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:

  • Can Gaming Increase Antibiotic Awareness in Children? A Mixed Methods Approach

    Date Submitted: Jul 28, 2016
    Open Peer Review Period: Jul 28, 2016 - Sep 22, 2016

    Background: e-Bug is a pan-European educational resource for junior and senior school children that contains activities covering prudent antibiotic use and the spread, treatment, and prevention of infection. Teaching resources for children aged 7-15 years are complemented by a student website that hosts games and interactive activities for the children to continue their learning at home. Objective: The aim of this study was to appraise young people’s opinions of three antibiotic games on the e-Bug student website by exploring children’s views and suggestions for improvements, and analysing change in awareness about the learning outcomes. The three games selected for evaluation all contained elements and learning outcomes relating to antibiotics, the correct use of antibiotics, and bacteria and viruses. Methods: A mixed methodological approach was undertaken. 153 pupils aged 9-11 in primary schools and summer schools in the Bristol and Gloucestershire area completed a questionnaire with antibiotic and microbe awareness questions, before and after playing three e-Bug games for a total of 15 minutes each. The after questionnaire also contained open-ended and Likert scale questions. In addition, six focus groups with 48 students and think-aloud sessions with four students who had all played the games were performed. Results: The questionnaire data showed a significant increase in awareness for 2 out of 7 questions, while all questions showed a small level of increase. The two areas of significant knowledge improvement focused around the use of antibiotics for bacterial versus viral infections, and ensuring the course of antibiotics is completed. Qualitative data showed that the e-Bug game 'Body Busters' was the most popular game, closely followed by ‘Doctor Doctor’, with 'Microbe Mania' being the least popular. Conclusions: The conclusions of this study show that two of the e-Bug antibiotic educational games are valuable. The ‘Body Busters’ game effectively increased antibiotic awareness in children and had the greatest flow and enjoyment for children. The ‘Doctor Doctor’ game also resulted in increased knowledge, but was less enjoyable. The ‘Microbe Mania’ game had neither flow nor knowledge gain and therefore needs much modification and review. These games, especially the ‘Body Busters’ and ‘Doctor Doctor’ games should be promoted to schools and families. The results from the qualitative part of this study will be very important to inform future modifications and improvements to the e-Bug games.

  • The Internet as a Source of Health Information – the Results of a Polish Survey Study

    Date Submitted: Jul 28, 2016
    Open Peer Review Period: Jul 28, 2016 - Sep 22, 2016

    Background: The popularisation of Internet access has made it one of the basic sources of information (in this article, the term “Internet” is understood as different kinds of: websites, blogs, social networking sites, such as: Facebook, Twitter, etc.; text messages, including: email, skype, other instant messengers; discussion forums). This relates also to health and its correlates. Objective: The main objective of the study was to evaluate the scale of the phenomenon of using the Internet to look for health information in Poland. The aim of the study was also to evaluate the influence of information about health published in the network on the behaviour of internet users. Methods: A questionnaire-based survey (face-to-face interview) was carried out among a representative group of 1000 inhabitants of Poland aged 15 years and older. Results: Among the 1000 respondents surveyed in this study, 670 (67%) declared using the Internet, more than half of which (53.7%) reported seeking, among others, health information. The most commonly sought information included: diet and healthy eating (33.3%), a particular medication or dietary supplement (its effect, dosage, side effects) (28.9%), reviews of doctors (26.7%), and how other people coped with similar health problems (25.3%). More than 53% of Internet health information seekers were driven by curiosity, 46.4% by the ease and speed of finding information, 32.5% by the opportunity of finding a lot of independent reviews in one place, and 29.7% by no extra costs. Conclusions: The importance of the Internet as a source of information about health is constantly increasing. Our study presents that in Poland, women, younger, well-educated, living in big cities, especially often look for health information on the web. However most people have limited trust in the data derived from that source. The influence of information about health published in the network on people's behaviour could be less than is commonly believed.

  • A mobile app to stabilize daily functional activity of breast cancer patients in collaboration with the physician: a randomized controlled clinical trial

    Date Submitted: Jul 26, 2016
    Open Peer Review Period: Jul 27, 2016 - Aug 3, 2016

    Background: The well-being of breast cancer patients and reporting of adverse events require close monitoring. Mobile apps allow continuous recording of disease and medication related symptoms in patients undergoing chemotherapy. Objective: We evaluated use of a mobile app (app) on patient-reported daily functional activity, in a supervised and unsupervised setting. Methods: We conducted a randomized controlled study of 139 breast cancer patients undergoing chemotherapy. Patient status was self-measured using Eastern Cooperative Oncology Group (ECOG) scoring and Common Terminology Criteria for Adverse Events (CTCAE 4.0). Participants were randomly assigned to a control group, an unsupervised group that used a mobile app to record data, or a supervised group that used the app and reviewed data with a physician. Primary outcome variables were change in daily functional activity and symptoms over three outpatient visits. Results: Functional activity scores declined in all groups from the first to second visit. However, from the second to third visit, only the supervised group improved, while the others continued to decline. Overall, the supervised group showed no significant difference from the first to third visit (p = 0.720). Both app-using groups reported more distinct adverse events in the app than in the questionnaire (supervised, 1033 vs. 656; unsupervised, 852 vs. 823), although the unsupervised group reported more symptoms overall (n = 4808) in the app than the supervised group (n = 4463). Conclusions: The mobile app was associated with stabilized daily functional activity when used under collaborative review. App-using participants could more frequently report adverse events, and those under supervision made fewer and more precise entries than unsupervised participants. Our findings suggest that patient well-being and awareness of chemotherapy side effects can be improved by using a mobile app in collaboration with the treating physician. Clinical Trial: ClinicalTrials.gov: NCT02004496

  • Online dissemination strategies of a Canada Research Chair: overview and lessons learned

    Date Submitted: Jul 26, 2016
    Open Peer Review Period: Jul 27, 2016 - Sep 21, 2016

    Background: Little is known about the use of online dissemination strategies, such as websites and social media, to increase the visibility and uptake of research. Objective: To describe two online dissemination strategies of the Canada Research Chair in Implementation of Shared Decision Making in Primary Care over an eight-year period. Methods: Our two sources of online dissemination data were the website of the Canada Research Chair in Implementation of Shared Decision Making in Primary Care and the Chair’s Twitter account. We conducted a content analysis of the news section of the website. We extracted website usage statistics using Google Analytics and analyzed indicators such as total number of visits, new and returning visitors, page views per visit, time spent onsite per visit, visitors’ country of origin and most popular pages. From the Chair’s Twitter account we collected the number of tweets, followers and follows. Results: From the website’s inception in March 2008 to December 31, 2015, we recorded an average of 7,906 visits per year (3,809 in 2008 to 8,874 in 2015), 66% of which involved new visitors. The average number of pages viewed per visit was 3.2 and the average bounce rate was 58%. Visitors spent an average of two minutes and 12 seconds per visit. We computed visits from 162 countries, with the majority from Canada (75 %). Although the website is in French and English, the most visited pages were in English. The seven most visited pages, in order of frequency, were: 1) home page with news of team activities (24,787 visits); 2) profile of the Chairholder (8,041 visits); 3) profiles of research team members (6,272 visits); 4) list of research team members (4,593 visits); 5) inventory of shared decision making programs (1,856 visits); 6) interprofessional approaches to shared decision making (1,689 visits) and 7) description of Chair activities (1,350 visits). From the inception of the Twitter account in April 2011 to March 23rd 2016 we recorded 4,865 tweets in French and English and 255 pictures and videos. The Twitter account had 1,343 followers and 748 follows. The total number of visits and visitors to the website increased during the first three years and then stabilized, while the number of visits from countries other than Canada increased steadily over the years (p=0.0001). Conclusions: Over an eight-year period the website received the most visitors in its first three years but visitors from elsewhere increased steadily. The opening of a Twitter account may have increased the number of visitors from countries other than Canada. Thus, a combination of online dissemination strategies may be needed to increase the visibility and uptake of research at the international level. Clinical Trial: Not applicable

  • The development and user evaluation of Foodbook24; a web-based 24 hour recall dietary assessment tool.

