The Karma system is currently undergoing maintenance (Monday, January 29, 2018).
The maintenance period has been extended to 8PM EST.

Karma Credits will not be available for redeeming during maintenance.

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:

  • My UmcUtrecht patient portal (montage). Source: UMC Utrecht; Copyright: UMC Utrecht; URL:; License: Licensed by JMIR.

    Use and the Users of a Patient Portal: Cross-Sectional Study


    Background: Patient portals offer patients access to their medical information and tools to communicate with health care providers. It has been shown that patient portals have the potential to positively impact health outcomes and efficiency of health care. It is therefore important that health care organizations identify the patients who use or do not use the patient portal and explore the reasons in either case. The Unified Theory of Acceptance and Use of Technology (UTAUT) is a frequently used theory for explaining the use of information technology. It consists of the following constructs: performance expectancy, effort expectancy, social influence, facilitating conditions, and behavioral intention to use. Objective: This study aimed to explore the prevalence of patient portal use and the characteristics of patients who use or do not use a patient portal. The main constructs of UTAUT, together with demographics and disease- and care-related characteristics, have been measured to explore the predictive factors of portal use. Methods: A cross-sectional study was conducted in the outpatient departments for adult patients of a university hospital in the Netherlands. Following outcomes were included: self-reported portal use, characteristics of users such as demographics, disease- and care-related data, eHealth literacy (modified score), and scores of UTAUT constructs. Descriptive analyses and univariate and multivariate logistic regression were also conducted. Results: In the analysis, 439 adult patients were included. Furthermore, 32.1% (141/439) identified as being a user of the patient portal; 31.2% (137/439) indicated as nonusers, but being aware of the existence of the portal; and 36.6% (161/439) as being nonusers not aware of the existence of the portal. In the entire study population, the factors of being chronically ill (odds ratio, OR 1.62, 95% CI 1.04-2.52) and eHealth literacy (modified score; OR 1.12, 95% CI 1.07-1.18) best predicted portal use. In users and nonusers who were aware of the portal, UTAUT constructs were added to the multivariate logistic regression, with chronically ill and modified eHealth literacy sum score. Effort expectancy (OR 13.02, 95% CI 5.68-29.87) and performance expectancy (OR 2.84, 95% CI 1.65-4.90) are shown to significantly influence portal use in this group. Conclusions: Approximately one-third of the patients of a university hospital self-reported using the patient portal; most expressed satisfaction. At first sight, being chronically ill and higher scores on the modified eHealth literacy scale explained portal use. Adding UTAUT constructs to the model revealed that effort expectancy (ease of use and knowledge and skills related to portal use) and performance expectancy (perceived usefulness) influenced portal use. Interventions to improve awareness of the portal and eHealth literacy skills of patients and further integration of the patient portal in usual face-to-face care are needed to increase use and potential subsequent patient benefits.

  • Source: Immunization Action Coalition; Copyright: Centers for Disease Control and Prevention; URL:; License: Public Domain (CC0).

    Discordance Between Human Papillomavirus Twitter Images and Disparities in Human Papillomavirus Risk and Disease in the United States: Mixed-Methods Analysis


    Background: Racial and ethnic minorities are disproportionately affected by human papillomavirus (HPV)-related cancer, many of which could have been prevented with vaccination. Yet, the initiation and completion rates of HPV vaccination remain low among these populations. Given the importance of social media platforms for health communication, we examined US-based HPV images on Twitter. We explored inconsistencies between the demographics represented in HPV images and the populations that experience the greatest burden of HPV-related disease. Objective: The objective of our study was to observe whether HPV images on Twitter reflect the actual burden of disease by select demographics and determine to what extent Twitter accounts utilized images that reflect the burden of disease in their health communication messages. Methods: We identified 456 image tweets about HPV that contained faces posted by US users between November 11, 2014 and August 8, 2016. We identified images containing at least one human face and utilized Face++ software to automatically extract the gender, age, and race of each face. We manually annotated the source accounts of these tweets into 3 types as follows: government (38/298, 12.8%), organizations (161/298, 54.0%), and individual (99/298, 33.2%) and topics (news, health, and other) to examine how images varied by message source. Results: Findings reflected the racial demographics of the US population but not the disease burden (795/1219, 65.22% white faces; 140/1219, 11.48% black faces; 71/1219, 5.82% Asian faces; and 213/1219, 17.47% racially ambiguous faces). Gender disparities were evident in the image faces; 71.70% (874/1219) represented female faces, whereas only 27.89% (340/1219) represented male faces. Among the 11-26 years age group recommended to receive HPV vaccine, HPV images contained more female-only faces (214/616, 34.3%) than males (37/616, 6.0%); the remainder of images included both male and female faces (365/616, 59.3%). Gender and racial disparities were present across different image sources. Faces from government sources were more likely to depict females (n=44) compared with males (n=16). Of male faces, 80% (12/15) of youth and 100% (1/1) of adults were white. News organization sources depicted high proportions of white faces (28/38, 97% of female youth and 12/12, 100% of adult males). Face++ identified fewer faces compared with manual annotation because of limitations with detecting multiple, small, or blurry faces. Nonetheless, Face++ achieved a high degree of accuracy with respect to gender, race, and age compared with manual annotation. Conclusions: This study reveals critical differences between the demographics reflected in HPV images and the actual burden of disease. Racial minorities are less likely to appear in HPV images despite higher rates of HPV incidence. Health communication efforts need to represent populations at risk better if we seek to reduce disparities in HPV infection.

