%0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17256 %T Technology Acceptance in Mobile Health: Scoping Review of Definitions, Models, and Measurement %A Nadal,Camille %A Sas,Corina %A Doherty,Gavin %+ School of Computer Science and Statistics, Trinity College Dublin, College Green, Dublin, D2, Ireland, 353 18963858, nadalc@tcd.ie %K Technology Acceptance Lifecycle %K patient acceptance %K mobile applications %K mHealth %K mobile phone %D 2020 %7 6.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Designing technologies that users will be interested in, start using, and keep using has long been a challenge. In the health domain, the question of technology acceptance is even more important, as the possible intrusiveness of technologies could lead to patients refusing to even try them. Developers and researchers must address this question not only in the design and evaluation of new health care technologies but also across the different stages of the user’s journey. Although a range of definitions for these stages exists, many researchers conflate related terms, and the field would benefit from a coherent set of definitions and associated measurement approaches. Objective: This review aims to explore how technology acceptance is interpreted and measured in mobile health (mHealth) literature. We seek to compare the treatment of acceptance in mHealth research with existing definitions and models, identify potential gaps, and contribute to the clarification of the process of technology acceptance. Methods: We searched the PubMed database for publications indexed under the Medical Subject Headings terms “Patient Acceptance of Health Care” and “Mobile Applications.” We included publications that (1) contained at least one of the terms “acceptability,” “acceptance,” “adoption,” “accept,” or “adopt”; and (2) defined the term. The final corpus included 68 relevant studies. Results: Several interpretations are associated with technology acceptance, few consistent with existing definitions. Although the literature has influenced the interpretation of the concept, usage is not homogeneous, and models are not adapted to populations with particular needs. The prevalence of measurement by custom surveys suggests a lack of standardized measurement tools. Conclusions: Definitions from the literature were published separately, which may contribute to inconsistent usage. A definition framework would bring coherence to the reporting of results, facilitating the replication and comparison of studies. We propose the Technology Acceptance Lifecycle, consolidating existing definitions, articulating the different stages of technology acceptance, and providing an explicit terminology. Our findings illustrate the need for a common definition and measurement framework and the importance of viewing technology acceptance as a staged process, with adapted measurement methods for each stage. %M 32628122 %R 10.2196/17256 %U https://www.jmir.org/2020/7/e17256 %U https://doi.org/10.2196/17256 %U http://www.ncbi.nlm.nih.gov/pubmed/32628122 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16228 %T The Acceptability and Usability of Digital Health Interventions for Adults With Depression, Anxiety, and Somatoform Disorders: Qualitative Systematic Review and Meta-Synthesis %A Patel,Shireen %A Akhtar,Athfah %A Malins,Sam %A Wright,Nicola %A Rowley,Emma %A Young,Emma %A Sampson,Stephanie %A Morriss,Richard %+ Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Institute of Mental Health Building, University of Nottingham Innovation Park, Triumph Road, Nottingham, NG7 2TU, United Kingdom, 44 115 8231434, shireen.patel@nottingham.ac.uk %K digital health interventions %K depression %K anxiety %K somatoform disorders %K smartphone %K mobile phone %D 2020 %7 6.7.2020 %9 Review %J J Med Internet Res %G English %X Background: The prevalence of mental health disorders continues to rise, with almost 4% of the world population having an anxiety disorder and almost 3.5% having depression in 2017. Despite the high prevalence, only one-third of people with depression or anxiety receive treatment. Over the last decade, the use of digital health interventions (DHIs) has risen rapidly as a means of accessing mental health care and continues to increase. Although there is evidence supporting the effectiveness of DHIs for the treatment of mental health conditions, little is known about what aspects are valued by users and how they might be improved. Objective: This systematic review aimed to identify, appraise, and synthesize the qualitative literature available on service users’ views and experiences regarding the acceptability and usability of DHIs for depression, anxiety, and somatoform disorders. Methods: A systematic search strategy was developed, and searches were run in 7 electronic databases. Qualitative and mixed methods studies published in English were included. A meta-synthesis was used to interpret and synthesize the findings from the included studies. Results: A total of 24 studies were included in the meta-synthesis, and 3 key themes emerged with descriptive subthemes. The 3 key themes were initial motivations and approaches to DHIs, personalization of treatment, and the value of receiving personal support in DHIs. The meta-synthesis suggests that participants’ initial beliefs about DHIs can have an important effect on their engagement with these types of interventions. Personal support was valued very highly as a major component of the success of DHIs. The main reason for this was the way it enabled individual personalization of care. Conclusions: Findings from the systematic review have implications for the design of future DHIs to improve uptake, retention, and outcomes in DHIs for depression, anxiety, and somatoform disorders. DHIs need to be personalized to the specific needs of the individual. Future research should explore whether the findings could be generalized to other health conditions. %M 32628116 %R 10.2196/16228 %U https://www.jmir.org/2020/7/e16228 %U https://doi.org/10.2196/16228 %U http://www.ncbi.nlm.nih.gov/pubmed/32628116 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18480 %T Methods and Evaluation Criteria for Apps and Digital Interventions for Diabetes Self-Management: Systematic Review %A Larbi,Dillys %A Randine,Pietro %A Årsand,Eirik %A Antypas,Konstantinos %A Bradway,Meghan %A Gabarron,Elia %+ Norwegian Centre for E-health Research, University Hospital of North Norway, Forskningsparken i Breivika 3rd Fl, Sykehusveien 23, Tromsø, 9019, Norway, 47 91193393, meghan.bradway@ehealthresearch.no %K self-management %K diabetes mellitus %K mobile applications %K computer communication networks %K mHealth %K eHealth %K health care evaluation mechanisms %D 2020 %7 6.7.2020 %9 Review %J J Med Internet Res %G English %X Background: There is growing evidence that apps and digital interventions have a positive impact on diabetes self-management. Standard self-management for patients with diabetes could therefore be supplemented by apps and digital interventions to increase patients’ skills. Several initiatives, models, and frameworks suggest how health apps and digital interventions could be evaluated, but there are few standards for this. And although there are many methods for evaluating apps and digital interventions, a more specific approach might be needed for assessing digital diabetes self-management interventions. Objective: This review aims to identify which methods and criteria are used to evaluate apps and digital interventions for diabetes self-management, and to describe how patients were involved in these evaluations. Methods: We searched CINAHL, EMBASE, MEDLINE, and Web of Science for articles published from 2015 that referred to the evaluation of apps and digital interventions for diabetes self-management and involved patients in the evaluation. We then conducted a narrative qualitative synthesis of the findings, structured around the included studies’ quality, methods of evaluation, and evaluation criteria. Results: Of 1681 articles identified, 31 fulfilled the inclusion criteria. A total of 7 articles were considered of high confidence in the evidence. Apps were the most commonly used platform for diabetes self-management (18/31, 58%), and type 2 diabetes (T2D) was the targeted health condition most studies focused on (12/31, 38%). Questionnaires, interviews, and user-group meetings were the most common methods of evaluation. Furthermore, the most evaluated criteria for apps and digital diabetes self-management interventions were cognitive impact, clinical impact, and usability. Feasibility and security and privacy were not evaluated by studies considered of high confidence in the evidence. Conclusions: There were few studies with high confidence in the evidence that involved patients in the evaluation of apps and digital interventions for diabetes self-management. Additional evaluation criteria, such as sustainability and interoperability, should be focused on more in future studies to provide a better understanding of the effects and potential of apps and digital interventions for diabetes self-management. %M 32628125 %R 10.2196/18480 %U https://www.jmir.org/2020/7/e18480 %U https://doi.org/10.2196/18480 %U http://www.ncbi.nlm.nih.gov/pubmed/32628125 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18386 %T Technology-Based Interventions in Oral Anticoagulation Management: Meta-Analysis of Randomized Controlled Trials %A Dai,Hengfen %A Zheng,Caiyun %A Lin,Chun %A Zhang,Yan %A Zhang,Hong %A Chen,Fan %A Liu,Yunchun %A Xiao,Jingwen %A Chen,Chaoxin %+ Fuqing City Hospital, 267 Qingrong Avenue, Fuqing, Fuzhou, 350300, China, 86 059185153395, saiun1992@163.com %K technology-based %K oral anticoagulation management %K meta-analysis %K randomized controlled trials %K telehealth %K warfarin %D 2020 %7 15.7.2020 %9 Review %J J Med Internet Res %G English %X Background: An increasing number of patients have received prophylactic or therapeutic oral anticoagulants (OACs) for thromboembolic complications of diseases. The use of OACs is associated with both clinical benefits and risks. Considering the challenges imposed by this class of drugs, as well as the enormous progress made in portable device technology, it is possible that technology-based interventions may improve clinical benefits for patients and optimize anticoagulation management. Objective: This study was designed to comprehensively evaluate the role of technology-based interventions in the management of OACs. Methods: We searched 6 databases—PubMed, EMBASE, Cochrane, Cumulative Index to Nursing and Allied Health Literature, Scopus, and PsycINFO—to retrieve relevant studies published as of November 1, 2019, to evaluate the effect of technology-based interventions on oral anticoagulation management. RevMan (version 5.3; Cochrane) software was used to evaluate and analyze clinical outcomes. The methodological quality of studies was assessed by the Cochrane risk of bias tool. Results: A total of 15 randomized controlled trials (RCTs) were selected for analysis. They reported data for 2218 patients (1110 patients in the intervention groups and 1108 patients in the control groups). A meta-analysis was performed on the effectiveness and safety data reported in the RCTs. Technology-based interventions significantly improved the effectiveness of oral anticoagulation management (mean difference [MD]=6.07; 95% CI 0.84-11.30; I2=72%; P=.02). The safety of oral anticoagulation management was also improved, but the results were not statistically significant. Bleeding events were reduced (major bleeding events MD=1.02; 95% CI 0.78-1.32; I2=0%; P=.90; minor bleeding events MD=1.06, 95% CI 0.77-1.44; I2=41%; P=.73) and thromboembolism events were reduced (MD=0.71; 95% CI 0.49-1.01; I2=0%; P=.06). In general, patients were more satisfied with technology-based interventions, which could also improve their knowledge of anticoagulation management, improve their quality of life, and reduce mortality and hospitalization events. Conclusions: Using technology to manage OACs can improve the effectiveness and safety of oral anticoagulation management, result in higher patient satisfaction, and allow greater understanding of anticoagulation. %M 32673227 %R 10.2196/18386 %U https://www.jmir.org/2020/7/e18386 %U https://doi.org/10.2196/18386 %U http://www.ncbi.nlm.nih.gov/pubmed/32673227 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15365 %T Digital Self-Management Interventions for People With Osteoarthritis: Systematic Review With Meta-Analysis %A Safari,Reza %A Jackson,Jessica %A Sheffield,David %+ Health and Social Care Research Centre, University of Derby, Kedleston Road, Derby, DE22 1GB, United Kingdom, 44 1332 592418, m.safari@derby.ac.uk %K osteoarthritis %K self-management %K internet-based intervention %K mobile phone %K eHealth %K mHealth %K systematic review %K meta-analysis %D 2020 %7 20.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Osteoarthritis (OA) is not curable, but the symptoms can be managed through self-management programs (SMPs). Owing to the growing burden of OA on the health system and the need to ensure high-quality integrated services, delivering SMPs through digital technologies could be an economic and effective community-based approach. Objective: This study aims to analyze the effectiveness of digital-based structured SMPs on patient outcomes in people with OA. Methods: A total of 7 web-based and 3 gray literature databases were searched for randomized controlled trials assessing digital-based structured SMPs on self-reported outcomes including pain, physical function, disability, and health-related quality of life (QoL) in people with OA. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk of bias sensitivity analysis, and subgroup analysis were performed where appropriate. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence. Results: A total of 8 studies were included in this review involving 2687 patients with knee (n=2); knee, hip, or both (n=5); and unspecified joint (n=1) OA. SMPs were delivered via telephone plus audio and video, internet, or mobile apps. Studies reported that digital-based structured SMPs compared with the treatment as usual control group (n=7) resulted in a significant, homogeneous, medium reduction in pain and improvement in physical function (standardized mean difference [SMD] –0.28, 95% CI –0.38 to –0.18 and SMD –0.26, 95% CI –0.35 to –0.16, respectively) at posttreatment. The digital-based structured SMP effect on pain and function reduced slightly at the 12-month follow-up but remained to be medium and significant. The posttreatment effect of digital-based structured SMPs was small and significant for disability, but nonsignificant for QoL (SMD –0.10, 95% CI –0.17 to 0.03 and SMD –0.17, 95% CI –0.47 to 0.14, respectively; each reported in 1 study only). The 12-month follow-up effect of the intervention was very small for disability and QoL. The quality of evidence was rated as moderate for pain and physical function and low and very low for disability and QoL, respectively, using the GRADE approach. Conclusions: Digital-based structured SMPs may result in improvement in pain and physical function that is largely sustained at the 12-month follow-up in people with knee and hip OA. The effects on disability and QoL are smaller and less clear. The quality of evidence is moderate to low, and further research is required to confirm the findings of the review and assess the effects of digital-based structured SMPs on other health-related outcomes. %M 32706657 %R 10.2196/15365 %U http://www.jmir.org/2020/7/e15365/ %U https://doi.org/10.2196/15365 %U http://www.ncbi.nlm.nih.gov/pubmed/32706657 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18477 %T Reinforcement Learning for Clinical Decision Support in Critical Care: Comprehensive Review %A Liu,Siqi %A See,Kay Choong %A Ngiam,Kee Yuan %A Celi,Leo Anthony %A Sun,Xingzhi %A Feng,Mengling %+ Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore, 65 65164988, ephfm@nus.edu.sg %K artificial intelligence %K reinforcement learning %K critical care %K decision support systems, clinical %K intensive care unit %K machine learning %D 2020 %7 20.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Decision support systems based on reinforcement learning (RL) have been implemented to facilitate the delivery of personalized care. This paper aimed to provide a comprehensive review of RL applications in the critical care setting. Objective: This review aimed to survey the literature on RL applications for clinical decision support in critical care and to provide insight into the challenges of applying various RL models. Methods: We performed an extensive search of the following databases: PubMed, Google Scholar, Institute of Electrical and Electronics Engineers (IEEE), ScienceDirect, Web of Science, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica Database (EMBASE). Studies published over the past 10 years (2010-2019) that have applied RL for critical care were included. Results: We included 21 papers and found that RL has been used to optimize the choice of medications, drug dosing, and timing of interventions and to target personalized laboratory values. We further compared and contrasted the design of the RL models and the evaluation metrics for each application. Conclusions: RL has great potential for enhancing decision making in critical care. Challenges regarding RL system design, evaluation metrics, and model choice exist. More importantly, further work is required to validate RL in authentic clinical environments. %M 32706670 %R 10.2196/18477 %U https://www.jmir.org/2020/7/e18477 %U https://doi.org/10.2196/18477 %U http://www.ncbi.nlm.nih.gov/pubmed/32706670 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17362 %T Implementing Web-Based Therapy in Routine Mental Health Care: Systematic Review of Health Professionals’ Perspectives %A Davies,Fiona %A Shepherd,Heather L %A Beatty,Lisa %A Clark,Brodie %A Butow,Phyllis %A Shaw,Joanne %+ Psycho-Oncology Co-operative Research Group, School of Psychology, The University of Sydney, Lifehouse Level 6-North (C39Z), Sydney, 2006, Australia, 61 2 8627 0828, heather.shepherd@sydney.edu.au %K health professional views %K implementation %K online psychological therapy %K online CBT %K barriers %K facilitators %K models of care %K cognitive behavioral therapy %K internet-based intervention %D 2020 %7 23.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Web-based therapies hold great promise to increase accessibility and reduce costs of delivering mental health care; however, uptake in routine settings has been low. Objective: Our objective in this review was to summarize what is known about health care professionals’ perceptions of the barriers to and facilitators of the implementation of web-based psychological treatments in routine care of adults in health care settings. Methods: We searched 5 major databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library) for qualitative, quantitative, or mixed-methods studies exploring health professionals’ views on computer- or internet-based psychological treatment programs. We coded included articles for risk of bias and extracted data using a prepiloted extraction sheet. Results: We identified 29 eligible articles: 14 qualitative, 11 quantitative, and 4 mixed methods. We identified the following themes: patient factors, health professional factors, the therapeutic relationship, therapy factors, organizational and system factors, and models of care. Health professionals supported web-based therapies only for patients with relatively straightforward, low-risk diagnoses, strong motivation and engagement, high computer literacy and access, and low need for tailored content. They perceived flexibility with timing and location as advantages of web-based therapy, but preferred blended therapy to facilitate rapport and allow active monitoring and follow-up of patients. They emphasized the need for targeted training and organizational support to manage changed workflows. Health professionals were concerned about the confidentiality and security of client data for web-based programs, suggesting that clear and transparent protocols need to be in place to reassure health professionals before they will be willing to refer. Conclusions: Without health professionals’ support, many people will not access web-based therapies. To increase uptake, it is important to ensure that health professionals receive education, familiarization, and training to support them in incorporating web-based therapies into their practice, and to design systems that support health professionals in this new way of working with patients and addressing their concerns. Trial Registration: PROSPERO CRD42018100869; https://tinyurl.com/y5vaoqsk %M 32706713 %R 10.2196/17362 %U http://www.jmir.org/2020/7/e17362/ %U https://doi.org/10.2196/17362 %U http://www.ncbi.nlm.nih.gov/pubmed/32706713 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14230 %T Using Digital Communication Technology to Increase HIV Testing Among Men Who Have Sex With Men and Transgender Women: Systematic Review and Meta-Analysis %A Veronese,Vanessa %A Ryan,Kathleen Elizabeth %A Hughes,Chad %A Lim,Megan SC %A Pedrana,Alisa %A Stoové,Mark %+ Disease Elimination Program, Burnet Institute, 85 Commerical Road, Melbourne, 3004, Australia, 61 0404387154, vanessa.veronese@burnet.edu.au %K digital technology %K men who have sex with men %K transgender women %K HIV testing %K HIV prevention %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: HIV continues to disproportionately affect men who have sex with men (MSM) and transgender women (TW). Undiagnosed HIV is a major driver of HIV transmission rates, and increasing the uptake of regular HIV testing and facilitating timely initiation of HIV treatment is a global HIV prevention priority. However, MSM and TW experience a range of barriers that limit their access to testing and other prevention services. Given their growing ubiquity, digital communication technologies are increasingly being used to support HIV prevention efforts, and a growing number of studies have trialed the use of digital technology to promote HIV testing among MSM and TW. Objective: We undertook a systematic review and meta-analysis to assess the impact of digital communication technology on HIV testing uptake among MSM and TW. Subanalyses aimed to identify the features and characteristics of digital interventions associated with greater impact. Methods: A systematic literature review was undertaken using select databases and conference repositories. Studies describing the use of a digital technology—internet-enabled devices, including phones, tablets, and computers—to increase HIV testing uptake among MSM or TW using either randomized or observational cohort design with measurement of HIV testing rates measured pre- and postintervention, and published in English between 2010 and 2018 were included. Pooled effect estimates were calculated using a random effects meta-analysis. Subanalyses calculated effect estimates grouped by selected features of digital interventions. Results: A total of 13 randomized or observational studies were included in the final review. Digital interventions most commonly used mainstream, existing social media platforms (n=7) or promotion through online peer educators (n=5). Most interventions (n=8) were categorized as interactive and allowed user engagement and most directly facilitated testing (n=7) either by providing self-testing kits or referral to testing services. A total of 1930 participants were included across the 13 studies. HIV testing uptake among MSM and TW exposed to digital interventions was 1.5 times higher than that of unexposed MSM and TW (risk ratio [RR] 1.5; 95% CI 1.3-1.7). Subanalyses suggested an increased impact on HIV testing uptake among interventions that were delivered through mainstream social media–based platforms (RR 1.7; 95% CI 1.3-2.1), included direct facilitation of HIV testing (RR 1.6; 95% CI 1.4-1.9), were interactive (RR 1.6; 95% CI 1.4-1.8), and involved end users in the design process (RR 1.6; 95% CI 1.3-2.0). Conclusions: These findings provide broad support for the integration of technology with existing approaches to promote and facilitate HIV testing among MSM and TW. Our findings identified key features that may be associated with greater impact on HIV testing uptake and can be used to inform future development efforts given the growing interest and application of digital technologies in HIV prevention. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42017070055; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017070055. %M 32720902 %R 10.2196/14230 %U https://www.jmir.org/2020/7/e14230 %U https://doi.org/10.2196/14230 %U http://www.ncbi.nlm.nih.gov/pubmed/32720902 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17907 %T Information Needs of Breast Cancer Patients: Theory-Generating Meta-Synthesis %A Lu,Hongru %A Xie,Juan %A Gerido,Lynette Hammond %A Cheng,Ying %A Chen,Ya %A Sun,Lizhu %+ School of Information Management, Nanjing University, 163 Xianlin Avenue, Nanjing, China, 86 138 5183 8364, chengy@nju.edu.cn %K breast cancer patients %K information needs %K incentives %K moderating variables %K meta-synthesis %D 2020 %7 28.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Breast cancer has become one of the most frequently diagnosed carcinomas and the leading cause of cancer deaths. The substantial growth in the number of breast cancer patients has put great pressure on health services. Meanwhile, the information patients need has increased and become more complicated. Therefore, a comprehensive and in-depth understanding of their information needs is urgently needed to improve the quality of health care. However, previous studies related to the information needs of breast cancer patients have focused on different perspectives and have only contributed to individual results. A systematic review and synthesis of breast cancer patients’ information needs is critical. Objective: This paper aims to systematically identify, evaluate, and synthesize existing primary qualitative research on the information needs of breast cancer patients. Methods: Web of Science, EBSCO, Scopus, ProQuest, PubMed, PsycINFO, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature were searched on February 12 and July 9, 2019, to collect relevant studies. A Google Scholar search, interpersonal network recommendations, and reference chaining were also conducted. Eligible studies included qualitative or mixed-methods studies focusing on the information needs (across the cancer continuum) of breast cancer patients or their social networks. Subsequently, a Critical Appraisals Skills Programme checklist was used to assess the quality of included research. The results, findings, and discussions were extracted. Data analysis was guided by the theory-generating meta-synthesis and grounded theory approach. Results: Three themes, 19 categories, and 55 concepts emerged: (1) incentives (physical abnormality, inquiry from others, subjective norm, and problems during appointments); (2) types of information needs (prevention, etiology, diagnosis, clinical manifestation, treatment, prognosis, impact and resumption of normal life, scientific research, and social assistance); (3) moderating variables (attitudes, health literacy, demographic characteristics, disease status, as well as political and cultural environment). The studies revealed that the information needs of breast cancer patients were triggered by different incentives. Subsequently, the patients sought a variety of information among different stages of the cancer journey. Five types of variables were also found to moderate the formation of information needs. Conclusions: This study contributes to a thorough model of information needs among breast cancer patients and provides practical suggestions for health and information professionals. %M 32720899 %R 10.2196/17907 %U https://www.jmir.org/2020/7/e17907 %U https://doi.org/10.2196/17907 %U http://www.ncbi.nlm.nih.gov/pubmed/32720899 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17915 %T Evidence Regarding Automatic Processing Computerized Tasks Designed For Health Interventions in Real-World Settings Among Adults: Systematic Scoping Review %A Jayasinghe,Harshani %A Short,Camille E %A Braunack-Mayer,Annette %A Merkin,Ashley %A Hume,Clare %+ School of Public Health, The University of Adelaide, Level 9, Adelaide Health and Medical Sciences Building, The University of Adelaide, Adelaide, 5000, Australia, 61 8313 4634, harshani.jayasinghepedige@adelaide.edu.au %K automatic processing %K computerized tasks %K health interventions %K real-world %K adult %K behavior change, mobile phone %D 2020 %7 29.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Dual process theories propose that the brain uses 2 types of thinking to influence behavior: automatic processing and reflective processing. Automatic processing is fast, immediate, nonconscious, and unintentional, whereas reflective processing focuses on logical reasoning, and it is slow, step by step, and intentional. Most digital psychological health interventions tend to solely target the reflective system, although the automatic processing pathway can have strong influences on behavior. Laboratory-based research has highlighted that automatic processing tasks can create behavior change; however, there are substantial gaps in the field on the design, implementation, and delivery of automatic processing tasks in real-world settings. It is important to identify and summarize the existing literature in this area to inform the translation of laboratory-based research to real-world settings. Objective: This scoping review aims to explore the effectiveness of automatic training tasks, types of training tasks commonly used, mode of delivery, and impacts of gamification on automatic processing tasks designed for digital psychological health interventions in real-world settings among adults. Methods: The scoping review methodology proposed by Arskey and O’Malley and Colquhoun was applied. A scoping review was chosen because of the novelty of the digital automatic processing field and to encompass a broad review of the existing evidence base. Electronic databases and gray literature databases were searched with the search terms “automatic processing,” “computerised technologies,” “health intervention,” “real-world,” and “adults” and synonyms of these words. The search was up to date until September 2018. A manual search was also completed on the reference lists of the included studies. Results: A total of 14 studies met all inclusion criteria. There was a wide variety of health conditions targeted, with the most prevalent being alcohol abuse followed by social anxiety. Attention bias modification tasks were the most prevalent type of automatic processing task, and the majority of tasks were most commonly delivered over the web via a personal computer. Of the 14 studies included in the review, 8 demonstrated significant changes to automatic processes and 4 demonstrated significant behavioral changes as a result of changed automatic processes. Conclusions: This is the first review to synthesize the evidence on automatic processing tasks in real-world settings targeting adults. This review has highlighted promising, albeit limited, research demonstrating that automatic processing tasks may be used effectively in a real-world setting to influence behavior change. %M 32499213 %R 10.2196/17915 %U http://www.jmir.org/2020/7/e17915/ %U https://doi.org/10.2196/17915 %U http://www.ncbi.nlm.nih.gov/pubmed/32499213 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18551 %T Design, Use, and Effects of Sex Dolls and Sex Robots: Scoping Review %A Döring,Nicola %A Mohseni,M Rohangis %A Walter,Roberto %+ Institute of Media and Communication Science, Ilmenau University of Technology, Ehrenbergstr. 29, Ilmenau, 98693, Germany, 49 3677694703, nicola.doering@tu-ilmenau.de %K sex toys %K sexual objectification %K anthropomorphization %K embodied sexual fantasies %K parasocial interactions and relationships, mobile phone %D 2020 %7 30.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Although sex toys representing human body parts are widely accepted and normalized, human-like full-body sex dolls and sex robots have elicited highly controversial debates. Objective: This systematic scoping review of the academic literature on sex dolls and sex robots, the first of its kind, aimed to examine the extent and type of existing academic knowledge and to identify research gaps against this backdrop. Methods: A comprehensive multidisciplinary, multidatabase search strategy was used. All steps of literature search and selection, data charting, and synthesis followed the leading methodological guideline, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. A total of 29 (17 peer reviewed) and 98 publications (32 peer reviewed) for sex dolls and sex robots, respectively, from 1993 to 2019 were included. Results: According to the topics and methodologies, the sex doll and sex robot publications were divided into 5 and 6 groups, respectively. The majority of publications were theoretical papers. Thus far, no observational or experimental research exists that uses actual sex dolls or sex robots as stimulus material. Conclusions: There is a need to improve the theoretical elaboration and the scope and depth of empirical research examining the sexual uses of human-like full-body material artifacts, particularly concerning not only risks but also opportunities for sexual and social well-being. %M 32729841 %R 10.2196/18551 %U https://www.jmir.org/2020/7/e18551 %U https://doi.org/10.2196/18551 %U http://www.ncbi.nlm.nih.gov/pubmed/32729841 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18839 %T Computer-Controlled Virtual Humans in Patient-Facing Systems: Systematic Review and Meta-Analysis %A Chattopadhyay,Debaleena %A Ma,Tengteng %A Sharifi,Hasti %A Martyn-Nemeth,Pamela %+ Department of Computer Science, University of Illinois at Chicago, 851 S Morgan (M/C 152), Room 1120 SEO, Chicago, IL, 60607, United States, 1 312413518, debchatt@uic.edu %K virtual humans %K avatars %K patient-facing systems %K meta-analysis %K conversational agents %K chatbot %K digital interlocutors %D 2020 %7 30.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Virtual humans (VH) are computer-generated characters that appear humanlike and simulate face-to-face conversations using verbal and nonverbal cues. Unlike formless conversational agents, like smart speakers or chatbots, VH bring together the capabilities of both a conversational agent and an interactive avatar (computer-represented digital characters). Although their use in patient-facing systems has garnered substantial interest, it is unknown to what extent VH are effective in health applications. Objective: The purpose of this review was to examine the effectiveness of VH in patient-facing systems. The design and implementation characteristics of these systems were also examined. Methods: Electronic bibliographic databases were searched for peer-reviewed articles with relevant key terms. Studies were included in the systematic review if they designed or evaluated VH in patient-facing systems. Of the included studies, studies that used a randomized controlled trial to evaluate VH were included in the meta-analysis; they were then summarized using the PICOTS framework (population, intervention, comparison group, outcomes, time frame, setting). Summary effect sizes, using random-effects models, were calculated, and the risk of bias was assessed. Results: Among the 8,125 unique records identified, 53 articles describing 33 unique systems, were qualitatively, systematically reviewed. Two distinct design categories emerged — simple VH and VH augmented with health sensors and trackers. Of the 53 articles, 16 (26 studies) with 44 primary and 22 secondary outcomes were included in the meta-analysis. Meta-analysis of the 44 primary outcome measures revealed a significant difference between intervention and control conditions, favoring the VH intervention (SMD = .166, 95% CI .039-.292, P=.012), but with evidence of some heterogeneity, I2=49.3%. There were more cross-sectional (k=15) than longitudinal studies (k=11). The intervention was delivered using a personal computer in most studies (k=18), followed by a tablet (k=4), mobile kiosk (k=2), head-mounted display (k=1), and a desktop computer in a community center (k=1). Conclusions: We offer evidence for the efficacy of VH in patient-facing systems. Considering that studies included different population and outcome types, more focused analysis is needed in the future. Future studies also need to identify what features of virtual human interventions contribute toward their effectiveness. %M 32729837 %R 10.2196/18839 %U http://www.jmir.org/2020/7/e18839/ %U https://doi.org/10.2196/18839 %U http://www.ncbi.nlm.nih.gov/pubmed/32729837 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17274 %T Effectiveness of Technology-Enabled Knowledge Translation Strategies in Improving the Use of Research in Public Health: Systematic Review %A Brown,Alison %A Barnes,Courtney %A Byaruhanga,Judith %A McLaughlin,Matthew %A Hodder,Rebecca K %A Booth,Debbie %A Nathan,Nicole %A Sutherland,Rachel %A Wolfenden,Luke %+ Hunter New England Population Health, Booth Building, Longworth Avenue, Wallsend, 2287, Australia, 61 249246685, alison.brown7@health.nsw.gov.au %K knowledge translation %K public health %D 2020 %7 31.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Knowledge translation (KT) aims to facilitate the use of research evidence in decision making. Changes in technology have provided considerable opportunities for KT strategies to improve access and use of evidence in decision making by public health policy makers and practitioners. Despite this opportunity, there have been no reviews that have assessed the effects of digital technology-enabled KT (TEKT) in the field of public health. Objective: This study aims to examine the effectiveness of digital TEKT strategies in (1) improving the capacity for evidence-based decision making by public health policy makers and practitioners, (2) changing public health policy or practice, and (3) changes in individual or population health outcomes. Methods: A search strategy was developed to identify randomized trials assessing the effectiveness of digital TEKT strategies in public health. Any primary research study with a randomized trial design was eligible. Searches for eligible studies were undertaken in multiple electronic bibliographic databases (Medical Literature Analysis and Retrieval System Online [MEDLINE], Excerpta Medica dataBASE [EMBASE], PsycINFO, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and Scopus) and the reference lists of included studies. A hand search of 2 journals (Implementation Science and Journal of Medical Internet Research) and a gray literature search were also conducted. Pairs of independent review authors screened studies, assessed the risk of bias, and extracted data from relevant studies. Results: Of the 6819 citations screened, 8 eligible randomized trials were included in the review. The studies examined the impact of digital TEKT strategies on health professionals, including nurses, child care health consultants, physiotherapists, primary health care workers, and public health practitioners. Overall, 5 of the interventions were web-training programs. The remaining 3 interventions included simulation games, access to digital resource materials and the use of tailored messaging, and a web-based registry. The findings suggest that digital TEKT interventions may be effective in improving the knowledge of public health professionals, relative to control, and may be as effective as a face-to-face KT approach. The effectiveness of digital TEKT strategies relative to a control or other digital KT interventions on measures of health professional self-efficacy to use evidence to enhance practice behavior or behavioral intention outcomes was mixed. The evidence regarding the effects on changes to health policy or practice following exposure to digital TEKT was mixed. No trials assessed the effects on individual or population-level health outcomes. Conclusions: This review is the first to synthesize the effectiveness of digital TEKT interventions in a public health setting. Despite its potential, relatively few trials have been undertaken to investigate the impacts of digital TEKT interventions. The findings suggest that although a digital TEKT intervention may improve knowledge, the effects of such interventions on other outcomes are equivocal. %M 32735231 %R 10.2196/17274 %U http://www.jmir.org/2020/7/e17274/ %U https://doi.org/10.2196/17274 %U http://www.ncbi.nlm.nih.gov/pubmed/32735231 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16924 %T Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review %A Brigden,Amberly %A Anderson,Emma %A Linney,Catherine %A Morris,Richard %A Parslow,Roxanne %A Serafimova,Teona %A Smith,Lucie %A Briggs,Emily %A Loades,Maria %A Crawley,Esther %+ Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, United Kingdom, 44 0117 42 83080, amberly.brigden@bristol.ac.uk %K mobile phone %K mHealth %K mobile health %K eHealth %K electronic health %K digital health %K behavior %K pediatrics %K chronic illness %K systematic review %D 2020 %7 31.7.2020 %9 Review %J J Med Internet Res %G English %X Background: The prevalence of chronic health conditions in childhood is increasing, and behavioral interventions can support the management of these conditions. Compared with face-to-face treatment, the use of digital interventions may be more cost-effective, appealing, and accessible, but there has been inadequate attention to their use with younger populations (children aged 5-12 years). Objective: This systematic review aims to (1) identify effective digital interventions, (2) report the characteristics of promising interventions, and (3) describe the user’s experience of the digital intervention. Methods: A total of 4 databases were searched (Excerpta Medica Database [EMBASE], PsycINFO, Medical Literature Analysis and Retrieval System Online [MEDLINE], and the Cochrane Library) between January 2014 and January 2019. The inclusion criteria for studies were as follows: (1) children aged between 5 and 12 years, (2) interventions for behavior change, (3) randomized controlled trials, (4) digital interventions, and (5) chronic health conditions. Two researchers independently double reviewed papers to assess eligibility, extract data, and assess quality. Results: Searches run in the databases identified 2643 papers. We identified 17 eligible interventions. The most promising interventions (having a beneficial effect and low risk of bias) were 3 targeting overweight or obesity, using exergaming or social media, and 2 for anxiety, using web-based cognitive behavioral therapy (CBT). Characteristics of promising interventions included gaming features, therapist support, and parental involvement. Most were purely behavioral interventions (rather than CBT or third wave), typically using the behavior change techniques (BCTs) feedback and monitoring, shaping knowledge, repetition and substitution, and reward. Three papers included qualitative data on the user’s experience. We developed the following themes: parental involvement, connection with a health professional is important for engagement, technological affordances and barriers, and child-centered design. Conclusions: Of the 17 eligible interventions, digital interventions for anxiety and overweight or obesity had the greatest promise. Using qualitative methods during digital intervention development and evaluation may lead to more meaningful, usable, feasible, and engaging interventions, especially for this underresearched younger population. The following characteristics could be considered when developing digital interventions for younger children: involvement of parents, gaming features, additional therapist support, behavioral (rather than cognitive) approaches, and particular BCTs (feedback and monitoring, shaping knowledge, repetition and substitution, and reward). This review suggests a model for improving the conceptualization and reporting of behavioral interventions involving children and parents. %M 32735227 %R 10.2196/16924 %U http://www.jmir.org/2020/7/e16924/ %U https://doi.org/10.2196/16924 %U http://www.ncbi.nlm.nih.gov/pubmed/32735227 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17707 %T Artificial Intelligence and Health Technology Assessment: Anticipating a New Level of Complexity %A Alami,Hassane %A Lehoux,Pascale %A Auclair,Yannick %A de Guise,Michèle %A Gagnon,Marie-Pierre %A Shaw,James %A Roy,Denis %A Fleet,Richard %A Ag Ahmed,Mohamed Ali %A Fortin,Jean-Paul %+ Institut national d'excellence en santé et services sociaux, 2021, Avenue Union, Montréal, QC, H3A 2S9, Canada, 1 514 873 2563 ext 24404, hassane.alami@umontreal.ca %K artificial intelligence %K health technology assessment %K eHealth %K health care %K medical device %K patient %K health services %D 2020 %7 7.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Artificial intelligence (AI) is seen as a strategic lever to improve access, quality, and efficiency of care and services and to build learning and value-based health systems. Many studies have examined the technical performance of AI within an experimental context. These studies provide limited insights into the issues that its use in a real-world context of care and services raises. To help decision makers address these issues in a systemic and holistic manner, this viewpoint paper relies on the health technology assessment core model to contrast the expectations of the health sector toward the use of AI with the risks that should be mitigated for its responsible deployment. The analysis adopts the perspective of payers (ie, health system organizations and agencies) because of their central role in regulating, financing, and reimbursing novel technologies. This paper suggests that AI-based systems should be seen as a health system transformation lever, rather than a discrete set of technological devices. Their use could bring significant changes and impacts at several levels: technological, clinical, human and cognitive (patient and clinician), professional and organizational, economic, legal, and ethical. The assessment of AI’s value proposition should thus go beyond technical performance and cost logic by performing a holistic analysis of its value in a real-world context of care and services. To guide AI development, generate knowledge, and draw lessons that can be translated into action, the right political, regulatory, organizational, clinical, and technological conditions for innovation should be created as a first step. %M 32406850 %R 10.2196/17707 %U https://www.jmir.org/2020/7/e17707 %U https://doi.org/10.2196/17707 %U http://www.ncbi.nlm.nih.gov/pubmed/32406850 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17199 %T Blockchain in Health Care: Hope or Hype? %A El-Gazzar,Rania %A Stendal,Karen %+ University of South-Eastern Norway, Bredalsveien 14, Hønefoss, 3511, Norway, 47 31009151, Rania.El-gazzar@usn.no %K blockchain %K health care %K innovation %K security %K implications %D 2020 %7 10.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X There has been an increasing interest in blockchain technology from the health care sector in the last couple of years. The value proposition for using blockchain technology in the health care sector is to share sensitive patient data among health care entities securely and to empower patients. Blockchain technology allows patients to have an active role in developing and updating their own patient data. However, is blockchain technology really the silver bullet it seems to be? With this paper, we aim to understand the benefits and challenges of blockchain technology in the health care sector. We discuss innovation and security implications concerning blockchain technology in health care. Furthermore, we show that there is a need for more use cases to ensure the secure sharing of data within the health care sector. In our opinion, blockchain technology will not solve the issues encountered by the health care sector; in fact, it may raise more issues than it will solve. %M 32673219 %R 10.2196/17199 %U http://www.jmir.org/2020/7/e17199/ %U https://doi.org/10.2196/17199 %U http://www.ncbi.nlm.nih.gov/pubmed/32673219 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16916 %T The Tango of Problem Formulation: A Patient’s/Researcher’s Reflection on an Action Design Research Journey %A Twomey,Michael B %A Sammon,David %A Nagle,Tadhg %+ Business Information Systems, Cork University Business School, University College Cork, College Road, Cork, Ireland, 353 021 4902136, michael.twomey@ucc.ie %K action design research %K patient %K reflection %K problem formulation %K checklist %K cystic fibrosis %D 2020 %7 14.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X This paper reports on the reflection of the lead researcher, a 48-year-old patient with cystic fibrosis (CF), and aims to portray his real-life experience of a 10-month action design research (ADR) project. Playing a dual role, as both a patient and researcher, the lead researcher reflects deeply on his ADR experience with particular emphasis on the problem formulation stage of creating a simple yet impactful checklist to aid memory recall of CF patients or caregivers during a medical appointment. Using Driscoll’s model of reflection, a real-life unsanitized ADR experience is carefully imparted via a series of 4 vignettes, including 4 key learnings, which highlight the connection between a meticulous considered approach to problem formulation and truly effective outcomes. By providing this rich account of problem formulation within ADR, it is hoped that this reflection will help researchers to better understand the complexity of problem formulation in design-oriented research; to avoid making assumptions and becoming fixated on solutions; and to move instead to an end point where several possible ways of examining a problem have been considered, explored, and understood—an end point where successful end results are reached through grit and determination. This paper advocates for the inclusion and portrayal of the actual realities or ups and downs of this dynamic and evolving stage of ADR, capturing the often-tacit knowledge of problem formulation and begetting a sense of realism and humanity to ADR serving as knowledge contributions in their own right. The lead researcher is the patient and researcher in this ADR project. This is my story! %M 32285802 %R 10.2196/16916 %U https://www.jmir.org/2020/7/e16916 %U https://doi.org/10.2196/16916 %U http://www.ncbi.nlm.nih.gov/pubmed/32285802 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18225 %T Codeveloping a Virtual Patient Simulation to Foster Nurses’ Relational Skills Consistent With Motivational Interviewing: A Situation of Antiretroviral Therapy Nonadherence %A Rouleau,Geneviève %A Pelletier,Jérôme %A Côté,José %A Gagnon,Marie-Pierre %A Martel-Laferrière,Valérie %A Lévesque,Rock %A , %A Fontaine,Guillaume %+ Research Chair in Innovative Nursing Practices, 850 rue St-Denis, Pavillon S, Door S01-110, Montréal, QC, H2X 0A9, Canada, 1 514 890 8000, genevieve.rouleau.chum@ssss.gouv.qc.ca %K motivational interviewing %K HIV %K nurses %K education, continuing %K virtual patient %K simulation %K nurse-patient relations %K communication %D 2020 %7 15.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Background: Although helping people living with HIV manage their antiretroviral therapy is a core competency of HIV nursing care, no educational intervention has sought to strengthen this competency. Thus, we codeveloped a simulation of a virtual patient (VP) having difficulty adhering to treatment to foster the relational skills that nurses require in such situations. Objective: This viewpoint paper aims to describe the codevelopment process and the content of VP simulation, as well as the challenges encountered and the strategies used to overcome them. Methods: We use a collaborative and iterative approach to develop the simulation based on qualitative evidence, theoretical approaches (strengths-based nursing, motivational interviewing [MI], and adult learning theories), and expert recommendations. We carried out 2 main phases: (1) planning the simulation development and (2) designing the simulation content, sequence, and format. We created the script as if we were writing a choose-your-own-adventure book. All relational skills (behavior change counseling techniques derived from MI) were integrated into a nurse-patient dialogue. The logic of the simulation is as follows: if the nurse uses techniques consistent with MI (eg, open-ended questions, summarizing), a dialogue is opened up with the VP. If the nurse uses relational skills inconsistent with MI (eg, providing advice without asking for permission), the VP will react accordingly (eg, defensively). Learners have opportunities to assess and reflect on their interventions with the help of quizzes and feedback loops. Results: Two main challenges are discussed. The most salient challenge was related to the second phase of the VP simulation development. The first was to start the project with divergent conceptions of how to approach the VP simulation—the simulation company’s perspective of a procedural-type approach versus the clinical team’s vision of a narrative approach. As a broad strategy, we came to a mutual understanding to develop a narrative-type VP simulation. It meshed with our conception of a nurse-patient relationship, the values of strengths-based nursing (a collaborative nurse-patient relationship), and the MI’s counseling style. The second challenge was the complexity in designing realistic relational skills in preprogrammed and simulated nurse-patient dialogue while preserving an immersive learning experience. As a broad strategy, we created a collaborative and work-in-progress writing template as a shared working tool. Conclusions: Our experience may be helpful to anyone looking for practical cues and guidance in developing narrative VP simulations. As relational skills are used by all nurses—from novices to experts—and other health care practitioners, focusing on this clinical behavior is a good way to ensure the simulation’s adaptability, sustainability, and efficiency. %M 32672679 %R 10.2196/18225 %U http://www.jmir.org/2020/7/e18225/ %U https://doi.org/10.2196/18225 %U http://www.ncbi.nlm.nih.gov/pubmed/32672679 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19667 %T Unmuting Medical Students’ Education: Utilizing Telemedicine During the COVID-19 Pandemic and Beyond %A Iancu,Ariella Magen %A Kemp,Michael Thomas %A Alam,Hasan Badre %+ Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, United States, 1 734 936 5823, alamh@med.umich.edu %K telemedicine %K medical education %K medical school %K COVID-19 %K education, medical, undergraduate %K curriculum %D 2020 %7 20.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Due to the coronavirus disease (COVID-19) pandemic, medical schools have paused traditional clerkships, eliminating direct patient encounters from medical students’ education for the immediate future. Telemedicine offers opportunities in a variety of specialties that can augment student education during this time. The projected growth of telemedicine necessitates that students learn new skills to be effective providers. In this viewpoint, we delineate specific telehealth opportunities that teach core competencies for patient care, while also teaching telemedicine-specific skills. Schools can further augment student education through a variety of telemedicine initiatives across multiple medical fields. The explosion of telemedicine programs due to the pandemic can be a catalyst for schools to integrate telemedicine into their current curricula. The depth and variety of telemedicine opportunities allow schools to continue providing high-quality medical education while maintaining social distancing policies. %M 32614776 %R 10.2196/19667 %U http://www.jmir.org/2020/7/e19667/ %U https://doi.org/10.2196/19667 %U http://www.ncbi.nlm.nih.gov/pubmed/32614776 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e20469 %T The Story of #GetMePPE and GetUsPPE.org to Mobilize Health Care Response to COVID-19 : Rapidly Deploying Digital Tools for Better Health Care %A He,Shuhan %A Ojo,Ayotomiwa %A Beckman,Adam L %A Gondi,Suhas %A Ranney,Megan %A Betz,Marian %A Faust,Jeremy S %A Choo,Esther %A Kass,Dara %A Raja,Ali S %+ Center for Innovation in Digital HealthCare, Massachusetts General Hospital, 50 Staniford street, suite 750, Boston, MA, 02114, United States, 1 8477074695, She8@partners.org %K digital health %K getusppe %K getmeppe %K COVID-19 %K personal protective equipment %K protection %K Twitter %K pandemic %K health care worker %D 2020 %7 20.