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Latest Submissions Open for Peer Review

JMIR has been a leader in applying openness, participation, collaboration and other "2.0" ideas to scholarly publishing, and since December 2009 offers open peer review articles, allowing JMIR users to sign themselves up as peer reviewers for specific articles currently considered by the Journal (in addition to author- and editor-selected reviewers).

For a complete list of all submissions across all JMIR journals as well as partner journals, see JMIR Preprints

Note that this is a not a complete list of submissions as authors can opt-out. The list below shows recently submitted articles where submitting authors have not opted-out of open peer-review and where the editor has not made a decision yet. (Note that this feature is for reviewing specific articles - if you just want to sign up as reviewer (and wait for the editor to contact you if articles match your interests), please sign up as reviewer using your profile).

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JMIR Submissions under Open Peer Review

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Titles/Abstracts of Articles Currently Open for Review:

  • Background: This study explores the integration of 'Bioceramic Resonance and Photoluminescence' (BR&PLB) with a Visual/Auditory Thematic Stimulation System (VASS) to address stress, mental imbalances, and altered states. Objective: Against Taiwan's evolving economic landscape, conventional medical systems often struggle to address health complexities. Methods: The material and methods section elucidates BIOCERAMIC technology's biophysical effects and PLB development, highlighting VASS's use with thematic stimuli for enhancement. Twenty-five participants, aged 18 to 80, sought relief from pain, emotional distress, or desired self-awareness. Results: The experimental protocol involved BR&PLB with VASS exposure, assessing improvements in physical, emotional, and consciousness states. Statistical analyses revealed reductions in pain and anxiety, with consciousness level increases post-exposure. Conclusions: Discussion integrates prior research, emphasizing technology's impact on altered consciousness and therapeutic potential for mental health. Insights from emotional problems, drug withdrawal, and extrasensory perception studies add to understanding. Comparisons with virtual reality studies highlight BR&PLB and VASS integration advantages. This approach shows promise for reducing pain, stress, anxiety, and enhancing consciousness levels, though further research is needed for validation. Combining BR&PLB with VASS could be a significant pathway to overall well-being. The integration of BR&PLB with VASS demonstrates stress reduction, anxiety alleviation, and heightened consciousness levels. This approach emerges as a valuable intervention for comprehensive well-being, requiring larger-scale studies for validation. The exploration positions it as a noteworthy pathway in holistic well-being pursuit. Considered within the ‘States of Consciousness Questionnaire’ framework, the integrated approach facilitates physical improvement, emotional well-being, and nuanced consciousness shifts, offering a holistic perspective and emphasizing multifaceted benefits. Clinical Trial: The study protocol received approval from the Human Subjects Committee (approval no.: TYGH111092) of Taoyuan General Hospital

  • Background: Smartphone overuse is associated with both psychological and physical health problems, including depression and musculoskeletal disorders. However, the association between smartphone overuse and neck pain remains unclear. Objective: We performed a meta-analysis to examine the relation between smartphone overuse and neck pain, and to identify high-risk usage patterns. Methods: PubMed, Embase and Cochrane CENTRAL databases were searched for relevant studies published up to August 16, 2023, using keywords including "smartphone" and "neck pain". Prospective, retrospective, and case-controlled studies assessing the correlation between smartphone overuse and neck pain were eligible. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. Meta-regression and sensitivity analysis using the leave-one-out approach were performed to test the robustness of the results. Results: Seven retrospective studies including 10,715 participants were included in the systematic review and meta-analysis. The mean age of the participants ranged from 19.9 to 42.9 years. The meta-analysis revealed that compared to participants without smartphone overuse, those who overused a smartphone had a significantly higher risk of neck pain (pooled adjusted odds ratio [aOR] = 2.34, 95% CI: 1.44-3.82). A significant correlation between increasing age and higher ORs for neck pain was found (coefficient = 0.051, P < 0.001). Conclusions: These results indicate a significant association between smartphone overuse and increased risk of neck pain, with risk escalating with age. Our findings underscore the necessity of addressing smartphone overuse as a health concern, especially considering its growing prevalence in modern society.

  • Use of chatGPT to explore gender and geographic disparities in scientific peer review

    Date Submitted: Feb 22, 2024
    Open Peer Review Period: Feb 26, 2024 - Apr 22, 2024

    This study used ChatGPT 4.0 to assess sentiment and politeness in 291 peer review reports across nine general medical journals. While no gender-based differences were found, notable regional disparities were observed, with articles from the Middle East, Latin America, and Africa receiving significantly lower scores. These findings underscore broader issues of inclusivity in peer review processes, particularly for researchers from regions facing systemic challenges in academic publishing.

  • Background: Cancer survivors face various challenges but also demonstrate resilience and find ways to adapt and cope with life after cancer. Self-efficacy and patient activation are two crucial factors that significantly impact the well-being of cancer survivors. These concepts play a vital role in enabling cancer survivors to take control of their health, manage their treatment effectively, and achieve positive long-term outcomes. Objective: The aim of this study is to assess the impact of a mobile health system (mHealthApp) to improve the self-efficacy and patient activation of breast cancer and colorectal cancer survivors. Methods: This study presents the findings from clinical trials conducted according to the published study protocol of the PERSIST project that was funded by European Commision to support cancer survivors using digital health technologies. The acceptability and usability of the mHealthApp, as well as the perceived self-efficacy and satisfaction with care, were assessed using validated tools such as CASE-cancer, PAM, and SUS. Results: The results indicate that the PERSIST project partially achieved its predefined objectives and hypotheses by enhancing the self-confidence and satisfaction of cancer survivors with healthcare and improving the effectiveness of cancer treatment and follow-up procedures to some extent. Conclusions: The PERSIST project demonstrates the potential to improve clinical outcomes, empower patients, and contribute to broader social goals in cancer survivorship. However, larger studies involving a more diverse patient population and a greater number of clinicians are necessary to establish the effectiveness of digital therapies in cancer survivorship care and to provide additional data and evidence.

  • Can we predict snacking behaviour just from previous instances?

    Date Submitted: Feb 20, 2024
    Open Peer Review Period: Feb 23, 2024 - Apr 19, 2024

    Background: Consuming too much food or drink with high levels of saturated fats, salt or sugar can be harmful for health. Many snack foods fall into this category (HFSS snacks). However, the palatability of these snacks means that people can sometimes struggle to reduce their intake. Machine learning algorithms could help by predicting the likely occurrence of HFSS snacking, so that just-in-time adaptive (JITAI) interventions can be deployed. However, HFSS snacking data has characteristics (such as sparseness and incompleteness), which make snacking prediction a challenging machine learning problem. Previous attempts have employed several potential predictor variables, achieving considerable success. Nevertheless, collecting information along several dimensions requires several potentially burdensome user questionnaires per day, so that this approach may be less acceptable among the general public. Objective: Our aim is to consider the capacity of machine learning algorithms to predict HFSS snacking based on minimal data that can be collected in a mostly automated way: day of week, time of day, and location (coarsened as work, home, other). Methods: A sample of 111 participants in the UK were asked to record HFSS snack occurrences and location category, over a period of 28 days, leading to a new dataset on HFSS snacks. Data collection was facilitated by a purpose-specific app. Additionally, we use a similar dataset from the Netherlands. For both datasets, we employ machine learning methods (random forests and neural networks). Results: We report results concerning the ability of machine learning methods to predict the time of the next HFSS snack. The quality of the prediction depended on both the dataset and temporal resolution employed. In some cases, predictions were accurate to as few as 17 minutes on average. Conclusions: We demonstrated that prediction of HFSS snacks on sparse data is possible to reasonable accuracy. We consider the type of prediction problem which may be most suitable for putative interventions in relation to HFSS snacking. While we think it was important to employ standard machine learning algorithms in this work, we also discuss ways to tailor both the machine learning algorithms and the prediction problem to better align with the unique characteristics of the problem.