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

    Using Partially-Observed Facebook Networks to Develop a Peer-Based HIV Prevention Intervention: Case Study


    Background: This is a case study from an HIV prevention project among young black men who have sex with men. Individual-level prevention interventions have had limited success among young black men who have sex with men, a population that is disproportionately affected by HIV; peer network–based interventions are a promising alternative. Facebook is an attractive digital platform because it enables broad characterization of social networks. There are, however, several challenges in using Facebook data for peer interventions, including the large size of Facebook networks, difficulty in assessing appropriate methods to identify candidate peer change agents, boundary specification issues, and partial observation of social network data. Objective: This study aimed to explore methodological challenges in using social Facebook networks to design peer network–based interventions for HIV prevention and present techniques to overcome these challenges. Methods: Our sample included 298 uConnect study respondents who answered a bio-behavioral survey in person and whose Facebook friend lists were downloaded (2013-2014). The study participants had over 180,000 total Facebook friends who were not involved in the study (nonrespondents). We did not observe friendships between these nonrespondents. Given the large number of nonrespondents whose networks were partially observed, a relational boundary was specified to select nonrespondents who were well connected to the study respondents and who may be more likely to influence the health behaviors of young black men who have sex with men. A stochastic model-based imputation technique, derived from the exponential random graph models, was applied to simulate 100 networks where unobserved friendships between nonrespondents were imputed. To identify peer change agents, the eigenvector centrality and keyplayer positive algorithms were used; both algorithms are suitable for identifying individuals in key network positions for information diffusion. For both algorithms, we assessed the sensitivity of identified peer change agents to the imputation model, the stability of identified peer change agents across the imputed networks, and the effect of the boundary specification on the identification of peer change agents. Results: All respondents and 78.9% (183/232) of nonrespondents selected as peer change agents by eigenvector on the imputed networks were also selected as peer change agents on the observed networks. For keyplayer, the agreement was much lower; 42.7% (47/110) and 35.3% (110/312) of respondent and nonrespondent peer change agents, respectively, selected on the imputed networks were also selected on the observed network. Eigenvector also produced a stable set of peer change agents across the 100 imputed networks and was much less sensitive to the specified relational boundary. Conclusions: Although we do not have a gold standard indicating which algorithm produces the most optimal set of peer change agents, the lower sensitivity of eigenvector centrality to key assumptions leads us to conclude that it may be preferable. The methods we employed to address the challenges in using Facebook networks may prove timely, given the rapidly increasing interest in using online social networks to improve population health.

  • Source: Royal Air Force Lakenheath (Erin O’Shea); Copyright: US Air Force; URL:; License: Public Domain (CC0).

    Automatic Extraction of Mental Health Disorders From Domestic Violence Police Narratives: Text Mining Study


    Background: Vast numbers of domestic violence (DV) incidents are attended by the New South Wales Police Force each year in New South Wales and recorded as both structured quantitative data and unstructured free text in the WebCOPS (Web-based interface for the Computerised Operational Policing System) database regarding the details of the incident, the victim, and person of interest (POI). Although the structured data are used for reporting purposes, the free text remains untapped for DV reporting and surveillance purposes. Objective: In this paper, we explore whether text mining can automatically identify mental health disorders from this unstructured text. Methods: We used a training set of 200 DV recorded events to design a knowledge-driven approach based on lexical patterns in text suggesting mental health disorders for POIs and victims. Results: The precision returned from an evaluation set of 100 DV events was 97.5% and 87.1% for mental health disorders related to POIs and victims, respectively. After applying our approach to a large-scale corpus of almost a half million DV events, we identified 77,995 events (15.83%) that mentioned mental health disorders, with 76.96% (60,032/77,995) of those linked to POIs versus 16.47% (12,852/77,995) for the victims and 6.55% (5111/77,995) for both. Depression was the most common mental health disorder mentioned in both victims (22.30%, 3258) and POIs (18.73%, 8918), followed by alcohol abuse for POIs (12.24%, 5829) and various anxiety disorders (eg, panic disorder, generalized anxiety disorder) for victims (11.43%, 1671). Conclusions: The results suggest that text mining can automatically extract targeted information from police-recorded DV events to support further public health research into the nexus between mental health disorders and DV.

