Latest Submissions Open for Peer Review

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients with Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial

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

    Background: Depression is a significant challenge for safety-net primary care systems. Collaborative depression care is effective, but complex system factors impede adoption and result in persistent disparities in depression outcomes. A care delivery model was evaluated that harnesses information and communication technologies to automate routine screening and monitoring of patient depressive symptoms and treatment adherence and to allow timely communication with providers. Objective: The aim of the study was to compare 6-month outcomes of the technology-facilitated care management (TC) model to usual care (UC) and a supported care (SC) model that involved team-based care management practice for safety-net primary care adult patients with type 2 diabetes. Methods: The Diabetes-Depression Care-Management Adoption Technologies Trial is a translational study in collaboration with Los Angeles County Department of Health Services, the second-largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: UC, SC, and TC. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. Results: A sample of 1,406 patients (484 in UC, 480 in SC, 442 in TC) was enrolled. A majority of the patients were Hispanic or Latino and female. Compared to UC, both SC and TC groups experienced significantly reduced depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate [LSE]: UC=6.35, SC=5.05, TC=5.16; P: SC vs. UC=.02, TC vs. UC=.02); decreased prevalence of major depression (odds ratio [OR]: SC vs. UC=0.45, TC vs. UC=0.33; P: SC vs. UC=.02, TC vs. UC=.007); and improved functional disability as measured by Sheehan Disability Scale scores (LSE: UC=3.21, SC=2.61, TC=2.59; P: SC vs. UC=.04, TC vs. UC=.03). Only TC, not SC, significantly improved depression remission (TC vs. UC: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: UC=3.20, TC=3.70; P=.05); reduced total cholesterol level (LSE: UC=176.40, TC=160.46; P=.01); improved satisfaction with diabetes care (LSE: UC=4.01, TC=4.20; P=.05); and increased the odds of taking an A1c test (TC vs. UC: OR=3.40, P<.001). Conclusions: Both the TC and SC delivery models can improve 6-month depression outcomes. Nevertheless, the TC model is more effective in improving depression remission, patient satisfaction, and diabetes care quality. Clinical Trial: NCT01781013

  • Use of the Internet to Communicate with Providers from 2003 to 2013: 10 years of Patient Engagement according to the Health Information National Trends Surveys (HINTS)

    Date Submitted: Apr 24, 2017
    Open Peer Review Period: Apr 25, 2017 - Jun 20, 2017

    Background: Communication is key in chronic disease management, and the Internet has altered the manner in which patient and providers can communicate. It is an additional avenue by which providers can engage patients. Adoption of secure messaging differs among patients due to the digital divide (i.e., disparities in technology access based on socio-economic factors). Objective: To examine the current state of online patient-provider communication, exploring longitudinal trends over time in the use of online patient-provider communication. Methods: A three part analytic process was used: 1) reanalysis, 2) close replication across years, and 3) trend analysis extension. During the reanalysis stage, the publicly available HINTS 1 and 2 data was used with the goal of identifying the precise analytic methodology used by in the original 2007 paper. The original analysis was extended to add additional data years (i.e., 2008, 2011, and 2013) using the same analytic approach with the purpose of identifying trends over time. Multivariate logistic regression was used to analyze pooled data across all years with year as an added predictor in addition to a model for each individual data year. Results: The odds of Internet users to communicate online with health care providers was significantly and increasingly higher by year compared to 2003 (2005 OR=1.32, 2008 OR=2.14, 2011 OR=2.92, and 2013 OR=5.75). Statistically significant socio-economic factors found to decrease the likelihood of Internet users communicating online with providers included: age, no insurance, no history of cancer, and non-urban area of residence. Conclusions: The proportion of Internet users communicating online with their healthcare providers has significantly increased since 2003, and though these trends are encouraged to continue through health care policy (e.g., HITECH Act), access challenges remain making it difficult to use this means of communication to engage all patients in all areas.

  • A Medical Student–Delivered Smoking Prevention Program, Education Against Tobacco, for Secondary Schools in Germany: Randomized Controlled Trial

    Date Submitted: Apr 23, 2017
    Open Peer Review Period: Apr 23, 2017 - May 2, 2017

    Background: More than 8,5 Million Germans suffer from chronic diseases attributable to smoking. Education Against Tobacco (EAT) is a multinational network of medical students who volunteer for school-based prevention in the classroom setting amongst other activities. EAT is implemented in 28 medical schools in Germany and present in 13 additional countries around the globe. A recent quasi-experimental study showed significant short-term smoking cessation effects on 11- to 15-year-old adolescents. Objective: The aim of this study was to provide the first randomized long-term evaluation of the optimized 2014 EAT curriculum involving a photoaging software for its effectiveness to reduce the smoking prevalence among 11- to 15-year-old pupils in German secondary schools. Methods: A randomized controlled trial was enrolled among 1.504 adolescents aged 11-15 years in grades 6-8 of 9 secondary schools in Germany of which 718 (47,7%) were identifiable for the prospective sample at one year follow-up. The experimental study design included measurements at baseline and at 6 and 12 months postintervention via questionnaire. The study groups consisted of 40 randomized classes receiving the standardized EAT intervention (two medical student-led interactive modules taking 120 minutes total) and 34 control classes within the same schools (no intervention). The primary end point was the difference of the cigarette smoking prevalence in the intervention group versus the difference in the control group at 12 months of follow-up. The differences in smoking behavior (smoking onset, quitting) between the 2 groups as well as effects on the different genders were studied as secondary outcomes. Results: None of the effects were significant with reference to a high loss-to-follow-up effect (52,3%). The smoking prevalence increased from 3,1% to 5,2% to 7,2% in the control group and from 3% to 5,4% to 5,8% in the intervention group (NNT: 68) with notable differences between the groups for the female gender (4,2% to 9,5% for controls vs. 4% to 5,2%; NNT: 24 vs. NNT: 207 for males), low educational background (7,3% to 12% for controls vs. 6,1% to 8,7%; NNT: 30), and migrational background at endline. The intervention appears to prevent smoking onset (NNT: 63) but does not appear to initiate quitting. Conclusions: The intervention appears to prevent smoking especially in females and students with a low educational background.