  • Empowering Community Health Workers with Scripted Medicine: A Design Science Research Study

    Date Submitted: Feb 20, 2024
    Open Peer Review Period: Feb 23, 2024 - Apr 19, 2024

    Background: The WHO anticipates a shortage of 14 million health workers by 2030, particularly affecting the Global South. Community health workers (CHWs) may mitigate the shortages of professional healthcare workers. Recent studies explore the feasibility and effectiveness of shifting non-communicable disease (NCD) services to CHWs. Challenges such as high attrition rates and variable performance persist due to inadequate organizational support and could hamper such efforts. Research on employee empowerment highlights how organizational structures affect employees’ perception of empowerment and retention. Objective: Collaboration engineering research offers insights that could help address the structural issues in community-based healthcare and facilitate task-shifting. This study aims to develop Scripted Medicine to empower CHWs to accept broader responsibilities in NCD care. Its objective is to convey relevant medical and counseling knowledge through medical algorithms and ThinkLets (i.e., social scripts). Methods: This study follows a design science research approach to implement a mHealth-supported community-based intervention in two districts of Lesotho. We first develop the medical algorithms and ThinkLets based on insights from collaboration engineering and algorithmic management literature. We then evaluate the designed approach in a field study in the ComBaCaL project. The field study includes ten newly recruited CHWs and spans over two weeks of training and 12 weeks of field experience. <> Following an abductive approach, we analyzed surveys, interviews, and observations to study how Scripted Medicine empowers CHWs to accept broader responsibilities in NCD care. Results: Scripted Medicine successfully conveys the required medical and counseling knowledge through medical algorithms and ThinkLets. We find that medical algorithms predominantly influence CHWs’ perception of structural empowerment, while ThinkLets affect their psychological empowerment. The different perceptions between the groups of CHWs from the two districts highlight the importance of considering the cultural and economic context. Conclusions: We propose Scripted Medicine as a novel approach to CHW empowerment inspired by collaboration engineering and algorithmic management. Scripted Medicine broadens the perspective on mHealth-supported community-based healthcare. It emphasizes the need to “script” not only essential medical knowledge but also “script” counseling expertise. These scripts allow CHWs to embed medical knowledge into the social interactions in community-based healthcare. Scripted Medicine empowers CHW to accept broader responsibilities to address the imminent shortage of medical professionals in the Global South.

  • Background: Osteoarthritis (OA) is more prevalent and severe among women compared to men, but women are less likely to access early diagnosis and first-line management, particularly racialized immigrant women. Prior research advocated for greater access to culturally-safe OA information for both diverse women and healthcare professionals. The Internet can reduce disparities by facilitating access to health information, but online materials can vary in quality. Objective: We aimed to assess the quality and cultural safety of online OA materials for persons affected by OA and healthcare professionals. Methods: We employed content analysis to describe publicly-available materials on OA first-line management developed by Canadian organizations for affected persons or healthcare professionals. Searching, screening and data extraction were done in triplicate. We identified materials by searching Google, MEDLINE and the references of OA-relevant guidelines and policies, and consulting our research team and collaborators. We assessed quality using DISCERN and a compiled framework for affected persons and healthcare professionals, respectively. We compiled frameworks to assess cultural safety. We derived an overall score, categorized as low (<50%), moderate (50% to 69%) or high (≥70%+) for criteria met. Results: After screening 176 items and eliminating 129, we included 47 OA materials published between 2013 and 2023. Of those, 43 were for persons with OA. Most were developed by charities (31, 72.1%), based on expert advice (16, 55.2%), and in the format of booklets (15, 34.9%) or text on web pages (10, 23.3%). Of those, 10 (23.3%), 20 (46.5%) and 13 (30.2%) scored low, moderate and high for quality; and 11 (25.6%), 21 (48.8%) and 11 (25.6%) were rated low, moderate and high cultural safety, respectively. Of the 47 included OA materials, 4 were for healthcare professionals. They were developed by a consortium (2, 50.0%), charity (1, 25.0%) and a professional society (1, 25.0%), and largely based on expert advice (3, 75.0%). Format included infographics (3, 75.0%) and text on web pages (1, 25.0%). Of those, 1 (25.0%), 1 (25.0%) and 2 (50.0%) were rated low, moderate and high quality, respectively; and all were rated low for cultural safety. Quality and cultural safety did not appear to be associated with OA material characteristics (e.g. type of developer, development method, format). Conclusions: Overall, included OA materials for persons affected by OA and healthcare professionals were low to moderate quality and cultural safety. These findings reveal the need for further efforts to improve existing or develop new OA materials for both affected persons, including ethno-culturally diverse immigrant women, and healthcare professionals. Further research is needed to assess the quality and cultural safety of OA materials developed by organizations outside of Canada, and to establish a framework or instrument to assess cultural safety in the OA context.

  • Training service users in the use of telehealth: a scoping review

    Date Submitted: Feb 23, 2024
    Open Peer Review Period: Feb 23, 2024 - Apr 19, 2024

    Background: The use of telehealth has rapidly increased, yet some populations may be disproportionally excluded from accessing and using this modality of care. Training service users in telehealth may increase accessibility for certain groups. The extent and nature of these training activities has not been explored. Objective: The objective of this scoping review is to identify and describe activities for training service users in the use of telehealth. Methods: Five databases (MEDLINE (via PubMed), Embase, CINAHL, PsycINFO, and Web of Science) were searched in June 2023. Studies of adult populations, including caregivers, and studies that described activities to train service users in the use of synchronous telehealth consultations were eligible for inclusion. Studies that focused on healthcare professional education were excluded. Articles were limited to those published in the English language. The review followed the Joanna Briggs Institute (JBI) guidelines for scoping reviews and is reported in line with the PRISMA-ScR guidelines. Titles and abstracts were screened by one reviewer. Full texts were screened by two reviewers. Data extraction was guided by the research question. Results: The search identified 8087 unique publications. Thirteen studies met the inclusion criteria. Telehealth training was commonly described as once-off pre-telehealth visit phone calls to service users, facilitated primarily by student volunteers, accompanied by written instructions. The training content included how to download and install software, troubleshooting, and adjusting device settings. Older adults were the most common target population for the training. All but one of the studies were conducted during the COVID-19 pandemic. Overall, training was feasible and well-received by service users, and studies mostly reported increased rates of video visits following training. There was limited evidence that training improved participants’ competency with telehealth. Conclusions: The review mapped the literature on training activities for service users in telehealth. The common features of telehealth training for service users included once-off preparatory phone calls on the technical elements of telehealth, targeted at older adults. Key issues for consideration include the need for co-designed training and improving broader digital skills of service users. There is a need for further studies to evaluate outcomes of telehealth training activities in geographically-diverse areas.

  • Background: Abstract Background: Patient consultations in general practice are undergoing a digital transformation, embracing diverse modalities such as video, text-based, and telephone consultations. The quality of communication in medical consultations is pivotal for successful outcomes, necessitating a comprehensive assessment of the impact on the doctor-patient communication and interaction following this transformation. Objective: Objective: To explore how the communication between Norwegian contract GPs and patients has been affected by the large-scale implementation of remote consultations following the Covid-19 pandemic. Methods: Methods: Five focus groups, comprising 18 GPs strategically recruited from diverse geographical regions in Norway, were convened in 2022. We applied thematic analysis, guided by the framework proposed by Braun and Clarke. Results: Results: Six themes resulted from the analysis. First, suitability regarding remote communication is context dependent: knowing the characteristics of the patient as a person and the clinical relationship is more important than the reason for contact or type of health problem - even more so than during ordinary physical consultations. Second, remote consultations favour a demarcated communication style, “keeping simple things simple,” that can increase work effectiveness. Third, a downside of such effective minimalism is that uncritical use of remote consultations may undermine quality of care. Communication becomes too transactional, limiting the chances of addressing more implicit and complex issues, with the risk of missing vital information. Fourth, remote consultations can facilitate establishment of alliances with patients who find it easier to open sensitive topics by distance than in a physical encounter. Fifth, GPs make communicative compromises to be able to maintain relationships with patients they see as vulnerable or fugitive. Finally, text-based consultations offer benefits such as multimedia-enabled patient expression and sharing of digital information. Nevertheless, concerns include risk of information loss through triage errors, managing informal language, and ending chat-like interactions between patients and doctors. Conclusions: Conclusion and implications: The implementation of remote consultations introduces a spectrum of effects on clinical interaction and communication, evoking issues of trust, risk and power. While these modalities can enhance efficiency, there is a discernible risk of compromised retrieval of essential information and unvoiced problems, potentially resulting in unintended consequences. The preservation of continuity of care emerges as a pivotal strategy to mitigate some of these challenges. Clinical Trial: Approval was obtained from the Norwegian Center for Research Data (reference: 531672).

