Latest Submissions Open for Peer Review

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

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

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Exploring the potential of a wearable camera to examine the early obesogenic home environment

    Date Submitted: Mar 25, 2017
    Open Peer Review Period: Mar 25, 2017 - May 20, 2017

    Background: The ‘obesogenic’ home environment is usually examined via self-report, and objective measures are required. Objective: This study explored whether the wearable camera ‘SenseCam’ can be used to examine the early obesogenic home environment, and whether it is useful for validation of self-report measures. Methods: Fifteen primary caregivers of young children (mean age of child 4 years) completed the Home Environment Interview (HEI). Seven to 19 days after the HEI, participants wore the SenseCam at home for 4 days. A semi-structured interview assessed participants’ experience of wearing the SenseCam. Intraclass correlation coefficients (ICCs), percent agreement, and kappa statistics were used as validity estimates for 54 home environment features. Results: Wearing the SenseCam was generally acceptable to participants. The SenseCam captured all 54 HEI features, but with varying detail. Thirty-six features (67%) had satisfactory validity (ICC or kappa ≥ 0.40; percent agreement 80 where kappa could not be calculated). Validity was good or excellent (ICC or kappa ≥ 0.60) for fresh fruit and vegetable availability, fresh vegetable variety, the display of food/drink (except sweet snacks), family meals, child eating lunch/dinner while watching TV, garden/play equipment, the number of TVs/DVD players, and media equipment in the child’s bedroom. Validity was poor for tinned and frozen vegetable availability/variety, and sweet snack availability. Conclusions: The SenseCam has the potential to objectively examine and validate multiple aspects of the obesogenic home environment. Further research should aim to replicate the findings in a larger, representative sample.

  • Recommending education materials for diabetic questions using information retrieval approaches

    Date Submitted: Mar 24, 2017
    Open Peer Review Period: Mar 25, 2017 - May 20, 2017

    Background: Self-management is crucial to diabetes care and providing expert-vetted content for answering patients’ questions is crucial in facilitating patient self-management. Objective: To investigate the use of information retrieval (IR) techniques in recommending patient education materials for diabetic questions of patients.   Methods: We compared two retrieval algorithms, one based on LDA topic modeling (TMB) and one based on semantic group (SGB), with the baseline retrieval models, vector space model (VSM) in recommending diabetic patient education materials to diabetic questions posted on the TuDiabetes forum. The evaluation was based on a gold standard data set consisting of 50 randomly selected diabetic questions where the relevancy of diabetic education materials to the questions was manually assigned by two experts. The performance was assessed using precision of top ranked documents. Results: We retrieved 7,510 diabetic questions on the forum and 144 diabetic patient educational materials from the patient education database at Mayo Clinic. Corpus analysis indicates language used by diabetic questions is different from patient education materials. TMB outperformed other retrieval algorithms. For example, for the top retrieved document, the precision of TMB, SGB, and VSM models is 67.0%, 62.8%, and 54.3% respectively. Conclusions: The study demonstrated that topic modeling can mitigate the vocabulary difference and that it achieved the best performance in recommending education materials for answering patients’ questions. One direction for future work is to assess the generalizability of our findings and to extend our study to other disease areas, other patient education material resources, and online forums.

  • Leveraging Social Networking Sites for an Autoimmune Hepatitis Research Study: A preliminary experience

    Date Submitted: Mar 21, 2017
    Open Peer Review Period: Mar 24, 2017 - May 19, 2017

    Background: Conventional study approaches are often inadequate in rare disease investigation. Social-networking sites, such as Facebook, may provide a vehicle to circumvent common research limitations and pitfalls. We report our preliminary experience with social media-based methodology for subject recruitment and participation into an ongoing study of autoimmune hepatitis (AIH). Objective: To test the hypothesis that a social media-based methodology is effective for recruiting participants into AIH patient-oriented research. Methods: We established a Facebook community, the Autoimmune Hepatitis Research Network (AHRN), in 2014 in order to provide a secure and reputable distillation of current literature and AIH research opportunities. Quarterly advertisements for our ongoing observational AIH study were posted on the AHRN over 2 years. Interested and self-reported AIH participants were subsequently enrolled after review of study materials and completion of an informed consent by our study coordinator. Participants returned completed study materials, including epidemiologic questionnaires and genetic material, to our facility via mail. Outside medical records were obtained and reviewed by a study physician. Results: We successfully obtained all study materials from 29 participants with self-reported AIH within 2 years from 20 different states. Liver biopsy results were available for 26 participants (90%), of which 21 (81%) had findings consistent with AIH, 4 (15%) were suggestive of AIH with features of primary biliary cholangitis (PBC), and one (4%) had PBC alone. Twenty-four of the participants (83%) had at least 2 of 3 proposed criteria: Positive autoimmune markers, consistent histologic findings of AIH on liver biopsy, and reported treatment with immunosuppressant medications. Self-reported and physician records were discrepant for immunosuppressant medications or for AIH/PBC diagnoses in 4 patients. Conclusions: Social networking sites can be effective ancillary tools for facilitating patient-oriented research in rare diseases. A social media-based approach transcends established limitations in rare disease research and can further develop research communities.

  • The Use of Mobile Applications and SMS Messaging as Physical and Mental Health Interventions: A Systematic Review

    Date Submitted: Mar 23, 2017
    Open Peer Review Period: Mar 23, 2017 - May 18, 2017

    Background: The initial introduction of the World Wide Web in 1990 brought around the biggest change in information acquisition that the modern world has ever seen. Due to the abundance of devices and ease of access they subsequently allow, the utility of mobile health (mHealth) has never been more endemic. A substantial amount of interactive and psychoeducational apps are readily available to download concerning a wide range of health issues. mHealth has the potential to reduce waiting times for appointments, eradicate the need to meet in person with a clinician, successively diminishing the workload of mental health professionals, be more cost effective to practises and encourage self-care tactics. Previous research has given valid evidence with empirical studies proving the effectiveness of physical and mental health interventions using mobile apps. Alongside apps, there is evidence to show that receiving SMS messages which entail psychoeducation, medication reminders and links to useful informative web pages can also be advantageous to a patient’s mental and physical wellbeing. Available mHealth apps and SMS services and their ever improving quality, necessitates a systematic review in the area in reference to reduction of symptomology, adherence to intervention and usability. Objective: The review aimed to study the efficacy of mobile applications and SMS messages as mHealth interventions for self-guided care. Methods: A systematic literature search was carried out in JMIR, PubMed, PsychINFO, PsychARTICLES, Google Scholar, MEDLINE & SAGE. The search spanned from January 2008-January 2017. The primary outcome measures consisted of; weight management, (pregnancy) smoking cessation, medication adherence, depression, anxiety and stress. Between group and within group effect sizes (Cohen’s d) for the mHealth intervention method group were determined. Results: Twenty seven studies, inclusive of 4658 participants were reviewed. The papers included RCT’s (n=19), within groups studies (n=7) and one within group study with qualitative aspect. Studies shown significant reductions on of anxiety, stress and depression. Within group and between groups effect sizes ranged from 0.05-3.37 (immediately post-test), 0.05-3.25 (one month follow up), 0.08-3.08 (two month follow up), 0.00-3.10 (three month follow up) and 0.02-0.27 (six month follow up).Usability and feasibility of mHealth interventions, where reported, also gave promising, significant results. Conclusions: The review shows the promising and emerging efficacy of using mobile applications and SMS messaging as mHealth interventions.

  • “Usage of an exercise application in the care for people with osteoarthritis – a user-driven exploratory study”

    Date Submitted: Mar 22, 2017
    Open Peer Review Period: Mar 22, 2017 - May 17, 2017

    Background: Exercise has proven to reduce pain and increase quality of life in osteoarthritis (OA). However, one major challenge is the adherence to exercise once supervision ends. Objective: This study aimed to identify mental and physical barriers, motivational and social aspects of training at home, and to test/further develop an exercise application Methods: The study was inspired from participatory design (PD), engaging users in the research process. Data was collected through focus group and workshops, and analysed by systematic text condensation. Results: Three main themes were found: competition as motivation, training together, and barriers. The results revealed that the participants wanted to do their training, had knowledge on exercise and pain, but found it hard to motivate themselves. They missed the observation, commenting and encouragement by the supervising physiotherapist, as well as their peers. Ways to optimize the training app was identified during the workshops as participants shared their experience. Conclusions: The conclusion of the study is that the long term continuation of exercising for patients with OA could be improved with the use of a technology tailored to user’s needs, including motivational and other behavioural factors.

