%0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e26528 %T User Engagement and Clinical Impact of the Manage My Pain App in Patients With Chronic Pain: A Real-World, Multi-site Trial %A Bhatia,Anuj %A Kara,Jamal %A Janmohamed,Tahir %A Prabhu,Atul %A Lebovic,Gerald %A Katz,Joel %A Clarke,Hance %+ Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, McL 2-405, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada, 1 4166035800 ext 6136, anuj.bhatia@uhn.ca %K pain %K psychology %K patient-oriented research %K quality of life %K digital health %K chronic pain %K pain app %K virtual care %K mHealth %K pain management %K chronic disease management %K remote monitoring %K app %K engagement %K impact %K outcome %D 2021 %7 4.3.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Chronic pain imposes a large burden on individuals and society. A patient-centric digital chronic pain management app called Manage My Pain (MMP) can be used to enhance communication between providers and patients and promote self-management. Objective: The purpose of this study was to evaluate the real-world engagement of patients in urban and rural settings in Ontario, Canada with the MMP app alongside their standard of care and assess the impact of its usage on clinical outcomes of pain and related mental health. Methods: A total of 246 participants with chronic pain at a rural and 2 urban pain clinics were recruited into this prospective, open-label, exploratory study that compared the use of MMP, a digital health app for pain that incorporates validated questionnaires and provides patients with summarized reports of their progress in combination with standard care (app group), against data entered on paper-based questionnaires (nonapp group). Participants completed validated questionnaires on anxiety, depression, pain catastrophizing, satisfaction, and daily opioid consumption up to 4.5 months after the initial visit (short-term follow-up) and between 4.5 and 7 months after the initial visit (long-term follow-up). Engagement and clinical outcomes were compared between participants in the two groups. Results: A total of 73.6% (181/246) of the participants agreed to use the app, with 63.4% (111/175) of them using it for at least one month. Individuals who used the app rated lower anxiety (reduction in Generalized Anxiety Disorder 7-item questionnaire score by 2.10 points, 95% CI –3.96 to –0.24) at short-term follow-up and had a greater reduction in pain catastrophizing (reduction in Pain Catastrophizing Scale score by 5.23 points, 95% CI –9.55 to –0.91) at long-term follow-up relative to patients with pain who did not engage with the MMP app. Conclusions: The use of MMP by patients with chronic pain is associated with engagement and improvements in self-reported anxiety and pain catastrophizing. Further research is required to understand factors that impact continued engagement and clinical outcomes in patients with chronic pain. Trial Registration: ClinicalTrials.gov NCT04762329; https://clinicaltrials.gov/ct2/show/NCT04762329 %M 33661130 %R 10.2196/26528 %U https://mhealth.jmir.org/2021/3/e26528 %U https://doi.org/10.2196/26528 %U http://www.ncbi.nlm.nih.gov/pubmed/33661130 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e21795 %T Attitudes of General Practitioners Toward Prescription of Mobile Health Apps: Qualitative Study %A Sarradon-Eck,Aline %A Bouchez,Tiphanie %A Auroy,Lola %A Schuers,Matthieu %A Darmon,David %+ Aix Marseille University, INSERM, IRD, SESSTIM, UMR1252-CanBios-SESSTIM, 232 Bb Ste Marguerite, Marseille, 13009, France, 33 4 91 22 33 09, aline.sarradon@inserm.fr %K mobile applications %K qualitative research %K general practitioners %K France %K mobile phone %D 2021 %7 4.3.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) apps are a potential means of empowering patients, especially in the case of multimorbidity, which complicates patients’ care needs. Previous studies have shown that general practitioners (GPs) have both expectations and concerns regarding patients’ use of mHealth apps that could impact their willingness to recommend the apps to patients. Objective: The aim of this qualitative study is to investigate French GPs’ attitudes toward the prescription of mHealth apps or devices aimed toward patients by analyzing GPs’ perceptions and expectations of mHealth technologies. Methods: A total of 36 GPs were interviewed individually (n=20) or in a discussion group (n=16). All participants were in private practice. A qualitative analysis of each interview and focus group was conducted using grounded theory analysis. Results: Considering the value assigned to mHealth apps by participants and their willingness or resistance to prescribe them, 3 groups were defined based on the attitudes or positions adopted by GPs: digital engagement (favorable attitude; mHealth apps are perceived as additional resources and complementary tools that facilitate the medical work, the follow-up care, and the monitoring of patients; and apps increase patients’ compliance and empowerment); patient protection (related to the management of patient care and fear of risks for patients, concerns about patient data privacy and security, doubt about the usefulness for empowering patients, standardization of the medical decision process, overmedicalization, risks for individual freedom, and increasing social inequalities in health); doctor protection (fear of additional tasks and burden, doubt about the actionability of patient-gathered health data, risk for medical liability, dehumanization of the patient-doctor relationship, fear of increased drug prescription, and commodification of patient data). Conclusions: A deep understanding of both the expectations and fears of GPs is essential to motivate them to recommend mHealth apps to their patients. The results of this study show the need to provide appropriate education and training to enhance GPs’ digital skills. Certification of the apps by an independent authority should be encouraged to reassure physicians about ethical and data security issues. Our results highlight the need to overcome technical issues such as interoperability between data collection and medical records to limit the disruption of medical work because of data flow. %M 33661123 %R 10.2196/21795 %U https://mhealth.jmir.org/2021/3/e21795 %U https://doi.org/10.2196/21795 %U http://www.ncbi.nlm.nih.gov/pubmed/33661123 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 3 %P e20175 %T Medical Food Assessment Using a Smartphone App With Continuous Glucose Monitoring Sensors: Proof-of-Concept Study %A Roux de Bézieux,Hector %A Bullard,James %A Kolterman,Orville %A Souza,Michael %A Perraudeau,Fanny %+ Pendulum Therapeutics, Inc, 933 20th Street, San Francisco, CA, 94107, United States, 1 650 276 6517, fanny.perraudeau@pendulum.co %K clinical trials %K continuous glucose monitoring %K lifestyle modification %K mobile app %K telemedicine %K diabetes %D 2021 %7 4.3.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Novel wearable biosensors, ubiquitous smartphone ownership, and telemedicine are converging to enable new paradigms of clinical research. A new generation of continuous glucose monitoring (CGM) devices provides access to clinical-grade measurement of interstitial glucose levels. Adoption of these sensors has become widespread for the management of type 1 diabetes and is accelerating in type 2 diabetes. In parallel, individuals are adopting health-related smartphone-based apps to monitor and manage care. Objective: We conducted a proof-of-concept study to investigate the potential of collecting robust, annotated, real-time clinical study measures of glucose levels without clinic visits. Methods: Self-administered meal-tolerance tests were conducted to assess the impact of a proprietary synbiotic medical food on glucose control in a 6-week, double-blind, placebo-controlled, 2×2 cross-over pilot study (n=6). The primary endpoint was incremental glucose measured using Abbott Freestyle Libre CGM devices associated with a smartphone app that provided a visual diet log. Results: All subjects completed the study and mastered CGM device usage. Over 40 days, 3000 data points on average per subject were collected across three sensors. No adverse events were recorded, and subjects reported general satisfaction with sensor management, the study product, and the smartphone app, with an average self-reported satisfaction score of 8.25/10. Despite a lack of sufficient power to achieve statistical significance, we demonstrated that we can detect meaningful changes in the postprandial glucose response in real-world settings, pointing to the merits of larger studies in the future. Conclusions: We have shown that CGM devices can provide a comprehensive picture of glucose control without clinic visits. CGM device usage in conjunction with our custom smartphone app can lower the participation burden for subjects while reducing study costs, and allows for robust integration of multiple valuable data types with glucose levels remotely. Trial Registration: ClinicalTrials.gov NCT04424888; http://clinicaltrials.gov/ct2/show/NCT04424888. %M 33661120 %R 10.2196/20175 %U https://formative.jmir.org/2021/3/e20175 %U https://doi.org/10.2196/20175 %U http://www.ncbi.nlm.nih.gov/pubmed/33661120 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e26399 %T Health Care Students’ Knowledge of and Attitudes, Beliefs, and Practices Toward the French COVID-19 App: Cross-sectional Questionnaire Study %A Montagni,Ilaria %A Roussel,Nicolas %A Thiébaut,Rodolphe %A Tzourio,Christophe %+ Bordeaux Population Health Research Center, U1219, Bordeaux University, INSERM, 146 rue Léo Saignat, Bordeaux, 33000, France, 33 05 57 57 16 5, ilaria.montagni@u-bordeaux.fr %K contact tracing %K COVID-19 %K mobile app %K students %K field survey %K app %K survey %K monitoring %K knowledge %K attitude %K belief %K practice %K communication %K use %D 2021 %7 3.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Many countries worldwide have developed mobile phone apps capable of supporting instantaneous contact tracing to control the COVID-19 pandemic. In France, a few people have downloaded and are using the StopCovid contact tracing app. Students in the health domain are of particular concern in terms of app uptake. Exploring their use and opinions about the app can inform improvements and diffusion of StopCovid among young people. Objective: The aim of this study is to investigate health care students’ knowledge of and attitudes, beliefs, and practices (KABP) toward the StopCovid app. Methods: A field survey was conducted among 318 students at the health sciences campus of the University of Bordeaux, France, between September 25 and October 16, 2020. A quota sampling method was used, and descriptive statistics and univariate analyses were performed. Results: Of the 318 respondents, 77.3% (n=246) had heard about the app, but only 11.3% (n=36) had downloaded it, and 4.7% (n=15) were still using it at the time of the survey. Among the 210 participants who had heard about the app but did not download it, the main reasons for not using the app were a belief that it was not effective given its limited diffusion (n=37, 17.6%), a lack of interest (n=37, 17.6%), and distrust in the data security and fear of being geolocated (n=33, 15.7%). Among the 72 students who had not heard of the app and were given a brief description of its functioning and confidentiality policy, 52.7% (n=38) said they would use it. Participants reported that the main solution for increasing the use of the app would be better communication about it (227/318, 71.4%). Conclusions: Even among health students, the contact tracing app was poorly used. The findings suggest that improved communication about its advantages and simplicity of use as well as clarifying false beliefs about it could help improve uptake. %M 33566793 %R 10.2196/26399 %U https://www.jmir.org/2021/3/e26399 %U https://doi.org/10.2196/26399 %U http://www.ncbi.nlm.nih.gov/pubmed/33566793 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e26550 %T Digital Interventions to Support Population Mental Health in Canada During the COVID-19 Pandemic: Rapid Review %A Strudwick,Gillian %A Sockalingam,Sanjeev %A Kassam,Iman %A Sequeira,Lydia %A Bonato,Sarah %A Youssef,Alaa %A Mehta,Rohan %A Green,Nadia %A Agic,Branka %A Soklaridis,Sophie %A Impey,Danielle %A Wiljer,David %A Crawford,Allison %+ Centre for Addiction and Mental Health, 1001 Queen St W, Toronto, ON, M6J 1H4, Canada, 1 416 535 8501, gillian.strudwick@camh.ca %K digital health %K psychiatry %K mental health %K informatics %K pandemic %K COVID-19 %K telemedicine %K eHealth %K public health %K virtual care %K mobile apps %K population health %D 2021 %7 2.3.2021 %9 Review %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has resulted in a number of negative health related consequences, including impacts on mental health. More than 22% of Canadians reported that they had felt depressed in the last week, in response to a December 2020 national survey. Given the need to physically distance during the pandemic, and the increase in demand for mental health services, digital interventions that support mental health and wellness may be beneficial. Objective: The purpose of this research was to identify digital interventions that could be used to support the mental health of the Canadian general population during the COVID-19 pandemic. The objectives were to identify (1) the populations these interventions were developed for, inclusive of exploring areas of equity such as socioeconomic status, sex/gender, race/ethnicity and culture, and relevance to Indigenous peoples and communities; (2) the effect of the interventions; and (3) any barriers or facilitators to the use of the intervention. Methods: This study was completed using a Cochrane Rapid Review methodology. A search of Embase, PsycInfo, Medline, and Web of Science, along with Google, Million Short, and popular mobile app libraries, was conducted. Two screeners were involved in applying inclusion criteria using Covidence software. Academic articles and mobile apps identified were screened using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields resource, the American Psychiatric Association App Evaluation Framework, and the Mental Health Commission of Canada’s guidance on app assessment and selection. Results: A total of 31 mobile apps and 114 web-based resources (eg, telemedicine, virtual peer support groups, discussion forums, etc) that could be used to support the mental health of the Canadian population during the pandemic were identified. These resources have been listed on a publicly available website along with search tags that may help an individual make a suitable selection. Variability exists in the populations that the interventions were developed for, and little assessment has been done with regard to areas of equity. The effect of the interventions was not reported for all those identified in this synthesis; however, for those that did report the effect, it was shown that they were effective in the context that they were used. A number of barriers and facilitators to using these interventions were identified, such as access, cost, and connectivity. Conclusions: A number of digital interventions that could support population mental health in Canada during the global COVID-19 pandemic were identified, indicating that individuals have several options to choose from. These interventions vary in their purpose, approach, design, cost, and targeted user group. While some research and digital interventions addressed equity-related considerations, more research and focused attention should be given to this area. %M 33650985 %R 10.2196/26550 %U https://mental.jmir.org/2021/3/e26550 %U https://doi.org/10.2196/26550 %U http://www.ncbi.nlm.nih.gov/pubmed/33650985 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 3 %P e19832 %T Characterizing Emotional State Transitions During Prolonged Use of a Mindfulness and Meditation App: Observational Study %A Athanas,Argus %A McCorrison,Jamison %A Campistron,Julie %A Bender,Nick %A Price,Jamie %A Smalley,Susan %A Schork,Nicholas J %+ Department of Quantitative Medicine, The Translational Genomics Research Institute, An Affiliate of the City of Hope National Medical Center, Translational Genomics Research Institute Headquarters, 445 N Fifth Street, Phoenix, AZ, 85004, United States, 1 602 343 8429, nschork@tgen.org %K mental health %K mobile apps %K smartphone %K mobile phone %K emotional distress %K mindfulness %D 2021 %7 2.3.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: The increasing demand for mental health care, a lack of mental health care providers, and unequal access to mental health care services have created a need for innovative approaches to mental health care. Digital device apps, including digital therapeutics, that provide recommendations and feedback for dealing with stress, depression, and other mental health issues can be used to adjust mood and ultimately show promise to help meet this demand. In addition, the recommendations delivered through such apps can also be tailored to an individual’s needs (ie, personalized) and thereby potentially provide greater benefits than traditional “one-size-fits-all” recommendations. Objective: This study aims to characterize individual transitions from one emotional state to another during the prolonged use of a digital app designed to provide a user with guided meditations based on their initial, potentially negative, emotional state. Understanding the factors that mediate such transitions can lead to improved recommendations for specific mindfulness and meditation interventions or activities (MMAs) provided in mental health apps. Methods: We analyzed data collected during the use of the Stop, Breathe & Think (SBT) mindfulness app. The SBT app prompts users to input their emotional state before and immediately after engaging with MMAs recommended by the app. Data were collected from more than 650,000 SBT users engaging in nearly 5 million MMAs. We limited the scope of our analysis to users with 10 or more MMA sessions that included at least 6 basal emotional state evaluations. Using clustering techniques, we grouped emotions recorded by individual users and then applied longitudinal mixed effect models to assess the associations between individual recommended MMAs and transitions from one group of emotions to another. Results: We found that basal emotional states have a strong influence on transitions from one emotional state to another after MMA engagement. We also found that different MMAs impact these transitions, and many were effective in eliciting a healthy transition but only under certain conditions. In addition, we observed gender and age effects on these transitions. Conclusions: We found that the initial emotional state of an SBT app user determines the type of SBT MMAs that will have a favorable effect on their transition from one emotional state to another. Our results have implications for the design and use of guided mental health recommendations for digital device apps. %M 33650986 %R 10.2196/19832 %U https://mental.jmir.org/2021/3/e19832 %U https://doi.org/10.2196/19832 %U http://www.ncbi.nlm.nih.gov/pubmed/33650986 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e26559 %T Exploring Usage of COVID Coach, a Public Mental Health App Designed for the COVID-19 Pandemic: Evaluation of Analytics Data %A Jaworski,Beth K %A Taylor,Katherine %A Ramsey,Kelly M %A Heinz,Adrienne %A Steinmetz,Sarah %A Pagano,Ian %A Moraja,Giovanni %A Owen,Jason E %+ National Center for PTSD, Dissemination & Training Division, US Department of Veterans Affairs, 795 Willow Road, Menlo Park, CA, 94025, United States, 1 650 308 9437, beth.jaworski@va.gov %K COVID-19 %K coronavirus %K mobile app %K mHealth %K digital health %K mental health %K public mental health %K stress %K coping %K public health %K app %D 2021 %7 1.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has significantly impacted mental health and well-being. Mobile mental health apps can be scalable and useful tools in large-scale disaster responses and are particularly promising for reaching vulnerable populations. COVID Coach is a free, evidence-informed mobile app designed specifically to provide tools and resources for addressing COVID-19–related stress. Objective: The purpose of this study was to characterize the overall usage of COVID Coach, explore retention and return usage, and assess whether the app was reaching individuals who may benefit from mental health resources. Methods: Anonymous usage data collected from COVID Coach between May 1, 2020, through October 31, 2020, were extracted and analyzed for this study. The sample included 49,287 unique user codes and 3,368,931 in-app events. Results: Usage of interactive tools for coping and stress management comprised the majority of key app events (n=325,691, 70.4%), and the majority of app users tried a tool for managing stress (n=28,009, 58.8%). COVID Coach was utilized for ≤3 days by 80.9% (n=34,611) of the sample whose first day of app use occurred within the 6-month observation window. Usage of the key content in COVID Coach predicted returning to the app for a second day. Among those who tried at least one coping tool on their first day of app use, 57.2% (n=11,444) returned for a second visit; whereas only 46.3% (n=10,546) of those who did not try a tool returned (P<.001). Symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) were prevalent among app users. For example, among app users who completed an anxiety assessment on their first day of app use (n=4870, 11.4% of users), 55.1% (n=2680) reported levels of anxiety that were moderate to severe, and 29.9% (n=1455) of scores fell into the severe symptom range. On average, those with moderate levels of depression on their first day of app use returned to the app for a greater number of days (mean 3.72 days) than those with minimal symptoms (mean 3.08 days; t1=3.01, P=.003). Individuals with significant PTSD symptoms on their first day of app use utilized the app for a significantly greater number of days (mean 3.79 days) than those with fewer symptoms (mean 3.13 days; t1=2.29, P=.02). Conclusions: As the mental health impacts of the pandemic continue to be widespread and increasing, digital health resources, such as apps like COVID Coach, are a scalable way to provide evidence-informed tools and resources. Future research is needed to better understand for whom and under what conditions the app is most helpful and how to increase and sustain engagement. %M 33606656 %R 10.2196/26559 %U https://www.jmir.org/2021/3/e26559 %U https://doi.org/10.2196/26559 %U http://www.ncbi.nlm.nih.gov/pubmed/33606656 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e20989 %T The Reliability of Remote Patient-Reported Outcome Measures via Mobile Apps to Replace Outpatient Visits After Rotator Cuff Repair Surgery: Repetitive Test-Retest Comparison Study for 1-Year Follow-up %A Hong,Taek Ho %A Kim,Myung Ku %A Ryu,Dong Jin %A Park,Jun Sung %A Bae,Gi Cheol %A Jeon,Yoon Sang %+ Department of Orthopedic Surgery, Inha University Hospital, 27 Inhang-ro, Jung-gu, Incheon, 22332, Republic of Korea, 82 010 8353 3695, ysjeon80@hanmail.net %K patient-reported outcome measures (PROMs) %K location %K remote PROMs using mobile application %K smartphone %K mobile phone %K follow-up loss %D 2021 %7 1.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: With the development of health care–related mobile apps, attempts have been made to implement remote patient-reported outcome measures (PROMs). In order for remote PROMs to be widely used by mobile apps, the results should not be different depending on the location; that is, remote PROM results performed in locations other than hospitals should be able to obtain reliable results equivalent to those performed in hospitals, and this is very important. However, to our knowledge, there are no studies that have assessed the reliability of PROMs using mobile apps according to the location by comparing the results performed remotely from the hospital and performed at the outpatient visits. Objective: The purpose of this study was to evaluate the reliability of remote PROMs using mobile apps compared to PROMs performed during outpatient follow-up visits after arthroscopic shoulder surgery. Methods: A total of 174 patients who underwent arthroscopic rotator cuff repair completed questionnaires 2 days before visiting the clinic for the 1-, 2-, 3-, 6-, and 12-month follow-ups (test A). The patients completed the questionnaires at the clinic (test B) using the same mobile app and device for the 1-, 2-, 3-, 6-, and 12-month follow-ups. Test-retest comparisons were performed to analyze the differences and reliability of the PROMs according to the period. Results: Comparisons of tests A and B showed statistically significant differences at 1, 2, and 3 months (all Ps<.05 except for the ASES function scale at 3-months) but not 6 or 12 months after surgery (all Ps>.05). The intraclass correlation values between the two groups were relatively low at the 1-, 2-, and 3-month follow-ups but were within the reliable range at 6 and 12 months after surgery. The rate of completion of tests A and B using the mobile app was significantly lower in the group older than 70 years than in the other groups for all postoperative periods (P<.001). Conclusions: PROMs using mobile apps with different locations differed soon after surgery but were reliably similar after 6 months. The remote PROMs using mobile apps could be used reliably for the patient more than 6 months after surgery. However, it is to be expected that the use of mobile app–based questionnaires is not as useful in the group older than 70 years as in other age groups. %M 33646133 %R 10.2196/20989 %U https://www.jmir.org/2021/3/e20989 %U https://doi.org/10.2196/20989 %U http://www.ncbi.nlm.nih.gov/pubmed/33646133 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 3 %P e18240 %T Delivering Perinatal Health Information via a Voice Interactive App (SMILE): Mixed Methods Feasibility Study %A Militello,Lisa %A Sezgin,Emre %A Huang,Yungui %A Lin,Simon %+ Martha S Pitzer Center for Women, Children & Youth, College of Nursing, The Ohio State University, 1585 Neil Ave, 145 Newton Hall, Columbus, OH, 43210, United States, 1 3128135007, militello.14@osu.edu %K perinatal care %K infant mortality %K health education %K mobile health %K feasibility studies %K family %K mobile phone %K webcasts as topic %K user-computer interface %D 2021 %7 1.3.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Perinatal health care is critically important for maternal health outcomes in infants. The United States fares considerably worse than comparable countries for maternal and infant mortality rates. As such, alternative models of care or engagement are warranted. Ubiquitous digital devices and increased use of digital health tools have the potential to extend the reach to women and infants in their everyday lives and make a positive impact on their health outcomes. As voice technology becomes more mainstream, research is prudent to establish evidence-based practice on how to best leverage voice technology to promote maternal-infant health. Objective: The aim of this study is to assess the feasibility of using voice technology to support perinatal health and infant care practices. Methods: Perinatal women were recruited from a large Midwest Children’s Hospital via hospital email announcements and word of mouth. Owing to the technical aspects of the intervention, participants were required to speak English and use an iPhone. Demographics, patterns of technology use, and technology use specific to perinatal health or self-care practices were assessed at baseline. Next, participants were onboarded and asked to use the intervention, Self-Management Intervention–Life Essentials (SMILE), over the course of 2 weeks. SMILE provided users with perinatal health content delivered through mini podcasts (ranging from 3 to 8 minutes in duration). After each podcast, SMILE prompted users to provide immediate verbal feedback to the content. An exit interview was conducted with participants to gather feedback on the intervention and further explore participants’ perceptions of voice technology as a means to support perinatal health in the future. Results: In total, 19 pregnant women (17 to 36 weeks pregnant) were consented. Themes identified as important for perinatal health information include establishing routines, expected norms, and realistic expectations and providing key takeaways. Themes identified as important for voice interaction include customization and user preferences, privacy, family and friends, and context and convenience. Qualitative analysis suggested that perinatal health promotion content delivered by voice should be accurate and succinctly delivered and highlight key takeaways. Perinatal health interventions that use voice should provide users with the ability to customize the intervention but also provide opportunities to engage family members, particularly spouses. As a number of women multitasked while the intervention was being deployed, future interventions should leverage the convenience of voice technology while also balancing the influence of user context (eg, timing or ability to listen or talk versus nonvoice interaction with the system). Conclusions: Our findings demonstrate the short-term feasibility of disseminating evidence-based perinatal support via podcasts and curate voice-captured data from perinatal women. However, key areas of improvement have been identified specifically for perinatal interventions leveraging voice technology. Findings contribute to future content, design, and delivery considerations of perinatal digital health interventions. %M 33646136 %R 10.2196/18240 %U https://formative.jmir.org/2021/3/e18240 %U https://doi.org/10.2196/18240 %U http://www.ncbi.nlm.nih.gov/pubmed/33646136 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e25289 %T Using Fitbit as an mHealth Intervention Tool to Promote Physical Activity: Potential Challenges and Solutions %A Balbim,Guilherme M %A Marques,Isabela G %A Marquez,David X %A Patel,Darshilmukesh %A Sharp,Lisa K %A Kitsiou,Spyros %A Nyenhuis,Sharmilee M %+ Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois at Chicago, 1919 W Taylor St (MC 530), Chicago, IL, 60612, United States, 1 312 355 3519, skitsiou@uic.edu %K physical activity %K fitness trackers %K Fitbit %K smartphones %K interventional studies %K adults %K older adults %K wearable %K intervention %D 2021 %7 1.3.2021 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Consumer-based physical activity (PA) trackers, also known as wearables, are increasingly being used in research studies as intervention or measurement tools. One of the most popular and widely used brands of PA trackers is Fitbit. Since the release of the first Fitbit in 2009, hundreds of experimental studies have used Fitbit devices to facilitate PA self-monitoring and behavior change via goal setting and feedback tools. Fitbit’s ability to capture large volumes of PA and physiological data in real time creates enormous opportunities for researchers. At the same time, however, it introduces a number of challenges (eg, technological, operational, logistical), most of which are not sufficiently described in study publications. Currently, there are no technical reports, guidelines, nor other types of publications discussing some of these challenges and offering guidance to researchers on how to best incorporate Fitbit devices in their study design and intervention to achieve their research goals. As a result, researchers are often left alone to discover and address some of these issues during the study through “trial and error.” This paper aims to address this gap. Drawing on our cumulative experience of conducting multiple studies with various Fitbit PA trackers over the years, we present and discuss various key challenges associated with the use of Fitbit PA trackers in research studies. Difficulties with the use of Fitbit PA trackers are encountered throughout the entire research process. Challenges and solutions are categorized in 4 main categories: study preparation, intervention delivery, data collection and analysis, and study closeout. Subsequently, we describe a number of empirically tested strategies used in 4 of our interventional studies involving participants from a broad range of demographic characteristics, racial/ethnic backgrounds, and literacy levels. Researchers should be prepared to address challenges and issues in a timely fashion to ensure that the Fitbit effectively assists participants and researchers in achieving research and outcome goals. %M 33646135 %R 10.2196/25289 %U https://mhealth.jmir.org/2021/3/e25289 %U https://doi.org/10.2196/25289 %U http://www.ncbi.nlm.nih.gov/pubmed/33646135 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e18853 %T Rural Residents’ Perspectives on an mHealth or Personalized Health Coaching Intervention: Qualitative Study With Focus Groups and Key Informant Interviews %A Schoenberg,Nancy %A Dunfee,Madeline %A Yeager,Hannah %A Rutledge,Matthew %A Pfammatter,Angela %A Spring,Bonnie %+ Department of Behavior Science, University of Kentucky, 760 Press Avenue, 372 Healthy Kentucky Research Building, Lexington, KY, 40536, United States, 1 859 323 8175, nesch@uky.edu %K rural populations %K technology %K exercise %K diet %K community-based participatory research %K mobile phone %D 2021 %7 26.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Compared with national averages, rural Appalachians experience extremely elevated rates of premature morbidity and mortality. New opportunities, including approaches incorporating personal technology, may help improve lifestyles and overcome health inequities. Objective: This study aims to gather perspectives on whether a healthy lifestyle intervention, specifically an app originally designed for urban users, may be feasible and acceptable to rural residents. In addition to a smartphone app, this program—Make Better Choices 2—consists of personalized health coaching, accelerometer use, and financial incentives. Methods: We convened 4 focus groups and 16 key informant interviews with diverse community stakeholders to assess perspectives on this novel, evidence-based diet and physical activity intervention. Participants were shown a slide presentation and asked open-ended follow-up questions. The focus group and key informant interview sessions were audiotaped, transcribed, and subjected to thematic analysis. Results: We identified 3 main themes regarding Appalachian residents’ perspectives on this mobile health (mHealth) intervention: personal technology is feasible and desirable; challenges persist in implementing mHealth lifestyle interventions in Appalachian communities; and successful mHealth interventions should include personal connections, local coaches, and educational opportunities. Although viewed as feasible and acceptable overall, lack of healthy lifestyle awareness, habitual behavior, and financial constraints may challenge the success of mHealth lifestyle interventions in Appalachia. Finally, participants described several minor elements that require modification, including expanding the upper age inclusion, providing extra coaching on technology use, emphasizing personal and supportive connections, employing local coaches, and ensuring adequate educational content for the program. Conclusions: Blending new technologies, health coaching, and other features is not only acceptable but may be essential to reach vulnerable rural residents. %M 33635278 %R 10.2196/18853 %U https://formative.jmir.org/2021/2/e18853 %U https://doi.org/10.2196/18853 %U http://www.ncbi.nlm.nih.gov/pubmed/33635278 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e26557 %T A Multimodal Mobile Sleep Intervention for Young Adults Engaged in Risky Drinking: Protocol for a Randomized Controlled Trial %A Fucito,Lisa M %A Ash,Garrett I %A DeMartini,Kelly S %A Pittman,Brian %A Barnett,Nancy P %A Li,Chiang-Shan R %A Redeker,Nancy S %A O'Malley,Stephanie S %+ Department of Psychiatry, Yale University School of Medicine, 20 York Street, Fitkin Building, F619, New Haven, CT, 06510, United States, 1 2032001470, lisa.fucito@yale.edu %K sleep %K binge drinking %K young adults %K mHealth %K biosensor %K behavior therapy %K mobile phone %D 2021 %7 26.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: This paper describes the research protocol for a randomized controlled trial of a multimodal mobile sleep intervention for heavy-drinking young adults. Young adults report the highest rates of heavy, risky alcohol consumption and are a priority population for alcohol prevention and intervention efforts. Alcohol strategies that leverage other health concerns and use technology may offer an innovative solution. Poor sleep is common among young adults and is a risk factor for developing an alcohol use disorder. Moreover, young adults are interested in information to help them sleep better, and behavioral sleep interventions address alcohol use as a standard practice. Objective: The primary aim of this study is to assess the effectiveness of a 2-week multimodal mobile sleep intervention for reducing drinks consumed per week among heavy-drinking young adults. We will explore the effects on alcohol-related consequences, assessing quantitative and qualitative sleep characteristics as secondary aims. The study’s goals are to identify the optimal combination of sleep intervention components for improving drinking outcomes, the feasibility and acceptability of these components, and the potential mechanisms by which these components may promote alcohol behavior change. Methods: Young adults (aged 18-25 years) who report recent heavy drinking will be randomly assigned to one of three conditions: mobile sleep hygiene advice (n=30), mobile sleep hygiene advice and sleep and alcohol diary self-monitoring (n=30), or mobile sleep hygiene advice, sleep and alcohol diary self-monitoring, and sleep and alcohol data feedback (n=60). For the feedback component, participants will complete two web-based sessions with a health coach during which they will receive summaries of their sleep and alcohol data, and the potential association between them along with brief advice tailored to their data. All participants will wear sleep and alcohol biosensors daily for 2 weeks for objective assessments of these outcomes. Results: The study was funded by the National Institutes of Health in May 2018. Recruitment began in December 2018 and will be concluded in Spring 2021. As of February 4, 2021, we have enrolled 110 participants. Conclusions: Ultimately, this research could result in an efficacious, low-cost intervention with broad population reach through the use of technology. In addition, this intervention may substantially impact public health by reducing alcohol use disorder risk at a crucial developmental stage. Trial Registration: ClinicalTrials.gov NCT03658954; https://clinicaltrials.gov/ct2/show/NCT03658954 International Registered Report Identifier (IRRID): DERR1-10.2196/26557 %M 33635276 %R 10.2196/26557 %U https://www.researchprotocols.org/2021/2/e26557 %U https://doi.org/10.2196/26557 %U http://www.ncbi.nlm.nih.gov/pubmed/33635276 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e17492 %T The Kurbo App: The Freemium Model and Developmental Behavior Concerns. Comment on “Impact of a Mobile App–Based Health Coaching and Behavior Change Program on Participant Engagement and Weight Status of Overweight and Obese Children: Retrospective Cohort Study” %A Vitolo,Marcia Regina %+ Federal University of Health Sciences of Porto Alegre, Rua Sarmento Leite 245, Porto Alegre, 90050170, Brazil, 55 1138651010, marciavitolo@hotmail.com %K childhood obesity %K intervention %K app %D 2021 %7 25.2.2021 %9 Letter to the Editor %J JMIR Mhealth Uhealth %G English %X %M 33629965 %R 10.2196/17492 %U https://mhealth.jmir.org/2021/2/e17492 %U https://doi.org/10.2196/17492 %U http://www.ncbi.nlm.nih.gov/pubmed/33629965 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e20445 %T Effects of Smartphone-Based Stress Management on Improving Work Engagement Among Nurses in Vietnam: Secondary Analysis of a Three-Arm Randomized Controlled Trial %A Sasaki,Natsu %A Imamura,Kotaro %A Tran,Thuy Thi Thu %A Nguyen,Huong Thanh %A Kuribayashi,Kazuto %A Sakuraya,Asuka %A Bui,Thu Minh %A Nguyen,Quynh Thuy %A Nguyen,Nga Thi %A Nguyen,Giang Thi Huong %A Zhang,Melvyn Weibin %A Minas,Harry %A Sekiya,Yuki %A Watanabe,Kazuhiro %A Tsutsumi,Akizumi %A Shimazu,Akihito %A Kawakami,Norito %+ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, , Japan, 81 3 5841 3522, nkawakami@m.u-tokyo.ac.jp %K stress management %K mental health %K occupational health %K digital health %K workplace %K LMICs %K South-East Asia %K health care professionals %D 2021 %7 23.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Work engagement is important for employee well-being and work performance. However, no intervention study has investigated the effect of an eMental Health intervention on work engagement among workers in low- and middle-income countries (LMICs). Objective: The aim of the study was to examine the effects of a newly developed smartphone-based stress management program (ABC Stress Management) on improving work engagement among hospital nurses in Vietnam, an LMIC. Methods: Full-time registered nurses (n=949) were randomly assigned to one of 2 intervention groups or a control group. The intervention groups were a 6-week, 6-lesson program offering basic cognitive behavioral therapy (CBT-based stress management skills), provided in either free-choice (program A) or fixed order (program B). Work engagement was assessed at baseline and 3-month and 7-month follow-ups in each of the 3 groups. Results: The scores of work engagement in both intervention groups improved from baseline to 3-month follow-up, and then decreased at the 7-month follow-up, while the score steadily increased from baseline to 7-month follow-up in the control group. Program B showed a significant intervention effect on improving work engagement at the 3-month follow-up (P=.049) with a small effect size (Cohen d= 0.16; 95% CI 0.001 to 0.43]). Program A showed nonsignificant trend (d=0.13; 95% CI –0.014 to 0.41; P=.07) toward improved engagement at 3 months. Neither program achieved effectiveness at the 7-month follow-up. Conclusions: The study demonstrated that a fixed order (program B) delivery of a smartphone-based stress management program was effective in improving work engagement in nurses in Vietnam. However, the effect was small and only temporary. Further improvement of this program is required to achieve a greater effect size and more sustained, longer lasting impact on work engagement. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000033139; tinyurl.com/55gxo253 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-025138 %M 33620328 %R 10.2196/20445 %U https://www.jmir.org/2021/2/e20445 %U https://doi.org/10.2196/20445 %U http://www.ncbi.nlm.nih.gov/pubmed/33620328 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e24452 %T A Mobile App to Facilitate Socially Distanced Hospital Communication During COVID-19: Implementation Experience %A Anyanwu,Emeka C %A Ward,R Parker %A Shah,Atman %A Arora,Vineet %A Umscheid,Craig A %+ Section of Cardiology, University of Chicago, 5841 S Maryland Avenue, Chicago, IL, 60637, United States, 1 (773) 834 0343, emeka@emeka.ca %K adoption %K communication %K COVID-19 %K hospital %K inpatient %K mHealth %K mobile app %K telemedicine %D 2021 %7 23.2.2021 %9 Short Paper %J JMIR Mhealth Uhealth %G English %X Background: COVID-19 has significantly altered health care delivery, requiring clinicians and hospitals to adapt to rapidly changing hospital policies and social distancing guidelines. At our large academic medical center, clinicians reported that existing information on distribution channels, including emails and hospital intranet posts, was inadequate to keep everyone abreast with these changes. To address these challenges, we adapted a mobile app developed in-house to communicate critical changes in hospital policies and enable direct telephonic communication between clinical team members and hospitalized patients, to support social distancing guidelines and remote rounding. Objective: This study aimed to describe the unique benefits and challenges of adapting an app developed in-house to facilitate communication and remote rounding during COVID-19. Methods: We adapted moblMD, a mobile app available on the iOS and Android platforms. In conjunction with our Hospital Incident Command System, resident advisory council, and health system innovation center, we identified critical, time-sensitive policies for app usage. A shared collaborative document was used to align app-based communication with more traditional communication channels. To minimize synchronization efforts, we particularly focused on high-yield policies, and the time of last review and the corresponding reviewer were noted for each protocol. To facilitate social distancing and remote patient rounding, the app was also populated with a searchable directory of numbers to patient bedside phones and hospital locations. We monitored anonymized user activity from February 1 to July 31, 2020. Results: On its first release, 1104 clinicians downloaded moblMD during the observation period, of which 46% (n=508) of downloads occurred within 72 hours of initial release. COVID-19 policies in the app were reviewed most commonly during the first week (801 views). Users made sustained use of hospital phone dialing features, including weekly peaks of 2242 phone number dials, 1874 directory searches, and 277 patient room phone number searches through the last 2 weeks of the observation period. Furthermore, clinicians submitted 56 content- and phone number–related suggestions through moblMD. Conclusions: We rapidly developed and deployed a communication-focused mobile app early during COVID-19, which has demonstrated initial and sustained value among clinicians in communicating with in-patients and each other during social distancing. Our internal innovation benefited from our team’s familiarity with institutional structures, short feedback loops, limited security and privacy implications, and a path toward sustainability provided by our innovation center. Challenges in content management were overcome through synchronization efforts and timestamping review. As COVID-19 continues to alter health care delivery, user activity metrics suggest that our solution will remain important in our efforts to continue providing safe and up-to-date clinical care. %M 33513562 %R 10.2196/24452 %U https://mhealth.jmir.org/2021/2/e24452 %U https://doi.org/10.2196/24452 %U http://www.ncbi.nlm.nih.gov/pubmed/33513562 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e23737 %T Implementation of a Newborn Clinical Decision Support Software (NoviGuide) in a Rural District Hospital in Eastern Uganda: Feasibility and Acceptability Study %A Muhindo,Mary %A Bress,Joshua %A Kalanda,Rogers %A Armas,Jean %A Danziger,Elon %A Kamya,Moses R %A Butler,Lisa M %A Ruel,Theodore %+ UCSF Preterm Birth Initiative, University of California San Francisco School of Medicine, 550 16th Street, 3rd Floor, San Francisco, CA, 94158, United States, 1 788551502, marymkakuru@gmail.com %K clinical decision support %K neonatology %K neonatal mortality %K mHealth %K mobile phone %D 2021 %7 19.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Lack of trained health care workers and nonadherence to national guidelines are key barriers to achieving high-quality newborn care in health care facilities in low- and middle-income countries. Traditional didactic approaches addressing these barriers fail to account for high staff turnover rates and result in temporary behavior change. NoviGuide, a clinical decision support software designed to standardize neonatal care through point-of-care assessments, has the potential to align bedside practice to national guidelines in settings lacking subspecialty neonatal providers. Objective: This study aims to determine the adaptation, adoption, feasibility, acceptability, and sustainability of NoviGuide and its impact on nurse-midwives’ knowledge in a rural hospital in eastern Uganda. Methods: This mixed methods observational study was guided by the Proctor framework. Experts reviewed the clinical content of NoviGuide to ensure fidelity to Uganda guidelines. We enrolled nurses and midwives providing newborn care at Tororo District Hospital, trained them on NoviGuide use, and followed them for 12 months. We assessed adoption, feasibility, acceptability, and sustainability by analyzing NoviGuide use data, comparing it with maternity registry data and administering the System Usability Scale (SUS) and the Center for Health Care Evaluation Provider Satisfaction Questionnaire. We compared the mean knowledge assessment score at baseline, 6 months, and 12 months using a two-tailed t test. Results: Five Ugandan experts suggested two minor changes to NoviGuide: the inclusion of an unsterile birth environment as an indication for empiric antibiotics and the addition of a reminder to follow-up with newborns with temperatures between 37.7°C and 37.9°C. Of the 19 nurse-midwives enrolled in February 2017, 74% (n=14) completed the follow-up in March 2018. The participants entered a total of 1705 assessments of varying newborn characteristics into NoviGuide throughout the day, evening, and night nursing shifts. The SUS score at the end of the study was very high (93.5, above the average of 68). Participants had a positive perception about NoviGuide, reporting that NoviGuide saved time (mean 5, SD 0) and prevented mistakes (mean 5, SD 0), and that they felt more confident in taking care of newborns when they used NoviGuide (mean 5, SD 0). Participants were highly satisfied with NoviGuide (mean 4.86, SD 0.36), although they lacked medical supplies and materials needed to follow NoviGuide recommendations (mean 3.3, SD 1.22). The participants’ knowledge scores improved by a mean change of 3.7 (95% CI 2.6-4.8) at 6 months and 6.7 (95% CI 4.6-8.2) at 12 months (P<.001). Conclusions: NoviGuide was easily adapted to the Uganda guidelines. Nurse-midwives used NoviGuide frequently and reported high levels of satisfaction despite challenges with medical supplies and high staff turnover. NoviGuide improved knowledge and confidence in newborn care without in-person didactic training. NoviGuide use has the potential to scale up quality newborn care by facilitating adherence to national guidelines. %M 33605886 %R 10.2196/23737 %U http://mhealth.jmir.org/2021/2/e23737/ %U https://doi.org/10.2196/23737 %U http://www.ncbi.nlm.nih.gov/pubmed/33605886 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e25451 %T Simple Smartphone-Based Assessment of Gait Characteristics in Parkinson Disease: Validation Study %A Su,Dongning %A Liu,Zhu %A Jiang,Xin %A Zhang,Fangzhao %A Yu,Wanting %A Ma,Huizi %A Wang,Chunxue %A Wang,Zhan %A Wang,Xuemei %A Hu,Wanli %A Manor,Brad %A Feng,Tao %A Zhou,Junhong %+ Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Roslindale, MA, 02131, United States, 1 6179715346, junhongzhou@hsl.harvard.edu %K smartphone %K gait %K stride time (variability) %K validity %K Parkinson disease %D 2021 %7 19.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Parkinson disease (PD) is a common movement disorder. Patients with PD have multiple gait impairments that result in an increased risk of falls and diminished quality of life. Therefore, gait measurement is important for the management of PD. Objective: We previously developed a smartphone-based dual-task gait assessment that was validated in healthy adults. The aim of this study was to test the validity of this gait assessment in people with PD, and to examine the association between app-derived gait metrics and the clinical and functional characteristics of PD. Methods: Fifty-two participants with clinically diagnosed PD completed assessments of walking, Movement Disorder Society Unified Parkinson Disease Rating Scale III (UPDRS III), Montreal Cognitive Assessment (MoCA), Hamilton Anxiety (HAM-A), and Hamilton Depression (HAM-D) rating scale tests. Participants followed multimedia instructions provided by the app to complete two 20-meter trials each of walking normally (single task) and walking while performing a serial subtraction dual task (dual task). Gait data were simultaneously collected with the app and gold-standard wearable motion sensors. Stride times and stride time variability were derived from the acceleration and angular velocity signal acquired from the internal motion sensor of the phone and from the wearable sensor system. Results: High correlations were observed between the stride time and stride time variability derived from the app and from the gold-standard system (r=0.98-0.99, P<.001), revealing excellent validity of the app-based gait assessment in PD. Compared with those from the single-task condition, the stride time (F1,103=14.1, P<.001) and stride time variability (F1,103=6.8, P=.008) in the dual-task condition were significantly greater. Participants who walked with greater stride time variability exhibited a greater UPDRS III total score (single task: β=.39, P<.001; dual task: β=.37, P=.01), HAM-A (single-task: β=.49, P=.007; dual-task: β=.48, P=.009), and HAM-D (single task: β=.44, P=.01; dual task: β=.49, P=.009). Moreover, those with greater dual-task stride time variability (β=.48, P=.001) or dual-task cost of stride time variability (β=.44, P=.004) exhibited lower MoCA scores. Conclusions: A smartphone-based gait assessment can be used to provide meaningful metrics of single- and dual-task gait that are associated with disease severity and functional outcomes in individuals with PD. %M 33605894 %R 10.2196/25451 %U http://mhealth.jmir.org/2021/2/e25451/ %U https://doi.org/10.2196/25451 %U http://www.ncbi.nlm.nih.gov/pubmed/33605894 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e24893 %T Access to Technology and Preferences for an mHealth Intervention to Promote Medication Adherence in Pediatric Acute Lymphoblastic Leukemia: Approach Leveraging Behavior Change Techniques %A Heneghan,Mallorie B %A Hussain,Tasmeen %A Barrera,Leonardo %A Cai,Stephanie W %A Haugen,Maureen %A Morgan,Elaine %A Rossoff,Jenna %A Weinstein,Joanna %A Hijiya,Nobuko %A Cella,David %A Badawy,Sherif M %+ Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, 100 N Mario Capecchi Drive, Salt Lake City, UT, 84113, United States, 1 801 662 4700, Mallorie.Heneghan@hsc.utah.edu %K acute lymphoblastic leukemia %K medication adherence %K behavior change technique %K oral chemotherapy %K mHealth %K patient-centered %D 2021 %7 18.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Suboptimal adherence to 6-mercaptopurine (6-MP) is prevalent in pediatric acute lymphoblastic leukemia (ALL) and associated with increased risk of relapse. Rapid uptake of personal technology makes mobile health (mHealth) an attractive platform to promote adherence. Objective: Study objectives were to examine access to mobile technology and preferences for an mHealth intervention to improve medication adherence in pediatric ALL. Methods: A cross-sectional survey was administered in oncology clinic to parents of children with ALL as well as adolescents and young adults (AYAs) with ALL receiving maintenance chemotherapy. Results: A total of 49 parents (median age [IQR] 39 [33-42] years; female 76% [37/49]) and 15 patients (median age [IQR] 17 [16-19]; male 80% [12/15]) participated. All parents and AYAs owned electronic tablets, smartphones, or both. Parents’ most endorsed mHealth app features included a list of medications (71%, 35/49), information about 6-MP (71%, 35/49), refill reminders (71%, 35/49), and reminders to take 6-MP (71%, 35/49). AYAs' most endorsed features included refill reminders (73%, 11/15), reminders to take 6-MP (73%, 11/15), and tracking 6-MP (73%, 11/15). Conclusions: Parents and AYAs reported ubiquitous access to mobile technology and strong interest in multiple adherence-specific mHealth app features. Parents and AYAs provided valuable insight into preferred features for a multifunctional behavioral intervention (mHealth app) to promote medication adherence in pediatric ALL. %M 33599621 %R 10.2196/24893 %U http://www.jmir.org/2021/2/e24893/ %U https://doi.org/10.2196/24893 %U http://www.ncbi.nlm.nih.gov/pubmed/33599621 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e24607 %T Framework for the Design Engineering and Clinical Implementation and Evaluation of mHealth Apps for Sleep Disturbance: Systematic Review %A Aji,Melissa %A Gordon,Christopher %A Stratton,Elizabeth %A Calvo,Rafael A %A Bartlett,Delwyn %A Grunstein,Ronald %A Glozier,Nick %+ Brain and Mind Center, The University of Sydney, Level 5, Professor Marie Bashir Centre, Missenden Road, Camperdown, 2050, Australia, 61 29515 1596, nick.glozier@sydney.edu.au %K mobile applications %K sleep %K insomnia %K internet-based intervention %K mHealth %K mobile health %K systematic review %D 2021 %7 17.2.2021 %9 Review %J J Med Internet Res %G English %X Background: Mobile health (mHealth) apps offer a scalable option for treating sleep disturbances at a population level. However, there is a lack of clarity about the development and evaluation of evidence-based mHealth apps. Objective: The aim of this systematic review was to provide evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance. Methods: A systematic search of studies published from the inception of databases through February 2020 was conducted using 5 databases (MEDLINE, Embase, Cochrane Library, PsycINFO, and CINAHL). Results: A total of 6015 papers were identified using the search strategy. After screening, 15 papers were identified that examined the design engineering and clinical implementation and evaluation of 8 different mHealth apps for sleep disturbance. Most of these apps delivered cognitive behavioral therapy for insomnia (CBT-I, n=4) or modified CBT-I (n=2). Half of the apps (n=4) identified adopting user-centered design or multidisciplinary teams in their design approach. Only 3 papers described user and data privacy. End-user acceptability and engagement were the most frequently assessed implementation metrics. Only 1 app had available evidence assessing all 4 implementation metrics (ie, acceptability, engagement, usability, and adherence). Most apps were prototype versions (n=5), with few matured apps. A total of 6 apps had supporting papers that provided a quantitative evaluation of clinical outcomes, but only 1 app had a supporting, adequately powered randomized controlled trial. Conclusions: This is the first systematic review to synthesize and examine evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance. The minimal number of apps with published evidence for design engineering and clinical implementation and evaluation contrasts starkly with the number of commercial sleep apps available. Moreover, there appears to be no standardization and consistency in the use of best practice design approaches and implementation assessments, along with very few rigorous efficacy evaluations. To facilitate the development of successful and evidence-based apps for sleep disturbance, we developed a high-level framework to guide researchers and app developers in the end-to-end process of app development and evaluation. %M 33595441 %R 10.2196/24607 %U http://www.jmir.org/2021/2/e24607/ %U https://doi.org/10.2196/24607 %U http://www.ncbi.nlm.nih.gov/pubmed/33595441 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e20700 %T Sociodemographic, Health and Lifestyle, Sampling, and Mental Health Determinants of 24-Hour Motor Activity Patterns: Observational Study %A Difrancesco,Sonia %A Riese,Harriëtte %A Merikangas,Kathleen R %A Shou,Haochang %A Zipunnikov,Vadim %A Antypa,Niki %A van Hemert,Albert M %A Schoevers,Robert A %A Penninx,Brenda W J H %A Lamers,Femke %+ Amsterdam Public Health Research Institute, Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Oldenaller 1, Amsterdam, 1078XL, Netherlands, 31 643193730, s.difrancesco@ggzingeest.nl %K actigraphy %K functional data analysis %K mental health %K well-being %K activity %D 2021 %7 17.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Analyzing actigraphy data using standard circadian parametric models and aggregated nonparametric indices may obscure temporal information that may be a hallmark of the circadian impairment in psychiatric disorders. Functional data analysis (FDA) may overcome such limitations by fully exploiting the richness of actigraphy data and revealing important relationships with mental health outcomes. To our knowledge, no studies have extensively used FDA to study the relationship between sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics and daily motor activity patterns assessed with actigraphy in a sample of individuals with and without depression/anxiety. Objective: We aimed to study the association between daily motor activity patterns assessed via actigraphy and (1) sociodemographic, health and lifestyle, and sampling factors, and (2) psychiatric clinical characteristics (ie, presence and severity of depression/anxiety disorders). Methods: We obtained 14-day continuous actigraphy data from 359 participants from the Netherlands Study of Depression and Anxiety with current (n=93), remitted (n=176), or no (n=90) depression/anxiety diagnosis, based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Associations between patterns of daily motor activity, quantified via functional principal component analysis (fPCA), and sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics were assessed using generalized estimating equation regressions. For exploratory purposes, function-on-scalar regression (FoSR) was applied to quantify the time-varying association of sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics on daily motor activity. Results: Four components of daily activity patterns captured 77.4% of the variability in the data: overall daily activity level (fPCA1, 34.3% variability), early versus late morning activity (fPCA2, 16.5% variability), biphasic versus monophasic activity (fPCA3, 14.8% variability), and early versus late biphasic activity (fPCA4, 11.8% variability). A low overall daily activity level was associated with a number of sociodemographic, health and lifestyle, and psychopathology variables: older age (P<.001), higher education level (P=.005), higher BMI (P=.009), greater number of chronic diseases (P=.02), greater number of cigarettes smoked per day (P=.02), current depressive and/or anxiety disorders (P=.05), and greater severity of depressive symptoms (P<.001). A high overall daily activity level was associated with work/school days (P=.02) and summer (reference: winter; P=.03). Earlier morning activity was associated with older age (P=.02), having a partner (P=.009), work/school days (P<.001), and autumn and spring (reference: winter; P=.02 and P<.001, respectively). Monophasic activity was associated with older age (P=.005). Biphasic activity was associated with work/school days (P<.001) and summer (reference: winter; P<.001). Earlier biphasic activity was associated with older age (P=.005), work/school days (P<.001), and spring and summer (reference: winter; P<.001 and P=.005, respectively). In FoSR analyses, age, work/school days, and season were the main determinants having a time-varying association with daily motor activity (all P<.05). Conclusions: Features of daily motor activity extracted with fPCA reflect commonly studied factors such as the intensity of daily activity and preference for morningness/eveningness. The presence and severity of depression/anxiety disorders were found to be associated mainly with a lower overall activity pattern but not with the time of the activity. Age, work/school days, and season were the variables most strongly associated with patterns and time of activity, and thus future epidemiological studies on motor activity in depression/anxiety should take these variables into account. %M 33595445 %R 10.2196/20700 %U http://www.jmir.org/2021/2/e20700/ %U https://doi.org/10.2196/20700 %U http://www.ncbi.nlm.nih.gov/pubmed/33595445 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e20329 %T Induction of Efficacy Expectancies in an Ambulatory Smartphone-Based Digital Placebo Mental Health Intervention: Randomized Controlled Trial %A Stalujanis,Esther %A Neufeld,Joel %A Glaus Stalder,Martina %A Belardi,Angelo %A Tegethoff,Marion %A Meinlschmidt,Gunther %+ Department of Clinical Psychology and Cognitive Behavioral Therapy, International Psychoanalytic University Berlin, Stromstraße 1, Berlin, 10555, Germany, 49 30 300117 710, gunther.meinlschmidt@ipu-berlin.de %K digital placebo effect %K efficacy expectancies %K ecological momentary assessment %K mHealth %K mobile phone %K placebo effect %K randomized controlled trial %K smartphone-based intervention %D 2021 %7 17.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is certain evidence on the efficacy of smartphone-based mental health interventions. However, the mechanisms of action remain unclear. Placebo effects contribute to the efficacy of face-to-face mental health interventions and may also be a potential mechanism of action in smartphone-based interventions. Objective: This study aimed to investigate whether different types of efficacy expectancies as potential factors underlying placebo effects could be successfully induced in a smartphone-based digital placebo mental health intervention, ostensibly targeting mood and stress. Methods: We conducted a randomized, controlled, single-blinded, superiority trial with a multi-arm parallel design. Participants underwent an Android smartphone-based digital placebo mental health intervention for 20 days. We induced prospective efficacy expectancies via initial instructions on the purpose of the intervention and retrospective efficacy expectancies via feedback on the success of the intervention at days 1, 4, 7, 10, and 13. A total of 132 healthy participants were randomized to a prospective expectancy–only condition (n=33), a retrospective expectancy–only condition (n=33), a combined expectancy condition (n=34), or a control condition (n=32). As the endpoint, we assessed changes in efficacy expectancies with the Credibility Expectancy Questionnaire, before the intervention and on days 1, 7, 14, and 20. For statistical analyses, we used a random effects model for the intention-to-treat sample, with intervention day as time variable and condition as two factors: prospective expectancy (yes vs no) and retrospective expectancy (yes vs no), allowed to vary over participant and intervention day. Results: Credibility (β=−1.63; 95% CI −2.37 to −0.89; P<.001) and expectancy (β=−0.77; 95% CI −1.49 to −0.05; P=.04) decreased across the intervention days. For credibility and expectancy, we found significant three-way interactions: intervention day×prospective expectancy×retrospective expectancy (credibility: β=2.05; 95% CI 0.60-3.50; P=.006; expectancy: β=1.55; 95% CI 0.14-2.95; P=.03), suggesting that efficacy expectancies decreased least in the combined expectancy condition and the control condition. Conclusions: To our knowledge, this is the first empirical study investigating whether efficacy expectancies can be successfully induced in a specifically designed placebo smartphone-based mental health intervention. Our findings may pave the way to diminish or exploit digital placebo effects and help to improve the efficacy of digital mental health interventions. Trial Registration: Clinicaltrials.gov NCT02365220; https://clinicaltrials.gov/ct2/show/NCT02365220. %M 33594991 %R 10.2196/20329 %U http://mhealth.jmir.org/2021/2/e20329/ %U https://doi.org/10.2196/20329 %U http://www.ncbi.nlm.nih.gov/pubmed/33594991 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e18288 %T Acceptability of a Mobile Health Behavior Change Intervention for Cancer Survivors With Obesity or Overweight: Nested Mixed Methods Study Within a Randomized Controlled Trial %A Groarke,Jenny M %A Richmond,Janice %A Mc Sharry,Jenny %A Groarke,AnnMarie %A Harney,Owen M %A Kelly,Mary Grace %A Walsh,Jane C %+ Centre for Improving Health-Related Quality of Life, School of Psychology, Queen's University Belfast, 18-30 Malone Road, Belfast, BT71NN, United Kingdom, 44 28 90974886, j.groarke@qub.ac.uk %K mHealth %K self-management %K text messaging %K activity tracker %K exercise %K diet %K overweight %K obesity %K cancer survivors %K qualitative research %K mobile phone %D 2021 %7 16.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A significant proportion of cancer survivors have overweight or obesity. Although this has negative implications for health, weight management is not a standard component of oncology aftercare. Mobile health (mHealth) technology, in combination with behavior change techniques (BCTs), has the potential to support positive lifestyle changes. Few studies have been carried out with cancer survivors; therefore, the acceptability of these tools and techniques requires further investigation. Objective: The aim of this study is to examine the acceptability of a behavior change intervention using mHealth for cancer survivors with a BMI of 25 or more and to gather constructive feedback from participants. Methods: The intervention consisted of educational sessions and an 8-week physical activity goal setting intervention delivered using mobile technology (ie, Fitbit activity monitor plus SMS contact). In the context of a two-arm randomized controlled trial, semistructured interviews were conducted to assess the retrospective acceptability of the intervention from the perspective of the recipients. The theoretical framework for the acceptability of health care interventions was used to inform a topic guide. The interviews were transcribed and analyzed using thematic analysis. A quantitative survey was also conducted to determine the acceptability of the intervention. A total of 13 participants were interviewed, and 36 participants completed the quantitative survey. Results: The results strongly support the acceptability of the intervention. The majority of the survey respondents held a positive attitude toward the intervention (35/36, 97%). In qualitative reports, many of the intervention components were enjoyed and the mHealth components (ie, Fitbit and goal setting through text message contact) were rated especially positively. Responses were mixed as to whether the burden of participating in the intervention was high (6/36, 17%) or low (5/36, 14%). Participants perceived the intervention as having high efficacy in improving health and well-being (34/36, 94%). Most respondents said that they understood how the intervention works (35/36, 97%), and qualitative data show that participants’ understanding of the aim of the intervention was broader than weight management and focused more on moving on psychologically from cancer. Conclusions: On the basis of the coherence of responses with theorized aspects of intervention acceptability, we are confident that this intervention using mHealth and BCTs is acceptable to cancer survivors with obesity or overweight. Participants made several recommendations concerning the additional provision of social support. Future studies are needed to assess the feasibility of delivery in clinical practice and the acceptability of the intervention to those delivering the intervention. International Registered Report Identifier (IRRID): RR2-10.2196/13214 %M 33591290 %R 10.2196/18288 %U http://mhealth.jmir.org/2021/2/e18288/ %U https://doi.org/10.2196/18288 %U http://www.ncbi.nlm.nih.gov/pubmed/33591290 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e23912 %T mHealth Strategies Related to HIV Postexposure Prophylaxis Knowledge and Access: Systematic Literature Review, Technology Prospecting of Patent Databases, and Systematic Search on App Stores %A Queiroz,Artur Acelino Francisco Luz Nunes %A Mendes,Isabel Amélia Costa %A de Godoy,Simone %A Velez Lapão,Luís %A Dias,Sónia %+ Department of General and Specialized Nursing, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, R Prof Hélio Lourenço, 3900 - Vila Monte Alegre, Ribeirão Preto, 14040-902, Brazil, 55 16 3315 4321, arturqueiroz@usp.br %K HIV %K eHealth %K mHealth %K postexposure prophylaxis %K PEP %K prevention %K mobile phone %D 2021 %7 16.2.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Globally, the number of HIV cases continue to increase, despite the development of multiple prevention strategies. New cases of HIV have been reported disproportionately more in men who have sex with men and other vulnerable populations. Issues such as internalized and structural homophobia prevent these men from accessing prevention strategies such as postexposure prophylaxis (PEP). Mobile health (mHealth) interventions are known to be one of the newest and preferred options to enhance PEP knowledge and access. Objective: The aim of this study was to identify and analyze the mobile apps addressing PEP for HIV infections. Methods: We conducted a descriptive exploratory study in 3 sequential phases: systematic literature review, patent analysis, and systematic search of app stores. For the systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines adapted for an integrative review in the databases of PubMed, Web of Knowledge, Scopus, Cochrane, Embase, Science Direct, Eric, Treasure, and CINAHL. The patent analysis was performed by exploring the databases of the Brazilian National Institute of Industrial Property, the United States Patent and Trademark Office, and the European Patent Office. For the systematic search, we analyzed mHealth apps related to HIV in 2 major app libraries, that is, Google Play Store and App Store. The apps were evaluated by name, characteristics, functions, and availability in iPhone operating system/Android phones. Results: We analyzed 22 studies, of which 2 were selected for the final stage. Both studies present the use of apps as mHealth strategies aimed at improving the sexual health of men who have sex with men, and they were classified as decision support systems. The search in the patent databases showed only 1 result, which was not related to the topic since it was a drug intervention. In the app libraries, 25 apps were found and analyzed, with 15 (60%) apps available for Android systems but only 3 (12%) addressing PEP. In general, the apps inform about HIV and HIV prevention and treatment, with the focus users being health care providers, people with HIV, or the general population, but they have only limited features available, that is, mainly text, images, and videos. The 3 apps exclusively focusing on PEP were created by researchers from Brazilian universities. Conclusions: Our review found no connection between the scientific studies, registered patents, and the available apps related to PEP; this finding indicates that these available apps do not have a theoretical or a methodological background in their creation. Thus, since the scientific knowledge on HIV is not translated into technological products, preventing the emergence of new infections, especially in the more vulnerable groups, is difficult. In the future, researchers and the community must work in synergy to create more mHealth tools aimed at PEP. %M 33591289 %R 10.2196/23912 %U http://mhealth.jmir.org/2021/2/e23912/ %U https://doi.org/10.2196/23912 %U http://www.ncbi.nlm.nih.gov/pubmed/33591289 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e25655 %T Development and Validation of Risk Scores for All-Cause Mortality for a Smartphone-Based “General Health Score” App: Prospective Cohort Study Using the UK Biobank %A Clift,Ashley K %A Le Lannou,Erwann %A Tighe,Christian P %A Shah,Sachin S %A Beatty,Matthew %A Hyvärinen,Arsi %A Lane,Stephen J %A Strauss,Tamir %A Dunn,Devin D %A Lu,Jiahe %A Aral,Mert %A Vahdat,Dan %A Ponzo,Sonia %A Plans,David %+ Huma Therapeutics, 13th Floor Millbank Tower, 21-24 Millbank, London, United Kingdom, 44 7527 016574, david.plans@huma.com %K C-Score %K mortality %K risk score %K smartphone %K health score %K medical informatics %K public health %K mobile health %K development %K validation %K app %K prospective %K cohort %K machine learning %D 2021 %7 16.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Given the established links between an individual’s behaviors and lifestyle factors and potentially adverse health outcomes, univariate or simple multivariate health metrics and scores have been developed to quantify general health at a given point in time and estimate risk of negative future outcomes. However, these health metrics may be challenging for widespread use and are unlikely to be successful at capturing the broader determinants of health in the general population. Hence, there is a need for a multidimensional yet widely employable and accessible way to obtain a comprehensive health metric. Objective: The objective of the study was to develop and validate a novel, easily interpretable, points-based health score (“C-Score”) derived from metrics measurable using smartphone components and iterations thereof that utilize statistical modeling and machine learning (ML) approaches. Methods: A literature review was conducted to identify relevant predictor variables for inclusion in the first iteration of a points-based model. This was followed by a prospective cohort study in a UK Biobank population for the purposes of validating the C-Score and developing and comparatively validating variations of the score using statistical and ML models to assess the balance between expediency and ease of interpretability and model complexity. Primary and secondary outcome measures were discrimination of a points-based score for all-cause mortality within 10 years (Harrell c-statistic) and discrimination and calibration of Cox proportional hazards models and ML models that incorporate C-Score values (or raw data inputs) and other predictors to predict the risk of all-cause mortality within 10 years. Results: The study cohort comprised 420,560 individuals. During a cohort follow-up of 4,526,452 person-years, there were 16,188 deaths from any cause (3.85%). The points-based model had good discrimination (c-statistic=0.66). There was a 31% relative reduction in risk of all-cause mortality per decile of increasing C-Score (hazard ratio of 0.69, 95% CI 0.663-0.675). A Cox model integrating age and C-Score had improved discrimination (8 percentage points; c-statistic=0.74) and good calibration. ML approaches did not offer improved discrimination over statistical modeling. Conclusions: The novel health metric (“C-Score”) has good predictive capabilities for all-cause mortality within 10 years. Embedding the C-Score within a smartphone app may represent a useful tool for democratized, individualized health risk prediction. A simple Cox model using C-Score and age balances parsimony and accuracy of risk predictions and could be used to produce absolute risk estimations for app users. %M 33591285 %R 10.2196/25655 %U http://mhealth.jmir.org/2021/2/e25655/ %U https://doi.org/10.2196/25655 %U http://www.ncbi.nlm.nih.gov/pubmed/33591285 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e23477 %T Effectiveness of Disease-Specific mHealth Apps in Patients With Diabetes Mellitus: Scoping Review %A Eberle,Claudia %A Löhnert,Maxine %A Stichling,Stefanie %+ Medicine with Specialization in Internal Medicine and General Medicine, Hochschule Fulda–University of Applied Sciences, Leipziger Strasse 123, Fulda, 36037, Germany, 49 661 9649 ext 6328, claudia.eberle@hs-fulda.de %K diabetes mellitus %K mobile apps %K mHealth apps %K medical apps %D 2021 %7 15.2.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: According to the World Health Organization, the worldwide prevalence of diabetes mellitus (DM) is increasing dramatically and DM comprises a large part of the global burden of disease. At the same time, the ongoing digitalization that is occurring in society today offers novel possibilities to deal with this challenge, such as the creation of mobile health (mHealth) apps. However, while a great variety of DM-specific mHealth apps exist, the evidence in terms of their clinical effectiveness is still limited. Objective: The objective of this review was to evaluate the clinical effectiveness of mHealth apps in DM management by analyzing health-related outcomes in patients diagnosed with type 1 DM (T1DM), type 2 DM (T2DM), and gestational DM. Methods: A scoping review was performed. A systematic literature search was conducted in MEDLINE (PubMed), Cochrane Library, EMBASE, CINAHL, and Web of Science Core Collection databases for studies published between January 2008 and October 2020. The studies were categorized by outcomes and type of DM. In addition, we carried out a meta-analysis to determine the impact of DM-specific mHealth apps on the management of glycated hemoglobin (HbA1c). Results: In total, 27 studies comprising 2887 patients were included. We analyzed 19 randomized controlled trials, 1 randomized crossover trial, 1 exploratory study, 1 observational study, and 5 pre-post design studies. Overall, there was a clear improvement in HbA1c values in patients diagnosed with T1DM and T2DM. In addition, positive tendencies toward improved self-care and self-efficacy as a result of mHealth app use were found. The meta-analysis revealed an effect size, compared with usual care, of a mean difference of –0.54% (95% CI –0.8 to –0.28) for T2DM and –0.63% (95% CI –0.93 to –0.32) for T1DM. Conclusions: DM-specific mHealth apps improved the glycemic control by significantly reducing HbA1c values in patients with T1DM and T2DM patients. In general, mHealth apps effectively enhanced DM management. However, further research in terms of clinical effectiveness needs to be done in greater detail. %M 33587045 %R 10.2196/23477 %U http://mhealth.jmir.org/2021/2/e23477/ %U https://doi.org/10.2196/23477 %U http://www.ncbi.nlm.nih.gov/pubmed/33587045 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e25578 %T Durability of Abstinence After Completing a Comprehensive Digital Smoking Cessation Program Incorporating a Mobile App, Breath Sensor, and Coaching: Cohort Study %A Marler,Jennifer D %A Fujii,Craig A %A Galanko,Joseph A %A Balbierz,Daniel J %A Utley,David S %+ Carrot Inc., 1400A Seaport Blvd, Suite 501, Redwood City, CA, 94063, United States, 1 415 757 7696, marler@carrot.co %K smoking cessation %K digital health %K smartphone %K digital sensor %K carbon monoxide %K breath sensor %K biofeedback %K mobile apps %K health promotion %K app %D 2021 %7 15.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite decreasing prevalence over the last several decades, cigarette smoking remains the leading cause of preventable death and disease, underscoring the need for innovative, effective solutions. Pivot is a novel, inclusive smoking cessation program designed for smokers along the entire spectrum of readiness to quit. Pivot leverages proven methods and technological advancements, including a personal portable breath carbon monoxide sensor, smartphone app, and in-app text-based coaching. We previously reported outcomes from the end of active Pivot program participation in 319 adult smokers. Herein, we report longer-term follow up in this cohort. Objective: The aim of this study was to assess and report participant outcomes 3 months after completion of Pivot, including smoking behavior, quit rates, continuous abstinence rates and durability, and predictors of abstinence. Methods: This prospective remote cohort study included US-based cigarette smokers aged 18 to 65 years who smoked ≥5 cigarettes per day (CPD). Three months after completion of active participation in Pivot, final follow-up data were collected via an online questionnaire. Outcomes included smoking behavior (CPD and quit attempts), self-reported quit rates (7- and 30-day point prevalence abstinence [PPA]), and continuous abstinence rates (proportion who achieved uninterrupted abstinence) and duration. Exploratory regression analyses were performed to identify baseline characteristics associated with achievement of 7-day PPA, 30-day PPA, and continuous abstinence. Results: A total of 319 participants completed onboarding (intention-to-treat [ITT]); 288/319 participants (90.3%) completed follow up (completers) at a mean of 7.2 (SD 1.2) months after onboarding. At final follow up, CPD were reduced by 52.6% (SE 2.1; P<.001) among all 319 participants, and most completers (152/288, 52.8%) reduced their CPD by at least 50%. Overall, most completers (232/288, 80.6%) made at least one quit attempt. Quit rates increased after the end of Pivot; using ITT analyses, 35.4% (113/319) achieved 7-day PPA and 31.3% (100/319) achieved 30-day PPA at final follow up compared with 32.0% (102/319) and 27.6% (88/319), respectively, at the end of the Pivot program. Continuous abstinence was achieved in about a quarter of those who onboarded (76/319, 23.8%) and in most who reported 30-day PPA at the end of Pivot (76/88, 86.4%), with a mean abstinence duration of 5.8 (SD 0.6) months. In exploratory regression analyses, lower baseline CPD, more positive baseline attitudes reflecting higher self-efficacy (higher confidence to quit and lower perceived difficulty of quitting), and higher education were associated with achieving abstinence. Conclusions: This study provides the first longer-term outcomes of the Pivot smoking cessation program. At final follow up, quit rates increased and continuous abstinence was favorable; the majority who achieved abstinence at the end of Pivot sustained abstinence throughout follow up. Decreases in CPD persisted and most participants made a quit attempt. Overall, final follow-up outcomes were stable or improved when compared to previous outcomes from the end of the program. These findings validate earlier results, and suggest that Pivot is an effective and durable solution for smoking cessation. Trial Registration: ClinicalTrials.gov NCT03295643; https://clinicaltrials.gov/ct2/show/NCT03295643 %M 33482628 %R 10.2196/25578 %U http://www.jmir.org/2021/2/e25578/ %U https://doi.org/10.2196/25578 %U http://www.ncbi.nlm.nih.gov/pubmed/33482628 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e19242 %T Investigator Experiences Using Mobile Technologies in Clinical Research: Qualitative Descriptive Study %A McKenna,Kevin Christopher %A Geoghegan,Cindy %A Swezey,Teresa %A Perry,Brian %A Wood,William A %A Nido,Virginia %A Morin,Steve L %A Grabert,Brigid K %A Hallinan,Zachary P %A Corneli,Amy L %+ Department of Population Health Sciences, Duke University, 215 Morris Street, Suite 210, Durham, NC, 27705, United States, 1 9196688274, kevin.mckenna@duke.edu %K mHealth %K mobile technology %K mobile clinical trials %K digital health %K clinical research %K mobile devices %K digital health technology %K mobile applications %K clinical trial %D 2021 %7 12.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The successful adoption of mobile technology for use in clinical trials relies on positive reception from key stakeholders, including clinical investigators; however, little information is known about the perspectives of investigators using mobile technologies in clinical trials. Objective: The aim of this study was to seek investigators’ insights on the advantages and challenges of mobile clinical trials (MCTs); site-level budgetary, training, and other support needs necessary to adequately prepare for and implement MCTs; and the advantages and disadvantages for trial participants using mobile technologies in clinical trials. Methods: Using a qualitative descriptive study design, we conducted in-depth interviews with investigators involved in the conduct of MCTs. Data were analyzed using applied thematic analysis. Results: We interviewed 12 investigators who represented a wide variety of clinical specialties and reported using a wide range of mobile technologies. Investigators most commonly cited 3 advantages of MCTs over traditional clinical trials: more streamlined study operations, remote data capture, and improvement in the quality of studies and data collected. Investigators also reported that MCTs can be designed around the convenience of trial participants, and individuals may be more willing to participate in MCTs because they can take part from their homes. In addition, investigators recognized that MCTs can also involve additional burden for participants and described that operational challenges, technology adoption barriers, uncertainties about data quality, and time burden made MCTs more challenging than traditional clinical trials. Investigators stressed that additional training and dedicated staff effort may be needed to select a particular technology for use in a trial, helping trial participants learn and use the technology, and for staff troubleshooting the technology. Investigators also expressed that sharing data collected in real time with investigators and trial participants is an important aspect of MCTs that warrants consideration and potentially additional training and education. Conclusions: Investigator perspectives can inform the use of mobile technologies in future clinical trials by proactively identifying and addressing potential challenges. %M 33576742 %R 10.2196/19242 %U http://mhealth.jmir.org/2021/2/e19242/ %U https://doi.org/10.2196/19242 %U http://www.ncbi.nlm.nih.gov/pubmed/33576742 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e23917 %T The Efficacy of WeChat-Based Parenting Training on the Psychological Well-being of Mothers With Children With Autism During the COVID-19 Pandemic: Quasi-Experimental Study %A Liu,Guihua %A Wang,Shuo %A Liao,Jinhua %A Ou,Ping %A Huang,Longsheng %A Xie,Namei %A He,Yingshuang %A Lin,Jinling %A He,Hong-Gu %A Hu,Rongfang %+ The School of Nursing, Fujian Medical University, 1 Xuefu Road, Shangjie Zhen, Minhou County, Fuzhou, 350000, China, 86 13509366729, hulu2886@sina.com %K coronavirus disease 2019 %K autism spectrum disorder %K parenting training %K psychological well-being %K social media %K WeChat %K COVID-19 %K autism %K parenting %K mental health %K well-being %K anxiety %K depression %K stress %D 2021 %7 10.2.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: During the COVID-19 pandemic, special education schools for children in most areas of China were closed between the end of January and the beginning of June in 2020. The sudden interruption in schooling and the pandemic itself caused parents to be anxious and even to panic. Mobile-based parenting skills education has been demonstrated to be an effective method for improving the psychological well-being of mothers with children with autism. However, whether it can improve the psychological states of mothers in the context of the COVID-19 pandemic is a subject that should be urgently investigated. Objective: The aim of this study is to evaluate the efficacy of WeChat-based parenting training on anxiety, depression, parenting stress, and hope in mothers with children with autism, as well as the feasibility of the program during the COVID-19 pandemic. Methods: This was a quasi-experimental trial. A total of 125 mothers with preschool children with autism were recruited in January 2020. The participants were assigned to the control group (n=60), in which they received routine care, or the intervention group (n=65), in which they received the 12-week WeChat-based parenting training plus routine care, according to their preferences. Anxiety, depression, parenting stress, hope, satisfaction, and adherence to the intervention were measured at three timepoints: baseline (T0), postintervention (T1), and a 20-week follow-up (T2). Results: In total, 109 mothers completed the T1 assessment and 104 mothers completed the T2 assessment. The results of the linear mixed model analysis showed statistically significant group × time interaction effects for the intervention on anxiety (F=14.219, P<.001), depression (F=26.563, P<.001), parenting stress (F=68.572, P<.001), and hope (F=197.608, P<.001). Of all mothers in the intervention group, 90.4% (48.8/54) reported that they were extremely satisfied with the WeChat-based parenting training. In total, 40.0% (26/65) logged their progress in home training each week and 61.5% (40/65) logged their progress more than 80% of the time for all 20 weeks. Conclusions: The WeChat-based parenting training is acceptable and appears to be an effective approach for reducing anxiety, depression, and parenting stress, as well as increasing hope in mothers with children with autism during the global COVID-19 pandemic. Future studies with rigorous designs and longer follow-up periods are needed to further detect the effectiveness of the WeChat-based parenting training. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000031772; http://www.chictr.org.cn/showproj.aspx?proj=52165 %M 33481751 %R 10.2196/23917 %U https://mental.jmir.org/2021/2/e23917 %U https://doi.org/10.2196/23917 %U http://www.ncbi.nlm.nih.gov/pubmed/33481751 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e25488 %T Use of a Smartphone Platform to Help With Emergency Management of Acute Ischemic Stroke: Observational Study %A Wu,Yiqun %A Chen,Fei %A Song,Haiqing %A Feng,Wuwei %A Sun,Jinping %A Liu,Ruisen %A Li,Dongmei %A Liu,Ying %+ Beijing Municipal Health Commission, No 70 Zaolinqian Street, Beijing, 100053, China, 86 1083970637, 13901124008@139.com %K acute ischemic stroke %K door-to-needle time %K smartphone platform %K emergency management %K smartphone %K mHealth %K stroke %K management %K emergency %K first aid %K utility %K digital health %D 2021 %7 9.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: To improve the outcomes of acute ischemic stroke (AIS), timely thrombolytic therapy is crucial. Series strategies were recommended to reduce door-to-needle (DTN) time for AIS. Mobile technologies are feasible and have been used in stroke management for various purposes. However, the use of smartphone platforms that integrate series strategies through the entire first aid process to improve emergency management of AIS remains to be verified. Objective: This study aims to describe the utility and application of a smartphone platform in the emergency management of AIS and report the DTN time for patients with AIS during its 2-year application period. Our results are relevant to digital health management. Methods: A smartphone platform named “Green” was developed to incorporate the field assessment, hospital recommendation, prehospital notification, real-time communication, clinical records creation, key time-stamping, and quality control to streamline and standardize overall AIS emergency management processes. The emergency medical system (EMS) and all the emergency departments in Beijing have used this platform since 2018. From January 1, 2018, to December 31, 2019, 8457 patients diagnosed with AIS received intravenous tissue-type plasminogen activator therapy. The median DTN time and the proportions of patients with DTN times of ≤60 minutes and ≤45 minutes were reported. Results: During the 2-year application period of this platform, the median DTN time was 45 minutes, and the proportions of patients with DTN times of ≤60 minutes and ≤45 minutes were 74.6% and 50.5%, respectively. The median DTN time was significantly reduced from 50 minutes in 2018 to 42 minutes in 2019 (P<.001). The proportions of patients with DTN times of ≤60 minutes and ≤45 minutes increased from 66.1% and 40.7%, respectively, in 2018 to 80.7% and 57.3%, respectively, in 2019 (both P<.001). Sustained improvement in DTN time was seen during all the observed months. The improvement occurred across all facilities, and the variations among hospitals also decreased. The median DTN time for patients transferred by ambulances (43 minutes) was significantly shorter than those who reached hospitals by themselves (47 minutes; P<.001). Conclusions: Sustained reductions in DTN time reflected the improvement in AIS emergency management processes. The use of a smartphone platform integrating recommended strategies throughout all first aid stages is a practical way to help the emergency management of AIS. %M 33560236 %R 10.2196/25488 %U http://mhealth.jmir.org/2021/2/e25488/ %U https://doi.org/10.2196/25488 %U http://www.ncbi.nlm.nih.gov/pubmed/33560236 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e25960 %T Implementation of Online Hospitals and Factors Influencing the Adoption of Mobile Medical Services in China: Cross-Sectional Survey Study %A Wang,Huanlin %A Liang,LanYu %A Du,ChunLin %A Wu,YongKang %+ West China Hospital, Sichuan University, No. 37 Guoxue Lane, Wuhou District, Sichuan, China, 86 2885423265, vipwyk@163.com %K COVID-19 %K online hospital %K mobile medical service %K Unified Theory of Acceptance and Use of Technology %K UTAUT %D 2021 %7 5.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Online hospitals are part of an innovative model that allows China to explore telemedicine services based on national conditions with large populations, uneven distribution of medical resources, and lack of quality medical resources, especially among residents needing to be protected from COVID-19 infection. Objective: In this study, we built a hypothesis model based on the Unified Theory of Acceptance and Use of Technology (UTAUT) in order to analyze the factors that may influence patients’ willingness to use mobile medical services. This research was designed to assist in the development of mobile medical services. Residents who do not live in urban areas and cannot access medical assistance would greatly benefit from this research, as they could immediately go to the online hospital when needed. Methods: A cross-sectional study based at the West China Hospital, Sichuan University, was conducted in July 2020. A total of 407 respondents, 18 to 59 years old, in Western China were recruited by convenience sampling. We also conducted an empirical test for the hypothesis model and applied structural equation modeling to estimate the significance of path coefficients so that we could better understand the influencing factors. Results: Out of 407 respondents, 95 (23.3%) were aware of online hospitals, while 312 (76.7%) indicated that they have never heard of online hospitals before. Gender (P=.048) and education level (P=.04) affected people’s willingness to use online hospitals, and both of these factors promoted the use of online hospitals (odds ratio [OR] 2.844, 95% CI 1.010-8.003, and OR 2.187, 95% CI 1.031-4.636, respectively). According to structural equation modeling, the results of the path coefficient analysis indicated that performance expectancy, effort expectancy, and facilitating conditions have positive effects on patients’ willingness to use online hospitals. Conclusions: The goal of our research was to determine the factors that influence patients’ awareness and willingness to use online hospitals. Currently, the public’s awareness and usage of online hospitals is low. In fact, effort expectancy was the most important factor that influenced the use of online hospitals; being female and having a high education also played positive roles toward the use of mobile medical services. %M 33444155 %R 10.2196/25960 %U http://mhealth.jmir.org/2021/2/e25960/ %U https://doi.org/10.2196/25960 %U http://www.ncbi.nlm.nih.gov/pubmed/33444155 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e24539 %T Examining an Integrative Cognitive Model of Predicting Health App Use: Longitudinal Observational Study %A Kim,Kwanho %A Lee,Chul-Joo %+ Annenberg School for Communication, University of Pennsylvania, 3620 Walnut Street, Philadelphia, PA, 19104, United States, 1 215 898 7041, kwanho.kim@asc.upenn.edu %K mHealth %K health apps %K digital divide %K integrative model of behavioral prediction %K path analysis %D 2021 %7 3.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Specifying the determinants of using health apps has been an important research topic for health scholars as health apps have proliferated during the past decade. Socioeconomic status (SES) has been revealed as a significant determinant of using health apps, but the cognitive mechanisms underlying the relationship between SES and health app use are unknown. Objective: This study aims to examine the cognitive mechanisms underlying the relationships between SES and use of health apps, applying the integrative model of behavioral prediction (IM). The model hypothesizes the indirect influences of SES on intentions to use health apps, which in turn predict actual use of health apps. The relationships between SES and intentions to use health apps were assumed to be mediated by proximal variables (attitudes, perceived behavioral control [PBC], injunctive norms, and descriptive norms). Methods: We conducted path analyses using data from a two-wave opt-in panel survey of Korean adults who knew about health apps. The number of respondents was 605 at baseline and 440 at follow-up. We compared our model with two alternative theoretical models based on modified IM to further clarify the roles of determinants of health app use. Results: Attitudes (β=.220, P<.001), PBC (β=.461, P<.001), and injunctive norms (β=.186, P<.001) were positively associated with intentions to use health apps, which, in turn, were positively related to actual use of health apps (β=.106, P=.03). Income was positively associated with intentions to use health apps, and this relationship was mediated by attitudes (B=0.012, 95% CI 0.001-0.023) and PBC (B=0.026, 95% CI 0.004-0.048). Education was positively associated with descriptive norms (β=.078, P=.03), but descriptive norms were not significantly related to intentions to use health apps. We also found that PBC interacted with attitudes (B=0.043, SE 0.022, P=.046) and jointly influenced intentions to use health apps, whereas the results did not support direct influences of education, income, and PBC on health app use. Conclusions: We found that PBC over using health apps may be the most important factor in predicting health app use. This suggests the necessity of designing and promoting health apps in a user-friendly way. Our findings also imply that socioeconomic inequalities in using health apps may be reduced by increasing positive attitudes toward, and boosting PBC over, health app use among individuals with low income. %M 33533724 %R 10.2196/24539 %U https://mhealth.jmir.org/2021/2/e24539 %U https://doi.org/10.2196/24539 %U http://www.ncbi.nlm.nih.gov/pubmed/33533724 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e17837 %T The Promise and Peril of Mobile Phones for Youth in Rural Uganda: Multimethod Study of Implications for Health and HIV %A Kreniske,Philip %A Basmajian,Alyssa %A Nakyanjo,Neema %A Ddaaki,William %A Isabirye,Dauda %A Ssekyewa,Charles %A Nakubulwa,Rosette %A Hirsch,Jennifer S %A Deisher,Andrea %A Nalugoda,Fred %A Chang,Larry W %A Santelli,John S %+ HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, 722 West 168th Street, New York, NY, New York, United States, 1 646 774 6947, pk2361@columbia.edu %K adolescence %K youth %K mobile phones %K cell phones %K mobility %K HIV %K East Africa %D 2021 %7 2.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: In East Africa, where landlines are used by 1% of the population and access to the internet is limited, owning a cell phone is rapidly becoming essential for acquiring information and resources. Our analysis illuminates the perils and potential promise of mobile phones with implications for future interventions to promote the health of adolescents and young adults (AYAs) and to prevent HIV infection. Objective: The aim of this study is to describe the current state of AYAs’ phone use in the region and trace out the implications for mobile health interventions. Methods: We identified 2 trading centers that were representative of southern Uganda in terms of key demographics, proportion of cell phone ownership, and community HIV prevalence. We stratified the sample of potential informants by age group (15-19 years and 20-24 years), gender, and phone ownership and randomly sampled 31 key informant interview participants within these categories. In addition, we conducted 24 ethnographic participant observations among AYAs in the communities of study. Results: AYA frequently reported barriers to using their phones, such as difficulty accessing electricity. Nearly all AYAs used mobile phones to participate in the local economy and communicate with sexual partners. Phone use was frequently a point of contention between sexual partners, with many AYAs reporting that their sexual partners associated phone use with infidelity. Few AYAs reported using their phones for health-related purposes, with most getting health information in person from health workers. However, most AYAs reported an instance when they used their phone in an emergency, with childbirth-related emergencies being the most common. Finally, most AYAs reported that they would like to use their phones for health purposes and specifically stated that they would like to use their mobile phones to access current HIV prevention information. Conclusions: This study demonstrates how mobile phones are related to income-generating practices in the region and communication with sexual partners but not access to health and HIV information. Our analysis offers some explanation for our previous study, which suggested an association between mobile phone ownership, having multiple sexual partners, and HIV risk. Mobile phones have untapped potential to serve as tools for health promotion and HIV prevention. %M 33528375 %R 10.2196/17837 %U https://www.jmir.org/2021/2/e17837 %U https://doi.org/10.2196/17837 %U http://www.ncbi.nlm.nih.gov/pubmed/33528375 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e19194 %T A Mobile App to Support Clinical Diagnosis of Upper Respiratory Problems (eHealthResp): Co-Design Approach %A Moura,João %A Almeida,Ana Margarida Pisco %A Roque,Fátima %A Figueiras,Adolfo %A Herdeiro,Maria Teresa %+ Department of Communication and Art/DigiMedia, University of Aveiro, campus universitário de santiago, Aveiro, 3810-193, Portugal, 351 234 370389 ext 2370, marga@ua.pt %K mHealth %K Clinical Decision Support Systems %K respiratory system %K diagnose %K interface %K mobile phone %D 2021 %7 28.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The misuse of antibiotics is a global public health issue that fosters bacterial resistance and jeopardizes generational health. The development of validated tools such as web-based courses and mobile apps to enhance clinical decisions in upper respiratory infections is of great importance in reducing the incorrect use of antibiotics in these situations. Objective: The aim of this study was to design and prevalidate the interface of a mobile app to assist and provide clinical support in the diagnosis of upper respiratory problems. We aimed to assess the adequacy and usability of the interface of the tool in the belief that it could be beneficial to health care delivery in the clinical decision setting. Methods: Using a co-design approach that brought together professionals in interface design and experts in pharmacology and pharmacoepidemiology, the mobile app interface was evaluated through peer review sessions held by interface design professionals on a heuristic survey. The reviewers accessed a high-fidelity interactive mock-up of the interface and filled in a questionnaire to assess the dimensions of layout and visual design and navigation and tasks. The resulting feedback of this evaluation supported the redesign of the primary interface, which was assessed for the second time by 2 of the previously mentioned reviewers. Results: With 4 as the highest score, the interface scored a mean of 3.16 (SD 0.45; median of the means 3.2) for layout and visual design and a mean of 3.43 (SD 0.33; median of the means 3.51) for navigation and tasks, reflecting an overall positive evaluation. The open-ended commentaries allowed us to better understand specific recommendations of the reviewers. Throughout this section, approximately 0.98 comments per parameter were registered, reflecting a high level of effectiveness of the chosen parameters in identifying potential problems. The resultant beta version of the interface, addressing the majority of the detected problems, was further assessed by 2 of the previous reviewers, validating the new design. Future tests with physicians and pharmacists will help assess credibility and user experience dimensions. Conclusions: Our study revealed that the designed interface is easy to interpret and use. Peer reviewers raised important issues that could be easily fixed and positively reassessed. As a result, the study enabled us to produce a new tool for interface usability assessment and a set of recommendations for developing mobile interfaces for clinical decision support systems in the scope of upper respiratory problems. %M 33507153 %R 10.2196/19194 %U http://www.jmir.org/2021/1/e19194/ %U https://doi.org/10.2196/19194 %U http://www.ncbi.nlm.nih.gov/pubmed/33507153 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e22061 %T Implementation of an Interactive Voice Response System for Cancer Awareness in Uganda: Mixed Methods Study %A Kabukye,Johnblack K %A Ilozumba,Onaedo %A Broerse,Jacqueline E W %A de Keizer,Nicolette %A Cornet,Ronald %+ Uganda Cancer Institute, Upper Mulago Hill Road, Kampala, PO Box 3935, Kampa, Uganda, 256 700447351, jkabukye@gmail.com %K telemedicine %K medical oncology %K health promotion %K low-and-middle-income countries %K participatory research %K mobile phone %D 2021 %7 26.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Cancer awareness is crucial for cancer care and prevention. However, cancer awareness in Uganda is low, and access to cancer information is limited. Objective: This study aims to (1) understand the cancer awareness situation in Uganda (perceptions, beliefs, information needs, and challenges to accessing cancer information) and opinions about interactive voice response (IVR) systems; (2) develop cancer awareness messages and implement them in an IVR system; and (3) evaluate user acceptance and use of the IVR system. Methods: A participatory design approach was adopted. To understand cancer awareness needs and challenges, 3 interviews and 7 focus group discussions (FGDs) were conducted with cancer health care providers, patients with cancer, caregivers and survivors, administrators, and lay citizens (n=73). On the basis of the resulting qualitative data, audio messages addressing cancer information needs were developed and implemented in an IVR system. The system and messages were tested with users (n=12) during 2 co-design workshops before final rollout. Finally, the system was evaluated over 6 months after going live, using call records and user feedback from telephone interviews with callers (n=40). Results: The cancer information needs included general topics such as what cancer is, what causes it, cancer screening and diagnosis, cancer treatment, and practical information on what to expect during cancer care. There were also myths and misconceptions that need to be addressed, such as that cancer is due to witchcraft and has no treatment. Information on COVID-19 was also sought after following the outbreak. We developed 20 audio cancer messages (approximately 2 minutes each) in English and Luganda, along with 14 IVR navigation instructions. These were implemented in an IVR system with 24/7 availability from all over Uganda via a toll-free multi-channel telephone number. The total number of calls made to the IVR system 6 months after going live was 3820. Of these, 2437 (63.8%) lasted at least 30 seconds and were made from 1230 unique telephone numbers. There were 191 voice messages and 760 calls to live agents, most of which (681/951, 71.6%) were in Luganda. Call volumes peaked following advertisement of the system and lockdowns due to COVID-19. Participants were generally familiar with IVR technology, and caller feedback was largely positive. Cited benefits included convenience, toll-free access, and detailed information. Recommendations for improvement of the system included adding live agents and marketing of the system to target users. Conclusions: IVR technology provides an acceptable and accessible method for providing cancer information to patients and the general public in Uganda. However, a need remains for health system reforms to provide additional cancer information sources and improve cancer care services in general. %M 33496672 %R 10.2196/22061 %U http://mhealth.jmir.org/2021/1/e22061/ %U https://doi.org/10.2196/22061 %U http://www.ncbi.nlm.nih.gov/pubmed/33496672 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e17537 %T General Behavioral Engagement and Changes in Clinical and Cognitive Outcomes of Patients with Type 2 Diabetes Using the Time2Focus Mobile App for Diabetes Education: Pilot Evaluation %A Batch,Bryan C %A Spratt,Susan E %A Blalock,Dan V %A Benditz,Chad %A Weiss,Andi %A Dolor,Rowena J %A Cho,Alex H %+ Division of Endocrinology, Metabolism and Nutrition, Duke University School of Medicine, DUMC 3031, Durham, NC, 27710, United States, 1 919 684 4005, bryan.batch@duke.edu %K mobile technology %K diabetes %K self management support %K self efficacy %K illness perception %D 2021 %7 20.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Type 2 diabetes affects 30 million Americans, representing a significant cause of morbidity and mortality. Self-management support is an important component of chronic illness care and is a key pillar of the chronic care model. Face-to-face teaching and patient education materials suffer from being static or incompatible with mobile lifestyles. Digital apps provide a self-management support alternative that is convenient and scalable. Objective: This pilot study tested the real-world deployment of a self-guided mobile app for diabetes education (Time2Focus app; MicroMass Communications Inc, Cary, NC), which utilizes evidence-based content and gamification to deliver an interactive learning experience. Methods: Primary care providers were approached for permission to invite their patients to participate. Eligible patients were 18 to 89 years of age, had a diagnosis of type 2 diabetes, hemoglobin A1c (HbA1c) ≥8% and <12% in the past 3 months, an active online patient portal account (tied to the electronic health record), and access to an iOS or Android smartphone. Interested patients were emailed a baseline survey, and once this was completed, were sent instructions for downloading the Time2Focus app. After completing all 12 levels, participants were sent a follow-up survey. The primary outcome was the change in HbA1c. Secondary outcomes included medication adherence, self-care activities, self-reporting of physical activities, diabetes self-efficacy, illness perceptions, diabetes distress scale, and users’ engagement with and rating of the app. Results: Of 1355 potentially eligible patients screened, 201 were consented. Of these 201 patients, 101 (50.2%) did not download the app. Of the 100 participants (49.8%) who downloaded the app, 16 (16.0%) completed 0 levels, 26 (26.0%) completed 1 to 4 levels, 10 (10.0%) completed 5 to 11 levels, and 48 (48.0%) completed all 12 levels of the app and the follow-up survey. Those completing one or more levels had a mean pre/post-HbA1c change of –0.41% (compared to –0.32% among those who completed zero levels); however, the unadjusted two-tailed t test indicated no significant difference between the two groups (P=.73). Diabetes self-efficacy showed a large and significant increase during app usage for completers (mean change 1.28, P<.001, d=.83). Severity of illness perceptions showed a small but significant decrease during app usage for completers (mean change –0.51, P=.004, d=.43). Diabetes distress showed a small but significant decrease during app usage for completers (mean change –0.45, P=.006, d=.41). The net promoter score was 62.5, indicating that those who completed all levels of the app rated it highly and would recommend it to others. Conclusions: Participants who engaged in all 12 levels of the Time2Focus mobile app showed an improvement in diabetes self-efficacy and a decrease in severity of illness perceptions. The decrease in HbA1c observed in app users relative to nonusers during this limited pilot study was not statistically significant. However, uptake and application of lessons learned from self-management support may be delayed. Further research is needed to address how to increase engagement through self-management support and to investigate if follow up over a longer period demonstrates a significant change in outcomes such as HbA1c. %M 33470947 %R 10.2196/17537 %U http://www.jmir.org/2021/1/e17537/ %U https://doi.org/10.2196/17537 %U http://www.ncbi.nlm.nih.gov/pubmed/33470947 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e19109 %T Young People’s Experiences Using an On-Demand Mobile Health Sexual and Reproductive Health Text Message Intervention in Kenya: Qualitative Study %A Mwaisaka,Jefferson %A Gonsalves,Lianne %A Thiongo,Mary %A Waithaka,Michael %A Sidha,Hellen %A Alfred,Otieno %A Mukiira,Carol %A Gichangi,Peter %+ International Centre for Reproductive Health, Kenya, Tom Mboya Street, Mombasa, Kenya, 254 723 206 132, jeffmwaisaka@gmail.com %K mHealth %K mobile phones %K sexual and reproductive health %K Kenya %D 2021 %7 15.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Digital health usability assessments can help explain how well mobile health (mHealth) apps targeting young people with sexual and reproductive health (SRH) information performed and whether the intended purpose was achieved. However, few digital health assessments have been conducted to evaluate young people’s perceptions regarding mHealth system interactions and content relevance on a wide range of SRH topics. In addition, the majority of randomized controlled trials (RCTs) have focused on push messaging platforms; therefore, the mHealth field lacks sufficient RCTs investigating on-demand mHealth SRH platforms. Objective: The objective of this study was to explore young people’s experiences using an on-demand SRH mHealth platform in Kenya. Methods: We used qualitative data related to the usability of an mHealth platform, Adolescent/Youth Reproductive Mobile Access and Delivery Initiatives for Love and Life Outcome (ARMADILLO), collected at the end of the intervention period. A total of 30 in-depth interviews (IDIs) were held with the intervention participants (15 women and 15 men) to elicit their experiences, opinions, and perspectives on the design and content of the ARMADILLO platform. The study participants were randomly selected from a list of intervention arm participants to participate in the IDIs. The interviews were later transcribed verbatim, translated into English, and coded and analyzed thematically using NVivo version 12 software (QSR International). Results: Respondents reported varied user experiences and levels of satisfaction, ranging from ease of use by the majority of the respondents to systematic frustrations that prevented some participants from progressing to other stages. Interesting features of the mHealth platform included the immediate response participants received when requesting messages, weekly remunerated quizzes, and perceived ability of educative and informative content and messages to change behaviors. Proposed enhancements to the platform included revising some concepts and words for easy understanding and increasing the interactivity of the platform, whereby young people could seek clarity when they came across difficult terms or had additional questions about the information they received. Conclusions: The importance of understanding the range of health literacy and technological variations when dealing with young people cannot be overemphasized. Young people, as mHealth end users, must be considered throughout intervention development to achieve optimum functionality. In addition, young people targeted with mHealth SRH interventions must be sensitized to the interactions on mHealth platforms or any other digital health apps if implemented in a nonresearch setting for optimal use by the targeted audience. %M 33448930 %R 10.2196/19109 %U http://mhealth.jmir.org/2021/1/e19109/ %U https://doi.org/10.2196/19109 %U http://www.ncbi.nlm.nih.gov/pubmed/33448930 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e23190 %T Mobile App–Based Remote Patient Monitoring in Acute Medical Conditions: Prospective Feasibility Study Exploring Digital Health Solutions on Clinical Workload During the COVID Crisis %A Shah,Sachin Shailendra %A Gvozdanovic,Andrew %A Knight,Matthew %A Gagnon,Julien %+ Huma Therapeutics, 13th Floor Millbank Tower, 21-24 Millbank, London, SW1P 4QP, United Kingdom, 44 7875210783, sachsshah@gmail.com %K mHealth %K remote patient monitoring %K digital health %K COVID-19 %K service improvement %K cost-effectiveness %K monitoring %D 2021 %7 15.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital remote patient monitoring can add value to virtual wards; this has become more apparent in the context of the COVID-19 pandemic. Health care providers are overwhelmed, resulting in clinical teams spread more thinly. We aimed to assess the impact of introducing an app-based remote patient monitoring system (Huma Therapeutics) on a clinician’s workload in the context of a COVID-19–specific virtual ward. Objective: This prospective feasibility study aimed to evaluate the health economic effects (in terms of clinical workload) of a mobile app on a telephone-based virtual ward used in the monitoring of patients with COVID-19 who are clinically ready for discharge from the hospital. Methods: A prospective feasibility study was carried out over 1 month where clinician workload was monitored, and full-time equivalents savings were determined. An NHS hospital repurposed a telephone-based respiratory virtual ward for COVID-19. Patients with COVID-19 in the amber zone (according to the National Health Service definition) were monitored for 14 days postdischarge to help identify deteriorating patients earlier. A smartphone-based app was introduced to monitor data points submitted by the patients via communication over telephone calls. We then comparatively evaluated the clinical workload between patients monitored by telephone only (cohort 1) with those monitored via mobile app and telephone (cohort 2). Results: In all, 56 patients were enrolled in the app-based virtual ward (cohort 2). Digital remote patient monitoring resulted in a reduction in the number of phone calls from a mean total of 9 calls to 4 calls over the monitoring period. There was no change in the mean duration of phone calls (8.5 minutes) and no reports of readmission or mortality. These results equate to a mean saving of 47.60 working hours. Moreover, it translates to 3.30 fewer full-time equivalents (raw phone call data), resulting in 1.1 fewer full-time equivalents required to monitor 100 patients when adjusted for time spent reviewing app data. Individual clinicians spent an average of 10.9 minutes per day reviewing data. Conclusions: Smartphone-based remote patient monitoring technologies may offer tangible reductions in clinician workload at a time when service is severely strained. In this small-scale pilot study, we demonstrated the economic and operational impact that digital remote patient monitoring technology can have in improving working efficiency and reducing operational costs. Although this particular RPM solution was deployed for the COVID-19 pandemic, it may set a precedent for wider utilization of digital, remote patient monitoring solutions in other clinical scenarios where increased care delivery efficiency is sought. %M 33400675 %R 10.2196/23190 %U http://formative.jmir.org/2021/1/e23190/ %U https://doi.org/10.2196/23190 %U http://www.ncbi.nlm.nih.gov/pubmed/33400675 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e24807 %T A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial %A Röhr,Susanne %A Jung,Franziska U %A Pabst,Alexander %A Grochtdreis,Thomas %A Dams,Judith %A Nagl,Michaela %A Renner,Anna %A Hoffmann,Rahel %A König,Hans-Helmut %A Kersting,Anette %A Riedel-Heller,Steffi G %+ Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Strasse 55, Leipzig, Germany, 49 341 97 24568, susanne.roehr@medizin.uni-leipzig.de %K app %K cost-utility analysis %K mHealth %K posttraumatic stress %K PTSD %K quality-adjusted life years %K randomized controlled trial %K refugees %K stimga %K Syrian refugees %K usability %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress. Objective: The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. Methods: In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. Results: Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay. Conclusions: Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. Trial Registration: German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2110-y %M 33439140 %R 10.2196/24807 %U http://mhealth.jmir.org/2021/1/e24807/ %U https://doi.org/10.2196/24807 %U http://www.ncbi.nlm.nih.gov/pubmed/33439140 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e18021 %T Assessing the Effectiveness and Acceptability of a Personalized Mobile Phone App in Improving Adherence to Oral Hygiene Advice in Orthodontic Patients: Protocol for a Feasibility Study and a Randomized Controlled Trial %A Sharif,Mohammad Owaise %A Newton,Jonathon Timothy %A Cunningham,Susan J %+ Eastman Dental Institute, University College London, Rockefeller Building, 21 University Street, London, WC1E 6DE, United Kingdom, 44 02034561067, mohammad.sharif.16@ucl.ac.uk %K orthodontics %K adherence %K smartphone apps %K mobile phone apps %K personalized health care %K information provision %D 2021 %7 13.