visits per 1000 vs. -440/1000; P=.001. Unadjusted total all-cause medical cost was decreased by $2,207 in the Intervention cohort compared to a $338 increase in the Controls, P=.001. After adjustment for other variables through structural equation analysis, the direct effect of the BCBH-D was -$815. Conclusions: Patients in the BCBH-D program experienced reduced all-cause healthcare utilization and costs. Direct cost savings were $815. While encouraging, given the complexity of the patient population, further study is needed to cross-validate the results. Clinical Trial: N/A

  • Internet and Social Media Access Among Youth Experiencing Homelessness

    Date Submitted: Oct 30, 2017
    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: Youth experiencing homelessness are at risk for a variety of adverse outcomes. Given the widespread use of internet and social media, these new technologies may be used to address their needs and for outreach purposes. However, little is known about how this group uses these resources. Objective: This study investigated how homeless adolescents use these technologies for general and health related purposes, whether the scope of their use changes with housing status, and their interest in a website dedicated to youth experiencing homelessness. Methods: A convenience sample of youth ages 18-21 were recruited from a youth specific homeless shelter. All participants completed a 47-item survey, with 10 individuals completing a semi-structured interview. Descriptive statistics, exact testing, and GEE modeling was performed for quantitative data analysis. Interviews were transcribed verbatim, and NVivo 10 was employed to facilitate double coding and thematic analysis. Results: 87 participants completed the survey with a mean age of 19.4 ±1.1 years. 56.3% accessed the internet at least once/day, with 86.1% accessing once/week. Access to a smartphone was associated with a 2.76 greater odds of getting online, and was the most frequently used device (65.5% of participants). While experiencing homelessness, subjects were less likely to access the internet at least once a day (79.3% vs. 56.3%, P < .001), spend more than 2 hours/day on the internet (56.3% vs. 24.1%, P < 0.001), use social media (97.0% vs. 85.1%, P = .006), and have access to a smartphone (85.1% vs. 65.5%, P = .006). Ten participants completed the semi-structured interview. Several themes were identified including, (1) changes in internet behaviors while experiencing homelessness, (2) health status as a major concern and reason for internet use, and (3) interest in a website dedicated to youth experiencing homelessness. While experiencing homelessness, participants indicated their behaviors were more goal oriented and less focused on leisure or entertainment activities. Conclusions: While homeless youth experience changes in the frequency, amount of time, and specific uses of the internet and social media, study participants were able to access the internet regularly. The internet was used to search health related topics. Given the importance of smartphones in accessing the internet, mobile-optimized websites may be an effective method for reach this group.

  • The Rise and Need for Mobile Apps for Maternal and Child Health Care in China- a survey based on App markets

    Date Submitted: Oct 31, 2017
    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: The mobile health (mHealth) services are booming in maternal and child health (MCH) in China, due to the expansion of e-health and the introduction of the ‘two child policy’ Countless MCH apps can be found in computer stores, but the exact number, downloads and functional features of such apps are not clear. Objective: To explore the use of MCH apps in Android and iOS app stores and describe the key functional features of the most popular ones with the purpose of providing insight for further research and development of MCH mobile health products. Methods: The researchers searched the three most popular Android app stores (Tencent MyApp, Baidu Mobile Assistant and 360 Mobile Assistant) and the iTunes App Store in China. All apps on family planning (contraception and preparing for pregnancy), pregnancy and perinatal care, neonatal care and health, and development for children under 6 years were counted. Any apps focusing on MCH product marketing, children's songs, animation and games were excluded from the study. The 50 most used apps in each of the Android and iTunes stores (78 de-duplicated apps in total) were downloaded for in-depth analysis. Results: A total of 5276 Android apps and 877 iOS apps were identified for MCH care. Of the 78 most popular ones, 43 (55.1%) apps focused on only one stage of MCH care, mainly targeting child care (25 apps) and pre-pregnancy (11 apps), while 35 (44.9%) apps covered two or more stages, with most of these (32 apps) related to both pregnancy and child care. The functions mostly covered by the popular apps were health education/promotion, communication, data collection and management, diary, reminder and counseling. Among the functions of ‘data collection and management’, the researchers found 47 independent tools, including pregnancy preparation, fetal heart monitoring, blood glucose and blood pressure monitoring, as well as some that prompted an action, such as visiting the doctor. A few apps were equipped with external devices (n=3) or cellphone-based measurement technology (n=1). No app was found having intelligent decision-support functions to support disease management such as gestational diabetes and pregnancy-induced hypertension. Only a small amount of apps (n=5) had a web connection with hospital information systems to support appointment scheduling, payments, hospital service guidance or to check on laboratory test results. Conclusions: There are thousands of MCH apps on the China market. The most popular apps tend to cover both pregnancy and child care, or child care or pre-pregnancy separately. They are usually equipped with various functions and tools. However, internet of things, intelligent decision-support and docking with existing hospital information systems are still being developed and need more research.

