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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:

  • Source: Flickr; Copyright: EdTech Stanford University School of Medicine; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Theories Predicting End-User Acceptance of Telemedicine Use: Systematic Review


    Background: Only a few telemedicine applications have made their way into regular care. One reason is the lack of acceptance of telemedicine by potential end users. Objective: The aim of this systematic review was to identify theoretical predictors that influence the acceptance of telemedicine. Methods: An electronic search was conducted in PubMed and PsycINFO in June 2018 and supplemented by a hand search. Articles were identified using predefined inclusion and exclusion criteria. In total, two reviewers independently assessed the title, abstract, and full-text screening and then individually performed a quality assessment of all included studies. Results: Out of 5917 potentially relevant titles (duplicates excluded), 24 studies were included. The Axis Tool for quality assessment of cross-sectional studies revealed a high risk of bias for all studies except for one study. The most commonly used models were the Technology Acceptance Model (n=11) and the Unified Theory of Acceptance and Use of Technology (n=9). The main significant predictors of acceptance were perceived usefulness (n=11), social influences (n=6), and attitude (n=6). The results show a superiority of technology acceptance versus original behavioral models. Conclusions: The main finding of this review is the applicability of technology acceptance models and theories on telemedicine adoption. Characteristics of the technology, such as its usefulness, as well as attributes of the individual, such as his or her need for social support, inform end-user acceptance. Therefore, in the future, requirements of the target group and the group’s social environment should already be taken into account when planning telemedicine applications. The results support the importance of theory-guided user-centered design approaches to telemedicine development.

  • Source: Flickr; Copyright: Army Medicine; URL:; License: Creative Commons Attribution (CC-BY).

    Health Data Processes: A Framework for Analyzing and Discussing Efficient Use and Reuse of Health Data With a Focus on Patient-Reported Outcome Measures


    The collection and use of patient health data are central to any kind of activity in the health care system. These data may be produced during routine clinical processes or obtained directly from the patient using patient-reported outcome (PRO) measures. Although efficiency and other reasons justify data availability for a range of potentially relevant uses, these data are nearly always collected for a single specific purpose. The health care literature reflects this narrow scope, and there is limited literature on the joint use of health data for daily clinical use, clinical research, surveillance, and administrative purposes. The aim of this paper is to provide a framework for discussing the efficient use of health data with a specific focus on the role of PRO measures. PRO data may be used at an individual patient level to inform patient care or shared decision making and to tailor care to individual needs or group-level needs as a complement to health record data, such as that on mortality and readmission, in order to inform service delivery and measure the real-world effectiveness of treatment. PRO measures may be used either for their own sake, to provide valuable information from the patient perspective, or as a proxy for clinical data that would otherwise not be feasible to collect. We introduce a framework to analyze any health care activity that involves health data. The framework consists of four data processes (patient identification, data collection, data aggregation and data use), further structured into two dichotomous dimensions in each data process (level: group vs patient; timeframe: ad hoc vs systematic). This framework is used to analyze various health activities with respect to joint use of data, considering the technical, legal, organizational, and logistical challenges that characterize each data process. Finally, we propose a model for joint use of health data with data collected during follow-up as a base. Demands for health data will continue to increase, which will further add to the need for the concerted use and reuse of PRO data for parallel purposes. Repeated and uncoordinated PRO data collection for the same patient for different purposes results in misuse of resources for the patient and the health care system as well as reduced response rates owing to questionnaire fatigue. PRO data can be routinely collected both at the hospital (from inpatients as well as outpatients) and outside of hospital settings; in primary or social care settings; or in the patient’s home, provided the health informatics infrastructure is in place. In the future, clinical settings are likely to be a prominent source of PRO data; however, we are also likely to see increased remote collection of PRO data by patients in their own home (telePRO). Data collection for research and quality surveillance will have to adapt to this circumstance and adopt complementary data capture methods that take advantage of the utility of PRO data collected during daily clinical practice. The European Union’s regulation with respect to the protection of personal data—General Data Protection Regulation—imposes severe restrictions on the use of health data for parallel purposes, and steps should be taken to alleviate the consequences while still protecting personal data against misuse.

