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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: Unsplash; Copyright:; URL:; License: Public Domain (CC0).

    Meeting Sexual Partners Through Internet Sites and Smartphone Apps in Australia: National Representative Study


    Background: Studies have reported on the proportion of the population looking for potential sexual partners using internet sites and smartphone apps, but few have investigated those who have sex with these partners, arguably a more important target group for health promotion. Objective: This study aimed to determine the proportion of people who have had sex with someone they met on an internet site or a smartphone app in the previous year. Methods: We analyzed data from the 2012-2013 Second Australian Study of Health and Relationships, a nationally representative telephone survey of Australian residents aged 16-69 years (N=20,091). The participation rate for the telephone survey was 66.22%. The prevalence of looking for a potential partner, physically meeting, and having sex with someone first met through an internet site or a smartphone app was estimated. Multivariate logistic regression was used for men and women separately to determine demographic and behavioral factors associated with having had sex with someone met on an internet site or a smartphone app in the last year. Results: Overall, 12.09% of respondents had looked for potential partners using these technologies and 5.40% had done so in the last year. In the last year, 2.98% had met someone in person and 1.95% reported having had sex with someone first met on an internet site or a smartphone app. The prevalence of all behaviors was greater in men than in women and in younger respondents than in older respondents. Among sexually active men, factors associated with having had sex with someone met using internet sites or smartphone apps included identifying as gay or bisexual (adjusted odds ratio, AOR: 15.37, 95% CI 8.34-28.35), having either 2-3 or >3 sexual partners in the last year (AOR: 9.20, 95% CI 9.20-34.68 and AOR: 35.77, 95% CI 18.04-70.94, respectively), having had a sexually transmissible infection (STI) test in the past year (AOR: 2.02, 95% CI 1.21-3.38), or an STI in the last year (AOR: 3.15, 95% CI 1.25-7.97). Among sexually active women, factors associated with having had sex with someone met on an internet site or a smartphone app were as follows: having either 2-3 or >3 sexual partners in the last year (AOR: 32.01, 95% CI 13.17-77.78 and AOR: 71:03, 95 % CI 27.48-183.57, respectively), very low and low income (vs very high AOR: 3.40, 95% CI 1.12-10.35), and identifying as lesbian or bisexual (AOR: 2.27, 95% CI 1.04-4.49). Conclusions: More than a third of adults who had looked for potential partners using websites and apps each year had sex with such partners, and those who had done so were more sexually active, suggesting that dating and hookup websites and applications are suitable settings for targeted sexual health interventions.

  • Activity tracker showing steps taken. Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    The Effectiveness of a Web-Based Computer-Tailored Physical Activity Intervention Using Fitbit Activity Trackers: Randomized Trial


    Background: Web-based interventions that provide personalized physical activity advice have demonstrated good effectiveness but rely on self-reported measures of physical activity, which are prone to overreporting, potentially reducing the accuracy and effectiveness of the advice provided. Objective: This study aimed to examine whether the effectiveness of a Web-based computer-tailored intervention could be improved by integrating Fitbit activity trackers. Methods: Participants received the 3-month TaylorActive intervention, which included 8 modules of theory-based, personally tailored physical activity advice and action planning. Participants were randomized to receive the same intervention either with or without Fitbit tracker integration. All intervention materials were delivered on the Web, and there was no face-to-face contact at any time point. Changes in physical activity (Active Australia Survey), sitting time (Workforce Sitting Questionnaire), and body mass index (BMI) were assessed 1 and 3 months post baseline. Advice acceptability, website usability, and module completion were also assessed. Results: A total of 243 Australian adults participated. Linear mixed model analyses showed a significant increase in total weekly physical activity (adjusted mean increase=163.2; 95% CI 52.0-274.5; P=.004) and moderate-to-vigorous physical activity (adjusted mean increase=78.6; 95% CI 24.4-131.9; P=.004) in the Fitbit group compared with the non-Fitbit group at the 3-month follow-up. The sitting time and BMI decreased more in the Fitbit group, but no significant group × time interaction effects were found. The physical activity advice acceptability and the website usability were consistently rated higher by participants in the Fitbit group. Non-Fitbit group participants completed 2.9 (SD 2.5) modules, and Fitbit group participants completed 4.4 (SD 3.1) modules. Conclusions: Integrating physical activity trackers into a Web-based computer-tailored intervention significantly increased intervention effectiveness. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616001555448; (Archived by WebCite at

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

    The Use of Social Networking Sites in Mental Health Interventions for Young People: Systematic Review


    Background: The onset of mental health problems peaks between adolescence and young adulthood; however, young people face barriers to treatment and are often reluctant to seek professional help. Many are instead seeking support and information regarding their mental health via the Web, especially via social networking sites (SNSs), and hence, there is a promising opportunity to use SNSs to deliver or integrate with youth-focused online mental health interventions. Previous reviews have evaluated the effectiveness of SNSs for specific disorders in young people; however, none of the reviews have covered the breadth of SNS–based youth mental health interventions available across all mental health issues. Objective: This review aimed to systematically identify available evidence regarding the use of SNS–based interventions to support the mental health of young people aged up to 25 years, to evaluate their effectiveness, suitability, and safety, and identify gaps and opportunities for future research. Methods: The PubMed and PsycINFO databases were searched using Medical Subject Headings terms and exploded keywords and phrases. Retrieved abstracts (n=974) were double screened, yielding 235 articles for screening at the full-text level. Of these, 9 articles met the review inclusion criteria. Given the small number of studies, and the variety of outcome measures used, a quantitative meta-analysis was not possible. Results: The 9 articles (quantitative studies, qualitative studies, and descriptions of the iterative design process) covered 5 separate interventions. Of the 5 interventions, 2 interventions used purpose-built platforms based on the moderated online social therapy (MOST) model, 2 used Facebook, and 1 evaluated a purpose-built mobile app. The 2 MOST interventions targeted specific mental health issues (depression and psychosis), whereas the others focused on improving mental health literacy, social support, and general well-being. Only 3 quantitative studies were identified, and all used a pre-post design (without a control group) to establish proof of concept. Of the outcome variables assessed, there were significant improvements in mental health knowledge and number of depressive symptoms but no improvement in anxiety or psychosis symptoms. Acceptability of and engagement with the SNS platforms were generally high, as were perceptions of usefulness and safety. Moderation by clinical experts was identified as a key component of the more successful interventions. When offered a choice, users showed a preference for mobile apps over Web-based interfaces. Conclusions: The evidence reviewed suggests young people find SNS–based interventions highly usable, engaging, and supportive. However, future studies need to address the current lack of high-quality evidence for their efficacy in reducing mental health symptoms. Given young people are already turning to SNSs to engage in knowledge seeking and peer-to-peer support, SNS–based youth mental health interventions provide an opportunity to address some of the barriers young people face in accessing qualified mental health support and information.

  • Source: Dreamstime; Copyright: Agenturfotografin; URL:; License: Licensed by the authors.

    The Advantages and Disadvantages of Online and Blended Therapy: Survey Study Amongst Licensed Psychotherapists in Austria


    Background: Web-based and blended (face-to-face plus Web-based) interventions for mental health disorders are gaining significance. However, many licensed psychotherapists still have guarded attitudes toward computer-assisted therapy, hindering dissemination efforts. Objective: The objective of this study was to provide a therapist-oriented evaluation of Web-based and blended therapies and identify commonalities and differences in attitudes toward both formats. Furthermore, it aimed to test the impact of an information clip on expressed attitudes. Methods: In total, 95 Austrian psychotherapists were contacted and surveyed via their listed occupational email address. An 8-minute information video was shown to half of the therapists before 19 advantages and 13 disadvantages had to be rated on a 6-point Likert scale. Results: The sample resembled all assessed properties of Austrian psychotherapists (age, theoretical orientation, and region). Therapists did not hold a uniform overall preference. Instead, perceived advantages of both interventions were rated as neutral (t94=1.89, P=.06; d=0.11), whereas Web-based interventions were associated with more disadvantages and risks (t94=9.86, P<.001; d=0.81). The information clip did not excerpt any detectable effect on therapists’ attitudes (r95=−.109, P=.30). The application of modern technologies in the own therapeutic practice and cognitive behavioral orientation were positively related to the given ratings. Conclusions: This study is the first to directly compare therapists’ attitudes toward Web-based and blended therapies. Positive attitudes play a pivotal role in the dissemination of new technologies, but unexperienced therapists seem to lack knowledge on how to benefit from technology-aided treatments. To speed up implementation, these aspects need to be addressed in the development of new interventions. Furthermore, the preference of blended treatments over Web-based interventions seems to relate to avoidance of risks. Although this study is likely to represent therapists’ attitudes in countries with less advanced electronic health services, therapists’ attitudes in more advanced countries might present differently.

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

    The Use and Effects of Electronic Health Tools for Patient Self-Monitoring and Reporting of Outcomes Following Medication Use: Systematic Review


    Background: Electronic health (eHealth) tools are becoming increasingly popular for helping patients’ self-manage chronic conditions. Little research, however, has examined the effect of patients using eHealth tools to self-report their medication management and use. Similarly, there is little evidence showing how eHealth tools might prompt patients and health care providers to make appropriate changes to medication use. Objective: The objective of this systematic review was to determine the impact of patients’ use of eHealth tools on self-reporting adverse effects and symptoms that promote changes to medication use. Related secondary outcomes were also evaluated. Methods: MEDLINE, EMBASE, and CINAHL were searched from January 1, 2000, to April 25, 2018. Reference lists of relevant systematic reviews and included articles from the literature search were also screened to identify relevant studies. Title, abstract, and full-text review as well as data extraction and risk of bias assessment were performed independently by 2 reviewers. Due to high heterogeneity, results were not meta-analyzed and instead presented as a narrative synthesis. Results: A total of 14 studies, including 13 randomized controlled trials (RCTs) and 1 open-label intervention, were included, from which 11 unique eHealth tools were identified. In addition, 14 RCTs found statistically significant increases in positive medication changes as a result of using eHealth tools, as did the single open-label study. Moreover, 8 RCTs found improvement in patient symptoms following eHealth tool use, especially in adolescent asthma patients. Furthermore, 3 RCTs showed that eHealth tools might improve patient self-efficacy and self-management of chronic disease. Little or no evidence was found to support the effectiveness of eHealth tools at improving medication recommendations and reconciliation by clinicians, medication-use behavior, health service utilization, adverse effects, quality of life, or patient satisfaction. eHealth tools with multifaceted functionalities and those allowing direct patient-provider communication may be more effective at improving patient self-management and self-efficacy. Conclusions: Evidence suggests that the use of eHealth tools may improve patient symptoms and lead to medication changes. Patients generally found eHealth tools useful in improving communication with health care providers. Moreover, health-related outcomes among frequent eHealth tool users improved in comparison with individuals who did not use eHealth tools frequently. Implementation issues such as poor patient engagement and poor clinician workflow integration were identified. More high-quality research is needed to explore how eHealth tools can be used to effectively manage use of medications to improve medication management and patient outcomes.

  • Source: Gunther Eysenbach, with material from Visualhunt; Copyright: Gunther Eysenbach; URL:; License: Public Domain (CC0).

    Nonpublication Rates and Characteristics of Registered Randomized Clinical Trials in Digital Health: Cross-Sectional Analysis


    Background: Clinical trials are key to advancing evidence-based medical research. The medical research literature has identified the impact of publication bias in clinical trials. Selective publication for positive outcomes or nonpublication of negative results could misdirect subsequent research and result in literature reviews leaning toward positive outcomes. Digital health trials face specific challenges, including a high attrition rate, usability issues, and insufficient formative research. These challenges may contribute to nonpublication of the trial results. To our knowledge, no study has thus far reported the nonpublication rates of digital health trials. Objective: The primary research objective was to evaluate the nonpublication rate of digital health randomized clinical trials registered in Our secondary research objective was to determine whether industry funding contributes to nonpublication of digital health trials. Methods: To identify digital health trials, a list of 47 search terms was developed through an iterative process and applied to the “Title,” “Interventions,” and “Outcome Measures” fields of registered trials with completion dates between April 1, 2010, and April 1, 2013. The search was based on the full dataset exported from the database, with 265,657 trials entries downloaded on February 10, 2018, to allow publication of studies within 5 years of trial completion. We identified publications related to the results of the trials through a comprehensive approach that included an automated and manual publication-identification process. Results: In total, 6717 articles matched the a priori search terms, of which 803 trials matched our latest completion date criteria. After screening, 556 trials were included in this study. We found that 150 (27%) of all included trials remained unpublished 5 years after their completion date. In bivariate analyses, we observed statistically significant differences in trial characteristics between published and unpublished trials in terms of the intervention target condition, country, trial size, trial phases, recruitment, and prospective trial registration. In multivariate analyses, differences in trial characteristics between published and unpublished trials remained statistically significant for the intervention target condition, country, trial size, trial phases, and recruitment; the odds of publication for non-US–based trials were significant, and these trials were 3.3 (95% CI 1.845-5.964) times more likely to be published than US–based trials. We observed a trend of 1.5 times higher nonpublication rates for industry-funded trials. However, the trend was not statistically significant. Conclusions: In the domain of digital health, 27% of registered clinical trials results are unpublished, which is lower than nonpublication rates in other fields. There are substantial differences in nonpublication rates between trials funded by industry and nonindustry sponsors. Further research is required to define the determinants and reasons for nonpublication and, more importantly, to articulate the impact and risk of publication bias in the field of digital health trials.

  • Source: Unsplash; Copyright: John Schnobrich; URL:; License: Licensed by JMIR.

    Internet-Based Cognitive Behavioral Therapy With Real-Time Therapist Support via Videoconference for Patients With Obsessive-Compulsive Disorder, Panic...