  • Background: Mental health problems are highly prevalent among college students. The majority of students with poor mental health, however, does not receive professional help. Internet-based self-help formats may increase the utilization of treatment. Objective: This randomized controlled trial evaluated the efficacy of an Internet-based, App-supported stress-management intervention for college students. Methods: 150 college students with elevated levels of stress (Perceived Stress Scale; PSS-4≥ 8) were randomly assigned to either an Internet- and mobile-based stress intervention group (IG) or a control group (CG). Self-report data were assessed at baseline, post-treatment (7 weeks) and 3-month follow-up. The primary outcome was perceived stress (Perceived Stress Scale; PSS-4). Secondary outcomes included mental health outcomes, modifiable risk and protective factors, and college-related outcomes. Subgroup analyses were conducted in students with clinical relevant symptoms of depression (CES-D>17). Results: Findings indicated significant effects of the intervention compared to the CG for stress (d=0.69; 95%CI:0.36-1.02), anxiety (d=0.76; 95%CI:0.43-1.09), depression (d=0.63; 95%CI:0.30-0.96), college-related productivity (d=0.33; 95%CI:0.01-0.65), academic work impairment (d=0.34; 95%CI:0.01-0.66) and other outcomes at post-treatment. Effects were sustained at follow-up and similar findings emerged in students with symptoms of depression. Conclusions: Internet- and mobile-based interventions could be an effective and cost-effective approach to reduce consequences of college-related stress. Clinical Trial: German Clinical Trial Register; DRKS00010212

  • Background: Telemonitoring of symptoms and physiological signs has been suggested as a means of early detection of exacerbations of chronic obstructive pulmonary disease (COPD) with a view to instituting timely treatment. However, current algorithms to identify exacerbations result in frequent false positive results and increased workload. Machine learning, when applied to predictive modelling, can determine patterns of risk factors useful for improving quality of predictions. Objective: To establish if machine learning techniques applied to telemonitoring datasets improve prediction of hospital admissions, decisions to start steroids, and to determine if the addition of weather data further improves such predictions. Methods: We used daily symptoms, physiological measures and medication data, with baseline demography, COPD severity, quality of life, and hospital admissions from a pilot and large randomised controlled trial of telemonitoring in COPD. In addition, we linked weather data from the UK Meteorological Office. We used feature selection and extraction techniques for time-series to construct up to 153 predictive patterns (features) from symptom, medication, and physiological measurements. The resulting variables were used for the construction of predictive models fitted to training sets of patients and compared to common algorithms. Results: We had a mean 363 days of telemonitoring data from 135 patients. The two most practical traditional score-counting algorithms, restricted to cases with complete data resulted in AUC estimates of 0.60 [CI 95% 0.51, 0.69] and 0.58 [0.50, 0.67] for predicting admissions based on a single day’s readings. However, in a real-world scenario allowing for missing data, with greater numbers of patient daily data and hospitalisations (N = 57,150, N+=17), the performance of all the traditional algorithms fell, including those based on two days data. One of the most frequently used algorithms performed no better than chance. Machine learning models demonstrated significant improvements; the best machine learning algorithm based on 57,150 episodes resulted in an aggregated AUC = 0.73 [0.67, 0.79]. Addition of weather data measurements resulted in a negligible improvement in the predictive performance of the best model (AUC = 0.74 [0.69, 0.79]). In order to achieve an 80% true positive rate (sensitivity), the traditional algorithms were associated with an 80% false positive rate: our algorithm halved this rate to approximately 40% (specificity approximately 60%). The machine learning algorithm was moderately superior to the best standard algorithm (AUC = 0.77 [0.74, 0.79] v AUC = 0.66 [0.63, 0.68]) at predicting the need for steroids. Conclusions: The early detection and management of COPD remains an important goal given the huge personal and economic costs of the condition. Machine learning approaches, which can be tailored to an individual’s baseline profile and can learn from experience of the individual patient are superior to existing predictive algorithms show promise in achieving this goal. Clinical Trial: NA

