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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: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Nature and Diffusion of Gynecologic Cancer–Related Misinformation on Social Media: Analysis of Tweets


    Background: Over the last two decades, the incidence and mortality rates of gynecologic cancers have increased at a constant rate in China. Gynecologic cancers have become one of the most serious threats to women’s health in China. With the widespread use of social media, an increasing number of individuals have employed social media to produce, seek, and share cancer-related information. However, health information on social media is not always accurate. Health, and especially cancer-related, misinformation has been widely spread on social media, which can affect individuals’ attitudinal and behavioral responses to cancer. Objective: The aim of this study was to examine the nature and diffusion of gynecologic cancer–related misinformation on Weibo, the Chinese equivalent of Twitter. Methods: A total of 2691 tweets related to 2 gynecologic cancers—breast cancer and cervical cancer—posted on Weibo from June 2015 to June 2016 were extracted using the Python Web Crawler. Two medical school graduate students with expertise in gynecologic diseases were recruited to code the tweets to differentiate between true information and misinformation as well as to identify the types of falsehoods. The diffusion characteristics of gynecologic cancer–related misinformation were compared with those of the true information. Results: While most of the gynecologic cancer–related tweets provided medically accurate information, approximately 30% of them were found to contain misinformation. Furthermore, it was found that tweets about cancer treatment contained a higher percentage of misinformation than prevention-related tweets. Nevertheless, the prevention-related misinformation diffused significantly more broadly and deeply than true information on social media. Conclusions: The findings of this study suggest the need for controlling and reducing the cancer-related misinformation on social media with the efforts from both service providers and medical professionals. More specifically, it is important to correct falsehoods related to the prevention of gynecologic cancers on social media and increase individuals’ capacity to assess the veracity of Web-based information to curb the spread and thus minimize the consequences of cancer-related misinformation.

  • Using information technology to improve interrater reliability in medical coding. Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Web-Based Information Infrastructure Increases the Interrater Reliability of Medical Coders: Quasi-Experimental Study


    Background: Medical coding is essential for standardized communication and integration of clinical data. The Unified Medical Language System by the National Library of Medicine is the largest clinical terminology system for medical coders and Natural Language Processing tools. However, the abundance of ambiguous codes leads to low rates of uniform coding among different coders. Objective: The objective of our study was to measure uniform coding among different medical experts in terms of interrater reliability and analyze the effect on interrater reliability using an expert- and Web-based code suggestion system. Methods: We conducted a quasi-experimental study in which 6 medical experts coded 602 medical items from structured quality assurance forms or free-text eligibility criteria of 20 different clinical trials. The medical item content was selected on the basis of mortality-leading diseases according to World Health Organization data. The intervention comprised using a semiautomatic code suggestion tool that is linked to a European information infrastructure providing a large medical text corpus of >300,000 medical form items with expert-assigned semantic codes. Krippendorff alpha (Kalpha) with bootstrap analysis was used for the interrater reliability analysis, and coding times were measured before and after the intervention. Results: The intervention improved interrater reliability in structured quality assurance form items (from Kalpha=0.50, 95% CI 0.43-0.57 to Kalpha=0.62 95% CI 0.55-0.69) and free-text eligibility criteria (from Kalpha=0.19, 95% CI 0.14-0.24 to Kalpha=0.43, 95% CI 0.37-0.50) while preserving or slightly reducing the mean coding time per item for all 6 coders. Regardless of the intervention, precoordination and structured items were associated with significantly high interrater reliability, but the proportion of items that were precoordinated significantly increased after intervention (eligibility criteria: OR 4.92, 95% CI 2.78-8.72; quality assurance: OR 1.96, 95% CI 1.19-3.25). Conclusions: The Web-based code suggestion mechanism improved interrater reliability toward moderate or even substantial intercoder agreement. Precoordination and the use of structured versus free-text data elements are key drivers of higher interrater reliability.

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

    Investigating the Perceptions of Primary Care Dietitians on the Potential for Information Technology in the Workplace: Qualitative Study


