Latest Submissions Open for Peer Review

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

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Development and Testing of an Intelligent Pain Management System (IPMS) on smart phone by a Randomized Trial among Chinese Cancer Patients: a New Approach in Cancer Pain Management

    Date Submitted: Jan 18, 2017
    Open Peer Review Period: Jan 19, 2017 - Mar 16, 2017

    Background: Cancer has become increasingly prevalent in China over the past few decades. Among symptoms related to the quality of life of cancer patients, pain has commonly been recognized as a most critical one that may also result in ineffective treatment of cancer. More than one-third of cancer patients in China have experienced cancer pain. Driven by the need for better pain management for cancer patients, our research team developed a mobile-based Intelligent Pain Management System (IPMS) in the hope of providing a low-cost approach to prompt pain response and effective care for cancer patients. Objective: Our objective was to design, develop, and test the IPMS to facilitate real-time pain recording and timely intervention among cancer patients with pain. The system’s usability, feasibility, compliance, and satisfaction were also assessed. Methods: A sample of 46 patients with cancer pain symptoms were recruited at the Oncology Center of Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Chongming Branch (hereinafter referred to as “the Oncology Center”). In a pre-test, participants completed a pain management knowledge questionnaire and were evaluated with the baseline cancer pain assessment and Karnofsky Performance Status (KPS) evaluation. The participants were then randomly assigned into two groups (the trial group and the control group). After a 14 days’ trial period, another round of cancer pain assessment was conducted. In the trial group, the data was fully automated collected by the IPMS. In the control group, the data was collected using conventional methods, such as phone interviews or door-to-door visits by physician. The pain management knowledge questionnaire and KPS evaluation were repeated in both groups at the end of the trial. The participants were also asked to complete a satisfaction questionnaire on the use of the IPMS. Results: All participants completed the trial successfully. The primary end point was to assess the feasibility of IPMS by observing the number of daily pain assessments recorded among patients. The usage of IPMS was very favorable with a mean of 2.37±0.53 pain assessment times per day. The secondary end point was to evaluate the users’ satisfaction, effectiveness of pain management and changes in the quality of their lives. All the participants gave high satisfaction score after they used IMPS. Both groups (IMPS=25 vs control=21) reported similar pain scores (3.28±0.68 of the trial group vs. 2.90±0.62 of the control group, P = 0.06) as well as the KPS scores (50.80±7.02 of the trial group vs. 50.95±7.40 of the control group, P = 0.94) at the baseline. During the trial period, the mean pain score of the trial group was 2.53±0.42, compared to a significantly higher score 2.81±0.47 of the control group (P < 0.001). At the end of the trial, the mean pain score of the trial group was 2.20±0.50, compared to a significantly higher score 2.95±0.59 of control group (P < 0.001). The ending KPS score was significantly higher of the trial group than of the control group (68.80±7.23 vs. 56.2±7.40, P < 0.001). As to the pain management knowledge score, there was a 2.96±0.61 increase in the trial group, compared to a 0.81±0.67 increase (P < 0.001) in the control group after using the IPMS for 14 days. At the same time, all the participants gave high satisfaction score after they used IMPS. Conclusions: The result demonstrated that IPMS was a feasible, effective, and low cost pain management tool for cancer patients. This study provided preliminary data to support the potentials of using IPMS in cancer pain communication between patients and doctors, and to provide real-time supportive intervention at a convenient basis in a low cost. Overall, the IPMS can serve as a reliable and effective approach to the control of cancer pain and improved quality of life for patients with cancer pain. Clinical Trial: Name: Intelligent Pain Management System for Assessing Pain in Cancer Patients Registration number: NCT02765269 URL:

  • A Web-Based Tailored Intervention to Support Illness Management in Patients Hospitalized for an Acute Coronary Syndrome: A Pilot Study

    Date Submitted: Jan 17, 2017
    Open Peer Review Period: Jan 18, 2017 - Mar 15, 2017

    Background: Illness management after an acute coronary syndrome (ACS) is crucial to prevent cardiac complications, foster participation in a cardiac rehabilitation program and optimize recovery. Web-based tailored interventions have the potential to provide individualized information and counselling to optimize patient’s illness management after hospital discharge. Objective: The primary objective of this pilot study was to develop and assess the feasibility, acceptability and preliminary effect of a Web-based tailored intervention (TAVIE@COEUR) designed to improve illness management related to self-care, medication adherence, anxiety management and cardiac risk factors reduction in patients hospitalized for an ACS. Methods: This pre-post pilot study was conducted with one group (N=30) of patients hospitalized for an ACS on the coronary care unit of a tertiary cardiology center. TAVIE@COEUR consists of three Web-based sessions with a duration ranging from 10 to 45 minutes and is structured around an algorithm to allow the tailoring of the intervention to different pathways according to patients’ responses to questions. TAVIE@COEUR includes 90 pages, 85 videos and 47 PDF documents divided across session 1 (S1), session 2 (S2) and session 3 (S3). These sessions concern self-care and self-observation skills related to medication-taking (S1), emotional control and problem-solving skills (S2) and social skills and interacting with health professionals (S3). Patients completed S1 before hospital discharge, and were asked to complete S2 and S3 within two weeks after discharge. Feasibility indicators were extracted from the TAVIE@COEUR Web-based platform. Data regarding acceptability and preliminary effect were assessed through telephone questionnaires at baseline and one month following discharge. Results: Twenty out of 30 participants (67%) completed S1, 10 (33%) completed S2 and 5 (17%) completed S3. High acceptability scores were observed for ease of navigation (mean 3.58, Standard Deviation [SD] 0.70; scale 0–4), ease of understanding (mean 3.46, SD 0.63; scale 0–4) and applicability (mean 3.55, SD 0.74; scale 0–4). The lowest acceptability scores were observed for information tailoring (mean 2.93, SD 0.68; scale 0–4) and individual relevance (mean 2.56, SD 0.96; scale 0–4). With regard to preliminary effect, we observed an overall self-care at 1 month following discharge score higher than at baseline (mean at one month: 54.07, SD 3.99 vs mean at baseline: 49.09, SD 6.92; scale 0–60). Conclusions: Although participants reported general satisfaction and appreciation of TAVIE@COEUR, feasibility results show the need for further development of the Web-based intervention to enhance its’ tailoring before undertaking a full-fledged randomized controlled trial. This may be accomplished by optimizing the adaptability of TAVIE@COEUR to patients’ knowledge, needs, interests, individual capabilities and emotional and cognitive responses during session completion.

  • The development of an IVR survey for NCD risk factor estimation: technical assessment and cognitive testing

    Date Submitted: Jan 17, 2017
    Open Peer Review Period: Jan 18, 2017 - Mar 15, 2017

    Background: The rise in mobile phone ownership in low- and middle-income countries (LMIC) presents an opportunity to transform existing data collection and surveillance methods. Administering surveys via interactive voice response technology (IVR)—a mobile phone survey method—has potential to expand the current surveillance coverage and data collection, but formative work to contextualize the survey for LMIC deployment is needed. Objective: The primary objectives of this study were: (1) to cognitively test and identify challenging questions in a non-communicable disease (NCD) risk factor questionnaire administered via an interactive voice response (IVR) platform and (2) to assess the usability of the IVR platform. Methods: We conducted two rounds of pilot testing the IVR survey in Baltimore, Maryland. Participants were included in the study if they identified as being from a LMIC. The first round included individual interviews to cognitively test participant’s understanding of the questions. In the second round, participants were placed in focus groups and were asked to comment on the usability of the IVR platform. Results: Twelve participants from LMICs were cognitively tested in Round 1 to assess their understanding and comprehension of questions in an IVR-administered survey. Overall, the participants found the majority of the questions to be easy to understand and did not have difficulty recording most answers. The most frequent recommendation was to use country-specific examples and units of measurement. In Round 2, twelve participants assessed the usability of the IVR platform. Overall, participants felt the length of the survey was appropriate (average: 18 minutes and 31 seconds), but the majority reported fatigue in answering questions that had a similar question structure. Almost all participants commented that they thought an IVR survey would lead to more honest, accurate responses than face-to-face questionnaires, especially for sensitive topics. Conclusions: Overall, the participants indicated a clear comprehension of the IVR-administered questionnaire and that the IVR platform was user-friendly. Formative research and cognitive testing of the questionnaire is needed for further adaptation before deploying in a LMIC.