  • An Ordinal Regression based Approach to Doctor Performance Evaluation in EHealth

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

    Background: Doctor performance evaluation (DPE) is an important task in eHealth, which aims to evaluate the overall quality of online diagnosis and patient outcomes so that high customer satisfaction and loyalty can be attained. However in reality most of customers trend not to give ratings to doctor performance. Therefore it is imperative to develop a model to make DPE automatically. When making auto-evaluation of doctor performance, we expect to rate the doctor performance into a score label that is as close as possible to the true one. Objective: This study aims to do DPE automatically from online textual consultation contents between doctors and customers by a novel machine learning method. Methods: We propose a solution which models DPE as an ordinal regression problem. In doing so, a combined SVM and Ordinal Partitioning model, namely SVMOP, along with an innovative prediction function is developed to capture the ordering labels hidden in preferences over DPE. Specifically, when conducting feature engineering, in addition to the basic text features, eight handcrafted features extracted from over 70,000 medical entries, are added and then further boosted by Gradient Boosting Decision Tree. Results: Real data sets from one of the largest mobile doctor-patient communication platforms in China are used in our study. In according with the statistics, 64% of data on eHealth platforms loss the evaluation labels from customers. Experimental results reveal that our approach can well support doctor performance evaluation automatically. Specifically, compared with other auto-evaluation models, SVMOP improve the MAE by up to 0.1, MSE by up to 0.5, PAcc by up to 5%; the handcrafted features that we suggest, improve the MAE by up to 0.1, MSE by 0.2, PAcc by up to 3%. After boosting, the performance can be further improved. Furthermore, based on OR-DPE model, we could also mine some predictive features like some useful polite expressions and sentiment words, which can be further applied to guide the development of eHealth platforms. Conclusions: It is the first time to model the problem of doctor performance evaluation on eHealth platforms as an ordinal regression problem. Apart from the basic text features, we use eight handcrafted features suggested by domain experts as important features to improve our model’s performance. Additionally, we propose a more reasonable and effective prediction function in SVMOP model. Experiments show that the performance of the model with revised prediction function is better than many other machine learning methods on MAE, MSE as well as Pairwise Accuracy. In summary, with this model the eHealth platform could not only make an auto-evaluation of doctor performance online but also mine the most effective features which could guide the promotion and development of doctors and platforms.

  • Background: Improving practice nurses’ adherence to smoking cessation counseling guidelines will benefit the quality of smoking cessation care and will potentially lead to higher smoking abstinence rates. However, support programs to aid practice nurses in improving their guideline uptake and adherence do not exist yet. Objective: To assess the effects of a novel computer-tailored e-learning program on practice nurses’ smoking cessation guideline adherence. Methods: A web-based randomized controlled trial was conducted in which an intervention group (N = 147) with full access to the e-learning program for six months was compared to a control group (N = 122) without access. Data collection was fully automated at baseline and six-month follow-up via online questionnaires, assessing practice nurses’ demographics, work-related factors, potential behavioral predictors based on the I-Change model and guideline adherence. Practice nurses also completed counseling checklists to retrieve self-reported counseling activities for each consultation with a smoker (N = 1,175). To assess the program’s effectiveness in improving practice nurses’ guideline adherence (i.e. overall adherence and adherence to individual counseling guideline steps), mixed linear and logistic regression analyses were conducted, thus accommodating for the smokers being nested within practice nurses. Potential effect moderation by work-related factors and behavioral predictors was also examined. Results: After six months, 121 practice nurses in the intervention group (43.4%) and 103 in the control group (36.9%) completed the follow-up questionnaire. Mixed linear regression analysis revealed that counseling experience moderated the program’s effect on practice nurses’ overall guideline adherence (β = 0.610; 95% CI 0.132 – 1.089; P = .013), indicating a positive program effect on adherence for practice nurses with a more than average level of counseling experience. Mixed logistic regression analyses regarding adherence to individual guideline steps revealed a trend towards moderating effects of baseline levels of behavioral predictors and counseling experience. More specifically, for practice nurses with less favorable scores on behavioral predictors (e.g. low baseline self-efficacy) and high levels of counseling experience the program significantly increased adherence. Conclusions: Results from our randomized controlled trial showed that among practice nurses with more than average counseling experience the e-learning program resulted in significantly better smoking cessation guideline adherence. Experienced practice nurses might have been better able to translate the content of our e-learning program into practically applicable counseling strategies compared to less experienced colleagues. Less favorable baseline levels of behavioral predictors among practice nurses possibly contributed to this effect, as there was more room for improvement by consulting the tailored content of the e-learning program. To further substantiate the effectiveness of e-learning programs on guideline adherence by healthcare professionals, it is important to assess how to support a wider range of healthcare professionals. Clinical Trial: No medical ethical clearance for this study was needed according to the Medical Ethics Committee Atrium-Orbis-Zuyd (14-N-17). The study is registered with the Dutch Trial Register (NTR4436).

