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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 21st 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 2018: 4.945, ranked #1 out of 26 journals in the medical informatics category) 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 a 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 an open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as with 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: Creative Commons Attribution (CC-BY).

    Causal Effect of Honorary Titles on Physicians’ Service Volumes in Online Health Communities: Retrospective Study


    Background: An OHC online health community (OHC) is an interactive platform for virtual communication between patients and physicians. Patients can typically search, seek, and share their experience and rate physicians, who may be involved in giving advice. Some OHC providers provide incentives in form of honorary titles to encourage the web-based involvement of physicians, but it is unclear whether the award of honorary titles has an impact on their consultation volume in an OHC. Objective: This study is designed to identify the differential treatment effect of the incentive policy on the service volumes for the subgroups of treatment and control in an OHC. This study aims to answer the following questions: Does an honorary title for physicians impact their service volumes in an OHC? During the period of discontinuity, can we identify the sharp effect of the incentive award on the outcomes of physicians’ service volumes? Methods: We acquired the targeted samples based on treatment, namely, physicians with an honorary title or not and outcomes measured before and after the award of the 2 subgroups. A regression discontinuity design was applied to investigate the impact of the honorary titles incentive as a treatment in an OHC. There was a sharply discontinuous effect of treatment on physicians’ online health service performance. The experimental data set consisted of 346 physicians in the treatment group (with honorary titles). Applying the propensity score matching method, the same size of physicians (n=346) was matched and selected as the control group. Results: A sharp discontinuity was found at the time of the physician receiving the honorary title. The results showed that the parametric estimates of the coefficient were significantly positively (P<.001) associated with monthly home page views. The jump in the monthly volumes of home page views was much sharper than that of the monthly consultations. Conclusions: The changes in the volumes of monthly consultations and home page views reflect the differential treatment effect of honorary titles on physicians’ service volumes. The effect of the incentive policy with honorary titles is objectively estimated from both the perspective of online and offline medical services in an OHC. Being named with honorary titles significantly multiplied monthly home page views, yet it did not significantly impact monthly consultations. This may be because consultation capacity is limited by the physician's schedule for consultations.

  • Source: freepik; Copyright: ijeab; URL:; License: Licensed by JMIR.

    Evaluating the Impact of the Grading and Assessment of Predictive Tools Framework on Clinicians and Health Care Professionals’ Decisions in Selecting...


    Background: While selecting predictive tools for implementation in clinical practice or for recommendation in clinical guidelines, clinicians and health care professionals are challenged with an overwhelming number of tools. Many of these tools have never been implemented or evaluated for comparative effectiveness. To overcome this challenge, the authors developed and validated an evidence-based framework for grading and assessment of predictive tools (the GRASP framework). This framework was based on the critical appraisal of the published evidence on such tools. Objective: The aim of the study was to examine the impact of using the GRASP framework on clinicians’ and health care professionals’ decisions in selecting clinical predictive tools. Methods: A controlled experiment was conducted through a web-based survey. Participants were randomized to either review the derivation publications, such as studies describing the development of the predictive tools, on common traumatic brain injury predictive tools (control group) or to review an evidence-based summary, where each tool had been graded and assessed using the GRASP framework (intervention group). Participants in both groups were asked to select the best tool based on the greatest validation or implementation. A wide group of international clinicians and health care professionals were invited to participate in the survey. Task completion time, rate of correct decisions, rate of objective versus subjective decisions, and level of decisional conflict were measured. Results: We received a total of 194 valid responses. In comparison with not using GRASP, using the framework significantly increased correct decisions by 64%, from 53.7% to 88.1% (88.1/53.7=1.64; t193=8.53; P<.001); increased objective decision making by 32%, from 62% (3.11/5) to 82% (4.10/5; t189=9.24; P<.001); decreased subjective decision making based on guessing by 20%, from 49% (2.48/5) to 39% (1.98/5; t188=−5.47; P<.001); and decreased prior knowledge or experience by 8%, from 71% (3.55/5) to 65% (3.27/5; t187=−2.99; P=.003). Using GRASP significantly decreased decisional conflict and increased the confidence and satisfaction of participants with their decisions by 11%, from 71% (3.55/5) to 79% (3.96/5; t188=4.27; P<.001), and by 13%, from 70% (3.54/5) to 79% (3.99/5; t188=4.89; P<.001), respectively. Using GRASP decreased the task completion time, on the 90th percentile, by 52%, from 12.4 to 6.4 min (t193=−0.87; P=.38). The average System Usability Scale of the GRASP framework was very good: 72.5% and 88% (108/122) of the participants found the GRASP useful. Conclusions: Using GRASP has positively supported and significantly improved evidence-based decision making. It has increased the accuracy and efficiency of selecting predictive tools. GRASP is not meant to be prescriptive; it represents a high-level approach and an effective, evidence-based, and comprehensive yet simple and feasible method to evaluate, compare, and select clinical predictive tools.

