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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2017: 4.671, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As leading high-impact journal in its' disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

As open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (eg, in grant proposals), and for open peer-review purposes. We also invite patients to participate (eg, as peer-reviewers) and have patient representatives on editorial boards.

Be a widely cited leader in the digitial health revolution and submit your paper today!


Recent Articles:

  • Patient-provider communication during a medical encounter. Source: iStock by Getty Images; Copyright: Sasha_Suzi; URL:; License: Licensed by the authors.

    Perceived Patient-Provider Communication Quality and Sociodemographic Factors Associated With Watching Health-Related Videos on YouTube: A Cross-Sectional...


    Background: Approximately 73% of US adults use YouTube, making it the most popular social media platform. Misinformation on social media is a growing concern; recent studies show a high proportion of misinformative health-related videos. Several studies on patient-provider communication and general health information seeking have been conducted. However, few studies to date have examined the potential association between patient-provider communication and health information seeking on specific social media platforms such as YouTube. A better understanding of this relationship may inform future health communication interventions. Objective: The aim was to use nationally representative cross-sectional data to describe the association between perceived patient-provider communication quality and sociodemographic factors on watching YouTube health-related videos. Methods: Data from the 2018 Health Information National Trends Survey were analyzed (N=3504). The primary outcome was whether participants watched a health-related video on YouTube over the past 12 months. A patient-provider communication composite score was created by summing responses about how often providers did the following: (1) gave you the chance to ask all the health-related questions you had, (2) gave attention to your feelings, (3) involved you in health care decisions as much as you wanted, (4) made sure that you understood the things you needed to do to take care of your health, (5) explained things in a way that you could understand, (6) spent enough time with you, and (7) helped you deal with feelings of uncertainty. Sociodemographic factors included age, gender, race/ethnicity, and education. Descriptive statistics and multivariable logistic regression were conducted. Results: Approximately 1067 (35% weighted prevalence) participants reported watching a health-related video on YouTube. Higher perceived quality of patient-provider communication on the composite score was significantly associated with lower odds of watching health-related videos on YouTube. Regarding sociodemographic factors, increasing age and being a high school graduate (compared with college graduate) were associated with lower odds of watching health-related videos on YouTube; whereas, Hispanic and non-Hispanic Asians were more likely to have watched a health-related video on YouTube. For individual aspects of patient-physician communication, two of seven patient-provider communication variables were significant. Those who reported that providers “sometimes” spent enough time with them had higher odds of watching a health-related video on YouTube, compared with those who said providers “always” spent enough time with them. Participants reporting that they “never” have a chance to ask all their health-related questions also had higher odds of watching health-related videos on YouTube compared with those who reported “always.” Conclusions: Higher perceived quality of patient-provider communication is associated with lower odds of watching health-related videos on YouTube. When providers do not spend enough time or give an opportunity to ask questions, patients are more likely to pursue health information on social media.

  • Source: Flickr; Copyright: Pan American Health Organization PAHO; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Case of Paradoxical Cultural Sensitivity: Mixed Method Study of Web-Based Health Informational Materials About the Human Papillomavirus Vaccine in Israel


    Background: Designing web-based informational materials regarding the human papillomavirus (HPV) vaccine has become a challenge for designers and decision makers in the health authorities because of the scientific and public controversy regarding the vaccine’s safety and effectiveness and the sexual and moral concerns related to its use. Objective: The study aimed to investigate how cultural sensitivity (CS) is articulated in the explanatory informational materials on the HPV vaccine that are posted on the websites of the Israeli health authorities. In addition, the study examined the effect of transparency on the expression of CS in the informational materials. Methods: The study employed a quantitative and qualitative content analysis of the texts of explanatory informational materials published on the Arabic and Hebrew websites of the Israel Ministry of Health and the Clalit health maintenance organization (HMO). Results: The findings revealed the differences in the dimensions of CS (based on the CS model by Resnicow) between the informational materials targeting the majority Jewish population and those targeting the minority Arab population. Indeed, the research findings point to a paradox. On the one hand, the materials appealing to the conservative Arab population exhibited CS, in that the sexual context of the vaccine was missing. On the other hand, analysis of Resnicow's deep dimensions showed that disregarding the sexual context does not allow the relevant target audience to reflect on the barriers and concerns. In addition, the way the information was provided exhibited a lack of transparency regarding the CS dimensions (surface and deep). Conclusions: The public health authorities have 2 main objectives in the context of vaccinations. One is to raise the vaccination rates and the other is to provide full and culturally sensitive information to give the public the tools to make intelligent decisions. The findings of this study indicated that despite the high uptake rate for HPV vaccination in the Arab population, the health authorities did not exercise full transparency and CS in transmitting the association between engaging in sexual relations and the necessity of the vaccination. Thus, the major challenge for the health authorities is to find ways to implement the objective of communicating information about the vaccination in a way that is transparent and culturally sensitive, even if this raises questions and fears among the public deriving from their culture.

