%0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10875 %T Electronic Systems for Patients to Report and Manage Side Effects of Cancer Treatment: Systematic Review %A Warrington,Lorraine %A Absolom,Kate %A Conner,Mark %A Kellar,Ian %A Clayton,Beverly %A Ayres,Michael %A Velikova,Galina %+ Section of Patient Centred Outcomes Research, Leeds Institute of Cancer and Pathology, University of Leeds, Beckett Street, Leeds, LS9 7TF, United Kingdom, 44 1132068504, l.warrington@leeds.ac.uk %K oncology %K chemotherapy %K patient reported outcomes %K patient centered %K medical informatics %D 2019 %7 24.01.2019 %9 Review %J J Med Internet Res %G English %X Background: There has been a dramatic increase in the development of electronic systems to support cancer patients to report and manage side effects of treatment from home. Systems vary in the features they offer to patients, which may affect how patients engage with them and how they improve patient-centered outcomes. Objective: This review aimed to (1) describe the features and functions of existing electronic symptom reporting systems (eg, symptom monitoring, tailored self-management advice), and (2) explore which features may be associated with patient engagement and patient-centered outcomes. Methods: The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and followed guidelines from the Centre for Reviews and Dissemination (University of York, United Kingdom). Primary searches were undertaken of MEDLINE, Embase, PsycInfo, Web of Science, Cochrane Central Register of Controlled Trials, and the Health Technology Assessment databases. Secondary searches were undertaken by screening reference lists and citations. Two researchers applied broad inclusion criteria to identify and select relevant records. Data were extracted and summarized using Microsoft Excel. In order to meet the aims, the study selection, data extraction, and data synthesis comprised two stages: (1) identifying and characterizing available systems and (2) summarizing data on patient engagement and patient-centered outcomes. Results: We identified 77 publications relating to 41 distinct systems. In Stage 1, all publications were included (N=77). The features identified that supported clinicians and care were facility for health professionals to remotely access and monitor patient-reported data (24/41, 58%) and function to send alerts to health professionals for severe symptoms (17/41, 41%). Features that supported patients were facility for patients to monitor/review their symptom reports over time (eg, graphs) (19/41, 46%), general patient information about cancer treatment and side effects (17/41, 41%), tailored automated patient advice on symptom management (12/41, 29%), feature for patients to communicate with the health care team (6/41, 15%), and a forum for patients to communicate with one another (4/41, 10%). In Stage 2, only publications that included some data on patient engagement or patient-centered outcomes were included (N=29). A lack of consistency between studies in how engagement was defined, measured, or reported, and a wide range of methods chosen to evaluate systems meant that it was not possible to compare across studies or make conclusions on relationships with system features. Conclusions: Electronic systems have the potential to help patients manage side effects of cancer treatment, with some evidence to suggest a positive effect on patient-centered outcomes. However, comparison across studies is difficult due to the wide range of assessment tools used. There is a need to develop guidelines for assessing and reporting engagement with systems, and a set of core outcomes for evaluation. We hope that this review will contribute to the field by introducing a taxonomy for characterizing system features. Trial Registration: PROSPERO CRD42016035915; www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016035915 %M 30679145 %R 10.2196/10875 %U http://www.jmir.org/2019/1/e10875/ %U https://doi.org/10.2196/10875 %U http://www.ncbi.nlm.nih.gov/pubmed/30679145 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11297 %T Consumer Health Information Technology in the Prevention of Substance Abuse: Scoping Review %A Pradhan,Apoorva Milind %A Park,Leah %A Shaya,Fadia T %A Finkelstein,Joseph %+ Department of Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, 12th Floor, 01-204, Baltimore, MD, 21201, United States, 1 410 706 5392, fshaya@rx.umaryland.edu %K consumer health information technology %K primary prevention %K substance abuse %K review %D 2019 %7 30.01.2019 %9 Review %J J Med Internet Res %G English %X Background: Addiction is one of the most rapidly growing epidemics that currently plagues nations around the world. In the United States, it has cost the government more than US $700 billion a year in terms of health care and other associated costs and is also associated with serious social, physical, and mental consequences. Increasing efforts have been made to tackle this issue at different levels, from primary prevention to rehabilitation across the globe. With the use of digital technology rapidly increasing, an effort to leverage the consumer health information technologies (CHITs) to combat the rising substance abuse epidemic has been underway. CHITs are identified as patient-focused technological platforms aimed to improve patient engagement in health care and aid them in navigating the complex health care system. Objective: This review aimed to provide a holistic and overarching view of the breadth of research on primary prevention of substance abuse using CHIT conducted over nearly past five decades. It also aimed to map out the changing landscape of CHIT over this period. Methods: We conducted a scoping review using the Arksey and O’Malley’s modified methodological framework. We searched 4 electronic databases (PubMed, Cochrane, Scopus, and EMBASE). Papers were included if the studies addressed the use of CHIT for primary prevention of substance abuse and were published in English between 1809 and 2018. Studies that did not focus solely on primary prevention or assessed additional comorbid conditions were eliminated. Results: Forty-two papers that met our inclusion criteria were included in the review. These studies were published between 1970 and 2018 and were not restricted by geography, age, race, or sex. The review mapped studies using the most commonly used CHIT platforms for substance abuse prevention from mass media in the 1970s to mobile and social media in 2018. Moreover, 191 studies that were exclusively focused on alcohol prevention were excluded and will be addressed in a separate paper. The studies included had diverse research designs although the majority were randomized controlled trials (RCT) or review papers. Many of the RCTs used interventions based on different behavioral theories such as family interactions, social cognitive theories, and harm-minimization framework. Conclusions: This review found CHIT platforms to be efficacious and cost-effective in the real-world settings. We also observed a gradual shift in the types and use of CHIT platforms over the past few decades and mapped out their progression. In addition, the review detected a shift in consumer preferences and behaviors from face-to-face interactions to technology-based platforms. However, the studies included in this review only focused on the aspect of primary prevention. Future reviews could assess the effectiveness of platforms for secondary prevention and for prevention of substance abuse among comorbid populations. %M 30698526 %R 10.2196/11297 %U http://www.jmir.org/2019/1/e11297/ %U https://doi.org/10.2196/11297 %U http://www.ncbi.nlm.nih.gov/pubmed/30698526 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12449 %T E-Learning for Medical Education in Sub-Saharan Africa and Low-Resource Settings: Viewpoint %A Barteit,Sandra %A Jahn,Albrecht %A Banda,Sekelani S %A Bärnighausen,Till %A Bowa,Annel %A Chileshe,Geoffrey %A Guzek,Dorota %A Jorge,Margarida Mendes %A Lüders,Sigrid %A Malunga,Gregory %A Neuhann,Florian %+ Heidelberg Institute of Global Health, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 06221 ext 5634030, barteit@uni-heidelberg.de %K medical e-learning %K technology-enhanced learning %K blended learning %K health workers %K health system strengthening %K universal health coverage %K medical education %K mHealth %K eHealth %K developing countries %K sub-Saharan Africa %K low-resource countries %D 2019 %7 09.01.2019 %9 Viewpoint %J J Med Internet Res %G English %X E-learning has been heralded as a revolutionary force for medical education, especially for low-resource countries still suffering from a dire lack of health care workers. However, despite over two decades of e-learning endeavors and interventions across sub-Saharan Africa and other low- and middle-income countries, e-learning for medical education has not gained momentum and continues to fall short of the anticipated revolution. Many e-learning interventions have been cul-de-sac pilots that have not been scaled up but rather terminated after the pilot phase. This is usually a result of not adopting a system-wide approach, which leads to insufficient scope of training, insufficient technological maintenance and user support, unattainably high expectations, and unrealistic financial planning. Thus, a multitude of e-learning evaluations have failed to provide scientifically sound evidence of the effectiveness of e-learning for medical education in low-resource countries. Instead, it appears that technological development has overwhelmed rather than revolutionized medical education. The question of how to push e-learning into a higher gear in low-resource countries persists. Provision of e-learning as a technology is insufficient. E-learning needs to be vigorously and sustainably integrated into the local educational setting and aligned with national strategies and other national endeavors and interventions. Adhering to a standardized framework for the implementation and evaluation of e-learning endeavors is key, especially to bridge the gap in robust evidence that should also guide e-learning implementations. The primary objective of e-learning for medical education is to strengthen the health system in order to serve the population’s health care needs and expectations. Currently, medical e-learning does not measure up to its potential or do justice to medical students in low-resource countries. Technology may help unfold the potential of e-learning, but an all-encompassing change is needed. This can only be achieved through a joint effort that follows a systematic and standardized framework, especially for implementation and evaluation. %M 30626565 %R 10.2196/12449 %U http://www.jmir.org/2019/1/e12449/ %U https://doi.org/10.2196/12449 %U http://www.ncbi.nlm.nih.gov/pubmed/30626565 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11528 %T Use of the Principles of Design Thinking to Address Limitations of Digital Mental Health Interventions for Youth: Viewpoint %A Scholten,Hanneke %A Granic,Isabela %+ Behavioural Science Institute, Radboud University, PO Box 9104, Nijmegen, 6500 HE, Netherlands, 31 24 3612527, h.scholten@bsi.ru.nl %K anxiety %K depression %K design thinking %K e-mental health %K youth %D 2019 %7 14.01.2019 %9 Viewpoint %J J Med Internet Res %G English %X Numerous reviews and meta-analyses have indicated the enormous potential of technology to improve the appeal, effectiveness, cost, and reach of mental health interventions. However, the promise of digital mental health interventions for youth has not yet been realized. Significant challenges have been repeatedly identified, including engagement, fidelity, and the lack of personalization. We introduce the main tenets of design thinking and explain how they can specifically address these challenges, with an entirely new toolbox of mindsets and practices. In addition, we provide examples of a new wave of digital interventions to demonstrate the applicability of design thinking to a wide range of intervention goals. In the future, it will be critical for scientists and clinicians to implement their scientific standards, methods, and review outlets to evaluate the contribution of design thinking to the next iteration of digital mental health interventions for youth. %M 31344671 %R 10.2196/11528 %U https://www.jmir.org/2019/1/e11528/ %U https://doi.org/10.2196/11528 %U http://www.ncbi.nlm.nih.gov/pubmed/31344671 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11752 %T Measuring the Implementation of Behavioral Intervention Technologies: Recharacterization of Established Outcomes %A Hermes,Eric DA %A Lyon,Aaron R %A Schueller,Stephen M %A Glass,Joseph E %+ Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, United States, 1 203 932 5711, eric.hermes@yale.edu %K mobile applications %K behavior therapy %K technology %K internet %K telemedicine %K diffusion of innovation %K translational medical research %K outcome assessment (health care) %K review %K implementation %K behavioral intervention technology %D 2019 %7 25.01.2019 %9 Viewpoint %J J Med Internet Res %G English %X Behavioral intervention technologies (BITs) are websites, software, mobile apps, and sensors designed to help users address or change behaviors, cognitions, and emotional states. BITs have the potential to transform health care delivery, and early research has produced promising findings of efficacy. BITs also favor new models of health care delivery and provide novel data sources for measurement. However, there are few examples of successful BIT implementation and a lack of consensus on as well as inadequate descriptions of BIT implementation measurement. The aim of this viewpoint paper is to provide an overview and characterization of implementation outcomes for the study of BIT use in routine practice settings. Eight outcomes for the evaluation of implementation have been previously described: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. In a proposed recharacterization of these outcomes with respect to BIT implementation, definitions are clarified, expansions to the level of analysis are identified, and unique measurement characteristics are discussed. Differences between BIT development and implementation, an increased focus on consumer-level outcomes, the expansion of providers who support BIT use, and the blending of BITs with traditional health care services are specifically discussed. BITs have the potential to transform health care delivery. Realizing this potential, however, will hinge on high-quality research that consistently and accurately measures how well such technologies have been integrated into health services. This overview and characterization of implementation outcomes support BIT research by identifying and proposing solutions for key theoretical and practical measurement challenges. %M 30681966 %R 10.2196/11752 %U http://www.jmir.org/2019/1/e11752/ %U https://doi.org/10.2196/11752 %U http://www.ncbi.nlm.nih.gov/pubmed/30681966 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12128 %T Human-Centered Design of Video-Based Health Education: An Iterative, Collaborative, Community-Based Approach %A Adam,Maya %A McMahon,Shannon A %A Prober,Charles %A Bärnighausen,Till %+ Stanford Center for Health Education, Stanford School of Medicine, Stanford University, 408 Panama Mall, Stanford, CA, 94305, United States, 1 650 839 3600, madam@stanford.edu %K human-centered design %K health promotion %K health behavior %K health knowledge, attitudes, practice %K community health workers %K telemedicine %K eHealth %K mHealth %D 2019 %7 30.01.2019 %9 Tutorial %J J Med Internet Res %G English %X Drawing on 5 years of experience designing, producing, and disseminating video health education programs globally, we outline the process of creating accessible, engaging, and relevant video health education content using a community-based, human-centered design approach. We show that this approach can yield a new generation of interventions, which are better aligned with the needs and contexts of target communities. The participation of target communities and local stakeholders in the content production and design process fosters ownership of the content and increases the likelihood that the resulting intervention will resonate within its intended primary audience and be disseminated broadly. Ease of future adaptation for additional global audiences and modification of the content for multiple dissemination pathways are important early considerations to ensure scalability and long-term impact of the intervention. Recent advances in mobile technology can facilitate the dissemination of accessible, engaging health education at scale, thereby enhancing the potential impact of video-based educational tools.Accessible and engaging health education is a cornerstone of health behavior change. Especially in low- and middle-income countries, increasing access to effective health education can contribute to improved health outcomes. Prior research has identified several characteristics of effective health education interventions. These include the integration of pictures, narratives, and entertainment-education, in which the health messages that make up the educational content are embedded. However, the effectiveness and long-term impact of health messages ultimately depend on how well the end users can identify with the content that is presented. This identification, in turn, is a function of how well the messages correspond to user needs and wants and how this correspondence is communicated through the design characteristics of the health education intervention. %M 30698531 %R 10.2196/12128 %U http://www.jmir.org/2019/1/e12128/ %U https://doi.org/10.2196/12128 %U http://www.ncbi.nlm.nih.gov/pubmed/30698531 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11250 %T Web-Based Exercise as an Effective Complementary Treatment for Patients With Nonalcoholic Fatty Liver Disease: Intervention Study %A Pfirrmann,Daniel %A Huber,Yvonne %A Schattenberg,Jörn Markus %A Simon,Perikles %+ Department of Sports Medicine, Disease Prevention and Rehabilitation, Institute of Sports Science, Johannes Gutenberg University, Johann-Joachim-Becher-Weg 31, Mainz, 55099, Germany, 49 6131 ext 3923586, simonpe@uni-mainz.de %K exercise %K fatty liver %K lifestyle %K NAFLD %K treatment %K Web-based %D 2019 %7 02.