JMIR Publications

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  Research Letter

  Apr 20, 2026

  The Impact of Ontario’s Virtual Care Payment Model on Cancer Care: A Natural Policy Experiment

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  Authors List:

  • Adam Suleman  
  • Zhihui Amy Liu  
  • Anna Sinaiko  
  • Anca Prica  
  • Danielle Rodin  

  Abstract:

  • J Med Internet Res 2026;28(1):e89151

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  Digital Health Reviews

  Apr 20, 2026

  Clinical Effectiveness of Immersive Virtual Reality Exercise Interventions: Systematic Review and Meta-Analysis of Randomized Controlled Trials

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  Authors List:

  • Riley C C Brown  
  • Megan H Ross  
  • Trevor G Russell  

  Abstract:

  Background: Physical inactivity remains a global health concern, with only one in 5 adults meeting combined aerobic and muscle-strengthening guidelines. Exercise interventions delivered through immersive virtual reality (IVR) offer a novel mode of delivery. Little is known about the clinical effectiveness or feasibility of exercise via IVR across population groups. A detailed understanding of clinical effectiveness and feasibility is required for clinicians to decide whether to include IVR in exercise practice. Objective: The objective of this systematic review was to assess the clinical effectiveness of IVR interventions using aerobic or anaerobic exercise. Methods: A systematic review incorporating meta-analyses was conducted. Searches were conducted across PubMed, Embase, Web of Science, and CINAHL from inception until January 6, 2026. Randomized controlled trials including participants with an acute health condition, chronic disease, history of reconstructive or restorative surgery, and older adults implementing IVR exercise and reporting clinical effectiveness outcomes were included. Random effects meta-analyses were conducted for between-group comparisons for clinical effectiveness outcomes, grouped according to comparator group activity (exercising/nonexercising). Risk of Bias was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence with Grading of Recommendations, Assessment, Development, and Evaluation. Results: Twenty-six trials with 846 total participants were included in this review, with 23 progressing to meta-analyses. Pooled analyses revealed a general trend for IVR, but no statistical differences with comparator intervention (exercising or nonexercising) for mobility and functional balance (exercising: standardized mean difference [SMD] −0.345, 95% CI −1.095 to 0.406; =.29; nonexercising SMD −0.322, 95% CI −0.931 to 0.288; =.22), functional leg strength (exercising: SMD −0.161, 95% CI −0.573 to 0.250; =.33; nonexercising: SMD −0.351, 95% CI −1.750 to 1.049; =.48), quality of life (exercising: SMD 0.036, 95% CI −0.444 to 0.516; =.84; nonexercising: SMD −0.053, 95% CI −0.839 to 0.728; =.80) or other outcome domains. Eighty percent of outcomes assessed were rated as “some concerns” (n=16) or at “high” (n=21) risk of overall bias. Grading of Recommendations, Assessment, Development, and Evaluation certainty grading was deemed to be “low” or “very low” for all outcomes. Conclusions: This systematic review incorporating meta-analyses provides initial evidence for the clinical effectiveness of IVR exercise interventions. This review differs from previous literature by systematically collecting and appraising evidence exclusively from IVR aerobic/anaerobic exercise interventions from across a variety of populations and settings, and including a broad range of clinical effectiveness outcomes. Initial evidence may suggest that IVR exercise does not seem to statistically differ from comparators for clinical effectiveness outcomes. However, high heterogeneity, substantial risk of bias among trials, and “low” to “very low” certainty in evidence reduce overall confidence in the findings. While these results indicate that IVR may be a viable option for the delivery of exercise, a more robust methodology in future trials is needed to properly verify findings and improve certainty. This will help to determine the real-world applicability of IVR exercise interventions for the improvement of health-related measures. Trial Registration: PROSPERO CRD420250650110; https://www.crd.york.ac.uk/PROSPERO/view/CRD420250650110

  • J Med Internet Res 2026;28(1):e87542

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  News and Perspectives

  Apr 20, 2026

  Hospital-at-Home: New Technology Brings Acute Care to Patients’ Homes

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  • Jenna Congdon

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  • J Med Internet Res 2026;28(1):e98143

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  Consumer & Patient Education and...

