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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 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 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:

  • Person using chat application on laptop. Source: Pexels.com; Copyright: Rawpixel.com; URL: https://www.pexels.com/photo/photography-of-person-using-laptop-1243365/; License: Licensed by JMIR.

    Development and Evaluation of ClientBot: Patient-Like Conversational Agent to Train Basic Counseling Skills

    Abstract:

    Background: Training therapists is both expensive and time-consuming. Degree–based training can require tens of thousands of dollars and hundreds of hours of expert instruction. Counseling skills practice often involves role-plays, standardized patients, or practice with real clients. Performance–based feedback is critical for skill development and expertise, but trainee therapists often receive minimal and subjective feedback, which is distal to their skill practice. Objective: In this study, we developed and evaluated a patient-like neural conversational agent, which provides real-time feedback to trainees via chat–based interaction. Methods: The text–based conversational agent was trained on an archive of 2354 psychotherapy transcripts and provided specific feedback on the use of basic interviewing and counseling skills (ie, open questions and reflections—summary statements of what a client has said). A total of 151 nontherapists were randomized to either (1) immediate feedback on their use of open questions and reflections during practice session with ClientBot or (2) initial education and encouragement on the skills. Results: Participants in the ClientBot condition used 91% (21.4/11.2) more reflections during practice with feedback (P<.001) and 76% (14.1/8) more reflections after feedback was removed (P<.001) relative to the control group. The treatment group used more open questions during training but not after feedback was removed, suggesting that certain skills may not improve with performance–based feedback. Finally, after feedback was removed, the ClientBot group used 31% (32.5/24.7) more listening skills overall (P<.001). Conclusions: This proof-of-concept study demonstrates that practice and feedback can improve trainee use of basic counseling skills.

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/focused-doctor-working-with-ipad_1198167.htm; License: Licensed by JMIR.

    Incorporating Information From Electronic and Social Media Into Psychiatric and Psychotherapeutic Patient Care: Survey Among Clinicians

    Abstract:

    Background: Obtaining collateral information from a patient is an essential component of providing effective psychiatric and psychotherapeutic care. Research indicates that patients’ social and electronic media contains information relevant to their psychotherapy and clinical care. However, it remains unclear to what degree this content is being actively utilized by clinicians as a part of diagnosis or therapy. Moreover, clinicians’ attitudes around this practice have not been well characterized. Objective: This survey aimed to establish the current attitudes and behaviors of outpatient clinicians regarding the incorporation of patients’ social and electronic media into psychotherapy. Methods: A Web-based survey was sent to outpatient psychotherapists associated with McLean Hospital in Belmont, Massachusetts. The survey asked clinicians to indicate to what extent and with which patients they reviewed patients’ social and electronic media content as part of their clinical practice, as well as their reasons for or against doing so. Results: Of the total 115 respondents, 71 (61.7%) indicated that they had viewed at least one patient’s social or electronic media as part of psychotherapy, and 65 of those 71 (92%) endorsed being able to provide more effective treatment as a result of this information. The use of either short message service text messages or email was significantly greater than the use of other electronic media platforms (χ21=24.1, n=115, P<.001). Moreover, the analysis of survey responses found patterns of use associated with clinicians’ years of experience and patient demographics, including age and primary diagnosis. Conclusions: The incorporation of patients’ social and electronic media into therapy is currently common practice among clinicians at a large psychiatric teaching hospital. The results of this survey have informed further questions about whether reviewing patient’s media impacts the quality and efficacy of clinical care.

  • Source: Flickr; Copyright: Make Me Local; URL: https://www.flickr.com/photos/makemelocal/26932391967/in/photolist-H2VxPD-cdkwa-bohPiW-64SDLW-8gH9jG-bBWdRR-7ZbqH5-4GLnUM-6X9V6y-73fwKw-5yYtyK-5x7eh5-7mBYdS-5VfJRr-b33gba-8gDvHe-86XWK5-2evAG5J-2fPAjgK-r9T4a3-H2VxZD-ZD3L-5qwC6k-kwsn2Z-9jbnYG-5qxP9z-SCm9me-; License: Creative Commons Attribution + Noncommercial + ShareAlike (CC-BY-NC-SA).