  • Building the evidence base for remote data collection in LMICs: comparing reliability and accuracy across survey modalities 

    Date Submitted: Jan 16, 2017
    Open Peer Review Period: Jan 18, 2017 - Mar 15, 2017

    Background: Given the growing interest in mobile data collection due to the proliferation of mobile phone ownership and network coverage in low- and middle-income countries (LMICs), we synthesized the evidence comparing estimates from multiple modes of data collection. In particular, we reviewed studies that compared a mode of remote data collection with at least one other mode in order to identify mode effects and areas for further research. Objective: To systematically review and summarize findings from articles and reports that compare a mode of remote data collection to at least one other mode. The aim of this synthesis is to examine mode effects on the reliability and accuracy of results. Methods: Seven online databases were systematically searched for primary and grey literature that conducted remote data collection in LMICs. Remote data collection included interactive voice response (IVR), computer-assisted telephone interviews (CATI), short message service (SMS), self-administered questionnaires and web surveys. Two research assistants reviewed abstracts to identify articles that met the primary inclusion criteria. The primary inclusion criteria required that the survey collected data from the respondent by SMS, IVR, CATI or via mobile phone. Articles that met primary screening criteria were read in full and screened using secondary inclusion criteria. The four secondary inclusion criteria were that the study had to be conducted in a LMIC, two or more modes of data collection were compared in the study, of which one mode had to be remote, and that the survey included a health component. Results: Of the 11,568 articles screened, ten articles were included in this study. Six distinct modes of remote data collection were identified: CATI, SMS, IVR, self-administered questionnaires completed off site and mailed back by post, mobile-web surveys, and personal computer web surveys. Of the two in-person modes (face-to-face [FTF] and self-administered questionnaire on-site), FTF was the most common (n=6). SMS was the most frequent remote mode (n=4). A variety of sampling methods were employed, a plethora of health topics were covered, and six of the ten articles included sensitive questions. None of the studies took place in Sub-Saharan Africa. When comparing in-person to remote data collection, remote data collection consistently elicited higher report of socially non-desirable behaviors. Of all the data collection comparisons, FTF and CATI most frequently reported consistency of measures across modes. Conclusions: This literature review adds to the remote data collection in the LMIC evidence base. Additional studies that compare reliability and construct validity across survey modalities are needed.

  • Online smoking cessation interventions in the Netherlands: effects, cost-effectiveness, and theoretical underpinnings

    Date Submitted: Jan 13, 2017
    Open Peer Review Period: Jan 17, 2017 - Mar 14, 2017

    Background: Tobacco smoking is a worldwide public health problem. In 2015, 26.3% of the Dutch population of 18 years and older smoked, which of 74.4% were daily smoker. More and more people have access to the internet worldwide, with about 94% of the Dutch population having online access. Internet-based smoking cessation interventions (online cessation interventions) have opportunities to tackle the scourge of tobacco. Objective: The goal of this paper was to provide an overview of online cessation interventions in the Netherlands, while exploring its effectivity, cost-effectiveness, and theoretical underpinnings. Methods: A mixed-method approach was used to identify Dutch online cessation interventions, using: (1) scientific literature search; (2) grey literature search; (3) and Expert input. In search for Dutch interventions, two independent researchers screened titles, abstracts, and then full-text in scientific literature, and titles and first page of the grey literature. Including expert input, this resulted in six interventions identified in the scientific literature and 39 interventions via the grey literature. Extracted data included: effectiveness, cost-effectiveness, theoretical factors and behavior change techniques used. Results: Overall, many interventions were offered without providing data on the effectiveness, except six interventions that were included in trials. Four of them were shown to be effective and cost-effective. The most important theoretical techniques used were: changing attitudes, providing social support, increasing self-efficacy, motivating smokers to make concrete action plans to prepare quit attempts and to cope with challenges, supporting identity change, rewarding abstinence, advising on changing routines, advising on coping, and advising on medication use. Conclusions: While the internet may provide the opportunity to offer various smoking cessation programs, the user is left in bewilderment concerning its efficacy, as most of these data are not available nor offered to the smokers. If the internet wants to live up its promising perspective, clear regulations need to be made concerning the effectiveness of these interventions, in order to avoid disappointment and useless quit attempts. Policy regulations are thus clearly needed in order to regulate the outburst of these interventions and to foster quality.

  • Social media use and access to digital technology in U.S. young adults, 2016

    Date Submitted: Jan 11, 2017
    Open Peer Review Period: Jan 17, 2017 - Mar 14, 2017

    Background: In 2015, 90% of U.S. young adults with internet access used social media. Digital and social media are highly prevalent modalities through which young adults explore identity formation, and by extension, learn and transmit norms about health and risk behaviors during this developmental life stage. Objective: The purpose of this study was to provide updated estimates of social media use from 2014 to 2016 and correlates of social media use and access to digital technology in data collected from a national sample of U.S. young adults in 2016. Methods: Young adult participants aged 18-24 years in Wave 7 (October 2014; N = 1,259) and Wave 9 (February 2016; N = 989) of the Truth Initiative Young Adult Cohort Study were asked about use frequency for eleven social media sites and access to digital devices, in addition to sociodemographic characteristics. Regular use was defined as using a given social media site at least weekly. Weighted analyses estimated the prevalence of use of each social media site, overlap between regular use of specific sites and correlates of using a greater number of social media sites regularly. Bivariate analyses identified sociodemographic correlates of access to specific digital devices. Results: In 2014, 89.42% (weighted n, 1126/1298) reported regular use of at least one social media site. This increased to 97.5% (weighted n, 965/989) of young adults in 2016. Among regular users of social media sites in 2016, the top five sites were Tumblr (85.5%), Vine (84.7%), Snapchat (81.7%), Instagram (80.7%), and LinkedIn (78.9%). Respondents reported regularly using an average of 7.6 social media sites, with 85% using 6 or more sites regularly. Overall, 87% of young adults reported access or use of a smartphone with internet access, 74% a desktop or laptop computer with internet access, 41% a tablet with internet access, 29% a smart TV or video game console with internet access, 11% a cell phone without internet access, and 3% none of these. Access to all digital devices with internet was lower in those reporting a lower subjective financial situation; there were also significant differences in access to specific digital devices with internet by race/ethnicity and education. Conclusions: The high mean number of social media sites used regularly and the substantial overlap in use of multiple social media sites reflect the rapidly changing social media environment. Mobile devices are a primary channel for social media and our study highlights disparities in access to digital technologies with internet access among U.S. young adults by race/ethnicity, education, and subjective financial status. Findings from the current study may guide the development and implementation of future health interventions for young adults delivered via the internet or social media sites.

  • Randomized Controlled Trial of a Mobile App for the Self-Management of Type 1 Diabetes Among Adolescents

    Date Submitted: Jan 17, 2017
    Open Peer Review Period: Jan 17, 2017 - Jan 25, 2017

