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

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Smartphone applications for mindfulness interventions with suicidality in Asian youths: Evidence is lacking

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

    Background: Background: The advent of mobile technology has ushered in an era where smartphone applications can be used for intervention for suicidality. Objective: Objective: Review recent research relevant to smartphone application that can be used for mindfulness intervention for suicidality in Asian youths. Methods: Methods: The inclusion criteria for this review is papers published in peer reviewed journals from 2007 to 2017 with usage of search terms namely ‘smartphone application’, and ‘mindfulness’, assessed against the inclusion criteria and screened by an experienced Asian clinician to be of clinical utility for mindfulness intervention for suicidality with Asian youths. Results: Results: Initial search on databases yielded 375 results. 14 Full text papers that fit the inclusion criteria were assessed for eligibility and 10 papers were included in the current review. Conclusions: Conclusions: This review highlighted the paucity of evidence-based and empirically validated research into effective smartphone applications that can be used for mindfulness interventions for suicidality with Asian youths. Clinical Trial: NA

  • User-centered design of a mobile app for weight and health management in adolescents with complex health needs: A qualitative needs assessment

    Date Submitted: Jun 23, 2017
    Open Peer Review Period: Jun 25, 2017 - Aug 20, 2017

    Background: Growing research has been conducted into the deployment and evaluation of mobile technology interventions for weight management in adolescents. However, no work has yet been conducted towards the development of these technologies for adolescents with complex health needs receiving specialized tertiary-level healthcare. Objective: The aim of the present study was to conduct a user-centered needs assessment of adolescents with complex health needs requiring specialized healthcare services and interested in weight management, their parents and healthcare providers, to inform the design and development of a mobile app for weight and health management. Methods: A qualitative study design was employed. Participants were recruited from 2 tertiary healthcare centres. Separate audio-taped focus group interviews were conducted with adolescents, parents and healthcare providers. Interviews were transcribed and field notes were collected by research staff. Iterative simple content analysis was performed independently by 4 research team members using computer software NVIVO 10.0. Results: 19 adolescents, 16 parents, and 21 healthcare providers were interviewed. Qualitative analysis revealed 7 major themes related to app functionality: healthy eating, social support, self-monitoring, communicating with healthcare professionals, supporting mental health, gamification and incentives, and user interface design. Adolescents provided several ideas related to each feature, while parents’ views focused on assistance with meal planning and greater access to healthcare professionals. Healthcare providers viewed the app as a novel and more acceptable platform to connect remotely with adolescents than conventional methods. They also strongly endorsed the value of social support capabilities and the ability to connect with a healthcare professional. Conclusions: This is the first study to conduct a qualitative needs assessment in adolescents receiving specialized healthcare services towards the design of a mobile app for weight and health management. Our results indicate that core components of the app should include tailored meal recommendations and assistance with meal planning, social networking for peer support, customized and convenient tracking, remote access to healthcare professionals, features to support mental health, and an attractive and engaging user interface. These findings will be used to develop and evaluate a mobile app targeting adolescents with complex health needs.

  • Comparison of the Effects of Exercise Therapy between Digital Video Disc and Web-site-based Interventions in Patients with Hip Osteoarthritis

    Date Submitted: Jun 23, 2017
    Open Peer Review Period: Jun 23, 2017 - Aug 18, 2017

    Background: Prevalence of developmental hip dysplasia is high in Japan, and morbidity associated with hip osteoarthritis has been reported as 1.0-4.3%. It is estimated that this figure will rise as the aging population grows. Exercise therapy has been proven effective to treat certain aspects of hip osteoarthritis. Moreover, therapy provided via DVDs and web sites, allows patients to exercise in the comfort of their own homes. However, no studies have evaluated the effectiveness of visual instructions in patients with hip disorders thus far. Objective: This study aimed to compare the effectiveness of exercise therapy administered via DVDs and that administered via web sites. Methods: We developed a six-step progressive exercise therapy program for patients with hip osteoarthritis, which included three kinds each of Open-Kinetic-Chain and Closed-Kinetic-Chain exercises. The exercise menu was designed such that patients could reach Step 6 in 3 months by advancing to a new step every 2 weeks, with 30 to 40 min of exercise daily. Once the program was developed, exercise DVDs were produced using easily comprehendible pictures, videos and relaxing music. The DVD users were shown the number of times each exercise should be performed, in order to promote exercise continuity. In addition to the six-step exercise program, our web site was enabled to count the number of exercises performed by each patient and was accessible via the internet at any time. We instructed the patients to start at an appropriate level and step up every two weeks unless they experienced pain, when they were asked to stop temporarily. Patients with hip osteoarthritis for whom surgery was not advised were enrolled by one university hospital. Clinical symptoms and hip function were quantified using the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire (JHEQ) and the Oxford Hip Score (OHS). Quality of life was measured using the SF-8 Health Survey, and self-efficacy for continued exercise was measured using the General Self-Efficacy Scale (GSES). Questionnaires were completed pre-intervention and after 6 months. Results: At 6-month follow-up, 10 DVD users (1 male, 9 female; mean age 51.3 [SD=16.1] years), and 18 web-site users (2 male, 16 female; mean age 52.3 [SD=10.4] years) were reachable. Small effect was observed for JHEQ-pain, SF-8 physical component summary (PCS) and SF-8 mental component summary in the DVD group, and for OHS, SF-8 (PCS) and GSES in the web-site group. Although we could not confirm a significant improvement, most parameters tended to improve over the 6 months. Conclusions: When comparing the effectiveness of exercise therapy between our DVD and web site, we found that, while both groups tended to improve in physical function, only the web-site group showed enhanced self-efficacy.

  • Transforming literature on people’s health experience s into a co-design workshop card-tool to inspire interaction

    Date Submitted: Jun 22, 2017
    Open Peer Review Period: Jun 23, 2017 - Aug 18, 2017

    Background: Patient experiences are an essential focus when designing healthcare services, as they are linked to patient outcomes, safety, clinical effectiveness and more meaningful health interactions. A wealth of peer-reviewed data exists in the current literature that can help with understanding peoples’ experiences of health and health care services. Yet, health improvement teams are unable to find practical ways to use it and may therefore overlook its value. Objective: This study explored how the existing healthcare experience literature can be utilised in healthcare design. A card-tool was developed that can be used in healthcare collaborative design (co-design) workshops to make existing literature accessible and thereby enable understanding of health experiences, trigger discussion and facilitate human-centered healthcare improvements. Methods: Qualitative research, exploring the experience of living with diabetes and preventing diabetic eye disease, was gathered through a review of the literature. The findings were analysed through a process of affinity diagramming to identify insights into the health experience. These insights were developed into a card-tool, the Health Experience Insight Cards: Living with Diabetes edition that was used in a co-design workshop with participants who had relevant professional experience to discuss the future prevention of diabetic eye-disease. Results: The review identified papers 13 papers that fit the selection criteria. These were analysed to develop the Health Experience Insight Cards, Living with Diabetes Edition. Six Participants used the cards, in a co-design workshop. Analysis of the workshop identified three types of interaction that resulted from playing the cards in the design-game: (a) applying the insight from the card to the character/story, (b) discussing real life and (c) discussing experiences. Conclusions: A method was developed to transform patient experience literature into Health Experience Insight Cards. The method aids understanding of experiences, facilitates discussion and enables groups to work towards improving healthcare from a human-centred perspective.

  • Evaluation of the effectiveness of mhealth applications in self-care management of chronic lower back pain

    Date Submitted: Jun 21, 2017
    Open Peer Review Period: Jun 22, 2017 - Aug 17, 2017

    Background: Reviews of patient-targeted smartphone applications for pain management [22] showed that despite the large availability of applications for pain tracking, self-management, and exercise training, the science of implementation of mHealth technologies and self-management of chronic conditions are important areas for further research [2, 23]. There has been little research regarding methods associated with continued user engagement, or the effectiveness of adherence to certain health platforms [6,14,24] for improving health outcomes among those living with chronic diseases. Objective: This study investigated the interaction of patients with various features of Limbr, a modular mHealth compliance enhancement intervention for self-management of Chronic Lower Back Pain (CLBP). Limbr is comprised of self-directed rehabilitation tutorial videos, personalizable, visual self-report tools, health coach support, and sensor-assisted passive tracking of activity levels. The Limbr program aims to promote adherence to the BackRx exercise rehabilitation regimen [21], increase engagement in self-directed management of pain (including pain, medication and exercise tracking) and improve self-reported outcomes of pain. Methods: We assessed CLBP patients’ adherence to (1) a 3-month, self-directed, rehabilitation program, and (2) user engagement in both self-reporting Activities of Daily Living (ADLs), medication, affect, and pain function, and frequency of messages to and from the health care coach. In addition, we tested the association between scores derived from our visual self-report method, YADL (an image based tool for tracking patient reported ADLs), and the well established Oswestry Disability Index (ODI) obtained from the Oswestry Low Back Pain Questionnaire. Participants were a convenience sample recruited through their clinician in New York, NY. 98 patients agreed to participate, of which, 35 patients completed the full 3 month intervention. In aggregate over 202 data points per patient were collected and analyzed. Results: Study results indicate that the Limbr mHealth intervention promoted engagement in patient self-monitoring and management of pain through use of the mobile applications. The 35 participants who completed the full three months of engagement demonstrated a sustained intensity of use of the Limbr system, with 65% of participants interacting at least once a week. Roughly 50% of participants perceived the visual self-reports as helpful in tracking pain-related ADLs, medication, and affect. In particular, about 60% of participants found YADL helpful in keeping track of ADLs. About two-thirds (71% and 67%) of the participants agreed that the daily notifications were beneficial in reminding them to complete the daily surveys and exercises respectively. 50% of the participants perceived the engagement features as highly motivating and very useful. It was also found that the Limbr self-assessment, YADL, is correlated to the ODI Index (P < .001). Conclusions: These results indicate that mHealth interventions that consist of visual self-reporting, personalized health coach messaging, weekly user updates and sensor-assisted reminders, can be very effective in promoting adherence to the self-management of chronic LBP and to a self-directed rehabilitation regimen. Clinical Trial: NCT03040310

  • e-Vita: Effect of integration of self-management web platforms on health status in COPD disease management in primary care

    Date Submitted: Jun 22, 2017
    Open Peer Review Period: Jun 22, 2017 - Aug 17, 2017

    Background: Worldwide nearly 3 million people die from chronic obstructive pulmonary disease (COPD) every year. Integrated disease management (IDM) improves quality of life for COPD patients and can reduce hospitalization. Self-management of COPD through eHealth is an effective method to improve IDM and clinical outcomes. Objective: The objective of this implementation study was to investigate the effect of three chronic obstructive pulmonary disease (COPD) eHealth programs applied in primary care on health status. The e-Vita COPD study compares different levels of integration of web-based self-management platforms in IDM in three primary care settings. Patients’ health status is examined using the Clinical COPD Questionnaire (CCQ). Methods: The parallel cohort design includes i) three levels of integration in IDM (groups 1, 2, 3) and ii) randomization of two levels of personal assistance for patients (group A high assistance, group B low assistance). Interrupted time series (ITS) design was used to collect CCQ data at multiple time points (before/after intervention) and multilevel linear regression modelling was used to analyse CCQ data. Results: Of the 702 invited patients, 215 (31%) registered to a platform. Of these, 82 participated in group 1 (high integration IDM), 36 in group 1A (high assistance), and 46 in group 1B (low assistance); 96 participated in group 2 (medium integration IDM), 44 in group 2A (high assistance) and 52 in group 2B (low assistance); also, 37 participated in group 3 (no integration IDM). In the total group, no significant difference was found in change in CCQ-trend (p=0.334) before (-0.47% per month) and after the intervention (-0.084% per month). Also, no significant difference was found in CCQ changes before vs. after the intervention between the groups with high vs. low personal assistance. In all subgroups, there was no significant change in the CCQ trend before and after the intervention (group 1A p=0.237; 1B p=0.991; 2A p=0.120; 2B p=0.166; group 3 p=0.945). Conclusions: The e-Vita eHealth-supported COPD programs had no beneficial impact on the health status of COPD patients. Also, no differences were found between the patient groups receiving different levels of personal assistance. Clinical Trial: NTR4098 (31072013)

  • A Predictive Cognitive Model for Implementation Intention and Reminder Effects on Behavior Change in a Mobile Health System

    Date Submitted: Jun 21, 2017
    Open Peer Review Period: Jun 21, 2017 - Jun 30, 2017

    Background: Implementation intentions are mental representations of simple plans to translate goal intentions into behavior under specific conditions. Studies show implementation intentions can produce moderate to large improvements in behavioral goal achievement. Human associative memory mechanisms have been implicated in the processes by which implementation intentions produce effects. Based on the ACT-R theory of cognition, we hypothesized that the strength of implementation intention effect could be manipulated in predictable ways using reminders delivered by a mobile health (mHealth) application. Objective: The aim of this experiment was to manipulate the effects of implementation intentions on daily behavioral goal success in ways predicted by the ACT-R theory concerning concerning mHealth reminder scheduling. Methods: An incomplete factorial design was used in this mHealth study. All participants were asked to choose a healthy behavior goal associated with Eat Slowly, Walking, or Eating More Vegetables, and were asked to set implementation intentions. N = 66 adult participants were in the study for 28 days. Participants were stratified by Self-Efficacy and assigned to one of two Reminder conditions: Reminders-presented versus Reminders-absent. Self-Efficacy and Reminder conditions were crossed. Nested within the Reminders-presented condition was a crossing of Frequency of reminders sent (High, Low) by Distribution of reminders sent (Distributed, Massed). Participants in the Low Frequency condition got 7 reminders over 28 days; those in the High Frequency condition were sent 14. Participants in the Distributed conditions were sent reminders at uniform intervals. Participants in the Massed Distribution conditions were sent reminders in clusters. Results: There was a significant overall effect of reminders on achieving a daily behavioral goal (coefficient = 2.018, SE = 0.572, odds ratio = 7.52, 95% CI [0.9037, 3.2594], P < .001). As predicted by ACT-R, using default theoretical parameters, there was an interaction of reminder Frequency by Distribution on daily goal success (coefficient = 0.7994, SE = 0.2215, odds ratio = 2.2242, 95% CI [0.3656, 1.2341], P < .001). The total number of times a reminder was acknowledged as received by a participant had a marginal effect on daily goal success (coefficient = 0.0694, SE = 0.0410, odds ratio = 1.0717, 95% CI [-0.01116, 0.1505], P = 0.09) and the time since acknowledging receipt of a reminder was highly significant (coefficient = -0.0490, SE -= 0.0104, odds ratio, 95% CI [-0.0700, -0.2852], P < .001). A dual system ACT-R mathematical model was fit to individuals’ daily goal successes and reminder acknowledgments: A goal-striving system dependent on declarative memory and a habit-forming system that acquires automatic procedures for performance of behavioral goals. Conclusions: Computational cognitive theory, such as ACT-R, can be used to make precise quantitative predictions concerning daily health behavior goal success in response to implementation intentions and the dosing schedules of reminders.