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Orthodontic treatment is a common health care intervention; treatment duration can be lengthy (2-3 years on average), and adherence to treatment advice is therefore essential for successful outcomes. It has been reported that up to 43% of patients fail to complete treatment, and there are currently no useful predictors of noncompletion. Given that the National Health Service England annual expenditure on primary-care orthodontic treatment is in excess of £200 million (US $267 million), noncompletion of treatment represents a significant inefficient use of public resources. Improving adherence to treatment is therefore essential. This necessitates behavior change, and interventions that improve adherence and are designed to elicit behavioral change must address an individual’s capability, opportunity, and motivation. Mobile phones are potentially an invaluable tool in this regard, as they are readily available and can be used in a number of ways to address an individual’s capability, opportunity, and motivation. Objective: This study will assess the effectiveness and acceptability of a personalized mobile phone app in improving adherence to orthodontic treatment advice by way of a randomized controlled trial. Methods: This study will be conducted in 2 phases at the Eastman Dental Hospital, University College London Hospitals Foundation Trust. Phase 1 is feasibility testing of the My Braces app. Participants will be asked to complete the user version of the Mobile Application Rating Scale. The app will be amended following analysis of the responses, if appropriate. Phase 2 is a randomized controlled trial to test the effectiveness and acceptability of the My Braces app. Results: This study was approved by the London – Bloomsbury Research Ethics Committee on November 5, 2019 (reference 19/LO/1555). No patients have been recruited to date. The anticipated start date for recruitment to phase 1 is October 2020. Conclusions: Given the availability, affordability, and versatility of mobile phones, it is proposed that they will aid in improving adherence to treatment advice and hence improve treatment completion rates. If effective, the applicability of this methodology to developing behavior change/modification interventions and improving adherence to treatment across health care provides an exciting opportunity. Trial Registration: ClinicalTrials.gov NCT04184739; https://clinicaltrials.gov/ct2/show/NCT04184739 International Registered Report Identifier (IRRID): PRR1-10.2196/18021 %M 33439142 %R 10.2196/18021 %U http://www.researchprotocols.org/2021/1/e18021/ %U https://doi.org/10.2196/18021 %U http://www.ncbi.nlm.nih.gov/pubmed/33439142 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e24806 %T Wrist-Worn Activity Trackers in Laboratory and Free-Living Settings for Patients With Chronic Pain: Criterion Validity Study %A Sjöberg,Veronica %A Westergren,Jens %A Monnier,Andreas %A Lo Martire,Riccardo %A Hagströmer,Maria %A Äng,Björn Olov %A Vixner,Linda %+ School of Education, Health and Social Studies, Dalarna University, Högskolegatan 2, Falun, SE-791 88, Sweden, 46 23 77 87 57, vsj@du.se %K chronic pain %K energy expenditure %K heart rate %K physical activity %K step count %K validity %K wearable devices %K wearable %K pain %K rehabilitation %D 2021 %7 12.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Physical activity is evidently a crucial part of the rehabilitation process for patients with chronic pain. Modern wrist-worn activity tracking devices seemingly have a great potential to provide objective feedback and assist in the adoption of healthy physical activity behavior by supplying data of energy expenditure expressed as metabolic equivalent of task units (MET). However, no studies of any wrist-worn activity tracking devices’ have examined criterion validity in estimating energy expenditure, heart rate, or step count in patients with chronic pain. Objective: The aim was to determine the criterion validity of wrist-worn activity tracking devices for estimations of energy expenditure, heart rate, and step count in a controlled laboratory setting and free-living settings for patients with chronic pain. Methods: In this combined laboratory and field validation study, energy expenditure, heart rate, and step count were simultaneously estimated by a wrist-worn activity tracker (Fitbit Versa), indirect calorimetry (Jaeger Oxycon Pro), and a research-grade hip-worn accelerometer (ActiGraph GT3X) during treadmill walking at 3 speeds (3.0 km/h, 4.5 km/h, and 6.0 km/h) in the laboratory setting. Energy expenditure and step count were also estimated by the wrist-worn activity tracker in free-living settings for 72 hours. The criterion validity of each measure was determined using intraclass and Spearman correlation, Bland-Altman plots, and mean absolute percentage error. An analysis of variance was used to determine whether there were any significant systematic differences between estimations. Results: A total of 42 patients (age: 25-66 years; male: 10/42, 24%; female: 32/42, 76%), living with chronic pain (duration, in years: mean 9, SD 6.72) were included. At baseline, their mean pain intensity was 3.5 (SD 1.1) out of 6 (Multidimensional Pain Inventory, Swedish version). Results showed that the wrist-worn activity tracking device (Fitbit Versa) systematically overestimated energy expenditure when compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X). Poor agreement and poor correlation were shown between Fitbit Versa and both Jaeger Oxycon Pro and ActiGraph GT3X for estimated energy expenditure at all treadmill speeds. Estimations of heart rate demonstrated poor to fair agreement during laboratory-based treadmill walks. For step count, the wrist-worn devices showed fair agreement and fair correlation at most treadmill speeds. In free-living settings; however, the agreement for step count between the wrist-worn device and waist-worn accelerometer was good, and the correlation was excellent. Conclusions: The wrist-worn device systematically overestimated energy expenditure and showed poor agreement and correlation compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X), which needs to be considered when used clinically. Step count measured with a wrist-worn device, however, seemed to be a valid estimation, suggesting that future guidelines could include such variables in this group with chronic pain. %M 33433391 %R 10.2196/24806 %U http://mhealth.jmir.org/2021/1/e24806/ %U https://doi.org/10.2196/24806 %U http://www.ncbi.nlm.nih.gov/pubmed/33433391 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e13770 %T Mobile App–Based Self-Report Questionnaires for the Assessment and Monitoring of Bipolar Disorder: Systematic Review %A Chan,Eric C %A Sun,Yuting %A Aitchison,Katherine J %A Sivapalan,Sudhakar %+ Department of Psychiatry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 7802332709, echantai@ualberta.ca %K mobile apps %K mental health %K bipolar disorder %K smartphone %K cell phone %D 2021 %7 8.1.2021 %9 Review %J JMIR Form Res %G English %X Background: Bipolar disorder is a chronic, progressive illness characterized by recurrent episodes of mania and depression. Self-report scales have historically played a significant role in the monitoring of bipolar symptoms. However, these tools rely on episodic memory, which can be unreliable and do not allow the clinician to monitor brief episodic symptoms or the course of symptoms over shorter periods of time. Mobile app–based questionnaires have been suggested as a tool to improve monitoring of patients with bipolar disorder. Objective: This paper aims to determine the feasibility and validity of mobile app–based self-report questionnaires. Methods: We performed a systematic review of the literature according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, PsycInfo, Web of Science, Ovid MEDLINE, and EMBASE databases were searched for papers published in English that assessed adherence to and the validity of mobile app–based self-report questionnaires. Relevant studies published from database creation to May 22, 2020, were identified, and results examining the validity of and rates of adherence to app-based self-report questionnaires are reported. Results: A total of 13 records were identified for inclusion in this review. Of these studies, 4 assessed the concurrent validity of mobile app–based self-report tools, with the majority of findings indicating significant associations between data collected using these tools and the Young Mania Rating Scale, Hamilton Depression Rating Scale-17, or Montgomery-Åsberg Depression Rating Scale (P<.001 to P=.24). Three studies comparing the variability or range of symptoms between patients with bipolar disorder and healthy controls suggested that these data are capable of differentiating between known groups. Two studies demonstrated statistically significant associations between data collected via mobile app–based self-report tools and instruments assessing other clinically important factors. Adherence rates varied across the studies examined. However, good adherence rates (>70%) were observed in all but 1 study using a once-daily assessment. There was a wide range of adherence rates observed in studies using twice-daily assessments (42%-95%). Conclusions: These findings suggest that mobile app–based self-report tools are valid in the assessment of symptoms of mania and depression in euthymic patients with bipolar disorder. Data collected using these tools appear to differ between patients with bipolar disorder and healthy controls and are significantly associated with other clinically important measures. It is unclear at this time whether these tools can be used to detect acute episodes of mania or depression in patients with bipolar disorder. Adherence data indicate that patients with bipolar disorder show good adherence to self-report assessments administered daily for the duration of the study periods evaluated. %M 33416510 %R 10.2196/13770 %U https://formative.jmir.org/2021/1/e13770 %U https://doi.org/10.2196/13770 %U http://www.ncbi.nlm.nih.gov/pubmed/33416510 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e20636 %T Cancer Patients’ Perceived Value of a Smartphone App to Enhance the Safety of Home-Based Chemotherapy: Feasibility Study %A Kongshaug,Nina %A Skolbekken,John-Arne %A Faxvaag,Arild %A Hofsli,Eva %+ Cancer Clinic, St. Olav's University Hospital, Postbox 8905, Trondheim, 7491, Norway, 47 99703704, nina.kongshaug@stolav.no %K mhealth %K mobile app %K smartphone app %K oral chemotherapy %K patient safety %K home-based cancer treatment %D 2021 %7 6.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Oral anticancer therapies can be self-administered by patients outside the hospital setting, which poses challenges of adherence to a drug plan and monitoring of side effects. Modern information technology may be developed and implemented to address these pertinent issues. Objective: The aim of this study was to explore how a smartphone app developed through a stepwise, iterative process can help patients using oral chemotherapy to take their drug, and to report adherence and side effects in a reliable and verifiable manner. Methods: Fourteen patients starting capecitabine treatment were included in this study and used the smartphone app in addition to regular follow up of capecitabine treatment. Nine of these patients fulfilled the treatment plan and were interviewed based on a semistructured interview guide and the System Usability Scale (SUS). In addition, two focus groups were completed with 7 oncologists and 7 oncology nurses, respectively. Interview data were analyzed in accordance with the principles of systematic text condensation. Features of the app were also assessed. Results: The smartphone app provided the patients with a feeling of reassurance regarding correct adherence of their oral chemotherapy treatment. They used the app as a memory tool about their treatment and possible serious side effects, as well as for treatment education. Patients expressed concerns about using the app to report side effects that were not considered to be obviously serious, fearing overreporting. The health personnel expressed an overall positive attitude to integrate this new tool in their everyday work. Conclusions: Patients on oral chemotherapy treatment at home felt safe and found the app to be helpful. The app promoted learning about their treatment and made the patients more independent of the cancer clinic, reducing the need for the clinic’s limited resources for follow up of patients on oral anticancer medications. %M 33404505 %R 10.2196/20636 %U https://formative.jmir.org/2021/1/e20636 %U https://doi.org/10.2196/20636 %U http://www.ncbi.nlm.nih.gov/pubmed/33404505 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e23725 %T Prevalence of Mental Illnesses in Domestic Violence Police Records: Text Mining Study %A Karystianis,George %A Simpson,Annabeth %A Adily,Armita %A Schofield,Peter %A Greenberg,David %A Wand,Handan %A Nenadic,Goran %A Butler,Tony %+ School of Population Health, University of New South Wales, Level 3, Samuels Building, Gate 11, Botany Street, UNSW Kensington Campus, Sydney, 2052, Australia, 61 (2) 9385 3811, g.karystianis@unsw.edu.au %K text mining %K mental illnesses %K domestic violence %K police data %K trend analysis %D 2020 %7 24.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The New South Wales Police Force (NSWPF) records details of significant numbers of domestic violence (DV) events they attend each year as both structured quantitative data and unstructured free text. Accessing information contained in the free text such as the victim’s and persons of interest (POI's) mental health status could be useful in the better management of DV events attended by the police and thus improve health, justice, and social outcomes. Objective: The aim of this study is to present the prevalence of extracted mental illness mentions for POIs and victims in police-recorded DV events. Methods: We applied a knowledge-driven text mining method to recognize mental illness mentions for victims and POIs from police-recorded DV events. Results: In 416,441 police-recorded DV events with single POIs and single victims, we identified 64,587 events (15.51%) with at least one mental illness mention versus 4295 (1.03%) recorded in the structured fixed fields. Two-thirds (67,582/85,880, 78.69%) of mental illnesses were associated with POIs versus 21.30% (18,298/85,880) with victims; depression was the most common condition in both victims (2822/12,589, 22.42%) and POIs (7496/39,269, 19.01%). Mental illnesses were most common among POIs aged 0-14 years (623/1612, 38.65%) and in victims aged over 65 years (1227/22,873, 5.36%). Conclusions: A wealth of mental illness information exists within police-recorded DV events that can be extracted using text mining. The results showed mood-related illnesses were the most common in both victims and POIs. Further investigation is required to determine the reliability of the mental illness mentions against sources of diagnostic information. %M 33361056 %R 10.2196/23725 %U http://www.jmir.org/2020/12/e23725/ %U https://doi.org/10.2196/23725 %U http://www.ncbi.nlm.nih.gov/pubmed/33361056 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e23955 %T Future Mobile Device Usage, Requirements, and Expectations of Physicians in German University Hospitals: Web-Based Survey %A Maassen,Oliver %A Fritsch,Sebastian %A Gantner,Julia %A Deffge,Saskia %A Kunze,Julian %A Marx,Gernot %A Bickenbach,Johannes %+ Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstrasse 30, Aachen, 52074, Germany, 49 2418080444, oliver.maassen@rwth-aachen.de %K mobile devices %K mobile applications %K apps %K mHealth %K smartphones %K tablets %K device usage %K requirements %K expectations %K hospital %K working equipment %D 2020 %7 21.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of mobile devices in hospital care constantly increases. However, smartphones and tablets have not yet widely become official working equipment in medical care. Meanwhile, the parallel use of private and official devices in hospitals is common. Medical staff use smartphones and tablets in a growing number of ways. This mixture of devices and how they can be used is a challenge to persons in charge of defining strategies and rules for the usage of mobile devices in hospital care. Objective: Therefore, we aimed to examine the status quo of physicians’ mobile device usage and concrete requirements and their future expectations of how mobile devices can be used. Methods: We performed a web-based survey among physicians in 8 German university hospitals from June to October 2019. The online survey was forwarded by hospital management personnel to physicians from all departments involved in patient care at the local sites. Results: A total of 303 physicians from almost all medical fields and work experience levels completed the web-based survey. The majority regarded a tablet (211/303, 69.6%) and a smartphone (177/303, 58.4%) as the ideal devices for their operational area. In practice, physicians are still predominantly using desktop computers during their worktime (mean percentage of worktime spent on a desktop computer: 56.8%; smartphone: 12.8%; tablet: 3.6%). Today, physicians use mobile devices for basic tasks such as oral (171/303, 56.4%) and written (118/303, 38.9%) communication and to look up dosages, diagnoses, and guidelines (194/303, 64.0%). Respondents are also willing to use mobile devices for more advanced applications such as an early warning system (224/303, 73.9%) and mobile electronic health records (211/303, 69.6%). We found a significant association between the technical affinity and the preference of device in medical care (χs2=53.84, P<.001) showing that with increasing self-reported technical affinity, the preference for smartphones and tablets increases compared to desktop computers. Conclusions: Physicians in German university hospitals have a high technical affinity and positive attitude toward the widespread implementation of mobile devices in clinical care. They are willing to use official mobile devices in clinical practice for basic and advanced mobile health uses. Thus, the reason for the low usage is not a lack of willingness of the potential users. Challenges that hinder the wider adoption of mobile devices might be regulatory, financial and organizational issues, and missing interoperability standards of clinical information systems, but also a shortage of areas of application in which workflows are adapted for (small) mobile devices. %M 33346735 %R 10.2196/23955 %U http://www.jmir.org/2020/12/e23955/ %U https://doi.org/10.2196/23955 %U http://www.ncbi.nlm.nih.gov/pubmed/33346735 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e16322 %T Prostate Cancer Risk Calculator Apps in a Taiwanese Population Cohort: Validation Study %A Chen,I-Hsuan Alan %A Chu,Chi-Hsiang %A Lin,Jen-Tai %A Tsai,Jeng-Yu %A Yu,Chia-Cheng %A Sridhar,Ashwin Narasimha %A Sooriakumaran,Prasanna %A Loureiro,Rui C V %A Chand,Manish %+ Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, No 386, Dazhong 1st Rd, Zuoying District, Kaohsiung, 813414, Taiwan, 886 975939290, jtlin@vghks.gov.tw %K diagnosis %K mHealth %K mobile apps %K prostate cancer %K prostate-specific antigen %K risk calculator %D 2020 %7 18.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile health apps have emerged as useful tools for patients and clinicians alike, sharing health information or assisting in clinical decision-making. Prostate cancer (PCa) risk calculator mobile apps have been introduced to assess risks of PCa and high-grade PCa (Gleason score ≥7). The Rotterdam Prostate Cancer Risk Calculator and Coral–Prostate Cancer Nomogram Calculator apps were developed from the 2 most-studied PCa risk calculators, the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the North American Prostate Cancer Prevention Trial (PCPT) risk calculators, respectively. A systematic review has indicated that the Rotterdam and Coral apps perform best during the prebiopsy stage. However, the epidemiology of PCa varies among different populations, and therefore, the applicability of these apps in a Taiwanese population needs to be evaluated. This study is the first to validate the PCa risk calculator apps with both biopsy and prostatectomy cohorts in Taiwan. Objective: The study’s objective is to validate the PCa risk calculator apps using a Taiwanese cohort of patients. Additionally, we aim to utilize postprostatectomy pathology outcomes to assess the accuracy of both apps with regard to high-grade PCa. Methods: All male patients who had undergone transrectal ultrasound prostate biopsies in a single Taiwanese tertiary medical center from 2012 to 2018 were identified retrospectively. The probabilities of PCa and high-grade PCa were calculated utilizing the Rotterdam and Coral apps, and compared with biopsy and prostatectomy results. Calibration was graphically evaluated with the Hosmer-Lemeshow goodness-of-fit test. Discrimination was analyzed utilizing the area under the receiver operating characteristic curve (AUC). Decision curve analysis was performed for clinical utility. Results: Of 1134 patients, 246 (21.7%) were diagnosed with PCa; of these 246 patients, 155 (63%) had high-grade PCa, according to the biopsy results. After confirmation with prostatectomy pathological outcomes, 47.2% (25/53) of patients were upgraded to high-grade PCa, and 1.2% (1/84) of patients were downgraded to low-grade PCa. Only the Rotterdam app demonstrated good calibration for detecting high-grade PCa in the biopsy cohort. The discriminative ability for both PCa (AUC: 0.779 vs 0.687; DeLong’s method: P<.001) and high-grade PCa (AUC: 0.862 vs 0.758; P<.001) was significantly better for the Rotterdam app. In the prostatectomy cohort, there was no significant difference between both apps (AUC: 0.857 vs 0.777; P=.128). Conclusions: The Rotterdam and Coral apps can be applied to the Taiwanese cohort with accuracy. The Rotterdam app outperformed the Coral app in the prediction of PCa and high-grade PCa. Despite the small size of the prostatectomy cohort, both apps, to some extent, demonstrated the predictive capacity for true high-grade PCa, confirmed by the whole prostate specimen. Following our external validation, the Rotterdam app might be a good alternative to help detect PCa and high-grade PCa for Taiwanese men. %M 33337340 %R 10.2196/16322 %U http://www.jmir.org/2020/12/e16322/ %U https://doi.org/10.2196/16322 %U http://www.ncbi.nlm.nih.gov/pubmed/33337340 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e19888 %T Evaluation of a Mobile App to Enhance Relational Awareness and Change During Cognitive Analytic Therapy: Mixed Methods Case Series %A Kellett,Stephen %A Easton,Katherine %A Cooper,Martin %A Millings,Abigail %A Simmonds-Buckley,Melanie %A Parry,Glenys %+ Sheffield Health & Social Care NHS Foundation Trust, University of Sheffield, 1 Vicar Lane, Sheffield, S1 2LT, United Kingdom, 44 114 222 6537, s.kellett@sheffield.ac.uk %K cognitive analytic therapy %K case series %K effectiveness %K outcome %K eHealth %K app %K awareness %K mHealth %K innovation %K therapy %D 2020 %7 18.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There has been a lack of technological innovation regarding improving the delivery of integrative psychotherapies. This project sought to evaluate an app designed to replace previous paper-based methods supporting relational awareness and change during cognitive analytic therapy (CAT). Objective: We aimed to assess patients’ and therapists’ experience of using the technology (ie, the “CAT-App”) and to evaluate the relationship between app usage and clinical outcome. Methods: The design was a mixed methods case series. Patients completed the Clinical Outcomes in Routine Evaluation-Outcome Measure pre- and post-CAT. Mood data plus the frequency and effectiveness of relational awareness and change were collected via the app. Therapists and patients were interviewed about their experiences using the app. Results: Ten patients (treated by 3 therapists) were enrolled; seven completed treatment and 4 had a reliable improvement in their mental health. App usage and mood change did not differ according to clinical outcome, but there was a statistically significant difference in app usage between completers and dropouts. The qualitative themes described by the therapists were (1) the challenge of incorporating the technology into their clinical practice and (2) the barriers and benefits of the technology. Clients’ themes were (1) data protection, (2) motivation and engagement, and (3) restrictions versus flexibility. Conclusions: The CAT-App is capable of supporting relational awareness and change and is an upgrade on older, paper-based formats. Further clinical evaluation is required. %M 33337342 %R 10.2196/19888 %U http://mental.jmir.org/2020/12/e19888/ %U https://doi.org/10.2196/19888 %U http://www.ncbi.nlm.nih.gov/pubmed/33337342 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 12 %P e17542 %T A Smartphone App for Patients With Acute Coronary Syndrome (MoTER-ACS): User-Centered Design Approach %A Bashi,Nazli %A Varnfield,Marlien %A Karunanithi,Mohanraj %+ Australian eHealth Research Centre, Commonwealth Scientific and Industrial Research Organisation, Level 5 - UQ Health Sciences, Building 901/16, Royal Brisbane and Women's Hospital, Brisbane, 4029, Australia, 61 732533611, ghafouryan@hotmail.com %K mobile health %K mHealth %K mobile health apps %K smartphone %K mobile phone %K self-management %K patient education %K cardiovascular disease %K acute coronary syndrome %D 2020 %7 18.12.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Postdischarge interventions are limited for patients with acute coronary syndrome (ACS) due to few scheduled visits to outpatient clinics and the need to travel from remote areas. Smartphones have become viable lifestyle technology to deliver home-based educational and health interventions. Objective: The aim of this study was to develop a smartphone-based intervention for providing postdischarge support to patients with ACS. Methods: The content of Mobile Technology–Enabled Rehabilitation for Patients with ACS (MoTER-ACS) was derived from a series of small studies, termed prestudy surveys, conducted in 2017. The prestudy surveys were conducted in Prince Charles Hospital, Queensland, Australia, and consisted of questionnaires among a convenience sample of patients with ACS (n=30), a focus group discussion with health care professionals (n=10), and an online survey among cardiologists (n=15). Responses from the patient survey identified educational topics of MoTER-ACS. The focus group with health care professionals assisted with identifying educational materials, health monitoring, and self-management interventions. Based on the results of the cardiologists’ survey, monitoring of symptoms related to heart failure exacerbation was considered as a weekly diary. Results: The MoTER-ACS app covers multimedia educational materials to adopt a healthy lifestyle and includes user-friendly tools to monitor physiological and health parameters such as blood pressure, weight, and pain, assisting patients in self-managing their condition. A web portal that is linked to the data from the smartphone app is available to clinicians to regularly access patients’ data and provide support. Conclusions: The MoTER-ACS platform extends the capabilities of previous mobile health platforms by providing a home-based educational and self-management intervention for patients with ACS following discharge from the hospital. The MoTER-ACS intervention narrows the gap between existing hospital-based programs and home-based interventions by complementing the postdischarge program for patients with ACS. %M 33337339 %R 10.2196/17542 %U http://formative.jmir.org/2020/12/e17542/ %U https://doi.org/10.2196/17542 %U http://www.ncbi.nlm.nih.gov/pubmed/33337339 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e19452 %T Mobile Health App With Social Media to Support Self-Management for Patients With Chronic Kidney Disease: Prospective Randomized Controlled Study %A Li,Wen-Yi %A Chiu,Fu-Chun %A Zeng,Jyun-Kai %A Li,Yao-Wei %A Huang,Su-Hua %A Yeh,Hui-Chin %A Cheng,Bor-Wen %A Yang,Feng-Jung %+ Renal Division, Department of Internal Medicine, National Taiwan University Hospital Yun Lin Branch, No. 579, Sec. 2, Yunlin Road, Douliu, 640, Taiwan, 886 5 5323911, fongrong@ntu.edu.tw %K chronic kidney disease %K self-management %K self-efficacy %K quality of life %K health management platform %K wearable device %D 2020 %7 15.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic kidney disease (CKD) is a global health burden. Self-management plays a key role in improving modifiable risk factors. Objective: The aim of this study was to evaluate the effectiveness of wearable devices, a health management platform, and social media at improving the self-management of CKD, with the goal of establishing a new self-management intervention model. Methods: In a 90-day prospective experimental study, a total of 60 people with CKD at stages 1-4 were enrolled in the intervention group (n=30) and control group (n=30). All participants were provided with wearable devices that collected exercise-related data. All participants maintained dietary diaries using a smartphone app. All dietary and exercise information was then uploaded to a health management platform. Suggestions about diet and exercise were provided to the intervention group only, and a social media group was created to inspire the participants in the intervention group. Participants’ self-efficacy and self-management questionnaire scores, Kidney Disease Quality of Life scores, body composition, and laboratory examinations before and after the intervention were compared between the intervention and control groups. Results: A total of 49 participants completed the study (25 in the intervention group and 24 in the control group); 74% of the participants were men and the mean age was 51.22 years. There were no differences in measured baseline characteristics between the groups except for educational background. After the intervention, the intervention group showed significantly higher scores for self-efficacy (mean 171.28, SD 22.92 vs mean 142.21, SD 26.36; P<.001) and self-management (mean 54.16, SD 6.71 vs mean 47.58, SD 6.42; P=.001). Kidney Disease Quality of Life scores were also higher in the intervention group (mean 293.16, SD 34.21 vs mean 276.37, SD 32.21; P=.02). The number of steps per day increased in the intervention group (9768.56 in week 1 and 11,389.12 in week 12). The estimated glomerular filtration rate (eGFR) of the intervention group was higher than that of the control group (mean 72.47, SD 24.28 vs mean 59.69, SD 22.25 mL/min/1.73m2; P=.03) and the decline in eGFR was significantly slower in the intervention group (–0.56 vs –4.58 mL/min/1.73m2). There were no differences in body composition between groups postintervention. Conclusions: The use of wearable devices, a health management platform, and social media support not only strengthened self-efficacy and self-management but also improved quality of life and a slower eGFR decline in people with CKD at stages 1-4. These results outline a new self-management model to promote healthy lifestyle behaviors for patients with CKD. Trial Registration: ClinicalTrials.gov NCT04617431; https://www.clinicaltrials.gov/ct2/show/NCT04617431 %M 33320101 %R 10.2196/19452 %U http://www.jmir.org/2020/12/e19452/ %U https://doi.org/10.2196/19452 %U http://www.ncbi.nlm.nih.gov/pubmed/33320101 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 12 %P e22000 %T ISO/IEEE 11073 Treadmill Interoperability Framework and its Test Method: Design and Implementation %A Huang,Zhi Yong %A Wang,Yujie %A Wang,Linling %+ School of Microelectronics and Communication Engineering, Chongqing University, No 174 Shazhengjie, Shapingba, Chongqing, 400044, China, 86 02365103544, zyhuang@cqu.edu.cn %K ISO/IEEE 11073-PHD %K treadmill %K standard frame model %K test standard %K sports health data %D 2020 %7 9.12.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Regular physical activity is proven to help prevent and treat noncommunicable diseases such as heart disease, stroke, diabetes, and breast and colon cancer. The exercise data generated by health and fitness devices (eg, treadmill, exercise bike) are very important for health management service providers to develop personalized training programs. However, at present, there is little research on a unified interoperability framework in the health and fitness domain, and there are not many solutions; besides, the privatized treadmill data transmission scheme is not conducive to data integration and analysis. Objective: This article will expand the IEEE 11073-PHD standard protocol family, develop standards for health and fitness device (using treadmill as an example) based on the latest version of the 11073-20601 optimized exchange protocol, and design protocol standards compliance testing process and inspection software, which can automatically detect whether the instantiated object of the treadmill meets the standard. Methods: The study includes the following steps: (1) Map the data transmitted by the treadmill to the 11073-PHD objects; (2) Construct a programming language structure corresponding to the 11073-PHD application protocol data unit (APDU) to complete the coding and decoding part of the test software; and (3) Transmit the instantiated simulated treadmill data to the gateway test software through transmission control protocol for standard compliance testing. Results: According to the characteristics of the treadmill, a data exchange framework conforming to 11073-PHD is constructed, and a corresponding testing framework is developed; a treadmill agent simulation is implemented, and the interoperability test is performed. Through the designed testing process, the corresponding testing software was developed to complete the standard compliance testing of the treadmill. Conclusions: The extended research of IEEE 11073-PHD in the field of health and fitness provides a potential new idea for the data transmission framework of sports equipment such as treadmills, which may also provide some help for the development of sports health equipment interoperability standards. %M 33295293 %R 10.2196/22000 %U http://medinform.jmir.org/2020/12/e22000/ %U https://doi.org/10.2196/22000 %U http://www.ncbi.nlm.nih.gov/pubmed/33295293 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e21923 %T Smartphone Overuse and Visual Impairment in Children and Young Adults: Systematic Review and Meta-Analysis %A Wang,Jian %A Li,Mei %A Zhu,Daqiao %A Cao,Yang %+ Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Södra Grev Rosengatan 1, Örebro, 70182, Sweden, 46 196026236, yang.cao@oru.se %K visual impairment %K smartphone %K mobile phone %K overuse %K child %K young adult %K systematic review %K meta-analysis %D 2020 %7 8.12.2020 %9 Review %J J Med Internet Res %G English %X Background: Smartphone overuse has been cited as a potentially modifiable risk factor that can result in visual impairment. However, reported associations between smartphone overuse and visual impairment have been inconsistent. Objective: The aim of this systematic review was to determine the association between smartphone overuse and visual impairment, including myopia, blurred vision, and poor vision, in children and young adults. Methods: We conducted a systematic search in the Cochrane Library, PubMed, EMBASE, Web of Science Core Collection, and ScienceDirect databases since the beginning of the databases up to June 2020. Fourteen eligible studies (10 cross-sectional studies and 4 controlled trials) were identified, which included a total of 27,110 subjects with a mean age ranging from 9.5 to 26.0 years. We used a random-effects model for meta-analysis of the 10 cross-sectional studies (26,962 subjects) and a fixed-effects model for meta-analysis of the 4 controlled trials (148 subjects) to combine odds ratios (ORs) and effect sizes (ES). The I2 statistic was used to assess heterogeneity. Results: A pooled OR of 1.05 (95% CI 0.98-1.13, P=.16) was obtained from the cross-sectional studies, suggesting that smartphone overuse is not significantly associated with myopia, poor vision, or blurred vision; however, these visual impairments together were more apparent in children (OR 1.06, 95% CI 0.99-1.14, P=.09) than in young adults (OR 0.91, 95% CI 0.57-1.46,P=.71). For the 4 controlled trials, the smartphone overuse groups showed worse visual function scores compared with the reduced-use groups. The pooled ES was 0.76 (95% CI 0.53-0.99), which was statistically significant (P<.001). Conclusions: Longer smartphone use may increase the likelihood of ocular symptoms, including myopia, asthenopia, and ocular surface disease, especially in children. Thus, regulating use time and restricting the prolonged use of smartphones may prevent ocular and visual symptoms. Further research on the patterns of use, with longer follow up on the longitudinal associations, will help to inform detailed guidelines and recommendations for smartphone use in children and young adults. %M 33289673 %R 10.2196/21923 %U https://www.jmir.org/2020/12/e21923 %U https://doi.org/10.2196/21923 %U http://www.ncbi.nlm.nih.gov/pubmed/33289673 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e19991 %T A Mobile Social Networking App for Weight Management and Physical Activity Promotion: Results From an Experimental Mixed Methods Study %A Laranjo,Liliana %A Quiroz,Juan C %A Tong,Huong Ly %A Arevalo Bazalar,Maria %A Coiera,Enrico %+ Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera road, Sydney, 2113, Australia, 61 413461852, liliana.laranjo@mq.edu.au %K mobile apps %K fitness trackers %K exercise %K social networking %K body weight maintenance %K mobile phone %D 2020 %7 8.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphone apps, fitness trackers, and online social networks have shown promise in weight management and physical activity interventions. However, there are knowledge gaps in identifying the most effective and engaging interventions and intervention features preferred by their users. Objective: This 6-month pilot study on a social networking mobile app connected to wireless weight and activity tracking devices has 2 main aims: to evaluate changes in BMI, weight, and physical activity levels in users from different BMI categories and to assess user perspectives on the intervention, particularly on social comparison and automated self-monitoring and feedback features. Methods: This was a mixed methods study involving a one-arm, pre-post quasi-experimental pilot with postintervention interviews and focus groups. Healthy young adults used a social networking mobile app intervention integrated with wireless tracking devices (a weight scale and a physical activity tracker) for 6 months. Quantitative results were analyzed separately for 2 groups—underweight-normal and overweight-obese BMI—using t tests and Wilcoxon sum rank, Wilcoxon signed rank, and chi-square tests. Weekly BMI change in participants was explored using linear mixed effects analysis. Interviews and focus groups were analyzed inductively using thematic analysis. Results: In total, 55 participants were recruited (mean age of 23.6, SD 4.6 years; 28 women) and 45 returned for the final session (n=45, 82% retention rate). There were no differences in BMI from baseline to postintervention (6 months) and between the 2 BMI groups. However, at 4 weeks, participants’ BMI decreased by 0.34 kg/m2 (P<.001), with a loss of 0.86 kg/m2 in the overweight-obese group (P=.01). Participants in the overweight-obese group used the app significantly less compared with individuals in the underweight-normal BMI group, as they mentioned negative feelings and demotivation from social comparison, particularly from upward comparison with fitter people. Participants in the underweight-normal BMI group were avid users of the app’s self-monitoring and feedback (P=.02) and social (P=.04) features compared with those in the overweight-obese group, and they significantly increased their daily step count over the 6-month study duration by an average of 2292 steps (95% CI 898-3370; P<.001). Most participants mentioned a desire for a more personalized intervention. Conclusions: This study shows the effects of different interventions on participants from higher and lower BMI groups and different perspectives regarding the intervention, particularly with respect to its social features. Participants in the overweight-obese group did not sustain a short-term decrease in their BMI and mentioned negative emotions from app use, while participants in the underweight-normal BMI group used the app more frequently and significantly increased their daily step count. These differences highlight the importance of intervention personalization. Future research should explore the role of personalized features to help overcome personal barriers and better match individual preferences and needs. %M 33289670 %R 10.2196/19991 %U http://www.jmir.org/2020/12/e19991/ %U https://doi.org/10.2196/19991 %U http://www.ncbi.nlm.nih.gov/pubmed/33289670 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e17536 %T Feasibility of a Digital Health Intervention to Improve Diet Quality Among Women With High Blood Pressure: Randomized Controlled Feasibility Trial %A Steinberg,Dori M %A Kay,Melissa C %A Svetkey,Laura P %A Askew,Sandy %A Christy,Jacob %A Burroughs,Jasmine %A Ahmed,Hira %A Bennett,Gary G %+ Duke University School of Nursing, 307 Trent Drive, DUMC 3322, Durham, NC, 27710, United States, 1 919 613 9439, dori.steinberg@duke.edu %K hypertension %K DASH dietary pattern %K digital health %K nutrition %K women’s health %K mHealth %D 2020 %7 7.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Over 100 million individuals have high blood pressure, and more than half of them are women. The Dietary Approaches to Stop Hypertension (DASH) dietary pattern is a proven lifestyle approach to lower blood pressure, yet population-level adherence is poor. Innovative strategies that promote DASH are needed. Objective: This paper aims to improve adherence to the DASH diet among women with hypertension or prehypertension. Methods: We conducted a 3-month randomized controlled feasibility trial comparing app-based diet tracking (active comparator) to app-based diet tracking plus feedback on DASH adherence via text message (intervention). The intervention platform extracted nutrient data from the app, compared it to DASH recommendations, and sent tailored feedback text messages. Outcomes included the number of days participants tracked their diet, changes in their DASH adherence score, and blood pressure. Results: The women (N=59) had a mean age of 49.9 (SD 11.9) years and were primarily non-Hispanic White (41/59, 69%) and college educated (49/59, 83%). The mean baseline DASH score was 2.3 (SD 1.3). At 3 months, the intervention and active comparator participants had similar mean days tracked per week (4.2, SD 2.1 days vs 4.6, SD 2.7 days; P=.54) and mean changes in their DASH score (0.8, 95% CI 0.2-1.5 vs 0.8, 95% CI 0.4-1.2; P=.75). Intervention participants had lower systolic (mean difference: –2.8 mmHg, 95% CI –1.8 to 7.4; P=.23) and diastolic (mean difference: –3.6 mmHg, 95% CI –0.2 to 7.3; P=.07) blood pressure compared with active comparator participants. Most intervention participants (23/29, 79%) said they would recommend the DASH Cloud intervention to a friend or family member. However, only 34% (10/59) indicated that the feedback text messages helped them reach their diet goals. Conclusions: A digital health intervention to improve DASH adherence is feasible and produces moderately high engagement among women with elevated blood pressure. The intervention did not enhance DASH adherence over diet tracking alone but resulted in greater reductions in blood pressure. Larger studies are needed to determine how digital health interventions can improve population-level adherence to DASH. Trial Registration: ClinicalTrials.gov NCT03215472; https://clinicaltrials.gov/ct2/show/study/NCT03215472 %M 33284116 %R 10.2196/17536 %U https://mhealth.jmir.org/2020/12/e17536 %U https://doi.org/10.2196/17536 %U http://www.ncbi.nlm.nih.gov/pubmed/33284116 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e19137 %T Awareness Development and Usage of Mobile Health Technology Among Individuals With Hypertension in a Rural Community of Bangladesh: Randomized Controlled Trial %A Jahan,Yasmin %A Rahman,Md Moshiur %A Faruque,Abu S G %A Chisti,Mohammod Jobayer %A Kazawa,Kana %A Matsuyama,Ryota %A Moriyama,Michiko %+ Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Minami-ku, Kasumi-cho, Hiroshima-shi, Hiroshima, 7340046, Japan, 81 0822575365, dr.yasminjahan@gmail.com %K mobile health %K hypertension %K behavior changes %K awareness development %K lifestyle %K Bangladesh %D 2020 %7 7.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Hypertension (HTN) is a major modifiable risk factor and the leading cause of premature deaths globally. The lack of awareness and knowledge have been identified as risk factors in low- and middle-income countries including Bangladesh. Recently, the use of mobile phone SMS text messaging is found to have an important positive impact on HTN management. Objective: The study aimed to develop awareness and knowledge in order to enhance lifestyle behavior changes among individuals with HTN in a rural community of Bangladesh by using health education and mobile health (mHealth) technology (SMS text messaging). Methods: A prospective randomized 5-month intervention, open-label (1:1), parallel-group trial was implemented among the individuals with HTN aged 35 years or older. Both men and women were included. Between August 2018 and July 2019, we enrolled 420 participants, selected from a tertiary level health facility and through door-to-door visits by community health workers. After block randomization, they were assigned to either the intervention group (received SMS text messaging and health education; n=209) or the control group (received only health education; n=211). The primary outcome was the evaluation of self-reported behavior changes (salt intake, fruits and vegetables intake, physical activity, and blood pressure [BP], and body weight monitoring behaviors). The secondary outcomes were measurements of actual salt intake and dietary salt excretion, blood glucose level, BP values, and quality of life (QOL). Results: During the study period, a total of 8 participants were dropped, and the completion rate was 98.0% (412/420). The adherence rates were significantly higher (9%) among the control group regarding salt intake (P=.04) and physical activity behaviors (P<.03), and little differences were observed in other behaviors. In primary outcome, the focused behavior, salt intake less than 6 g/day, showed significant chronological improvement in both groups (P<.001). The fruits intake behavior steadily improved in both groups (P<.001). Participants in both groups had a custom of vegetables intake everyday/week. Physical activity suddenly increased and continued until the study end (P<.001 in both groups). Both BP and body weight monitoring status increased from baseline to 1 month but decreased afterward (P<.001). In case of secondary outcomes, significant chronological changes were observed in food salt concentration and urinary salinity between the groups (P=.01). The mean systolic BP and diastolic BP significantly chronologically decreased in both groups (systolic BP, P=.04; diastolic BP, P=.02.P<.05). All of these supported self-reported behavior changes. For the QOL, both groups showed significant improvement over the study periods (P<.001). Conclusions: Based on these results, we suggest that face-to-face health education requires integration of home health care provision and more relevant and timely interactive SMS text messages to increase the effectiveness of the intervention. Besides, community awareness can be created to encourage “low-salt culture” and educate family members. Trial Registration: Bangladesh Medical Research Council (BMRC) 06025072017; ClinicalTrials.gov NCT03614104; https://clinicaltrials.gov/ct2/show/NCT03614104 and UMIN-CTR R000033736; https://tinyurl.com/y48yfcoo International Registered Report Identifier (IRRID): RR2-10.2196/15523 %M 33284129 %R 10.2196/19137 %U https://www.jmir.org/2020/12/e19137 %U https://doi.org/10.2196/19137 %U http://www.ncbi.nlm.nih.gov/pubmed/33284129 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 12 %P e15602 %T Use of Different Food Image Recognition Platforms in Dietary Assessment: Comparison Study %A Van Asbroeck,Stephanie %A Matthys,Christophe %+ Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinology, KU Leuven, Herestraat 49, DIEET, Leuven, Belgium, 32 016 34 26 55, christophe.matthys@uzleuven.be %K image recognition %K dietary assessment %K automated food recognition %K accuracy %D 2020 %7 7.12.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: In the domain of dietary assessment, there has been an increasing amount of criticism of memory-based techniques such as food frequency questionnaires or 24 hour recalls. One alternative is logging pictures of consumed food followed by an automatic image recognition analysis that provides information on type and amount of food in the picture. However, it is currently unknown how well commercial image recognition platforms perform and whether they could indeed be used for dietary assessment. Objective: This is a comparative performance study of commercial image recognition platforms. Methods: A variety of foods and beverages were photographed in a range of standardized settings. All pictures (n=185) were uploaded to selected recognition platforms (n=7), and estimates were saved. Accuracy was determined along with totality of the estimate in the case of multiple component dishes. Results: Top 1 accuracies ranged from 63% for the application programming interface (API) of the Calorie Mama app to 9% for the Google Vision API. None of the platforms were capable of estimating the amount of food. These results demonstrate that certain platforms perform poorly while others perform decently. Conclusions: Important obstacles to the accurate estimation of food quantity need to be overcome before these commercial platforms can be used as a real alternative for traditional dietary assessment methods. %M 33284118 %R 10.2196/15602 %U https://formative.jmir.org/2020/12/e15602 %U https://doi.org/10.2196/15602 %U http://www.ncbi.nlm.nih.gov/pubmed/33284118 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e17139 %T Availability of Spanish-Language Medical Apps in Google Play and the App Store: Retrospective Descriptive Analysis Using Google Tools %A Grau-Corral,Inmaculada %A Gascon,Pau %A Grajales III,Francisco J %A Kostov,Belchin %A Sisó Almirall,Antoni %+ Fundación iSYS, C/Mallorca 140, 2-4, Barcelona, 08036, Spain, 34 692241233, Imma.grau.corral@gmail.com %K apps %K mobile health %K mHealth assessment %K evaluation studies %K health apps %K ratings %K mobile apps, Spanish apps %K patient apps %K Google Advanced Search %K mobile phone %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The number of medical and health apps in the App Store and Google Play repositories has been increasing in the recent years, and most of these apps are in English. However, little is known about the domain of Spanish health apps and their evolution. Objective: The aim of this study was to perform a retrospective descriptive analysis of medical apps for patients in the Spanish language by using Google search tools over a 5-year period and to compare the results by using a reproducible methodology to obtain a better knowledge of the medical apps available in the Spanish Language. Methods: Over a 5-year period, medical apps were catalogued using a Google-based methodology. Keywords of the first 14 categories of the International Classification of Diseases, Tenth Revision, were selected, and in December of each year, searches of the URLs of Google Play and the App Store were conducted using Google Advanced Search. The first 10 results were taken, and apps meeting the inclusion criteria were selected and rated with the iSYScore method. Results: Out of a sample of 1358 apps, 136 met the inclusion criteria. The 3 main categories of the medical apps were in the fields of endocrinology (diabetes), respiratory (chronic obstructive pulmonary disease, asthma, and allergies), and neurology (multiple sclerosis, Parkinson disease, and Alzheimer disease). Few apps were maintained over the 5 years. Only 10 of the 136 apps were maintained for 3 years or more. There was a large number of original apps in other languages that were translated into Spanish (56/136, 41.2%). In the last year of the study, the main reason (73/280, 26.1%) for discarding an app was the date of the last update. Conclusions: The market of Spanish apps is poor; only few apps have appeared repeatedly over 5 years. Differences were found with the international market in terms of apps related to mental health, heart and circulatory system, and cancer, and coincidences were found in the relevance of apps for diabetes control. %M 33270031 %R 10.2196/17139 %U https://mhealth.jmir.org/2020/12/e17139 %U https://doi.org/10.2196/17139 %U http://www.ncbi.nlm.nih.gov/pubmed/33270031 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e16746 %T Ambulatory Phonation Monitoring With Wireless Microphones Based on the Speech Energy Envelope: Algorithm Development and Validation %A Wang,Chi-Te %A Han,Ji-Yan %A Fang,Shih-Hau %A Lai,Ying-Hui %+ Department of Biomedical Engineering, National Yang-Ming University, No155, Sec 2, Linong Street, Taipei, 112, Taiwan, 886 228267021, yh.lai@gm.ym.edu.tw %K voice disorder %K speech envelope %K phonation habits %K background noise %K noise reduction %K adaptive threshold %K dosimetry %K phonotrauma %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Voice disorders mainly result from chronic overuse or abuse, particularly in occupational voice users such as teachers. Previous studies proposed a contact microphone attached to the anterior neck for ambulatory voice monitoring; however, the inconvenience associated with taping and wiring, along with the lack of real-time processing, has limited its clinical application. Objective: This study aims to (1) propose an automatic speech detection system using wireless microphones for real-time ambulatory voice monitoring, (2) examine the detection accuracy under controlled environment and noisy conditions, and (3) report the results of the phonation ratio in practical scenarios. Methods: We designed an adaptive threshold function to detect the presence of speech based on the energy envelope. We invited 10 teachers to participate in this study and tested the performance of the proposed automatic speech detection system regarding detection accuracy and phonation ratio. Moreover, we investigated whether the unsupervised noise reduction algorithm (ie, log minimum mean square error) can overcome the influence of environmental noise in the proposed system. Results: The proposed system exhibited an average accuracy of speech detection of 89.9%, ranging from 81.0% (67,357/83,157 frames) to 95.0% (199,201/209,685 frames). Subsequent analyses revealed a phonation ratio between 44.0% (33,019/75,044 frames) and 78.0% (68,785/88,186 frames) during teaching sessions of 40-60 minutes; the durations of most of the phonation segments were less than 10 seconds. The presence of background noise reduced the accuracy of the automatic speech detection system, and an adjuvant noise reduction function could effectively improve the accuracy, especially under stable noise conditions. Conclusions: This study demonstrated an average detection accuracy of 89.9% in the proposed automatic speech detection system with wireless microphones. The preliminary results for the phonation ratio were comparable to those of previous studies. Although the wireless microphones are susceptible to background noise, an additional noise reduction function can alleviate this limitation. These results indicate that the proposed system can be applied for ambulatory voice monitoring in occupational voice users. %M 33270033 %R 10.2196/16746 %U https://mhealth.jmir.org/2020/12/e16746 %U https://doi.org/10.2196/16746 %U http://www.ncbi.nlm.nih.gov/pubmed/33270033 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e18074 %T Stakeholder Feedback of Electronic Medication Adherence Products: Qualitative Analysis %A Faisal,Sadaf %A Ivo,Jessica %A McDougall,Aidan %A Patel,Tejal %+ School of Pharmacy, University of Waterloo, 10 Victoria St S, Kitchener, ON, N2G 1C5, Canada, 1 519 888 4567 ext 21337, t5patel@uwaterloo.ca %K medication nonadherence %K technology %K aged %K patient preferences %K eHealth %K qualitative research %K adherence %D 2020 %7 1.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Medication management among older adults continues to be a challenge, and innovative electronic medication adherence products have been developed to address this need. Objective: The aim of this study is to examine user experience with electronic medication adherence products, with particular emphasis on features, usefulness, and preferences. Methods: Older adults, caregivers, and health care providers tested the usability of 22 electronic medication adherence products. After testing 5 products, participants were invited to participate in a one-on-one interview to investigate their perceptions and experiences with the features, usefulness, and preference for electronic medication adherence products tested. The interviews were audio recorded, transcribed, and analyzed using exploratory inductive coding to generate themes. The first 13 interviews were independently coded by 2 researchers. The percentage agreement and Cohen kappa after analyzing those interviews were 79% and 0.79, respectively. A single researcher analyzed the remaining interviews. Results: Of the 37 participants, 21 (57%) were older adults, 5 (14%) were caregivers, and 11 (30%) were health care providers. The themes and subthemes generated from the qualitative analysis included product factors (subthemes: simplicity and product features, including availability and usability of alarms, portability, restricted access to medications, and storage capacity) and user factors (subthemes: sentiment, affordability, physical and cognitive capability, and technology literacy and learnability). Conclusions: Electronic medication adherence products have the potential to enable independent medication management in older adults. The choice of a particular product should be made after considering individual preferences for product features, affordability, and the sentiment of the users. Older adults, caregivers, and health care providers prefer electronic medication adherence products that are simple to set up and use, are portable, have easy-to-access medication compartments, are secure, and have adequate storage capacity. %M 33258778 %R 10.2196/18074 %U https://www.jmir.org/2020/12/e18074 %U https://doi.org/10.2196/18074 %U http://www.ncbi.nlm.nih.gov/pubmed/33258778 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 11 %P e14787 %T Smartphone and App Usage in Orthopedics and Trauma Surgery: Survey Study of Physicians Regarding Acceptance, Risks, and Future Prospects in Germany %A Dittrich,Florian %A Back,David Alexander %A Harren,Anna Katharina %A Landgraeber,Stefan %A Reinecke,Felix %A Serong,Sebastian %A Beck,Sascha %+ Department for Orthopaedics and Orthopaedic Surgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Kirrbergerstraße 100, Building 37, Homburg, 66421, Germany, 49 68411624520, Florian.Dittrich@uks.eu %K mHealth %K smartphone %K communication %K medicine %K surveys and questionnaires %K technology %K orthopedics %K trauma surgery %D 2020 %7 30.11.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: In the course of digitization, smartphones are affecting an increasing number of areas of users’ lives, giving them almost ubiquitous access to the internet and other web applications. Mobile health (mHealth) has become an integral part of some areas of patient care. In contrast to other disciplines, routine integration of mobile devices in orthopedics and trauma surgery in Germany is still in its infancy. Objective: This study aimed to investigate physicians’ current state of opinion regarding acceptance, future prospects, and risks of medical apps in the field of orthopedics and trauma surgery in Germany. Methods: A web-based survey among orthopedics and trauma surgeons in German university hospitals on the use of medical apps in everyday clinical practice was conducted between September 2018 and February 2019. The survey consisted of 13 open- and closed-ended or multiple-choice questions. A logistic regression analysis was performed to ascertain the effects of interindividual characteristics on the likelihood of participants’ app and smartphone usage behavior. Results: A total of 206 physicians participated in the survey. All of the participants (206/206, 100%) owned a smartphone, and 79.1% (159/201) used the device, while 64.7% (130/201) used apps regularly in everyday clinical practice. Medical apps were perceived as beneficial, given their substantial future promise, by 90.1% (181/201) of the participants. However, 62.5% (120/192) of the participants were not satisfied with the current supply of medical apps in app stores. Desired specifications for future apps were “intuitive usability” (167/201, 83.1%), “no advertising” (145/201, 72.1%), and “free apps” (92/201, 45.8%). The attributes “transparent app development and app sponsoring” (75/201, 37.3%) and the existence of an “easy-to-understand privacy statement” (50/201, 24.9%) were of minor relevance. The majority of the participants (162/194, 83.5%) considered that future apps in the field of “medical research” would provide the greatest benefit. The greatest predicted risks were “data misuse” (147/189, 77.8%), “usage of untrustworthy apps” (135/189, 71.4%), and “alienation from patients” (51/189, 27.0%). Increasing age was significantly associated with a reduction in the likelihood of regular smartphone (odds ratio [OR] 0.91, 95% CI 0.86-0.97; P=.002) and app (OR 0.90, 95% CI 0.85-0.96; P=.001) usage, while the medical profession grade had no significant impact on the usage behavior. Conclusions: The study demonstrates that young German doctors in orthopedics and trauma surgery already use smartphones and apps in everyday clinical practice. Medical apps are considered to play an important role in the future. However, a significant discrepancy exists between the supply and demand of mHealth applications, which creates a legal and ethical vacuum with regard to data protection. %M 33252340 %R 10.2196/14787 %U http://formative.jmir.org/2020/11/e14787/ %U https://doi.org/10.2196/14787 %U http://www.ncbi.nlm.nih.gov/pubmed/33252340 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e18889 %T Self-Monitoring App Preferences for Sun Protection: Discrete Choice Experiment Survey Analysis %A Nittas,Vasileios %A Mütsch,Margot %A Braun,Julia %A Puhan,Milo Alan %+ Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Hirschengraben 84, Zurich, 8001, Switzerland, 41 44 63 44946, vasileios.nittas@uzh.ch %K preventive medicine %K mHealth %K telemedicine %K health informatics %K health economics %K preferences %K sun protection %D 2020 %7 27.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The availability and use of health apps continues to increase, revolutionizing the way mobile health interventions are delivered. Apps are increasingly used to prevent disease, improve well-being, and promote healthy behavior. On a similar rise is the incidence of skin cancers. Much of the underlying risk can be prevented through behavior change and adequate sun protection. Self-monitoring apps have the potential to facilitate prevention by measuring risk (eg, sun intensity) and encouraging protective behavior (eg, seeking shade). Objective: Our aim was to assess health care consumer preferences for sun protection with a self-monitoring app that tracks the duration and intensity of sun exposure and provides feedback on when and how to protect the skin. Methods: We conducted an unlabeled discrete choice experiment with 8 unique choice tasks, in which participants chose among 2 app alternatives, consisting of 5 preidentified 2-level attributes (self-monitoring method, privacy control, data sharing with health care provides, reminder customizability, and costs) that were the result of a multistep and multistakeholder qualitative approach. Participant preferences, and thus, the relative importance of attributes and their levels were estimated using conditional logit modeling. Analyses consisted of 200 usable surveys, yielding 3196 observations. Results: Our respondents strongly preferred automatic over manually operated self-monitoring (odds ratio [OR] 2.37, 95% CI 2.06-2.72) and no cost over a single payment of 3 Swiss francs (OR 1.72, 95% CI 1.49-1.99). They also preferred having over not having the option of sharing their data with a health care provider of their choice (OR 1.66, 95% CI 1.40-1.97), repeated over single user consents, whenever app data are shared with commercial thirds (OR 1.57, 95% CI 1.31-1.88), and customizable over noncustomizable reminders (OR 1.30, 95% CI 1.09-1.54). While most participants favored thorough privacy infrastructures, the attribute of privacy control was a relatively weak driver of app choice. The attribute of self-monitoring method significantly interacted with gender and perceived personal usefulness of health apps, suggesting that female gender and lower perceived usefulness are associated with relatively weaker preferences for automatic self-monitoring. Conclusions: Based on the preferences of our respondents, we found that the utility of a self-monitoring sun protection app can be increased if the app is simple and adjustable; requires minimal effort, time, or expense; and has an interoperable design and thorough privacy infrastructure. Similar features might be desirable for preventive health apps in other areas, paving the way for future discrete choice experiments. Nonetheless, to fully understand these preference dynamics, further qualitative or mixed method research on mobile self-monitoring-based sun protection and broader preventive mobile self-monitoring is required. International Registered Report Identifier (IRRID): RR2-10.2196/16087 %M 33245282 %R 10.2196/18889 %U http://www.jmir.org/2020/11/e18889/ %U https://doi.org/10.2196/18889 %U http://www.ncbi.nlm.nih.gov/pubmed/33245282 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e15978 %T Using Mobile Health Technology to Deliver a Community-Based Closed-Loop Management System for Chronic Obstructive Pulmonary Disease Patients in Remote Areas of China: Development and Prospective Observational Study %A Deng,Ning %A Chen,Juan %A Liu,Yiyuan %A Wei,Shuoshuo %A Sheng,Leiyi %A Lu,Rong %A Wang,Zheyu %A Zhu,Jiarong %A An,Jiye %A Wang,Bei %A Lin,Hui %A Wang,Xiuyan %A Zhou,Yumin %A Duan,Huilong %A Ran,Pixin %+ State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, 195 Dongfeng Xi Road, Guangzhou, , China, 86 020 3710 3001, pxran@gzhmu.edu.cn %K COPD %K mobile health technology %K closed-loop care pathway %K chronic disease management %K exacerbations %D 2020 %7 25.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) technology is an increasingly recognized and effective method for disease management and has the potential to intervene in pulmonary function, exacerbation risk, and psychological status of patients with chronic obstructive pulmonary disease (COPD). Objective: This study aimed to investigate the feasibility of an mHealth-based COPD management system designed for Chinese remote areas with many potential COPD patients but limited medical resources. Methods: The system was implemented based on a tailored closed-loop care pathway that breaks the heavy management tasks into detailed pieces to be quantified and executed by computers. Low-cost COPD evaluation and questionnaire-based psychological intervention are the 2 main characteristics of the pathway. A 6-month prospective observational study at the community level was performed to evaluate the effect of the system. Primary outcomes included changes in peak expiratory flow values, quality of life measured using the COPD assessment test scale, and psychological condition. Acute exacerbations, compliance, and adverse events were also measured during the study. Compliance was defined as the ratio of the actual frequency of self-monitoring records to the prescribed number. Results: A total of 56 patients was enrolled; 39 patients completed the 6-month study. There was no significant difference in the mean peak expiratory flow value before and after the 6-month period (366.1, SD 106.7 versus 313.1, SD 116.6; P=.11). Psychological condition significantly improved after 6 months, especially for depression, as measured using the Patient Health Questionnaire-9 scale (median 6.0, IQR 3.0-9.0 versus median 4.0, IQR 0.0-6.0; P=.001). The COPD assessment test score after 6 months of intervention was also lower than that at the baseline, and the difference was significant (median 4.0, IQR 1.0-6.0 versus median 3.0, IQR 0.0-6.0; P=.003). The median overall compliance was 91.1% (IQR 67%-100%). In terms of acute exacerbation, 110 exacerbations were detected and confirmed by health care providers (per 6 months, median 2.0, IQR 1.0-5.0). Moreover, 72 adverse events occurred during the study, including 1 death, 19 hospitalizations, and 52 clinic visits due to persistent respiratory symptoms. Conclusions: We designed and validated a feasible mHealth-based method to manage COPD in remote Chinese areas with limited medical resources. The proposed closed-loop care pathway was effective at the community level. Proper education and frequent communication with health care providers may encourage patients’ acceptance and use of smartphones to support COPD self-management. In addition, WeChat might play an important role in improving patient compliance and psychological distress. Further research might explore the effect of such systems on a larger scale and at a higher evidence level. %M 33237036 %R 10.2196/15978 %U http://mhealth.jmir.org/2020/11/e15978/ %U https://doi.org/10.2196/15978 %U http://www.ncbi.nlm.nih.gov/pubmed/33237036 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 5 %N 4 %P e19650 %T Mobile Clinical Decision Support System for the Management of Diabetic Patients With Kidney Complications in UK Primary Care Settings: Mixed Methods Feasibility Study %A Alhodaib,Hala Ibrahim %A Antza,Christina %A Chandan,Joht Singh %A Hanif,Wasim %A Sankaranarayanan,Sailesh %A Paul,Sunjay %A Sutcliffe,Paul %A Nirantharakumar,Krishnarajah %+ Division of Health Sciences, Warwick Medical School, University of Warwick, Medical School Building, Coventry, CV4 7AL, United Kingdom, 44 2476 574505, P.A.Sutcliffe@warwick.ac.uk %K eHealth %K clinical decision support application %K diabetes mellitus %K chronic kidney disease %K feasibility study %D 2020 %7 18.11.2020 %9 Original Paper %J JMIR Diabetes %G English %X Background: Attempts to utilize eHealth in diabetes mellitus (DM) management have shown promising outcomes, mostly targeted at patients; however, few solutions have been designed for health care providers. Objective: The purpose of this study was to conduct a feasibility project developing and evaluating a mobile clinical decision support system (CDSS) tool exclusively for health care providers to manage chronic kidney disease (CKD) in patients with DM. Methods: The design process was based on the 3 key stages of the user-centered design framework. First, an exploratory qualitative study collected the experiences and views of DM specialist nurses regarding the use of mobile apps in clinical practice. Second, a CDSS tool was developed for the management of patients with DM and CKD. Finally, a randomized controlled trial examined the acceptability and impact of the tool. Results: We interviewed 15 DM specialist nurses. DM specialist nurses were not currently using eHealth solutions in their clinical practice, while most nurses were not even aware of existing medical apps. However, they appreciated the potential benefits that apps may bring to their clinical practice. Taking into consideration the needs and preferences of end users, a new mobile CDSS app, “Diabetes & CKD,” was developed based on guidelines. We recruited 39 junior foundation year 1 doctors (44% male) to evaluate the app. Of them, 44% (17/39) were allocated to the intervention group, and 56% (22/39) were allocated to the control group. There was no significant difference in scores (maximum score=13) assessing the management decisions between the app and paper-based version of the app’s algorithm (intervention group: mean 7.24 points, SD 2.46 points; control group: mean 7.39, SD 2.56; t37=–0.19, P=.85). However, 82% (14/17) of the participants were satisfied with using the app. Conclusions: The findings will guide the design of future CDSS apps for the management of DM, aiming to help health care providers with a personalized approach depending on patients’ comorbidities, specifically CKD, in accordance with guidelines. %M 33206055 %R 10.2196/19650 %U https://diabetes.jmir.org/2020/4/e19650 %U https://doi.org/10.2196/19650 %U http://www.ncbi.nlm.nih.gov/pubmed/33206055 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 11 %P e21874 %T Assessment of mHealth Interventions: Need for New Studies, Methods, and Guidelines for Study Designs %A Ologeanu-Taddei,Roxana %+ TBS Business School, 1, place Alphonse Jourdain, Toulouse, 31068, France, 33 5 61 29 48 51, r.ologeanu-taddei@tbs-education.fr %K eHealth %K mHealth %K usability %K management %K survey %K trust %K guidelines %K evaluation %D 2020 %7 18.11.2020 %9 Viewpoint %J JMIR Med Inform %G English %X This viewpoint argues that the clinical effects of mobile health (mHealth) interventions depends on the acceptance and adoption of these interventions and their mediators, such as usability of the mHealth software, software performance and features, training and motivation of patients and health care professionals to participate in the experience, or characteristics of the intervention (eg, personalized feedback). %M 33206060 %R 10.2196/21874 %U http://medinform.jmir.org/2020/11/e21874/ %U https://doi.org/10.2196/21874 %U http://www.ncbi.nlm.nih.gov/pubmed/33206060 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e20009 %T Vaping-Related Mobile Apps Available in the Google Play Store After the Apple Ban: Content Review %A Meacham,Meredith C %A Vogel,Erin A %A Thrul,Johannes %+ Department of Psychiatry and Behavioral Sciences, University of California San Francisco, 401 Parnassus Ave, San Francisco, CA, 94143, United States, 1 415 206 4253, Meredith.Meacham@ucsf.edu %K vaping %K mobile apps %K nicotine %K cannabis %D 2020 %7 13.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In response to health concerns about vaping devices (eg, youth nicotine use, lung injury), Apple removed 181 previously approved vaping-related apps from the App Store in November 2019. This policy change may lessen youth exposure to content that glamorizes vaping; however, it may also block important sources of information and vaping device control for adults seeking to use vaping devices safely. Objective: Understanding the types of nicotine and cannabis vaping–related apps still available in the competing Google Play Store can shed light on how digital apps may reflect information available to consumers. Methods: In December 2019, we searched the Google Play Store for vaping-related apps using the keywords "vape" and "vaping" and reviewed the first 100 apps presented in the results. We reviewed app titles, descriptions, screenshots, and metadata to categorize the intended substance (nicotine or cannabis/tetrahydrocannabinol) and the app’s purpose. The most installed apps in each purpose category were downloaded and evaluated for quality and usability with the Mobile App Rating Scale. Results: Of the first 100 apps, 79 were related to vaping. Of these 79 apps, 43 (54%) were specific to nicotine, 3 (4%) were specific to cannabis, 1 (1%) was intended for either, and for the remaining 31 (39%), the intended substance was unclear. The most common purposes of the apps were making do-it-yourself e-liquids (28/79, 35%) or coils (25/79, 32%), games/entertainment (19/79, 24%), social networking (16/79, 20%), and shopping for vaping products (15/79, 19%). Of the 79 apps, at least 4 apps (5%) paired with vaping devices to control temperature or dose settings, 8 apps (10%) claimed to help people quit smoking using vaping, and 2 apps (3%) had the goal of helping people quit vaping. Conclusions: The majority of vaping-related apps in the Google Play Store had features either to help users continue vaping, such as information for modifying devices, or to maintain interest in vaping. Few apps were for controlling device settings or assisting with quitting smoking or vaping. Assuming that these Google Play Store apps were similar in content to the Apple App Store apps that were removed, it appears that Apple’s ban would have a minimal effect on people who vape with the intention of quitting smoking or who are seeking information about safer vaping via mobile apps. %M 33185565 %R 10.2196/20009 %U http://www.jmir.org/2020/11/e20009/ %U https://doi.org/10.2196/20009 %U http://www.ncbi.nlm.nih.gov/pubmed/33185565 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e17405 %T A Mobile Health Mindfulness Intervention for Women With Moderate to Moderately Severe Postpartum Depressive Symptoms: Feasibility Study %A Avalos,Lyndsay A %A Aghaee,Sara %A Kurtovich,Elaine %A Quesenberry Jr,Charles %A Nkemere,Linda %A McGinnis,MegAnn K %A Kubo,Ai %+ Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA, 94612, United States, 1 510 891 3426, Lyndsay.A.Avalos@kp.org %K depression %K postpartum %K health services, mental %K eHealth %K mental health %K internet-based intervention %K mindfulness %K behavioral intervention %K mobile phone %D 2020 %7 12.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Approximately 20% of women suffer from postpartum depression (PPD). Due to barriers such as limited access to care, half of the women with PPD do not receive treatment. Therefore, it is critical to identify effective and scalable interventions. Traditional mindfulness programs have been effective in reducing depressive symptoms, however access remains a barrier. A self-paced mobile health (mHealth) mindfulness program may fit the lifestyle of busy mothers who are unable to attend in-person classes. However, little is known regarding the feasibility or efficacy of mHealth mindfulness interventions in postpartum women with depressive symptoms. Objective: This study aims to assess the feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms. Methods: We conducted a single-arm feasibility trial of an mHealth mindfulness intervention within Kaiser Permanente Northern California (KPNC), a large integrated health care system. Participants were identified through clinician referral and electronic health records via KPNC's universal perinatal depression screening program and recruited by the study team. Inclusion criteria included the following: English-speaking, up to 6 months postpartum with a Patient Health Questionnaire (PHQ-8) score of 10 to 19, and no regular mindfulness/meditation practice. Participants were asked to use a mindfulness app, Headspace, 10 to 20 min/day for 6 weeks. Baseline and postintervention surveys captured data on patient-reported outcomes (depression and stress symptoms, sleep quality, and mindfulness). Semistructured interviews captured acceptability. Retention and adherence were used to assess feasibility. Results: Of the 115 women who were contacted and met the eligibility criteria or declined participation before eligibility assessment, 27 (23%) were enrolled. In addition, 70% (19/27) completed the study. The mean age of participants was 31 years (SD 5.2), 30% (8/27) were non-Hispanic White, and, on average, participants were 12.3 weeks postpartum (SD 5.7). Of the women who completed the study, 100% (19/19) used the Headspace app at least once, and nearly half (9/19, 47%) used the app on ≥50% of the days during the 6-week intervention period. Of the 16 participants who completed the postintervention interview, 69% (11/16) reported that they were very or extremely satisfied with the app. Interviews indicated that women appreciated the variety of meditations and felt that the program led to reduced anxiety and improved sleep. Significant improvements in pre- and postintervention scores were observed for depressive symptoms (PHQ-8: −3.8, P=.004), perceived stress (10-item Perceived Stress Scale: −6.0, P=.005), and sleep quality (Pittsburgh Sleep Quality Index: −2.1, P=.02, indicating less sleep disturbance). Improvements in mindfulness were also significant (Five Facet Mindfulness Questionnaire-Short Form: 10.9, P=.01). Conclusions: An mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms is feasible and acceptable. An efficacy trial is warranted. %M 33180028 %R 10.2196/17405 %U https://mental.jmir.org/2020/11/e17405 %U https://doi.org/10.2196/17405 %U http://www.ncbi.nlm.nih.gov/pubmed/33180028 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e19260 %T Asynchronous mHealth Interventions in Rheumatoid Arthritis: Systematic Scoping Review %A Seppen,Bart F %A den Boer,Pim %A Wiegel,Jimmy %A ter Wee,Marieke M %A van der Leeden,Marike %A de Vries,Ralph %A van der Esch,Martin %A Bos,Wouter H %+ Amsterdam Rheumatology and Immunology Center, Reade, Doctor Jan van Breemenstraat 1, Amsterdam, 1056 AB, Netherlands, 31 202421800, b.seppen@reade.nl %K mobile health %K eHealth %K digital health %K telehealth %K telerheumatology %K mHealth %K web app %K smartphone app %K activity tracker %K rheumatoid arthritis %K rheumatology %K review %K telemonitoring %D 2020 %7 5.11.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Mobile devices such as smartphones and tablets have surged in popularity in recent years, generating numerous possibilities for their use in health care as mobile health (mHealth) tools. One advantage of mHealth is that it can be provided asynchronously, signifying that health care providers and patients are not communicating in real time. The integration of asynchronous mHealth into daily clinical practice might therefore help to make health care more efficient for patients with rheumatoid arthritis (RA). The benefits have been reviewed in various medical conditions, such as diabetes and asthma, with promising results. However, to date, it is unclear what evidence exists for the use of asynchronous mHealth in the field of RA. Objective: The objective of this study was to map the different asynchronous mHealth interventions tested in clinical trials in patients with RA and to summarize the effects of the interventions. Methods: A systematic search of Pubmed, Scopus, Cochrane, and PsycINFO was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were initially screened and later assessed by two independent researchers. Disagreements on inclusion or exclusion of studies were resolved by discussion. Results: The literature search yielded 1752 abstracts. After deduplication and screening, 10 controlled intervention studies were included. All studies were assessed to be at risk for bias in at least one domain of the Cochrane risk-of-bias tool. In the 10 selected studies, 4 different types of mHealth interventions were used: SMS reminders (to increase medication adherence or physical activity; n=3), web apps (for disease monitoring and/or to provide medical information; n=5), smartphone apps (for disease monitoring; n=1), and pedometers (to increase and track steps; n=1). Measured outcomes varied widely between studies; improvements were seen in terms of medication compliance (SMS reminders), reaching rapid remission (web app), various domains of physical activity (pedometer, SMS reminders, and web apps), patient-physician interaction (web apps), and self-efficacy (smartphone app). Conclusions: SMS reminders, web apps, smartphone apps, and pedometers have been evaluated in intervention studies in patients with RA. These interventions have been used to monitor patients or to support them in their health behavior. The use of asynchronous mHealth led to desirable outcomes in nearly all studies. However, since all studies were at risk of bias and methods used were very heterogeneous, high-quality research is warranted to corroborate these promising results. %M 33151161 %R 10.2196/19260 %U http://mhealth.jmir.org/2020/11/e19260/ %U https://doi.org/10.2196/19260 %U http://www.ncbi.nlm.nih.gov/pubmed/33151161 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e15116 %T A Mobile App, KhunLook, to Support Thai Parents and Caregivers With Child Health Supervision: Development, Validation, and Acceptability Study %A Areemit,Rosawan %A Lumbiganon,Pagakrong %A Suphakunpinyo,Chanyut %A Jetsrisuparb,Arunee %A Sutra,Sumitr %A Sripanidkulchai,Kunwadee %+ Department of Computer Engineering, Faculty of Engineering, Chulalongkorn University, Phayatai Road, Wang Mai, Pathumwan, Bangkok, 10330, Thailand, 66 2 218 6998, kunwadee@cp.eng.chula.ac.th %K mobile app %K mHealth %K KhunLook %K child health supervision %K maternal and child health handbook %K feasibility %K acceptability %K Thailand %K mobile phone %D 2020 %7 30.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In Thailand, children born in government hospitals receive a maternal and child health handbook (MCHH). However, when a new MCHH edition is released, those with the previous editions do not have access to the updated information. A mobile app is an appealing platform to fill this gap. We developed a mobile app called “KhunLook” as an interactive electronic MCHH intended to assist parents in child health supervision. Objective: This study describes the user requirements and development of the KhunLook mobile app, validity of parents’ growth assessments, and parents’ evaluation of feasibility and acceptability of the app. Methods: Phase 1 was a qualitative study using individual interviews. The interview data were used to revise the prototype. In phase 2, parents were randomly assigned to assess their children’s growth with the app or the MCHH. The outcomes were compared to those of the physician’s assessment, and congruence was determined. In phase 3, parents evaluated the feasibility and acceptability of the app in comparison to the MCHH through a web-based survey. Results: Four health care providers and 8 parents participated in phase 1. Two themes were identified: (1) the mobile app potentially counters parents’ infrequent use of the MCHH with accuracy, attractiveness, convenience, and simplicity, and (2) health supervision needs to be standard, up-to-date, and understandable. KhunLook was publicly launched with a family page and 7 key features: growth and nutrition, development, immunizations, oral health, reminders for the next appointment, memories, and health advice. In phase 2, 56 parents participated in the growth parameter assessments; 34 were in the App group and 22 in the MCHH group. The outcomes of the growth parameter assessments between parents and physicians in both the App and MCHH groups were not significantly different. The congruence proportions were higher in the App group for weight and head circumference, but the differences were not statistically significant. In phase 3, 356 parents from all over Thailand participated in a web-based survey. Parents rated the app feasibility as “very easy to easy” to use at higher proportions than the MCHH in all health assessment domains (growth, development, and immunizations) and ease-of-use domains with statistical significance (P<.001). The KhunLook app received a significantly higher mean score (8.59/10) than the MCHH (7.6/10) (P<.001). Most parents (317/356, 89.0%) preferred the app over MCHH. Further, 93.5% (333/356) of the parents stated that they would continue to use the app and 96.9% (345/356) would recommend others to use it. Conclusions: KhunLook, a Thai mobile app for child health supervision, was developed, validated for growth assessments, and was well accepted for ease-of-use by parents. Further studies should be conducted with a large scale of users, and the impact of this app on health behaviors and health outcomes must be evaluated. %M 33124989 %R 10.2196/15116 %U http://mhealth.jmir.org/2020/10/e15116/ %U https://doi.org/10.2196/15116 %U http://www.ncbi.nlm.nih.gov/pubmed/33124989 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e21159 %T Primary Prevention of Cardiovascular Disease and Type 2 Diabetes Mellitus Using Mobile Health Technology: Systematic Review of the Literature %A Buss,Vera Helen %A Leesong,Stuart %A Barr,Margo %A Varnfield,Marlien %A Harris,Mark %+ Centre for Primary Health Care and Equity, University of New South Wales, Level 3, AGSM Building, UNSW Sydney, Sydney, 2052, Australia, 61 293851547, v.buss@student.unsw.edu.au %K systematic review %K mobile health %K telemedicine %K primary prevention %K cardiovascular diseases %K diabetes mellitus, type 2 %D 2020 %7 29.10.2020 %9 Review %J J Med Internet Res %G English %X Background: Digital technology is an opportunity for public health interventions to reach a large part of the population. Objective: This systematic literature review aimed to assess the effectiveness of mobile health–based interventions in reducing the risk of cardiovascular disease and type 2 diabetes mellitus. Methods: We conducted the systematic search in 7 electronic databases using a predefined search strategy. We included articles published between inception of the databases and March 2019 if they reported on the effectiveness of an intervention for prevention of cardiovascular disease or type 2 diabetes via mobile technology. One researcher performed the search, study selection, data extraction, and methodological quality assessment. The steps were validated by the other members of the research team Results: The search yielded 941 articles for cardiovascular disease, of which 3 met the inclusion criteria, and 732 for type 2 diabetes, of which 6 met the inclusion criteria. The methodological quality of the studies was low, with the main issue being nonblinding of participants. Of the selected studies, 4 used SMS text messaging, 1 used WhatsApp, and the remaining ones used specific smartphone apps. Weight loss and reduction in BMI were the most reported successful outcomes (reported in 4 studies). Conclusions: Evidence on the effectiveness of mobile health-based interventions in reducing the risk for cardiovascular disease and type 2 diabetes is low due to the quality of the studies and the small effects that were measured. This highlights the need for further high-quality research to investigate the potential of mobile health interventions. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019135405; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=135405 %M 33118936 %R 10.2196/21159 %U http://www.jmir.org/2020/10/e21159/ %U https://doi.org/10.2196/21159 %U http://www.ncbi.nlm.nih.gov/pubmed/33118936 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e18858 %T Mobile Apps for Speech-Language Therapy in Adults With Communication Disorders: Review of Content and Quality %A Vaezipour,Atiyeh %A Campbell,Jessica %A Theodoros,Deborah %A Russell,Trevor %+ RECOVER Injury Research Centre, Faculty of Health and Behavioural Sciences, The University of Queensland, 288 Herston Road, Brisbane, 4006, Australia, 61 7 3365 5560, a.vaezipour@uq.edu.au %K communication disorders %K speech therapy %K language therapy %K ergonomics %K rehabilitation %K mobile health %K mHealth %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Worldwide, more than 75% of people with acquired brain injury (ABI) experience communication disorders. Communication disorders are impairments in the ability to communicate effectively, that is, sending, receiving, processing, and comprehending verbal and nonverbal concepts and symbols. Such disorders may have enduring impacts on employment, social participation, and quality of life. Technology-enabled interventions such as mobile apps have the potential to increase the reach of speech-language therapy to treat communication disorders. However, ensuring that apps are evidence-based and of high quality is critical for facilitating safe and effective treatment for adults with communication disorders. Objective: The aim of this review is to identify mobile apps that are currently widely available to adults with communication disorders for speech-language therapy and to assess their content and quality using the validated Mobile App Rating Scale (MARS). Methods: Google Play Store, Apple App Store, and webpages were searched to identify mobile apps for speech-language therapy. Apps were included in the review if they were designed for the treatment of adult communication disorders after ABI, were in English, and were either free or for purchase. Certified speech-language pathologists used the MARS to assess the quality of the apps. Results: From a total of 2680 apps identified from Google Play Store, Apple App Store, and web searches, 2.61% (70/2680) apps met the eligibility criteria for inclusion. Overall, 61% (43/70) were available for download on the iPhone Operating System (iOS) platform, 20% (14/70) on the Android platform, and 19% (13/70) on both iOS and Android platforms. A content analysis of the apps revealed 43 apps for language, 17 apps for speech, 8 apps for cognitive communication, 6 apps for voice, and 5 apps for oromotor function or numeracy. The overall MARS mean score was 3.7 out of 5, SD 0.6, ranging between 2.1 and 4.5, with functionality being the highest-scored subscale (4.3, SD 0.6), followed by aesthetics (3.8, SD 0.8), information (3.4, SD 0.6), and engagement (3.3, SD 0.6). The top 5 apps were Naming Therapy (4.6/5), Speech Flipbook Standard (4.6/5), Number Therapy (4.5/5), Answering Therapy, and Constant Therapy (4.4/5). Conclusions: To our knowledge, this is the first study to systematically identify and evaluate a broad range of mobile apps for speech-language therapy for adults with communication disorders after sustaining ABI. We found a lack of interactive and engaging elements in the apps, a critical factor in sustaining self-managed speech-language therapy. More evidence-based apps with a focus on human factors, user experience, and a patient-led design approach are required to enhance effectiveness and long-term use. %M 33118953 %R 10.2196/18858 %U http://mhealth.jmir.org/2020/10/e18858/ %U https://doi.org/10.2196/18858 %U http://www.ncbi.nlm.nih.gov/pubmed/33118953 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e16898 %T Creating a Smartphone App for Caregivers of Children With Atopic Dermatitis With Caregivers, Health Care Professionals, and Digital Health Experts: Participatory Co-Design %A Xu,Xiaomeng %A Griva,Konstadina %A Koh,Mark %A Lum,Elaine %A Tan,Woan Shin %A Thng,Steven %A Car,Josip %+ Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Clinical Sciences Building, 11 Mandalay Road, Singapore, 308232, Singapore, 65 81616659, xxu020@e.ntu.edu.sg %K atopic dermatitis %K eczema %K mobile phone %K telehealth %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone apps could support patients and caregivers in disease self-management. However, as patients’ experiences and needs might not always align with clinical judgments, the eliciting and engaging of perspectives of all stakeholders in the smartphone app design process is of paramount importance. Objective: The aims of this study are to better understand the needs of and challenges facing caregivers and health care professionals (HCPs) who care for children with atopic dermatitis (AD) and to explore the desirable features and content of a smartphone app that would support AD self-management. Methods: This study adopted a qualitative participatory co-design methodology involving 3 focus group discussions: workshop one focused on caregivers; workshop two engaged with HCPs; and in the last workshop, caregivers and digital health experts were asked to design the wireframe prototype. The participants completed a sociodemographic questionnaire, a technology acceptance questionnaire, and a workshop evaluation form. Results: Twelve caregivers participated in the first workshop, and 10 HCPs participated in the second workshop. Eight caregivers and 4 digital health experts attended the third workshop. Three superordinate themes that reflected caregivers’ and HCPs’ challenges and needs were identified: empowerment by education, confusion over treatment, and emotional impact. Workshop participants also raised a series of suggestions on the features and contents of the AD self-management app, which informed the last co-design workshop, and described their needs and challenges. In the last workshop, the participants developed a wireframe prototype of the app following the identified requirements and recommendations. Conclusions: The co-design approach was found to be a successful way of engaging with the participants, as it allowed them to express their creativity and helped us to articulate the root of the clinical problems. The co-design workshop was successful in creating and generating new ideas and solutions for smartphone app development. %M 33118949 %R 10.2196/16898 %U http://mhealth.jmir.org/2020/10/e16898/ %U https://doi.org/10.2196/16898 %U http://www.ncbi.nlm.nih.gov/pubmed/33118949 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e15076 %T Evaluating Asthma Mobile Apps to Improve Asthma Self-Management: User Ratings and Sentiment Analysis of Publicly Available Apps %A Camacho-Rivera,Marlene %A Vo,Huy %A Huang,Xueqi %A Lau,Julia %A Lawal,Adeola %A Kawaguchi,Akira %+ Department of Community Health Sciences, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, MSC 43, Brooklyn, NY, 11203, United States, 1 7182704386, marlene.camacho-rivera@downstate.edu %K mHealth %K asthma apps %K sentiment analysis %K user ratings %K smartphone %K mobile phone %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The development and use of mobile health (mHealth) apps for asthma management have risen dramatically over the past two decades. Asthma apps vary widely in their content and features; however, prior research has rarely examined preferences of users of publicly available apps. Objective: The goals of this study were to provide a descriptive overview of asthma mobile apps that are publicly available and to assess the usability of asthma apps currently available on the market to identify content and features of apps associated with positive and negative user ratings. Methods: Reviews were collected on June 23, 2020, and included publicly posted reviews until June 21, 2020. To characterize features associated with high or low app ratings, we first dichotomized the average user rating of the asthma app into 2 categories: a high average rating and a low average rating. Asthma apps with average ratings of 4 and above were categorized as having a high average rating. Asthma apps with average ratings of less than 4 were categorized as having a low average rating. For the sentiment analysis, we modeled both 2-word (bi-gram) and 3-word (tri-gram) phrases which commonly appeared across highly rated and lowly rated apps. Results: Of the 10 apps that met the inclusion criteria, a total of 373 reviews were examined across all apps. Among apps reviewed, 53.4% (199/373) received high ratings (average ratings of 4 or 5) and 47.2% (176/373) received low ratings (average ratings of 3 or less). The number of ratings across all apps ranged from 188 (AsthmaMD) to 10 (My Asthma App); 30% (3/10) of apps were available on both Android and iOS. From the sentiment analysis, key features of asthma management that were common among highly rated apps included the tracking of peak flow readings (n=48), asthma symptom monitoring (n=11), and action plans (n=10). Key features related to functionality that were common among highly rated apps included ease of use (n=5). Users most commonly reported loss of data (n=14) and crashing of app (n=12) as functionality issues among poorly rated asthma apps. Conclusions: Our study results demonstrate that asthma app quality, maintenance, and updates vary widely across apps and platforms. These findings may call into question the long-term engagement with asthma apps, a crucial factor for determining their potential to improve asthma self-management and asthma clinical outcomes. %M 33118944 %R 10.2196/15076 %U http://mhealth.jmir.org/2020/10/e15076/ %U https://doi.org/10.2196/15076 %U http://www.ncbi.nlm.nih.gov/pubmed/33118944 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e19503 %T Vaccipack, A Mobile App to Promote Human Papillomavirus Vaccine Uptake Among Adolescents Aged 11 to 14 Years: Development and Usability Study %A Teitelman,Anne M %A Gregory,Emily F %A Jayasinghe,Joshua %A Wermers,Zara %A Koo,Ja H %A Morone,Jennifer F %A Leri,Damien C %A Davis,Annet %A Feemster,Kristen A %+ University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA, 19104, United States, 1 2158981910, teitelm@nursing.upenn.edu %K cervical cancer %K prevention %K mobile health %K parents %K adolescent health %K vaccine %K human papillomavirus %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Nursing %G English %X Background: More than 90% of human papillomavirus (HPV)-related cancers could be prevented by widespread uptake of the HPV vaccine, yet vaccine use in the United States falls short of public health goals. Objective: The purpose of this study was to describe the development, acceptability, and intention to use the mobile app Vaccipack, which was designed to promote uptake and completion of the adolescent HPV vaccine series. Methods: Development of the mobile health (mHealth) content was based on the integrated behavioral model (IBM). The technology acceptance model (TAM) was used to guide the app usability evaluation. App design utilized an iterative process involving providers and potential users who were parents and adolescents. App features include a vaccine-tracking function, a discussion forum, and stories with embedded messages to promote intention to vaccinate. Parents and adolescents completed surveys before and after introducing the app in a pediatric primary care setting with low HPV vaccination rates. Results: Surveys were completed by 54 participants (20 adolescents aged 11 to 14 years and 34 parents). Notably, 75% (15/20) of adolescents and 88% (30/34) of parents intended to use the app in the next 2 weeks. Acceptability of the app was high among both groups: 88% (30/34) of parents and 75% (15/20) of adolescents indicated that Vaccipack was easy to use, and 82% (28/34) of parents and 85% (17/20) of adolescents perceived the app to be beneficial. Higher levels of app acceptability were found among parents with strong intentions to use the app (P=.09; 95% CI –2.15 to 0.15). Conclusions: mHealth technology, such as Vaccipack, may be an acceptable and nimble platform for providing information to parents and adolescents and advancing the uptake of important vaccines. %R 10.2196/19503 %U https://nursing.jmir.org/2020/1/e19503/ %U https://doi.org/10.2196/19503 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e17470 %T Patients’ Experiences of Using Smartphone Apps to Support Self-Management and Improve Medication Adherence in Hypertension: Qualitative Study %A McBride,Ciara M %A Morrissey,Eimear C %A Molloy,Gerard J %+ School of Psychology, National Univeristy of Ireland Galway, University Road, Galway, H91 TK33, Ireland, 353 91524411, mcbrideciara5@gmail.com %K hypertension %K self-management %K mobile applications %K feasibility %K usability %K medication adherence %K qualitative research %K digital technology %K mobile phone %D 2020 %7 28.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Worldwide, hypertension control rates remain suboptimal despite clinically effective antihypertensive drug therapy. Patient failure to take medication as prescribed (ie, nonadherence) is the most important factor contributing to poor control. Smartphone apps can facilitate the delivery of evidence-based behavior change techniques to improve adherence and may provide a scalable, usable, and feasible method to deliver self-management support. Objective: The aim of this study is to explore patients’ experiences of the usability and feasibility of smartphone apps to support self-management and improve medication adherence in hypertension. Methods: A qualitative descriptive study was conducted. A total of 11 people living with hypertension from the West of Ireland were sampled purposively and interviewed about their experience of using a self-management app for a 4-week period, which included two key functionalities: self-monitoring of blood pressure (BP) and medication reminders. Thematic analysis was carried out on the semistructured interview data. Results: Participants’ age ranged from 43 to 74 years (mean 62 years, SD 9.13). Three themes were identified: digital empowerment of self-management, human versus digital systems, and digital sustainability. Although patients’ experience of using the technology to self-monitor BP was one of empowerment, characterized by an enhanced insight and understanding into their condition, control, and personal responsibility, the reminder function was only feasible for patients who reported unintentional nonadherence to treatment. Patients experienced the app as a sustainable tool to support self-management and found it easy to use, including those with limited technological competence. Conclusions: The study’s findings provide new insights into the experience of using apps to support medication adherence in hypertension. Overall, the data support apps as a usable and feasible method to aid self-management of hypertension and highlight the need for personalized functionality, particularly with regard to medication adherence reminder strategies. The study’s findings challenge the perspective that the use of these technologies to support self-management can inevitably add to the burden of treatment experienced by patients. %M 33112251 %R 10.2196/17470 %U http://mhealth.jmir.org/2020/10/e17470/ %U https://doi.org/10.2196/17470 %U http://www.ncbi.nlm.nih.gov/pubmed/33112251 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e22108 %T Evaluating the Utility of Smartphone-Based Sensor Assessments in Persons With Multiple Sclerosis in the Real-World Using an App (elevateMS): Observational, Prospective Pilot Digital Health Study %A Pratap,Abhishek %A Grant,Daniel %A Vegesna,Ashok %A Tummalacherla,Meghasyam %A Cohan,Stanley %A Deshpande,Chinmay %A Mangravite,Lara %A Omberg,Larsson %+ Sage Bionetworks, 2901 Third Avenue, Suite 330, Seattle, WA, 98121, United States, 1 (206) 928 8260, larsson.omberg@sagebionetworks.org %K multiple sclerosis %K digital health %K real-world data %K real-world evidence %K remote monitoring %K smartphone %K mobile phone %K neurodegeneration %D 2020 %7 27.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Multiple sclerosis (MS) is a chronic neurodegenerative disease. Current monitoring practices predominantly rely on brief and infrequent assessments, which may not be representative of the real-world patient experience. Smartphone technology provides an opportunity to assess people’s daily-lived experience of MS on a frequent, regular basis outside of episodic clinical evaluations. Objective: The objectives of this study were to evaluate the feasibility and utility of capturing real-world MS-related health data remotely using a smartphone app, “elevateMS,” to investigate the associations between self-reported MS severity and sensor-based active functional tests measurements, and the impact of local weather conditions on disease burden. Methods: This was a 12-week, observational, digital health study involving 3 cohorts: self-referred participants who reported an MS diagnosis, clinic-referred participants with neurologist-confirmed MS, and participants without MS (controls). Participants downloaded the elevateMS app and completed baseline assessments, including self-reported physical ability (Patient-Determined Disease Steps [PDDS]), as well as longitudinal assessments of quality of life (Quality of Life in Neurological Disorders [Neuro-QoL] Cognitive, Upper Extremity, and Lower Extremity Function) and daily health (MS symptoms, triggers, health, mobility, pain). Participants also completed functional tests (finger-tapping, walk and balance, voice-based Digit Symbol Substitution Test [DSST], and finger-to-nose) as an independent assessment of MS-related cognition and motor activity. Local weather data were collected each time participants completed an active task. Associations between self-reported baseline/longitudinal assessments, functional tests, and weather were evaluated using linear (for cross-sectional data) and mixed-effects (for longitudinal data) regression models. Results: A total of 660 individuals enrolled in the study; 31 withdrew, 495 had MS (n=359 self-referred, n=136 clinic-referred), and 134 were controls. Participation was highest in clinic-referred versus self-referred participants (median retention: 25.5 vs 7.0 days). The top 5 most common MS symptoms, reported at least once by participants with MS, were fatigue (310/495, 62.6%), weakness (222/495, 44.8%), memory/attention issues (209/495, 42.2%), and difficulty walking (205/495, 41.4%), and the most common triggers were high ambient temperature (259/495, 52.3%), stress (250/495, 50.5%), and late bedtime (221/495, 44.6%). Baseline PDDS was significantly associated with functional test performance in participants with MS (mixed model–based estimate of most significant feature across functional tests [β]: finger-tapping: β=–43.64, P<.001; DSST: β=–5.47, P=.005; walk and balance: β=–.39, P=.001; finger-to-nose: β=.01, P=.01). Longitudinal Neuro-QoL scores were also significantly associated with functional tests (finger-tapping with Upper Extremity Function: β=.40, P<.001; walk and balance with Lower Extremity Function: β=–99.18, P=.02; DSST with Cognitive Function: β=1.60, P=.03). Finally, local temperature was significantly associated with participants’ test performance (finger-tapping: β=–.14, P<.001; DSST: β=–.06, P=.009; finger-to-nose: β=–53.88, P<.001). Conclusions: The elevateMS study app captured the real-world experience of MS, characterized some MS symptoms, and assessed the impact of environmental factors on symptom severity. Our study provides further evidence that supports smartphone app use to monitor MS with both active assessments and patient-reported measures of disease burden. App-based tracking may provide unique and timely real-world data for clinicians and patients, resulting in improved disease insights and management. %M 33107827 %R 10.2196/22108 %U http://mhealth.jmir.org/2020/10/e22108/ %U https://doi.org/10.2196/22108 %U http://www.ncbi.nlm.nih.gov/pubmed/33107827 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e17213 %T Screening for Hearing Impairment in Older Adults by Smartphone-Based Audiometry, Self-Perception, HHIE Screening Questionnaire, and Free-Field Voice Test: Comparative Evaluation of the Screening Accuracy With Standard Pure-Tone Audiometry %A Li,Lok Yee Joyce %A Wang,Shin-Yi %A Wu,Cheng-Jung %A Tsai,Cheng-Yu %A Wu,Te-Fang %A Lin,Yaoh-Shiang %+ Department of Otolaryngology, Shuang Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd, Zhonghe District, New Taipei City, 23561, Taiwan, 886 22490088, b101090126@tmu.edu.tw %K hearing impairment %K self-perception %K HHIE-S questionnaire %K free-field voice test %K mobile phone %K audiometry %K mobile health %D 2020 %7 27.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Hearing impairment is the most frequent sensory deficit in humans, affecting more than 360 million people worldwide. In fact, hearing impairment is not merely a health problem, but it also has a great impact on the educational performance, economic income, and quality of life. Hearing impairment is therefore an important social concern. Objective: We aimed to evaluate and compare the accuracy of self-perception, Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) questionnaire, free-field voice test, and smartphone-based audiometry as tests for screening moderate hearing impairment in older adults in China. Methods: In this study, 41 patients were recruited through a single otology practice. All patients were older than 65 years. Patients with otorrhea and cognitive impairment were excluded. Moderate hearing impairment was defined as mean hearing thresholds at 500, 1000, 2000, and 4000 Hz >40 dB hearing loss (pure-tone average > 40 dB hearing loss). All patients completed 5 hearing tests, namely, the self-perception test, HHIE-S questionnaire test, free-field voice test, smartphone-based audiometry test, and standard pure-tone audiometry by the same audiologist. We compared the results of these tests to the standard audiogram in the better-hearing ear. Results: The sensitivity and the specificity of the self-perception test were 0.58 (95% CI 0.29-0.84) and 0.34 (95% CI 0.19-0.54), respectively. The sensitivity and the specificity of the HHIE-S questionnaire test were 0.67 (95% CI 0.35-0.89) and 0.31 (95% CI 0.316-0.51), respectively. The sensitivity and the specificity of the free-field voice test were 0.83 (95% CI 0.51-0.97) and 0.41 (95% CI 0.24-0.61), respectively. The sensitivity and the specificity of the smartphone-based audiometry test were 0.92 (95% CI 0.60-0.99) and 0.76 (95% CI 0.56-0.89), respectively. Smartphone-based audiometry correctly diagnosed the presence of hearing loss with high sensitivity and high specificity. Conclusions: Smartphone-based audiometry may be a dependable screening test to rule out moderate hearing impairment in the older population. %M 33107828 %R 10.2196/17213 %U http://mhealth.jmir.org/2020/10/e17213/ %U https://doi.org/10.2196/17213 %U http://www.ncbi.nlm.nih.gov/pubmed/33107828 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e20482 %T Assessing the Food and Drug Administration’s Risk-Based Framework for Software Precertification With Top Health Apps in the United States: Quality Improvement Study %A Alon,Noy %A Stern,Ariel Dora %A Torous,John %+ Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, United States, 1 7143359858, jtorous@bidmc.harvard.edu %K mobile health %K smartphone %K Food and Drug Administration %K software %K mobile phone %D 2020 %7 26.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: As the development of mobile health apps continues to accelerate, the need to implement a framework that can standardize the categorization of these apps to allow for efficient yet robust regulation is growing. However, regulators and researchers are faced with numerous challenges, as apps have a wide variety of features, constant updates, and fluid use cases for consumers. As past regulatory efforts have failed to match the rapid innovation of these apps, the US Food and Drug Administration (FDA) has proposed that the Software Precertification (Pre-Cert) Program and a new risk-based framework could be the solution. Objective: This study aims to determine whether the risk-based framework proposed by the FDA’s Pre-Cert Program could standardize categorization of top health apps in the United States. Methods: In this quality improvement study during summer 2019, the top 10 apps for 6 disease conditions (addiction, anxiety, depression, diabetes, high blood pressure, and schizophrenia) in Apple iTunes and Android Google Play Store in the United States were classified using the FDA’s risk-based framework. Data on the presence of well-defined app features, user engagement methods, popularity metrics, medical claims, and scientific backing were collected. Results: The FDA’s risk-based framework classifies an app’s risk by the disease condition it targets and what information that app provides. Of the 120 apps tested, 95 apps were categorized as targeting a nonserious health condition, whereas only 7 were categorized as targeting a serious condition and 18 were categorized as targeting a critical condition. As the majority of apps targeted a nonserious condition, their risk categorization was largely determined by the information they provided. The apps that were assessed as not requiring FDA review were more likely to be associated with the integration of external devices than those assessed as requiring FDA review (15/58, 26% vs 5/62, 8%; P=.03) and health information collection (24/58, 41% vs 9/62, 15%; P=.008). Apps exempt from the review were less likely to offer health information (25/58, 43% vs 45/62, 72%; P<.001), to connect users with professional care (7/58, 12% vs 14/62, 23%; P=.04), and to include an intervention (8/58, 14% vs 35/62, 55%; P<.001). Conclusions: The FDA’s risk-based framework has the potential to improve the efficiency of the regulatory review process for health apps. However, we were unable to identify a standard measure that differentiated apps requiring regulatory review from those that would not. Apps exempt from the review also carried concerns regarding privacy and data security. Before the framework is used to assess the need for a formal review of digital health tools, further research and regulatory guidance are needed to ensure that the Pre-Cert Program operates in the greatest interest of public health. %M 32927429 %R 10.2196/20482 %U http://mhealth.jmir.org/2020/10/e20482/ %U https://doi.org/10.2196/20482 %U http://www.ncbi.nlm.nih.gov/pubmed/32927429 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e18801 %T Wearable Technology Acceptance in Health Care Based on National Culture Differences: Cross-Country Analysis Between Chinese and Swiss Consumers %A Yang Meier,Dong %A Barthelmess,Petra %A Sun,Wei %A Liberatore,Florian %+ International Management Institute, School of Management and Law, Zurich University of Applied Sciences, Theaterstrasse 17, Winterthur, 8400, Switzerland, 41 792987655, yanm@zhaw.ch %K wearables %K health care wearables %K wearables acceptance %K cross culture %K national culture %K Chinese %K Swiss %K moderator %K digital health %K health technology acceptance %K smartwatch %D 2020 %7 22.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The advancement of wearable devices and growing demand of consumers to monitor their own health have influenced the medical industry. Health care providers, insurers, and global technology companies intend to develop more wearable devices incorporating medical technology and to target consumers worldwide. However, acceptance of these devices varies considerably among consumers of different cultural backgrounds. Consumer willingness to use health care wearables is influenced by multiple factors that are of varying importance in various cultures. However, there is insufficient knowledge of the extent to which social and cultural factors affect wearable technology acceptance in health care. Objective: The aims of this study were to examine the influential factors on the intention to adopt health care wearables, and the differences in the underlying motives and usage barriers between Chinese and Swiss consumers. Methods: A new model for acceptance of health care wearables was conceptualized by incorporating predictors of different theories such as technology acceptance, health behavior, and privacy calculus based on an existing framework. To verify the model, a web-based survey in both the Chinese and German languages was conducted in China and Switzerland, resulting in 201 valid Chinese and 110 valid Swiss respondents. A multigroup partial least squares path analysis was applied to the survey data. Results: Performance expectancy (β=.361, P<.001), social influence (β=.475, P<.001), and hedonic motivation (β=.111, P=.01) all positively affected the behavioral intention of consumers to adopt wearables, whereas effort expectancy, functional congruence, health consciousness, and perceived privacy risk did not demonstrate a significant impact on behavioral intention. The group-specific path coefficients indicated health consciousness (β=.150, P=.01) as a factor positively affecting only the behavior intention of the Chinese respondents, whereas the factors affecting only the behavioral intention of the Swiss respondents proved to be effort expectancy (β=.165, P=.02) and hedonic motivation (β=.212, P=.02). Performance expectancy asserted more of an influence on the behavioral intention of the Swiss (β=.426, P<.001) than the Chinese (β=.271, P<.001) respondents, whereas social influence had a greater influence on the behavioral intention of the Chinese (β=.321, P<.001) than the Swiss (β=.217, P=.004) respondents. Overall, the Chinese consumers displayed considerably higher behavioral intention (P<.001) than the Swiss. These discrepancies are explained by differences in national culture. Conclusions: This is one of the first studies to investigate consumers’ intention to adopt wearables from a cross-cultural perspective. This provides a theoretical and methodological foundation for future research, as well as practical implications for global vendors and insurers developing and promoting health care wearables with appropriate features in different countries. The testimonials and support by physicians, evidence of measurement accuracy, and easy handling of health care wearables would be useful in promoting the acceptance of wearables in Switzerland. The opinions of in-group members, involvement of employers, and multifunctional apps providing credible health care advice and solutions in cooperation with health care institutions would increase acceptance among the Chinese. %M 33090108 %R 10.2196/18801 %U http://www.jmir.org/2020/10/e18801/ %U https://doi.org/10.2196/18801 %U http://www.ncbi.nlm.nih.gov/pubmed/33090108 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e20982 %T Using mHealth to Provide Mobile App Users With Visualization of Health Checkup Data and Educational Videos on Lifestyle-Related Diseases: Methodological Framework for Content Development %A Aida,Azusa %A Svensson,Thomas %A Svensson,Akiko Kishi %A Urushiyama,Hirokazu %A Okushin,Kazuya %A Oguri,Gaku %A Kubota,Naoto %A Koike,Kazuhiko %A Nangaku,Masaomi %A Kadowaki,Takashi %A Yamauchi,Toshimasa %A Chung,Ung-Il %+ Precision Health, Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan, 81 3 5841 4737, akiko-kishi@umin.ac.jp %K apps %K educational videos %K health checkup %K lifestyle-related disease %K mHealth, prevention %K telehealth %K visualization %D 2020 %7 21.