    Background: Cognitive behavioral therapy (CBT) is the first-line treatment for adults with obsessive-compulsive disorder (OCD), panic disorder (PD), and social anxiety disorder (SAD). Patients in rural areas can access CBT via the internet. The effectiveness of internet-delivered cognitive behavioral therapy (ICBT) has been consistently shown, but no clinical studies have demonstrated the feasibility of ICBT with real-time therapist support via videoconference for OCD, PD, and SAD at the same time. Objectives: This study aimed to evaluate the feasibility of videoconference-delivered CBT for patients with OCD, PD, or SAD. Methods: A total of 30 Japanese participants (mean age 35.4 years, SD 9.2) with OCD, SAD, or PD received 16 sessions of individualized videoconference-delivered CBT with real-time support of a therapist, using tablet personal computer (Apple iPad Mini 2). Treatment involved individualized CBT formulations specific to the presenting diagnosis; all sessions were provided by the same therapist. The primary outcomes were reduction in symptomatology, using the Yale-Brown obsessive-compulsive scale (Y-BOCS) for OCD, Panic Disorder Severity Scale (PDSS) for PD, and Liebowitz Social Anxiety Scale (LSAS) for SAD. The secondary outcomes included the EuroQol-5 Dimension (EQ-5D) for Quality of Life, the Patient Health Questionnaire (PHQ-9) for depression, the Generalized Anxiety Disorder (GAD-7) questionnaire for anxiety, and Working Alliance Inventory-Short Form (WAI-SF). All primary outcomes were assessed at baseline and at weeks 1 (baseline), 8 (midintervention), and 16 (postintervention) face-to-face during therapy. The occurrence of adverse events was observed after each session. For the primary analysis comparing between pre- and posttreatments, the participants’ points and 95% CIs were estimated by the paired t tests with the change between pre- and posttreatment. Results: A significant reduction in symptom of obsession-compulsion (Y-BOCS=−6.2; Cohen d=0.74; 95% CI −9.4 to −3.0, P=.002), panic (PDSS=−5.6; Cohen d=0.89; 95% CI −9.83 to −1.37; P=.02), social anxiety (LSAS=−33.6; Cohen d=1.10; 95% CI −59.62 to −7.49, P=.02) were observed. In addition, depression (PHQ-9=−1.72; Cohen d=0.27; 95% CI −3.26 to −0.19; P=.03) and general anxiety (GAD-7=−3.03; Cohen d=0.61; 95% CI −4.57 to −1.49, P<.001) were significantly improved. Although there were no significant changes at 16 weeks from baseline in EQ-5D (0.0336; Cohen d=-0.202; 95% CI −0.0198 to 0.00869; P=.21), there were high therapeutic alliance (ie, WAI-SF) scores (from 68.0 to 73.7) throughout treatment, which significantly increased (4.14; 95% CI 1.24 to 7.04; P=.007). Of the participants, 86% (25/29) were satisfied with videoconference-delivered CBT, and 83% (24/29) preferred videoconference-delivered CBT to face-to-face CBT. An adverse event occurred to a patient with SAD; the incidence was 3% (1/30). Conclusions: Videoconference-delivered CBT for patients with OCD, SAD, and SAD may be feasible and acceptable.

  • Source: The Authors; Copyright: Siren Care Inc; URL:; License: Licensed by the authors.

    Continuous Temperature-Monitoring Socks for Home Use in Patients With Diabetes: Observational Study


    Background: Over 30 million people in the United States (over 9%) have been diagnosed with diabetes. About 25% of people with diabetes will experience a diabetic foot ulcer (DFU) in their lifetime. Unresolved DFUs may lead to sepsis and are the leading cause of lower-limb amputations. DFU rates can be reduced by screening patients with diabetes to enable risk-based interventions. Skin temperature assessment has been shown to reduce the risk of foot ulceration. While several tools have been developed to measure plantar temperatures, they only measure temperature once a day or are designed for clinic use only. In this report, wireless sensor-embedded socks designed for daily wear are introduced, which perform continuous temperature monitoring of the feet of persons with diabetes in the home environment. Combined with a mobile app, this wearable device informs the wearer about temperature increases in one foot relative to the other, to facilitate early detection of ulcers and timely intervention. Objective: A pilot study was conducted to assess the accuracy of sensors used in daily wear socks, obtain user feedback on how comfortable sensor-embedded socks were for home use, and examine whether observed temperatures correlated with clinical observations. Methods: Temperature accuracy of sensors was assessed both prior to incorporation in the socks, as well as in the completed design. The measured temperatures were compared to the reference standard, a high-precision thermostatic water bath in the range 20°C-40°C. A total of 35 patients, 18 years of age and older, with diabetic peripheral neuropathy were enrolled in a single-site study conducted under an Institutional Review Board–approved protocol. This study evaluated the usability of the sensor-embedded socks and correlated the observed temperatures with clinical findings. Results: The temperatures measured by the stand-alone sensors were within 0.2°C of the reference standard. In the sensor-embedded socks, across multiple measurements for each of the six sensors, a high agreement (R2=1) between temperatures measured and the reference standard was observed. Patients reported that the socks were easy to use and comfortable, ranking them at a median score of 9 or 10 for comfort and ease of use on a 10-point scale. Case studies are presented showing that the temperature differences observed between the feet were consistent with clinical observations. Conclusions: We report the first use of wireless continuous temperature monitoring for daily wear and home use in patients with diabetes and neuropathy. The wearers found the socks to be no different from standard socks. The temperature studies conducted show that the sensors used in the socks are reliable and accurate at detecting temperature and the findings matched clinical observations. Continuous temperature monitoring is a promising approach as an early warning system for foot ulcers, Charcot foot, and reulceration.

