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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:

  • Mobile videoconferencing. Source: iStock by Getty Images; Copyright: AndreyPopov; URL:; License: Licensed by the authors.

    A Mobile Videoconference-Based Intervention on Stress Reduction and Resilience Enhancement in Employees: Randomized Controlled Trial


    Background: Videoconferencing-based treatments have shown great potential in increasing engagement and compliance by decreasing the barriers of time and distance. In general, employees tend to experience a lot of stress, but find it difficult to visit a clinic during office hours. Objective: The purpose of this study was to investigate the effectiveness of a mobile videoconference-based intervention for stress reduction and resilience enhancement in employees. Methods: In total, 81 participants were randomly allocated to one of the three conditions: mobile videoconferencing, in-person, and self-care; of these, 72 completed the study. All participants underwent assessment via self-reported questionnaires before, immediately after, and 1 month after the intervention. Intervention lasted for 4 weeks and consisted of elements of cognitive behavioral therapy, positive psychology, and meditation. Changes in clinical variables regarding stress and resilience across time were compared between treatment conditions. Results: There were significant condition × time effects on variables measuring perceived stress, resilience, emotional labor, and sleep, demonstrating significantly differential effects across time according to treatment condition. Moreover, there were significant effects of condition on perceived stress and occupational stress. There were no significant differences in any variable between the mobile videoconferencing and in-person conditions at 1 month after the intervention. Conclusions: Results indicate that both mobile videoconferencing and in-person interventions were comparably effective in decreasing stress and enhancing resilience. Further studies with a larger sample size and a longer follow-up period are warranted to investigate the long-term effect of mobile videoconferencing interventions. Trial Registration: identifier NCT03256682; (Archived by WebCite at

  • A crowd of people, all with different characteristics, who need to be grouped for optimal prediction of mental health scores. Source: Flickr; Copyright: Gonzalo Rodriguez; URL:; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Group-Personalized Regression Models for Predicting Mental Health Scores From Objective Mobile Phone Data Streams: Observational Study


    Background: Objective behavioral markers of mental illness, often recorded through smartphones or wearable devices, have the potential to transform how mental health services are delivered and to help users monitor their own health. Linking objective markers to illness is commonly performed using population-level models, which assume that everyone is the same. The reality is that there are large levels of natural interindividual variability, both in terms of response to illness and in usual behavioral patterns, as well as intraindividual variability that these models do not consider. Objective: The objective of this study was to demonstrate the utility of splitting the population into subsets of individuals that exhibit similar relationships between their objective markers and their mental states. Using these subsets, “group-personalized” models can be built for individuals based on other individuals to whom they are most similar. Methods: We collected geolocation data from 59 participants who were part of the Automated Monitoring of Symptom Severity study at the University of Oxford. This was an observational data collection study. Participants were diagnosed with bipolar disorder (n=20); borderline personality disorder (n=17); or were healthy controls (n=22). Geolocation data were collected using a custom Android app installed on participants’ smartphones, and participants weekly reported their symptoms of depression using the 16-item quick inventory of depressive symptomatology questionnaire. Population-level models were built to estimate levels of depression using features derived from the geolocation data recorded from participants, and it was hypothesized that results could be improved by splitting individuals into subgroups with similar relationships between their behavioral features and depressive symptoms. We developed a new model using a Dirichlet process prior for splitting individuals into groups, with a Bayesian Lasso model in each group to link behavioral features with mental illness. The result is a model for each individual that incorporates information from other similar individuals to augment the limited training data available. Results: The new group-personalized regression model showed a significant improvement over population-level models in predicting mental health severity (P<.001). Analysis of subgroups showed that different groups were characterized by different features derived from raw geolocation data. Conclusions: This study demonstrates the importance of handling interindividual variability when developing models of mental illness. Population-level models do not capture nuances in how different individuals respond to illness, and the group-personalized model demonstrates a potential way to overcome these limitations when estimating mental state from objective behavioral features.

  • Authors’ Reply: Comment on “A New Cuffless Device for Measuring Blood Pressure: A Real-Life Validation Study”


  • Blood Pressure Measurement Validation Off the Cuff? Comment on “A New Cuffless Device for Measuring Blood Pressure: A Real-Life Validation Study”


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

    Modeling and Predicting Outcomes of eHealth Usage by European Physicians: Multidimensional Approach from a Survey of 9196 General Practitioners


