%0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20581 %T Digital Interventions for Screening and Treating Common Mental Disorders or Symptoms of Common Mental Illness in Adults: Systematic Review and Meta-analysis %A Sin,Jacqueline %A Galeazzi,Gian %A McGregor,Elicia %A Collom,Jennifer %A Taylor,Anna %A Barrett,Barbara %A Lawrence,Vanessa %A Henderson,Claire %+ School of Psychology and Clinical Language Sciences, University of Reading, Earley Gate, Whiteknights, Reading, RG6 6AL, United Kingdom, 44 7817027035, jacqueline.sin@reading.ac.uk %K eHealth %K mHealth %K psychiatric illness %K mental disorders %K common mental illness %K depression %K anxiety %K self-care %D 2020 %7 2.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Digital interventions targeting common mental disorders (CMDs) or symptoms of CMDs are growing rapidly and gaining popularity, probably in response to the increased prevalence of CMDs and better awareness of early help-seeking and self-care. However, no previous systematic reviews that focus on these novel interventions were found. Objective: This systematic review aims to scope entirely web-based interventions that provided screening and signposting for treatment, including self-management strategies, for people with CMDs or subthreshold symptoms. In addition, a meta-analysis was conducted to evaluate the effectiveness of these interventions for mental well-being and mental health outcomes. Methods: Ten electronic databases including MEDLINE, PsycINFO, and EMBASE were searched from January 1, 1999, to early April 2020. We included randomized controlled trials (RCTs) that evaluated a digital intervention (1) targeting adults with symptoms of CMDs, (2) providing both screening and signposting to other resources including self-care, and (3) delivered entirely through the internet. Intervention characteristics including target population, platform used, key design features, and outcome measure results were extracted and compared. Trial outcome results were included in a meta-analysis on the effectiveness of users’ well-being and mental health outcomes. We also rated the meta-analysis results with the Grading of Recommendations, Assessment, Development, and Evaluations approach to establish the quality of the evidence. Results: The electronic searches yielded 21 papers describing 16 discrete digital interventions. These interventions were investigated in 19 unique trials including 1 (5%) health economic study. Most studies were conducted in Australia and North America. The targeted populations varied from the general population to allied health professionals. All interventions offered algorithm-driven screening with measures to assess symptom levels and to assign treatment options including automatic web-based psychoeducation, self-care strategies, and signposting to existing services. A meta-analysis of usable trial data showed that digital interventions improved well-being (3 randomized controlled trials [RCTs]; n=1307; standardized mean difference [SMD] 0.40; 95% CI 0.29 to 0.51; I2=28%; fixed effect), symptoms of mental illness (6 RCTs; n=992; SMD −0.29; 95% CI −0.49 to −0.09; I2=51%; random effects), and work and social functioning (3 RCTs; n=795; SMD −0.16; 95% CI −0.30 to −0.02; I2=0%; fixed effect) compared with waitlist or attention control. However, some follow-up data failed to show any sustained effects beyond the post intervention time point. Data on mechanisms of change and cost-effectiveness were also lacking, precluding further analysis. Conclusions: Digital mental health interventions to assess and signpost people experiencing symptoms of CMDs appear to be acceptable to a sufficient number of people and appear to have enough evidence for effectiveness to warrant further study. We recommend that future studies incorporate economic analysis and process evaluation to assess the mechanisms of action and cost-effectiveness to aid scaling of the implementation. %M 32876577 %R 10.2196/20581 %U https://www.jmir.org/2020/9/e20581 %U https://doi.org/10.2196/20581 %U http://www.ncbi.nlm.nih.gov/pubmed/32876577 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19468 %T Internet-Based Supportive Interventions for Family Caregivers of People With Dementia: Systematic Review and Meta-Analysis %A Leng,Minmin %A Zhao,Yajie %A Xiao,Hongmei %A Li,Ce %A Wang,Zhiwen %+ School of Nursing, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, China, 86 15901566817, wzwjing@sina.com %K family caregivers %K dementia %K supportive interventions %K internet %K systematic review %D 2020 %7 9.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Caring for people with dementia is perceived as one of the most stressful and difficult forms of caring. Family caregivers always experience high levels of psychological burden and physical strain, so effective and practical support is essential. Internet-based supportive interventions can provide convenient and efficient support and education to potentially reduce the physical and psychological burden associated with providing care. Objective: This review aimed to (1) assess the efficacy of internet-based supportive interventions in ameliorating health outcomes for family caregivers of people with dementia, and (2) evaluate the potential effects of internet-based supportive intervention access by caregivers on their care recipients. Methods: An electronic literature search of the PubMed, EMBASE, Web of Science, CINAHL, Cochrane Library, and PsycINFO databases was conducted up to January 2020. Two reviewers (ML and YZ) worked independently to identify randomized controlled trials (RCTs) that met the inclusion criteria and independently extracted data. The quality of the included RCTs was evaluated using the approach recommended by the Cochrane Handbook for Systematic Reviews of Interventions. Standardized mean differences (SMDs) with 95% CIs were applied to calculate the pooled effect sizes. Results: In total, 17 RCTs met the eligibility criteria and were included in this systematic review. The meta-analysis showed that internet-based supportive interventions significantly ameliorated depressive symptoms (SMD=–0.21; 95% CI –0.31 to –0.10; P<.001), perceived stress (SMD=–0.40; 95% CI –0.55 to –0.24; P<.001), anxiety (SMD=–0.33; 95% CI –0.51 to –0.16; P<.001), and self-efficacy (SMD=0.19; 95% CI 0.05-0.33; P=.007) in dementia caregivers. No significant improvements were found in caregiver burden, coping competence, caregiver reactions to behavioral symptoms, or quality of life. Six studies assessed the unintended effects of internet-based supportive intervention access by caregivers on their care recipients. The results showed that internet-based supportive interventions had potential benefits on the quality of life and neuropsychiatric symptoms in care recipients. Conclusions: Internet-based supportive interventions are generally effective at ameliorating depressive symptoms, perceived stress, anxiety, and self-efficacy in dementia caregivers and have potential benefits on care recipients. Future studies are encouraged to adopt personalized internet-based supportive interventions to improve the health of family caregivers and their care recipients. Trial Registration: PROSPERO CRD42020162434; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=162434 %M 32902388 %R 10.2196/19468 %U http://www.jmir.org/2020/9/e19468/ %U https://doi.org/10.2196/19468 %U http://www.ncbi.nlm.nih.gov/pubmed/32902388 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18621 %T Effectiveness of Individual Real-Time Video Counseling on Smoking, Nutrition, Alcohol, Physical Activity, and Obesity Health Risks: Systematic Review %A Byaruhanga,Judith %A Atorkey,Prince %A McLaughlin,Matthew %A Brown,Alison %A Byrnes,Emma %A Paul,Christine %A Wiggers,John %A Tzelepis,Flora %+ Hunter New England Population Health, Locked Bag 10, Wallsend, , Australia, 61 249246454, judith.byaruhanga@uon.edu.au %K telehealth %K videoconferencing %K smoking cessation %K diet %K alcohol drinking %K physical activity %K obesity %K mobile phone %D 2020 %7 11.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Real-time video communication technology allows virtual face-to-face interactions between the provider and the user, and can be used to modify risk factors for smoking, nutrition, alcohol consumption, physical activity, and obesity. No systematic reviews have examined the effectiveness of individual real-time video counseling for addressing each of the risk factors for smoking, nutrition, alcohol consumption, physical activity, and obesity. Objective: This systematic review aims to examine the effectiveness of individually delivered real-time video counseling on risk factors for smoking, nutrition, alcohol consumption, physical activity, and obesity. Methods: The MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica Database), PsycINFO, Cochrane Register of Controlled Trials, and Scopus databases were searched for eligible studies published up to November 21, 2019. Eligible studies were randomized or cluster randomized trials that tested the effectiveness of individual real-time video communication interventions on smoking, nutrition, alcohol, physical activity, and obesity in any population or setting; the comparator was a no-intervention control group or any other mode of support (eg, telephone); and an English-language publication. Results: A total of 13 studies were eligible. Four studies targeted smoking, 3 alcohol, 3 physical activity, and 3 obesity. In 2 of the physical activity studies, real-time video counseling was found to significantly increase physical activity when compared with usual care at week 9 and after 5 years. Two obesity studies found a significant change in BMI between a video counseling and a documents group, with significantly greater weight loss in the video counseling group than the in-person as well as the control groups. One study found that those in the video counseling group were significantly more likely than those in the telephone counseling group to achieve smoking cessation. The remaining studies found no significant differences between video counseling and telephone counseling or face-to-face counseling for smoking cessation, video counseling and face-to-face treatment on alcohol consumption, video counseling and no counseling for physical activity, and video counseling and face-to-face treatment on BMI. The global methodological quality rating was moderate in 1 physical activity study, whereas 12 studies had a weak global rating. Conclusions: Video counseling is potentially more effective than a control group or other modes of support in addressing physical inactivity and obesity and is not less effective in modifying smoking and alcohol consumption. Further research is required to determine the relative benefits of video counseling in terms of other policy and practice decision-making factors such as costs and feasibility. %M 32915156 %R 10.2196/18621 %U http://www.jmir.org/2020/9/e18621/ %U https://doi.org/10.2196/18621 %U http://www.ncbi.nlm.nih.gov/pubmed/32915156 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18986 %T Identification of Patient Perceptions That Can Affect the Uptake of Interventions Using Biometric Monitoring Devices: Systematic Review of Randomized Controlled Trials %A Perlmutter,Alexander %A Benchoufi,Mehdi %A Ravaud,Philippe %A Tran,Viet-Thi %+ Department of Epidemiology, Mailman School of Public Health, Columbia University, Room 720.10, 722 W 168th St, New York, NY, 10032, United States, 1 703 336 9067, asp2183@cumc.columbia.edu %K systematic review %K patient perceptions %K biometric monitoring device %K randomized controlled trials %K accelerometer %K pedometer %K ecological momentary assessment %K electrochemical biosensor %K adoption %K uptake %K real-world %D 2020 %7 11.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Biometric monitoring devices (BMDs) are wearable or environmental trackers and devices with embedded sensors that can remotely collect high-frequency objective data on patients’ physiological, biological, behavioral, and environmental contexts (for example, fitness trackers with accelerometer). The real-world effectiveness of interventions using biometric monitoring devices depends on patients’ perceptions of these interventions. Objective: We aimed to systematically review whether and how recent randomized controlled trials (RCTs) evaluating interventions using BMDs assessed patients’ perceptions toward the intervention. Methods: We systematically searched PubMed (MEDLINE) from January 1, 2017, to December 31, 2018, for RCTs evaluating interventions using BMDs. Two independent investigators extracted the following information: (1) whether the RCT collected information on patient perceptions toward the intervention using BMDs and (2) if so, what precisely was collected, based on items from questionnaires used and/or themes and subthemes identified from qualitative assessments. The two investigators then synthesized their findings in a schema of patient perceptions of interventions using BMDs. Results: A total of 58 RCTs including 10,071 participants were included in the review (the median number of randomized participants was 60, IQR 37-133). BMDs used in interventions were accelerometers/pedometers (n=35, 60%), electrochemical biosensors (eg, continuous glucose monitoring; n=18, 31%), or ecological momentary assessment devices (eg, carbon monoxide monitors for smoking cessation; n=5, 9%). Overall, 26 (45%) trials collected information on patient perceptions toward the intervention using BMDs and allowed the identification of 76 unique aspects of patient perceptions that could affect the uptake of these interventions (eg, relevance of the information provided, alarm burden, privacy and data handling, impact on health outcomes, independence, interference with daily life). Patient perceptions were unevenly collected in trials. For example, only 5% (n=3) of trials assessed how patients felt about privacy and data handling aspects of the intervention using BMDs. Conclusions: Our review showed that less than half of RCTs evaluating interventions using BMDs assessed patients’ perceptions toward interventions using BMDs. Trials that did assess perceptions often only assessed a fraction of them. This limits the extrapolation of the results of these RCTs to the real world. We thus provide a comprehensive schema of aspects of patient perceptions that may affect the uptake of interventions using BMDs and which should be considered in future trials. Trial Registration: PROSPERO CRD42018115522; https://tinyurl.com/y5h8fjgx %M 32915153 %R 10.2196/18986 %U http://www.jmir.org/2020/9/e18986/ %U https://doi.org/10.2196/18986 %U http://www.ncbi.nlm.nih.gov/pubmed/32915153 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19436 %T Use of Decision Support Tools to Empower Pregnant Women: Systematic Review %A Ngo,Elin %A Truong,Maria Bich-Thuy %A Nordeng,Hedvig %+ PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Postboks 1068 Blindern, Oslo, 0316, Norway, 47 93849866, e.t.p.ngo@farmasi.uio.no %K decision support tools %K pregnancy %K mobile application %K empowerment %D 2020 %7 14.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Women face many health-related decisions during pregnancy. Digitalization, new technology, and a greater focus on empowering patients have driven the development of patient-centered decision support tools. Objective: This systematic review provides an overview of studies investigating the effect of patient-centered decision support tools for pregnant women. Methods: We searched 5 online databases, MEDLINE, EMBASE, Web of Science, PsycINFO, and Scopus, from inception to December 1, 2019. Two independent researchers screened titles, abstracts, and full-texts against the inclusion criteria. All studies investigating the effect of patient-centered decision support tools for health-related issues among pregnant women were included. Study characteristics and results were extracted using the review management tool Rayyan and analyzed according to topic, type of decision support tools, control group, outcome measurements, and results. Results: The 25 eligible studies covered a range of health topics, including prenatal screening (n=10), gestational diabetes and weight gain (n=7), lifestyle (n=3), blood pressure and preeclampsia (n=2), depression (n=1), asthma (n=1), and psychological well-being (n=1). In general, the use of decision support tools increased women's knowledge, and recording symptoms enhanced satisfaction with maternity care. Conclusions: The opportunities created by digitalization and technology should be used to develop innovative patient-centered decision support tools tailored to support pregnant women. Effect on clinical outcomes should be documented. %M 32924961 %R 10.2196/19436 %U http://www.jmir.org/2020/9/e19436/ %U https://doi.org/10.2196/19436 %U http://www.ncbi.nlm.nih.gov/pubmed/32924961 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20701 %T Artificial Intelligence-Based Conversational Agents for Chronic Conditions: Systematic Literature Review %A Schachner,Theresa %A Keller,Roman %A v Wangenheim,Florian %+ Department of Management, Technology, and Economics, ETH Zurich, WEV G 228, Weinbergstr 56/58, Zurich , Switzerland, 41 446325209, tschachner@ethz.ch %K artificial intelligence %K conversational agents %K chatbots %K healthcare %K chronic diseases %K systematic literature review %D 2020 %7 14.9.2020 %9 Review %J J Med Internet Res %G English %X Background: A rising number of conversational agents or chatbots are equipped with artificial intelligence (AI) architecture. They are increasingly prevalent in health care applications such as those providing education and support to patients with chronic diseases, one of the leading causes of death in the 21st century. AI-based chatbots enable more effective and frequent interactions with such patients. Objective: The goal of this systematic literature review is to review the characteristics, health care conditions, and AI architectures of AI-based conversational agents designed specifically for chronic diseases. Methods: We conducted a systematic literature review using PubMed MEDLINE, EMBASE, PyscInfo, CINAHL, ACM Digital Library, ScienceDirect, and Web of Science. We applied a predefined search strategy using the terms “conversational agent,” “healthcare,” “artificial intelligence,” and their synonyms. We updated the search results using Google alerts, and screened reference lists for other relevant articles. We included primary research studies that involved the prevention, treatment, or rehabilitation of chronic diseases, involved a conversational agent, and included any kind of AI architecture. Two independent reviewers conducted screening and data extraction, and Cohen kappa was used to measure interrater agreement.A narrative approach was applied for data synthesis. Results: The literature search found 2052 articles, out of which 10 papers met the inclusion criteria. The small number of identified studies together with the prevalence of quasi-experimental studies (n=7) and prevailing prototype nature of the chatbots (n=7) revealed the immaturity of the field. The reported chatbots addressed a broad variety of chronic diseases (n=6), showcasing a tendency to develop specialized conversational agents for individual chronic conditions. However, there lacks comparison of these chatbots within and between chronic diseases. In addition, the reported evaluation measures were not standardized, and the addressed health goals showed a large range. Together, these study characteristics complicated comparability and open room for future research. While natural language processing represented the most used AI technique (n=7) and the majority of conversational agents allowed for multimodal interaction (n=6), the identified studies demonstrated broad heterogeneity, lack of depth of reported AI techniques and systems, and inconsistent usage of taxonomy of the underlying AI software, further aggravating comparability and generalizability of study results. Conclusions: The literature on AI-based conversational agents for chronic conditions is scarce and mostly consists of quasi-experimental studies with chatbots in prototype stage that use natural language processing and allow for multimodal user interaction. Future research could profit from evidence-based evaluation of the AI-based conversational agents and comparison thereof within and between different chronic health conditions. Besides increased comparability, the quality of chatbots developed for specific chronic conditions and their subsequent impact on the target patients could be enhanced by more structured development and standardized evaluation processes. %M 32924957 %R 10.2196/20701 %U http://www.jmir.org/2020/9/e20701/ %U https://doi.org/10.2196/20701 %U http://www.ncbi.nlm.nih.gov/pubmed/32924957 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18290 %T Effectiveness of Virtual Reality in Nursing Education: Meta-Analysis %A Chen,Feng-Qin %A Leng,Yu-Fei %A Ge,Jian-Feng %A Wang,Dan-Wen %A Li,Cheng %A Chen,Bin %A Sun,Zhi-Ling %+ School of Nursing, Nanjing University of Chinese Medicine, 138 Xian Lin Road, Nanjing, China, 86 13813892093, szl@njucm.edu.cn %K virtual reality %K nursing education %K meta-analysis %D 2020 %7 15.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) is the use of computer technology to create an interactive three-dimensional (3D) world, which gives users a sense of spatial presence. In nursing education, VR has been used to help optimize teaching and learning processes. Objective: The purpose of this study was to evaluate the effectiveness of VR in nursing education in the areas of knowledge, skills, satisfaction, confidence, and performance time. Methods: We conducted a meta-analysis of the effectiveness of VR in nursing education based on the Cochrane methodology. An electronic literature search using the Cochrane Library, Web of Science, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature), up to December 2019 was conducted to identify studies that reported the effectiveness of VR on knowledge, skills, satisfaction, confidence, and performance time. The study selection and data extraction were carried out by two independent reviewers. The methodological quality of the selected studies was determined using the Cochrane criteria for risk-of-bias assessment. Results: A total of 12 studies, including 821 participants, were selected for the final analysis. We found that VR was more effective than the control conditions in improving knowledge (standard mean difference [SMD]=0.58, 95% CI 0.41-0.75, P<.001, I2=47%). However, there was no difference between VR and the control conditions in skills (SMD=0.01, 95% CI –0.24 to 0.26, P=.93, I2=37%), satisfaction (SMD=0.01, 95% CI –0.79 to 0.80, P=.99, I2=86%), confidence (SMD=0.00, 95% CI –0.28 to 0.27, P=.99, I2=0%), and performance time (SMD=–0.55, 95% CI –2.04 to 0.94, P=.47, I2=97%). Conclusions: The results of this study suggest that VR can effectively improve knowledge in nursing education, but it was not more effective than other education methods in areas of skills, satisfaction, confidence, and performance time. Further rigorous studies with a larger sample size are warranted to confirm these results. %M 32930664 %R 10.2196/18290 %U http://www.jmir.org/2020/9/e18290/ %U https://doi.org/10.2196/18290 %U http://www.ncbi.nlm.nih.gov/pubmed/32930664 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18976 %T Patient Portal Functionalities and Patient Outcomes Among Patients With Diabetes: Systematic Review %A Alturkistani,Abrar %A Qavi,Ambar %A Anyanwu,Philip Emeka %A Greenfield,Geva %A Greaves,Felix %A Costelloe,Ceire %+ Global Digital Health Unit, Department of Primary Care and Public Health, Imperial College London, St Dunstan's Rd, Hammersmith, London, W6 8RP, United Kingdom, 44 (0)20 7589 5111, Abrar.alturkistani16@imperial.ac.uk %K personal health record %K patient portal %K electronic health records %K online access %K patient records %K systematic review %D 2020 %7 22.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Patient portal use could help improve the care and health outcomes of patients with diabetes owing to functionalities, such as appointment booking, electronic messaging (e-messaging), and repeat prescription ordering, which enable patient-centered care and improve patient self-management of the disease. Objective: This review aimed to summarize the evidence regarding patient portal use (portals that are connected to electronic health care records) or patient portal functionality use (eg, appointment booking and e-messaging) and their reported associations with health and health care quality outcomes among adult patients with diabetes. Methods: We searched the MEDLINE, Embase, and Scopus databases and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed the full texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tool to assess the risk of bias of the included studies. Data were summarized through narrative synthesis. Results: Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and health care quality outcomes. Six studies reported e-messaging or email use–associated outcomes, and two studies reported prescription refill–associated outcomes. The reported health outcomes included the associations of patient portal use with blood pressure, low-density lipoprotein cholesterol, and BMI. Few studies reported health care utilization outcomes such as office visits, emergency department visits, and hospitalizations. A limited number of studies reported overall quality of care for patients with diabetes who used patient portals. Conclusions: The included studies mostly reported improved glycemic control outcomes for patients with diabetes who used patient portals. However, limitations of studying the effects of patient portals exist, which do not guarantee whether the outcomes reported are completely the result of patient portal use or if confounding factors exist. Randomized controlled trials and mixed-methods studies could help understand the mechanisms involved in health outcome improvements and patient portal use among patients with diabetes. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019141131; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019141131. International Registered Report Identifier (IRRID): RR2-10.2196/14975 %M 32960182 %R 10.2196/18976 %U http://www.jmir.org/2020/9/e18976/ %U https://doi.org/10.2196/18976 %U http://www.ncbi.nlm.nih.gov/pubmed/32960182 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17809 %T Digital Health Coaching Programs Among Older Employees in Transition to Retirement: Systematic Literature Review %A Stara,Vera %A Santini,Sara %A Kropf,Johannes %A D'Amen,Barbara %+ Centre for Socio-Economic Research on Aging, IRCCS INRCA-National Institute of Health and Science on Aging, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Nazionale Ricovero e Cura per Anziani, via S. Margherita 5, Ancona, 60124, Italy, 39 3286191298, s.santini2@inrca.it %K older workers %K retirees %K transition to retirement %K healthy aging %K active aging %K digital coach %K virtual coach %K user-centered design %K virtual agent %K avatar, virtual personal assistant %D 2020 %7 24.9.2020 %9 Review %J J Med Internet Res %G English %X Background: The rapid increase of the aging population is pushing many national governments to reshape retirement legislation in order to extend older adults’ working life. Once retired, older adults can be invaluable resources for the community as family carers, as volunteers, or by returning to work. Healthy aging is one of the main conditions for being able to work longer and being active after retirement. The latter, indeed, represents a very sensitive life transition, which can entail psychological and social difficulties. Interventions for promoting older workers’ health and well-being and supporting the transition to retirement are on the top of the policy agenda of most European countries. Recently, computer-based and digital health interventions have been seen as promising means to reach this purpose. Objective: This systematic literature review aimed to explore studies on digital health coaching programs for older workers that followed a user-centered design approach and evaluated their effectiveness in providing older adults with guidance for adopting a healthy lifestyle and being active in the community. Methods: The search identified 1931 papers, and 2 relevant articles were selected by applying specific eligibility criteria. Results: To our knowledge, only few digital health coaching programs have targeted the population of older workers to date; there is an insufficient number of studies on the efficacy of such programs. The results show the difficulties of assessing the efficacy of digital coaching itself and with respect to older employees. The 2 studies suggest that digital health programs for workplaces can improve various aspects of older employees’ well-being; however, they considered health mainly from a physical perspective and neglected contextual, social, psychological, and cultural factors that can influence older workers’ health and general well-being. Future digital health coaching programs should adopt the healthy aging paradigm as a multidimensional lens for interpreting the impact of eHealth technology on aging and retirement. The literature around this issue remains at an embryonic state, and this gap needs to be filled by further investigations that apply a user-centered approach for designing the technology, test innovative research methodologies, and adopt new technical solutions for high-quality interaction design. Conclusions: Further digital health coaching programs aimed at supporting healthy and active living for older workers and retirees are necessary. The user-centered design approach is recommended in order to fully address the users’ health needs and the technological requirements throughout development. Moreover, the healthy aging perspective allows inclusion of physical, social, and psychological factors influencing the transition from work to retirement, as well as the experiences and interactions of individuals with the technology. %M 32969827 %R 10.2196/17809 %U http://www.jmir.org/2020/9/e17809/ %U https://doi.org/10.2196/17809 %U http://www.ncbi.nlm.nih.gov/pubmed/32969827 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17831 %T Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Adolescents and Young Adults: Systematic Review and Meta-Analysis %A Christ,Carolien %A Schouten,Maria JE %A Blankers,Matthijs %A van Schaik,Digna JF %A Beekman,Aartjan TF %A Wisman,Marike A %A Stikkelbroek,Yvonne AJ %A Dekker,Jack JM %+ Department of Psychiatry, GGZ inGeest, Amsterdam UMC, Vrije Universiteit Amsterdam, Oldenaller 1, Amsterdam, 1081 HJ, Netherlands, 31 20 590 1339, c.christ@ggzingeest.nl %K cognitive behavior therapy %K internet %K anxiety %K depression %K youth %K meta-analysis %D 2020 %7 25.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Anxiety and depressive disorders are prevalent in adolescents and young adults. However, most young people with mental health problems do not receive treatment. Computerized cognitive behavior therapy (cCBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in young people is limited. Objective: The objective was to perform an up-to-date comprehensive systematic review and meta-analysis of the effectiveness of cCBT in treating anxiety and depression in adolescents and young adults compared with active treatment and passive controls. We aimed to examine posttreatment and follow-up effects and explore the moderators of treatment effects. Methods: We conducted systematic searches in the following six electronic databases: PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing cCBT with any control group in adolescents or young adults (age 12-25 years) with anxiety or depressive symptoms. The quality of included studies was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2.0. Overall quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Posttreatment means and SDs were compared between intervention and control groups, and pooled effect sizes (Hedges g) were calculated. Random-effects meta-analyses were conducted using Comprehensive Meta-Analysis software. Subgroup analyses and meta-regression analyses were conducted to explore whether age, guidance level, and adherence rate were associated with treatment outcome. Results: The search identified 7670 papers, of which 24 studies met the inclusion criteria. Most included studies (22/24) had a high risk of bias owing to self-report measures and/or inappropriate handling of missing data. Compared with passive controls, cCBT yielded small to medium posttreatment pooled effect sizes regarding depressive symptoms (g=0.51, 95% CI 0.30-0.72, number needed to treat [NNT]=3.55) and anxiety symptoms (g=0.44, 95% CI 0.23-0.65, NNT=4.10). cCBT yielded effects similar to those of active treatment controls regarding anxiety symptoms (g=0.04, 95% CI −0.23 to 0.31). For depressive symptoms, the nonsignificant pooled effect size favored active treatment controls (g=−0.70, 95% CI −1.51 to 0.11, P=.09), but heterogeneity was very high (I2=90.63%). No moderators of treatment effects were identified. At long-term follow-up, cCBT yielded a small pooled effect size regarding depressive symptoms compared with passive controls (g=0.27, 95% CI 0.09-0.45, NNT=6.58). No other follow-up effects were found; however, power was limited owing to the small number of studies. Conclusions: cCBT is beneficial for reducing posttreatment anxiety and depressive symptoms in adolescents and young adults compared with passive controls. Compared with active treatment controls, cCBT yielded similar effects regarding anxiety symptoms. Regarding depressive symptoms, however, the results remain unclear. More high-quality research involving active controls and long-term follow-up assessments is needed in this population. Trial Registration: PROSPERO CRD42019119725; https://tinyurl.com/y5acfgd9. %M 32673212 %R 10.2196/17831 %U https://www.jmir.org/2020/9/e17831 %U https://doi.org/10.2196/17831 %U http://www.ncbi.nlm.nih.gov/pubmed/32673212 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19818 %T Doctors Routinely Share Health Data Electronically Under HIPAA, and Sharing With Patients and Patients’ Third-Party Health Apps is Consistent: Interoperability and Privacy Analysis %A Savage,Mark %A Savage,Lucia Clara %+ Center for Digital Health Innovation, University of California, San Francisco, 1700 Owens Street, Suite 541, San Francisco, CA, 94158, United States, 1 415 225 1676, Mark.Savage@ucsf.edu %K digital health %K privacy %K interoperability %K mobile phone, smartphone %K electronic health records %K EHR %K patient access %K patient engagement %K Health Insurance Portability and Accountability Act %K HIPAA %K Health Information Technology for Economic and Clinical Health Act %K HITECH %K covered entity %K business associate %K protected health information %K PHI %K digital health applications %K apps %D 2020 %7 2.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X Since 2000, federal regulations have affirmed that patients have a right to a complete copy of their health records from their physicians and hospitals. Today, providers across the nation use electronic health records and electronic information exchange for health care, and patients are choosing digital health apps to help them manage their own health and health information. Some doctors and health systems have voiced concern about whether they may transmit a patient’s data upon the patient’s request to the patient or the patient’s health app. This hesitation impedes shared information and care coordination with patients. It impairs patients’ ability to use the state-of-the-art digital health tools they choose to track and manage their health. It undermines the ability of patients’ family caregivers to monitor health and to work remotely to provide care by using the nearly unique capabilities of health apps on people’s smartphones. This paper explains that sharing data electronically with patients and patients’ third-party apps is legally consistent under the Health Insurance Portability and Accountability Act (HIPAA) with routine electronic data sharing with other doctors for treatment or with insurers for reimbursement. The paper explains and illustrates basic principles and scenarios around sharing with patients, including patients’ third-party apps. Doctors routinely and legally share health data electronically under HIPAA whether or not their organizations retain HIPAA responsibility. Sharing with patients and patients’ third-party apps is no different and should be just as routine. %M 32876582 %R 10.2196/19818 %U https://www.jmir.org/2020/9/e19818 %U https://doi.org/10.2196/19818 %U http://www.ncbi.nlm.nih.gov/pubmed/32876582 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20953 %T Telemonitoring for Patients With COVID-19: Recommendations for Design and Implementation %A Silven,Anna V %A Petrus,Annelieke H J %A Villalobos-Quesada,María %A Dirikgil,Ebru %A Oerlemans,Carlijn R %A Landstra,Cyril P %A Boosman,Hileen %A van Os,Hendrikus J A %A Blanker,Marco H %A Treskes,Roderick W %A Bonten,Tobias N %A Chavannes,Niels H %A Atsma,Douwe E %A Teng,Y K Onno %+ Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, Netherlands, 31 715262038, d.e.atsma@lumc.nl %K telemonitoring %K telemedicine %K eHealth %K digital health %K COVID-19 %D 2020 %7 2.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X Despite significant efforts, the COVID-19 pandemic has put enormous pressure on health care systems around the world, threatening the quality of patient care. Telemonitoring offers the opportunity to carefully monitor patients with a confirmed or suspected case of COVID-19 from home and allows for the timely identification of worsening symptoms. Additionally, it may decrease the number of hospital visits and admissions, thereby reducing the use of scarce resources, optimizing health care capacity, and minimizing the risk of viral transmission. In this paper, we present a COVID-19 telemonitoring care pathway developed at a tertiary care hospital in the Netherlands, which combined the monitoring of vital parameters with video consultations for adequate clinical assessment. Additionally, we report a series of medical, scientific, organizational, and ethical recommendations that may be used as a guide for the design and implementation of telemonitoring pathways for COVID-19 and other diseases worldwide. %M 32833660 %R 10.2196/20953 %U https://www.jmir.org/2020/9/e20953 %U https://doi.org/10.2196/20953 %U http://www.ncbi.nlm.nih.gov/pubmed/32833660 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21276 %T Regulatory Sandboxes: A Cure for mHealth Pilotitis? %A Bhatia,Abhishek %A Matthan,Rahul %A Khanna,Tarun %A Balsari,Satchit %+ FXB Center for Health and Human Rights, Harvard TH Chan School of Public Health, 651 Huntington Avenue, 703C, Boston, MA, , United States, 1 6174951000, balsari@hsph.harvard.edu %K COVID-19 %K mHealth %K digital health %K design thinking %K regulation %K intervention %K regulatory sandbox %D 2020 %7 15.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X Mobile health (mHealth) and related digital health interventions in the past decade have not always scaled globally as anticipated earlier despite large investments by governments and philanthropic foundations. The implementation of digital health tools has suffered from 2 limitations: (1) the interventions commonly ignore the “law of amplification” that states that technology is most likely to succeed when it seeks to augment and not alter human behavior; and (2) end-user needs and clinical gaps are often poorly understood while designing solutions, contributing to a substantial decrease in usage, referred to as the “law of attrition” in eHealth. The COVID-19 pandemic has addressed the first of the 2 problems—technology solutions, such as telemedicine, that were struggling to find traction are now closely aligned with health-seeking behavior. The second problem (poorly designed solutions) persists, as demonstrated by a plethora of poorly designed epidemic prediction tools and digital contact-tracing apps, which were deployed at scale, around the world, with little validation. The pandemic has accelerated the Indian state’s desire to build the nation’s digital health ecosystem. We call for the inclusion of regulatory sandboxes, as successfully done in the fintech sector, to provide a real-world testing environment for mHealth solutions before deploying them at scale. %M 32763889 %R 10.2196/21276 %U http://www.jmir.org/2020/9/e21276/ %U https://doi.org/10.2196/21276 %U http://www.ncbi.nlm.nih.gov/pubmed/32763889 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20896 %T Can Disinfection Robots Reduce the Risk of Transmission of SARS-CoV-2 in Health Care and Educational Settings? %A Cresswell,Kathrin %A Sheikh,Aziz %+ Usher Institute, The University of Edinburgh, Teviot Place, Edinburgh, United Kingdom, 44 131 650 8102, kathrin.cresswell@ed.ac.uk %K robotics %K disinfection %K SARS-CoV-2 %K COVID-19 %K risk %K transmission %K virus %D 2020 %7 15.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X We explore the opportunities and challenges surrounding the use of disinfection robots to reduce the risk of SARS-CoV-2 transmission in health care and educational settings. Although there is some potential for deploying robots to help with manual cleaning, the evidence base is mixed, and we highlight that there needs to be work to establish and enhance the effectiveness of these robots in inactivating the virus. %M 32903196 %R 10.2196/20896 %U http://www.jmir.org/2020/9/e20896/ %U https://doi.org/10.2196/20896 %U http://www.ncbi.nlm.nih.gov/pubmed/32903196 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21922 %T Ethical Challenges and Opportunities Associated With the Ability to Perform Medical Screening From Interactions With Search Engines: Viewpoint %A Yom-Tov,Elad %A Cherlow,Yuval %+ Microsoft Research, Alan Turing 3, Herzeliya, 4672415, Israel, 972 747111359, eladyt@microsoft.com %K search engines %K diagnosis %K screening %D 2020 %7 16.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X Recent research has shown the efficacy of screening for serious medical conditions from data collected while people interact with online services. In particular, queries to search engines and the interactions with them were shown to be advantageous for screening a range of conditions including diabetes, several forms of cancer, eating disorders, and depression. These screening abilities offer unique advantages in that they can serve a broad strata of the society, including people in underserved populations and in countries with poor access to medical services. However, these advantages need to be balanced against the potential harm to privacy, autonomy, and nonmaleficence, which are recognized as the cornerstones of ethical medical care. Here, we discuss these opportunities and challenges, both when collecting data to develop online screening services and when deploying them. We offer several solutions that balance the advantages of these services with the ethical challenges they pose. %M 32936082 %R 10.2196/21922 %U http://www.jmir.org/2020/9/e21922/ %U https://doi.org/10.2196/21922 %U http://www.ncbi.nlm.nih.gov/pubmed/32936082 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17423 %T Adoption of Blockchain in Health Care %A Gaynor,Mark %A Tuttle-Newhall,Janet %A Parker,Jessica %A Patel,Arti %A Tang,Clare %+ School of Public Health and Social Justice, Saint Louis University, 3545 Lafayette Ave, St Louis, MO, 63104, United States, 1 314 977 8304, mark.gaynor@slu.edu %K blockchain adoption %K blockchain technology in health care %K supply chain %K data management %D 2020 %7 17.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X This study aims to review current issues regarding the application of blockchain technology in health care. We illustrated the various ways in which blockchain can solve current health care issues in three main arenas: data exchange, contracts, and supply chain management. This paper presents several current and projected uses of blockchain technology in the health care industry. We predicted which of these applications are likely to be adopted quickly and provided a supply chain example of tracking the transportation of organs for transplantation. %M 32940618 %R 10.2196/17423 %U https://www.jmir.org/2020/9/e17423 %U https://doi.org/10.2196/17423 %U http://www.ncbi.nlm.nih.gov/pubmed/32940618 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21685 %T A New Era of Epidemiology: Digital Epidemiology for Investigating the COVID-19 Outbreak in China %A He,Zonglin %A Zhang,Casper J P %A Huang,Jian %A Zhai,Jingyan %A Zhou,Shuang %A Chiu,Joyce Wai-Ting %A Sheng,Jie %A Tsang,Winghei %A Akinwunmi,Babatunde O %A Ming,Wai-Kit %+ Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, 601 Huangpu W Ave, Guangzhou, , China, 86 14715485116, wkming@connect.hku.hk %K digital epidemiology %K COVID-19 %K risk %K control %K public health %K epidemiology %K China %K outbreak %K case study %D 2020 %7 17.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X A novel pneumonia-like coronavirus disease (COVID-19) caused by a novel coronavirus named SARS-CoV-2 has swept across China and the world. Public health measures that were effective in previous infection outbreaks (eg, wearing a face mask, quarantining) were implemented in this outbreak. Available multidimensional social network data that take advantage of the recent rapid development of information and communication technologies allow for an exploration of disease spread and control via a modernized epidemiological approach. By using spatiotemporal data and real-time information, we can provide more accurate estimates of disease spread patterns related to human activities and enable more efficient responses to the outbreak. Two real cases during the COVID-19 outbreak demonstrated the application of emerging technologies and digital data in monitoring human movements related to disease spread. Although the ethical issues related to using digital epidemiology are still under debate, the cases reported in this article may enable the identification of more effective public health measures, as well as future applications of such digitally directed epidemiological approaches in controlling infectious disease outbreaks, which offer an alternative and modern outlook on addressing the long-standing challenges in population health. %M 32805703 %R 10.2196/21685 %U https://www.jmir.org/2020/9/e21685 %U https://doi.org/10.2196/21685 %U http://www.ncbi.nlm.nih.gov/pubmed/32805703 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e23692 %T Cybersecurity Risks in a Pandemic %A Williams,Christina Meilee %A Chaturvedi,Rahul %A Chakravarthy,Krishnan %+ School of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, United States, 1 6096512690, rchaturv@health.ucsd.edu %K cybersecurity %K pandemic %K COVID-19 %K SARS-CoV-2 %K risk %K privacy %K hack %K patient data %D 2020 %7 17.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X Cybersecurity threats are estimated to cost the world US $6 trillion a year by 2021, and the number of attacks has increased five-fold after COVID-19. Although there is substantial literature on the threats technological vulnerabilities have on the health care industry, less research exists on how pandemics like COVID-19 are opportunistic for cybercriminals. This paper outlines why cyberattacks have been particularly problematic during COVID-19 and ways that health care industries can better protect patient data. The Office for Civil Rights has loosened enforcement of the Health Insurance Portability and Accountability Act, which, although useful in using new platforms like Zoom, has also loosened physical and technical safeguards to cyberattacks. This is especially problematic given that 90% of health care providers had already encountered data breaches. Companies must implement well-defined software upgrade procedures, should use secure networks like virtual local area networks, and conduct regular penetration tests of their systems. By understanding factors that make individuals, health care organizations, and employers more susceptible to cyberattacks, we can better prepare for the next pandemic. %M 32897869 %R 10.2196/23692 %U http://www.jmir.org/2020/9/e23692/ %U https://doi.org/10.2196/23692 %U http://www.ncbi.nlm.nih.gov/pubmed/32897869 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19217 %T Leveraging Interdisciplinary Teams to Develop and Implement Secure Websites for Behavioral Research: Applied Tutorial %A Martin,Christie L %A Kramer-Kostecka,Eydie N %A Linde,Jennifer A %A Friend,Sarah %A Zuroski,Vanessa R %A Fulkerson,Jayne A %+ School of Nursing, University of Minnesota, 5-140 Weaver-Densford Hall, 308 Harvard Street SE, Minneapolis, MN, 55455, United States, 1 612 624 9600, mart1026@umn.edu %K research ethics and compliance %K website development %K behavioral research %K digital interventions %K website authentication %K website security %D 2020 %7 23.9.2020 %9 Tutorial %J J Med Internet Res %G English %X Behavioral researchers are increasingly using interactive digital platforms, either as standalone or supplementary intervention tools, to facilitate positive changes in research participants’ health habits. Research-oriented interactive websites optimally offer a variety of participatory mediums, such as blogs, user-driven content, or health activities. Owing to the multidirectional features of interactive websites, and a corresponding need to protect research participants’ identity and data, it is paramount that researchers design ethical platforms that ensure privacy and minimize loss of anonymity and confidentiality. Authentication (ie, digital verification of one’s identity) of interactive sites is one viable solution to these concerns. Although previous publications have addressed ethical requirements related to authenticated platforms, few applied guidelines in the literature facilitate adherence to ethical principles and legally compliant study protocols during all phases of research website creation (feasibility, design, implementation, and maintenance). Notably, to remain compliant with ethical standards and study protocols, behavioral researchers must collaborate with interdisciplinary teams to ensure that the authenticated site remains secure and usable in all stages of the project. In this tutorial, we present a case study conducted at a large research university. Through iterative and practical recommendations, we detail lessons learned from collaborations with the Institutional Review Board, legal experts, and information technology teams. Although the intricacies of our applied tutorial may require adaptations based on each institution’s technological capacity, we are confident that the core takeaways are universal and thus useful to behavioral researchers creating ethically responsible and compliant interactive websites. %M 32965234 %R 10.2196/19217 %U http://www.jmir.org/2020/9/e19217/ %U https://doi.org/10.2196/19217 %U http://www.ncbi.nlm.nih.gov/pubmed/32965234 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17285 %T Engagement With Motivational Interviewing and Cognitive Behavioral Therapy Components of a Web-Based Alcohol Intervention, Elicitation of Change Talk and Sustain Talk, and Impact on Drinking Outcomes: Secondary Data Analysis %A Mujcic,Ajla %A Linke,Stuart %A Hamilton,Fiona %A Phillips,Alexandria %A Khadjesari,Zarnie %+ Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Burgemeester Oudlaan 50, Rotterdam, Netherlands, 31 030 29 59 256, amujcic@trimbos.nl %K eHealth %K digital health %K self-management %K alcohol use %K motivational interviewing %K cognitive behavioural therapy %K engagement %D 2020 %7 1.