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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.

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Recent Articles:

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

    Tracking Healthy People 2020 Internet, Broadband, and Mobile Device Access Goals: An Update Using Data From the Health Information National Trends Survey


    Background: As the year 2020 approaches, there is a need to evaluate progress toward the United States government’s Healthy People 2020 (HP2020) health information technology and communication objectives to establish baselines upon which Healthy People 2030 objectives can be based. Objective: The aim of this study was to use the National Cancer Institute’s (NCI) Health Information National Trends Survey (HINTS) to benchmark progress toward HP2020 goals related to increasing internet access using broadband, and to assess the state of the digital divide for various sociodemographic groups. Methods: We merged and analyzed data from 8 administrations of HINTS (2003-2017). Descriptive statistics were generated, and predicted marginals were calculated using interaction terms between survey year and selected sociodemographic variables of interest, including age, sex, race and ethnicity, income, education, and geography (rural versus urban), to test for differential change over time. Results: The number of users having access to the internet increased between 2003 and 2014 (63.15% [3982/6358] to 83.41% [2802/3629]); it remained relatively steady from 2014 to 2017 (81.15% [2533/3283]). Broadband access increased between 2003 and 2011 (from 32.83% [1031/3352] to 77.87% [3375/4405]), but has been declining since (55.93% [1364/2487] in 2017). Access via cellular network increased between 2008 and 2017 (from 6.86% [240/4405] to 65.43% [1436/2489]). Statistically significant disparities in overall internet access were noted in the predicted marginals for age, sex, race and ethnicity, income, and education; for age, sex, income, and geography for broadband access; and for age and sex for cellular network. Conclusions: The targets set forth in HP2020 were met for overall internet access and for internet access via cellular network; however, the target was not met for internet access via broadband. Furthermore, although the digital divide persisted by sociodemographic characteristics, the magnitude of many disparities in access decreased over time.

  • Surgical crew using an information system of surgical safety checklist in modern surgery and anesthesia safety management system construction and promotion project. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Key Issues in the Development of an Evidence-Based Stratified Surgical Patient Safety Improvement Information System: Experience From a Multicenter Surgical...


    Surgery is still far from being completely safe and reliable. Surgical safety has, therefore, been the focus of considerable attention over the last few decades, and there are a growing number of national drives to improve it. There are also a number of large surgical complication reporting systems and system-based interventions, both of which have made remarkable progress in the past two decades. These systems, however, have either mainly focused on reporting complications and played a limited role in guiding practice or have provided nonselective interventions to all patients, perhaps imposing unnecessary burdens on frontline medical staff. We have, therefore, developed an evidence-based stratified surgical safety information system based on a multicenter surgical safety improvement program. This study discusses some critical issues in the process of developing this information system, including (1) decisions about data gathering, (2) establishing and sharing knowledge, (3) developing functions for the system, (4) system implementation, and (5) evaluation and continuous improvement. Using examples drawn from the surgical safety improvement program, we have shown how this type of system can be fitted into day-to-day clinical practice and how it can guide medical practice by incorporating inherent patient-related risk and providing tailored interventions for patients with different levels of risk. We concluded that multidisciplinary collaboration, involving experts in health care (including senior staff in surgery, nursing, and anesthesia), data science, health care management, and health information technology, can help build an evidence-based stratified surgical patient safety improvement system. This can provide an information-intensified surgical safety learning platform and, therefore, benefit surgical patients by delivering tailored interventions and an integrated workflow.

  • Source: iStock by Getty Images; Copyright: pixelfit; URL:; License: Licensed by the authors.

    Persuasive System Design Principles and Behavior Change Techniques to Stimulate Motivation and Adherence in Electronic Health Interventions to Support Weight...