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Physicians, nurses, and other health care providers initiated the #GetMePPE movement on Twitter to spread awareness of the shortage of personal protective equipment (PPE) during the coronavirus disease (COVID-19) pandemic. Dwindling supplies, such as face masks, gowns and goggles, and inadequate production to meet increasing demand have placed health care workers and patients at risk. The momentum of the #GetMePPE Twitter hashtag resulted in the creation of a petition to urge public officials to address the PPE shortage through increased funding and production. Simultaneously, the GetUsPPE.org website was launched through the collaboration of physicians and software engineers to develop a digital platform for the donation, request, and distribution of multi-modal sources of PPE. GetUsPPE.org and #GetMePPE were merged in an attempt to combine public engagement and advocacy on social media with the coordination of PPE donation and distribution. Within 10 days, over 1800 hospitals and PPE suppliers were registered in a database that enabled the rapid coordination and distribution of scarce and in-demand materials. One month after its launch, the organization had distributed hundreds of thousands of PPE items and had built a database of over 6000 PPE requesters. The call for action on social media and the rapid development of this digital tool created a productive channel for the public to contribute to the health care response to COVID-19 in meaningful ways. #GetMePPE and GetUsPPE.org were able to mobilize individuals and organizations outside of the health care system to address the unmet needs of the medical community. The success of GetUsPPE.org demonstrates the potential of digital tools as a platform for larger health care institutions to rapidly address urgent issues in health care. In this paper, we outline this process and discuss key factors determining success. %M 32530813 %R 10.2196/20469 %U https://www.jmir.org/2020/7/e20469 %U https://doi.org/10.2196/20469 %U http://www.ncbi.nlm.nih.gov/pubmed/32530813 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19916 %T Online Antenatal Care During the COVID-19 Pandemic: Opportunities and Challenges %A Wu,Huailiang %A Sun,Weiwei %A Huang,Xinyu %A Yu,Shinning %A Wang,Hao %A Bi,Xiaoyu %A Sheng,Jie %A Chen,Sihan %A Akinwunmi,Babatunde %A Zhang,Casper J P %A Ming,Wai-Kit %+ Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No 602 Huangpu Avenue West, Tianhe District, Guangzhou, 510000, China, 86 14715485116, wkming@connect.hku.hk %K coronavirus disease %K COVID-19 %K SARS-CoV-2 %K online prenatal education %K pregnancy %K online education %K antenatal %K telehealth %K convenience %K inequality %D 2020 %7 22.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X People across the world have been greatly affected by the ongoing coronavirus disease (COVID-19) pandemic. The high infection risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in hospitals is particularly problematic for recently delivered mothers and currently pregnant women who require professional antenatal care. Online antenatal care would be a preferable alternative for these women since it can provide pregnancy-related information and remote clinic consultations. In addition, online antenatal care may help to provide relatively economical medical services and diminish health care inequality due to its convenience and cost-effectiveness, especially in developing countries or regions. However, some pregnant women will doubt the reliability of such online information. Therefore, it is important to ensure the quality and safety of online services and establish a stable, mutual trust between the pregnant women, the obstetric care providers and the technology vis-a-vis the online programs. Here, we report how the COVID-19 pandemic brings not only opportunities for the development and popularization of online antenatal care programs but also challenges. %M 32658860 %R 10.2196/19916 %U http://www.jmir.org/2020/7/e19916/ %U https://doi.org/10.2196/19916 %U http://www.ncbi.nlm.nih.gov/pubmed/32658860 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14958 %T An Integrative Model for the Effectiveness of Biofeedback Interventions for Anxiety Regulation: Viewpoint %A Weerdmeester,Joanneke %A van Rooij,Marieke MJW %A Engels,Rutger CME %A Granic,Isabela %+ Behavioural Science Institute, Radboud University, Montessorilaan 3, Nijmegen, 6525 HR, Netherlands, 31 243612076, j.weerdmeester@psych.ru.nl %K biofeedback %K neurofeedback %K anxiety %K appraisal %K mechanisms %K mental health %K eHealth %K video games %K wearable technology %K review %K mobile phone %D 2020 %7 23.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Biofeedback has shown to be a promising tool for the treatment of anxiety; however, several theoretical as well as practical limitations have prevented widespread adaptation until now. With current technological advances and the increasing interest in the use of self-monitoring technology to improve mental health, we argue that this is an ideal time to launch a new wave of biofeedback training. In this viewpoint paper, we reflect on the current state of biofeedback training, including the more traditional techniques and mechanisms that have been thought to explain the effectiveness of biofeedback such as the integration of operant learning and meditation techniques, and the changes in interoceptive awareness and physiology. Subsequently, we propose an integrative model that includes a set of cognitive appraisals as potential determinants of adaptive trajectories within biofeedback training such as growth mindset, self-efficacy, locus of control, and threat-challenge appraisals. Finally, we present a set of detailed guidelines based on the integration of our model with the mechanics and mechanisms offered by emerging interactive technology to encourage a new phase of research and implementation using biofeedback. There is a great deal of promise for future biofeedback interventions that harness the power of wearables and video games, and that adopt a user-centered approach to help people regulate their anxiety in a way that feels engaging, personal, and meaningful. %M 32706654 %R 10.2196/14958 %U https://www.jmir.org/2020/7/e14958 %U https://doi.org/10.2196/14958 %U http://www.ncbi.nlm.nih.gov/pubmed/32706654 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17493 %T Using Digital Technology to Reduce the Prevalence of Mental Health Disorders in Populations: Time for a New Approach %A Taylor,C Barr %A Ruzek,Josef I %A Fitzsimmons-Craft,Ellen E %A Sadeh-Sharvit,Shiri %A Topooco,Naira %A Weissman,Ruth Striegel %A Eisenberg,Daniel %A Mohr,David %A Graham,Andrea %A Jacobi,Corinna %A Oldenburg,Brian %+ Stanford University, Palo Alto University, 850 Esplanada Way, Stanford, CA, 94305, United States, 1 4159871810, btaylor@stanford.edu %K internet %K mental health, interventions %K outcome %K prevalence %D 2020 %7 24.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Digital technology, which includes the collection, analysis, and use of data from a variety of digital devices, has the potential to reduce the prevalence of disorders and improve mental health in populations. Among the many advantages of digital technology is that it allows preventive and clinical interventions, both of which are needed to reduce the prevalence of mental health disorders, to be feasibly integrated into health care and community delivery systems and delivered at scale. However, the use of digital technology also presents several challenges, including how systems can manage and implement interventions in a rapidly changing digital environment and handle critical issues that affect population-wide outcomes, including reaching the targeted population, obtaining meaningful levels of uptake and use of interventions, and achieving significant outcomes. We describe a possible solution, which is to have an outcome optimization team that focuses on the dynamic use of data to adapt interventions for populations, while at the same time, addressing the complex relationships among reach, uptake, use, and outcome. We use the example of eating disorders in young people to illustrate how this solution could be implemented at scale. We also discuss system, practitioner-related, and other issues related to the adaptation of such an approach. Digital technology has great potential for facilitating the reduction of mental illness rates in populations. However, achieving this goal will require the implementation of new approaches. As a solution, we argue for the need to create outcome optimization teams, tasked with integrating data from various sources and using advanced data analytics and new designs to develop interventions/strategies to increase reach, uptake, use/engagement, and outcomes for both preventive and treatment interventions. %M 32706665 %R 10.2196/17493 %U https://www.jmir.org/2020/7/e17493 %U https://doi.org/10.2196/17493 %U http://www.ncbi.nlm.nih.gov/pubmed/32706665 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16337 %T Social Medical Capital: How Patients and Caregivers Can Benefit From Online Social Interactions %A Panzarasa,Pietro %A Griffiths,Christopher J %A Sastry,Nishanth %A De Simoni,Anna %+ School of Business and Management, Queen Mary University of London, Mile End Road, London, E1 4NS, United Kingdom, 44 (0)20 7882 6984, p.panzarasa@qmul.ac.uk %K online health communities %K self-care %K social networks %K social capital %K open and closed structures %K social cohesion %K brokerage %D 2020 %7 28.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X The rapid growth of online health communities and the increasing availability of relational data from social media provide invaluable opportunities for using network science and big data analytics to better understand how patients and caregivers can benefit from online conversations. Here, we outline a new network-based theory of social medical capital that will open up new avenues for conducting large-scale network studies of online health communities and devising effective policy interventions aimed at improving patients’ self-care and health. %M 32720910 %R 10.2196/16337 %U http://www.jmir.org/2020/7/e16337/ %U https://doi.org/10.2196/16337 %U http://www.ncbi.nlm.nih.gov/pubmed/32720910 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18087 %T Bringing Code to Data: Do Not Forget Governance %A Suver,Christine %A Thorogood,Adrian %A Doerr,Megan %A Wilbanks,John %A Knoppers,Bartha %+ Sage Bionetworks, 2901 Third Avenue, Suite 330, Seattle, WA, 98121, United States, 1 206 928 8242, cfsuver@gmail.com %K data management %K privacy %K ethics, research %K data science %K machine learning %D 2020 %7 28.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Developing or independently evaluating algorithms in biomedical research is difficult because of restrictions on access to clinical data. Access is restricted because of privacy concerns, the proprietary treatment of data by institutions (fueled in part by the cost of data hosting, curation, and distribution), concerns over misuse, and the complexities of applicable regulatory frameworks. The use of cloud technology and services can address many of the barriers to data sharing. For example, researchers can access data in high performance, secure, and auditable cloud computing environments without the need for copying or downloading. An alternative path to accessing data sets requiring additional protection is the model-to-data approach. In model-to-data, researchers submit algorithms to run on secure data sets that remain hidden. Model-to-data is designed to enhance security and local control while enabling communities of researchers to generate new knowledge from sequestered data. Model-to-data has not yet been widely implemented, but pilots have demonstrated its utility when technical or legal constraints preclude other methods of sharing. We argue that model-to-data can make a valuable addition to our data sharing arsenal, with 2 caveats. First, model-to-data should only be adopted where necessary to supplement rather than replace existing data-sharing approaches given that it requires significant resource commitments from data stewards and limits scientific freedom, reproducibility, and scalability. Second, although model-to-data reduces concerns over data privacy and loss of local control when sharing clinical data, it is not an ethical panacea. Data stewards will remain hesitant to adopt model-to-data approaches without guidance on how to do so responsibly. To address this gap, we explored how commitments to open science, reproducibility, security, respect for data subjects, and research ethics oversight must be re-evaluated in a model-to-data context. %M 32540846 %R 10.2196/18087 %U http://www.jmir.org/2020/7/e18087/ %U https://doi.org/10.2196/18087 %U http://www.ncbi.nlm.nih.gov/pubmed/32540846 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17987 %T Seeking Meaningful Innovation: Lessons Learned Developing, Evaluating, and Implementing the Electronic Patient-Reported Outcome Tool %A Steele Gray,Carolyn %+ Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 1 Bridgepoint Drive, Toronto, ON, M4M 2B5, Canada, 1 4164618252 ext 2908, Carolyn.SteeleGray@sinaihealth.ca %K digital health %K implementation %K meaningfulness %D 2020 %7 29.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Digital health solutions, in particular information communication technologies, often experience implementation failures leading to slower adoption than expected. This implementation challenge has spurred the development of frameworks to help navigate this uncertain and messy process. These frameworks point to environmental, organizational, individual, and technological factors that can drive or hinder implementation, with some in the field suggesting that perceived value may play a pivotal role. However, the concept of value can have varying meanings and be challenging to operationalize as a means to support implementation. Attending to philosophical and psychological meaningfulness for users and organizations in which technologies are adopted may offer a useful lens, by linking perceived value to individual behavior changes often required as part of implementing digital health technologies. Lessons learned from developing, evaluating, and implementing the electronic Patient-Reported Outcome (ePRO) tool demonstrate how qualitative methods can be used to uncover meaningfulness. By drawing from this example and other similar studies, this viewpoint offers suggestions on how future inquiry could deepen an understanding of meaningful innovation to help drive the implementation of digital health technologies. %M 32723725 %R 10.2196/17987 %U http://www.jmir.org/2020/7/e17987/ %U https://doi.org/10.2196/17987 %U http://www.ncbi.nlm.nih.gov/pubmed/32723725 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15024 %T Predictors of Self-Determined Module Choice in a Web-Based Computer-Tailored Diet and Physical Activity Intervention: Secondary Analysis of Data From a Randomized Controlled Trial %A Coumans,Juul M J %A Bolman,Catherine A W %A Oenema,Anke %A Lechner,Lilian %+ Department of Health Psychology, Faculty of Psychology, Open University of the Netherlands, Valkenburgerweg 177, Heerlen , Netherlands, 31 45 576 2635, juul.coumans@ou.nl %K eHealth %K computer-tailoring %K self-determination theory %K multiple health behaviors %K lifestyle promotion %K module choice %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Tailoring an online intervention to participant preferences (eg, by giving participants a choice which modules to follow) may increase engagement in the intervention, motivation for behavioral change, and possibly intervention effects. So far, little is known about what characteristics predict these module choices. Filling this knowledge gap is useful for optimizing program engagement. Objective: We investigated participant choice for a dietary and/or physical activity (PA) promotion module in our web-based computer-tailored intervention based on self-determination theory (SDT) and motivational interviewing (MI). Furthermore, we investigated which demographic characteristics, current behavior, psychosocial constructs and constructs from SDT and MI, and program-related variables such as advice on which module to follow were associated with these choices. Methods: Observational data were used from the randomized controlled trial MyLifestyleCoach of participants who were randomized into the intervention condition, completed the baseline questionnaire, and made a module choice in the opening session of the intervention. Here, they received advice on their own dietary and PA behavior. At the session’s end, they chose which lifestyle modules they would like to follow (both, diet, PA, or no module). Measurements included demographic information; self-reported diet and PA; and several psychosocial, SDT, and MI constructs. In total, data from 619 Dutch adults (59.6% women; mean age was 51.9 [SD 13.5] years) were analyzed. A stepwise multinomial logistic regression analysis was conducted to investigate which characteristics are related to module choice; the diet module served as reference category as almost everyone was advised to follow this module. Results: Of this sample, 54.8% (339/619) chose to do both the diet and PA module, 25.4% (157/619) chose to follow the diet module, 17.8% (110/619) preferred to follow no module, and 2.1% (13/619) chose to do the PA module only. Furthermore, it was found that older people, those who consumed more fruit, and those who scored lower on importance to change their current diet were more likely to choose no module compared to the diet module. People who had more motivation to change their current PA and those who received strong advice compared with slight advice to follow the diet module were more likely to choose both modules compared with the diet module only. Conclusions: The results show that more than half of the sample was interested in following both the diet and PA module in this online lifestyle intervention. Several characteristics were found to be related to module choice. A future challenge is to examine how this knowledge can be used to improve future interventions, such as tailoring (messages or content) on specific groups or examining where and how MI could be used to motivate people to make a certain module choice. Trial Registration: Netherlands Trial Register NL7333; https://www.trialregister.nl/trial/7333 %M 32706659 %R 10.2196/15024 %U http://www.jmir.org/2020/7/e15024/ %U https://doi.org/10.2196/15024 %U http://www.ncbi.nlm.nih.gov/pubmed/32706659 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19734 %T Use of an Unguided, Web-Based Distress Self-Management Program After Breast Cancer Diagnosis: Sub-Analysis of CaringGuidance Pilot Study %A Lally,Robin M %A Kupzyk,Kevin %A Gallo,Steve %A Berry,Donna %+ College of Nursing, Fred & Pamela Buffett Cancer Center, University of Nebraska Medical Center, UNMC College of Nursing Center For Nursing Science, 985330 Nebraska Medical Center, Omaha, NE, 68198-0001, United States, 1 4025595464, robin.lally@unmc.edu %K eHealth %K psychoeducation %K supportive oncology %K distress %K self-management %K oncology %K breast cancer %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Unguided, web-based psychoeducational interventions are gaining interest as a way to reach patients while reducing pressure on clinical resources. However, there has been little research on how patients with cancer use these interventions. Objective: The objective of this analysis was to evaluate how women newly diagnosed with breast cancer used the unguided web-based, psychoeducational distress self-management program CaringGuidance After Breast Cancer Diagnosis while enrolled in a pilot feasibility study. Methods: Women with stage 0 to II breast cancer diagnosed within the prior three months were recruited from clinics primarily in the Northeastern United States for participation in a 12-week pilot study of CaringGuidance plus usual care versus usual care alone. Usage prompts included sets of emails sent weekly for 12 weeks; standardized congratulatory emails after every two hours of program use, and informative emails for each cognitive-behavioral exercise. Individual user activity on the site was automatically tracked by an analytics system and recorded directly in the CaringGuidance database. Results: Complete usage data were available for 54 subjects. Ninety-eight percent of the intervention group logged into CaringGuidance independently at least once. Thirty-eight (70%) logged in during all three months, 15 (28%) were intermittent users, and one (2%) was a non-user. Users (n=53) averaged 15.6 (SD 9.85) logins. Mean logins were greatest in month 1 (7.26, SD 4.02) and declined in months 2 (4.32, SD 3.66) and month 3 (4.02, SD 3.82). Eleven (21%) used CaringGuidance with both the frequency and activity level intended at study outset, 9 (17%) exceeded intended frequency and activity (high-high users), and 10 (19%) were below expected usage on both login frequency and activity (low-low users). Low-low users and high-high users differed significantly (P<.001) in the total number of views and unique views of all program components. Change in depressive symptoms and the number of sessions (r=.351) and logins (r=.348) between study months 1 and 2 were significantly correlated (P=.018, .019). Higher baseline distress was associated with more unique views of program resources (r=.281, P=.043). Change in intrusive/avoidant thoughts from baseline to month 3, and the number of users’ unique exercise views were negatively correlated (r=–.319, P=.035) so that more unique exercise views, equated with greater decline in intrusive/avoidant thoughts from baseline to month 3. Conclusions: These findings favor the hypothesis that the key ingredient is not the amount of program use, but each user’s self-selected activity within the program. More research is needed on the ideal ways to maintain use, and capture and define engagement and enactment of behaviors by people with cancer accessing unguided, self-management web-based programs. %M 32628117 %R 10.2196/19734 %U https://www.jmir.org/2020/7/e19734 %U https://doi.org/10.2196/19734 %U http://www.ncbi.nlm.nih.gov/pubmed/32628117 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16136 %T Adherence to Established Treatment Guidelines Among Unguided Digital Interventions for Depression: Quality Evaluation of 28 Web-Based Programs and Mobile Apps %A Bubolz,Stefan %A Mayer,Gwendolyn %A Gronewold,Nadine %A Hilbel,Thomas %A Schultz,Jobst-Hendrik %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 6221 56 38176, nadine.gronewold@med.uni-heidelberg.de %K web-based interventions %K depression %K mHealth %K mental health %K telemedicine %K mobile phone %K eHealth %K electronic mental health %K online therapy %D 2020 %7 13.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based interventions for depression have been widely tested for usability and functioning. However, the few studies that have addressed the therapeutic quality of these interventions have mainly focused on general aspects without consideration of specific quality factors related to particular treatment components. Clinicians and scientists are calling for standardized assessment criteria for web-based interventions to enable effective and trustworthy patient care. Therefore, an extensive evaluation of web-based interventions at the level of individual treatment components based on therapeutic guidelines and manuals is needed. Objective: The objective of this study was to evaluate the quality of unguided web-based interventions for depression at the level of individual treatment components based on their adherence to current gold-standard treatment guidelines and manuals. Methods: A comprehensive online search of popular app stores and search engines in January 2018 revealed 11 desktop programs and 17 smartphone apps that met the inclusion criteria. Programs and apps were included if they were available for German users, interactive, unguided, and targeted toward depression. All programs and apps were tested by three independent researchers following a standardized procedure with a predefined symptom trajectory. During the testing, all web-based interventions were rated with a standardized list of criteria based on treatment guidelines and manuals for depression. Results: Overall interrater reliability for all raters was substantial with an intraclass correlation coefficient of 0.73 and Gwet AC1 value of 0.80. The main features of web-based interventions included mood tracking (24/28, 86%), psychoeducation (21/28, 75%), cognitive restructuring (21/28, 75%), crisis management (20/28, 71%), behavioral activation (19/29, 68%), and relaxation training (18/28, 64%). Overall, therapeutic meaningfulness was rated higher for desktop programs (mean 4.13, SD 1.17) than for smartphone apps (mean 2.92, SD 1.46). Conclusions: Although many exercises from manuals are included in web-based interventions, the necessary therapeutic depth of the interventions is often not reached, and risk management is frequently lacking. There is a need for further research targeting general principles for the development and evaluation of therapeutically sound web-based interventions for depression. %M 32673221 %R 10.2196/16136 %U https://www.jmir.org/2020/7/e16136 %U https://doi.org/10.2196/16136 %U http://www.ncbi.nlm.nih.gov/pubmed/32673221 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17031 %T Effects of the e-Motivate4Change Program on Metabolic Syndrome in Young Adults Using Health Apps and Wearable Devices: Quasi-Experimental Study %A Lee,Ji-Soo %A Kang,Min-Ah %A Lee,Soo-Kyoung %+ Keimyung University, 1095 Dalgubeol-daero, Dalseo-Gu, Daegu, 42601, Republic of Korea, 82 53 258 7665, soo1005s@gmail.com %K metabolic syndrome %K telemedicine %K mobile apps %K preventive care %K wearable electronic devices %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The health behaviors of young adults lag behind those of other age groups, and active health management is needed to improve health behaviors and prevent chronic diseases. In addition, developing good lifestyle habits earlier in life could reduce the risk of metabolic syndrome (MetS) later on. Objective: The aim of this study is to investigate the effects of the e-Motivate4Change program, for which health apps and wearable devices were selected based on user needs. The program was developed for the prevention and management of MetS in young adults. Methods: This experimental study used a nonequivalent control group. In total, 59 students from 2 universities in Daegu, Korea participated in the study (experimental group n=30; control group n=29). Data were collected over 4 months, from June 1 to September 30, 2018. The experimental group received a 12-week e-Motivate4Change program intervention, and the control group received MetS education and booklets without the e-Motivate4Change program intervention. Results: After the program, the experimental group had significantly higher scores for health-related lifestyle (t=3.86; P<.001) and self-efficacy (t=6.00; P<.001) than did the control group. Concerning BMI, there were significant effects by group (F=1.01; P<.001) and for the group × time interaction (F=4.71; P=.034). Concerning cholesterol, there were significant main effects for group (F=4.32; P=.042) and time (F=9.73; P<.001). Conclusions: The e-Motivate4Change program effectively improved participants’ health-related lifestyle scores and self-efficacy, and significantly reduced their BMI and cholesterol levels. The program can be used to identify and prevent MetS among young adults. %M 32729838 %R 10.2196/17031 %U http://www.jmir.org/2020/7/e17031/ %U https://doi.org/10.2196/17031 %U http://www.ncbi.nlm.nih.gov/pubmed/32729838 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14822 %T Dose-Response Relationship of a Web-Based Tailored Intervention Promoting Human Papillomavirus Vaccination: Process Evaluation of a Randomized Controlled Trial %A Pot,Mirjam %A Paulussen,Theo GWM %A Ruiter,Robert AC %A Mollema,Liesbeth %A Hofstra,Miranda %A Van Keulen,Hilde M %+ Child Health, Netherlands Organization for Applied Scientific Research (TNO), Schipholweg 77, Leiden, 2316ZL, Netherlands, 31 643234293, mirjampot90@gmail.com %K HPV vaccination %K web-based tailored intervention %K process evaluation %K intervention use %K dose-response relationship %K randomized controlled trial %K informed decision making %D 2020 %7 17.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the Netherlands, human papillomavirus (HPV) vaccination uptake remains low. To improve informed decision making (IDM) and HPV vaccination acceptability, we systematically developed an interactive, web-based tailored intervention to which mothers of Dutch girls were invited to participate. Objective: The aim of this study was to provide insight into the intervention’s working mechanisms by evaluating (1) program use, (2) program acceptability, and (3) the relationship of program use with program acceptability and intervention effects (ie, dose-response relationship). Methods: Only mothers from the intervention arm of a randomized controlled trial that assessed the effectiveness of the web-based, tailored intervention were included in this study. They were invited to visit the website of the web-based intervention between baseline (January 2015, just before access to the intervention) and follow up (March 2015, prior to the first HPV vaccination). Indicators for program use were time of website use (ie, duration of intervention exposure) and completeness (ie, proportion of all available web pages visited). HPV vaccination uptake registered by Praeventis was used as the primary outcome. Secondary outcomes were IDM, decisional conflict, and social-psychological determinants of HPV vaccination uptake. Results: Among the 3995 invited mothers, 2509 (62.80%) logged on to the website, 2239 of whom (89.24%) visited at least one page of the intervention components. On average, mothers spent 21.39 minutes (SD 12.41) on the website and completed 50.04% (SD 26.18%) of the website components. Participants rated the website 7.64 (SD 1.39) on a 10-point scale. Program acceptability was significantly associated with completeness (β=4.36, P<.001), but not with time of website use (β=–.07, P=.77). Intention-to-treat analysis (N=3995) showed a significant positive effect of completeness on all outcome measures (all P<.003; Bonferroni-corrected α=.05/15 factors), including on HPV vaccination uptake. Time of website use had a significant positive effect on all outcomes (all P<.003), except for uptake (P=.20), risk perception when not vaccinated (P=.14), subjective norms (P=.03), and habit (P=.01). Conclusions: Program use and acceptability of the intervention were adequate. Completeness was positively associated with acceptability. Furthermore, positive effects (ie, dose-response effects) were found for completeness and time of website use on the mothers’ IDM, decisional conflict, and almost all of the social-psychological determinants of HPV vaccination acceptability. In addition, the extent to which mothers completed the intervention had a positive impact on their daughters’ vaccination uptake. This indicates that the web-based, tailored intervention fits well with the mothers’ needs, and that completeness of use is essential for improving HPV vaccination uptake, acceptability, and IDM. Program use should therefore be promoted. Trial Registration: Netherlands Trial Register NTR4795; https://www.trialregister.nl/trial/4795 %M 32520718 %R 10.2196/14822 %U https://www.jmir.org/2020/7/e14822 %U https://doi.org/10.2196/14822 %U http://www.ncbi.nlm.nih.gov/pubmed/32520718 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15591 %T Implementation Strategies for Web-Based Apps for Screening: Scoping Review %A Ooi,Chor Yau %A Ng,Chirk Jenn %A Sales,Anne E %A Lim,Hooi Min %+ University of Malaya eHealth Initiative, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, , Kuala Lumpur, , Malaysia, 60 79492306, ngcj@um.edu.my %K internet %K mHealth %K eHealth %K mass screening %K implementation strategies %D 2020 %7 20.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Screening is an effective primary prevention strategy in health care, as it enables the early detection of diseases. However, the uptake of such screening remains low. Different delivery methods for screening have been developed and found to be effective in increasing the uptake of screening, including the use of web-based apps. Studies have shown that web-based apps for screening are effective in increasing the uptake of health screening among the general population. However, not much is known about the effective implementation of such web-based apps in the real-world setting. Implementation strategies are theory-based methods or techniques used to enhance the adoption, implementation, and sustainability of evidence-based interventions. Implementation strategies are important, as they allow us to understand how to implement an evidence-based intervention. Therefore, a scoping review to identify the various implementation strategies for web-based apps for screening is warranted. Objective: This scoping review aims to identify (1) strategies used to implement web-based apps for health screening, (2) frameworks used for implementing web-based apps for health screening, (3) outcome measures of implementation strategies, and (4) effective implementation strategies. Methods: This scoping review was conducted based on Arksey and O’Malley’s framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, International Standard Randomised Controlled Trial Number Registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Web of Science. This was followed by charting the data using a standardized form. Finally, we collated, summarized, and reported the results quantitatively and qualitatively based on the review objectives. Results: A total of 16,476 studies were retrieved, of which 5669 were duplicates. From a total of 10,807 studies, 10,784 studies were excluded based on their titles and abstracts. There were 23 full-text articles reviewed, and 4 articles were included in the final analysis. Many studies were excluded because they focused on the effectiveness and not on the implementation of web-based apps. Facilitation was the most cited implementation strategy used, followed by reminders, clinical champions, and educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity, and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings, and clinical champions. Conclusions: There is a dearth of literature on the implementation of web-based apps for health screening. Implementation strategies were developed without any reported use of implementation theories or frameworks in most studies. More research on the development and evaluation of web-based screening app implementations is needed. %M 32706655 %R 10.2196/15591 %U http://www.jmir.org/2020/7/e15591/ %U https://doi.org/10.2196/15591 %U http://www.ncbi.nlm.nih.gov/pubmed/32706655 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e13145 %T Internet-Based Self-Management Support After High-Altitude Climate Treatment for Severe Asthma: Randomized Controlled Trial %A Beerthuizen,Thijs %A Rijssenbeek-Nouwens,Lucia H %A van Koppen,Sophia M %A Khusial,Rishi J %A Snoeck-Stroband,Jiska B %A Sont,Jacob K %+ Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands, Leiden, 2300 RC, Netherlands, 31 71 5264578, j.k.sont@lumc.nl %K self-management %K pulmonary rehabilitation %K severe asthma %K quality of life %K asthma control %K internet %K monitoring %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In patients with severe asthma, high-altitude climate treatment has been shown to improve asthma control. However, asthma symptoms and limitations may increase after finishing inpatient rehabilitation programs and returning to sea level. Objective: We assessed the effectiveness of a patient-tailored, internet-based, self-management strategy in addition to usual care after finishing high-altitude climate treatment. Methods: We performed a randomized controlled trial with a 1-year follow-up in patients from a high-altitude asthma center in Davos, Switzerland. At the end of a 12-week multidisciplinary rehabilitation program, 62 adults with asthma were randomized to receive either internet-based self-management support in addition to usual care (n=33) or usual care only after discharge (n=29). The endpoints were changes in asthma-related quality of life according to the Asthma Quality of Life Questionnaire (AQLQ) (a higher score is better) and asthma control according to the Asthma Control Questionnaire (ACQ) (a lower score is better), with a minimally important difference of 0.5 points for both. Results: Asthma-related quality of life and asthma control declined over time in the usual care strategy group, whereas there was a slower decline in the internet-based strategy group. For both endpoints, mixed-model analysis showed a significant positive effect in favor of internet-based self-management during follow-up (mean AQLQ score difference 0.39, 95% CI 0.092-0.69; P=.01 and ACQ score difference −0.50, 95% CI −0.86 to −0.15; P=.006), which was prominent among patients with uncontrolled asthma at discharge (AQLQ score difference 0.59, 95% CI 0.19-0.99; P=.003 and ACQ score difference −0.73, 95% CI −1.18 to −0.28; P=.002). Conclusions: Internet-based self-management support was associated with a smaller decline in quality of life and asthma control as compared with usual care, especially in patients with lower asthma control, after completion of high-altitude climate treatment. Internet-based self-management support in adults with severe asthma seems feasible and effective to maintain quality of life and asthma control. Trial Registration: The trial is registered in the Netherlands Trial Register (NTR1995). %M 32706692 %R 10.2196/13145 %U https://www.jmir.org/2020/7/e13145 %U https://doi.org/10.2196/13145 %U http://www.ncbi.nlm.nih.gov/pubmed/32706692 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18584 %T Novel Stepped Care Approach to Provide Education and Exercise Therapy for Patellofemoral Pain: Feasibility Study %A De Oliveira Silva,Danilo %A Pazzinatto,Marcella F %A Crossley,Kay M %A Azevedo,Fabio M %A Barton,Christian J %+ La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Plenty Road & Kingsbury Drive, Bundoora VIC, Melbourne, 3086, Australia, 61 0426188766, danilo110190@hotmail.com %K pain %K internet %K knee %K rehabilitation %K eHealth %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patellofemoral pain (PFP) impairs joint- and health-related quality of life and may be associated with knee osteoarthritis. We developed a novel, 2-phase, stepped-care approach for PFP, combining (1) self-directed web-based education and exercise therapy with (2) physiotherapist-supported education and exercise therapy. Physiotherapy sessions can be provided using 2 different modalities: face-to-face and telerehabilitation. Objective: This study aims to (1) determine the feasibility of our stepped-care approach, (2) explore patient-reported outcomes following self-directed web-based education and exercise therapy in people with PFP (phase 1), and (3) estimate the differences in treatment effects between face-to-face and telerehabilitation to support further education and exercise therapy (phase 2) in those who had not completely recovered following self-directed care. Methods: Phase 1 involved 6 weeks of self-directed web-based education and exercise therapy. Phase 2 involved random allocation to a further 12 weeks of physiotherapist-led (up to 8 sessions) education and exercise therapy delivered face-to-face or via telerehabilitation to participants who did not rate themselves as completely recovered following phase 1. Feasibility indicators of process, adherence, and participant retention were collected as primary outcomes alongside patient-reported outcomes on Global Rating of Change and knee pain, disability, knee-related quality of life, pain catastrophism, kinesiophobia, and knee self-efficacy. All participants were assessed at baseline, 6 weeks, and 18 weeks. Results: A total of 71 participants were screened to identify 35 participants with PFP to enter the study. Overall, 100% (35/35) and 88% (31/35) of the participants were followed up with at 6 and 18 weeks, respectively. In phase 1 of the study, participants accessed the My Knee Cap website for an average of 6 (7.5) days and performed the exercises for an average of 2.5 (3.6) times per week. A total of 20% (7/35) of the participants reported that they had completely recovered at 6 weeks. Furthermore, 93% (26/28) of the participants who were followed up and had not completely recovered at 6 weeks agreed to be enrolled in phase 2. No statistically significant differences were found between the face-to-face and telerehabilitation groups for any outcome. The novel stepped-care approach was associated with marked improvement or complete recovery in 40% (14/35) of the participants following phase 1 and 71% (25/35) of the participants following phase 2. Conclusions: Self-directed web-based education and exercise therapy for people with PFP is feasible, as noted by the high rate of participant retention and home exercise adherence achieved in this study. Furthermore, 20% (7/35) of people reported complete recovery at 6 weeks. Both face-to-face and telerehabilitation physiotherapy should be considered for those continuing to seek care, as there is no difference in outcomes between these delivery modes. Determining the efficacy of the stepped-care model may help guide more efficient health care for PFP. %M 32706674 %R 10.2196/18584 %U http://www.jmir.org/2020/7/e18584/ %U https://doi.org/10.2196/18584 %U http://www.ncbi.nlm.nih.gov/pubmed/32706674 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15732 %T Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial %A Pihlaja,Satu %A Lahti,Jari %A Lipsanen,Jari Olavi %A Ritola,Ville %A Gummerus,Eero-Matti %A Stenberg,Jan-Henry %A Joffe,Grigori %+ Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Hospital District of Helsinki and Uusimaa, PO Box 590, Helsinki, 00029 HUS, Finland, 358 40 513 6500, Grigori.joffe@hus.fi %K internet CBT %K depression %K scheduled telephone support %K adherence %K routine clinical practice %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient. Objective: This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression. Methods: Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ≥14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)–measured depressive symptoms and time spent in treatment. Results: Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ. Conclusions: Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131. %M 32706658 %R 10.2196/15732 %U http://www.jmir.org/2020/7/e15732/ %U https://doi.org/10.2196/15732 %U http://www.ncbi.nlm.nih.gov/pubmed/32706658 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16380 %T Evaluation of a Blended Physical Activity Intervention for Older Adults: Mixed Methods Study %A Mehra,Sumit %A van den Helder,Jantine %A Visser,Bart %A Engelbert,Raoul H H %A Weijs,Peter J M %A Kröse,Ben J A %+ Applied Psychology, Faculty of Applied Social Sciences and Law, Amsterdam University of Applied Sciences, Wibautstraat 3b, Amsterdam, 1091 GH, Netherlands, 31 0621156956, s.mehra@hva.nl %K frail elderly %K aged %K activities of daily living %K exercise %K health behavior %K telemedicine %K mobile devices %K tablet computers %K usability testing %K evaluation %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity can prolong the ability of older adults to live independently. Home-based exercises can help achieve the recommended physical activity levels. A blended intervention was developed to support older adults in performing home-based exercises. A tablet and a personal coach were provided to facilitate the self-regulation of exercise behavior. Objective: In line with the Medical Research Council framework, this study aimed to carry out process evaluation of a blended intervention. The objectives were (1) to assess the long-term usability of the tablet adopted in the blended intervention and (2) to explore how the tablet, in conjunction with a personal coach, supported older adults in performing home-based exercises. Methods: The process evaluation was conducted with a mixed-methods approach. At baseline, older adults participating in the blended intervention were asked to fill out a questionnaire about their general experience with information and communication technology (ICT) devices and rate their own skill level. After 6 months, participants filled out the Usefulness, Satisfaction, and Ease of use (USE) questionnaire to assess the usefulness, satisfaction, and ease of use of the tablet. With a random selection of participants, in-depth interviews were held to explore how the tablet and coach supported the self-regulation. The interviews were double coded and analyzed with the directed content analysis method. Results: At baseline, 29% (65/224) of participants who started the intervention (mean age 72 years) filled out the ICT survey and 36% (37/103) of participants who used the tablet for 6 months (mean age 71 years) filled out the USE questionnaire. Furthermore, with 17% (18/103) of participants (mean age 73 years), follow-up interviews were held. The results of the baseline questionnaire showed that the large majority of participants already had experience with a tablet, used it regularly, and reported being skillful in operating ICT devices. After 6 months of use, the participants rated the usefulness, satisfaction, and ease of use of the tablet on average as 3.8, 4.2, and 4.1, respectively, on a 5-point scale. The analysis of the interviews showed that the participants felt that the tablet supported action planning, behavior execution, and self-monitoring. On the other hand, especially during the first few months, the personal coach added value during the goal setting, behavior execution, and evaluation phases of self-regulation. Conclusions: The results of the process evaluation showed that older adults who participated in the study were positive about the blended intervention that was designed to support them in performing home-based exercises. Participants reported that the tablet helped them to perform the exercises better, more frequently, and safely. It supported them in various phases of self-regulation. The availability of a personal coach was nevertheless crucial. To support physical activity in older adults, a blended approach is promising. %M 32459652 %R 10.2196/16380 %U http://www.jmir.org/2020/7/e16380/ %U https://doi.org/10.2196/16380 %U http://www.ncbi.nlm.nih.gov/pubmed/32459652 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17422 %T Evaluation of a Web-Based Self-Management Program for Patients With Cardiovascular Disease: Explorative Randomized Controlled Trial %A Engelen,Marscha M %A van Dulmen,Sandra %A Puijk-Hekman,Saskia %A Vermeulen,Hester %A Nijhuis-van der Sanden,Maria WG %A Bredie,Sebastian JH %A van Gaal,Betsie GI %+ IQ Healthcare, Radboud Institute for Health Sciences, Radboud university medical center, PO Box 9101, Nijmegen, Netherlands, 31 654272129, marscha.engelen@radboudumc.nl %K explorative randomized controlled trial %K cardiovascular diseases %K self-management %K eHealth support programs %K internet %K lifestyle %K nursing %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based self-management programs have the potential to support patients with cardiovascular disease (CVD) in their self-management (eg, by focusing on behavior change and improving physical activity). The intervention mapping framework was used to develop a web-based program called Vascular View. The Vascular View program contained 6 modules (coping with CVD, setting boundaries, lifestyle, healthy nutrition, being physically active, interaction with health professionals) aiming to increase self-management behavior by tailoring to the perceived problems and (support) needs of patients after CVD. Objective: The aim was to test the effectiveness of Vascular View before embarking on a full-scale randomized clinical trial (RCT) by evaluating the potential effectiveness and effect sizes of the Vascular View program and identifying outcome measures most likely to capture the potential benefits. Methods: An explorative RCT was performed. Both control and intervention groups received care as usual and, in addition, the intervention group received 12 months of access to a web-based self-management program. Assessment occurred at baseline, 6 months, and 12 months. Outcome measures included general patient-reported outcome measurements: Illness Perception Questionnaire (IPQ), Rand-36, Patient Activation Measure, and patient self-efficacy. Module-specific patient-reported outcome measurements were Beliefs about Medicines Questionnaire, International Physical Activity Questionnaire, Dutch Healthy Diet Index, Fagerström Test for Nicotine Dependence (FTND), Alcohol Use Disorders Identification Test, and Perceived Efficacy in Patient-Physician Interaction. Linear mixed models for repeated measures using intention-to-treat and per-protocol analysis were applied to study differences between the patients in the intervention and control groups. Floor and ceiling effects were explored to give insight into the outcome measures most likely to capture the potential benefits. Results: A total of 105 patients in the control group and 103 patients in the intervention group participated in the study. A positive direction of change between baseline and 12 months was shown for most outcome measurements in favor of the intervention group, of which 2 out of 10 outcomes showed a significant effect: attribution of cause of the disease to risk factors and immunity factors (IPQ) and dependency of nicotine (FTND). Floor and ceiling effects were seen in the IPQ, Rand-36, and the self-efficacy questionnaire. Conclusions: No conclusion for the efficacy of the Vascular View program or selection of outcome measurements can be taken yet. A process evaluation will be conducted to gain thorough insight into the working elements of the program, patient needs in eHealth, and the use of the program by patients. This can determine for whom web-based self-management programs will work and help to adapt the program. Trial Registration: Dutch Trial Register NTR5412; https://www.trialregister.nl/trial/5303 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.6352 %M 32706708 %R 10.2196/17422 %U http://www.jmir.org/2020/7/e17422/ %U https://doi.org/10.2196/17422 %U http://www.ncbi.nlm.nih.gov/pubmed/32706708 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14223 %T An mHealth Intervention (ReZone) to Help Young People Self-Manage Overwhelming Feelings: Cluster-Randomized Controlled Trial %A Edridge,Chloe %A Wolpert,Miranda %A Deighton,Jessica %A Edbrooke-Childs,Julian %+ Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 020 7443 2218, Chloe.edridge@annafreud.org %K cluster trial %K behavioral difficulties %K schools %K mHealth %K digital %K mental health %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health difficulties in young people are increasing, and there is a need for evidence on the effectiveness of digital interventions to increase opportunities for supporting mental health in young people. Such studies are complicated due to issues of implementation and adoption, outcome measurement, and appropriate study designs. Objective: The objective of this study was to examine the effectiveness of an mHealth intervention (ReZone) in reducing mental health difficulties in young people. Methods: The cluster-randomized controlled trial enrolled 409 participants aged 10-15 years, and classes were allocated to ReZone or management as usual. Self-reported questionnaires were completed at baseline and 3-month follow-up. Results: There were no significant differences between the ReZone condition and management as usual in the self-reported outcome measures. However, there were 3467 usage sessions, which corresponds to 16.9 times per student (total of 205 students) in classes allocated to ReZone. Conclusions: It is essential to publish studies that do not show significant differences, as these findings can still contribute to the literature, help in learning, and inform the direction of future work. The results reported in this paper could be due to a range of reasons, including whether ReZone has the scope to impact change or limitations related to the setting, context, and appropriateness of an RCT. The findings of this study suggest that ReZone was implemented and adopted. International Registered Report Identifier (IRRID): RR2-10.2196/resprot.7019 %M 32716299 %R 10.2196/14223 %U http://www.jmir.org/2020/7/e14223/ %U https://doi.org/10.2196/14223 %U http://www.ncbi.nlm.nih.gov/pubmed/32716299 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17673 %T Impact of an Electronic Health Service on Child Participation in Pediatric Oncology Care: Quasiexperimental Study %A Gilljam,Britt-Mari %A Nygren,Jens M %A Svedberg,Petra %A Arvidsson,Susann %+ School of Health and Welfare, Halmstad University, Box 823, Halmstad, 301 18, Sweden, 46 35 16 71 00, Britt-mari.gilljam@hh.se %K cancer %K child care %K communication %K eHealth %K patient participation %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: For children 6-12 years old, there is a shortage of electronic Health (eHealth) services that promote their participation in health care. Therefore, a digital communication tool, called Sisom, was developed to give children a voice in their health care. Children with long-term diseases want to be more involved in their health care and have the right to receive information, be listened to, express their opinions, and participate in decision making in health care. However, the outcomes of using Sisom in practice at pediatric oncology clinics have not been investigated. Objective: The aim of this study was to investigate children’s participation during appointments with pediatricians at pediatric oncology clinics, with or without the use of the eHealth service Sisom. Methods: A quasiexperimental design with mixed methods was used. We analyzed 27 filmed appointments with pediatricians for 14 children (8 girls and 6 boys) aged 6-12 years (mean 8.3 years) with a cancer diagnosis. The intervention group consisted of children who used Sisom prior to their appointments with pediatricians at a pediatric oncology clinic, and the control group consisted of children who had appointments with pediatricians at 4 pediatric oncology clinics. Data from observations from the videos were quantitatively and qualitatively analyzed. The quantitative analysis included manual calculations of how many times the pediatricians spoke directly to the children, the proportion of the appointment time that the children were talking, and levels of participation by the children. For the qualitative analysis, we used directed content analysis to analyze the children’s levels of participation guided by a framework based on Shier’s model of participation. Results: Pediatricians directed a greater proportion of their discussion toward the child in the intervention group (731 occasions) than in the control group (624 occasions), but the proportion of the appointment time the children talked was almost the same for both the intervention and control groups (mean 17.0 minutes vs 17.6 minutes). The levels of participation corresponded to the first three levels of Shier’s participation model: children were listened to, children were supported to express their views, and children’s views were taken into account. The results showed an increased level of participation by the children in the intervention group. Several codes that were found did not fit into any of the existing categories, and a new category was thus formed: children received information. Conclusions: This study shows that the eHealth service Sisom can increase children’s participation during appointments with health care professionals. Further studies employing a randomized control design focusing on the effects of eHealth services on children’s health outcomes, perceived participation, and cost-effectiveness could make a significant contribution to guiding the implementation of eHealth services in pediatric care. %M 32720907 %R 10.2196/17673 %U http://www.jmir.org/2020/7/e17673/ %U https://doi.org/10.2196/17673 %U http://www.ncbi.nlm.nih.gov/pubmed/32720907 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16234 %T Teens Taking Charge: A Randomized Controlled Trial of a Web-Based Self-Management Program With Telephone Support for Adolescents With Juvenile Idiopathic Arthritis %A Stinson,Jennifer N %A Lalloo,Chitra %A Hundert,Amos S %A Campillo,Sarah %A Cellucci,Tania %A Dancey,Paul %A Duffy,Ciaran %A Ellsworth,Janet %A Feldman,Brian M %A Huber,Adam M %A Johnson,Nicole %A Jong,Geert't %A Oen,Kiem %A Rosenberg,Alan M %A Shiff,Natalie J %A Spiegel,Lynn %A Tse,Shirley M L %A Tucker,Lori %A Victor,Joseph Charles %+ The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada, 1 (416) 8131500, jennifer.stinson@sickkids.ca %K eHealth %K randomized controlled trial %K adolescents %K juvenile idiopathic arthritis %K self-management %K self-efficacy %K technology %K patient education %K internet %K pediatric pain %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Juvenile idiopathic arthritis (JIA) is a serious and potentially debilitating pediatric illness. Improved disease self-management may help to improve health outcomes. Objective: This study aimed to evaluate the effectiveness of the Teens Taking Charge Web-based self-management intervention in reducing symptoms and improving health-related quality of life (HRQL) in adolescents with JIA compared with a Web-based education control condition. Methods: Adolescents with JIA aged 12 to 18 years were recruited from 11 Canadian pediatric rheumatology centers. Caregivers were invited to participate along with their child. In addition to standard medical care, participants were randomized to receive either (1) the Teens Taking Charge self-management intervention or (2) a Web-based education control condition for a period of 12 weeks. Adolescents in the intervention group completed website modules addressing cognitive behavioral coping skills, stress management, and other self-management topics, while also receiving monthly telephone calls from a trained health coach. Adolescents in the education control group were instructed to view a series of preselected public JIA educational websites and received monthly calls from a coach who asked about their own best efforts at managing JIA. Caregivers in the intervention group completed website modules related to promoting independence and disease self-management in their child. Caregivers in the