  • Betel nuts arranged on beach in Guam. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An Instagram-Based Study to Understand Betel Nut Use Culture in Micronesia: Exploratory Content Analysis


    Background: A 2012 World Health Organization report recognizes betel nut use as an urgent public health threat faced by the Western Pacific region. However, compared with other addictive substances, little is known about how betel nuts are depicted on social media platforms. In particular, image-based social media platforms can be powerful tools for health communication. Studying the content of substance use on visual social media may provide valuable insights into public health interventions. Objective: This study aimed to explore and document the ways that betel nut is portrayed on the photo-sharing site Instagram. The analysis focuses on the hashtag #pugua, which refers to the local term for betel nut in Guam and other parts of Micronesia. Methods: An exploratory content analysis of 242 Instagram posts tagged #pugua was conducted based on previous research on substance use and Instagram and betel nut practices in Micronesia. In addition, the study examined the social engagement of betel nut content on the image-based platform. Results: The study findings revealed content themes referencing the betel nut or betel nut tree, betel nut preparation practices, and the unique social and cultural context surrounding betel nut activity in Guam and Micronesia. In addition, certain practices and cultural themes encouraged social engagement on Instagram. Conclusions: The findings from this study emphasize the cultural relevance of betel nut use in Micronesia. These findings provide a basis for empirically testing hypotheses related to the etiological roles of cultural identity and pride in shaping betel nut use behavior among Micronesians, particularly youths and young adults. Such research is likely to inform the development of culturally relevant betel nut prevention and cessation programs.

  • Source: freepik; Copyright: drobotdean; URL:; License: Licensed by JMIR.

    Benefits of Massive Open Online Course Participation: Deductive Thematic Analysis


    Background: Massive open online courses (MOOCs), as originally conceived, promised to provide educational access to anyone with an internet connection. However, the expansiveness of MOOC education has been found to be somewhat limited. Nonetheless, leading universities continue to offer MOOCs, including many in the health sciences, on a number of private platforms. Therefore, research on online education must include thorough understanding of the role of MOOCs. To date, studies on MOOC participants have focused mainly on learners’ assessment of the course. It is known that MOOCs are not reaching the universal audiences that were predicted, and much knowledge has been gained about learners’ perceptions of MOOCs. However, there is little scholarship on what learners themselves gain from participating in MOOCs. Objective: As MOOC development persists and expands, scholars and developers should be made aware of the role of MOOCs in education by examining what these courses do offer their participants. The objective of this qualitative synthesis of a set of MOOC evaluation studies was to explore outcomes for MOOC learners, that is, how the learners themselves benefit from participating in MOOCs. Methods: To explore MOOC learners’ outcomes, we conducted a qualitative synthesis in the form of a deductive thematic analysis, aggregating findings from 17 individual studies selected from an existing systematic review of MOOC evaluation methods. We structured our inquiry using the Kirkpatrick model, considering Kirkpatrick levels 2, 3, and 4 as potential themes in our analysis. Results: Our analysis identified six types of Kirkpatrick outcomes in 17 studies. Five of these outcomes (learning/general knowledge, skills, attitudes, confidence, and commitment) fit into Kirkpatrick Level 2, while Kirkpatrick Level 3 outcomes concerning behavior/application were seen in four studies. Two additional themes were identified outside of the Kirkpatrick framework: culture and identity outcomes and affective/emotional outcomes. Kirkpatrick Level 4 was not represented among the outcomes we examined. Conclusions: Our findings point to some gains from MOOCs. While we can expect MOOCs to persist, how learners benefit from the experience of participating in MOOCs remains unclear.

  • Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    The Effects of Telemonitoring on Patient Compliance With Self-Management Recommendations and Outcomes of the Innovative Telemonitoring Enhanced Care Program...