    Background: While optimal blood glucose control (BG) is known to reduce the long-term complications associated with Type 1 Diabetes Mellitus (T1DM), adolescents often struggle to achieve their BG targets. However, their strong propensity towards technology presents a unique opportunity for the delivery of novel self-management interventions. To support T1DM self-management in this population the diabetes self-management app bant was developed, which included wireless BG reading transfer, out-of-range BG trend alerts, coaching around out-of-range trend causes and fixes, and a point-based incentive system. Objective: To evaluate bant’s effect on clinical outcomes (i.e. hemoglobin A1c) and to assess its impact on the self-management behaviours of adolescents with T1DM. Methods: Ninety-two adolescents were enrolled into a 12-month randomized controlled trial, with 46 receiving usual care and 46 receiving usual care plus bant. Clinical outcome data were collected at quarterly research visits via validated tools, electronic chart review, glucometer downloads and semi-structured interviews. App satisfaction was assessed at 6 and 12 months, and at trial end users ranked bant components based on perceived usefulness. Mobile analytics tracked frequency of BG uploads and was used to categorize subjects into high, moderate, low or very low engagement levels. Results: The study showed no changes in primary and secondary clinical outcomes. However, exploratory analysis demonstrated a statistically significant association between increased self-monitoring blood glucose (SMBG) and improved hemoglobin A1c in the intervention group. This relationship among bant users strengthened significantly over trial duration, specifically when comparing 9 (P=0.002) and 12 month visits (P=0.008) to baseline. For a subgroup of bant users taking SMBG>=5, they demonstrated a significant improvement in A1c of 0.58% (P=0.02), while the parallel subgroup in the control arm experienced no significant change in A1c (decrease of 0.06%, P=0.84). This indicated that bant may positively impact longitudinal glycemic control among those who test their BG more often. Although usage did diminish over the trial, on average, 35% (16/46 subjects) were classified as moderately or highly engaged (uploaded ≥3 days a week) over the 12 months. Conclusions: Although primary analysis of clinical outcomes did not demonstrate differences between the bant group and control, exploratory analysis suggests bant may positively impact use of SMBG data and glycemic control among youth. The next generation of bant will aim to remove barriers to use, such as deploying directly to personal devices instead of secondary research phones, and explore the utility of integrating bant into routine clinical care to facilitate more frequently feedback. Future evaluations of mHealth apps should consider more robust research tools (e.g. ResearchKit) and alternative RCT study designs, to enable more rapid and iterative evaluations, better suited to the nature of rapidly evolving consumer technology. Clinical Trial: NCT01899274

  • User testing of mobile apps and wearables to monitor rare disease in India

    Date Submitted: Jan 13, 2017
    Open Peer Review Period: Jan 14, 2017 - Mar 11, 2017

    Background: Remote monitoring may offer solutions for patients with limited access to clinicians, chronic disease sufferers who lives rurally or a great distance from specialist Doctors, and could offer a resolution to the data problem suffered in rare disease groups, where small populations and limited disease progression data exists. Objective: This was a user testing exercise coordinated with the Gauchers Association [UK] and the Lysosomal Storage Disorder Support Society [LSDSS] to explore the reception of remote monitoring using a wearable and mobile app with Type I Gauchers patients in India. Methods: Participants were provided with a wearable wristband that counts steps and a mobile app that collects additional health data. They had the opportunity to use these for a month before answering an online questionnaire about their experience of using the tech. Results: Six volunteers participated, with four becoming active users and responding to the questionnaires Conclusions: The mobile app and band collected information for all users. While the band was able to collect objective step data, some subjective measures in the app were identified as being more useful than others, and additional measurements were identified for future trials. The experience demonstrated that the tech could be successfully deployed in India and resulted in good engagement and adherence with patients. Clinical Trial: Not applicable

  • Assess suicide risk and emotional distress in Chinese social media by natural language use

    Date Submitted: Jan 9, 2017
    Open Peer Review Period: Jan 13, 2017 - Mar 10, 2017

    Background: The mainstream assessment of individuals’ suicide risk or emotional distress relies on self-report scales or clinical assessments. Such assessment relies on individuals’ willingness and ability to seek help/treatment, which is often challenging for distressed or suicidal people. Objective: The present study explores how natural language can be utilized to proactively assess one’s suicide risk and emotional distress in Chinese social media. Methods: An online survey was conducted on Sina Weibo to assess the respondents’ suicide risk and emotional distress. With the respondents’ consent, we also downloaded all of their Weibo posts which were posted in the public domain during the 12 months prior to the survey by calling the Weibo API. Weibo posts were tokenized and language features were extracted by applying Simplified Chinese Linguistic Inquiry and Word Count (SC-LIWC). Logistic regression analysis were operated to examine the relationship between use of SC-LIWC categories and the respondents’ suicide risk with emotional distress. Support Vector Machines were trained to automatically classify whether a respondent was showing suicide risk or emotional distress. ROC curve analysis was operated for examining the diagnostic accuracy of the machine classifiers. Results: Weibo users with high suicide risk were marked by a higher usage of pronoun, prepend words, and multifunction words, a lower usage of verb, and a greater total word count. Severe depression was marked by more use of second-person plural and achievement-related words, but less use of work-related words. Anxiety was also marked by less use of work-related words. Stress was marked by more use of third-person and second-person plural, health-related words, and death-related word. and stress were marked by more use of second-person plural, and less use of work-related words. The machine classification on suicide risk and depression achieved satisfying results after adding a filter of Weibo suicide communication. However, the classification results for severe depression and stress were still not significant. Conclusions: The study demonstrates the utility of natural language as alternative assessment tool of suicide risk and emotional distress in Chinese social media. The current development can improve assessment coverage and efficiency but still requires experts’ inputs to increase accuracy. Clinical Trial: N/A

  • Key Components in eHealth Interventions Combining Self-Tracking and Persuasive eCoaching to Promote a Healthier Lifestyle: a Scoping Review

    Date Submitted: Jan 9, 2017
    Open Peer Review Period: Jan 13, 2017 - Mar 10, 2017

    Background: The combination of self-tracking and persuasive eCoaching in automated interventions is a new and promising approach for healthy lifestyle management. Objective: This scoping review aims to identify key components of self-tracking and persuasive eCoaching in automated healthy lifestyle interventions that contribute to the effectiveness on health outcomes, usability, and adherence. A secondary aim was to identify the way in which the key components should be designed to contribute to improved health outcomes, usability, and adherence. Knowledge about these key components can be used during development of such healthy lifestyle interventions. Methods: The scoping review methodology proposed by Arskey and O’Malley was applied. Scopus, EMBASE, PsycINFO and PubMed were searched for publications between January 1st, 2013 – January 31st, 2016 that included (1) self-tracking, (2) persuasive eCoaching, and (3) healthy lifestyle intervention. Results: The search resulted in 32 publications of which 17 publications provided results on the effect on health outcomes, 27 studies provided results on usability and 13 studies provided results on adherence. Among the 32 publications, 27 described an intervention. The most commonly applied persuasive eCoaching components in the described interventions were personalization (n=24), suggestion (n=19), goal-setting (n=17), simulation (n=17), and reminders (n=15). Concerning self-tracking components, most interventions utilized an accelerometer to measure steps (n=11). In addition, the intervention was most often delivered via a smartphone (n=10). The following key components and their specific design both seem to influence health outcomes and usability in a positive way: reduction by setting short term goals to eventually reach long-term goals, personalization of goals, praise messages, reminders to input self-tracking data into the technology, use of validity tested devices, integration of self-tracking and persuasive eCoaching, and provision of face-to-face instructions during implementation. In addition, it did not seem to negatively affect health outcomes or usability when more effort was requested from participants to input data into the technology. Data extracted from the included publications limited the ability to provide key components on adherence. However, one key component identified for both usability and adherence was the provision of personalized content. Conclusions: This scoping review provides a first overview of the key components in automated healthy lifestyle interventions combining self-tracking and persuasive eCoaching that can be utilized during the development of such interventions. Future studies should focus on the identification of key components for effect on adherence as adherence is a prerequisite for an intervention to be effective.

  • Critical Appraisal of E-Health Intervention for Anxiety Management in Youths

    Date Submitted: Jan 3, 2017
    Open Peer Review Period: Jan 11, 2017 - Mar 8, 2017

    Background: Advances in technology are progressively more relevant to the clinical practice of psychology and mental health services generally. Studies indicate that technology facilitates the delivery of interventions, such as Cognitive Behavioral Therapy (CBT), in the treatment of a number of psychological disorders in adults, including depression, anxiety, obsessive–compulsive disorder, panic symptoms, and eating disorders. Fewer data exist for computer-based (stand-alone; self-help) and computer-assisted (in combination with face-to-face therapy; therapist guided) programs in youths. Objective: This article summarizes and critically reviews the literature evaluating the acceptability and efficacy of using technology with treatment and prevention programs for anxiety in young children and adolescents. The aim is to improve the understanding of what would be critical for future development of effective technology-based interventions. Methods: A systematic literature search was conducted in three scientific electronic databases (including PsycINFO, Science Direct and PubMed). Keywords with various combinations were used: child/children, adolescent, pre-school children, anxiety, intervention or treatment or program, smartphone applications or apps, online or web-based tool, computer-based tool, serious games, cognitive behavioral therapy (CBT), biofeedback. Results: Available studies demonstrate promising results in reducing anxiety, especially relative to the application of CBT with technology. For those programs demonstrating efficacy, no difference was noted when compared with traditional intervention. Other approaches have been applied to technology-based interventions with inconclusive results. The majority of existing programs are developed to be used concurrently with traditional treatments and lack long term evaluation. Very little has been done in terms of prevention interventions. Conclusions: Future development of e-Health programs for the management of anxiety in children will have to address several unmet needs and overcome key challenges: although developmental stages may limit the applicability to preschool children, prevention should start in early ages; self-help format and personalization are highly relevant for large-scale dissemination; automated data collection should be built in for program evaluation and effectiveness assessment; a strategy to stimulate motivation to play and maintain high adherence should be carefully considered.

