Latest Submissions Open for Peer Review

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

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

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

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

  • A mobile health intervention to early detect exacerbation for older people with Heart Failure: Randomized Control Trial

    Date Submitted: Oct 25, 2016
    Open Peer Review Period: Oct 25, 2016 - Dec 20, 2016

    Background: Heart Failure is the most common cause of hospitalization amongst patients aged 65 years and over. There are no publications on the effectiveness of eHealth in the monitoring after discharge focused on older people with Heart Failure and on the usefulness of non-classical, functional biomarkers in this population. Objective: To assess the effectiveness of a mobile intervention to early detect heart failure exacerbation, and to minimize readmissions and length of re-hospitalizations. Methods: We conducted a randomized non-blind controlled trial with a follow-up of 3 months after a hospitalization due to heart failure exacerbation. We remotely monitored functional status (i.e. gait speed and strength), vital signs (i.e. weight, oxygen saturation, heart rate and blood pressure) and symptoms after discharge from the Geriatric Acute Care Unit using a Smartphone connected to sensors. The main outcomes were the emergency visits rate, the readmissions and the length of stay of these readmissions. Effectiveness of the intervention was assessed through logistic models. Results: 90 patients were enrolled (median age, 86 years; females: 72.2%). 50 patients were randomly allocated to the intervention group-IG, (47 completed the study); and 40 to the control group-CG. Their characteristics were similar except for age (people in the IG is one year older). The adherence to the program was high, being the minimum rate of observations 70%. Patients in IG had a better clinical outcome measured as the risk for readmissions, which decreases more than 60% in comparison with CG. We did not find differences regarding visits to the emergency room. In addition, in those of the IG who were readmitted, 80% of the readmissions were shorter or equal than 7 days. In CG, this percentage was reached at 13th day. Median of stay differs between groups in 3.5 days (p= 0.02). The only biomarkers predicting the outcomes were the changes in the gait speed OR 1.34 (95% CI 1.04-1.72) and the oxygen saturation 0.743 (95% CI 0.566-0.976). Conclusions: Mobile systems are feasible and effective in this very old population of patients with heart failure. Functional variables as gait speed have predictive value, opening new ways of monitoring these patients. Clinical Trial: Identifier: NCT02506738

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  • Evidence of benefit of telerehabilitation after orthopaedic surgery: a systematic review.

    Date Submitted: Oct 17, 2016
    Open Peer Review Period: Oct 17, 2016 - Dec 12, 2016

    Background: In addition to traditional physiotherapy, Telerehabilitation programs [TR] have proven their effectiveness, validity, noninferiority and important advantages in various neurological, cognitive diseases and musculoskeletal disorders; meaning an opportunity to define new social policies and intervention Objective: The aim of this systematic review is to investigate the effects of telerehabilitation after surgical procedures in orthopaedic conditions, as well as to describe how interventions are designed and to determine if telerehabilitation is comparable to conventional methods of delivery within this population. This systematic review summarizes the levels of evidence and grades of recommendation regarding telerehabilitation intervention [synchronous and asynchronous provided via telerehabilitation medium, either in conjunction with, or in isolation of, other treatment interventions were included] after surgical procedures in orhopaedic conditions Methods: Study quality was assessed using the PEDro scores and grade of recommendation following the recommendation of the oxford center for evidence based medicine. Results: We found 3 studies with PEDro scores between 6-8, what it is considered level 1 of evidence [good [21,4%]], 4 studies scores 5 what it is considered level 2 of evidence [acceptable [21,4%]], and rest of 8 studies scores 4 or less what it is considered [poor [57,1%]]. A total of 1316 participants receive telerehabilitation intervention in the studies selected where knee and hip replacement suppose the 75% of all the studies. Strong and moderate grade of evidence [grade of recommendation A-B] were found in knee and hip replacement interventions. Studies in the upper limb suppose the 25% of studies but only one study present moderate grade of evidence [grade or recommendation B] and rest are poor methodological quality with weak evidence [grade of recommendation C]. Conclusions: Conclusive evidence on the efficacy of telerehabilitation for treatment after orthopaedic surgery, regardless of pathology, was not reached. We found strong evidence for telerehabilitation in patients following total knee arthroplasty and hip replacement [clinical outcomes are comparable and no inferiority]. Future research needs to have stronger and solid studies. In the authors’ knowledge this is the first attempt to evaluate the quality of telerehabilitation intervention research after surgical procedures in orthopaedic conditions in a systematic review. Clinical Trial: The review protocol was registered with an international registration database [PROSPERO Registration Number: CRD42016047846.

  • Twitter for marijuana surveillance: An on-line social network-based approach to get real-time marijuana related information

    Date Submitted: Oct 16, 2016
    Open Peer Review Period: Oct 16, 2016 - Dec 11, 2016

    Background: Marijuana use has shown steady growth in recent years, forcing governments to spend more money in order to palliate the side effects produced by drug consumption. For this reason, there is a need to look for new tools, which will quickly allow monitor what is going on with the population. Thus, on-line social networks seem a good option for this purpose, since they provide environments where users can freely share large amounts of information related to their own lives. Objective: The aim of this study is to collect information texted by Chilean users on the social network Twitter, including relationships among them, conducting to build a system able to monitor and evaluate marijuana consumption and its perception on the network. This should allow us to try to find similarities within the total population of the country. Methods: The study considered extraction of tweets related to marijuana, classifying them into three categories, extracting polarities and combining them to later compute measures of social network analysis in order to predict people’s actual marijuana use behavior. To know real categories of tweets, a sample were labeled by Twitter experts, and a sample of Twitter users was directly asked for marijuana consumption. Results: An algorithm was developed to identify Chilean Twitter users, obtaining a database of 1,361,285 valid users. Among all tweets created by them, 441,406 were classified as being related to marijuana, with an accuracy of 0.95. Only two of three categories for marijuana tweet classification were used: consumption and control policies, with a precision of 0.84 and 0.83 respectively. The marijuana consumption classifier per users had precision, recall and f-measure results close to 0.7. Considering the obtained results, it is possible to say that the prevalence of marijuana consumption has increased in recent years and negative perception of the drug has dropped. Conclusions: The combination of fairly good models is useful to predict marijuana consumption in an individual and at the aggregate level. It is also possible to discover what people think about the drug, i.e., perception. That is substantially important because this kind of dynamical information (potentially real-time) can be used in the design and evaluation of national preventive programs and campaigns.

