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Journal Description

The Journal of Medical Internet Research (JMIR), now in its 21st year, is the pioneer open access eHealth journal and is the flagship journal of JMIR Publications. It is the leading digital health journal globally in terms of quality/visibility (Impact Factor 2019: 5.03), ranking Q1 in the medical informatics category, and is also the largest journal in the field. The journal focuses on emerging technologies, medical devices, apps, engineering, telehealth and informatics applications for patient education, prevention, population health and clinical care. As a leading high-impact journal in its disciplines (health informatics and health services research), it is selective, but it is now complemented by almost 30 specialty JMIR sister journals, which have a broader scope, and which together receive over 6.000 submissions a year. Peer-review reports are portable across JMIR journals and papers can be transferred, so authors save time by not having to resubmit a paper to different journal but can simply transfer it between journals. 

As an open access journal, we are read by clinicians, allied health professionals, informal caregivers, and patients alike, and have (as with all JMIR journals) a focus on readable and applied science reporting the design and evaluation of health innovations and emerging technologies. We publish original research, viewpoints, and reviews (both literature reviews and medical device/technology/app reviews).

We are also a leader in participatory and open science approaches, and offer the option to publish new submissions immediately as preprints, which receive DOIs for immediate citation (eg, in grant proposals), and for open peer-review purposes. We also invite patients to participate (eg, as peer-reviewers) and have patient representatives on editorial boards.

Be a widely cited leader in the digitial health revolution and submit your paper today!


Recent Articles:

  • Source: Pexels; Copyright: Anna Shvets; URL:; License: Licensed by JMIR.

    Adapting an Outpatient Psychiatric Clinic to Telehealth During the COVID-19 Pandemic: A Practice Perspective


    As the demand for telepsychiatry increases during the COVID-19 pandemic, the strengths and challenges of telepsychiatry implementation must be articulated to improve clinical practices in the long term. Currently, observations within US contexts are lacking; therefore, we report on the rapid implementation of telepsychiatry and workflow experiences in a psychiatric practice based within a large health care system in southeast Texas with a national catchment area. We discuss the logistics of the implementation, including modes of communication, scheduling, coordination, and capacity; the psychological effects of web-based services, including both the loss of the physical therapeutic environment and the unique interpersonal dynamics experienced in the virtual environment; and postadoption patterns of engagement with our services and with other clinical functions affected by the rapid adaptation to telemedicine. Our art therapy group programming serves as an applied case study, demonstrating the value of a well-managed web-based program (eg, patients were receptive and well-engaged, and they appreciated the continuity of accessible service) as well as the challenges (eg, the need for backup plans and technological fallbacks, managing interruptions and telecommunication learning curves, and working around the difference in resources for art and music therapy between a well-stocked clinical setting versus clients’ home spaces). We conclude from our experience that the overall strengths of telepsychiatry include receptive and well-engaged responses from patients as well as the expansion of boundaries, which provides a directly contextualized view into patients’ home lives. Challenges and corresponding recommendations include the need for more careful safety planning for high-risk patients; maintaining professional boundaries in the newly informal virtual setting; designing the physical space to both frame the patient encounter and maintain work-life balance for the therapist; allowing for delays and interruptions (including an initial acclimation session); and preserving interprofessional care team collaboration when the physical locations that normally facilitate such encounters are not accessible. We believe that careful observations of the strengths and challenges of telepsychiatry during this pandemic will better inform practices that are considering telepsychiatry adoption both within pandemic contexts and more broadly thereafter.

  • Source: Shutterstock; Copyright: Andrey Popov; URL:; License: Licensed by JMIR.

    Private Video Consultation Services and the Future of Primary Care


    In many countries, private companies provide primary care services based predominantly on offering video consultations via smartphones. One example is Babylon GP at Hand (BGPaH), which offers video consultations to National Health Service patients, 24 hours a day, and has grown rapidly in London over the last 3 years. The development of this type of service has been controversial, particularly in the United Kingdom, but there has been little formal published evaluation of these services in any country. This paper outlines the main controversies about the use of privately provided video consultation services for primary care and shows how they are informed by the limited evaluations that have been conducted, particularly the evaluation of BGPaH. This paper describes the advantages of these services in terms of convenience, speed of access, the ability to consult without traveling or face-to-face patient-doctor contact, and the possibility of recruiting doctors who cannot work in conventional settings or do not live near the patients. It also highlights the concerns and uncertainties about quality and safety, demand, fragmentation of care, impact on other health services, efficiency, and equity. There are questions about whether private primary care services based on video consultations have a sustainable business model and whether they will undermine other health care providers. During the recent COVID-19 pandemic, the use of video consulting has become more widespread within conventional primary care services, and this is likely to have lasting consequences for the future delivery of primary care. It is important to understand the extent to which lessons from the evaluation of BGPaH and other private services based on a video-first model are relevant to the use of video consulting within conventional general practices, and to consider the advantages and disadvantages of these developments, before video consultation–based services in primary care become more widely established.

  • Source: Pixabay; Copyright: William Iven (@FirmBee); URL:; License: Creative Commons Attribution (CC-BY).

    Research Participants’ Perspectives on Using an Electronic Portal for Engagement and Data Collection: Focus Group Results From a Large Epidemiologic Cohort


    Background: Epidemiologic cohort studies have begun to leverage electronic research participant portals to facilitate data collection, integrate wearable technologies, lower costs, and engage participants. However, little is known about the acceptability of portal use by research participants. Objective: The aim of this study is to conduct focus groups among a sample of Cancer Prevention Study-3 (CPS-3) participants to better understand their preferences and concerns about research portals. Methods: CPS-3 participants were stratified based on sex, race and ethnicity, age, and cancer status, and randomly invited to participate. Focus groups used an exploratory case design with semistructured guides to prompt discussion. Using a constant comparison technique, transcripts were assigned codes to identify themes. Results: Participants (31/59, 52% women; 52/59, 88% White/non-Latinx) were favorably disposed toward using a research participant portal to take surveys, communicate with the study staff, and upload data. Most participants indicated that a portal would be beneficial and convenient but expressed concerns over data safety. Participants stressed the importance of an easy-to-use and trustworthy portal that is compatible with mobile devices. Conclusions: In addition to being beneficial to researchers, portals may also benefit participants as long as the portals are secure and simple. Participants believe that portals can provide convenient ways to report data and remain connected to the study.

  • App from WHO under use. Source: The Authors; Copyright: The Authors; URL:; License: CC-BY 3.0 IGO.

    Building a Digital Tool for the Adoption of the World Health Organization’s Antenatal Care Recommendations: Methodological Intersection of Evidence,...


    Background: One of the key mandates of the World Health Organization (WHO) is to develop guidelines, defined as “a document containing recommendations for clinical practice or public health policy.” Guidelines represent the global standard for information sources shaping clinical practice and public health policies. Despite the rigorous development process and the value of guidelines for setting standards, implementing such standards within local contexts and at the point of care is a well-documented challenge. Digital technologies enable agile information management and may facilitate the adaptation of guidelines to diverse settings of health services delivery. Objective: The objective of this paper is to detail the systematic and iterative process involved in transforming the WHO Antenatal Care (ANC) guidelines into a digital decision-support and patient-record application for routine use in primary health care settings, known as the WHO digital ANC module. Methods: The WHO convened a team of clinical and digital health experts to develop the WHO digital ANC module as a tool to assist health care professionals in the implementation of WHO evidence-based recommendations for pregnant women. The WHO digital ANC module’s creation included the following steps: defining a minimum viable product (MVP), developing clinical workflows and algorithms, algorithm testing, developing a data dictionary, and the creation of a user interface or application development. The overall process of development took approximately 1 year to reach a stable prototype and to finalize the underlying content requirements of the data dictionary and decision support algorithms. Results: The first output is a reference software reflecting the generic WHO ANC guideline content, known as the WHO digital ANC module. Within it, all actionable ANC recommendations have related data fields and algorithms to confirm whether the associated task was performed. WHO recommendations that are not carried out by the health care worker are saved as pending tasks on a woman’s health record, and those that are adequately fulfilled trigger messages with positive reinforcement. The second output consists of the structured documentation of the different components which contributed to the development of the WHO digital ANC module, such as the data dictionary and clinical decision support workflows. Conclusions: This is a novel approach to facilitate the adoption and adaptation of recommendations through digital systems at the health service delivery level. It is expected that the WHO digital ANC module will support the implementation of evidence-based practices and provide information for monitoring and surveillance; however, further evidence is needed to understand how the WHO digital ANC module impacts the implementation of WHO recommendations. Further, the module’s implementation will inform the WHO’s ongoing efforts to create a pathway to adaptive and integrated (Smart) Guidelines in Digital Systems to improve health system quality, coverage, and accountability.

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

    Effects of the COVID-19 Pandemic on Obsessive-Compulsive Symptoms Among University Students: Prospective Cohort Survey Study


    Background: The COVID-19 pandemic is associated with common mental health problems. However, evidence for the association between fear of COVID-19 and obsessive-compulsive disorder (OCD) is limited. Objective: This study aimed to examine if fear of negative events affects Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores in the context of a COVID-19–fear-invoking environment. Methods: All participants were medical university students and voluntarily completed three surveys via smartphone or computer. Survey 1 was conducted on February 8, 2020, following a 2-week-long quarantine period without classes; survey 2 was conducted on March 25, 2020, when participants had been taking online courses for 2 weeks; and survey 3 was conducted on April 28, 2020, when no new cases had been reported for 2 weeks. The surveys comprised the Y-BOCS and the Zung Self-Rating Anxiety Scale (SAS); additional items included questions on demographics (age, gender, only child vs siblings, enrollment year, major), knowledge of COVID-19, and level of fear pertaining to COVID-19. Results: In survey 1, 11.3% of participants (1519/13,478) scored ≥16 on the Y-BOCS (defined as possible OCD). In surveys 2 and 3, 3.6% (305/8162) and 3.5% (305/8511) of participants had scores indicative of possible OCD, respectively. The Y-BOCS score, anxiety level, quarantine level, and intensity of fear were significantly lower at surveys 2 and 3 than at survey 1 (P<.001 for all). Compared to those with a lower Y-BOCS score (<16), participants with possible OCD expressed greater intensity of fear and had higher SAS standard scores (P<.001). The regression linear analysis indicated that intensity of fear was positively correlated to the rate of possible OCD and the average total scores for the Y-BOCS in each survey (P<.001 for all). Multiple regressions showed that those with a higher intensity of fear, a higher anxiety level, of male gender, with sibling(s), and majoring in a nonmedicine discipline had a greater chance of having a higher Y-BOCS score in all surveys. These results were redemonstrated in the 5827 participants who completed both surveys 1 and 2 and in the 4006 participants who completed all three surveys. Furthermore, in matched participants, the Y-BOCS score was negatively correlated to changes in intensity of fear (r=0.74 for survey 2, P<.001; r=0.63 for survey 3, P=.006). Conclusions: Our findings indicate that fear of COVID-19 was associated with a greater Y-BOCS score, suggesting that an environment (COVID-19 pandemic) × psychology (fear and/or anxiety) interaction might be involved in OCD and that a fear of negative events might play a role in the etiology of OCD.

  • Source: Pexels; Copyright: Andrea Piacquadio; URL:; License: Licensed by JMIR.

    VA Video Connect for Clinical Care in Older Adults in a Rural State During the COVID-19 Pandemic: Cross-Sectional Study


    Background: The COVID-19 pandemic has accelerated the need for telehealth at home. Although the Department of Veterans Affairs is a leading provider of telehealth, disparities may exist in reaching older veterans living in rural areas. VA Video Connect (VVC) is a video conferencing app that enables veterans to connect with their health care provider via a secure and private session. Objective: The aim of this study was to examine the capability and willingness of older veterans to participate in a VVC visit during the COVID-19 pandemic. Methods: A cross-sectional study was conducted on older veterans (N=118) at the Central Arkansas Veterans Healthcare System. Participants were interviewed over the phone and responses to the following items were recorded: availability of internet, email, and an electronic device with a camera; veterans’ willingness to complete an appointment via a VVC visit; and availability of assistance from a caregiver for those who were unable to participate in a VVC visit alone. Results: Participants’ mean age was 72.6 (SD 8.3) years, 92% (n=108) were male, 69% (n=81) were Caucasian, 30% (n=35) were African Americans, and 36% (n=42) lived in a rural location. The majority reported having access to the internet (n=93, 77%) and email service (n=83, 70%), but only 56% (n=67) had a camera-equipped device. Overall, 53% (n=63) were willing and capable of participating in a VVC visit. The availability of internet access was significantly lower in rural compared to nonrural participants (P=.045) and in those with or less than a high school education compared to those who pursued higher education (P=.02). Willingness to participate in the VVC visit was significantly lower in rural compared to nonrural participants (P=.03). Of the participants who reported they were able and willing to partake in a VVC visit (n=54), 65% (n=35) opted for VVC and 35% (n=19) preferred a phone visit. In total, 77% (n=27) of the scheduled VVC visits were successful. Conclusions: Despite advances in technology, and willingness on the part of health care systems, there are some lingering issues with capability and willingness to participate in video telehealth visits, particularly among older adults residing in rural areas.

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

    Artificial Intelligence Chatbot Behavior Change Model for Designing Artificial Intelligence Chatbots to Promote Physical Activity and a Healthy Diet: Viewpoint


    Background: Chatbots empowered by artificial intelligence (AI) can increasingly engage in natural conversations and build relationships with users. Applying AI chatbots to lifestyle modification programs is one of the promising areas to develop cost-effective and feasible behavior interventions to promote physical activity and a healthy diet. Objective: The purposes of this perspective paper are to present a brief literature review of chatbot use in promoting physical activity and a healthy diet, describe the AI chatbot behavior change model our research team developed based on extensive interdisciplinary research, and discuss ethical principles and considerations. Methods: We conducted a preliminary search of studies reporting chatbots for improving physical activity and/or diet in four databases in July 2020. We summarized the characteristics of the chatbot studies and reviewed recent developments in human-AI communication research and innovations in natural language processing. Based on the identified gaps and opportunities, as well as our own clinical and research experience and findings, we propose an AI chatbot behavior change model. Results: Our review found a lack of understanding around theoretical guidance and practical recommendations on designing AI chatbots for lifestyle modification programs. The proposed AI chatbot behavior change model consists of the following four components to provide such guidance: (1) designing chatbot characteristics and understanding user background; (2) building relational capacity; (3) building persuasive conversational capacity; and (4) evaluating mechanisms and outcomes. The rationale and evidence supporting the design and evaluation choices for this model are presented in this paper. Conclusions: As AI chatbots become increasingly integrated into various digital communications, our proposed theoretical framework is the first step to conceptualize the scope of utilization in health behavior change domains and to synthesize all possible dimensions of chatbot features to inform intervention design and evaluation. There is a need for more interdisciplinary work to continue developing AI techniques to improve a chatbot’s relational and persuasive capacities to change physical activity and diet behaviors with strong ethical principles.

  • Periconception lifestyle counselling. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Impact of a Blended Periconception Lifestyle Care Approach on Lifestyle Behaviors: Before-and-After Study


    Background: Periconception lifestyle behaviors affect maternal, paternal, offspring, and transgenerational health outcomes. Previous research in other target populations has shown that personalized lifestyle interventions, in which face-to-face counseling and eHealth (“blended care”) are combined, may effectively target these lifestyle behaviors. Objective: We aimed to assess the effectiveness of a periconceptional lifestyle intervention on the improvement of specific lifestyle components. Methods: A blended periconception lifestyle care approach was developed, combining the outpatient lifestyle counseling service “Healthy Pregnancy” with the eHealth platform “Smarter Pregnancy” ( in which lifestyle was coached for 24 weeks. All couples contemplating pregnancy or already pregnant (≤12 weeks of gestation) who visited the outpatient clinics of the Department of Obstetrics and Gynecology at the Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands, between June and December 2018, were invited to participate. We measured changes in lifestyle behaviors at weeks 12 and 24 compared with baseline. Generalized estimating equations were used to analyze the changes in lifestyle behaviors over time. Subgroup analyses were performed for women with obesity (BMI ≥30 kg/m2), women pregnant at the start of the intervention, and those participating as a couple. Results: A total of 539 women were screened for eligibility, and 450 women and 61 men received the blended periconception intervention. Among the participating women, 58.4% (263/450) were included in the preconception period. Moreover, 78.9% (403/511) of the included participants completed the online lifestyle coaching. At baseline, at least one poor lifestyle behavior was present in most women (379/450, 84.2%) and men (58/61, 95.1%). In the total group, median fruit intake increased from 1.8 to 2.2 pieces/day (P<.001) and median vegetable intake increased from 151 to 165 grams/day (P<.001) after 24 weeks of online coaching. The probability of taking folic acid supplementation among women increased from 0.97 to 1 (P<.001), and the probability of consuming alcohol and using tobacco in the total group decreased from 0.25 to 0.19 (P=.002) and from 0.20 to 0.15 (P=.63), respectively. Overall, the program showed the strongest effectiveness for participating couples. Particularly for vegetable and fruit intake, their consumption increased from 158 grams/day and 1.8 pieces/day at baseline to 190 grams/day and 2.7 pieces/day at the end of the intervention, respectively. Conclusions: We succeeded in including most participating women in the preconception period. A high compliance rate was achieved and users demonstrated improvements in several lifestyle components. The blended periconception lifestyle care approach seems to be an effective method to improve lifestyle behaviors. The next step is to further disseminate this approach and to perform a randomized trial to compare the use of blended care with the provision of only eHealth. Additionally, the clinical relevance of these results will need to be substantiated further.

  • Source: Pexels; Copyright: Matthias Zomer; URL:; License: Licensed by JMIR.

    A Personalized Health Monitoring System for Community-Dwelling Elderly People in Hong Kong: Design, Implementation, and Evaluation Study


    Background: Telehealth is an effective means to assist existing health care systems, particularly for the current aging society. However, most extant telehealth systems employ individual data sources by offline data processing, which may not recognize health deterioration in a timely way. Objective: Our study objective was two-fold: to design and implement an integrated, personalized telehealth system on a community-based level; and to evaluate the system from the perspective of user acceptance. Methods: The system was designed to capture and record older adults’ health-related information (eg, daily activities, continuous vital signs, and gait behaviors) through multiple measuring tools. State-of-the-art data mining techniques can be integrated to detect statistically significant changes in daily records, based on which a decision support system could emit warnings to older adults, their family members, and their caregivers for appropriate interventions to prevent further health deterioration. A total of 45 older adults recruited from 3 elderly care centers in Hong Kong were instructed to use the system for 3 months. Exploratory data analysis was conducted to summarize the collected datasets. For system evaluation, we used a customized acceptance questionnaire to examine users’ attitudes, self-efficacy, perceived usefulness, perceived ease of use, and behavioral intention on the system. Results: A total of 179 follow-up sessions were conducted in the 3 elderly care centers. The results of exploratory data analysis showed some significant differences in the participants’ daily records and vital signs (eg, steps, body temperature, and systolic blood pressure) among the 3 centers. The participants perceived that using the system is a good idea (ie, attitude: mean 5.67, SD 1.06), comfortable (ie, self-efficacy: mean 4.92, SD 1.11), useful to improve their health (ie, perceived usefulness: mean 4.99, SD 0.91), and easy to use (ie, perceived ease of use: mean 4.99, SD 1.00). In general, the participants showed a positive intention to use the first version of our personalized telehealth system in their future health management (ie, behavioral intention: mean 4.45, SD 1.78). Conclusions: The proposed health monitoring system provides an example design for monitoring older adults’ health status based on multiple data sources, which can help develop reliable and accurate predictive analytics. The results can serve as a guideline for researchers and stakeholders (eg, policymakers, elderly care centers, and health care providers) who provide care for older adults through such a telehealth system.

  • Graphic of a patient and clinician using MyDiabetesPlan in the clinic. Source: Image created by MyDiabetesPlan team; Copyright: Catherine H Yu; License: Creative Commons Attribution (CC-BY).

    Impact of MyDiabetesPlan, a Web-Based Patient Decision Aid on Decisional Conflict, Diabetes Distress, Quality of Life, and Chronic Illness Care in Patients...


    Background: Person-centered care is critical for delivering high-quality diabetes care. Shared decision making (SDM) is central to person-centered care, and in diabetes care, it can improve decision quality, patient knowledge, and patient risk perception. Delivery of person-centered care can be facilitated with the use of patient decision aids (PtDAs). We developed MyDiabetesPlan, an interactive SDM and goal-setting PtDA designed to help individualize care priorities and support an interprofessional approach to SDM. Objective: This study aims to assess the impact of MyDiabetesPlan on decisional conflict, diabetes distress, health-related quality of life, and patient assessment of chronic illness care at the individual patient level. Methods: A two-step, parallel, 10-site cluster randomized controlled trial (first step: provider-directed implementation only; second step: both provider- and patient-directed implementation 6 months later) was conducted. Participants were adults 18 years and older with diabetes and 2 other comorbidities at 10 family health teams (FHTs) in Southwestern Ontario. FHTs were randomly assigned to MyDiabetesPlan (n=5) or control (n=5) through a computer-generated algorithm. MyDiabetesPlan was integrated into intervention practices, and clinicians (first step) followed by patients (second step) were trained on its use. Control participants received static generic Diabetes Canada resources. Patients were not blinded. Participants completed validated questionnaires at baseline, 6 months, and 12 months. The primary outcome at the individual patient level was decisional conflict; secondary outcomes were diabetes distress, health-related quality of life, chronic illness care, and clinician intention to practice interprofessional SDM. Multilevel hierarchical regression models were used. Results: At the end of the study, the intervention group (5 clusters, n=111) had a modest reduction in total decisional conflicts compared with the control group (5 clusters, n=102; −3.5, 95% CI −7.4 to 0.42). Although there was no difference in diabetes distress or health-related quality of life, there was an increase in patient assessment of chronic illness care (0.7, 95% CI 0.4 to 1.0). Conclusions: Use of goal-setting decision aids modestly improved decision quality and chronic illness care but not quality of life. Our findings may be due to a gap between goal setting and attainment, suggesting a role for optimizing patient engagement and behavioral support. The next steps include clarifying the mechanisms by which decision aids impact outcomes and revising MyDiabetesPlan and its delivery. Trial Registration: NCT02379078;

  • Chinese factory workers took body temperature before entering the workplace during work resumption following the COVID-19 outbreak. Source: Seventh Affiliated Hospital, Sun Yat-sen University; Copyright: The authors; URL:; License: Creative Commons Attribution (CC-BY).

    Self-Reported Compliance With Personal Preventive Measures Among Chinese Factory Workers at the Beginning of Work Resumption Following the COVID-19 Outbreak:...


    Background: Maintaining compliance with personal preventive measures is important to achieve a balance of COVID-19 pandemic control and work resumption. Objective: The aim of this study was to investigate self-reported compliance with four personal measures to prevent COVID-19 among a sample of factory workers in Shenzhen, China, at the beginning of work resumption in China following the COVID-19 outbreak. These preventive measures included consistent wearing of face masks in public spaces (the workplace and other public settings); sanitizing hands using soap, liquid soap, or alcohol-based hand sanitizer after returning from public spaces or touching public installations and equipment; avoiding social and meal gatherings; and avoiding crowded places. Methods: The participants were adult factory workers who had resumed work in Shenzhen, China. A stratified two-stage cluster sampling design was used. We randomly selected 14 factories that had resumed work. All full-time employees aged ≥18 years who had resumed work in these factories were invited to complete a web-based survey. Out of 4158 workers who had resumed work in these factories, 3035 (73.0%) completed the web-based survey from March 1 to 14, 2020. Multilevel logistic regression models were fitted. Results: Among the 3035 participants, 2938 (96.8%) and 2996 (98.7%) reported always wearing a face mask in the workplace and in other public settings, respectively, in the past month. However, frequencies of self-reported sanitizing hands (2152/3035, 70.9%), avoiding social and meal gatherings (2225/3035, 73.3%), and avoiding crowded places (1997/3035, 65.8%) were relatively low. At the individual level, knowledge about COVID-19 (adjusted odds ratios [AORs] from 1.16, CI 1.10-1.24, to 1.29, CI 1.21-1.37), perceived risk (AORs from 0.58, CI 0.50-0.68, to 0.85, CI 0.72-0.99) and severity (AOR 1.05, CI 1.01-1.09, and AOR 1.07, CI 1.03-1.11) of COVID-19, perceived effectiveness of preventive measures by the individual (AORs from 1.05, CI 1.00-1.10, to 1.09, CI 1.04-1.13), organization (AOR 1.30, CI 1.20-1.41), and government (AORs from 1.14, CI 1.04-1.25, to 1.21, CI 1.02-1.42), perceived preparedness for a potential outbreak after work resumption (AORs from 1.10, CI 1.00-1.21, to 1.50, CI 1.36-1.64), and depressive symptoms (AORs from 0.93, CI 0.91-0.94, to 0.96, CI 0.92-0.99) were associated with self-reported compliance with at least one personal preventive measure. At the interpersonal level, exposure to COVID-19–specific information through official media channels (AOR 1.08, CI 1.04-1.11) and face-to-face communication (AOR 0.90, CI 0.83-0.98) were associated with self-reported sanitizing of hands. The number of preventive measures implemented in the workplace was positively associated with self-reported compliance with all four preventive measures (AORs from 1.30, CI 1.08-1.57, to 1.63, CI 1.45-1.84). Conclusions: Measures are needed to strengthen hand hygiene and physical distancing among factory workers to reduce transmission following work resumption. Future programs in workplaces should address these factors at multiple levels.

  • Source:; Copyright:; URL:; License: Public Domain (CC0).

    Understanding the Community Risk Perceptions of the COVID-19 Outbreak in South Korea: Infodemiology Study


    Background: South Korea is among the best-performing countries in tackling the coronavirus pandemic by using mass drive-through testing, face mask use, and extensive social distancing. However, understanding the patterns of risk perception could also facilitate effective risk communication to minimize the impacts of disease spread during this crisis. Objective: We attempt to explore patterns of community health risk perceptions of COVID-19 in South Korea using internet search data. Methods: Google Trends (GT) and NAVER relative search volumes (RSVs) data were collected using COVID-19–related terms in the Korean language and were retrieved according to time, gender, age groups, types of device, and location. Online queries were compared to the number of daily new COVID-19 cases and tests reported in the Kaggle open-access data set for the time period of December 5, 2019, to May 31, 2020. Time-lag correlations calculated by Spearman rank correlation coefficients were employed to assess whether correlations between new COVID-19 cases and internet searches were affected by time. We also constructed a prediction model of new COVID-19 cases using the number of COVID-19 cases, tests, and GT and NAVER RSVs in lag periods (of 1-3 days). Single and multiple regressions were employed using backward elimination and a variance inflation factor of <5. Results: The numbers of COVID-19–related queries in South Korea increased during local events including local transmission, approval of coronavirus test kits, implementation of coronavirus drive-through tests, a face mask shortage, and a widespread campaign for social distancing as well as during international events such as the announcement of a Public Health Emergency of International Concern by the World Health Organization. Online queries were also stronger in women (r=0.763-0.823; P<.001) and age groups ≤29 years (r=0.726-0.821; P<.001), 30-44 years (r=0.701-0.826; P<.001), and ≥50 years (r=0.706-0.725; P<.001). In terms of spatial distribution, internet search data were higher in affected areas. Moreover, greater correlations were found in mobile searches (r=0.704-0.804; P<.001) compared to those of desktop searches (r=0.705-0.717; P<.001), indicating changing behaviors in searching for online health information during the outbreak. These varied internet searches related to COVID-19 represented community health risk perceptions. In addition, as a country with a high number of coronavirus tests, results showed that adults perceived coronavirus test–related information as being more important than disease-related knowledge. Meanwhile, younger, and older age groups had different perceptions. Moreover, NAVER RSVs can potentially be used for health risk perception assessments and disease predictions. Adding COVID-19–related searches provided by NAVER could increase the performance of the model compared to that of the COVID-19 case–based model and potentially be used to predict epidemic curves. Conclusions: The use of both GT and NAVER RSVs to explore patterns of community health risk perceptions could be beneficial for targeting risk communication from several perspectives, including time, population characteristics, and location.

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    Open Peer Review Period: Sep 27, 2020 - Nov 22, 2020

    Background: Mobile health (mHealth) apps offer a scalable option for treating sleep disturbance at a population level. However, there is a lack of clarity about the development and evaluation of evide...

    Background: Mobile health (mHealth) apps offer a scalable option for treating sleep disturbance at a population level. However, there is a lack of clarity about the development and evaluation of evidence-based 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 inception of databases through to February 2020 was conducted using 5 databases (MEDLINE, EMBASE, Cochrane Library, PsycInfo and CINAHL). Results: A total of 6,015 papers were found using the search strategy. After screening, 15 papers were identified which examined the design engineering and clinical implementation and evaluation of 8 different mHealth apps for sleep disturbance. The majority of these apps delivered 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 three papers described user and data privacy. End-user acceptability and engagement were the most frequently assessed implementation metrics. Only one app had available evidence assessing all four implementation metrics. Most apps were prototype versions (n=5), with few matured apps. Six apps had papers which provided a quantitative evaluation of clinical outcomes, but only one app had a supporting adequately-powered RCT. Conclusions: This is the first systematic review to synthesise 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 standardisation and consistency in 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 have developed a high-level framework to guide researchers and app developers in the end-to-end process of app development and evaluation.

  • The effect of blended self-management interventions on disease burden in chronic obstructive pulmonary disease and asthma patients: A systematic review and meta-analysis

    Date Submitted: Sep 26, 2020

    Open Peer Review Period: Sep 26, 2020 - Nov 21, 2020

    Background: There is a high prevalence of and high disease burden in Chronic Obstructive Pulmonary Disease (COPD) and asthma. Blended self-management interventions, which combine eHealth with face-to-...

    Background: There is a high prevalence of and high disease burden in Chronic Obstructive Pulmonary Disease (COPD) and asthma. Blended self-management interventions, which combine eHealth with face-to-face interventions, could help to reduce this disease burden. Objective: This systematic review and meta-analysis was performed to examine the effectiveness of blended self-management interventions on health-related effectiveness and process outcomes for people with COPD or asthma. Methods: Eligible randomized controlled trials (RCTs) were identified in five databases. Study quality was assessed using the Cochrane Collaboration tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Results: Of the 2694 identified publications, 17 RCTs were included in the systematic review. In the twelve COPD studies mixed effects were observed in the four health-related effectiveness outcomes. A large effect was found on body mass index (d = 0.80) and a small effect on exacerbations (d = 0.25). For (re)admission, no effect was found in the majority of COPD studies, although one study found a moderate effect (d = 0.57). No effect was found on mortality. Eleven process outcomes were studied. One study found a small positive effect on self-management ability (d = 0.26), whereas another study found no effect. No effect was found on the other process outcomes. The five asthma studies included four health-related effectiveness outcomes. The blended self-management intervention had a positive effect on asthma control (d: 0.36 to 2.11), lung function (d: 0.33 to 0.48), and – in the majority of studies - the quality of life (QoL) (d: 0.36 to 0.60), while no effect was found on admission. No effect was reported in all three process outcomes. Seven COPD studies were included in the meta-analysis. A small improvement was found on exercise capacity (g = 0.45, 95% CI: 0.04 to 0.86) and a moderate improvement on QoL (g = 0.54, 95% CI: 0.02 to 1.06). No significant effect was found on dyspnea and lung function. No asthma studies were included in the meta-analysis. Furthermore, the overall risk of bias was relatively low, and the quality of evidence varied. Conclusions: In COPD patients, the blended self-management interventions had mixed effects on health-related outcomes, with the strongest evidence found for exercise capacity and QoL. Furthermore, the review suggested that the blended self-management intervention resulted in small to large effects for asthma control, lung function and QoL in asthma patients. The results need to be interpreted carefully, because the quality of evidence varied across studies and because of the limited number of studies. Future RCTs are needed, also to examine the most effective intervention combination and duration. To conclude, there is some evidence the effectiveness of blended self-management interventions for COPD and asthma patients; yet more research is needed to confirm the effectiveness. Clinical Trial: The review was registered in PROSPERO (number 2019: CRD42019119894).

  • How doctors on social media can provide valid health information on novel coronavirus

    Date Submitted: Sep 29, 2020

    Open Peer Review Period: Sep 25, 2020 - Nov 20, 2020

    In the wake of COVID-19, the information stream has overflowed with a mixture of valid knowledge, misinformation and constantly changing guidelines. The need for help in navigating what is trustworthy...

    In the wake of COVID-19, the information stream has overflowed with a mixture of valid knowledge, misinformation and constantly changing guidelines. The need for help in navigating what is trustworthy health information is great and the official channels are struggling to keep up. As a consequence we created a Facebook group where volunteer doctors would answer questions from laymen about the novel coronavirus. There is not much precedence in healthcare professional driven Facebook groups and the framework was thus invented on the go. We ended up with an approach without room for debate to keep the group calm, trustworthy and safe to enter for the inquirers. Substantial moderator effort was needed to ensure high quality and consistency through collaboration between the more than hundred doctors participating. In the end we were able to provide a much needed service to more than 34.000 people in Denmark in time of crisis.

  • Social Stigma and Mental Health Among Overseas Chinese During the COVID-19 Pandemic

    Date Submitted: Sep 25, 2020

    Open Peer Review Period: Sep 24, 2020 - Nov 19, 2020

    Background: The COVID-19 has led to stigma and discrimination among various groups of people in different populations. However, there is no data quantifying the pattern of COVID-19 social stigma and i...

    Background: The COVID-19 has led to stigma and discrimination among various groups of people in different populations. However, there is no data quantifying the pattern of COVID-19 social stigma and its impacts on mental health. Objective: To assess COVID-19 social stigma and mental health, and to examine their association among overseas Chinese during the COVID-19 pandemic. Methods: A cross-sectional study was conducted among 519 overseas Chinese from 23 countries who were sampled using the snowball sampling method and invited to participate in an online survey during April 21 to May 7, 2020. Depression was assessed by the Chinese version of the World Health Organization Five Well-Being Index (WHO-5), and anxiety was assessed by the Chinese version of the Generalized Anxiety Disorder Scale (GAD-7). COVID-19 social stigma was assessed by a validated 6-item COVID-19 social stigma scale. Covariates included gender, age (10-year categories), educational level, marital status, occupation, length of stay in the immigrant country, perceived severity of COVID-19 (PSC), and perceived effectiveness of prevention and control measures (PEPC) in the city where they currently lived. Results: A total of 519 participants from 23 countries were involved in the current study. The prevalence of depression was 37.2% (95%CI: 33.0%–41.5%), and that of anxiety was 15.8% (95%CI: 12.8%–19.2%). During the COVID-19 pandemic, 24.2% and 26.0% of participants reported having been refused services and work or study, more than 85% reported having read “Chinese virus” or “Wuhan virus” in the media, and 54.6% reported having heard these phrases during interpersonal communication. After controlling for covariates, perceived severity, and perceived effectiveness of control, compared to those with the lowest-quartile social stigma, the odds ratios (ORs) of depression among those with the third- and highest-quartile social stigma were 2.41(95%CI: 1.25–4.65) and 3.33 (95%CI: 1.71–6.48). The OR of anxiety among those with the highest-quartile social stigma was 5.40 (95%CI: 1.95–14.95). Conclusions: Overseas Chinese face some increased social stigma, including discrimination and labeling, which is associated with a high prevalence of depression and anxiety, during the COVID-19 pandemic.