    Background: Chronic diseases are the leading cause of morbidity and mortality worldwide. The primary health care setting is an effective avenue for the management and prevention of chronic diseases. Dietitians working in this setting assist with the management of modifiable risk factors of chronic diseases. However, health care professionals report challenges in providing care in this setting because of time and financial constraints. Information technology offers the potential to improve health care quality, safety, efficiency, and cost-efficiency, but there exists limited understanding of dietitians’ application of technology in this setting. Objective: The objective of this study was to explore the perceptions of primary care dietitians about using information technology in their workplace. Methods: We recruited 20 Australian primary care dietitians using purposive and snowball sampling for semistructured telephonic interviews. Interview questions aimed to gain an understanding of dietitians’ perceptions about sharing patient outcomes through a national database and the benefits, disadvantages, feasibility, and barriers of using information technology. Interviews were audiorecorded, transcribed verbatim, and thematically analyzed for emerging themes and subthemes. Finally, the technologies used by participants were collated by name and researched for their key attributes. Results: The following 4 distinct themes emerged from the data: information technology improving the efficiency of practice tasks, experiencing barriers to using information technology in practice, information technology enhancing outcomes through education and monitoring, and information technology for sharing information with others. Participants identified several advantages and disadvantages of using technology and expressed willingness to share patient outcomes using a Web-based database. Conclusions: This study suggests that information technology is perceived to have benefits to dietitians and patients in primary health care. However, to achieve the optimal benefit, support is required to overcome barriers to integrate information technology into practice better. Further development of patient management systems and standardized Web-based data collection systems are needed to support better usage by dietitians.

  • Patient experience tweet sentiment by region over time. K represents thousand, where any number is followed by three zeros (eg, 100K equals 100,000). Source: Figure 1 from; Copyright: the authors; License: Creative Commons Attribution (CC-BY).

    Using Twitter to Examine Web-Based Patient Experience Sentiments in the United States: Longitudinal Study


    Background: There are documented differences in access to health care across the United States. Previous research indicates that Web-based data regarding patient experiences and opinions of health care are available from Twitter. Sentiment analyses of Twitter data can be used to examine differences in patient views of health care across the United States. Objective: The objective of our study was to provide a characterization of patient experience sentiments across the United States on Twitter over a 4-year period. Methods: Using data from Twitter, we developed a set of 4 software components to automatically label and examine a database of tweets discussing patient experience. The set includes a classifier to determine patient experience tweets, a geolocation inference engine for social data, a modified sentiment classifier, and an engine to determine if the tweet is from a metropolitan or nonmetropolitan area in the United States. Using the information retrieved, we conducted spatial and temporal examinations of tweet sentiments at national and regional levels. We examined trends in the time of the day and that of the week when tweets were posted. Statistical analyses were conducted to determine if any differences existed between the discussions of patient experience in metropolitan and nonmetropolitan areas. Results: We collected 27.3 million tweets between February 1, 2013 and February 28, 2017, using a set of patient experience-related keywords; the classifier was able to identify 2,759,257 tweets labeled as patient experience. We identified the approximate location of 31.76% (876,384/2,759,257) patient experience tweets using a geolocation classifier to conduct spatial analyses. At the national level, we observed 27.83% (243,903/876,384) positive patient experience tweets, 36.22% (317,445/876,384) neutral patient experience tweets, and 35.95% (315,036/876,384) negative patient experience tweets. There were slight differences in tweet sentiments across all regions of the United States during the 4-year study period. We found the average sentiment polarity shifted toward less negative over the study period across all the regions of the United States. We observed the sentiment of tweets to have a lower negative fraction during daytime hours, whereas the sentiment of tweets posted between 8 pm and 10 am had a higher negative fraction. Nationally, sentiment scores for tweets in metropolitan areas were found to be more extremely negative and mildly positive compared with tweets in nonmetropolitan areas. This result is statistically significant (P<.001). Tweets with extremely negative sentiments had a medium effect size (d=0.34) at the national level. Conclusions: This study presents methodologies for a deeper understanding of Web-based discussion related to patient experience across space and time and demonstrates how Twitter can provide a unique and unsolicited perspective from users on the health care they receive in the United States.

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

    Tailored, Therapist-Guided Internet-Based Cognitive Behavioral Therapy Compared to Care as Usual for Patients With Rheumatoid Arthritis: Economic Evaluation...


    Background: Internet-based cognitive behavioral therapy can aid patients with rheumatoid arthritis with elevated levels of distress to enhance their quality of life. However, implementation is currently lacking and there is little evidence available on the (cost-) effectiveness of different treatment strategies. Objective: Cost-benefit ratios are necessary for informing stakeholders and motivating them to implement effective treatment strategies for improving health-related quality of life (HRQoL) of patients with rheumatoid arthritis. A cost-effectiveness study from a societal perspective was conducted alongside a randomized controlled trial on a tailored, therapist-guided internet-based cognitive behavioral therapy (ICBT) intervention for patients with rheumatoid arthritis with elevated levels of distress as an addition to care as usual (CAU). Methods: Data were collected at baseline or preintervention, 6 months or postintervention, and every 3 months thereafter during the 1-year follow-up. Effects were measured in terms of quality-adjusted life years (QALYs) and costs from a societal perspective, including health care sector costs (health care use, medication, and intervention costs), patient travel costs for health care use, and costs associated with loss of labor. Results: The intervention improved the quality of life compared with only CAU (Δ QALYs=0.059), but at a higher cost (Δ=€4211). However, this increased cost substantially reduced when medication costs were left out of the equation (Δ=€1863). Of all, 93% (930/1000) of the simulated incremental cost-effectiveness ratios were in the north-east quadrant, indicating a high probability that the intervention was effective in improving HRQoL, but at a greater monetary cost for society compared with only CAU. Conclusions: A tailored and guided ICBT intervention as an addition to CAU for patients with rheumatoid arthritis with elevated levels of distress was effective in improving quality of life. Consequently, implementation of ICBT into standard health care for patients with rheumatoid arthritis is recommended. However, further studies on cost reductions in this population are warranted. Trial Registration: Nederlands Trial Register NTR2100; (Archived by WebCite at