    Date Submitted: Jul 26, 2016
    Open Peer Review Period: Jul 27, 2016 - Sep 21, 2016

    Background: The application of technology in the area of dietary assessment has resulted in the development of an array of tools which are often specifically designed for a particular country/region. Objective: The aim of this study is to describe the development and user evaluation of a web-based dietary assessment tool Foodbook24 which was developed to provide a user-friendly and cost effective approach to nutrition surveillance in Ireland. Methods: The development of Foodbook24 was informed by various stakeholder engagement activities, ESFA guidelines issued on the collection of dietary information and an extensive literature review. To assess the user acceptability of the tool, participants involved in both a comparison and validation study using Foodbook24 against a distinct reference method were asked to complete a 16 item, online evaluation questionnaire. Results: The final design of Foodbook24 resulted in a web based dietary assessment tool with several different components such as demographic and consent questionnaires, a 24 hour recall component and a Food Frequency Questionnaire. All components of the tool are independent of each other and can be activated or deactivated depending on study design. Completeness of collection mechanisms and portion size photographs were incorporated into the 24 hour dietary recall component of the tool to enhance the usability of the tool. A total of 118 adult participants evaluated the acceptability of Foodbook24. The tool was well received with the majority of respondents: having no issues with reporting all food and drinks (95.8%); willing to use Foodbook24 for a week (82.2%); satisfied with ease of use (69%) and the time required to complete recalls as OK (63.6%) or short (22.9%). Importantly, the majority opted for Foodbook24 as the preferred method for future dietary intake assessment when compared against a traditional interviewer led recall and semi weighed food diary (67.8%). Conclusions: The results of this study demonstrate the potential for Foodbook24 as a web based dietary assessment method and presents a viable alternative to nutritional surveillance in Ireland.

  • Assessment of stress in healthy individuals using smartphones: a systematic review

    Date Submitted: Jul 26, 2016
    Open Peer Review Period: Jul 26, 2016 - Sep 20, 2016

    Background: Stress is a common experience in today’s society. Smartphone ownership is widespread and smartphones can be used to monitor health and wellbeing. Smartphone-based subjective self-assessment of stress can be done in naturalistic settings. Smartphone data may potentially reflect a person’s real-time stress level. Objective: The objectives of this systematic review were 1) to evaluate how smartphones have been used to measure self-assessed stress in healthy adult individuals, 2) to evaluate the validity of self-assessed stress on smartphones compared with validated stress scales and 3) to evaluate the association between self-assessed stress and smartphone generated objective data. Methods: A systematic review of the scientific literature was reported and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The scientific databases PubMed, PsycINFO, Embase, IEEE and ACM were searched and supplemented by a hand search of reference lists. The databases were searched for original studies involving healthy individuals over the age of 18 years, measuring self-assessed stress on a smartphone. Results: A total of 31 published articles comprising a total of 1259 individuals were included for review. According to the objectives 1) The study designs were heterogeneous and self-assessed stress was measured using various methods, including a) a dichotomised question on stress (yes/no), b) a Likert-scale on stress and c) a questionnaire on stress; 2) The validity of self-assessed stress compared with validated stress scales was investigated in three studies, and of these only one study found a moderate statistically significant positive correlation (r=0.4; P < 0.05); 3) Some of the reported smartphone generated objective data, including voice, activity and usage data, were found to correlate with self-assessed stress in exploratory analyses. Conclusions: Smartphones are being used to measure self-assessed stress in different contexts. The evidence of the validity of self-assessed stress is limited and should be investigated further. Smartphone generated objective data can potentially be used to monitor, predict and reduce stress-levels.

  • Can Facebook be used for Research? Experiences using Facebook to Recruit Pregnant Women for a Randomized Control Trial in Edmonton, Alberta

    Date Submitted: Jul 25, 2016
    Open Peer Review Period: Jul 25, 2016 - Sep 19, 2016

    Background: Recruitment is often a difficult and costly part of any human research study. Social media and other emerging means of mass communication hold promise as means to complement traditional strategies used for recruiting participants because they can reach a large number of people, in short amount of time. With the ability to target a specified audience, paid Facebook advertisements have potential to reach future research participants of a specific demographic. A randomized control trial in trial in Edmonton, Alberta trialed various traditional recruitment approaches in addition to paid Facebook advertisements to find healthy pregnant women between 8-20 weeks gestation, to participate in a prenatal study. Objective: To evaluate the effectiveness of paid advertisements on Facebook as a platform for recruiting pregnant women to a randomized control trial, in comparison to Traditional recruitment approaches. Methods: Recruitment using Traditional approaches occurred for 7 months, while Facebook advertisements were trialed for a total of 26 days. Interested women were prompted to contact the study staff for a screening call to determine study eligibility. Costs associated with each recruitment approach were recorded and used to calculate the cost to recruit eligible participants. Performance of Facebook advertisements was monitored using Facebook Ads Manager. Results: Of the 115 women included, 39% (n=45) of the women who contacted study staff heard about the study through Facebook, while 61% (n=70) of them had heard about it through Traditional recruitment approaches. During the 215 days (~ 7 months) that the Traditional approaches were used, the average rate of interest was 0.3±0.2 women/day, while the 26 days of Facebook advertisements resulted in an average interest rate of 2.8±2.1 women/day. Facebook advertisements cost $506.91, with a cost per eligible participant of $20.28. In comparison, the Traditional approaches cost $1087, with an approximate of $24.15 per eligible participant. Demographic characteristics of women were similar between the two recruitment methods, except that women recruited using Facebook were significantly earlier in their pregnancy than those recruited using Traditional approaches (p<.03). Conclusions: Paid Facebook advertisements hold promise as a platform for reaching pregnant women. The relative ease of placing an ad, the comparable cost per participant recruited, and the dramatically improved recruitment rates in comparison to Traditional approaches highlights the importance of combining novel and traditional recruitment approaches to recruit women for pregnancy related studies. Clinical Trial: ClinicalTrials.gov ID: NCT02711644

  • A Five-Step Framework on Biomedical Signal Analysis for Tackling Noncommunicable Diseases: Current and Future Perspectives

    Date Submitted: Jul 25, 2016
    Open Peer Review Period: Jul 25, 2016 - Sep 19, 2016

    Low- and middle-income countries (LMICs) continue to face major challenges in providing high-quality and universally accessible healthcare. Researchers, policy-makers, donors, and program implementers consistently strive to develop and provide innovative approaches to eliminate geographical and financial barriers to healthcare access. Recently, interest has increased in using mobile health (mHealth) as a potential solution to overcome barriers to improving healthcare in LMICs. Moreover, with use increasing and cost decreasing for cellphones and internet, mHealth solutions are becoming considerably more promising and efficient. As part of mHealth solutions, biomedical signals collection and processing could play a major role in improving global healthcare. Information extracted from biomedical signals might increase diagnostic precision while augmenting the robustness of healthcare workers’ clinical decision making. This paper presents a high-level framework using biomedical signal processing (BSP) to tackle noncommunicable diseases (NCDs), especially in LMICs. Researchers can consider each of these elements during the research and design of BSP-based devices, enabling them to elevate their work to a level that extends beyond the scope of local application and use. This paper includes technical examples to emphasize the applicability of the proposed framework, which is relevant to a wide variety of stakeholders, including researchers, policy makers, clinicians, computer scientists, and engineers.