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The number of people with lifestyle-related diseases continues to increase worldwide. Improving lifestyle behavior with health literacy may be the key to address lifestyle-related diseases. The delivery of educational videos using mobile health (mHealth) services can replace the conventional way of educating individuals, and visualization can replace the provision of health checkup data. Objective: This paper aimed to describe the development of educational content for MIRAMED, a mobile app aimed at improving users’ lifestyle behaviors and health literacy for lifestyle-related diseases. Methods: All videos were based on a single unified framework to provide users with a consistent flow of information. The framework was later turned into a storyboard. The final video contents were created based on this storyboard and further discussions with leading experts and specialist physicians on effective communication with app users about lifestyle-related diseases. Results: The app uses visualization of personal health checkup data and educational videos on lifestyle-related diseases based on the current health guidelines, scientific evidence, and expert opinions of leading specialist physicians in the respective fields. A total of 8 videos were created for specific lifestyle-related diseases affecting 8 organs: (1) brain–cerebrovascular disorder, (2) eyes–diabetic retinopathy, (3) lungs–chronic obstructive pulmonary disease, (4) heart–ischemic heart disease, (5) liver–fatty liver, (6) kidneys–chronic kidney disease (diabetic kidney disease), (7) blood vessels–peripheral arterial disease, and (8) nerves–diabetic neuropathy. Conclusions: Providing enhanced mHealth education using novel digital technologies to visualize conventional health checkup data and lifestyle-related diseases is an innovative strategy. Future studies to evaluate the efficacy of the developed content are planned. %M 33084586 %R 10.2196/20982 %U http://mhealth.jmir.org/2020/10/e20982/ %U https://doi.org/10.2196/20982 %U http://www.ncbi.nlm.nih.gov/pubmed/33084586 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e18237 %T Accuracy of Nutrient Calculations Using the Consumer-Focused Online App MyFitnessPal: Validation Study %A Evenepoel,Charlotte %A Clevers,Egbert %A Deroover,Lise %A Van Loo,Wendy %A Matthys,Christophe %A Verbeke,Kristin %+ Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Herestraat 49, TARGID, O&N1, box 701, Leuven, 3000, Belgium, 32 16330150, kristin.verbeke@kuleuven.be %K dietary assessment %K MyFitnessPal %K Nubel %K nutrition %K online application %K diet %D 2020 %7 21.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital food registration via online platforms that are coupled to large food databases obviates the need for manual processing of dietary data. The reliability of such platforms depends on the quality of the associated food database. Objective: In this study, we validate the database of MyFitnessPal versus the Belgian food composition database, Nubel. Methods: After carefully given instructions, 50 participants used MyFitnessPal to each complete a 4-day dietary record 2 times (T1 and T2), with 1 month in between T1 and T2. Nutrient intake values were calculated either manually, using the food composition database Nubel, or automatically, using the database coupled to MyFitnessPal. First, nutrient values from T1 were used as a training set to develop an algorithm that defined upper limit values for energy intake, carbohydrates, fat, protein, fiber, sugar, cholesterol, and sodium. These limits were applied to the MyFitnessPal dataset extracted at T2 to remove extremely high and likely erroneous values. Original and cleaned T2 values were correlated with the Nubel calculated values. Bias was estimated using Bland-Altman plots. Finally, we simulated the impact of using MyFitnessPal for nutrient analysis instead of Nubel on the power of a study design that correlates nutrient intake to a chosen outcome variable. Results: Per food portion, the following upper limits were defined: 1500 kilocalories for total energy intake, 95 grams (g) for carbohydrates, 92 g for fat, 52 g for protein, 22 g for fiber, 70 g for sugar, 600 mg for cholesterol, and 3600 mg for sodium. Cleaning the dataset extracted at T2 resulted in a 2.8% rejection. Cleaned MyFitnessPal values demonstrated strong correlations with Nubel for energy intake (r=0.96), carbohydrates (r=0.90), fat (r=0.90), protein (r=0.90), fiber (r=0.80), and sugar (r=0.79), but weak correlations for cholesterol (ρ=0.51) and sodium (ρ=0.53); all P values were ≤.001. No bias was found between both methods, except for a fixed bias for fiber and a proportional bias for cholesterol. A 5-10% power loss should be taken into account when correlating energy intake and macronutrients obtained with MyFitnessPal to an outcome variable, compared to Nubel. Conclusions: Dietary analysis with MyFitnessPal is accurate and efficient for total energy intake, macronutrients, sugar, and fiber, but not for cholesterol and sodium. %M 33084583 %R 10.2196/18237 %U http://www.jmir.org/2020/10/e18237/ %U https://doi.org/10.2196/18237 %U http://www.ncbi.nlm.nih.gov/pubmed/33084583 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e22443 %T Patterns of Use and Key Predictors for the Use of Wearable Health Care Devices by US Adults: Insights from a National Survey %A Chandrasekaran,Ranganathan %A Katthula,Vipanchi %A Moustakas,Evangelos %+ Department of Information & Decision Sciences, University of Illinois at Chicago, 601 S Morgan St, Chicago, IL, 60607, United States, 1 3129962847, ranga@uic.edu %K wearable healthcare devices %K mobile health %K HINTS %K health technology adoption and use %K smart wearables %D 2020 %7 16.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the growing popularity of wearable health care devices (from fitness trackes such as Fitbit to smartwatches such as Apple Watch and more sophisticated devices that can collect information on metrics such as blood pressure, glucose levels, and oxygen levels), we have a limited understanding about the actual use and key factors affecting the use of these devices by US adults. Objective: The main objective of this study was to examine the use of wearable health care devices and the key predictors of wearable use by US adults. Methods: Using a national survey of 4551 respondents, we examined the usage patterns of wearable health care devices (use of wearables, frequency of their use, and willingness to share health data from a wearable with a provider) and a set of predictors that pertain to personal demographics (age, gender, race, education, marital status, and household income), individual health (general health, presence of chronic conditions, weight perceptions, frequency of provider visits, and attitude towards exercise), and technology self-efficacy using logistic regression analysis. Results: About 30% (1266/4551) of US adults use wearable health care devices. Among the users, nearly half (47.33%) use the devices every day, with a majority (82.38% weighted) willing to share the health data from wearables with their care providers. Women (16.25%), White individuals (19.74%), adults aged 18-50 years (19.52%), those with some level of college education or college graduates (25.60%), and those with annual household incomes greater than US $75,000 (17.66%) were most likely to report using wearable health care devices. We found that the use of wearables declines with age: Adults aged >50 years were less likely to use wearables compared to those aged 18-34 years (odds ratios [OR] 0.46-0.57). Women (OR 1.26, 95% CI 0.96-1.65), White individuals (OR 1.65, 95% CI 0.97-2.79), college graduates (OR 1.05, 95% CI 0.31-3.51), and those with annual household incomes greater than US $75,000 (OR 2.6, 95% CI 1.39-4.86) were more likely to use wearables. US adults who reported feeling healthier (OR 1.17, 95% CI 0.98-1.39), were overweight (OR 1.16, 95% CI 1.06-1.27), enjoyed exercise (OR 1.23, 95% CI 1.06-1.43), and reported higher levels of technology self-efficacy (OR 1.33, 95% CI 1.21-1.46) were more likely to adopt and use wearables for tracking or monitoring their health. Conclusions: The potential of wearable health care devices is under-realized, with less than one-third of US adults actively using these devices. With only younger, healthier, wealthier, more educated, technoliterate adults using wearables, other groups have been left behind. More concentrated efforts by clinicians, device makers, and health care policy makers are needed to bridge this divide and improve the use of wearable devices among larger sections of American society. %M 33064083 %R 10.2196/22443 %U http://www.jmir.org/2020/10/e22443/ %U https://doi.org/10.2196/22443 %U http://www.ncbi.nlm.nih.gov/pubmed/33064083 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e19227 %T Fitness-Tracker Assisted Frailty-Assessment Before Transcatheter Aortic Valve Implantation: Proof-of-Concept Study %A Mach,Markus %A Watzal,Victoria %A Hasan,Waseem %A Andreas,Martin %A Winkler,Bernhard %A Weiss,Gabriel %A Strouhal,Andreas %A Adlbrecht,Christopher %A Delle Karth,Georg %A Grabenwöger,Martin %+ Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Ebene 20A, Waehringer Guertel 18-20, Vienna, 1090, Austria, 43 6645158360, markus.mach@meduniwien.ac.at %K frailty %K activity %K fitness %K tracker %K transcatheter aortic valve implantation %K transcatheter aortic valve repair %D 2020 %7 15.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: While transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic valve stenosis, wearable health-monitoring devices are gradually transforming digital patient care. Objective: The aim of this study was to develop a simple, efficient, and economical method for preprocedural frailty assessment based on parameters measured by a wearable health-monitoring device. Methods: In this prospective study, we analyzed data of 50 consecutive patients with mean (SD) age of 77.5 (5.1) years and a median (IQR) European system for cardiac operative risk evaluation (EuroSCORE) II of 3.3 (4.1) undergoing either transfemoral or transapical TAVR between 2017 and 2018. Every patient was fitted with a wrist-worn health-monitoring device (Garmin Vivosmart 3) for 1 week prior to the procedure. Twenty different parameters were measured, and threshold levels for the 3 most predictive categories (ie, step count, heart rate, and preprocedural stress) were calculated. Patients were assigned 1 point per category for exceeding the cut-off value and were then classified into 4 stages (no, borderline, moderate, and severe frailty). Furthermore, the FItness-tracker assisted Frailty-Assessment Score (FIFA score) was compared with the scores of the preprocedural gait speed category derived from the 6-minute walk test (GSC-6MWT) and the Edmonton Frail Scale classification (EFS-C). The primary study endpoint was hospital mortality. Results: The overall preprocedural stress level (P=.02), minutes of high stress per day (P=.02), minutes of rest per day (P=.045), and daily heart rate maximum (P=.048) as single parameters were the strongest predictors of hospital mortality. When comparing the different frailty scores, the FIFA score demonstrated the greatest predictive power for hospital mortality (FIFA area under the curve [AUC] 0.844, CI 0.656-1.000; P=.048; GSC-6MWT AUC 0.671, CI 0.487-0.855; P=.42; EFS-C AUC 0.636, CI 0.254-1.000; P=.44). Conclusions: This proof-of-concept study demonstrates the strong predictive performance of the FIFA score compared to that of the conventional frailty assessments. %M 33055057 %R 10.2196/19227 %U https://mhealth.jmir.org/2020/10/e19227 %U https://doi.org/10.2196/19227 %U http://www.ncbi.nlm.nih.gov/pubmed/33055057 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e17066 %T Costing and Cost-Effectiveness of a Mobile Health Intervention (ImTeCHO) in Improving Infant Mortality in Tribal Areas of Gujarat, India: Cluster Randomized Controlled Trial %A Modi,Dhiren %A Saha,Somen %A Vaghela,Prakash %A Dave,Kapilkumar %A Anand,Ankit %A Desai,Shrey %A Shah,Pankaj %+ Indian Institute of Public Health Gandhinagar, NH-147, Palaj Village, opp. New Air Force Station HQ, Gandhinagar, 382042, India, 91 9687207549, ssaha@iiphg.org %K mHealth, cost-effectiveness %K life-years saved %K India, ASHA %D 2020 %7 14.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: During 2013, a mobile health (mHealth) program, Innovative Mobile Technology for Community Health Operation (ImTeCHO), was launched in predominantly tribal and rural communities of Gujarat, India. ImTeCHO was developed as a job aid for Accredited Social Health Activists (ASHAs) and staff of primary health centers to increase coverage of maternal, neonatal, and child health care. Objective: In this study, we assessed the incremental cost per life-years saved as a result of the ImTeCHO intervention as compared to routine maternal, neonatal, and child health care programs. Methods: A two-arm, parallel, stratified cluster randomized trial with 11 clusters (primary health centers) randomly allocated to the intervention (280 ASHAs, n=2,34,134) and control (281 ASHAs, n=2,42,809) arms was initiated in 2015 in a predominantly tribal and rural community of Gujarat. A system of surveillance assessed all live births and infant deaths in the intervention and control areas. All costs, including those required during the start-up and implementation phases, were estimated from a program perspective. Incremental cost-effectiveness ratios were estimated by dividing the incremental cost of the intervention with the number of deaths averted to estimate the cost per infant death averted. This was further analyzed to estimate the cost per life-years saved for the purpose of comparability. Sensitivity analysis was undertaken to account for parameter uncertainties. Results: Out of a total of 5754 live births (3014 in the intervention arm, 2740 in the control arm) reported in the study area, per protocol analysis showed that the implementation of ImTeCHO resulted in saving 11 infant deaths per 1000 live births in the study area at an annual incremental cost of US $163,841, which is equivalent to US $54,360 per 1000 live births. Overall, ImTeCHO is a cost-effective intervention from a program perspective at an incremental cost of US $74 per life-years saved or US $5057 per death averted. In a realistic environment with district scale-up, the program is expected to become even more cost-effective. Conclusions: Overall, the findings of our study strongly suggest that the mHealth intervention as part of the ImTeCHO program is cost-effective and should be considered for replication elsewhere in India. Trial Registration: Clinical Trials Registry of India CTRI/2015/06/005847; http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=11820&EncHid=&modid=&compid=%27,%2711820det%27 %M 33052122 %R 10.2196/17066 %U https://mhealth.jmir.org/2020/10/e17066 %U https://doi.org/10.2196/17066 %U http://www.ncbi.nlm.nih.gov/pubmed/33052122 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e20529 %T The Association Between Electronic Device Use During Family Time and Family Well-Being: Population-Based Cross-Sectional Study %A Zhao,Sheng Zhi %A Guo,Ningyuan %A Wang,Man Ping %A Fong,Daniel Yee Tak %A Lai,Agnes Yuen Kwan %A Chan,Sophia Siu-Chee %A Lam,Tai Hing %A Ho,Daniel Sai Yin %+ School of Nursing, University of Hong Kong, 21 Sassoon Road, Pokfulam, HK, Hong Kong, 000000, China (Hong Kong), 852 39176636, mpwang@hku.hk %K eDevice %K smartphone %K mobile phone %K well-being %K family dinner %K family communication %K public health %D 2020 %7 14.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Electronic devices (eDevices) may have positive or negative influences on family communication and well-being depending on how they are used. Objective: We examined eDevice use during family time and its association with the quality of family communication and well-being in Hong Kong Chinese adults. Methods: In 2017, a probability-based 2-stage random sampling landline telephone survey collected data on eDevice use in daily life and during family time (eg, family dinner) and the presence of rules banning eDevice use during family dinner. Family communication quality was rated from 0 to 10 with higher scores being favorable. Family well-being was calculated as a composite mean score of 3 items each using the same scale from 0 to 10. The associations of family communication quality and well-being with eDevice use in daily life and during family time were estimated using beta-coefficient (β) adjusting for sociodemographics. The mediating role of family communication quality in the association between eDevice use and family well-being was analyzed. Results: Of the 2064 respondents (mean age 56.4 [SD 19.2] years, 1269/2064 [61.48%] female), 1579/2059 (76.69%) used an eDevice daily for a mean of 3.6 hours (SD 0.1) and 257/686 (37.5%) used it for 30+ minutes before sleep. As much as 794/2046 (38.81%) often or sometimes used an eDevice during family time including dinner (311/2017, 15.42%); 713/2012 (35.44%) reported use of an eDevice by family members during dinner. Lower family communication quality was associated with hours of eDevice use before sleep (adjusted β=–.25; 95% CI –0.44 to –0.05), and often use (vs never use) of eDevice during family dinner by oneself (adjusted β=–.51; 95% CI –0.91 to –0.10) and family members (adjusted β=–.54; 95% CI –0.79 to –0.29). Similarly, lower family well-being was associated with eDevice use before sleep (adjusted β=–.26; 95% CI –0.42 to –0.09), and often use during family dinner by oneself (adjusted β=–.48; 95% CI –0.83 to –0.12) and family members (adjusted β=–.50; 95% CI –0.72 to –0.28). Total ban of eDevice use during family dinner was negatively associated with often use by oneself (adjusted odds ratio 0.49; 95% CI 0.29 to 0.85) and family members (adjusted odds ratio 0.41; 95% CI 0.28, 0.60) but not with family communication and well-being. Lower family communication quality substantially mediated the total effect of the association of eDevice use time before sleep (61.2%) and often use at family dinner by oneself (87.0%) and by family members (67.8%) with family well-being. Conclusions: eDevice use before sleep and during family dinner was associated with lower family well-being, and the association was substantially mediated by family communication quality. Our results suggest that interventions on smart use of eDevice may improve family communication and well-being. %M 33052120 %R 10.2196/20529 %U http://www.jmir.org/2020/10/e20529/ %U https://doi.org/10.2196/20529 %U http://www.ncbi.nlm.nih.gov/pubmed/33052120 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19716 %T Mobile Insight in Risk, Resilience, and Online Referral (MIRROR): Psychometric Evaluation of an Online Self-Help Test %A van Herpen,Merel Marjolein %A Boeschoten,Manon A %A te Brake,Hans %A van der Aa,Niels %A Olff,Miranda %+ ARQ Centre of Expertise for the Impact of Disasters and Crises, Nienoord 5, Diemen, , Netherlands, 31 610082023, m.van.herpen@impact.arq.org %K potentially traumatic events %K mobile mental health %K self-help %K online %K resilience %K posttraumatic stress disorder %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Most people who experience a potentially traumatic event (PTE) recover on their own. A small group of individuals develops psychological complaints, but this is often not detected in time or guidance to care is suboptimal. To identify these individuals and encourage them to seek help, a web-based self-help test called Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) was developed. MIRROR takes an innovative approach since it integrates both negative and positive outcomes of PTEs and time since the event and provides direct feedback to the user. Objective: The goal of this study was to assess MIRROR’s use, examine its psychometric properties (factor structure, internal consistency, and convergent and divergent validity), and evaluate how well it classifies respondents into different outcome categories compared with reference measures. Methods: MIRROR was embedded in the website of Victim Support Netherlands so visitors could use it. We compared MIRROR’s outcomes to reference measures of PTSD symptoms (PTSD Checklist for DSM-5), depression, anxiety, stress (Depression Anxiety Stress Scale–21), psychological resilience (Resilience Evaluation Scale), and positive mental health (Mental Health Continuum Short Form). Results: In 6 months, 1112 respondents completed MIRROR, of whom 663 also completed the reference measures. Results showed good internal consistency (interitem correlations range .24 to .55, corrected item-total correlations range .30 to .54, and Cronbach alpha coefficient range .62 to .68), and convergent and divergent validity (Pearson correlations range –.259 to .665). Exploratory and confirmatory factor analyses (EFA+CFA) yielded a 2-factor model with good model fit (CFA model fit indices: χ219=107.8, P<.001, CFI=.965, TLI=.948, RMSEA=.065), conceptual meaning, and parsimony. MIRROR correctly classified respondents into different outcome categories compared with the reference measures. Conclusions: MIRROR is a valid and reliable self-help test to identify negative (PTSD complaints) and positive outcomes (psychosocial functioning and resilience) of PTEs. MIRROR is an easily accessible online tool that can help people who have experienced a PTE to timely identify psychological complaints and find appropriate support, a tool that might be highly needed in times like the coronavirus pandemic. %M 32975521 %R 10.2196/19716 %U http://www.jmir.org/2020/9/e19716/ %U https://doi.org/10.2196/19716 %U http://www.ncbi.nlm.nih.gov/pubmed/32975521 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e16444 %T Potential Benefits and Risks Resulting From the Introduction of Health Apps and Wearables Into the German Statutory Health Care System: Scoping Review %A Heidel,Alexandra %A Hagist,Christian %+ Chair of Economic and Social Policy, WHU – Otto Beisheim School of Management, Burgplatz 2, Vallendar, 56179, Germany, 49 261 6509 256, alexandra.heidel@whu.edu %K health apps %K wearables %K digital health application %K mHealth %D 2020 %7 23.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Germany is the first country worldwide that has introduced a digital care act as an incentive system to enhance the use of digital health devices, namely health apps and wearables, among its population. The act allows physicians to prescribe statutory financed and previously certified health apps and wearables to patients. This initiative has the potential to improve treatment quality through better disease management and monitoring. Objective: The aim of this paper was to outline the key concepts related to the potential risks and benefits discussed in the current literature about health apps and wearables. Furthermore, this study aimed to answer the research question: Which risks and benefits may result from the implementation of the digital care act in Germany? Methods: We conducted the scoping study by searching the databases PubMed, Google Scholar, and JMIR using the keywords health apps and wearables. We discussed 55 of 136 identified articles published in the English language from 2015 to March 2019 in this paper using a qualitative thematic analysis approach. Results: We identified four key themes within the articles: Effectivity of health apps and wearables to improve health; users of health apps and wearables; the potential of bring-your-own, self-tracked data; and concerns and data privacy risks. Within these themes, we identified three main stages of benefits for the German health care system: Usage of health apps and wearables; continuing to use health apps and wearables; and sharing bring-your-own; self-tracked data with different agents in the health care sector. Conclusions: The digital care act could lead to an improvement in treatment quality through better patient monitoring, disease management, personalized therapy, and better health education. However, physicians should play an active role in recommending and supervising health app use to reach digital-illiterate or health-illiterate people. Age must not be an exclusion criterion. Yet, concerns about data privacy and security are very strong in Germany. Transparency about data processing should be provided at all times for continuing success of the digital care act in Germany. %M 32965231 %R 10.2196/16444 %U http://mhealth.jmir.org/2020/9/e16444/ %U https://doi.org/10.2196/16444 %U http://www.ncbi.nlm.nih.gov/pubmed/32965231 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19923 %T Determinants of Scale-up From a Small Pilot to a National Electronic Immunization Registry in Vietnam: Qualitative Evaluation %A Dang,Huyen %A Dao,Sang %A Carnahan,Emily %A Kawakyu,Nami %A Duong,Hong %A Nguyen,Trung %A Nguyen,Doan %A Nguyen,Linh %A Rivera,Maya %A Ngo,Tuan %A Werner,Laurie %A Nguyen,Nga %+ PATH, #1101, 11th Floor, Hanoi Towers, 49 Hai Bai Trung Street, Hoan Kiem District, Hanoi, , Vietnam, 84 24 3936 2216 ext 105, ntnguyen@path.org %K immunization %K immunization information system %K electronic immunization registry %K scale-up %K digital health intervention %K mHealth %K eHealth %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health innovations can improve health system performance, yet previous experience has shown that many innovations do not advance beyond the pilot stage to achieve scale. Vietnam’s National Immunization Information System (NIIS) began as a series of digital health pilots, first initiated in 2010, and was officially launched nationwide in 2017. The NIIS is one of the few examples of an electronic immunization registry (EIR) at national scale in low- and middle-income countries. Objective: The aim of this study was to understand the determinants of scale-up of the national EIR in Vietnam. Methods: This qualitative study explored the facilitators and barriers to national scale-up of the EIR in Vietnam. Qualitative data were collected from October to December 2019 through in-depth key informant interviews and desk review. The mHealth Assessment and Planning for Scale (MAPS) Toolkit guided the development of the study design, interview guides, and analytic framework. MAPS defines the key determinants of success, or the “axes of scale,” to be groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation. Results: The partnership and operations axes were critical to the successful scale-up of the EIR in Vietnam, while the groundwork and monitoring and the evaluation axes were considered to be strong contributors in the success of all the other axes. The partnership model leveraged complementary strengths of the technical working group partners: the Ministry of Health General Department of Preventive Medicine, the National Expanded Program on Immunization, Viettel (the mobile network operator), and PATH. The operational approach to introducing the NIIS with lean, iterative, and integrated training and supervision was also a key facilitator to successful scale-up. The financial health, technology and architecture, and operations axes were identified as barriers to successful deployment and scale-up. Key barriers to scale-up included insufficient estimates of operational costs, unanticipated volume of data storage and transmission, lack of a national ID to support interoperability, and operational challenges among end users. Overall, the multiple phases of EIR deployment and scale-up from 2010 to 2017 allowed for continuous learning and improvement that strengthened all the axes and contributed to successful scale-up. Conclusions: The results highlight the importance of the measured, iterative approach that was taken to gradually expand a series of small pilots to nationwide scale. The findings from this study can be used to inform other countries considering, introducing, or in the process of scaling an EIR or other digital health innovations. %M 32960184 %R 10.2196/19923 %U http://www.jmir.org/2020/9/e19923/ %U https://doi.org/10.2196/19923 %U http://www.ncbi.nlm.nih.gov/pubmed/32960184 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e15307 %T Identifying Mobile Health Engagement Stages: Interviews and Observations for Developing Brief Message Content %A Burns,Kara %A Nicholas,Rebekah %A Beatson,Amanda %A Chamorro-Koc,Marianella %A Blackler,Alethea %A Gottlieb,Udo %+ School of Advertising, Marketing and Public Relations, QUT Business School, Queensland University of Technology, George St, Brisbane, QLD, 4000, Australia, 61 414294967, drkaraburns@gmail.com %K mobile health %K text messaging %K social media %K mobile phone %K health communication %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Interest in mobile health (mHealth) has increased recently, and research suggests that mHealth devices can enhance end-user engagement, especially when used in conjunction with brief message content. Objective: This research aims to explore the stages of engagement framework for mHealth devices and develop a method to generate brief message content to promote sustained user engagement. This study uses the framework by O’Brien and Toms as a point of departure, where engagement is defined as the uptake or the use of an mHealth device. The framework is a linear repeatable process, including point of engagement, period of engagement, disengagement, and re-engagement. Each stage is characterized by attributes related to a person’s technology experience. Although the literature has identified stages of engagement for health-related technology, few studies explore mHealth engagement. Furthermore, little research has determined a method for creating brief message content at each stage in this engagement journey. Methods: Interviews and observations from 19 participants who used mHealth technologies (apps, devices, or wellness websites) in a solo capacity were recruited for sample group 1. In sample group 2, interviews, and observations from 25 participants using mHealth technologies in a group capacity through the Global Corporate Challenge were used. These samples were investigated at 3 time points in both research contexts. The results underwent deductive-inductive thematic analysis for the engagement stages’ framework and attributes. Results: In addition to the 4 stages identified by O’Brien and Toms, 2 additional stages, self-management and limited engagement, were identified. Self-management captures where users had disengaged from their technology but were still engaged with their health activity. Limited engagement captures where group mHealth users had minimal interaction with their mHealth technology but continued to engage in a group fitness activity. The results revealed that mHealth engagement stages were nonlinear and embedded in a wider engagement context and that each stage was characterized by a combination of 49 attributes that could be organized into 8 themes. Themes documented the total user experience and included technology usability, technology features, technology aesthetics, use motivations, health awareness, goal setting, social support, and interruptions. Different themes were found to have more relevance at different engagement stages. Knowing themes and attributes at all engagement stages allows technology developers and health care professionals to generate relevant brief message content informed by a person-centered approach. Conclusions: This research extends an existing engagement stages framework and identifies attributes and themes relevant to mHealth technology users’ total user experience and incorporates concepts derived from health, business studies, and information systems literature. In addition, we offer a practical 5-step process based on a person-centered approach to develop mHealth technology brief message content for sustained engagement. %M 32960181 %R 10.2196/15307 %U http://www.jmir.org/2020/9/e15307/ %U https://doi.org/10.2196/15307 %U http://www.ncbi.nlm.nih.gov/pubmed/32960181 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 9 %P e20165 %T Feasibility of Self-Monitoring Rheumatoid Arthritis With a Smartphone App: Results of Two Mixed-Methods Pilot Studies %A Seppen,Bart F %A Wiegel,Jimmy %A L'ami,Merel J %A Duarte dos Santos Rico,Sharon %A Catarinella,Fabio S %A Turkstra,Franktien %A Boers,Maarten %A Bos,Wouter H %+ Amsterdam Rheumatology and Immunology Center, Reade, Dr Jan van Breemenstraat 2, Amsterdam , Netherlands, 31 616796208, b.seppen@reade.nl %K mHealth %K eHealth %K patient-reported outcome, smartphone app %K rheumatoid arthritis %K self-monitoring %K telemonitoring %K mobile phone %D 2020 %7 21.9.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Several mobile apps that monitor symptoms of rheumatoid arthritis (RA) exist, but a recent systematic review indicated that high-quality apps are lacking. When patients self-monitor their own disease with patient-reported outcomes (PROs) and self-initiate care at the right moment, it may be possible to reduce the frequency of their clinic visits, which would reduce health care burden and costs. We developed an app, that is, the MijnReuma Reade app, for this purpose and performed 2 pilot tests with weekly self-monitoring. Objective: The primary objective of this study was to design, develop, and evaluate the usability, satisfaction, and usage of the MijnReuma Reade app—an app that allows patients with RA to monitor their own disease. The secondary objective was to review the patients’ perspectives on app usage and its intended purpose. Methods: This app was designed in collaboration with patients with RA, rheumatologists, and information technology experts. Two 1-month pilot studies were performed, after which satisfaction (0-10 scale), usability (system usability scale, 0-100), and usage (proportion of completed questionnaires) of this app were assessed. After the second pilot study, semistructured interviews were performed to determine patients’ perspectives and the promoters and barriers of app usage. Results: In the first and second pilot study, 42 and 27 patients were included, respectively. Overall, the patients were satisfied (medians, 8 and 7) and found the app usable (mean system usability scores, 76 and 71) in pilot studies 1 and 2, respectively. App usage declined over time in both the pilot studies; 61% (17/28) and 37% (10/27) of the patients who disclosed their usage statistics completed the final weekly questionnaire in pilot study 1 and pilot study 2, respectively. Approximately 81% (25/31) of the patients indicated they would like to skip hospital visits if the self-monitored disease activity is low. In the semistructured interviews, technical problems, internal resistance (respondent fatigue, the app reminded them of their disease), and a lack of symptoms were identified as barriers for usage. Patients reported that “experiencing more grip on their disease” and “improved communication with their physician” were promoters for usage. Patients reported that pain positively mediated usage, that is, more pain promoted and less pain discouraged app usage. Conclusions: This study illustrates the feasibility of the MijnReuma Reade app that enables self-monitoring of the disease activity in patients with RA with the overarching aim to allocate clinical consultations according to need. Satisfaction with the app and usability of the app were found to be high; however, app usage declined over time. Patients acknowledged the potential of the app to self-monitor their own disease and would like to be able to skip clinic visits if the monitored disease activity is low. To evaluate this strategy, a randomized controlled trial is underway. %M 32955447 %R 10.2196/20165 %U http://formative.jmir.org/2020/9/e20165/ %U https://doi.org/10.2196/20165 %U http://www.ncbi.nlm.nih.gov/pubmed/32955447 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18663 %T New Path to Recovery and Well-Being: Cross-Sectional Study on WeChat Use and Endorsement of WeChat-Based mHealth Among People Living With Schizophrenia in China %A Yu,Yu %A Li,Yilu %A Li,Tongxin %A Xi,Shijun %A Xiao,Xi %A Xiao,Shuiyuan %A Tebes,Jacob Kraemer %+ Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Upper Mayuanling Road No. 238, Changsha, 410008, China, 86 0731 84805459, xiaosy@csu.edu.cn %K WeChat %K mHealth %K schizophrenia %K China %K symptoms %K functioning %K recovery %K quality of life %K well-being %D 2020 %7 18.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The past few decades have seen an exponential increase in using mobile phones to support medical care (mobile health [mHealth]) among people living with psychosis worldwide, yet little is known about WeChat use and WeChat-based mHealth among people living with schizophrenia (PLS) in China. Objective: This study aims to assess WeChat use, endorsement of WeChat-based mHealth programs, and health related to WeChat use among PLS. Methods: We recruited a random sample of 400 PLS from 12 communities in Changsha City of Hunan Province, China. WeChat use was assessed using the adapted WeChat Use Intensity Questionnaire (WUIQ). We also compared psychiatric symptoms, functioning, disability, recovery, quality of life, and general well-being between WeChat users and nonusers using one-to-one propensity-score matching. Results: The WeChat use rate was 40.8% in this sample (163/400); 30.7% (50/163) had more than 50 WeChat friends and nearly half (81/163, 49.7%) spent more than half an hour on WeChat, a pattern similar to college students and the elderly. PLS also showed higher emotional connectedness to WeChat use than college students. About 80.4% (131/163) of PLS were willing to participate in a WeChat-based mHealth program, including psychoeducation (91/163, 55.8%), professional support (82/163, 50.3%), and peer support (67/163, 41.1%). Compared with nonusers, WeChat users were younger, better educated, and more likely to be employed. WeChat use was associated with improved health outcomes, including lower psychiatric symptoms, lower depression, higher functioning, better recovery, and higher quality of life. Conclusions: WeChat-based mHealth programs hold promise as an empowering tool to provide cost-effective interventions, to foster global recovery, and to improve both physical and mental well-being among PLS. WeChat and WeChat-based mHealth programs have the potential to offer a new path to recovery and well-being for PLS in China. %M 32945774 %R 10.2196/18663 %U http://www.jmir.org/2020/9/e18663/ %U https://doi.org/10.2196/18663 %U http://www.ncbi.nlm.nih.gov/pubmed/32945774 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19627 %T Adherence of HIV Self-Testing Among Men Who Have Sex With Men in China: Longitudinal Study %A Yan,Xiangyu %A Su,Hexuan %A Zhang,Bo %A Li,Yongjie %A Zhang,Lingling %A Jia,Zhongwei %+ National Institute on Drug Dependence, Peking University, 38 Xueyuan Road, Haidian District, Beijing, , China, 86 10 82802457, urchinjj@163.com %K HIV self-testing %K adherence %K men who have sex with men %K HIV infection %K condom use %K mobile app %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The World Health Organization recommended HIV self-testing (HIVST) for individuals practicing unsafe sexual behaviors; however, the adherence to HIV testing has not been reported. Objective: In this study, we attempted to determine the adherence to HIVST among men who have sex with men (MSM), as well as the impact factors and potential effects of their adherence. Methods: We conducted a longitudinal study among MSM in Harbin, Heilongjiang province, China from July 1, 2017 to June 30, 2018. A mobile app system was used to provide the “Mailing rapid test reagent kit” for the HIVST service. The proportion of those who adhered to HIV testing every 3 months was calculated. Logistic regression was used to explore the impact factors related to adherence to HIVST. Rates of HIV infection between MSM who adhered to HIVST and those who did not were compared using Cox proportional hazards regression. Changes of condom use behaviors between the two groups were also compared using the chi-square test. Results: A total of 1315 MSM who received the HIVST service through the app were included in the study. Overall, 10% of the MSM adhered to HIVST, and the proportion of adhering tests was only 34.9%. Adherence of HIVST was associated with marital status (adjusted odds ratio [OR]unmarried vs married 2.31, 95% CI 1.13-4.71) and the number of HIV tests they received (adjusted OR3 times vs 2 times or below 3.36, 95% CI 2.01-5.63; adjusted OR4 times or above vs 2 times or below 7.30, 95% CI 4.67-11.42). Twenty HIV seroconversions were observed during 1-year follow up. The rate of HIV infection in the adherence group (17.10 per 100 person years, 95% CI 8.80-30.84) was significantly higher than that in the nonadherence group (4.80 per 100 person years, 95% CI 2.77-7.88; adjusted hazard ratio 3.33, 95% CI 1.35-8.20). Those who adhered to HIV testing were more likely to improve condom use behaviors, although the difference was not statistically significant. Conclusions: Regular HIV testing is necessary for early detection of HIV infection among MSM. Given the poor adherence, a new internet-based management paradigm for MSM is needed to raise their health awareness to optimize the implementation of HIVST. %M 32940619 %R 10.2196/19627 %U http://www.jmir.org/2020/9/e19627/ %U https://doi.org/10.2196/19627 %U http://www.ncbi.nlm.nih.gov/pubmed/32940619 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18414 %T Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study %A Zaidi,Shehla %A Kazi,Abdul Momin %A Riaz,Atif %A Ali,Ammarah %A Najmi,Rabia %A Jabeen,Rawshan %A Khudadad,Umerdad %A Sayani,Saleem %+ Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan, 92 3062016825, shehla.zaidi@aku.edu %K mHealth %K community health workers %K usability %K usefulness %K task-technology fit %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan. Objective: Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems. Methods: The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis. Results: Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants. Conclusions: The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology. %M 32940612 %R 10.2196/18414 %U http://www.jmir.org/2020/9/e18414/ %U https://doi.org/10.2196/18414 %U http://www.ncbi.nlm.nih.gov/pubmed/32940612 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17659 %T Exploring the Use of Mobile Health to Improve Community-Based Health and Nutrition Service Utilization in the Hills of Nepal: Qualitative Study %A Acharya,Ajay %A Cunningham,Kenda %A Manandhar,Shraddha %A Shrestha,Niva %A Chen,Mario %A Weissman,Amy %+ Asia Pacific Regional Office, Family Health International 360, 19th Floor, Tower 3, Sindhorn Building, 130-132 Wireless Road, Lumpini, Phatumwan, Bangkok, 10330, Thailand, 66 2 263 5200 ext 20226, aweissman@fhi360.org %K mobile health %K text messages %K SMS text message %K qualitative study %K Nepal %K health and nutrition services %K health mothers’ group %K female community health volunteers %K mobile phone %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: With mobile phone coverage and ownership expanding globally, mobile health (mHealth) interventions are increasingly being used to improve coverage and quality of health and nutrition services. However, evidence on mHealth intervention feasibility and factors to consider during program design is limited in low- and middle-income countries like Nepal. Objective: This study aimed to examine the potential of using text messages to improve health and nutrition services by exploring mobile phone ownership and sharing; mobile phone use and skills; and interest, preferences, and limitations regarding mHealth interventions. Methods: We conducted 35 in-depth interviews with 1000-day women (the period from conception to a child’s second birthday), health facility staff, and female community health volunteers (FCHVs), as well as eight focus group discussions with health facility staff, FCHVs, and 1000-day household decision-makers (ie, husbands, mothers-in-law, and fathers-in-law). We also conducted a mobile phone skills test. We employed thematic analysis using framework matrices and analytical memos. Results: The study included 70 study participants, of whom 68 (97%) had a mobile phone, and phone sharing was uncommon. Use of text messages was most commonly reported by 1000-day women and health facility staff than household decision-makers and FCHVs. More than 8 in 10 participants (54/64, 84%) could dial numbers, and the majority (28/34, 82%) of 1000-day women, health facility staff, and male decision-makers could also read and write text messages. We found that 1000-day women preferred educational and reminder messages, whereas health facility staff and FCHVs desired educational and motivational messages. Participants suggested different types of texts for 1000-day women, families, FCHVs, and health facility staff, and reported less value for texts received from unknown phone numbers. Conclusions: A text message–based mHealth intervention is acceptable in the hills of Nepal and has the potential to improve community health and nutrition service utilization, particularly by sending meeting reminders and by providing information. Our findings contribute to text message–based mHealth intervention design in under-resourced settings. %M 32915151 %R 10.2196/17659 %U http://www.jmir.org/2020/9/e17659/ %U https://doi.org/10.2196/17659 %U http://www.ncbi.nlm.nih.gov/pubmed/32915151 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18080 %T Intention to use Medical Apps Among Older Adults in the Netherlands: Cross-Sectional Study %A Askari,Marjan %A Klaver,Nicky Sabine %A van Gestel,Thimon Johannes %A van de Klundert,Joris %+ Erasmus School of Health Policy & Management, Erasmus University, PO Box 1738, Rotterdam, 3000 DR, Netherlands, 31 104088641, askari@eshpm.eur.nl %K Senior Technology Acceptance Model %K intention to use %K elderly %K older adults %K medical apps %K mHealth %K adoption %D 2020 %7 4.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The increasing health service demand driven by the aging of the global population calls for the development of modes of health service delivery that are less human resource–intensive. Electronic health (eHealth) and medical apps are expected to play an important role in this development. Although evidence shows mobile medical apps might be effective in improving the care, self-management, self-efficacy, health-related behavior, and medication adherence of older adults, little is known about older adults’ intention to use these technologies when needed, or the factors influencing this intention. Objective: The objective of this study was to investigate the relationship of technology acceptance factors and intention to use mobile medical apps among community-dwelling older adults. Methods: Data was collected using questionnaires. The factors selected from the literature have been validated using Cronbach α and tested for significance using logistic regressions. Results: Almost half (49.7%) of the included older adults reported no intention to use medical apps. Adjusted logistic regression analysis per factor showed that the factors Attitude toward use (odds ratio [OR] 8.50), Perceived usefulness (OR 5.25), Perceived ease of use (OR 4.22), Service availability (OR 3.46), Sense of control (OR 3.40), Self-perceived effectiveness (OR 2.69), Facilities (OR 2.45), Personal innovativeness (OR 2.08), Social relationships (OR 1.79), Subjective norm (OR 1.48), and Feelings of anxiety (OR 0.62) significantly influenced the intention to use mobile medical apps among older adults, whereas the factor Finance (OR 0.98) did not. When considered together, a controlled multivariate logistic regression yielded high explained variances of 0.542 (Cox-Snell R2) and 0.728 (Nagelkerke R2). Conclusions: The high odds ratios and explained variance indicate that the factors associated with the intention to use medical apps are largely understood and the most important factors have been identified. To advance the evidence base, experimental controlled research should investigate the causality between the factors, intention to use, and actual use. For this purpose, our evidence suggests that policies designed to improve Attitude toward use appear most effective, followed by policies addressing Perceived usefulness, Perceived ease of use, Service availability, and Sense of control. %M 32624465 %R 10.2196/18080 %U https://www.jmir.org/2020/9/e18080 %U https://doi.org/10.2196/18080 %U http://www.ncbi.nlm.nih.gov/pubmed/32624465 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e18346 %T Technology Evaluation and Assessment Criteria for Health Apps (TEACH-Apps): Pilot Study %A Camacho,Erica %A Hoffman,Liza %A Lagan,Sarah %A Rodriguez-Villa,Elena %A Rauseo-Ricupero,Natali %A Wisniewski,Hannah %A Henson,Philip %A Torous,John %+ Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, United States, 1 7143359858, jtorous@bidmc.harvard.edu %K app %K mobile phones %K smartphones %K app evaluation %K technology %D 2020 %7 27.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the emergence of app evaluation tools, there remains no well-defined process receptive to diverse local needs, rigorous standards, and current content. The need for such a process to assist in the implementation of app evaluation across all medical fields is evident. Such a process has the potential to increase stakeholder engagement and catalyze interest and engagement with present-day app evaluation models. Objective: This study aimed to develop and pilot test the Technology Evaluation and Assessment Criteria for Health apps (TEACH-apps). Methods: Tailoring a well-known implementation framework, Replicating Effective Programs, we present a new process to approach the challenges faced in implementing app evaluation tools today. As a culmination of our experience implementing this process and feedback from stakeholders, we present the four-part process to aid the implementation of mobile health technology. This paper outlines the theory, evidence, and initial versions of the process. Results: The TEACH-apps process is designed to be broadly usable and widely applicable across all fields of health. The process comprises four parts: (1) preconditions (eg, gathering apps and considering local needs), (2) preimplementation (eg, customizing criteria and offering digital skills training), (3) implementation (eg, evaluating apps and creating educational handouts), and (4) maintenance and evolution (eg, repeating the process every 90 days and updating content). TEACH-apps has been tested internally at our hospital, and there is growing interest in partnering health care facilities to test the system at their sites. Conclusions: This implementation framework introduces a process that equips stakeholders, clinicians, and users with the foundational tools to make informed decisions around app use and increase app evaluation engagement. The application of this process may lead to the selection of more culturally appropriate and clinically relevant tools in health care. %M 32535548 %R 10.2196/18346 %U https://www.jmir.org/2020/8/e18346 %U https://doi.org/10.2196/18346 %U http://www.ncbi.nlm.nih.gov/pubmed/32535548 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e15680 %T Improving Retention in Care and Promoting Adherence to HIV Treatment: Protocol for a Multisite Randomized Controlled Trial of Mobile Phone Text Messaging %A Tanue,Elvis Asangbeng %A Nsagha,Dickson Shey %A Theophile,Nana Njamen %A Assob,Jules Clement Nguedia %+ Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, PO Box 12, Buea, 00237, Cameroon, 237 677499429, dsnsagha@gmail.com %K adherence %K antiretroviral %K HIV %K randomized controlled trial %K retention in care %K text messaging %D 2020 %7 27.8.2020 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The World Health Organization has prioritized the use of new technologies to assist in health care delivery in resource-limited settings. Findings suggest that the use of SMS on mobile phones is an advantageous application in health care delivery, especially in communities with an increasing use of this device. Objective: The main aim of this trial is to assess whether sending weekly motivational text messages (SMS) through mobile phones versus no text messaging will improve retention in care and promote adherence to treatment and health outcomes among patients receiving HIV treatment in Fako Division of Cameroon. Methods: This is a multisite randomized controlled single-blinded trial. Computer-generated random block sizes shall be used to produce a randomization list. Participants shall be randomly allocated into the intervention and control groups determined by serially numbered sealed opaque envelopes. The 156 participants will either receive the mobile phone text message or usual standard of care. We hypothesize that sending weekly motivational SMS reminders will produce a change in behavior to enhance retention; treatment adherence; and, hence, health outcomes. Participants shall be evaluated and data collected at baseline and then at 2, 4, and 6 months after the launch of the intervention. Text messages shall be sent out, and the delivery will be recorded. Primary outcome measures are retention in care and adherence to treatment. Secondary outcomes are clinical (weight, body mass index), biological (virologic suppression, tuberculosis coinfection), quality of life, treatment discontinuation, and mortality. The analysis shall be by intention-to-treat. Analysis of covariates shall be performed to determine factors influencing outcomes. Results: Recruitment and random allocation are complete; 160 participants were allocated into 3 groups (52 in the single SMS, 55 in the double SMS, and 53 in the control). Data collection and analysis are ongoing, and statistical results will be available by the end of August 2019. Conclusions: The interventions will contribute to an improved understanding of which intervention types can be feasible in improving retention in care and promoting adherence to antiretroviral therapy. Trial Registration: Pan African Clinical Trial Registry in South Africa PACTR201802003035922; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3035 International Registered Report Identifier (IRRID): DERR1-10.2196/15680 %M 32852282 %R 10.2196/15680 %U http://www.researchprotocols.org/2020/8/e15680/ %U https://doi.org/10.2196/15680 %U http://www.ncbi.nlm.nih.gov/pubmed/32852282 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e18506 %T Beneficial Features of a mHealth Asthma App for Children and Caregivers: Qualitative Study %A Iio,Misa %A Miyaji,Yumiko %A Yamamoto-Hanada,Kiwako %A Narita,Masami %A Nagata,Mayumi %A Ohya,Yukihiro %+ College of Nursing, Kanto Gakuin University, 1-50-1 Mutsuurahigashi, Kanazawa-ku, Yokohama, 236-8503, Japan, 81 45 786 5641, misaiio@kanto-gakuin.ac.jp %K children %K caregivers %K asthma %K mobile app %K proposed beneficial features %D 2020 %7 24.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: mHealth and uHealth apps are available for children with asthma and their caregivers. However, previous studies on mHealth apps for children older than 7 years old with asthma are limited, and most studies on asthma apps do not consider interactions involving communication between children and caregivers. Therefore, a prototype mHealth child asthma app was developed for children and their caregivers, with features of tailored feedback messages in continuing self-management and interactions between children and caregivers. Objective: The aim of this study was to identify the beneficial features of a prototype mHealth app developed for children with asthma and their caregivers. Methods: Children diagnosed with persistent asthma by allergy specialists at the National Center for Child Health and Development were recruited. The features of a prototype mHealth app for children with asthma and their caregivers were investigated using semistructured interviews after they tried the app. Data were analyzed using thematic analysis. Content-characteristic words were named and grouped together as categories to explore themes. Results: We recruited 27 children with asthma aged 2 to 12 years and 26 their caregivers. Findings on the good aspects of the app for children older than 7 years old and caregivers suggested 4 themes (confirmation of asthma knowledge, child-caregiver interaction, design of the app, and child’s interest), and 6 categories were identified. Findings on the good aspects of app for children 7 to 12 years old and caregivers suggested 5 themes (new knowledge, manga as a Japanese-style comic, child’s interest, trigger of self-management, and design and operability), and 11 categories were identified. Findings on the beneficial features of app suggested 6 themes (asthma knowledge, elements for continuous, universal design, notification, monitoring, and functions), and 12 categories were identified. Conclusions: Children with asthma and their caregivers perceived that the good aspects of the app were learning asthma knowledge with fun, including manga; interaction between child and caregiver; and easy-to-read design, such as colors. They wanted not only the asthma knowledge but also the universal design and enhanced elements, monitoring, and notification functions of the app. %M 32831181 %R 10.2196/18506 %U http://mhealth.jmir.org/2020/8/e18506/ %U https://doi.org/10.2196/18506 %U http://www.ncbi.nlm.nih.gov/pubmed/32831181 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e20679 %T A Digital Health Intervention for Weight Management for Latino Families Living in Rural Communities: Perspectives and Lessons Learned During Development %A Yin,Zenong %A Errisuriz,Vanessa L %A Evans,Martin %A Inupakutika,Devasena %A Kaghyan,Sahak %A Li,Shiyu %A Esparza,Laura %A Akopian,David %A Parra-Medina,Deborah %+ Latino Research Institute, The University of Texas at Austin, 210 W 24th St, Mailcode F9200, Austin, TX, 78712, United States, 1 512 471 4557, parramedina@austin.utexas.edu %K mhealth %K digital intervention %K Latino families %K rural population %K weight %K self-management %K diet %K lifestyle %K chronic disease %D 2020 %7 20.8.2020 %9 Viewpoint %J JMIR Form Res %G English %X Rural residents face numerous challenges in accessing quality health care for management of chronic diseases (eg, obesity, diabetes), including scarcity of health care services and insufficient public transport. Digital health interventions, which include modalities such as internet, smartphones, and monitoring sensors, may help increase rural residents’ access to health care. While digital health interventions have become an increasingly popular intervention strategy to address obesity, research examining the use of technological tools for obesity management among rural Latino populations is limited. In this paper, we share our experience developing a culturally tailored, interactive health intervention using digital technologies for a family-oriented, weight management program in a rural, primarily Latino community. We describe the formative research that guided the development of the intervention, discuss the process of developing the intervention technologies including issues of privacy and data security, examine the results of a pilot study, and share lessons learned. Our experience can help others design user-centered digital health interventions to engage underserved populations in the uptake of healthy lifestyle and disease management skills. %M 32726748 %R 10.2196/20679 %U http://formative.jmir.org/2020/8/e20679/ %U https://doi.org/10.2196/20679 %U http://www.ncbi.nlm.nih.gov/pubmed/32726748 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e18946 %T Development and Feasibility of a Mobile Health–Supported Comprehensive Intervention Model (CIMmH) for Improving the Quality of Life of Patients With Esophageal Cancer After Esophagectomy: Prospective, Single-Arm, Nonrandomized Pilot Study %A Cheng,Chao %A Ho,Rainbow Tin Hung %A Guo,Yan %A Zhu,Mengting %A Yang,Weixiong %A Li,Yiran %A Liu,Zhenguo %A Zhuo,Shuyu %A Liang,Qi %A Chen,Zhenghong %A Zeng,Yu %A Yang,Jiali %A Zhang,Zhanfei %A Zhang,Xu %A Monroe-Wise,Aliza %A Yeung,Sai-Ching %+ Department of Medical statistics, School of Public Health, Sun-Yat-Sen University, No. 74 2nd Zhongshan Road, Guangzhou 510080, China, Guangzhou, 510080, China, 86 0208733420, guoy8@mail.sysu.edu.cn %K esophageal cancer %K quality of life %K nutrition %K physical exercise %K psychological support %K mobile health %K mHealth %D 2020 %7 18.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients with esophageal cancer often experience clinically relevant deterioration of quality of life (QOL) after esophagectomy owing to malnutrition, lack of physical exercise, and psychological symptoms. Objective: This study aimed to evaluate the feasibility, safety, and efficacy of a comprehensive intervention model using a mobile health system (CIMmH) in patients with esophageal cancer after esophagectomy. Methods: Twenty patients with esophageal cancer undergoing the modified McKeown surgical procedure were invited to join the CIMmH program with both online and offline components for 12 weeks. The participants were assessed before surgery and again at 1 and 3 months after esophagectomy. QOL, depressive symptoms, anxiety, stress, nutrition, and physical fitness were measured. Results: Of the 20 patients, 16 (80%) completed the program. One month after esophagectomy, patients showed significant deterioration in overall QOL (P=.02), eating (P=.005), reflux (P=.04), and trouble with talking (P<.001). At the 3-month follow-up, except for pain (P=.02), difficulty with eating (P=.03), dry mouth (P=.04), and trouble with talking (P=.003), all other QOL dimensions returned to the preoperative level. There were significant reductions in weight (P<.001) and BMI (P=.02) throughout the study, and no significant changes were observed for physical fitness measured by change in the 6-minute walk distance between baseline and the 1-month follow-up (P=.22) or between baseline and the 3-month follow-up (P=.52). Depressive symptoms significantly increased 1 month after surgery (P<.001), while other psychological measures did not show relevant changes. Although there were declines in many measures 1 month after surgery, these were much improved at the 3-month follow-up, and the recovery was more profound and faster than with traditional rehabilitation programs. Conclusions: The CIMmH was feasible and safe and demonstrated encouraging efficacy testing with a control group for enhancing recovery after surgery among patients with esophageal cancer in China. Trial Registration: Chinese Clinical Trial Registry (ChiCTR-IPR-1800019900); http://www.chictr.org.cn/showprojen.aspx?proj=32811. %M 32808933 %R 10.2196/18946 %U http://www.jmir.org/2020/8/e18946/ %U https://doi.org/10.2196/18946 %U http://www.ncbi.nlm.nih.gov/pubmed/32808933 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e19006 %T Mobile Health App for Japanese Adult Patients With Asthma: Clinical Observational Study %A Harada,Norihiro %A Harada,Sonoko %A Ito,Jun %A Atsuta,Ryo %A Hori,Satoshi %A Takahashi,Kazuhisa %+ Department of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan, 81 3 5802 1063, nor@juntendo.ac.jp %K asthma %K cough variant asthma %K mobile health %K ResearchKit %D 2020 %7 14.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Inappropriate asthma control reduces quality of life and causes increased exacerbations. Mobile health (mHealth) employs information and communication technology for surveying health-related issues. Objective: This noninterventional, observational study assessed current real-world asthma control levels among Japanese patients with asthma and cough variant asthma (CVA) using the Zensoku-Log app. Methods: We developed the app using the ResearchKit platform and conducted a mobile-based, self-reporting, observational survey among patients with asthma and CVA. The app was downloaded 7855 times between February 2016 and February 2018, and enabled collection of data on symptoms, comorbidities, quality of life, medications, asthma control, and adherence. Results: Of the 1744 eligible participants (median age 33 years; range 20-74 years; male-to-female ratio 38.7:61.3), 50.97% (889/1744) reported unscheduled visits, 62.84% (1096/1744) reported regularly scheduled visits, 23.14% (402/1737) smoked, and 40.75% (705/1730) had pets. In addition, 91.89% (1598/1739) of participants had atopic predisposition, including allergic rhinitis and atopic dermatitis. Daily inhaled corticosteroid and oral corticosteroid treatment had been prescribed for 89.45% (1552/1735) and 22.07% (383/1735) of participants, respectively. Although an asthma control questionnaire demonstrated poor asthma control in 58.48% (1010/1727), a leukotriene receptor antagonist, theophylline, and a long-acting muscarinic antagonist had been prescribed for only 30.66% (532/1735), 15.91% (276/1735), and 4.38% (76/1735), respectively. The Adherence Starts with Knowledge 12 total score was 29. In the 421 participants who repeated the questionnaire, asthma control increased significantly between the initial and last rounds (P=.002). Conclusions: Users of this mHealth app in Japan had poorly controlled asthma and may need more treatment for asthma and their comorbidities. Repeated app users demonstrated improved asthma control. Trial Registration: UMIN Clinical Trial Registry UMIN000021043; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000023913. %M 32795993 %R 10.2196/19006 %U https://www.jmir.org/2020/8/e19006 %U https://doi.org/10.2196/19006 %U http://www.ncbi.nlm.nih.gov/pubmed/32795993 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17019 %T Smartphone-Enhanced Symptom Management In Psychosis: Open, Randomized Controlled Trial %A Lewis,Shon %A Ainsworth,John %A Sanders,Caroline %A Stockton-Powdrell,Charlotte %A Machin,Matthew %A Whelan,Pauline %A Hopkins,Richard %A He,Zhimin %A Applegate,Eve %A Drake,Richard %A Bamford,Charlie %A Roberts,Chris %A Wykes,Til %+ Manchester Academic Health Sciences Centre, Greater Manchester Mental Health Foundation Trust, The University of Manchester, Faculty of Biology, Medicine & Health, Oxford Road, Manchester, M13 9PL, United Kingdom, 44 1613067944, shon.lewis@manchester.ac.uk %K digital %K smartphone %K m-health %K psychosis %K mental health %K self management %D 2020 %7 13.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Improving recovery from acute symptoms and preventing relapse are two significant challenges in severe mental illness. We developed a personalized smartphone-based app to monitor symptoms in real time and validated its acceptance, reliability, and validity. Objective: To assess (i) acceptability of continuous monitoring to SMI patients and health professionals over 3 months; (ii) impact of active self-monitoring on positive psychotic symptoms assessed at 6 and 12 weeks; and (iii) the feasibility of detecting early warning signs of relapse. Methods: The active symptom monitoring smartphone app was built into an end-to-end system in two NHS Trusts to enable real-time symptom self-monitoring and detection by the clinical team of early signs of relapse in people with severe mental illness. We conducted an open randomized controlled trial of active symptom monitoring compared to usual management to assess: (i) acceptability and safety of continuous monitoring over 3 months; (ii) impact of active self-monitoring on positive psychotic symptoms assessed at 6 and 12 weeks; (iii) feasibility of detecting early warning signs of relapse communicated to the healthcare staff via an app streaming data to the electronic health record. Eligible participants with a Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnosis of schizophrenia and related disorders, and a history of relapse within the previous two years were enrolled from an early intervention team and a community mental health team. Results: Of 181 eligible patients, 81 (45%) consented and were randomized to either active symptom monitoring or management as usual. At 12 weeks, 90% (33/36) of those in the active monitoring group continued to use the system and exhibited an adherence rate (defined as responding to >33% of alerts) of 84% (30/36}. Active symptom monitoring was associated with no difference on the empowerment scale in comparison to the usual management group at 12 weeks. The pre-planned intent-to-treat analysis of the primary outcome, a positive score on the Positive and Negative Syndrome Scale (PANSS) scale, showed a significant reduction in the active symptom monitoring group over 12 weeks in the early intervention center. Alerts for personalized early warning signs of relapse were built into the workflows of both NHS Trusts, and 100% of health professional staff used the system in a new digital workflow. Qualitative analyses supported the acceptability of the system to participants and staff. Conclusions: The active smartphone monitoring system is feasible and was accepted by users in a 3-month study of people with severe mental illness, with surprisingly high levels of adherence. App use was associated with psychotic symptom improvement in recent-onset participants, but not those with longstanding illness, supporting the notion of improved self-management. When built into clinical management workflows to enable personalized alerts of symptom deterioration, the app has demonstrated utility in promoting earlier intervention for relapse. Trial Registration: ISRCTN Registry ISRCTN88145142; http://www.isrctn.com/ISRCTN88145142 %M 32788150 %R 10.2196/17019 %U https://www.jmir.org/2020/8/e17019 %U https://doi.org/10.2196/17019 %U http://www.ncbi.nlm.nih.gov/pubmed/32788150 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e15506 %T Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study %A Betthauser,Lisa M %A Stearns-Yoder,Kelly A %A McGarity,Suzanne %A Smith,Victoria %A Place,Skyler %A Brenner,Lisa A %+ Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center, 1700 N Wheeling St, Aurora, CO, 80045, United States, 1 720 723 4867, lisa.betthauser@va.gov %K veterans %K mobile app %K smartphone %K mental health %K acceptability %K feasibility %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. Objective: Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. Methods: A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. Results: Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire–8, 79% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6%) reported concerns regarding personal privacy. Conclusions: Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide. %M 32779572 %R 10.2196/15506 %U https://www.jmir.org/2020/8/e15506 %U https://doi.org/10.2196/15506 %U http://www.ncbi.nlm.nih.gov/pubmed/32779572 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17058 %T Engagement in an Interactive App for Symptom Self-Management during Treatment in Patients With Breast or Prostate Cancer: Mixed Methods Study %A Crafoord,Marie-Therése %A Fjell,Maria %A Sundberg,Kay %A Nilsson,Marie %A Langius-Eklöf,Ann %+ Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, Stockholm, 14183, Sweden, 46 8524 837 49, marie-therese.crafoord@ki.se %K engagement %K adherence %K mHealth %K mobile app %K cancer supportive care %K symptom management %K usage metrics %K breast cancer %K prostate cancer %D 2020 %7 10.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Using mobile technology for symptom management and self-care can improve patient-clinician communication and clinical outcomes in patients with cancer. The interactive app Interaktor has been shown to reduce symptom burden during cancer treatment. It includes symptom assessment, an alert system for contact with health care professionals, access to self-care advice, and visualization of symptom history. It is essential to understand how digital interventions operate; one approach is to examine engagement by assessing usage and exploring user experiences. Actual usage in relation to the intended use—adherence—is an essential factor of engagement. Objective: This study aimed to describe engagement with the Interaktor app among patients with breast or prostate cancer during treatment. Methods: Patients from the intervention groups of two separate randomized controlled trials were included: patients with breast cancer receiving neoadjuvant chemotherapy (n=74) and patients with locally advanced prostate cancer receiving treatment with radiotherapy (n=75). The patients reported their symptoms daily. Sociodemographic and clinical data were obtained from baseline questionnaires and medical records. Logged data usage was retrieved from the server and analyzed descriptively and with multiple regression analysis. Telephone interviews were conducted with patients about their perceptions of using the app and analyzed using content analysis. Results: The median adherence percentage to daily symptom reporting was 83%. Most patients used the self-care advice and free text message component. Among the patients treated for breast cancer, higher age predicted a higher total number of free text messages sent (P=.04). Among the patients treated for prostate cancer, higher age (P=.01) and higher education level (P=.04), predicted an increase in total views on self-care advice, while higher comorbidity (P=.004) predicted a decrease in total views on self-care advice. Being married or living with a partner predicted a higher adherence to daily symptom reporting (P=.02). Daily symptom reporting created feelings of having continuous contact with health care professionals, being acknowledged, and safe. Being contacted by a nurse after a symptom alert was considered convenient and highly valued. Treatment and time-related aspects influenced engagement. Daily symptom reporting was perceived as particularly meaningful at the beginning of treatment. Requests were made for advice on diet and psychological symptoms, as well as for more comprehensive and detailed information as the patient progressed through treatment. Conclusions: Patient engagement in the interactive app Interaktor was high. The app promoted patient participation in their care through continuous and convenient contact with health care professionals. The predictive ability of demographic variables differed between patient groups, but higher age and a higher educational level predicted higher usage of specific app functions for both patient groups. Patients’ experience of relevance and interactivity influenced their engagement positively. %M 32663140 %R 10.2196/17058 %U https://www.jmir.org/2020/8/e17058 %U https://doi.org/10.2196/17058 %U http://www.ncbi.nlm.nih.gov/pubmed/32663140 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e16797 %T Examining Responsiveness to an Incentive-Based Mobile Health App: Longitudinal Observational Study %A Brower,Jacob %A LaBarge,Monica C %A White,Lauren %A Mitchell,Marc S %+ Smith School of Business, Queen's University, 805 Johnson St, Kingston, ON, K7L2B6, Canada, 1 6132174726, jbrower@queensu.ca %K mHealth %K behavioral economics %K public health %K incentives %K mobile apps %K mobile phone %D 2020 %7 10.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The Carrot Rewards app was developed as part of a public-private partnership to reward Canadians with loyalty points for downloading the app, referring friends, completing educational health quizzes, and health-related behaviors with long-term objectives of increasing health knowledge and encouraging healthy behaviors. During the first 3 months after program rollout in British Columbia, a number of program design elements were adjusted, creating observed differences between groups of users with respect to the potential impact of program features on user engagement levels. Objective: This study examines the impact of reducing reward size over time and explored the influence of other program features such as quiz timing, health intervention content, and type of reward program on user engagement with a mobile health (mHealth) app. Methods: Participants in this longitudinal, nonexperimental observational study included British Columbia citizens who downloaded the app between March and July 2016. A regression methodology was used to examine the impact of changes to several program design features on quiz offer acceptance and engagement with this mHealth app. Results: Our results, based on the longitudinal app use of 54,917 users (mean age 35, SD 13.2 years; 65.03% [35,647/54,917] female), indicated that the key drivers of the likelihood of continued user engagement, in order of greatest to least impact, were (1) type of rewards earned by users (eg, movies [+355%; P<.001], air travel [+210%; P<.001], and grocery [+140%; P<.001] relative to gas), (2) time delay between early offers (−64%; P<.001), (3) the content of the health intervention (eg, healthy eating [−10%; P<.001] vs exercise [+20%, P<.001] relative to health risk assessments), and (4) changes in the number of points offered. Our results demonstrate that reducing the number of points associated with a particular quiz by 10% only led to a 1% decrease in the likelihood of offer response (P<.001) and that each of the other design features had larger impacts on participant retention than did changes in the number of points. Conclusions: The results of this study demonstrate that this program, built around the principles of behavioral economics in the form of the ongoing awarding of a small number of reward points instantly following the completion of health interventions, was able to drive significantly higher engagement levels than those demonstrated in previous literature exploring the intersection of mHealth apps and financial incentives. Previous studies have demonstrated the presence of incentive matters to user engagement; however, our results indicate that the number of points offered for these reward point–based health interventions is less important than other program design features such as the type of reward points being offered, the timing of intervention and reward offers, and the content of the health interventions in driving continued engagement by users. %M 32773371 %R 10.2196/16797 %U https://www.jmir.org/2020/8/e16797 %U https://doi.org/10.2196/16797 %U http://www.ncbi.nlm.nih.gov/pubmed/32773371 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e16239 %T #BlackBreastsMatter: Process Evaluation of Recruitment and Engagement of Pregnant African American Women for a Social Media Intervention Study to Increase Breastfeeding %A Dauphin,Cassy %A Clark,Nikia %A Cadzow,Renee %A Saad-Harfouche,Frances %A Rodriguez,Elisa %A Glaser,Kathryn %A Kiviniemi,Marc %A Keller,Maria %A Erwin,Deborah %+ Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, United States, 1 716 845 2927, deborah.erwin@roswellpark.org %K breastfeeding %K breast cancer education %K African American mothers %K Facebook %K mobile phone, social media %D 2020 %7 10.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the United States, there are lower rates of breastfeeding among African American mothers, particularly those who are younger women. Recent epidemiological studies have shown a strong association of more aggressive types of breast cancer (estrogen receptor negative) among African American women, with a higher risk in African American women who did not breastfeed their children. Objective: This study aims to describe the process evaluation of recruitment and educational strategies to engage pregnant African American participants for a pilot study designed to determine whether social media messaging about breast cancer risk reduction through breastfeeding may positively influence breastfeeding rates. Methods: This pilot study is conducted in collaboration with a local Women, Infants, and Children (WIC) organization and hospital and prenatal clinics of a local health care network. To engage African American women to enroll in the study, several methods and monitoring processes were explored, including WIC electronic text-based messages sent out to all phones of current WIC recipients (referred to as e-blasts); keyword responses to texts from flyers and posters in local community-based organizations, hospitals, and prenatal clinics; keyword responses using electronic links posted in established Facebook groups; and snowball recruitment of other pregnant women by current participants through Facebook. Once enrolled, participants were randomized to 2 study conditions: (1) an intervention group receiving messages about breast cancer risk reduction and breastfeeding or (2) a control group receiving breastfeeding-only messages. Data were obtained through electronic monitoring, SurveyMonkey, qualitative responses on Facebook, focus groups, and interviews. Results: More than 3000 text messages were sent and received through WIC e-blasts and keyword responses from flyers. A total of 472 women were recruited through WIC e-blast, and 161 responded to flyers and contacts through the local health care network, community-based organizations, Facebook, and friend referrals. A total of 633 women were assessed for eligibility to participate in the study. A total of 288 pregnant African American women were enrolled, consented, and completed presurvey assessments (102.8% of the goal), and 22 participants attended focus groups or interviews reporting on their experiences with Facebook and the educational messages. Conclusions: This process evaluation suggests that using electronic, smartphone apps with social media holds promise for both recruitment and conduct of health education intervention studies for pregnant African American women. Providing messaging and resources through social media to reinforce and educate women about breastfeeding and potentially provide lactation support is intriguing. Convenience (for researchers and participants) is an attribute of social media for this demographic of women and worthy of further research as an educational tool. Trial Registration: ClinicalTrials.gov NCT03680235; https://clinicaltrials.gov/ct2/show/NCT03680235 %M 32773377 %R 10.2196/16239 %U https://www.jmir.org/2020/8/e16239 %U https://doi.org/10.2196/16239 %U http://www.ncbi.nlm.nih.gov/pubmed/32773377 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e20596 %T Mobile Health Apps That Help With COVID-19 Management: Scoping Review %A John Leon Singh,Hanson %A Couch,Danielle %A Yap,Kevin %+ Department of Public Health, School of Psychology and Public Health, La Trobe University, Health Sciences 2 Building, Melbourne, 3086, Australia, 61 3 9479 6068, kevinyap.ehealth@gmail.com %K COVID-19 %K mobile apps %K mHealth %K contact tracing %K symptom monitoring %K information provision %K mobile health %D 2020 %7 6.8.2020 %9 Review %J JMIR Nursing %G English %X Background: Mobile health (mHealth) apps have played an important role in mitigating the coronavirus disease (COVID-19) response. However, there is no resource that provides a holistic picture of the available mHealth apps that have been developed to combat this pandemic. Objective: Our aim is to scope the evidence base on apps that were developed in response to COVID-19. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews, literature searches were conducted on Google Search, Google Scholar, and PubMed using the country’s name as keywords and “coronavirus,” “COVID-19,” “nCOV19,” “contact tracing,” “information providing apps,” “symptom tracking,” “mobile apps,” “mobile applications,” “smartphone,” “mobile phone,” and “mHealth.” Countries most affected by COVID-19 and those that first rolled out COVID-19–related apps were included. Results: A total of 46 articles were reviewed from 19 countries, resulting in a total of 29 apps. Among them, 15 (52%) apps were on contact tracing, 7 (24%) apps on quarantine, 7 (24%) on symptom monitoring, and 1 (3%) on information provision. More than half (n=20, 69%) were from governmental sources, only 3 (10%) were from private organizations, and 3 (10%) from universities. There were 6 (21%) apps available on either Android or iOS, and 10 (34%) were available on both platforms. Bluetooth was used in 10 (34%) apps for collecting data, 12 (41%) apps used GPS, and 12 (41%) used other forms of data collection. Conclusions: This review identifies that the majority of COVID-19 apps were for contact tracing and symptom monitoring. However, these apps are effective only if taken up by the community. The sharing of good practices across different countries can enable governments to learn from each other and develop effective strategies to combat and manage this pandemic. %M 32897271 %R 10.2196/20596 %U https://nursing.jmir.org/2020/1/e20596/ %U https://doi.org/10.2196/20596 %U http://www.ncbi.nlm.nih.gov/pubmed/32897271 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e19216 %T Effect of Adding Telephone-Based Brief Coaching to an mHealth App (Stay Strong) for Promoting Physical Activity Among Veterans: Randomized Controlled Trial %A Damschroder,Laura J %A Buis,Lorraine R %A McCant,Felicia A %A Kim,Hyungjin Myra %A Evans,Richard %A Oddone,Eugene Z %A Bastian,Lori A %A Hooks,Gwendolyn %A Kadri,Reema %A White-Clark,Courtney %A Richardson,Caroline R %A Gierisch,Jennifer M %+ Veterans Affairs Center for Clinical Management Research, Ann Arbor Healthcare System, 2215 Fuller Rd (152), Ann Arbor, MI, 48105, United States, 1 7348453603, laura.damschroder@va.gov %K exercise %K veterans %K smartphones %K wearable physical activity tracker %K behavior change %K mobile phone %K online %K app %K mobile app %K wearable %D 2020 %7 4.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone. Objective: The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching. Methods: Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation. Results: The average age of participants was 39.8 (SD 8.7) years, and 25.2% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0% (120/179) for Stay Strong and 61.8% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm. Conclusions: Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial’s 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up. Trial Registration: ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293 International Registered Report Identifier (IRRID): RR2-10.2196/12526 %M 32687474 %R 10.2196/19216 %U http://www.jmir.org/2020/8/e19216/ %U https://doi.org/10.2196/19216 %U http://www.ncbi.nlm.nih.gov/pubmed/32687474 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17760 %T The Mobile App Development and Assessment Guide (MAG): Delphi-Based Validity Study %A Llorens-Vernet,Pere %A Miró,Jordi %+ Unit for the Study and Treatment of Pain-ALGOS, Research Center for Behavior Assessment, Universitat Rovira i Virgili, Carretera de Valls, s/n, Tarragona, 43007, Spain, 34 +34649298921, jordi.miro@urv.cat %K assessment %K Delphi method %K MAG %K mobile apps %K mobile health %K validity %K guide %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In recent years, there has been an exponential growth of mobile health (mHealth)–related apps. This has occurred in a somewhat unsupervised manner. Therefore, having a set of criteria that could be used by all stakeholders to guide the development process and the assessment of the quality of the apps is of most importance. Objective: The aim of this paper is to study the validity of the Mobile App Development and Assessment Guide (MAG), a guide recently created to help stakeholders develop and assess mobile health apps. Methods: To conduct a validation process of the MAG, we used the Delphi method to reach a consensus among participating stakeholders. We identified 158 potential participants: 45 patients as potential end users, 41 health care professionals, and 72 developers. We sent participants an online survey and asked them to rate how important they considered each item in the guide to be on a scale from 0 to 10. Two rounds were enough to reach consensus. Results: In the first round, almost one-third (n=42) of those invited participated, and half of those (n=24) also participated in the second round. Most items in the guide were found to be important to a quality mHealth-related app; a total of 48 criteria were established as important. “Privacy,” “security,” and “usability” were the categories that included most of the important criteria. Conclusions: The data supports the validity of the MAG. In addition, the findings identified the criteria that stakeholders consider to be most important. The MAG will help advance the field by providing developers, health care professionals, and end users with a valid guide so that they can develop and identify mHealth-related apps that are of quality. %M 32735226 %R 10.2196/17760 %U http://mhealth.jmir.org/2020/7/e17760/ %U https://doi.org/10.2196/17760 %U http://www.ncbi.nlm.nih.gov/pubmed/32735226 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17481 %T A Mobile Health Approach for Improving Outcomes in Suicide Prevention (SafePlan) %A O'Grady,Conor %A Melia,Ruth %A Bogue,John %A O'Sullivan,Mary %A Young,Karen %A Duggan,Jim %+ School of Computer Science, National University of Ireland Galway, University Road, Galway, H91 TK33, Ireland, 353 91493336, james.duggan@nuigalway.ie %K mobile apps %K suicide %K mHealth %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a prominent cause of death worldwide, particularly among young people. It was the second leading cause of death among those aged 15-29 years globally in 2016. Treatment for patients with suicidal thoughts or behaviors often includes face-to-face psychological therapy with a mental health professional. These forms of interventions may involve maintaining and updating paper-based reports or worksheets in between sessions. Mobile technology can offer a way to support the implementation of evidence-based psychological techniques and the acquisition of protective coping skills. Objective: This study aims to develop a mobile app to facilitate service users’ access to mental health support and safety planning. This process involved eliciting expert input from clinicians who are actively engaged in the provision of mental health care. Methods: A survey was distributed to targeted health care professionals to determine what features should be prioritized in a new mobile app relating to suicide prevention. On the basis of the survey results, a clinical design group, comprising 6 members with experience in fields such as mobile health (mHealth), clinical psychology, and suicide prevention, was established. This group was supplemented with further input from additional clinicians who provided feedback over three focus group sessions. The sessions were centered on refining existing app components and evaluating new feature requests. This process was iterated through regular feedback until agreement was reached on the overall app design and functionality. Results: A fully functional mobile app, known as the SafePlan app, was developed and tested with the input of clinicians through an iterative design process. The app’s core function is to provide an interactive safety plan to support users with suicidal thoughts or behaviors as an adjunct to face-to-face therapy. A diary component that facilitates the generalization of skills learned through dialectical behavior therapy was also implemented. Usability testing was carried out on the final prototype by students from a local secondary school, who are representative of the target user population in both age and technology experience. The students were asked to complete a system usability survey (SUS) at the end of this session. The mean overall SUS rating was 71.85 (SD 1.38). Conclusions: The participatory process involving key stakeholders (clinicians, psychologists, and information technology specialists) has resulted in the creation of an mHealth intervention technology that has the potential to increase accessibility to this type of mental health service for the target population. The app has gone through the initial testing phase, and the relevant recommendations have been implemented, and it is now ready for trialing with both clinicians and their patients. %M 32729845 %R 10.2196/17481 %U http://www.jmir.org/2020/7/e17481/ %U https://doi.org/10.2196/17481 %U http://www.ncbi.nlm.nih.gov/pubmed/32729845 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e19721 %T Patient Experiences of Rehabilitation and the Potential for an mHealth System with Biofeedback After Breast Cancer Surgery: Qualitative Study %A Brennan,Louise %A Kessie,Threase %A Caulfield,Brian %+ Physiotherapy Department, Beacon Hospital, Sandyford Business Park, Dublin, Ireland, 353 851437364, louise.brennan@ucdconnect.ie %K breast cancer %K physiotherapy %K rehabilitation %K mHealth %K biofeedback %K user-centred design %K cancer %D 2020 %7 29.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Physiotherapy-led home rehabilitation after breast cancer surgery can protect against the development of upper limb dysfunction and other disabling consequences of surgery. A variety of barriers can limit physical rehabilitation outcomes, and patients may benefit from more support during this time. Mobile health (mHealth) systems can assist patients during rehabilitation by providing exercise support, biofeedback, and information. Before designing mHealth systems for a specific population, developers must first engage with users to understand their experiences and needs. Objective: The aims of this study were to explore patients’ rehabilitation experiences and unmet needs during home rehabilitation after breast cancer surgery and to understand their experiences of mHealth technology and the requirements they desire from an mHealth system. Methods: This was the first stage of a user-centered design process for an mHealth system. We interviewed 10 breast cancer survivors under the two main topics of “Rehabilitation” and “Technology” and performed a thematic analysis on the interview data. Results: Discussions regarding rehabilitation focused on the acute and long-term consequences of surgery; unmet needs and lack of support; self-driven rehabilitation; and visions for high-quality rehabilitation. Regarding technology, participants reported a lack of mHealth options for this clinical context and using non-cancer–specific applications and wearables. Participants requested an mHealth tool from a reliable source that provides exercise support. Conclusions: There are unmet needs surrounding access to physiotherapy, information, and support during home rehabilitation after breast cancer surgery that could be addressed with an mHealth system. Breast cancer survivors are open to using an mHealth system and require that it comes from a reliable source and focuses on supporting exercise performance. %M 32687476 %R 10.2196/19721 %U http://mhealth.jmir.org/2020/7/e19721/ %U https://doi.org/10.2196/19721 %U http://www.ncbi.nlm.nih.gov/pubmed/32687476 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18413 %T Evaluating Network Readiness for mHealth Interventions Using the Beacon Mobile Phone App: Application Development and Validation Study %A Scherr,Thomas Foster %A Moore,Carson Paige %A Thuma,Philip %A Wright,David Wilson %+ Department of Chemistry, Vanderbilt University, 7300 Stevenson Center, 1234 Stevenson Center Lane, Nashville, TN, 37235, United States, 1 615 322 5516, Thomas.f.scherr@vanderbilt.edu %K mHealth %K network readiness %K network assessment %K mobile network %D 2020 %7 28.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) interventions have the potential to transform the global health care landscape. The processing power of mobile devices continues to increase, and growth of mobile phone use has been observed worldwide. Uncertainty remains among key stakeholders and decision makers as to whether global health interventions can successfully tap into this trend. However, when correctly implemented, mHealth can reduce geographic, financial, and social barriers to quality health care. Objective: The aim of this study was to design and test Beacon, a mobile phone–based tool for evaluating mHealth readiness in global health interventions. Here, we present the results of an application validation study designed to understand the mobile network landscape in and around Macha, Zambia, in 2019. Methods: Beacon was developed as an automated mobile phone app that continually collects spatiotemporal data and measures indicators of network performance. Beacon was used in and around Macha, Zambia, in 2019. Results were collected, even in the absence of network connectivity, and asynchronously uploaded to a database for further analysis. Results: Beacon was used to evaluate three mobile phone networks around Macha. Carriers A and B completed 6820/7034 (97.0%) and 6701/7034 (95.3%) downloads and 1349/1608 (83.9%) and 1431/1608 (89.0%) uploads, respectively, while Carrier C completed only 62/1373 (4.5%) file downloads and 0/1373 (0.0%) file uploads. File downloads generally occurred within 4 to 12 seconds, and their maximum download speeds occurred between 2 AM and 5 AM. A decrease in network performance, demonstrated by increases in upload and download durations, was observed beginning at 5 PM and continued throughout the evening. Conclusions: Beacon was able to compare the performance of different cellular networks, show times of day when cellular networks experience heavy loads and slow down, and identify geographic “dead zones” with limited or no cellular service. Beacon is a ready-to-use tool that could be used by organizations that are considering implementing mHealth interventions in low- and middle-income countries but are questioning the feasibility of the interventions, including infrastructure and cost. It could also be used by organizations that are looking to optimize the delivery of an existing mHealth intervention with improved logistics management. %M 32720909 %R 10.2196/18413 %U http://mhealth.jmir.org/2020/7/e18413/ %U https://doi.org/10.2196/18413 %U http://www.ncbi.nlm.nih.gov/pubmed/32720909 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17134 %T Assessment of the Fairness of Privacy Policies of Mobile Health Apps: Scale Development and Evaluation in Cancer Apps %A Benjumea,Jaime %A Ropero,Jorge %A Rivera-Romero,Octavio %A Dorronzoro-Zubiete,Enrique %A Carrasco,Alejandro %+ Department of Electronic Technology, Universidad de Sevilla, Escuela Técnica Superior de Ingeniería Informática, Avda Reina Mercedes s/n, Sevilla, Spain, 34 6306 29719, jaimebm@us.es %K privacy %K mhealth apps %K fairness assessment scale %K cancer apps %K GDPR %D 2020 %7 28.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Cancer patients are increasingly using mobile health (mHealth) apps to take control of their health. Many studies have explored their efficiency, content, usability, and adherence; however, these apps have created a new set of privacy challenges, as they store personal and sensitive data. Objective: The purpose of this study was to refine and evaluate a scale based on the General Data Protection Regulation and assess the fairness of privacy policies of mHealth apps. Methods: Based on the experience gained from our previous work, we redefined some of the items and scores of our privacy scale. Using the new version of our scale, we conducted a case study in which we analyzed the privacy policies of cancer Android apps. A systematic search of cancer mobile apps was performed in the Spanish version of the Google Play website. Results: The redefinition of certain items reduced discrepancies between reviewers. Thus, use of the scale was made easier, not only for the reviewers but also for any other potential users of our scale. Assessment of the privacy policies revealed that 29% (9/31) of the apps included in the study did not have a privacy policy, 32% (10/31) had a score over 50 out of a maximum of 100 points, and 39% (12/31) scored fewer than 50 points. Conclusions: In this paper, we present a scale for the assessment of mHealth apps that is an improved version of our previous scale with adjusted scores. The results showed a lack of fairness in the mHealth app privacy policies that we examined, and the scale provides developers with a tool to evaluate their privacy policies. %M 32720913 %R 10.2196/17134 %U http://mhealth.jmir.org/2020/7/e17134/ %U https://doi.org/10.2196/17134 %U http://www.ncbi.nlm.nih.gov/pubmed/32720913 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16856 %T Perceptions and Acceptability of Digital Interventions Among Tuberculosis Patients in Cambodia: Qualitative Study of Video-Based Directly Observed Therapy %A Rabinovich,Lila %A Molton,James Steven %A Ooi,Wei Tsang %A Paton,Nicholas Iain %A Batra,Shelly %A Yoong,Joanne %+ Center for Economic and Social Research, University of Southern California, 1090 Vermont Avenue, NW, Washington, DC, 20005, United States, 1 2138210537, lilarabi@usc.edu %K directly observed therapy %K video recording %K telemedicine %K mobile health %K mHealth %K tuberculosis %K low-income settings %K developing countries %K patient acceptance of health care %K patient acceptability %K Cambodia %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the development of effective drugs for treatment, tuberculosis remains one of the leading causes of death from an infectious disease worldwide. One of the greatest challenges to tuberculosis control is patient adherence to treatment. Recent research has shown that video-based directly observed therapy is a feasible and effective approach to supporting treatment adherence in high-income settings. However, few studies have explored the potential for such a solution in a low- or middle-income country setting. Globally, these countries’ rapidly rising rate of mobile penetration suggests that the potential for translation of these results may be high. Objective: We sought to examine patient perceptions related to the use of mobile health, and specifically video-based directly observed therapy, in a previously unstudied patient demographic: patients with tuberculosis in a low-income country setting (Cambodia). Methods: We conducted a cross-sectional qualitative study in urban and periurban areas in Cambodia, consisting of 6 focus groups with tuberculosis patients who were receiving treatment (standard directly observed therapy) through a nongovernmental organization. Results: Familiarity with mobile technology and apps was widespread in this population, and overall willingness to consider a mobile app for video-based directly observed therapy was high. However, we identified potential challenges. First, patients very much valued their frequent in-person interactions with their health care provider, which may be reduced with the video-based directly observed therapy intervention. Second, there may be technical issues to address, including how to make the app suitable for illiterate participants. Conclusions: While video-based directly observed therapy is a promising technology, even in country settings where mobile penetration is reportedly almost universal, it should be introduced with caution. However, the results were generally promising and yielded important insights that not only will be translated into the further adaptation of key features of video-based directly observed therapy for tuberculosis patients in Cambodia, but also can inform the future design and successful implementation of video-based directly observed therapy interventions in low- and middle-income settings more generally. %M 32716309 %R 10.2196/16856 %U https://www.jmir.org/2020/7/e16856 %U https://doi.org/10.2196/16856 %U http://www.ncbi.nlm.nih.gov/pubmed/32716309 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14915 %T Mobile Mental Health Apps in China: Systematic App Store Search %A Yin,Huifang %A Wardenaar,Klaas J %A Wang,Yuhao %A Wang,Nan %A Chen,Wenjin %A Zhang,Yan %A Xu,Guangming %A Schoevers,Robert A %+ Tianjin Anding Hospital, No 13, Liulin Road, Hexi district, Tianjin, China, 86 15122997716, xugm@ymail.com %K smartphone %K app %K mobile mental health %K mental illness %K mental health problem %K China %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphones have become ubiquitous in China, offering a promising way to deliver mental health interventions; however, little is known about the current use and characteristics of smartphone apps for mental health. Objective: The purpose of this study was to gain insight into mobile mental health apps available in China as of December 2018. Methods: A systematic search was conducted to identify and evaluate the most downloaded apps from iOS and Android platforms. Apps were categorized according to their main purpose and downloaded to evaluate their content. Each app’s affiliation, cost, target users, information security, and evidence-based nature were evaluated. Results: Of the 172 unique apps that were identified, there were 37 apps (21.5%) for psychological counseling, 50 apps (29.1%) for assessment, 12 apps (7.0%) to relieve stress, 24 apps (14.0%) for psychoeducation, and 49 (28.4%) multipurpose apps (ie, a combination of counseling and assessment). Most apps were developed for adults in the general population (166/172, 96.5%), rather than for psychiatric patients. App-based counseling was mostly provided by psychologists, and of the assessed apps, only 40% (70/172) used evidence-based scales to assess mental health problems such as anxiety or depressed mood. Guided meditation was used as the main technique in stress-relieving apps. Conclusions: Many apps contained useful and evidence-based elements, such as good quality information, validated measurements, and useful meditation methods; however, for mobile apps to contribute significantly to mental health care in China, considerable challenges remain, including the need for more patient-focused apps that can actually take on the role of a health care provider. In addition, efficacy studies are needed. %M 32716301 %R 10.2196/14915 %U https://www.jmir.org/2020/7/e14915 %U https://doi.org/10.2196/14915 %U http://www.ncbi.nlm.nih.gov/pubmed/32716301 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14223 %T An mHealth Intervention (ReZone) to Help Young People Self-Manage Overwhelming Feelings: Cluster-Randomized Controlled Trial %A Edridge,Chloe %A Wolpert,Miranda %A Deighton,Jessica %A Edbrooke-Childs,Julian %+ Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 020 7443 2218, Chloe.edridge@annafreud.org %K cluster trial %K behavioral difficulties %K schools %K mHealth %K digital %K mental health %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health difficulties in young people are increasing, and there is a need for evidence on the effectiveness of digital interventions to increase opportunities for supporting mental health in young people. Such studies are complicated due to issues of implementation and adoption, outcome measurement, and appropriate study designs. Objective: The objective of this study was to examine the effectiveness of an mHealth intervention (ReZone) in reducing mental health difficulties in young people. Methods: The cluster-randomized controlled trial enrolled 409 participants aged 10-15 years, and classes were allocated to ReZone or management as usual. Self-reported questionnaires were completed at baseline and 3-month follow-up. Results: There were no significant differences between the ReZone condition and management as usual in the self-reported outcome measures. However, there were 3467 usage sessions, which corresponds to 16.9 times per student (total of 205 students) in classes allocated to ReZone. Conclusions: It is essential to publish studies that do not show significant differences, as these findings can still contribute to the literature, help in learning, and inform the direction of future work. The results reported in this paper could be due to a range of reasons, including whether ReZone has the scope to impact change or limitations related to the setting, context, and appropriateness of an RCT. The findings of this study suggest that ReZone was implemented and adopted. International Registered Report Identifier (IRRID): RR2-10.2196/resprot.7019 %M 32716299 %R 10.2196/14223 %U http://www.jmir.org/2020/7/e14223/ %U https://doi.org/10.2196/14223 %U http://www.ncbi.nlm.nih.gov/pubmed/32716299 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e17373 %T A Companion App to Support Rheumatology Patients Treated with Certolizumab Pegol: Results From a Usability Study %A Domańska,Barbara %A Vansant,Stijn %A Mountian,Irina %+ UCB Pharma, 208 Bath Road, Slough, United Kingdom, 44 1615 197676, barbara.domanska@UCB.com %K rheumatology %K internet %K digital health %K mobile health %K mHealth %K smartphone %K mobile phone %K validation human factors study %D 2020 %7 27.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Certolizumab pegol (CZP) is an anti-tumor necrosis factor drug approved for the treatment of multiple moderate to severe chronic inflammatory diseases. In the European Union, CZP is approved for administration by subcutaneous self-injection using a prefilled syringe, prefilled pen, or reusable electromechanical auto-injector (electronic device). CimplyMe is a companion app for use alongside CZP self-injection devices, designed to support CZP-treated patients self-managing their treatment and disease. Objective: This study aimed to validate the usability of the companion app by demonstrating that tasks required for use can be performed successfully by intended end users. Methods: We recruited 15 patients with moderate to severe rheumatoid arthritis, currently prescribed biologic treatment, and using apps on a smart phone. Patients were assessed on their ability to use the companion app in a setting designed to simulate a location where patients regularly administer biologic treatment. To assess the usability of the key features of the app, 8 critical and 3 noncritical tasks were designed. Patients’ success on each task was recorded through observations or knowledge-based questions. Successes with difficulty and use errors were also recorded. If a patient made a use error at the first attempt, a second attempt was allowed. Second-attempt use errors were recorded as a task failure. Results: A total of 207 first attempts at the 14 components of the 8 critical tasks were evaluated (3 patients failed to complete one component); 178 (86.0%) critical tasks were successfully completed at the first attempt. The remaining first attempts comprised 16 (7.7%) successes with difficulty and 13 (6.3%) use errors, which had to be repeated. One critical task was not re-attempted by one patient due to time constraints; however, there were no use errors in the 12 completed second attempts. A total of 107 first attempts at the 3 noncritical tasks were made, all of which (107/107, 100.0%) were completed without use errors. Conclusions: In simulated testing, patients were able to successfully use the companion app without formal training. This study suggests the companion app is easy to use and could help patients prescribed CZP better manage their treatment and disease. %M 32716310 %R 10.2196/17373 %U http://formative.jmir.org/2020/7/e17373/ %U https://doi.org/10.2196/17373 %U http://www.ncbi.nlm.nih.gov/pubmed/32716310 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e17541 %T Efficacy of a Smartphone App Intervention for Reducing Caregiver Stress: Randomized Controlled Trial %A Fuller-Tyszkiewicz,Matthew %A Richardson,Ben %A Little,Keriann %A Teague,Samantha %A Hartley-Clark,Linda %A Capic,Tanja %A Khor,Sarah %A Cummins,Robert A %A Olsson,Craig A %A Hutchinson,Delyse %+ Deakin University, 1 Gheringhap Street, Geelong, 3220, Australia, 61 3 9251 7344, matthewf@deakin.edu.au %K mHealth %K mobile phone %K caregiver %K psychological stress %K mental health %D 2020 %7 24.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Caregivers play a pivotal role in maintaining an economically viable health care system, yet they are characterized by low levels of psychological well-being and consistently report unmet needs for psychological support. Mobile app–based (mobile health [mHealth]) interventions present a novel approach to both reducing stress and improving well-being. Objective: This study aims to evaluate the effectiveness of a self-guided mobile app–based psychological intervention for people providing care to family or friends with a physical or mental disability. Methods: In a randomized, single-blind, controlled trial, 183 caregivers recruited through the web were randomly allocated to either an intervention (n=73) or active control (n=110) condition. The intervention app contained treatment modules combining daily self-monitoring with third-wave (mindfulness-based) cognitive-behavioral therapies, whereas the active control app contained only self-monitoring features. Both programs were completed over a 5-week period. It was hypothesized that intervention app exposure would be associated with decreases in depression, anxiety, and stress, and increases in well-being, self-esteem, optimism, primary and secondary control, and social support. Outcomes were assessed at baseline, postintervention, and 3-4 months postintervention. App quality was also assessed. Results: In total, 25% (18/73) of the intervention participants were lost to follow-up at 3 months, and 30.9% (34/110) of the participants from the wait-list control group dropped out before the postintervention survey. The intervention group experienced reductions in stress (b=−2.07; P=.04) and depressive symptoms (b=−1.36; P=.05) from baseline to postintervention. These changes were further enhanced from postintervention to follow-up, with the intervention group continuing to report lower levels of depression (b=−1.82; P=.03) and higher levels of emotional well-being (b=6.13; P<.001), optimism (b=0.78; P=.007), self-esteem (b=−0.84; P=.005), support from family (b=2.15; P=.001), support from significant others (b=2.66; P<.001), and subjective well-being (b=4.82; P<.001). On average, participants completed 2.5 (SD 1.05) out of 5 treatment modules. The overall quality of the app was also rated highly, with a mean score of 3.94 out of a maximum score of 5 (SD 0.58). Conclusions: This study demonstrates that mHealth psychological interventions are an effective treatment option for caregivers experiencing high levels of stress. Recommendations for improving mHealth interventions for caregivers include offering flexibility and customization in the treatment design. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12616000996460; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371170 %M 32706716 %R 10.2196/17541 %U http://mental.jmir.org/2020/7/e17541/ %U https://doi.org/10.2196/17541 %U http://www.ncbi.nlm.nih.gov/pubmed/32706716 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e14315 %T mHealth and Engagement Concerning Persons With Chronic Somatic Health Conditions: Integrative Literature Review %A Tuvesson,Hanna %A Eriksén,Sara %A Fagerström,Cecilia %+ Department of Health and Caring Sciences, Linnaeus University, Universitetsplatsen 1, Växjö, Sweden, 46 0480446915, hanna.tuvesson@lnu.se %K engagement %K eHealth %K mHealth %K somatic disease %K integrative literature review %K telehealth %D 2020 %7 24.7.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Chronic somatic health conditions are a global public health challenge. Being engaged in one’s own health management for such conditions is important, and mobile health (mHealth) solutions are often suggested as key to promoting engagement. Objective: The aim of this study was to review, critically appraise, and synthesize the available research regarding engagement through mHealth for persons with chronic somatic health conditions. Methods: An integrative literature review was conducted. The PubMed, CINAHL, and Inspec databases were used for literature searches. Quality assessment was done with the guidance of Critical Appraisal Skills Programme (CASP) checklists. We used a self-designed study protocol comprising 4 engagement aspects—cognitive, behavioral and emotional, interactional, and the usage of mHealth—as part of the synthesis and analysis. Results: A total of 44 articles met the inclusion criteria and were included in the analysis. mHealth usage was the most commonly occurring engagement aspect, behavioral and emotional aspects the second, cognitive aspects the third, and interactional aspects of engagement the least common aspect in the included articles. The results showed that there is a mix of enablers and barriers to engagement in relation to the 4 engagement aspects. The perceived meaningfulness and need for the solution and its content were important to create and maintain engagement. When perceived as meaningful, suitable, and usable, mHealth can support knowledge gain and learning, facilitate emotional and behavioral aspects such as a sense of confidence, and improve interactions and communications with health care professionals. Conclusions: mHealth solutions have the potential to support health care engagement for persons with chronic somatic conditions. More research is needed to further understand how, by which means, when, and among whom mHealth could further improve engagement for this population. %M 32706686 %R 10.2196/14315 %U http://mhealth.jmir.org/2020/7/e14315/ %U https://doi.org/10.2196/14315 %U http://www.ncbi.nlm.nih.gov/pubmed/32706686 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17238 %T Worldwide Prevalence of Hearing Loss Among Smartphone Users: Cross-Sectional Study Using a Mobile-Based App %A Masalski,Marcin %A Morawski,Krzysztof %+ Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Wroclaw Medical University, Wybrzeze Ludwika Pasteura 1, Wroclaw, 50-367, Poland, 48 515086252, marcin.masalski@pwr.edu.pl %K hearing loss %K epidemiology %K mobile-based %K hearing test %K pure-tone audiometry %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In addition to the aging process, risk factors for hearing loss in adults include, among others, exposure to noise, use of ototoxic drugs, genetics, and limited access to medical care. Differences in exposure to these factors are bound to be reflected in the prevalence of hearing loss. Assessment of hearing loss can easily be carried out on a large scale and at low cost using mobile apps. Objective: This study aimed to conduct a worldwide assessment of the differences in hearing loss prevalence between countries in a group of mobile device users. Methods: Hearing tests were conducted using the open-access Android-based mobile app Hearing Test. The app is available free of charge in the Google Play store, provided that consent to the use of the results for scientific purposes is given. This study included hearing tests carried out on device models supported by the app with bundled headphones in the set. Calibration factors for supported models were determined using the biological method. The tests consisted of self-determining the quietest audible tone in the frequency range from 250 Hz to 8 kHz by adjusting its intensity using the buttons. The ambient noise level was optionally monitored using a built-in microphone. Following the test, the user could compare his hearing threshold against age norms by providing his or her age. The user's location was identified based on the phone’s IP address. Results: From November 23, 2016 to November 22, 2019, 733,716 hearing tests were conducted on 236,716 mobile devices across 212 countries. After rejecting the tests that were incomplete, performed with disconnected headphones, not meeting the time criterion, repeated by the same user, or carried out regularly on one device, 116,733 of 733,716 tests (15.9%) were qualified for further analysis. The prevalence of hearing loss, defined as the average threshold at frequencies 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz above 25 dB HL in the better ear, was calculated at 15.6% (95% CI 15.4-15.8). Statistically significant differences were found between countries (P<.001), with the highest prevalences for Bangladesh, Pakistan, and India (>28%) and the lowest prevalences for Taiwan, Finland, and South Korea (<11%). Conclusions: Hearing thresholds measured by means of mobile devices were congruent with the literature data on worldwide hearing loss prevalence. Uniform recruitment criteria simplify the comparison of the hearing loss prevalence across countries. Hearing testing on mobile devices may be a valid tool in epidemiological studies carried out on a large scale. %M 32706700 %R 10.2196/17238 %U http://www.jmir.org/2020/7/e17238/ %U https://doi.org/10.2196/17238 %U http://www.ncbi.nlm.nih.gov/pubmed/32706700 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17609 %T Assessing Apps for Patients with Genitourinary Tumors Using the Mobile Application Rating Scale (MARS): Systematic Search in App Stores and Content Analysis %A Amor-García,Miguel Ángel %A Collado-Borrell,Roberto %A Escudero-Vilaplana,Vicente %A Melgarejo-Ortuño,Alejandra %A Herranz-Alonso,Ana %A Arranz Arija,José Ángel %A Sanjurjo-Sáez,María %+ Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo, 46, Madrid, 28007, Spain, 34 915867714, vicente.escudero@salud.madrid.org %K genitourinary cancer %K mobile apps %K eHealth %K mHealth %K rating tool %D 2020 %7 23.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The large number of available cancer apps and their impact on the population necessitates a transparent, objective, and comprehensive evaluation by app experts, health care professionals, and users. To date, there have been no analyses or classifications of apps for patients with genitourinary cancers, which are among the most prevalent types of cancer. Objective: The objective of our study was to analyze the quality of apps for patients diagnosed with genitourinary cancers using the Mobile Application Rating Scale (MARS) and identify high-quality apps. Methods: We performed an observational cross-sectional descriptive study of all smartphone apps for patients diagnosed with genitourinary cancers available on iOS and Android platforms. In July 2019, we searched for all available apps for patients with genitourinary cancers (bladder, prostate, cervical, uterine, endometrial, kidney, testicular, and vulvar) or their caregivers. Apps were downloaded and evaluated, and the general characteristics were entered into a database. The evaluation was performed by 2 independent researchers using the MARS questionnaire, which rates 23 evaluation criteria clustered in 5 domains (Engagement, Functionality, Esthetics, Information, and Subjective Quality) on a scale from 1 to 5. Results: In total, 46 apps were analyzed. Of these, 31 (67%) were available on Android, 6 (13%) on iOS, and 9 (20%) on both platforms. The apps were free in 89% of cases (41/46), and 61% (28/46) had been updated in the previous year. The apps were intended for prostate cancer in 30% of cases (14/46) and cervical cancer in 17% (8/46). The apps were mainly informative (63%, 29/46), preventive (24%, 11/46), and diagnostic (13%, 6/46). Only 7/46 apps (15%) were developed by health care organizations. The mean MARS score for the overall quality of the 46 apps was 2.98 (SD 0.77), with a maximum of 4.63 and a minimum of 1.95. Functionality scores were quite similar for most of the apps, with the greatest differences in Engagement and Esthetics, which showed acceptable scores in one-third of the apps. The 5 apps with the highest MARS score were the following: “Bladder cancer manager,” “Kidney cancer manager,” “My prostate cancer manager,” “Target Ovarian Cancer Symptoms Diary,” and “My Cancer Coach.” We observed statistically significant differences in the MARS score between the operating systems and the developer types (P<.001 and P=.01, respectively), but not for cost (P=.62). Conclusions: MARS is a helpful methodology to decide which apps can be prescribed to patients and to identify which features should be addressed to improve these tools. Most of the apps designed for patients with genitourinary cancers only try to provide data about the disease, without coherent interactivity. The participation of health professionals in the development of these apps is low; nevertheless, we observed that both the participation of health professionals and regular updates were correlated with quality. %M 32706737 %R 10.2196/17609 %U http://mhealth.jmir.org/2020/7/e17609/ %U https://doi.org/10.2196/17609 %U http://www.ncbi.nlm.nih.gov/pubmed/32706737 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17039 %T Use of Mobile Phone App Interventions to Promote Weight Loss: Meta-Analysis %A Islam,Md Mohaimenul %A Poly,Tahmina Nasrin %A Walther,Bruno Andres %A (Jack) Li,Yu-Chuan %+ Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan, 886 886 2 2736166, jaak88@gmail.com %K mobile app %K mHealth %K obesity %K physical activity %K weight gain prevention %D 2020 %7 22.