  • Towards understanding pain-monitoring electronic technologies for adults: a Systematic Literature Review

    Date Submitted: Jan 6, 2017
    Open Peer Review Period: Jan 9, 2017 - Mar 6, 2017

    Background: Remote monitoring of patients may decrease treatment costs and improve quality of care. Pain is the most common health problem that people seek help for in hospitals. Therefore, remote monitoring of patients with pain may have significant impact in improving treatment. Several studies have studied factors affecting pain, however, no previous study has characterized a patient’s situation through all the relevant contextual information that a monitoring system may capture. Objective: The objective of this study was to conduct a systematic review to (1) determine what types of technologies have been used to monitor adult patients with pain, and (2) construct a model of the context information relevant to pain monitoring that may be used to implement applications and devices aimed at monitoring patients with pain. Methods: A literature search (2005-2015) was conducted in electronic databases pertaining to medical and computer science literature (PubMed, Science Direct, ACM Digital Library, and IEEE Xplore), using a defined search string. Article selection was done through a process of removing duplicates, analyzing title and abstract, and then reviewing the full text of the article. Results: 87 articles were included in the final analysis and 53 of them (61%) used technologies to collect contextual information. 49 types of context information were found and a five-dimension model of context information to monitor patients was proposed, expanding a previous model. Most technological interfaces for pain monitoring are wearable, possibly because they can be used in more realistic contexts. Few studies focus on older adults, creating a relevant avenue of research on how to create devices for users that may have impaired cognitive skills or low digital literacy. Conclusions: The design of remote monitoring devices and interfaces for patients with pain must deal with the challenge of selecting relevant contextual information to understand the user’s situation, and not overburdening or inconveniencing users with information requests. A complete model of contextual information that a device can capture may be used by designers to review possible contextual information and choose which is relevant for a particular device.

  • User and website characteristics related to attrition in a self-regulation-based eHealth intervention to promote a healthy lifestyle

    Date Submitted: Jan 6, 2017
    Open Peer Review Period: Jan 8, 2017 - Mar 5, 2017

    Background: EHealth interventions can reach large populations and are effective in increasing physical activity (PA) and fruit and vegetable intake. Nevertheless, the effects of eHealth interventions are overshadowed by high attrition rates. Examining more closely when users decide to leave the intervention can help eHealth developers to make informed decisions about which intervention components should be reshaped or simply removed. Investigating which users are more likely to quit an intervention can inform developers about whether and how their intervention should be adapted to specific subgroups of users. Objective: This study investigates the pattern of attrition in a web-based intervention to increase PA, fruit and vegetable intake. The first aim is to describe attrition rates according to different self-regulation components. A second aim is to investigate if certain user characteristics are predictors for start session completion, returning to a follow-up session and intervention completion. Methods: The sample consisted of 549 adults who participated in an online intervention, based on self-regulation theory, to promote PA and fruit and vegetable intake, called ‘MyPlan 1.0’. Using descriptive analysis, attrition was explored per self-regulation component (e.g. action planning, coping planning, …). To identify which user characteristics predict completion, logistic regression analyses were conducted. Results: At the end of the intervention programme, there was an attrition rate of 78.2%. Attrition rates were very similar for the different self-regulation components. However, attrition levels were higher for the fulfilment of questionnaires (e.g. to generate tailored feedback) than for the more interactive components. The highest amount of attrition could be observed when people were asked to make their own action plan. There were no significant predictors for first session completion. Yet, two subgroups had a lower chance to complete the intervention, namely male users (OR: 2.24, 95% CI= 1.23-4.08) and younger adults (OR: 1.02, 95% CI= 1.00-1.04). Furthermore, younger adults were less likely to return to the website for the first follow-up after one week (OR= 1.03, 95% CI= 1.01-1.04). Conclusions: This study informs us that eHealth interventions should avoid the use of extensive questionnaires and that users should be provided with a rationale for several components (e.g. making an action plan, completing questions, …). Furthermore, future interventions should focus first on motivating users for the behaviour change, before guiding them through action planning. Though, this study provides no evidence for removal of one of the self-regulation techniques based on attrition rates. Lastly, strong efforts are needed to motivate male users and younger adults to complete eHealth interventions.

  • A health professional-led synchronous discussion in Facebook can provide personalized information and support but does not generate a peer-support network.

    Date Submitted: Jan 3, 2017
    Open Peer Review Period: Jan 6, 2017 - Mar 3, 2017

    Background: Arthritis is a major cause of pain and disability. Arthritis New Zealand is a non-government organization that provides advocacy, information, and advice and support services for people with arthritis in New Zealand. Since many people seek health information online Arthritis New Zealand has a webpage and a Facebook page. In addition to static content, Arthritis New Zealand provides synchronous discussions with an Arthritis Educator (AE) each week via Facebook. Objective: To determine how synchronous discussion with a health educator on a social media platform may provide information and support to people with arthritis and if such activity on social media can provide useful insights into consumers’ health care needs. Methods: Interpretive multi-methods were used. Facebook Analytics were used to describe the users of the Arthritis NZ Facebook page and provide descriptive summary statistics. Gephi and manual graphic analysis were used to summarise activity during a convenience sample of ten AE-led synchronous discussions. Principles of thematic analysis were employed to interpret transcripts of all comments from these ten weekly AE-led discussions. Results: Users of the Arthritis NZ Facebook page were predominately female (81%), aged 18-54 years. Three major activities occurred during AE-led synchronous discussions: (1) seeking or giving support; (2) information enquiry; and (3) information sharing across a broad range of topic areas, largely relating to symptoms and maintaining physical functioning. There was limited peer-to-peer interaction, with most threads consisting of two-comment exchanges between users and the AEs. Conclusions: The AE-led discussions provided a forum for informational and emotional support for users. The facilitated discussion forum for people with arthritis on Facebook could be enhanced by encouraging increased user participation and increasing peer-to-peer interactions, and further training of AEs in facilitation of online discussion. Future research should focus on addressing barriers to user participation and assessing the impact of AE facilitation training, with the latter leveraging the Action Research paradigm.

  • Framework for Clinical Validation of Heart Rate Apps

    Date Submitted: Jan 3, 2017
    Open Peer Review Period: Jan 3, 2017 - Feb 28, 2017

    Background: Photoplethysmography (PPG) is a proven way to measure heart rate (HR). This technology is already available in smartphones, which allows measuring HR only by using the smartphone. Given the widespread availability of smartphones, this creates a scalable way to enable mobile HR monitoring. An essential precondition is that these technologies are as reliable and accurate as the current clinical (gold) standards. At this moment, there is no consensus on a gold standard method for the validation of HR applications. This results in different validation processes that not always reflect the veracious outcome of comparison. Objective: To investigate and describe the necessary elements in validating and comparing heart rate apps versus gold-standard technology. Methods: The FibriCheck application was used in two separate prospective, non-randomized studies. In the first study, the HR of the FibriCheck application was consecutively compared with two different FDA-cleared HR devices: the Nonin oximeter and the AliveCor Mobile ECG. In the second study, a next step in validation was performed by comparing the beat-to-beat intervals of the FibriCheck application to a synchronized ECG recording. Results: In the first study, the HR (beats/min) of 80 random subjects consecutively measured with the 3 devices showed a correlation coefficient of 0,856 between FibriCheck and Nonin, 0,937 between FibriCheck and AliveCor and 0,892 between Nonin and AliveCor. A single way ANOVA (p = 0.481) was executed to test the hypothesis that there was no significant difference between the heart rates as measured by the 3 devices. In the second study, 20298 RRI - PPI intervals (ms) from 229 subjects were analysed. A positive correlation of 0.993 was found between the PPI from FibriCheck and the RRI from the wearable ECG. There was no significant difference (p = 0.9215) between these intervals. Conclusions: The current findings suggest that the best suitable method for the validation of a HR app is a simultaneous measurement of the HR by the smartphone application and an ECG system, compared on the basis of beat-to-beat analysis. This approach could lead to very high accuracy in the clinical setting.