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Down Your Drink (DYD) is a widely used unguided web-based alcohol moderation program for the general public based on cognitive behavioral therapy (CBT) and motivational interviewing (MI); it provides users with many opportunities to enter free-text responses. Objective: The aim of this study was to assess participants’ use of key CBT and MI components, the presence of change talk and sustain talk within their responses, and whether these data are associated with drinking outcomes after 3 months. Methods: An exploratory secondary data analysis was conducted on data collected in 2008 from the definitive randomized trial of DYD (N=503). Past week alcohol use at baseline and 3-month follow-up were measured with the TOT-AL. Covariates included baseline alcohol use, age, gender, education level, and word count of the responses. Use of MI and CBT components and presence of change talk and sustain talk were coded by two independent coders (Cohen κ range 0.91-1). Linear model regressions on the subsample of active users (n=410) are presented along with a negative binomial regression. Results: The most commonly used component was the listing of pros and cons of drinking. The number of listed high-risk situations was associated with lower alcohol use at 3-month follow-up (Badj −2.15, 95% CI −3.92 to −0.38, P=.02). Findings on the effects of the percentage of change talk and the number of listed strategies to deal with high-risk situations were inconsistent. Conclusions: An unguided web-based alcohol moderation program can elicit change talk and sustain talk. This secondary analysis suggests that the number of listed high-risk situations can predict alcohol use at 3-month follow-up. Other components show inconsistent findings and should be studied further. %M 32870162 %R 10.2196/17285 %U https://www.jmir.org/2020/9/e17285 %U https://doi.org/10.2196/17285 %U http://www.ncbi.nlm.nih.gov/pubmed/32870162 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e16450 %T User Experience and Effects of an Individually Tailored Transdiagnostic Internet-Based and Mobile-Supported Intervention for Anxiety Disorders: Mixed-Methods Study %A Weisel,Kiona K %A Zarski,Anna-Carlotta %A Berger,Thomas %A Krieger,Tobias %A Moser,Christian T %A Schaub,Michael P %A Görlich,Dennis %A Berking,Matthias %A Ebert,David D %+ Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Nägelsbachstraße 25a, Erlangen, Germany, 49 (0)9131 ext 8567570, kiona.weisel@fau.de %K transdiagnostic %K anxiety %K depression %K tailored %K internet intervention %D 2020 %7 16.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet interventions have been shown to be effective in treating anxiety disorders. Most interventions to date focus on single disorders and disregard potential comorbidities. Objective: The aim of this mixed-methods study was to investigate feasibility, user experience, and effects of a newly developed individually tailored transdiagnostic guided internet intervention for anxiety disorders. Methods: This study is an uncontrolled, within-group, baseline, postintervention pilot trial with an embedded qualitative and quantitative process and effect evaluation. In total, 49 adults with anxiety disorders (generalized anxiety disorder n=20, social phobia n=19, agoraphobia without panic n=12, panic with agoraphobia n=6, panic without agoraphobia n=4, subclinical depression n=41) received access to the 7-session intervention. We examined motivation and expectations, intervention use, user experience, impact, and modification requests. Qualitative data were assessed using semistructured interviews and analyzed by qualitative content analysis. Quantitative outcomes included symptom severity of anxiety and depression (Hamilton Anxiety Rating Scale [HAM-A], Quick Item Inventory of Depressive Symptomatology clinician rating [QIDS-C]), diagnostic status in clinical interviews (Mini International Neuropsychiatric Interview [MINI]), and web-based self-reports (Generalized Anxiety Disorder–7 [GAD-7], Center for Epidemiological Studies Depression Scale [CES-D], Beck Anxiety Inventory [BAI], Panic and Agoraphobia Scale [PAS], Social Phobia Scale [SPS], Patient Health Questionnaire–9 [PHQ-9]) at baseline and postassessment. Quantitative data was analyzed by comparing within-group means expressed as Cohen d. Results: Anxiety symptom severity (HAM-A d=1.19) and depressive symptoms (QIDS-C d=0.42) improved significantly, and 54% (21/39) no longer were diagnosed as having any anxiety disorder. The main positive effects were the general improvement of disease burden and attentiveness to feelings and risk situations while the main negative effects experienced were lack of change in disease burden and symptom deterioration. The most prevalent reasons for participation were the advantages of online treatment, symptom burden, and openness toward online treatment. Helpful factors included support, psychoeducation and practicing strategies in daily life; the main hindering factors were too little individualization and being overwhelmed by the content and pace. Conclusions: The intervention was found to be feasible and results show preliminary data indicating potential efficacy for improving anxiety and depression. The next step should be the evaluation within a randomized controlled trial. Concerning intervention development, it was found that future interventions should emphasize individualization even more in order to further improve the fit to individual characteristics, preferences, and needs. %M 32936085 %R 10.2196/16450 %U http://www.jmir.org/2020/9/e16450/ %U https://doi.org/10.2196/16450 %U http://www.ncbi.nlm.nih.gov/pubmed/32936085 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19066 %T Designing a Web-Based Psychological Intervention for Patients With Myocardial Infarction With Nonobstructive Coronary Arteries: User-Centered Design Approach %A Humphries,Sophia Monica %A Rondung,Elisabet %A Norlund,Fredrika %A Sundin,Örjan %A Tornvall,Per %A Held,Claes %A Spaak,Jonas %A Lyngå,Patrik %A Olsson,Erik M G %+ Department of Women's and Children's Health, Uppsala University, Akademiska Hospital, Uppsala, 75185, Sweden, 46 760341186, sophia.humphries@kbh.uu.se %K web-based intervention %K iCBT %K myocardial infarction %K nonobstructive coronary arteries %K patient involvement %K psychological treatment %K MINOCA %K takotsubo cardiomyopathy %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The involvement of patient research partners (PRPs) in research aims to safeguard the needs of patient groups and produce new interventions that are developed based on patient input. Myocardial infarction with nonobstructive coronary arteries (MINOCA), unlike acute myocardial infarction (MI) with obstructive coronary arteries, is presented with no significant obstructive coronary artery disease. Patients with this diagnosis are a subset of those diagnosed with traditional MI and often need more psychological support, something that is presently not established in the current treatment scheme in Swedish health care or elsewhere, to our knowledge. An internet-delivered intervention might offer patients with MINOCA the opportunity to access a psychological treatment that is tailored to their specific needs after MINOCA and could therefore supplement the existing medical care in an easily accessible format. Objective: This paper aims to describe the development of a therapist-guided, internet-delivered psychological intervention designed specifically for patients with MINOCA. Methods: The study used a participatory design that involved 7 PRPs diagnosed with MINOCA who collaborated with a team consisting of researchers, cardiologists, and psychologists. Intervention content was developed iteratively and presented to the PRPs across several prototypes, each continually adjusted and redesigned according to the feedback received. The intervention and experience of it were discussed by PRPs in a final meeting and then presented to a panel of 2 clinical psychologists and a cardiologist for further input. Results: The outcome of the collaboration between PRPs and the research group produced a web-based psychological 9-step program focusing on stress, worry, and valued action. The input from PRPs contributed substantially to the therapy content, homework tasks, interactive activities, multimedia, and design presentation. Conclusions: Working with PRPs to develop an intervention for people with MINOCA produced a web-based intervention that can be further evaluated with the goal of offering a new psychological treatment option to a patient group currently without one. Direct contribution from PRPs enabled us to obtain relevant, insightful, and valuable feedback that was put towards the overall design and content of the intervention. %M 32940615 %R 10.2196/19066 %U http://www.jmir.org/2020/9/e19066/ %U https://doi.org/10.2196/19066 %U http://www.ncbi.nlm.nih.gov/pubmed/32940615 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18038 %T Factors Affecting the Implementation of Electronic Antiretroviral Therapy Adherence Monitoring and Associated Interventions for Routine HIV Care in Uganda: Qualitative Study %A Haberer,Jessica E %A Garrison,Lindsey %A Tumuhairwe,John Bosco %A Baijuka,Robert %A Tindimwebwa,Edna %A Tinkamanyire,James %A Burns,Bridget F %A Asiimwe,Stephen %+ Center for Global Health, Massachusetts General Hospital, 125 Nashua St, Suite 722, Boston, MA, United States, 1 617 724 0351, jhaberer@partners.org %K adherence %K antiretroviral therapy %K electronic monitoring %K implementation science %D 2020 %7 10.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: High, sustained adherence to HIV antiretroviral therapy (ART) is critical for achieving viral suppression, which in turn leads to important individual health benefits and reduced secondary viral transmission. Electronic adherence monitors record a date-and-time stamp with each opening as a proxy for pill-taking behavior. These monitors can be combined with interventions (eg, data-informed adherence counseling, SMS-based adherence support, and/or alarms) and have been shown to improve adherence in multiple settings. Their use, however, has largely been limited to the research context. Objective: The goal of the research was to use the Consolidated Framework for Implementation Research (CFIR) to understand factors relevant for implementing a low-cost electronic adherence monitor and associated interventions for routine HIV clinical care in Uganda. Methods: We conducted in-depth qualitative interviews with health care administrators, clinicians, and ART clients about likes and dislikes of the features and functions of electronic adherence monitors and associated interventions, their potential to influence HIV care, suggestions on how to measure their value, and recommendations for their use in routine care. We used an inductive, content analysis approach to understand participant perspectives, identifying aspects of CFIR most relevant to technology implementation in this setting. Results: We interviewed 34 health care administrators/clinicians and 15 ART clients. Participants largely saw the monitors and associated interventions as favorable and beneficial for supporting adherence and improving clinical outcomes through efficient, differentiated care. Relevant outside factors included structural determinants of health, international norms around supporting adherence, and limited funding that necessitates careful assessment of costs and benefits. Within the clinic, the adherence data were felt likely to improve the quality of counseling and thereby morale, as well as increase the efficiency of care delivery. Existing infrastructure and care expenditures and the need for proper training were other noted considerations. At the individual level, the desire for good health and a welcomed pressure to adhere favored uptake of the monitors, although some participants were concerned with clients not using the monitors as planned and the influence of poverty, stigma, and need for privacy. Finally, participants felt that decisions around the implementation process would have to come from the Ministry of Health and other funders and would be influenced by sustainability of the technology and the target population for its use. Coordination across the health care system would be important for implementation. Conclusions: Low-cost electronic adherence monitoring combined with data-informed counseling, SMS-based support, and/or alarms have potential for use in routine HIV care in Uganda. Key metrics of successful implementation will include their impact on efficiency of care delivery and clinical outcomes with careful attention paid to factors such as stigma and cost. Further theory-driven implementation science efforts will be needed to move promising technology from research into clinical care. Trial Registration: ClinicalTrials.gov NCT03825952; https://clinicaltrials.gov/ct2/show/NCT03825952 %M 32687473 %R 10.2196/18038 %U http://www.jmir.org/2020/9/e18038/ %U https://doi.org/10.2196/18038 %U http://www.ncbi.nlm.nih.gov/pubmed/32687473 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e11543 %T Motivation Predicts Change in Nurses’ Physical Activity Levels During a Web-Based Worksite Intervention: Results From a Randomized Trial %A Brunet,Jennifer %A Tulloch,Heather E %A Wolfe Phillips,Emily %A Reid,Robert D %A Pipe,Andrew L %A Reed,Jennifer L %+ Faculty of Health Sciences, University of Ottawa, Montpetit Hall 339, 125 University Private, Ottawa, ON, K1N 6N5, Canada, 1 613 562 5800 ext 3068, jennifer.brunet@uottawa.ca %K physical activity %K motivation %K wearable technology %K nurses %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Low physical activity levels can negatively affect the health of nurses. Given the low physical activity levels reported by nurses, there is a clear need for brief and economical interventions designed to increase physical activity levels in this population. We developed a web-based intervention that used motivational strategies to increase nurses’ physical activity levels. The intervention provided the nurses with feedback from an activity monitor coupled with a web-based individual, friend, or team physical activity challenge. Objective: In this parallel-group randomized trial, we examine whether nurses’ motivation at baseline predicted changes in objectively measured physical activity levels during the 6-week intervention. Methods: The participants were 76 nurses (n=74, 97% female; mean age 46, SD 11 years) randomly assigned to 1 of 3 physical activity challenge conditions: (1) individual, (2) friend, or (3) team. The nurses completed a web-based questionnaire designed to assess motivational regulations for physical activity levels before the intervention and wore a Tractivity activity monitor before and during the 6-week intervention. We analyzed data using multilevel modeling for repeated measures. Results: The nurses’ physical activity levels increased (linear estimate=10.30, SE 3.15; P=.001), but the rate of change decreased over time (quadratic estimate=−2.06, SE 0.52; P<.001). External and identified regulations (ß=−2.08 to 11.55; P=.02 to .04), but not intrinsic and introjected regulations (ß=−.91 to 6.29; P=.06 to .36), predicted changes in the nurses’ physical activity levels. Conclusions: Our findings provide evidence that an intervention that incorporates self-monitoring and physical activity challenges can be generally effective in increasing nurses’ physical activity levels in the short term. They also suggest that drawing solely on organismic integration theory to predict changes in physical activity levels among the nurses participating in web-based worksite interventions may have been insufficient. Future research should examine additional personal (eg, self-efficacy) and occupational factors (eg, shift length and shift type) that influence physical activity levels to identify potential targets for intervention among nurses. Trial Registration: ClinicalTrials.gov NCT04524572; https://clinicaltrials.gov/ct2/show/NCT04524572 %M 32915158 %R 10.2196/11543 %U http://www.jmir.org/2020/9/e11543/ %U https://doi.org/10.2196/11543 %U http://www.ncbi.nlm.nih.gov/pubmed/32915158 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19256 %T Digital Health Tools and Patients With Drug Use Disorders: Qualitative Patient Experience Study of the Electronic Case-Finding and Help Assessment Tool (eCHAT) %A Choy,Melinda Ada %A Sturgiss,Elizabeth %A Goodyear-Smith,Felicity %A Smith,Gavin JD %+ Academic Unit of General Practice, College of Health and Medicine, The Australian National University, Building 4, Level 2, The Canberra Hospital, Garran, 2605, Australia, 61 5124 5592, melinda.choy@anu.edu.au %K eCHAT %K eHealth %K mHealth %K digital health %K drug use disorders %K patient experience %K stigma %K patient experience %K family medicine %K general practice %D 2020 %7 14.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: One of the promises of digital health is to better engage patients and improve care for vulnerable populations. Patients with drug use disorders are a vulnerable population who often do not receive the care they need, both for their drug use disorders as well as their other health care needs. Appropriate primary care for patients with drug use disorders needs to be patient-centered, holistic, highly accessible, and engaging. The electronic Case-finding and Help Assessment Tool (eCHAT) was designed as a patient-centered tool for the identification and measurement of problematic health behaviors and mood states. Objective: The aim of this study was to explore the patient experience of eCHAT at an Australian family medicine clinic for patients with drug use disorders. Methods: A total of 12 semistructured interviews were conducted with patients, two interviews were conducted with doctors, and one focus group was conducted with patient advocates who were former patients of the clinic where the study took place. The transcripts were analyzed using inductive thematic analysis. Results: The key themes identified from the interviews and the focus group were as follows: (1) eCHAT helped reduce stigma related to drug use in the doctor-patient consultation, (2) restricted answer options impacted the ability of patients to tell their stories, (3) patient-related response factors, (4) increased efficiency in the consultation process, and (5) divergence in level of concern around security and privacy. Conclusions: eCHAT has the potential to help vulnerable patients in primary care to engage more with their doctors and reduce experiences of stigma. eCHAT may be a useful digital health intervention in a family medicine clinic for patients with drug use disorders. It has the potential to improve patient engagement and access to health care, which are crucial areas of need in this vulnerable population. However, it is important to clearly communicate the privacy risk of digital health tools and to implement eCHAT such that it will add value to, rather than displace, in-person consultations with the family doctor. %M 32924959 %R 10.2196/19256 %U http://www.jmir.org/2020/9/e19256/ %U https://doi.org/10.2196/19256 %U http://www.ncbi.nlm.nih.gov/pubmed/32924959 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18037 %T Sun Safe Partners Online: Pilot Randomized Controlled Clinical Trial %A Manne,Sharon %A Buller,David %A Devine,Katie %A Heckman,Carolyn %A Pagoto,Sherry %A Frederick,Sara %A Mitarotondo,Anna %+ Rutgers Cancer Institute of New Jersey, CINJ, 195 Little Albany Street, New Brunswick, NJ, 08903, United States, 1 732 235 9780, mannesl@cinj.rutgers.edu %K sun protection %K behavior intervention %K online interventions %K couples %K skin cancer prevention %K mobile phone %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Harnessing supportive influences in close relationships is an innovative and potentially effective strategy to improve sun protection behaviors. Objective: This pilot randomized controlled clinical trial evaluates the feasibility and impact of Sun Safe Partners Online, a web-based, couples-focused intervention to improve sun protection behavior. Methods: A total of 75 couples reporting suboptimal levels of sun protection recruited from Facebook advertisements were randomized to receive a web-based intervention called Sun Safe Partners Online or a Generic Online Sun Safety Information intervention. Sun Safe Partners Online had 4 individual-focused modules and 4 couples-focused modules. Feasibility was assessed by study enrollment, engagement, follow-up survey completion, and intervention evaluation. Participants completed baseline and a 1-month postintervention survey assessing sun protection and exposure, along with individual and relationship attitudes about the importance of sun protection. Results: Using Facebook as a recruitment strategy resulted in rapid enrollment and higher acceptance than for the prior telephone and print trial. The follow-up survey completion was higher in the Generic Online condition (100%) than in the Sun Safe Partners Online condition (87.2%). Engagement in Sun Safe Partners Online was high, with more than two-thirds of participants completing all modules. Evaluations of Sun Safe Partners Online content and features as well as ease of navigation were excellent. Sun Safe Partners Online showed small effects on sun protection behaviors and sun exposure on weekends compared with the Generic Online intervention and moderate effect size increases in the Sun Safe Partners Online condition. Conclusions: This study uses a novel approach to facilitate engagement in sun protection by harnessing the influence of relationships among spouses and cohabiting partners. A couples-focused intervention may hold promise as a means to improve sun protection behaviors beyond interventions focused solely on individuals by leveraging the concern, collaboration, and support among intimate partners and addressing relationship-based barriers to sun protection. Trial Registration: ClinicalTrials.gov NCT04549675; https://clinicaltrials.gov/ct2/show/NCT04549675 %M 32673215 %R 10.2196/18037 %U https://www.jmir.org/2020/9/e18037 %U https://doi.org/10.2196/18037 %U http://www.ncbi.nlm.nih.gov/pubmed/32673215 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17927 %T Effectiveness of a Web-Based SUpport PRogram (SUPR) for Hearing Aid Users Aged 50+: Two-Arm, Cluster Randomized Controlled Trial %A Meijerink,Janine FJ %A Pronk,Marieke %A Lissenberg-Witte,Birgit I %A Jansen,Vera %A Kramer,Sophia E %+ Otolaryngology—Head and Neck Surgery, Ear and Hearing, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, Netherlands, 1 +31 020 444 905, m.pronk@amsterdamumc.nl %K hearing loss %K hearing aids %K auditory rehabilitation %K self-management %K communication programs %K internet %K hearing aid dispensing practice %K randomized controlled trial %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Hearing aid (HA) use is known to improve health outcomes for people with hearing loss. Despite that, HA use is suboptimal, and communication issues and hearing-related activity limitations and participation restrictions often remain. Web-based self-management communication programs may support people with hearing loss to effectively self-manage the impact of hearing loss in their daily lives. Objective: The goal of the research is to examine the short- and long-term effects of a web-based self-management SUpport PRogram (SUPR) on communication strategy use (primary outcome) and a range of secondary outcomes for HA users aged 50 years and older. Methods: Clients of 36 HA dispensing practices were randomized to SUPR (SUPR recipients; n=180 HA users) and 34 to care as usual (controls; n=163 HA users). SUPR recipients received a practical support booklet and online materials delivered via email over the course of their 6-month HA rehabilitation trajectory. They were encouraged to appoint a communication partner and were offered optional email contact with the HA dispensing practice. The online materials included 3 instruction videos on HA handling, 5 videos on communication strategies, and 3 testimonial videos. Care as usual included a HA fitting rehabilitation trajectory only. Measurements were carried out at baseline, immediately postintervention, 6 months postintervention, and 12 months postintervention. The primary outcome measure was self-reported use of communication strategies (3 subscales of the Communication Profile for the Hearing Impaired [CPHI]). Secondary outcome measures included self-reported personal adjustment to hearing loss (CPHI); use, satisfaction and benefit of HAs and SUPR (use questionnaire; International Outcome Inventory for Hearing Aids [IOI-HA], Alternative Interventions [IOI-AI]); recommendation of HA dispensing services; self-efficacy for HA handling (Measure of Audiologic Rehabilitation Self-Efficacy for Hearing Aids [MARS-HA]); readiness to act on hearing loss (University of Rhode Island Change Assessment adapted for hearing loss [URICA-HL]); and hearing disability (Amsterdam Inventory for Auditory Disability and Handicap [AIADH]). Results: Linear mixed model analyses (intention to treat) showed no significant differences between the SUPR and control group in the course of communication strategy use (CPHI). Immediately postintervention, SUPR recipients showed significantly higher self-efficacy for advanced HA handling than the controls, which was sustained at 12 months (MARS-HA; mean difference immediately postintervention: 5.3, 95% CI 0.3 to 10.4; P=.04). Also, SUPR recipients showed significantly greater HA satisfaction than controls immediately postintervention (IOI-HA; 0.3, 95% CI 0.09 to 0.5; P=.006), which was sustained at 12 months, and significantly greater HA use than the controls immediately postintervention (IOI-HA; 0.3, 95% CI 0.02 to 0.5; P=.03), which was not sustained at 12 months. Conclusions: This study provides ground to recommend adding SUPR to standard HA dispensing care, as long-term, modest improvements in HA outcomes were observed. Further research is needed to evaluate what adjustments to SUPR are needed to establish long-term effectiveness on outcomes in the psychosocial domain. Trial Registration: ISRCTN77340339; http://www.isrctn.com/ISRCTN77340339 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2016-015012 %M 32960175 %R 10.2196/17927 %U http://www.jmir.org/2020/9/e17927/ %U https://doi.org/10.2196/17927 %U http://www.ncbi.nlm.nih.gov/pubmed/32960175 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18519 %T Understanding the Steps Toward Mobile Early Intervention for Mothers and Their Infants Exiting the Neonatal Intensive Care Unit: Descriptive Examination %A Baggett,Kathleen M %A Davis,Betsy %A Landry,Susan H %A Feil,Edward G %A Whaley,Anna %A Schnitz,Alana %A Leve,Craig %+ Mark Chaffin Center for Healthy Development, School of Public Health, Georgia State Universtiy, 14th Marietta Street NW, Suite 100&200, GA 30303, Atlanta, GA, 30303, United States, 1 4044131571, kbaggett@gsu.edu %K early intervention %K equity %K NICU %K low birthweight %K transition %K mobile internet intervention %K infants %K mothers %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Neonatal intensive care unit (NICU) history, combined with systemic inequities for mothers of nondominant cultures and mothers who are socioeconomically disadvantaged, places infants at an extraordinary risk for poor developmental outcomes throughout life. Although receipt of early intervention (EI) is the best single predictor of developmental outcomes among children with and at risk for early developmental delays, mothers and infants with the greatest needs are least likely to receive EI. Mobile internet-based interventions afford substantial advantages for overcoming logistical challenges that often prevent mothers who are economically disadvantaged from accessing EI. However, the bridge from the NICU to a mobile internet intervention has been virtually unexplored. Objective: This study aims to examine progression flow from NICU exit referral to an early mobile internet intervention to increase EI access and promote parent mediation of infant social-emotional and communication development. Methods: Three NICUs serving the urban poor in a Midwestern city were provided support in establishing an electronic NICU exit referral mechanism into a randomized controlled trial of a mobile internet intervention for mothers and their infants. Measurement domains to reflect the bridge to service included each crucial gateway required for navigating the path into Part C EI, including referral, screening, assessment, and intervention access. An iterative process was used and documented to facilitate each NICU in establishing an individualized accountability plan for sharing referral materials with mothers before their NICU exit. Subsequent to the referral, progression flow was documented on the basis of a real-time electronic recording of service receipt and contact records. Mother and infant risk characteristics were also assessed. Descriptive analyses were conducted to summarize and characterize each measurement domain. Results: NICU referral rates for EI were 3 to 4 times higher for open-shared versus closed-single gatekeeper referral processes. Of 86 referred dyads, 67 (78%) were screened, and of those screened, 51 (76%) were eligible for assessment. Of the 51 assessment-eligible mothers and infants, 35 dyads (69%) completed the assessment and 31 (89%) went on to complete at least one remote coaching intervention session. The dyads who accessed and engaged in intervention were racially and ethnically diverse and experiencing substantial adversity. Conclusions: The transition from the NICU to home was fraught with missed opportunities for an EI referral. Beyond the referral, the most prominent reason for not participating in screening was that mothers could not be located after exiting the NICU. Stronger NICU referral mechanisms for EI are needed. It may be essential to initiate mobile interventions before exiting the NICU for maintaining post-NICU contact with some mothers. In contrast to a closed, single point of referral gatekeeper systems in NICUs, open, shared referral gating systems may be less stymied by individual service provider biases and disruptions. %M 32960178 %R 10.2196/18519 %U http://www.jmir.org/2020/9/e18519/ %U https://doi.org/10.2196/18519 %U http://www.ncbi.nlm.nih.gov/pubmed/32960178 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17880 %T Exploring Participants’ Experiences of a Web-Based Program for Bulimia and Binge Eating Disorder: Qualitative Study %A Yim,See Heng %A Bailey,Emma %A Gordon,Gemma %A Grant,Nina %A Musiat,Peter %A Schmidt,Ulrike %+ King's College London, Institute of Psychiatry, Psychology and Neuroscience , PO Box 59, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 2078480160, see.yim@hmc.ox.ac.uk %K eHealth %K self-help %K eating disorders %K bulimia %K binge eating disorder %K internet-based intervention %K qualitative research %D 2020 %7 23.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Guided cognitive behavioral self-help is a recommended first-line treatment for eating disorders (EDs) such as bulimia nervosa (BN) or binge eating disorder (BED). Online versions of such self-help programs are increasingly being studied in randomized controlled trials (RCTs), with some evidence that they can reduce ED symptoms, although intervention dropout is variable across interventions. However, in-depth research into participants’ experiences and views on the acceptability of web-based interventions is limited. Objective: This is a qualitative process study of participants’ experiences of everyBody Plus, a web-based cognitive behavioral intervention, integrated into a large RCT to aid the interpretation of the main trial’s results. To our knowledge, this is the first such study in digital intervention for EDs research to include real-time feedback into the qualitative analysis. This study aims to build upon the emerging literature by qualitatively exploring participants’ experiences of a web-based intervention for BN and BED. Methods: Participants were those who took part in the UK arm of a larger RCT investigating the efficacy of the everyBody Plus intervention. Reflexive thematic analysis was completed on 2 sources of data from the online platform: real-time feedback quotes provided at the end of completing a module on the platform (N=104) and semistructured telephone interview transcripts (n=12). Results: Four main themes were identified. The first theme identified positive and negative user experiences, with a desire for a more customized and personalized intervention. Another theme positively reflected on how flexible and easy the intervention was to embed into daily life, compared with the silo of face-to-face therapy. The third theme identified how the intervention had a holistic impact cognitively, emotionally, interpersonally, and behaviorally. The final theme was related to how the intervention was not a one size fits all and how the perceived usefulness and relevance were often dependent on participants’ demographic and clinical characteristics. Conclusions: Overall, participants reported positive experiences with the use of the everyBody Plus web-based intervention, including flexibility of use and the potential to holistically impact people’s lives. The participants also provided valuable suggestions for how similar future web-based interventions could be improved and, in the context of EDs, how programs can be designed to be more inclusive of people by encompassing different demographic and clinical characteristics. %M 32965235 %R 10.2196/17880 %U http://www.jmir.org/2020/9/e17880/ %U https://doi.org/10.2196/17880 %U http://www.ncbi.nlm.nih.gov/pubmed/32965235 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17906 %T Self-Practice of Stabilizing and Guided Imagery Techniques for Traumatized Refugees via Digital Audio Files: Qualitative Study %A Zehetmair,Catharina %A Nagy,Ede %A Leetz,Carla %A Cranz,Anna %A Kindermann,David %A Reddemann,Luise %A Nikendei,Christoph %+ Department of General Internal Medicine and Psychosomatics, Center for Psychosocial Medicine, University Hospital of Heidelberg, Thibautstraße 4, Heidelberg, 69115, Germany, 49 6221568373, Catharina.Zehetmair@med.uni-heidelberg.de %K stabilizing techniques %K guided imagery %K refugees %K qualitative analyses %K posttraumatic stress disorder %K mental health %K PTSD %K audio %K therapy %D 2020 %7 23.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Refugees have an increased risk of developing mental health problems. There are insufficient psychosocial care structures to meet the resulting need for support. Stabilizing and guided imagery techniques have shown promising results in increasing traumatized refugees’ emotional stabilization. If delivered via audio files, the techniques can be practiced autonomously and independent of time, space, and human resources or stable treatment settings. Objective: This study aimed to evaluate the self-practice of stabilizing and guided imagery techniques via digital audio files for traumatized refugees living in a reception and registration center in Germany. Methods: From May 2018 to February 2019, 42 traumatized refugees participated in our study. At T1, patients received digital audio files in English, French, Arabic, Farsi, Turkish, or Serbian for self-practice. Nine days later, at T2, a face-to-face interview was conducted. Two months after T2, a follow-up interview took place via telephone. Results: At T2, about half of the patients reported the daily practice of stabilizing and guided imagery techniques. At follow-up, the average frequency of practice was once weekly or more for those experiencing worse symptoms. No technical difficulties were reported. According to T2 and follow-up statements, the techniques helped the patients dealing with arousal, concentration, sleep, mood, thoughts, empowerment, and tension. The guided imagery technique “The Inner Safe Place” was the most popular. Self-practice was impeded by postmigratory distress factors, like overcrowded accommodations. Conclusions: The results show that self-practice of stabilizing and guided imagery techniques via digital audio files was helpful to and well accepted by the assessed refugees. Even though postmigratory distress factors hampered self-practice, “The Inner Safe Place” technique was particularly well received. Overall, the self-practiced audio-based stabilizing and guided imagery techniques showed promising results among the highly vulnerable group of newly arrived traumatized refugees. %M 32965229 %R 10.2196/17906 %U http://www.jmir.org/2020/9/e17906/ %U https://doi.org/10.2196/17906 %U http://www.ncbi.nlm.nih.gov/pubmed/32965229 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19431 %T An Internet-Based Intervention Augmented With a Diet and Physical Activity Consultation to Decrease the Risk of Dementia in At-Risk Adults in a Primary Care Setting: Pragmatic Randomized Controlled Trial %A Anstey,Kaarin J %A Cherbuin,Nicolas %A Kim,Sarang %A McMaster,Mitchell %A D'Este,Catherine %A Lautenschlager,Nicola %A Rebok,George %A McRae,Ian %A Torres,Susan J %A Cox,Kay L %A Pond,Constance Dimity %+ School of Psychology, University of New South Wales, Matthews Building, Kensington, Sydney, 2031, Australia, 61 412935746, k.anstey@unsw.edu.au %K risk reduction behavior %K dementia prevention & control %K primary prevention %K pragmatic clinical trial %K prevention %K primary care %D 2020 %7 24.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is a need to develop interventions to reduce the risk of dementia in the community by addressing lifestyle factors and chronic diseases over the adult life course. Objective: This study aims to evaluate a multidomain dementia risk reduction intervention, Body Brain Life in General Practice (BBL-GP), targeting at-risk adults in primary care. Methods: A pragmatic, parallel, three-arm randomized trial involving 125 adults aged 18 years or older (86/125, 68.8% female) with a BMI of ≥25 kg/m2 or a chronic health condition recruited from general practices was conducted. The arms included (1) BBL-GP, a web-based intervention augmented with an in-person diet and physical activity consultation; (2) a single clinician–led group, Lifestyle Modification Program (LMP); and (3) a web-based control. The primary outcome was the Australian National University Alzheimer Disease Risk Index Short Form (ANU-ADRI-SF). Results: Baseline assessments were conducted on 128 participants. A total of 125 participants were randomized to 3 groups (BBL-GP=42, LMP=41, and control=42). At immediate, week 18, week 36, and week 62 follow-ups, the completion rates were 43% (18/42), 57% (24/42), 48% (20/42), and 48% (20/42), respectively, for the BBL-GP group; 71% (29/41), 68% (28/41), 68% (28/41), and 51% (21/41), respectively, for the LMP group; and 62% (26/42), 69% (29/42), 60% (25/42), and 60% (25/42), respectively, for the control group. The primary outcome of the ANU-ADRI-SF score was lower for the BBL-GP group than the control group at all follow-ups. These comparisons were all significant at the 5% level for estimates adjusted for baseline differences (immediate: difference in means −3.86, 95% CI −6.81 to −0.90, P=.01; week 18: difference in means −4.05, 95% CI −6.81 to −1.28, P<.001; week 36: difference in means −4.99, 95% CI −8.04 to −1.94, P<.001; and week 62: difference in means −4.62, 95% CI −7.62 to −1.62, P<.001). Conclusions: A web-based multidomain dementia risk reduction program augmented with allied health consultations administered within the general practice context can reduce dementia risk exposure for at least 15 months. This study was limited by a small sample size, and replication on a larger sample with longer follow-up will strengthen the results. Trial Registration: Australian clinical trials registration number (ACTRN): 12616000868482; https://anzctr.org.au/ACTRN12616000868482.aspx. %M 32969833 %R 10.2196/19431 %U http://www.jmir.org/2020/9/e19431/ %U https://doi.org/10.2196/19431 %U http://www.ncbi.nlm.nih.gov/pubmed/32969833 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18233 %T Effectiveness of Human Versus Computer-Based Instructions for Exercise on Physical Activity–Related Health Competence in Patients with Hip Osteoarthritis: Randomized Noninferiority Crossover Trial %A Durst,Jennifer %A Roesel,Inka %A Sudeck,Gorden %A Sassenberg,Kai %A Krauss,Inga %+ Department of Sports Medicine, University Hospital, University of Tuebingen, Hoppe-Seyler-Str. 6, Tuebingen, 72076, Germany, 49 7071 2986486, inga.krauss@med.uni-tuebingen.de %K digital app %K exercise %K movement control %K self-efficacy %K control competence %K mHealth %K osteoarthritis %K tablet %D 2020 %7 28.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Hip and knee osteoarthritis is ranked as the 11th highest contributor to global disability. Exercise is a core treatment in osteoarthritis. The model for physical activity–related health competence describes possibilities to empower patients to perform physical exercises in the best possible health-promoting manner while taking into account their own physical condition. Face-to-face supervision is the gold standard for exercise guidance. Objective: The aim of this study was to evaluate whether instruction and guidance via a digital app is not inferior to supervision by a physiotherapist with regard to movement quality, control competence for physical training, and exercise-specific self-efficacy. Methods: Patients with clinically diagnosed hip osteoarthritis were recruited via print advertisements, emails and flyers. The intervention consisted of two identical training sessions with one exercise for mobility, two for strength, and one for balance. One session was guided by a physiotherapist and the other was guided by a fully automated tablet computer-based app. Both interventions took place at a university hospital. Outcomes were assessor-rated movement quality, and self-reported questionnaires on exercise-specific self-efficacy and control competence for physical training. Participants were randomly assigned to one of two treatment sequences. One sequence started with the app in the first session followed by the physiotherapist in the second session after a minimum washout phase of 27 days (AP group) and the other sequence occurred in the reverse order (PA group). Noninferiority was defined as a between-treatment effect (gIG)<0.2 in favor of the physiotherapist-guided training, including the upper confidence interval. Participants, assessors, and the statistician were neither blinded to the treatment nor to the treatment sequence. Results: A total of 54 participants started the first training session (32 women, 22 men; mean age 62.4, SD 8.2 years). The treatment sequence groups were similar in size (PA: n=26; AP: n=28). Seven subjects did not attend the second training session (PA: n=3; AP: n=4). The app was found to be inferior to the physiotherapist in all outcomes considered, except for movement quality of the mobility exercise (gIG –0.13, 95% CI –0.41-0.16). In contrast to the two strengthening exercises in different positions (supine gIG 0.76, 95% CI 0.39-1.13; table gIG 1.19, 95% CI 0.84-1.55), movement quality of the balance exercise was close to noninferiority (gIG 0.15, 95% CI –0.17-0.48). Exercise-specific self-efficacy showed a strong effect in favor of the physiotherapist (gIG 0.84, 95% CI 0.46-1.22). In terms of control competence for physical training, the app was only slightly inferior to the physiotherapist (gIG 0.18, 95% CI –0.14-0.50). Conclusions: Despite its inferiority in almost all measures of interest, exercise-specific self-efficacy and control competence for physical training did improve in patients who used the digital app. Movement quality was acceptable for exercises that are easy to conduct and instruct. The digital app opens up possibilities as a supplementary tool to support patients in independent home training for less complex exercises; however, it cannot replace a physiotherapist. Trial Registration: German Clinical Trial Register: DRKS00015759; http://www.drks.de/DRKS00015759 %M 32985991 %R 10.2196/18233 %U http://www.jmir.org/2020/9/e18233/ %U https://doi.org/10.2196/18233 %U http://www.ncbi.nlm.nih.gov/pubmed/32985991 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21749 %T Behavior Change Text Messages for Home Exercise Adherence in Knee Osteoarthritis: Randomized Trial %A Bennell,Kim %A Nelligan,Rachel K %A Schwartz,Sarah %A Kasza,Jessica %A Kimp,Alexander %A Crofts,Samuel JC %A Hinman,Rana S %+ Department of Physiotherapy, University of Melbourne, Centre for Health, Exercise and Sports Medicine, Level 7, Alan Gilbert Building, 161 Barry St, Carlton, 3053, Australia, 61 383444135, k.bennell@unimelb.edu.au %K knee osteoarthritis %K exercise %K patient compliance %K mobile phone %K randomized controlled trial %D 2020 %7 28.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Exercise is a core recommended treatment for knee osteoarthritis (OA), yet adherence declines, particularly following cessation of clinician supervision. Objective: This study aims to evaluate whether a 24-week SMS intervention improves adherence to unsupervised home exercise in people with knee OA and obesity compared with no SMS. Methods: A two-group superiority randomized controlled trial was performed in a community setting. Participants were people aged 50 years with knee OA and BMI ≥30 kg/m2 who had undertaken a 12-week physiotherapist-supervised exercise program as part of a preceding clinical trial. Both groups were asked to continue their home exercise program unsupervised three times per week for 24 weeks and were randomly allocated to a behavior change theory–informed, automated, semi-interactive SMS intervention addressing exercise barriers and facilitators or to control (no SMS). Primary outcomes were self-reported home exercise adherence at 24 weeks measured by the Exercise Adherence Rating Scale (EARS) Section B (0-24, higher number indicating greater adherence) and the number of days exercised in the past week (0-3). Secondary outcomes included self-rated adherence (numeric rating scale), knee pain, physical function, quality of life, global change, physical activity, self-efficacy, pain catastrophizing, and kinesiophobia. Results: A total of 110 participants (56 SMS group and 54 no SMS) were enrolled and 99 (90.0%) completed both primary outcomes (48/56, 86% SMS group and 51/54, 94% no SMS). At 24 weeks, the SMS group reported higher EARS scores (mean 16.5, SD 6.5 vs mean 13.3, SD 7.0; mean difference 3.1, 95% CI 0.8-5.5; P=.01) and more days exercised in the past week (mean 1.8, SD 1.2 vs mean 1.3, SD 1.2; mean difference 0.6, 95% CI 0.2-1.0; P=.01) than the control group. There was no evidence of between-group differences in secondary outcomes. Conclusions: An SMS program increased self-reported adherence to unsupervised home exercise in people with knee OA and obesity, although this did not translate into improved clinical outcomes. Trial Registration: Australian New Zealand Clinical Trials Registry 12617001243303; https://tinyurl.com/y2ud7on5 International Registered Report Identifier (IRRID): RR2-10.1186/s12891-019-2801-z %M 32985994 %R 10.2196/21749 %U http://www.jmir.org/2020/9/e21749/ %U https://doi.org/10.2196/21749 %U http://www.ncbi.nlm.nih.gov/pubmed/32985994 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19703 %T Promoting Safe Injection Practices, Substance Use Reduction, Hepatitis C Testing, and Overdose Prevention Among Syringe Service Program Clients Using a Computer-Tailored Intervention: Pilot Randomized Controlled Trial %A Hochstatter,Karli R %A Hull,Shawnika J %A Sethi,Ajay K %A Burns,Marguerite E %A Mundt,Marlon P %A Westergaard,Ryan P %+ Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY, 10027, United States, 1 2128512300, krh2151@columbia.edu %K hepatitis C virus %K intravenous drug abuse %K drug overdose %K harm reduction %K web-based intervention %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Syringe service programs (SSPs) are safe, highly effective programs for promoting health among people who inject drugs. However, resource limitations prevent the delivery of a full package of prevention services to many clients in need. Computer-tailored interventions may represent a promising approach for providing prevention information to people who inject drugs in resource-constrained settings. Objective: The aim of this paper is to assess the effect of a computer-tailored behavioral intervention, called Hep-Net, on safe injection practices, substance use reduction, overdose prevention, and hepatitis C virus (HCV) testing among SSP clients. Methods: Using a social network–based recruitment strategy, we recruited clients of an established SSP in Wisconsin and peers from their social networks. Participants completed a computerized baseline survey and were then randomly assigned to receive the Hep-Net intervention. Components of the intervention included an overall risk synthesis, participants’ selection of a behavioral goal, and an individualized risk reduction exercise. Individuals were followed up 3 months later to assess their behavior change. The effect of Hep-Net on receiving an HCV screening test, undergoing Narcan training, reducing the frequency of drug use, and sharing drug equipment was assessed. The individual’s readiness to change each behavior was also examined. Results: From 2014 to 2015, a total of 235 people who injected drugs enrolled into the Hep-Net study. Of these, 64.3% (151/235) completed the follow-up survey 3-6 months postenrollment. Compared with the control group, individuals who received the Hep-Net intervention were more likely to undergo HCV testing (odds ratio [OR] 2.23, 95% CI 1.05-4.74; P=.04) and receive Narcan training (OR 2.25, 95% CI 0.83-6.06; P=.11), and they shared drug equipment less frequently (OR 0.06, 95% CI 0.55-0.65; P<.001). Similarly, individuals who received the intervention were more likely to advance in their stage of readiness to change these 3 behaviors. However, intervention participants did not appear to reduce the frequency of drug use or increase their readiness to reduce drug use more than control participants, despite the fact that the majority of the intervention participants selected this as the primary goal to focus on after participation in the baseline survey. Conclusions: Implementing computer-based risk reduction interventions in SSPs may reduce harms associated with the sharing of injection equipment and prevent overdose deaths; however, brief computerized interventions may not be robust enough to overcome the challenges associated with reducing and ceasing drug use when implemented in settings centered on the delivery of prevention services. Trial Registration: ClinicalTrials.gov NCT02474043; https://clinicaltrials.gov/ct2/show/NCT02474043 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.4830 %M 32990630 %R 10.2196/19703 %U http://www.jmir.org/2020/9/e19703/ %U https://doi.org/10.2196/19703 %U http://www.ncbi.nlm.nih.gov/pubmed/32990630 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20283 %T Rates of Attrition and Dropout in App-Based Interventions for Chronic Disease: Systematic Review and Meta-Analysis %A Meyerowitz-Katz,Gideon %A Ravi,Sumathy %A Arnolda,Leonard %A Feng,Xiaoqi %A Maberly,Glen %A Astell-Burt,Thomas %+ Western Sydney Diabetes, Western Sydney Local Health District, Blacktown Road, Blacktown NSW, , Australia, 61 2 9881 8878, gideon.meyerowitzkatz@health.nsw.gov.au %K chronic disease %K mHealth %K mobile apps %K attrition %K dropout %D 2020 %7 29.