    Background: Telemonitoring enables care providers to remotely support outpatients in self-managing chronic heart failure (CHF), but the objective assessment of patient compliance with self-management recommendations has seldom been studied. Objective: This study aimed to evaluate patient compliance with self-management recommendations of an innovative telemonitoring enhanced care program for CHF (ITEC-CHF). Methods: We conducted a multicenter randomized controlled trial with a 6-month follow-up. The ITEC-CHF program comprised the provision of Bluetooth-enabled scales linked to a call center and nurse care services to assist participants with weight monitoring compliance. Compliance was defined a priori as weighing at least 4 days per week, analyzed objectively from weight recordings on the scales. The intention-to-treat principle was used to perform the analysis. Results: A total of 184 participants (141/184, 76.6% male), with a mean age of 70.1 (SD 12.3) years, were randomized to receive either ITEC-CHF (n=91) or usual care (control; n=93), of which 67 ITEC-CHF and 81 control participants completed the intervention. For the compliance criterion of weighing at least 4 days per week, the proportion of compliant participants in the ITEC-CHF group was not significantly higher than that in the control group (ITEC-CHF: 67/91, 74% vs control: 56/91, 60%; P=.06). However, the proportion of ITEC-CHF participants achieving the stricter compliance standard of at least 6 days a week was significantly higher than that in the control group (ITEC-CHF: 41/91, 45% vs control: 23/93, 25%; P=.005). Conclusions: ITEC-CHF improved participant compliance with weight monitoring, although the withdrawal rate was high. Telemonitoring is a promising method for supporting both patients and clinicians in the management of CHF. However, further refinements are required to optimize this model of care. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12614000916640;

  • Source:; Copyright: JESHOOTS.COM; URL:; License: Licensed by JMIR.

    Artificial Intelligence and Health Technology Assessment: Anticipating a New Level of Complexity


    Artificial intelligence (AI) is seen as a strategic lever to improve access, quality, and efficiency of care and services and to build learning and value-based health systems. Many studies have examined the technical performance of AI within an experimental context. These studies provide limited insights into the issues that its use in a real-world context of care and services raises. To help decision makers address these issues in a systemic and holistic manner, this viewpoint paper relies on the health technology assessment core model to contrast the expectations of the health sector toward the use of AI with the risks that should be mitigated for its responsible deployment. The analysis adopts the perspective of payers (ie, health system organizations and agencies) because of their central role in regulating, financing, and reimbursing novel technologies. This paper suggests that AI-based systems should be seen as a health system transformation lever, rather than a discrete set of technological devices. Their use could bring significant changes and impacts at several levels: technological, clinical, human and cognitive (patient and clinician), professional and organizational, economic, legal, and ethical. The assessment of AI’s value proposition should thus go beyond technical performance and cost logic by performing a holistic analysis of its value in a real-world context of care and services. To guide AI development, generate knowledge, and draw lessons that can be translated into action, the right political, regulatory, organizational, clinical, and technological conditions for innovation should be created as a first step.

  • Source: The Authors/Placeit; Copyright: The Authors/Placeit; URL:; License: Licensed by JMIR.

    Requirements of Health Data Management Systems for Biomedical Care and Research: Scoping Review


    Background: Over the last century, disruptive incidents in the fields of clinical and biomedical research have yielded a tremendous change in health data management systems. This is due to a number of breakthroughs in the medical field and the need for big data analytics and the Internet of Things (IoT) to be incorporated in a real-time smart health information management system. In addition, the requirements of patient care have evolved over time, allowing for more accurate prognoses and diagnoses. In this paper, we discuss the temporal evolution of health data management systems and capture the requirements that led to the development of a given system over a certain period of time. Consequently, we provide insights into those systems and give suggestions and research directions on how they can be improved for a better health care system. Objective: This study aimed to show that there is a need for a secure and efficient health data management system that will allow physicians and patients to update decentralized medical records and to analyze the medical data for supporting more precise diagnoses, prognoses, and public insights. Limitations of existing health data management systems were analyzed. Methods: To study the evolution and requirements of health data management systems over the years, a search was conducted to obtain research articles and information on medical lawsuits, health regulations, and acts. These materials were obtained from the Institute of Electrical and Electronics Engineers, the Association for Computing Machinery, Elsevier, MEDLINE, PubMed, Scopus, and Web of Science databases. Results: Health data management systems have undergone a disruptive transformation over the years from paper to computer, web, cloud, IoT, big data analytics, and finally to blockchain. The requirements of a health data management system revealed from the evolving definitions of medical records and their management are (1) medical record data, (2) real-time data access, (3) patient participation, (4) data sharing, (5) data security, (6) patient identity privacy, and (7) public insights. This paper reviewed health data management systems based on these 7 requirements across studies conducted over the years. To our knowledge, this is the first analysis of the temporal evolution of health data management systems giving insights into the system requirements for better health care. Conclusions: There is a need for a comprehensive real-time health data management system that allows physicians, patients, and external users to input their medical and lifestyle data into the system. The incorporation of big data analytics will aid in better prognosis or diagnosis of the diseases and the prediction of diseases. The prediction results will help in the development of an effective prevention plan.

