JMIR Publications

Journal of Medical Internet Research

The leading peer-reviewed journal for health and healthcare in the Internet age.

JMIR's Thomson Reuter Impact Factor of 4.5 for 2015

Recent Articles:

  • Doctor and patient discuss health information on the Internet. Image sourced and copyright owned by authors.

    Internet Health Information Seeking and the Patient-Physician Relationship: A Systematic Review


    Background: With online health information becoming increasingly popular among patients, concerns have been raised about the impact of patients’ Internet health information-seeking behavior on their relationship with physicians. Therefore, it is pertinent to understand the influence of online health information on the patient-physician relationship. Objective: Our objective was to systematically review existing research on patients’ Internet health information seeking and its influence on the patient-physician relationship. Methods: We systematically searched PubMed and key medical informatics, information systems, and communication science journals covering the period of 2000 to 2015. Empirical articles that were in English were included. We analyzed the content covering themes in 2 broad categories: factors affecting patients’ discussion of online findings during consultations and implications for the patient-physician relationship. Results: We identified 18 articles that met the inclusion criteria and the quality requirement for the review. The articles revealed barriers, facilitators, and demographic factors that influence patients’ disclosure of online health information during consultations and the different mechanisms patients use to reveal these findings. Our review also showed the mechanisms in which online information could influence patients’ relationship with their physicians. Conclusions: Results of this review contribute to the understanding of the patient-physician relationship of Internet-informed patients. Our main findings show that Internet health information seeking can improve the patient-physician relationship depending on whether the patient discusses the information with the physician and on their prior relationship. As patients have better access to health information through the Internet and expect to be more engaged in health decision making, traditional models of the patient-provider relationship and communication strategies must be revisited to adapt to this changing demographic.

  • Pain. Image source: Author: Samantha Evans. Copyright:

    It’s About Me: Patients’ Experiences of Patient Participation in the Web Behavior Change Program for Activity in Combination With Multimodal Pain...


    Background: Patients’ participation in their health care is recognized as a key component in high-quality health care. Persons with persistent pain are recommended treatments with a cognitive approach from a biopsychosocial explanation of pain, in which a patient’s active participation in their rehabilitation is in focus. Web-based interventions for pain management have the potential to increase patient participation by enabling persons to play a more active role in rehabilitation. However, little is known about patients’ experiences of patient participation in Web-based interventions in clinical practice. Objective: The objective of our study was to explore patients’ experiences of patient participation in a Web Behavior Change Program for Activity (Web-BCPA) in combination with multimodal rehabilitation (MMR) among patients with persistent pain in primary health care. Methods: Qualitative interviews were conducted with 15 women and 4 men, with a mean age of 45 years. Data were analyzed with qualitative content analysis. Results: One theme, “It’s about me,” and 4 categories, “Take part in a flexible framework of own priority,” “Acquire knowledge and insights,” “Ways toward change,” and “Personal and environmental conditions influencing participation,” were developed. Patient participation was depicted as being confirmed in an individualized and structured rehabilitation framework of one’s own choice. Being confirmed was fundamental to patient participation in the interaction with the Web-BCPA and with the health care professionals in MMR. To acquire knowledge and insights about pain and their life situation, through self-reflection in the solitary work in the Web-BCPA and through feedback from the health care professionals in MMR, was experienced as patient participation by the participants. Patient participation was described as structured ways to reach their goals of behavior change, which included analyzing resources and restrictions, problem solving, and evaluation. The individual’s emotional and cognitive resources and restrictions, as well as health care professionals and significant others’ attitudes and behavior influenced patient participation in the rehabilitation. To some extent there were experiences of restrained patient participation through the great content of the Web-BCPA. Conclusions: Patient participation was satisfactory in the Web-BCPA in combination with MMR. The combined treatment was experienced to increase patient participation in the rehabilitation. Being confirmed through self-identification and finding the content of the Web-BCPA trustworthy was emphasized. Patient participation was experienced as a learning process leading to new knowledge and insights. Higher user control regarding the timing of the Web-BCPA and therapist guidance of the content may further increase patient participation in the combined treatment.