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Chronic disease represents a large and growing burden to the health care system worldwide. One method of managing this burden is the use of app-based interventions; however attrition, defined as lack of patient use of the intervention, is an issue for these interventions. While many apps have been developed, there is some evidence that they have significant issues with sustained use, with up to 98% of people only using the app for a short time before dropping out and/or dropping use down to the point where the app is no longer effective at helping to manage disease. Objective: Our objectives are to systematically appraise and perform a meta-analysis on dropout rates in apps for chronic disease and to qualitatively synthesize possible reasons for these dropout rates that could be addressed in future interventions. Methods: MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, Cochrane CENTRAL (Central Register of Controlled Trials), and Embase were searched from 2003 to the present to look at mobile health (mHealth) and attrition or dropout. Studies, either randomized controlled trials (RCTs) or observational trials, looking at chronic disease with measures of dropout were included. Meta-analysis of attrition rates was conducted in Stata, version 15.1 (StataCorp LLC). Included studies were also qualitatively synthesized to examine reasons for dropout and avenues for future research. Results: Of 833 studies identified in the literature search, 17 were included in the review and meta-analysis. Out of 17 studies, 9 (53%) were RCTs and 8 (47%) were observational trials, with both types covering a range of chronic diseases. The pooled dropout rate was 43% (95% CI 29-57), with observational studies having a higher dropout rate (49%, 95% CI 27-70) than RCTs in more controlled scenarios, which only had a 40% dropout rate (95% CI 16-63). The studies were extremely varied, which is represented statistically in the high degree of heterogeneity (I2>99%). Qualitative synthesis revealed a range of reasons relating to attrition from app-based interventions, including social, demographic, and behavioral factors that could be addressed. Conclusions: Dropout rates in mHealth interventions are high, but possible areas to minimize attrition exist. Reducing dropout rates will make these apps more effective for disease management in the long term. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019128737; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128737 %M 32990635 %R 10.2196/20283 %U http://www.jmir.org/2020/9/e20283/ %U https://doi.org/10.2196/20283 %U http://www.ncbi.nlm.nih.gov/pubmed/32990635 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19378 %T Impact of a Blended Periconception Lifestyle Care Approach on Lifestyle Behaviors: Before-and-After Study %A van der Windt,Melissa %A van der Kleij,Rianne Maria %A Snoek,Katinka Marianne %A Willemsen,Sten Paul %A Dykgraaf,Ramon Henny Maria %A Laven,Joop Stephanus Elisabeth %A Schoenmakers,Sam %A Steegers-Theunissen,Régine Patricia Maria %+ Department of Obstetrics and Gynecology, Erasmus University Medical Center, PO Box 2040, Rotterdam, 3000CA, Netherlands, +31 107038255, r.steegers@erasmusmc.nl %K eHealth %K periconception period %K lifestyle intervention %D 2020 %7 30.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Periconception lifestyle behaviors affect maternal, paternal, offspring, and transgenerational health outcomes. Previous research in other target populations has shown that personalized lifestyle interventions, in which face-to-face counseling and eHealth (“blended care”) are combined, may effectively target these lifestyle behaviors. Objective: We aimed to assess the effectiveness of a periconceptional lifestyle intervention on the improvement of specific lifestyle components. Methods: A blended periconception lifestyle care approach was developed, combining the outpatient lifestyle counseling service “Healthy Pregnancy” with the eHealth platform “Smarter Pregnancy” (www.smarterpregnancy.co.uk) in which lifestyle was coached for 24 weeks. All couples contemplating pregnancy or already pregnant (≤12 weeks of gestation) who visited the outpatient clinics of the Department of Obstetrics and Gynecology at the Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands, between June and December 2018, were invited to participate. We measured changes in lifestyle behaviors at weeks 12 and 24 compared with baseline. Generalized estimating equations were used to analyze the changes in lifestyle behaviors over time. Subgroup analyses were performed for women with obesity (BMI ≥30 kg/m2), women pregnant at the start of the intervention, and those participating as a couple. Results: A total of 539 women were screened for eligibility, and 450 women and 61 men received the blended periconception intervention. Among the participating women, 58.4% (263/450) were included in the preconception period. Moreover, 78.9% (403/511) of the included participants completed the online lifestyle coaching. At baseline, at least one poor lifestyle behavior was present in most women (379/450, 84.2%) and men (58/61, 95.1%). In the total group, median fruit intake increased from 1.8 to 2.2 pieces/day (P<.001) and median vegetable intake increased from 151 to 165 grams/day (P<.001) after 24 weeks of online coaching. The probability of taking folic acid supplementation among women increased from 0.97 to 1 (P<.001), and the probability of consuming alcohol and using tobacco in the total group decreased from 0.25 to 0.19 (P=.002) and from 0.20 to 0.15 (P=.63), respectively. Overall, the program showed the strongest effectiveness for participating couples. Particularly for vegetable and fruit intake, their consumption increased from 158 grams/day and 1.8 pieces/day at baseline to 190 grams/day and 2.7 pieces/day at the end of the intervention, respectively. Conclusions: We succeeded in including most participating women in the preconception period. A high compliance rate was achieved and users demonstrated improvements in several lifestyle components. The blended periconception lifestyle care approach seems to be an effective method to improve lifestyle behaviors. The next step is to further disseminate this approach and to perform a randomized trial to compare the use of blended care with the provision of only eHealth. Additionally, the clinical relevance of these results will need to be substantiated further. %M 32996885 %R 10.2196/19378 %U http://www.jmir.org/2020/9/e19378/ %U https://doi.org/10.2196/19378 %U http://www.ncbi.nlm.nih.gov/pubmed/32996885 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18080 %T Intention to use Medical Apps Among Older Adults in the Netherlands: Cross-Sectional Study %A Askari,Marjan %A Klaver,Nicky Sabine %A van Gestel,Thimon Johannes %A van de Klundert,Joris %+ Erasmus School of Health Policy & Management, Erasmus University, PO Box 1738, Rotterdam, 3000 DR, Netherlands, 31 104088641, askari@eshpm.eur.nl %K Senior Technology Acceptance Model %K intention to use %K elderly %K older adults %K medical apps %K mHealth %K adoption %D 2020 %7 4.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The increasing health service demand driven by the aging of the global population calls for the development of modes of health service delivery that are less human resource–intensive. Electronic health (eHealth) and medical apps are expected to play an important role in this development. Although evidence shows mobile medical apps might be effective in improving the care, self-management, self-efficacy, health-related behavior, and medication adherence of older adults, little is known about older adults’ intention to use these technologies when needed, or the factors influencing this intention. Objective: The objective of this study was to investigate the relationship of technology acceptance factors and intention to use mobile medical apps among community-dwelling older adults. Methods: Data was collected using questionnaires. The factors selected from the literature have been validated using Cronbach α and tested for significance using logistic regressions. Results: Almost half (49.7%) of the included older adults reported no intention to use medical apps. Adjusted logistic regression analysis per factor showed that the factors Attitude toward use (odds ratio [OR] 8.50), Perceived usefulness (OR 5.25), Perceived ease of use (OR 4.22), Service availability (OR 3.46), Sense of control (OR 3.40), Self-perceived effectiveness (OR 2.69), Facilities (OR 2.45), Personal innovativeness (OR 2.08), Social relationships (OR 1.79), Subjective norm (OR 1.48), and Feelings of anxiety (OR 0.62) significantly influenced the intention to use mobile medical apps among older adults, whereas the factor Finance (OR 0.98) did not. When considered together, a controlled multivariate logistic regression yielded high explained variances of 0.542 (Cox-Snell R2) and 0.728 (Nagelkerke R2). Conclusions: The high odds ratios and explained variance indicate that the factors associated with the intention to use medical apps are largely understood and the most important factors have been identified. To advance the evidence base, experimental controlled research should investigate the causality between the factors, intention to use, and actual use. For this purpose, our evidence suggests that policies designed to improve Attitude toward use appear most effective, followed by policies addressing Perceived usefulness, Perceived ease of use, Service availability, and Sense of control. %M 32624465 %R 10.2196/18080 %U https://www.jmir.org/2020/9/e18080 %U https://doi.org/10.2196/18080 %U http://www.ncbi.nlm.nih.gov/pubmed/32624465 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17659 %T Exploring the Use of Mobile Health to Improve Community-Based Health and Nutrition Service Utilization in the Hills of Nepal: Qualitative Study %A Acharya,Ajay %A Cunningham,Kenda %A Manandhar,Shraddha %A Shrestha,Niva %A Chen,Mario %A Weissman,Amy %+ Asia Pacific Regional Office, Family Health International 360, 19th Floor, Tower 3, Sindhorn Building, 130-132 Wireless Road, Lumpini, Phatumwan, Bangkok, 10330, Thailand, 66 2 263 5200 ext 20226, aweissman@fhi360.org %K mobile health %K text messages %K SMS text message %K qualitative study %K Nepal %K health and nutrition services %K health mothers’ group %K female community health volunteers %K mobile phone %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: With mobile phone coverage and ownership expanding globally, mobile health (mHealth) interventions are increasingly being used to improve coverage and quality of health and nutrition services. However, evidence on mHealth intervention feasibility and factors to consider during program design is limited in low- and middle-income countries like Nepal. Objective: This study aimed to examine the potential of using text messages to improve health and nutrition services by exploring mobile phone ownership and sharing; mobile phone use and skills; and interest, preferences, and limitations regarding mHealth interventions. Methods: We conducted 35 in-depth interviews with 1000-day women (the period from conception to a child’s second birthday), health facility staff, and female community health volunteers (FCHVs), as well as eight focus group discussions with health facility staff, FCHVs, and 1000-day household decision-makers (ie, husbands, mothers-in-law, and fathers-in-law). We also conducted a mobile phone skills test. We employed thematic analysis using framework matrices and analytical memos. Results: The study included 70 study participants, of whom 68 (97%) had a mobile phone, and phone sharing was uncommon. Use of text messages was most commonly reported by 1000-day women and health facility staff than household decision-makers and FCHVs. More than 8 in 10 participants (54/64, 84%) could dial numbers, and the majority (28/34, 82%) of 1000-day women, health facility staff, and male decision-makers could also read and write text messages. We found that 1000-day women preferred educational and reminder messages, whereas health facility staff and FCHVs desired educational and motivational messages. Participants suggested different types of texts for 1000-day women, families, FCHVs, and health facility staff, and reported less value for texts received from unknown phone numbers. Conclusions: A text message–based mHealth intervention is acceptable in the hills of Nepal and has the potential to improve community health and nutrition service utilization, particularly by sending meeting reminders and by providing information. Our findings contribute to text message–based mHealth intervention design in under-resourced settings. %M 32915151 %R 10.2196/17659 %U http://www.jmir.org/2020/9/e17659/ %U https://doi.org/10.2196/17659 %U http://www.ncbi.nlm.nih.gov/pubmed/32915151 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18414 %T Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study %A Zaidi,Shehla %A Kazi,Abdul Momin %A Riaz,Atif %A Ali,Ammarah %A Najmi,Rabia %A Jabeen,Rawshan %A Khudadad,Umerdad %A Sayani,Saleem %+ Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan, 92 3062016825, shehla.zaidi@aku.edu %K mHealth %K community health workers %K usability %K usefulness %K task-technology fit %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan. Objective: Our study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems. Methods: The Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis. Results: Although a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants. Conclusions: The digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology. %M 32940612 %R 10.2196/18414 %U http://www.jmir.org/2020/9/e18414/ %U https://doi.org/10.2196/18414 %U http://www.ncbi.nlm.nih.gov/pubmed/32940612 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19627 %T Adherence of HIV Self-Testing Among Men Who Have Sex With Men in China: Longitudinal Study %A Yan,Xiangyu %A Su,Hexuan %A Zhang,Bo %A Li,Yongjie %A Zhang,Lingling %A Jia,Zhongwei %+ National Institute on Drug Dependence, Peking University, 38 Xueyuan Road, Haidian District, Beijing, , China, 86 10 82802457, urchinjj@163.com %K HIV self-testing %K adherence %K men who have sex with men %K HIV infection %K condom use %K mobile app %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The World Health Organization recommended HIV self-testing (HIVST) for individuals practicing unsafe sexual behaviors; however, the adherence to HIV testing has not been reported. Objective: In this study, we attempted to determine the adherence to HIVST among men who have sex with men (MSM), as well as the impact factors and potential effects of their adherence. Methods: We conducted a longitudinal study among MSM in Harbin, Heilongjiang province, China from July 1, 2017 to June 30, 2018. A mobile app system was used to provide the “Mailing rapid test reagent kit” for the HIVST service. The proportion of those who adhered to HIV testing every 3 months was calculated. Logistic regression was used to explore the impact factors related to adherence to HIVST. Rates of HIV infection between MSM who adhered to HIVST and those who did not were compared using Cox proportional hazards regression. Changes of condom use behaviors between the two groups were also compared using the chi-square test. Results: A total of 1315 MSM who received the HIVST service through the app were included in the study. Overall, 10% of the MSM adhered to HIVST, and the proportion of adhering tests was only 34.9%. Adherence of HIVST was associated with marital status (adjusted odds ratio [OR]unmarried vs married 2.31, 95% CI 1.13-4.71) and the number of HIV tests they received (adjusted OR3 times vs 2 times or below 3.36, 95% CI 2.01-5.63; adjusted OR4 times or above vs 2 times or below 7.30, 95% CI 4.67-11.42). Twenty HIV seroconversions were observed during 1-year follow up. The rate of HIV infection in the adherence group (17.10 per 100 person years, 95% CI 8.80-30.84) was significantly higher than that in the nonadherence group (4.80 per 100 person years, 95% CI 2.77-7.88; adjusted hazard ratio 3.33, 95% CI 1.35-8.20). Those who adhered to HIV testing were more likely to improve condom use behaviors, although the difference was not statistically significant. Conclusions: Regular HIV testing is necessary for early detection of HIV infection among MSM. Given the poor adherence, a new internet-based management paradigm for MSM is needed to raise their health awareness to optimize the implementation of HIVST. %M 32940619 %R 10.2196/19627 %U http://www.jmir.org/2020/9/e19627/ %U https://doi.org/10.2196/19627 %U http://www.ncbi.nlm.nih.gov/pubmed/32940619 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18663 %T New Path to Recovery and Well-Being: Cross-Sectional Study on WeChat Use and Endorsement of WeChat-Based mHealth Among People Living With Schizophrenia in China %A Yu,Yu %A Li,Yilu %A Li,Tongxin %A Xi,Shijun %A Xiao,Xi %A Xiao,Shuiyuan %A Tebes,Jacob Kraemer %+ Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Upper Mayuanling Road No. 238, Changsha, 410008, China, 86 0731 84805459, xiaosy@csu.edu.cn %K WeChat %K mHealth %K schizophrenia %K China %K symptoms %K functioning %K recovery %K quality of life %K well-being %D 2020 %7 18.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The past few decades have seen an exponential increase in using mobile phones to support medical care (mobile health [mHealth]) among people living with psychosis worldwide, yet little is known about WeChat use and WeChat-based mHealth among people living with schizophrenia (PLS) in China. Objective: This study aims to assess WeChat use, endorsement of WeChat-based mHealth programs, and health related to WeChat use among PLS. Methods: We recruited a random sample of 400 PLS from 12 communities in Changsha City of Hunan Province, China. WeChat use was assessed using the adapted WeChat Use Intensity Questionnaire (WUIQ). We also compared psychiatric symptoms, functioning, disability, recovery, quality of life, and general well-being between WeChat users and nonusers using one-to-one propensity-score matching. Results: The WeChat use rate was 40.8% in this sample (163/400); 30.7% (50/163) had more than 50 WeChat friends and nearly half (81/163, 49.7%) spent more than half an hour on WeChat, a pattern similar to college students and the elderly. PLS also showed higher emotional connectedness to WeChat use than college students. About 80.4% (131/163) of PLS were willing to participate in a WeChat-based mHealth program, including psychoeducation (91/163, 55.8%), professional support (82/163, 50.3%), and peer support (67/163, 41.1%). Compared with nonusers, WeChat users were younger, better educated, and more likely to be employed. WeChat use was associated with improved health outcomes, including lower psychiatric symptoms, lower depression, higher functioning, better recovery, and higher quality of life. Conclusions: WeChat-based mHealth programs hold promise as an empowering tool to provide cost-effective interventions, to foster global recovery, and to improve both physical and mental well-being among PLS. WeChat and WeChat-based mHealth programs have the potential to offer a new path to recovery and well-being for PLS in China. %M 32945774 %R 10.2196/18663 %U http://www.jmir.org/2020/9/e18663/ %U https://doi.org/10.2196/18663 %U http://www.ncbi.nlm.nih.gov/pubmed/32945774 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19923 %T Determinants of Scale-up From a Small Pilot to a National Electronic Immunization Registry in Vietnam: Qualitative Evaluation %A Dang,Huyen %A Dao,Sang %A Carnahan,Emily %A Kawakyu,Nami %A Duong,Hong %A Nguyen,Trung %A Nguyen,Doan %A Nguyen,Linh %A Rivera,Maya %A Ngo,Tuan %A Werner,Laurie %A Nguyen,Nga %+ PATH, #1101, 11th Floor, Hanoi Towers, 49 Hai Bai Trung Street, Hoan Kiem District, Hanoi, , Vietnam, 84 24 3936 2216 ext 105, ntnguyen@path.org %K immunization %K immunization information system %K electronic immunization registry %K scale-up %K digital health intervention %K mHealth %K eHealth %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health innovations can improve health system performance, yet previous experience has shown that many innovations do not advance beyond the pilot stage to achieve scale. Vietnam’s National Immunization Information System (NIIS) began as a series of digital health pilots, first initiated in 2010, and was officially launched nationwide in 2017. The NIIS is one of the few examples of an electronic immunization registry (EIR) at national scale in low- and middle-income countries. Objective: The aim of this study was to understand the determinants of scale-up of the national EIR in Vietnam. Methods: This qualitative study explored the facilitators and barriers to national scale-up of the EIR in Vietnam. Qualitative data were collected from October to December 2019 through in-depth key informant interviews and desk review. The mHealth Assessment and Planning for Scale (MAPS) Toolkit guided the development of the study design, interview guides, and analytic framework. MAPS defines the key determinants of success, or the “axes of scale,” to be groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation. Results: The partnership and operations axes were critical to the successful scale-up of the EIR in Vietnam, while the groundwork and monitoring and the evaluation axes were considered to be strong contributors in the success of all the other axes. The partnership model leveraged complementary strengths of the technical working group partners: the Ministry of Health General Department of Preventive Medicine, the National Expanded Program on Immunization, Viettel (the mobile network operator), and PATH. The operational approach to introducing the NIIS with lean, iterative, and integrated training and supervision was also a key facilitator to successful scale-up. The financial health, technology and architecture, and operations axes were identified as barriers to successful deployment and scale-up. Key barriers to scale-up included insufficient estimates of operational costs, unanticipated volume of data storage and transmission, lack of a national ID to support interoperability, and operational challenges among end users. Overall, the multiple phases of EIR deployment and scale-up from 2010 to 2017 allowed for continuous learning and improvement that strengthened all the axes and contributed to successful scale-up. Conclusions: The results highlight the importance of the measured, iterative approach that was taken to gradually expand a series of small pilots to nationwide scale. The findings from this study can be used to inform other countries considering, introducing, or in the process of scaling an EIR or other digital health innovations. %M 32960184 %R 10.2196/19923 %U http://www.jmir.org/2020/9/e19923/ %U https://doi.org/10.2196/19923 %U http://www.ncbi.nlm.nih.gov/pubmed/32960184 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19895 %T Health Goal Attainment of Patients With Chronic Diseases in Web-Based Patient Communities: Content and Survival Analysis %A Song,Jiahe %A Xu,Pei %A Paradice,David B %+ Harbert College of Business, Auburn University, 420 Lowder Hall, Auburn, AL, 36849, United States, 1 3348446513, pzx0002@auburn.edu %K web-based patient communities %K self-reflection %K social support %K goal attainment %K web-based chronic disease management %K survival analysis %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Activities directed at attaining health goals are a major part of the daily lives of those fighting chronic diseases. A proliferating population of patients with chronic diseases are participating in web-based patient communities, wherein they can exchange health information and pursue health goals with others virtually. Objective: In this study, we aimed to understand the effect of participation in social media–enabled web-based patient communities on health goal attainment. In particular, we studied the antecedents of health goal attainment in terms of social support and self-reflection in web-based patient communities. Methods: This data set consists of web-based health management activities of 392 patients across 13 health support groups, that is, groups with medical issues such as high blood pressure, diabetes, and breast cancer; the data of the activities were collected from a leading web-based patient community. Content analysis was used to code the social interactions among the patients on the web-based platform. Cox regression for survival analysis was used to model the hazard ratio of health goal attainment. Results: Our analysis indicated that emotional support from web-based patient communities can increase patients’ probability of achieving their goals (hazard ratio 1.957, 95% CI 1.416-2.706; P<.001) while informational support does not appear to be effective (P=.06). In addition, health-related self-reflection increases the patients’ likelihood of goal attainment through web-based patient communities (hazard ratio 1.937, 95% CI 1.318-2.848; P<.001), but leisure-oriented self-reflection reduces this likelihood (hazard ratio 0.588, 95% CI 0.442-0.784; P<.001). Conclusions: Social media–enabled web-based platforms assist health goal management via both social interaction and personal discipline. This study extends the understanding of web-based patient communities by investigating the effects of both social and cognitive factors on goal attainment. In particular, our study advocates that health goals relating to chronic conditions can be better managed when patients use the facilities of web-based health communities strategically. %M 32915152 %R 10.2196/19895 %U http://www.jmir.org/2020/9/e19895/ %U https://doi.org/10.2196/19895 %U http://www.ncbi.nlm.nih.gov/pubmed/32915152 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19694 %T Exploring the Health-Related Quality of Life of Patients Treated With Immune Checkpoint Inhibitors: Social Media Study %A Cotté,François-Emery %A Voillot,Paméla %A Bennett,Bryan %A Falissard,Bruno %A Tzourio,Christophe %A Foulquié,Pierre %A Gaudin,Anne-Françoise %A Lemasson,Hervé %A Grumberg,Valentine %A McDonald,Laura %A Faviez,Carole %A Schück,Stéphane %+ Kap Code, 28 rue d'Enghien, Paris, 75010, France, 33 624058742, pamela.voillot@kapcode.fr %K health-related quality of life %K immunotherapy %K patients with cancer %K social media use %K measures %K real world %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Immune checkpoint inhibitors (ICIs) are increasingly used to treat several types of tumors. Impact of this emerging therapy on patients’ health-related quality of life (HRQoL) is usually collected in clinical trials through standard questionnaires. However, this might not fully reflect HRQoL of patients under real-world conditions. In parallel, users’ narratives from social media represent a potential new source of research concerning HRQoL. Objective: The aim of this study is to assess and compare coverage of ICI-treated patients’ HRQoL domains and subdomains in standard questionnaires from clinical trials and in real-world setting from social media posts. Methods: A retrospective study was carried out by collecting social media posts in French language written by internet users mentioning their experiences with ICIs between January 2011 and August 2018. Automatic and manual extractions were implemented to create a corpus where domains and subdomains of HRQoL were classified. These annotations were compared with domains covered by 2 standard HRQoL questionnaires, the EORTC QLQ-C30 and the FACT-G. Results: We identified 150 users who described their own experience with ICI (89/150, 59.3%) or that of their relative (61/150, 40.7%), with 137 users (91.3%) reporting at least one HRQoL domain in their social media posts. A total of 8 domains and 42 subdomains of HRQoL were identified: Global health (1 subdomain; 115 patients), Symptoms (13; 76), Emotional state (10; 49), Role (7; 22), Physical activity (4; 13), Professional situation (3; 9), Cognitive state (2; 2), and Social state (2; 2). The QLQ-C30 showed a wider global coverage of social media HRQoL subdomains than the FACT-G, 45% (19/42) and 29% (12/42), respectively. For both QLQ-C30 and FACT-G questionnaires, coverage rates were particularly suboptimal for Symptoms (68/123, 55.3% and 72/123, 58.5%, respectively), Emotional state (7/49, 14% and 24/49, 49%, respectively), and Role (17/22, 77% and 15/22, 68%, respectively). Conclusions: Many patients with cancer are using social media to share their experiences with immunotherapy. Collecting and analyzing their spontaneous narratives are helpful to capture and understand their HRQoL in real-world setting. New measures of HRQoL are needed to provide more in-depth evaluation of Symptoms, Emotional state, and Role among patients with cancer treated with immunotherapy. %M 32915159 %R 10.2196/19694 %U http://www.jmir.org/2020/9/e19694/ %U https://doi.org/10.2196/19694 %U http://www.ncbi.nlm.nih.gov/pubmed/32915159 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21416 %T Defining the Digital Self: A Qualitative Study to Explore the Digital Component of Professional Identity in the Health Professions %A Ruan,Brandon %A Yilmaz,Yusuf %A Lu,Daniel %A Lee,Mark %A Chan,Teresa M %+ Division of Emergency Medicine / Division of Education and Innovation, Department of Medicine, Faculty of Health Sciences, McMaster University, 237 Barton St E, McMaster Clinic, Room 255, Hamilton General Hospital, Hamilton, ON, L8L 2X2, Canada, 1 9055212100, teresa.chan@medportal.ca %K professional identity %K social media %K digital identity %K health care professionals %K e-professionalism %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Recent medical education literature pertaining to professional identity development fails to reflect the impact social media has on professional identity theory. Social media is transforming the field of medicine, as the web-based medium is now an avenue for professional development and socialization for medical students and residents. Research regarding identity development in social media has been primarily confined to electronic professionalism through best practice guidelines. However, this neglects other potential aspects pertinent to digital identity that have not yet been explored. Objective: This study aims to define the properties and development of the digital self and its interactions with the current professional identity development theory. Methods: A qualitative study was conducted using thematic analysis. A total of 17 participants who are social media education and knowledge translation experts were interviewed. The initial participants were from emergency medicine, and a snowball sampling method was used following their respective web-based semistructured interviews to enable global recruitment of other participants from interprofessional disciplines. The research team consisted of a diverse group of researchers including one current social media knowledge translation physician clinician educator, one postdoctoral researcher who is regularly engaged in social media knowledge translation, and 3 nonphysician research assistants who are not social media users. Half of the team conducted the initial coding and analysis, whereas the other 2 investigators audited the procedures followed. Results: A total of 4 themes were identified that pertain to digital identity. In the first theme, origins of initial digital identity formation were found to be derived from perceived needs in professional roles (eg, as a medical student or resident). The second theme consisted of the cultivation of digital identity, in which digital identity was developed parallel to professional identity. The third theme that emerged was the management between the professional and personal components of digital identity. Participants initially preferred keeping these components completely separate; however, attempts to do so were inadequate while the integration of both components provided benefits. The fourth theme was the management of real-life identity and digital identity. Participants preferred real-life identity to be wholly represented on the web. Instances of misalignment resulted in identity conflict, compromising one of the identities. Conclusions: Social media introduces new features to professional identity in the digital world. The formation of digital identity, its development, and reconciliation with other identities were features captured in our analysis. The virtual component of professional identity must not be neglected but instead further explored, as educational institutions continue to give more importance to navigating professional identity development. %M 32990636 %R 10.2196/21416 %U http://www.jmir.org/2020/9/e21416/ %U https://doi.org/10.2196/21416 %U http://www.ncbi.nlm.nih.gov/pubmed/32990636 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21849 %T Development of a Social Network for People Without a Diagnosis (RarePairs): Evaluation Study %A Kühnle,Lara %A Mücke,Urs %A Lechner,Werner M %A Klawonn,Frank %A Grigull,Lorenz %+ Hannover Medical School, Carl-Neuberg-Straße 1, Hannover, 30625, Germany, 49 511532 ext 3220, muecke.urs@mh-hannover.de %K rare disease %K diagnostic support tool %K prototype %K social network %K machine learning %K artificial intelligence %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Diagnostic delay in rare disease (RD) is common, occasionally lasting up to more than 20 years. In attempting to reduce it, diagnostic support tools have been studied extensively. However, social platforms have not yet been used for systematic diagnostic support. This paper illustrates the development and prototypic application of a social network using scientifically developed questions to match individuals without a diagnosis. Objective: The study aimed to outline, create, and evaluate a prototype tool (a social network platform named RarePairs), helping patients with undiagnosed RDs to find individuals with similar symptoms. The prototype includes a matching algorithm, bringing together individuals with similar disease burden in the lead-up to diagnosis. Methods: We divided our project into 4 phases. In phase 1, we used known data and findings in the literature to understand and specify the context of use. In phase 2, we specified the user requirements. In phase 3, we designed a prototype based on the results of phases 1 and 2, as well as incorporating a state-of-the-art questionnaire with 53 items for recognizing an RD. Lastly, we evaluated this prototype with a data set of 973 questionnaires from individuals suffering from different RDs using 24 distance calculating methods. Results: Based on a step-by-step construction process, the digital patient platform prototype, RarePairs, was developed. In order to match individuals with similar experiences, it uses answer patterns generated by a specifically designed questionnaire (Q53). A total of 973 questionnaires answered by patients with RDs were used to construct and test an artificial intelligence (AI) algorithm like the k-nearest neighbor search. With this, we found matches for every single one of the 973 records. The cross-validation of those matches showed that the algorithm outperforms random matching significantly. Statistically, for every data set the algorithm found at least one other record (match) with the same diagnosis. Conclusions: Diagnostic delay is torturous for patients without a diagnosis. Shortening the delay is important for both doctors and patients. Diagnostic support using AI can be promoted differently. The prototype of the social media platform RarePairs might be a low-threshold patient platform, and proved suitable to match and connect different individuals with comparable symptoms. This exchange promoted through RarePairs might be used to speed up the diagnostic process. Further studies include its evaluation in a prospective setting and implementation of RarePairs as a mobile phone app. %M 32990634 %R 10.2196/21849 %U http://www.jmir.org/2020/9/e21849/ %U https://doi.org/10.2196/21849 %U http://www.ncbi.nlm.nih.gov/pubmed/32990634 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21204 %T Factors Engaging Users of Diabetes Social Media Channels on Facebook, Twitter, and Instagram: Observational Study %A Gabarron,Elia %A Larbi,Dillys %A Dorronzoro,Enrique %A Hasvold,Per Erlend %A Wynn,Rolf %A Årsand,Eirik %+ Norwegian Centre for E-health Research, University Hospital of North Norway, Sykehusveien. 23, Tromsø, , Norway, 47 77754030, elia.gabarron@ehealthresearch.no %K social media %K Facebook %K Twitter %K Instagram %K diabetes %K engagement %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Diabetes patient associations and diabetes-specific patient groups around the world are present on social media. Although active participation and engagement in these diabetes social media groups has been mostly linked to positive effects, very little is known about the content that is shared on these channels or the post features that engage their users the most. Objective: The objective of this study was to analyze (1) the content and features of posts shared over a 3-year period on 3 diabetes social media channels (Facebook, Twitter, and Instagram) of a diabetes association, and (2) users’ engagement with these posts (likes, comments, and shares). Methods: All social media posts published from the Norwegian Diabetes Association between January 1, 2017, and December 31, 2019, were extracted. Two independent reviewers classified the posts into 7 categories based on their content. The interrater reliability was calculated using Cohen kappa. Regression analyses were carried out to analyze the effects of content topic, social media channel, and post features on users’ engagement (likes, comments, and shares). Results: A total of 1449 messages were posted. Posts of interviews and personal stories received 111% more likes, 106% more comments, and 112% more shares than miscellaneous posts (all P<.001). Messages posted about awareness days and other celebrations were 41% more likely to receive likes than miscellaneous posts (P<.001). Conversely, posts on research and innovation received 31% less likes (P<.001), 35% less comments (P=.02), and 25% less shares (P=.03) than miscellaneous posts. Health education posts received 38% less comments (P=.003) but were shared 39% more than miscellaneous posts (P=.007). With regard to social media channel, Facebook and Instagram posts were both 35 times more likely than Twitter posts to receive likes, and 60 times and almost 10 times more likely to receive comments, respectively (P<.001). Compared to text-only posts, those with videos had 3 times greater chance of receiving likes, almost 4 times greater chance of receiving comments, and 2.5 times greater chance of being shared (all P<.001). Including both videos and emoji in posts increased the chances of receiving likes by almost 7 times (P<.001). Adding an emoji to posts increased their chances of receiving likes and being shared by 71% and 144%, respectively (P<.001). Conclusions: Diabetes social media users seem to be least engaged in posts with content topics that a priori could be linked to greater empowerment: research and innovation on diabetes, and health education. Diabetes social media groups, public health authorities, and other stakeholders interested in sharing research and innovation content and promoting health education on social media should consider including videos and emoji in their posts, and publish on popular and visual-based social media channels, such as Facebook and Instagram, to increase user engagement. International Registered Report Identifier (IRRID): RR2-10.1186/s12913-018-3178-7 %M 32990632 %R 10.2196/21204 %U http://www.jmir.org/2020/9/e21204/ %U https://doi.org/10.2196/21204 %U http://www.ncbi.nlm.nih.gov/pubmed/32990632 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18458 %T Compensatory Social Networking Site Use, Family Support, and Depression Among College Freshman: Three-Wave Panel Study %A Zhou,Mingjie %A Li,Fugui %A Wang,Yanhong %A Chen,Shuang %A Wang,Kexin %+ College of Media and International Culture, Zhejiang University, Main Teaching Building, 4th Fl., Hangzhou, 310007, China, 86 18611897400, wangkexin0809@zju.edu.cn %K freshmen %K introversion %K compensatory use of SNS %K depression %K family support %K social media %D 2020 %7 2.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Freshmen were found to use social networking sites (SNS) as a useful medium to effectively adjust to college life, which hints at a tendency to resort to SNS for social compensation. However, the compensatory use of SNS is usually problematic. Objective: This study explores why a subgroup of freshmen developed depressive symptoms while socially adjusting to college by investigating the antecedent role of introversion, the explanatory role of compensatory use of SNS, and the protective role of perceived family support. The study is among the first to point out the relevance of the compensatory use of SNS in explaining the indirect association between introversion and depression with a longitudinal design. Methods: A 3-wave panel sample of freshmen (N=1137) is used to examine the moderated mediation model. Results: We found that introversion at Wave 1 positively predicted compensatory use of SNS at Wave 2 and subsequently increased depression at Wave 3 (unstandardized B=0.07, SE 0.02, P<.001, 95% CI 0.04-0.10; unstandardized B=0.09, SE 0.01, P<.001, 95% CI 0.06-0.12). The moderated mediation model further examined the buffering role of perceived family support within the link between introversion and compensatory SNS use (index=0.0031, SE 0.0015, 95% CI 0.0003-0.0062). Unexpectedly, we found that family support in Wave 1 decreased compensatory SNS use for less introverted freshmen in Wave 2 and further decreased depression in Wave 3. Conclusions: Unexpectedly, our findings uncover an enhancing effect, rather than a buffering effect, of family support by embedding its effect within the relationship between introversion and compensatory SNS use. Appreciating the differences in the casual pathways for freshmen with different levels of introversion clarifies how SNS affect young adults' lives. %M 32795999 %R 10.2196/18458 %U https://www.jmir.org/2020/9/e18458 %U https://doi.org/10.2196/18458 %U http://www.ncbi.nlm.nih.gov/pubmed/32795999 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20632 %T Real-World Evidence on the Effect of Missing an Oral Contraceptive Dose: Analysis of Internet Search Engine Queries %A Hochberg,Irit %A Orshalimy,Sharon %A Yom-Tov,Elad %+ Microsoft Research, 13 Shenkar st, Herzeliya, 46733, Israel, 972 747111359, eladyt@microsoft.com %K search engines %K birth control %K abortion %K miscarriage %D 2020 %7 15.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Oral contraceptives (OCs) are a unique chronic medication with which a memory slip may result in a threat that could change a person’s life course. Subjective concerns of missed OC doses among women have been addressed infrequently. Anonymized queries to internet search engines provide unique access to concerns and information gaps faced by a large number of internet users. Objective: We aimed to quantitate the frequency of queries by women seeking information in an internet search engine, after missing one or more doses of an OC; their further queries on emergency contraception, abortion, and miscarriage; and their rate of reporting a pregnancy timed to the cycle of missing an OC. Methods: We extracted all English-language queries submitted to Bing in the United States during 2018, which mentioned a missed OC and subsequent queries of the same users on miscarriage, abortion, emergency contraceptives, and week of pregnancy. Results: We identified 26,395 Bing users in the United States who queried about missing OC pills and the fraction that further queried about miscarriage, abortion, emergency contraceptive, and week of pregnancy. Users under the age of 30 years who asked about forgetting an OC dose were more likely to ask about abortion (1.5 times) and emergency contraception (1.7 times) (P<.001 for both), while users at ages of 30-34 years were more likely to query about pregnancy (2.1 times) and miscarriage (5.4 times) (P<.001 for both). Conclusions: Our data indicate that many women missing a dose of OC might not have received sufficient information from their health care providers or chose to obtain it online. Queries about abortion and miscarriage peaking in the subsequent days indicate a common worry of possible pregnancy. These results reinforce the importance of providing comprehensive written information on missed pills when prescribing an OC. %M 32930672 %R 10.2196/20632 %U http://www.jmir.org/2020/9/e20632/ %U https://doi.org/10.2196/20632 %U http://www.ncbi.nlm.nih.gov/pubmed/32930672 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18662 %T Changing Emotions About Fukushima Related to the Fukushima Nuclear Power Station Accident—How Rumors Determined People’s Attitudes: Social Media Sentiment Analysis %A Hasegawa,Shin %A Suzuki,Teppei %A Yagahara,Ayako %A Kanda,Reiko %A Aono,Tatsuo %A Yajima,Kazuaki %A Ogasawara,Katsuhiko %+ Faculty of Health Sciences, Hokkaido University, N12-W5, Kita-ku, Sapporo, 060-0812, Japan, 81 11 706 3409, oga@hs.hokudai.ac.jp %K Fukushima nuclear accident %K Twitter messaging %K radiation %K radioactivity %K radioactive hazard release %K information dissemination %K belief in rumors %K disaster medicine %K infodemiology %K infoveillance %K infodemic %D 2020 %7 2.