    Influence of Climate on Google Internet Searches for Pruritus Across 16 German Cities: Retrospective Analysis

    Abstract:

    Background: The burden of pruritus is high, especially among patients with dermatologic diseases. Identifying trends in pruritus burden and people’s medical needs is challenging, since not all affected people consult a physician. Objective: The purpose of this study was to investigate pruritus search behavior trends in Germany and identify associations with weather factors. Methods: Google AdWords Keyword Planner was used to quantify pruritus-related search queries in 16 German cities from August 2014 to July 2018. All identified keywords were qualitatively categorized and pruritus-related terms were descriptively analyzed. The number of search queries per 100,000 inhabitants of each city was compared to environmental factors such as temperature, humidity, particulate matter 10 micrometers or less in diameter (PM10), and sunshine duration to investigate potential correlations. Results: We included 1150 pruritus-related keywords, which resulted in 2,851,290 queries. “Pruritus” (n=115,680) and “anal pruritus” (n=102,390) were the most-searched-for keywords. Nearly half of all queries were related to the category localization, with Berlin and Munich having a comparatively high proportion of people that searched for pruritus in the genital and anal areas. People searched more frequently for information on chronic compared to acute pruritus. The most populated cities had the lowest number of queries per 100,000 inhabitants (Berlin, n=13,641; Hamburg, n=18,303; and Munich, n=21,363), while smaller cities (Kiel, n=35,027; and Freiburg, n=39,501) had the highest. Temperature had a greater effect on search query number (beta -7.94, 95% CI -10.74 to -5.15) than did PM10 (beta -5.13, 95% CI -7.04 to -3.22), humidity (beta 4.73, 95% CI 2.70 to 6.75), or sunshine duration (beta 0.66, 95% CI 0.36 to 0.97). The highest relative number of search queries occurred during the winter (ie, December to February). Conclusions: By taking into account the study results, Google data analysis helps to examine people’s search frequency, behavior, and interest across cities and regions. The results indicated a general increase in search queries during the winter as well as differences across cities located in the same region; for example, there was a decline in search volume in Saarbrucken, while there were increases in Cologne, Frankfurt, and Dortmund. In addition, the detected correlation between search volume and weather data seems to be valuable in predicting an increase in pruritus burden, since a significant association with rising humidity and sunshine duration, as well as declining temperature and PM10, was found. Accordingly, this is an unconventional and inexpensive method to identify search behavior trends and respective inhabitants’ needs.

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/young-man-sitting-office-using-laptop_4831029.htm; License: Licensed by JMIR.

    Computerized Quality of Life Assessment: A Randomized Experiment to Determine the Impact of Individualized Feedback on Assessment Experience

    Abstract:

    Background: Quality of life (QoL) assessments, or patient-reported outcome measures (PROMs), are becoming increasingly important in health care and have been associated with improved decision making, higher satisfaction, and better outcomes of care. Some physicians and patients may find questionnaires too burdensome; however, this issue could be addressed by making use of computerized adaptive testing (CAT). In addition, making the questionnaire more interesting, for example by providing graphical and contextualized feedback, may further improve the experience of the users. 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 CAT 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 CAT version of the World Health Organization Quality of Life assessment (WHOQOL-CAT) or the fixed-length WHOQOL-BREF, an abbreviated version of the WHOQOL-100. We randomly assigned participants to conditions in which they would receive no feedback, graphical feedback only, or graphical and adaptive text-based 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-based feedback was provided along with PROMs (Δ=0.22, P<.001). Providing graphical feedback alone was weakly associated with improvement in overall experience (Δ=0.10, P=.006). Graphical and text-based feedback made the questionnaire more interesting, and users were more likely to report they would share the results with a physician or family member (Δ=0.17, P<.001, and Δ=0.17, P<.001, respectively). No difference was found in perceived accuracy of the graphical feedback scores of the WHOQOL-CAT and WHOQOL-BREF (Δ=0.06, P=.05). CAT (stopping rule [SE<0.45]) resulted in the administration of 25% fewer items than the fixed-length assessment, but it did not result in an improved user experience (P=.21). Conclusions: Using tailored text-based 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. Fixed-length forms are already generally acceptable to respondents; however, CAT might have an advantage over longer questionnaires that would be considered burdensome. Further research is warranted to explore the relationship between assessment length, feedback, and response burden in diverse populations.

  • Source: Pexels; Copyright: Christina Morillo; URL: https://www.pexels.com/photo/person-using-silver-macbook-pro-1181467/; License: Licensed by JMIR.

    Artificial Intelligence and the Implementation Challenge

    Abstract:

    Background: Applications of artificial intelligence (AI) in health care have garnered much attention in recent years, but the implementation issues posed by AI have not been substantially addressed. Objective: In this paper, we have focused on machine learning (ML) as a form of AI and have provided a framework for thinking about use cases of ML in health care. We have structured our discussion of challenges in the implementation of ML in comparison with other technologies using the framework of Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies (NASSS). Methods: After providing an overview of AI technology, we describe use cases of ML as falling into the categories of decision support and automation. We suggest these use cases apply to clinical, operational, and epidemiological tasks and that the primary function of ML in health care in the near term will be decision support. We then outline unique implementation issues posed by ML initiatives in the categories addressed by the NASSS framework, specifically including meaningful decision support, explainability, privacy, consent, algorithmic bias, security, scalability, the role of corporations, and the changing nature of health care work. Results: Ultimately, we suggest that the future of ML in health care remains positive but uncertain, as support from patients, the public, and a wide range of health care stakeholders is necessary to enable its meaningful implementation. Conclusions: If the implementation science community is to facilitate the adoption of ML in ways that stand to generate widespread benefits, the issues raised in this paper will require substantial attention in the coming years.