  • Reliability of women epilepsy related information from main web search engines in China:deceitful web search environment and illumination

    Date Submitted: Mar 20, 2017
    Open Peer Review Period: Mar 20, 2017 - May 15, 2017

    Background: All electronic health practices like app/software are involved in web search engine due to its convenience for receiving information. The success of electronic health has link with the success of web search engines in field of health. Yet information reliability from search engine results remains to be evaluated. A detail analysis can find out setbacks and bring inspiration. Objective: Find out reliability of women epilepsy related information from the searching results of main search engines in China. Methods: Six physicians conducted the search work every week. Search key words are one kind of AEDs (valproate acid/oxcarbazepine/levetiracetam/ lamotrigine) plus "huaiyun"/"renshen", both of which means pregnancy in Chinese. The search were conducted in different devices (computer/cellphone), different engines (Baidu/Sogou/360). Top ten results of every search result page were included. Two physicians classified every results into 9 categories according to their contents and also evaluated the reliability. Results: A total of 16411 searching results were included. 85.1% of web pages were with advertisement. 55% were categorized into question and answers according to their contents. Only 9% of the searching results are reliable, 50.7% are partly reliable, 40.3% unreliable. With the ranking of the searching results higher, advertisement up and the proportion of those unreliable increase. All contents from hospital websites are unreliable at all and all from academic publishing are reliable. Conclusions: Several first principles must be emphasized to further the use of web search engines in field of healthcare. First, identification of registered physicians and development of an efficient system to guide the patients to physicians guarantee the quality of information provided. Second, corresponding department should restrict the excessive advertisement sale trades in healthcare area by specific regulations to avoid negative impact on patients. Third, information from hospital websites should be carefully judged before embracing them wholeheartedly.

  • Knowledge, Attitudes, Practices Regarding Zika:Results of a Paper- and Internet-Based Survey in Zhejiang, China

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

    Background: As public access to internet increase, many health workers prefer to carry out health education online, traditional way of health education in community was kind of ignored. From March 2016, 4 Zika cases were confirmed in Zhejiang, China. Rapid assessment of people’s knowledge, attitudes and practices (KAP) regarding Zika is crucial to the prevention and control of it. Online survey to assess public KAP maybe a trend in the future. However, we have done little. Objective: This study aimed to explore people’s KAP regarding Zika in Zhejiang using both traditional and innovative internet-based investigation, and to compare the resources involved and the results of the two different methods. Methods: An anonymous questionnaire was designed by Zhejiang Provincial Center for Disease Control and Prevention. Paper-based survey in community and internet-based survey through Wechat, a smartphone application, were executed. Results: Eighty-three (892/1068) participants knew transmission route of Zika, 76.0% (813/1068) knew pregnant women are high-risk group for severe complications, 66.4%(709/1068) knew Zika virus infection during pregnancy may lead to newborn babies with microcephaly, 66.4%(709/1068) knew places where mosquitos usually haunted. Participants of online survey had a much higher level knowledge of Zika than participants from community. The proportion of participants that were worried of contracting Zika were much higher in internet-based survey (47.0%, 502/1068) than in paper-based survey (35.1%, 157/447) (=43.6, P<.0001). Over 95% participants from both internet and community took practices to preventive mosquito bites. Participants of online survey (93.6%, 581/624) intend to seek health information on Zika more willingly than paper-based survey (72.3%, 323/447) (=2.8, P=0.092). Online survey had higher proportion of younger (=144.7, P<.0001) and well-educated participants (=423.5, P<.0001) than paper-based survey. We spent over twice time (2 weeks vs. 1week) and money (45RMB VS. 20RMB on one questionnaire) in paper-based survey than in online survey. Conclusions: Participants of Internet-based survey had a higher level of basic knowledge, more positive attitudes and behaviors than paper-based survey in community. While providing online health information, the government should also ensure access to health information for older and less educated people in community to achieve greater health equity. Internet-based survey involves considerably fewer resources, including money, time, and human resources. Thus, in the outbreak of emerging infectious disease, online survey could be used for emergency assessment for health education needs.

  • Interactive Voice Response System: Data Considerations and Lessons Learned During a Rectal Microbicide Placebo Adherence Trial for Young Men Who Have Sex with Men

    Date Submitted: Mar 10, 2017
    Open Peer Review Period: Mar 12, 2017 - May 7, 2017

    Background: Rectal microbicides, if proven effective, may aid in reducing HIV incidence; however, demonstration of efficacy and effectiveness is contingent on accurate measurement of product adherence. Delays in self-report, in particular, may affect the accuracy of behavioral data. Objective: Capitalizing on mobile phone use by young men who have sex with men (YMSM), we examined the use of an interactive voice response system (IVRS) by YMSM aged 18-30 years enrolled in a multisite, 12-week microbicide safety and acceptability trial. Methods: Ninety-five YMSM enrolled across three sites (Boston, Pittsburgh, San Juan) were asked to report their use of an applicator applied placebo rectal gel product during receptive anal intercourse (RAI) using the IVRS. IVRS was available in Spanish and English. After the 12-week trial, we examined whether IVRS problems were associated with YMSM’s sociodemographic characteristics (e.g., age, race/ethnicity, education), sexual behavior, or recruitment site. We used a multinomial logistic regression to compare YMSM who experienced no IVRS problems (N=40) to those who reported one IVRS problem (N=25) or two or more IVRS problems (N=30). Results: We recorded 1,494 IVRS calls over 12-weeks. Over half of participants (N=55; 57.9%) experienced challenges using the IVRS during the 12-week trial. YMSM reporting greater RAI occasions during the trial were more likely to experience IVRS challenges. Greater educational attainment was associated with multiple IVRS challenges. Participants in the Puerto Rico site were most likely to report multiple IVRS problems. Conclusions: Although IVRS was a useful data collection technology in our trial, several challenges experienced by English and Spanish speaking YMSM diminish its overall acceptability. We discuss strategies to optimize future development of IVRS data quality protocols based on lessons learned. Clinical Trial: Registration Number: NCT01283360

  • The assessment of quality of dental caries-related information in Brazilian websites

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

    Background: Health seekers can easily reach a vast range of contents in the Internet, such as dental caries knowledge. Dental caries is still considered the most common chronic oral disease, with an average DMFT of 2.11, affecting 2.4 billion people worldwide. It impacts the patients socially and economically, threatening the quality of their lives. However, the comprehension of the multifactorial etiology of dental caries may be difficult for most people. It involves the interplay between the tooth surface, the dental biofilm, the availability of dietary fermentable carbohydrates, and genetic and behavioral factors. Therefore, a high-level of specialization is required to the production of materials addressed to the education and counseling of patients about this issue. In this sense, the publication of uncertain contents on the Internet might be connected with the low quality of dental caries-related information. Objective: The aim of this study was to assess the readability and the quality of dental caries-related information from Brazilian websites. Methods: Seventy-five websites were selected through Google, Bing, Yahoo!, and Baidu. The order that each website was ranked in these search machines was registered. Two independent examiners evaluated the quality of websites using the DISCERN questionnaire and JAMA benchmark criteria. The Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), and Férnandez-Huerta Readability Formula (FHRF) were employed to assess the readability of websites. The statistical analysis was performed with P<0.05 considered significant. Results: The digital contents were classified as of poor quality using both DISCERN (x̅=35.68, 19-64) and JAMA (x̅=1.12, 0-3) scores, being considered as high-difficulty reading materials by FRE scores and as simple and accessible by FHRF scores. A negative correlation was observed between the ranking and the quality scores (Spearman’s rank test). The quality of information of health and non-health websites was similar (Mann-Whitney U test); however, the websites with a greater variety of dental caries information were significantly better than those with limited contents (hierarchical clustering analysis by Ward’s minimum variance method, Kruskal Wallis and post-hoc Dunn’s test). Conclusions: Dental caries-related contents found in Brazilian websites were considered simple, accessible and of poor quality, without differences between health and non-health websites. These findings indicate the need of the development of policies for the production and publication of web health information, encouraging dentists to guide their patients in searching for recommended oral health websites.