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

    The Potential of Smartphone Apps in Informing Protobacco and Antitobacco Messaging Efforts Among Underserved Communities: Longitudinal Observational Study


    Background: People from underserved communities such as those from lower socioeconomic positions or racial and ethnic minority groups are often disproportionately targeted by the tobacco industry, through the relatively high levels of tobacco retail outlets (TROs) located in their neighborhood or protobacco marketing and promotional strategies. It is difficult to capture the smoking behaviors of individuals in actual locations as well as the extent of exposure to tobacco promotional efforts. With the high ownership of smartphones in the United States—when used alongside data sources on TRO locations—apps could potentially improve tobacco control efforts. Health apps could be used to assess individual-level exposure to tobacco marketing, particularly in relation to the locations of TROs as well as locations where they were most likely to smoke. To date, it remains unclear how health apps could be used practically by health promotion organizations to better reach underserved communities in their tobacco control efforts. Objective: This study aimed to demonstrate how smartphone apps could augment existing data on locations of TROs within underserved communities in Massachusetts and Texas to help inform tobacco control efforts. Methods: Data for this study were collected from 2 sources: (1) geolocations of TROs from the North American Industry Classification System 2016 and (2) 95 participants (aged 18 to 34 years) from underserved communities who resided in Massachusetts and Texas and took part in an 8-week study using location tracking on their smartphones. We analyzed the data using spatial autocorrelation, optimized hot spot analysis, and fitted power-law distribution to identify the TROs that attracted the most human traffic using mobility data. Results: Participants reported encountering protobacco messages mostly from store signs and displays and antitobacco messages predominantly through television. In Massachusetts, clusters of TROs (Dorchester Center and Jamaica Plain) and reported smoking behaviors (Dorchester Center, Roxbury Crossing, Lawrence) were found in economically disadvantaged neighborhoods. Despite the widespread distribution of TROs throughout the communities, participants overwhelmingly visited a relatively small number of TROs in Roxbury and Methuen. In Texas, clusters of TROs (Spring, Jersey Village, Bunker Hill Village, Sugar Land, and Missouri City) were found primarily in Houston, whereas clusters of reported smoking behaviors were concentrated in West University Place, Aldine, Jersey Village, Spring, and Baytown. Conclusions: Smartphone apps could be used to pair geolocation data with self-reported smoking behavior in order to gain a better understanding of how tobacco product marketing and promotion influence smoking behavior within vulnerable communities. Public health officials could take advantage of smartphone data collection capabilities to implement targeted tobacco control efforts in these strategic locations to reach underserved communities in their built environment.

  • Source:; Copyright: H Shaw (@hikeshaw); URL:; License: Licensed by JMIR.

    Assessing Patient Experience and Healthcare Quality of Dental Care Using Patient Online Reviews in the United States: Mixed Methods Study


    Background: Over the last two decades, patient review websites have emerged as an essential online platform for doctor ratings and reviews. Recent studies suggested the significance of such websites as a data source for patients to choose doctors for healthcare providers to learn and improve from patient feedback and to foster a culture of trust and transparency between patients and healthcare providers. However, as compared to other medical specialties, studies of online patient reviews that focus on dentists in the United States remain absent. Objective: This study sought to understand to what extent online patient reviews can provide performance feedbacks that reflect dental care quality and patient experience. Methods: Using mixed informatics methods incorporating statistics, natural language processing, and domain expert evaluation, we analyzed the online patient reviews of 204,751 dentists extracted from HealthGrades with two specific aims. First, we examined the associations between patient ratings and a variety of dentist characteristics. Second, we identified topics from patient reviews that can be mapped to the national assessment of dental patient experience measured by the Patient Experience Measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Dental Plan Survey. Results: Higher ratings were associated with female dentists (t71881=2.45, P<.01, g=0.01), dentists at a younger age (F7, 107128=246.97, P<.001, g=0.11), and those whose patients experienced a short wait time (F4, 150055=10417.77, P<0.001, g=0.18). We also identified several topics that corresponded to CAHPS measures, including discomfort (eg, painful/painless root canal or deep cleaning), and ethics (eg, high-pressure sales, and unnecessary dental work). Conclusions: These findings suggest that online patient reviews could be used as a data source for understanding the patient experience and healthcare quality in dentistry.

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Relationships Between the Usage of Televisions, Computers, and Mobile Phones and the Quality of Sleep in a Chinese Population: Community-Based...


