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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 20th year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2017: 4.671, ranked #1 out of 22 journals) and in terms of size (number of papers published). The journal focuses on emerging technologies, medical devices, apps, engineering, and informatics applications for patient education, prevention, population health and clinical care. As leading high-impact journal in its' disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journals. 

As open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (eg, in grant proposals), and for open peer-review purposes. We also invite patients to participate (eg, as peer-reviewers) and have patient representatives on editorial boards.

Be a widely cited leader in the digitial health revolution and submit your paper today!

 

Recent Articles:

  • Source: Tyndale Air Force Base (Solomon Cook); Copyright: US Air Force; URL: https://www.tyndall.af.mil/News/Photos/igphoto/2001558525/; License: Public Domain (CC0).

    Improving the Understanding of Test Results by Substituting (Not Adding) Goal Ranges: Web-Based Between-Subjects Experiment

    Abstract:

    Background: Most displays of laboratory test results include a standard reference range. For some patients (eg, those with chronic conditions), however, getting a result within the standard range may be unachievable, inappropriate, or even harmful. Objective: The objective of our study was to test the impact of including clinically appropriate goal ranges outside the standard range in the visual displays of laboratory test results. Methods: Participants (N=6776) from a demographically diverse Web-based panel viewed hypothetical glycated hemoglobin (HbA1c) test results (HbA1c either 6.2% or 8.2%) as part of a type 2 diabetes management scenario. Test result visual displays included either a standard range (4.5%-5.7%) only, a goal range (6.5%-7.5%) added to the standard range, or the goal range only. The results were displayed in 1 of the following 3 display formats: (1) a table; (2) a simple, two-colored number line (simple line); or (3) a number line with diagnostic categories indicated via colored blocks (block line). Primary outcome measures were comprehension of and negative reactions to test results. Results: While goal range information did not influence the understanding of HbA1c=8.2% results, the goal range only display produced higher levels of comprehension and decreased negative reactions to HbA1c=6.2% test results compared with the no goal range and goal range added conditions. Goal range information was less helpful in the block line condition versus the other formats. Conclusions: Replacing the standard range with a clinically appropriate goal range could help patients better understand how their test results relate to their personal targets.

  • The social alarm: a widely used technology in caring practices. Source: Colourbox; Copyright: Colourbox; URL: https://www.colourbox.com/image/emergency-button-image-11221786; License: Licensed by the authors.

    Older People Negotiating Independence and Safety in Everyday Life Using Technology: Qualitative Study

    Authors List:

    Abstract:

    Background: Due to demographic changes with an aging population, there is a demand for technology innovations in care services. However, technology innovations have proven difficult to implement in regular use. To understand the complexity of technology innovations in care practices, we need a knowledge base of the complex and diverse experiences of people interacting with established technologies. Objective: This paper addresses the research gap in relation to understanding the microcontext of co-production of care involving established technologies integrated into care practices. The paper also aims to provide a framework for exploring what really happens when different actors use technology in care practices. Methods: Participant observations and 22 interviews with actors using social alarms were conducted employing the critical incident technique. A stepwise deductive-inductive analysis was then performed. Results: The results reveal how co-production of care assumes different meanings according to how actors use the technology. The results also show how technology innovation changes the dynamics between the actors and rearranges care practices. Independent and safe living is co-produced through performing bricolages and optimizing practice. Additionally, this opens up for unexpected results and bricolages as an integrated part of technology innovations. Conclusions: This study illustrates how care services are always co-produced between the actors involved. By using aspects from science and technology studies, this paper provides a framework for exploring technology in use in care practices. The framework provides tools to unpack and articulate the process of co-producing services.

  • Source: Freepik; Copyright: Freepik; URL: https://www.freepik.com/free-photo/cheerful-coworkers-at-table-with-gadgets_1291635.htm#term=coworkers&page=1&position=30; License: Licensed by JMIR.