  • The user acceptance of computerised cognitive behaviour therapy for depression – a systematic review

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

    Background: Computerised cognitive behaviour therapy (cCBT) has been proven to be effective in depression care. Moreover, cCBT packages are becoming increasingly popular. A central aspect concerning the take-up and success of any treatment is its user acceptance. Objective: This paper aims to update and to expand on earlier work on user acceptance of cCBT for depression. Methods: This article systematically reviews quantitative and qualitative studies regarding the user acceptance of cCBT for depression. The initial search was conducted in January 2016 and involved the following databases: Web of Science, PubMed, the Cochrane Library and PsychInfo. Results: A total of 1.736 studies were identified, of which 29 studies were eligible for review. User acceptance was operationalised and analysed very heterogeneously. Eight studies reported a very high level of acceptance, 17 studies indicated a high level of acceptance and one study showed a moderate level of acceptance. Two qualitative studies considered the positive and negatives aspects concerning the user acceptance of cCBT. However, a substantial proportion of reviewed studies revealed several methodical shortcomings. Conclusions: In general, people experience cCBT for depression as predominantly positive which supports the potential role of these innovative treatments. However, methodological challenges do exist in terms of defining user acceptance, clear operationalisation of concepts and measurement.

  • Implementation of the blended care self-management program ‘Partner in Balance’ for caregivers of people with early-stage dementia: process evaluation of a randomized controlled trial

    Date Submitted: Mar 9, 2017
    Open Peer Review Period: Mar 9, 2017 - May 4, 2017

    Background: The blended care self-management program ‘Partner in Balance’ (PiB) for family caregivers was executed in Dutch dementia care organizations. The program combines face-to-face coaching with tailored online modules. Next to an evaluation of program effectiveness, an evaluation of sampling and intervention quality is essential for the generalizability of results. Objective: A process evaluation of Partner in Balance (PiB) was performed from the perspective of both family caregivers (participants) and professionals delivering the intervention (coaches) to explore its credibility and generalizability. Methods: Implementation, sampling, and intervention quality were evaluated with quantitative and qualitative data from (1) logistical research data, (2) coach questionnaires (N=13), and (3) interviews with coaches (N=10) and participants (N=49). Goal attainment scaling was used to measure treatment-induced change. Analyses were performed with descriptive statistics and deductive content analysis. Results: Caregivers were recruited by clinicians (N=122); the Dutch Alzheimer Association (N=26); family members (N=4), or magazines and newspapers (N=11). The participation rate of eligible caregivers was (80/154) 52%. Recruitment barriers were no computer and no need for support. Recruitment facilitators were young age and being employed. Coaches (N=13) had a professional background as psychologist (N=7) or psychiatric nurse (N=6). All coaches received training and supervision in blended care self-management. They followed a structured protocol, but reported deviations on intervention time, structure and feedback. Coaches reported an intensified relationship with the caregiver post-intervention. Caregivers appreciated the tailored content and positive feedback and the blended structure increased their openness. The discussion forum was appreciated less. Implementation barriers included lack of financing, time and deviating target population. Overall, personal goals were attained after the program (T>50). Conclusions: Caregivers and coaches were satisfied with the intervention, but the content needs adaptation to fit the needs of younger caregivers. Awareness of benefits of blended care self-management and training is required for sufficient program implementation. Clinical Trial: Dutch Trial Register (NTR): NTR4217

  • An exploratory study of consumers’ health-related activities on social media

    Date Submitted: Mar 7, 2017
    Open Peer Review Period: Mar 8, 2017 - May 3, 2017

    Background: Although a number of studies have investigated how consumers use social media (SM) for health-related purposes, there is a paucity of studies in the Australian context. Objective: This study, therefore, aimed to explore how Australian consumers used SM for health-related purposes, specifically how they identified SM platforms, which were used, and which health-related activities commonly took place. Methods: Five focus groups (n=36 participants), each lasting 60 to 90 minutes were conducted in the Sydney metropolitan area. The group discussions were audio-recorded and transcribed verbatim. The transcripts were coded line by line and thematically analysed. Results: Participants used general search engines to locate health-related SM platforms. They accessed a wide range of SM on a daily basis, using several electronic devices, in particular, mobile phones. Although privacy was a concern, it did not prevent consumers from fully engaging in SM for health-related purposes. Blogs were used to learn from other people’s experiences with the same condition. Facebook allowed consumers to follow health-related pages and to participate in disease-specific groups discussions. Wikipedia was used for factual information about diseases and treatments. YouTube was accessed to learn about medical procedures, such as surgery. No participant reported editing or contributing to Wikipedia, or posting YouTube videos related to health topics. Twitter was rarely used for health-related purposes. SM allowed consumers to obtain and provide disease and treatment-related information, and social and emotional support for those living with the same condition. Most considered their participation as observational, but some also contributed (e.g. responded to people’s questions). Conclusions: Participants used a wide range of SM for health-related purposes. Medical information exchange (e.g. disease and treatment) and social and emotional support were the cornerstones of their online activities. SM appears to be used as a key tool to support disease self-management.

  • Using Relational Agents to Promote Exercise and Sun Protection: An assessment of Participants’ Experiences with two Interventions

    Date Submitted: Mar 6, 2017
    Open Peer Review Period: Mar 6, 2017 - May 1, 2017

    Background: Relational Agents (RAs) are electronic, computational figures designed to engage participants in the change process. A recent study tested the effectiveness of RAs, combined with existing computer-based interventions, to increase regular exercise and sun protection behaviors. Results showed these interventions can be effective but need further development Objective: This purpose of this study is to examine participants’ experiences using RA, using mixed methods approaches. Methods: A 25-question interview guide assessed different components of participants’ experiences with the intervention, including motivation, engagement, satisfaction/ dissatisfaction, quality of their interaction with the RA, and behavior change. Quantitative assessment of satisfaction was based a scale of 1 to 10, with 1 representing least satisfied and 10 representing most satisfied. A summative analytic approach was used to assess individuals’ qualitative responses. An analysis of variance (ANOVA) examined levels of satisfaction by gender. Results: Of the original 1354 participants enrolled in Project RAISE, 490 of 1354 (36.1%) were assigned to the RA group. 216 of 490 (44.0%) participants assigned to the RA group completed both 12-and 24-month follow-ups and were contact to participate in the semi-structured interview. 34 of 216 (15.7%) completed the semi-structured interview. Participants were motivated by and satisfied with the intervention, viewed the RA as supportive, informative, and caring, and reported positive behavior change in both exercise and sun protection. Some participants (15 of 34; 44%) noted the RA was less judgmental and less “overbearing” compared to a human counselor, other participants (12 of 34; 35%) said that the interaction was sometimes repetitive or overly general. The majority of participants (22 of 34; 65%) viewed the RA as an important contributor to their behavior change for exercise, sun protection, or both. Levels of satisfaction ranged between 7 and 10 and gender differences were not noted when analyzed (P=.51) Conclusions: : RAs provide an innovative and attractive platform to increase exercise and sun protection behaviors and potentially other health behaviors.