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Obesity and lack of physical activity are major health risk factors for many life-threatening diseases, such as cardiovascular diseases, type 2 diabetes, and cancer. The use of mobile app interventions to promote weight loss and boost physical activity among children and adults is fascinating owing to the demand for cutting-edge and more efficient interventions. Previously published studies have examined different types of technology-based interventions and their impact on weight loss and increase in physical activity, but evidence regarding the impact of only a mobile phone app on weight loss and increase in physical activity is still lacking. Objective: The main objective of this study was to assess the efficacy of a mobile phone app intervention for reducing body weight and increasing physical activity among children and adults. Methods: PubMed, Google Scholar, Scopus, EMBASE, and the Web of Science electronic databases were searched for studies published between January 1, 2000, and April 30, 2019, without language restrictions. Two experts independently screened all the titles and abstracts to find the most appropriate studies. To be included, studies had to be either a randomized controlled trial or a case-control study that assessed a mobile phone app intervention with body weight loss and physical activity outcomes. The Cochrane Collaboration Risk of Bias tool was used to examine the risk of publication bias. Results: A total of 12 studies involving a mobile phone app intervention were included in this meta-analysis. Compared with the control group, the use of a mobile phone app was associated with significant changes in body weight (−1.07 kg, 95% CI −1.92 to −0.21, P=.01) and body mass index (−0.45 kg/m2, 95% CI −0.78 to −0.12, P=.008). Moreover, a nonsignificant increase in physical activity was observed (0.17, 95% CI −2.21 to 2.55, P=.88). Conclusions: The findings of this study demonstrate the promising and emerging efficacy of using mobile phone app interventions for weight loss. Future studies are needed to explore the long-term efficacy of mobile app interventions in larger samples. %M 32706724 %R 10.2196/17039 %U https://mhealth.jmir.org/2020/7/e17039 %U https://doi.org/10.2196/17039 %U http://www.ncbi.nlm.nih.gov/pubmed/32706724 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15873 %T Experiences With Wearable Activity Data During Self-Care by Chronic Heart Patients: Qualitative Study %A Andersen,Tariq Osman %A Langstrup,Henriette %A Lomborg,Stine %+ Department of Computer Science, University of Copenhagen, Universitetsparken 5, Copenhagen, 2100, Denmark, 45 26149169, tariq@di.ku.dk %K consumer health information %K wearable electronic devices %K self-care %K chronic illness %K patient experiences %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Most commercial activity trackers are developed as consumer devices and not as clinical devices. The aim is to monitor and motivate sport activities, healthy living, and similar wellness purposes, and the devices are not designed to support care management in a clinical context. There are great expectations for using wearable sensor devices in health care settings, and the separate realms of wellness tracking and disease self-monitoring are increasingly becoming blurred. However, patients’ experiences with activity tracking technologies designed for use outside the clinical context have received little academic attention. Objective: This study aimed to contribute to understanding how patients with a chronic disease experience activity data from consumer self-tracking devices related to self-care and their chronic illness. Our research question was: “How do patients with heart disease experience activity data in relation to self-care and chronic illness?” Methods: We conducted a qualitative interview study with patients with chronic heart disease (n=27) who had an implanted cardioverter-defibrillator. Patients were invited to wear a FitBit Alta HR wearable activity tracker for 3-12 months and provide their perspectives on their experiences with step, sleep, and heart rate data. The average age was 57.2 years (25 men and 2 women), and patients used the tracker for 4-49 weeks (mean 26.1 weeks). Semistructured interviews (n=66) were conducted with patients 2–3 times and were analyzed iteratively in workshops using thematic analysis and abductive reasoning logic. Results: Of the 27 patients, 18 related the heart rate, sleep, and step count data directly to their heart disease. Wearable activity trackers actualized patients’ experiences across 3 dimensions with a spectrum of contrasting experiences: (1) knowing, which spanned gaining insight and evoking doubts; (2) feeling, which spanned being reassured and becoming anxious; and (3) evaluating, which spanned promoting improvements and exposing failure. Conclusions: Patients’ experiences could reside more on one end of the spectrum, could reside across all 3 dimensions, or could combine contrasting positions and even move across the spectrum over time. Activity data from wearable devices may be a resource for self-care; however, the data may simultaneously constrain and create uncertainty, fear, and anxiety. By showing how patients experience self-tracking data across dimensions of knowing, feeling, and evaluating, we point toward the richness and complexity of these data experiences in the context of chronic illness and self-care. %M 32706663 %R 10.2196/15873 %U https://www.jmir.org/2020/7/e15873 %U https://doi.org/10.2196/15873 %U http://www.ncbi.nlm.nih.gov/pubmed/32706663 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17817 %T A Dietary Mobile App for Patients Undergoing Hemodialysis: Prospective Pilot Study to Improve Dietary Intakes %A Fakih El Khoury,Cosette %A Crutzen,Rik %A Schols,Jos M G A %A Halfens,Ruud J G %A Karavetian,Mirey %+ Department of Health Sciences, Zayed University, PO Box 19282, Dubai, United Arab Emirates, 971 562446865, Mirey.Karavetian@zu.ac.ae %K mHealth %K dietary app %K hemodialysis diet %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile technology has an impact on the health care sector, also within dietetics. Mobile health (mHealth) apps may be used for dietary assessment and self-monitoring, allowing for real-time reporting of food intakes. Changing eating behaviors is quite challenging, and patients undergoing hemodialysis, particularly, struggle to meet the target intakes set by dietary guidelines. Usage of mobile apps that are developed in a person-centered approach and in line with recommendations may support both patients and health care practitioners. Objective: This study is a pilot that aims at estimating the potential efficacy of a dietary intervention using a theory-based, person-centered smartphone app. Results will be used to improve both the app and a planned large-scale trial intended to assess app efficacy thoroughly. Methods: A prospective pilot study was performed at the hemodialysis unit of Al Qassimi Hospital (The Emirate of Sharjah). All patients that fulfilled the study inclusion criteria were considered eligible to be enrolled in the pilot study. Upon successful installation of the app, users met with a dietitian once a week. Outcomes were measured at baseline (T0) and 2 weeks post app usage (T1). This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT 2010 checklist for reporting pilot or feasibility trials. Results: A total of 23 patients completed the pilot intervention. Mean energy intakes increased from 24.4 kcal/kg/day (SD 8.0) to 29.1 kcal/kg/day (SD 7.8) with a medium effect size (d=0.6, 95% CI 0.0-1.2). Mean protein intakes increased from 0.9 g/kg/day (SD 0.3) to 1.3 g/kg/day (SD 0.5) with a large effect size (d=1.0, 95% CI 0.4-1.6); mean intake of high biological value (%HBV) proteins also increased from 58.6% (SD 10.1) to 70.1% (SD 10.7) with a large effect size (d=1.1, 95% CI 0.5-1.7). Dietary intakes of minerals did not change, apart from sodium which decreased from a mean intake of 2218.8 mg/day (SD 631.6) to 1895.3 mg/day (SD 581.0) with a medium effect size (d=0.5, 95% CI 0.1-1.1). Mean serum phosphorus, potassium, and albumin levels did not change relevantly. Mean serum iron increased from 7.9 mg/dL (SD 2.8) to 11.5 mg/dL (SD 7.9) postintervention with a medium effect size (d=0.6, 95% CI 0.0-1.2). Conclusions: This pilot study showed that the KELA.AE app has the potential to improve dietary intakes. Processes related to procedure, resources, tools, and app improvement for a future trial were assessed. A more extended intervention using a randomized controlled trial is required to estimate parameters concerning app efficacy accurately. %M 32706698 %R 10.2196/17817 %U http://www.jmir.org/2020/7/e17817/ %U https://doi.org/10.2196/17817 %U http://www.ncbi.nlm.nih.gov/pubmed/32706698 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18018 %T Co-designing a Self-Management App Prototype to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Mixed Methods Study %A Amann,Julia %A Fiordelli,Maddalena %A Brach,Mirjam %A Bertschy,Sue %A Scheel-Sailer,Anke %A Rubinelli,Sara %+ Swiss Paraplegic Research, Guido A Zäch Strasse 4, Nottwil, 6207, Switzerland, 41 41939 ext 6567, julia.amann@hest.ethz.ch %K co-design %K mHealth %K eHealth %K self-management %K spinal cord injury %K pressure injury %D 2020 %7 9.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Spinal cord injury is a complex chronic health condition that requires individuals to actively self-manage. Therefore, an evidence-based, self-management app would be of value to support individuals with spinal cord injury in the prevention of pressure injuries. Objective: The main objectives of this study were to (1) establish a co-design approach for developing a high-fidelity prototype app for the self-management of individuals with spinal cord injury, (2) design the prototype that resulted from this process, and (3) conduct the first usability assessment of the prototype app. Methods: We adopted a co-design approach to develop an evidence-based app prototype. Starting from a preliminary content model (based on clinical guidelines for the prevention of pressure injuries) and three research-based user personas, we conducted an ideation workshop involving individuals with spinal cord injury and health care professionals. The ideation workshop formed the basis for two consecutive design sprints. The result of this co-design phase was an interactive app prototype. The prototype was evaluated in two rounds of usability testing (N=4 and N=15, respectively) using a combination of qualitative and quantitative methods. Results: The co-design process resulted in a high-fidelity prototype with two key components: a self-management component and a communication component. The final prototype included a combination of features to support individuals with spinal cord injury in the prevention of pressure injuries, namely a smart camera, pressure injury diary, expert consultation, reminders, and knowledge repository. Findings of the usability testing showed that most participants navigated the app fluently with little back and forth navigation and were able to successfully complete a set of assigned tasks. These positive results are supported by the average system usability score achieved (78.5/100; range 47.5-95.0) and our qualitative analysis of the semistructured interviews. Despite an overall positive evaluation of the app prototype, we identified areas for improvement (eg, inclusion of a search function). Conclusions: Individuals with spinal cord injury often need to navigate competing interests and priorities, paired with uncertainty about the accuracy and relevance of clinical recommendations. Understanding what matters to individuals with spinal cord injury can help guide the design of behavioral interventions that are useful and acceptable to these individuals in their daily lives. This study shows that involving individuals with spinal cord injury and health care professionals in co-designing a self-management app can foster knowledge cocreation at the intersection of lived experience, medical expertise, and technical solutions. %M 32673241 %R 10.2196/18018 %U https://mhealth.jmir.org/2020/7/e18018 %U https://doi.org/10.2196/18018 %U http://www.ncbi.nlm.nih.gov/pubmed/32673241 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17588 %T Drivers of Mobile Health Acceptance and Use From the Patient Perspective: Survey Study and Quantitative Model Development %A Salgado,Tânia %A Tavares,Jorge %A Oliveira,Tiago %+ NOVA Information Management School, Universidade Nova de Lisboa, Campus de Campolide, Lisbon, 1070-312 Lisboa, Portugal, 351 213828610, d2012072@novaims.unl.pt %K digital health %K mHealth %K UTAUT2 %K health management %K patient empowerment %D 2020 %7 9.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) has potential to play a significant role in realizing a reversal of the current paradigm in health care toward a more patient-centric and more collaborative system to improve the outcomes obtained along with the quality and sustainability of health care systems. Objective: The aim of this study was to explore and understand individual mHealth acceptance drivers between two groups of users: those with chronic health conditions and those without. Methods: The extended unified theory of acceptance and usage of technology (UTAUT2) was enhanced with a new health-related framework: behavior intention to recommend and new mediation effects. We applied partial least squares (PLS) causal modeling to test the research model. Results: We obtained 322 valid responses through an online questionnaire. The drivers of behavior intention with statistical significance were performance expectancy (β=.29, P<.001), habit (β=.39, P<.001), and personal empowerment (β=.18, P=.01). The precursors of use behavior were habit (β= .47, P<.001) and personal empowerment (β=.17, P=.01). Behavior intention to recommend was significantly influenced by behavior intention (β=.58, P<.001) and personal empowerment (β=.26, P<.001). The model explained 66% of the total variance in behavior intention, 54% of the variance in use behavior, and 70% of the variance in behavior intention to recommend. Conclusions: Our study demonstrates a significant role of personal empowerment, as a second-order construct, in the mHealth acceptance context. The presence of a chronic health condition predicates an impact on acceptance of this technology. %M 32673249 %R 10.2196/17588 %U https://mhealth.jmir.org/2020/7/e17588 %U https://doi.org/10.2196/17588 %U http://www.ncbi.nlm.nih.gov/pubmed/32673249 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17842 %T Mobile Delivery of the Diabetes Prevention Program in People With Prediabetes: Randomized Controlled Trial %A Toro-Ramos,Tatiana %A Michaelides,Andreas %A Anton,Maria %A Karim,Zulekha %A Kang-Oh,Leah %A Argyrou,Charalambos %A Loukaidou,Elisavet %A Charitou,Marina M %A Sze,Wilson %A Miller,Joshua D %+ Noom, Inc, 229 W 28th St, New York, NY, , United States, 1 5168087328, andreas@noom.com %K prediabetes %K body weight %K mHealth %K mobile app %K mobile phone %K randomized controlled trial %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Centers for Disease Control and Prevention (CDC) diabetes prevention program (DPP) has formed the foundation for Type 2 Diabetes Mellitus (T2DM) prevention efforts and lifestyle change modifications in multiple care settings. To our knowledge, no randomized controlled trial has verified the efficacy of a fully mobile version of CDC’s diabetes prevention program (DPP). Objective: This study aimed to investigate the long-term weight loss and glycemic efficacy of a mobile-delivered DPP compared with a control group receiving usual medical care. Methods: Adults with prediabetes (N=202) were recruited from a clinic and randomized to either a mobile-delivered, coach-guided DPP (Noom) or a control group that received regular medical care including a paper-based DPP curriculum and no formal intervention. The intervention group learned how to use the Noom program, how to interact with their coach, and the importance of maintaining motivation. They had access to an interactive coach-to-participant interface and group messaging, daily challenges for behavior change, DPP-based education articles, food logging, and automated feedback. Primary outcomes included changes in weight and hemoglobin A1c (HbA1c) levels at 6 and 12 months, respectively. Exploratory secondary outcomes included program engagement as a predictor of changes in weight and HbA1c levels. Results: A total of 202 participants were recruited and randomized into the intervention (n=101) or control group (n=99). In the intention-to-treat (ITT) analyses, changes in the participants’ weight and BMI were significantly different at 6 months between the intervention and control groups, but there was no difference in HbA1c levels (mean difference 0.004%, SE 0.05; P=.94). Weight and BMI were lower in the intervention group by −2.64 kg (SE 0.71; P<.001) and −0.99 kg/m2 (SE 0.29; P=.001), respectively. These differences persisted at 12 months. However, in the analyses that did not involve ITT, program completers achieved a significant weight loss of 5.6% (SE 0.81; P<.001) at 6 months, maintaining 4.7% (SE 0.88; P<.001) of their weight loss at 12 months. The control group lost −0.15% at 6 months (SE 0.64; P=.85) and gained 0.33% (SE 0.70; P=.63) at 12 months. Those randomized to the intervention group who did not start the program had no meaningful weight or HbA1c level change, similar to the control group. At 1 year, the intervention group showed a 0.23% reduction in HbA1c levels; those who completed the intervention showed a 0.28% reduction. Those assigned to the control group had a 0.16% reduction in HbA1c levels. Conclusions: This novel mobile-delivered DPP achieved significant weight loss reductions for up to 1 year compared with usual care. This type of intervention reduces the risk of overt diabetes without the added barriers of in-person interventions. Trial Registration: ClinicalTrials.gov NCT03865342; https://clinicaltrials.gov/ct2/show/NCT03865342 %M 32459631 %R 10.2196/17842 %U https://mhealth.jmir.org/2020/7/e17842 %U https://doi.org/10.2196/17842 %U http://www.ncbi.nlm.nih.gov/pubmed/32459631 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17508 %T Requirements of Health Data Management Systems for Biomedical Care and Research: Scoping Review %A Ismail,Leila %A Materwala,Huned %A Karduck,Achim P %A Adem,Abdu %+ Department of Computer Science and Software Engineering, College of Information Technology, United Arab Emirates University, Al Maqam Campus, Al Ain, Abu Dhabi, 15551, United Arab Emirates, 971 37673333 ext 5530, leila@uaeu.ac.ae %K big data %K blockchain %K data analytics %K eHealth %K electronic medical records %K health care %K health information management %K Internet of Things %K medical research %K mHealth %D 2020 %7 7.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Over the last century, disruptive incidents in the fields of clinical and biomedical research have yielded a tremendous change in health data management systems. This is due to a number of breakthroughs in the medical field and the need for big data analytics and the Internet of Things (IoT) to be incorporated in a real-time smart health information management system. In addition, the requirements of patient care have evolved over time, allowing for more accurate prognoses and diagnoses. In this paper, we discuss the temporal evolution of health data management systems and capture the requirements that led to the development of a given system over a certain period of time. Consequently, we provide insights into those systems and give suggestions and research directions on how they can be improved for a better health care system. Objective: This study aimed to show that there is a need for a secure and efficient health data management system that will allow physicians and patients to update decentralized medical records and to analyze the medical data for supporting more precise diagnoses, prognoses, and public insights. Limitations of existing health data management systems were analyzed. Methods: To study the evolution and requirements of health data management systems over the years, a search was conducted to obtain research articles and information on medical lawsuits, health regulations, and acts. These materials were obtained from the Institute of Electrical and Electronics Engineers, the Association for Computing Machinery, Elsevier, MEDLINE, PubMed, Scopus, and Web of Science databases. Results: Health data management systems have undergone a disruptive transformation over the years from paper to computer, web, cloud, IoT, big data analytics, and finally to blockchain. The requirements of a health data management system revealed from the evolving definitions of medical records and their management are (1) medical record data, (2) real-time data access, (3) patient participation, (4) data sharing, (5) data security, (6) patient identity privacy, and (7) public insights. This paper reviewed health data management systems based on these 7 requirements across studies conducted over the years. To our knowledge, this is the first analysis of the temporal evolution of health data management systems giving insights into the system requirements for better health care. Conclusions: There is a need for a comprehensive real-time health data management system that allows physicians, patients, and external users to input their medical and lifestyle data into the system. The incorporation of big data analytics will aid in better prognosis or diagnosis of the diseases and the prediction of diseases. The prediction results will help in the development of an effective prevention plan. %M 32348265 %R 10.2196/17508 %U https://www.jmir.org/2020/7/e17508 %U https://doi.org/10.2196/17508 %U http://www.ncbi.nlm.nih.gov/pubmed/32348265 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14178 %T A Virtual Reality–Supported Intervention for Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Mixed Methods Study %A Jung,Timothy %A Moorhouse,Natasha %A Shi,Xin %A Amin,Muhammad Farhan %+ Manchester Metropolitan University, Business School, Oxford Road, Manchester, M15 6BH, United Kingdom, 44 7527423967, x.shi@mmu.ac.uk %K virtual reality %K COPD %K rehabilitation %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The uptake of traditional pulmonary rehabilitation classes by patients with chronic obstructive pulmonary disease (COPD) is poor because of personal factors that prevent accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation, and virtual reality (VR) could be a promising technology for patients with COPD to access services remotely. Objective: This study aimed to investigate whether VR improves compliance with pulmonary rehabilitation among patients with COPD, a particularly vulnerable patient group (Medical Research Council [MRC] 4 or 5), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programs. Methods: This was an 8-week patient trial using an innovative VR pulmonary rehabilitation program. A purposive sample of 10 patients with COPD graded MRC 4 or 5 and registered at a selected health care center and a hospital in Cumbria, United Kingdom, were included. Qualitative (focus groups and interviews) data were collected, and to further support the qualitative findings, quantitative data (self-report patient surveys) were gathered before and after the 8-week trial. The 5 self-reported surveys included the Patient Activation Measure, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Short Physical Performance Battery, and the Edmonton Frail Scale. Results: In a thematic analysis of the qualitative data, 11 themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further support the qualitative findings by revealing significant improvements in all physical measures. Conclusions: Overall, this study demonstrates how remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing this service to patients with COPD at scale. %M 32673224 %R 10.2196/14178 %U https://www.jmir.org/2020/7/e14178 %U https://doi.org/10.2196/14178 %U http://www.ncbi.nlm.nih.gov/pubmed/32673224 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17704 %T Barriers and Facilitators to the Adoption of Mobile Health Among Health Care Professionals From the United Kingdom: Discrete Choice Experiment %A Leigh,Simon %A Ashall-Payne,Liz %A Andrews,Tim %+ The Organisation for the Review of Care and Health Applications, Sci-Tech Daresbury, Vanguard House, Keckwick Lane, Daresbury, WA4 4AB, United Kingdom, 44 07503955592, simon.leigh@orcha.co.uk %K digital health %K mHealth %K discrete-choice %K preferences %K mobile phone %D 2020 %7 6.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite the increasing availability of mobile health services, clinical engagement remains minimal. Objective: This study aims to identify and weight barriers to and drivers of health app use among health care professionals (HCPs) from the United Kingdom. Methods: A discrete choice experiment was conducted with 222 HCPs using a web-based survey between March 2019 and June 2019. Participants were recruited to take part via social media and asked to choose their preferred option of 2 hypothetical health apps to prescribe to a hypothetical patient or to prescribe neither. Choices were characterized by differing levels of patient age, cost, published evidence bases, whether they had a National Health Service (NHS) stamp of approval, personal familiarity with the technology, and whether they were recommended by a fellow HCP. The results were analyzed using a mixed logit model, with subgroup analyses to account for heterogeneity. Results: We received 230 responses, a total of 96.5% (n=222/230) of respondents understood the survey task and passed the test of rationality. The median age was between 36 and 45 years, and 62.6% (n=139/222) of the health care providers responding to the survey had previously recommended the use of health apps to patients. Health apps were most likely to be prescribed to patients if they had an NHS stamp of approval or if they were recommended by another HCP (both P<.001). Published studies detailing clinical effectiveness were important (P<.001), but it would take five published studies to have the same impact on prescribing behavior as an NHS stamp of approval and two studies to be as convincing as having used the technology personally. Increasing patient age and costs resulted in significant reductions in digital health prescribing (P<.001), none more so than among allied health professionals. Willingness-to-pay for health apps increased by £124.61 (US $151.14) if an NHS stamp of approval was present and by £29.20 (US $35.42) for each published study. Overall, 8.1% (n=18/222) of respondents were reluctant to use health apps, always choosing the I would prescribe neither option, particularly among older HCPs, nurses, and those who do not use health apps personally. Subgroup analyses revealed significant differences in preferences among HCPs of differing ages and clinical backgrounds. Conclusions: An NHS stamp of approval, published studies, and recommendations from fellow HCPs are significant facilitators of digital prescribing, whereas increasing costs and patient age are significant barriers to engagement. These findings suggest that demonstrating assurances of health apps and supporting both the dissemination and peer-to-peer recommendation of evidence-based technologies are critical if the NHS is to achieve its long-term digital transformation ambitions. %M 32628118 %R 10.2196/17704 %U https://mhealth.jmir.org/2020/7/e17704 %U https://doi.org/10.2196/17704 %U http://www.ncbi.nlm.nih.gov/pubmed/32628118 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17183 %T Effect of a Health System–Sponsored Mobile App on Perinatal Health Behaviors: Retrospective Cohort Study %A Cawley,Caroline %A Buckenmeyer,Hannelore %A Jellison,Trina %A Rinaldi,Joseph B %A Vartanian,Keri B %+ Center for Outcomes Research and Education, Providence Portland Medical Center, 5251 NE Glisan Street, Portland, OR, 97213, United States, 1 503 215 2594, Keri.Vartanian@providence.org %K mobile health %K perinatal health %K health behaviors %D 2020 %7 6.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pregnancy mobile apps are becoming increasingly popular, with parents-to-be seeking information related to their pregnancy and their baby through mobile technology. This increase raises the need for prenatal apps with evidence-based content that is personalized and reliable. Previous studies have looked at whether prenatal apps impact health and behavior outcomes among pregnant and postpartum individuals; however, research has been limited. Objective: The primary objective of this study is to assess whether the use of a health system–sponsored mobile app—Circle by Providence—aimed at providing personalized and reliable health information on pregnancy, postpartum recovery, and infant care is associated with improved health outcomes and increased healthy behaviors and knowledge among users. Methods: This observational study compared app users and app nonusers using a self-reported survey and electronic medical records. The study took place over 18 months and was conducted at Providence St. Joseph Health in Portland, Oregon. The sample included patients who received prenatal care at one of seven Providence clinics and had a live birth at a Providence hospital. Recruitment occurred on a rolling basis and only those who completed the survey were included. Survey respondents were separated into app users and app nonusers, and survey responses and clinical outcomes were compared across groups using univariate and adjusted multivariate logistic regression. Results: A total of 567 participants were enrolled in the study—167 in the app user group and 400 in the nonuser group. We found statistically significant differences between the two groups for certain behavior outcomes: subjects who used the app had 75% greater odds of breastfeeding beyond 6 months postpartum (P=.012), were less likely to miss prenatal appointments (P=.046), and were 50% more likely to exercise 3 or more times a week during pregnancy (P=.04). There were no differences in nutritional measures, including whether they took prenatal vitamins, ate 5 fruits or vegetables a day, or drank caffeine. We found no differences in many of the infant care outcomes; however, there was an increase in awareness of “purple crying.” Finally, there were no significant differences in measured clinical health outcomes, including cesarean births, length of hospital stays (in minutes), low birth weight infants, preterm births, small-for-gestational-age births, large-for-gestational-age births, and neonatal intensive care unit stays. Conclusions: The use of the Circle app, which provides access to personalized and evidence-based health information, was associated with an increase in certain healthy behaviors and health knowledge, although there was no impact on clinical health outcomes. More research is needed to determine the impact of mobile prenatal apps on healthy pregnancies, clinical health outcomes, and infant care. %M 32628123 %R 10.2196/17183 %U https://mhealth.jmir.org/2020/7/e17183 %U https://doi.org/10.2196/17183 %U http://www.ncbi.nlm.nih.gov/pubmed/32628123 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17120 %T Ecological Momentary Assessment Within a Digital Health Intervention for Reminiscence in Persons With Dementia and Caregivers: User Engagement Study %A Potts,Courtney %A Bond,Raymond %A Ryan,Assumpta %A Mulvenna,Maurice %A McCauley,Claire %A Laird,Elizabeth %A Goode,Deborah %+ Ulster University, School of Computing, Shore Road, Jordanstown, United Kingdom, 44 28 9036 8602, md.mulvenna@ulster.ac.uk %K ecological momentary assessment %K EMA %K app %K behaviour analytics %K event logging %K dementia %K carers %K reminiscence %K reminiscing %K mHealth %D 2020 %7 6.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: User-interaction event logs provide rich and large data sets that can provide valuable insights into how people engage with technology. Approaches such as ecological momentary assessment (EMA) can be used to gather accurate real-time data in an individual’s natural environment by asking questions at any given instant. Objective: The purpose of this study was to evaluate user engagement and responses to EMA questions using InspireD, an app used for reminiscence by persons with dementia and their caregivers. Research findings can be used to inform EMA use within digital health interventions. Methods: A feasibility trial was conducted in which participants (n=56) used the InspireD app over a 12-week period. Participants were a mean age of 73 (SD 13) and were either persons with dementia (n=28) or their caregivers (n=28). Questions, which they could either answer or choose to dismiss, were presented to participants at various instants after reminiscence with personal or generic photos, videos, and music. Presentation and dismissal rates for questions were compared by hour of the day and by trial week to investigate user engagement. Results: Overall engagement was high, with 69.1% of questions answered when presented. Questions that were presented in the evening had the lowest dismissal rate; the dismissal rate for questions presented at 9 PM was significantly lower than the dismissal rate for questions presented at 11 AM (9 PM: 10%; 11 AM: 50%; χ21=21.4, P<.001). Questions asked following reminiscence with personal media, especially those asked after personal photos, were less likely to be answered compared to those asked after other media. In contrast, questions asked after the user had listened to generic media, in particular those asked after generic music, were much more likely to be answered. Conclusions: The main limitation of our study was the lack of generalizability of results to a larger population given the quasi-experimental design and older demographic where half of participants were persons with dementia; however, this study shows that older people are willing to participate and engage in EMA. Based on this study, we propose a series of recommendations for app design to increase user engagement with EMA. These include presenting questions no more than once per day, after 8 PM in the evening, and only if the user is not trying to complete a task within the app. %M 32420890 %R 10.2196/17120 %U https://mhealth.jmir.org/2020/7/e17120 %U https://doi.org/10.2196/17120 %U http://www.ncbi.nlm.nih.gov/pubmed/32420890 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 6 %P e14486 %T Barriers to Gestational Diabetes Management and Preferred Interventions for Women With Gestational Diabetes in Singapore: Mixed Methods Study %A Hewage,Sumali %A Audimulam,Jananie %A Sullivan,Emily %A Chi,Claudia %A Yew,Tong Wei %A Yoong,Joanne %+ Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore, 65 65164988, sumali_hewage@u.nus.edu %K gestational diabetes %K pregnancy %K telemedicine %K self-management %K patient-centered care %K mobile phone %D 2020 %7 30.6.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Gestational diabetes mellitus (GDM) is associated with risks for both the mother and child. The escalated prevalence of GDM because of obesity and changes in screening criteria demands for greater health care needs than before. Objective: This study aimed to understand the perception of patients and health care providers of the barriers to GDM management and preferred interventions to manage GDM in an Asian setting. Methods: This mixed methods study used a convergent parallel design. Survey data were collected from 216 women with GDM, and semistructured interviews were conducted with 15 women and with 8 health care providers treating patients with GDM. Participants were recruited from 2 specialized GDM clinics at the National University Hospital, Singapore. Results: The patients were predominantly Chinese (102/214, 47.6%), employed (201/272, 73.9%), with higher education (150/216, 69.4%) and prenatal attendance at a private clinic (138/214, 64.2%), already on diet control (210/214, 98.1%), and receiving support and information from the GDM clinic (194/215, 90.2%) and web-based sources (131/215, 60.9%). In particular, working women reported barriers to GDM management, including the lack of reminders for blood glucose monitoring, diet control, and insufficient time for exercise. Most women preferred getting such support directly from health care providers, whether at the GDM clinic (174/215, 80.9%) or elsewhere (116/215, 53.9%). Smartphone apps were the preferred means of additional intervention. Desirable intervention features identified by patients included more information on GDM, diet and exercise options, reminders for blood glucose testing, a platform to record blood glucose readings and illustrate or understand trends, and a means to communicate with care providers. Conclusions: A GDM-focused smartphone app that is able to integrate testing, education, and communication may be a feasible and acceptable intervention to provide support to women with GDM, particularly for working women. %M 32602845 %R 10.2196/14486 %U http://formative.jmir.org/2020/6/e14486/ %U https://doi.org/10.2196/14486 %U http://www.ncbi.nlm.nih.gov/pubmed/32602845 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e18996 %T Stratification of Individual Symptoms of Contact Lens–Associated Dry Eye Using the iPhone App DryEyeRhythm: Crowdsourced Cross-Sectional Study %A Inomata,Takenori %A Nakamura,Masahiro %A Iwagami,Masao %A Midorikawa-Inomata,Akie %A Sung,Jaemyoung %A Fujimoto,Keiichi %A Okumura,Yuichi %A Eguchi,Atsuko %A Iwata,Nanami %A Miura,Maria %A Fujio,Kenta %A Nagino,Ken %A Hori,Satoshi %A Tsubota,Kazuo %A Dana,Reza %A Murakami,Akira %+ Department of Ophthalmology, Juntendo University Faculty of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan, 81 3 3813 3111, tinoma@juntendo.ac.jp %K contact lens-associated dry eye %K mobile health %K ResearchKit %K smartphone app %K DryEyeRhythm %K subjective symptoms %K risk factors %K dry eye %K stratification %K mobile phone %D 2020 %7 26.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Discontinuation of contact lens use is mainly caused by contact lens–associated dry eye. It is crucial to delineate contact lens–associated dry eye's multifaceted nature to tailor treatment to each patient’s individual needs for future personalized medicine. Objective: This paper aims to quantify and stratify individual subjective symptoms of contact lens–associated dry eye and clarify its risk factors for future personalized medicine using the smartphone app DryEyeRhythm (Juntendo University). Methods: This cross-sectional study included iPhone (Apple Inc) users in Japan who downloaded DryEyeRhythm. DryEyeRhythm was used to collect medical big data related to contact lens–associated dry eye between November 2016 and January 2018. The main outcome measure was the incidence of contact lens–associated dry eye. Univariate and multivariate adjusted odds ratios of risk factors for contact lens–associated dry eye were determined by logistic regression analyses. The t-distributed Stochastic Neighbor Embedding algorithm was used to depict the stratification of subjective symptoms of contact lens–associated dry eye. Results: The records of 4454 individuals (median age 27.9 years, SD 12.6), including 2972 female participants (66.73%), who completed all surveys were included in this study. Among the included participants, 1844 (41.40%) were using contact lenses, and among those who used contact lenses, 1447 (78.47%) had contact lens–associated dry eye. Multivariate adjusted odds ratios of risk factors for contact lens–associated dry eye were as follows: younger age, 0.98 (95% CI 0.96-0.99); female sex, 1.53 (95% CI 1.05-2.24); hay fever, 1.38 (95% CI 1.10-1.74); mental illness other than depression or schizophrenia, 2.51 (95% CI 1.13-5.57); past diagnosis of dry eye, 2.21 (95% CI 1.63-2.99); extended screen exposure time >8 hours, 1.61 (95% CI 1.13-2.28); and smoking, 2.07 (95% CI 1.49-2.88). The t-distributed Stochastic Neighbor Embedding analysis visualized and stratified 14 groups based on the subjective symptoms of contact lens–associated dry eye. Conclusions: This study identified and stratified individuals with contact lens–associated dry eye and its risk factors. Data on subjective symptoms of contact lens–associated dry eye could be used for prospective prevention of contact lens–associated dry eye progression. %M 32589162 %R 10.2196/18996 %U http://www.jmir.org/2020/6/e18996/ %U https://doi.org/10.2196/18996 %U http://www.ncbi.nlm.nih.gov/pubmed/32589162 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e17567 %T Medical Device Apps: An Introduction to Regulatory Affairs for Developers %A Keutzer,Lina %A Simonsson,Ulrika SH %+ Department of Pharmaceutical Biosciences, Uppsala University, Box 591, Uppsala, 75124, Sweden, 46 18 471 4000, Ulrika.Simonsson@farmbio.uu.se %K MDR %K medical device regulation %K medical devices, medical device software %K mHealth %K eHealth %K mobile apps %K smartphone apps %D 2020 %7 26.6.2020 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X The Poly Implant Prothèse (PIP) scandal in France prompted a revision of the regulations regarding the marketing of medical devices. The new Medical Device Regulation (MDR [EU]) 2017/745 was developed and entered into force on May 25, 2017. After a transition period of 3 years, the regulations must be implemented in all EU and European Economic Area member states. The implementation of this regulation bears many changes for medical device development and marketing, including medical device software and mobile apps. Medical device development and marketing is a complex process by which manufacturers must keep many regulatory requirements and obligations in mind. The objective of this paper is to provide an introduction and overview of regulatory affairs for manufacturers that are new to the field of medical device software and apps with a specific focus on the new MDR, accompanying harmonized standards, and guidance documents from the European Commission. This work provides a concise overview of the qualification and classification of medical device software and apps, conformity assessment routes, technical documentation, clinical evaluation, the involvement of notified bodies, and the unique device identifier. Compared to the previous Medical Device Directive (MDD) 93/42/EEC, the MDR provides greater detail about the requirements for software qualification and classification. In particular, rule 11 sets specific rules for the classification of medical device software and will be described in this paper. In comparison to the previous MDD, the MDR is more stringent, especially regarding the classification of health apps and software. The implementation of the MDR in May 2020 and its interpretation by the authorities will demonstrate how app and software manufacturers as well as patients will be affected by the regulation. %M 32589154 %R 10.2196/17567 %U http://mhealth.jmir.org/2020/6/e17567/ %U https://doi.org/10.2196/17567 %U http://www.ncbi.nlm.nih.gov/pubmed/32589154 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17109 %T Menstrual Cycle Length and Patterns in a Global Cohort of Women Using a Mobile Phone App: Retrospective Cohort Study %A Grieger,Jessica A %A Norman,Robert J %+ Robinson Research Institute, University of Adelaide, North Terrace, Adelaide, 5000, Australia, 61 88137697, jessica.grieger@adelaide.edu.au %K body mass index %K follicular phase %K fertility %K luteal phase %K menstrual cycle %K mobile application %K internet %K ovulation %K mobile phone %D 2020 %7 24.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is increasing information characterizing menstrual cycle length in women, but less information is available on the potential differences across lifestyle variables. Objective: This study aimed to describe differences in menstrual cycle length, variability, and menstrual phase across women of different ages and BMI among a global cohort of Flo app users. We have also reported on demographic and lifestyle characteristics across median cycle lengths. Methods: The analysis was run based on the aggregated anonymized dataset from a menstrual cycle tracker and ovulation calendar that covers all phases of the reproductive cycle. Self-reported information is documented, including demographics, menstrual flow and cycle length, ovulation information, and reproductive health and diseases. Data from women aged ≥18 years and who had logged at least three cycles (ie, 2 completed cycles and 1 current cycle) in the Flo app were included (1,579,819 women). Results: Of the 1.5 million users, approximately half (638,683/1,579,819, 40.42%) were aged between 18 and 24 years. Just over half of those reporting BMIs were in the normal range (18.5-24.9 kg/m2; 202,420/356,598, 56.76%) and one-third were overweight or obese (>25 kg/m2; 120,983/356,598, 33.93%). A total of 16.32% (257,889/1,579,819) of women had a 28-day median cycle length. There was a higher percentage of women aged ≥40 years who had a 27-day median cycle length than those aged between 18 and 24 years (22,294/120,612, 18.48% vs 60,870/637,601, 9.55%), but a lower percentage with a 29-day median cycle length (10,572/120,612, 8.77% vs 79,626/637,601, 12.49%). There were a higher number of cycles with short luteal phases in younger women, whereas women aged ≥40 years had a higher number of cycles with longer luteal phases. Median menstrual cycle length and the length of the follicular and luteal phases were not remarkably different with increasing BMI, except for the heaviest women at a BMI of ≥50 kg/m2. Conclusions: On a global scale, we have provided extensive evidence on the characteristics of women and their menstrual cycle length and patterns across different age and BMI groups. This information is necessary to support updates of current clinical guidelines around menstrual cycle length and patterns for clinical use in fertility programs. %M 32442161 %R 10.2196/17109 %U http://www.jmir.org/2020/6/e17109/ %U https://doi.org/10.2196/17109 %U http://www.ncbi.nlm.nih.gov/pubmed/32442161 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 6 %P e18134 %T Machine Learning–Based Signal Quality Evaluation of Single-Period Radial Artery Pulse Waves: Model Development and Validation %A Ding,Xiaodong %A Cheng,Feng %A Morris,Robert %A Chen,Cong %A Wang,Yiqin %+ Shanghai Key Laboratory of Health Identification and Assessment, Laboratory of Traditional Chinese Medicine Four Diagnostic Information, Shanghai University of Traditional Chinese Medicine, 1200 Cailun Road, Shanghai, 201203, China, 86 21 51322271, wangyiqin2380@vip.sina.com %K pulse wave %K quality evaluation %K single period %K segmentation %K machine learning %D 2020 %7 22.6.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: The radial artery pulse wave is a widely used physiological signal for disease diagnosis and personal health monitoring because it provides insight into the overall health of the heart and blood vessels. Periodic radial artery pulse signals are subsequently decomposed into single pulse wave periods (segments) for physiological parameter evaluations. However, abnormal periods frequently arise due to external interference, the inherent imperfections of current segmentation methods, and the quality of the pulse wave signals. Objective: The objective of this paper was to develop a machine learning model to detect abnormal pulse periods in real clinical data. Methods: Various machine learning models, such as k-nearest neighbor, logistic regression, and support vector machines, were applied to classify the normal and abnormal periods in 8561 segments extracted from the radial pulse waves of 390 outpatients. The recursive feature elimination method was used to simplify the classifier. Results: It was found that a logistic regression model with only four input features can achieve a satisfactory result. The area under the receiver operating characteristic curve from the test set was 0.9920. In addition, these classifiers can be easily interpreted. Conclusions: We expect that this model can be applied in smart sport watches and watchbands to accurately evaluate human health status. %M 32568091 %R 10.2196/18134 %U http://medinform.jmir.org/2020/6/e18134/ %U https://doi.org/10.2196/18134 %U http://www.ncbi.nlm.nih.gov/pubmed/32568091 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16345 %T Smartphone-Guided Algorithms for Use by Community Volunteers to Screen and Refer People With Eye Problems in Trans Nzoia County, Kenya: Development and Validation Study %A Rono,Hillary %A Bastawrous,Andrew %A Macleod,David %A Bunywera,Cosmas %A Mamboleo,Ronald %A Wanjala,Emmanuel %A Burton,Matthew %+ Clinical Research Department, International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom, 254 722627207, hillary.rono@lshtm.ac.uk %K visual impairment %K algorithms %K mobile phone %K screening %K mHealth %K sensitivity %K specificity %D 2020 %7 19.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The provision of eye care services is currently insufficient to meet the requirements of eye care. Many people remain unnecessarily visually impaired or at risk of becoming so because of treatable or preventable eye conditions. A lack of access and awareness of services is, in large part, a key barrier to handle this unmet need. Objective: This study aimed to assess whether utilizing novel smartphone-based clinical algorithms can task-shift eye screening to community volunteers (CVs) to accurately identify and refer patients to primary eye care services. In particular, we developed the Peek Community Screening app and assessed its validity in making referral decisions for patients with eye problems. Methods: We developed a smartphone-based clinical algorithm (the Peek Community Screening app) using age, distance vision, near vision, and pain as referral criteria. We then compared CVs’ referral decisions using this app with those made by an experienced ophthalmic clinical officer (OCO), which was the reference standard. The same participants were assessed by a trained CV using the app and by an OCO using standard outreach equipment. The outcome was the proportion of all decisions that were correct when compared with that of the OCO. Results: The required sensitivity and specificity for the Peek Community Screening app were achieved after seven iterations. In the seventh iteration, the OCO identified referable eye problems in 65.9% (378/574) of the participants. CVs correctly identified 344 of 378 (sensitivity 91.0%; 95% CI 87.7%-93.7%) of the cases and correctly identified 153 of 196 (specificity 78.1%; 95% CI 71.6%-83.6%) cases as not having a referable eye problem. The positive predictive value was 88.9% (95% CI 85.3%-91.8%), and the negative predictive value was 81.8% (95% CI 75.5%-87.1%). Conclusions: Development of such an algorithm is feasible; however, it requires considerable effort and resources. CVs can accurately use the Peek Community Screening app to identify and refer people with eye problems. An iterative design process is necessary to ensure validity in the local context. %M 32558656 %R 10.2196/16345 %U https://mhealth.jmir.org/2020/6/e16345 %U https://doi.org/10.2196/16345 %U http://www.ncbi.nlm.nih.gov/pubmed/32558656 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e17730 %T Digital Phenotyping Self-Monitoring Behaviors for Individuals With Type 2 Diabetes Mellitus: Observational Study Using Latent Class Growth Analysis %A Yang,Qing %A Hatch,Daniel %A Crowley,Matthew J %A Lewinski,Allison A %A Vaughn,Jacqueline %A Steinberg,Dori %A Vorderstrasse,Allison %A Jiang,Meilin %A Shaw,Ryan J %+ School of Nursing, Duke University, 307 Trent Drive, Durham, NC, 27710, United States, 1 9196139768, qing.yang@duke.edu %K digital phenotype %K latent class growth analysis %K type 2 diabetes %K self-management %K self-monitoring %K Mobile Health %D 2020 %7 11.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Sustained self-monitoring and self-management behaviors are crucial to maintain optimal health for individuals with type 2 diabetes mellitus (T2DM). As smartphones and mobile health (mHealth) devices become widely available, self-monitoring using mHealth devices is an appealing strategy in support of successful self-management of T2DM. However, research indicates that engagement with mHealth devices decreases over time. Thus, it is important to understand engagement trajectories to provide varying levels of support that can improve self-monitoring and self-management behaviors. Objective: The aims of this study were to develop (1) digital phenotypes of the self-monitoring behaviors of patients with T2DM based on their engagement trajectory of using multiple mHealth devices, and (2) assess the association of individual digital phenotypes of self-monitoring behaviors with baseline demographic and clinical characteristics. Methods: This longitudinal observational feasibility study included 60 participants with T2DM who were instructed to monitor their weight, blood glucose, and physical activity using a wireless weight scale, phone-tethered glucometer, and accelerometer, respectively, over 6 months. We used latent class growth analysis (LCGA) with multitrajectory modeling to associate the digital phenotypes of participants’ self-monitoring behaviors based on their engagement trajectories with multiple mHealth devices. Associations between individual characteristics and digital phenotypes on participants’ self-monitoring behavior were assessed by analysis of variance or the Chi square test. Results: The engagement with accelerometers to monitor daily physical activities was consistently high for all participants over time. Three distinct digital phenotypes were identified based on participants’ engagement with the wireless weight scale and glucometer: (1) low and waning engagement group (24/60, 40%), (2) medium engagement group (20/60, 33%), and (3) consistently high engagement group (16/60, 27%). Participants that were younger, female, nonwhite, had a low income, and with a higher baseline hemoglobin A1c level were more likely to be in the low and waning engagement group. Conclusions: We demonstrated how to digitally phenotype individuals’ self-monitoring behavior based on their engagement trajectory with multiple mHealth devices. Distinct self-monitoring behavior groups were identified. Individual demographic and clinical characteristics were associated with different self-monitoring behavior groups. Future research should identify methods to provide tailored support for people with T2DM to help them better monitor and manage their condition. International Registered Report Identifier (IRRID): RR2-10.2196/13517 %M 32525492 %R 10.2196/17730 %U https://mhealth.jmir.org/2020/6/e17730 %U https://doi.org/10.2196/17730 %U http://www.ncbi.nlm.nih.gov/pubmed/32525492 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e15893 %T Reliability of Smartphone for Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomography Scores in Acute Ischemic Stroke Patients: Diagnostic Test Accuracy Study %A Sakai,Kenichiro %A Komatsu,Teppei %A Iguchi,Yasuyuki %A Takao,Hiroyuki %A Ishibashi,Toshihiro %A Murayama,Yuichi %+ Department of Neurology, The Jikei University School of Medicine, Nishishinbashi 3-25-8, Tokyo, 1050003, Japan, 81 3 3433 1111, k.sakai.0127@gmail.com %K smartphone app %K DWI %K ASPECTS %D 2020 %7 9.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: High-quality neuroimages can be viewed using a medical app installed on a smartphone. Although interdevice agreement between smartphone and desktop PC monitor was found to be favorable for evaluating computed tomography images, there are no interdevice agreement data for diffusion-weighted imaging (DWI). Objective: The aim of our study was to compare DWI interpretation using the Join smartphone app with that using a desktop PC monitor, in terms of interdevice and interrater agreement and elapsed interpretation time. Methods: The ischemic change in the DWI of consecutive patients with acute stroke in the middle cerebral artery territory was graded by 2 vascular neurologists using the Join smartphone app and a desktop PC monitor. The vascular neurologists were blinded to all patient information. Each image was categorized as either Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomography Scores (DWI-ASPECTS) ≥7 or DWI-ASPECTS <7 according to the Japanese Society for Neuroendovascular Therapy. We analyzed interdevice agreement and interrater agreement with respect to DWI-ASPECTS. Elapsed interpretation time was compared between DWI-ASPECTS evaluated by the Join smartphone app and a desktop PC monitor. Results: We analyzed the images of 111 patients (66% male; median age=69 years; median National Institutes of Health Stroke Scale score on admission=4). Interdevice agreement regarding DWI-ASPECTS between the smartphone and the desktop PC monitor was favorable (vascular neurologist 1: κ=0.777, P<.001, vascular neurologist 2: κ=0.787, P<.001). Interrater agreement was also satisfactory for the smartphone (κ=0.710, P<.001) and the desktop PC monitor (κ=0.663, P<.001). Median elapsed interpretation time was similar between the smartphone and the desktop PC monitor (vascular neurologist 1: 1.7 min vs 1.6 min; P=.64); vascular neurologist 2: 2.4 min vs 2.0 min; P=.14). Conclusions: The use of a smartphone app enables vascular neurologists to estimate DWI-ASPECTS accurately and rapidly. The Join medical smartphone app shows great promise in the management of acute stroke. %M 32515744 %R 10.2196/15893 %U https://www.jmir.org/2020/6/e15893 %U https://doi.org/10.2196/15893 %U http://www.ncbi.nlm.nih.gov/pubmed/32515744 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e18531 %T Effectiveness of a 3-Month Mobile Phone–Based Behavior Change Program on Active Transportation and Physical Activity in Adults: Randomized Controlled Trial %A Ek,Anna %A Alexandrou,Christina %A Söderström,Emmie %A Bergman,Patrick %A Delisle Nyström,Christine %A Direito,Artur %A Eriksson,Ulf %A Henriksson,Pontus %A Maddison,Ralph %A Trolle Lagerros,Ylva %A Bendtsen,Marcus %A Löf,Marie %+ Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, 581 83, Sweden, 46 73 656 9338, marie.lof@liu.se %K behavior change %K mobile phone intervention %K physical activity %K active transportation %K mobile phone app %K smartphone app %D 2020 %7 8.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Active transportation (AT; ie, walking and cycling as a mode for transportation) has been associated with decreased morbidity and mortality; however, low-cost and scalable intervention programs are lacking. Objective: The goal of the research was to determine the effectiveness of a 3-month behavior change program delivered via a mobile phone app to promote AT (TravelVu Plus) on time spent in moderate-to-vigorous physical activity (MVPA). Methods: For this 2-arm parallel randomized controlled trial, we recruited a population-based sample of 254 adults from Stockholm County who were aged 20 to 65 years and had access to a smartphone. On completion of 1-week baseline measures, the 254 participants were randomized to either the control or intervention group (1:1 ratio). Both groups had access to the standard TravelVu app (Trivector AB) for monitoring their AT for 6 months. The intervention group also received a 3-month behavior change program to promote AT (TravelVu Plus app). Assessors of outcomes were blinded to group allocation. Outcomes were objectively measured MVPA at 3 (primary) and 6 months. Secondary outcomes were AT, attitudes toward AT, and health-related quality of life at 3 and 6 months. Results: No effect on MVPA was observed after 3 months (P=.29); however, at 6 months the intervention group had a greater improvement in MVPA than the controls (6.05 minutes per day [95% CI 0.36 to 11.74; P=.04]). A Bayesian analyses showed that there was a 98% probability that the intervention had any effect at 6 months, and a 63% probability that this effect was >5 minute MVPA per day. Conclusions: No effect on MVPA immediately after the intervention period (at 3 months) was observed; however, there was a delayed effect on MVPA (6 minutes per day) at 6 months, which corresponds to approximately 30% of the weekly MVPA recommendation. Our findings suggest that a behavior change program promoting AT delivered via an app may have a relevant effect on PA. Trial Registration: ClinicalTrials.gov NCT03086837; https://clinicaltrials.gov/ct2/show/NCT03086837 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-018-5658-4 %M 32510462 %R 10.2196/18531 %U https://mhealth.jmir.org/2020/6/e18531 %U https://doi.org/10.2196/18531 %U http://www.ncbi.nlm.nih.gov/pubmed/32510462 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17457 %T Medical Mobile App Classification Using the National Institute for Health and Care Excellence Evidence Standards Framework for Digital Health Technologies: Interrater Reliability Study %A Nwe,Khine %A Larsen,Mark Erik %A Nelissen,Natalie %A Wong,David Chi-Wai %+ Centre for Health Informatics, University of Manchester, Vaughan House, Portsmouth Street, Manchester, M13 9GB, United Kingdom, 44 1613069280, david.wong@manchester.ac.uk %K mHealth %K telehealth %K evaluation %K evidence %K interrater %K NHS Apps Library %K NICE %D 2020 %7 5.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Clinical governance of medical mobile apps is challenging, and there is currently no standard method for assessing the quality of such apps. In 2018, the National Institute for Health and Care Excellence (NICE) developed a framework for assessing the required level of evidence for digital health technologies (DHTs), as determined by their clinical function. The framework can potentially be used to assess mobile apps, which are a subset of DHTs. To be used reliably in this context, the framework must allow unambiguous classification of an app’s clinical function. Objective: The objective of this study was to determine whether mobile health apps could be reliably classified using the NICE evidence standards framework for DHTs. Methods: We manually extracted app titles, screenshots, and content descriptions for all apps listed on the National Health Service (NHS) Apps Library website on July 12, 2019; none of the apps were downloaded. Using this information, 2 mobile health (mHealth) researchers independently classified each app to one of the 4 functional tiers (ie, 1, 2, 3a, and 3b) described in the NICE digital technologies evaluation framework. Coders also answered contextual questions from the framework to identify whether apps were deemed to be higher risk. Agreement between coders was assessed using Cohen κ statistic. Results: In total, we assessed 76 apps from the NHS Apps Library. There was classification agreement for 42 apps. Of these, 0 apps were unanimously classified into Tier 1; 24, into Tier 2; 15, into Tier 3a; and 3, into Tier 3b. There was disagreement between coders in 34/76 cases (45%); interrater agreement was poor (Cohen κ=0.32, 95% CI 0.16-0.47). Further investigation of disagreements highlighted 5 main explanatory themes: apps that did not correspond to any tier, apps that corresponded to multiple tiers, ambiguous tier descriptions, ambiguous app descriptions, and coder error. Conclusions: The current iteration of the NICE evidence standards framework for DHTs did not allow mHealth researchers to consistently and unambiguously classify digital health mobile apps listed on the NHS app library according to their functional tier. %M 32501271 %R 10.2196/17457 %U http://www.jmir.org/2020/6/e17457/ %U https://doi.org/10.2196/17457 %U http://www.ncbi.nlm.nih.gov/pubmed/32501271 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e17272 %T Influence of the Business Revenue, Recommendation, and Provider Models on Mobile Health App Adoption: Three-Country Experimental Vignette Study %A Lupiáñez-Villanueva,Francisco %A Folkvord,Frans %A Vanden Abeele,Mariek %+ Tilburg School of Humanities and Digital Sciences, Tilburg University, Warrandelaan 2, Tilburg, 5000 LE, Netherlands, 31 610948122, fransfolkvord@Gmail.com %K mHealth adoption %K experiment %K mobile apps %K self-monitoring %K privacy paradox %K business model %K data protection %K recommendation %K health consciousness %K health information orientation %K eHealth literacy %D 2020 %7 4.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite the worldwide growth in mobile health (mHealth) tools and the possible benefits of mHealth for patients and health care providers, scientific research examining factors explaining the adoption level of mHealth tools remains scarce. Objective: We performed an experimental vignette study to investigate how four factors related to the business model of an mHealth app affect its adoption and users’ willingness to pay: (1) the revenue model (ie, sharing data with third parties vs accepting advertisements); (2) the data protection model (General Data Protection Regulation [GDPR]-compliant data handling vs nonGDPR-compliant data handling); (3) the recommendation model (ie, doctor vs patient recommendation); and (4) the provider model (ie, pharmaceutical vs medical association provider). In addition, health consciousness, health information orientation, and electronic health literacy were explored as intrapersonal predictors of adoption. Methods: We conducted an experimental study in three countries, Spain (N=800), Germany (N=800), and the Netherlands (N=416), to assess the influence of multiple business models and intrapersonal characteristics on the willingness to pay and intention to download a health app. Results: The revenue model did not affect willingness to pay or intentions to download the app in all three countries. In the Netherlands, data protection increased willingness to pay for the health app (P<.001). Moreover, in all three countries, data protection increased the likelihood of downloading the app (P<.001). In Germany (P=.04) and the Netherlands (P=.007), a doctor recommendation increased both willingness to pay and intention to download the health app. For all three countries, apps manufactured in association with a medical organization were more likely to be downloaded (P<.001). Finally, in all three countries, men, younger individuals, those with higher levels of education, and people with a health information orientation were willing to pay more for adoption of the health app and had a higher intention to download the app. Conclusions: The finding that people want their data protected by legislation but are not willing to pay more for data protection suggests that in the context of mHealth, app privacy protection cannot be leveraged as a selling point. However, people do value a doctor recommendation and apps manufactured by a medical association, which particularly influence their intention to download an mHealth app. %M 32496204 %R 10.2196/17272 %U https://mhealth.jmir.org/2020/6/e17272 %U https://doi.org/10.2196/17272 %U http://www.ncbi.nlm.nih.gov/pubmed/32496204 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17152 %T Associations Between Commercial App Use and Physical Activity: Cross-Sectional Study %A Petersen,Jasmine Maria %A Kemps,Eva %A Lewis,Lucy K %A Prichard,Ivanka %+ SHAPE Research Centre, Flinders University, GPO Box 2100, Adelaide, Australia, 61 8 82013713, jasmine.petersen@flinders.edu.au %K physical activity %K mobile applications %K social networking %D 2020 %7 3.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In today’s society, commercial physical activity apps (eg, Fitbit and Strava) are ubiquitous and hold considerable potential to increase physical activity behavior. Many commercial physical activity apps incorporate social components, in particular app-specific communities (allowing users to interact with other app users) or the capacity to connect to existing social networking platforms (eg, Facebook or Instagram). There is a growing need to gain greater insights into whether commercial physical activity apps and specific components of these apps (social components) are beneficial in facilitating physical activity. Objective: This study aimed to examine the relationship between the use of commercial physical activity apps and engagement in physical activity. The social components of commercial physical activity apps (app-specific communities and existing social networking platforms) were also explored. This involved isolating specific features (eg, sharing, providing, and receiving encouragement, comparisons, and competitions) of app-specific communities and existing social networking platforms that were most valuable in facilitating physical activity. Methods: A cross-sectional web-based survey was conducted. Participants were 1432 adults (mean age 34.1 years, 1256/1432, 88.00% female) who completed measures assessing physical activity, the use of commercial physical activity apps, and engagement with app-specific communities and existing social networking platforms. Results: Overall, 53.14% (761/1432) of the sample reported engaging with a commercial physical activity app. The most commonly used apps were Fitbit (171/761, 22.5%), Strava (130/761, 17.1%), and Garmin (102/761, 13.4%). The use of physical activity apps was significantly associated with physical activity. Notably, the use of app-specific communities and existing social networking platforms facilitated significantly greater engagement in physical activity. The features of app-specific communities that were most beneficial in promoting engagement in physical activity were providing encouragement to a partner, receiving encouragement from close friends and family, and engaging in competitions with members of public app-specific communities. In relation to existing social networking platforms, sharing physical activity posts predicted engagement in physical activity. Conclusions: The findings indicate that app-specific communities and existing social networking platforms are components of apps that are fundamental in facilitating physical activity. They further suggest that commercial physical activity apps afford high population level reach and hold great potential to promote engagement in physical activity, an important public health consideration. %M 32490836 %R 10.2196/17152 %U https://www.jmir.org/2020/6/e17152 %U https://doi.org/10.2196/17152 %U http://www.ncbi.nlm.nih.gov/pubmed/32490836 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e18073 %T A Prospective Study of Usability and Workload of Electronic Medication Adherence Products by Older Adults, Caregivers, and Health Care Providers %A Patel,Tejal %A Ivo,Jessica %A Faisal,Sadaf %A McDougall,Aidan %A Carducci,Jillian %A Pritchard,Sarah %A Chang,Feng %+ School of Pharmacy, University of Waterloo, 10 Victoria St S, Kitchener, ON, N2G 1C5, Canada, 1 519 888 4567 ext 21337, t5patel@uwaterloo.ca %K electronic medication adherence %K usability %K workload %K geriatrics %K older adults %K mobile phone %D 2020 %7 2.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: A decreased capacity to self-manage medications results in nonadherence, medication errors, and drug-related problems in older adults. Previous research identified 80 electronic medication adherence products available to assist patients with self-management of medications. Unfortunately, the usability and workload of these products are unknown. Objective: This study aimed to examine the usability and workload of a sample of electronic medication adherence products. Methods: In a prospective, mixed methods study, a sample of older adults, health care professionals, and caregivers tested the usability and workload of 21 electronic medication adherence products. Each participant tested 5 products, one at a time, after which they completed the system usability scale (SUS) and NASA-task load index (NASA-TLX), instruments that measure the usability and workload involved in using a product. Higher SUS scores indicate more user-friendliness, whereas lower NASA-TLX raw scores indicate less workload when using a product. Results: Electronic medication adherence products required a mean of 12.7 steps (range 5-20) for the appropriate use and took, on average, 15.19 min to complete the setup tasks (range 1-56). Participants were able to complete all steps without assistance 55.3% of the time (103 out of the 186 tests were completed by 39 participants; range 0%-100%). The mean SUS and NASA-TLX raw scores were 52.8 (SD 28.7; range 0-100) and 50.0 (SD 25.7; range 4.2-99.2), respectively, revealing significant variability among the electronic medication adherence products. The most user-friendly products were found to be TimerCap travel size (mean 78.67, SD 15.57; P=.03) and eNNOVEA Weekly Planner with Advanced Auto Reminder (mean 78.13, SD 14.13; P=.049) as compared with MedReady 1700 automated medication dispenser (mean 28.63, SD 21.24). Similarly, MedReady (72.92, SD 18.69) was found to be significantly more work intensive when compared with TimerCap (29.35, SD 20.35; P=.03), e-pill MedGlider home medication management system (28.43, SD 20.80; P=.02), and eNNOVEA (28.65, SD 14.97; P=.03). The e-pill MedTime Station automatic pill dispenser with tipper (71.77, SD 21.98) had significantly more workload than TimerCap (P=.04), MedGlider (P=.03), and eNNOVEA (P=.04). Conclusions: This study demonstrated that variability exists in the usability and workload of different electronic medication adherence products among older adults, caregivers, and clinicians. With few studies having investigated the usability and workload of electronic medication adherence products, no benchmarks exist to compare the usability and workload of these products. However, our study highlights the need to assess the usability and workload of different products marketed to assist with medication taking and provides guidance to clinicians regarding electronic medication adherence product recommendations for their patients. Future development of electronic medication adherence products should ensure that the target populations of patients are able to use these products adequately to improve medication management. %M 32348292 %R 10.2196/18073 %U https://www.jmir.org/2020/6/e18073 %U https://doi.org/10.2196/18073 %U http://www.ncbi.nlm.nih.gov/pubmed/32348292 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16497 %T mHealth App Prescription in Australian General Practice: Pre-Post Study %A Byambasuren,Oyungerel %A Beller,Elaine %A Hoffmann,Tammy %A Glasziou,Paul %+ Institute for Evidence-Based Healthcare, Bond University, 14 University Dr,, Robina, 4226, Australia, 61 755955518, obyambas@bond.edu.au %K mHealth apps %K app prescription %K general practice %D 2020 %7 1.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Evidence of effectiveness of mobile health (mHealth) apps as well as their usability as non-drug interventions in primary care are emerging around the globe. Objective: This study aimed to explore the feasibility of mHealth app prescription by general practitioners (GPs) and to evaluate the effectiveness of an implementation intervention to increase app prescription. Methods: A single-group, before-and-after study was conducted in Australian general practice. GPs were given prescription pads for 6 mHealth apps and reported the number of prescriptions dispensed for 4 months. After the reporting of month 2, a 2-minute video of one of the apps was randomly selected and sent to each GP. Data were collected through a prestudy questionnaire, monthly electronic reporting, and end-of-study interviews. The primary outcome was the number of app prescriptions (total, monthly, per GP, and per GP per fortnight). Secondary outcomes included confidence in prescribing apps (0-5 scale), the impact of the intervention video on subsequent prescription numbers, and acceptability of the interventions. Results: Of 40 GPs recruited, 39 commenced, and 36 completed the study. In total, 1324 app prescriptions were dispensed over 4 months. The median number of apps prescribed per GP was 30 (range 6-111 apps). The median number of apps prescribed per GP per fortnight increased from the pre-study level of 1.7 to 4.1. Confidence about prescribing apps doubled from a mean of 2 (not so confident) to 4 (very confident). App videos did not affect subsequent prescription rates substantially. Post-study interviews revealed that the intervention was highly acceptable. Conclusions: mHealth app prescription in general practice is feasible, and our implementation intervention was effective in increasing app prescription. GPs need more tailored education and training on the value of mHealth apps and knowledge of prescribable apps to be able to successfully change their prescribing habits to include apps. The future of sustainable and scalable app prescription requires a trustworthy electronic app repository of prescribable mHealth apps for GPs. %M 32478660 %R 10.2196/16497 %U https://mhealth.jmir.org/2020/6/e16497 %U https://doi.org/10.2196/16497 %U http://www.ncbi.nlm.nih.gov/pubmed/32478660 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17458 %T Mobile Apps for Mental Health Issues: Meta-Review of Meta-Analyses %A Lecomte,Tania %A Potvin,Stéphane %A Corbière,Marc %A Guay,Stéphane %A Samson,Crystal %A Cloutier,Briana %A Francoeur,Audrey %A Pennou,Antoine %A Khazaal,Yasser %+ Department of Psychology, University of Montreal, 90 rue Vincent d'Indy, Bur C-358, CP 6128, Succ Centre-Ville, Montreal, QC, H3C 3J7, Canada, 1 343 6274, tania.lecomte@umontreal.ca %K apps %K mental health %K depression %K anxiety %K review %K meta %D 2020 %7 29.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health apps have great potential to help people needing support to cope with distress or specific symptoms. In fact, there is an exponential increase in the number of mental health apps available on the internet, with less than 5% being actually studied. Objective: This study aimed to assess the quality of the available evidence regarding the use of mental health apps and to summarize the results obtained so far. Methods: Systematic reviews and meta-analyses were searched, specifically for mobile apps on mental health issues or symptoms, and rated using the Grading of Recommendations Assessment, Development and Evaluation system. Results: A total of 7 meta-analyses were carefully reviewed and rated. Although some meta-analyses looked at any mental health issue and analyzed the data together, these studies were of poorer quality and did not offer strong empirical support for the apps. Studies focusing specifically on anxiety symptoms or depressive symptoms were of moderate to high quality and generally had small to medium effect sizes. Similarly, the effects of apps on stress and quality of life tended to offer small to medium effects and were of moderate to high quality. Studies looking at stand-alone apps had smaller effect sizes but better empirical quality than studies looking at apps with guidance. The studies that included follow-ups mostly found a sustained impact of the app at an 11-week follow-up. Conclusions: This meta-review revealed that apps for anxiety and depression hold great promise with clear clinical advantages, either as stand-alone self-management or as adjunctive treatments. More meta-analyses and more quality studies are needed to recommend apps for other mental health issues or for specific populations. %M 32348289 %R 10.2196/17458 %U https://mhealth.jmir.org/2020/5/e17458 %U https://doi.org/10.2196/17458 %U http://www.ncbi.nlm.nih.gov/pubmed/32348289 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 5 %P e16980 %T Categorization of Third-Party Apps in Electronic Health Record App Marketplaces: Systematic Search and Analysis %A Ritchie,Jordon %A Welch,Brandon %+ Medical University of South Carolina, 135 Cannon Street, MSC 200, Suite 405, Charleston, SC, 29425, United States, 1 8435183769, welchbm@musc.edu %K electronic health records %K medical informatics %K software %K interoperability %K apps %K app marketplace %D 2020 %7 29.5.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: Third-party electronic health record (EHR) apps allow health care organizations to extend the capabilities and features of their EHR system. Given the widespread utilization of EHRs and the emergence of third-party apps in EHR marketplaces, it has become necessary to conduct a systematic review and analysis of apps in EHR app marketplaces. Objective: The goal of this review is to organize, categorize, and characterize the availability of third-party apps in EHR marketplaces. Methods: Two informaticists (authors JR and BW) used grounded theory principles to review and categorize EHR apps listed in top EHR vendors’ public-facing marketplaces. Results: We categorized a total of 471 EHR apps into a taxonomy consisting of 3 primary categories, 15 secondary categories, and 55 tertiary categories. The three primary categories were administrative (n=203, 43.1%), provider support (n=159, 33.8%), and patient care (n=109, 23.1%). Within administrative apps, we split the apps into four secondary categories: front office (n=77, 37.9%), financial (n=53, 26.1%), office administration (n=49, 24.1%), and office device integration (n=17, 8.4%). Within the provider support primary classification, we split the apps into eight secondary categories: documentation (n=34, 21.3%), records management (n=27, 17.0%), care coordination (n=23, 14.4%), population health (n=18, 11.3%), EHR efficiency (n=16, 10.1%), ordering and prescribing (n=15, 9.4%), medical device integration (n=13, 8.2%), and specialty EHR (n=12, 7.5%). Within the patient care primary classification, we split the apps into three secondary categories: patient engagement (n=50, 45.9%), clinical decision support (n=40, 36.7%), and remote care (n=18, 16.5%). Total app counts varied substantially across EHR vendors. Overall, the distribution of apps across primary categories were relatively similar, with a few exceptions. Conclusions: We characterized and organized a diverse and rich set of third-party EHR apps. This work provides an important reference for developers, researchers, and EHR customers to more easily search, review, and compare apps in EHR app marketplaces. %M 32469324 %R 10.2196/16980 %U http://medinform.jmir.org/2020/5/e16980/ %U https://doi.org/10.2196/16980 %U http://www.ncbi.nlm.nih.gov/pubmed/32469324 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e16875 %T Digital Biomarkers of Social Anxiety Severity: Digital Phenotyping Using Passive Smartphone Sensors %A Jacobson,Nicholas C %A Summers,Berta %A Wilhelm,Sabine %+ Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, 46 Centerra Parkway, Suite 300, Office # 333S, Lebanon, NH, 03766, United States, 1 6036467037, Nicholas.C.Jacobson@dartmouth.edu %K biomarkers %K machine learning %K technology assessment, biomedical %K social anxiety %K social anxiety disorder %K mobile phone %D 2020 %7 29.5.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Social anxiety disorder is a highly prevalent and burdensome condition. Persons with social anxiety frequently avoid seeking physician support and rarely receive treatment. Social anxiety symptoms are frequently underreported and underrecognized, creating a barrier to the accurate assessment of these symptoms. Consequently, more research is needed to identify passive biomarkers of social anxiety symptom severity. Digital phenotyping, the use of passive sensor data to inform health care decisions, offers a possible method of addressing this assessment barrier. Objective: This study aims to determine whether passive sensor data acquired from smartphone data can accurately predict social anxiety symptom severity using a publicly available dataset. Methods: In this study, participants (n=59) completed self-report assessments of their social anxiety symptom severity, depressive symptom severity, positive affect, and negative affect. Next, participants installed an app, which passively collected data about their movement (accelerometers) and social contact (incoming and outgoing calls and texts) over 2 weeks. Afterward, these passive sensor data were used to form digital biomarkers, which were paired with machine learning models to predict participants’ social anxiety symptom severity. Results: The results suggested that these passive sensor data could be utilized to accurately predict participants’ social anxiety symptom severity (r=0.702 between predicted and observed symptom severity) and demonstrated discriminant validity between depression, negative affect, and positive affect. Conclusions: These results suggest that smartphone sensor data may be utilized to accurately detect social anxiety symptom severity and discriminate social anxiety symptom severity from depressive symptoms, negative affect, and positive affect. %M 32348284 %R 10.2196/16875 %U http://www.jmir.org/2020/5/e16875/ %U https://doi.org/10.2196/16875 %U http://www.ncbi.nlm.nih.gov/pubmed/32348284 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e15111 %T Mobile Phone–Based Behavioral Interventions in Pregnancy to Promote Maternal and Fetal Health in High-Income Countries: Systematic Review %A Hussain,Tasmeen %A Smith,Patricia %A Yee,Lynn M %+ Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, United States, 1 312 472 4685, lynn.yee@northwestern.edu %K mHealth %K mobile health %K pregnancy %K smartphone %K text messaging %K mobile applications %K software %K chronic disease %K health behavior %D 2020 %7 28.5.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Chronic diseases have recently had an increasing effect on maternal-fetal health, especially in high-income countries. However, there remains a lack of discussion regarding health management with technological approaches, including mobile health (mHealth) interventions. Objective: This study aimed to systematically evaluate mHealth interventions used in pregnancy in high-income countries and their effects on maternal health behaviors and maternal-fetal health outcomes. Methods: This systematic review identified studies published between January 1, 2000, and November 30, 2018, in MEDLINE via PubMed, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and gray literature. Studies were eligible for inclusion if they included only pregnant women in high-income countries and evaluated stand-alone mobile phone interventions intended to promote healthy maternal beliefs, behaviors, and/or maternal-fetal health outcomes. Two researchers independently reviewed and categorized aspects of full-text articles, including source, study design, intervention and control, duration, participant age, attrition rate, main outcomes, and risk of bias. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and the study was registered in PROSPERO before initiation. Results: Of the 2225 records examined, 28 studies were included and categorized into 4 themes: (1) gestational weight gain, obesity and physical activity (n=9); (2) smoking cessation (n=9); (3) influenza vaccination (n=2); and (4) general prenatal health, preventive strategies, and miscellaneous topics (n=8). Reported sample sizes ranged from 16 to 5243 with a median of 91. Most studies were performed in the United States (18/28, 64%) and were randomized controlled trials (21/28, 75%). All participants in the included studies were pregnant at the time of study initiation. Overall, 14% (4/28) of studies showed association between intervention use and improved health outcomes; all 4 studies focused on healthy gestational weight. Among those, 3 studies showed intervention use was associated with less overall gestational weight gain. These 3 studies involved interventions with text messaging or an app in combination with another communication strategy (Facebook or email). Regarding smoking cessation, influenza vaccination, and miscellaneous topics, there was some evidence of positive effects on health behaviors and beliefs, but very limited correlation with improved health outcomes. Data and interventions were heterogeneous, precluding a meta-analysis. Conclusions: In high-income countries, utilization of mobile phone–based health behavior interventions in pregnancy demonstrates some correlation with positive beliefs, behaviors, and health outcomes. More effective interventions are multimodal in terms of features and tend to focus on healthy gestational weight gain. %M 32463373 %R 10.2196/15111 %U https://mhealth.jmir.org/2020/5/e15111 %U https://doi.org/10.2196/15111 %U http://www.ncbi.nlm.nih.gov/pubmed/32463373 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e16137 %T A Patient Safety Educational Tool for Patients With Chronic Kidney Disease: Development and Usability Study %A Bowman,Cassandra %A Lunyera,Joseph %A Alkon,Aviel %A Boulware,L Ebony %A St Clair Russell,Jennifer %A Riley,Jennie %A Fink,Jeffrey C %A Diamantidis,Clarissa %+ Division of General Internal Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, United States, 1 919 668 1261, clarissa.diamantidis@duke.edu %K patient safety %K chronic kidney disease %K patient education %K mhealth %D 2020 %7 28.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Chronic kidney disease (CKD) is a health condition that threatens patient safety; however, few interventions provide patient-centered education about kidney-specific safety hazards. Objective: We sought to develop and test the usability of a mobile tablet–based educational tool designed to promote patient awareness of relevant safety topics in CKD. Methods: We used plain language principles to develop content for the educational tool, targeting four patient-actionable safety objectives that are relevant for individuals with CKD. These four objectives included avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs); hypoglycemia awareness (among individuals with diabetes); temporary cessation of certain medications during acute volume depletion to prevent acute kidney injury (ie, “sick day protocol”); and contrast dye risk awareness. Our teaching strategies optimized human-computer interaction and content retention using audio, animation, and clinical vignettes to reinforce themes. For example, using a vignette of a patient with CKD with pain and pictures of common NSAIDs, participants were asked “Which of the following pain medicines are safe for Mr. Smith to take for his belly pain?” Assessment methods consisted of preknowledge and postknowledge surveys, with provision of correct responses and explanations. Usability testing of the tablet-based tool was performed among 12 patients with any stage of CKD, and program tasks were rated upon completion as no error, noncritical error (self-corrected), or critical error (needing assistance). Results: The 12 participants in this usability study were predominantly 65 years of age or older (n=7, 58%) and female (n=7, 58%); all participants owned a mobile device and used it daily. Among the 725 total tasks that the participants completed, there were 31 noncritical errors (4.3%) and 15 critical errors (2.1%); 1 participant accounted for 30 of the total errors. Of the 12 participants, 10 (83%) easily completed 90% or more of their tasks. Most participants rated the use of the tablet as very easy (n=7, 58%), the activity length as “just right” (rather than too long or too short) (n=10, 83%), and the use of clinical vignettes as helpful (n=10, 83%); all participants stated that they would recommend this activity to others. The median rating of the activity was 8 on a scale of 1 to 10 (where 10 is best). We incorporated all participant recommendations into the final version of the educational tool. Conclusions: A tablet-based patient safety educational tool is acceptable and usable by individuals with CKD. Future studies leveraging iterations of this educational tool will explore its impact on health outcomes in this high-risk population. %M 32463366 %R 10.2196/16137 %U http://formative.jmir.org/2020/5/e16137/ %U https://doi.org/10.2196/16137 %U http://www.ncbi.nlm.nih.gov/pubmed/32463366 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e17179 %T Assessing Feasibility of an Early Childhood Intervention Using Mobile Phones Among Low-Income Mothers of Newborns: Qualitative Interview Study %A Zhang,Donglan %A Jin,Lan %A Liang,Di %A Geng,Ruijin %A Liu,Yun %A Ling,Yu %A Jiang,Fan %A Zhang,Yunting %+ Child Health Advocacy Institute, National Children’s Medical Center, Shanghai Children’s Medical Center, 1678 Dongfang Road, Pudong, Shanghai, China, 86 21 3862606, zhangyunting@scmc.com.cn %K mobile health %K interview %K health belief model %K early child development %D 2020 %7 28.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Many children aged younger than 5 years living in low- and middle-income countries are at risk for poor development. Early child development (ECD) programs are cost-effective strategies to reduce poverty, crime, school dropouts, and socioeconomic inequality. With the spread of low-cost mobile phones and internet access in low- and middle-income countries, new service delivery models such as mobile phone–aided interventions have a great potential to improve early childhood development. Objective: This study aimed to identify the beliefs on importance of ECD, feasibility of a proposed intervention using mobile phones and factors that may affect the usability of the intervention among mothers of newborns in a poverty-stricken area in southwestern China. Methods: We conducted an in-depth, semistructured interview study of 25 low-income mothers of newborns recruited from two county hospitals in Yunnan Province. We applied the health belief model and cultural competence theories to identify the facilitators, barriers, and preferences among the target population for parenting knowledge. Results: The results showed that the participants had low health literacy and high perceived needs for learning ECD knowledge. At the same time, they experienced several barriers to learning parenting information and following evidence-based instructions including having limited time, limited financial resources, and different opinions on childcare among family members. Many participants preferred to receive personalized messages tailored to their specific needs and preferred videos or graphics to text only in the messages. Many favored a separate module to support postpartum mental health. Conclusions: The study assessed the acceptability of an early childhood intervention using mobile phones to meet the needs of the target population based on their beliefs, traits, and preferences and provided suggestions to refine the intervention to improve its usability. %M 32463374 %R 10.2196/17179 %U http://formative.jmir.org/2020/5/e17179/ %U https://doi.org/10.2196/17179 %U http://www.ncbi.nlm.nih.gov/pubmed/32463374 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e17968 %T Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study %A Gimbel,Ronald W %A Rennert,Lior M %A Crawford,Paul %A Little,Jeanette R %A Truong,Khoa %A Williams,Joel E %A Griffin,Sarah F %A Shi,Lu %A Chen,Liwei %A Zhang,LingLing %A Moss,Jennie B %A Marshall,Robert C %A Edwards,Karen W %A Crawford,Kristy J %A Hing,Marie %A Schmeltz,Amanda %A Lumsden,Brandon %A Ashby,Morgan %A Haas,Elizabeth %A Palazzo,Kelly %+ Department of Public Health Sciences, Clemson University, 501 Edwards Hall, Clemson, SC, 29634, United States, 1 5405223759, rgimbel@clemson.edu %K mHealth %K diabetes mellitus %K patient activation %K patient-centered care %K eHealth %D 2020 %7 26.5.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. Objective: The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense’s Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. Methods: A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. Results: The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean −0.53, intervention mean −0.11; P=.006), and low-density lipoprotein cholesterol (control mean −7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean −0.09, intervention mean −0.52; P=.04), BMI (control mean 0.58, intervention mean −1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean −4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). Conclusions: Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. Trial Registration: ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.6993 %M 32329438 %R 10.2196/17968 %U http://www.jmir.org/2020/5/e17968/ %U https://doi.org/10.2196/17968 %U http://www.ncbi.nlm.nih.gov/pubmed/32329438 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e14375 %T Understanding and Preventing Health Concerns About Emerging Mobile Health Technologies %A Materia,Frank T %A Faasse,Kate %A Smyth,Joshua M %+ The Pennsylvania State University, 219 Biobehavioral Health Building, University Park, PA, 16802, United States, 1 814 863 8402, Smyth@psu.edu %K mHealth %K technology %K nocebo effect %K implementation science %K medically unexplained symptoms %D 2020 %7 25.5.2020 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X New technologies and innovations have often improved population well-being and societal function; however, these are also often initially accompanied by worry and fear. In some cases, such worries can impede, or even prevent entirely, the adoption of the technology. Mobile health (mHealth), a discipline broadly focused on employing ambulatory technologies to improve the affordability, reach, and effectiveness of health promotion and clinical intervention approaches, offers new innovations and opportunities. Despite emerging evidence supporting mHealth efficacy (eg, for improving health outcomes), some individuals have concerns about mHealth technology that may impede scalability, efficacy, and, ultimately, the public health benefits of mHealth. We present a review and conceptual framework to examine these issues, focusing on three overarching themes: biophysiological, psychological, and societal concerns. There are features of mHealth that lead to worries about the potential negative effects on an individual’s health (eg, due to exposure to electromagnetic or radio waves), despite evidence supporting the safety of these technologies. When present, such beliefs can lead to worry that gives rise to the experience of unpleasant and concerning physical symptoms—the nocebo effect. This may represent an important implementational barrier because of apprehension toward beneficial mHealth products (or features thereof, such as wireless charging, wearable or implantable sensors, etc) and may also have broader ramifications (eg, leading to economic, governmental, and legislative actions). In addition to reviewing evidence on these points, we provide a broad three-step model of implementation research in mHealth that focuses on understanding and preventing health concerns to facilitate the safe and effective scalability of mHealth (and that may be generalizable and applied to similar technologies): (1) evaluating and better discerning public perceptions and misperceptions (and how these may differ between populations), (2) developing theory-based public health communication strategies regarding the safety of mHealth, and (3) disseminating this messaging using evidence-based methods. Collectively, these steps converge on reviewing evidence regarding the potential role of worry and nocebo in mHealth and providing a model for understanding and changing attitudes and preventing unfounded negative perceptions related to mHealth technology. %M 32449688 %R 10.2196/14375 %U http://mhealth.jmir.org/2020/5/e14375/ %U https://doi.org/10.2196/14375 %U http://www.ncbi.nlm.nih.gov/pubmed/32449688 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17034 %T Mood and Stress Evaluation of Adult Patients With Moyamoya Disease in Korea: Ecological Momentary Assessment Method Using a Mobile Phone App %A Yang,Yong Sook %A Ryu,Gi Wook %A Park,Chang Gi %A Yeom,Insun %A Shim,Kyu Won %A Choi,Mona %+ Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 222283341, monachoi@yuhs.ac %K affect %K ecological momentary assessment %K mood %K Moyamoya disease %K psychological stress %D 2020 %7 25.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Moyamoya disease (MMD) is a known progressive obstructive cerebrovascular disorder. Monitoring and managing mood and stress are critical for patients with MMD, as they affect clinical outcomes. The ecological momentary assessment (EMA) method is a longitudinal study design by which multiple variable assessments can be performed over time to detect momentary fluctuations and changes in psychological dimensions such as mood and stress over time. Objective: This study aimed to identify predicting factors associated with momentary mood and stress at both the within-person and between-person levels and to examine individual fluctuation of mood over time in the short term using an EMA method combined with a mobile phone app. Methods: Participants aged older than 18 years were recruited from a tertiary hospital in Seoul, Korea, between July 2018 and January 2019. The PsyMate scale for negative affect (NA) and positive affect (PA) and the Trier Inventory for Chronic Stress Scale were uploaded on patient mobile phones. Using a mobile app, data were collected four times a day for 7 days. Pearson correlations and mixed modeling were used to predict relationships between repeatedly measured variables at both the between-person and within-person levels. Results: The mean age of the 93 participants was 40.59 (SD 10.06) years, 66 (71%) were female, and 71 (76%) were married. Participants provided 1929 responses out of a possible 2604 responses (1929/2604, 74.08%). The mean momentary NA and PA values were 2.15 (SD 1.12) and 4.70 (SD 1.31) out of 7, respectively. The momentary stress value was 2.03 (SD 0.98) out of 5. Momentary NA, PA, and stress were correlated (P<.001) and varied over time in relation to momentary variables. Common momentary variables associated with momentary mood and stress at both the within-person (level 1) and between-person (level 2) levels were identified. Momentary NA increased when being alone and being at the hospital at both levels, whereas momentary PA increased when eating or drinking, resting, being at a café, restaurant or a public place but decreased when being alone at both levels. Momentary stress increased when being at the office, at a public place, or as the time of the day went by but decreased when resting or during the weekend. Different factors affecting mood and stress at different levels were identified. Fluctuations in individual momentary mood over time at the within-person level were captured. Conclusions: The EMA method using a mobile phone app demonstrated its ability to capture changes in mood and stress in various environmental contexts in patients with MMD. The results could provide baseline information for developing interventions to manage negative mood and stress of patients with MMD based on the identified predictors affecting mood and stress at two different levels. %M 32449687 %R 10.2196/17034 %U http://mhealth.jmir.org/2020/5/e17034/ %U https://doi.org/10.2196/17034 %U http://www.ncbi.nlm.nih.gov/pubmed/32449687 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e18537 %T A Brief Music App to Address Pain in the Emergency Department: Prospective Study %A Chai,Peter R %A Schwartz,Emily %A Hasdianda,Mohammad Adrian %A Azizoddin,Desiree R %A Kikut,Anna %A Jambaulikar,Guruprasad D %A Edwards,Robert R %A Boyer,Edward W %A Schreiber,Kristin L %+ Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, United States, 1 617 732 5640, pchai@bwh.harvard.edu %K music therapy %K pain %K smartphone %K technology %K telemedicine %K emergency service, hospital %D 2020 %7 20.5.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Emergency physicians face the challenge of relieving acute pain daily. While opioids are a potent treatment for pain, the opioid epidemic has ignited a search for nonopioid analgesic alternatives that may decrease the dose or duration of opioid exposure. While behavioral therapies and complementary medicine are effective, they are difficult to deploy in the emergency department. Music is a potential adjunctive therapy that has demonstrated effectiveness in managing pain. Objective: Our objective was to understand the feasibility and potential for an effect of a novel music app to address acute pain and anxiety in patients admitted to an emergency department observation unit. Methods: This prospective cohort study enrolled patients admitted to an emergency department observation unit with pain who had received orders for opioids. We gathered baseline pain and psychosocial characteristics including anxiety, sleep disturbance, and pain catastrophizing using validated questionnaires. Participants received a smartphone-based music intervention and listened to the music in either a supervised (research assistant–delivered music session 3 times during their stay) or unsupervised manner (music used ad lib by participant). The app collected premusic and postmusic pain and anxiety scores, and participants provided qualitative feedback regarding acceptability of operating the music intervention. Results: We enrolled 81 participants and randomly assigned 38 to an unsupervised and 43 to a supervised group. Mean pain in both groups was 6.1 (1.8) out of a possible score of 10. A total of 43 (53%) reported previous use of music apps at home. We observed an overall modest but significant decrease in pain (mean difference –0.81, 95% CI –0.45 to –1.16) and anxiety (mean difference –0.72, 95% CI –0.33 to –1.12) after music sessions. Reduction of pain and anxiety varied substantially among participants. Individuals with higher baseline pain, catastrophizing (about pain), or anxiety reported greater relief. Changes in pain were correlated to changes in anxiety (Pearson ρ=0.3, P=.02) but did not vary between supervised and unsupervised groups. Upon conclusion of the study, 46/62 (74%) reported they liked the music intervention, 57/62 (92%) reported the app was easy to use, and 49/62 (79%) reported they would be willing to use the music intervention at home. Conclusions: A smartphone-based music intervention decreased pain and anxiety among patients in an emergency department observation unit, with no difference between supervised and unsupervised use. Individuals reporting the greatest reduction in pain after music sessions included those scoring highest on baseline assessment of catastrophic thinking, suggesting there may be specific patient populations that may benefit more from using music as an analgesic adjunct in the emergency department. Qualitative feedback suggested that this intervention was feasible and acceptable by emergency department patients. %M 32432550 %R 10.2196/18537 %U http://www.jmir.org/2020/5/e18537/ %U https://doi.org/10.2196/18537 %U http://www.ncbi.nlm.nih.gov/pubmed/32432550 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 5 %P e16237 %T An Automated Mobile Mood Tracking Technology (Mood 24/7): Validation Study %A Kumar,Anupama %A Wang,Michael %A Riehm,Alison %A Yu,Eileen %A Smith,Ted %A Kaplin,Adam %+ Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Room 121, 600 N Wolfe Street, Meyer Building, Baltimore, MD, 21287-0005, United States, 1 4106143307, akaplin@jhmi.edu %K depression %K text messaging %K patient monitoring %K mobile phone %K short message service %K ecological momentary assessment %K digital health %D 2020 %7 20.5.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Electronic tracking has been utilized for a variety of health conditions. Previous studies have shown that there is higher adherence to electronic methods vs paper-and-pencil tracking modalities. Electronic tracking also ensures that there are no back-filled entries, where patients have—to appear compliant—entered their responses retrospectively just before their visits with their health care provider. On the basis of the recognition of an unmet need for a Web-based automated platform to track psychiatric outcomes, Johns Hopkins University partnered with Health Central (a subsidiary of Remedy Health Media LLC) to develop Mood 24/7, an electronic, mobile, automated, SMS-based mood tracker. This is a pilot study to validate the use of Mood 24/7 in anticipation of clinical trials to demonstrate the therapeutic benefit on patients’ health outcomes of utilizing digital mood-tracking technology. Objective: Mood 24/7 is an electronic mood-monitoring platform developed to accurately and efficiently track mood over time through automated daily SMS texts or emails. This study was designed to assess the accuracy and validity of Mood 24/7 in an outpatient psychiatric setting. Methods: This pilot study involved a retrospective chart review for depressed outpatients (N=9) to compare their self-reported Mood 24/7 daily mood ratings with their psychiatrist’s independent clinical mood assessment at the time of the patient’s visit. Their mood ratings via Mood 24/7 were collected over 36 weeks. In addition, a mixed model analysis was applied to compare the weekly Montgomery-Åsberg Depression Rating Scale (MADRS) scores with Mood 24/7 scores over an average of 3 months. Results: A 97.2% (315/324) digital mood reporting adherence was found over 36 weeks, and a significant correlation (r=0.86, P<.001) was observed between patients’ Mood 24/7 scores and their psychiatrist’s blinded clinical assessment of the patient’s mood when seen in the clinic. In addition, a significant concordance (intraclass correlation of 0.69, 95% CI 0.33-0.91, P<.001) was observed in the mixed model analysis of the clinician-administered MADRS vs Mood 24/7 scores over time. Conclusions: Our chart review and mixed model analyses demonstrate that Mood 24/7 is a valid instrument for convenient, simple, noninvasive, and accurate longitudinal mood assessment in the outpatient clinical setting. %M 32432558 %R 10.2196/16237 %U https://mental.jmir.org/2020/5/e16237 %U https://doi.org/10.2196/16237 %U http://www.ncbi.nlm.nih.gov/pubmed/32432558 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e16658 %T Use of Smartphones to Detect Diabetic Retinopathy: Scoping Review and Meta-Analysis of Diagnostic Test Accuracy Studies %A Tan,Choon Han %A Kyaw,Bhone Myint %A Smith,Helen %A Tan,Colin S %A Tudor Car,Lorainne %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Singapore, Singapore, 65 6904 1258, lorainne.tudor.car@ntu.edu.sg %K diabetic retinopathy %K smartphone %K mobile phone %K ophthalmoscopy %K artificial intelligence %K telemedicine %D 2020 %7 15.5.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Diabetic retinopathy (DR), a common complication of diabetes mellitus, is the leading cause of impaired vision in adults worldwide. Smartphone ophthalmoscopy involves using a smartphone camera for digital retinal imaging. Utilizing smartphones to detect DR is potentially more affordable, accessible, and easier to use than conventional methods. Objective: This study aimed to determine the diagnostic accuracy of various smartphone ophthalmoscopy approaches for detecting DR in diabetic patients. Methods: We performed an electronic search on the Medical Literature Analysis and Retrieval System Online (MEDLINE), EMBASE, and Cochrane Library for literature published from January 2000 to November 2018. We included studies involving diabetic patients, which compared the diagnostic accuracy of smartphone ophthalmoscopy for detecting DR to an accurate or commonly employed reference standard, such as indirect ophthalmoscopy, slit-lamp biomicroscopy, and tabletop fundus photography. Two reviewers independently screened studies against the inclusion criteria, extracted data, and assessed the quality of included studies using the Quality Assessment of Diagnostic Accuracy Studies–2 tool, with disagreements resolved via consensus. Sensitivity and specificity were pooled using the random effects model. A summary receiver operating characteristic (SROC) curve was constructed. This review is reported in line with the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies guidelines. Results: In all, nine studies involving 1430 participants were included. Most studies were of high quality, except one study with limited applicability because of its reference standard. The pooled sensitivity and specificity for detecting any DR was 87% (95% CI 74%-94%) and 94% (95% CI 81%-98%); mild nonproliferative DR (NPDR) was 39% (95% CI 10%-79%) and 95% (95% CI 91%-98%); moderate NPDR was 71% (95% CI 57%-81%) and 95% (95% CI 88%-98%); severe NPDR was 80% (95% CI 49%-94%) and 97% (95% CI 88%-99%); proliferative DR (PDR) was 92% (95% CI 79%-97%) and 99% (95% CI 96%-99%); diabetic macular edema was 79% (95% CI 63%-89%) and 93% (95% CI 82%-97%); and referral-warranted DR was 91% (95% CI 86%-94%) and 89% (95% CI 56%-98%). The area under SROC curve ranged from 0.879 to 0.979. The diagnostic odds ratio ranged from 11.3 to 1225. Conclusions: We found heterogeneous evidence showing that smartphone ophthalmoscopy performs well in detecting DR. The diagnostic accuracy for PDR was highest. Future studies should standardize reference criteria and classification criteria and evaluate other available forms of smartphone ophthalmoscopy in primary care settings. %M 32347810 %R 10.2196/16658 %U http://www.jmir.org/2020/5/e16658/ %U https://doi.org/10.2196/16658 %U http://www.ncbi.nlm.nih.gov/pubmed/32347810 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e15094 %T Identifying Women at Risk for Polycystic Ovary Syndrome Using a Mobile Health App: Virtual Tool Functionality Assessment %A Rodriguez,Erika Marie %A Thomas,Daniel %A Druet,Anna %A Vlajic-Wheeler,Marija %A Lane,Kevin James %A Mahalingaiah,Shruthi %+ Department of Environmental Health, Harvard TH Chan School of Public Health, 665 Huntington Ave, Building 1, Boston, MA, 02115, United States, 1 617 432 4381, shruthi@hsph.harvard.edu %K polycystic ovary syndrome %K mobile health app %K Clue %K menstrual irregularities %K telemedicine %K mHealth, mobile phone %D 2020 %7 14.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Polycystic ovary syndrome (PCOS) is an endocrine disrupting disorder affecting about 10% of reproductive-aged women. PCOS diagnosis may be delayed several years and may require multiple physicians, resulting in lost time for risk-reducing interventions. Menstrual tracking apps are a potential tool to alert women of their risk while also prompting evaluation from a medical professional. Objective: The primary objective of this study was to develop and pilot test the irregular cycle feature, a predictive model that generated a PCOS risk score, in the menstrual tracking app, Clue. The secondary objectives were to run the model using virtual test subjects, create a quantitative risk score, compare the feature’s risk score with that of a physician, and determine the sensitivity and specificity of the model before empirical testing on human subjects. Methods: A literature review was conducted to generate a list of signs and symptoms of PCOS, termed variables. Variables were then assigned a probability and built into a Bayesian network. Questions were created based on these variables. A total of 9 virtual test subjects were identified using self-reported menstrual cycles and answers to the feature’s questions. Upon completion of the questionnaire, a Result Screen and Doctor’s Report summarizing the probability of having PCOS was displayed. This provided information about PCOS and data to facilitate diagnosis by a medical professional. To assess the accuracy of the feature, the same set of 9 virtual test subjects was assigned probabilities by the feature and the physician, who served as the gold standard. The feature recommended individuals with a score greater than or equal to 25% to follow-up with a physician. Differences between the feature and physician scores were evaluated using a t test and a Pearson correlation coefficient in 8 of the 9 virtual test subjects. A second iteration was conducted to assess the feature’s probability capabilities. Results: The irregular cycle feature’s first iteration produced 1 false-positive compared with the physician score and had an absolute mean difference of 15.5% (SD 15.1%) among the virtual test subjects. The second iteration had 2 false positives compared with the physician score and had an absolute mean difference of 18.8% (SD 13.6%). The feature overpredicted the virtual test subjects’ risk of PCOS compared with the physician. However, a significant positive correlation existed between the feature and physician score (Pearson correlation coefficient=0.82; P=.01). The second iteration performed worse, with a Pearson correlation coefficient of 0.73 (P=.03). Conclusions: The first iteration of the feature outperformed the second and better predicted the probability of PCOS. Although further research is needed with a more robust sample size, this pilot study indicates the potential value for developing a screening tool to prompt high-risk subjects to seek evaluation by a medical professional. %M 32406861 %R 10.2196/15094 %U https://formative.jmir.org/2020/5/e15094 %U https://doi.org/10.2196/15094 %U http://www.ncbi.nlm.nih.gov/pubmed/32406861 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 7 %N 2 %P e16605 %T A Cyber-Physical System for Near Real-Time Monitoring of At-Home Orthopedic Rehabilitation and Mobile–Based Provider-Patient Communications to Improve Adherence: Development and Formative Evaluation %A Stevens,Timothy %A McGinnis,Ryan S %A Hewgill,Blake %A Choquette,Rebecca H %A Tourville,Timothy W %A Harvey,Jean %A Lachapelle,Richard %A Beynnon,Bruce D %A Toth,Michael J %A Skalka,Christian %+ Department of Medicine, University of Vermont, Health Science Research Facility Rm 126B, 149 Beaumont Ave, Burlington, VT, 05405, United States, 1 (802) 656 7989, michael.toth@med.uvm.edu %K device use tracking %K internet of things %K neuromuscular electrical stimulation %K exercise %K smart devices %K mHealth %K rehabilitation %K mobile health %K digital health %D 2020 %7 11.5.2020 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Knee extensor muscle performance is reduced after lower extremity trauma and orthopedic surgical interventions. At-home use of neuromuscular electrical stimulation (NMES) may improve functional recovery, but adherence to at-home interventions is low. Greater benefits from NMES may be realized with closer monitoring of adherence to at-home prescriptions and more frequent patient-provider interactions. Objective: This study aimed to develop a cyber-physical system to monitor at-home adherence to NMES prescription and facilitate patient-provider communications to improve adherence in near real time. Methods: The RehabTracker cyber-physical system was developed to accomplish this goal and comprises four components: (1) hardware modifications to a commercially available NMES therapy device to monitor device use and provide Bluetooth functionality; (2) an iPhone Operating System–based mobile health (mHealth) app that enables patient-provider communications in near real time; (3) a clinician portal to allow oversight of patient adherence with device use; and (4) a back-end server to store data, enable adherence analysis, and send automated push notifications to the patient. These four elements were designed to be fully compliant with the Health Insurance Portability and Accountability Act. The system underwent formative testing in a cohort of patients following anterior cruciate ligament rupture (n=7) to begin to assess face validity. Results: Compared with the NMES device software–tracked device use, the RehabTracker system recorded 83% (40/48) of the rehabilitation sessions, with 100% (32/32) of all sessions logged by the system in 4 out of 7 patients. In patients for whom tracking of automated push notifications was enabled, 100% (29/29) of the push notifications sent by the back-end server were received by the patient. Process, hardware, and software issues contributing to these inaccuracies are detailed. Conclusions: RehabTracker represents a promising mHealth app for tracking and improving adherence with at-home NMES rehabilitation programs and warrants further refinement and testing. %M 32384052 %R 10.2196/16605 %U http://humanfactors.jmir.org/2020/2/e16605/ %U https://doi.org/10.2196/16605 %U http://www.ncbi.nlm.nih.gov/pubmed/32384052 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e19577 %T Telemedicine During the COVID-19 Pandemic: Experiences From Western China %A Hong,Zhen %A Li,Nian %A Li,Dajiang %A Li,Junhua %A Li,Bing %A Xiong,Weixi %A Lu,Lu %A Li,Weimin %A Zhou,Dong %+ Department of Neurology, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, China, 86 28 8542 2893, zhoudong66@yahoo.de %K COVID-19 %K coronavirus disease %K medical education %K pandemics %K teleteaching %K tele-education %K telemedicine %D 2020 %7 8.5.2020 %9 Viewpoint %J J Med Internet Res %G English %X Disasters and pandemics pose unique challenges to health care delivery. As health care resources continue to be stretched due to the increasing burden of the coronavirus disease (COVID-19) pandemic, telemedicine, including tele-education, may be an effective way to rationally allocate medical resources. During the COVID-19 pandemic, a multimodal telemedicine network in Sichuan Province in Western China was activated immediately after the first outbreak in January 2020. The network synergizes a newly established 5G service, a smartphone app, and an existing telemedicine system. Telemedicine was demonstrated to be feasible, acceptable, and effective in Western China, and allowed for significant improvements in health care outcomes. The success of telemedicine here may be a useful reference for other parts of the world. %M 32349962 %R 10.2196/19577 %U http://www.jmir.org/2020/5/e19577/ %U https://doi.org/10.2196/19577 %U http://www.ncbi.nlm.nih.gov/pubmed/32349962 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e15083 %T A Persuasive mHealth Behavioral Change Intervention for Promoting Physical Activity in the Workplace: Feasibility Randomized Controlled Trial %A Haque,Md Sanaul %A Kangas,Maarit %A Jämsä,Timo %+ Research Unit of Medical Imaging Physics and Technology, Faculty of Medicine, University of Oulu, PO Box 5000, Oulu, 90014, Finland, 358 469557272, md.haque@oulu.fi %K mHealth behavioral change intervention %K persuasive app %K UCD %K game elements %K physical activity %K SDT %D 2020 %7 4.