  • Source: Freepik; Copyright: Freepik; URL: https://www.freepik.com/free-photo/serious-guy-studying-with-laptop-desk_1370875.htm#page=4&index=38&query=teenager%20laptop; License: Licensed by JMIR.

    Brief Motivational Interviewing Delivered by Clinician or Computer to Reduce Sexual Risk Behaviors in Adolescents: Acceptability Study

    Abstract:

    Background: Clinicians are expected to screen their adolescent patients for an increasing number of health behaviors and intervene when they uncover risky behaviors, yet, the clinic time allotted to screen, intervene, and provide resources is insufficient. Brief motivational interviewing (MI) offers succinct behavior change counseling; however, for implementation, clinicians need training, skill, and time. Computerized screening and counseling adjuvants may help clinicians increase their scope of behavioral screening, especially with sensitive topics such as sexual health, and provide risk-reduction interventions without consuming provider time during visits. Objective: The objectives of this study were to (1) understand the extent to which health care providers use brief MI for sexual health discussions with adolescent patients and (2) assess the acceptability of incorporating a brief MI-based intervention to reduce sexual risk behaviors into their clinical practice delivered by either themselves or a computer. Methods: At a national medical conference, surveys were administered to clinicians who provide sexual health care to adolescents. They were asked about their current use of MI for sexual risk behavior discussions and their willingness to implement computerized sexual health screening and computerized sexual risk behavior interventions into their clinical practice. Results: The large majority (87.6%, 170/194) of clinicians already used MI with their patients with less than half (72/148, 48.6%) reporting they had been formally trained in MI. Despite all (195/195, 100.0%) clinicians feeling very or completely comfortable discussing sexual risk behaviors with their patients, the large majority (160/195, 82.1%) reported it would be useful, very useful, or extremely useful for a computerized program to do it all: screen their patients, generate risk profiles, and provide the risk-reduction counseling rather than doing it themselves. Conclusions: In this study, most clinicians used some form of brief MI or client-centered counseling when discussing sexual risk behaviors with adolescents and are very comfortable doing so. However, the large majority would prefer to implement computerized sexual health screening, risk assessment, and sexual risk behavior interventions into their clinical care of adolescents.

  • Source: Flickr; Copyright: Peter Van Lancker; URL: https://www.flickr.com/photos/petervanlancker/29818863828/in/photolist-MqZtkS-6ouLaG-EHKB5v-9BAFpr-8dewyi-eYLZR1-9Mx9n-d9cxku-sZZ4yG-6ovnqZ-s3eSYL-t1wuwK-sHGdcm-b1mvYZ-6fVQL3-7znHEt-4b22Fc-73SfP8-ebvRau-GTYz2b-t19oC8-3iURQw-2f1ZTCb-2fF4tH-55imHN-23RfGP-3v; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Identification and Quantification of Gaps in Access to Autism Resources in the United States: An Infodemiological Study

    Abstract:

    Background: Autism affects 1 in every 59 children in the United States, according to estimates from the Centers for Disease Control and Prevention’s Autism and Developmental Disabilities Monitoring Network in 2018. Although similar rates of autism are reported in rural and urban areas, rural families report greater difficulty in accessing resources. An overwhelming number of families experience long waitlists for diagnostic and therapeutic services. Objective: The objective of this study was to accurately identify gaps in access to autism care using GapMap, a mobile platform that connects families with local resources while continuously collecting up-to-date autism resource epidemiological information. Methods: After being extracted from various databases, resources were deduplicated, validated, and allocated into 7 categories based on the keywords identified on the resource website. The average distance between the individuals from a simulated autism population and the nearest autism resource in our database was calculated for each US county. Resource load, an approximation of demand over supply for diagnostic resources, was calculated for each US county. Results: There are approximately 28,000 US resources validated on the GapMap database, each allocated into 1 or more of the 7 categories. States with the greatest distances to autism resources included Alaska, Nevada, Wyoming, Montana, and Arizona. Of the 7 resource categories, diagnostic resources were the most underrepresented, comprising only 8.83% (2472/28,003) of all resources. Alarmingly, 83.86% (2635/3142) of all US counties lacked any diagnostic resources. States with the highest diagnostic resource load included West Virginia, Kentucky, Maine, Mississippi, and New Mexico. Conclusions: Results from this study demonstrate the sparsity and uneven distribution of diagnostic resources in the United States, which may contribute to the lengthy waitlists and travel distances—barriers to be overcome to be able to receive diagnosis in specific regions. More data are needed on autism diagnosis demand to better quantify resource needs across the United States.