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Public interest in radiation rose after the Tokyo Electric Power Company (TEPCO) Fukushima Daiichi Nuclear Power Station accident was caused by an earthquake off the Pacific coast of Tohoku on March 11, 2011. Various reports on the accident and radiation were spread by the mass media, and people displayed their emotional reactions, which were thought to be related to information about the Fukushima accident, on Twitter, Facebook, and other social networking sites. Fears about radiation were spread as well, leading to harmful rumors about Fukushima and the refusal to test children for radiation. It is believed that identifying the process by which people emotionally responded to this information, and hence became gripped by an increased aversion to Fukushima, might be useful in risk communication when similar disasters and accidents occur in the future. There are few studies surveying how people feel about radiation in Fukushima and other regions in an unbiased form. Objective: The purpose of this study is to identify how the feelings of local residents toward radiation changed according to Twitter. Methods: We used approximately 19 million tweets in Japanese containing the words “radiation” (放射線), “radioactivity” (放射能), and “radioactive substances” (放射性物質) that were posted to Twitter over a 1-year period following the Fukushima nuclear accident. We used regional identifiers contained in tweets (ie, nouns, proper nouns, place names, postal codes, and telephone numbers) to categorize them according to their prefecture, and then analyzed the feelings toward those prefectures from the semantic orientation of the words contained in individual tweets (ie, positive impressions or negative impressions). Results: Tweets about radiation increased soon after the earthquake and then decreased, and feelings about radiation trended positively. We determined that, on average, tweets associating Fukushima Prefecture with radiation show more positive feelings than those about other prefectures, but have trended negatively over time. We also found that as other tweets have trended positively, only bots and retweets about Fukushima Prefecture have trended negatively. Conclusions: The number of tweets about radiation has decreased overall, and feelings about radiation have trended positively. However, the fact that tweets about Fukushima Prefecture trended negatively, despite decreasing in percentage, suggests that negative feelings toward Fukushima Prefecture have become more extreme. We found that while the bots and retweets that were not about Fukushima Prefecture gradually trended toward positive feelings, the bots and retweets about Fukushima Prefecture trended toward negative feelings. %M 32876574 %R 10.2196/18662 %U https://www.jmir.org/2020/9/e18662 %U https://doi.org/10.2196/18662 %U http://www.ncbi.nlm.nih.gov/pubmed/32876574 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18306 %T Social Media Listening to Understand the Lived Experience of Presbyopia: Systematic Search and Content Analysis Study %A Wolffsohn,James S %A Leteneux-Pantais,Claudia %A Chiva-Razavi,Sima %A Bentley,Sarah %A Johnson,Chloe %A Findley,Amy %A Tolley,Chloe %A Arbuckle,Rob %A Kommineni,Jyothi %A Tyagi,Nishith %+ Patient-Centered Outcomes, Adelphi Values Ltd, Adelphi Mill, Grimshaw Lane, Bollington, SK10 5JB, United Kingdom, 44 1625576815, sarah.bentley@adelphivalues.com %K presbyopia %K near vision %K social media %K social media listening %K infodemiology %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Presbyopia is defined as the age-related deterioration of near vision over time which is experienced in over 80% of people aged 40 years or older. Individuals with presbyopia have difficulty with tasks that rely on near vision. It is not currently possible to stop or reverse the aging process that causes presbyopia; generally, it is corrected with glasses, contact lenses, surgery, or the use of a magnifying glass. Objective: This study aimed to explore how individuals used social media to describe their experience of presbyopia with regard to the symptoms experienced and the impacts of presbyopia on their quality of life. Methods: Social media sources including Twitter, forums, blogs, and news outlets were searched using a predefined search string relating to symptoms and impacts of presbyopia. The data that were downloaded, based on the keywords, underwent manual review to identify relevant data points. Relevant posts were further manually analyzed through a process of data tagging, categorization, and clustering. Key themes relating to symptoms, impacts, treatment, and lived experiences were identified. Results: A total of 4456 social media posts related to presbyopia were identified between May 2017 and August 2017. Using a random sampling methodology, we selected 2229 (50.0%) posts for manual review, with 1470 (65.9%) of these 2229 posts identified as relevant to the study objectives. Twitter was the most commonly used channel for discussions on presbyopia compared to forums and blogs. The majority of relevant posts originated in Spain (559/1470, 38.0%) and the United States (426/1470, 29.0%). Of the relevant posts, 270/1470 (18.4%) were categorized as posts written by individuals who have presbyopia, of which 37 of the 270 posts (13.7%) discussed symptoms. On social media, individuals with presbyopia most frequently reported experiencing difficulty reading small print (24/37, 64.9%), difficulty focusing on near objects (15/37, 40.5%), eye strain (12/37, 32.4%), headaches (9/37, 24.3%), and blurred vision (8/37, 21.6%). 81 of the 270 posts (30.0%) discussed impacts of presbyopia—emotional burden (57/81, 70.4%), functional or daily living impacts (46/81, 56.8%), such as difficulty reading (46/81, 56.8%) and using electronic devices (21/81, 25.9%), and impacts on work (3/81, 3.7%). Conclusions: Findings from this social media listening study provided insight into how people with presbyopia discuss their condition online and highlight the impact of presbyopia on individuals’ quality of life. The social media listening methodology can be used to generate insights into the lived experience of a condition, but it is recommended that this research be combined with prospective qualitative research for added rigor and for confirmation of the relevance of the findings. %M 32955443 %R 10.2196/18306 %U http://www.jmir.org/2020/9/e18306/ %U https://doi.org/10.2196/18306 %U http://www.ncbi.nlm.nih.gov/pubmed/32955443 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18481 %T Impact of the Internet on Medical Decisions of Chinese Adults: Longitudinal Data Analysis %A Ma,Qianqian %A Sun,Dongxu %A Cui,Fangfang %A Zhai,Yunkai %A Zhao,Jie %A He,Xianying %A Shi,Jinming %A Gao,Jinghong %A Li,Mingyuan %A Zhang,Wenjie %+ National Engineering Laboratory for Internet Medical Systems and Applications, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Erqi District, Zhengzhou, Henan, 450052, China, 86 371 67966215, zhaiyunkai@zzu.edu.cn %K internet %K medical decision %K health care provider choice %K adult %K longitudinal data analysis %K hierarchical medical policy %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet has caused the explosive growth of medical information and has greatly improved the availability of medical knowledge. This makes the internet one of the main ways for residents to obtain medical information and knowledge before seeking medical treatment. However, little has been researched on how the internet affects medical decisions. Objective: The purpose of this study was to explore the associations between internet behaviors and medical decisions among Chinese adults aged 18 or over, including whether to go to the hospital and which level of medical institution to choose. Methods: With the adult residents (≥18 years old) in 12 regions including urban and rural areas taken as the research objects, the differences in medical choices of adults with various characteristics were analyzed, and generalized linear mixed models were adopted to analyze the longitudinal data of the China Health Nutrition Survey from 2006 to 2015. Results: Adult groups with different ages, genders, education levels, regions, places of residence, severities of illness and injury, years of suffering from hypertension, and history of chronic diseases showed diverse medical decisions, and the differences were statistically significant (P<.05). After controlling for these potential confounding factors and taking self-care as the reference, the probability of Chinese adults who participated in online browsing activities selecting hospital care was 0.82 (95% CI 0.69-0.98; P=.03) times that of residents who did not participate in online browsing activities. In terms of medical institution choices, adults who participated in online browsing activities were 1.86 (95% CI 1.35-2.58; P<.001) times more likely to opt for municipal medical treatment than primary care. However, the effect of online browsing on the selection probability of county-level hospitals was not significant compared with primary hospitals (P=.59). Robust analysis verified that accessing the internet had a similar effect on Chinese adults’ medical decisions. Conclusions: Chinese adults who use the internet are a little less likely to go to the hospital than self-care. The internet has broken down the barriers to obtain knowledge of common diseases and thus has a slight substitution effect of self-care on hospital care. Internet use may increase the probability of adults going to municipal hospitals. The rising tendency of visiting high-level medical institutions may be consequently exacerbated due to knowledge monopoly of severe and complicated diseases that is difficult to eliminate, and the increase in inconsistent and incomplete medical information online will blur the residents’ cognitive boundary of common diseases and severe diseases. Exploring the substantive impact of the internet on medical decision making is of great significance for further rational planning and utilization of the internet, in order to guide patients to appropriate medical institution. %M 32880581 %R 10.2196/18481 %U https://www.jmir.org/2020/9/e18481 %U https://doi.org/10.2196/18481 %U http://www.ncbi.nlm.nih.gov/pubmed/32880581 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19195 %T How People with Parkinson's Disease and Health Care Professionals Wish to Partner in Care Using eHealth: Co-Design Study %A Wannheden,Carolina %A Revenäs,Åsa %+ Medical Management Centre, Department of Learning, Informatics Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, Stockholm, 171 77, Sweden, 46 0852483934, carolina.wannheden@ki.se %K chronic care %K Parkinson's disease %K co-creation %K co-design %K participatory design %K eHealth %K mHealth %K clinical decision support %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Worldwide, the number of people with Parkinson’s disease (PD) is predicted to double between the years 2005 and 2030. Chronic care management requires active collaboration and knowledge exchange between patients and health care professionals (HCPs) for best possible health outcomes, which we describe as co-care. eHealth services have the potential to support the realization of co-care between people with PD (PwP) and HCPs. Objective: This study aimed to explore how co-care could be operationalized in PD care, supported by eHealth. More specifically, this study explores PwP's and HCPs' expectations and desired eHealth functionalities to achieve co-care. Methods: Principles of participatory design were used to enable the identification of co-care needs and design ideas, in a series of 4 half-day co-design workshops. The sample included 7 (4 women) PwP and 9 (4 women) HCPs, including 4 neurologists, 3 nurses, and 2 physiotherapists. The co-design process resulted in a functional prototype that was evaluated by the co-design participants in the last workshop. Data were collected through note cards produced by the participants during the first 3 workshops and focus group discussions during the 3rd and 4th workshops. The data were analyzed using qualitative thematic analysis. After the workshop series, the prototype was demonstrated at a Mini Fair for ongoing PD research and evaluated using a self-developed questionnaire with 37 respondents: 31 PwP (14 women) and 6 informal caregivers (3 women). Descriptive statistics are reported. Results: The qualitative analysis of data resulted in 2 main themes. The first theme, core eHealth functionalities and their expected values, describes 6 desired eHealth functionalities for supporting PD co-care between PwP and HCPs: (1) self-tracking, (2) previsit forms, (3) graphical visualization, (4) clinical decision support, (5) self-care recommendations, and (6) asynchronous communication. The second theme, individual and organizational constraints, describes constraints that need to be addressed to succeed with an eHealth service for co-care. Individual constraints include eHealth literacy and acceptance; organizational constraints include teamwork and administrative workload. The majority of the questionnaire respondents (31/37, 84%) perceived that they would benefit from an eHealth service similar to the demonstrated prototype. All prototype functionalities were rated as very important or important by the majority of respondents (ranging from 86% to 97% per functionality). Conclusions: This study adds to our knowledge on how PD co-care could be operationalized. Co-care implies a shift from episodic routine-driven care to more flexible care management that is driven by the mutual needs of patients and HCPs and supported by active information exchange between them, as well as automated information processing to generate patient-specific advice. More research is needed to further explore the concept of co-care in chronic care management and what it means for self-care and health care. International Registered Report Identifier (IRRID): RR2-10.2196/11278 %M 32955448 %R 10.2196/19195 %U http://www.jmir.org/2020/9/e19195/ %U https://doi.org/10.2196/19195 %U http://www.ncbi.nlm.nih.gov/pubmed/32955448 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21012 %T Understanding the Intention to Use Telehealth Services in Underserved Hispanic Border Communities: Cross-Sectional Study %A Ghaddar,Suad %A Vatcheva,Kristina P %A Alvarado,Samantha G %A Mykyta,Laryssa %+ Department of Health and Biomedical Sciences, University of Texas Rio Grande Valley, EHABW 2.206, 1201 W. University Dr., Edinburg, TX, , United States, 1 956 665 5269, suad.ghaddar@utrgv.edu %K telehealth %K eHealth literacy %K health information technologies %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite the United States having one of the leading health care systems in the world, underserved minority communities face significant access challenges. These communities can benefit from telehealth innovations that promise to improve health care access and, consequently, health outcomes. However, little is known about the attitudes toward telehealth in these communities, an essential first step toward effective adoption and use. Objective: The purpose of this study is to assess the factors that shape behavioral intention to use telehealth services in underserved Hispanic communities along the Texas-Mexico border and examine the role of electronic health (eHealth) literacy in telehealth use intention. Methods: We used cross-sectional design to collect data at a community health event along the Texas-Mexico border. The area is characterized by high poverty rates, low educational attainment, and health care access challenges. Trained bilingual students conducted 322 in-person interviews over a 1-week period. The survey instrument assessed sociodemographic information and telehealth-related variables. Attitudes toward telehealth were measured by asking participants to indicate their level of agreement with 9 statements reflecting different aspects of telehealth use. For eHealth literacy, we used the eHealth Literacy Scale (eHEALS), an 8-item scale designed to measure consumer confidence in finding, evaluating, and acting upon eHealth information. To assess the intention to use telehealth, we asked participants about the likelihood that they would use telehealth services if offered by a health care provider. We analyzed data using univariate, multivariate, and mediation statistical models. Results: Participants were primarily Hispanic (310/319, 97.2%) and female (261/322, 81.1%), with an average age of 43 years. Almost three-quarters (219/298) reported annual household incomes below $20,000. Health-wise, 42.2% (136/322) self-rated their health as fair or poor, and 79.7% (255/320) were uninsured. The overwhelming majority (289/319, 90.6%) had never heard of telehealth. Once we defined the term, participants exhibited positive attitudes toward telehealth, and 78.9% (254/322) reported being somewhat likely or very likely to use telehealth services if offered by a health care provider. Based on multivariate proportional odds regression analysis, a 1-point increase in telehealth attitudes reduced the odds of lower versus higher response in the intention to use telehealth services by 23% (OR 0.77, 95% CI 0.73-0.81). Mediation analysis revealed that telehealth attitudes fully mediated the association between eHealth literacy and intention to use telehealth services. For a 1-point increase in eHEALS, the odds of lower telehealth use decreased by a factor of 0.95 (5%; OR 0.95, 95% CI 0.93-0.98; P<.001) via the increase in the score of telehealth attitudes. Conclusions: Telehealth promises to address many of the access challenges facing ethnic and racial minorities, rural communities, and low-income populations. Findings underscore the importance of raising awareness of telehealth and promoting eHealth literacy as a key step in fostering positive attitudes toward telehealth and furthering interest in its use. %M 32880579 %R 10.2196/21012 %U https://www.jmir.org/2020/9/e21012 %U https://doi.org/10.2196/21012 %U http://www.ncbi.nlm.nih.gov/pubmed/32880579 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19149 %T Teleconsultation Between Patients and Health Care Professionals in the Catalan Primary Care Service: Message Annotation Analysis in a Retrospective Cross-Sectional Study %A López Seguí,Francesc %A Walsh,Sandra %A Solans,Oscar %A Adroher Mas,Cristina %A Ferraro,Gabriela %A García-Altés,Anna %A García Cuyàs,Francesc %A Salvador Carulla,Luis %A Sagarra Castro,Marta %A Vidal-Alaball,Josep %+ Health Promotion in Rural Areas Research Group, Gerència Territorial de la Catalunya Central, Institut Català de la Salut, Carrer Pica d'Estats, 36, Sant Fruitós de Bages, 08272, Spain, 34 936 93 00 40, jvidal.cc.ics@gencat.cat %K teleconsultation %K primary care %K remote consultation %K message annotation %K face-to-face visits %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Over the last decade, telemedicine services have been introduced in the public health care systems of several industrialized countries. In Catalonia, the use of eConsulta, an asynchronous teleconsultation service between primary care professionals and citizens in the public health care system, has already reached 1 million cases. Before the COVID-19 pandemic, the use of eConsulta was growing at a monthly rate of 7%, and the growth has been exponential from March 15, 2020 to the present day. Despite its widespread usage, there is little qualitative evidence describing how this tool is used. Objective: The aim of this study was to annotate a random sample of teleconsultations from eConsulta, and to evaluate the level of agreement between health care professionals with respect to the annotation. Methods: Twenty general practitioners retrospectively annotated a random sample of 5382 cases managed by eConsulta according to three aspects: the type of interaction according to 6 author-proposed categories, whether the practitioners believed a face-to-face visit was avoided, and whether they believed the patient would have requested a face-to-face visit had eConsulta not been available. A total of 1217 cases were classified three times by three different professionals to assess the degree of consensus among them. Results: The general practitioners considered that 79.60% (4284/5382) of the teleconsultations resulted in avoiding a face-to-face visit, and considered that 64.96% (3496/5382) of the time, the patient would have made a face-to-face visit in the absence of a service like eConsulta. The most frequent uses were for management of test results (26.77%, 1433/5354), management of repeat prescriptions (24.30%, 1301/5354), and medical enquiries (14.23%, 762/5354). The degree of agreement among professionals as to the annotations was mixed, with the highest consensus demonstrated for the question “Has the online consultation avoided a face-to-face visit?” (3/3 professionals agreed 67.95% of the time, 827/1217), and the lowest consensus for the type of use of the teleconsultation (3/3 professionals agreed 57.60% of the time, 701/1217). Conclusions: This study shows the ability of eConsulta to reduce the number of face-to-face visits for 55% (79% × 65%) to 79% of cases. In comparison to previous research, these results are slightly more pessimistic, although the rates are still high and in line with administrative data proxies, showing that 84% of patients using teleconsultations do not make an in-person appointment in the following 3 months. With respect to the type of consultation performed, our results are similar to the existing literature, thus providing robust support for eConsulta’s usage. The mixed degree of consensus among professionals implies that results derived from artificial intelligence tools such as message classification algorithms should be interpreted in light of these shortcomings. %M 32687477 %R 10.2196/19149 %U https://www.jmir.org/2020/9/e19149 %U https://doi.org/10.2196/19149 %U http://www.ncbi.nlm.nih.gov/pubmed/32687477 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19550 %T Patients' and Nurses’ Experiences and Perceptions of Remote Monitoring of Implantable Cardiac Defibrillators in Heart Failure: Cross-Sectional, Descriptive, Mixed Methods Study %A Liljeroos,Maria %A Thylén,Ingela %A Strömberg,Anna %+ Department of Health, Medicine and Caring Sciences, Linköping University, Campus US, Linköping, 581 83, Sweden, 46 703728329, maria.liljeroos@liu.se %K heart failure %K remote patient monitoring %K implantable cardioverter-defibrillator %D 2020 %7 28.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The new generation of implantable cardioverter-defibrillators (ICDs) supports wireless technology, which enables remote patient monitoring (RPM) of the device. In Sweden, it is mainly registered nurses with advanced education and training in ICD devices who handle the arrhythmias and technical issues of the remote transmissions. Previous studies have largely focused on the perceptions of physicians, and it has not been explored how the patients’ and nurses’ experiences of RPM correspond to each other. Objective: Our objective is to describe, explore, and compare the experiences and perceptions, concerning RPM of ICD, of patients with heart failure (HF) and nurses performing ICD follow-up. Methods: This study has a cross-sectional, descriptive, mixed methods design. All patients with HF and an ICD with RPM from one region in Sweden, who had transitioned from office-based visits to implementing RPM, and ICD nurses from all ICD clinics in Sweden were invited to complete a purpose-designed, 8-item questionnaire to assess experiences of RPM. The questionnaire started with a neutral question: “What are your experiences of RPM in general?” This was followed by one positive subscale with three questions (score range 3-12), with higher scores reflecting more positive experiences, and one negative subscale with three questions (score range 3-12), with lower scores reflecting more negative experiences. One open-ended question was analyzed with qualitative content analysis. Results: The sample consisted of 175 patients (response rate 98.9%) and 30 ICD nurses (response rate 60%). The majority of patients (154/175, 88.0%) and nurses (23/30, 77%) experienced RPM as very good; however, the nurses noted more downsides than did the patients. The mean scores of the negative experiences subscale were 11.5 (SD 1.1) for the patients and 10.7 (SD 0.9) for the nurses (P=.08). The mean scores of the positive experiences subscale were 11.1 (SD 1.6) for the patients and 8.5 (SD 1.9) for the nurses (P=.04). A total of 11 out of 175 patients (6.3%) were worried or anxious about what the RPM entailed, while 15 out of 30 nurses (50%) felt distressed by the responsibility that accompanied their work with RPM (P=.04). Patients found that RPM increased their own (173/175, 98.9%) and their relatives’ (169/175, 96.6%) security, and all nurses (30/30, 100%) answered that they found RPM to be necessary from a safety perspective. Most patients found it to be an advantage with fewer office-based visits. Nurses found it difficult to handle different systems with different platforms, especially for smaller clinics with few patients. Another difficulty was to set the correct number of alarms for the individual patient. This caused a high number of transmissions and a risk to miss important information. Conclusions: Both patients and nurses found that RPM increased assurance, reliance, and safety. Few patients were anxious about what the RPM entailed, while about half of the nurses felt distressed by the responsibility that accompanied their work with RPM. To increase nurses’ sense of security, it seems important to adjust organizational routines and reimbursement systems and to balance the workload. %M 32985997 %R 10.2196/19550 %U http://www.jmir.org/2020/9/e19550/ %U https://doi.org/10.2196/19550 %U http://www.ncbi.nlm.nih.gov/pubmed/32985997 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19198 %T Client Satisfaction and Experience With Telepsychiatry: Development and Validation of a Survey Using Clinical Quality Domains %A Serhal,Eva %A Kirvan,Anne %A Sanches,Marcos %A Crawford,Allison %+ Virtual Mental Health and Outreach, Centre for Addiction and Mental Health, 825-250 College St, Toronto, ON, M5T1R8, Canada, 1 4165358501 ext 30318, allison.crawford@utoronto.ca %K telemedicine %K psychiatry %K mental health %K patient satisfaction %K quality of health care %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Telepsychiatry is an increasingly used model of mental health care that connects patients with psychiatrists at a distance via videoconference. Telepsychiatry is an effective clinical intervention that improves access to quality care in regions with limited resources or in clinical situations where in-person care is unavailable. Objective: This study aims to develop a validated survey tool to measure patient experience and satisfaction with telepsychiatry based on the quality of care domains. This study also seeks to understand which health service outcomes were most strongly correlated with overall satisfaction in the context of telepsychiatry. Methods: The survey created in this study was developed and validated with a panel of subject matter and process experts and was piloted with 274 patients who received clinical consultations through the TeleMental Health Program at the Centre for Addiction and Mental Health. Factor analysis was used to determine correlations between questions and quality of care domains and was also used to assess model fit. Results: The study provides a validated survey to measure patient satisfaction and experience with telepsychiatry across 4 domains: access and timeliness, appropriateness, effectiveness, and safety. Both safety and access and timeliness were found to be statistically significant predictors of satisfaction in our sample. Conclusions: By situating patient satisfaction and experience within this framework, the survey facilitates patient data collection and interpretation through a clinical quality lens. %M 32755896 %R 10.2196/19198 %U http://www.jmir.org/2020/9/e19198/ %U https://doi.org/10.2196/19198 %U http://www.ncbi.nlm.nih.gov/pubmed/32755896 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19223 %T A Personalized Health Monitoring System for Community-Dwelling Elderly People in Hong Kong: Design, Implementation, and Evaluation Study %A Wang,Hailiang %A Zhao,Yang %A Yu,Lisha %A Liu,Jiaxing %A Zwetsloot,Inez Maria %A Cabrera,Javier %A Tsui,Kwok-Leung %+ School of Data Science, City University of Hong Kong, Tat Chee Avenue, Hong Kong, China, 86 34422177, kltsui@cityu.edu.hk %K telehealth monitoring %K personalized health %K technology acceptance %K digital biomarkers %K digital phenotyping %K wearables %K falls detection %K fitness tracker %K sensors %K elderly population %D 2020 %7 30.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Telehealth is an effective means to assist existing health care systems, particularly for the current aging society. However, most extant telehealth systems employ individual data sources by offline data processing, which may not recognize health deterioration in a timely way. Objective: Our study objective was two-fold: to design and implement an integrated, personalized telehealth system on a community-based level; and to evaluate the system from the perspective of user acceptance. Methods: The system was designed to capture and record older adults’ health-related information (eg, daily activities, continuous vital signs, and gait behaviors) through multiple measuring tools. State-of-the-art data mining techniques can be integrated to detect statistically significant changes in daily records, based on which a decision support system could emit warnings to older adults, their family members, and their caregivers for appropriate interventions to prevent further health deterioration. A total of 45 older adults recruited from 3 elderly care centers in Hong Kong were instructed to use the system for 3 months. Exploratory data analysis was conducted to summarize the collected datasets. For system evaluation, we used a customized acceptance questionnaire to examine users’ attitudes, self-efficacy, perceived usefulness, perceived ease of use, and behavioral intention on the system. Results: A total of 179 follow-up sessions were conducted in the 3 elderly care centers. The results of exploratory data analysis showed some significant differences in the participants’ daily records and vital signs (eg, steps, body temperature, and systolic blood pressure) among the 3 centers. The participants perceived that using the system is a good idea (ie, attitude: mean 5.67, SD 1.06), comfortable (ie, self-efficacy: mean 4.92, SD 1.11), useful to improve their health (ie, perceived usefulness: mean 4.99, SD 0.91), and easy to use (ie, perceived ease of use: mean 4.99, SD 1.00). In general, the participants showed a positive intention to use the first version of our personalized telehealth system in their future health management (ie, behavioral intention: mean 4.45, SD 1.78). Conclusions: The proposed health monitoring system provides an example design for monitoring older adults’ health status based on multiple data sources, which can help develop reliable and accurate predictive analytics. The results can serve as a guideline for researchers and stakeholders (eg, policymakers, elderly care centers, and health care providers) who provide care for older adults through such a telehealth system. %M 32996887 %R 10.2196/19223 %U http://www.jmir.org/2020/9/e19223/ %U https://doi.org/10.2196/19223 %U http://www.ncbi.nlm.nih.gov/pubmed/32996887 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19358 %T Primary Care Pre-Visit Electronic Patient Questionnaire for Asthma: Uptake Analysis and Predictor Modeling %A Kouri,Andrew %A Yamada,Janet %A Sale,Joanna E M %A Straus,Sharon E %A Gupta,Samir %+ Division of Respirology, Department of Medicine, St. Michael’s Hospital, Unity Health Toronto, Bond Wing, Suite 6042, 30 Bond St., Toronto, ON, M5B 1W8, Canada, 1 416 864 6026, samir.gupta@unityhealth.to %K electronic questionnaire %K tablet %K mHealth uptake %K asthma %K modeling %D 2020 %7 18.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: mHealth tablet-based interventions are increasingly being studied and deployed in various health care settings, yet little knowledge exists regarding patient uptake and acceptance or how patient demographics influence these important implementation metrics. Objective: To determine which factors influence the uptake and successful completion of an mHealth tablet questionnaire by analyzing its implementation in a primary care setting. Methods: We prospectively studied a patient-facing electronic touch-tablet asthma questionnaire deployed as part of the Electronic Asthma Management System. We describe tablet uptake and completion rates and corresponding predictor models for these behaviors. Results: The tablet was offered to and accepted by patients in 891/1715 (52.0%) visits. Patients refused the tablet in 33.0% (439/1330) visits in which it was successfully offered. Patients aged older than 65 years of age (odds ratio [OR] 2.30, 95% CI 1.33-3.95) and with concurrent chronic obstructive pulmonary disease (OR 2.22, 95% CI 1.05-4.67) were more likely to refuse the tablet, and those on an asthma medication (OR 0.55, 95% CI 0.30-0.99) were less likely to refuse it. Once accepted, the questionnaire was completed in 784/891 (88.0%) instances, with those on an asthma medication (OR 0.53, 95% CI 0.32-0.88) being less likely to leave it incomplete. Conclusions: Older age predicted initial tablet refusal but not tablet questionnaire completion, suggesting that perceptions of mHealth among older adults may negatively impact uptake, independent of usability. The influence of being on an asthma medication suggests that disease severity may also mediate mHealth acceptance. Although use of mHealth questionnaires is growing rapidly across health care settings and diseases, few studies describe their real-world acceptance and its predictors. Our results should be complemented by qualitative methods to identify barriers and enablers to uptake and may inform technological and implementation strategies to drive successful usage. %M 32945779 %R 10.2196/19358 %U http://www.jmir.org/2020/9/e19358/ %U https://doi.org/10.2196/19358 %U http://www.ncbi.nlm.nih.gov/pubmed/32945779 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19517 %T Sociodemographic Representativeness in a Nationwide Web-Based Survey of the View of Men on Involvement in Health Care Decision-Making: Cross-Sectional Questionnaire Study %A Birkeland,Søren F %A Haakonsson,Anders K %A Pedersen,Susanne S %A Rottmann,Nina %A Barry,Michael J %A Möller,Sören %+ Open Patient Data Explorative Network (OPEN), Odense University Hospital and Department of Clinical Medicine, University of Southern Denmark, J. B. Winsløws Vej 9 a, 3. floor, Odense, DK-5000, Denmark, 45 29166730, sbirkeland@health.sdu.dk %K research methodology %K electronic data capture %K internet-based survey %K representativeness %K generalizability %K user involvement %K patient satisfaction %K bioethics %K medical law %K cancer %D 2020 %7 2.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Being able to generalize research findings to a broader population outside of the study sample is an important goal in surveys on the internet. We conducted a nationwide, cross-sectional, web-based survey with vignettes illustrating different levels of patient involvement to investigate men’s preferences regarding participation in health care decision-making. Following randomization into vignette variants, we distributed the survey among men aged 45 to 70 years through the state-authorized digital mailbox provided by the Danish authorities for secure communication with citizens. Objective: This study aimed to investigate the sociodemographic representativeness of our sample of men obtained in a nationwide web-based survey using the digital mailbox. Methods: Response rate estimates were established, and comparisons were made between responders and nonresponders in terms of age profiles (eg, average age) and municipality-level information on sociodemographic characteristics. Results: Among 22,288 men invited during two waves, a total of 6756 (30.31%) participants responded to the survey. In adjusted analyses, responders’ characteristics mostly resembled those of nonresponders. Response rates, however, were significantly higher in older men (odds ratio [OR] 2.83 for responses among those aged 65-70 years compared with those aged 45-49 years, 95% CI 2.58-3.11; P<.001) and in rural areas (OR 1.10 compared with urban areas, 95% CI 1.03-1.18; P=.005). Furthermore, response rates appeared lower in areas with a higher tax base (OR 0.89 in the highest tertile, 95% CI 0.81-0.98; P=.02). Conclusions: Overall, the general population of men aged 45 to 70 years was represented very well by the responders to our web-based survey. However, the imbalances identified highlight the importance of supplementing survey findings with studies of the representativeness of other characteristics of the sample like trait and preference features, so that proper statistical corrections can be made in upcoming analyses of survey responses whenever needed. %M 32663149 %R 10.2196/19517 %U https://www.jmir.org/2020/9/e19517 %U https://doi.org/10.2196/19517 %U http://www.ncbi.nlm.nih.gov/pubmed/32663149 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e15352 %T Online Health Resource Use by Individuals With Inflammatory Bowel Disease: Analysis Using the National Health Interview Survey %A Yin,Rong %A Neyens,David M %+ Department of Industrial Engineering, Clemson University, 100 Freeman Hall, Clemson, SC, 29634, United States, 1 8646564719, dneyens@clemson.edu %K internet %K searching behavior %K access to information %K inflammatory bowel disease %K logistic regression model %K National Health Interview Survey %D 2020 %7 24.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet has enabled convenient and efficient health information searching which is valuable for individuals with chronic conditions requiring some level of self-management. However, there is little research evaluating what factors may impact the use of the internet for health-related tasks for specific clinical populations, such as individuals with inflammatory bowel diseases. Objective: Our goal was to investigate the factors that influence internet use in acquiring health information by individuals with inflammatory bowel diseases. Specifically, we identified factors associated with internet searching behavior and using the internet for completing health-related tasks. Methods: We used 2016 National Health Interview Survey weighted data to develop logistic regression models to predict the likelihood that individuals with inflammatory bowel diseases would use the internet for 2 types of tasks: seeking health information through online searches and using the internet to perform health-related tasks including scheduling appointments and emailing care providers. Results: 2016 National Health Interview Survey weighted data include more than 3 million weighted adult respondents with inflammatory bowel diseases (approximately 1.29% of adults in the weighted data set). Our results suggest that approximately 66.3% of those with inflammatory bowel diseases reported using the internet at least once a day, and approximately 14.7% reported being dissatisfied with their current health care. About 62.3% of those with inflammatory bowel diseases reported that they had looked up health information online, 16.3% of those with inflammatory bowel diseases reported that they had scheduled an appointment with a health care provider online, and 21.6% reported having used a computer to communicate with a health provider by email. We found that women who were self-regulating their care were more likely to look up health information online than others. Both middle-aged and older adults with inflammatory bowel diseases who were unsatisfied with their current health care were less likely to look up health information online. Frequent internet users who were worried about medical costs were more likely to look up health information online. Similarly, the results from our statistical models suggest that individuals with inflammatory bowel diseases who were frequent internet users were more likely to use the internet for specific health-related tasks. Additionally, women with inflammatory bowel diseases who reported being married were less likely to use the internet for specific health-related tasks. Conclusions: For those with inflammatory bowel diseases, there are additional socioeconomic and behavioral factors that impact the use of the internet for health information and health-related tasks. Future research should evaluate how these factors moderate the use of the internet and identify how online resources can support clinical populations in ways that improve access to information, support health self-management, and subsequently improve health outcomes. %M 32969831 %R 10.2196/15352 %U http://www.jmir.org/2020/9/e15352/ %U https://doi.org/10.2196/15352 %U http://www.ncbi.nlm.nih.gov/pubmed/32969831 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19732 %T Consumer-Grade Wearable Device for Predicting Frailty in Canadian Home Care Service Clients: Prospective Observational Proof-of-Concept Study %A Kim,Ben %A McKay,Sandra M %A Lee,Joon %+ Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada, 1 403 220 2968, joonwu.lee@ucalgary.ca %K frailty %K mobile health %K wearables %K physical activity %K home care %K prediction %K predictive modeling, older adults %K activities of daily living, sleep %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Frailty has detrimental health impacts on older home care clients and is associated with increased hospitalization and long-term care admission. The prevalence of frailty among home care clients is poorly understood and ranges from 4.0% to 59.1%. Although frailty screening tools exist, their inconsistent use in practice calls for more innovative and easier-to-use tools. Owing to increases in the capacity of wearable devices, as well as in technology literacy and adoption in Canadian older adults, wearable devices are emerging as a viable tool to assess frailty in this population. Objective: The objective of this study was to prove that using a wearable device for assessing frailty in older home care clients could be possible. Methods: From June 2018 to September 2019, we recruited home care clients aged 55 years and older to be monitored over a minimum of 8 days using a wearable device. Detailed sociodemographic information and patient assessments including degree of comorbidity and activities of daily living were collected. Frailty was measured using the Fried Frailty Index. Data collected from the wearable device were used to derive variables including daily step count, total sleep time, deep sleep time, light sleep time, awake time, sleep quality, heart rate, and heart rate standard deviation. Using both wearable and conventional assessment data, multiple logistic regression models were fitted via a sequential stepwise feature selection to predict frailty. Results: A total of 37 older home care clients completed the study. The mean age was 82.27 (SD 10.84) years, and 76% (28/37) were female; 13 participants were frail, significantly older (P<.01), utilized more home care service (P=.01), walked less (P=.04), slept longer (P=.01), and had longer deep sleep time (P<.01). Total sleep time (r=0.41, P=.01) and deep sleep time (r=0.53, P<.01) were moderately correlated with frailty. The logistic regression model fitted with deep sleep time, step count, age, and education level yielded the best predictive performance with an area under the receiver operating characteristics curve value of 0.90 (Hosmer-Lemeshow P=.88). Conclusions: We proved that a wearable device could be used to assess frailty for older home care clients. Wearable data complemented the existing assessments and enhanced predictive power. Wearable technology can be used to identify vulnerable older adults who may benefit from additional home care services. %M 32880582 %R 10.2196/19732 %U https://www.jmir.org/2020/9/e19732 %U https://doi.org/10.2196/19732 %U http://www.ncbi.nlm.nih.gov/pubmed/32880582 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18253 %T Relationship Between Chronic Stress and Heart Rate Over Time Modulated by Gender in a Cohort of Office Workers: Cross-Sectional Study Using Wearable Technologies %A van Kraaij,Alex Wilhelmus Jacobus %A Schiavone,Giuseppina %A Lutin,Erika %A Claes,Stephan %A Van Hoof,Chris %+ OnePlanet Research Center, imec-the Netherlands, Bronland 10, Wageningen, 6708 WH, Netherlands, 31 404020400, alex.vankraaij@imec.nl %K chronic stress %K heart rate %K circadian rhythm %K gender %K age %K wearable device %D 2020 %7 9.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic stress is increasing in prevalence and is associated with several physical and mental disorders. Although it is proven that acute stress changes physiology, much less is known about the relationship between physiology and long-term stress. Continuous measurement of vital signs in daily life and chronic stress detection algorithms could serve this purpose. For this, it is paramount to model the effects of chronic stress on human physiology and include other cofounders, such as demographics, enabling the enrichment of a population-wide approach with individual variations. Objective: The main objectives of this study were to investigate the effect of chronic stress on heart rate (HR) over time while correcting for weekdays versus weekends and to test a possible modulation effect by gender and age in a healthy cohort. Methods: Throughout 2016 and 2017, healthy employees of technology companies were asked to participate in a 5-day observation stress study. They were required to wear two wearables, of which one included an electrocardiogram sensor. The derived HR was averaged per hour and served as an output for a mixed design model including a trigonometric fit over time with four harmonics (periods of 24, 12, 8, and 6 hours), gender, age, whether it was a workday or weekend day, and a chronic stress score derived from the Perceived Stress Scale (PSS) as predictors. Results: The study included 328 subjects, of which 142 were female and 186 were male participants, with a mean age of 38.9 (SD 10.2) years and a mean PSS score of 13.7 (SD 6.0). As main effects, gender (χ21=24.02, P<.001); the hour of the day (χ21=73.22, P<.001); the circadian harmonic (χ22=284.4, P<.001); and the harmonic over 12 hours (χ22=242.1, P<.001), over 8 hours (χ22=23.78, P<.001), and over 6 hours (χ22=82.96, P<.001) had a significant effect on HR. Two three-way interaction effects were found. The interaction of age, whether it was a workday or weekend day, and the circadian harmonic over time were significantly correlated with HR (χ22=7.13, P=.03), as well as the interaction of gender, PSS score, and the circadian harmonic over time (χ22=7.59, P=.02). Conclusions: The results show a relationship between HR and the three-way interaction of chronic stress, gender, and the circadian harmonic. The modulation by gender might be related to evolution-based energy utilization strategies, as suggested in related literature studies. More research, including daily cortisol assessment, longer recordings, and a wider population, should be performed to confirm this interpretation. This would enable the development of more complete and personalized models of chronic stress. %M 32902392 %R 10.2196/18253 %U http://www.jmir.org/2020/9/e18253/ %U https://doi.org/10.2196/18253 %U http://www.ncbi.nlm.nih.gov/pubmed/32902392 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19133 %T Social Reminiscence in Older Adults’ Everyday Conversations: Automated Detection Using Natural Language Processing and Machine Learning %A Ferrario,Andrea %A Demiray,Burcu %A Yordanova,Kristina %A Luo,Minxia %A Martin,Mike %+ Department of Management, Technology, and Economics, ETH Zurich, Weinbergstrasse 56/58, Zurich, 8092, Switzerland, 41 44 632 86 24, aferrario@ethz.ch %K aging %K dementia %K reminiscence %K real-life conversations %K electronically activated recorder (EAR) %K natural language processing %K machine learning %K imbalanced learning %D 2020 %7 15.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Reminiscence is the act of thinking or talking about personal experiences that occurred in the past. It is a central task of old age that is essential for healthy aging, and it serves multiple functions, such as decision-making and introspection, transmitting life lessons, and bonding with others. The study of social reminiscence behavior in everyday life can be used to generate data and detect reminiscence from general conversations. Objective: The aims of this original paper are to (1) preprocess coded transcripts of conversations in German of older adults with natural language processing (NLP), and (2) implement and evaluate learning strategies using different NLP features and machine learning algorithms to detect reminiscence in a corpus of transcripts. Methods: The methods in this study comprise (1) collecting and coding of transcripts of older adults’ conversations in German, (2) preprocessing transcripts to generate NLP features (bag-of-words models, part-of-speech tags, pretrained German word embeddings), and (3) training machine learning models to detect reminiscence using random forests, support vector machines, and adaptive and extreme gradient boosting algorithms. The data set comprises 2214 transcripts, including 109 transcripts with reminiscence. Due to class imbalance in the data, we introduced three learning strategies: (1) class-weighted learning, (2) a meta-classifier consisting of a voting ensemble, and (3) data augmentation with the Synthetic Minority Oversampling Technique (SMOTE) algorithm. For each learning strategy, we performed cross-validation on a random sample of the training data set of transcripts. We computed the area under the curve (AUC), the average precision (AP), precision, recall, as well as F1 score and specificity measures on the test data, for all combinations of NLP features, algorithms, and learning strategies. Results: Class-weighted support vector machines on bag-of-words features outperformed all other classifiers (AUC=0.91, AP=0.56, precision=0.5, recall=0.45, F1=0.48, specificity=0.98), followed by support vector machines on SMOTE-augmented data and word embeddings features (AUC=0.89, AP=0.54, precision=0.35, recall=0.59, F1=0.44, specificity=0.94). For the meta-classifier strategy, adaptive and extreme gradient boosting algorithms trained on word embeddings and bag-of-words outperformed all other classifiers and NLP features; however, the performance of the meta-classifier learning strategy was lower compared to other strategies, with highly imbalanced precision-recall trade-offs. Conclusions: This study provides evidence of the applicability of NLP and machine learning pipelines for the automated detection of reminiscence in older adults’ everyday conversations in German. The methods and findings of this study could be relevant for designing unobtrusive computer systems for the real-time detection of social reminiscence in the everyday life of older adults and classifying their functions. With further improvements, these systems could be deployed in health interventions aimed at improving older adults’ well-being by promoting self-reflection and suggesting coping strategies to be used in the case of dysfunctional reminiscence cases, which can undermine physical and mental health. %M 32866108 %R 10.2196/19133 %U http://www.jmir.org/2020/9/e19133/ %U https://doi.org/10.2196/19133 %U http://www.ncbi.nlm.nih.gov/pubmed/32866108 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21916 %T Associations Between Substance Use and Instagram Participation to Inform Social Network–Based Screening Models: Multimodal Cross-Sectional Study %A Bergman,Brandon G %A Wu,Weiyi %A Marsch,Lisa A %A Crosier,Benjamin S %A DeLise,Timothy C %A Hassanpour,Saeed %+ Recovery Research Institute, Center for Addiction Medicine, Massachusetts General Hospital, & Harvard Medical School, 151 Merrimac Street, 6th Floor, Boston, MA, 02114, United States, 1 617 643 7563, bgbergman@mgh.harvard.edu %K substance use %K social network sites %K health risk %K screening %K machine learning %K social media %K Instagram %K alcohol %K drug %D 2020 %7 16.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Technology-based computational strategies that leverage social network site (SNS) data to detect substance use are promising screening tools but rely on the presence of sufficient data to detect risk if it is present. A better understanding of the association between substance use and SNS participation may inform the utility of these technology-based screening tools. Objective: This paper aims to examine associations between substance use and Instagram posts and to test whether such associations differ as a function of age, gender, and race/ethnicity. Methods: Participants with an Instagram account were recruited primarily via Clickworker (N=3117). With participant permission and Instagram’s approval, participants’ Instagram photo posts were downloaded with an application program interface. Participants’ past-year substance use was measured with an adapted version of the National Institute on Drug Abuse Quick Screen. At-risk drinking was defined as at least one past-year instance having “had more than a few alcoholic drinks a day,” drug use was defined as any use of nonprescription drugs, and prescription drug use was defined as any nonmedical use of prescription medications. We used logistic regression to examine the associations between substance use and any Instagram posts and negative binomial regression to examine the associations between substance use and number of Instagram posts. We examined whether age (18-25, 26-38, 39+ years), gender, and race/ethnicity moderated associations in both logistic and negative binomial models. All differences noted were significant at the .05 level. Results: Compared with no at-risk drinking, any at-risk drinking was associated with both a higher likelihood of any Instagram posts and a higher number of posts, except among Hispanic/Latino individuals, in whom at-risk drinking was associated with a similar number of posts. Compared with no drug use, any drug use was associated with a higher likelihood of any posts but was associated with a similar number of posts. Compared with no prescription drug use, any prescription drug use was associated with a similar likelihood of any posts and was associated with a lower number of posts only among those aged 39 years and older. Of note, main effects showed that being female compared with being male and being Hispanic/Latino compared with being White were significantly associated with both a greater likelihood of any posts and a greater number of posts. Conclusions: Researchers developing computational substance use risk detection models using Instagram or other SNS data may wish to consider our findings showing that at-risk drinking and drug use were positively associated with Instagram participation, while prescription drug use was negatively associated with Instagram participation for middle- and older-aged adults. As more is learned about SNS behaviors among those who use substances, researchers may be better positioned to successfully design and interpret innovative risk detection approaches. %M 32936081 %R 10.2196/21916 %U http://www.jmir.org/2020/9/e21916/ %U https://doi.org/10.2196/21916 %U http://www.ncbi.nlm.nih.gov/pubmed/32936081 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18297 %T A New Approach for Detecting Sleep Apnea Using a Contactless Bed Sensor: Comparison Study %A Sadek,Ibrahim %A Heng,Terry Tan Soon %A Seet,Edwin %A Abdulrazak,Bessam %+ AMI-Lab, Computer Science Department, Faculty of Science, University of Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada, 1 819 821 8000 ext 62860, ibrahim.sadek@usherbrooke.ca %K ballistocardiography %K sleep apnea %K vital signs %K eHealth %K mobile health %K home care %D 2020 %7 18.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: At present, there is an increased demand for accurate and personalized patient monitoring because of the various challenges facing health care systems. For instance, rising costs and lack of physicians are two serious problems affecting the patient’s care. Nonintrusive monitoring of vital signs is a potential solution to close current gaps in patient monitoring. As an example, bed-embedded ballistocardiogram (BCG) sensors can help physicians identify cardiac arrhythmia and obstructive sleep apnea (OSA) nonintrusively without interfering with the patient’s everyday activities. Detecting OSA using BCG sensors is gaining popularity among researchers because of its simple installation and accessibility, that is, their nonwearable nature. In the field of nonintrusive vital sign monitoring, a microbend fiber optic sensor (MFOS), among other sensors, has proven to be suitable. Nevertheless, few studies have examined apnea detection. Objective: This study aims to assess the capabilities of an MFOS for nonintrusive vital signs and sleep apnea detection during an in-lab sleep study. Data were collected from patients with sleep apnea in the sleep laboratory at Khoo Teck Puat Hospital. Methods: In total, 10 participants underwent full polysomnography (PSG), and the MFOS was placed under the patient’s mattress for BCG data collection. The apneic event detection algorithm was evaluated against the manually scored events obtained from the PSG study on a minute-by-minute basis. Furthermore, normalized mean absolute error (NMAE), normalized root mean square error (NRMSE), and mean absolute percentage error (MAPE) were employed to evaluate the sensor capabilities for vital sign detection, comprising heart rate (HR) and respiratory rate (RR). Vital signs were evaluated based on a 30-second time window, with an overlap of 15 seconds. In this study, electrocardiogram and thoracic effort signals were used as references to estimate the performance of the proposed vital sign detection algorithms. Results: For the 10 patients recruited for the study, the proposed system achieved reasonable results compared with PSG for sleep apnea detection, such as an accuracy of 49.96% (SD 6.39), a sensitivity of 57.07% (SD 12.63), and a specificity of 45.26% (SD 9.51). In addition, the system achieved close results for HR and RR estimation, such as an NMAE of 5.42% (SD 0.57), an NRMSE of 6.54% (SD 0.56), and an MAPE of 5.41% (SD 0.58) for HR, whereas an NMAE of 11.42% (SD 2.62), an NRMSE of 13.85% (SD 2.78), and an MAPE of 11.60% (SD 2.84) for RR. Conclusions: Overall, the recommended system produced reasonably good results for apneic event detection, considering the fact that we are using a single-channel BCG sensor. Conversely, satisfactory results were obtained for vital sign detection when compared with the PSG outcomes. These results provide preliminary support for the potential use of the MFOS for sleep apnea detection. %M 32945773 %R 10.2196/18297 %U http://www.jmir.org/2020/9/e18297/ %U https://doi.org/10.2196/18297 %U http://www.ncbi.nlm.nih.gov/pubmed/32945773 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19516 %T Automated Fall Detection Algorithm With Global Trigger Tool, Incident Reports, Manual Chart Review, and Patient-Reported Falls: Algorithm Development and Validation With a Retrospective Diagnostic Accuracy Study %A Dolci,Elisa %A Schärer,Barbara %A Grossmann,Nicole %A Musy,Sarah Naima %A Zúñiga,Franziska %A Bachnick,Stefanie %A Simon,Michael %+ Institute of Nursing Science, Department of Public Health, Faculty of Medicine, University of Basel, Bernoullistrasse 28, Basel, 4056, Switzerland, 1 41 612670912, m.simon@unibas.ch %K falls %K adverse event %K harm %K algorithm %K natural language processing %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Falls are common adverse events in hospitals, frequently leading to additional health costs due to prolonged stays and extra care. Therefore, reliable fall detection is vital to develop and test fall prevention strategies. However, conventional methods—voluntary incident reports and manual chart reviews—are error-prone and time consuming, respectively. Using a search algorithm to examine patients’ electronic health record data and flag fall indicators offers an inexpensive, sensitive, cost-effective alternative. Objective: This study’s purpose was to develop a fall detection algorithm for use with electronic health record data, then to evaluate it alongside the Global Trigger Tool, incident reports, a manual chart review, and patient-reported falls. Methods: Conducted on 2 campuses of a large hospital system in Switzerland, this retrospective diagnostic accuracy study consisted of 2 substudies: the first, targeting 240 patients, for algorithm development and the second, targeting 298 patients, for validation. In the development study, we compared the new algorithm’s in-hospital fall rates with those indicated by the Global Trigger Tool and incident reports; in the validation study, we compared the algorithm’s in-hospital fall rates with those from patient-reported falls and manual chart review. We compared the various methods by calculating sensitivity, specificity, and predictive values. Results: Twenty in-hospital falls were discovered in the development study sample. Of these, the algorithm detected 19 (sensitivity 95%), the Global Trigger Tool detected 18 (90%), and incident reports detected 14 (67%). Of the 15 falls found in the validation sample, the algorithm identified all 15 (100%), the manual chart review identified 14 (93%), and the patient-reported fall measure identified 5 (33%). Owing to relatively high numbers of false positives based on falls present on admission, the algorithm’s positive predictive values were 50% (development sample) and 47% (validation sample). Instead of requiring 10 minutes per case for a full manual review or 20 minutes to apply the Global Trigger Tool, the algorithm requires only a few seconds, after which only the positive results (roughly 11% of the full case number) require review. Conclusions: The newly developed electronic health record algorithm demonstrated very high sensitivity for fall detection. Applied in near real time, the algorithm can record in-hospital falls events effectively and help to develop and test fall prevention measures. %M 32955445 %R 10.2196/19516 %U http://www.jmir.org/2020/9/e19516/ %U https://doi.org/10.2196/19516 %U http://www.ncbi.nlm.nih.gov/pubmed/32955445 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19201 %T Comparability of Emotion Dynamics Derived From Ecological Momentary Assessments, Daily Diaries, and the Day Reconstruction Method: Observational Study %A Schneider,Stefan %A Junghaenel,Doerte U %A Gutsche,Tania %A Mak,Hio Wa %A Stone,Arthur A %+ University of Southern California, Dornsife Center for Self-Report Science, 635 Downey Way, Los Angeles, CA, 90089-3332, United States, 1 2138211774, schneids@usc.edu %K ecological momentary assessment %K daily diaries %K day reconstruction method %K emotion dynamics %K emotion variability %K mobile phone %D 2020 %7 24.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Interest in the measurement of the temporal dynamics of people’s emotional lives has risen substantially in psychological and medical research. Emotions fluctuate and change over time, and measuring the ebb and flow of people’s affective experiences promises enhanced insights into people’s health and functioning. Researchers have used a variety of intensive longitudinal assessment (ILA) methods to create measures of emotion dynamics, including ecological momentary assessments (EMAs), end-of-day (EOD) diaries, and the day reconstruction method (DRM). To date, it is unclear whether they can be used interchangeably or whether ostensibly similar emotion dynamics captured by the methods differ in meaningful ways. Objective: This study aims to examine the extent to which different ILA methods yield comparable measures of intraindividual emotion dynamics. Methods: Data from 90 participants aged 50 years or older were collected in a probability-based internet panel, the Understanding America Study, and analyzed. Participants provided positive and negative affect ratings using 3 ILA methods: (1) smartphone-based EMA, administered 6 times per day over 1 week, (2) web-based EOD diaries, administered daily over the same week, and (3) web-based DRM, administered once during that week. We calculated 11 measures of emotion dynamics (addressing mean levels, variability, instability, and inertia separately for positive and negative affect, as well as emotion network density, mixed emotions, and emotional dialecticism) from each ILA method. The analyses examined mean differences and correlations of scores addressing the same emotion dynamic across the ILA methods. We also compared the patterns of intercorrelations among the emotion dynamics and their relationships with health outcomes (general health, pain, and fatigue) across ILA methods. Results: Emotion dynamics derived from EMAs and EOD diaries demonstrated moderate-to-high correspondence for measures of mean emotion levels (ρ≥0.95), variability (ρ≥0.68), instability (ρ≥0.51), mixed emotions (ρ=0.92), and emotional dialecticism (ρ=0.57), and low correspondence for measures of inertia (ρ≥0.17) and emotion network density (ρ=0.36). DRM-derived measures showed correlations with EMAs and EOD diaries that were high for mean emotion levels and mixed emotions (ρ≥0.74), moderate for variability (ρ=0.38-.054), and low to moderate for other measures (ρ=0.03-0.41). Intercorrelations among the emotion dynamics showed high convergence across EMAs and EOD diaries, and moderate convergence between the DRM and EMAs as well as EOD diaries. Emotion dynamics from all 3 ILA methods produced very similar patterns of relationships with health outcomes. Conclusions: EMAs and EOD diaries provide corresponding information about individual differences in various emotion dynamics, whereas the DRM provides corresponding information about emotion levels and (to a lesser extent) variability, but not about more complex emotion dynamics. Our results caution researchers against viewing these ILA methods as universally interchangeable. %M 32969835 %R 10.2196/19201 %U http://www.jmir.org/2020/9/e19201/ %U https://doi.org/10.2196/19201 %U http://www.ncbi.nlm.nih.gov/pubmed/32969835 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20910 %T Exploring Types of Information Sources Used When Choosing Doctors: Observational Study in an Online Health Care Community %A Zhang,Shuang %A Wang,Jying-Nan %A Chiu,Ya-Ling %A Hsu,Yuan-Teng %+ Research Center of Finance, Shanghai Business School, No 2271 West Zhong Shan Rd, Shanghai, 200235, China, 86 21 64870020 ext 1404, yuanteng.hsu@gmail.com %K information source %K decision making %K online reviews %K online health care community %K doctor %K health information %D 2020 %7 16.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patients attempt to make appropriate decisions based on their own knowledge when choosing a doctor. In this process, the first question usually faced is that of how to obtain useful and relevant information. This study investigated the types of information sources that are used widely by patients in choosing a doctor and identified ways in which the preferred sources differ in various situations. Objective: This study aims to address the following questions: (1) What is the proportion in which each of the various information sources is used? (2) How does the information source preferred by patients in choosing a doctor change when there is a difference in the difficulty of medical decision making, in the level of the hospital, or in a rural versus urban situation? (3) How do information sources used by patients differ when they choose doctors with different specialties? Methods: This study overcomes a major limitation in the use of the survey technique by employing data from the Good Doctor website, which is now China's leading online health care community, data which are objective and can be obtained relatively easily and frequently. Multinomial logistic regression models were applied to examine whether the proportion of use of these information sources changes in different situations. We then used visual analysis to explore the question of which type of information source patients prefer to use when they seek medical assistance from doctors with different specialties. Results: The 3 main information sources were online reviews (OR), family and friend recommendations (FR), and doctor recommendations (DR), with proportions of use of 32.93% (559,345/1,698,666), 23.68% (402,322/1,698,666), and 17.48% (296,912/1,698,666), respectively. Difficulty in medical decision making, the hospital level, and rural-urban differences were significantly associated with patients’ preferred information sources for choosing doctors. Further, the sources of information that patients prefer to use were found to vary when they looked for doctors with different medical specialties. Conclusions: Patients are less likely to use online reviews when medical decisions are more difficult or when the provider is not a tertiary hospital, the former situation leading to a greater use of online reviews and the latter to a greater use of family and friend recommendations. In addition, patients in large cities are more likely to use information from online reviews than family and friend recommendations. Among different medical specialties, for those in which personal privacy is a concern, online reviews are the most common source. For those related to children, patients are more likely to refer to family and friend recommendations, and for those related to surgery, they value doctor recommendations more highly. Our results can not only contribute to aiding government efforts to further promote the dissemination of health care information but may also help health care industry managers develop better marketing strategies. %M 32936080 %R 10.2196/20910 %U http://www.jmir.org/2020/9/e20910/ %U https://doi.org/10.2196/20910 %U http://www.ncbi.nlm.nih.gov/pubmed/32936080 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e16984 %T Impact of MyDiabetesPlan, a Web-Based Patient Decision Aid on Decisional Conflict, Diabetes Distress, Quality of Life, and Chronic Illness Care in Patients With Diabetes: Cluster Randomized Controlled Trial %A Yu,Catherine %A Choi,Dorothy %A Bruno,Brigida A %A Thorpe,Kevin E %A Straus,Sharon E %A Cantarutti,Paul %A Chu,Karen %A Frydrych,Paul %A Hoang-Kim,Amy %A Ivers,Noah %A Kaplan,David %A Leung,Fok-Han %A Maxted,John %A Rezmovitz,Jeremy %A Sale,Joanna %A Sodhi-Helou,Sumeet %A Stacey,Dawn %A Telner,Deanna %+ St. Michael's Hospital (Unity Health Toronto), 30 Bond St, Toronto, ON, Canada, 1 416 864 6060, catherine.yu@unityhealth.to %K shared decision making %K goals of care %K decision aid %K diabetes mellitus %K decisional conflict %K quality of life %K patient assessment of chronic illness care %K diabetes distress %K randomized clinical trials %D 2020 %7 30.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Person-centered care is critical for delivering high-quality diabetes care. Shared decision making (SDM) is central to person-centered care, and in diabetes care, it can improve decision quality, patient knowledge, and patient risk perception. Delivery of person-centered care can be facilitated with the use of patient decision aids (PtDAs). We developed MyDiabetesPlan, an interactive SDM and goal-setting PtDA designed to help individualize care priorities and support an interprofessional approach to SDM. Objective: This study aims to assess the impact of MyDiabetesPlan on decisional conflict, diabetes distress, health-related quality of life, and patient assessment of chronic illness care at the individual patient level. Methods: A two-step, parallel, 10-site cluster randomized controlled trial (first step: provider-directed implementation only; second step: both provider- and patient-directed implementation 6 months later) was conducted. Participants were adults 18 years and older with diabetes and 2 other comorbidities at 10 family health teams (FHTs) in Southwestern Ontario. FHTs were randomly assigned to MyDiabetesPlan (n=5) or control (n=5) through a computer-generated algorithm. MyDiabetesPlan was integrated into intervention practices, and clinicians (first step) followed by patients (second step) were trained on its use. Control participants received static generic Diabetes Canada resources. Patients were not blinded. Participants completed validated questionnaires at baseline, 6 months, and 12 months. The primary outcome at the individual patient level was decisional conflict; secondary outcomes were diabetes distress, health-related quality of life, chronic illness care, and clinician intention to practice interprofessional SDM. Multilevel hierarchical regression models were used. Results: At the end of the study, the intervention group (5 clusters, n=111) had a modest reduction in total decisional conflicts compared with the control group (5 clusters, n=102; −3.5, 95% CI −7.4 to 0.42). Although there was no difference in diabetes distress or health-related quality of life, there was an increase in patient assessment of chronic illness care (0.7, 95% CI 0.4 to 1.0). Conclusions: Use of goal-setting decision aids modestly improved decision quality and chronic illness care but not quality of life. Our findings may be due to a gap between goal setting and attainment, suggesting a role for optimizing patient engagement and behavioral support. The next steps include clarifying the mechanisms by which decision aids impact outcomes and revising MyDiabetesPlan and its delivery. Trial Registration: ClinicalTrials.gov NCT02379078; https://clinicaltrials.gov/ct2/show/NCT02379078 %M 32996893 %R 10.2196/16984 %U http://www.jmir.org/2020/9/e16984/ %U https://doi.org/10.2196/16984 %U http://www.ncbi.nlm.nih.gov/pubmed/32996893 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18870 %T Patient Portal Barriers and Group Differences: Cross-Sectional National Survey Study %A Turner,Kea %A Clary,Alecia %A Hong,Young-Rock %A Alishahi Tabriz,Amir %A Shea,Christopher M %+ Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 USF Magnolia Drive, MRC-CANCONT, Tampa, FL, 33612, United States, 1 813 745 5213, kea.turner@gmail.com %K patient portal %K personal health record %K electronic health record %K implementation %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Past studies examining barriers to patient portal adoption have been conducted with a small number of patients and health care settings, limiting generalizability. Objective: This study had the following two objectives: (1) to assess the prevalence of barriers to patient portal adoption among nonadopters and (2) to examine the association between nonadopter characteristics and reported barriers in a nationally representative sample. Methods: Data from this study were obtained from the 2019 Health Information National Trends Survey. We calculated descriptive statistics to determine the most prevalent barriers and conducted multiple variable logistic regression analysis to examine which characteristics were associated with the reported barriers. Results: The sample included 4815 individuals. Among these, 2828 individuals (58.73%) had not adopted a patient portal. Among the nonadopters (n=2828), the most prevalent barriers were patient preference for in-person communication (1810/2828, 64.00%), no perceived need for the patient portal (1385/2828, 48.97%), and lack of comfort and experience with computers (735/2828, 25.99%). Less commonly, individuals reported having no patient portal (650/2828, 22.98%), no internet access (650/2828, 22.98%), privacy concerns (594/2828, 21.00%), difficulty logging on (537/2828, 18.99%), and multiple patient portals (255/2828, 9.02%) as barriers. Men had significantly lower odds of indicating a preference for speaking directly to a provider compared with women (odds ratio [OR] 0.75, 95% CI 0.60-0.94; P=.01). Older age (OR 1.01, 95% CI 1.00-1.02; P<.001), having a chronic condition (OR 1.83, 95% CI 1.44-2.33; P<.001), and having an income lower than US $20,000 (OR 1.61, 95% CI 1.11-2.34; P=.01) were positively associated with indicating a preference for speaking directly to a provider. Hispanic individuals had significantly higher odds of indicating that they had no need for a patient portal (OR 1.59, 95% CI 1.24-2.05; P<.001) compared with non-Hispanic individuals. Older individuals (OR 1.05, 95% CI 1.04-1.06; P<.001), individuals with less than a high school diploma (OR 3.15, 95% CI 1.79-5.53; P<.001), and individuals with a household income of less than US $20,000 (OR 2.78, 95% CI 1.88-4.11; P<.001) had significantly higher odds of indicating that they were uncomfortable with a computer. Conclusions: The most common barriers to patient portal adoption are preference for in-person communication, not having a need for the patient portal, and feeling uncomfortable with computers, which are barriers that are modifiable and can be intervened upon. Patient characteristics can help predict which patients are most likely to experience certain barriers to patient portal adoption. Further research is needed to tailor implementation approaches based on patients’ needs and preferences. %M 32940620 %R 10.2196/18870 %U http://www.jmir.org/2020/9/e18870/ %U https://doi.org/10.2196/18870 %U http://www.ncbi.nlm.nih.gov/pubmed/32940620 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e16373 %T Electronic Health Record Portal Messages and Interactive Voice Response Calls to Improve Rates of Early Season Influenza Vaccination: Randomized Controlled Trial %A Wijesundara,Jessica G %A Ito Fukunaga,Mayuko %A Ogarek,Jessica %A Barton,Bruce %A Fisher,Lloyd %A Preusse,Peggy %A Sundaresan,Devi %A Garber,Lawrence %A Mazor,Kathleen M %A Cutrona,Sarah L %+ Health Services Research & Development, Center of Innovation, Edith Nourse Rogers Memorial Hospital, Veterans Health Administration, 200 Springs St, Building 70, Bedford, MA, 01730, United States, 1 508 856 4046, Sarah.Cutrona@umassmed.edu %K electronic health records %K influenza vaccination %K patient care %K patient engagement %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patient reminders for influenza vaccination, delivered via an electronic health record patient portal and interactive voice response calls, offer an innovative approach to engaging patients and improving patient care. Objective: The goal of this study was to test the effectiveness of portal and interactive voice response outreach in improving rates of influenza vaccination by targeting patients in early September, shortly after vaccinations became available. Methods: Using electronic health record portal messages and interactive voice response calls promoting influenza vaccination, outreach was conducted in September 2015. Participants included adult patients within a large multispecialty group practice in central Massachusetts. Our main outcome was electronic health record–documented early influenza vaccination during the 2015-2016 influenza season, measured in November 2015. We randomly assigned all active portal users to 1 of 2 groups: (1) receiving a portal message promoting influenza vaccinations, listing upcoming clinics, and offering online scheduling of vaccination appointments (n=19,506) or (2) receiving usual care (n=19,505). We randomly assigned all portal nonusers to 1 of 2 groups: (1) receiving interactive voice response call (n=15,000) or (2) receiving usual care (n=43,596). The intervention also solicited patient self-reports on influenza vaccinations completed outside the clinic. Self-reported influenza vaccination data were uploaded into the electronic health records to increase the accuracy of existing provider-directed electronic health record clinical decision support (vaccination alerts) but were excluded from main analyses. Results: Among portal users, 28.4% (5549/19,506) of those randomized to receive messages and 27.1% (5294/19,505) of the usual care group had influenza vaccinations documented by November 2015 (P=.004). In multivariate analysis of portal users, message recipients were slightly more likely to have documented vaccinations when compared to the usual care group (OR 1.07, 95% CI 1.02-1.12). Among portal nonusers, 8.4% (1262/15,000) of those randomized to receive calls and 8.2% (3586/43,596) of usual care had documented vaccinations (P=.47), and multivariate analysis showed nonsignificant differences. Over half of portal messages sent were opened (10,112/19,479; 51.9%), and over half of interactive voice response calls placed (7599/14,984; 50.7%) reached their intended target, thus we attained similar levels of exposure to the messaging for both interventions. Among portal message recipients, 25.4% of message openers (2570/10,112) responded to a subsequent question on receipt of influenza vaccination; among interactive voice response recipients, 72.5% of those reached (5513/7599) responded to a similar question. Conclusions: Portal message outreach to a general primary care population achieved a small but statistically significant improvement in rates of influenza vaccination (OR 1.07, 95% CI 1.02-1.12). Interactive voice response calls did not significantly improve vaccination rates among portal nonusers (OR 1.03, 95% CI 0.96-1.10). Rates of patient engagement with both modalities were favorable. Trial Registration: ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277 %M 32975529 %R 10.2196/16373 %U http://www.jmir.org/2020/9/e16373/ %U https://doi.org/10.2196/16373 %U http://www.ncbi.nlm.nih.gov/pubmed/32975529 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18570 %T DenTiUS Plaque, a Web-Based Application for the Quantification of Bacterial Plaque: Development and Usability Study %A Vila-Blanco,Nicolás %A Freire,Vicente %A Balsa-Castro,Carlos %A Tomás,Inmaculada %A Carreira,María J %+ Centro Singular de Investigación en Tecnoloxías Intelixentes, Universidade de Santiago de Compostela, C/Jenaro de la Fuente, s/n, Santiago de Compostela, E15782, Spain, 34 881816430, mariajose.carreira@usc.es %K computer-aided diagnoses %K computer-based biomedical applications %K dental health %K dental plaque quantification %K web-based tools %K medical informatics %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the dentistry field, the analysis of dental plaque is vital because it is the main etiological factor in the 2 most prevalent oral diseases: caries and periodontitis. In most of the papers published in the dental literature, the quantification of dental plaque is carried out using traditional, non-automated, and time-consuming indices. Therefore, the development of an automated plaque quantification tool would be of great value to clinicians and researchers. Objective: This study aimed to develop a web-based tool called DenTiUS and various clinical indices to evaluate dental plaque levels using image analysis techniques. Methods: The tool was executed as a web-based application to facilitate its use by researchers. Expert users are free to define experiments, including images from either a single patient (to observe an individual plaque growth pattern) or several patients (to perform a group characterization) at a particular moment or over time. A novel approach for detecting visible plaque has been developed as well as a new concept known as nonvisible plaque. This new term implies the classification of the remaining dental area into 3 subregions according to the risk of accumulating plaque in the near future. New metrics have also been created to describe visible and nonvisible plaque levels. Results: The system generates results tables of the quantitative analysis with absolute averages obtained in each image (indices about visible plaque) and relative measurements (indices about visible and nonvisible plaque) relating to the reference moment. The clinical indices that can be calculated are the following: plaque index of an area per intensity (API index, a value between 0 and 100), area growth index (growth rate of plaque per unit of time in hours; percentage area/hour), and area time index (the time in days needed to achieve a plaque area of 100% concerning the initial area at the same moment). Images and graphics can be obtained for a moment from a patient in addition to a full report presenting all the processing data. Dentistry experts evaluated the DenTiUS Plaque software through a usability test, with the best-scoring questions those related to the workflow efficiency, value of the online help, attractiveness of the user interface, and overall satisfaction. Conclusions: The DenTiUS Plaque software allows automatic, reliable, and repeatable quantification of dental plaque levels, providing information about area, intensity, and growth pattern. Dentistry experts recognized that this software is suitable for quantification of dental plaque levels. Consequently, its application in the analysis of plaque evolution patterns associated with different oral conditions, as well as to evaluate the effectiveness of various oral hygiene measures, can represent an improvement in the clinical setting and the methodological quality of research studies. %M 32663148 %R 10.2196/18570 %U https://www.jmir.org/2020/9/e18570 %U https://doi.org/10.2196/18570 %U http://www.ncbi.nlm.nih.gov/pubmed/32663148 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21195 %T Health Technology Readiness Profiles Among Danish Individuals With Type 2 Diabetes: Cross-Sectional Study %A Thorsen,Ida Kær %A Rossen,Sine %A Glümer,Charlotte %A Midtgaard,Julie %A Ried-Larsen,Mathias %A Kayser,Lars %+ The Centre for Physical Activity Research, University of Copenhagen, Rigshospitalet 7641, Blegdamsvej 9, Copenhagen, DK-2100, Denmark, 45 35 45 76 41, ida.kaer.thorsen@regionh.dk %K readiness for health technology %K telemedicine %K diabetes mellitus, type 2 %K socioeconomic factors %K mental health %K psychological distress %K healthcare disparities %K delivery of healthcare %K exercise %D 2020 %7 15.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Information technologies (IT) are increasingly implemented in type 2 diabetes (T2D) treatment as a resource for remotely supported health care. However, possible pitfalls of introducing IT in health care are generally overlooked. Specifically, the effectiveness of IT to improve health care may depend on the user’s readiness for health technology. Objective: We aim to investigate readiness for health technology in relation to mental well-being, sociodemographic, and disease-related characteristics among individuals with T2D. Methods: Individuals with T2D (aged ≥18 years) who had been referred to self-management education, exercise, diet counseling, smoking cessation, or alcohol counseling completed a questionnaire survey covering (1) background information, (2) the 5-item World Health Organization Well-Being Index (WHO-5), (3) receptiveness to IT use in physical activity, and (4) the Readiness and Enablement Index for Health Technology (READHY), constituted by dimensions related to self-management, social support, and eHealth literacy. Individuals were divided into profiles using cluster analysis based on their READHY scores. Outcomes included differences across profiles in mental well-being, sociodemographic, and disease-related characteristics. Results: Participants in the study were 155 individuals with T2D with a mean age of 60.2 (SD 10.7) years, 55.5% (86/155) of which were men and 44.5% (69/155) of which were women. Participants were stratified into 5 health technology readiness profiles based on the cluster analysis: Profile 1, high health technology readiness; Profile 2, medium health technology readiness; Profile 3, medium health technology readiness and high level of emotional distress; Profile 4, medium health technology readiness and low-to-medium eHealth literacy; Profile 5, low health technology readiness. No differences in sociodemographic and disease-related characteristics were observed across profiles; however, we identified 3 vulnerable subgroups of individuals: Profile 3 (21/155, 13.5%), younger individuals (mean age of 53.4 years, SD 8.9 years) with low mental well-being (mean 42.7, SD 14.7) and emotional distress (mean 1.69, SD 0.38); Profile 4 (20/155, 12.9%), older individuals (mean age 66.3 years, SD 9.0 years) with less IT use (50.0% used IT for communication) and low-to-medium eHealth literacy; and Profile 5 (36/155, 23.2%) with low mental well-being (mean 43.4, SD 20.1) and low readiness for health technology. Conclusions: Implementation of IT in health care of individuals with T2D should be based on comprehensive consideration of mental well-being, emotional distress, and readiness for health technology rather than sociodemographic and disease-related characteristics to identify the individuals in need of social support, self-management education, and extensive IT support. A one-size-fits-all approach to IT implementation in health care will potentially increase the risk of treatment failure among the most vulnerable individuals. %M 32930669 %R 10.2196/21195 %U http://www.jmir.org/2020/9/e21195/ %U https://doi.org/10.2196/21195 %U http://www.ncbi.nlm.nih.gov/pubmed/32930669 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19472 %T Validation of the Raw National Aeronautics and Space Administration Task Load Index (NASA-TLX) Questionnaire to Assess Perceived Workload in Patient Monitoring Tasks: Pooled Analysis Study Using Mixed Models %A Said,Sadiq %A Gozdzik,Malgorzata %A Roche,Tadzio Raoul %A Braun,Julia %A Rössler,Julian %A Kaserer,Alexander %A Spahn,Donat R %A Nöthiger,Christoph B %A Tscholl,David Werner %+ Department of Anesthesiology, University Hospital Zurich, Raemistrasse 100, Zurich, 8091, Switzerland, 41 786718911, sadiq.said@usz.ch %K workload %K questionnaires %K National Aeronautics and Space Administration Task Load Index %K awareness %K situation awareness %K patient monitoring %K thromboelastometry %D 2020 %7 7.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Patient monitoring is indispensable in any operating room to follow the patient’s current health state based on measured physiological parameters. Reducing workload helps to free cognitive resources and thus influences human performance, which ultimately improves the quality of care. Among the many methods available to assess perceived workload, the National Aeronautics and Space Administration Task Load Index (NASA-TLX) provides the most widely accepted tool. However, only few studies have investigated the validity of the NASA-TLX in the health care sector. Objective: This study aimed to validate a modified version of the raw NASA-TLX in patient monitoring tasks by investigating its correspondence with expected lower and higher workload situations and its robustness against nonworkload-related covariates. This defines criterion validity. Methods: In this pooled analysis, we evaluated raw NASA-TLX scores collected after performing patient monitoring tasks in four different investigator-initiated, computer-based, prospective, multicenter studies. All of them were conducted in three hospitals with a high standard of care in central Europe. In these already published studies, we compared conventional patient monitoring with two newly developed situation awareness–oriented monitoring technologies called Visual Patient and Visual Clot. The participants were resident and staff anesthesia and intensive care physicians, and nurse anesthetists with completed specialization qualification. We analyzed the raw NASA-TLX scores by fitting mixed linear regression models and univariate models with different covariates. Results: We assessed a total of 1160 raw NASA-TLX questionnaires after performing specific patient monitoring tasks. Good test performance and higher self-rated diagnostic confidence correlated significantly with lower raw NASA-TLX scores and the subscores (all P<.001). Staff physicians rated significantly lower workload scores than residents (P=.001), whereas nurse anesthetists did not show any difference in the same comparison (P=.83). Standardized distraction resulted in higher rated total raw NASA-TLX scores (P<.001) and subscores. There was no gender difference regarding perceived workload (P=.26). The new visualization technologies Visual Patient and Visual Clot resulted in significantly lower total raw NASA-TLX scores and all subscores, including high self-rated performance, when compared with conventional monitoring (all P<.001). Conclusions: This study validated a modified raw NASA-TLX questionnaire for patient monitoring tasks. The scores obtained correctly represented the assumed influences of the examined covariates on the perceived workload. We reported high criterion validity. The NASA-TLX questionnaire appears to be a reliable tool for measuring subjective workload. Further research should focus on its applicability in a clinical setting. %M 32780712 %R 10.2196/19472 %U http://www.jmir.org/2020/9/e19472/ %U https://doi.org/10.2196/19472 %U http://www.ncbi.nlm.nih.gov/pubmed/32780712 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20641 %T Automatic Grading of Stroke Symptoms for Rapid Assessment Using Optimized Machine Learning and 4-Limb Kinematics: Clinical Validation Study %A Park,Eunjeong %A Lee,Kijeong %A Han,Taehwa %A Nam,Hyo Suk %+ Department of Neurology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemoon-gu, Seoul, 03722, Republic of Korea, 82 222280245, hsnam@yuhs.ac %K machine learning %K artificial intelligence %K sensors %K kinematics %K stroke %K telemedicine %D 2020 %7 16.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Subtle abnormal motor signs are indications of serious neurological diseases. Although neurological deficits require fast initiation of treatment in a restricted time, it is difficult for nonspecialists to detect and objectively assess the symptoms. In the clinical environment, diagnoses and decisions are based on clinical grading methods, including the National Institutes of Health Stroke Scale (NIHSS) score or the Medical Research Council (MRC) score, which have been used to measure motor weakness. Objective grading in various environments is necessitated for consistent agreement among patients, caregivers, paramedics, and medical staff to facilitate rapid diagnoses and dispatches to appropriate medical centers. Objective: In this study, we aimed to develop an autonomous grading system for stroke patients. We investigated the feasibility of our new system to assess motor weakness and grade NIHSS and MRC scores of 4 limbs, similar to the clinical examinations performed by medical staff. Methods: We implemented an automatic grading system composed of a measuring unit with wearable sensors and a grading unit with optimized machine learning. Inertial sensors were attached to measure subtle weaknesses caused by paralysis of upper and lower limbs. We collected 60 instances of data with kinematic features of motor disorders from neurological examination and demographic information of stroke patients with NIHSS 0 or 1 and MRC 7, 8, or 9 grades in a stroke unit. Training data with 240 instances were generated using a synthetic minority oversampling technique to complement the imbalanced number of data between classes and low number of training data. We trained 2 representative machine learning algorithms, an ensemble and a support vector machine (SVM), to implement auto-NIHSS and auto-MRC grading. The optimized algorithms performed a 5-fold cross-validation and were searched by Bayes optimization in 30 trials. The trained model was tested with the 60 original hold-out instances for performance evaluation in accuracy, sensitivity, specificity, and area under the receiver operating characteristics curve (AUC). Results: The proposed system can grade NIHSS scores with an accuracy of 83.3% and an AUC of 0.912 using an optimized ensemble algorithm, and it can grade with an accuracy of 80.0% and an AUC of 0.860 using an optimized SVM algorithm. The auto-MRC grading achieved an accuracy of 76.7% and a mean AUC of 0.870 in SVM classification and an accuracy of 78.3% and a mean AUC of 0.877 in ensemble classification. Conclusions: The automatic grading system quantifies proximal weakness in real time and assesses symptoms through automatic grading. The pilot outcomes demonstrated the feasibility of remote monitoring of motor weakness caused by stroke. The system can facilitate consistent grading with instant assessment and expedite dispatches to appropriate hospitals and treatment initiation by sharing auto-MRC and auto-NIHSS scores between prehospital and hospital responses as an objective observation. %M 32936079 %R 10.2196/20641 %U http://www.jmir.org/2020/9/e20641/ %U https://doi.org/10.2196/20641 %U http://www.ncbi.nlm.nih.gov/pubmed/32936079 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18234 %T A Rapid Electronic Cognitive Assessment Measure for Multiple Sclerosis: Validation of Cognitive Reaction, an Electronic Version of the Symbol Digit Modalities Test %A Middleton,Rod M %A Pearson,Owen R %A Ingram,Gillian %A Craig,Elaine M %A Rodgers,William J %A Downing-Wood,Hannah %A Hill,Joseph %A Tuite-Dalton,Katherine %A Roberts,Christopher %A Watson,Lynne %A Ford,David V %A Nicholas,Richard %A , %+ Population Data Science, Swansea University Medical School, Swansea University, Data Science Building, Singleton Park, Swansea, SA2 8PP, United Kingdom, 44 1792606760, r.m.middleton@swansea.ac.uk %K cognition %K multiple sclerosis %K eHealth %K electronic assessment %K patient reported outcomes %K neurology %D 2020 %7 23.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Incorporating cognitive testing into routine clinical practice is a challenge in multiple sclerosis (MS), given the wide spectrum of both cognitive and physical impairments people can have and the time that testing requires. Shortened paper and verbal assessments predominate but still are not used routinely. Computer-based tests are becoming more widespread; however, changes in how a paper test is implemented can impact what exactly is being assessed in an individual. The Symbol Digit Modalities Test (SDMT) is one validated test that forms part of the cognitive batteries used in MS and has some computer-based versions. We developed a tablet-based SDMT variant that has the potential to be ultimately deployed to patients’ own devices. Objective: This paper aims to develop, validate, and deploy a computer-based SDMT variant, the Cognition Reaction (CoRe) test, that can reliably replicate the characteristics of the paper-based SDMT. Methods: We carried out analysis using Pearson and intraclass correlations, as well as a Bland-Altman comparison, to examine consistency between the SDMT and CoRe tests and for test-retest reliability. The SDMT and CoRe tests were evaluated for sensitivity to disability levels and age. A novel metric in CoRe was found: question answering velocity could be calculated. This was evaluated in relation to disability levels and age for people with MS and compared with a group of healthy control volunteers. Results: SDMT and CoRe test scores were highly correlated and consistent with 1-month retest values. Lower scores were seen in patients with higher age and some effect was seen with increasing disability. There was no learning effect evident. Question answering velocity demonstrated a small increase in speed over the 90-second duration of the test in people with MS and healthy controls. Conclusions: This study validates a computer-based alternative to the SDMT that can be used in clinics and beyond. It enables accurate recording of elements of cognition relevant in MS but offers additional metrics that may offer further value to clinicians and people with MS. %M 32965240 %R 10.2196/18234 %U http://www.jmir.org/2020/9/e18234/ %U https://doi.org/10.2196/18234 %U http://www.ncbi.nlm.nih.gov/pubmed/32965240 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19716 %T Mobile Insight in Risk, Resilience, and Online Referral (MIRROR): Psychometric Evaluation of an Online Self-Help Test %A van Herpen,Merel Marjolein %A Boeschoten,Manon A %A te Brake,Hans %A van der Aa,Niels %A Olff,Miranda %+ ARQ Centre of Expertise for the Impact of Disasters and Crises, Nienoord 5, Diemen, , Netherlands, 31 610082023, m.van.herpen@impact.arq.org %K potentially traumatic events %K mobile mental health %K self-help %K online %K resilience %K posttraumatic stress disorder %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Most people who experience a potentially traumatic event (PTE) recover on their own. A small group of individuals develops psychological complaints, but this is often not detected in time or guidance to care is suboptimal. To identify these individuals and encourage them to seek help, a web-based self-help test called Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) was developed. MIRROR takes an innovative approach since it integrates both negative and positive outcomes of PTEs and time since the event and provides direct feedback to the user. Objective: The goal of this study was to assess MIRROR’s use, examine its psychometric properties (factor structure, internal consistency, and convergent and divergent validity), and evaluate how well it classifies respondents into different outcome categories compared with reference measures. Methods: MIRROR was embedded in the website of Victim Support Netherlands so visitors could use it. We compared MIRROR’s outcomes to reference measures of PTSD symptoms (PTSD Checklist for DSM-5), depression, anxiety, stress (Depression Anxiety Stress Scale–21), psychological resilience (Resilience Evaluation Scale), and positive mental health (Mental Health Continuum Short Form). Results: In 6 months, 1112 respondents completed MIRROR, of whom 663 also completed the reference measures. Results showed good internal consistency (interitem correlations range .24 to .55, corrected item-total correlations range .30 to .54, and Cronbach alpha coefficient range .62 to .68), and convergent and divergent validity (Pearson correlations range –.259 to .665). Exploratory and confirmatory factor analyses (EFA+CFA) yielded a 2-factor model with good model fit (CFA model fit indices: χ219=107.8, P<.001, CFI=.965, TLI=.948, RMSEA=.065), conceptual meaning, and parsimony. MIRROR correctly classified respondents into different outcome categories compared with the reference measures. Conclusions: MIRROR is a valid and reliable self-help test to identify negative (PTSD complaints) and positive outcomes (psychosocial functioning and resilience) of PTEs. MIRROR is an easily accessible online tool that can help people who have experienced a PTE to timely identify psychological complaints and find appropriate support, a tool that might be highly needed in times like the coronavirus pandemic. %M 32975521 %R 10.2196/19716 %U http://www.jmir.org/2020/9/e19716/ %U https://doi.org/10.2196/19716 %U http://www.ncbi.nlm.nih.gov/pubmed/32975521 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17164 %T Nonprofessional Peer Support to Improve Mental Health: Randomized Trial of a Scalable Web-Based Peer Counseling Course %A Bernecker,Samantha L %A Williams,Joseph Jay %A Caporale-Berkowitz,Norian A %A Wasil,Akash R %A Constantino,Michael J %+ Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115-5899, United States, 1 8145749625, samantha.bernecker@gmail.com %K online learning %K nonprofessional education %K educational technology %K computer-assisted instruction %K social support %K mental health %K psychological stress %K eHealth %K internet %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Millions of people worldwide are underserved by the mental health care system. Indeed, most mental health problems go untreated, often because of resource constraints (eg, limited provider availability and cost) or lack of interest or faith in professional help. Furthermore, subclinical symptoms and chronic stress in the absence of a mental illness diagnosis often go unaddressed, despite their substantial health impact. Innovative and scalable treatment delivery methods are needed to supplement traditional therapies to fill these gaps in the mental health care system. Objective: This study aims to investigate whether a self-guided web-based course can teach pairs of nonprofessional peers to deliver psychological support to each other. Methods: In this experimental study, a community sample of 30 dyads (60 participants, mostly friends), many of whom presented with mild to moderate psychological distress, were recruited to complete a web-based counseling skills course. Dyads were randomized to either immediate or delayed access to training. Before and after training, dyads were recorded taking turns discussing stressors. Participants’ skills in the helper role were assessed before and after taking the course: the first author and a team of trained research assistants coded recordings for the presence of specific counseling behaviors. When in the client role, participants rated the session on helpfulness in resolving their stressors and supportiveness of their peers. We hypothesized that participants would increase the use of skills taught by the course and decrease the use of skills discouraged by the course, would increase their overall adherence to the guidelines taught in the course, and would perceive posttraining counseling sessions as more helpful and their peers as more supportive. Results: The course had large effects on most helper-role speech behaviors: helpers decreased total speaking time, used more restatements, made fewer efforts to influence the speaker, and decreased self-focused and off-topic utterances (ds=0.8-1.6). When rating the portion of the session in which they served as clients, participants indicated that they made more progress in addressing their stressors during posttraining counseling sessions compared with pretraining sessions (d=1.1), but they did not report substantive changes in feelings of closeness and supportiveness of their peers (d=0.3). Conclusions: The results provide proof of concept that nonprofessionals can learn basic counseling skills from a scalable web-based course. The course serves as a promising model for the development of web-based counseling skills training, which could provide accessible mental health support to some of those underserved by traditional psychotherapy. %M 32955451 %R 10.2196/17164 %U http://www.jmir.org/2020/9/e17164/ %U https://doi.org/10.2196/17164 %U http://www.ncbi.nlm.nih.gov/pubmed/32955451 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18737 %T Influencing Factors of Continuous Use of Web-Based Diagnosis and Treatment by Patients With Diabetes: Model Development and Data Analysis %A Ju,Chunhua %A Zhang,Shuangzhu %+ Business Administration College, Zhejiang Gongshang University, 18 Xuezheng Street, Hangzhou City, Zhejiang Province, Zhejiang Province, 310001, China, 86 15968138344, zhangshuangzhu0917@126.com %K online health communities %K patient-doctor trust %K ELM %K trust theory %K structural equation modeling %K online continuous diagnosis and treatment %D 2020 %7 28.