  • Scalable Passive Sleep Monitoring using Smartphones: Opportunities and Obstacles

    Date Submitted: Oct 14, 2016
    Open Peer Review Period: Oct 15, 2016 - Dec 10, 2016

    Background: Tracking sleep can help us monitor the wellbeing of individuals. Traditional methods of sleep tracking are either time- and resource-intensive, or suffer from self-reporting biases. Recently, researchers have started to use smartphones to track sleep in individuals’ daily lives. However, this work remains in its early stages, having only examined relatively small and homogeneous populations in carefully controlled contexts. Thus, it remains an open question as to how well mobile device-based sleep monitoring generalizes to larger populations in typical use cases. Objective: To assess performance of sleep-tracking using mobile devices in a large, nation-wide cohort. Methods: We collected smartphone sensor data as well as self-reported sleep and wake-up times from 211 individuals, diverse in age, education, and employment status, across the United States over 6 weeks. Sensor data consisted of geographic location, motion, light, sound, and in-phone activities. No specific instructions were given to the participants regarding phone placement. We trained both personalized and global classifiers to predict sleep states from the phone sensor data. Results: Using all available sensor features, the average accuracy of classifying whether a 10-minute segment is sleep was 88.8%. This is somewhat better than using the time of day alone, which gives an average accuracy of 86.9%. The accuracy of the model considerably varied across the participants, ranging from 65.1% to 97.3%. We found that low accuracy in some participants was due to two main factors: missing sensor data and misreports. After correcting for these, the average accuracy increased to 91.8%, corresponding to an average median absolute deviation (MAD) of 38 minutes for sleep start time detection and 36 minutes for sleep end time. These numbers are close to the range reported by previous research in more controlled situations. Conclusions: We find that smartphones provide adequate sleep monitoring in typical use cases, and that our methods generalize well to a broader population than has previously been studied. However, we also observe several types of data artifacts when collecting data in uncontrolled settings. Some of these we resolve to significant affect, but others likely impose a ceiling on the accuracy of sleep prediction for certain subjects. Future research will need to focus more on the understanding of people’s behavior in their natural settings in order to develop sleep monitoring tools that work reliably in all cases for all people.

  • Using Mobile Sensing to Test Clinical Models of Depression, Social Anxiety, State Affect, and Social Isolation

    Date Submitted: Oct 14, 2016
    Open Peer Review Period: Oct 15, 2016 - Dec 10, 2016

    Background: Research in psychology demonstrates a strong link between state and trait affect (as reflected in depression and social anxiety symptoms) and social isolation. However, existing work is based almost exclusively on static, self-reported descriptions of emotions and behavior that limit generalizability. Despite adopting increasingly sophisticated research designs and technology (e.g., ecological momentary assessment, mobile sensing using global positioning systems; GPS), little research has integrated these seemingly disparate forms of data to improve understanding of how emotional experiences in everyday life are associated with day-to-day social isolation, and whether this is influenced by depression and social anxiety symptoms. Objective: We hypothesized that more time spent at home (a marker of social isolation) would be associated with more negative/less positive affect. Given the innovation of the methods and technology for data collection, we explored four different models that differed with regard to their temporal links for a more nuanced understanding of how actual mobility is related to affect in everyday life. Methods: 72 undergraduate participants were recruited from a Southeast University. Depression and social anxiety symptoms were assessed using self-report instruments at a baseline laboratory session, and an app (Sensus) installed on people’s personal mobile phones repeatedly collected in situ self-reported affect and passively sensed data from GPS sensor for up to two weeks. Time spent at home was used as a proxy for social isolation. Results: We tested separate models in which state affect predicted time spent at home, with levels of depression and social anxiety examined as moderators. Models differed only in the temporal links examined. One model focused on changes in affect predicting time spent at home within a short time window. Three other models focused on mean-level affect within a day predicting time spent at home: (a) the same day; (b) the following day; and (c) the previous day. The expected main effects indicating that more time at home is associated with feeling worse (e.g., more symptoms, and/or more negative/less positive affect) were found across all models (though a number of null effects were also observed). Interactions indicated that, among individuals higher in social anxiety, higher negative affect and lower positive affect within a day led to more time spent at home the next day. Conclusions: Results demonstrate the feasibility and utility of modeling the relationship between affect and social isolation using fine-grained mobility data from everyday life. Although these findings must be replicated in a larger study and with clinical samples, they suggest that integrating repeated state affect assessments in situ with continuous GPS data can increase understanding of how actual mobility is related to affect in everyday life and symptoms of anxiety and depression.

  • A Modular Platform for Monitoring Process, Outcome and Algorithm-Based Treatment Planning in Psychotherapy

    Date Submitted: Oct 14, 2016
    Open Peer Review Period: Oct 14, 2016 - Dec 9, 2016

    Background: In recent years, the assessment of mental disorders has become more and more personalized. Modern technologies like internet-enabled mobile phones and increased computing capacity make it possible to tap sources of information that have long been unavailable to mental health practitioners. Objective: Software packages that combine algorithm-based treatment planning, process monitoring and outcome monitoring are scarce. The proposed application seeks to fill the gap by providing a software solution that can be used by both researchers to conduct state-of-the-art psychotherapy process research, and clinicians for planning treatments and monitoring psychotherapeutic processes. Methods: In this paper, we report on the current state of a web application that can be used for assessing the temporal structure of mental disorders using information on their temporal and synchronous associations. A treatment planning algorithm automatically interprets the data and delivers priority scores of symptoms to practitioners. The application is also capable of monitoring psychotherapeutic processes during therapy and of monitoring treatment outcomes. This application was developed using the R programming language and the Shiny web application framework. It is made entirely from open-source software packages and thus is easily extensible. Results: The capabilities of the proposed application are demonstrated. Case illustrations are provided to exemplify its usefulness in clinical practice. Conclusions: With the broad availability of internet-enabled smart phones and similar devices, collecting data on psychopathology and psychotherapeutic processes has become easier than ever before. The proposed application is a valuable tool for capturing, processing and visualizing this data. The combination of dynamic assessment, process- and outcome monitoring has the potential to improve the efficacy and effectiveness of psychotherapy.

  • Assessing the equivalence of paper, smartphone, and tablet survey administration using psychometrically equivalent halves of the PROMIS depression item bank.

    Date Submitted: Oct 14, 2016
    Open Peer Review Period: Oct 14, 2016 - Dec 9, 2016

    Background: The computerized administration of self-report psychiatric diagnostic and outcomes assessments has risen in popularity. If results are similar enough across different administration technologies, new administration technologies can be utilized interchangeably and the choice of technology can be based on other factors such as convenience in the study design. An IRT-based assessment such as the PROMIS item banks, offers new possibilities for assessing the effect of technology choice upon results. Objective: To create equivalent halves of the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression Item Bank and to use these halves to compare survey responses among administration modalities--paper, smartphone, or tablet. Methods: The 28 PROMIS depression items were divided into two halves based on simulations with an established PROMIS response data set. A total of 129 participants were recruited from an outpatient public sector mental health clinic based in Memphis. All participants took both non-overlapping halves of the PROMIS IRT-based depression items (Part A and Part B): once using paper and pencil, and once using either smartphone or tablet. An eight-cell randomization was done on technology used, order of technologies used, and order of PROMIS Part A and B. Both Part A and Part B were administered as fixed-length assessments and both were scored using published IRT parameters. Results: All 129 participants received either Part A or B via paper assessment. 63 participants were also administered the opposite assessment half using smartphone and 66 using a tablet. There was no significant difference in item response scores for Part A versus Part B, for digitally versus paper assessment, or for assessments via smartphone versus tablet. All three of the technologies yielded essentially identical assessment results and essentially equivalent satisfaction levels. Conclusions: Our findings show that the PROMIS depression assessment can be divided into two equivalent halves, with the potential to simplify future experimental methodologies. The PROMIS items function similarly whether administered via paper, tablet, or smartphone. Since paper, smartphone, and tablet administrations yielded similar results, the choice of technology should be based on factors such as convenience and can even be changed during a study without adversely affecting the comparability of results.

  • Scientific misconduct and social media: The role of Twitter in the STAP cells scandal

    Date Submitted: Oct 13, 2016
    Open Peer Review Period: Oct 14, 2016 - Dec 9, 2016

    Background: The academic scandal on a study on stimulus triggered acquisition of pluripotency (STAP) cells in Japan in 2014 involved suspicions of scientific misconduct by the lead author of the study after the paper had been reviewed on a peer review website. The present study investigated the discussions on STAP cells on Twitter and content of newspaper articles in an attempt to assess the role of social compared with traditional media in scientific peer review. Objective: This study examined Twitter utilization in scientific peer review on STAP cells misconduct. Methods: Searches for tweets and newspaper articles containing the term “STAP cells” were carried out through Twitter’s search engine and Nikkei Telecom database, respectively. The search period was from January 1 to July 1, 2014. The nouns appearing in the Top Tweets and newspaper articles were extracted through a morphological analysis, and their frequency of appearance and changes over time were investigated. Results: The total numbers of Top Tweets and newspaper articles containing the term were 134,958 and 1,646, respectively. Negative words concerning STAP cells began to appear on Twitter by February 9 to 15, 2014, or three weeks after Obokata presented a paper on STAP cells. The number of negative words in newspaper articles gradually increased beginning in the week of March 12 to 18, 2014. A total of 1,000 tweets were randomly selected and found to contain STAP-related opinions (43%), links to news sites and other sources (41%), questions on medical or scientific accuracy (9%), and unrelated topics (7%). Conclusions: The discussion on scientific misconduct during the STAP cell scandal took place at an earlier stage on Twitter than in newspapers, a traditional medium.

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

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

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

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

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

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

  • Similar annual pattern in healthcare professionals’ online searches and national register-based diagnoses of Lyme borreliosis: A register-based study

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

    Background: Both healthcare professionals and non-professionals seek medical information online. Using web-based search engine searches to detect outbreaks has, however, been problematic. Physician’s Databases (PD) is a chargeable online evidence-based medicine (EBM) portal for healthcare professionals and is available throughout the entire healthcare system in Finland. Lyme borreliosis (LB), a well-defined disease model, shows temporal and regional variation, also in Finland. Little data exist on healthcare professionals’ searches from Internet-based EBM databases in public health surveillance. Objective: The aim of this study was to assess whether healthcare professionals’ use of online EBM databases could describe seasonal increases of the disease and supplement routine public health surveillance. Methods: Two registers, PD and the Register of Primary Health Care Visits (Avohilmo), were used to compare healthcare professionals’ searches on LB from online EBM databases and national register-based LB diagnoses in order to evaluate annual and regional variations of LB in the whole country and in three selected high-incidence LB regions in Finland during 2011-2015. Results: Both registers, PD and Avohilmo, show visually similar patterns in annual and regional variation of LB in Finland and in three high-incidence LB regions during 2011-2015. Conclusions: Healthcare professionals’ searches from online EBM databases coincide with national register findings of LB. PD searches showed a clear seasonal variation. In addition, notable regional differences were present in both registers. Physicians’ online medical searches should be considered as a supplementary source of information for disease surveillance.

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

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

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

  • Website use and Effects of Online Information about Tobacco Additives among the Dutch general population: A Randomized Controlled Trial

    Date Submitted: Oct 11, 2016
    Open Peer Review Period: Oct 11, 2016 - Dec 6, 2016

    Background: By a legal obligation, the Dutch government publishes online information about tobacco additives (TA) to make sure that it is publicly available. Little is known about the effect of visiting this website ( and how it is evaluated by visitors. Objective: This study assessed how visitors used the website, its effects on knowledge, risk perception, attitude, smoking behaviour, and how the website was evaluated among a sample of the Dutch general population including smokers and non-smokers. Methods: A randomized controlled trial was conducted, recruiting participants from an online panel. At baseline (n=672) participants were asked to fill out an online questionnaire about TA. Next, participants were randomly allocated to one of the two experimental groups and were invited to visit the website providing information about TA (either with or without a database containing product specific information) or a control group which had no access to the website. Follow-up measurement took place after three months. Results: At follow-up (n=492), no statistical significant differences were found for knowledge, risk perception, attitude, or smoking behaviour in the intervention and control groups. Website visit was positively related to younger participants (B=-0.07; [CI=-0.12, -0.01], t(11)=-2.43, P =.02) and having a low risk perception towards TA (B=-0.32, [CI=-0.63, -0.02], t(11)=-2.07, P =.04); whereas being lower educated (B=-0.67, [CI=--1.14, -0.17], t(11)=-2.65, P=.01) is a significant predictor for making less use of the website Furthermore, the website has been evaluated less positive by smokers compared to non-smokers (t(324)=-3.55 P≤.001) and males compared to females (t(324)=-2.21, P=.017). Conclusions: The website did not change the perceptions of TA nor smoking behaviour. Further research is necessary to find out how effective health communication about the risks of TA can be realised by providing online information. Clinical Trial: Nederlands Trial Register NTR4620

  • Web use for pre-diagnosis symptom appraisal for physical health conditions: A systematic review

    Date Submitted: Oct 6, 2016
    Open Peer Review Period: Oct 7, 2016 - Dec 2, 2016

    Background: The Web has become an important information source for appraising symptoms. We need to understand the role it currently plays in help-seeking and symptom evaluation. This will help to inform website design to make health information more findable and useful. Objective: To systematically review the literature currently available on Web use prior to diagnosis (WUPD) with regard to three review questions: 1) How common is WUPD? 2) How is WUPD conducted (search strategies)? 3) What are the behavioural and emotional consequences of WUPD? Methods: Data sources: Pubmed, Embase, PsycInfo, ACM digital library, SCOPUS, Web of Science. Study eligibility criteria: Empirical studies that address the use of the Web by lay people to evaluate symptoms for physical conditions. Study appraisal and synthesis methods: Papers were excluded if they did not meet minimum quality criteria [1]. Study findings were synthesised using a deductive thematic approach. Results: 31 studies were included. Study designs included cross-sectional surveys, qualitative studies, experimental studies, and studies involving website/search engine usage data. Approximately 35% of adults engage in WUPD, but this proportion varies between 23-75% depending on sociodemographic and disease-related factors. Most searches are symptom-based rather than condition-based. Users view only the top search results and engage more with results that mention serious conditions. WUPD impacts on the decision to present to health services, communication with doctors, and anxiety. Conclusions: WUPD has the potential to influence the timing of help-seeking for symptoms, and the communication between patients and healthcare professionals during consultations. This review indicates that WUPD is linked to changes in anxiety levels and help-seeking behaviour but the available evidence does not show when this is appropriate.

  • Implementation of Routine Electronic Patient-Reported Outcome Assessments in an Oncology Rehabilitation Centre

    Date Submitted: Oct 6, 2016
    Open Peer Review Period: Oct 7, 2016 - Dec 2, 2016

    Background: Patient-reported outcomes (PRO) like quality of life (QOL) can add the patient’s perspective to traditional clinical outcomes in a structured and standardized way, enhancing clinical care and enabling comprehensive evaluation of rehabilitation services. Objective: The aim of this paper is to present the implementation of routine electronic PRO assessment at an oncology inpatient rehabilitation centre, collecting data prior to and after the rehabilitation stay, using the software Computer-based Health Evaluation System (CHES). Assessed data was used for psycho-oncology treatment planning as well as evaluation of the rehabilitation program performed. Methods: Multiple stakeholders were included in the development of a pragmatic PRO implementation strategy relying on the Replicating Effective Programs (REP). Issues like purpose of PRO data collection, choice of PRO instruments, integration in the clinical workflow and stepwise implementation of assessments have been discussed within several on-site meetings before opening of the rehabilitation centre and onset of assessments. Alternating trainings and process evaluations were scheduled for audit and enhancement of procedures. Adopting the PRO data collection procedure from an associated rehabilitation centre, data was assessed starting with January 2014 prior to and after patients’ rehabilitation stay, using paper-pencil forms for an initial phase of six months. Subsequently, beginning in June 2014, the assessment mode was switched to ePRO data collection, changing materials send out to patients accordingly (instead of paper questionnaires, patients received an informational sheet providing a unique user name and password for logging in on a secure home page). Results: As patients’ return rates of completed questionnaires were rather low (about 22%), 3 evaluation meetings and training sessions have been conducted in October 2014, April 2015 and September 2015. Those sessions prompted a revision of the postal cover letter, the adaptation of the administered PRO set (exclusion of one questionnaire, which was rated to be inappropriate by patients), and additional reminder phone calls, resulting in increasing participation rates (up to 98%). The integration of PRO data within the medical discharge letter and plans to start follow-up assessments in September 2016 evolved from stakeholder initiatives. The post-rehabilitation ePRO assessment was integrated into the patients‘ closing meeting conducted by psycho-oncologists. Conclusions: The implementation of routine electronic assessment of PROs was successful and has been shown to be feasible before and after cancer rehabilitation. Throughout stakeholder involvement paved the way for further projects initiated by users themselves (e.g. a comprehensive ePRO follow-up using a versatile online patient portal) and resulted in efforts to additionally integrate PROs into the clinical workflow for use in routine care. Besides well organised pre-implementation meetings, continuous evaluation and well adapted trainings are necessary to fit the assessment procedure to centre-specific requirements. Clinical Trial: not applicable

  • Evaluation of Hospitals’ Performance in Social Networks: A Longitudinal and Comparative Study in Spain

    Date Submitted: Oct 7, 2016
    Open Peer Review Period: Oct 7, 2016 - Dec 2, 2016

    Background: Social media is shifting the way in which citizens and health professionals communicate. Previous studies try to assess the use of Health 2.0 that hospitals do, showing a clear evidence in the growth in later years. In order to understand whether this happens in Spain, there is the need of assessing the presence, evolution and impact of healthcare institutions in the Internet social media networks with quantitative and objective indicators. Objective: To analyze how hospitals in Spain perform in the Internet and social media networks by determining quantitative indicators in three different dimensions: Presence, Use and Impact in the three most common social networks (Facebook, Twitter and YouTube), and to find out if the private/public factor affects in the use of the mentioned Social Networks Methods: The evolution of presence, use and impact metrics are studied over the time from 2011 to 2015. The study population accounts for all the hospitals listed into the National Hospitals Catalogue. The percentage of hospitals having Facebook, Twitter, and YouTube has been used to show the presence and evolution of hospitals in social media networks along the time. Usage has been assessed by analyzing the content generated on each social network (number of tweets and videos) over the time. Impact evaluation is done by drawing the trend of subscribers in each Social Network (SN). Statistical analysis is done using a lognormal transformation to approximate to a normal distribution and also with a non-parametric distribution, with the aim of comparing t-Student and Wilcoxon statistical independence tests for each of the observed variables. Results: From the 787 hospitals identified in the Spanish National Hospitals Catalogue, 550 have an institutional web page and 269 of them have at least one profile in one of the studied SNs in December 2015. The evolution of the Internet presence has increased in more than 300% and SN presence has been multiplied by ten from 2011. Only the 69,8% (550) have an official Web 1.0 (just plain information with no multimedia and reduced interaction with visitors) and only the 34% (269) has presence in any of the studied Social networks. Twitter stands as the preferred social network for public hospitals, whereas private hospitals have better metrics in Facebook and YouTube. Two sided Wilcoxon Test and t-Student Test at a CI of 95% show that the use of twitter (number of tweets and number of followers) is different with an adequate significance level (p<.001) for private and public hospitals in Spain, whereas, the other variables show a non-significant different behavior. Conclusions: Internet presence of Spanish hospitals is high, nonetheless, the presence into the three main SNs is not still widespread. The situation in Spain is constantly changing, with an incremental growth year by year, nonetheless, the presence of hospitals in Social networks is very low in comparison to hospitals in the US and Western Europe. Public hospitals are more active in Twitter, whereas private hospitals have a better performance in Facebook and YouTube. Spanish healthcare system need to maintain high-ranking positions, and to do so, this study suggests that hospitals, both public and private, should devote more efforts and awareness with respect to SNs with a clear strategy in the establishment of new relationships with patients