  • Background: In Swiss adults, prevalence of asthma and COPD is around 7%. To date, asthma and COPD are not curable but treatable respiratory diseases. The burden of each disease among patients is high and people affected are frequently hospitalised due to exacerbations. This is associated with accelerated lung function decline, increased mortality and reduced health-related quality of life (HRQoL). However, there are numerous reasons for the lack of disease control in asthma and COPD patients. It is repeatedly associated with non-adherence to guidelines regarding treatment recommendation on the part of the health care provider and with poor inhalation technique and/or non-adherence to the prescribed treatment plan by the patient. Objective: This study aims at presenting data on compliance in accordance with current treatment guidelines. Moreover, we provide baseline data on inhaler application and its impact on quality of life and symptom control in a typical population with chronic lung disease from the Adherence-Trial. Methods: For this cross-sectional analysis, 169 in- and out-patients with asthma and COPD were recruited. Correct application of inhaler devices was tested using pre-defined checklists. Quality of life and symptom control were investigated using COPD Assessment Test (CAT) and Asthma Control Test (ACT). Spirometry was used to measure forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Results: Overall, correct inhalation technique ranged from 55% to 100% depending on the type of inhaler. 112 participants (68%) participants were treated according to global guidelines. COPD patients with incorrect device application had a higher CAT sum score compared to those with a correct device application (P=.02). Moreover, COPD patients with incorrect device application had more often cough (P=.03) and were more breathless while walking up hills or one flight of stairs (P=.02). While there was no significance found in asthma patients, COPD patients who used their devices correctly had a significantly better mean FEV1% predicted at baseline compared to those who applied their devices incorrectly (P=.04). Conclusions: Regular and comprehensive training of correct an inhalation technique is recommended in patients with chronic lung disease, in particular COPD. Correct inhalation of prescribed medication is associated with improved health status and lung function. These findings should encourage physicians and pharmacists to provide instructions on correct inhalation technique and to re-evaluate the patients’ inhalation technique on a regular basis. Clinical Trial: Trial registration: ClinicalTrials.gov: NCT02386722

  • Higher efficacy ratings for self-medication with psychedelics than offered treatment for psychopathologies

    Date Submitted: Oct 26, 2017
    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: A substantial number of people worldwide suffer from mental health problems during their lifetime. Current first-line treatments are not efficacious for a considerable number of patients and the need for alternative treatments is high. Recent scientific studies suggest that psychedelic drugs have high therapeutic potential for a variety of difficult to treat mental disorders. Objective: To the best of our knowledge the present survey study is the first to assess the tendency of psychedelic users to self-medicate with psychedelics and to compare the efficacy of self-administered psychedelics to treat their disorder, and the treatment offered by a medical professional. Methods: In total 2319 (47.4%) participants completed the survey of which 1967 consented and were 18 years or older. The mean (±SD) age of this final set was 25.9 (8.7); 78.7% were males, 19.9% females, and 1.3% classified themselves as ‘other’. Results: Almost half of the final set (45.7%) indicated to have suffered or to be currently suffering from a mental disorder; 77.5% of those were diagnosed by a medical professional. In 92.5% of the diagnosed cases some kind of treatment was offered; 77.3% of them searched for treatments outside a medical professional’s recommendation and 15% of those had used or were using psychedelics to treat or cure symptoms. Self-administered psychedelic treatment had a higher likelihood of being efficacious, with higher symptoms reduction and larger quality of life improvement compared to treatment offered by a medical professional. Conclusions: Lifetime prevalence of psychopathologies in the current sample of psychedelic drug users seemed to be higher than in the general population. Self-medication with psychedelics was not highly frequent, though when it occurred it was rated as significantly more effective as treatment offered by a medical professional. Current findings support research exploring the potential of psychedelics in the treatment of psychopathologies. Clinical Trial: na