    Background: Maintaining weight after weight loss is a major health challenge, and eHealth (electronic health) solutions may be a way to meet this challenge. Application of behavior change techniques (BCTs) and persuasive system design (PSD) principles in eHealth development may contribute to the design of technologies that positively influence behavior and motivation to support the sustainable health behavior change needed. Objective: This review aimed to identify BCTs and PSD principles applied in eHealth interventions to support weight loss and weight loss maintenance, as well as techniques and principles applied to stimulate motivation and adherence for long-term weight loss maintenance. Methods: A systematic literature search was conducted in PsycINFO, Ovid MEDLINE (including PubMed), EMBASE, Scopus, Web of Science, and AMED, from January 1, 2007 to June 30, 2018. Arksey and O’Malley’s scoping review methodology was applied. Publications on eHealth interventions were included if focusing on weight loss or weight loss maintenance, in combination with motivation or adherence and behavior change. Results: The search identified 317 publications, of which 45 met the inclusion criteria. Of the 45 publications, 11 (24%) focused on weight loss maintenance, and 34 (76%) focused on weight loss. Mobile phones were the most frequently used technology (28/45, 62%). Frequently used wearables were activity trackers (14/45, 31%), as well as other monitoring technologies such as wireless or digital scales (8/45, 18%). All included publications were anchored in behavior change theories. Feedback and monitoring and goals and planning were core behavior change technique clusters applied in the majority of included publications. Social support and associations through prompts and cues to support and maintain new habits were more frequently used in weight loss maintenance than weight loss interventions. In both types of interventions, frequently applied persuasive principles were self-monitoring, goal setting, and feedback. Tailoring, reminders, personalization, and rewards were additional principles frequently applied in weight loss maintenance interventions. Results did not reveal an ideal combination of techniques or principles to stimulate motivation, adherence, and weight loss maintenance. However, the most frequently mentioned individual techniques and principles applied to stimulate motivation were, personalization, simulation, praise, and feedback, whereas associations were frequently mentioned to stimulate adherence. eHealth interventions that found significant effects for weight loss maintenance all applied self-monitoring, feedback, goal setting, and shaping knowledge, combined with a human social support component to support healthy behaviors. Conclusions: To our knowledge, this is the first review examining key BCTs and PSD principles applied in weight loss maintenance interventions compared with those of weight loss interventions. This review identified several techniques and principles applied to stimulate motivation and adherence. Future research should aim to examine which eHealth design combinations can be the most effective in support of long-term behavior change and weight loss maintenance.

  • Blockchain in health care. Source: iStock by Getty Images; Copyright: LeoWolfert; URL:; License: Licensed by the authors.

    The Potential of Blockchain Technology for Health Information Exchange: Experimental Study From Patients’ Perspectives


    Background: Nowadays, a number of mechanisms and tools are being used by health care organizations and physicians to electronically exchange the personal health information of patients. The main objectives of different methods of health information exchange (HIE) are to reduce health care costs, minimize medical errors, and improve the coordination of interorganizational information exchange across health care entities. The main challenges associated with the common HIE systems are privacy concerns, security risks, low visibility of system transparency, and lack of patient control. Blockchain technology is likely to disrupt the current information exchange models utilized in the health care industry. Objective: Little is known about patients’ perceptions and attitudes toward the implementation of blockchain-enabled HIE networks, and it is still not clear if patients (as one of the main HIE stakeholders) are likely to opt in to the applications of this technology in HIE initiatives. Thus, this study aimed at exploring the core value of blockchain technology in the health care industry from health care consumers’ views. Methods: To recognize the potential applications of blockchain technology in health care practices, we designed 16 information exchange scenarios for controlled Web-based experiments. Overall, 2013 respondents participated in 16 Web-based experiments. Each experiment described an information exchange condition characterized by 4 exchange mechanisms (ie, direct, lookup, patient-centered, and blockchain), 2 types of health information (ie, sensitive vs nonsensitive), and 2 types of privacy policy (weak vs strong). Results: The findings show that there are significant differences in patients’ perceptions of various exchange mechanisms with regard to patient privacy concern, trust in competency and integrity, opt-in intention, and willingness to share information. Interestingly, participants hold a favorable attitude toward the implementation of blockchain-based exchange mechanisms for privacy protection, coordination, and information exchange purposes. This study proposed the potentials and limitations of a blockchain-based attempt in the HIE context. Conclusions: The results of this research should be of interest to both academics and practitioners. The findings propose potential limitations of a blockchain-based HIE that should be addressed by health care organizations to exchange personal health information in a secure and private manner. This study can contribute to the research in the blockchain area and enrich the literature on the use of blockchain in HIE efforts. Practitioners can also identify how to leverage the benefit of blockchain to promote HIE initiatives nationwide.

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

    A Mobility-Focused Knowledge Translation Randomized Controlled Trial to Improve Physical Activity: Process Evaluation of the Move4Age Study