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

    Reach of Messages in a Dental Twitter Network: Cohort Study Examining User Popularity, Communication Pattern, and Network Structure


    Background: Increasing the reach of messages disseminated through Twitter promotes the success of Twitter-based health education campaigns. Objective: This study aimed to identify factors associated with reach in a dental Twitter network (1) initially and (2) sustainably at individual and network levels. Methods: We used instructors’ and students’ Twitter usernames from a Saudi dental school in 2016-2017 and applied Gephi (a social network analysis tool) and social media analytics to calculate user and network metrics. Content analysis was performed to identify users disseminating oral health information. The study outcomes were reach at baseline and sustainably over 1.5 years. The explanatory variables were indicators of popularity (number of followers, likes, tweets retweeted by others), communication pattern (number of tweets, retweets, replies, tweeting/ retweeting oral health information or not). Multiple logistic regression models were used to investigate associations. Results: Among dental users, 31.8% had reach at baseline and 62.9% at the end of the study, reaching a total of 749,923 and dropping to 37,169 users at the end. At an individual level, reach was associated with the number of followers (baseline: odds ratio, OR=1.003, 95% CI=1.001-1.005 and sustainability: OR=1.002, 95% CI=1.0001-1.003), likes (baseline: OR=1.001, 95% CI=1.0001-1.002 and sustainability: OR=1.0031, 95% CI=1.0003-1.002), and replies (baseline: OR=1.02, 95% CI=1.005-1.04 and sustainability: OR=1.02, 95% CI=1.004-1.03). At the network level, users with the least followers, tweets, retweets, and replies had the greatest reach. Conclusions: Reach was reduced by time. Factors increasing reach at the user level had different impact at the network level. More than one strategy is needed to maximize reach.

  • Source: Flickr / Adobe Stock; Copyright: JMIR Publications; URL:; License: Licensed by JMIR.

    Audio-/Videorecording Clinic Visits for Patient’s Personal Use in the United States: Cross-Sectional Survey


    Background: Few clinics in the United States routinely offer patients audio or video recordings of their clinic visits. While interest in this practice has increased, to date, there are no data on the prevalence of recording clinic visits in the United States. Objective: Our objectives were to (1) determine the prevalence of audiorecording clinic visits for patients’ personal use in the United States, (2) assess the attitudes of clinicians and public toward recording, and (3) identify whether policies exist to guide recording practices in 49 of the largest health systems in the United States. Methods: We administered 2 parallel cross-sectional surveys in July 2017 to the internet panels of US-based clinicians (SERMO Panel) and the US public (Qualtrics Panel). To ensure a diverse range of perspectives, we set quotas to capture clinicians from 8 specialties. Quotas were also applied to the public survey based on US census data (gender, race, ethnicity, and language other than English spoken at home) to approximate the US adult population. We contacted 49 of the largest health systems (by clinician number) in the United States by email and telephone to determine the existence, or absence, of policies to guide audiorecordings of clinic visits for patients’ personal use. Multiple logistic regression models were used to determine factors associated with recording. Results: In total, 456 clinicians and 524 public respondents completed the surveys. More than one-quarter of clinicians (129/456, 28.3%) reported that they had recorded a clinic visit for patients’ personal use, while 18.7% (98/524) of the public reported doing so, including 2.7% (14/524) who recorded visits without the clinician’s permission. Amongst clinicians who had not recorded a clinic visit, 49.5% (162/327) would be willing to do so in the future, while 66.0% (346/524) of the public would be willing to record in the future. Clinician specialty was associated with prior recording: specifically oncology (odds ratio [OR] 5.1, 95% CI 1.9-14.9; P=.002) and physical rehabilitation (OR 3.9, 95% CI 1.4-11.6; P=.01). Public respondents who were male (OR 2.11, 95% CI 1.26-3.61; P=.005), younger (OR 0.73 for a 10-year increase in age, 95% CI 0.60-0.89; P=.002), or spoke a language other than English at home (OR 1.99; 95% CI 1.09-3.59; P=.02) were more likely to have recorded a clinic visit. None of the large health systems we contacted reported a dedicated policy; however, 2 of the 49 health systems did report an existing policy that would cover the recording of clinic visits for patient use. The perceived benefits of recording included improved patient understanding and recall. Privacy and medicolegal concerns were raised. Conclusions: Policy guidance from health systems and further examination of the impact of recordings—positive or negative—on care delivery, clinician-related outcomes, and patients’ behavioral and health-related outcomes is urgently required.