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Employees in an office setting are more likely to remain physically inactive. Physical inactivity has become one of the major barriers to overcoming the risk factors for anxiety, depression, coronary heart disease, certain cancers, and type 2 diabetes. Currently, there is a gap in mobile health (mHealth) apps to promote physical activity (PA) for workers in the workplace. Studies on behavior change theories have concluded that health apps generally lack the use of theoretical constructs. Objective: The objective of this study was to study the feasibility of a persuasive app aimed at encouraging PA among employees and to understand the motivational aspects behind the implementation of mHealth apps among office workers. Methods: A 4-week study using a mixed methods (quantitative and qualitative) design was conducted with office-based employees in cities in 4 countries: Oulu, Finland; Carlow, Ireland; London, United Kingdom; and Dhaka, Bangladesh. Of the 220 invited participants (experimental group, n=115; control group, n=105), 84 participated (experimental group, n=56; control group, n=28), consisting of working-age volunteers working in an office setting. Participants used 2 different interventions: The experimental group used an mHealth app for PA motivation, and the control group used a paper diary. The purpose was to motivate employees to engage in healthier behavior regarding the promotion of PA in the workplace. A user-centered design process was followed to design, develop, and evaluate the mHealth app, incorporating self-determination theory (SDT) and using game elements. The paper diary had no specific theory-driven approach, design technique, nor game elements. Results: Compliance with app usage remained relatively low, with 27 participants (experimental group, n=20; control group, n=7) completing the study. The results support the original hypothesis that the mHealth app would help increase PA (ie, promoting daily walking in the workplace) in comparison to a paper diary (P=.033). The mHealth app supported 2 of the basic SDT psychological needs, namely autonomy (P=.004) and competence (P=.014), but not the needs of relatedness (P=.535). Conclusions: The SDT-based mHealth application motivated employees to increase their PA in the workplace. However, compliance with app usage remained low. Future research should further develop the app based on user feedback and test it in a larger sample. %M 32364506 %R 10.2196/15083 %U https://formative.jmir.org/2020/5/e15083 %U https://doi.org/10.2196/15083 %U http://www.ncbi.nlm.nih.gov/pubmed/32364506 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e16262 %T Testing Usability and Feasibility of a Mobile Educator Tool for Pediatric Diabetes Self-Management: Mixed Methods Pilot Study %A Otis,Marisa %A Zhu,Jack %A Mustafa-Kutana,Suleiman N %A Bernier,Angelina V %A Ma Shum,Julio %A Soros Dupre,Arlette A %A Wang,Monica L %+ Department of Community Health Sciences, Boston University School of Public Health, Crosstown Center, 4th Floor, 801 Massachusetts Avenue, Boston, MA, 02118, United States, 1 617 414 1357, mlwang@bu.edu %K diabetes mellitus %K self-management %K health education %K mHealth %K mobile health %K child health %D 2020 %7 1.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Mobile interventions hold promise as an intervention modality to engage children in improving diabetes self-management education, attitudes, and behaviors. Objective: This pilot study aimed to explore the usability, acceptability, and feasibility of delivering a mobile diabetes educational tool to parent-child pairs in a clinical setting. Methods: This mixed methods pilot study comprised two concurrent phases with differing study participants. Phase 1 used user testing interviews to collect qualitative data on the usability and acceptability of the tool. Phase 2 used a single-arm pre- and poststudy design to quantitatively evaluate the feasibility and preliminary efficacy of the intervention. Study participants (English-speaking families with youth aged 5-14 years with insulin-dependent diabetes) were recruited from an urban hospital in Massachusetts, United States. In phase 1, parent-child pairs were invited to complete the intervention together and participate in 90-min user testing interviews assessing the tool’s usability and acceptability. Interview transcripts were analyzed using a directed content analysis approach. In phase 2, parent-child pairs were invited to complete the intervention together in the clinical setting. Measures included parental and child knowledge, attitudes, and behaviors related to diabetes management (self-report surveys) and child hemoglobin A1c levels (medical record extractions); data were collected at baseline and 1-month follow-up. Pre- and postoutcomes were compared using paired t tests and the Fisher exact test. Results: A total of 11 parent-child pairs (N=22) participated in phase 1 of the study, and 10 parent-child pairs (N=20) participated in phase 2 of the study. Participants viewed the mobile educational tool as acceptable (high engagement and satisfaction with the layout, activities, and videos) and identified the areas of improvement for tool usability (duration, directions, and animation). Conclusions: The findings from this pilot study suggest that the mobile educational tool is an informative, engaging, and feasible way to deliver diabetes self-management education to parents and children in an urban hospital setting. Data will inform future iterations of this mobile diabetes educational intervention to improve usability and test intervention efficacy. %M 32356773 %R 10.2196/16262 %U https://formative.jmir.org/2020/5/e16262 %U https://doi.org/10.2196/16262 %U http://www.ncbi.nlm.nih.gov/pubmed/32356773 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e15780 %T The Development of a Mobile Health App for Breast Cancer Self-Management Support in Taiwan: Design Thinking Approach %A Hou,I-Ching %A Lan,Min-Fang %A Shen,Shan-Hsiang %A Tsai,Pei Yu %A Chang,King Jen %A Tai,Hao-Chih %A Tsai,Ay-Jen %A Chang,Polun %A Wang,Tze-Fang %A Sheu,Shuh-Jen %A Dykes,Patricia C %+ School of Nursing, National Yang-Ming University, No 155, Sec 2, Li-Nong Street, Beitou, Taipei, 11221, Taiwan, 886 28267000 ext 7315, evita@ym.edu.tw %K breast cancer %K mobile health application %K self-management %K design thinking %D 2020 %7 30.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Evidence has shown that breast cancer self-management support from mobile health (mHealth) apps can improve the quality of life of survivors. Although many breast cancer self-management support apps exist, few papers have documented the procedure for the development of a user-friendly app from the patient’s perspective. Objective: This study aimed to investigate the information needs of Taiwanese women with breast cancer to inform the development of a self-management support mHealth app. Methods: A 5-step design thinking approach, comprising empathy, define, ideate, prototype, and test steps, was used in the focus groups and individual interviews conducted to collect information on the requirements and expectations of Taiwanese women with breast cancer with respect to the app. A thematic analysis was used to identify information needs. Results: A total of 8 major themes including treatment, physical activity, diet, emotional support, health records, social resources, experience sharing, and expert consultation were identified. Minor themes included the desire to use the app under professional supervision and a trustworthy app manager to ensure the credibility of information. Conclusions: The strengths of the design thinking approach were user-centered design and cultural sensitivity. The results retrieved from each step contributed to the development of the app and reduction of the gap between end users and developers. An mHealth app that addresses these 8 main themes can facilitate disease self-management for Taiwanese women with breast cancer. %M 32352390 %R 10.2196/15780 %U http://mhealth.jmir.org/2020/4/e15780/ %U https://doi.org/10.2196/15780 %U http://www.ncbi.nlm.nih.gov/pubmed/32352390 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17883 %T Habit Strength, Medication Adherence, and Habit-Based Mobile Health Interventions Across Chronic Medical Conditions: Systematic Review %A Badawy,Sherif M %A Shah,Richa %A Beg,Usman %A Heneghan,Mallorie B %+ Department of Pediatrics, Northwestern University Feinberg School of Medicine, 225 E Chicago Avenue, Box #30, Chicago, IL, 60654, United States, 1 3122274836, sbadawy@luriechildrens.org %K habit strength %K medication adherence %K habit index %K medication compliance %K mobile health %K health %K digital health %K interventions %K mobile phone %D 2020 %7 28.4.2020 %9 Review %J J Med Internet Res %G English %X Background: Unintentional medication nonadherence is common and has been associated with poor health outcomes and increased health care costs. Earlier research demonstrated a relationship between habit strength and medication adherence. Previous research also examined a habit’s direct effect on adherence and how habit interacts with more conscious factors to influence or overrule them. However, the relationship between habit and adherence and the role of habit-based mobile health (mHealth) interventions remain unclear. Objective: This review aimed to systematically evaluate the most recent evidence for habit strength, medication adherence, and habit-based mHealth interventions across chronic medical conditions. Methods: A keyword search with combinations of the terms habit, habit strength, habit index, medication adherence, and medication compliance was conducted on the PubMed database. After duplicates were removed, two authors conducted independent abstract and full-text screening. The guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed when reporting evidence across the included and reviewed studies. Results: Of the 687 records examined, 11 met the predefined inclusion criteria and were finalized for data extraction, grading, and synthesis. Most included studies (6/11, 55%) were cross-sectional and used a theoretical model (8/11, 73%). The majority of studies measured habit strength using the self-report habit index and self-report behavioral automaticity index (9/11, 82%). Habit strength was positively correlated with medication adherence in most studies (10/11, 91%). Habit mediated the effects of self-efficacy on medication adherence (1/11, 9%), and social norms moderated the effects of habit strength on medication adherence (1/11, 9%). Habit strength also moderated the effects of poor mental health symptoms and medication adherence (1/11, 9%). None of the included studies reported on using or proposing a habit-based mHealth behavioral intervention to promote medication adherence. Conclusions: Habit strength was strongly correlated with medication adherence, and stronger habit was associated with higher medication adherence rates, regardless of the theoretical model and/or guiding framework. Habit-based interventions should be used to increase medication adherence, and these interventions could leverage widely available mobile technology tools such as mobile apps or text messaging, and existing routines. %M 32343250 %R 10.2196/17883 %U http://www.jmir.org/2020/4/e17883/ %U https://doi.org/10.2196/17883 %U http://www.ncbi.nlm.nih.gov/pubmed/32343250 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e14595 %T Sustainability of mHealth Effects on Cardiometabolic Risk Factors: Five-Year Results of a Randomized Clinical Trial %A Bernabe-Ortiz,Antonio %A Pauschardt,Julia %A Diez-Canseco,Francisco %A Miranda,J Jaime %+ CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Avenida Armendáriz 445, Miraflores, Lima, 15074, Peru, 51 12416978, antonio.bernabe@upch.pe %K mHealth %K low- and middle-income countries %K blood pressure %K body weight %D 2020 %7 21.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The long-term effects of mobile health (mHealth) interventions have not been documented, especially in resource-constrained settings. Objective: This study aimed to assess the effects of a 1-year mHealth intervention on blood pressure levels and body weight in low-resource urban settings in Peru, 4 years after the completion of the original study. Methods: Four years after the original Grupo de Investigación en Salud Móvil en America Latina (GISMAL) study, we attempted to contact the 212 individuals originally enrolled in the study in Peru. The primary outcomes were systolic and diastolic blood pressure levels and hypertension incidence. Secondary outcome measures were body weight, BMI, and self-reported target behaviors. The study personnel collecting the data were masked to the group assignment. Linear mixed models were used to evaluate the effects of the intervention on primary and secondary outcomes in an intention-to-treat analysis. Results: Data from 164 (77.4%) of the 212 originally enrolled participants were available and analyzed (80 in the intervention group and 84 in the control group). The intervention did not result in changes in systolic (–2.54 mm Hg, 95% CI –8.23 to 3.15) or diastolic (3.41 mm Hg, 95% CI –0.75 to 7.57) blood pressure compared with the control group. The intervention reduced the risk of developing hypertension, but the result was not significant (risk ratio (RR) 0.76, 95% CI 0.45-1.28). However, those who received the intervention had lower body weight (–5.42 kg, 95% CI –10.4 to –0.48) and BMI (–2.56 kg/m2, 95% CI –4.46 to –0.66). In addition, compared to the control participants, those who received ≥50% of the scheduled calls during the intervention had greater reductions in body weight (–6.23 kg, 95% CI –11.47 to –0.99) and BMI (–2.81 kg/m2, 95% CI –4.77 to –0.85). Conclusions: An mHealth intervention comprising motivational interview calls and SMS text messaging appears to have effects on health 4 years after intervention completion. Although there were no effects on blood pressure levels, important reductions in body weight and BMI were seen 5 years after randomization. Thus, mHealth appears to be a promising preventive strategy for noncommunicable diseases in resource-constrained settings. Trial Registration: Clinicaltrials.gov NCT01295216; https://clinicaltrials.gov/ct2/show/NCT01295216 %M 32314970 %R 10.2196/14595 %U http://www.jmir.org/2020/4/e14595/ %U https://doi.org/10.2196/14595 %U http://www.ncbi.nlm.nih.gov/pubmed/32314970 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e15561 %T Developing Mental or Behavioral Health Mobile Apps for Pilot Studies by Leveraging Survey Platforms: A Do-it-Yourself Process %A Chow,Philip I %+ Center for Behavioral Health and Technology, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, 560 Ray C. Hunt Dr., Charlottesville, VA, 22908, United States, 1 434 924 5401, philip.i.chow@gmail.com %K app %K mental health %K mHealth %D 2020 %7 20.4.2020 %9 Tutorial %J JMIR Mhealth Uhealth %G English %X Background: Behavioral health researchers are increasingly recognizing the potential of mobile phone apps to deliver empirically supported treatments. However, current options for developing apps typically require large amounts of expertise or money. Objective: This paper aims to describe a pragmatic do-it-yourself approach for researchers to create and pilot an Android mobile phone app using existing survey software (eg, Qualtrics survey platform). Methods: This study was conducted at an academic research center in the United States focused on developing and evaluating behavioral health technologies. The process outlined in this paper was derived and condensed from the steps to building an existing app intervention, iCanThrive, which was developed to enhance mental well-being in women cancer survivors. Results: This paper describes an inexpensive, practical process that uses a widely available survey software, such as Qualtrics, to create and pilot a mobile phone intervention that is presented to participants as a Web viewer app that is downloaded from the Google Play store. Health researchers who are interested in using this process to pilot apps are encouraged to inquire about the survey platforms available to them, the level of security those survey platforms provide, and the regulatory guidelines set forth by their institution. Conclusions: As app interventions continue to gain interest among researchers and consumers alike, it is important to find new ways to efficiently develop and pilot app interventions before committing a large amount of resources. Mobile phone app interventions are an important component to discovering new ways to reach and support individuals with behavioral or mental health disorders. %M 32310143 %R 10.2196/15561 %U https://mhealth.jmir.org/2020/4/e15561 %U https://doi.org/10.2196/15561 %U http://www.ncbi.nlm.nih.gov/pubmed/32310143 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e16939 %T Clinical Integration of a Smartphone App for Patients With Chronic Pain: Retrospective Analysis of Predictors of Benefits and Patient Engagement Between Clinic Visits %A Ross,Edgar L %A Jamison,Robert N %A Nicholls,Lance %A Perry,Barbara M %A Nolen,Kim D %+ Brigham and Women's Hospital, Harvard Medical School, Pain Management Center, 850 Boyston Street, Suite 320, Chestnut Hill, MA, United States, 1 3392211441, rjamison@bwh.harvard.edu %K chronic pain %K patient engagement %K telemedicine %K mHealth %K pain measurement %D 2020 %7 16.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although many pain-related smartphone apps exist, little attention has been given to understanding how these apps are used over time and what factors contribute to greater compliance and patient engagement. Objective: This retrospective analysis was designed to help identify factors that predicted the benefits and future use of a smartphone pain app among patients with chronic pain. Methods: An app designed for both Android and iOS devices was developed by Brigham and Women’s Hospital Pain Management Center (BWH-PMC) for users with chronic pain to assess and monitor pain and communicate with their providers. The pain app offered chronic pain assessment, push notification reminders and communication, personalized goal setting, relaxation sound files, topics of interest with psychological and medical pain management strategies, and line graphs from daily assessments. BWH-PMC recruited 253 patients with chronic pain over time to use the pain app. All subjects completed baseline measures and were asked to record their progress every day using push notification daily assessments. After 3 months, participants completed follow-up questionnaires and answered satisfaction questions. We defined the number of completed daily assessments as a measure of patient engagement with the pain app. Results: The average age of participants was 51.5 years (SD 13.7, range 18-92), 72.8% (182/253) were female, and 36.8% (78/212) reported the low back as their primary pain site. The number of daily assessments ranged from 1 to 426 (average 62.0, SD 49.9). The app was easy to introduce among patients, and it was well accepted. Those who completed more daily assessments (greater patient engagement) throughout the study were more likely to report higher pain intensity, more activity interference, and greater disability and were generally overweight compared with others. Patients with higher engagement with the app rated the app as offering greater benefit in coping with their pain and expressed more willingness to use the app in the future (P<.05) compared with patients showing lower engagement. Patients completing a small number of daily assessments reported less pain intensity, less daily activity interference, and less pain-related disability on average and were less likely to use the two-way messaging than those who were more engaged with the pain app (P<.05). Conclusions: Patients with chronic pain who appeared to manage their pain better were less likely to report benefits of a smartphone pain app designed for chronic pain management. They demonstrated lower patient engagement in reporting their daily progress, in part, owing to the perceived burden of regularly using an app without a perceived benefit. An intrinsically different pain app designed and targeted for individuals based on early identification of user characteristics and adapted for each individual would likely improve compliance and app-related patient engagement. %M 32297871 %R 10.2196/16939 %U http://www.jmir.org/2020/4/e16939/ %U https://doi.org/10.2196/16939 %U http://www.ncbi.nlm.nih.gov/pubmed/32297871 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 1 %P e14632 %T An App for Identifying Children at Risk for Developmental Problems Using Multidimensional Computerized Adaptive Testing: Development and Usability Study %A Hsu,Chen-Fang %A Chien,Tsair-Wei %A Chow,Julie Chi %A Yeh,Yu-Tsen %A Chou,Willy %+ Department of Physical Medicine and Rehabilitation, Chi Mei Medical Center, Chi Mei Medical Groups, No. 901, Chung Hwa Road, Yung Kung District, Tainan, 710, Taiwan, 886 62812811, ufan0101@ms22.hinet.net %K computer adaptive testing %K developmental delay %K multidimensional %K mobile phone %K screening %D 2020 %7 16.4.2020 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: The use of multidomain developmental screening tools is a viable strategy for pediatric professionals to identify children at risk for developmental problems. However, a specialized multidimensional computer adaptive testing (MCAT) tool has not been developed to date. Objective: We developed an app using MCAT, combined with Multidimensional Screening in Child Development (MuSiC) for toddlers, to help patients and their family members or clinicians identify developmental problems at an earlier stage. Methods: We retrieved 75 item parameters from the MuSiC literature item bank for 1- to 3-year-old children, and simulated 1000 person measures from a normal standard distribution to compare the efficiency and precision of MCAT and nonadaptive testing (NAT) in five domains (ie, cognitive skills, language skills, gross motor skills, fine motor skills, and socioadaptive skills). The number of items saved and the cutoff points for the tool were determined and compared. We then developed an app for a Web-based assessment. Results: MCAT yielded significantly more precise measurements and was significantly more efficient than NAT, with 46.67% (=(75-40)/75) saving in item length when measurement differences less than 5% were allowed. Person-measure correlation coefficients were highly consistent among the five domains. Significantly fewer items were answered on MCAT than on NAT without compromising the precision of MCAT. Conclusions: Developing an app as a tool for parents that can be implemented with their own computers, tablets, or mobile phones for the online screening and prediction of developmental delays in toddlers is useful and not difficult. %M 32297867 %R 10.2196/14632 %U http://pediatrics.jmir.org/2020/1/e14632/ %U https://doi.org/10.2196/14632 %U http://www.ncbi.nlm.nih.gov/pubmed/32297867 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17011 %T Mobile Health for Perinatal Depression and Anxiety: Scoping Review %A Hussain-Shamsy,Neesha %A Shah,Amika %A Vigod,Simone N %A Zaheer,Juveria %A Seto,Emily %+ Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street 4th Floor, Toronto, ON, M5T 3M6, Canada, 1 416 978 4326, neesha.hussainshamsy@mail.utoronto.ca %K mental health %K depression %K anxiety %K pregnancy %K postpartum %K smartphone %K mobile phone %K text message %K mHealth %D 2020 %7 13.4.2020 %9 Review %J J Med Internet Res %G English %X Background: The perinatal period is a vulnerable time during which depression and anxiety commonly occur. If left untreated or undertreated, there may be significant adverse effects; therefore, access to rapid, effective treatment is essential. Treatments for mild-to-moderate symptoms according to a stepped-care approach involve psychoeducation, peer support, and psychological therapy, all of which have been shown to be efficaciously delivered through digital means. Women experience significant barriers to care because of system- and individual-level factors, such as cost, accessibility, and availability of childcare. The use of mobile phones is widespread in this population, and the delivery of mental health services via mobile phones has been suggested as a means of reducing barriers. Objective: This study aimed to understand the extent, range, and nature of mobile health (mHealth) tools for prevention, screening, and treatment of perinatal depression and anxiety in order to identify gaps and inform opportunities for future work. Methods: Using a scoping review framework, 4 databases were searched for terms related to mobile phones, perinatal period, and either depression or anxiety. A total of 477 unique records were retrieved, 81 of which were reviewed by full text. Peer-reviewed publications were included if they described the population as women pregnant or up to 1 year postpartum and a tool explicitly delivered via a mobile phone for preventing, screening, or treating depression or anxiety. Studies published in 2007 or earlier, not in English, or as case reports were excluded. Results: A total of 26 publications describing 22 unique studies were included (77% published after 2017). mHealth apps were slightly more common than texting-based interventions (12/22, 54% vs 10/22, 45%). Most tools were for either depression (12/22, 54%) or anxiety and depression (9/22, 41%); 1 tool was for anxiety only (1/22, 4%). Interventions starting in pregnancy and continuing into the postpartum period were rare (2/22, 9%). Tools were for prevention (10/22, 45%), screening (6/22, 27%), and treatment (6/22, 27%). Interventions delivered included psychoeducation (16/22, 73%), peer support (4/22, 18%), and psychological therapy (4/22, 18%). Cost was measured in 14% (3/22) studies. Conclusions: Future work in this growing area should incorporate active psychological treatment, address continuity of care across the perinatal period, and consider clinical sustainability to realize the potential of mHealth. %M 32281939 %R 10.2196/17011 %U http://www.jmir.org/2020/4/e17011/ %U https://doi.org/10.2196/17011 %U http://www.ncbi.nlm.nih.gov/pubmed/32281939 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e14802 %T Lifestyle Intervention Enabled by Mobile Technology on Weight Loss in Patients With Nonalcoholic Fatty Liver Disease: Randomized Controlled Trial %A Lim,Su Lin %A Johal,Jolyn %A Ong,Kai Wen %A Han,Chad Yixian %A Chan,Yiong Huak %A Lee,Yin Mei %A Loo,Wai Mun %+ Dietetics Department, National University Hospital, National University Health System, 5 Lower Kent Ridge Road, Main Building, Level 1, Singapore, 119074, Singapore, 65 67724580, su_lin_lim@nuhs.edu.sg %K diet %K NAFLD %K mHealth %K mobile app, weight loss %K liver enzymes %K lifestyle intervention %D 2020 %7 13.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The prevalence of nonalcoholic fatty liver disease (NAFLD) reaches up to 30% in the Asian adult population, with a higher prevalence in obese patients. Weight reduction is typically recommended for patients at high risk or diagnosed with NAFLD, but is a challenge to achieve. Objective: We aimed to evaluate the effect of a lifestyle intervention with a mobile app on weight loss in NAFLD patients. Methods: This prospective randomized controlled trial included 108 adults with NAFLD confirmed by steatosis on ultrasound and a body mass index ≥23 kg/m2 who were recruited from a fatty liver outpatient clinic. The patients were randomly allocated to either a control group (n=53) receiving standard care, consisting of dietary and lifestyle advice by a trained nurse, or an intervention group (n=55) utilizing the Nutritionist Buddy (nBuddy) mobile app in addition to receiving dietary and lifestyle advice by a dietitian. Body weight, alanine aminotransferase (ALT), aspartate aminotransferase (AST), waist circumference, and blood pressure were measured at baseline, and then at 3 and 6 months. Intention-to-treat and per-protocol analyses were used for statistical comparisons. Results: The intervention group had a 5-fold higher likelihood (relative risk 5.2, P=.003, 95% CI 1.8-15.4) of achieving ≥5% weight loss compared to the control group at 6 months. The intervention group also showed greater reductions in weight (mean 3.2, SD 4.1 kg vs mean 0.5, SD 2.9 kg; P<.001), waist circumference (mean 2.9, SD 5.0 cm vs mean –0.7, SD 4.4 cm; P<.001), systolic blood pressure (mean 12.4, SD 14.8 mmHg vs mean 2.4, SD 12.4 mmHg; P=.003), diastolic blood pressure (mean 6.8, SD 8.9 mmHg vs mean –0.9, SD 10.0 mmHg; P=.001), ALT (mean 33.5, SD 40.4 IU/L vs mean 11.5, SD 35.2 IU/L; P=.004), and AST (mean 17.4, SD 27.5 U/L vs mean 7.4, SD 17.6 IU/L, P=.03) at 6 months. Conclusions: Lifestyle intervention enabled by a mobile app can be effective in improving anthropometric indices and liver enzymes in patients with NAFLD. This treatment modality has the potential to be extended to a larger population scale. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12617001001381; https://tinyurl.com/w9xnfmp %M 32281943 %R 10.2196/14802 %U http://mhealth.jmir.org/2020/4/e14802/ %U https://doi.org/10.2196/14802 %U http://www.ncbi.nlm.nih.gov/pubmed/32281943 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 4 %P e16151 %T Development and Modification of a Mobile Health Program to Promote Postpartum Weight Loss in Women at Elevated Risk for Cardiometabolic Disease: Single-Arm Pilot Study %A Nicklas,Jacinda M %A Leiferman,Jenn A %A Lockhart,Steven %A Daly,Kristen M %A Bull,Sheana S %A Barbour,Linda A %+ Division of General Internal Medicine, University of Colorado School of Medicine, 12348 E Montview Blvd, Aurora, CO, 80045, United States, 1 3037249028, Jacinda.Nicklas@cuanschutz.edu %K mobile health %K postpartum %K chronic disease %K prevention %K weight loss %D 2020 %7 9.4.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Pregnancy complications in combination with postpartum weight retention lead to significant risks of cardiometabolic disease and obesity. The majority of traditional face-to-face interventions have not been effective in postpartum women. Mobile technology enables the active engagement of postpartum women to promote lifestyle changes to prevent chronic diseases. Objective: We sought to employ an interactive, user-centered, and participatory method of development, evaluation, and iteration to design and optimize the mobile health (mHealth) Fit After Baby program. Methods: For the initial development, a multidisciplinary team integrated evidence-based approaches for health behavior, diet and physical activity, and user-centered design and engagement. We implemented an iterative feedback and design process via 3 month-long beta pilots in which postpartum women with cardiometabolic risk factors participated in the program and provided weekly and ongoing feedback. We also conducted two group interviews using a structured interview guide to gather additional feedback. Qualitative data were recorded, transcribed, and analyzed using established qualitative methods. Modifications based on feedback were integrated into successive versions of the app. Results: We conducted three pilot testing rounds with a total of 26 women. Feedback from each pilot cohort informed changes to the functionality and content of the app, and then a subsequent pilot group participated in the program. We optimized the program in response to feedback through three iterations leading to a final version. Conclusions: This study demonstrates the feasibility of using an interactive, user-centered, participatory method of rapid, iterative design and evaluation to develop and optimize a mHealth intervention program for postpartum women. Trial Registration: ClinicalTrials.gov NCT02384226; https://www.clinicaltrials.gov/ct2/show/NCT02384226 %M 32271149 %R 10.2196/16151 %U https://formative.jmir.org/2020/4/e16151 %U https://doi.org/10.2196/16151 %U http://www.ncbi.nlm.nih.gov/pubmed/32271149 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e17122 %T Patterns of Mobile Phone Ownership and Use Among Pregnant Women in Southern Tanzania: Cross-Sectional Survey %A Vasudevan,Lavanya %A Ostermann,Jan %A Moses,Sara Marwerwe %A Ngadaya,Esther %A Mfinanga,Sayoki Godfrey %+ Department of Family Medicine and Community Health, School of Medicine, Duke University, DUMC 104006, Durham, NC, 27710, United States, 1 9196131423, lavanya.vasudevan@duke.edu %K digital health %K mobile health %K pregnant women %K Tanzania %D 2020 %7 8.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is a paucity of subnational data on patterns of mobile phone ownership and use in Tanzania to inform the development of digital health interventions. Objective: The aim of this study is to assess patterns of mobile phone ownership and use in pregnant women to inform the feasibility and design of digital health interventions for promoting timely uptake of childhood vaccines in southern Tanzania. Methods: Between August and November 2017, pregnant women in their third trimester were enrolled at health facilities and from surrounding communities, and asked about their patterns of mobile phone ownership and use in an interviewer administered survey. Results: Of 406 women, only 3 had never used a phone. Most women (>98%) could make and receive phone calls. Compared to urban women, rural women reported higher mobile phone use rates but were less likely to be sole owners of phones, and less likely to send or receive SMS, transact money, browse the internet, or use social media via mobile phones. Conclusions: The findings suggest high feasibility for digital health interventions delivered via mobile phones to pregnant women in southern Tanzania. The feasibility of smartphone-based interventions or strategies relying on the use of social media or the internet is limited. %M 32267240 %R 10.2196/17122 %U https://mhealth.jmir.org/2020/4/e17122 %U https://doi.org/10.2196/17122 %U http://www.ncbi.nlm.nih.gov/pubmed/32267240 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e15806 %T A Smartphone-Based Health Care Chatbot to Promote Self-Management of Chronic Pain (SELMA): Pilot Randomized Controlled Trial %A Hauser-Ulrich,Sandra %A Künzli,Hansjörg %A Meier-Peterhans,Danielle %A Kowatsch,Tobias %+ Department of Applied Psychology, University of Applied Sciences Zurich, Pfingstweidstrasse 96, Zurich, 8005, Switzerland, 41 58 934 84 ext 51, sandra.hauser-ulrich@zhaw.ch %K conversational agent %K chatbot %K digital health %K pain self-management %K cognitive behavior therapy %K smartphone %K psychoeducation %K text-based %K health care %K chronic pain %D 2020 %7 3.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Ongoing pain is one of the most common diseases and has major physical, psychological, social, and economic impacts. A mobile health intervention utilizing a fully automated text-based health care chatbot (TBHC) may offer an innovative way not only to deliver coping strategies and psychoeducation for pain management but also to build a working alliance between a participant and the TBHC. Objective: The objectives of this study are twofold: (1) to describe the design and implementation to promote the chatbot painSELfMAnagement (SELMA), a 2-month smartphone-based cognitive behavior therapy (CBT) TBHC intervention for pain self-management in patients with ongoing or cyclic pain, and (2) to present findings from a pilot randomized controlled trial, in which effectiveness, influence of intention to change behavior, pain duration, working alliance, acceptance, and adherence were evaluated. Methods: Participants were recruited online and in collaboration with pain experts, and were randomized to interact with SELMA for 8 weeks either every day or every other day concerning CBT-based pain management (n=59), or weekly concerning content not related to pain management (n=43). Pain-related impairment (primary outcome), general well-being, pain intensity, and the bond scale of working alliance were measured at baseline and postintervention. Intention to change behavior and pain duration were measured at baseline only, and acceptance postintervention was assessed via self-reporting instruments. Adherence was assessed via usage data. Results: From May 2018 to August 2018, 311 adults downloaded the SELMA app, 102 of whom consented to participate and met the inclusion criteria. The average age of the women (88/102, 86.4%) and men (14/102, 13.6%) participating was 43.7 (SD 12.7) years. Baseline group comparison did not differ with respect to any demographic or clinical variable. The intervention group reported no significant change in pain-related impairment (P=.68) compared to the control group postintervention. The intention to change behavior was positively related to pain-related impairment (P=.01) and pain intensity (P=.01). Working alliance with the TBHC SELMA was comparable to that obtained in guided internet therapies with human coaches. Participants enjoyed using the app, perceiving it as useful and easy to use. Participants of the intervention group replied with an average answer ratio of 0.71 (SD 0.20) to 200 (SD 58.45) conversations initiated by SELMA. Participants’ comments revealed an appreciation of the empathic and responsible interaction with the TBHC SELMA. A main criticism was that there was no option to enter free text for the patients’ own comments. Conclusions: SELMA is feasible, as revealed mainly by positive feedback and valuable suggestions for future revisions. For example, the participants’ intention to change behavior or a more homogenous sample (eg, with a specific type of chronic pain) should be considered in further tailoring of SELMA. Trial Registration: German Clinical Trials Register DRKS00017147; https://tinyurl.com/vx6n6sx, Swiss National Clinical Trial Portal: SNCTP000002712; https://www.kofam.ch/de/studienportal/suche/70582/studie/46326. %M 32242820 %R 10.2196/15806 %U http://mhealth.jmir.org/2020/4/e15806/ %U https://doi.org/10.2196/15806 %U http://www.ncbi.nlm.nih.gov/pubmed/32242820 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e15863 %T Effectiveness of One-Way Text Messaging on Attendance to Follow-Up Cervical Cancer Screening Among Human Papillomavirus–Positive Tanzanian Women (Connected2Care): Parallel-Group Randomized Controlled Trial %A Linde,Ditte S %A Andersen,Marianne S %A Mwaiselage,Julius %A Manongi,Rachel %A Kjaer,Susanne K %A Rasch,Vibeke %+ Department of Clinical Research, University of Southern Denmark, Kløvervænget 10, 10th Fl, Odense, 5000, Denmark, 45 61666564, dsondergaard@health.sdu.dk %K telemedicine %K cervical cancer %K HPV %K early detection of cancer %K Africa %D 2020 %7 2.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Rapid human papillomavirus (HPV) DNA testing is an emerging cervical cancer screening strategy in resource-limited countries, yet it requires follow-up of women who test HPV positive. Objective: This study aimed to determine if one-way text messages improved attendance to a 14-month follow-up cervical cancer screening among HPV-positive women. Methods: This multicenter, parallel-group randomized controlled trial was conducted at 3 hospitals in Tanzania. Eligible participants were aged between 25 and 60 years, had tested positive to a rapid HPV test during a patient-initiated screening, had been informed of their HPV result, and had a private mobile phone with a valid number. Participants were randomly assigned in a 1:1 ratio to the intervention or control group through an incorporated algorithm in the text message system. The intervention group received one-way text messages, and the control group received no text messages. The primary outcome was attendance at a 14-month health provider-initiated follow-up screening. Participants were not blinded, but outcome assessors were. The analysis was based on intention to treat. Results: Between August 2015 and July 2017, 4080 women were screened for cervical cancer, of which 705 were included in this trial—358 women were allocated to the intervention group, and 347 women were allocated to the control group. Moreover, 16 women were excluded before the analysis because they developed cervical cancer or died (8 from each group). In the intervention group, 24.0% (84/350) women attended their follow-up screening, and in the control group, 23.8% (80/335) women attended their follow-up screening (risk ratio 1.02, 95% CI 0.79-1.33). Conclusions: Attendance to a health provider-initiated follow-up cervical cancer screening among HPV-positive women was strikingly low, and one-way text messages did not improve the attendance rate. Implementation of rapid HPV testing as a primary screening method at the clinic level entails the challenge of ensuring a proper follow-up of women. Trial Registration: ClinicalTrials.gov NCT02509702; https://clinicaltrials.gov/ct2/show/NCT02509702. International Registered Report Identifier (IRRID): RR2-10.2196/10.2196/15863 %M 32238335 %R 10.2196/15863 %U http://www.jmir.org/2020/4/e15863/ %U https://doi.org/10.2196/15863 %U http://www.ncbi.nlm.nih.gov/pubmed/32238335 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e14897 %T Smartphone Apps for the Treatment of Mental Disorders: Systematic Review %A Miralles,Ignacio %A Granell,Carlos %A Díaz-Sanahuja,Laura %A Van Woensel,William %A Bretón-López,Juana %A Mira,Adriana %A Castilla,Diana %A Casteleyn,Sven %+ Universitat Jaume I, Av Vicent Sos Baynat, s/n, Castellón de la Plana, 12071, Spain, 34 964728000, mirallei@uji.es %K mental health %K mental disorders %K treatment %K intervention %K mHealth %K smartphone %K mobile phone %K mobile apps %K systematic review %D 2020 %7 2.4.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Smartphone apps are an increasingly popular means for delivering psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyze and summarize the state of the art, both from a psychological and technical perspective. Objective: This study aimed to systematically review the literature on the use of smartphones for psychological interventions. Our systematic review has the following objectives: (1) analyze the coverage of mental disorders in research articles per year; (2) study the types of assessment in research articles per mental disorder per year; (3) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media, per mental disorder; (4) provide an overview of smartphone apps per mental disorder; and (5) provide an overview of the key characteristics of empirical assessments with rigorous designs (ie, randomized controlled trials [RCTs]). Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, American Psychological Association PsycNET, and Medical Literature Analysis and Retrieval System Online, covering a period of 6 years (2013-2018). We included papers that described the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and computer science, to select and classify articles based on psychological and technical features. Results: We found 158 articles that met the inclusion criteria. We observed an increasing interest in smartphone-based interventions over time. Most research targeted disorders with high prevalence, that is, depressive (31/158,19.6%) and anxiety disorders (18/158, 11.4%). Of the total, 72.7% (115/158) of the papers focused on six mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum, and other psychotic disorders, or a combination of disorders. More than half of known mental disorders were not or very scarcely (<3%) represented. An increasing number of studies were dedicated to assessing clinical effects, but RCTs were still a minority (25/158, 15.8%). From a technical viewpoint, interventions were leveraging the improved modalities (screen and sound) and interactivity of smartphones but only sparingly leveraged their truly novel capabilities, such as sensors, alternative delivery paradigms, and analytical methods. Conclusions: There is a need for designing interventions for the full breadth of mental disorders, rather than primarily focusing on most prevalent disorders. We further contend that an increasingly systematic focus, that is, involving RCTs, is needed to improve the robustness and trustworthiness of assessments. Regarding technical aspects, we argue that further exploration and innovative use of the novel capabilities of smartphones are needed to fully realize their potential for the treatment of mental health disorders. %M 32238332 %R 10.2196/14897 %U https://mhealth.jmir.org/2020/4/e14897 %U https://doi.org/10.2196/14897 %U http://www.ncbi.nlm.nih.gov/pubmed/32238332 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 3 %P e16917 %T Patient Attitudes Toward Mobile Device Use by Health Care Providers in the Emergency Department: Cross-Sectional Survey %A Alameddine,Mohamad %A Tamim,Hani %A Hadid,Dima %A Cheaito,Mohamad-Ali %A Makki,Maha %A Maatouk,Hadi %A Hitti,Eveline %+ Department of Emergency Medicine, American University of Beirut, Riad El Solh 1107 2020, Beirut, , Lebanon, 961 1350000, hittieveline@gmail.com %K smart devices %K emergency department %K patients %K attitudes %K digital professionalism %K code of conduct %K empathy %K professionalism %K distraction %K attention %D 2020 %7 31.3.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Health care provider usage of mobile devices is increasing globally; however, there is little understanding of patient perceptions on this behavior in a health care setting. Objective: The aim of this study was to assess patients’ attitudes toward mobile device usage by health care providers in the emergency department and to identify predictors of these attitudes. Methods: The study was carried out at the emergency department of a large academic tertiary care medical center in Lebanon. A cross-sectional survey design was adopted by administering a questionnaire to medically stable adult patients who presented to the emergency department with an emergency severity index of 3, 4, or 5 between January 2017 and March 2018. The questionnaire collected relevant patient demographic information and included questions related to their mobile device usage along with those evaluating attitudes for the use of mobile devices by health care providers with respect to six major domains: role in health care, distraction potential, impact on communication, empathy, privacy, and professionalism. The attitude toward mobile device usage by health care providers in the emergency department was the main outcome variable. A stepwise logistic regression model was used to assess the association between the outcome variable and the demographic and attitude-related independent variables. Results: Among the 438 eligible patients, 338 patients responded to the questionnaire for a response rate of 70.0%. Overall, 313/338 (92.6%) respondents agreed that mobile devices improve health care delivery, whereas 132/338 (39.1%) respondents were opposed to their usage by health care providers in the emergency department (95% CI: 34.0-44.4). The majority (240/338, 71.0%) of patients agreed that mobile devices are a source of distraction to health care providers in the workplace. Females (odds ratio [OR]=1.67, 95% CI: 1.00-2.78) as well as all patients (OR=2.54, 95% CI 1.36-4.76) who believed that mobile devices were a source of distraction, reflecting a lack of professionalism (OR=2.77, 95% CI 1.59-4.82) and impacting the provider’s ability to relate to the patient (OR=2.93, 95% CI 1.72-4.99), were more likely to agree that mobile devices should not be used in the emergency department. Conclusions: Patients’ negative attitude toward mobile device use in the emergency department is largely driven by patient gender (females), patient perception of the distraction potential of the devices, and their negative impact on the health care provider’s empathy and professionalism. The findings of this study shed light on the importance of encouraging stakeholders to impose a digital professionalism code of conduct for providers working in acute health care settings. %M 32229474 %R 10.2196/16917 %U http://mhealth.jmir.org/2020/3/e16917/ %U https://doi.org/10.2196/16917 %U http://www.ncbi.nlm.nih.gov/pubmed/32229474 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15642 %T Social Comparison Features in Physical Activity Promotion Apps: Scoping Meta-Review %A Arigo,Danielle %A Brown,Megan M %A Pasko,Kristen %A Suls,Jerry %+ Department of Psychology, Rowan University, 201 Mullica Hill Road, Robinson 116G, Glassboro, NJ, 08028, United States, 1 8562564500 ext 53775, Arigo@Rowan.edu %K smartphone app %K physical activity %K mHealth %K social comparison %K behavior change technique %D 2020 %7 27.3.2020 %9 Review %J J Med Internet Res %G English %X Background: Smartphone apps promoting physical activity (PA) are abundant, but few produce substantial and sustained behavior change. Although many PA apps purport to induce users to compare themselves with others (by invoking social comparison processes), improvements in PA and other health behaviors are inconsistent. Existing literature suggests that social comparison may motivate PA for some people under some circumstances. However, 2 aspects of work that apply social comparison theory to PA apps remain unclear: (1) how comparison processes have been operationalized or harnessed in existing PA apps and (2) whether incorporating sources of variability in response to comparison have been used to tailor comparison features of apps, which could improve their effectiveness for promoting PA. Objective: The aim of this meta-review was to summarize existing systematic, quantitative, and narrative reviews of behavior change techniques in PA apps, with an emphasis on social comparison features, to examine how social comparison is operationalized and implemented. Methods: We searched PubMed, Web of Science, and PsycINFO for reviews of PA smartphone apps. Of the 3743 initial articles returned, 26 reviews met the inclusion criteria. Two independent raters extracted the data from these reviews, including the definition of social comparison used to categorize app features, the percentage of apps categorized as inducing comparison, specific features intended to induce comparison, and any mention of tailoring comparison features. For reference, these data were also extracted for related processes (such as behavioral modeling, norm referencing, and social networking). Results: Of the included review articles, 31% (8/26) categorized app features as prompting social comparison. The majority of these employed Abraham and Michie’s earliest definition of comparison, which differs from versions in later iterations of the same taxonomy. Very few reviews specified what dimension users were expected to compare (eg, steps, physical fitness) or which features of the apps were used to induce comparison (eg, leaderboards, message boards). No review referenced tailoring of comparison features. In contrast, 54% (14/26) reviews categorized features for prompting behavioral modeling and 31% (8/26) referenced tailoring app features for users’ personal goals or preferences. Conclusions: The heterogeneity across reviews of PA apps and the absence of relevant information (eg, about dimensions or features relevant for comparison) create confusion about how to best harness social comparison to increase PA and its effectiveness in future research. No evidence was found that important findings from the broader social comparison literature (eg, that people have differing preferences for and responses to social comparison information) have been incorporated in the design of existing PA apps. Greater integration of the mobile health (mHealth) and social comparison literatures may improve the effectiveness of PA apps, thereby increasing the public health impact of these mHealth tools. International Registered Report Identifier (IRRID): RR2-https://osf.io/nh4td/ %M 32217499 %R 10.2196/15642 %U http://www.jmir.org/2020/3/e15642/ %U https://doi.org/10.2196/15642 %U http://www.ncbi.nlm.nih.gov/pubmed/32217499 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e17282 %T Text Messaging as a Screening Tool for Depression and Related Conditions in Underserved, Predominantly Minority Safety Net Primary Care Patients: Validity Study %A Jin,Haomiao %A Wu,Shinyi %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 S Olive Street, Suite 1400, Los Angeles, CA, 90015, United States, 1 2138216441, haomiaoj@usc.edu %K depression %K diabetes mellitus %K comorbidity %K screening %K primary care %K health information technology %K mobile health %K text messaging %K patient reported outcome measures %D 2020 %7 26.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: SMS text messaging is an inexpensive, private, and scalable technology-mediated assessment mode that can alleviate many barriers faced by the safety net population to receive depression screening. Some existing studies suggest that technology-mediated assessment encourages self-disclosure of sensitive health information such as depressive symptoms while other studies show the opposite effect. Objective: This study aimed to evaluate the validity of using SMS text messaging to screen depression and related conditions, including anxiety and functional disability, in a low-income, culturally diverse safety net primary care population. Methods: This study used a randomized design with 4 study groups that permuted the order of SMS text messaging and the gold standard interview (INTW) assessment. The participants for this study were recruited from the participants of the prior Diabetes-Depression Care-management Adoption Trial (DCAT). Depression was screened by using the 2-item and 8-item Patient Health Questionnaire (PHQ-2 and PHQ-8, respectively). Anxiety was screened by using the 2-item Generalized Anxiety Disorder scale (GAD-2), and functional disability was assessed by using the Sheehan Disability Scale (SDS). Participants chose to take up the assessment in English or Spanish. Internal consistency and test-retest reliability were evaluated by using Cronbach alpha and intraclass correlation coefficient (ICC), respectively. Concordance was evaluated by using an ICC, a kappa statistic, an area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. A regression analysis was conducted to examine the association between the participant characteristics and the differences in the scores between the SMS text messaging and INTW assessment modes. Results: Overall, 206 participants (average age 57.1 [SD 9.18] years; females: 119/206, 57.8%) were enrolled. All measurements except the SMS text messaging–assessed PHQ-2 showed Cronbach alpha values ≥.70, indicating acceptable to good internal consistency. All measurements except the INTW-assessed SDS had ICC values ≥0.75, indicating good to excellent test-retest reliability. For concordance, the PHQ-8 had an ICC of 0.73 and AUROC of 0.93, indicating good concordance. The kappa statistic, sensitivity, and specificity for major depression (PHQ-8 ≥8) were 0.43, 0.60, and 0.86, respectively. The concordance of the shorter PHQ-2, GAD-2, and SDS scales was poor to fair. The regression analysis revealed that a higher level of personal depression stigma was associated with reporting higher SMS text messaging–assessed PHQ-8 and GAD-2 scores than the INTW-assessed scores. The analysis also determined that the differences in the scores were associated with marital status and personality traits. Conclusions: Depression screening conducted using the longer PHQ-8 scale via SMS text messaging demonstrated good internal consistency, test-retest reliability, and concordance with the gold standard INTW assessment mode. However, care must be taken when deploying shorter scales via SMS text messaging. Further regression analysis supported that a technology-mediated assessment, such as SMS text messaging, may create a private space with less pressure from the personal depression stigma and therefore encourage self-disclosure of depressive symptoms. Trial Registration: ClinicalTrials.gov NCT01781013; https://clinicaltrials.gov/ct2/show/NCT01781013 International Registered Report Identifier (IRRID): RR2-10.2196/12392 %M 32213473 %R 10.2196/17282 %U http://www.jmir.org/2020/3/e17282/ %U https://doi.org/10.2196/17282 %U http://www.ncbi.nlm.nih.gov/pubmed/32213473 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 3 %P e17208 %T A Mobile Health Intervention for Mental Health Promotion Among University Students: Randomized Controlled Trial %A Bendtsen,Marcus %A Müssener,Ulrika %A Linderoth,Catharina %A Thomas,Kristin %+ Linköping University, 581 83 Linköping, Linköping, Sweden, 46 13282546, kristin.thomas@liu.se %K mHealth %K positive mental health %K university students %K randomized controlled trial %D 2020 %7 20.3.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: High positive mental health, including the ability to cope with the normal stresses of life, work productively, and be able to contribute to one’s community, has been associated with various health outcomes. The role of positive mental health is therefore increasingly recognized in national mental health promotion programs and policies. Mobile health (mHealth) interventions could be a cost-effective way to disseminate positive psychological interventions to the general population. Objective: The aim of this study was to estimate the effect of a fully automated mHealth intervention on positive mental health, and anxiety and depression symptomology among Swedish university students using a randomized controlled trial design. Methods: A 2-arm, single-blind (researchers), parallel-groups randomized controlled trial with an mHealth positive psychology program intervention group and a relevant online mental health information control group was employed to estimate the effect of the novel intervention. Participants were recruited using digital advertising through student health care centers in Sweden. Inclusion criteria were (1) university students, (2) able to read and understand Swedish, (3) and have access to a mobile phone. Exclusion criteria were high positive mental health, as assessed by the Mental Health Continuum Short Form (MHC-SF), or high depression and anxiety symptomology, as assessed by the Hospital Anxiety Depression Scale (HADS). The primary outcome was positive mental health (MHC-SF), and the secondary outcomes were depression and anxiety symptomatology (HADS). The subscales of MHC-SF were also analyzed as exploratory outcomes. Outcomes were measured 3 months after randomization through questionnaires completed on the participants’ mobile phones. Results: A total of 654 participants (median age 25 years), including 510 (78.0%) identifying as female, were randomized to either the intervention (n=348) or control group (n=306). At follow-up, positive mental health was significantly higher in the intervention group compared with the control group (incidence rate ratio [IRR]=1.067, 95% CI 1.024-1.112, P=.002). For both depression and anxiety symptomatology, the intervention group showed significantly lower scores at follow-up compared with the control group (depression: IRR=0.820, 95% CI 0.714-0.942, P=.005; anxiety: IRR=0.899, 95% CI 0.840-0.962, P=.002). Follow-up rates were lower than expected (58.3% for primary outcomes and 52.3% for secondary outcomes); however, attrition analyses did not identify any systematic attrition with respect to baseline variables. Conclusions: The mHealth intervention was estimated to be superior to usual care in increasing positive mental health among university students. A protective effect of the intervention was also found on depressive and anxiety symptoms. These findings demonstrate the feasibility of using an automated mobile phone format to enhance positive mental health, which offers promise for the use of mHealth solutions in public mental health promotion. Trial Registration: International Standard Randomized Controlled Trial Registry ISRCTN54748632; http://www.isrctn.com/ISRCTN54748632 %M 32196462 %R 10.2196/17208 %U http://mhealth.jmir.org/2020/3/e17208/ %U https://doi.org/10.2196/17208 %U http://www.ncbi.nlm.nih.gov/pubmed/32196462 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 3 %P e16251 %T Pilot Study of a Multilevel Mobile Health App for Substance Use, Sexual Risk Behaviors, and Testing for Sexually Transmitted Infections and HIV Among Youth: Randomized Controlled Trial %A Cordova,David %A Munoz-Velazquez,Jaime %A Mendoza Lua,Frania %A Fessler,Kathryn %A Warner,Sydni %A Delva,Jorge %A Adelman,Nicole %A , %A Fernandez,Angela %A Bauermeister,Jose %+ School of Social Work, University of Michigan, 1080 S University Ave, Room 2772, Ann Arbor, MI, 48109, United States, 1 734 763 6201, cordovad@umich.edu %K youth %K mHealth %K illicit drugs %K sex behavior %K HIV %K primary care %D 2020 %7 17.3.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Preventing and reducing substance use disorders, sexually transmitted infections (STIs)/HIV, and teen pregnancy, and the associated risk behaviors (ie, substance use and sexual risk behaviors) among youth remain public health priorities in the United States. Equally important is improving the uptake of STI/HIV testing among the youth. Mobile health (mHealth) apps may be a solution to ameliorate these public health concerns; however, few mHealth preventive interventions have demonstrated efficacy in reducing substance use or sexual risk behaviors or improving the uptake of STI/HIV testing among the youth, particularly in clinic settings. Objective: This small-scale study aimed to examine the feasibility of conducting a pilot randomized controlled trial (RCT). We evaluated the effects of Storytelling 4 Empowerment (S4E), relative to enhanced usual practice, on the potential mechanisms by which behavior change occurs, namely clinician-youth risk communication, prevention knowledge, and substance use and sexual risk refusal self-efficacy. We also assessed the ability to measure targeted outcomes of past 30-day substance use (ie, alcohol, tobacco, and other drug use), condomless sex, and alcohol or drug use before sex, as well as the uptake of STI/HIV testing. Methods: Employing community-based participatory research principles, 50 youths aged 13 to 21 years were recruited from a youth-centered community health clinic in Southeast Michigan, randomized sequentially to either S4E or enhanced usual practice, and assessed at baseline, immediately postintervention, and 30 days postintervention. S4E consists of 3 modules, including alcohol and drug use, tobacco, and STI/HIV. Results: Relative to youth in the enhanced usual practice group, S4E participants demonstrated higher youth-clinician risk communication (mean 3.22, SD 1.67) and increases in prevention knowledge (∆ score mean 0.36, SD 0.51) and self-efficacy (∆ score mean 0.16, SD 0.47). In addition, youth in the S4E group showed reductions in the proportions of past 30-day overall substance use (Cohen h=0.71, 95% CI 0.15 to 1.27), as well as past 30-day alcohol (Cohen h=0.71, 95% CI 0.15 to 1.27), tobacco (Cohen h=0.17, 95% CI −0.39 to 0.73), and drug use (Cohen h=1.28, 95% CI 0.72 to 1.84). The results also suggest a reduction in the proportion of youths who reported past 30-day condomless sex (Cohen h=0.18, 95% CI −0.38 to 0.74) and alcohol use before sex (Cohen h=0.44, 95% CI −0.12 to 1.00). Finally, the findings also demonstrated an increase in the proportion of youths who reported STI/HIV testing over time (Cohen h=0.16, 95% CI −0.39 to 0.72). Conclusions: The findings suggest the feasibility of a small-scale pilot RCT. S4E demonstrated shifts in the hypothesized direction, reducing substance use, sexual risk behaviors, and improving the uptake of STI/HIV testing among youth in a clinic setting. The findings suggest that a larger RCT may be warranted. Trial Registration: ClinicalTrails.gov NCT03855410, https://clinicaltrials.gov/ct2/show/NCT03855410. %M 32181747 %R 10.2196/16251 %U https://mhealth.jmir.org/2020/3/e16251 %U https://doi.org/10.2196/16251 %U http://www.ncbi.nlm.nih.gov/pubmed/32181747 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e16642 %T Adherence to Prescribed E-Diary Recording by Patients With Seasonal Allergic Rhinitis: Observational Study %A Di Fraia,Marco %A Tripodi,Salvatore %A Arasi,Stefania %A Dramburg,Stephanie %A Castelli,Sveva %A Villalta,Danilo %A Buzzulini,Francesca %A Sfika,Ifigenia %A Villella,Valeria %A Potapova,Ekaterina %A Perna,Serena %A Brighetti,Maria Antonia %A Travaglini,Alessandro %A Verardo,Pierluigi %A Pelosi,Simone %A Zicari,Anna Maria %A Matricardi,Paolo Maria %+ Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité University Medicine, Augustenburger Platz 1, Berlin, 13353, Germany, 49 30 450 566 406, paolo.matricardi@charite.de %K mobile health %K e-Diary %K precision medicine %K pollen %K seasonal allergic rhinitis %K blended care %D 2020 %7 16.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Complete diagnosis and therapy of seasonal allergic rhinoconjunctivitis require evidence that exposure to the sensitizing pollen triggers allergic symptoms. Electronic clinical diaries, by recording disease severity scores and pollen exposure, can demonstrate this association. However, patients who spontaneously download an e-diary app show very low adherence to their recording. Objective: The objective of our study was to assess adherence of patients with seasonal allergic rhinitis to symptom recording via e-diary explicitly prescribed by an allergist within a blended care approach. Methods: The @IT-2020 project is investigating the diagnostic synergy of mobile health and molecular allergology in patients with seasonal allergic rhinitis. In the pilot phase of the study, we recruited Italian children (Rome, Italy) and adults (Pordenone, Italy) with seasonal allergic rhinitis and instructed them to record their symptoms, medication intake, and general conditions daily through a mobile app (Allergy.Monitor) during the relevant pollen season. Results: Overall, we recruited 101 Italian children (Rome) and 93 adults (Pordenone) with seasonal allergic rhinitis. Adherence to device use slowly declined during monitoring in 3 phases: phase A: first week, ≥1267/1358, 90%; phase B: second to sixth week, 4992/5884, 80% to 90%; and phase C: seventh week onward, 2063/2606, 70% to 80%. At the individual level, the adherence assessed in the second and third weeks of recording predicted with enough confidence (Rome: Spearman ρ=0.75; P<.001; Pordenone: ρ=0.81; P<.001) the overall patient adherence to recording and was inversely related to postponed reporting (ρ=–0.55; P<.001; in both centers). Recording adherence was significantly higher during the peak grass pollen season in Rome, but not in Pordenone. Conclusions: Adherence to daily recording in an e-diary, prescribed and motivated by an allergist in a blended care setting, was very high. This observation supports the use of e-diaries in addition to face-to-face visits for diagnosis and treatment of seasonal allergic rhinitis and deserves further investigation in real-life contexts. %M 32175909 %R 10.2196/16642 %U https://www.jmir.org/2020/3/e16642 %U https://doi.org/10.2196/16642 %U http://www.ncbi.nlm.nih.gov/pubmed/32175909 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 3 %P e14118 %T A Mobile Phone Intervention to Improve Obesity-Related Health Behaviors of Adolescents Across Europe: Iterative Co-Design and Feasibility Study %A Martin,Anne %A Caon,Maurizio %A Adorni,Fulvio %A Andreoni,Giuseppe %A Ascolese,Antonio %A Atkinson,Sarah %A Bul,Kim %A Carrion,Carme %A Castell,Conxa %A Ciociola,Valentina %A Condon,Laura %A Espallargues,Mireia %A Hanley,Janet %A Jesuthasan,Nithiya %A Lafortuna,Claudio L %A Lang,Alexandra %A Prinelli,Federica %A Puidomenech Puig,Elisa %A Tabozzi,Sarah A %A McKinstry,Brian %+ UK Medical Research Council / Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, United Kingdom, 44 141353 ext 7603, Anne.Martin@glasgow.ac.uk %K health behavior %K obesity %K co-design %K mHealth %K mobile app %K mobile phone %K adolescents %K youth %K focus groups %D 2020 %7 2.3.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Promotion of physical activity, healthy eating, adequate sleep, and reduced sedentary behavior in adolescents is a major priority globally given the current increase in population health challenges of noncommunicable diseases and risk factors such as obesity. Adolescents are highly engaged with mobile technology, but the challenge is to engage them with mobile health (mHealth) technology. Recent innovations in mobile technology provide opportunities to promote a healthy lifestyle in adolescents. An increasingly utilized approach to facilitate increased engagement with mHealth technology is to involve potential users in the creation of the technology. Objective: This study aimed to describe the process of and findings from co-designing and prototyping components of the PEGASO Fit for Future (F4F) mHealth intervention for adolescents from different cultural backgrounds. Methods: A total of 74 adolescents aged 13 to 16 years from Spain, Italy, and the United Kingdom participated in the co-design of the PEGASO F4F technology. In 3 iterative cycles over 12 months, participants were involved in the co-design, refinement, and feasibility testing of a system consisting of diverse mobile apps with a variety of functions and facilities to encourage healthy weight–promoting behaviors. In the first iteration, participants attended a single workshop session and were presented with mock-ups or early-version prototypes of different apps for user requirements assessment and review. During the second iteration, prototypes of all apps were tested by participants for 1 week at home or school. In the third iteration, further developed prototypes were tested for 2 weeks. Participants’ user experience feedback and development ideas were collected through focus groups and completion of questionnaires. Results: For the PEGASO F4F technology to be motivating and engaging, participants suggested that it should (1) allow personalization of the interface, (2) have age-appropriate and easy-to-understand language (of icons, labels, instructions, and notifications), (3) provide easily accessible tutorials on how to use the app or navigate through a game, (4) present a clear purpose and end goal, (5) have an appealing and self-explanatory reward system, (6) offer variation in gamified activities within apps and the serious game, and (7) allow to seek peer support and connect with peers for competitive activities within the technology. Conclusions: Incorporating adolescents’ preferences, the PEGASO F4F technology combines the functions of a self-monitoring, entertainment, advisory, and social support tool. This was the first study demonstrating that it is possible to develop a complex mobile phone-based technological system applying the principles of co-design to mHealth technology with adolescents across 3 countries. The findings from this study informed the development of an mHealth system for healthy weight promotion to be tested in a controlled multinational pilot trial. %M 32130179 %R 10.2196/14118 %U https://mhealth.jmir.org/2020/3/e14118 %U https://doi.org/10.2196/14118 %U http://www.ncbi.nlm.nih.gov/pubmed/32130179 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e15377 %T Remote Management of Poststroke Patients With a Smartphone-Based Management System Integrated in Clinical Care: Prospective, Nonrandomized, Interventional Study %A Kim,Do Yeon %A Kwon,Hee %A Nam,Ki-Woong %A Lee,Yongseok %A Kwon,Hyung-Min %A Chung,Young Seob %+ Department of Neurology, Seoul National University College of Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 20 Boramae-ro, Dongjak-gu, Seoul, , Republic of Korea, 82 2 870 2865, hmkwon@snu.ac.kr %K mHealth %K mobile apps %K stroke care %K health care %K patient education %K self-monitoring of blood pressure %D 2020 %7 27.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Advances in mobile health (mHealth) have enabled systematic and continuous management of patients with chronic diseases. Objective: We developed a smartphone-based mHealth system and aimed to evaluate its effects on health behavior management and risk factor control in stroke patients. Methods: With a multifaceted stroke aftercare management system that included exercise, medication, and educational materials, we performed a 12-week single-arm intervention among eligible poststroke patients in the stroke clinic from September to December 2016. The intervention consisted of (1) regular blood pressure (BP), blood glucose, and physical activity measurements; (2) stroke education; (3) an exercise program; (4) a medication program; and (5) feedback on reviewing of records by clinicians. Clinical assessments consisted of the stroke awareness score, Beck Depression Inventory-II (BDI), EuroQol-5 Dimensions (EQ-5D), and BP at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks). Temporal differences in the parameters over 12 weeks were investigated with repeated-measures analysis of variance. Changes in medication adherence at visit 1-2 (from visit 1 to visit 2) and visit 2-3 (from visit 2 to visit 3) were compared. System satisfaction was evaluated with a self-questionnaire using a 5-point Likert scale at visit 3. Results: The study was approved by the Institutional Review Board in September 2016, and participants were enrolled from September to December 2016. Among the 110 patients enrolled for the study, 99 were included in our analyses. The mean stroke awareness score (baseline: 59.6 [SD 18.1]; 4 weeks: 67.6 [SD 16.0], P<.001; 12 weeks: 74.7 [SD 14.0], P<.001) and BDI score (baseline: 12.7 [SD 10.1]; 4 weeks: 11.2 [SD 10.2], P=.01; 12 weeks: 10.7 [SD 10.2], P<.001) showed gradual improvement; however, no significant differences were found in the mean EQ-5D score (baseline: 0.66 [SD 0.33]; 4 weeks: 0.69 [SD 0.34], P=.01; 12 weeks: 0.69 [SD 0.34], P<.001). Twenty-six patients who had uncontrolled BP at baseline had −13.92 mmHg (P=.001) and −6.19 mmHg (P<.001) reductions on average in systolic and diastolic BP, respectively, without any antihypertensive medication change. Medication compliance was better at visit 2-3 (60.9% [SD 37.2%]) than at visit 1-2 (47.8% [SD 38.7%], P<.001). Conclusions: Awareness of stroke, depression, and BP was enhanced when using the smartphone-based mHealth system. Emerging mHealth techniques have potential as new nonpharmacological secondary prevention methods because of their ubiquitous access, near real-time responsiveness, and comparatively lower cost. %M 32130140 %R 10.2196/15377 %U http://www.jmir.org/2020/2/e15377/ %U https://doi.org/10.2196/15377 %U http://www.ncbi.nlm.nih.gov/pubmed/32130140 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 2 %P e14466 %T Using Goal-Directed Design to Create a Mobile Health App to Improve Patient Compliance With Hypertension Self-Management: Development and Deployment %A Duan,Huilong %A Wang,Zheyu %A Ji,Yumeng %A Ma,Li %A Liu,Fang %A Chi,Mingwei %A Deng,Ning %A An,Jiye %+ College of Biomedical Engineering and Instrument Science, Ministry of Education Key Laboratory of Biomedical Engineering, Zhejiang University, 38 Zheda Rd, Zhouyiqing Bldg 512, Yuquan Campus, Hangzhou, China, 86 571 2295 2693, zju.dengning@gmail.com %K goal-directed design %K smartphone %K mobile health %K patients %K hypertension self-management %K mobile phone %D 2020 %7 25.2.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Hypertension is a lifestyle-induced chronic disease that threatens the lives of patients. Control of hypertension requires patients to follow self-management regimes; unfortunately, however, patient compliance with hypertension self-management is low, especially in developing countries. Improvement of patient compliance is premised on meeting patient needs. Mobile health apps are becoming increasingly popular for self-management of chronic diseases. However, few mobile apps have been designed to meet patient needs for hypertension self-management. Objective: The goal of this study was to develop a mobile health app to improve patient compliance with hypertension self-management and evaluate the effectiveness of the app in terms of patient compliance. Methods: The goal-directed design method was applied to guide study design. We divided the study into 4 stages. Stages 1 to 3 comprised the development process. To improve the applicability of the goal-directed design method to chronic disease management, we extracted elements of user models concerned with patient compliance and defined a concrete process for user modeling. In stage 1, personas of hypertensive patients were built using qualitative and quantitative methods. Clustering methods based on questionnaire responses were used to group patients. Qualitative interviews were conducted to identify the needs of different groups. In stage 2, several functional modules were designed to meet the needs of different groups based on the results from stage 1. In stage 3, prototypes of functional modules were designed and implemented as a real app. Stage 4 was the deployment process, in which we conducted a pilot study to investigate patient compliance after using the app. Patient compliance was calculated through the frequency with which they took blood pressure measurements. In addition, qualitative interviews were conducted to learn the underlying reasons for the compliance results. Results: In stage 1, patients were divided into 3 groups based on 82 valid questionnaire responses. Eighteen patients from the different groups (7, 5, and 6 patients) were interviewed, and the needs of the groups were summarized as follows: improve self-management ability, enhance self-management motivation, and receive self-management support. In stages 2 and 3, 6 functional modules were designed and implemented based on specified needs, and the usability of the app was improved through usability tests. In stage 4, 143 patients were recruited to use different versions of the app for 2 months. Results show that patient compliance improved as functional modules were added (P<.001) and was maintained at a high level (rate of 0.73). Interview results from 32 patients show that the design of the app met different needs; thus, patients were more compliant with it. Conclusions: This study developed a mobile health app for hypertension self-management using the goal-directed design method. The app proved to be effective for improving patient compliance with hypertension self-management. %M 32130161 %R 10.2196/14466 %U http://mhealth.jmir.org/2020/2/e14466/ %U https://doi.org/10.2196/14466 %U http://www.ncbi.nlm.nih.gov/pubmed/32130161 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e16767 %T Translating the Burden of Pollen Allergy Into Numbers Using Electronically Generated Symptom Data From the Patient’s Hayfever Diary in Austria and Germany: 10-Year Observational Study %A Bastl,Katharina %A Bastl,Maximilian %A Bergmann,Karl-Christian %A Berger,Markus %A Berger,Uwe %+ Aerobiology and Pollen Information Research Unit, Department of Oto-Rhino-Laryngology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria, 43 4040033380, maximilian.bastl@meduniwien.ac.at %K symptom data %K Patient’s Hayfever Diary %K pollen allergy %K symptom score calculation %D 2020 %7 21.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Pollen allergies affect a significant proportion of the population globally. At present, Web-based tools such as pollen diaries and mobile apps allow for easy and fast documentation of allergic symptoms via the internet. Objective: This study aimed to characterize the users of the Patient’s Hayfever Diary (PHD), a Web-based platform and mobile app, to apply different symptom score calculations for comparison, and to evaluate the contribution of organs and medications to the total score for the first time. Methods: The PHD users were filtered with regard to their location in Austria and Germany, significant positive correlation to the respective pollen type (birch/grass), and at least 15 entries in the respective season. Furthermore, 4 different symptom score calculation methods were applied to the datasets from 2009 until 2018, of which 2 were raw symptom scores and 2 were symptom load index (normalized) calculations. Pearson correlation coefficients were calculated pairwise for these 4 symptom score calculations. Results: Users were mostly male and belonged to the age groups of 21 to 40 years or >40 years. User numbers have increased in the last 5 years, especially when mobile apps were made available. The Pearson correlation coefficients showed a significant linear relationship above 0.9 among the 4 symptom score datasets and thus indicated no significant difference between the different methods of symptom score calculation. The nose contributed the most to the symptom score and determined about 40% of the score. Conclusions: The exact method of calculation of the symptom score is not critical. All computation methods show the same behavior (increase/decrease during the season). Therefore, the symptom load index is a useful computation method in all fields exploring pollen allergy, and Web-based diaries are a globally applicable tool to monitor the effect of pollen on human health via electronically generated symptom data. %M 32130130 %R 10.2196/16767 %U http://www.jmir.org/2020/2/e16767/ %U https://doi.org/10.2196/16767 %U http://www.ncbi.nlm.nih.gov/pubmed/32130130 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e14735 %T Four-Year Trends in Sleep Duration and Quality: A Longitudinal Study Using Data from a Commercially Available Sleep Tracker %A Robbins,Rebecca %A Affouf,Mahmoud %A Seixas,Azizi %A Beaugris,Louis %A Avirappattu,George %A Jean-Louis,Girardin %+ Division of Sleep and Circadian Disorders, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, United States, 1 617 732 5500, rrobbins4@bwh.harvard.edu %K big data %K sleep health %K fitness tracker %K mHealth %D 2020 %7 20.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Population estimates of sleep duration and quality are inconsistent because they rely primarily on self-reported data. Passive and ubiquitous digital tracking and wearable devices may provide more accurate estimates of sleep duration and quality. Objective: This study aimed to identify trends in sleep duration and quality in New York City based on 2 million nights of data from users of a popular mobile sleep app. Methods: We examined sleep duration and quality using 2,161,067 nights of data captured from 2015 to 2018 by Sleep Cycle, a popular sleep-tracking app. In this analysis, we explored differences in sleep parameters based on demographic factors, including age and sex. We used graphical matrix representations of data (heat maps) and geospatial analyses to compare sleep duration (in hours) and sleep quality (based on time in bed, deep sleep time, sleep consistency, and number of times fully awake), considering potential effects of day of the week and seasonality. Results: Women represented 46.43% (1,003,421/2,161,067) of the sample, and men represented 53.57% (1,157,646/2,161,067) of individuals in the sample. The average age of the sample was 31.0 years (SD 10.6). The mean sleep duration of the total sample was 7.11 hours (SD 1.4). Women slept longer on average (mean 7.27 hours, SD 1.4) than men (mean 7 hours, SD 1.3; P<.001). Trend analysis indicated longer sleep duration and higher sleep quality among older individuals than among younger (P<.001). On average, sleep duration was longer on the weekend nights (mean 7.19 hours, SD 1.5) than on weeknights (mean 7.09 hours, SD 1.3; P<.001). Conclusions: Our study of data from a commercially available sleep tracker showed that women experienced longer sleep duration and higher sleep quality in nearly every age group than men, and a low proportion of young adults obtained the recommended sleep duration. Future research may compare sleep measures obtained via wearable sleep trackers with validated research-grade measures of sleep. %M 32078573 %R 10.2196/14735 %U https://www.jmir.org/2020/2/e14735 %U https://doi.org/10.2196/14735 %U http://www.ncbi.nlm.nih.gov/pubmed/32078573 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 2 %P e14737 %T Using Text Messaging to Improve Access to Prenatal Health Information in Urban African American and Afro-Caribbean Immigrant Pregnant Women: Mixed Methods Analysis of Text4baby Usage %A Blackwell,Tenya M %A Dill,LeConte J %A Hoepner,Lori A %A Geer,Laura A %+ Department of Environmental and Occupational Health Sciences, SUNY Downstate Health Sciences University, School of Public Health, 450 Clarkson Avenue, Brooklyn, NY, United States, 1 7182703101, tblackwell@arthurasheinstitute.org %K Text4baby %K mHealth %K pregnancy %K text messaging %K health information %K prenatal health %K disparities %D 2020 %7 13.2.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Text4baby (T4B) mobile health (mHealth) program is acclaimed to provide pregnant women with greater access to prenatal health care, resources, and information. However, little is known about whether urban African American and Afro-Caribbean immigrant pregnant women in the United States are receptive users of innovative health communication methods or of the cultural and systematic barriers that inhibit their behavioral intent to use T4B. Objective: This study aimed to understand the lived experiences of urban African American and Afro-Caribbean immigrant pregnant women with accessing quality prenatal health care and health information; to assess usage of mHealth for seeking prenatal health information; and to measure changes in participants’ knowledge, perceptions, and behavioral intent to use the T4B mHealth educational intervention. Methods: An exploratory sequential mixed methods study was conducted among pregnant women and clinical professionals for a phenomenological exploration with focus groups, key informants, interviews, and observations. Qualitative themes were aligned with behavioral and information technology communications theoretical constructs to develop a survey instrument used. repeated-measures pre- and post-test design to evaluate changes in participants’ knowledge, attitudes, and beliefs, of mHealth and T4B after a minimum of 4 weeks’ exposure to the text message–based intervention. Triangulation and mixing of both qualitative and quantitative data occurred primarily during the survey development and also during final analysis. Results: A total of 9 women participated in phase 1, and 49 patients signed up for T4B and completed a 31-item survey at baseline and again during follow-up. Three themes were identified: (1) patient-provider engagement, (2) social support, and (3) acculturation. With time as a barrier to quality care, inadequate patient-provider engagement left participants feeling indifferent about the prenatal care and information they received in the clinical setting. Of 49 survey participants, 63% (31/49) strongly agreed that T4B would provide them with extra support during their pregnancy. On a Likert scale of 1 to 5, participants’ perception of the usefulness of T4B ranked at 4.26, and their perception of the compatibility and relative advantage of using T4B ranked at 4.41 and 4.15, respectively. At follow-up, there was a 14% increase in participants reporting their intent to use T4B and a 28% increase from pretest and posttest in pregnant women strongly agreeing to speak more with their doctor about the information learned through T4B. Conclusions: Urban African American and Afro-Caribbean immigrant pregnant women in Brooklyn endure a number of social and ecological determinants like low health literacy, income, and language that serve as barriers to accessing quality prenatal health care and information, which negatively impacts prenatal health behaviors and outcomes. Our study indicates a number of systematic, political, and other microsystem-level factors that perpetuate health inequities in our study population. %M 32053117 %R 10.2196/14737 %U http://mhealth.jmir.org/2020/2/e14737/ %U https://doi.org/10.2196/14737 %U http://www.ncbi.nlm.nih.gov/pubmed/32053117 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 2 %P e13468 %T Validation of an Electronic Visual Analog Scale mHealth Tool for Acute Pain Assessment: Prospective Cross-Sectional Study %A Escalona-Marfil,Carles %A Coda,Andrea %A Ruiz-Moreno,Jorge %A Riu-Gispert,Lluís Miquel %A Gironès,Xavier %+ Facultat de Ciències de la Salut de Manresa, Universitat de Vic–Universitat Central de Catalunya, Av Universitària, 4-6, Manresa, Spain, 34 938 77 41 79 ext 234, carlesescalona@gmail.com %K pain %K visual analog pain scale %K pain measurement %K mobile phone %K mHealth %K validation %K tablet %D 2020 %7 12.2.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Accurate measurement of pain is required to improve its management and in research. The visual analog scale (VAS) on paper format has been shown to be an accurate, valid, reliable, and reproducible way to measure pain intensity. However, some limitations should be considered, some of which can be implemented with the introduction of an electronic VAS version, suitable to be used both in a tablet and a smartphone. Objective: This study aimed to validate a new method of recording pain level by comparing the traditional paper VAS with the pain level module on the newly designed Interactive Clinics app. Methods: A prospective observational cross-sectional study was designed. The sample consisted of 102 participants aged 18 to 65 years. A Force Dial FDK 20 algometer (Wagner Instruments) was employed to induce mild pressure symptoms on the participants’ thumbs. Pain was measured using a paper VAS (10 cm line) and the app. Results: Intermethod reliability estimated by ICC(3,1) was 0.86 with a 95% confidence interval of 0.81 to 0.90, indicating good reliability. Intramethod reliability estimated by ICCa(3,1) was 0.86 with a 95% confidence interval of 0.81 to 0.90, also indicating good reliability. Bland-Altman analysis showed a difference of 0.175 (0.49), and limits of agreement ranged from –0.79 to 1.14. Conclusions: The pain level module on the app is highly reliable and interchangeable with the paper VAS version. This tool could potentially help clinicians and researchers precisely assess pain in a simple, economic way with the use of a ubiquitous technology. %M 32049063 %R 10.2196/13468 %U http://www.jmir.org/2020/2/e13468/ %U https://doi.org/10.2196/13468 %U http://www.ncbi.nlm.nih.gov/pubmed/32049063 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 2 %P e14661 %T International ResearchKit App for Women with Menstrual Pain: Development, Access, and Engagement %A Wang,Jiani %A Rogge,Alizé A %A Armour,Mike %A Smith,Caroline A %A D’Adamo,Christopher R %A Pischke,Claudia R %A Yen,Hung-Rong %A Wu,Mei-Yao %A Moré,Ari Ojeda Ocampo %A Witt,Claudia M %A Pach,Daniel %+ Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute for Social Medicine, Epidemiology and Health Economics, Luisenstraße 57, Berlin, 10117, Germany, 49 30450529011, daniel.pach@charite.de %K dysmenorrhea %K mHealth %K mobile applications %K acupressure %K pain %K behavior change techniques (BCTs) %K ResearchKit %K recruitment %D 2020 %7 11.2.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Primary dysmenorrhea is a common condition in women of reproductive age. A previous app-based study undertaken by our group demonstrated that a smartphone app supporting self-acupressure introduced by a health care professional can reduce menstrual pain. Objective: This study aims to evaluate whether a specific smartphone app is effective in reducing menstrual pain in 18- to 34-year-old women with primary dysmenorrhea in a self-care setting. One group of women has access to the full-featured study app and will be compared with 2 control groups who have access to fewer app features. Here, we report the trial design, app development, user access, and engagement. Methods: On the basis of the practical implications of the previous app-based study, we revised and reengineered the study app and included the ResearchKit (Apple Inc) framework. Behavior change techniques (BCTs) were implemented in the app and validated by expert ratings. User access was estimated by assessing recruitment progress over time. User evolution and baseline survey respondent rate were assessed to evaluate user engagement. Results: The development of the study app for a 3-armed randomized controlled trial required a multidisciplinary team. The app is accessible for the target population free of charge via the Apple App Store. In Germany, within 9 months, the app was downloaded 1458 times and 328 study participants were recruited using it without external advertising. A total of 98.27% (5157/5248) of the app-based baseline questions were answered. The correct classification of BCTs used in the app required psychological expertise. Conclusions: Conducting an innovative app study requires multidisciplinary effort. Easy access and engagement with such an app can be achieved by recruitment via the App Store. Future research is needed to investigate the determinants of user engagement, optimal BCT application, and potential clinical and self-care scenarios for app use. Trial Registration: ClinicalTrials.gov NCT03432611; https://clinicaltrials.gov/ct2/show/NCT03432611 (Archived by WebCite at http://www.webcitation.org/75LLAcnCQ). %M 32058976 %R 10.2196/14661 %U https://mhealth.jmir.org/2020/2/e14661 %U https://doi.org/10.2196/14661 %U http://www.ncbi.nlm.nih.gov/pubmed/32058976 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 1 %P e15503 %T Mobile Clinical Decision Tools Among Emergency Department Clinicians: Web-Based Survey and Analytic Data for Evaluation of The Ottawa Rules App %A Quan,Amanda My Linh %A Stiell,Ian %A Perry,Jeffrey J %A Paradis,Michelle %A Brown,Erica %A Gignac,Jordan %A Wilson,Lindsay %A Wilson,Kumanan %+ The Ottawa Hospital Research Institute, Clinical Epidemiology, 1053 Carling Avenue, Box 684, Administrative Services Building, Ottawa, ON, K1Y 4E9, Canada, 1 (613) 7985555, kwilson@ohri.ca %K emergency departments %K mHealth %K clinical prediction rule %K decision aids %D 2020 %7 29.1.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Canadian CT Head Rule (CCHR), the Canadian Transient Ischemic Attack (TIA) Score, and the Subarachnoid Hemorrhage (SAH) Rule have all previously demonstrated the potential to significantly standardize care and improve the management of patients in emergency departments (EDs). On the basis of user feedback, we believe that the addition of these rules to the Ottawa Rules App has the potential to increase the app’s usability and user acceptability. Objective: This study aimed to evaluate the perceived usefulness, acceptability, and uptake of the enhanced Ottawa Rules App (which now includes CCHR, TIA, and SAH Rules) among ED clinicians (medical students, residents, nurses, and physicians). Methods: The enhanced Ottawa Rules App was publicly released for free on iOS and Android operating systems in November 2018. This study was conducted across 2 tertiary EDs in Ottawa, Canada. Posters, direct enrollment, snowball sampling, and emails were used for study recruitment. A 24-question Web-based survey was administered to participants via email, and this was used to determine user acceptability of the app and Technology Readiness Index (TRI) scores. In-app user analytics were collected to track user behavior, such as the number of app sessions, length of app sessions, frequency of rule use, and the date app was first opened. Results: A total of 77 ED clinicians completed the study, including 34 nurses, 12 residents, 14 physicians, and 17 medical students completing ED rotations. The median TRI score for this group was 3.38, indicating a higher than average propensity to embrace and adopt new technologies to accomplish goals in their work or daily lives. The majority of respondents agreed or strongly agreed that the app helped participants accurately carry out the clinical rules (56/77, 73%) and that they would recommend this app to their colleagues (64/77, 83%). Feedback from study participants suggested further expansion of the app—more clinical decision rules (CDRs) and different versions of the app tailored to the clinician role. Analysis and comparison of Google Analytics data and in-app data revealed similar usage behavior among study-enrolled users and all app users globally. Conclusions: This study provides evidence that using the Ottawa Rules App (version 3.0.2) to improve and guide patient care would be feasible and widely accepted. The ability to verify self-reported user data (via a Web-based survey) against server analytics data is a notable strength of this study. Participants’ continued app use and request for the addition of more CDRs warrant the further development of this app and call for additional studies to evaluate its feasibility and usability in different settings as well as assessment of clinical impact. %M 32012095 %R 10.2196/15503 %U https://mhealth.jmir.org/2020/1/e15503 %U https://doi.org/10.2196/15503 %U http://www.ncbi.nlm.nih.gov/pubmed/32012095 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e15889 %T A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO %A Ledel Solem,Ingrid Konstanse %A Varsi,Cecilie %A Eide,Hilde %A Kristjansdottir,Olöf Birna %A Børøsund,Elin %A Schreurs,Karlein M G %A Waxenberg,Lori B %A Weiss,Karen E %A Morrison,Eleshia J %A Haaland-Øverby,Mette %A Bevan,Katherine %A Zangi,Heidi Andersen %A Stubhaug,Audun %A Solberg Nes,Lise %+ Department of Digital Health Research, Division of Medicine, Oslo University Hospital, Pb 4950 Nydalen, Oslo, N-0424, Norway, 47 91332341, lise.solberg.nes@rr-research.no %K Web-based interventions %K eHealth %K mobile apps %K evidence-based, user-centered design approach %K service design %K chronic pain %K cognitive behavioral therapy %K acceptance and commitment therapy %D 2020 %7 21.1.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic pain conditions are complicated and challenging to live with. Electronic health (eHealth) interventions show promise in helping people cope with chronic illness, including pain. The success of these interventions depends not only on the technology and intervention content but also on the users’ acceptance and adherence. Involving all stakeholders (eg, patients, spouses, health care providers, designers, software developers, and researchers) and exploring their input and preferences in the design and development process is an important step toward developing meaningful interventions and possibly strengthening treatment outcomes. Objective: The aim of this study was to design and develop a user-centered, evidence-based eHealth self-management intervention for people with chronic pain. Methods: The study employed a multidisciplinary and user-centered design approach. Overall, 20 stakeholders from the project team (ie, 7 researchers, 5 editors, 7 software developers, and 1 user representative), together with 33 external stakeholders (ie, 12 health care providers, 1 health care manger, 1 eHealth research psychologist, and 17 patients with chronic pain and 2 of their spouses) participated in a user-centered development process that included workshops, intervention content development, and usability testing. Intervention content was developed and finalized based on existing evidence, stakeholder input, and user testing. Stakeholder input was examined through qualitative analyses with rapid and in-depth analysis approaches. Results: Analyses from stakeholder input identified themes including a need for reliable, trustworthy, and evidence-based content, personalization, options for feedback, behavioral tracking, and self-assessment/registration as factors to include in the intervention. Evidence-based intervention content development resulted in one face-to-face introduction session and 9 app-based educational and exercise-based modules. Usability testing provided further insight into how to optimize the design of the intervention to the user group, identifying accessibility and a simple design to be essential. Conclusions: The design and development process of eHealth interventions should strive to combine well-known evidence-based concepts with stakeholder input. This study, designing and developing the pain management intervention EPIO, illustrates how a stakeholder-centered design approach can provide essential input in the development of an eHealth self-management intervention for people with chronic pain. Trial Registration: ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104 %M 31961331 %R 10.2196/15889 %U http://www.jmir.org/2020/1/e15889/ %U https://doi.org/10.2196/15889 %U http://www.ncbi.nlm.nih.gov/pubmed/31961331 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 1 %P e16652 %T A Smartphone App Designed to Help Cancer Patients Stop Smoking: Results From a Pilot Randomized Trial on Feasibility, Acceptability, and Effectiveness %A Bricker,Jonathan B %A Watson,Noreen L %A Heffner,Jaimee L %A Sullivan,Brianna %A Mull,Kristin %A Kwon,Diana %A Westmaas,Johann Lee %A Ostroff,Jamie %+ Fred Hutchinson Cancer Research Center, Division of Public Health Sciences, 1100 Fairview Avenue N, Seattle, WA, 98109, United States, 1 2066675074, jbricker@fredhutch.org %K smartphone app %K mHealth %K tobacco %K smoking %K cancer patient %D 2020 %7 17.1.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Persistent smoking after a cancer diagnosis predicts worse treatment outcomes and mortality, but access to effective smoking cessation interventions is limited. Smartphone apps can address this problem by providing a highly accessible, low-cost smoking cessation intervention designed for patients with a recent cancer diagnosis. Objective: This study aimed to summarize our development process and report the trial design, feasibility, participant acceptability, preliminary effectiveness, and impact on processes of change (eg, cancer stigma) of the first-known smoking cessation smartphone app targeted for cancer patients. Methods: We used an agile, user-centered design framework to develop a fully automated smartphone app called Quit2Heal that provided skills training and stories from cancer survivors focusing on coping with internalized shame, cancer stigma, depression, and anxiety as core triggers of smoking. Quit2Heal was compared with the National Cancer Institute’s QuitGuide, a widely used stop smoking app for the general population, in a pilot double-blinded randomized trial with a 2-month follow-up period. Participants were 59 adult smokers diagnosed with cancer within the past 12 months and recruited through 2 cancer center care networks and social media over a 12-month period. The most common types of cancer diagnosed were lung (21/59, 36%) and breast (10/59, 17%) cancers. The 2-month follow-up survey retention rate was 92% (54/59) and did not differ by study arm (P=.15). Results: Compared with QuitGuide participants, Quit2Heal participants were more satisfied with their assigned app (90% [19/21] for Quit2Heal vs 65% [17/26] for QuitGuide; P=.047) and were more likely to report that the app assigned to them was made for someone like them (86% [18/21] for Quit2Heal vs 62% [16/26] for QuitGuide; P=.04). Quit2Heal participants opened their app a greater number of times during the 2-month trial period, although this difference was not statistically significant (mean 10.0, SD 14.40 for Quit2Heal vs mean 6.1, SD 5.3 for QuitGuide; P=.33). Self-reported 30-day point prevalence quit rates at the 2-month follow-up were 20% (5/25) for Quit2Heal versus 7% (2/29) for QuitGuide (odds ratio 5.16, 95% CI 0.71-37.29; P=.10). Quit2Heal participants also showed greater improvement in internalized shame, cancer stigma, depression, and anxiety, although these were not statistically significant (all P>.05). Conclusions: In a pilot randomized trial with a high short-term retention rate, Quit2Heal showed promising acceptability and effectiveness for helping cancer patients stop smoking. Testing in a full-scale randomized controlled trial with a longer follow-up period and a larger sample size is required to test the effectiveness, mediators, and moderators of this promising digital cessation intervention. Trial Registration: ClinicalTrials.gov NCT03600038; https://clinicaltrials.gov/ct2/show/NCT03600038 %M 31951215 %R 10.2196/16652 %U http://formative.jmir.org/2020/1/e16652/ %U https://doi.org/10.2196/16652 %U http://www.ncbi.nlm.nih.gov/pubmed/31951215 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 1 %P e12516 %T Mobile Health Technology Interventions for Suicide Prevention: Systematic Review %A Melia,Ruth %A Francis,Kady %A Hickey,Emma %A Bogue,John %A Duggan,Jim %A O'Sullivan,Mary %A Young,Karen %+ School of Psychology, National University of Ireland Galway, Arts Millennium Building, Galway, H91 TK33, Ireland, 353 877710431, ruth.melia@hse.ie %K mHealth %K systematic review %D 2020 %7 15.1.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Digital interventions are proposed as one way by which effective treatments for self-harm and suicidal ideation may be improved and their scalability enhanced. Mobile devices offer a potentially powerful medium to deliver evidence-based interventions with greater specificity to the individual when the intervention is needed. The recent proliferation of publicly available mobile apps designed for suicide prevention underlines the need for robust evidence to promote safe practice. Objective: This review aimed to examine the effectiveness of currently available mobile health (mHealth) technology tools in reducing suicide-specific outcomes. Methods: The following databases were searched: Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and relevant sources of gray literature. All published and unpublished randomized controlled trials (RCTs), pseudo-RCTs, and pre-post observational studies that evaluated the effectiveness of mHealth technology in suicide prevention delivered via mobile computing and communication technology were included. Studies were included if they measured at least one suicide outcome variable (ie, suicidal ideation, suicidal intent, nonsuicidal self-injurious behavior, and suicidal behavior). A total of 2 review authors independently extracted data and assessed study suitability, in accordance with the Cochrane Collaboration Risk of Bias Tool, on July 31, 2018. Owing to the heterogeneity of outcomes found across studies, results were not amenable for pooled synthesis, and a meta-analysis was not performed. A narrative synthesis of the available research is presented here. Results: A total of 7 studies met criteria for inclusion . Four published articles that reported on the effectiveness of the following mobile phone apps were included: iBobbly, Virtual Hope Box, BlueIce, and Therapeutic Evaluative Conditioning. Results demonstrated some positive impacts for individuals at elevated risk of suicide or self-harm, including reductions in depression, psychological distress, and self-harm and increases in coping self-efficacy. None of the apps evaluated demonstrated the ability to significantly decrease suicidal ideation compared with a control condition. In addition, 3 unpublished and recently completed trials also met criteria for inclusion in the review. Conclusions: Further research is needed to evaluate the efficacy of stand-alone mHealth technology–based interventions in suicide prevention. The small number of studies reported in this review tentatively indicate that such tools may have a positive impact on suicide-specific outcomes. Future mHealth intervention evaluations would benefit from addressing the following 3 main methodological limitations : (1) heterogeneity of outcomes: a lack of standardized measurement of suicide outcomes across studies; (2) ecological validity: the tendency to exclude potential participants because of the elevated suicide risk may reduce generalizability within clinical settings; and (3) app regulation and definition: the lack of a standardized classification system for mHealth intervention type points to the need for better definition of the scope of such technologies to promote safe practice. Trial Registration: PROSPERO CRD42017072899; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72899 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8635 %M 31939744 %R 10.2196/12516 %U https://mhealth.jmir.org/2020/1/e12516 %U https://doi.org/10.2196/12516 %U http://www.ncbi.nlm.nih.gov/pubmed/31939744 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 1 %P e14213 %T A Gig mHealth Economy Framework: Scoping Review of Internet Publications %A Alanezi,Fahad %A Alanzi,Turki %+ Health Information Management and Technology Department, College of Public Health, Imam Abdulrahman Bin Faisal University, 2835 King Faisal Road, Dammam, Saudi Arabia, 966 133331211, talanzi@iau.edu.sa %K gig economy %K gigs %K mHealth %K sharing economy %K gig mHealth %D 2020 %7 15.1.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The gig economy (characterized by short-term contracts rather than being a full-time employee in an organization) is one of the most recent and important tendencies that have expanded through the global economic market thanks to advances in internet and communication technologies. Similarly, mobile health (mHealth) technologies have also evolved rapidly with the development of the internet and mobile apps, attracting attention globally for their health care benefits. Objective: This study aimed to propose an integration of mHealth within the framework of the gig economy that leads to a new dimension of health care services and the proposal of a new term: gig mHealth. Methods: A review and systematic search of articles, books, and opinions that allowed for answering the research questions were executed through the internet. In this sense, the concept of the gig economy and examples, advantages and disadvantages, were reviewed. Similarly, the general characteristics of mHealth technologies were revised. In addition, the role of technology in supporting the development of the gig economy and mHealth technologies and the interactions between them were investigated. Results: The findings suggested that the gig economy is characterized by its flexibility in working hours, on-demand work, free agents, freelancing, freedom in the choice of work, and independent contracts. In addition, an analysis of an mHealth system indicated that it was composed of patients, specialists, nurses, and database administrators. In this system, patients and specialists or nurses are connected to cloud services for the transmission of data and medical information through a mobile app. Here, the administrators update the database and app features, among other technical tasks. Conversely, a general structure of an integrated gig mHealth system was developed. In this structure, the mHealth care services and the mHealth care activities were incorporated into a gig economy model. In addition, a practical example of an integrated view of a gig economy app in mHealth that illustrates the interaction between the patients (consumers) and providers (partners) of mHealth care services, mHealth care activities, health care professionals, and individual contractors was presented. The consumers and providers were interconnected with the health care company, brand, or firm through digital means using a mobile app or Windows platforms. Conclusions: The analysis carried out in this study suggested the possibility of integrating mHealth within the framework of the gig economy enhancing health care service delivery and the management of health care activities. The following 4 major areas of apps proposed in the mHealth framework that can catalyze the operations using the features of the gig economy were sharing/renting medical and diagnostic equipment and resources, on-demand appointments/self-health management, on-demand health care services, and assigning health care activities/gigs to individual contractors. This integration leads to a new dimension for health care services and the proposal of a new term: gig mHealth. %M 31939745 %R 10.2196/14213 %U https://mhealth.jmir.org/2020/1/e14213 %U https://doi.org/10.2196/14213 %U http://www.ncbi.nlm.nih.gov/pubmed/31939745 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 1 %P e16424 %T An Integrated mHealth App for Dengue Reporting and Mapping, Health Communication, and Behavior Modification: Development and Assessment of Mozzify %A Herbuela,Von Ralph Dane Marquez %A Karita,Tomonori %A Francisco,Micanaldo Ernesto %A Watanabe,Kozo %+ Graduate School of Science and Engineering, Ehime University, Bunkyo-cho 3, Matsuyama, Japan, 81 89-927-9847, watanabe_kozo@cee.ehime-u.ac.jp %K dengue fever %K mHealth %K real-time surveillance %K health communication %K behavior modification %D 2020 %7 8.1.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: For the last 10 years, mobile phones have provided the global health community with innovative and cost-effective strategies to address the challenges in the prevention and management of dengue fever. Objective: The aim is to introduce and describe the design and development process of Mozzify, an integrated mobile health (mHealth) app that features real-time dengue fever case reporting and mapping system, health communication (real-time worldwide news and chat forum/timeline, within-app educational videos, links to local and international health agency websites, interactive signs and symptoms checker, and a hospital directions system), and behavior modification (reminders alert program on the preventive practices against dengue fever). We also aim to assess Mozzify in terms of engagement and information-sharing abilities, functionality, aesthetics, subjective quality, and perceived impact. Methods: The main goals of the Mozzify app were to increase awareness, improve knowledge, and change attitudes about dengue fever, health care-seeking behavior, and intention-to-change behavior on preventive practices for dengue fever among users. It was assessed using the Mobile Application Rating Scale (MARS) among 50 purposively sampled individuals: public health experts (n=5), environment and health-related researchers (n=23), and nonclinical (end users) participants (n=22). Results: High acceptability and excellent satisfaction ratings (mean scores ≥4.0 out of 5) based on the MARS subscales indicate that the app has excellent user design, functionality, usability, engagement, and information among public health experts, environment and health-related researchers, and end users. The app’s subjective quality (recommending the app to other people and the app’s overall star rating), and specific quality (increase awareness, improve knowledge, and change attitudes about dengue fever; health care-seeking behavior; and intention-to-change behavior on preventive practices for dengue fever) also obtained excellent satisfaction ratings from the participants. Some issues and suggestions were raised during the focus group and individual discussions regarding the availability of the app for Android devices, language options limitations, provision of predictive surveillance, and inclusion of other mosquito-borne diseases. Conclusions: Mozzify may be a promising integrated strategic health intervention system for dengue fever case reporting and mapping; increase awareness, improve knowledge, and change attitude about dengue fever; and disseminating and sharing information on dengue fever among the general population and health experts. It also can be an effective aid in the successful translation of knowledge on preventive measures against dengue fever to practice. %M 31913128 %R 10.2196/16424 %U https://formative.jmir.org/2020/1/e16424 %U https://doi.org/10.2196/16424 %U http://www.ncbi.nlm.nih.gov/pubmed/31913128 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e15644 %T Clinically Meaningful Use of Mental Health Apps and its Effects on Depression: Mixed Methods Study %A Zhang,Renwen %A Nicholas,Jennifer %A Knapp,Ashley A %A Graham,Andrea K %A Gray,Elizabeth %A Kwasny,Mary J %A Reddy,Madhu %A Mohr,David C %+ Department of Communication Studies, Northwestern University, 2240 Campus Dr, MTS Program, Evanston, IL, 60208, United States, 1 8479976596, alicezhang@u.northwestern.edu %K mHealth %K mobile apps %K mental health %K engagement %D 2019 %7 20.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: User engagement is key to the effectiveness of digital mental health interventions. Considerable research has examined the clinical outcomes of overall engagement with mental health apps (eg, frequency and duration of app use). However, few studies have examined how specific app use behaviors can drive change in outcomes. Understanding the clinical outcomes of more nuanced app use could inform the design of mental health apps that are more clinically effective to users. Objective: This study aimed to classify user behaviors in a suite of mental health apps and examine how different types of app use are related to depression and anxiety outcomes. We also compare the clinical outcomes of specific types of app use with those of generic app use (ie, intensity and duration of app use) to understand what aspects of app use may drive symptom improvement. Methods: We conducted a secondary analysis of system use data from an 8-week randomized trial of a suite of 13 mental health apps. We categorized app use behaviors through a mixed methods analysis combining qualitative content analysis and principal component analysis. Regression analyses were used to assess the association between app use and levels of depression and anxiety at the end of treatment. Results: A total of 3 distinct clusters of app use behaviors were identified: learning, goal setting, and self-tracking. Each specific behavior had varied effects on outcomes. Participants who engaged in self-tracking experienced reduced depression symptoms, and those who engaged with learning and goal setting at a moderate level (ie, not too much or not too little) also had an improvement in depression. Notably, the combination of these 3 types of behaviors, what we termed “clinically meaningful use,” accounted for roughly the same amount of variance as explained by the overall intensity of app use (ie, total number of app use sessions). This suggests that our categorization of app use behaviors succeeded in capturing app use associated with better outcomes. However, anxiety outcomes were neither associated with specific behaviors nor generic app use. Conclusions: This study presents the first granular examination of user interactions with mental health apps and their effects on mental health outcomes. It has important implications for the design of mobile health interventions that aim to achieve greater user engagement and improved clinical efficacy. %M 31859682 %R 10.2196/15644 %U http://www.jmir.org/2019/12/e15644/ %U https://doi.org/10.2196/15644 %U http://www.ncbi.nlm.nih.gov/pubmed/31859682 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e16630 %T Old-Fashioned Technology in the Era of “Bling”: Is There a Future for Text Messaging in Health Care? %A Willcox,Jane C %A Dobson,Rosie %A Whittaker,Robyn %+ School of Allied Health, Human Services and Sport, La Trobe University, Plenty Rd, Bundoora, 3083, Australia, 61 94791520, j.willcox@latrobe.edu.au %K text messaging %K mHealth %K behavior change %K digital health %D 2019 %7 20.12.2019 %9 Viewpoint %J J Med Internet Res %G English %X In the quest to discover the next high-technology solution to solve many health problems, proven established technologies are often overlooked in favor of more “technologically advanced” systems that have not been fully explored for their applicability to support behavior change theory, or used by consumers. Text messages or SMS is one example of an established technology still used by consumers, but often overlooked as part of the mobile health (mHealth) toolbox. The purpose of this paper is to describe the benefits of text messages as a health promotion modality and to advocate for broader scale implementation of efficacious text message programs. Text messaging reaches consumers in a ubiquitous real-time exchange, contrasting the multistep active engagement required for apps and wearables. It continues to be the most widely adopted and least expensive mobile phone function. As an intervention modality, text messaging has taught researchers substantial lessons about tailored interactive health communication; reach and engagement, particularly in low-resource settings; and embedding of behavior change models into digital health. It supports behavior change techniques such as reinforcement, prompts and cues, goal setting, feedback on performance, support, and progress review. Consumers have provided feedback to indicate that text messages can provide them with useful information, increase perceived support, enhance motivation for healthy behavior change, and provide prompts to engage in health behaviors. Significant evidence supports the effectiveness of text messages alone as part of an mHealth toolbox or in combination with health services, to support healthy behavior change. Systematic reviews have consistently reported positive effects of text message interventions for health behavior change and disease management including smoking cessation, medication adherence, and self-management of long-term conditions and health, including diabetes and weight loss. However, few text message interventions are implemented on a large scale. There is still much to be learned from investing in text messaging delivered research. When a modality is known to be effective, we should be learning from large-scale implementation. Many other technologies currently suffer from poor long-term engagement, the digital divide within society, and low health and technology literacy of users. Investing in and incorporating the learnings and lessons from large-scale text message interventions will strengthen our way forward in the quest for the ultimate digitally delivered behavior change model. %M 31859678 %R 10.2196/16630 %U http://www.jmir.org/2019/12/e16630/ %U https://doi.org/10.2196/16630 %U http://www.ncbi.nlm.nih.gov/pubmed/31859678 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e14012 %T Peer Mentorship via Mobile Phones for Newly Diagnosed HIV-Positive Youths in Clinic Care in Khayelitsha, South Africa: Mixed Methods Study %A Hacking,Damian %A Mgengwana-Mbakaza,Zodwa %A Cassidy,Tali %A Runeyi,Pumeza %A Duran,Laura Trivino %A Mathys,Ruth Henwood %A Boulle,Andrew %+ Medecins Sans Frontieres, Operational Centre Brussels, South African Mission, 1st floor Isivivana Centre, 8 Mzala Street, Khayelitsha, 7784, South Africa, 27 213645490, damianuct@gmail.com %K youth %K HIV %K peer influence %K retention in care %K mobile phone %K patient navigator %D 2019 %7 10.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Youths in South Africa are poor utilizers of HIV health services. Medecins Sans Frontieres has been piloting youth-adapted services at a youth clinic in Khayelitsha, including a peer virtual mentorship program over mobile phones, piloted from March 2015 to May 2016. Objective: The objective of this study was to evaluate the effect of the peer mentorship program on youth engagement with HIV services and explore the acceptability of the program to both mentors and mentees. Methods: Antiretroviral initiation, retention in care (RIC), and viral load suppression were compared between youths engaged in the virtual mentorship program and two matched controls. In-depth interviews were also conducted for 5 mentors and 5 mentees to explore acceptability and impact of the program. Results: A total of 40 youths were recruited into the virtual mentorship program over the study period. Of these, data were obtained for 35 and 2 matched controls were randomly sampled for each. There was no difference in baseline demographics (eg, age, gender, and CD4 count). Mentees had increased antiretroviral initiation (28/35, 80% vs 30/70, 42% in matched controls) and viral load completion (28/35, 80% vs 32/70, 45%); however, no differences were found in viral load suppression or RIC at 6 or 12 months. Mentors reported being motivated to participate in the program because of previous personal struggles with HIV and a desire to help their peers. Mentees reported fears of disclosure and lack of acceptance of their status as barrier to accessing services, but they felt free to talk to their mentors, valued the mentorship program, and indicated a preference for phone calls. Conclusions: Peer mentorship in youths is acceptable to both mentors and mentees and appears to increase linkage to care and viral load completion rates. %M 31821150 %R 10.2196/14012 %U https://www.jmir.org/2019/12/e14012 %U https://doi.org/10.2196/14012 %U http://www.ncbi.nlm.nih.gov/pubmed/31821150 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e15401 %T Effectiveness of Smartphone App–Based Interactive Management on Glycemic Control in Chinese Patients With Poorly Controlled Diabetes: Randomized Controlled Trial %A Zhang,Lei %A He,Xingxing %A Shen,Yun %A Yu,Haoyong %A Pan,Jiemin %A Zhu,Wei %A Zhou,Jian %A Bao,Yuqian %+ Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233, China, 86 2164369181, zhoujian@sjtu.edu.cn %K app %K self-management %K interactive management %K guidance %K glycated hemoglobin A1c %K diabetes %D 2019 %7 9.