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

    Pediatric Web-Based Chat Services for Caregivers of Children: Descriptive Study


    Background: Pediatric physician-led Web-based chat services offer a novel, low-threshold communication channel between caregivers and physicians. Objective: Our aim was to describe chat conversations between caregivers and physicians in a Web-based chat service to determine the factors that should be considered when planning a similar chat service. We also aimed to evaluate whether caregivers considered the consultations helpful, whether physicians considered they could answer caregivers’ questions, and whether further face-to-face medical contact was needed. Methods: In September 2015, a private medical center for children in the greater Helsinki area initiated a Web-based chat service, accessible via any device with an internet connection, open from 9 am to 9 pm local time. Four residents in pediatrics, who had performed at least 60% of their 6-year residency program, served as the physicians responsible for chat consultations with caregivers of children. Between October 2015 and March 2016, 343 consecutive consultations were immediately evaluated by a chat physician. On average, caregivers were followed up by email questionnaire 7-14 days later, which 98 caregivers answered a median of 11 (interquartile range, IQR, 7-20) days later. Results: The age of the children whose caregivers contacted the chat service was a median of 2.1 (IQR 0.83-4.69) years, and 29.8% (102/342) of the children were less than 1 year old. The majority (119/343, 34.7%) of the chat conversations took place from 9 am to noon, and infections were the most common concern in over half of cases (189/343, 55.1%). Chat physicians recommended a face-to-face appointment with a physician for that same day in 13.7% (47/343) of the cases. A face-to-face exam was recommended for that same day more often if the chat concerned infection (36/189, 19.0% cases) compared with other reasons (11/154, 7.1%, cases; P=.001). Physicians felt capable of answering caregivers’ questions in 72.6% (249/343) of the cases, whereas 93% (91/98) of caregivers considered physicians’ answers helpful. Whether caregivers had to take their children to see a physician that same day or whether caregivers’ main concern was infection was not found to be associated with whether caregivers considered physicians’ answers helpful or not. However, physicians felt more capable of answering caregivers’ questions when the main concern was infection. Conclusions: Parental consultations via Web-based chat service often take place before noon and focus on infection-related issues as well as on the health and illness of very young children. These factors should be considered when planning or setting up such a service. Based on the high satisfaction with the chat service by both physicians and caregivers, Web-based chat services may be a useful way to help caregivers with concerns about their child’s health or illness.

  • Source: Fotolia; Copyright: highwaystarz; URL:; License: Licensed by the authors.

    Efficacy of a Parent-Based, Indicated Prevention for Anorexia Nervosa: Randomized Controlled Trial


    Background: Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak. Objective: The primary objective of this study was to evaluate the efficacy of an indicated, parent-based, Web-based preventive program Eltern als Therapeuten (E@T) in reducing risk factors and symptoms of AN. Methods: Girls aged between 11 and 17 years were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre- and postintervention (6 weeks later) and at 6- and 12-month follow-up (FU). Results: A total of 12,377 screening questionnaires were handed out in 86 German schools, and 3941 including consent returned. Overall, 477 (447/3941, 12.10%) girls were identified as at risk for AN and 256 of those could be contacted. In all, 66 families (66/256, 25.8% of those contacted) were randomized to the E@T or a wait-list control condition, 43 (43/66, 65%) participated in postassessments, and 27 (27/66, 41%) in 12-month FUs. Due to low participation and high dropout rates of parents, recruitment was terminated prematurely. At 12-month FU, girls’ expected body weight (EBW) percentage was significantly greater for intervention participants compared with control participants (group by time interaction beta=21.0 [CI 5.81 to 36.13], P=.007; group by time squared interaction beta=−15.5 [CI −26.6 to −4.49], P=.007; estimated Cohen d=0.42]. No other significant effects were found on risk factors and attitudes of disturbed eating. Conclusions: Despite a significant increase in girls’ EBW percentage, parental participation and adherence to the intervention were low. Overall, parent-based, indicated prevention for children at risk for AN does not seem very promising, although it might be useful for parents who engage in the intervention. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 18614564; (Archived by WebCite at

  • Source: Unsplash; Copyright: Rob Hampson; URL:; License: Licensed by the authors.

    Examining Predictors of Real-World User Engagement with Self-Guided eHealth Interventions: Analysis of Mobile Apps and Websites Using a Novel Dataset