  Apr 17, 2026

  The Real-Time Support Role of Augmented Reality Technology in Shared Decision-Making in Neurosurgery Under the SEGUE Framework: Randomized Controlled Trial

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  Authors List:

  • Zhengbo Yuan  
  • Zhongjie Shi  
  • Zhanxiang Wang  

  Abstract:

  Background: Preoperative risk communication is essential for shared decision-making (SDM) in neurosurgery; however, conveying complex neuroanatomy and surgical risks using traditional verbal explanations can limit understanding and contribute to dissatisfaction and medicolegal disputes. Augmented reality (AR) may provide patient-specific, interactive 3D visualization to support these conversations. Objective: This study evaluates whether AR-assisted preoperative risk communication improves objective understanding and other SDM-related outcomes, compared with communication supported by a conventional physical anatomical model within a standardized SEGUE-informed protocol. Methods: A prospective, single-center, randomized controlled trial was conducted with 62 neurosurgery communication recipients (patients when capable; otherwise, a legally authorized representative [LAR]). Patients were stratified by planned surgical approach (frontal, parietal, and occipital) and, within each stratum, were randomized into an experimental AR group and a control physical-model group. The primary outcome was postsession objective understanding, assessed by a multiple-choice knowledge questionnaire. Secondary outcomes were subjective understanding, communication satisfaction, pre-to-post anxiety changes, communication duration, and neurosurgeons’ communication skills from video recordings. Results: Of the 67 individuals screened, 62 communication recipients were enrolled and completed all assessments (patients, n=30; LARs, n=32; AR, n=32; and control, n=30). Objective understanding was higher with AR than with the physical model in the prespecified pooled comparison (P=.01). Communication satisfaction was also higher with AR (P<.001). There were no clear between-group differences in subjective understanding (P=.41), anxiety changes (ΔState-Trait Anxiety Inventory [ΔSTAI] Y-1, P=.37; ΔSTAI Y-2, P=.84), in-session face-to-face communication duration (excluding any presession AR technical preparation time; P=.73), or SEGUE scores (P=.60). Exploratory stratified analyses suggested larger comprehension gains with AR in the parietal and occipital approach strata. Conclusions: In a standardized preoperative SDM conversation, an integrated visualization-support package combining AR, patient-specific modeling, and interactivity improved neurosurgical decision makers’ objective understanding and satisfaction without prolonging in-session, face-to-face communication duration. Larger multicenter trials with longer-term outcomes are warranted to confirm effectiveness and to evaluate implementation and cost considerations. Trial Registration: ISRCTN Registry ISRCTN11483487; http://www.isrctn.com/ISRCTN11483487

  • J Med Internet Res 2026;28(1):e87198

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  Digital Health Reviews

  Apr 17, 2026

  Comparing Pulmonary Telerehabilitation and Center-Based Pulmonary Rehabilitation for Effectiveness and Adherence in Chronic Obstructive Pulmonary Disease:...

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  Authors List:

  • Ya Li  
  • Hailong Zhang  
  • Guixiang Zhao  
  • Jiansheng Li  
  • Haoxuan Huang  
  • Longyu Wang  
  • Peilin Jia  

  Abstract:

  Background: Pulmonary rehabilitation (PR) is a cornerstone of chronic obstructive pulmonary disease (COPD) management; however, access to traditional center-based PR (CBPR) remains limited. Digital and remote models, collectively termed pulmonary telerehabilitation (Tele-PR), have increasingly been used, but their heterogeneity in technology use, supervision, and interaction mode may influence effectiveness and sustainability. Objective: This systematic review and meta-analysis aimed to compare the effectiveness and adherence of Tele-PR with those of CBPR in adults with COPD while systematically evaluating the impacts of supervision intensity and delivery models on key clinical outcomes. Methods: This review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 and PRISMA-S (Preferred Reporting Items for Systematic reviews and Meta-Analyses literature search extension) guidelines. PubMed, Embase, the Cochrane Library, and the Web of Science were searched from inception to December 10, 2025, to identify randomized controlled trials comparing Tele-PR or home-based PR (HBPR) with CBPR in adults with COPD. Random effects meta-analyses were conducted using the Hartung-Knapp-Sidik-Jonkman method. Between-study heterogeneity was assessed using τ², , and 95% prediction intervals. Risk of bias was evaluated with the Cochrane Risk of Bias 2 tool, and certainty of evidence was graded using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Results: Seventeen randomized controlled trials involving 1658 participants were included. After intervention, Tele-PR and CBPR showed comparable average effects on exercise capacity by 6-minute walk distance (k=9; n=950, 57.3%; mean difference –5.37 m, 95% CI –15.68 to 4.95; =.26; τ²=103.97; =28.2%; 95% prediction intervals=–32.73 to 22.27). Although pooled effects were not statistically significant, substantial heterogeneity was observed across remote delivery models. Subgroup analyses linked digitally supported, synchronously supervised Tele-PR to less between-study variance across several outcomes, indicating greater consistency in treatment effects across different settings while revealing that low-technology HBPR yielded more variable outcomes, particularly in symptom burden. At long-term follow-up (≥6 mo), between-group differences in functional and symptom outcomes diminished, and short-term gains in exercise capacity did not consistently translate into increased daily physical activity. Certainty of evidence ranged from moderate to very low, mainly downgraded for performance bias, inconsistency across intervention models, and imprecision. Conclusions: Tele-PR may achieve short-term clinical outcomes comparable to CBPR. Distinct from prior reviews, we stratified remote programs by delivery models and supervision, identifying digitally supported Tele-PR and low-technology HBPR as 2 clinically distinct paradigms with differing consistency of effects. We further propose a structured “supervision gradient” to interpret model-dependent variability in effects across Tele-PR approaches, providing a context-sensitive framework for evidence-informed, model-specific implementation. Future remote rehabilitation should integrate real-time professional supervision and long-term behavioral maintenance to sustain benefits. Tele-PR may be particularly valuable for expanding PR access, while CBPR remains essential for patients requiring close in-person supervision or complex multidisciplinary care. Trial Registration: PROSPERO CRD42025633252; https://www.crd.york.ac.uk/PROSPERO/view/CRD42025633252

  • J Med Internet Res 2026;28(1):e80500

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  Web-based and Mobile Health...

  Apr 17, 2026

  Effectiveness of mHealth Interventions for Improving eHealth Literacy Among Patients With Chronic Diseases: Meta-Analysis and Systematic Review

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  Authors List:

  • Xueqin Yang  
  • Yingping Ma  
  • Yueting Wang  
  • Mengting Liu  
  • Xingyu Liu  
  • Xueping Jiao  
  • Fanghong Yan  
  • Yuxia Ma  
  • Lin Han  
  • Yanan Zhang  

  Abstract:

  Background: With the widespread use of the internet and mobile devices, eHealth literacy promotion is critical for medical equity. Mobile health (mHealth) serves as a pivotal tool for enhancing eHealth literacy by providing accessible, interactive platforms for health information engagement. However, the evidence regarding the effectiveness of mHealth interventions on eHealth literacy among patients with chronic diseases remains inconclusive. Objective: This study aimed to evaluate the effectiveness of mHealth interventions on eHealth literacy among patients with chronic diseases based on randomized controlled trials (RCTs) and summarize supportive evidence from quasi-experimental and qualitative studies. Methods: A comprehensive search strategy was developed, and 8 electronic databases were systematically searched for studies published up to February 12, 2026. Patients with chronic diseases were included based on predefined inclusion criteria. The Cochrane risk of bias 2 tool for RCTs and the ROBINS-I tool for quasi-experimental studies were used to assess the risk of bias. Given the anticipated substantial heterogeneity among the studies included, we used a random-effects model based on the Hartung-Knapp-Sidik-Jonkman method to pool effect sizes. A narrative and quantitative synthesis of the findings was provided where appropriate. Results: A total of 15 studies were included in this review, including 6 RCTs, 5 quasi-experimental studies, and 4 qualitative studies, involving a total of 2884 patients with chronic diseases. Meta-analyses of RCTs suggested that mHealth interventions could improve eHealth literacy, with a pooled mean effect size of standardized mean difference (SMD)=1. 19 (95% CI 0.14-2.23; .03; =97.75%; PI [prediction interval]=−2.68 to 5.05). Subgroup analyses by intervention targets showed that interventions on targets with specific disease produced larger mean effects (SMD=1.61; 95% CI 0.16-3.06; PI=−5.40 to 8.63), while interventions targeting the population with general chronic diseases produced smaller effects (SMD=0.36; 95% CI 0-0. 73; PI=−0. 21 to 0. 94). Analysis by intervention duration subgroup showed that the combined effect of studies with intervention duration <3 months was statistically significant (SMD=0.61; 95% CI 0.09-1.13; =88.04%; PI=−5.72 to 6.95); while the combined effect of studies with intervention duration ≥3 months was not statistically significant. Taking into account bias and the risk of GRADE (Grading of Recommendations, Assessment, Development, and Evaluation), the certainty of RCT evidence was moderate, and the certainty of quasi-experimental evidence was low. Conclusions: mHealth interventions could improve eHealth literacy among patients with chronic diseases on average. By using prediction intervals, this study reveals that the effectiveness of mHealth interventions is highly context-dependent and closely linked to implementation factors. Advancing beyond prior work, this study centers on eHealth literacy as a core outcome and integrates multiple types of evidence. Meanwhile, this finding emphasizes the need for evidence-based intervention programs and more rigorous implementation of intervention designs in future research. Trial Registration: PROSPERO CRD 42024622807; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024622807