  • Evaluating Web-based Electronic Health Records Coaching Programme for Patients with Chronic Obstructive Pulmonary Disease in China:a randomized controlled trail

    Date Submitted: Oct 6, 2016
    Open Peer Review Period: Oct 6, 2016 - Dec 1, 2016

    Background: Chronic Obstructive Pulmonary Disease (COPD), now the fourth leading cause of death in the world, continues to increase in the developing countries. The World Health Organization (WHO) expects COPD to be the third most common cause of death in the world by 2020. Effective continued post-discharge care can help patients maintain health. Electronic Health Records (EHRs) which was used as an element of community care are new technology in China. Objective: The aim of this study is to develop and evaluate Web-based Electronic Health Records Coaching Programme on physical function and health related quality of life for patients with COPD in China. Methods: A randomized controlled trial design was conducted from 2008 to 2015 at two hospitals. The control group (n=68) received routine care and the intervention group (n=62) received routine care with the addition of the Web-based Electronic Health Records Coaching Programme. The programme included Web-based Electronic Health Records education, telephone follow-ups and structured home visits. Participants were not blinded to group assignment. After 12 month, the effects of the intervention were evaluated by lung function, SGRQ, MMRC and 6MWT. Data were collected before discharge, and at the end of one, three, six and twelve months post discharge. Results: Of the 130 participants, 120 (92.3%) completed the 12-month follow-up programme. There were statistically significant in FEV1% (F=5.474, P=0.00),FVC%(F=3.055, P=0.02), PEF(F=12.486,P<0.001),MEF75%FVC(F=2.621,P=0.41),MEF50%FVC (F=2.701,P=0.05),total of SGRQ (F=23.300,P<0.001),Symptom of SGRQ (F=12.384,P<0.001) ,activity of SGRQ(F=8.351,P<0.001),impact of SGRQ (F=12.259,P<0.001),MMRC(F=47.940,P<0.001) and 6MWT(F=35.541,P<0.001)between two groups with the variation of time tendency. Conclusions: Web-based Electronic Health Records Coaching Programme in China appears to be useful for the patients with COPD when they are discharged from hospital to the community. It promoted hospital and community nurses sharing patients’ medical information, and achieved dynamic management and follow-up analysis. In the meantime, this programme can postpone the decreasing rate of lung function, improve quality of life, decrease dyspnea and increase physical capacity.

  • Social Health Inequalities and E-Health: A systematic Review

    Date Submitted: Oct 1, 2016
    Open Peer Review Period: Oct 2, 2016 - Nov 27, 2016

    Background: E-health is developing rapidly and brings with it a promise to reduce social health inequalities (SHI). Yet, it appears that it also has the potential to increase them. Objective: The goal of this systematic review of the literature is to describe current knowledge on the link between e-health and SHI, to identify the characteristics of people at risk of experiencing SHI, to understand the causes of SHI in relation to e-health and to highlight strategies encouraging the development of the tool of e-health while reducing SHI. Methods: Following the EPPI approach, two databases were searched for the terms social health inequalities and e-health and their derivatives in titles and abstracts. Qualitative, quantitative and mixed articles were included and evaluated. The software NVivo was employed to extract the data and allow for a metasynthesis of the data. Results: Of the 73 articles retained, 12 were theoretical, 6 were from systematic reviews and 55 were based on empirical studies. Of the latter, 40 used a quantitative approach, 6 a qualitative approach, 6 a mixed method and only 3 a participatory research-action approach. The digital divide in e-health is a serious barrier and contributes greatly to SHI. Ethnicity and low income are the most commonly used characteristics to identify people at risk of SHI. The most promising actions for reducing SHI via e-health are to aim for universal access to the tool of e-health, become aware of users’ literacy level, create e-health tools which respect the cultural attributes of future users and encourage the participation of people at risk of SHI. Conclusions: E-health has the potential to widen the gulf between those at risk of SHI and the rest of the population. The widespread expansion of e-health technologies calls for rigorous consideration of interventions which are not likely to exacerbate SHI. Clinical Trial: Not applicable

  • Effect of caffeine on attention and alertness measured in a home-setting, using web-based cognition tests

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

    Background: Background: There is an increasing interest among nutritional researchers to perform life style and nutritional intervention studies in a home setting instead of testing subjects in a clinical unit. The term used in other disciplines is ‘ecological validity’ stressing a realistic situation. This becomes more and more feasible since devices and self-tests that enable such studies are more commonly available. Here we present such a study, in which we reproduced the effect of caffeine on attention and alertness in an at-home setting. Objective: Objective: The study is aimed to reproduce the effect of caffeine on attention and alertness using a web-based study environment of subjects at home performing different online cognition tests. Methods: Study design: The study is designed as a randomized, placebo-controlled, double blind, cross-over study. Methods: Subjects were provided with coffee sachets (two with and two without caffeine). They were also provided with a written instruction of the test days. Healthy volunteers consumed a cup of coffee after an overnight fast. Coffee was prepared from a sachet containing either regular coffee or decaf coffee. Each intervention was repeated once. Before and one hour after coffee consumption subjects performed online cognitive performance tests at home which measured alertness and attention, established by three computerized tests provided by Quantified Mind. Each test was performed for five minutes. Results: The recruitment via internet was fast and efficient. Within two weeks about 100 subjects applied of whom 70 were eligible. Of these, 53 completed all four test sessions, indicating that they were able to perform the do it yourself tests at home correctly. The Go-NoGo cognition test performed at home showed the same significant improvement in performance with caffeine as found in controlled studies in a metabolic ward. Conclusions: The study showed that the effects of caffeine consumption on a cognition test in an at-home setting revealed similar results as in a controlled setting. The Go-NoGo test applied showed improved results after caffeine intake, similar as seen in clinical trials. This type of study thus is a fast, reliable, economical and easy way to demonstrate effectiveness of a supplement and is rapidly becoming a viable alternative for the classical RCT to evaluate life style and nutritional interventions. Clinical Trial: Registration of the study was done at (NCT 02061982).

  • The Impact of Internet Health Information on the Physiotherapist-Patient Relationship: the Case of the Lebanese Community.

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

    Background: With the evolution of the internet and communication media, endless information are made available for all individuals, most of the time free of charge. The health care field seems to be of high interest for patients who surf the net for pathology definitions, symptoms, treatments and medications mostly before visiting a health practitioner. No matter the quantity of information found on the internet, the quality and credibility of this information is sometimes questionable, leading to undesirable health outcomes or resulting in inappropriate requests for clinical interventions. Few researches on physiotherapy were generally conducted and almost none in Lebanon and none targeted specifically the impact of internet use for medical information research. Objective: This research attempts to examine the effect of searching for health related information by patients over the internet on the physiotherapist-patient relationship, exploring particularly how the online medical information can affect the physiotherapist-patient relationship and the patients’ acceptance of the physiotherapist’s medical approach. Methods: This research adopts a positivist and deductive approach, based on similar studies conducted in the context of other health care specialties. A questionnaire-based survey was sent using communication media to a representative sample population and data was computerized and analyzed using SPSS program to be able to analyze the results and accept or reject H1 and H2. Results: According to the order of physiotherapist in Lebanon2, 1935 physiotherapists are currently registered at the order and working within the Lebanon territory. Our sample is 92 physiotherapists, chosen from those registered at the OPTL, distributed in Lebanon, using an acceptable error of 10% and a confidence level of 95%. Eighty six percent of the physiotherapists valued the recent increase of health information on the internet. Eighty percent found the time to discuss that information with their patients. Seventy three percent believed that the latter positively affects the physiotherapist-patient relationship and eighty one percent said that it positively engages patients in the treatment plan. For H1, 32% of the variation in the physiotherapist-patient relationship was caused by seeking health information on the internet, and in H2: 27.2% of the variation in the acceptance of the physiotherapist’s medical plan was caused by seeking health information on the internet. Conclusions: This study is the first of its kind in the physiotherapy field in general and in Lebanon specifically, aiming to explore the impact of the medical information research on the internet and how it affects the physiotherapist-patient relationship. This study can help raising PTs awareness on how to use appropriate skills to assist their patients in facing information overflow and achieving good health outcomes.

  • Internet-based cognitive behaviour therapy for stress, anxiety and depressive symptoms among perinatal women: A systematic review and meta-analysis

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

    Background: A growing number of meta-analyses have supported the application of Internet-based cognitive behaviour therapy (iCBT) for psychological disorders across different populations, but relatively few meta-analyses have concentrated on perinatal women. Objective: This meta-analysis evaluated the efficacy of iCBT in improving stress, anxiety and depressive symptoms among perinatal women. Methods: Ten electronic databases were used to search for published and unpublished trials. Cochrane Collaboration’s tool for assessing risk of bias was utilised to measure methodological quality. Meta-analysis was performed using RevMan software. Among the 789 studies identified, nine randomised controlled trials were selected, involving 1,626 participants across seven countries. Results: More than half (63%) of the selected studies had a low risk of bias with no to moderate heterogeneity. Results revealed that iCBT significantly improved stress (d = 0.70, n = 6), anxiety (d = 0.32, n = 7) and depressive symptoms (d = 0.63, n = 8,) of the intervention group compared to those of the control group at post-intervention. Significant subgroup differences according to different control conditions and supportive types were found on stress symptoms. Conclusions: This review revealed that iCBT significantly improve stress, anxiety, and depressive symptoms among perinatal women with small to medium effects. Future effectiveness studies should establish the essential components, format and approach of iCBT with optimal levels of human support to maximize a long-term effect.

  • Non-participation in Videoconferencing-based Treatment for Alcohol Use Disorder

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

    Background: We recently conducted an effectiveness study randomized controlled pilot trial concerning videoconferencing-based treatment for alcohol use disorder (AUD). In short, the aim was to test if optional videoconferencing increases adherence and effect in treatment for AUD. Due to a lower patient- and participation rate than anticipated arose the opportunity and need to examine why the patients declined to participate in the effectiveness study. Objective: To examine non-participants’ barriers against participating in an effectiveness study randomized controlled pilot trial and to examine differences between participants and non-participants. Objective: To examine non-participants’ barriers against participating in an effectiveness study randomized controlled pilot trial and to examine differences between participants and non-participants. Methods: The design of this study was mixed methods; an analysis of barriers against participating using an anonymous questionnaire filled out by non-participants, and a comparative analysis of participants and non-participants using data from a clinical database. Results: 43 non-participants filled out the questionnaire. Two categories were derived: scientific barriers, which were barriers against the scientific study in general, and technical barriers, which were barriers against using a laptop and/or videoconferencing in specific. 6 patients stated scientific barriers: of these, 6 patients declined to participate in a research project, and 1 patient also declined to participate in a randomization. 27 patients stated technical barriers: of these, 22 patients declined to use videoconferencing, 12 declined to learn how to use a laptop, and 13 declined to spend time learning it. Non-participants who had technical barriers to participating in the study were older, more often female and part of the work force than those who did not have technical barriers. 13 patients elaborated on technical barriers. 9 patients found it impersonal, preferred personal contact, and would rather attend face-to-face treatment at the clinic. There were no significant differences between participants and non-participants according to socio-demographics, alcohol measures, and composite scores. Conclusions: Patients’ barriers against participating in the effectiveness study were mainly concerned with the technology. They declined to participate because they refused to receive treatment via videoconferencing. Clinical Trial: The regional health research ethics committee system in Southern Denmark, S-20110052

  • Techniques for Improving Communication of Emotional Content in Text-only Online Therapeutic Communications – A Systematic Review

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

    Background: Online typed exchanges are increasingly used by professionals to provide emotional support to patients. Although some empirical evidence exists to suggest that various strategies may be used to convey emotion during online typed exchanges, there has been no critical review of these data. Objective: The objective of this review was to identify the techniques used to convey emotion in written or typed online communication and assess the empirical evidence regarding impact on communication and psychological outcomes. Methods: An electronic search of databases including Medline, CINAHL, PsycINFO, Embase and the Cochrane Library was conducted to identify literature published between 1990 and 2015. Searches were also conducted using Google Scholar, manual searching of reference lists of identified articles and manual searching of tables of contents for selected relevant journals. Data extraction and coding were completed by two reviewers. Publications were assessed against the eligibility criteria and excluded if they: were duplicates; were not published in English; were published before 1990; referenced animal/non-human subjects; did not describe original research; were not journal articles; or did not empirically test the effect of one or more non-verbal communication techniques (for instance smilies, emoticons, emotional bracketing, voice accentuation, trailers (ellipsis) and pseudowords) as part of online, web-based or typed communication on communication-related variables including: message interpretation, social presence, the nature of the interaction (e.g. therapeutic alliance), consumer perceptions of the interaction (e.g. participant satisfaction), or psychological outcomes including depression, anxiety and distress. Results: A total of 4617 unique publications were identified. Of these, four publications met the eligibility criteria and were included in a narrative synthesis. All four studies addressed the effect of smilies or emoticons on participant responses, message interpretation or social presence of the writer. It was found that smilies and emoticons were able to convey a limited amount of emotion. No studies addressed other techniques for conveying emotion in written communication. No studies addressed the effects of any techniques on the nature of the interaction (e.g. therapeutic alliance), consumer perceptions of the interaction (e.g. participant satisfaction) or psychological outcomes (depression, anxiety or distress). Conclusions: There is a need for greater empirical attention to the effects of the various proposed techniques for conveying emotion in online or typed communications in order to inform health service providers regarding best-practice online communication skills.

  • Telehealth interventions to support self-management of long-term conditions: a systematic meta-review of diabetes, heart failure, asthma, chronic obstructive pulmonary disease and cancer.

    Date Submitted: Sep 26, 2016
    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions. This meta-review synthesises evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support. Objective: The objectives of this review were a) to assess the impact of telehealth interventions to support self-management on disease control and healthcare utilisation, and b) to identify components of telehealth support and their impact on disease control and the process of self-management. Methods: We performed a meta-review (a systematic review of systematic reviews) of randomised controlled trials (RCTs) of telehealth interventions to support self-management in six exemplar long-term conditions. Seven databases were searched from January 2000 to May 2016 and studies screened against eligibility criteria. Reviews were weighted by quality (R-AMSTAR), size and relevance). Results were combined in a narrative synthesis and using Harvest Plots. Results: Fifty-three systematic reviews, comprising 232 unique RCTs, were included. Reviews concerned diabetes (type 1 (n=6), type 2 (n=11), mixed (n=19)), heart failure (n=9), asthma (n=7), COPD (n=7) and cancer (n=3). Findings varied between and within disease areas. The highest weighted reviews showed blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycaemic control in type-2, but not type-1, diabetes; telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure; but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multi-faceted interventions were associated with greater improvements in diabetes, heart failure and asthma. Conclusions: While not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth represents a safe option for delivery for self-management support, particularly in conditions such as heart failure and type 2 diabetes where the evidence base is more developed. Larger scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.

  • Student Evaluation of a Distance Learning Module Using The Sigu Questionnaire

    Date Submitted: Sep 26, 2016
    Open Peer Review Period: Sep 26, 2016 - Nov 21, 2016

    Background: Infectious diseases remain a public health concern in Brazil. To achieve success in this process and to implement surveillance and public policy action, it is necessary to have health professionals that are highly trained and updated with the latest skills. The Brazilian government, through the Open University of SUS (UNA-SUS), in partnership with public universities in several states, offers specialization courses, further training and extension courses with free access, in the distance learning (DE) modality. In order to assess the DE courses offered by the institution, UNA-SUS/UFMA created the SIGU questionnaire, a subsystem that facilitates the processing and interpretation of data that is collected when students assess course’s modules. Objective: This study aimed to analyze students’ perceptions regarding didactic and pedagogical aspects related to the content and activities, educational resources, and tutoring in the Communicable Disease module in two distance learning (DE) postgraduate courses at UNA-SUS/UFMA. Methods: The authors analyzed a sample of 319 students, enrolled in two Postgraduate in Family Health classes (class of 2013 and 2014), and two Postgraduate Classes in Primary Care (two classes of 2014), who had completed the Communicable Diseases module and responded to evaluation questions through the SIGU questionnaire, an auxiliary system for processing and interpreting assessments of distance education modules offered by UNA-SUS/UFMA. By way of a statistical analysis, evaluation variables were dichotomized into either a positive outcome (“great” and “good”) or a negative outcome (“bad” and “insufficient”). Data were analyzed using SPSS (Version 18); the significance level was set at 5% (P < .05). Results: After analyzing the data, the authors observed that 99% of the students evaluated the module positively. With regard to the evaluation of the content and activities developed in the module, 53% (169), 43.6% (139), and 3.4% (11) of students evaluated the item workload of the course educational units as great, good, and bad, respectively. The highest rated item was tutor performance, with a rating of “great” from 229 (71.8%) of the students. Conclusions: Overall, the results contributed to the improvement of DE courses offered by UNA-SUS/UFMA from the perspectives of controlling dropout rates and the development of public health services offered in Brazil.

  • Attachment style and Internet addiction

    Date Submitted: Sep 25, 2016
    Open Peer Review Period: Sep 25, 2016 - Nov 20, 2016

    Background: One of the clinically relevant problems of Internet use is the phenomenon of Internet addiction. Overall, the estimated prevalence of computer game and Internet addiction is between 3 and 5%. Considering the fact that there is ample evidence for the relationship between attachment style and substance abuse, it stands to reason that attachment theory can also make an important contribution to the understanding of the pathogenesis of Internet addiction. Accordingly, the aim of this study was to examine people’s tendency toward pathological Internet usage in relation to their attachment style. Method: An online survey was conducted. Sociodemographic data, attachment style (Bielefeld questionnaire partnership expectations), symptoms of Internet addiction (scale for online addiction for adults), used Internet services and online relationship motives (Cyper relationship motive Scale) were assessed. In order to confirm the findings, a study using the Rorschach test was also conducted. Results: In total N = 245 subjects were recruited. Participants with insecure attachment style showed a higher tendency to pathological Internet usage compared to securely-attached participants. An ambivalent attachment style was particularly associated with pathological Internet usage. Escapist and social-compensatory motives played an important role for insecurely attached subjects. However, there were no significant effects with respect to online services and applications used. Results of the analysis of the Rorschach protocol with N = 16 subjects corroborated these results. Users with pathological Internet use frequently showed signs of infantile relationship structures in the context of social groups. This refers to the results of the online survey, in which interpersonal relationships were the result of an insecure attachment style. Conclusions: In summary, pathological Internet use was a function of insecure attachment and limited interpersonal relationships.

  • Designing patient-centered text messaging interventions for increasing physical activity among participants with Type II Diabetes: Qualitative results from the Text to Move intervention

    Date Submitted: Sep 21, 2016
    Open Peer Review Period: Sep 22, 2016 - Nov 17, 2016

    Background: The Text to Move (TTM) study was a six-month 2-parallel group randomized controlled trial of individuals with type II diabetes (T2DM) to increase physical activity, measured by a pedometer. The intervention arm received twice daily text messages for 6 months that were tailored to the participant’s stage of behavior change as defined by the Transtheoretical Model of Behavior Change. Objective: The purpose of this follow-up study was to collect feedback from participants in the TTM program and explore their views on text messaging as a health promotion tool. Categorizing the perceived barriers and facilitators to the TTM program will help inform the design of future technology-based studies to maximize participant engagement. Methods: We assessed participants’ attitudes regarding their experience with text messaging, focusing on perceived barriers and facilitators, through two focus groups and telephone interviews. All interviews were audio-recorded, transcribed verbatim, coded and analyzed using a grounded theory approach. Results: The response rate was 67.4% (31/46 participants). The average age was 51 and 61% were male. The majority of individuals were English speakers and married, had completed at least 12th grade and approximately half of all participants were employed full-time. Overall, participants were satisfied with the TTM program and recalled the text messages as educational, informational, and motivational. Program involvement increased the sense of connection with their healthcare center. The wearing of pedometers and daily step count information served as motivational reminders and created a sense of accountability through the sentinel effect. However, there was frustration concerning the automation of the text message program, including the repetitiveness, predictability of text time delivery, and lack of customization and interactivity of text message content. Participants recommended personalization of texting content and frequency as well as more contact time with personnel for a stronger sense of support, including greater surveillance and feedback based on their own results and comparison to other participants. Conclusions: Participants in a theory-based text messaging intervention identified key facilitators and barriers to program efficacy that should be incorporated into future texting interventions to optimize participant satisfaction and outcomes. Clinical Trial:

  • Does usage of an e-health intervention reduce the risk of excessive gestational weight gain?