  • Mobile Applications in Oncology: A Survey on the Attitude of Healthcare Professionals about Telemedicine, mHealth and an Oncological App

    Date Submitted: Jul 25, 2016
    Open Peer Review Period: Jul 25, 2016 - Sep 19, 2016

    Background: Mobile applications (apps) are an evolving trend in the medical field. To date, few apps in an oncological context exist. Objective: We analyzed health care professionals’ (HCP) attitude about telemedicine, mHealth, and mobile apps. Methods: We developed and conducted an online survey with 24 questions evaluating HCPs’ attitude towards telemedicine and patients using medical mobile apps in general, as well as specified questions on functionality and possible disadvantages of an app. Results: A total of 108 HCPs completed the survey. Of all, 88.9% consider telemedicine as useful, 84.3% versus 15.7% support the idea of an oncological app complementing classical treatment. Automatic reminders, timetables, and assessing side effects as well as quality of life during therapy were rated as the most important functions. In contrast, uncertainty regarding medical responsibility and data security were reasons mostly named by critics. Favorable of an alert function due to data input by patients with the need for further clarification are 64.8% (versus 35.2%), 94.3% are willing to contact the patient after notification. Of all, 93.5% support the idea to use collected data for scientific research and 75.0% believe it could beneficial for the providing hospital. Conclusions: A majority of HCPs are in favor of telemedicine and the use of an oncological app by patients. Not least because the fields of application are limitless. Assessing side effects can lead to quicker response and thus lower inconvenience of patients. Clinical data as life quality and treatment satisfaction could be used to evaluate and improve the therapy workflow. Eventually, a mobile app would enhance the patient relation to his treating department as he is continually linked to it by the mobile app. Clinical Trial: no registration needed

  • Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme

    Date Submitted: Jul 22, 2016
    Open Peer Review Period: Jul 22, 2016 - Sep 16, 2016

    Background: Diabetes self-management involves adherence to good daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption. Objective: This systematic review seeks to identify and classify barriers to adoption of remote systems for management of type 2 diabetes. Methods: Six electronic databases, MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier), were searched for articles published from 2010 to 2015. The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of two to review and extract data from identified papers. Information collected included study characteristics, outcomes, drop-out rates, technologies used, and barriers identified. Results: Fifty-three publications on 42 studies met the specified criteria. Lack of data accuracy due to input bias (n=13/42, 31%), limitations on scalability (n=10/42, 24%), and technology illiteracy (n=10/42, 24%) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations while limitations on scalability was more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. Forty-one percent of identified barrier instances impeded patient engagement, which is manifest in the large drop-out rates cited (up to 57%). Conclusions: The barriers identified represent major challenges in the design of remote health systems for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high drop-out rates, and new interventions are needed to identify and assist those at greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financially sustainability.

  • Technologies to support community-dwelling persons with dementia: an INTERDEM position paper on issues regarding development, usability, (cost)effectiveness, implementation and ethics

    Date Submitted: Jul 20, 2016
    Open Peer Review Period: Jul 21, 2016 - Sep 15, 2016

    Background: With the expected growing number of people with dementia, providing timely, adequate and affordable care and support is challenging. Assistive and health technologies may be a valuable contribution in dementia care, but new challenges may emerge. Objective: To review the state of the art of technologies for people with dementia in three fields of technologies: 1) managing everyday life, 2) pleasurable and meaningful activities, and 3) health care technologies to support dementia care provision. And to identify challenges and calls for action. Methods: Reviews of literature in the three fields of technologies regarding issues on development, usability, (cost)effectiveness, implementation and ethics. Results: Results showed that: persons with dementia want to be included in development of technologies, little research is performed on usability of assistive technologies, various benefits are reported but mainly based on low quality studies, various barriers are found to implementation of technologies in dementia care and ethical issues were addressed by researchers but often not studied. Many challenges remain. These are: including the target group more often in development, performing more high quality studies on usability and (cost)effectiveness, having access to high quality data on existing technologies to enable adequate implementation of technologies in dementia care and to ensure that ethical issues are considered an important topic for researchers to include in their evaluation of assistive technologies. Conclusions: Based on the results of the state of the art, various actions are recommended for development, usability, evaluation, implementation and ethics of assistive and health technologies across Europe. Examples are to ensure that unnecessary replication of technology development that is provenly unhelpful or ineffective does not occur and to better focus on how technological services succeed in addressing individual needs of persons with dementia, as the population is heterogeneous and many face co-morbid conditions. Furthermore, it is suggested to have these recommendations implemented in national and international calls for funding and assistive technology research programmes in the coming decade. In practice, policy makers, care insurers and care providers together with technology enterprises and researchers should prepare strategies for the implementation of assistive technologies in different care settings, to ensure that next generations of people with dementia are enabled to actually utilize the developed technologies in an affordable way and that they can all benefit from it Clinical Trial: NO clinical trial

  • The Inclusion of Ethnic Minority Patients and the Role of Language in Telehealth Trials for Type 2 Diabetes: A Systematic Review

    Date Submitted: Jul 20, 2016
    Open Peer Review Period: Jul 20, 2016 - Sep 14, 2016

    Background: Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and prevent secondary complications. However, trials designed to test the effectiveness of telehealth interventions may under-recruit or exclude ethnic minority patients, with language a potential barrier to recruitment. The underrepresentation of minorities in trials limits the external validity of the findings for this key patient demographic. Objective: This systematic review examines (1) the research reporting practices and prevalence of ethnic minority patients included in telehealth randomized controlled trials (RCTs) targeting type 2 diabetes, as well as the trial characteristics associated with recruiting a high proportion of minority patients, and (2) the proportion of included RCTs that report using English language proficiency as a patient screening criterion and how and why they do so. Methods: Telehealth RCTs published in refereed journals targeting type 2 diabetes as a primary condition for adults in Western majority English speaking countries were included. Ethnically-targeted RCTs were excluded from the main review but included in a post-hoc subgroup analysis. Abstract and full-text screening, risk of bias assessment, and data extraction were independently conducted by two reviewers. Results: Of 3358 records identified in the search, 79 articles comprising 58 RCTs were included. Nearly two-thirds of the RCTs (38/58) reported on the ethnic composition of participants, with a median proportion of 23.5% patients (range: 0%-97.7%). Fourteen studies (24%) that included at least 30% minority patients were all US-based, predominantly recruited from urban areas, and described the target population as underserved, financially deprived, or uninsured. Seven of these 14 studies (50%) offered intervention materials in a language other than English or employed bilingual staff. Half of all identified RCTs (29/58) included language proficiency as a participant screening criterion. Language proficiency was operationalized using non-standardized measures (e.g., having sufficient “verbal fluency”), with only three studies providing reasons for excluding patients on language grounds. Conclusions: There was considerable variability across studies in the inclusion of ethnic minority patients in RCTs, with higher participation rates in countries with legislation to mandate their inclusion (e.g., US) than in those without such legislation (e.g., UK). Less than 25% of the RCTs recruited a sizeable proportion of ethnic minorities, which raises concerns about external validity. The lack of objective measures or common procedures for assessing language proficiency across trials implies that language-related eligibility decisions are often based on trial recruiters’ impressionistic judgments, which could be subject to bias. The variability and inconsistent reporting on ethnicity and other socioeconomic factors in descriptions of research participants could be more specifically emphasized in trial reporting guidelines to promote best practice. Clinical Trial: PROSPERO International Prospective Register of Systematic Reviews: CRD42015024899 http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015024899

  • Datathons and software to promote reproducible research

    Date Submitted: Jul 17, 2016
    Open Peer Review Period: Jul 18, 2016 - Sep 12, 2016

    Background: Datathons facilitate collaboration between clinicians, statisticians, and data scientists in order to answer important clinical questions. Previous datathons have resulted in numerous publications of interest to the critical care community and serve as a viable model for interdisciplinary collaboration. In the most recent datathon, participants were provided with open-source software called Chatto that was created by members of our group. Results: This suite of tools fulfills two purposes: (1) facilitation of interdisciplinary teamwork through archiving and version control of datasets, analytical code, and team discussions; and (2) advancement of research reproducibility by functioning post-publication as an online environment in which independent investigators can rerun or modify analyses with relative ease. Conclusions: With the introduction of Chatto, we hope to solve a variety of challenges presented by collaborative data mining projects while improving research reproducibility.