  • Background: Using a Community-Based Participatory Research (CBPR) approach may increase the likelihood of relevance and acceptability of the designed intervention, especially on a college campus. Furthermore, recruiting and training college students to design and implement a social marketing framed healthy lifestyle intervention for their peers will allow the intervention to be tailored to the needs of the campus Objective: To describe the process of training college students to develop a campus-based, social marketing health promotion intervention Methods: Four universities recruited current college students (18+ y.o.) to develop a social marketing and environmental intervention (SMEI), which was completed during a 16-week semester course. Researchers and Extension professionals trained students to design 24 weeks of intervention events that would be implemented the upcoming year. Results: Seventy-eight students enrolled in the study and SMEI course among the four intervention states (FL=30, SD=8, TN=13, WV=27); students were predominately Caucasian (65.8%), females (84.0%), and sophomore status in college (64.9%). Throughout the semester, students assessed their campus environments, set priorities, and developed weekly events and resources needed to implement the intervention on their campuses. By the end of the semester, the students had designed 24 weeks of intervention events focusing on nutrition/food/diet, physical activity, stress management, sleep, and time management. SMEI students designed interactive events, advertisements, artwork, and social media posts for the intervention. These events and resources were catalogued into a digital toolkit of instructions and activities for each week of intervention events. Conclusions: Training students to be social marketing and environmental interventionists via the CBPR process allows for the development of an intervention that stems from grass roots efforts and is tailored to the acceptability and needs of their peers. Clinical Trial: This study was prospectively registered in October 2016 on clinicaltrials.gov, NCT 02941497.

  • TaskExchange: Facilitating online collaboration in evidence synthesis

    Date Submitted: Oct 26, 2017
    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: The conduct and publication of scientific research is increasingly open and collaborative. There is growing interest in online platforms that can effectively enable global, multidisciplinary scientific teams, and create networks of scientists in areas of shared research interest. Designed to facilitate online collaboration in research evidence synthesis, TaskExchange highlights the potential of these kinds of platforms. Objective: This paper describes the development, growth and future for TaskExchange, an online platform facilitating collaboration in research evidence synthesis. Methods: The original aim for the development of TaskExchange was to create a platform that connected people who needed help with their Cochrane Systematic Reviews (rigorous syntheses of health research) with people who had the time and expertise to help. The scope of TaskExchange has now been expanded to include other evidence synthesis tasks, including guideline development. The development of TaskExchange was undertaken in four agile development phases with substantial user engagement. In each phase, software was iteratively deployed as it was developed and tested, enabling close cycles of development and refinement. Results: TaskExchange enables users to browse and search tasks and members by key word or nested filters, post and respond to tasks, sign up to notification emails and acknowledge the work of TaskExchange members. The pilot platform has been open access since August 2016, has almost 1500 members and has hosted more than 400 tasks, covering a wide range of research synthesis-related tasks. Response rates are consistently over 70% and user feedback has been positive. Conclusions: TaskExchange demonstrates the potential for new technologies to support online collaboration in health research. Development of a relatively simple platform for peer-to-peer exchange has provided opportunities for systematic reviewers to get their reviews completed more quickly, and provides an effective pathway for people to join the global health evidence community.

  • Depression is predicted by emotional instability on Facebook, but by reduced emotion variability on Twitter

    Date Submitted: Oct 25, 2017
    Open Peer Review Period: Oct 26, 2017 - Dec 21, 2017

    Background: Frequent expression of negative emotion words on social media has been linked to depression. However, metrics have relied on average values, not dynamic measures of emotional volatility. Objective: This study reports on the associations between depression severity and the variability (time-unstructured) and instability (time-structured) in emotion word expression on Facebook and Twitter across status updates. Methods: Status updates and depression severity ratings of 29 Facebook users and 49 Twitter users were collected through the app MoodPrism. The average proportion of positive and negative emotion words used, within-person variability, and instability were computed. Results: Negative emotion word instability was a significant predictor of greater depression severity on Facebook (rs(29) =.44, p = .017, 95% CI [.09, .69]), even after controlling for the average proportion of negative emotion words used (partial rs(26)= .51, p = .006) and within-person variability (partial rs(26) = .49, p = .009). A different pattern emerged on Twitter where greater negative emotion word variability indicated lower depression severity (rs(49) = -.34, p = .011, 95% CI [-.58, .09]). Differences between Facebook and Twitter users in their emotion word patterns and psychological characteristics were explored. Conclusions: The findings suggest that negative emotion word instability may be a simple yet sensitive measure of time-structured variability useful when screening for depression through social media, though this may only be the case for Facebook.