  • Source: Flickr; Copyright: Mode Shift Move Together; URL:; License: Creative Commons Attribution + Noncommercial + ShareAlike (CC-BY-NC-SA).

    A Digital Behavioral Weight Gain Prevention Intervention in Primary Care Practice: Cost and Cost-Effectiveness Analysis


    Background: Obesity is one of the largest drivers of health care spending but nearly half of the population with obesity demonstrate suboptimal readiness for weight loss treatment. Black women are disproportionately likely to have both obesity and limited weight loss readiness. However, they have been shown to be receptive to strategies that prevent weight gain. Objective: The aim of this study was to evaluate the costs and cost-effectiveness of a digital weight gain prevention intervention (Shape) for black women. Shape consisted of adaptive telephone-based coaching by health system personnel, a tailored skills training curriculum, and patient self-monitoring delivered via a fully automated interactive voice response system. Methods: A cost and cost-effectiveness analysis based on a randomized clinical trial of the Shape intervention was conducted from the payer perspective. Costs included those of delivering the program to 91 intervention participants in the trial and were summarized by program elements: self-monitoring, skills training, coaching, and administration. Effectiveness was measured in quality-adjusted life years (QALYs). The primary outcome was the incremental cost per QALY of Shape relative to usual care. Results: Shape cost an average of US $758 per participant. The base-case model in which quality of life benefits decay linearly to zero 5 years post intervention cessation, generated an incremental cost-effectiveness ratio (ICER) of US $55,264 per QALY. Probabilistic sensitivity analyses suggest an ICER below US $50,000 per QALY and US $100,000 per QALY in 39% and 98% of simulations, respectively. Results are highly sensitive to durability of benefits, rising to US $165,730 if benefits end 6 months post intervention. Conclusions: Results suggest that the Shape intervention is cost-effective based on established benchmarks, indicating that it can be a part of a successful strategy to address the nation’s growing obesity epidemic in low-income at-risk communities.

  • Using a blockchain system in a clinical trial. Source: Pixabay / Pexels / The Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Secure and Scalable mHealth Data Management Using Blockchain Combined With Client Hashchain: System Design and Validation


    Background: Blockchain is emerging as an innovative technology for secure data management in many areas, including medical practice. A distributed blockchain network is tolerant against network fault, and the registered data are resistant to tampering and revision. The technology has a high affinity with digital medicine like mobile health (mHealth) and provides reliability to the medical data without labor-intensive third-party contributions. On the other hand, the reliability of the medical data is not insured before registration to the blockchain network. Furthermore, there are issues with regard to how the clients' mobile devices should be dealt with and authenticated in the blockchain network in order to avoid impersonation. Objective: The aim of the study was to design and validate an mHealth system that enables the compatibility of the security and scalability of the medical data using blockchain technology. Methods: We designed an mHealth system that sends medical data to the blockchain network via relay servers. The architecture provides scalability and convenience of operation of the system. In order to ensure the reliability of the data from clients' mobile devices, hash values with chain structure (client hashchain) were calculated in the clients' devices and the results were registered on the blockchain network. Results: The system was applied and deployed in mHealth for insomnia treatment. Clinical trials for mHealth were conducted with insomnia patients. Medical data of the recruited patients were successfully registered with the blockchain network via relay servers along with the hashchain calculated on the clients' mobile devices. The correctness of the data was validated by identifying illegal data, which were made by simulating fraudulent access. Conclusions: Our proposed mHealth system, blockchain combined with client hashchain, ensures compatibility of security and scalability in the data management of mHealth medical practice. Trial Registration: UMIN Clinical Trials Registry UMIN000032951; bin/ctr_e/ctr_view.cgi?recptno=R000037564 (Archived by WebCite at

  • Source: Freepik; Copyright: Freepik; URL:; License: Licensed by JMIR.

    Assessment of Use and Preferences Regarding Internet-Based Health Care Delivery: Cross-Sectional Questionnaire Study


    Background: There has been an incremental increase in the use of technology in health care delivery. Feasibility, acceptability, and efficacy of interventions based on internet technologies are supported by a growing body of evidence. Objective: The aim of this study was to investigate use and preferences in the general adult population in Germany for remote, internet-based interaction (eg, email, videoconferencing, electronic medical records, apps). Methods: A nationwide cross-sectional questionnaire survey in adults that was representative in terms of age, sex and educational level was carried out. Results: A total of 22.16% (538/2428) of survey participants reported not using the internet for work or private use. The nonuser phenotype can be described as being older, having lower educational and income status, and living in less populated areas. The majority of participants within the cohort of internet users reported that they would not consider using electronic medical records (973/1849, 52.62%), apps (988/1854, 53.29%), or emails to report symptoms (1040/1838, 56.58%); teleconference with one (1185/1852, 63.98%) or more experts (1239/1853, 66.86%); or participate in video psychotherapy (1476/1853, 79.65%) for the purpose of medical consultation or treatment. Older age and lower educational level were the most robust predictors of assumed future denial of use. Conclusions: Our results point toward low use and preference rates among the general population for the use of telemedicine. It also seems that those who might benefit from telemedical interventions the most, are, in fact, those who are most hesitating. These low use and preference rates of eHealth should be considered prior to designing and providing future telemedical care, supporting the need for easy-to-use, data secure solutions.