  • How do ehealth programs for adolescents with depression work? A realist review of persuasive system design components in Internet-based psychological therapies

    Date Submitted: Mar 2, 2017
    Open Peer Review Period: Mar 6, 2017 - May 1, 2017

    Background: Major depressive disorders are common among adolescents and can impact all aspects of their daily life. Traditional therapies have been delivered face-to-face, however, Internet-based (online) delivery of these therapies is emerging as an option for adolescents. Internet-based psychological therapies involve: 1) therapeutic content, 2) interaction between the user and the system, and 3) different technological features embedded into the online program (e.g., multi-media). Studies of Internet-based psychological therapies for adolescent depression differ on all three aspects, and variable, positive therapy effects have been reported. A better understanding of the conditions that influence therapy outcomes is important to designing and evaluating these novel therapies. Objective: To examine the human-technology interactions within Internet-based psychological therapies for adolescent depression, and document their relation to therapy outcomes. Methods: We performed a realist synthesis. We started with an extensive search of published and grey literature. We included intervention studies that evaluated an Internet-based psychological therapy for adolescent depression. We included mixed-methods and qualitative studies, theoretical papers, and policy/implementation documents if they included a focus on how Internet-based psychological therapy is proposed to work for adolescents with depression/depressive symptoms. We used the mixed-methods appraisal tool (MMAT) was used to assess the methodological quality of studies. We used the Persuasive System Design (PSD) model as a framework for data extraction and analysis to examine how technology-based systems influence the attitudes and behaviours of system users. PSD components described for each therapy were linked to therapy outcomes using a cross-case comparison method and thematic synthesis. Results: Nineteen Internet-based cognitive behavioural therapies (CBT) were identified in 59 documents. Seventy-one percent of studies were of moderate-to-high quality. The PSD features surface credibility (competent ‘look and feel’), dialogue support (online program + in-person support), liking and similarity (aesthetics and content appeal to adolescent users), the reduction and tunneling of therapeutic content (reducing online content into simple tasks, guiding users), and use of self-monitoring were present in therapies that resulted in improved therapy engagement, satisfaction and adherence, as well as symptom and functional impairments. Conclusions: When incorporated into Internet-based CBT for adolescent depression, PSD features may improve adolescent adherence, satisfaction and depression-related outcomes. Testing of these features using hypothesis-driven, dismantling approaches is recommended to advance our understanding of how these features contribute to therapy effectiveness.

  • Convergent validity of ecological momentary assessment of physical activity

    Date Submitted: Mar 1, 2017
    Open Peer Review Period: Mar 1, 2017 - Apr 26, 2017

    Background: Ecological momentary assessment (EMA) may elicit PA estimates that are less prone to bias than traditional self-report measures, while providing context. Objective: To examine the convergent validity of EMA-assessed PA compared to accelerometry. Methods: Participants self-reported their PA (International Physical Activity Questionnaire [IPAQ] and Behavioral Risk Factor Surveillance System [BRFSS]), and wore an accelerometer while completing daily EMAs for 7 days. Weekly summary estimates included: sedentary time, moderate-, vigorous-, and moderate-to vigorous-intensity physical activity (MVPA). Spearman’s coefficients and Lin’s concordance correlation coefficients (LCC) examined the linear association and agreement for EMA and the questionnaires compared to accelerometry. Results: Participants were aged 43.3 (±13.1) years, more than half were African American (51.7%), 74.8% were overweight/obese, and 52.4% were low income. The linear associations of EMA and traditional self-reports with accelerometer estimates were statistically significant (p<0.05) for sedentary time (EMA: ρ=0.16), moderate intensity PA (EMA: ρ=0.29; BRFSS: ρ=0.17; IPAQ: ρ=0.24) and MVPA (EMA: ρ=0.31; BRFSS: ρ=0.17; IPAQ: ρ=0.20). Only EMA estimates were statistically significant compared to accelerometer for agreement. Conclusions: EMA showed better correlation and agreement to accelerometer estimates than traditional self-report methods. These findings suggest that EMA may be a practical alternative to accelerometers to assess PA in free-living settings.

  • Issues in Conducting Research on Social Media-Based Interventions for Health

    Date Submitted: Feb 27, 2017
    Open Peer Review Period: Feb 27, 2017 - Apr 24, 2017

    The use of social media platforms by healthcare professionals and public health organisations to deliver health care and support is in its early stages and challenges are emerging. While social media platforms offer great potential to deliver health support development and testing of social media interventions for chronic disease management remains in its infancy, with ‘good practices’ not yet established. Designing social media interventions that are acceptable to users, practitioners and researchers is a challenge and there is a poor fit with traditional research and evaluation methods. Human research policy cannot match the rapid pace of change dictated by the commercially focused social media developers. While social media platforms reduce participant burden in engaging group support programs, they may create additional concerns for researchers in terms of intervention compliance, adherence an ethical practice.

  • Evaluation on physician-patient interactions in online medical consultations in China and the influencing factors on the interactions

    Date Submitted: Feb 24, 2017
    Open Peer Review Period: Feb 26, 2017 - Apr 23, 2017

    Background: In China, there are more than 100 million people that consult physicians on websites every year. But patients gained little from these superficial interactions that can easily cause a misunderstanding. So the interaction degree can be viewed as an index to measure the influence of online medical consultations on the patients. Works about the investigations and evaluations on these interactions in China have not been carried out. Objective: Investigated and evaluated the interaction degree about the online medical consultations, analyzed the influences of the replies and the job title of the physicians on the interactions, and finally gave some advice on improving the interactions. Methods: (1) The Alexa top 5 medical websites in China were selected. A crawler was developed and with it the hierarchical data on the websites were obtained. 8,911,327 times consultations have been obtained by the end of December 2016. (2) according to the data patients asked and physicians replied several measures such as the words count of interactions and times of interactions were defined. With these indexes the influences on interactions were measured. (3) analyzed how the physicians’ replies influenced the interactions and how the job titles of the physicians influenced the interactions. Results: (1) in the studied medical websites, the average words count that patients asked is 74, the average words count that physicians replied is 107, the average times of patient-physician interactions is 1.19. (2) compared to the average times of interaction, (a) if physicians’ replies contained any questioning, such as “are there any other symptoms”, the interaction times increased by 60%; (b) if there were drugs and examinations in the replies of physicians, the patients made a detail inquiry that made interaction times increased by 31%; (c) if physicians’ replies contained caring for patients, such as “pay attention to rest”, the interaction times increased by 43%. (3) amount of chief physicians that take part in consultations is 8%, and 9% for deputy chief physicians, 17% for attending physicians, 65% for the physicians with other titles. (4) the average consultation times of attending physicians were 300, whereas those of chief physicians, deputy chief physicians, and other physicians were from 171-198. Conclusions: Statistical results showed that: (1) physician-patient interactions helped patients little, and could not satisfy them. (2) the medical consultation websites can increase physician-patient interactions with the following methods: (a) encourage physicians to ask patients’ illness in replies; (b) encourage the physicians to give a reference to drugs and examinations; (c) encourage physicians to show caring for patients; (d) attract physicians who have higher professional tiles to take part in consultations.

  • Total knee replacement pathways: How can technology support patient cocreation for improved outcomes?

    Date Submitted: Feb 24, 2017
    Open Peer Review Period: Feb 24, 2017 - Apr 21, 2017

    Background: Total knee replacement (TKR) surgery is an increasingly common procedure to return mobility and relieve pain for people suffering from osteoarthritis. Patients can improve their TKR outcomes through active participation or cocreation of their health service delivery. Patient cocreation in TKR can include activities such as active information seeking, shared decision making with clinicians, self-managing rehabilitation (e.g. physiotherapy), and self-monitoring (e.g. recovery/progress). Objective: Our aim was to investigate how information and communication technology (e.g. electronic health, mobile health) can enhance patient engagement as cocreators of their own health outcomes in the TKR journey. Methods: A multi-perspective qualitative study of user needs was conducted with Australian stakeholders (N= 34): surgeons (n = 12), physiotherapists (n = 3), patients (n = 11) and general practitioners (n = 8) to understand the opportunities for enhancing patient cocreation using information and communication technologies. Data from focus groups and interviews was recorded, transcribed and analysed using thematic analysis. Results: The current care delivery pathway for TKR is identified in terms of patient journey and information/communication flow. Numerous opportunities exist for technology to assist and enhance patient participation in, preparation for and recovery from TKR surgery. Technology could enhance the delivery of information to patients, as well as improve management and adherence to home exercise programs through instructional videos, reminders, and gamification. Self-monitoring of mobility, functional improvement, sleep quality, and detection of wound infection could be incorporated with wearable technology and self-management tools. Potential benefits for the healthcare system include reduced length of stay and reduced burden of disease associated with postoperative morbidity. Conclusions: Health outcomes are a result of collaboration between healthcare professionals and their patients. This multiple stakeholder needs analysis shows the potential for technology to enhance patient cocreation and improve TKR outcomes. For healthcare providers, empowering patients is about designing and delivering healthcare that is more inclusive of the patient to facilitate patient empowerment and cocreation.