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/portrait-happy-male-doctor-using-laptop_3453497.htm; License: Licensed by JMIR.

    Telehealth Interventions for Improving Self-Management in Patients With Hemophilia: Scoping Review of Clinical Studies

    Abstract:

    Background: The introduction of home therapy for hemophilia has empowered patients and their families to manage the disease more independently. However, self-management of hemophilia is demanding and complex. The uses of innovative interventions delivered by telehealth routes such as social media and Web-based and mobile apps, may help monitor bleeding events and promote the appropriate use of clotting factors among patients with hemophilia. Objective: This scoping review aims to summarize the literature evaluating the effectiveness of telehealth interventions for improving health outcomes in patients with hemophilia and provides direction for future research. Methods: A search was conducted in Ovid MEDLINE, EMBASE, and PubMed databases for studies that (1) focused on patients with hemophilia A or B; (2) tested the use of remote telehealth interventions via the internet, wireless, satellite, telephone, and mobile phone media on patients and caregivers; and (3) reported on at least one of the following patient-/caregiver-focused outcomes related to empowering patients/caregivers to be active decision makers in the emotional, social, and medical management of the illness: quality of life, monitoring of bleeding episodes, joint damage or other measures of functional status, medication adherence, and patients’ knowledge. Implementation outcomes (user metrics, cost saving, and accuracy of electronic records) were also evaluated. Reviews, commentaries, and case reports comprising ≤10 cases were excluded. Results: Sixteen articles fulfilled the inclusion criteria. The majority of the interventions (10/16, 62%) evaluated both implementation outcomes and patient-/caregiver-focused outcomes. User performance and accuracy and comprehensiveness of electronic records were also measured in most studies (4/16, 87%). The components of the interventions were rather homogenous and typically involved electronic logging and reminders for prophylactic infusions, reporting of spontaneous and traumatic bleeding events, monitoring of infusion product usage and home inventory, and real-time communication with health care professionals and hemophilia clinics. Telemedicine-supported education and information interventions seemed to be particularly effective among adolescent and young adult patients. Although the patients reported improvements in their health-related quality of life and perception of illness, telemonitoring devices did not appear to have a significant effect on quantifiable health outcomes such as joint health. Longitudinal studies seemed to suggest that the response and adherence rates to recording decreased over time. Conclusions: Preliminary evidence from this review suggests that telehealth-delivered interventions could feasibly improve patients’ adherence to medication use and promote independence in disease management. Given the complexity and resources involved in developing a mature and established system, support from a dedicated network of hemophilia specialists and data managers will be required to maintain the technology, improve adherence to prophylactic treatment and recording, and validate the electronic data locally.

  • A time lapse of an ambulance driving with its lights on. Source: Camilo Jimenez / Unsplash; Copyright: Camilo Jimenez; URL: https://unsplash.com/photos/vGu08RYjO-s; License: Licensed by JMIR.

    Hacking 9-1-1: Infrastructure Vulnerabilities and Attack Vectors

    Abstract:

    9-1-1 call centers are a critical component of prehospital care: they accept emergency calls, dispatch field responders such as emergency medical services, and provide callers with emergency medical instructions before their arrival. The aim of this study was to describe the technical structure of the 9-1-1 call-taking system and to describe its vulnerabilities that could lead to compromised patient care. 9-1-1 calls answered from mobile phones and landlines use a variety of technologies to provide information about caller location and other information. These interconnected technologies create potential cyber vulnerabilities. A variety of attacks could be carried out on 9-1-1 infrastructure to various ends. Attackers could target individuals, groups, or entire municipalities. These attacks could result in anything from a nuisance to increased loss of life in a physical attack to worse overall outcomes owing to delays in care for time-sensitive conditions. Evolving 9-1-1 systems are increasingly connected and dependent on network technology. As implications of cybersecurity vulnerabilities loom large, future research should examine methods of hardening the 9-1-1 system against attack.

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/woman-working-holding-baby_2059375.htm; License: Licensed by JMIR.