  • The effect of text messaging interventions on cancer screening rates: a systematic review.

    Date Submitted: Apr 20, 2017
    Open Peer Review Period: Apr 22, 2017 - Jun 17, 2017

    Background: Despite high quality evidence that demonstrates screening reduces mortality from breast, cervical, colorectal, and lung cancer, a substantial portion of the population remains inadequately screened. There is a critical need to identify interventions that increase the uptake and adoption of evidence-based screening guidelines for preventable cancers at the community practice level. Text messaging has been effective in promoting behavioral change in various clinical settings, but the overall impact and reach of text messaging interventions on cancer screening is unknown. Objective: We performed a systematic review to assess the effect of text messaging interventions on screening for breast, cervical, colorectal, and lung cancer. Methods: We searched multiple databases for studies published between the years 2000-2017, including Pubmed, EMBASE, and the Cochrane Database of Systematic Reviews, to identify controlled trials that measured the effect of text messaging on screening for breast, cervical, colorectal, or lung cancer. Study quality was evaluated using the Cochrane risk of bias tool. Results: Our search yielded 2,238 citations, of which 31 underwent full review and nine met inclusion criteria. Five studies examined screening for breast cancer, one for cervical cancer, and three for colorectal cancer. No studies were found for lung cancer screening. Absolute screening rates for individuals who received text message interventions were 0.6% to 15.0% higher than for controls. Unadjusted relative screening rates for text message recipients were 4% to 63% higher compared to controls. Conclusions: Text messaging interventions appear to moderately increase screening rates for breast and cervical cancer and may have a small effect on colorectal cancer screening. Benefit was observed in various countries, including resource-poor and non-English speaking populations. Given the paucity of data, additional research is needed to better quantify the effectiveness of this promising intervention.

  • A proof of concept study evaluating the variability and accuracy among scribes’ transcribed notes using EHR integrated simulation and qualitative evaluation of scribe simulation

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

    Background: Background: The increasing adoption of Electronic Health Records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. In spite of this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely suffer from similar challenges. This highlights the need for new assessment tools for medical scribes. Objective: To develop a virtual, video based simulation to demonstrate and quantify the variability and accuracy of scribes’ transcribed notes in the EHR. Methods: We created 3 simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video recorded a standardized patient-provider encounter. 5 scribes with at least 6 months experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated electronic health record (EHR) environment. Transcribed notes were evaluated for inter-scribe variability and compared to a gold-standard for accuracy. Results: All scribes completed all simulated cases. There was significant inter-scribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. Note length varied by 55, 85, and 115 fold differences between the 3 cases and word economy ranged between 23-71%. Overall, there was a wide inter- and intra-scribe variation in accuracy for each section of the notes with ranges from 50-76%. This resulting in an overall positive predictive value for each note between 38-81%. Conclusions: We created a high fidelity, video based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency.

  • Telemedicine and mobile health solutions in oncology: an opinion poll of representatives of Polish medical societies

    Date Submitted: Apr 19, 2017
    Open Peer Review Period: Apr 21, 2017 - Jun 16, 2017

    Background: Telemedicine, or diagnosis/treatment of patients via telecommunications technology, and mobile health (mHealth) is increasingly gaining acceptance across numerous medical fields worldwide. Indeed, the World Health Organization strongly recommends that mHealth technologies should be implemented in health care systems across all Member States of the European Union. However, in Poland, the public health system has not yet implemented the institutional framework, including legislation, to facilitate an mHealth model. Objective: This study aimed to obtain the opinion from management representatives of Polish medical societies on the use and possibilities of telemedicine and mHealth solutions in Poland, particularly those relating to cancer. Methods: Eleven Polish medical societies, whose members perform tasks related to prevention, diagnosis, or treatment of cancer, were invited to participate in this study. A total of nine experts from seven medical societies accepted the invitation. The study was conducted using partially structured individual interviews, lasting 45 to 70 minutes. A qualitative analysis of the experts’ responses was performed. Results: We found telemedicine is currently more widely known and used among the oncology experts than mHealth technologies. According to the experts, widespread dissemination of telemedicine is expected across all medical fields, including oncology, in future; however, the use of mHealth applications (apps) may not be as easily accepted in the clinic. The biggest advantages of telemedicine stated by the respondents were its ability to save time and to improve the quality of health care. Challenges to mHealth solutions in clinical practice in Poland include low technological literacy, the threat to data security, and insufficient scientific evidence of efficacy and safety. Conclusions: Telemedicine and mHealth solutions can offer many advantages to both patients and health care professionals. However, there is a necessity to create a system of financing telemedicine and mHealth to achieve more widespread use of these technologies in Poland. We must also create a legal framework to support the health care professionals and to protect patients’ personal data. Patients must be educated prior to the implementation of mHealth apps to ensure an adequate use. App developers should involve health care professionals in their development process and consider the needs of older people and those with poor technology literacy. Finally, there should be more scientific validation of mHealth apps.

  • Patients’ Acceptance of Smartphone Health Technology for Chronic Disease Management: a Theoretical Model and Empirical Test

    Date Submitted: Apr 19, 2017
    Open Peer Review Period: Apr 21, 2017 - Jun 16, 2017

    Background: Chronic disease patients often face multiple challenges from difficult comorbidities. Smartphone health technology can be used to help them manage their conditions only if they accept and use the technology. Objective: This study developed and tested a theoretical model to predict and explain the factors influencing patients’ acceptance of smartphone health technology for chronic disease management. Methods: Multiple theories and factors that may influence patients’ acceptance of smartphone health technology have been reviewed. The technology acceptance model (TAM), the dual factor model, and the health belief model, along with a number of other factors have been used to build a hybrid theoretical model. Data collected from patient questionnaire surveys and computer log records from about 157 hypertensive patients’ actual use of a smartphone health application. The partial least square (PLS) method was used to test the theoretical model. Results: The model accounted for 41.2% of the variance in patients’ intention to adopt the smartphone health technology. Intention to use accounted for 11.1% of the variance in actual use and had a significant weak relationship with the latter. Perceived ease of use was affected by patients’ smartphone usage experience, relationship with the doctor, and self-efficacy. Although they did not have a significant effect on the intention to use, perceived ease of use, perceived threat, relationship with the doctor, and resistance to change had a positive influence on perceived usefulness. Perceived usefulness, perceived health threat, and resistance to change significantly predicted patients’ intentions to use the technology. The study also confirmed the positive relationship between intention to use and actual use of smartphone health applications for chronic disease management. Conclusions: This study developed a theoretical model to predict patients’ acceptance of smartphone health technology for chronic disease management. It suggests that the patients’ perceived usefulness of smartphone health technology is positively influenced by their perceived health threat, relationship with their doctor, and perceived ease of use, but negatively influenced by resistance to change. While being significantly influenced by resistance to change, perceived health threat and perceived usefulness, intention to use had a weak yet significant relationship with actual use of the technology. The finding suggests that to effectively use smartphone health technology for chronic disease management, three antecedent factors—resistance to change, perceived health threat, and relationship with the doctor—need to be carefully managed.

  • Systematic Review of Information Architecture of Web-based Interventions to Improve Health Outcomes

    Date Submitted: Apr 19, 2017
    Open Peer Review Period: Apr 21, 2017 - Jun 16, 2017

    Background: The rise in usage of and access to new technologies in recent years has led to a growth of digital health behavior change interventions. However, as the shift to digital platforms continues to grow, it is increasingly important to consider how the field of information architecture (IA) can inform the development of digital health interventions. IA concerns the way in which digital content is organized and displayed, which strongly impacts users’ ability to find and use content. While many information architecture best practices exist, there is a dearth of empirical evidence on the role that information architecture plays in influencing behavior change and health outcomes. Objective: To conduct a systematic review synthesizing the existing literature on website information architecture and its effect on health outcomes, behavioral outcomes, and website engagement. Methods: To identify all existing information architecture and health behavior literature, we searched articles published in English in the following databases (all years/months were considered, i.e., filters restricting years of publication were not used): ACM Digital Library, CINAHL, Cochrane Library, Google Scholar, Ebsco, and PubMed. The search terms used included information terms (e.g. information architecture, interaction design, persuasive design), behavior terms (e.g. health behavior, behavioral intervention, ehealth), and health terms (e.g., smoking, physical activity, diabetes). The search results were subsequently reviewed to determine if they met predetermined inclusion and exclusion criteria created to identify empirical research that studied the effect of information architecture on health outcomes, behavioral outcomes, or website engagement. Data from articles that met inclusion criteria were extracted using a priori categories established by three reviewers. Results: The initial literature search yielded 688 results, which was narrowed down to three publications that examined the effect of information architecture on health outcomes, behavioral outcomes, or website engagement. One publication studied the isolated impact of information architecture on outcomes of interest (i.e., website use and engagement; health-related knowledge, attitudes, and beliefs, and health behaviors) while the other two publications studied the impact of information architecture, website features (e.g., interactivity, email prompts, and forums), and tailored content on these outcomes. The paper that investigated IA exclusively found a tunneled IA improved site engagement and behavior knowledge, but decreased perceived efficiency. One first study that did not isolate IA found an enhanced site condition improved site usage but not amount of content viewed. The second study that did not isolate IA found a tailored site condition improved site usage, behavior knowledge, and some behavior outcomes. Conclusions: No clear conclusion can be made about the relationship between information architecture and health outcomes, given limited evidence in the peer-reviewed literature connecting IA to behavioral outcomes and website engagement. We recommend improving the scientific evidence base such that additional, empirical studies investigate the impact of IA in isolation. Moreover, information from gray literature and expert opinion might be identified and added to the evidence base, in order to lay the groundwork for hypothesis generation to improve empirical evidence on information architecture and health and behavior outcomes.

  • Adoption of a national Personal Health Record in Portugal – Characteristics of the ‘innovators’

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

    Background: Personal Health Records (PHRs) are increasingly being deployed worldwide, but their rates of adoption by patients vary widely across countries and health systems. Five main categories of adopters are usually considered when evaluating the diffusion of innovations: innovators, early adopters, early majority, late majority, and laggards. In May 2013, a web-based PHR was implemented in Portugal, being freely available to the Portuguese population. Data was obtained from individuals who registered to use the PHR during the first three months after its deployment (defined as ‘the innovators’ for the purposes of this study). Objective: We aimed to evaluate adoption three months after the release of the Portuguese PHR, as well as characterize the individuals who registered and used the system for that period of time. Methods: Cross-sectional study characterizing individuals who were registered in the Portuguese PHR by July 2013, three months after its official release. ‘Users’ and ‘non-users’ were defined based on their input, or not, of information related to allergies, emergency contacts, height, weight, systolic blood pressure, diastolic blood pressure, glycemia, cholesterol or triglycerides levels. Users of the PHR were compared with non-users regarding demographic and clinical variables. Users were further characterized according to their intensity of information input: ‘single input’ (only recorded one of the above fields, once) and ‘multiple inputs’. Multivariate logistic regression was used to model the probability of being in the ‘multiple inputs’ group. ArcGis was used to create maps of the proportion of PHR registrations by region and district. Results: The number of registered individuals in the Portuguese PHR three months after its release was 109,619 (60.6% women; mean age: 44.7 ± 18.1 years). The highest proportion of registrations was observed between 30 and 39 years of age (25,810; 23.6%). Also, 18,504 (16.9%) registered individuals were considered ‘users’ and 91,115 (83.1%) ‘non-users’. Among PHR users, 5,955 (32.2%) engaged in ‘single input’ and 12,549 (67.8%) in ‘multiple inputs’. Younger individuals and male users had higher odds of engaging in ‘multiple inputs’ [Odds Ratio for male individuals 1.32 (1.19-1.48)]. Geographic analysis revealed a gap in PHR adoption between urban centers and rural regions. Conclusions: Approximately 1% of the country’s population registered during the first three months of the Portuguese PHR. Registered individuals were more frequently female and between 30 and 39 years of age. There is evidence of a geographic gap in the adoption of the Portuguese PHR, which may reflect the existence of a digital divide.

  • Identifying the Potential Epidemics of Norovirus Infection in China via Internet Surveillance

    Date Submitted: Apr 12, 2017
    Open Peer Review Period: Apr 17, 2017 - Jun 12, 2017

    Background: Norovirus (NoV) is a common virus that causes acute gastroenteritis worldwide, and a monitoring system for NoV is unavailable in China. Objective: We aimed to identify NoV epidemics through Internet surveillance and construct an appropriate model to predict the potential NoV infections. Methods: The NoV-related data of selected outbreak in Jiaxing Municipality, Zhejiang Province of China in 2014 were collected from immediate epidemiological investigation, and the Internet searching volume, as indicated by Baidu Index (BDI), was acquired from Baidu search engine. All correlated searching keywords in relation to NoV were captured, screened and composited to establish the composited BDI at different time lags by Spearman’s rank correlation. Besides, the optimal model was chosen and possibly predicted maps in Zhejiang Province were presented by ArcGIS software. Results: The combination of two vital keywords at a time lag of 1 days was ultimately identified as optimal (r=0.924, P<0.001). Meanwhile, Exponential curve model (ECM) with the was constructed, suggesting that one-unit increase in averaged composited BDI contributed to an increase of NoV infections by 2.15 time during the outbreak. Besides Jiaxing Municipality, Hangzhou Municipality might also exist potential epidemics in the study time from the predicted model. Conclusions: Although existing limitations in early warning and unavoidable biases, Internet surveillance may be still useful for the monitoring of NoV epidemics when a monitoring system is unavailable.

  • Internet hospital in China: a cross-sectional survey

    Date Submitted: Apr 12, 2017
    Open Peer Review Period: Apr 17, 2017 - Jun 12, 2017

    Background: Internet hospital is rapidly developing in China, because it has the potential to provide widely accessible outpatient service delivery via Internet technologies. To date, China’s Internet hospitals have not been systematically investigated. Objective: The aim of this study was to describe the characteristics and to assess the health service capacity of China’s Internet hospitals. Methods: We searched Baidu to identify Internet hospital up to March 31, 2017, using search terms such as Internet hospital, web hospital, or cloud hospital. All Internet hospitals in mainland China were eligible for inclusion if they have been officially registered. Results: We identified 68 Internet hospitals, of which 43 have been put into use and 25 are under construction. Of the 43 established Internet hospitals, 13 (30.2%) were in hospital informatization stage, 24 (55.8%) were in web ward stage, and 6 (14.0%) were in full Internet hospital stage. Patients accessed outpatient service delivery via website (n=32, 74.4%), app (n=18, 41.9%), or offline medical consultation facility (n=16, 37.2%) from the Internet hospital. 25 (58.1%) Internet hospitals asked doctor to deliver health service at specific web clinic, and 18 (41.9%) not required. The consulting methods include video chat (n=26, 60.5%), telephone (n=8, 18.6%), and graphic message (n=12, 27.9%), while 13 (30.2%) Internet hospitals cannot be consulted online now. Only six Internet hospitals are included in the coverage of health insurance. The median number of doctors available online was zero (interquartile [IQR] 0 to 5; max 16492). The median consultation fee per time was ¥20 (approximately US$2.90, IQR ¥0 to ¥200). Conclusions: Internet hospitals provide convenient outpatient service delivery. However, many of the Internet hospitals are not yet mature with various issues such as online doctor scarcity and not being covered by health insurance. China's Internet hospital is heading in the right direction to improve how health service is effectively provided, but much more remains to be done.

  • Social media-promoted weight loss among occupational population: a WeChat smartphone application-based campaign

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

    Background: Being overweight and obesity are major risk factors for noncommunicable diseases such as diabetes and cardiovascular diseases. However, the prevalence of being overweight and obesity is high throughout the world and these issues are very serious in the Shunyi District in China. As mobile technologies have rapidly developed, mobile apps such as WeChat have the potential to improve health behaviors and are well accepted. Objective: This study aims to evaluate the effectiveness of mobile app (WeChat) interventions on weight loss behavior. Methods: This study was conducted among occupational population from August 2015 to February 2016 in the Shunyi District of Beijing. Before the intervention, the Shunyi District Government released an official document for weight loss to all 134 government agencies and enterprises in Shunyi District. The participants who were willing to use our official WeChat account were enrolled in a WeChat group and received six months of interventions for weight loss, and those who were not willing to use the account were in the control group. Results: A total of 15,310 occupational participants were enrolled. A total of 3467 participants (32.6%) were in the control group and 11,843 participants (77.4%) were in the WeChat group. The mean weight loss and waist circumference in the control group were 1.78 kg (SD=2.96) and 2.39 cm (SD=3.91), respectively, while in the WeChat group, the weight and waist circumference decreased by 2.09 kg (SD=3.43) and 2.74cm (SD=4.48), respectively. In the control group, after six months, normal weight increased by 3.4% and in the WeChat group, it increased by 8.8%. The results of the stratified analysis show that for males, the weight loss difference was statistically significant. Participants who were female, older, and had educational levels of high school or below were more active in using WeChat for weight loss. The results of the stratified analysis indicate that among male participants aged 40 years and above with a university/college degree or above, those who were active in WeChat were more likely to lose weight than those who were inactive. For participants who were female and had a university/college degree or above, regardless of age, they were more active in using the app and lost more weight. Conclusions: The weight loss intervention campaign based on the official WeChat account among occupational population in Shunyi District was proven to be effective and well accepted.

  • From e-mental health to i-mental health: transition to participatory and personalized medicine in mental health

    Date Submitted: Apr 11, 2017
    Open Peer Review Period: Apr 12, 2017 - Jun 7, 2017

    Clinical assessment in psychiatry is commonly based on findings from brief, regularly scheduled in-person appointments. Although critically important, this approach reduces assessment to cross-sectional observations that miss essential information about disease course. The mental health provider makes all medical decisions based on this limited information. Thanks to recent technological advances, electronic-health (e-health) data collection strategies now can provide access to real-time patient self-report data during the interval between visits. Intelligent-health (i-health) further builds on and expands e-health by adding novel built-in data analysis approaches to enhance medical decision-making.

  • An empirical study on the key influence factors of consumers’ intentions towards promoting the mobile health based on DDANPMV model

    Date Submitted: Apr 10, 2017
    Open Peer Review Period: Apr 12, 2017 - Jun 7, 2017

    Background: Mobile health industry for mobile device and market demand has a good development prospects. Mobile health service brings great social benefit and economic benefit because of its convenience and efficiency in regulating hospital resource allocation. However, the research conducted by Rock Health shows the result that although there are over 13,000 apps about fitness and health in app store, it is found out only 19% users download such applications. There is still a large space for consumers to accept and adopt mobile health. Objective: The significance of this study lies in analyzing influential factors of consumers’ adoption intention and making mobile health products a better promotion. On the process of promoting mobile health, there will be various obstacles. For instance, users’ queries on the safety and privacy of personal information, and the influence on medical reimbursement from e-payment. Previous researches about mobile health mostly focused on technology level and clinical expansion, and there is few researches on consumers’ adoption of medical health. Since mobile health needs to read personal information, it puts forward higher requirements for privacy and safety. The study on the influential factors of consumers’ adoption will be of a great importance in improving and promoting mobile health. Based on the key influential factors found in the research, decision-makers can take measures accordingly to promote consumers’ adoption of mobile health better. Methods: A new hybrid modified MCDM method can be adopted: Firstly, construct the influential network relation map (INRM) and determine the influential weights (IWs) of DANP (DEMATEL-based ANP) by using the influence relation matrix through DEMATEL technique; Then, combine the influential weights with the modified VIKOR method as integration weighting in criteria evaluation based on INRM for establishing the performance gap improvement strategies by systematics, called these processes as DDANPMV (DEMATEL + DANP + Modified VIKOR) model. Therefore, this study proposed DDANPMV model to solve this problem will be more effective. Results: Therefore, this study proposed DDANPMV model to solve this problem will be more effective. An empirical real case is illustrated to demonstrate the feasibility and effectiveness of proposed method, the paper selects four mobile health products (P1 is developed by a sensor company, P2 is a smart pill with an embedded chip in it developed by a start-up company, P3 is the smart health scanner launched by a health care products company, and P4 is a mobile electrocardiogram equipment developed by a biotechnology company) as examples in real cases. Conclusions: (1) Construct the evaluation index system of influential factors in consumers’ adoption of mobile health including three dimensions and eight criteria. A large of existing domestic/foreign researches on consumers' adoption of mobile health focus on the analysis of one or several certain factors, which lacks the construction of a scientific evaluation index system systematically. This paper analyzes the characteristics of mobile health and develops previous relevant studies on the basis of literature review, previous theories, discussion and summary. (2) Recognize the interrelationships among dimensions/criteria graphically through INRM, from which the paper concludes that technological dimension (D1) has directly influence on subjective dimension (D2) and environment dimension (D3), and subjective dimension (D2) also influences environment dimension (D3). Providers are able to improve their products more flexible and accurate based on the identification of cause-effect relationships among dimensions/criteria and the actual situation of their own products. (3) Verify the VIKOR method through an empirical case to identify performance gaps of four mobile health products and rank them for continuous improvement and products-development. The paper compares the traditional VIKOR method and the modified VIKOR method to illustrate the effectiveness of the latter. The modified VIKOR helps not only in products comparison within a specific criterion, the comparison among all criteria is also meaningful because of an unified reference point/benchmark. In this process, the paper provided guiding meanings in product improvement strategies for decision-makers as well as in consumers’ ranking and selection of different alternatives to better solve the problems in the real world. It conforms better to the logic and thoughts in real life because it assigns to represent the best value rather than “picks the best apple among a barrel of rotten apples”.

  • Pilot Evaluation of the Living the Example Social Media Substance Use Prevention Program

    Date Submitted: Apr 7, 2017
    Open Peer Review Period: Apr 11, 2017 - Jun 6, 2017

    Background: Adolescent substance use rates in rural areas of the U.S., such as upstate New York (NY) have risen substantially in recent years, calling for new intervention approaches in response to this trend. The Mentor Foundation USA conducts the Living the Example campaign (LTE) to engage youth in prevention using an experiential approach. As part of LTE, youth create their own prevention messages following a training curriculum in techniques for effective messaging and then share them via social media. This paper reports on a pilot evaluation of the LTE program. Objective: To conduct a pilot test of LTE in two rural high schools in upstate NY. We hypothesized that positive anti-drug brand representations could be promoted using social media strategies to complement the STM in-person, event-based approach (H1), and that youth would respond positively and engage with prevention messages disseminated by their peers. We also hypothesized that exposure to the social media prevention messages would be associated with more positive substance use avoidance attitudes and beliefs, reductions in future use intentions, and decreased substance use at post-test (H2). Methods: We adapted a previously published curriculum created by the authors that focuses on branding, messaging, and social media for prevention. The curriculum consisted of five, one-hour sessions. It was delivered to participating youth in five sequential weeks after school at the two high schools in late October and early November 2016. We designed a pre-test, post-test pilot implementation study to evaluate the effects of LTE on student uptake of the intervention and short-term substance use and related outcomes. Working at two high schools in upstate NY, we conducted a pilot feasibility evaluation of LTE with 9th grade students (Freshmen) at these high schools. We administered a 125-item questionnaire online to capture data on media use; attitudes toward social media; next 30-day personal drug use intentions; personal reasons to use drugs; Reasons they believe their peers would use drugs; Self-reported exposure to the LTE program; and Receptivity to the LTE program (among those reporting exposure). We constructed multivariable logistic regression models to analyze the relationship between program receptivity and outcomes. First, in a cross-sectional logistic regression model, we regressed self-reported LTE message receipt on drug use intent and actions related to LTE messaging. Then, for analysis of participants with matched pre-post responses, we used multilevel Generalized Estimating Equation (GEE) techniques to model changes in behavior from baseline to follow-up. Results: Youth reported increased intentions to use marijuana (OR 2.134, p < .02) between pre-post, which may be expected given the age range of 14-15 years and concomitant increase in drug use intentions observed in other research. However, among youth who reported exposure and receptivity to LTE, they reported a significant decrease in intentions (OR 0.239, p < .008). We observed a similar pattern for use of any drug use – an increase in reported intentions overall (OR 2.141, p < .021), but a decrease among youth who reported exposure and receptivity to LTE (OR 0.111, p < .004). Conclusions: We observed some evidence of significant LTE program effects. Social media may be an effective strategy for peer-to-peer substance use prevention in the future. These findings point both to the potential of LTE and the social media diffusion model, and to the need for more research on a larger scale with an expanded youth population in the future. Clinical Trial: N/A