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical inactivity is a major risk factor for nonalcoholic fatty liver disease (NAFLD). Exercise-based prevention interventions for improving cardiorespiratory fitness are a recommended complementary treatment for NAFLD. Achievement of minimally effective physical activity to improve cardiorespiratory fitness among patients typically involves high personal and financial expenses in face-to-face settings. We designed an eHealth approach for patients with NAFLD to improve the cardiorespiratory fitness and report the first results of the HELP (Hepatic Inflammation and Physical Performance in Patients With NASH [nonalcoholic steatohepatitis]) study. Objective: We aimed to assess the effectiveness of an 8-week, tailored, Web-based exercise intervention for cardiorespiratory fitness improvement, expressed as peak oxygen uptake (peak volume of oxygen [VO2peak]), in patients with histologically confirmed NAFLD. Methods: In a 24-month period, 44 patients were enrolled into an 8-week, prospective, single-arm study with 12 weeks of follow-up. After a medical examination and performance diagnostics, a sports therapist introduced the patients to a Web-based platform for individualized training support. Regular individual patient feedback was provided to systematically adapt the weekly exercise schedule, which allowed us to monitor and ensure patient adherence to strength and endurance training and optimize the step-wise progressive exercise load. Exercise progression was based on an a priori algorithm that considered the subjective rate for both perceived exhaustion and general physical discomfort. The VO2peak was assessed at baseline and at the end of the study by spiroergometry. Results: A total of 43 patients completed the intervention with no adverse events. The VO2peak increased significantly by 2.4 mL/kg/min (8.8%; 95% confidence interval [CI]: 1.48-3.27; P<.001) accompanied by a reduction of 1.0 kg in a body weight (95% CI: 0.33-1.58; P=.004) and 1.3 kg in body fat mass (95% CI: 0.27-2.27; P=.01). In an exploratory analysis, step-wise logistic regression analysis revealed low body fat and VO2peak at baseline and the total minutes of endurance training during the intervention as main contributors to a positive change in VO2peak. Our predictive model indicated that the average patient with NAFLD needed 223 min for stabilization of VO2peak and 628 min for average improvement in VO2peak. However, in patients with a VO2peak approximately 20% higher than the average VO2peak, 628 min were only sufficient to stabilize the VO2peak and >40% reduction in the average fat mass would be required to achieve an average outcome. Conclusions: This is the first study to show that patients with NAFLD can be effectively supported by a Web-based approach, which can increase the VO2peak to a similar extent as face-to-face interventions. Patients with low body fat and low VO2peak benefited the most from our intervention. In terms of future treatment strategies, NAFLD patients with high body fat may particularly benefit from body-fat reduction through a strict nutritional intervention, subsequently enabling a more effective exercise intervention. Trial Registration: ClinicalTrials.gov NCT02526732; https://clinicaltrials.gov/ct2/show/NCT02526732 (Archived by WebCite at http://www.webcitation.org/74pXhXXfq) International Registered Report Identifier (IRRID): RR2-10.2196/resprot.8607 %M 30602434 %R 10.2196/11250 %U http://www.jmir.org/2019/1/e11250/ %U https://doi.org/10.2196/11250 %U http://www.ncbi.nlm.nih.gov/pubmed/30602434 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e298 %T Web-Based Digital Health Interventions for Weight Loss and Lifestyle Habit Changes in Overweight and Obese Adults: Systematic Review and Meta-Analysis %A Beleigoli,Alline M %A Andrade,Andre Q %A Cançado,Alexandre G %A Paulo,Matheus NL %A Diniz,Maria De Fátima H %A Ribeiro,Antonio L %+ Internal Medicine Department, Faculty of Medicine, Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena, 190 Santa Efigenia, Belo Horizonte, 30130100, Brazil, 55 3134099746, abeleigoli@gmail.com %K internet %K mobile phone %K meta-analysis %K obesity %K telemedicine %D 2019 %7 08.01.2019 %9 Review %J J Med Internet Res %G English %X Background: Obesity is a highly prevalent condition with important health implications. Face-to-face interventions to treat obesity demand a large number of human resources and time, generating a great burden to individuals and health system. In this context, the internet is an attractive tool for delivering weight loss programs due to anonymity, 24-hour-accessibility, scalability, and reachability associated with Web-based programs. Objective: We aimed to investigate the effectiveness of Web-based digital health interventions, excluding hybrid interventions and non-Web-based technologies such as text messaging, short message service, in comparison to nontechnology active or inactive (wait list) interventions on weight loss and lifestyle habit changes in individuals with overweight and obesity. Methods: We searched PubMed or Medline, SciELO, Lilacs, PsychNet, and Web of Science up to July 2018, as well as references of previous reviews for randomized trials that compared Web-based digital health interventions to offline interventions. Anthropometric changes such as weight, body mass index (BMI), waist, and body fat and lifestyle habit changes in adults with overweight and obesity were the outcomes of interest. Random effects meta-analysis and meta-regression were performed for mean differences (MDs) in weight. We rated the risk of bias for each study and the quality of evidence across studies using the Grades of Recommendation, Assessment, Development, and Evaluation approach. Results: Among the 4071 articles retrieved, 11 were included. Weight (MD −0.77 kg, 95% CI −2.16 to 0.62; 1497 participants; moderate certainty evidence) and BMI (MD −0.12 kg/m2; 95% CI −0.64 to 0.41; 1244 participants; moderate certainty evidence) changes were not different between Web-based and offline interventions. Compared to offline interventions, digital interventions led to a greater short-term (<6 months follow-up) weight loss (MD −2.13 kg, 95% CI −2.71 to −1.55; 393 participants; high certainty evidence), but not in the long-term (MD −0.17 kg, 95% CI −2.10 to 1.76; 1104 participants; moderate certainty evidence). Meta-analysis was not possible for lifestyle habit changes. High risk of attrition bias was identified in 5 studies. For weight and BMI outcomes, the certainty of evidence was moderate mainly due to high heterogeneity, which was mainly attributable to control group differences across studies (R2=79%). Conclusions: Web-based digital interventions led to greater short-term but not long-term weight loss than offline interventions in overweight and obese adults. Heterogeneity was high across studies, and high attrition rates suggested that engagement is a major issue in Web-based interventions. %M 30622090 %R 10.2196/jmir.9609 %U https://www.jmir.org/2019/1/e298/ %U https://doi.org/10.2196/jmir.9609 %U http://www.ncbi.nlm.nih.gov/pubmed/30622090 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10421 %T Identifying Brief Message Content for Interventions Delivered via Mobile Devices to Improve Medication Adherence in People With Type 2 Diabetes Mellitus: A Rapid Systematic Review %A Long,Hannah %A Bartlett,Yvonne K %A Farmer,Andrew J %A French,David P %+ Manchester Centre for Health Psychology, School of Health Sciences, University of Manchester, Coupland 1 Building, Coupland Street, Manchester, M13 9PL, United Kingdom, 44 161 275 2605, david.french@manchester.ac.uk %K medication adherence %K diabetes mellitus %K systematic review %K text messaging %K mHealth %K self-management %D 2019 %7 09.01.2019 %9 Review %J J Med Internet Res %G English %X Background: Current interventions to support medication adherence in people with type 2 diabetes are generally resource-intensive and ineffective. Brief messages, such as those delivered via short message service (SMS) systems, are increasingly used in digital health interventions to support adherence because they can be delivered on a wide scale and at low cost. The content of SMS text messages is a crucial intervention feature for promoting behavior change, but it is often unclear what the rationale is for chosen wording or any underlying mechanisms targeted for behavioral change. There is little guidance for developing and optimizing brief message content for use in mobile device–delivered interventions. Objective: This review aimed to (1) identify theoretical constructs (ie, the targets that interventions aim to change) and behavioral strategies (ie, features of intervention content) found to be associated with medication adherence in patients with type 2 diabetes and (2) map these onto a standard taxonomy for behavior change techniques (BCTs, that is, active ingredients of interventions used to promote behavioral change, to produce an evidence-based set of approaches that have shown promise of improving adherence in previous studies and which could be further tested in digital health interventions. Methods: A rapid systematic review of existing relevant systematic reviews was conducted. MEDLINE and PsycINFO databases were searched from inception to April 10, 2017. Inclusion criteria were (1) systematic reviews of quantitative data if the studies reviewed identified predictors of or correlates with medication adherence or evaluated medication adherence–enhancing interventions and included adult participants taking medication to manage a chronic physical health condition, and (2) systematic reviews of qualitative studies of experiences of medication adherence for adult participants with type 2 diabetes. Data were extracted on review characteristics and BCTs, theoretical constructs, or behavioral strategies associated with improved adherence. Constructs and strategies were mapped onto the BCT version 1 taxonomy. Results: A total of 1701 references were identified; 25 systematic reviews (19 quantitative reviews, 3 qualitative reviews, and 3 mixed-method reviews) were included. Moreover, 20 theoretical constructs (eg, self-efficacy) and 19 behavioral strategies (eg, habit analysis) were identified in the included reviews. In total, 46 BCTs were identified as being related to medication adherence in type 2 diabetes (eg, habit formation, prompts or cues, and information about health consequences). Conclusions: We identified 46 promising BCTs related to medication adherence in type 2 diabetes on which the content of brief messages delivered through mobile devices to improve adherence could be based. By using explicit systematic review methods and linking our findings to a standardized taxonomy of BCTs, we have described a novel approach for the development of digital message content. Future brief message interventions that aim to support medication adherence could incorporate the identified BCTs. %M 30626562 %R 10.2196/10421 %U https://www.jmir.org/2019/1/e10421/ %U https://doi.org/10.2196/10421 %U http://www.ncbi.nlm.nih.gov/pubmed/30626562 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11566 %T Evaluating a Web-Based Social Anxiety Intervention Among Community Users: Analysis of Real-World Data %A McCall,Hugh Cameron %A Helgadottir,Fjola Dogg %A Menzies,Ross G %A Hadjistavropoulos,Heather D %A Chen,Frances S %+ AI-Therapy, 5515 Stellar Place, North Vancouver, BC, V7R 4N3, Canada, 1 604 652 5440, fjola@ai-therapy.com %K social anxiety %K internet %K cognitive behavioral therapy %K psychotherapy %K mental health %D 2019 %7 10.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Social anxiety is both harmful and prevalent. It also currently remains among the most undertreated major mental disorders, due, in part, to socially anxious individuals’ concerns about the stigma and expense of seeking help. The privacy and affordability of computer-aided psychotherapy interventions may render them particularly helpful in addressing these concerns, and they are also highly scalable, but most tend to be only somewhat effective without therapist support. However, a recent evaluation of a new self-guided, 7-module internet-delivered cognitive behavioral therapy intervention called Overcome Social Anxiety found that it was highly effective. Objective: The initial evaluation of Overcome Social Anxiety revealed that it led to significant reductions in symptom severity among university undergraduates. The aim of this study was to extend the results of the initial study and investigate their generalizability by directly evaluating the intervention’s effectiveness among a general community sample. Methods: While signing up for Overcome Social Anxiety, users consented to the usage of their anonymized outcome data for research purposes. Before and after completing the intervention, users completed the Fear of Negative Evaluation Scale (FNE), which we employed as the primary outcome measure. Secondary outcome measures included the Depression Anxiety Stress Scales (DASS) and 2 bespoke questionnaires measuring socially anxious thoughts (Thoughts Questionnaire) and avoidance behaviors (Avoidance Questionnaire). Results: Participants who completed the intervention (102/369, 27.7%) experienced significant reductions in the severity of their symptoms on all measures employed, including FNE (P<.001; Cohen d=1.76), the depression subscale of DASS (P<.001; Cohen d=0.70), the anxiety subscale of DASS (P<.001; Cohen d=0.74), the stress subscale of DASS (P<.001; Cohen d=0.80), the Thoughts Questionnaire (P<.001; Cohen d=1.46), and the Avoidance Questionnaire (P<.001; Cohen d=1.42). Conclusions: Our results provide further evidence that Overcome Social Anxiety reduces the severity of social anxiety symptoms among those who complete it and suggest that its effectiveness extends to the general community. The completion rate is the highest documented for a fully automated intervention for anxiety, depression, or low mood in a real community sample. In addition, our results indicate that Overcome Social Anxiety reduces the severity of symptoms of depression, physiological symptoms of anxiety, and stress in addition to symptoms of social anxiety. %M 30632965 %R 10.2196/11566 %U http://www.jmir.org/2019/1/e11566/ %U https://doi.org/10.2196/11566 %U http://www.ncbi.nlm.nih.gov/pubmed/30632965 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10868 %T A Novel Insight Into the Challenges of Diagnosing Degenerative Cervical Myelopathy Using Web-Based Symptom Checkers %A Davies,Benjamin Marshall %A Munro,Colin Fraser %A Kotter,Mark RN %+ Academic Neurosurgery Unit, Department of Clinical Neurosciences, University of Cambridge, ED Adrian Building, Forvie Site, Robinson Way, Cambridge, CB2 2PY, United Kingdom, 44 7887790773, mrk25@cam.ac.uk %K cord compression %K degenerative cervical myelopathy %K diagnosis %K differential %K spondylosis %D 2019 %7 11.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Degenerative cervical myelopathy (DCM) is a common debilitating condition resulting from degeneration of the cervical spine. While decompressive surgery can halt disease progression, existing spinal cord damage is often permanent, leaving patients with lifelong disability. Early surgery improves the likelihood of recovery, yet the average time from the onset of symptoms to correct diagnosis is over 2 years. The majority of delays occur initially, before and within primary care, mainly due to a lack of recognition. Symptom checkers are widely used by patients before medical consultation and can be useful for preliminary triage and diagnosis. Lack of recognition of DCM by symptom checkers may contribute to the delay in diagnosis. Objective: The aims of this study were to investigate whether Web-based symptom checkers were able to recognize relevant symptoms of DCM, to characterize the DCM differential they returned , and to evaluate the diagnostic performance of recognized DCM symptoms. Methods: We pooled classical DCM symptoms from leading review articles. These symptoms were entered into the algorithms used by the top 20 symptom checker websites (N=4; Google Search). The most widely cited symptom checker, WebMD, was used to characterize the differential diagnosis for DCM symptoms. Results: A total of 31 classical DCM symptoms were identified, of which 45% (14/31) listed DCM as a differential and 10% (3/31) placed DCM in the top third of the differential. The mean differential rank for motor symptoms was significantly better than that for arthritic symptoms (P=.01) and the average differential rank for all symptoms (P=.048). The symptom checker WebMD performed best at recognizing DCM, placing the condition nearer to the top of the differential list (mean rank of 5.6) than either Healthline (rank of 12.9, P=.02) or Healthtools.AARP (rank of 15.5, P=.001). On WebMD, only one combination of symptoms resulted in DCM as the primary differential: neck, shoulder, and arm pain with hand weakness. Moreover, 151 differential diagnoses for DCM symptoms were recorded on WebMD. Multiple sclerosis and peripheral neuropathy were the most common differentials, shortlisted for 52% (16/31) and 32% (10/31) of the DCM symptoms, respectively. Conclusions: DCM symptoms are poorly identified by Web-based symptom checkers, which leads to a large differential of many other common conditions. While a diagnosis becomes more likely as the number of symptoms increases, this represents more advanced disease and will not support much-needed earlier diagnosis. Symptom checkers remain an attractive concept with potential. Further research is required to support their optimization. %M 30300137 %R 10.2196/10868 %U http://www.jmir.org/2019/1/e10868/ %U https://doi.org/10.2196/10868 %U http://www.ncbi.nlm.nih.gov/pubmed/30300137 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12530 %T Internet-Delivered Acceptance and Commitment Therapy for Anxiety Treatment: Systematic Review %A Kelson,Joshua %A Rollin,Audrey %A Ridout,Brad %A Campbell,Andrew %+ Cyberpsychology Research Group, Faculty of Health Sciences, The University of Sydney, City Road, Sydney, 2006, Australia, 61 2 9351 7089, joshnkelson@gmail.com %K anxiety %K anxiety disorders %K acceptance and commitment therapy %K mindfulness %K telemedicine %K internet %K e-therapy %D 2019 %7 29.01.2019 %9 Review %J J Med Internet Res %G English %X Background: Anxiety conditions are debilitating and prevalent throughout the world. Acceptance and Commitment Therapy (ACT) is an effective, acceptance-based behavioral therapy for anxiety. However, there are treatment barriers (eg, financial, geographical, and attitudinal), which prevent people from accessing it. To overcome these barriers, internet-delivered ACT (iACT) interventions have been developed in recent years. These interventions use websites to deliver ACT information and skill training exercises on the Web, either as pure self-help or with therapist guidance. Objective: This systematic review aimed to examine the therapeutic impact of iACT on all anxiety conditions. Methods: The EMBASE, MEDLINE, ProQuest Central, PsycINFO, Scopus, and Web of Science databases were searched up to September 2018. The titles and abstracts of remaining records after deduplication were screened by 2 authors with a total of 36 full-text articles being retained for closer inspection next to eligibility criteria. Empirical studies of all designs, population types, and comparator groups were included if they appraised the impact of iACT treatment on any standardized measure of anxiety. Included studies were appraised on methodological quality and had their data extracted into a standardized coding sheet. Findings were then tabulated, and a narrative synthesis was performed because of the heterogeneity found between studies. Results: A total of 20 studies met inclusion criteria. There were 11 randomized controlled trials (RCTs) and 9 uncontrolled pilot studies. Participants across all studies were adults. The anxiety conditions treated were as follows: generalized anxiety disorder (GAD), social anxiety disorder (SAD), illness anxiety disorder (IAD), and general anxiety symptoms, with or without comorbid physical and mental health problems. A total of 18 studies reported significant anxiety reduction after iACT treatment. This was observed in studies that delivered iACT with (n=13) or without (n=5) therapist guidance. The average attrition rate across all included studies during the active iACT treatment phase was 19.19%. In the 13 studies that assessed treatment satisfaction, participants on average rated their iACT experience with above average to high treatment satisfaction. Conclusions: These findings indicate that iACT can be an efficacious and acceptable treatment for adults with GAD and general anxiety symptoms. More RCT studies are needed to corroborate these early iACT findings using empirical treatments in active control groups (eg, internet-delivered cognitive behavioral therapy). This would potentially validate the promising results found for SAD and IAD as well as address the full spectrum of anxiety disorders. %M 30694201 %R 10.2196/12530 %U http://www.jmir.org/2019/1/e12530/ %U https://doi.org/10.2196/12530 %U http://www.ncbi.nlm.nih.gov/pubmed/30694201 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10674 %T Electronic Health Program to Empower Patients in Returning to Normal Activities After Colorectal Surgical Procedures: Mixed-Methods Process Evaluation Alongside a Randomized Controlled Trial %A den Bakker,Chantal M %A Huirne,Judith AF %A Schaafsma,Frederieke G %A de Geus,Charlotte %A Bonjer,Hendrik J %A Anema,Johannes R %+ Department of Occupational and Public Health, Amsterdam Public Health Research Institute, VU University Medical Center, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 20 4445703, c.denbakker@vumc.nl %K return to normal activities %K return to work %K patient reported outcome measures %K colectomy %K process evaluation %D 2019 %7 29.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Long-term recovery takes longer than expected despite improved surgical techniques and Enhanced Recovery After Surgery programs. An electronic health (eHealth) care program (“ikherstel”) was developed to partially substitute perioperative care for patients undergoing colorectal surgical procedures. Successfully tested eHealth programs are not always implemented in usual care, and it is, therefore, important to evaluate the process to optimize future implementation. Objective: The aim of this study was to evaluate whether the eHealth intervention was executed as planned. Methods: A mixed-methods process evaluation was carried out alongside a multicenter randomized controlled trial (RCT). This evaluation was performed using the Linnan and Steckler framework for the quantitative part of this study, measuring the components reach, dose delivered, dose received, fidelity, and participants’ attitudes. Total implementation scores were calculated using the averaging approach, in which the sum of all data points is divided by the number of data points and the total adherence to the protocol is measured. For the qualitative part, the Unified Theory of Acceptance and Use of Technology framework was used. The quantitative data were based on participants’ questionnaires, a logistic database, a weblog, and participants’ medical files and were obtained by performing semistructured interviews with participants of the RCT. Results: A total of 151 participants of 340 eligible patients were included in the RCT, of which 73 participants were allocated to the intervention group. On the basis of the quantitative process data, total implementation scores for the website, mobile app, electronic consult, and activity tracker were 64%, 63%, 44%, and 67%, respectively. Participants in the qualitative part experienced the program as supportive and provided guidance on their recovery process after colorectal surgery. Most frequently mentioned barriers were the limited interaction with and feedback from health care professionals and the lack of tailoring of the convalescence plan in case of a different course of recovery. Conclusions: The intervention needs more interaction with and feedback from health care professionals and needs more tailored guidance in case of different recovery or treatment courses. To ensure a successful implementation of the program in daily practice, some adjustments are required to optimize the program in a blended care form. Trial Registration: Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC= 5686 (Archieved by WebCite at http://www.webcitation.org/75LrJaHrr) %M 30694205 %R 10.2196/10674 %U http://www.jmir.org/2019/1/e10674/ %U https://doi.org/10.2196/10674 %U http://www.ncbi.nlm.nih.gov/pubmed/30694205 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11571 %T Using the Facebook Advertisement Platform to Recruit Chinese, Korean, and Latinx Cancer Survivors for Psychosocial Research: Web-Based Survey Study %A Tsai,William %A Zavala,Daisy %A Gomez,Sol %+ Department of Applied Psychology, New York University, 246 Greene Street, 8th Floor, New York, NY, 10003, United States, 1 212 998 5552, will.tsai@nyu.edu %K ethnic minority cancer survivor %K Facebook recruitment %K Korean cancer survivor %K Chinese cancer survivor %K Latinx cancer survivor %K mobile phone %D 2019 %7 10.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Ethnic minority cancer survivors remain an understudied and underrepresented population in cancer research, in part, due to the challenge of low participant recruitment rates. Therefore, identifying effective recruitment strategies is imperative for reducing cancer health disparities among this population. With the widespread use of social media, health researchers have turned to Facebook as a potential source of recruitment. Objective: We aimed to evaluate the feasibility and effectiveness of purchasing ads on Facebook to recruit Chinese, Korean, and Latinx cancer survivors residing in the United States. We assessed their experience with participating in a Web-based survey and their interest for future research. Methods: We showed 5 purchased ads in English, simplified Chinese, traditional Chinese, Korean, and Spanish on Facebook. Participants who clicked on the Facebook ad were directed to the study website and asked to submit their emails to receive the link to the 30-minute Web-based survey. Inclusion criteria included being of Asian or Latinx heritage, age ≥18 years, having a cancer diagnosis, and being within 5 years of cancer treatment. Participants who completed the survey were sent a US $10 Walmart eGiftcard. Results: The Facebook ads were shown for 48 consecutive days for a total spending of US $1200.46 (US $25/day budget). Overall, 11 East Asian and 15 Latinx cancer survivors completed the study, resulting in an average cost per participant of US $46.17. The East Asian and Latinx cancer survivors did not significantly differ in age, years lived in the United States, education level, generation status, and time since diagnosis. However, Latinx cancer survivors were marginally more likely to have limited English proficiency and lower annual income than East Asian cancer survivors. Both Latinx and East Asian cancer survivors reported that they enjoyed participating in this study and indicated an interest in participating in future psychosocial research studies. Conclusions: The use of Facebook ads successfully resulted in the recruitment of East Asian and Latinx cancer survivors with different cancer diagnoses who reside in various geographic regions of the United States. We found that East Asian and Latinx cancer survivors recruited through Facebook were interested in participating in future psychosocial research, thereby providing support for the feasibility and effectiveness of using Facebook as a source of recruitment for ethnic minority cancer survivors. %M 30632966 %R 10.2196/11571 %U http://www.jmir.org/2019/1/e11571/ %U https://doi.org/10.2196/11571 %U http://www.ncbi.nlm.nih.gov/pubmed/30632966 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10179 %T How Search Engine Data Enhance the Understanding of Determinants of Suicide in India and Inform Prevention: Observational Study %A Adler,Natalia %A Cattuto,Ciro %A Kalimeri,Kyriaki %A Paolotti,Daniela %A Tizzoni,Michele %A Verhulst,Stefaan %A Yom-Tov,Elad %A Young,Andrew %+ ISI Foundation, Via Chisola 5, Torino, 10126, Italy, 39 011 660 3090, daniela.paolotti@isi.it %K internet data %K India %K suicide %K mobile phone %D 2019 %7 04.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: India is home to 20% of the world’s suicide deaths. Although statistics regarding suicide in India are distressingly high, data and cultural issues likely contribute to a widespread underreporting of the problem. Social stigma and only recent decriminalization of suicide are among the factors hampering official agencies’ collection and reporting of suicide rates. Objective: As the product of a data collaborative, this paper leverages private-sector search engine data toward gaining a fuller, more accurate picture of the suicide issue among young people in India. By combining official statistics on suicide with data generated through search queries, this paper seeks to: add an additional layer of information to more accurately represent the magnitude of the problem, determine whether search query data can serve as an effective proxy for factors contributing to suicide that are not represented in traditional datasets, and consider how data collaboratives built on search query data could inform future suicide prevention efforts in India and beyond. Methods: We combined official statistics on demographic information with data generated through search queries from Bing to gain insight into suicide rates per state in India as reported by the National Crimes Record Bureau of India. We extracted English language queries on “suicide,” “depression,” “hanging,” “pesticide,” and “poison”. We also collected data on demographic information at the state level in India, including urbanization, growth rate, sex ratio, internet penetration, and population. We modeled the suicide rate per state as a function of the queries on each of the 5 topics considered as linear independent variables. A second model was built by integrating the demographic information as additional linear independent variables. Results: Results of the first model fit (R2) when modeling the suicide rates from the fraction of queries in each of the 5 topics, as well as the fraction of all suicide methods, show a correlation of about 0.5. This increases significantly with the removal of 3 outliers and improves slightly when 5 outliers are removed. Results for the second model fit using both query and demographic data show that for all categories, if no outliers are removed, demographic data can model suicide rates better than query data. However, when 3 outliers are removed, query data about pesticides or poisons improves the model over using demographic data. Conclusions: In this work, we used search data and demographics to model suicide rates. In this way, search data serve as a proxy for unmeasured (hidden) factors corresponding to suicide rates. Moreover, our procedure for outlier rejection serves to single out states where the suicide rates have substantially different correlations with demographic factors and query rates. %M 30609976 %R 10.2196/10179 %U https://www.jmir.org/2019/1/e10179/ %U https://doi.org/10.2196/10179 %U http://www.ncbi.nlm.nih.gov/pubmed/30609976 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10677 %T Association Between Cancer Incidence and Mortality in Web-Based Data in China: Infodemiology Study %A Xu,Chenjie %A Wang,Yi %A Yang,Hongxi %A Hou,Jie %A Sun,Li %A Zhang,Xinyu %A Cao,Xinxi %A Hou,Yabing %A Wang,Lan %A Cai,Qiliang %A Wang,Yaogang %+ School of Public Health, Tianjin Medical University, No 22, Qixiangtai Road, Heping District, Tianjin,, China, 86 13820046130, wyg@tmu.edu.cn %K cancer %K incidence %K mortality %K web-based data %K internet searching %D 2019 %7 29.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Cancer poses a serious threat to the health of Chinese people, resulting in a major challenge for public health work. Today, people can obtain relevant information from not only medical workers in hospitals, but also the internet in any place in real-time. Search behaviors can reflect a population’s awareness of cancer from a completely new perspective, which could be driven by the underlying cancer epidemiology. However, such Web-retrieved data are not yet well validated or understood. Objective: This study aimed to explore whether a correlation exists between the incidence and mortality of cancers and normalized internet search volumes on the big data platform, Baidu. We also assessed whether the distribution of people who searched for specific types of cancer differed by gender. Finally, we determined whether there were regional disparities among people who searched the Web for cancer-related information. Methods: Standard Boolean operators were used to choose search terms for each type of cancer. Spearman’s correlation analysis was used to explore correlations among monthly search index values for each cancer type and their monthly incidence and mortality rates. We conducted cointegration analysis between search index data and incidence rates to examine whether a stable equilibrium existed between them. We also conducted cointegration analysis between search index data and mortality data. Results: The monthly Baidu index was significantly correlated with cancer incidence rates for 26 of 28 cancers in China (lung cancer: r=.80, P<.001; liver cancer: r=.28, P=.016; stomach cancer: r=.50, P<.001; esophageal cancer: r=.50, P<.001; colorectal cancer: r=.81, P<.001; pancreatic cancer: r=.86, P<.001; breast cancer: r=.56, P<.001; brain and nervous system cancer: r=.63, P<.001; leukemia: r=.75, P<.001; Non-Hodgkin lymphoma: r=.88, P<.001; Hodgkin lymphoma: r=.91, P<.001; cervical cancer: r=.64, P<.001; prostate cancer: r=.67, P<.001; bladder cancer: r=.62, P<.001; gallbladder and biliary tract cancer: r=.88, P<.001; lip and oral cavity cancer: r=.88, P<.001; ovarian cancer: r=.58, P<.001; larynx cancer: r=.82, P<.001; kidney cancer: r=.73, P<.001; squamous cell carcinoma: r=.94, P<.001; multiple myeloma: r=.84, P<.001; thyroid cancer: r=.77, P<.001; malignant skin melanoma: r=.55, P<.001; mesothelioma: r=.79, P<.001; testicular cancer: r=.57, P<.001; basal cell carcinoma: r=.83, P<.001). The monthly Baidu index was significantly correlated with cancer mortality rates for 24 of 27 cancers. In terms of the whole population, the number of women who searched for cancer-related information has slowly risen over time. People aged 30-39 years were most likely to use search engines to retrieve cancer-related knowledge. East China had the highest Web search volumes for cancer. Conclusions: Search behaviors indeed reflect public awareness of cancer from a different angle. Research on internet search behaviors could present an innovative and timely way to monitor and estimate cancer incidence and mortality rates, especially for cancers not included in national registries. %M 30694203 %R 10.2196/10677 %U https://www.jmir.org/2019/1/e10677/ %U https://doi.org/10.2196/10677 %U http://www.ncbi.nlm.nih.gov/pubmed/30694203 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e9076 %T Evaluating Digital Maturity and Patient Acceptability of Real-Time Patient Experience Feedback Systems: Systematic Review %A Khanbhai,Mustafa %A Flott,Kelsey %A Darzi,Ara %A Mayer,Erik %+ Centre for Health Policy, Imperial College London, 10th Floor QEQM Building, Centre for Health Policy, London, W2 1NY, United Kingdom, 44 02033126428, m.khanbhai@imperial.ac.uk %K digital maturity %K digital technology %K feedback %K patient experience %K real time %D 2019 %7 14.01.2019 %9 Review %J J Med Internet Res %G English %X Background: One of the essential elements of a strategic approach to improving patients’ experience is to measure and report on patients’ experiences in real time. Real-time feedback (RTF) is increasingly being collected using digital technology; however, there are several factors that may influence the success of the digital system. Objective: The aim of this review was to evaluate the digital maturity and patient acceptability of real-time patient experience feedback systems. Methods: We systematically searched the following databases to identify papers that used digital systems to collect RTF: The Cochrane Library, Global Health, Health Management Information Consortium, Medical Literature Analysis and Retrieval System Online, EMBASE, PsycINFO, Web of Science, and CINAHL. In addition, Google Scholar and gray literature were utilized. Studies were assessed on their digital maturity using a Digital Maturity Framework on the basis of the following 4 domains: capacity/resource, usage, interoperability, and impact. A total score of 4 indicated the highest level of digital maturity. Results: RTF was collected primarily using touchscreens, tablets, and Web-based platforms. Implementation of digital systems showed acceptable response rates and generally positive views from patients and staff. Patient demographics according to RTF responses varied. An overrepresentation existed in females with a white predominance and in patients aged ≥65 years. Of 13 eligible studies, none had digital systems that were deemed to be of the highest level of maturity. Three studies received a score of 3, 2, and 1, respectively. Four studies scored 0 points. While 7 studies demonstrated capacity/resource, 8 demonstrated impact. None of the studies demonstrated interoperability in their digital systems. Conclusions: Patients and staff alike are willing to engage in RTF delivered using digital technology, thereby disrupting previous paper-based feedback. However, a lack of emphasis on digital maturity may lead to ineffective RTF, thwarting improvement efforts. Therefore, given the potential benefits of RTF, health care services should ensure that their digital systems deliver across the digital maturity continuum. %M 31344680 %R 10.2196/jmir.9076 %U https://www.jmir.org/2019/1/e9076/ %U https://doi.org/10.2196/jmir.9076 %U http://www.ncbi.nlm.nih.gov/pubmed/31344680 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11161 %T Additional Telemedicine Rounds as a Successful Performance-Improvement Strategy for Sepsis Management: Observational Multicenter Study %A Deisz,Robert %A Rademacher,Susanne %A Gilger,Katrin %A Jegen,Rudolf %A Sauerzapfe,Barbara %A Fitzner,Christina %A Stoppe,Christian %A Benstoem,Carina %A Marx,Gernot %+ Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 8089471, cbenstoem@ukaachen.de %K intensive care %K outcome improvement %K sepsis %K sepsis bundle compliance %K SSC %K tele-ICU %K telemedicine %D 2019 %7 15.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Sepsis is a major health care problem with high morbidity and mortality rates and affects millions of patients. Telemedicine, defined as the exchange of medical information via electronic communication, improves the outcome of patients with sepsis and decreases the mortality rate and length of stay in the intensive care unit (ICU). Additional telemedicine rounds could be an effective component of performance-improvement programs for sepsis, especially in underserved rural areas and hospitals without ready access to critical care physicians. Objective: Our aim was to evaluate the impact of additional daily telemedicine rounds on adherence to sepsis bundles. We hypothesized that additional telemedicine support may increase adherence to sepsis guidelines and improve the detection rates of sepsis and septic shock. Methods: We conducted a retrospective, observational, multicenter study between January 2014 and July 2015 with one tele-ICU center and three ICUs in Germany. We implemented telemedicine as part of standard care and collected data continuously during the study. During the daily telemedicine rounds, routine screening for sepsis was conducted and adherence to the Surviving Sepsis Campaign’s 3-hour and 6-hour sepsis bundles were evaluated. Results: In total, 1168 patients were included in this study, of which 196 were positive for severe sepsis and septic shock. We found that additional telemedicine rounds improved adherence to the 3-hour (Quarter 1, 35% vs Quarter 6, 76.2%; P=.01) and 6-hour (Quarter 1, 50% vs Quarter 6, 95.2%; P=.001) sepsis bundles. In addition, we noted an increase in adherence to the item “Administration of fluids when hypotension” (Quarter 1, 80% vs Quarter 6, 100%; P=.049) of the 3-hour bundle and the item “Remeasurement of lactate” (Quarter 1, 65% vs Quarter 6, 100%, P=.003) of the 6-hour bundle. The ICU length of stay after diagnosis of severe sepsis and septic shock remained unchanged over the observation period. Due to a higher number of patients with sepsis in Quarter 5 (N=60) than in other quarters, we observed stronger effects of the additional rounds on mortality in this quarter (Quarter 1, 50% vs Quarter 5, 23.33%, P=.046). Conclusions: Additional telemedicine rounds are an effective component of and should be included in performance-improvement programs for sepsis management. %M 30664476 %R 10.2196/11161 %U http://www.jmir.org/2019/1/e11161/ %U https://doi.org/10.2196/11161 %U http://www.ncbi.nlm.nih.gov/pubmed/30664476 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12790 %T Use of the CHA2DS2-VASc Score for Risk Stratification of Hospital Admissions Among Patients With Cardiovascular Diseases Receiving a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study %A Lee,Jen-Kuang %A Hung,Chi-Sheng %A Huang,Ching-Chang %A Chen,Ying-Hsien %A Chuang,Pao-Yu %A Yu,Jiun-Yu %A Ho,Yi-Lwun %+ Telehealth Center, National Taiwan University Hospital, No 7, Chung-Shan South Road, Taipei,, Taiwan, 886 2 23123456 ext 63651, ylho@ntu.edu.tw %K CHA2DS2-VASc score %K fourth-generation synchronous telehealth program %K hospitalization %K cardiovascular disease %D 2019 %7 31.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Telehealth programs are generally diverse in approaching patients, from traditional telephone calling and texting message and to the latest fourth-generation synchronous program. The predefined outcomes are also different, including hypertension control, lipid lowering, cardiovascular outcomes, and mortality. In previous studies, the telehealth program showed both positive and negative results, providing mixed and confusing clinical outcomes. A comprehensive and integrated approach is needed to determine which patients benefit from the program in order to improve clinical outcomes. Objective: The CHA2DS2-VASc (congestive heart failure, hypertension, age >75 years [doubled], type 2 diabetes mellitus, previous stroke, transient ischemic attack or thromboembolism [doubled], vascular disease, age of 65-75 years, and sex) score has been widely used for the prediction of stroke in patients with atrial fibrillation. This study investigated the CHA2DS2-VASc score to stratify patients with cardiovascular diseases receiving a fourth-generation synchronous telehealth program. Methods: This was a retrospective cohort study. We recruited patients with cardiovascular disease who received the fourth-generation synchronous telehealth program at the National Taiwan University Hospital between October 2012 and June 2015. We enrolled 431 patients who had joined a telehealth program and compared them to 1549 control patients. Risk of cardiovascular hospitalization was estimated with Kaplan-Meier curves. The CHA2DS2-VASc score was used as the composite parameter to stratify the severity of patients’ conditions. The association between baseline characteristics and clinical outcomes was assessed via the Cox proportional hazard model. Results: The mean follow-up duration was 886.1 (SD 531.0) days in patients receiving the fourth-generation synchronous telehealth program and 707.1 (SD 431.4) days in the control group (P<.001). The telehealth group had more comorbidities at baseline than the control group. Higher CHA2DS2-VASc scores (≥4) were associated with a lower estimated rate of remaining free from cardiovascular hospitalization (46.5% vs 54.8%, log-rank P=.003). Patients with CHA2DS2-VASc scores ≥4 receiving the telehealth program were less likely to be admitted for cardiovascular disease than patients not receiving the program. (61.5% vs 41.8%, log-rank P=.01). The telehealth program remained a significant prognostic factor after multivariable Cox analysis in patients with CHA2DS2-VASc scores ≥4 (hazard ratio=0.36 [CI 0.22-0.62], P<.001) Conclusions: A higher CHA2DS2-VASc score was associated with a higher risk of cardiovascular admissions. Patients accepting the fourth-generation telehealth program with CHA2DS2-VASc scores ≥4 benefit most by remaining free from cardiovascular hospitalization. %M 30702437 %R 10.2196/12790 %U https://www.jmir.org/2019/1/e12790/ %U https://doi.org/10.2196/12790 %U http://www.ncbi.nlm.nih.gov/pubmed/30702437 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10861 %T A Web-Based Application to Improve Data Collection in an Interventional Study Targeting Childhood Obesity: Pre-Post Analysis %A Hanbury,Meagan M %A Sadeghi,Banafsheh %A Tseregounis,Iraklis Erik %A Gomez-Camacho,Rosa %A Manzo,Rosa D %A Rangel,Maria Isabel %A Alexandrescu,Bogdan %A de la Torre,Adela %+ Center for Transnational Health, University of California, Davis, 328 D Street, Davis, CA, 95616, United States, 1 617 877 6795, mhanbury@ucdavis.edu %K data collection %K internet %K rural population %K efficiency %D 2019 %7 16.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Although participatory action research (PAR) studies have proliferated in recent years, the development of technological resources to manage these types of projects has not kept pace. Few studies show how Web-based applications can be used to efficiently manage the data collection process. Objective: This study described the development, use, and impact of a Web-based application to facilitate data management in Niños Sanos, Familia Sana (Healthy Children, Healthy Family), an interventional multifaceted PAR field study. Methods: We described the transformation of the data management process and evaluated the impact of the application in terms of time efficiency of data collection and engagement of community-based data collectors. We defined time efficiency as the total number of days it took to collect 3 main surveys, per year of data collection. The engagement of data collectors was assessed based on qualitative reports. Results: The amount of time it took to perform a round of data collection was reduced after implementation of the field team application (between 382 and 383 days and 198 and 233 days). Secondary data were also collected in a tighter time frame around collection of the primary outcome, and communication among data collectors, the field staff, and the research team was streamlined. In focus groups, community-based data collectors reported feeling more empowered and engaged in the data collection process after implementation of the application. Conclusions: A Web-based management application was successful in improving data collection time efficiency and engagement among data collectors. %M 30664465 %R 10.2196/10861 %U http://www.jmir.org/2019/1/e10861/ %U https://doi.org/10.2196/10861 %U http://www.ncbi.nlm.nih.gov/pubmed/30664465 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11696 %T Digital Exclusion Among Mental Health Service Users: Qualitative Investigation %A Greer,Ben %A Robotham,Dan %A Simblett,Sara %A Curtis,Hannah %A Griffiths,Helena %A Wykes,Til %+ Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London,, United Kingdom, 44 0207848 ext 0423, ben.greer@kcl.ac.uk %K digital exclusion %K digital divide %K digital inequality %K technology %K eHealth %K mental health %K social exclusion %K mobile phone %D 2019 %7 09.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Access to internet-enabled technology and Web-based services has grown exponentially in recent decades. This growth potentially excludes some communities and individuals with mental health difficulties, who face a heightened risk of digital exclusion. However, it is unclear what factors may contribute to digital exclusion in this population. Objective: To explore in detail the problems of digital exclusion in mental health service users and potential facilitators to overcome them. Methods: We conducted semistructured interviews with 20 mental health service users who were deemed digitally excluded. We recruited the participants from a large secondary mental health provider in South London, United Kingdom. We employed thematic analysis to identify themes and subthemes relating to historical and extant reasons for digital exclusion and methods of overcoming it. Results: There were three major themes that appeared to maintain digital exclusion: a perceived lack of knowledge, being unable to access the necessary technology and services owing to personal circumstances, and the barriers presented by mental health difficulties. Specific facilitators for overcoming digital exclusion included intrinsic motivation and a personalized learning format that reflects the individual’s unique needs and preferences. Conclusions: Multiple factors contribute to digital exclusion among mental health service users, including material deprivation and mental health difficulties. This means that efforts to overcome digital exclusion must address the multiple deprivations individuals may face in the offline world in addition to their individual mental health needs. Additional facilitators include fostering an intrinsic motivation to overcome digital exclusion and providing a personalized learning format tailored to the individual’s knowledge gaps and preferred learning style. %M 30626564 %R 10.2196/11696 %U http://www.jmir.org/2019/1/e11696/ %U https://doi.org/10.2196/11696 %U http://www.ncbi.nlm.nih.gov/pubmed/30626564 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11454 %T Differences Between Mothers and Fathers of Young Children in Their Use of the Internet to Support Healthy Family Lifestyle Behaviors: Cross-Sectional Study %A Laws,Rachel %A Walsh,Adam D %A Hesketh,Kylie D %A Downing,Katherine L %A Kuswara,Konsita %A Campbell,Karen J %+ Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, Geelong, 3125, Australia, 61 432388593, r.laws@deakin.edu.au %K child %K family %K healthy lifestyle %K infant %K internet %K obesity %K parents %D 2019 %7 23.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In early life, both mothers and fathers are important influences on their children’s diet, active play, and obesity risk. Parents are increasingly relying on the internet and social media as a source of information on all aspects of parenting. However, little is known about the use of Web-based sources of information relevant to family lifestyle behaviors and, in particular, differences between mothers’ and fathers’ use and sociodemographic predictors. Objective: The objective of this study was to examine if mothers and fathers differ in their use of the internet for information on their own health and their child’s health, feeding, and playing and to examine sociodemographic predictors of the use of the internet for information on these topics. Methods: We conducted a secondary analysis on data collected from mothers (n=297) and fathers (n=207) participating in the extended Infant Feeding, Activity and Nutrition Trial (InFANT Extend) when their children were 36 months of age. The main outcome variables were the use of the internet for information gathering for parents’ own health and child health, feeding, and playing. Binary logistic regression was used to examine the sociodemographic predictors of outcomes. Results: Compared with fathers (n=296), a higher proportion of mothers (n=198) used the internet for information on their own health (230, 78.5% vs 93, 46.5%), child health (226, 77.1% vs 84, 42.4%), child feeding (136, 46.3% vs 35, 17.5%), and child play (123, 42.1% vs 28, 14.0%) and intended to use Facebook to connect with other parents (200, 74.9% vs 43, 30.5%). Despite the high use of the internet to support family health behaviors, only 15.9% (47/296) of mothers reported consulting health practitioners for advice and help for their own or their child’s weight, diet, or physical activity. Sociodemographic predictors of internet use differed between mothers and fathers and explained only a small proportion of the variance in internet use to support healthy family lifestyle behaviors. Conclusions: Our findings support the use of the internet and Facebook as an important potential avenue for reaching mothers with information relevant to their own health, child health, child diet, and active play. However, further research is required to understand the best avenues for engaging fathers with information on healthy family lifestyle behaviors to support this important role in their child’s life. Trial Registration: ISRCTN Registry ISRCTN81847050; http://www.isrctn.com/ISRCTN81847050 %M 30674450 %R 10.2196/11454 %U http://www.jmir.org/2019/1/e11454/ %U https://doi.org/10.2196/11454 %U http://www.ncbi.nlm.nih.gov/pubmed/30674450 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11481 %T How Women Use Digital Technologies for Health: Qualitative Interview and Focus Group Study %A Lupton,Deborah %A Maslen,Sarah %+ News and Media Research Centre, Faculty of Arts & Design, University of Canberra, Building 9, Bruce,, Australia, 61 04 0307 6791, deborah.lupton@canberra.edu.au %K digital health %K websites %K online forums %K social media %K apps %K wearable devices %K women %K Australia %K feminist new materialism %K qualitative research %D 2019 %7 25.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: A range of digital technologies are available to lay people to find, share, and generate health-related information. Few studies have directed attention specifically to how women are using these technologies from the diverse array available to them. Even fewer have focused on Australian women’s use of digital health. Objective: The Australian Women and Digital Health Project aimed to investigate which types of digital technologies women used regularly for health-related purposes and which they found most helpful and useful. Qualitative methods—semistructured interviews and focus groups—were employed to shed light on the situated complexities of the participants’ enactments of digital health technologies. The project adopted a feminist new materialism theoretical perspective, focusing on the affordances, relational connections, and affective forces that came together to open up or close off the agential capacities generated with and through these enactments. Methods: The project comprised two separate studies including a total of 66 women. In study 1, 36 women living in the city of Canberra took part in face-to-face interviews and focus groups, while study 2 involved telephone interviews with 30 women from other areas of Australia. Results: The affordances of search engines to locate health information and websites and social media platforms for providing information and peer support were highly used and valued. Affective forces such as the desire for trust, motivation, empowerment, reassurance, control, care, and connection emerged in the participants’ accounts. Agential capacities generated with and through digital health technologies included the capacity to seek and generate information and create a better sense of knowledge and expertise about bodies, illness, and health care, including the women’s own bodies and health, that of their families and friends, and that of their often anonymous online social networks. The participants referred time and again to appreciating the feelings of agency and control that using digital health technologies afforded them. When the technologies failed to work as expected, these agential capacities were not realized. Women responded with feelings of frustration, disappointment, and annoyance, leading them to become disenchanted with the possibilities of the digital technologies they had tried. Conclusions: The findings demonstrate the nuanced and complex ways in which the participants were engaging with and contributing to online sources of information and using these sources together with face-to-face encounters with doctors and other health care professionals and friends and family members. They highlight the lay forms of expertise that the women had developed in finding, assessing, and creating health knowledges. The study also emphasized the key role that many women play in providing advice and health care for family members not only as digitally engaged patients but also as digitally engaged carers. %M 30681963 %R 10.2196/11481 %U http://www.jmir.org/2019/1/e11481/ %U https://doi.org/10.2196/11481 %U http://www.ncbi.nlm.nih.gov/pubmed/30681963 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11280 %T Internet Access and Hypertension Management Among the Elderly Population: A Nationally Representative Cross-Sectional Survey in China %A Jin,Yinzi %A Jing,Mingxia %A Zhang,Luyu %A Song,Suhang %A Ma,Xiaochen %+ China Center for Health Development Studies, Peking University, Xueyuan Rd 38#, Haidian District, Beijing,, China, 86 10 82805706, xma@hsc.pku.edu.cn %K China %K health disparity %K hypertension %K internet %D 2019 %7 31.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Hypertension is a rapidly growing epidemic in China. Yet, it remains inadequately controlled, especially in rural areas. The internet has shown potential for better health management in different settings; however, few studies have investigated its role in hypertension management in China. Objective: This study aims to examine the association between internet access and hypertension awareness, treatment, and control among elderly Chinese adults and to investigate whether the association between internet access and hypertension management differed between those living in urban and rural areas. Methods: We obtained data from the nationally representative survey of the China Health and Retirement Longitudinal Study in 2011. Hypertension was defined as (1) average systolic blood pressure of ≥140 mm Hg or average diastolic blood pressure of ≥90 mm Hg or (2) currently taking antihypertensive medications. The outcome assessed included hypertension awareness, treatment, and control. The key independent variable was defined as whether one had internet access at home. We performed multivariate logistic regressions for each of the 3 outcomes. Results: Among 5135 hypertensive respondents (age 62.4 [SD 9.9] years; 2351/5135, 45.78% men), 12.89% (662/5135) had internet access at home. Compared with those who had no internet access, internet access was positively associated with hypertension awareness (odds ratio [OR] 1.36, 95% CI 1.07-1.73) and treatment (OR 1.38, 95% CI 1.09-1.75), but not with control (OR 1.19, 95% CI 0.90-1.58). Internet access reduced urban-rural disparity in hypertension awareness by 9.6% (P=.02), treatment by 8.3% (P=.05), but not in control. In addition, the moderating effect of internet access on urban-rural disparities in hypertension management was larger among females. The decreased urban-rural disparities were primarily driven by that internet access improved the management level in rural areas. Conclusions: Despite the low rate of internet access among the elderly population, the internet shows its potential as a platform for achieving better hypertension management in China. Strategies for reducing the disparities in hypertension management and overall disease burden of hypertension among the elderly population might consider the internet as a platform. %M 30702439 %R 10.2196/11280 %U http://www.jmir.org/2019/1/e11280/ %U https://doi.org/10.2196/11280 %U http://www.ncbi.nlm.nih.gov/pubmed/30702439 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11939 %T Technical Support by Smart Glasses During a Mass Casualty Incident: A Randomized Controlled Simulation Trial on Technically Assisted Triage and Telemedical App Use in Disaster Medicine %A Follmann,Andreas %A Ohligs,Marian %A Hochhausen,Nadine %A Beckers,Stefan K %A Rossaint,Rolf %A Czaplik,Michael %+ Medical Technology Section, Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, D-52074, Germany, 49 2418036219, afollmann@ukaachen.de %K augmented reality %K disaster medicine %K emergency medical service physician %K mass casualty incident %K Smart Glasses %K telemedicine %K triage %D 2019 %7 03.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: To treat many patients despite lacking personnel resources, triage is important in disaster medicine. Various triage algorithms help but often are used incorrectly or not at all. One potential problem-solving approach is to support triage with Smart Glasses. Objective: In this study, augmented reality was used to display a triage algorithm and telemedicine assistance was enabled to compare the duration and quality of triage with a conventional one. Methods: A specific Android app was designed for use with Smart Glasses, which added information in terms of augmented reality with two different methods—through the display of a triage algorithm in data glasses and a telemedical connection to a senior emergency physician realized by the integrated camera. A scenario was created (ie, randomized simulation study) in which 31 paramedics carried out a triage of 12 patients in 3 groups as follows: without technical support (control group), with a triage algorithm display, and with telemedical contact. Results: A total of 362 assessments were performed. The accuracy in the control group was only 58%, but the assessments were quicker (on average 16.6 seconds). In contrast, an accuracy of 92% (P=.04) was achieved when using technical support by displaying the triage algorithm. This triaging took an average of 37.0 seconds. The triage group wearing data glasses and being telemedically connected achieved 90% accuracy (P=.01) in 35.0 seconds. Conclusions: Triage with data glasses required markedly more time. While only a tally was recorded in the control group, Smart Glasses led to digital capture of the triage results, which have many tactical advantages. We expect a high potential in the application of Smart Glasses in disaster scenarios when using telemedicine and augmented reality features to improve the quality of triage. %M 30609988 %R 10.2196/11939 %U https://www.jmir.org/2019/1/e11939/ %U https://doi.org/10.2196/11939 %U http://www.ncbi.nlm.nih.gov/pubmed/30609988 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e9955 %T Informing Adults With Back Pain About Placebo Effects: Randomized Controlled Evaluation of a New Website With Potential to Improve Informed Consent in Clinical Research %A Bishop,Felicity L %A Greville-Harris,Maddy %A Bostock,Jennifer %A Din,Amy %A Graham,Cynthia A %A Lewith,George %A Liossi,Christina %A O'Riordan,Tim %A White,Peter %A Yardley,Lucy %+ Department of Psychology, University of Southampton, Building 44, Highfield Campus, University Road, Southampton,, United Kingdom, 44 2380599020, f.l.bishop@southampton.ac.uk %K placebos %K placebo effects %K informed consent %K research ethics %K health knowledge, attitudes, practice %K internet %D 2019 %7 17.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Placebo effects and their underpinning mechanisms are increasingly well understood. However, this is poorly communicated to participants in placebo-controlled trials. For valid informed consent, participants should be informed about the potential benefits and risks of participating in placebo-controlled trials. Existing information leaflets often fail to describe the potential benefits and adverse effects associated with placebo allocation. This study tested the effects of a new website designed to inform patients about placebo effects (The Power of Placebos, PoP). PoP was designed using qualitative methods in combination with theory- and evidence-based approaches to ensure it was engaging, informative, and addressed patients’ concerns. Objective: This study aimed to test the effects of PoP, compared with a control website, on people’s knowledge about placebo and the ability to make an informed choice about taking part in a placebo-controlled trial. Methods: A total of 350 adults with back pain recruited from 26 general practices in Southern England participated in this Web-based study. Participants were randomly assigned to PoP (which presented scientifically accurate information about placebo effects in an engaging way) or a control website (based on existing information leaflets from UK trials). Participants self-completed Web-based pre- and postintervention questionnaire measures of knowledge about placebo effects and preintervention questionnaire measures of attitudes toward and intentions to participate in a placebo-controlled trial. The 2 primary outcomes were (1) knowledge and (2) informed choice to take part in a placebo-controlled trial (computed from knowledge, attitudes, and intentions). Results: After viewing PoP, participants had significantly greater knowledge about placebos (mean 8.28 [SD 1.76]; n=158) than participants who viewed the control (mean 5.60 [SD 2.24]; n=174; F1,329=173.821; P<.001; η2=.346). Participants who viewed PoP were 3.16 times more likely than those who viewed the control to make an informed choice about placebos (χ21=36.5; P<.001). Conclusions: In a sample of adults with back pain, PoP increased knowledge and rates of informed choice about placebos compared with a control website. PoP could be used to improve knowledge about placebo effects in back pain. After essential further development and testing in clinical trial settings, it could support informed consent in placebo-controlled trials. %M 30664462 %R 10.2196/jmir.9955 %U https://www.jmir.org/2019/1/e9955/ %U https://doi.org/10.2196/jmir.9955 %U http://www.ncbi.nlm.nih.gov/pubmed/30664462 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10793 %T Improving Electronic Health Record Note Comprehension With NoteAid: Randomized Trial of Electronic Health Record Note Comprehension Interventions With Crowdsourced Workers %A Lalor,John P %A Woolf,Beverly %A Yu,Hong %+ Department of Computer Science, University of Massachusetts Lowell, 1 University Avenue, Lowell, MA,, United States, 1 508 612 7292, hong.yu@umassmed.edu %K health literacy %K crowdsourcing %K natural language processing %K information storage and retrieval %K psychometrics %K MedlinePlus %D 2019 %7 16.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Patient portals are becoming more common, and with them, the ability of patients to access their personal electronic health records (EHRs). EHRs, in particular the free-text EHR notes, often contain medical jargon and terms that are difficult for laypersons to understand. There are many Web-based resources for learning more about particular diseases or conditions, including systems that directly link to lay definitions or educational materials for medical concepts. Objective: Our goal is to determine whether use of one such tool, NoteAid, leads to higher EHR note comprehension ability. We use a new EHR note comprehension assessment tool instead of patient self-reported scores. Methods: In this work, we compare a passive, self-service educational resource (MedlinePlus) with an active resource (NoteAid) where definitions are provided to the user for medical concepts that the system identifies. We use Amazon Mechanical Turk (AMT) to recruit individuals to complete ComprehENotes, a new test of EHR note comprehension. Results: Mean scores for individuals with access to NoteAid are significantly higher than the mean baseline scores, both for raw scores (P=.008) and estimated ability (P=.02). Conclusions: In our experiments, we show that the active intervention leads to significantly higher scores on the comprehension test as compared with a baseline group with no resources provided. In contrast, there is no significant difference between the group that was provided with the passive intervention and the baseline group. Finally, we analyze the demographics of the individuals who participated in our AMT task and show differences between groups that align with the current understanding of health literacy between populations. This is the first work to show improvements in comprehension using tools such as NoteAid as measured by an EHR note comprehension assessment tool as opposed to patient self-reported scores. %M 30664453 %R 10.2196/10793 %U http://www.jmir.org/2019/1/e10793/ %U https://doi.org/10.2196/10793 %U http://www.ncbi.nlm.nih.gov/pubmed/30664453 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10178 %T EuroQol (EQ-5D-5L) Validity in Assessing the Quality of Life in Adults With Asthma: Cross-Sectional Study %A Hernandez,Gimena %A Garin,Olatz %A Dima,Alexandra L %A Pont,Angels %A Martí Pastor,Marc %A Alonso,Jordi %A Van Ganse,Eric %A Laforest,Laurent %A de Bruin,Marijn %A Mayoral,Karina %A Serra-Sutton,Vicky %A Ferrer,Montse %A , %+ Health Services Research Group, Hospital del Mar Medical Research Institute, Dr Aiguader 88, Barcelona, 08003, Spain, 34 933160763, mferrer@imim.es %K asthma %K EQ-5D-5L %K EuroQol %K health-related quality of life %K Web-based survey %K validity %K patient-reported outcome measures %D 2019 %7 23.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The EuroQol-5 Dimension (EQ-5D), developed in 1990, is a most widely used generic tool to measure the health-related quality of life (HRQoL) and considered suitable for patients with asthma. In 2009, the EuroQol Group developed a new EQ-5D version to overcome limitations related to its consistently reported high ceiling effect. To enhance the sensitivity for assessing the HRQoL in further patient populations, the number of responses of EQ-5D was increased from 3 to 5 levels (EQ-5D-5L). Moreover, the availability of well-defined requirements for its Web-based administration allows EQ-5D-5L use to monitor the HRQoL in electronic health (eHealth) programs. No study has evaluated the metric properties of the new EQ-5D-5L in patients with asthma yet. Objective: This study aims to examine the distribution, construct validity, and reliability of the new EQ-5D-5L questionnaire administered online to adults with asthma. Methods: We evaluated patients with asthma (age: 18-40 years) from a primary care setting in France and England, who self-completed the EQ-5D-5L questionnaire online. The inclusion criteria were persistent asthma defined as >6 months of prescribed inhaled corticosteroids and long-acting beta-agonists or inhaled corticosteroids alone during the 12 months prior to inclusion. The EQ-5D index was obtained by applying the English preference value set for the new EQ-5D-5L and the French 3L-5L crosswalk value set. Both value sets produced single preference-based indices ranging from 1 (best health state) to negative values (health states valued as worse than death), where 0=death, allowing the calculation of quality-adjusted life years. Responses to dimensions and index distribution, including ceiling and floor effects, were examined. The construct validity was assessed by comparing the means of known groups by analyses of variance and calculation of effect sizes. Results: Of 312 patients answering the baseline Web-based survey, 290 completed the EQ-5D-5L (93%). The floor effect was null, and the ceiling effect was 26.5% (74/279). The mean EQ-5D-5L index was 0.88 (SD 0.14) with the English value set and 0.83 (SD 0.19) with the French 3L-5L crosswalk value set. In both indices, large effect sizes were observed for known groups defined by the Asthma Control Questionnaire (1.06 and 1.04, P<.001). Differences between extreme groups defined by chronic conditions (P=.002 and P=.003 for the English value set and French 3L-5L crosswalk value set, respectively), short-acting beta-agonists (SABAs) canisters in the last 12 months (P=.02 and P=.03), or SABA use during the previous 4 weeks (P=.03 and P=.01) were of moderate magnitude with effect sizes around 0.5. Conclusions: The new EQ-5D-5L questionnaire has an acceptable ceiling effect, a good construct validity based on the discriminant ability for distinguishing among health-related known groups, and high reliability, supporting its adequacy for assessing the HRQoL in patients with asthma. EQ-5D-5L completion by most Web-based respondents supports the feasibility of this administration form. %M 30672744 %R 10.2196/10178 %U http://www.jmir.org/2019/1/e10178/ %U https://doi.org/10.2196/10178 %U http://www.ncbi.nlm.nih.gov/pubmed/30672744 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12075 %T A Modular Health-Related Quality of Life Instrument for Electronic Assessment and Treatment Monitoring: Web-Based Development and Psychometric Validation of Core Thrive Items %A Wicks,Paul %A McCaffrey,Stacey %A Goodwin,Kim %A Black,Ryan %A Hoole,Michael %A Heywood,James %+ PatientsLikeMe, 160 2nd Street, Cambridge, MA, 02142, United States, 1 6174994003, pwicks@patientslikeme.com %K personal health records %K health-related quality of life %K patient reported outcome measures %D 2019 %7 25.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Patient-reported outcome (PRO) measures describe natural history, manage disease, and measure the effects of interventions in trials. Patients themselves increasingly use Web-based PRO tools to track their progress, share their data, and even self-experiment. However, existing PROs have limitations such as being: designed for paper (not screens), long and burdensome, negatively framed, under onerous licensing restrictions, either too generic or too specific. Objective: This study aimed to develop and validate the core items of a modular, patient-centric, PRO system (Thrive) that could measure health status across a range of chronic conditions with minimal burden. Methods: Thrive was developed in 4 phases, largely consistent with Food and Drug Administration guidance regarding PRO development. First, preliminary core items (common across multiple conditions: core Thrive items) were developed through literature review, analysis of approximately 20 existing PROs on PatientsLikeMe, and feedback from psychometric and content experts. Second, 2 rounds of cognitive interviews were iteratively conducted with patients (N=14) to obtain feedback on the preliminary items. Third, core Thrive items were administered electronically along with comparator measures, including 20-item Short-Form General Health Survey (SF)-20 and Patient Health Questionnaire (PHQ)-9, to a large sample (N=2002) of adults with chronic diseases through the PatientsLikeMe platform. On the basis of theoretical and empirical rationale, items were revised or removed. Fourth, the revised core Thrive items were administered to another sample of patients (N=704) with generic and condition-specific comparator measures. A psychometric evaluation, which included both modern and classical test theory approaches, was conducted on these items, and several more items were removed. Results: Cognitive interviews helped to remove confusing or redundant items. Empirical testing of subscales revealed good internal consistency (Cronbach alpha=.712-.879), test-retest reliability (absolute intraclass correlations=.749-.912), and convergent validity with legacy PRO scales (eg, Pearson r=.5-.75 between Thrive subscales and PHQ-9 total). The finalized instrument consists of a 19-item core including 5 multi-item subscales: Core symptoms, Abilities, Mobility, Sleep, and Thriving. Results provide evidence of construct (content, convergent) validity, high levels of test-retest and internal consistency reliability, and the ability to detect change over time. The items did not exhibit bias based on gender or age, and the items generally functioned similarly across conditions. These results support the use of Thrive Core items across diverse chronic patient populations. Conclusions: Thrive appears to be a useful approach for capturing important domains for patients with chronic conditions. This core set serves as a foundation to begin developing modular condition-specific versions in the near future. Cross-walking against traditional PROs from the PatientsLikeMe platform is underway, in addition to clinical validation and comparison with biomarkers. Thrive is licensed under Creative Commons Attribution ShareAlike 4.0. %M 30681962 %R 10.2196/12075 %U http://www.jmir.org/2019/1/e12075/ %U https://doi.org/10.2196/12075 %U http://www.ncbi.nlm.nih.gov/pubmed/30681962 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10133 %T Improving the Efficacy of Cognitive Training for Digital Mental Health Interventions Through Avatar Customization: Crowdsourced Quasi-Experimental Study %A Birk,Max Valentin %A Mandryk,Regan Lee %+ University of Saskatchewan, Department of Computer Science, 110 Science Place, Saskatoon, SK, S7N 5C9, Canada, 1 3069662327, max.birk@usask.ca %K cognitive therapy %K computer-assisted therapy %K video games %K attentional bias %K cognitive bias %K motivation %D 2019 %7 08.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The success of internet-based mental health interventions in practice—that is, in the wild—depends on the uptake and retention of the application and the user’s focused attention in the moment of use. Incorporating game-based motivational design into digital interventions delivered in the wild has been shown to increase uptake and retention in internet-based training; however, there are outstanding questions about the potential of game-based motivational strategies to increase engagement with a task in the moment of use and the effect on intervention efficacy. Objective: Designers of internet-based interventions need to know whether game-based motivational design strategies can increase in-the-moment engagement and thus improve digital interventions. The aim of this study was to investigate the effects of 1 motivational design strategy (avatar customization) in an example mental health intervention (computerized cognitive training for attention bias modification). Methods: We assigned 317 participants to either a customized avatar or an assigned avatar condition. After measuring state anxiety (State-Trait Anxiety Inventory), we randomly assigned half of the participants in each condition to either an attentional retraining condition (Attention Bias Modification Training) or a control condition. After training, participants were exposed to a negative mood induction using images with strong negative valance (International Affective Picture System), after which we measured state anxiety again. Results: Avatar customization decreased posttraining state anxiety when controlling for baseline state anxiety for those in the attentional retraining condition; however, those who did not train experienced decreased resilience to the negative mood induction (F1,252=6.86, P=.009, ηp2=.027). This interaction effect suggests that customization increased task engagement with the intervention in the moment of use. Avatar customization also increased avatar identification (F5,252=12.46, P<.001, R2=.23), regardless of condition (F1,252=.79, P=.38). Avatar identification reduced anxiety after the negative mood induction for participants who underwent training but increased poststimulus anxiety for participants who did not undergo training, further suggesting that customization increases engagement in the task (F1,252=6.19, P=.01). The beneficial effect of avatar customization on training was driven by participants who were low in their basic satisfaction of relatedness (F10,248=18.5, P<.001, R2=.43), which is important because these are the participants who are most likely in need of digital interventions for mental health. Conclusions: Our results suggest that applying motivational design—specifically avatar customization—is a viable strategy to increase engagement and subsequently training efficacy in a computerized cognitive task. %M 30622095 %R 10.2196/10133 %U https://www.jmir.org/2019/1/e10133/ %U https://doi.org/10.2196/10133 %U http://www.ncbi.nlm.nih.gov/pubmed/30622095 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10008 %T Assessing the Effectiveness of Engaging Patients and Their Families in the Three-Step Fall Prevention Process Across Modalities of an Evidence-Based Fall Prevention Toolkit: An Implementation Science Study %A Duckworth,Megan %A Adelman,Jason %A Belategui,Katherine %A Feliciano,Zinnia %A Jackson,Emily %A Khasnabish,Srijesa %A Lehman,I-Fong Sun %A Lindros,Mary Ellen %A Mortimer,Heather %A Ryan,Kasey %A Scanlan,Maureen %A Berger Spivack,Linda %A Yu,Shao Ping %A Bates,David Westfall %A Dykes,Patricia C %+ Division of General Internal Medicine, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor Division of General Internal Medicine, Boston, MA, 02115, United States, 1 6172764527, msd4cs@virginia.edu %K clinical decision support %K fall prevention %K fall prevention toolkit %K health information technology %K implementation science %K patient safety %D 2019 %7 21.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Patient falls are a major problem in hospitals. The development of a Patient-Centered Fall Prevention Toolkit, Fall TIPS (Tailoring Interventions for Patient Safety), reduced falls by 25% in acute care hospitals by leveraging health information technology to complete the 3-step fall prevention process—(1) conduct fall risk assessments; (2) develop tailored fall prevention plans with the evidence-based interventions; and (3) consistently implement the plan. We learned that Fall TIPS was most effective when patients and family were engaged in all 3 steps of the fall prevention process. Over the past decade, our team developed 3 Fall TIPS modalities—the original electronic health record (EHR) version, a laminated paper version that uses color to provide clinical decision support linking patient-specific risk factors to the interventions, and a bedside display version that automatically populates the bedside monitor with the patients’ fall prevention plan based on the clinical documentation in the EHR. However, the relative effectiveness of each Fall TIPS modality for engaging patients and family in the 3-step fall prevention process remains unknown. Objective: This study aims to examine if the Fall TIPS modality impacts patient engagement in the 3-step fall prevention process and thus Fall TIPS efficacy. Methods: To assess patient engagement in the 3-step fall prevention process, we conducted random audits with the question, “Does the patient/family member know their fall prevention plan?” In addition, audits were conducted to measure adherence, defined by the presence of the Fall TIPS poster at the bedside. Champions from 3 hospitals reported data from April to June 2017 on 6 neurology and 7 medical units. Peer-to-peer feedback to reiterate the best practice for patient engagement was central to data collection. Results: Overall, 1209 audits were submitted for the patient engagement measure and 1401 for the presence of the Fall TIPS poster at the bedside. All units reached 80% adherence for both measures. While some units maintained high levels of patient engagement and adherence with the poster protocol, others showed improvement over time, reaching clinically significant adherence (>80%) by the final month of data collection. Conclusions: Each Fall TIPS modality effectively facilitates patient engagement in the 3-step fall prevention process, suggesting all 3 can be used to integrate evidence-based fall prevention practices into the clinical workflow. The 3 Fall TIPS modalities may prove an effective strategy for the spread, allowing diverse institutions to choose the modality that fits with the organizational culture and health information technology infrastructure. %M 30664454 %R 10.2196/10008 %U http://www.jmir.org/2019/1/e10008/ %U https://doi.org/10.2196/10008 %U http://www.ncbi.nlm.nih.gov/pubmed/30664454 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e9711 %T Farm Owners and Workers as Key Informants in User-Centered Occupational Health Prototype Development: A Stakeholder-Engaged Project %A Weichelt,Bryan %A Bendixsen,Casper %A Keifer,Matthew %+ Marshfield Clinic Research Institute, National Farm Medicine Center, 701 W Kalsched Ave, Marshfield, WI, 54449, United States, 1 715 221 7276, weichelt.bryan@mcrf.mfldclin.edu %K agriculture %K farmworkers %K injuries %K occupational medicine %K return to work %K software application %D 2019 %7 29.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The cost of workplace injuries and illnesses significantly impacts the overall cost of health care and is a significant annual economic burden in the United States. Many dairy and pork farm owners in the Upper Midwest have expanded operations and taken on the role of manager and employer yet receive little training in injury prevention, farm safety, or workers’ compensation programs and processes. Clinicians play a key role in the return to work of injured and ill farmers and farmworkers to their jobs, though little to no formal training is offered by medical schools. Objective: This stakeholder-engaged project aimed to develop a prototype application designed to assist clinicians in returning injured farmworkers to light-duty job assignments with their current employers and to assess farm owners’ and managers’ attitudes toward and barriers to adopting mobile health tools for themselves or their employees. Methods: We conducted 12 semistructured interviews with English-speaking farm owners and farmworkers from the Upper Midwest: 5 English-speaking and Spanish-speaking farmworker focus groups and 8 postproject interviews with farm owners that focused on attitudes and barriers to adoption of the developed software. Interviews and focus groups were audio recorded, and data were analyzed and thematically coded using audio coding. Results: Interviews and worker focus groups guided an iterative design and development cycle, which informed workflow design, button placement, and output sheets that offer specific light-duty farm work recommendations for the injured worker to discuss with his or her employer. Conclusions: The development of a complex prototype intended to impact patient care is a significant undertaking. Reinventing a paper-based process that can eventually integrate with an electronic health record or a private company’s human resources system requires substantial stakeholder input from each facet including patients, employers, and clinical care teams. The prototype is available for testing, but further research is needed in the form of clinical trials to assess the effectiveness of the process and the software’s impact on patients and employers. %M 30694202 %R 10.2196/jmir.9711 %U https://www.jmir.org/2019/1/e9711/ %U https://doi.org/10.2196/jmir.9711 %U http://www.ncbi.nlm.nih.gov/pubmed/30694202 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11935 %T The Absence of Evidence is Evidence of Non-Sense: Cross-Sectional Study on the Quality of Psoriasis-Related Videos on YouTube and Their Reception by Health Seekers %A Mueller,Simon M %A Jungo,Pierre %A Cajacob,Lucian %A Schwegler,Simon %A Itin,Peter %A Brandt,Oliver %+ Department of Dermatology, University Hospital Basel, Petersgraben 4, Basel, 4031, Switzerland, 41 61 328 69 64, simon.mueller@usb.ch %K psoriasis %K YouTube videos %K layperson %K poor quality %K misleading information %K dangerous content %D 2019 %7 16.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Approximately 80% of internet users access health information online and patients with chronic illnesses especially rely on internet-based resources. YouTube ranks second among the most accessed websites worldwide and hosts an increasing number of videos with medical information. However, their quality is sometimes unscientific, misleading, or even harmful. Objective: As little is known about YouTube as a source of information on psoriasis, we aimed to investigate the quality of psoriasis-related videos and, if necessary, point out strategies for their improvement. Methods: The quality of the 100 most viewed psoriasis-related videos was assessed using the DISCERN instrument and the Global Quality Scale (GQS) by categorizing the videos into useful, misleading, and dangerous and by evaluating the reception of the videos by users. Results: Evaluation of the videos exhibited a total of 117,221,391 views and a total duration of 10:28 hour. The majority of clips contained anecdotal personal experiences with complementary and alternative psoriasis treatments, topical treatments, and nutrition and diets being the most frequently addressed topics. While advertisements accounted for 26.0% (26/100) of the videos, evidence-based health information amounted to only 20.0% (20/100); 32.0% (32/100) of the videos were classified as useful, 52.0% (52/100) as misleading, and 11.0% (11/100) as even dangerous. The quality of the videos evaluated by DISCERN and GQS was generally low (1.87 and 1.95, respectively, on a 1 to 5 scale with 5 being the maximum). Moreover, we found that viewers rated poor-quality videos better than higher quality videos. Conclusions: Our in-depth study demonstrates that nearly two-thirds of the psoriasis-related videos we analyzed disseminate misleading or even dangerous content. Subjective anecdotal and unscientific content is disproportionately overrepresented and poor-quality videos are predominantly rated positively by users, while higher quality video clips receive less positive ratings. Strategies by professional dermatological organizations are urgently needed to improve the quality of information on psoriasis on YouTube and other social media. %M 30664460 %R 10.2196/11935 %U http://www.jmir.org/2019/1/e11935/ %U https://doi.org/10.2196/11935 %U http://www.ncbi.nlm.nih.gov/pubmed/30664460 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10986 %T Consumer Health Search on the Web: Study of Web Page Understandability and Its Integration in Ranking Algorithms %A Palotti,Joao %A Zuccon,Guido %A Hanbury,Allan %+ Institute for Information Systems Engineering, Technische Universität Wien, Favoritenstraße 9-11/194 04, Vienna, 1040, Austria, 43 158801188310, allan.hanbury@tuwien.ac.at %K readability %K literacy %K comprehension %K patients %K machine learning %D 2019 %7 30.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Understandability plays a key role in ensuring that people accessing health information are capable of gaining insights that can assist them with their health concerns and choices. The access to unclear or misleading information has been shown to negatively impact the health decisions of the general public. Objective: The aim of this study was to investigate methods to estimate the understandability of health Web pages and use these to improve the retrieval of information for people seeking health advice on the Web. Methods: Our investigation considered methods to automatically estimate the understandability of health information in Web pages, and it provided a thorough evaluation of these methods using human assessments as well as an analysis of preprocessing factors affecting understandability estimations and associated pitfalls. Furthermore, lessons learned for estimating Web page understandability were applied to the construction of retrieval methods, with specific attention to retrieving information understandable by the general public. Results: We found that machine learning techniques were more suitable to estimate health Web page understandability than traditional readability formulae, which are often used as guidelines and benchmark by health information providers on the Web (larger difference found for Pearson correlation of .602 using gradient boosting regressor compared with .438 using Simple Measure of Gobbledygook Index with the Conference and Labs of the Evaluation Forum eHealth 2015 collection). Conclusions: The findings reported in this paper are important for specialized search services tailored to support the general public in seeking health advice on the Web, as they document and empirically validate state-of-the-art techniques and settings for this domain application. %M 30698536 %R 10.2196/10986 %U http://www.jmir.org/2019/1/e10986/ %U https://doi.org/10.2196/10986 %U http://www.ncbi.nlm.nih.gov/pubmed/30698536 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11507 %T Protecting User Privacy and Rights in Academic Data-Sharing Partnerships: Principles From a Pilot Program at Crisis Text Line %A Pisani,Anthony R %A Kanuri,Nitya %A Filbin,Bob %A Gallo,Carlos %A Gould,Madelyn %A Lehmann,Lisa Soleymani %A Levine,Robert %A Marcotte,John E %A Pascal,Brian %A Rousseau,David %A Turner,Shairi %A Yen,Shirley %A Ranney,Megan L %+ Department of Psychiatry, University of Rochester Medical Center, University of Rochester, 300 Crittenden Boulevard Box PSYCH, Rochester, NY, 14642, United States, 1 585 275 3571, anthony_pisani@urmc.rochester.edu %K data sharing %K privacy %K crisis intervention %K text messaging %K ethics, business %K technology %K industry %K cooperative behavior %K information dissemination %D 2019 %7 17.01.2019 %9 Viewpoint %J J Med Internet Res %G English %X Data sharing between technology companies and academic health researchers has multiple health care, scientific, social, and business benefits. Many companies remain wary about such sharing because of unaddressed concerns about ethics, data security, logistics, and public relations. Without guidance on these issues, few companies are willing to take on the potential work and risks involved in noncommercial data sharing, and the scientific and societal potential of their data goes unrealized. In this paper, we describe the 18-month long pilot of a data-sharing program led by Crisis Text Line (CTL), a not-for-profit technology company that provides a free 24/7 text line for people in crisis. The primary goal of the data-sharing pilot was to design, develop, and implement a rigorous framework of principles and protocols for the safe and ethical sharing of user data. CTL used a stakeholder-based policy process to develop a feasible and ethical data-sharing program. The process comprised forming a data ethics committee; identifying policy challenges and solutions; announcing the program and generating interest; and revising the policy and launching the program. Once the pilot was complete, CTL examined how well the program ran and compared it with other potential program models before putting in place the program that was most suitable for its organizational needs. By drawing on CTL’s experiences, we have created a 3-step set of guidelines for other organizations that wish to develop their own data-sharing program with academic researchers. The guidelines explain how to (1) determine the value and suitability of the data and organization for creating a data-sharing program; (2) decide on an appropriate data sharing and collaboration model; and (3) develop protocols and technical solutions for safe and ethical data sharing and the best organizational structure for implementing the program. An internal evaluation determined that the pilot satisfied CTL’s goals of sharing scientific data and protecting client confidentiality. The policy development process also yielded key principles and protocols regarding the ethical challenges involved in data sharing that can be applied by other organizations. Finally, CTL’s internal review of the pilot program developed a number of alternative models for sharing data that will suit a range of organizations with different priorities and capabilities. In implementing and studying this pilot program, CTL aimed both to optimize its own future data-sharing programs and to inform similar decisions made by others. Open data programs are both important and feasible to establish. With careful planning and appropriate resources, data sharing between big data companies and academic researchers can advance their shared mission to benefit society and improve lives. %M 30664452 %R 10.2196/11507 %U https://www.jmir.org/2019/1/e11507/ %U https://doi.org/10.2196/11507 %U http://www.ncbi.nlm.nih.gov/pubmed/30664452 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10171 %T Leading by Example: Web-Based Sexual Health Influencers Among Men Who Have Sex With Men Have Higher HIV and Syphilis Testing Rates in China %A Wu,Dan %A Tang,Weiming %A Lu,Haidong %A Zhang,Tiange P %A Cao,Bolin %A Ong,Jason J %A Lee,Amy %A Liu,Chuncheng %A Huang,Wenting %A Fu,Rong %A Li,Katherine %A Pan,Stephen W %A Zhang,Ye %A Fu,Hongyun %A Wei,Chongyi %A Tucker,Joseph D %+ University North Carolina at Chapel Hill, Project-China, No 2 Lujing Road, Yuexiu District, Guangzhou, 510091, China, 86 16602065374, wudan@seshglobal.org %K health promotion %K peer influence %K internet %K social networks %K social media %K HIV %K syphilis %K men who have sex with men %K China %D 2019 %7 21.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The spread of healthy behaviors through social networks may be accelerated by influential individuals. Previous studies have used lay health influencers to prevent sexually transmitted infections (STIs) among internet-using men who have sex with men (MSM). However, there is a lack of understanding of the characteristics of this key subset of MSM. Objective: This study aimed to examine sociodemographic characteristics, HIV and syphilis testing, and sexual behaviors of Web-based MSM sexual health influencers (SHIs) in China, defined as individuals with relatively stronger influence on spreading HIV and STI information online. Methods: A Web-based survey of MSM was conducted in August 2017 as a final follow-up of a randomized controlled trial promoting HIV testing in 8 Chinese cities. Men were recruited through a gay social networking mobile phone app and were included if they were born biologically male, aged 16 years and above, ever had sex with another man, and HIV negative or with unknown HIV status. Information regarding sociodemographic characteristics, sexual behaviors, and HIV and syphilis testing was obtained. We assessed men’s Web-based sexual health influence using a standardized 6-item opinion leadership scale focused on HIV and STI information. Influencers were defined as those whose mean score ranked within the top 13% (a higher score means greater influence). We used multivariable linear and logistic regression models to measure Web-based sexual health influence’s association with HIV and syphilis testing, controlling for intervention trial effects, age, education, income, and marital status. Results: Overall, 1031 men completed the survey. Most men were younger than 30 years (819/1031, 79.43%) and had at least college education (667/1031, 64.69%). Influencers were more likely to get tested for HIV (73/132, 55.3% vs 337/899, 37.5%; P<.001) and syphilis (35/132, 26.5% vs 137/899, 15.2%; P=.001) in the last 3 months compared with noninfluencers. There were no significant differences in condomless sex with male partners (26/132, 19.7% vs 203/899, 22.6%; P=.46), mean number of male sex partners (1.32 vs 1.11; P=.16) in the last 3 months, and mainly meeting male sex partners online in the last 12 months (97/132, 73.5% vs 669/899, 74.4%; P=.82) between influencers and noninfluencers. Regression analyses showed that influencers had higher odds of HIV testing (adjusted odds ratio, AOR 2.16, 95% CI 1.48-3.17) and syphilis testing (AOR 1.99, 95% CI 1.28-3.10) in the last 3 months. Conclusions: We identified Web-based SHIs who might be more likely to help promote healthy HIV and syphilis testing behaviors through MSM populations. Leveraging existing influencers may help improve HIV and syphilis testing among their networks. %M 30664490 %R 10.2196/10171 %U http://www.jmir.org/2019/1/e10171/ %U https://doi.org/10.2196/10171 %U http://www.ncbi.nlm.nih.gov/pubmed/30664490 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11291 %T Assessing the Impact of a Social Marketing Campaign on Program Outcomes for Users of an Internet-Based Testing Service for Sexually Transmitted and Blood-Borne Infections: Observational Study %A Gilbert,Mark %A Salway,Travis %A Haag,Devon %A Kwag,Michael %A Edward,Joshua %A Bondyra,Mark %A Cox,Joseph %A Hart,Trevor A %A Grace,Daniel %A Grennan,Troy %A Ogilvie,Gina %A Shoveller,Jean %+ British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada, 1 604 707 5619, mark.gilbert@bccdc.ca %K advertisements %K diagnostic tests %K health promotion %K internet %K men who have sex with men %K social marketing %D 2019 %7 21.01.2019 %9 Short Paper %J J Med Internet Res %G English %X Background: While social marketing (SM) campaigns can be effective in increasing testing for sexually transmitted and blood-borne infections (STBBIs), they are seldom rigorously evaluated and often rely on process measures (eg, Web-based ad click-throughs). With Web-based campaigns for internet-based health services, there is a potential to connect campaign process measures to program outcomes, permitting the assessment of venue-specific yield based on health outcomes (eg, click-throughs per test). Objective: This study aims to evaluate the impact of an SM campaign by the promotional venue on use and diagnostic test results of the internet-based STBBI testing service GetCheckedOnline.com (GCO). Methods: Through GCO, clients create an account using an access code, complete a risk assessment, print a lab form, submit specimens at a lab, and get results online or by phone. From April to August 2015, a campaign promoted GCO to gay, bisexual, and other men who have sex with men in Vancouver, Canada. The campaign highlighted GCO’s convenience in 3 types of promotional venues—location advertisements in print or video displayed in gay venues or events, ads on a queer news website, and ads on geosocial websites and apps. Where feasible, individuals were tracked from campaign exposures to account creation and testing using venue-specific GCO access codes. In addition, Web-based ads were linked to alternate versions of the campaign website, which used URLs with embedded access codes to connect ad exposure to account creation. Furthermore, we examined the number of individuals creating GCO accounts, number tested, and cost per account created and test for each venue type. Results: Over 6 months, 177 people created a GCO account because of the campaign, where 22.0% (39/177) of these completed testing; the overall cost was Can $118 per account created and Can $533 per test. Ads on geosocial websites and apps accounted for 46.9% (83/177) of all accounts; ads on the news website had the lowest testing rate and highest cost per test. We observed variation between different geosocial websites and apps with some ads having high click-through rates yet low GCO account creation rates, and vice versa. Conclusions: Developing mechanisms to track individuals from Web-based exposure to SM campaigns to outcomes of internet-based health services permits greater evaluation of the yield and cost-effectiveness of different promotional efforts. Web-based ads with high click-through rates may not have a high conversion to service use, the ultimate outcome of SM campaigns. %M 30664456 %R 10.2196/11291 %U http://www.jmir.org/2019/1/e11291/ %U https://doi.org/10.2196/11291 %U http://www.ncbi.nlm.nih.gov/pubmed/30664456 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11658 %T Digital Recruitment and Acceptance of a Stepwise Model to Prevent Chronic Disease in the Danish Primary Care Sector: Cross-Sectional Study %A Larsen,Lars Bruun %A Sondergaard,Jens %A Thomsen,Janus Laust %A Halling,Anders %A Sønderlund,Anders Larrabee %A Christensen,Jeanette Reffstrup %A Thilsing,Trine %+ Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, Odense, 5000, Denmark, 45 65503830, lblarsen@health.sdu.dk %K promotion of health %K clinical decision support systems %K cross-sectional studies %D 2019 %7 21.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: During recent years, stepwise approaches to health checks have been advanced as an alternative to general health checks. In 2013, we set up the Early Detection and Prevention project (Tidlig Opsporing og Forebyggelse, TOF) to develop a stepwise approach aimed at patients at high or moderate risk of a chronic disease. A novel feature was the use of a personal digital mailbox for recruiting participants. A personal digital mailbox is a secure digital mailbox provided by the Danish public authorities. Apart from being both safe and secure, it is a low-cost, quick, and easy way to reach Danish residents. Objective: In this study we analyze the association between the rates of acceptance of 2 digital invitations sent to a personal digital mailbox and the sociodemographic determinants, medical treatment, and health care usage in a stepwise primary care model for the prevention of chronic diseases. Methods: We conducted a cross-sectional analysis of the rates of acceptance of 2 digital invitations sent to randomly selected residents born between 1957 and 1986 and residing in 2 Danish municipalities. The outcome was acceptance of the 2 digital invitations. Statistical associations were determined by Poisson regression. Data-driven chi-square automatic interaction detection method was used to generate a decision tree analysis, predicting acceptance of the digital invitations. Results: A total of 8814 patients received an invitation in their digital mailbox from 47 general practitioners. A total of 40.22% (3545/8814) accepted the first digital invitation, and 30.19 % (2661/8814) accepted both digital invitations. The rates of acceptance of both digital invitations were higher among women, older patients, patients of higher socioeconomic status, and patients not diagnosed with or being treated for diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular disease. Conclusions: To our knowledge, this is the first study to report on the rates of acceptance of digital invitations to participate in a stepwise model for prevention of chronic diseases. More studies of digital invitations are needed to determine if the acceptance rates seen in this study should be expected from future studies as well. Similarly, more research is needed to determine whether a multimodal recruitment approach, including digital invitations to personal digital mailboxes will reach hard-to-reach subpopulations more effectively than digital invitations only. %M 30664466 %R 10.2196/11658 %U http://www.jmir.org/2019/1/e11658/ %U https://doi.org/10.2196/11658 %U http://www.ncbi.nlm.nih.gov/pubmed/30664466 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10885 %T Expertise Modulates Students’ Perception of Pain From a Self-Perspective: Quasi-Experimental Study %A Said Yekta-Michael,Sareh %A Schüppen,André %A Gaebler,Arnim Johannes %A Ellrich,Jens %A Koten,Jan Willem %+ Department of Conservative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen University, Pauwelsstrasse 30, Aachen, 52074, Germany, 49 02418088118, samichael@ukaachen.de %K medical education %K virtual reality %K questionnaires %K physician %D 2019 %7 23.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Perception of stimuli presented in a virtual dentistry environment affects regions of the brain that are related to pain perception. Objective: We investigated whether neural correlates of virtual pain perception are affected by education in dentistry. Methods: In this functional magnetic resonance imaging study, a sample of 20 dental students and 20 age-matched controls viewed and listened to video clips presenting a dental treatment from the first‐person perspective. An anxiety questionnaire was used to assess the level of dental anxiety. Neural correlates of pain perception were investigated through classic general linear model analysis and in-house classification methods. Results: Dental students and naïve controls exhibited similar anxiety levels for invasive stimuli. Invasive dentistry scenes evoked a less affective component of pain in dental students compared with naïve controls (P<.001). Reduced affective pain perception went along with suppressed brain activity in pain matrix regions including the insula, anterior cingulate cortex, and basal ganglia. Furthermore, a substantial reduction of brain activity was observed in motor-related regions, particularly the supplementary motor area, premotor cortex, and basal ganglia. Within this context, a classifier analysis based on neural activity in the nucleus lentiformis could identify dental students and controls on the individual subject level in 85% of the cases (34 out of 40 participants, sensitivity=90%, specificity=80%). Conclusions: Virtual dental treatment activates pain-related brain regions in controls. By contrast, dental students suppress affective and motor-related aspects of pain. We speculate that dental students learn to control motoric aspects of pain perception during their education because it is a prerequisite for the professional manual treatment of patients. We discuss that a specific set of learning mechanisms might affect perceived self-efficacy of dental students, which in turn might reduce their affective component of pain perception. %M 30674449 %R 10.2196/10885 %U http://www.jmir.org/2019/1/e10885/ %U https://doi.org/10.2196/10885 %U http://www.ncbi.nlm.nih.gov/pubmed/30674449 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11182 %T Identifying Common Methods Used by Drug Interaction Experts for Finding Evidence About Potential Drug-Drug Interactions: Web-Based Survey %A Grizzle,Amy J %A Horn,John %A Collins,Carol %A Schneider,Jodi %A Malone,Daniel C %A Stottlemyer,Britney %A Boyce,Richard David %+ Center for Health Outcomes & PharmacoEconomic Research, College of Pharmacy, University of Arizona, PO Box 210202, 1295 N Martin Ave, Tucson, AZ, 85721-0202, United States, 1 520 626 4721, grizzle@pharmacy.arizona.edu %K drug interactions %K drug interaction experts %K potential drug-drug interactions %K surveys   %D 2019 %7 04.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Preventing drug interactions is an important goal to maximize patient benefit from medications. Summarizing potential drug-drug interactions (PDDIs) for clinical decision support is challenging, and there is no single repository for PDDI evidence. Additionally, inconsistencies across compendia and other sources have been well documented. Standard search strategies for complete and current evidence about PDDIs have not heretofore been developed or validated. Objective: This study aimed to identify common methods for conducting PDDI literature searches used by experts who routinely evaluate such evidence. Methods: We invited a convenience sample of 70 drug information experts, including compendia editors, knowledge-base vendors, and clinicians, via emails to complete a survey on identifying PDDI evidence. We created a Web-based survey that included questions regarding the (1) development and conduct of searches; (2) resources used, for example, databases, compendia, search engines, etc; (3) types of keywords used to search for the specific PDDI information; (4) study types included and excluded in searches; and (5) search terms used. Search strategy questions focused on 6 topics of the PDDI information—(1) that a PDDI exists; (2) seriousness; (3) clinical consequences; (4) management options; (5) mechanism; and (6) health outcomes. Results: Twenty participants (response rate, 20/70, 29%) completed the survey. The majority (17/20, 85%) were drug information specialists, drug interaction researchers, compendia editors, or clinical pharmacists, with 60% (12/20) having >10 years’ experience. Over half (11/20, 55%) worked for clinical solutions vendors or knowledge-base vendors. Most participants developed (18/20, 90%) and conducted (19/20, 95%) search strategies without librarian assistance. PubMed (20/20, 100%) and Google Scholar (11/20, 55%) were most commonly searched for papers, followed by Google Web Search (7/20, 35%) and EMBASE (3/20, 15%). No respondents reported using Scopus. A variety of subscription and open-access databases were used, most commonly Lexicomp (9/20, 45%), Micromedex (8/20, 40%), Drugs@FDA (17/20, 85%), and DailyMed (13/20, 65%). Facts and Comparisons was the most commonly used compendia (8/20, 40%). Across the 6 attributes of interest, generic drug name was the most common keyword used. Respondents reported using more types of keywords when searching to identify the existence of PDDIs and determine their mechanism than when searching for the other 4 attributes (seriousness, consequences, management, and health outcomes). Regarding the types of evidence useful for evaluating a PDDI, clinical trials, case reports, and systematic reviews were considered relevant, while animal and in vitro data studies were not. Conclusions: This study suggests that drug interaction experts use various keyword strategies and various database and Web resources depending on the PDDI evidence they are seeking. Greater automation and standardization across search strategies could improve one’s ability to identify PDDI evidence. Hence, future research focused on enhancing the existing search tools and designing recommended standards is needed. %M 30609981 %R 10.2196/11182 %U https://www.jmir.org/2019/1/e11182/ %U https://doi.org/10.2196/11182 %U http://www.ncbi.nlm.nih.gov/pubmed/30609981 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10929 %T Measuring the Impact of an Open Web-Based Prescribing Data Analysis Service on Clinical Practice: Cohort Study on NHS England Data %A Walker,Alex J %A Curtis,Helen J %A Croker,Richard %A Bacon,Seb %A Goldacre,Ben %+ Evidence Based Medicine DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, United Kingdom, 44 1865289313, ben.goldacre@phc.ox.ac.uk %K drug prescribing %K cost control %K patient safety %K treatment efficacy %D 2019 %7 16.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: OpenPrescribing is a freely accessible service that enables any user to view and analyze the National Health Service (NHS) primary care prescribing data at the level of individual practices. This tool is intended to improve the quality, safety, and cost-effectiveness of prescribing. Objective: We aimed to measure the impact of OpenPrescribing being viewed on subsequent prescribing. Methods: Having preregistered our protocol and code, we measured three different metrics of prescribing quality (mean percentile across 34 existing OpenPrescribing quality measures, available “price-per-unit” savings, and total “low-priority prescribing” spend) to see whether they changed after the viewing of Clinical Commissioning Group (CCG) and practice pages. We also measured whether practices whose data were viewed on OpenPrescribing differed in prescribing, prior to viewing, compared with those who were not. We used fixed-effects and between-effects linear panel regression to isolate change over time and differences between practices, respectively. We adjusted for the month of prescribing in the fixed-effects model to remove underlying trends in outcome measures. Results: We found a reduction in available price-per-unit savings for both practices and CCGs after their pages were viewed. The saving was greater at practice level (−£40.42 per thousand patients per month; 95% CI −54.04 to −26.81) than at CCG level (−£14.70 per thousand patients per month; 95% CI −25.56 to −3.84). We estimate a total saving since launch of £243 thosand at practice level and £1.47 million at CCG level between the feature launch and end of follow-up (August to November 2017) among practices viewed. If the observed savings from practices viewed were extrapolated to all practices, this would generate £26.8 million in annual savings for the NHS, approximately 20% of the total possible savings from this method. The other two measures were not different after CCGs or practices were viewed. Practices that were viewed had worse prescribing quality scores overall prior to viewing. Conclusions: We found a positive impact from the use of OpenPrescribing, specifically for the class of savings opportunities that can only be identified by using this tool. Furthermore, we show that it is possible to conduct a robust analysis of the impact of such a Web-based service on clinical practice. %M 30664459 %R 10.2196/10929 %U http://www.jmir.org/2019/1/e10929/ %U https://doi.org/10.2196/10929 %U http://www.ncbi.nlm.nih.gov/pubmed/30664459 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10013 %T Application of Efficient Data Cleaning Using Text Clustering for Semistructured Medical Reports to Large-Scale Stool Examination Reports: Methodology Study %A Woo,Hyunki %A Kim,Kyunga %A Cha,KyeongMin %A Lee,Jin-Young %A Mun,Hansong %A Cho,Soo Jin %A Chung,Ji In %A Pyo,Jeung Hui %A Lee,Kun-Chul %A Kang,Mira %+ Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea, 82 2 3410 3882, mira90.kang@samsung.com %K data cleaning %K text clustering %K key collision %K nearest neighbor methods %K OpenRefine %D 2019 %7 08.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Since medical research based on big data has become more common, the community’s interest and effort to analyze a large amount of semistructured or unstructured text data, such as examination reports, have rapidly increased. However, these large-scale text data are often not readily applicable to analysis owing to typographical errors, inconsistencies, or data entry problems. Therefore, an efficient data cleaning process is required to ensure the veracity of such data. Objective: In this paper, we proposed an efficient data cleaning process for large-scale medical text data, which employs text clustering methods and value-converting technique, and evaluated its performance with medical examination text data. Methods: The proposed data cleaning process consists of text clustering and value-merging. In the text clustering step, we suggested the use of key collision and nearest neighbor methods in a complementary manner. Words (called values) in the same cluster would be expected as a correct value and its wrong representations. In the value-converting step, wrong values for each identified cluster would be converted into their correct value. We applied these data cleaning process to 574,266 stool examination reports produced for parasite analysis at Samsung Medical Center from 1995 to 2015. The performance of the proposed process was examined and compared with data cleaning processes based on a single clustering method. We used OpenRefine 2.7, an open source application that provides various text clustering methods and an efficient user interface for value-converting with common-value suggestion. Results: A total of 1,167,104 words in stool examination reports were surveyed. In the data cleaning process, we discovered 30 correct words and 45 patterns of typographical errors and duplicates. We observed high correction rates for words with typographical errors (98.61%) and typographical error patterns (97.78%). The resulting data accuracy was nearly 100% based on the number of total words. Conclusions: Our data cleaning process based on the combinatorial use of key collision and nearest neighbor methods provides an efficient cleaning of large-scale text data and hence improves data accuracy. %M 30622098 %R 10.2196/10013 %U https://www.jmir.org/2019/1/e10013/ %U https://doi.org/10.2196/10013 %U http://www.ncbi.nlm.nih.gov/pubmed/30622098 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11683 %T Use of In-Game Rewards to Motivate Daily Self-Report Compliance: Randomized Controlled Trial %A Taylor,Sara %A Ferguson,Craig %A Peng,Fengjiao %A Schoeneich,Magdalena %A Picard,Rosalind W %+ Affective Computing Group, Department of Media Arts and Sciences, Massachusetts Institute of Technology, 77 Massachusetts Avenue, E14-348V, Cambridge, MA, 02142, United States, 1 6128608622, sataylor@mit.edu %K self-reports %K protocol compliance %K recreational games %D 2019 %7 03.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Encouraging individuals to report daily information such as unpleasant disease symptoms, daily activities and behaviors, or aspects of their physical and emotional state is difficult but necessary for many studies and clinical trials that rely on patient-reported data as primary outcomes. Use of paper diaries is the traditional method of completing daily diaries, but digital surveys are becoming the new standard because of their increased compliance; however, they still fall short of desired compliance levels. Objective: Mobile games using in-game rewards offer the opportunity to increase compliance above the rates of digital diaries and paper diaries. We conducted a 5-week randomized control trial to compare the completion rates of a daily diary across 3 conditions: a paper-based participant-reported outcome diary (Paper PRO), an electronic-based participant-reported outcome diary (ePRO), and a novel ePRO diary with in-game rewards (Game-Motivated ePRO). Methods: We developed a novel mobile game that is a combination of the idle and pet collection genres to reward individuals who complete a daily diary with an in-game reward. Overall, 197 individuals aged 6 to 24 years (male: 100 and female: 97) were enrolled in a 5-week study after being randomized into 1 of the 3 methods of daily diary completion. Moreover, 157 participants (male: 84 and female: 69) completed at least one diary and were subsequently included in analysis of compliance rates. Results: We observed a significant difference (F2,124=6.341; P=.002) in compliance to filling out daily diaries, with the Game-Motivated ePRO group having the highest compliance (mean completion 86.4%, SD 19.6%), followed by the ePRO group (mean completion 77.7%, SD 24.1%), and finally, the Paper PRO group (mean completion 70.6%, SD 23.4%). The Game-Motivated ePRO (P=.002) significantly improved compliance rates above the Paper PRO. In addition, the Game-Motivated ePRO resulted in higher compliance rates than the rates of ePRO alone (P=.09). Equally important, even though we observed significant differences in completion of daily diaries between groups, we did not observe any statistically significant differences in association between the responses to a daily mood question and study group, the average diary completion time (P=.52), or the System Usability Scale score (P=.88). Conclusions: The Game-Motivated ePRO system encouraged individuals to complete the daily diaries above the compliance rates of the Paper PRO and ePRO without altering the participants’ responses. Trial Registration: ClinicalTrials.gov NCT03738254; http://clinicaltrials.gov/ct2/show/NCT03738254 (Archived by WebCite at http://www.webcitation.org/74T1p8u52) %M 30609986 %R 10.2196/11683 %U https://www.jmir.org/2019/1/e11683/ %U https://doi.org/10.2196/11683 %U http://www.ncbi.nlm.nih.gov/pubmed/30609986 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11302 %T Measurement of Quality of Life in Patients with Mycosis Fungoides/Sézary Syndrome Cutaneous T-Cell Lymphoma: Development of an Electronic Instrument %A McCaffrey,Stacey %A Black,Ryan A %A Nagao,Mitchell %A Sepassi,Marjan %A Sharma,Gaurav %A Thornton,Susan %A Kim,Youn H %A Braverman,Julia %+ PatientsLikeMe, Inc, 160 Second Street, Cambridge, MA, 02142, United States, 1 6174994003, research@patientslikeme.com %K quality of life %K Rasch %K patient-reported outcome %K cutaneous T-cell lymphoma %K mycosis fungoides %K Sézary syndrome %D 2019 %7 07.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Although the quality of life (QoL) plays an important role in treatment decision making and clinical management of mycosis fungoides (MF) or Sézary syndrome (SS) subtypes of cutaneous T-cell lymphomas (MF/SS-CTCLs), an MF- or SS-specific measure of QoL does not exist. Objective: The objective of this research was to develop and validate the first QoL instrument for MF/SS-CTCL using a patient-centered approach. Methods: A conceptual framework for the MF/SS-CTCL QoL was developed through a literature review and interviews with key opinion leaders. Concept elicitation with patients was utilized to refine the conceptual model and generate preliminary items. The items were then revised based on qualitative and quantitative feedback obtained through cognitive debriefing surveys and interviews with patients. Next, participants (N=126) completed the preliminary MF/SS-CTCL QoL and a comparator measure of health-related QoL (Skindex-29) through the PatientsLikeMe Open Research Exchange. The MF/SS-CTCL QoL was completed again 5 days later by 66 participants for the purposes of evaluating test-retest reliability. The MF/SS-CTCL QoL was finalized based on results from an empirical evaluation, which included both classical and modern test theory approaches. Specifically, this included evaluation of (1) the optimal item response theory measurement model; (2) item fit; (3) unidimensionality; (4) rating scale performance; (5) reliability; (6) test information (precision); (7) person-to-item map; (8) convergent and discriminant validity; and (9) presence of bias via differential item function. Results: Results from the comprehensive psychometric evaluation utilizing a Rasch-Grouped Rating Scale model yielded a final 12-item instrument. The rating scale functioned as expected, and the instrument exhibited adequate person reliability (.87), good to excellent test-retest reliability (r=.89, P<.001), high levels of measurement precision, and good person-to-item targeting. The correlation between the MF/SS-CTCL QoL and the Skindex-29 (r=.852, P<.001) was significantly greater than the correlation between the MF/SS-CTCL QoL and syndrome stage (r=.260, P<.001), providing support for convergent and discriminant validity. Items did not show significant bias based on gender, age, or race. Rasch scores were converted to scaled scores with qualitative descriptive categories for ease of interpretation. Conclusions: Empirical evaluation demonstrated strong evidence of excellent psychometric properties. Utilizing a patient-centered measure development approach ensures that this QoL instrument captures the information that is most meaningful and clinically relevant to patients. %M 30617041 %R 10.2196/11302 %U https://www.jmir.org/2019/1/e11302/ %U https://doi.org/10.2196/11302 %U http://www.ncbi.nlm.nih.gov/pubmed/30617041 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10004 %T An Electronic Patient-Reported Outcome Tool for the FACT-B (Functional Assessment of Cancer Therapy-Breast) Questionnaire for Measuring the Health-Related Quality of Life in Patients With Breast Cancer: Reliability Study %A Matthies,Lina Maria %A Taran,Florin-Andrei %A Keilmann,Lucia %A Schneeweiss,Andreas %A Simoes,Elisabeth %A Hartkopf,Andreas D %A Sokolov,Alexander N %A Walter,Christina B %A Sickenberger,Nina %A Wallwiener,Stephanie %A Feisst,Manuel %A Gass,Paul %A Lux,Michael P %A Schuetz,Florian %A Fasching,Peter A %A Sohn,Christof %A Brucker,Sara Y %A Graf,Joachim %A Wallwiener,Markus %+ Hospital for General Obstetrics and Gynecology, Gynecologic Oncology, National Center for Tumor Diseases, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, 69120, Germany, 49 (0)6221 5636956, markus.wallwiener@gmail.com %K breast cancer %K ePRO measurement %K FACT-B %K HRQoL %K patient-reported outcomes %K reliability of ePRO %D 2019 %7 22.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The most frequent malignant disease in women is breast cancer. In the metastatic setting, quality of life is the primary therapeutic goal, and systematic treatment has only a limited effect on survival rates; therefore, the concept of the health-related quality of life (HRQoL) and measurement of patient-reported outcomes (PROs) are gaining more and more importance in the therapy setting of diseases such as breast cancer. One of the frequently used questionnaires for measuring the HRQoL in patients with breast cancer is the Functional Assessment of Cancer Therapy-Breast (FACT-B). Currently, paper-based surveys still predominate, as only a few reliable and validated electronic-based questionnaires are available. ePRO tools for the FACT-B questionnaire with proven reliability are missing so far. Objective: The aim of this study was to analyze the reliability of tablet-based measurement of FACT-B in the German language in adjuvant (curative) and metastatic breast cancer patients. Methods: Paper- and tablet-based questionnaires were completed by a total of 106 female adjuvant and metastatic breast cancer patients. All patients were required to complete the electronically based (ePRO) and paper-based version of the FACT-B. A frequency analysis was performed to determine descriptive sociodemographic characteristics. Both dimensions of reliability (parallel forms reliability using Wilcoxon test and test of internal consistency using Spearman ρ) and agreement rates for single items, Kendall tau for each subscale, and total score were analyzed. Results: High correlations were shown for both dimensions of reliability (parallel forms reliability and internal consistency) in the patients’ response behavior between paper-based and electronically based questionnaires. Regarding the reliability test of parallel forms, no significant differences were found in 35 of 37 single items, while significant correlations in the test for consistency were found in all 37 single items, in all 5 sum individual item subscale scores, as well as in total FACT-B score. Conclusions: The ePRO version of the FACT-B questionnaire is reliable for patients with breast cancer in both adjuvant and metastatic settings, showing highly significant correlations with the paper-based version in almost all questions all subscales and the total score. %M 30668517 %R 10.2196/10004 %U http://www.jmir.org/2019/1/e10004/ %U https://doi.org/10.2196/10004 %U http://www.ncbi.nlm.nih.gov/pubmed/30668517 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11429 %T The Most Influential Medical Journals According to Wikipedia: Quantitative Analysis %A Jemielniak,Dariusz %A Masukume,Gwinyai %A Wilamowski,Maciej %+ Department of Management in Networked and Digital Societies, Kozminski University, Jagiellonska 59, Warszawa, 03301, Poland, 48 604901352, darekj@kozminski.edu.pl %K citizen science %K medical journals %K open knowledge %K Wikipedia %K knowledge translation %K journalology %K medical publishing %K scholarly publishing %D 2019 %7 18.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Wikipedia, the multilingual encyclopedia, was founded in 2001 and is the world’s largest and most visited online general reference website. It is widely used by health care professionals and students. The inclusion of journal articles in Wikipedia is of scholarly interest, but the time taken for a journal article to be included in Wikipedia, from the moment of its publication to its incorporation into Wikipedia, is unclear. Objective: We aimed to determine the ranking of the most cited journals by their representation in the English-language medical pages of Wikipedia. In addition, we evaluated the number of days between publication of journal articles and their citation in Wikipedia medical pages, treating this measure as a proxy for the information-diffusion rate. Methods: We retrieved the dates when articles were included in Wikipedia and the date of journal publication from Crossref by using an application programming interface. Results: From 11,325 Wikipedia medical articles, we identified citations to 137,889 journal articles from over 15,000 journals. There was a large spike in the number of journal articles published in or after 2002 that were cited by Wikipedia. The higher the importance of a Wikipedia article, the higher was the mean number of journal citations it contained (top article, 48.13 [SD 33.67]; lowest article, 6.44 [SD 9.33]). However, the importance of the Wikipedia article did not affect the speed of reference addition. The Cochrane Database of Systematic Reviews was the most cited journal by Wikipedia, followed by The New England Journal of Medicine and The Lancet. The multidisciplinary journals Nature, Science, and the Proceedings of the National Academy of Sciences were among the top 10 journals with the highest Wikipedia medical article citations. For the top biomedical journal papers cited in Wikipedia's medical pages in 2016-2017, it took about 90 days (3 months) for the citation to be used in Wikipedia. Conclusions: We found evidence of “recentism,” which refers to preferential citation of recently published journal articles in Wikipedia. Traditional high-impact medical and multidisciplinary journals were extensively cited by Wikipedia, suggesting that Wikipedia medical articles have robust underpinnings. In keeping with the Wikipedia policy of citing reviews/secondary sources in preference to primary sources, the Cochrane Database of Systematic Reviews was the most referenced journal. %M 30664451 %R 10.2196/11429 %U http://www.jmir.org/2019/1/e11429/ %U https://doi.org/10.2196/11429 %U http://www.ncbi.nlm.nih.gov/pubmed/30664451 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12064 %T Perceptions of Visualizing Physical Activity as a 3D-Printed Object: Formative Study %A Crossley,Sam Graeme Morgan %A McNarry,Melitta Anne %A Hudson,Joanne %A Eslambolchilar,Parisa %A Knowles,Zoe %A Mackintosh,Kelly Alexandra %+ Human Factors Technology Research Priority Area, School of Computer Science and Informatics, Cardiff University, Queen's Buildings, North Building, 5 The Parade, Newport Road, Cardiff, CF24 3AA, United Kingdom, 44 0 29 2087 9346, EslambolchilarP@cardiff.ac.uk %K 3D printing %K feedback %K youth %K education %K school %D 2019 %7 30.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The UK government recommends that children engage in moderate-to-vigorous physical activity for at least 60 min every day. Despite associated physiological and psychosocial benefits of physical activity, many youth fail to meet these guidelines partly due to sedentary screen-based pursuits displacing active behaviors. However, technological advances such as 3D printing have enabled innovative methods of visualizing and conceptualizing physical activity as a tangible output. Objective: The aim of this study was to elicit children’s, adolescents’, parents’, and teachers’ perceptions and understanding of 3D physical activity objects to inform the design of future 3D models of physical activity. Methods: A total of 28 primary school children (aged 8.4 [SD 0.3] years; 15 boys) and 42 secondary school adolescents (aged 14.4 [SD 0.3] years; 22 boys) participated in semistructured focus groups, with individual interviews conducted with 8 teachers (2 male) and 7 parents (2 male). Questions addressed understanding of the physical activity guidelines, 3D model design, and both motivation for and potential engagement with a 3D physical activity model intervention. Pupils were asked to use Play-Doh to create and describe a model that could represent their physical activity levels (PAL). Data were transcribed verbatim and thematically analyzed, and key emergent themes were represented using pen profiles. Results: Pupils understood the concept of visualizing physical activity as a 3D object, although adolescents were able to better analyze and critique differences between low and high PAL. Both youths and adults preferred a 3D model representing a week of physical activity data when compared with other temporal representations. Furthermore, all participants highlighted that 3D models could act as a motivational tool to enhance youths’ physical activity. From the Play-Doh designs, 2 key themes were identified by pupils, with preferences indicated for models of abstract representations of physical activity or bar charts depicting physical activity, respectively. Conclusions: These novel findings highlight the potential utility of 3D objects of physical activity as a mechanism to enhance children’s and adolescents’ understanding of, and motivation to increase, their PAL. This study suggests that 3D printing may offer a unique strategy for promoting physical activity in these groups. %M 30698532 %R 10.2196/12064 %U http://www.jmir.org/2019/1/e12064/ %U https://doi.org/10.2196/12064 %U http://www.ncbi.nlm.nih.gov/pubmed/30698532 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12959 %T Virtual Reality for Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration %A Kyaw,Bhone Myint %A Saxena,Nakul %A Posadzki,Pawel %A Vseteckova,Jitka %A Nikolaou,Charoula Konstantia %A George,Pradeep Paul %A Divakar,Ushashree %A Masiello,Italo %A Kononowicz,Andrzej A %A Zary,Nabil %A Tudor Car,Lorainne %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore,, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K virtual reality %K health professions education %K randomized controlled trials %K systematic review %K meta-analysis %D 2019 %7 22.01.2019 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice. Objective: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction. Methods: We performed a systematic review of the effectiveness of VR in pre- and postregistration health professions education following the gold standard Cochrane methodology. We searched 7 databases from the year 1990 to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data, and assessed risk of bias, and then, we compared the information in pairs. We contacted authors of the studies for additional information if necessary. All pooled analyses were based on random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to rate the quality of the body of evidence. Results: A total of 31 studies (2407 participants) were included. Meta-analysis of 8 studies found that VR slightly improves postintervention knowledge scores when compared with traditional learning (standardized mean difference [SMD]=0.44; 95% CI 0.18-0.69; I2=49%; 603 participants; moderate certainty evidence) or other types of digital education such as online or offline digital education (SMD=0.43; 95% CI 0.07-0.79; I2=78%; 608 participants [8 studies]; low certainty evidence). Another meta-analysis of 4 studies found that VR improves health professionals’ cognitive skills when compared with traditional learning (SMD=1.12; 95% CI 0.81-1.43; I2=0%; 235 participants; large effect size; moderate certainty evidence). Two studies compared the effect of VR with other forms of digital education on skills, favoring the VR group (SMD=0.5; 95% CI 0.32-0.69; I2=0%; 467 participants; moderate effect size; low certainty evidence). The findings for attitudes and satisfaction were mixed and inconclusive. None of the studies reported any patient-related outcomes, behavior change, as well as unintended or adverse effects of VR. Overall, the certainty of evidence according to the GRADE criteria ranged from low to moderate. We downgraded our certainty of evidence primarily because of the risk of bias and/or inconsistency. Conclusions: We found evidence suggesting that VR improves postintervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness, and clinical practice or behavior change. %M 30668519 %R 10.2196/12959 %U http://www.jmir.org/2019/1/e12959/ %U https://doi.org/10.2196/12959 %U http://www.ncbi.nlm.nih.gov/pubmed/30668519 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e9818 %T Server-Focused Security Assessment of Mobile Health Apps for Popular Mobile Platforms %A Müthing,Jannis %A Brüngel,Raphael %A Friedrich,Christoph M %+ University of Applied Sciences and Arts Dortmund, Department of Computer Science, Emil-Figge-Straße 42, Dortmund, 44227, Germany, 49 231 9112 ext 6796, christoph.friedrich@fh-dortmund.de %K mobile health %K mobile apps %K data security %K computer security %K confidentiality %K health information technology %K servers %K data protection %D 2019 %7 23.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The importance of mobile health (mHealth) apps is growing. Independent of the technologies used, mHealth apps bring more functionality into the hands of users. In the health context, mHealth apps play an important role in providing information and services to patients, offering health care professionals ways to monitor vital parameters or consult patients remotely. The importance of confidentiality in health care and the opaqueness of transport security in apps make the latter an important research subject. Objective: This study aimed to (1) identify relevant security concerns on the server side of mHealth apps, (2) test a subset of mHealth apps regarding their vulnerability to those concerns, and (3) compare the servers used by mHealth apps with servers used in all domains. Methods: Server security characteristics relevant to the security of mHealth apps were assessed, presented, and discussed. To evaluate servers, appropriate tools were selected. Apps from the Android and iOS app stores were selected and tested, and the results for functional and other backend servers were evaluated. Results: The 60 apps tested communicate with 823 servers. Of these, 291 were categorized as functional backend servers, and 44 (44/291, 15.1%) of these received a rating below the A range (A+, A, and A−) by Qualys SSL Labs. A chi-square test was conducted against the number of servers receiving such ratings from SSL Pulse by Qualys SSL Labs. It was found that the tested servers from mHealth apps received significantly fewer ratings below the A range (P<.001). The internationally available apps from the test set performed significantly better than those only available in the German stores (alpha=.05; P=.03). Of the 60 apps, 28 (28/60, 47%) were found using at least one functional backend server that received a rating below the A range from Qualys SSL Labs, endangering confidentiality, authenticity, and integrity of the data displayed. The number of apps that used at least one entirely unsecured connection was 20 (20/60, 33%) when communicating with functional backend servers. It was also found that a majority of apps used advertising, tracking, or external content provider servers. When looking at all nonfunctional backend servers, 48 (48/60, 80%) apps used at least one server that received a rating below the A range. Conclusions: The results show that although servers in the mHealth domain perform significantly better regarding their security, there are still problems with the configuration of some. The most severe problems observed can expose patient communication with health care professionals, be exploited to display false or harmful information, or used to send data to an app facilitating further damage on the device. Following the recommendations for mHealth app developers, the most regularly observed security issues can be avoided or mitigated. %M 30672738 %R 10.2196/jmir.9818 %U https://www.jmir.org/2019/1/e9818/ %U https://doi.org/10.2196/jmir.9818 %U http://www.ncbi.nlm.nih.gov/pubmed/30672738