  • The Physical Activity Tracker Testing in Youth (P.A.T.T.Y) Study: Content analysis and Children’s Perceptions

    Date Submitted: Jul 15, 2016
    Open Peer Review Period: Jul 15, 2016 - Sep 9, 2016

    Background: Activity trackers are widely used by adults and several models are now marketed for childre Objective: The purposes of this study were to: 1) perform a content analysis of behavioral change techniques (BCTs) used by three commercially available youth-oriented activity trackers; 2) obtain feedback describing children’s perception of these devices and the associated websites. Methods: A content analysis recorded the presence of 36 possible BCTs for the MovBand™, Sqord™ and Zamzee™ activity trackers (MB, SQ, and ZZ, respectively). In addition, 16 participants (age: 8.6±1.6 y, 50% female) received all three trackers and oriented to the devices and websites. Participants were instructed to wear the trackers on 4 consecutive days and spend ≥10 min/d on each website. A cognitive interview and survey were administered when the participant returned the devices. Qualitative data analysis was used to analyze the content of the cognitive interviews. Chi square analyses were used to determine differences in behavioral monitoring and social interaction features between websites. Results: The MB, SQ, and ZZ devices/websites included 8, 15 and 14 of the possible 36 BCTs, respectively. All of the websites had a behavioral monitoring feature (charts for tracking activity) but the percentage of participants indicating that they “liked” those features varied by website (MB: 50%, SQ: 38%, ZZ: 69%). Two websites (SQ and ZZ) included an “avatar” the user could create to represent themselves on the website. Participants reported that they “liked” creating and changing their avatar (SQ: 75%, ZZ: 94%), which was supported by the qualitative analyses of the cognitive interviews. Most participants (75%) indicated that they would want to wear the devices more if their friends were wearing a tracker. No significant differences were observed between SQ and ZZ devices in regards to liking or use of social support interaction features (P=0.21-0.37) Conclusions: The websites contained several BCTs consistent with previously identified strategies. Children “liked” the social aspects of the websites more than the activity tracking features. Developers of commercial activity trackers for youth may benefit from considering a theoretical perspective during the website design process.

  • Comprehensive laboratory- and field-based validation of youth-oriented activity trackers

    Date Submitted: Jul 15, 2016
    Open Peer Review Period: Jul 15, 2016 - Sep 9, 2016

    Background: Commercial activity trackers are growing in popularity among adults and some are beginning to be marketed to children. There is, however, a paucity of independent research examining the validity of these devices to detect physical activity of different intensity levels. Objective: The purpose of this study was to determine the validity of the output from three commercial youth-oriented activity trackers in three phases; 1) orbital shaker, 2) structured indoor activities, and 3) four days of free-living activity. Methods: Four units of each activity tracker (Movband™, Sqord™, and Zamzee™; MB, SQ, and ZZ, respectively) were tested in an orbital shaker for 5-minutes at three frequencies (1.3, 1.9, and 2.5 Hz). Participants for Phase 2 (N=14) and Phase 3 (N=16) were 6-12 year old children (50% male). For Phase 2, participants completed nine structured activities while wearing each tracker, the ActiGraph GT3X+ (AG) research accelerometer, and a portable indirect calorimetry system to assess energy expenditure (EE). For Phase 3, participants wore all four devices for four consecutive days. Correlation coefficients, linear models and non-parametric statistics evaluated the criterion and construct validity of the activity tracker output. Results: Output from all devices was significantly associated with oscillation frequency (r = .92 to .99). During Phase 2 the MB and ZZ only differentiated sedentary from light intensity (P < .01) while the SQ significantly differentiated among all intensity categories (all comparisons P < .01), similar to AG and EE. During Phase 3, AG counts were significantly associated with activity tracker output (r = .76, .86, and .59 for the MB, SQ, and ZZ, respectively). Conclusions: Across study phases, the SQ demonstrated stronger validity than the MB and ZZ. The validity of youth-oriented activity trackers may directly impact their effectiveness as behavior modification tools, demonstrating a need for more research on such devices.

  • Development of a mobile, avatar-based application for improving body perceptions among adolescents

    Date Submitted: Jul 14, 2016
    Open Peer Review Period: Jul 14, 2016 - Sep 8, 2016

    Background: One barrier to effectively treating weight issues among adolescents is that most adolescents do not perceive they are overweight or that being overweight is a problem. When adolescents correctly perceive themselves as overweight, they are more likely to adopt healthy lifestyle behaviors. Objective: The purpose of this pilot test was to develop and assess acceptability and feasibility of an avatar-based, theoretically derived, mobile application entitled, Having A Positive Perception of You Application (HAPPY App). Methods: The HAPPY App was engineered for high school students to identify what they thought they looked like, what they wanted to look like, and what they actually looked like based on body measurements using avatars. Results: The HAPPY App was pilot tested with male and female adolescents ages 15 to 18 to assess for acceptability and feasibility. A total of 42 students created and viewed their avatars. A majority of the students were female (67%), age 16 (38.1%), white (74%), non-Hispanic (86%), and in Grade 10 (47.5%). The students had positive reactions to the avatar application. Almost half thought it was good to be able to see their actual selves. Most of the students were comfortable creating and viewing the avatars (95.2%) and would use the application in the future to see how their bodies change (95.2%) over time. Conclusions: Avatar-based mobile applications, such as the HAPPY App, provide immediate feedback and allow users to engage with images that are personalized to represent their perceptions and actual body images. This pilot study adds to the increasing but limited research of using games to improve health outcomes among high school students. There is a need to further adapt the HAPPY App and implore feedback from a larger number of high school students including those from diverse backgrounds.

  • Twitter content analysis for investigating subjective experience and the influence of weather among fibromyalgia sufferers

    Date Submitted: Jul 13, 2016
    Open Peer Review Period: Jul 13, 2016 - Sep 7, 2016

    Background: Little is understood about the determinants of symptom expression in individuals with fibromyalgia syndrome (FMS). While FMS sufferers often report environmental influences, including weather events, on their symptom severity, a consistent effect of specific weather conditions on FMS symptoms has yet to be demonstrated. Content analysis of a large number of messages by FMS sufferers on Twitter can provide valuable insights into variation in the fibromyalgia experience from a first-person perspective. Objective: To use content analysis of tweets to investigate the association between weather conditions and fibromyalgia symptoms among individuals who tweet about fibromyalgia. Secondly, to gain insight into how Twitter is used as a form of communication and expression by fibromyalgia sufferers, and to explore and uncover thematic clusters and communities related to weather. Methods: Computerised sentiment analysis was performed to measure the association between negative sentiment scores (indicative of severe symptoms such as pain) and coincident environmental variables. Date, time and location data for each individual tweet were used to identify corresponding climate data (such as temperature). We used graph analysis to investigate the frequency and distribution of domain-related terms exchanged in Twitter and their association strengths. A community detection algorithm was applied to partition the graph and detect different communities. Results: We analysed 140,432 tweets related to fibromyalgia from 2008 to 2014. There was a very weak positive correlation between humidity and negative sentiment scores (r=.009, P=.001). There was no significant correlation between other environmental variables and negative sentiment scores. The graph analysis showed that ‘pain’ and ‘chronicpain’ were the most frequently used terms. The Louvain method identified 6 communities. Community 1 was related to feelings and symptoms at the time (subjective experience). It also included a list of weather related terms such as ‘weather’, ‘cold’ and ’rain’. Conclusions: According to our results, a uniform causal effect of weather variation on fibromyalgia symptoms at the group level remains unlikely. Any impact of weather on fibromyalgia symptoms may vary geographically or at an individual level. Future work will further explore geographical variation and interactions focusing on individual pain trajectories over time. Clinical Trial: N/A

  • Methods for Evaluating Respondent Attrition in Online Survey Data

    Date Submitted: Jul 12, 2016
    Open Peer Review Period: Jul 12, 2016 - Sep 6, 2016

    Background: Electronic surveys are a convenient, cost effective, and increasingly popular tool to collect information. While the online platform allows researchers to recruit and enroll more participants, there is an increased risk of participant dropout in web-based research. Often, these dropout trends are simply reported, adjusted for, or ignored altogether. Objective: This manuscript proposes a conceptual framework for analyzing respondent attrition and demonstrates the utility of these methods through application to existing survey data. Methods: First, we suggest visualization of attrition trends using bar charts and survival curves. Next, we propose a generalized linear mixed model (GLMM) to detect or confirm significant points of attrition. Finally, we suggest applications of existing statistical methods to investigate the effect of internal survey characteristics and patient characteristics on dropout. In order to apply this framework, we present a case study, a seventeen-item Informed Decision-Making (IDM) module addressing how and why patients make decisions about cancer screening. Results: Using this framework, we were able to find significant points of attrition at Questions 4, 6, 7, and 9. We were also able to identify participant responses and characteristics associated with dropout at these points and overall. Conclusions: When applied to survey data, these methods reveal significant attrition trends, both visually and empirically, that can inspire researchers to investigate factors associated with survey dropout, address whether survey completion is associated with health outcomes, and compare attrition patterns between groups. The framework can be used to extract information beyond simple responses, can be useful during survey development, and can help determine the external validity of survey results.