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

    Mindfulness-Based Resilience Training in the Workplace: Pilot Study of the Internet-Based Resilience@Work (RAW) Mindfulness Program


    Background: The impact of mental illness on society is far reaching and has been identified as the leading cause of sickness absence and work disability in most developed countries. By developing evidence-based solutions that are practical, affordable, and accessible, there is potential to deliver substantial economic benefits while improving the lives of individual workers. Academic and industry groups are now responding to this public health issue. A key focus is on developing practical solutions that enhance the mental health and psychological resilience of workers. A growing body of research suggests resilience training may play a pivotal role in the realm of public health and prevention, particularly with regards to protecting the long-term well-being of workers. Objective: Our aim is to examine whether a mindfulness-based resilience-training program delivered via the internet is feasible and engaging to a group of high-risk workers. Additionally, we aim to measure the effect of the Resilience@Work Resilience@Work Mindfulness program on measures of resilience and related skills. Methods: The current pilot study recruited 29 full-time firefighters. Participants were enrolled in the 6-session internet-based resilience-training program and were administered questionnaires prior to training and directly after the program ended. Measurements examined program feasibility, psychological resilience, experiential avoidance, and thought entanglement. Results: Participants reported greater levels of resilience after Resilience@Work training compared to baseline, with a mean increase in their overall resilience score of 1.5 (95% CI -0.25 to 3.18, t14=1.84, P=.09). Compared to baseline, participants also reported lower levels of psychological inflexibility and experiential avoidance following training, with a mean decrease of -1.8 (95% CI -3.78 to 0.20, t13=-1.94, P=.07). With regards to cognitive fusion (thought entanglement), paired-samples t tests revealed a trend towards reduction in mean scores post training (P=.12). Conclusions: This pilot study of the Resilience@Work program suggests that a mindfulness-based resilience program delivered via the Internet is feasible in a high-risk workplace setting. In addition, the firefighters using the program showed a trend toward increased resilience and psychological flexibility. Despite a number of limitations, the results of this pilot study provide some valuable insights into what form of resilience training may be viable in occupational settings particularly among those considered high risk, such as emergency workers. To the best of our knowledge, this is the first time a mindfulness-based resilience-training program delivered wholly via the internet has been tested in the workplace.

  • Young person using the Mental Health eClinic. Source: The Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Using New and Innovative Technologies to Assess Clinical Stage in Early Intervention Youth Mental Health Services: Evaluation Study


    Background: Globally there is increasing recognition that new strategies are required to reduce disability due to common mental health problems. As 75% of mental health and substance use disorders emerge during the teenage or early adulthood years, these strategies need to be readily accessible to young people. When considering how to provide such services at scale, new and innovative technologies show promise in augmenting traditional clinic-based services. Objective: The aim of this study was to test new and innovative technologies to assess clinical stage in early intervention youth mental health services using a prototypic online system known as the Mental Health eClinic (MHeC). Methods: The online assessment within the MHeC was compared directly against traditional clinician assessment within 2 Sydney-based youth-specific mental health services (headspace Camperdown and headspace Campbelltown). A total of 204 young people were recruited to the study. Eligible participants completed both face-to-face and online assessments, which were randomly allocated and counterbalanced at a 1-to-3 ratio. These assessments were (1) a traditional 45- to 60-minute headspace face-to-face assessment performed by a Youth Access Clinician and (2) an approximate 60-minute online assessment (including a self-report Web-based survey, immediate dashboard of results, and a video visit with a clinician). All assessments were completed within a 2-week timeframe from initial presentation. Results: Of the 72 participants who completed the study, 71% (51/72) were female and the mean age was 20.4 years (aged 16 to 25 years); 68% (49/72) of participants were recruited from headspace Camperdown and the remaining 32% (23/72) from headspace Campbelltown. Interrater agreement of participants’ stage, as determined after face-to-face assessment or online assessment, demonstrated fair agreement (kappa=.39, P<.001) with concordance in 68% of cases (49/72). Among the discordant cases, those who were allocated to a higher stage by online raters were more likely to report a past history of mental health disorders (P=.001), previous suicide planning (P=.002), and current cannabis misuse (P=.03) compared to those allocated to a lower stage. Conclusions: The MHeC presents a new and innovative method for determining key clinical service parameters. It has the potential to be adapted to varied settings in which young people are connected with traditional clinical services and assist in providing the right care at the right time.

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

    Clinical Decision Support Systems for Drug Allergy Checking: Systematic Review


    Background: Worldwide, the burden of allergies—in particular, drug allergies—is growing. In the process of prescribing, dispensing, or administering a drug, a medication error may occur and can have adverse consequences; for example, a drug may be given to a patient with a documented allergy to that particular drug. Computerized physician order entry (CPOE) systems with built-in clinical decision support systems (CDSS) have the potential to prevent such medication errors and adverse events. Objective: The aim of this review is to provide a comprehensive overview regarding all aspects of CDSS for drug allergy, including documenting, coding, rule bases, alerts and alert fatigue, and outcome evaluation. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as much as possible and searches were conducted in 5 databases using CPOE, CDSS, alerts, and allergic or allergy as keywords. Bias could not be evaluated according to PRISMA guidelines due to the heterogeneity of study types included in the review. Results: Of the 3160 articles considered, 60 met the inclusion criteria. A further 9 articles were added based on expert opinion, resulting in a total of 69 articles. An interrater agreement of 90.9% with a reliability Κ=.787 (95% CI 0.686-0.888) was reached. Large heterogeneity across study objectives, study designs, study populations, and reported results was found. Several key findings were identified. Evidence of the usefulness of clinical decision support for drug allergies has been documented. Nevertheless, there are some important problems associated with their use. Accurate and structured documenting of information on drug allergies in electronic health records (EHRs) is difficult, as it is often not clear to healthcare providers how and where to document drug allergies. Besides the underreporting of drug allergies, outdated or inaccurate drug allergy information in EHRs poses an important problem. Research on the use of coding terminologies for documenting drug allergies is sparse. There is no generally accepted standard terminology for structured documentation of allergy information. The final key finding is the consistently reported low specificity of drug allergy alerts. Current systems have high alert override rates of up to 90%, leading to alert fatigue. Important challenges remain for increasing the specificity of drug allergy alerts. We found only one study specifically reporting outcomes related to CDSS for drug allergies. It showed that adverse drug events resulting from overridden drug allergy alerts do not occur frequently. Conclusions: Accurate and comprehensive recording of drug allergies is required for good use of CDSS for drug allergy screening. We found considerable variation in the way drug allergy are recorded in EHRs. It remains difficult to reduce drug allergy alert overload while maintaining patient safety as the highest priority. Future research should focus on improving alert specificity, thereby reducing override rates and alert fatigue. Also, the effect on patient outcomes and cost-effectiveness should be evaluated.

  • The need for an ecosystem of digital health solutions. Source: Pxhere; Copyright: Pxhere; URL:; License: Public Domain (CC0).

    Proposing an Ecosystem of Digital Health Solutions for Teens With Chronic Conditions Transitioning to Self-Management and Independence: Exploratory...


    Background: Chronic disease management is critical to quality of life for both teen patients with chronic conditions and their caregivers. However, current literature is largely limited to a specific digital health tool, method, or approach to manage a specific disease. Guiding principles on how to use digital tools to support the transition to independence are rare. Considering the physiological, psychological, and environmental changes that teens experience, the issues surrounding the transition to independence are worth investigating to develop a deeper understanding to inform future strategies for digital interventions. Objective: The purpose of this study was to inform the design of digital health solutions by systematically identifying common challenges among teens and caregivers living with chronic diseases. Methods: Chronically ill teens (n=13) and their caregivers (n=13) were interviewed individually and together as a team. Verbal and projective techniques were used to examine teens’ and caregivers’ concerns in-depth. The recorded and transcribed responses were thematically analyzed to identify and organize the identified patterns. Results: Teens and their caregivers identified 10 challenges and suggested technological solutions. Recognized needs for social support, access to medical education, symptom monitoring, access to health care providers, and medical supply management were the predominant issues. The envisioned ideal transition included a 5-component solution ecosystem in the transition to independence for teens. Conclusions: This novel study systematically summarizes the challenges, barriers, and technological solutions for teens with chronic conditions and their caregivers as teens transition to independence. A new solution ecosystem based on the 10 identified challenges would guide the design of future implementations to test and validate the effectiveness of the proposed 5-component ecosystem.

  • Participant receiving health care through Web-based cognitive behavioral therapy. Source: Max Pixel; Copyright: Max Pixel; URL:; License: Public Domain (CC0).

    Patient Experiences of Web-Based Cognitive Behavioral Therapy for Heart Failure and Depression: Qualitative Study


    Background: Web-based cognitive behavioral therapy (wCBT) has been proposed as a possible treatment for patients with heart failure and depressive symptoms. Depressive symptoms are common in patients with heart failure and such symptoms are known to significantly worsen their health. Although there are promising results on the effect of wCBT, there is a knowledge gap regarding how persons with chronic heart failure and depressive symptoms experience wCBT. Objective: The aim of this study was to explore and describe the experiences of participating and receiving health care through a wCBT intervention among persons with heart failure and depressive symptoms. Methods: In this qualitative, inductive, exploratory, and descriptive study, participants with experiences of a wCBT program were interviewed. The participants were included through purposeful sampling among participants previously included in a quantitative study on wCBT. Overall, 13 participants consented to take part in this study and were interviewed via telephone using an interview guide. Verbatim transcripts from the interviews were qualitatively analyzed following the recommendations discussed by Patton in Qualitative Research & Evaluation Methods: Integrating Theory and Practice. After coding each interview, codes were formed into categories. Results: Overall, six categories were identified during the analysis process. They were as follows: “Something other than usual health care,” “Relevance and recognition,” “Flexible, understandable, and safe,” “Technical problems,” “Improvements by real-time contact,” and “Managing my life better.” One central and common pattern in the findings was that participants experienced the wCBT program as something they did themselves and many participants described the program as a form of self-care. Conclusions: Persons with heart failure and depressive symptoms described wCBT as challenging. This was due to participants balancing the urge for real-time contact with perceived anonymity and not postponing the work with the program. wCBT appears to be a valuable tool for managing depressive symptoms.

  • Source: The Authors / Unsplash; Copyright: Gemma Crawford; URL:; License: Creative Commons Attribution (CC-BY).