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

    Eliciting the Impact of Digital Consulting for Young People Living With Long-Term Conditions (LYNC Study): Cognitive Interviews to Assess the Face and...


    Background: Digital consulting, using email, text, and Skype, is increasingly offered to young people accessing specialist care for long-term conditions. No patient-reported outcome measures (PROMs) have been evaluated for assessing outcomes of digital consulting. Systematic and scoping reviews, alongside patient involvement, revealed 2 candidate PROMs for this purpose: the patient activation measure (PAM) and the physician’s humanistic behaviors questionnaire (PHBQ). PAM measures knowledge, beliefs, and skills that enable people to manage their long-term conditions. PHBQ assesses the presence of behaviors that are important to patients in their physician-patient interactions. Objective: This study aimed to assess the face and content validity of PAM and PHBQ to explore whether they elicit important outcomes of digital consulting and whether the PROMs can isolate the digital consultation component of care. Methods: Participants were drawn from 5 clinics providing specialist National Health Service care to 16- to 24-year-olds with long-term health conditions participating in the wider LYNC (Long-Term Conditions, Young People, Networked Communications) study. Overall, 14 people undertook a cognitive interview in this substudy. Of these, 7 participants were young people with either inflammatory bowel disease, cystic fibrosis, or cancer. The remaining 7 participants were clinicians who were convenience sampled. These included a clinical psychologist, 2 nurses, 3 consultant physicians, and a community youth worker practicing in cancer, diabetes, cystic fibrosis, and liver disease. Cognitive interviews were transcribed and analyzed, and a spreadsheet recorded the participants’ PROM item appraisals. Illustrative quotes were extracted verbatim from the interviews for all participants. Results: Young people found 11 of the PAM 13 items and 7 of the additional 8 PAM 22 items to be relevant to digital consulting. They were only able to provide spontaneous examples of digital consulting for 50% (11/22) of the items. Of the 7 clinicians, 4 appraised all PAM 13 items and 20 of the PAM 22 items to be relevant to evaluating digital consulting and articulated operationalization of the items with reference to their own digital consulting practice with greater ease than the young people. Appraising the PHBQ, in 14 of the 25 items, two-thirds of the young people’s appraisals offered digital consulting examples with ease, suggesting that young people can detect and discern humanistic clinician behaviors via digital as well as face-to-face communication channels. Moreover, 17 of the 25 items were appraised as relevant by the young people. This finding was mirrored in the clinician appraisals. Both young people and the clinicians found the research task complex. Young participants required considerably more researcher prompting to elicit examples related to digital consulting rather than their face-to-face care. Conclusions: PAM and PHBQ have satisfactory face and content validity for evaluating digital consulting to warrant proceeding to psychometric evaluation. Completion instructions require revision to differentiate between digital and face-to-face consultations.

  • Source: Pexels; Copyright: Pietro Jeng; URL:; License: Licensed by JMIR.

    Drug Repositioning to Accelerate Drug Development Using Social Media Data: Computational Study on Parkinson Disease


    Background: Due to the high cost and low success rate in new drug development, systematic drug repositioning methods are exploited to find new indications for existing drugs. Objective: We sought to propose a new computational drug repositioning method to identify repositioning drugs for Parkinson disease (PD). Methods: We developed a novel heterogeneous network mining repositioning method that constructed a 3-layer network of disease, drug, and adverse drug reaction and involved user-generated data from online health communities to identify potential candidate drugs for PD. Results: We identified 44 non-Parkinson drugs by using the proposed approach, with data collected from both pharmaceutical databases and online health communities. Based on the further literature analysis, we found literature evidence for 28 drugs. Conclusions: In summary, the proposed heterogeneous network mining repositioning approach is promising for identifying repositioning candidates for PD. It shows that adverse drug reactions are potential intermediaries to reveal relationships between disease and drug.

  • Smartphone showing a Cool Runnings message (montage). Source: Pexels / The Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Combining Technology and Research to Prevent Scald Injuries (the Cool Runnings Intervention): Randomized Controlled Trial


    Background: New technologies, internet accessibility, social media, and increased smartphone ownership provide new opportunities for health researchers to communicate and engage target audiences. An innovative burn prevention intervention was developed using these channels. Objective: The aim of this study was to evaluate the efficacy of Cool Runnings, an app-based intervention to increase knowledge of childhood burn risk (specifically hot beverage scalds) and correct burn first aid among mothers of young children. Methods: This was a 2-group, parallel, single-blinded randomized controlled trial (RCT). Participants were women aged 18 years and above, living in Queensland, Australia, with at least 1 child aged 5-12 months at time of enrollment. The primary outcome measures were change in knowledge about risk of burns and correct burn first aid assessed via 2 methods: (1) overall score and (2) categorized as adequate (score=4) versus inadequate (score<4). Efficacy of gamification techniques was also assessed. Results: In total, 498 participants were recruited via social media and enrolled. At the 6-month follow-up, 244 participants completed the posttest questionnaire. Attrition rates in both groups were similar. Participants who remained in the study did not differ from those lost to follow-up on any characteristics except education level. Although similar at baseline, intervention group participants achieved significantly greater improvement in overall knowledge posttest than control group participants on both primary outcome measures (overall knowledge intervention: mean [SD] of overall knowledge 2.68 [SD 1.00] for intervention vs 2.13 [SD 1.03] for control; 20.7% [25/121] adequate in intervention vs 7.3% [2/123] in control). Consequently, the number needed to treat was 7.46. Logistic regression showed participants exposed to the highest level of disadvantage had 7.3 times higher odds of improved overall knowledge scores than participants in other levels of disadvantage. There were also significant correlations between gamification techniques and knowledge change (P<.001). In addition, odds of knowledge improvement between baseline and 6-month follow-up was higher in participants with low-moderate app activity compared with no app activity (odds ratio [OR] 8.59, 95% CI 2.9-25.02) and much higher in participants with high app activity (OR 18.26, 95% CI 7.1-46.8). Conclusions: Despite substantial loss to follow-up, this RCT demonstrates the Cool Runnings app was an effective intervention for improving knowledge about risks of hot beverage scalds and burn first aid in mothers of young children. The benefits of combining gamification elements in the intervention were also highlighted. Given the low cost and large reach of smartphone apps to deliver content to and engage with targeted populations, the results from this RCT provide important information on how smartphone apps can be used for widespread injury prevention campaigns and public health campaigns generally. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000019404; (Archived by WebCite at

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

    Predicting Adherence to Internet-Delivered Psychotherapy for Symptoms of Depression and Anxiety After Myocardial Infarction: Machine Learning Insights From...


    Background: Low adherence to recommended treatments is a multifactorial problem for patients in rehabilitation after myocardial infarction (MI). In a nationwide trial of internet-delivered cognitive behavior therapy (iCBT) for the high-risk subgroup of patients with MI also reporting symptoms of anxiety, depression, or both (MI-ANXDEP), adherence was low. Since low adherence to psychotherapy leads to a waste of therapeutic resources and risky treatment abortion in MI-ANXDEP patients, identifying early predictors for adherence is potentially valuable for effective targeted care. Objectives: The goal of the research was to use supervised machine learning to investigate both established and novel predictors for iCBT adherence in MI-ANXDEP patients. Methods: Data were from 90 MI-ANXDEP patients recruited from 25 hospitals in Sweden and randomized to treatment in the iCBT trial Uppsala University Psychosocial Care Programme (U-CARE) Heart study. Time point of prediction was at completion of the first homework assignment. Adherence was defined as having completed more than 2 homework assignments within the 14-week treatment period. A supervised machine learning procedure was applied to identify the most potent predictors for adherence available at the first treatment session from a range of demographic, clinical, psychometric, and linguistic predictors. The internal binary classifier was a random forest model within a 3×10–fold cross-validated recursive feature elimination (RFE) resampling which selected the final predictor subset that best differentiated adherers versus nonadherers. Results: Patient mean age was 58.4 years (SD 9.4), 62% (56/90) were men, and 48% (43/90) were adherent. Out of the 34 potential predictors for adherence, RFE selected an optimal subset of 56% (19/34; Accuracy 0.64, 95% CI 0.61-0.68, P<.001). The strongest predictors for adherence were, in order of importance, (1) self-assessed cardiac-related fear, (2) sex, and (3) the number of words the patient used to answer the first homework assignment. Conclusions: For developing and testing effective iCBT interventions, investigating factors that predict adherence is important. Adherence to iCBT for MI-ANXDEP patients in the U-CARE Heart trial was best predicted by cardiac-related fear and sex, consistent with previous research, but also by novel linguistic predictors from written patient behavior which conceivably indicate verbal ability or therapeutic alliance. Future research should investigate potential causal mechanisms and seek to determine what underlying constructs the linguistic predictors tap into. Whether these findings replicate for other interventions outside of Sweden, in larger samples, and for patients with other conditions who are offered iCBT should also be investigated. Trial registration: NCT01504191; (Archived at Webcite at

  • Source: Shutterstock; Copyright: nito; URL:; License: Licensed by the authors.

    Discourse on Exposure to Pornography Content Online Between Arab Adolescents and Parents: Qualitative Study on its Impact on Sexual Education and Behavior


    Background: The internet revolution of the 21st century has made sexual content available and accessible on a scale that has never existed before. Many studies have indicated that the use of pornography was associated with more permissive sexual attitudes and tended to be linked with stronger gender-stereotypical sexual beliefs. It also seemed to be associated with other risky behaviors and sexual promiscuity. Pornography exposure in conservative societies leads to conflicts with religious and cultural taboos. Objective: The aim of this study was to characterize the barriers and difficulties that prevent sexual discourse in the Arab society and enable pornography viewing according to the perceptions of adolescents and mothers. Methods: This study involved qualitative research methods and in-depth interviews with 40 participants. This study included 20 Arab adolescents, sampled by 2 age groups (14-16 years and 16-18 years), and 20 mothers of adolescents from both sexes. Results: The findings indicate that mothers “turn a blind eye” to porn viewing and sexual activity by boys; however, they show a sweeping prohibition and denial of such behavior by girls. Boys reported viewing porn routinely, whereas girls denied doing so, but admitted that their female friends watched porn. The study also found that boys experienced guilt during and after viewing porn as a result of the clash between modernity and traditional values. The mothers and adolescents emphasized the need for an open sexual discourse to reduce violent behaviors such as Web-based sexual harassment, including sending videos and pictures of naked girls, often accompanied by threats and blackmail. Conclusions: It is necessary to find a way to encourage a significant sexual discourse to prevent the violent consequences of its absence in the Arab society. A controlled, transparent, and critical sexual discourse could help youth make more informed decisions concerning the search for sexual content, porn viewing, and sexual behavior.

  • Source: Unsplash; Copyright: Dai KE; URL:; License: Licensed by the authors.

    Designing a Patient Portal for Patient-Centered Care: Cross-Sectional Survey


    Background: In recent literature, patient portals are considered as important tools for the delivery of patient-centered care. To date, it is not clear how patients would conceptualize a patient portal and which health information needs they have when doing so. Objective: This study aimed (1) to investigate health information needs, expectations, and attitudes toward a patient portal and (2) to assess whether determinants, such as patient characteristics, health literacy, and empowerment status, can predict two different variables, namely the importance people attribute to obtaining health information when using a patient portal and the expectations concerning personal health care when using a patient portal. Methods: We conducted a cross-sectional survey of the Flemish population on what patients prefer to know about their digital health data and their expectations and attitudes toward using a patient portal to access their electronic health record. People were invited to participate in the survey through newsletters, social media, and magazines. We used a questionnaire including demographics, health characteristics, health literacy, patient empowerment, and patient portal characteristics. Results: We received 433 completed surveys. The health information needs included features such as being notified when one’s health changes (371/396, 93.7%), being notified when physical parameters increase to dangerous levels (370/395, 93.7%), observing connections between one’s symptoms or diseases or biological parameters (339/398, 85.2%), viewing the evolution of one’s health in function of time (333/394, 84.5%), and viewing information about the expected effect of treatment (349/395, 88.4%). Almost 90% (369/412) of respondents were interested in using a patient portal. Determinants of patients’ attachment for obtaining health information on a patient portal were (1) age between 45 and 54 years (P=.05); (2) neutral (P=.03) or interested attitude (P=.008) toward shared decision making; and (3) commitment to question physicians’ decisions (P=.03, R2=0.122). Determinants of patients’ expectations on improved health care by accessing a patient portal were (1) lower education level (P=.04); (2) neutral (P=.03) or interested attitude (P=.008) toward shared decision making; and (3) problems in understanding health information (P=.04; R2=0.106). Conclusions: The interest in using a patient portal is considerable in Flanders. People would like to receive alerts or some form of communication from a patient portal in case they need to act to manage their health. Determinants such as education, attached importance to shared decision making, difficulties in finding relevant health information, and the attached importance in questioning the decisions of physicians need to be considered in the design of a patient portal.