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The internet has become a major source of health care information for patients and has enabled them to obtain continuous diagnosis and treatment services. However, the quality of web-based health care information is mixed, which raises concerns about the credibility of physician advice obtained on the internet and markedly affects patients’ choices and decision-making behavior with regard to web-based diagnosis and treatment. Therefore, it is important to identify the influencing factors of continuous use of web-based diagnosis and treatment from the perspective of trust. Objective: The objective of our study was to investigate the influencing factors of patients’ continuous use of web-based diagnosis and treatment based on the elaboration likelihood model and on trust theory in the face of a decline in physiological conditions and the lack of convenient long-term professional guidance. Methods: Data on patients with diabetes in China who used an online health community twice or more from January 2018 to June 2019 were collected by developing a web crawler. A total of 2437 valid data records were obtained and then analyzed using correlation factor analysis and regression analysis to validate our research model and hypotheses. Results: The timely response rate (under the central route), the reference group (under the peripheral route), and the number of thank-you letters and patients’ ratings that measure physicians’ electronic word of mouth are all positively related with the continuous use of web-based diagnosis and treatment by patients with diabetes. Moreover, the physician’s professional title and hospital’s ranking level had weak effects on the continuous use of web-based diagnosis and treatment by patients with diabetes, and the effect size of the physician’s professional title was greater than that of the hospital’s ranking level. Conclusions: From the patient's perspective, among all indicators that measure physicians’ service quality, the effect size of a timely response rate is much greater than those of effect satisfaction and attitude satisfaction; thus, the former plays an essential role in influencing the patients’ behavior of continuous use of web-based diagnosis and treatment services. In addition, the effect size of electronic word of mouth was greater than that of the physician’s offline reputation. Physicians who provide web-based services should seek clues to patients’ needs and preferences for receiving health information during web-based physician-patient interactions and make full use of their professionalism and service reliability to communicate effectively with patients. Furthermore, the platform should improve its electronic word of mouth mechanism to realize its full potential in trust transmission and motivation, ultimately promoting the patient’s information-sharing behavior and continuous use of web-based diagnosis and treatment. %M 32771982 %R 10.2196/18737 %U http://www.jmir.org/2020/9/e18737/ %U https://doi.org/10.2196/18737 %U http://www.ncbi.nlm.nih.gov/pubmed/32771982 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19096 %T An Ovarian Reserve Assessment Model Based on Anti-Müllerian Hormone Levels, Follicle-Stimulating Hormone Levels, and Age: Retrospective Cohort Study %A Xu,Huiyu %A Shi,Li %A Feng,Guoshuang %A Xiao,Zhen %A Chen,Lixue %A Li,Rong %A Qiao,Jie %+ Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, 49 Huayuan North, Haidian District, Beijing, , China, 86 1082266836, roseli001@sina.com %K ovarian reserve %K poor ovarian response %K AMH %K AFC %K FSH %K logistic regression %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Previously, we reported a model for assessing ovarian reserves using 4 predictors: anti-Müllerian hormone (AMH) level, antral follicle count (AFC), follicle-stimulating hormone (FSH) level, and female age. This model is referred as the AAFA (anti-Müllerian hormone level–antral follicle count–follicle-stimulating hormone level–age) model. Objective: This study aims to explore the possibility of establishing a model for predicting ovarian reserves using only 3 factors: AMH level, FSH level, and age. The proposed model is referred to as the AFA (anti-Müllerian hormone level–follicle-stimulating hormone level–age) model. Methods: Oocytes from ovarian cycles stimulated by gonadotropin-releasing hormone antagonist were collected retrospectively at our reproductive center. Poor ovarian response (<5 oocytes retrieved) was defined as an outcome variable. The AFA model was built using a multivariable logistic regression analysis on data from 2017; data from 2018 were used to validate the performance of AFA model. Measurements of the area under the curve (AUC), sensitivity, specificity, positive predictive value, and negative predicative value were used to evaluate the performance of the model. To rank the ovarian reserves of the whole population, we ranked the subgroups according to the predicted probability of poor ovarian response and further divided the 60 subgroups into 4 clusters, A-D, according to cut-off values consistent with the AAFA model. Results: The AUCs of the AFA and AAFA models were similar for the same validation set, with values of 0.853 (95% CI 0.841-0.865) and 0.850 (95% CI 0.838-0.862), respectively. We further ranked the ovarian reserves according to their predicted probability of poor ovarian response, which was calculated using our AFA model. The actual incidences of poor ovarian response in groups from A-D in the AFA model were 0.037 (95% CI 0.029-0.046), 0.128 (95% CI 0.099-0.165), 0.294 (95% CI 0.250-0.341), and 0.624 (95% CI 0.577-0.669), respectively. The order of ovarian reserve from adequate to poor followed the order from A to D. The clinical pregnancy rate, live-birth rate, and specific differences in groups A-D were similar when predicted using the AFA and AAFA models. Conclusions: This AFA model for assessing the true ovarian reserve was more convenient, cost-effective, and objective than our original AAFA model. %M 32667898 %R 10.2196/19096 %U https://www.jmir.org/2020/9/e19096 %U https://doi.org/10.2196/19096 %U http://www.ncbi.nlm.nih.gov/pubmed/32667898 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20268 %T Using Item Response Theory for Explainable Machine Learning in Predicting Mortality in the Intensive Care Unit: Case-Based Approach %A Kline,Adrienne %A Kline,Theresa %A Shakeri Hossein Abad,Zahra %A Lee,Joon %+ Department of Biomedical Engineering, University of Calgary, 2500 University Drive NW, Calgary, AB, Canada, 1 5875831725, askline1@gmail.com %K item response theory %K machine learning %K statistical model %K mortality %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Supervised machine learning (ML) is being featured in the health care literature with study results frequently reported using metrics such as accuracy, sensitivity, specificity, recall, or F1 score. Although each metric provides a different perspective on the performance, they remain to be overall measures for the whole sample, discounting the uniqueness of each case or patient. Intuitively, we know that all cases are not equal, but the present evaluative approaches do not take case difficulty into account. Objective: A more case-based, comprehensive approach is warranted to assess supervised ML outcomes and forms the rationale for this study. This study aims to demonstrate how the item response theory (IRT) can be used to stratify the data based on how difficult each case is to classify, independent of the outcome measure of interest (eg, accuracy). This stratification allows the evaluation of ML classifiers to take the form of a distribution rather than a single scalar value. Methods: Two large, public intensive care unit data sets, Medical Information Mart for Intensive Care III and electronic intensive care unit, were used to showcase this method in predicting mortality. For each data set, a balanced sample (n=8078 and n=21,940, respectively) and an imbalanced sample (n=12,117 and n=32,910, respectively) were drawn. A 2-parameter logistic model was used to provide scores for each case. Several ML algorithms were used in the demonstration to classify cases based on their health-related features: logistic regression, linear discriminant analysis, K-nearest neighbors, decision tree, naive Bayes, and a neural network. Generalized linear mixed model analyses were used to assess the effects of case difficulty strata, ML algorithm, and the interaction between them in predicting accuracy. Results: The results showed significant effects (P<.001) for case difficulty strata, ML algorithm, and their interaction in predicting accuracy and illustrated that all classifiers performed better with easier-to-classify cases and that overall the neural network performed best. Significant interactions suggest that cases that fall in the most arduous strata should be handled by logistic regression, linear discriminant analysis, decision tree, or neural network but not by naive Bayes or K-nearest neighbors. Conventional metrics for ML classification have been reported for methodological comparison. Conclusions: This demonstration shows that using the IRT is a viable method for understanding the data that are provided to ML algorithms, independent of outcome measures, and highlights how well classifiers differentiate cases of varying difficulty. This method explains which features are indicative of healthy states and why. It enables end users to tailor the classifier that is appropriate to the difficulty level of the patient for personalized medicine. %M 32975523 %R 10.2196/20268 %U http://www.jmir.org/2020/9/e20268/ %U https://doi.org/10.2196/20268 %U http://www.ncbi.nlm.nih.gov/pubmed/32975523 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17947 %T Giving Children With Osteogenesis Imperfecta a Voice: Participatory Approach for the Development of the Interactive Assessment and Communication Tool Sisom OI %A Siedlikowski,Maia %A Rauch,Frank %A Tsimicalis,Argerie %+ Ingram School of Nursing, Faculty of Medicine and Health Sciences, McGill University, Suite 1800 Room 1835, 680 Sherbrooke Street West, Montreal, QC, , Canada, 1 5147706069, argerie.tsimicalis@mcgill.ca %K child health %K symptom assessment, communication, mobile apps, software %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Children with osteogenesis imperfecta (OI) experience acute and chronic symptoms that expose them to physical, mental, and social challenges. Empowering these children by involving them in their care can help them to cope with OI. Sisom is an interactive assessment and communication tool designed to help children aged 6-12 years with chronic illnesses express their symptoms. This tool has not yet been adapted to the unique needs of OI. Objective: The aim of this study was to develop a Sisom OI paper prototype by seeking the perspectives of end users. Methods: A participatory approach was adopted to develop the prototype overseen by an expert panel of 9 clinicians at a university-affiliated pediatric hospital. Purposive sampling was used to recruit 12 children with OI who were aged 6-12 years. The study was carried out over the course of 3 feedback cycles. Data were deductively interpreted using content analysis techniques. Results: Overall, 64% (57/89) of the Sisom symptoms were deemed relevant for inclusion in Sisom OI, with 42% (37/89) directly incorporated and 22% (20/89) incorporated with changes. In total, 114 symptoms were used to create the prototype, of which 57 were newly generated. The relevant symptoms addressed children’s thoughts and feelings about hospitalization and their wishes for participation in their own care. The new symptoms addressed fractures, body image, and social isolation related to difficulties with accessibility and intimidation. Conclusions: Once developed, Sisom OI will offer clinicians an innovative and child-centered approach to capture children’s perspectives on their condition. %M 32960176 %R 10.2196/17947 %U http://www.jmir.org/2020/9/e17947/ %U https://doi.org/10.2196/17947 %U http://www.ncbi.nlm.nih.gov/pubmed/32960176 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e17978 %T Understanding the Information Needs and Context of Trauma Handoffs to Design Automated Sensing Clinical Documentation Technologies: Qualitative Mixed-Method Study of Military and Civilian Cases %A Novak,Laurie Lovett %A Simpson,Christopher L %A Coco,Joseph %A McNaughton,Candace D %A Ehrenfeld,Jesse M %A Bloos,Sean M %A Fabbri,Daniel %+ Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1475, Nashville, TN, 37203, United States, 1 615 936 6497, laurie.l.novak@vumc.org %K trauma handoffs %K military field medicine %K documentation %K trauma %K health records %K hospital %K emergency %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Current methods of communication between the point of injury and receiving medical facilities rely on verbal communication, supported by brief notes and the memory of the field medic. This communication can be made more complete and reliable with technologies that automatically document the actions of field medics. However, designing state-of-the-art technology for military field personnel and civilian first responders is challenging due to the barriers researchers face in accessing the environment and understanding situated actions and cognitive models employed in the field. Objective: To identify design insights for an automated sensing clinical documentation (ASCD) system, we sought to understand what information is transferred in trauma cases between prehospital and hospital personnel, and what contextual factors influence the collection, management, and handover of information in trauma cases, in both military and civilian cases. Methods: Using a multi-method approach including video review and focus groups, we developed an understanding of the information needs of trauma handoffs and the context of field documentation to inform the design of an automated sensing documentation system that uses wearables, cameras, and environmental sensors to passively infer clinical activity and automatically produce documentation. Results: Comparing military and civilian trauma documentation and handoff, we found similarities in the types of data collected and the prioritization of information. We found that military environments involved many more contextual factors that have implications for design, such as the physical environment (eg, heat, lack of lighting, lack of power) and the potential for active combat and triage, creating additional complexity. Conclusions: An ineffectiveness of communication is evident in both the civilian and military worlds. We used multiple methods of inquiry to study the information needs of trauma care and handoff, and the context of medical work in the field. Our findings informed the design and evaluation of an automated documentation tool. The data illustrated the need for more accurate recordkeeping, specifically temporal aspects, during transportation, and characterized the environment in which field testing of the developed tool will take place. The employment of a systems perspective in this project produced design insights that our team would not have identified otherwise. These insights created exciting and interesting challenges for the technical team to resolve. %M 32975522 %R 10.2196/17978 %U http://www.jmir.org/2020/9/e17978/ %U https://doi.org/10.2196/17978 %U http://www.ncbi.nlm.nih.gov/pubmed/32975522 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e16752 %T Evaluating Two Common Strategies for Research Participant Recruitment Into Autism Studies: Observational Study %A Ahmed,Kelli L %A Simon,Andrea R %A Dempsey,Jack R %A Samaco,Rodney C %A Goin-Kochel,Robin P %+ Autism Center, Texas Children's Hospital, 8080 N Stadium Drive, Suite 100, Houston, TX, 77054, United States, 1 8328243390, kochel@bcm.edu %K autism spectrum disorder %K participant recruitment %K social media %K Facebook %K radio %K genetic studies %D 2020 %7 24.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Ongoing research is necessary to better understand the causes of autism spectrum disorder (ASD), the developmental outcomes for individuals diagnosed with ASD, and the efficacy of the interventions. However, it is often difficult to recruit sufficient numbers of participants for studies, and despite the prevalence of ASD (currently estimated to affect 1 in 54 children), little research has focused on how to efficiently recruit participants with ASD. Objective: The aim of this study was to determine the efficacy of two different paid advertisements—social media and radio advertising—in recruiting participants for a study enrolling people with ASD and their family members by examining the number of participants enrolled, the cost per participant, and the geographic reach of each type of advertising. Methods: We examined participant enrollment in a study following nonoverlapping paid advertisements on a popular FM radio station (aired in three cities across two states) and Facebook (six advertisements that ran in five cities across two states). The total paid investment in the radio campaign was $12,030 and that in the Facebook campaign was $2950. Following the advertising campaigns, 1391 participants in the study who were affiliated with the Houston, Texas, site received email invitations to participate in a brief survey about the ways in which they learned about the study (eg, social media, medical provider, website) and which of these were most influential in their decisions to participate; 374 (26.8%) of the participants completed this survey. Results: Social media advertising outperformed radio in all three parameters examined by enrolling more participants (338 vs 149), with a lower average cost per participant ($8.73 vs $80.74) and a wider geographic reach, based on a comparison of the number of zip codes within and outside of Texas for questionnaire respondents who rated social media as the most influential method of contact (n=367, χ21=5.85, P=.02). Of the 374 survey participants, 139 (37.2%) reported that they had seen the study on social media prior to enrollment, while only 9 (2.4%) said they heard about it via radio. Conclusions: Our findings suggest that advertising on social media can efficiently reach a large pool of potential participants with ASD, increasing the likelihood of meeting study enrollment goals. Researchers should consider allocating at least some portion of recruitment dollars to social media platforms as a means of quickly and inexpensively reaching out to their target populations, including for studies with in-person procedures. %M 32969826 %R 10.2196/16752 %U http://www.jmir.org/2020/9/e16752/ %U https://doi.org/10.2196/16752 %U http://www.ncbi.nlm.nih.gov/pubmed/32969826 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19668 %T Xigua Video as a Source of Information on Breast Cancer: Content Analysis %A Pan,Peng %A Yu,Changhua %A Li,Tao %A Zhou,Xilei %A Dai,Tingting %A Tian,Hanhan %A Xiong,Yaozu %+ Department of Radiation Oncology, The Affiliated Huaian No 1 People's Hospital of Nanjing Medical University, Jiangsu province, Radiotherapy Department Building, 4th floor, Huaian , China, 86 517 8490 7286, yu884443@sina.com %K breast cancer %K internet %K Xigua Video %K content analysis %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Seeking health information on the internet is a popular trend. Xigua Video, a short video platform in China, ranks among the most accessed websites in the country and hosts an increasing number of videos with medical information. However, the nature of these videos is frequently unscientific, misleading, or even harmful. Objective: Little is known about Xigua Video as a source of information on breast cancer. Thus, the study aimed to investigate the contents, quality, and reliability of breast cancer–related content on Xigua Video. Methods: On February 4, 2020, a Xigua Video search was performed using the keyword “breast cancer.” Videos were categorized by 2 doctors based on whether the video content provided useful or misleading information. Furthermore, the reliability and quality of the videos were assessed using the 5-point DISCERN tool and 5-point global quality score criteria. Results: Out of the 170 videos selected for the study, 64 (37.6%) were classified as useful, whereas 106 (62.4%) provided misleading information. A total of 41.8% videos (71/170) were generated by individuals compared to 19.4% videos (33/170) contributed by health care professionals. The topics mainly covered etiology, anatomy, symptoms, preventions, treatments, and prognosis. The top topic was “treatments” (119/170, 70%). The reliability scores and global quality scores of the videos in the useful information group were high (P<.001). No differences were observed between the 2 groups in terms of video length, duration in months, and comments. The number of total views was higher for the misleading information group (819,478.5 vs 647,940) but did not reach a level of statistical significance (P=.112). The uploading sources of the videos were mainly health care professionals, health information websites, medical advertisements, and individuals. Statistical differences were found between the uploading source groups in terms of reliability scores and global quality scores (P<.001). In terms of total views, video length, duration, and comments, no statistical differences were indicated among the said groups. However, a statistical difference was noted between the useful and misleading information video groups with respect to the uploading sources (P<.001). Conclusions: A large number of Xigua videos pertaining to breast cancer contain misleading information. There is a need for accurate health information to be provided on Xigua Video and other social media; health care professionals should address this challenge. %M 32883651 %R 10.2196/19668 %U http://www.jmir.org/2020/9/e19668/ %U https://doi.org/10.2196/19668 %U http://www.ncbi.nlm.nih.gov/pubmed/32883651 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19746 %T Public Disclosure on Social Media of Identifiable Patient Information by Health Professionals: Content Analysis of Twitter Data %A Ahmed,Wasim %A Jagsi,Reshma %A Gutheil,Thomas G %A Katz,Matthew S %+ Department of Marketing, Operations and Systems, Newcastle University Business School, Newcastle University, 5 Barrack Rd, Newcastle upon Tyne, NE1 4SE, United Kingdom, 44 191 2081704, Wasim.Ahmed@Newcastle.ac.uk %K Social Media %K Twitter %K Patient Information %K Confidentiality %K Health Professionals %D 2020 %7 1.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Respecting patient privacy and confidentiality is critical for doctor-patient relationships and public trust in medical professionals. The frequency of potentially identifiable disclosures online during periods of active engagement is unknown. Objective: The objective of this study was to quantify potentially identifiable content shared on social media by physicians and other health care providers using the hashtag #ShareAStoryInOneTweet. Methods: We accessed and searched Twitter’s API using Symplur software for tweets that included the hashtag #ShareAStoryInOneTweet. We identified 1206 tweets by doctors, nurses, and other health professionals out of 43,374 tweets shared in May 2018. Tweet content was evaluated in January 2019 to determine the incidence of instances where names or potentially identifiable information about patients were shared; content analysis of tweets in which information about others had been disclosed was performed. The study also evaluated whether participants raised concerns about privacy breaches and estimated the frequency of deleted tweets. The study used dual, blinded coding for a 10% sample to estimate intercoder reliability using Cohen κ statistic for identifying the potential identifiability of tweet content. Results: Health care professionals (n=656) disclosing information about others included 486 doctors (74.1%) and 98 nurses (14.9%). Health care professionals sharing stories about patient care disclosed the time frame in 95 tweets (95/754, 12.6%) and included patient names in 15 tweets (15/754, 2.0%). It is estimated that friends or families could likely identify the clinical scenario described in 242 of the 754 tweets (32.1%). Among 348 tweets about potentially living patients, it was estimated that 162 (46.6%) were likely identifiable by patients. Intercoder reliability in rating the potential identifiability demonstrated 86.8% agreement, with a Cohen κ of 0.8 suggesting substantial agreement. We also identified 78 out of 754 tweets (6.5%) that had been deleted on the website but were still viewable in the analytics software data set. Conclusions: During periods of active sharing online, nurses, physicians, and other health professionals may sometimes share more information than patients or families might expect. More study is needed to determine whether similar events arise frequently and to understand how to best ensure that patients’ rights are adequately respected. %M 32870160 %R 10.2196/19746 %U https://www.jmir.org/2020/9/e19746 %U https://doi.org/10.2196/19746 %U http://www.ncbi.nlm.nih.gov/pubmed/32870160 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e15307 %T Identifying Mobile Health Engagement Stages: Interviews and Observations for Developing Brief Message Content %A Burns,Kara %A Nicholas,Rebekah %A Beatson,Amanda %A Chamorro-Koc,Marianella %A Blackler,Alethea %A Gottlieb,Udo %+ School of Advertising, Marketing and Public Relations, QUT Business School, Queensland University of Technology, George St, Brisbane, QLD, 4000, Australia, 61 414294967, drkaraburns@gmail.com %K mobile health %K text messaging %K social media %K mobile phone %K health communication %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Interest in mobile health (mHealth) has increased recently, and research suggests that mHealth devices can enhance end-user engagement, especially when used in conjunction with brief message content. Objective: This research aims to explore the stages of engagement framework for mHealth devices and develop a method to generate brief message content to promote sustained user engagement. This study uses the framework by O’Brien and Toms as a point of departure, where engagement is defined as the uptake or the use of an mHealth device. The framework is a linear repeatable process, including point of engagement, period of engagement, disengagement, and re-engagement. Each stage is characterized by attributes related to a person’s technology experience. Although the literature has identified stages of engagement for health-related technology, few studies explore mHealth engagement. Furthermore, little research has determined a method for creating brief message content at each stage in this engagement journey. Methods: Interviews and observations from 19 participants who used mHealth technologies (apps, devices, or wellness websites) in a solo capacity were recruited for sample group 1. In sample group 2, interviews, and observations from 25 participants using mHealth technologies in a group capacity through the Global Corporate Challenge were used. These samples were investigated at 3 time points in both research contexts. The results underwent deductive-inductive thematic analysis for the engagement stages’ framework and attributes. Results: In addition to the 4 stages identified by O’Brien and Toms, 2 additional stages, self-management and limited engagement, were identified. Self-management captures where users had disengaged from their technology but were still engaged with their health activity. Limited engagement captures where group mHealth users had minimal interaction with their mHealth technology but continued to engage in a group fitness activity. The results revealed that mHealth engagement stages were nonlinear and embedded in a wider engagement context and that each stage was characterized by a combination of 49 attributes that could be organized into 8 themes. Themes documented the total user experience and included technology usability, technology features, technology aesthetics, use motivations, health awareness, goal setting, social support, and interruptions. Different themes were found to have more relevance at different engagement stages. Knowing themes and attributes at all engagement stages allows technology developers and health care professionals to generate relevant brief message content informed by a person-centered approach. Conclusions: This research extends an existing engagement stages framework and identifies attributes and themes relevant to mHealth technology users’ total user experience and incorporates concepts derived from health, business studies, and information systems literature. In addition, we offer a practical 5-step process based on a person-centered approach to develop mHealth technology brief message content for sustained engagement. %M 32960181 %R 10.2196/15307 %U http://www.jmir.org/2020/9/e15307/ %U https://doi.org/10.2196/15307 %U http://www.ncbi.nlm.nih.gov/pubmed/32960181 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19945 %T The Influence of Three Modes of Human Support on Attrition and Adherence to a Web- and Mobile App–Based Mental Health Promotion Intervention in a Nonclinical Cohort: Randomized Comparative Study %A Renfrew,Melanie Elise %A Morton,Darren Peter %A Morton,Jason Kyle %A Hinze,Jason Scott %A Przybylko,Geraldine %A Craig,Bevan Adrian %+ Lifestyle and Health Research Centre, Avondale University College, 582 Freemans Drive, Cooranbong, NSW, Australia, 61 405445151, melanie.renfrew@avondale.edu.au %K human support %K adherence %K attrition %K engagement %K web-based mental health %K health promotion %K eHealth %K SMS %K videoconferencing %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The escalating prevalence of mental health disorders necessitates a greater focus on web- and mobile app–based mental health promotion initiatives for nonclinical groups. However, knowledge is scant regarding the influence of human support on attrition and adherence and participant preferences for support in nonclinical settings. Objective: This study aimed to compare the influence of 3 modes of human support on attrition and adherence to a digital mental health intervention for a nonclinical cohort. It evaluated user preferences for support and assessed whether adherence and outcomes were enhanced when participants received their preferred support mode. Methods: Subjects participated in a 10-week digital mental health promotion intervention and were randomized into 3 comparative groups: standard group with automated emails (S), standard plus personalized SMS (S+pSMS), and standard plus weekly videoconferencing support (S+VCS). Adherence was measured by the number of video lessons viewed, points achieved for weekly experiential challenge activities, and the total number of weeks that participants recorded a score for challenges. In the postquestionnaire, participants ranked their preferred human support mode from 1 to 4 (S, S+pSMS, S+VCS, S+pSMS & VCS combined). Stratified analysis was conducted for those who received their first preference. Preintervention and postintervention questionnaires assessed well-being measures (ie, mental health, vitality, depression, anxiety, stress, life satisfaction, and flourishing). Results: Interested individuals (N=605) enrolled on a website and were randomized into 3 groups (S, n=201; S+pSMS, n=202; S+VCS, n=201). Prior to completing the prequestionnaire, a total of 24.3% (147/605) dropped out. Dropout attrition between groups was significantly different (P=.009): 21.9% (44/201) withdrew from the S group, 19.3% (39/202) from the S+pSMS group, and 31.6% (64/202) from the S+VCS group. The remaining 75.7% (458/605) registered and completed the prequestionnaire (S, n=157; S+pSMS, n=163; S+VCS, n=138). Of the registered participants, 30.1% (138/458) failed to complete the postquestionnaire (S, n=54; S+pSMS, n=49; S+VCS, n=35), but there were no between-group differences (P=.24). For the 69.9% (320/458; S, n=103; S+pSMS, n=114; S+VCS, n=103) who completed the postquestionnaire, no between-group differences in adherence were observed for mean number of videos watched (P=.42); mean challenge scores recorded (P=.71); or the number of weeks that challenge scores were logged (P=.66). A total of 56 participants (17.5%, 56/320) received their first preference in human support (S, n=22; S+pSMS, n=26; S+VCS, n=8). No differences were observed between those who received their first preference and those who did not with regard to video adherence (P=.91); challenge score adherence (P=.27); or any of the well-being measures including, mental health (P=.86), vitality (P=.98), depression (P=.09), anxiety (P=.64), stress (P=.55), life satisfaction (P=.50), and flourishing (P=.47). Conclusions: Early dropout attrition may have been influenced by dissatisfaction with the allocated support mode. Human support mode did not impact adherence to the intervention, and receiving the preferred support style did not result in greater adherence or better outcomes. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): 12619001009101; http://www.anzctr.org.au/ACTRN12619001009101.aspx %M 32990633 %R 10.2196/19945 %U http://www.jmir.org/2020/9/e19945/ %U https://doi.org/10.2196/19945 %U http://www.ncbi.nlm.nih.gov/pubmed/32990633 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e16224 %T Web-Based Technology for Remote Viewing of Radiological Images: App Validation %A Min,Qiusha %A Wang,Xin %A Huang,Bo %A Xu,Liangzhou %+ School of Educational Information Technology, Central China Normal University, No.152 Luoyu Road, Wuhan, Hubei, 430079, China, 86 27 67867597, qiusham@mail.ccnu.edu.cn %K internet access %K medical informatics applications %K computer-assisted image analyses %K computer-assisted three-dimensional imaging %K medical imaging %K radiology %K application %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Internet technologies can create advanced and rich web-based apps that allow radiologists to easily access teleradiology systems and remotely view medical images. However, each technology has its own drawbacks. It is difficult to balance the advantages and disadvantages of these internet technologies and identify an optimal solution for the development of medical imaging apps. Objective: This study aimed to compare different internet platform technologies for remotely viewing radiological images and analyze their advantages and disadvantages. Methods: Oracle Java, Adobe Flash, and HTML5 were each used to develop a comprehensive web-based medical imaging app that connected to a medical image server and provided several required functions for radiological interpretation (eg, navigation, magnification, windowing, and fly-through). Java-, Flash-, and HTML5-based medical imaging apps were tested on different operating systems over a local area network and a wide area network. Three computed tomography colonography data sets and 2 ordinary personal computers were used in the experiment. Results: The experimental results demonstrated that Java-, Flash-, and HTML5-based apps had the ability to provide real-time 2D functions. However, for 3D, performances differed between the 3 apps. The Java-based app had the highest frame rate of volume rendering. However, it required the longest time for surface rendering and failed to run surface rendering in macOS. The HTML5-based app had the fastest surface rendering and the highest speed for fly-through without platform dependence. Volume rendering, surface rendering, and fly-through performances of the Flash-based app were significantly worse than those of the other 2 apps. Conclusions: Oracle Java, Adobe Flash, and HTML5 have individual strengths in the development of remote access medical imaging apps. However, HTML5 is a promising technology for remote viewing of radiological images and can provide excellent performance without requiring any plug-ins. %M 32975520 %R 10.2196/16224 %U http://www.jmir.org/2020/9/e16224/ %U https://doi.org/10.2196/16224 %U http://www.ncbi.nlm.nih.gov/pubmed/32975520 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e15916 %T Data Quality Issues With Physician-Rating Websites: Systematic Review %A Mulgund,Pavankumar %A Sharman,Raj %A Anand,Priya %A Shekhar,Shashank %A Karadi,Priya %+ School of Management, State University of New York Buffalo, 160 Jacobs Management Center, Buffalo, NY , United States, 1 7167481552, pmulgund@buffalo.edu %K physician-rating websites %K data quality issues %K doctor ratings %K reviews %K data quality framework %D 2020 %7 28.9.2020 %9 Review %J J Med Internet Res %G English %X Background: In recent years, online physician-rating websites have become prominent and exert considerable influence on patients’ decisions. However, the quality of these decisions depends on the quality of data that these systems collect. Thus, there is a need to examine the various data quality issues with physician-rating websites. Objective: This study’s objective was to identify and categorize the data quality issues afflicting physician-rating websites by reviewing the literature on online patient-reported physician ratings and reviews. Methods: We performed a systematic literature search in ACM Digital Library, EBSCO, Springer, PubMed, and Google Scholar. The search was limited to quantitative, qualitative, and mixed-method papers published in the English language from 2001 to 2020. Results: A total of 423 articles were screened. From these, 49 papers describing 18 unique data quality issues afflicting physician-rating websites were included. Using a data quality framework, we classified these issues into the following four categories: intrinsic, contextual, representational, and accessible. Among the papers, 53% (26/49) reported intrinsic data quality errors, 61% (30/49) highlighted contextual data quality issues, 8% (4/49) discussed representational data quality issues, and 27% (13/49) emphasized accessibility data quality. More than half the papers discussed multiple categories of data quality issues. Conclusions: The results from this review demonstrate the presence of a range of data quality issues. While intrinsic and contextual factors have been well-researched, accessibility and representational issues warrant more attention from researchers, as well as practitioners. In particular, representational factors, such as the impact of inline advertisements and the positioning of positive reviews on the first few pages, are usually deliberate and result from the business model of physician-rating websites. The impact of these factors on data quality has not been addressed adequately and requires further investigation. %M 32986000 %R 10.2196/15916 %U http://www.jmir.org/2020/9/e15916/ %U https://doi.org/10.2196/15916 %U http://www.ncbi.nlm.nih.gov/pubmed/32986000 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18509 %T Clusters of Adolescent Physical Activity Tracker Patterns and Their Associations With Physical Activity Behaviors in Finland and Ireland: Cross-Sectional Study %A Ng,Kwok %A Kokko,Sami %A Tammelin,Tuija %A Kallio,Jouni %A Belton,Sarahjane %A O'Brien,Wesley %A Murphy,Marie %A Powell,Cormac %A Woods,Catherine %+ School of Educational Sciences and Psychology, University of Eastern Finland, PO Box 111, Joensuu, 80101, Finland, 358 504724051, kwok.ng@hbsc.org %K wearables %K children %K activity trackers %K active travel %K organised sport %K self-quantification %D 2020 %7 1.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity trackers (PATs) such as apps and wearable devices (eg, sports watches, heart rate monitors) are increasingly being used by young adolescents. Despite the potential of PATs to help monitor and improve moderate-to-vigorous physical activity (MVPA) behaviors, there is a lack of research that confirms an association between PAT ownership or use and physical activity behaviors at the population level. Objective: The purpose of this study was to examine the ownership and use of PATs in youth and their associations with physical activity behaviors, including daily MVPA, sports club membership, and active travel, in 2 nationally representative samples of young adolescent males and females in Finland and Ireland. Methods: Comparable data were gathered in the 2018 Finnish School-aged Physical Activity (F-SPA 2018, n=3311) and the 2018 Irish Children’s Sport Participation and Physical Activity (CSPPA 2018, n=4797) studies. A cluster analysis was performed to obtain the patterns of PAT ownership and usage by adolescents (age, 11-15 years). Four similar clusters were identified across Finnish and Irish adolescents: (1) no PATs, (2) PAT owners, (3) app users, and (4) wearable device users. Adjusted binary logistic regression analyses were used to evaluate how PAT clusters were associated with physical activity behaviors, including daily MVPA, membership of sports clubs, and active travel, after stratification by gender. Results: The proportion of app ownership among Finnish adolescents (2038/3311, 61.6%) was almost double that of their Irish counterparts (1738/4797, 36.2%). Despite these differences, the clustering patterns of PATs were similar between the 2 countries. App users were more likely to take part in daily MVPA (males, odds ratio [OR] 1.27, 95% CI 1.04-1.55; females, OR 1.49, 95% CI 1.20-1.85) and be members of sports clubs (males, OR 1.37, 95% CI 1.15-1.62; females, OR 1.25, 95% CI 1.07-1.50) compared to the no PATs cluster, after adjusting for country, age, family affluence, and disabilities. These associations, after the same adjustments, were even stronger for wearable device users to participate in daily MVPA (males, OR 1.83, 95% CI 1.49-2.23; females, OR 2.25, 95% CI 1.80-2.82) and be members of sports clubs (males, OR 1.88, 95% CI 1.55-2.88; females, OR 2.07, 95% CI 1.71-2.52). Significant associations were observed between male users of wearable devices and taking part in active travel behavior (OR 1.39, 95% CI 1.04-1.86). Conclusions: Although Finnish adolescents report more ownership of PATs than Irish adolescents, the patterns of use and ownership remain similar among the cohorts. The findings of our study show that physical activity behaviors were positively associated with wearable device users and app users. These findings were similar between males and females. Given the cross-sectional nature of this data, the relationship between using apps or wearable devices and enhancing physical activity behaviors requires further investigation. %M 32667894 %R 10.2196/18509 %U https://www.jmir.org/2020/9/e18509 %U https://doi.org/10.2196/18509 %U http://www.ncbi.nlm.nih.gov/pubmed/32667894 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e16053 %T Cost-Effectiveness of a Continuous Glucose Monitoring Mobile App for Patients With Type 2 Diabetes Mellitus: Analysis Simulation %A Tsuji,Shintaro %A Ishikawa,Tomoki %A Morii,Yasuhiro %A Zhang,Hongjian %A Suzuki,Teppei %A Tanikawa,Takumi %A Nakaya,Jun %A Ogasawara,Katsuhiko %+ Graduate School of Health Sciences, Hokkaido University, N12-W5, Kita-ku, Sapporo, 060-0812, Japan, 81 117063409, oga@hs.hokudai.ac.jp %K Markov model %K telehealth %K continuous glucose monitoring (CGM) %K type 2 diabetes mellitus %K cost-effectiveness %K incremental cost and effective ratio (ICER) %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Apps for real-time continuous glucose monitoring (CGM) on smartphones and other devices linked to CGM systems have recently been developed, and such CGM apps are also coming into use in Japan. In comparison with conventional retrospective CGM, the use of CGM apps improves patients’ own blood glucose control, which is expected to help slow the progression of type 2 diabetes mellitus (DM) and prevent complications, but the effect of their introduction on medical costs remains unknown. Objective: Our objective in this study was to perform an economic appraisal of CGM apps from the viewpoint of assessing public medical costs associated with type 2 DM, using the probability of developing type 2 DM–associated complications, and data on medical costs and utility value to carry out a medical cost simulation using a Markov model in order to ascertain the cost-effectiveness of the apps. Methods: We developed a Markov model with the transition states of insulin therapy, nephrosis, dialysis, and cardiovascular disease, all of which have a major effect on medical costs, to identify changes in medical costs and utility values resulting from the introduction of a CGM app and calculated the incremental cost-effectiveness ratio (ICER). Results: The ICER for CGM app use was US $33,039/quality-adjusted life year (QALY). Conclusions: Sensitivity analyses showed that, with the exception of conditions where the transition probability of insulin therapy, utility value, or increased medical costs increases, the ICER for the introduction of CGM apps was below the threshold of US $43,478/QALY used by the Central Social Insurance Medical Council. Our results provide basic data on the cost-effectiveness of introducing CGM apps, which are currently starting to come into use. %M 32940613 %R 10.2196/16053 %U https://www.jmir.org/2020/9/e16053 %U https://doi.org/10.2196/16053 %U http://www.ncbi.nlm.nih.gov/pubmed/32940613 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19898 %T Assessing Digital Health Implementation for a Pediatric Chronic Pain Intervention: Comparing the RE-AIM and BIT Frameworks Against Real-World Trial Data and Recommendations for Future Studies %A de la Vega,Rocio %A Ritterband,Lee %A Palermo,Tonya M %+ Center for Child Health, Behavior and Development, Seattle Children's Research Institute, P.O. Box 5371/SCRI, M/S CW8-6, Seattle, WA, 98145-5005, United States, 1 206 884 4208, tonya.palermo@seattlechildrens.org %K mobile health %K eHealth %K mHealth %K implementation science %K chronic pain %K adolescents %K mobile phone %D 2020 %7 1.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health interventions have demonstrated efficacy for several conditions including for pediatric chronic pain. However, the process of making interventions available to end users in an efficient and sustained way is challenging and remains a new area of research. To advance this field, comprehensive frameworks have been created. Objective: The aim of this study is to compare the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Behavior Interventions using Technology (BIT) frameworks with data collected from the web-based management of adolescent pain (WebMAP Mobile; WMM) randomized controlled trial (RCT). Methods: We conducted a hybrid effectiveness-implementation cluster RCT with a stepped wedge design in which the intervention was sequentially implemented in 8 clinics, following a usual care period. Participants were 143 youths (mean age 14.5 years, SD 1.9; 117/143, 81.8% female) with chronic pain, from which 73 were randomized to receive the active intervention. Implementation outcomes were assessed using the RE-AIM and BIT frameworks. Results: According to the RE-AIM framework, the WMM showed excellent reach, recruiting a sample 19% larger than the size originally planned and consenting 79.0% (143/181) of eligible referred adolescents. Effectiveness was limited, with only global impression of change showing significantly greater improvements in the treatment group; however, greater treatment engagement was associated with greater reductions in pain and disability. Adoption was excellent (all the invited clinics participated and referred patients). Implementation was acceptable, showing good user engagement and moderate adherence and positive attitudes of providers. Costs were similar to planned, with a 7% increase in funds needed to make the WMM publicly available. Maintenance was evidenced by 56 new patients downloading the app during the maintenance period and by all clinics agreeing to continue making referrals and all, but one, making new referrals. According to the BIT, 82% (60/73) of adolescents considered the treatment acceptable. In terms of adoption, 93% (68/73) downloaded the app, and all of them used it after their first log-in. In terms of appropriateness at the user level, 2 participants were unable to download the app. Perceptions of the appearance, navigation, and theme were positive. Providers perceived the WMM as a good fit for their clinic, beneficial, helpful, and resource efficient. In terms of feasibility, no technical issues were reported. In terms of fidelity, 40% (29/73) completed the treatment. Implementation costs were 7% above the budget. With regard to penetration, 56 new users accessed the app during the maintenance period. In terms of sustainability, 88% (7/8) of clinics continued recommending the WMM after the end of the study. Conclusions: For the first time, a real-world digital health intervention was used as a proof of concept to test all the domains in the RE-AIM and BIT frameworks, allowing for comparisons. International Registered Report Identifier (IRRID): RR2-10.1016/j.cct.2018.10.003 %M 32870158 %R 10.2196/19898 %U https://www.jmir.org/2020/9/e19898 %U https://doi.org/10.2196/19898 %U http://www.ncbi.nlm.nih.gov/pubmed/32870158 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18091 %T Artificial Intelligence and Its Effect on Dermatologists’ Accuracy in Dermoscopic Melanoma Image Classification: Web-Based Survey Study %A Maron,Roman C %A Utikal,Jochen S %A Hekler,Achim %A Hauschild,Axel %A Sattler,Elke %A Sondermann,Wiebke %A Haferkamp,Sebastian %A Schilling,Bastian %A Heppt,Markus V %A Jansen,Philipp %A Reinholz,Markus %A Franklin,Cindy %A Schmitt,Laurenz %A Hartmann,Daniela %A Krieghoff-Henning,Eva %A Schmitt,Max %A Weichenthal,Michael %A von Kalle,Christof %A Fröhling,Stefan %A Brinker,Titus J %+ Digital Biomarkers for Oncology Group (DBO), National Center for Tumor Diseases (NCT), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, Heidelberg, 69120, Germany, 49 62213219304, titus.brinker@nct-heidelberg.de %K artificial intelligence %K machine learning %K deep learning %K neural network %K dermatology %K diagnosis %K nevi %K melanoma %K skin neoplasm %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Early detection of melanoma can be lifesaving but this remains a challenge. Recent diagnostic studies have revealed the superiority of artificial intelligence (AI) in classifying dermoscopic images of melanoma and nevi, concluding that these algorithms should assist a dermatologist’s diagnoses. Objective: The aim of this study was to investigate whether AI support improves the accuracy and overall diagnostic performance of dermatologists in the dichotomous image–based discrimination between melanoma and nevus. Methods: Twelve board-certified dermatologists were presented disjoint sets of 100 unique dermoscopic images of melanomas and nevi (total of 1200 unique images), and they had to classify the images based on personal experience alone (part I) and with the support of a trained convolutional neural network (CNN, part II). Additionally, dermatologists were asked to rate their confidence in their final decision for each image. Results: While the mean specificity of the dermatologists based on personal experience alone remained almost unchanged (70.6% vs 72.4%; P=.54) with AI support, the mean sensitivity and mean accuracy increased significantly (59.4% vs 74.6%; P=.003 and 65.0% vs 73.6%; P=.002, respectively) with AI support. Out of the 10% (10/94; 95% CI 8.4%-11.8%) of cases where dermatologists were correct and AI was incorrect, dermatologists on average changed to the incorrect answer for 39% (4/10; 95% CI 23.2%-55.6%) of cases. When dermatologists were incorrect and AI was correct (25/94, 27%; 95% CI 24.0%-30.1%), dermatologists changed their answers to the correct answer for 46% (11/25; 95% CI 33.1%-58.4%) of cases. Additionally, the dermatologists’ average confidence in their decisions increased when the CNN confirmed their decision and decreased when the CNN disagreed, even when the dermatologists were correct. Reported values are based on the mean of all participants. Whenever absolute values are shown, the denominator and numerator are approximations as every dermatologist ended up rating a varying number of images due to a quality control step. Conclusions: The findings of our study show that AI support can improve the overall accuracy of the dermatologists in the dichotomous image–based discrimination between melanoma and nevus. This supports the argument for AI-based tools to aid clinicians in skin lesion classification and provides a rationale for studies of such classifiers in real-life settings, wherein clinicians can integrate additional information such as patient age and medical history into their decisions. %M 32915161 %R 10.2196/18091 %U https://www.jmir.org/2020/9/e18091 %U https://doi.org/10.2196/18091 %U http://www.ncbi.nlm.nih.gov/pubmed/32915161 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21573 %T An Innovative Artificial Intelligence–Based App for the Diagnosis of Gestational Diabetes Mellitus (GDM-AI): Development Study %A Shen,Jiayi %A Chen,Jiebin %A Zheng,Zequan %A Zheng,Jiabin %A Liu,Zherui %A Song,Jian %A Wong,Sum Yi %A Wang,Xiaoling %A Huang,Mengqi %A Fang,Po-Han %A Jiang,Bangsheng %A Tsang,Winghei %A He,Zonglin %A Liu,Taoran %A Akinwunmi,Babatunde %A Wang,Chi Chiu %A Zhang,Casper J P %A Huang,Jian %A Ming,Wai-Kit %+ Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China, 86 14715485116, wkming@connect.hku.hk %K AI %K application %K disease diagnosis %K maternal health care %K artificial intelligence %K app %K women %K rural %K innovation %K diabetes %K gestational diabetes %K diagnosis %D 2020 %7 15.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Gestational diabetes mellitus (GDM) can cause adverse consequences to both mothers and their newborns. However, pregnant women living in low- and middle-income areas or countries often fail to receive early clinical interventions at local medical facilities due to restricted availability of GDM diagnosis. The outstanding performance of artificial intelligence (AI) in disease diagnosis in previous studies demonstrates its promising applications in GDM diagnosis. Objective: This study aims to investigate the implementation of a well-performing AI algorithm in GDM diagnosis in a setting, which requires fewer medical equipment and staff and to establish an app based on the AI algorithm. This study also explores possible progress if our app is widely used. Methods: An AI model that included 9 algorithms was trained on 12,304 pregnant outpatients with their consent who received a test for GDM in the obstetrics and gynecology department of the First Affiliated Hospital of Jinan University, a local hospital in South China, between November 2010 and October 2017. GDM was diagnosed according to American Diabetes Association (ADA) 2011 diagnostic criteria. Age and fasting blood glucose were chosen as critical parameters. For validation, we performed k-fold cross-validation (k=5) for the internal dataset and an external validation dataset that included 1655 cases from the Prince of Wales Hospital, the affiliated teaching hospital of the Chinese University of Hong Kong, a non-local hospital. Accuracy, sensitivity, and other criteria were calculated for each algorithm. Results: The areas under the receiver operating characteristic curve (AUROC) of external validation dataset for support vector machine (SVM), random forest, AdaBoost, k-nearest neighbors (kNN), naive Bayes (NB), decision tree, logistic regression (LR), eXtreme gradient boosting (XGBoost), and gradient boosting decision tree (GBDT) were 0.780, 0.657, 0.736, 0.669, 0.774, 0.614, 0.769, 0.742, and 0.757, respectively. SVM also retained high performance in other criteria. The specificity for SVM retained 100% in the external validation set with an accuracy of 88.7%. Conclusions: Our prospective and multicenter study is the first clinical study that supports the GDM diagnosis for pregnant women in resource-limited areas, using only fasting blood glucose value, patients’ age, and a smartphone connected to the internet. Our study proved that SVM can achieve accurate diagnosis with less operation cost and higher efficacy. Our study (referred to as GDM-AI study, ie, the study of AI-based diagnosis of GDM) also shows our app has a promising future in improving the quality of maternal health for pregnant women, precision medicine, and long-distance medical care. We recommend future work should expand the dataset scope and replicate the process to validate the performance of the AI algorithms. %M 32930674 %R 10.2196/21573 %U https://www.jmir.org/2020/9/e21573 %U https://doi.org/10.2196/21573 %U http://www.ncbi.nlm.nih.gov/pubmed/32930674 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21983 %T Artificial Intelligence for the Prediction of Helicobacter Pylori Infection in Endoscopic Images: Systematic Review and Meta-Analysis Of Diagnostic Test Accuracy %A Bang,Chang Seok %A Lee,Jae Jun %A Baik,Gwang Ho %+ Department of Internal Medicine, Hallym University College of Medicine, Sakju-ro 77, Chuncheon, , Republic of Korea, 82 33 240 5000, csbang@hallym.ac.kr %K artificial intelligence %K convolutional neural network %K deep learning %K machine learning %K endoscopy %K Helicobacter pylori %D 2020 %7 16.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Helicobacter pylori plays a central role in the development of gastric cancer, and prediction of H pylori infection by visual inspection of the gastric mucosa is an important function of endoscopy. However, there are currently no established methods of optical diagnosis of H pylori infection using endoscopic images. Definitive diagnosis requires endoscopic biopsy. Artificial intelligence (AI) has been increasingly adopted in clinical practice, especially for image recognition and classification. Objective: This study aimed to evaluate the diagnostic test accuracy of AI for the prediction of H pylori infection using endoscopic images. Methods: Two independent evaluators searched core databases. The inclusion criteria included studies with endoscopic images of H pylori infection and with application of AI for the prediction of H pylori infection presenting diagnostic performance. Systematic review and diagnostic test accuracy meta-analysis were performed. Results: Ultimately, 8 studies were identified. Pooled sensitivity, specificity, diagnostic odds ratio, and area under the curve of AI for the prediction of H pylori infection were 0.87 (95% CI 0.72-0.94), 0.86 (95% CI 0.77-0.92), 40 (95% CI 15-112), and 0.92 (95% CI 0.90-0.94), respectively, in the 1719 patients (385 patients with H pylori infection vs 1334 controls). Meta-regression showed methodological quality and included the number of patients in each study for the purpose of heterogeneity. There was no evidence of publication bias. The accuracy of the AI algorithm reached 82% for discrimination between noninfected images and posteradication images. Conclusions: An AI algorithm is a reliable tool for endoscopic diagnosis of H pylori infection. The limitations of lacking external validation performance and being conducted only in Asia should be overcome. Trial Registration: PROSPERO CRD42020175957; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=175957 %M 32936088 %R 10.2196/21983 %U http://www.jmir.org/2020/9/e21983/ %U https://doi.org/10.2196/21983 %U http://www.ncbi.nlm.nih.gov/pubmed/32936088 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20645 %T Marrying Medical Domain Knowledge With Deep Learning on Electronic Health Records: A Deep Visual Analytics Approach %A Li,Rui %A Yin,Changchang %A Yang,Samuel %A Qian,Buyue %A Zhang,Ping %+ The Ohio State University, Lincoln Tower 310A, 1800 Cannon Drive, Columbus, OH, 43210, United States, 1 614 293 9286, zhang.10631@osu.edu %K electronic health records %K interpretable deep learning %K knowledge graph %K visual analytics %D 2020 %7 28.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Deep learning models have attracted significant interest from health care researchers during the last few decades. There have been many studies that apply deep learning to medical applications and achieve promising results. However, there are three limitations to the existing models: (1) most clinicians are unable to interpret the results from the existing models, (2) existing models cannot incorporate complicated medical domain knowledge (eg, a disease causes another disease), and (3) most existing models lack visual exploration and interaction. Both the electronic health record (EHR) data set and the deep model results are complex and abstract, which impedes clinicians from exploring and communicating with the model directly. Objective: The objective of this study is to develop an interpretable and accurate risk prediction model as well as an interactive clinical prediction system to support EHR data exploration, knowledge graph demonstration, and model interpretation. Methods: A domain-knowledge–guided recurrent neural network (DG-RNN) model is proposed to predict clinical risks. The model takes medical event sequences as input and incorporates medical domain knowledge by attending to a subgraph of the whole medical knowledge graph. A global pooling operation and a fully connected layer are used to output the clinical outcomes. The middle results and the parameters of the fully connected layer are helpful in identifying which medical events cause clinical risks. DG-Viz is also designed to support EHR data exploration, knowledge graph demonstration, and model interpretation. Results: We conducted both risk prediction experiments and a case study on a real-world data set. A total of 554 patients with heart failure and 1662 control patients without heart failure were selected from the data set. The experimental results show that the proposed DG-RNN outperforms the state-of-the-art approaches by approximately 1.5%. The case study demonstrates how our medical physician collaborator can effectively explore the data and interpret the prediction results using DG-Viz. Conclusions: In this study, we present DG-Viz, an interactive clinical prediction system, which brings together the power of deep learning (ie, a DG-RNN–based model) and visual analytics to predict clinical risks and visually interpret the EHR prediction results. Experimental results and a case study on heart failure risk prediction tasks demonstrate the effectiveness and usefulness of the DG-Viz system. This study will pave the way for interactive, interpretable, and accurate clinical risk predictions. %M 32985996 %R 10.2196/20645 %U http://www.jmir.org/2020/9/e20645/ %U https://doi.org/10.2196/20645 %U http://www.ncbi.nlm.nih.gov/pubmed/32985996 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22845 %T Artificial Intelligence Chatbot Behavior Change Model for Designing Artificial Intelligence Chatbots to Promote Physical Activity and a Healthy Diet: Viewpoint %A Zhang,Jingwen %A Oh,Yoo Jung %A Lange,Patrick %A Yu,Zhou %A Fukuoka,Yoshimi %+ Department of Communication, University of California, Davis, One Shields Avenue, Davis, CA, 95616, United States, 1 530 754 1472, jwzzhang@ucdavis.edu %K chatbot %K conversational agent %K artificial intelligence %K physical activity %K diet %K intervention %K behavior change %K natural language processing %K communication %D 2020 %7 30.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X Background: Chatbots empowered by artificial intelligence (AI) can increasingly engage in natural conversations and build relationships with users. Applying AI chatbots to lifestyle modification programs is one of the promising areas to develop cost-effective and feasible behavior interventions to promote physical activity and a healthy diet. Objective: The purposes of this perspective paper are to present a brief literature review of chatbot use in promoting physical activity and a healthy diet, describe the AI chatbot behavior change model our research team developed based on extensive interdisciplinary research, and discuss ethical principles and considerations. Methods: We conducted a preliminary search of studies reporting chatbots for improving physical activity and/or diet in four databases in July 2020. We summarized the characteristics of the chatbot studies and reviewed recent developments in human-AI communication research and innovations in natural language processing. Based on the identified gaps and opportunities, as well as our own clinical and research experience and findings, we propose an AI chatbot behavior change model. Results: Our review found a lack of understanding around theoretical guidance and practical recommendations on designing AI chatbots for lifestyle modification programs. The proposed AI chatbot behavior change model consists of the following four components to provide such guidance: (1) designing chatbot characteristics and understanding user background; (2) building relational capacity; (3) building persuasive conversational capacity; and (4) evaluating mechanisms and outcomes. The rationale and evidence supporting the design and evaluation choices for this model are presented in this paper. Conclusions: As AI chatbots become increasingly integrated into various digital communications, our proposed theoretical framework is the first step to conceptualize the scope of utilization in health behavior change domains and to synthesize all possible dimensions of chatbot features to inform intervention design and evaluation. There is a need for more interdisciplinary work to continue developing AI techniques to improve a chatbot’s relational and persuasive capacities to change physical activity and diet behaviors with strong ethical principles. %M 32996892 %R 10.2196/22845 %U https://www.jmir.org/2020/9/e22845 %U https://doi.org/10.2196/22845 %U http://www.ncbi.nlm.nih.gov/pubmed/32996892 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19634 %T Weight Reduction Through a Digital Nutrition and Food Purchasing Platform Among Users With Obesity: Longitudinal Study %A Hu,Emily A %A Nguyen,Viet %A Langheier,Jason %A Shurney,Dexter %+ Zipongo, Inc, DBA Foodsmart, 600 California Street, 11th Floor, San Francisco, CA, 94108, United States, 1 415 604 4122, emily.hu@zipongo.com %K digital %K nutrition %K meal planning %K weight loss %K obese %K food environment %K food ordering %K food purchasing %K behavioral economics %K behavior change %K eating behavior %K mHealth %K app %D 2020 %7 2.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital nutrition apps that monitor or provide recommendations on diet have been found to be effective in behavior change and weight reduction among individuals with obesity. However, there is less evidence on how integration of personalized nutrition recommendations and changing the food purchasing environment through online meal planning and grocery delivery, meal kits, and grocery incentives impacts weight loss among individuals with obesity. Objective: The objective of this observational longitudinal study was to examine weight loss and predictors of weight loss among individuals with obesity who are users of a digital nutrition platform that integrates tools to provide nutrition recommendations and changes in the food purchasing environment grounded in behavioral theory. Methods: We included 8977 adults with obesity who used the digital Foodsmart platform, created by Zipongo, Inc, DBA Foodsmart between January 2013 and April 2020. We retrospectively analyzed user characteristics and their associations with weight loss. Participants reported age, gender, height, at least 2 measures of weight, and usual dietary intake. Healthy Diet Score, a score to measure overall diet quality, was calculated based on responses to a food frequency questionnaire. We used paired t tests to compare differences in baseline and final weights and baseline and final Healthy Diet Scores. We used univariate and multivariate logistic regression models to estimate odds ratios and 95% CI of achieving 5% weight loss by gender, age, baseline BMI, Healthy Diet Score, change in Healthy Diet Score, and duration of enrollment. We conducted stratified analyses to examine mean percent weight change by enrollment duration and gender, age, baseline BMI, and change in Healthy Diet Score. Results: Over a median (IQR) of 9.9 (0.03-54.7) months of enrollment, 59% of participants lost weight. Of the participants who used the Foodsmart platform for at least 24 months, 33.3% achieved 5% weight loss. In the fully adjusted logistic regression model, we found that baseline BMI (OR 1.02, 95% CI 1.02-1.03; P<.001), baseline Healthy Diet Score (OR 1.06, 95% CI 1.05-1.08; P<.001), greater change in Healthy Diet Score (OR 1.12, 95% CI 1.11-1.14; P<.001), and enrollment length (OR 1.28, 95% CI 1.23-1.32; P<.001) were all significantly associated with higher odds of achieving at least 5% weight loss. Conclusions: This study found that a digital app that provides personalized nutrition recommendations and change in one’s food purchasing environment appears to be successful in meaningfully reducing weight among individuals with obesity. %M 32792332 %R 10.2196/19634 %U http://www.jmir.org/2020/9/e19634/ %U https://doi.org/10.2196/19634 %U http://www.ncbi.nlm.nih.gov/pubmed/32792332 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19897 %T A Personalized Voice-Based Diet Assistant for Caregivers of Alzheimer Disease and Related Dementias: System Development and Validation %A Li,Juan %A Maharjan,Bikesh %A Xie,Bo %A Tao,Cui %+ University of Texas Health Science Center at Houston, 7000 Fannin Street Suite 600, Houston, TX, 77030, United States, 1 7135003981, cui.tao@uth.tmc.edu %K Alzheimer disease %K dementia %K diet %K knowledge %K ontology %K voice assistant %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The world’s aging population is increasing, with an expected increase in the prevalence of Alzheimer disease and related dementias (ADRD). Proper nutrition and good eating behavior show promise for preventing and slowing the progression of ADRD and consequently improving patients with ADRD’s health status and quality of life. Most ADRD care is provided by informal caregivers, so assisting caregivers to manage patients with ADRD’s diet is important. Objective: This study aims to design, develop, and test an artificial intelligence–powered voice assistant to help informal caregivers manage the daily diet of patients with ADRD and learn food and nutrition-related knowledge. Methods: The voice assistant is being implemented in several steps: construction of a comprehensive knowledge base with ontologies that define ADRD diet care and user profiles, and is extended with external knowledge graphs; management of conversation between users and the voice assistant; personalized ADRD diet services provided through a semantics-based knowledge graph search and reasoning engine; and system evaluation in use cases with additional qualitative evaluations. Results: A prototype voice assistant was evaluated in the lab using various use cases. Preliminary qualitative test results demonstrate reasonable rates of dialogue success and recommendation correctness. Conclusions: The voice assistant provides a natural, interactive interface for users, and it does not require the user to have a technical background, which may facilitate senior caregivers’ use in their daily care tasks. This study suggests the feasibility of using the intelligent voice assistant to help caregivers manage patients with ADRD’s diet. %M 32955452 %R 10.2196/19897 %U http://www.jmir.org/2020/9/e19897/ %U https://doi.org/10.2196/19897 %U http://www.ncbi.nlm.nih.gov/pubmed/32955452 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18787 %T Quality of Care Perceived by Older Patients and Caregivers in Integrated Care Pathways With Interviewing Assistance From a Social Robot: Noninferiority Randomized Controlled Trial %A Boumans,Roel %A van Meulen,Fokke %A van Aalst,William %A Albers,Joyce %A Janssen,Marèse %A Peters-Kop,Marieke %A Huisman - de Waal,Getty %A van de Poll,Alexandra %A Hindriks,Koen %A Neerincx,Mark %A Olde Rikkert,Marcel %+ Geriatric Department, Radboud University Medical Center, Reinier Postlaan 4, Nijmegen, 6525 GC, Netherlands, 31 0622372708, roel.boumans@radboudumc.nl %K integrated care pathway %K social robot %K quality of care %K noninferiority randomized controlled trial %D 2020 %7 9.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Society is facing a global shortage of 17 million health care workers, along with increasing health care demands from a growing number of older adults. Social robots are being considered as solutions to part of this problem. Objective: Our objective is to evaluate the quality of care perceived by patients and caregivers for an integrated care pathway in an outpatient clinic using a social robot for patient-reported outcome measure (PROM) interviews versus the currently used professional interviews. Methods: A multicenter, two-parallel-group, nonblinded, randomized controlled trial was used to test for noninferiority of the quality of care delivered through robot-assisted care. The randomization was performed using a computer-generated table. The setting consisted of two outpatient clinics, and the study took place from July to December 2019. Of 419 patients who visited the participating outpatient clinics, 110 older patients met the criteria for recruitment. Inclusion criteria were the ability to speak and read Dutch and being assisted by a participating health care professional. Exclusion criteria were serious hearing or vision problems, serious cognitive problems, and paranoia or similar psychiatric problems. The intervention consisted of a social robot conducting a 36-item PROM. As the main outcome measure, the customized Consumer Quality Index (CQI) was used, as reported by patients and caregivers for the outpatient pathway of care. Results: In total, 75 intermediately frail older patients were included in the study, randomly assigned to the intervention and control groups, and processed: 36 female (48%) and 39 male (52%); mean age 77.4 years (SD 7.3), range 60-91 years. There was no significant difference in the total patient CQI scores between the patients included in the robot-assisted care pathway (mean 9.27, SD 0.65, n=37) and those in the control group (mean 9.00, SD 0.70, n=38): P=.08, 95% CI –0.04 to 0.58. There was no significant difference in the total CQI scores between caregivers in the intervention group (mean 9.21, SD 0.76, n=30) and those in the control group (mean 9.09, SD 0.60, n=35): P=.47, 95% CI –0.21 to 0.46. No harm or unintended effects occurred. Conclusions: Geriatric patients and their informal caregivers valued robot-assisted and nonrobot-assisted care pathways equally. Trial Registration: ClinicalTrials.gov NCT03857789; https://clinicaltrials.gov/ct2/show/NCT03857789 %M 32902387 %R 10.2196/18787 %U http://www.jmir.org/2020/9/e18787/ %U https://doi.org/10.2196/18787 %U http://www.ncbi.nlm.nih.gov/pubmed/32902387 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18623 %T Combating Health Care Fraud and Abuse: Conceptualization and Prototyping Study of a Blockchain Antifraud Framework %A Mackey,Tim Ken %A Miyachi,Ken %A Fung,Danny %A Qian,Samson %A Short,James %+ UC San Diego - School of Medicine, Department of Anesthesiology and Division of Infectious Diseases and Global Public Health, 8950 Villa La Jolla Drive, A124, La Jolla, CA, 92037, United States, 1 9514914161, tmackey@ucsd.edu %K fraud %K blockchain %K medical informatics %K delivery of healthcare %K Medicare %K information science %D 2020 %7 10.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: An estimated US $2.6 billion loss is attributed to health care fraud and abuse. With traditional health care claims verification and reimbursement, the health care provider submits a claim after rendering services to a patient, which is then verified and reimbursed by the payer. However, this process leaves out a critical stakeholder: the patient for whom the services are actually rendered. This lack of patient participation introduces a risk of fraud and abuse. Blockchain technology enables secure data management with transparency, which could mitigate this risk of health care fraud and abuse. Objective: The aim of this study is to develop a framework using blockchain to record claims data and transactions in an immutable format and to enable the patient to act as a validating node to help detect and prevent health care fraud and abuse. Methods: We developed a health care fraud and abuse blockchain technical framework and prototype using key blockchain tools and application layers including consensus algorithms, smart contracts, tokens, and governance based on digital identity on the Ethereum platform (Ethereum Foundation). Results: Our technical framework maps to the claims adjudication process and focuses on Medicare claims, with the US Centers for Medicare and Medicaid Services (CMS) as the central authority. A prototype of the framework system was developed using the blockchain platform Ethereum (Ethereum Foundation), with its design features, workflow, smart contract functions, system architecture, and software implementation outlined. The software stack used to build the system consisted of a front-end user interface framework, a back-end processing server, and a blockchain network. React was used for the user interface framework, and NodeJS and an Express server were used for the back-end processing server; Solidity was the smart contract language used to interact with a local Ethereum blockchain network. Conclusions: The proposed framework and the initial prototype have the potential to improve the health care claims process by using blockchain technology for secure data storage and consensus mechanisms, which make the claims adjudication process more patient-centric for the purposes of identifying and preventing health care fraud and abuse. Future work will focus on the use of synthetic or historic CMS claims data to assess the real-world viability of the framework. %M 32909952 %R 10.2196/18623 %U http://www.jmir.org/2020/9/e18623/ %U https://doi.org/10.2196/18623 %U http://www.ncbi.nlm.nih.gov/pubmed/32909952 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21691 %T Current Challenges of Digital Health Interventions in Pakistan: Mixed Methods Analysis %A Kazi,Abdul Momin %A Qazi,Saad Ahmed %A Ahsan,Nazia %A Khawaja,Sadori %A Sameen,Fareeha %A Saqib,Muhammad %A Khan Mughal,Muhammad Ayub %A Wajidali,Zabin %A Ali,Sikander %A Ahmed,Rao Moueed %A Kalimuddin,Hussain %A Rauf,Yasir %A Mahmood,Fatima %A Zafar,Saad %A Abbasi,Tufail Ahmad %A Khoumbati,Khalil-Ur-Rahmen %A Abbasi,Munir A %A Stergioulas,Lampros K %+ Department of Pediatrics and Child Health, Aga Khan University, Stadium Road​, P.O. Box 350​0, Karachi, 74800, Pakistan, 92 2134864232, momin.kazi@aku.edu %K digital health %K eHealth %K LMICs %K mHealth %K Pakistan %K SWOT %K telehealth %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health is well-positioned in low and middle-income countries (LMICs) to revolutionize health care due, in part, to increasing mobile phone access and internet connectivity. This paper evaluates the underlying factors that can potentially facilitate or hinder the progress of digital health in Pakistan. Objective: The objective of this study is to identify the current digital health projects and studies being carried out in Pakistan, as well as the key stakeholders involved in these initiatives. We aim to follow a mixed-methods strategy and to evaluate these projects and studies through a strengths, weaknesses, opportunities, and threats (SWOT) analysis to identify the internal and external factors that can potentially facilitate or hinder the progress of digital health in Pakistan. Methods: This study aims to evaluate digital health projects carried out in the last 5 years in Pakistan with mixed methods. The qualitative and quantitative data obtained from field surveys were categorized according to the World Health Organization’s (WHO) recommended building blocks for health systems research, and the data were analyzed using a SWOT analysis strategy. Results: Of the digital health projects carried out in the last 5 years in Pakistan, 51 are studied. Of these projects, 46% (23/51) used technology for conducting research, 30% (15/51) used technology for implementation, and 12% (6/51) used technology for app development. The health domains targeted were general health (23/51, 46%), immunization (13/51, 26%), and diagnostics (5/51, 10%). Smartphones and devices were used in 55% (28/51) of the interventions, and 59% (30/51) of projects included plans for scaling up. Artificial intelligence (AI) or machine learning (ML) was used in 31% (16/51) of projects, and 74% (38/51) of interventions were being evaluated. The barriers faced by developers during the implementation phase included the populations’ inability to use the technology or mobile phones in 21% (11/51) of projects, costs in 16% (8/51) of projects, and privacy concerns in 12% (6/51) of projects. Conclusions: We conclude that while digital health has a promising future in Pakistan, it is still in its infancy at the time of this study. However, due to the coronavirus disease 2019 (COVID-19) pandemic, there is an increase in demand for digital health and implementation of health outcomes following global social distancing protocols, especially in LMICs. Hence, there is a need for active involvement by public and private organizations to regulate, mobilize, and expand the digital health sector for the improvement of health care systems in countries. %M 32880584 %R 10.2196/21691 %U https://www.jmir.org/2020/9/e21691 %U https://doi.org/10.2196/21691 %U http://www.ncbi.nlm.nih.gov/pubmed/32880584 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18062 %T Examining Patterns of Information Exchange and Social Support in a Web-Based Health Community: Exponential Random Graph Models %A Liu,Xuan %A Jiang,Shan %A Sun,Min %A Chi,Xiaotong %+ East China University of Science and Technology, 130 Meilong Rd East China University of Science and Technology, Shanghai, China, 86 86 21 64253177, xuanliu@ecust.edu.cn %K web-based health communities %K information exchange %K social support %K ERGM %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although an increasing number of studies have attempted to understand how people interact with others in web-based health communities, studies focusing on understanding individuals’ patterns of information exchange and social support in web-based health communities are still limited. In this paper, we discuss how patients’ social interactions develop into social networks based on a network exchange framework and empirically validate the framework in web-based health care community contexts. Objective: This study aims to explore various patterns of information exchange and social support in web-based health care communities and identify factors that affect such patterns. Methods: Using social network analysis and text mining techniques, we empirically validated a network exchange framework on a 10-year data set collected from a popular web-based health community. A reply network was extracted from the data set, and exponential random graph models were used to discover patterns of information exchange and social support from the network. Results: Results showed that reciprocated information exchange was common in web-based health communities. The homophily effect existed in general conversations but was weakened when exchanging knowledge. New members in web-based health communities tended to receive more support. Furthermore, polarized sentiment increases the chances of receiving replies, and optimistic users play an important role in providing social support to the entire community. Conclusions: This study complements the literature on network exchange theories and contributes to a better understanding of social exchange patterns in the web-based health care context. Practically, this study can help web-based patients obtain information and social support more effectively. %M 32990628 %R 10.2196/18062 %U http://www.jmir.org/2020/9/e18062/ %U https://doi.org/10.2196/18062 %U http://www.ncbi.nlm.nih.gov/pubmed/32990628 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19644 %T Accelerating Innovation in Health Care: Insights From a Qualitative Inquiry Into United Kingdom and United States Innovation Centers %A Cresswell,Kathrin %A Williams,Robin %A Carlile,Narath %A Sheikh,Aziz %+ Usher Institute, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, United Kingdom, 44 131 651 4151, kathrin.beyer@ed.ac.uk %K innovation %K health information technology %K health care %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health innovations are being prioritized on international policy agendas in the hope that they will help to address the existing health system challenges. Objective: The aim of this study was to explore the setup, design, facilities, and strategic priorities of leading United Kingdom and United States health care innovation centers to identify transferable lessons for accelerating their creation and maximizing their impact. Methods: We conducted qualitative case studies consisting of semistructured, audio-recorded interviews with decision makers and center staff in 6 innovation centers. We also conducted nonparticipant observations of meetings and center tours, where we took field notes. Qualitative data were analyzed initially within and then across cases facilitated by QSR International’s NVivo software. Results: The centers had different institutional arrangements, including university-associated institutes or innovation laboratories, business accelerators or incubators, and academic health science partnership models. We conducted interviews with 34 individuals, 1 group interview with 3 participants, and observations of 4 meetings. Although the centers differed significantly in relation to their mission, structure, and governance, we observed key common characteristics. These included high-level leadership support and incentives to engage in innovation activities, a clear mission to address identified gaps within their respective organizational and health system settings, physical spaces that facilitated networking through open-door policies, flat managerial structures characterized by new organizational roles for which boundary spanning was key, and a wider innovation ecosystem that was strategically and proactively engaged with the center facilitating external partnerships. Conclusions: Although innovation in health care settings is unpredictable, we offer insights that may help those establishing innovation centers. The key in this respect is the ability to support different kinds of innovations at different stages through adequate support structures, including the development of new career pathways. %M 32975524 %R 10.2196/19644 %U http://www.jmir.org/2020/9/e19644/ %U https://doi.org/10.2196/19644 %U http://www.ncbi.nlm.nih.gov/pubmed/32975524 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e14944 %T Comment on “Prediction of the 1-Year Risk of Incident Lung Cancer: Prospective Study Using Electronic Health Records from the State of Maine” %A Rahmani,Jamal %A Karimi,Roya %A Khani,Yousef %A Sabour,Siamak %+ Department of Clinical Epidemiology, School of Health and Safety, Shahid Beheshti University of Medical Sciences, Chamran Highway, Velenjak, Daneshjoo Blvd, Tehran, 198353-5511, Iran, 98 2122421814, s.sabour@sbmu.ac.ir %K prediction %K area under the curve %K AUC %K lung cancer %D 2020 %7 15.9.2020 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 32930665 %R 10.2196/14944 %U https://www.jmir.org/2020/9/e14944 %U https://doi.org/10.2196/14944 %U http://www.ncbi.nlm.nih.gov/pubmed/32930665 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e16179 %T Comment on “Designing Robust N-of-1 Studies for Precision Medicine: Simulation Study and Design Recommendations” %A Landes,Reid D %+ Department of Biostatistics, University of Arkansas for Medical Sciences, 4301 W Markham St, Slot 781, Little Rock, AR, 72205, United States, 1 501 526 6714, rdlandes@uams.edu %K sample size %K misleading statements %D 2020 %7 15.9.2020 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 32930671 %R 10.2196/16179 %U https://www.jmir.org/2020/9/e16179 %U https://doi.org/10.2196/16179 %U http://www.ncbi.nlm.nih.gov/pubmed/32930671 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e23996 %T Correction: Real-Time Forecasting of the COVID-19 Outbreak in Chinese Provinces: Machine Learning Approach Using Novel Digital Data and Estimates From Mechanistic Models %A Liu,Dianbo %A Clemente,Leonardo %A Poirier,Canelle %A Ding,Xiyu %A Chinazzi,Matteo %A Davis,Jessica %A Vespignani,Alessandro %A Santillana,Mauricio %+ Computational Health Informatics Program, Boston Children’s Hospital, 300 Longwood Avenue, Landmark 5th Floor East, Boston, MA, 02215, United States, 1 (617) 919 1795, msantill@g.harvard.edu %D 2020 %7 22.9.2020 %9 Corrigenda and Addenda %J J Med Internet Res %G English %X %M 32960774 %R 10.2196/23996 %U http://www.jmir.org/2020/9/e23996/ %U https://doi.org/10.2196/23996 %U http://www.ncbi.nlm.nih.gov/pubmed/32960774 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19338 %T Digital Response During the COVID-19 Pandemic in Saudi Arabia %A Hassounah,Marwah %A Raheel,Hafsa %A Alhefzi,Mohammed %+ Prince Sattam Chair for Epidemiology and Public Health Research, Department of Family and Community Medicine, College of Medicine, King Saud University, Room No. 321/27, Third Floor, Medical Education Department, Riyadh, , Saudi Arabia, 966 556942926, hafsaraheel@yahoo.com %K digital response %K COVID-19 %K Saudi Arabia %K digital health %K containment %K public health %K pandemic %K prevention %D 2020 %7 1.9.2020 %9 Viewpoint %J J Med Internet Res %G English %X Background: The first case of COVID-19 in Saudi Arabia was confirmed on March 3, 2020. Saudi Arabia, like many other countries worldwide, implemented lockdown of most public and private services in response to the pandemic and established population movement restrictions nationwide. With the implementation of these strict mitigation regulations, technology and digital solutions have enabled the provision of essential services. Objective: The aim of this paper is to highlight how Saudi Arabia has used digital technology during the COVID-19 pandemic in the domains of public health, health care services, education, telecommunication, commerce, and risk communication. Methods: We documented the use of digital technology in Saudi Arabia during the pandemic using publicly available official announcements, press briefings and releases, news clips, published data, peer-reviewed literature, and professional discussions. Results: Saudi Arabia’s government and private sectors combined developed and launched approximately 19 apps and platforms that serve public health functions and provide health care services. A detailed account of each is provided. Education processes continued using an established electronic learning infrastructure with a promising direction toward wider adoption in the future. Telecommunication companies exhibited smooth collaboration as well as innovative initiatives to support ongoing efforts. Risk communication activities using social media, websites, and SMS text messaging followed best practice guides. Conclusions: The Saudi Vision 2030 framework, released in 2017, has paved the path for digital transformation. COVID-19 enabled the promotion and testing of this transition. In Saudi Arabia, the use of artificial intelligence in integrating different data sources during future outbreaks could be further explored. Also, decreasing the number of mobile apps and merging their functions could increase and facilitate their use. %M 32790642 %R 10.2196/19338 %U https://www.jmir.org/2020/9/e19338 %U https://doi.org/10.2196/19338 %U http://www.ncbi.nlm.nih.gov/pubmed/32790642 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21758 %T Efficacy of Hydroxychloroquine and Tocilizumab in Patients With COVID-19: Single-Center Retrospective Chart Review %A Roomi,Sohaib %A Ullah,Waqas %A Ahmed,Faizan %A Farooq,Soban %A Sadiq,Usama %A Chohan,Asad %A Jafar,Munnam %A Saddique,Maryum %A Khanal,Shristi %A Watson,Robert %A Boigon,Margot %+ Jefferson Health Abington, 1200 Old York Rd, Abington, PA, United States, 1 2674666985, roomigujjar251@gmail.com %K COVID-19 %K hydroxychloroquine %K tocilizumab %D 2020 %7 1.