  • Screenshot of the ZIPSE information portal about rare diseases. Source:

    Rare Diseases on the Internet: An Assessment of the Quality of Online Information


    Background: The importance of the Internet as a medium for publishing and sharing health and medical information has increased considerably during the last decade. Nonetheless, comprehensive knowledge and information are scarce and difficult to find, especially for rare diseases. Additionally, the quality of health or medical information about rare diseases is frequently difficult to assess for the patients and their family members. Objective: The aim of this study is to assess the quality of information on the Internet about rare diseases. Additionally, the study aims to evaluate if the quality of information on rare diseases varies between different information supplier categories. Methods: A total of 13 quality criteria for websites providing medical information about rare diseases were transferred to a self-disclosure questionnaire. Identified providers of information on the Internet about rare diseases were invited to fill out the questionnaire. The questionnaire contained questions about the information provider in general (eg, supplier category, information category, language, use of quality certificates, and target group) and about quality aspects that reflect the 13 quality criteria. Differences in subgroup analyses were performed using t tests. Results: We identified 693 websites containing information about rare diseases. A total of 123 questionnaires (17.7%) were completely filled out by the information suppliers. For the remaining identified suppliers (570/693, 82.3%), the questionnaires were filled out by the authors based on the information available on their website. In many cases, the quality of websites was proportionally low. Furthermore, subgroup analysis showed no statistically significant differences between the quality of information provided by support group/patient organization compared to medical institution (P=.19). The quality of information by individuals (patient/relative) was significantly lower compared to information provided by support group/patient organization (P=.001), medical institution (P=.009), and other associations and sponsoring bodies (P=.001) as well. Conclusions: Overall, the quality of information on the Internet about rare diseases is low. Quality certificates are rarely used and important quality criteria are often not fulfilled completely. Additionally, some information categories are underrepresented (eg, information about psychosocial counseling, social-legal advice, and family planning). Nevertheless, due to the high amount of information provided by support groups, this study shows that these are extremely valuable sources of information for patients suffering from a rare disease and their relatives.

  • Happiness Inventors: Prototypes & Sketches. Image sourced and copyright owned by authors.

    “Happiness Inventors”: Informing Positive Computing Technologies Through Participatory Design With Children


    Background: Positive psychological interventions for children have typically focused on direct adaptations of interventions developed for adults. As the community moves toward designing positive computing technologies to support child well-being, it is important to use a more participatory process that directly engages children’s voices. Objective: Our objectives were, through a participatory design study, to understand children’s interpretations of positive psychology concepts, as well as their perspectives on technologies that are best suited to enhance their engagement with practice of well-being skills. Methods: We addressed these questions through a content analysis of 434 design ideas, 51 sketches, and 8 prototype and videos, which emerged from a 14-session cooperative inquiry study with 12 child “happiness inventors.” The study was part of a summer learning camp held at the children’s middle school, which focused on teaching the invention process, teaching well-being skills drawn from positive psychology and related areas (gratitude, mindfulness, and problem solving), and iterating design ideas for technologies to support these skills. Results: The children’s ideas and prototypes revealed specific facets of how they interpreted gratitude (as thanking, being positive, and doing good things), mindfulness (as externally representing thought and emotions, controlling those thoughts and emotions, getting through unpleasant things, and avoiding forgetting something), and problem solving (as preventing bad decisions, seeking alternative solutions, and not dwelling on unproductive thoughts). This process also revealed that children emphasized particular technologies in their solutions. While desktop or laptop solutions were notably lacking, other ideas were roughly evenly distributed between mobile apps and embodied computing technologies (toys, wearables, etc). We also report on desired functionalities and approaches to engagement in the children’s ideas, such as a notable emphasis on representing and responding to internal states. Conclusions: Our findings point to promising directions for the design of positive computing technologies targeted at children, with particular emphases on the perspectives, technologies, engagement approaches, and functionalities that appealed to the children in our study. The dual focus of the study on teaching skills while designing technologies is a novel methodology in the design of positive computing technologies intended to increase child well-being.

  • Screenshot of the community under study (

    Factors Associated With Weight Change in Online Weight Management Communities: A Case Study in the LoseIt Reddit Community