  • Feasibility of online group-exercising among older adults in Siberia: Findings from two pilot trials

    Date Submitted: Feb 23, 2017
    Open Peer Review Period: Feb 24, 2017 - Apr 21, 2017

    Background: Regular physical activity has a positive effect on physical health, well-being and life satisfaction for older adults. However, engaging in regular physical activity can be challenging for older adults due to reduced mobility, low motivation or lack of the proper infrastructures in their communities. Objective: The goal of this paper is to study the feasibility of home-based online group training - under different group cohesion settings - and its effects on adherence and well-being among Russian older adults. We focus particularly on the technology usability and usage, and on adherence to the training (in light of pre-measures of social support, enjoyment of physical activity and leg muscle strength). As a secondary objective we also explore the effects of the technology-supported intervention on the subjective well-being and loneliness. Methods: Two pilot trials were carried out exploring two different group cohesion settings (weak cohesion and strong cohesion) in the period 2015-2016, in Tomsk, Russian Federation. A total of 44 older adults (59-83 years old) participated in the two pilots, and followed a strength and balance training program (OTAGO) for eight weeks with the help of a tablet-based virtual gym application. Participants in each pilot were assigned to a Social condition, representing the online-group exercising, and a Control condition, representing a home-based individual training. Both conditions featured persuasion strategies but differed in the ability to socialise and train together. Results: Both Social and Control group reported on the high usability of the technology. Trainees showed a high level of application acceptance that also comprises the high score in intention to future use (4.2-5.0 on a 5-point Likert scale). Surprisingly, the Social group made significantly more use of private messages compared to public messages. However, joint participations to training sessions (co-presence) were higher for the Social group with higher cohesion. The overall adherence to the training (persistence rate) was of 74% (SD=27%). Higher levels of social support at baseline were associated with higher adherence in the study with low cohesion among trainees (F(1, 18)=5.23, p=.034), whereas in the high cohesion study the adherence was not significantly associated with the initial social support. Overall improvement in the satisfaction with life score was observed between pre and post measures (F(1,31)=5.85, p=.022), but no decrease in loneliness. Conclusions: Online group-exercising was proven feasible among healthy independently living older adults in Russia. The pilots suggest that a physical training performed in a virtual environment positively affect the life satisfaction of the trainees, but it does not provide support for a decrease in loneliness. High cohesion groups are preferable for group-exercising, especially to mitigate effects of low social support on adherence. Further research in motivating group interactions in training settings is needed.

  • Using the Medical Research Council framework for development and evaluation of complex interventions in a low resource setting to develop a theory-based treatment support intervention delivered via SMS text message to improve blood pressure control.

    Date Submitted: Feb 9, 2017
    Open Peer Review Period: Feb 21, 2017 - Apr 18, 2017

    Background: Several frameworks now exist to guide intervention development but there remains only limited evidence of their application to health interventions based around use of mobile phones or devices, particularly in a low-resource setting. Objective: We describe our experience of using the Medical Research Council (MRC) Framework on complex interventions to develop and evaluate an adherence support intervention for high blood pressure delivered by SMS text message. We describe the developed intervention in line with reporting guidelines for a structured and systematic description. Methods: We used a non-sequential and flexible approach guided by the 2008 MRC Framework for the development and evaluation of complex interventions. Results: We reviewed published literature and established a multi-disciplinary expert group to guide the development process. We selected health psychology theory and behaviour change techniques that have been shown to be important in adherence and persistence with chronic medications. Semi-structured interviews and focus groups with various stakeholders identified ways in which treatment adherence could be supported and also identified key features of well-regarded messages: polite tone, credible information, contextualised, and endorsed by identifiable member of primary care facility staff. Direct and indirect user testing enabled us to refine the intervention including refining use of language and testing of interactive components. Conclusions: Our experience shows that using a formal intervention development process is feasible in a low-resource multi-lingual setting. The process enabled us to pre-test assumptions about the intervention and the evaluation process, allowing the improvement of both. Describing how a multi-component intervention was developed including standardised descriptions of content aimed to support behaviour change will enable comparison with other similar interventions and support development of new interventions. Even in low-resource settings, funders and policy-makers should provide researchers with time and resources for intervention development work and encourage evaluation of the entire design and testing process. Clinical Trial: The trial of the intervention is registered with South African National Clinical Trials Register number (SANCTR DOH-27-1212-386); Pan Africa Trial Register (PACTR201411000724141); (NCT02019823).

  • Differentiation strategy in online physician competition: Does specialization matter?

    Date Submitted: Feb 19, 2017
    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

    Background: A successful product differentiation strategy leads to competitive advantages and higher profits for firms, and this is also the case for the hospital industry. However, we do not know whether a physician’s specialization differentiation strategy will have any impact on her online income in an e-Consultation market; nor do we know the market conditions under which this strategy will be more effective. Objective: We aim to investigate how a specialization differentiation strategy impacts a physician’s online income and the market conditions under which a specialization differentiation strategy has stronger effects. Methods: We employed secondary data in an econometric analysis of transactions obtained from an e-Consultation website ( for four diseases (infantile pneumonia, diabetes, infertility, and pancreatic cancer) from 2008 to 2015. A total of 1160 physicians were included in the analysis. Results: Specialization, the differentiation strategy, has a significant positive impact on the physician’s online income (β =0.011, p < 0.001). Moreover, specialization will improve a physician’s competitive advantage when market competition is more intense (β =0.116, p < 0.001). Conclusions: Physicians whose expertise is differs from that of the majority have higher online incomes, and this impact will be stronger when market competition is more intense. Our study indicates that e-Consultations may accelerate the specialization trend observed in the health care industry because the online market favors more-specialized physicians, and competition in the online market is stronger than in the offline market. Such an impact may be positive for some very complicated diseases but less positive for some chronic diseases. Policy makers should be careful with the double-edged sword of e-Consultation.

  • Implementation Decisions and Design Trade-offs in Developing an EHR-linked Mobile Application to Reduce Parental Uncertainty Around Childhood Cancer

    Date Submitted: Feb 16, 2017
    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

    Background: Parents of children newly diagnosed with cancer are confronted with multiple stressors that place them at risk for significant psychological distress. One strategy that has been shown to help reduce uncertainty is the provision of basic information. Families of newly diagnosed cancer patients are often bombarded with educational material, however. Technology has the potential to help families manage their informational needs and move towards normalization. Objective: We sought to create a mobile application that pulls together data from both the electronic health record (EHR) and vetted external information resources, in order to provide tailored information to parents of newly diagnosed children as one method to reduce the uncertainty around their child’s illness. This application was developed to be used by families in a National Institutes of Health (NIH)-funded randomized controlled trial (RCT) aimed at decreasing uncertainty and the subsequent psychological distress. Methods: A 2-phase qualitative study was conducted to elicit the features and content of the mobile application based on the needs and experience of parents of children newly diagnosed with cancer and their providers. Example functions include the ability to view laboratory results, look up appointments, and to access educational material. Educational material was obtained from databases maintained by the National Cancer Institute (NCI) and groups like the Children’s Oncology Group (COG) and care teams within Cincinnati Children’s Hospital Medical Center. The use of EHR-based web services was explored to allow data-like laboratory results to be retrieved in real-time. Results: The ethnographic design process resulted in an application framework that divided the content of the mobile application into 4 sections: 1) information about the patient’s current treatment and other information from the EHR; 2) educational background material; 3) a calendar to view upcoming appointments at their medical center; 4) a section where participants in the RCT document the study data. Integration with the NCI databases was straightforward, however, accessing the EHR web services posed a challenge, though the roadblocks were not technical in nature. The lack of a formal, end-to-end institutional process for requesting web service access and a mechanism to shepherd the request through all stages of implementation proved to be the biggest barrier. Conclusions: We successfully deployed a mobile application with a custom user interface that can integrate with the EHR to retrieve laboratory results and appointment information using vendor-provided web services. Developers should expect to face hurdles when integrating with the EHR, but many of them can be addressed with frequent communication and thorough documentation. Executive sponsorship is also a key factor for success. Clinical Trial: NCT02505165