  • Parental Technoference and Child Problematic Media Use: A Meta-analysis

    Date Submitted: Feb 23, 2024
    Open Peer Review Period: Feb 23, 2024 - Apr 19, 2024

    Background: The phenomenon of parental technoference, where parents' use of technology interrupts family interactions, has been suggested to influence children's media habits negatively. However, the extent of this relationship and its implications for child problematic media use remains unclear. Objective: To systematically examine the relationship between parental technoference and child problematic media use, and to identify moderating factors such as age, parental technoference group, and type of problematic media use that could influence this relationship. Methods: Following the PRISMA guidelines, a systematic literature search was conducted to identify studies published before October 2023 that explored the relationship between parental technoference and child problematic media use. Forty-two studies comprising 47,212 participants (mean age 13.37 years) were included. A random-effects meta-analysis was performed to assess the association between parental technoference and child problematic media use, and moderation analyses were conducted to explore the effects of age, parental technoference group, and type of problematic media use. Results: The meta-analysis revealed a positive association between parental technoference and child problematic media use (r = 0.282, 95% CI = [0.250, 0.313]). Age, parental technoference group, and type of problematic media use significantly moderated this relationship. The association was stronger with increasing age of the child, when both parents engaged in technoference as opposed to only one, and for children's general problematic media use compared to specific problematic media use. Conclusions: The findings underscore the significant impact of parental technoference on child problematic media use, highlighting the need for increased awareness and targeted interventions to mitigate its effects. Addressing parental technoference could play a crucial role in preventing problematic media use among children, thereby supporting healthier developmental outcomes and mental health.

  • #Chronicillness, Posts with Medical Content Receive More Attention on Instagram: Content Analysis

    Date Submitted: Feb 19, 2024
    Open Peer Review Period: Feb 22, 2024 - Apr 18, 2024

    Background: Social media is an integral part of modern life in which people connect, learn, and share. The content shared on social media can drive behavior change as people, especially adolescents, seek to gain or maintain popularity. #Chronicillness is a rising trend on social media, yet the content and attention it garners remain poorly understood. Objective: This study aimed to analyze Instagram posts related to chronic illness by examining their content and assessing if posts with medical-related content received greater attention. Methods: To study individuals with chronic illness, publicly available Instagram posts were searched for hashtags related to chronic illness. We used a mixed-methods approach which included qualitative analysis of captions, hashtags, and photos for medical conditions, locations, and presence of medical equipment, alongside quantitative analysis to examine the relationship between medical content and attention. Multivariate analyses were performed to determine the odds of medical content Overperforming, a proxy measure for attention. Results: Content analysis of 279 posts revealed caption themes including Medical Experiences, Illness Journey, Connection, and Non-illness Experiences. Among the posts, 97 (35%) included medical content, 52 (19%) featured advertisements, and 10 (4%) depicted invasive medical equipment. Hashtags covered a wide range of 107 different conditions. Posts with medical content exhibited significantly higher odds of overperforming (OR 1.85; 95% CI: 1.01, 3.42), as did posts with photos containing invasive medical equipment (OR 6.19; 95% CI: 1.16, 32.99). Conclusions: Our findings underscore the potential reinforcing effect of sharing medical information on Instagram, the inadvertent promotion of invasive medical procedures as visible signs of illness, and the possibility of adolescents mimicking this attention-generating content. It is crucial to implement strategies for fostering positive and informed interactions within online communities, and to address the potential risks associated with overmedicalization, misinformation, and the commodification of health experiences.

  • Background: Ward rounds are an essential component of inpatient care. Patient participation in rounds is increasingly encouraged, despite the occasional complicated circumstances, especially in acute care settings. Objective: This study aimed to evaluate the effect of real-time ward round notifications using text messaging on the satisfaction of inpatients in an acute medical ward. Methods: Since January 2021, a service implementing real-time ward round notifications via text messaging (WR-SMS) has been operational at a tertiary-care medical center in Korea. To assess its effect on the satisfaction of patients who had been admitted to the acute medical unit and participated in the Seoul National University Bundang Hospital (SNUBH) patient-experience survey during 2020-2021, we conducted a retrospective cohort study. We assessed the satisfaction of the participants based on the SNUBH patient experience survey results and compared the scores from 2020 (before WR-SMS implementation, 2020 group) with those of 2021 (after WR-SMS implementation, 2021 group). Results: From January 2020 to December 2021, a total of 100 patients were enrolled (53 patients in the 2020 group, and 47 patients in the 2021 group). Compared with the 2020 group, the 2021 group showed significantly greater satisfaction about being informed about round schedules (3.43 ± 0.910 vs 3.89 ± 0.375, P < .001) and felt more emotionally supported during admission (3.49 ± 0.800 vs 3.87 ± 0.397, P < .001). Regarding other questionnaire scores, the 2021 group showed an overall, although statistically insignificant, improvement compared to the 2020 group. Conclusions: Real-time round notifications using a user-friendly short message service may improve inpatient satisfaction effectively.

  • Assessing the Impact of Telemedicine Interventions on Health Care Costs and Utilization: A Scoping Review

    Date Submitted: Feb 15, 2024
    Open Peer Review Period: Feb 16, 2024 - Apr 12, 2024

    Background: The utilization of telemedicine has increased notably since the onset of the pandemic. Understanding the influence of telemedicine on health care costs and utilization can contribute to the monitoring and evaluation of telemedicine programs. Objective: This scoping review aimed to document the potential impact of telemedicine on health care costs and utilization across diverse health care contexts and to offer a summary of the statistical methodological approaches employed in assessing the impact of telemedicine on health care costs and utilization. Methods: A literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews guidelines, spanning the last 10 years across 3 electronic databases: PubMed/Medline, Web of Science, and Scopus. The search strategy was in accordance with the PICO criteria; patients were defined as the target population; telehealth or telemedicine was defined as the intervention; and standard care or before-and-after self-comparison was defined as the comparison, with health care costs and utilization as the outcome measures. Additionally, the six different structural layers of the TOAST framework for telehealth services were utilized to characterize the interventions. The findings were synthesized and are presented in tables and figures for clarity. Results: Out of a total of 4,454 identified articles, 14 were selected for review, with approximately 36% (n=5) focusing on chronic conditions. The delivery modalities included telephone call, videoconference, web portal, and smartphone applications, mainly spanning teleconsultation, telemonitoring, and teletherapy with clinicians and nursing support or health care team involvement. Approximately 86% of the studies employed standard face-to-face clinical visits for the control group. Six out of the 12 studies evaluating health care costs and four out of the seven studies assessing health care utilization revealed statistically significant improvements in telehealth compared to the control group. In addition, approximately 43% of the studies conducted univariate and multivariable analyses, with half of the studies incorporating adjusted analyses to control for confounding variables. Conclusions: Our scoping review suggested that, in the treatment phase, compared with standard face-to-face clinical visits, telemedicine has the potential to decrease health care costs and optimally utilize health resources. Additionally, a regression model was the most commonly used statistical approach for assessing the impact of telemedicine.

  • Exploring TikTok Mental Health Content in Current Literature: A Scoping Review

    Date Submitted: Feb 13, 2024
    Open Peer Review Period: Feb 15, 2024 - Apr 11, 2024

    Background: The rise of social media platforms has introduced novel avenues for individuals to express and share their experiences, including those related to mental health. Among these platforms, TikTok has emerged as a popular medium for content creation and dissemination. However, studies have revealed concerns regarding the accuracy and quality of content information alongside users’ tendency to self-diagnose mental health issues. Objective: This scoping review aimed to provide an overview of the current literature exploring TikTok's mental health content. Specifically, we pursued 3 objectives: (1) identify TikTok mental health topics explored in current literature; (2) research methods employed; and (3) gaps and areas for further research. Methods: A systematic search of electronic databases involving SCOPUS, ScienceDirect, PubMed, and Web of Science were conducted to identify relevant studies published within 2019-2023. Subsequently, a Google Scholar search was conducted as a secondary database to identify relevant additional studies. This review was guided by Arksey and O’Malley’s methodological framework for scoping review. Results were reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Results: Out of 7,919 articles, 18 were included in this review consisting of 16 primary studies, 1 systematic review study, and 1 preliminary study. Most of the studies identified from database search were excluded as they did not explore mental health content on TikTok. Topics explored in reviewed studies were mainly general mental health content (n=5), followed by eating disorders (n=3), dementia (n=2), anxiety (n=2), and ADHD (n=2). Some studies explored specific topics such psychiatric hospitalization experiences (n=1), substance abuse (n=1), autism (n=1), and common mental illnesses (n=1). 17 studies were cross-sectional except for 1 that conducted an intervention study. Common research design used was content analysis (n=9) followed by thematic analysis (n=3). Other designs identified were discourse analysis (n=1), online ethnography (n=1), within-subject field experiment (n=1), semi-structured interview (n=1), and survey (n=1). Conclusions: It is evident that there remains a notable gap in comprehensive research in this burgeoning field. The limited number of identified studies underscores the need for further exploration and investigation. Critical aspects, such as the long-term effects of exposure to mental health content on TikTok, the platform's role in shaping attitudes toward mental health and its treatment, and the diversity of perspectives within the user community warrant further exploration.