    Date Submitted: Sep 13, 2016
    Open Peer Review Period: Sep 13, 2016 - Nov 8, 2016

    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Online interventions have the potential for delivering innovative, interactive excessive GWG prevention to large numbers of people. Objective: This study creates a novel measure of online intervention usage patterns and examines whether online intervention usage is associated with reduced risk of excessive GWG. Methods: The online intervention was theory based and emphasized the active ingredients of weight gain tracking and behavioral goal-setting and self-monitoring. One-thousand three hundred and thirty-five (898 intervention and 437 control) relatively diverse and healthy pregnant women were randomly assigned to the intervention arms or control arm. Usage patterns were examined for both intervention and control arm participants using Latent Class Analysis. A modified Poisson regression approach was used to estimate the relative risk of excessive total or weekly GWG for women with different usage patterns. Results: Five usage patterns best characterized the usage of the intervention arm participants. Three usage patterns best characterized control arm participants’ usage. Control arm usage patterns were not associated with excessive GWG, whereas intervention arm usage patterns were associated with excessive GWG. Conclusions: The control and intervention arm usage pattern characterization is a unique methodological contribution to process evaluations for self-directed, online interventions. Clinical Trial: NCT01331564,,

  • Opportunities and Challenges of Behavior Change Support Systems for Enhancing Habit Formation: Qualitative Study

    Date Submitted: Sep 9, 2016
    Open Peer Review Period: Sep 9, 2016 - Nov 4, 2016

    Background: Calls for action to break down the global burden of obesity have arisen, where already 5% weight loss can reduce the significantly prevalence of metabolic syndrome. Studies of health Behavior Change Support Systems (hBCSS) have been made, where individuals use the system to influence their own attitude or behavior to achieve their personal goals. However hardly any research have been made to study how users perceive habit formation with the help of eHealth intervention, not to mention how to design information systems aimed to particularly enhance habit formation. Habits are considered to play a fundamental role in behavior change, and the formation of healthy habits may be the key to aid maintenance beyond the intervention period. Objective: The objective of this article is to study hBCSS users’ experiences regarding habit formation of system use and healthier lifestyle. In addition this study aims to compare elements of PSD model with stages of habit formation suggested by Lally and Gardner. Methods: This study employs a web based hBCSS named Onnikka, a lifestyle intervention designed for prevention of metabolic syndrome for participants who are at risk of developing a metabolic syndrome or already suffering from it. A total of 43 Onnikka users were interviewed for this study during and after a 52-week eHealth-intervention period. The system was designed according to the principles of the Persuasive System Design (PSD) model and Behavior Change Support System framework. The research approach here is hermeneutics, which leans ontologically to social construction of reality, gained through language, consciousness, and shared meaning. Lally and Gardner’s research on stages of habit formation is used as a lens to explain data. In addition, the system’s login data and subjects’ weight measurements were utilized to build an interpretation of the results. Results: Habit formation stages provide possible explanation for why self-monitoring, reminders and tunneling were perceived as valuable features in this research case. The findings of this study suggest that IT habits appear to have a strong linkage with use adherence, whereas lifestyle habits did not seem to resonate with the 5% weight loss among subjects. Conclusions: Complete lifestyle change is highly complex activity where behavior change in one area might not be sufficient for sustainable weight management. Holistic eHealth interventions are needed to support weight loss, and stages of habit formation provide valuable guidance for hBCSS design. PSD model can offer practical design tools for developing a eHealth intervention system development that enhances also habit formation.

  • Filtering entities to optimize ADR identification from social media: how can the number of words between entities in the messages help?

    Date Submitted: Sep 1, 2016
    Open Peer Review Period: Sep 1, 2016 - Oct 27, 2016

    Background: With the increasing popularity of web 2.0 applications, social media has made it possible for individuals to post messages on adverse drug reactions. In such online conversations, patients discuss their symptoms, medical history, and diseases. These disorders may correspond to adverse drug reactions (ADRs) or any other medical condition. Therefore, methods must be developed to distinguish between false positives and true ADR declarations. Objective: We investigated a method for filtering out disorder terms that did not correspond to adverse events by using the distance between the drug term and the disorder/symptom term in the post. Methods: We analyzed a corpus of 648 messages corresponding to a total of 1 654 (drug, disorder) pairs from five French forums using Gaussian mixture models and an expectation-maximization (EM) algorithm. Results: The distribution of the distances between the drug term and the disorder term enabled the filtering of 50 % of the disorders that were not ADRs. Conclusions: This study suggests that such distance between terms can be used for identifying false positives, thereby improving ADR detection in social media.

  • Online Physician Rating Sites in Germany: Developments in the Frequency of Ratings and Evaluation Tendencies Compared with 2010 Baseline

    Date Submitted: Sep 1, 2016
    Open Peer Review Period: Sep 1, 2016 - Oct 27, 2016

    Background: At the beginning of 2010, the frequency of ratings and evaluation tendency on six German-language physician rating sites (PRSs) were investigated. This forms the basis for the present re-examination of PRSs, five years later. Objective: To examine the frequency of ratings and evaluation tendency of selected German-language PRSs and to compare these data with 2010 results. Methods: A total of 298 randomly selected physicians from the physician associations in Hamburg and Thuringia were searched for in 7 German-language PRSs regarding the quantity and quality of ratings. Results: Overall, between 64% and 95% of the physicians from the random sample could be identified on the selected PRSs. The average rating remains very positive and has improved even further towards “very good” since 2010. The average number of ratings per physician ranged from 1.2 to 8.9 across PRSs. While this represented an increase (range in 2010 was from 1.1 and 3.9), this increase reflects one more rating per physician per year. Conclusions: Further research is needed to identify barriers for patients to rate their physicians, to assist efforts to increase the number of ratings on PRSs, and therefore, improve the fairness and practical importance of PRSs. Clinical Trial: N/A