    Prevention of HIV and Other Sexually Transmissible Infections in Expatriates and Traveler Networks: Qualitative Study of Peer Interaction in an Online Forum


    Background: In high-income countries such as Australia, an increasing proportion of HIV cases have been acquired overseas, including among expatriates and travelers. Australia’s national strategies have highlighted the need for public health interventions for priority populations. One approach is to expand efforts to places or spaces where expatriate communities reside. Online settings such as forums used by expatriates and travelers have potential for preventing sexually transmissible infections with those hard to reach through more traditional interventions. Objective: Our objectives were to (1) identify and describe domains of social interaction and engagement in 1 online forum used by Australian expatriates and travelers living or working in Thailand; and (2) make recommendations to health-promoting organizations and policy makers regarding the role of these forums in public health interventions with mobile populations who may be at risk of acquiring HIV or other sexually transmissible infections. Methods: We identified forums and users in 2 stages. We identified 13 online forums and analyzed them for inclusion criteria. We searched 1 forum that met the required criteria for users who met inclusion criteria (n=5). Discussion threads, rather than individual posts, were units of analysis. For each user, we collected as transcripts the first 100 posts and 10 most recent posts, including the thread in which they were posted. We analyzed and thematically coded each post (n=550). Transcripts and analyses were reviewed and refined by multiple members of the research team to improve rigor. Themes were not totally emergent but explored against symbolic interactionism concepts of presentation of self, meaning, and socialization. Results: Key domains were as follows: the forum (characteristics of the space and reasons for use), gaining access (forum hierarchy and rules), identity (presentation of self and role of language), advice, support, and information (sources of information, support provided, influencers, topics of discussion, and receptiveness to advice), and risk (expectations and perceptions). The forum exhibited evidence of unique language, rules and norms, and processes for managing conflict and key influencers. The forum was a substantial source of health information and advice provided to users via confirmation, reassurance, or affirmation of beliefs and experiences. Risk perception and expectations varied. Risk taking, including around sex, appeared to be a key expectation of travel or the experience of being an expatriate or traveler. Conclusions: Australian expatriate and long-term traveler participation in the online forum formed, influenced, and reinforced knowledge, attitudes, interaction, and identity. Such forums can be used by policy makers and health-promoting organizations to provide supplementary sources of support and information to hard-to-reach mobile populations who may be at risk of acquiring HIV or other sexually transmissible infections. This will complement existing engagement with health professionals and other public health interventions.

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Latest Submissions Open for Peer-Review:

View All Open Peer Review Articles
  • Do millions of prayers increase one’s longevity? A cohort study of the impact of intercessory prayers on the mortality of Roman Catholic bishops

    Date Submitted: Sep 14, 2018

    Open Peer Review Period: Sep 19, 2018 - Nov 14, 2018

    Background: There have been mixed results of the studies checking whether prayers do actually extend the life duration of the people prayed for. Most studies on the topic included a small number of pr...

    Background: There have been mixed results of the studies checking whether prayers do actually extend the life duration of the people prayed for. Most studies on the topic included a small number of prayers and most of them focused on people already struggling with a medical condition. Intercessory prayer’s influence on health is of scholarly interest, yet it is unclear if its effect may be dependent on the number of prayers for a named individual received per annum. Objective: We sought to examine if there is a noticeable increased longevity effect of intercessory prayer for a named individual’s well-being, if he receives a very high number of prayers per annum for an extended period. Methods: We retrieved and conducted a statistical analysis of the data about the length of life for 857 Roman Catholic bishops, 500 Catholic priests, and 3038 male academics from the US, France, Italy, Poland, Brazil, and Mexico. We obtained information for these individuals who died between 1988 and 2018 from Wikidata, and conducted an observational cohort study. Bishops were chosen for the study, as they receive millions of individual prayers for well being, according to conservative estimates. Results: There was a main effect for occupation F(2, 4391) = 4.07, p = .017, ηp 2 = .002, with pairwise comparisons indicating significant differences between the mean life duration of bishops (M=30489) and of priests (M=29894), but none between the academic teachers (M=30147) and either of the other groups. A comparison analysis between bishops from the largest and the smallest dioceses showed no significant difference t(67.31)=1.61, p = .11. Our main outcome measure is covariance of the mean length of life in each of the categories: bishops, priests, academic teachers, controlled for nationality. Conclusions: The first analysis proved that bishops live longer than priests, but due to a marginal effect size this result should be treated with caution. No difference was found between the mean length of life of bishops from the largest and the smallest dioceses. We found no difference between bishops and male academics. These results show that the impact of intercessory prayers on longevity is not observable.

  • Assessing the Acceptability and Perceived Accuracy of Tailored Feedback and Computerized Adaptive Testing in Quality of Life Assessment

    Date Submitted: Sep 14, 2018

    Open Peer Review Period: Sep 19, 2018 - Nov 14, 2018

    Background: Quality of life (QoL) assessments, or patient-reported outcome measures (PROMs), are becoming increasingly important and can improve decision making, satisfaction, and outcomes of care. S...