  • The Impact of Crowdfunding on Knowledge of Science and Rare Genet-ic Diseases Research

    Date Submitted: Dec 24, 2016
    Open Peer Review Period: Jan 2, 2017 - Feb 27, 2017

    Background: Although the cost to sequence a genome has been substantially reduced, it is still unaffordable for many patients because it is rarely covered by health insurance. Financial strain is all too familiar to many Americans today. Nearly half of respondents to a 2011 poll from the National Bureau of Economic Research stated that if they were given a 30-day timeframe, they would be unable to produce an extra $2,000. Beyond overtaxed household budgets, families dealing with undiagnosed or rare diseases incur countless unexpected healthcare costs that create tremendous financial burdens. These families shoulder these staggering health care expenses accumulated over years of seeking treatment. Crowdfunding may help support patients in need of DNA sequencing by providing access to a test that might uncover the cause of their disease and potentially lead to viable clinical treatment. Objective: The goal of Amplify Hope was to test the effectiveness of strategies for raising the necessary funding for trio exome sequencing through crowdfunding campaigns. More generally, we sought to understand the strategies that are the most successful for crowdfunding campaigns for medical expenses. Methods: Our research sought to 1) provide demographic information on the donor population; 2) identify common factors among successful medical crowdfunding campaigns; 3) identify factors that influenced people to donate, as reported by donors; and 4) describe the im-pact crowdfunding campaigns had on donors’ knowledge of genomics. We conducted the study in several phases, including a needs assessment, participant recruitment, a 30-day crowdfunding training period, a 30-day online crowdfunding period, and follow-up surveys given to participants and donors. Results: We found that social media played an important role in all campaigns. Specifically, a strong social media network, an active outreach process, and a high degree of comfort with networking all correlated with a higher success rate. Amplify Hope donors were more likely to support projects that were near their fundraising goals, and found video far more effective for learning about genomics than any other medium. Conclusions: The campaigns that achieved complete funding during the 30-day online crowdfunding campaign study period shared several characteristics. Individual campaign organizers who reached their campaign goals engaged more during the training program prior to the start of the crowdfunding campaign, as compared to those that did not achieve their campaign goals. These organizers read our shared Amplify Hope study materials, followed recommended guidelines, and perhaps most importantly initiated communication via phone calls and emails to their networks prior to the campaign launch. In other words, the successful campaigners frontloaded their campaigns. They also actively engaged their network and donors by providing updates throughout the campaigns rather than trailing off.

  • Gathering opinions on depression information needs and preferences: Samples and opinions in clinic vs. Internet surveys

    Date Submitted: Dec 25, 2016
    Open Peer Review Period: Dec 28, 2016 - Feb 22, 2017

    Background: There has been limited research on the information needs and preferences of members of the public concerning treatment for depression. There has also been limited research comparing samples and opinions when recruitment for surveys is done over the Internet (responding to a mass mailing or clicking on a link in a posted invitation) as opposed to being done with a personal invitation to complete a paper survey. Objective: This study aimed first to explore information needs and preferences among members of the public and second to compare Clinic and Internet samples on sample characteristics and survey findings. Methods: Internet survey participants were recruited with a notice on three self-help association websites (N=280). Clinic survey participants were recruited by a research assistant in the waiting rooms of a family medicine clinic and a walk-in medical clinic (N=238) and completed a paper version of the survey. Results: The Clinic and Internet samples were similar in age, education, and proportion in full time employment. The Clinic sample was more diverse in demographic characteristics and closer to the demographic characteristics of the region with a higher proportion of males (43% vs 16%) and non-Caucasians (29% vs. 14%). The Internet sample reported a higher level of emotional distress and had more previous psychological (80% vs. 35%) and pharmacological (72% vs, 24%) treatment. In terms of opinions, most respondents in both settings saw information on a wide range of topics around depression treatment as very important including information about treatment choices, effectiveness of treatment, now long treatment takes to work, how long treatment continues, what happens when treatment stops, advantages and disadvantages of treatments, and potential side effects. Females, respondents with a Caucasian background, and those who had received or felt they would have benefitted from therapy in the past saw more information topics as very important. Those who had received or thought they would have benefitted in the past from medication treatment saw fewer topics as important. Participants in both groups expressed an interest in receiving information through discussion with a counsellor or a physician, through written brochures, or through a recommended website. Conclusions: The recruitment strategies were helpful in obtaining opinions from members of the public with different concerns and perspectives, and the results from the two methods were complementary. Persons coping with emotional distress and individuals not specifically seeking help for depression would be interested in information to answer a wide range of important questions about depression treatment. The Clinic sample yielded more cultural diversity that is a closer match to the population. The Internet sample was less costly to recruit and included persons who were most interested in receiving information. Clinical Trial: NA

  • Healthier Together: Using an Internet-Based Communication Campaign and Improvement Science to Build Engagement in a Learning Network

    Date Submitted: Dec 22, 2016
    Open Peer Review Period: Dec 28, 2016 - Feb 22, 2017

    Background: Network-based Learning Health Systems that facilitate patient, clinician and researcher collaboration are emerging as a means to improve health and the healthcare system. The first step to engaging in a network is becoming aware that one exists. Objective: Our objective was to determine whether an Internet-based communication campaign within a network focused on improving outcomes for children and adolescents with inflammatory bowel disease could be used as a strategy for engaging a broad base of stakeholders – patients, families, clinicians and researchers – in a peer-produced learning network. Methods: We developed an Internet-based communication campaign targeting all stakeholder groups (patients, families, clinicians, researchers) in the ImproveCareNow (ICN) Network. Using existing network communication channels and 56 ICN clinical care centers as distribution nodes, we aimed to collect 1,000 expressions of support for collaborative healthcare and ICN over 9 weeks. Participants were stakeholder groups (patients, families, clinicians, researchers) in the ICN Network. Outreach took place via social media, email, blogs, e-newsletters, list-serves, webinars, and ICN clinics. Individuals were asked to post an expression of support on the microsite. We used quality improvement methods to evaluate outreach channels and strategies and guide subsequent outreach interventions. The main outcome and measures were the number of microsite visits, number of posted expressions of support, and microsite visit-to-posted expression conversion rate were tracked daily via run and controls charts to determine impact. Results: Over the course of 9 weeks, the microsite received 5,496 visits from 2,183 unique visitors and collected over 1,000 expressions of support for collaborative healthcare, including written statements, photos, and videos. Expressions came from all stakeholder groups, including patients/families/friends (48%), clinicians (30%), researchers (5%), and interested others (17%). Submissions included stories of the importance of collaboration in improving health and healthcare. Frequent, repeated prompting, direct requests from known individuals, and increasing urgency were related to increased postings. Conclusions: An Internet-based communication campaign using network communication channels and care centers can be an effective means of motivating awareness and simple participation in contributing to improvement in care and outcomes.

  • Too Far to Care? The Role of Psychological Distance in Online Public Attention and Fear for Ebola

    Date Submitted: Dec 22, 2016
    Open Peer Review Period: Dec 28, 2016 - Feb 22, 2017

    Background: In 2014 the world was startled by a sudden outbreak of Ebola. Despite only a handful of cases occurring in countries outside Guinea, Sierra Leone and Liberia, the epidemic caused a great stir of seemingly irrational human responses among the public in Western countries. While previous research has shown the potential of social media to assess real-time public opinion and sentiment, generalizable insights that further theory development have remained lacking. The current study builds on Construal Level Theory to examine the relationship between physical distance to an epidemic, and public attention and sentiment expressed on Twitter. Objective: To increase theoretical understanding of the relationship between psychological distance to a health crisis, public attention and sentiment expressed on Twitter. Methods: Epidemiological (number of Ebola infections and fatalities) and media data (tweet volume and key events reported in the media) for the 2014 Ebola outbreak were during the outbreak, and Twitter content was coded across 3.5 months with regard to (1) expressions of fear for self or fear for others and for (2) psychological distance of the outbreak to the tweet source. Results: Findings revealed that online public attention and expressions of fear responded mainly to the psychological distance of the epidemic. A Chi square test showed a significant positive relation between proximity and fear: χ2=103.20 (p<.001). Public attention and fear for self in the Netherlands showed peaks when Ebola became physically closer by crossing the Mediterranean Sea and Atlantic Ocean. Fear for others was mostly affected by the social distance to the affected parties. Increases in public attention co-occurred with severe events related to the epidemic, but not all severe events evoked fear. Conclusions: We discuss the role of psychological distance as an important boundary determinant of public responses that needs to be taken into account when communicating about human tragedies.