  • Source: Image created by the authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Effectiveness of the Malnutrition eLearning Course for Global Capacity Building in the Management of Malnutrition: Cross-Country Interrupted Time-Series Study


    Background: Scaling up improved management of severe acute malnutrition has been identified as the nutrition intervention with the largest potential to reduce child mortality, but lack of operational capacity at all levels of the health system constrains scale-up. We therefore developed an interactive malnutrition eLearning course that is accessible at scale to build capacity of the health sector workforce to manage severely malnourished children according to the guidelines of the World Health Organization. Objective: The aim of this study was to test whether the malnutrition eLearning course improves knowledge and skills of in-service and preservice health professionals in managing children with severe acute malnutrition and enables them to apply the gained knowledge and skills in patient care. Methods: This 2-year prospective, longitudinal, cross-country, interrupted time-series study took place in Ghana, Guatemala, El Salvador, and Colombia between January 2015 and February 2017. A subset of 354 in-service health personnel from 12 hospitals and 2 Ministries of Health, 703 preservice trainees from 9 academic institutions, and 204 online users participated. Knowledge gained after training and retention over time was measured through pre- and postassessments comprising questions pertaining to screening, diagnosis, pathophysiology and treatment, and prevention of malnutrition. Comprehension, application, and integration of knowledge were tested. Changes in perception, confidence, and clinical practice were assessed through questionnaires and interviews. Results: Before the course, awareness of the World Health Organization guidelines was 36.73% (389/1059) overall, and 26.3% (94/358) among in-service professionals. The mean score gain in knowledge after access to the course in 606 participants who had pre- and postassessment data was 11.8 (95% CI 10.8-12.9; P<.001)—a relative increase of 41.5%. The proportion of participants who achieved a score above the pass mark posttraining was 58.7% (356/606), compared with 18.2% (110/606) in pretraining. Of the in-service professionals, 85.9% (128/149) reported applying their knowledge by changing their clinical practice in screening, assessment, diagnosis, and management. This group demonstrated significantly increased retained knowledge 6 months after training (mean difference [SD] from preassessment of 12.1 [11.8]), retaining 65.8% (12.1/18.4) of gained knowledge from the training. Changes in the management of malnutrition were reported by trained participants, and institutional, operational, and policy changes were also found. Conclusions: The malnutrition eLearning course improved knowledge, understanding, and skills of health professionals in the diagnosis and management of children with severe acute malnutrition, and changes in clinical practice and confidence were reported following the completion of the course.

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  • E-learning for Medical Education in Sub-Saharan Africa and Low-Resource Settings – A Viewpoint on the Way Forward

    Date Submitted: Oct 14, 2018

    Open Peer Review Period: Oct 15, 2018 - Oct 23, 2018

    E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. Yet, despite over two decade...

    E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. Yet, despite over two decades of e-learning endeavours and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. Thus, the majority of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question remains of how to kick e-learning into a higher gear in low-resource countries. Providing e-learning as technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavours and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavours is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system to serve the population's health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, specifically for implementation and evaluation.

  • A web-based appearance intervention to promote sleep: Randomized controlled trial

    Date Submitted: Oct 14, 2018

    Open Peer Review Period: Oct 14, 2018 - Dec 9, 2018

    Background: Receiving insufficient sleep has wide-ranging consequences for health and well-being. Although educational programs have been developed to promote sleep, these have had limited success in...

    Background: Receiving insufficient sleep has wide-ranging consequences for health and well-being. Although educational programs have been developed to promote sleep, these have had limited success in extending sleep duration. To address this gap, we developed a web-based program emphasizing how physical appearances change with varying amounts of sleep. Objective: The aims of this study were to evaluate: (1) whether participants can detect changes in appearances as a function of sleep, and (2) whether this intervention can alter habitual sleep patterns. Methods: We conducted a 5-week, parallel-group, randomized controlled trial amongst 70 habitual short sleepers (healthy adults who reported having <7 hours of sleep routinely). Upon study enrolment, participants were randomly assigned (1:1) to receive either standard information or an appearance-based intervention. Both groups received educational materials about sleep, but those in the appearance group also viewed a website containing digitally-edited photographs that showed how they would look with varying amounts of sleep. As outcome variables, sleep duration was monitored objectively via actigraphy (at baseline, and at post-intervention weeks 1 and 4), and participants completed a measure of sleep hygiene (at baseline, and at post-intervention weeks 2, 4, and 5). For each outcome, we ran intention-to-treat analyses using linear mixed-effects models. Results: In total, 35 participants were assigned to each group. Validating the intervention, participants in the appearance group: (i) were able to identify what they looked like at baseline, and (ii) judged that they would look more attractive with a longer sleep duration (P < .001). In turn, this translated to changes in sleep hygiene: whereas participants in the appearance group showed improvements following the intervention (P = .003), those in the information group did not (P = .66). Finally, there was no significant effect of group nor interaction of group and time on actigraphy-measured sleep duration (smallest P = .26). Conclusions: Our findings suggest that an appearance-based intervention – while not sufficient as a standalone – could have an adjunctive role in sleep promotion. Clinical Trial: NCT02491138