  • J Med Internet Res 2026;28(1):e82004

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  Peer-to-Peer Support and Online...

  Apr 17, 2026

  A Peer-Led, Nurse-Involved Blended Online and Offline Peer Support Program (PNO2PSP) for Psychosocial Adjustment in Young- to Middle-Aged Patients With...

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  Authors List:

  • Yiheng Zhang  
  • Haiyan He  
  • Ye Zhang  
  • Youxian Zhong  
  • Chunhong Luo  
  • Juanjuan Chen  
  • Lili Chen  
  • Ni Zhang  
  • Shihao Sun  
  • Baoyi Zhang  
  • Jia Fang  
  • Jingwen Yan  
  • Meifen Zhang  

  Abstract:

  Background: Young- to middle-aged patients with breast cancer face significant psychosocial challenges. Existing interventions often lack comprehensiveness, timely initiation, and tailoring specific to this population’s unique needs. Objective: This study aimed to evaluate the impact of a peer-led, nurse-involved, blended online and offline peer support intervention program (PNO2PSP) on psychosocial adjustment in young- to middle-aged patients with breast cancer. Methods: The effectiveness of PNO2PSP was evaluated through a single-center cluster randomized controlled trial involving 70 newly diagnosed young- to middle-aged patients with breast cancer (35 in each group). The intervention group received an 8-week PNO2PSP in addition to routine care. Psychosocial adjustment, self-efficacy, social support, and coping modes were assessed presurgery and at 4, 8, and 12 weeks post surgery. Generalized estimating equations were used for intention-to-treat analyses. In-depth interviews with 9 participants explored their experiences. Results: Compared to the control group, the intervention group demonstrated significantly lower psychosocial adjustment scores at 8 weeks (T2; Wald =14.96; <.001) and 12 weeks (T3; Wald =7.49; =.006); social support was higher at 8 weeks (T2; Wald =7.65; =.006). Confrontation coping scores were higher at T2 (Wald =5.46; =.02), T3 (Wald =10.04; =.002), while avoidance coping scores were lower at T1 (Wald =8.24; =.004), T2 (Wald =7.45; =.006), and T3 (Wald =5.70; =.02). Qualitative findings supported these quantitative results, highlighting the program’s role in facilitating psychosocial adjustment, providing vital support, boosting treatment confidence, and fostering positive coping. Conclusions: The PNO2PSP effectively improved psychosocial adjustment, social support, and positive coping in young- to middle-aged patients with breast cancer. Its scientifically validated, feasible, and patient-centered design supports its recommendation for wider clinical implementation, with continued training for peer supporters and sustained delivery of peer support. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300076471; https://www.chictr.org.cn/showprojEN.html?proj=198622

  • J Med Internet Res 2026;28(1):e86097

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  News and Perspectives

  Apr 17, 2026

  The Need for Continued Investment in Digital Pain Assessment

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  • Vanessa Nirode

  Abstract:

  • J Med Internet Res 2026;28(1):e97777

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  Digital Mental Health Interventions,...

  Apr 17, 2026

  Long-Term Outcomes, Moderators, and Predictors in Online Mindfulness–Based Cognitive Therapy for People With Cancer: Secondary Analysis of a Randomized...