  • Differences in user characteristics and intervention use for a Web-based and print-based computer-tailored physical activity intervention for prostate and colorectal cancer survivors

    Date Submitted: Apr 7, 2017
    Open Peer Review Period: Apr 11, 2017 - Jun 6, 2017

    Background: Physical activity (PA) is beneficial in improving negative physical and psychological effects of cancer. The rapidly increasing number of cancer survivors, resulting from ageing and improved cancer care, emphasizes the importance to develop and provide low cost, easy accessible PA programs. Such programs could be provided online, but cancer survivors not familiar with the Internet might then be excluded. Therefore, we developed a computer-tailored PA intervention for prostate and colorectal cancer survivors in which both Web-based and print materials are provided and participants can choose their own preferred delivery mode. Objective: The current study aims to assess the participants characteristics related to delivery mode and use of intervention materials. Methods: We studied characteristics of participants using Web-based and/or printed intervention materials in a randomized controlled trial. Prostate and colorectal cancer survivors recruited from hospitals were randomized to OncoActive (computer-tailored PA intervention) or a usual-care control group. OncoActive participants received both Web-based and printed materials. Participants were classified into initial print- or web-based participants based on their preferred mode of completion of the first questionnaire, which was needed for the computer-tailored PA advice. Intervention material use during the remainder of the intervention was compared for initial print- or web-based participants. Additionally, participants were classified into those using only print materials and those using Web-based materials. ANOVAs, chi-square tests and logistic regressions were performed to study differences in participant characteristics and intervention material use. Results: The majority of the participants in the intervention group (n=249) were classified as initial Web-based participants (n=170; 68.3%) and 84.9% (n=191) used Web-based intervention materials. Dropout was low (6.0%) and differed between initial Web- (2.4%) and print-based (13.9%) participants. Participants were less likely to start online with higher age (OR .93), longer time since last treatment (OR .87) and higher fatigue (OR .96), and more likely with higher education (OR 4.08) and having completed treatments (OR 5.58). Those who were older (OR .93) and post-treatment for a longer time (OR .86) were less likely to use Web-based intervention materials. Initial print-based participants predominantly used print-based materials, whereas initial Web-based participants used both print- and Web-based materials. Conclusions: To our knowledge, this is one of the first studies that assessed participant characteristics in relation to delivery mode in an intervention in which participants had a free choice of delivery modes. Use of print-based materials among the initial Web-based participants was substantial, indicating the importance of print-based materials. According to our findings, both Web- and print-based materials should be offered alongside each other. Providing Web-based materials only would exclude some of those who are older, lower educated, more fatigued or are currently undergoing treatment. Especially these groups are more vulnerable and could benefit most from PA interventions. Clinical Trial: The study is registered in the Dutch Trial Register (NTR4296) on November 23rd 2013 and can be accessed at (Archived by WebCite at

  • Towards m-health brief contact interventions in suicide prevention: A Case Series from the Suicide Intervention Assisted by Messages (SIAM) randomized controlled study

    Date Submitted: Apr 5, 2017
    Open Peer Review Period: Apr 6, 2017 - Jun 1, 2017

    Background: Research indicates that maintaining contact either via letter or postcard with at-risk adults following discharge from care services after a suicide attempt can reduce reattempt risk. Pilot studies have demonstrated that interventions using mobile-health technologies are feasible in a suicide prevention setting. Objective: The aim of the current study is to report three cases of patients recruited in the Suicide Intervention Assisted by Messages (SIAM) study in order to describe how a mobile intervention may influence follow-up. Methods: SIAM is a two-year, multi-center randomized controlled trial conducted by the Brest University Hospital, France. Participants in the intervention group receive the SIAM text messages 48 hours after discharge, then at day 8, day 15, and months 1, 2, 3, 4, 5 and 6. The study includes participants aged 18 or over, who have attended a participating hospital for a suicide attempt, and have been discharged from the ED or a Psychiatric Unit (PU) for a stay of less than seven days. Eligible participants are randomized between the SIAM intervention messages and a control group. This study present a case series from the ongoing SIAM study, which demonstrates the capability of a mobile-based brief contact intervention triggering patient-initiated contact with a crisis support team at various time points through the study period. Results: Three cases from the randomized controlled study were chosen to illustrate the impact of the m-health on further suicide ideation. Participants initiated contact with the emergency crisis support service after receiving text messages up to six months following discharge from hospital. Contact was initiated immediately following receipt of a text message, up to six days following a message. Conclusions: This text-message based brief contact intervention has demonstrated the potential to reconnect suicidal individuals with crisis support services, while they are experiencing suicidal ideation as well as a period after receive messages. As follow-up phone calls over an extended period of time may not be feasible, this intervention has the potential to offer a simple technological support for individuals following discharge from the emergency department. Clinical Trial: NCT02106949

  • Facilitating factors and barriers to the use of new technologies for suicide prevention in Europe: a multi-country exploratory study

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

    Background: This study provides an analysis on the use of new technologies for prevention of suicide in eight different European countries. Objective: We want to analyse the potentiality of using new technologies in the area of suicide prevention based on the opinion of different professionals involved in suicide prevention. Methods: Opinions of three different groups of stakeholders were gathered using a specifically designed questionnaire to explore dimensions underlying perception of facilitating factors and barriers in relation to the use of new technologies for suicide prevention. Results: Goal 1: Facilitating factors for the use of new technologies in suicide prevention. Northern European countries, except for Belgium, attach greater relevance to those that optimize implementation and benefits. Southern European countries, on the other hand, attach greater importance to professionally-oriented and user-centred facilitating factors. The analysis of these facilitating factors according to different stakeholders evidences that professionals in the field of social work attach greater relevance to those that optimize implementation and those that optimize the benefits. However, professionals involved in the area of mental health, policy makers and political decision-makers give greater importance to professionally-oriented and user-centred facilitating factors. Goal 2: Barriers to the usability of new technologies for suicide prevention. Both countries and stakeholders attach greater importance to barriers associated with resource constraints than to those centred on personal limitations. There are no differences between countries or between stakeholders. Nevertheless, there is a certain stakeholders-countries interaction that indicates that the opinions on resource constraints expressed by the different stakeholders do not follow a uniform pattern in the different countries, but different ones depending on the country. Conclusions: While all countries and stakeholders agree in identifying resource constraints as the main barrier to the use of new technologies, factors facilitating their use in suicide prevention differ among countries and among stakeholders.

  • A Characterization of Patient Interest in Provider-Based Consumer Health Information Technology

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

    Background: Consumer Health Information Technology (CHIT) can improve patient engagement in their healthcare and assist in navigating the complexities of healthcare delivery. However, the CHIT offerings of health systems are often driven by provider rather than patient perspectives, inadequately address patient needs, and are thus limited in adoption by patients. Consideration given to patients as stakeholders in the development of such technologies, may improve adoption, efficacy, and CHIT resource allocation. Objective: To measure patient interest in various health system CHIT applications, and determine the influence of patient characteristics on CHIT interest. Methods: Patients seen at the Cleveland Clinic Neurological Institute were electronically surveyed on their interest in using different CHIT applications. A self-efficacy scale, PHQ-9 depression screen, and EQ-5D health-related quality of life scale, were also completed by patients. Logistic regression was used to determine the influence of patient characteristics on interest in CHIT in the categories of self-management, education, and communication. Results: The majority of 3852 patient respondents had an interest in all technology categories assessed in the survey. Highest interest was in applications that allow patients to ask questions of providers (90.24% (3476/3852)) and to schedule appointments (83.64% (3211/3839). Patient interest in CHIT was significantly associated with greater depression symptoms, worse quality of life, greater health self-efficacy, and smart phone ownership (P<.001 for all listed). Conclusions: The majority of patients demonstrated a strong interest in CHIT involving education, communication, and self-management. Highest-interest technology applications include those allowing patients to ask questions of providers and schedule appointments. Interest in CHIT varies according to patient self-efficacy, health-related quality of life, and depression. This information can be used to help prioritize the development of CHIT applications and target implementation to the most appropriate patient populations.

  • Seeing the Whole Picture: Integrated Pre-Surgery Reports Using Optique

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

    Background: Information technology has transformed the way healthcare is conducted. There is a deluge of patient data dispersed in different systems that are commonly not interoperable. As a result, access to patient data has become a major bottleneck for healthcare professionals that struggle to find the relevant information in a timely way and without missing critical clinical information. Objective: We propose a novel hybrid semantic and text-based system that was commissioned by a large hospital in Norway for providing integrated access to patient health records scattered in several databases and document repositories. Methods: We use OBDA technology for the seamless integration of the structured databases at the hospital through the Optique platform. We employ text analysis techniques to extract vital sign measures and clinical findings from patient documents. Results: The envisioned system was developed and deployed at the hospital. This solution demonstrates how OBDA technology can provide integrated data access to disparate structured sources in healthcare, without requiring the replacement of existing databases. Unstructured clinical text is also mined to extract patient findings, while the GUI provides a single access point that hides the underlying complexity of the system. We ran a usability study with 5 target users, obtaining a SUS score of 86. Further, participants in the study stressed the simplicity of the GUI and the integration of data sources enabled by the system. Conclusions: This pilot study showcases the use of OBDA technology and text analysis to enable the integration of patient data for supporting clinical surgery operations. The resulting system is usable and can be easily employed by medical personnel to find patient data in a timely way.

  • Social Media Utilization Among Orthopedic Surgeons in a Large US City

    Date Submitted: Mar 27, 2017
    Open Peer Review Period: Mar 29, 2017 - May 24, 2017

    Background: Physician Internet and social media presence is increasingly common as a sophisticated patient population and referral base continues to seek information when selecting an orthopedic surgeon. Objective: We hypothesized that American Academy of Orthopedic Surgeons (AAOS) Fellows of fewer than 20 years would have a higher Internet and social media presence when compared to AAOS fellows of more than 20 years. We limited our analysis regionally to San Francisco, California. Methods: A current list of AAOS Fellows practicing in San Francisco was obtained from the AAOS Website. A total of 86 current fellows, not including candidate and resident members, were compiled. The list was divided into AAOS Fellows of fewer than 20 years and AAOS Fellows of more than 20 years. An investigation was made regarding Internet and social media presence via search engines for both individual physicians and for websites for physician practices (solo or group versus hospital or university-based). Additionally, the presence of physician and practice accounts for Facebook, LinkedIn, and Twitter, and physician accounts for Instagram, YouTube, and Google+ was identified. Internet and social media presence was compared between these two groups and percentage of participation was evaluated. Results: 94% of all San Francisco AAOS Fellows have an active Internet website accessible to the general public and 41% of Fellows have online appointment availability. Despite Fellows in the under 20-year group and private practice not having significantly more online appointment availability than the over 20-year group and university/hospital-based setting, there was a clear trend in that direction. The under 20-year group participated in an average of 1.2 more social media sites (4.1 vs 2.9 P=0.02). There was no significant difference between private practice and university/hospital-based practice with regard to social media usage. Google+ was the most likely utilized social media website followed by LinkedIn, YouTube, Facebook, Twitter, and Instagram. The under 20-year group utilized newer social media sites like Twitter and Instagram more frequently than the over 20-year group. Conclusions: Internet and social media presence is clearly and important component of physician practice amongst San Francisco orthopedic surgeons. Private practice physicians and surgeons with fewer years in practice are more likely to utilize online appointment software.

  • To what extent should patients control access to patient records? A trial by citizens’ jury

    Date Submitted: Mar 28, 2017
    Open Peer Review Period: Mar 29, 2017 - May 24, 2017

    Background: The secondary use of health data for societal and commercial benefit raises complex questions of privacy and governance. Such questions are ill-suited to opinion polling where citizens must choose quickly between multiple-choice answers based on little information. Objective: This project aims to extend knowledge about what control informed citizens would seek over health records after participating in a deliberative process, using "citizens’ juries". Methods: Two citizens’ juries, of 17 citizens each, were convened; each jury was chosen to reflect UK national demographics, from 355 eligible applicants. Juries met separately over three days, to address the charge “To what extent should patients control access to patient records for secondary use?”. Jurors heard from and questioned five expert witnesses (chosen either to inform the jury, or to argue for and against the secondary use of data), interspersed with structured opportunities to deliberate amongst themselves including discussion, and role-play. Jurors voted on a series of questions associated with the jury charge, giving their rationale. Individual views were polled using questionnaires at the beginning and end of the process. Results: At the end of the process, 33 out of 34 jurors voted in support of the secondary use of data, with 24 wanting individuals to be able to opt-out, 6 favouring opt-in and 3 voting that all records should be available without any consent process. When considering who should get access to data, both juries had very similar rationales. Both thought that public benefit was a key justification for access. Jury 1 was more strongly supportive of sharing patient records for public benefit, whilst Jury 2 was more cautious and sought to give patients more control. Many jurors changed their opinion about who should get access to health records: 17 people became more willing to support wider information sharing of health data for public benefit, whereas two people moved towards more patient control over patient records. Conclusions: The findings highlight that, when comprehensively informed of both risks and opportunities associated with data sharing, citizens believe an individual’s right to privacy should not prevent research that can benefit the general public. The juries also concluded that patients should be notified of any such scheme and have the right to ‘opt-out’ if they so choose. Many jurors changed their minds about this complex policy question when they became more informed. Many, but not all, jurors became less sceptical about health data sharing as they became better informed of its benefits and risks. Clinical Trial: N/A

  • Evaluation of a motivational interview delivered by NAO robot

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

    Background: Most people do not achieve the government’s minimum recommendations for physical activity and want help to increase their levels but are unable to gain access to face-to-face counselling to support motivation. Motivational interviewing (MI) is one of the most effective psychological interventions for supporting behaviour change and social robots that can deliver effective motivational support could offer a way to close this gap and help people develop and sustain more physically active lifestyles. Objective: We have developed a virtual health intervention with a robot counsellor based on MI for encouraging physical activity. We used a NAO robot programed with Choregraphe software to deliver a motivational interview designed to be comprehensible in the absence of an empathetic response from the interviewer. The intonation and speed of each sentence were carefully developed together with the choice of movements for the interview. We utilized a breathing function, in which the robot moves gently, for a natural apperance. The robot’s face-tracking mode enabled the robot to always gaze at the participant’s face, regardless of their movements during the course of the interview, giving a sense that NAO was paying attention to them. Methods: A total of 20 participants took part in the robot-delivered motivational interview, and evaluated it after one week. Each participant was left alone with the robot in a lab styled as a living room, and advanced through a series of questions by tapping the robot head sensor. Their evaluations were content analyzed utilizing Boyatzis’ (1998) steps which include (1) sampling and design, (2) developing themes and codes, and (3) validating and applying the codes. Categories originated from the text itself, generating themes focused on interaction with the robot, assessment of content, and motivation for change. Results: Participants found the instructions clear and the navigation easy to use. Most enjoyed the interaction but also found it was restricted by the lack of individualised response from the robot. Some found it off-putting to touch the robot’s head sensor to advance to the next question. Many participants positively appraised the non-judgemental aspect of the interview and how it gave space to articulate their motivation for change. Some participants felt that the intervention increased their activity levels. Conclusions: The NAO robot was effective at eliciting discussion from the participants about their goals and motivations. Because they are perceived as non-judgemental, robots may have advantages over humanoid avatars for delivering virtual support for behavioural change.

  • Integrated Decentralised Training (I-DecT): A Proposal for UKZN, South Africa

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

    Background: This project is aligned to a current need for healthcare within a South African context to address resource poor climates in rural and peri-urban settings shifting focus from an overserved urban region. The University of KwaZulu-Natal, in South Africa has embarked on a programme within the School of Health Sciences (SHS) to decentralise the clinical learning platform in order to address this disparity in healthcare in the country. Framed in a pragmatic stance, this proposal is geared towards informing the roll out of the decentralised training within the province of KwaZulu-Natal within the SHS. Whilst this vision is the driving force, there currently remains uncertainty as to how the implementation of this programme would unfold, especially for the diverse School which includes Audiology, Dentistry, Occupational Therapy, Optometry, Pharmacy, Physiotherapy, Speech-Language Pathology and Sport Science. Consequently, there is a need to carefully monitor and manage this DCT in order to ensure that the students exposed to this longitudinal placement have a positive learning experience and achieve expected academic outcomes and that the needs of the communities are addressed adequately. Objective: The study aims to explore the factors that will influence the roll-out of the DCT towards the development of an inclusive and context-specific model that would suit the SHS in the DCT programme at UKZN. Methods: Key role players, including, but not limited to, the ministry of health policy makers and clinicians, as well as policy makers in the university, and clinical educators, academicians and students of UKZN within the SHS will participate in this project. Once the infrastructural, staffing and pedagogical enablers and challenges are identified, together with a review of existing models of decentralised training, a context-specific model of decentralised training for the school will be proposed based on initial pilot data that will be tested within iterative cycles in an action learning action research process in this project. Results: The study was designed to fit within the existing structures and emerging framework and memorandum of understanding between the partners in this initiative, namely, the Ministry of Health and the UKZN. In embracing this call to develop healthcare professionals that are competent and prepared for the changing dynamics of healthcare in a developing world. Conclusions: It is envisaged that this study, the first to include a combination of health professionals in a decentralised clinical training platform at UKZN, would not only contribute to effective service delivery but may also serve to inform an inter-professional programme within the SHS and tertiary institutions in similar settings.

  • 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.

  • “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.

  • 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.

  • 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.