education control group were instructed to view a series of preselected public JIA educational websites. Outcome assessment occurred at baseline, 12 weeks (posttreatment), and at 6 and 12 months postrandomization. The primary outcomes were pain intensity, pain interference, and HRQL. Secondary outcomes were emotional symptoms, adherence, coping, knowledge, and self-efficacy. Results: In total, 333 adolescents and 306 caregivers were enrolled. Significant overall reductions in pain intensity (P=.02) and pain interference (P=.007) were observed for intervention group participants compared with those in the education control group, after adjusting for baseline levels. There was a significant overall improvement in HRQL related to problems with pain (P=.02) and problems with daily activities (P=.01). There was also a significant difference in the intervention group over time (P=.008) for HRQL related to treatment problems, with the intervention group participants demonstrating improved HRQL by 12 months compared with education control group participants. Both groups showed nonsignificant improvements compared with baseline in other primary outcomes. There were no significant differences between the groups in any secondary outcomes or caregiver-reported outcomes. Conclusions: The results of this randomized trial suggest that the Teens Taking Charge Web-based intervention is effective at reducing both pain intensity and pain interference, as well as improving HRQL in adolescents with JIA, compared with education control. These effects are sustained for up to 12 months following program completion. The Teens Taking Charge program is now publicly available at no cost. Trial Registration: ClinicalTrials.gov NCT01572896; https://clinicaltrials.gov/ct2/show/NCT01572896 %M 32723728 %R 10.2196/16234 %U https://www.jmir.org/2020/7/e16234 %U https://doi.org/10.2196/16234 %U http://www.ncbi.nlm.nih.gov/pubmed/32723728 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18157 %T Designing a Personalized Digital Patient Support Program for Patients Treated With Growth Hormone: Key Design Considerations %A Malik,Sumaira %A Moloney,Clare %A Koledova,Ekaterina %A Reston,Jonathan %A Weinman,John %+ Atlantis Healthcare, Building 5 Chiswick Park, Chiswick High Road, London, W4 5YA, United Kingdom, 44 2087474360, sumaira.malik@atlantishealthcare.com %K growth hormone %K behavior change wheel %K somatropin %K adherence %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Recombinant human growth hormone treatment can optimize growth potential; however, optimal outcomes are not always achieved for several reasons, including poor adherence. The overall objective of this project was to design a patient support program to maximize the chances of treatment success for people being treated with somatropin injection. An approach known as the behavior change wheel was used to enhance the development of the patient support program. The behavior change wheel provided a comprehensive framework to support the design of interventions. Objective: The aim of this paper was to describe how the steps of the behavior change wheel were applied to the development of a patient support program for individuals with growth hormone deficiency undergoing treatment with somatropin. Methods: We followed a series of steps that align to tenets of the behavior change wheel, namely, a narrative literature review to identify which behaviors needed to change and the potential drivers of and barriers to the behaviors, the selection of an intervention strategy and discrete behavior change techniques, and, finally, intervention specification. Results: A recent systematic review identified a range of potentially modifiable factors found to have an influence on patient adherence to growth hormone treatment. Insights from the systematic review were used to guide the development of a patient support program. The final design of the patient support program consisted of four elements: (1) a personalization questionnaire to tailor support for each individual, (2) tailored reminder and support SMS text messages, (3) nurse-led phone calls, and (4) Easypod connect, an automated electronic autoinjector drug-delivery device with a transmitter and connection platform for Saizen (somatropin) that allows automatic recording, storage, and transmission of drug-usage data, thus providing insight into suboptimal adherence. Conclusions: The patient support program that was designed is currently being piloted with patients to assess engagement with the program and determine its impact on patient outcomes. Results from the pilot will be used to further refine the program to ensure it meets user needs. %M 32723712 %R 10.2196/18157 %U http://www.jmir.org/2020/7/e18157/ %U https://doi.org/10.2196/18157 %U http://www.ncbi.nlm.nih.gov/pubmed/32723712 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17481 %T A Mobile Health Approach for Improving Outcomes in Suicide Prevention (SafePlan) %A O'Grady,Conor %A Melia,Ruth %A Bogue,John %A O'Sullivan,Mary %A Young,Karen %A Duggan,Jim %+ School of Computer Science, National University of Ireland Galway, University Road, Galway, H91 TK33, Ireland, 353 91493336, james.duggan@nuigalway.ie %K mobile apps %K suicide %K mHealth %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide is a prominent cause of death worldwide, particularly among young people. It was the second leading cause of death among those aged 15-29 years globally in 2016. Treatment for patients with suicidal thoughts or behaviors often includes face-to-face psychological therapy with a mental health professional. These forms of interventions may involve maintaining and updating paper-based reports or worksheets in between sessions. Mobile technology can offer a way to support the implementation of evidence-based psychological techniques and the acquisition of protective coping skills. Objective: This study aims to develop a mobile app to facilitate service users’ access to mental health support and safety planning. This process involved eliciting expert input from clinicians who are actively engaged in the provision of mental health care. Methods: A survey was distributed to targeted health care professionals to determine what features should be prioritized in a new mobile app relating to suicide prevention. On the basis of the survey results, a clinical design group, comprising 6 members with experience in fields such as mobile health (mHealth), clinical psychology, and suicide prevention, was established. This group was supplemented with further input from additional clinicians who provided feedback over three focus group sessions. The sessions were centered on refining existing app components and evaluating new feature requests. This process was iterated through regular feedback until agreement was reached on the overall app design and functionality. Results: A fully functional mobile app, known as the SafePlan app, was developed and tested with the input of clinicians through an iterative design process. The app’s core function is to provide an interactive safety plan to support users with suicidal thoughts or behaviors as an adjunct to face-to-face therapy. A diary component that facilitates the generalization of skills learned through dialectical behavior therapy was also implemented. Usability testing was carried out on the final prototype by students from a local secondary school, who are representative of the target user population in both age and technology experience. The students were asked to complete a system usability survey (SUS) at the end of this session. The mean overall SUS rating was 71.85 (SD 1.38). Conclusions: The participatory process involving key stakeholders (clinicians, psychologists, and information technology specialists) has resulted in the creation of an mHealth intervention technology that has the potential to increase accessibility to this type of mental health service for the target population. The app has gone through the initial testing phase, and the relevant recommendations have been implemented, and it is now ready for trialing with both clinicians and their patients. %M 32729845 %R 10.2196/17481 %U http://www.jmir.org/2020/7/e17481/ %U https://doi.org/10.2196/17481 %U http://www.ncbi.nlm.nih.gov/pubmed/32729845 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15378 %T Participatory Interventions for Sexual Health Promotion for Adolescents and Young Adults on the Internet: Systematic Review %A Martin,Philippe %A Cousin,Lorraine %A Gottot,Serge %A Bourmaud,Aurelie %A de La Rochebrochard,Elise %A Alberti,Corinne %+ Université de Paris, ECEVE, INSERM, 10 Avenue de Verdun, Paris, 75010, France, 33 676606491, philippe.martin@inserm.fr %K sexual health %K health promotion %K internet %K participatory interventions %K adolescents and young adults %K methods %D 2020 %7 31.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The World Health Organization recommends the development of participatory sexuality education. In health promotion, web-based participatory interventions have great potential in view of the internet’s popularity among young people. Objective: The aim of this review is to describe existing published studies on online participatory intervention methods used to promote the sexual health of adolescents and young adults. Methods: We conducted a systematic review based on international scientific and grey literature. We used the PubMed search engine and Aurore database for the search. Articles were included if they reported studies on participatory intervention, included the theme of sexual health, were conducted on the internet (website, social media, online gaming system), targeted populations aged between 10 and 24 years, and had design, implementation, and evaluation methods available. We analyzed the intervention content, study implementation, and evaluation methods for all selected articles. Results: A total of 60 articles were included, which described 37 interventions; several articles were published about the same intervention. Process results were published in many articles (n=40), in contrast to effectiveness results (n=23). Many of the 37 interventions were developed on websites (n=20). The second most used medium is online social networks (n=13), with Facebook dominating this group (n=8). Online peer interaction is the most common participatory component promoted by interventions (n=23), followed by interaction with a professional (n=16). Another participatory component is game-type activity (n=10). Videos were broadcast for more than half of the interventions (n=20). In total, 43% (n=16) of the interventions were based on a theoretical model, with many using the Information-Motivation-Behavioral Skills model (n=7). Less than half of the interventions have been evaluated for effectiveness (n=17), while one-third (n=12) reported plans to do so and one-fifth (n=8) did not indicate any plan for effectiveness evaluation. The randomized controlled trial is the most widely used study design (n=16). Among the outcomes (evaluated or planned for evaluation), sexual behaviors are the most evaluated (n=14), followed by condom use (n=11), and sexual health knowledge (n=8). Conclusions: Participatory online interventions for young people’s sexual health have shown their feasibility, practical interest, and attractiveness, but their effectiveness has not yet been sufficiently evaluated. Online peer interaction, the major participatory component, is not sufficiently conceptualized and defined as a determinant of change or theoretical model component. One potential development would be to build a conceptual model integrating online peer interaction and support as a component. %M 32735217 %R 10.2196/15378 %U http://www.jmir.org/2020/7/e15378/ %U https://doi.org/10.2196/15378 %U http://www.ncbi.nlm.nih.gov/pubmed/32735217 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16961 %T Perceived Effectiveness and Motivations for the Use of Web-Based Mental Health Programs: Qualitative Study %A Eccles,Heidi %A Nannarone,Molly %A Lashewicz,Bonnie %A Attridge,Mark %A Marchand,Alain %A Aiken,Alice %A Ho,Kendall %A Wang,Jianli %+ Work & Mental Health Research Unit, The Institute of Mental Health Research, University of Ottawa, Room 5404, 1145 Carling Ave, Ottawa, ON, K1Z7K4, Canada, 1 6137226521, jianli.wang@theroyal.ca %K prevention %K mental health %K depression %K cognitive behavioral therapy %K motivators %K perceived effectiveness %K internet-based intervention %K interview %D 2020 %7 31.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The prevalence of depression is high and has been stable despite increased treatment, research, and dissemination. People encounter barriers to seeking traditional mental health services, which could be mitigated by using web-based prevention methods. Objective: This study aims to understand what people at high risk for depression perceive as effective aspects of web-based mental health programs and what motivates people at high risk for depression to use web-based mental health programs. Methods: We conducted an inductive content analysis using telephone interview data from 77 participants at high risk for depression who were recruited from 2 randomized controlled trials (RCTs). Participants from the first RCT were working men who had been randomly assigned to 1 of the following 3 groups: control group, who had access to general depression information from a website called BroMatters; intervention group 1, who had access to the BroMatters website along with the associated BroHealth web-based mental health program; and intervention group 2, who had access to the BroMatters website, the BroHealth web-based mental health program, and telephone sessions with a life coach. Participants from the second RCT were men and women who had been assigned to the intervention group, who received access to the HardHat web-based mental health program, or the control group, who only received access to the HardHat web-based mental health program following completion of the RCT. Participants for this inductive content analysis study were recruited from the intervention groups in both RCTs. Two groups of participants (n=41 and n=20) were recruited from the BroHealth RCT, and a third group comprised 16 participants that were recruited from the HardHat RCT. Results: We generated four categories regarding the perceived effectiveness of web-based programs and five categories related to what motivates the use of web-based programs. Participants identified awareness, program medium and functionality, program content, and coaches as categories related to the effectiveness of the programs. Categories of motivators to use web-based programs included providing reminders or incentives, promotion of the programs, providing appropriate medium and functionality, appropriate content, and perceived need. The final category related to motivators reflects perceptions of participants who were either unsure about what motivates them or believed that there is no way to motivate use. Conclusions: Conflicting evidence was obtained regarding the perceived effectiveness of aspects of the content and functionality of web-based programs. In general, web-based mental health programs were perceived to help increase mental health awareness, especially when it includes live access to a coach. However, the results also revealed that it is difficult to motivate people to begin using web-based mental health programs. Strategies that may motivate the use of such programs include perceived personal need, effective promotion, providing incentives and reminders, and improving functionality. %M 32735216 %R 10.2196/16961 %U http://www.jmir.org/2020/7/e16961/ %U https://doi.org/10.2196/16961 %U http://www.ncbi.nlm.nih.gov/pubmed/32735216 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14178 %T A Virtual Reality–Supported Intervention for Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Mixed Methods Study %A Jung,Timothy %A Moorhouse,Natasha %A Shi,Xin %A Amin,Muhammad Farhan %+ Manchester Metropolitan University, Business School, Oxford Road, Manchester, M15 6BH, United Kingdom, 44 7527423967, x.shi@mmu.ac.uk %K virtual reality %K COPD %K rehabilitation %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The uptake of traditional pulmonary rehabilitation classes by patients with chronic obstructive pulmonary disease (COPD) is poor because of personal factors that prevent accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation, and virtual reality (VR) could be a promising technology for patients with COPD to access services remotely. Objective: This study aimed to investigate whether VR improves compliance with pulmonary rehabilitation among patients with COPD, a particularly vulnerable patient group (Medical Research Council [MRC] 4 or 5), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programs. Methods: This was an 8-week patient trial using an innovative VR pulmonary rehabilitation program. A purposive sample of 10 patients with COPD graded MRC 4 or 5 and registered at a selected health care center and a hospital in Cumbria, United Kingdom, were included. Qualitative (focus groups and interviews) data were collected, and to further support the qualitative findings, quantitative data (self-report patient surveys) were gathered before and after the 8-week trial. The 5 self-reported surveys included the Patient Activation Measure, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Short Physical Performance Battery, and the Edmonton Frail Scale. Results: In a thematic analysis of the qualitative data, 11 themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further support the qualitative findings by revealing significant improvements in all physical measures. Conclusions: Overall, this study demonstrates how remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing this service to patients with COPD at scale. %M 32673224 %R 10.2196/14178 %U https://www.jmir.org/2020/7/e14178 %U https://doi.org/10.2196/14178 %U http://www.ncbi.nlm.nih.gov/pubmed/32673224 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17817 %T A Dietary Mobile App for Patients Undergoing Hemodialysis: Prospective Pilot Study to Improve Dietary Intakes %A Fakih El Khoury,Cosette %A Crutzen,Rik %A Schols,Jos M G A %A Halfens,Ruud J G %A Karavetian,Mirey %+ Department of Health Sciences, Zayed University, PO Box 19282, Dubai, United Arab Emirates, 971 562446865, Mirey.Karavetian@zu.ac.ae %K mHealth %K dietary app %K hemodialysis diet %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile technology has an impact on the health care sector, also within dietetics. Mobile health (mHealth) apps may be used for dietary assessment and self-monitoring, allowing for real-time reporting of food intakes. Changing eating behaviors is quite challenging, and patients undergoing hemodialysis, particularly, struggle to meet the target intakes set by dietary guidelines. Usage of mobile apps that are developed in a person-centered approach and in line with recommendations may support both patients and health care practitioners. Objective: This study is a pilot that aims at estimating the potential efficacy of a dietary intervention using a theory-based, person-centered smartphone app. Results will be used to improve both the app and a planned large-scale trial intended to assess app efficacy thoroughly. Methods: A prospective pilot study was performed at the hemodialysis unit of Al Qassimi Hospital (The Emirate of Sharjah). All patients that fulfilled the study inclusion criteria were considered eligible to be enrolled in the pilot study. Upon successful installation of the app, users met with a dietitian once a week. Outcomes were measured at baseline (T0) and 2 weeks post app usage (T1). This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT 2010 checklist for reporting pilot or feasibility trials. Results: A total of 23 patients completed the pilot intervention. Mean energy intakes increased from 24.4 kcal/kg/day (SD 8.0) to 29.1 kcal/kg/day (SD 7.8) with a medium effect size (d=0.6, 95% CI 0.0-1.2). Mean protein intakes increased from 0.9 g/kg/day (SD 0.3) to 1.3 g/kg/day (SD 0.5) with a large effect size (d=1.0, 95% CI 0.4-1.6); mean intake of high biological value (%HBV) proteins also increased from 58.6% (SD 10.1) to 70.1% (SD 10.7) with a large effect size (d=1.1, 95% CI 0.5-1.7). Dietary intakes of minerals did not change, apart from sodium which decreased from a mean intake of 2218.8 mg/day (SD 631.6) to 1895.3 mg/day (SD 581.0) with a medium effect size (d=0.5, 95% CI 0.1-1.1). Mean serum phosphorus, potassium, and albumin levels did not change relevantly. Mean serum iron increased from 7.9 mg/dL (SD 2.8) to 11.5 mg/dL (SD 7.9) postintervention with a medium effect size (d=0.6, 95% CI 0.0-1.2). Conclusions: This pilot study showed that the KELA.AE app has the potential to improve dietary intakes. Processes related to procedure, resources, tools, and app improvement for a future trial were assessed. A more extended intervention using a randomized controlled trial is required to estimate parameters concerning app efficacy accurately. %M 32706698 %R 10.2196/17817 %U http://www.jmir.org/2020/7/e17817/ %U https://doi.org/10.2196/17817 %U http://www.ncbi.nlm.nih.gov/pubmed/32706698 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15873 %T Experiences With Wearable Activity Data During Self-Care by Chronic Heart Patients: Qualitative Study %A Andersen,Tariq Osman %A Langstrup,Henriette %A Lomborg,Stine %+ Department of Computer Science, University of Copenhagen, Universitetsparken 5, Copenhagen, 2100, Denmark, 45 26149169, tariq@di.ku.dk %K consumer health information %K wearable electronic devices %K self-care %K chronic illness %K patient experiences %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Most commercial activity trackers are developed as consumer devices and not as clinical devices. The aim is to monitor and motivate sport activities, healthy living, and similar wellness purposes, and the devices are not designed to support care management in a clinical context. There are great expectations for using wearable sensor devices in health care settings, and the separate realms of wellness tracking and disease self-monitoring are increasingly becoming blurred. However, patients’ experiences with activity tracking technologies designed for use outside the clinical context have received little academic attention. Objective: This study aimed to contribute to understanding how patients with a chronic disease experience activity data from consumer self-tracking devices related to self-care and their chronic illness. Our research question was: “How do patients with heart disease experience activity data in relation to self-care and chronic illness?” Methods: We conducted a qualitative interview study with patients with chronic heart disease (n=27) who had an implanted cardioverter-defibrillator. Patients were invited to wear a FitBit Alta HR wearable activity tracker for 3-12 months and provide their perspectives on their experiences with step, sleep, and heart rate data. The average age was 57.2 years (25 men and 2 women), and patients used the tracker for 4-49 weeks (mean 26.1 weeks). Semistructured interviews (n=66) were conducted with patients 2–3 times and were analyzed iteratively in workshops using thematic analysis and abductive reasoning logic. Results: Of the 27 patients, 18 related the heart rate, sleep, and step count data directly to their heart disease. Wearable activity trackers actualized patients’ experiences across 3 dimensions with a spectrum of contrasting experiences: (1) knowing, which spanned gaining insight and evoking doubts; (2) feeling, which spanned being reassured and becoming anxious; and (3) evaluating, which spanned promoting improvements and exposing failure. Conclusions: Patients’ experiences could reside more on one end of the spectrum, could reside across all 3 dimensions, or could combine contrasting positions and even move across the spectrum over time. Activity data from wearable devices may be a resource for self-care; however, the data may simultaneously constrain and create uncertainty, fear, and anxiety. By showing how patients experience self-tracking data across dimensions of knowing, feeling, and evaluating, we point toward the richness and complexity of these data experiences in the context of chronic illness and self-care. %M 32706663 %R 10.2196/15873 %U https://www.jmir.org/2020/7/e15873 %U https://doi.org/10.2196/15873 %U http://www.ncbi.nlm.nih.gov/pubmed/32706663 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16856 %T Perceptions and Acceptability of Digital Interventions Among Tuberculosis Patients in Cambodia: Qualitative Study of Video-Based Directly Observed Therapy %A Rabinovich,Lila %A Molton,James Steven %A Ooi,Wei Tsang %A Paton,Nicholas Iain %A Batra,Shelly %A Yoong,Joanne %+ Center for Economic and Social Research, University of Southern California, 1090 Vermont Avenue, NW, Washington, DC, 20005, United States, 1 2138210537, lilarabi@usc.edu %K directly observed therapy %K video recording %K telemedicine %K mobile health %K mHealth %K tuberculosis %K low-income settings %K developing countries %K patient acceptance of health care %K patient acceptability %K Cambodia %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the development of effective drugs for treatment, tuberculosis remains one of the leading causes of death from an infectious disease worldwide. One of the greatest challenges to tuberculosis control is patient adherence to treatment. Recent research has shown that video-based directly observed therapy is a feasible and effective approach to supporting treatment adherence in high-income settings. However, few studies have explored the potential for such a solution in a low- or middle-income country setting. Globally, these countries’ rapidly rising rate of mobile penetration suggests that the potential for translation of these results may be high. Objective: We sought to examine patient perceptions related to the use of mobile health, and specifically video-based directly observed therapy, in a previously unstudied patient demographic: patients with tuberculosis in a low-income country setting (Cambodia). Methods: We conducted a cross-sectional qualitative study in urban and periurban areas in Cambodia, consisting of 6 focus groups with tuberculosis patients who were receiving treatment (standard directly observed therapy) through a nongovernmental organization. Results: Familiarity with mobile technology and apps was widespread in this population, and overall willingness to consider a mobile app for video-based directly observed therapy was high. However, we identified potential challenges. First, patients very much valued their frequent in-person interactions with their health care provider, which may be reduced with the video-based directly observed therapy intervention. Second, there may be technical issues to address, including how to make the app suitable for illiterate participants. Conclusions: While video-based directly observed therapy is a promising technology, even in country settings where mobile penetration is reportedly almost universal, it should be introduced with caution. However, the results were generally promising and yielded important insights that not only will be translated into the further adaptation of key features of video-based directly observed therapy for tuberculosis patients in Cambodia, but also can inform the future design and successful implementation of video-based directly observed therapy interventions in low- and middle-income settings more generally. %M 32716309 %R 10.2196/16856 %U https://www.jmir.org/2020/7/e16856 %U https://doi.org/10.2196/16856 %U http://www.ncbi.nlm.nih.gov/pubmed/32716309 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17758 %T Detection of Suicidal Ideation on Social Media: Multimodal, Relational, and Behavioral Analysis %A Ramírez-Cifuentes,Diana %A Freire,Ana %A Baeza-Yates,Ricardo %A Puntí,Joaquim %A Medina-Bravo,Pilar %A Velazquez,Diego Alejandro %A Gonfaus,Josep Maria %A Gonzàlez,Jordi %+ Department of Information and Communication Technologies, Universitat Pompeu Fabra, Carrer de Tànger, 122-140, Barcelona, 08018, Spain, 34 643294184, diana.ramirez@upf.edu %K social media %K mental health %K suicidal ideation %K risk assessment %K machine learning %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suicide risk assessment usually involves an interaction between doctors and patients. However, a significant number of people with mental disorders receive no treatment for their condition due to the limited access to mental health care facilities; the reduced availability of clinicians; the lack of awareness; and stigma, neglect, and discrimination surrounding mental disorders. In contrast, internet access and social media usage have increased significantly, providing experts and patients with a means of communication that may contribute to the development of methods to detect mental health issues among social media users. Objective: This paper aimed to describe an approach for the suicide risk assessment of Spanish-speaking users on social media. We aimed to explore behavioral, relational, and multimodal data extracted from multiple social platforms and develop machine learning models to detect users at risk. Methods: We characterized users based on their writings, posting patterns, relations with other users, and images posted. We also evaluated statistical and deep learning approaches to handle multimodal data for the detection of users with signs of suicidal ideation (suicidal ideation risk group). Our methods were evaluated over a dataset of 252 users annotated by clinicians. To evaluate the performance of our models, we distinguished 2 control groups: users who make use of suicide-related vocabulary (focused control group) and generic random users (generic control group). Results: We identified significant statistical differences between the textual and behavioral attributes of each of the control groups compared with the suicidal ideation risk group. At a 95% CI, when comparing the suicidal ideation risk group and the focused control group, the number of friends (P=.04) and median tweet length (P=.04) were significantly different. The median number of friends for a focused control user (median 578.5) was higher than that for a user at risk (median 372.0). Similarly, the median tweet length was higher for focused control users, with 16 words against 13 words of suicidal ideation risk users. Our findings also show that the combination of textual, visual, relational, and behavioral data outperforms the accuracy of using each modality separately. We defined text-based baseline models based on bag of words and word embeddings, which were outperformed by our models, obtaining an increase in accuracy of up to 8% when distinguishing users at risk from both types of control users. Conclusions: The types of attributes analyzed are significant for detecting users at risk, and their combination outperforms the results provided by generic, exclusively text-based baseline models. After evaluating the contribution of image-based predictive models, we believe that our results can be improved by enhancing the models based on textual and relational features. These methods can be extended and applied to different use cases related to other mental disorders. %M 32673256 %R 10.2196/17758 %U https://www.jmir.org/2020/7/e17758 %U https://doi.org/10.2196/17758 %U http://www.ncbi.nlm.nih.gov/pubmed/32673256 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e13954 %T An Instagram-Based Study to Understand Betel Nut Use Culture in Micronesia: Exploratory Content Analysis %A Buente,Wayne %A Dalisay,Francis %A Pokhrel,Pallav %A Kramer,Hanae Kurihara %A Pagano,Ian %+ School of Communications, University of Hawaii at Manoa, 2550 Campus Road, Crawford Hall, Honolulu, HI, 96822, United States, 1 8089563360, wbuente@hawaii.edu %K betel nut %K areca catechu %K areca %K cancer %K health %K Guam %K Micronesia %K Instagram %K mobile phone %K culture %D 2020 %7 9.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: A 2012 World Health Organization report recognizes betel nut use as an urgent public health threat faced by the Western Pacific region. However, compared with other addictive substances, little is known about how betel nuts are depicted on social media platforms. In particular, image-based social media platforms can be powerful tools for health communication. Studying the content of substance use on visual social media may provide valuable insights into public health interventions. Objective: This study aimed to explore and document the ways that betel nut is portrayed on the photo-sharing site Instagram. The analysis focuses on the hashtag #pugua, which refers to the local term for betel nut in Guam and other parts of Micronesia. Methods: An exploratory content analysis of 242 Instagram posts tagged #pugua was conducted based on previous research on substance use and Instagram and betel nut practices in Micronesia. In addition, the study examined the social engagement of betel nut content on the image-based platform. Results: The study findings revealed content themes referencing the betel nut or betel nut tree, betel nut preparation practices, and the unique social and cultural context surrounding betel nut activity in Guam and Micronesia. In addition, certain practices and cultural themes encouraged social engagement on Instagram. Conclusions: The findings from this study emphasize the cultural relevance of betel nut use in Micronesia. These findings provide a basis for empirically testing hypotheses related to the etiological roles of cultural identity and pride in shaping betel nut use behavior among Micronesians, particularly youths and young adults. Such research is likely to inform the development of culturally relevant betel nut prevention and cessation programs. %M 32673220 %R 10.2196/13954 %U https://www.jmir.org/2020/7/e13954 %U https://doi.org/10.2196/13954 %U http://www.ncbi.nlm.nih.gov/pubmed/32673220 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16962 %T Characterizing Social Media Messages Related to Underage JUUL E-Cigarette Buying and Selling: Cross-Sectional Analysis of Reddit Subreddits %A Liu,Hejing %A Li,Qiudan %A Zhan,Yongcheng %A Zhang,Zhu %A Zeng,Daniel D %A Leischow,Scott J %+ The State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, 95 Zhongguancun East Rd, Beijing, 100190, China, 86 10 82449802, qiudan.li@ia.ac.cn %K JUUL %K e-cigarette %K Reddit %K cross-sectional analysis %K electronic nicotine delivery system %K underage JUUL use %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Stopping the epidemic of e-cigarette use among youth has become the common goal of both regulatory authorities and health departments. JUUL is currently the most popular e-cigarette brand on the market. Young people usually obtain and exchange information about JUUL with the help of social media platforms. Along with the rising prevalence of JUUL, posts about underage JUUL buying and selling have appeared on social media platforms such as Reddit, which sharply increase the risk of minors being exposed to JUUL. Objective: This study aims to analyze Reddit messages about JUUL buying and selling among the users of the UnderageJuul subreddit, and to further summarize the characteristics of those messages. The findings and insights can contribute to a better understanding of the patterns of underage JUUL use, and help public health officials provide timely education and guidance to minors who have intentions of accessing JUUL. Methods: We used a novel cross-subreddit method to analyze the Reddit messages on 2 subreddits. From July 9, 2017, to January 7, 2018, we collected data from the UnderageJuul subreddit, which was created for underage JUUL use discussion. The data set included 716 threads, 2935 comments, and 844 Reddit users (ie, Redditors). We collected our second data set, comprising 23,840 threads and 162,106 comments posted between July 9, 2017, and January 8, 2019, from the JUUL subreddit. We conducted analyses including the following: (1) annotation of users with buying/selling intention, (2) posting patterns discovery and topic comparison, and (3) posting activeness observation of discovered Redditors. Term frequency–inverse document frequency and regular expression-enhanced keyword search methods were applied during the content analysis to extract the posting patterns. The public posting records of the discovered users on the JUUL subreddit during the year after the UnderageJuul subreddit was shut down were analyzed to determine whether they were still active and interested in obtaining JUUL. Results: Our study revealed the following: (1) Among the 716 threads on the UnderageJuul subreddit, there were 214 threads related to JUUL sale and 168 threads related to JUUL purchase, which accounted for 53.5% (382/714) of threads. (2) Among the 844 Redditors of the UnderageJuul subreddit, 23.82% (201/844) of users were annotated with buying intention, and 21.10% (178/844) of users were annotated with selling intention. There were 34 users with buying/selling intention that self-reported as being <21 years old. (3) The most common key phrases used in selling threads were “WTS,” “want to sell,” “for sale,” and “selling” (154/214, 72.0%). The most common key phrases used in buying threads were “look for/get JUUL/pods” (58/168, 34.5%) and “WTB” (53/168, 31.5%). (4) The most important concern that UnderageJuul Redditors had in obtaining JUULs was the price (311/1306, 23.81%), followed by the delivery service (68/1306, 5.21%). (5) The most popular flavors among the users with buying/selling intention were mango, cucumber, and mint. The flavor preferences remained consistent on both subreddits. Adverse symptoms related to the mango flavor were reported by 3 users on the JUUL subreddit. (6) In total, 24.4% (49/201) of users wanted to buy JUULs and 46.6% (83/178) of users wanted to sell JUULs, including 11 self-reported underage users, who also participated in the discussions on the JUUL subreddit. (7) Within one year of the UnderageJuul subreddit shutting down, there were 40 users who continued to post 186 threads on the JUUL subreddit, including 10 threads indicating buying/selling willingness that were posted shortly after the UnderageJuul subreddit was closed. Conclusions: There were overlapping users active in the JUUL and UnderageJuul subreddits. The buying/selling-related content appeared in multiple venues with certain posting patterns from July 9, 2017, to January 7, 2018. Such content might lead to a high risk of health problems for minors, such as nicotine addiction. Based on these findings, this study provided some insights and suggestions that might contribute to the decision-making processes of regulators and public health officials. %M 32706661 %R 10.2196/16962 %U http://www.jmir.org/2020/7/e16962/ %U https://doi.org/10.2196/16962 %U http://www.ncbi.nlm.nih.gov/pubmed/32706661 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16212 %T The Development of a Smart Health Awareness Message Framework Based on the Use of Social Media: Quantitative Study %A Alsisi,Elaf Ali %A Al-Ashaab,Ahmed %A Abualfaraa,Wadhah Ahmed %+ Cranfield University, Bedfordshire, MK43 0AL, Cranfield, United Kingdom, 44 1234750111 ext 5622, e.alsisi85@gmail.com %K social media %K health promotion and social media %K health awareness %K health promotion %K eHealth %K technology acceptance theory %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Social media has recently provided a remarkable means of delivering health information broadly and in a cost-effective way. Despite its benefits, some difficulties are encountered in attempting to influence the public to change their behavior in response to social media health messages. Objective: This study aimed to explore the factors that affect individuals’ acceptance of using social media as a tool for receiving health awareness messages and adapting such content accordingly by developing a smart health awareness message framework. Methods: A quantitative method was adapted to validate the hypotheses and proposed framework through the development of a survey based on the technology acceptance model with the extension of other constructs. The survey was distributed on the web to 701 participants from different countries via Qualtrics software; it generated 391 completed questionnaires, and the response rate was 55.8% (391/701). Results: Of the 391 respondents, 121 (30.9%) used social media platforms often during the week, and 27 participants (6.9%) did not use social media. In addition, 24.0% (94/391) of the respondents used these platforms to seek health information. On the basis of the results, perceived usefulness (β=.37; P<.001), gain-framed message (β=.04; P<.001), and loss-framed message (β=.08; P<.001) were seen to positively and significantly influence people’s intention to use social media as a means to spread information about health promotion. The proposed smart health awareness message framework identifies 64.2% of the variance in intention to use, 55.4% of the variance of perceived usefulness, and 26.2% of the variance of perceived ease of use. Conclusions: This study sheds light on the factors that are associated with people’s intention to use and adopt social media in the health promotion domain. The findings reveal that the intention of using social media for health awareness purposes is positively impacted by the perception of usefulness of social media and the design of health messages. Future research might seek to explore other factors that relate to people’s behavior. This point of view will assist health organizations in developing their health messages more effectively and to be patient friendly. %M 32459627 %R 10.2196/16212 %U https://www.jmir.org/2020/7/e16212 %U https://doi.org/10.2196/16212 %U http://www.ncbi.nlm.nih.gov/pubmed/32459627 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18474 %T Sudden Infant Death Syndrome on Facebook: Qualitative Descriptive Content Analysis to Guide Prevention Efforts %A Pretorius,Kelly %A Choi,Eunju %A Kang,Sookja %A Mackert,Michael %+ The University of Texas at Austin, 1710 Red River St, Austin, TX, 78712, United States, 1 5124717913, kpretorius@utexas.edu %K sudden infant death %K SIDS %K infant mortality %K safe sleep %K social media %K social support %K health communication %K maternal health %K qualitative research %K health care providers %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Sudden unexpected infant death (SUID), which includes the diagnosis of sudden infant death syndrome (SIDS), is a leading cause of infant mortality in the United States. Despite prevention efforts, many parents continue to create unsafe infant sleep environments and use potentially dangerous infant sleep and monitoring devices, ultimately leading to sleep-related infant deaths. Analyzing Facebook conversations regarding SIDS may offer a unique maternal perspective to guide future research and prevention efforts. Objective: This study aims to describe and analyze conversations among mothers engaged in discussions about SIDS on a Facebook mother’s group. We were interested in understanding maternal knowledge of SIDS, identifying information sources for SIDS, describing actual infant sleep practices, exploring opinions regarding infant sleep products and monitoring devices, and discovering evidence of provider communication regarding SIDS. Methods: We extracted and analyzed 20 posts and 912 comments from 512 mothers who participated in a specific Facebook mother’s group and engaged in conversations about SIDS. There were 2 reviewers who coded the data using qualitative descriptive content analysis. Themes were induced after discussion among researchers and after the study objectives were addressed. Results: The theme of social support emerged, specifically informational and emotional support. A variety of informational sources for SIDS and safe sleep were identified, as was a continuum of infant sleep practices (ranging from unsafe to safe sleep per the American Academy of Pediatrics standards). There was widespread discussion regarding infant sleep products and monitoring devices. Embedded within conversations were (1) confusion among commonly used medical terminology, (2) the practice of unsafe infant sleep, (3) inconsistency in provider communication about SIDS, and (4) maternal anxiety regarding SIDS. Conclusions: We uncovered new findings in this analysis, such as the commonality of infant sleep products and monitoring devices and widespread maternal anxiety regarding SIDS. Additionally, mothers who participated in the Facebook group provided and received informational and emotional support regarding SIDS via this social media format. Such results can guide future prevention efforts by informing health communication regarding SUID and safe sleep. Future provider and public health agency communication on the topic of SUID and safe sleep should be simple and clear, address infant sleep products and monitoring devices, address maternal anxiety regarding SIDS, and address the common practice of unsafe sleep. %M 32729842 %R 10.2196/18474 %U http://www.jmir.org/2020/7/e18474/ %U https://doi.org/10.2196/18474 %U http://www.ncbi.nlm.nih.gov/pubmed/32729842 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17296 %T Assessing the Credibility and Authenticity of Social Media Content for Applications in Health Communication: Scoping Review %A Jenkins,Eva L %A Ilicic,Jasmina %A Barklamb,Amy M %A McCaffrey,Tracy A %+ Department of Nutrition, Dietetics and Food, Monash University, Level 1, 264 Ferntree Gully Road, Notting Hill, 3168, Australia, 61 400421391, tracy.mccaffrey@monash.edu %K review %K trust %K social media %K nutrition science %K health %K communication %K health communication %D 2020 %7 23.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Nutrition science is currently facing issues regarding the public’s perception of its credibility, with social media (SM) influencers increasingly becoming a key source for nutrition-related information with high engagement rates. Source credibility and, to an extent, authenticity have been widely studied in marketing and communications but have not yet been considered in the context of nutrition or health communication. Thus, an investigation into the factors that impact perceived source and message credibility and authenticity is of interest to inform health communication on SM. Objective: This study aims to explore the factors that impact message and source credibility (which includes trustworthiness and expertise) or authenticity judgments on SM platforms to better inform nutrition science SM communication best practices. Methods: A total of 6 databases across a variety of disciplines were searched in March 2019. The inclusion criteria were experimental studies, studies focusing on microblogs, studies focusing on healthy adult populations, and studies focusing on either source credibility or authenticity. Exclusion criteria were studies involving participants aged under 18 years and clinical populations, gray literature, blogs, WeChat conversations, web-based reviews, non-English papers, and studies not involving participants’ perceptions. Results: Overall, 22 eligible papers were included, giving a total of 25 research studies. Among these studies, Facebook and Twitter were the most common SM platforms investigated. The most effective communication style differed depending on the SM platform. Factors reported to impact credibility included language used online, expertise heuristics, and bandwagon heuristics. No papers were found that assessed authenticity. Conclusions: Credibility and authenticity are important concepts studied extensively in the marketing and communications disciplines; however, further research is required in a health context. Instagram is a less-researched platform in comparison with Facebook and Twitter. %M 32706675 %R 10.2196/17296 %U http://www.jmir.org/2020/7/e17296/ %U https://doi.org/10.2196/17296 %U http://www.ncbi.nlm.nih.gov/pubmed/32706675 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17894 %T Influence of Social Media on Sexualized Drug Use and Chemsex Among Chinese Men Who Have Sex With Men: Observational Prospective Cohort Study %A Wang,Zixin %A Yang,Xue %A Mo,Phoenix K H %A Fang,Yuan %A Ip,Tsun Kwan Mary %A Lau,Joseph T F %+ Centre for Health Behaviours Research, JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Room 508, School of Public Health, Prince of Wales Hospital, Hong Kong, 666888, Hong Kong, 852 22528740, wangzx@cuhk.edu.hk %K influence of social media %K sexualized drug use %K chemsex %K men who have sex with men %K prospective observational cohort study %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Sexualized drug use (SDU; the use of any psychoactive substance before or during sexual intercourse) is prevalent among men who have sex with men (MSM) and may aggravate the worsening HIV epidemic in this key population. Objective: This observational prospective cohort study investigated factors predicting the occurrence of SDU within a 6-month follow-up period among a sample of MSM in Hong Kong. We hypothesized that perceptions related to SDU would mediate the association between the influence of social media/gay social networking apps and SDU during the follow-up period. Methods: Participants were Chinese-speaking men in Hong Kong, China who had anal intercourse with at least one man in the past year. Among 600 participants who completed the baseline telephone survey, 407 (67.8%) completed another telephone survey 6 months later. Logistic regression models and path analysis were fitted. Results: At Month 6, 6.9% (28/407) and 4.4% (18/407) of participants reported SDU and chemsex during the follow-up period. After adjustment for significant baseline background variables (use of pre-exposure prophylaxis; history of HIV and other sexually transmitted infections; anal intercourse with nonregular male sex partners, condomless anal intercourse with men, multiple male sex partnerships, and SDU at baseline), three constructs of the Theory of Planned Behavior (TPB) were significantly associated with SDU during the follow-up period: (1) positive attitudes toward SDU (adjusted odds ratio [AOR] 1.19, 95% CI 1.05-1.36), (2) perceived support for SDU from significant others (AOR 1.15, 95% CI 1.01-1.30), and (3) perceived behavioral control of refraining from SDU (AOR 0.76, 95% CI 0.59-0.98). Exposure to information supporting SDU on social media and gay social networking apps was also significantly associated with SDU (AOR 1.11, 95% CI 1.01-1.22). Bootstrapping analyses indicated that social media influence was indirectly associated with SDU through TPB-related perceptions of SDU (β=.04; B=.002, 95% CI 0.001-0.01). Conclusions: Social media and gay social networking apps may be a major source of influence on MSM’s perceptions and actual behaviors related to SDU. %M 32706705 %R 10.2196/17894 %U http://www.jmir.org/2020/7/e17894/ %U https://doi.org/10.2196/17894 %U http://www.ncbi.nlm.nih.gov/pubmed/32706705 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18723 %T Blended Care-Cognitive Behavioral Therapy for Depression and Anxiety in Real-World Settings: Pragmatic Retrospective Study %A Lungu,Anita %A Jun,Janie Jihee %A Azarmanesh,Okhtay %A Leykin,Yan %A Chen,Connie E-Jean %+ Lyra Health, 287 Lorton Avenue, Burlingame, CA, 94010, United States, 1 6505673136, anita@lyrahealth.com %K cognitive behavior therapy %K blended psychotherapy %K dissemination %K implementation %K depression %K anxiety/anxiety disorders %K internet %K web based %K video psychotherapy %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The past few decades saw considerable advances in research and dissemination of evidence-based psychotherapies, yet available treatment resources are not able to meet the high need for care for individuals suffering from depression or anxiety. Blended care psychotherapy, which combines the strengths of therapist-led and internet interventions, can narrow this gap and be clinically effective and efficient, but has rarely been evaluated outside of controlled research settings. Objective: This study evaluated the effectiveness of a blended care intervention (video-based cognitive behavior therapy and internet intervention) under real-world conditions. Methods: This is a pragmatic retrospective cohort analysis of 385 participants with clinical range depression and/or anxiety symptoms at baseline, measured using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), who enrolled in blended care psychotherapy treatment. Participants resided in the United States and had access to the blended care intervention as a mental health benefit offered through their employers. Levels of depression and anxiety were tracked throughout treatment. Hierarchical linear modeling was used to examine the change in symptoms over time. The effects of age, gender, and providers on participants’ symptom change trajectories were also evaluated. Paired sample t-tests were also conducted, and rates of positive clinical change and clinically significant improvement were calculated. Results: The average depression and anxiety symptoms at 6 weeks after the start of treatment were 5.94 and 6.57, respectively. There were significant linear effects of time on both symptoms of depression and anxiety (β=–.49, P<.001 and β=–.64, P<.001). The quadratic effect was also significant for both symptoms of depression and anxiety (β=.04, P<.001 for both), suggesting a decelerated decrease in symptoms over time. Approximately 73% (n=283) of all 385 participants demonstrated reliable improvement, and 83% (n=319) recovered on either the PHQ-9 or GAD-7 measures. Large effect sizes were observed on both symptoms of depression (Cohen d=1.08) and of anxiety (d=1.33). Conclusions: Video blended care cognitive behavioral therapy interventions can be effective and efficient in treating symptoms of depression and anxiety in real-world conditions. Future research should investigate the differential and interactive contribution of the therapist-led and digital components of care to patient outcomes to optimize care. %M 32628120 %R 10.2196/18723 %U https://www.jmir.org/2020/7/e18723 %U https://doi.org/10.2196/18723 %U http://www.ncbi.nlm.nih.gov/pubmed/32628120 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18220 %T Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial %A González-Robles,Alberto %A Díaz-García,Amanda %A García-Palacios,Azucena %A Roca,Pablo %A Ramos-Quiroga,Josep Antoni %A Botella,Cristina %+ Department of Basic and Clinical Psychology, and Psychobiology, Universitat Jaume I, Sos Baynat Avenue, Campus del Riu Sec, Research II Building, Labpsitec, Castellón de la Plana, 12071, Spain, 34 964387646 ext 7646, vrobles@uji.es %K transdiagnostic %K internet %K cognitive behavioral therapy %K emotional disorders %K depression %K anxiety %K specialized care %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Anxiety disorders and depression (emotional disorders) are highly prevalent mental disorders. Extensive empirical evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of these disorders. However, there are still some barriers related to their dissemination and implementation, which make it difficult for patients to receive these treatments, especially in public health care settings where resources are limited. Recent advances in improving CBT dissemination encompass different perspectives. One is the transdiagnostic approach, which offers treatment protocols that can be used for a range of emotional disorders. Another approach is the use of the internet to reach a larger number of people who could benefit from CBT. Objective: This study aimed to analyze the effectiveness and acceptability of a transdiagnostic internet-delivered protocol (EmotionRegulation) with human and automated guidance in patients from public specialized mental health care settings. Methods: A 2-armed randomized controlled trial (RCT) was conducted to compare the effectiveness of EmotionRegulation with treatment as usual (TAU) in specialized mental health care. In all, 214 participants were randomly assigned to receive either EmotionRegulation (n=106) or TAU (n=108). Measurement assessments were conducted at pre- and postintervention and at a 3-month follow-up. Results: The results revealed the superiority of EmotionRegulation over TAU on measures of depression (d=0.41), anxiety (d=0.35), and health-related quality of life (d=−0.45) at posttreatment, and these gains were maintained at the 3-month follow-up. Furthermore, the results for expectations and opinions showed that EmotionRegulation was well accepted by participants. Conclusions: EmotionRegulation was more effective than TAU for the treatment of emotional disorders in the Spanish public mental health system. The implications of this RCT, limitations, and suggestions for future research are discussed. Trial Registration: ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668 %M 32673226 %R 10.2196/18220 %U https://www.jmir.org/2020/7/e18220 %U https://doi.org/10.2196/18220 %U http://www.ncbi.nlm.nih.gov/pubmed/32673226 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14865 %T Habits and Attitudes of Video Gaming and Information Technology Use in People with Schizophrenia: Cross-Sectional Survey %A Choi,William TH %A Yu,Dan KS %A Wong,Terry %A Lantta,Tella %A Yang,Min %A Välimäki,Maritta %+ Department of Nursing Science, Faculty of Medicine, University of Turku, ICT-City, A-wing, 5th floor, Joukahaisenkatu 3–5, Turku, 20520, Finland, 358 29 450 236, maritta.valimaki@polyu.edu.hk %K video gaming %K internet %K information technology %K schizophrenia %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Information technology and video gaming have potential advantages in the treatment of schizophrenia. However, information regarding the habits and attitudes related to internet use and video gaming in people with schizophrenia is limited. Objective: The aim of this study was to explore the habits and attitudes regarding video gaming and information technology usage and their associated factors in people with schizophrenia in Hong Kong. Methods: In this cross-sectional survey, service users with schizophrenia were recruited from 6 halfway hostels and 7 integrated centers for mental wellness in Hong Kong. A 79-item self-report questionnaire was utilized to explore the habits of internet use and video gaming in these people with schizophrenia. The attitude toward video gaming was assessed using the Gaming Attitudes, Motivations, and Experiences Scales. Of the 148 individuals in a convenience sample who were invited to participate in this study, 110 willingly participated (a response rate of 74.3%). The data were analyzed using descriptive statistics, a two-tailed independent t test, Pearson correlation, and principal analysis with 3 methods of rotation (varimax, equimax, and promax). Results: Most participants (100/110, 90.9%) had access to the internet and half of them (54/110, 49.1%) used the internet daily mostly to watch videos (66/110, 60.0%) or read news or books, etc (42/110, 38.2%). One-third of the participants (36/110, 32.7%) used the internet to play web-based games, and most of them (88/110, 80.0%) had played a video game in the past year. The most favorable gaming platforms were cellular phones (43/88, 49%) followed by computers (19/88, 22%) and arcade cabinets (6/88, 7%). The most favorable game genre was action games (34/145, 23.4%). Those who had a bachelor’s degree or higher scored lower in social interaction than those with a lower education level (P=.03). Those who played video games daily scored higher in the category of story than those who did not play daily (t86=2.03, P=.05). The most popular gaming category was autonomy and the least popular categories were violent catharsis and violent reward. Two motives, “social playing” and “evasive playing,” were formed to describe the characteristics of playing video games. Conclusions: Our data showed a high internet utilization rate among people with schizophrenia in Hong Kong. Only a few of them used the internet to search for health-related information. Our study also exemplified the unique habits of gaming among the participants. Health care professionals could utilize video games to engage people with schizophrenia and promote coping with stress and provide social skills training to such people with schizophrenia. Identification of the gaming attitudes can contribute to the development of serious games for the schizophrenic population. Further investigation is vital for the promotion of mental health through web-based platforms. %M 32459646 %R 10.2196/14865 %U http://www.jmir.org/2020/7/e14865/ %U https://doi.org/10.2196/14865 %U http://www.ncbi.nlm.nih.gov/pubmed/32459646 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14915 %T Mobile Mental Health Apps in China: Systematic App Store Search %A Yin,Huifang %A Wardenaar,Klaas J %A Wang,Yuhao %A Wang,Nan %A Chen,Wenjin %A Zhang,Yan %A Xu,Guangming %A Schoevers,Robert A %+ Tianjin Anding Hospital, No 13, Liulin Road, Hexi district, Tianjin, China, 86 15122997716, xugm@ymail.com %K smartphone %K app %K mobile mental health %K mental illness %K mental health problem %K China %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphones have become ubiquitous in China, offering a promising way to deliver mental health interventions; however, little is known about the current use and characteristics of smartphone apps for mental health. Objective: The purpose of this study was to gain insight into mobile mental health apps available in China as of December 2018. Methods: A systematic search was conducted to identify and evaluate the most downloaded apps from iOS and Android platforms. Apps were categorized according to their main purpose and downloaded to evaluate their content. Each app’s affiliation, cost, target users, information security, and evidence-based nature were evaluated. Results: Of the 172 unique apps that were identified, there were 37 apps (21.5%) for psychological counseling, 50 apps (29.1%) for assessment, 12 apps (7.0%) to relieve stress, 24 apps (14.0%) for psychoeducation, and 49 (28.4%) multipurpose apps (ie, a combination of counseling and assessment). Most apps were developed for adults in the general population (166/172, 96.5%), rather than for psychiatric patients. App-based counseling was mostly provided by psychologists, and of the assessed apps, only 40% (70/172) used evidence-based scales to assess mental health problems such as anxiety or depressed mood. Guided meditation was used as the main technique in stress-relieving apps. Conclusions: Many apps contained useful and evidence-based elements, such as good quality information, validated measurements, and useful meditation methods; however, for mobile apps to contribute significantly to mental health care in China, considerable challenges remain, including the need for more patient-focused apps that can actually take on the role of a health care provider. In addition, efficacy studies are needed. %M 32716301 %R 10.2196/14915 %U https://www.jmir.org/2020/7/e14915 %U https://doi.org/10.2196/14915 %U http://www.ncbi.nlm.nih.gov/pubmed/32716301 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14337 %T Surveilling Influenza Incidence With Centers for Disease Control and Prevention Web Traffic Data: Demonstration Using a Novel Dataset %A Caldwell,Wendy K %A Fairchild,Geoffrey %A Del Valle,Sara Y %+ X Computational Physics Division, Los Alamos National Laboratory, P.O. Box 1663, Mail Stop T086, Los Alamos, NM, 87545, United States, 1 5056678593, wkcaldwell@lanl.gov %K influenza %K surveillance %K infoveillance %K infodemiology %K projections and predictions %K internet %K data sources %D 2020 %7 3.