  • Source: Unsplash; Copyright: Lucian Novosel; URL:; License: Licensed by the authors.

    A Web-Based Cognitive Behavior Therapy Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The SpringboarD Trial):...


    Background: Depressive symptoms are common in people with type 2 diabetes mellitus (T2DM). Effective depression treatments exist; however, access to psychological support is characteristically low. Web-based cognitive behavioral therapy (CBT) is accessible, nonstigmatizing, and may help address substantial personal and public health impact of comorbid T2DM and depression. Objective: The aim of this study was to evaluate the Web-based CBT program, myCompass, for improving social and occupational functioning in adults with T2DM and mild-to-moderate depressive symptoms. myCompass is a fully automated, self-guided public health treatment program for common mental health problems. The impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior was also examined. Methods: Participants with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited online via Google and Facebook advertisements targeting adults with T2DM and via community and general practice settings. Screening, consent, and self-report scales were all self-administered online. Participants were randomized using double-blind computerized block randomization to either myCompass (n=391) for 8 weeks plus a 4-week tailing-off period or an active placebo intervention (n=379). At baseline and postintervention (3 months), participants completed the Work and Social Adjustment Scale, the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item, Diabetes Distress Scale, Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Results: myCompass users logged in an average of 6 times and completed an average of .29 modules. Healthy Lifestyles users logged in an average of 4 times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite an extensive recruitment process. Approximately 61.6% (473/780) of participants completed the postintervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress, and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity, or treatment engagement. Conclusions: Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than for users of the control program at 3 months postintervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample, and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with T2DM, and the impact of illness comorbidity on patient conceptualization and experience of mental health symptoms, is essential to reduce the burden of T2DM. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000931572; (Archived by WebCite at

  • 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.

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  • Trustworthy Health Tweets on Social Media in Saudi Arabia

    Date Submitted: May 19, 2019

    Open Peer Review Period: May 21, 2019 - May 27, 2019

    Background: Social media (SM) platforms play a vital role in the dissemination of health information. However, evidence suggests that a high proportion of Twitter posts (known as tweets) are not neces...

    Background: Social media (SM) platforms play a vital role in the dissemination of health information. However, evidence suggests that a high proportion of Twitter posts (known as tweets) are not necessarily accurate and many studies suggest that tweets do not need to be accurate (or at least evidence-based) to receive traction. This is a dangerous combination in the sphere of health information. Objective: The first objective of this pilot study is to examine the health tweets in terms of their accuracy in Saudi Arabia. The second objective is to fin d factors that relate to the accuracy and dissemination of tweets, thereby enabling the identification of ways to enhance the dissemination of accurate tweets. The initial findings from this pilot study and methodological improvements will then be employed for a larger scale study that will address these issues in more detail. Methods: A health lexicon was used to extract health-related tweets using the Twitter application programming interface (API), and the results further filtered manually. 300 tweets were each labelled by two doctors with 109 classified as accurate, or inaccurate. Other measures were taken from these tweets’ meta-data to see if there was any relationship between those characteristics in relation to accuracy and dissemination. The entire range of this meta-data was analysed using Python to answer the research questions posed. Results: About 31% of 109 tweets in the dataset used by this study were classified as untrustworthy health information. These came mainly from non–health background users and SM accounts that had no corresponding physical (organization) manifestation. Unsurprisingly, traditionally trusted health users are more likely than other users to tweet accurate health information. Likewise, these provisional results suggest that tweets posted in the morning are more trustworthy than tweets posted at night (possibly corresponding to official and casual posts, respectively) and that the crowd are quite good at identifying trustworthy information sources, as evidenced by their favourite-author tags. Conclusions: Our results indicate that there are some surprising factors that might have an association with the accuracy of the tweets and dissemination. To implement large-scale analytics using data analysis techniques, a much larger data set is required and there are plans to put this into operation soon.

  • Online information on electronic cigarettes – a comparative study of relevant websites from Baidu and Google search engines

    Date Submitted: May 16, 2019

    Open Peer Review Period: May 21, 2019 - Jul 16, 2019

    Background: Online information on e-cigarettes may influence people’s perception and use of e-cigarettes. Objective: This study aimed to assess and compare types and credibility of web-based informa...