    Background: Quality of life (QoL) assessments, or patient-reported outcome measures (PROMs), are becoming increasingly important and can improve decision making, satisfaction, and outcomes of care. Some physicians and patients find questionnaires too burdensome, which could be reduced by using computerized adaptive testing. Furthermore, questionnaire user experience might increase by making a questionnaire more interesting, for example by providing graphical and contextualized feedback. However, little is known about how shorter assessments and feedback impact user experience. Objective: We conducted a controlled experiment to assess the impact of tailored multimodal feedback and computerized adaptive testing on user experience in QoL assessment using validated PROMs. Methods: We recruited a representative sample from the general population in the United Kingdom using the Oxford Prolific academic web panel. Participants completed either a computer adaptive testing version of the World Health Organization Quality of Life assessment (WHOQOL-CAT) or the fixed-length WHOQOL-BREF. We randomly assigned participants to conditions in which they would receive either no feedback, graphical feedback only, or graphical and adaptive text feedback. Participants rated the assessment in terms of perceived acceptability, engagement, clarity, and accuracy. Results: We included 1386 participants in our analysis. Assessment experience was improved when graphical and tailored text feedback was provided together alongside PROMs (p<0.001, Δ=0.22). Providing graphical feedback alone was not associated with improvement in overall experience (p=0.006, Δ=0.10). Graphical and text feedback made the questionnaire more interesting and users were more likely to share the results with a physician or family member (p<0.001, Δ=0.17, and p<0.001, Δ=0.17, respectively). No difference was found in perceived accuracy of the graphical feedback scores of the WHOQOL-CAT and WHOQOL-BREF (p=0.05, Δ = 0.06). Computerized adaptive testing resulted in a 25% item reduction (SE<0.45) compared to the fixed-length assessment but did not result in an increased user experience (p=0.21). Conclusions: Using tailored text feedback to contextualize numeric scores maximized the acceptability of electronic QoL assessment. Improving user experience may increase response rates and reduce attrition in research and clinical use of PROMs. In this study, CAT administration was associated with a modest decrease in assessment length but did not improve user experience. Patient perceived accuracy of feedback was equivalent when comparing CAT with fixed-length assessment. Further research is warranted to explore the relationship between assessment length, feedback, and response burden in diverse populations.

  • A retrospective observational study of post-vaccination fever response in children collected via the mobile application Fever Coach

    Date Submitted: Sep 15, 2018

    Open Peer Review Period: Sep 19, 2018 - Nov 14, 2018

    Background: Post-vaccination fever (PVF) is a mild adverse event that is naturally reversible without complications, but is highly prevalent and, in some cases, accompanied by febrile convulsions. The...

    Background: Post-vaccination fever (PVF) is a mild adverse event that is naturally reversible without complications, but is highly prevalent and, in some cases, accompanied by febrile convulsions. These adverse effects may cause parents to delay or abandon vaccinating their children. Objective: The aim of this paper was to identify PVF patterns and the ability of antipyretics to affect changes in these patterns. Methods: We used the data collected by the parents of the feverish children in the mobile application named Fever Coach to identify the PVF patterns according to the vaccinations and the use of antipyretic drugs. We selected single vaccination records that contained 5 or more body temperature readings performed within 48 hours of vaccination and analyzed PVF onset, offset, duration, and maximum temperature. By observing PVF response to vaccination, we identified effects of antipyretic drugs on PVF onset, offset, and duration times; the extent of fever; and rate of decline. We also performed the logistic regression test to determine demographic variables (age, weight, and gender) to produce relatively high fevers (≥39 ° C). Results: The highest body temperature at which infants and young children received antipyretic drugs was 38 ° C (9.8% of the total data). The number of instances where this temperature threshold was reached was more than four times greater than the number reaching 37.9 ° C. Analyses showed no significant difference in onset time between antipyretic and non-antipyretic cases, but offset time and duration time were significantly shorter in non-antipyretic cases (P < .001). In non-antipyretic cases, offset times and duration times were, on average, 9.9 hours and 10.1 hours shorter, respectively than antipyretic cases. Body temperatures also decreased faster in non-antipyretic cases. Besides, we found that fevers associated with the influenza vaccine lasted relatively long, while fevers associated with the pneumococcus vaccine were relatively short-lived. Conclusions: These findings suggest that PVF has its own fever pattern that is dependent upon vaccine type and presence of antipyretic drugs, and post-vaccination temperature monitoring may ease fever phobia and reduce unnecessary use of antipyretics and medical care.

  • Considerations in the Design and Development of Smoking Cessation Apps: Smokers Perspective in China

    Date Submitted: Sep 13, 2018

    Open Peer Review Period: Sep 17, 2018 - Nov 13, 2018

    Background: Although there are more than 60 smartphone applications (apps) for smoking cessation in China, many do not include the content and features that smokers prefer—which may make them imprac...