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Influenza epidemics result in a public health and economic burden worldwide. Traditional surveillance techniques, which rely on doctor visits, provide data with a delay of 1 to 2 weeks. A means of obtaining real-time data and forecasting future outbreaks is desirable to provide more timely responses to influenza epidemics. Objective: This study aimed to present the first implementation of a novel dataset by demonstrating its ability to supplement traditional disease surveillance at multiple spatial resolutions. Methods: We used internet traffic data from the Centers for Disease Control and Prevention (CDC) website to determine the potential usability of this data source. We tested the traffic generated by 10 influenza-related pages in 8 states and 9 census divisions within the United States and compared it against clinical surveillance data. Results: Our results yielded an r2 value of 0.955 in the most successful case, promising results for some cases, and unsuccessful results for other cases. In the interest of scientific transparency to further the understanding of when internet data streams are an appropriate supplemental data source, we also included negative results (ie, unsuccessful models). Models that focused on a single influenza season were more successful than those that attempted to model multiple influenza seasons. Geographic resolution appeared to play a key role, with national and regional models being more successful, overall, than models at the state level. Conclusions: These results demonstrate that internet data may be able to complement traditional influenza surveillance in some cases but not in others. Specifically, our results show that the CDC website traffic may inform national- and division-level models but not models for each individual state. In addition, our results show better agreement when the data were broken up by seasons instead of aggregated over several years. We anticipate that this work will lead to more complex nowcasting and forecasting models using this data stream. %M 32437327 %R 10.2196/14337 %U https://www.jmir.org/2020/7/e14337 %U https://doi.org/10.2196/14337 %U http://www.ncbi.nlm.nih.gov/pubmed/32437327 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17693 %T Evaluation of Volume of News Reporting and Opioid-Related Deaths in the United States: Comparative Analysis Study of Geographic and Socioeconomic Differences %A Hswen,Yulin %A Zhang,Amanda %A Freifeld,Clark %A Brownstein,John S %+ University of California San Francisco, Department of Epidemiology and Biostatistics, Bakar Computational Health Sciences Institute, 505 Parnassus Ave, San Francisco, CA, 94143, United States, 1 6177751889, yhswen@gmail.com %K opioid epidemic %K news media %K geographic %K socioeconomic %K addiction %K overdose %D 2020 %7 10.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: News media coverage is a powerful influence on public attitude and government action. The digitization of news media covering the current opioid epidemic has changed the landscape of coverage and may have implications for how to effectively respond to the opioid crisis. Objective: This study aims to characterize the relationship between volume of online opioid news reporting and opioid-related deaths in the United States and how these measures differ across geographic and socioeconomic county-level factors. Methods: Online news reports from February 2018 to April 2019 on opioid-related events in the United States were extracted from Google News. News data were aggregated at the county level and compared against opioid-related death counts. Ordinary least squares regression was used to model opioid-related death rate and opioid news coverage with the inclusion of socioeconomic and geographic explanatory variables. Results: A total of 35,758 relevant news reports were collected representing 1789 counties. Regression analysis revealed that opioid-related death rate was positively associated with news reporting. However, opioid-related death rate and news reporting volume showed opposite correlations with educational attainment and rurality. When controlling for variation in death rate, counties in the Northeast were overrepresented by news coverage. Conclusions: Our results suggest that regional variation in the volume of opioid-related news reporting does not reflect regional variation in opioid-related death rate. Differences in the amount of media attention may influence perceptions of the severity of opioid epidemic. Future studies should investigate the influence of media reporting on public support and action on opioid issues. %M 32673248 %R 10.2196/17693 %U http://www.jmir.org/2020/7/e17693/ %U https://doi.org/10.2196/17693 %U http://www.ncbi.nlm.nih.gov/pubmed/32673248 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17626 %T Eating Disorder Awareness Campaigns: Thematic and Quantitative Analysis Using Twitter %A Viguria,Iranzu %A Alvarez-Mon,Miguel Angel %A Llavero-Valero,Maria %A Asunsolo del Barco,Angel %A Ortuño,Felipe %A Alvarez-Mon,Melchor %+ Department of Medicine and Medical Specialities, University of Alcala, Campus Universitario - C/ 19, Av de Madrid, Km 33,600, Alcalá de Henares, 28871, Spain, 34 918854505, maalvarezdemon@icloud.com %K awareness campaigns %K eating disorders %K Twitter %K social media %D 2020 %7 14.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Health awareness initiatives are frequent but their efficacy is a matter of controversy. We have investigated the effect of the Eating Disorder Awareness Week and Wake Up Weight Watchers campaigns on Twitter. Objective: We aimed to examine whether the Eating Disorder Awareness Week and Wake Up Weight Watchers initiatives increased the volume and dissemination of Twitter conversations related to eating disorders and investigate what content generates the most interest on Twitter. Methods: Over a period of 12 consecutive days in 2018, we collected tweets containing the hashtag #wakeupweightwatchers and hashtags related to Eating Disorder Awareness Week (#eatingdisorderawarenessweek, #eatingdisorderawareness, or #EDAW), with the hashtag #eatingdisorder as a control. The content of each tweet was rated as medical, testimony, help offer, awareness, pro-ana, or anti-ana. We analyzed the number of retweets and favorites generated, as well as the potential reach and impact of the hashtags and the characteristics of contributors. Results: The number of #wakeupweightwatchers tweets was higher than that of Eating Disorder Awareness Week and #eatingdisorder tweets (3900, 2056, and 1057, respectively). The content of tweets was significantly different between the hashtags analyzed (P<.001). Medical content was lower in the awareness campaigns. Awareness and help offer content were lower in #wakeupweightwatchers tweets. Retweet and favorite ratios were highest in #wakeupweightwatchers tweets. Eating Disorder Awareness Week achieved the highest impact, and very influential contributors participated. Conclusions: Both awareness campaigns effectively promoted tweeting about eating disorders. The majority of tweets did not promote any specific preventive or help-seeking behaviors. %M 32673225 %R 10.2196/17626 %U http://www.jmir.org/2020/7/e17626/ %U https://doi.org/10.2196/17626 %U http://www.ncbi.nlm.nih.gov/pubmed/32673225 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e13979 %T Conversations and Misconceptions About Chemotherapy in Arabic Tweets: Content Analysis %A Alghamdi,Abdulrahman %A Abumelha,Khalid %A Allarakia,Jawad %A Al-Shehri,Ahmed %+ College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Makkah-Jeddah Hwy, Jeddah, 22384, Saudi Arabia, 966 012 224 5000, abdurrahman.essa@gmail.com %K internet %K chemotherapy %K cancer %K Twitter %K social media %K Arab world %K misconceptions %K infodemiology %K infoveillance %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although chemotherapy was first introduced for the treatment of cancer more than 60 years ago, the public understanding and acceptance of chemotherapy is still debatable. To the best of our knowledge, no study has assessed the conversations and misconceptions about chemotherapy as a treatment for cancer on social media platforms among the Arabic-speaking populations. Objective: The aim of this study was to assess the types of conversations and misconceptions that were shared on Twitter regarding chemotherapy as a treatment for cancer among the Arabic-speaking populations. Methods: All Arabic tweets containing any of the representative set of keywords related to chemotherapy and written between May 1, 2017 and October 31, 2017 were retrieved. A manual content analysis was performed to identify the categories of the users, general themes of the tweets, and the common misconceptions about chemotherapy. A chi-square test for independence with adjusted residuals was used to assess the significant associations between the categories of the users and the themes of the tweets. Results: A total of 402,157 tweets were retrieved, of which, we excluded 309,602 retweets and 62,651 irrelevant tweets. Therefore, 29,904 tweets were included in the final analysis. The majority of the tweets were posted by general users (25,774/29,904, 86.2%), followed by the relatives and friends of patients with cancer (1913/29,904, 6.4%). The tweets were classified into 9 themes; prayers and wishes for the well-being of patients undergoing chemotherapy was the most common theme (20,288/29,904, 67.8%), followed by misconceptions about chemotherapy (2084/29,904, 7.0%). There was a highly significant association between the category of the users and the themes of the tweets (χ240= 16904.4, P<.001). Conclusions: Our findings support those of the previous infodemiology studies that Twitter is a valuable social media platform for assessing public conversations, discussions, and misconceptions about various health-related topics. The most prevalent theme of the tweets in our sample population was supportive messages for the patients undergoing chemotherapy, thereby suggesting that Twitter could play a role as a support mechanism for such patients. The second most prevalent theme of the tweets in our study was the various misconceptions about chemotherapy. The findings of our exploratory analysis can help physicians and health care organizations tailor educational efforts in the future to address different misconceptions about chemotherapy, thereby leading to increased public acceptance of chemotherapy as a suitable mode of treatment for cancer. %M 32723724 %R 10.2196/13979 %U http://www.jmir.org/2020/7/e13979/ %U https://doi.org/10.2196/13979 %U http://www.ncbi.nlm.nih.gov/pubmed/32723724 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17633 %T Causality Analysis of Google Trends and Dengue Incidence in Bandung, Indonesia With Linkage of Digital Data Modeling: Longitudinal Observational Study %A Syamsuddin,Muhammad %A Fakhruddin,Muhammad %A Sahetapy-Engel,Jane Theresa Marlen %A Soewono,Edy %+ Faculty of Mathematics and Natural Sciences, Institut Teknologi Bandung, Jalan Ganesha 10, Bandung, 40132, Indonesia, 62 8122000534, esoewono@math.itb.ac.id %K dengue %K Google Trends %K infodemiology %K infoveillance %K vector error correction model %K Granger causality %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The popularity of dengue can be inferred from Google Trends that summarizes Google searches of related topics. Both the disease and its Google Trends have a similar source of causation in the dengue virus, leading us to hypothesize that dengue incidence and Google Trends results have a long-run equilibrium. Objective: This research aimed to investigate the properties of this long-run equilibrium in the hope of using the information derived from Google Trends for the early detection of upcoming dengue outbreaks. Methods: This research used the cointegration method to assess a long-run equilibrium between dengue incidence and Google Trends results. The long-run equilibrium was characterized by their linear combination that generated a stationary process. The Dickey-Fuller test was adopted to check the stationarity of the processes. An error correction model (ECM) was then adopted to measure deviations from the long-run equilibrium to examine the short-term and long-term effects. The resulting models were used to determine the Granger causality between the two processes. Additional information about the two processes was obtained by examining the impulse response function and variance decomposition. Results: The Dickey-Fuller test supported an implicit null hypothesis that the dengue incidence and Google Trends results are nonstationary processes (P=.01). A further test showed that the processes were cointegrated (P=.01), indicating that their particular linear combination is a stationary process. These results permitted us to construct ECMs. The model showed the direction of causality of the two processes, indicating that Google Trends results will Granger-cause dengue incidence (not in the reverse order). Conclusions: Various hypothesis testing results in this research concluded that Google Trends results can be used as an initial indicator of upcoming dengue outbreaks. %M 32706682 %R 10.2196/17633 %U http://www.jmir.org/2020/7/e17633/ %U https://doi.org/10.2196/17633 %U http://www.ncbi.nlm.nih.gov/pubmed/32706682 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17087 %T Investigation of Geographic and Macrolevel Variations in LGBTQ Patient Experiences: Longitudinal Social Media Analysis %A Hswen,Yulin %A Zhang,Amanda %A Sewalk,Kara C %A Tuli,Gaurav %A Brownstein,John S %A Hawkins,Jared B %+ Computational Epidemiology Lab, Harvard Medical School, 401 Park Drive, Boston, MA, United States, 1 6177751889, yhswen@gmail.com %K LGBTQ %K sexual and gender minorities %K health care quality %K health care disparities %K social media %K digital health %K sentiment analysis %K infodemiology %D 2020 %7 31.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Discrimination in the health care system contributes to worse health outcomes among lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. Objective: The aim of this study is to examine disparities in patient experience among LGBTQ persons using social media data. Methods: We collected patient experience data from Twitter from February 2013 to February 2017 in the United States. We compared the sentiment of patient experience tweets between Twitter users who self-identified as LGBTQ and non-LGBTQ. The effect of state-level partisan identity on patient experience sentiment and differences between LGBTQ users and non-LGBTQ users were analyzed. Results: We observed lower (more negative) patient experience sentiment among 13,689 LGBTQ users compared to 1,362,395 non-LGBTQ users. Increasing state-level liberal political identification was associated with higher patient experience sentiment among all users but had stronger effects for LGBTQ users. Conclusions: Our findings highlight that social media data can yield insights about patient experience for LGBTQ persons and suggest that a state-level sociopolitical environment influences patient experience for this group. Efforts are needed to reduce disparities in patient care for LGBTQ persons while taking into context the effect of the political climate on these inequities. %M 33137713 %R 10.2196/17087 %U http://www.jmir.org/2020/7/e17087/ %U https://doi.org/10.2196/17087 %U http://www.ncbi.nlm.nih.gov/pubmed/33137713 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17559 %T The Effects of Telemonitoring on Patient Compliance With Self-Management Recommendations and Outcomes of the Innovative Telemonitoring Enhanced Care Program for Chronic Heart Failure: Randomized Controlled Trial %A Ding,Hang %A Jayasena,Rajiv %A Chen,Sheau Huey %A Maiorana,Andrew %A Dowling,Alison %A Layland,Jamie %A Good,Norm %A Karunanithi,Mohanraj %A Edwards,Iain %+ The Australian e-Health Research Centre, Commonwealth Scientific & Industrial Research Organisation Health & Biosecurity, 343 Royal Parade, Parkville VIC 3052, Melbourne, 3052, Australia, 61 416129871, Rajiv.Jayasena@csiro.au %K heart failure %K digital health %K telemonitoring %K remote monitoring %K patient compliance %K randomized controlled trial %D 2020 %7 8.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Telemonitoring enables care providers to remotely support outpatients in self-managing chronic heart failure (CHF), but the objective assessment of patient compliance with self-management recommendations has seldom been studied. Objective: This study aimed to evaluate patient compliance with self-management recommendations of an innovative telemonitoring enhanced care program for CHF (ITEC-CHF). Methods: We conducted a multicenter randomized controlled trial with a 6-month follow-up. The ITEC-CHF program comprised the provision of Bluetooth-enabled scales linked to a call center and nurse care services to assist participants with weight monitoring compliance. Compliance was defined a priori as weighing at least 4 days per week, analyzed objectively from weight recordings on the scales. The intention-to-treat principle was used to perform the analysis. Results: A total of 184 participants (141/184, 76.6% male), with a mean age of 70.1 (SD 12.3) years, were randomized to receive either ITEC-CHF (n=91) or usual care (control; n=93), of which 67 ITEC-CHF and 81 control participants completed the intervention. For the compliance criterion of weighing at least 4 days per week, the proportion of compliant participants in the ITEC-CHF group was not significantly higher than that in the control group (ITEC-CHF: 67/91, 74% vs control: 56/91, 60%; P=.06). However, the proportion of ITEC-CHF participants achieving the stricter compliance standard of at least 6 days a week was significantly higher than that in the control group (ITEC-CHF: 41/91, 45% vs control: 23/93, 25%; P=.005). Conclusions: ITEC-CHF improved participant compliance with weight monitoring, although the withdrawal rate was high. Telemonitoring is a promising method for supporting both patients and clinicians in the management of CHF. However, further refinements are required to optimize this model of care. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12614000916640; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366691 %M 32673222 %R 10.2196/17559 %U https://www.jmir.org/2020/7/e17559 %U https://doi.org/10.2196/17559 %U http://www.ncbi.nlm.nih.gov/pubmed/32673222 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17032 %T Wearable Motion Sensor Device to Facilitate Rehabilitation in Patients With Shoulder Adhesive Capsulitis: Pilot Study to Assess Feasibility %A Chen,Yu-Pin %A Lin,Chung-Ying %A Tsai,Ming-Jr %A Chuang,Tai-Yuan %A Lee,Oscar Kuang-Sheng %+ Institute of Clinical Medicine, National Yang Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan, 886 2 28200183, oscarlee9203@gmail.com %K motion sensor %K adhesive capsulitis %K rehabilitation %K home-based exercise %K telerehabilitation %K telehealth, telemonitoring %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Adhesive capsulitis (AC) of the shoulder is a common disorder that painfully reduces the shoulder range of motion (ROM) among middle-aged individuals. Although physical therapy with home-based exercises is widely advised to restore ROM in the treatment of AC, clinical results vary owing to inconsistent patient compliance. Objective: In this study, we aimed to verify the feasibility of a treatment model that involves applying a wearable motion sensor device to assist patients conduct home-based exercises to improve training compliance and the accuracy of exercises, with the ultimate goal of improving the functional recovery of patients with AC. Methods: The motion sensor device was comprised of inertial measurement unit–based sensors and mobile apps for patients and physicians, offering shoulder mobility tracing, home-based exercise support, and progress monitoring. The interrater reliability of shoulder mobility measurement using the motion sensor device on 10 healthy participants and 15 patients with AC was obtained using an intraclass correlation coefficient analysis and compared with the assessments performed by two highly experienced physicians. A pilot prospective control trial was then carried out to allocate the 15 patients with AC to two groups: home-based exercise group and motion sensor–assisted rehabilitation group. Changes in active and passive shoulder ROM, pain and functional scores, and exercise completion rates were compared between the groups during a treatment period of 3 months. Results: Shoulder ROM, as measured using the motion sensor device, exhibited good to excellent reliability based on the comparison with the measurements of two physicians (intraclass correlation coefficient range, 0.771 to 0.979). Compared with patients with AC in the home-based exercise group, those in the motion sensor–assisted rehabilitation group exhibited better shoulder mobility and functional recovery and a higher exercise completion rate during and after 3 months of rehabilitation. Conclusions: Motion sensor device–assisted home-based rehabilitation for the treatment of AC is a useful treatment model for telerehabilitation that enhances the compliance of patients through training, thus improving functional recovery. This helps overcome important obstacles in physiotherapy at home by providing comprehensible and easily accessible exercise instructions, enhancing compliance, ensuring the correctness of exercise, and monitoring the progress of patients. %M 32457026 %R 10.2196/17032 %U http://www.jmir.org/2020/7/e17032/ %U https://doi.org/10.2196/17032 %U http://www.ncbi.nlm.nih.gov/pubmed/32457026 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17414 %T Health Care Professionals’ Views on Using Remote Measurement Technology in Managing Central Nervous System Disorders: Qualitative Interview Study %A Andrews,Jacob A %A Craven,Michael P %A Jamnadas-Khoda,Jennifer %A Lang,Alexandra R %A Morriss,Richard %A Hollis,Chris %A , %+ Division of Psychiatry and Applied Psychology, Institute of Mental Health, School of Medicine, University of Nottingham, Mindtech, Institute of Mental Health, Jubilee Campus, Nottingham, NG7 2TU, United Kingdom, 44 01157484218, jacob.andrews@nottingham.ac.uk %K epilepsy %K multiple sclerosis %K depression %K medical devices %K barriers %K health personnel %K qualitative %K mobile phones %K mHealth %K eHealth %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Remote measurement technologies (RMT) can be used to collect data on a variety of bio-behavioral variables, which may improve the care of patients with central nervous system disorders. Although various studies have explored their potential, prior work has highlighted a knowledge gap in health care professionals’ (HCPs) perceptions of the value of RMT in clinical practice. Objective: This study aims to understand HCPs’ perspectives on using RMT in health care practice for the care of patients with depression, epilepsy, or multiple sclerosis (MS). Methods: Semistructured interviews were conducted with 26 multidisciplinary primary and secondary care HCPs who care for patients with epilepsy, depression, or MS. Interviews were transcribed verbatim and analyzed using thematic analysis. Results: A total of 8 main themes emerged from the analysis: (1) potential clinical value of RMT data; (2) when to use RMT in care pathways; (3) roles of health care staff who may use RMT data; (4) presentation and accessibility of data; (5) obstacles to successful use of RMT; (6) limits to the role of RMT; (7) empowering patients; and (8) considerations around alert-based systems. Conclusions: RMT could add value to the system of care for patients with central nervous system disorders by providing clinicians with graphic summaries of data in the patient record. Barriers of both technical and human nature should be considered when using these technologies, as should the limits to the benefits they can offer. %M 32706664 %R 10.2196/17414 %U https://www.jmir.org/2020/7/e17414 %U https://doi.org/10.2196/17414 %U http://www.ncbi.nlm.nih.gov/pubmed/32706664 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18058 %T Comprehensive Telestroke Network to Optimize Health Care Delivery for Cerebrovascular Diseases: Algorithm Development %A Bayona,Hernán %A Ropero,Brenda %A Salazar,Antonio José %A Pérez,Juan Camilo %A Granja,Manuel Felipe %A Martínez,Carlos Fernando %A Useche,Juan Nicolás %+ Primary Stroke Center, Neurology Department, University Hospital Fundación Santa Fe de Bogotá, Calle 119 No. 7-75, Bogotá DC, Colombia, 57 16030303 ext 5370, hernanbayonao@gmail.com %K stroke %K telestroke %K cerebrovascular disease %K software %K algorithms %K emergency medicine %K clinical pathways %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Health care delivery for cerebrovascular diseases is a complex process, which may be improved using telestroke networks. Objective: The purpose of this work was to establish and implement a protocol for the management of patients with acute stroke symptoms according to the available treatment alternatives at the initial point of care and the transfer possibilities. Methods: The review board of our institutions approved this work. The protocol was based on the latest guidelines of the American Heart Association and American Stroke Association. Stroke care requires human and technological resources, which may differ according to the patient’s point of entry into the health care system. Three health care settings were identified to define the appropriate protocols: primary health care setting, intermediate health care setting, and advanced health care setting. Results: A user-friendly web-based telestroke solution was developed. The predictors, scales, and scores implemented in this system allowed the assessment of the vascular insult severity and neurological status of the patient. The total number of possible pathways implemented was as follows: 10 in the primary health care setting, 39 in the intermediate health care setting, and 1162 in the advanced health care setting. Conclusions: The developed comprehensive telestroke platform is the first stage in optimizing health care delivery for patients with stroke symptoms, regardless of the entry point into the emergency network, in both urban and rural regions. This system supports health care personnel by providing adequate inpatient stroke care and facilitating the prompt transfer of patients to a more appropriate health care setting if necessary, especially for patients with acute ischemic stroke within the therapeutic window who are candidates for reperfusion therapies, ultimately contributing to mitigating the mortality and morbidity associated with stroke. %M 32716302 %R 10.2196/18058 %U http://www.jmir.org/2020/7/e18058/ %U https://doi.org/10.2196/18058 %U http://www.ncbi.nlm.nih.gov/pubmed/32716302 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17995 %T The Internet Hospital as a Telehealth Model in China: Systematic Search and Content Analysis %A Han,Yangyang %A Lie,Reidar K %A Guo,Rui %+ School of Public Health, Capital Medical University, No 10 Xitoutiao, Youanmenwai, Fengtai District, Beijing, 100069, China, 86 01083911573, guorui@ccmu.edu.cn %K Internet hospital %K telehealth %K telemedicine %K ehealth %K digital health %K digital medicine %K health services research %K China %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet hospital is an innovative organizational form and service mode under the tide of internet plus in the Chinese medical industry. It is the product of the interaction between consumer health needs and supply-side reform. However, there has still been no systematic summary of its establishment and definition, nor has there been an analysis of its service content. Objective: The primary purpose of this study was to understand the definition, establishment, and development status of internet hospitals. Methods: Data on internet hospitals were obtained via the Baidu search engine for results up until January 1, 2019. Based on the results of the search, we obtained more detailed information from the official websites and apps of 130 online hospitals and formed a database for descriptive analysis. Results: By January 2019, the number of registered internet hospitals had expanded to approximately 130 in 25 provinces, accounting for 73.5% of all provinces or province-level municipalities in China. Internet hospitals, as a new telehealth model, are distinct but overlap with online health, telemedicine, and mobile medical. They offer four kinds of services—convenience services, online medical services, telemedicine, and related industries. In general, there is an underlying common treatment flowchart of care in ordinary and internet hospitals. There are three different sponsors—government-led integration, hospital-led, and enterprise-led internet hospitals—for which stakeholders have different supporting content and responsibilities. Conclusions: Internet hospitals are booming in China, and it is the joint effort of the government and the market to alleviate the coexistence of shortages of medical resources and wasted medical supplies. The origin of internet hospitals in the eastern and western regions, the purpose of the establishment initiator, and the content of online and offline services are different. Only further standardized management and reasonable industry freedom can realize the original intention of the internet hospital of meeting various health needs. %M 32723721 %R 10.2196/17995 %U http://www.jmir.org/2020/7/e17995/ %U https://doi.org/10.2196/17995 %U http://www.ncbi.nlm.nih.gov/pubmed/32723721 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18598 %T Technology-Enabled Self-Management of Chronic Obstructive Pulmonary Disease With or Without Asynchronous Remote Monitoring: Randomized Controlled Trial %A Stamenova,Vess %A Liang,Kyle %A Yang,Rebecca %A Engel,Katrina %A van Lieshout,Florence %A Lalingo,Elizabeth %A Cheung,Angelica %A Erwood,Adam %A Radina,Maria %A Greenwald,Allen %A Agarwal,Payal %A Sidhu,Aman %A Bhatia,R Sacha %A Shaw,James %A Shafai,Roshan %A Bhattacharyya,Onil %+ Institute for Health System Solutions and Virtual Care, Women's College Hospital, 76 Grenville St, Toronto, ON, M5S 1B2, Canada, 1 4163236000 ext 5112, vess.stamenova@wchospital.ca %K COPD %K eHealth %K telemedicine %K remote consultation %K self-care %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and leads to frequent hospital admissions and emergency department (ED) visits. COPD exacerbations are an important patient outcome, and reducing their frequency would result in significant cost savings. Remote monitoring and self-monitoring could both help patients manage their symptoms and reduce the frequency of exacerbations, but they have different resource implications and have not been directly compared. Objective: This study aims to compare the effectiveness of implementing a technology-enabled self-monitoring program versus a technology-enabled remote monitoring program in patients with COPD compared with a standard care group. Methods: We conducted a 3-arm randomized controlled trial evaluating the effectiveness of a remote monitoring and a self-monitoring program relative to standard care. Patients with COPD were recruited from outpatient clinics and a pulmonary rehabilitation program. Patients in both interventions used a Bluetooth-enabled device kit to monitor oxygen saturation, blood pressure, temperature, weight, and symptoms, but only patients in the remote monitoring group were monitored by a respiratory therapist. All patients were assessed at baseline and at 3 and 6 months after program initiation. Outcomes included self-management skills, as measured by the Partners in Health (PIH) Scale; patient symptoms measured with the St George’s Respiratory Questionnaire (SGRQ); and the Bristol COPD Knowledge Questionnaire (BCKQ). Patients were also asked to self-report on health system use, and data on health use were collected from the hospital. Results: A total of 122 patients participated in the study: 40 in the standard care, 41 in the self-monitoring, and 41 in the remote monitoring groups. Although all 3 groups improved in PIH scores, BCKQ scores, and SGRQ impact scores, there were no significant differences among any of the groups. No effects were observed on the SGRQ activity or symptom scores or on hospitalizations, ED visits, or clinic visits. Conclusions: Despite regular use of the technology, patients with COPD assigned to remote monitoring or self-monitoring did not have any improvement in patient outcomes such as self-management skills, knowledge, or symptoms, or in health care use compared with each other or with a standard care group. This may be owing to low health care use at baseline, the lack of structured educational components in the intervention groups, and the lack of integration of the action plan with the technology. Trial Registration: ClinicalTrials.gov NCT03741855; https://clinicaltrials.gov/ct2/show/ NCT03741855 %M 32729843 %R 10.2196/18598 %U http://www.jmir.org/2020/7/e18598/ %U https://doi.org/10.2196/18598 %U http://www.ncbi.nlm.nih.gov/pubmed/32729843 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17231 %T Clinical Characteristics of an Internet-Based Cohort of Patient-Reported Diagnosis of Granulomatosis With Polyangiitis and Microscopic Polyangiitis: Observational Study %A Springer,Jason Michael %A Kermani,Tanaz A %A Sreih,Antoine %A Shaw,Dianne G %A Young,Kalen %A Burroughs,Cristina M %A Merkel,Peter A %+ University of Kansas Medical Center, 3901 Rainbow Blvd MS 2026, Kansas City, KS, 66160, United States, 1 913 588 6009, jspringer2@kumc.edu %K granulomatosis with polyangiitis %K microscopic polyangiitis %K vasculitis %K patient-reported outcomes %K patient registry %K electronic health records %K questionnaire %K online cohort %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Utilizing the traditional centers of excellence approach to conduct clinical trials involving rare diseases remains challenging. Patient-based registries have been shown to be both feasible and valid in several other diseases. Objective: This report outlines the clinical characteristics of a large internet registry cohort of participants with a self-reported diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis. Methods: Patients with a self-reported diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis in an internet-based prospective longitudinal cohort (from the Vasculitis Patient-Powered Research Network) were included. Data on symptoms, diagnostic testing, and treatment were collected using standardized questionnaires. Results: The study compared patients with granulomatosis with polyangiitis (n=762) and patients with microscopic polyangiitis (n=164). Of the cohort, 97.7% (904/925) reported the diagnosis had been confirmed by a physician. Compared to microscopic polyangiitis, patients with granulomatosis with polyangiitis reported significantly more ear, nose, and throat manifestations (granulomatosis with polyangiitis: 641/723, 88.7%; microscopic polyangiitis: 89/164, 54.3%; z=10.42, P<.001), fevers (granulomatosis with polyangiitis: 325/588, 55.3%; microscopic polyangiitis: 64/139, 46.0%; z=1.96, P=.05), joint involvement (granulomatosis with polyangiitis: 549/688, 79.8%; microscopic polyangiitis: 106/154, 68.8%; z=2.96, P=.003), and pulmonary involvement (granulomatosis with polyangiitis: 523/734, 71.3%; microscopic polyangiitis: 90/154, 58.4%; z=3.13, P=.002). Compared to microscopic polyangiitis, patients with granulomatosis with polyangiitis reported significantly less renal involvement (granulomatosis with polyangiitis: 457/743, 61.5%; microscopic polyangiitis: 135/163, 82.8%; z=–5.18, P<.001) and renal transplantation (granulomatosis with polyangiitis: 10/721, 1.4%; microscopic polyangiitis: 7/164, 4.3%; z=–2.43, P=.02). Antineutrophil cytoplasmic antibody positivity was reported in 94.2% (652/692) of patients with granulomatosis with polyangiitis and 96.1% (147/153) of patients with microscopic polyangiitis. A biopsy showing vasculitis was reported in 77.0% (562/730) of patients with granulomatosis with polyangiitis and 81.9% (131/160) of patients with microscopic polyangiitis. Conclusions: In this large, internet-based cohort of patients with a self-reported diagnosis of granulomatosis with polyangiitis or microscopic polyangiitis, disease manifestations were consistent with expectations for each type of vasculitis. Given the rarity of these and other vasculitides, conducting some types of research through internet-based registries may provide an efficient alternative to inperson, center-of-excellence clinical trials. %M 32459634 %R 10.2196/17231 %U https://www.jmir.org/2020/7/e17231 %U https://doi.org/10.2196/17231 %U http://www.ncbi.nlm.nih.gov/pubmed/32459634 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17238 %T Worldwide Prevalence of Hearing Loss Among Smartphone Users: Cross-Sectional Study Using a Mobile-Based App %A Masalski,Marcin %A Morawski,Krzysztof %+ Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Wroclaw Medical University, Wybrzeze Ludwika Pasteura 1, Wroclaw, 50-367, Poland, 48 515086252, marcin.masalski@pwr.edu.pl %K hearing loss %K epidemiology %K mobile-based %K hearing test %K pure-tone audiometry %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In addition to the aging process, risk factors for hearing loss in adults include, among others, exposure to noise, use of ototoxic drugs, genetics, and limited access to medical care. Differences in exposure to these factors are bound to be reflected in the prevalence of hearing loss. Assessment of hearing loss can easily be carried out on a large scale and at low cost using mobile apps. Objective: This study aimed to conduct a worldwide assessment of the differences in hearing loss prevalence between countries in a group of mobile device users. Methods: Hearing tests were conducted using the open-access Android-based mobile app Hearing Test. The app is available free of charge in the Google Play store, provided that consent to the use of the results for scientific purposes is given. This study included hearing tests carried out on device models supported by the app with bundled headphones in the set. Calibration factors for supported models were determined using the biological method. The tests consisted of self-determining the quietest audible tone in the frequency range from 250 Hz to 8 kHz by adjusting its intensity using the buttons. The ambient noise level was optionally monitored using a built-in microphone. Following the test, the user could compare his hearing threshold against age norms by providing his or her age. The user's location was identified based on the phone’s IP address. Results: From November 23, 2016 to November 22, 2019, 733,716 hearing tests were conducted on 236,716 mobile devices across 212 countries. After rejecting the tests that were incomplete, performed with disconnected headphones, not meeting the time criterion, repeated by the same user, or carried out regularly on one device, 116,733 of 733,716 tests (15.9%) were qualified for further analysis. The prevalence of hearing loss, defined as the average threshold at frequencies 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz above 25 dB HL in the better ear, was calculated at 15.6% (95% CI 15.4-15.8). Statistically significant differences were found between countries (P<.001), with the highest prevalences for Bangladesh, Pakistan, and India (>28%) and the lowest prevalences for Taiwan, Finland, and South Korea (<11%). Conclusions: Hearing thresholds measured by means of mobile devices were congruent with the literature data on worldwide hearing loss prevalence. Uniform recruitment criteria simplify the comparison of the hearing loss prevalence across countries. Hearing testing on mobile devices may be a valid tool in epidemiological studies carried out on a large scale. %M 32706700 %R 10.2196/17238 %U http://www.jmir.org/2020/7/e17238/ %U https://doi.org/10.2196/17238 %U http://www.ncbi.nlm.nih.gov/pubmed/32706700 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17616 %T Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study %A Heponiemi,Tarja %A Jormanainen,Vesa %A Leemann,Lars %A Manderbacka,Kristiina %A Aalto,Anna-Mari %A Hyppönen,Hannele %+ Finnish Institution for Health and Welfare, PO Box 30, Helsinki, , Finland, 358 295247434, tarja.heponiemi@thl.fi %K digital divide %K online services %K benefits %K skills %K access %K sociodemographics %K participation %K Finland %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The number of online services in health care is increasing rapidly in developed countries. Users are expected to take a more skilled and active role in taking care of their health and prevention of ill health. This induces risks that users (especially those who need the services the most) will drop out of digital services, resulting in a digital divide or exclusion. To ensure wide and equal use of online services, all users must experience them as beneficial. Objective: This study aimed to examine associations of (1) demographics (age, gender, and degree of urbanization), (2) self-rated health, (3) socioeconomic position (education, experienced financial hardship, labor market position, and living alone), (4) social participation (voting, satisfaction with relationships, and keeping in touch with friends and family members), and (5) access, skills, and extent of use of information and communication technologies (ICT) with perceived benefits of online health care and social welfare services. Associations were examined separately for perceived health, economic, and collaboration benefits. Methods: We used a large random sample representative of the Finnish population including 4495 (56.77% women) respondents aged between 20 and 97 years. Analyses of covariance were used to examine the associations of independent variables with perceived benefits. Results: Access to online services, ICT skills, and extent of use were associated with all examined benefits of online services. ICT skills seemed to be the most important factor. Poor self-rated health was also consistently associated with lower levels of perceived benefits. Similarly, those who were keeping in touch with their friends and relatives at least once a week perceived online services more often beneficial in all the examined dimensions. Those who had experienced financial hardship perceived fewer health and economic benefits than others. Those who were satisfied with their relationships reported higher levels of health and collaboration benefits compared with their counterparts. Also age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services. Conclusions: According to our results, providing health care services online has the potential to reinforce existing social and health inequalities. Our findings suggest that access to online services, skills to use them, and extent of use play crucial roles in perceiving them as beneficial. Moreover, there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them. %M 32673218 %R 10.2196/17616 %U https://www.jmir.org/2020/7/e17616 %U https://doi.org/10.2196/17616 %U http://www.ncbi.nlm.nih.gov/pubmed/32673218 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18095 %T Relationships Between the Usage of Televisions, Computers, and Mobile Phones and the Quality of Sleep in a Chinese Population: Community-Based Cross-Sectional Study %A Xie,Yao Jie %A Cheung,Daphne SK %A Loke,Alice Y %A Nogueira,Bernice L %A Liu,Karry M %A Leung,Angela YM %A Tsang,Alice SM %A Leong,Cindy SU %A Molassiotis,Alex %+ School of Nursing, The Hong Kong Polytechnic University, FG424, PolyU, Hong Kong, China (Hong Kong), 852 63135399, grace.yj.xie@polyu.edu.hk %K electronic device %K screen-based %K sleep %K Chinese %K digital %K mobile phone %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: No study has comprehensively investigated the association between the usage of typical screen-based electronic media devices and sleep quality in a Chinese population with individuals in a wide range of ages. Objective: This study aimed to understand the characteristics of television (TV) viewing, computer usage, and mobile phone usage in a representative Chinese population in Macau and to examine their roles in predicting the variations in sleep quality. Methods: This cross-sectional study was an analysis of 1500 Macau residents aged 15 to 90 years based on a community-based health needs assessment study entitled, “Healthy Living, Longer Lives.” Data collection was conducted in 7 districts of Macau from 2017 to 2018 through face-to-face interviews. The durations of daily TV viewing, computer usage, and mobile phone usage were recorded in a self-administered questionnaire. The Chinese version of the Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality. Results: The prevalence of TV, computer, and mobile phone usage was 78.4% (1176/1500), 51.6% (769/1490), and 85.5% (1276/1492), respectively. The average daily hours of usage were 1.75 (1.62), 1.53 (2.26), and 2.85 (2.47) hours, respectively. Females spent more time watching TV (P=.03) and using mobile phones (P=.02) and less time on the computer (P=.04) as compared to males. Older adults were more likely to watch TV while young people spent more time using the computer and mobile phones (P for all trends<.001). The mean PSQI global score was 4.79 (2.80) among the participants. Females exhibited significantly higher PSQI scores than males (5.04 vs 4.49, respectively; P<.001). No linear association was observed between the PSQI score and the amount of time spent on the 3 electronic devices (P=.58 for PSQI-TV, P=.05 for PSQI-computer, and P=.52 for PSQI-mobile phone). Curve estimation showed significant quadratic curvilinear associations in PSQI-TV (P=.003) and PSQI-computer (P<.001) among all the participants and in PSQI-mobile phone among youths (age, 15-24 years; P=.04). After adjustment of the gender, age, body mass index, demographics, and lifestyle factors, more than 3 hours of TV viewing and 4 hours of computer usage or mobile phone usage was associated with 85% (95% CI 1.04-1.87; P=.008), 72% (95% CI 1.01-2.92; P=.045), and 53% (95% CI 1.06-2.22; P=.03) greater odds of having poor sleep quality (PSQI score>5), respectively. Conclusions: The mobile phone was the most popular screen-based electronic device used in the Macau population, especially among young people. “J” shape associations were observed between sleep quality and the duration of TV viewing, computer usage, and mobile phone usage, indicating that the extreme use of screen-based electronic devices predicted poorer sleep status, whereas moderate use would be acceptable. %M 32369439 %R 10.2196/18095 %U https://www.jmir.org/2020/7/e18095 %U https://doi.org/10.2196/18095 %U http://www.ncbi.nlm.nih.gov/pubmed/32369439 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15683 %T Exploring the Relationship Between Internet Use and Mental Health Among Older Adults in England: Longitudinal Observational Study %A Lam,Sabrina Sze Man %A Jivraj,Stephen %A Scholes,Shaun %+ University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 20 7679 1721, stephen.jivraj@gmail.com %K internet %K socioeconomic factors %K mental health %K life satisfaction %K depression %K effect modifier %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is uncertainty about the impact of internet use on mental health in older adults. Moreover, there is very little known specifically about the impact of particular purposes of internet use. Objective: This study aims to investigate the longitudinal relationship between two distinct concepts of mental health with the frequency of internet use among older adults: the moderating role of socioeconomic position (SEP) and the association between specific purposes of internet use. Methods: Longitudinal fixed and random effects (27,507 person-years) models were fitted using waves 6-8 of the English Longitudinal Study of Ageing to examine the relationship between different aspects of internet use (frequency and purpose) and two mental health outcomes (depression and life satisfaction). The potential moderating effect of SEP on these associations was tested using interaction terms. Results: Infrequent internet use (monthly or less vs daily) was predictive of deteriorating life satisfaction (β=−0.512; P=.02) but not depression. Education and occupational class had a moderating effect on the association between frequency of internet use and mental health. The associations were stronger in the highest educational group in both depression (P=.09) and life satisfaction (P=.02), and in the highest occupational group in life satisfaction (P=.05) only. Using the internet for communication was associated with lower depression (β=−0.24; P=.002) and better life satisfaction (β=.97; P<.001), whereas those using the internet for information access had worse life satisfaction (β=−0.86; P<.001) compared with those who did not. Conclusions: Policies to improve mental health in older adults should encourage internet use, especially as a tool to aid communication. %M 32718913 %R 10.2196/15683 %U https://www.jmir.org/2020/7/e15683 %U https://doi.org/10.2196/15683 %U http://www.ncbi.nlm.nih.gov/pubmed/32718913 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18813 %T Understanding the Dimensions of Medical Crowdfunding: A Visual Analytics Approach %A Ren,Jie %A Raghupathi,Viju %A Raghupathi,Wullianallur %+ Gabelli School of Business, Fordham University, 140 W 62nd Street, New York, NY, 10023, United States, 1 2126367230, raghupathi@fordham.edu %K crowdfunding %K medical crowdfunding %K GoFundMe %K fundraising %K health care %K health care affordability %K patient %K Facebook %K fundraiser %D 2020 %7 3.