  • Applying Social Network Analysis to Understand the Percentages of Keywords within Abstracts of Journals: A System Review of Three Journals

    Date Submitted: Jun 20, 2017
    Open Peer Review Period: Jun 20, 2017 - Aug 15, 2017

    Background: Academic literature suggests keywords that are retrieved from a paper’s title and abstract represent important concepts in that study. The percentage of keywords within an abstract (PKWA) is required to investigate. Objective: To compare the PKWA in journals of medical informatics and the keyword network relationship in order to develop a self-examining policy for the journal. Methods: Selecting 5,985 abstracts and their corresponding keywords in three journals (JMIR, JAMIA, and BMC Med Inform Decis Mak.) published between 1995 to 2017(April) on the US National Library of Medicine National Institutes of Health (Pubmed.org), we computed the PKWA for each journal by using MS Excel modules and compared the percentage differences across journals and years via a two-way ANOVA. Social network analysis (SNA) was performed to explore the relations of keywords in journals. Results: The PKWA are 48.81, 41.59, and 56.84 for the three journals, respectively. A statistically significant difference (p < 0.05) is found in the percentages among journals selected. In contrast, no differences (p> 0.05) are found (1) between years (2016 and 2017) and (2) in interaction effects between journals and years. Three journals display significantly different patterns in network keywords and major cohesion measures. Conclusions: It is required to apply the computer module when inspecting whether keywords are within abstracts. The cohesion measure provides journal editors with a method of examining keywords within an abstract for a paper under review.

  • Time-Series Analysis of Newspaper Articles about HPV Vaccines

    Date Submitted: Jun 19, 2017
    Open Peer Review Period: Jun 20, 2017 - Aug 15, 2017

    Background: Media coverage and reports are also major factors in influencing individual vaccination and other health-related activities. People use the media to seek information and knowledge on health-related behaviors. people obtain health-related information from media such as television and newspapers, and they trust such information. While a number of studies have examined the relation between media coverage and individual health, there is a lack of studies that analyze media reports of health information. In particular, no analyses related to cervical cancer vaccine were found. Objective: This study aims to focus on reports pertaining to the Human Papillomavirus vaccine mentioned in Japan’s printed news media and reveal their characteristics. Methods: “Yomidasu Rekishikan,” which is Yomiuri Shinbun’s archival database, and “Kikuzo II Visual,” which is Asahi Shinbun’s archival database, were used for text mining. First, a database was created by extracting articles published between January 1, 2007, and December 31, 2014, which matched the terms “cervical cancer, vaccination” in a keyword search. Then, the extracted articles were tallied based on the month of publication, and number of characters to conduct a time-series analysis. Results: A total of 219 articles were extracted. Of these, 154 [70.3%] were positive, and 51 [23.3%] were negative. Of the 51 negative articles, 4 articles [8.0%] were published before June 2013, when routine vaccination was temporarily discontinued due to concerns regarding side effects, and 47 articles [92.0%] were published since then. The negative reports commonly cited side effects, although prior to June 2013, these issues were hardly mentioned. Although foreign media reports mentioned side effects before the routine vaccination was temporarily discontinued, fewer articles included side effects than articles recommending vaccinations. Furthermore, on June 13, 2013, WHO’s advisory body GACVS [Global Advisory Committee on Vaccine Safety] issued a statement regarding the safety of cervical cancer vaccine, but hardly any articles reported this statement. Rather, several articles were written about the side effects after June 2013. Conclusions: As we consider media coverage as a factor that affects human health behavior, the media should extensively report on the cost of not receiving cervical cancer vaccination, global trends concerning cervical cancer vaccination, and statements released by various agencies on the subject.

  • A preliminary study to evaluate the perceived benefits of an artificial intelligence embedded mobile app for the self-management of chronic neck and back pain.

    Date Submitted: Jun 20, 2017
    Open Peer Review Period: Jun 20, 2017 - Aug 15, 2017

    Background: Chronic musculoskeletal neck and back pain are disabling conditions among adults. Use of technologies had been suggested to be an alternative way to increase exercise therapy uptake and may improve clinical outcomes. Objective: To evaluate the feasibility of an artificial intelligence embedded mobile app to self-manage chronic neck and back pain. Methods: 161 users responded to the invitation to take part. The evaluation questionnaire included 13 questions that were intended to discover if using the AI system may: 1) increase adherence and uptake of exercise therapy; 2) affect pain level; and 3) reduce the need for other interventions. Results: An increase in time spent on exercise therapy per day was observed. The average reduction of pain level was one point. Three-point reduction was reported from users who had used the system for over six months. Reduction in the usage of other interventions while using the AI system was also observed. Conclusions: This study supported the perceived beneficiary effect of the AI embedded mobile app to provide a personalized intervention. It showed the potential benefits to support the self-management of these conditions. The positive results suggested that it at least warrant further study to investigate the benefit of the AI system and how it compares with routine clinical care.

  • Development of a Whole Slide Imaging System on Smartphones and Evaluation with Frozen Section Samples

    Date Submitted: Jun 19, 2017
    Open Peer Review Period: Jun 20, 2017 - Aug 15, 2017

    Background: Whole slide scanners, which turn thousands of field-of-views (FoVs) under microscopes into virtual slides (VS's), is an essential but costly link in digital pathology and automatic analysis. Utilizing capturing and processing capability of smartphones and existing optical microscopes for whole slide imaging has been a promising alternative but no commercial-quality products had been available. Objective: The aim was to develop scalable Whole Slide Imaging (sWSI), a whole slide imaging system based on smartphones coupled with optical microscopes. This ultra-low-cost solution should offer diagnostic-ready imaging quality on par with standalone scanners, supporting both oil and dry object lens of different magnification. All performance metrics should be evaluated by expert pathologists and match those of high-end scanners. Methods: In the sWSI design, the digitization process is split between clients on smartphones and cloud servers. The clients automatically capture FoVs at up to 12-mega-pixel resolution and process real-timely to give instant feedback of guidance. The servers computationally correct unknown non-linear distortion introduced by the lens of smartphones on-the-fly before combining all FoVs into one giga-pixel virtual slide for each scan. In the evaluation experiment, 100 frozen section slides from patients randomly selected among in-patients of the participating hospital are scanned both by a high-end Leica scanner and sWSI. All virtual slides were examined by senior pathologists whose diagnosis are compared against those made from optical microscopy as ground truth to evaluate the image quality. Results: The sWSI system is developed for both Android and iPhone smartphones and currently being offered to the public. The image quality is solid and throughput is approximately 1 FoV per second, yielding a 15-by-15 mm slide under 20X object lens around 30-35 minutes with little training for the operator. The expected cost for setup is about $100 and scanning each slide costs between $1 and $10, making sWSI highly cost-effective for infrequent or low-throughput usage. In the clinical evaluation on sample-wise diagnostic reliability, 0.78, 0.88, 0.68 and 0.50 average accuracy for breast, uterine corpus, thyroid and lung samples are achieved by sWSI-scan-based diagnosis, respectively. The respective low-sensitivity rates are 0.05, 0.05, 0.13 and 0.25 while the respective low-specificity rates are 0.18, 0.08, 0.20 and 0.25. The participating pathologists agreed that the overall quality is generally on par with that produced by high-end scanners, not affecting diagnosis in most cases. They confirmed that sWSI is reliable enough for standard diagnosis of most tissue categories while can be used for quick screening for the difficult ones. Conclusions: As an ultra-low-cost alternative to whole slide scanners, diagnosis-ready virtual slide quality and robustness for commercial usage is achieved in the sWSI solution. Operated on main-stream smartphones installed on normal optical microscopes, sWSI readily offers affordable and reliable whole slide imaging to resource-limited or infrequent clinical users.

  • Replacing Alumni Surveys with Extant Internet Data plus a Single-Question Survey

    Date Submitted: Jun 16, 2017
    Open Peer Review Period: Jun 19, 2017 - Aug 14, 2017

    Background: A standardized alumni survey that is short, provides program-specific feedback, and could allow programs to compare their performance to each other is not available. Objective: To test if a single-question survey, along with additional information readily available on the web, can be used to create a standardized alumni survey for academic programs. Methods: Alumni surveys were conducted for two programs: Master of Health Administration (MHA) and Master of Science in Health Informatics (MSHI). Most of the information collected through alumni surveys (demographic, emails, career information, industry, location of work, and estimated salary) were obtained by examining information available on the alumni on the web. Additional information (review of program content and courses) was obtained by emailing the alumni and asking them “Regarding your recent degree, what worked well and what needed improvement?” The available data and alumni responses were weighted to be representative of all alumni and not just the group whose information were on the web. Results: Among 41 MHA and 50 MSHI alumni 1-2 years out of the program, email information was available 43% and 55% of time respectively. Other information, including demographic (100%, 100%), current employer (89%, 82%), and estimated salary (78%, 74%) were also widely available. When available, the average estimated salary for MHA graduates 1-2 years out was $92,957 and for MSHI graduates was $72,904. In addition, among the MHA and MSHI who were contacted by email, 75% of MHA and 34% of MSHI alumni completed the free-text program review. Their comments were detailed and program specific. Independent reviewers classified comments into Curriculum, Program Organization, Capstone Related, Job Placement, External Relationships, Student Body, Personal Growth, and Value/Cost categories. Most comments (80% for MHA and 74% for MSHI) were positive and focused on program organization and program curriculum. Conclusions: The proposed alumni survey can be applied to different programs. Items in this survey had a high response/availability rate. The survey identified the impact of the program on employment and salary. Furthermore, the program review component of the survey provided useful insight on how programs could be improved in the future. Additionally, these procedures can be used to benchmark different programs against each other.

  • Development and Pretest of a Computer-assisted Personal Interview in REDCapTM to Administer Time Trade-off Surveys

    Date Submitted: Jun 13, 2017
    Open Peer Review Period: Jun 16, 2017 - Aug 11, 2017

    Background: The time trade-off (TTO) task is a method of eliciting health utility scores, which range from 0 (equivalent to death) to 1 (equivalent to perfect health). These scores numerically represent a person’s health-related quality-of-life (HRQoL). Software applications exist to administer the TTO task; however, most of these applications are poorly documented and unavailable to researchers. Objective: To fill the void, we developed an online application to administer the TTO task for a research study that is examining general public proxy HRQoL estimates for persons with Alzheimer’s disease (AD). This manuscript describes the development and pretest of the application. Methods: We used Research Electronic Data Capture (REDCap™) to build the TTO application. The application’s modular structure and REDCap™’s object-oriented environment facilitated development. After the TTO application was built, we recruited a purposive sample of 11 members of the general public to pretest its functionality and ease-of-use. Results: Feedback from the pretest group was positive. Minor modifications included clarity enhancements, i.e., re-arranging some paragraph text into bullet points, labelling the application to delineate different question sections, and revising or deleting text. We also added a research question to enable the identification of respondents who know someone with Alzheimer’s disease (AD). Conclusions: We developed an online application to administer the TTO task. Other researchers may access and customize the application for their own research purposes.