  • The Rise of the Empowered Physician in the Digital Health Era

    Date Submitted: Oct 13, 2018

    Open Peer Review Period: Oct 14, 2018 - Dec 9, 2018

    Background: Being 21st century healthcare workers is extremely demanding. The growing number of chronic diseases, lack of medical workforce, increasing amount of administrative tasks and cost of medic...

    Background: Being 21st century healthcare workers is extremely demanding. The growing number of chronic diseases, lack of medical workforce, increasing amount of administrative tasks and cost of medical treatment and the rising of life expectancy mean immense challenge on medical professionals. This transformation is triggered by the appearance of digital health. Digital health doesn’t only mean technological transformation but it fundamentally reshapes physician-patient relationship and treatment circumstances. We argue that patient empowerment, the spread of digital health, the bio-psycho-social-digital approach and the disappearance of the ivory tower of medicine lead to a new role for physicians. Main text: Digital health offers the opportunity to make the job of being a medical professional rewarding and creative. The general idol of a physician could shift from self-confident to curious; from rule-follower to creative; and from the lone hero to a team worker. E-physicians are “electronic” they use digital technologies in their practice with ease. They are “enabled" by regulations and guidelines and "empowered" by technologies that support their job and e-patients. They are "experts" of using technologies in their practice or know the best and most reliable and trustworthy sources and technologies. And also “engaged” to understand the feelings and point of view of the patients, giving relevant feedback and involving them throughout the whole healing process. Conclusion: There are major factors that facilitate this transition from demigods to guides who enjoy their job. Examples include meaningful incentives proposed by providers; a well-designed medical curriculum, post-graduate education teaching relevant skills; the wider availability of technologies; useful recommendations from peers; a rising number of evidence-based papers and guidelines; technologies that help save time and effort; and generally, a good experience with e-patients.

  • Efficacy of an online self-management enhancing programme for patients with rheumatoid arthritis: an explorative RCT

    Date Submitted: Oct 12, 2018

    Open Peer Review Period: Oct 14, 2018 - Dec 9, 2018

    Background: Online self-management enhancing programmes has the potential to support patients with Rheumatoid Arthritis in their self-management, for example improve their health status and self-effic...

    Background: Online self-management enhancing programmes has the potential to support patients with Rheumatoid Arthritis in their self-management, for example improve their health status and self-efficacy or decrease overuse of medication. We developed an online self-management enhancing program in collaboration with RA patients and professionals as co-designers, based on the Intervention Mapping Framework. While self-management programs are complex interventions, it is informative to perform an explorative Randomized Controlled Trial before embarking on a larger trial. Objective: This study aimed to evaluate the efficacy of an online self-management enhancing programme for patients with rheumatoid arthritis and to identify outcome measures most likely to capture potential benefits. Methods: A multicentre exploratory randomised controlled trial was performed with an intervention and a control group. Both groups received care as usual. In addition, the intervention group received 12 months of access to an online self-management programme. Assessment occurred at baseline, 6 and 12 months. Outcome measures included self-management behaviour (PAM-13, SMAS-S), self-efficacy (RASE, PEPPI-5), general health status (RAND-36), focus on fatigue (MPCI-F), perceived pain and fatigue (NRS scales). A linear mixed model for repeated measures, using the intention-to-treat principle, was applied to study differences between the patients in the intervention (n=78) and control (n=79) groups. A sensitivity analysis was performed in the intervention group to study the influence of patients with high (N=30) and low (N=40) use of the intervention. Results: The intervention group scored statistically significantly better on the subscale RAND-36 vitality. The group with high use scored statistically significantly better on the subscale RAND-36 perception, although the effect sizes were small. No other statistically significant or clinically relevant effects were found. Conclusions: Based on these results, it is not possible to conclude on the positive effects of the intervention or to select outcome measures to be regarded as the primary/main or secondary outcomes for a future trial. A process evaluation should be performed to provide more insight into the low compliance with and effectiveness of the intervention. Clinical Trial: The trial is registered in the Dutch Trial Register (ID: NTR4871). URL:

  • Preliminary Flu Outbreak Prediction Using Efficient Twitter Posts Classification and Linear Regression with Historical CDC Reports

    Date Submitted: Oct 7, 2018

    Open Peer Review Period: Oct 14, 2018 - Dec 9, 2018

    Background: Social Networking Sites (SNS) such as Twitter are widely used by diverse demographic populations. The amount of data within SNS has created an efficient resource for real-time analysis. Th...