  • Source: PxHere; Copyright: PxHere; URL:; License: Public Domain (CC0).

    Prediction of the 1-Year Risk of Incident Lung Cancer: Prospective Study Using Electronic Health Records from the State of Maine


    Background: Lung cancer is the leading cause of cancer death worldwide. Early detection of individuals at risk of lung cancer is critical to reduce the mortality rate. Objective: The aim of this study was to develop and validate a prospective risk prediction model to identify patients at risk of new incident lung cancer within the next 1 year in the general population. Methods: Data from individual patient electronic health records (EHRs) were extracted from the Maine Health Information Exchange network. The study population consisted of patients with at least one EHR between April 1, 2016, and March 31, 2018, who had no history of lung cancer. A retrospective cohort (N=873,598) and a prospective cohort (N=836,659) were formed for model construction and validation. An Extreme Gradient Boosting (XGBoost) algorithm was adopted to build the model. It assigned a score to each individual to quantify the probability of a new incident lung cancer diagnosis from October 1, 2016, to September 31, 2017. The model was trained with the clinical profile in the retrospective cohort from the preceding 6 months and validated with the prospective cohort to predict the risk of incident lung cancer from April 1, 2017, to March 31, 2018. Results: The model had an area under the curve (AUC) of 0.881 (95% CI 0.873-0.889) in the prospective cohort. Two thresholds of 0.0045 and 0.01 were applied to the predictive scores to stratify the population into low-, medium-, and high-risk categories. The incidence of lung cancer in the high-risk category (579/53,922, 1.07%) was 7.7 times higher than that in the overall cohort (1167/836,659, 0.14%). Age, a history of pulmonary diseases and other chronic diseases, medications for mental disorders, and social disparities were found to be associated with new incident lung cancer. Conclusions: We retrospectively developed and prospectively validated an accurate risk prediction model of new incident lung cancer occurring in the next 1 year. Through statistical learning from the statewide EHR data in the preceding 6 months, our model was able to identify statewide high-risk patients, which will benefit the population health through establishment of preventive interventions or more intensive surveillance.

  • Source: Flickr; Copyright: US Department of Agriculture; URL:; License: Creative Commons Attribution (CC-BY).

    Developing the National Usability-Focused Health Information System Scale for Physicians: Validation Study


    Background: Problems in the usability of health information systems (HISs) are well acknowledged, but research still lacks a validated questionnaire for measuring and monitoring different dimensions of usability of HISs. Such questionnaires are needed not only for research but also for developing usability of HISs from the viewpoint of end-user experiences. Objective: This study aimed to develop and test the validity of the questionnaire measuring the National Usability-Focused HIS-Scale (NuHISS) among a nationally representative sample of Finnish physicians. Methods: We utilized 2 cross-sectional data collected from a random sample of Finnish physicians in 2014 (N=3781; of which 2340 [61.9%] were women) and 2017 (N=4018; of which 2604 [64.8%] were women). Exploratory and confirmatory factor analyses (structural equation modeling [SEM]) were applied to test the structural validity of the NuHISS. As the concurrent validity measure, we used the self-reported overall quality of the electronic health record system (school grade) provided by the participants using marginal structural models. Results: The exploratory factor analyses with Varimax rotation suggested that the 7-factor solution did offer a good fit to the data in both samples (C2=2136.14 in 2014 and C2=2109.83 in 2017, both P<.001). Moreover, structural equation modelling analyses, using comparative fit index (CFI), Tucker-Lewis Index (TLI), Normed Fit Index (NFI), root mean squared error of approximation (RMSEA), and Standardized Root Mean square Residual (SRMR), showed that the 7-factor solution provided an acceptable fit in both samples (CFI=0.92/0.91, TLI=0.92/0.91, NFI=0.92/0.91, RMSEA=0.048/0.049, and SRMR=0.040/0.039). In addition, concurrent validity of this solution was shown to be acceptable. Ease of use, but also all other dimensions, was especially associated with overall quality reports independent of measured confounders. The 7-factor solution included dimensions of technical quality, information quality, feedback, ease of use, benefits, internal collaboration, and cross-organizational collaboration. Conclusions: NuHISS provides a useful tool for measuring usability of HISs among physicians and offers a valid measure for monitoring the long-term development of HISs on a large scale. The relative importance of items needs to be assessed against national electronic health policy goals and complemented with items that have remained outside the NuHISS from the questionnaire when appropriate.

  • Source: Marco Verch; Copyright: Marco Verch; URL:; License: Creative Commons Attribution (CC-BY).

    Methodology Used in Ecological Momentary Assessment Studies About Sedentary Behavior in Children, Adolescents, and Adults: Systematic Review Using the...