  • Biomedical Semantic Indexing using search and graph database technologies

    Date Submitted: Jun 12, 2017
    Open Peer Review Period: Jun 16, 2017 - Aug 11, 2017

    Background: Biomedical Semantic Indexing is a very useful support tool for human curators in their efforts for indexing and cataloguing the biomedical literature. Objective: This paper describes a system to automatically assign Medical Subject Headings (MeSH) to biomedical articles from Medline. Methods: Our approach relies on the assumption that similar documents should be classified by similar MeSH terms. While previous work has already exploited the document similarity by using a k-Nearest-Neighbours (kNN) algorithm, we calculate document similarity using a search engine. In addition, we implement one of the main guidelines used by human curators to annotate Medline articles. To do this, the MeSH thesaurus is represented as a graph database, which allow us to employ graph search algorithms in order to faster and easily capture hierarchical relationships such as the shortest path between two terms or their lowest common ancestor. Results: Our experiments show promising results with an F1 of 70% on the test dataset, overcoming the top participating systems in the BioASQ 2016 task 4a. Conclusions: To the best of our knowledge, this is the first work that uses an approach based on search and graph database technologies for the task of biomedical semantic indexing.

  • Web-based decision-aid to assist help-seeking choices for young people who self-harm: Outcomes from a randomised controlled feasibility trial

    Date Submitted: Jun 16, 2017
    Open Peer Review Period: Jun 16, 2017 - Aug 11, 2017

    Background: Adolescents who self-harm are often unsure how or where to get help. We developed a web-based personalised decision aid (DA), designed to support young people in decision-making about seeking help for their self-harm. Objective: Our aim was to evaluate the feasibility and acceptability of the DA intervention and the randomised controlled trial (RCT) in a school setting. Methods: We conducted a 2-group, single blind, randomised controlled feasibility trial in a school setting. Participants aged 12-18 years who reported self-harm in the past 12 months were randomised to either an web-based DA or to general information about mood and feelings. Feasibility of recruitment, randomisation and follow-up rates were assessed, as was acceptability of the intervention and study procedures. Descriptive data were collected on outcome measures examining decision-making and help-seeking behaviour. Qualitative interviews were conducted with young people, parents/carers and staff, and subjected to thematic analysis to explore their views of the DA and study processes. Results: Parental consent was a significant barrier to young people participating in the trial, with only 208 (18%) of the 1,164 parent/guardians contacted for consent responding to study invitations. Where parental consent was obtained, we were able to recruit 82% (n=170) of young people into the study. Of those young people screened, 14% (n=23) had self-harmed in the past year. Ten participants were randomised to receiving the DA and 13 were randomised to the control group. Four-week follow-up assessments were completed with all participants. The DA had good acceptability but qualitative interviews suggested that a DA that addressed broader mental health problems such as depression, anxiety and self-harm may be more beneficial. Conclusions: A broad-based mental health DA addressing a wide range of psychosocial problems may be useful for young people. The requirement for parental consent is a key barrier to intervention research on self-harm in the school setting. Adaptations to the research design and/or the intervention are needed before generalisable research about DAs can be successfully conducted in a school setting. Clinical Trial: ISRCTN11230559

  • Mining Online Author’s Publication to Report the Core Research Domain with PubMed MeSH Terms: A Systematic Review for a Journal

    Date Submitted: Jun 15, 2017
    Open Peer Review Period: Jun 15, 2017 - Aug 10, 2017

    Background: Identifying an author’s research domain (RD) using MeSH (Medical Subject Headings) terms is important for a journal’s development and for its readership, but no journal uses mining online methods or social network analysis (SNA) to extract journal publication information to report an author’s contributions. Objective: To select prestigious authors and papers that have contributed most to a journal, we retrospectively (1) calculated an SCI (Science Citation Index) journal’s most recent impact factors (IF) and (2) used graphical representations that include MeSH terms of RDs for authors and journals. Methods: We collected 2053 papers published between July 1, 1999, and April 3, 2017, in the Journal of Medical Internet Research (JMIR) and cited by 673 journals, for which we also collected annual IFs for 394 SCI journals, including the JMIR. The prestigious authors and JMIR papers based on the weight of the 5-year SCI IFs from 394 cited-by papers in 2015. The JMIR core aims and scope are presented using major MeSH terms based on their corresponding average weighted scores. Social network analysis was used to create a graphical RD pattern for JMIR, and its prestigious papers and authors. Results: All JMIR 5-year IFs have not been less than 2.9 for the past 14 years. The authors who contributed most to JMIR in number of publications and in weighted citations are Gunther Eysenbach and My Hua. Their cohesion measures (ranging from 0 to 1.0) to JMIR are 34% and 5.7%, respectively. The highest prestige weighted contribution among papers published in JMIR is the one (PMID: 23567935 /DOI: 10.2196/jmir.2324 ) with a cohesion measure of 4.5%. Conclusions: An author’s research domain is required with an essential and graphical presentation along with the author’s submission to the target journal. Journal editors also look forward to evaluating an author’s research domain and the submitted paper’s cohesion measure for the journal.

  • Towards developing consumer health vocabulary by mining health forum texts based on word vector space: a semi-automatic approach

    Date Submitted: Jun 15, 2017
    Open Peer Review Period: Jun 15, 2017 - Aug 10, 2017

    Background: Vocabulary gap between consumers and professionals in medical domain hinders information seeking and communication. Objective: To explore the application of a distributed word vector space model to identify new words in certain semantic categories, to build up a Chinese consumer health vocabulary, and to fill the gap between professional medical terminology and consumer vocabulary. Methods: Textual content from one of the largest Chinese online community, the Tianya community, was crawled and extracted. Word2vec was employed to construct a word vector for each word in the corpus. Then we used small sets of terms from ICD-10 and other human-curated dictionaries as seed words, from which we expand the vocabularies by calculating word-word similarities and word-category similarities. We explored how these word vectors help find synonyms for each term, and help identify new terms that belong to certain semantic categories. Results: The best precision for finding new words via the category representative word vector was 90%, and the coverage of words belong to the categories expanded as much as 14.51 times. Experimental results demonstrate that the method is able to identify common misspellings and abbreviations frequently used by consumers which does not exist in original professional terminologies. Conclusions: This study demonstrates the effectiveness of using distributed word vector as semantic representations of health-related consumer words in Chinese, and its capability to identify new words in certain semantic categories via calculating word-word similarities and word-category similarities. We show that our method has the potential to be employed to develop a Chinese consumer health vocabulary to improve consumers’ experiences in searching health information. Clinical Trial: None

  • Using Social Media Content to Assess the Population Impact of a New Paediatric Influenza Vaccination Programme in England

    Date Submitted: Jun 15, 2017
    Open Peer Review Period: Jun 15, 2017 - Aug 10, 2017

    Background: A new childhood live attenuated influenza vaccine (LAIV) programme was launched in England in 2013, which consisted of a national campaign for all 2 and 3 year olds and several pilot locations offering the vaccine to primary school (4-11 years) children during the influenza season. The 2014/15 influenza season saw the national programme extended and included additional pilot regions, some of which offered the vaccine to secondary school (11-13 years) children as well. Objective: We utilise social media content to obtain a complementary assessment of the programmes that were launched in England during the 2013/14 and 2014/15 flu seasons. The overall community-wide impact on transmission in pilot areas is estimated for the different age groups that were targeted for vaccination. Methods: A previously developed statistical framework is applied, which consists of a non-linear regression model that is learnt to infer influenza-like illness (ILI) rates from Twitter posts originating in pilot (vaccinated) and control areas. The control areas are then used to estimate ILI rates in pilot areas, had the intervention not taken place. These predictions are compared with their corresponding Twitter-based ILI estimates. Results: Results suggest a reduction in ILI rates of 14% (1%-25%) and 17% (2%-30%) across all ages in primary school age only vaccine pilot areas during the 2013/14 and 2014/15 influenza season, respectively. No significant impact is observed in areas where only two age cohorts of secondary school children were vaccinated. Conclusions: These findings corroborate independent assessments from traditional surveillance data, thereby informing on the most effective vaccination strategies for the campaign and providing evidence of the value of social media content as an additional syndromic surveillance tool.

  • Clinical decision support systems for drug allergy checking: a systematic review

    Date Submitted: Jun 15, 2017
    Open Peer Review Period: Jun 15, 2017 - Aug 10, 2017

    Background: Worldwide the burden of allergies, and in particular drug allergies, is growing. In the process of prescribing, dispensing or administering a drug, a medication error can occur, which can have adverse consequences, for example when a drug is given to a patient with a documented allergy to this particular drug. Computerized physician order entry systems (CPOE) with built-in clinical decision support systems (CDSS) have the potential to prevent these medication errors and consequent adverse events. Objective: In this systematic review, we provide a comprehensive overview regarding all aspects of CDSS for drug allergies including development, implementation, coding terminologies, and outcome evaluation. Methods: PRISMA guidelines were followed and searches were conducted in five databases using CPOE, CDSS, alerts, and allergic or allergy as keywords. Results: Of the 3,160 articles considered, 60 met the inclusion criteria. Nine additional articles were added based on expert opinion, resulting in a total of 69 articles. Large heterogeneity across study objectives, study designs, study populations and reported results was found. Several key findings were identified. Evidence of the usefulness of CDS for drug allergies has been documented. Nevertheless, there are some important problems associated with their use. Accurate and structured documenting of drug allergy information in the electronic health record is difficult, as it is often not clear for healthcare providers how and where to document drug allergies. Besides underreporting of drug allergies, outdated or inaccurate drug allergy information in the electronic health record poses an important problem. Research on the use of coding terminologies for documenting drug allergies is sparse. There is a lack of use of a generally accepted standard terminology for the structured documentation of allergy information. A last key finding is the consistently reported low specificity of drug allergy alerts. Current systems have high alert override rates of up to 90% leading to alert fatigue. Important challenges remain for increasing the specificity of drug allergy alerts. We only found one study specifically reporting on outcome related to CDSS for drug allergies. It showed that ADEs resulting from overridden drug allergy alerts do not occur frequently. Conclusions: Accurate and comprehensive recording of drug allergies is required for the good use of CDSS for drug allergy screening. We found considerable variation in the way drug allergies are recorded in the EHR. It remains difficult to reduce drug allergy alert overload while keeping patient safety as highest priority. Future research should focus on improving alert specificity, thereby reducing override rates and alert fatigue. Also the effect on patient outcome and the cost-effectiveness should be evaluated.

  • Fall Detection in Individuals with Lower-limb Amputation using Mobile Phones: Machine Learning Enhances Robustness for Real-World Applications

    Date Submitted: Jun 13, 2017
    Open Peer Review Period: Jun 14, 2017 - Aug 9, 2017

    Background: Automatically detecting falls with smartphones provides an opportunity for rapid response to injuries and better knowledge of what precipitated the fall and its consequences. This is beneficial for populations that are prone to falling, such as people with lower limb amputations. Many prior studies have focused on fall detection in able-bodied individuals and using data from a lab-setting only. Such approaches may provide a limited ability to detect falls in amputees and in real-world scenarios. Objective: We sought to develop a classifier which uses data from able-bodied subjects to detect falls in individuals with a lower-limb amputation, as they freely carry the smartphone in different locations both in lab and at home. Methods: We obtained 861 simulated indoor and outdoor falls from 10 young able-bodied subjects and 6 individuals with a lower limb amputation. In addition, we recorded a broad database of activities of daily living (ADL), including data from 3 subjects’ free-living routine. Sensor readings (accelerometer and gyroscope) from a smartphone were recorded, as subjects freely carried it in three common locations – on the waist, in a pocket, and in the hand. A set of 40 features were computed from the sensors data and 4 classifiers were trained and combined through stacking to detect falls. We compared the performance of 2 population-specific models, trained and tested on either healthy or amputee subjects, with that of a model trained on healthy subjects and tested on amputees. A simple threshold-based classifier was used to benchmark our machine learning classifier. Results: The accuracy of fall detection in amputees for a model trained on able-bodied (Sens: 0.98 ± 0.02, Spec: 0.97 ± 0.03) was not statistically different (P = 0.69) from that of a model trained on the amputee population (Sens: 0.98 ± 0.02, Spec: 0.97 ± 0.02). Detection of falls in able-bodied yielded similar results (Sens: 0.98 ± 0.02, Spec: 0.99 ± 0.01). An average number of 2.2 ± 1.69 false alarms per day were obtained when evaluating the model (vs 122 ± 166 based on thresholds) on data recorded as subjects carried the phone during their daily routine for 2 or more days. Machine learning classifiers outperformed the threshold-based one (P < 0.002). Conclusions: A smartphone-based fall detection model can use data from able-bodied to detect falls in individuals walking with a prosthesis. We successfully detected falls when the mobile phone is carried across multiple locations and without a predetermined orientation. Furthermore, the number of false alarms yielded by the model over a longer period of time was reasonably low, considering that users carried and used the phone freely and without any specific instruction. This moves the application of smartphone-based fall detection systems closer to a real-world use case scenario.

  • Mining the Posts with Unified Medical Language System Metathesaurus to Enhance Online Patients' Knowledge Support

    Date Submitted: Jun 13, 2017
    Open Peer Review Period: Jun 13, 2017 - Aug 8, 2017

    Background: Online health communities (OHCs) provide patients effective social healthcare services and a channel where patients can discuss their health conditions and share their experiences with others. The posts contain a vast amount of biomedical information in natural language, including drugs, symptoms and conditions, but are hard for secondary use to provide better knowledge support to online patients in disease prevention and self-management due to the semantic complexity of the texts. Objective: The objective of this study is to propose a practical mining method to make the best use of explicit and implicit biomedical knowledge in the patient-reported posts to improve patients’ abilities of seeking knowledge support online. Methods: By integrating the biomedical knowledge sources including Unified Medical Language System (UMLS) Metathesaurus, Systematized Nomenclature of Medicine -- Clinical Terms (SNOMED CT), and MetaMap program, a new mining method is proposed. Furthermore, we collected 372,343 patient-reported posts from an OHC to test the proposed mining method in terms of information extraction and knowledge discovery. Three metrics, namely the Knowledge Richness Degree (KRD), the Potential Knowledge Conversion Rate (PKCR) and the Knowledge-Constrained Online Behavior Index (KC-OBI), are proposed to evaluate the performance of the proposed method to provide knowledge support. Results: The results of the experiment on 671 drug-related posts (0.18% of total 372,343 posts), show significant difference between our proposed mining method and traditional dictionary-based method according to the Mann-Whitney Test with α=.05 and P<.001. The distribution of the KRD falls in the range [0.20, 0.60] for the traditional method and in the range [0.03, 0.20] for our proposed method. According to the evaluation of the changes of PKCR , as the number of discovered biomedical concepts increases; however, the PKCR of the post reduces (Skewness=5.93, Kurtosis=40.47, P=.003<.05), which exponentially reduces. Conclusions: The results suggest that by integrating the biomedical domain knowledge into the process of mining online posts, the healthcare platforms are enhanced to implement the knowledge-based support for online patients in their disease prevention and continual self-management training. Therefore, the designers of the community should make use of the biomedical knowledge indicators to help the system to implement machine learning techniques to analyze the online health reports.

  • “Eating chicken feet with pickled peppers cause avian influenza”? An observational case study on a hot topic in the Chinese social media during the avian influenza A (H7N9) outbreak

    Date Submitted: Jun 13, 2017
    Open Peer Review Period: Jun 13, 2017 - Aug 8, 2017

    Background: A hot topic on the relationship between a popular avian-origin food and avian influenza occurred in the social media during the outbreak of the emerging avian influenza A (H7N9). The misinformation generated from this topic had caused great confusion and public concern. Objective: Our goals were to explore the trend and contents of the relevant posts with the hot topic. We also aimed to understand the characteristics of the misinformation and to provide suggestion to reduce public misconception in the social media during the emerging disease outbreak. Methods: The original microblog posts were collected from China’s Sina Weibo and Tencent Weibo using a combination of key words between April 1, 2013 and June 2, 2013. We analyzed the weekly and daily trend of the relevant posts. Content analysis were applied to categorize the posts into four kinds with a unified sorting criteria. The posts’ characteristics and geographic locations were also analyzed in each category. We conducted further analysis on the top 5 most popular misleading posts. Results: A total of 1680 original microblog posts on the topic were retrieved and 341 (20.3%) of them were categorized as “misleading messages”. The number of relevant posts had not increased a lot during the first 2 weeks but rose to a high level in the next 2 weeks after the suddenly rising number of reported cases at the beginning of week 3. The posts under “misleading messages” also occurred and increased from the beginning of week 3, but their daily posting number decreased when the daily number of posts under “correcting messages” outnumbered them. The bloggers of the misleading posts had the lowest mean rank of followers and previous posts, but their posts had a higher mean rank of the replies or number of retweets. The proportion of “misleading messages” in the places with no reported cases was significantly higher than that in the epidemic areas (25.8%>16.4%). The most popular misleading posts appeared to be narrative and attractive. Conclusions: Our findings suggested the importance to respond to common questions and misconception in the social media from the beginning of disease outbreaks. Authorities need to release clear and reliable information related to the popular topics early. The bloggers posting correct information should be empowered and their posts could be promoted to clarify false information. Equal importance should be attached to clarify misinformation in both the outbreak and non-outbreak areas.

  • Discovering Cohorts of Pregnant Women from Social Media for Safety Surveillance and Analysis

    Date Submitted: Jun 8, 2017
    Open Peer Review Period: Jun 10, 2017 - Aug 5, 2017

    Background: Pregnancy exposure registries are the primary sources of information about the safety of maternal usage of medications during pregnancy. Such registries enroll pregnant women in a voluntary fashion early on in pregnancy, and follow them until the end of pregnancy or longer to systematically collect information regarding specific pregnancy outcomes. While the model of pregnancy registries has distinct advantages over other study designs, they are faced with numerous challenges and limitations, such as low enrollment rate, high cost and selection bias. Objective: The primary objectives of this study were to systematically assess if social media (Twitter) can be used to discover cohorts of pregnant women, and to develop and deploy a natural language processing and machine learning pipeline for automatic collection of cohort information. In addition, we also attempted to ascertain, in a preliminary fashion, what types of longitudinal information may potentially be mined from the collected cohort information. Methods: Our discovery of pregnant women relies on detecting pregnancy-indicating tweets (PITs)—which are statements posted by pregnant women regarding their pregnancies. We use a set of 14 patterns to first detect potential PITs. We manually annotated a sample of 14,156 of the retrieved user posts to distinguish real PITs from false positives, and trained a supervised classification system to detect real PITs. We optimize the classification system via cross validation with features and settings targeted towards optimizing precision for the positive class. For users identified to be posting real PITs via automatic classification, our pipeline collects all their available past and future posts, from which other information (e.g., medication usage and fetal outcomes) may be mined. Results: Our rule-based PIT detection approach retrieved over 200,000 posts over a period of 18 months. Manual annotation agreement for three annotators was very high at κ=0.79. On a blind test set, the implemented classifier obtained overall F1-score of 0.84 (0.88 for the pregnancy class; 0.68 for the non-pregnancy class). Precision for the pregnancy class was 0.93, and recall was 0.84. Feature analysis showed that the combination of dense and sparse vectors for classification achieved optimal performance. Employing the trained classifier resulted in the identification of 71,954 users from the collected posts. Over 200 million posts were retrieved for these users, which provided a multitude of longitudinal information about them. Conclusions: Social media sources such as Twitter can be used to identify large cohorts of pregnant women, and to gather longitudinal information via automated processing of their postings. Considering the many drawbacks and limitations of pregnancy registries, social media mining may provide beneficial complementary information. While the cohort sizes identified over social media are large, future research will have to assess the completeness of the information available through them.

  • The SCI & U Story: Participatory Design of an Online Self-Management Tool for Spinal Cord Injured Users

    Date Submitted: Jun 6, 2017
    Open Peer Review Period: Jun 7, 2017 - Aug 2, 2017

    Background: Re-hospitalization rates resulting from secondary complications in individuals with spinal cord injuries (SCI) are high. Self-management programs for many chronic conditions have been associated with decreases in hospital re-admissions. However, in the SCI community, evidence suggests satisfaction with traditional self-management programs to be low. Persons with SCI have indicated preference for programs that are online (rather than in-person), that target SCI-specific concerns and are led by peers with SCI. There is currently no program with all of these features and which addresses self-management of secondary complications after SCI. Objective: This study details a Participatory Design (PD) process for an internet-mediated self-management intervention for users with SCI (called SCI & U) and presents initial design and development products resulting from this process. Methods: Users were involved in development as co-designers, co-developers and key informants. Co-designers and co-developers were recruited from Ontario consumer advocacy groups and worked with a core University of Toronto-based development team. Key informants were recruited from geographically distributed consumer advocacy groups to form a product advisory group; this group has met regularly with the core team. During meetings, co-designers and informants have walked through phases of work that typify PD processes, namely exploration, discovery and prototyping. This paper focuses on ten meetings which took place between August 2015 and May 2016. Meetings were recorded, transcribed and analyzed using a qualitative descriptive methodology; resulting themes were then organized based on their relationship to PD phases and design products. Results: A total of 16 individuals participated in meeting discussions, including 7 researchers and 9 persons with SCI from 4 Canadian provinces. Group members with SCI reported using the internet to access self-management information, yet few had experience with interactive tools to promote community dialogue about health conditions, like forums or review sites. Review of existing tools elicited concerns related both to the credibility and volume of online information about self-care. To mitigate concerns, the group proposed and designed systems to filter and promote “credible” online information; these included: 1) community-based ratings and reviews; 2) access to online ‘peer navigators’; and 3) group conversations or chats. Selected design concepts are illustrated. Conclusions: A PD process engaging users as co-designers, co-developers and informants successfully identified key considerations related to the organization and presentation of online self-management information for the SCI community. A working prototype with systems and features proposed by the group is currently available online and is to serve as a baseline for further development.

  • Using WhatsApp to support quality improvement teams: Experiences from an Indian hospital

    Date Submitted: Jun 7, 2017
    Open Peer Review Period: Jun 7, 2017 - Aug 2, 2017

    Background: Quality improvement involves four steps: 1) forming a team to work on this specific aim, 2) analyzing the reasons for current poor performance, 3) developing changes that could improve care and testing these changes using plan-do-study-act (PDSA) cycles, and 4) putting place interventions to sustain the changes that work. Teamwork and group discussion are key for effective quality improvement, but convening in-person meetings with all staff can be challenging due to workload and shift changes. Mobile technologies can support communication within a team when face-to-face meetings are not possible. WhatsApp, a mobile messaging platform, was implemented as a communication tool by a neonatal intensive care unit (NICU) team in an Indian tertiary hospital seeking to reduce nosocomial infections in newborns. Objective: An exploratory qualitative study was performed to examine experiences with WhatsApp as a communication tool which improving adherence to aseptic protocol and how WhatsApp can be used as a coaching tool to strengthen quality improvement team functioning. Methods: Ten quality improvement team members and the external coach were interviewed on communication processes and approaches and thematically analyzed. The WhatsApp transcript for the implementation period was also included in the analysis. Results: WhatsApp was effective for disseminating information, including guides on how to do quality improvement, clinical guidance, and performance indicator data. It was not effective as a platform for group discussion to generate change ideas or analyze the performance indicator data. The decision of who to include in the WhatsApp group and how members engaged in the group may have reinforced existing hierarchies. Using WhatsApp created a work environment in which members were accessible all the time, breaking down barriers between personal and professional time. The continual influx of messages was distracting to some respondents, and how respondents managed these messages (e.g., using the silent function) may have influenced their perceptions of WhatsApp. The coach used WhatsApp to share information, schedule site visits, and prompt action on behalf of the team. Conclusions: WhatsApp is a productive communication tool that can be used by teams and coaches to disseminate information and prompt action to improve the quality of care, but cannot replace in-person meetings.

  • Challenges during implementation of a patient-facing mobile app for surgical rehabilitation

    Date Submitted: Jun 6, 2017
    Open Peer Review Period: Jun 7, 2017 - Aug 2, 2017

    Background: Translating research into practice, especially the implementation of digital health technologies in routine care, is increasingly important. Yet, there are few studies examining the challenges of implementing patient-facing digital technologies in healthcare settings. Objective: To report challenges experienced when implementing mobile apps for patients to support their post-surgical rehabilitation in an orthopaedic setting. Methods: A mobile app was tailored to the needs of patients undergoing rotator cuff repair. A 30-minute usability session and a 12-week feasibility study were conducted with patients to evaluate the app in routine care. Implementation records (observation reports, issues log, and email correspondence) explored factors that hindered or facilitated patient acceptance. Interviews with clinicians explored factors that influenced app integration in routine care. Results: Participant completion was low (47%, 9/19). Factors that affected patient acceptance included digital literacy, health status, IT infrastructure at home, privacy concerns, time limitations, the role of carer, inconsistencies in instruction received from clinicians and the app, and app advice not reflective of patient progress over time. Factors that negatively influenced app integration in routine care include competing demands among clinicians, IT infrastructure in healthcare settings, identifying the ‘right’ time to introduce the app to patients, user interface complexity for older patients, lack of coordination among multidisciplinary clinicians, and technical issues with app installation. Conclusions: Three insights were identified for mobile app implementation in routine care: 1) apps for patients need to reflect their journey over time, and in particular post-operative apps ought to be introduced as part of pre-operative care with opportunities for patients to learn and adopt the app during their postoperative journey; 2) strategies to address digital literacy issues among patients and clinicians are essential; and that 3) impact of the app on patient outcomes and clinician workflow needs to be communicated, monitored and reviewed. Ultimately, digital health interventions should supplement but not replace patient interaction with clinicians.