    Background: Recent research has shown that of the 72% of American Internet users who have looked for health information online, 22% have searched for help to lose or control weight. This demand for information has given rise to many online weight management communities, where users support one another throughout their weight loss process. Whether and how user engagement in online communities relates to weight change is not totally understood. Objective: We investigated the activity behavior and analyze the semantic content of the messages of active users in LoseIt (r/loseit), a weight management community of the online social network Reddit. We then explored whether these features are associated with weight loss in this online social network. Methods: A data collection tool was used to collect English posts, comments, and other public metadata of active users (ie, users with at least one post or comment) on LoseIt from August 2010 to November 2014. Analyses of frequency and intensity of user interaction in the community were performed together with a semantic analysis of the messages, done by a latent Dirichlet allocation method. The association between weight loss and online user activity patterns, the semantics of the messages, and real-world variables was found by a linear regression model using 30-day weight change as the dependent variable. Results: We collected posts and comments of 107,886 unique users. Among these, 101,003 (93.62%) wrote at least one comment and 38,981 (36.13%) wrote at least one post. Median percentage of days online was 3.81 (IQR 9.51). The 10 most-discussed semantic topics on posts were related to healthy food, clothing, calorie counting, workouts, looks, habits, support, and unhealthy food. In the subset of 754 users who had gender, age, and 30-day weight change data available, women were predominant and 92.9% (701/754) lost weight. Female gender, body mass index (BMI) at baseline, high levels of online activity, the number of upvotes received per post, and topics discussed within the community were independently associated with weight change. Conclusions: Our findings suggest that among active users of a weight management community, self-declaration of higher BMI levels (which may represent greater dissatisfaction with excess weight), high online activity, and engagement in discussions that might provide social support are associated with greater weight loss. These findings have the potential to aid health professionals to assist patients in online interventions by focusing efforts on increasing engagement and/or starting discussions on topics of higher impact on weight change.

  • A digital pill. Image sourced and copyright owned by Peter R Chai.

    Digital Pills to Measure Opioid Ingestion Patterns in Emergency Department Patients With Acute Fracture Pain: A Pilot Study


    Background: Nonadherence to prescribed regimens for opioid analgesic agents contributes to increasing opioid abuse and overdose death. Opioids are frequently prescribed on an as-needed basis, placing the responsibility to determine opioid dose and frequency with the patient. There is wide variability in physician prescribing patterns because of the lack of data describing how patients actually use as-needed opioid analgesics. Digital pill systems have a radiofrequency emitter that directly measures medication ingestion events, and they provide an opportunity to discover the dose, timing, and duration of opioid therapy. Objective: The purpose of this study was to determine the feasibility of a novel digital pill system to measure as-needed opioid ingestion patterns in patients discharged from the emergency department (ED) after an acute bony fracture. Methods: We used a digital pill with individuals who presented to a teaching hospital ED with an acute extremity fracture. The digital pill consisted of a digital radiofrequency emitter within a standard gelatin capsule that encapsulated an oxycodone tablet. When ingested, the gastric chloride ion gradient activated the digital pill, transmitting a radiofrequency signal that was received by a hip-worn receiver, which then transmitted the ingestion data to a cloud-based server. After a brief, hands-on training session in the ED, study participants were discharged home and used the digital pill system to ingest oxycodone prescribed as needed for pain for one week. We conducted pill counts to verify digital pill data and open-ended interviews with participants at their follow-up appointment with orthopedics or at one week after enrollment in the study to determine the knowledge, attitudes, beliefs, and practices regarding digital pills. We analyzed open-ended interviews using applied thematic analysis. Results: We recruited 10 study participants and recorded 96 ingestion events (87.3%, 96/110 accuracy). Study participants reported being able to operate all aspects of the digital pill system after their training. Two participants stopped using the digital pill, reporting they were in too much pain to focus on the novel technology. The digital pill system detected multiple simultaneous ingestion events by the digital pill system. Participants ingested a mean 8 (SD 5) digital pills during the study period and four participants continued on opioids at the end of the study period. After interacting with the digital pill system in the real world, participants found the system highly acceptable (80%, 8/10) and reported a willingness to continue to use a digital pill to improve medication adherence monitoring (90%, 9/10). Conclusions: The digital pill is a feasible method to measure real-time opioid ingestion patterns in individuals with acute pain and to develop real-time interventions if opioid abuse is detected. Deploying digital pills is possible through the ED with a short instructional course. Patients who used the digital pill accepted the technology.

  • A Practice Approach to Developing Nutrition Label Reading Skills. Image sourced and copyright owned by authors.

    Developing Nutrition Label Reading Skills: A Web-Based Practice Approach


    Background: Nutrition labels offer the information needed to follow Dietary Guidelines for Americans, yet many individuals use labels infrequently or ineffectively due to limited comprehension and the effort required to use them. Objective: The objective of our study was to develop and test a Web-based label-reading training tool to improve individuals’ ability to use labels to select more healthful foods. We were particularly interested in determining whether practice can lead to increased accuracy using labels as well as decreased effort, together reflecting greater efficiency. We compared a basic and an enhanced, prior-knowledge version of the tool that contained an additional component, a brief nutrition tutorial. Methods: Participants were 140 college students with an average age of 20.7 (SD 2.1) years and education 14.6 (SD 1.2) years, who completed 3 sets of practice that were designed to teach them, through repetition and feedback, how to use nutrition labels to select more healthful products. Prior to training, participants in the prior-knowledge group viewed a multimedia nutrition presentation, which those in the basic group did not receive. Mixed-effects models tested for improvement in accuracy and speed with practice, and whether improvements varied by group. Results: The training led to significant increases in average accuracy across the 3 practice sets (averaging 79% [19/24 questions], 92% [22/24], 96% [23/24] respectively, P<.001), as well as decreases in time to complete with mean (SD) values of 8.7 (2.8), 4.6 (1.8), and 4.1 (1.7) seconds, respectively. In block 3, the odds of a correct answer for the prior-knowledge group were 79% higher (odds ratio, OR=1.79, 95% CI 1.1-2.9) than those for the basic group (P=.02). There was no significant difference between the groups in block 2 (P=.89). Conclusions: Practice led to improvements in nutrition label reading skills that are indicative of early stages of automatic processing. To the extent that automatic processes are at the core of healthy habit change, this may be an efficient way to improve dietary decision-making.

  • Xbox Kinect interaction. Image sourced and copyright owned by authors.

    The Use of Motion-Based Technology for People Living With Dementia or Mild Cognitive Impairment: A Literature Review


    Background: The number of people living with dementia and mild cognitive impairment (MCI) is increasing substantially. Although there are many research efforts directed toward the prevention and treatment of dementia and MCI, it is also important to learn more about supporting people to live well with dementia or MCI through cognitive, physical, and leisure means. While past research suggests that technology can be used to support positive aging for people with dementia or MCI, the use of motion-based technology has not been thoroughly explored with this population. Objective: The aim of this study was to identify and synthesize the current literature involving the use of motion-based technology for people living with dementia or MCI by identifying themes while noting areas requiring further research. Methods: A systematic review of studies involving the use of motion-based technology for human participants living with dementia or MCI was conducted. Results: A total of 31 articles met the inclusion criteria. Five questions are addressed concerning (1) context of use; (2) population included (ie, dementia, MCI, or both); (3) hardware and software selection; (4) use of motion-based technology in a group or individual setting; and (5) details about the introduction, teaching, and support methods applied when using the motion-based technology with people living with dementia or MCI. Conclusions: The findings of this review confirm the potential of motion-based technology to improve the lives of people living with dementia or MCI. The use of this technology also spans across several contexts including cognitive, physical, and leisure; all of which support multidimensional well-being. The literature provides evidence that people living with dementia or MCI can learn how to use this technology and that they enjoy doing so. However, there is a lack of information provided in the literature regarding the introduction, training, and support methods applied when using this form of technology with this population. Future research should address the appropriate introduction, teaching, and support required for people living with dementia or MCI to use the motion-based technology. In addition, it is recommended that the diverse needs of these specific end-users be considered in the design and development of this technology.

  • Aboriginal health provider training. Image sourced and copyright owned by authors.

    Translating E-Mental Health Into Practice: What Are the Barriers and Enablers to E-Mental Health Implementation by Aboriginal and Torres Strait Islander...