  • Background: In the shared healthcare model that eHealth proposes, the literature has noted the need to use more advanced methods and models to evaluate physicians’ eHealth usage outcomes. Objective: The goal of our study was to design and evaluate a predictive multidimensional model of European general practitioners’ eHealth usage outcomes. Methods: We used data from a 2012-2013 survey of a sample of 9,196 European general practitioners. We proposed and tested two composite indicators of eHealth usage outcomes (internal practices [IP] and practices with patients [PP]) by means of two-stage structural equation modeling with latent variables and measurement errors. Logistic regression (odds ratios, OR) to model the predictors of eHealth usage outcomes indicators was performed using independent variables corresponding to sociodemographic circumstances, attitudes towards ICT impact, and working conditions. Results: The dimensions with more explanatory power of eHealth usage outcomes in internal practices were ICT usage, electronic health records_data, electronic health records_decision support systems, personal health records and Telehealth. In contrast, the eHealth usage outcomes in practices with patients were only explained by the composite indicator of eHealth usage outcomes in the internal practices and by Telehealth usage. For 54.8% (5,035/9,196) and for 55.8% (5,133/9,196) of European general practitioners, the eHealth usage outcomes in internal practices and in practices with patients were more favorable (greater than the mean). European general practitioners who were female (IP OR 1.15, 95% CI 1.10–1.20; PP OR 1.19, 95% CI 1.14–1.24) and younger –aged < 35 years (IP OR 1.14, 95% CI 1.02–1.26; PP OR 1.32, 95% CI 1.13–1.54) and aged 36-45 years (IP OR 1.16, 95% CI 1.06–1.28; PP OR 1.21, 95% CI 1.10–1.33) – had a higher propensity towards favorable eHealth usage outcomes in internal practices (IP) and in practices with patients (PP). European general practitioners who positively valued the effect of ICT on their personal work processes (IP OR 5.30, 95% CI 4.73–5.93; PP OR 4.83, 95% CI 4.32–5.40), teamwork processes (IP OR 4.19, 95% CI 3.78–4.65; PP OR 3.38, 95% CI 3.05–3.74) and relations with patients (IP OR 3.97, 95% CI 3.60–4.37; PP OR 6.02, 95% CI 5.43–6.67) showed a high propensity towards the favorable results of eHealth uses (IP and PP). European general practitioners who had used 2.0 applications in their personal lives frequently (IP OR 1.77, 95% CI 1.60–1.97; PP OR 1.94, 95% CI 1.74–2.15) or occasionally (IP OR 1.16, 95% CI 1.06–1.28; PP OR 1.19, 95% CI 1.08–1.31) also had a high propensity towards favorable eHealth usage outcomes. Self-employed European general practitioners (IP OR 1.33, 95% CI 1.22–1.45; PP OR 1.10, 95% CI 1.03–1.28) also showed more favorable results in eHealth usage. Lastly, general practitioners who reported that the number of patients treated had remained constant (IP OR 1.08, 95% CI 1.01–1.17) or had increased in the last two years (PP OR 1.12, 95% CI 1.03–1.22) had a greater predisposition towards favorable eHealth usage outcomes. Conclusions: We provide new evidence of predictors (sociodemographic issues, attitudes towards ICT impacts, and working conditions) explaining favorable eHealth usage outcomes. The results highlight the need to develop more specific policies for general practitioners’ eHealth usage to address different realities. Clinical Trial: NONE

  • Background: OpenNotes is a national initiative to share clinicians’ visit notes with patients. Studies suggest that transparent notes can improve care, but little is known about their effect on care for vulnerable populations. Objective: To examine the importance of online visit notes to vulnerable patients. Methods: Patients at an urban academic medical center with an active patient portal account and at least one available ambulatory visit note over the prior year were surveyed during June-Sep 2016. The survey assessed importance of reading notes for: 1) understanding health conditions, 2) feeling informed about care, 3) understanding how patients’ providers are thinking about their medical conditions, 4) remembering the plan of care, and 5) making decisions about care. Response options ranged from 0 to 10. We compared the proportion of patients reporting 9-10 (“extremely important”) for each item across three sociodemographic factors: education level, race/ethnicity, and self-reported health. Results: 6,913/24,722 (28%) patients completed the survey. Non-white patients and those with a high school education or less were more likely to report that notes are “extremely important” for all 5 items than white and more educated respondents, respectively (p< 0.01 for all comparisons). Patients with poorer self-reported health were as or more likely to indicate that notes are "extremely important" for all items. Conclusions: Patients who are non-white, less educated, and sicker each assigned higher importance to reading open notes for several health behaviors than white, highly educated and healthier patients. Some vulnerable patients who use the portal may find OpenNotes especially valuable for understanding their health and engaging in their care. Facilitating access to notes may improve engagement in health care for some vulnerable populations who have historically been more challenging to reach.