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In recent years, the rapid development of mobile medical technology has provided multiple ways for the long-term management of chronic diseases, especially diabetes. As a new type of management model, smartphone apps are global, convenient, cheap, and interactive. Although apps were proved to be more effective at glycemic control, compared with traditional computer- and Web-based telemedicine technologies, how to gain a further and sustained improvement is still being explored. Objective: The objective of this study was to investigate the effectiveness of an app-based interactive management model by a professional health care team on glycemic control in Chinese patients with poorly controlled diabetes. Methods: This study was a 6-month long, single-center, prospective randomized controlled trial. A total of 276 type 1 or type 2 diabetes patients were enrolled and randomized to the control group (group A), app self-management group (group B), and app interactive management group (group C) in a 1:1:1 ratio. The primary outcome was the change in glycated hemoglobin (HbA1c) level. Missing data were handled by multiple imputation. Results: At months 3 and 6, all 3 groups showed significant decreases in HbA1c levels (all P<.05). Patients in the app interactive management group had a significantly lower HbA1clevel than those in the app self-management group at 6 months (P=.04). The average HbA1c reduction in the app interactive management group was larger than that in the app self-management and control groups at both months 3 and 6 (all P<.05). However, no differences in HbA1c reduction were observed between the app self-management and control groups at both months 3 and 6 (both P>.05). Multivariate line regression analyses also showed that the app interactive management group was associated with the larger reduction of HbA1c compared with groups A and B at both months 3 and 6 (all P>.05). In addition, the app interactive management group had better control of triglyceride and high-density lipoprotein cholesterol levels at both months 3 and 6 compared with baseline (both P<.05). Conclusions: In Chinese patients with poorly controlled diabetes, it was difficult to achieve long-term effective glucose improvement by using app self-management alone, but combining it with interactive management can help achieve rapid and sustained glycemic control. Trial Registration: ClinicalTrials.gov NCT02589730; https://clinicaltrials.gov/ct2/show/NCT02589730. %M 31815677 %R 10.2196/15401 %U https://www.jmir.org/2019/12/e15401 %U https://doi.org/10.2196/15401 %U http://www.ncbi.nlm.nih.gov/pubmed/31815677 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 12 %P e14909 %T Validation of Single Centre Pre-Mobile Atrial Fibrillation Apps for Continuous Monitoring of Atrial Fibrillation in a Real-World Setting: Pilot Cohort Study %A Zhang,Hui %A Zhang,Jie %A Li,Hong-Bao %A Chen,Yi-Xin %A Yang,Bin %A Guo,Yu-Tao %A Chen,Yun-Dai %+ Department of Cardiology, Chinese PLA General Hospital, 28 Fuxing Rd, Beijing, 100853, China, 86 13810021492, guoyutao2010@126.com %K atrial fibrillation %K photoplethysmography %K continuous detection %K accuracy %K smartphone %K smart band %K algorithm %D 2019 %7 3.12.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Atrial fibrillation is the most common recurrent arrhythmia in clinical practice, with most clinical events occurring outside the hospital. Low detection and nonadherence to guidelines are the primary obstacles to atrial fibrillation management. Photoplethysmography is a novel technology developed for atrial fibrillation screening. However, there has been limited validation of photoplethysmography-based smart devices for the detection of atrial fibrillation and its underlying clinical factors impacting detection. Objective: This study aimed to explore the feasibility of photoplethysmography-based smart devices for the detection of atrial fibrillation in real-world settings. Methods: Subjects aged ≥18 years (n=361) were recruited from September 14 to October 16, 2018, for screening of atrial fibrillation with active measurement, initiated by the users, using photoplethysmography-based smart wearable devices (ie, a smart band or smart watches). Of these, 200 subjects were also automatically and periodically monitored for 14 days with a smart band. The baseline diagnosis of “suspected” atrial fibrillation was confirmed by electrocardiogram and physical examination. The sensitivity and accuracy of photoplethysmography-based smart devices for monitoring atrial fibrillation were evaluated. Results: A total of 2353 active measurement signals and 23,864 periodic measurement signals were recorded. Eleven subjects were confirmed to have persistent atrial fibrillation, and 20 were confirmed to have paroxysmal atrial fibrillation. Smart devices demonstrated >91% predictive ability for atrial fibrillation. The sensitivity and specificity of devices in detecting atrial fibrillation among active recording of the 361 subjects were 100% and about 99%, respectively. For subjects with persistent atrial fibrillation, 127 (97.0%) active measurements and 2240 (99.2%) periodic measurements were identified as atrial fibrillation by the algorithm. For subjects with paroxysmal atrial fibrillation, 36 (17%) active measurements and 717 (19.8%) periodic measurements were identified as atrial fibrillation by the algorithm. All persistent atrial fibrillation cases could be detected as “atrial fibrillation episodes” by the photoplethysmography algorithm on the first monitoring day, while 14 (70%) patients with paroxysmal atrial fibrillation demonstrated “atrial fibrillation episodes” within the first 6 days. The average time to detect paroxysmal atrial fibrillation was 2 days (interquartile range: 1.25-5.75) by active measurement and 1 day (interquartile range: 1.00-2.00) by periodic measurement (P=.10). The first detection time of atrial fibrillation burden of <50% per 24 hours was 4 days by active measurement and 2 days by periodic measurementThe first detection time of atrial fibrillation burden of >50% per 24 hours was 1 day for both active and periodic measurements (active measurement: P=.02, periodic measurement: P=.03). Conclusions: Photoplethysmography-based smart devices demonstrated good atrial fibrillation predictive ability in both active and periodic measurements. However, atrial fibrillation type could impact detection, resulting in increased monitoring time. Trial Registration: Chinese Clinical Trial Registry of the International Clinical Trials Registry Platform of the World Health Organization ChiCTR-OOC-17014138; http://www.chictr.org.cn/showprojen.aspx?proj=24191. %M 31793887 %R 10.2196/14909 %U https://www.jmir.org/2019/12/e14909 %U https://doi.org/10.2196/14909 %U http://www.ncbi.nlm.nih.gov/pubmed/31793887 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e14730 %T Mobile Health Apps for Self-Management of Rheumatic and Musculoskeletal Diseases: Systematic Literature Review %A Najm,Aurélie %A Gossec,Laure %A Weill,Catherine %A Benoist,David %A Berenbaum,Francis %A Nikiphorou,Elena %+ Department of Rheumatology, Nantes University Hospital, 1, place Alexis Ricordeau, Nantes, 44000, France, 33 633444793, aurelie.najm@gmail.com %K mobile health %K self-management %K arthritis %K telemedicine %K musculoskeletal diseases %D 2019 %7 26.11.2019 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Although the increasing availability of mobile health (mHealth) apps may enable people with rheumatic and musculoskeletal diseases (RMDs) to better self-manage their health, there is a general lack of evidence on ways to ensure appropriate development and evaluation of apps. Objective: This study aimed to obtain an overview on existing mHealth apps for self-management in patients with RMDs, focusing on content and development methods. Methods: A search was performed up to December 2017 across 5 databases. For each publication relevant to an app for RMDs, information on the disease, purpose, content, and development strategies was extracted and qualitatively assessed. Results: Of 562 abstracts, 32 were included in the analysis. Of these 32 abstracts, 11 (34%) referred to an app linked to a connected device. Most of the apps targeted rheumatoid arthritis (11/32, 34%). The top three aspects addressed by the apps were pain (23/32, 71%), fatigue (15/32, 47%), and physical activity (15/32, 47%). The development process of the apps was described in 84% (27/32) of the articles and was of low to moderate quality in most of the cases. Despite most of the articles having been published within the past two years, only 5 apps were still commercially available at the time of our search. Moreover, only very few studies showed improvement of RMD outcome measures. Conclusions: The development process of most apps was of low or moderate quality in many studies. Owing to the increasing RMD patients’ willingness to use mHealth apps for self-management, optimal standards and quality assurance of new apps are mandatory. %M 31769758 %R 10.2196/14730 %U https://mhealth.jmir.org/2019/11/e14730 %U https://doi.org/10.2196/14730 %U http://www.ncbi.nlm.nih.gov/pubmed/31769758 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e12442 %T Assessment of a Mobile App by Adolescents and Young Adults With Cystic Fibrosis: Pilot Evaluation %A Rudolf,Isa %A Pieper,Katharina %A Nolte,Helga %A Junge,Sibylle %A Dopfer,Christian %A Sauer-Heilborn,Annette %A Ringshausen,Felix C %A Tümmler,Burkhard %A von Jan,Ute %A Albrecht,Urs-Vito %A Fuge,Jan %A Hansen,Gesine %A Dittrich,Anna-Maria %+ Pediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, 30625, Germany, 49 17615329785, dittrich.anna-maria@mh-hannover.de %K mobile phone %K mobile phone app %K mHealth %K self-management %K adolescence %K cystic fibrosis %D 2019 %7 21.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Cystic fibrosis (CF) continues to be the most common life-limiting chronic pulmonary disease in adolescents and young adults. Treatment of CF demands a high treatment time investment to slow the progression of lung function decline, the most important contributor to morbidity and mortality. Adherence is challenging in CF due to the high treatment burden and the lack of immediate health consequences in case of nonadherence. Lung function decline is particularly pronounced in the transition phase between 12 and 24 years of age. The improvement of self-management and self-responsibility and independence from parents and desire for normalcy are conflicting aspects for many adolescents with CF, which influence adherence to the time-consuming pulmonary therapy. Mobile health (mHealth) care apps could help to support self-management and independence and thereby reconcile seemingly conflicting goals to improve adherence, quality of life, and ultimately CF life expectancy. Objective: This study aimed to (1) assess user behavior and satisfaction among adolescents and young adults with CF over an observation period of three months using an mHealth app; (2) identify areas of improvement for this mHealth app; and (3) compare overall and disease-specific satisfaction, lung function, and anthropometry before and after using the mHealth app. Methods: A total of 27 adolescents and young adults with CF (age range 12-24 years, mean age 16 years, SD 3 years; 14 females, 11 males) used a free mHealth app for three months of whom 25 provided questionnaire data for analysis at the end of the study. Data collection was carried out using questionnaires on usage characteristics and life satisfaction, and standardized assessment of lung function and anthropometry. Results: The use of the reminder function for medication declined from 70% (15/21) of the participants at week 4 to 65% (13/20) at week 8 of the observation period. At the end of the study, only 17% (4/23) of the participants wanted to continue using the app. Nevertheless, 56% (14/25) of participants saw the mobile app as a support for everyday life. Potential improvements targeting hedonistic qualities were identified to improve mHealth app adherence. Comparisons of satisfaction with different life aspects hinted at improvements or stabilization for the subitem respiration and the subitem lack of handicap by CF, suggesting that app use might stabilize certain CF-specific aspects of the weighted satisfaction with life. Lung function and anthropometry were not affected consistently. Conclusions: Most of the patients did not want to continue using the app after the study period. Only a few CF-specific aspects of weighted life satisfaction were possibly stabilized by the mHealth app; clinical parameters were not affected. Adaptation of the functions to adolescent-specific needs could improve the long-term use and thus positively affect the disease course. %M 31750841 %R 10.2196/12442 %U https://mhealth.jmir.org/2019/11/e12442 %U https://doi.org/10.2196/12442 %U http://www.ncbi.nlm.nih.gov/pubmed/31750841 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 7 %N 4 %P e15601 %T Interpretability and Class Imbalance in Prediction Models for Pain Volatility in Manage My Pain App Users: Analysis Using Feature Selection and Majority Voting Methods %A Rahman,Quazi Abidur %A Janmohamed,Tahir %A Clarke,Hance %A Ritvo,Paul %A Heffernan,Jane %A Katz,Joel %+ Department of Computer Science, Lakehead University, 955 Oliver Road, Thunder Bay, ON, Canada, 1 (807) 346 7789, quazi.rahman@lakeheadu.ca %K chronic pain %K pain volatility %K data mining %K cluster analysis %K machine learning %K prediction model %K Manage My Pain %K pain app %D 2019 %7 20.11.2019 %9 Original Paper %J JMIR Med Inform %G English %X Background: Pain volatility is an important factor in chronic pain experience and adaptation. Previously, we employed machine-learning methods to define and predict pain volatility levels from users of the Manage My Pain app. Reducing the number of features is important to help increase interpretability of such prediction models. Prediction results also need to be consolidated from multiple random subsamples to address the class imbalance issue. Objective: This study aimed to: (1) increase the interpretability of previously developed pain volatility models by identifying the most important features that distinguish high from low volatility users; and (2) consolidate prediction results from models derived from multiple random subsamples while addressing the class imbalance issue. Methods: A total of 132 features were extracted from the first month of app use to develop machine learning–based models for predicting pain volatility at the sixth month of app use. Three feature selection methods were applied to identify features that were significantly better predictors than other members of the large features set used for developing the prediction models: (1) Gini impurity criterion; (2) information gain criterion; and (3) Boruta. We then combined the three groups of important features determined by these algorithms to produce the final list of important features. Three machine learning methods were then employed to conduct prediction experiments using the selected important features: (1) logistic regression with ridge estimators; (2) logistic regression with least absolute shrinkage and selection operator; and (3) random forests. Multiple random under-sampling of the majority class was conducted to address class imbalance in the dataset. Subsequently, a majority voting approach was employed to consolidate prediction results from these multiple subsamples. The total number of users included in this study was 879, with a total number of 391,255 pain records. Results: A threshold of 1.6 was established using clustering methods to differentiate between 2 classes: low volatility (n=694) and high volatility (n=185). The overall prediction accuracy is approximately 70% for both random forests and logistic regression models when using 132 features. Overall, 9 important features were identified using 3 feature selection methods. Of these 9 features, 2 are from the app use category and the other 7 are related to pain statistics. After consolidating models that were developed using random subsamples by majority voting, logistic regression models performed equally well using 132 or 9 features. Random forests performed better than logistic regression methods in predicting the high volatility class. The consolidated accuracy of random forests does not drop significantly (601/879; 68.4% vs 618/879; 70.3%) when only 9 important features are included in the prediction model. Conclusions: We employed feature selection methods to identify important features in predicting future pain volatility. To address class imbalance, we consolidated models that were developed using multiple random subsamples by majority voting. Reducing the number of features did not result in a significant decrease in the consolidated prediction accuracy. %M 31746764 %R 10.2196/15601 %U http://medinform.jmir.org/2019/4/e15601/ %U https://doi.org/10.2196/15601 %U http://www.ncbi.nlm.nih.gov/pubmed/31746764 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e15681 %T Exploring People’s Candidacy for Mobile Health–Supported HIV Testing and Care Services in Rural KwaZulu-Natal, South Africa: Qualitative Study %A Adeagbo,Oluwafemi %A Herbst,Carina %A Blandford,Ann %A McKendry,Rachel %A Estcourt,Claudia %A Seeley,Janet %A Shahmanesh,Maryam %+ Africa Health Research Institute, KwaZulu-Natal, R168 Hlabisa Road Somkhele, PO Box 198, Mtubatuba, 3935, South Africa, 27 355507695, Oluwafemi.Adeagbo@ahri.org %K mHealth %K antiretroviral therapy %K HIV testing %K South Africa %K candidacy framework %D 2019 %7 18.11.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of mobile communication technologies (mHealth: mobile health) in chronic disease management has grown significantly over the years. mHealth interventions have the potential to decentralize access to health care and make it convenient, particularly in resource-constrained settings. It is against this backdrop that we aimed to codevelop (with potential users) a new generation of mobile phone–connected HIV diagnostic tests and Web-based clinical care pathways needed for optimal delivery of decentralized HIV testing, prevention, and care in low- and middle-income countries. Objective: The aim of this study was to understand ways in which an mHealth intervention could be developed to overcome barriers to existing HIV testing and care services and promote HIV self-testing and linkage to prevention and care in a poor, HIV hyperendemic community in rural KwaZulu-Natal, South Africa. Methods: A total of 54 in-depth interviews and 9 focus group discussions were conducted with potential users (including health care providers) in 2 different communities. Theoretically informed by the candidacy framework, themes were identified from the interview transcripts, manually coded, and thematically analyzed. Results: Participants reported barriers, such as fear of HIV identity, stigma, long waiting hours, clinic space, and health care workers’ attitudes, as major impediments to effective uptake of HIV testing and care services. People continued to reassess their candidacy for HIV testing and care services on the basis of their experiences and how they or others were treated within the health systems. Despite the few concerns raised about new technology, mobile phone–linked HIV testing was broadly acceptable to potential users (particularly men and young people) and providers because of its privacy (individual control of HIV testing over health provider–initiated testing), convenience (individual time and place of choice for HIV testing versus clinic-based testing), and time saving. Conclusions: Mobile phone–connected HIV testing and Web-based clinical care and prevention pathways have the potential to support access to HIV prevention and care, particularly for young people and men. Although mHealth provides a way for individuals to test their candidacy for HIV services, the barriers that can make the service unattractive at the clinic level will also need to be addressed if potential demand is to turn into actual demand. %M 31738174 %R 10.2196/15681 %U https://www.jmir.org/2019/11/e15681 %U https://doi.org/10.2196/15681 %U http://www.ncbi.nlm.nih.gov/pubmed/31738174 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e14458 %T Impact of a Mobile App–Based Health Coaching and Behavior Change Program on Participant Engagement and Weight Status of Overweight and Obese Children: Retrospective Cohort Study %A Cueto,Victor %A Wang,C Jason %A Sanders,Lee Michael %+ Division of General Internal Medicine, Department of Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, H-251, Newark, NJ, 07101, United States, 1 973 972 5672, vcueto@alumni.stanford.edu %K child obesity %K mHealth %K mobile apps %K health coaching %K health behavior %K self-monitoring %K behavior change %D 2019 %7 15.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Effective treatment of obesity in children and adolescents traditionally requires frequent in-person contact, and it is often limited by low participant engagement. Mobile health tools may offer alternative models that enhance participant engagement. Objective: The aim of this study was to assess child engagement over time, with a mobile app–based health coaching and behavior change program for weight management, and to examine the association between engagement and change in weight status. Methods: This was a retrospective cohort study of user data from Kurbo, a commercial program that provides weekly individual coaching via video chat and supports self-monitoring of health behaviors through a mobile app. Study participants included users of Kurbo between March 2015 and March 2017, who were 5 to 18 years old and who were overweight or obese (body mass index; BMI ≥ 85th percentile or ≥ 95th percentile) at baseline. The primary outcome, engagement, was defined as the total number of health coaching sessions received. The secondary outcome was change in weight status, defined as the change in BMI as a percentage of the 95th percentile (%BMIp95). Analyses of outcome measures were compared across three initial commitment period groups: 4 weeks, 12 to 16 weeks, or 24 weeks. Multivariable linear regression models were constructed to adjust outcomes for the independent variables of sex, age group (5-11 years, 12-14 years, and 15-18 years), and commitment period. A sensitivity analysis was conducted, excluding a subset of participants involuntarily assigned to the 12- to 16-week commitment period by an employer or health plan. Results: A total of 1120 participants were included in analyses. At baseline, participants had a mean age of 12 years (SD 2.5), mean BMI percentile of 96.6 (SD 3.1), mean %BMIp95 of 114.5 (SD 16.5), and they were predominantly female 68.04% (762/1120). Participant distribution across commitment periods was 26.07% (292/1120) for 4 weeks, 61.61% (690/1120) for 12-16 weeks, and 12.32% (138/1120) for 24 weeks. The median coaching sessions (interquartile range) received were 8 (3-16) for the 4-week group, 9 (5-12) for the 12- to 16-week group, and 19 (11-25) for the 24-week group (P<.001). Adjusted for sex and age group, participants in the 4- and 12-week groups participated in –8.03 (95% CI –10.19 to –5.87) and –9.34 (95% CI –11.31 to –7.39) fewer coaching sessions, compared with those in the 24-week group (P<.001). Adjusted for commitment period, sex, and age group, the overall mean change in %BMIp95 was –0.21 (95% CI –0.25 to –0.17) per additional coaching session (P<.001). Conclusions: Among overweight and obese children using a mobile app–based health coaching and behavior change program, increased engagement was associated with longer voluntary commitment periods, and increased number of coaching sessions was associated with decreased weight status. %M 31730041 %R 10.2196/14458 %U http://mhealth.jmir.org/2019/11/e14458/ %U https://doi.org/10.2196/14458 %U http://www.ncbi.nlm.nih.gov/pubmed/31730041 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 11 %P e16393 %T Smartphone Apps to Support Coordinated Specialty Care for Prodromal and Early Course Schizophrenia Disorders: Systematic Review %A Camacho,Erica %A Levin,Leonard %A Torous,John %+ Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, United States, 1 6176676799, jtorous@bidmc.harvard.edu %K smartphones %K mobile phones %K app %K schizophrenia %D 2019 %7 12.11.2019 %9 Review %J J Med Internet Res %G English %X Background: Demand for mental health services, especially for clinical high-risk and early psychosis, has increased, creating a need for new solutions to increase access to and quality of care. Smartphones and mobile technology are potential tools to support coordinated specialty care for early psychosis, given their potential to augment the six core roles of care: case management and team leadership, recovery-oriented psychotherapy, medication management, support for employment and education, coordination with primary care services, and family education and support. However, the services smartphones are actually offering specifically for coordinated specialty care and the level of evidence are unknown. Objective: This study aimed to review the published literature on smartphone technology to enhance care for patients with prodromal and early course psychosis and schizophrenia and to analyze studies by type, aligned with coordinated specialty care domains. Methods: A systematic literature search was conducted on August 16 and 17, 2019, using the PubMed, EMBASE, Web of Sciences, and PsycINFO electronic databases. The eligible studies were reviewed and screened based on inclusion and exclusion criteria. Results: The search uncovered 388 unique results, of which 32 articles met the initial inclusion criteria; 21 eligible studies on 16 unique app platforms were identified. Feasibility studies showed a high user engagement and interest among patients, monitoring studies demonstrated a correlation between app assessments and clinical outcomes, and intervention studies indicated that these apps have the potential to advance care. Eighteen studies reported on app use for the case management roles of coordinated specialty care. No app studies focused on employment and education, coordination with primary care services, and family education and support. Conclusions: Although the published literature on smartphone apps for prodromal and first-episode psychosis is small, it is growing exponentially and holds promise to augment both monitoring and interventions. Although the research results and protocols for app studies are not well aligned with all coordinated specialty care roles today, high rates of adoption and feasibility suggest the potential for future efforts. These results will be used to develop coordinated specialty care–specific app evaluation scales and toolkits. %M 31714250 %R 10.2196/16393 %U http://www.jmir.org/2019/11/e16393/ %U https://doi.org/10.2196/16393 %U http://www.ncbi.nlm.nih.gov/pubmed/31714250 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e15122 %T Examining Mobile Technologies to Support Older Adults With Dementia Through the Lens of Personhood and Human Needs: Scoping Review %A Koo,Bon Mi %A Vizer,Lisa M %+ SSK Research Center for Mental Health and Communal Society, Kwangwoon University, Chambit 604, 20 Gwangun-ro, Nowon-gu, Seoul, 01897, Republic of Korea, 82 2 940 5430, bmkmon@gmail.com %K dementia %K Alzheimer disease %K mobile health %K consumer health informatics %K personhood %K systematic review %K smartphone %K mobile phone %K tablet computers %D 2019 %7 11.11.2019 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: With the world’s rapidly growing older adult population, there is an increase in the number of people living with dementia. This growth leads to a strain on their caregivers and our health care system and to an increased attention on mitigating strain by using mobile technology to sustain the independence of people with dementia. However, less attention is given to whether these technologies meet the stated and unstated needs of people with dementia. Objective: The aim of this study was to provide an overview of the current research on mobile technologies for people with dementia, considering the current research through the lens of personhood and human needs, and to identify any gaps that represent research opportunities. Methods: We performed a systematic search in Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE), and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2018. We screened 5560 articles and identified 24 that met our inclusion and exclusion criteria. We then performed thematic analysis to organize the articles by the types of support mobile technologies provide and mapped those types of support to human needs to identify the gaps in support. Results: Articles described research on mobile technologies that support people with dementia to (1) perform daily activities, (2) maintain social interaction, (3) aid memory, (4) engage in leisure activities, (5) track location, and (6) monitor health. At least one type of support mapped to each human need, with most supporting lower-level needs such as physiological and safety needs. Little attention seems to be paid to personhood. Conclusions: Mobile technologies that support daily activities, relationships, memory, leisure activities, health, and safety can partially compensate for decreased function owing to dementia, but the human needs of people with dementia are often not adequately considered. Most technologies support basic physiological and safety needs, whereas many pay little attention to higher-level needs such as self-esteem and agency. Important research opportunities include using person-centered methods to develop technology to meet higher-level needs and to preserve personhood by incorporating human and psychological needs of people with dementia along with ethical considerations. %M 31710305 %R 10.2196/15122 %U https://mhealth.jmir.org/2019/11/e15122 %U https://doi.org/10.2196/15122 %U http://www.ncbi.nlm.nih.gov/pubmed/31710305 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e15301 %T Mind the App: Considerations for the Future of Mobile Health in Canada %A Zawati,Ma'n H %A Lang,Michael %+ Centre of Genomics and Policy, McGill University, 740, Avenue Dr Penfield, Suite 5203, Montreal, QC, H3A 0G1, Canada, 1 5146686599, man.zawati@mcgill.ca %K smartphone %K mobile phone %K regulation %K patients %K physicians %D 2019 %7 4.11.2019 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Over the past decade, smartphone technology has become increasingly sophisticated and ubiquitous. Modern smartphones, now owned by more than three quarters of Canadians and 94% of millennials, perform an array of functions that are potentially useful in the health care context, such as tracking fitness data, enabling health record sharing, and providing user-friendly platforms for disease management. Approximately half of smartphone users have downloaded at least one health app, and clinicians are increasingly using them in their practice. However, despite widespread use, there is little evidence that supports their safety and efficacy. Few apps have been independently evaluated and many lack basic patient protections such as privacy policies. In this context, the demand for the regulation of mobile health apps has increased. Against this backdrop, regulators, including Health Canada, have begun to propose regulating the use of smartphones in health care. In this viewpoint, we respond to Health Canada’s recent proposal to regulate smartphone use in Canada according to a risk-based model. We argue that although Health Canada’s recent proposed approach is promising, it may require complementary regulation and oversight. %M 31682580 %R 10.2196/15301 %U https://mhealth.jmir.org/2019/11/e15301 %U https://doi.org/10.2196/15301 %U http://www.ncbi.nlm.nih.gov/pubmed/31682580 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e14452 %T Development of a Deep Learning Model for Dynamic Forecasting of Blood Glucose Level for Type 2 Diabetes Mellitus: Secondary Analysis of a Randomized Controlled Trial %A Faruqui,Syed Hasib Akhter %A Du,Yan %A Meka,Rajitha %A Alaeddini,Adel %A Li,Chengdong %A Shirinkam,Sara %A Wang,Jing %+ Center on Smart and Connected Health Technologies, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, United States, 1 210 450 8561, wangj1@uthscsa.edu %K type 2 diabetes %K long short-term memory (LSTM)-based recurrent neural networks (RNNs) %K glucose level prediction %K mobile health lifestyle data %D 2019 %7 1.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Type 2 diabetes mellitus (T2DM) is a major public health burden. Self-management of diabetes including maintaining a healthy lifestyle is essential for glycemic control and to prevent diabetes complications. Mobile-based health data can play an important role in the forecasting of blood glucose levels for lifestyle management and control of T2DM. Objective: The objective of this work was to dynamically forecast daily glucose levels in patients with T2DM based on their daily mobile health lifestyle data including diet, physical activity, weight, and glucose level from the day before. Methods: We used data from 10 T2DM patients who were overweight or obese in a behavioral lifestyle intervention using mobile tools for daily monitoring of diet, physical activity, weight, and blood glucose over 6 months. We developed a deep learning model based on long short-term memory–based recurrent neural networks to forecast the next-day glucose levels in individual patients. The neural network used several layers of computational nodes to model how mobile health data (food intake including consumed calories, fat, and carbohydrates; exercise; and weight) were progressing from one day to another from noisy data. Results: The model was validated based on a data set of 10 patients who had been monitored daily for over 6 months. The proposed deep learning model demonstrated considerable accuracy in predicting the next day glucose level based on Clark Error Grid and ±10% range of the actual values. Conclusions: Using machine learning methodologies may leverage mobile health lifestyle data to develop effective individualized prediction plans for T2DM management. However, predicting future glucose levels is challenging as glucose level is determined by multiple factors. Future study with more rigorous study design is warranted to better predict future glucose levels for T2DM management. %M 31682586 %R 10.2196/14452 %U https://mhealth.jmir.org/2019/11/e14452 %U https://doi.org/10.2196/14452 %U http://www.ncbi.nlm.nih.gov/pubmed/31682586 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e14198 %T Quality of Deaf and Hard-of-Hearing Mobile Apps: Evaluation Using the Mobile App Rating Scale (MARS) With Additional Criteria From a Content Expert %A Romero,Ryan Lee %A Kates,Frederick %A Hart,Mark %A Ojeda,Amanda %A Meirom,Itai %A Hardy,Stephen %+ College of Public Health and Health Professions, University of Florida, 1225 Center Drive, Gainesville, FL, United States, 1 (352) 273 6060, ryan.romero1000@ufl.edu %K eHealth %K mobile health %K mHealth %K mobile app %K hearing %K deaf persons %K sign language %D 2019 %7 30.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The spread of technology and dissemination of knowledge across the World Wide Web has prompted the development of apps for American Sign Language (ASL) translation, interpretation, and syntax recognition. There is limited literature regarding the quality, effectiveness, and appropriateness of mobile health (mHealth) apps for the deaf and hard-of-hearing (DHOH) that pose to aid the DHOH in their everyday communication and activities. Other than the star-rating system with minimal comments regarding quality, the evaluation metrics used to rate mobile apps are commonly subjective. Objective: This study aimed to evaluate the quality and effectiveness of DHOH apps using a standardized scale. In addition, it also aimed to identify content-specific criteria to improve the evaluation process by using a content expert, and to use the content expert to more accurately evaluate apps and features supporting the DHOH. Methods: A list of potential apps for evaluation was generated after a preliminary screening for apps related to the DHOH. Inclusion and exclusion criteria were developed to refine the master list of apps. The study modified a standardized rating scale with additional content-specific criteria applicable to the DHOH population for app evaluation. This was accomplished by including a DHOH content expert in the design of content-specific criteria. Results: The results indicate a clear distinction in Mobile App Rating Scale (MARS) scores among apps within the study’s three app categories: ASL translators (highest score=3.72), speech-to-text (highest score=3.6), and hard-of-hearing assistants (highest score=3.90). Of the 217 apps obtained from the search criteria, 21 apps met the inclusion and exclusion criteria. Furthermore, the limited consideration for measures specific to the target population along with a high app turnover rate suggests opportunities for improved app effectiveness and evaluation. Conclusions: As more mHealth apps enter the market for the DHOH population, more criteria-based evaluation is needed to ensure the safety and appropriateness of the apps for the intended users. Evaluation of population-specific mHealth apps can benefit from content-specific measurement criteria developed by a content expert in the field. %M 31670695 %R 10.2196/14198 %U http://mhealth.jmir.org/2019/10/e14198/ %U https://doi.org/10.2196/14198 %U http://www.ncbi.nlm.nih.gov/pubmed/31670695 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e15362 %T Methodological Challenges in Randomized Controlled Trials on Smartphone-Based Treatment in Psychiatry: Systematic Review %A Tønning,Morten Lindbjerg %A Kessing,Lars Vedel %A Bardram,Jakob Eivind %A Faurholt-Jepsen,Maria %+ Copenhagen Affective Disorder Research Center, Psychiatric Center Copenhagen, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9, Copenhagen, 2100, Denmark, 45 28975755, Morten.lindbjerg.toenning@regionh.dk %K psychiatry %K methodology %K smartphone %K mHealth %K mobile Health %K digital health %K digital psychiatry %K systematic review %D 2019 %7 27.10.2019 %9 Review %J J Med Internet Res %G English %X Background: Smartphone-based technology is developing at high speed, and many apps offer potential new ways of monitoring and treating a range of psychiatric disorders and symptoms. However, the effects of most available apps have not been scientifically investigated. Within medicine, randomized controlled trials (RCTs) are the standard method for providing the evidence of effects. However, their rigidity and long time frame may contrast with the field of information technology research. Therefore, a systematic review of methodological challenges in designing and conducting RCTs within mobile health is needed. Objective: This systematic review aimed to (1) identify and describe RCTs investigating the effect of smartphone-based treatment in adult patients with a psychiatric diagnosis, (2) discuss methodological challenges in designing and conducting individual trials, and (3) suggest recommendations for future trials. Methods: A systematic search in English was conducted in PubMed, PsycINFO, and EMBASE up to August 12, 2019. The search terms were (1) psychiatric disorders in broad term and for specific disorders AND (2) smartphone or app AND (3) RCT. The Consolidated Standards of Reporting Trials electronic health guidelines were used as a template for data extraction. The focus was on trial design, method, and reporting. Only trials having sufficient information on diagnosis and acceptable diagnostic procedures, having a smartphone as a central part of treatment, and using an RCT design were included. Results: A total of 27 trials comprising 3312 patients within a range of psychiatric diagnoses were included. Among them, 2 trials were concerning drug or alcohol abuse, 3 psychosis, 10 affective disorders, 9 anxiety and posttraumatic stress disorder, 1 eating disorder, and 1 attention-deficit/hyperactivity disorder. In addition, 1 trial used a cross-diagnostic design, 7 trials included patients with a clinical diagnosis that was subsequently assessed and validated by the researchers, and 11 trials had a sample size above 100. Generally, large between-trial heterogeneity and multiple approaches to patient recruitment, diagnostic procedures, trial design, comparator, outcome measures, and analyses were identified. Only 5 trials published a trial protocol. Furthermore, 1 trial provided information regarding technological updates, and only 18 trials reported on the conflicts of interest. No trial addressed the ethical aspects of using smartphones in treatment. Conclusions: This first systematic review of the methodological challenges in designing and conducting RCTs investigating smartphone-based treatment in psychiatric patients suggests an increasing number of trials but with a lower quality compared with classic medical RCTs. Heterogeneity and methodological issues in individual trials limit the evidence. Methodological recommendations are presented. %M 31663859 %R 10.2196/15362 %U http://www.jmir.org/2019/10/e15362/ %U https://doi.org/10.2196/15362 %U http://www.ncbi.nlm.nih.gov/pubmed/31663859 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 10 %P e14115 %T A Novel Mobile Tool (Somatomap) to Assess Body Image Perception Pilot Tested With Fashion Models and Nonmodels: Cross-Sectional Study %A Ralph-Nearman,Christina %A Arevian,Armen C %A Puhl,Maria %A Kumar,Rajay %A Villaroman,Diane %A Suthana,Nanthia %A Feusner,Jamie D %A Khalsa,Sahib S %+ Laureate Institute for Brain Research, 6655 S Yale Avenue, Tulsa, OK, 74133, United States, 1 918 502 5100, ChristinaRalphNearman@gmail.com %K body image %K body perception %K body representation %K body image disorder %K eating disorder %K mobile health %K mental health %K mobile app %K digital health %D 2019 %7 29.10.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Distorted perception of one’s body and appearance, in general, is a core feature of several psychiatric disorders including anorexia nervosa and body dysmorphic disorder and is operative to varying degrees in nonclinical populations. Yet, body image perception is challenging to assess, given its subjective nature and variety of manifestations. The currently available methods have several limitations including restricted ability to assess perceptions of specific body areas. To address these limitations, we created Somatomap, a mobile tool that enables individuals to visually represent their perception of body-part sizes and shapes as well as areas of body concerns and record the emotional valence of concerns. Objective: This study aimed to develop and pilot test the feasibility of a novel mobile tool for assessing 2D and 3D body image perception. Methods: We developed a mobile 2D tool consisting of a manikin figure on which participants outline areas of body concern and indicate the nature, intensity, and emotional valence of the concern. We also developed a mobile 3D tool consisting of an avatar on which participants select individual body parts and use sliders to manipulate their size and shape. The tool was pilot tested on 103 women: 65 professional fashion models, a group disproportionately exposed to their own visual appearance, and 38 nonmodels from the general population. Acceptability was assessed via a usability rating scale. To identify areas of body concern in 2D, topographical body maps were created by combining assessments across individuals. Statistical body maps of group differences in body concern were subsequently calculated using the formula for proportional z-score. To identify areas of body concern in 3D, participants’ subjective estimates from the 3D avatar were compared to corresponding measurements of their actual body parts. Discrepancy scores were calculated based on the difference between the perceived and actual body parts and evaluated using multivariate analysis of covariance. Results: Statistical body maps revealed different areas of body concern between models (more frequently about thighs and buttocks) and nonmodels (more frequently about abdomen/waist). Models were more accurate at estimating their overall body size, whereas nonmodels tended to underestimate the size of individual body parts, showing greater discrepancy scores for bust, biceps, waist, hips, and calves but not shoulders and thighs. Models and nonmodels reported high ease-of-use scores (8.4/10 and 8.5/10, respectively), and the resulting 3D avatar closely resembled their actual body (72.7% and 75.2%, respectively). Conclusions: These pilot results suggest that Somatomap is feasible to use and offers new opportunities for assessment of body image perception in mobile settings. Although further testing is needed to determine the applicability of this approach to other populations, Somatomap provides unique insight into how humans perceive and represent the visual characteristics of their body. %M 31469647 %R 10.2196/14115 %U http://mental.jmir.org/2019/10/e14115/ %U https://doi.org/10.2196/14115 %U http://www.ncbi.nlm.nih.gov/pubmed/31469647 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e15775 %T A Mobile Health App (Roadmap 2.0) for Patients Undergoing Hematopoietic Stem Cell Transplant: Qualitative Study on Family Caregivers' Perspectives and Design Considerations %A Chaar,Dima %A Shin,Ji Youn %A Mazzoli,Amanda %A Vue,Rebecca %A Kedroske,Jacob %A Chappell,Grant %A Hanauer,David A %A Barton,Debra %A Hassett,Afton L %A Choi,Sung Won %+ University of Michigan, Medical School, Blood and Marrow Transplantation Program, Medical Professional Building, D4118 SPC 5718, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, United States, 1 734 615 5707, sungchoi@umich.edu %K caregivers %K allogeneic hematopoietic stem cell transplant %K home interviews %K user experience %K mobile health apps %D 2019 %7 24.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Hematopoietic stem cell transplantation (HCT), also referred to as blood and marrow transplantation (BMT), is a high-risk, but potentially curative therapy for a number of cancer and noncancer conditions. BMT Roadmap (Roadmap 1.0) is a mobile health app that was developed as a family caregiver–facing tool to provide informational needs about the health status of patients undergoing inpatient HCT. Objective: This study explored the views and perceptions of family caregivers of patients undergoing HCT and their input regarding further technology development and expansion of BMT Roadmap into the outpatient setting (referred to as Roadmap 2.0). Methods: Semistructured qualitative interviews were conducted among 24 family caregivers. Questions were developed from existing literature coupled with prior in-depth observations and interviews in hospital-based settings to explore the study objectives. Participants were recruited during routine outpatient clinic appointments of HCT patients, and all interviews were conducted in the participants’ homes, the setting in which Roadmap 2.0 is intended for use. A thematic analysis was performed using a consistent set of codes derived from our prior research. New emerging codes were also included, and the coding structure was refined with iterative cycles of coding and data collection. Results: Four major themes emerged through our qualitative analysis: (1) stress related to balancing caregiving duties; (2) learning and adapting to new routines (resilience); (3) balancing one’s own needs with the patient’s needs (insight); and (4) benefits of caregiving. When caregivers were further probed about their views on engagement with positive activity interventions (ie, pleasant activities that promote positive emotions and well-being such as expressing gratitude or engaging in activities that promote positive thoughts, emotions, and behaviors), they preferred a “menu” of positive activities to help support caregiver health and well-being. Conclusions: This study involved family caregivers as participants in the development of new components for Roadmap 2.0. Our research provided a further understanding of the many priorities that hematopoietic stem cell transplant family caregivers face while maintaining balance in their lives. Their schedules can often be unpredictable, even more so once the patient is discharged from the hospital. Our findings suggest that expanding Roadmap 2.0 into the outpatient setting may provide critical caregiver support and that HCT caregivers are interested in and willing to engage in positive activities that may enhance well-being and attenuate the stress associated with caregiving. International Registered Report Identifier (IRRID): RR2-10.2196/resprot.4918 %M 31651402 %R 10.2196/15775 %U http://mhealth.jmir.org/2019/10/e15775/ %U https://doi.org/10.2196/15775 %U http://www.ncbi.nlm.nih.gov/pubmed/31651402 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e15544 %T The Influence of Physician Information on Patients’ Choice of Physician in mHealth Services Using China’s Chunyu Doctor App: Eye-Tracking and Questionnaire Study %A Shan,Wei %A Wang,Ying %A Luan,Jing %A Tang,Pengfei %+ School of Economics and Management, Beijing Jiaotong University, 3 Shangyuancun, Haidian District, Beijing, 100044, China, 86 18146510686, jingluan@bjtu.edu.cn %K mHealth %K physician information %K choice %K trust %D 2019 %7 23.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) is becoming more popular as a way of sharing medical information. For the patient, it saves time, reduces the need for travel, reduces the cost of searching for information, and brings medical services “to your fingertips.” However, it also brings information overload and makes the patient’s choice of physician more difficult. Objective: This study aimed to identify the types of physician information that play a key role in patients’ choice of physician and to explore the mechanism by which this information contributes to this choice. Methods: Based on the stimulus-organism-response (SOR) model and online trust theory, we proposed a research model to explain the influence of physician information on patients’ choice of physician. The model was based on cognitive trust and affective trust and considered the moderating role of patient expertise. Study 1 was an eye-tracking experiment (n=42) to identify key factors affecting patients’ choice of physician. Study 2 was a questionnaire study (n=272); Partial Least Squares Structural Equation Modeling was used to validate the research model. Results: The results of Study 1 revealed that seven types of physician information played a key role in patients’ choice of physician. The results of Study 2 revealed that (1) physicians’ profile photo information affected patients’ choice of physician by positively influencing affective trust (P<.001); (2) physicians’ nonprofile photo information affected patients’ choice of physician by positively influencing cognitive trust (P<.001); (3) patient-generated information affected patients’ choice of physician by positively affecting cognitive trust (P<.001) and affective trust (P<.001), and patient expertise played a positive moderating role on both (P=.04 and P=.01, respectively); and (4) cognitive trust and affective trust both positively affected patients’ choice of physician, with affective trust playing a more significant role (P<.001 and P<.001, respectively). Conclusions: Seven types of physician information were mainly used by patients when choosing physicians offering mHealth services; trust played an important role in this choice. In addition, the level of patient expertise was an important variable in moderating the influence of physician information and patients’ trust. This paper supports the theoretical basis of information selection and processing by patients. These findings can help guide app developers in the construction of medical apps and in the management of physician information in order to facilitate patients’ choice of physician. %M 31647466 %R 10.2196/15544 %U http://mhealth.jmir.org/2019/10/e15544/ %U https://doi.org/10.2196/15544 %U http://www.ncbi.nlm.nih.gov/pubmed/31647466 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e14276 %T The Fever Coach Mobile App for Participatory Influenza Surveillance in Children: Usability Study %A Kim,Myeongchan %A Yune,Sehyo %A Chang,Seyun %A Jung,Yuseob %A Sa,Soon Ok %A Han,Hyun Wook %+ Department of Biomedical Informatics, Graduate School of Medicine, CHA University, Pangyo-ro 335, Bundang-gu, Seongnam-si, Gyeonggi-do, 13488, Republic of Korea, 82 31 881 7109, stepano7@gmail.com %K data collection %K detecting epidemics %K mobile app %K health care app %K influenza epidemics %K influenza in children %D 2019 %7 17.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Effective surveillance of influenza requires a broad network of health care providers actively reporting cases of influenza-like illnesses and positive laboratory results. Not only is this traditional surveillance system costly to establish and maintain but there is also a time lag between a change in influenza activity and its detection. A new surveillance system that is both reliable and timely will help public health officials to effectively control an epidemic and mitigate the burden of the disease. Objective: This study aimed to evaluate the use of parent-reported data of febrile illnesses in children submitted through the Fever Coach app in real-time surveillance of influenza activities. Methods: Fever Coach is a mobile app designed to help parents and caregivers manage fever in young children, currently mainly serviced in South Korea. The app analyzes data entered by a caregiver and provides tailored information for care of the child based on the child’s age, sex, body weight, body temperature, and accompanying symptoms. Using the data submitted to the app during the 2016-2017 influenza season, we built a regression model that monitors influenza incidence for the 2017-2018 season and validated the model by comparing the predictions with the public influenza surveillance data from the Korea Centers for Disease Control and Prevention (KCDC). Results: During the 2-year study period, 70,203 diagnosis data, including 7702 influenza reports, were submitted. There was a significant correlation between the influenza activity predicted by Fever Coach and that reported by KCDC (Spearman ρ=0.878; P<.001). Using this model, the influenza epidemic in the 2017-2018 season was detected 10 days before the epidemic alert announced by KCDC. Conclusions: The Fever Coach app successfully collected data from 7.73% (207,699/2,686,580) of the target population by providing care instruction for febrile children. These data were used to develop a model that accurately estimated influenza activity measured by the central government agency using reports from sentinel facilities in the national surveillance network. %M 31625946 %R 10.2196/14276 %U https://mhealth.jmir.org/2019/10/e14276 %U https://doi.org/10.2196/14276 %U http://www.ncbi.nlm.nih.gov/pubmed/31625946 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14748 %T Technology Acceptance and Information System Success of a Mobile Electronic Platform for Nonphysician Clinical Students in Zambia: Prospective, Nonrandomized Intervention Study %A Barteit,Sandra %A Neuhann,Florian %A Bärnighausen,Till %A Bowa,Annel %A Wolter,Sigrid %A Siabwanta,Hinson %A Jahn,Albrecht %+ Heidelberg Institute of Global Health, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 06221 ext 5634030, barteit@uni-heidelberg.de %K computers, handheld %K tablets %K education, medical %K sub-Saharan Africa %K Zambia %K mHealth %K evidence-based practice %K medicine %D 2019 %7 9.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Zambia is still experiencing a severe shortage of health workers, which is impacting the national health care system. Very few people are trained, educational infrastructure is inadequate, and senior human resources for training are not yet sufficient to produce the number of health care workers needed, especially for currently underserved rural areas. Therefore, to strengthen the medical education program of medical licentiates, we implemented a tablet-based electronic learning platform (e-platform) with a medical decision-support component. Objective: As the primary objective, this study aimed to explore the acceptance and information system (IS) success of an e-platform focused on offline-based tablet usage for nonphysician clinical students in a low-resource context in Zambia, Africa. Furthermore, we aimed to evaluate student demographic factors and prior technological experience, as well as medical lecturers’ acceptance of technology of the e-platform. Methods: We collected data for the study before and after the intervention. Before the intervention, we collected student demographic data and prior technological experience using a questionnaire. After the intervention, we collected results of the questionnaire on technology acceptance of students and IS success of the e-platform, as well as technology acceptance of medical lecturers. We calculated statistical measures such as means, standard deviations, and correlations of investigated variables. The study report was compiled using the Consolidated Standards of Reporting Trials-Electronic Health checklist. Results: Overall, questionnaire results of students and medical lecturers indicated acceptance of the e-platform and showed higher ratings for overall net benefits and information quality (students) and perceived ease of use and perceived usefulness (medical lecturers) as compared with ratings of other categories. The lowest scores were conveyed for system use and service quality (students) and attitude and behavioral intention (medical lecturers). Conclusions: Acceptance of the e-platform as a learning technology for strengthening medical education in a low-resource context in Zambia was generally high for students and medical lecturers, but shortcomings were also identified. Results indicated low overall usage of the e-platform as a learning and teaching tool. One hindering factor was the tablets’ overall weak reliability with regard to its service life and battery life span, and another was the teachers’ low engagement with the e-platform. Next steps may include other hardware and more technology-based training for medical lecturers. The evaluation results indicated that the e-platform may open new promise for further strengthening and expanding medical education in this context, especially with more affordable and viable technologies that are available. %M 31599731 %R 10.2196/14748 %U http://www.jmir.org/2019/10/e14748/ %U https://doi.org/10.2196/14748 %U http://www.ncbi.nlm.nih.gov/pubmed/31599731 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e13238 %T Comparison of On-Site Versus Remote Mobile Device Support in the Framingham Heart Study Using the Health eHeart Study for Digital Follow-up: Randomized Pilot Study Set Within an Observational Study Design %A Spartano,Nicole L %A Lin,Honghuang %A Sun,Fangui %A Lunetta,Kathryn L %A Trinquart,Ludovic %A Valentino,Maureen %A Manders,Emily S %A Pletcher,Mark J %A Marcus,Gregory M %A McManus,David D %A Benjamin,Emelia J %A Fox,Caroline S %A Olgin,Jeffrey E %A Murabito,Joanne M %+ Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University School of Medicine, 720 Harrison Ave, Suite 8100, Boston, MA, United States, 1 3154152040, spartano@bu.edu %K wearable electronic devices %K cell phone %K fitness trackers %K electrocardiography %K epidemiology %D 2019 %7 30.9.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: New electronic cohort (e-Cohort) study designs provide resource-effective methods for collecting participant data. It is unclear if implementing an e-Cohort study without direct, in-person participant contact can achieve successful participation rates. Objective: The objective of this study was to compare 2 distinct enrollment methods for setting up mobile health (mHealth) devices and to assess the ongoing adherence to device use in an e-Cohort pilot study. Methods: We coenrolled participants from the Framingham Heart Study (FHS) into the FHS–Health eHeart (HeH) pilot study, a digital cohort with infrastructure for collecting mHealth data. FHS participants who had an email address and smartphone were randomized to our FHS-HeH pilot study into 1 of 2 study arms: remote versus on-site support. We oversampled older adults (age ≥65 years), with a target of enrolling 20% of our sample as older adults. In the remote arm, participants received an email containing a link to enrollment website and, upon enrollment, were sent 4 smartphone-connectable sensor devices. Participants in the on-site arm were invited to visit an in-person FHS facility and were provided in-person support for enrollment and connecting the devices. Device data were tracked for at least 5 months. Results: Compared with the individuals who declined, individuals who consented to our pilot study (on-site, n=101; remote, n=93) were more likely to be women, highly educated, and younger. In the on-site arm, the connection and initial use of devices was ≥20% higher than the remote arm (mean percent difference was 25% [95% CI 17-35] for activity monitor, 22% [95% CI 12-32] for blood pressure cuff, 20% [95% CI 10-30] for scale, and 43% [95% CI 30-55] for electrocardiogram), with device connection rates in the on-site arm of 99%, 95%, 95%, and 84%. Once connected, continued device use over the 5-month study period was similar between the study arms. Conclusions: Our pilot study demonstrated that the deployment of mobile devices among middle-aged and older adults in the context of an on-site clinic visit was associated with higher initial rates of device use as compared with offering only remote support. Once connected, the device use was similar in both groups. %M 31573928 %R 10.2196/13238 %U https://mhealth.jmir.org/2019/9/e13238 %U https://doi.org/10.2196/13238 %U http://www.ncbi.nlm.nih.gov/pubmed/31573928 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e14567 %T Objective User Engagement With Mental Health Apps: Systematic Search and Panel-Based Usage Analysis %A Baumel,Amit %A Muench,Frederick %A Edan,Stav %A Kane,John M %+ Department of Community Mental Health, University of Haifa, Abba Khoushy Ave 199, Haifa, 3498838, Israel, 972 048240111, abaumel@univ.haifa.ac.il %K user engagement %K usage %K adherence %K retention %K mental health %K depression %K anxiety %K mHealth %D 2019 %7 25.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Understanding patterns of real-world usage of mental health apps is key to maximizing their potential to increase public self-management of care. Although developer-led studies have published results on the use of mental health apps in real-world settings, no study yet has systematically examined usage patterns of a large sample of mental health apps relying on independently collected data. Objective: Our aim is to present real-world objective data on user engagement with popular mental health apps. Methods: A systematic engine search was conducted using Google Play to identify Android apps with 10,000 installs or more targeting anxiety, depression, or emotional well-being. Coding of apps included primary incorporated techniques and mental health focus. Behavioral data on real-world usage were obtained from a panel that provides aggregated nonpersonal information on user engagement with mobile apps. Results: In total, 93 apps met the inclusion criteria (installs: median 100,000, IQR 90,000). The median percentage of daily active users (open rate) was 4.0% (IQR 4.7%) with a difference between trackers (median 6.3%, IQR 10.2%) and peer-support apps (median 17.0%) versus breathing exercise apps (median 1.6%, IQR 1.6%; all z≥3.42, all P<.001). Among active users, daily minutes of use were significantly higher for mindfulness/meditation (median 21.47, IQR 15.00) and peer support (median 35.08, n=2) apps than for apps incorporating other techniques (tracker, breathing exercise, psychoeducation: medians range 3.53-8.32; all z≥2.11, all P<.05). The medians of app 15-day and 30-day retention rates were 3.9% (IQR 10.3%) and 3.3% (IQR 6.2%), respectively. On day 30, peer support (median 8.9%, n=2), mindfulness/meditation (median 4.7%, IQR 6.2%), and tracker apps (median 6.1%, IQR 20.4%) had significantly higher retention rates than breathing exercise apps (median 0.0%, IQR 0.0%; all z≥2.18, all P≤.04). The pattern of daily use presented a descriptive peak toward the evening for apps incorporating most techniques (tracker, psychoeducation, and peer support) except mindfulness/meditation, which exhibited two peaks (morning and night). Conclusions: Although the number of app installs and daily active minutes of use may seem high, only a small portion of users actually used the apps for a long period of time. More studies using different datasets are needed to understand this phenomenon and the ways in which users self-manage their condition in real-world settings. %M 31573916 %R 10.2196/14567 %U http://www.jmir.org/2019/9/e14567/ %U https://doi.org/10.2196/14567 %U http://www.ncbi.nlm.nih.gov/pubmed/31573916 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e12606 %T The Association Among Social Support, Self-Efficacy, Use of Mobile Apps, and Physical Activity: Structural Equation Models With Mediating Effects %A Wang,Taotao %A Ren,Mengyuan %A Shen,Ying %A Zhu,Xiaorou %A Zhang,Xing %A Gao,Min %A Chen,Xueying %A Zhao,Ai %A Shi,Yuhui %A Chai,Weizhong %A Liu,Xinchuan %A Sun,Xinying %+ Department of Social Medicine and Health Education, School of Public Health, Peking University, No 38, Xueyuan Road, Haidian District, Beijing, 100191, China, 86 13691212050, xysun@bjmu.edu.cn %K mobile apps %K physical activity %K social support %K self-efficacy %K structural equation modeling %D 2019 %7 25.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Physical inactivity is a risk factor for chronic noncommunicable diseases. Insufficient physical activity has become an important public health problem worldwide. As mobile apps have rapidly developed, physical activity apps have the potential to improve the level of physical activity among populations. Objective: This study aimed to evaluate the effect of physical activity apps on levels of physical activity among college students. Methods: A Web-based questionnaire was used to survey college students in Beijing from December 27, 2017, to January 5, 2018. According to a previous survey, 43% of college students using physical activity apps and 36% of those who never used such apps achieved the physical activity recommendations. In this study, the sample size was calculated to be 500. The questionnaire consisted of 5 parts: the use of physical activity apps, sports habits, social support, self-efficacy, and social demographic information. Structural equation modeling was used to test the relationships between the use of physical activity apps, self-efficacy, social support, and level of physical activity. Results: Of the 1245 participants, 384 college students (30.8%) used physical activity apps (in the past month). Of these 384 students, 191 (49.7%) gained new friends via the app. College students who were using physical activity apps had a higher level of physical activity and higher scores for social support and self-efficacy (P<.001) than those who did not use such apps. The use of physical activity apps significantly affected the mediating effect of physical activity level through social support (beta=.126; P<.001) and self-efficacy (beta=.294; P<.001). Gender played an important role in app use, self-efficacy, and physical activity in the mediation model: male users spent more time on physical activity and had higher self-efficacy scores (P<.001). Conclusions: This study focused on college students in Beijing and found that the use of physical activity apps is associated with higher physical activity levels among these students. This effect is mainly through the mediation effect of social support and self-efficacy, rather than the direct effect of physical activity apps. The use of physical activity apps is associated with a higher social support level and higher self-efficacy score. Furthermore, a high social support level and high self-efficacy score are associated with higher physical activity levels. %M 31573936 %R 10.2196/12606 %U http://mhealth.jmir.org/2019/9/e12606/ %U https://doi.org/10.2196/12606 %U http://www.ncbi.nlm.nih.gov/pubmed/31573936 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e15620 %T Predicting Inpatient Aggression in Forensic Services Using Remote Monitoring Technology: Qualitative Study of Staff Perspectives %A Greer,Ben %A Newbery,Katie %A Cella,Matteo %A Wykes,Til %+ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Henry Wellcome Building, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 02078480423, ben.greer@kcl.ac.uk %K telemedicine %K remote sensing technology %K wearable sensors %K aggression %K risk assessment %D 2019 %7 19.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Monitoring risk of imminent aggression in inpatient forensic mental health services could be supported by passive remote monitoring technology, but staff attitudes toward the relevance and likelihood of engagement with this technology are unknown. Objective: This study aimed to explore staff views, specifically potential benefits and implementation barriers, on using this technology for monitoring risk of inpatient aggression. Methods: We conducted semistructured focus groups with nurses in an inpatient forensic mental health service. We used thematic analysis with two independent raters to identify themes and subthemes related to staff attitudes toward passive remote monitoring. We subsequently checked with members to ensure the validity of the themes identified by the raters. Results: From January to March 2019, a total of 25 nurses took part in five focus groups. We identified five main themes, one of which concerned the potential benefits that passive remote monitoring could provide for monitoring risk of aggression. Staff suggested it could provide an early warning of impending aggression and enable support to be provided earlier. The remaining themes concerned implementation barriers, including risks to the users’ physical and mental well-being; data security concerns and potential access by third parties; the negative impact of a constant stream of real-time data on staff workload; and design characteristics and user awareness of the benefits of passive remote monitoring. Conclusions: Passive remote monitoring technology could support existing methods of monitoring inpatient aggression risk, but multiple barriers to implementation exist. Empirical research is required to investigate whether these potential benefits can be realized, and to identify ways of addressing these barriers to ensure acceptability and user engagement. %M 31538943 %R 10.2196/15620 %U https://www.jmir.org/2019/9/e15620 %U https://doi.org/10.2196/15620 %U http://www.ncbi.nlm.nih.gov/pubmed/31538943 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 9 %P e13608 %T Mobile Apps for Medication Management: Review and Analysis %A Tabi,Katarina %A Randhawa,Abnashi Singh %A Choi,Fiona %A Mithani,Zamina %A Albers,Friederike %A Schnieder,Maren %A Nikoo,Mohammadali %A Vigo,Daniel %A Jang,Kerry %A Demlova,Regina %A Krausz,Michael %+ Department of Psychiatry, University of British Columbia, 430-5950 University Boulevard, Vancouver, BC, V6T1Z3, Canada, 1 604 875 3525, katarina.tabi@gmail.com %K eHealth %K mHealth %K drugs %K pharmaceuticals %K therapy %D 2019 %7 11.09.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pharmacotherapy remains one of the major interventional strategies in medicine. However, patients from all age groups and conditions face challenges when taking medications, such as integrating them into the daily routine, understanding their effects and side effects, and monitoring outcomes. In this context, a reliable medication management tool adaptable to the patient’s needs becomes critical. As most people have a mobile phone, mobile apps offer a platform for such a personalized support tool available on the go. Objective: This study aimed to provide an overview of available mobile apps, focusing on those that help patients understand and take their medications. We reviewed the existing apps and provided suggestions for future development based on the concept understand and manage, instead of the conventional adhere to medication. This concept aims to engage and empower patients to be in charge of their health, as well as see medication as part of a broader clinical approach, working simultaneously with other types of interventions or lifestyle changes, to achieve optimal outcomes. Methods: We performed a Web search in the iOS Apple App Store and Android Google Play Store, using 4 search terms: medication management, pill reminder, medication health monitor, and medication helper. We extracted information from the app store descriptions for each eligible app and categorized into the following characteristics: features, author affiliation, specialty, user interface, cost, and user rating. In addition, we conducted Google searches to obtain more information about the author affiliation. Results: A total of 328 apps (175 Android and 153 iOS) were categorized. The majority of the apps were developed by the software industry (73%, 11/15), a minority of them were codeveloped by health care professionals (15%, 3/20) or academia (2.1%; 7/328). The most prevalent specialty was diabetes (23 apps). Only 7 apps focused on mental health, but their content was highly comprehensive in terms of features and had the highest prevalence of the education component. The most prevalent features were reminder, symptom tracker, and ability to share data with a family member or doctor. In addition, we highlighted the features considered innovative and listed practical suggestions for future development and innovations. Conclusions: We identified detailed characteristics of the existing apps, with the aim of informing future app development. Ultimately, the goal was to provide users with effective mobile health solutions, which can be expected to improve their engagement in the treatment process and long-term well-being. This study also highlighted the need for improved standards for reporting on app stores. Furthermore, it underlined the need for a platform to offer health app users an ongoing evaluation of apps by health professionals in addition to other users and to provide them with tools to easily select an appropriate and trustworthy app. %M 31512580 %R 10.2196/13608 %U http://mhealth.jmir.org/2019/9/e13608/ %U https://doi.org/10.2196/13608 %U http://www.ncbi.nlm.nih.gov/pubmed/31512580 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e13463 %T An Assessment of Physical Activity Data Collected via a Smartphone App and a Smart Band in Breast Cancer Survivors: Observational Study %A Chung,Il Yong %A Jung,Miyeon %A Lee,Sae Byul %A Lee,Jong Won %A Park,Yu Rang %A Cho,Daegon %A Chung,Haekwon %A Youn,Soyoung %A Min,Yul Ha %A Park,Hye Jin %A Lee,Minsun %A Chung,Seockhoon %A Son,Byung Ho %A Ahn,Sei-Hyun %+ Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, 05505, Seoul,, Republic of Korea, 82 10 7209 4620, newstar153@hanmail.net %K telemedicine %K breast neoplasms %K mobile apps %K quality of life %K stress, psychological %K patient compliance %K smartphone %K mobile phone %K wearable electronic devices %K survivorship %D 2019 %7 06.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Although distress screening is crucial for cancer survivors, it is not easy for clinicians to recognize distress. Physical activity (PA) data collected by mobile devices such as smart bands and smartphone apps have the potential to be used to screen distress in breast cancer survivors. Objective: The aim of this study was to assess data collection rates of smartphone apps and smart bands in terms of PA data, investigate the correlation between PA data from mobile devices and distress-related questionnaires from smartphone apps, and demonstrate factors associated with data collection with smart bands and smartphone apps in breast cancer survivors. Methods: In this prospective observational study, patients who underwent surgery for breast cancer at Asan Medical Center, Seoul, Republic of Korea, between June 2017 and March 2018 were enrolled and asked to use both a smartphone app and smart band for 6 months. The overall compliance rates of the daily PA data collection via the smartphone walking apps and wearable smart bands were analyzed in a within-subject manner. The longitudinal daily collection rates were calculated to examine the dropout pattern. We also performed multivariate linear regression analysis to examine factors associated with compliance with daily collection. Finally, we tested the correlation between the count of daily average steps and distress level using Pearson correlation analysis. Results: A total of 160 female patients who underwent breast cancer surgeries were enrolled. The overall compliance rates for using a smartphone app and smart bands were 88.0% (24,224/27,513) and 52.5% (14,431/27,513), respectively. The longitudinal compliance rate for smartphone apps was 77.8% at day 180, while the longitudinal compliance rate for smart bands rapidly decreased over time, reaching 17.5% at day 180. Subjects who were young, with other comorbidities, or receiving antihormonal therapy or targeted therapy showed significantly higher compliance rates to the smartphone app. However, no factor was associated with the compliance rate to the smart band. In terms of the correlation between the count of daily steps and distress level, step counts collected via smart band showed a significant correlation with distress level. Conclusions: Smartphone apps or smart bands are feasible tools to collect data on the physical activity of breast cancer survivors. PA data from mobile devices are correlated with participants’ distress data, which suggests the potential role of mobile devices in the management of distress in breast cancer survivors. Trial Registration: ClinicalTrials.gov NCT03072966; https://clinicaltrials.gov/ct2/show/NCT03072966 %M 31493319 %R 10.2196/13463 %U https://www.jmir.org/2019/9/e13463 %U https://doi.org/10.2196/13463 %U http://www.ncbi.nlm.nih.gov/pubmed/31493319 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e14017 %T Literature on Wearable Technology for Connected Health: Scoping Review of Research Trends, Advances, and Barriers %A Loncar-Turukalo,Tatjana %A Zdravevski,Eftim %A Machado da Silva,José %A Chouvarda,Ioanna %A Trajkovik,Vladimir %+ Faculty of Technical Sciences, University of Novi Sad, Trg Dositeja Obradovica 6, Novi Sad, 21000, Serbia, 381 691463297, turukalo@uns.ac.rs %K wearable technology %K telemedicine %K assisted living facilities %K review %D 2019 %7 05.09.2019 %9 Review %J J Med Internet Res %G English %X Background: Wearable sensing and information and communication technologies are key enablers driving the transformation of health care delivery toward a new model of connected health (CH) care. The advances in wearable technologies in the last decade are evidenced in a plethora of original articles, patent documentation, and focused systematic reviews. Although technological innovations continuously respond to emerging challenges and technology availability further supports the evolution of CH solutions, the widespread adoption of wearables remains hindered. Objective: This study aimed to scope the scientific literature in the field of pervasive wearable health monitoring in the time interval from January 2010 to February 2019 with respect to four important pillars: technology, safety and security, prescriptive insight, and user-related concerns. The purpose of this study was multifold: identification of (1) trends and milestones that have driven research in wearable technology in the last decade, (2) concerns and barriers from technology and user perspective, and (3) trends in the research literature addressing these issues. Methods: This study followed the scoping review methodology to identify and process the available literature. As the scope surpasses the possibilities of manual search, we relied on the natural language processing tool kit to ensure an efficient and exhaustive search of the literature corpus in three large digital libraries: Institute of Electrical and Electronics Engineers, PubMed, and Springer. The search was based on the keywords and properties to be found in articles using the search engines of the digital libraries. Results: The annual number of publications in all segments of research on wearable technology shows an increasing trend from 2010 to February 2019. The technology-related topics dominated in the number of contributions, followed by research on information delivery, safety, and security, whereas user-related concerns were the topic least addressed. The literature corpus evidences milestones in sensor technology (miniaturization and placement), communication architectures and fifth generation (5G) cellular network technology, data analytics, and evolution of cloud and edge computing architectures. The research lag in battery technology makes energy efficiency a relevant consideration in the design of both sensors and network architectures with computational offloading. The most addressed user-related concerns were (technology) acceptance and privacy, whereas research gaps indicate that more efforts should be invested into formalizing clear use cases with timely and valuable feedback and prescriptive recommendations. Conclusions: This study confirms that applications of wearable technology in the CH domain are becoming mature and established as a scientific domain. The current research should bring progress to sustainable delivery of valuable recommendations, enforcement of privacy by design, energy-efficient pervasive sensing, seamless monitoring, and low-latency 5G communications. To complement technology achievements, future work involving all stakeholders providing research evidence on improved care pathways and cost-effectiveness of the CH model is needed. %M 31489843 %R 10.2196/14017 %U https://www.jmir.org/2019/9/e14017/ %U https://doi.org/10.2196/14017 %U http://www.ncbi.nlm.nih.gov/pubmed/31489843 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e14863 %T Adherence and Satisfaction of Smartphone- and Smartwatch-Based Remote Active Testing and Passive Monitoring in People With Multiple Sclerosis: Nonrandomized Interventional Feasibility Study %A Midaglia,Luciana %A Mulero,Patricia %A Montalban,Xavier %A Graves,Jennifer %A Hauser,Stephen L %A Julian,Laura %A Baker,Michael %A Schadrack,Jan %A Gossens,Christian %A Scotland,Alf %A Lipsmeier,Florian %A van Beek,Johan %A Bernasconi,Corrado %A Belachew,Shibeshih %A Lindemann,Michael %+ F Hoffmann–La Roche Ltd, 124 Grenzacherstrasse, Basel,, Switzerland, 41 61 687 5113, christian.gossens@roche.com %K multiple sclerosis %K patient adherence %K patient satisfaction %K smartphone %K wearable electronic devices %K mobile phone %D 2019 %7 30.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Current clinical assessments of people with multiple sclerosis are episodic and may miss critical features of functional fluctuations between visits. Objective: The goal of the research was to assess the feasibility of remote active testing and passive monitoring using smartphones and smartwatch technology in people with multiple sclerosis with respect to adherence and satisfaction with the FLOODLIGHT test battery. Methods: People with multiple sclerosis (aged 20 to 57 years; Expanded Disability Status Scale 0-5.5; n=76) and healthy controls (n=25) performed the FLOODLIGHT test battery, comprising active tests (daily, weekly, every two weeks, or on demand) and passive monitoring (sensor-based gait and mobility) for 24 weeks using a smartphone and smartwatch. The primary analysis assessed adherence (proportion of weeks with at least 3 days of completed testing and 4 hours per day passive monitoring) and questionnaire-based satisfaction. In-clinic assessments (clinical and magnetic resonance imaging) were performed. Results: People with multiple sclerosis showed 70% (16.68/24 weeks) adherence to active tests and 79% (18.89/24 weeks) to passive monitoring; satisfaction score was on average 73.7 out of 100. Neither adherence nor satisfaction was associated with specific population characteristics. Test-battery assessments had an at least acceptable impact on daily activities in over 80% (61/72) of people with multiple sclerosis. Conclusions: People with multiple sclerosis were engaged and satisfied with the FLOODLIGHT test battery. FLOODLIGHT sensor-based measures may enable continuous assessment of multiple sclerosis disease in clinical trials and real-world settings. Trial Registration: ClinicalTrials.gov: NCT02952911; https://clinicaltrials.gov/ct2/show/NCT02952911 %M 31471961 %R 10.2196/14863 %U http://www.jmir.org/2019/8/e14863/ %U https://doi.org/10.2196/14863 %U http://www.ncbi.nlm.nih.gov/pubmed/31471961 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14250 %T Assessing Mobile Phone Digital Literacy and Engagement in User-Centered Design in a Diverse, Safety-Net Population: Mixed Methods Study %A Nouri,Sarah S %A Avila-Garcia,Patricia %A Cemballi,Anupama Gunshekar %A Sarkar,Urmimala %A Aguilera,Adrian %A Lyles,Courtney Rees %+ Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, 1545 Divisadero Street, Box 0320, San Francisco, CA, 94143, United States, 1 2149126555, sarah.nouri@ucsf.edu %K health information technology %K mHealth %K user-centered design %K health literacy %K digital literacy %K limited English proficiency %D 2019 %7 29.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Health care systems are rapidly deploying digital tools for disease management; however, few studies have evaluated their usability by vulnerable populations. To understand the barriers to app usage among vulnerable populations, we employed user-centered design (UCD) methods in the development of a new text messaging app. Objective: The study aimed to describe variations in patients’ engagement in the app design process, focusing on limited health literacy (LHL), limited English proficiency (LEP), and limited digital literacy (LDL). Methods: We conducted 20 in-depth semistructured interviews with primary care patients at a public health care system, used open-ended discussions and card sorting tasks to seek input about mobile phones and text messaging, and used open coding to categorize the patterns of mobile phone usage and to evaluate engagement in the card sorting process. We examined qualitative differences in engagement by examining the extensiveness of participant feedback on existing and novel text messaging content and calculated the proportion of patients providing extensive feedback on existing and novel content, overall and by health literacy, English proficiency, and digital literacy. Results: The average age of the 20 participants was 59 (SD 8) years; 13 (65%) were female, 18 (90%) were nonwhite, 16 (80%) had LHL, and 13 (65%) had LEP. All had depression, and 14 (70%) had diabetes. Most participants had smartphones (18/20, 90%) and regularly used text messaging (15/20, 75%), but 14 (70%) of them reported having difficulty texting because of inability to type, physical disability, and low literacy. We identified 10 participants as specifically having LDL; 7 of these participants had LEP, and all 10 had LHL. Half of the participants required a modification of the card sorting activity owing to not understanding it or not being able to read the cards in the allotted time. The proportion of participants who gave extensive feedback on existing content was lower in participants with limited versus adequate English proficiency (4/13, 30% vs 5/7, 71%), limited versus adequate health literacy (7/16, 44% vs 3/4, 75%), and limited versus adequate digital literacy (4/10, 40% vs 6/10, 60%); none of these differences were statistically significant. When examining the proportion of patients who gave extensive feedback for novel messaging content, those with LHL were less engaged than those with adequate health literacy (8/16, 50% vs 4/4, 100%); there were no statistical differences by any subgroup. Conclusions: Despite widespread mobile phone use, digital literacy barriers are common among vulnerable populations. Engagement in the card sorting activity varied among participants and appeared to be lower among those with LHL, LEP, and LDL. Researchers employing traditional UCD methods should routinely measure these communication domains among their end-user samples. Future work is needed to replicate our findings in larger samples, but augmentation of card sorting with direct observation and audiovisual cues may be more productive in eliciting feedback for those with communication barriers. %M 31469083 %R 10.2196/14250 %U http://mhealth.jmir.org/2019/8/e14250/ %U https://doi.org/10.2196/14250 %U http://www.ncbi.nlm.nih.gov/pubmed/31469083 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e13609 %T Comparison of the Effects of Coaching and Receipt of App Recommendations on Depression, Anxiety, and Engagement in the IntelliCare Platform: Factorial Randomized Controlled Trial %A Mohr,David C %A Schueller,Stephen M %A Tomasino,Kathryn Noth %A Kaiser,Susan M %A Alam,Nameyeh %A Karr,Chris %A Vergara,Jessica L %A Gray,Elizabeth L %A Kwasny,Mary J %A Lattie,Emily G %+ Center for Behavioral Intervention Technologies, Northwestern University, 750 N Lakeshore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 312 503 1403, d-mohr@northwestern.edu %K depression %K anxiety %K mHealth %K clinical trial %D 2019 %7 28.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: IntelliCare is a modular platform that includes 12 simple apps targeting specific psychological strategies for common mental health problems. Objective: This study aimed to examine the effect of 2 methods of maintaining engagement with the IntelliCare platform, coaching, and receipt of weekly recommendations to try different apps on depression, anxiety, and app use. Methods: A total of 301 participants with depression or anxiety were randomized to 1 of 4 treatments lasting 8 weeks and were followed for 6 months posttreatment. The trial used a 2X2 factorial design (coached vs self-guided treatment and weekly app recommendations vs no recommendations) to compare engagement metrics. Results: The median time to last use of any app during treatment was 56 days (interquartile range 54-57), with 253 participants (84.0%, 253/301) continuing to use the apps over a median of 92 days posttreatment. Receipt of weekly recommendations resulted in a significantly higher number of app use sessions during treatment (overall median=216; P=.04) but only marginal effects for time to last use (P=.06) and number of app downloads (P=.08). Coaching resulted in significantly more app downloads (P<.001), but there were no significant effects for time to last download or number of app sessions (P=.36) or time to last download (P=.08). Participants showed significant reductions in the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) across all treatment arms (P s<.001). Coached treatment led to larger GAD-7 reductions than those observed for self-guided treatment (P=.03), but the effects for the PHQ-9 did not reach significance (P=.06). Significant interaction was observed between receiving recommendations and time for the PHQ-9 (P=.04), but there were no significant effects for GAD-7 (P=.58). Conclusions: IntelliCare produced strong engagement with apps across all treatment arms. Coaching was associated with stronger anxiety outcomes, and receipt of recommendations enhanced depression outcomes. Trial Registration: ClinicalTrials.gov NCT02801877; https://clinicaltrials.gov/ct2/show/NCT02801877 %M 31464192 %R 10.2196/13609 %U http://www.jmir.org/2019/8/e13609/ %U https://doi.org/10.2196/13609 %U http://www.ncbi.nlm.nih.gov/pubmed/31464192 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e14750 %T Automated Text Messaging With Patients in Department of Veterans Affairs Specialty Clinics: Cluster Randomized Trial %A Yakovchenko,Vera %A Hogan,Timothy P %A Houston,Thomas K %A Richardson,Lorilei %A Lipschitz,Jessica %A Petrakis,Beth Ann %A Gillespie,Chris %A McInnes,D Keith %+ Center for Healthcare Organization and Implementation Research, Bedford Department of Veterans Affairs Medical Center, Department of Veterans Affairs, , Bedford, MA,, United States, 1 781 687 3374, vera.yakovchenko@va.gov %K implementation facilitation %K texting %K veterans %K eHealth %K self-management %K digital health %K digital medicine %D 2019 %7 4.8.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Acceptability of mobile phone text messaging as a means of asynchronous communication between health care systems and patients is growing. The US Department of Veterans Affairs (VA) has adopted an automated texting system (aTS) for national rollout. The aTS allows providers to develop clinical texting protocols to promote patient self-management and allows clinical teams to monitor patient progress between in-person visits. Texting-supported hepatitis C virus (HCV) treatment has not been previously tested. Objective: Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), we developed an aTS HCV protocol and conducted a mixed methods, hybrid type 2 effectiveness implementation study comparing two programs supporting implementation of the aTS HCV protocol for medication adherence in patients with HCV. Methods: Seven VA HCV specialty clinics were randomized to usual aTS implementation versus an augmented implementation facilitation program. Implementation process measures included facilitation metrics, usability, and usefulness. Implementation outcomes included provider and patient use of the aTS HCV protocol, and effectiveness outcomes included medication adherence, health perceptions and behaviors, and sustained virologic response (SVR). Results: Across the seven randomized clinics, there were 293 facilitation events using a core set of nine implementation strategies (157 events in augmented implementation facilitation, 136 events in usual implementation). Providers found the aTS appropriate with high potential for scale-up but not without difficulties in startup, patient selection and recruitment, and clinic workflow integration. Patients largely found the aTS easy to use and helpful; however, low perceived need for self-management support contributed to high declination. Reach and use was modest with 197 patients approached, 71 (36%) enrolled, 50 (25%) authenticated, and 32 (16%) using the aTS. In augmented implementation facilitation clinics, more patients actively used the aTS HCV protocol compared with usual clinic patients (20% vs 12%). Patients who texted reported lower distress about failing HCV treatment (13/15, 87%, vs 8/15, 53%; P=.05) and better adherence to HCV medication (11/15, 73%, reporting excellent adherence vs 6/15, 40%; P=.06), although SVR did not differ by group. Conclusions: The aTS is a promising intervention for improving patient self-management; however, augmented approaches to implementation may be needed to support clinician buy-in and patient engagement. Considering the behavioral, social, organizational, and technical scale-up challenges that we documented, successful and sustained implementation of the aTS may require implementation strategies that operate at the clinic, provider, and patient levels. Trial Registration: Retrospectively registered at ClinicalTrials.gov NCT03898349; https://clinicaltrials.gov/ct2/show/NCT03898349 %M 31444872 %R 10.2196/14750 %U https://www.jmir.org/2019/8/e14750/ %U https://doi.org/10.2196/14750 %U http://www.ncbi.nlm.nih.gov/pubmed/31444872 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e14630 %T Digital Health Apps in the Clinical Care of Inflammatory Bowel Disease: Scoping Review %A Yin,Andrew Lukas %A Hachuel,David %A Pollak,John P %A Scherl,Ellen J %A Estrin,Deborah %+ Medical College, Weill Cornell Medicine, 1300 York Avenue, New York, NY,, United States, 1 212 746 1067, aly2011@med.cornell.edu %K digital health %K mHealth %K mobile health %K mobile technology %K smartphone %K eHealth %K review %K inflammatory bowel disease %K Crohn’s disease %K ulcerative colitis %D 2019 %7 19.08.2019 %9 Review %J J Med Internet Res %G English %X Background: Digital health is poised to transform health care and redefine personalized health. As Internet and mobile phone usage increases, as technology develops new ways to collect data, and as clinical guidelines change, all areas of medicine face new challenges and opportunities. Inflammatory bowel disease (IBD) is one of many chronic diseases that may benefit from these advances in digital health. This review intends to lay a foundation for clinicians and technologists to understand future directions and opportunities together. Objective: This review covers mobile health apps that have been used in IBD, how they have fit into a clinical care framework, and the challenges that clinicians and technologists face in approaching future opportunities. Methods: We searched PubMed, Scopus, and ClinicalTrials.gov to identify mobile apps that have been studied and were published in the literature from January 1, 2010, to April 19, 2019. The search terms were (“mobile health” OR “eHealth” OR “digital health” OR “smart phone” OR “mobile app” OR “mobile applications” OR “mHealth” OR “smartphones”) AND (“IBD” OR “Inflammatory bowel disease” OR “Crohn's Disease” (CD) OR “Ulcerative Colitis” (UC) OR “UC” OR “CD”), followed by further analysis of citations from the results. We searched the Apple iTunes app store to identify a limited selection of commercial apps to include for discussion. Results: A total of 68 articles met the inclusion criteria. A total of 11 digital health apps were identified in the literature and 4 commercial apps were selected to be described in this review. While most apps have some educational component, the majority of apps focus on eliciting patient-reported outcomes related to disease activity, and a few are for treatment management. Significant benefits have been seen in trials relating to education, quality of life, quality of care, treatment adherence, and medication management. No studies have reported a negative impact on any of the above. There are mixed results in terms of effects on office visits and follow-up. Conclusions: While studies have shown that digital health can fit into, complement, and improve the standard clinical care of patients with IBD, there is a need for further validation and improvement, from both a clinical and patient perspective. Exploring new research methods, like microrandomized trials, may allow for more implementation of technology and rapid advancement of knowledge. New technologies that can objectively and seamlessly capture remote data, as well as complement the clinical shift from symptom-based to inflammation-based care, will help the clinical and health technology communities to understand the full potential of digital health in the care of IBD and other chronic illnesses. %M 31429410 %R 10.2196/14630 %U http://www.jmir.org/2019/8/e14630/ %U https://doi.org/10.2196/14630 %U http://www.ncbi.nlm.nih.gov/pubmed/31429410 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12687 %T A Comparison of Physical Activity Mobile Apps With and Without Existing Web-Based Social Networking Platforms: Systematic Review %A Petersen,Jasmine Maria %A Prichard,Ivanka %A Kemps,Eva %+ College of Nursing and Health Sciences, Flinders University, GPO Box 2100, Adelaide,, Australia, 61 8 82013713, jasmine.petersen@flinders.edu.au %K physical activity %K mobile applications %K social networking %D 2019 %7 16.08.2019 %9 Review %J J Med Internet Res %G English %X Background: Physical activity mobile apps present a unique medium to disseminate scalable interventions to increase levels of physical activity. However, the effectiveness of mobile apps has previously been limited by low levels of engagement. Existing Web-based social networking platforms (eg, Facebook and Twitter) afford high levels of popularity, reach, and sustain engagement and, thus, may present an innovative strategy to enhance the engagement, and ultimately the effectiveness of mobile apps. Objective: This study aimed to comparatively examine the effectiveness of, and engagement with, interventions that incorporate physical activity mobile apps in conjunction with and without existing Web-based social networking platforms (eg, Facebook and Twitter). Methods: A systematic review was conducted by following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines. A systematic search of the following databases was conducted: Medline, PsycINFO, Web of Science, Scopus, CINAHL, ProQuest, SPORTDiscus, EMBASE, and Cochrane. According to the comparative objective of this review, 2 independent literature searches were conducted. The first incorporated terms related to apps and physical activity; the second also incorporated terms related to Web-based social networking. The results of the two searches were synthesized and compared narratively. Results: A total of 15 studies were identified, 10 incorporated a physical activity app alone and 5 incorporated an app in conjunction with an existing Web-based social networking platform. Overall, 10 of the 15 interventions were effective in improving one or more physical activity behaviors. Specifically, improvements in physical activity behaviors were reported in 7 of the 10 interventions incorporating physical activity apps alone and in 3 of the 5 interventions incorporating physical activity apps in conjunction with existing Web-based social networking platforms. Interventions incorporating physical activity apps alone demonstrated a decline in app engagement. In contrast, the physical activity apps in conjunction with existing Web-based social networking platforms showed increased and sustained intervention engagement. Conclusions: The interventions incorporating physical activity apps in conjunction with and without existing Web-based social networking platforms demonstrated effectiveness in improving physical activity behaviors. Notably, however, the interventions that incorporated existing Web-based social networking platforms achieved higher levels of engagement than those that did not. This review provides preliminary evidence that existing Web-based social networking platforms may be fundamental to increase engagement with physical activity interventions. %M 31420956 %R 10.2196/12687 %U https://www.jmir.org/2019/8/e12687/ %U https://doi.org/10.2196/12687 %U http://www.ncbi.nlm.nih.gov/pubmed/31420956 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 7 %N 3 %P e10010 %T Artificial Intelligence Versus Clinicians in Disease Diagnosis: Systematic Review %A Shen,Jiayi %A Zhang,Casper J P %A Jiang,Bangsheng %A Chen,Jiebin %A Song,Jian %A Liu,Zherui %A He,Zonglin %A Wong,Sum Yi %A Fang,Po-Han %A Ming,Wai-Kit %+ Department of Obstetrics and Gynecology, The First Affiliated Hospital of Sun Yat-sen University, No 58 Zhongshan Road 2, Guangzhou, , China, 86 14715485116, wkming@connect.hku.hk %K artificial intelligence %K deep learning %K diagnosis %K diagnostic imaging %K image interpretation, computer-assisted %K patient-centered care %D 2019 %7 16.08.2019 %9 Review %J JMIR Med Inform %G English %X Background: Artificial intelligence (AI) has been extensively used in a range of medical fields to promote therapeutic development. The development of diverse AI techniques has also contributed to early detections, disease diagnoses, and referral management. However, concerns about the value of advanced AI in disease diagnosis have been raised by health care professionals, medical service providers, and health policy decision makers. Objective: This review aimed to systematically examine the literature, in particular, focusing on the performance comparison between advanced AI and human clinicians to provide an up-to-date summary regarding the extent of the application of AI to disease diagnoses. By doing so, this review discussed the relationship between the current advanced AI development and clinicians with respect to disease diagnosis and thus therapeutic development in the long run. Methods: We systematically searched articles published between January 2000 and March 2019 following the Preferred Reporting Items for Systematic reviews and Meta-Analysis in the following databases: Scopus, PubMed, CINAHL, Web of Science, and the Cochrane Library. According to the preset inclusion and exclusion criteria, only articles comparing the medical performance between advanced AI and human experts were considered. Results: A total of 9 articles were identified. A convolutional neural network was the commonly applied advanced AI technology. Owing to the variation in medical fields, there is a distinction between individual studies in terms of classification, labeling, training process, dataset size, and algorithm validation of AI. Performance indices reported in articles included diagnostic accuracy, weighted errors, false-positive rate, sensitivity, specificity, and the area under the receiver operating characteristic curve. The results showed that the performance of AI was at par with that of clinicians and exceeded that of clinicians with less experience. Conclusions: Current AI development has a diagnostic performance that is comparable with medical experts, especially in image recognition-related fields. Further studies can be extended to other types of medical imaging such as magnetic resonance imaging and other medical practices unrelated to images. With the continued development of AI-assisted technologies, the clinical implications underpinned by clinicians’ experience and guided by patient-centered health care principle should be constantly considered in future AI-related and other technology-based medical research. %M 31420959 %R 10.2196/10010 %U http://medinform.jmir.org/2019/3/e10010/ %U https://doi.org/10.2196/10010 %U http://www.ncbi.nlm.nih.gov/pubmed/31420959 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e14318 %T Counseling With Guided Use of a Mobile Well-Being App for Students Experiencing Anxiety or Depression: Clinical Outcomes of a Feasibility Trial Embedded in a Student Counseling Service %A Broglia,Emma %A Millings,Abigail %A Barkham,Michael %+ Research Department, British Association for Counselling and Psychotherapy, 15 St John's Business Park, Lutterworth, Leicestershire,, United Kingdom, 44 1455 883318, emma.broglia@bacp.co.uk %K counseling %K students %K mental health %K mobile app %K feasibility studies %K outcome measures %K depressive symptoms %K generalized anxiety %K universities %D 2019 %7 15.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Anxiety and depression continue to be prominent experiences of students approaching their university counseling service. These services face unique challenges to ensure that they continue to offer quality support with fewer resources to a growing student population. The convenience and availability of mobile phone apps offer innovative solutions to address therapeutic challenges and expand the reach of traditional support. Objective: The primary aim of this study was to establish the feasibility of a trial in which guided use of a mobile phone well-being app was introduced into a student counseling service and offered as an adjunct to face-to-face counseling. Methods: The feasibility trial used a two-arm, parallel nonrandomized design comparing counseling alone (treatment as usual, or TAU) versus counseling supplemented with guided use of a mobile phone well-being app (intervention) for 38 university students experiencing moderate anxiety or depression. Students in both conditions received up to 6 sessions of face-to-face counseling within a 3-month period. Students who approached the counseling service and were accepted for counseling were invited to join the trial. Feasibility factors evaluated include recruitment duration, treatment preference, randomization acceptability, and intervention fidelity. Clinical outcomes and clinical change were assessed with routine clinical outcome measures administered every counseling session and follow-up phases at 3 and 6 months after recruitment. Results: Both groups demonstrated reduced clinical severity by the end of counseling. This was particularly noticeable for depression, social anxiety, and hostility, whereby clients moved from elevated clinical to low clinical or from low clinical to nonclinical by the end of the intervention. By the 6-month follow-up, TAU clients’ (n=18) anxiety had increased whereas intervention clients’ (n=20) anxiety continued to decrease, and this group difference was significant (Generalized Anxiety Disorder–7: t22=3.46, P=.002). This group difference was not replicated for levels of depression: students in both groups continued to decrease their levels of depression by a similar amount at the 6-month follow-up (Physical Health Questionnaire–9: t22=1.30, P=.21). Conclusion: Supplementing face-to-face counseling with guided use of a well-being app is a feasible and acceptable treatment option for university students experiencing moderate anxiety or depression. The feasibility trial was successfully embedded into a university counseling service without denying access to treatment and with minimal disruption to the service. This study provides preliminary evidence for using a well-being app to maintain clinical improvements for anxiety following the completion of counseling. The design of the feasibility trial provides the groundwork for the development of future pilot trials and definitive trials embedded in a student counseling service. Trial registration: ISRCTN registry ISRCTN55102899; http://www.isrctn.com/ISRCTN55102899 %M 31418424 %R 10.2196/14318 %U http://mhealth.jmir.org/2019/8/e14318/ %U https://doi.org/10.2196/14318 %U http://www.ncbi.nlm.nih.gov/pubmed/31418424 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e15062 %T Association Between the Use of a Mobile Health Strategy App and Biological Changes in Breast Cancer Survivors: Prospective Pre-Post Study %A Lozano-Lozano,Mario %A Melguizo-Rodríguez,Lucia %A Fernández-Lao,Carolina %A Galiano-Castillo,Noelia %A Cantarero-Villanueva,Irene %A Martín-Martín,Lydia %A Arroyo-Morales,Manuel %+ Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Avda de la Ilustracion, 60, Granada, 18016, Spain, 34 958242070, lydia@ugr.es %K mHealth %K interleukin-6 %K C-reactive protein %K breast cancer survivors %K low-grade inflammatory %D 2019 %7 14.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: There is a bidirectional relationship between chronic low-grade inflammation and cancer. Inflammatory markers, such as interleukin-6 (IL-6), have been associated with both the malignant transformation of epithelial cells and tumor progression, thus linking low-grade inflammation with a higher risk of cancer and recurrence in the survival phase. Therefore, they are considered valuable prognostic biomarkers. Knowing and finding appropriate primary prevention strategies to modify these parameters is a major challenge in reducing the risk of cancer recurrence and increasing survival. Different therapeutic strategies have shown efficacy in the modification of these and other biological parameters, but with contradictory results. There are apparently no strategies in which telemedicine, and specifically mobile health (mHealth), are used as a means to potentially cause biological changes. Objective: The objectives of this study were to: (1) check whether it is feasible to find changes in inflammation biomarkers through an mHealth strategy app as a delivery mechanism of an intervention to monitor energy balance; and (2) discover potential predictors of change of these markers in breast cancer survivors (BCSs). Methods: A prospective quasi-experimental pre-post study was conducted through an mHealth energy balance monitoring app with 73 BCSs, defined as stage I-IIIA of breast cancer and at least six months from the completion of the adjuvant therapy. Measurements included were biological salivary markers (IL-6 and C-reactive protein [CRP]), self-completed questionnaires (the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, the user version of the Mobile Application Rating Scale [uMARS] and an ad hoc clinical and sociodemographic questionnaire) and physical objective measures (accelerometry, weight and height). In addition, using the logging data of the mHealth app, the rate of use (in days) was recorded during the entire experimental phase of the study. Using Stata software, a paired two-tailed t test, Pearson and Spearman correlations, and a stepwise multiple regression analysis were used to interpret the data. Results: Analyzing changes in inflammatory biomarker concentrations after using the mHealth app, differences between preassessment CRP (4899.04 pg/ml; SD 1085.25) and IL-6 (87.15 pg/ml; SD 33.59) and postassessment CRP (4221.24 pg/ml; SD 911.55) and IL-6 (60.53 pg/ml; SD 36.31) showed a significant decrease in both markers, with a mean difference of –635.25 pg/ml (95% CI –935.65 to –334.85; P<.001) in CRP and –26.61 pg/ml (95% CI –42.51 to –10.71; P=.002) in IL-6. Stepwise regression analyses revealed that changes in global quality of life, as well as uMARS score and hormonal therapy, were possible predictors of change in CRP concentration after using the mHealth app. In the same way, the type of tumor removal surgery conducted, as well as changes in weight and pain score, were possible predictors of change in IL-6 concentration after using the app. Conclusions: In conclusion, through the results of this study, we hypothesize that there is a possible association between an mHealth energy balance monitoring strategy and biological changes in BCSs. These changes could be explained by different biopsychosocial parameters, such as the use of the application itself, quality of life, pain, type of tumor removal surgery, hormonal treatment or obesity. %M 31414667 %R 10.2196/15062 %U http://www.jmir.org/2019/8/e15062/ %U https://doi.org/10.2196/15062 %U http://www.ncbi.nlm.nih.gov/pubmed/31414667 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e15023 %T Factors Influencing Patients’ Intentions to Use Diabetes Management Apps Based on an Extended Unified Theory of Acceptance and Use of Technology Model: Web-Based Survey %A Zhang,Yiyu %A Liu,Chaoyuan %A Luo,Shuoming %A Xie,Yuting %A Liu,Fang %A Li,Xia %A Zhou,Zhiguang %+ Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, No 139, Renmin Road, Changsha, 410011, China, 86 073185292154, zhouzhiguang@csu.edu.cn %K diabetes mellitus %K mobile applications %K survey %K structural equation modeling %K China %D 2019 %7 13.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Diabetes poses heavy social and economic burdens worldwide. Diabetes management apps show great potential for diabetes self-management. However, the adoption of diabetes management apps by diabetes patients is poor. The factors influencing patients’ intention to use these apps are unclear. Understanding the patients’ behavioral intention is necessary to support the development and promotion of diabetes app use. Objective: This study aimed to identify the determinants of patients’ intention to use diabetes management apps based on an integrated theoretical model. Methods: The hypotheses of our research model were developed based on an extended Unified Theory of Acceptance and Use of Technology (UTAUT). From April 20 to May 20, 2019, adult patients with diabetes across China, who were familiar with diabetes management apps, were surveyed using the Web-based survey tool Sojump. Structural equation modeling was used to analyze the data. Results: A total of 746 participants who met the inclusion criteria completed the survey. The fitness indices suggested that the collected data fit well with the research model. The model explained 62.6% of the variance in performance expectancy and 57.1% of the variance in behavioral intention. Performance expectancy and social influence had the strongest total effects on behavioral intention (β=0.482; P=.001). Performance expectancy (β=0.482; P=.001), social influence (β=0.223; P=.003), facilitating conditions (β=0.17; P=.006), perceived disease threat (β=0.073; P=.005), and perceived privacy risk (β=–0.073; P=.012) had direct effects on behavioral intention. Additionally, social influence, effort expectancy, and facilitating conditions had indirect effects on behavioral intention that were mediated by performance expectancy. Social influence had the highest indirect effects among the three constructs (β=0.259; P=.001). Conclusions: Performance expectancy and social influence are the most important determinants of the intention to use diabetes management apps. Health care technology companies should improve the usefulness of apps and carry out research to provide clinical evidence for the apps’ effectiveness, which will benefit the promotion of these apps. Facilitating conditions and perceived privacy risk also have an impact on behavioral intention. Therefore, it is necessary to improve facilitating conditions and provide solid privacy protection. Our study supports the use of UTAUT in explaining patients’ intention to use diabetes management apps. Context-related determinants should also be taken into consideration. %M 31411146 %R 10.2196/15023 %U http://www.jmir.org/2019/8/e15023/ %U https://doi.org/10.2196/15023 %U http://www.ncbi.nlm.nih.gov/pubmed/31411146 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 8 %P e13938 %T Accuracy of 12 Wearable Devices for Estimating Physical Activity Energy Expenditure Using a Metabolic Chamber and the Doubly Labeled Water Method: Validation Study %A Murakami,Haruka %A Kawakami,Ryoko %A Nakae,Satoshi %A Yamada,Yosuke %A Nakata,Yoshio %A Ohkawara,Kazunori %A Sasai,Hiroyuki %A Ishikawa-Takata,Kazuko %A Tanaka,Shigeho %A Miyachi,Motohiko %+ Department of Physical Activity Research, National Institutes of Biomedical Innovation, Health and Nutrition, 1-23-1 Toyama, Shinjuku, Tokyo, 162-8636, Japan, 81 3 3203 8061 ext 4201, miyachi@nibiohn.go.jp %K physical activity %K accelerometry %K energy expenditure %K indirect calorimetry %K doubly labeled water %D 2019 %7 02.08.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Self-monitoring using certain types of pedometers and accelerometers has been reported to be effective for promoting and maintaining physical activity (PA). However, the validity of estimating the level of PA or PA energy expenditure (PAEE) for general consumers using wearable devices has not been sufficiently established. Objective: We examined the validity of 12 wearable devices for determining PAEE during 1 standardized day in a metabolic chamber and 15 free-living days using the doubly labeled water (DLW) method. Methods: A total of 19 healthy adults aged 21 to 50 years (9 men and 10 women) participated in this study. They followed a standardized PA protocol in a metabolic chamber for an entire day while simultaneously wearing 12 wearable devices: 5 devices on the waist, 5 on the wrist, and 2 placed in the pocket. In addition, they spent their daily lives wearing 12 wearable devices under free-living conditions while being subjected to the DLW method for 15 days. The PAEE criterion was calculated by subtracting the basal metabolic rate measured by the metabolic chamber and 0.1×total energy expenditure (TEE) from TEE. The TEE was obtained by the metabolic chamber and DLW methods. The PAEE values of wearable devices were also extracted or calculated from each mobile phone app or website. The Dunnett test and Pearson and Spearman correlation coefficients were used to examine the variables estimated by wearable devices. Results: On the standardized day, the PAEE estimated using the metabolic chamber (PAEEcha) was 528.8±149.4 kcal/day. The PAEEs of all devices except the TANITA AM-160 (513.8±135.0 kcal/day; P>.05), SUZUKEN Lifecorder EX (519.3±89.3 kcal/day; P>.05), and Panasonic Actimarker (545.9±141.7 kcal/day; P>.05) were significantly different from the PAEEcha. None of the devices was correlated with PAEEcha according to both Pearson (r=−.13 to .37) and Spearman (ρ=−.25 to .46) correlation tests. During the 15 free-living days, the PAEE estimated by DLW (PAEEdlw) was 728.0±162.7 kcal/day. PAEE values of all devices except the Omron Active style Pro (716.2±159.0 kcal/day; P>.05) and Omron CaloriScan (707.5±172.7 kcal/day; P>.05) were significantly underestimated. Only 2 devices, the Omron Active style Pro (r=.46; P=.045) and Panasonic Actimarker (r=.48; P=.04), had significant positive correlations with PAEEdlw according to Pearson tests. In addition, 3 devices, the TANITA AM-160 (ρ=.50; P=.03), Omron CaloriScan (ρ=.48; P=.04), and Omron Active style Pro (ρ=.48; P=.04), could be ranked in PAEEdlw. Conclusions: Most wearable devices do not provide comparable PAEE estimates when using gold standard methods during 1 standardized day or 15 free-living days. Continuous development and evaluations of these wearable devices are needed for better estimations of PAEE. %M 31376273 %R 10.2196/13938 %U https://mhealth.jmir.org/2019/8/e13938/ %U https://doi.org/10.2196/13938 %U http://www.ncbi.nlm.nih.gov/pubmed/31376273 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e14373 %T Assessment of Medication Adherence Using a Medical App Among Patients With Multiple Sclerosis Treated With Interferon Beta-1b: Pilot Digital Observational Study (PROmyBETAapp) %A Limmroth,Volker %A Hechenbichler,Klaus %A Müller,Christian %A Schürks,Markus %+ Bayer Vital GmbH, Neurologie, Immunologie & Ophthalmologie, Leverkusen, 51368, Germany, 49 2143051455, markus.schuerks@bayer.com %K digital observational study %K BETACONNECT %K myBETAapp %K interferon beta-1b %K multiple sclerosis %K medication adherence %K medication compliance %K medication persistence %D 2019 %7 29.07.