    Mothers’ Perceptions of the Internet and Social Media as Sources of Parenting and Health Information: Qualitative Study

    Abstract:

    Background: Traditionally, guidance and support to new parents have come from family, friends, and health care providers. However, the internet and social media are growing sources of guidance and support for parents. Little is known about how the internet and social media are used by parents of young infants and specifically about parental perceptions of the internet and social media as sources of parenting and infant health information. Objective: The aim of this study was to explore, using qualitative methods, parental perceptions of the advantages and disadvantages of the internet and social media as sources of parenting and health information regarding their infant. Methods: A total of 28 mothers participated in focus groups or individual interviews. Probing questions concerning parenting and health information sources were asked. Themes were developed in an iterative manner from coded data. Results: The central themes were (1) reasons that mothers turn to the internet for parenting and health information, (2) cautionary advice about the internet, and (3) reasons that mothers turn to social media for parenting and health information. Mothers appreciated the ability to gather unlimited information and multiple opinions quickly and anonymously, but recognized the need to use reputable sources of information. Mothers also appreciated the immediacy of affirmation, support, and tailored information available through social media. Conclusions: The internet and social media are rapidly becoming important and trusted sources of parenting and health information that mothers turn to when making infant care decisions.

  • Source: iStock by Getty Images; Copyright: metamorworks; URL: https://www.istockphoto.com/de/foto/medizintechnik-konzept-gm1054552130-281766574; License: Licensed by the authors.

    Data Work: Meaning-Making in the Era of Data-Rich Medicine

    Abstract:

    In the era of data-rich medicine, an increasing number of domains of people’s lives are datafied and rendered usable for health care purposes. Yet, deriving insights for clinical practice and individual life choices and deciding what data or information should be used for this purpose pose difficult challenges that require tremendous time, resources, and skill. Thus, big data not only promises new clinical insights but also generates new—and heretofore largely unarticulated—forms of work for patients, families, and health care providers alike. Building on science studies, medical informatics, Anselm Strauss and colleagues’ concept of patient work, and subsequent elaborations of articulation work, in this article, we analyze the forms of work engendered by the need to make data and information actionable for the treatment decisions and lives of individual patients. We outline three areas of data work, which we characterize as the work of supporting digital data practices, the work of interpretation and contextualization, and the work of inclusion and interaction. This is a first step toward naming and making visible these forms of work in order that they can be adequately seen, rewarded, and assessed in the future. We argue that making data work visible is also necessary to ensure that the insights of big and diverse datasets can be applied in meaningful and equitable ways for better health care.

  • Source: freepik; Copyright: freepik; URL: https://www.freepik.com/free-photo/ethnic-young-employee-working-laptop_4821916.htm; License: Licensed by JMIR.

    Internet-Based Interventions for Carers of Individuals With Psychiatric Disorders, Neurological Disorders, or Brain Injuries: Systematic Review

    Abstract:

    Background: Nonprofessional carers who provide support to an individual with a psychiatric or neurological disorder will often themselves experience symptoms of stress, anxiety, or low mood, and they perceive that they receive little support. Internet-based interventions have previously been found to be effective in the prevention and treatment of a range of mental health difficulties in carers. Objective: This review seeks to establish the status of internet-based interventions for informal (nonprofessional) carers of people with psychiatric or neurological disorders by investigating (1) the number and quality of studies evaluating the efficacy or effectiveness of internet-based carer interventions and (2) the impact that such interventions have on carer mental health, as well as (3) how internet-based interventions compare with other intervention types (eg, face-to-face treatment). Methods: A systematic literature search was conducted in January 2019 using the EMBASE (1974-present), Ovid MEDLINE (1946-present), PsychARTICLES, PsychINFO (1806-present), and Global Health (1973-present) databases, via the Ovid Technologies database. Search terms included carer, caregiver, online, technology, internet-based, internet, interactive, intervention, and evaluation. Studies selected for inclusion in this review met the following predetermined criteria: (1) delivering an intervention aimed primarily at informal carers, (2) carers supporting individuals with psychiatric disorders, stroke, dementia, or brain injury, (3) the intervention delivered to the carers was primarily internet based, (4) the study reported a pre- and postquantitative measure of carer depression, anxiety, stress, burden, or quality of life, (5) appeared in a peer-reviewed journal, and (6) was accessible in English. Results: A total of 46 studies were identified for inclusion through the detailed search strategy. The search was conducted, and data were extracted independently by 2 researchers. The majority of studies reported that 1 or more measures relating to carer mental health improved following receipt of a relevant intervention, with interventions for carers of people with traumatic brain injury showing a consistent link with improved outcomes. Conclusions: Studies investigating internet-based interventions for carers of individuals with diverse psychiatric or neurological difficulties show some evidence in support of the effectiveness of these interventions. In addition, such interventions are acceptable to carers. Available evidence is of varying quality, and more high-quality trials are needed. Further research should also establish how specific intervention components, such as structure or interactivity, contribute to their overall efficacy with regard to carer mental health.