    Background: No study has comprehensively investigated the association between the usage of typical screen-based electronic media devices and sleep quality in a Chinese population with individuals in a wide range of ages. Objective: This study aimed to understand the characteristics of television (TV) viewing, computer usage, and mobile phone usage in a representative Chinese population in Macau and to examine their roles in predicting the variations in sleep quality. Methods: This cross-sectional study was an analysis of 1500 Macau residents aged 15 to 90 years based on a community-based health needs assessment study entitled, “Healthy Living, Longer Lives.” Data collection was conducted in 7 districts of Macau from 2017 to 2018 through face-to-face interviews. The durations of daily TV viewing, computer usage, and mobile phone usage were recorded in a self-administered questionnaire. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality. Results: The prevalence of TV, computer, and mobile phone usage was 78.4% (1176/1500), 51.6% (769/1490), and 85.5% (1276/1492), respectively. The average daily hours of usage were 1.75 (1.62), 1.53 (2.26), and 2.85 (2.47) hours, respectively. Females spent more time watching TV (P=.03) and using mobile phones (P=.02) and less time on the computer (P=.04) as compared to males. Older adults were more likely to watch TV while young people spent more time using the computer and mobile phones (P for all trends<.001). The mean PSQI global score was 4.79 (2.80) among the participants. Females exhibited significantly higher PSQI scores than males (5.04 vs 4.49, respectively; P<.001). No linear association was observed between the PSQI score and the amount of time spent on the 3 electronic devices (P=.58 for PSQI-TV, P=.05 for PSQI-computer, and P=.52 for PSQI-mobile phone). Curve estimation showed significant quadratic curvilinear associations in PSQI-TV (P=.003) and PSQI-computer (P<.001) among all the participants and in PSQI-mobile phone among youths (age, 15-24 years; P=.04). After adjustment of the gender, age, body mass index, demographics, and lifestyle factors, more than 3 hours of TV viewing and 4 hours of computer usage or mobile phone usage was associated with 85% (95% CI 1.04-1.87; P=.008), 72% (95% CI 1.01-2.92; P=.045), and 53% (95% CI 1.06-2.22; P=.03) greater odds of having poor sleep quality (PSQI score>5), respectively. Conclusions: The mobile phone was the most popular screen-based electronic device used in the Macau population, especially among young people. “J” shape associations were observed between sleep quality and the duration of TV viewing, computer usage, and mobile phone usage, indicating that the extreme use of screen-based electronic devices predicted poorer sleep status, whereas moderate use would be acceptable.

  • Source: VASTAVALO; Copyright: Riitta Weijola; URL:; License: Licensed by the authors.

    Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study


    Background: The number of online services in health care is increasing rapidly in developed countries. Users are expected to take a more skilled and active role in taking care of their health and prevention of ill health. This induces risks that users (especially those who need the services the most) will drop out of digital services, resulting in a digital divide or exclusion. To ensure wide and equal use of online services, all users must experience them as beneficial. Objective: This study aimed to examine associations of (1) demographics (age, gender, and degree of urbanization), (2) self-rated health, (3) socioeconomic position (education, experienced financial hardship, labor market position, and living alone), (4) social participation (voting, satisfaction with relationships, and keeping in touch with friends and family members), and (5) access, skills, and extent of use of information and communication technologies (ICT) with perceived benefits of online health care and social welfare services. Associations were examined separately for perceived health, economic, and collaboration benefits. Methods: We used a large random sample representative of the Finnish population including 4495 (56.77% women) respondents aged between 20 and 97 years. Analyses of covariance were used to examine the associations of independent variables with perceived benefits. Results: Access to online services, ICT skills, and extent of use were associated with all examined benefits of online services. ICT skills seemed to be the most important factor. Poor self-rated health was also consistently associated with lower levels of perceived benefits. Similarly, those who were keeping in touch with their friends and relatives at least once a week perceived online services more often beneficial in all the examined dimensions. Those who had experienced financial hardship perceived fewer health and economic benefits than others. Those who were satisfied with their relationships reported higher levels of health and collaboration benefits compared with their counterparts. Also age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services. Conclusions: According to our results, providing health care services online has the potential to reinforce existing social and health inequalities. Our findings suggest that access to online services, skills to use them, and extent of use play crucial roles in perceiving them as beneficial. Moreover, there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them.

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

    Assessment of Adaptive Engagement and Support Model for People With Chronic Health Conditions in Online Health Communities: Combined Content Analysis