  • Continuous monitoring of vital parameters using wearable devices on the general ward: a pilot study

    Date Submitted: Dec 21, 2016
    Open Peer Review Period: Dec 28, 2016 - Feb 22, 2017

    Background: Background: Measurement of vital parameters in hospitalized patients is necessary to assess the clinical situation of the patient. Early Warning Scores (EWS), such as the Modified Early Warning Score (MEWS), are generally calculated three times a day, but may not capture early deterioration. A delay in diagnosing deterioration is associated with increased mortality. Continuous monitoring with wearable devices might detect clinical deterioration at an earlier stage, which allows clinicians to take corrective actions. Objective: In this pilot study, the feasibility of continuous monitoring using the ViSi Mobile (VM) and HealthPatch (HP) was tested and experiences of patients and nurses were collected. Methods: In this feasibility study, twenty patients at the internal medicine and surgical ward were monitored with VM and HP simultaneously for 2-3 days. Technical problems were analyzed. Vital parameter measurements by nurses were taken as reference and compared with vital parameters measured by both devices. Patient and nurse experiences were obtained by semi-structured interviews. Results: In total, 86 out of 120 MEWS measurements were used for analysis. Predominant VM artefact (70%) was a connection failure. Over 50% of all HP artefacts had an unknown cause, were self-limiting and never took longer than one hour. Vital parameter measurements by VM and HP were generally consistent with nurse measurements. In 30% of the cases, clinical relevant differences in MEWS were found based on inconsistent respiratory rate registrations. The majority of patients, relatives, and nurses were positive about the VM and HP. Conclusions: Both VM and HP are promising for continuously monitoring vital parameters in hospitalized patients, if the frequency and duration of artefacts are reduced. The devices were well received and comfortable for most patients.

  • Identification and Prediction of COPD Exacerbations during Home Monitoring in a Clinical Trial

    Date Submitted: Dec 21, 2016
    Open Peer Review Period: Dec 28, 2016 - Feb 22, 2017

    Background: Chronic Obstructive Pulmonary Disease (COPD) is a progressive, chronic respiratory disease with a significant socioeconomic burden. Exacerbations, the sudden and sustained worsening of symptoms, can lead to hospitalisation and reduce quality of life. Major limitations of previous telemonitoring interventions for COPD include low compliance, lack of consensus on what constitutes an exacerbation, limited numbers of patients and short monitoring periods. We developed a telemonitoring system based on a digital health platform that was used to collect data from the one-year EDGE COPD clinical trial aiming at daily monitoring in a heterogeneous group of patients with moderate to severe COPD. Objective: Firstly, to develop a systematic and reproducible approach to exacerbation identification, and to track the progression of patient condition during remote monitoring; and secondly to develop a robust algorithm able to predict COPD exacerbation, based on vital signs acquired from a pulse oximeter. Methods: We used data from 110 patients, with a combined monitoring period of over 35,000 days. We propose a finite-state machine based approach for modelling COPD exacerbation to gain a deeper insight into COPD patient condition during home monitoring to take account of the time-course of symptoms. A robust algorithm based on short-period trend analysis and logistic regression using vital signs derived from a pulse oximeter is also developed to predict exacerbations. Results: Based on 27,260 sessions recorded during the clinical trial (average usage of 5.3 times per week for 12 months), there were 361 exacerbation events. There was considerable variation in the length of exacerbation events, with a mean length of 8.2 days. The mean value of oxygen saturation was lower, and both the pulse rate and respiratory rate were higher prior to an impending exacerbation episode, compared to stable periods. Based on the classifier developed in this work, prediction of COPD exacerbation episodes with 60-80% sensitivity will result in 68-36% specificity. Conclusions: All three vital signs acquired from a pulse oximeter (pulse rate, oxygen saturation and respiratory rate) are predictive of COPD exacerbation events, with oxygen saturation being the most predictive, followed by respiratory rate and pulse rate. Combination of these vital signs with a robust algorithm based on machine learning leads to further improvement in positive predictive accuracy. Clinical Trial: ISRCTN40367841

  • Implementing an Internet-delivered skin cancer genetic testing intervention to improve sun protection behavior in a diverse population

    Date Submitted: Dec 27, 2016
    Open Peer Review Period: Dec 28, 2016 - Feb 22, 2017

    Background: Currently little translational genomic research exists to guide the availability, comprehension, and appropriate use of personalized genomics in diverse, general population subgroups that stand to benefit from it in the coming years. Melanoma skin cancers are preventable, curable, common in the general population, and disproportionately increasing in Hispanics. Variants in the melanocortin receptor gene (MC1R) are present in about 70% of the population, interact with sun exposure, and confer a 2-3 fold increase in melanoma risk in the general population, even in darker skin populations, thus feedback regarding MC1R risk status may raise risk awareness and protective behavior in the general population. Objective: We are conducting a randomized controlled trial examining Internet presentation of the risks and benefits of personalized genomic (MC1R) testing for melanoma (PGT-M). Methods: We will enroll 885 participants, who will be randomized 6:1 to PGT-M versus waiting list control. Control participants will be offered testing after outcome assessments. Participants will be balanced across self-reported Hispanic versus Non-Hispanic ethnicity, n=750 in PGT-M arm; n=135 in control arm), and will be recruited from a general population cohort in Albuquerque New Mexico, where there is year-round sun exposure. Results: Aim I of the trial will examine the personal utility of PGT-M in terms of short-term (three month) sun protection, skin screening behavior, family and physician communication, melanoma threat and control beliefs (i.e., putative mediators of behavior change). We hypothesize that behaviors and putative mediators will be higher in those who test compared to those who decline testing. We will also examine potential unintended consequences of testing among those who receive average risk PGT-M findings, examining predictors of sun protection at three months as the outcome. These findings will be used to develop messages for groups that receive average risk feedback. Aim II will compare rates of test consideration of PGT-M in Hispanic versus Non-Hispanics in terms of consideration of the pros and cons of testing and registration of PGT-M decision, either for or against testing. We hypothesize that Hispanics will show reduced reach, but that the reduction will reflect levels of health literacy, health system distrust, and sociocultural factors (cancer fatalism, family health orientation, skin cancer misconceptions), not ethnicity. Aim III will examine PGT-M feedback comprehension, recall, satisfaction, and cancer-related distress in those who undergo testing, and whether these outcomes differ by ethnicity (Hispanic versus Non-Hispanic) or sociocultural or demographic factors. Conclusions: The study has important implications for personalized genomics in the melanoma context, and may be broadly applicable as a model for delivery of personalized genomic feedback for other health conditions.