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Medical crowdfunding has emerged as a growing field for fundraising opportunities. Some environmental trends have driven the emergence of campaigns to raise funds for medical care. These trends include lack of medical insurance, economic backlash following the 2008 financial collapse, and shortcomings of health care regulations. Objective: Research regarding crowdfunding campaign use, reasons, and effects on the provision of medical care and individual relationships in health systems is limited. This study aimed to explore the nature and dimensions of the phenomenon of medical crowdfunding using a visual analytics approach and data crawled from the GoFundMe crowdfunding platform in 2019. We aimed to explore and identify the factors that contribute to a successful campaign. Methods: This data-driven study used a visual analytics approach. It focused on descriptive analytics to obtain a panoramic insight into medical projects funded through the GoFundMe crowdfunding platform. Results: This study highlighted the relevance of positioning the campaign for fundraising. In terms of motivating donors, it appears that people are typically more generous in contributing to campaigns for children rather than those for adults. The results emphasized the differing dynamics that a picture posted in the campaign brings to the potential for medical crowdfunding. In terms of donor’s motivation, the results show that a picture depicting the pediatric patient by himself or herself is the most effective. In addition, a picture depicting the current medical condition of the patient as severe is more effective than one depicting relative normalcy in the condition. This study also drew attention to the optimum length of the title. Finally, an interesting trend in the trajectory of donations is that the average amount of a donation decreases with an increase in the number of donors. This indicates that the first donors tend to be the most generous. Conclusions: This study examines the relationship between social media, the characteristics of a campaign, and the potential for fundraising. Its analysis of medical crowdfunding campaigns across the states offers a window into the status of the country’s health care affordability. This study shows the nurturing role that social media can play in the domain of medical crowdfunding. In addition, it discusses the drivers of a successful fundraising campaign with respect to the GoFundMe platform. %M 32618573 %R 10.2196/18813 %U https://www.jmir.org/2020/7/e18813 %U https://doi.org/10.2196/18813 %U http://www.ncbi.nlm.nih.gov/pubmed/32618573 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17451 %T The Potential of Smartphone Apps in Informing Protobacco and Antitobacco Messaging Efforts Among Underserved Communities: Longitudinal Observational Study %A Lee,Edmund WJ %A Bekalu,Mesfin Awoke %A McCloud,Rachel %A Vallone,Donna %A Arya,Monisha %A Osgood,Nathaniel %A Li,Xiaoyan %A Minsky,Sara %A Viswanath,Kasisomayajula %+ Dana-Farber Cancer Institute, 375 Longwood Avenue, Boston, MA, 02215, United States, 1 6178587988, Edmund_Lee@dfci.harvard.edu %K mobile health %K mobile phone %K tobacco use %K big data %K spatial analysis %K data science %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: People from underserved communities such as those from lower socioeconomic positions or racial and ethnic minority groups are often disproportionately targeted by the tobacco industry, through the relatively high levels of tobacco retail outlets (TROs) located in their neighborhood or protobacco marketing and promotional strategies. It is difficult to capture the smoking behaviors of individuals in actual locations as well as the extent of exposure to tobacco promotional efforts. With the high ownership of smartphones in the United States—when used alongside data sources on TRO locations—apps could potentially improve tobacco control efforts. Health apps could be used to assess individual-level exposure to tobacco marketing, particularly in relation to the locations of TROs as well as locations where they were most likely to smoke. To date, it remains unclear how health apps could be used practically by health promotion organizations to better reach underserved communities in their tobacco control efforts. Objective: This study aimed to demonstrate how smartphone apps could augment existing data on locations of TROs within underserved communities in Massachusetts and Texas to help inform tobacco control efforts. Methods: Data for this study were collected from 2 sources: (1) geolocations of TROs from the North American Industry Classification System 2016 and (2) 95 participants (aged 18 to 34 years) from underserved communities who resided in Massachusetts and Texas and took part in an 8-week study using location tracking on their smartphones. We analyzed the data using spatial autocorrelation, optimized hot spot analysis, and fitted power-law distribution to identify the TROs that attracted the most human traffic using mobility data. Results: Participants reported encountering protobacco messages mostly from store signs and displays and antitobacco messages predominantly through television. In Massachusetts, clusters of TROs (Dorchester Center and Jamaica Plain) and reported smoking behaviors (Dorchester Center, Roxbury Crossing, Lawrence) were found in economically disadvantaged neighborhoods. Despite the widespread distribution of TROs throughout the communities, participants overwhelmingly visited a relatively small number of TROs in Roxbury and Methuen. In Texas, clusters of TROs (Spring, Jersey Village, Bunker Hill Village, Sugar Land, and Missouri City) were found primarily in Houston, whereas clusters of reported smoking behaviors were concentrated in West University Place, Aldine, Jersey Village, Spring, and Baytown. Conclusions: Smartphone apps could be used to pair geolocation data with self-reported smoking behavior in order to gain a better understanding of how tobacco product marketing and promotion influence smoking behavior within vulnerable communities. Public health officials could take advantage of smartphone data collection capabilities to implement targeted tobacco control efforts in these strategic locations to reach underserved communities in their built environment. %M 32673252 %R 10.2196/17451 %U https://www.jmir.org/2020/7/e17451 %U https://doi.org/10.2196/17451 %U http://www.ncbi.nlm.nih.gov/pubmed/32673252 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18697 %T Diagnosing Parkinson Disease Through Facial Expression Recognition: Video Analysis %A Jin,Bo %A Qu,Yue %A Zhang,Liang %A Gao,Zhan %+ Dongbei University of Finance and Economics, 217 Jianshan St, Shahekou District, Dalian, China, 86 15524709655, liang.zhang@dufe.edu.cn %K Parkinson disease %K face landmarks %K machine learning %K artificial intelligence %D 2020 %7 10.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The number of patients with neurological diseases is currently increasing annually, which presents tremendous challenges for both patients and doctors. With the advent of advanced information technology, digital medical care is gradually changing the medical ecology. Numerous people are exploring new ways to receive a consultation, track their diseases, and receive rehabilitation training in more convenient and efficient ways. In this paper, we explore the use of facial expression recognition via artificial intelligence to diagnose a typical neurological system disease, Parkinson disease (PD). Objective: This study proposes methods to diagnose PD through facial expression recognition. Methods: We collected videos of facial expressions of people with PD and matched controls. We used relative coordinates and positional jitter to extract facial expression features (facial expression amplitude and shaking of small facial muscle groups) from the key points returned by Face++. Algorithms from traditional machine learning and advanced deep learning were utilized to diagnose PD. Results: The experimental results showed our models can achieve outstanding facial expression recognition ability for PD diagnosis. Applying a long short-term model neural network to the positions of the key features, precision and F1 values of 86% and 75%, respectively, can be reached. Further, utilizing a support vector machine algorithm for the facial expression amplitude features and shaking of the small facial muscle groups, an F1 value of 99% can be achieved. Conclusions: This study contributes to the digital diagnosis of PD based on facial expression recognition. The disease diagnosis model was validated through our experiment. The results can help doctors understand the real-time dynamics of the disease and even conduct remote diagnosis. %M 32673247 %R 10.2196/18697 %U https://www.jmir.org/2020/7/e18697 %U https://doi.org/10.2196/18697 %U http://www.ncbi.nlm.nih.gov/pubmed/32673247 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18059 %T Characterization and Correction of Bias Due to Nonparticipation and the Degree of Loyalty in Large-Scale Finnish Loyalty Card Data on Grocery Purchases: Cohort Study %A Vuorinen,Anna-Leena %A Erkkola,Maijaliisa %A Fogelholm,Mikael %A Kinnunen,Satu %A Saarijärvi,Hannu %A Uusitalo,Liisa %A Näppilä,Turkka %A Nevalainen,Jaakko %+ Faculty of Social Sciences (Health Sciences), Tampere University, Arvo Ylpön katu 34, FI-33014, Tampere, , Finland, 358 408485966, anna-leena.vuorinen@vtt.fi %K loyalty card data %K diet %K selection bias %K weighting %K raking %K food %D 2020 %7 15.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: To date, the evaluation of diet has mostly been based on questionnaires and diaries that have their limitations in terms of being time and resource intensive, and a tendency toward social desirability. Loyalty card data obtained in retailing provides timely and objective information on diet-related behaviors. In Finland, the market is highly concentrated, which provides a unique opportunity to investigate diet through grocery purchases. Objective: The aims of this study were as follows: (1) to investigate and quantify the selection bias in large-scale (n=47,066) loyalty card (LoCard) data and correct the bias by developing weighting schemes and (2) to investigate how the degree of loyalty relates to food purchases. Methods: Members of a loyalty card program from a large retailer in Finland were contacted via email and invited to take part in the study, which involved consenting to the release of their grocery purchase data for research purposes. Participants’ sociodemographic background was obtained through a web-based questionnaire and was compared to that of the general Finnish adult population obtained via Statistics Finland. To match the distributions of sociodemographic variables, poststratification weights were constructed by using the raking method. The degree of loyalty was self-estimated on a 5-point rating scale. Results: On comparing our study sample with the general Finnish adult population, in our sample, there were more women (65.25%, 30,696/47,045 vs 51.12%, 2,273,139/4,446,869), individuals with higher education (56.91%, 20,684/36,348 vs 32.21%, 1,432,276/4,446,869), and employed individuals (60.53%, 22,086/36,487 vs 52.35%, 2,327,730/4,446,869). Additionally, in our sample, there was underrepresentation of individuals aged under 30 years (14.44%, 6,791/47,045 vs 18.04%, 802,295/4,446,869) and over 70 years (7.94%, 3,735/47,045 vs 18.20%, 809,317/4,446,869), as well as retired individuals (23.51%, 8,578/36,487 vs 31.82%, 1,414,785/4,446,869). Food purchases differed by the degree of loyalty, with higher shares of vegetable, red meat & processed meat, and fat spread purchases in the higher loyalty groups. Conclusions: Individuals who consented to the use of their loyalty card data for research purposes tended to diverge from the general Finnish adult population. However, the high volume of data enabled the inclusion of sociodemographically diverse subgroups and successful correction of the differences found in the distributions of sociodemographic variables. In addition, it seems that food purchases differ according to the degree of loyalty, which should be taken into account when researching loyalty card data. Despite the limitations, loyalty card data provide a cost-effective approach to reach large groups of people, including hard-to-reach population subgroups. %M 32459633 %R 10.2196/18059 %U http://www.jmir.org/2020/7/e18059/ %U https://doi.org/10.2196/18059 %U http://www.ncbi.nlm.nih.gov/pubmed/32459633 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e20443 %T Ontological Organization and Bioinformatic Analysis of Adverse Drug Reactions From Package Inserts: Development and Usability Study %A Li,Xiaoying %A Lin,Xin %A Ren,Huiling %A Guo,Jinjing %+ Institute of Medical Information, Chinese Academy of Medical Sciences, 69 Dongdan N St, Beijing, 100005, China, 86 10 52328911, ren.huiling@imicams.ac.cn %K ontology %K adverse drug reactions %K package inserts %K information retrieval %K natural language processing %K bioinformatics %K drug %K adverse events %K machine-understandable knowledge %K clinical applications %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Licensed drugs may cause unexpected adverse reactions in patients, resulting in morbidity, risk of mortality, therapy disruptions, and prolonged hospital stays. Officially approved drug package inserts list the adverse reactions identified from randomized controlled clinical trials with high evidence levels and worldwide postmarketing surveillance. Formal representation of the adverse drug reaction (ADR) enclosed in semistructured package inserts will enable deep recognition of side effects and rational drug use, substantially reduce morbidity, and decrease societal costs. Objective: This paper aims to present an ontological organization of traceable ADR information extracted from licensed package inserts. In addition, it will provide machine-understandable knowledge for bioinformatics analysis, semantic retrieval, and intelligent clinical applications. Methods: Based on the essential content of package inserts, a generic ADR ontology model is proposed from two dimensions (and nine subdimensions), covering the ADR information and medication instructions. This is followed by a customized natural language processing method programmed with Python to retrieve the relevant information enclosed in package inserts. After the biocuration and identification of retrieved data from the package insert, an ADR ontology is automatically built for further bioinformatic analysis. Results: We collected 165 package inserts of quinolone drugs from the National Medical Products Administration and other drug databases in China, and built a specialized ADR ontology containing 2879 classes and 15,711 semantic relations. For each quinolone drug, the reported ADR information and medication instructions have been logically represented and formally organized in an ADR ontology. To demonstrate its usage, the source data were further bioinformatically analyzed. For example, the number of drug-ADR triples and major ADRs associated with each active ingredient were recorded. The 10 ADRs most frequently observed among quinolones were identified and categorized based on the 18 categories defined in the proposal. The occurrence frequency, severity, and ADR mitigation method explicitly stated in package inserts were also analyzed, as well as the top 5 specific populations with contraindications for quinolone drugs. Conclusions: Ontological representation and organization using officially approved information from drug package inserts enables the identification and bioinformatic analysis of adverse reactions caused by a specific drug with regard to predefined ADR ontology classes and semantic relations. The resulting ontology-based ADR knowledge source classifies drug-specific adverse reactions, and supports a better understanding of ADRs and safer prescription of medications. %M 32706718 %R 10.2196/20443 %U https://www.jmir.org/2020/7/e20443 %U https://doi.org/10.2196/20443 %U http://www.ncbi.nlm.nih.gov/pubmed/32706718 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19781 %T QardioArm Blood Pressure Monitoring in a Population With Type 2 Diabetes: Validation Study %A Mazoteras-Pardo,Victoria %A Becerro-De-Bengoa-Vallejo,Ricardo %A Losa-Iglesias,Marta Elena %A Martínez-Jiménez,Eva María %A Calvo-Lobo,César %A Romero-Morales,Carlos %A López-López,Daniel %A Palomo-López,Patricia %+ Faculty of Health Sciences, Universidad Rey Juan Carlos, Avenida de Atenas S/N, Alcorcón, Spain, 34 91 488 8508, marta.losa@urjc.es %K blood pressure %K hypertension %K type 2 diabetes %K mobile applications %K software validation %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Home blood pressure monitoring has many benefits, even more so, in populations prone to high blood pressure, such as persons with diabetes. Objective: The purpose of this research was to validate the QardioArm mobile device in a sample of individuals with noninsulin-dependent type 2 diabetes in accordance with the guidelines of the second International Protocol of the European Society of Hypertension. Methods: The sample consisted of 33 patients with type 2 diabetes. To evaluate the validity of QardioArm by comparing its data with that obtained with a digital sphygmomanometer (Omron M3 Intellisense), two nurses collected diastolic blood pressure, systolic blood pressure, and heart rate with both devices. Results: The analysis indicated that the test device QardioArm met all the validation requirements using a sample population with type 2 diabetes. Conclusions: This paper reports the first validation of QardioArm in a population of individuals with noninsulin-dependent type 2 diabetes. QardioArm for home monitoring of blood pressure and heart rate met the requirements of the second International Protocol of the European Society of Hypertension. %M 32706672 %R 10.2196/19781 %U http://www.jmir.org/2020/7/e19781/ %U https://doi.org/10.2196/19781 %U http://www.ncbi.nlm.nih.gov/pubmed/32706672 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16904 %T Understanding the Acceptability of Subdermal Implants as a Possible New HIV Prevention Method: Multi-Stage Mixed Methods Study %A Rael,Christine Tagliaferri %A Lentz,Cody %A Carballo-Diéguez,Alex %A Giguere,Rebecca %A Dolezal,Curtis %A Feller,Daniel %A D'Aquila,Richard T %A Hope,Thomas J %+ HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, 1051 Riverside Dr, New York, NY, 10032, United States, 1 6467746967, cr2857@cumc.columbia.edu %K PrEP implant %K YouTube %K acceptability %K long-acting PrEP %K systemic PrEP %K human-centered design %K HIV prevention %K removable implant %K long-acting HIV prevention %K gay and bisexual men %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: A long-acting implant for HIV pre-exposure prophylaxis (PrEP) is in development in the Sustained Long-Action Prevention Against HIV (SLAP-HIV) trial. This could provide an alternative to oral PrEP. Objective: Our mixed methods study aimed to understand (1) users’ experiences with a similar subdermal implant for contraception and (2) factors influencing the likelihood that gay and bisexual men (GBM) would use a proposed PrEP implant. Methods: Work was completed in 4 stages. In stage 1, we conducted a scientific literature review on existing subdermal implants, focusing on users’ experiences with implant devices. In stage 2, we reviewed videos on YouTube, focusing on the experiences of current or former contraceptive implant users (as these implants are similar to those in development in SLAP-HIV). In stage 3, individuals who indicated use of a subdermal implant for contraception in the last 5 years were recruited via a web-based questionnaire. Eligible participants (n=12 individuals who liked implants a lot and n=12 individuals who disliked implants a lot) completed in-depth phone interviews (IDIs) about their experiences. In stage 4, results from IDIs were used to develop a web-based survey for HIV-negative GBM to rate their likelihood of using a PrEP implant on a scale (1=very unlikely and 5=very likely) based on likely device characteristics and implant concerns identified in the IDIs. Results: In the scientific literature review (stage 1), concerns about contraceptive implants that could apply to the PrEP implants in development included potential side effects (eg, headache), anticipated high cost of the device, misconceptions about PrEP implants (eg, specific contraindications), and difficulty accessing PrEP implants. In the stage 2 YouTube review, individuals who had used contraceptive implants reported mild side effects related to their device. In stage 3, implant users reported that devices were comfortable, unintrusive, and presented only minor discomfort (eg, bruising) before or after insertion and removal. They mainly reported removing or disliking the device due to contraceptive-related side effects (eg, prolonged menstruation). Participants in the stage 4 quantitative survey (N=304) were mainly gay (204/238, 85.7%), white (125/238, 52.5%), cisgender men (231/238, 97.1%), and 42.0% (73/174) of them were on oral PrEP. Not having to take a daily pill increased the likelihood of using PrEP implants (mean 4.13). Requiring >1 device to achieve 1 year of protection (mean range 1.79-2.94) mildly discouraged PrEP implant use. Participants did not mind moderate bruising, a small scar, tenderness, or bleeding after insertion or removal, and an implant with a size slightly larger than a matchstick (mean ratings 3.18-3.69). Conclusions: PrEP implants are promising among GBM. Implant features and insertion or removal-related concerns do not seem to discourage potential users. To ensure acceptability, PrEP implants should require the fewest possible implants for the greatest protection duration. %M 32348277 %R 10.2196/16904 %U https://www.jmir.org/2020/7/e16904 %U https://doi.org/10.2196/16904 %U http://www.ncbi.nlm.nih.gov/pubmed/32348277 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15605 %T A Precision Medicine Tool for Patients With Multiple Sclerosis (the Open MS BioScreen): Human-Centered Design and Development %A Schleimer,Erica %A Pearce,Jennifer %A Barnecut,Andrew %A Rowles,William %A Lizee,Antoine %A Klein,Arno %A Block,Valerie J %A Santaniello,Adam %A Renschen,Adam %A Gomez,Refujia %A Keshavan,Anisha %A Gelfand,Jeffrey M %A Henry,Roland G %A Hauser,Stephen L %A Bove,Riley %+ Department of Neurology, UCSF Weill Institute for Neurosciences, 675 Nelson Rising Lane, San Francisco, CA, 94158, United States, 1 14155952795, Riley.bove@ucsf.edu %K human-centered design %K mobile phone %K personal health record %K participatory medicine %K visualization in eHealth %K human factors %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients with multiple sclerosis (MS) face several challenges in accessing clinical tools to help them monitor, understand, and make meaningful decisions about their disease course. The University of California San Francisco MS BioScreen is a web-based precision medicine tool initially designed to be clinician facing. We aimed to design a second, openly available tool, Open MS BioScreen, that would be accessible, understandable, and actionable by people with MS. Objective: This study aimed to describe the human-centered design and development approach (inspiration, ideation, and implementation) for creating the Open MS BioScreen platform. Methods: We planned an iterative and cyclical development process that included stakeholder engagement and iterative feedback from users. Stakeholders included patients with MS along with their caregivers and family members, MS experts, generalist clinicians, industry representatives, and advocacy experts. Users consisted of anyone who wants to track MS measurements over time and access openly available tools for people with MS. Phase I (inspiration) consisted of empathizing with users and defining the problem. We sought to understand the main challenges faced by patients and clinicians and what they would want to see in a web-based app. In phase II (ideation), our multidisciplinary team discussed approaches to capture, display, and make sense of user data. Then, we prototyped a series of mock-ups to solicit feedback from clinicians and people with MS. In phase III (implementation), we incorporated all concepts to test and iterate a minimally viable product. We then gathered feedback through an agile development process. The design and development were cyclical—many times throughout the process, we went back to the drawing board. Results: This human-centered approach generated an openly available, web-based app through which patients with MS, their clinicians, and their caregivers can access the site and create an account. Users can enter information about their MS (basic level as well as more advanced concepts), visualize their data longitudinally, access a series of algorithms designed to empower them to make decisions about their treatments, and enter data from wearable devices to encourage realistic goal setting about their ambulatory activity. Agile development will allow us to continue to incorporate precision medicine tools, as these are validated in the clinical research arena. Conclusions: After engaging intended users into the iterative human-centered design of the Open MS BioScreen, we will now monitor the adaptation and dissemination of the tool as we expand its functionality and reach. The insights generated from this approach can be applied to the development of a number of self-tracking, self-management, and user engagement tools for patients with chronic conditions. %M 32628124 %R 10.2196/15605 %U https://www.jmir.org/2020/7/e15605 %U https://doi.org/10.2196/15605 %U http://www.ncbi.nlm.nih.gov/pubmed/32628124 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17744 %T The Promise of Patient Portals for Individuals Living With Chronic Illness: Qualitative Study Identifying Pathways of Patient Engagement %A Stewart,Maureen T %A Hogan,Timothy P %A Nicklas,Jeff %A Robinson,Stephanie A %A Purington,Carolyn M %A Miller,Christopher J %A Vimalananda,Varsha G %A Connolly,Samantha L %A Wolfe,Hill L %A Nazi,Kim M %A Netherton,Dane %A Shimada,Stephanie L %+ Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, United States, 1 7816872208, stephanie.shimada@va.gov %K patient engagement %K patient portal %K chronic disease %K diabetes %K secure messaging %K veterans %D 2020 %7 17.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients play a critical role in managing their health, especially in the context of chronic conditions like diabetes. Electronic patient portals have been identified as a potential means to improve patient engagement; that is, patients’ involvement in their care. However, little is known about the pathways through which portals may help patients engage in their care. Objective: Our objective is to understand how an electronic patient portal facilitates patient engagement among individuals with diabetes. Methods: This qualitative study employed semistructured telephone interviews of 40 patients living with diabetes since at least 2011, who had experienced uncontrolled diabetes, and had used secure messaging through a portal at least 4 times over 18 months. The interviews were recorded, transcribed, coded, and analyzed using primarily an inductive approach to identify how patients living with diabetes use an online health portal to support diabetes self-management. Results: Overall, patients who used the portal reported feeling engaged in their health care. We identified four pathways by which the portal facilitates patient engagement and some challenges. The portal provides a platform that patients use to (1) better understand their health by asking questions about new symptoms, notes, or labs, (2) prepare for medical appointments by reviewing labs and notes, (3) coordinate care between VA (Veterans Affairs) and non-VA health care teams, and (4) reach out to providers to request help between visits. Several patients reported that the portal helped improve the patient-provider relationship; however, aspects of the portal design may hinder engagement for others. Patients reported challenges with both secure messaging and access to medical records that had negative impacts on their engagement. Benefits for patient engagement were described by many types of portal users with varying degrees of diabetes control. Conclusions: Patient portals support engagement by facilitating patient access to their health information and by facilitating patient-provider communication. Portals can help a wide range of users engage with their care. %M 32706679 %R 10.2196/17744 %U https://www.jmir.org/2020/7/e17744 %U https://doi.org/10.2196/17744 %U http://www.ncbi.nlm.nih.gov/pubmed/32706679 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15798 %T Features of a Patient Portal for Blood Test Results and Patient Health Engagement: Web-Based Pre-Post Experiment %A Struikman,Bas %A Bol,Nadine %A Goedhart,Annelijn %A van Weert,Julia C M %A Talboom-Kamp,Esther %A van Delft,Sanne %A Brabers,Anne E M %A van Dijk,Liset %+ Nivel (Netherlands Institute for Health Services Research), PO Box 1568, 3500 BN, Utrecht, Netherlands, 31 30 2729755, l.vandijk@nivel.nl %K online patient portals %K patient health engagement %K blood testing %K blood test results %K consumer panel, visualization %K patient information %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of patient portals for presenting health-related patient data, such as blood test results, is becoming increasingly important in health practices. Patient portals have the potential to enhance patient health engagement, but content might be misinterpreted. Objective: This study aimed to discover whether the way of presenting blood test outcomes in an electronic patient portal is associated with patient health engagement and whether this varies across different blood test outcomes. Methods: A 2x3 between-subjects experiment was conducted among members of the Nivel Dutch Health Care Consumer Panel. All participants read a scenario in which they were asked to imagine themselves receiving blood test results. These results differed in terms of the presented blood values (ie, normal vs partially abnormal vs all abnormal) as well as in terms of whether the results were accompanied with explanatory text and visualization. Patient health engagement was measured both before (T0) and after (T1) participants were exposed to their fictive blood test results. Results: A total 487 of 900 invited members responded (response rate 54%), of whom 50.3% (245/487) were female. The average age of the participants was 52.82 years (SD 15.41 years). Patient health engagement saw either a significant decrease or a nonsignificant difference in the experimental groups after viewing the blood test results. The mean difference was smaller in the groups that received blood test results with additional text and visualization (meanT0 5.33, SE 0.08; meanT1 5.14, SE 0.09; mean difference 0.19, SE 0.08, P=.02) compared with groups that received blood test results without explanatory text and visualization (meanT0 5.19, SE 0.08; meanT1 4.55, SE 0.09; mean difference 0.64, SE 0.08, P<.001). Adding text and visualization, in particular, reduced the decline in patient health engagement in participants who received normal results or mixed results (ie, combination of normal and abnormal results). Conclusions: Adding text and visualization features can attenuate the decrease in patient health engagement in participants who receive outcomes of a blood test via a patient portal, particularly when blood test results are (partly) normal. This suggests that explanatory text and visualization can be reassuring. Future research is warranted to determine whether these results can be generalized to a patient population who receive their actual blood test results. %M 32706704 %R 10.2196/15798 %U https://www.jmir.org/2020/7/e15798 %U https://doi.org/10.2196/15798 %U http://www.ncbi.nlm.nih.gov/pubmed/32706704 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18466 %T An Untapped Potential in Primary Care: Semi-Structured Interviews with Clinicians on How Patient Portals Will Work for Caregivers in the Safety Net %A Casillas,Alejandra %A Cemballi,Anupama Gunshekar %A Abhat,Anshu %A Lemberg,Miya %A Portz,Jennifer D %A Sadasivaiah,Shobha %A Ratanawongsa,Neda %A Semere,Wagahta %A Brown,Arleen %A Lyles,Courtney Rees %+ Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA David Geffen School of Medicine, 1100 Glendon Avenue, Suite 850, Los Angeles, CA, 90278, United States, 1 310 794 0150, acasillas@mednet.ucla.edu %K patient portal %K caregivers %K vulnerable populations %K digital divide %K mobile phone %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients within safety-net settings are less likely to access health information on patient portals, despite expressed interest. Family and friends are important resources to assist these patients (ie, Medicaid recipients, older patients, patients with limited English proficiency) in navigating health systems, and provider support of the use of patient portals among these groups may also facilitate caregivers’ use of their patients’ portal. Objective: Because safety net providers work closely with caregivers to care for their patients, we used qualitative methods to explore safety net providers’ perspectives on portal use among caregivers for their patients, especially as there is limited literature about caregivers’ use of portals in the safety net. Methods: We conducted 45- to 60-min semistructured telephone interviews with providers from three large California safety-net health systems. The interviews focused on providers’ experiences with caregivers, caregiver roles, and how the portal could be leveraged as a tool to support caregivers in their responsibilities. A total of three coders analyzed the interview transcripts using both deductive and inductive approaches and established a consensus regarding major themes. Results: Of the 16 participants interviewed, 4 specialized in geriatrics, and all held a leadership or administrative role. We described themes highlighting providers’ recognition of potential benefits associated with caregiver portal use and specific challenges to caregiver engagement. Conclusions: Providers recognized the potential for portals to improve information delivery and communication by helping caregivers assist socially and medically complex patients in the safety net. Providers in safety net sites also discussed a clear need for better ways to keep in touch with patients and connect with caregivers, yet security and privacy are perhaps of higher importance in these settings and may pose challenges to portal adoption. They noted that caregivers of patients in the safety net likely face similar communication barriers as patients, especially with respect to digital literacy, health literacy, and English proficiency. Further research is needed to assess and support caregivers’ interest and ability to access portals across barriers in health and digital literacy, and English proficiency. Portal platforms and health systems must also address specific strategies to uphold patient preferences while maintaining privacy and security. %M 32706709 %R 10.2196/18466 %U https://www.jmir.org/2020/7/e18466 %U https://doi.org/10.2196/18466 %U http://www.ncbi.nlm.nih.gov/pubmed/32706709 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18973 %T Patient Portal Implementation and Uptake: Qualitative Comparative Case Study %A Avdagovska,Melita %A Ballermann,Mark %A Olson,Karin %A Graham,Timothy %A Menon,Devidas %A Stafinski,Tania %+ University of Alberta, School of Public Health, 3021, Research Transition Facility, 8308 114 Street, Edmonton, AB, T6G 2V2, Canada, 1 7809083334, avdagovs@ualberta.ca %K patient portals %K information technology %K adoption %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Giving patients access to their health information is a provincial and national goal, and it is critical to the delivery of patient-centered care. With this shift, patient portals have become more prevalent. In Alberta, the Alberta Health Services piloted a portal (MyChart). There was a need to identify factors that promoted the use of this portal. Furthermore, it was imperative to understand why there was variability in uptake within the various clinics that participated in the pilot. Objective: This study aims to identify potential factors that could improve the uptake of MyChart from the perspectives of both users and nonusers at pilot sites. We focused on factors that promoted the use of MyChart along with related benefits and barriers to its use, with the intention that this information could be incorporated into the plan for its province-wide implementation. Methods: A qualitative comparative case study was conducted to determine the feasibility, acceptability, and initial perceptions of users and to identify ways to increase uptake. Semistructured interviews were conducted with 56 participants (27 patients, 21 providers, 4 nonmedical staff, and 4 clinic managers) from 5 clinics. Patients were asked about the impact of MyChart on their health and health care. Providers were asked about the impact on the patient-provider relationship and workflow. Managers were asked about barriers to implementation. The interviews were recorded, transcribed verbatim, and entered into NVivo. A thematic analysis was used to analyze the data. Results: Results from a comparison of factors related to uptake of MyChart in 5 clinics (2 clinics with high uptake, 1 with moderate uptake, 1 with low uptake, and 1 with no uptake) are reported. Some theoretical constructs in our study, such as intention to use, perceived value, similarity (novelty) of the technology, and patient health needs, were similar to findings published by other research teams. We also identified some new factors associated with uptake, including satisfaction or dissatisfaction with the current status quo, performance expectancy, facilitating conditions, behavioral intentions, and use behavior. All these factors had an impact on the level of uptake in each setting and created different opportunities for end users. Conclusions: There is limited research on factors that influence the uptake of patient portals. We identified some factors that were consistent with those reported by others but also several new factors that were associated with the update of MyChart, a new patient portal, in the clinics we studied. On the basis of our results, we posit that a shared understanding of the technology among patients, clinicians, and managers, along with dissatisfaction with nonportal-based communications, is foundational and must be addressed for patient portals to support improvements in care. %M 32716308 %R 10.2196/18973 %U http://www.jmir.org/2020/7/e18973/ %U https://doi.org/10.2196/18973 %U http://www.ncbi.nlm.nih.gov/pubmed/32716308 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17967 %T The Assessment of Supportive Accountability in Adults Seeking Obesity Treatment: Psychometric Validation Study %A Chhabria,Karishma %A Ross,Kathryn M %A Sacco,Shane J %A Leahey,Tricia M %+ The Center for Health Care Data, Department of Management, Policy and Community Health, University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX, 77030, United States, 1 713 500 9428, karishma.s.chhabria@uth.tmc.edu %K supportive accountability %K social support %K SALLIS %K factor analysis %K obesity %K weight loss %K technology %K mobile phone %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Technology-mediated obesity treatments are commonly affected by poor long-term adherence. Supportive Accountability Theory suggests that the provision of social support and oversight toward goals may help to maintain adherence in technology-mediated treatments. However, no tool exists to measure the construct of supportive accountability. Objective: This study aimed to develop and psychometrically validate a supportive accountability measure (SAM) by examining its performance in technology-mediated obesity treatment. Methods: Secondary data analyses were conducted in 2 obesity treatment studies to validate the SAM (20 items). Study 1 examined reliability, criterion validity, and construct validity using an exploratory factor analysis in individuals seeking obesity treatment. Study 2 examined the construct validity of SAM in technology-mediated interventions involving different self-monitoring tools and varying amounts of phone-based interventionist support. Participants received traditional self-monitoring tools (standard, in-home self-monitoring scale [SC group]), newer, technology-based self-monitoring tools (TECH group), or these newer technology tools plus additional phone-based support (TECH+PHONE group). Given that the TECH+PHONE group involves more interventionist support, we hypothesized that this group would have greater supportive accountability than the other 2 arms. Results: In Study 1 (n=353), the SAM showed strong reliability (Cronbach α=.92). A factor analysis revealed a 3-factor solution (representing Support for Healthy Eating Habits, Support for Exercise Habits, and Perceptions of Accountability) that explained 69% of the variance. Convergent validity was established using items from the motivation for weight loss scale, specifically the social regulation subscale (r=0.33; P<.001) and social pressure for weight loss subscale (r=0.23; P<.001). In Study 2 (n=80), the TECH+PHONE group reported significantly higher SAM scores at 6 months compared with the SC and TECH groups (r2=0.45; P<.001). Higher SAM scores were associated with higher adherence to weight management behaviors, including higher scores on subscales representing healthy dietary choices, the use of self-monitoring strategies, and positive psychological coping with weight management challenges. The association between total SAM scores and percent weight change was in the expected direction but not statistically significant (r=−0.26; P=.06). Conclusions: The SAM has strong reliability and validity across the 2 studies. Future studies may consider using the SAM in technology-mediated weight loss treatment to better understand whether support and accountability are adequately represented and how supportive accountability impacts treatment adherence and outcomes. Trial Registration: ClinicalTrials.gov NCT01999244; https://clinicaltrials.gov/ct2/show/NCT01999244 %M 32720911 %R 10.2196/17967 %U https://www.jmir.org/2020/7/e17967 %U https://doi.org/10.2196/17967 %U http://www.ncbi.nlm.nih.gov/pubmed/32720911 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17318 %T Benefits of Massive Open Online Course Participation: Deductive Thematic Analysis %A Blum,Elizabeth R %A Stenfors,Terese %A Palmgren,Per J %+ Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Tomtebodavägen 18a, Stockholm, 171 77, Sweden, 46 8 524 85 294, per.palmgren@ki.se %K MOOC %K MOOC evaluation %K qualitative %K thematic analysis %K learner %K online education %K Kirkpatrick framework %K outcomes %K MOOC outcomes %D 2020 %7 8.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Massive open online courses (MOOCs), as originally conceived, promised to provide educational access to anyone with an internet connection. However, the expansiveness of MOOC education has been found to be somewhat limited. Nonetheless, leading universities continue to offer MOOCs, including many in the health sciences, on a number of private platforms. Therefore, research on online education must include thorough understanding of the role of MOOCs. To date, studies on MOOC participants have focused mainly on learners’ assessment of the course. It is known that MOOCs are not reaching the universal audiences that were predicted, and much knowledge has been gained about learners’ perceptions of MOOCs. However, there is little scholarship on what learners themselves gain from participating in MOOCs. Objective: As MOOC development persists and expands, scholars and developers should be made aware of the role of MOOCs in education by examining what these courses do offer their participants. The objective of this qualitative synthesis of a set of MOOC evaluation studies was to explore outcomes for MOOC learners, that is, how the learners themselves benefit from participating in MOOCs. Methods: To explore MOOC learners’ outcomes, we conducted a qualitative synthesis in the form of a deductive thematic analysis, aggregating findings from 17 individual studies selected from an existing systematic review of MOOC evaluation methods. We structured our inquiry using the Kirkpatrick model, considering Kirkpatrick levels 2, 3, and 4 as potential themes in our analysis. Results: Our analysis identified six types of Kirkpatrick outcomes in 17 studies. Five of these outcomes (learning/general knowledge, skills, attitudes, confidence, and commitment) fit into Kirkpatrick Level 2, while Kirkpatrick Level 3 outcomes concerning behavior/application were seen in four studies. Two additional themes were identified outside of the Kirkpatrick framework: culture and identity outcomes and affective/emotional outcomes. Kirkpatrick Level 4 was not represented among the outcomes we examined. Conclusions: Our findings point to some gains from MOOCs. While we can expect MOOCs to persist, how learners benefit from the experience of participating in MOOCs remains unclear. %M 32672680 %R 10.2196/17318 %U https://www.jmir.org/2020/7/e17318 %U https://doi.org/10.2196/17318 %U http://www.ncbi.nlm.nih.gov/pubmed/32672680 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17491 %T Use of a Low-Cost Portable 3D Virtual Reality Gesture-Mediated Simulator for Training and Learning Basic Psychomotor Skills in Minimally Invasive Surgery: Development and Content Validity Study %A Alvarez-Lopez,Fernando %A Maina,Marcelo Fabián %A Saigí-Rubió,Francesc %+ Faculty of Health Sciences, Universitat Oberta de Catalunya, Avinguda Tibidabo, 39-43, Barcelona, 08035, Spain, 34 933263622, fsaigi@uoc.edu %K simulation training %K minimally invasive surgery %K user-computer interface %K operating rooms %K medical education %K computer-assisted surgery %D 2020 %7 14.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Simulation in virtual environments has become a new paradigm for surgeon training in minimally invasive surgery (MIS). However, this technology is expensive and difficult to access. Objective: This study aims first to describe the development of a new gesture-based simulator for learning skills in MIS and, second, to establish its fidelity to the criterion and sources of content-related validity evidence. Methods: For the development of the gesture-mediated simulator for MIS using virtual reality (SIMISGEST-VR), a design-based research (DBR) paradigm was adopted. For the second objective, 30 participants completed a questionnaire, with responses scored on a 5-point Likert scale. A literature review on the validity of the MIS training-VR (MIST-VR) was conducted. The study of fidelity to the criterion was rated using a 10-item questionnaire, while the sources of content-related validity evidence were assessed using 10 questions about the simulator training capacity and 6 questions about MIS tasks, and an iterative process of instrument pilot testing was performed. Results: A good enough prototype of a gesture-based simulator was developed with metrics and feedback for learning psychomotor skills in MIS. As per the survey conducted to assess the fidelity to the criterion, all 30 participants felt that most aspects of the simulator were adequately realistic and that it could be used as a tool for teaching basic psychomotor skills in laparoscopic surgery (Likert score: 4.07-4.73). The sources of content-related validity evidence showed that this study’s simulator is a reliable training tool and that the exercises enable learning of the basic psychomotor skills required in MIS (Likert score: 4.28-4.67). Conclusions: The development of gesture-based 3D virtual environments for training and learning basic psychomotor skills in MIS opens up a new approach to low-cost, portable simulation that allows ubiquitous learning and preoperative warm-up. Fidelity to the criterion was duly evaluated, which allowed a good enough prototype to be achieved. Content-related validity evidence for SIMISGEST-VR was also obtained. %M 32673217 %R 10.2196/17491 %U http://www.jmir.org/2020/7/e17491/ %U https://doi.org/10.2196/17491 %U http://www.ncbi.nlm.nih.gov/pubmed/32673217 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16687 %T Building a Successful Massive Open Online Course About Multiple Sclerosis: A Process Description %A Claflin,Suzi B %A Gates,Rachael %A Maher,Maree %A Taylor,Bruce V %+ Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, 7000, Australia, 61 0362267728, suzi.claflin@utas.edu.au %K multiple sclerosis %K health education %D 2020 %7 29.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X Background: Over the course of a year, we developed and tested a 6-week massive open online course (MOOC) on multiple sclerosis (MS) in consultation with the MS community. The course targeted the MS community and interested laypeople and was titled Understanding MS. The primary purpose of the course was to improve MS knowledge, health literacy, and resilience among participants. The final version of the MOOC made available for open enrollment was ranked first among all MOOCs released in 2019 (n>2400) based on participant reviews. Objective: The aim of this study was to present a detailed description and assessment of the development process of the Understanding MS MOOC. Methods: The development process included a course development focus group; the creation of more than 50 content videos and related text, quizzes, activities, and discussion prompts; the creation of original images and animations; a pilot study; and collaborations with people living with MS, MS nurses, allied health care practitioners, and neurologists and researchers from 4 universities. Results: Overall, the process was efficient and effective. With a few small changes, we recommend this approach to those seeking to develop a similar course. This process led to the development of a highly reviewed MOOC with excellent user satisfaction. Conclusions: We identified 5 key lessons from this process: (1) community support is essential, (2) stakeholder involvement improves content quality, (3) plan for research from the beginning, (4) coordination between the academic lead and project manager team ensures a consistent voice, and (5) a network of collaborators is a key resource. %M 32723726 %R 10.2196/16687 %U https://www.jmir.org/2020/7/e16687 %U https://doi.org/10.2196/16687 %U http://www.ncbi.nlm.nih.gov/pubmed/32723726 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17100 %T Evaluation of Adaptive Feedback in a Smartphone-Based Game on Health Care Providers’ Learning Gain: Randomized Controlled Trial %A Tuti,Timothy %A Winters,Niall %A Edgcombe,Hilary %A Muinga,Naomi %A Wanyama,Conrad %A English,Mike %A Paton,Chris %+ Kellogg College, University of Oxford, 60 Banbury Road, Oxford, OX2 6PN, United Kingdom, 44 7501966958, timothy.tuti@kellogg.ox.ac.uk %K neonatal mortality %K education %K emergency medical services %K global health %K smartphone %K feedback %K health workforce %K developing countries %K mobile phone %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although smartphone-based emergency care training is more affordable than traditional avenues of training, it is still in its infancy, remains poorly implemented, and its current implementation modes tend to be invariant to the evolving learning needs of the intended users. In resource-limited settings, the use of such platforms coupled with gamified approaches remains largely unexplored, despite the lack of traditional training opportunities, and high mortality rates in these settings. Objective: The primary aim of this randomized experiment is to determine the effectiveness of offering adaptive versus standard feedback, on the learning gains of clinicians, through the use of a smartphone-based game that assessed their management of a simulated medical emergency. A secondary aim is to examine the effects of learner characteristics and learning spacing with repeated use of the game on the secondary outcome of individualized normalized learning gain. Methods: The experiment is aimed at clinicians who provide bedside neonatal care in low-income settings. Data were captured through an Android app installed on the study participants’ personal phones. The intervention, which was based on successful attempts at a learning task, included adaptive feedback provided within the app to the experimental arm, whereas the control arm received standardized feedback. The primary end point was completion of the second learning session. Of the 572 participants enrolled between February 2019 and July 2019, 247 (43.2%) reached the primary end point. The primary outcome was standardized relative change in learning gains between the study arms as measured by the Morris G effect size. The secondary outcomes were the participants individualized normalized learning gains. Results: The effect of adaptive feedback on care providers’ learning gain was found to be g=0.09 (95% CI −0.31 to 0.46; P=.47). In exploratory analysis, using normalized learning gains, when subject-treatment interaction and differential time effect was controlled for, this effect increased significantly to 0.644 (95% CI 0.35 to 0.94; P<.001) with immediate repetition, which is a moderate learning effect, but reduced significantly by 0.28 after a week. The overall learning change from the app use in both arms was large and may have obscured a direct effect of feedback. Conclusions: There is a considerable learning gain between the first two rounds of learning with both forms of feedback and a small added benefit of adaptive feedback after controlling for learner differences. We suggest that linking the adaptive feedback provided to care providers to how they space their repeat learning session(s) may yield higher learning gains. Future work might explore in more depth the feedback content, in particular whether or not explanatory feedback (why answers were wrong) enhances learning more than reflective feedback (information about what the right answers are). Trial Registration: Pan African Clinical Trial Registry (PACTR) 201901783811130; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5836 International Registered Report Identifier (IRRID): RR2-10.2196/13034 %M 32628115 %R 10.2196/17100 %U https://www.jmir.org/2020/7/e17100 %U https://doi.org/10.2196/17100 %U http://www.ncbi.nlm.nih.gov/pubmed/32628115 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14861 %T An Internet-Based Psychological Intervention With a Serious Game to Improve Vitality, Psychological and Physical Condition, and Immune Function in Healthy Male Adults: Randomized Controlled Trial %A Schakel,Lemmy %A Veldhuijzen,Dieuwke S %A van Middendorp,Henriët %A Prins,Corine %A Drittij,Anne M H F %A Vrieling,Frank %A Visser,Leo G %A Ottenhoff,Tom H M %A Joosten,Simone A %A Evers,Andrea W M %+ Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, Leiden, Netherlands, 31 715273627, a.evers@fsw.leidenuniv.nl %K BCG vaccination %K cognitive behavioral therapy %K immune system %K stress %K ICBT %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Recently, internet-based cognitive behavioral therapy (ICBT) and serious gaming interventions have been suggested to enhance accessibility to interventions and engagement in psychological interventions that aim to promote health outcomes. Few studies, however, have investigated their effectiveness in the context of simulated real-life challenges. Objective: We aimed to examine the effectivity of a guided ICBT combined with a serious gaming intervention in improving self-reported psychophysiological and immunological health endpoints in response to psychophysiological and immune-related challenges. Methods: Sixty-nine healthy men were randomly assigned to the intervention condition, receiving ICBT combined with serious gaming for 6 weeks, or the control condition, receiving no intervention. Self-reported vitality was the primary endpoint. Other self-reported psychophysiological and immunological endpoints were assessed following various challenges, including a bacillus Calmette-Guérin vaccination evoking pro-inflammatory responses, 1 and 4 weeks after the intervention period. Results: Although the intervention did not affect vitality-associated parameters, self-reported sleep problems (P=.027) and bodily sensations (P=.042) were lower directly after the intervention compared with controls. Furthermore, wellbeing (P=.024) was higher in the intervention group after the psychophysiological challenges. Although no significant group differences were found for the psychophysiological and immunological endpoints, the data provided preliminary support for increased immunoglobulin antibody responses at the follow-up time points (P<.05). Differential chemokine endpoints between conditions were observed at the end of the test day. Conclusions: The present study provides some support for improving health endpoints with an innovative ICBT intervention. Future research should replicate and further extend the present findings by consistently including challenges and a wide range of immune parameters into the study design. Trial Registration: Nederlands Trial Register NTR5610; https://www.trialregister.nl/trial/5466 %M 32706667 %R 10.2196/14861 %U https://www.jmir.org/2020/7/e14861 %U https://doi.org/10.2196/14861 %U http://www.ncbi.nlm.nih.gov/pubmed/32706667 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17851 %T Diabetes-Related Topics in an Online Forum for Caregivers of Individuals Living With Alzheimer Disease and Related Dementias: Qualitative Inquiry %A Du,Yan %A Paiva,Kristi %A Cebula,Adrian %A Kim,Seon %A Lopez,Katrina %A Li,Chengdong %A White,Carole %A Myneni,Sahiti %A Seshadri,Sudha %A Wang,Jing %+ Center on Smart and Connected Health Technologies, School of Nursing, The University of Texas Health Science Center at San Antonio, 7739 Floyd Drive, San Antonio, TX, 78229, United States, 1 210 450 8561, wangj1@uthscsa.edu %K diabetes %K Alzheimer disease %K dementia %K caregivers %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Diabetes and Alzheimer disease and related dementias (ADRD) are the seventh and sixth leading causes of death in the United States, respectively, and they coexist in many older adults. Caring for a loved one with both ADRD and diabetes is challenging and burdensome. Objective: This study aims to explore diabetes-related topics in the Alzheimer’s Association ALZConnected caregiver forum by family caregivers of persons living with ADRD. Methods: User posts on the Alzheimer’s Association ALZConnected caregiver forum were extracted. A total of 528 posts related to diabetes were included in the analysis. Of the users who generated the 528 posts, approximately 96.1% (275/286) were relatives of the care recipient with ADRD (eg, child, grandchild, spouse, sibling, or unspecified relative). Two researchers analyzed the data independently using thematic analysis. Any divergence was discussed among the research team, and an agreement was reached with a senior researcher’s input as deemed necessary. Results: Thematic analysis revealed 7 key themes. The results showed that comorbidities of ADRD were common topics of discussions among family caregivers. Diabetes management in ADRD challenged family caregivers. Family caregivers might neglect their own health care because of the caring burden, and they reported poor health outcomes and reduced quality of life. The online forum provided a platform for family caregivers to seek support in their attempts to learn more about how to manage the ADRD of their care recipients and seek support for managing their own lives as caregivers. Conclusions: The ALZConnected forum provided a platform for caregivers to seek informational and emotional support for caring for persons living with ADRD and diabetes. The overwhelming burdens with these two health conditions were apparent for both caregivers and care recipients based on discussions from the online forum. Studies are urgently needed to provide practical guidelines and interventions for diabetes management in individuals with diabetes and ADRD. Future studies to explore delivering diabetes management interventions through online communities in caregivers and their care recipients with ADRD and diabetes are warranted. %M 32628119 %R 10.2196/17851 %U http://www.jmir.org/2020/7/e17851/ %U https://doi.org/10.2196/17851 %U http://www.ncbi.nlm.nih.gov/pubmed/32628119 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17338 %T Assessment of Adaptive Engagement and Support Model for People With Chronic Health Conditions in Online Health Communities: Combined Content Analysis %A Green,Brian M %A Van Horn,Katelyn Tente %A Gupte,Ketki %A Evans,Megan %A Hayes,Sara %A Bhowmick,Amrita %+ Health Union, LLC, 1217 Sansom Street, 2nd Floor, Philadelphia, PA, 19107, United States, 1 2673072525, brian.m.green@health-union.com %K social media %K social support %K health education %K qualitative research %K patient empowerment %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: With the pervasiveness of social media, online health communities (OHCs) are an important tool for facilitating information sharing and support among people with chronic health conditions. Importantly, OHCs offer insight into conversations about the lived experiences of people with particular health conditions. Little is known about the aspects of OHCs that are important to maintain safe and productive conversations that support health. Objective: This study aimed to assess the provision of social support and the role of active moderation in OHCs developed in accordance with and managed by an adaptive engagement model. This study also aimed to identify key elements of the model that are central to the development, maintenance, and adaptation of OHCs for people with chronic health conditions. Methods: This study used combined content analysis, a mixed methods approach, to analyze sampled Facebook post comments from 6 OHCs to understand how key aspects of the adaptive engagement model facilitate different types of social support. OHCs included in this study are for people living with multiple sclerosis, migraine, irritable bowel syndrome, rheumatoid arthritis, lung cancer, and prostate cancer. An exploratory approach was used in the analysis, and initial codes were grouped into thematic categories and then confirmed through thematic network analysis using the Dedoose qualitative analysis software tool. Thematic categories were compared for similarities and differences for each of the 6 OHCs and by topic discussed. Results: Data on the reach and engagement of the Facebook posts and the analysis of the sample of 5881 comments demonstrate that people with chronic health conditions want to engage on the web and find value in supporting and sharing their experiences with others. Most comments made in these Facebook posts were expressions of social support for others living with the same health condition (3405/5881, 57.89%). Among the comments with an element of support, those where community members validated the knowledge or experiences of others were most frequent (1587/3405, 46.61%), followed by the expression of empathy and understanding (1089/3405, 31.98%). Even among posts with more factual content, such as insurance coverage issues, user comments still had frequent expressions of support for others (80/213, 37.5%). Conclusions: The analysis of this OHC adaptive engagement model in action shows that the foundational elements—social support, engagement, and moderation—can effectively be used to provide a rich and dynamic community experience for individuals with chronic health conditions. Social support is demonstrated in a variety of ways, including sharing information or validating information shared by others, expressions of empathy, and sharing encouraging statements with others. %M 32492651 %R 10.2196/17338 %U https://www.jmir.org/2020/7/e17338 %U https://doi.org/10.2196/17338 %U http://www.ncbi.nlm.nih.gov/pubmed/32492651 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18548 %T Characteristics, Symptom Severity, and Experiences of Patients Reporting Chronic Kidney Disease in the PatientsLikeMe Online Health Community: Retrospective and Qualitative Study %A James,Glen %A Nyman,Elisabeth %A Fitz-Randolph,Marcy %A Niklasson,Anna %A Hedman,Katarina %A Hedberg,Jonatan %A Wittbrodt,Eric T %A Medin,Jennie %A Moreno Quinn,Carol %A Allum,Alaster M %A Emmas,Cathy %+ AstraZeneca, 136 Hills Rd, Cambridge, CB2 8PA, United Kingdom, 44 7384538548, glen.james@astrazeneca.com %K community networks %K chronic kidney disease %K real-world experience %K patient experience %K retrospective %K observational %K diabetes %K interview %K online %K social media %D 2020 %7 15.