    Background: The literature suggests that the product design of self-guided electronic health (eHealth) interventions impacts user engagement. Traditional trial settings, however, do not enable the examination of these relationships in real-world use. Objective: This study aimed to examine whether the qualities of product design, research evidence, and publicly available data predict real-world user engagement with mobile and Web-based self-guided eHealth interventions. Methods: This analysis included self-guided mobile and Web-based eHealth interventions available to the public—with their qualities assessed using the Enlight suite of scales. Scales included Usability, Visual Design, User Engagement, Content, Therapeutic Persuasiveness, Therapeutic Alliance, Credibility, and Research Evidence. Behavioral data on real-world usage were obtained from a panel that provides aggregated nonpersonal information on user engagement with websites and mobile apps, based on a time window of 18 months that was set between November 1, 2016 and April 30, 2018. Real-world user engagement variables included average usage time (for both mobile apps and websites) and mobile app user retention 30 days after download. Results: The analysis included 52 mobile apps (downloads median 38,600; interquartile range [IQR] 116,000) and 32 websites (monthly unique visitors median 5689; IQR 30,038). Results point to moderate correlations between Therapeutic Persuasiveness, Therapeutic Alliance, and the 3 user engagement variables (.31≤rs≤.51; Ps≤.03). Visual Design, User Engagement, and Content demonstrated similar degrees of correlation with mobile app engagement variables (.25≤rs≤.49; Ps≤.04) but not with average usage time of Web-based interventions. Positive correlations were also found between the number of reviews on Google Play and average app usage time (r=.58; P<.001) and user retention after 30 days (r=.23; P=.049). Although several product quality ratings were positively correlated with research evidence, the latter was not significantly correlated with real-world user engagement. Hierarchical stepwise regression analysis revealed that either Therapeutic Persuasiveness or Therapeutic Alliance explained 15% to 26% of user engagement variance. Data on Google Play (number of reviews) explained 15% of the variance of mobile app usage time above Enlight ratings; however, publicly available data did not significantly contribute to explaining the variance of the other 2 user-engagement variables. Conclusions: Results indicate that the qualities of product design predict real-world user engagement with eHealth interventions. The use of real-world behavioral datasets is a novel way to learn about user behaviors, creating new avenues for eHealth intervention research.

  • Stakeholders considering what are enablers and impediments of trust in digital health. Source: Unsplash; Copyright: Timothy Muza; URL:; License: Licensed by the authors.

    Elements of Trust in Digital Health Systems: Scoping Review


    Background: Information and communication technologies have long become prominent components of health systems. Rapid advances in digital technologies and data science over the last few years are predicted to have a vast impact on health care services, configuring a paradigm shift into what is now commonly referred to as digital health. Forecasted to curb rising health costs as well as to improve health system efficiency and safety, digital health success heavily relies on trust from professional end users, administrators, and patients. Yet, what counts as the building blocks of trust in digital health systems has so far remained underexplored. Objective: The objective of this study was to analyze what relevant stakeholders consider as enablers and impediments of trust in digital health. Methods: We performed a scoping review to map out trust in digital health. To identify relevant digital health studies, we searched 5 electronic databases. Using keywords and Medical Subject Headings, we targeted all relevant studies and set no boundaries for publication year to allow a broad range of studies to be identified. The studies were screened by 2 reviewers after which a predefined data extraction strategy was employed and relevant themes documented. Results: Overall, 278 qualitative, quantitative, mixed-methods, and intervention studies in English, published between 1998 and 2017 and conducted in 40 countries were included in this review. Patients and health care professionals were the two most prominent stakeholders of trust in digital health; a third—health administrators—was substantially less prominent. Our analysis identified cross-cutting personal, institutional, and technological elements of trust that broadly cluster into 16 enablers (altruism, fair data access, ease of use, self-efficacy, sociodemographic factors, recommendation by other users, usefulness, customizable design features, interoperability, privacy, initial face-to-face contact, guidelines for standardized use, stakeholder engagement, improved communication, decreased workloads, and service provider reputation) and 10 impediments (excessive costs, limited accessibility, sociodemographic factors, fear of data exploitation, insufficient training, defective technology, poor information quality, inadequate publicity, time-consuming, and service provider reputation) to trust in digital health. Conclusions: Trust in digital health technologies and services depends on the interplay of a complex set of enablers and impediments. This study is a contribution to ongoing efforts to understand what determines trust in digital health according to different stakeholders. Therefore, it offers valuable points of reference for the implementation of innovative digital health services. Building on insights from this study, actionable metrics can be developed to assess the trustworthiness of digital technologies in health care.

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    Date Submitted: Dec 14, 2018

    Open Peer Review Period: Dec 17, 2018 - Feb 11, 2019

    Background: Young people aged 10-24yrs are at the highest risk for mental health problems, while being the least likely to seek professional treatment due to various barriers to help-seeking. Owing to...