    Background: Social Networking Sites (SNS) such as Twitter are widely used by diverse demographic populations. The amount of data within SNS has created an efficient resource for real-time analysis. Thus, SNS data can be used effectively to track disease outbreaks and provide necessary warnings. Current SNS-based flu detection and prediction frameworks apply conventional machine learning approaches that require lengthy training and testing which is not the optimal solution for new outbreaks with new signs and symptoms. Objective: The objective of this study is to propose an efficient and accurate framework that uses SNS data to track disease outbreaks and provide early warnings, even for newest outbreaks accurately. Methods: We present a framework of outbreak prediction that includes three main modules: text classification, mapping, and linear regression for weekly flu rate predictions. The text classification module utilizes the features of sentiment analysis and predefined keyword occurrences. Various classifiers, including FastText and six conventional machine learning algorithms, are evaluated to identify the most efficient and accurate one for the proposed framework. The text classifiers have been trained and tested using a pre-labeled dataset of flu-related and unrelated Twitter postings. The selected text classifier is then used to classify over 8,400,000 tweet documents. The flu-related documents are then mapped on a weekly basis using a mapping module. Lastly, the mapped results are passed together with historical Center for Disease Control and Prevention (CDC) data to a linear regression module for weekly flu rate predictions. Results: The evaluation of flu tweet classification shows that FastText, together, with the extracted features, has achieved accurate results with an F-measure value of 89.9% in addition to its efficiency. Therefore, FastText has been chosen to be the classification module to work together with the other modules in the proposed framework, including the linear regression module, for flu trend predictions. The prediction results are compared with the available recent data from CDC as the ground truth, and show a strong correlation of 96.29%. Conclusions: The results demonstrate the efficiency and the accuracy of the proposed framework that can be used even for new outbreaks with new signs and symptoms. The classification results demonstrate that the FastText based framework improves the accuracy and the efficiency of flu disease surveillance systems that use unstructured data such as SNS data.

  • Telehealth Interventions for Improving Self-Management in Patients with Hemophilia: A Systematic Review of Clinical Studies

    Date Submitted: Oct 8, 2018

    Open Peer Review Period: Oct 14, 2018 - Dec 9, 2018

    Background: The introduction of home therapy for hemophilia has empowered patients and their families to manage the disease more independently. However, the self-management of hemophilia is demanding...

    Background: The introduction of home therapy for hemophilia has empowered patients and their families to manage the disease more independently. However, the self-management of hemophilia is demanding and complex. The uses of innovative interventions delivered by telehealth routes, such as social media, web-based and mobile applications, may help to monitor bleeding events and promote the appropriate use of clotting factors among patients with hemophilia. Objective: This review aims to systematically summarize the literature evaluating the effectiveness of telehealth interventions for improving health outcomes in patients with hemophilia, and provides direction for future research. Methods: A search was conducted on Ovid MEDLINE, EMBASE and PubMed for studies that (1) focused on patients with hemophilia A or B; (2) tested the use of remote telehealth interventions via Internet, wireless, satellite, telephone and mobile phone media; (3) and reported on at least one of the following outcomes: quality of life; monitoring of bleeding episodes, joint damage or other measures of functional status; medication adherence; patient knowledge or any other outcomes related to empowering patients to be active decision makers in the emotional, social or medical management of their illness. Reviews, commentaries or case reports comprising 10 or fewer cases, were excluded. Results: Sixteen articles fulfilled the inclusion criteria. The majority of the interventions (n=13) were designed with the primary objective of empowering patients and caregivers to manage their condition and treatment more independently. The components of the interventions were rather homogenous and typically involved electronic (1) logging and reminders for prophylactic infusions; (2) reporting of spontaneous and traumatic bleeding events; (3) monitoring of infusion product usage and home inventory and (4) real-time communication with healthcare professionals and hemophilia clinics. Telemedicine-supported education and information interventions seemed to be particularly effective among adolescent and young adult patients. Although the patients reported improvements in their health-related quality of life and perception of illness, telemonitoring devices did not appear to have a significant effect on quantifiable health outcomes, such as joint health. Longitudinal studies seemed to suggest that the response and compliance rates decreased over time. Conclusions: Preliminary evidence from this review suggests that telehealth-delivered interventions could feasibly improve patients’ adherence to medication use and promote independence in disease management. Given the complexity and resources involved in developing a mature and established system, support from a dedicated network of hemophilia specialists and data managers will be required to maintain the technology, improve compliance and validate the electronic data locally.