  • The role of Web-based health information in help-seeking behaviour prior to a diagnosis of lung cancer: A mixed-methods study

    Date Submitted: Jul 11, 2016
    Open Peer Review Period: Jul 12, 2016 - Sep 6, 2016

    Background: Early diagnosis of lung cancer depends largely on timely presentation of symptoms to health services. The Web has become an important lay information source and is often used to appraise symptoms. Objective: A questionnaire and interview study was conducted to understand the role of the Web in symptom appraisal prior to lung cancer diagnosis. Methods: Patients diagnosed with lung cancer in the 6 months before study entry completed a survey about Web use to appraise their symptoms prior to diagnosis. Based on survey responses, sociodemographic variables and smoking status, we purposively sampled patients and their family/friends for semi-structured interviews (24 interviews with 33 participants). Survey data were analysed descriptively. Interview data were analysed qualitatively using Framework Analysis. Results: 113 patients completed the survey (mean age=67, SD=8.8). 20.5% (23/112) reported they or a family member/friend had researched symptoms online. Only seven patients (7/112, 6.3%) had researched their own symptoms, four of these with the help of family/friends. The remainder of searches were conducted by family members/friends. Interview results suggest that patients and family/friends perceived an impact of Web use on decisions to seek help and on communication with health professionals. Some reported Web-based information triggered help-seeking while others reported it delayed help-seeking. Some participants used information found online to support their requests for further investigations of symptoms. Online health information also reportedly impacted on understanding of medical jargon during the diagnostic process. Conclusions: Although its role is at present still limited, the Web appears to have an impact on the diagnostic process, and seems to play a role not only in the time before seeking medical help, but also following first consultation with a health professional. Improving online resources to meet specific needs may help to encourage early help-seeking and facilitate communication with health professionals. Clinical Trial: n/a

  • Tweet for (Behaviour) Change: Using Social Media for the Dissemination of Public Health Messages

    Date Submitted: Jul 8, 2016
    Open Peer Review Period: Jul 8, 2016 - Sep 2, 2016

    Background: Social media (SM) public health campaigns have the advantage of tailored messaging at low cost and large reach but we know little about what in practice would determine their feasibility as tools for inducing attitude and behaviour change and subsequent effectiveness. Objective: Our aim is to test the feasibility of designing, implementing and evaluating a bespoke SM-enabled intervention for skin cancer prevention and to learn broader lessons for using SM in public health practice. Methods: A quasi-experimental study, utilising SM (Twitter) to disseminate different message “frames” relating to Care in the Sun and cancer prevention was employed. Phase 1 utilised the Northern Ireland (NI) regional cancer charity’s Twitter platform between May 1st and July 14th 2015, and content was tracked using unique hashtags. Following a 2-week “washout” period, Phase 2 commenced (August 1st to September 30th 2015) using a bespoke campaign-specific Twitter platform and hashtag. Phase 2 also included a Thunderclap, whereby users allow their SM accounts to automatically post a bespoke common message created for the intervention on their behalf. Message frames were categorised; humour, shock/disgust, informative, personal stories and opportunistic. Seed users with a notable SM following, as identified at a co-design workshop, were contacted to be ‘influencers’ in retweeting campaign content to their followers, with the aim of ultimately creating viral health messages. A pre- and post-intervention online survey recorded knowledge and attitudes regarding skin cancer prevention in NI (population 1.8 million). Results: During the campaign period, there was a total of 417,678 tweet impressions, 11,213 engagements and 1,211 retweets related to our specific campaign hashtags. Of those, 92 retweets were part of the Thunderclap. Of the message frames employed, shocking messages generated the greatest number of impressions (shock n=2,369; informative n=2,258; humorous n=1,458; story n=1,680), whereas humorous messages generated greater engagement with Twitter social media users (humorous n=148; shock n=147; story n=117; informative n=100). Informative messages however, resulted in the greatest number of shares (informative n=17; humorous n=10; shock n=9; story n=7). Tweets which were paid-for, promoted posts did not notably increase impressions, engagements or retweets. Study findings included a trend towards improved knowledge of skin cancer severity in a pre- and post-intervention online survey, with greater awareness that skin cancer is the most common form of cancer (pre-intervention: 28.5% vs. post-intervention: 39.3% answered ‘True’) and that melanoma is most serious (49.4% vs. 55.5%). Results also suggest a trend towards improved attitudes towards UV exposure and skin cancer with a reduction in agreement that respondents “like to tan” (60.4% vs 55.6%). Conclusions: Social media disseminated public health messages reached over 23% of the NI population and an online survey suggested that the campaign may have contributed to a trend in improved knowledge and attitudes towards skin cancer among the target population. Findings also suggest that shocking and humour messages generated greatest impressions and engagement, but informative messages were likely to be shared most. The extent of any behaviour change as a result of the campaign remains to be explored, however the trend in change of attitudes and knowledge is promising. Social media is an inexpensive, effective method for delivering public health messages. However, existing and traditional process evaluation methods utilised may not be suitable for SM.

  • Are demographic and indication-specific variables associated with social network engagement?

    Date Submitted: Jul 7, 2016
    Open Peer Review Period: Jul 7, 2016 - Sep 1, 2016

    Background: Digital Health Social Networks (DHSNs) are widespread, and the general consensus is that they contribute to wellness through offering social support and knowledge sharing. The success of a DHSN is based on number of participants, and their consistent creation of externalities though the generation of new content. To promote network growth and individual agency, it would be helpful to identify actors who create value by generating positive network externalities. Objective: The objective of this study is to examine the association between posting behavior, demographic characteristics, and indication severity from actors and non-actors from four large DHSNs. Methods: Data were extracted from the custom SQL databases of four digital health behavior change interventions. To investigate associations between user characteristics and social network engagement, ten models were analyzed with standard multiple regression and F-tests. Results: The DHSNs varied in number of days active (36,580 vs. 5,210), number of registrants (5,049 vs. 78,903), number of actors (1,085 vs. 8,452), and number of posts (16,231 vs. 620,487). Eight of the ten models had low R2 results (.004-.064), with limited statistically significant demographic and indication specific independent variables. The exception was the panic disorder social network, where the R2 results were 0.363 for all registrants, and 0.343 for all actors. F-tests indicated that independent variables were preferable to reduced models in six of the ten models. In regards to categorical variables, level of education had limited association with engagement. Conclusions: Some of the demographic variables were statistically associated with social network engagement as evidenced by t-tests and F-tests for ungrouped variables, and F-tests for categorical variables. Although some of these individual variables are statistically significant, they do not appear to be significant from a practical perspective due to the low R2 results. Based on the large number of study participants, variation in DHSN theme, and extensive time-period, we did not find strong evidence that demographic characteristics or indication severity sufficiently explain the variability in number of posts per actor. Researchers should investigate alternative models that identify individuals who promote social network growth.

  • Analysis of Requirements for developing an mHealth based Health Management Platform

    Date Submitted: Jul 7, 2016
    Open Peer Review Period: Jul 7, 2016 - Sep 1, 2016

    Background: Studies have consistently shown that mobile and web-based applications have positive impacts on people’s daily lifestyles, health management and disease treatment. As the development of medical and health informationization in China has evolved, different kinds of mobile based applications for individuals and hospitals have been developed by software vendors. However, doubts and challenges posed by the media have prevented these applications from having a stable and substantial user base. We think the key problem is that the software does not satisfy the main needs of general users, which means an analysis of user requirements has not been performed prior to design of the application. The health information government authority in Liaoning Province, China, was planning to set up a mHealth based health management platform, aiming to alleviate the difficulties citizens have in seeking hospital services. Objective: The goal of this study was to determine the actual health and medical needs of citizens that may be addressed by medical information technologies. The results may contribute to the functional design and development of health management and appointed treatment-oriented mobile applications. Methods: In this study, an unstructured questionnaire on mHealth requirements was designed and tested, and 240 questionnaires were given to the outpatients of the First Hospital of the China Medical University in Shenyang, Liaoning Province, China; of these, 228 valid responses were collected, for a response rate of 95%. We discussed the current development of mHealth with 50 related experts and engineers from health authorities and a medical information company. SPSS 13.0 was used for statistical and analysis. Results: After detailed analysis of the questionnaire data and interview results, several findings were made: firstly, most citizens were unclear about their health conditions (64.5%) and would like to receive a mobile application (app) as a tool to manage their health and medical needs (71.1%); on the other hand, the main problems for outpatients were long waiting times (66.4%) and difficulties in making appointments (46.5%), and they also worried about payments and internet problems when using a mobile application for appointment reservations. Furthermore, as the main service target of mHealth is innovated health management of the general population, first we need to solve the associated interoperability and data security problems. Conclusions: This study provides insight into the health and medical requirements of Smartphone apps and draws attention to some of the challenges and opportunities of mHealth. We suggest several value-added features and characteristics that app developers should take into consideration when developing health and medical related apps. The findings also highlight some major challenges that require further consideration and research to ensure these apps meet the core needs of patients and aid the development of the health information system in Liaoning Province, China. Clinical Trial: This study had been confirmed by ethics committee of Shengjing Hospital of China Medical University before started that the study has no relationship with any clinical actions with patients or animals , the need for ethics approval is not necessary.

  • Stepping into the Era of Personal Big Data: a Roadmap to the Design of a Personal Digital Life Coach

    Date Submitted: Jul 5, 2016
    Open Peer Review Period: Jul 5, 2016 - Aug 30, 2016

    The increased availability of devices that can record every aspect of a person’s life will allow the recording of a large amount of data that will be primarily useful for that particular user. These devices and their data will place each and every one of us at the doorstep of the era of personal big data. Using this data, in a not so distant future, we will be able to set a personal digital life coach, a digital platform that will act at an individual level, but also considering a global interaction, not only as a social networking tool, but as a platform that will profit from the individual experiences of its users. This position paper focuses on the identification of the milestones that will mark the creation of such a software and hardware platform, by exploring the opportunities and challenges that it poses to the computer science researchers, and how such a solution can be designed to be a user-adoptable lifestyles monitoring and training tool.

  • Improving medical student communication skills through a telehealth training platform

    Date Submitted: Jul 4, 2016
    Open Peer Review Period: Jul 4, 2016 - Aug 29, 2016

    Background: In the interests of patient health outcomes, it is important for medical students to develop clinical communication skills. We previously proposed a telehealth communication skill training platform (EQClinic) with automated nonverbal behavior feedback for medical students, and it was able to improve medical students’ awareness of their nonverbal communication. Objective: This study aimed to evaluate the effectiveness of EQClinic to improve clinical communication skills of medical students. Methods: Two group randomised crossover trial was conducted between February and May 2016. Participants were 268 (Group A: n=133; Group B: n=135) second year medical students enrolled in a clinical communication skills course at an Australian university. Student-Patient Observed Communication Assessment (SOCA) was collected by blinded assessors (n=28) at two time points and a standardized patient (SP; n=83). Students were randomly allocated to complete EQClinic training and clinical consultation with an SP immediately in weeks 1-5 (Group A) or were allocated to complete EQClinic in weeks 8-11 (Group B). EQClinic delivered a combination of automated visual presentation of students’ nonverbal behaviour coupled with human feedback from the SP. Tutor-rated clinical communications skills in face-to-face consultations was the primary outcome and was assessed with the SOCA. T-tests were used to examine the students’ performance during face-to-face consultations pre- and post-exposure to EQClinic. Results: SOCA communication skills measures (score range 4-16) from the first face-to-face consultation were significantly improved for students who completed EQClinic training and reviewed the nonverbal behaviour feedback (Group A) compared to Group B who completed only the course curriculum components (p=0.04). Furthermore the group that completed a tele-consultation between the two face-to-face consultations (Group B) showed improved communication skills (p=0.005), yet the one who had tele-consultations before face-to-face did not show improvement. Conclusions: The EQClinic is a useful tool for medical students clinical communication skills training that can be applied to university settings to improve students clinical communication skills development.

  • You sort of go down a rabbit hole ……You’re just going to keep on searching’. A qualitative study of searching online for pregnancy related information during pregnancy

    Date Submitted: Jul 1, 2016
    Open Peer Review Period: Jul 1, 2016 - Aug 26, 2016

    Background: The internet is becoming increasing popular for gaining information on medical/health issues; with women in particular likely to search online for this type of information and support. Despite the increased use of the internet for health-related information, we need to question if the internet and the ease of seeking health information that it provides, leads to more [patient] empowerment. Pregnancy is a particularly worrying time for women, especially first time mums-to-be, with unfamiliar experiences and symptoms and concerns for the baby as well as the self. Objective: Our aim was to explore how and why pregnant women with different levels of health anxiety (HA) use the internet to gain information and support during pregnancy and what they consider a reliable source. The aim was also to explore any notable differences between women with differing levels of HA. Methods: To meet the objectives of the study, a qualitative approach was required to gather information on the experiences of currently pregnant women who use the internet to gain information and support during their pregnancy. Sixteen pregnant women took part in a semi-structured interview, either face-to-face or via telephone. Qualitative analytical procedures were employed, supported by NVivo software. Results: Pregnant women found reassurance from the experiences of others. This reassurance resulted in them feeling less alone, as well as enabling them to normalize any symptoms or experiences they were undergoing. The women understood that caution was needed at times whilst reading the stories of others, acknowledging the potential for extreme cases or worst case scenarios. This is particularly pertinent to the internet, as this wide range of stories may not be as easily accessible if stories where confined to those in a woman’s offline social circle. The interviews combined with the HA levels of the participants provide insights into how and why pregnant women search online for information and perhaps more so, support whilst pregnant. The project had the novel aspect of HA level as well as the interview data, this made for a more interesting discussion in relation to anxiety level and disparities between those with low, moderate and high health anxiety in terms of what was said. Conclusions: Searching for health information and advice online during pregnancy is viewed as quick, easy and accessible. The affordances of the internet provided women the opportunity to go online as a first port of call, irrespective of health anxiety levels. Knowing they were not alone and reading the experiences and/or symptoms of other pregnant women enabled women to normalize their experience and was ultimately reassuring for pregnant women. Clinical Trial: n/a

  • LGBT health-care disparities in Multiple Sclerosis: a cross-sectional web-based study in Italy

    Date Submitted: Jun 25, 2016
    Open Peer Review Period: Jun 25, 2016 - Aug 20, 2016

    Background: Lesbian, gay, bisexual and transgender (LGBT) patients might experience unique difficulties and barriers to treatment of chronic diseases related to their sexual orientation. Objective: To investigate health-care disparities experienced by LGBT patients with multiple sclerosis (MS). Methods: We conducted a survey on an Italian social-network (www.smsocialnetwork.com) for MS patients, by using standardized multiple-choice questions. The survey investigated: socio-demographic factors, lifestyle habits, MS-related health status and LGBT specific issues (e.g. friendliness to their sexual orientation or homophobic behaviors from the staff of their MS Center). Results: LGBT patients were associated with a smaller number of psychological consultations, compared to heterosexuals (Coeff.=-0.449; p<0.001; 95%CI=-0.682--0.217). LGBT patients were more likely to change MS Center, compared to heterosexuals (OR=2.064; p=0.046; 95%CI=1.011-4.212). The number of MS Center changes was associated with MS Center friendliness (p=0.037; rho=-0.229) and with the occurrence of homophobic behaviors (p=0.036; rho=0.234). Conclusions: LGBT MS patients more frequently changed MS Center and had a reduced use of psychological services, compared to heterosexuals. The attitude towards LGBT MS patients might affect resource utilizations and, possibly, LGBTs’ health status.