    Background: Young people aged 10-24yrs are at the highest risk for mental health problems, while being the least likely to seek professional treatment due to various barriers to help-seeking. Owing to their high consumption of Internet content, e-Mental Health Services tailored to young people have globally proliferated as a means to address the barriers this population experiences to mental health care. A primary intervention at many such services is Text-Based Online Counselling, which while demonstrating promising findings in emerging literature, has shown greater variance in outcome compared with other e-Mental Health interventions for young people. Objective: The present pilot study aimed to qualitatively explore the characteristics of young service users accessing Text-Based Online Counselling services; their motivations for access; and their perceptions about factors believed to increase and decrease effectiveness on these modalities. Methods: E-surveys were administered naturalistically to 100 young service users aged between 15 and 25yrs accessing webchat and email counselling services via an Australian e-Mental Health Service. Thematic analysis of qualitative themes, and quantitative descriptive and proportional data, presented in E-surveys were examined across the areas of: user characteristics, motivations for access, and perceptions of Text-Based Online Counselling effectiveness. Results: Participants were predominately female high school students of Caucasian or European descent from low middle socioeconomic backgrounds living with parents in major cities. Four primary themes, and various subthemes, were related to participants’ motivations for selecting Text-Based Online Counselling and their perceptions of its effectiveness: Contextual factors (i.e., Physical and Mental Health syndrome, Perceived Social Difficulties, Low Social Support, Prior Negative Help-Seeking Experience); Selection factors (i.e., Safety, Avoidance Motivation, Accessibility, Expectation); and Factors perceived to increase effectiveness (i.e. General Therapeutic Benefits, Efficacious Modality and Service Factors, Persisting with TBOC Despite Substantial Benefit) or reduce effectiveness (i.e., Negative Modality and Service Factors). Conclusions: Findings suggest that unique contextual factors may influence the motivation of young people select to use Text-Based Online Counselling modalities; while unique therapeutic, service and modality factors may increase and decrease intervention effectiveness.

  • Patient portal: how does it change our health behaviors and outcomes? – a single case study at Penn Medicine

    Date Submitted: Dec 14, 2018

    Open Peer Review Period: Dec 17, 2018 - Feb 11, 2019

    Background: Patient portals are frequently deployed in modern healthcare systems as an engagement and communication tool. An increased focus on the potential value of these communication channels to i...

    Background: Patient portals are frequently deployed in modern healthcare systems as an engagement and communication tool. An increased focus on the potential value of these communication channels to improve health outcomes is warranted. Objective: This paper aims to quantify the impacts of portal use on patients’ preventive health behavior and chronic health outcomes. Methods: We conducted a retrospective, observational cohort study of 10,000 patients ≥50 years of age treated at the University of Pennsylvania Health System (UPHS) from September 1st, 2014 to October 31st, 2016. The data were sourced from the UPHS electronic health records (EHR). We investigated the association between patient portal use and patients’ preventive health behaviors or chronic health outcomes, controlling for confounders using a novel cardinality matching approach based on propensity scoring and a subsequent bootstrapping method to estimate the variance of association estimates. Results: Patient-level characteristics differed substantially between portal users (U), comprising ~59% of the cohort, and non-users (NU). On average, users were more likely to be younger (U: 63.5 years; NU: 66.0 years), white (U: 72.8%, NU: 53.3%), have commercial insurance (U: 61.2%, NU: 39.8%), and have higher annual incomes (U: $74,172/yr, NU: $62,940/yr). Even after adjusting for these potential confounders, patient portal use had positive and clinically meaningful impacts on patients’ preventive health behaviors, but not on chronic health outcomes. Conclusions: This paper contributes to the understanding of the impacts of patient portal use on health outcomes, and is the first study identifying a meaningful subgroup of patients’ health outcomes that improved with portal use. These findings may encourage providers to promote portal use to improve patients’ preventive health behaviors. Clinical Trial: NA

  • eHealth Literacy and Dietary Behaviors in Taiwanese College Students: Cross-Sectional Study

    Date Submitted: Dec 14, 2018

    Open Peer Review Period: Dec 17, 2018 - Feb 11, 2019

    Background: Given the prevalence of lifestyle-related chronic diseases along with an increase in unhealthy dietary practices, promoting healthy dietary habits is a key element in any health program. T...

    Background: Given the prevalence of lifestyle-related chronic diseases along with an increase in unhealthy dietary practices, promoting healthy dietary habits is a key element in any health program. This study attempted to measure the relationship between a broader concept of eHealth literacy and dietary behaviors, in contrast to previous studies that focused solely on functional eHealth literacy. College students may put themselves at increased risk by consuming unsafe foods or not following accepted food safety practices. It is necessary to clarify the mechanisms whereby the three levels of eHealth literacy (functional, interactive, and critical) affect the four aspects of dietary behavior (consumer health, balanced diet, regular eating habits, and unhealthy food intake) in order to develop an effective eHealth literacy educational program to promote healthy behavior among college students. Objective: To investigate the association between eHealth literacy and dietary behaviors. Methods: The eHealth Literacy Scale is a 12-item instrument designed to measure college students’ functional, interactive, and critical eHealth literacy. The Dietary Behaviors Scale is a 14-item instrument developed to measure four aspects of dietary behaviors by college students. A national sample of college students was surveyed, and 792 valid responses were obtained. We conducted a multiple regression analysis to examine the association between eHealth literacy and dietary behaviors. Results: The study found that functional eHealth literacy was negatively related to the unhealthy food intake aspect (t784=-3.56, P<.001), and interactive eHealth literacy was positively related to the balanced diet and consumer health aspects (t784=2.12-3.08, P<.05). Moreover, critical eHealth literacy was positively related to the consumer health, balanced diet, and regular eating habits aspects (t784=3.69-6.30, P<.001). Conclusions: This study showed that Taiwanese college students with functional eHealth literacy were more likely to engage in fewer unhealthy food consumption practices. Moreover, Taiwanese college students with interactive eHealth literacy were more likely to ngage in balanced diet and consumer health practices. Finally, Taiwanese college students with critical eHealth literacy were more likely to engage in positive dietary behaviors than those with functional or interactive eHealth literacy.