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic kidney disease (CKD) is a major global health burden, and is associated with increased adverse outcomes, poor quality of life, and substantial health care costs. While there is an increasing need to build patient-centered pathways for improving CKD management in clinical care, data in this field are scarce. Objective: The aim of this study was to understand patient-reported experiences, symptoms, outcomes, and treatment journeys among patients with CKD through a retrospective and qualitative approach based on data available through PatientsLikeMe (PLM), an online community where patients can connect and share experiences. Methods: Adult members (aged ≥18 years) with self-reported CKD within 30 days of enrollment, who were not on dialysis, and registered between 2011 and 2018 in the PLM community were eligible for the retrospective study. Patient demographics and disease characteristics/symptoms were collected from this retrospective data set. Qualitative data were collected prospectively through semistructured phone interviews in a subset of patients, and questions were oriented to better understand patients’ experiences with CKD and its management. Results: The retrospective data set included 1848 eligible patients with CKD, and median age was 56 years. The majority of patients were female (1217/1841, 66.11%) and most were US residents (1450/1661, 87.30%). Of the patients who reported comorbidities (n=1374), the most common were type 2 diabetes (783/1374, 56.99%), hypertension (664/1374, 48.33%), hypercholesterolemia (439/1374, 31.95%), and diabetic neuropathy (376/1374, 27.37%). The most commonly reported severe or moderate symptoms in patients reporting these symptoms were fatigue (347/484, 71.7%) and pain (278/476, 58.4%). In the qualitative study, 18 eligible patients (13 females) with a median age of 60 years and who were mainly US residents were interviewed. Three key concepts were identified by patients to be important to optimal care and management: listening to patient needs, coordinating health care across providers, and managing clinical care. Conclusions: This study provides a unique source of real-world information on the patient experience of CKD and its management by utilizing the PLM network. The results reveal the challenges these patients face living with an array of symptoms, and report key concepts identified by patients that can be used to further improve clinical care and management and inform future CKD studies. %M 32673242 %R 10.2196/18548 %U http://www.jmir.org/2020/7/e18548/ %U https://doi.org/10.2196/18548 %U http://www.ncbi.nlm.nih.gov/pubmed/32673242 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15770 %T Evaluating the Impact of the Grading and Assessment of Predictive Tools Framework on Clinicians and Health Care Professionals’ Decisions in Selecting Clinical Predictive Tools: Randomized Controlled Trial %A Khalifa,Mohamed %A Magrabi,Farah %A Gallego Luxan,Blanca %+ Centre for Health Informatics, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Rd, North Ryde, NSW 2113, Sydney, 2113, Australia, 61 438632060, mohamed.khalifa@mq.edu.au %K clinical prediction rule %K clinical decision rules %K evidence-based medicine %K evaluation study %D 2020 %7 9.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: While selecting predictive tools for implementation in clinical practice or for recommendation in clinical guidelines, clinicians and health care professionals are challenged with an overwhelming number of tools. Many of these tools have never been implemented or evaluated for comparative effectiveness. To overcome this challenge, the authors developed and validated an evidence-based framework for grading and assessment of predictive tools (the GRASP framework). This framework was based on the critical appraisal of the published evidence on such tools. Objective: The aim of the study was to examine the impact of using the GRASP framework on clinicians’ and health care professionals’ decisions in selecting clinical predictive tools. Methods: A controlled experiment was conducted through a web-based survey. Participants were randomized to either review the derivation publications, such as studies describing the development of the predictive tools, on common traumatic brain injury predictive tools (control group) or to review an evidence-based summary, where each tool had been graded and assessed using the GRASP framework (intervention group). Participants in both groups were asked to select the best tool based on the greatest validation or implementation. A wide group of international clinicians and health care professionals were invited to participate in the survey. Task completion time, rate of correct decisions, rate of objective versus subjective decisions, and level of decisional conflict were measured. Results: We received a total of 194 valid responses. In comparison with not using GRASP, using the framework significantly increased correct decisions by 64%, from 53.7% to 88.1% (88.1/53.7=1.64; t193=8.53; P<.001); increased objective decision making by 32%, from 62% (3.11/5) to 82% (4.10/5; t189=9.24; P<.001); decreased subjective decision making based on guessing by 20%, from 49% (2.48/5) to 39% (1.98/5; t188=−5.47; P<.001); and decreased prior knowledge or experience by 8%, from 71% (3.55/5) to 65% (3.27/5; t187=−2.99; P=.003). Using GRASP significantly decreased decisional conflict and increased the confidence and satisfaction of participants with their decisions by 11%, from 71% (3.55/5) to 79% (3.96/5; t188=4.27; P<.001), and by 13%, from 70% (3.54/5) to 79% (3.99/5; t188=4.89; P<.001), respectively. Using GRASP decreased the task completion time, on the 90th percentile, by 52%, from 12.4 to 6.4 min (t193=−0.87; P=.38). The average System Usability Scale of the GRASP framework was very good: 72.5% and 88% (108/122) of the participants found the GRASP useful. Conclusions: Using GRASP has positively supported and significantly improved evidence-based decision making. It has increased the accuracy and efficiency of selecting predictive tools. GRASP is not meant to be prescriptive; it represents a high-level approach and an effective, evidence-based, and comprehensive yet simple and feasible method to evaluate, compare, and select clinical predictive tools. %M 32673228 %R 10.2196/15770 %U https://www.jmir.org/2020/7/e15770 %U https://doi.org/10.2196/15770 %U http://www.ncbi.nlm.nih.gov/pubmed/32673228 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17940 %T Paving the Way for the Implementation of a Decision Support System for Antibiotic Prescribing in Primary Care in West Africa: Preimplementation and Co-Design Workshop With Physicians %A Peiffer-Smadja,Nathan %A Poda,Armel %A Ouedraogo,Abdoul-Salam %A Guiard-Schmid,Jean-Baptiste %A Delory,Tristan %A Le Bel,Josselin %A Bouvet,Elisabeth %A Lariven,Sylvie %A Jeanmougin,Pauline %A Ahmad,Raheelah %A Lescure,François-Xavier %+ Infection Antimicrobials Modelling Evolution (IAME), UMR 1137, University of Paris, French Institute for Medical Research (INSERM), UMR 1137, 16 rue Henri Huchard, Paris, 75870, France, 33 618662638, nathan.psmadja@gmail.com %K decision support systems, clinical %K antibiotic resistance, microbial %K drug resistance, microbial %K antibiotic stewardship %K implementation science %K Africa, Western %K diffusion of innovation %K medical informatics applications %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Suboptimal use of antibiotics is a driver of antimicrobial resistance (AMR). Clinical decision support systems (CDSS) can assist prescribers with rapid access to up-to-date information. In low- and middle-income countries (LMIC), the introduction of CDSS for antibiotic prescribing could have a measurable impact. However, interventions to implement them are challenging because of cultural and structural constraints, and their adoption and sustainability in routine clinical care are often limited. Preimplementation research is needed to ensure relevant adaptation and fit within the context of primary care in West Africa. Objective: This study examined the requirements for a CDSS adapted to the context of primary care in West Africa, to analyze the barriers and facilitators of its implementation and adaptation, and to ensure co-designed solutions for its adaptation and sustainable use. Methods: We organized a workshop in Burkina Faso in June 2019 with 47 health care professionals representing 9 West African countries and 6 medical specialties. The workshop began with a presentation of Antibioclic, a publicly funded CDSS for antibiotic prescribing in primary care that provides personalized antibiotic recommendations for 37 infectious diseases. Antibioclic is freely available on the web and as a smartphone app (iOS, Android). The presentation was followed by a roundtable discussion and completion of a questionnaire with open-ended questions by participants. Qualitative data were analyzed using thematic analysis. Results: Most of the participants had access to a smartphone during their clinical consultations (35/47, 74%), but only 49% (23/47) had access to a computer and none used CDSS for antibiotic prescribing. The participants considered that CDSS could have a number of benefits including updating the knowledge of practitioners on antibiotic prescribing, improving clinical care and reducing AMR, encouraging the establishment of national guidelines, and developing surveillance capabilities in primary care. The most frequently mentioned contextual barrier to implementing a CDSS was the potential risk of increasing self-medication in West Africa, where antibiotics can be bought without a prescription. The need for the CDSS to be tailored to the local epidemiology of infectious diseases and AMR was highlighted along with the availability of diagnostic tests and antibiotics using national guidelines where available. Participants endorsed co-design involving all stakeholders, including nurses, midwives, and pharmacists, as central to any introduction of CDSS. A phased approach was suggested by initiating and evaluating CDSS at a pilot site, followed by dissemination using professional networks and social media. The lack of widespread internet access and computers could be circumvented by a mobile app with an offline mode. Conclusions: Our study provides valuable information for the development and implementation of a CDSS for antibiotic prescribing among primary care prescribers in LMICs and may, in turn, contribute to improving antibiotic use, clinical outcomes and decreasing AMR. %M 32442155 %R 10.2196/17940 %U https://www.jmir.org/2020/7/e17940 %U https://doi.org/10.2196/17940 %U http://www.ncbi.nlm.nih.gov/pubmed/32442155 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16981 %T Asthma Exacerbation Prediction and Risk Factor Analysis Based on a Time-Sensitive, Attentive Neural Network: Retrospective Cohort Study %A Xiang,Yang %A Ji,Hangyu %A Zhou,Yujia %A Li,Fang %A Du,Jingcheng %A Rasmy,Laila %A Wu,Stephen %A Zheng,W Jim %A Xu,Hua %A Zhi,Degui %A Zhang,Yaoyun %A Tao,Cui %+ School of Biomedical Informatics, The University of Texas Health Science Center at Houston, UCT 600, 7000 Fannin Street, Houston, TX, 77030, United States, 1 713 500 3981, Cui.Tao@uth.tmc.edu %K asthma %K deep learning %K electronic health records %K health risk appraisal %D 2020 %7 31.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Asthma exacerbation is an acute or subacute episode of progressive worsening of asthma symptoms and can have a significant impact on patients’ quality of life. However, efficient methods that can help identify personalized risk factors and make early predictions are lacking. Objective: This study aims to use advanced deep learning models to better predict the risk of asthma exacerbations and to explore potential risk factors involved in progressive asthma. Methods: We proposed a novel time-sensitive, attentive neural network to predict asthma exacerbation using clinical variables from large electronic health records. The clinical variables were collected from the Cerner Health Facts database between 1992 and 2015, including 31,433 adult patients with asthma. Interpretations on both patient and cohort levels were investigated based on the model parameters. Results: The proposed model obtained an area under the curve value of 0.7003 through a five-fold cross-validation, which outperformed the baseline methods. The results also demonstrated that the addition of elapsed time embeddings considerably improved the prediction performance. Further analysis observed diverse distributions of contributing factors across patients as well as some possible cohort-level risk factors, which could be found supporting evidence from peer-reviewed literature such as respiratory diseases and esophageal reflux. Conclusions: The proposed neural network model performed better than previous methods for the prediction of asthma exacerbation. We believe that personalized risk scores and analyses of contributing factors can help clinicians better assess the individual’s level of disease progression and afford the opportunity to adjust treatment, prevent exacerbation, and improve outcomes. %M 32735224 %R 10.2196/16981 %U https://www.jmir.org/2020/7/e16981 %U https://doi.org/10.2196/16981 %U http://www.ncbi.nlm.nih.gov/pubmed/32735224 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18779 %T Development and Usability Evaluation of a Facebook-Based Intervention Program for Childhood Cancer Patients: Mixed Methods Study %A Park,Bu Kyung %A Kim,Ji Yoon %A Rogers,Valerie E %+ College of Nursing, Research Institute of Nursing Science, Kyungpook National University, 680 Gukchaegosang-ro, Jung-gu, Daegu, 41944, Republic of Korea, 82 53 420 4929, bukpark@knu.ac.kr %K pediatric cancer patients %K childhood cancer %K social network site %K Facebook %K usability %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Childhood cancers previously considered to be incurable now have 5-year survival rates up to 84%. Nevertheless, these patients remain at risk of morbidity and mortality from therapy-related complications. Thus, patient education and self-management strategies for promoting a healthy lifestyle are of tantamount importance for improving short- and long-term health outcomes. A Facebook-based “Healthy Teens for Soaam” (a Korean term for childhood cancers) program was developed to help improve knowledge and self-management practices of teens with cancer related to their disease and treatment. Objective: The two-fold purpose of this usability study was (1) to describe the process of developing an 8-week Facebook-based intervention program for teens with cancer, and (2) to evaluate its usability to refine the program. Methods: Multiple phases and methods were employed to develop and evaluate the usability of the program. Study phases included: (1) needs assessment through focus group interviews and qualitative content analysis, (2) development of module content, (3) expert review and feedback on module content, (4) Facebook-based program development, (5) usability evaluation by heuristic evaluation, (6) usability evaluation by targeted end-user testing, and (7) modification and final version of the program. Usability of the final version was confirmed through feedback loops of these phases. Results: Based on 6 focus group discussion sessions, it was determined that teens with cancer were interested in seeing stories of successful childhood cancer cases and self-management after discharge, and preferred multimedia content over text. Therefore, each Facebook module was redesigned to include multimedia materials such as relevant video clips tailored for teens. Usability assessed by heuristic evaluation and user testing revealed several critical usability issues, which were then revised. Potential end users tested the final program and perceived it to be usable and useful for teens with cancer. Conclusions: To our knowledge, “Healthy Teens for Soaam” is the first Facebook-based intervention program for teens with cancer. We actively worked with current childhood cancer patients and survivors to develop and improve this program, achieved good usability, and met the expressed needs and preferences of target end users. This 8-week Facebook-based educational program for teens with cancer, developed as the first step of an upcoming intervention study, will be useful for improving knowledge and self-management strategies of teens. %M 32720897 %R 10.2196/18779 %U http://www.jmir.org/2020/7/e18779/ %U https://doi.org/10.2196/18779 %U http://www.ncbi.nlm.nih.gov/pubmed/32720897 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17132 %T Enabling Better Use of Person-Generated Health Data in Stroke Rehabilitation Systems: Systematic Development of Design Heuristics %A Dimaguila,Gerardo Luis %A Gray,Kathleen %A Merolli,Mark %+ School of Computing and Information Systems, University of Melbourne, Parkville, Melbourne, 3010, Australia, 61 9035 5511, dgl@student.unimelb.edu.au %K person-generated health data %K patient-reported outcome measures %K heuristics %K stroke rehabilitation %K consumer health informatics %K evidence-based practice %K information technology %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: An established and well-known method for usability assessment of various human-computer interaction technologies is called heuristic evaluation (HE). HE has been adopted for evaluations in a wide variety of specialized contexts and with objectives that go beyond usability. A set of heuristics to evaluate how health information technologies (HITs) incorporate features that enable effective patient use of person-generated health data (PGHD) is needed in an era where there is a growing demand and variety of PGHD-enabled technologies in health care and where a number of remote patient-monitoring technologies do not yet enable patient use of PGHD. Such a set of heuristics would improve the likelihood of positive effects from patients’ use of PGHD and lower the risk of negative effects. Objective: This study aims to describe the development of a set of heuristics for the design and evaluation of how well remote patient therapeutic technologies enable patients to use PGHD (PGHD enablement). We used the case of Kinect-based stroke rehabilitation systems (K-SRS) in this study. Methods: The development of a set of heuristics to enable better use of PGHD was primarily guided by the R3C methodology. Closer inspection of the methodology reveals that neither its development nor its application to a case study were described in detail. Thus, where relevant, each step was grounded through best practice activities in the literature and by using Nielsen’s heuristics as a basis for determining the new set of heuristics. As such, this study builds on the R3C methodology, and the implementation of a mixed process is intended to result in a robust and credible set of heuristics. Results: A total of 8 new heuristics for PGHD enablement in K-SRS were created. A systematic and detailed process was applied in each step of heuristic development, which bridged the gaps described earlier. It is hoped that this would aid future developers of specialized heuristics, who could apply the detailed process of heuristic development for other domains of technology, and additionally for the case of PGHD enablement for other health conditions. The R3C methodology was also augmented through the use of qualitative studies with target users and domain experts, and it is intended to result in a robust and credible set of heuristics, before validation and refinement. Conclusions: This study is the first to develop a new set of specialized heuristics to evaluate how HITs incorporate features that enable effective patient use of PGHD, with K-SRS as a key case study. In addition, it is the first to describe how the identification of initial HIT features and concepts to enable PGHD could lead to the development of a specialized set of heuristics. %M 32720901 %R 10.2196/17132 %U http://www.jmir.org/2020/7/e17132/ %U https://doi.org/10.2196/17132 %U http://www.ncbi.nlm.nih.gov/pubmed/32720901 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18446 %T Recruiting and Retaining Youth and Young Adults in the Policy and Communication Evaluation (PACE) Vermont Study: Randomized Controlled Trial of Participant Compensation %A Villanti,Andrea C %A Vallencourt,Christie P %A West,Julia C %A Peasley-Miklus,Catherine %A LePine,S Elisha %A McCluskey,Caitlin %A Klemperer,Elias %A Priest,Jeffrey S %A Logan,Alison %A Patton,Bill %A Erickson,Nancy %A Hicks,Jennifer %A Horton,Kathleen %A Livingston,Shayla %A Roemhildt,Maria %A Singer,Erin %A Trutor,Megan %A Williams,Rhonda %+ Department of Psychiatry, Vermont Center on Behavior and Health, University of Vermont Larner College of Medicine, 1 South Prospect Street, MS 482, Burlington, VT, 05401, United States, 1 8026561187, avillant@uvm.edu %K recruitment %K retention %K adolescents %K young adults %K prevention %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The standard approach for evaluating the effects of population-level substance use prevention efforts on youth and young adult perceptions and behaviors has been to compare outcomes across states using national surveillance data. Novel surveillance methods that follow individuals over shorter time intervals and capture awareness of substance use prevention policy and communication efforts may provide a stronger basis for their evaluation than annual cross-sectional studies. Objective: This study aimed to identify a combination of strategies to recruit a sample of youth and young adults sufficiently representative of the Vermont population and determine how best to retain a web-based panel of youth and young adults over a 6-month period. Methods: Eligible participants were Vermont residents aged 12 to 25 years who were willing to complete three 10 to 15-minute web-based surveys over a 6-month period. Recruitment was conducted via the following three main mechanisms: (1) web-based recruitment (paid and unpaid), (2) community-based recruitment through partners, and (3) participant referrals via a personalized link. Upon completion of the baseline survey, participants were randomly assigned to one of the following three retention incentive conditions: (1) guaranteed incentive (US $10), (2) lottery incentive (US $50 weekly lottery drawing), and (3) preferred method (guaranteed or lottery). Analyses examined cost per survey start by recruitment source, distribution of demographic characteristics across incentive conditions, and retention by study condition at 3-month and 6-month follow-ups. Results: Over a 10-week period in 2019, we recruited 480 eligible youth (aged 12-17 years) and 1037 eligible young adults (aged 18-25 years) to the Policy and Communication Evaluation (PACE) Vermont Study. Facebook and Instagram advertising produced the greatest number of survey starts (n=2013), followed by posts to a state-wide web-based neighborhood forum (n=822) and Google advertisements (n=749). Retention was 78.11% (1185/1517) at 3 months and 72.18% (1095/1517) at 6 months. Retention was equivalent across all incentive study conditions at both waves, despite a strong stated preference among study participants for the guaranteed payment at baseline. Youth had greater retention than young adults at both waves (wave 2: 395/480, 82.3% vs 790/1037, 76.18%; wave 3: 366/480, 76.3% vs 729/1037, 70.30%). Substance use prevalence in this cohort was similar to national and state-level surveillance estimates for young adults, but was lower than state-level surveillance estimates for youth. Most participants retained at wave 3 provided positive qualitative feedback on their experience. Conclusions: Our study supports the feasibility of recruiting a web-based cohort of youth and young adults with representation across an entire state to evaluate substance use prevention efforts. Findings suggest that a guaranteed payment immediately upon survey completion coupled with a bonus for completing all survey waves and weekly survey reminders may facilitate retention in a cohort of youth and young adults. %M 32706681 %R 10.2196/18446 %U http://www.jmir.org/2020/7/e18446/ %U https://doi.org/10.2196/18446 %U http://www.ncbi.nlm.nih.gov/pubmed/32706681 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e12619 %T Effectiveness of Social Media Approaches to Recruiting Young Adult Cigarillo Smokers: Cross-Sectional Study %A Cavallo,David %A Lim,Rock %A Ishler,Karen %A Pagano,Maria %A Perovsek,Rachel %A Albert,Elizabeth %A Koopman Gonzalez,Sarah %A Trapl,Erika %A Flocke,Susan %+ Department of Nutrition, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106-4954, United States, 1 216 368 6627, david.cavallo@case.edu %K adolescent, young adult %K tobacco products %K social media %K research subject recruitment %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The prevalence of social media use among youth and young adults suggests it is an appropriate platform for study recruitment from this population. Previous studies have examined the use of social media for recruitment, but few have compared platforms, and none, to our knowledge, have attempted to recruit cigarillo users. Objective: The purpose of this study was to examine the effectiveness of different social media platforms and advertisement images for recruiting cigarillo users aged 14-28 years to complete a cigarillo use survey. Methods: We obtained objective data for advertisement impressions for a 39-week social media recruitment campaign. Advertisements were targeted to users based on their age, geography, and interests. Effectiveness was defined as the percentage of approved surveys per advertising impression. Chi-square tests were performed to compare the effectiveness of different advertisement images and platforms. Results: Valid survey completers (n=1089) were predominately older (25-28 years old, n=839, 77%). Of the 1089 survey completers, 568 (52%) identified as male, 335 (31%) as African American, and 196 (18%) as Hispanic. Advertisements delivered via Facebook/Instagram were more effective than Twitter; 311/1,027,738 (0.03%) vs 661/2,998,715 (0.02%); χ21=21.45, N=4,026,453); P<.001. Across platforms, ads featuring exclusively an image of cigarillos were more effective (397/682,994, 0.06%) than ads with images of individuals smoking (254/1,308,675, 0.02%), individuals not smoking (239/1,393,134, .02%), and groups not smoking (82/641,650, 0.01%); χ23133.73, N=4,026,453; P<.001. Conclusions: The campaign was effective in recruiting a diverse sample representative of relevant racial/ethnic categories. Advertisements on Facebook were more effective than Twitter. Advertisements that featured an image of a cigarillo were consistently the most effective and should be considered by others recruiting cigarillo users via social media. %M 32459629 %R 10.2196/12619 %U https://www.jmir.org/2020/7/e12619 %U https://doi.org/10.2196/12619 %U http://www.ncbi.nlm.nih.gov/pubmed/32459629 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18055 %T Exploring the Privacy-Preserving Properties of Word Embeddings: Algorithmic Validation Study %A Abdalla,Mohamed %A Abdalla,Moustafa %A Hirst,Graeme %A Rudzicz,Frank %+ Department of Computer Science, University of Toronto, Bahen Centre for Information Technology, 40 St. George Street, Room 4283, Toronto, ON, M5S 2E4, Canada, 1 4169787816, mohamed.abdalla@mail.utoronto.ca %K privacy %K data anonymization %K natural language processing %K personal health records %D 2020 %7 15.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Word embeddings are dense numeric vectors used to represent language in neural networks. Until recently, there had been no publicly released embeddings trained on clinical data. Our work is the first to study the privacy implications of releasing these models. Objective: This paper aims to demonstrate that traditional word embeddings created on clinical corpora that have been deidentified by removing personal health information (PHI) can nonetheless be exploited to reveal sensitive patient information. Methods: We used embeddings created from 400,000 doctor-written consultation notes and experimented with 3 common word embedding methods to explore the privacy-preserving properties of each. Results: We found that if publicly released embeddings are trained from a corpus anonymized by PHI removal, it is possible to reconstruct up to 68.5% (n=411/600) of the full names that remain in the deidentified corpus and associated sensitive information to specific patients in the corpus from which the embeddings were created. We also found that the distance between the word vector representation of a patient’s name and a diagnostic billing code is informative and differs significantly from the distance between the name and a code not billed for that patient. Conclusions: Special care must be taken when sharing word embeddings created from clinical texts, as current approaches may compromise patient privacy. If PHI removal is used for anonymization before traditional word embeddings are trained, it is possible to attribute sensitive information to patients who have not been fully deidentified by the (necessarily imperfect) removal algorithms. A promising alternative (ie, anonymization by PHI replacement) may avoid these flaws. Our results are timely and critical, as an increasing number of researchers are pushing for publicly available health data. %M 32673230 %R 10.2196/18055 %U https://www.jmir.org/2020/7/e18055 %U https://doi.org/10.2196/18055 %U http://www.ncbi.nlm.nih.gov/pubmed/32673230 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17340 %T Surveillance of Noncommunicable Disease Epidemic Through the Integrated Noncommunicable Disease Collaborative Management System: Feasibility Pilot Study Conducted in the City of Ningbo, China %A Li,Sixuan %A Zhang,Liang %A Liu,Shiwei %A Hubbard,Richard %A Li,Hui %+ Division of Chronic and Noncommunicable Disease Control and Prevention, Ningbo Municipal Center for Disease Control and Prevention, 237 Yongfeng Road, Haishu District, Ningbo, 315010, China, 86 0574 87274542, lihui4329@163.com %K surveillance %K noncommunicable diseases %K regional health information platform %K electronic health records. %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Noncommunicable diseases (NCDs) have become the main public health concern worldwide. With rapid economic development and changes in lifestyles, the burden of NCDs in China is increasing dramatically every year. Monitoring is a critical measure for NCDs control and prevention. However, because of the lack of regional representativeness, unsatisfactory data quality, and inefficient data sharing and utilization, the existing surveillance systems and surveys in China cannot track the status and transition of NCDs epidemic. Objective: To efficaciously track NCDs epidemic in China, this pilot program conducted in Ningbo city by the Chinese Center for Disease Control and Prevention (CDC) aimed to develop an innovative model for NCDs surveillance and management: the integrated noncommunicable disease collaborative management system (NCDCMS). Methods: This Ningbo model was designed and developed through a 3-level (county/district, municipal, and provincial levels) direct reporting system based on the regional health information platform. The uniform data standards and interface specifications were established to connect different platforms and conduct data exchanges. The performance of the system was evaluated based on the 9 attributes of surveillance system evaluation framework recommended by the US CDC. Results: NCDCMS allows automatic NCDs data exchanging and sharing via a 3-level public health data exchange platform in China. It currently covers 201 medical institutions throughout the city. Compared with previous systems, automatic popping up of the report card, automatic patient information extraction, and real-time data exchange process have highly improved the simplicity and timeliness of the system. The data quality meets the requirements to monitor the incidence trend of NCDs accurately, and the comprehensive data types obtained from the database (ie, directly from the 3-level platform on the data warehouse) also provide a useful information to conduct scientific studies. So far, 98.1% (201/205) of medical institutions across Ningbo having been involved in data exchanges with the model. Evaluations of the system performance showed that NCDCMS has high levels of simplicity, data quality, acceptability, representativeness, and timeliness. Conclusions: NCDCMS completely reshaped the process of NCD surveillance reporting and had unique advantages, which include reducing the work burden of different stakeholders by data sharing and exchange, eliminating unnecessary redundancies, reducing the amount of underreporting, and structuring population-based cohorts. The Ningbo model will be gradually promoted elsewhere following this success of the pilot project, and is expected to be a milestone in NCDs surveillance, control, and prevention in China. %M 32706706 %R 10.2196/17340 %U http://www.jmir.org/2020/7/e17340/ %U https://doi.org/10.2196/17340 %U http://www.ncbi.nlm.nih.gov/pubmed/32706706 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15121 %T Considerations for Health Researchers Using Social Media for Knowledge Translation: Multiple Case Study %A Elliott,Sarah A %A Dyson,Michele P %A Wilkes,Gilbert V %A Zimmermann,Gabrielle L %A Chambers,Christine T %A Wittmeier,Kristy DM %A Russell,Dianne J %A Scott,Shannon D %A Thomson,Denise %A Hartling,Lisa %+ Alberta Research Center for Health Evidence, Department of Pediatrics, University of Alberta, 11405 - 87 Avenue Edmonton, Edmonton, AB, Canada, 1 7804926124, se2@ualberta.ca %K social media %K knowledge translation %K health research %K engagement %K dissemination %K exchange %K evaluation %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite extensive literature describing the use of social media in health research, a gap exists around best practices in establishing, implementing, and evaluating an effective social media knowledge translation (KT) and exchange strategies. Objective: This study aims to examine successes, challenges, and lessons learned from using social media within health research and to create practical considerations to guide other researchers. Methods: The Knowledge Translation Platform of the Alberta Strategy for Patient-Oriented Research SUPPORT Unit formed a national working group involving platform staff, academics, and a parent representative with experience using social media for health research. We collected and analyzed 4 case studies that used a variety of social media platforms and evaluation methods. The case studies covered a spectrum of initiatives from participant recruitment and data collection to dissemination, engagement, and evaluation. Methods and findings from each case study as well as barriers and facilitators encountered were summarized. Through iterative discussions, we converged on recommendations and considerations for health researchers planning to use social media for KT. Results: We provide recommendations for elements to consider when developing a social media KT strategy: (1) set a clear goal and identify a theory, framework, or model that aligns with the project goals and objectives; (2) understand the intended audience (use social network mapping to learn what platforms and social influences are available); (3) choose a platform or platforms that meet the needs of the intended audience and align well with the research team’s capabilities (can you tap into an existing network, and what mode of communication does it support?); (4) tailor messages to meet user needs and platform requirements (eg, plain language and word restrictions); (5) consider timing, frequency, and duration of messaging as well as the nature of interactions (ie, social filtering and negotiated awareness); (6) ensure adequate resources and personnel are available (eg, content creators, project coordinators, communications experts, and audience stakeholder or patient advocate); (7) develop an evaluation plan a priori driven by goals and types of data available (ie, quantitative and qualitative); and (8) consider ethical approvals needed (driven by evaluation and type of data collection). Conclusions: In the absence of a comprehensive framework to guide health researchers using social media for KT, we provide several key considerations. Future research will help validate the proposed components and create a body of evidence around best practices for using and evaluating social media as part of a KT strategy %M 32706653 %R 10.2196/15121 %U http://www.jmir.org/2020/7/e15121/ %U https://doi.org/10.2196/15121 %U http://www.ncbi.nlm.nih.gov/pubmed/32706653 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17207 %T Adherence to Blended or Face-to-Face Smoking Cessation Treatment and Predictors of Adherence: Randomized Controlled Trial %A Siemer,Lutz %A Brusse-Keizer,Marjolein G J %A Postel,Marloes G %A Ben Allouch,Somaya %A Sanderman,Robbert %A Pieterse,Marcel E %+ Technology, Health & Care Research Group, Saxion University of Applied Sciences, MH Tromplaan 28, Enschede, 7513 AB, Netherlands, 31 17678025906, l.siemer@utwente.nl %K blended treatment %K smoking cessation %K adherence %K predictors %K tobacco %K prevention %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Blended face-to-face and web-based treatment is a promising way to deliver smoking cessation treatment. Since adherence has been shown to be an indicator of treatment acceptability and a determinant for effectiveness, we explored and compared adherence and predictors of adherence to blended and face-to-face alone smoking cessation treatments with similar content and intensity. Objective: The objectives of this study were (1) to compare adherence to a blended smoking cessation treatment with adherence to a face-to-face treatment; (2) to compare adherence within the blended treatment to its face-to-face mode and web mode; and (3) to determine baseline predictors of adherence to both treatments as well as (4) the predictors to both modes of the blended treatment. Methods: We calculated the total duration of treatment exposure for patients (N=292) of a Dutch outpatient smoking cessation clinic who were randomly assigned either to the blended smoking cessation treatment (n=130) or to a face-to-face treatment with identical components (n=162). For both treatments (blended and face-to-face) and for the two modes of delivery within the blended treatment (face-to-face vs web mode), adherence levels (ie, treatment time) were compared and the predictors of adherence were identified within 33 demographic, smoking-related, and health-related patient characteristics. Results: We found no significant difference in adherence between the blended and the face-to-face treatments. Participants in the blended treatment group spent an average of 246 minutes in treatment (median 106.7% of intended treatment time, IQR 150%-355%) and participants in the face-to-face group spent 238 minutes (median 103.3% of intended treatment time, IQR 150%-330%). Within the blended group, adherence to the face-to-face mode was twice as high as that to the web mode. Participants in the blended group spent an average of 198 minutes (SD 120) in face-to-face mode (152% of the intended treatment time) and 75 minutes (SD 53) in web mode (75% of the intended treatment time). Higher age was the only characteristic consistently found to uniquely predict higher adherence in both the blended and face-to-face groups. For the face-to-face group, more social support for smoking cessation was also predictive of higher adherence. The variability in adherence explained by these predictors was rather low (blended R2=0.049; face-to-face R2=0.076). Within the blended group, living without children predicted higher adherence to the face-to-face mode (R2=0.034), independent of age. Higher adherence to the web mode of the blended treatment was predicted by a combination of an extrinsic motivation to quit, a less negative attitude toward quitting, and less health complaints (R2=0.164). Conclusions: This study represents one of the first attempts to thoroughly compare adherence and predictors of adherence of a blended smoking cessation treatment to an equivalent face-to-face treatment. Interestingly, although the overall adherence to both treatments appeared to be high, adherence within the blended treatment was much higher for the face-to-face mode than for the web mode. This supports the idea that in blended treatment, one mode of delivery can compensate for the weaknesses of the other. Higher age was found to be a common predictor of adherence to the treatments. The low variance in adherence predicted by the characteristics examined in this study suggests that other variables such as provider-related health system factors and time-varying patient characteristics should be explored in future research. Trial Registration: Netherlands Trial Register NTR5113; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5113 %M 32459643 %R 10.2196/17207 %U http://www.jmir.org/2020/7/e17207/ %U https://doi.org/10.2196/17207 %U http://www.ncbi.nlm.nih.gov/pubmed/32459643 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18338 %T Effects of Incentives on Adherence to a Web-Based Intervention Promoting Physical Activity: Naturalistic Study %A Wurst,Ramona %A Maliezefski,Anja %A Ramsenthaler,Christina %A Brame,Judith %A Fuchs,Reinhard %+ Department of Sport and Sport Science, University of Freiburg, Schwarzwaldstrasse 175, Freiburg, 79117, Germany, 49 7612034563, ramona.wurst@sport.uni-freiburg.de %K internet-based intervention %K adherence %K incentive %K reward %K mHealth %K eHealth %K exercise %K dropout rate %K usage %K attrition %K telemedicine %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite many advantages of web-based health behavior interventions such as wide accessibility or low costs, these interventions are often accompanied by high attrition rates, particularly in usage under real-life conditions. It would therefore be helpful to implement strategies such as the use of financial incentives to motivate program participation and increase adherence. Objective: This naturalistic study examined real-life usage data of a 12-week web-based physical activity (PA) intervention (Fitness Coach) among insurants who participated in an additional incentive program (incentive group) and those who did not (nonincentive group). Users in the incentive group had the perspective of receiving €30 (about US $33) cash back at the end of the intervention. Methods: Registration and real-life usage data as part of routine data management and evaluation of the Fitness Coach were analyzed between September 2016 and June 2018. Depending on the duration of use and the weekly recording of tasks, 4 adherence groups (low, occasional, strong, and complete adherence) were defined. Demographic characteristics were collected by a self-reported questionnaire at registration. We analyzed baseline predictors and moderators of complete adherence such as participation in the program, age, gender, and BMI using binary logistic regressions. Results: A total of 18,613 eligible persons registered for the intervention. Of these, 15,482 users chose to participate in the incentive program (incentive group): mean age 42.4 (SD 14.4) years, mean BMI 24.5 (SD 4.0) kg/m2, median (IQR) BMI 23.8 (21.7-26.4) kg/m2; 65.12% (10,082/15,482) female; and 3131 users decided not to use the incentive program (nonincentive group): mean age 40.7 (SD 13.4) years, mean BMI 26.2 (SD 5.0) kg/m2, median BMI 25.3 (IQR 22.6-28.7) kg/m2; 72.18% (2260/3131) female. At the end of the intervention, participants in the incentive program group showed 4.8 times higher complete adherence rates than those in the nonincentive program group (39.2% vs 8.1%), also yielding significantly higher odds to complete the intervention (odds ratio [OR] 12.638) for the incentive program group. Gender significantly moderated the effect with men in the incentive group showing higher odds to be completely adherent than women overall and men in the nonincentive group (OR 1.761). Furthermore, older age and male gender were significant predictors of complete adherence for all participants, whereas BMI did not predict intervention completion. Conclusions: This is the first naturalistic study in the field of web-based PA interventions that shows the potential of even small financial incentives to increase program adherence. Male users, in particular, seem to be strongly motivated by incentives to complete the intervention. Based on these findings, health care providers can use differentiated incentive systems to increase regular participation in web-based PA interventions. %M 32729835 %R 10.2196/18338 %U http://www.jmir.org/2020/7/e18338/ %U https://doi.org/10.2196/18338 %U http://www.ncbi.nlm.nih.gov/pubmed/32729835 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19752 %T Synthesizing Multiple Stakeholder Perspectives on Using Virtual Reality to Improve the Periprocedural Experience in Children and Adolescents: Survey Study %A Ahmadpour,Naseem %A Weatherall,Andrew David %A Menezes,Minal %A Yoo,Soojeong %A Hong,Hanyang %A Wong,Gail %+ Design Lab, School of Architecture, Design and Planning, The University of Sydney, 148 City Road, Darlington, NSW, 2006, Australia, 61 286275649, naseem.ahmadpour@sydney.edu.au %K virtual reality %K periprocedural anxiety %K children %K adolescents %K stakeholder perspective %K design %K VR %K pediatrics %K patient experience %K app %K eHealth %D 2020 %7 17.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) technology is a powerful tool for augmenting patient experience in pediatric settings. Incorporating the needs and values of stakeholders in the design of VR apps in health care can contribute to better outcomes and meaningful experiences for patients. Objective: We used a multiperspective approach to investigate how VR apps can be designed to improve the periprocedural experiences of children and adolescents, particularly those with severe anxiety. Methods: This study included a focus group (n=4) and a survey (n=56) of clinicians. Semistructured interviews were conducted with children and adolescents in an immunization clinic (n=3) and perioperative setting (n=65) and with parents and carers in an immunization clinic (n=3) and perioperative setting (n=35). Results: Qualitative data were examined to determine the experience and psychological needs and intervention and design strategies that may contribute to better experiences for children in three age groups (4-7, 8-11, and 12-17 years). Quantitative data were used to identify areas of priority for future VR interventions. Conclusions: We propose a set of ten design considerations for the creation of future VR experiences for pediatric patients. Enhancing patient experience may be achieved by combining multiple VR solutions through a holistic approach considering the roles of clinicians and carers and the temporality of the patient’s experience. These situations require personalized solutions to fulfill the needs of pediatric patients before and during the medical procedure. In particular, communication should be placed at the center of preprocedure solutions, while emotional goals can be embedded into a procedure-focused VR app to help patients shift their focus in a meaningful way to build skills to manage their anxiety. %M 32706671 %R 10.2196/19752 %U http://www.jmir.org/2020/7/e19752/ %U https://doi.org/10.2196/19752 %U http://www.ncbi.nlm.nih.gov/pubmed/32706671 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17096 %T Combination of 3-Dimensional Virtual Reality and Hands-On Aromatherapy in Improving Institutionalized Older Adults’ Psychological Health: Quasi-Experimental Study %A Cheng,Vivian Ya-Wen %A Huang,Chiu-Mieh %A Liao,Jung-Yu %A Hsu,Hsiao-Pei %A Wang,Shih-Wen %A Huang,Su-Fei %A Guo,Jong-Long %+ Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, 162, Section 1, He-ping East Road, Taipei, 10610, Taiwan, 886 277493705, jonglong@ntnu.edu.tw %K three-dimensional %K virtual reality %K aromatherapy %K older adult %K happiness %K stress %K sleep quality %K meditation %K life satisfaction %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In Taiwan, which has one of the most rapidly aging populations in the world, it is becoming increasingly critical to promote successful aging strategies that are effective, easily usable, and acceptable to institutionalized older adults. Although many practitioners and professionals have explored aromatherapy and identified its psychological benefits, the effectiveness of combining 3-dimensional (3D) virtual reality and hands-on aromatherapy remains unknown. Objective: A quasi-experimental trial was designed to evaluate the effectiveness of this combination in lowering perceived stress and promoting happiness, sleep quality, meditation experience, and life satisfaction among institutionalized older adults in Taiwan. Methods: A total of 60 institutionalized elderly participants either received the combined intervention or were in a control group. Weekly 2-hour sessions were implemented over 9 weeks. The outcome variables were happiness, perceived stress, sleep quality, meditation experience, and life satisfaction, which were assessed at baseline and after the intervention. Results: Generalized estimating equation (GEE) analyses indicated that the experimental group showed significant post-intervention improvements in terms of scores for happiness, perceived stress, sleep quality, meditation experience, and life satisfaction (n=48; all P<.001). Another GEE analysis showed that the significant improvements in the 5 outcome variables persisted in participants aged 80 years and older (n=35; all P<.001). Conclusions: This is the first trial to explore the effectiveness of a combination of 3D virtual reality and hands-on aromatherapy in improving older adults’ psychological health. The results are promising for the promotion of psychological health in institutionalized older adults. Trial Registration: ClinicalTrials.gov NCT04324216; https://clinicaltrials.gov/ct2/show/NCT04324216. %M 32706660 %R 10.2196/17096 %U http://www.jmir.org/2020/7/e17096/ %U https://doi.org/10.2196/17096 %U http://www.ncbi.nlm.nih.gov/pubmed/32706660 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17571 %T Virtual Reality Smartphone-Based Intervention for Smoking Cessation: Pilot Randomized Controlled Trial on Initial Clinical Efficacy and Adherence %A Goldenhersch,Emilio %A Thrul,Johannes %A Ungaretti,Joaquín %A Rosencovich,Nicolas %A Waitman,Cristian %A Ceberio,Marcelo Rodriguez %+ Laboratorio de Investigación en Neurociencia y Ciencias Sociales, Universidad de Flores, Avenida Rivadavia 5741, Ciudad Autónoma de Buenos Aires, CP 1414, Argentina, 1 4808860102, emiliogolden@gmail.com %K smoking cessation %K nicotine dependence %K craving %K virtual reality %K mindfulness %K digital therapy %K mHealth %K mobile phone %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Obstacles to current tobacco cessation programs include limited access and adherence to effective interventions. Digital interventions offer a great opportunity to overcome these difficulties, yet virtual reality has not been used as a remote and self-administered tool to help increase adherence and effectiveness of digital interventions for tobacco cessation. Objective: This study aimed to evaluate participant adherence and smoking cessation outcomes in a pilot randomized controlled trial of the digital intervention Mindcotine (MindCotine Inc) using a self-administered treatment of virtual reality combined with mindfulness. Methods: A sample of 120 participants was recruited in the city of Buenos Aires, Argentina (mean age 43.20 years, SD 9.50; 57/120, 47.5% female). Participants were randomly assigned to a treatment group (TG), which received a self-assisted 21-day program based on virtual reality mindful exposure therapy (VR-MET) sessions, daily surveys, and online peer-to-peer support moderated by psychologists, or a control group (CG), which received the online version of the smoking cessation manual from the Argentine Ministry of Health. Follow-up assessments were conducted by online surveys at postintervention and 90-day follow-up. The primary outcome was self-reported abstinence at postintervention, with missing data assumed as still smoking. Secondary outcomes included sustained abstinence at 90-day follow-up, adherence to the program, and readiness to quit. Results: Follow-up rates at day 1 were 93% (56/60) for the TG and 100% (60/60) for the CG. At postintervention, the TG reported 23% (14/60) abstinence on that day compared with 5% (3/60) in the CG. This difference was statistically significant (χ21=8.3; P=.004). The TG reported sustained abstinence of 33% (20/60) at 90 days. Since only 20% (12/60) of participants in the CG completed the 90-day follow-up, we did not conduct a statistical comparison between groups at this follow-up time point. Among participants still smoking at postintervention, the TG was significantly more ready to quit compared to the CG (TG: mean 7.71, SD 0.13; CG: mean 7.16, SD 0.13; P=.005). A total of 41% (23/56) of participants completed the treatment in the time frame recommended by the program. Conclusions: Results provide initial support for participant adherence to and efficacy of Mindcotine and warrant testing the intervention in a fully powered randomized trial. However, feasibility of trial follow-up assessment procedures for control group participants needs to be improved. Further research is needed on the impact of VR-MET on long-term outcomes. Trial Registration: ISRCTN Registry ISRCTN50586181; http://www.isrctn.com/ISRCTN50586181 %M 32723722 %R 10.2196/17571 %U http://www.jmir.org/2020/7/e17571/ %U https://doi.org/10.2196/17571 %U http://www.ncbi.nlm.nih.gov/pubmed/32723722 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17502 %T Biased Sampling and Causal Estimation of Health-Related Information: Laboratory-Based Experimental Research %A Moreno-Fernández,María Manuela %A Matute,Helena %+ Departamento de Fundamentos y Métodos de la Psicología, Faculty of Psychology and Education, University of Deusto, Avenida de las Universidades, 24, Bilbao, 48007, Spain, 34 944 139 000 ext 3229, manuela.moreno@deusto.es %K information sampling %K causal illusion %K causal bias %K health information %K health communication %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet is a relevant source of health-related information. The huge amount of information available on the internet forces users to engage in an active process of information selection. Previous research conducted in the field of experimental psychology showed that information selection itself may promote the development of erroneous beliefs, even if the information collected does not. Objective: The aim of this study was to assess the relationship between information searching strategy (ie, which cues are used to guide information retrieval) and causal inferences about health while controlling for the effect of additional information features. Methods: We adapted a standard laboratory task that has previously been used in research on contingency learning to mimic an information searching situation. Participants (N=193) were asked to gather information to determine whether a fictitious drug caused an allergic reaction. They collected individual pieces of evidence in order to support or reject the causal relationship between the two events by inspecting individual cases in which the drug was or was not used or in which the allergic reaction appeared or not. Thus, one group (cause group, n=105) was allowed to sample information based on the potential cause, whereas a second group (effect group, n=88) was allowed to sample information based on the effect. Although participants could select which medical records they wanted to check—cases in which the medicine was used or not (in the cause group) or cases in which the effect appeared or not (in the effect group)—they all received similar evidence that indicated the absence of a causal link between the drug and the reaction. After observing 40 cases, they estimated the drug–allergic reaction causal relationship. Results: Participants used different strategies for collecting information. In some cases, participants displayed a biased sampling strategy compatible with positive testing, that is, they required a high proportion of evidence in which the drug was administered (in the cause group) or in which the allergic reaction appeared (in the effect group). Biased strategies produced an overrepresentation of certain pieces of evidence at the detriment of the representation of others, which was associated with the accuracy of causal inferences. Thus, how the information was collected (sampling strategy) demonstrated a significant effect on causal inferences (F1,185=32.53, P<.001, η2p=0.15) suggesting that inferences of the causal relationship between events are related to how the information is gathered. Conclusions: Mistaken beliefs about health may arise from accurate pieces of information partially because of the way in which information is collected. Patient or person autonomy in gathering health information through the internet, for instance, may contribute to the development of false beliefs from accurate pieces of information because search strategies can be biased. %M 32706735 %R 10.2196/17502 %U http://www.jmir.org/2020/7/e17502/ %U https://doi.org/10.2196/17502 %U http://www.ncbi.nlm.nih.gov/pubmed/32706735 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17853 %T Crawling the German Health Web: Exploratory Study and Graph Analysis %A Zowalla,Richard %A Wetter,Thomas %A Pfeifer,Daniel %+ Department of Medical Informatics, Heilbronn University, Max-Planck-Str 39, Heilbronn, , Germany, 49 713 150 46791, richard.zowalla@hs-heilbronn.de %K health information %K internet %K web crawling %K distributed system %D 2020 %7 24.