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  Authors List:

  • Nasim Badaghi  
  • Jelle Lubbers  
  • Judith Prins  
  • Saskia Kelders  
  • Anne Speckens  
  • Linda Kwakkenbos  

  Abstract:

  Background: A 3-armed randomized controlled trial (RCT) demonstrated that 2 formats of online mindfulness–based cognitive therapy (eMBCT)—group-blended and individual-unguided—effectively reduced psychological distress and improved positive health outcomes in people with cancer and survivors, when compared to care as usual, up to 3 months posttreatment. However, the long-term effectiveness and possible predictors and moderators of treatment outcomes remain unknown. Objective: This study examined the long-term effects (up to 9 months posttreatment) of group-blended and individual-unguided eMBCTs on psychological distress and other mental health outcomes in people with cancer. Additionally, it explored possible predictors and moderators of treatment effects across the 2 delivery formats. Methods: The study population consisted of people with cancer who were initially randomized to group-blended or individual-unguided eMBCT within a 3-arm RCT, augmented by those who completed the waitlist condition and were subsequently randomly allocated to one of the eMBCT formats. Both groups were assessed over a 9-month follow-up period. Outcomes completed at baseline, posttreatment, and 3-, 6-, and 9-month follow-up assessments included psychological distress (primary), fear of cancer recurrence, rumination, fatigue, mindfulness skills, decentering, self-compassion, and well-being. Linear mixed-effects models examined changes over time, while linear mixed-effects models and binary logistic regression analyzed potential predictors and moderators of psychological distress and dropout. Results: Of the 186 participants enrolled in the 3-arm RCT, 161 participants were randomly assigned to either group-blended or individual-unguided eMBCTs after adding those initially assigned to the waiting condition (group-blended: n=71; individual-unguided: n=90). The majority of participants were female (n=129, 80%), diagnosed with breast cancer (n=78, 48%), and were undergoing or had completed treatment with curative intent (n=124, 77%). The mean age was 52.8 (SD 11.4) years. Both eMBCT formats resulted in significant reductions in psychological distress, fear of cancer recurrence, rumination, and fatigue, alongside improvements in mindfulness skills, decentering, and self-compassion, up to 9 months posttreatment. Higher baseline rumination, as well as lower mindfulness skills and self-compassion at baseline, predicted larger reductions in psychological distress from baseline to the 9-month follow-up period. Additionally, highly distressed participants in the group-blended eMBCT arm were more prone to dropout than those with lower distress scores, whereas psychological distress was not associated with dropout in the individual-unguided format. No other significant moderators were identified. Conclusions: Group-blended and individual-unguided eMBCTs effectively reduced psychological distress and improved well-being among people with cancer and survivors, with greater benefits for those with fewer psychological resources. However, individuals experiencing higher levels of distress were more likely to discontinue group-blended eMBCT. These findings highlight the importance of considering individual preferences and pragmatic factors in treatment decisions. Larger, fully powered RCTs are needed to confirm these results and provide more definitive guidance on treatment format selection. Trial Registration: Dutch Registry CCMO NL73117.091.20; https://onderzoekmetmensen.nl/en/trial/49163 and ClinicalTrials.gov NCT05336916; https://clinicaltrials.gov/study/NCT05336916

  • J Med Internet Res 2026;28(1):e79928

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  Digital Health Reviews

  Apr 17, 2026

  Multimodal Intelligent Monitoring of Parkinson Disease: Scoping Review of Progress and Translational Challenges

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  Authors List:

  • Jianhui Tan  
  • Xiuzhen Deng  
  • Cuilan Wu  
  • Molin Yao  
  • Jingyi Liao  
  • Haoli Zheng  
  • Changlin Lian  

  Abstract:

  Background: Parkinson disease (PD) is a progressive neurodegenerative disorder with a rapidly growing global prevalence. Current clinical assessments, such as the Unified Parkinson Disease Rating Scale, are limited by subjectivity and episodic application, creating a need for continuous, objective monitoring solutions. While previous reviews have often focused on single technologies, there is a growing trend toward integrating multiple data sources to provide a more holistic view of PD. Objective: This scoping review synthesizes progress in multimodal intelligent monitoring systems for PD, focusing on the quantification of motor and nonmotor symptoms, algorithm development, and the clinical translation of remote monitoring platforms. Furthermore, we propose a novel heuristic framework (Care-Platform Transformation in PD [CPT-PD]) that provides a forward-looking conceptual design for integrating these technologies into clinical workflows, demonstrating promising potential for future development. Methods: A targeted literature search was conducted on August 15, 2025, in PubMed, Web of Science, and China National Knowledge Infrastructure for research published between January 1, 2019, and December 31, 2024. The final search was rerun on January 22, 2026, solely to ensure completeness of coverage for this time window; no articles published after December 31, 2024, were included. Results: Wearable sensors (n=9) demonstrated high concordance with clinical scores in validation studies (eg, 99% for tremor detection), while computer vision (n=6) achieved moderate agreement with clinician ratings in controlled assessments (intraclass correlation coefficient 0.74 for bradykinesia). For nonmotor symptoms, intelligent systems (n=7) demonstrated sleep disturbance detection with up to 92.9% accuracy and autonomic dysfunction monitoring (n=7) via heart rate variability (area under the curve 0.90) and voice analysis (94.55% accuracy). Algorithm studies (n=16) explored single-modality feature extraction and cross-modal fusion, with emerging applications in federated learning. Remote platforms (n=22) improved medication adherence (172/201, 85.6%) and reduced outpatient visits (by 29% in one study). A heuristic CPT-PD framework was proposed to integrate key components of diagnosis, treatment, and management. Collectively, these advancements demonstrate the technical viability and clinical benefits of shifting from episodic, subjective assessments toward a data-driven, continuous, and multimodal approach to PD management. Conclusions: While current evidence largely reflects multisensor systems rather than deeply integrated multimodal platforms, the field holds promise for advancing toward genuine data fusion that could further improve clinical decision-making. Persistent challenges include fragmented symptom focus, algorithmic heterogeneity, and barriers to adoption among older adults. Future efforts should build on integrated frameworks such as CPT-PD to develop patient-centered ecosystems, ultimately enabling precision medicine in PD management.

  • J Med Internet Res 2026;28(1):e89057

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  E-Health / Health Services Research...

  Apr 17, 2026

  Facility-Level Associations Between Use of a Digital Health Platform for Voluntary Counseling and Testing and HIV Testing Outcomes in the Urban Primary...

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  Authors List:

  • Ye Chen  
  • Yu-Fei Wang  
  • Yu-Zhou Gu  
  • Xiao-Ru Fan  
  • Yong-Heng Lu  
  • Ju-Shuang Li  
  • Jun Wang  
  • Zhi-Ye Lin  
  • Chun-Li Zhang  
  • Meng-Die Li  
  • Ning-Jun Ren  
  • Zhi-Zhong Luo  
  • Rui-Fei Zuo  
  • Fu-Chuan Xiong  
  • Yu-Tong Kang  
  • Xiu-Rong Lin  
  • Chun Hao  

  Abstract:

  Background: WellTest, a digital health platform designed to facilitate HIV voluntary counseling and testing (VCT) services, has been widely implemented in Guangzhou, China. However, the extent of its use by primary health care centers (PHCs) and the facility-level associations between WellTest use and HIV testing outcomes remain unclear. Objective: This study aimed to assess the use of WellTest at the facility level across PHCs in urban Guangzhou, China, and to explore the associations between WellTest use and HIV testing outcomes. Methods: We obtained data on VCT services visits from the National HIV/AIDS Prevention and Control Information System and the WellTest platform between January 1 and December 31, 2022. Two facility-level HIV testing outcomes, the HIV testing volume and HIV positivity rate, were calculated for each PHC. A structured questionnaire collected data on the PHCs’ characteristics. Multilevel negative binomial regression and zero-inflated gamma models were used to examine associations between WellTest use and 2 HIV testing outcomes at the facility level. Results: A total of 81 PHCs across 5 urban districts in Guangzhou were included. WellTest was used for 7997 active consultations and 7969 HIV tests that resulted in 157 newly diagnosed HIV cases, for an overall positivity rate of 2.0%, during 2022. The median share of clients booking via WellTest was 71% (IQR 34%-98%), and 81% (66/81) of PHCs offered online slots on all service days without mandates. PHCs that actively confirmed appointments had significantly lower HIV testing volumes compared with those that took no actions after clients scheduled appointments (incidence rate ratio 0.75, 95% CI 0.58-0.97; P=.03) but exhibited higher HIV positivity rates (β=.39, 95% CI 0.02-0.76; P=.04). Additionally, PHCs where ≥50% of clients used WellTest to schedule appointments showed higher HIV positivity rates than those with lower uptake (β=1.11; 95% CI 0.82-1.40; P<.001). Conclusions: WellTest showed substantial use among VCT clients and providers in urban Guangzhou PHCs, with greater use of digital appointments and counselor follow-up linked to increased HIV positivity rates. Strategies to optimize institutional adoption may help address stigma-related barriers, strengthen engagement in HIV testing, and support HIV case finding in primary health care settings.