    Background: The use of ecological momentary assessment (EMA) to measure sedentary behavior (SB) in children, adolescents, and adults can increase the understanding of the role of the context of SB in health outcomes. Objective: The aim of this study was to systematically review literature to describe EMA methodology used in studies on SB in youth and adults, verify how many studies adhere to the Methods aspect of the Checklist for Reporting EMA Studies (CREMAS), and detail measures used to assess SB and this associated context. Methods: A systematic literature review was conducted in the PubMed, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and SPORTDiscus databases, covering the entire period of existence of the databases until January 2018. Results: This review presented information about the characteristics and methodology used in 21 articles that utilized EMA to measure SB in youth and adults. There were more studies conducted among youth compared with adults, and studies of youth included more waves and more participants (n=696) than studies with adults (n=97). Most studies (85.7%) adhered to the Methods aspect of the CREMAS. The main criteria used to measure SB in EMA were self-report (81%) with only 19% measuring SB using objective methods (eg, accelerometer). The main equipment to collect objective SB was the ActiGraph, and the cutoff point to define SB was <100 counts/min. Studies most commonly used a 15-min window to compare EMA and accelerometer data. Conclusions: The majority of studies in this review met minimum CREMAS criteria for studies conducted with EMA. Most studies measured SB with EMA self-report (n=17; 81.0%), and a few studies also used objective methods (n=4; 19%). The standardization of the 15-min window criteria to compare EMA and accelerometer data would lead to a comparison between these and new studies. New studies using EMA with mobile phones should be conducted as they can be considered an attractive method for capturing information about the specific context of SB activities of young people and adults in real time or very close to it.

  • Source: Freepik; Copyright: katemangostar; URL:; License: Licensed by JMIR.

    An Internet-Based Self-Testing Model (Easy Test): Cross-Sectional Survey Targeting Men Who Have Sex With Men Who Never Tested for HIV in 14 Provinces of China


    Background: With China’s explosive internet growth, activities such as socializing and partner seeking among men who have sex with men (MSM) has also become Web based through popular services such as Blued. This creates a new mode of health promotion with the potential to instantly reach large numbers of MSM, including those who rarely access traditional offline testing facilities. Objective: This study aimed to assess the feasibility of the Easy Test in increasing access and uptake of HIV testing and treatment services among MSM and to identify demographic and behavioral predictors of program uptake to inform future implementation. Methods: A feasibility study of the Easy Test model was conducted from October 2017 to December 2017 in 14 Chinese provinces. Applicants who provided informed consent completed a self-administered questionnaire and submitted a US $5 deposit to have the free test kit delivered to their homes. Orders were then received, processed, and posted by volunteers from local community-based organizations. Once applicants submitted images of their test results, the deposit was refunded to the applicant. Those whose test results were deemed to be HIV-positive were then connected to a peer navigator to accompany the individual to follow-up medical services. A chi-squared trend test was used to assess the relationship between lifetime HIV testing volume and HIV prevalence. Logistic regression models were used to identify independent risk factors associated with two outcomes: (1) never having tested for HIV and (2) receiving an HIV-positive result. Results: A total of 879 individuals submitted Web-based requests for test kits. Their median age was 28 (interquartile range 24-34 years); 69.3% (609/879) had at least a college education, and 51.5% (453/879) had a monthly income between US $450 to $750; 77.7% (683/879) of the applicants submitted images of their test results, among whom 14.3% (98/683) had an HIV-positive result. Among the 42.9% (293/683) who were first-time testers, the HIV prevalence was 18.8% (55/293). Nearly three-quarters (71/98, 72.4%) of those with a positive test result were connected with a peer navigator and enrolled in treatment. Among the first-time testers, having multiple sexual partners (2-3 sexual partners: adjusted odds ratio [aOR] 2.44, 95% CI 1.08-5.50; 4 or above sexual partners: aOR 3.55, 95% CI 1.18-10.68) and reporting inconsistent condom use in the previous 3 months (aOR 7.95, 95% CI 3.66-17.26) were both associated with an HIV-positive result. An inverse dose response relationship between lifetime HIV testing volume and HIV prevalence was also observed in this study (χ23=55.0; P<.001). Conclusions: The Easy Test model reached a larger portion of first-time testers, many who reported higher risk sexual behaviors. This highlights the potential for an internet-based self-test model to increase access to HIV treatment services for HIV-positive MSM in China.