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet has become an increasingly important resource for health information. However, with a growing amount of web pages, it is nearly impossible for humans to manually keep track of evolving and continuously changing content in the health domain. To better understand the nature of all web-based health information as given in a specific language, it is important to identify (1) information hubs for the health domain, (2) content providers of high prestige, and (3) important topics and trends in the health-related web. In this context, an automatic web crawling approach can provide the necessary data for a computational and statistical analysis to answer (1) to (3). Objective: This study demonstrates the suitability of a focused crawler for the acquisition of the German Health Web (GHW) which includes all health-related web content of the three mostly German speaking countries Germany, Austria and Switzerland. Based on the gathered data, we provide a preliminary analysis of the GHW’s graph structure covering its size, most important content providers and a ratio of public to private stakeholders. In addition, we provide our experiences in building and operating such a highly scalable crawler. Methods: A support vector machine classifier was trained on a large data set acquired from various German content providers to distinguish between health-related and non–health-related web pages. The classifier was evaluated using accuracy, recall and precision on an 80/20 training/test split (TD1) and against a crowd-validated data set (TD2). To implement the crawler, we extended the open-source framework StormCrawler. The actual crawl was conducted for 227 days. The crawler was evaluated by using harvest rate and its recall was estimated using a seed-target approach. Results: In total, n=22,405 seed URLs with country-code top level domains .de: 85.36% (19,126/22,405), .at: 6.83% (1530/22,405), .ch: 7.81% (1749/22,405), were collected from Curlie and a previous crawl. The text classifier achieved an accuracy on TD1 of 0.937 (TD2=0.966), a precision on TD1 of 0.934 (TD2=0.954) and a recall on TD1 of 0.944 (TD2=0.989). The crawl yields 13.5 million presumably relevant and 119.5 million nonrelevant web pages. The average harvest rate was 19.76%; recall was 0.821 (4105/5000 targets found). The resulting host-aggregated graph contains 215,372 nodes and 403,175 edges (network diameter=25; average path length=6.466; average degree=1.872; average in-degree=1.892; average out-degree=1.845; modularity=0.723). Among the 25 top-ranked pages for each country (according to PageRank), 40% (30/75) were web sites published by public institutions. 25% (19/75) were published by nonprofit organizations and 35% (26/75) by private organizations or individuals. Conclusions: The results indicate, that the presented crawler is a suitable method for acquiring a large fraction of the GHW. As desired, the computed statistical data allows for determining major information hubs and important content providers on the GHW. In the future, the acquired data may be used to assess important topics and trends but also to build health-specific search engines. %M 32706701 %R 10.2196/17853 %U http://www.jmir.org/2020/7/e17853/ %U https://doi.org/10.2196/17853 %U http://www.ncbi.nlm.nih.gov/pubmed/32706701 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17312 %T Psychometric Properties of the Norwegian Version of the Electronic Health Literacy Scale (eHEALS) Among Patients After Percutaneous Coronary Intervention: Cross-Sectional Validation Study %A Brørs,Gunhild %A Wentzel-Larsen,Tore %A Dalen,Håvard %A Hansen,Tina B %A Norman,Cameron D %A Wahl,Astrid %A Norekvål,Tone M %A , %+ Department of Heart Disease, Haukeland University Hospital, Postbox 1400, Bergen, 5020, Norway, 47 99044635, tone.merete.norekval@helse-bergen.no %K eHealth literacy %K eHEALS %K health literacy %K percutaneous coronary intervention %K psychometric properties %K validation %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Web-based technology has recently become an important source for sharing health information with patients after an acute cardiac event. Therefore, consideration of patients’ perceived electronic health (eHealth) literacy skills is crucial for improving the delivery of patient-centered health information. Objective: The aim of this study was to translate and adapt the eHealth Literacy Scale (eHEALS) to conditions in Norway, and to determine its psychometric properties. More specifically, we set out to determine the reliability (internal consistency, test-retest) and construct validity (structural validity, hypotheses testing, and cross-cultural validity) of the eHEALS in self-report format administered to patients after percutaneous coronary intervention. Methods: The original English version of the eHEALS was translated into Norwegian following a widely used cross-cultural adaptation process. Internal consistency was calculated using Cronbach α. The intraclass correlation coefficient (ICC) was used to assess the test-retest reliability. Confirmatory factor analysis (CFA) was performed for a priori-specified 1-, 2-, and 3-factor models. Demographic, health-related internet use, health literacy, and health status information was collected to examine correlations with eHEALS scores. Results: A total of 1695 patients after percutaneous coronary intervention were included in the validation analysis. The mean age was 66 years, and the majority of patients were men (1313, 77.46%). Cronbach α for the eHEALS was >.99. The corresponding Cronbach α for the 2-week retest was .94. The test-retest ICC for eHEALS was 0.605 (95% CI 0.419-0.743, P<.001). The CFA showed a modest model fit for the 1- and 2-factor models (root mean square error of approximation>0.06). After modifications in the 3-factor model, all of the goodness-of-fit indices indicated a good fit. There was a weak correlation with age (r=–0.206). Between-groups analysis of variance showed a difference according to educational groups and the eHEALS score, with a mean difference ranging from 2.24 (P=.002) to 4.61 (P<.001), and a higher eHEALS score was found for patients who were employed compared to those who were retired (mean difference 2.31, P<.001). The eHEALS score was also higher among patients who reported using the internet to find health information (95% CI –21.40 to –17.21, P<.001), and there was a moderate correlation with the patients’ perceived usefulness (r=0.587) and importance (r=0.574) of using the internet for health information. There were also moderate correlations identified between the eHEALS score and the health literacy domains appraisal of health information (r=0.380) and ability to find good health information (r=0.561). Weak correlations with the mental health composite score (r=0.116) and physical health composite score (r=0.116) were identified. Conclusions: This study provides new information on the psychometric properties of the eHEALS for patients after percutaneous coronary intervention, suggesting a multidimensional rather than unidimensional construct. However, the study also indicated a redundancy of items, indicating the need for further validation studies. Trial Registration: ClinicalTrials.gov NCT03810612; https://clinicaltrials.gov/ct2/show/NCT03810612 %M 32720900 %R 10.2196/17312 %U https://www.jmir.org/2020/7/e17312 %U https://doi.org/10.2196/17312 %U http://www.ncbi.nlm.nih.gov/pubmed/32720900 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17508 %T Requirements of Health Data Management Systems for Biomedical Care and Research: Scoping Review %A Ismail,Leila %A Materwala,Huned %A Karduck,Achim P %A Adem,Abdu %+ Department of Computer Science and Software Engineering, College of Information Technology, United Arab Emirates University, Al Maqam Campus, Al Ain, Abu Dhabi, 15551, United Arab Emirates, 971 37673333 ext 5530, leila@uaeu.ac.ae %K big data %K blockchain %K data analytics %K eHealth %K electronic medical records %K health care %K health information management %K Internet of Things %K medical research %K mHealth %D 2020 %7 7.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Over the last century, disruptive incidents in the fields of clinical and biomedical research have yielded a tremendous change in health data management systems. This is due to a number of breakthroughs in the medical field and the need for big data analytics and the Internet of Things (IoT) to be incorporated in a real-time smart health information management system. In addition, the requirements of patient care have evolved over time, allowing for more accurate prognoses and diagnoses. In this paper, we discuss the temporal evolution of health data management systems and capture the requirements that led to the development of a given system over a certain period of time. Consequently, we provide insights into those systems and give suggestions and research directions on how they can be improved for a better health care system. Objective: This study aimed to show that there is a need for a secure and efficient health data management system that will allow physicians and patients to update decentralized medical records and to analyze the medical data for supporting more precise diagnoses, prognoses, and public insights. Limitations of existing health data management systems were analyzed. Methods: To study the evolution and requirements of health data management systems over the years, a search was conducted to obtain research articles and information on medical lawsuits, health regulations, and acts. These materials were obtained from the Institute of Electrical and Electronics Engineers, the Association for Computing Machinery, Elsevier, MEDLINE, PubMed, Scopus, and Web of Science databases. Results: Health data management systems have undergone a disruptive transformation over the years from paper to computer, web, cloud, IoT, big data analytics, and finally to blockchain. The requirements of a health data management system revealed from the evolving definitions of medical records and their management are (1) medical record data, (2) real-time data access, (3) patient participation, (4) data sharing, (5) data security, (6) patient identity privacy, and (7) public insights. This paper reviewed health data management systems based on these 7 requirements across studies conducted over the years. To our knowledge, this is the first analysis of the temporal evolution of health data management systems giving insights into the system requirements for better health care. Conclusions: There is a need for a comprehensive real-time health data management system that allows physicians, patients, and external users to input their medical and lifestyle data into the system. The incorporation of big data analytics will aid in better prognosis or diagnosis of the diseases and the prediction of diseases. The prediction results will help in the development of an effective prevention plan. %M 32348265 %R 10.2196/17508 %U https://www.jmir.org/2020/7/e17508 %U https://doi.org/10.2196/17508 %U http://www.ncbi.nlm.nih.gov/pubmed/32348265 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19274 %T The Influence of Electronic Health Record Use on Physician Burnout: Cross-Sectional Survey %A Tajirian,Tania %A Stergiopoulos,Vicky %A Strudwick,Gillian %A Sequeira,Lydia %A Sanches,Marcos %A Kemp,Jessica %A Ramamoorthi,Karishini %A Zhang,Timothy %A Jankowicz,Damian %+ Centre for Addiction and Mental Health, 6168F, 100 Stokes St., Toronto, ON, M6J1H4, Canada, 1 4165358501 ext 30515, Tania.Tajirian@camh.ca %K electronic health record %K physician %K burnout %K psychiatry %K medical informatics %D 2020 %7 15.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Physician burnout has a direct impact on the delivery of high-quality health care, with health information technology tools such as electronic health records (EHRs) adding to the burden of practice inefficiencies. Objective: The aim of this study was to determine the extent of burnout among physicians and learners (residents and fellows); identify significant EHR-related contributors of physician burnout; and explore the differences between physicians and learners with regard to EHR-related factors such as time spent in EHR, documentation styles, proficiency, training, and perceived usefulness. In addition, the study aimed to address gaps in the EHR-related burnout research methodologies by determining physicians’ patterns of EHR use through usage logs. Methods: This study used a cross-sectional survey methodology and a review of administrative data for back-end log measures of survey respondents’ EHR use, which was conducted at a large Canadian academic mental health hospital. Chi-square and Fisher exact tests were used to examine the association of EHR-related factors with general physician burnout. The survey was sent out to 474 individuals between May and June 2019, including physicians (n=407), residents (n=53), and fellows (n=14), and we measured physician burnout and perceptions of EHR stressors (along with demographic and practice characteristics). Results: Our survey included 208 respondents, including physicians (n=176) and learners (n=32). The response rate was 43.2% for physicians (full-time: 156/208, 75.0%; part-time: 20/199, 10.1%), and 48% (32/67) for learners. A total of 25.6% (45/176) of practicing physicians and 19% (6/32) of learners reported having one or more symptoms of burnout, and 74.5% (155/208) of all respondents who reported burnout symptoms identified the EHR as a contributor. Lower satisfaction and higher frustration with the EHRs were significantly associated with perceptions of EHR contributing toward burnout. Physicians’ and learners’ experiences with the EHR, gathered through open-ended survey responses, identified challenges around the intuitiveness and usability of the technology as well as workflow issues. Metrics gathered from back-end usage logs demonstrated a 13.6-min overestimation in time spent on EHRs per patient and a 5.63-hour overestimation of after-hours EHR time, when compared with self-reported survey data. Conclusions: This study suggests that the use of EHRs is a perceived contributor to physician burnout. There should be a focus on combating physician burnout by reducing the unnecessary administrative burdens of EHRs through efficient implementation of systems and effective postimplementation strategies. %M 32673234 %R 10.2196/19274 %U https://www.jmir.org/2020/7/e19274 %U https://doi.org/10.2196/19274 %U http://www.ncbi.nlm.nih.gov/pubmed/32673234 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16300 %T Adoption and Performance of Complementary Clinical Information Technologies: Analysis of a Survey of General Practitioners %A Poba-Nzaou,Placide %A Uwizeyemungu,Sylvestre %A Liu,Xuecheng %+ Department of Organization and Human Resources, University of Quebec in Montreal, 315, Sainte-Catherine East, Montreal, QC, H2X 3X2, Canada, 1 514 987 3000 ext 7744, poba-nzaou.placide@uqam.ca %K electronic health record %K personal health record %K health information exchange %K telehealth %K general practitioners %K quality of care %K efficiency %K organizational productivity %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The benefits from the combination of 4 clinical information systems (CISs)—electronic health records (EHRs), health information exchange (HIE), personal health records (PHRs), and telehealth—in primary care depend on the configuration of their functional capabilities available to clinicians. However, our empirical knowledge of these configurations and their associated performance implications is very limited because they have mostly been studied in isolation. Objective: This study aims to pursue 3 objectives: (1) characterize general practitioners (GPs) by uncovering the typical profiles of combinations of 4 major CIS capabilities, (2) identify physician and practice characteristics that predict cluster membership, and (3) assess the variation in the levels of performance associated with each configuration. Methods: We used data from a survey of GPs conducted throughout the European Union (N=5793). First, 4 factors, that is, EHRs, HIE, PHRs, and Telehealth, were created. Second, a cluster analysis helps uncover clusters of GPs based on the 4 factors. Third, we compared the clusters according to five performance outcomes using an analysis of variance (ANOVA) and a Tamhane T2 post hoc test. Fourth, univariate and multivariate multinomial logistic regressions were used to identify predictors of the clusters. Finally, with a multivariate multinomial logistic regression, among the clusters, we compared performance in terms of the number of patients treated (3 levels) over the last 2 years. Results: We unveiled 3 clusters of GPs with different levels of CIS capability profiles: strong (1956/5793, 37.36%), medium (2764/5793, 47.71%), and weak (524/5793, 9.04%). The logistic regression analysis indicates that physicians (younger, female, and less experienced) and practice (solo) characteristics are significantly associated with a weak profile. The ANOVAs revealed a strong cluster associated with significantly high practice performance outcomes in terms of the quality of care, efficiency, productivity, and improvement of working processes, and two noncomprehensive medium and weak profiles associated with medium (equifinal) practice performance outcomes. The logistic regression analysis also revealed that physicians in the weak profile are associated with a decrease in the number of patients treated over the last 2 years. Conclusions: Different CIS capability profiles may lead to similar equifinal performance outcomes. This underlines the importance of looking beyond the adoption of 1 CIS capability versus a cluster of capabilities when studying CISs. GPs in the strong cluster exhibit a comprehensive CIS capability profile and outperform the other two clusters with noncomprehensive profiles, leading to significantly high performance in terms of the quality of care provided to patients, efficiency of the practice, productivity of the practice, and improvement of working processes. Our findings indicate that medical practices should develop high capabilities in all 4 CISs if they have to maximize their performance outcomes because efforts to develop high capabilities selectively may only be in vain. %M 32706715 %R 10.2196/16300 %U http://www.jmir.org/2020/7/e16300/ %U https://doi.org/10.2196/16300 %U http://www.ncbi.nlm.nih.gov/pubmed/32706715 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19126 %T Information Overload in Emergency Medicine Physicians: A Multisite Case Study Exploring the Causes, Impact, and Solutions in Four North England National Health Service Trusts %A Sbaffi,Laura %A Walton,James %A Blenkinsopp,John %A Walton,Graham %+ Information School, University of Sheffield, 211 Portobello Street, Regent Court, Sheffield, S1 4DP, United Kingdom, 44 114 2222686, L.Sbaffi@sheffield.ac.uk %K emergency medicine %K information overload %K physicians %K national health care system %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Information overload is affecting modern society now more than ever because of the wide and increasing distribution of digital technologies. Social media, emails, and online communications among others infuse a sense of urgency as information must be read, produced, and exchanged almost instantaneously. Emergency medicine is a medical specialty that is particularly affected by information overload with consequences on patient care that are difficult to quantify and address. Understanding the current causes of medical information overload, their impact on patient care, and strategies to handle the inflow of constant information is crucial to alleviating stress and anxiety that is already crippling the profession. Objective: This study aims to identify and evaluate the main causes and sources of medical information overload, as experienced by emergency medicine physicians in selected National Health Service (NHS) trusts in the United Kingdom. Methods: This study used a quantitative, survey-based data collection approach including close- and open-ended questions. A web-based survey was distributed to emergency physicians to assess the impact of medical information overload on their jobs. In total, 101 valid responses were collected from 4 NHS trusts in north England. Descriptive statistics, principal component analysis, independent sample two-tailed t tests, and one-way between-group analysis of variance with post hoc tests were performed on the data. Open-ended questions were analyzed using thematic analysis to identify key topics. Results: The vast majority of respondents agreed that information overload is a serious issue in emergency medicine, and it increases with time. The always available culture (mean 5.40, SD 1.56), email handling (mean 4.86, SD 1.80), and multidisciplinary communications (mean 4.51, SD 1.61) are the 3 main reasons leading to information overload. Due to this, emergency physicians experience guideline fatigue, stress and tension, longer working hours, and impaired decision making, among other issues. Aspects of information overload are also reported to have different impacts on physicians depending on demographic factors such as age, years spent in emergency medicine, and level of employment. Conclusions: There is a serious concern regarding information overload in emergency medicine. Participants identified a considerable number of daily causes affecting their job, particularly the traditional culture of emergency departments being always available on the ward, exacerbated by email and other forms of communication necessary to maintain optimal, evidence-based practice standards. However, not all information is unwelcome, as physicians also need to stay updated with the latest guidelines on conditions and treatment, and communicate with larger medical teams to provide quality care. %M 32716313 %R 10.2196/19126 %U http://www.jmir.org/2020/7/e19126/ %U https://doi.org/10.2196/19126 %U http://www.ncbi.nlm.nih.gov/pubmed/32716313 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18652 %T Assessing Patient Experience and Healthcare Quality of Dental Care Using Patient Online Reviews in the United States: Mixed Methods Study %A Lin,Ye %A Hong,Y Alicia %A Henson,Bradley S %A Stevenson,Robert D %A Hong,Simon %A Lyu,Tianchu %A Liang,Chen %+ Arnold School of Public Health, University of South Carolina, Suite 347, 915 Greene Street, Columbia, SC, 29208, United States, 1 803 777 8139, cliang@mailbox.sc.edu %K dental care %K healthcare quality %K consumer health informatics %K patient online reviews %K patient review websites %K natural language processing %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Over the last two decades, patient review websites have emerged as an essential online platform for doctor ratings and reviews. Recent studies suggested the significance of such websites as a data source for patients to choose doctors for healthcare providers to learn and improve from patient feedback and to foster a culture of trust and transparency between patients and healthcare providers. However, as compared to other medical specialties, studies of online patient reviews that focus on dentists in the United States remain absent. Objective: This study sought to understand to what extent online patient reviews can provide performance feedbacks that reflect dental care quality and patient experience. Methods: Using mixed informatics methods incorporating statistics, natural language processing, and domain expert evaluation, we analyzed the online patient reviews of 204,751 dentists extracted from HealthGrades with two specific aims. First, we examined the associations between patient ratings and a variety of dentist characteristics. Second, we identified topics from patient reviews that can be mapped to the national assessment of dental patient experience measured by the Patient Experience Measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Dental Plan Survey. Results: Higher ratings were associated with female dentists (t71881=2.45, P<.01, g=0.01), dentists at a younger age (F7, 107128=246.97, P<.001, g=0.11), and those whose patients experienced a short wait time (F4, 150055=10417.77, P<0.001, g=0.18). We also identified several topics that corresponded to CAHPS measures, including discomfort (eg, painful/painless root canal or deep cleaning), and ethics (eg, high-pressure sales, and unnecessary dental work). Conclusions: These findings suggest that online patient reviews could be used as a data source for understanding the patient experience and healthcare quality in dentistry. %M 32673240 %R 10.2196/18652 %U https://www.jmir.org/2020/7/e18652 %U https://doi.org/10.2196/18652 %U http://www.ncbi.nlm.nih.gov/pubmed/32673240 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18527 %T Causal Effect of Honorary Titles on Physicians’ Service Volumes in Online Health Communities: Retrospective Study %A Yu,Haiyan %A Wang,Yali %A Wang,Jying-Nan %A Chiu,Ya-Ling %A Qiu,Hang %A Gao,Mingyue %+ Life Course Epidemiology and Biostatistics, Population, Policy, and Practice Programme, Great Ormond Street Institute of Child Health, University College London, Guilford Street, London, WC1N 1EH, United Kingdom, 44 07410372022, ming.gao.17@ucl.ac.uk %K causality %K health information systems %K organizational policy %K physician-patient relations %K remote consultation %D 2020 %7 9.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: An OHC online health community (OHC) is an interactive platform for virtual communication between patients and physicians. Patients can typically search, seek, and share their experience and rate physicians, who may be involved in giving advice. Some OHC providers provide incentives in form of honorary titles to encourage the web-based involvement of physicians, but it is unclear whether the award of honorary titles has an impact on their consultation volume in an OHC. Objective: This study is designed to identify the differential treatment effect of the incentive policy on the service volumes for the subgroups of treatment and control in an OHC. This study aims to answer the following questions: Does an honorary title for physicians impact their service volumes in an OHC? During the period of discontinuity, can we identify the sharp effect of the incentive award on the outcomes of physicians’ service volumes? Methods: We acquired the targeted samples based on treatment, namely, physicians with an honorary title or not and outcomes measured before and after the award of the 2 subgroups. A regression discontinuity design was applied to investigate the impact of the honorary titles incentive as a treatment in an OHC. There was a sharply discontinuous effect of treatment on physicians’ online health service performance. The experimental data set consisted of 346 physicians in the treatment group (with honorary titles). Applying the propensity score matching method, the same size of physicians (n=346) was matched and selected as the control group. Results: A sharp discontinuity was found at the time of the physician receiving the honorary title. The results showed that the parametric estimates of the coefficient were significantly positively (P<.001) associated with monthly home page views. The jump in the monthly volumes of home page views was much sharper than that of the monthly consultations. Conclusions: The changes in the volumes of monthly consultations and home page views reflect the differential treatment effect of honorary titles on physicians’ service volumes. The effect of the incentive policy with honorary titles is objectively estimated from both the perspective of online and offline medical services in an OHC. Being named with honorary titles significantly multiplied monthly home page views, yet it did not significantly impact monthly consultations. This may be because consultation capacity is limited by the physician's schedule for consultations. %M 32673232 %R 10.2196/18527 %U https://www.jmir.org/2020/7/e18527 %U https://doi.org/10.2196/18527 %U http://www.ncbi.nlm.nih.gov/pubmed/32673232 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14455 %T Gender, Soft Skills, and Patient Experience in Online Physician Reviews: A Large-Scale Text Analysis %A Dunivin,Zackary %A Zadunayski,Lindsay %A Baskota,Ujjwal %A Siek,Katie %A Mankoff,Jennifer %+ University of Washington, Bill & Melinda Gates Center for Computer Science and Engineering, 3800 E Stevens Way NE, Seattle, WA, 98112, United States, 1 4125677720, jmankoff@acm.org %K reviews %K physician-patient relationship %K gender %K soft-skills %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Online physician reviews are an important source of information for prospective patients. In addition, they represent an untapped resource for studying the effects of gender on the doctor-patient relationship. Understanding gender differences in online reviews is important because it may impact the value of those reviews to patients. Documenting gender differences in patient experience may also help to improve the doctor-patient relationship. This is the first large-scale study of physician reviews to extensively investigate gender bias in online reviews or offer recommendations for improvements to online review systems to correct for gender bias and aid patients in selecting a physician. Objective: This study examines 154,305 reviews from across the United States for all medical specialties. Our analysis includes a qualitative and quantitative examination of review content and physician rating with regard to doctor and reviewer gender. Methods: A total of 154,305 reviews were sampled from Google Place reviews. Reviewer and doctor gender were inferred from names. Reviews were coded for overall patient experience (negative or positive) by collapsing a 5-star scale and coded for general categories (process, positive/negative soft skills), which were further subdivided into themes. Computational text processing methods were employed to apply this codebook to the entire data set, rendering it tractable to quantitative methods. Specifically, we estimated binary regression models to examine relationships between physician rating, patient experience themes, physician gender, and reviewer gender). Results: Female reviewers wrote 60% more reviews than men. Male reviewers were more likely to give negative reviews (odds ratio [OR] 1.15, 95% CI 1.10-1.19; P<.001). Reviews of female physicians were considerably more negative than those of male physicians (OR 1.99, 95% CI 1.94-2.14; P<.001). Soft skills were more likely to be mentioned in the reviews written by female reviewers and about female physicians. Negative reviews of female doctors were more likely to mention candor (OR 1.61, 95% CI 1.42-1.82; P<.001) and amicability (OR 1.63, 95% CI 1.47-1.90; P<.001). Disrespect was associated with both female physicians (OR 1.42, 95% CI 1.35-1.51; P<.001) and female reviewers (OR 1.27, 95% CI 1.19-1.35; P<.001). Female patients were less likely to report disrespect from female doctors than expected from the base ORs (OR 1.19, 95% CI 1.04-1.32; P=.008), but this effect overrode only the effect for female reviewers. Conclusions: This work reinforces findings in the extensive literature on gender differences and gender bias in patient-physician interaction. Its novel contribution lies in highlighting gender differences in online reviews. These reviews inform patients’ choice of doctor and thus affect both patients and physicians. The evidence of gender bias documented here suggests review sites may be improved by providing information about gender differences, controlling for gender when presenting composite ratings for physicians, and helping users write less biased reviews. %M 32729844 %R 10.2196/14455 %U https://www.jmir.org/2020/7/e14455 %U https://doi.org/10.2196/14455 %U http://www.ncbi.nlm.nih.gov/pubmed/32729844 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17351 %T Changing the Health Behavior of Patients With Cardiovascular Disease Through an Electronic Health Intervention in Three Different Countries: Cost-Effectiveness Study in the Do Cardiac Health: Advanced New Generation Ecosystem (Do CHANGE) 2 Randomized Controlled Trial %A Piera-Jiménez,Jordi %A Winters,Marjolein %A Broers,Eva %A Valero-Bover,Damià %A Habibovic,Mirela %A Widdershoven,Jos W M G %A Folkvord,Frans %A Lupiáñez-Villanueva,Francisco %+ Open Evidence Research Group, Universitat Oberta de Catalunya, Rambla del Poblenou, 156, Barcelona, 08018, Spain, 34 651041515, jpieraj@uoc.edu %K cost-effectiveness %K randomized controlled trial %K RCT %K eHealth %K cardiovascular disease %K engagement %K behavior change %K digital health %D 2020 %7 28.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: During the last few decades, preventing the development of cardiovascular disease has become a mainstay for reducing cardiovascular morbidity and mortality. It has been suggested that interventions should focus more on committed approaches of self-care, such as electronic health techniques. Objective: This study aimed to provide evidence to understand the financial consequences of implementing the “Do Cardiac Health: Advanced New Generation Ecosystem” (Do CHANGE 2) intervention, which was evaluated in a multisite randomized controlled trial to change the health behavior of patients with cardiovascular disease. Methods: The cost-effectiveness analysis of the Do CHANGE 2 intervention was performed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, based on a Markov model of five health states. The following two types of costs were considered for both study groups: (1) health care costs (ie, costs associated with the time spent by health care professionals on service provision, including consultations, and associated unplanned hospitalizations, etc) and (2) societal costs (ie, costs attributed to the time spent by patients and informal caregivers on care activities). Results: The Do CHANGE 2 intervention was less costly in Spain (incremental cost was −€2514.90) and more costly in the Netherlands and Taiwan (incremental costs were €1373.59 and €1062.54, respectively). Compared with treatment as usual, the effectiveness of the Do CHANGE 2 program in terms of an increase in quality-adjusted life-year gains was slightly higher in the Netherlands and lower in Spain and Taiwan. Conclusions: In general, we found that the incremental cost-effectiveness ratio strongly varied depending on the country where the intervention was applied. The Do CHANGE 2 intervention showed a positive cost-effectiveness ratio only when implemented in Spain, indicating that it saved financial costs in relation to the effect of the intervention. Trial Registration: ClinicalTrials.gov NCT03178305; https://clinicaltrials.gov/ct2/show/NCT03178305 %M 32720908 %R 10.2196/17351 %U http://www.jmir.org/2020/7/e17351/ %U https://doi.org/10.2196/17351 %U http://www.ncbi.nlm.nih.gov/pubmed/32720908 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17996 %T The Cyclic Value-Context Reinforcement Model of Problematic Internet Use: Empirical Validation Using a Thematic Analysis of Children’s Counseling Data %A Doh,Young Yim %A Kim,Bugeun %A Lee,Seul %A Gweon,Gahgene %+ Graduate School of Convergence Science and Technology, Seoul National University, 1 Gwanakro, Seoul, Republic of Korea, 82 318889172, ggweon@snu.ac.kr %K problematic internet use %K children %K cyclic value context reinforcement model %K psychosocial value %K environmental context %K internet utility %D 2020 %7 14.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Research on problematic internet use has focused on devising diagnostic criteria or describing the factors that influence internet overuse. However, a paradigm shift is necessary in studying the phenomenon of increased internet use not just from a pathological point of view but also from a developmental point of view that considers children’s behavior of adapting to a technology-oriented society. Objective: In this paper, we propose the Cyclic Value-Context Reinforcement Model (CVCRM) to understand problematic internet use behavior. The purpose of our study was to construct a developmental process model that provides a holistic understanding of problematic internet use behavior of children and to empirically validate the proposed model by conducting a thematic analysis on actual counseling data. Methods: To validate the CVCRM, we conducted thematic analysis using the counseling data from 312 Korean children aged 7-18 years. For the coding process, 7 master’s and doctoral student researchers participated as coders, and 2 professors supervised the coding process and results. Results: This project was funded from October 2015 to September 2019 to analyze counseling data from 312 children who participated in counseling sessions during January 2012 to May 2014. Based on the data analysis, we present the CVCRM, which integrates existing theoretical approaches and encompasses the 3 interacting aspects that induce and reinforce problematic internet use in children: psychosocial value, environmental context, and internet utility. Specifically, using counseling data, we empirically ascertained that problematic internet use behavior feeds into children’s psychosocial values and environmental contexts, which in turn facilitates problematic internet use in a cyclical manner. Conclusions: Through this empirical validation, the CVCRM can provide a theoretical framework and an integrated perspective on the developmental mechanism of problematic internet use behavior of children. %M 32460233 %R 10.2196/17996 %U https://www.jmir.org/2020/7/e17996 %U https://doi.org/10.2196/17996 %U http://www.ncbi.nlm.nih.gov/pubmed/32460233 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16649 %T Public Perception of Artificial Intelligence in Medical Care: Content Analysis of Social Media %A Gao,Shuqing %A He,Lingnan %A Chen,Yue %A Li,Dan %A Lai,Kaisheng %+ School of Journalism and Communication, Jinan University, 601 Whampoa Ave W, Guangzhou, , China, 86 020 38374980, kaishenglai@126.com %K artificial intelligence %K public perception %K social media %K content analysis %K medical care %D 2020 %7 13.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: High-quality medical resources are in high demand worldwide, and the application of artificial intelligence (AI) in medical care may help alleviate the crisis related to this shortage. The development of the medical AI industry depends to a certain extent on whether industry experts have a comprehensive understanding of the public’s views on medical AI. Currently, the opinions of the general public on this matter remain unclear. Objective: The purpose of this study is to explore the public perception of AI in medical care through a content analysis of social media data, including specific topics that the public is concerned about; public attitudes toward AI in medical care and the reasons for them; and public opinion on whether AI can replace human doctors. Methods: Through an application programming interface, we collected a data set from the Sina Weibo platform comprising more than 16 million users throughout China by crawling all public posts from January to December 2017. Based on this data set, we identified 2315 posts related to AI in medical care and classified them through content analysis. Results: Among the 2315 identified posts, we found three types of AI topics discussed on the platform: (1) technology and application (n=987, 42.63%), (2) industry development (n=706, 30.50%), and (3) impact on society (n=622, 26.87%). Out of 956 posts where public attitudes were expressed, 59.4% (n=568), 34.4% (n=329), and 6.2% (n=59) of the posts expressed positive, neutral, and negative attitudes, respectively. The immaturity of AI technology (27/59, 46%) and a distrust of related companies (n=15, 25%) were the two main reasons for the negative attitudes. Across 200 posts that mentioned public attitudes toward replacing human doctors with AI, 47.5% (n=95) and 32.5% (n=65) of the posts expressed that AI would completely or partially replace human doctors, respectively. In comparison, 20.0% (n=40) of the posts expressed that AI would not replace human doctors. Conclusions: Our findings indicate that people are most concerned about AI technology and applications. Generally, the majority of people held positive attitudes and believed that AI doctors would completely or partially replace human ones. Compared with previous studies on medical doctors, the general public has a more positive attitude toward medical AI. Lack of trust in AI and the absence of the humanistic care factor are essential reasons why some people still have a negative attitude toward medical AI. We suggest that practitioners may need to pay more attention to promoting the credibility of technology companies and meeting patients’ emotional needs instead of focusing merely on technical issues. %M 32673231 %R 10.2196/16649 %U http://www.jmir.org/2020/7/e16649/ %U https://doi.org/10.2196/16649 %U http://www.ncbi.nlm.nih.gov/pubmed/32673231 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18082 %T Automatic Recognition, Segmentation, and Sex Assignment of Nocturnal Asthmatic Coughs and Cough Epochs in Smartphone Audio Recordings: Observational Field Study %A Barata,Filipe %A Tinschert,Peter %A Rassouli,Frank %A Steurer-Stey,Claudia %A Fleisch,Elgar %A Puhan,Milo Alan %A Brutsche,Martin %A Kotz,David %A Kowatsch,Tobias %+ Center for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Weinbergstrasse 56/57, Zurich, 8092, Switzerland, 41 446323509, fbarata@ethz.ch %K asthma %K cough recognition %K cough segmentation %K sex assignment %K deep learning %K smartphone %K mobile phone %D 2020 %7 14.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Asthma is one of the most prevalent chronic respiratory diseases. Despite increased investment in treatment, little progress has been made in the early recognition and treatment of asthma exacerbations over the last decade. Nocturnal cough monitoring may provide an opportunity to identify patients at risk for imminent exacerbations. Recently developed approaches enable smartphone-based cough monitoring. These approaches, however, have not undergone longitudinal overnight testing nor have they been specifically evaluated in the context of asthma. Also, the problem of distinguishing partner coughs from patient coughs when two or more people are sleeping in the same room using contact-free audio recordings remains unsolved. Objective: The objective of this study was to evaluate the automatic recognition and segmentation of nocturnal asthmatic coughs and cough epochs in smartphone-based audio recordings that were collected in the field. We also aimed to distinguish partner coughs from patient coughs in contact-free audio recordings by classifying coughs based on sex. Methods: We used a convolutional neural network model that we had developed in previous work for automated cough recognition. We further used techniques (such as ensemble learning, minibatch balancing, and thresholding) to address the imbalance in the data set. We evaluated the classifier in a classification task and a segmentation task. The cough-recognition classifier served as the basis for the cough-segmentation classifier from continuous audio recordings. We compared automated cough and cough-epoch counts to human-annotated cough and cough-epoch counts. We employed Gaussian mixture models to build a classifier for cough and cough-epoch signals based on sex. Results: We recorded audio data from 94 adults with asthma (overall: mean 43 years; SD 16 years; female: 54/94, 57%; male 40/94, 43%). Audio data were recorded by each participant in their everyday environment using a smartphone placed next to their bed; recordings were made over a period of 28 nights. Out of 704,697 sounds, we identified 30,304 sounds as coughs. A total of 26,166 coughs occurred without a 2-second pause between coughs, yielding 8238 cough epochs. The ensemble classifier performed well with a Matthews correlation coefficient of 92% in a pure classification task and achieved comparable cough counts to that of human annotators in the segmentation of coughing. The count difference between automated and human-annotated coughs was a mean –0.1 (95% CI –12.11, 11.91) coughs. The count difference between automated and human-annotated cough epochs was a mean 0.24 (95% CI –3.67, 4.15) cough epochs. The Gaussian mixture model cough epoch–based sex classification performed best yielding an accuracy of 83%. Conclusions: Our study showed longitudinal nocturnal cough and cough-epoch recognition from nightly recorded smartphone-based audio from adults with asthma. The model distinguishes partner cough from patient cough in contact-free recordings by identifying cough and cough-epoch signals that correspond to the sex of the patient. This research represents a step towards enabling passive and scalable cough monitoring for adults with asthma. %M 32459641 %R 10.2196/18082 %U https://www.jmir.org/2020/7/e18082 %U https://doi.org/10.2196/18082 %U http://www.ncbi.nlm.nih.gov/pubmed/32459641 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18228 %T Artificial Intelligence in Health Care: Bibliometric Analysis %A Guo,Yuqi %A Hao,Zhichao %A Zhao,Shichong %A Gong,Jiaqi %A Yang,Fan %+ Social Welfare Program, School of Public Administration, Dongbei University of Finance and Economics, 217 Jianshan Street, Shahekou District, Dalian, China, 86 411 84710562, fyang10@dufe.edu.cn %K health care %K artificial intelligence %K bibliometric analysis %K telehealth %K neural networks %K machine learning %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: As a critical driving power to promote health care, the health care–related artificial intelligence (AI) literature is growing rapidly. Objective: The purpose of this analysis is to provide a dynamic and longitudinal bibliometric analysis of health care–related AI publications. Methods: The Web of Science (Clarivate PLC) was searched to retrieve all existing and highly cited AI-related health care research papers published in English up to December 2019. Based on bibliometric indicators, a search strategy was developed to screen the title for eligibility, using the abstract and full text where needed. The growth rate of publications, characteristics of research activities, publication patterns, and research hotspot tendencies were computed using the HistCite software. Results: The search identified 5235 hits, of which 1473 publications were included in the analyses. Publication output increased an average of 17.02% per year since 1995, but the growth rate of research papers significantly increased to 45.15% from 2014 to 2019. The major health problems studied in AI research are cancer, depression, Alzheimer disease, heart failure, and diabetes. Artificial neural networks, support vector machines, and convolutional neural networks have the highest impact on health care. Nucleosides, convolutional neural networks, and tumor markers have remained research hotspots through 2019. Conclusions: This analysis provides a comprehensive overview of the AI-related research conducted in the field of health care, which helps researchers, policy makers, and practitioners better understand the development of health care–related AI research and possible practice implications. Future AI research should be dedicated to filling in the gaps between AI health care research and clinical applications. %M 32723713 %R 10.2196/18228 %U http://www.jmir.org/2020/7/e18228/ %U https://doi.org/10.2196/18228 %U http://www.ncbi.nlm.nih.gov/pubmed/32723713 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16021 %T Effectiveness and Safety of Using Chatbots to Improve Mental Health: Systematic Review and Meta-Analysis %A Abd-Alrazaq,Alaa Ali %A Rababeh,Asma %A Alajlani,Mohannad %A Bewick,Bridgette M %A Househ,Mowafa %+ College of Science and Engineering, Hamad Bin Khalifa University, Liberal Arts and Sciences Building, Education City, Ar Rayyan, Doha, Qatar, 974 55708549, mhouseh@hbku.edu.qa %K chatbots %K conversational agents %K mental health %K mental disorders %K depression %K anxiety %K effectiveness %K safety %D 2020 %7 13.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The global shortage of mental health workers has prompted the utilization of technological advancements, such as chatbots, to meet the needs of people with mental health conditions. Chatbots are systems that are able to converse and interact with human users using spoken, written, and visual language. While numerous studies have assessed the effectiveness and safety of using chatbots in mental health, no reviews have pooled the results of those studies. Objective: This study aimed to assess the effectiveness and safety of using chatbots to improve mental health through summarizing and pooling the results of previous studies. Methods: A systematic review was carried out to achieve this objective. The search sources were 7 bibliographic databases (eg, MEDLINE, EMBASE, PsycINFO), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently selected the studies, extracted data from the included studies, and assessed the risk of bias. Data extracted from studies were synthesized using narrative and statistical methods, as appropriate. Results: Of 1048 citations retrieved, we identified 12 studies examining the effect of using chatbots on 8 outcomes. Weak evidence demonstrated that chatbots were effective in improving depression, distress, stress, and acrophobia. In contrast, according to similar evidence, there was no statistically significant effect of using chatbots on subjective psychological wellbeing. Results were conflicting regarding the effect of chatbots on the severity of anxiety and positive and negative affect. Only two studies assessed the safety of chatbots and concluded that they are safe in mental health, as no adverse events or harms were reported. Conclusions: Chatbots have the potential to improve mental health. However, the evidence in this review was not sufficient to definitely conclude this due to lack of evidence that their effect is clinically important, a lack of studies assessing each outcome, high risk of bias in those studies, and conflicting results for some outcomes. Further studies are required to draw solid conclusions about the effectiveness and safety of chatbots. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019141219; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019141219 %M 32673216 %R 10.2196/16021 %U http://www.jmir.org/2020/7/e16021/ %U https://doi.org/10.2196/16021 %U http://www.ncbi.nlm.nih.gov/pubmed/32673216 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17750 %T Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial %A Anthony,Chris A %A Rojas,Edward Octavio %A Keffala,Valerie %A Glass,Natalie Ann %A Shah,Apurva S %A Miller,Benjamin J %A Hogue,Matthew %A Willey,Michael C %A Karam,Matthew %A Marsh,John Lawrence %+ Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, United States, 1 319 356 8690, edward-rojas@uiowa.edu %K acceptance and commitment therapy %K opioid crisis %K patient-reported outcome measures %K postoperative pain %K orthopedics %K text messaging %K chatbot %K conversational agents %K mHealth %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain. Objective: This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries. Methods: Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups. Results: A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone–based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04). Conclusions: In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference. Trial Registration: ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546 %M 32723723 %R 10.2196/17750 %U https://www.jmir.org/2020/7/e17750 %U https://doi.org/10.2196/17750 %U http://www.ncbi.nlm.nih.gov/pubmed/32723723 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15726 %T Reactions to an Online Demonstration of the Effect of Increased Fruit and Vegetable Consumption on Appearance: Survey Study %A Cairns,Patrick %A Ozakinci,Gozde %A Perrett,David Ian %+ Perception Lab, School of Psychology & Neuroscience, University of St Andrews, St Mary’s Quad, South Street, St Andrews, KY16 9JP, United Kingdom, 44 1334 463044, pc74@st-andrews.ac.uk %K diet %K skin appearance %K motivations %K fruit and vegetables %K carotenoid %D 2020 %7 14.