    Background: Maintaining physical activity and physical function is important for healthy aging. We recently completed a randomized controlled trial of a targeted knowledge translation (KT) intervention delivered through the McMaster Optimal Aging Portal with the goal to increase physical activity and physical mobility in middle-aged and older adults, with results reported elsewhere. Objective: The purpose of this process evaluation study is to explore which KT strategies were used by both intervention and control group participants, as well as the intervention groups’ engagement, satisfaction, and perceived usefulness of the targeted KT intervention. Methods: Data on engagement with the intervention materials were gathered quantitatively through Google Analytics and Hootsuite throughout the intervention. Qualitative data were collected through a combination of open-ended surveys and qualitative interviews with a subset of participants at the end of the study to further understand engagement, satisfaction, and usefulness of the KT strategies. Results: Throughout the intervention period, engagement with content delivered through weekly emails was highest, and participants rated email content most favorably in both surveys and interviews. Participants were generally satisfied with the intervention, noting the ease of participating and the distillation of information in an easy-to-access format being beneficial features. Participants who did not find the intervention useful were those with already high levels of baseline physical activity or physical function and those who were looking for more specific or individualized content. Conclusions: This process evaluation provides insight into our randomized controlled trial findings and provides information that can be used to improve future online KT interventions. Trial Registration: NCT02947230; (Archived by WebCite at

  • An all-in-one device for vital-sign monitoring. Source: Sebastian JH Bredie; Copyright: Sebastian JH Bredie; URL:; License: Creative Commons Attribution (CC-BY).

    Feasibility of a New Cuffless Device for Ambulatory Blood Pressure Measurement in Patients With Hypertension: Mixed Methods Study


    Background: Frequent home blood pressure (BP) measurements result in a better estimation of the true BP. However, traditional cuff-based BP measurements are troublesome for patients. Objective: This study aimed to evaluate the feasibility of a cuffless device for ambulatory systolic blood pressure (SBP) measurement. Methods: This was a mixed method feasibility study in patients with hypertension. Performance of ambulatory SBPs with the device was analyzed quantitatively by intrauser reproducibility and comparability to a classic home BP monitor. Correct use by the patients was checked with video, and user-friendliness was assessed using a validated questionnaire, the System Usability Scale (SUS). Patient experiences were assessed using qualitative interviews. Results: A total of 1020 SBP measurements were performed using the Checkme monitor in 11 patients with hypertension. Duplicate SBPs showed a high intrauser correlation (R=0.86, P<.001). SBPs measured by the Checkme monitor did not correlate well with those of the different home monitors (R=0.47, P=.007). However, the mean SBPs measured by the Checkme and home monitors over the 3-week follow-up were strongly correlated (R=0.75, P=.008). In addition, 36.4% (n=4) of the participants performed the Checkme measurements without any mistakes. The mean SUS score was 86.4 (SD 8.3). The most important facilitator was the ease of using the Checkme monitor. Most important barriers included the absence of diastolic BP and the incidental difficulties in obtaining an SBP result. Conclusions: Given the good intrauser reproducibility, user-friendliness, and patient experience, all of which facilitate patients to perform frequent measurements, cuffless BP monitoring may change the way patients measure their BP at home in the context of ambulant hypertension management.

  • Source: Unsplash; Copyright: Lesly Juarez; URL:; License: Licensed by the authors.

    Participant Engagement in and Perspectives on a Web-Based Mindfulness Intervention for 9-1-1 Telecommunicators: Multimethod Study


    Background: Demanding working conditions and secondary exposure to trauma may contribute to a high burden of stress among 9-1-1 telecommunicators, decreasing their ability to work effectively and efficiently. Web-based mindfulness-based interventions (MBIs) can be effective in reducing stress in similar populations. However, low engagement may limit the effectiveness of the intervention. Objective: The aim of this study was to assess participant engagement in a Web-based MBI designed for 9-1-1 telecommunicators. Specifically, we sought to describe the following: (1) participant characteristics associated with intervention engagement, (2) participant perspectives on engaging with the intervention, and (3) perceived challenges and facilitators to engaging. Methods: We used qualitative and quantitative data from participant surveys (n=149) that were collected to assess the efficacy of the intervention. We conducted descriptive and bivariate analyses to identify associations between demographic, psychosocial, and workplace characteristics and engagement. We conducted a thematic analysis of qualitative survey responses to describe participant experiences with the MBI. Results: We found that no individual participant characteristics were associated with the level of engagement (low vs high number of lessons completed). Participant engagement did vary by the call center (P<.001). We identified the following overarching qualitative themes: (1) the participants perceived benefits of mindfulness practice, (2) the participants perceived challenges to engage with mindfulness and the intervention, and (3) intervention components that facilitated engagement. The participants expressed positive beliefs in the perceived benefits of practicing mindfulness, including increased self-efficacy in coping with stressors and increased empathy with callers. The most commonly cited barriers were work-related, particularly not having time to participate in the intervention at work. Facilitators included shorter meditation practices and the availability of multiple formats and types of intervention content. Conclusions: The findings of this study suggest that efforts to improve intervention engagement should focus on organizational-level factors rather than individual participant characteristics. Future research should explore the effect of mindfulness practice on the efficiency and effectiveness of 9-1-1 telecommunicators at work. Trial Registration: NCT02961621;