  • The Mediating Effect of Internet Addiction in the Relationship between Individualism and Cyberbullying

    Date Submitted: Oct 22, 2017
    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Among a variety of dynamics that may have an effect in Internet-related behaviors, cultural orientation is particularly important. Previous studies suggest that individualism is a strong determinant of aggressive behavior. In addition, findings suggest that vertical individualism may lead to the development of more tolerance for addiction and aggression. Objective: The study aimed to test whether vertical individualism has significant positive effects on cyberbullying and Internet addiction and whether horizontal individualism has significant negative effects on cyberbullying and Internet addiction. A theoretical model was specified to test the relationships among vertical versus horizontal individualism, cyberbullying, and Internet addiction. Methods: A total of 665 college students were selected using convenience sampling method and willingly participated in the study. Participants’ ages ranged from 17 years old to 19 years old (mean age=17.94, SD=1.12). Of the group, 462 were women (69.5 %) and 203 were men (30.5%). Study majors represented are mathematics (n=113, 17%), science (n=102, 15.3%), instructional technology (n=99, 14.9%), psychology (n=98, 14.7%), and others (n=253, 38.1%). Self-report instruments were used to measure vertical/horizontal individualism, cyberbullying, and Internet addiction. Results: Results show significant positive effect of vertical individualism (.10) and significant negative effect of horizontal individualism (-.12) on cyberbullying. In addition, the direct effect of vertical individualism on Internet addiction was significant (.28) but the direct effect of horizontal individualism was not (-.05). Finally, Internet addiction had a significant direct effect on cyberbullying (.39) as well as an intervening effect in the relationship between vertical individualism and cyberbullying. Results also indicate significant gender differences in cultural patterns and Internet addiction. Conclusions: Points raised in the current study should be valuable to researchers and taken into account by practitioners who design and implement prevention or treatment programs in dealing with Internet addiction or cyberbullying.

  • Background: Information and communication technologies are currently one of the supporting elements that may contribute to improving health and changing lifestyles. Objective: To evaluate the long-term effectiveness of adding an app to standardized counselling in order to increase physical activity (PA) and adherence to the Mediterranean diet (MD) and to analyze the effects of app adherence in lifestyles changes. Methods: Randomized, multicenter clinical trial with 12 month-follow up, including 833 participants, recruited by random sampling in six primary Spanish care centers (415 versus 418). Interventions: Counseling on PA and MD was given to both groups by a nurse research. The counseling+app group (IG) received additional training in the use of an app that was designed to promote MD and PA over a 3-month period. Main Outcomes and Measures: PA by accelerometer and the 7-day Physical Activity Recall (PAR) questionnaire and adherence to the MD by an adherence screener questionnaire. We considered adherence to the app to be high when it was used for >60 days. Results: The mean age was 51 years (SD 12) in the IG and 52.3 (SD 12.0) in the counseling only group (CG); females predominated in both groups (60.0% and 64.1%, respectively). PA by accelerometer declined in both groups at 12 months (p for tendency in moderate-vigorous PA [MVPA]=0.146).The subgroup of IG with high app adherence had better behavior than the low adherence subgroup (p for tendency in MVPA=0.001). The PA analyzed by 7-day PAR did not show changes at 12 months in any of the groups (p for tendency=0.245). In MD, an increase in adherence was observed in both groups at 12 months with no differences between them (p for tendency=0.465). In these two cases the group with high app adherence also had better behavior although without reaching significance for the tendency (p >0.05). Conclusions: In subjects with high app adherence, better results in healthy lifestyle improvements were observed. Overall, however, no differences were found between the IG group and CG in PA increase and adherence to the MD in the long-term. Clinical Trial: Clinical Trials.gov Identifier: NCT02016014 (https://clinicaltrials.gov/ct2/show/NCT02016014)