  • Disparities in using information and communication technologies especially video call for family life information sharing with family well-being: A population-based survey

    Date Submitted: Jun 2, 2017
    Open Peer Review Period: Jun 2, 2017 - Jul 28, 2017

    Background: The use of information and communication technologies (ICTs) for information sharing in family members is increasing dramatically. However, little was known about the associated factors and how it related to family well-being. Objective: We investigated the pattern and social determinants of family life information sharing with family and the associations of different methods of sharing with perceived family health, happiness and harmony (3Hs) in Hong Kong, where smartphone ownership and Internet access are among the most prevalent, easiest and fastest in the world. Methods: A territory-wide population-based telephone survey was conducted from January to August 2016 on different methods of family life information (information related to family communication, relationships with family members, emotion and stress management) sharing with family members, including face-to-face, phone, instant messaging (IM), social media sites, video call and email. Family well-being was assessed by three single items on perceived family health, happiness and harmony, with higher scores indicating better family well-being. Adjusted prevalence ratios were used to assess the associations of socio-demographic factors with family life information sharing, and adjusted beta coefficients (β) for family well-being. Results: Of 2017 respondents, face-to-face was the most common method to share family life information (74.45%, 1502/2017), followed by IM (40.86%, 824/2017), phone (28.10%, 567/2017), social media sites (11.91%, 240/2017), video call (5.89%, 119/2017) and email (5.48%, 111/2017). Younger age and higher education were associated with the use of any (at least one) method, face-to-face, IM, and social media sites for sharing family life information (all P for trend <.01). Higher education was most strongly associated with the use of video call (adjusted prevalence ratio =5.61, 95% CI 2.29-13.7). Higher household income was significantly associated with the use of any method, face-to-face and IM (all P for trend <.05). Sharing family life information was associated with a higher level of perceived family well-being (β=0.56, 95% CI 0.37-0.75), especially by face-to-face (β=0.62, 95% CI 0.45-0.80) and video call (β=0.34, 95% CI 0.04-0.65). The combination of face-to-face and video call was most strongly associated with a higher level of perceived family well-being (β=0.81, 95% CI 0.45-1.16). Conclusions: The differential use of ICT to share family life information supports the Inverse Information Law. The prevalence of video call was low but associated with much better family well-being. Intervention studies to promote the use of video call to communicate and share information with family, particularly in disadvantaged groups are warranted, and may reduce socioeconomic disparities.

  • Validity and reliability of central and peripheral augmentation index estimated by a novel wrist-worn tonometer

    Date Submitted: Jun 1, 2017
    Open Peer Review Period: Jun 2, 2017 - Jul 28, 2017

    Background: Incorporation in clinical practice of pulse wave analysis (PWA) still have difficulties mainly due to training requires and time spent. Objective: Analyze the reliability and validity of Pulse Wave Analysis as reported by a novel wrist-worn device, easy and quick to use, comparing central and peripheral augmentation index (AIx) with the same measures from the SphygmoCor MM3. Additionally, we analyzed the association with other parameters of vascular structure and function, end-organ damage, and cardiovascular risk. Methods: Cross sectional study including 254 subjects. Mean age was 51.9±13.4 and the subject population was 53% women. Main measures reported are: Peripheral AIx (PAIx), Central AIx, (CAIx) by the wrist-worn device and SphygmoCor; carotid-femoral (cf) pulse wave velocity (PWV) by SphygmoCor MM3; cardio-ankle vascular index (CAVI), ankle-brachial index (ABI) y brachial-ankle (ba) PWV by the Vasera device; carotid intima media thickness (IMT) measured using ultrasound; other measures of cardiac and renal function and cardiovascular risk. Results: Intra-observer intra-class correlation coefficient (ICC) for PAIx was 0.886 (95%CI:0.803 to 0.934) and for CAIx was 0.943 (95%CI:0.901 to 0.968) with Bland Altman limits of agreement of -0.75 (-23.8 to 21.8) and 0.08 (-15.7 to 15.9) respectively. The inter-observer ICC for PAIx was 0.952 (95%CI 0.915 to 0.972) and CAIx was 0.893 (95%CI:0.811 to 0.939) with limits of agreement of -0.45 (-13.7 to 12.8) and 0.43 (-17.7 to 18.5) respectively. Comparing the wrist-worn device to SphygmoCor, we observed an ICC of 0.849 (95%CI:0.798 to 0.887) for PAIx, and 0.783 (95%CI:0.711 to 0.838) CAIx. In Bland Altman analysis, limits of agreement for PAIx were -1.03 (-22.73 to 20.67) and CAIx 2.14 (-20.50 to 24.79). PAIx, CAIx, and heart rate-adjusted CAIx (CAIx_HR75) correlated with age, CAVI, ABI, baPWV, cfPWV, IMT, glomerular filtration rate, and cardiovascular risk. Conclusions: The wrist-worn device shows a good intra-observer and inter-observer reliability and inter-device reliability when compared to the SphygmoCor MM3, and a good validity when compared with other clinical measures that evaluate arterial stiffness, end-organ damage and cardiovascular risk. Clinical Trial: Clinicaltrials.gov NCT02623894;https://clinicaltrials.gov/ct2/show/NCT02623894

  • What Clinical Information is of Value to Doctors using a Mobile Electronic Medical Record and When?

    Date Submitted: Jun 1, 2017
    Open Peer Review Period: Jun 2, 2017 - Jul 28, 2017

    Background: There is a lack of understanding regarding what specific clinical information is most valuable for doctors to access through mobile electronic medical records (m-EMRs). Furthermore, it has not been discussed when the value of such information is high. Objective: The goal of this study is 1) to investigate what clinical information is most valuable for doctors to access through m-EMRs and 2) to discuss when such information is valuable. Methods: This study uses data from the usage logs of an m-EMR used by medical personnel in tertiary hospitals in South Korea. The study included 531,916 usage logs recorded during a ten-month period and demographics from 653 doctors. Several descriptive analyses were conducted to explore the overall usage patterns of the m-EMR. To assess the value of clinical information, the study first defined peak usage times as continuous intervals having normalized usage values of the m-EMR greater than 0.5. Second, usage logs were processed to be an indicator representing specific clinical information using factor analysis. Third, random intercept logistic regression was used to explore what clinical information is frequently accessed during the peak usage times. Based on the analyses results, the study discusses when particular information would be valuable. Results: The peak usage time of m-EMRs lasted between 6:00 a.m. and 10:00 a.m., and this was different from those of a hospital information system (HIS). Five factors representing types of clinical information were extracted through factor analysis based on the usage logs. Factors related to (1) patient investigation status and (2) patient conditions were associated with the peak usage times of m-EMRs (p < 0.01). Conclusions: Information on patient investigation status and patient conditions is highly demanded by doctors early in the morning, since the information is crucial for decision making in morning rounds. However, HIS access is highly limited around those hours. Thus, m-EMRs would best evolve in a manner that enhances the accessibility of specific clinical information helpful for decision making during rounds.

  • Feasibility and usability of a novel eHealth application for self-reports of sports-related injuries and illnesses in Paralympic sport

    Date Submitted: May 31, 2017
    Open Peer Review Period: May 31, 2017 - Jul 26, 2017

    Background: Few prospective studies have assessed sports-related injuries and illnesses in Paralympic sport (SRIIPS). Advances in smartphone technology and networking systems offer novel opportunities to develop innovative eHealth applications for collection of data on SRIIPS directly from athletes. Using eHealth applications for collection of self-reports in populations of Paralympic athletes with a broad range of impairments is, however, an unexplored area. Before initiation of full-scale programs, the validity of the approach needs to be ascertained. Objective: The aim of this study is to evaluate the monitoring feasibility and system usability of a novel eHealth application for longitudinal epidemiological research on self-reported SRIIPS. Methods: A prototype eHealth application for routine collection of data from athletes was developed and adapted to Paralympic athletes. A four-week pilot study was performed where Paralympic athletes (n=28) were asked to weekly self-report sport exposure, training load, general well-being, pain, sleep, anxiety and possible SRIIPS. The data collection was followed by a post-study use assessment survey. Quantitative data related to the system use, for example completed self-reports and missing answers, were analysed using descriptive statistical methods. The qualitative feasibility and usability data provided by the athletes were condensed and categorized using thematic analysis methods. Results: The weekly response rate was 95%. The athletes were of the opinion that the eHealth application was sustainable and feasible, but they stated that it was not fully conceptually adapted to Paralympic athletes and their impairments. For example, it was found difficult to understand how a new injury or illness should be identified when the impairment was involved. More survey items asking for data related to the impairment were requested as it was perceived that incidents often occurred because of the impairment. Options for description of multifactorial incidents including an injury, an illness, and the impairment were also found to be insufficient. Relatively few technical usability issues were encountered, but athletes with visual impairment reported usability difficulties with the speech synthesizer. A cumulative incidence of 1.8 injuries and 1.7 illnesses/100 hours of athlete exposure were recorded. The weekly pain prevalence was 57% and the impairment contributed to 20% of the reported incidents. Conclusions: eHealth-based data collection of self-reports of SRIIPS is generally perceived as feasible and usable. With some adaptation to accommodate Paralympic athletes’ conceptual prerequisites and improved technical support for VI athletes, the eHealth application can be recommended for use in longitudinal studies of SRIIPS. Clinical Trial: ClinicalTrials.gov (Identifier: NCT02788500)

  • Web-based medical service: Technology attractiveness, medical creditability, information source, and behavior intention

    Date Submitted: May 30, 2017
    Open Peer Review Period: May 31, 2017 - Jul 26, 2017

    Web-based medical service (WBMS), defined as a cooperative relationship between medical service and Internet-related technology, has been called one of the most innovative services of the 21st century. However, the business promotion and implementation in medical industry have not been executed as well as manufacturers expected. Few studies have explored this phenomenon in terms of medical credibility and medical information sources from patient’s viewpoint. The primary goal of this study was to explore whether those factors could create users’ behavior intention. This study explored the related effects in web-based medical service by using three situations to manipulate medical information sources. Questionnaires were used to collect the relative item scores about acceptance of inexperienced users in each situation. The analyses were performed with SPSS software, using hierarchical regression to examine the mediation and moderated-mediation effects. Perceived ease of use and perceived usefulness are significantly positive to enhance behavior intentions, and medical credibility is a mediator, but are not significantly different under diverse manipulative information channels. The results indicate that medical credibility could explain extra variation between technology attractiveness and behavior, but no significant at different medical information sources.

  • User Participation and Engagement with the See Me Smoke-Free mHealth App: Results of a Prospective Feasibility Trial

    Date Submitted: Apr 21, 2017

    Background: The See Me Smoke-Free (SMSF) mobile health (mHealth) application (app) was developed to help women quit smoking by targeting concerns about body weight, body image, and self-efficacy through cognitive behavioral techniques and guided imagery audio files addressing smoking, diet, and physical activity. A feasibility trial found associations between SMSF usage and positive treatment outcomes. This paper reports a detailed exploration of program use among those who downloaded the app, and the relationship between program use and treatment outcomes. Objective: To determine whether: 1) participants were more likely to set quit dates, be current smokers, and report higher levels of smoking at baseline than non-participants; 2) participants opened the app and listened to audio files more frequently than non-participants; and 3) participants with more app usage had a higher likelihood of smoking abstinence at follow-up. Methods: The SMSF feasibility trial was a single arm, within-subjects, prospective cohort study with assessments at baseline, 30- and 90-days post-enrollment. The SMSF app was deployed on the Google Play store for download, and basic profile characteristics were obtained for all app installers. Additional variables were assessed for study participants. Participants were prompted to use the app daily during study participation. Crude differences in baseline characteristics between trial participants and non-participants were evaluated using t-tests (continuous variables) and Fisher’s exact tests (categorical variables). Exact Poisson tests were used to assess group-level differences in mean usage rates over the full study period, using aggregate Google Analytics data on participation and usage. Negative binomial regression models were used to estimate associations of app usage with participant baseline characteristics, after adjustment for putative confounders. Associations between app usage and smoking abstinence were assessed using separate logistic regression models for each outcome measure. Results: Participants (n=151) were more likely than non-participants (n=96) to report female gender (P < 0.02) and smoking in the 30 days prior to enrollment (P < 0.0001). Participants and non-participants opened the app and updated quit dates at the same average rate (Rate ratio (RR) 0.98; 95% CI: 0.92, 1.04; P = 0.43), but participants started audio files (RR 1.07; 95% CI: 1.00, 1.13; P < 0.04) and completed audio files (RR 1.11; 95% CI: 1.03, 1.18; P < 0.003) at significantly higher rates than non-participants. Higher app usage among participants was generally associated with increased smoking cessation, and most effect sizes suggested strong associations, though generally without statistical significance. Conclusions: The current study suggests potential efficacy of the SMSF app, as increased usage was generally associated with higher smoking abstinence. A planned randomized controlled trial will assess the SMSF app’s efficacy as an intervention tool to help women quit smoking. Clinical Trial: ClinicalTrials.gov NCT02972515

  • Low- and No-Cost Strategies to Recruit Women to a Mobile Health Smoking Cessation Trial

    Date Submitted: Jan 19, 2017

    Background: Successful recruitment and retention of adequate numbers of participants to mobile health (mHealth) studies remains a challenge. Given that researchers must decide how to invest limited recruitment resources, it is important to identify the most effective recruitment strategies, defined as those that incur low costs relative to participant yield. Objective: The objective of this manuscript is to describe the development and implementation process for the recruitment phase of an mHealth intervention designed to increase smoking cessation among weight-concerned women smokers. These recruitment methods could be applicable across a range of mHealth studies. Methods: Study information was released to the media in multiple phases. First, local city and state media were contacted, followed by national women’s health media, and finally outlets in states with high smoking rates. Stories and mentions resulting from the press releases (earned media) were disseminated via existing department and new study-specific social media accounts. Strategic hashtags were used in Facebook and Twitter posts to connect with broader smoking cessation campaigns. Posts were also made to third-party Facebook smoking cessation communities and Internet classifieds sites. Results: Media coverage was documented across 75 publications and radio/television broadcasts, 35 of which were local, 39 national, and 1 international. Between March 30th and July 31st, 2015, 151 participants were successfully recruited to the study. Conclusions: Leveraging social media, and coordinating with university public affairs offices were effective and low-cost strategies to earn media coverage, and reach potential participants. Clinical Trial: Not Applicable