  • Cox proportional hazard regression versus a deep learning algorithm in the prediction of dementia: an analysis based on periodic health examination

    Date Submitted: Dec 14, 2018

    Open Peer Review Period: Dec 17, 2018 - Feb 11, 2019

    Background: As the world’s population is aging, there are growing needs for prevention and prediction of dementia among the general population. The availability of national time-series health examin...

    Background: As the world’s population is aging, there are growing needs for prevention and prediction of dementia among the general population. The availability of national time-series health examination data in South Korea invites an opportunity to utilise deep learning, an artificial intelligence technology, to expedite the analysis of mass and sequential data. Objective: We aimed to compare the discriminative accuracy between a time-series deep learning algorithm and conventional statistical methods for predicting all-cause dementia and Alzheimer’s dementia using periodic health examination data. Methods: We used a South Korean national health examination cohort database to identify dementia and Alzheimer’s dementia based on diagnostic codes in medical claims data over a 10-year period. Our analyses of all-cause dementia and Alzheimer’s dementia included 479,845 and 465,081 individuals, respectively, who were 40–79 years of age and without dementia at baseline. We compared the predictive performance of three models: Cox proportional hazards model using only baseline data (HR-B), Cox proportional hazards model using repeated measurements (HR-R), and deep learning model using repeated measurements (DL-R). Results: The discrimination indices (95% confidence interval) for HR-B, HR-R, and DL-R models predicting all-cause dementia were 0.84 (0.83–0.85), 0.87 (0.86–0.88), and 0.90 (0.90–0.90), respectively. The discrimination indices for HR-B, HR-R, and DL-R models predicting Alzheimer’s dementia were 0.87 (0.86–0.88), 0.90 (0.88–0.91), and 0.91 (0.91–0.91), respectively. Thus, the DL-R model showed the best performance, followed by the HR-R model, in predicting both all-cause dementia and Alzheimer’s dementia. The DL-R model was superior to the HR-R model in all validation groups tested. Conclusions: A deep learning algorithm using time-series data could be an accurate, cost-effective method of predicting dementia. A combination of deep learning and proportional hazards models could help enhance prevention strategies for dementia.

  • Feasibility study of Driving to Health: A mental health mobile-friendly website for taxi drivers

    Date Submitted: Dec 13, 2018

    Open Peer Review Period: Dec 17, 2018 - Feb 11, 2019

    Background: Psychological distress among taxi drivers is five times higher than the general population and more than half of all drivers have experienced three or more potentially traumatic events in...

    Background: Psychological distress among taxi drivers is five times higher than the general population and more than half of all drivers have experienced three or more potentially traumatic events in their lifetime. Yet help-seeking for mental health problems in this male-dominated, predominately immigrant workforce is low. Mobile technologies have the potential to increase mental health awareness, teach self-help skills and encourage help-seeking in this hard-to-reach population. Objective: This study aims to assess the feasibility, acceptability and potential efficacy of Driving to Health, a mobile-phone friendly mental health website application (app) designed for people working as taxi drivers. Methods: Drivers (n=46) were recruited from the Melbourne Airport Taxi Holding Yard to participate in a single-arm trial. Self-reported, paper-based assessments were completed at baseline and at one month. Feasibility was measured by completion rates, representativeness of study participants and levels of use. Acceptability was assessed by measuring users’ perception of the quality of the app and anticipated levels of future use. The efficacy of Driving to Health to increase awareness, self-help behaviours and intentions to seek help was assessed using the User Version of the Mobile App Rating Scale (uMARS) and the General Help-Seeking Questionnaire (GHSQ). Psychological symptoms were measured using the short form of the Depression, Anxiety and Stress Scale (DASS-21). Data was analysed using complete case analysis. Results: Forty-two participants, comprising drivers from 10 different countries of origin and 14 different languages, completed pre and post study measures (91% completion rate). Just under half (45%) of participants used the app more than once with an average visit of 4 minutes 8 seconds. Responding to the uMARS, 62% said they would recommend the app to many people. Nearly all (95%) participants said that Driving to Health increased awareness of their own mental health, 86% said it increased their mental health knowledge, and 76% said it increased their self-help behaviours. Increases in help-seeking intentions on the GHSQ were not significant while increases on all three scales on the DASS-21 were not reliable or meaningful. Conclusions: This study suggests that Driving to Health is an acceptable and feasible eHealth intervention for a hard to reach population. Our findings also suggest Driving to Health results in increases in mental health awareness, behaviours and willingness to seek help. Clinical Trial: n/a