    Promoting Psychological Well-Being at Work by Reducing Stress and Improving Sleep: Mixed-Methods Analysis

    Abstract:

    Background: Workplace programs designed to improve the health and psychological well-being of employees are becoming increasingly popular. However, there are mixed reports regarding the effectiveness of such programs and little analysis of what helps people to engage with such programs. Objective: This evaluation of a particularly broad, team-based, digital health and well-being program uses mixed methods to identify the elements of the program that reduce work stress and promote psychological well-being, sleep quality, and productivity of employees. Methods: Participation in the Virgin Pulse Global Challenge program during May to September 2016 was studied. Self-reported stress, sleep quality, productivity, and psychological well-being data were collected both pre- and postprogram. Participant experience data were collected through a third final survey. However, the response rates for the last 2 surveys were only 48% and 10%, respectively. A random forest was used to estimate the probability of the completion of the last 2 surveys based on the preprogram assessment data and the demographic data for the entire sample (N=178,350). The inverse of these estimated probabilities were used as weights in hierarchical linear models in an attempt to address any estimation bias caused by the low response rates. These linear models described changes in psychological well-being, stress, sleep, and productivity over the duration of the program in relation to gender and age, engagement with each of the modules, each of the program features, and participant descriptions of the Virgin Pulse Global Challenge. A 0.1% significance level was used due to the large sample size for the final survey (N=18,653). Results: The final analysis suggested that the program is more beneficial for older people, with 2.9% greater psychological well-being improvements observed on average in the case of women than men (P<.001). With one exception, all the program modules contributed significantly to the outcome measures with the following average improvements observed: psychological well-being, 4.1%-6.0%; quality of sleep, 3.2%-6.9%; work-related stress, 1.7%-6.8%; and productivity, 1.9%-4.2%. However, only 4 of the program features were found to have significant associations with the outcome measures with the following average improvements observed: psychological well-being, 3.7%-5.6%; quality of sleep, 3.4%-6.5%; work-related stress, 4.1%-6.4%; and productivity, 1.6%-3.2%. Finally, descriptions of the Virgin Pulse Global Challenge produced 5 text topics that were related to the outcome measures. Healthy lifestyle descriptions showed a positive association with outcomes, whereas physical activity and step count tracking descriptions showed a negative association with outcomes. Conclusions: The complementary use of qualitative and quantitative survey data in a mixed-methods analysis provided rich information that will inform the development of this and other programs designed to improve employee health. However, the low response rates and the lack of a control group are limitations, despite the attempts to address these problems in the analysis.

  • Source: Freepik; Copyright: Pressfoto; URL: https://www.freepik.com/free-photo/grandparents-using-laptop_857853.htm#term=middle%20age%20laptop&page=1&position=0; License: Licensed by JMIR.

    Preferences for Health Information Technologies Among US Adults: Analysis of the Health Information National Trends Survey

    Abstract:

    Background: Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and facilitating adherence to chronic disease management. However, there is a lack of studies on differences in the preference for using information exchange technologies between patients with chronic and nonchronic diseases and factors affecting these differences. Objective: The purpose of this paper is to understand the preferences and use of information technology for information exchange among a nationally representative sample of adults with and without 3 chronic disease conditions (ie, cardiovascular disease [CVD], diabetes, and hypertension) and to assess whether these preferences differ according to varying demographic variables. Methods: We utilized data from the 2012 and 2014 iteration of the Health Information National Trends Survey (N=7307). We used multiple logistic regressions, adjusting for relevant demographic covariates, to identify the independent factors associated with lower odds of using health information technology (HIT), thus, identifying targets for awareness. Analyses were weighted for the US population and adjusted for the sociodemographic variables of age, gender, race, and US census region. Results: Of 7307 participants, 3529 reported CVD, diabetes, or hypertension. In the unadjusted models, individuals with diabetes, CVD, or hypertension were more likely to report using email to exchange medical information with their provider and less likely to not use any of the technology in health information exchange, as well as more likely to say it was not important for them to access personal medical information electronically. In the unadjusted model, additional significant odds ratio (OR) values were observed. However, after adjustment, most relationships regarding the use and interest in exchanging information with the provider were no longer significant. In the adjusted model, individuals with CVD, diabetes, or hypertension were more likely to access Web-based personal health information through a website or app. Furthermore, we assessed adjusted ORs for demographic variables. Those aged >65 years and Hispanic people were more likely to report no use of email to exchange medical information with their provider. Minorities (Hispanic, non-Hispanic black, and Asian people) were less likely to indicate they had no interest in exchanging general health tips with a provider electronically. Conclusions: The analysis did not show any significant association among those with comorbidities and their proclivity toward health information, possibly implying that HIT-related interventions, particularly design of information technologies, should focus more on demographic factors, including race, age, and region, than on comorbidities or chronic disease status to increase the likelihood of use. Future research is needed to understand and explore more patient-friendly use and design of information technologies, which can be utilized by diverse age, race, and education or health literacy groups efficiently to further bridge the patient-provider communication gap.

  • Source: Pixabay; Copyright: rawpixel; URL: https://pixabay.com/photo-3343887/; License: Public Domain (CC0).

    Assessment of Personal Health Care Management and Chronic Disease Prevalence: Comparative Analysis of Demographic, Socioeconomic, and Health-Related Variables

    Abstract:

    Background: The use of personal health care management (PHM) is increasing rapidly within the United States because of implementation of health technology across the health care continuum and increased regulatory requirements for health care providers and organizations promoting the use of PHM, particularly the use of text messaging (short message service), Web-based scheduling, and Web-based requests for prescription renewals. Limited research has been conducted comparing PHM use across groups based on chronic conditions. Objective: This study aimed to describe the overall utilization of PHM and compare individual characteristics associated with PHM in groups with no reported chronic conditions, with 1 chronic condition, and with 2 or more such conditions. Methods: Datasets drawn from the National Health Interview Survey were analyzed using multiple logistic regression to determine the level of PHM use in relation to demographic, socioeconomic, or health-related factors. Data from 47,814 individuals were analyzed using logistic regression. Results: Approximately 12.19% (5737/47,814) of respondents reported using PHM, but higher rates of use were reported by individuals with higher levels of education and income. The overall rate of PHM remained stable between 2009 and 2014, despite increased focus on the promotion of patient engagement initiatives. Demographic factors predictive of PHM use included people who were younger, non-Hispanic, and who lived in the western region of the United States. There were also differences in PHM use based on socioeconomic factors. Respondents with college-level education were over 2.5 times more likely to use PHM than respondents without college-level education. Health-related factors were also predictive of PHM use. Individuals with health insurance and a usual place for health care were more likely to use PHM than individuals with no health insurance and no usual place for health care. Individuals reporting a single chronic condition or multiple chronic conditions reported slightly higher levels of PHM use than individuals reporting no chronic conditions. Individuals with no chronic conditions who did not experience barriers to accessing health care were more likely to use PHM than individuals with 1 or more chronic conditions. Conclusions: The findings of this study illustrated the disparities in PHM use based on the number of chronic conditions and that multiple factors influence the use of PHM, including economics and education. These findings provide evidence of the challenge associated with engaging patients using electronic health information as the health care industry continues to evolve.

  • Researcher conducts a search for papers that classified skin lesions using convolutional neural networks (montage). Source: PubMed / Placeit.net; Copyright: JMIR Publications; URL: http://www.jmir.org/2018/10/e11936/; License: Creative Commons Attribution (CC-BY).