  • What is eHealth? The development of a conceptual model for eHealth based on qualitative interviews with key informants

    Date Submitted: May 29, 2017
    Open Peer Review Period: May 30, 2017 - Jul 25, 2017

    Background: Despite rapid growth in eHealth research, there remains a lack of consistency in defining, and using, terms related to eHealth. More widely cited definitions provide broad understanding of eHealth but lack sufficient conceptual clarity to operationalise eHealth and enable its implementation in healthcare practice, research, education and policy. Definitions that are more detailed are often context or discipline specific, limiting ease of translation of these definitions across the breadth of eHealth perspectives and situations. A conceptual model of eHealth that adequately captures its complexity and potential overlaps is required. This model must also be sufficiently detailed to enable eHealth operationalisation and hypothesis testing. Objective: This study aimed to develop a conceptual practice-based model of eHealth to support health professionals in applying eHealth to their particular professional or discipline contexts. Methods: Semi-structured interviews were conducted with key informants (n = 25) from organisations involved in health care delivery, research, education, practice, governance and policy to explore their perspectives on, and experiences with, eHealth. Purposeful sampling was used for maximum diversity. Interviews were coded and thematically analysed for emergent domains. Results: Thematic analyses revealed three prominent but overlapping domains of eHealth: (a) health in our hands (using eHealth technologies to monitor, track, and inform health), (b) interacting for health (using digital technologies to enable health communication among practitioners and between health professionals and clients/patients), and (c) data enabling health (collecting, managing and using health data). These domains formed a model of eHealth that addresses the need for clear definitions and a taxonomy of eHealth while acknowledging the fluidity of this area and the strengths of initiatives that span multiple eHealth domains. Conclusions: This model extends current understanding of eHealth by providing clearly defined domains of eHealth while highlighting the benefits of using digital technologies in ways that cross several domains. It provides the depth of perspectives and examples of eHealth use that is lacking in previous research. Based on this model, it is suggested that eHealth initiatives that are most impactful would include elements from all three domains.

  • Part of a system – the changing place of online activity within a sexual health economy

    Date Submitted: May 26, 2017
    Open Peer Review Period: May 29, 2017 - Jul 24, 2017

    Background: Regular testing for sexually transmitted infections (STIs) is important to maintain sexual health. Self-sampling kits, ordered online and delivered to the user in the post may increase user choice, convenience and cost-effectiveness. Sexual health economies may target limited resources more effectively by signposting users towards online or face-to face services according to clinical need. Objective: This paper investigates the impact of two interventions on testing activity across a whole sexual health economy a) the introduction of open access online STI testing services and b) a clinic policy of ‘triage and signpost’ online where users without symptoms who attended clinics for STI testing were supported to access the online service instead. Methods: Data on attendances at all specialist public sexual health providers in an inner-London area were collated into a single database. Each record included information on user demographics, service type accessed and clinical activity provided including test results. Clinical activity was categorised as a simple STI test (could be done in clinic or online), a complex visit (requiring face-to-face consultation) or other. Results: Introduction of online services increased total testing activity across the whole sexual health economy by 17.5%, suggesting unmet need for testing in the area. Triage and signposting shifted activity out of the clinic onto the online service with simple STI testing in the clinic decreasing from 17% to 12% of total activity and complex activity in the clinic increasing from 69% to75% of total activity. This intervention created a new population of online users who were different age, sex, presence of symptoms and positivity from those who use online services spontaneously. Some triage and signposted users (29%) did not complete the online testing process with the potential for missed diagnoses. Conclusions: This evaluation shows that users can effectively be transitioned from online to face-to-face services and that this introduces a new population to online service use and changes the focus of clinic based activity. Further development is underway to optimise the triage and signposting process to support test completion.

  • Thought Spot: Optimization of an eHealth solution through participatory action research with transition-aged youth in post-secondary settings

    Date Submitted: May 26, 2017
    Open Peer Review Period: May 29, 2017 - Jul 24, 2017

    Background: Seventy percent of lifetime cases of mental illness emerge prior to age 24, but many youth are unable to access the supports and services they require in a timely and appropriate way. With most youth using the Internet, eHealth interventions are promising tools for reaching this population. Through participatory action research (PAR) and participatory design research (PDR) engagement methods, Thought Spot, a web- and mobile-based platform, was redeveloped to facilitate access to mental health services by transition-aged youth in post-secondary settings. Objective: To describe the process of engaging with transition-aged youth through PAR and PDR approaches with the ultimate goal of optimizing the Thought Spot platform. Methods: Consistent with PAR and PDR approaches, five student-led workshops, attended by 41 students, were facilitated to obtain student feedback regarding help-seeking behaviours, the platform’s usability and functionality and its potential value in a post-secondary setting. The workshops were co-designed and co-facilitated by students to increase ownership by youth over the research process. Various creative engagement activities were delivered to provide opportunities for youth to share their experiences, including semi-structured focus groups, questionnaires, personas, journey mapping and a world café. Results: Participants discussed the following issues related to help-seeking throughout the workshops: feelings of confusion and vulnerability when accessing health or mental health services; concerns about stigma, taboos and labelling; and overall health care costs and time constraints. Innovative technological features and refinements were also brainstormed during the workshops. By using PAR methods of engagement, participants felt confident that their ideas and recommendations were welcomed and appreciated. There was also an overall sense of respect and care integrated into each group, which facilitated a genuine exchange of ideas and opinions. Conclusions: The process of engaging with transition-aged youth to redesign the Thought Spot digital platform through PAR and PDR has been effective. Findings from these workshops will significantly inform new technological features within the app that enable positive help-seeking behaviours among transition-aged youth. These behaviors will be further explored in the second phase that involves a randomized controlled trial.

  • Needle in a haystack: A comparison of online survey recruitment platforms for hard-to-reach populations

    Date Submitted: May 26, 2017
    Open Peer Review Period: May 26, 2017 - Jul 21, 2017

    Background: Smoking during pregnancy is the leading cause of infant mortality and pregnancy complications. Effective smoking cessation programs can significantly reduce the negative health outcomes associated with smoking while pregnant. This population, however, is difficult to recruit due to the social stigma surrounding the issue. Objective: To determine the feasibility of recruiting a hard-to-reach population of pregnant smokers using four different online platforms. Additionally, we aimed to describe the populations of participants available on each of the channels. Methods: A screener and survey were distributed online through Qualtrics Panel, Soapbox Sample, Reddit, and Amazon Mechanical Turk (mTurk). Descriptive statistics were used to summarize results of each recruitment channel, including eligibility yield, quality yield, income, race, age, and gestational age. Results: Of the 3,848 participants screened for eligibility across all four online platforms, 308 were eligible and completed the survey. Amazon mTurk yielded the least amount of completed responses (n=9), 93% of which passed several quality metrics verifying pregnancy and smoking status. Qualtrics Panel yielded 14 completed responses, 0.87% of which passed the quality screening. Soapbox Sample produced 107 completed surveys, 51.02% of which were found to be quality responses. Advertising through Reddit produced the highest completion rate (n=178) but only 29% of those surveys passed the quality metrics. Conclusions: Although each platform successfully recruited pregnant smokers, the results varied in quality, cost, and percentage of complete responses. Moving forward, investigators should pay careful attention to the percentage yield and cost of online recruitment channels to maximize internal and external validity.

  • Systematic adaptation of an eHealth intervention to promote physical activity and social network of single, chronically impaired older adults

    Date Submitted: May 24, 2017
    Open Peer Review Period: May 26, 2017 - Jul 21, 2017

    Background: Especially for single older adults with chronic diseases, physical inactivity and a poor social network are regarded as serious threats to their health and independence. The Active Plus intervention is a totally automated computer tailored eHealth intervention that has been proven effective to promote physical activity in the general population of older adults aged over 50. Objective: The aim of the present study is to report on the methods and results of the systematic adaptation of Active Plus to the narrower target population of single people over the age of 65 who have one or more chronic diseases, as this target population may encounter specific challenges regarding physical activity and social network. Methods: The Intervention Mapping Protocol is used to systematically adapt the existing intervention to optimally suit the new target population. A literature study is performed, and quantitative and qualitative data is derived from health care professionals (by questionnaires (n = 10)) and the target population (by focus group interviews (n = 14)), and systematically integrated into the adapted intervention. Results: Since the health problems and the targeted behaviour are largely the same in the original and adapted intervention, the performance objectives (i.e. the behaviour that the target population has to perform to reach the overall program objective) are not changed. As found in the literature study and in data derived from health professionals and the target population, the relative importance and operationalization of the relevant psychosocial determinants related to these objectives are different from the original intervention, resulting in a refinement of the change objectives (i.e. the intervention objectives specific for this intervention) to optimally fit the target population. This refinement - based on data derived from the target population - also resulted in changes in the practical applications, program components, intervention materials and in the evaluation- and implementation strategy. Conclusions: The present study demonstrates that the adaptation of an existing intervention is an intensive process in which adopting the Intervention Mapping protocol is an invaluable tool. The study provides a broad insight in adapting interventions aimed at single older adults with a chronic disease. It is concluded that even when the new target population is a sizable segment of the original target population, the adapted intervention still needs considerable changes to optimally fit the needs and situational differences of the narrower target population. Clinical Trial: Not applicable as this article does not report on the results of an intervention.

  • Cardiac patients’ experiences and perceptions of social media: a mixed methods study

    Date Submitted: May 22, 2017
    Open Peer Review Period: May 24, 2017 - Jul 19, 2017

    Background: Traditional in-person cardiac rehabilitation has substantial benefits for cardiac patients, which are offset by poor attendance. The rapid increase in social media use in older adults provides an opportunity to reach patients eligible for cardiac rehabilitation but who are unable to attend traditional face-to-face groups. However, there is a paucity of research on cardiac patient’s experiences and perspectives on using social media to support their health. Objective: This study aims to describe cardiac rehabilitation patient’s experiences in using social media in general and their perspective on using social media to support their cardiac health and secondary prevention efforts. Methods: A mixed methods study was undertaken among cardiac rehabilitation patients in both urban and rural areas which comprised a survey (n = 284) on social media use and six focus group interviews with current social media users (n = 18) to elucidate social media experience and perspectives. Results: Social media use was common (28%; 79/282) particularly in patients who were under 70 years of age, employed and had completed high school. Social media users accessed online information on general health issues (65%; 51/79), medications (56%; 44/79) and heart health (43%; 34/79). Patients were motivated to invest time in using social media for ‘keeping in touch’ with family and friends, and to be informed by expert cardiac health professionals and fellow cardiac patients if given the opportunity. Social media capability (understanding of features and the consequences of their use and efficiency in use) appears to influence the frequency and degree of engagement of social media use and the willingness to participate in a cardiac social media group. More capable users were more receptive to the use of social media for cardiac rehabilitation and more likely to express interest in providing peer support. Recommended features for a cardiac rehabilitation social media group using a Facebook platform included a closed group, expert cardiac professional involvement, provision of cardiac health information and ensuring trustworthiness of the group. Conclusions: Cardiac health professionals have an opportunity to capitalise on cardiac patients’ motivations and social media capability for supporting cardiac rehabilitation and secondary prevention. Patients’ favoured purposeful time spent on social media, and their cardiac health provides such a purpose for a social media intervention. The study results will inform the development of a social media intervention for secondary prevention of cardiovascular disease.

  • Methods for Co-Designing a Collaborative Chronic Care Network (C3N)

    Date Submitted: May 20, 2017
    Open Peer Review Period: May 21, 2017 - Jul 16, 2017

    Background: Learning Health Systems (LHSs) are seen as a means to accelerate outcomes, improve care delivery, and further clinical research, yet few such systems exist. Objective: We describe the process of co-designing, with all relevant stakeholders, an approach for creating a collaborative chronic care network (C3N), a peer-produced networked LHS. Methods: The setting was ImproveCareNow, an improvement network for pediatric inflammatory bowel disease. In collaboration with patients and families, clinicians, researchers, social scientists, technologists, and designers, C3N leaders used a modified idealized design process to develop a design for a C3N. Results: Over 100 people participated in the design process, which resulted in: a) an overall “concept design” for the ImproveCareNow C3N, b) a logic model for bringing about this system, and c) thirteen potential innovations likely to increase awareness and agency, make it easier to collect and share information, and to enhance collaboration – that could be tested collectively to bring about the C3N. Conclusions: Our current healthcare system fails to deliver necessary results and incremental system improvements are not enough. We demonstrate methods that resulted in a design that has the potential to transform the chronic care system. Our experience suggests that employing structured co-design processes in collaboration with all relevant stakeholders can result in a potentially transformative design for the chronic care delivery system.