    Background: With increasing evidence for the effectiveness of e-mental health interventions for enhancing mental health and well-being, a growing challenge is how to translate promising research findings into service delivery contexts. A 2012 e-mental health initiative by the Australian Federal Government (eMHPrac) has sought to address the issue through several strategies, one of which has been to train different health professional workforces in e-mental health (e-MH). Objective: The aim of the study was to report on the barriers and enablers of e-MH uptake in a cohort of predominantly Aboriginal and Torres Strait Islander health professionals (21 Indigenous, 5 non-Indigenous) who occupied mainly support or case management roles within their organizations. Methods: A 3- or 2-day e-MH training program was followed by up to 5 consultation sessions (mean 2.4 sessions) provided by the 2 trainers. The trainer-consultants provided written reports on each of the 30 consultation sessions for 7 consultation groups. They were also interviewed as part of the study. The written reports and interview data were thematically analyzed by 2 members of the research team. Results: Uptake of e-MH among the consultation group was moderate (22%-30% of participants). There were significant organizational barriers to uptake resulting from procedural and administrative problems, demanding workloads, prohibitive policies, and a lack of fit between the organizational culture and the introduction of new technologies. Personal barriers included participant beliefs about the applicability of e-MH to certain populations, and workers’ lack of confidence and skills. However, enthusiastic managers and tech-savvy champions could provide a counter-balance as organizational enablers of e-MH; and the consultation sessions themselves appear to have enhanced skills and confidence, shifted attitudes to new technologies, and seeded a perception that e-MH could be a valuable health education resource. Conclusions: A conclusion from the program was that it was important to match e-MH training and resources to work roles. In the latter stages of the consultation sessions, the Aboriginal and Torres Strait Islander health professionals responded very positively to YouTube video clips and apps with a health education dimension. Therapy-oriented apps and programs may fit less well within the scope of practice of some workforces, including this one. We suggest that researchers broaden their focus and definitions of e-MH and give rather more weight to e-MH’s health education possibilities. Developing criteria for evaluating apps and YouTube videos may empower a rather greater section of health workforce to use e-MH with their clients.

  • Pregnancy test. Image source: . Author: Johannes Jander. Copyright:

    Patient Information Websites About Medically Induced Second-Trimester Abortions: A Descriptive Study of Quality, Suitability, and Issues


    Background: Patients undergoing medically induced second-trimester abortions feel insufficiently informed and use the Web for supplemental information. However, it is still unclear how people who have experience with pregnancy termination appraise the quality of patient information websites about medically induced second-trimester abortions, whether they consider the websites suitable for patients, and what issues they experience with the websites. Objective: Our objective was to investigate the quality of, suitability of, and issues with patient information websites about medically induced second-trimester abortions and potential differences between websites affiliated with the health care system and private organizations. Methods: We set out to answer the objective by using 4 laypeople who had experience with pregnancy termination as quality assessors. The first 50 hits of 26 systematic searches were screened (N=1300 hits) using search terms reported by the assessors. Of these hits, 48% (628/1300) were irrelevant and 51% (667/1300) led to websites about medically induced second-trimester abortions. After correcting for duplicate hits, 42 patient information websites were included, 18 of which were affiliated with the health care system and 24 with private organizations. The 4 assessors systematically assessed the websites with the DISCERN instrument (total score range 16-80), the Ensuring Quality Information for Patients (EQIP) tool (total score range 0-100), as well as questions concerning website suitability and perceived issues. Results: The interrater reliability was 0.8 for DISCERN and EQIP, indicating substantial agreement between the assessors. The total mean score was 36 for DISCERN and 40 for EQIP, indicating poor overall quality. Websites from the health care system had greater total EQIP (45 vs 37, P>.05) and reliability scores (22 vs 20, P>.05). Only 1 website was recommended by all assessors and 57% (24/42) were rated as very unsuitable by at least one assessor. The most reported issues with the websites involved lack of information (76%, 32/42), and poor design (36%, 15/42). Conclusions: The high number of irrelevant hits and poor quality of patient information websites are considerable issues that must be addressed and considered when consulting patients awaiting medically induced second-trimester abortions. In clinical encounters, health professionals should initiate discussions concerning websites about medically induced second-trimester abortions and inform patients about the issues and quality deficits associated with these websites.

  • Laptop. Image source: Author: John Loo. Copyright:

    The Associations Among Individual Factors, eHealth Literacy, and Health-Promoting Lifestyles Among College Students


    Background: eHealth literacy is gaining importance for maintaining and promoting health. Studies have found that individuals with high eHealth literacy are more likely to adopt healthy eating, exercise, and sleep behaviors. In addition, previous studies have shown that various individual factors (eg, frequency of seeking information on health issues, degree of health concern, frequency of eating organic food, and students’ college major) are associated with eHealth literacy and health-promoting lifestyles. Nevertheless, few studies have explored the associations among individual factors, eHealth literacy, and health-promoting lifestyles among college students. Moreover, there is a lack of studies that focus on eHealth literacy as a predictor of psychological health behaviors. Objective: To examine the associations among various individual factors, eHealth literacy, and health-promoting lifestyles. Methods: The eHealth Literacy Scale is a 12-item instrument designed to measure college students’ functional, interactive, and critical eHealth literacy. The Health-promoting Lifestyle Scale is a 23-item instrument developed to measure college students’ self-actualization, health responsibility, interpersonal support, exercise, nutrition, and stress management. A nationally representative sample of 556 valid college students in Taiwan was surveyed. A questionnaire was administered to gather the respondents’ background information, including the frequency of seeking information on health issues, the frequency of eating organic food, the degree of health concern, and the students’ major. We then conducted a multiple regression analysis to examine the associations among individual factors, eHealth literacy, and health-promoting lifestyles. Results: The study found that factors such as medical majors (t550=2.47-7.55, P<.05) and greater concern with health (t550=2.15-9.01, P<.05) predicted college students’ 4-6 health-promoting lifestyle dimensions and the 3 dimensions of eHealth literacy. Moreover, critical eHealth literacy positively predicted all 6 health-promoting lifestyle dimensions (t547=2.66-7.28, P<.01), functional literacy positively predicted 2 dimensions (t547=2.32-2.98, P<.05), and interactive literacy predicted only the self-actualization dimension (t547=2.81, P<.01). Conclusions: This study found that participants who majored in medical fields had greater concern with their health and frequently sought health information, exhibited better eHealth literacy, and had a positive health-promoting lifestyle. Moreover, this study showed that college students with a higher critical eHealth literacy engaged better in health-promoting activities than those with functional and interactive literacy.

  • Screenshot of the intervention arm website dashboard. Image sourced and copyright owned by authors.

    Does Usage of an eHealth Intervention Reduce the Risk of Excessive Gestational Weight Gain? Secondary Analysis From a Randomized Controlled Trial


    Background: Excessive gestational weight gain (GWG) contributes to the development of obesity in mother and child. Internet-based interventions have the potential for delivering innovative and interactive options for prevention of excessive GWG to large numbers of people. Objective: The objective of this study was to create a novel measure of Internet-based intervention usage patterns and examine whether usage of an Internet-based intervention is associated with reduced risk of excessive GWG. Methods: The website featured blogs, local resources, articles, frequently asked questions (FAQs), and events that were available to women in both the intervention and control arm. Weekly reminders to use the website and to highlight new content were emailed to participants in both arms. Only intervention arm participants had access to the weight gain tracker and diet and physical activity goal-setting tools. A total of 1335 (898 intervention and 437 control) relatively diverse and healthy pregnant women were randomly assigned to the intervention arm or control arm. Usage patterns were examined for both intervention and control arm participants using latent class analysis. Regression analyses were used to estimate the association between usage patterns and three GWG outcomes: excessive total GWG, excessive GWG rate, and GWG. Results: Five usage patterns best characterized the usage of the intervention by intervention arm participants. Three usage patterns best characterized control arm participants’ usage. Control arm usage patterns were not associated with excessive GWG, whereas intervention arm usage patterns were associated with excessive GWG. Conclusions: The control and intervention arm usage pattern characterization is a unique methodological contribution to process evaluations for self-directed Internet-based interventions. In the intervention arm some usage patterns were associated with GWG outcomes. ClinicalTrial:; Clinical Trials Number: NCT01331564; (Archived by WebCite at http://www.webcitation/6nI9LuX9w)

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

    Date Submitted: Jan 18, 2017

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

    Background: Cancer has become increasingly prevalent in China over the past few decades. Among symptoms related to the quality of life of cancer patients, pain has commonly been recognized as a most c...

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

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

    Date Submitted: Jan 17, 2017

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

    Background: Illness management after an acute coronary syndrome (ACS) is crucial to prevent cardiac complications, foster participation in a cardiac rehabilitation program and optimize recovery. Web-b...

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

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

    Date Submitted: Jan 17, 2017

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

    Background: The rise in mobile phone ownership in low- and middle-income countries (LMIC) presents an opportunity to transform existing data collection and surveillance methods. Administering surveys...

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

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

    Date Submitted: Jan 16, 2017

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

    Background: Given the growing interest in mobile data collection due to the proliferation of mobile phone ownership and network coverage in low- and middle-income countries (LMICs), we synthesized the...

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

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

    Date Submitted: Jan 13, 2017

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

    Background: Tobacco smoking is a worldwide public health problem. In 2015, 26.3% of the Dutch population of 18 years and older smoked, which of 74.4% were daily smoker. More and more people have acces...

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

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

    Date Submitted: Jan 11, 2017

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

    Background: In 2015, 90% of U.S. young adults with internet access used social media. Digital and social media are highly prevalent modalities through which young adults explore identity formation, an...

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