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  • Assessing the Emergent Public Health Concern of All-Terrain Vehicle Injuries in Rural and Agricultural Environments: An Initial Review of Available National Datasets in the U.S.

    Date Submitted: Jul 12, 2019

    Open Peer Review Period: Jul 15, 2019 - Sep 9, 2019

    Background: Injuries related to the operation of off-road vehicles (ORVs), including all-terrain vehicles (ATVs), continue to be a significant public health concern, especially in rural areas and agri...

    Background: Injuries related to the operation of off-road vehicles (ORVs), including all-terrain vehicles (ATVs), continue to be a significant public health concern, especially in rural areas and agricultural production. In the United States alone, ATVs have played a role in thousands of fatalities and millions of injuries in recent decades. Yet, no known centralized federal surveillance system consistently captures these data. Traditional injury data sources include surveys, police reports, trauma registries, emergency department data, newspaper and on-line media reports, and state and federal agency databases. Objective: Like many other subsectors of injury prevention and injury epidemiology, there is lack of a comprehensive national injury surveillance system for ORV-related injuries, including those from agricultural use of the vehicle. The main purpose of this article is to review existing U.S. datasets for ORV-related injuries. Methods: We examined 137 manuscripts retrieved using PubMed queries in relation to their data source. Terms used in various combinations in MeSH and Key Word searches included: “off-road vehicles”, “fatalities”, “accidents”, “wounds”, “injuries”, “ATV”, “UTV”, and “mortality”. Our search yielded 137 results, and 70 were published between 2014 and 2018. From the 70, we selected the articles which used a database in their study (n=17). Results: Even sources that included a variety of vehicle and crash-related variables rarely indicated whether the vehicle was used for recreational or occupational purposes. Our review found that these data sources cannot provide a complete picture of the incidents or the circumstantial details needed to effectively inform ORV injury prevention efforts. This is particularly true with regards to ORV injuries related to production agriculture. Conclusions: We encourage the establishment of a federally funded national agricultural injury surveillance system. However, in lieu of this, use of multiple data sources will be necessary to piece together a more complete picture of ORV and other agricultural injuries and fatalities.

  • Continuous monitoring of vital signs at the general ward using wearable devices: patients’ and healthcare professionals’ views

    Date Submitted: Jul 12, 2019

    Open Peer Review Period: Jul 15, 2019 - Sep 9, 2019

    Background: Wearable devices are eligible for continuous patient monitoring at the general ward, increasing patient safety. Little is known about experiences and expectations of patients and health ca...

    Background: Wearable devices are eligible for continuous patient monitoring at the general ward, increasing patient safety. Little is known about experiences and expectations of patients and health care professionals regarding continuous monitoring with these devices. Objective: We sought to identify positive and negative effects, and barriers and facilitators for use of two wearable devices: ViSi Mobile (VM; Sotera Wireless) and HealthPatch (HP; Vital Connect). Methods: In this randomized controlled trial study, 90 patients admitted to the internal medicine and surgical wards of a university hospital in the Netherlands were randomly assigned to continuous vital sign monitoring using VM or HP, and a control group. User experiences and expectations were addressed using semi-structured interviews. Nurses, physician assistants and medical doctors were interviewed as well. Interviews were analyzed using thematic content analysis. Psychological distress was assessed using State Trait Anxiety Inventory (STAI) and Pain Catastrophizing Scale (PCS). The System Usability Scale (SUS) was used to assess the usability of both devices. Results: Sixty patients, 20 nurses, 3 physician assistants, and 6 medical doctors were interviewed. We identified 47 positive and 30 negative effects, and 19 facilitators and 36 barriers for the use of VM and HP. Most mentioned topics regarded earlier identification of clinical deterioration, increased feelings of safety, and VM lines and electrodes. No differences related to psychological distress and usability were found between randomization groups or devices. Conclusions: Both devices were well received by most patients and healthcare professionals and the majority encouraged the idea of monitoring vital signs continuously at the general ward. This comprehensive overview of barriers and facilitators of using wireless devices may serve as a guide for future researchers, developers and healthcare institutions that consider implementing continuous monitoring at the ward. Clinical Trial: HEEL-2015-03

  • Improving engagement with mHealth in chronic patients: a systematic review

    Date Submitted: Jul 11, 2019

    Open Peer Review Period: Jul 15, 2019 - Sep 9, 2019

    Background: Chronic disease burden continues being a principal healthcare system concern, in addition to the integration of mHealth interventions for telemonitoring of these patients. These facilities...