  • Development of a Context-Driven Dynamic XML Ophthalmologic Data Capture Application

    Date Submitted: Feb 7, 2017
    Open Peer Review Period: Feb 20, 2017 - Apr 17, 2017

    Background: The capture and integration of ophthalmologic data into electronic health records (EHRs) has historically been a challenge. However, the importance of this activity for patient care and research is critical. Objective: The purpose of this study was to develop a context-driven dynamic XML ophthalmology data capture application for research and clinical care that could be easily integrated into an electronic health record system. Methods: Stakeholders in the medical, research, and informatics fields were interviewed and surveyed to determine data and system requirements for ophthalmologic data capture. Based on these requirements, an ophthalmology data capture application was developed to collect and store discrete data elements with important graphical information. Results: The context-driven data entry application supports several features including: ink-over drawing capability for documenting eye abnormalities, context-based web controls that guide data entry based on pre-established dependencies, and an adaptable database or XML schema that stores web form specifications and allows for immediate changes in form layout or content. The application utilizes web services to enable data integration with a variety of EHRs for retrieval and storage of patient data. Conclusions: This paper describes the development process used to create a context-driven dynamic XML data capture application for optometry and ophthalmology. The list of ophthalmologic data elements identified as important for care and research can be used as a baseline list for future ophthalmologic data collection activities.


    Date Submitted: Feb 14, 2017
    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Despite the potential benefits described by international organizations, 68–80% of survivors do not meet the described guidelines in terms of diet and physical activity. This concern could be approached with a user-friendly mobile health (mHealth) application for assessing and monitoring healthy lifestyles in breast cancer survivors (BCS). Objective: The main aim is to investigate the test-retest reliability and concurrent validity against accelerometry and dietary records of a novel mHealth system called BENECA (ENErgy Balance on CAncer). Methods: We conducted a descriptive reliability study (N=20 BCS) who were recruited from the Virgen de las Nieves Hospital of the Andalusian Health Service in Granada (Spain) between December 2015 and April 2016. Test-retest reliability analysis used an overlap of approximately 2 hours between times. During an 8-day period tri-axial accelerometers (ActiGraphGT3X+, Pensacola, Fl., US) were worn by patients for concurrent validity analysis. Alike, at baseline 24-hour dietary recalls (also after 8-day period), sociodemographic questionnaire and daily dietary record questionnaires were recorded. For the inter-rater reliability trials, two-way random effect intra-class correlation coefficients (Rho) and their confidence intervals were calculated. Moreover, the agreement in diet between gold-standard and BENECA m-Health System was evaluated using a method described previously by Hillier. Finally, the accuracy of BENECA m-Health System was assessed using a linear regression analysis to determine the correlation coefficient and a Passing-Bablok regression to evaluate bias. Results: The compliance rates for all assessment methods were very high. All outcome measures showed reliability estimates (α)≥0.90; the lowest reliability was obtained for portions of the FV (α=0.94). The inter-rater reliability (gold standard method versus BENECA mHealth system) was very good (Rho≥0.90). The mean match rate between food items reported using BENECA and those registered by gold-standards was 93.51%, with a phantom rate of 3.35%. There were no substantial differences between the BENECA m-Health system and the gold standard assessment methods. There was no fised bias and mean differences between methods were -0.15 for FAT, -0.01 for fruits and vegetables and -8.89 for minutes of moderate-to-vigorous physical activity. There were not any adverse events. One breast cancer survivor could not use the BENECA m-Health System because she was using a previous version of the Android System with which BENECA was incompatible. Conclusions: The BENECA mHealth system is a simple, quick, reliable and low burden method to assess diet and physical activity in BCS. This novel option has potential implications in the cancer units to examine energy balance-related behaviours. Further research is now required to study the usage of both BENECA mHealth system and objective measurement of physical activity because it could suppose a major advance for a growing cancer population whose energy imbalance increases risk of some of the most prevalent cancer processes.

  • An eAlert System Between Family Caregivers and Clinicians Reduces Symptom Distress in Patients With Advanced Cancer: A Pooled Analysis of Two Randomized Clinical Trials

    Date Submitted: Feb 8, 2017
    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: Symptom distress toward the end of life can change rapidly. Family caregivers have the potential to help manage those symptoms, as well as their own stress, if they are equipped with the proper resources. eHealth systems may be able to provide those resources. Very sick patients may not be able to use such systems themselves to report on their symptoms, but family caregivers could. Objective: Assess the effects of an eHealth system that alerts clinicians to significant changes in a cancer patient’s symptom distress, as reported by a family caregiver. Methods: A pooled analysis from two randomized clinical trials (NCT00214162 and NCT00365963) compared outcomes at 12 months for two unblinded groups: a control group (CHESS-Only) that gave caregivers access to an online support system, the Comprehensive Health Enhancement Support System (CHESS), and an experimental group (CHESS+CR [Clinician Report]), which also had CHESS, but with a Clinician Report that automatically alerted clinicians if symptoms exceeded a predetermined threshold. Participants were dyads (n = 235) of patients with advanced lung, breast, or prostate cancer and their family caregivers from five oncology clinics in the United States. The proportion of improved patient threshold symptoms was compared between groups using area-under-the-curve analysis and binomial proportion tests. The proportion of threshold symptoms out of all reported symptoms was also examined. Results: When caregivers in CHESS+CR reported an over-threshold symptom, they were more likely to subsequently report threshold symptom improvement, P < .001, than in the group that did not include CR. Moreover, fewer caregivers in the CHESS+CR group completed symptom reports than in the CHESS-Only group (P < .001). Knowing their reports might be sent to a doctor, they might have been reluctant to “bother” the clinician. Conclusions: This study suggests that a caregiver-focused eHealth system that alerts clinicians to worrisome changes in patient health status may lead to a reduction in patient distress. Clinical Trial: NCT00214162; (Archived by WebCite at NCT00365963; (Archived by WebCite at )

  • Content Analysis of Smartphone Apps for Smoking Cessation in China

    Date Submitted: Feb 16, 2017
    Open Peer Review Period: Feb 19, 2017 - Apr 16, 2017

    Background: With 360 million smokers, China consumes more cigarettes than any other country in the world. Given that 620 million Chinese own smartphones, smartphone applications (apps) for smoking cessation are increasingly used in China to help smokers quit. Objective: This study analyzed and evaluated the contents of all smoking cessation apps (iOS & Android) available in China, applying the China Clinical Smoking Cessation Guideline (CCSSG; identical to the U.S. Clinical Practice Guideline for Treating Tobacco Use and Dependence) as a framework for analysis. Methods: We conducted a content analysis of Chinese Android and iOS smoking cessation apps (N=64) designed to assist users in quitting smoking. Each app was independently coded by two raters for its approach to smoking cessation and adherence to the CCSSG. We also recorded the features of smoking cessation apps (e.g., release date, size, frequency of downloads, user ratings, type, quality scores by raters, and designers). Linear regression was used to test predictors of popularity and user-rated quality. Results: Chinese smoking cessation apps have low levels of adherence, with an average score of 11.1 for Android and 14.6 for iOS apps, on a scale of 0 to 46. There was no significant association between popularity, user rating, and the characteristics of apps. However, there was a positive relationship between popularity, user rating, and adherence score. Conclusions: Chinese apps for smoking cessation have low levels of adherence to standard clinical practice guidelines. New apps need be developed and existing apps be revised following evidence-based principles in China.