    Background: With the pervasiveness of social media, online health communities (OHCs) are an important tool for facilitating information sharing and support among people with chronic health conditions. Importantly, OHCs offer insight into conversations about the lived experiences of people with particular health conditions. Little is known about the aspects of OHCs that are important to maintain safe and productive conversations that support health. Objective: This study aimed to assess the provision of social support and the role of active moderation in OHCs developed in accordance with and managed by an adaptive engagement model. This study also aimed to identify key elements of the model that are central to the development, maintenance, and adaptation of OHCs for people with chronic health conditions. Methods: This study used combined content analysis, a mixed methods approach, to analyze sampled Facebook post comments from 6 OHCs to understand how key aspects of the adaptive engagement model facilitate different types of social support. OHCs included in this study are for people living with multiple sclerosis, migraine, irritable bowel syndrome, rheumatoid arthritis, lung cancer, and prostate cancer. An exploratory approach was used in the analysis, and initial codes were grouped into thematic categories and then confirmed through thematic network analysis using the Dedoose qualitative analysis software tool. Thematic categories were compared for similarities and differences for each of the 6 OHCs and by topic discussed. Results: Data on the reach and engagement of the Facebook posts and the analysis of the sample of 5881 comments demonstrate that people with chronic health conditions want to engage on the web and find value in supporting and sharing their experiences with others. Most comments made in these Facebook posts were expressions of social support for others living with the same health condition (3405/5881, 57.89%). Among the comments with an element of support, those where community members validated the knowledge or experiences of others were most frequent (1587/3405, 46.61%), followed by the expression of empathy and understanding (1089/3405, 31.98%). Even among posts with more factual content, such as insurance coverage issues, user comments still had frequent expressions of support for others (80/213, 37.5%). Conclusions: The analysis of this OHC adaptive engagement model in action shows that the foundational elements—social support, engagement, and moderation—can effectively be used to provide a rich and dynamic community experience for individuals with chronic health conditions. Social support is demonstrated in a variety of ways, including sharing information or validating information shared by others, expressions of empathy, and sharing encouraging statements with others.

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  • Knowledge, attitudes, and practices towards COVID-19 among primary and middle school students during the COVID-19 outbreak period in Beijing: An online cross-sectional survey

    Date Submitted: Jul 8, 2020

    Open Peer Review Period: Jul 8, 2020 - Sep 2, 2020

    Background: The distribution and influence factors of knowledge, attitudes and practices (KAP) towards coronavirus disease 2019 (COVID-19) among children and adolescents remain unknown. Objective: Thi...

    Background: The distribution and influence factors of knowledge, attitudes and practices (KAP) towards coronavirus disease 2019 (COVID-19) among children and adolescents remain unknown. Objective: This study aimed to investigate the KAP towards COVID-19 and their influencing factors among primary and middle school students during the self-quarantine period in Beijing. Methods: This was a cross-sectional study among students from 18 primary and middle schools in Beijing during March 2020. Stratified cluster sampling was conducted. Demographic and KAP-related COVID-19 information was collected through an online questionnaire. The influencing factors were analyzed by multivariable logistic regression. Results: A total of 7,377 students were included. The overall correct rate for COVID-19 knowledge was 74.1%, while only 31.5% and 40.5% could identify the high-risk places of cross-infection and warning body temperature. Although 94.5% of respondents believed the epidemic could be controlled, over 50% expressed various concerns about the epidemic. The compliance rates for basic preventing behaviors were all over 80%, while those for "rational and effective ventilation" (39.2%) and "dinning separately" (38.6%) were low. The KAP levels were significantly differed according to various school categories of students. The COVID-19 knowledge (OR= 3.309, 95% CI: 2.921, 3.748) and attitude (OR=1.145, 95% CI: 1.003, 1.308) were associated with preventive practices. Besides, female, urban students, those with a healthy lifestyle, and those with the willingness to engage in healthcare tended to have better preventive practices. Conclusions: Most students in Beijing hold a high level of knowledge, optimistic attitudes and have appropriate practices towards COVID-19. However, targeted interventions are still necessary, especially for students with high-risk characteristics. Keywords: COVID-19; primary and middle school students; knowledge; attitude; practice Clinical Trial: Because the study is not a clinical study, there is no trial ID for this study.

  • Age Matters: COVID-19 Prevalence in a Vaping Population - An Observational Study

    Date Submitted: Jul 7, 2020

    Open Peer Review Period: Jul 7, 2020 - Sep 1, 2020

    Background: Currently, there is limited or no data demonstrating that vaping is associated with increased transmission or prevalence of coronavirus disease-2019 (COVID-19). Our study aims to investiga...