    Background: Chronic disease burden continues being a principal healthcare system concern, in addition to the integration of mHealth interventions for telemonitoring of these patients. These facilities permit patients to increase their involvement in the decisions related to treatment and more control of their prognosis. But little is known about the degree to which users engage and interaction matches the usage pattern for which the mHealth interventions were designed. Objective: To describe the characteristics and results of mHealth tools that have investigated the effects of these interventions on the patient’s engagement in the context of chronic diseases. Methods: A systematic technique was used to recover systematic reviews of interventional studies focused on the engagement of chronic patients using mHealth technologies for critical analysis. The search strategy (from 1st January 2010) was adapted to MEDLINE (Pubmed), EMBASE, The Cochrane Library, PychoINFO and Scielo. Critical Appraisal Skills Programme (CASP) tool was applied for studies quality assessment. Engagement was described as the level of patient implication or participation in self-care interventions. The number of logs to website or platform, the frequency of usage, the amount of messages exchange and task completion were used as engagement measures. Results: Initially, 627 papers were detected, after applying inclusion and exclusion criteria 10 studies were included. Sample size oscillated between 6 and 270 individuals predominantly men. Cardiac disease was the principal target to compare traditional and mHealth interventions for engagement improvement. Patient’s involvement with mHealth technologies varied between 50% and 97%, the highest level with smartphones devices limited to one or two tools. Conclusions: The mHealth interventions yielded an improvement of engagement. However, there are scarce studies that use specific engagement’s measures and the period of study is usually shorter. Smartphones with a single tool with reminders feature can improve patient’s involvement and induce to a higher engagement with mHealth interventions in chronic patients.

  • Assessing the Appeal of Instagram E-liquid Promotions and Warnings among Young Adults: A Focus Group Study

    Date Submitted: Jul 10, 2019

    Open Peer Review Period: Jul 15, 2019 - Sep 9, 2019

    Background: While marketing for electronic cigarette refill liquids (“e-liquids”) is widespread on Instagram, little is known about the post elements that create appeal among young adult Instagram...

    Background: While marketing for electronic cigarette refill liquids (“e-liquids”) is widespread on Instagram, little is known about the post elements that create appeal among young adult Instagram users. Further information is needed to help shape regulatory strategies appropriate for social media. Objective: This study examined young adult Instagram user perceptions of actual e-liquid marketing posts and U.S. Food and Drug Administration (“FDA”) mandated nicotine addiction warning statements on Instagram. Methods: A series of 12 focus groups (n=69) were held with non-tobacco users, vapers, smokers, and dual users in Wisconsin between September and December 2018. Participants discussed the elements of posts that they found appealing or unappealing, in addition to completing a survey about each post/product. Focus group transcripts were analyzed by smoking status using a framework analysis approach. Results: Although willingness to try e-liquids was highest among nicotine users, focus group discussions indicated that Instagram posts promoting e-liquids held appeal for individuals across smoking statuses. The primary elements that created appeal were the perceived trustworthiness and authenticity of the Instagram account, attractive design and flavor visuals, and promotion of flavors and nicotine levels that met personal preferences. Post appeal was reduced by references to vaping subcultures, not taking addiction to nicotine seriously, and FDA mandated nicotine warning statements. Non-tobacco users were particularly drawn to posts featuring nicotine-free e-liquids with attractive visual designs and flavors known from foods. Conclusions: Young adults consider a broad range of elements in assessing the appeal of e-liquid marketing on Instagram, with minor but notable distinctions by smoking status. Non-tobacco users are uniquely drawn to nicotine-free e-liquids and are more deterred by the FDA’s mandated nicotine addiction warning statements than those from other smoking statuses. This suggests that it may be possible to tailor policy interventions in a manner that helps to reduce novel update of vaping, without significantly diminishing its potential harm-reduction benefits.

  • Effectiveness of a web-based computer-tailored intervention to reduce alcohol consumption and binge drinking among Spanish adolescents: a cluster randomized controlled trial.

    Date Submitted: Jul 10, 2019

    Open Peer Review Period: Jul 15, 2019 - Sep 9, 2019

    Background: Alcohol consumption, including binge drinking and excessive drinking, is one of the leading risk factors in Spanish adolescents with significant social, health and economic consequences. R...