  • Barriers and facilitators to use eHealth in daily practice, perspectives of patients and professionals in dermatology

    Date Submitted: Feb 15, 2017
    Open Peer Review Period: Feb 18, 2017 - Apr 15, 2017

    Background: The number of eHealth interventions in the management of chronic diseases, such as atopic dermatitis (AD) is growing. Despite promising results, the implementation and use of these interventions is limited. Objective: This study aimed to assess opinions of most important stakeholders influencing the implementation and use of eHealth services in daily dermatology practice. Methods: A cross sectional survey based on the eHealth implementation toolkit (eHit) was conducted to explore factors influencing the adoption of eHealth interventions offering the possibility of e-consultations, online monitoring and online self-management training among dermatologists and dermatology nurses. Perspectives of patients with atopic dermatitis (AD) regarding the use of eHealth services were discussed in an online focus group. Results: Healthcare professionals (n=99) and patients (n=9) acknowledged the value of eHealth services and were willing to use these digital tools in daily dermatology practice. Key identified barriers in the implementation and adoption of eHealth interventions included concerns about the availability and allocation of resources; financial aspects; reliability, security and confidentially of the intervention itself and the lack of education and training. Conclusions: Healthcare professionals and patients acknowledge the benefits arising from the implementation and use of eHealth services in daily dermatology practice. However, we identified some important barriers that might be useful in addressing the implementation strategy in order to enhance the implementation success of eHealth interventions in dermatology.

  • ICT for health in the EU: the effect of multimorbidity

    Date Submitted: Feb 10, 2017
    Open Peer Review Period: Feb 18, 2017 - Apr 15, 2017

    Background: Multimorbidity is becoming increasingly common and is a key challenge that societies with ageing populations are now facing. The presence of multimorbidity entails the implication of patients to coordinate, understand and use the information obtained from different health care professionals, in addition to striving to distinguish the symptoms of different diseases and self manage their sometimes conflicting health problems. Information and communications technology (ICT) tools are an opportunity for health information and education for both patients and health professionals, and hold promise for more efficient and cost-effective care processes. Objective: This study aims to analyze the use of ICT tools, particularly the Internet, for health purposes, taking into account the citizens’ socio-demographic and clinical characteristics, and above all, the presence of multimorbidity. Methods: Cross-sectional and exploratory research using online survey data from July-August 2011 was conducted, including a total of 14,000 citizens from 14 European countries between 16 and 74 years of age, and who had used the Internet in the previous three months. The variables of study were the questionnaire items related to how often the Internet was used for health purposes, the degree of morbidity and the ICT for health gradient. Chi-square tests were conducted to classify participants and examine the relationship between the sociodemographic and clinical variables of participants and the ICT user group. A one-way analysis of variance (Anova) made it possible to compare the ICT for health gradient average between different groups of individuals according to their morbidity level. A two-way between-groups Anova was performed to explore the effects of multimorbidity and age group on the ICT for health gradient. Results: According to the ICT for health gradient, most participants (68.1%; 9,541) were labelled as Rare Users, being the majority of them (55.1%) 25-54 years old, with upper secondary education (50.3%), employed (49.3%) and living in medium-sized cities (40.7%). Results of the one-way Anova showed that the number of health problems significantly affected the use of ICT for health purposes [F (2, 13996) = 11.584; p = .001]. A two-way ANOVA showed there was a statistically significant interaction between the effects of age and number of health problems on the ICT for health gradient, F (4, 11991) = 7.936, p = .001. Conclusions: Although multimorbidity patients can benefit from Internet use for health-related activities, there is a need to consider different strategies to make ICT for health tools more sensitive to the particularities of older people and to reduce digital disadvantages.

  • Internet-based assessment of oncology healthcare professional learning style and optimization of materials for web-based learning: Controlled trial with concealed allocation

    Date Submitted: Feb 14, 2017
    Open Peer Review Period: Feb 15, 2017 - Apr 12, 2017

    Background: Precision medicine has resulted in increasing complexity in the treatment of cancer. Web-based educational materials can help address the needs of oncology healthcare professionals seeking to understand up-to-date treatment strategies. Objective: This study aimed to assess learning styles of oncology healthcare professionals and to determine whether learning style–tailored educational materials leads to enhanced learning. Methods: 21,465 oncology healthcare professionals were invited by email to participate in the fully automated, parallel group study. Enrollment and follow-up occurred between July 13 and September 7, 2015. Self-enrolled participants took a learning style survey and were assigned to the intervention or control arm using concealed alternating allocation. Participants in the intervention group viewed educational materials consistent with their preferences for learning (reading, listening and/or watching); participants in the control group viewed educational materials typical of the My Cancer Genome website. Educational materials covered the topic of treatment of metastatic ER+ breast cancer using CDK4/6 inhibitors. Participant knowledge was assessed immediately before (pre-test), immediately after (post-test), and two weeks after (follow-up test) review of the educational materials. Study statisticians were blinded to group assignment. Results: 751 participants enrolled in the study. Of these, 367 were allocated to the intervention arm, and 384 were allocated to the control arm. Of those allocated to the intervention arm, 256 completed all assessments. Of those allocated to the control arm, 296 completed all assessments. An additional 12 participants were deemed ineligible, and one withdrew. Four hundred thirty-eight of 552 participants (79.3%) self-identified as multi-modal learners. The intervention arm showed greater improvement in post-test score compared to the control group (0.4 points, or 4.0%, more improvement on average; P = 0.004) and a higher follow-up test score than the control group (0.3 points, or 3.3%, more improvement on average; P = 0.016). There were no important harms. Conclusions: While the study demonstrated more learning with learning style–tailored educational materials, the magnitude of increased learning and the largely multimodal learning styles preferred by the study participants led us to conclude that future content-creation efforts should focus on multimodal educational materials rather than learning style–tailored content.

  • A Mobile Application to Streamline the Development of Wearable Sensor Based Exercise Biofeedback Systems: System Development and Evaluation

    Date Submitted: Feb 7, 2017
    Open Peer Review Period: Feb 13, 2017 - Apr 10, 2017

    Background: Biofeedback systems which utilise inertial measurement units (IMUs) have been shown recently to have the ability to objectively assess exercise technique. However, there are a number of challenges in developing such systems; vast amounts of IMU exercise datasets must be collected and manually labelled for each exercise variation and naturally-occurring technique deviations may not be well detected. One method of combatting these issues is through the development of personalised exercise technique classifiers. Objective: We aimed to create a tablet application for physiotherapists and personal trainers which would automate the development of personalised multiple and single IMU based exercise biofeedback systems for their clients. We also sought to complete a preliminary investigation of the accuracy of such individualised systems in a ‘real world’ evaluation. Methods: A tablet application was developed which automates the key steps in exercise technique classifier creation through synchronising video and IMU data collection, automatic signal processing, data segmentation, data labelling of segmented videos by an exercise professional, automatic feature computation and classifier creation. Fifteen volunteers (12 males, 3 females, age: 23.6 +/- 2 years, height: 1.79 +/- 0.07 m, body mass: 77.4 +/- 9.9 kg) then completed 4 lower-limb late stage rehabilitation exercises using a personalised single IMU based classification system. The real world accuracy of the systems was evaluated. Results: The tablet application successfully automated the process of creating individualised exercise biofeedback systems. The personalised systems achieved an average of 90% accuracy, with 90% sensitivity and 89% specificity for assessing aberrant and acceptable technique with a single IMU positioned on the left thigh. Conclusions: A tablet application was developed that automates the process required to create a personalised exercise technique classification system. This tool can be applied to any cyclical, repetitive exercise. The personalised classification model displayed excellent system accuracy even when assessing acute deviations in compound exercises with a single IMU. Clinical Trial: N/A.