  • Costs and Cost-Effectiveness of a Web-Based Physical Activity Intervention for Spanish Speaking Latinas

    Date Submitted: Jun 22, 2016
    Open Peer Review Period: Jun 22, 2016 - Aug 17, 2016

    Background: Latinas report particularly low levels of physical activity (PA), and suffer from greater rates of lifestyle-related conditions such as obesity and diabetes. Interventions are needed that can increase physical activity in this growing population in a large-scale, cost-effective manner. Web-based interventions may have potential given the increase in Internet use among Latinos and the scalability of web-based programs. Objective: To examine the costs and cost-effectiveness of a web-based Spanish language PA intervention for Latinas compared to a contact control. Methods: Healthy adult Latinas (N=205) were recruited from the community and randomly assigned to receive a Spanish language web-based individually-tailored PA intervention (Intervention), or were given access to a website with content on wellness topics other than PA (Control). PA was measured by 7-Day Physical Activity Recall Interview and ActiGraph accelerometer at baseline, 6 months (post-intervention) and 12 months (maintenance phase). Costs were estimated from a payer perspective and included all features necessary to implement the intervention in a community setting, including staff time (wage, benefits and overhead), materials, hardware, website hosting, and routine website maintenance. Results: At 6 months, the cost of the Intervention and Control groups were $17/month and $8/month, respectively. These fell to $12 and $6 at 12 months. Linear interpolation showed Intervention participants increased their PA by 1362 total minutes at six months (523 by accelerometer) compared to 715 minutes in Controls (186 by accelerometer). At six months, each minute increase in PA for the Intervention cost $0.08 ($0.20 by accelerometer), compared to $0.07 in Controls ($0.26 by accelerometer). Incremental costs per minute increase associated with the intervention were $0.08 at six months and $0.04 at 12 months ($0.16 and $0.08 by accelerometer, respectively). Sensitivity analyses showed variations in staffing costs or intervention effectiveness yielded only modest changes in incremental costs. Conclusions: While the web-based PA intervention was more expensive than the wellness control, both were quite low cost compared to face-to-face or mail-delivered interventions. Cost-effectiveness ranged markedly based on physical activity measure, and was similar between the two conditions. Overall, the web-based intervention was effective and low cost, suggesting a promising channel for increasing PA on a large scale in this at-risk population. Clinical Trial: NCT01834287

  • Happy, a Smartphone-based Intervention to Promote Cancer Prevention Behaviors: Usability and Feasibility Study

    Date Submitted: Jun 22, 2016
    Open Peer Review Period: Jun 22, 2016 - Aug 17, 2016

    Background: Estimates predict that more than half of all cancers are due to inadequate lifestyle choices. Smartphones can be successfully used to support the behavior change needed to prevent cancer. Objective: The purpose of this study was to field-test Happy, a smartphone app designed to promote cancer prevention behaviors, based on tailored-messages deliver. Methods: Thirty-two participants downloaded and used the app for 28 consecutive days (4 weeks). At the end of this period, they all answered to an online questionnaire and ten of them were interviewed. Usability, feasibility, message receptivity, and perceived impact of the app were assessed. Results: Compliance with cancer prevention guidelines was lower than expected. Happy was considered simple, intuitive and easy to use. Messages sent by the app were considered easy to understand, providing good advices and meaningful information that grabbed reader’s attention. Participants also considered that Happy might be an effective way to promote cancer prevention. Behavioral data collected during the trial showed an increase in several cancer prevention behaviors and a significant increase in the overall cancer prevention level, 7 points in average (P=.031). Conclusions: This study showed the viability of designing and implementing smartphone-based interventions to promote cancer prevention behaviors. The results suggest that Happy is usable and might help users change their behavior, making healthier choices, thus reducing their personal risk of developing cancer.

  • Internet and adolescents: use and access, behavior, cyberbullying and grooming. Results of an investigative whole city survey.

    Date Submitted: Jun 21, 2016
    Open Peer Review Period: Jun 21, 2016 - Aug 16, 2016

    Background: According to the Digital Agenda for Europe, the way children use Internet and mobile technologies changed dramatically in the past years. Objective: This study aims to break down the modalities of access and use of the Internet by teenagers to assess risks and risky behaviours and to provide scientific data to evaluate and counsel safe use of the Internet and new technologies by teenagers. Methods: The study was conducted under the program “Strategies for a better internet for children” started in May 2012 by the European Commission. It represents the main result of the project launched by Telecom Italia “Anche io ho qualcosa da dire” (I too have something to say) thanks to which many of contributions were collected and used to develop a survey. The questionnaire was structured in 45 questions, covering three macro areas of interest and it was approved by the Department Board at UMG’s School of Medicine. After authorization from the regional high school authority, it was administered to all 1534 students (aged 13 to 19) in the city of Catanzaro, Italy. Results: The data has been broken down into three main groups: describing education and access to the Internet, methods of use and social networking and finally perception and evaluation of risk and risky behaviours. Among noteworthy results in the first group we can mention that the average age of first contact with information technologies was around 9 years old. Moreover, 79% of the interviewed students reported the access to a smartphone or a tablet. Among the results of the second group we find that the most used social networks were Facebook (85%), Youtube (61%), and Google+ (52%). 72% of the interviewed teenagers use their name and surname on social networks. 40% of them knew all their Facebook contacts personally. Among the results of the third group we find that 7,7% of the interviewed teenagers have uploaded pictures or movies that they feel ashamed of. 27% have received invitations from people they met on the Internet to meet in real life, and 8,4% have accepted such invitations. Conclusions: The results offer a breakdown of the teenagers’ use of the Internet, focusing on how teenagers learn to use and access it considering factors such as parental coaching, schooling or self-education. It describes how they approach and interact with social networks, and how they perceive risks and/or risky behaviours in a virtual environment. Information technology must be seen as an instrument and not as a hindrance. For this to happen parental guidance, schooling, and medical counseling are needed for a sound evolution of the child in this critical stage of development.

  • WhatsApp Messenger as an Adjunctive Tool for Medical Internet: A Review

    Date Submitted: Jun 17, 2016
    Open Peer Review Period: Jun 17, 2016 - Aug 12, 2016

    Background: The advent of medical internet has allowed physicians to deliver medical treatment to patients from a distance. Mobile applications such as WhatsApp Messenger, an instant messaging service, came as a novel concept in all fields of medicine. The use of instant messaging services has been shown to improve communication within medical teams by providing means for quick teleconsultation, information sharing, and starting treatment as soon as possible. Objective: The aim of the current study was to perform a comprehensive systematic review of present literature on the use of the WhatsApp Messenger application as an adjunctive healthcare tool. Methods: Searches were performed in PubMed, Embase, and the Cochrane Library using the term whatsapp* in articles published before January 2016. A bibliography of all relevant original articles that used the WhatsApp Messenger application was created. The impact and the indications of WhatsApp Messenger are discussed in order to understand the extent to which this application currently functions an adjunctive tool for telemedicine. Results: The database search identified a total of 30 studies in which the term whatsapp* was used. Each article’s list of references was evaluated item by item. After review articles, letters to the editor, and low-quality studies were excluded, a total of 10 studies were found to be eligible for inclusion. Of these studies, nine had been published in the English language and one had been published in Spanish. Conclusions: The pooled data presents compelling evidence that the WhatsApp Messenger application is a promising system, whether used as a communication tool between healthcare professionals, as a means of communication between healthcare professionals and the general public, or as a learning tool for providing healthcare information to professionals or to the general population. However, high-quality and properly evaluated research is needed, as are improvements in descriptions of the methodology and the study processes. These improvements will allow WhatsApp Messenger to be categorically defined as an effective telemedicine tool in many different fields of healthcare.

  • Using Text Messaging in Long-Term Arthroplasty Follow-Up

    Date Submitted: Jun 16, 2016
    Open Peer Review Period: Jun 17, 2016 - Aug 12, 2016

    Background: Patient Reported Outcome Measures (PROMs) and mobile technology have to potential to change the way patients are monitored following joint replacement surgery. Objective: The aim of this study was to determine the feasibility of text-messaging to record PROMs in long-term follow-up of hip/knee arthroplasty. In this pilot study our participants were 17 patients two-years-plus post hip/knee arthroplasty attending clinic with a mobile telephone number on record. Methods: A simple PROM (Oswestry Very Short Form) was texted to the patient. Responses were compared to clinical, radiographic and existing PROM findings. Patients were interviewed to discover their opinions on this use of texting. Results: Eleven patients engaged with the text-messaging. The mean age was 67. Reasons for six not engaging included wrong numbers, physical barriers and lack of understanding. Eight attending clinic allowed comparison of text-messaging with clinic findings. Four patients’ text-messaging responses matched clinical and radiographic findings; three also matched PROM scores collected in clinic. The three patients with mixed responses had abnormal clinical, radiographic or PROM findings. One patient’s text responses conflicted with clinical outcome. Analysis of patients’ views showed a generally positive opinion: patients were happy to communicate with surgeons by text. Practical problems, PROM limitations and trustworthiness of texting were highlighted. Conclusions: Engaging with changing technology created challenges for patients and healthcare professionals. Our results suggest text-messaging is a promising way to communicate with arthroplasty patients. Earlier integration of technology throughout the patient pathway may be important and needs further research.