  • Integrated Internet of Things button to gauge restroom cleanliness. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An Internet of Things Buttons to Measure and Respond to Restroom Cleanliness in a Hospital Setting: Descriptive Study


    Background: Restroom cleanliness is an important factor in hospital quality. Due to its dynamic process, it can be difficult to detect the presence of dirty restrooms that need to be cleaned. Using an Internet of Things (IoT) button can permit users to designate restrooms that need cleaning and in turn, allow prompt response from housekeeping to maintain real-time restroom cleanliness. Objective: This study aimed to describe the deployment of an IoT button–based notification system to measure hospital restroom cleanliness reporting system usage and qualitative feedback from housekeeping staff on IoT button use. Methods: We deployed IoT buttons in 16 hospital restrooms. Over an 8-month period, housekeeping staff received real-time notifications and responded to button presses for restroom cleaning. All button presses were recorded. We reported average button usage by hospital area, time of day, and day of week. We also conducted interviews with housekeeping supervisors and staff to understand their acceptance of and experience with the system. Results: Over 8 months, 1920 requests to clean restrooms in the main hospital lobby and satellite buildings were received. The hospital lobby IoT buttons received over half (N=1055, 55%) of requests for cleaning. Most requests occurred in afternoon hours from 3 PM to midnight. Requests for cleaning remained stable throughout the work week with fewer requests occurring over weekends. IoT button use was sustained throughout the study period. Interviews with housekeeping supervisors and staff demonstrated acceptance of the IoT buttons; actual use was centered around asynchronous communication between supervisors and staff in response to requests to clean restrooms. Conclusions: An IoT button system is a feasible method to generate on-demand request for restroom cleaning that is easy to deploy and that users will consistently engage with. Data from this system have the potential to enable responsive scheduling for restroom service and anticipate periods of high restroom utilization in a hospital.

  • Source: Pexels; Copyright: LinkedIn Sales Navigator; URL:; License: Licensed by the authors.

    Comparing Treatment Acceptability and 12-Month Cessation Rates in Response to Web-Based Smoking Interventions Among Smokers Who Do and Do Not Screen Positive...


    Background: Web-based cessation programs are now common for intervening with smokers. However, it remains unclear how acceptable or effective these interventions are among people with affective disorders and symptoms (ADS; eg, depression and anxiety). Research examining this is extremely limited, with mixed results on cessation rates. Additional large studies are needed to more fully understand whether Web-based interventions are similarly used and equally effective among people with and without affective disorder symptomology. If not, more targeted Web-based interventions may be required. Objective: The goal of the research was to compare Web-based treatment acceptability (defined by satisfaction and use) and 12-month cessation outcomes between smokers with and without ADS. Methods: Participants (N=2512) were adult smokers enrolled in a randomized, comparative effectiveness trial of two Web-based smoking interventions designed for the general population of smokers. At baseline, participants reported demographic and smoking characteristics and completed measures assessing ADS. Participants were then classified into subgroups based on their self-reported ADS—either into a no ADS group or into six nonmutually exclusive subgroups: depression, posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and more than one ADS. Surveys at 12 months postrandomization included subjective ratings of treatment acceptability and self-reported smoking cessation. Treatment use (ie, number of log-ins and total duration of exposure) was assessed via automated records. Results: Relative to the no ADS group, all six ADS subgroups reported significantly greater satisfaction with their assigned Web treatment program, but they spent less time logged in than those with no ADS. For number of log-ins, a treatment arm by ADS group interaction was observed across all ADS subgroups except GAD, suggesting that relative to the no ADS group, they logged in less to one website but not the other. At the 12-month follow-up, abstinence rates in the no ADS group (153/520, 29.42%) were significantly higher than for participants who screened positive for depression (306/1267, 24.15%; P=.03), PTSD (294/1215, 24.19%; P=.03), PD (229/1003, 23.83%; P=.009), and two or more ADS (323/1332, 24.25%; P=.03). Post hoc analyses suggest the lower quit rates may be associated with differences in baseline nicotine dependence and levels of commitment to resist smoking in difficult situations. Website use did not explain the differential abstinence rates. Conclusions: Despite reporting higher levels of treatment satisfaction, most smokers with ADS used their assigned intervention less often and had lower quit rates than smokers with no ADS at treatment onset. The results support the need for developing more targeted interventions for smokers with ADS. Trial registration: Clinical NCT01812278; (Archived by WebCite at

  • Source: Unsplash; Copyright: Hannah Wei; URL:; License: Licensed by the authors.

    Not Just a Headache: Qualitative Study About Web-Based Self-Presentation and Social Media Use by People With Migraine


    Background: To help with a long-term but invisible medical condition such as migraine, many people seek information and support on social media. The effect of using social media for people with migraine is not fully understood and remains to be investigated. Objective: The aim of this study was to describe how people with migraine use social media and how social media use affects their identity and sense of self. Methods: A total of 20 participants who experienced migraine were recruited via migraine-specific charities. Semistructured interviews were conducted with questions based on a topic guide. Interviews were transcribed verbatim, and transcripts were analyzed using thematic analysis. Results: People with migraine are using social media to obtain information to better understand their condition and treatment options. Social media offers instant access to continuous information and social support. This exchange of social support and information was viewed as mutually beneficial. Participants viewed social media as an outlet to vent frustrations and validate the migraine experience. Several participants pointed out that the invisible and episodic nature of migraine can lead to societal misunderstanding of the impact and or severity of their condition. Some participants masked their online migraine-related behavior using different sites or closed online groups to control who saw their migraine-related content. Participating in closed social media groups sometimes changed Web-based behavior in other areas of the platform. This illustrates the complex relationship between migraine, social media, and identity. Conclusions: How migraine is part of an individual’s identity and how this is represented online can vary. Social media can provide people who experience migraine with instant and continuous access to support and information, from a group of empathic others with similar lived experiences. Social media is used to validate the illness experience, as well as provide reassurance and help reduce feelings of isolation.

  • Source: Flickr; Copyright: Marco Verch Professional Photographer and Speaker; URL:; License: Creative Commons Attribution (CC-BY).

    Associations of Social Media Use With Physical Activity and Sleep Adequacy Among Adolescents: Cross-Sectional Survey


    Background: Adolescents’ use of social media, which has increased considerably in the past decade, has both positive and negative influences on adolescents’ health and health behaviors. As social media is the most prominent communication tool of choice for adolescents, it is important to understand the relationship between the frequency of social media use and health behaviors among this population. Objective: The objective of our study was to examine the associations between the frequency of social media use and physical activity and sleep adequacy among middle and high school students. Methods: We used data from the Monitoring the Future survey (2014 and 2015), a nationally representative, annual, cross-sectional survey of American 8th-, 10th-, and 12th-grade students (N=43,994). Health behaviors examined were frequency of vigorous physical activity and frequency of getting 7 hours of sleep (never/seldom, sometimes, and every day/nearly every day). We measured frequency of social media use using a Likert-like scale (never, a few times a year, 1-2 times a month, once a week, or every day). Multivariable generalized ordered logistic regressions examined the association of social media use with different levels of physical activity and sleep. We estimated marginal effects (MEs) for the main independent variable (social media use frequency) by holding all other variables at their observed values. Results: The study population comprised 51.13% (21,276/42,067) female students, 37.48% (17,160/43,994) from the South, and 80.07% (34,953/43,994) from a metropolitan area, with 76.90% (33,831/43,994) reporting using social media every day. Among physically active students, frequent social media use was associated with a higher likelihood of vigorous daily exercise (ME 50.1%, 95% CI 49.2%-51.0%). Among sedentary students, frequent social media use was associated with a lower likelihood of vigorous daily exercise (ME 15.8%, 95% CI 15.1%-16.4%). Moderately active students who used social media once or twice a month had the highest likelihood of reporting vigorous daily exercise (ME 42.0%, 95% CI 37.6%-46.3%). Among those who normally got adequate sleep, daily social media users were least likely to report adequate sleep (ME 41.3%, 95% CI 40.4%-42.1%). Among those who were usually sleep deprived, daily social media users were more likely to report adequate sleep (ME 18.3%, 95% CI 17.6%-19.0%). Conclusions: Regular social media use every day was associated with a reinforcement of health behaviors at both extremes of health behaviors, whereas a medium intensity of social media use was associated with the highest levels of physical activity and lowest sleep adequacy among those with moderate health behaviors. Hence, finding an optimal level of social media use that is beneficial to a variety of health behaviors would be most beneficial to adolescents who are in the middle of the health behavior spectrum.

  • A young man performing a vape trick. Source: Flickr; Copyright: rpavich; URL:; License: Creative Commons Attribution (CC-BY).

    Promotion of Vape Tricks on YouTube: Content Analysis


    Background: The ability to perform vape tricks (ie, blowing large vapor clouds or shapes like rings) using e-cigarettes appeals to youth. Vape tricks are promoted on social media, but the promotion of vape tricks on social media is not well understood. Objective: The aim of this study was to examine how vape tricks were promoted on YouTube to youth. Methods: Videos on vape tricks that could be accessed by underage youth were identified. The videos were coded for number of views, likes, dislikes, and content (ie, description of vape tricks, e-cigarette devices used for this purpose, video sponsors [private or industry], brand marketing, and contextual characteristics [eg, model characteristics, music, and profanity]). Results: An analysis of 59 sample videos on vape tricks identified 25 distinct vape tricks. These videos had more likes than dislikes (11 to 1 ratio) and a 32,017 median view count. 48% (28/59) of the videos were posted by industry accounts (27% [16/59] provaping organizations, 15% [9/59] online shops, and 3% [2/59] vape shops) and 53% by private accounts (55% [17/31] private users, 26% [8/31] vape enthusiasts, and 19% [6/31] YouTube influencers); 53% (31/59) of the videos promoted a brand of e-cigarette devices, e-liquids, or online/vape shops, and 99% of the devices used for vape tricks were advanced generation devices. The models in the videos were 80.2% (160/198) male, 51.5% white (102/198), and 61.6% (122/198) aged 18 to 24 years; 85% (50/59) of the videos had electronic dance music and hip hop, and 32% (19/59) had profanity. Conclusions: Vape trick videos on YouTube, about half of which were industry sponsored, were accessible to youth. Restrictions of e-cigarette marketing on social media, such as YouTube, are needed.

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  • Effects of e-learning in a continuing education context on nursing care: A systematic review of systematic qualitative, quantitative and mixed studies reviews

    Date Submitted: Jun 24, 2019

    Open Peer Review Period: Jun 24, 2019 - Jul 2, 2019

    Background: e-Learning is rapidly growing as an alternative way of delivering education in nursing. Two contexts regarding the use of e-learning in nursing are discussed in the literature: 1) educatio...

    Background: e-Learning is rapidly growing as an alternative way of delivering education in nursing. Two contexts regarding the use of e-learning in nursing are discussed in the literature: 1) education among nursing students and 2) nurses’ continuing education in a life-long learning perspective. A previous systematic review of systematic reviews on e-learning for nursing and health professional students in an academic context has been published previously, but no such reviews exist regarding e-learning for registered nurses in a continuing education context. Objective: We aimed to systematically summarize the qualitative and quantitative evidence regarding the effects of e-learning on nursing care among nurses in a continuing education context. Methods: We conducted a systematic review of systematic qualitative, quantitative and mixed studies reviews, searching in four bibliographic databases. The eligibility criteria were formulated using the PICOS (population, interventions, comparisons, outcomes, study design) format. Included population was registered nurses. e-Learning interventions were included, compared with face-to-face, any other e-learning interventions and blended learning. The outcomes of interest derived from two models: nursing sensitive indicators from the Nursing Care Performance Framework (e.g., teaching, collaboration) and the levels of evaluation from the Kirkpatrick Model (reaction, learning, behavior and results). Results: We identified a total of 12,906 records. We retrieved 222 full-text papers for detailed evaluation, from which 22 systematic reviews published between 2008 and 2018 met the eligibility criteria. The effects of e-learning on nursing care were grouped under Kirkpatrick’s levels of evaluation: 1) Nurse reactions with e-learning; 2) Nurse learning; 3) Behavior; 4) Results. Level 2, nurse learning, was divided into these three subthemes: knowledge, skills, and attitude/self-efficacy. Level 4, results, was divided into patient outcomes and costs. Most of the outcomes were reported in a positive way. For instance, nurses were satisfied with the use of e-learning and they improved their knowledge. The most common topic covered by the e-learning interventions was medication calculation, preparation and administration. Conclusions: The effects of e-learning are mainly reported in terms of nurse reactions, knowledge and skills, i.e., the two first levels of the Kirkpatrick Model. The effectiveness of e-learning interventions for nurses in a continuing education context remains unknown regarding how the learning can be transferred to change practice and affect patient outcomes. Further scientific, methodological, theoretical and practice-based breakthroughs are needed in the fast-growing field of e-learning in nursing education, especially in a life-learning perspective. Clinical Trial: Trial Registration: PROSPERO International Prospective Register of Systematic Reviews:

  • Impact of a mobility-focused knowledge translation randomized controlled trial on physical activity: the Move4Age study

    Date Submitted: Jun 21, 2019

    Open Peer Review Period: Jun 24, 2019 - Aug 19, 2019

    Background: The McMaster Optimal Aging Portal (the Portal) was launched in 2014 as a knowledge translation tool to increase access to evidence-based health information. Objective: The purpose of this...