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Accurate measurement of medication adherence using classical observational studies typically depends on patient self-reporting and is often costly and slow. In contrast, digital observational studies that collect data directly from the patient may pose minimal burden to patients while facilitating accurate, timely, and cost-efficient collection of real-world data. In Germany, ~80% of patients with multiple sclerosis (MS) treated with interferon beta 1b (Betaferon) use an electronic autoinjector (BETACONNECT), which automatically records every injection. Patients may also choose to use a medical app (myBETAapp) to document injection data and their well-being (using a “wellness tracker” feature). Objective: The goal of this pilot study was to establish a digital study process that allows the collection of medication usage data and to assess medication usage among patients with MS treated with interferon beta-1b who use myBETAapp. Methods: The PROmyBETAapp digital observational study was a mixed prospective and retrospective, noninterventional, cohort study conducted among users of myBETAapp in Germany (as of December 2017: registered accounts N=1334; actively used accounts N=522). Between September and December 2017, users received two invitations on their app asking them to participate. Interested patients were provided detailed information and completed an electronic consent process. Data from consenting patients’ devices were collected retrospectively starting from the first day of usage if historical data were available in the database and collected prospectively following consent attainment. In total, 6 months of data on medication usage behavior were collected along with 3 months of wellness tracker data. Descriptive statistics were used to analyze persistence, compliance, and adherence to therapy. Results: Of the 1334 registered accounts, 96 patients (7.2%) provided informed consent to participate in the study. Of these, one patient withdrew consent later. For another patient, injection data could not be recorded during the study period. Follow-up of the remaining 94 patients ended in May 2018. The mean age of participants was 46.6 years, and 50 (53%) were female. Over the 6-month study period, persistence with myBETAapp usage was 96% (90/94), mean compliance was 94% of injections completed, and adherence (persistence and ≥80% compliance) was 89% (84/94). There was no apparent difference between male and female participants and no trend across age groups. The wellness tracker was used by 21% of participants (20/94), with a mean of 3.1 entries per user. Conclusions: This study provides important information on medication usage among patients with MS treated with interferon beta-1b and on consenting behavior of patients in digital studies. In future studies, this approach may allow patients’ feedback to be rapidly implemented in existing digital solutions. Trial Registration: ClinicalTrials.gov NCT03134573; https://clinicaltrials.gov/ct2/show/NCT03134573 %M 31359863 %R 10.2196/14373 %U http://www.jmir.org/2019/7/e14373/ %U https://doi.org/10.2196/14373 %U http://www.ncbi.nlm.nih.gov/pubmed/31359863 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 7 %P e13503 %T A Smart and Multifaceted Mobile Health System for Delivering Evidence-Based Secondary Prevention of Stroke in Rural China: Design, Development, and Feasibility Study %A Wu,Na %A Gong,Enying %A Wang,Bo %A Gu,Wanbing %A Ding,Nan %A Zhang,Zhuoran %A Chen,Mengyao %A Yan,Lijing L %A Oldenburg,Brian %A Xu,Li-Qun %+ Center of Excellence for mHealth and Smart Healthcare, China Mobile Research Institute, China Mobile Communications Corporation, 32 Xuanwumen West Street, Xicheng District, Beijing, 100032, China, 86 158 0169 6688 ext 35971, xuliqun@chinamobile.com %K stroke %K secondary prevention %K rural health services %K mobile application %K software design %K China %D 2019 %7 19.07.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) technologies hold great promise in improving the delivery of high-quality health care services. Yet, there has been little research so far applying mHealth technologies in the context of delivering stroke care in resource-limited rural regions. Objective: This study aimed to introduce the design and development of an mHealth system targeting primary health care providers and to ascertain its feasibility in supporting the delivery of a System-Integrated techNology-Enabled Model of cAre (SINEMA) service for strengthening secondary prevention of stroke in rural China. Methods: The SINEMA mHealth system was designed by a multidisciplinary team comprising public health researchers, neurologists, and information and communication technology experts. The iterative co-design and development of the mHealth system involved the following 5 steps: (1) assessing the needs of relevant end users through in-depth interviews of stakeholders, (2) designing the functional modules and evidence-based care content, (3) designing and building the system and user interface, (4) improving and enhancing the system through a 3-month pilot test in 4 villages, and (5) finalizing the system and deploying it in field trial, and finally, evaluating its feasibility through a survey of the dominant user group. Results: From the in-depth interviews of 49 relevant stakeholders, we found that village doctors had limited capacity in caring for village-dwelling stroke patients in rural areas. Primary health care workers demonstrated real needs in receiving appropriate training and support from the mHealth system as well as great interests in using the mHealth technologies and tools. Using these findings, we designed a multifaceted mHealth system with 7 functional modules by following the iterative user-centered design and software development approach. The mHealth system, aimed at 3 different types of users (village doctors, town physicians, and county managers), was developed and utilized in a cluster-randomized controlled trial by 25 village doctors in a resource-limited county in rural China to manage 637 stroke patients between July 2017 and July 2018. In the end, a survey on the usability and functions of the mHealth system among village doctors (the dominant group of users, response rate=96%, 24/25) revealed that most of them were satisfied with the essential functions provided (71%) and were keen to continue using it (92%) after the study. Conclusions: The mHealth system was feasible for assisting primary health care providers in rural China in delivering the SINEMA service on the secondary prevention of stroke. Further research and initiatives in scaling up the SINEMA approach and this mHealth system to other resource-limited regions in China and beyond will likely enhance the quality and accessibility of essential secondary prevention among stroke patients. ClinicalTrial: ClinicalTrials.gov NCT03185858; https://clinicaltrials.gov/ct2/show/NCT03185858 International Registered Report Identifier (IRRID): RR2-10.1016/j.ahj.2018.08.015 %M 31325288 %R 10.2196/13503 %U http://mhealth.jmir.org/2019/7/e13503/ %U https://doi.org/10.2196/13503 %U http://www.ncbi.nlm.nih.gov/pubmed/31325288 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 6 %P e14592 %T Development and Testing of a Mobile Phone App for Risk Estimation of Gas Volume Expansion and Intraocular Pressure Elevation in Patients With Intravitreous Gas or Air Tamponade: Interobserver Assessment Study %A Zhang,Zhaotian %A Li,Fei %A Zhang,Haochuan %A Miao,Zhipeng %A Wei,Yantao %A Wang,Li %A Zhang,Shaochong %+ State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, 54S Xianlie Road, Guangzhou, 510060, China, 86 2087330415, zhangshaochong@gzzoc.com %K intraocular pressure %K mobile phone %K vitrectomy %K air %D 2019 %7 26.06.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pars plana vitrectomy (PPV) with intravitreous tamponade of gas or air has been widely used for a series of vitreoretinal diseases. It is estimated that 100,000 patients per year undergo PPV globally, and half of them were subsequently tamponaded with gas or air. According to Boyle’s law (P1V1=P2V2), patients with an intravitreous remnant of gas or air will be under high risk of intraocular pressure (IOP) elevation and subsequent vision loss owing to the expanded intravitreous gas or air when traveling post operation to a place with a significantly higher altitude. We always explain to patients why postoperative travel is potentially risky. Emergency cases of elevated IOP caused by postoperative traveling would sometimes come to surgeons. However, there have been few disease education or reference tools for both the surgeons and patients to have better communication. Objective: The aim of this study was to introduce and evaluate a mobile phone app developed by surgeons (the authors) for preliminary risk estimation of volume expansion and IOP elevation in patients with intravitreous gas or air when traveling to a place of higher altitude. Methods: The app was developed on the iOS and Android operating systems. Boyle’s law (P1V1=P2V2) was the theoretical basis of the app. Intravitreous gas or air volume and altitude values were independent factors to deduce the risk report. Consecutive patients underwent vitrectomy, and those with an intravitreous remnant of gas or air were recruited. The surgeons judged the vertical height of the fluid/gas interface through the dilated pupil; the patients were instructed to judge it according to their visual field when looking straight ahead and line it out on a chart included in the app. Finally, all the patients were required to fill a Likert scale–based questionnaire with 2 main items to evaluate the participants’ user experience and attitudes toward the app. Results: A total of 50 patients were included (30 males and 20 females). All patients could independently operate the app to complete the test. The median heights of the fluid/gas interface independently judged by the surgeon and patients were 40% (range: 10%-75%) and 41% (range: 9%-78%), respectively (P=.63). The median altitude of the participants’ destinations was 150.0 m (range: 0-3490 m). The Bland-Altman analysis revealed a good agreement between the surgeons’ and patients’ judgments (bias of −0.3%), with 95% limits of agreement of −5.8% to 5.3%. Overall, the Likert scale revealed a positive attitude from the patients toward the app. Conclusions: The app is reliable for patients to have preliminary risk estimation of intravitreous gas or air volume expansion and IOP elevation if travel to a place of higher altitude is planned. The surgeons could also use it as a platform for better disease communication. %M 31244482 %R 10.2196/14592 %U http://mhealth.jmir.org/2019/6/e14592/ %U https://doi.org/10.2196/14592 %U http://www.ncbi.nlm.nih.gov/pubmed/31244482 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e12505 %T Mobile Apps for Increasing Treatment Adherence: Systematic Review %A Pérez-Jover,Virtudes %A Sala-González,Marina %A Guilabert,Mercedes %A Mira,José Joaquín %+ Departamento Psicología de la Salud, Universidad Miguel Hernández, Altamira Building, Avda de la Universidad s/n, Elche, 03202, Spain, 34 966658600 ext 8984, mguilabert@umh.es %K mobile health %K medication alert systems %K medication adherence %D 2019 %7 18.06.2019 %9 Review %J J Med Internet Res %G English %X Background: It is estimated that 20% to 50% of patients do not take their medication correctly, and this leads to increased morbidity and inefficacy of therapeutic approaches. Fostering treatment adherence is a priority objective for all health systems. The growth of mobile apps to facilitate therapeutic adherence has significantly increased in recent years. However, the effectiveness of the apps for this purpose has not been evaluated. Objective: This study aimed to analyze whether mobile apps are perceived as useful for managing medication at home and if they actually contribute to increasing treatment adherence in patients. Methods: We carried out a systematic review of research published using Scopus, Cochrane Library, ProQuest, and MEDLINE databases and analyzed the information about their contribution to increasing therapeutic adherence and the perceived usefulness of mobile apps. This review examined studies published between 2000 and 2017. Results: Overall, 11 studies fulfilled the inclusion criteria. The sample sizes of these studies varied between 16 and 99 participants. In addition, 7 studies confirmed that the mobile app increased treatment adherence. In 5 of them, the before and after adherence measures suggested significant statistical improvements, when comparing self-reported adherence and missed dose with a percentage increase ranging between 7% and 40%. The users found mobile apps easy to use and useful for managing their medication. The patients were mostly satisfied with their use, with an average score of 8.1 out of 10. Conclusions: The use of mobile apps helps increase treatment adherence, and they are an appropriate method for managing medication at home. %M 31215517 %R 10.2196/12505 %U http://www.jmir.org/2019/6/e12505/ %U https://doi.org/10.2196/12505 %U http://www.ncbi.nlm.nih.gov/pubmed/31215517 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 6 %P e11701 %T Addressing Depression Comorbid With Diabetes or Hypertension in Resource-Poor Settings: A Qualitative Study About User Perception of a Nurse-Supported Smartphone App in Peru %A Brandt,Lena R %A Hidalgo,Liliana %A Diez-Canseco,Francisco %A Araya,Ricardo %A Mohr,David C %A Menezes,Paulo R %A Miranda,J Jaime %+ CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Avenida Armendariz 497, Miraflores, Lima, Peru, 51 12416978, fdiezcanseco@gmail.com %K mental health %K depression %K noncommunicable diseases %K mHealth %K smartphone %K developing countries %D 2019 %7 18.06.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphone apps could constitute a cost-effective strategy to overcome health care system access barriers to mental health services for people in low- and middle-income countries. Objective: The aim of this paper was to explore the patients’ perspectives of CONEMO (Emotional Control, in Spanish: Control Emocional), a technology-driven, psychoeducational, and nurse-supported intervention delivered via a smartphone app aimed at reducing depressive symptoms in people with diabetes, hypertension or both who attend public health care centers, as well as the nurses’ feedback about their role and its feasibility to be scaled up. Methods: This study combines data from 2 pilot studies performed in Lima, Peru, between 2015 and 2016, to test the feasibility of CONEMO. Interviews were conducted with 29 patients with diabetes, hypertension or both with comorbid depressive symptoms who used CONEMO and 6 staff nurses who accompanied the intervention. Using a content analysis approach, interview notes from patient interviews were transferred to a digital format, coded, and categorized into 6 main domains: the perceived health benefit, usability, adherence, user satisfaction with the app, nurse’s support, and suggestions to improve the intervention. Interviews with nurses were analyzed by the same approach and categorized into 4 domains: general feedback, evaluation of training, evaluation of study activities, and feasibility of implementing this intervention within the existing structures of health system. Results: Patients perceived improvement in their emotional health because of CONEMO, whereas some also reported better physical health. Many encountered some difficulties with using CONEMO, but resolved them with time and practice. However, the interactive elements of the app, such as short message service, android notifications, and pop-up messages were mostly perceived as challenging. Satisfaction with CONEMO was high, as was the self-reported adherence. Overall, patients evaluated the nurse accompaniment positively, but they suggested improvements in the technological training and an increase in the amount of contact. Nurses reported some difficulties in completing their tasks and explained that the CONEMO intervention activities competed with their everyday work routine. Conclusions: Using a nurse-supported smartphone app to reduce depressive symptoms among people with chronic diseases is possible and mostly perceived beneficial by the patients, but it requires context-specific adaptations regarding the implementation of a task shifting approach within the public health care system. These results provide valuable information about user feedback for those building mobile health interventions for depression. %M 31215511 %R 10.2196/11701 %U https://mental.jmir.org/2019/6/e11701/ %U https://doi.org/10.2196/11701 %U http://www.ncbi.nlm.nih.gov/pubmed/31215511 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e14094 %T A Mobile Health Intervention for Prostate Biopsy Patients Reduces Appointment Cancellations: Cohort Study %A Balakrishnan,Ashwin S %A Nguyen,Hao G %A Shinohara,Katsuto %A Au Yeung,Reuben %A Carroll,Peter R %A Odisho,Anobel Y %+ Department of Urology, University of California San Francisco, 400 Parnassus Ave, San Francisco, CA,, United States, 1 415 476 1611, anobel.odisho@ucsf.edu %K text messaging %K appointments and schedules %K mHealth %K quality improvement %K urology %K prostate neoplasm %D 2019 %7 2.6.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Inadequate patient education and preparation for office-based procedures often leads to delayed care, poor patient satisfaction, and increased costs to the health care system. We developed and deployed a mobile health (mHealth) reminder and education program for patients scheduled for transrectal prostate biopsy. Objective: We aimed to evaluate the impact of an mHealth reminder and education program on appointment cancellation rates, communication frequency, and patient satisfaction. Methods: We developed a text message (SMS, short message service)–based program with seven reminders containing links to Web-based content and surveys sent over an 18-day period (14 days before through 3 days after prostate biopsy). Messages contained educational content, reminders, and readiness questionnaires. Demographic information, appointment cancellations or change data, and patient/provider communication events were collected for 6 months before and after launching the intervention. Patient satisfaction was evaluated in the postintervention cohort. Results: The preintervention (n=473) and postintervention (n=359) cohorts were composed of men of similar median age and racial/ethnic distribution living a similar distance from clinic. The postintervention cohort had significantly fewer canceled or rescheduled appointments (33.8% vs 21.2%, P<.001) and fewer same-day cancellations (3.8% vs 0.5%, P<.001). There was a significant increase in preprocedural telephone calls (0.6 vs 0.8 calls per patient, P=.02) in the postintervention cohort, but not a detectable change in postprocedural calls. The mean satisfaction with the program was 4.5 out of 5 (SD 0.9). Conclusions: An mHealth periprocedural outreach program significantly lowered appointment cancellation and rescheduling and was associated with high patient satisfaction scores with a slight increase in preprocedural telephone calls. This led to fewer underused procedure appointments and high patient satisfaction. %M 31199294 %R 10.2196/14094 %U https://www.jmir.org/2019/6/e14094/ %U https://doi.org/10.2196/14094 %U http://www.ncbi.nlm.nih.gov/pubmed/31199294 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e13387 %T Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care in British Columbia: Phase I %A Gill,Roopan %A Ogilvie,Gina %A Norman,Wendy V %A Fitzsimmons,Brian %A Maher,Ciana %A Renner,Regina %+ Department of Obstetrics and Gynaecology, Women's Health Research Institute, University of British Columbia, 4500 Oak Street, Vancouver, BC,, Canada, 1 604 369 0774, roopan.gill@gmail.com %K mHealth %K family planning %K abortion, induced %K sexual health %K digital health %K user-centered design %D 2019 %7 29.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Over 30% of women in Canada undergo an abortion. Despite the prevalence of the procedure, stigma surrounding abortion in Canada leads to barriers for women to access this service. The vast majority of care is concentrated in urban settings. There is evidence to support utilization of innovative mobile and other technology solutions to empower women to safely and effectively self-manage aspects of the abortion process. This study is part 1 of a 3-phase study that utilizes user-centered design methodology to develop a digital health solution to specifically support follow-up after an induced surgical abortion. Objective: This study aimed to (1) understand how women at 3 surgical abortion clinics in an urban center of British Columbia utilize their mobile phones to access health care information and (2) understand women’s preferences of content and design of an intervention that will support follow-up care after an induced abortion, including contraceptive use. Methods: The study design was based on development-evaluation-implementation process from Medical Research Council Framework for Complex Medical Interventions. This was a mixed-methods formative study. Women (aged 14-45 years) were recruited from 3 urban abortion facilities in British Columbia who underwent an induced abortion. Adaptation of validated surveys and using the technology acceptance model and theory of reasoned action, a cross-sectional survey was designed. Interview topics included demographic information; type of wireless device used; cell phone usage; acceptable information to include in a mobile intervention to support women’s abortion care; willingness to use a mobile phone to obtain reproductive health information; optimal strategies to use a mobile intervention to support women; understand preferences for health information resources; and design qualities in a mobile intervention important for ease of use, privacy, and security. Responses to questions in the survey were summarized using descriptive statistics. Qualitative analysis was conducted with NVivo using a thematic analysis approach. This study was approved by the local ethics board. Results: A waiting-room survey was completed by 50 participants, and semistructured interviews were completed with 8 participants. The average age of participants was 26 years. Furthermore, 94% (47/50) owned a smartphone, 85% (41/48) used their personal phones to go online, and 85% would use their cell phone to assist in clinical care. Qualitative analysis demonstrated that women prefer a comprehensive website that included secure email or text notifications to provide tools and resources for emotional well-being, contraceptive decision making, general sexual health, and postprocedure care. Conclusions: A community-based mixed-methods approach allowed us to understand how women use their cell phones and what women desire in a mobile intervention to support their postabortion care. The findings from this formative phase will assist in the development and testing of a mobile intervention to support follow-up care after an induced surgical abortion. %M 31144668 %R 10.2196/13387 %U http://www.jmir.org/2019/5/e13387/ %U https://doi.org/10.2196/13387 %U http://www.ncbi.nlm.nih.gov/pubmed/31144668 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e13645 %T Smartphone Apps to Support Self-Management of Hypertension: Review and Content Analysis %A Alessa,Tourkiah %A Hawley,Mark S %A Hock,Emma S %A de Witte,Luc %+ Centre for Assistive Technology and Connected Healthcare, School of Health and Related Research, University of Sheffield, 30 Regent Street, Sheffield,, United Kingdom, 44 1142224399, l.p.dewitte@sheffield.ac.uk %K smartphone apps %K mobile apps %K self-management %K hypertension %K blood pressure %K mobile applications %D 2019 %7 28.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Hypertension is a widespread chronic disease, and its effective treatment requires self-management by patients. Health-related apps provide an effective way of supporting hypertension self-management. However, the increasing range and variety of hypertension apps available on the market, owing to the global growth in apps, creates the need for patients and health care professionals to be informed about the effectiveness of these apps and the levels of privacy and security that they provide. Objective: This study aimed to describe and assess all available apps supporting hypertension self-management in the most popular app stores and investigate their functionalities. Methods: In January 2018, the UK Apple and Google Play stores were scanned for all free and paid apps supporting hypertension self-management. Apps were included if they were in English, had functionality supporting hypertension self-management, and targeted adult users with hypertension. The included apps were downloaded and their functionalities were investigated. Behavior change techniques (BCTs) linked with the theoretical domain framework (TDF) underpinning potentially effective apps were independently coded by two reviewers. The data privacy and security of the apps were also independently assessed. Results: A total of 186 hypertension apps that met the inclusion criteria were included in this review. The majority of these apps had only one functionality (n=108), while the remainder offered different combinations of functionalities. A small number of apps had comprehensive functionalities (n=30) that are likely to be more effective in supporting hypertension self-management. Most apps lacked a clear theoretical basis, and 24 BCTs identified in these 30 apps were mapped to 10 TDF mechanisms of actions. On an average, 18.4 BCTs were mapped to 6 TDF mechanisms of actions that may support hypertension self-management behaviors. There was a concerning absence of evidence related to the effectiveness and usability of all 186 apps, and involvement of health care professionals in the app development process was minimal. Most apps did not meet the current standards of data security and privacy. Conclusions: Despite the widespread accessibility and availability of smartphone apps with a range of combinations of functionalities that can support the self-management of hypertension, only a small number of apps are likely to be effective. Many apps lack security measures as well as a clear theoretical basis and do not provide any evidence concerning their effectiveness and usability. This raises a serious issue, as health professionals and those with hypertension have insufficient information to make decisions on which apps are safe and effective. %M 31140434 %R 10.2196/13645 %U http://mhealth.jmir.org/2019/5/e13645/ %U https://doi.org/10.2196/13645 %U http://www.ncbi.nlm.nih.gov/pubmed/31140434 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e11967 %T Methodology Used in Ecological Momentary Assessment Studies About Sedentary Behavior in Children, Adolescents, and Adults: Systematic Review Using the Checklist for Reporting Ecological Momentary Assessment Studies %A Romanzini,Catiana Leila Possamai %A Romanzini,Marcelo %A Batista,Mariana Biagi %A Barbosa,Cynthia Correa Lopes %A Shigaki,Gabriela Blasquez %A Dunton,Genevieve %A Mason,Tyler %A Ronque,Enio Ricardo Vaz %+ Londrina State University, Department of Physical Education, Rodovia Celso Garcia Cid | Pr 445 Km 380 | Campus Universitário Cx Postal 10.011, Londrina, 86.057-970, Brazil, 55 4333714238, clpossamai@uel.br %K physical activity %K accelerometry %K health behavior %D 2019 %7 15.05.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of ecological momentary assessment (EMA) to measure sedentary behavior (SB) in children, adolescents, and adults can increase the understanding of the role of the context of SB in health outcomes. Objective: The aim of this study was to systematically review literature to describe EMA methodology used in studies on SB in youth and adults, verify how many studies adhere to the Methods aspect of the Checklist for Reporting EMA Studies (CREMAS), and detail measures used to assess SB and this associated context. Methods: A systematic literature review was conducted in the PubMed, Scopus, Web of Science, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and SPORTDiscus databases, covering the entire period of existence of the databases until January 2018. Results: This review presented information about the characteristics and methodology used in 21 articles that utilized EMA to measure SB in youth and adults. There were more studies conducted among youth compared with adults, and studies of youth included more waves and more participants (n=696) than studies with adults (n=97). Most studies (85.7%) adhered to the Methods aspect of the CREMAS. The main criteria used to measure SB in EMA were self-report (81%) with only 19% measuring SB using objective methods (eg, accelerometer). The main equipment to collect objective SB was the ActiGraph, and the cutoff point to define SB was <100 counts/min. Studies most commonly used a 15-min window to compare EMA and accelerometer data. Conclusions: The majority of studies in this review met minimum CREMAS criteria for studies conducted with EMA. Most studies measured SB with EMA self-report (n=17; 81.0%), and a few studies also used objective methods (n=4; 19%). The standardization of the 15-min window criteria to compare EMA and accelerometer data would lead to a comparison between these and new studies. New studies using EMA with mobile phones should be conducted as they can be considered an attractive method for capturing information about the specific context of SB activities of young people and adults in real time or very close to it. %M 31094349 %R 10.2196/11967 %U https://www.jmir.org/2019/5/e11967/ %U https://doi.org/10.2196/11967 %U http://www.ncbi.nlm.nih.gov/pubmed/31094349 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12679 %T Feasibility of a Mobile Phone App to Promote Adherence to a Heart-Healthy Lifestyle: Single-Arm Study %A Lunde,Pernille %A Nilsson,Birgitta Blakstad %A Bergland,Astrid %A Bye,Asta %+ Department of Physiotherapy, Faculty of Health Sciences, Oslo Metropolitan University, P50, PB 4, St Olavs Plass, Oslo,, Norway, 47 48 06 35 37, plunde@oslomet.no %K mHealth %K eHealth %K mobile phone app %K cardiac rehabilitation %D 2019 %7 19.4.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Long-term maintenance of preventive activities is fundamental for achieving improved outcomes in cardiac rehabilitation (CR). Despite this, it has been shown to be a major challenge for many patients to follow recommendations and thereby adhere to a heart-healthy lifestyle. Mobile phone apps have been emphasized as potential tools to promote preventive activities after attendance in a CR program. Before commencing a trial to assess the potential effect of using an app to promote long-term adherence to preventive activities after attendance in CR, a study to assess if it is feasible to use an app is warranted. Objective: The goal of the research is to assess if it is feasible to use a mobile phone app for promoting and monitoring patients’ adherence to a heart-healthy lifestyle after CR. Methods: The study included an experimental, pre-post single-arm trial lasting for 12 weeks. All patients received access to an app aimed to guide individuals to change or maintain a heart-healthy lifestyle. During the study period, patients received weekly, individualized monitoring through the app, based on their own goals. Feasibility outcomes assessed were recruitment rate, adherence to the app, resource requirements, and efficacy regarding capability to detect a change in quality of life, health status, and perceived goal achievement as well as evaluating ceiling and floor effect in these outcomes. Criteria for success were preset to be able to evaluate whether the app was feasible to use in a potential future RCT. Results: In total, 71% (17/24) of the patients who completed CR were eligible for a potential RCT as well as for this study. All 14 patients included in the study used the app to promote preventive activities throughout the study. Satisfaction with the technology was high, and the patients found the technology-based follow-up intervention both useful and motivational. Ceiling effect was present in more than 20% of the patients in several domains of the questionnaires evaluating quality of life (36-Item Short Form Health Survey and COOP/WONCA functional health assessments) and health status (EQ-5D). Overall self-rated health status (EuroQol Visual Analog Scale) and perceived goal achievement were found to be outcomes able to detect a change. Conclusions: Individual follow-up through an app after attendance in CR is feasible. All patients used the app for preventive activities and found the app both useful and motivating. Several points of guidance from the patients in the study have been adopted and incorporated into the final design of the RCT now in the field. %M 31066684 %R 10.2196/12679 %U http://formative.jmir.org/2019/2/e12679/ %U https://doi.org/10.2196/12679 %U http://www.ncbi.nlm.nih.gov/pubmed/31066684 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e12251 %T Wearable Proximity Sensors for Monitoring a Mass Casualty Incident Exercise: Feasibility Study %A Ozella,Laura %A Gauvin,Laetitia %A Carenzo,Luca %A Quaggiotto,Marco %A Ingrassia,Pier Luigi %A Tizzoni,Michele %A Panisson,André %A Colombo,Davide %A Sapienza,Anna %A Kalimeri,Kyriaki %A Della Corte,Francesco %A Cattuto,Ciro %+ Data Science Laboratory, Institute for Scientific Interchange Foundation, Via Chisola 5, Torino, 10131, Italy, 39 3491973277, laura.ozella@gmail.com %K contact patterns %K contact networks %K wearable proximity sensors %K mass casualty incident %K simulation %K medical staff – patient interaction %K patients’ flow %D 2019 %7 26.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Over the past several decades, naturally occurring and man-made mass casualty incidents (MCIs) have increased in frequency and number worldwide. To test the impact of such events on medical resources, simulations can provide a safe, controlled setting while replicating the chaotic environment typical of an actual disaster. A standardized method to collect and analyze data from mass casualty exercises is needed to assess preparedness and performance of the health care staff involved. Objective: In this study, we aimed to assess the feasibility of using wearable proximity sensors to measure proximity events during an MCI simulation. In the first instance, our objective was to demonstrate how proximity sensors can collect spatial and temporal information about the interactions between medical staff and patients during an MCI exercise in a quasi-autonomous way. In addition, we assessed how the deployment of this technology could help improve future simulations by analyzing the flow of patients in the hospital. Methods: Data were obtained and collected through the deployment of wearable proximity sensors during an MCI functional exercise. The scenario included 2 areas: the accident site and the Advanced Medical Post, and the exercise lasted 3 hours. A total of 238 participants were involved in the exercise and classified in categories according to their role: 14 medical doctors, 16 nurses, 134 victims, 47 Emergency Medical Services staff members, and 27 health care assistants and other hospital support staff. Each victim was assigned a score related to the severity of his/her injury. Each participant wore a proximity sensor, and in addition, 30 fixed devices were placed in the field hospital. Results: The contact networks show a heterogeneous distribution of the cumulative time spent in proximity by the participants. We obtained contact matrices based on the cumulative time spent in proximity between the victims and rescuers. Our results showed that the time spent in proximity by the health care teams with the victims is related to the severity of the patient’s injury. The analysis of patients’ flow showed that the presence of patients in the rooms of the hospital is consistent with the triage code and diagnosis, and no obvious bottlenecks were found. Conclusions: Our study shows the feasibility of the use of wearable sensors for tracking close contacts among individuals during an MCI simulation. It represents, to our knowledge, the first example of unsupervised data collection—ie, without the need for the involvement of observers, which could compromise the realism of the exercise—of face-to-face contacts during an MCI exercise. Moreover, by permitting detailed data collection about the simulation, such as data related to the flow of patients in the hospital, such deployment provides highly relevant input for the improvement of MCI resource allocation and management. %M 31025944 %R 10.2196/12251 %U http://www.jmir.org/2019/4/e12251/ %U https://doi.org/10.2196/12251 %U http://www.ncbi.nlm.nih.gov/pubmed/31025944 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 4 %P e11698 %T Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru %A Menezes,Paulo %A Quayle,Julieta %A Garcia Claro,Heloísa %A da Silva,Simone %A Brandt,Lena R %A Diez-Canseco,Francisco %A Miranda,J Jaime %A Price,LeShawndra N %A Mohr,David C %A Araya,Ricardo %+ Department of Preventive Medicine, University of São Paulo, Rua Doutor Arnaldo 455, Cerqueira César, São Paulo, 01246903, Brazil, 55 1130617093, pmenezes@usp.br %K depression %K mHealth %K pilot study %K feasibility study %K PHQ-9 %D 2019 %7 26.04.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders. Objective: This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs). Methods: Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up. Results: The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings. Conclusions: The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants’ depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings. %M 31025949 %R 10.2196/11698 %U http://mental.jmir.org/2019/4/e11698/ %U https://doi.org/10.2196/11698 %U http://www.ncbi.nlm.nih.gov/pubmed/31025949 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e12223 %T Postvaccination Fever Response Rates in Children Derived Using the Fever Coach Mobile App: A Retrospective Observational Study %A Ahn,Sang Hyun %A Zhiang,Jooho %A Kim,Hyery %A Chang,Seyun %A Shin,Jaewon %A Kim,Myeongchan %A Lee,Yura %A Lee,Jae-Ho %A Park,Yu Rang %+ Department of Biomedical Systems Informatics, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2228 2493, yurangpark@yuhs.ac %K patient-generated health data %K vaccination %K postvaccination fever %K digital health care %K mobile app %D 2019 %7 22.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Postvaccination fever is a mild adverse event that naturally improves without complications, but is highly prevalent and can be accompanied by febrile convulsions in some cases. These adverse effects may cause parents to delay or avoid vaccinating their children. Objective: This study aimed to identify postvaccination fever patterns and the ability of antipyretics to affect changes in these patterns from data collected from a mobile app named Fever Coach. Methods: Data provided by parents of feverish children derived from a mobile app, Fever Coach, were used to identify postvaccination fever patterns according to vaccinations and the use of antipyretic drugs. We selected single vaccination records that contained five or more body temperature readings performed within 48 hours of vaccination, and we analyzed postvaccination fever onset, offset, duration, and maximum body temperature. Through observing the postvaccination fever response to vaccination, we identified the effects of antipyretic drugs on postvaccination fever onset, offset, and duration times; the extent of fever; and the rate of decline. We also performed logistic regression analysis to determine demographic variables (age, weight, and sex) involved in relatively high fevers (body temperature ≥39°C). Results: The total number of Fever Coach users was 25,037, with 3834 users having entered single vaccination records, including 4448 vaccinations and 55,783 body temperature records. Most records were obtained from children receiving the following vaccinations: pneumococcus (n=2069); Japanese encephalitis (n=911); influenza (n=669); diphtheria, tetanus, and pertussis (n=403); and hepatitis A (n=252). According to the 4448 vaccination records, 3427 (77.05%) children had taken antipyretic drugs, and 3238 (89.15%) children took antibiotics at body temperatures above 38°C. The number of children taking antipyretics at a body temperature of 38°C was more than four times that of those taking antipyretics at 37.9°C (307 vs 67 cases). The number of instances in which this temperature threshold was reached was more than four times greater than the number when the temperature was 37.9°C. A comparative analysis of antipyretic and nonantipyretic cases showed there was no difference in onset time; however, offset and duration times were significantly shorter in nonantipyretic cases than in antipyretic cases (P<.001). In nonantipyretic cases, offset times and duration times were 9.9 and 10.1 hours shorter, respectively, than in antipyretic cases. Body temperatures also decreased faster in nonantipyretic cases. Influenza vaccine-associated fevers lasted relatively longer, whereas pneumococcus vaccine-associated fevers were relatively short-lived. Conclusions: These findings suggest that postvaccination fever has its own fever pattern, which is dependent on vaccine type and the presence of antipyretic drugs, and that postvaccination temperature monitoring may ease fever phobia and reduce the unnecessary use of antipyretics in medical care. %M 31008712 %R 10.2196/12223 %U http://mhealth.jmir.org/2019/4/e12223/ %U https://doi.org/10.2196/12223 %U http://www.ncbi.nlm.nih.gov/pubmed/31008712 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e13404 %T Wearable Sensors Reveal Menses-Driven Changes in Physiology and Enable Prediction of the Fertile Window: Observational Study %A Goodale,Brianna Mae %A Shilaih,Mohaned %A Falco,Lisa %A Dammeier,Franziska %A Hamvas,Györgyi %A Leeners,Brigitte %+ Ava AG, Gutstrasse 73, Zurich, 8055, Switzerland, 41 788737163, brianna.goodale@avawomen.com %K algorithms %K fertility/physiology %K heart rate %K machine learning %K menstrual cycle %K ovulation detection/methods %K respiratory rate %K perfusion %K skin temperature %K wearable electronic devices %D 2019 %7 18.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Previous research examining physiological changes across the menstrual cycle has considered biological responses to shifting hormones in isolation. Clinical studies, for example, have shown that women’s nightly basal body temperature increases from 0.28 to 0.56 ˚C following postovulation progesterone production. Women’s resting pulse rate, respiratory rate, and heart rate variability (HRV) are similarly elevated in the luteal phase, whereas skin perfusion decreases significantly following the fertile window’s closing. Past research probed only 1 or 2 of these physiological features in a given study, requiring participants to come to a laboratory or hospital clinic multiple times throughout their cycle. Although initially designed for recreational purposes, wearable technology could enable more ambulatory studies of physiological changes across the menstrual cycle. Early research suggests that wearables can detect phase-based shifts in pulse rate and wrist skin temperature (WST). To date, previous work has studied these features separately, with the ability of wearables to accurately pinpoint the fertile window using multiple physiological parameters simultaneously yet unknown. Objective: In this study, we probed what phase-based differences a wearable bracelet could detect in users’ WST, heart rate, HRV, respiratory rate, and skin perfusion. Drawing on insight from artificial intelligence and machine learning, we then sought to develop an algorithm that could identify the fertile window in real time. Methods: We conducted a prospective longitudinal study, recruiting 237 conception-seeking Swiss women. Participants wore the Ava bracelet (Ava AG) nightly while sleeping for up to a year or until they became pregnant. In addition to syncing the device to the corresponding smartphone app daily, women also completed an electronic diary about their activities in the past 24 hours. Finally, women took a urinary luteinizing hormone test at several points in a given cycle to determine the close of the fertile window. We assessed phase-based changes in physiological parameters using cross-classified mixed-effects models with random intercepts and random slopes. We then trained a machine learning algorithm to recognize the fertile window. Results: We have demonstrated that wearable technology can detect significant, concurrent phase-based shifts in WST, heart rate, and respiratory rate (all P<.001). HRV and skin perfusion similarly varied across the menstrual cycle (all P<.05), although these effects only trended toward significance following a Bonferroni correction to maintain a family-wise alpha level. Our findings were robust to daily, individual, and cycle-level covariates. Furthermore, we developed a machine learning algorithm that can detect the fertile window with 90% accuracy (95% CI 0.89 to 0.92). Conclusions: Our contributions highlight the impact of artificial intelligence and machine learning’s integration into health care. By monitoring numerous physiological parameters simultaneously, wearable technology uniquely improves upon retrospective methods for fertility awareness and enables the first real-time predictive model of ovulation. %M 30998226 %R 10.2196/13404 %U http://www.jmir.org/2019/4/e13404/ %U https://doi.org/10.2196/13404 %U http://www.ncbi.nlm.nih.gov/pubmed/30998226 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 4 %P e13119 %T Reducing Alcohol Consumption Among Risky Drinkers in the General Population of Sweden Using an Interactive Mobile Health Intervention: Protocol for a Randomized Controlled Trial %A Bendtsen,Marcus %A McCambridge,Jim %+ Department of Medical and Health Sciences, Linköping University, Linköping University, Linköping, 58183, Sweden, 46 733140708, marcus.bendtsen@liu.se %K telemedicine %K alcohol drinking %K randomized controlled trial %D 2019 %7 18.04.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Harmful use of alcohol continues to be a leading contributor to premature deaths globally. Not only does harmful drinking have consequences for the individuals consuming at increased levels, but it may also result in a range of negative consequences for their family members and friends. Interventions delivered via mobile phones (mobile health [mHealth] interventions) could potentially support risky drinkers seeking help to reduce their alcohol consumption. Objective: This protocol describes a randomized controlled trial that aims to validly estimate the effect of a novel mHealth intervention targeting risky drinkers in the general population of Sweden. Nested within the trial are 3 substudies that focus on methodological and user satisfaction research questions. Methods: A 2-arm parallel group randomized controlled trial will be employed to estimate the effect of the novel intervention. Participants will be recruited through Web advertisements and social media. The inclusion criteria are as follows: 18 years or older, ownership of a mobile phone, and being classified as a risky drinker according to Swedish guidelines. Participants allocated to the intervention group will receive a novel mHealth intervention. The intervention consists of weekly screening, personalized feedback on current consumption, functions allowing for planning of future consumption, as well as a series of messages delivered throughout the week. Participants allocated to the control group will receive a short message regarding negative consequences of alcohol consumption and a hyperlink that offers more information. Following 2 and 4 months after randomization, both groups will be asked to complete follow-up questionnaires (2-month interval being primary). Primary outcomes are weekly alcohol consumption and heavy episodic drinking. Participants in the control group will be given access to the novel intervention after completing the 4-month follow-up. The trial includes 3 substudies: We will explore whether the mode of presenting information before participants giving informed consent affects participation rates and recall of trial parameters, investigate if the content of the short message received by the control group affects study outcomes and requests for more information, and explore user satisfaction with the intervention and reactions of the control group. Results: Participant recruitment is planned to begin in April 2019 and to last for a maximum of 24 months. The first dataset will be available approximately 2 months after the final participant has been recruited, and the final dataset will be available approximately 2 months later. No participants had been recruited at the time of submitting this protocol. Conclusions: If found effective, the intervention has the potential to reduce negative consequences of alcohol consumption for individuals. The technology has been designed to have potential for extensive reach among those who may benefit. Trial Registration: ISRCTN Registry ISRCTN48317451; http://www.isrctn.com/ISRCTN48317451 (Archived by WebCite at http://www.webcitation.org/779tKLsu3) International Registered Report Identifier (IRRID): PRR1-10.2196/13119 %M 30998221 %R 10.2196/13119 %U http://www.researchprotocols.org/2019/4/e13119/ %U https://doi.org/10.2196/13119 %U http://www.ncbi.nlm.nih.gov/pubmed/30998221 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e12368 %T Augmented Reality in Emergency Medicine: A Scoping Review %A Munzer,Brendan William %A Khan,Mohammad Mairaj %A Shipman,Barbara %A Mahajan,Prashant %+ Department of Emergency Medicine, University of Michigan, 1501 E Medical Center Dr, Ann Arbor, MI, 48108, United States, 1 602 403 3296, bmunzer@med.umich.edu %K augmented reality %K emergency medicine %K education %K telemedicine %D 2019 %7 17.04.2019 %9 Review %J J Med Internet Res %G English %X Background: Augmented reality is increasingly being investigated for its applications to medical specialties as well as in medical training. Currently, there is little information about its applicability to training and care delivery in the context of emergency medicine. Objective: The objective of this article is to review current literature related to augmented reality applicable to emergency medicine and its training. Methods: Through a scoping review utilizing Scopus, MEDLINE, and Embase databases for article searches, we identified articles involving augmented reality that directly involved emergency medicine or was in an area of education or clinical care that could be potentially applied to emergency medicine. Results: A total of 24 articles were reviewed in detail and were categorized into three groups: user-environment interface, telemedicine and prehospital care, and education and training. Conclusions: Through analysis of the current literature across fields, we were able to demonstrate that augmented reality has utility and feasibility in clinical care delivery in patient care settings, in operating rooms and inpatient settings, and in education and training of emergency care providers. Additionally, we found that the use of augmented reality for care delivery over distances is feasible, suggesting a role in telehealth. Our results from the review of the literature in emergency medicine and other specialties reveal that further research into the uses of augmented reality will have a substantial role in changing how emergency medicine as a specialty will deliver care and provide education and training. %M 30994463 %R 10.2196/12368 %U http://www.jmir.org/2019/4/e12368/ %U https://doi.org/10.2196/12368 %U http://www.ncbi.nlm.nih.gov/pubmed/30994463 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e12772 %T Validation of Two Automatic Blood Pressure Monitors With the Ability to Transfer Data via Bluetooth %A Wetterholm,Madeleine %A Bonn,Stephanie Erika %A Alexandrou,Christina %A Löf,Marie %A Trolle Lagerros,Ylva %+ Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Eugeniahemmet T2, Stockholm, SE 171 76, Sweden, 46 851779183, madeleine.wetterholm@ki.se %K blood pressure monitors %K diabetes mellitus, type 2 %K hypertension %K methods %K mHealth %K self-care %K self-management %D 2019 %7 17.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients with chronic diseases are in need of regular health controls. Diabetes mellitus type 2 is currently the most prevalent chronic metabolic disease. A majority of diabetic patients have at least one comorbid chronic disease, where hypertension is the most common. The standard for blood pressure (BP) measurement is manual BP monitoring at health care clinics. Nevertheless, several advantages of self-measured BP have been documented. With BP data transfer from an automatic BP monitor via Bluetooth to software, for example, a smartphone app, home measurement could effectively be integrated into regular care. Objective: The aim of this study was to validate two commercially available automatic BP monitors with the ability to transfer BP data via Bluetooth (Beurer BM 85 and Andersson Lifesense BDR 2.0), against manual BP monitoring in patients with type 2 diabetes. Methods: A total of 181 participants with type 2 diabetes were recruited from 6 primary care centers in Stockholm, Sweden. BP was first measured using a manual BP monitor and then measured using the two automatic BP monitors. The mean differences between the automatic and manual measurements were calculated by subtracting the manual BP monitor measurement from the automatic monitor measurement. Validity of the two automatic BP monitors was further assessed using Spearman rank correlation coefficients and the Bland-Altman method. Results: In total, 180 participants, 119 men and 61 women, were included. The mean age was 60.1 (SD 11.4) years and the mean body mass index was 30.4 (SD 5.4) kg/m2. The mean difference between the Beurer BM 85 and the manual BP monitor was 11.1 (SD 11.2) mmHg for systolic blood pressure (SBP) and 8.0 (SD 8.1) mmHg for diastolic blood pressure (DBP). The mean difference between the Andersson Lifesense BDR 2.0 and the manual BP monitor was 3.2 (SD 10.8) mmHg for SBP and 4.2 (SD 7.2) mmHg for DBP. The automatic BP measurements were significantly correlated (P<.001) with the manual BP measurement values (Andersson Lifesense BDR 2.0: r=0.78 for SBP and r=0.71 for DBP; Beurer BM 85: r=0.78 for SBP and r=0.69 for DBP). Conclusions: The two automatic BP monitors validated measure sufficiently accurate on a group level, with the Andersson Lifesense BDR 2.0 more often falling within the ranges for what is acceptable in clinical practice compared with the Beurer BM 85. %M 30994459 %R 10.2196/12772 %U https://www.jmir.org/2019/4/e12772/ %U https://doi.org/10.2196/12772 %U http://www.ncbi.nlm.nih.gov/pubmed/30994459 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e11029 %T Mood Prediction of Patients With Mood Disorders by Machine Learning Using Passive Digital Phenotypes Based on the Circadian Rhythm: Prospective Observational Cohort Study %A Cho,Chul-Hyun %A Lee,Taek %A Kim,Min-Gwan %A In,Hoh Peter %A Kim,Leen %A Lee,Heon-Jeong %+ Korea University College of Medicine, Department of Psychiatry, Anam Hospital, Korea University College of Medicine, Seoul,, Republic of Korea, 82 029205815, leehjeong@korea.ac.kr %K mood disorder %K circadian rhythm %K projections and predictions %K machine learning %K digital phenotype %K wearable device %D 2019 %7 17.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtually, all organisms on Earth have their own circadian rhythm, and humans are no exception. Circadian rhythms are associated with various human states, especially mood disorders, and disturbance of the circadian rhythm is known to be very closely related. Attempts have also been made to derive clinical implications associated with mood disorders using the vast amounts of digital log that is acquired by digital technologies develop and using computational analysis techniques. Objective: This study was conducted to evaluate the mood state or episode, activity, sleep, light exposure, and heart rate during a period of about 2 years by acquiring various digital log data through wearable devices and smartphone apps as well as conventional clinical assessments. We investigated a mood prediction algorithm developed with machine learning using passive data phenotypes based on circadian rhythms. Methods: We performed a prospective observational cohort study on 55 patients with mood disorders (major depressive disorder [MDD] and bipolar disorder type 1 [BD I] and 2 [BD II]) for 2 years. A smartphone app for self-recording daily mood scores and detecting light exposure (using the installed sensor) were provided. From daily worn activity trackers, digital log data of activity, sleep, and heart rate were collected. Passive digital phenotypes were processed into 130 features based on circadian rhythms, and a mood prediction algorithm was developed by random forest. Results: The mood state prediction accuracies for the next 3 days in all patients, MDD patients, BD I patients, and BD II patients were 65%, 65%, 64%, and 65% with 0.7, 0.69, 0.67, and 0.67 area under the curve (AUC) values, respectively. The accuracies of all patients for no episode (NE), depressive episode (DE), manic episode (ME), and hypomanic episode (HME) were 85.3%, 87%, 94%, and 91.2% with 0.87, 0.87, 0.958, and 0.912 AUC values, respectively. The prediction accuracy in BD II patients was distinctively balanced as high showing 82.6%, 74.4%, and 87.5% of accuracy (with generally good sensitivity and specificity) with 0.919, 0.868, and 0.949 AUC values for NE, DE, and HME, respectively. Conclusions: On the basis of the theoretical basis of chronobiology, this study proposed a good model for future research by developing a mood prediction algorithm using machine learning by processing and reclassifying digital log data. In addition to academic value, it is expected that this study will be of practical help to improve the prognosis of patients with mood disorders by making it possible to apply actual clinical application owing to the rapid expansion of digital technology. %M 30994461 %R 10.2196/11029 %U http://www.jmir.org/2019/4/e11029/ %U https://doi.org/10.2196/11029 %U http://www.ncbi.nlm.nih.gov/pubmed/30994461 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11245 %T Mobile Health Interventions: Exploring the Use of Common Relationship Factors %A Grekin,Emily R %A Beatty,Jessica R %A Ondersma,Steven J %+ Department of Psychology, Wayne State University, 5057 Woodward Ave, Detroit, MI, 48202, United States, 1 313 577 2366, grekine@wayne.edu %K mobile health %K mHealth %K smartphone %K empathy %K mobile applications %K therapeutic alliance %D 2019 %7 15.04.2019 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X The use of mobile health (mHealth) interventions has risen dramatically over the past two decades. It is important to consider mHealth intervention research within the broader therapy outcome literature. Among other key findings, this broader literature suggests that common relationship factors such as empathy, positive regard, and genuineness may play a critical role in therapy effectiveness. These findings raise intriguing questions for mobile interventions. For example, can mobile interventions incorporate aspects of common factors to augment their efficacy? Will the absence of relationship-based common factors make mobile interventions less effective? This viewpoint paper addresses these questions as well as related issues such as how to operationalize relationship qualities in the context of a mobile intervention and whether common relationship factors apply to computers or computerized narrators. The paper concludes by outlining a future research agenda guided by theory and empirical studies. %M 30985281 %R 10.2196/11245 %U http://mhealth.jmir.org/2019/4/e11245/ %U https://doi.org/10.2196/11245 %U http://www.ncbi.nlm.nih.gov/pubmed/30985281 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 2 %P e8540 %T FightHPV: Design and Evaluation of a Mobile Game to Raise Awareness About Human Papillomavirus and Nudge People to Take Action Against Cervical Cancer %A Ruiz-López,Tomás %A Sen,Sagar %A Jakobsen,Elisabeth %A Tropé,Ameli %A Castle,Philip E %A Hansen,Bo Terning %A Nygård,Mari %+ HPV Research Group, Department of Research, Cancer Registry of Norway, Ullernchausseen 64, 0379 Oslo, Norway, Oslo,, Norway, 47 95181886, mari.nygard@kreftregisteret.no %K papillomavirus vaccines %K educational technology %K uterine cervical neoplasms %K papillomavirus infections %K primary prevention %K secondary prevention %K early detection of cancer %K mobile applications %K health education %K learning %D 2019 %7 08.04.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Human papillomavirus (HPV) is the most common sexually transmitted infection globally. High-risk HPV types can cause cervical cancer, other anogenital cancer, and oropharyngeal cancer; low-risk HPV types can cause genital warts. Cervical cancer is highly preventable through HPV vaccination and screening; however, a lack of awareness and knowledge of HPV and these preventive strategies represents an important barrier to reducing the burden of the disease. The rapid development and widespread use of mobile technologies in the last few years present an opportunity to overcome this lack of knowledge and create new, effective, and modern health communication strategies. Objective: This study aimed to describe the development of a mobile app called FightHPV, a game-based learning tool that educates mobile technology users about HPV, the disease risks associated with HPV infection, and existing preventive methods. Methods: The first version of FightHPV was improved in a design-development-evaluation loop, which incorporated feedback from a beta testing study of 40 participants, a first focus group of 6 participants aged between 40 and 50 years and a second focus group of 23 participants aged between 16 and 18 years. Gameplay data from the beta testing study were collected using Google Analytics (Google), whereas feedback from focus groups was evaluated qualitatively. Of the 29 focus group participants, 26 returned self-administered questionnaires. HPV knowledge before and after playing the game was evaluated in the 22 participants from the second focus group who returned a questionnaire. Results: FightHPV communicates concepts about HPV, associated diseases and their prevention by representing relationships among 14 characters in 6 episodes of 10 levels each, with each level being represented by a puzzle. Main concepts were reinforced with text explanations. Beta testing revealed that many players either failed or had to retry several times before succeeding at the more difficult levels in the game. It also revealed that players gave up at around level 47 of 60, which prompted the redesign of FightHPV to increase accessibility to all episodes. Focus group discussions led to several improvements in the user experience and dissemination of health information in the game, such as making all episodes available from the beginning of the game and rewriting the information in a more appealing way. Among the 26 focus group participants who returned a questionnaire, all stated that FightHPV is an appealing educational tool, 69% (18/26) reported that they liked the game, and 81% (21/26) stated that the game was challenging. We observed an increase in HPV knowledge after playing the game (P=.001). Conclusions: FightHPV was easy to access, use, and it increased awareness about HPV infection, its consequences, and preventive measures. FightHPV can be used to educate people to take action against HPV and cervical cancer. %M 30958271 %R 10.2196/games.8540 %U https://games.jmir.org/2019/2/e8540/ %U https://doi.org/10.2196/games.8540 %U http://www.ncbi.nlm.nih.gov/pubmed/30958271 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e12033 %T A Mobile Phone–Based Approach for Hearing Screening of School-Age Children: Cross-Sectional Validation Study %A Chu,Yuan-Chia %A Cheng,Yen-Fu %A Lai,Ying-Hui %A Tsao,Yu %A Tu,Tzong-Yang %A Young,Shuenn Tsong %A Chen,Tzer-Shyong %A Chung,Yu-Fang %A Lai,Feipei %A Liao,Wen-Huei %+ Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, No 201, Sec 2, Shipai Rd, Beitou District, Taipei, 11217, Taiwan, 886 938102333, whliaovictor@gmail.com %K hearing tests %K telemedicine %K mobile apps %K audiometry, pure-tone %D 2019 %7 01.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pure-tone screening (PTS) is considered as the gold standard for hearing screening programs in school-age children. Mobile devices, such as mobile phones, have the potential for audiometric testing. Objective: This study aimed to demonstrate a new approach to rapidly screen hearing status and provide stratified test values, using a smartphone-based hearing screening app, for each screened ear of school-age children. Method: This was a prospective cohort study design. The proposed smartphone-based screening method and a standard sound-treated booth with PTS were used to assess 85 school-age children (170 ears). Sound-treated PTS involved applying 4 test tones to each tested ear: 500 Hz at 25 dB and 1000 Hz, 2000 Hz, and 4000 Hz at 20 dB. The results were classified as pass (normal hearing in the ear) or fail (possible hearing impairment). The proposed smartphone-based screening employs 20 stratified hearing scales. Thresholds were compared with those of pure-tone average (PTA). Results: A total of 85 subjects (170 ears), including 38 males and 47 females, aged between 11 and 12 years with a mean (SD) of 11 (0.5) years, participated in the trial. Both screening methods produced comparable pass and fail results (pass in 168 ears and fail in 2 ears). The smartphone-based screening detected moderate or worse hearing loss (average PTA>25 dB) accurately. Both the sensitivity and specificity of the smartphone-based screening method were calculated at 100%. Conclusions: The results of the proposed smartphone-based self-hearing test demonstrated high concordance with conventional PTS in a sound-treated booth. Our results suggested the potential use of the proposed smartphone-based hearing screening in a school-age population. %M 30932870 %R 10.2196/12033 %U https://mhealth.jmir.org/2019/4/e12033/ %U https://doi.org/10.2196/12033 %U http://www.ncbi.nlm.nih.gov/pubmed/30932870 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11300 %T Challenges in the Development of e-Quit worRx: An iPad App for Smoking Cessation Counseling and Shared Decision Making in Primary Care %A Doarn,Charles R %A Vonder Meulen,Mary Beth %A Pallerla,Harini %A Acquavita,Shauna P %A Regan,Saundra %A Elder,Nancy %A Tubb,Matthew R %+ Department of Family and Community Medicine, University of Cincinnati, 231 Albert Sabin Way, ML0582, Cincinnati, OH, 45267, United States, 1 5135586148, charles.doarn@uc.edu %K mobile health %K smoking cessation %K primary care %K decision aid %D 2019 %7 29.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Smoking is the leading preventable cause of morbidity and mortality in the United States, killing more than 450,000 Americans. Primary care physicians (PCPs) have a unique opportunity to discuss smoking cessation evidence in a way that enhances patient-initiated change and quit attempts. Patients today are better equipped with technology such as mobile devices than ever before. Objective: The aim of this study was to evaluate the challenges in developing a tablet-based, evidence-based smoking cessation app to optimize interaction for shared decision making between PCPs and their patients who smoke. Methods: A group of interprofessional experts developed content and a graphical user interface for the decision aid and reviewed these with several focus groups to determine acceptability and usability in a small population. Results: Using a storyboard methodology and subject matter experts, a mobile app, e-Quit worRx, was developed through an iterative process. This iterative process helped finalize the content and ergonomics of the app and provided valuable feedback from both patients and provider teams. Once the app was made available, other technical and programmatic challenges arose. Conclusions: Subject matter experts, although generally amenable to one another’s disciplines, are often challenged with effective interactions, including language, scope, clinical understanding, technology awareness, and expectations. The successful development of this app and its evaluation in a clinical setting highlighted those challenges and reinforced the need for effective communications and team building. %M 30924783 %R 10.2196/11300 %U https://formative.jmir.org/2019/1/e11300/ %U https://doi.org/10.2196/11300 %U http://www.ncbi.nlm.nih.gov/pubmed/30924783 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 4 %N 1 %P e10271 %T Appropriation of Mobile Health for Diabetes Self-Management: Lessons From Two Qualitative Studies %A Rossmann,Constanze %A Riesmeyer,Claudia %A Brew-Sam,Nicola %A Karnowski,Veronika %A Joeckel,Sven %A Chib,Arul %A Ling,Rich %+ Department of Media and Communication Science, University of Erfurt, Nordhaeuser Str 63, Erfurt, 99089, Germany, 49 3617374171, constanze.rossmann@uni-erfurt.de %K diabetes %K Germany %K mHealth %K mobile phone %K self-management %K Singapore %D 2019 %7 29.03.2019 %9 Original Paper %J JMIR Diabetes %G English %X Background: To achieve clarity on mobile health’s (mHealth’s) potential in the diabetes context, it is necessary to understand potential users’ needs and expectations, as well as the factors determining their mHealth use. Recently, a few studies have examined the user perspective in the mHealth context, but their explanatory value is constrained because of their limitation to adoption factors. Objective: This paper uses the mobile phone appropriation model to examine how individuals with type 1 or type 2 diabetes integrate mobile technology into their everyday self-management. The study advances the field beyond mere usage metrics or the simple dichotomy of adoption versus rejection. Methods: Data were gathered in 2 qualitative studies in Singapore and Germany, with 21 and 16 respondents, respectively. Conducting semistructured interviews, we asked respondents about their explicit use of diabetes-related apps, their general use of varied mobile technologies to manage their disease, and their daily practices of self-management. Results: The analysis revealed that although some individuals with diabetes used dedicated diabetes apps, most used tools across the entire mobile-media spectrum, including lifestyle and messaging apps, traditional health information websites and forums. The material indicated general barriers to usage, including financial, technical, and temporal restrictions. Conclusions: In sum, we find that use patterns differ regarding users’ evaluations, expectancies, and appropriation styles, which might explain the inconclusive picture of effects studies in the diabetes mHealth context. %M 30924786 %R 10.2196/10271 %U http://diabetes.jmir.org/2019/1/e10271/ %U https://doi.org/10.2196/10271 %U http://www.ncbi.nlm.nih.gov/pubmed/30924786 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 2 %N 1 %P e12850 %T Mentalizing Imagery Therapy Mobile App to Enhance the Mood of Family Dementia Caregivers: Feasibility and Limited Efficacy Testing %A Sikder,Abu Taher %A Yang,Francis Cheng %A Schafer,Rhiana %A Dowling,Glenna A %A Traeger,Lara %A Jain,Felipe Ananda %+ Depression Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, One Bowdoin Square, 6th Floor, Boston, MA, 02114, United States, 1 617 643 4682, felipe.jain@post.harvard.edu %K family caregivers %K mindfulness %K depression %K mobile apps %K psychotherapy %D 2019 %7 21.03.2019 %9 Original Paper %J JMIR Aging %G English %X Background: Family caregivers of patients with Alzheimer disease and related dementias (AD and ADRD) often experience high stress and are at high risk for depression. Technologically delivered therapy is attractive for AD and ADRD caregivers because of the time demands associated with in-person participation. Objective: We aimed to study the feasibility and conduct limited efficacy testing of a mobile app intervention delivering mentalizing imagery therapy (MIT) for family caregivers. Methods: A 4-week trial of the MIT app for family AD and ADRD caregivers was conducted to assess the feasibility of use and investigate changes in depression symptoms, mood, and caregiving experience. Semistructured interviews were conducted to characterize participants’ perceived feasibility and benefits. Results: A total of 17 of the 21 (80%) consented participants (mean age 67 years, range 54-79) utilized the app at least once and were further analyzed. Average usage of audio recordings was on 14 (SD 10) days out of 28 possible and comprised 29 (SD 28) individual sessions. There were improvements in depression with a large effect size for those who used the app at least moderately (P=.008), increases in positive mood postintervention (P<.05), and acute increases in mood following daily guided imagery practice (Stretching and Breathing, P<.001; Eye in the Center, P<.001; Nesting Doll, P=.002; Situation Solver, P=.003; and Life Globe, P=.006). Semistructured interviews revealed perceived benefits such as greater ability to remain “centered” despite caregiving challenges and positive reframing of the caregiver experience. Conclusions: App delivery of MIT is feasible for family AD and ADRD caregivers, including aging seniors. Results showed moderate to high usage of the app for a majority of users. Limited efficacy testing provides justification for studying the MIT app for AD and ADRD caregivers to improve mood and reduce depression in larger, controlled trials. %M 31518275 %R 10.2196/12850 %U http://aging.jmir.org/2019/1/e12850/ %U https://doi.org/10.2196/12850 %U http://www.ncbi.nlm.nih.gov/pubmed/31518275 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 3 %P e11572 %T Exploring the Use of Multiple Mental Health Apps Within a Platform: Secondary Analysis of the IntelliCare Field Trial %A Kwasny,Mary J %A Schueller,Stephen M %A Lattie,Emily %A Gray,Elizabeth L %A Mohr,David C %+ Division of Biostatistics, Department of Preventive Medicine, Northwestern University, Suite 1400, 680 N Lake Shore Drive, Chicago, IL, 60611, United States, 1 3125032294, m-kwasny@northwestern.edu %K mobile apps %K depression %K anxiety %K mobile phone %D 2019 %7 21.03.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: IntelliCare is a mental health app platform with 14 apps that are elemental, simple and brief to use, and eclectic. Although a variety of apps may improve engagement, leading to better outcomes, they may require navigation aids such as recommender systems that can quickly direct a person to a useful app. Objective: As the first step toward developing navigation and recommender tools, this study explored app-use patterns across the IntelliCare platform and their relationship with depression and anxiety outcomes. Methods: This is a secondary analysis of the IntelliCare Field Trial, which recruited people with depression or anxiety. Participants of the trial received 8 weeks of coaching, primarily by text, and weekly random recommendations for apps. App-use metrics included frequency and lifetime use. Depression and anxiety, measured using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, respectively, were assessed at baseline and end of treatment. Cluster analysis was utilized to determine patterns of app use; ordinal logistic regression models and log-rank tests were used to determine if these use metrics alone, or in combination, predicted improvement or remission in depression or anxiety. Results: The analysis included 96 people who generally followed recommendations to download and try new apps each week. Apps were clustered into 5 groups: Thinking (apps that targeted or relied on thinking), Calming (relaxation and insomnia), Checklists (apps that used checklists), Activity (behavioral activation and activity), and Other. Both overall frequency of use and lifetime use predicted response for depression and anxiety. The Thinking, Calming, and Checklist clusters were associated with improvement in depression and anxiety, and the Activity cluster was associated with improvement in Anxiety only. However, the use of clusters was less strongly associated with improvement than individual app use. Conclusions: Participants in the field trial remained engaged with a suite of apps for the full 8 weeks of the trial. App-use patterns did fall into clusters, suggesting that some knowledge about the use of one app may be useful in selecting another app that the person is more likely to use and may help suggest apps based on baseline symptomology and personal preference. %M 30896433 %R 10.2196/11572 %U http://mental.jmir.org/2019/3/e11572/ %U https://doi.org/10.2196/11572 %U http://www.ncbi.nlm.nih.gov/pubmed/30896433 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e11486 %T The Association Between Medication Adherence for Chronic Conditions and Digital Health Activity Tracking: Retrospective Analysis %A Quisel,Tom %A Foschini,Luca %A Zbikowski,Susan M %A Juusola,Jessie L %+ Evidation Health, 167 2nd Avenue, San Mateo, CA,, United States, 1 650 279 8855, jjuusola@evidation.com %K activity tracker %K health behavior %K eHealth %K mHealth %K medication adherence %D 2019 %7 20.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic diseases have a widespread impact on health outcomes and costs in the United States. Heart disease and diabetes are among the biggest cost burdens on the health care system. Adherence to medication is associated with better health outcomes and lower total health care costs for individuals with these conditions, but the relationship between medication adherence and health activity behavior has not been explored extensively. Objective: The aim of this study was to examine the relationship between medication adherence and health behaviors among a large population of insured individuals with hypertension, diabetes, and dyslipidemia. Methods: We conducted a retrospective analysis of health status, behaviors, and medication adherence from medical and pharmacy claims and health behavior data. Adherence was measured in terms of proportion of days covered (PDC), calculated from pharmacy claims using both a fixed and variable denominator methodology. Individuals were considered adherent if their PDC was at least 0.80. We used step counts, sleep, weight, and food log data that were transmitted through devices that individuals linked. We computed metrics on the frequency of tracking and the extent to which individuals engaged in each tracking activity. Finally, we used logistic regression to model the relationship between adherent status and the activity-tracking metrics, including age and sex as fixed effects. Results: We identified 117,765 cases with diabetes, 317,340 with dyslipidemia, and 673,428 with hypertension between January 1, 2015 and June 1, 2016 in available data sources. Average fixed and variable PDC for all individuals ranged from 0.673 to 0.917 for diabetes, 0.756 to 0.921 for dyslipidemia, and 0.756 to 0.929 for hypertension. A subgroup of 8553 cases also had health behavior data (eg, activity-tracker data). On the basis of these data, individuals who tracked steps, sleep, weight, or diet were significantly more likely to be adherent to medication than those who did not track any activities in both the fixed methodology (odds ratio, OR 1.33, 95% CI 1.29-1.36) and variable methodology (OR 1.37, 95% CI 1.32-1.43), with age and sex as fixed effects. Furthermore, there was a positive association between frequency of activity tracking and medication adherence. In the logistic regression model, increasing the adjusted tracking ratio by 0.5 increased the fixed adherent status OR by a factor of 1.11 (95% CI 1.06-1.16). Finally, we found a positive association between number of steps and adherent status when controlling for age and sex. Conclusions: Adopters of digital health activity trackers tend to be more adherent to hypertension, diabetes, and dyslipidemia medications, and adherence increases with tracking frequency. This suggests that there may be value in examining new ways to further promote medication adherence through programs that incentivize health tracking and leveraging insights derived from connected devices to improve health outcomes. %M 30892271 %R 10.2196/11486 %U http://www.jmir.org/2019/3/e11486/ %U https://doi.org/10.2196/11486 %U http://www.ncbi.nlm.nih.gov/pubmed/30892271 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e12053 %T Can Smartphone Apps Increase Physical Activity? Systematic Review and Meta-Analysis %A Romeo,Amelia %A Edney,Sarah %A Plotnikoff,Ronald %A Curtis,Rachel %A Ryan,Jillian %A Sanders,Ilea %A Crozier,Alyson %A Maher,Carol %+ Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, University of South Australia, GPO Box 2471, Adelaide, 5001, Australia, 61 8 830 22315, carol.maher@unisa.edu.au %K physical activity %K smartphone %K mobile phone %K app %K mobile apps %K program %K health behavior %K systematic review %K meta-analysis %D 2019 %7 19.03.2019 %9 Review %J J Med Internet Res %G English %X Background: Smartphone apps are a promising tool for delivering accessible and appealing physical activity interventions. Given the large growth of research in this field, there are now enough studies using the “gold standard” of experimental design—the randomized controlled trial design—and employing objective measurements of physical activity, to support a meta-analysis of these scientifically rigorous studies. Objective: This systematic review and meta-analysis aimed to determine the effectiveness of smartphone apps for increasing objectively measured physical activity in adults. Methods: A total of 7 electronic databases (EMBASE, EmCare, MEDLINE, Scopus, Sport Discus, The Cochrane Library, and Web of Science) were searched from 2007 to January 2018. Following the Population, Intervention, Comparator, Outcome and Study Design format, studies were eligible if they were randomized controlled trials involving adults, used a smartphone app as the primary or sole component of the physical activity intervention, used a no- or minimal-intervention control condition, and measured objective physical activity either in the form of moderate-to-vigorous physical activity minutes or steps. Study quality was assessed using a 25-item tool based on the Consolidated Standards of Reporting Trials checklist. A meta-analysis of study effects was conducted using a random effects model approach. Sensitivity analyses were conducted to examine whether intervention effectiveness differed on the basis of intervention length, target behavior (physical activity alone vs physical activity in combination with other health behaviors), or target population (general adult population vs specific health populations). Results: Following removal of duplicates, a total of 6170 studies were identified from the original database searches. Of these, 9 studies, involving a total of 1740 participants, met eligibility criteria. Of these, 6 studies could be included in a meta-analysis of the effects of physical activity apps on steps per day. In comparison with the control conditions, smartphone apps produced a nonsignificant (P=.19) increase in participants’ average steps per day, with a mean difference of 476.75 steps per day (95% CI −229.57 to 1183.07) between groups. Sensitivity analyses suggested that physical activity programs with a duration of less than 3 months were more effective than apps evaluated across more than 3 months (P=.01), and that physical activity apps that targeted physical activity in isolation were more effective than apps that targeted physical activity in combination with diet (P=.04). Physical activity app effectiveness did not appear to differ on the basis of target population. Conclusions: This meta-analysis provides modest evidence supporting the effectiveness of smartphone apps to increase physical activity. To date, apps have been most effective in the short term (eg, up to 3 months). Future research is needed to understand the time course of intervention effects and to investigate strategies to sustain intervention effects over time. %M 30888321 %R 10.2196/12053 %U http://www.jmir.org/2019/3/e12053/ %U https://doi.org/10.2196/12053 %U http://www.ncbi.nlm.nih.gov/pubmed/30888321 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 7 %N 1 %P e12350 %T Understanding Determinants of Health Care Professionals’ Perspectives on Mobile Health Continuance and Performance %A Hsiao,Ju-Ling %A Chen,Rai-Fu %+ Department of Information Management, Chia-Nan University of Pharmacy and Science, No 60, Sec 1, Erren Rd, Rende Dist, Tainan City, 71710, Taiwan, 886 6 2664911 ext 5308, rafuchen@gmail.com %K delivery of health care %K mobile health %K health information management %K health care quality, access, and evaluation %D 2019 %7 18.03.2019 %9 Original Paper %J JMIR Med Inform %G English %X Background: With the widespread use of mobile technologies, mobile information systems have become crucial tools in health care operations. Although the appropriate use of mobile health (mHealth) may result in major advances in expanding health care coverage (increasing decision-making speeds, managing chronic conditions, and providing suitable health care in emergencies), previous studies have argued that current mHealth research does not adequately evaluate mHealth interventions, and it does not provide sufficient evidence regarding the effects on health. Objective: The aim of this study was to facilitate the widespread use of mHealth systems; an accurate evaluation of the systems from the users’ perspective is essential after the implementation and use of the system in daily health care practices. This study extends the expectation-confirmation model by using characteristics of individuals, technology, and tasks to identify critical factors affecting mHealth continuance and performance from the perspective of health care professionals (HCPs). Methods: A questionnaire survey was used to collect data from HCPs who were experienced in using mHealth systems of a Taiwanese teaching hospital. In total, 282 questionnaires were distributed, and 201 complete and valid questionnaires were returned, thus indicating a valid response rate of 71.3% (201/282). The collected data were analyzed using WarpPLS version 5.0 (ScriptWarp Systems). Results: The results revealed that mHealth continuance (R2=0.522) was mainly affected by perceived usefulness, technology maturity, individual habits, task mobility, and user satisfaction, whereas individual performance (R2=0.492) was affected by mHealth continuance. In addition, user satisfaction (R2=0.548) was affected by confirmation and perceived usefulness of mHealth, whereas perceived usefulness (R2=0.521) was affected by confirmation. This implied that confirmation played a key role in affecting perceived usefulness and user satisfaction. Furthermore, the results showed that mHealth continuance positively affected individual performance. Conclusions: The identified critical factors influencing mHealth continuance and performance can be used as a useful assessment tool by hospitals that have implemented mHealth systems to facilitate the use and infusion of the systems. Furthermore, the results can help health care institutions that intend to introduce or develop mHealth applications to identify critical issues and effectively allocate limited resources to mHealth systems. %M 30882353 %R 10.2196/12350 %U http://medinform.jmir.org/2019/1/e12350/ %U https://doi.org/10.2196/12350 %U http://www.ncbi.nlm.nih.gov/pubmed/30882353 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e11296 %T User Experience of an App-Based Treatment for Stress Urinary Incontinence: Qualitative Interview Study %A Asklund,Ina %A Samuelsson,Eva %A Hamberg,Katarina %A Umefjord,Göran %A Sjöström,Malin %+ Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, The Research Unit, Region Jämtland Härjedalen, Box 654, Umeå, SE-831 27, Sweden, 46 704788148, ina.asklund@umu.se %K mobile applications %K urinary incontinence %K stress %K pelvic floor muscle training %K self-management %K qualitative research %K grounded theory %K women’s health %D 2019 %7 14.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Stress urinary incontinence (SUI) affects 10%-39% of women. Its first-line treatment consists of lifestyle interventions and pelvic floor muscle training (PFMT), which can be performed supervised or unsupervised. Health apps are increasing in number and can be used to improve adherence to treatments. We developed the Tät app, which provides a 3-month treatment program with a focus on PFMT for women with SUI. The app treatment was evaluated in a randomized controlled trial, which demonstrated efficacy for improving incontinence symptoms and quality of life. In this qualitative interview study, we investigated participant experiences of the app-based treatment. Objective: This study aimed to explore women’s experiences of using an app-based treatment program for SUI. Methods: This qualitative study is based on telephone interviews with 15 selected women, with a mean age of 47 years, who had used the app in the previous randomized controlled trial. A semistructured interview guide with open-ended questions was used, and the interviews were transcribed verbatim. Data were analyzed according to the grounded theory. Results: The results were grouped into three categories: “Something new!” “Keeping motivation up!” and “Good enough?” A core category, “Enabling my independence,” was identified. The participants appreciated having a new and modern way to access a treatment program for SUI. The use of new technology seemed to make incontinence treatment feel more prioritized and less embarrassing for the subjects. The closeness to their mobile phone and app features like reminders and visual graphs helped support and motivate the women to carry through the PFMT. The participants felt confident that they could perform the treatment program on their own, even though they expressed some uncertainty about whether they were doing the pelvic floor muscle contractions correctly. They felt that the app-based treatment increased their self-confidence and enabled them to take responsibility for their treatment. Conclusions: Use of the app-based treatment program for SUI empowered the women in this study and helped them self-manage their incontinence treatment. They appreciated the app as a new tool for supporting their motivation to carry through a slightly challenging PFMT program. Trial Registration: ClinicalTrials.gov NCT01848938; https://clinicaltrials.gov/ct2/show/NCT01848938 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01848938) %M 30869644 %R 10.2196/11296 %U http://www.jmir.org/2019/3/e11296/ %U https://doi.org/10.2196/11296 %U http://www.ncbi.nlm.nih.gov/pubmed/30869644 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 3 %P e11163 %T A Mobile Health Contraception Decision Support Intervention for Latina Adolescents: Implementation Evaluation for Use in School-Based Health Centers %A Tebb,Kathleen P %A Leng Trieu,Sang %A Rico,Rosario %A Renteria,Robert %A Rodriguez,Felicia %A Puffer,Maryjane %+ Department of Pediatrics, University of California, San Francisco, 3333 California Street, Suite 245, San Francisco, CA, 94118, United States, 1 415 514 0941, Kathleen.tebb@ucsf.edu %K mobile health %K adolescent health %K pregnancy in adolescence %D 2019 %7 14.03.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Health care providers are a trusted and accurate source of sexual health information for most adolescents, and clinical guidelines recommend that all youth receive comprehensive, confidential sexual health information and services. However, these guidelines are followed inconsistently. Providers often lack the time, comfort, and skills to provide patient-centered comprehensive contraceptive counseling and services. There are significant disparities in the provision of sexual health services for Latino adolescents, which contribute to disproportionately higher rates of teenage pregnancy. To address this, we developed Health-E You or Salud iTu in Spanish, an evidence-informed mobile health (mHealth) app, to provide interactive, individually tailored sexual health information and contraception decision support for English and Spanish speakers. It is designed to be used in conjunction with a clinical encounter to increase access to patient-centered contraceptive information and services for adolescents at risk of pregnancy. Based on user input, the app provides tailored contraceptive recommendations and asks the youth to indicate what methods they are most interested in. This information is shared with the provider before the in-person visit. The app is designed to prepare youth for the visit and acts as a clinician extender to support the delivery of health education and enhance the quality of patient-centered sexual health care. Despite the promise of this app, there is limited research on the integration of such interventions into clinical practice. Objective: This study described efforts used to support the successful adoption and implementation of the Health-E You app in clinical settings and described facilitators and barriers encountered to inform future efforts aimed at integrating mHealth interventions into clinical settings. Methods: This study was part of a larger, cluster randomized control trial to evaluate the effectiveness of Health-E You on its ability to reduce health disparities in contraceptive knowledge, access to contraceptive services, and unintended pregnancies among sexually active Latina adolescents at 18 school-based health centers (SBHCs) across Los Angeles County, California. App development and implementation were informed by the theory of diffusion of innovation, the Patient-Centered Outcomes Research Institute’s principles of engagement, and iterative pilot testing with adolescents and clinicians. Implementation facilitators and barriers were identified through monthly conference calls, site visits, and quarterly in-person collaborative meetings. Results: Implementation approaches enhanced the development, adoption, and integration of Health-E You into SBHCs. Implementation challenges were also identified to improve the integration of mHealth interventions into clinical settings. Conclusions: This study provides important insights that can inform and improve the implementation efforts for future mHealth interventions. In particular, an implementation approach founded in a strong theoretical framework and active engagement with patient and community partners can enhance the development, adoption, and integration of mHealth technologies into clinical practice. Trial Registration: ClinicalTrials.gov NCT02847858; https://clinicaltrials.gov/ct2/show/NCT02847858 (Archived by WebCite at http://www.webcitation.org/761yVIRTp). %M 30869649 %R 10.2196/11163 %U http://mhealth.jmir.org/2019/3/e11163/ %U https://doi.org/10.2196/11163 %U http://www.ncbi.nlm.nih.gov/pubmed/30869649 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e12143 %T Design and Preliminary Findings From a New Electronic Cohort Embedded in the Framingham Heart Study %A McManus,David D %A Trinquart,Ludovic %A Benjamin,Emelia J %A Manders,Emily S %A Fusco,Kelsey %A Jung,Lindsey S %A Spartano,Nicole L %A Kheterpal,Vik %A Nowak,Christopher %A Sardana,Mayank %A Murabito,Joanne M %+ Boston University's and National Heart, Lung, and Blood Institute's Framingham Heart Study, 73 Mount Wayte Ave, Framingham, MA, 01701, United States, 1 508 935 3400, murabito@bu.edu %K smartphone %K tele-medicine %K blood pressure monitoring %K ambulatory %K cohort studies %D 2019 %7 01.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: New models of scalable population-based data collection that integrate digital and mobile health (mHealth) data are necessary. Objective: The aim of this study was to describe a cardiovascular digital and mHealth electronic cohort (e-cohort) embedded in a traditional longitudinal cohort study, the Framingham Heart Study (FHS). Methods: We invited eligible and consenting FHS Generation 3 and Omni participants to download the electronic Framingham Heart Study (eFHS) app onto their mobile phones and co-deployed a digital blood pressure (BP) cuff. Thereafter, participants were also offered a smartwatch (Apple Watch). Participants are invited to complete surveys through the eFHS app, to perform weekly BP measurements, and to wear the smartwatch daily. Results: Up to July 2017, we enrolled 790 eFHS participants, representing 76% (790/1044) of potentially eligible FHS participants. eFHS participants were, on average, 53±8 years of age and 57% were women. A total of 85% (675/790) of eFHS participants completed all of the baseline survey and 59% (470/790) completed the 3-month survey. A total of 42% (241/573) and 76% (306/405) of eFHS participants adhered to weekly digital BP and heart rate (HR) uploads, respectively, over 12 weeks. Conclusions: We have designed an e-cohort focused on identifying novel cardiovascular disease risk factors using a new smartphone app, a digital BP cuff, and a smartwatch. Despite minimal training and support, preliminary findings over a 3-month follow-up period show that uptake is high and adherence to periodic app-based surveys, weekly digital BP assessments, and smartwatch HR measures is acceptable. %M 30821691 %R 10.2196/12143 %U http://www.jmir.org/2019/3/e12143/ %U https://doi.org/10.2196/12143 %U http://www.ncbi.nlm.nih.gov/pubmed/30821691 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e10736 %T eHealth Apps Replacing or Complementing Health Care Contacts: Scoping Review on Adverse Effects %A Stevens,Wilhelmina Josepha Maria %A van der Sande,Rob %A Beijer,Lilian J %A Gerritsen,Maarten GM %A Assendelft,Willem JJ %+ Faculty of Health, Hogeschool van Arnhem en Nijmegen University of Applied Sciences, Kapittelweg 33, Nijmegen, 6525 EN, Netherlands, 31 651450260, marjo.stevens@han.nl %K eHealth %K adverse effects %K scoping review %D 2019 %7 01.03.2019 %9 Review %J J Med Internet Res %G English %X Background: The use of eHealth has increased tremendously in recent years. eHealth is generally considered to have a positive effect on health care quality and to be a promising alternative to face-to-face health care contacts. Surprisingly little is known about possible adverse effects of eHealth apps. Objective: We conducted a scoping review on empirical research into adverse effects of eHealth apps that aim to deliver health care at a distance. We investigated whether adverse effects were reported and the nature and quality of research into these possible adverse effects. Methods: For this scoping review, we followed the five steps of Arksey and O’Malley’s scoping review methodology. We searched specifically for studies into eHealth apps that replaced or complemented the face-to-face contact between a health professional and a patient in the context of treatment, health monitoring, or supporting self-management. Studies were included when eHealth and adverse effects were mentioned in the title or abstract and when empirical data on adverse effects were provided. All health conditions, with the exception of mental health conditions, all ages, and all sample sizes were included. We examined the literature published between December 2012 and August 2017 in the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and the Cochrane Library. The methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklists. Results: Our search identified 79 papers that were potentially relevant; 11 studies met our inclusion criteria after screening. These studies differed in many ways and the majority were characterized by small research populations and low study quality. Adverse effects are rarely subject to systematic scientific research. So far, information on real adverse effects is mainly limited to incidental reporting or as a bycatch from qualitative pilot studies. Despite the shortage of solid research, we found some indications of possible negative impact on patient-centeredness and efficiency, such as less transparency in the relationship between health professionals and patients and time-consuming work routines. Conclusions: There is a lack of high-quality empirical research on adverse effects of eHealth apps that replace or complement face-to-face care. While the development of eHealth apps is ongoing, the knowledge with regard to possible adverse effects is limited. The available research often focuses on efficacy, added value, implementation issues, use, and satisfaction, whereas adverse effects are underexplored. A better understanding of possible adverse effects could be a starting point in improving the positive impact of eHealth-based health care delivery. %M 30821690 %R 10.2196/10736 %U https://www.jmir.org/2019/3/e10736/ %U https://doi.org/10.2196/10736 %U http://www.ncbi.nlm.nih.gov/pubmed/30821690 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12895 %T Influences on the Implementation of Mobile Learning for Medical and Nursing Education: Qualitative Systematic Review by the Digital Health Education Collaboration %A Lall,Priya %A Rees,Rebecca %A Law,Gloria Chun Yi %A Dunleavy,Gerard %A Cotič,Živa %A Car,Josip %+ Evidence for Policy and Practice Information and Co-ordinating Centre, Social Science Research Unit, Department of Social Science, University College London Institute of Education, University College London, 18 Woburn Square, London, WCIH 0NR, United Kingdom, 44 07932 243030, rebecca.rees@ucl.ac.uk %K medical education %K nursing education %K distance education %K qualitative research %K systematic review %D 2019 %7 28.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In the past 5 decades, digital education has increasingly been used in health professional education. Mobile learning (mLearning), an emerging form of educational technology using mobile devices, has been used to supplement learning outcomes through enabling conversations, sharing information and knowledge with other learners, and aiding support from peers and instructors regardless of geographic distance. Objective: This review aimed to synthesize findings from qualitative or mixed-methods studies to provide insight into factors facilitating or hindering implementation of mLearning strategies for medical and nursing education. Methods: A systematic search was conducted across a range of databases. Studies with the following criteria were selected: examined mLearning in medical and nursing education, employed a mixed-methods or qualitative approach, and published in English after 1994. Findings were synthesized using a framework approach. Results: A total of 1946 citations were screened, resulting in 47 studies being selected for inclusion. Most studies evaluated pilot mLearning interventions. The synthesis identified views on valued aspects of mobile devices in terms of efficiency and personalization but concerns over vigilance and poor device functionality; emphasis on the social aspects of technology, especially in a clinical setting; the value of interaction learning for clinical practice; mLearning as a process, including learning how to use a device; and the importance of institutional infrastructure and policies. Conclusions: The portability of mobile devices can enable interactions between learners and educational material, fellow learners, and educators in the health professions. However, devices need to be incorporated institutionally, and learners and educators need additional support to fully comprehend device or app functions. The strategic support of mLearning is likely to require procedural guidance for practice settings and device training and maintenance services on campus. %M 30816847 %R 10.2196/12895 %U https://www.jmir.org/2019/2/e12895/ %U https://doi.org/10.2196/12895 %U http://www.ncbi.nlm.nih.gov/pubmed/30816847 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 1 %P e11444 %T Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial %A Höchsmann,Christoph %A Infanger,Denis %A Klenk,Christopher %A Königstein,Karsten %A Walz,Steffen P %A Schmidt-Trucksäss,Arno %+ Department of Sport, Exercise and Health, University of Basel, Birsstrasse 320 B, Basel, 4052, Switzerland, 41 612074740, arno.schmidt-trucksaess@unibas.ch %K behavior change %K exercise adherence %K gamification %K intrinsic motivation %K mhealth %K mobile phone game %K physical activity %K type 2 diabetes %D 2019 %7 13.02.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients. Objective: To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation. Methods: Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data. Results: Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales “interest/enjoyment” (+2.0 (SD 1.9) points, P<.001) and “perceived competence” (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01). Conclusions: In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks. Trial Registration: ClinicalTrials.gov NCT02657018; https://clinicaltrials.gov/ct2/show/NCT02657018 %M 30758293 %R 10.2196/11444 %U http://games.jmir.org/2019/1/e11444/ %U https://doi.org/10.2196/11444 %U http://www.ncbi.nlm.nih.gov/pubmed/30758293 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11268 %T Mobile Technology for Community Health in Ghana: Is Maternal Messaging and Provider Use of Technology Cost-Effective in Improving Maternal and Child Health Outcomes at Scale? %A Willcox,Michelle %A Moorthy,Anitha %A Mohan,Diwakar %A Romano,Karen %A Hutchful,David %A Mehl,Garrett %A Labrique,Alain %A LeFevre,Amnesty %+ Health Intelligence Initiative, Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Falmouth Rd, Observatory, Cape Town, 7925, South Africa, 27 0767828704, aelefevre@gmail.com %K child health %K frontline health workers %K Ghana %K health information systems %K maternal health %K mHealth %K mobile phone %K newborn health %D 2019 %7 13.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries. Objective: This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana. Methods: MOTECH’s “Client Data Application” allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH’s other main component, the “Mobile Midwife,” sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters. Results: MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana’s districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50. Conclusions: This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health. %M 30758296 %R 10.2196/11268 %U http://www.jmir.org/2019/2/e11268/ %U https://doi.org/10.2196/11268 %U http://www.ncbi.nlm.nih.gov/pubmed/30758296 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 2 %P e10930 %T Research-Tested Mobile Apps for Breast Cancer Care: Systematic Review %A Jongerius,Chiara %A Russo,Selena %A Mazzocco,Ketti %A Pravettoni,Gabriella %+ Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, 1100 DD, Netherlands, 31 205667787, c.jongerius@amc.uva.nl %K breast cancer care %K breast cancer management %K breast cancer prevention %K breast cancer survivorship %K mobile applications %K mHealth applications %D 2019 %7 11.02.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The use of mobile health (mHealth) apps in clinical settings is increasing widely. mHealth has been used to promote prevention, improve early detection, manage care, and support survivors and chronic patients. However, data on the efficacy and utility of mHealth apps are limited. Objective: The main objective of this review was to provide an overview of the available research-tested interventions using mHealth apps and their impact on breast cancer care. Methods: A systematic search of Medline, PsycINFO, Embase, and Scopus was performed to identify relevant studies. From the selected studies, the following information was extracted: authors, publication date, study objectives, study population, study design, interventions’ features, outcome measures, and results. Results: We identified 29 empirical studies that described a health care intervention using an mHealth app in breast cancer care. Of these, 7 studies were about the use of an mHealth application in an intervention for breast cancer prevention and early detection, 12 targeted care management, and 10 focused on breast cancer survivors. Conclusions: Our results indicate consistent and promising findings of interventions using mHealth apps that target care management in breast cancer. Among the categories of mHealth apps focusing on survivorship, mHealth-based interventions showed a positive effect by promoting weight loss, improving the quality of life, and decreasing stress. There is conflicting and less conclusive data on the effect of mHealth apps on psychological dimensions. We advocate further investigation to confirm and strengthen these findings. No consistent evidence for the impact of interventions using mHealth apps in breast cancer prevention and early detection was identified due to the limited number of studies identified by our search. Future research should continue to explore the impact of mHealth apps on breast cancer care to build on these initial recommendations. %M 30741644 %R 10.2196/10930 %U http://mhealth.jmir.org/2019/2/e10930/ %U https://doi.org/10.2196/10930 %U http://www.ncbi.nlm.nih.gov/pubmed/30741644 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11919 %T Mobile Phone Apps Targeting Medication Adherence: Quality Assessment and Content Analysis of User Reviews %A Park,Jamie Yea Eun %A Li,Jenny %A Howren,Alyssa %A Tsao,Nicole Wen %A De Vera,Mary %+ Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada, 1 604 827 2138, mdevera@mail.ubc.ca %K medication adherence %K mobile apps %K mHealth %D 2019 %7 31.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With the accessibility and widespread use of mobile phones, mobile phone apps targeting medication adherence may be useful tools to help patients take medications as prescribed. Objective: Our objectives were to (1) characterize and assess mobile phone medication adherence apps guided by a conceptual framework on the focus of adherence interventions and (2) conduct a content analysis of Web-based reviews to explore users’ perspectives and experiences with mobile phone medication adherence apps. Methods: We searched for mobile phone medication adherence apps using keyword searches in Apple and Android operating systems. We characterized all apps in terms of number of downloads, ratings, languages, cost, and disease target. We categorized apps according to 4 key features of (1) alerting to take medication, (2) tracking medication taking, (3) reminding to refill or indicating amount of medication left, and (4) storing medication information. We then selected representative apps from each operating system for detailed quality assessment and user testing. We also downloaded Web-based reviews for these selected apps and conducted a qualitative content analysis using an inductive approach involving steps of initial open coding, construction of categories, and abstraction into themes. Results: We identified 704 apps (443 from Apple and 261 from Android). The majority of apps across both operating systems had 1 or 2 features—specifically, 37.2% (165/443) and 38.1% (169/443) of Apple apps, respectively, and 41.4% (108/261) and 31.4% (108/261) of Android apps, respectively. Quality assessment and user testing of 20 selected apps revealed apps varied in quality and commonly focused on behavioral strategies to enhance medication adherence through alerts, reminders, and logs. A total of 1323 eligible Web-based reviews from these 20 selected apps were analyzed, and the following themes emerged: (1) features and functions appreciated by users, which included the ability to set up customized medication regimen details and reminders, monitor other health information (eg, vitals, supplements, and manage multiple people or pets), support health care visits (eg, having a list of medications and necessary health information in 1 app); (2) negative user experiences that captured technical difficulties (glitches, confusing app navigation, and poor interoperability), dosage schedule, and reminder setup inflexibility; and (3) desired functions and features related to optimization of information input, improvement of reminders, and upgrading app performance (better synchronization or backup of data and interoperability). Conclusions: A large number of mobile phone medication adherence apps are currently available. The majority of apps have features representing a behavioral approach to intervention. Findings of the content analysis offer mostly positive feedback as well as insights into current limitations and improvements that could be addressed in current and future medication adherence apps. %M 30702435 %R 10.2196/11919 %U http://mhealth.jmir.org/2019/1/e11919/ %U https://doi.org/10.2196/11919 %U http://www.ncbi.nlm.nih.gov/pubmed/30702435 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11325 %T Barriers to and Facilitators of Engagement With mHealth Technology for Remote Measurement and Management of Depression: Qualitative Analysis %A Simblett,Sara %A Matcham,Faith %A Siddi,Sara %A Bulgari,Viola %A Barattieri di San Pietro,Chiara %A Hortas López,Jorge %A Ferrão,José %A Polhemus,Ashley %A Haro,Josep Maria %A de Girolamo,Giovanni %A Gamble,Peter %A Eriksson,Hans %A Hotopf,Matthew %A Wykes,Til %A , %+ Institute of Psychology, Psychiatry and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, United Kingdom, 44 207 848 0762, sara.simblett@kcl.ac.uk %K acceptability %K barriers %K depression %K facilitators %K feasibility %K mHealth %K qualitative %D 2019 %7 30.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile technology has the potential to provide accurate, impactful data on the symptoms of depression, which could improve health management or assist in early detection of relapse. However, for this potential to be achieved, it is essential that patients engage with the technology. Although many barriers to and facilitators of the use of this technology are common across therapeutic areas and technology types, many may be specific to cultural and health contexts. Objective: This study aimed to determine the potential barriers to and facilitators of engagement with mobile health (mHealth) technology for remote measurement and management of depression across three Western European countries. Methods: Participants (N=25; 4:1 ratio of women to men; age range, 25-73 years) who experienced depression participated in five focus groups held in three countries (two in the United Kingdom, two in Spain, and one in Italy). The focus groups investigated the potential barriers to and facilitators of the use of mHealth technology. A systematic thematic analysis was used to extract themes and subthemes. Results: Facilitators and barriers were categorized as health-related factors, user-related factors, and technology-related factors. A total of 58 subthemes of specific barriers and facilitators or moderators emerged. A core group of themes including motivation, potential impact on mood and anxiety, aspects of inconvenience, and ease of use was noted across all countries. Conclusions: Similarities in the barriers to and facilitators of the use of mHealth technology have been observed across Spain, Italy, and the United Kingdom. These themes provide guidance on ways to promote the design of feasible and acceptable cross-cultural mHealth tools. %M 30698535 %R 10.2196/11325 %U http://mhealth.jmir.org/2019/1/e11325/ %U https://doi.org/10.2196/11325 %U http://www.ncbi.nlm.nih.gov/pubmed/30698535 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11099 %T Assessing the Validity of the MyJump2 App for Measuring Different Jumps in Professional Cerebral Palsy Football Players: An Experimental Study %A Coswig,Victor %A Silva,Anselmo De Athayde Costa E %A Barbalho,Matheus %A Faria,Fernando Rosch De %A Nogueira,Claudio D %A Borges,Mariane %A Buratti,Jéssica R %A Vieira,Ivaldo B %A Román,Francisco Javier López %A Gorla,José I %+ Faculty of Physical Education, Federal University of Pará, Campus Castanhal, Rua Major Wilson 3094, Casa 180 qd 8, Castanhal, 68742-89, Brazil, 55 91984273036, vcoswig@gmail.com %K cerebral palsy football %K jump performance %K mobile apps %K mobile phone %K paralympic sports %D 2019 %7 30.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Vertical jumps can be used to assess neuromuscular status in sports performance. This is particularly important in Cerebral Palsy Football (CP Football) because players are exposed to high injury risk, but it may be complicated because the gold standard for assessing jump performance is scarce in field evaluation. Thus, field techniques, such as mobile apps, have been proposed as an alternative method for solving this problem. Objective: This study aims to evaluate the reliability of the measures of the MyJump2 app to assess vertical jump performance in professional CP Football. Methods: We assessed 40 male CP Football athletes (age 28.1 [SD 1.4] years, weight 72.5 [SD 6.2] kg, and height 176 [SD 4.2] cm) through the countermovement jump (CMJ) and squat jump (SJ) using a contact mat. At the same time, we assessed the athletes using the MyJump2 app. Results: There were no significant differences between the instruments in SJ height (P=.12) and flight time (P=.15). Additionally, there were no significant differences between the instruments for CMJ in jump height (P=.16) and flight time (P=.13). In addition, it was observed that there were significant and strong intraclass correlations in all SJ variables varying from 0.86 to 0.89 (both P<.001), which was classified as “almost perfect.” Similar results were observed in all variables from the CMJ, varying from 0.92 to 0.96 (both P ≤.001). Conclusions: We conclude that the MyJump2 app presents high validity and reliability for measuring jump height and flight time of the SJ and CMJ in CP Football athletes. %M 30698529 %R 10.2196/11099 %U http://mhealth.jmir.org/2019/1/e11099/ %U https://doi.org/10.2196/11099 %U http://www.ncbi.nlm.nih.gov/pubmed/30698529 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e9711 %T Farm Owners and Workers as Key Informants in User-Centered Occupational Health Prototype Development: A Stakeholder-Engaged Project %A Weichelt,Bryan %A Bendixsen,Casper %A Keifer,Matthew %+ Marshfield Clinic Research Institute, National Farm Medicine Center, 701 W Kalsched Ave, Marshfield, WI, 54449, United States, 1 715 221 7276, weichelt.bryan@mcrf.mfldclin.edu %K agriculture %K farmworkers %K injuries %K occupational medicine %K return to work %K software application %D 2019 %7 29.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The cost of workplace injuries and illnesses significantly impacts the overall cost of health care and is a significant annual economic burden in the United States. Many dairy and pork farm owners in the Upper Midwest have expanded operations and taken on the role of manager and employer yet receive little training in injury prevention, farm safety, or workers’ compensation programs and processes. Clinicians play a key role in the return to work of injured and ill farmers and farmworkers to their jobs, though little to no formal training is offered by medical schools. Objective: This stakeholder-engaged project aimed to develop a prototype application designed to assist clinicians in returning injured farmworkers to light-duty job assignments with their current employers and to assess farm owners’ and managers’ attitudes toward and barriers to adopting mobile health tools for themselves or their employees. Methods: We conducted 12 semistructured interviews with English-speaking farm owners and farmworkers from the Upper Midwest: 5 English-speaking and Spanish-speaking farmworker focus groups and 8 postproject interviews with farm owners that focused on attitudes and barriers to adoption of the developed software. Interviews and focus groups were audio recorded, and data were analyzed and thematically coded using audio coding. Results: Interviews and worker focus groups guided an iterative design and development cycle, which informed workflow design, button placement, and output sheets that offer specific light-duty farm work recommendations for the injured worker to discuss with his or her employer. Conclusions: The development of a complex prototype intended to impact patient care is a significant undertaking. Reinventing a paper-based process that can eventually integrate with an electronic health record or a private company’s human resources system requires substantial stakeholder input from each facet including patients, employers, and clinical care teams. The prototype is available for testing, but further research is needed in the form of clinical trials to assess the effectiveness of the process and the software’s impact on patients and employers. %M 30694202 %R 10.2196/jmir.9711 %U https://www.jmir.org/2019/1/e9711/ %U https://doi.org/10.2196/jmir.9711 %U http://www.ncbi.nlm.nih.gov/pubmed/30694202 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e10899 %T Mobile Health Interventions for Self-Control of Unhealthy Alcohol Use: Systematic Review %A Song,Ting %A Qian,Siyu %A Yu,Ping %+ Centre for IT-Enabled Transformation, School of Computing and Information Technology, Faculty of Engineering and Information Sciences, University of Wollongong, Northfields Avenue, Wollongong, 2522, Australia, 61 2 4221 5412, ping@uow.edu.au %K systematic review %K alcohol drinking %K self-control %K mobile health %K mHealth %K treatment outcome %D 2019 %7 29.01.2019 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Unhealthy alcohol use (UAU) is one of the major causes of preventable morbidity, mortality, and associated behavioral risks worldwide. Although mobile health (mHealth) interventions can provide consumers with an effective means for self-control of UAU in a timely, ubiquitous, and cost-effective manner, to date, there is a lack of understanding about different health outcomes brought by such interventions. The core components of these interventions are also unclear. Objective: This study aimed to systematically review and synthesize the research evidence about the efficacy of mHealth interventions on various health outcomes for consumer self-control of UAU and to identify the core components to achieve these outcomes. Methods: We systematically searched 7 electronic interdisciplinary databases: Scopus, PubMed, PubMed Central, CINAHL Plus with full text, MEDLINE with full text, PsycINFO, and PsycARTICLES. Search terms and Medical Subject Headings “mHealth,” “text message,” “SMS,” “App,” “IVR,” “self-control,” “self-regulation,” “alcohol*,” and “intervention” were used individually or in combination to identify peer-reviewed publications in English from 2008 to 2017. We screened titles and abstracts and assessed full-text papers as per inclusion and exclusion criteria. Data were extracted from the included papers according to the Consolidated Standards of Reporting Trials-EHEALTH checklist (V 1.6.1) by 2 authors independently. Data quality was assessed by the Mixed Methods Appraisal Tool. Data synthesis and analyses were conducted following the procedures for qualitative content analysis. Statistical testing was also conducted to test differences among groups of studies. Results: In total, 19 studies were included in the review. Of these 19 studies, 12 (63%) mHealth interventions brought significant positive outcomes in improving participants’ health as measured by behavioral (n=11), physiological (n=1), and cognitive indicators (n=1). No significant health outcome was reported in 6 studies (6/19, 32%). Surprisingly, a significant negative outcome was reported for the male participants in the intervention arm in 1 study (1/19, 5%), but no change was found for the female participants. In total, 5 core components reported in the mHealth interventions for consumer self-control of UAU were context, theoretical base, delivery mode, content, and implementation procedure. However, sound evidence is yet to be generated about the role of each component for mHealth success. The health outcomes were similar regardless of types of UAU, deployment setting, with or without nonmobile cointervention, and with or without theory. Conclusions: Most studies reported mHealth interventions for self-control of UAU appeared to be improving behavior, especially the ones delivered by short message service and interactive voice response systems. Further studies are needed to gather sound evidence about the effects of mHealth interventions on improving physiological and cognitive outcomes as well as the optimal design of these interventions, their implementation, and effects in supporting self-control of UAU. %M 30694200 %R 10.2196/10899 %U http://mhealth.jmir.org/2019/1/e10899/ %U https://doi.org/10.2196/10899 %U http://www.ncbi.nlm.nih.gov/pubmed/30694200 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 1 %P e11334 %T Adoption of Mobile Apps for Depression and Anxiety: Cross-Sectional Survey Study on Patient Interest and Barriers to Engagement %A Lipschitz,Jessica %A Miller,Christopher J %A Hogan,Timothy P %A Burdick,Katherine E %A Lippin-Foster,Rachel %A Simon,Steven R %A Burgess,James %+ Department of Psychiatry, Brigham and Women's Hospital, 221 Longwood Ave, Boston, MA, 02115, United States, 1 617 732 6548, jlipschitz@bwh.harvard.edu %K mHealth %K depression %K anxiety %K mobile apps %K patient preference %D 2019 %7 25.01.