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Inadequate fruit and vegetable consumption causes a considerable disease burden and premature mortality. Despite public health promotion of a healthy diet, the average consumption is still below recommended levels. Fruit and vegetable consumption influences human skin color, increasing red/yellow/orange pigment in the skin. Given that this color is deemed attractive and healthy-looking, the appearance benefit may motivate to eat more fruit and vegetables. Such appearance motivation could be particularly useful in young individuals who currently eat the least fruit and vegetables. Objective: Our objectives were to assess how widely the impact of diet on skin color is known within the UK and to compare the strength of motivation to eat fruit and vegetables based on health and appearance benefits among different demographic groups. Methods: Four groups of UK residents (N=200 per group) were recruited through the Prolific online platform. Groups comprised younger (aged 18-24) and older adults (aged 40-60) of low and high self-reported socioeconomic status (1-5 and 6-10 on a 10-point rating scale). Facial images simulating the skin color associated with low and high fruit and vegetable diets were shown to participants. Questionnaires were used to assess (1) background knowledge of the health and skin color effects of dietary fruit and vegetables, (2) the specific motivational impact of the skin color illustration, and (3) the relative importance of motivation to consume fruit and vegetables arising from health and skin color appearance benefits. Results: We found that 61% (n=487) of all participants were unaware of the dietary–skin color association. We also found that 57% (n=457) of participants found the simple demonstration of the dietary impact on skin color positively motivating to eat more fruit and vegetables. The visual demonstration was equally motivating for participants of high and low self-reported socioeconomic status (P=.63) and different ethnic backgrounds (White N=453, Black N=182, Asian N=87, P=.22). Health benefits from a diet high in fruit and vegetables were regarded as more motivating than skin color appearance benefits. The appearance-changing benefits of a high fruit and vegetable diet (compared to the health benefits) were relatively more important for the younger participants (Mann-Whitney U=96,263, P<.001) and for women (N=489) than for men (N=310, U=83,763, P=.01). Conclusions: These findings indicate that the promotion of the skin color effects of diets high in fruit and vegetables could provide additional motivation for a healthier diet. Our study indicates the broad appeal of appearance benefits from dietary fruit and vegetable (across ethnicity and socioeconomic status) and particularly amongst young adults where an inadequate diet is most prevalent. %M 32459626 %R 10.2196/15726 %U https://www.jmir.org/2020/7/e15726 %U https://doi.org/10.2196/15726 %U http://www.ncbi.nlm.nih.gov/pubmed/32459626 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18619 %T The Current State of Research, Challenges, and Future Research Directions of Blockchain Technology in Patient Care: Systematic Review %A Durneva,Polina %A Cousins,Karlene %A Chen,Min %+ Department of Information Systems & Business Analytics, Florida International University, 11200 SW 8th Street, Miami, FL, 33199, United States, 1 305 348 2160, kcousins@fiu.edu %K blockchain %K health information technology %K systematic review %K security %K privacy %K interoperability %K health outcomes %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Blockchain offers a promising new distributed technology to address the challenges of data standardization, system interoperability, security, privacy, and accessibility of medical records. Objective: The purpose of this review is to assess the research on the use of blockchain technology for patient care and the associated challenges and to provide a research agenda for future research. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We queried the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed, Excerpta Medica dataBASE (EMBASE), and Web of Science databases for peer-reviewed research articles published up to December 2019 that examined the implementation of blockchain technology in health care settings. We identified 800 articles from which we selected 70 empirical research articles for a detailed review. Results: Blockchain-based patient care applications include medical information systems, personal health records, mobile health and telemedicine, data preservation systems and social networks, health information exchanges and remote monitoring systems, and medical research systems. These blockchain-based health care applications may improve patient engagement and empowerment, improve health care provider access to information, and enhance the use of health care information for medical research. Conclusions: Blockchain health information technology (HIT) provides benefits such as ensuring data privacy and security of health data, facilitating interoperability of heterogeneous HIT systems, and improving the quality of health care outcomes. However, barriers to using blockchain technology to build HIT include security and privacy vulnerabilities, user resistance, high computing power requirements and implementation costs, inefficient consensus algorithms, and challenges of integrating blockchain with existing HIT. With 51% of the research focused on medical information systems such as electronic health record and electronic medical record, and 53% of the research focused on data security and privacy issues, this review shows that HIT research is primarily focused on the use of blockchain technologies to address the current challenges HIT faces. Although Blockchain presents significant potential for disrupting health care, most ideas are in their infancy. %M 32706668 %R 10.2196/18619 %U http://www.jmir.org/2020/7/e18619/ %U https://doi.org/10.2196/18619 %U http://www.ncbi.nlm.nih.gov/pubmed/32706668 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14283 %T Integrating Health Technologies in Health Services for Syrian Refugees in Lebanon: Qualitative Study %A Talhouk,Reem %A Akik,Chaza %A Araujo-Soares,Vera %A Ahmad,Balsam %A Mesmar,Sandra %A Olivier,Patrick %A Balaam,Madeline %A Montague,Kyle %A Garbett,Andrew %A Ghattas,Hala %+ School of Design, Northumbria University, City Campus East 2, Newcastle upon Tyne, United Kingdom, 44 191 208 4642, reem.talhouk@northumbria.ac.uk %K Syrian refugees %K Lebanon %K health technologies %K eHealth %K mHealth %K primary health care %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Lebanon currently hosts around one million Syrian refugees. There has been an increasing interest in integrating eHealth and mHealth technologies into the provision of primary health care to refugees and Lebanese citizens. Objective: We aimed to gain a deeper understanding of the potential for technology integration in primary health care provision in the context of the protracted Syrian refugee crisis in Lebanon. Methods: A total of 17 face-to-face semistructured interviews were conducted with key informants (n=8) and health care providers (n=9) involved in the provision of health care to the Syrian refugee population in Lebanon. Interviews were audio recorded and directly translated and transcribed from Arabic to English. Thematic analysis was conducted. Results: Study participants indicated that varying resources, primarily time and the availability of technologies at primary health care centers, were the main challenges for integrating technologies for the provision of health care services for refugees. This challenge is compounded by refugees being viewed by participants as a mobile population thus making primary health care centers less willing to invest in refugee health technologies. Lastly, participant views regarding the health and technology literacies of refugees varied and that was considered to be a challenge that needs to be addressed for the successful integration of refugee health technologies. Conclusions: Our findings indicate that in the context of integrating technology into the provision of health care for refugees in a low or middle income country such as Lebanon, some barriers for technology integration related to the availability of resources are similar to those found elsewhere. However, we identified participant views of refugees’ health and technology literacies to be a challenge specific to the context of this refugee crisis. These challenges need to be addressed when considering refugee health technologies. This could be done by increasing the visibility of refugee capabilities and configuring refugee health technologies so that they may create spaces in which refugees are empowered within the health care system and can work toward debunking the views discovered in this study. %M 32628121 %R 10.2196/14283 %U https://www.jmir.org/2020/7/e14283 %U https://doi.org/10.2196/14283 %U http://www.ncbi.nlm.nih.gov/pubmed/32628121 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16644 %T Internet-Based Sharing Nurse Program and Nurses’ Perceptions in China: Cross-Sectional Survey %A Huang,Rendong %A Xu,Mei %A Li,Xiuting %A Wang,Yinping %A Wang,Bin %A Cui,Naixue %+ School of Nursing, Cheeloo College of Medicine, Shandong University, No 44 West Wenhua Road, Jinan, 250012, China, 86 531 88382268, cnx@sdu.edu.cn %K sharing nurse %K home visiting %K internet plus nursing program %K perception %K China %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: China is currently piloting a “Sharing Nurse” program that aims to increase the accessibility of nursing services to at-home patients by enabling patients to order nursing services using mobile apps or online platforms. Objective: This study aims to assess nurses’ perceptions of the Sharing Nurse program, including their acceptance, concerns, needs, and willingness to take part in the program. Methods: A total of 694 nurses participated in the questionnaire survey. The survey collected their sociodemographic and work-related information and their perceptions of the Sharing Nurse program using a self-developed questionnaire. Results: The 694 respondents agreed that the Sharing Nurse program could provide patients with better access to nursing care (n=483, 69.6%). Their main concerns about the program were unclear liability division when medical disputes occur (n=637, 90.3%) and potential personal safety issues (n=604, 87%). They reported that insurance (n=611, 88%), permits from their affiliated hospital (n=562, 81.0%), clear instructions concerning rights and duties (n=580, 83.6%), real time positioning while delivering the service (n=567, 81.7%), and one-key alarm equipment (n=590, 85.0%) were necessary for better implementation of the program. More than half of the respondents (n=416, 60%) had an optimistic attitude toward the development of the Sharing Nurse program in China. However, only 19.4% (n=135) of the respondents expressed their willingness to be a “shared nurse.” Further analyses found that nurses with a master’s degree or above (χ23=28.835, P<.001) or from tertiary hospitals (χ23=18.669, P<.001) were more likely to be aware of the Sharing Nurse program and that male nurses were more willing to be shared nurses (Z=–2.275, P=.02). Conclusions: The Chinese Sharing Nurse program is still in its infancy and many refinements are needed before it can be implemented nationwide. Generally, Chinese nurses are positive about the Sharing Nurse program and are willing to participate if the program is thoroughly regulated and supervised. %M 32706711 %R 10.2196/16644 %U http://www.jmir.org/2020/7/e16644/ %U https://doi.org/10.2196/16644 %U http://www.ncbi.nlm.nih.gov/pubmed/32706711 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18569 %T Consequences of Gift Giving in Online Health Communities on Physician Service Quality: Empirical Text Mining Study %A Peng,Li %A Wang,Yanan %A Chen,Jing %+ School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Qiaokou District, Wuhan, Hubei, China, 86 15972965520, yanan_wang2020@163.com %K online health community %K gift giving %K affective/instrumental gifts %K service quality %K bedside manner %K physicians %K physician-patient relationship %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Gift giving, which has been a heavily debated topic in health care for many years, is considered as a way of expressing gratitude and to be beneficial for the physician-patient relationship within a reasonable range. However, not much work has been done to examine the influence of gift giving on physicians’ service quality, especially in the online health care environment. Objective: This study addressed the consequences of gift giving by mining and analyzing the dynamic physician-patient interaction processes in an online health community. Specifically, gift types (affective or instrumental) based on the motivations and physician-patient tie strength were carefully considered to account for differences in physicians’ service quality. Methods: The dynamic interaction processes (involving 3154 gifts) between 267 physicians and 14,187 patients from a well-known online health community in China (haodf.com) were analyzed to obtain empirical results. Results: Our results reveal that patient gift giving inspires physicians to improve their service quality as measured by physicians’ more detailed responses and improved bedside manner, and the degree of influence varied according to the strength of the physician-patient tie. Moreover, affective gifts and instrumental gifts had different effects in improving physicians’ service quality online. Conclusions: This study is among the first to explore gift giving in online health communities providing both important theoretical and practical contributions. All of our results suggest that gift giving online is of great significance to promoting effective physician-patient communication and is conducive to the relief of physician-patient conflicts. %M 32729834 %R 10.2196/18569 %U http://www.jmir.org/2020/7/e18569/ %U https://doi.org/10.2196/18569 %U http://www.ncbi.nlm.nih.gov/pubmed/32729834 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15607 %T The Use of Social Media to Increase the Impact of Health Research: Systematic Review %A Bardus,Marco %A El Rassi,Rola %A Chahrour,Mohamad %A Akl,Elie W %A Raslan,Abdul Sattar %A Meho,Lokman I %A Akl,Elie A %+ Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad-El-Solh, Beirut, 1107 2020, Lebanon, 961 1 374 374, ea32@aub.edu.lb %K social media %K research %K bibliometrics %K Altmetrics %K journal impact factor %K translational medical research %D 2020 %7 6.7.2020 %9 Review %J J Med Internet Res %G English %X Background: Academics in all disciplines increasingly use social media to share their publications on the internet, reaching out to different audiences. In the last few years, specific indicators of social media impact have been developed (eg, Altmetrics), to complement traditional bibliometric indicators (eg, citation count and h-index). In health research, it is unclear whether social media impact also translates into research impact. Objective: The primary aim of this study was to systematically review the literature on the impact of using social media on the dissemination of health research. The secondary aim was to assess the correlation between Altmetrics and traditional citation-based metrics. Methods: We conducted a systematic review to identify studies that evaluated the use of social media to disseminate research published in health-related journals. We specifically looked at studies that described experimental or correlational studies linking the use of social media with outcomes related to bibliometrics. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases using a predefined search strategy (International Prospective Register of Systematic Reviews: CRD42017057709). We conducted independent and duplicate study selection and data extraction. Given the heterogeneity of the included studies, we summarized the findings through a narrative synthesis. Results: Of a total of 18,624 retrieved citations, we included 51 studies: 7 (14%) impact studies (answering the primary aim) and 44 (86%) correlational studies (answering the secondary aim). Impact studies reported mixed results with several limitations, including the use of interventions of inappropriately low intensity and short duration. The majority of correlational studies suggested a positive association between traditional bibliometrics and social media metrics (eg, number of mentions) in health research. Conclusions: We have identified suggestive yet inconclusive evidence on the impact of using social media to increase the number of citations in health research. Further studies with better design are needed to assess the causal link between social media impact and bibliometrics. %M 32628113 %R 10.2196/15607 %U https://www.jmir.org/2020/7/e15607 %U https://doi.org/10.2196/15607 %U http://www.ncbi.nlm.nih.gov/pubmed/32628113 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14591 %T Information Loss in Harmonizing Granular Race and Ethnicity Data: Descriptive Study of Standards %A Wang,Karen %A Grossetta Nardini,Holly %A Post,Lori %A Edwards,Todd %A Nunez-Smith,Marcella %A Brandt,Cynthia %+ Equity Research and Innovation Center, General Internal Medicine, Yale School of Medicine, 100 Church Street South, A200, New Haven, CT, 06520, United States, 1 203 785 5233, karen.wang@yale.edu %K continental population groups %K multiracial populations %K multiethnic groups %K data standards %K health status disparities %K race factors %K demography %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Data standards for race and ethnicity have significant implications for health equity research. Objective: We aim to describe a challenge encountered when working with a multiple–race and ethnicity assessment in the Eastern Caribbean Health Outcomes Research Network (ECHORN), a research collaborative of Barbados, Puerto Rico, Trinidad and Tobago, and the US Virgin Islands. Methods: We examined the data standards guiding harmonization of race and ethnicity data for multiracial and multiethnic populations, using the Office of Management and Budget (OMB) Statistical Policy Directive No. 15. Results: Of 1211 participants in the ECHORN cohort study, 901 (74.40%) selected 1 racial category. Of those that selected 1 category, 13.0% (117/901) selected Caribbean; 6.4% (58/901), Puerto Rican or Boricua; and 13.5% (122/901), the mixed or multiracial category. A total of 17.84% (216/1211) of participants selected 2 or more categories, with 15.19% (184/1211) selecting 2 categories and 2.64% (32/1211) selecting 3 or more categories. With aggregation of ECHORN data into OMB categories, 27.91% (338/1211) of the participants can be placed in the “more than one race” category. Conclusions: This analysis exposes the fundamental informatics challenges that current race and ethnicity data standards present to meaningful collection, organization, and dissemination of granular data about subgroup populations in diverse and marginalized communities. Current standards should reflect the science of measuring race and ethnicity and the need for multidisciplinary teams to improve evolving standards throughout the data life cycle. %M 32706693 %R 10.2196/14591 %U http://www.jmir.org/2020/7/e14591/ %U https://doi.org/10.2196/14591 %U http://www.ncbi.nlm.nih.gov/pubmed/32706693 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e15361 %T Efficacy of a Guided Web-Based Self-Management Intervention for Depression or Dysthymia: Randomized Controlled Trial With a 12-Month Follow-Up Using an Active Control Condition %A Oehler,Caroline %A Görges,Frauke %A Rogalla,Mandy %A Rummel-Kluge,Christine %A Hegerl,Ulrich %+ German Depression Foundation, Goerdelerring 9, Leipzig, 04109, Germany, 49 03412238 ext 20, caroline.oehler@deutsche-depressionshilfe.de %K depression %K dysthymic disorder %K randomized controlled trial %K cognitive behavioral therapy %K internet-based intervention %K active control %K iCBT %K self-management %K iFightDepression %K web-based intervention %D 2020 %7 14.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: An increasing number of studies suggest that web-based interventions for patients with depression can reduce their symptoms and are expected to fill currently existing treatment gaps. However, evidence for their efficacy has mainly been derived from comparisons with wait-list or treatment as usual controls. In particular, designs using wait-list controls are unlikely to induce hope and may even have nocebo effects, making it difficult to draw conclusions about the intervention’s efficacy. Studies using active controls are rare and have not yielded conclusive results. Objective: The main objective of this study is to assess the acute and long-term antidepressant efficacy of a 6-week, guided, web-based self-management intervention building on the principles of cognitive behavioral therapy (iFightDepression tool) for patients with depression compared with web-based progressive muscle relaxation as an active control condition. Methods: A total of 348 patients with mild-to-moderate depressive symptoms or dysthymia (according to the Mini International Neuropsychiatric Interview) were recruited online and randomly assigned to 1 of the 2 intervention arms. Acute antidepressant effects after 6 weeks and long-term effects at 3-, 6-, and 12-month follow-up were studied using the Inventory of Depressive Symptomatology–self-rating as a primary outcome parameter and change in quality of life (Short Form 12) and user satisfaction (client satisfaction questionnaire) as secondary outcome parameters. Treatment effects were assessed using mixed model analyses. Results: Over the entire observation period, a greater reduction in symptoms of depression (P=.01) and a greater improvement of life quality (P<.001) was found in the intervention group compared with the active control group. Separate tests for each time point revealed significant effects on depressive symptoms at the 3-month follow-up (d=0.281; 95% CI 0.069 to 0.493), but not after 6 weeks (main outcome:d=0.192; 95% CI −0.020 to 0.404) and 6 and 12 months. The intervention was significantly superior to the control condition with respect to user satisfaction (25.31 vs 21.97; t259=5.804; P<.01). Conclusions: The fact that antidepressant effects have been found for a guided self-management tool in comparison with an active control strengthens the evidence base for the efficacy of web-based interventions. The antidepressant effect became most prominent at the 3-month follow-up. After 6 weeks of intervention, significant positive effects were observed on life quality but not on depressive symptoms. Although the effect size of such web-based interventions on symptoms of depression might be smaller than that suggested by earlier studies using wait-list control conditions, they can be a cost-effective addition to antidepressants and face-to-face psychotherapy. Trial Registration: International Clinical Trials Registry Platform ICTRP080-15-09032015; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00009323 %M 32673233 %R 10.2196/15361 %U http://www.jmir.org/2020/7/e15361/ %U https://doi.org/10.2196/15361 %U http://www.ncbi.nlm.nih.gov/pubmed/32673233 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19029 %T Generalizable Layered Blockchain Architecture for Health Care Applications: Development, Case Studies, and Evaluation %A Zhuang,Yan %A Chen,Yin-Wu %A Shae,Zon-Yin %A Shyu,Chi-Ren %+ Institute for Data Science and Informatics, University of Missouri - Columbia, 241 Robert and Patricia Naka Hall, University of Missouri, Columbia, MO, 65211, United States, 1 5738823884, shyuc@missouri.edu %K blockchain %K smart contract %K health information exchange %K electronic health records %K health care application %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Data coordination across multiple health care facilities has become increasingly important for many emerging health care applications. Distrust has been recognized as a key barrier to the success of such applications. Leveraging blockchain technology could provide potential solutions tobuild trust between data providers and receivers by taking advantage of blockchain properties such as security, immutability, anonymity, decentralization, and smart contracts. Many health technologies have empirically proven that blockchain designs fit well with the needs of health care applications with certain degrees of success. However, there is a lack of robust architecture to provide a practical framework for developers to implement applications and test the performance of stability, efficiency, and scalability using standard blockchain designs. A generalized blockchain model is needed for the health care community to adopt blockchain technology and develop applications in a timely fashion. Objective: This study aimed at building a generalized blockchain architecture that provides data coordination functions, including data requests, permission granting, data exchange, and usage tracking, for a wide spectrum of health care application developments. Methods: An augmented, 3-layered blockchain architecture was built on a private blockchain network. The 3 layers, from bottom to top, are as follows: (1) incorporation of fundamental blockchain settings and smart contract design for data collection; (2) interactions between the blockchain and health care application development environment using Node.js and web3.js; and (3) a flexible development platform that supports web technologies such as HTML, https, and various programing languages. Two example applications, health information exchange (HIE) and clinical trial recruitment, were developed in our design to demonstrate the feasibility of the layered architecture. Case studies were conducted to test the performance in terms of stability, efficiency, and scalability of the blockchain system. Results: A total of 331,142 simulated HIE requests from accounts of 40,000 patients were successfully validated through this layered blockchain architecture with an average exchange time of 11.271 (SD 2.208) seconds. We also simulated a clinical trial recruitment scenario with the same set of patients and various recruitment criteria to match potential subjects using the same architecture. Potential subjects successfully received the clinical trial recruitment information and granted permission to the trial sponsors to access their health records with an average time of 3.07 seconds. Conclusions: This study proposes a generalized layered blockchain architecture that offers health technology community blockchain features for application development without requiring developers to have extensive experience with blockchain technology. The case studies tested the performance of our design and empirically proved the feasibility of the architecture in 2 relevant health application domains. %M 32716300 %R 10.2196/19029 %U https://www.jmir.org/2020/7/e19029 %U https://doi.org/10.2196/19029 %U http://www.ncbi.nlm.nih.gov/pubmed/32716300 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e21027 %T Correction: Optimizing Text Messages to Promote Engagement With Internet Smoking Cessation Treatment: Results From a Factorial Screening Experiment %A Graham,Amanda L %A Papandonatos,George D %A Jacobs,Megan A %A Amato,Michael S %A Cha,Sarah %A Cohn,Amy M %A Abroms,Lorien C %A Whittaker,Robyn %+ Innovations Center, Truth Initiative, 900 G Street, NW, 4th Floor, Washington, DC, 20001, United States, 1 12024545938, agraham@truthinitiative.org %D 2020 %7 28.7.2020 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 32721924 %R 10.2196/21027 %U https://www.jmir.org/2020/7/e21027 %U https://doi.org/10.2196/21027 %U http://www.ncbi.nlm.nih.gov/pubmed/32721924 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e21381 %T Correction: A Facilitated Web-Based Self-Management Tool for People With Type 1 Diabetes Using an Insulin Pump: Intervention Development Using the Behavior Change Wheel and Theoretical Domains Framework %A Reidy,Claire %A Foster,Claire %A Rogers,Anne %+ National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, School of Health Sciences, Faculty of Environmental & Life Sciences, University of Southampton, University Road, Southampton, SO17 1BJ, United Kingdom, 44 23 8059 7628, c.reidy@soton.ac.uk %D 2020 %7 30.7.2020 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 32730220 %R 10.2196/21381 %U http://www.jmir.org/2020/7/e21381/ %U https://doi.org/10.2196/21381 %U http://www.ncbi.nlm.nih.gov/pubmed/32730220 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19961 %T Authorship Correction: The Association Between Pain Relief Using Video Games and an Increase in Vagal Tone in Children With Cancer: Analytic Observational Study With a Quasi-Experimental Pre/Posttest Methodology %A Alonso Puig,Mario %A Alonso-Prieto,Mercedes %A Miró,Jordi %A Torres-Luna,Raquel %A Plaza López de Sabando,Diego %A Reinoso-Barbero,Francisco %+ Pediatric Pain Unit, Anesthesiology-Critical Care Service, University La Paz Hospital, Paseo de la Castellana, 261, Madrid, 28046, Spain, 34 676687569, meme27@hotmail.es %D 2020 %7 7.7.2020 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 32673254 %R 10.2196/19961 %U https://www.jmir.org/2020/7/e19961 %U https://doi.org/10.2196/19961 %U http://www.ncbi.nlm.nih.gov/pubmed/32673254 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e21753 %T Correction: Development of an Online Health Care Assessment for Preventive Medicine: A Machine Learning Approach %A Yu,Cheng-Sheng %A Lin,Yu-Jiun %A Lin,Chang-Hsien %A Lin,Shiyng-Yu %A Wu,Jenny L %A Chang,Shy-Shin %+ Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, 250 Wuxing St, Taipei, 11031, Taiwan, 886 2 23565926, sschang0529@gmail.com %D 2020 %7 27.7.2020 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 32716902 %R 10.2196/21753 %U http://www.jmir.org/2020/7/e21753/ %U https://doi.org/10.2196/21753 %U http://www.ncbi.nlm.nih.gov/pubmed/32716902 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e22565 %T Correction: Effectiveness of a Web-Based Tailored Intervention With Virtual Assistants Promoting the Acceptability of HPV Vaccination Among Mothers of Invited Girls: Randomized Controlled Trial %A Pot,Mirjam %A Paulussen,Theo GWM %A Ruiter,Robert AC %A Eekhout,Iris %A de Melker,Hester E %A Spoelstra,Maxine EA %A van Keulen,Hilde M %+ Netherlands Organization for Applied Scientific Research (TNO), Child Health, Schipholweg 77, Leiden, 2316 ZL, Netherlands, 31 643234293, mirjampot90@gmail.com %D 2020 %7 28.7.2020 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 32721923 %R 10.2196/22565 %U http://www.jmir.org/2020/7/e22565/ %U https://doi.org/10.2196/22565 %U http://www.ncbi.nlm.nih.gov/pubmed/32721923 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e18831 %T Mapping of Health Literacy and Social Panic Via Web Search Data During the COVID-19 Public Health Emergency: Infodemiological Study %A Xu,Chenjie %A Zhang,Xinyu %A Wang,Yaogang %+ School of Public Health, Tianjin Medical University, No 22, Qixiangtai Road, Heping District, Tianjin, 300070, China, 86 13820046130, wangyg@tmu.edu.cn %K COVID-19 %K China %K Baidu %K infodemiology %K web search %K internet %K public health %K emergency %K outbreak %K infectious disease %K pandemic %K health literacy %D 2020 %7 2.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Coronavirus disease (COVID-19) is a type of pneumonia caused by a novel coronavirus that was discovered in 2019. As of May 6, 2020, 84,407 cases and 4643 deaths have been confirmed in China. The Chinese population has expressed great concern since the COVID-19 outbreak. Meanwhile, an average of 1 billion people per day are using the Baidu search engine to find COVID-19–related health information. Objective: The aim of this paper is to analyze web search data volumes related to COVID-19 in China. Methods: We conducted an infodemiological study to analyze web search data volumes related to COVID-19. Using Baidu Index data, we assessed the search frequencies of specific search terms in Baidu to describe the impact of COVID-19 on public health, psychology, behaviors, lifestyles, and social policies (from February 11, 2020, to March 17, 2020). Results: The search frequency related to COVID-19 has increased significantly since February 11th. Our heat maps demonstrate that citizens in Wuhan, Hubei Province, express more concern about COVID-19 than citizens from other cities since the outbreak first occurred in Wuhan. Wuhan citizens frequently searched for content related to “medical help,” “protective materials,” and “pandemic progress.” Web searches for “return to work” and “go back to school” have increased eight-fold compared to the previous month. Searches for content related to “closed community and remote office” have continued to rise, and searches for “remote office demand” have risen by 663% from the previous quarter. Employees who have returned to work have mainly engaged in the following web searches: “return to work and prevention measures,” “return to work guarantee policy,” and “time to return to work.” Provinces with large, educated populations (eg, Henan, Hebei, and Shandong) have been focusing on “online education” whereas medium-sized cities have been paying more attention to “online medical care.” Conclusions: Our findings suggest that web search data may reflect changes in health literacy, social panic, and prevention and control policies in response to COVID-19. %M 32540844 %R 10.2196/18831 %U https://www.jmir.org/2020/7/e18831 %U https://doi.org/10.2196/18831 %U http://www.ncbi.nlm.nih.gov/pubmed/32540844 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19514 %T Monitoring and Management of Home-Quarantined Patients With COVID-19 Using a WeChat-Based Telemedicine System: Retrospective Cohort Study %A Xu,Hui %A Huang,Sufang %A Qiu,Chun %A Liu,Shangkun %A Deng,Juan %A Jiao,Bo %A Tan,Xi %A Ai,Ling %A Xiao,Yaru %A Belliato,Mirko %A Yan,Li %+ Department of Emergency Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1095 Jie Fang Avenue, Qiaokou District, Wuhan, 430030, China, 86 13607124420, yanli008@163.com %K telemedicine system %K home quarantine %K quarantine management assessment %K progressive COVID-19 patients %K COVID-19 %D 2020 %7 2.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Most patients with coronavirus disease (COVID-19) who show mild symptoms are sent home by physicians to recover. However, the condition of some of these patients becomes severe or critical as the disease progresses. Objective: The aim of this study was to evaluate a telemedicine model that was developed to address the challenges of treating patients with progressive COVID-19 who are home-quarantined and shortages in the medical workforce. Methods: A telemedicine system was developed to continuously monitor the progression of home-quarantined patients with COVID-19. The system was built based on a popular social media smartphone app called WeChat; the app was used to establish two-way communication between a multidisciplinary team consisting of 7 medical workers and 188 home-quarantined individuals (including 74 confirmed patients with COVID-19). The system helped patients self-assess their conditions and update the multidisciplinary team through a telemedicine form stored on a cloud service, based on which the multidisciplinary team made treatment decisions. We evaluated this telemedicine system via a single-center retrospective study conducted at Tongji Hospital in Wuhan, China, in January 2020. Results: Among 188 individuals using the telemedicine system, 114 (60.6%) were not infected with COVID-19 and were dismissed. Of the 74 confirmed patients with COVID-19, 26 (35%) recovered during the study period and voluntarily stopped using the system. The remaining 48/76 confirmed patients with COVID-19 (63%) used the system until the end of the study, including 6 patients whose conditions progressed to severe or critical. These 6 patients were admitted to hospital and were stabilized (one received extracorporeal membrane oxygenation support for 17 days). All 74 patients with COVID-19 eventually recovered. Through a comparison of the monitored symptoms between hospitalized and nonhospitalized patients, we found prolonged persistence and deterioration of fever, dyspnea, lack of strength, and muscle soreness to be diagnostic of need for hospitalization. Conclusions: By continuously monitoring the changes in several key symptoms, the telemedicine system reduces the risks of delayed hospitalization due to disease progression for patients with COVID-19 quarantined at home. The system uses a set of scales for quarantine management assessment that enables patients to self-assess their conditions. The results are useful for medical staff to identify disease progression and, hence, make appropriate and timely treatment decisions. The system requires few staff to manage a large cohort of patients. In addition, the system can solicit help from recovered but self-quarantined medical workers to alleviate shortages in the medical workforce and free healthy medical workers to fight COVID-19 on the front line. Thus, it optimizes the usage of local medical resources and prevents cross-infections among medical workers and patients. %M 32568727 %R 10.2196/19514 %U https://www.jmir.org/2020/7/e19514 %U https://doi.org/10.2196/19514 %U http://www.ncbi.nlm.nih.gov/pubmed/32568727 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e20472 %T Racial and Ethnic Digital Divides in Posting COVID-19 Content on Social Media Among US Adults: Secondary Survey Analysis %A Campos-Castillo,Celeste %A Laestadius,Linnea I %+ Department of Sociology, University of Wisconsin-Milwaukee, 3210 N Maryland Ave, Milwaukee, WI, 53201, United States, 1 414 229 1113, camposca@uwm.edu %K COVID-19 %K digital divides %K user characteristics %K race %K ethnicity %K algorithm bias %K social media %K bias %K surveillance %K public health %D 2020 %7 3.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Public health surveillance experts are leveraging user-generated content on social media to track the spread and effects of COVID-19. However, racial and ethnic digital divides, which are disparities among people who have internet access and post on social media, can bias inferences. This bias is particularly problematic in the context of the COVID-19 pandemic because due to structural inequalities, members of racial and ethnic minority groups are disproportionately vulnerable to contracting the virus and to the deleterious economic and social effects from mitigation efforts. Further, important demographic intersections with race and ethnicity, such as gender and age, are rarely investigated in work characterizing social media users; however, they reflect additional axes of inequality shaping differential exposure to COVID-19 and its effects. Objective: The aim of this study was to characterize how the race and ethnicity of US adults are associated with their odds of posting COVID-19 content on social media and how gender and age modify these odds. Methods: We performed a secondary analysis of a survey conducted by the Pew Research Center from March 19 to 24, 2020, using a national probability sample (N=10,510). Respondents were recruited from an online panel, where panelists without an internet-enabled device were given one to keep at no cost. The binary dependent variable was responses to an item asking whether respondents “used social media to share or post information about the coronavirus.” We used survey-weighted logistic regressions to estimate the odds of responding in the affirmative based on the race and ethnicity of respondents (white, black, Latino, other race/ethnicity), adjusted for covariates measuring sociodemographic background and COVID-19 experiences. We examined how gender (female, male) and age (18 to 30 years, 31 to 50 years, 51 to 64 years, and 65 years and older) intersected with race and ethnicity by estimating interactions. Results: Respondents who identified as black (odds ratio [OR] 1.29, 95% CI 1.02-1.64; P=.03), Latino (OR 1.66, 95% CI 1.36-2.04; P<.001), or other races/ethnicities (OR 1.33, 95% CI 1.02-1.72; P=.03) had higher odds than respondents who identified as white of reporting that they posted COVID-19 content on social media. Women had higher odds of posting than men regardless of race and ethnicity (OR 1.58, 95% CI 1.39-1.80; P<.001). Among men, respondents who identified as black, Latino, or members of other races/ethnicities were significantly more likely to post than respondents who identified as white. Older adults (65 years or older) had significantly lower odds (OR 0.73, 95% CI 0.57-0.94; P=.01) of posting compared to younger adults (18-29 years), particularly among those identifying as other races/ethnicities. Latino respondents were the most likely to report posting across all age groups. Conclusions: In the United States, members of racial and ethnic minority groups are most likely to contribute to COVID-19 content on social media, particularly among groups traditionally less likely to use social media (older adults and men). The next step is to ensure that data collection procedures capture this diversity by encompassing a breadth of search criteria and social media platforms. %M 32568726 %R 10.2196/20472 %U https://www.jmir.org/2020/7/e20472 %U https://doi.org/10.2196/20472 %U http://www.ncbi.nlm.nih.gov/pubmed/32568726 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19322 %T Rapid Utilization of Telehealth in a Comprehensive Cancer Center as a Response to COVID-19: Cross-Sectional Analysis %A Lonergan,Peter E %A Washington III,Samuel L %A Branagan,Linda %A Gleason,Nathaniel %A Pruthi,Raj S %A Carroll,Peter R %A Odisho,Anobel Y %+ Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94143, United States, 1 (415) 353 2200, anobel.odisho@ucsf.edu %K health informatics %K telehealth %K video visits %K COVID-19 %K video consultation %K pandemic %K electronic health record %K EHR %D 2020 %7 6.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The emergence of the coronavirus disease (COVID-19) pandemic in March 2020 created unprecedented challenges in the provision of scheduled ambulatory cancer care. As a result, there has been a renewed focus on video-based telehealth consultations as a means to continue ambulatory care. Objective: The aim of this study is to analyze the change in video visit volume at the University of California, San Francisco (UCSF) Comprehensive Cancer Center in response to COVID-19 and compare patient demographics and appointment data from January 1, 2020, and in the 11 weeks after the transition to video visits. Methods: Patient demographics and appointment data (dates, visit types, and departments) were extracted from the electronic health record reporting database. Video visits were performed using a HIPAA (Health Insurance Portability and Accountability Act)-compliant video conferencing platform with a pre-existing workflow. Results: In 17 departments and divisions at the UCSF Cancer Center, 2284 video visits were performed in the 11 weeks before COVID-19 changes were implemented (mean 208, SD 75 per week) and 12,946 video visits were performed in the 11-week post–COVID-19 period (mean 1177, SD 120 per week). The proportion of video visits increased from 7%-18% to 54%-72%, between the pre– and post–COVID-19 periods without any disparity based on race/ethnicity, primary language, or payor. Conclusions: In a remarkably brief period of time, we rapidly scaled the utilization of telehealth in response to COVID-19 and maintained access to complex oncologic care at a time of social distancing. %M 32568721 %R 10.2196/19322 %U https://www.jmir.org/2020/7/e19322 %U https://doi.org/10.2196/19322 %U http://www.ncbi.nlm.nih.gov/pubmed/32568721 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e20001 %T Similarities and Differences in COVID-19 Awareness, Concern, and Symptoms by Race and Ethnicity in the United States: Cross-Sectional Survey %A Jones,Jeb %A Sullivan,Patrick S %A Sanchez,Travis H %A Guest,Jodie L %A Hall,Eric W %A Luisi,Nicole %A Zlotorzynska,Maria %A Wilde,Gretchen %A Bradley,Heather %A Siegler,Aaron J %+ Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, United States, 1 4047122275, jeb.jones@emory.edu %K COVID-19 %K SARS-CoV-2 %K race %K ethnicity %K awareness %K concern %K symptom %K cross-sectional %K knowledge %K health disparity %K inequality %D 2020 %7 10.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Existing health disparities based on race and ethnicity in the United States are contributing to disparities in morbidity and mortality during the coronavirus disease (COVID-19) pandemic. We conducted an online survey of American adults to assess similarities and differences by race and ethnicity with respect to COVID-19 symptoms, estimates of the extent of the pandemic, knowledge of control measures, and stigma. Objective: The aim of this study was to describe similarities and differences in COVID-19 symptoms, knowledge, and beliefs by race and ethnicity among adults in the United States. Methods: We conducted a cross-sectional survey from March 27, 2020 through April 1, 2020. Participants were recruited on social media platforms and completed the survey on a secure web-based survey platform. We used chi-square tests to compare characteristics related to COVID-19 by race and ethnicity. Statistical tests were corrected using the Holm Bonferroni correction to account for multiple comparisons. Results: A total of 1435 participants completed the survey; 52 (3.6%) were Asian, 158 (11.0%) were non-Hispanic Black, 548 (38.2%) were Hispanic, 587 (40.9%) were non-Hispanic White, and 90 (6.3%) identified as other or multiple races. Only one symptom (sore throat) was found to be different based on race and ethnicity (P=.003); this symptom was less frequently reported by Asian (3/52, 5.8%), non-Hispanic Black (9/158, 5.7%), and other/multiple race (8/90, 8.9%) participants compared to those who were Hispanic (99/548, 18.1%) or non-Hispanic White (95/587, 16.2%). Non-Hispanic White and Asian participants were more likely to estimate that the number of current cases was at least 100,000 (P=.004) and were more likely to answer all 14 COVID-19 knowledge scale questions correctly (Asian participants, 13/52, 25.0%; non-Hispanic White participants, 180/587, 30.7%) compared to Hispanic (108/548, 19.7%) and non-Hispanic Black (25/158, 15.8%) participants. Conclusions: We observed differences with respect to knowledge of appropriate methods to prevent infection by the novel coronavirus that causes COVID-19. Deficits in knowledge of proper control methods may further exacerbate existing race/ethnicity disparities. Additional research is needed to identify trusted sources of information in Hispanic and non-Hispanic Black communities and create effective messaging to disseminate correct COVID-19 prevention and treatment information. %M 32614778 %R 10.2196/20001 %U http://www.jmir.org/2020/7/e20001/ %U https://doi.org/10.2196/20001 %U http://www.ncbi.nlm.nih.gov/pubmed/32614778 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19982 %T Influence of Mass and Social Media on Psychobehavioral Responses Among Medical Students During the Downward Trend of COVID-19 in Fujian, China: Cross-Sectional Study %A Lin,Yulan %A Hu,Zhijian %A Alias,Haridah %A Wong,Li Ping %+ Department of Epidemiology and Health Statistics, Fujian Provincial Key Laboratory of Environment Factors and Cancer, School of Public Health, Fujian Medical University, 1 Xue Yuan Road, University Town, Fuzhou, 350122, China, 86 (0)591 2286 ext 2573, huzhijian@fjmu.edu.cn %K psychobehavioral %K COVID-19 %K mass media %K social media %K medical students %K China %D 2020 %7 20.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: An extensive amount of information related to the novel coronavirus (COVID-19) pandemic was disseminated by mass and social media in China. To date, there is limited evidence on how this infodemic may influence psychobehavioral responses to the crisis. Objective: The aim of this study is to assess the psychobehavioral responses to the COVID-19 outbreak and examine their associations with mass and social media exposure. Methods: A cross-sectional study among medical and health sciences students from the Fujian Medical University in Fuzhou, China, was conducted between April 6-22, 2020. Results: A total of 2086 completed responses were received. Multivariable analyses demonstrated that four constructs of the Health Belief Model (HBM)—higher perception of susceptibility (odds ratio [OR] 1.44; 95% CI 1.07-1.94), severity (OR 1.32; 95% CI 1.10-1.59), self-efficacy (OR 1.61; 95% CI 1.21-2.15), and perceived control or intention to carry out prevention measures (OR 1.32; 95% CI 1.09-1.59)—were significantly associated with a higher mass media exposure score, whereas only three constructs—higher perception of severity (OR 1.43; 95% CI 1.19-1.72), self-efficacy (OR 1.85; 95% CI 1.38-2.48), and perceived control or intention to carry out prevention measures (OR 1.32; 95% CI 1.08-1.58)—were significantly associated with a higher social media exposure score. Lower emotional consequences and barriers to carry out prevention measures were also significantly associated with greater mass and social media exposure. Our findings on anxiety levels revealed that 38.1% (n=795; 95% CI 36.0-40.2) of respondents reported moderate-to-severe anxiety. A lower anxiety level was significantly associated with higher mass and social media exposure in the univariable analyses; however, the associations were not significant in the multivariable analyses. Conclusions: In essence, both mass and social media are useful means of disseminating health messages and contribute to the betterment of psychobehavioral responses to COVID-19. Our findings stress the importance of the credibility of information shared through mass and social media outlets and viable strategies to counter misinformation during a pandemic. %M 32584779 %R 10.2196/19982 %U https://www.jmir.org/2020/7/e19982 %U https://doi.org/10.2196/19982 %U http://www.ncbi.nlm.nih.gov/pubmed/32584779 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19904 %T Impact of National Containment Measures on Decelerating the Increase in Daily New Cases of COVID-19 in 54 Countries and 4 Epicenters of the Pandemic: Comparative Observational Study %A Wong,Carlos K H %A Wong,Janet Y H %A Tang,Eric H M %A Au,Chi Ho %A Lau,Kristy T K %A Wai,Abraham K C %+ Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Room 514, William MW Mong Block, Faculty of Medicine Building, 21 Sassoon Road, Pokfulam, Hong Kong, , China (Hong Kong), 852 3917 9859, awai@hku.hk %K COVID-19 %K national containment %K lockdown %K curfew %K stay-at-home %K epidemic curve %D 2020 %7 22.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Coronavirus disease (COVID-19) is a worldwide epidemic, and various countries have responded with different containment measures to reduce disease transmission, including stay-at-home orders, curfews, and lockdowns. Comparative studies have not yet been conducted to investigate the impact of these containment measures; these studies are needed to facilitate public health policy-making across countries. Objective: The aim of this study was to describe and evaluate the impact of national containment measures and policies (stay-at-home orders, curfews, and lockdowns) on decelerating the increase in daily new cases of COVID-19 in 54 countries and 4 epicenters of the pandemic in different jurisdictions worldwide. Methods: We reviewed the effective dates of the national containment measures (stay-at-home order, curfew, or lockdown) of 54 countries and 4 epicenters of the COVID-19 pandemic (Wuhan, New York State, Lombardy, and Madrid), and we searched cumulative numbers of confirmed COVID-19 cases and daily new cases provided by health authorities. Data were drawn from an open, crowdsourced, daily-updated COVID-19 data set provided by Our World in Data. We examined the trends in the percent increase in daily new cases from 7 days before to 30 days after the dates on which containment measures went into effect by continent, World Bank income classification, type of containment measures, effective date of containment measures, and number of confirmed cases on the effective date of the containment measures. Results: We included 122,366 patients with confirmed COVID-19 infection from 54 countries and 24,071 patients from 4 epicenters on the effective dates on which stay-at-home orders, curfews, or lockdowns were implemented between January 23 and April 11, 2020. Stay-at-home, curfew, and lockdown measures commonly commenced in countries with approximately 30%, 20%, or 10% increases in daily new cases. All three measures were found to lower the percent increase in daily new cases to <5 within one month. Among the countries studied, 20% had an average percent increase in daily new cases of 30-49 over the seven days prior to the commencement of containment measures; the percent increase in daily new cases in these countries was curbed to 10 and 5 a maximum of 15 days and 23 days after the implementation of containment measures, respectively. Conclusions: Different national containment measures were associated with a decrease in daily new cases of confirmed COVID-19 infection. Stay-at-home orders, curfews, and lockdowns curbed the percent increase in daily new cases to <5 within a month. Resurgence in cases within one month was observed in some South American countries. %M 32658858 %R 10.2196/19904 %U http://www.jmir.org/2020/7/e19904/ %U https://doi.org/10.2196/19904 %U http://www.ncbi.nlm.nih.gov/pubmed/32658858 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19483 %T Regional Infoveillance of COVID-19 Case Rates: Analysis of Search-Engine Query Patterns %A Cousins,Henry C %A Cousins,Clara C %A Harris,Alon %A Pasquale,Louis R %+ Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1183, New York, NY, 10029, United States, 1 212 241 6752, louis.pasquale@mssm.edu %K epidemiology %K infoveillance %K COVID-19 %K internet activity %K Google Trends %K infectious disease %K surveillance %K public health %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Timely allocation of medical resources for coronavirus disease (COVID-19) requires early detection of regional outbreaks. Internet browsing data may predict case outbreaks in local populations that are yet to be confirmed. Objective: We investigated whether search-engine query patterns can help to predict COVID-19 case rates at the state and metropolitan area levels in the United States. Methods: We used regional confirmed case data from the New York Times and Google Trends results from 50 states and 166 county-based designated market areas (DMA). We identified search terms whose activity precedes and correlates with confirmed case rates at the national level. We used univariate regression to construct a composite explanatory variable based on best-fitting search queries offset by temporal lags. We measured the raw and z-transformed Pearson correlation and root-mean-square error (RMSE) of the explanatory variable with out-of-sample case rate data at the state and DMA levels. Results: Predictions were highly correlated with confirmed case rates at the state (mean r=0.69, 95% CI 0.51-0.81; median RMSE 1.27, IQR 1.48) and DMA levels (mean r=0.51, 95% CI 0.39-0.61; median RMSE 4.38, IQR 1.80), using search data available up to 10 days prior to confirmed case rates. They fit case-rate activity in 49 of 50 states and in 103 of 166 DMA at a significance level of .05. Conclusions: Identifiable patterns in search query activity may help to predict emerging regional outbreaks of COVID-19, although they remain vulnerable to stochastic changes in search intensity. %M 32692691 %R 10.2196/19483 %U http://www.jmir.org/2020/7/e19483/ %U https://doi.org/10.2196/19483 %U http://www.ncbi.nlm.nih.gov/pubmed/32692691 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e20912 %T Multiple Epidemic Wave Model of the COVID-19 Pandemic: Modeling Study %A Kaxiras,Efthimios %A Neofotistos,Georgios %+ Department of Physics, Harvard University, Lyman Lab 339, 17 Oxford Street, Cambridge, MA, 02138, United States, 1 617 495 7977, kaxiras@physics.harvard.edu %K COVID-19 %K multiple waves %K transmission %K intervention measures %K simulations %K modeling %K pandemic response index %K pandemic %K virus %K intervention %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Intervention measures have been implemented around the world to mitigate the spread of the coronavirus disease (COVID-19) pandemic. Understanding the dynamics of the disease spread and the effectiveness of the interventions is essential in predicting its future evolution. Objective: The aim of this study is to simulate the effect of different social distancing interventions and investigate whether their timing and stringency can lead to multiple waves (subepidemics), which can provide a better fit to the wavy behavior observed in the infected population curve in the majority of countries. Methods: We have designed and run agent-based simulations and a multiple wave model to fit the infected population data for many countries. We have also developed a novel Pandemic Response Index to provide a quantitative and objective way of ranking countries according to their COVID-19 response performance. Results: We have analyzed data from 18 countries based on the multiple wave (subepidemics) hypothesis and present the relevant parameters. Multiple waves have been identified and were found to describe the data better. The effectiveness of intervention measures can be inferred by the peak intensities of the waves. Countries imposing fast and stringent interventions exhibit multiple waves with declining peak intensities. This result strongly corroborated with agent-based simulations outcomes. We also provided an estimate of how much lower the number of infections could have been if early and strict intervention measures had been taken to stop the spread at the first wave, as actually happened for a handful of countries. A novel index, the Pandemic Response Index, was constructed, and based on the model’s results, an index value was assigned to each country, quantifying in an objective manner the country’s response to the pandemic. Conclusions: Our results support the hypothesis that the COVID-19 pandemic can be successfully modeled as a series of epidemic waves (subepidemics) and that it is possible to infer to what extent the imposition of early intervention measures can slow the spread of the disease. %M 32692690 %R 10.2196/20912 %U http://www.jmir.org/2020/7/e20912/ %U https://doi.org/10.2196/20912 %U http://www.ncbi.nlm.nih.gov/pubmed/32692690