  • A woman using the cooperative citizen science platform. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    The Role of Social Interactions in Motor Performance: Feasibility Study Toward Enhanced Motivation in Telerehabilitation


    Background: Robot-mediated telerehabilitation has the potential to provide patient-tailored cost-effective rehabilitation. However, compliance with therapy can be a problem that undermines the prospective advantages of telerehabilitation technologies. Lack of motivation has been identified as a major factor that hampers compliance. Exploring various motivational interventions, the integration of citizen science activities in robotics-based rehabilitation has been shown to increase patients’ motivation to engage in otherwise tedious exercises by tapping into a vast array of intrinsic motivational drivers. Patient engagement can be further enhanced by the incorporation of social interactions. Objective: Herein, we explored the possibility of bolstering engagement in physical therapy by leveraging cooperation among users in an environmental citizen science project. Specifically, we studied how the integration of cooperation into citizen science influences user engagement, enjoyment, and motor performance. Furthermore, we investigated how the degree of interdependence among users, such that is imposed through independent or joint termination (JT), affects participation in citizen science-based telerehabilitation. Methods: We developed a Web-based citizen science platform in which users work in pairs to classify images collected by an aquatic robot in a polluted water canal. The classification was carried out by labeling objects that appear in the images and trashing irrelevant labels. The system was interfaced by a haptic device for fine motor rehabilitation. We recruited 120 healthy volunteers to operate the platform. Of these volunteers, 98 were cooperating in pairs, with 1 user tagging images and the other trashing labels. The other 22 volunteers performed both tasks alone. To vary the degree of interdependence within cooperation, we implemented independent and JTs. Results: We found that users’ engagement and motor performance are modulated by their assigned task and the degree of interdependence. Motor performance increased when users were subjected to independent termination (P=.02), yet enjoyment decreased when users were subjected to JT (P=.005). A significant interaction between the type of termination and the task was found to influence productivity (P<.001) as well as mean speed, peak speed, and path length of the controller (P=.01, P=.006, and P<.001, respectively). Conclusions: Depending on the type of termination, cooperation was not always positively associated with engagement, enjoyment, and motor performance. Therefore, enhancing user engagement, satisfaction, and motor performance through cooperative citizen science tasks relies on both the degree of interdependence among users and the perceived nature of the task. Cooperative citizen science may enhance motivation in robotics-based telerehabilitation, if designed attentively.

  • Source: Wikimedia Commons; Copyright: Sigismund von Dobschütz; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Remediating Reduced Autobiographical Memory in Healthy Older Adults With Computerized Memory Specificity Training (c-MeST): An Observational Before-After Study


    Background: The ability to retrieve specific autobiographical memories decreases with cognitive aging. This decline is clinically relevant due to its association with impairments in problem solving, daily functioning, and depression. A therapist-delivered group training protocol, Memory Specificity Training (MeST), has been shown to enhance the retrieval of specific memories while ameliorating the impairments and negative outcomes associated with reduced specificity. The therapist-delivered nature of this intervention means it is relatively expensive to deliver and difficult for people with mobility impairments, such as older people, to receive. Objective: The objective of this study was to test if a novel, Web-based computerized version of a group training protocol called Memory Specificity Training, has the potential to increase autobiographical memory specificity and impact associated secondary psychological processes. Methods: A total of 21 participants (13 female; mean age 67.05, SD 6.55) who experienced a deficit in retrieving specific autobiographical memory were trained with c-MeST. We assessed memory specificity at preintervention and postintervention, as well as secondary processes such as depressive symptoms, rumination, and problem-solving skills. Results: Memory specificity increased significantly after participants completed c-MeST (r=.57). Session-to-session scores indicated that autobiographical memory specificity improved most from the online baseline assessment to the first Web-based session. Symptoms or secondary processes such as problem-solving skills did not change significantly. Conclusions: A Web-based automated individual version of MeST is a feasible, low-cost intervention for reduced memory specificity in healthy older adults. Future studies should clarify the preventive impact of c-MeST in other at-risk sample populations with longer follow-up times.

  • Source: Freepik; Copyright: yanalya; URL:; License: Licensed by JMIR.

    Profiles of a Health Information–Seeking Population and the Current Digital Divide: Cross-Sectional Analysis of the 2015-2016 California Health Interview...


    Background: Internet use for health information is important, given the rise of electronic health (eHealth) that integrates technology into health care. Despite the perceived widespread use of the internet, a persistent “digital divide” exists in which many individuals have ready access to the internet and others do not. To date, most published reports have compared characteristics of internet users seeking health information vs nonusers. However, there is little understanding of the differences between internet users seeking health information online and users who do not seek such information online. Understanding these differences could enable targeted outreach for health interventions and promotion of eHealth technologies. Objective: This study aims to assess population-level characteristics associated with different types of internet use, particularly for seeking online health information. Methods: The 2015-2016 California Health Interview Survey datasets were used for this study. Internet use was classified as never used the internet (Never use), ever used the internet but not to search for health information in the last 12 months (Use not for health), and ever used the internet and have used it to search for health information in the last 12 months (Use for health). Weighted multinomial logistic regression was used to assess sociodemographic and health characteristics associated with types of internet use. Findings are reported as odds ratios (ORs) with 95% CIs. Results: Among 42,087 participants (weighted sample of 29,236,426), 19% reported Never Use of the internet, 27.9% reported Use not for health, and 53.1% reported Use for health. Compared to Never Use individuals, Use for health individuals were more likely to be younger (OR: 0.1, 95% CI 0.1-0.2 for ≥60 years vs <60 years), female (OR: 1.6, 95% CI 1.3-1.9 compared to males), and non-Hispanic white (OR: 0.54, 95% CI 0.4-0.7 for Latinos and OR: 0.2, 95% CI 0.2-0.4 for African Americans) and have a higher socioeconomic status (>400% of Federal Poverty Guidelines; OR: 1.3, 95% CI 1.4-2.4). Overall, characteristics for the Use not for health and Use for health groups were similar, except for those with lower levels of education and respondents not having visited a physician in the last year. For these two characteristics, the Use not for health group was more similar to the Never Use group. Conclusions: Our findings indicate that a digital divide characterized by sociodemographic and health information exists across three types of users. Our results are in line with those of previous studies on the divide, specifically with regard to disparities in use and access related to age, race/ethnicity, and socioeconomic status. Disparities in online health-seeking behavior may reflect existing disparities in health care access extending into a new era of health technology. These findings support the need for interventions to target internet access and health literacy among Never Use and Use not for health groups.