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Emerging research suggests that mobile apps can be used to effectively treat common mental illnesses like depression and anxiety. Despite promising efficacy results and ease of access to these interventions, adoption of mobile health (mHealth; mobile device–delivered) interventions for mental illness has been limited. More insight into patients’ perspectives on mHealth interventions is required to create effective implementation strategies and to adapt existing interventions to facilitate higher rates of adoption. Objective: The aim of this study was to examine, from the patient perspective, current use and factors that may impact the use of mHealth interventions for mental illness. Methods: This was a cross-sectional survey study of veterans who had attended an appointment at a single Veterans Health Administration facility in early 2016 that was associated with one of the following mental health concerns: unipolar depression, any anxiety disorder, or posttraumatic stress disorder. We used the Veteran Affairs Corporate Data Warehouse to create subsets of eligible participants demographically stratified by gender (male or female) and minority status (white or nonwhite). From each subset, 100 participants were selected at random and mailed a paper survey with items addressing the demographics, overall health, mental health, technology ownership or use, interest in mobile app interventions for mental illness, reasons for use or nonuse, and interest in specific features of mobile apps for mental illness. Results: Of the 400 potential participants, 149 (37.3%, 149/400) completed and returned a survey. Most participants (79.9%, 119/149) reported that they owned a smart device and that they use apps in general (71.1%, 106/149). Most participants (73.1%, 87/149) reported interest in using an app for mental illness, but only 10.7% (16/149) had done so. Paired samples t tests indicated that ratings of interest in using an app recommended by a clinician were significantly greater than general interest ratings and even greater when the recommending clinician was a specialty mental health provider. The most frequent concerns related to using an app for mental illness were lacking proof of efficacy (71.8%, 107/149), concerns about data privacy (59.1%, 88/149), and not knowing where to find such an app (51.0%, 76/149). Participants expressed interest in a number of app features with particularly high-interest ratings for context-sensitive apps (85.2%, 127/149), and apps focused on the following areas: increasing exercise (75.8%, 113/149), improving sleep (73.2%, 109/149), changing negative thinking (70.5%, 105/149), and increasing involvement in activities (67.1%, 100/149). Conclusions: Most respondents had access to devices to use mobile apps for mental illness, already used apps for other purposes, and were interested in mobile apps for mental illness. Key factors that may improve adoption include provider endorsement, greater publicity of efficacious apps, and clear messaging about efficacy and privacy of information. Finally, multifaceted apps that address a range of concerns, from sleep to negative thought patterns, may be best received. %M 30681968 %R 10.2196/11334 %U http://mental.jmir.org/2019/1/e11334/ %U https://doi.org/10.2196/11334 %U http://www.ncbi.nlm.nih.gov/pubmed/30681968 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e9836 %T Assessing the Quality of Mobile Phone Apps for Weight Management: User-Centered Study With Employees From a Lebanese University %A Bardus,Marco %A Ali,Ahmed %A Demachkieh,Farah %A Hamadeh,Ghassan %+ Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Van Dyck - Room 302, PO Box 11-0236 Riad El-Solh, Beirut, 1107 2020, Lebanon, 961 1 350 000 ext 4694, marco.bardus@gmail.com %K mobile apps %K weight loss %K physical activity %K healthy diet %K workplace %K mHealth %D 2019 %7 23.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Evaluating the quality of mobile health apps for weight loss and weight management is important to understand whether these can be used for obesity prevention and treatment. Recent reviews call for more research on multidimensional aspects of app quality, especially involving end users, as there are already many expert reviews on this domain. However, no quantitative study has investigated how laypersons see popular apps for weight management and perceive different dimensions of app quality. Objective: This study aimed to explore how laypersons evaluate the quality of 6 free weight management apps (My Diet Coach, SparkPeople, Lark, MyFitnessPal, MyPlate, and My Diet Diary), which achieved the highest quality ratings in a related and recent expert review. Methods: A user-centered study was conducted with 36 employees of a Lebanese university. Participants enrolled in the study on a rolling basis between October 2016 and March 2017. Participants were randomly assigned an app to use for 2 weeks. App quality was evaluated at the end of the trial period using the Mobile App Rating Scale user version (uMARS). uMARS assesses the dimensions of engagement, functionality, aesthetics, information, and subjective quality on 5-point scales. Internal consistency and interrater agreement were examined. The associations between uMARS scores and users’ demographic characteristics were also explored using nonparametric tests. Analyses were completed in November 2017. Results: Overall, the 6 apps were of moderately good quality (median uMARS score 3.6, interquartile range [IQR] 0.3). The highest total uMARS scores were achieved by Lark (mean 4.0 [SD 0.5]) and MyPlate (mean 3.8 [SD 0.4]), which also achieved the highest subjective quality scores (Lark: mean 3.3 [SD 1.4]; MyPlate: mean 3.3 [SD 0.8]). Functionality was the domain with the highest rating (median 3.9, IQR 0.3), followed by aesthetics (median 3.7, IQR 0.5), information (median 3.7, IQR 0.1), and engagement (median 3.3, IQR 0.2). Subjective quality was judged low (median 2.5, IQR 0.9). Overall, subjective quality was strongly and positively related (P<.001) with total uMARS score (ρ=.75), engagement (ρ=.68), information, and aesthetics (ρ=.60) but not functionality (ρ=.40; P=.02). Higher engagement scores were reported among healthy (P=.003) and obese individuals (P=.03), who also showed higher total uMARS (P=.04) and subjective quality (P=.05) scores. Conclusions: Although the apps were considered highly functional, they were relatively weak in engagement and subjective quality scores, indicating a low propensity of using the apps in the future. As engagement was the subdomain most strongly associated with subjective quality, app developers and researchers should focus on creating engaging apps, holding constant the functionality, aesthetics, and information quality. The tested apps (in particular Lark and MyPlate) were perceived as more engaging and of higher quality among healthy, obese individuals, making them a promising mode of delivery for self-directed interventions promoting weight control among the sampled population or in similar and comparable settings. %M 30672742 %R 10.2196/mhealth.9836 %U https://mhealth.jmir.org/2019/1/e9836/ %U https://doi.org/10.2196/mhealth.9836 %U http://www.ncbi.nlm.nih.gov/pubmed/30672742 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11509 %T Feasibility of a Therapist-Supported, Mobile Phone–Delivered Online Intervention for Depression: Longitudinal Observational Study %A Goldin,Philippe R %A Lindholm,Riku %A Ranta,Kristian %A Hilgert,Outi %A Helteenvuori,Tiia %A Raevuori,Anu %+ Betty Irene Moore School of Nursing, University of California Davis, 4610 X Street, Sacramento, CA, 95817, United States, 1 4156769793, philippegoldin@gmail.com %K cognitive therapy %K depression %K digital health %K digital therapeutics %K mindfulness %K online intervention %D 2019 %7 22.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Depression is a very common condition that impairs functioning and is often untreated. More than 60% of the treatments for depressive disorder are administered in primary care settings by care providers who lack the time and expertise to treat depression. To address this issue, we developed Ascend, a therapist-supported, mobile phone–delivered 8-week intervention administered at the Meru Health Online Clinic in Finland. Objective: We conducted two pilot studies to examine the feasibility of the Ascend intervention, specifically, dropout rates, daily practice, weekly group chat use, and changes in depression symptoms. We also explored whether daily practice and weekly group chat use were associated with changes in depression symptoms. Methods: A total of 117 Finnish adults with elevated depressive symptoms enrolled in Ascend, a program that included daily cognitive behavioral and mindfulness meditation exercises delivered through a mobile phone app, anonymous group chat with other users, and chat/phone access to a licensed therapist. Eight weekly themes were delivered in a fixed, sequential format. Depression symptoms were measured at baseline, every second week during the intervention, immediately after the intervention, and 4 weeks after completion of the intervention. Data were analyzed using intent-to-treat repeated-measures analysis of variance and linear regression models. Results: For studies 1 and 2, we observed dropout rates of 27% and 15%, respectively, decreasing daily practice and group chat use, and decreased depression symptoms from baseline to immediately and 4 weeks after the intervention (P<.001). We found that both more daily practice and chat group use predicted the occurrence of fewer depressive symptoms at 4 weeks postintervention (Study 1: ∆R2=.38, P=.004 and ∆R2=.38, P=.002, respectively; Study 2: ∆R2=.16, P<.001 and ∆R2=.08, P=.002, respectively). Conclusions: This therapist-supported, mobile phone–delivered treatment for depression is feasible and associated with reduced depression symptoms. Design features that enhance daily practice and group chat use are areas of future investigation. Validation of these results using a controlled study design is needed to establish the evidence base for the Ascend intervention. %R 10.2196/11509 %U http://formative.jmir.org/2019/1/e11509/ %U https://doi.org/10.2196/11509 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e3 %T Valuing Mobile Health: An Open-Ended Contingent Valuation Survey of a National Digital Health Program %A Somers,Camilla %A Grieve,Eleanor %A Lennon,Marilyn %A Bouamrane,Matt-Mouley %A Mair,Frances S %A McIntosh,Emma %+ General Practice and Primary Care, University of Glasgow, 1 Horselethill Road, Glasgow, G12 9LX, United Kingdom, 44 1413308317, Frances.Mair@glasgow.ac.uk %K mHealth %K public health %K delivery of health care %K public health systems research %D 2019 %7 17.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Changing population demographics and technology developments have resulted in growing interest in the potential of consumer-facing digital health. In the United Kingdom, a £37 million (US $49 million) national digital health program delivering assisted living lifestyles at scale (dallas) aimed to deploy such technologies at scale. However, little is known about how consumers value such digital health opportunities. Objective: This study explored consumers’ perspectives on the potential value of digital health technologies, particularly mobile health (mHealth), to promote well-being by examining their willingness-to-pay (WTP) for such health solutions. Methods: A contingent valuation study involving a UK-wide survey that asked participants to report open-ended absolute and marginal WTP or willingness-to-accept for the gain or loss of a hypothetical mHealth app, Healthy Connections. Results: A UK-representative cohort (n=1697) and a dallas-like (representative of dallas intervention communities) cohort (n=305) were surveyed. Positive absolute and marginal WTP valuations of the app were identified across both cohorts (absolute WTP: UK-representative cohort £196 or US $258 and dallas-like cohort £162 or US $214; marginal WTP: UK-representative cohort £160 or US $211 and dallas-like cohort £151 or US $199). Among both cohorts, there was a high prevalence of zeros for both the absolute WTP (UK-representative cohort: 467/1697, 27.52% and dallas-like cohort: 95/305, 31.15%) and marginal WTP (UK-representative cohort: 487/1697, 28.70% and dallas-like cohort: 99/305, 32.5%). In both cohorts, better general health, previous amount spent on health apps (UK-representative cohort 0.64, 95% CI 0.27 to 1.01; dallas-like cohort: 1.27, 95% CI 0.32 to 2.23), and age had a significant (P>.00) association with WTP (UK-representative cohort: −0.1, 95% CI −0.02 to −0.01; dallas-like cohort: −0.02, 95% CI −0.03 to −0.01), with younger participants willing to pay more for the app. In the UK-representative cohort, as expected, higher WTP was positively associated with income up to £30,000 or US $39,642 (0.21, 95% CI 0.14 to 0.4) and increased spending on existing phone and internet services (0.52, 95% CI 0.30 to 0.74). The amount spent on existing health apps was shown to be a positive indicator of WTP across cohorts, although the effect was marginal (UK-representative cohort 0.01, 95% CI 0.01 to 0.01; dallas-like cohort 0.01, 95% CI 0.01 to 0.02). Conclusions: This study demonstrates that consumers value mHealth solutions that promote well-being, social connectivity, and health care control, but it is not universally embraced. For mHealth to achieve its potential, apps need to be tailored to user accessibility and health needs, and more understanding of what hinders frequent users of digital technologies and those with long-term conditions is required. This novel application of WTP in a digital health context demonstrates an economic argument for investing in upskilling the population to promote access and expedite uptake and utilization of such digital health and well-being apps. %M 30664488 %R 10.2196/mhealth.9990 %U http://mhealth.jmir.org/2019/1/e3/ %U https://doi.org/10.2196/mhealth.9990 %U http://www.ncbi.nlm.nih.gov/pubmed/30664488 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e11118 %T Health Benefits and Cost-Effectiveness From Promoting Smartphone Apps for Weight Loss: Multistate Life Table Modeling %A Cleghorn,Christine %A Wilson,Nick %A Nair,Nisha %A Kvizhinadze,Giorgi %A Nghiem,Nhung %A McLeod,Melissa %A Blakely,Tony %+ BODE³ Programme, Department of Public Health, University of Otago, PO Box 7343, Wellington South, Wellington, 6242, New Zealand, 64 4 918 6182 ext 6182, cristina.cleghorn@otago.ac.nz %K weight loss diet %K telemedicine %K smartphone %K cost-utility analysis %K life tables %K quality-adjusted life years %D 2019 %7 15.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Obesity is an important risk factor for many chronic diseases. Mobile health interventions such as smartphone apps can potentially provide a convenient low-cost addition to other obesity reduction strategies. Objective: This study aimed to estimate the impacts on quality-adjusted life-years (QALYs) gained and health system costs over the remainder of the life span of the New Zealand population (N=4.4 million) for a smartphone app promotion intervention in 1 calendar year (2011) using currently available apps for weight loss. Methods: The intervention was a national mass media promotion of selected smartphone apps for weight loss compared with no dedicated promotion. A multistate life table model including 14 body mass index–related diseases was used to estimate QALYs gained and health systems costs. A lifetime horizon, 3% discount rate, and health system perspective were used. The proportion of the target population receiving the intervention (1.36%) was calculated using the best evidence for the proportion who have access to smartphones, are likely to see the mass media campaign promoting the app, are likely to download a weight loss app, and are likely to continue using this app. Results: In the base-case model, the smartphone app promotion intervention generated 29 QALYs (95% uncertainty interval, UI: 14-52) and cost the health system US $1.6 million (95% UI: 1.1-2.0 million) with the standard download rate. Under plausible assumptions, QALYs increased to 59 (95% UI: 27-107) and costs decreased to US $1.2 million (95% UI: 0.5-1.8) when standard download rates were doubled. Costs per QALY gained were US $53,600 for the standard download rate and US $20,100 when download rates were doubled. On the basis of a threshold of US $30,000 per QALY, this intervention was cost-effective for Māori when the standard download rates were increased by 50% and also for the total population when download rates were doubled. Conclusions: In this modeling study, the mass media promotion of a smartphone app for weight loss produced relatively small health gains on a population level and was of borderline cost-effectiveness for the total population. Nevertheless, the scope for this type of intervention may expand with increasing smartphone use, more easy-to-use and effective apps becoming available, and with recommendations to use such apps being integrated into dietary counseling by health workers. %M 30664471 %R 10.2196/11118 %U https://mhealth.jmir.org/2019/1/e11118/ %U https://doi.org/10.2196/11118 %U http://www.ncbi.nlm.nih.gov/pubmed/30664471 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e12228 %T Mobile Phone Ownership, Health Apps, and Tablet Use in US Adults With a Self-Reported History of Hypertension: Cross-Sectional Study %A Langford,Aisha T %A Solid,Craig A %A Scott,Ebony %A Lad,Meeki %A Maayan,Eli %A Williams,Stephen K %A Seixas,Azizi A %+ Division of Comparative Effectiveness and Decision Science, Department of Population Health, NYU School of Medicine, 227 E 30th Street #645, New York, NY, 10016, United States, 1 646 501 2914, aisha.langford@nyulangone.org %K smartphone %K text messaging %K health communication %K ownership %K goals %K cell phone %K telemedicine %K hypertension %K tablets %K chronic disease %D 2019 %7 14.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile phone and tablet ownership have increased in the United States over the last decade, contributing to the growing use of mobile health (mHealth) interventions to help patients manage chronic health conditions like diabetes. However, few studies have characterized mobile device ownership and the presence of health-related apps on mobile devices in people with a self-reported history of hypertension. Objective: This study aimed to describe the prevalence of smartphone, tablet, and basic mobile phone ownership and the presence of health apps by sociodemographic factors and self-reported hypertension status (ie, history) in a nationally representative sample of US adults, and to describe whether mobile devices are associated with health goal achievement, medical decision making, and patient-provider communication. Methods: Data from 3285 respondents from the 2017 Health Information National Trends Survey were analyzed. Participants were asked if they owned a smartphone, tablet, or basic mobile phone and if they had health apps on a smartphone or tablet. Participants were also asked if their smartphones or tablets helped them achieve a health-related goal like losing weight, make a decision about how to treat an illness, or talk with their health care providers. Chi-square analyses were conducted to test for differences in mobile device ownership, health app presence, and app helpfulness by patient characteristics. Results: Approximately 1460 (37.6% weighted prevalence) participants reported a history of hypertension. Tablet and smartphone ownership were lower in participants with a history of hypertension than in those without a history of hypertension (55% vs 66%, P=.001, and 86% vs 68%, P<.001, respectively). Participants with a history of hypertension were more likely to own a basic mobile phone only as compared to those without a history of hypertension (16% vs 9%, P<.001). Among those with a history of hypertension exclusively, basic mobile phone, smartphone, and tablet ownership were associated with age and education, but not race or sex. Older adults were more likely to report having a basic mobile phone only, whereas those with higher education were more likely to report owning a tablet or smartphone. Compared to those without a history of hypertension, participants with a history of hypertension were less likely to have health-related apps on their smartphones or tablets (45% vs 30%, P<.001) and report that mobile devices helped them achieve a health-related goal (72% vs 63%, P=.01). Conclusions: Despite the increasing use of smartphones, tablets, and health-related apps, these tools are used less among people with a self-reported history of hypertension. To reach the widest cross-section of patients, a mix of novel mHealth interventions and traditional health communication strategies (eg, print, web based, and in person) are needed to support the diverse needs of people with a history of hypertension. %M 31344667 %R 10.2196/12228 %U http://mhealth.jmir.org/2019/1/e12228/ %U https://doi.org/10.2196/12228 %U http://www.ncbi.nlm.nih.gov/pubmed/31344667 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11939 %T Technical Support by Smart Glasses During a Mass Casualty Incident: A Randomized Controlled Simulation Trial on Technically Assisted Triage and Telemedical App Use in Disaster Medicine %A Follmann,Andreas %A Ohligs,Marian %A Hochhausen,Nadine %A Beckers,Stefan K %A Rossaint,Rolf %A Czaplik,Michael %+ Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, D-52074, Germany, 49 2418036219, afollmann@ukaachen.de %K augmented reality %K disaster medicine %K emergency medical service physician %K mass casualty incident %K Smart Glasses %K telemedicine %K triage %D 2019 %7 03.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: To treat many patients despite lacking personnel resources, triage is important in disaster medicine. Various triage algorithms help but often are used incorrectly or not at all. One potential problem-solving approach is to support triage with Smart Glasses. Objective: In this study, augmented reality was used to display a triage algorithm and telemedicine assistance was enabled to compare the duration and quality of triage with a conventional one. Methods: A specific Android app was designed for use with Smart Glasses, which added information in terms of augmented reality with two different methods—through the display of a triage algorithm in data glasses and a telemedical connection to a senior emergency physician realized by the integrated camera. A scenario was created (ie, randomized simulation study) in which 31 paramedics carried out a triage of 12 patients in 3 groups as follows: without technical support (control group), with a triage algorithm display, and with telemedical contact. Results: A total of 362 assessments were performed. The accuracy in the control group was only 58%, but the assessments were quicker (on average 16.6 seconds). In contrast, an accuracy of 92% (P=.04) was achieved when using technical support by displaying the triage algorithm. This triaging took an average of 37.0 seconds. The triage group wearing data glasses and being telemedically connected achieved 90% accuracy (P=.01) in 35.0 seconds. Conclusions: Triage with data glasses required markedly more time. While only a tally was recorded in the control group, Smart Glasses led to digital capture of the triage results, which have many tactical advantages. We expect a high potential in the application of Smart Glasses in disaster scenarios when using telemedicine and augmented reality features to improve the quality of triage. %M 30609988 %R 10.2196/11939 %U https://www.jmir.org/2019/1/e11939/ %U https://doi.org/10.2196/11939 %U http://www.ncbi.nlm.nih.gov/pubmed/30609988 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 12 %P e11447 %T An Analytics Platform to Evaluate Effective Engagement With Pediatric Mobile Health Apps: Design, Development, and Formative Evaluation %A Pham,Quynh %A Graham,Gary %A Lalloo,Chitra %A Morita,Plinio P %A Seto,Emily %A Stinson,Jennifer N %A Cafazzo,Joseph A %+ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, Suite 425, 155 College Street, Toronto, ON, M5T 3M6, Canada, 1 (416) 340 4800 ext 4765, q.pham@mail.utoronto.ca %K analytics %K engagement %K log data %K mobile health %K mobile apps %K chronic disease %D 2018 %7 21.12.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) apps for pediatric chronic conditions are growing in availability and challenge investigators to conduct rigorous evaluations that keep pace with mHealth innovation. Traditional research methods are poorly suited to operationalize the agile, iterative trials required to evidence and optimize these digitally mediated interventions. Objective: We sought to contribute a resource to support the quantification, analysis, and visualization of analytic indicators of effective engagement with mHealth apps for chronic conditions. Methods: We applied user-centered design methods to design and develop an Analytics Platform to Evaluate Effective Engagement (APEEE) with consumer mHealth apps for chronic conditions and implemented the platform to analyze both retrospective and prospective data generated from a smartphone-based pain self-management app called iCanCope for young people with chronic pain. Results: Through APEEE, we were able to automate the process of defining, operationalizing, and evaluating effective engagement with iCanCope. Configuring the platform to integrate with the app was feasible and provided investigators with a resource to consolidate, analyze, and visualize engagement data generated by participants in real time. Preliminary efforts to evaluate APEEE showed that investigators perceived the platform to be an acceptable evaluative resource and were satisfied with its design, functionality, and performance. Investigators saw potential in APEEE to accelerate and augment evidence generation and expressed enthusiasm for adopting the platform to support their evaluative practice once fully implemented. Conclusions: Dynamic, real-time analytic platforms may provide investigators with a powerful means to characterize the breadth and depth of mHealth app engagement required to achieve intended health outcomes. Successful implementation of APEEE into evaluative practice may contribute to the realization of effective and evidence-based mHealth care. %M 30578179 %R 10.2196/11447 %U http://mhealth.jmir.org/2018/12/e11447/ %U https://doi.org/10.2196/11447 %U http://www.ncbi.nlm.nih.gov/pubmed/30578179 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 12 %P e11439 %T Using a Mobile Social Networking App to Promote Physical Activity: A Qualitative Study of Users’ Perspectives %A Tong,Huong Ly %A Coiera,Enrico %A Laranjo,Liliana %+ Centre for Health Informatics, Australian Institute of Health Innovation, Level 6, 75 Talavera Road, Sydney, 2109, Australia, 61 029850 ext 2475, huong-ly.tong@students.mq.edu.au %K exercise %K fitness trackers %K mobile apps %K mobile phone %K social networking %D 2018 %7 21.12.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite many health benefits of physical activity, nearly a third of the world’s adult population is insufficiently active. Technological interventions, such as mobile apps, wearable trackers, and Web-based social networks, offer great promise in promoting physical activity, but little is known about users’ acceptability and long-term engagement with these interventions. Objective: The aim of this study was to understand users’ perspectives regarding a mobile social networking intervention to promote physical activity. Methods: Participants, mostly university students and staff, were recruited using purposive sampling techniques. Participants were enrolled in a 6-month feasibility study where they were provided with a wearable physical activity tracker (Fitbit Flex 2) and a wireless scale (Fitbit Aria) integrated with a social networking mobile app (named “fit.healthy.me”). We conducted semistructured, in-depth qualitative interviews and focus groups pre- and postintervention, which were recorded and transcribed verbatim. The data were analyzed in Nvivo 11 using thematic analysis techniques. Results: In this study, 55 participants were enrolled; 51% (28/55) were females, and the mean age was 23.6 (SD 4.6) years. The following 3 types of factors emerged from the data as influencing engagement with the intervention and physical activity: individual (self-monitoring of behavior, goal setting, and feedback on behavior), social (social comparison, similarity and familiarity between users, and participation from other users in the network), and technological. In addition, automation and personalization were observed as enhancing the delivery of both individual and social aspects. Technological limitations were mentioned as potential barriers to long-term usage. Conclusions: Self-regulatory techniques and social factors are important to consider when designing a physical activity intervention, but a one-size-fits-all approach is unlikely to satisfy different users’ preferences. Future research should adopt innovative research designs to test interventions that can adapt and respond to users’ needs and preferences throughout time. %M 30578201 %R 10.2196/11439 %U https://www.jmir.org/2018/12/e11439/ %U https://doi.org/10.2196/11439 %U http://www.ncbi.nlm.nih.gov/pubmed/30578201 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e11988 %T “How Is My Child’s Asthma?” Digital Phenotype and Actionable Insights for Pediatric Asthma %A Jaimini,Utkarshani %A Thirunarayan,Krishnaprasad %A Kalra,Maninder %A Venkataraman,Revathy %A Kadariya,Dipesh %A Sheth,Amit %+ Ohio Center of Excellence in Knowledge-enabled Computing (Kno.e.sis), Department of Computer Sciene, Wright State University, 3640 Colonel Glenn Hwy, Dayton, OH, 45435, United States, 1 937 775 1000, amit@knoesis.org %K digital phenotype %K actionable insights %K asthma control level %K asthma control test %K digital phenotype score %K controller compliance score %K mobile health %D 2018 %7 30.11.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: In the traditional asthma management protocol, a child meets with a clinician infrequently, once in 3 to 6 months, and is assessed using the Asthma Control Test questionnaire. This information is inadequate for timely determination of asthma control, compliance, precise diagnosis of the cause, and assessing the effectiveness of the treatment plan. The continuous monitoring and improved tracking of the child’s symptoms, activities, sleep, and treatment adherence can allow precise determination of asthma triggers and a reliable assessment of medication compliance and effectiveness. Digital phenotyping refers to moment-by-moment quantification of the individual-level human phenotype in situ using data from personal digital devices, in particular, mobile phones. The kHealth kit consists of a mobile app, provided on an Android tablet, that asks timely and contextually relevant questions related to asthma symptoms, medication intake, reduced activity because of symptoms, and nighttime awakenings; a Fitbit to monitor activity and sleep; a Microlife Peak Flow Meter to monitor the peak expiratory flow and forced exhaled volume in 1 second; and a Foobot to monitor indoor air quality. The kHealth cloud stores personal health data and environmental data collected using Web services. The kHealth Dashboard interactively visualizes the collected data. Objective: The objective of this study was to discuss the usability and feasibility of collecting clinically relevant data to help clinicians diagnose or intervene in a child’s care plan by using the kHealth system for continuous and comprehensive monitoring of child’s symptoms, activity, sleep pattern, environmental triggers, and compliance. The kHealth system helps in deriving actionable insights to help manage asthma at both the personal and cohort levels. The Digital Phenotype Score and Controller Compliance Score introduced in the study are the basis of ongoing work on addressing personalized asthma care and answer questions such as, “How can I help my child better adhere to care instructions and reduce future exacerbation?” Methods: The Digital Phenotype Score and Controller Compliance Score summarize the child’s condition from the data collected using the kHealth kit to provide actionable insights. The Digital Phenotype Score formalizes the asthma control level using data about symptoms, rescue medication usage, activity level, and sleep pattern. The Compliance Score captures how well the child is complying with the treatment protocol. We monitored and analyzed data for 95 children, each recruited for a 1- or 3-month-long study. The Asthma Control Test scores obtained from the medical records of 57 children were used to validate the asthma control levels calculated using the Digital Phenotype Scores. Results: At the cohort level, we found asthma was very poorly controlled in 37% (30/82) of the children, not well controlled in 26% (21/82), and well controlled in 38% (31/82). Among the very poorly controlled children (n=30), we found 30% (9/30) were highly compliant toward their controller medication intake—suggesting a re-evaluation for change in medication or dosage—whereas 50% (15/30) were poorly compliant and candidates for a more timely intervention to improve compliance to mitigate their situation. We observed a negative Kendall Tau correlation between Asthma Control Test scores and Digital Phenotype Score as −0.509 (P<.01). Conclusions: kHealth kit is suitable for the collection of clinically relevant information from pediatric patients. Furthermore, Digital Phenotype Score and Controller Compliance Score, computed based on the continuous digital monitoring, provide the clinician with timely and detailed evidence of a child’s asthma-related condition when compared with the Asthma Control Test scores taken infrequently during clinic visits. %M 31008446 %R 10.2196/11988 %U http://pediatrics.jmir.org/2018/2/e11988/ %U https://doi.org/10.2196/11988 %U http://www.ncbi.nlm.nih.gov/pubmed/31008446 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 12 %P e10338 %T Accuracy of Wrist-Worn Activity Monitors During Common Daily Physical Activities and Types of Structured Exercise: Evaluation Study %A Reddy,Ravi Kondama %A Pooni,Rubin %A Zaharieva,Dessi P %A Senf,Brian %A El Youssef,Joseph %A Dassau,Eyal %A Doyle III,Francis J %A Clements,Mark A %A Rickels,Michael R %A Patton,Susana R %A Castle,Jessica R %A Riddell,Michael C %A Jacobs,Peter G %+ Department of Biomedical Engineering, Oregon Health & Science University, 3303 SW Bond Avenue, Portland, OR, 97239, United States, 1 503 358 2291, jacobsp@ohsu.edu %K heart rate %K energy metabolism %K fitness trackers %K high-intensity interval training %K artificial pancreas %D 2018 %7 10.12.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Wrist-worn activity monitors are often used to monitor heart rate (HR) and energy expenditure (EE) in a variety of settings including more recently in medical applications. The use of real-time physiological signals to inform medical systems including drug delivery systems and decision support systems will depend on the accuracy of the signals being measured, including accuracy of HR and EE. Prior studies assessed accuracy of wearables only during steady-state aerobic exercise. Objective: The objective of this study was to validate the accuracy of both HR and EE for 2 common wrist-worn devices during a variety of dynamic activities that represent various physical activities associated with daily living including structured exercise. Methods: We assessed the accuracy of both HR and EE for two common wrist-worn devices (Fitbit Charge 2 and Garmin vívosmart HR+) during dynamic activities. Over a 2-day period, 20 healthy adults (age: mean 27.5 [SD 6.0] years; body mass index: mean 22.5 [SD 2.3] kg/m2; 11 females) performed a maximal oxygen uptake test, free-weight resistance circuit, interval training session, and activities of daily living. Validity was assessed using an HR chest strap (Polar) and portable indirect calorimetry (Cosmed). Accuracy of the commercial wearables versus research-grade standards was determined using Bland-Altman analysis, correlational analysis, and error bias. Results: Fitbit and Garmin were reasonably accurate at measuring HR but with an overall negative bias. There was more error observed during high-intensity activities when there was a lack of repetitive wrist motion and when the exercise mode indicator was not used. The Garmin estimated HR with a mean relative error (RE, %) of −3.3% (SD 16.7), whereas Fitbit estimated HR with an RE of −4.7% (SD 19.6) across all activities. The highest error was observed during high-intensity intervals on bike (Fitbit: −11.4% [SD 35.7]; Garmin: −14.3% [SD 20.5]) and lowest error during high-intensity intervals on treadmill (Fitbit: −1.7% [SD 11.5]; Garmin: −0.5% [SD 9.4]). Fitbit and Garmin EE estimates differed significantly, with Garmin having less negative bias (Fitbit: −19.3% [SD 28.9], Garmin: −1.6% [SD 30.6], P<.001) across all activities, and with both correlating poorly with indirect calorimetry measures. Conclusions: Two common wrist-worn devices (Fitbit Charge 2 and Garmin vívosmart HR+) show good HR accuracy, with a small negative bias, and reasonable EE estimates during low to moderate-intensity exercise and during a variety of common daily activities and exercise. Accuracy was compromised markedly when the activity indicator was not used on the watch or when activities involving less wrist motion such as cycle ergometry were done. %M 30530451 %R 10.2196/10338 %U https://mhealth.jmir.org/2018/12/e10338/ %U https://doi.org/10.2196/10338 %U http://www.ncbi.nlm.nih.gov/pubmed/30530451 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 1 %N 2 %P e12178 %T Evaluating the Use of Mobile Health Technology in Older Adults With Heart Failure: Mixed-Methods Study %A Lefler,Leanne L %A Rhoads,Sarah J %A Harris,Melodee %A Funderburg,Ashley E %A Lubin,Sandra A %A Martel,Isis D %A Faulkner,Jennifer L %A Rooker,Janet L %A Bell,Deborah K %A Marshall,Heather %A Beverly,Claudia J %+ College of Nursing, University of Arkansas for Medical Sciences, 4301 W Markham, #529, Little Rock, AR, 72205, United States, 1 5012961939, L.Lefler@uams.edu %K heart failure %K remote monitoring %K mHealth %K older adults %K feasibility %K self-management %D 2018 %7 04.12.2018 %9 Original Paper %J JMIR Aging %G English %X Background: Heart failure (HF) is associated with high rates of hospitalizations, morbidity, mortality, and costs. Remote patient monitoring (mobile health, mHealth) shows promise in improving self-care and HF management, thus increasing quality of care while reducing hospitalizations and costs; however, limited information exists regarding perceptions of older adults with HF about mHealth use. Objective: This study aimed to compare perspectives of older adults with HF who were randomized to either (1) mHealth equipment connected to a 24-hour call center, (2) digital home equipment, or (3) standard care, with regard to ease and satisfaction with equipment, provider communication and engagement, and ability to self-monitor and manage their disease. Methods: We performed a pilot study using a mixed-methods descriptive design with pre- and postsurveys, following participants for 12 weeks. We augmented these data with semistructured qualitative interviews to learn more about feasibility, satisfaction, communication, and self-management. Results: We enrolled 28 patients with HF aged 55 years and above, with 57% (16/28) male, 79% (22/28) non-Hispanic white, and with multiple comorbid conditions. At baseline, 50% (14/28) rated their health fair or poor and 36% (10/28) and 25% (7/28) were very often/always frustrated and discouraged by their health. At baseline, 46% (13/28) did not monitor their weight, 29% (8/28) did not monitor their blood pressure, and 68% (19/28) did not monitor for symptoms. Post intervention, 100% of the equipment groups home monitored daily. For technology anxiety, 36% (10/28) indicated technology made them nervous, and 32% (9/28) reported fear of technology, without significant changes post intervention. Technology usability post intervention scored high (91/100), reflecting ease of use. A majority indicated that a health care provider should be managing their health, and 71% reported that one should trust and not question the provider. Moreover, 57% (16/28) believed it was better to seek professional help than caring for oneself. Post intervention, mHealth users relied more on themselves, which was not mirrored in the home equipment or standard care groups. Participants were satisfied with communication and engagement with providers, yet many described access problems. Distressing symptoms were unpredictable and prevailed over the 12 weeks with 79 provider visits and 7 visits to emergency departments. The nurse call center received 872 readings, and we completed 289 telephone calls with participants. Narrative data revealed the following main themes: (1) traditional communication and engagement with providers prevailed, delaying access to care; (2) home monitoring with technology was described as useful, and mHealth users felt secure knowing that someone was observing them; (3) equipment groups felt more confident in self-monitoring and managing; and finally, (4) uncertainty and frustration with persistent health problems. Conclusions: mHealth equipment is feasible with potential to improve patient-centered outcomes and increase self-management in older adults with HF. %M 31518257 %R 10.2196/12178 %U http://aging.jmir.org/2018/2/e12178/ %U https://doi.org/10.2196/12178 %U http://www.ncbi.nlm.nih.gov/pubmed/31518257 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e10258 %T An Unsupervised Smart App–Optimized HIV Self-Testing Program in Montreal, Canada: Cross-Sectional Study %A Pant Pai,Nitika %A Smallwood,Megan %A Desjardins,Laurence %A Goyette,Alexandre %A Birkas,Krisztian G %A Vassal,Anne-Fanny %A Joseph,Lawrence %A Thomas,Réjean %+ Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 5252 Boul de Maisonneuve O, Montreal, QC, H4A 3S5, Canada, 1 5149341934 ext 44729, nitika.pai@mcgill.ca %K feasibility %K HIV %K impact %K mobile phone %K MSM %K self-testing %D 2018 %7 27.11.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Although HIV self-testing strategies have been recommended by the World Health Organization, HIV self-tests are not yet approved in Canada. Currently approved HIV self-tests offer toll-free lines that are insufficient for initiating expedited linkages to counseling and care, accurate interpretation, and support during HIV self-testing. We developed an innovative, multilingual software app called HIVSmart! to plug these gaps. Objective: This study aimed to test our app-optimized oral HIV self-testing strategy for feasibility in men who have sex with men (MSM) who presented to test at a large sexual health clinic (Clinique Médicale L’Actuel) in Montreal. Methods: Between July 2016 and February 2017, we offered a strategy consisting of the OraQuick In-Home HIV Test (an investigational device) and a tablet installed with the HIVSmart! app to study participants, who presented at a private office in the clinic, mimicking an unsupervised home environment. We evaluated the strategy for its feasibility, acceptability, and preference. Using the HIVSmart! app, participants were guided through the self-testing process. We determined feasibility with a metric defined as the completion rate, which consisted of the following 3 steps: (1) self-test conduct; (2) self-test interpretation; and (3) linkages to care. Participants independently performed, interpreted, recorded their self-test and result, engaged in pre- and posttest counseling, and sought linkages to care. Laboratory tests (p24, Western Blot, and RNA), as per country algorithms, were expedited, and linkages based on the rapid test status were arranged. Results: Mean age of the 451 participants enrolled was 34 (range, 18-73) years. Of all participants, 97.1% (438/451) completed and submitted the survey through the HIVSmart! app. In total, 84.7% (371/438) of the participants were well educated (beyond high school) and 52.5% (230/438) had been tested within the past 6 months. Of the 451, 11.5% (52/451) were on pre-exposure prophylaxis. Feasibility (completion rate), an average proportion of the 3 steps, was computed to be 96.6% (419/451). The acceptability of the strategy was high at 98.5% (451/458). A majority of the participants (448/451, 99.3%) were found to be self-tested and lab-confirmed negative and were counseled after self- and rapid tests. In total, 0.7% (3/451) of the participants who self-tested positive and were lab-confirmed positive were linked to a physician within the same day. Furthermore, 98.8% (417/422) of the participants found the app to be useful and 94.0% (424/451) were willing to recommend it to a friend or partner. Conclusions: The HIVSmart! app-optimized strategy was feasible, accepted, and preferred by an educated, urban MSM population of Montreal. With the app, participants were able to perform, interpret, store results, and get rapidly linked to care. The HIVSmart!-optimized, self-testing strategy could be adapted and contextualized to many at-risk populations within Canada and worldwide, thereby maximizing its public health impact. %M 30465709 %R 10.2196/10258 %U http://www.jmir.org/2018/11/e10258/ %U https://doi.org/10.2196/10258 %U http://www.ncbi.nlm.nih.gov/pubmed/30465709 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 1 %N 2 %P e11569 %T A Fall Risk mHealth App for Older Adults: Development and Usability Study %A Hsieh,Katherine L %A Fanning,Jason T %A Rogers,Wendy A %A Wood,Tyler A %A Sosnoff,Jacob J %+ Department of Kinesiology and Community Health, University of Illinois at Urbana Champaign, 906 South Goodwin Avenue, Urbana, IL, 61801, United States, 1 217 244 7006, jsosnoff@illinois.edu %K usability %K fall risk %K mHealth app %K mobile phone %D 2018 %7 20.11.2018 %9 Original Paper %J JMIR Aging %G English %X Background: Falls are the leading cause of injury-related death in older adults. Due to various constraints, objective fall risk screening is seldom performed in clinical settings. Smartphones offer a high potential to provide fall risk screening for older adults in home settings. However, there is limited understanding of whether smartphone technology for falls screening is usable by older adults who present age-related changes in perceptual, cognitive, and motor capabilities. Objective: The aims of this study were to develop a fall risk mobile health (mHealth) app and to determine the usability of the fall risk app in healthy, older adults. Methods: A fall risk app was developed that consists of a health history questionnaire and 5 progressively challenging mobility tasks to measure individual fall risk. An iterative design-evaluation process of semistructured interviews was performed to determine the usability of the app on a smartphone and tablet. Participants also completed a Systematic Usability Scale (SUS). In the first round of interviews, 6 older adults participated, and in the second round, 5 older adults participated. Interviews were videotaped and transcribed, and the data were coded to create themes. Average SUS scores were calculated for the smartphone and tablet. Results: There were 2 themes identified from the first round of interviews, related to perceived ease of use and perceived usefulness. While instructions for the balance tasks were difficult to understand, participants found it beneficial to learn about their risk for falls, found the app easy to follow, and reported confidence in using the app on their own. Modifications were made to the app, and following the second round of interviews, participants reported high ease of use and usefulness in learning about their risk of falling. Few differences were reported between using a smartphone or tablet. Average SUS scores ranged from 79 to 84. Conclusions: Our fall risk app was found to be highly usable by older adults as reported from interviews and high scores on the SUS. When designing a mHealth app for older adults, developers should include clear and simple instructions and preventative strategies to improve health. Furthermore, if the design accommodates for age-related sensory changes, smartphones can be as effective as tablets. A mobile app to assess fall risk has the potential to be used in home settings by older adults. %M 31518234 %R 10.2196/11569 %U http://aging.jmir.org/2018/2/e11569/ %U https://doi.org/10.2196/11569 %U http://www.ncbi.nlm.nih.gov/pubmed/31518234 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e12001 %T Defining and Predicting Pain Volatility in Users of the Manage My Pain App: Analysis Using Data Mining and Machine Learning Methods %A Rahman,Quazi Abidur %A Janmohamed,Tahir %A Pirbaglou,Meysam %A Clarke,Hance %A Ritvo,Paul %A Heffernan,Jane M %A Katz,Joel %+ ManagingLife, Inc, Unit 4, 850 Richmond Street W, Toronto, ON, M6J1C9, Canada, 1 4169103760, tahir@managinglife.com %K chronic pain %K pain volatility %K data mining %K cluster analysis %K machine learning %K prediction model %K Manage My Pain %K pain app %D 2018 %7 15.11.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Measuring and predicting pain volatility (fluctuation or variability in pain scores over time) can help improve pain management. Perceptions of pain and its consequent disabling effects are often heightened under the conditions of greater uncertainty and unpredictability associated with pain volatility. Objective: This study aimed to use data mining and machine learning methods to (1) define a new measure of pain volatility and (2) predict future pain volatility levels from users of the pain management app, Manage My Pain, based on demographic, clinical, and app use features. Methods: Pain volatility was defined as the mean of absolute changes between 2 consecutive self-reported pain severity scores within the observation periods. The k-means clustering algorithm was applied to users’ pain volatility scores at the first and sixth month of app use to establish a threshold discriminating low from high volatility classes. Subsequently, we extracted 130 demographic, clinical, and app usage features from the first month of app use to predict these 2 volatility classes at the sixth month of app use. Prediction models were developed using 4 methods: (1) logistic regression with ridge estimators; (2) logistic regression with Least Absolute Shrinkage and Selection Operator; (3) Random Forests; and (4) Support Vector Machines. Overall prediction accuracy and accuracy for both classes were calculated to compare the performance of the prediction models. Training and testing were conducted using 5-fold cross validation. A class imbalance issue was addressed using a random subsampling of the training dataset. Users with at least five pain records in both the predictor and outcome periods (N=782 users) are included in the analysis. Results: k-means clustering algorithm was applied to pain volatility scores to establish a threshold of 1.6 to differentiate between low and high volatility classes. After validating the threshold using random subsamples, 2 classes were created: low volatility (n=611) and high volatility (n=171). In this class-imbalanced dataset, all 4 prediction models achieved 78.1% (611/782) to 79.0% (618/782) in overall accuracy. However, all models have a prediction accuracy of less than 18.7% (32/171) for the high volatility class. After addressing the class imbalance issue using random subsampling, results improved across all models for the high volatility class to greater than 59.6% (102/171). The prediction model based on Random Forests performs the best as it consistently achieves approximately 70% accuracy for both classes across 3 random subsamples. Conclusions: We propose a novel method for measuring pain volatility. Cluster analysis was applied to divide users into subsets of low and high volatility classes. These classes were then predicted at the sixth month of app use with an acceptable degree of accuracy using machine learning methods based on the features extracted from demographic, clinical, and app use information from the first month. %M 30442636 %R 10.2196/12001 %U http://www.jmir.org/2018/11/e12001/ %U https://doi.org/10.2196/12001 %U http://www.ncbi.nlm.nih.gov/pubmed/30442636 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e11066 %T Usability Study of Mainstream Wearable Fitness Devices: Feature Analysis and System Usability Scale Evaluation %A Liang,Jun %A Xian,Deqiang %A Liu,Xingyu %A Fu,Jing %A Zhang,Xingting %A Tang,Buzhou %A Lei,Jianbo %+ Center for Medical Informatics, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, China, 86 8280 5901, jblei@hsc.pku.edu.cn %K wearable devices %K usability %K System Usability Scale %K function comparison %K fitness %D 2018 %7 08.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Wearable devices have the potential to promote a healthy lifestyle because of their real-time data monitoring capabilities. However, device usability is a critical factor that determines whether they will be adopted on a large scale. Usability studies on wearable devices are still scarce. Objective: This study aims to compare the functions and attributes of seven mainstream wearable devices and to evaluate their usability. Methods: The wearable devices selected were the Apple Watch, Samsung Gear S, Fitbit Surge, Jawbone Up3, Mi Band, Huawei Honor B2, and Misfit Shine. A mixed method of feature comparison and a System Usability Scale (SUS) evaluation based on 388 participants was applied; the higher the SUS score, the better the usability of the product. Results: For features, all devices had step counting, an activity timer, and distance recording functions. The Samsung Gear S had a unique sports track recording feature and the Huawei Honor B2 had a unique wireless earphone. The Apple Watch, Samsung Gear S, Jawbone Up3, and Fitbit Surge could measure heart rate. All the devices were able to monitor sleep, except the Apple Watch. For product characteristics, including attributes such as weight, battery life, price, and 22 functions such as step counting, activity time, activity type identification, sleep monitoring, and expandable new features, we found a very weak negative correlation between the SUS scores and price (r=−.10, P=.03) and devices that support expandable new features (r=−.11, P=.02), and a very weak positive correlation between the SUS scores and devices that support the activity type identification function (r=.11, P=.02). The Huawei Honor B2 received the highest score of mean 67.6 (SD 16.1); the lowest Apple Watch score was only 61.4 (SD 14.7). No significant difference was observed among brands. The SUS score had a moderate positive correlation with the user’s experience (length of time the device was used) (r=.32, P<.001); participants in the medical and health care industries gave a significantly higher score (mean 61.1, SD 17.9 vs mean 68.7, SD 14.5, P=.03). Conclusions: The functions of wearable devices tend to be homogeneous and usability is similar across various brands. Overall, Mi Band had the lowest price and the lightest weight. Misfit Shine had the longest battery life and most functions, and participants in the medical and health care industries had the best evaluation of wearable devices. The perceived usability of mainstream wearable devices is unsatisfactory and customer loyalty is not high. A consumer’s SUS rating for a wearable device is related to their personal situation instead of the device brand. Device manufacturers should put more effort into developing innovative functions and improving the usability of their products by integrating more cognitive behavior change techniques. %M 30409767 %R 10.2196/11066 %U http://mhealth.jmir.org/2018/11/e11066/ %U https://doi.org/10.2196/11066 %U http://www.ncbi.nlm.nih.gov/pubmed/30409767 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 4 %N 2 %P e10296 %T Novel mHealth App to Deliver Geriatric Assessment-Driven Interventions for Older Adults With Cancer: Pilot Feasibility and Usability Study %A Loh,Kah Poh %A Ramsdale,Erika %A Culakova,Eva %A Mendler,Jason H %A Liesveld,Jane L %A O'Dwyer,Kristen M %A McHugh,Colin %A Gilles,Maxence %A Lloyd,Terri %A Goodman,Molly %A Klepin,Heidi D %A Mustian,Karen M %A Schnall,Rebecca %A Mohile,Supriya G %+ Division of Hematology/Oncology, James P Wilmot Cancer Institute, University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, United States, 1 4133069767, kahpoh_loh@urmc.rochester.edu %K Mobile health application %K geriatric assessment %K older adults %K cancer %D 2018 %7 29.10.2018 %9 Original Paper %J JMIR Cancer %G English %X Background: Older patients with cancer are at an increased risk of adverse outcomes. A geriatric assessment (GA) is a compilation of reliable and validated tools to assess domains that are predictors of morbidity and mortality, and it can be used to guide interventions. However, the implementation of GA and GA-driven interventions is low due to resource and time limitations. GA-driven interventions delivered through a mobile app may support the complex needs of older patients with cancer and their caregivers. Objective: We aimed to evaluate the feasibility and usability of a novel app (TouchStream) and to identify barriers to its use. As an exploratory aim, we gathered preliminary data on symptom burden, health care utilization, and satisfaction. Methods: In a single-site pilot study, we included patients aged ≥65 years undergoing treatment for systemic cancer and their caregivers. TouchStream consists of a mobile app and a Web portal. Patients underwent a GA at baseline with the study team (on paper), and the results were used to guide interventions delivered through the app. A tablet preloaded with the app was provided for use at home for 4 weeks. Feasibility metrics included usability (system usability scale of >68 is considered above average), recruitment, retention (number of subjects consented who completed postintervention assessments), and percentage of days subjects used the app. For the last 8 patients, we assessed their symptom burden (severity and interference with 17-items scored from 0-10 where a higher score indicates worse symptoms) using a clinical symptom inventory, health care utilization from the electronic medical records, and satisfaction (6 items scored on a 5-point Likert Scale for both patients and caregivers where a higher score indicates higher satisfaction) using a modified satisfaction survey. Barriers to use were elicited through interviews. Results: A total of 18 patients (mean age 76.8, range 68-87) and 13 caregivers (mean age 69.8, range 38-81) completed the baseline assessment. Recruitment and retention rates were 67% and 80%, respectively. The mean SUS score was 74.0 for patients and 72.2 for caregivers. Mean percentage of days the TouchStream app was used was 78.7%. Mean symptom severity and interference scores were 1.6 and 2.8 at preintervention, and 0.9 and 1.5 at postintervention, respectively. There was a total of 27 clinic calls during the intervention period and 15 during the postintervention period (week 5-8). One patient was hospitalized during the intervention period (week 1-4) and two patients during the postintervention period (week 5-8). Mean satisfaction scores of patients and caregivers with the mobile app were 20.4 and 23.4, respectively. Barriers fell into 3 themes: general experience, design, and functionality. Conclusions: TouchStream is feasible and usable for older patients on cancer treatment and their caregivers. Future studies should evaluate the effects of the TouchStream on symptoms and health care utilization in a randomized fashion. %M 30373733 %R 10.2196/10296 %U http://cancer.jmir.org/2018/2/e10296/ %U https://doi.org/10.2196/10296 %U http://www.ncbi.nlm.nih.gov/pubmed/30373733 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e11231 %T Benefits of Mobile Apps in Pain Management: Systematic Review %A Thurnheer,Simon E %A Gravestock,Isaac %A Pichierri,Giuseppe %A Steurer,Johann %A Burgstaller,Jakob M %+ Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, Zurich, 8032, Switzerland, 41 442558709, simon.thurnheer@usz.ch %K mobile application %K pain %K pain management %K smartphone %K cell phone %K telemedicine %K review %D 2018 %7 22.10.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Pain is a common condition with a significant physical, psychosocial, and economic impact. Due to enormous progress in mobile device technology as well as the increase in smartphone ownership in the general population, mobile apps can be used to monitor patients with pain and support them in pain management. Objective: The aim of this review was to assess the efficacy of smartphone or computer tablet apps in the management of patients with pain. Methods: In December 2017, a literature search was performed in the following databases: MEDLINE, EMBASE, CINAHL, Cochrane, and PsycINFO. In addition, a bibliography search was conducted. We included studies with at least 20 participants per arm that evaluated the effects of apps on smartphones or computer tablets on improvement in pain. Results: A total of 15 studies with 1962 patients met the inclusion criteria. Of these, 4 studies examined the effect of mobile apps on pain management in an in-clinic setting and 11 in an out-clinic setting. The majority of the original studies reported beneficial effects of the use of a pain app. Severity of pain decreased in most studies where patients were using an app compared with patients not using an app. Other outcomes, such as worst pain or quality of life showed improvements in patients using an app. Due to heterogeneity between the original studies—patient characteristics, app content, and study setting—a synthesis of the results by statistical methods was not performed. Conclusions: Apps for pain management may be beneficial for patients, particularly in an out-clinic setting. Studies have shown that pain apps are workable and well liked by patients and health care professionals. There is no doubt that in the near future, mobile technologies will develop further. Medicine could profit from this development as indicated by our results, but there is a need for more scientific inputs. It is desirable to know which elements of apps or additional devices and tools may improve usability and help patients in pain management. %M 30348633 %R 10.2196/11231 %U http://mhealth.jmir.org/2018/10/e11231/ %U https://doi.org/10.2196/11231 %U http://www.ncbi.nlm.nih.gov/pubmed/30348633 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e10771 %T Self-Management Education Through mHealth: Review of Strategies and Structures %A Bashi,Nazli %A Fatehi,Farhad %A Fallah,Mina %A Walters,Darren %A Karunanithi,Mohanraj %+ Australian eHealth Research Centre, Commonwealth Scientific and Industrial Research Organisation (CSIRO), Level 5 - UQ Health Sciences, Building 901/16, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia, 61 7 3253 3611, nazli.bashi@csiro.au %K health education %K mHealth %K mobile apps %K mobile phone %K patient education %K self-management education %D 2018 %7 19.10.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Despite the plethora of evidence on mHealth interventions for patient education, there is a lack of information regarding their structures and delivery strategies. Objective: This review aimed to investigate the structures and strategies of patient education programs delivered through smartphone apps for people with diverse conditions and illnesses. We also examined the aim of educational interventions in terms of health promotion, disease prevention, and illness management. Methods: We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and PsycINFO for peer-reviewed papers that reported patient educational interventions using mobile apps and published from 2006 to 2016. We explored various determinants of educational interventions, including the content, mode of delivery, interactivity with health care providers, theoretical basis, duration, and follow-up. The reporting quality of studies was evaluated according to the mHealth evidence and reporting assessment criteria. Results: In this study, 15 papers met the inclusion criteria and were reviewed. The studies mainly focused on the use of mHealth educational interventions for chronic disease management, and the main format for delivering interventions was text. Of the 15 studies, 6 were randomized controlled trials (RCTs), which have shown statistically significant effects on patients’ health outcomes, including patients’ engagement level, hemoglobin A1c, weight loss, and depression. Although the results of RCTs were mostly positive, we were unable to identify any specific effective structure and strategy for mHealth educational interventions owing to the poor reporting quality and heterogeneity of the interventions. Conclusions: Evidence on mHealth interventions for patient education published in peer-reviewed journals demonstrates that current reporting on essential mHealth criteria is insufficient for assessing, understanding, and replicating mHealth interventions. There is a lack of theory or conceptual framework for the development of mHealth interventions for patient education. Therefore, further research is required to determine the optimal structure, strategies, and delivery methods of mHealth educational interventions. %M 30341042 %R 10.2196/10771 %U https://mhealth.jmir.org/2018/10/e10771/ %U https://doi.org/10.2196/10771 %U http://www.ncbi.nlm.nih.gov/pubmed/30341042 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e10776 %T An mHealth Diabetes Intervention for Glucose Control: Health Care Utilization Analysis %A Quinn,Charlene C %A Swasey,Krystal K %A Torain,Jamila M %A Shardell,Michelle D %A Terrin,Michael L %A Barr,Erik A %A Gruber-Baldini,Ann L %+ Department of Epidemiology and Public Health, University of Maryland School of Medicine, 660 W Redwood Street, Howard Hall Suite 200, Baltimore, MD, 21201, United States, 1 410 706 2406, cquinn@som.umaryland.edu %K cluster randomized clinical trial %K health care %K health service utilization %K mHealth %K type 2 diabetes %D 2018 %7 15.10.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Type 2 diabetes (T2D) is a major chronic condition requiring management through lifestyle changes and recommended health service visits. Mobile health (mHealth) is a promising tool to encourage self-management, but few studies have investigated the impact of mHealth on health care utilization. Objective: The objective of this analysis was to determine the change in 2-year health service utilization and whether utilization explained a 1.9% absolute decrease in glycated hemoglobin (HbA1c) over 1-year in the Mobile Diabetes Intervention Study (MDIS). Methods: We used commercial claims data from 2006 to 2010 linked to enrolled patients’ medical chart data in 26 primary care practices in Maryland, USA. Secondary claims data analyses were available for 56% (92/163) of participants. In the primary MDIS study, physician practices were recruited and randomized to usual care and 1 of 3 increasingly complex interventions. Patients followed physician randomization assignment. The main variables in the analysis included health service utilization by type of service and change in HbA1c. The claims data was aggregated into 12 categories of utilization to assess change in 2-year health service usage, comparing rates of usage pre- and posttrial. We also examined whether utilization explained the 1.9% decrease in HbA1c over 1 year in the MDIS cluster randomized clinical trial. Results: A significant group by time effect was observed in physician office visits, general practitioner visits, other outpatient services, prescription medications, and podiatrist visits. Physician office visits (P=.01) and general practitioner visits (P=.02) both decreased for all intervention groups during the study period, whereas prescription claims (P<.001) increased. The frequency of other outpatient services (P=.001) and podiatrist visits (P=.04) decreased for the control group and least complex intervention group but increased for the 2 most complex intervention groups. No significant effects of utilization were observed to explain the clinically significant change in HbA1c. Conclusions: Claims data analyses identified patterns of utilization relevant to mHealth interventions. Findings may encourage patients and health providers to discuss the utilization of treatment-recommended services, lab tests, and prescribed medications. Trial Registration: ClinicalTrials.gov NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by Webcite at http://www.webcitation.org/72XgTaxIj) %M 30322839 %R 10.2196/10776 %U http://mhealth.jmir.org/2018/10/e10776/ %U https://doi.org/10.2196/10776 %U http://www.ncbi.nlm.nih.gov/pubmed/30322839 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e11192 %T Assessing the Attitudes and Perceptions Regarding the Use of Mobile Health Technologies for Living Kidney Donor Follow-Up: Survey Study %A Eno,Ann K %A Thomas,Alvin G %A Ruck,Jessica M %A Van Pilsum Rasmussen,Sarah E %A Halpern,Samantha E %A Waldram,Madeleine M %A Muzaale,Abimereki D %A Purnell,Tanjala S %A Massie,Allan B %A Garonzik Wang,Jacqueline M %A Lentine,Krista L %A Segev,Dorry L %A Henderson,Macey L %+ Department of Surgery, Johns Hopkins University School of Medicine, 2000 East Monument Street, Baltimore, MD, 21205, United States, 1 443 287 6649, macey@jhmi.edu %K follow-up %K kidney transplantation %K living kidney donor %K mobile phone, mHealth %D 2018 %7 09.10.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In 2013, the Organ Procurement and Transplantation Network began requiring transplant centers in the United States to collect and report postdonation living kidney donor follow-up data at 6 months, 1 year, and 2 years. Despite this requirement, <50% of transplant centers have been able to collect and report the required data. Previous work identified a number of barriers to living kidney donor follow-up, including logistical and administrative barriers for transplant centers and cost and functional barriers for donors. Novel smartphone-based mobile health (mHealth) technologies might reduce the burden of living kidney donor follow-up for centers and donors. However, the attitudes and perceptions toward the incorporation of mHealth into postdonation care among living kidney donors are unknown. Understanding donor attitudes and perceptions will be vital to the creation of a patient-oriented mHealth system to improve living donor follow-up in the United States. Objective: The goal of this study was to assess living kidney donor attitudes and perceptions associated with the use of mHealth for follow-up. Methods: We developed and administered a cross-sectional 14-question survey to 100 living kidney donors at our transplant center. All participants were part of an ongoing longitudinal study of long-term outcomes in living kidney donors. The survey included questions on smartphone use, current health maintenance behaviors, accessibility to health information, and attitudes toward using mHealth for living kidney donor follow-up. Results: Of the 100 participants surveyed, 94 owned a smartphone (35 Android, 58 iPhone, 1 Blackberry), 37 had accessed their electronic medical record on their smartphone, and 38 had tracked their exercise and physical activity on their smartphone. While 77% (72/93) of participants who owned a smartphone and had asked a medical question in the last year placed the most trust with their doctors, nurses, or other health care professionals regarding answering a health-related question, 52% (48/93) most often accessed health information elsewhere. Overall, 79% (74/94) of smartphone-owning participants perceived accessing living kidney donor information and resources on their smartphone as useful. Additionally, 80% (75/94) perceived completing some living kidney donor follow-up via mHealth as useful. There were no significant differences in median age (60 vs 59 years; P=.65), median years since donation (10 vs 12 years; P=.45), gender (36/75, 36%, vs 37/75, 37%, male; P=.57), or race (70/75, 93%, vs 18/19, 95%, white; P=.34) between those who perceived mHealth as useful for living kidney donor follow-up and those who did not, respectively. Conclusions: Overall, smartphone ownership was high (94/100, 94.0%), and 79% (74/94) of surveyed smartphone-owning donors felt that it would be useful to complete their required follow-up with an mHealth tool, with no significant differences by age, sex, or race. These results suggest that patients would benefit from an mHealth tool to perform living donor follow-up. %M 30305260 %R 10.2196/11192 %U http://mhealth.jmir.org/2018/10/e11192/ %U https://doi.org/10.2196/11192 %U http://www.ncbi.nlm.nih.gov/pubmed/30305260 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e167 %T Behavior Change Techniques in mHealth Apps for the Mental and Physical Health of Employees: Systematic Assessment %A de Korte,Elsbeth %A Wiezer,Noortje %A Bakhuys Roozeboom,Maartje %A Vink,Peter %A Kraaij,Wessel %+ Netherlands Organization for Applied Scientific Research, Schipholweg 77-89, Leiden, 2316 ZL, Netherlands, 31 6 21134434, elsbeth.dekorte@tno.nl %K behavior change techniques %K mHealth %K mental health %K physical health %K lifestyle %K workplace %K app %K employee %K work %D 2018 %7 03.10.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Employees remain at risk of developing physical and mental health problems. To improve the lifestyle, health, and productivity many workplace interventions have been developed. However, not all of these interventions are effective. Mobile and wireless technology to support health behavior change (mobile health [mHealth] apps) is a promising, but relatively new domain for the occupational setting. Research on mHealth apps for the mental and physical health of employees is scarce. Interventions are more likely to be useful if they are rooted in health behavior change theory. Evaluating the presence of specific combinations of behavior change techniques (BCTs) in mHealth apps might be used as an indicator of potential quality and effectiveness. Objective: The aim of this study was to assess whether mHealth apps for the mental and physical health of employees incorporate BCTs and, if so, which BCTs can be identified and which combinations of BCTs are present. Methods: An assessment was made of apps aiming to reduce the risk of physical and psychosocial work demands and to promote a healthy lifestyle for employees. A systematic search was performed in iTunes and Google Play. Forty-five apps were screened and downloaded. BCTs were identified using a taxonomy applied in similar reviews. The mean and ranges were calculated. Results: On average, the apps included 7 of the 26 BCTs (range 2-18). Techniques such as “provide feedback on performance,” “provide information about behavior-health link,” and “provide instruction” were used most frequently. Techniques that were used least were “relapse prevention,” “prompt self-talk,” “use follow-up prompts,” and “provide information about others’ approval.” “Stress management,” “prompt identification as a role model,” and “agree on behavioral contract” were not used by any of the apps. The combination “provide information about behavior-health link” with “prompt intention formation” was found in 7/45 (16%) apps. The combination “provide information about behavior-health link” with “provide information on consequences,” and “use follow-up prompts” was found in 2 (4%) apps. These combinations indicated potential effectiveness. The least potentially effective combination “provide feedback on performance” without “provide instruction” was found in 13 (29%) apps. Conclusions: Apps for the occupational setting might be substantially improved to increase potential since results showed a limited presence of BCTs in general, limited use of potentially successful combinations of BCTs in apps, and use of potentially unsuccessful combinations of BCTs. Increasing knowledge on the effectiveness of BCTs in apps might be used to develop guidelines for app developers and selection criteria for companies and individuals. Also, this might contribute to decreasing the burden of work-related diseases. To achieve this, app developers, health behavior change professionals, experts on physical and mental health, and end-users should collaborate when developing apps for the working context. %R 10.2196/mhealth.6363 %U https://mhealth.jmir.org/2018/10/e167/ %U https://doi.org/10.2196/mhealth.6363 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e10035 %T Mobile App Use by Primary Care Patients to Manage Their Depressive Symptoms: Qualitative Study %A Pung,Alison %A Fletcher,Susan Louise %A Gunn,Jane Maree %+ Department of General Practice, The University of Melbourne, 200 Berkeley Street, Victoria, 3053, Australia, 61 3 9035 4872, susanlf@unimelb.edu.au %K mobile apps %K depression %K health care %K general practice %D 2018 %7 27.09.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile apps are emerging as tools with the potential to revolutionize the treatment of mental health conditions such as depression. At the forefront of the community health sector, general practitioners are in a unique position to guide the integration of technology and depression management; however, little is currently known about how primary care patients with depressive symptoms are currently using apps. Objective: The objective of our study was to explore the natural patterns of mobile app use among patients with depressive symptoms to facilitate the understanding of the potential role for mobile apps in managing depressive symptoms in the community. Methods: Semistructured phone interviews were conducted with primary care patients in Victoria, Australia, who reported symptoms of depression and were enrolled in a larger randomized controlled trial of depression care. Interviews explored current depression management strategies and the use of mobile apps (if any). Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was iteratively conducted using QSR NVivo 11 Pro to identify emergent themes. Results: A total of 16 participants, aged between 20 to 58 years, took part in the interviews with 11 reporting the use of at least one mobile app to manage depressive symptoms and 5 reporting no app use. A variety of apps were described including relaxation, mindfulness, cognitive, exercise, gaming, social media, and well-being apps to aid with depressive symptoms. Among users, there were the following 4 main patterns of app use: skill acquisition, social connectedness, inquisitive trial, and safety netting. Factors that influenced app use included accessibility, perceptions of technology, and personal compatibility. Health care providers also had a role in initiating app use. Conclusions: Mobile apps are being utilized for self-management of depressive symptoms by primary care patients. This study provided insight into the natural patterns and perspectives of app use, which enhanced the understanding of how this technology may be integrated into the toolbox for the management of depression. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000537459; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367152 (Archived at WebCite at http://www.webcitation.org/71Vf06X2T) %M 30262449 %R 10.2196/10035 %U http://www.jmir.org/2018/9/e10035/ %U https://doi.org/10.2196/10035 %U http://www.ncbi.nlm.nih.gov/pubmed/30262449 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 9 %P e266 %T Internet-Based and Mobile-Based General Practice: Cross-Sectional Survey %A Qiu,Yan %A Liu,Ying %A Ren,Wen %A Qiu,Yunqing %A Ren,Jingjing %+ The First Affiliated Hospital, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China, 86 057187235012, lisarjj@126.com %K general practice %K mHealth %K mobile phone %K satisfaction %K health service %K internet hospital %D 2018 %7 25.9.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Globally, mHealth is increasing as a promising technology for promoting the quality of health care. Thus, a growing number of internet hospitals have been established in China to avail all its advantages. However, no study has investigated the service scope and patient satisfaction of the internet hospital to date. Objective: The objective of our study was to explore the features of outpatients in general practice, the disease information, and the satisfaction through an internet rating site. Methods: We collected data from the internet hospital of the First Affiliated Hospital, Zhejiang University between February 2016 and February 2017. Patients visited Web-based clinic via a computer or smartphone. The data included patients’ demographic characteristics, disease information, and patients’ comments. Results: We enrolled 715 patients with 365 health-related problems. All health conditions involved diseases ranging from internal medicine, surgery, gynecology and obstetrics, pediatrics, dermatology, ophthalmology, stomatology to emergency. Among them, 63.1% patients (451/715) visited traditional hospitals for further management, 25.3% (181/715) had prescriptions, laboratory, or imaging examination appointment, 1% (9/715) used emergency service, and 10% (74/715) needed routine follow-up. All patients received health education. Almost all patients gave positive feedback and 4-5-star rating. Conclusions: The internet hospital is suitable for all health conditions with high satisfaction only when patients have the access to internet via a computer or smartphone. %M 30257819 %R 10.2196/jmir.8378 %U http://www.jmir.org/2018/9/e266/ %U https://doi.org/10.2196/jmir.8378 %U http://www.ncbi.nlm.nih.gov/pubmed/30257819 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 9 %P e178 %T Evaluating the Carrot Rewards App, a Population-Level Incentive-Based Intervention Promoting Step Counts Across Two Canadian Provinces: Quasi-Experimental Study %A Mitchell,Marc %A White,Lauren %A Lau,Erica %A Leahey,Tricia %A Adams,Marc A %A Faulkner,Guy %+ Western University, Somerville House, Room 2360C, London, ON, N6A 5B9, Canada, 1 519 661 2111 ext 87936, marc.mitchell@uwo.ca %K behavioral economics %K financial health incentives %K mHealth %K mobile phone %K physical activity %K public health %D 2018 %7 20.9.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Carrot Rewards app was developed as part of an innovative public-private partnership to reward Canadians with loyalty points, exchangeable for retail goods, travel rewards, and groceries for engaging in healthy behaviors such as walking. Objective: This study examined whether a multicomponent intervention including goal setting, graded tasks, biofeedback, and very small incentives tied to daily step goal achievement (assessed by built-in smartphone accelerometers) could increase physical activity in two Canadian provinces, British Columbia (BC) and Newfoundland and Labrador (NL). Methods: This 12-week, quasi-experimental (single group pre-post) study included 78,882 participants; 44.39% (35,014/78,882) enrolled in the Carrot Rewards “Steps” walking program during the recruitment period (June 13–July 10, 2016). During the 2-week baseline (or “run-in”) period, we calculated participants’ mean steps per day. Thereafter, participants earned incentives in the form of loyalty points (worth Can $0.04 ) every day they reached their personalized daily step goal (ie, baseline mean+1000 steps=first daily step goal level). Participants earned additional points (Can $0.40) for meeting their step goal 10+ nonconsecutive times in a 14-day period (called a “Step Up Challenge”). Participants could earn up to Can $5.00 during the 12-week evaluation period. Upon meeting the 10-day contingency, participants could increase their daily goal by 500 steps, aiming to gradually increase the daily step number by 3000. Only participants with ≥5 valid days (days with step counts: 1000-40,000) during the baseline period were included in the analysis (n=32,229).The primary study outcome was mean steps per day (by week), analyzed using linear mixed-effects models. Results: The mean age of 32,229 participants with valid baseline data was 33.7 (SD 11.6) years; 66.11% (21,306/32,229) were female. The mean daily step count at baseline was 6511.22. Over half of users (16,336/32,229, 50.69%) were categorized as “physically inactive,” accumulating <5000 daily steps at baseline. Results from mixed-effects models revealed statistically significant increases in mean daily step counts when comparing baseline with each study week (P<.001). Compared with baseline, participants walked 115.70 more steps (95% CI 74.59 to 156.81; P<.001) at study week 12. BC and NL users classified as “high engagers” (app engagement above sample median; 15,511/32,229, 48.13%) walked 738.70 (95% CI 673.81 to 803.54; P<.001) and 346.00 (95% CI 239.26 to 452.74; P<.001) more steps, respectively. Physically inactive, high engagers (7022/32,229, 21.08%) averaged an increase of 1224.66 steps per day (95% CI 1160.69 to 1288.63; P<.001). Effect sizes were modest. Conclusions: Providing very small but immediate rewards for personalized daily step goal achievement as part of a multicomponent intervention increased daily step counts on a population scale, especially for physically inactive individuals and individuals who engaged more with the walking program. Positive effects in both BC and NL provide evidence of replicability. %M 30148712 %R 10.2196/mhealth.9912 %U http://mhealth.jmir.org/2018/9/e178/ %U https://doi.org/10.2196/mhealth.9912 %U http://www.ncbi.nlm.nih.gov/pubmed/30148712 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e16 %T Improving Transitions of Care for Young Adults With Congenital Heart Disease: Mobile App Development Using Formative Research %A Lopez,Keila N %A O'Connor,Michael %A King,Jason %A Alexander,James %A Challman,Melissa %A Lovick,Donna K %A Goodly,Nicole %A Smith,Amelia %A Fawcett,Elliott %A Mulligan,Courtney %A Thompson,Debbe %A Fordis,Michael %+ Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, 6621 Fannin Street, MC 19-345, Houston, TX, 77030, United States, 1 832 826 5600, knlopez@bcm.edu %K adolescent health %K chronic disease %K transitions of care %K health disparities %K mobile health %K mHealth %K patient empowerment %K patient involvement %K self-efficacy %K user-centered design %D 2018 %7 11.09.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Congenital heart diseases (CHDs) are the most common type of birth defects. Improvements in CHD care have led to approximately 1.4 million survivors reaching adulthood. Successful transition and transfer from pediatric to adult care is crucial. Unfortunately, less than 30% of adolescents with CHD successfully transition to adult care; this number is lower for minority and lower socioeconomic status populations. Few CHD programs exist to facilitate successful transition. Objective: The goal of our study was to describe the formative research used to develop a prototype mobile app to facilitate transition to adult care for adolescents with CHD. Methods: A literature search about best practices in transition medicine for CHD was conducted to inform app development. Formative research with a diverse group of CHD adolescents and their parents was conducted to determine gaps and needs for CHD transition to adult care. As part of the interview, surveys assessing transition readiness and CHD knowledge were completed. Two adolescent CHD expert panels were convened to inform educational content and app design. Results: The literature review revealed 113 articles, of which 38 were studies on transition programs and attitudes and 3 identified best practices in transition specific to CHD. A total of 402 adolescents aged 15 to 22 years (median 16 years) participated in semistructured interviews. The group was racially and ethnically diverse (12.6% [51/402] African American and 37.8% [152/402] Latino) and 42.0% (169/402) female; 36.3% (146/402) received public insurance. Most adolescents (313/402, 76.7%) had moderate or severe CHD complexity and reported minimal CHD understanding (79.0% [275/348] of those aged 15 to 17 years and 61.1% [33/54] of those aged 18 to 22 years). Average initial transition readiness score was 50.9/100, meaning that transition readiness training was recommended. When participants with moderate to severe CHD (313/402, 77.9%) were asked about technology use, 94.2% (295/313) reported having access to a mobile phone. Interviews with parents revealed limited interactions with the pediatric cardiologist about transition-related topics: 79.4% (331/417) reported no discussions regarding future family planning, and 55.2% (230/417) reported the adolescent had not been screened for mental health concerns (depression, anxiety). Further, 66.4% (277/417) reported not understanding how health care changes as adolescents become adults. Adolescents in the expert panels (2 groups of 3 adolescents each) expressed interest in a CHD-specific tailored app consisting of quick access to specific educational questions (eg, “Can I exercise?”), a CHD story-blog forum, a mentorship platform, a question and answer space, and a checklist to facilitate transition. They expressed interest in using the app to schedule CHD clinic appointments and receive medication reminders. Based on this data, a prototype mobile app was created to assist in adolescent CHD transition. Conclusions: Formative research revealed that most adolescents with CHD had access to mobile phones, were not prepared for transition to adult care, and were interested in an app to facilitate transition to adult CHD care. Understanding adolescent and parent needs, interests, and concerns helped in the development of a mobile app with a broader, tailored approach for adolescents with CHD. %R 10.2196/formative.9963 %U http://formative.jmir.org/2018/2/e16/ %U https://doi.org/10.2196/formative.9963 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 9 %P e10456 %T Smartphone-Based Contingency Management Intervention to Improve Pre-Exposure Prophylaxis Adherence: Pilot Trial %A Mitchell,John T %A LeGrand,Sara %A Hightow-Weidman,Lisa B %A McKellar,Mehri S %A Kashuba,Angela DM %A Cottrell,Mackenzie %A McLaurin,Tony %A Satapathy,Goutam %A McClernon,F Joseph %+ Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2608 Erwin Road, Pavilion East, Suite 300, Durham, NC, 27705, United States, 1 919 681 0012, john.mitchell@duke.edu %K HIV %K preexposure prophylaxis %K mobile health %D 2018 %7 10.09.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pre-exposure prophylaxis (PrEP) provides a strong preventative benefit to individuals at risk for HIV. While PrEP adherence is highly correlated with its efficacy, adherence rates are variable both across and within persons. Objective: The objective of this study was to develop and pilot-test a smartphone-based intervention, known as mSMART, that targets PrEP adherence. mSMART provides contingency management in the form of monetary incentives for daily PrEP adherence based on a real-time adherence assessment using a camera-based medication event-monitoring tool as well as medication reminders, PrEP education, individualized behavioral strategies to address PrEP adherence barriers, and medication adherence feedback. Methods: This was a 4-week open-label, phase I trial in a community sample of young men who have sex with men already on PrEP (N=10). Results: Although adherence composite scores corresponding to PrEP biomarkers indicated that 90% (9/10) of the sample already had an acceptable baseline adherence in the protective range, by the end of the 4-week period, the scores improved for 30% (3/10) of the sample—adherence did not worsen for any participants. Participants reported mean PrEP adherence rates of 91% via daily entries in mSMART. At the end of the 4-week period, participants indicated acceptable ratings of satisfaction, usability, and willingness to recommend mSMART to others. There were no technical difficulties associated with smartphone compatibility, user misunderstandings about mSMART features that interfered with daily use, or study attrition. Conclusions: This study is the first to apply contingency management to PrEP adherence. Findings indicated that mSMART is feasible and acceptable. Such an adherence intervention administered via a user-friendly smartphone app can allow for widespread dissemination. Future efficacy trials are needed. Trial Registration: ClinicalTrials.gov NCT02895893; https://clinicaltrials.gov/ct2/show/NCT02895893 (Accessed by Webcite at http://www.webcitation.org/72JskjDJq) %M 30201601 %R 10.2196/10456 %U http://mhealth.jmir.org/2018/9/e10456/ %U https://doi.org/10.2196/10456 %U http://www.ncbi.nlm.nih.gov/pubmed/30201601 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 9 %P e175 %T A Dietary Assessment App for Hospitalized Patients at Nutritional Risk: Development and Evaluation of the MyFood App %A Paulsen,Mari Mohn %A Hagen,Martina Lovise Lindhart %A Frøyen,Marte Hesvik %A Foss-Pedersen,Rikke Julie %A Bergsager,Dagfinn %A Tangvik,Randi Julie %A Andersen,Lene Frost %+ Institute of Basic Medical Sciences, Department of Nutrition, University of Oslo, PO Box 1046, Blindern, Oslo, 0317, Norway, 47 22851103, m.m.paulsen@medisin.uio.no %K decision support system %K disease-related malnutrition %K eHealth %K mHealth %K dietary assessment %K validation study %D 2018 %7 07.09.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Disease-related malnutrition is a common challenge among hospitalized patients. There seems to be a lack of an effective system to follow-up nutritional monitoring and treatment of patients at nutritional risk after risk assessment. We identify a need for a more standardized system to prevent and treat disease-related malnutrition. Objective: We aimed to develop a dietary assessment app for tablets for use in a hospital setting and to evaluate the app’s ability to measure individual intake of energy, protein, liquid, and food and beverage items among hospitalized patients for two days. We also aimed to measure patients’ experiences using the app. Methods: We have developed the MyFood app, which consists of three modules: 1) collection of information about the patient, 2) dietary assessment function, and 3) evaluation of recorded intake compared to individual needs. We used observations from digital photography of the meals, combined with partial weighing of the meal components, as a reference method to evaluate the app’s dietary assessment system for two days. Differences in the intake estimations of energy, protein, liquid, and food and beverage items between MyFood and the photograph method were analyzed on both group and individual level. Results: Thirty-two patients hospitalized at Oslo University Hospital were included in the study. The data collection period ran from March to May 2017. About half of the patients had ≥90% agreement between MyFood and the photograph method for energy, protein, and liquid intake on both recording days. Dinner was the meal with the lowest percent agreement between methods. MyFood overestimated patients’ intake of bread and cereals and underestimated fruit consumption. Agreement between methods increased from day 1 to day 2 for bread and cereals, spreads, egg, yogurt, soup, hot dishes, and desserts. Ninety percent of participants reported that MyFood was easy to use, and 97% found the app easy to navigate. Conclusions: We developed the MyFood app as a tool to monitor dietary intake among hospitalized patients at nutritional risk. The recorded intake of energy, protein, and liquid using MyFood showed good agreement with the photograph method for the majority of participants. The app’s ability to estimate intake within food groups was good, except for bread and cereals which were overestimated and fruits which were underestimated. The app was well accepted among study participants and has the potential to be a dietary assessment tool for use among patients in clinical practice. %M 30194059 %R 10.2196/mhealth.9953 %U http://mhealth.jmir.org/2018/9/e175/ %U https://doi.org/10.2196/mhealth.9953 %U http://www.ncbi.nlm.nih.gov/pubmed/30194059 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e256 %T A Church-Based Weight Loss Intervention in African American Adults using Text Messages (LEAN Study): Cluster Randomized Controlled Trial %A Newton Jr,Robert L %A Carter,Leah A %A Johnson,William %A Zhang,Dachuan %A Larrivee,Sandra %A Kennedy,Betty M %A Harris,Melissa %A Hsia,Daniel S %+ Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA, 70808, United States, 1 225 763 3034, Robert.Newton@pbrc.edu %K African Americans %K behavioral strategies %K community health %K mHealth %K mobile phone %K obesity %K text messages %K weight loss %D 2018 %7 24.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: African American adults experience a high prevalence of obesity and its associated comorbidities, including diabetes. Church-based interventions have been shown to be effective in decreasing weight in this population. mHealth interventions can address two needs for obesity treatment in this community, including enhancing weight loss and providing wide dissemination. Objective: This study aimed to assess the feasibility and efficacy of a church-based weight loss intervention that incorporates mHealth technology. Methods: In this study, 8 churches (n=97) were randomly assigned to the intervention or delayed intervention condition (control group). We recruited participants through their respective church. Volunteer church members were trained by study staff to deliver the 10-session, 6-month intervention. Participants in the intervention group attended group sessions and received automated short message service (SMS) text messages designed to reinforce behavioral strategies. Conversely, participants in the delayed intervention condition received SMS text messages related to health conditions relevant for African American adults. We obtained measures of body composition, blood pressure, blood glucose, and cholesterol. Results: We successfully recruited 97 African American adults, with a mean age of 56.0 (SE 10.3) years and a mean body mass index of 38.6 (SE 6.4) kg/m2 (89/97, 91.8% females), who attended the churches that were randomized to the intervention (n=68) or control (n=29) condition. Of these, 74.2% (72/97) of the participants (47/68, 69.1% intervention; 25/29, 86.2% delayed intervention) completed the 6-month assessment. The average intervention group attendance was 55%. There was a significant difference in weight loss (P=.04) between participants in the intervention (–1.5 (SE 0.5) kg) and control (0.11 (SE 0.6) kg) groups. Among participants in the intervention group, the correlation between the number of SMS text messages sent and the percent body fat loss was r=.3 with P=.04. The participants reported high satisfaction with the automated SMS text messages. Conclusions: Automated SMS text messages were well-received by participants, suggesting that more enhanced mHealth technologies are a viable option for interventions targeting African American adults. Trial Registration: ClinicalTrials.gov NCT02863887; https://clinicaltrials.gov/ct2/show/NCT02863887 (Archived by WebCite at http://www.webcitation.org/71JiYzizO) %M 30143478 %R 10.2196/jmir.9816 %U http://www.jmir.org/2018/8/e256/ %U https://doi.org/10.2196/jmir.9816 %U http://www.ncbi.nlm.nih.gov/pubmed/30143478 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e10003 %T Effect and Process Evaluation of a Smartphone App to Promote an Active Lifestyle in Lower Educated Working Young Adults: Cluster Randomized Controlled Trial %A Simons,Dorien %A De Bourdeaudhuij,Ilse %A Clarys,Peter %A De Cocker,Katrien %A Vandelanotte,Corneel %A Deforche,Benedicte %+ Unit Health Promotion and Education, Department of Public Health, Ghent University, Corneel Heymanslaan 10, Entrance 42 (K3), Ghent, 9000, Belgium, 32 498457442, dorien.simons@ugent.be %K mHealth %K mobile apps %K active transport %K Fitbit %K accelerometers %K mobile phone %K emerging adulthood %K physical activity intervention %K health promotion %D 2018 %7 24.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile technologies have great potential to promote an active lifestyle in lower educated working young adults, an underresearched target group at a high risk of low activity levels. Objective: The objective of our study was to examine the effect and process evaluation of the newly developed evidence- and theory-based smartphone app “Active Coach” on the objectively measured total daily physical activity; self-reported, context-specific physical activity; and self-reported psychosocial variables among lower educated working young adults. Methods: We recruited 130 lower educated working young adults in this 2-group cluster randomized controlled trial and assessed outcomes at baseline, posttest (baseline+9 weeks), and follow-up (posttest+3 months). Intervention participants (n=60) used the Active Coach app (for 9 weeks) combined with a Fitbit activity tracker. Personal goals, practical tips, and educational facts were provided to encourage physical activity. The control group received print-based generic physical activity information. Both groups wore accelerometers for objective measurement of physical activity, and individual interviews were conducted to assess the psychosocial variables and context-specific physical activity. Furthermore, intervention participants were asked process evaluation questions and generalized linear mixed models and descriptive statistics were applied. Results: No significant intervention effects were found for objectively measured physical activity, self-reported physical activity, and self-reported psychosocial variables (all P>.05). Intervention participants evaluated the Active Coach app and the combined use with the Fitbit wearable as self-explanatory (36/51, 70.6%), user friendly (40/51, 78.4%), and interesting (34/51, 66.7%). Throughout the intervention, we observed a decrease in the frequency of viewing graphical displays in the app (P<.001); reading the tips, facts, and goals (P<.05); and wearing the Fitbit wearable (P<.001). Few intervention participants found the tips and facts motivating (10/41, 24.4%), used them to be physically active (8/41, 19.6%), and thought they were tailored to their lifestyle (7/41, 17.1%). Conclusions: The lack of significant intervention effects might be due to low continuous user engagement. Advice or feedback that was not perceived as adequately tailored and the difficulty to compete with many popular commercial apps on young people’s smartphones may be responsible for a decrease in the engagement. A stand-alone app does not seem sufficient to promote an active lifestyle among lower educated working young adults; therefore, multicomponent interventions (using both technological and human support), as well as context-specific sensing to provide tailored advice, might be needed in this population. Trial Registration: ClinicalTrials.gov NCT02948803; https://clinicaltrials.gov/ct2/show/results/NCT02948803 (Archived by WebCite at http://www.webcitation.org/71OPFwaoA) %M 30143477 %R 10.2196/10003 %U http://mhealth.jmir.org/2018/8/e10003/ %U https://doi.org/10.2196/10003 %U http://www.ncbi.nlm.nih.gov/pubmed/30143477 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e163 %T A Mobile App (WhiteTeeth) to Promote Good Oral Health Behavior Among Dutch Adolescents with Fixed Orthodontic Appliances: Intervention Mapping Approach %A Scheerman,Janneke Francisca Maria %A van Empelen,Pepijn %A van Loveren,Cor %A van Meijel,Berno %+ Department of Preventive Dentistry, Academic Center for Dentistry Amsterdam, University of Amsterdam and Vrije Universiteit Amsterdam, Gustav Mahlerlaan 3004, Amsterdam, 1081LA, Netherlands, 31 +31614409741, jscheerman@hotmail.com %K health behavior %K mHealth %K oral health %K oral hygiene %K dental caries %K adolescent %K dental plaque %K prevention %K intervention mapping %D 2018 %7 17.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The insertion of fixed orthodontic appliances increases the risk of dental caries, particularly in adolescents. Caries can be prevented through good oral health behavior. To support adolescents with fixed orthodontic appliances and for promoting oral health behavior, we developed a theory- and evidence-based mHealth program, the WhiteTeeth app. Objective: The objective of our paper was to describe the systematic development and content of the WhiteTeeth app. Methods: For systematic development of the program, we used the intervention mapping (IM) approach. In this paper, we present the results of applying the first 5 steps of IM to the design of an mHealth program: (1) identifying target behaviors and determinants through problem analysis, including a literature search, a survey study, and semistructured interviews, to explore adolescent oral health behavior during orthodontic therapy; (2) defining program outcomes and objectives; (3) selecting theoretical methods and translating them into practical strategies for the program design; (4) producing the program, including a pilot test with 28 adolescents testing the acceptability and usability of the WhiteTeeth app; and (5) planning implementation and adoption. Results: On the basis of our literature search, we identified fluoride use and control of dental plaque levels (eg, tooth brushing and proxy brush usage) as target behaviors for preventing caries. Next, we identified important and changeable determinants of oral health behavior that fitted the theoretical concepts of the Health Action Process Approach (HAPA) theory. The HAPA theory, the self-regulation theory, and the results of the semistructured interviews were used to define the program objectives, that is, the performance and change objectives. After defining the objectives, we identified multiple behavior change techniques that could be used to achieve these objectives, such as providing oral health information and feedback, prompting self-monitoring, coaching of set actions and coping plans, and sending reminders. We translated these methods into practical strategies, such as videos and a brushing timer. Next, we combined these strategies into a single program resulting in the WhiteTeeth app (which is available on both iTunes and Google Play stores as “Witgebit”). Adolescents with fixed orthodontic appliances and dental professionals were included in the development process to increase the success of implementation. The pilot test revealed that the app users appreciated and liked the app. The WhiteTeeth app can be integrated into current orthodontic care. Conclusions: IM allowed us to identify multiple techniques that have been shown to be the most effective in initiating behavior change, but have not yet been incorporated into existing orthodontic apps. The WhiteTeeth app contains all these techniques, which makes it a unique and promising home-based app for promoting oral health in adolescents with fixed orthodontic appliances. %M 30120085 %R 10.2196/mhealth.9626 %U http://mhealth.jmir.org/2018/8/e163/ %U https://doi.org/10.2196/mhealth.9626 %U http://www.ncbi.nlm.nih.gov/pubmed/30120085 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e10976 %T A Face-Aging App for Smoking Cessation in a Waiting Room Setting: Pilot Study in an HIV Outpatient Clinic %A Brinker,Titus Josef %A Brieske,Christian Martin %A Esser,Stefan %A Klode,Joachim %A Mons,Ute %A Batra,Anil %A Rüther,Tobias %A Seeger,Werner %A Enk,Alexander H %A von Kalle,Christof %A Berking,Carola %A Heppt,Markus V %A Gatzka,Martina V %A Bernardes-Souza,Breno %A Schlenk,Richard F %A Schadendorf,Dirk %+ National Center for Tumor Diseases, Department of Translational Oncology, German Cancer Research Center, Im Neuenheimer Feld 460, Heidelberg, 69120, Germany, 49 15175084347, titus.brinker@nct-heidelberg.de %K face aging %K smoking cessation %K HIV %K mobile apps %K HIV patients %K HIV seropositivity %K smoking %K cessation %K tobacco smoking %K morphing %D 2018 %7 15.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: There is strong evidence for the effectiveness of addressing tobacco use in health care settings. However, few smokers receive cessation advice when visiting a hospital. Implementing smoking cessation technology in outpatient waiting rooms could be an effective strategy for change, with the potential to expose almost all patients visiting a health care provider without preluding physician action needed. Objective: The objective of this study was to develop an intervention for smoking cessation that would make use of the time patients spend in a waiting room by passively exposing them to a face-aging, public morphing, tablet-based app, to pilot the intervention in a waiting room of an HIV outpatient clinic, and to measure the perceptions of this intervention among smoking and nonsmoking HIV patients. Methods: We developed a kiosk version of our 3-dimensional face-aging app Smokerface, which shows the user how their face would look with or without cigarette smoking 1 to 15 years in the future. We placed a tablet with the app running on a table in the middle of the waiting room of our HIV outpatient clinic, connected to a large monitor attached to the opposite wall. A researcher noted all the patients who were using the waiting room. If a patient did not initiate app use within 30 seconds of waiting time, the researcher encouraged him or her to do so. Those using the app were asked to complete a questionnaire. Results: During a 19-day period, 464 patients visited the waiting room, of whom 187 (40.3%) tried the app and 179 (38.6%) completed the questionnaire. Of those who completed the questionnaire, 139 of 176 (79.0%) were men and 84 of 179 (46.9%) were smokers. Of the smokers, 55 of 81 (68%) said the intervention motivated them to quit (men: 45, 68%; women: 10, 67%); 41 (51%) said that it motivated them to discuss quitting with their doctor (men: 32, 49%; women: 9, 60%); and 72 (91%) perceived the intervention as fun (men: 57, 90%; women: 15, 94%). Of the nonsmokers, 92 (98%) said that it motivated them never to take up smoking (men: 72, 99%; women: 20, 95%). Among all patients, 102 (22.0%) watched another patient try the app without trying it themselves; thus, a total of 289 (62.3%) of the 464 patients were exposed to the intervention (average waiting time 21 minutes). Conclusions: A face-aging app implemented in a waiting room provides a novel opportunity to motivate patients visiting a health care provider to quit smoking, to address quitting at their subsequent appointment and thereby encourage physician-delivered smoking cessation, or not to take up smoking. %M 30111525 %R 10.2196/10976 %U http://www.jmir.org/2018/8/e10976/ %U https://doi.org/10.2196/10976 %U http://www.ncbi.nlm.nih.gov/pubmed/30111525 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e165 %T Correlations Between Objective Behavioral Features Collected From Mobile and Wearable Devices and Depressive Mood Symptoms in Patients With Affective Disorders: Systematic Review %A Rohani,Darius A %A Faurholt-Jepsen,Maria %A Kessing,Lars Vedel %A Bardram,Jakob E %+ Embedded Systems Engineering, Department of Applied Mathematics and Computer Science, Technical University of Denmark, Richard Petersens Plads, Bldg 324, 1st Floor, Room 160, Kongens Lyngby, 2800, Denmark, 45 61452393, daroh@dtu.dk %K mood disorder %K affective disorder %K depression %K depressive mood symptoms %K bipolar disorder %K objective features %K correlation %K behavior %K sensor data %K mobile phone %K wearable devices %K systematic review %D 2018 %7 13.08.2018 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Several studies have recently reported on the correlation between objective behavioral features collected via mobile and wearable devices and depressive mood symptoms in patients with affective disorders (unipolar and bipolar disorders). However, individual studies have reported on different and sometimes contradicting results, and no quantitative systematic review of the correlation between objective behavioral features and depressive mood symptoms has been published. Objective: The objectives of this systematic review were to (1) provide an overview of the correlations between objective behavioral features and depressive mood symptoms reported in the literature and (2) investigate the strength and statistical significance of these correlations across studies. The answers to these questions could potentially help identify which objective features have shown most promising results across studies. Methods: We conducted a systematic review of the scientific literature, reported according to the preferred reporting items for systematic reviews and meta-analyses guidelines. IEEE Xplore, ACM Digital Library, Web of Sciences, PsychINFO, PubMed, DBLP computer science bibliography, HTA, DARE, Scopus, and Science Direct were searched and supplemented by hand examination of reference lists. The search ended on April 27, 2017, and was limited to studies published between 2007 and 2017. Results: A total of 46 studies were eligible for the review. These studies identified and investigated 85 unique objective behavioral features, covering 17 various sensor data inputs. These features were divided into 7 categories. Several features were found to have statistically significant and consistent correlation directionality with mood assessment (eg, the amount of home stay, sleep duration, and vigorous activity), while others showed directionality discrepancies across the studies (eg, amount of text messages [short message service] sent, time spent between locations, and frequency of mobile phone screen activity). Conclusions: Several studies showed consistent and statistically significant correlations between objective behavioral features collected via mobile and wearable devices and depressive mood symptoms. Hence, continuous and everyday monitoring of behavioral aspects in affective disorders could be a promising supplementary objective measure for estimating depressive mood symptoms. However, the evidence is limited by methodological issues in individual studies and by a lack of standardization of (1) the collected objective features, (2) the mood assessment methodology, and (3) the statistical methods applied. Therefore, consistency in data collection and analysis in future studies is needed, making replication studies as well as meta-analyses possible. %M 30104184 %R 10.2196/mhealth.9691 %U http://mhealth.jmir.org/2018/8/e165/ %U https://doi.org/10.2196/mhealth.9691 %U http://www.ncbi.nlm.nih.gov/pubmed/30104184 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 8 %P e10130 %T Using Mobile Apps to Assess and Treat Depression in Hispanic and Latino Populations: Fully Remote Randomized Clinical Trial %A Pratap,Abhishek %A Renn,Brenna N %A Volponi,Joshua %A Mooney,Sean D %A Gazzaley,Adam %A Arean,Patricia A %A Anguera,Joaquin A %+ Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, UW Medicine South Lake Union, Building C, Box 358047, 850 Republican Street, Seattle, WA, 98109, United States, 1 206 928 8263, apratap@uw.edu %K mobile apps %K smartphone %K depression %K Hispanics %K Latinos %K clinical trial %K cognition %K problem solving %K mHealth %K minority groups %D 2018 %7 09.08.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Most people with mental health disorders fail to receive timely access to adequate care. US Hispanic/Latino individuals are particularly underrepresented in mental health care and are historically a very difficult population to recruit into clinical trials; however, they have increasing access to mobile technology, with over 75% owning a smartphone. This technology has the potential to overcome known barriers to accessing and utilizing traditional assessment and treatment approaches. Objective: This study aimed to compare recruitment and engagement in a fully remote trial of individuals with depression who either self-identify as Hispanic/Latino or not. A secondary aim was to assess treatment outcomes in these individuals using three different self-guided mobile apps: iPST (based on evidence-based therapeutic principles from problem-solving therapy, PST), Project Evolution (EVO; a cognitive training app based on cognitive neuroscience principles), and health tips (a health information app that served as an information control). Methods: We recruited Spanish and English speaking participants through social media platforms, internet-based advertisements, and traditional fliers in select locations in each state across the United States. Assessment and self-guided treatment was conducted on each participant's smartphone or tablet. We enrolled 389 Hispanic/Latino and 637 non-Hispanic/Latino adults with mild to moderate depression as determined by Patient Health Questionnaire-9 (PHQ-9) score≥5 or related functional impairment. Participants were first asked about their preferences among the three apps and then randomized to their top two choices. Outcomes were depressive symptom severity (measured using PHQ-9) and functional impairment (assessed with Sheehan Disability Scale), collected over 3 months. Engagement in the study was assessed based on the number of times participants completed active surveys. Results: We screened 4502 participants and enrolled 1040 participants from throughout the United States over 6 months, yielding a sample of 348 active users. Long-term engagement surfaced as a key issue among Hispanic/Latino participants, who dropped from the study 2 weeks earlier than their non-Hispanic/Latino counterparts (P<.02). No significant differences were observed for treatment outcomes between those identifying as Hispanic/Latino or not. Although depressive symptoms improved (beta=–2.66, P=.006) over the treatment course, outcomes did not vary by treatment app. Conclusions: Fully remote mobile-based studies can attract a diverse participant pool including people from traditionally underserved communities in mental health care and research (here, Hispanic/Latino individuals). However, keeping participants engaged in this type of “low-touch” research study remains challenging. Hispanic/Latino populations may be less willing to use mobile apps for assessing and managing depression. Future research endeavors should use a user-centered design to determine the role of mobile apps in the assessment and treatment of depression for this population, app features they would be interested in using, and strategies for long-term engagement. Trial Registration: Clinicaltrials.gov NCT01808976; https://clinicaltrials.gov/ct2/show/NCT01808976 (Archived by WebCite at http://www.webcitation.org/70xI3ILkz) %M 30093372 %R 10.2196/10130 %U http://www.jmir.org/2018/8/e10130/ %U https://doi.org/10.2196/10130 %U http://www.ncbi.nlm.nih.gov/pubmed/30093372 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 4 %N 3 %P e11203 %T Bringing Real-Time Geospatial Precision to HIV Surveillance Through Smartphones: Feasibility Study %A Nsabimana,Alain Placide %A Uzabakiriho,Bernard %A Kagabo,Daniel M %A Nduwayo,Jerome %A Fu,Qinyouen %A Eng,Allison %A Hughes,Joshua %A Sia,Samuel K %+ Junco Labs, 423 W 127th Street, Ground Floor, New York, NY,, United States, 1 518 880 9667, samuelsia@juncolabs.com %K HIV surveillance %K smartphones %K mobile phones %K geospatial data %D 2018 %7 07.08.2018 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Precise measurements of HIV incidences at community level can help mount a more effective public health response, but the most reliable methods currently require labor-intensive population surveys. Novel mobile phone technologies are being tested for adherence to medical appointments and antiretroviral therapy, but using them to track HIV test results with automatically generated geospatial coordinates has not been widely tested. Objective: We customized a portable reader for interpreting the results of HIV lateral flow tests and developed a mobile phone app to track HIV test results in urban and rural locations in Rwanda. The objective was to assess the feasibility of this technology to collect front line HIV test results in real time and with geospatial context to help measure HIV incidences and improve epidemiological surveillance. Methods: Twenty health care workers used the technology to track the test results of 2190 patients across 3 hospital sites (2 urban sites in Kigali and a rural site in the Western Province of Rwanda). Mobile phones for less than US $70 each were used. The mobile phone app to record HIV test results could take place without internet connectivity with uploading of results to the cloud taking place later with internet. Results: A total of 91.51% (2004/2190) of HIV test results could be tracked in real time on an online dashboard with geographical resolution down to street level. Out of the 20 health care workers, 14 (70%) would recommend the lateral flow reader, and 100% would recommend the mobile phone app. Conclusions: Smartphones have the potential to simplify the input of HIV test results with geospatial context and in real time to improve public health surveillance of HIV. %M 30087088 %R 10.2196/11203 %U http://publichealth.jmir.org/2018/3/e11203/ %U https://doi.org/10.2196/11203 %U http://www.ncbi.nlm.nih.gov/pubmed/30087088 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e10131 %T Using Mobile Phone Sensor Technology for Mental Health Research: Integrated Analysis to Identify Hidden Challenges and Potential Solutions %A Boonstra,Tjeerd W %A Nicholas,Jennifer %A Wong,Quincy JJ %A Shaw,Frances %A Townsend,Samuel %A Christensen,Helen %+ Black Dog Institute, University of New South Wales, Hospital Road, Sydney,, Australia, 61 2 9382 9285, t.boonstra@unsw.edu.au %K passive sensing %K mental health %K ubiquitous computing %K ethics %K depression %K mobile health %K smartphone %K wearable sensors %D 2018 %7 30.07.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile phone sensor technology has great potential in providing behavioral markers of mental health. However, this promise has not yet been brought to fruition. Objective: The objective of our study was to examine challenges involved in developing an app to extract behavioral markers of mental health from passive sensor data. Methods: Both technical challenges and acceptability of passive data collection for mental health research were assessed based on literature review and results obtained from a feasibility study. Socialise, a mobile phone app developed at the Black Dog Institute, was used to collect sensor data (Bluetooth, location, and battery status) and investigate views and experiences of a group of people with lived experience of mental health challenges (N=32). Results: On average, sensor data were obtained for 55% (Android) and 45% (iOS) of scheduled scans. Battery life was reduced from 21.3 hours to 18.8 hours when scanning every 5 minutes with a reduction of 2.5 hours or 12%. Despite this relatively small reduction, most participants reported that the app had a noticeable effect on their battery life. In addition to battery life, the purpose of data collection, trust in the organization that collects data, and perceived impact on privacy were identified as main factors for acceptability. Conclusions: Based on the findings of the feasibility study and literature review, we recommend