    Background: Alcohol consumption, including binge drinking and excessive drinking, is one of the leading risk factors in Spanish adolescents with significant social, health and economic consequences. Reduction of binge drinking and excessive drinking in adolescents can be achieved using web-based computer-tailored interventions, providing highly personalized feedback that is adapted to a person’s individual characteristics and needs. Randomized controlled trials assessing the effects of tailored binge-drinking reduction programs among Spanish adolescents are scarce. Objective: The aim was to test the effectiveness of the Web-based Computer-Tailored intervention (Alerta Alcohol) aimed at the prevention of binge drinking in Spanish adolescents. The adherence and process evaluation were also assessed. Methods: A cluster randomized controlled trial conducted among 15 Spanish schools was developed. Each school was randomized into either an experimental (n=742) or a control (n=505) condition. Baseline assessment took place in January and February 2017. Demographic variables and alcohol use were assessed at baseline. Follow-up assessment of alcohol use took place 4 months later (May and June 2017). The independent variable was the participation versus non-participation in the intervention. After the baseline assessment, participants in the experimental condition started with the intervention consisting of short stories about binge drinking in which computer-tailored feedback was based on the I-change model to change behaviours. Participants in the control condition only received the baseline questionnaire. Effects of the intervention were assessed using a three-level mixed logistic regression analysis for binge drinking, excessive drinking, and lifetime consumption, and a three-level mixed linear regression analysis for weekly consumption. Results: In total, 1247 adolescents participated in the baseline assessment, and 612 adolescents in the follow-up (attrition rate = 50.9%). The intervention was effective in reducing excessive drinking among adolescents, being 9 times the odds of excessive drinking in the control condition than in the experimental condition (p=.040). No effects were found for binge drinking, lifetime consumption and weekly consumption. Process evaluations revealed that the adolescents were satisfied with the program (68.8%), would use the program again (52.9%), and would recommend the program to someone else (62.8%). In general, females and non-binge drinkers showed better responses in the process evaluation. Conclusions: Our intervention was effective for adolescents concerning excessive drinking but not for binge drinking, weekly consumption and lifetime consumption. It may be that limiting alcohol consumption to prevent excessive drinking was easier in the Spanish context than it was to carry out further steps such as reducing other patterns of alcohol consumption. Hence, additional actions are needed to accomplish these latter goals, including community approaches and policy actions aimed at denormalizing alcohol consumption among Spanish adolescents. Clinical Trial: Trial registration number (ClinicalTrials.gov): NCT03288896. This study was retrospectively registered on 19/09/2017.

  • Occurrence of and reasons for “missing events” in mobile dietary assessments: Results from three event-based EMA studies

    Date Submitted: Jul 10, 2019

    Open Peer Review Period: Jul 15, 2019 - Sep 9, 2019

    Background: Establishing a methodology to assess nutritional behavior comprehensively and accurately is extremely challenging. Mobile technologies such as mobile applications (apps) enable eating even...

    Background: Establishing a methodology to assess nutritional behavior comprehensively and accurately is extremely challenging. Mobile technologies such as mobile applications (apps) enable eating events to be assessed in-the-moment in real-time, which reduces the memory biases that are inherent in retrospective food records. However, users might find it challenging to take images of the food they consume at every eating event over an extended period of time, which might lead to incomplete eating event records (“missing events”). Objective: The three present studies assessed how often eating events (meals and snacks) were missed over a period of 8 days in a naturalistic stetting by comparing the number of recorded events (1) to the number of normative expected events, (2) over time, and (3) to recollections of missing events. Methods: The participants in three eating event-based EMA studies using mobile image-based dietary assessments (MIDA) were asked to record all eating events for 8 consecutive days (Study 1, N=38, 1,070 eating events; Study 2, N=35, 934 eating events; Study 3, N=110, 3,469 eating events). Study 1 used a “basic” app, Study 2 included one fixed reminder and an addendum feature, and Study 3 included two fixed reminders and the option to record skipped meals. Later recordings of missed events and their reasons were also assessed. Results: Overall, the 183 participants reported 5,473 eating events (3,803 main meals, 1,505 snacks, 165 afternoon teas). While the momentary adherence rate as indexed by a comparison with normative expected events was generally high across all three studies, a differential pattern of results emerged with a higher rate of logged meals in the more technically intensive Study 3. Multilevel models for the logging trajectories of reported meals in all three studies showed a significant, albeit small decline over time (b = -0.11- -0.14, p < .001, pseudo-R² = .04-.06), mainly due to a drop in reported snacks between days 1 and 2. Intra-class coefficients indicate that 38% or less of the observed variance was due to individual differences. The most common reasons for missing events were being engaged in competing activities and technical issues, while situational barriers were less important. Conclusions: The three different criteria (normative, time stability and recalled missing events) consistently indicated missing events. However, given the intensive nature of diet EMA protocols, the effects sizes were rather small and the logging trajectories over time were remarkably stable. Moreover, the actual state of the individual and the context seem to be of greater influence on adherence rates than stable individual differences, which emphasizes the need for a more nuanced understanding of the factors that affect momentary adherence.

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