  • Patient Health Record Systems’ Scope and Functionalities: A Literature Review and Future Directions

    Date Submitted: May 19, 2017
    Open Peer Review Period: May 21, 2017 - Jul 16, 2017

    Background: A new generation of user-centric information systems is emerging in healthcare as Patient Health Record systems. These systems create a platform supporting the new vision of health services that empowers patients and enables patient-provider communication, with the goal of improving health outcomes and reducing costs. This evolution has generated new sets of data and capabilities; providing opportunities and challenges at the user, system and industry levels. Objective: To assess patient health records (PHR) data through a review of the literature, to inform the healthcare informatics community and provide recommendations for PHR design, research and practice. Methods: In this paper we review the literature to identify challenges associated with the development PHR systems. We survey PubMed, Embase and Medline databases from 1966 to 2015 for studies of personal health records resulting in 1822 articles, from which we select a total of 106 articles for a detailed review of PHR data content. We present several key findings related to the scope and functionalities in current PHR systems. We also present a functional taxonomy and chronological analyses of PHR data types and functionalities. Based on the evolution of prior PHR systems, we develop a maturity model for evaluation of multi-organizational systems such as PHR systems and identify implications on future health information systems research; improving understanding and providing insights for future directions. Results: Functional taxonomy analysis of the extracted data revealed the presence of new PHR data sources such as tracking devices, and data types such as time series data. Chronological data analysis revealed an evolution of PHR systems’ functionalities over time from simple data access, to data modification, and more recently automated assessment, prediction and recommendation. Conclusions: Efforts are needed to improve PHR 1) data quality through patient-centered user interface design and standardized patient-generated data guidelines, 2) data integrity through consolidation of various types and sources, 3) functionality through application of new data analytics methods and 4) metrics to evaluate clinical outcomes associated with automated PHR systems’ use, and cost associated with PHR data storage and analytics.

  • Getting to the Root of Reinvestment - An fNIRS study in Dentistry using Virtual Reality Haptic Simulation

    Date Submitted: May 15, 2017
    Open Peer Review Period: May 18, 2017 - Jul 13, 2017

    Background: Personality has been identified as a factor that influences learning in healthcare. Movement specific reinvestment is a dimension of personality that has been shown to influence psychomotor learning because it has a central role in conscious control of movements. Currently, there is little evidence considering the relationship between movement specific reinvestment and working memory in terms of functional brain activation of the dorsolateral prefrontal cortex (DLPFC) during motor skill performance. Objective: This study used functional near infrared spectroscopy (fNIRS) to examine the research gap between movement specific reinvestment and working memory using undergraduate dental students performing dental virtual reality (VR) psychomotor tasks. Methods: The propensity for movement specific reinvestment was assessed in 24 dental students, who completed two dental tasks (clinical, non-clinical) on a VR haptic simulator. Portable fNIRS equipment was used to assess oxygen demands in the left and right DLPFC hemispheres during performance. Results: Students with a high propensity for movement specific reinvestment displayed significantly greater oxyhaemoglobin demands in and area associated with working memory during the non-clinical task (Spearman correlation, rs = -0.49, p = 0.033). Conclusions: This small-scale study suggests that neurophysiological differences are evident between high and low reinvesters during a dental VR task in terms of oxyhaemoglobin demands in an area associated with working memory. The results contribute to understanding the neurological processes underpinning conscious control of movements and may assist in the design of individualized training plans for psychomotor skills.

  • Development and Validation of a Functional Behavioural Assessment Ontology to Support Behavioural Health Interventions

    Date Submitted: May 15, 2017
    Open Peer Review Period: May 18, 2017 - Jul 13, 2017

    Background: In the cognitive behavioural approach, Functional Behavioural Assessment is one of the most effective methods to identify the variables that determine a problem behaviour. In this context, the use of modern technologies can encourage the collection and sharing of behavioural patterns, effective intervention strategies, and statistical evidences about antecedents and consequences of clusters of problem behaviours, encouraging the designing of function-based interventions. Objective: The paper describes the development and validation process used to design a specific Functional Behavioural Assessment Ontology (FBA-Ontology). The FBA-Ontology is a semantic representation of the variables that intervene in a behavioral observation process, facilitating the systematic collection of behavioral data, the consequential planning of treatment strategies and, indirectly, the scientific improvement in this field of study. Methods: The ontology has been developed deducing concepts and relationships of the ontology from a golden standard and then performing a machine-based validation and a human-based assessment to validate the Functional Behavioural Assessment Ontology. These validation and verification processes were aimed to verify how much the ontology is conceptually well founded and semantically and syntactically correct. Results: The Pellet reasoner checked the logical consistency and the integrity of classes and properties defined in the ontology, not detecting any violation of constraints in the ontology definition. In order to assess whether the ontology definition is coherent with the knowledge domain or not, a human evaluation of the ontology were performed asking 84 people to fill in a questionnaire composed by 13 questions assessing concepts, relations between concepts, and concepts’ attributes. The response rate for the survey was 34.52%. The domain experts confirmed that the concepts, the attributes, and the relationships between concepts defined in the FBA-Ontology are valid and well represent the Functional Behavioural Assessment process. Conclusions: The new ontology developed could be a useful tool to design new evidence-based systems in the Behavioral Interventions practices, encouraging the link with other Linked Open Data datasets and repositories to provide users with new models of e-health focused on the management of problem behaviours. Therefore, new researches and efforts are needed to develop and implement innovative strategies to improve the poor reproducibility and translatability of basic research findings in the field of behavioural assessment.

  • Reduction of health disparities by increasing vegetables intake with a web-based nutrition education intervention among lower-income adults: a randomized-controlled trial

    Date Submitted: May 14, 2017
    Open Peer Review Period: May 17, 2017 - Jul 12, 2017

    Background: No existing web-based nutrition education interventions have yet been evaluated with consideration of socio-economic status. Objective: To investigate the effect of a randomized controlled trial on reducing vegetable intake disparities between lower- and middle household income with a web-based intervention. Methods: Randomized controlled trial. Participants were assessed at three timepoints: participants were assessed at baseline (T1), post intervention (5 weeks later; T2), and a follow-up after 3 months (T3) from October 2015 to March 2016. A web-based intervention survey was conducted via a Japanese online research service containing data including sociodemographic attributes for 8,564 adults aged 30–59 years. Participants (n = 1,500) were stratified per national population statistics for sex, age, and household income, and randomly divided into intervention and control groups. The intervention program content encouraged behavioral changes using behavioral theories and techniques tailored to assumed stages of behavioral change. The outcome was vegetable intake servings (350 g per day, 5 small bowls). Results: This study had the high levels of compliance (low income: 82.4%, middle income: 85.7% at T2). The vegetable intake increased in the low-income among intervention group from T1 to T2 (0.42 SV; 95% CI: 0.11–0.72). A two-way ANOVA showed that low-income households had significant main effects (Group: η2 = 0.04, p = .012, Time: η2 = 0.01, p < .001) and a significant interaction (η2 = 0.01, p = .009). Middle-income households also had a significant main effect (Time: η2 = 0.01, p = .006) and a significant interaction (η2 = 0.01, p = .046). Conclusions: Web-based nutritional education intervention could fill the vegetable intake gap between low- and middle-income and be expected to prevent non-communicable and lifestyle-related diseases. Further intervention program improvements are necessary to maintain and increase vegetables intake for other groups. Clinical Trial: Current Controlled Trials UMIN-ICDR UMIN000019376 (Registered October 16, 2015)

  • A web-based self-management application ‘Oncokompas’ including a breast cancer-specific module to facilitate access to optimal supportive care: a feasibility study among breast cancer survivors

    Date Submitted: May 11, 2017
    Open Peer Review Period: May 13, 2017 - Jul 8, 2017

    Background: Cancer survivors have to deal with symptoms and concerns related to cancer and its treatment. In Oncokompas, cancer survivors can monitor their quality of life by completing patient reported outcome measures (PROMs) (‘Measure’), followed by personalized feedback and self-care advices (‘Learn’) and an overview of optimal supportive care options (‘Act’) to stimulate patient activation. To improve sustainable usage, we optimized Oncokompas by developing tumor-specific modules such as the Oncokompas breast cancer (BC) module. Objective: To investigate the feasibility and effects of Oncokompas including the newly developed BC specific module among BC survivors. Methods: A pretest-posttest design was used, conducting a survey before providing access to Oncokompas, and 1 week after. Feasibility was investigated by means of adoption (intention to use Oncokompas), usage (actual use of Oncokompas based on logging data), and satisfaction (mean score of two study-specific questions: general satisfaction and user friendliness (10-point scales) and the Net Promoter Score (NPS)). Several socio-demographic (age, health literacy, marital status, educational level, occupational status, need for supportive care) and clinical (treatment modality, time since diagnosis) factors, and health-related quality of life (HRQOL) were explored that might be associated with patient satisfaction. Barriers and facilitators of the feasibility of Oncokompas were investigated by evaluating reports from face-to-face consultations between BC survivors and their oncology nurses. The effects of Oncokompas on patient activation (Patient Activation Measure (PAM)) and on patient-physician interaction (Perceived Efficacy in Patient-Physician Interaction (PEPPI-5)) were investigated. Results: In total 101 BC survivors participated. Oncokompas had an adoption rate of 75%, a usage rate of 75-84%, a mean satisfaction score of 6.9 and a NPS of -36 (N=68). The BC module had a mean satisfaction score of 7.5. The most frequently consulted BC specific topics were lymphedema, (early) menopausal symptoms and sexuality. BC survivors who received surgery including chemotherapy and/or radiotherapy were significantly more satisfied than BC survivors with surgery alone (p = 0.013). Six facilitators (e.g. the well-being score in Oncokompas is congruent with participants’ own perception) and ten barriers (e.g. Oncokompas was considered too extensive) of the feasibility of Oncokompas were identified. After using Oncokompas, BC survivors scored significantly higher on patient activation (PAM) (p= .007; r = .24), but not on patient-physician interaction (PEPPI) (p = .75). Conclusions: Oncokompas including a BC module is considered feasible, but needs further optimization to increase user satisfaction. This study shows the value of tailoring eHealth applications for cancer survivors to their specific tumor type. Oncokompas including the BC module seems effective to improve patient activation among BC survivors. A randomized controlled trial is warranted to assess (cost-)effectiveness.

  • Using Big Data to Understand Social Conversations about Electronic Cigarettes: Pre- and Post-FDA Electronic Cigarette Ruling (2016) Using Twitter Data

    Date Submitted: May 11, 2017
    Open Peer Review Period: May 13, 2017 - Jul 8, 2017

    Background: Electronic cigarette (e-cigarette) use has become a controversial public health issue that is now impacted by the FDA ruling on tobacco products. Social media such as Twitter has given rise to a form of Big Data (i.e., extremely large datasets) that provide a unique opportunity to approach public health and policy issues as viewed and disseminated by social media users. The application of machine learning methods to Big Data can help reveal the public’s organic reaction to and subsequent social conversations about health policies such as the FDA ruling. Objective: The purpose of this study was to compare Twitter-based social conversation themes about e-cigarettes in the U.S. pre- and post-FDA ruling using social networking data via Twitter. Methods: We sought to identify and separate a subset of e-cigarette related tweets for two time periods, before and after the legislative ruling event in early May 2016. The months before May 2016 represent a baseline of typical e-cigarette related tweets prior to the ruling. The months after reveal the impact the ruling had on this typical Twitter dialogue. The data collected was used to identify dominant themes in the tweets. Results: There were a total of 12,531 tweets collected from both time periods, with 7,416 in the pre-ruling period (period 1) January 1, 2016 to April 24, 2016 and 5,115 in the post-ruling period (period 2) April 25, 2016 to July 11, 2016. The Word Adjacency Graph (WAG) modeling applied to this large dataset was able to separate relevant from non-relevant tweets regarding e-cigarettes. The pre-ruling period revealed 10 relevant word clusters and four primary themes: safety, support, opposition, and smoking cessation. The post-ruling period was analyzed and six relevant word clusters and six themes were identified: safety, legislative communication, public health, support, marketing, and the FDA ruling. Conclusions: Examining public response to the FDA ruling on e-cigarettes using Twitter data provides valuable insight into the public perspective. While there are multiple perspectives and layers of complexity associated with the FDA ruling, social network analysis of Twitter data provides increased e-cigarette dialogue for health professionals to engage their patients, legislators, and the community. Clinical Trial: N/A

  • Information-seeking behaviour for Zika virus and microcephaly in Brazil: infodemiological study of Google Trends-based search queries

    Date Submitted: May 9, 2017
    Open Peer Review Period: May 12, 2017 - Jul 7, 2017

    Background: Google Trends (GT) has been used to provide real-time epidemiological trends of several diseases. Objective: We assessed the information-seeking behaviour for Zika virus and microcephaly in Brazil using infodemiological data provided by GT. Methods: This was an observational infodemiology study of information and search activity on ZIKV and microcephaly in Brazil conducted using GT. Results: Data showed high search by the two topics between December 2015 and February 2016, coincident with the appearance of cases of microcephaly in Brazil and new findings on the subject. Conclusions: The current study demonstrates the potential of using search queries to assess the degree of the population concern for the ZIKV and microcephaly in Brazil and the strong influence of reports from local and international media and international organizations in the number of web search during the outbreak.