  • J Med Internet Res 2026;28(1):e83662

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  Digital Mental Health Interventions,...

  Apr 16, 2026

  Identifying Evidence-Based Strategies in a Digital Mental Health Intervention for Depression: Qualitative Content Analysis

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  Authors List:

  • Geneva K Jonathan  
  • Jenna Y Sung  
  • Heyli T Arcese  
  • Phoebe Holz  
  • Kathryn H Bentley  
  • Emily E Bernstein  
  • Hilary M Weingarden  
  • Jennifer L Greenberg  
  • Oliver T Harrison  
  • Sabine Wilhelm  

  Abstract:

  Background: Depression is one of the leading causes of disability worldwide. Cognitive behavioral therapy (CBT) is an effective treatment, but it is difficult to access due to clinician shortages, waitlists, and logistical barriers. Smartphone-based CBT interventions offer a scalable alternative to traditional face-to-face care, but few provide transparency regarding how closely they adhere to evidence-based therapeutic principles. Understanding what therapeutic components are included in interventions helps clinicians and patients determine whether they follow CBT principles and how they might help reduce depressive symptoms. Objective: This study aimed to characterize the therapeutic content of Mindset (Koa Health), a therapist-guided smartphone intervention for depression, by identifying the core CBT techniques it delivers and the specific behavioral strategies the app uses to put those techniques into practice. Methods: A qualitative content analysis was conducted on all 393 unique intervention pages of Mindset. Using established CBT strategy definitions and the behavior change technique (BCT) Taxonomy version 1 (BCTTv1), coders independently evaluated each page using a collaborative consensus approach. Interrater agreement was 93.75% for CBT and 93.62% for BCT coding. Descriptive statistics (frequency, mean, and SD) and overlap between the two were calculated. Results: All 16 core CBT techniques were identified. CBT techniques were used a total of 528 times (mean per module 66.0, SD 56.0). The most frequently used techniques included psychoeducation (164/325, 50.5% of pages), skill building (110/325, 33.8%), cognitive restructuring (46/325, 14.2%), activity scheduling (42/325, 12.9%), and self-monitoring (39/325, 12%). Across modules, 37 of 93 possible BCTs were coded 878 times (mean per module 109.8, SD 92.0) across 13 of 16 BCTTv1 categories. The most frequently applied BCT categories were shaping knowledge (205/325, 63.1% of pages), repetition and substitution (138/325, 42.5%), and feedback and monitoring (113/325, 34.8%). Overlap between the 2 frameworks was common, with the most frequent CBT-BCT pairings being psychoeducation (CBT technique)×Shaping knowledge (BCT category; appearing together on 119 pages), skill building×Shaping knowledge (80 pages), activity scheduling×Shaping knowledge (42 pages), and activity scheduling×Repetition and substitution (42 pages). Conclusions: Mindset demonstrates coverage of CBT techniques and alignment with evidence-based BCTs. This study is the first to introduce mechanism mapping, a dual-coding approach that describes the presence of therapeutic strategies and how they are behaviorally operationalized, addressing a gap in digital mental health transparency. Unlike existing content evaluations that use presence or absence checklists, our framework captures implementation depth through systematic documentation of behavioral scaffolding. This replicable methodology enables researchers to evaluate therapeutic fidelity, supports clinicians in making evidence-informed recommendations for digital mental health treatments, and provides a foundation for the development of adaptive interventions that can enhance real-world treatment outcomes for individuals with depression.

  • J Med Internet Res 2026;28(1):e84030

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