  • Background: Internet-based CBT (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but has not yet been examined when disseminated as a public health intervention. If effective, iCBT programs may offer promise as a first-step, low-intensity intervention that can be easily accessed by young people. Objective: The aim of this study was to examine changes in anxiety severity in young people enrolling in a publicly available online, self-help iCBT program (BRAVE Self-Help). Methods: This study conducted an open trial, involving the analysis of data collected from 1094 children and adolescents aged 7-17 years who presented with elevated anxiety at baseline and commenced the program during the data collection period. The iCBT program was delivered through an open-access portal with no professional support. Anxiety severity was assessed via scores on the Children’s Anxiety Scale, 8-item (CAS-8) at four time points; baseline, Session 4, Session 7 and Session 10. Results: Statistically significant reductions in anxiety were evident across all time points for both children and adolescents. For users who completed 6 or more sessions, there was an average 4-point improvement in CAS-8 scores (d=0.87 for children, d=0.81 for adolescents) indicative of a moderate to large effect size. For participants who completed 9 sessions, 58.3% (95 out of 163) achieved clinically meaningful, and 54.6% (89 out of 163) achieved statistically reliable reductions in anxiety. Conclusions: Substantial and meaningful reductions in anxiety symptoms were achieved by many children and adolescents taking part in a completely open-access and self-directed iCBT program. Online self-help CBT may offer an effective and viable first step for service delivery with children and adolescents with anxiety. Clinical Trial: n/a

  • Background: Carriers of BRCA mutations are asked to communicate genetic test results to their close biological relatives and advocate for genetic services. This process is highly variable from family to family. Interventions that support communication of genetic test results, coping, and offer decision support in families that harbor a pathogenic variant may contribute to more effective management of hereditary cancer. Objective: This paper describes the development of the Family Gene Toolkit©, a web-based intervention targeting BRCA carriers and untested biological relatives, designed to enhance coping, family communication, and decision-support. Methods: We present findings from focus groups regarding intervention acceptability and participant satisfaction, and findings from a pre-post pilot study with random allocation to a wait listed control group regarding intervention feasibility and usability. Results: The Family Gene Toolkit© was developed by a multidisciplinary team as a psycho-educational and skills-building intervention, including two live webinar sessions and a follow-up phone call guided by a certified genetic counselor and a Master’s prepared oncology nurse. Each live webinar includes two modules (total four modules) presenting information about BRCA mutations, a decision-aid for genetic testing, and two skills-building modules for effective coping and family communication. Participants in focus groups (n=11) were highly satisfied with the intervention, reporting it was useful and illustrative of pertinent issues. From the n=12 dyads recruited in the pre-post pilot study (response rate 23%), completion rate was 71% and 20% for the intervention and wait-listed control group, respectively. Conclusions: Acceptability and satisfaction with the Family Gene Toolkit© is high. Based on usability and feasibility testing, modifications on timing, delivery mode, and recruitment methods are planned. Clinical Trial: NCT02154633

  • Background: Electronic Health Records (EHR) are becoming the standard of care in healthcare settings, with their great potentials to reduce operational costs, improve healthcare quality, and patient’s safety. Various factors may influence physicians’ satisfaction, and there is a need to address them according to healthcare workers’ needs in Saudi Arabia. Objective: The objective of this study was to explore factors that may have influenced satisfaction with a newly-implemented EHR system (namely: eSiHi or Electronic System for Integrated Health Information) among Physicians in the Pediatric Department at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia Methods: Methods: A cross-sectional survey was conducted on the physicians of Pediatric Department, KSUMC, between July-August 2015, after two months of launching the EHR system (eSiHi). Results: A total of 150 physicians enrolled in the survey, only (120, 80%) responded to the survey in a timely manner. Tentative analysis of missing values, however, revealed that 112 surveys were complete and suitable for inclusion in the analysis. As such, response rate was 74.6%. 60% of the physicians were males and 40% were females. 27.6% of them were consultants, 43% specialists, followed by 28% who were residents. Almost half of the physicians had no previous experience with Electronic Medical Records (51.8%). 86.7% of the respondents have attended the workshops and the training courses before the implementation of the new EHR system. On average, they rated their satisfaction levels with the EHR (eSiHi) at 5.2 out of 10, and for the usefulness for the patient's care it was rated on average (6.4 out of 10). 82.2% of respondents believed that the EHR improves the Quality of care and reduces errors and 73% of the respondents agreed that EHR's Improve the quality of the clinical practice environment. 55.8% indicated that EHR increased the practice productivity. Conclusions: There is a global and national transition toward an EHR system in the hospitals and the physicians have the willing to support this transition and they appreciate the potential benefits of this system over the paper-based system. In order to increase the like hood of a successful transition, an ongoing technical support must be considere

  • 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.