    Background: Although there are more than 60 smartphone applications (apps) for smoking cessation in China, many do not include the content and features that smokers prefer—which may make them impractical and/or ineffective. Objective: We therefore investigated what Chinese smokers want from a smartphone app for smoking cessation. Methods: Between May 1, 2016 and August 31, 2016, eligible Chinese smokers who own smartphones (N = 357) responded to a survey collecting data on their socio-demographic characteristics and their opinions on the importance of 20 smoking cessation app design features validated in previous research. Results: Few smokers (14/319, 4.4%) had ever downloaded a smoking cessation app. More than 60% of smokers rated the following four features as very or extremely important: allow sharing the process of smoking cessation with family members and friends (67.7%), help smokers track their progress (such as amount of smoking per day) (66.8%), help with the side effects of medications and nicotine withdrawal symptoms (63.0%), and adapt to ongoing needs and interests of smokers (60.8%). Among subgroups of smokers, supportive content (e.g., information about cessation medications) features were rated as more important among females (vs. males; all p<.05) and among those age 35 and younger (vs. age 36 and older; all ps<.05). Conclusions: Contrary to a similar study of American smokers (McClure et al., 2016), Chinese smokers highly value a smoking cessation app’s reputation and ability to communicate with family members and friends as important features whereas privacy and security were less important. Women and those age 36 and over tend to value more supportive features. Overall, design of health behavior change apps should consider cultural and demographic differences.

  • Design and Preliminary Findings from a new e-Cohort embedded in the Framingham Heart Study (eFHS)

    Date Submitted: Sep 13, 2018

    Open Peer Review Period: Sep 17, 2018 - Nov 13, 2018

    Background: New models of scalable population-based data collection that integrate digital and mobile health data are necessary. Objective: To describe a cardiovascular digital and mobile health e-coh...

    Background: New models of scalable population-based data collection that integrate digital and mobile health data are necessary. Objective: To describe a cardiovascular digital and mobile health e-cohort embedded in a traditional longitudinal cohort study, the Framingham Heart Study (FHS). Methods: We invited eligible and consenting FHS Generation 3 and Omni participants to download the eFHS app onto their smartphones and co-deployed a digital blood pressure (BP) cuff. Soon thereafter, participants were also offered a smartwatch (Apple Watch). Participants are invited to complete surveys through the eFHS app, to perform weekly BP measurements and to wear the smartwatch daily. Results: Up to July 2017, we have enrolled 790 eFHS participants, representing 75.7% of potentially eligible FHS participants. eFHS participants were, on average, 538 years of age and 57% were women. 85% (n=675) of eFHS participants completed all of the baseline survey and 59% (n=470) completed the 3-month survey. 42% (n=241 of 573) and 76% (n=306 of 405) of eFHS participants adhered to weekly digital BP and HR uploads, respectively over 12 weeks. Conclusions: We have designed an e-cohort focused on identifying novel CVD risk factors using a new smartphone app, a digital BP cuff, and a smartwatch. Despite minimal training and support, preliminary findings over a 3-month follow-up period show that uptake is high and adherence to periodic app-based surveys, weekly digital BP assessments, and smartwatch HR measures is acceptable.

  • Efficacy of a mobile social networking intervention in promoting physical activity: A feasibility study

    Date Submitted: Sep 12, 2018

    Open Peer Review Period: Sep 17, 2018 - Nov 12, 2018

    Background: Technological interventions such as mobile applications (apps), online social networks and wearable trackers have the potential to influence physical activity; yet, few studies have examin...

    Background: Technological interventions such as mobile applications (apps), online social networks and wearable trackers have the potential to influence physical activity; yet, few studies have examined the efficacy of an intervention bundle combining these different technologies. Objective: To pilot test an intervention composed of a social networking mobile app, connected with a wearable tracker and investigate its efficacy in improving physical activity, as well as explore participant engagement, and the usability of the app. Methods: Pre-post quasi-experimental study with one arm, where participants were subjected to the intervention for a six-month period. The primary outcome measure was the difference in daily step count between baseline and six months. Secondary outcome measures included engagement with the intervention and system usability. Descriptive and inferential statistical tests were conducted; post-hoc subgroup analyses were carried out for participants with different levels of: steps at baseline, app usage and social features usage. Results: Fifty-five participants were enrolled in the study; the mean age was 23.6 years and 28 (50.1%) were female. At six months, the retention rate was 81.8% (45/55). There was a non-significant increase of 1039 steps per day in average daily step count between baseline and 6 months (P = 0.06, 95% confidence interval [-61, 2139]). Subgroup analysis comparing the high and low physical activity groups at baseline showed that the latter significantly increased their daily step count by throughout the study 2677 steps per day (P = 0.002, 95% confidence interval [785, 3658]). Conclusions: Our study showed the efficacy of a mobile social networking intervention, integrated with a wearable tracker to promote physical activity, particularly for physically inactive subgroups of the population. Future research should explore how to address challenges faced by physically inactive people to provide tailored advices. Additionally, users’ perspectives should be explored to shed light on factors that might influence their engagement with the intervention.