  • Test-Enhanced Online Learning Strategies in Postgraduate Medical Education

    Date Submitted: Jun 14, 2016
    Open Peer Review Period: Jun 14, 2016 - Aug 9, 2016

    Background: The optimal design of pedagogical strategies for online learning in graduate and postgraduate medical education remains to be determined. Video-based e-learning use is increasing, with initial research suggesting that taking short breaks while watching videos (independent of answering test questions) may improve learning by focusing attention. Interspersed test questions may also improve knowledge acquisition and retention. Objective: We undertook this study to examine the effect of interspersed test questions and periodic breaks on immediate knowledge acquisition and retention at six months by pediatric residents engaged in video-based online learning. Methods: First and second year pediatric residents were randomized to one of three groups: viewing the complete video uninterrupted (full video), viewing the video interrupted with unrelated logic puzzles (logic puzzles), or viewing the video interrupted with brief comprehension test questions (short answer questions). Residents answered pre- and post-tests before and after video viewing, followed by a retention test at six months. Primary outcome included comparison of the change in test scores between groups. Results: Forty-nine residents completed the initial testing session. All three learning groups had comparable mean increases in immediate knowledge gain, but with no significant differences between groups (F(2,46)=0.35, P=0.71). Thirty-five residents completed retention testing with comparable degrees of knowledge retention in the full video and short answer test questions groups (P<0.001) but no significant change in the logic puzzles group (F(1,32)=2.44, P=0.13). Conclusions: Neither answering interspersed questions nor completing an alternate mind-engaging activity during interrupted online video viewing improved the amount of knowledge gain as compared to traditional uninterrupted video viewing. Both uninterrupted video viewing and answering interspersed test questions during interrupted video viewing demonstrated significant knowledge retention at six months.

  • mHealth or eHealth? A randomized controlled trial testing the efficacy, use, and appreciation of a web-based computer-tailored physical activity intervention for Dutch adults.

    Date Submitted: Jun 8, 2016
    Open Peer Review Period: Jun 8, 2016 - Aug 3, 2016

    Background: Until a few years ago, web-based computer-tailored interventions were almost exclusively delivered via the computer (eHealth). However, nowadays, interventions delivered via smartphones (mHealth) are an interesting alternative for health promotion as they may more easily reach people 24/7. Objective: The first aim of this study was to compare the efficacy of a mHealth and eHealth version of a web-based computer-tailored physical activity intervention with a control group. The second aim was to assess potential differences in use and appreciation between the 2 versions. Methods: Data was collected among 373 Dutch adults at 5 points in time (baseline, after 1 week, after 2 weeks, after 3 weeks and after 6 months). Participants were recruited via a Dutch online research panel and randomly assigned to the eHealth (N= 138), the mHealth (N= 108), or the control condition (N= 127). All participants were asked to complete questionnaires at the 5 points in time. Participants in the eHealth and mHealth group received fully automated tailored feedback messages about their current level of physical activity. Furthermore, they received personal feedback aimed at increasing their amount of physical activity when needed. ANOVA and linear regression analyses were used to examine differences between the study groups with regards to efficacy, use, and appreciation. Results: Participants receiving feedback messages (eHealth and mHealth together) were significantly more physically active after 6 months than participants in the control group (B = 8.48, P = .025, df= 2; Cohen’s d = 0.27). A small effect size was found favoring the eHealth condition over the control group (B = 6.13, df = 2; P =.091, Cohen’s d = 0.21). The eHealth condition had lower dropout rates (84.4%) than the mHealth condition (75.0%) and the control group (71.7 %). Furthermore, the eHealth condition was appreciated better in comparison to the mHealth condition with regard to receiving (t= 3.07; df= 182; P= .002) and reading the feedback messages (t = 2.34; df= 181; P = .02) as well as the clarity of the messages (t = 1.99; df = 181; P = .049). Conclusions: The overall effect was mainly caused by the more effective eHealth intervention. The mHealth application was less appreciated than the eHealth version. More research is needed to assess how both methods can complement each other. Clinical Trial: Dutch Trial Register: NTR4503

  • The issues associated with the use of Semantic Web Technology in Clinical Decision Support Systems: A Systematic Review of the Literature

    Date Submitted: Jun 6, 2016
    Open Peer Review Period: Jun 7, 2016 - Aug 2, 2016

    Background: Clinical Decision Support System (CDSS) is a particular form of intelligent system that helps practitioners to make a decision regarding diagnosis or treatment. Knowledge acquisition is one of the well-known bottlenecks in CDSS, partly because of the enormous growth in health related knowledge and the difficulty in assessing the quality of this knowledge. The semantic web (SW) represents a set of technologies that may be able to assist in automatically discovering relevant and high-quality knowledge for CDSS along with discovering data that may be relevant for the decision-making process` Objective: The paper aims to define the role of Semantic Web technology in acquiring knowledge for CDSS and identifying issues with these approaches Methods: We conducted a systematic review of the recent related work using search key terms in different scientific databases Results: The retrieved papers were categorized based on four main issues addressed; format heterogeneity, lack of semantic definition, lack of automatic analysis system and data heterogeneity and lack of data integration. Most existing approaches will be discussed under these categories. 21 papers have been reviewed in this study. Conclusions: The potential for using Semantic Web technology in CDSS has only been considered to a minor extent so far despite its promise. The review shows the capability of using Semantic Web technology to supply knowledge for a CDSS. Clinical Trial: N/A

  • Point-of-sale tobacco advertising and display bans: results from a policy evaluation study using mobile data gathering methods in five Russian cities

    Date Submitted: Jun 6, 2016
    Open Peer Review Period: Jun 6, 2016 - Aug 1, 2016

    Background: Background: The tobacco industry uses point-of-sale (POS) advertising, promotion and product display to increase consumption of their products among current users, to attract new consumers, and to encourage former customers to resume tobacco use. As part of a comprehensive tobacco control effort, Russia – having one of the highest tobacco use prevalence rates in the world – enacted legislation that banned tobacco POS advertising in effect November 15, 2013, and banned the display of tobacco and the sale of cigarettes in kiosks, effective June 1, 2014. Objective: Objective: Evaluate the implementation of the national law by assessing the state of POS advertising and promotion and product display, and sales in kiosks across Russia. Methods: Methods: Two waves of observations were conducted to measure compliance with the POS restrictions: wave 1 took place April-May 2014 after the advertising ban was in effect, and again in August-September 2014 after the display ban and elimination of tobacco sales in kiosks came into effect. Observations were conducted by local trained staff who traveled to 5 populous cities in different regions of Russia (Moscow, St. Petersburg, Kazan, Ekaterinburg, and Novosibirsk). Staff followed a published POS evaluation protocol, and used smartphones to collect data. Observations were conducted in a roughly equal number of chain supermarkets, convenience stores, and kiosks. Observed items included advertising at POS, product displays, and cigarette sales in kiosks. Results: Results: Observations were made in 780 venues in wave 1, and 779 revisited venues in wave 2. In wave 1, approximately a third of supermarkets and convenience stores (34%) were advertising cigarettes using lightboxes, and over half of observed venues (54%) had signage such as banners or shelf liners that used colors or images related to cigarette brands. Product displays were common in wave 1. In Wave 2, compliance with advertising restrictions was very good: there were virtually no lightboxes (1%, n=5); banners or shelf liners were observed in 30% of supermarkets/convenience stores; approximately 7% of venues were still displaying products in a Powerwall. In wave 2, 41% (n=100) of kiosks continued to sell tobacco. Conclusions: Conclusion: Russia’s compliance with POS bans was excellent. Remaining compliance issues are largely with the use of cigarette brand colors or images used in banners or shelf liners; this type of infraction is more difficult to enforce as inspectors need to be deeply familiar with tobacco industry products and marketing. A sizeable proportion of kiosks continue to sell tobacco post restrictions. Clinical Trial: Not Applicable