    Background: The McMaster Optimal Aging Portal (the Portal) was launched in 2014 as a knowledge translation tool to increase access to evidence-based health information. Objective: The purpose of this study is to understand if and how dissemination of mobility information through the Portal impacts physical activity of older adults. Methods: In this randomized controlled trial, participants (n = 510) were assigned to a 12-week mobility-focused tailored knowledge translation intervention or self-serve control group. The intervention included weekly email alerts and a study-specific social media hashtag linking to mobility-focused Portal materials. The control group was able to access the Portal on their own, but did not receive targeted knowledge translation strategies. Participants completed questionnaires (including the Rapid Assessment of Physical Activity to quantify physical activity) at baseline, end-of-study, and three-month follow-up. Results: Participants were predominantly female (84.3%), mean age 64.7 years with no baseline differences between groups. Over half (54.3%) were classified as ‘active’ at baseline. Overall, both groups increased their physical activity with improvements maintained at three-month follow-up (p<0.001). There was no significant between-group difference in physical activity category. In planned subgroup analyses, the knowledge translation intervention had a significant effect for those with poor/fair baseline self-rated health (p=0.03). Conclusions: Accessing the Portal appears to increase physical activity amongst middle age and older adults, with changes that are sustained beyond participation in a research study. Findings suggest that different knowledge translation strategies may be useful for different types of users, with more intense interventions being most impactful for certain groups (i.e., those with lower self-rated health). Clinical Trial: NCT02947230,

  • Digitalizing health services by implementing a personal electronic health record (PHR) in Germany: Qualitative analysis of fundamental prerequisites

    Date Submitted: Jun 19, 2019

    Open Peer Review Period: Jun 24, 2019 - Aug 19, 2019

    Background: The implementation of a personal electronic health record (PHR) is a central objective of digitalization policies in the German health care system. Corresponding legislation was passed wit...

    Background: The implementation of a personal electronic health record (PHR) is a central objective of digitalization policies in the German health care system. Corresponding legislation was passed with the 2015 Act for Secure Digital Communication and Applications in the Health Sector (eHealth Act). However, compared to other European countries, Germany still lags behind concerning the implementation of a PHR. Objective: In order to explore potential barriers and facilitators for the adoption of a PHR in routine health care in Germany, this article aims to identify policies, structures and practices of the German health care system that influence the up-take and use of a PHR. Methods: A total of 33 semi-structured interviews were conducted with a purposive sample of experts: 23 interviews with different health care professionals (HCP) and 10 interviews with key actors of the German health care system and telematics, e-health and information technology experts (e-health experts). The interviews were transcribed verbatim and sub-jected to a content analysis. Results: From the expert perspective, a PHR was basically considered desirable, and unavoidable. At the same time, a number of challenges for implementation in Germany have been outlined. Three crucial themes emerged: 1) Documentation standards: Prevailing ideas of the analog bureaucratic paper world 2) Interoperability: The Plurality of actors and electronic systems 3) Political structure: The lack of clear political regulations and political incentive structures. Conclusions: With regard to the implementation of a PHR, an important precondition of a successful digitalization will be the precedent reform of the system to be digitized. Whether the recently passed "Act for Faster Appointments and Better Care" will be a step in the right direction remains to be seen.

  • An online pain education program for working adults: a pilot randomized controlled trial with one-month follow-up

    Date Submitted: Jun 18, 2019

    Open Peer Review Period: Jun 21, 2019 - Aug 16, 2019

    Background: Pain is a common public health concern, and the pain situation among general population is serious in mainland China reported in the previous study. Working adults are easily to suffer fro...