    Skin Cancer Classification Using Convolutional Neural Networks: Systematic Review

    Abstract:

    Background: State-of-the-art classifiers based on convolutional neural networks (CNNs) were shown to classify images of skin cancer on par with dermatologists and could enable lifesaving and fast diagnoses, even outside the hospital via installation of apps on mobile devices. To our knowledge, at present there is no review of the current work in this research area. Objective: This study presents the first systematic review of the state-of-the-art research on classifying skin lesions with CNNs. We limit our review to skin lesion classifiers. In particular, methods that apply a CNN only for segmentation or for the classification of dermoscopic patterns are not considered here. Furthermore, this study discusses why the comparability of the presented procedures is very difficult and which challenges must be addressed in the future. Methods: We searched the Google Scholar, PubMed, Medline, ScienceDirect, and Web of Science databases for systematic reviews and original research articles published in English. Only papers that reported sufficient scientific proceedings are included in this review. Results: We found 13 papers that classified skin lesions using CNNs. In principle, classification methods can be differentiated according to three principles. Approaches that use a CNN already trained by means of another large dataset and then optimize its parameters to the classification of skin lesions are the most common ones used and they display the best performance with the currently available limited datasets. Conclusions: CNNs display a high performance as state-of-the-art skin lesion classifiers. Unfortunately, it is difficult to compare different classification methods because some approaches use nonpublic datasets for training and/or testing, thereby making reproducibility difficult. Future publications should use publicly available benchmarks and fully disclose methods used for training to allow comparability.

  • Source: Image created by the Authors; Copyright: The Authors; URL: http://www.jmir.org/2018/10/e11515/; License: Licensed by JMIR.

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

    Abstract:

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

  • Using information technology to improve interrater reliability in medical coding. Source: The Authors; Copyright: The Authors; URL: http://www.jmir.org/2018/10/e274; License: Licensed by JMIR.

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

    Abstract:

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

  • Source: Pexels; Copyright: rawpixel.com; URL: https://www.pexels.com/photo/adult-agreement-beard-beverage-541522/; License: Licensed by JMIR.

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

    Abstract:

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

  • Patient experience tweet sentiment by region over time. K represents thousand, where any number is followed by three zeros (eg, 100K equals 100,000). Source: Figure 1 from https://www.jmir.org/2018/10/e10043; Copyright: the authors; License: Creative Commons Attribution (CC-BY).

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

    Abstract:

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

  • Source: Pexels; Copyright: rawpixel.com; URL: https://www.pexels.com/photo/person-holding-white-medication-tablet-1389104/; License: Licensed by JMIR.

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

    Abstract:

    Background: Internet-based cognitive behavioral therapy can aid patients with rheumatoid arthritis with elevated levels of distress to enhance their quality of life. However, implementation is currently lacking and there is little evidence available on the (cost-) effectiveness of different treatment strategies. Objective: Cost-benefit ratios are necessary for informing stakeholders and motivating them to implement effective treatment strategies for improving health-related quality of life (HRQoL) of patients with rheumatoid arthritis. A cost-effectiveness study from a societal perspective was conducted alongside a randomized controlled trial on a tailored, therapist-guided internet-based cognitive behavioral therapy (ICBT) intervention for patients with rheumatoid arthritis with elevated levels of distress as an addition to care as usual (CAU). Methods: Data were collected at baseline or preintervention, 6 months or postintervention, and every 3 months thereafter during the 1-year follow-up. Effects were measured in terms of quality-adjusted life years (QALYs) and costs from a societal perspective, including health care sector costs (health care use, medication, and intervention costs), patient travel costs for health care use, and costs associated with loss of labor. Results: The intervention improved the quality of life compared with only CAU (Δ QALYs=0.059), but at a higher cost (Δ=€4211). However, this increased cost substantially reduced when medication costs were left out of the equation (Δ=€1863). Of all, 93% (930/1000) of the simulated incremental cost-effectiveness ratios were in the north-east quadrant, indicating a high probability that the intervention was effective in improving HRQoL, but at a greater monetary cost for society compared with only CAU. Conclusions: A tailored and guided ICBT intervention as an addition to CAU for patients with rheumatoid arthritis with elevated levels of distress was effective in improving quality of life. Consequently, implementation of ICBT into standard health care for patients with rheumatoid arthritis is recommended. However, further studies on cost reductions in this population are warranted. Trial Registration: Nederlands Trial Register NTR2100; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2100 (Archived by WebCite at http://www.webcitation.org/724t9pvr2)