    Background: Currently, there is limited or no data demonstrating that vaping is associated with increased transmission or prevalence of coronavirus disease-2019 (COVID-19). Our study aims to investigate the relationship of vaping with the prevalence of COVID-19 infection across the United States and in the District of Columbia. Objective: By providing as assessment of prevalence of COVID-19 in vaping young adult population, our study aims to provide unique information for clinicians and patients about the importance of avoidance of vaping in the young adult population. Methods: COVID-19 case counts by state and the District of Columbia were obtained via the Worldometers website on 04/30/2020. Prevalence of COVID-19 cases per 100,000 residents were calculated using estimated 2019 population data from the US Census Department. Age ranges analyzed were: high school age children, Ages 18-24, Ages 25-44, and Ages 45-65. Spearman correlation analysis was conducted to determine if the rate of vaping was correlated with a higher prevalence of COVID-19 cases per 100,000 population. Results: The Spearman correlation analysis demonstrated that persons vaping between 18 years and 24 years of age had a correlation coefficient of 0.278 with prevalence of COVID-19 infection (P=.048). Vaping high school students had a correlation coefficient of 0.153 with prevalence of COVID-19 (P=.328). Persons vaping in the age group 25-45 years had a correlation coefficient of 0.101 in association to COVID-19 prevalence (P=.478). And finally, persons vaping between the age 45-65 years old had a correlation coefficient 0.130 with respect to COVID-19 prevalence (P=.364). Conclusions: Increased COVID-19 prevalence is associated with vaping in the adolescent population between ages 18 and 24. Further prospective studies need to be performed in order investigate the severity of outcomes of vaping in association with COVID-19 infection.

  • System-wide Accelerated Implementation of Telemedicine in Response to COVID-19: A Mixed-Methods Evaluation

    Date Submitted: Jul 4, 2020

    Open Peer Review Period: Jul 4, 2020 - Aug 29, 2020

    Background: As the COVID-19 pandemic disrupted medical practice, telemedicine emerged as an alternative to outpatient visits. However, it is unknown how patients and physicians respond to an accelerat...

    Background: As the COVID-19 pandemic disrupted medical practice, telemedicine emerged as an alternative to outpatient visits. However, it is unknown how patients and physicians respond to an accelerated implementation of this model of medical care. Objective: To report the system-wide accelerated implementation of telemedicine, compare patient satisfaction between telemedicine and in-person visits, and report provider perceptions. Methods: A convergent parallel mixed-methods study design consisting of simultaneous use of both qualitative and quantitative methods. This study was conducted at the UC-Christus Health Network, a large private academic health network in Santiago, Chile. Satisfaction of patients receiving telemedicine care between March and April, 2020, was compared to those receiving in-person care during the same period (concurrent control group) and during March and April, 2019 (retrospective control group). Patient satisfaction with in-person care was measured using the Net Promoter Score (NPS) survey. Satisfaction with telemedicine was assessed by patients using an online survey assessing similar domains. Providers rated their satisfaction and responded to open-ended questions assessing challenges, strategies to address them, the diagnostic process, treatment, and the patient-provider relationship. Results: A total of 3,962 patients receiving telemedicine, 1,187 patients from the concurrent control group, and 1,848 from the retrospective control group completed the surveys. Satisfaction was very high with both telemedicine and in-person services. Overall, 263 physicians from over 41 specialties responded the survey. During telemedicine visits, most providers felt their clinical skills were challenged (61.8%). Female providers felt more challenged than male providers (70.7% vs 50.9%, P = .002). Surgeons, obstetricians and gynecologists felt their clinical skills were challenged the least, compared to providers from non-surgical specialties (P < .001). Challenges related to the delivery modality, diagnostic process, and patient-provider relationship differed according to the provider’s specialty (P = .046, P < .001, and P = .022, respectively). Conclusions: Telemedicine implemented in response to the COVID-19 pandemic produced high patient and provider satisfaction. Specialty groups perceive the impact of this new mode of clinical practice differently.

  • A COVID-19 Contact Tracing Self-Confirmation System for the General Population in Japan: Design and Implementation Evaluation

    Date Submitted: Jul 4, 2020

    Open Peer Review Period: Jul 4, 2020 - Aug 29, 2020

    Background: The global spread of coronavirus disease (COVID-19) has attracted extensive research concerns. It is an infectious disease resulting from a novel virus termed severe acute respiratory synd...