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  • Exploring Patient Needs in Online Health Communities Using Text Mining--Taking Diabetes and Depression as Examples

    Date Submitted: May 14, 2019

    Open Peer Review Period: May 17, 2019 - Jul 12, 2019

    Background: Online Health Community (OHC) refers to a forum where patients, their family members, doctors and caregivers communicate with each other. Patients who participate in OHCs can obtain benefi...

    Background: Online Health Community (OHC) refers to a forum where patients, their family members, doctors and caregivers communicate with each other. Patients who participate in OHCs can obtain benefits for disease treatments and health management, so identifying the categories of patient needs and how they are satisfied are significant to determining theories of patient demand and community construction. Objective: (1) Explore the needs of patients in the Internet environment. (2) Distinguish the similarities and differences of patient needs among OHCs of different types and concerning different diseases. (3) Proposed a method for automatically identifying patient demands in Internet environments. Methods: This study used a combination of manual annotation and computer-aided method to mine value of 9936 posts collected from four OHCs in China. On one hand, we recruited 7 diabetes or depression medical experts to label text according to a theoretical framework, forming patient need theory in Internet environments, which is designed for the first two research goals. On the other hand, based on the corpus constructed by manual annotation, this research used Natural Language Processing (NLP) and Machine Learning (ML) to train a model for automatically identifying patient demands, which is planned to reach the third research purpose. Results: According to statistical results, the proportion of posts related to patient needs in OHCs was approximately 91%, and posts concerned with Emotional Support (18%), Information (28%) and Socialization (44%) needs were the top three most prevalent categories. However, when OHCs were divided according to user composition and disease type, patient needs were diverse: the chief demand was Socialization in Patient Interaction OHCs (65%), Diabetes OHCs (50%), and Depression OHCs (69%), while Information (96%) was the chief demand in Patient-Doctor Interaction OHCs. A model was trained to identify patient needs taking Linguistic Features (LF) and Category Keyword Features (CKF) as input and Random Forest as the classifier, of which the F1 value was higher than 0.80 on test set. Conclusions: Patient needs in the Internet environment mainly include Emotional Support needs, Information needs and Socialization needs. Differences in community type and disease type can lead to diverse patient needs in OHCs. It is practical to use computer-aided methods to identify patient needs in OHCs automatically.

  • Sustainability of mHealth effects on cardiometabolic risk factors: 5-year results of a randomized clinical trial

    Date Submitted: May 14, 2019

    Open Peer Review Period: May 17, 2019 - Jul 12, 2019

    Background: Long-term effect of mHealth interventions has not been documented, especially in resource-constrained settings. Objective: This study aimed at assessing the 5-year effect of a mHealth inte...

    Background: Long-term effect of mHealth interventions has not been documented, especially in resource-constrained settings. Objective: This study aimed at assessing the 5-year effect of a mHealth intervention on blood pressure levels and bodyweight in low-resource urban settings in Peru. Methods: After 5 years from randomisation, we attempted to contact the 212 individuals originally enrolled in the GISMAL Study in Peru. Primary outcomes were changes in systolic and diastolic blood pressure; and, in addition, hypertension incidence was also evaluated. Secondary outcome measures were changes in bodyweight and body mass index, and self-reported target behaviours. Study personnel collecting data were masked to group assignment. Linear mixed models were used to evaluate the effect of the intervention in primary and secondary outcomes in an intent-to-treat analysis. Results: Data from 164 (77.4%) out of 212 participants originally enrolled were available and analysed (80 in the intervention and 84 in the control group). The intervention did not result in changes in systolic (-2.54 mm Hg; 95% CI: -8.23; 3.15) or diastolic blood pressure (3.41 mm Hg; 95% CI: -0.75; 7.57) compared with the control group. The intervention reduced the risk of developing hypertension, but result was not significant (RR = 0.76; 95% CI: 0.45; 1.28). However, among secondary outcomes, those who received the intervention had a lower bodyweight (-5.42 kg; 95% CI: -10.4; -0.48) and BMI (-2.56 kg/m2; 95% CI: -4.46; -0.66). In addition, compared to controls, those who received ≥50% of the scheduled calls during the intervention had greater reductions of bodyweight (-6.23 kg; 95% CI: -11.47; -0.99) and BMI (-2.81 kg/m2; 95% CI: -4.77; -0.85). Conclusions: An mHealth intervention comprising motivational interview calls and SMS appears to have long-term effects on health. Although there were no effects on blood pressure levels, important reductions in bodyweight and BMI were seen five years after randomisation. Thus, mHealth appears to be a promising preventive strategy for non-communicable diseases in resource-constrained settings. Clinical Trial: N/A