  • Outcomes of a Comprehensive Mobile Vaping Cessation Program in Adults Who Vape Daily: Cohort Study

    Date Submitted: Feb 14, 2024
    Open Peer Review Period: Feb 14, 2024 - Feb 29, 2024

    Background: In the United States, e-cigarettes, or vapes, are the second most-commonly used tobacco product. Despite abundant smartphone app-based cigarette cessation programs, there are few such programs for vaping and even less supporting data. Objective: This initial evaluation of the Pivot vaping cessation program aimed to assess participant engagement and retention, changes in attitudes toward quitting vaping, changes in vaping behavior, and participant feedback. Methods: U.S. adults aged ≥ 21 years who vape daily, report ≥ 5 vape sessions per day, and plan to quit vaping in the next 6 months were recruited online. Participants completed an online screening form, screening call, electronic informed consent, registration, and onboarding before beginning Pivot. Data were self-reported via app and web-based questionnaires. Outcomes focused on engagement and retention (i.e., weeks in the program, number of Pivot app openings, number of messages sent to coach); vaping attitudes (i.e., success to quit [STQ], difficulty to stay quit [DTQ]); vaping behavior (i.e., quit attempts, Penn State Electronic Cigarette Dependence Index [PSECDI], 7- and 30-day point prevalence abstinence [PPA], continuous abstinence [defined as ≥ 7-day PPA at 12 weeks + 30-day PPA at 26 weeks + 0 vaping sessions since 12 weeks]); and participant feedback. Results: Seventy-three participants completed onboarding (intention-to-treat [ITT] sample); 68/73 (93%) completed the 12- and 26-week questionnaires (completer samples). On average, participants were active in Pivot for 13.8 (SD 7.3) weeks, had 71.3 (SD 79.7) app sessions, and sent 37.6 (SD 42.3) messages to their coach over 26 weeks. STQ and DTQ (scale 1-10) improved from baseline to 12 weeks: STQ 4.9 (SD 2.9) to 7.0 (SD 3.0); DTQ 4.0 (SD 2.8) to 6.2 (SD 3.1); both P < .001). Most participants (64/73, 88%) made ≥ 1 quit attempt. At 26 weeks, ITT 7-day PPA, 30-day PPA and continuous abstinence rates were: 35/73 (48%), 33/73 (45%), and 22/73 (30%), respectively. Thirty-three participants did not achieve 7-day PPA at 26 weeks; their mean PSECDI score decreased from baseline (13.9, SD 3.1) to 26 weeks (10.8, SD 4.5) (mean change -3.2, SD 3.9, P < .001); almost half (16/33, 48%) had improvement in e-cigarette dependence category. At 2 weeks, 51/71 (72%) reported using Pivot increased their motivation to quit vaping; at 4 weeks, 55/70 (79%) reported using Pivot decreased the amount they vape per day. Conclusions: This study evaluated Pivot’s initial performance in adult daily vapers. At 6 months, almost half of participants achieved abstinence. With the rise in vaping popularity and attendant need for evidence-based cessation programs, this study supports Pivot as a viable solution. Clinical Trial: NCT05642598;

  • Efficacy of an augmented reality application developed for ACLs training of Nurses: a quasi-experiment Study.

    Date Submitted: Feb 12, 2024
    Open Peer Review Period: Feb 14, 2024 - Apr 10, 2024

    Background: Having Advanced Cardiac Life Support (ACLs) skills is essential for nurses. During the COVID-19 pandemic, augmented reality (AR) technologies were incorporated into medical education to increase learning motivation and accessibility. Objective: To determine whether using augmented reality for educational applications can significantly improve first aid cart learning, learning motivation, cognitive load, and system usability among nurses in ACLs training of nurses. Methods: The present study was a quasi-experiment study in a medical center in southern Taiwan. An ACLs cart training course was developed using augmented reality (AR) technologies in the first stage. However, the efficacy of the developed ACLs training course was evaluated. Results: All of 102 nurses completed the course, with 43 nurses in the AR group and 59 nurses in the control group. The AR group outperformed the control group regarding overall ACLs outcomes and first aid cart learning outcomes (P = .002; P = .011). Especially for new staff, regardless of the overall learning effect and the first aid cart effect, the improvement rate is the largest. Conclusions: Learning outcomes were effectively improved by teaching aids that incorporated AR technologies. Constraints in classroom teaching were overcome. Clinical Trial: NCT06057285, 09/20/2023, Retrospectively registered

  • Background: Physical activity during childhood is very important. However, the lack of exercise among children and adolescents is currently becoming a global reality. Moreover, following the coronavirus disease 2019 pandemic, the increase in time spent at home has led to qualitative changes such as home exercise using web-based exercise video content. Objective: To conduct qualitative assessments for web-based exercise educational programs as video content and exercise education programs. Methods: Python-based video data crawling of YouTube using the keywords “children + exercise,” “kid + exercise,” “child + physical activity,” and “kid + physical activity” was performed on November 27, 2023. Duplicate videos, non-English videos, videos older than 5 years as of the search date, videos with playtime <60 s or >30 min, and videos judged by the researcher as irrelevant were excluded. Basic characteristics of video contents were collected, and video popularity-related parameters, including video power index, qualitative analysis of video contents (m-DISCERN, GQS), and qualitative analysis of exercise programs (i-CONTENT, CONTENT, CERT) were assessed. Results: Finally, 126 of 2,936 videos were selected. The proportion of videos uploaded by health professionals was only approximately 10%, and most of the videos covered aerobic and muscle strengthening exercises. Qualitative analysis for video content showed moderate to high quality, but only a few video contents satisfied the criteria of effective exercise program, especially in outcome measurement, presence of supervisor, target eligibility, adherence, and providing individualized exercise options. For correlation analysis between items of video contents and exercise program quality, only a few items among them showed a statistically significant correlation. Conclusions: Web-based exercise educational content targeting children may be inadequate as an exercise education program, with no correlation with video popularity. Although an overall weak to moderate correlation was observed between the quality evaluation of exercise education and the video content, it was insufficient to evaluate the quality of the exercise program using the video quality assessment tools. Clinical Trial: Not applicable

  • Background: Psychological disorders are recognized as independent risk factors for cardiovascular diseases (CVDs), contributing to increased morbidity and mortality. While eHealth is increasingly used to deliver psychological interventions, their effectiveness for patients with or at high-risk of CVDs remains unclear. Objective: This meta-analysis aimed to evaluate the effects of eHealth psychological interventions for patients with or at high-risk of CVDs. Methods: Eligible studies were retrieved from five databases, covering the period from inception to Sep 2023. Randomized controlled trials (RCTs) investigating the effect of evidence-based eHealth psychological intervention to improve psychosocial wellbeing and cardiovascular outcomes for people with or at high-risk of CVDs were included. Cochrane Risk‐of‐Bias Assessment Tool V2 was used to judge the methodological quality of reviewed studies. RevMan 5.3 was used for meta-analysis. Quality of evidence was assessed using the GRADE approach. Results: A total of 12 RCTs, including 2,319 participants from 10 countries were included in the review. The results demonstrated significant alleviation of depression for participants receiving eHealth psychological intervention compared to controls [n=7, SMD=-0.30, 95% CI (-0.47, -0.14), I2=57%, P < .001]. More specifically, in six trials where Internet-based cognitive behavior therapy was delivered a significant alleviation of depression was achieved [SMD=-0.39, 95% CI (-0.56, -0.21), I2=53%, P <.001]. There was no significant change in anxiety or quality of life. Synthesis without meta-analysis regarding stress, adverse events and cardiovascular events showed inconclusive findings. Conclusions: eHealth psychological interventions, particularly internet-based cognitive behavioral therapy, can significantly reduce depressive symptoms among patients with or at high-risk of CVDs. A multi-disciplinary approach is crucial for comprehensively improving psychological and cardiovascular outcomes. Future research should explore integrating persuasive design elements into eHealth and involving mental healthcare professionals to support and guide intervention delivery. Clinical Trial: CRD42023452276

  • Internet Use Maintains Cognitive Function among middle- and old-aged Chinese: A Five-year Longitudinal Study

    Date Submitted: Feb 15, 2024
    Open Peer Review Period: Feb 13, 2024 - Apr 9, 2024

    Background: Cognitive decline poses one of the greatest global challenges for health and social care, particularly in China, where the burden on the elderly population is most pronounced. At present, there is a limited understanding of the long-term cognitive impacts of internet usage among middle-aged and elderly individuals. Objective: This study aims to explore the association between internet usage and age-related cognitive decline among middle- and old-aged Chinese. Methods: We analyzed data based on 12,770 dementia-free participants aged ≥ 45 years from the China Health and Retirement Longitudinal Study. We employed a fixed-effects model to measure the relationship between internet usage and cognitive decline and further validated it using multiple linear regression, generalized estimating equations (GEE), propensity score matching (PSM), inverse probability of treatment weighting (IPTM), and overlap weighting (OW). It also focused on the varying effects that internet devices and usage frequency have on cognitive function. The Karlson-Holm-Breen (KHB) method was used to estimate the mediating role of internet usage in the urban-rural cognitive gap. Results: After adjusting for demographic and health risk factors, there is a positive correlation between internet use and cognitive function (β=0.551, 95% CI 0.391 to 0.710). The negative impact of age on cognitive function was consistently more minor among internet users compared to non-users after the age of 50. With the increase in internet usage frequency, the cognitive benefits for middle-aged and elderly individuals become more evident (rs = 0.378, P<.001). As digital devices for internet access, cellphones (β=0.398, 95% CI 0.283 to 0.495) seem to have a higher level of cognitive protection compared to computers (β=0.147, 95% CI 0.091 to 0.204). The urban-rural disparity in cognitive function was partially attributed to the disparity in internet use (34.18% of the total effects, P<0.001). Conclusions: This study reveals that the use of internet by individuals aged 45 years and older is associated with a reduced risk of cognitive decline. Internet usage has the potential to be a viable, cost-effective, non-pharmacological intervention for cognitive decline among middle-aged and elderly individuals.

  • The Perception of Health Professions Educators in Using Immersive Virtual Reality

    Date Submitted: Feb 6, 2024
    Open Peer Review Period: Feb 9, 2024 - Apr 5, 2024

    Background: The Fourth Industrial Revolution has ushered in innovative educational tools such as VR, transforming teaching and learning practices, notably in health professional education. Despite initial resistance to the shift towards e-learning, it has become a crucial part of global education, prompting efforts such as the U.S. National Education Technology Plan to effectively harness these technological advancements. VR's immersion and interactivity offer significant learning enhancements while posing challenges like cost, accessibility, and information overload. Objective: This study aims to explore educator perspectives on using VR in educational settings. Methods: The study uses multiple descriptive case studies to describe an intervention or phenomenon and the real-life context in which it occurred. In the case studies, semi-structured interviews were used. Results: articipants appreciated VR's immersive and interactive nature, noting its potential to make abstract concepts tangible and enhance engagement, particularly in healthcare education for risk-free clinical education. However, issues related to physical discomfort (cybersickness), high cost, and accessibility were identified as potential impediments to widespread VR adoption, raising concerns about equity. Participants also highlighted the risk of information overload, underscoring the importance of careful instructional design. Further, the study underscores the necessity of aligning VR use with curriculum and pedagogical objectives, with a cautious approach to avoid adopting VR solely for its novelty. Conclusions: The findings suggest that while VR has transformative potential in education, its effective integration requires thoughtful planning to address challenges and ensure alignment with learning objectives.

  • Background: Although several digital health interventions (DHIs) have shown promise in the care of skin diseases their uptake in Germany has been limited. To fully understand the reasons for the low uptake, an in-depth analysis of patients' and healthcare providers' barriers and facilitators in dermatology is needed. Objective: We aimed to investigate the attitudes and perceptions of patients, dermatologists, and nurses towards DHIs in dermatology and to identify potential barriers and facilitators to their implementation. Methods: We conducted six focus groups each with dermatological patients (n=34), dermatologists (n=30), and nurses (n=30) using semi-structured guidelines with short descriptions of DHIs described in the literature. A content analysis was performed using deductive and inductive categories. Results: Patients identified many positive performance expectancies, such as reduced travel times and improvement of follow-up appointments. Dermatologists also stated positive effects (e.g., promotion of standardized care), but also negative implications of healthcare digitalization (e.g., increased workload). All stakeholders reported that a DHI should bring additional value to all stakeholders. A lack of digital competence among patients was identified as the major barrier to DHI adoption by all three groups. Nurses and dermatologists want applications that are easy to use and easy to implement into their daily routines. Trust in selected institutions (e.g., physician or patient associations), colleagues, and physicians was identified as a facilitator for DHIs. Patients reported their dependence on the dermatologists’ acceptance. All groups expressed concerns about data privacy risks and dermatologists even stated insecurities towards data privacy laws. Conclusions: To ensure successful digitalization in dermatology, applications should be user-friendly, adapted to users' skill levels, and beneficial for all stakeholders. The incorporation of dermatologists’ perspective is especially important as their acceptance may impact utilization among patients and nurses. DHIs should ensure and be transparent about data privacy. The found barriers and facilitators can be used for implementation strategies and thus enhance the delivery of dermatological care.

  • An innovative approach to the primary care shortage: virtual enabled primary care

    Date Submitted: Feb 2, 2024
    Open Peer Review Period: Feb 6, 2024 - Apr 2, 2024

    There is a mismatch between primary care supply and demand in our country, which translates into fewer Americans achieving the health benefits tied to primary care. Addressing these issues requires creative and multifaceted solutions - however many of these can take years to achieve; virtual enabled primary care is a novel model that can help us address these issues immediately. Virtual enabled primary care is an innovative care delivery model that has been gaining traction and is using technology to enable virtual team-based care models to deliver comprehensive primary care to patients across the country. With federal and state policy certainty, this delivery model has the potential to help close the gap in primary care access.

  • Background: The transition to motherhood is a pivotal time for promoting healthy behaviours, particularly among indigenous women, who encounter significant barriers to accessing health information. Mobile health interventions (mHealth) promoting healthy lifestyle changes, offer an adaptable and inexpensive method for improving access health information but require cultural appropriateness and suitability for acceptance and effectiveness in indigenous populations. No systematic review on effective mHealth interventions for indigenous women during pregnancy and the early childhood years has been conducted. Objective: This study evaluated the effectiveness of mHealth interventions, promoting healthy lifestyle changes, for indigenous mothers and children from conception to five years post-partum. It explored the effectiveness differences based on participant engagement, intervention nature, and provision of context. Methods: A systematic search of five databases; SCOPUS, MEDLINE, CINAHL, PsycINFO, and ProQuest (Dissertation or Thesis); was conducted to identify studies focusing on maternal and child health, indigenous populations, and mHealth following a pre-registered PROSPERO protocol (CRD42023395710). HealthInfoNet was searched for grey literature and the reference lists of included studies were hand searched. Randomised controlled trials and other interventional study designs including pre-post comparison and cohort studies were eligible for inclusion. Quality of studies was evaluated by two independent reviewers using the Mixed Methods Quality Appraisal Tool and the Centre of Excellence in Aboriginal Chronic Disease Knowledge Translation and Exchange tool. Details from the studies was extracted using a predeveloped extraction form and a descriptive synthesis of the data was performed. Results: Of the 688 articles screened, only three met the eligibility criteria. Each paper evaluated a different mHealth intervention. The three mHealth interventions identified were: Remote Prenatal Education, the Short Messaging System (SmS) Parent Action Intervention, and the Screening, Brief Intervention and Referral to Treatment eCHECKUP To Go. All included studies had a small sample size, and none provided a rationale for the power calculation of the sample size for the outcomes reported. Therefore, it was not possible to establish whether the differences in the effectiveness were due to the interventions. Conclusions: The current literature does not have any evidence of the effectiveness of mHealth interventions for maternal and child health behaviour change. A thorough evaluation with consideration of cultural contexts and user preferences during intervention design and development is crucial for maximizing their potential. Despite scant evidence, mHealth interventions, hold promise for enhancing indigenous mothers' health.

  • Background: Although suicide bereavement is highly distressing and is associated with an increased risk of suicidal behaviors and mental and physical health impairments, those bereaved by suicide encounter difficulties accessing support. Online resources offer new forms of support for bereaved people. However, online resources dedicated to those bereaved by suicide are still limited. Objective: We aimed to develop and implement an evidence-based, innovative and adaptive online resource for people bereaved by suicide, based on their needs and expectations. Methods: We performed a mixed-method participatory usercentered study seeking to build resources from the perspectives of people bereaved by suicide and professionals or volunteers working in the field of postvention. We used the Information System Research (ISR) framework, which employs a 3-stage research cycle, including (1) the relevance cycle, (2) the design cycle and (3) the rigor cycle. Results: A total of 478 people participated in the study, including 451 people bereaved by suicide, 8 members of charities and 19 mental health professionals working in the field of postvention. The development stage of the resource lasted 18 months, from October 2021 to March 2023. A total of 9 focus groups, 1 online surveys, 30 usability tests and 30 semistructured interviews were performed. A website for people bereaved by suicide named ‘ESPOIR’ was developed that includes the following features: a) evidence-based information on suicide prevention and bereavement, b) testimonies of people bereaved by suicide, c) a delayed chat to ask questions on suicide and bereavement to a specialized team of mental health professionals, and d) an interactive nationwide resource directory. The mean system usability score was 90.3/100 for 30 participants, with 94.0% of them having a rating above 80. Since the implementation of ESPOIR in March 2023, 11,549 connections were recorded, 91 local resources have been registered nationwide, and 26 questions have been posted in the chat. Conclusions: The use of a mixed-method participatory user-centered design allowed us to implement an evidence-based, innovative and functional website for people bereaved by suicide that was highly relevant for fulfilling the needs and expectations of French people bereaved by suicide.

  • Background: Sepsis is a common cause of serious illness and death. Sepsis management remains challenging and sub-optimal. To support rapid sepsis diagnosis and treatment, screening tools have been embedded into hospital digital systems to appear as digital alerts. The implementation of digital alerts to improve management of sepsis/deterioration is a complex intervention which has to fit with team workflow and the views and practices of hospital staff. Despite the importance of human decision making and behaviour in optimal implementation, there are limited qualitative studies that explore the views and experiences of professionals regarding digital alert for sepsis/deterioration. Objective: To explore the views and experiences of healthcare professionals on the use of digital alerts for sepsis/deterioration and to identify barriers and facilitators to their implementation and use in NHS hospitals. Methods: A qualitative, multi-site study with unstructured observations and semi-structured interviews with healthcare professionals from emergency departments, outreach teams and intensive/acute units in three NHS hospital Trusts in England. Data from both interviews and observations were analysed together inductively using thematic analysis. Results: Twenty-two healthcare professionals were interviewed and twelve observation sessions were undertaken. Three themes were identified in relation to digital alerts for sepsis/deterioration: 1) Participants viewed them as useful tools in decision-making, but emphasised that they did not substitute their knowledge and experience; 2) Participants expressed that they served as reminders for different clinical actions depending on the hospital unit and the job role; 3) Participants felt they could be improved by being more accessible, more accurate, and that they should be integrated across the whole healthcare system. A higher-level domain was identified indicating that optimal use of digital alerts is supported by a combination of factors at the level of the individual, the hospital unit, the Trust, and the digital tool itself. Digital alerts for sepsis/deterioration are more optimally used: in a general, non-intensive care unit with a lower senior decision maker/patient ratio; by professionals with experience of a similar technology; when supported by a 24/7 emergency outreach team; when accompanied by quality improvement initiatives and continuous sepsis training; with strong technological resources in a Trust; with good staffing and teamwork and when the tool itself is easy to use, not one of many and not intrusive. Conclusions: Trust implementation of digital alerts for sepsis/deterioration requires support on multiple levels and at all phases of the intervention – starting from a pre-go-live analysis addressing organisational needs and readiness. Advancements towards minimally disruptive and smart digital alerts for sepsis/deterioration – which are more accurate and specific, but at the same time scalable and accessible – have to see policy changes and investments in multidisciplinary research. Clinical Trial: The registration identifier for this study is NCT05741801; the protocol ID is 16347.

  • Background: Several machine learning (ML) prediction models for neurodegenerative diseases (ND) in type 2 diabetes mellitus (T2DM) have recently been developed. However, the predictive power of these models is limited by the lack of multiple risk factors. Objective: This study aimed to assess the validity and utility of an ML model for predicting the three year incidence of ND in patients with T2DM. Methods: We used data from two independent cohorts, the discovery cohort (one hospital; n=22,311) and the validation cohort (two hospitals; n=2,915), to predict ND. The outcome of interest was the presence or absence of ND at three years. We selected different ML-based models with hyperparameter tuning in the discovery cohort and conducted an area under the receiver operating characteristic curve (AUROC) analysis in the validation cohort. Results: The study dataset included 22,311 (discovery) and 2,915 (validation) patients with T2DM recruited between 2008 and 2022. ND was observed in 133 (0.6%) and 15 patients (0.5%) in the discovery and validation cohorts, respectively. The AdaBoost model had a mean AUROC of 0.82 (95% CI, 0.79-0.85) in the discovery dataset. When this result was applied to the validation dataset, the AdaBoost model exhibited the best performance among the models, with an AUROC of 0.83 (accuracy of 78.6%, sensitivity of 78.6%, specificity of 78.6%, and balanced accuracy of 78.6%). The most influential factors in the AdaBoost model were age and cardiovascular disease. Conclusions: This study shows the utility and feasibility of ML for assessing the incidence of ND in patients with T2DM and suggests its potential for use in screening patients. Further international studies are required to validate these findings.

  • Can Large Language Models Logically Predict Myocardial Infarction? Evaluation based on UK Biobank Cohort

    Date Submitted: Jan 28, 2024
    Open Peer Review Period: Jan 28, 2024 - Mar 24, 2024

    Background: Large language models (LLMs) have seen extraordinary advances with applications in clinical decision support. However, high-quality evidence is urgently needed on the potential and limitation of LLMs in providing accurate clinical decisions. Objective: To evaluate the predictability of a universal state-of-the-art LLM (ChatGPT) on the risk of myocardial infarction (MI), and to further make comparison between various models to assess the performance of ChatGPT comprehensively. Methods: In this retrospective cohort study, 132008 participants recruited from 2006 to 2010 were initially included in UK Biobank database and later on resampled into a final cohort of 1540 participants. For each participant, tabular data of the risk factors of MI were transformed into standardized textual descriptions for ChatGPT recognition. Responses were generated by asking ChatGPT to select a score ranging from 0.1 to 0.9 representing the risk. The predictive performance of ChatGPT was compared with baseline logistic regression, equation based medical indices, machine learning models and other natural language processing (NLP) models. Results: ChatGPT shows a significantly lower discrimination (AUC: 0.58, 95% CI: 0.55~0.61) than that of logistic regression (AUC: 0.78, 95% CI: 0.71~0.85). Under the best threshold, the accuracy of ChatGPT is also relatively unsatisfactory (ChatGPT: 0.57, 95% CI: 0.54~0.59; logistic model: 0.74, 95% CI: 0.66~0.80). In comparison with other models, the performance of ChatGPT is significantly poorer than that of medical indices and machine learning models, but no significant differences were found between ChatGPT and NLP models. Conclusions: Current LLMs represented by ChatGPT may not be able to make logical decisions. While cautious application of LLMs in clinical medicine fields under strict evaluation is suggested, evidence-based rules should be introduced into future LLM-based systems to better complete medical tasks.

  • Recommendations For Successful Development And Implementation Of Digital Health Solutions

    Date Submitted: Jan 25, 2024
    Open Peer Review Period: Jan 25, 2024 - Mar 21, 2024

    Digital technologies are rapidly transforming healthcare and medicine. In the form of mobile health applications, wearable devices, telehealth, molecular technologies, augmented electronic health records, and associated advanced analytics, these tools are being used to improve patient outcomes and streamline clinical workflows. Beyond the aim to optimize existing workflows in terms of quality, efficiency, and costs, digital health technologies hold even greater potential. Entirely new forms of healthcare are envisioned that are not only more participatory and personalized but also intricately woven into the fabric of patients' everyday lives. This seamless integration, ranging from real-time health monitoring to personalized treatment plans accessible from personal devices, offers profound benefits, including increased access to care and patient engagement, timely interventions, and a more holistic approach to health management. However, developing and implementing effective digital health solutions (DHS), which combine digital technologies with suitable analytics and user-friendly interfaces, involves a variety of challenges including but not limited to technology selection, data integration, regulatory compliance, user adoption, and ongoing maintenance. In this contribution, we target a broad readership spanning healthcare professionals, engineers, developers, and researchers to provide practical guidance and step-by-step recommendations to address common pitfalls and optimize key aspects of DHS design. The focus is not on pure digital technology/hardware implementation for the healthcare sector, but on DHS development in general, including mobile applications and data analytics that build on existing hardware. While not aiming to present exhaustive or project-specific methodologies, our suggested recommendations highlight important generic considerations at each development phase based on lessons learned from real-world studies, from initial scoping and planning through launch and to full sustainability. Core themes identified include the need for human-centered design, rigorous evaluation, ethical oversight, and continuous quality improvement. By combining technology with empathy for end-user needs and perspectives, and maintaining a commitment to safety, efficiency and fairness, we believe that innovators can realize the great potential of digital solutions to transform healthcare delivery. While our guide focuses on opportunities, each recommendation also highlights common risks to avoid. Our proposition is that this succinct and pragmatic guide will support readers in successfully developing digital capabilities to improve healthcare.

  • Construction and expert evaluation of an intelligent medication scheduling system

    Date Submitted: Jan 26, 2024
    Open Peer Review Period: Jan 25, 2024 - Mar 21, 2024

    Background: Many patients with chronic diseases, especially those with multiple diseases, may need to take a variety of drugs every day to control their condition1, which may lead to a decline in patient medication compliance. The decline of compliance is often manifested in the behavior of taking medicine not according to the prescribed time, not taking medicine or interrupting taking medicine. This has a negative impact on the therapeutic effect, resulting in varying degrees of maximal consequences and an increased risk of complications. Objective: In order to solve the problems of poor multiple medication adherence and difficult medication scheduling in the elderly, an intelligent medication scheduling system for patient medication reminder was established, and its performance was evaluated through testing and compared with the artificial intelligence GPT-4. Methods: Medication time constraint with one drug (MTCOD) data were designed by integrating the physicochemical properties of the drug, dining constraints, and chronopharmacology, and drug interactions (DI) were considered to design the medication time constraint with multi-drug (MTCMD) data. Combining the above elements and taking into account the patient's situation and their needs, an optimal medication scheduling program was developed for them. Based on the above rules, a universal medication schedule (UMS) system is established, including a complete drug information database and a medication reminder system. The UMS system and GPT-4 were used to test the prescriptions of 20 elderly patients with chronic diseases, and 12 experts of clinicians, pharmacists or nurses were invited to evaluate the medication time of the system in terms of accuracy, safety, adherence, and usefulness using a Likert 5-level scale. Results: The drug database has been constructed and loaded with 1,926 items of basic drug information and 350,351 items of DI data, and 2,229 items of MTCOD and 87,248 items of MTCMD have been originally created. The medication reminder system has been constructed and clinically tested to generate a universal medication schedule, which can be used by medical staff to develop personalized medication schedules for patients. The expert evaluation results showed that the UMS group had high accuracy and safety scores, which were significantly better than the performance of the GPT-4 (P<0.001) and close to the results of professionals. Conclusions: Universal medication scheduling system provides data support for intelligent medication reminders, automatic identification of drug interactions, and monitoring system, which is more accurate and safer compared with GPT-4, and can be used as a powerful supplement to the clinical work of pharmacists.

  • Background: Digital health history devices (DHHDs) represent a promising wave of digital tools with the potential to enhance the quality and efficiency of medical consultations. They achieve this by providing physicians with standardized, high-quality patient history summaries and facilitating the development of differential diagnoses (DD) prior to consultation and make the patient feel involved in this process. Objective: This study focuses on evaluating the efficacy of one such DHHD, 'DIANNA,' in compiling appropriate lists of DDs within the outpatient setting. Methods: A pseudo-randomized controlled trial involved 101 patients seeking care at the University Hospital Geneva emergency outpatient department, presenting a range of conditions affecting the limbs, back, and chest. The initial 51 patients were assigned to the control group, while the subsequent 50 formed the intervention group. In the control group, physicians were tasked with establishing an extensive DD list based on traditional history-taking and clinical examination. Conversely, in the intervention group, physicians had the advantage of reviewing the DIANNA report, which included suggested DDs, before interacting with the patient. In both groups, a senior physician independently reviewed the patient and formulated a DD list, serving as the 'gold standard' for comparison. Results: The study findings showcased a notable improvement in DD accuracy when DIANNA was employed (mean 79.3%, SD 24%), as compared to the control group (mean 70.5%, SD 33%; P=.014). Subgroup analysis further elucidated this enhancement, with an 8% difference in favor of the intervention group for low complexity cases (1-2 possible DDs; P=.08). This advantage expanded to 17% for intermediate complexity cases (3 possible DDs; P=.03), while high complexity cases (4-5 possible DDs) saw a 15% increase (P=.92). DIANNA was found to effectively determine appropriate DDs in 81.6% of cases, and physicians recognized its assistance in establishing the correct DD in 26% of instances. Conclusions: The study conclusively affirms the effectiveness of DIANNA in supporting physicians to formulate more precise DDs. This underscores the potential of DHHDs like DIANNA to enhance clinical decision-making and improve the accuracy of patient diagnoses in the medical field. Clinical Trial: This trial was registered on clinical trials (NCT03901495).

  • Background: Veterans are disproportionately affected by chronic pain, with high rates of pain diagnoses (47 – 56%) and a 40% greater rate of severe pain than non-veterans. This is often accompanied by negative functional outcomes such as decreased work productivity, less familial social support and closeness, increased chronic health conditions (e.g., cancer, heart disease), and higher mortality compared to veterans without chronic pain. Combined with research suggesting medical treatments for chronic pain are often insufficient, there is an urgent need for non-medical pain self-management programs. An interactive, mobile platform to deliver an efficacious treatment for chronic pain such as Acceptance and Commitment Therapy (ACT) could be this option and assist veterans with pain care at home. Objective: The purpose of this study was to evaluate the virtual coach-guided Veteran ACT for Chronic Pain online program (VACT-CP) compared to a waitlist and treatment as usual control group (WL+TAU) through a small pilot feasibility RCT. The primary aim was to evaluate the feasibility and acceptability of VACT-CP and study procedures, including ease of recruitment, treatment receptivity, attrition and retention, sustained participation, system usability, and assessment of trial procedures. Secondary aims explored differences in the VACT-CP and WL+TAU groups on pre- and post-test outcome measures for pain, mental health, functioning, and ACT processes. Methods: Veterans with chronic pain (n=42) were recruited and randomized to either the VACT-CP or WL+TAU condition. Self-report surveys were administered to participants at baseline (Week 0), the intervention midpoint (Week 3), immediately after the intervention (Week 7: primary outcome time point), and at 1-month follow-up (Week 11). To explore outcome data, non-parametric analyses were used on the intention-to-treat sample. Results: Evaluation of study procedures showed good feasibility related to recruitment, enrollment, randomization, and completion rates. Participants reported that VACT-CP was easy to use (System Usability Scale Mean=79.6, SD=12.8, Median = 82.5), completing an average of five of the seven total VACT-CP modules with high post-use satisfaction rates. Qualitative feedback suggested a positive response to program usability, content, tailoring, veteran-centeredness, and perceived impact on pain management. Although the pilot feasibility trial was not powered to detect differences in clinical outcomes, participants the VACT-CP group experienced significant increases in chronic pain acceptance (specifically activity engagement) and decreases in depressive symptoms. Conclusions: VACT-CP showed high feasibility, usability, and acceptance, while also providing initial promising results in improving a key process in ACT for chronic pain —notably chronic pain acceptance — after engaging with the online program. These results suggest the potential for VACT-CP to provide an accessible, acceptable, and useful at-home chronic pain management program, and a larger trial is now needed. Clinical Trial: This pilot trial was registered on as NCT03655132.

  • Background: Hospitals use triage systems to prioritize the needs of patients within available resources. Misclassification of a patient can lead to either adverse outcomes in a patient who did not receive appropriate care in the case of undertriage or waste of hospital resources in the case of overtriage. Recent advances in machine learning algorithms allow for the quantification of variables important to under- and overtriage. Objective: The aim of this study was to identify clinical features most strongly associated with triage misclassification using a machine learning classification model to capture non-linear relationships. Methods: Multicenter retrospective cohort data from two big regional hospitals in Norway was extracted. The South African Triage system is used at Bergen University Hospital and the Rapid Emergency Triage and Treatment System is used at Trondheim University Hospital. Variables included triage score, age, gender, arrival time, subject area affiliation, reason for emergency department contact, discharge location, level of care, and time of death were retrieved. Random forest classification models were used to identify features with the strongest association with overtriage and undertriage in clinical practice in Bergen and Trondheim. We reported variable importance as SHAP-values (SHapley Additive exPlanations). Results: We collected data on 205,488 patient records from Bergen University Hospital and 304,997 patient records from Trondheim University Hospital. Overall, overtriage was very uncommon at both hospitals (all <0.1%), with undertriage differing between both location with 0.8% at Bergen and 0.2% at Trondheim University Hospital. Demographics were similar for both hospitals, however the percentage given a high priority triage score (red or orange) was higher in Bergen (24%) compared to 9% in Trondheim. Clinical referral department was found to be the variable with the strongest association with undertriage (mean SHAP +0.62 and +0.37 for Bergen and Trondheim, respectively). Conclusions: We identified subgroups of patients consistently undertriaged using two common triage systems. While the importance of clinical characteristics to triage misclassification varies by triage system and location, but we found consistent evidence between the two locations that clinical referral department is the most important variable associated with triage misclassification. Replication of this approach at other centers could help to further improve triage scoring systems and improve patient care worldwide.

  • Background: In recent decades, digital stress management training, typically using the internet to reach targeted individuals, has gained increasing attention in occupational health promotion. Evidence for Internet-based training delivered in group formats is scarce, however, despite its broad implementation for traditional non-digital health promotion. Objective: This study’s aim was to explore the feasibility of live, online stress management training delivered in a group format and compare it to Internet-based training targeting individuals. Methods: Employees (N=62), recruited from an open access website, were randomized into either group or individual training. Group training consisted of seven weekly online appointments led by a trainer and conducted via videoconference. Individual training consisted of seven web-based sessions which included written feedback provided by an e-coach after each session. The primary outcome was perceived stress eight weeks after training initiation. Feasibility was analyzed in terms of participants’ satisfaction, adherence, and perceived benefits of both training formats, assessed via both written questionnaires and interviews. Results: Participants in group training [Cohen’s d = 0.9 (95% confidence interval: 0.4 to 1.5)] and individual training [1.3 (0.6 to 2.0)] both experienced statistically-significant reductions in stress, with no significant difference between the two training formats [0.25 (-0.32 to 0.83); p = .579)]. Full adherence rates were 70% in the group training and 50% in the individual training. Participants were satisfied with both formats, appreciating the social support and personal contact of the group setting, while appreciating the time flexibility and personal contact with an e-coach offered through individual training. Conclusions: This pilot study showed promising effects for the acceptance and health-related effectiveness of stress management training delivered in a group setting via videoconference. The findings highlight the value of personal contact with a coach and peers for positive user experiences during digital stress management interventions. Clinical Trial: German Clinical Trials Register (DRKS00024965)

  • Background: The advent of the internet has transformed the landscape of health information acquisition and sharing. Subreddits like r/medical_advice on Reddit have become hubs for such activities, affecting patient knowledge and decision-making. While the popularity of these platforms is recognized, research into the interactions and content within these communities remains sparse. Understanding the dynamics of these platforms is crucial for improving online health information quality. Objective: This study aims to quantitatively analyze the subreddit r/medical_advice to characterize the medical questions posed and the demographics of individuals providing answers. Insights into the subreddit's user engagement, information-seeking behavior, and the quality of shared information will contribute to the existing body of literature on health information-seeking in the digital era. Methods: A cross-sectional study was conducted, examining all posts and top comments from r/medical_advice since its creation on October 1, 2011. Data were collected on March 2, 2023, from, and analysis covered post and author flairs, scores, and engagement metrics. Statistical analyses were performed using RStudio and GraphPad Prism 9.0. Results: From October 2011 to March 2023, 201,680 posts and 721,882 comments were analyzed. Excluding auto-generated comments, 528,383 comments were included. 41% of posts had no user flairs, while verified medical professionals made only 0.1% of posts. Average engagement per post was 2.00 ± 7.03 scores and 3.32 ± 4.89 comments. In Period 2, urgent questions and level 10 pain reported higher engagement, with significant differences in scores and comments based on flair type (P < .001). Period 3 saw the highest engagement in posts related to pregnancy and the lowest in bones/joints/ligaments. Media inclusion significantly increased engagement, with video posts receiving the highest interaction (P < .001). Conclusions: The study reveals significant engagement with r/medical_advice, with user interactions influenced by the type of query and inclusion of visual media. High engagement with posts concerning pregnancy and urgent medical queries reflects focused public interest and the subreddit's role as a preliminary health information resource. The predominance of non-verified medical professionals as information providers highlights a shift towards community-based knowledge exchange, though it raises questions about the reliability of the information. Future research should explore cross-platform behaviors and the impact of misinformation on public health. Effective moderation and the involvement of verified medical professionals are recommended to enhance the subreddit's role as a reliable health information resource. Clinical Trial: N/A

  • Background: The conflict in Syria has produced the largest forced displacement crisis since the Second World War. As a result, Syrians have experienced various stressors across the migratory process, putting them at an increased risk of developing mental health issues, which for some Syrian asylum seekers and refugees has resulted in suicidal ideation. Despite their high rates of SI across Europe, there remain various barriers to accessing treatment. One way to increase access is the use of culturally adapted digital interventions. The study therefore aimed to better understand Syrian asylum seekers’ and refugees’ cultural conceptualizations, coping strategies, and help-seeking behavior for SI. This involved a unique cultural adaptation framework to intervene at points of lived experience with the migratory process where Syrian mental health beliefs and signs of psychopathology converge. Likewise, co-design events were used to adapt points of experience with the intervention where Syrian culture and the intervention conflict. In addition to providing unique insights into the mental health and SI of Syrian asylum seekers and refugees in the UK, the study provides an intuitive methodology for culturally adapting digital interventions for refugee populations in general. Objective: The objective of the study was to increase access to mental health treatment for Syrian asylum seekers and refugees in the United Kingdom by culturally adapting a digital intervention to reduce SI. Methods: The study used experience-based co-design, an action research method, to culturally adapt a digital intervention to reduce SI for Syrian asylum seekers and refugees in the United Kingdom. This involved conducting 16 interviews to understand their cultural concepts, coping-strategies, help-seeking behaviour for mental health and SI in relation to their lived experiences with the migratory process, as well as their perceptions of digital mental health interventions. In addition, 3 co-design events with 4 participants in each were be held to collaboratively adapt the intervention. Touchpoints and themes extracted from each phase were prioritized by a community panel before adapting the intervention. Results: The following are the main findings of the study protocol (RR2-10.2196/47627). First, participant's cultural concepts and help-seeking behaviour for mental health became more complex across the migratory process due to their increased experiences of mental health symptoms and mental health literacy. Their coping-strategies however remained the same and included both personal (religious beliefs and practices, exercise, and hobbies) and collective (volunteering, collective problem-solving, etc.) coping-stratgies. Second, participant's core cultural concepts and help-seeking behaviour for suicidal ideation (SI) remained relatively stable across the migratory process, however they showed increased awareness of its causes. Given the prohibition of suicide in Islam, participants either experienced a wish for death or an SI crisis. While participants attributed SI to torture, the asylum process, social isolation, and a lack of mental health services, they believed that stressors and suicide were mediated by weak iman (faith), junun (insanity), and a loss of ruh (soul) and shakhsiyya (character). Their coping-strategies for SI were overall religious in nature including understanding their experiences as ibtila' (a test) from God, and engaging salat (ritual prayer) and reading the Quran. Third, the study revealed facilitators and barriers to engagement with digital mental health interventions. Facilitators included cultural adaptation for Arab populations; Arabic translation; anonymity; no burden of travel; early post-migration intervention; cultural brokers; etc. Barriers included low mental health and digital literacy, and a lack of electricity and internet access in Syria. Forth, the study revealed themes related to guidance, methods of delivery, case examples, culture shock, exercises, and language. While it was previously expected that the intervention required shortening, participants preferred a non-directive approach and therefore a variety of exercises accompanied with explanations, encouragement, reminders, and goal setting. Importantly, participants emphasised adapting the intervention for Syrian asylum seekers' and refugees' experiences in the first year after arriving to the UK. In this year, Syrian asylum seekers and refugees deal with culture shock as well as uncertainty about their asylum application and the possibility of returning to Syria. Conclusions: Access to treatment for some of the most severe mental health issues is still limited for Syrian asylum seekers and refugees in the United Kingdom. Cultural adaptations of digital interventions developed for general populations have the potential to increase access to treatment for this population. This study has shown that this can be achieved with only minor adaptations to the intervention. The main component of the cultural adaptation was Syrian asylum seekers' and refugees' cultural concepts of SI including the lived experiences that give rise to it, which in turn helped identify points at which to provide the intervention. A future feasibility study will assess the acceptability of the intervention and identify optimal recruitment strategies.