    Background: The global spread of coronavirus disease (COVID-19) has attracted extensive research concerns. It is an infectious disease resulting from a novel virus termed severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The joint collaboration of Ministry of Health, Labor and Welfare (MHLW) in Japan and new coronavirus infection control team has led to the formal issuance of a Bluetooth-based mobile app, which integrates privacy and security protection with methodical processing required for effective contact tracing of exposure to COVID-19. Objective: Due to the demand for a contact tracing instrument that timely keeps track of exposure, teams of professionals and authority experts contributed to the design and implementation of a mobile app intended to provide the general population with updates of contacts at the individual level, including both the infected and the exposed, to manage the risk of close contacts in Japan. This study aims to evaluate the development and distribution of a Bluetooth-based mobile contact-confirming application (COCOA) for COVID-19 to integrate the efforts by healthcare practitioners, the infected and the exposed to contain the spread of COVID-19. Methods: The Exposure Notification Framework (AGF) co-provided by Apple and Google is used in the provision of service. It distributes validated incremental information of COVID-19 that is closely related but might be unware to the individuals. Great emphasis is placed on the correct understanding of seven major steps (issue and confirm process code, report infection status, request information of the infected, calculate and compare exposure summary, provision of response guidance) needed in the process. Results: COCOA consists of three major components: the two mobile apps for the infected and exposed individuals respectively and the notification system that is used to manage and broadcast the information of infection and exposure. Users can self-confirm the risk of exposure to the COVID-19 by periodically fetching the outbreak data and choose provided available response to COVID-19. Conclusions: COCOA is a mobile-based self-confirmation telehealth system developed to assist not only the government and healthcare providers, but also the infected and the exposed individuals to contain COVID-19 through rapid responses and effective non-contact cooperation. The design and the mechanism presents a desirable capacity to promote non-contact cooperation, forecast the potential risk of being infected and facilitate consequential measures to prevent further spread.

  • Internet-based and mobile-supported stress management as a universal prevention approach – Effectiveness and moderators from a large pragmatic randomized-controlled trial

    Date Submitted: Jul 3, 2020

    Open Peer Review Period: Jul 3, 2020 - Aug 28, 2020

    Background: Emerging evidence indicates the effectiveness of Internet-based mobile supported stress management (iSMIs) in highly stressed employees. It is yet unclear, however, whether iSMIs are also...

    Background: Emerging evidence indicates the effectiveness of Internet-based mobile supported stress management (iSMIs) in highly stressed employees. It is yet unclear, however, whether iSMIs are also effective without a preselection process in a universal prevention approach which more closely resembles routine occupational health care. Moreover, evidence for whom iSMIs might be suitable and for whom not is scarce. Objective: The present study aims to evaluate the iSMI GET.ON Stress without baseline inclusion criteria and examine moderators of intervention effects. Methods: 396 employees were randomly assigned to the intervention condition (IC) or the six-month waiting list control condition (WLC). The iSMI consisted of seven sessions and one booster session with and offered no therapeutic guidance. Self-report data were assessed at baseline, seven weeks, and at six months following randomization. The primary outcome was perceived stress (PSS-10). Several a priori defined moderators were explored as potential effect modifiers. Results: Participants of the IC reported significantly lower perceived stress at post-treatment (d=0.71) and six-month follow-up (d=0.61) compared to the WLC. Significant differences with medium to large effect sizes were found for all mental health and most work-related outcomes. Resilience, agreeableness, psychological strain and self-regulation moderated intervention effects. Conclusions: This study indicates that iSMIs can be effective in a broad range of employees with no need for pre-selection to achieve substantial effects. The subgroups that might not profit all had extreme values on the respective measures and represented only a very small proportion of the investigated sample, indicating a broad applicability of GET.ON Stress.

  • Noncommunicable chronic disease and the risk of COVID-19: a population-based case-control study

    Date Submitted: Jul 2, 2020

    Open Peer Review Period: Jul 2, 2020 - Aug 27, 2020

    Objective: To investigate the association of the non-communicable chronic disease (NCD) with the risk of coronavirus disease 2019 (COVID-19). Methods: A case-control study was conducted. The cases we...

    Objective: To investigate the association of the non-communicable chronic disease (NCD) with the risk of coronavirus disease 2019 (COVID-19). Methods: A case-control study was conducted. The cases were laboratory-confirmed COVID-19 who were treated in the Union Hospital in Wuhan. The healthy controls were randomly selected from the participants of the Hunan Government Employee Cohort study who were not infected with COVID-19, matching by age and sex. NCDs including hypertension, diabetes, coronary heart disease, chronic pulmonary disease, and cancer were determined by self-reportings, use of medications, measurements, and/or laboratory testings. The severity of COVID-19 was determined by physicians according to the guideline. Logistic regression was used to estimate the association, in terms of odds ratio (OR). Results: A total of 468 cases and 1404 controls (1:3) were included in the analysis with a mean age of 59.1±12.8 years and 51.7% male. The case group comprised 134 moderately ill, 275 severely ill, and 59 critically ill COVID-19 patients. Patients with diabetes (OR=3.23, P<0.001), chronic pulmonary disease (OR=5.99, P<0.001), and hypertension (OR=1.45, P=0.001) showed a significantly increased risk of COVID-19 infection compared to the healthy controls. Additionally, diabetes, chronic pulmonary disease, hypertension, and the number of comorbid NCDs were associated with the severity of COVID-19 dose-dependently. Conclusions: Patients with diabetes, hypertension, and chronic pulmonary disease are at a higher risk of having COVID-19 and developing severe type of the disease.