    Background: Online information on e-cigarettes may influence people’s perception and use of e-cigarettes. Objective: This study aimed to assess and compare types and credibility of web-based information on e-cigarettes identified from Google (in English language) and Baidu (in Chinese language) search engines. Methods: We used key words “vaping” or “e-cigarettes” for Google search engine, and equivalent Chinese characters for Baidu search engine, and included the first 50 unique and relevant websites from each of the two search engines. The main characteristics, credibility of and claims made on included websites were systematically assessed and compared. Results: Relatively more included Baidu websites were owned by manufacturers or retailers than Google websites (33/50, 66% vs. 15/50, 30%; P<0.001). None of the Baidu websites, compared with 12 (24%) of the Google websites, were provided by public or health institutions. Baidu websites were more likely to contain e-cigarette advertising (P<0.001), and less likely to provide information on health education (P<0.001). The overall credibility of the included Baidu websites was lower than the Google websites (P<0.001). An age restriction warning was shown on all advertising websites from Google search engine (15/15), but only on 10 of the 33 (30%) advertising websites from Baidu search engine (P<0.001). Conflicting or unclear health and social claims were common on the included websites. Conclusions: Although conflicting or unclear claims on e-cigarettes were common on websites from both Baidu and Google search engines, there was a lack of online information from public health organisations in China. It is crucial to restrict e-cigarette marketing and reduce the attractiveness of e-cigarettes to young people by effectively implementing relevant regulations. Clinical Trial: Not applicable.

  • Internet-based cognitive behavioural therapy programme tailored to patients with cardiovascular disease and depression: a randomised controlled trial

    Date Submitted: May 15, 2019

    Open Peer Review Period: May 19, 2019 - Jul 14, 2019

    Background: Depression is a common cause of poorer wellbeing and prognosis in patients with cardiovascular disease (CVD). Yet there is a lack of effective intervention strategies targeting depression....

    Background: Depression is a common cause of poorer wellbeing and prognosis in patients with cardiovascular disease (CVD). Yet there is a lack of effective intervention strategies targeting depression. Objective: To evaluate the effect of a nurse-delivered and tailored internet-based cognitive behavioural therapy (iCBT) programme aimed at reducing depression in patients with CVD. Methods: A randomised controlled trial. 144 CVD patients with at least mild depression (Patient Health Questionnaire-9 (PHQ-9) score ≥ 5) were randomised 1.1 to nine-week iCBT (n=72) or an active control participating in a Web-based discussion forum (ODF, n=72). The iCBT programme was adapted to fit patients with CVD. Feedback was provided by nurses with experience of CVD and a short introduction in CBT. The primary outcome, depression, was measured by the PHQ-9. Secondary outcomes were depression measured with Montgomery Åsberg Depression Rating Scale-self rating Scale (MADRS-S), Health-related Quality of life measured with Short Form 12 (SF-12) and EQ-VAS and adherence. Intention-to-treat analysis with multiple imputations was used. Between group differences of the primary and secondary outcomes was determined by analysis of covariance and sensitivity analysis was performed with mixed models. Results: iCBT had compared to ODF a significant and moderate treatment effect on the primary outcome depression (i.e. PHQ-9) (mean group difference -2.34 [95 % CI -3.58 to -1.10], P <0.001., Cohens d=0.62). In the secondary outcomes iCBT compared to ODF had a significant and large effect on depression (i.e. MADRS-S) (P<.001, Cohens d=0.86) and a significant and moderate effects on the mental component scale of the SF-12 (P<.001., Cohens d=0.66) and the EQ-VAS (P<.001., Cohens d=0.62). A total of 60% (n=43) in the iCBT group completed all seven modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study due to high risk of suicide or deterioration in depression. Conclusions: Nurse-delivered iCBT can reduce depression and improve HRQoL in CVD patients enabling treatment for depression in their own homes and at their own preferences of time. Clinical Trial:, NCT02778074

  • 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.