  • Effect of a Web-based Intervention on Physical Activity and Fruit and Vegetable Intake Among Chinese University Students: a Randomized Controlled Trial

    Date Submitted: Dec 22, 2016
    Open Peer Review Period: Dec 28, 2016 - Feb 22, 2017

    Background: Ample evidence demonstrates that university students are at high risk for sedentary behaviours and inadequate fruit and vegetable intake. Internet-based interventions for multiple health behaviour appear to be promising in changing such unhealthy habits. Limited randomized controlled trials have tested this assumption among Chinese university students. Objective: This study aimed to test the efficacy of an 8-week web-based intervention compared to a control group condition to improve physical activity (PA) and fruit and vegetable intake (FVI) in Chinese university students. The intervention content was based on the Health Action Process Approach, and developed on the basis of previous evidence from the western hemisphere. Self-reported data including PA and FVI, stages of change for PA and FVI, motivational (risk perception, outcome expectancies, self-efficacy), volitional (action planning, coping planning, social support), and psychological (intention, habit) indicators for PA and FVI, as well as perceived health outcomes (quality of life, depression) were evaluated. Methods: In a randomized controlled trial, university students from one university in the central region of China were recruited during their PE class. 493 students were then randomly assigned into one of two groups: (1) intervention group: first 4-weeks on PA and subsequent 4-weeks on FVI; (2) the control group. Three web-based assessments were conducted including one at the beginning of the intervention (T1, N=493), at the end of the 8-week intervention (T2, N=337), and at a 1 month follow-up after the intervention (T3, N=142). The entire study was conducted throughout the fall semester of 2015. Results: Significant treatment by group interactions revealed superior intervention effects on FVI, motivational, volitional and psychological indicators of FVI behaviour change, and motivational indicators of PA behaviour change, with an effect size of Eta² ranging from .11 to .13. In addition, the overall intervention effects were significant for stage progression to the action group from T1 to T2 in PA (Chi² =11.75, df=1, P=.001) and FVI (Chi²=15.64, df=1, P<.001). Furthermore, the intervention effect was seen in the improvement of quality of life (F=1.23, Eta²=.03, P=.02). Conclusions: The present study is the first of its kind to provide evidence for the efficacy of a web-based multiple health behaviour intervention among Chinese university students. The majority of the study assumptions were supported. Future research should address the high dropout rate and optimize the most effective components of this intervention. Clinical Trial: Clinical trial ID number: NCT01909349

  • Effectiveness of personalized web-based advice in combination with youth health care well-child visits to prevent overweight in young children: a cluster randomized controlled trial.

    Date Submitted: Dec 20, 2016
    Open Peer Review Period: Dec 23, 2016 - Feb 17, 2017

    Background: Overweight is a major health issue, and parent-targeted interventions to promote healthy development in children are needed. Objective: The objective of this study was to evaluate E-health4Uth Healthy Toddler, an intervention that educates parents of children 18-24 months of age regarding overweight-related behaviors. The effect of this intervention on the following primary outcomes was evaluated when the children were 36 months of age: health-related behaviors (outside play, eating breakfast, sweetened beverage consumption, television viewing, and computer time) and body mass index (BMI). Methods: The BeeBOFT study is a cluster randomized controlled trial involving 51 Youth Health Care (YHC) teams. In total, 1094 parents participated in the control group and 1008 parents participated in the E-health4Uth Healthy Toddler intervention group. The intervention consisted of web-based personalized advice given to parents who completed an e-health module. The advice was then discussed during a regular well-child visit with a YHC professional when the child was 18 and 24 months of age. Parents completed questionnaires regarding family characteristics and health-related behaviors when the child was 1 month (inclusion), 6 months, 14 months, and 36 months (follow-up) of age. The child’s height and weight were measured by trained healthcare professionals from birth through 36 months of age. Multilevel linear and logistic regression models were used to evaluate the primary outcomes at 36 months of age. Results: Compared to the control group, the children in the intervention group ate breakfast at the table more often (OR: 1.39; 95% CI: 1.06 to 1.84) and ate breakfast less often while sitting on the couch in front of the television (OR: 1.39; 95% CI: 1.10 to 1.77). In contrast, the two groups did not differ significantly with respect to BMI or the prevalence of overweight or obesity at follow-up (P>.05). An analysis of the intervention effect revealed that boys and non-Dutch children benefited from eating breakfast daily, drinking ≤2 glasses of sweetened beverages per weekday, and playing outside daily (p<0.05) compared to the control group. Conclusions: The E-health4Uth Healthy Toddler intervention resulted in significant improvements in the family’s breakfast-eating behaviors, but had no significant effects with respect to the child’s BMI. Therefore, the E-health4Uth Healthy Toddler intervention may be useful for pediatric healthcare professionals in terms of providing parents with personalized information regarding their child’s health-related behaviors. Clinical Trial: Netherlands Trial Register: NTR1831, (Archived by WebCite at

  • Persuasive antismoking interventions: Promoting smoking reduction and cessation through Facebook, email-listserv, and MTurk

    Date Submitted: Dec 16, 2016
    Open Peer Review Period: Dec 22, 2016 - Feb 16, 2017

    Background: We employed persuasion strategies to develop and evaluate social media- and crowdsourcing-based interventions for smoking reduction and cessation. Objective: We delivered various levels of informational and social support to current smokers and pilot-tested the acceptability, feasibility and persuasion effects of three antismoking interventions, Facebook Group (information and social support), Email-Listserv (information), and MTurk (assessment only) interventions. Methods: We used Amazon Mechanical Turk (MTurk) to solicit potential participants (N=223). Among 173 applicants who confirmed their interest, 46 U.S.-based eligible smokers were randomly assigned to one of three conditions. During the 4-week intervention, participants in the Email-Listserv (n=15) and Facebook (n=16) conditions received 56 randomly-ordered antismoking information materials. The Facebook Group participants also had the opportunity to exchange social support with other group members. MTurk participants (n=15) did not receive these antismoking messages or social support. All participants completed a baseline survey, weekly surveys and a 2-week follow-up survey via MTurk. Results: We achieved 100% study retention: all participants engaged in their assigned intervention and completed final assessments. Intervention feasibility and acceptability scores were above average. Participants significantly reduced the number of weekly-smoked cigarettes measured at baseline and at follow-up, t(45)=9.51, p<.01, Md =80.91, SDd = 57.70, 95% CI=63.78-98.05, , and 12-18% quit smoking, with the Facebook group reporting the higher rate of quitting. Smoking reduction did not significantly differ across conditions, F(2,43)=1.56, p=.22. Perceived social support was significantly higher among Facebook Group participants (M=4.63, SD=.71), compared to Email-Listserv participants (M=3.64, SD=1.15) and MTurk participants (M=3.38, SD=1.32), F(2,43)= 5.79, p = .006, η²=.21. Sustained motivation to quit was a significant predictor of reduction in smoking when baseline smoking was adjusted, B=10.79, SE=5.27, F(1, 45)=4.18, p=.05, 95% CI=.12-21.47. Conclusions: We leveraged strategic persuasion principles as well as features of Facebook, Email, and MTurk to disseminate antismoking content, achieve rapid outreach to smokers in the US and facilitate social support among current smokers. These social media and crowdsourcing platforms were acceptable and feasible in delivering antismoking interventions, maintaining motivation to quit, and promoting smoking reduction and cessation. Our findings suggest that all three intervention platforms may be beneficial, but the social support within Facebook user groups may be particularly promising and deserves further research. Clinical Trial: NA

  • Feasibility of an e-learning module to improve non-genetic health professionals’ assessment of colorectal cancer genetic risk

    Date Submitted: Dec 15, 2016
    Open Peer Review Period: Dec 18, 2016 - Feb 12, 2017

    Background: Non-genetic health providers lack relevant knowledge, experience as well as communicative skills to adequately detect familial colorectal cancer (CRC), despite a possibly positive attitude towards a cancer family history assessment. Dedicated training may enable them to more optimally refer patients to genetic counseling. Objective: The aim of this study was to: 1) develop an e-learning module for gastroenterologists and surgeons (in training) aimed at improving attitudes, knowledge and comprehension of communication skills, and 2) assess the feasibility of the e-learning module for continued medical education of these specialists. Methods: A focus group was used to inform the development of a training framework. Next, the e-learning module itself was developed. Feasibility-testing of the e-learning module was performed first among a group of Dutch surgeons in training (3rd and 4th year residents) (SRs) and then among Dutch gastroenterologists (GEs) using pre- (T0) and post- (T1) questionnaires. Results: 124 SRs and 14 GEs participated. The e-learning was positively received (7.5 on a scale from 1-10). Attitude increased significantly on six of ten items from T0 to T1. Mean test score showed that knowledge and comprehension of communication skills improved significantly from 49-72% correct on the pretest to 67-87% correct on the posttest. Conclusions: We demonstrated feasibility of a problem-based e-learning on recognizing a hereditary predisposition in CRC patients for SRs and GEs. The e-learning led to intended improvements in attitude towards assessment of cancer family history, knowledge on criteria for referral to genetic counseling for colorectal cancer and comprehension of communication skills.