  • Source: Freepik; Copyright: Pressfoto; URL: https://www.freepik.com/free-photo/smart-teenager-studying-in-class_866038.htm; License: Licensed by JMIR.

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

    Abstract:

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

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  • Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: A Systematic Review

    Date Submitted: Oct 18, 2018

    Open Peer Review Period: Oct 19, 2018 - Oct 26, 2018

    Background: Anxiety conditions are debilitating and prevalent throughout the world. Acceptance and Commitment Therapy (ACT) is an effective, mindfulness-based psychological treatment for anxiety. Ho...

    Background: Anxiety conditions are debilitating and prevalent throughout the world. Acceptance and Commitment Therapy (ACT) is an effective, mindfulness-based psychological treatment for anxiety. However, there are treatment barriers (e.g. financial, geographical, and attitudinal) which prevent people from accessing it. To overcome these barriers, internet-delivered Acceptance and Commitment Therapy (iACT) interventions have been developed in recent years. These interventions use websites to deliver ACT information and skill training exercises online, either as pure self-help or with therapist guidance. Objective: The present systematic review aimed to examine the therapeutic impact of iACT on all anxiety conditions. Empirical studies of all designs, population types, and comparator groups were included if they appraised the impact of iACT treatment on any standardised measure of anxiety. Data on participant characteristics, intervention delivery, anxiety outcomes, user attrition rates, and treatment satisfaction were extracted to help identify efficacious and acceptable interventions, elucidate research gaps, and guide the design, development and administration of new iACT programs. Methods: The Embase, Medline, ProQuest Central, PsycINFO, Scopus, and Web of Science databases were searched up to September 2018. The titles and abstracts of remaining records after deduplication were screened by two authors with a total of 36 full-text articles being retained for closer inspection next to eligibility criteria. Included studies were appraised on methodological quality and had their data extracted into a standardised coding sheet. Findings were then tabulated and a narrative synthesis was performed due to the heterogeneity found between studies. Results: Twenty studies met inclusion criteria. There were 11 randomised controlled trials and 9 uncontrolled pilot studies. Participants across all studies were adults. Treated anxiety conditions included: generalised anxiety disorder, social anxiety disorder, illness anxiety disorder, and general anxiety symptoms with or without comorbid physical and/or mental health problems. Eighteen studies reported significant anxiety reduction after iACT treatment with effect sizes ranging from small to large. This was observed in studies that delivered iACT with (n = 13) or without (n = 5) therapist guidance. The average attrition rate across all included studies during the active iACT treatment phase was 24.21%. In the 13 studies that assessed treatment satisfaction, participants on average rated their iACT experience with above average to high treatment satisfaction. Conclusions: These findings indicate that iACT can be an efficacious and acceptable treatment for adults with generalised anxiety disorder and general anxiety symptoms. More randomised controlled trial studies are needed to corroborate these early iACT findings using empirical treatments in active control groups (e.g. internet-delivered cognitive behavioural therapy). This would potentially validate the promising results found for social anxiety disorder and illness anxiety disorder as well as address the full spectrum of anxiety disorders.

  • Feasibility study of an online support group intervention for adolescents living with HIV in Nigeria

    Date Submitted: Oct 16, 2018

    Open Peer Review Period: Oct 19, 2018 - Oct 24, 2018

    Background: Adolescents living with HIV (ALHIV) enrolled in HIV treatment services experience greater loss to follow-up and suboptimal adherence compared to other age groups. HIV-related stigma, issue...