  • Presentation of laboratory test results in patient portals: influence of interface design on risk interpretation and visual search behaviour

    Date Submitted: May 9, 2017
    Open Peer Review Period: May 12, 2017 - Jul 7, 2017

    Background: Patient portals are often assumed to be valuable in self-management, however, there are concerns over how patients might interpret and act on the clinical information they access. Objective: To investigate how different online, portal-based presentations of laboratory test results may influence risk interpretation and visual search behaviours. Methods: We conducted a controlled study with 20 kidney transplant patients. Participants viewed three different graphical presentations in each of low, medium and high risk clinical scenarios composed of results for 28 laboratory tests. After viewing each clinical scenario, patients were asked how they would have acted in real life if the results were their own, as a proxy of their risk interpretation. They could choose between: 1) Calling their doctor immediately (high interpreted risk); 2) Trying to arrange an appointment within the next four weeks (medium interpreted risk); 3) Waiting for the next appointment in three months (low interpreted risk). For each presentation, we assessed accuracy of patients’ risk interpretation, and employed eye tracking to assess and compare visual search behaviour. Results: There was no statistically significant difference in the accuracy of risk interpretation between the different forms of presentation of results. Misinterpretation of risk was common, with 65% of participants underestimating the need for action across all presentations at least once. Participants found it particularly difficult to interpret medium risk clinical scenarios. Participants who consistently understood when action was needed showed a higher visual search efficiency, suggesting a better strategy to cope with information overload that helped them to focus on the laboratory tests most relevant to their condition. Conclusions: This study confirms patients’ difficulties in interpreting laboratories test results, with many patients underestimating the need for action, even when abnormal values were highlighted or grouped together. Our findings raise patient safety concerns and may limit the potential of patient portals to actively involve patients in their own healthcare.

  • Syndromic surveillance models using Web data: the case of Influenza in Greece and Italy using Google Trends

    Date Submitted: May 10, 2017
    Open Peer Review Period: May 11, 2017 - Jul 6, 2017

    Background: An extended discussion and research has been performed in recent years, using data collected through search queries submitted via Internet. It has been shown that the social activity in the internet is related to the number of cases of an infectious disease outbreak Objective: In our research, to define a similar correlation between data from Google Trends and data collected by the official authorities of Greece and Europe, we examine the development and the spread of seasonal influenza in Greece and Italy. Methods: We use multiple regressions of the terms submitted in the Google search engine related to influenza for the period 2011-2012 in Greece and Italy. We then use the Auto Regression Integrated Moving Average statistical model (ARIMA) to determine the correlation between the Google search data and the real influenza cases confirmed by the above-mentioned authorities. Two methods are used: a "flu score" was created for the case of Greece and another method by comparing data from a neighbor country of Greece, which is Italy. Results: The results show that there is a significant correlation that can help the prediction of the spread and the peak of the seasonal influenza, using data from Google searches. The correlation is .909, .831 for Greece and .979, .933 for Italy for 2011 and 2012 respectively. The prediction of the peak is quite precise and provides a forecast before it arrives to population Conclusions: We can create an internet surveillance system, based on Google Searches to track Influenza in Greece in Italy

  • Smart Diet Management: Collecting Dietary Intake for Chinese Foods Using RFID Technology

    Date Submitted: May 5, 2017
    Open Peer Review Period: May 7, 2017 - Jul 2, 2017

    Background: Dietary intake assessment is important for personal health management. However, it is challenging to record food consumption information in an efficient, accurate and sustainable manner, particularly for the Chinese food consumptions Objective: This study aims to develop an intelligent method for Chinese food consumption data collection and nutrient analysis. Methods: Radio Frequency Identification (RFID) technology was applied to collect group’s food records via intelligent plates embedded with RFID chips in place where people went to eat a meal. Chinese food name and quantity information were collected via the cooked dish recipes to exact the key ingredients and to estimate their weights. The Chinese foods were separated into three main types: staple food (e.g., rice, steamed buns), cooked dish (e.g., cooked tomato with eggs), and soup (e.g., egg drop soup). In addition, food ingredients, food quantity and cooking methods were obtained to calculate energy and nutrients (carbohydrate, fat, fiber and etc.) according to the Chinese recipe database and China Food Composition database. Results: We applied the system to collect Chinese dietary intake for a group of 1,0528 individuals in lunch during 25 weeks. A total of 489 Chinese dishes were identified. Based on a Chinese recipe database and China Food Composition database, the Chinese foods were transformed to food ingredients, food quantity, cooking method, as well as nutrient values. Given a Chinese dish (e.g., Garlic Puree Cooked Pork Leg), we compared its nutrient values calculated by our method with the chemical measurements. The mean absolute percentage deviation (MAPD) showed our method enable collecting dietary intake for Chinese foods. Conclusions: A smart dietary management system using RFID technology is useful and is capable to record Chinese food dietary information efficiently and effectively. It can be used for individuals and dietarians for setting up personalized nutrient plan in the future.

  • Use of social media in the assessment of relative effectiveness: An explorative review with examples from oncology. Hopeful or hopeless?

    Date Submitted: May 2, 2017
    Open Peer Review Period: May 4, 2017 - Jun 29, 2017

    Background: An element of health technology assessment (HTA) constitutes assessing the clinical effectiveness of drugs, generally called relative effectiveness assessment (REA). Directly after market access little evidence from the real world is available, therefore randomized controlled trials are used to inform REA. However, there is growing interest in using real world data (RWD) for REA. Social media may provide a source of RWD. Objective: We assessed the extent to which social media-generated health data could contribute to REA. Methods: An explorative literature review was conducted following PRISMA guidelines to identify examples in oncology where health data was collected using social media. Scientific and grey literature published between January 2010 and June 2016 was identified by two reviewers, who independently screened studies for eligibility and extracted data. A descriptive qualitative analysis was performed. Results: Of 1032 articles identified, 8 were included: 4 articles identified adverse events to cancer treatment, 3 articles disseminated quality of life (QoL) surveys, and 1 study assessed the occurrence of disease-specific symptoms. Several strengths of social media-generated health data were highlighted in the articles, such as efficient collection of patient experiences and recruiting patients with rare diseases. Conversely, limitations included validation of authenticity and presence of information and selection bias. Conclusions: Social media may provide a potential source of RWD for REA, particularly on aspects such as adverse events, symptom occurrence, QoL, and adherence behaviour. This potential has not yet been fully realised and the degree of usefulness for REA should be further explored.

  • Online primary care computerised medical record and associated service access for patients with Type 2 Diabetes: a systematic review.

    Date Submitted: May 4, 2017
    Open Peer Review Period: May 4, 2017 - Jun 29, 2017

    Background: Online access to medical records has the potential to support patient-centred care,improve convenience for patients and patient satisfaction. Enabling patients’ greater access to their medical records and linked online services may not only empower self-management, but also facilitate the organisation and delivery of care. Objective: To assess use and impact of online access to computerised medical record (CMR) systems and associated services in primary care by patients with Type 2 diabetes (T2DM). Methods: Multiple international databases including Medline, Embase, CINAHL, PsycINFO and the Cochrane Library were searched between 2004 and 2016). No limitation was placed on study design, though we applied detailed inclusion and exclusion criteria. Thematic analysis was used to synthesise the evidence. Results: 917 studies were identified and 28 were included in this review. Five themes were identified: (1) Disparities in uptake of online record access and online services use by different patient groups. They varied by age, gender, ethnicity, educational attainment, and number of comorbidities. (2) Improved health outcomes: largely of surrogate makers of quality, glycaemic control, BP and cholesterol. (3) Self-management support included improved patient self-care and shared management, satisfaction, convenience and a generally positive effect on clinician-patient relationship. (4) Accessibility, patients valued more convenient access to health care where it worked efficiently. (5) Service design issues which may impact on online access and service use. Conclusions: Patients who accessed them valued these systems; and the improved access they offered. Professionals were cautious about using such systems primarily due to concerns about a rise in workload, patient safety, and maintaining confidentiality. CMR online access appears to be safe, popular though it may increase disparities and there is a lack of rigorous research showing positive impact on health outcomes.

  • Connected activity trackers have high feasibility in patients with rheumatoid arthritis or axial spondyloarthritis to assess physical activity patterns : a 3-months prospective study of 157 patients.

    Date Submitted: May 2, 2017
    Open Peer Review Period: May 2, 2017 - Jun 27, 2017

    Background: Physical activity can be traked using connected devices and is recommended in rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA). The World Health Organization recommends at least 150 min/week of moderate to vigorous physical activity (MVPA). Objective: The objectives were to assess physical activity and its patterns in RA and axSpA patients using an activity tracker and to assess the feasibility of connected devices in this population. Methods: This multicentric prospective observational study (ActConnect) included patients who had definite RA or axSpA, and a smartphone. Physical activity was assessed over 3 months using a connected activity tracker, recording the number of steps per minute. RA and axSpA were compared, using linear mixed models, for number of steps, proportion of morning steps, duration of total activity and MVPA. Physical activity trajectories were identified using the K-means method, and factors related to the low activity trajectory were explored by logistic regression. Acceptability was assessed by the mean number of days the tracker was worn over the 3 months (i.e. adherence), the percentage of wearing time, and by an acceptability questionnaire. Results: 157 patients (83 RA, 74 axSpA) were analyzed: their mean age was 46 (+/-12) years, and mean disease duration 11 (+/-9) years; 57 (36%) were males. RA and axSpA patients had similar physical activity levels; respectively, 16 (+/-11) and 15 (+/-12) min/day of MVPA. Only 43 (27%) patients reached the recommendations (mean MVPA of 106 (+/-77) min/week). Three trajectories were identified with constant activity: low (54% of patients), moderate (43%) and high (3%) levels of MVPA. A higher body mass index was significantly related to less physical activity (odds ratio 1.12, 95% confidence interval [1.11, 1.14]). The activity trackers were worn during a mean of 79(+/-17) days, corresponding to a mean of 88(+/-19)% of days over the 3 months. Overall, patients considered the use of the watch very acceptable. Conclusions: RA and axSpA patients performed insufficient physical activity without differences depending on disease. Activity trackers allow accurate longitudinal assessment of physical activity. The good adherence to this study and the good acceptability of wearing activity trackers confirmed the feasibility of the use of a connected activity tracker in patients with rheumatic diseases.

  • Determinants of a poor sleep based on data from 15 000 users of connected devices

    Date Submitted: May 2, 2017
    Open Peer Review Period: May 2, 2017 - Jun 27, 2017

    Background: Sleep is a modifiable lifestyle factor that can be a target for efficient intervention studies to improve the quality of life and decrease the risk or the burden of some chronic conditions. Knowing the profiles of individuals with poor sleep patterns is therefore a prerequisite. Wearable devices have recently opened new perspectives in health. Objective: To identify the determinants of poor sleep, based on a data from a large population of users of connected devices. Methods: We analyzed data from 15,839 individuals (13,658 males and 2,181 females) considered as “highly connected” customers having purchased and used several Withings connected devices. Total and deep sleep durations, as well as the deep/total ratio as a proxy of sleep quality were analyzed in association with available data on age, sex, weight, heart rate, steps, diastolic and systolic blood pressure. Results: With respect to the deep/total sleep duration ratio used as a proxy of sleep quality, we have observed that those at risk of having a poor ratio (≤ 0.40) were more frequently males (ORfemale vs male = 0.45 [0.38-0.54]), younger individuals (OR>60 y vs 18-30 y = 0.47 [0.35-0.63]), those with elevated heart rate (OR>78 bpm vs ≤ 61 bpm= 1.18 [1.04-1.34]) and high systolic blood pressure (OR>133 mmHg vs ≤ 116 mmHg = 1.22 [1.04-1.43]). An association with weight was observed for total sleep duration exclusively. Conclusions: Wearables can provide useful information to target individuals at risk of poor sleep. Future alert or smartphone notification systems, based on poor sleep determinants measured with wearables, could be tested in intervention studies to evaluate the benefits. Clinical Trial: NA

  • Development of a pilot mHealth MNCH communication intervention in a mountainous area of Thai Nguyen province, Vietnam

    Date Submitted: May 1, 2017
    Open Peer Review Period: May 2, 2017 - Jun 27, 2017

    Background: The mMom project piloted and implemented a cost-effective mHealth solution to a problem of longstanding concern in Vietnam: how to improve the maternal, newborn and child health (MNCH) of ethnic minority women (EMW) living in mountainous and remote areas. Available evidence shows that EMW have disproportionately high infant and maternal mortality rates due to poverty and remoteness from poor quality health centres, and ethnographic fieldwork determined that current MNCH approaches in Thai Nguyen province in northern Vietnam fall short of providing effective antenatal and postnatal care. Objective: The project’s objective was to determine whether the implementation of an integrated mHealth intervention would improve access to MNCH services for women in remote areas of Thai Nguyen. Methods: The intervention created partnerships with the provincial health department to build an mHealth platform which was integrated into the existing health management information system (HMIS). The system sends active Behaviour Change Communication (BCC) health information SMS messages to local women via their mobile phones, and sends messages to health workers with the aim of increasing client-provider interactions and increasing demand for quality natal care. Results: The mMom intervention was able to effectively engage partners at the commune, district and provincial levels to integrate a novel mHealth system into an existing HMIS, and effectively train local health workers on its application for MNCH in Thai Nguyen. Conclusions: The pilot project demonstrates the feasibility of implementing an mHealth intervention in a remote area to provide MNCH health information and promote health service utilization.