    Background: Pain is a common public health concern, and the pain situation among general population is serious in mainland China reported in the previous study. Working adults are easily to suffer from pain because of long sitting time, lack of time and exercise etc. Lack of pain related knowledge is also a significant factor. Educational and therapeutic programs delivered online were used more in the western countries and accessible program in China is limited, especially for pain management. Therefore, we carried out an online pain education program for working adults to self-manage pain. The program was delivered through WeChat which is a popular and secure social media with a large population base in China. Objective: (1) To provide pain related knowledge and self-relieve strategies; (2) To help participants reduce pain and improve pain related emotional well-being; (3) To explore participants’ learning performance and the acceptability to the online pain education program. Methods: It was a randomized controlled trail. Chinese adults between 16 and 60 with full-time employment, have pain in past 6 months and without any mental illnesses were recruited using snowball sampling through internet and were randomly allocated into experimental group and control group with 1:1 ratio after the baseline assessment. The education program lasted for 4 weeks including basic knowledge of pain, pharmacological and non-pharmacological treatments and related resources was provided only for the experimental group. Outcome of pain, depression, anxiety, stress and pain self-efficacy were measured at baseline (T0), post-treatment (T1) and one-month follow-up (T2). Participants’ acceptability and satisfaction were explored after completing the education. Results: Totally 95 eligible participants joined in the program with 47 in the experimental group and 48 in control group. Neck/shoulder, head and back were most commonly reported pain sites with high pain score. Pain intensity and interference of the experimental group were significantly reduced after the education. Depression, anxiety, stress were clinically improved. Pain self-efficacy was also improved after the education. The difference in depression, anxiety, stress and pain self-efficacy within group or between groups were not statistically significant, yet, the clinical improvements had been demonstrated. Pain intensity and depression was shown significantly correlated with the dosage of intervention. After completing the education, more than half of the participants showed acceptance and satisfaction to the program and they were willing to recommend to others. Conclusions: To conclude, our findings highlight the significant potential of this online education programs in the treatment of pain. Further promotion to the public can be made to help more pain suffers. Clinical Trial: Clinical Trials, NCT03952910. Retrospectively registered 15 May 2019.

  • Performing Distributed Regression Analysis with a SAS Application Integrated with PopMedNetTM: Precision and Operational Performance

    Date Submitted: Jun 17, 2019

    Open Peer Review Period: Jun 20, 2019 - Aug 15, 2019

    Background: Distributed data networks (DDNs) combined with distributed regression analysis (DRA) can reduce the risk of disclosing sensitive individual and institutional information in multi-center st...

    Background: Distributed data networks (DDNs) combined with distributed regression analysis (DRA) can reduce the risk of disclosing sensitive individual and institutional information in multi-center studies. However, software and analytical packages that facilitate large-scale and efficient implementation of DRA are limited. Objective: To assess the precision and operational performance of a new SAS-based DRA application and a file transfer workflow within PopMedNetTM, an open-source distributed file-sharing software, within a horizontally partitioned DDN. Methods: We executed the application to perform distributed linear, logistic, and Cox proportional hazards regression analysis on a real-world test case with three data partners. We used PopMedNet to iteratively and automatically transfer highly summarized information between the data partners and the analysis center. We compared the DRA regression parameters, standard errors, model fit statistics, and model fit curves to the results obtained from standard SAS procedures executed on the pooled individual-level dataset. We computed the execution time of each step in the workflow to evaluate the operational performance of the application. Results: All DRA regression results were precise (< 10-12) and DRA model fit curves were identical or similar to those obtained from the corresponding pooled individual-level data analysis. All regression models required less than 20 minutes for full end-to-end execution. Conclusions: We integrated a SAS-based DRA application with an open-source file-sharing software and successfully tested the new capability within an active DDN. The study demonstrated the validity and feasibility of using DRA to enable privacy-protecting analysis in multi-center studies.

  • Randomized, Controlled Trial of an Information and Communication Technology-based Health Management Program for Patients with Cardiovascular Risk

    Date Submitted: Jun 16, 2019

    Open Peer Review Period: Jun 19, 2019 - Aug 14, 2019

    Background: In addition to medication, the management of health behavior is crucial in patients with multiple risks of cardiovascular mortality. Objective: This study aimed to examine the efficacy of...

    Background: In addition to medication, the management of health behavior is crucial in patients with multiple risks of cardiovascular mortality. Objective: This study aimed to examine the efficacy of a self-management strategy-based information and communication technology (ICT) program. Methods: Methods: This was a randomized, controlled trial of a self-management strategy-based ICT program (n = 53) versus an attention control (n = 53) in 106 patients with at least one indicator of poor disease control and who had hypertension, diabetes, or hypercholesterolemia. Intervention group were provided with the program. Control subjects received basic educational material concerning disease content. The primary outcome was the percentage of patients achieving three clinical indicators after 3 months: HbA1c < 7.0%, systolic blood pressure (SBP) < 130 mmHg, or LDL cholesterol < 130 mg/dL. Results: Results: The intervention group showed a significantly high success rate for achieving all three clinical indicators (p = 0.016). Only patients with hypertension showed a significant improvement in SBP from baseline as compared to controls (72.8% vs 35.7%, p = 0.035). There was a significant reduction in HbA1c in the intervention group compared to controls (difference = 0.54%, p = 0.014). In the intervention group, 20% of patients with diabetes exhibited a ≥ 1% decrease in HbA1c (vs. 0% among controls, p = 0.038). Conclusions: Conclusion: A short-term self-management strategy-based ICT intervention may improve clinical outcomes among patients with cardiovascular risk. Clinical Trial: NCT03294044