  • Scaling up the adoption and use of health technologies: Insights from practice theory

    Date Submitted: Feb 10, 2017
    Open Peer Review Period: Feb 11, 2017 - Apr 8, 2017

    Background: The challenge of promoting the spread and scale of new health technologies (including mobile health, telemedicine, and telehealth technologies) is now widely recognized around the world. Despite the growing attention to methods to achieve successful spread and scale, many scale-up initiatives continue to yield disappointing results. One central reason for the continued failure of these scale-up initiatives is a lack of understanding of how context influences the diffusion of technologies. Objective: In this paper we describe the contributions of “practice theory” to informing efforts to scale-up health technologies across entire systems of health and social care. Methods: Drawing on an individual case study from the Studies in co-Creating Assisted Living Solutions (SCALS) research program in the United Kingdom, and a review of practice theory, we identify key considerations in the effort to scale and spread health technologies. After describing the key tenets of practice theory, we present data from a case study of the implementation of a Global Positioning System (GPS) “geo-fence” for a person living with dementia. We conclude by summarizing the key insights that practice theory brings to efforts to scale up this technology and others, and offer questions to guide further work in this important field. Results: Illustrated through the case of the GPS “geo-fence”, practice theory suggests that efforts to scale-up technologies must attend to three key insights. First, scaling up technologies is in part unpredictable as a result of the experience and judgment integrated into clinical decision-making. Second, the successful scale-up of technologies depends on existing social networks, and considering those social networks will enable stronger plans for the scale and spread of health technologies. Finally, scaling up new technologies means changing routines of a wide range of people, raising the importance of understanding which routines are most likely to change. Conclusions: If health care leaders, policymakers, and other figures driving the scaling up of health technologies continue to neglect the real-world contexts of individual experiences, social networks, and habitual routine practices, the scaling up process will continue to be thwarted by the more important stuff that dominates peoples’ everyday lives. Future work in this domain should include a focus on strategies by which new technologies can be tailored to individual needs, and system-level strategies to provide enabling contexts for the integrated of technologies into routine care delivery.

  • Public Perceptions Regarding Use of Virtual Reality in Healthcare: A Social Media Ethnographic Analysis Using Facebook

    Date Submitted: Feb 7, 2017
    Open Peer Review Period: Feb 8, 2017 - Apr 5, 2017

    Background: Virtual reality (VR) technology provides an immersive, multisensory, and three-dimensional environment that enables users to have modified experiences of reality. VR is increasingly used to manage patients with pain, disability, obesity, neurologic dysfunction, anxiety, or depression. However, public opinion regarding use of VR in healthcare has not been explored. Understanding public attitudes, concerns, beliefs, and recommended use cases for VR is critical to ensure effective implementation and appropriate dissemination of this emerging technology. Objective: We sought to examine public opinion about healthcare VR using digital ethnography, a qualitative analysis method that allows for exploration of unfiltered views of topics discussed online. Methods: In March 2016, NBC News produced a video depicting use of VR for patient care. The video was repackaged by NowThis, a social media news website, and distributed on Facebook by Upworthy, a news aggregator, yielding 4.3 million views and 2,401 comments. We used Microsoft Power Query and ATLAS.ti software to analyze the comments using thematic analysis and categorized the comments around first-, second-, and third-order concepts. We determined self-identified gender from the user’s Facebook page and performed sentiment analysis of language to analyze whether perception of VR differed by gender using Pearson’s chi-square tests. Results: Of the 1,614 analyzable comments, 1,021 (63.26%) were attributed to female Facebook users, 572 (35.44%) to male users, and 21 (1.30%) to users of unknown gender. There were 1,197 comments coded as expressing a positive perception about VR (74.16%), 251 as a negative perception and/or concern (15.55%), and 560 as neutral (34.70%). Respondents identified 20 use cases for VR in healthcare, including for pain and stress reduction, bed-bound individuals, women during labor, and patients undergoing chemotherapy, dialysis, radiation, or imaging procedures, among others. Negative comments expressed concerns about patient safety and overdependence on technology. Respondents also expressed concerns about radiation, infection risk, motion sickness, and the ubiquity of and overall dependence on technology. There was a statistically significant association between language valence and gender of the Facebook user; men were more likely to post negative perceptions about VR use for healthcare, while women were more likely to post positive perceptions (P < 0.001). Conclusions: This study provides a blueprint for healthcare organizations and the VR community regarding where to prioritize research and implementation of VR for patient care. Most respondents to this natural experiment expressed positive perceptions about the use of VR in a wide range of healthcare settings. However, many expressed concerns that should be acknowledged and addressed as healthcare VR continues to evolve. Our results provide guidance in determining whether, when, and where to implement VR in patient care, and offer a formal opportunity for public opinion to shape the VR research agenda.

  • Computerised adaptive testing improves the reliability and efficiency of depression assessment using the CES-D scale

    Date Submitted: Feb 6, 2017
    Open Peer Review Period: Feb 6, 2017 - Apr 3, 2017

    Background: The CES-D is a commonly-used measure of depression. We assess its performance as an item bank for measuring depression using a computer adaptive testing (CAT) administration protocol. Objective: To provide evidence on the efficiency and accuracy of the CES-D when administer using CAT. Methods: We applied a battery of psychometric assessments to the legacy CES-D questionnaire. Dimensionality as assessed using confirmatory factor and Mokken analysis. Advanced psychometric properties were assessed using item response theory (IRT) including assessments of item and scale fit to the graded response model, local dependency and differential item functioning. Results: Confirmatory Factor analysis (CFA) was employed to investigate the unidimensionality of the CES-D scale. Initial CFA results indicate a poor fit to the model. Thus, Mokken analysis was employed to explore the dimensional structure of the CESD-D. Three items were eliminated to conform to a single dimension. The remaining 17 items to Samejima’s graded response model. Examination of the factor loadings revealed that all items loaded significantly on the single factor. Evaluation of local dependency resulted in no correlated residuals greater than 0.2. Significant differential item functioning was not found between age and gender groups. Estimates of the level of CES-D trait score provided by the simulated CAT algorithm and the original CES-D trait score derived from original scale were correlated highly. The CAT simulation conducted using real data found a downward trend in the length of items given to individuals, indicating higher precision at the extreme (higher) levels of the depression spectrum. Conclusions: In summary, the CES-D CAT is a precise and efficient measurement of a highly relevant psychological construct. Even in its current form, the CES-D CAT shows the immediate advantages which can be employed to measure depression that is more accurate, interpretable, and efficient than using a paper-based test.

  • Ontology-based analysis of social media data related to adolescent depression

    Date Submitted: Feb 6, 2017
    Open Peer Review Period: Feb 6, 2017 - Apr 3, 2017

    Background: Social network services (SNSs) contain abundant information about the feelings, thoughts, interests, and patterns of behavior of adolescents that can be obtained by analyzing SNS postings. An ontology that expresses the shared concepts and their relationships in a specific field could be used as a semantic framework for social media data analytics. Objective: The aims of this study were to develop an ontology and terminology as a framework for analyzing social media data on adolescent depression and to evaluate a formal description of classes and relationships in the ontology and its applicability. Methods: The domain and scope of the ontology were defined using competency questions. Concepts constituting the ontology and terminology were collected from clinical practice guidelines, the literature, and social-media postings on adolescent depression. Class concepts, their hierarchy, and relationships among class concepts were defined. An internal structure of the ontology was designed using the entity-attribute-value (EAV) triplet data model, and superclasses of the ontology were aligned with the upper ontology. Description logics of the ontology were evaluated by competency questions using description logic queries. Applicability of the ontology was validated by examining the representability of 10 sentiment phrases using the ontology data model and conducting sentiment analyses of social media data using logistic regression, decision tree, and association rules. Results: The ontology consisted of five top-level classes with 438 subordinate classes arranged into three or four levels of hierarchy. In total, 443 classes with 1,682 synonyms had 19 different types of property relationships. All of the answers that were inferred from the ontology according to the queries were found to be correct. Regarding applicability, it was possible to represent the 10 sentiment phrases using the EAV triplet of the ontology class concepts. It was also found that ‘academic stresses’ and ‘suicide’ contributed negatively to the sentiment of adolescent depression. Conclusions: The ontology and terminology developed in this study provide a semantic foundation for analyzing social media data on adolescent depression. To be useful in social media data analysis, the ontology, especially the terminology, needs to be updated constantly to reflect rapidly changing terms used by adolescents in social media postings.