    Background: Adolescents living with HIV (ALHIV) enrolled in HIV treatment services experience greater loss to follow-up and suboptimal adherence compared to other age groups. HIV-related stigma, issues related to disclosure, lack of social support, and limited HIV knowledge thwart ALHIV from adhering to antiretroviral therapy (ART) and being retained in HIV services. The 90-90-90 goals for ALHIV will only be met through strategies targeted to meet their specific needs. Objective: We tested the feasibility of implementing a social media-based intervention to improve HIV knowledge, social support, ART adherence and retention among ALHIV ages 15-19 years on ART in Nigeria. Methods: We conducted a single-group pre/post-test study from June 2017 to January 2018. We adapted an existing support group curriculum and delivered it through trained facilitators in five support groups using Facebook groups. This pilot intervention included five week-long sessions. We conducted structured interviews with participants pre- and post-intervention, extracted clinical data, and documented intervention implementation and participation. In-depth interviews were conducted with a subset of participants at endline. Quantitative data from structured interviews and group participation data were summarized descriptively and qualitative data were coded and summarized. Results: Forty-one ALHIV enrolled in the study. At baseline, 93% of participants reported existing phone access; 65% used the internet and 64% were Facebook users. Thirty-seven participants completed the 5-session intervention; 32 actively posted comments in at least one session online and at least half commented in each of the five sessions. Facilitators delivered most sessions as intended and on-time. Participants were enthusiastic about the intervention. Most liked aspects included: interacting with other ALHIV; learning about HIV; sharing questions, experiences and fears. Key recommendations included having larger groups and encouraging more group interaction. Specific recommendations on various intervention components were also made to improve the intervention. Conclusions: This novel intervention proved feasible to implement in a predominantly suburban/rural Nigerian setting. Social media may be leveraged to provide much needed information and social support on platforms accessible and familiar to many, even in resource constrained communities. Findings have been incorporated into the intervention and an outcome study is underway. Clinical Trial: NCT03076996

  • Text Message Responsivity in a Two-Way SMS Pilot Intervention with AYA Survivors of Cancer

    Date Submitted: Oct 18, 2018

    Open Peer Review Period: Oct 19, 2018 - Dec 14, 2018

    Background: Text message interventions hold promise for adolescents and young adults (AYA) with chronic health conditions, including childhood cancer survivors. However, engagement is often suboptimal...

    Background: Text message interventions hold promise for adolescents and young adults (AYA) with chronic health conditions, including childhood cancer survivors. However, engagement is often suboptimal. Limited research has studied mHealth intervention outcomes beyond efficacy. Understanding responsivity to different types of text messages (i.e., when a participant texts back) can provide practical, actionable information to optimize engagement in future projects. Objective: Within a two-way text messaging study in AYA who recently completed treatment for cancer, we sought to evaluate text message responsivity across different types of text messages. Methods: AYA who recently completed treatment for cancer (n = 26, M age = 16, 62% female) received two-way text messages about survivorship health topics over a 16-week period. Using participants’ text message log data, we coded responsivity to text messages and evaluated trends in responsivity to unprompted text messages and prompted text messages of varying content (e.g., medication reminders, appointment reminders, texts about personal experiences as a cancer survivor). Results: Across prompted and unprompted text messages, responsivity rapidly decreased and plateaued by the third week of the intervention. However, participants were more responsive to prompted text messages than unprompted messages. They also demonstrated stable responsivity to certain prompted content: medication reminders, appointment reminders, goal motivation, goal progress, and patient experience texts. Conclusions: Our methodology of evaluating text message responsivity revealed important patterns of engagement in a two-way text message intervention for AYA cancer survivors.

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

    Date Submitted: Oct 14, 2018

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

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

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

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

    Date Submitted: Oct 14, 2018

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

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

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

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

    Date Submitted: Oct 13, 2018

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

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

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

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