  • Systematic attrition of heavy drinkers in a web-based alcohol intervention study

    Date Submitted: Dec 13, 2016
    Open Peer Review Period: Dec 16, 2016 - Feb 10, 2017

    Background: Web-based alcohol interventions are a promising way to reduce alcohol consumption due to their anonymity and the possibility to reach high numbers of individuals including heavy drinkers. However, web-based interventions are often characterized by high rates of attrition. To date, very few studies have investigated whether individuals with higher alcohol consumption show higher attrition rates in web-based alcohol interventions compared to individuals with lower alcohol consumption. Objective: The aim of this study was to examine the attrition rate and predictors of attrition in a web-based intervention study on alcohol consumption. Methods: Analysis of predictors for attrition rate collected in a web-based randomized control trial. Data collection took place in [blinded for Review], Germany. 898 people (46.8% males; 53.2% women) with a mean age of 23.57 years (SD = 5.19) initially volunteered to participate in a web-based intervention study to reduce alcohol consumption. Participants were classified as non-completers (n = 439, 48.9%) if they did not complete the web-based intervention at time point 1. Potential predictors of attrition were self-reported alcohol consumption in the last seven days, per week, from Monday to Thursday, at weekends, excessive drinking behavior measured with the Alcohol Use Disorder Identification Test (AUDIT), and drinking motives measured by the drinking Motive Questionnaire (DMQ-R SF). Results: Significant differences between completers and non-completers emerged regarding alcohol consumption at weekends (B = -.05, 95% CI [0.92;0.98]), in the last seven days (B = -.02, 95% CI [0.97;1.00]), the AUDIT (B = -.06, 95% CI [0.90;0.98], and the status as a student (B = .68., 95% CI [1.92;2.99]). Most importantly, non-completers had a significantly higher alcohol consumption compared to completers. Conclusions: Hazardous alcohol consumption appears to be a key factor of the dropout rate in a web-based alcohol intervention study.

  • Smartphone-based monitoring of objective and subjective data in mood disorders: Where are we and where are we going? – A systematic review

    Date Submitted: Dec 15, 2016
    Open Peer Review Period: Dec 16, 2016 - Feb 10, 2017

    Background: E-mental health interventions for mood disorders have increased rapidly over the past decade, most recently in the form of various systems and applications (apps) that are delivered via smartphones. Objective: To provide an overview about studies on smartphone-based systems combining subjective ratings with objectively measured data for longitudinal monitoring of patients with affective disorders. Specifically, to examine current knowledge on 1) feasibility, acceptability and adherence of such systems; 2) the association of recorded data with affective symptoms and changes in symptomatology; and 3) effects on clinical outcomes. Methods: We searched PubMed, Web of Science, PsycINFO and the Cochrane Central Register of Controlled Trials for relevant articles published in the last ten years applying Boolean search operators with an iterative combination of search terms. Additional articles were identified via pearling, author correspondence, selected reference lists and trial protocols. Results: A total of 1276 records were identified, of which 23 met our inclusion criteria and were included in the review. In total, seven different self-monitoring systems for affective disorders that use subjective mood ratings as well as objective measurements of physiological and behavioral parameters were included. These parameters include phone usage, physical activity, location, physiological features, light exposure, as well as voice/speech features. Out of the 23 articles, 17 contained results of patients with affective disorders regarding acceptability and feasibility; and also partially showed a reasonable accuracy of predicting mood status and mood fluctuations according to time-series analysis of the objective measures. Only one article reported results from an RCT concerning effects on clinical outcome in patients with bipolar disorder. Conclusions: The first experimental studies substantiate the value of smartphone-based approaches for gathering long-term objective data other than self-ratings to monitor clinical symptoms, to predict changes in clinical states and to investigate causal inferences about state changes in patients with affective disorders. Though promising, a much larger evidence-base is necessary to fully assess the potential and the risks of these approaches as methodological limitations of the available studies such as small sample sizes, variations in the number of observations or monitoring duration, lack of RCTs and heterogeneity of methods restrict the interpretability of the results. However, a number of study protocols stated ambitions to expand and intensify research in this emerging and promising field. Clinical Trial: not applicable

  • Patient Portals as a Tool for Healthcare Engagement: A mixed-method Study of Older Adults with Varying Levels of Health Literacy and Prior Patient Portal Use

    Date Submitted: Dec 7, 2016
    Open Peer Review Period: Dec 9, 2016 - Feb 3, 2017

    Background: Growing evidence that patient engagement improves health outcomes and reduces healthcare costs has fueled healthcare organizations’ focus on patient portals as the primary access point for personal health information and patient-provider communication. While much attention has been given to identifying characteristics of older adults who do and do not adopt patient portals and necessary adaptions to portal design, little is known about older adults’ attitudes and perceptions regarding patient portal use as a tool for engagement in their healthcare within the context of health literacy, experience navigating online health information, and previous patient portal use. Objective: The specific aims of this study are to explore attitudes towards portal adoption and its perceived usefulness as a tool for healthcare engagement among adults (65 and older) who have varying levels of health literacy and degrees of prior patient portal use. Methods: A phone survey of 100 community dwelling adults gathered socio-demographic, health and technology related information. Older adults were purposefully selected for four follow-up focus groups based on survey responses to health literacy (high/low) and previous patient portal use (yes/no). A mixed-method approach was used to integrate phone survey data with thematic analysis of four focus groups. Due to variability in attitudes between focus group participants, an individual case analysis was performed and thematic patterns were used as the basis for subgroup formation. Results: Differences in health literacy, comfort navigating health information online, and previous portal experience explained some but not all differences related to the seven themes that emerged in the focus groups analysis. Individual cases who shared attitudes were arranged into 5 subgroups from least to most able and willing to engage in healthcare via a patient portal. The subgroups overall portal adoption attitudes were 1) Don’t want to feel pushed into anything, 2) Will only adopt if required, 3) Somebody needs to help me, 4) See general convenience of the portal for simple tasks and medical history, but prefer human contact for questions, 5) Appreciates current features and excited about new possibilities. Conclusions: Most older adults are interested in using a patient portal regardless of health literacy level, previous patient portal adoption or experience navigating health information online; only a minority of older adults believe security risks or trouble learning something new outweighs the potential benefits. Research targeting informal caregivers of older adults who are unable or unwilling to engage with information technology in healthcare on their own is warranted. Healthcare organizations should consider tailored strategies to meet the needs of older adults (and their informal caregivers) and explore alternative workflows that integrate patient portal information into phone conversations and face-to-face contact with healthcare providers.

  • Comparison of different recruitment methods for sexual and reproductive health research: social media-based versus conventional methods.

    Date Submitted: Dec 5, 2016
    Open Peer Review Period: Dec 8, 2016 - Feb 2, 2017

    Background: Prior research about the sexual and reproductive health of young women has relied on self-reported survey studies. Recruitment using web-based methods can improve sexual and reproductive health research about cervical cancer prevention. In the prior study we reported that Facebook (Menlo Park, CA, USA) is a promising way to reach young women for sexual and reproductive health research. However, it is unknown whether web-based or the other classical recruitment methods (i.e., face-to-face or flyer distribution) yield comparable survey responses from similar participants. Objective: We conducted a survey to determine whether there was a difference in the sexual and reproductive health survey responses of young Japanese women based on recruitment methods, social media-based or conventional methods. Methods: From July 2012 to March 2013 (9 months), we invited 16- to 35-year-old women in Kanagawa, Japan, to complete a web-based questionnaire and recruited through either a social media-based (SNS group) or by conventional methods (Conventional group). All participants enrolled were required to fill out and submit their responses through web-based questionnaire about their sexual and reproductive health for cervical cancer prevention. Results: Of the 243, 52% (127/243) were recruited by SNS, whilst 48% (116/243) were by Conventional methods. We found no differences between recruitment methods in responses to behaviors and attitudes to sexual and reproductive health survey, although more participants from the Conventional group (14.7%, 14/95) selected not to answer the age of first intercourse ) as compared to the SNS group (5.2%, 6/116) (P = .03). Conclusions: No differences were found between recruitment methods in young Japanese women to a social media-based sexual and reproductive health survey.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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