    Background: The literature has noted the need to use more advanced methods and models to evaluate physicians’ outcomes in the shared health care model that electronic health (eHealth) proposes. Objective: The goal of our study was to design and evaluate a predictive multidimensional model of the outcomes of eHealth usage by European physicians. Methods: We used 2012-2013 survey data from a sample of 9196 European physicians (general practitioners). We proposed and tested two composite indicators of eHealth usage outcomes (internal practices and practices with patients) through 2-stage structural equation modeling. Logistic regression (odds ratios, ORs) to model the predictors of eHealth usage outcomes indicators were also calculated. Results: European general practitioners who were female (internal practices OR 1.15, 95% CI 1.10-1.20; practices with patients OR 1.19, 95% CI 1.14-1.24) and younger—aged <35 years (internal practices OR 1.14, 95% CI 1.02-1.26; practices with patients OR 1.32, 95% CI 1.13-1.54) and aged 36-45 years (internal practices OR 1.16, 95% CI 1.06-1.28; practices with patients OR 1.21, 95% CI 1.10-1.33)—had a greater propensity toward favorable eHealth usage outcomes in internal practices and practices with patients. European general practitioners who positively valued information and communication technology (ICT) impact on their personal working processes (internal practices OR 5.30, 95% CI 4.73-5.93; practices with patients OR 4.83, 95% CI 4.32-5.40), teamwork processes (internal practices OR 4.19, 95% CI 3.78-4.65; practices with patients OR 3.38, 95% CI 3.05-3.74), and the doctor-patient relationship (internal practices OR 3.97, 95% CI 3.60-4.37; practices with patients OR 6.02, 95% CI 5.43-6.67) had a high propensity toward favorable effects of eHealth usage on internal practices and practices with patients. More favorable eHealth outcomes were also observed for self-employed European general practitioners (internal practices OR 1.33, 95% CI 1.22-1.45; practices with patients OR 1.10, 95% CI 1.03-1.28). Finally, general practitioners who reported that the number of patients treated in the last 2 years had remained constant (internal practices OR 1.08, 95% CI 1.01-1.17) or increased (practices with patients OR 1.12, 95% CI 1.03-1.22) had a higher propensity toward favorable eHealth usage outcomes. Conclusions: We provide new evidence of predictors (sociodemographic issues, attitudes toward ICT impacts, and working conditions) that explain favorable eHealth usage outcomes. The results highlight the need to develop more specific policies for eHealth usage to address different realities.

  • Source: Tyndale Air Force Base (Solomon Cook); Copyright: US Air Force; URL:; License: Public Domain (CC0).

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


    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:; License: Licensed by the authors.

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

    Authors List:


    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:; License: Licensed by JMIR.

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


    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:; License: Licensed by JMIR.

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


    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:; License: Public Domain (CC0).

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


    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 /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Skin Cancer Classification Using Convolutional Neural Networks: Systematic Review


    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:; License: Licensed by JMIR.

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


    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.

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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.

  • 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: 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.

  • Efficacy of an online self-management enhancing programme for patients with rheumatoid arthritis: an explorative RCT

    Date Submitted: Oct 12, 2018

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

    Background: Online self-management enhancing programmes has the potential to support patients with Rheumatoid Arthritis in their self-management, for example improve their health status and self-effic...

    Background: Online self-management enhancing programmes has the potential to support patients with Rheumatoid Arthritis in their self-management, for example improve their health status and self-efficacy or decrease overuse of medication. We developed an online self-management enhancing program in collaboration with RA patients and professionals as co-designers, based on the Intervention Mapping Framework. While self-management programs are complex interventions, it is informative to perform an explorative Randomized Controlled Trial before embarking on a larger trial. Objective: This study aimed to evaluate the efficacy of an online self-management enhancing programme for patients with rheumatoid arthritis and to identify outcome measures most likely to capture potential benefits. Methods: A multicentre exploratory randomised controlled trial was performed with an intervention and a control group. Both groups received care as usual. In addition, the intervention group received 12 months of access to an online self-management programme. Assessment occurred at baseline, 6 and 12 months. Outcome measures included self-management behaviour (PAM-13, SMAS-S), self-efficacy (RASE, PEPPI-5), general health status (RAND-36), focus on fatigue (MPCI-F), perceived pain and fatigue (NRS scales). A linear mixed model for repeated measures, using the intention-to-treat principle, was applied to study differences between the patients in the intervention (n=78) and control (n=79) groups. A sensitivity analysis was performed in the intervention group to study the influence of patients with high (N=30) and low (N=40) use of the intervention. Results: The intervention group scored statistically significantly better on the subscale RAND-36 vitality. The group with high use scored statistically significantly better on the subscale RAND-36 perception, although the effect sizes were small. No other statistically significant or clinically relevant effects were found. Conclusions: Based on these results, it is not possible to conclude on the positive effects of the intervention or to select outcome measures to be regarded as the primary/main or secondary outcomes for a future trial. A process evaluation should be performed to provide more insight into the low compliance with and effectiveness of the intervention. Clinical Trial: The trial is registered in the Dutch Trial Register (ID: NTR4871). URL: