%0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11985 %T Digital Trespass: Ethical and Terms-of-Use Violations by Researchers Accessing Data From an Online Patient Community %A Chiauzzi,Emil %A Wicks,Paul %+ PatientsLikeMe, Inc, 160 Second Street, Cambridge, MA, 02142, United States, 1 617 499 4003, echiauzzi@outlook.com %K ethical issues %K social media %K data sharing %K privacy %K informed consent %K data protection %K data anonymization %D 2019 %7 21.02.2019 %9 Editorial %J J Med Internet Res %G English %X With the expansion and popularity of research on websites such as Facebook and Twitter, there has been increasing concern about investigator conduct and social media ethics. The availability of large data sets has attracted researchers who are not traditionally associated with health data and its associated ethical considerations, such as computer and data scientists. Reliance on oversight by ethics review boards is inadequate and, due to the public availability of social media data, there is often confusion between public and private spaces. In addition, social media participants and researchers may pay little attention to traditional terms of use. In this paper, we review four cases involving ethical and terms-of-use violations by researchers seeking to conduct social media studies in an online patient research network. These violations involved unauthorized scraping of social media data, entry of false information, misrepresentation of researcher identities of participants on forums, lack of ethical approval and informed consent, use of member quotations, and presentation of findings at conferences and in journals without verifying accurate potential biases and limitations of the data. The correction of these ethical lapses often involves much effort in detecting and responding to violators, addressing these lapses with members of an online community, and correcting inaccuracies in the literature (including retraction of publications and conference presentations). Despite these corrective actions, we do not regard these episodes solely as violations. Instead, they represent broader ethical issues that may arise from potential sources of confusion, misinformation, inadequacies in applying traditional informed consent procedures to social media research, and differences in ethics training and scientific methodology across research disciplines. Social media research stakeholders need to assure participants that their studies will not compromise anonymity or lead to harmful outcomes while preserving the societal value of their health-related studies. Based on our experience and published recommendations by social media researchers, we offer potential directions for future prevention-oriented measures that can be applied by data producers, computer/data scientists, institutional review boards, research ethics committees, and publishers. %M 30789346 %R 10.2196/11985 %U http://www.jmir.org/2019/2/e11985/ %U https://doi.org/10.2196/11985 %U http://www.ncbi.nlm.nih.gov/pubmed/30789346 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11953 %T The Messages Presented in Electronic Cigarette–Related Social Media Promotions and Discussion: Scoping Review %A McCausland,Kahlia %A Maycock,Bruce %A Leaver,Tama %A Jancey,Jonine %+ Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Kent Street, Bentley, 6102, Australia, 61 92667382 ext 7382, kahlia.mccausland@curtin.edu.au %K electronic nicotine delivery systems %K social media %K public health %K review %D 2019 %7 05.02.2019 %9 Review %J J Med Internet Res %G English %X Background: There has been a rapid rise in the popularity of electronic cigarettes (e-cigarettes) over the last decade, with growth predicted to continue. The uptake of these devices has escalated despite inconclusive evidence of their efficacy as a smoking cessation device and unknown long-term health consequences. As smoking rates continue to drop or plateau in many well-developed countries, transnational tobacco companies have transitioned into the vaping industry and are now using social media to promote their products. Evidence indicates e-cigarettes are being marketed on social media as a harm reduction alternative, with retailers and manufacturers utilizing marketing techniques historically used by the tobacco industry. Objective: This study aimed to identify and describe the messages presented in e-cigarette–related social media (Twitter, YouTube, Instagram, and Pinterest) promotions and discussions and identify future directions for research, surveillance, and regulation. Methods: Data sources included MEDLINE, Scopus, ProQuest, Informit, the Journal of Medical Internet Research, and Google Scholar. Included studies were published in English between 2007 and 2017, analyzed content captured from e-cigarette–related social media promotions or discussions, and reported results for e-cigarettes separately from other forms of tobacco and nicotine delivery. Database search ceased in October 2017. Initial searches identified 536 studies. Two reviewers screened studies by title and abstract. One reviewer examined 71 full-text articles to determine eligibility and identified 25 studies for inclusion. This process was undertaken with the assistance of the Web-based screening and data extraction tool—Covidence. The review was registered with the Joanna Briggs Institute (JBI) Systematic Reviews database and followed the methodology for JBI Scoping Reviews. Results: Several key messages are being used to promote e-cigarettes including as a safer alternative to cigarettes, efficacy as a smoking cessation aid, and for use where smoking is prohibited. Other major marketing efforts aimed at capturing a larger market involve promotion of innovative flavoring and highlighting the public performance of vaping. Discussion and promotion of these devices appear to be predominantly occurring among the general public and those with vested interests such as retailers and manufacturers. There is a noticeable silence from the public health and government sector in these discussions on social media. Conclusions: The social media landscape is dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents. The uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues and highlights the need for public health professionals to interact with the public to actively influence social media conversations and create a more balanced discussion. With the vaping industry changing so rapidly, real-time monitoring and surveillance of how these devices are discussed, promoted, and used on social media is necessary in conjunction with evidence published in academic journals. %M 30720440 %R 10.2196/11953 %U https://www.jmir.org/2019/2/e11953/ %U https://doi.org/10.2196/11953 %U http://www.ncbi.nlm.nih.gov/pubmed/30720440 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11079 %T Digital Interventions to Reduce Sedentary Behaviors of Office Workers: Scoping Review %A Huang,Yitong %A Benford,Steve %A Blake,Holly %+ Horizon Centre for Doctoral Training, University of Nottingham, B06, Computer Science, Wollaton Road, Nottingham, NG8 1BB, United Kingdom, 44 115 823255, yitong.huang@nottingham.ac.uk %K telemedicine %K sedentary behavior %K workplace %K technology %K internet %K microcomputers %D 2019 %7 07.02.2019 %9 Review %J J Med Internet Res %G English %X Background: There is a clear public health need to reduce office workers’ sedentary behaviors (SBs), especially in the workplace. Digital technologies are increasingly being deployed in the workplace to measure and modify office workers’ SBs. However, knowledge of the range and nature of research on this topic is limited; it also remains unclear to what extent digital interventions have exploited the technological possibilities. Objective: This study aimed to investigate the technological landscape of digital interventions for SB reduction in office workers and to map the research activity in this field. Methods: Terms related to SB, office worker, and digital technology were applied in various combinations to search Cochrane Library, Joanna Briggs Institute Database of Systematic Reviews, MEDLINE, PsycARTICLES, PsycINFO, Scopus, Association for Computing Machinery Digital Library, Engineering index Compendex, and Google Scholar for the years 2000 to 2017. Data regarding the study and intervention details were extracted. Interventions and studies were categorized into development, feasibility and/piloting, evaluation, or implementation phase based on the UK Medical Research Council (MRC) framework for developing and evaluating complex interventions. A novel framework was developed to classify technological features and annotate technological configurations. A mix of quantitative and qualitative approaches was used to summarize data. Results: We identified 68 articles describing 45 digital interventions designed to intervene with office workers’ SB. A total of 6 common technological features had been applied to interventions with various combinations. Configurations such as “information delivery and mediated organizational and social support” and “digital log and automated tailored feedback” were well established in evaluation and implementation studies; in contrast, the integration of passive data collection, connected devices, and ATF or scheduled prompts was mostly present in development and piloting research. Conclusions: This review is the first to map and describe the use of digital technologies in research on SB reduction in office workers. Interdisciplinary collaborations can help to maximize the potential of technologies. As novel modes of delivery that capitalize on embedded computing and electronics, wireless technologies have been developed and piloted in engineering, computing, and design fields, efforts can be directed to move them to the next phase of evaluation with more rigorous study designs. Quality of research may be improved by fostering conversations between different research communities and encouraging researchers to plan, conduct, and report their research under the MRC framework. This review will be particularly informative to those deciding on areas where further research or development is needed and to those looking to locate the relevant expertise, resources, and design inputs when designing their own systems or interventions. %M 30730294 %R 10.2196/11079 %U http://www.jmir.org/2019/2/e11079/ %U https://doi.org/10.2196/11079 %U http://www.ncbi.nlm.nih.gov/pubmed/30730294 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10966 %T A Framework for Analyzing and Measuring Usage and Engagement Data (AMUsED) in Digital Interventions: Viewpoint %A Miller,Sascha %A Ainsworth,Ben %A Yardley,Lucy %A Milton,Alex %A Weal,Mark %A Smith,Peter %A Morrison,Leanne %+ Center for Clinical and Community Applications of Health Psychology, Department of Psychology, University of Southampton, Highfield Campus, Southampton, SO17 1BJ, United Kingdom, 44 07972583059, S.J.Miller@soton.ac.uk %K behavioral research %K internet %K health %K patient engagement %K data analysis %D 2019 %7 15.02.2019 %9 Viewpoint %J J Med Internet Res %G English %X Trials of digital interventions can yield extensive, in-depth usage data, yet usage analyses tend to focus on broad descriptive summaries of how an intervention has been used by the whole sample. This paper proposes a novel framework to guide systematic, fine-grained usage analyses that better enables understanding of how an intervention works, when, and for whom. The framework comprises three stages to assist in the following: (1) familiarization with the intervention and its relationship to the captured data, (2) identification of meaningful measures of usage and specifying research questions to guide systematic analyses of usage data, and (3) preparation of datasheets and consideration of available analytical methods with which to examine the data. The framework can be applied to inform data capture during the development of a digital intervention and/or in the analysis of data after the completion of an evaluation trial. We will demonstrate how the framework shaped preparation and aided efficient data capture for a digital intervention to lower transmission of cold and flu viruses in the home, as well as how it informed a systematic, in-depth analysis of usage data collected from a separate digital intervention designed to promote self-management of colds and flu. The Analyzing and Measuring Usage and Engagement Data (AMUsED) framework guides systematic and efficient in-depth usage analyses that will support standardized reporting with transparent and replicable findings. These detailed findings may also enable examination of what constitutes effective engagement with particular interventions. %M 30767905 %R 10.2196/10966 %U http://www.jmir.org/2019/2/e10966/ %U https://doi.org/10.2196/10966 %U http://www.ncbi.nlm.nih.gov/pubmed/30767905 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e9938 %T Electronic Health Program to Empower Patients in Returning to Normal Activities After General Surgical and Gynecological Procedures: Intervention Mapping as a Useful Method for Further Development %A den Bakker,Chantal M %A Schaafsma,Frederieke G %A van der Meij,Eva %A Meijerink,Wilhelmus JHJ %A van den Heuvel,Baukje %A Baan,Astrid H %A Davids,Paul HP %A Scholten,Petrus C %A van der Meij,Suzan %A van Baal,W Marchien %A van Dalsen,Annette D %A Lips,Daniel J %A van der Steeg,Jan Willem %A Leclercq,Wouter KG %A Geomini,Peggy MAJ %A Consten,Esther CJ %A Schraffordt Koops,Steven E %A de Castro,Steve MM %A van Kesteren,Paul JM %A Cense,Huib A %A Stockmann,Hein BAC %A ten Cate,A Dorien %A Bonjer,Hendrik J %A Huirne,Judith AF %A Anema,Johannes R %+ Amsterdam Public Health Research Institute, Department of Occupational and Public Health, VU University Medical Center, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 204445703, c.denbakker@vumc.nl %K intervention mapping %K eHealth %K return to normal activities %K return to work %K patient reported outcome measures %K colectomy %K hysterectomy %D 2019 %7 06.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Support for guiding and monitoring postoperative recovery and resumption of activities is usually not provided to patients after discharge from the hospital. Therefore, a perioperative electronic health (eHealth) intervention (“ikherstel” intervention or “I recover” intervention) was developed to empower gynecological patients during the perioperative period. This eHealth intervention requires a need for further development for patients who will undergo various types of general surgical and gynecological procedures. Objective: This study aimed to further develop the “ikherstel” eHealth intervention using Intervention Mapping (IM) to fit a broader patient population. Methods: The IM protocol was used to guide further development of the “ikherstel” intervention. First, patients’ needs were identified using (1) the information of a process evaluation of the earlier performed “ikherstel” study, (2) a review of the literature, (3) a survey study, and (4) focus group discussions (FGDs) among stakeholders. Next, program outcomes and change objectives were defined. Third, behavior change theories and practical tools were selected for the intervention program. Finally, an implementation and evaluation plan was developed. Results: The outcome for an eHealth intervention tool for patients recovering from abdominal general surgical and gynecological procedures was redefined as “achieving earlier recovery including return to normal activities and work.” The Attitude-Social Influence-Self-Efficacy model was used as a theoretical framework to transform personal and external determinants into change objectives of personal behavior. The knowledge gathered by needs assessment and using the theoretical framework in the preparatory steps of the IM protocol resulted in additional tools. A mobile app, an activity tracker, and an electronic consultation (eConsult) will be incorporated in the further developed eHealth intervention. This intervention will be evaluated in a multicenter, single-blinded randomized controlled trial with 18 departments in 11 participating hospitals in the Netherlands. Conclusions: The intervention is extended to patients undergoing general surgical procedures and for malignant indications. New intervention tools such as a mobile app, an activity tracker, and an eConsult were developed. Trial Registration: Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5686  %M 30724740 %R 10.2196/jmir.9938 %U https://www.jmir.org/2019/2/e9938/ %U https://doi.org/10.2196/jmir.9938 %U http://www.ncbi.nlm.nih.gov/pubmed/30724740 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10265 %T Weight Management in Young Adults: Systematic Review of Electronic Health Intervention Components and Outcomes %A Willmott,Taylor Jade %A Pang,Bo %A Rundle-Thiele,Sharyn %A Badejo,Abi %+ Social Marketing @ Griffith, Griffith Business School, Griffith University, 170 Kessels Road, Nathan, 4111, Australia, 61 737358433, t.willmott@griffith.edu.au %K body weight maintenance %K eHealth %K health behavior %K obesity %K overweight %K review %K technology %K weight gain %K young adult %D 2019 %7 06.02.2019 %9 Review %J J Med Internet Res %G English %X Background: Young adulthood is a vulnerable period for unhealthy lifestyle adoption and excess weight gain. Scant attention has been focused on developing and evaluating effective weight gain prevention strategies for this age group. Electronic health (eHealth) offers potential as a cost-effective means of delivering convenient, individually-tailored, and contextually-meaningful interventions at scale. Objective: The primary aim of this systematic review was to locate and synthesize the evidence on eHealth weight management interventions targeting young adults, with a particular focus on (eHealth) intervention components and outcomes. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search strategy was executed across the following electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, EBSCO, EMBASE, Emerald, Education Resources Information Center, Medical Literature Analysis and Retrieval System Online, Ovid, ProQuest, PsycINFO, PubMed, Science Direct, Scopus, and Web of Science. Furthermore, 2 reviewers independently assessed records for eligibility: peer-reviewed, published in English, and report evaluations of eHealth weight management interventions targeting healthy young adults (aged 18-35 years). Data were then extracted from studies that met the criteria for inclusion. The methodological quality of studies was independently assessed by 2 reviewers using the Effective Public Health Practice Project’s (EPHPP) quality assessment tool. A comprehensive narrative evidence synthesis was then completed. Results: Out of the 1301 studies assessed for eligibility, 24 met the criteria for inclusion. According to the EPHPP quality assessment tool, overall, 19 studies were as rated weak, 5 as moderate, and none as strong. The narrative synthesis of intervention outcomes found 8 studies reported positive weight-related outcomes, 4 reported mixed outcomes, and 12 did not report any significant changes in weight-related outcomes. The narrative synthesis of (eHealth) intervention components led to 3 levels of classification. A total of 14 studies were classified as Web-based, 3 as mobile-based, and 7 as multicomponent interventions. Following the narrative synthesis, 5 key strategies were thematically identified: self-regulation (goal setting and self-monitoring), tailored or personalized feedback, contact with an interventionist, social support, and behavioral prompts (nudges and reminders) and booster messages. Conclusions: Findings highlight the limited evidence base for eHealth weight management interventions targeting young adults. The complex nature of weight management presents an ongoing challenge for interventionists to identify what works, for whom, how, and when. The quality of the evidence in this review was generally assessed as weak; however, assessment tools such as the EPHPP are principally concerned with what should be and this is seldom equivalent to what works. Thus, while sampling, study design and retention rates will remain key determining factors of reliability and validity, further research attention directed toward the development of guiding tools for community trials is warranted. %M 30724736 %R 10.2196/10265 %U http://www.jmir.org/2019/2/e10265/ %U https://doi.org/10.2196/10265 %U http://www.ncbi.nlm.nih.gov/pubmed/30724736 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11964 %T An Internet-Based Childhood Obesity Prevention Program (Time2bHealthy) for Parents of Preschool-Aged Children: Randomized Controlled Trial %A Hammersley,Megan L %A Okely,Anthony D %A Batterham,Marijka J %A Jones,Rachel A %+ Early Start, Faculty of Social Sciences, University of Wollongong, Northfields Avenue, Wollongong, 2522, Australia, 61 242215670, megan.hammersley1@uowmail.edu.au %K internet %K eHealth %K food intake %K physical activity %K screen time %K sleep %K self efficacy %K body mass index %D 2019 %7 08.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Electronic health (eHealth) obesity programs offer benefits to traditionally delivered programs and have shown promise in improving obesity-related behaviors in children. Objective: This study aimed to assess the efficacy of a parent-focused, internet-based healthy lifestyle program for preschool-aged children, who are overweight or at or above the fiftieth percentile for body mass index (BMI) for their age and sex, on child BMI, obesity-related behaviors, parent modeling, and parent self-efficacy. Methods: The Time2bHealthy randomized controlled trial was conducted in Australia, during 2016 to 2017. Participants were recruited both online and through more traditional means within the community. Parent or carer, and child (aged 2-5 years) dyads were randomized into an intervention or comparison group. Intervention participants received an 11-week internet-based healthy lifestyle program, underpinned by social cognitive theory, followed by fortnightly emails for 3 months thereafter. Intervention participants set goals and received individual feedback from a dietitian. They were also encouraged to access and contribute to a closed Facebook group to communicate with other participants and the dietitian. Comparison participants received email communication only. Objectively measured child BMI was the primary outcome. Secondary outcomes included objectively measured physical activity, parent-measured and objectively measured sleep habits, and parent-reported dietary intake, screen time, child feeding, parent modeling, and parent self-efficacy. All data were collected at face-to-face appointments at baseline, 3 months, and 6 months by blinded data collectors. Randomization was conducted using a computerized random number generator post baseline data collection. Results: A total of 86 dyads were recruited, with 42 randomized to the intervention group and 44 to the comparison group. Moreover, 78 dyads attended the 3- and 6-month follow-ups, with 7 lost to follow-up and 1 withdrawing. Mean child age was 3.46 years and 91% (78/86) were in the healthy weight range. Overall, 69% (29/42) of participants completed at least 5 of the 6 modules. Intention-to-treat analyses found no significant outcomes for change in BMI between groups. Compared with children in the comparison group, those in the intervention group showed a reduced frequency of discretionary food intake (estimate −1.36, 95% CI −2.27 to −0.45; P=.004), and parents showed improvement in child feeding pressure to eat practices (−0.30, 95% CI 0.06 to −0.00; P=.048) and nutrition self-efficacy (0.43, 95% CI 0.10 to 0.76; P=.01). No significant time by group interaction was found for other outcomes. Conclusions: The trial demonstrated that a parent-focused eHealth childhood obesity prevention program can provide support to improve dietary-related practices and self-efficacy but was not successful in reducing BMI. The target sample size was not achieved, which would have affected statistical power. Trial Registration: Australian New Zealand Clinical Trials Registry ANZCTR12616000119493; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370030 (Archived by WebCite at http://www.webcitation.org/74Se4S7ZZ). %M 30735139 %R 10.2196/11964 %U http://www.jmir.org/2019/2/e11964/ %U https://doi.org/10.2196/11964 %U http://www.ncbi.nlm.nih.gov/pubmed/30735139 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10816 %T Effectiveness of a Technology-Based Supportive Educational Parenting Program on Parental Outcomes (Part 1): Randomized Controlled Trial %A Shorey,Shefaly %A Ng,Yvonne Peng Mei %A Ng,Esperanza Debby %A Siew,An Ling %A Mörelius,Evalotte %A Yoong,Joanne %A Gandhi,Mihir %+ Clinical Research Centre, Alice Lee Centre for Nursing Studies, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K parents %K social support %D 2019 %7 13.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Transitioning into parenthood can be stressful for new parents, especially with the lack of continuity of care from health care professionals during the postpartum period. Short hospital stays limit the availability of support and time parents need to be well equipped with parenting and infant care skills. Poor parental adjustment may, in turn, lead to negative parental outcomes and adversely affect the child’s development. For the family’s future well-being, and to facilitate a smoother transition into parenthood, there is a need for easily accessible, technology-based educational programs to support parents during the crucial perinatal period. Objective: This study aimed to examine the effectiveness of a technology-based supportive educational parenting program (SEPP) on parenting outcomes during the perinatal period in couples. Methods: A randomized, single-blinded, parallel-armed, controlled trial was conducted. The study recruited 236 parents (118 couples) from an antenatal clinic of a tertiary hospital in Singapore. Eligible parents were randomly assigned to the intervention group (n=118) or the control group (n=118). The SEPP is based on Bandura’s self-efficacy theory and Bowlby’s theory of attachment. Components of the intervention include 2 telephone-based educational sessions (1 antenatal and 1 immediately postnatal) and a mobile health app follow-up for 1 month. The control group only received routine perinatal care provided by the hospital. Outcome measures including parenting self-efficacy (PSE), parental bonding, perceived social support, parenting satisfaction, postnatal depression (PND), and anxiety were measured using reliable and valid instruments. Data were collected over 6 months at 4 time points: during pregnancy (third trimester), 2 days postpartum, 1 month postpartum, and 3 months postpartum. Outcomes were standardized using baseline means and SDs. Linear mixed models were used to compare the groups for postpartum changes in the outcome variables. Results: The intervention group showed significantly better outcome scores than the control group from baseline to 3 months postpartum for PSE (mean difference, MD, 0.37; 95% CI 0.06 to 0.68; P=.02), parental bonding (MD −1.32; 95% CI −1.89 to −0.75; P<.001), self-perceived social support (MD 0.69; 95% CI 0.18 to 1.19; P=.01), parenting satisfaction (MD 1.40; 95% CI 0.86 to 1.93; P<.001), and PND (MD −0.91; 95% CI −1.34 to −0.49; P<.001). Postnatal anxiety (PNA) scores of the intervention group were only significantly better after adjusting for covariates (MD −0.82; 95% CI −1.15 to −0.49; P<.001). Conclusions: The technology-based SEPP is effective in enhancing parental bonding, PSE, perceived social support and parental satisfaction, and in reducing PND and PNA. Health care professionals could incorporate it with existing hands-on infant care classes and routine care to better meet parents’ needs and create positive childbirth experiences, which may in turn encourage parents to have more children. Trial Registration: ISRCTN Registry ISRCTN48536064; http://www.isrctn.com/ISRCTN48536064 (Archived by WebCite at http://www.webcitation.org/6wMuEysiO). %M 30758289 %R 10.2196/10816 %U http://www.jmir.org/2019/2/e10816/ %U https://doi.org/10.2196/10816 %U http://www.ncbi.nlm.nih.gov/pubmed/30758289 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11065 %T Evaluation of Mothers’ Perceptions of a Technology-Based Supportive Educational Parenting Program (Part 2): Qualitative Study %A Shorey,Shefaly %A Ng,Esperanza Debby %+ National University of Singapore, Level 2 Clinical Research Centre, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K education %K mothers %K parenting %K technology %D 2019 %7 13.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Transitioning into parenthood can be stressful as parents struggle to cope with new parenting responsibilities. Although perinatal care in hospitals aims to improve parental outcomes, there is a general consensus that it is suboptimal and insufficient. Therefore, many studies have designed intervention methods to supplement support for parents during this stressful period. However, studies often focus on parental outcomes as indicators of their interventions’ success and effectiveness. Studies evaluating participants’ experiences and feedback are limited. Objective: This study aimed to examine the experiences and perceptions of participants who participated in a supportive education parenting program intervention study. Methods: A qualitative semistructured interview was conducted with 16 mothers (6 control and 10 intervention) from a randomized controlled trial. The supportive education parenting program received by the intervention group included 2 phone-based perinatal educational sessions, a phone-based educational session after childbirth, and a 1-month postpartum access to a mobile health app. The interviews were approximately 30- to 60-min long, audiotaped and transcribed verbatim, and analyzed using thematic analysis. Study findings were reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. Results: The 3 main themes evaluating mothers’ experiences and perceptions were generated: (1) changed perspective toward parenthood, (2) journey from pregnancy to after birth, and (3) a way forward. Mothers from the intervention group mostly had good perinatal experiences with sufficient support received, which elevated their emotional well-being and increased parenting involvement. Mothers in the control group, although satisfied with the hospital care received, were more stressed and shared a need for professional advice and extra support. Apart from technical enhancements, mothers also requested extended social support during early pregnancy up to 1 year postpartum, taking into consideration Asian cultural practices. Conclusions: Mothers who received the intervention were overall satisfied with the support provided by the technology-based supportive educational parenting program. The success of the educational program in this study highlights the need to supplement standard care in hospitals with technology-based educational programs. Future research should include fathers’ perceptions to attain an in-depth understanding of overall participants’ experiences and needs in the future development of supportive and educational programs. %M 30758295 %R 10.2196/11065 %U https://www.jmir.org/2019/2/e11065/ %U https://doi.org/10.2196/11065 %U http://www.ncbi.nlm.nih.gov/pubmed/30758295 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12894 %T Resilience@Work Mindfulness Program: Results From a Cluster Randomized Controlled Trial With First Responders %A Joyce,Sadhbh %A Shand,Fiona %A Lal,Tara J %A Mott,Brendan %A Bryant,Richard A %A Harvey,Samuel B %+ School of Psychiatry, Faculty of Medicine, University of New South Wales, The Black Dog Institute, Hospital Road, Randwick, 2031, Australia, 61 401297711, sadhbh.joyce@unsw.edu.au %K resilience training %K workplace mental health %K occupational health %K well-being %K online intervention %K employee resilience %K health and safety %K psychological health %K first responders %D 2019 %7 19.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: A growing body of research suggests that resilience training can play a pivotal role in creating mentally healthy workplaces, particularly with regard to protecting the long-term well-being of workers. Emerging research describes positive outcomes from various types of resilience training programs (RTPs) among different occupational groups. One specific group of workers that may benefit from this form of proactive resilience training is first responders. Given the nature of their work, first responders are frequently exposed to stressful circumstances and potentially traumatic events, which may impact their overall resilience and well-being over time. Objective: This study aimed to examine whether a mindfulness-based RTP (the Resilience@Work [RAW] Mindfulness Program) delivered via the internet can effectively enhance resilience among a group of high-risk workers. Methods: We conducted a cluster randomized controlled trial (RCT) comprising 24 Primary Fire and Rescue and Hazmat stations within New South Wales. Overall, 12 stations were assigned to the 6-session RAW Mindfulness Program and 12 stations were assigned to the control condition. A total of 143 active full-time firefighters enrolled in the study. Questionnaires were administered at baseline, immediately post training, and at 6-month follow-up. Measurements examined change in both adaptive and bounce-back resilience as well as several secondary outcomes examining resilience resources and acceptance and mindfulness skills. Results: Mixed-model repeated measures analysis found that the overall test of group-by-time interaction was significant (P=.008), with the intervention group increasing in adaptive resilience over time. However, no significant differences were found between the intervention group and the control group in terms of change in bounce-back resilience (P=.09). At 6-month follow-up, the group receiving the RAW intervention had an average increase in their resilience score of 1.3, equating to a moderate-to-large effect size compared with the control group of 0.73 (95% CI 0.38-1.06). Per-protocol analysis found that compared with the control group, the greatest improvements in adaptive resilience were observed among those who completed most of the RAW program, that is, 5 to 6 sessions (P=.002). Conclusions: The results of this RCT suggest that mindfulness-based resilience training delivered in an internet format can create improvements in adaptive resilience and related resources among high-risk workers, such as first responders. Despite a number of limitations, the results of this study suggest that the RAW Mindfulness Program is an effective, scalable, and practical means of delivering online resilience training in high-risk workplace settings. To the best of our knowledge, this is the first time a mindfulness-based RTP delivered entirely via the internet has been tested in the workplace. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615000574549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368296 (Archived by WebCite at http://www.webcitation.org/75w4xtrpw). %M 30777846 %R 10.2196/12894 %U http://www.jmir.org/2019/2/e12894/ %U https://doi.org/10.2196/12894 %U http://www.ncbi.nlm.nih.gov/pubmed/30777846 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12854 %T A Smoking Prevention Program Delivered by Medical Students to Secondary Schools in Brazil Called “Education Against Tobacco”: Randomized Controlled Trial %A Lisboa,Oscar Campos %A Bernardes-Souza,Breno %A Xavier,Luiz Eduardo De Freitas %A Almeida,Matheus Rocha %A Corrêa,Paulo César Rodrigues Pinto %A Brinker,Titus Josef %+ National Center for Tumor Diseases, German Cancer Research Center, University of Heidelberg, Im Neuenheimer Feld 460, Heidelberg, 69120, Germany, 49 62213219304, titus.brinker@nct-heidelberg.de %K smoking %K tobacco %K prevention %K medical students %K schools %D 2019 %7 21.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Smoking is the largest preventable cause of mortality in Brazil. Education Against Tobacco (EAT) is a network of more than 3500 medical students and physicians across 14 countries who volunteer for school-based smoking prevention programs. EAT educates 50,000 adolescents per year in the classroom setting. A recent quasi-experimental study conducted in Germany showed that EAT had significant short-term smoking cessation effects among adolescents aged 11 to 15 years. Objective: The aim is to measure the long-term effectiveness of the most recent version of the EAT curriculum in Brazil. Methods: A randomized controlled trial was conducted among 2348 adolescents aged 12 to 21 years (grades 7-11) at public secondary schools in Brazil. The prospective experimental design included measurements at baseline and at 6 and 12 months postintervention. The study groups comprised randomized classes receiving the standardized EAT intervention (90 minutes of mentoring in a classroom setting) and control classes in the same schools (no intervention). Data were collected on smoking status, gender, social aspects, and predictors of smoking. The primary endpoint was the difference in the change in smoking prevalence between the intervention group and the control group at 12-month follow-up. Results: From baseline to 12 months, the smoking prevalence increased from 11.0% to 20.9% in the control group and from 14.1% to 15.6% in the intervention group. This difference was statistically significant (P<.01). The effects were smaller for females (control 12.4% to 18.8% vs intervention 13.1% to 14.6%) than for males (control 9.1% to 23.6% vs intervention 15.3% to 16.8%). Increased quitting rates and prevented onset were responsible for the intervention effects. The differences in change in smoking prevalence from baseline to 12 months between the intervention and control groups were increased in students with low school performance. Conclusions: To our knowledge, this is the first randomized trial on school-based tobacco prevention in Brazil that shows significant long-term favorable effects. The EAT program encourages quitting and prevents smoking onset, especially among males and students with low educational background. Trial Registration: ClinicalTrials.gov NCT02725021; https://clinicaltrials.gov/ct2/show/NCT02725021 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.7134 %M 30789347 %R 10.2196/12854 %U http://www.jmir.org/2019/2/e12854/ %U https://doi.org/10.2196/12854 %U http://www.ncbi.nlm.nih.gov/pubmed/30789347 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11268 %T Mobile Technology for Community Health in Ghana: Is Maternal Messaging and Provider Use of Technology Cost-Effective in Improving Maternal and Child Health Outcomes at Scale? %A Willcox,Michelle %A Moorthy,Anitha %A Mohan,Diwakar %A Romano,Karen %A Hutchful,David %A Mehl,Garrett %A Labrique,Alain %A LeFevre,Amnesty %+ Health Intelligence Initiative, Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Falmouth Rd, Observatory, Cape Town, 7925, South Africa, 27 0767828704, aelefevre@gmail.com %K child health %K frontline health workers %K Ghana %K health information systems %K maternal health %K mHealth %K mobile phone %K newborn health %D 2019 %7 13.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries. Objective: This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana. Methods: MOTECH’s “Client Data Application” allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH’s other main component, the “Mobile Midwife,” sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters. Results: MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana’s districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50. Conclusions: This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health. %M 30758296 %R 10.2196/11268 %U http://www.jmir.org/2019/2/e11268/ %U https://doi.org/10.2196/11268 %U http://www.ncbi.nlm.nih.gov/pubmed/30758296 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11534 %T Digital Marketing to Promote Healthy Weight Gain Among Pregnant Women in Alberta: An Implementation Study %A Graham,Jocelyn E %A Moore,Jana L %A Bell,Rhonda C %A Miller,Terri %+ Reproductive Health, Population, Public and Indigenous Health, Alberta Health Services, 10101 Southport Road SW, Calgary, AB, T2W 3N2, Canada, 1 403 943 1878, Jocelyn.Graham@ahs.ca %K internet %K maternal health %K mobile phone %K pregnant women %K search engine %K social media %D 2019 %7 01.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: As the use of digital media for health promotion has become increasingly common, descriptive studies exploring current and innovative marketing strategies can enhance the understanding of effective strategies and best practices. Objective: This study aims to describe the implementation of a provincial digital media campaign using complementary advertising platforms to promote healthy pregnancy weight gain messages and direct a Web audience to a credible website. Methods: The digital media campaign occurred in 3 phases, each for 8 weeks, and consisted of search engine marketing using Google AdWords and social media advertising through Facebook. All advertising materials directed users to evidence-based pregnancy-related weight gain content on the Healthy Parents, Healthy Children website. Results: Google Ads received a total of 43,449 impressions, 2522 clicks, and an average click-through rate (CTR) of 5.80%. Of people who clicked on a Google ad, 78.9% (1989/2522) completed an action on the website. Across all Facebook advertisements, there were 772,263 impressions, 14,482 clicks, and an average CTR of 1.88%. The highest-performing advertisement was an image of a group of diverse pregnant women with the headline “Pregnancy weight is not the same for every woman.” Conclusions: This study supports the use of digital marketing as an important avenue for delivering health messages and directing Web users to credible sources of information. The opportunity to reach large, yet targeted audiences, along with the ability to monitor and evaluate metrics to optimize activities throughout a campaign is a powerful advantage over traditional marketing tactics. Health organizations can use the results and insights of this study to help inform the design and implementation of similar Web-based activities. %M 30707100 %R 10.2196/11534 %U https://www.jmir.org/2019/2/e11534/ %U https://doi.org/10.2196/11534 %U http://www.ncbi.nlm.nih.gov/pubmed/30707100 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10441 %T Mitigation of Participant Loss to Follow-Up Using Facebook: All Our Families Longitudinal Pregnancy Cohort %A Stephenson,Nikki Lee %A Hetherington,Erin %A Dodd,Shawn %A Mathews,Alexander %A Tough,Suzanne %+ Department of Paediatrics, Cumming School of Medicine, University of Calgary, Owerko Centre, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada, 1 403 441 8450, stough@ucalgary.ca %K social media %K social networking %K longitudinal studies %K patient dropouts %K cohort studies %K follow-up studies %K lost to follow-up %D 2019 %7 15.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Facebook, a popular social media site, allows users to communicate and exchange information. Social media sites can also be used as databases to search for individuals, including cohort participants. Retaining and tracking cohort participants are essential for the validity and generalizability of data in longitudinal research. Despite numerous strategies to minimize loss to follow-up, maintaining contact with participants is time-consuming and resource-intensive. Social media may provide alternative methods of contacting participants who consented to follow-up but could not be reached, and thus are potentially “lost to follow-up.” Objective: The aim of this study was to determine if Facebook was a feasible method for identifying and contacting participants of a longitudinal pregnancy cohort who were lost to follow-up and re-engaging them without selection bias. Methods: This study used data from the All Our Families cohort. Of the 2827 mother-child dyads within the cohort, 237 participants were lost to follow-up. Participants were considered lost to follow-up if they had agreed to participate in additional research, completed at least one of the perinatal questionnaires, did not complete the 5-year postpartum questionnaire, and could not be contacted after numerous attempts via phone, email, or mail. Participants were considered to be matched to a Facebook profile if 2 or more characteristics matched information previously collected. Participants were sent both a friend request and a personal message through the study’s Facebook page and were invited to verify their enrollment in the study. The authors deemed a friend request was necessary because of the reduced functionality of nonfriend direct messaging at the time. If the participant accepted the study’s friend request, then a personalized message was sent. Participants were considered reconnected if they accepted the friend request or responded to any messages. Participants were considered re-engaged if they provided up-to-date contact information. Results: Compared with the overall cohort, participants who were lost to follow-up (n=237) were younger (P=.003), nonmarried (P=.02), had lower household income (P<.001), less education (P<.001), and self-identified as being part of an ethnic minority (P=.02). Of the 237 participants considered lost to follow-up, 47.7% (113/237) participants were identified using Facebook. Among the 113 identified participants, 77.0% (87/113) were contacted, 32.7% (37/113) were reconnected, and 17.7% (20/113) were re-engaged. No significant differences were found between those identified on Facebook (n=113) and those who were not able to be identified (n=124). Conclusions: Facebook identified 47.6% (113/237) of participants who were considered lost to follow-up, and the social media site may be a practical tool for reconnecting with participants. The results from this study demonstrate that social networking sites, such as Facebook, could be included in the development of retention practices and can be implemented at any point in cohort follow-up. %M 30767901 %R 10.2196/10441 %U https://www.jmir.org/2019/2/e10441/ %U https://doi.org/10.2196/10441 %U http://www.ncbi.nlm.nih.gov/pubmed/30767901 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11694 %T Older Adults’ Perspectives on Using Digital Technology to Maintain Good Mental Health: Interactive Group Study %A Andrews,Jacob A %A Brown,Laura JE %A Hawley,Mark S %A Astell,Arlene J %+ Centre for Assistive Technology and Connected Healthcare, School of Health and Related Research, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, United Kingdom, 44 1142220682, mark.hawley@sheffield.ac.uk %K mental health %K older adults %K technology %K digital technology %K Internet %K apps %D 2019 %7 13.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: A growing number of apps to support good mental health and well-being are available on digital platforms. However, very few studies have examined older adults’ attitudes toward the use of these apps, despite increasing uptake of digital technologies by this demographic. Objective: This study sought to explore older adults’ perspectives on technology to support good mental health. Methods: A total of 15 older adults aged 50 years or older, in two groups, participated in sessions to explore the use of digital technologies to support mental health. Interactive activities were designed to capture participants’ immediate reactions to apps and websites designed to support mental health and to explore their experiences of using technology for these purposes in their own lives. Template analysis was used to analyze transcripts of the group discussions. Results: Older adults were motivated to turn to technology to improve mood through mechanisms of distraction, normalization, and facilitated expression of mental states, while aiming to reduce burden on others. Perceived barriers to use included fear of consequences and the impact of low mood on readiness to engage with technology, as well as a lack of prior knowledge applicable to digital technologies. Participants were aware of websites available to support mental health, but awareness alone did not motivate use. Conclusions: Older adults are motivated to use digital technologies to improve their mental health, but barriers remain that developers need to address for this population to access them. %M 30758292 %R 10.2196/11694 %U http://www.jmir.org/2019/2/e11694/ %U https://doi.org/10.2196/11694 %U http://www.ncbi.nlm.nih.gov/pubmed/30758292 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11128 %T Design and Delivery Features That May Improve the Use of Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Anxiety: A Realist Literature Synthesis With a Persuasive Systems Design Perspective %A Radomski,Ashley D %A Wozney,Lori %A McGrath,Patrick %A Huguet,Anna %A Hartling,Lisa %A Dyson,Michele P %A Bennett,Kathryn %A Newton,Amanda S %+ Department of Pediatrics, University of Alberta, 3-526 Edmonton Clinic Health Academy, 11405 - 87 Avenue, Edmonton, AB, T6G 1C9, Canada, 1 780 248 5581, mandi.newton@ualberta.ca %K internet %K cognitive behavioral therapy %K computer-assisted therapy %K persuasive communication %K anxiety %K children %K adolescents %K review %K adherence %D 2019 %7 05.02.2019 %9 Review %J J Med Internet Res %G English %X Background: Internet-based cognitive behavioral therapy (iCBT) is a persuasive system as its design combines therapeutic content, technological features, and interactions between the user and the program to reduce anxiety for children and adolescents. How iCBT is designed and delivered differs across programs. Although iCBT is considered an effective approach for treating child and adolescent anxiety, rates of program use (eg, module completion) are highly variable for reasons that are not clear. As the extent to which users complete a program can impact anxiety outcomes, understanding what iCBT design and delivery features improve program use is critical for optimizing treatment effects. Objective: The objectives of this study were to use a realist synthesis approach to explore the design and delivery features of iCBT for children and adolescents with anxiety as described in the literature and to examine their relationship to program use outcomes. Methods: A search of published and gray literature was conducted up to November 2017. Prespecified inclusion criteria identified research studies, study protocols, and program websites on iCBT for child and adolescent anxiety. Literature was critically appraised for relevance and methodological rigor. The persuasive systems design (PSD) model, a comprehensive framework for designing and evaluating persuasive systems, was used to guide data extraction. iCBT program features were grouped under 4 PSD categories—Primary task support, Dialogue support, System credibility support, and Social support. iCBT design (PSD Mechanisms) and delivery features (Context of use) were linked to program use (Outcomes) using meta-ethnographic methods; these relationships were described as Context-Mechanism-Outcome configurations. For our configurations, we identified key PSD features and delivery contexts that generated moderate-to-high program use based on moderate-to-high quality evidence found across multiple iCBT programs. Results: A total of 44 documents detailing 10 iCBT programs were included. Seven iCBT programs had at least one document that scored high for relevance; most studies were of moderate-to-high methodological rigor. We developed 5 configurations that highlighted 8 PSD features (Tailoring, Personalization [Primary task supports]; Rewards, Reminders, Social role [Dialogue supports]; and Trustworthiness, Expertise, Authority [System credibility supports]) associated with moderate-to-high program use. Important features of delivery Context were adjunct support (a face-to-face, Web- or email-based communications component) and whether programs targeted the prevention or treatment of anxiety. Incorporating multiple PSD features may have additive or synergistic effects on program use. Conclusions: The Context-Mechanism-Outcome configurations we developed suggest that, when delivered with adjunct support, certain PSD features contribute to moderate-to-high use of iCBT prevention and treatment programs for children and adolescents with anxiety. Standardization of the definition and measurement of program use, formal testing of individual and combined PSD features, and use of real-world design and testing methods are important next steps to improving how we develop and deliver increasingly useful treatments to target users. %M 30720436 %R 10.2196/11128 %U https://www.jmir.org/2019/2/e11128/ %U https://doi.org/10.2196/11128 %U http://www.ncbi.nlm.nih.gov/pubmed/30720436 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11711 %T How Do Adolescents Use Electronic Diaries? A Mixed-Methods Study Among Adolescents With Depressive Symptoms %A Metsäranta,Kiki %A Kurki,Marjo %A Valimaki,Maritta %A Anttila,Minna %+ Department of Nursing Science, University of Turku, Hoitotieteen laitos, Joukahaisenkatu 3-5, Turun yliopisto, 20014, Finland, 358 456716156, kianme@utu.fi %K adolescent %K depression %K electronic diary %K mental health %K mobile phone %K outpatient care %D 2019 %7 20.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression in adolescence is common. Less than half of the adolescents with depression receive mental health care; furthermore, treatment tends to be suspended, and its success rates are low. There is a need for these adolescents to have a safe place to share their thoughts. Studies have shown that writing may be a useful treatment method for people with mental health problems. Objective: This study aims to describe the use of an electronic diary (e-diary) among adolescents with depressive symptoms. Methods: This paper describes a substudy of a randomized controlled trial. We used a mixed-methods approach to understand the way in which e-diaries were used by participants in the intervention under the randomized controlled trial. Data were collected during 2008-2010 at 2 university hospitals in Finland. Study participants (N=89) were 15-17-year-old adolescents who had been referred to an adolescent outpatient psychiatric clinic due to depressive symptoms. Participants were instructed to use the e-diary at least once a week to describe their thoughts, feelings, and moods. The content of the e-diary data was analyzed using descriptive statistics and inductive content analysis. Results: Overall, 53% (47/89) of the adolescents used the e-diary. Most of them (39/47, 83%) logged into the program during the first week, and about one-third (19/47, 40%) logged into the e-diary weekly as suggested. The number of words used in the e-diary per each log ranged between 8 and 1442 words. The 3 topics most often written about in the e-diary were related to mental health problems (mental disorder), social interaction (relationship), and one’s own development (identity). Conclusions: An e-diary may be a usable tool to reflect experiences and thoughts, especially among adolescents who have signs of depression. The results of this study can be used to develop user-centered electronic health applications that allow users to express their own thoughts and experiences in ways other than systematic mood monitoring. %M 30785408 %R 10.2196/11711 %U http://www.jmir.org/2019/2/e11711/ %U https://doi.org/10.2196/11711 %U http://www.ncbi.nlm.nih.gov/pubmed/30785408 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10450 %T Causal Relationships Among Pollen Counts, Tweet Numbers, and Patient Numbers for Seasonal Allergic Rhinitis Surveillance: Retrospective Analysis %A Wakamiya,Shoko %A Matsune,Shoji %A Okubo,Kimihiro %A Aramaki,Eiji %+ Institute for Research Initiatives, Nara Institute of Science and Technology, 8916-5 Takayama-cho, Ikoma, 630-0192, Japan, 81 743726053, wakamiya@is.naist.jp %K seasonal allergic rhinitis %K social media %K Twitter %K causal relationship %K infoveillance %K disease surveillance %D 2019 %7 20.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Health-related social media data are increasingly used in disease-surveillance studies, which have demonstrated moderately high correlations between the number of social media posts and the number of patients. However, there is a need to understand the causal relationship between the behavior of social media users and the actual number of patients in order to increase the credibility of disease surveillance based on social media data. Objective: This study aimed to clarify the causal relationships among pollen count, the posting behavior of social media users, and the number of patients with seasonal allergic rhinitis in the real world. Methods: This analysis was conducted using datasets of pollen counts, tweet numbers, and numbers of patients with seasonal allergic rhinitis from Kanagawa Prefecture, Japan. We examined daily pollen counts for Japanese cedar (the major cause of seasonal allergic rhinitis in Japan) and hinoki cypress (which commonly complicates seasonal allergic rhinitis) from February 1 to May 31, 2017. The daily numbers of tweets that included the keyword “kafunshō” (or seasonal allergic rhinitis) were calculated between January 1 and May 31, 2017. Daily numbers of patients with seasonal allergic rhinitis from January 1 to May 31, 2017, were obtained from three healthcare institutes that participated in the study. The Granger causality test was used to examine the causal relationships among pollen count, tweet numbers, and the number of patients with seasonal allergic rhinitis from February to May 2017. To determine if time-variant factors affect these causal relationships, we analyzed the main seasonal allergic rhinitis phase (February to April) when Japanese cedar trees actively produce and release pollen. Results: Increases in pollen count were found to increase the number of tweets during the overall study period (P=.04), but not the main seasonal allergic rhinitis phase (P=.05). In contrast, increases in pollen count were found to increase patient numbers in both the study period (P=.04) and the main seasonal allergic rhinitis phase (P=.01). Increases in the number of tweets increased the patient numbers during the main seasonal allergic rhinitis phase (P=.02), but not the overall study period (P=.89). Patient numbers did not affect the number of tweets in both the overall study period (P=.24) and the main seasonal allergic rhinitis phase (P=.47). Conclusions: Understanding the causal relationships among pollen counts, tweet numbers, and numbers of patients with seasonal allergic rhinitis is an important step to increasing the credibility of surveillance systems that use social media data. Further in-depth studies are needed to identify the determinants of social media posts described in this exploratory analysis. %M 30785411 %R 10.2196/10450 %U http://www.jmir.org/2019/2/e10450/ %U https://doi.org/10.2196/10450 %U http://www.ncbi.nlm.nih.gov/pubmed/30785411 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12783 %T Tweet Classification Toward Twitter-Based Disease Surveillance: New Data, Methods, and Evaluations %A Wakamiya,Shoko %A Morita,Mizuki %A Kano,Yoshinobu %A Ohkuma,Tomoko %A Aramaki,Eiji %+ Institute for Research Initiatives, Nara Institute of Science and Technology, 8916-5 Takayama-cho, Ikoma, 630-0192, Japan, 81 743 72 6053, socialcomputing-office@is.naist.jp %K text mining %K social media %K machine learning %K natural language processing %K artificial intelligence %K surveillance %K infodemiology %K infoveillance %D 2019 %7 20.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The amount of medical and clinical-related information on the Web is increasing. Among the different types of information available, social media–based data obtained directly from people are particularly valuable and are attracting significant attention. To encourage medical natural language processing (NLP) research exploiting social media data, the 13th NII Testbeds and Community for Information access Research (NTCIR-13) Medical natural language processing for Web document (MedWeb) provides pseudo-Twitter messages in a cross-language and multi-label corpus, covering 3 languages (Japanese, English, and Chinese) and annotated with 8 symptom labels (such as cold, fever, and flu). Then, participants classify each tweet into 1 of the 2 categories: those containing a patient’s symptom and those that do not. Objective: This study aimed to present the results of groups participating in a Japanese subtask, English subtask, and Chinese subtask along with discussions, to clarify the issues that need to be resolved in the field of medical NLP. Methods: In summary, 8 groups (19 systems) participated in the Japanese subtask, 4 groups (12 systems) participated in the English subtask, and 2 groups (6 systems) participated in the Chinese subtask. In total, 2 baseline systems were constructed for each subtask. The performance of the participant and baseline systems was assessed using the exact match accuracy, F-measure based on precision and recall, and Hamming loss. Results: The best system achieved exactly 0.880 match accuracy, 0.920 F-measure, and 0.019 Hamming loss. The averages of match accuracy, F-measure, and Hamming loss for the Japanese subtask were 0.720, 0.820, and 0.051; those for the English subtask were 0.770, 0.850, and 0.037; and those for the Chinese subtask were 0.810, 0.880, and 0.032, respectively. Conclusions: This paper presented and discussed the performance of systems participating in the NTCIR-13 MedWeb task. As the MedWeb task settings can be formalized as the factualization of text, the achievement of this task could be directly applied to practical clinical applications. %M 30785407 %R 10.2196/12783 %U http://www.jmir.org/2019/2/e12783/ %U https://doi.org/10.2196/12783 %U http://www.ncbi.nlm.nih.gov/pubmed/30785407 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10362 %T Health Care Professionals’ Perceptions of Home Telemonitoring in Heart Failure Care: Cross-Sectional Survey %A Aamodt,Ina Thon %A Lycholip,Edita %A Celutkiene,Jelena %A Strömberg,Anna %A Atar,Dan %A Falk,Ragnhild Sørum %A von Lueder,Thomas %A Hellesø,Ragnhild %A Jaarsma,Tiny %A Lie,Irene %+ Centre for Patient-Centered Heart and Lung Research, Department of Cardiothoracic Surgery, Oslo University Hospital Ullevål, Building 63, Box 4956 Nydalen and Postboks 1130 Blindern, 0318, Oslo,, Norway, 47 48090883, inamarieaamodt@gmail.com %K nurses %K physicians %K perception %K telemedicine %K heart failure %K self-care %D 2019 %7 06.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Noninvasive telemonitoring (TM) can be used in heart failure (HF) patients to perform early detection of decompensation at home, prevent unnecessary health care utilization, and decrease health care costs. However, the evidence is not sufficient to be part of HF guidelines for follow-up care, and we have no knowledge of how TM is used in the Nordic Baltic region. Objective: The aim of this study was to describe health care professionals’ (HCPs) perception of and presumed experience with noninvasive TM in daily HF patient care, perspectives of the relevance of and reasons for applying noninvasive TM, and barriers to the use of noninvasive TM. Methods: A cross-sectional survey was performed between September and December 2016 in Norway and Lithuania with physicians and nurses treating HF patients at either a hospital ward or an outpatient clinic. A total of 784 questionnaires were sent nationwide by postal mail to 107 hospitals. The questionnaire consisted of 43 items with close- and open-ended questions. In Norway, the response rate was 68.7% (226/329), with 57 of 60 hospitals participating, whereas the response rate was 68.1% (310/455) in Lithuania, with 41 of 47 hospitals participating. Responses to the closed questions were analyzed using descriptive statistics, and the open-ended questions were analyzed using summative content analysis. Results: This study showed that noninvasive TM is not part of the current daily clinical practice in Norway or Lithuania. A minority of HCPs responded to be familiar with noninvasive TM in HF care in Norway (48/226, 21.2%) and Lithuania (64/310, 20.6%). Approximately half of the HCPs in both countries perceived noninvasive TM to be relevant in follow-up of HF patients in Norway (131/226, 58.0%) and Lithuania (172/310, 55.5%). For physicians in both countries and nurses in Norway, the 3 most mentioned reasons for introducing noninvasive TM were to improve self-care, to reduce hospitalizations, and to provide high-quality care, whereas the Lithuanian nurses described ability to treat more patients and to reduce their workload as reasons for introducing noninvasive TM. The main barriers to implement noninvasive TM were lack of funding from health care authorities or the Territorial Patient Fund. Moreover, HCPs perceive that HF patients themselves could represent barriers because of their physical or mental condition in addition to a lack of internet access. Conclusions: HCPs in Norway and Lithuania are currently nonusers of TM in daily HF care. However, they perceive a future with TM to improve the quality of care for HF patients. Financial barriers and HF patients’ condition may have an impact on the use of TM, whereas sufficient funding from health care authorities and improved knowledge may encourage the more widespread use of TM in the Nordic Baltic region and beyond. %M 30724744 %R 10.2196/10362 %U http://www.jmir.org/2019/2/e10362/ %U https://doi.org/10.2196/10362 %U http://www.ncbi.nlm.nih.gov/pubmed/30724744 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10985 %T Cardiac Rehabilitees’ Technology Experiences Before Remote Rehabilitation: Qualitative Study Using a Grounded Theory Approach %A Anttila,Marjo-Riitta %A Kivistö,Heikki %A Piirainen,Arja %A Kokko,Katja %A Malinen,Anita %A Pekkonen,Mika %A Sjögren,Tuulikki %+ Faculty of Sport and Health Sciences, University of Jyväskylä, PO Box 35, Jyväskylä,, Finland, 358 40 805 4648, marjo-riitta.m-r.anttila@jyu.fi %K coronary disease %K rehabilitees’ experience %K focus group %K qualitative study %K grounded theory %K remote rehabilitation %K e-health %K e-rehabilitation %K telerehabilitation %K secondary prevention %D 2019 %7 07.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Even though technology is becoming increasingly common in rehabilitation programs, insufficient data are as yet available on rehabilitees’ perceptions and experiences. It is important to understand their abilities when using technology for remote rehabilitation. Objective: This is a qualitative study on technology experiences of persons affected by cardiovascular disease assessed before remote rehabilitation. The aim of the study was to explore rehabilitees’ experiences and attitudes toward technology before 12 months of remote rehabilitation. Methods: Qualitative interviews were conducted with 39 rehabilitees in four focus groups. The subjects were aged 34 to 77 years (average age 54.8 years) and 74% (29/39) of them were male. They had been diagnosed with coronary artery disease and were undergoing treatment in a rehabilitation center. The interviews were conducted between September 2015 and November 2016. Data were analyzed using Glaser’s mode of the grounded theory approach. Results: The result of the study was an “identifying e-usage” experience category, which refers to the rehabilitees’ notions of the use of information and communication technologies (e-usage) in the process of behavior change. The main category comprises four subcategories that define the rehabilitees’ technology experience. These subcategories are “feeling outsider,” “being uninterested,” “reflecting benefit,” and “enthusiastic using.” All rehabilitees expected that technology should be simple, flexible, and easy to use and learn. The results reflecting their technology experience can be used in e-rehabilitation programs. Rehabilitees who feel like outsiders and are not interested in technology need face-to-face communication for the major part of rehabilitation, while rehabilitees who reflect benefit and are enthusiastic about the use of technology need incrementally less face-to-face interaction and feel that Web-based coaching could offer sufficient support for rehabilitation. Conclusions: The findings show that persons affected by heart disease had different experiences with technology and expectations toward counseling, while all rehabilitees expected technology to be easy to use and their experiences to be smooth and problem-free. The results can be used more widely in different contexts of social and health care for the planning of and training in remote rehabilitation counseling and education. Trial Registration: ISRCTN Registry ISRCTN61225589; http://www.isrctn.com/ISRCTN61225589 (Archived by WebCite at http://www.webcitation.org/74jmrTXFD) %M 30730298 %R 10.2196/10985 %U http://www.jmir.org/2019/2/e10985/ %U https://doi.org/10.2196/10985 %U http://www.ncbi.nlm.nih.gov/pubmed/30730298 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11398 %T What Affects the Completion of Ecological Momentary Assessments in Chronic Pain Research? An Individual Patient Data Meta-Analysis %A Ono,Masakatsu %A Schneider,Stefan %A Junghaenel,Doerte U %A Stone,Arthur A %+ Center for Self-Report Science, Center for Economic and Social Research, University of Southern California, 635 Downey Way, Los Angeles, CA, 90089, United States, 1 213 821 8862, masakatsu.ono@manchester.ac.uk %K chronic pain %K completion rate %K compliance rate %K ecological momentary assessment %K experience sampling %K IPD meta-analysis %D 2019 %7 05.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Ecological momentary assessment (EMA) involves repeated sampling of people’s current experiences in real time in their natural environments, which offers a granular perspective on patients’ experience of pain and other symptoms. However, EMA can be burdensome to patients, and its benefits depend upon patients’ engagement in the assessments. Objective: The goal of this study was to investigate factors affecting EMA-completion rates among patients with chronic pain. Methods: This individual patient data meta-analysis was based on 12 EMA datasets that examined patients with chronic noncancer-related pain (n=701). The EMA-completion rates were calculated on a daily basis for each patient. Multilevel models were used to test the following predictors of completion rates at different levels: within-patient factors (days into the study and daily pain level), between-patient factors (age, sex, pain diagnosis, and average pain level per person), and between-study EMA design factors (study duration, sampling density, and survey length). Results: Across datasets, an EMA-completion rate of 85% was observed. The strongest results were found for the between-patient factor age: Younger respondents reported lower completion rates than older respondents (P=.002). One within-patient factor, study day, was associated with completion rates (P<.001): over the course of the studies, the completion rates declined. The two abovementioned factors interacted with each other (P=.02) in that younger participants showed a more rapid decline in EMA completion over time. In addition, none of the other hypothesized factors including gender, chronic pain diagnoses, pain intensity levels, or measures of study burden showed any significant effects. Conclusion: Many factors thought to influence the EMA-completion rates in chronic pain studies were not confirmed. However, future EMA research in chronic pain should note that study length and young age can impact the quality of the momentary data and devise strategies to maximize completion rates across different age groups and study days. %M 30720437 %R 10.2196/11398 %U https://www.jmir.org/2019/2/e11398/ %U https://doi.org/10.2196/11398 %U http://www.ncbi.nlm.nih.gov/pubmed/30720437 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12400 %T Online Information-Seeking About Potential Breast Cancer Symptoms: Capturing Online Behavior With an Internet Browsing Tracking Tool %A Marcu,Afrodita %A Muller,Cecile %A Ream,Emma %A Whitaker,Katriina L %+ School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Duke of Kent Building, Guildford, GU2 7XH, United Kingdom, 44 0148 36 82515, afrodita.marcu@surrey.ac.uk %K breast cancer %K health information %K internet search %K online information seeking %D 2019 %7 06.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: People engage in health information-seeking online when experiencing unusual or unfamiliar bodily changes. It is not well understood how people consult the internet for health information after the onset of unfamiliar symptoms and before receiving a potential diagnosis and how online information-seeking can help people appraise their symptoms. This lack of evidence may be partly due to methodological limitations in capturing in real time the online information-seeking process. Objective: We explored women’s symptom attribution and online health information-seeking in response to a hypothetical and unfamiliar breast change suggestive of cancer (nipple rash). We also aimed to establish the feasibility of capturing in real time the online information-seeking process with a tool designed to track participant online searches and visited websites, the Vizzata browser tracker. Methods: An online survey was completed by 56 cancer-free women (mean age 60.34 [SD 7.73] years) responding to a scenario asking them to imagine noticing a red scaly rash on the nipple. Participants were asked to make symptom attributions when presented with the scenario (T1) and again after seeking information online (T2). The online tracking tool, embedded in the survey, was used to capture in real time participant search terms and accessed websites. Results: The tracking tool captured the search terms and accessed websites of most of the participants (46/56, 82%). For the rest (10/56, 18%), there was evidence of engagement in online information-seeking (eg, medical terminology and cancer attribution at T2) despite their searching activity not being recorded. A total of 25 participants considered cancer as a potential cause for the nipple rash at T1, yet only one of these used cancer as a search term. Most participants (40/46, 87%) used rash-related search terms, particularly nipple rash and rash on nipple. The majority (41/46, 89%) accessed websites containing breast cancer information, with the National Health Service webpage “Paget disease of the nipple” being the most visited one. At T2, after engaging in the internet search task, more participants attributed the nipple rash to breast cancer than at T1 (37/46, 66% vs 25/46, 45%), although a small number of participants (6/46) changed from making a cancer attribution at T1 to a noncancer one at T2. Conclusions: Making a cancer attribution for an unfamiliar breast change did not necessarily translate into cancer-termed searches. Equally, not all internet searches led to a cancer attribution. The findings suggest that online information-seeking may not necessarily help women who experience unfamiliar breast cancer symptoms understand their condition. Despite some technical issues, this study showed that it is feasible to use an online browser tracking tool to capture in real time information-seeking about unfamiliar symptoms. %M 30724741 %R 10.2196/12400 %U http://www.jmir.org/2019/2/e12400/ %U https://doi.org/10.2196/12400 %U http://www.ncbi.nlm.nih.gov/pubmed/30724741 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10404 %T Developing a Decision-Aid Website for Breast Cancer Surgery: An Action Research Approach %A Hung,Yu-Ting %A Wu,Ching-Fang %A Liang,Te-Hsin %A Chou,Shin-Shang %A Chen,Guan-Liang %A Wu,Pei-Ni %A Su,Guan-Rong %A Jang,Tsuey-Huah %A Liu,Chang-Yi %A Wang,Ching-Yen %A Tseng,Ling-Ming %A Sheu,Shuh-Jen %+ Institute of Community Health Care, School of Nursing, National Yang-Ming University, Nursing Building Room 404, Number 155, Section 2, Linong Street, Taipei, 11221, Taiwan, 886 2 28267271, sjsheu@ym.edu.tw %K breast cancer %K surgery-related decision making %K website %K action research %D 2019 %7 04.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients with early-stage breast cancer have numerous options when choosing the type of breast surgery method to be applied. Each of these options lead to a similar long-term survival rate, but result in significant differences in appearance, function, cost, recurrence rate, and various other relevant considerations. However, the time available for detailed communication with each patient is often limited in clinics, which puts these women under great psychological stress and can hinder their surgery-related decision making. Objective: The objective of this study was to develop a multipurpose surgery decision-making website providing medical information, psychological support, and decision-related simulation for women during breast cancer surgery-related decision making. Methods: Using the 4 steps of action research, which involve multigroup teamwork via regular team meetings, the following were performed: (1) Planning: searching, analyzing, and evaluating health websites to consensually decide the major infrastructure; (2) Action: work was performed simultaneously in 4 groups, which consisted of medical information collection and editing, patient interviews and data extraction, webpage content design, and programming to create or host the website; (3) Evaluation: the website was tested by clinical experts and focus groups of former breast cancer patients to assess its effectiveness and pinpoint appropriate improvements; and (4) Reflection: constant dialogue was conducted between the various participants at each step, which was used as the foundation and motivation of next plan-action-evaluation-reflection circle. Results: Using the action research approach, we completed the development of our website, which includes the following: (1) “Woman’s Voice”—an animated comic depicting the story of a female breast cancer patient with interspersed questions for the users that will help them better empathize with the experience; (2) “Cancer Information Treasure House”—providing breast cancer surgery-related information through text, tables, pictures and a presentation video; (3) “Decision-making Simulator”—helping patients think through and check the pros and cons of the different surgical options via visual-based interactions including “Stairs Climbing” and “Fruit of Hope”; and (4) “Recommended Links”—providing reliable websites for further reference. Additionally, we have further improved the website based on the feedback received from postsurgery breast cancer patients and clinicians. We hope to continue improving to better meet both the patients’ and health providers’ needs and become a practical decision-making aid for patients undergoing breast cancer surgery. Conclusions: We have created the first breast cancer surgery decision-making assistance tool in Taiwan using a “Web-based” and multifunctional website design. This site aims to provide health care knowledge, psychological healing, and emotional support functions, as well as decision-making capability enhancement simulations. We look forward to assisting breast cancer patients in their decision-making process and expect our website to increase patient’s autonomy and improve their communication with clinicians. %M 30714941 %R 10.2196/10404 %U https://www.jmir.org/2019/2/e10404/ %U https://doi.org/10.2196/10404 %U http://www.ncbi.nlm.nih.gov/pubmed/30714941 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12234 %T The Digital Education to Limit Salt in the Home Program Improved Salt-Related Knowledge, Attitudes, and Behaviors in Parents %A Khokhar,Durreajam %A Nowson,Caryl Anne %A Margerison,Claire %A West,Madeline %A Campbell,Karen J %A Booth,Alison Olivia %A Grimes,Carley Ann %+ Institute for Physical Activity and Nutrition Research, Deakin University, Deakin University Locked Bag 20000, Waurn Ponds, Geelong, 3220, Australia, 61 39244 6223, carley.grimes@deakin.edu.au %K dietary sodium %K knowledge %K attitude %K behavior %K parent %K internet %K family %K Australia %D 2019 %7 25.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Currently, Australian children and adults are eating too much salt, increasing their risk of cardiovascular-related conditions. Web-based programs provide an avenue to engage the parents of primary schoolchildren in salt-specific messages, which may positively impact their own salt-related knowledge, attitudes, and behaviors (KABs). Objective: This pilot study aimed to determine whether parents’ salt-related KABs improved following participation in the Digital Education to LImit Salt in the Home (DELISH) Web-based education program. Methods: The DELISH program was a 5-week, home-delivered, Web-based intervention, with a pre- and posttest design, targeting schoolchildren aged 7 to 10 years and their parents. Parents received weekly Web-based educational newsletters and text messages and completed online pre- and postprogram surveys assessing salt-related KABs. Upon completion of the program, all parents were also invited to complete an online evaluation survey. Changes in KABs outcomes were assessed using McNemar tests and paired t tests. Results: Of the 80 parents that commenced the program, 73 parents (mean age 41.0, SD 7.0 years; 86% (63/73) females) completed both pre- and postsurveys. Overall, mean score for salt-related knowledge improved (+3.6 [standard error (SE) 0.41] points), and mean behavior score also improved (+4.5 [SE 0.61] points), indicating a higher frequency of engaging in behaviors to reduce salt in the diet, and mean attitude score decreased (−0.7 [SE 0.19] points), representing lower importance of using salt to enhance the taste of food (all P<.001). Following participation, the proportion of parents aware of the daily salt intake recommendation increased from 40% (29/73) to 74% (54/73) (P<.001), and awareness of bread as the main source of salt increased from 58% (42/73) to 95% (69/73) (P<.001). The proportion of parents who agreed that salt should be used in cooking to enhance the flavor of food decreased from 30% (22/73) to 11% (8/73) (P=.002) and the proportion who agreed that sodium information displayed on food labels was difficult to understand decreased from 52% (38/73) to 32% (23/73) (P=.009). There was a reduction in the proportion of parents who reported adding salt during cooking (55% [40/73] vs 41% [30/73]; P=.03) and at the table (32% [23/73] vs 18% [13/73]; P=.002). Of the 16 parents who completed the evaluation survey, 75% (12/16) enjoyed the program, and all parents found the newsletters to be useful. Almost all parents (15/16, 94%) agreed that the DELISH program would be useful to other parents. Conclusions: The improvement in salt-related KABs in the DELISH program indicates the potential for online technology, to disseminate simple salt reduction education messages to families with primary school–aged children. Future work should seek to improve the quality of data collected by including a larger sample size and a control group to integrate the program within the school setting to enable wider dissemination. %M 30801255 %R 10.2196/12234 %U http://www.jmir.org/2019/2/e12234/ %U https://doi.org/10.2196/12234 %U http://www.ncbi.nlm.nih.gov/pubmed/30801255 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11371 %T Design and Development of a Person-Centered Patient Portal Using Participatory Stakeholder Co-Design %A Kildea,John %A Battista,John %A Cabral,Briana %A Hendren,Laurie %A Herrera,David %A Hijal,Tarek %A Joseph,Ackeem %+ Gerald Bronfman Department of Oncology, McGill University, Suite 720, 5100 de Maisonneuve Boulevard West, Montreal, QC,, Canada, 1 5149341934 ext 44154, john.kildea@mcgill.ca %K patient portals %K patient participation %K telemedicine %K software design %D 2019 %7 11.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Patient portals are increasingly accepted as part of standard medical care. However, to date, most patient portals provide just passive access to medical data. The use of modern technology such as smartphones and data personalization algorithms offers the potential to make patient portals more person-centered and enabling. Objective: The aim of this study is to share our experience in designing and developing a person-centered patient portal following a participatory stakeholder co-design approach. Methods: Our stakeholder co-design approach comprised 6 core elements: (1) equal coleadership, including a cancer patient on treatment; (2) patient preference determination; (3) security, governance, and legal input; (4) continuous user evaluation and feedback; (5) continuous staff input; and (6) end-user testing. We incorporated person-centeredness by recognizing that patients should decide for themselves their level of medical data access, all medical data should be contextualized with explanatory content, and patient educational material should be personalized and timely. Results: Using stakeholder co-design, we built, and are currently pilot-testing, a person-centered patient portal smartphone app called Opal. Conclusions: Inclusion of all stakeholders in the design and development of patient-facing software can help ensure that the necessary elements of person-centeredness, clinician acceptability, and informatics feasibility are achieved. %M 30741643 %R 10.2196/11371 %U http://www.jmir.org/2019/2/e11371/ %U https://doi.org/10.2196/11371 %U http://www.ncbi.nlm.nih.gov/pubmed/30741643 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10377 %T Development of the Multidimensional Readiness and Enablement Index for Health Technology (READHY) Tool to Measure Individuals’ Health Technology Readiness: Initial Testing in a Cancer Rehabilitation Setting %A Kayser,Lars %A Rossen,Sine %A Karnoe,Astrid %A Elsworth,Gerald %A Vibe-Petersen,Jette %A Christensen,Jesper Frank %A Ried-Larsen,Mathias %A Osborne,Richard H %+ Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen, DK-1014, Denmark, 45 28757291, lk@sund.ku.dk %K health technology readiness %K questionnaire %K eHealth literacy, enablement %D 2019 %7 12.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The increasing digitization of health care services with enhanced access to fast internet connections, along with wide use of smartphones, offers the opportunity to get health advice or treatment remotely. For service providers, it is important to consider how consumers can take full advantage of available services and how this can create an enabling environment. However, it is important to consider the digital context and the attributes of current and future users, such as their readiness (ie, knowledge, skills, and attitudes, including trust and motivation). Objective: The objective of this study was to evaluate how the eHealth Literacy Questionnaire (eHLQ) combined with selected dimensions from the Health Education Impact Questionnaire (heiQ) and the Health Literacy Questionnaire (HLQ) can be used together as an instrument to characterize an individual’s level of health technology readiness and explore how the generated data can be used to create health technology readiness profiles of potential users of health technologies and digital health services. Methods: We administered the instrument and sociodemographic questions to a population of 305 patients with a recent cancer diagnosis referred to rehabilitation in a setting that plans to introduce various technologies to assist the individuals. We evaluated properties of the Readiness and Enablement Index for Health Technology (READHY) instrument using confirmatory factor analysis, convergent and discriminant validity analysis, and exploratory factor analysis. To identify different health technology readiness profiles in the population, we further analyzed the data using hierarchical and k-means cluster analysis. Results: The confirmatory factor analysis found a suitable fit for the 13 factors with only 1 cross-loading of 1 item between 2 dimensions. The convergent and discriminant validity analysis revealed many factor correlations, suggesting that, in this population, a more parsimonious model might be achieved. Exploratory factor analysis pointed to 5 to 6 constructs based on aggregates of the existing dimensions. The results were not satisfactory, so we performed an 8-factor confirmatory factor analysis, resulting in a good fit with only 1 item cross-loading between 2 dimensions. Cluster analysis showed that data from the READHY instrument can be clustered to create meaningful health technology readiness profiles of users. Conclusions: The 13 dimensions from heiQ, HLQ, and eHLQ can be used in combination to describe a user’s health technology readiness level and degree of enablement. Further studies in other populations are needed to understand whether the associations between dimensions are consistent and the number of dimensions can be reduced. %M 30747717 %R 10.2196/10377 %U http://www.jmir.org/2019/2/e10377/ %U https://doi.org/10.2196/10377 %U http://www.ncbi.nlm.nih.gov/pubmed/30747717 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11241 %T Use of Learning Analytics Data in Health Care–Related Educational Disciplines: Systematic Review %A Chan,Albert KM %A Botelho,Michael G %A Lam,Otto LT %+ Prosthodontics, Faculty of Dentistry, The University of Hong Kong, Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun,, China (Hong Kong), 852 2859 0412, botelho@hku.hk %K education %K e-learning %K learning analytics %K learning management systems %K online learning %K systematic review %D 2019 %7 13.02.2019 %9 Review %J J Med Internet Res %G English %X Background: While the application of learning analytics in tertiary education has received increasing attention in recent years, a much smaller number have explored its use in health care-related educational studies. Objective: This systematic review aims to examine the use of e-learning analytics data in health care studies with regards to how the analytics is reported and if there is a relationship between e-learning analytics and learning outcomes. Methods: We performed comprehensive searches of papers from 4 electronic databases (MEDLINE, EBSCOhost, Web of Science, and ERIC) to identify relevant papers. Qualitative studies were excluded from this review. Papers were screened by 2 independent reviewers. We selected qualified studies for further investigation. Results: A total of 537 papers were screened, and 19 papers were identified. With regards to analytics undertaken, 11 studies reported the number of connections and time spent on e-learning. Learning outcome measures were defined by summative final assessment marks or grades. In addition, significant statistical results of the relationships between e-learning usage and learning outcomes were reported in 12 of the identified papers. In general, students who engaged more in e-learning resources would get better academic attainments. However, 2 papers reported otherwise with better performing students consuming less e-learning videos. A total of 14 papers utilized satisfaction questionnaires for students, and all were positive in their attitude toward e-learning. Furthermore, 6 of 19 papers reported descriptive statistics only, with no statistical analysis. Conclusions: The nature of e-learning activities reported in this review was varied and not detailed well. In addition, there appeared to be inadequate reporting of learning analytics data observed in over half of the selected papers with regards to definitions and lack of detailed information of what the analytic was recording. Although learning analytics data capture is popular, a lack of detail is apparent with regards to the capturing of meaningful and comparable data. In particular, most analytics record access to a management system or particular e-learning materials, which may not necessarily detail meaningful learning time or interaction. Hence, learning analytics data should be designed to record the time spent on learning and focus on key learning activities. Finally, recommendations are made for future studies. %M 30758291 %R 10.2196/11241 %U http://www.jmir.org/2019/2/e11241/ %U https://doi.org/10.2196/11241 %U http://www.ncbi.nlm.nih.gov/pubmed/30758291 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10716 %T Developing a Web-Based Comic for Newly Diagnosed Women With Breast Cancer: An Action Research Approach %A Lee,Tzu-I %A Sheu,Shuh-Jen %A Chang,Hsueh-Chin %A Hung,Yu-Ting %A Tseng,Ling-Ming %A Chou,Shin-Shang %A Liang,Te-Hsin %A Liu,Hui-Ju %A Lu,Hui-Ling %A Chen,Mei-Chun %A Liu,Ying-Chun %A Tsai,Chi-Shan %A Sun,Jui-Chiung %+ Institute of Community Health Care, School of Nursing, National Yang-Ming University, Nursing Building Room 404, Number155, Section 2, Linong Street, Taipei, 112, Taiwan, 886 2 28267271, sjsheu@ym.edu.tw %K action research %K breast cancer %K comic %K narrative %D 2019 %7 04.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Personal narratives have been seen as a useful way of communicating about cancer treatment options and providing recovery information. Many printed versions of such material are available, including comics that explore the individual memories of patients who have gone through cancer treatment. These studies have been used to orientate patients, patients’ relatives, and physicians. However, only a few Web-based comics have been specifically designed for patients with breast cancer and used as aids to decision making. Objective: We aimed to describe the developmental process of creating an animated comic as a Web-based surgery decision-making tool; the comic was aimed at illustrating the feelings, thoughts, and meanings when a patient suffers from breast cancer. This was done by recounting the symptoms, diagnostic process, treatments, and treatment effects of such women from the diagnosis stage onward. Methods: Using cycles of planning, action, evaluation, and reflection, which involved collaborative work, action research was conducted to develop a Web-based animated comic. The stages of action research consisted of (1) semistructured and in-depth interviews to collect experiences of women with breast cancer; (2) construction of an animated comic by editors, graphics designers, dubbers, and information technology engineers; (3) redrawing of pictures of the comic after gathering feedback from a breast surgeon; and (4) evaluation of the Web-based animated comic using 6 patient focus groups. Results: The comic was produced and showcased on the website “The Network of Making-decision Aids for Breast Cancer Surgery”; the comic was accompanied by soft music and audio explanations. The comic functions as a personal statement that describes experiencing breast cancer. The animated comic consists of 8 chapters, based on the 8 themes deducted from the findings obtained during the analysis of relevant interviews. The 8 chapters include (1) the appearance of a lump; (2) confirmation by medical diagnosis; (3) the uncertainty of waiting (4) fear of life-threatening disease; (5) choosing life over despair; (6) being brave and deciding to undergo treatment; (7) choosing the type of surgery; and (8) being reborn. Conclusions: Using action research, this study illustrated that the comic that sheds light on issues of feelings, emotions, and thoughts that are present when a woman is diagnosed with breast cancer and provides a communication medium to explain the steps in the process. Meanwhile, it implies that hope will be able to overcome the challenges that will be faced. Within the Web-based decision aid for patients with breast cancer, the animated comic acts as an information resource and is aimed at patients’ understanding of impacts of emotions arising when suffering from breast cancer. It is potentially applicable as a therapeutic tool that facilitates self-reflection and self-healing among newly diagnosed patients with breast cancer. %M 30714947 %R 10.2196/10716 %U https://www.jmir.org/2019/2/e10716/ %U https://doi.org/10.2196/10716 %U http://www.ncbi.nlm.nih.gov/pubmed/30714947 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10724 %T Step Counts of Middle-Aged and Elderly Adults for 10 Months Before and After the Release of Pokémon GO in Yokohama, Japan %A Hino,Kimihiro %A Asami,Yasushi %A Lee,Jung Su %+ Department of Urban Engineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan, 81 3 5841 6225, hino@ua.t.u-tokyo.ac.jp %K augmented reality %K location-based games %K mobile phone %K pedometer %K physical activity %K Pokémon GO %K smartphone %D 2019 %7 05.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphones have been integrated into our society and are expected to serve as tools to improve health outcomes. In the summer of 2016, Pokémon GO, a location-based augmented reality game for smartphones was released; it attracted attention from the perspective of health, especially with its potential to increase physical activity (PA). A few studies have compared objectively measured step counts before and after the release of the game; however, they were conducted over a short study period and evaluated only young people. Objective: The objective of this study was to confirm whether there was a difference in step counts between middle-aged and elderly players and nonplayers before and after the release of Pokémon GO. Methods: A total of 46 players and 184 nonplayers aged ≥40 years were matched for sex, age group, and PA level; they were respondents to a questionnaire randomly sent to citizens who were given free pedometers by Yokohama city. Their play status was identified through the questionnaire. To investigate the change in step counts before and after the release of Pokémon GO according to play status, a 2-way repeated-measures analysis of variance was performed. Step counts 1 month before the release of the game were compared with those 8 months after the release. In addition, subgroup analyses according to sex, age group, PA level, and subjective health status were performed. Results: The mean ages of players and nonplayers were 56.5 (SD 9.9) years and 57.3 (SD 9.6) years, respectively, and the mean baseline step counts of players and nonplayers were 7641.8 (SD 2754.5) and 7903.3 (SD 2674.7), respectively. There was no significant difference in the age and baseline step counts according to a t test (2-tailed). In the analysis of all samples, the interaction between play status and time effect was significant for 3 of 8 months after release. In the subgroup analyses, the interaction was significant for 3 months in men, 7 months in the 55-64-year-old group, 2 months in workers, 4 months in the active group in PA level, and 2 months in participants with subjectively good health. The interaction was significant for only 1 month, at most, in other subgroups. Conclusions: The present study confirmed a difference in step counts between players and nonplayers before and after the release of Pokémon GO. According to our analysis, step counts were higher until 7 months after the release. The player group maintained their step counts in winter, despite the decrease in step counts of nonplayers. In subgroup analyses, players were more likely to be men, aged <55 years, workers, active, and subjectively in good health. %M 30720438 %R 10.2196/10724 %U https://www.jmir.org/2019/2/e10724/ %U https://doi.org/10.2196/10724 %U http://www.ncbi.nlm.nih.gov/pubmed/30720438 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12341 %T An Integrated Influenza Surveillance Framework Based on National Influenza-Like Illness Incidence and Multiple Hospital Electronic Medical Records for Early Prediction of Influenza Epidemics: Design and Evaluation %A Yang,Cheng-Yi %A Chen,Ray-Jade %A Chou,Wan-Lin %A Lee,Yuarn-Jang %A Lo,Yu-Sheng %+ Graduate Institute of Biomedical Informatics, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan, 886 939588576, Loyusen@tmu.edu.tw %K influenza %K epidemics %K influenza surveillance %K electronic disease surveillance %K electronic medical records %K electronic health records %K public health %D 2019 %7 01.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Influenza is a leading cause of death worldwide and contributes to heavy economic losses to individuals and communities. Therefore, the early prediction of and interventions against influenza epidemics are crucial to reduce mortality and morbidity because of this disease. Similar to other countries, the Taiwan Centers for Disease Control and Prevention (TWCDC) has implemented influenza surveillance and reporting systems, which primarily rely on influenza-like illness (ILI) data reported by health care providers, for the early prediction of influenza epidemics. However, these surveillance and reporting systems show at least a 2-week delay in prediction, indicating the need for improvement. Objective: We aimed to integrate the TWCDC ILI data with electronic medical records (EMRs) of multiple hospitals in Taiwan. Our ultimate goal was to develop a national influenza trend prediction and reporting tool more accurate and efficient than the current influenza surveillance and reporting systems. Methods: First, the influenza expertise team at Taipei Medical University Health Care System (TMUHcS) identified surveillance variables relevant to the prediction of influenza epidemics. Second, we developed a framework for integrating the EMRs of multiple hospitals with the ILI data from the TWCDC website to proactively provide results of influenza epidemic monitoring to hospital infection control practitioners. Third, using the TWCDC ILI data as the gold standard for influenza reporting, we calculated Pearson correlation coefficients to measure the strength of the linear relationship between TMUHcS EMRs and regional and national TWCDC ILI data for 2 weekly time series datasets. Finally, we used the Moving Epidemic Method analyses to evaluate each surveillance variable for its predictive power for influenza epidemics. Results: Using this framework, we collected the EMRs and TWCDC ILI data of the past 3 influenza seasons (October 2014 to September 2017). On the basis of the EMRs of multiple hospitals, 3 surveillance variables, TMUHcS-ILI, TMUHcS-rapid influenza laboratory tests with positive results (RITP), and TMUHcS-influenza medication use (IMU), which reflected patients with ILI, those with positive results from rapid influenza diagnostic tests, and those treated with antiviral drugs, respectively, showed strong correlations with the TWCDC regional and national ILI data (r=.86-.98). The 2 surveillance variables—TMUHcS-RITP and TMUHcS-IMU—showed predictive power for influenza epidemics 3 to 4 weeks before the increase noted in the TWCDC ILI reports. Conclusions: Our framework periodically integrated and compared surveillance data from multiple hospitals and the TWCDC website to maintain a certain prediction quality and proactively provide monitored results. Our results can be extended to other infectious diseases, mitigating the time and effort required for data collection and analysis. Furthermore, this approach may be developed as a cost-effective electronic surveillance tool for the early and accurate prediction of epidemics of influenza and other infectious diseases in densely populated regions and nations. %M 30707099 %R 10.2196/12341 %U http://www.jmir.org/2019/2/e12341/ %U https://doi.org/10.2196/12341 %U http://www.ncbi.nlm.nih.gov/pubmed/30707099 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11016 %T Detecting Potential Adverse Drug Reactions Using a Deep Neural Network Model %A Wang,Chi-Shiang %A Lin,Pei-Ju %A Cheng,Ching-Lan %A Tai,Shu-Hua %A Kao Yang,Yea-Huei %A Chiang,Jung-Hsien %+ Department of Computer Science and Information Engineering, National Cheng Kung University, 1 University Road, Tainan, 701, Taiwan, 886 6 2757575 ext 62534, jchiang@mail.ncku.edu.tw %K adverse drug reactions %K deep neural network %K drug representation %K machine learning %K pharmacovigilance %D 2019 %7 06.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Adverse drug reactions (ADRs) are common and are the underlying cause of over a million serious injuries and deaths each year. The most familiar method to detect ADRs is relying on spontaneous reports. Unfortunately, the low reporting rate of spontaneous reports is a serious limitation of pharmacovigilance. Objective: The objective of this study was to identify a method to detect potential ADRs of drugs automatically using a deep neural network (DNN). Methods: We designed a DNN model that utilizes the chemical, biological, and biomedical information of drugs to detect ADRs. This model aimed to fulfill two main purposes: identifying the potential ADRs of drugs and predicting the possible ADRs of a new drug. For improving the detection performance, we distributed representations of the target drugs in a vector space to capture the drug relationships using the word-embedding approach to process substantial biomedical literature. Moreover, we built a mapping function to address new drugs that do not appear in the dataset. Results: Using the drug information and the ADRs reported up to 2009, we predicted the ADRs of drugs recorded up to 2012. There were 746 drugs and 232 new drugs, which were only recorded in 2012 with 1325 ADRs. The experimental results showed that the overall performance of our model with mean average precision at top-10 achieved is 0.523 and the rea under the receiver operating characteristic curve (AUC) score achieved is 0.844 for ADR prediction on the dataset. Conclusions: Our model is effective in identifying the potential ADRs of a drug and the possible ADRs of a new drug. Most importantly, it can detect potential ADRs irrespective of whether they have been reported in the past. %M 30724742 %R 10.2196/11016 %U http://www.jmir.org/2019/2/e11016/ %U https://doi.org/10.2196/11016 %U http://www.ncbi.nlm.nih.gov/pubmed/30724742 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11757 %T Patient-Level Prediction of Cardio-Cerebrovascular Events in Hypertension Using Nationwide Claims Data %A Park,Jaram %A Kim,Jeong-Whun %A Ryu,Borim %A Heo,Eunyoung %A Jung,Se Young %A Yoo,Sooyoung %+ Office of eHealth Research and Business, Seoul National University Bundang Hospital, 173beon-gil 82, Gumi-ro, Bundang-gu, Seongnam, 13620, Republic of Korea, 82 31 787 8980, yoosoo0@gmail.com %K health risk appraisal %K risk %K hypertension %K chronic disease %K clustering and classification %K decision support systems %D 2019 %7 15.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Prevention and management of chronic diseases are the main goals of national health maintenance programs. Previously widely used screening tools, such as Health Risk Appraisal, are restricted in their achievement this goal due to their limitations, such as static characteristics, accessibility, and generalizability. Hypertension is one of the most important chronic diseases requiring management via the nationwide health maintenance program, and health care providers should inform patients about their risks of a complication caused by hypertension. Objective: Our goal was to develop and compare machine learning models predicting high-risk vascular diseases for hypertensive patients so that they can manage their blood pressure based on their risk level. Methods: We used a 12-year longitudinal dataset of the nationwide sample cohort, which contains the data of 514,866 patients and allows tracking of patients’ medical history across all health care providers in Korea (N=51,920). To ensure the generalizability of our models, we conducted an external validation using another national sample cohort dataset, comprising one million different patients, published by the National Health Insurance Service. From each dataset, we obtained the data of 74,535 and 59,738 patients with essential hypertension and developed machine learning models for predicting cardiovascular and cerebrovascular events. Six machine learning models were developed and compared for evaluating performances based on validation metrics. Results: Machine learning algorithms enabled us to detect high-risk patients based on their medical history. The long short-term memory-based algorithm outperformed in the within test (F1-score=.772, external test F1-score=.613), and the random forest-based algorithm of risk prediction showed better performance over other machine learning algorithms concerning generalization (within test F1-score=.757, external test F1-score=.705). Concerning the number of features, in the within test, the long short-term memory-based algorithms outperformed regardless of the number of features. However, in the external test, the random forest-based algorithm was the best, irrespective of the number of features it encountered. Conclusions: We developed and compared machine learning models predicting high-risk vascular diseases in hypertensive patients so that they may manage their blood pressure based on their risk level. By relying on the prediction model, a government can predict high-risk patients at the nationwide level and establish health care policies in advance. %M 30767907 %R 10.2196/11757 %U http://www.jmir.org/2019/2/e11757/ %U https://doi.org/10.2196/11757 %U http://www.ncbi.nlm.nih.gov/pubmed/30767907 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11505 %T Novel Approach to Inpatient Fall Risk Prediction and Its Cross-Site Validation Using Time-Variant Data %A Cho,Insook %A Boo,Eun-Hee %A Chung,Eunja %A Bates,David W %A Dykes,Patricia %+ Inha University, Nursing Department (5E 301), Inharo 100, Nam-gu, Incheon, 22212, Republic of Korea, 82 328608201, insook.cho@inha.ac.kr %K across sites validation %K electronic medical records %K inpatient falls %K nursing dataset %K predictive model %D 2019 %7 19.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Electronic medical records (EMRs) contain a considerable amount of information about patients. The rapid adoption of EMRs and the integration of nursing data into clinical repositories have made large quantities of clinical data available for both clinical practice and research. Objective: In this study, we aimed to investigate whether readily available longitudinal EMR data including nursing records could be utilized to compute the risk of inpatient falls and to assess their accuracy compared with existing fall risk assessment tools. Methods: We used 2 study cohorts from 2 tertiary hospitals, located near Seoul, South Korea, with different EMR systems. The modeling cohort included 14,307 admissions (122,179 hospital days), and the validation cohort comprised 21,172 admissions (175,592 hospital days) from each of 6 nursing units. A probabilistic Bayesian network model was used, and patient data were divided into windows with a length of 24 hours. In addition, data on existing fall risk assessment tools, nursing processes, Korean Patient Classification System groups, and medications and administration data were used as model parameters. Model evaluation metrics were averaged using 10-fold cross-validation. Results: The initial model showed an error rate of 11.7% and a spherical payoff of 0.91 with a c-statistic of 0.96, which represent far superior performance compared with that for the existing fall risk assessment tool (c-statistic=0.69). The cross-site validation revealed an error rate of 4.87% and a spherical payoff of 0.96 with a c-statistic of 0.99 compared with a c-statistic of 0.65 for the existing fall risk assessment tool. The calibration curves for the model displayed more reliable results than those for the fall risk assessment tools alone. In addition, nursing intervention data showed potential contributions to reducing the variance in the fall rate as did the risk factors of individual patients. Conclusions: A risk prediction model that considers longitudinal EMR data including nursing interventions can improve the ability to identify individual patients likely to fall. %M 30777849 %R 10.2196/11505 %U https://www.jmir.org/2019/2/e11505/ %U https://doi.org/10.2196/11505 %U http://www.ncbi.nlm.nih.gov/pubmed/30777849 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11129 %T Evaluating the Quality of Health Information in a Changing Digital Ecosystem %A Keselman,Alla %A Arnott Smith,Catherine %A Murcko,Anita C %A Kaufman,David R %+ Division of Specialized Information Services, National Library of Medicine, National Institutes of Health, 6707 Democracy Boulevard, Bethesda, MD, MSC 5467, United States, 1 301 827 5671, allagkeselman@gmail.com %K eHealth %K eHealth literacy %K type 2 diabetes mellitus %K consumer health information %K health literacy %K information evaluation %K information quality %K information literacy %D 2019 %7 08.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Critical evaluation of online health information has always been central to consumer health informatics. However, with the emergence of new Web media platforms and the ubiquity of social media, the issue has taken on a new dimension and urgency. At the same time, many established existing information quality evaluation guidelines address information characteristics other than the content (eg, authority and currency), target information creators rather than users as their main audience, or do not address information presented via novel Web technologies. Objective: The aim of this formative study was to (1) develop a methodological approach for analyzing health-related Web pages and (2) apply it to a set of relevant Web pages. Methods: This qualitative study analyzed 25 type 2 diabetes pages, which were derived from the results of a Google search with the keywords “diabetes,” “reversal,” and “natural.” The coding scheme, developed via a combination of theory- and data-driven approaches, includes 5 categories from existing guidelines (resource type, information authority, validity of background information sources, objectivity, and currency) and 7 novel categories (treatment or reversal method, promises and certainty, criticisms of establishment, emotional appeal, vocabulary, rhetoric and presentation, and use of science in argumentation). The coding involves both categorical judgment and in-depth narrative characterization. On establishing satisfactory level of agreement on the narrative coding, the team coded the complete dataset of 25 pages. Results: The results set included “traditional” static pages, videos, and digitized versions of printed newspapers or magazine articles. Treatments proposed by the pages included a mixture of conventional evidence-based treatments (eg, healthy balanced diet exercise) and unconventional treatments (eg, dietary supplements, optimizing gut flora). Most pages either promised or strongly implied high likelihood of complete recovery. Pages varied greatly with respect to the authors’ stated background and credentials as well as the information sources they referenced or mentioned. The majority included criticisms of the traditional health care establishment. Many sold commercial products ranging from dietary supplements to books. The pages frequently used colloquial language. A significant number included emotional personal anecdotes, made positive mentions of the word cure, and included references to nature as a positive healing force. Most pages presented some biological explanations of their proposed treatments. Some of the explanations involved the level of complexity well beyond the level of an educated layperson. Conclusions: Both traditional and data-driven categories of codes used in this work yielded insights about the resources and highlighted challenges faced by their users. This exploratory study underscores the challenges of consumer health information seeking and the importance of developing support tools that would help users seek, evaluate, and analyze information in the changing digital ecosystem. %M 30735144 %R 10.2196/11129 %U https://www.jmir.org/2019/2/e11129/ %U https://doi.org/10.2196/11129 %U http://www.ncbi.nlm.nih.gov/pubmed/30735144 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12376 %T Toward an Objective Assessment of Implementation Processes for Innovations in Health Care: Psychometric Evaluation of the Normalization Measure Development (NoMAD) Questionnaire Among Mental Health Care Professionals %A Vis,Christiaan %A Ruwaard,Jeroen %A Finch,Tracy %A Rapley,Tim %A de Beurs,Derek %A van Stel,Henk %A van Lettow,Britt %A Mol,Mayke %A Kleiboer,Annet %A Riper,Heleen %A Smit,Jan %+ Department of Clinical, Neuro-, & Developmental Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 646098094, p.d.c.vis@vu.nl %K implementation science %K eHealth %K psychometrics %K eMental health %K normalization process theory %K implementation assessment %D 2019 %7 20.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Successfully implementing eMental health (eMH) interventions in routine mental health care constitutes a major challenge. Reliable instruments to assess implementation progress are essential. The Normalization MeAsure Development (NoMAD) study developed a brief self-report questionnaire that could be helpful in measuring implementation progress. Based on the Normalization Process Theory, this instrument focuses on 4 generative mechanisms involved in implementation processes: coherence, cognitive participation, collective action, and reflexive monitoring. Objective: The aim of this study was to translate the NoMAD questionnaire to Dutch and to confirm the factor structure in Dutch mental health care settings. Methods: Dutch mental health care professionals involved in eMH implementation were invited to complete the translated NoMAD questionnaire. Confirmatory factor analysis (CFA) was conducted to verify interpretability of scale scores for 3 models: (1) the theoretical 4-factor structure, (2) a unidimensional model, and (3) a hierarchical model. Potential improvements were explored, and correlated scale scores with 3 control questions were used to assess convergent validity. Results: A total of 262 professionals from mental health care settings in the Netherlands completed the questionnaire (female: 81.7%; mean age: 45 [SD=11]). The internal consistency of the 20-item questionnaire was acceptable (.62≤alpha≤.85). The theorized 4-factor model fitted the data slightly better in the CFA than the hierarchical model (Comparative Fit Index=0.90, Tucker Lewis Index=0.88, Root Mean Square Error of Approximation=0.10, Standardized Root Mean Square Residual=0.12, χ22=22.5, P≤.05). However, the difference is small and possibly not outweighing the practical relevance of a total score and subscale scores combined in one hierarchical model. One item was identified as weak (λCA.2=0.10). A moderate-to-strong convergent validity with 3 control questions was found for the Collective Participation scale (.47≤r≤.54, P≤.05). Conclusions: NoMAD’s theoretical factor structure was confirmed in Dutch mental health settings to acceptable standards but with room for improvement. The hierarchical model might prove useful in increasing the practical utility of the NoMAD questionnaire by combining a total score with information on the 4 generative mechanisms. Future research should assess the predictive value and responsiveness over time and elucidate the conceptual interpretability of NoMAD in eMH implementation practices. %M 30785402 %R 10.2196/12376 %U http://www.jmir.org/2019/2/e12376/ %U https://doi.org/10.2196/12376 %U http://www.ncbi.nlm.nih.gov/pubmed/30785402 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12525 %T QuikLitE, a Framework for Quick Literacy Evaluation in Medicine: Development and Validation %A Zheng,Jiaping %A Yu,Hong %+ Department of Computer Science, University of Massachusetts Lowell, One University Avenue, Lowell, MA, 01854, United States, 1 978 934 3620, yu_hong@uml.edu %K health literacy %K psychometrics %K crowdsourcing %D 2019 %7 22.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: A plethora of health literacy instruments was developed over the decades. They usually start with experts curating passages of text or word lists, followed by psychometric validation and revision based on test results obtained from a sample population. This process is costly and it is difficult to customize for new usage scenarios. Objective: This study aimed to develop and evaluate a framework for dynamically creating test instruments that can provide a focused assessment of patients’ health literacy. Methods: A health literacy framework and scoring method were extended from the vocabulary knowledge test to accommodate a wide range of item difficulties and various degrees of uncertainty in the participant’s answer. Web-based tests from Amazon Mechanical Turk users were used to assess reliability and validity. Results: Parallel forms of our tests showed high reliability (correlation=.78; 95% CI 0.69-0.85). Validity measured as correlation with an electronic health record comprehension instrument was higher (.47-.61 among 3 groups) than 2 existing tools (Short Assessment of Health Literacy-English, .38-.43; Short Test of Functional Health Literacy in Adults, .34-.46). Our framework is able to distinguish higher literacy levels that are often not measured by other instruments. It is also flexible, allowing customizations to the test the designer’s focus on a particular interest in a subject matter or domain. The framework is among the fastest health literacy instrument to administer. Conclusions: We proposed a valid and highly reliable framework to dynamically create health literacy instruments, alleviating the need to repeat a time-consuming process when a new use scenario arises. This framework can be customized to a specific need on demand and can measure skills beyond the basic level. %M 30794206 %R 10.2196/12525 %U http://www.jmir.org/2019/2/e12525/ %U https://doi.org/10.2196/12525 %U http://www.ncbi.nlm.nih.gov/pubmed/30794206 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11330 %T Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial %A Buvik,Astrid %A Bergmo,Trine S %A Bugge,Einar %A Smaabrekke,Arvid %A Wilsgaard,Tom %A Olsen,Jan Abel %+ Department of Orthopaedic Surgery, University Hospital of North Norway, PO Box 4,, Tromsø, 9038, Norway, 47 95255148, Astrid.buvik@unn.no %K telemedicine %K orthopedics %K videoconferencing %K remote consultation %K outpatients %K randomized controlled trial %K economic evaluation %K cost-effectiveness analysis %K QALY %D 2019 %7 19.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. Objective: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. Methods: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. Results: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. Conclusions: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. Trial Registration: ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX) %M 30777845 %R 10.2196/11330 %U http://www.jmir.org/2019/2/e11330/ %U https://doi.org/10.2196/11330 %U http://www.ncbi.nlm.nih.gov/pubmed/30777845 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11874 %T A Web-Based Intervention (MotivATE) to Increase Attendance at an Eating Disorder Service Assessment Appointment: Zelen Randomized Controlled Trial %A Denison-Day,James %A Muir,Sarah %A Newell,Ciarán %A Appleton,Katherine M %+ Research Centre for Behaviour Change, Psychology Department, Bournemouth University, P104, Poole House, Talbot Campus, Poole, BH12 5BB, United Kingdom, 44 7590989774, jday2@bournemouth.ac.uk %K feeding disorders %K eating disorders %K anorexia nervosa %K bulimia nervosa %K binge-eating disorder %K motivation %K early medical intervention %K Internet %D 2019 %7 27.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Early assessment and treatment of eating disorder patients is important for patient outcomes. However, up to a third of people referred for treatment do not access services and 16.4% do not attend their first scheduled assessment appointment. MotivATE is a fully automated, novel, Web-based program intended to increase motivation to change eating disorder behaviors, designed for delivery at the point of invitation to an eating disorder service, with the aim of increasing service attendance. Objective: This paper assesses the impact of MotivATE on attendance at assessment when compared with treatment-as-usual. Methods: A Zelen randomized controlled design was used. All individuals referred to a specialist eating disorder service, Kimmeridge Court in Dorset, UK, over the course of a year (October 24, 2016-October 23, 2017) were randomized to treatment-as-usual only or treatment-as-usual plus an additional letter offering access to MotivATE. Attendance at the initial scheduled assessment appointment was documented. Logistic regression analysis assessed the impact of MotivATE on attendance at assessment. Additional analyses based on levels of engagement with MotivATE were also undertaken. Results: A total of 313 participants took part: 156 (49.8%) were randomized to treatment-as-usual and 157 (50.2%) were randomized to receive the additional offer to access MotivATE. Intention-to-treat analysis between conditions showed no impact of MotivATE on attendance at assessment (odds ratio [OR] 1.35, 95% CI 0.69-2.66, P=.38). Examination of the usage data indicated that only 53 of 157 participants (33.8%) in the MotivATE condition registered with the Web-based intervention. An analysis comparing those that registered with the intervention with those that did not found greater attendance at assessment in those that had registered (OR 9.46, 95% CI 1.22-73.38, P=.03). Conclusions: Our primary analyses suggest no impact of MotivATE on attendance at the first scheduled assessment appointment, but secondary analyses revealed limited engagement with the program and improved attendance in those who did engage. It is unclear, however, if engagement with the program increased motivation and, in turn, attendance or if more motivated individuals were more likely to access the intervention. Further research is required to facilitate engagement with Web-based interventions and to understand the full value of MotivATE for users. Trial Registration: ClinicalTrials.gov NCT02777944; https://clinicaltrials.gov/ct2/show/NCT02777944 (Archived by WebCite at http://www.webcitation.org/75VDEFZZ4) %M 30810533 %R 10.2196/11874 %U http://www.jmir.org/2019/2/e11874/ %U https://doi.org/10.2196/11874 %U http://www.ncbi.nlm.nih.gov/pubmed/30810533 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12533 %T Is Blockchain Technology Suitable for Managing Personal Health Records? Mixed-Methods Study to Test Feasibility %A Park,Yu Rang %A Lee,Eunsol %A Na,Wonjun %A Park,Sungjun %A Lee,Yura %A Lee,Jae-Ho %+ Department of Biomedical Informatics, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul,, Republic of Korea, 82 02 3010 3350, jaeholee@amc.seoul.kr %K personal health record %K mobile health %K blockchain %K Ethereum %D 2019 %7 08.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: There are many perspectives on the advantages of introducing blockchain in the medical field, but there are no published feasibility studies regarding the storage, propagation, and management of personal health records (PHRs) using blockchain technology. Objective: The purpose of this study was to investigate the usefulness of blockchains in the medical field in relation to transactions with and propagation of PHRs in a private blockchain. Methods: We constructed a private blockchain network using Ethereum version 1.8.4 and conducted verification using the de-identified PHRs of 300 patients. The private blockchain network consisted of one hospital node and 300 patient nodes. In order to verify the effectiveness of blockchain-based PHR management, PHRs at a time were loaded in a transaction between the hospital and patient nodes and propagated to the whole network. We obtained and analyzed the time and gas required for data transaction and propagation on the blockchain network. For reproducibility, these processes were repeated 100 times. Results: Of 300 patient records, 74 (24.7%) were not loaded in the private blockchain due to the data block size of the transaction block. The remaining 226 individual health records were classified into groups A (80 patients with outpatient visit data less than 1 year old), B (84 patients with outpatient data from between 1 and 3 years before data collection), and C (62 patients with outpatient data 3 to 5 years old). With respect to mean transaction time in the blockchain, C (128.7 seconds) had the shortest time, followed by A (132.2 seconds) and then B (159.0 seconds). The mean propagation times for groups A, B, and C were 1494.2 seconds, 2138.9 seconds, and 4111.4 seconds, respectively; mean file sizes were 5.6 KB, 18.6 KB, and 45.38 KB, respectively. The mean gas consumption values were 1,900,767; 4,224,341; and 4,112,784 for groups A, B, and C, respectively. Conclusions: This study confirms that it is possible to exchange PHR data in a private blockchain network. However, to develop a blockchain-based PHR platform that can be used in practice, many improvements are required, including reductions in data size, improved personal information protection, and reduced operating costs. %M 30735142 %R 10.2196/12533 %U http://www.jmir.org/2019/2/e12533/ %U https://doi.org/10.2196/12533 %U http://www.ncbi.nlm.nih.gov/pubmed/30735142 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12902 %T Beyond One-Off Integrations: A Commercial, Substitutable, Reusable, Standards-Based, Electronic Health Record–Connected App %A Mandl,Kenneth D %A Gottlieb,Daniel %A Ellis,Alyssa %+ Computational Health Informatics Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States, 1 6173554145, kenneth_mandl@harvard.edu %K electronic medical records %K application programming interfaces %D 2019 %7 01.02.2019 %9 Viewpoint %J J Med Internet Res %G English %X The Substitutable Medical Apps and Reusable Technology (SMART) Health IT project launched in 2010 to facilitate the development of medical apps that are scalable and substitutable. SMART defines an open application programming interface (API) specification that enables apps to connect to electronic health record systems and data warehouses without custom integration efforts. The SMART-enabled version of the Meducation app, developed by Polyglot, has been implemented at scores of hospitals and clinics in the United States, nation-wide. After expanding their product’s reach by relying on a universal, open API for integrations, the team estimates that one project manager can handle up to 20 simultaneous implementations. The app is made available through the SMART App Gallery, an open app store that supports discovery of apps and, because the apps are substitutable, market competition. This case illustrates how a universal open API for patient and clinician-facing health IT systems supported and accelerated commercial success for a start-up company. Giving end users a wide and ever-growing choice of apps that leverage data generated by the health care system and patients at home through a universal, open API is a promising and generalizable approach for rapid diffusion of innovation across health systems. %M 30707097 %R 10.2196/12902 %U http://www.jmir.org/2019/2/e12902/ %U https://doi.org/10.2196/12902 %U http://www.ncbi.nlm.nih.gov/pubmed/30707097 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11253 %T Understanding Youths’ Ability to Interpret 3D-Printed Physical Activity Data and Identify Associated Intensity Levels: Mixed-Methods Study %A Crossley,Sam Graeme Morgan %A McNarry,Melitta Anne %A Rosenberg,Michael %A Knowles,Zoe R %A Eslambolchilar,Parisa %A Mackintosh,Kelly Alexandra %+ Applied Sports Science Technology and Medicine Research Centre (A-STEM), Swansea University, Bay Campus, Engineering East Building, Swansea, SA1 8EN, United Kingdom, 44 07707470931, 557947@swansea.ac.uk %K 3D printing %K education %K adolescent %K child %K comprehension %K understanding %K mental recall %D 2019 %7 22.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: A significant proportion of youth in the United Kingdom fail to meet the recommended 60 minutes of moderate-to-vigorous physical activity every day. One of the major barriers encountered in achieving these physical activity recommendations is the perceived difficulty for youths to interpret physical activity intensity levels and apply them to everyday activities. Personalized physical activity feedback is an important method to educate youths about behaviors and associated outcomes. Recent advances in 3D printing have enabled novel ways of representing physical activity levels through personalized tangible feedback to enhance youths’ understanding of concepts and make data more available in the everyday physical environment rather than on screen. Objective: The purpose of this research was to elicit youths’ (children and adolescents) interpretations of two age-specific 3D models displaying physical activity and to assess their ability to appropriately align activities to the respective intensity. Methods: Twelve primary school children (9 boys; mean age 7.8 years; SD 0.4 years) and 12 secondary school adolescents (6 boys; mean age 14.1 years; SD 0.3 years) participated in individual semistructured interviews. Interview questions, in combination with two interactive tasks, focused on youths’ ability to correctly identify physical activity intensities and interpret an age-specific 3D model. Interviews were transcribed verbatim, content was analyzed, and outcomes were represented via tables and diagrammatic pen profiles. Results: Youths, irrespective of age, demonstrated a poor ability to define moderate-intensity activities. Moreover, children and adolescents demonstrated difficulty in correctly identifying light- and vigorous-intensity activities, respectively. Although youths were able to correctly interpret different components of the age-specific 3D models, children struggled to differentiate physical activity intensities represented in the models. Conclusions: These findings support the potential use of age-specific 3D models of physical activity to enhance youths’ understanding of the recommended guidelines and associated intensities. %M 30794204 %R 10.2196/11253 %U http://www.jmir.org/2019/2/e11253/ %U https://doi.org/10.2196/11253 %U http://www.ncbi.nlm.nih.gov/pubmed/30794204 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12439 %T Implementing Blockchains for Efficient Health Care: Systematic Review %A Vazirani,Anuraag A %A O'Donoghue,Odhran %A Brindley,David %A Meinert,Edward %+ Healthcare Translation Research Group, Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford,, United Kingdom, 44 7824446808, edward.meinert@paediatrics.ox.ac.uk %K blockchain %K electronic health records %K efficiency %K interoperability %K health %K information science %K computers %D 2019 %7 12.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The decentralized nature of sensitive health information can bring about situations where timely information is unavailable, worsening health outcomes. Furthermore, as patient involvement in health care increases, there is a growing need for patients to access and control their data. Blockchain is a secure, decentralized online ledger that could be used to manage electronic health records (EHRs) efficiently, therefore with the potential to improve health outcomes by creating a conduit for interoperability. Objective: This study aimed to perform a systematic review to assess the feasibility of blockchain as a method of managing health care records efficiently. Methods: Reviewers identified studies via systematic searches of databases including PubMed, MEDLINE, Scopus, EMBASE, ProQuest, and Cochrane Library. Suitability for inclusion of each was assessed independently. Results: Of the 71 included studies, the majority discuss potential benefits and limitations without evaluation of their effectiveness, although some systems were tested on live data. Conclusions: Blockchain could create a mechanism to manage access to EHRs stored on the cloud. Using a blockchain can increase interoperability while maintaining privacy and security of data. It contains inherent integrity and conforms to strict legal regulations. Increased interoperability would be beneficial for health outcomes. Although this technology is currently unfamiliar to most, investments into creating a sufficiently user-friendly interface and educating users on how best to take advantage of it would lead to improved health outcomes. International Registered Report Identifier (IRRID): RR2-10.2196/10994 %M 30747714 %R 10.2196/12439 %U http://www.jmir.org/2019/2/e12439/ %U https://doi.org/10.2196/12439 %U http://www.ncbi.nlm.nih.gov/pubmed/30747714 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12937 %T Mobile Digital Education for Health Professions: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration %A Dunleavy,Gerard %A Nikolaou,Charoula Konstantia %A Nifakos,Sokratis %A Atun,Rifat %A Law,Gloria Chun Yi %A Tudor Car,Lorainne %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Level 18, Clinical Science Building, 11 Mandalay Road, Singapore, 308232, Singapore, 65 6904 1258, lorainne.tudor.car@ntu.edu.sg %K mLearning %K digital education %K health workforce %K systematic review %K meta-analysis %D 2019 %7 12.02.2019 %9 Review %J J Med Internet Res %G English %X Background: There is a pressing need to implement efficient and cost-effective training to address the worldwide shortage of health professionals. Mobile digital education (mLearning) has been mooted as a potential solution to increase the delivery of health professions education as it offers the opportunity for wide access at low cost and flexibility with the portability of mobile devices. To better inform policy making, we need to determine the effectiveness of mLearning. Objective: The primary objective of this review was to evaluate the effectiveness of mLearning interventions for delivering health professions education in terms of learners’ knowledge, skills, attitudes, and satisfaction. Methods: We performed a systematic review of the effectiveness of mLearning in health professions education using standard Cochrane methodology. We searched 7 major bibliographic databases from January 1990 to August 2017 and included randomized controlled trials (RCTs) or cluster RCTs. Results: A total of 29 studies, including 3175 learners, met the inclusion criteria. A total of 25 studies were RCTs and 4 were cluster RCTs. Interventions comprised tablet or smartphone apps, personal digital assistants, basic mobile phones, iPods, and Moving Picture Experts Group-1 audio layer 3 player devices to deliver learning content. A total of 20 studies assessed knowledge (n=2469) and compared mLearning or blended learning to traditional learning or another form of digital education. The pooled estimate of studies favored mLearning over traditional learning for knowledge (standardized mean difference [SMD]=0.43, 95% CI 0.05-0.80, N=11 studies, low-quality evidence). There was no difference between blended learning and traditional learning for knowledge (SMD=0.20, 95% CI –0.47 to 0.86, N=6 studies, low-quality evidence). A total of 14 studies assessed skills (n=1097) and compared mLearning or blended learning to traditional learning or another form of digital education. The pooled estimate of studies favored mLearning (SMD=1.12, 95% CI 0.56-1.69, N=5 studies, moderate quality evidence) and blended learning (SMD=1.06, 95% CI 0.09-2.03, N=7 studies, low-quality evidence) over traditional learning for skills. A total of 5 and 4 studies assessed attitudes (n=440) and satisfaction (n=327), respectively, with inconclusive findings reported for each outcome. The risk of bias was judged as high in 16 studies. Conclusions: The evidence base suggests that mLearning is as effective as traditional learning or possibly more so. Although acknowledging the heterogeneity among the studies, this synthesis provides encouraging early evidence to strengthen efforts aimed at expanding health professions education using mobile devices in order to help tackle the global shortage of health professionals. %M 30747711 %R 10.2196/12937 %U http://www.jmir.org/2019/2/e12937/ %U https://doi.org/10.2196/12937 %U http://www.ncbi.nlm.nih.gov/pubmed/30747711 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12913 %T Digital Education in Health Professions: The Need for Overarching Evidence Synthesis %A Car,Josip %A Carlstedt-Duke,Jan %A Tudor Car,Lorainne %A Posadzki,Pawel %A Whiting,Penny %A Zary,Nabil %A Atun,Rifat %A Majeed,Azeem %A Campbell,James %A , %+ Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore,, Singapore, 65 6340 2480, josip.car@ntu.edu.sg %K methods %K education, medical %K systematic reviews %K evidence-based %K education, distance %K education, professional %D 2019 %7 14.02.2019 %9 Viewpoint %J J Med Internet Res %G English %X Synthesizing evidence from randomized controlled trials of digital health education poses some challenges. These include a lack of clear categorization of digital health education in the literature; constantly evolving concepts, pedagogies, or theories; and a multitude of methods, features, technologies, or delivery settings. The Digital Health Education Collaboration was established to evaluate the evidence on digital education in health professions; inform policymakers, educators, and students; and ultimately, change the way in which these professionals learn and are taught. The aim of this paper is to present the overarching methodology that we use to synthesize evidence across our digital health education reviews and to discuss challenges related to the process. For our research, we followed Cochrane recommendations for the conduct of systematic reviews; all reviews are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. This included assembling experts in various digital health education fields; identifying gaps in the evidence base; formulating focused research questions, aims, and outcome measures; choosing appropriate search terms and databases; defining inclusion and exclusion criteria; running the searches jointly with librarians and information specialists; managing abstracts; retrieving full-text versions of papers; extracting and storing large datasets, critically appraising the quality of studies; analyzing data; discussing findings; drawing meaningful conclusions; and drafting research papers. The approach used for synthesizing evidence from digital health education trials is commonly regarded as the most rigorous benchmark for conducting systematic reviews. Although we acknowledge the presence of certain biases ingrained in the process, we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor, methodological integrity, and standard operating procedures. This paper will be a valuable asset for researchers and methodologists undertaking systematic reviews in digital health education. %M 30762583 %R 10.2196/12913 %U http://www.jmir.org/2019/2/e12913/ %U https://doi.org/10.2196/12913 %U http://www.ncbi.nlm.nih.gov/pubmed/30762583 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12997 %T Digital Health Professions Education on Diabetes Management: Systematic Review by the Digital Health Education Collaboration %A Huang,Zhilian %A Semwal,Monika %A Lee,Shuen Yee %A Tee,Mervin %A Ong,William %A Tan,Woan Shin %A Bajpai,Ram %A Tudor Car,Lorainne %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Level 18, Clinical Sciences Building, Singapore, 308232, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K evidence-based practice %K health personnel %K learning %K systematic review %K diabetes mellitus %D 2019 %7 21.02.2019 %9 Review %J J Med Internet Res %G English %X Background: There is a shortage of health care professionals competent in diabetes management worldwide. Digital education is increasingly used in educating health professionals on diabetes. Digital diabetes self-management education for patients has been shown to improve patients’ knowledge and outcomes. However, the effectiveness of digital education on diabetes management for health care professionals is still unknown. Objective: The objective of this study was to assess the effectiveness and economic impact of digital education in improving health care professionals’ knowledge, skills, attitudes, satisfaction, and competencies. We also assessed its impact on patient outcomes and health care professionals’ behavior. Methods: We included randomized controlled trials evaluating the impact of digitalized diabetes management education for health care professionals pre- and postregistration. Publications from 1990 to 2017 were searched in MEDLINE, EMBASE, Cochrane Library, PsycINFO, CINAHL, ERIC, and Web of Science. Screening, data extraction and risk of bias assessment were conducted independently by 2 authors. Results: A total of 12 studies met the inclusion criteria. Studies were heterogeneous in terms of digital education modality, comparators, outcome measures, and intervention duration. Most studies comparing digital or blended education to traditional education reported significantly higher knowledge and skills scores in the intervention group. There was little or no between-group difference in patient outcomes or economic impact. Most studies were judged at a high or unclear risk of bias. Conclusions: Digital education seems to be more effective than traditional education in improving diabetes management–related knowledge and skills. The paucity and low quality of the available evidence call for urgent and well-designed studies focusing on important outcomes such as health care professionals’ behavior, patient outcomes, and cost-effectiveness as well as its impact in diverse settings, including developing countries. %M 30789348 %R 10.2196/12997 %U http://www.jmir.org/2019/2/e12997/ %U https://doi.org/10.2196/12997 %U http://www.ncbi.nlm.nih.gov/pubmed/30789348 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e13269 %T Online Digital Education for Postregistration Training of Medical Doctors: Systematic Review by the Digital Health Education Collaboration %A George,Pradeep Paul %A Zhabenko,Olena %A Kyaw,Bhone Myint %A Antoniou,Panagiotis %A Posadzki,Pawel %A Saxena,Nakul %A Semwal,Monika %A Tudor Car,Lorainne %A Zary,Nabil %A Lockwood,Craig %A Car,Josip %+ Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Experimental Medicine Building, 59 Nanyang Drive, Singapore,, Singapore, 65 6592 3960, josip.car@ntu.edu.sg %K randomized controlled trials %K effectiveness %K systematic review %K medical education %K internet %D 2019 %7 25.02.2019 %9 Review %J J Med Internet Res %G English %X Background: Globally, online and local area network–based (LAN) digital education (ODE) has grown in popularity. Blended learning is used by ODE along with traditional learning. Studies have shown the increasing potential of these technologies in training medical doctors; however, the evidence for its effectiveness and cost-effectiveness is unclear. Objective: This systematic review evaluated the effectiveness of online and LAN-based ODE in improving practicing medical doctors’ knowledge, skills, attitude, satisfaction (primary outcomes), practice or behavior change, patient outcomes, and cost-effectiveness (secondary outcomes). Methods: We searched seven electronic databased for randomized controlled trials, cluster-randomized trials, and quasi-randomized trials from January 1990 to March 2017. Two review authors independently extracted data and assessed the risk of bias. We have presented the findings narratively. We mainly compared ODE with self-directed/face-to-face learning and blended learning with self-directed/face-to-face learning. Results: A total of 93 studies (N=16,895) were included, of which 76 compared ODE (including blended) and self-directed/face-to-face learning. Overall, the effect of ODE (including blended) on postintervention knowledge, skills, attitude, satisfaction, practice or behavior change, and patient outcomes was inconsistent and ranged mostly from no difference between the groups to higher postintervention score in the intervention group (small to large effect size, very low to low quality evidence). Twenty-one studies reported higher knowledge scores (small to large effect size and very low quality) for the intervention, while 20 studies reported no difference in knowledge between the groups. Seven studies reported higher skill score in the intervention (large effect size and low quality), while 13 studies reported no difference in the skill scores between the groups. One study reported a higher attitude score for the intervention (very low quality), while four studies reported no difference in the attitude score between the groups. Four studies reported higher postintervention physician satisfaction with the intervention (large effect size and low quality), while six studies reported no difference in satisfaction between the groups. Eight studies reported higher postintervention practice or behavior change for the ODE group (small to moderate effect size and low quality), while five studies reported no difference in practice or behavior change between the groups. One study reported higher improvement in patient outcome, while three others reported no difference in patient outcome between the groups. None of the included studies reported any unintended/adverse effects or cost-effectiveness of the interventions. Conclusions: Empiric evidence showed that ODE and blended learning may be equivalent to self-directed/face-to-face learning for training practicing physicians. Few other studies demonstrated that ODE and blended learning may significantly improve learning outcomes compared to self-directed/face-to-face learning. The quality of the evidence in these studies was found to be very low for knowledge. Further high-quality randomized controlled trials are required to confirm these findings. %M 30801252 %R 10.2196/13269 %U http://www.jmir.org/2019/2/e13269/ %U https://doi.org/10.2196/13269 %U http://www.ncbi.nlm.nih.gov/pubmed/30801252 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12895 %T Influences on the Implementation of Mobile Learning for Medical and Nursing Education: Qualitative Systematic Review by the Digital Health Education Collaboration %A Lall,Priya %A Rees,Rebecca %A Law,Gloria Chun Yi %A Dunleavy,Gerard %A Cotič,Živa %A Car,Josip %+ Evidence for Policy and Practice Information and Co-ordinating Centre, Social Science Research Unit, Department of Social Science, University College London Institute of Education, University College London, 18 Woburn Square, London, WCIH 0NR, United Kingdom, 44 07932 243030, rebecca.rees@ucl.ac.uk %K medical education %K nursing education %K distance education %K qualitative research %K systematic review %D 2019 %7 28.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In the past 5 decades, digital education has increasingly been used in health professional education. Mobile learning (mLearning), an emerging form of educational technology using mobile devices, has been used to supplement learning outcomes through enabling conversations, sharing information and knowledge with other learners, and aiding support from peers and instructors regardless of geographic distance. Objective: This review aimed to synthesize findings from qualitative or mixed-methods studies to provide insight into factors facilitating or hindering implementation of mLearning strategies for medical and nursing education. Methods: A systematic search was conducted across a range of databases. Studies with the following criteria were selected: examined mLearning in medical and nursing education, employed a mixed-methods or qualitative approach, and published in English after 1994. Findings were synthesized using a framework approach. Results: A total of 1946 citations were screened, resulting in 47 studies being selected for inclusion. Most studies evaluated pilot mLearning interventions. The synthesis identified views on valued aspects of mobile devices in terms of efficiency and personalization but concerns over vigilance and poor device functionality; emphasis on the social aspects of technology, especially in a clinical setting; the value of interaction learning for clinical practice; mLearning as a process, including learning how to use a device; and the importance of institutional infrastructure and policies. Conclusions: The portability of mobile devices can enable interactions between learners and educational material, fellow learners, and educators in the health professions. However, devices need to be incorporated institutionally, and learners and educators need additional support to fully comprehend device or app functions. The strategic support of mLearning is likely to require procedural guidance for practice settings and device training and maintenance services on campus. %M 30816847 %R 10.2196/12895 %U https://www.jmir.org/2019/2/e12895/ %U https://doi.org/10.2196/12895 %U http://www.ncbi.nlm.nih.gov/pubmed/30816847 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12945 %T Digital Problem-Based Learning in Health Professions: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration %A Tudor Car,Lorainne %A Kyaw,Bhone Myint %A Dunleavy,Gerard %A Smart,Neil A %A Semwal,Monika %A Rotgans,Jerome I %A Low-Beer,Naomi %A Campbell,James %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, 11 Mandalay Road, Singapore, 308232, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K randomized controlled trials %K effectiveness %K systematic review %K problem-based learning %K medical education %D 2019 %7 28.02.2019 %9 Review %J J Med Internet Res %G English %X Background: The use of digital education in problem-based learning, or digital problem-based learning (DPBL), is increasingly employed in health professions education. DPBL includes purely digitally delivered as well as blended problem-based learning, wherein digital and face-to-face learning are combined. Objective: The aim of this review is to evaluate the effectiveness of DPBL in improving health professionals’ knowledge, skills, attitudes, and satisfaction. Methods: We used the gold-standard Cochrane methods to conduct a systematic review of randomized controlled trials (RCTs). We included studies that compared the effectiveness of DPBL with traditional learning methods or other forms of digital education in improving health professionals’ knowledge, skills, attitudes, and satisfaction. Two authors independently screened studies, extracted data, and assessed the risk of bias. We contacted study authors for additional information, if necessary. We used the random-effects model in the meta-analyses. Results: Nine RCTs involving 890 preregistration health professionals were included. Digital technology was mostly employed for presentation of problems. In three studies, PBL was delivered fully online. Digital technology modalities spanned online learning, offline learning, virtual reality, and virtual patients. The control groups consisted of traditional PBL and traditional learning. The pooled analysis of seven studies comparing the effect of DPBL and traditional PBL reported little or no difference in postintervention knowledge outcomes (standardized mean difference [SMD] 0.19, 95% CI 0.00-0.38). The pooled analysis of three studies comparing the effect of DPBL to traditional learning on postintervention knowledge outcomes favored DPBL (SMD 0.67, 95% CI 0.14-1.19). For skill development, the pooled analysis of two studies comparing DPBL to traditional PBL favored DPBL (SMD 0.30, 95% CI 0.07-0.54). Findings on attitudes and satisfaction outcomes were mixed. The included studies mostly had an unclear risk of bias. Conclusions: Our findings suggest that DPBL is as effective as traditional PBL and more effective than traditional learning in improving knowledge. DPBL may be more effective than traditional learning or traditional PBL in improving skills. Further studies should evaluate the use of digital technology for the delivery of other PBL components as well as PBL overall. %M 30816846 %R 10.2196/12945 %U https://www.jmir.org/2019/2/e12945/ %U https://doi.org/10.2196/12945 %U http://www.ncbi.nlm.nih.gov/pubmed/30816846 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12644 %T Health Care and Cybersecurity: Bibliometric Analysis of the Literature %A Jalali,Mohammad S %A Razak,Sabina %A Gordon,William %A Perakslis,Eric %A Madnick,Stuart %+ MGH Institute for Technology Assessment, Harvard Medical School, 101 Merrimac Street, Suite 1010, Boston, MA, 02114, United States, 1 617 724 3738, msjalali@mgh.harvard.edu %K bibliometric review %K cybersecurity %K health care %K literature analysis %K text mining %D 2019 %7 15.02.2019 %9 Review %J J Med Internet Res %G English %X Background: Over the past decade, clinical care has become globally dependent on information technology. The cybersecurity of health care information systems is now an essential component of safe, reliable, and effective health care delivery. Objective: The objective of this study was to provide an overview of the literature at the intersection of cybersecurity and health care delivery. Methods: A comprehensive search was conducted using PubMed and Web of Science for English-language peer-reviewed articles. We carried out chronological analysis, domain clustering analysis, and text analysis of the included articles to generate a high-level concept map composed of specific words and the connections between them. Results: Our final sample included 472 English-language journal articles. Our review results revealed that majority of the articles were focused on technology: Technology–focused articles made up more than half of all the clusters, whereas managerial articles accounted for only 32% of all clusters. This finding suggests that nontechnological variables (human–based and organizational aspects, strategy, and management) may be understudied. In addition, Software Development Security, Business Continuity, and Disaster Recovery Planning each accounted for 3% of the studied articles. Our results also showed that publications on Physical Security account for only 1% of the literature, and research in this area is lacking. Cyber vulnerabilities are not all digital; many physical threats contribute to breaches and potentially affect the physical safety of patients. Conclusions: Our results revealed an overall increase in research on cybersecurity and identified major gaps and opportunities for future work. %M 30767908 %R 10.2196/12644 %U https://www.jmir.org/2019/2/e12644/ %U https://doi.org/10.2196/12644 %U http://www.ncbi.nlm.nih.gov/pubmed/30767908 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e12015 %T Correction: A Web-Based Acceptance-Facilitating Intervention for Identifying Patients’ Acceptance, Uptake, and Adherence of Internet- and Mobile-Based Pain Interventions: Randomized Controlled Trial %A Lin,Jiaxi %A Faust,Bianca %A Ebert,David Daniel %A Krämer,Lena %A Baumeister,Harald %+ Institute of Psychology, Department of Clinical Psychology and Psychotherapy, University of Ulm, Albert-Einstein-Allee 47, D Ulm, Ulm, 89069, Germany, 49 07315032800, harald.baumeister@uni-ulm.de %K uptake %K acceptance %K adherence %K eHealth %K chronic pain %K randomized controlled trial %D 2019 %7 06.02.2019 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 30726188 %R 10.2196/12015 %U https://www.jmir.org/2019/2/e12015/ %U https://doi.org/10.2196/12015 %U http://www.ncbi.nlm.nih.gov/pubmed/30726188 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e13125 %T Corrigendum and Editorial Warning Regarding Use of the MMAS-8 Scale (A Remote Medication Monitoring System for Chronic Heart Failure Patients to Reduce Readmissions: A Two-Arm Randomized Pilot Study) %A Hale,Timothy M %A Jethwani,Kamal %A Kandola,Manjinder Singh %A Saldana,Fidencio %A Kvedar,Joseph C %+ Partners Healthcare, Connected Health, 25 New Chardon Street Suite 300, Boston, MA, 02114, United States, 1 617 643 9852, tmhale@mgh.harvard.edu %D 2019 %7 05.02.2019 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 30721131 %R 10.2196/13125 %U https://www.jmir.org/2019/2/e13125/ %U https://doi.org/10.2196/13125 %U http://www.ncbi.nlm.nih.gov/pubmed/30721131