  • Telelactation among Rural Breastfeeding Mothers: Use, Experiences, and Satisfaction

    Date Submitted: Mar 8, 2019

    Open Peer Review Period: May 17, 2019 - Jul 12, 2019

    Background: Telelactation services connect breastfeeding mothers to remotely located lactation consultants through audio-visual technology and can increase access to professional breastfeeding support...

    Background: Telelactation services connect breastfeeding mothers to remotely located lactation consultants through audio-visual technology and can increase access to professional breastfeeding support in rural areas. Objective: To identify maternal characteristics associated with demand for and use of telelactation and to describe visit characteristics. Methods: We conducted a descriptive study within the context of a randomized controlled trial. Participant survey data and vendor EMR data were used to assess video call characteristics including timing, duration, and topics discussed and participant satisfaction. Recruitment occurred from 2016-2018 at a rural critical access hospital in Pennsylvania. Enrolled women (n=94) were given access to unlimited, on demand video calls with lactation consultants through a mobile phone application. Results: Forty-seven (50%) participants reported participating in one or more video calls, and 31 (33%) completed one or more calls that included a substantive discussion of a breastfeeding challenge. Participants who used telelactation were more likely to be working at 12 weeks post-partum (68% vs. 41%, p=0.02), less likely to have prior breastfeeding experience (39% vs. 65%, p=0.02), and less likely to have breastfed exclusively prior to hospital discharge (52% vs. 81%, p<.01). Most video calls (70%) occurred during the infant’s first month of life, and 41% occurred outside of business hours. The most common challenges discussed included: breast pain, soreness, and infection (30% of calls), use of nipple shields (25%), latch/positioning (24%). Most telelactation users (91%) expressed satisfaction with the help received. Conclusions: Telelactation is an innovation in the delivery of professional breastfeeding support. This research documents demand for and positive experiences with telelactation in an underserved population.

  • GDPR on the Edge: Health Data Protection in an EU Candidate Country – Example of Serbia

    Date Submitted: May 9, 2019

    Open Peer Review Period: May 16, 2019 - Jul 11, 2019

    As of May 2018, all relevant institutions in EEA member countries have to comply with the European General Data Protection Regulation (GDPR) or face significant fines. In addition to EEA countries, th...

    As of May 2018, all relevant institutions in EEA member countries have to comply with the European General Data Protection Regulation (GDPR) or face significant fines. In addition to EEA countries, this regulation has a notable effect on EU candidate countries which are undergoing the process of harmonizing their legislature with EU, as part of their accession process. The Republic of Serbia is an example of a country which is not a member of the EU but is significantly impacted by the GDPR. Serbia’s new Personal Data Protection Act mirrors the majority of provisions given in the GDPR. We outline the context for the implementation of the new Act in Serbia, present the experiences of delivering change in health data management across the health system so far, and outline the impact on the capability of candidate countries to conduct international health data research projects. GDPR has an extraterritorial application for non-EU data controllers who process the data of the EU citizens and residents. This primarily affects Serbian private practices which target EU citizens, although some visitors also end up in the public healthcare institutions. Serbia is a popular destination for medical tourism due to low prices, quality services, and geographical proximity. There are also ex-pat visitors, dual citizens, regular tourists from EU, business visitors, and those in transit to and from member countries. Serbia generally does not have well-established procedures to support international research collaborations around data created in Serbian healthcare institutions. In simpler endeavors, arrangements can be made with institution management and their ethics committees and then secured through contracts. Even then, smaller institutions that have not previously participated in similar ventures may require approval or support from health authorities. Larger studies that involve multi-site data, typically require the support of central health system institutions such as MoH, NHIF or the National Institute of Public Health, as well as any relevant research data aggregators and EHR vendors. Lack of framework for preparation, anonymization, and assurance of privacy preservation requires the researchers to rely heavily on local expertise and support. Given the current limitation of its health and data governance systems and potential issues with the forthcoming legislation, it remains to be seen whether the move toward the GDPR will be beneficial for the Serbian health system and medical research, with respect to the protection of personal data and privacy rights and medical research capacity. Although significant progress has been made so far, direct application of implementation methods designed for more advanced health data environments can be risky but can also stimulate the community to move forward. Serbia needs a strategic approach at the country level, systematic elimination of the problems with insufficient resources in the area of data protection, and further development of a modern personal data protection regulatory and institutional environment. This can only be achieved through a targeted educational effort among health workers and decision makers, aiming to improve awareness and develop the necessary skills and knowledge in the workforce. Privacy Act; Patient Data Privacy; Data Sharing; Information Disclosure; Ethical Issues; Medical Tourists; Healthcare Systems; Privacy policies; Privacy protections; Social aspects of security and privacy

  • A tablet app supporting self-management of people with dementia: Analysis of adoption and use patterns

    Date Submitted: May 13, 2019

    Open Peer Review Period: May 16, 2019 - Jul 11, 2019

    Background: Assistive technology (AT) is fast emerging within dementia care and support. One area of application is AT to support people with dementia in compensating for cognitive symptoms and thereb...

    Background: Assistive technology (AT) is fast emerging within dementia care and support. One area of application is AT to support people with dementia in compensating for cognitive symptoms and thereby promote their self-management. There is, however, generally little evidence for the applicability, usability and effectiveness of AT for people with dementia and a need to identify factors that can promote adoption. Objective: The aims of this study were (1) to evaluate the applicability and usability of an app, tailormade for people with dementia, (2) to explore factors affecting adoption, (3) to explore the possible influence of caregiver involvement and (4) contribute to process evaluation of the intervention. Methods: The ReACT app had been designed as a holistic solution to support memory and structure in daily living. The person with dementia had access to a personal user-account and family caregivers were given a parallel login. Written and online materials were provided to support self-applied implementation. A mixed methods design was applied to explore adoption and use-patterns, including background and disease-related data, qualitative data from a survey and log data. Adoption was defined as use of the app over a period of 90 or more days. Results: Data from 112 participants and 98 caregivers were included. Shorter time from diagnosis (U=595 P=0.046, r=.19) and caregiver having activated the app (p=.02; FET) had a significant impact on participant adoption status. Logistic regression analysis showed that if caregivers had activated the app the participant was 5 times more likely to become an adoptor (OR 5.1; 95% CI 1.29-19.99; P=.02). The overall predictive power was however low and there was quite wide variation in background and disease-related characteristics among adoptors. Level of experience and skills in tablet-use were not significantly different between adoptors and non-adoptors. Adoptors generally rated the app high on usefulness, satisfaction, and ease of using (rated on the USEdem questionnaire). Their scores were significantly higher compared to non-adoptors (U=5.5 P=0.02, r=.64). Analysis of use-patterns showed that all functionalities of the app were used among adoptors. Conclusions: Results confirmed the applicability and usefulness of the ReACT app and self-applied methods for implementation in a mixed group of people with dementia. The study provided insight into the importance of timely introduction and caregiver support for adoption of AT among people with dementia. It also underlined the high complexity of personal and contextual factors that influence adoption. These complex factors need to be considered when designing and implementing AT for people with dementia.

  • Patient Satisfaction Outcomes Following Antibiotic Resistance Education for Adults in Primary Care: A Quasi-Experimental Study

    Date Submitted: May 12, 2019

    Open Peer Review Period: May 15, 2019 - Jul 10, 2019

    Background: Antibiotics have saved many lives since their discovery, but today, due to their overuse, are becoming less effective. A portion of provider reimbursement from Medicare and Medicaid is ba...

    Background: Antibiotics have saved many lives since their discovery, but today, due to their overuse, are becoming less effective. A portion of provider reimbursement from Medicare and Medicaid is based on patient satisfaction. Because of the previous effectiveness of antibiotics, patients have come to expect them from their provider when being seen for bronchitis, sinusitis, otitis media, and pharyngitis. Evidence suggests that educating patients, utilizing shared decision-making strategies, and communicating the reason for or against antibiotic prescriptions can produce positive outcomes when treating upper respiratory infections. Objective: The purpose of this evidence-based quality initiative which employs a quasi-experimental pre- and post- design is to determine if patient education and shared decision-making with regards to pharmacologic treatment for adults with upper respiratory infections will increase patient satisfaction in a primary care clinic setting in urban Kansas. Methods: Antibiotic resistance education was provided to 64 participants who are over the age of 18 and present to the clinic with upper respiratory complaints. Patient satisfaction will be measured with the Consumer Assessment of Healthcare Providers and Systems survey and compared to results from 61 participants who were treated for upper respiratory complaints prior to implementation of the standardized educational intervention. Results: Evidence suggests the two groups were not comparable (p=0.02). The evidence-based quality improvement initiative proved successful at increasing patient satisfaction in two areas, the antibiotic resistance education was recommended to the clinic for adoption as standard of care for patients with upper respiratory complaints. Conclusions: The EBQI has potential to decrease inappropriate antibiotic use and improve healthcare consumer satisfaction at the local level. A similar model of education and shared decision-making could be applied to other clinical problems in the future.