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: During the initial phases of the COVID-19 pandemic, there was an unfounded fervor surrounding the use of hydroxychloroquine (HCQ) and tocilizumab (TCZ); however, evidence on their efficacy and safety have been controversial. Objective: The purpose of this study is to evaluate the overall clinical effectiveness of HCQ and TCZ in patients with COVID-19. We hypothesize that HCQ and TCZ use in these patients will be associated with a reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. Methods: A retrospective cohort study was performed to determine the impact of HCQ and TCZ use on hard clinical outcomes during hospitalization. A total of 176 hospitalized patients with a confirmed COVID-19 diagnosis was included. Patients were divided into two comparison groups: (1) HCQ (n=144) vs no-HCQ (n=32) and (2) TCZ (n=32) vs no-TCZ (n=144). The mean age, baseline comorbidities, and other medications used during hospitalization were uniformly distributed among all the groups. Independent t tests and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios with 95% CIs, respectively. Results: The unadjusted odds ratio for patients upgraded to a higher level of care (ie, intensive care unit) (OR 2.6, 95% CI 1.19-5.69; P=.003) and reductions in C-reactive protein (CRP) level on day 7 of hospitalization (21% vs 56%, OR 0.21, 95% CI 0.08-0.55; P=.002) were significantly higher in the TCZ group compared to the control group. There was no significant difference in the odds of in-hospital mortality, upgrade to intensive medical care, need for invasive mechanical ventilation, acute kidney failure necessitating dialysis, or discharge from the hospital after recovery in both the HCQ and TCZ groups compared to their respective control groups. Adjusted odds ratios controlled for baseline comorbidities and medications closely followed the unadjusted estimates. Conclusions: In this cohort of patients with COVID-19, neither HCQ nor TCZ offered a significant reduction in in-hospital mortality, upgrade to intensive medical care, invasive mechanical ventilation, or acute renal failure needing dialysis. These results are similar to the recently published preliminary results of the HCQ arm of the Recovery trial, which showed no clinical benefit from the use of HCQ in hospitalized patients with COVID-19 (the TCZ arm is ongoing). Double-blinded randomized controlled trials are needed to further evaluate the impact of these drugs in larger patient samples so that data-driven guidelines can be deduced to combat this global pandemic. %M 32784192 %R 10.2196/21758 %U https://www.jmir.org/2020/9/e21758 %U https://doi.org/10.2196/21758 %U http://www.ncbi.nlm.nih.gov/pubmed/32784192 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21419 %T Public Perceptions and Attitudes Toward COVID-19 Nonpharmaceutical Interventions Across Six Countries: A Topic Modeling Analysis of Twitter Data %A Doogan,Caitlin %A Buntine,Wray %A Linger,Henry %A Brunt,Samantha %+ Department of Data Science and AI, Faculty of Information Technology, Monash University, Wellington Rd, Clayton, 3800, Australia, 61 3 9903 1004, caitlin.doogan@monash.edu %K COVID-19 %K SARS-CoV-2 %K topic modeling %K nonpharmaceutical interventions %K social media %K public health %K machine learning %K social distancing %K lockdown %K face masks %K infodemiology %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Nonpharmaceutical interventions (NPIs) (such as wearing masks and social distancing) have been implemented by governments around the world to slow the spread of COVID-19. To promote public adherence to these regimes, governments need to understand the public perceptions and attitudes toward NPI regimes and the factors that influence them. Twitter data offer a means to capture these insights. Objective: The objective of this study is to identify tweets about COVID-19 NPIs in six countries and compare the trends in public perceptions and attitudes toward NPIs across these countries. The aim is to identify factors that influenced public perceptions and attitudes about NPI regimes during the early phases of the COVID-19 pandemic. Methods: We analyzed 777,869 English language tweets about COVID-19 NPIs in six countries (Australia, Canada, New Zealand, Ireland, the United Kingdom, and the United States). The relationship between tweet frequencies and case numbers was assessed using a Pearson correlation analysis. Topic modeling was used to isolate tweets about NPIs. A comparative analysis of NPIs between countries was conducted. Results: The proportion of NPI-related topics, relative to all topics, varied between countries. The New Zealand data set displayed the greatest attention to NPIs, and the US data set showed the lowest. The relationship between tweet frequencies and case numbers was statistically significant only for Australia (r=0.837, P<.001) and New Zealand (r=0.747, P<.001). Topic modeling produced 131 topics related to one of 22 NPIs, grouped into seven NPI categories: Personal Protection (n=15), Social Distancing (n=9), Testing and Tracing (n=10), Gathering Restrictions (n=18), Lockdown (n=42), Travel Restrictions (n=14), and Workplace Closures (n=23). While less restrictive NPIs gained widespread support, more restrictive NPIs were perceived differently across countries. Four characteristics of these regimes were seen to influence public adherence to NPIs: timeliness of implementation, NPI campaign strategies, inconsistent information, and enforcement strategies. Conclusions: Twitter offers a means to obtain timely feedback about the public response to COVID-19 NPI regimes. Insights gained from this analysis can support government decision making, implementation, and communication strategies about NPI regimes, as well as encourage further discussion about the management of NPI programs for global health events, such as the COVID-19 pandemic. %M 32784190 %R 10.2196/21419 %U https://www.jmir.org/2020/9/e21419 %U https://doi.org/10.2196/21419 %U http://www.ncbi.nlm.nih.gov/pubmed/32784190 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19471 %T Willingness to Use Home Collection Methods to Provide Specimens for SARS-CoV-2/COVID-19 Research: Survey Study %A Hall,Eric William %A Luisi,Nicole %A Zlotorzynska,Maria %A Wilde,Gretchen %A Sullivan,Patrick %A Sanchez,Travis %A Bradley,Heather %A Siegler,Aaron J %+ Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, United States, 1 404 712 9733, asiegle@emory.edu %K COVID-19 %K SARS-CoV-2 %K specimen collection %K survey %K research %K public health %K infectious disease %K virus %K test %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Innovative laboratory testing approaches for SARS-CoV-2 infection and immune response are needed to conduct research to establish estimates of prevalence and incidence. Self-specimen collection methods have been successfully used in HIV and sexually transmitted infection research and can provide a feasible opportunity to scale up SARS-CoV-2 testing for research purposes. Objective: The aim of this study was to assess the willingness of adults to use different specimen collection modalities for themselves and children as part of a COVID-19 research study. Methods: Between March 27 and April 1, 2020, we recruited 1435 adults aged 18 years or older though social media advertisements. Participants completed a survey that included 5-point Likert scale items stating how willing they were to use the following specimen collection testing modalities as part of a research study: home collection of a saliva sample, home collection of a throat swab, home finger-prick blood collection, drive-through site throat swab, clinic throat swab, and clinic blood collection. Additionally, participants indicated how the availability of home-based collection methods would impact their willingness to participate compared to drive-through and clinic-based specimen collection. We used Kruskal-Wallis tests and Spearman rank correlations to assess if willingness to use each testing modality differed by demographic variables and characteristics of interest. We compared the overall willingness to use each testing modality and estimated effect sizes with Cohen d. Results: We analyzed responses from 1435 participants with a median age of 40.0 (SD=18.2) years and over half of which were female (761/1435, 53.0%). Most participants agreed or strongly agreed that they would be willing to use specimens self-collected at home to participate in research, including willingness to collect a saliva sample (1259/1435, 87.7%) or a throat swab (1191/1435, 83.1%). Willingness to collect a throat swab sample was lower in both a drive-through setting (64%) and clinic setting (53%). Overall, 69.0% (990/1435) of participants said they would be more likely to participate in a research study if they could provide a saliva sample or throat swab at home compared to going to a drive-through site; only 4.4% (63/1435) of participants said they would be less likely to participate using self-collected samples. For each specimen collection modality, willingness to collect specimens from children for research was lower than willingness to use on oneself, but the ranked order of modalities was similar. Conclusions: Most participants were willing to participate in a COVID-19 research study that involves laboratory testing; however, there was a strong preference for home specimen collection procedures over drive-through or clinic-based testing. To increase participation and minimize bias, epidemiologic research studies of SARS-CoV-2 infection and immune response should consider home specimen collection methods. %M 32790639 %R 10.2196/19471 %U https://www.jmir.org/2020/9/e19471 %U https://doi.org/10.2196/19471 %U http://www.ncbi.nlm.nih.gov/pubmed/32790639 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21279 %T Effects of COVID-19 on College Students’ Mental Health in the United States: Interview Survey Study %A Son,Changwon %A Hegde,Sudeep %A Smith,Alec %A Wang,Xiaomei %A Sasangohar,Farzan %+ Department of Industrial and Systems Engineering, Texas A&M University, 3131 TAMU, College Station, TX, 77843, United States, 1 979 458 2337, sasangohar@tamu.edu %K COVID-19 %K pandemic %K college student %K mental health %K stress %K anxiety %K self-management %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Student mental health in higher education has been an increasing concern. The COVID-19 pandemic situation has brought this vulnerable population into renewed focus. Objective: Our study aims to conduct a timely assessment of the effects of the COVID-19 pandemic on the mental health of college students. Methods: We conducted interview surveys with 195 students at a large public university in the United States to understand the effects of the pandemic on their mental health and well-being. The data were analyzed through quantitative and qualitative methods. Results: Of the 195 students, 138 (71%) indicated increased stress and anxiety due to the COVID-19 outbreak. Multiple stressors were identified that contributed to the increased levels of stress, anxiety, and depressive thoughts among students. These included fear and worry about their own health and of their loved ones (177/195, 91% reported negative impacts of the pandemic), difficulty in concentrating (173/195, 89%), disruptions to sleeping patterns (168/195, 86%), decreased social interactions due to physical distancing (167/195, 86%), and increased concerns on academic performance (159/195, 82%). To cope with stress and anxiety, participants have sought support from others and helped themselves by adopting either negative or positive coping mechanisms. Conclusions: Due to the long-lasting pandemic situation and onerous measures such as lockdown and stay-at-home orders, the COVID-19 pandemic brings negative impacts on higher education. The findings of our study highlight the urgent need to develop interventions and preventive strategies to address the mental health of college students. %M 32805704 %R 10.2196/21279 %U https://www.jmir.org/2020/9/e21279 %U https://doi.org/10.2196/21279 %U http://www.ncbi.nlm.nih.gov/pubmed/32805704 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20143 %T Rapid Implementation and Innovative Applications of a Virtual Intensive Care Unit During the COVID-19 Pandemic: Case Study %A Dhala,Atiya %A Sasangohar,Farzan %A Kash,Bita %A Ahmadi,Nima %A Masud,Faisal %+ Department of Industrial and Systems Engineering, Texas A&M University, 3131 TAMU, College Station, TX, 77843, United States, 1 9794582337, sasangohar@tamu.edu %K intensive care units %K critical care %K pandemics %K SARS-CoV-2 %K telemedicine %K infection control %K COVID-19 %D 2020 %7 3.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has necessitated a rapid increase of space in highly infectious disease intensive care units (ICUs). At Houston Methodist Hospital (HMH), a virtual intensive care unit (vICU) was used amid the COVID-19 outbreak. Objective: The aim of this paper was to detail the novel adaptations and rapid expansion of the vICU that were applied to achieve patient-centric solutions while protecting staff and patients’ families during the pandemic. Methods: The planned vICU implementation was redirected to meet the emerging needs of conversion of COVID-19 ICUs, including alterations to staged rollout timing, virtual and in-person staffing, and scope of application. With the majority of the hospital critical care physician workforce redirected to rapidly expanded COVID-19 ICUs, the non–COVID-19 ICUs were managed by cardiovascular surgeons, cardiologists, neurosurgeons, and acute care surgeons. HMH expanded the vICU program to fill the newly depleted critical care expertise in the non–COVID-19 units to provide urgent, emergent, and code blue support to all ICUs. Results: Virtual family visitation via the Consultant Bridge application, palliative care delivery, and specialist consultation for patients with COVID-19 exemplify the successful adaptation of the vICU implementation. Patients with COVID-19, who were isolated and separated from their families to prevent the spread of infection, were able to virtually see and hear their loved ones, which bolstered the mental and emotional status of those patients. Many families expressed gratitude for the ability to see and speak with their loved ones. The vICU also protected medical staff and specialists assigned to COVID-19 units, reducing exposure and conserving personal protective equipment. Conclusions: Telecritical care has been established as an advantageous mechanism for the delivery of critical care expertise during the expedited rollout of the vICU at Houston Methodist Hospital. Overall responses from patients, families, and physicians are in favor of continued vICU care; however, further research is required to examine the impact of innovative applications of telecritical care in the treatment of critically ill patients. %M 32795997 %R 10.2196/20143 %U http://www.jmir.org/2020/9/e20143/ %U https://doi.org/10.2196/20143 %U http://www.ncbi.nlm.nih.gov/pubmed/32795997 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22227 %T Depression and Psychological-Behavioral Responses Among the General Public in China During the Early Stages of the COVID-19 Pandemic: Survey Study %A Zhang,Weiyu %A Yang,Xiaoting %A Zhao,Jinfeng %A Yang,Fengzhi %A Jia,Yajing %A Cui,Can %A Yang,Xiaoshi %+ Department of Social Medicine, School of Public Health, China Medical University, No 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, China, 86 18900910796, xsyang@cmu.edu.cn %K depression %K COVID-19 %K social support %K the general public %D 2020 %7 4.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has recently spread dramatically worldwide, raising considerable concerns and resulting in detrimental effects on the psychological health of people who are vulnerable to the disease. Therefore, assessment of depression in members of the general public and their psychological and behavioral responses is essential for the maintenance of health. Objective: This study aimed to assess the prevalence of depression and the associated factors among the general public during the early stages of the COVID-19 pandemic in China. Methods: A cross-sectional survey with convenience sampling was conducted from February 11 to 16, 2020, in the early stages of the COVID-19 outbreak in China. A self-administrated smartphone questionnaire based on the Patient Health Questionnaire-9 (PHQ-9) and psychological and behavioral responses was distributed to the general public. Hierarchical multiple regression analysis and multivariate logistic regression analysis were conducted to explore the associated factors of depression.aA cross-sectional survey with convenience sampling was conducted from February 11 to 16, 2020, in the early stages of the COVID-19 outbreak in China. A self-administrated smartphone questionnaire based on the Patient Health Questionnaire-9 (PHQ-9) and psychological and behavioral responses was distributed to the general public. Hierarchical multiple regression analysis and multivariate logistic regression analysis were conducted to explore the associated factors of depression. Results: The prevalence of depression (PHQ-9 score ≥10) among the general public during the COVID-19 pandemic was 182/1342 (13.6%). Regression analysis indicated that feeling stressed, feeling helpless, persistently being worried even with support, never feeling clean after disinfecting, scrubbing hands and items repeatedly, hoarding food, medicine, or daily supplies, and being distracted from work or study were positively associated with depression, while social support and being calm were negatively associated with depression. Conclusions: The general public suffered from high levels of depression during the early stages of the COVID-19 pandemic. Thus, COVID-19–related mood management and social support should be provided to attenuate depression in the general public. %M 32886066 %R 10.2196/22227 %U https://www.jmir.org/2020/9/e22227 %U https://doi.org/10.2196/22227 %U http://www.ncbi.nlm.nih.gov/pubmed/32886066 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22002 %T Perinatal Distress During COVID-19: Thematic Analysis of an Online Parenting Forum %A Chivers,Bonnie R %A Garad,Rhonda M %A Boyle,Jacqueline A %A Skouteris,Helen %A Teede,Helena J %A Harrison,Cheryce L %+ Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Wellington Rd, Clayton, Australia, 61 3 8572 2662, cheryce.harrison@monash.edu %K pregnancy %K perinatal %K maternal %K COVID-19 %K communication %K social support %K qualitative research %K mental health %K health information %K online support %K thematic analysis %K sentiment analysis %K word frequency %D 2020 %7 7.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 global pandemic has impacted the whole of society, requiring rapid implementation of individual-, population-, and system-level public health responses to contain and reduce the spread of infection. Women in the perinatal period (pregnant, birthing, and postpartum) have unique and timely needs for directives on health, safety, and risk aversion during periods of isolation and physical distancing for themselves, their child or children, and other family members. In addition, they are a vulnerable group at increased risk of psychological distress that may be exacerbated in the context of social support deprivation and a high-risk external environment. Objective: The aim of this study is to examine the public discourse of a perinatal cohort to understand unmet health information and support needs, and the impacts on mothering identity and social dynamics in the context of COVID-19. Methods: A leading Australian online support forum for women pre- through to postbirth was used to interrogate all posts related to COVID-19 from January 27 to May 12, 2020, inclusive. Key search terms included “COVID,” “corona,” and “pandemic.” A three-phase analysis was conducted, including thematic analysis, sentiment analysis, and word frequency calculations. Results: The search yielded 960 posts, of which 831 were included in our analysis. The qualitative thematic analysis demonstrated reasonable understanding, interpretation, and application of relevant restrictions in place, with five emerging themes identified. These were (1) heightened distress related to a high-risk external environment; (2) despair and anticipatory grief due to deprivation of social and family support, and bonding rituals; (3) altered family and support relationships; (4) guilt-tampered happiness; and (5) family future postponed. Sentiment analysis revealed that the content was predominantly negative (very negative: n=537 and moderately negative: n=443 compared to very positive: n=236 and moderately positive: n=340). Negative words were frequently used in the 831 posts with associated derivatives including “worried” (n=165, 19.9%), “risk” (n=143, 17.2%), “anxiety” (n=98, 11.8%), “concerns” (n=74, 8.8%), and “stress” (n=69, 8.3%). Conclusions: Women in the perinatal period are uniquely impacted by the current pandemic. General information on COVID-19 safe behaviors did not meet the particular needs of this cohort. The lack of nuanced and timely information may exacerbate the risk of psychological and psychosocial distress in this vulnerable, high-risk group. State and federal public health departments need to provide a central repository of information that is targeted, consistent, accessible, timely, and reassuring. Compensatory social and emotional support should be considered, using alternative measures to mitigate the risk of mental health disorders in this cohort. %M 32857707 %R 10.2196/22002 %U http://www.jmir.org/2020/9/e22002/ %U https://doi.org/10.2196/22002 %U http://www.ncbi.nlm.nih.gov/pubmed/32857707 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19913 %T Perceptions, Knowledge, and Behaviors Related to COVID-19 Among Social Media Users: Cross-Sectional Study %A Ali,Khawla F %A Whitebridge,Simon %A Jamal,Mohammad H %A Alsafy,Mohammad %A Atkin,Stephen L %+ Royal College of Surgeons in Ireland-Medical University of Bahrain, PO Box 15503, Adliya, Bahrain, 974 973 34611722, khawlafouad@hotmail.com %K COVID-19 %K social media %K public health %K perception %K knowledge %K health information %K health education %K virus %D 2020 %7 8.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Social media is one of the most rapid and impactful ways of obtaining and delivering information in the modern era. Objective: The aim of this study was to rapidly obtain information on public perceptions, knowledge, and behaviors related to COVID-19 in order to identify deficiencies in key areas of public education. Methods: Using a cross-sectional study design, a survey web link was posted on the social media and messaging platforms Instagram, Twitter, and WhatsApp by the study investigators. Participants, aged ≥18 years, filled out the survey on a voluntary basis. The main outcomes measured were knowledge of COVID-19 symptoms, protective measures against COVID-19, and source(s) of information about COVID-19. Subgroup analyses were conducted to determine the effects of age, gender, underlying illness, and working or studying in the health care industry on the perceived likelihood of acquiring COVID-19 and getting vaccinated. Results: A total of 5677 subjects completed the survey over the course of 1 week. “Fever or chills” (n=4973, 87.6%) and “shortness of breath” (n=4695, 82.7%) were identified as the main symptoms of COVID-19. Washing and sanitizing hands (n=4990, 87.9%) and avoiding public places and crowds (n=4865, 85.7%) were identified as the protective measures most frequently used against COVID-19. Social media was the most utilized source for information on the disease (n=4740, 83.5%), followed by the World Health Organization (n=2844, 50.1%). Subgroup analysis revealed that younger subjects (<35 years), males, and those working or studying in health care reported a higher perceived likelihood of acquiring COVID-19, whereas older subjects, females, and those working or studying in non–health care areas reported a lower perceived likelihood of acquiring COVID-19. Similar trends were observed for vaccination against COVID-19, with older subjects, females, and those working or studying in non–health care sectors reporting a lower likelihood of vaccinating against COVID-19. Conclusions: Our results are indicative of a relatively well-informed cohort implementing appropriate protective measures. However, key knowledge deficiencies exist with regards to vaccination against COVID-19, which future efforts should aim at correcting. %M 32841153 %R 10.2196/19913 %U http://www.jmir.org/2020/9/e19913/ %U https://doi.org/10.2196/19913 %U http://www.ncbi.nlm.nih.gov/pubmed/32841153 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19907 %T Real-World Implications of a Rapidly Responsive COVID-19 Spread Model with Time-Dependent Parameters via Deep Learning: Model Development and Validation %A Jung,Se Young %A Jo,Hyeontae %A Son,Hwijae %A Hwang,Hyung Ju %+ Department of Mathematics, Pohang University of Science and Technology, 77, Cheongam-ro, Nam-gu, Pohang-si, Gyeongsangbuk-do, Pohang, 37673, Republic of Korea, 82 542792056, hjhwang@postech.ac.kr %K epidemic models %K SIR models %K time-dependent parameters %K neural networks %K deep learning %K COVID-19 %K modeling %K spread %K outbreak %D 2020 %7 9.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has caused major disruptions worldwide since March 2020. The experience of the 1918 influenza pandemic demonstrated that decreases in the infection rates of COVID-19 do not guarantee continuity of the trend. Objective: The aim of this study was to develop a precise spread model of COVID-19 with time-dependent parameters via deep learning to respond promptly to the dynamic situation of the outbreak and proactively minimize damage. Methods: In this study, we investigated a mathematical model with time-dependent parameters via deep learning based on forward-inverse problems. We used data from the Korea Centers for Disease Control and Prevention (KCDC) and the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University for Korea and the other countries, respectively. Because the data consist of confirmed, recovered, and deceased cases, we selected the susceptible-infected-recovered (SIR) model and found approximated solutions as well as model parameters. Specifically, we applied fully connected neural networks to the solutions and parameters and designed suitable loss functions. Results: We developed an entirely new SIR model with time-dependent parameters via deep learning methods. Furthermore, we validated the model with the conventional Runge-Kutta fourth order model to confirm its convergent nature. In addition, we evaluated our model based on the real-world situation reported from the KCDC, the Korean government, and news media. We also crossvalidated our model using data from the CSSE for Italy, Sweden, and the United States. Conclusions: The methodology and new model of this study could be employed for short-term prediction of COVID-19, which could help the government prepare for a new outbreak. In addition, from the perspective of measuring medical resources, our model has powerful strength because it assumes all the parameters as time-dependent, which reflects the exact status of viral spread. %M 32877350 %R 10.2196/19907 %U http://www.jmir.org/2020/9/e19907/ %U https://doi.org/10.2196/19907 %U http://www.ncbi.nlm.nih.gov/pubmed/32877350 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20786 %T Patient Satisfaction With Telemedicine During the COVID-19 Pandemic: Retrospective Cohort Study %A Ramaswamy,Ashwin %A Yu,Miko %A Drangsholt,Siri %A Ng,Eric %A Culligan,Patrick J %A Schlegel,Peter N %A Hu,Jim C %+ Department of Urology, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, United States, 1 646 962 9600, asr9066@nyp.org %K telemedicine %K medicine %K pandemics %K patient satisfaction %K remote consultation %K disruptive technology %K medical informatics %K health care delivery %K practice patterns %K physicians %K health policy %K health services research %K health care reform %K COVID-19 %D 2020 %7 9.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: New York City was the international epicenter of the COVID-19 pandemic. Health care providers responded by rapidly transitioning from in-person to video consultations. Telemedicine (ie, video visits) is a potentially disruptive innovation; however, little is known about patient satisfaction with this emerging alternative to the traditional clinical encounter. Objective: This study aimed to determine if patient satisfaction differs between video and in-person visits. Methods: In this retrospective observational cohort study, we analyzed 38,609 Press Ganey patient satisfaction survey outcomes from clinic encounters (620 video visits vs 37,989 in-person visits) at a single-institution, urban, quaternary academic medical center in New York City for patients aged 18 years, from April 1, 2019, to March 31, 2020. Time was categorized as pre–COVID-19 and COVID-19 (before vs after March 4, 2020). Wilcoxon-Mann-Whitney tests and multivariable linear regression were used for hypothesis testing and statistical modeling, respectively. Results: We experienced an 8729% increase in video visit utilization during the COVID-19 pandemic compared to the same period last year. Video visit Press Ganey scores were significantly higher than in-person visits (94.9% vs 92.5%; P<.001). In adjusted analyses, video visits (parameter estimate [PE] 2.18; 95% CI 1.20-3.16) and the COVID-19 period (PE 0.55; 95% CI 0.04-1.06) were associated with higher patient satisfaction. Younger age (PE –2.05; 95% CI –2.66 to –1.22), female gender (PE –0.73; 95% CI –0.96 to –0.50), and new visit type (PE –0.75; 95% CI –1.00 to –0.49) were associated with lower patient satisfaction. Conclusions: Patient satisfaction with video visits is high and is not a barrier toward a paradigm shift away from traditional in-person clinic visits. Future research comparing other clinic visit quality indicators is needed to guide and implement the widespread adoption of telemedicine. %M 32810841 %R 10.2196/20786 %U http://www.jmir.org/2020/9/e20786/ %U https://doi.org/10.2196/20786 %U http://www.ncbi.nlm.nih.gov/pubmed/32810841 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21956 %T App-Based Tracking of Self-Reported COVID-19 Symptoms: Analysis of Questionnaire Data %A Zens,Martin %A Brammertz,Arne %A Herpich,Juliane %A Südkamp,Norbert %A Hinterseer,Martin %+ Department of Medicine, Kliniken Ostallgaeu-Kaufbeuren, Stadtbleiche 1, Fuessen, 87629, Germany, 49 8362 500 726, martin.zens@me.com %K COVID-19 %K self-reporting %K symptom %K tracking %K app %K surveillance %K distribution %K digital tool %K screening %D 2020 %7 9.9.2020 %9 Short Paper %J J Med Internet Res %G English %X Background: COVID-19 is an infectious disease characterized by various clinical presentations. Knowledge of possible symptoms and their distribution allows for the early identification of infected patients. Objective: To determine the distribution pattern of COVID-19 symptoms as well as possible unreported symptoms, we created an app-based self-reporting tool. Methods: The COVID-19 Symptom Tracker is an app-based daily self-reporting tool. Between April 8 and May 15, 2020, a total of 22,327 individuals installed this app on their mobile device. An initial questionnaire asked for demographic information (age, gender, postal code) and past medical history comprising relevant chronic diseases. The participants were reminded daily to report whether they were experiencing any symptoms and if they had been tested for SARS-CoV-2 infection. Participants who sought health care services were asked additional questions regarding diagnostics and treatment. Participation was open to all adults (≥18 years). The study was completely anonymous. Results: In total, 11,829 (52.98%) participants completed the symptom questionnaire at least once. Of these, 291 (2.46%) participants stated that they had undergone an RT-PCR (reverse transcription-polymerase chain reaction) test for SARS-CoV-2; 65 (0.55%) reported a positive test result and 226 (1.91%) a negative one. The mean number of reported symptoms among untested participants was 0.81 (SD 1.85). Participants with a positive test result had, on average, 5.63 symptoms (SD 2.82). The most significant risk factors were diabetes (odds ratio [OR] 8.95, 95% CI 3.30-22.37) and chronic heart disease (OR 2.85, 95% CI 1.43-5.69). We identified chills, fever, loss of smell, nausea and vomiting, and shortness of breath as the top five strongest predictors for a COVID-19 infection. The odds ratio for loss of smell was 3.13 (95% CI 1.76-5.58). Nausea and vomiting (OR 2.84, 95% CI 1.61-5.00) had been reported as an uncommon symptom previously; however, our data suggest a significant predictive value. Conclusions: Self-reported symptom tracking helps to identify novel symptoms of COVID-19 and to estimate the predictive value of certain symptoms. This aids in the development of reliable screening tools. Clinical screening with a high pretest probability allows for the rapid identification of infections and the cost-effective use of testing resources. Based on our results, we suggest that loss of smell and taste be considered cardinal symptoms; we also stress that diabetes is a risk factor for a highly symptomatic course of COVID-19 infection. %M 32791493 %R 10.2196/21956 %U http://www.jmir.org/2020/9/e21956/ %U https://doi.org/10.2196/21956 %U http://www.ncbi.nlm.nih.gov/pubmed/32791493 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21319 %T Assessing the Impact of the COVID-19 Pandemic in Spain: Large-Scale, Online, Self-Reported Population Survey %A Oliver,Nuria %A Barber,Xavier %A Roomp,Kirsten %A Roomp,Kristof %+ The Institute for Human(ity)-Centric Artificial Intelligence, ELLIS Unit Alicante Foundation, Avenida Universidad, Alicante, 03690, Spain, 34 630726085, nuria@alum.mit.edu %K COVID-19 %K SARS-CoV-2 %K public health authorities %K large-scale online surveys %K infectious disease %K outbreak %K public engagement %K disease prevalence %K impact %K survey %K spain %K public health %K perception %D 2020 %7 10.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Spain has been one of the countries most impacted by the COVID-19 pandemic. Since the first confirmed case was reported on January 31, 2020, there have been over 405,000 cases and 28,000 deaths in Spain. The economic and social impact is without precedent. Thus, it is important to quickly assess the situation and perception of the population. Large-scale online surveys have been shown to be an effective tool for this purpose. Objective: We aim to assess the situation and perception of the Spanish population in four key areas related to the COVID-19 pandemic: social contact behavior during confinement, personal economic impact, labor situation, and health status. Methods: We obtained a large sample using an online survey with 24 questions related to COVID-19 in the week of March 28-April 2, 2020, during the peak of the first wave of COVID-19 in Spain. The self-selection online survey method of nonprobability sampling was used to recruit 156,614 participants via social media posts that targeted the general adult population (age >18 years). Given such a large sample, the 95% CI was ±0.843 for all reported proportions. Results: Regarding social behavior during confinement, participants mainly left their homes to satisfy basic needs. We found several statistically significant differences in social behavior across genders and age groups. The population’s willingness to comply with the confinement measures is evident. From the survey answers, we identified a significant adverse economic impact of the pandemic on those working in small businesses and a negative correlation between economic damage and willingness to stay in confinement. The survey revealed that close contacts play an important role in the transmission of the disease, and 28% of the participants lacked the necessary resources to properly isolate themselves. We also identified a significant lack of testing, with only 1% of the population tested and 6% of respondents unable to be tested despite their doctor’s recommendation. We developed a generalized linear model to identify the variables that were correlated with a positive SARS-CoV-2 test result. Using this model, we estimated an average of 5% for SARS-CoV-2 prevalence in the Spanish population during the time of the study. A seroprevalence study carried out later by the Spanish Ministry of Health reported a similar level of disease prevalence (5%). Conclusions: Large-scale online population surveys, distributed via social media and online messaging platforms, can be an effective, cheap, and fast tool to assess the impact and prevalence of an infectious disease in the context of a pandemic, particularly when there is a scarcity of official data and limited testing capacity. %M 32870159 %R 10.2196/21319 %U http://www.jmir.org/2020/9/e21319/ %U https://doi.org/10.2196/21319 %U http://www.ncbi.nlm.nih.gov/pubmed/32870159 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21490 %T Association Between Generalized Anxiety Disorder Scores and Online Activity Among US Adults During the COVID-19 Pandemic: Cross-Sectional Analysis %A Singh,Parvati %A Cumberland,William G %A Ugarte,Dominic %A Bruckner,Tim-Allen %A Young,Sean D %+ University of California Institute for Prediction Technology, University of California, Irvine, Irvine, CA, United States, 1 310 794 8530, parvatis@uci.edu %K online activity %K COVID-19 %K anxiety %K generalized anxiety disorder %K GAD %K scores %K stress %K anxiety %K internet %K survey %K cross-sectional %D 2020 %7 10.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Evidence from past pandemics suggests that fear, uncertainty, and loss of control during large-scale public health crises may lead to increased pandemic-related information seeking, particularly among persons predisposed to high anxiety. In such groups, a greater consumption of information pertaining to the COVID-19 pandemic may increase anxiety. Objective: In this study, we examine the association between online activity and Generalized Anxiety Disorder 7 (GAD-7) scores in the United States. Methods: We recruited participants for an online survey through advertisements on various platforms such as Google, Facebook, and Reddit. A total of 406 adult US participants with moderate to severe (≥10) GAD-7 scores met the inclusion criteria and completed the survey. Anxiety levels measured using the GAD-7 scale formed our primary outcome. Our key independent variables were average daily time spent online and average daily time spent online searching about COVID-19 within the past 14 days. We used as controls potential confounders of the relation between our key independent variables and GAD-7 scores, namely, sleep quality, the COVID-19 Fear Inventory scale, binge drinking, substance use, prescription drug abuse, and sociodemographic attributes. Results: Linear multivariate regression analyses showed that GAD-7 scores were higher among those who spent >4 hours online (per day) searching for information about COVID-19 (coefficient 1.29, P=.002), controlling for all other covariates. The total time spent online was not statistically associated with GAD-7 scores. Conclusions: Results from this study indicate that limiting pandemic-related online information seeking may aid anxiety management in our study population. %M 32841152 %R 10.2196/21490 %U http://www.jmir.org/2020/9/e21490/ %U https://doi.org/10.2196/21490 %U http://www.ncbi.nlm.nih.gov/pubmed/32841152 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21562 %T Excess Patient Visits for Cough and Pulmonary Disease at a Large US Health System in the Months Prior to the COVID-19 Pandemic: Time-Series Analysis %A Elmore,Joann G %A Wang,Pin-Chieh %A Kerr,Kathleen F %A Schriger,David L %A Morrison,Douglas E %A Brookmeyer,Ron %A Pfeffer,Michael A %A Payne,Thomas H %A Currier,Judith S %+ Department of Medicine, David Geffen School of Medicine, UCLA, 1100 Glendon Ave, Suite 900, Los Angeles, CA, 90024, United States, 1 310 794 9505, jelmore@mednet.ucla.edu %K COVID-19 %K pandemic %K electronic health record %K time-series analysis %K prediction %K forecast %D 2020 %7 10.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Accurately assessing the regional activity of diseases such as COVID-19 is important in guiding public health interventions. Leveraging electronic health records (EHRs) to monitor outpatient clinical encounters may lead to the identification of emerging outbreaks. Objective: The aim of this study is to investigate whether excess visits where the word “cough” was present in the EHR reason for visit, and hospitalizations with acute respiratory failure were more frequent from December 2019 to February 2020 compared with the preceding 5 years. Methods: A retrospective observational cohort was identified from a large US health system with 3 hospitals, over 180 clinics, and 2.5 million patient encounters annually. Data from patient encounters from July 1, 2014, to February 29, 2020, were included. Seasonal autoregressive integrated moving average (SARIMA) time-series models were used to evaluate if the observed winter 2019/2020 rates were higher than the forecast 95% prediction intervals. The estimated excess number of visits and hospitalizations in winter 2019/2020 were calculated compared to previous seasons. Results: The percentage of patients presenting with an EHR reason for visit containing the word “cough” to clinics exceeded the 95% prediction interval the week of December 22, 2019, and was consistently above the 95% prediction interval all 10 weeks through the end of February 2020. Similar trends were noted for emergency department visits and hospitalizations starting December 22, 2019, where observed data exceeded the 95% prediction interval in 6 and 7 of the 10 weeks, respectively. The estimated excess over the 3-month 2019/2020 winter season, obtained by either subtracting the maximum or subtracting the average of the five previous seasons from the current season, was 1.6 or 2.0 excess visits for cough per 1000 outpatient visits, 11.0 or 19.2 excess visits for cough per 1000 emergency department visits, and 21.4 or 39.1 excess visits per 1000 hospitalizations with acute respiratory failure, respectively. The total numbers of excess cases above the 95% predicted forecast interval were 168 cases in the outpatient clinics, 56 cases for the emergency department, and 18 hospitalized with acute respiratory failure. Conclusions: A significantly higher number of patients with respiratory complaints and diseases starting in late December 2019 and continuing through February 2020 suggests community spread of SARS-CoV-2 prior to established clinical awareness and testing capabilities. This provides a case example of how health system analytics combined with EHR data can provide powerful and agile tools for identifying when future trends in patient populations are outside of the expected ranges. %M 32791492 %R 10.2196/21562 %U https://www.jmir.org/2020/9/e21562 %U https://doi.org/10.2196/21562 %U http://www.ncbi.nlm.nih.gov/pubmed/32791492 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22288 %T Association of Socioeconomic Changes due to the COVID-19 Pandemic With Health Outcomes in Patients With Skin Diseases: Cross-Sectional Survey Study %A Guo,Yeye %A Shen,Minxue %A Zhang,Xu %A Xiao,Yi %A Zhao,Shuang %A Yin,Mingzhu %A Bu,Wenbo %A Wang,Yan %A Chen,Xiang %A Su,Juan %+ Department of Dermatology, Xiangya Hospital, Central South University, Xiangya Road #87, Changsha, 410008, China, 86 731 84327377, sujuanderm@csu.edu.cn %K skin diseases %K coronavirus disease 2019 %K unemployment %K quality of life %K web-based %K survey %K dermatology %K COVID-19 %K lifestyle %K impact %K outcome %K isolation %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The outbreak of COVID-19 has profoundly influenced people’s lifestyles; these impacts have varied across subgroups of people. The pandemic-related impacts on the health outcomes of people with dermatological conditions are unknown. Objective: The aim of this paper was to study the association of COVID-19 pandemic–related impacts with health-related quality of life in patients with skin diseases. Methods: This was a cross-sectional study among Chinese patients with skin diseases. A self-administered web-based questionnaire was distributed through social media. Demographic and clinical data and pandemic-related impacts (isolation status, income changes, and employment status) were collected. The main outcomes included perceived stress (Visual Analog Scale), symptoms of anxiety (Generalized Anxiety Disorder-7) and depression (9-Item Patient Health Questionnaire), quality of life (Dermatology Life Quality Index), and health utility mapping based on the EQ-5D-3L descriptive system. Multivariable logistic regression was used to investigate the associations. Results: A total of 506 patients with skin diseases completed the survey. The mean age of the patients was 33.5 years (SD 14.0), and 217/506 patients (42.9%) were male. Among the 506 respondents, 128 (25.3%) were quarantined, 102 (20.2%) reported unemployment, and 317 (62.6%) reported decrease or loss of income since the pandemic. The pandemic-related impacts were significantly associated with impaired mental well-being and quality of life with different effects. Unemployment and complete loss of income were associated with the highest risks of adverse outcomes, with increases of 110% to 162% in the prevalence of anxiety, depression, and impaired quality of life. Conclusions: Isolation, income loss, and unemployment are associated with impaired health-related quality of life in patients with skin diseases during the COVID-19 pandemic. %M 32845850 %R 10.2196/22288 %U http://www.jmir.org/2020/9/e22288/ %U https://doi.org/10.2196/22288 %U http://www.ncbi.nlm.nih.gov/pubmed/32845850 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20955 %T Excessive Media Consumption About COVID-19 is Associated With Increased State Anxiety: Outcomes of a Large Online Survey in Russia %A Nekliudov,Nikita A %A Blyuss,Oleg %A Cheung,Ka Yan %A Petrou,Loukia %A Genuneit,Jon %A Sushentsev,Nikita %A Levadnaya,Anna %A Comberiati,Pasquale %A Warner,John O %A Tudor-Williams,Gareth %A Teufel,Martin %A Greenhawt,Matthew %A DunnGalvin,Audrey %A Munblit,Daniel %+ Department of Infectious Disease, Faculty of Medicine, Imperial College London, Wright Fleming Building, Norfolk Place, Paddington, London, W2 1PG, United Kingdom, 44 (0) 7898257151, daniel.munblit08@imperial.ac.uk %K anxiety %K COVID-19 %K media consumption %K SARS-CoV-2 %K STAI %K state anxiety %K trait anxiety %K trust to government %K trust %K mental health %K social media %K survey %D 2020 %7 11.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has potentially had a negative impact on the mental health and well-being of individuals and families. Anxiety levels and risk factors within particular populations are poorly described. Objective: This study aims to evaluate confidence, understanding, trust, concerns, and levels of anxiety during the COVID-19 pandemic in the general population and assess risk factors for increased anxiety. Methods: We launched a cross-sectional online survey of a large Russian population between April 6 and 15, 2020, using multiple social media platforms. A set of questions targeted confidence, understanding, trust, and concerns in respondents. The State-Trait Anxiety Inventory was used to measure anxiety. Multiple linear regressions were used to model predictors of COVID-19–related anxiety. Results: The survey was completed by 23,756 out of 53,966 (44.0% response rate) unique visitors; of which, 21,364 were residing in 62 areas of Russia. State Anxiety Scale (S-Anxiety) scores were higher than Trait Anxiety Scale scores across all regions of Russia (median S-Anxiety score 52, IQR 44-60), exceeding published norms. Time spent following news on COVID-19 was strongly associated with an increased S-Anxiety adjusted for baseline anxiety level. One to two hours spent reading COVID-19 news was associated with a 5.46 (95% CI 5.03-5.90) point difference, 2-3 hours with a 7.06 (95% CI 6.37-7.74) point difference, and more than three hours with an 8.65 (95% CI 7.82-9.47) point difference, all compared to less than 30 minutes per day. Job loss during the pandemic was another important factor associated with higher S-Anxiety scores (3.95, 95% CI 3.31-4.58). Despite survey respondents reporting high confidence in information regarding COVID-19 as well as an understanding of health care guidance, they reported low overall trust in state and local authorities, and perception of country readiness. Conclusions: Among Russian respondents from multiple social media platforms, there was evidence of higher levels of state anxiety associated with recent job loss and increased news consumption, as well as lower than expected trust in government agencies. These findings can help inform the development of key public health messages to help reduce anxiety and raise perceived trust in governmental response to this current national emergency. Using a similar methodology, comparative surveys are ongoing in other national populations. %M 32788143 %R 10.2196/20955 %U https://www.jmir.org/2020/9/e20955 %U https://doi.org/10.2196/20955 %U http://www.ncbi.nlm.nih.gov/pubmed/32788143 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22469 %T An Index for Lifting Social Distancing During the COVID-19 Pandemic: Algorithm Recommendation for Lifting Social Distancing %A Chen,Sam Li-Sheng %A Yen,Amy Ming-Fang %A Lai,Chao-Chih %A Hsu,Chen-Yang %A Chan,Chang-Chuan %A Chen,Tony Hsiu-Hsi %+ Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Room 533, No 17, Xu-Zhou Road, Taipei, 100, Taiwan, 886 233668033, chenlin@ntu.edu.tw %K COVID-19 %K pandemic %K social distancing %K index %K algorithm %K data analysis %K decision making %K global health %K public health %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Implementing and lifting social distancing (LSD) is an urgent global issue during the COVID-19 pandemic, particularly when the travel ban is lifted to revive international businesses and economies. However, when and whether LSD can be considered is subject to the spread of SARS-CoV-2, the recovery rate, and the case-fatality rate. It is imperative to provide real-time assessment of three factors to guide LSD. Objective: A simple LSD index was developed for health decision makers to do real-time assessment of COVID-19 at the global, country, region, and community level. Methods: Data on the retrospective cohort of 186 countries with three factors were retrieved from a publicly available repository from January to early July. A simple index for guiding LSD was measured by the cumulative number of COVID-19 cases and recoveries, and the case-fatality rate was envisaged. If the LSD index was less than 1, LSD can be considered. The dynamic changes of the COVID-19 pandemic were evaluated to assess whether and when health decision makers allowed for LSD and when to reimplement social distancing after resurgences of the epidemic. Results: After large-scale outbreaks in a few countries before mid-March (prepandemic phase), the global weekly LSD index peaked at 4.27 in March and lasted until mid-June (pandemic phase), during which most countries were affected and needed to take various social distancing measures. Since, the value of LSD has gradually declined to 0.99 on July 5 (postpandemic phase), at which 64.7% (120/186) of countries and regions had an LSD<1 with the decile between 0 and 1 to refine risk stratification by countries. The LSD index decreased to 1 in about 115 days. In addition, we present the results of dynamic changes of the LSD index for the world and for each country and region with different time windows from January to July 5. The results of the LSD index on the resurgence of the COVID-19 epidemic in certain regions and validation by other emerging infectious diseases are presented. Conclusions: This simple LSD index provides a quantitative assessment of whether and when to ease or implement social distancing to provide advice for health decision makers and travelers. %M 32886622 %R 10.2196/22469 %U http://www.jmir.org/2020/9/e22469/ %U https://doi.org/10.2196/22469 %U http://www.ncbi.nlm.nih.gov/pubmed/32886622 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22817 %T Investigating Mental Health of US College Students During the COVID-19 Pandemic: Cross-Sectional Survey Study %A Wang,Xiaomei %A Hegde,Sudeep %A Son,Changwon %A Keller,Bruce %A Smith,Alec %A Sasangohar,Farzan %+ Industrial and Systems Engineering, Texas A&M University, Emerging Technologies Building, 3131 TAMU, 101 Bizzell Street, College Station, TX, 77843, United States, 1 9794582337, sasangohar@tamu.edu %K mental health %K online survey %K COVID-19 %K coronavirus %K college student %K student %K stress %K depression %K university %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Evidence suggests that the COVID-19 pandemic has generally increased levels of stress and depression among the public. However, the impact on college students in the United States has not been well-documented. Objective: This paper surveys the mental health status and severity of depression and anxiety of college students in a large university system in the United States during the COVID-19 pandemic. Methods: An online survey was conducted among undergraduate and graduate students recruited from Texas A&M University via email. The survey consisted of two standardized scales—the Patient Health Questionnaire-9 and the General Anxiety Disorder-7—for depression and anxiety, and additional multiple-choice and open-ended questions regarding stressors and coping mechanisms specific to COVID-19. Results: Among the 2031 participants, 48.14% (n=960) showed a moderate-to-severe level of depression, 38.48% (n=775) showed a moderate-to-severe level of anxiety, and 18.04% (n=366) had suicidal thoughts. A majority of participants (n=1443, 71.26%) indicated that their stress/anxiety levels had increased during the pandemic. Less than half of the participants (n=882, 43.25%) indicated that they were able to cope adequately with the stress related to the current situation. Conclusions: The proportion of respondents showing depression, anxiety, and/or suicidal thoughts is alarming. Respondents reported academic-, health-, and lifestyle-related concerns caused by the pandemic. Given the unexpected length and severity of the outbreak, these concerns need to be further understood and addressed. %M 32897868 %R 10.2196/22817 %U http://www.jmir.org/2020/9/e22817/ %U https://doi.org/10.2196/22817 %U http://www.ncbi.nlm.nih.gov/pubmed/32897868 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20548 %T New York Inner City Hospital COVID-19 Experience and Current Data: Retrospective Analysis at the Epicenter of the American Coronavirus Outbreak %A Mani,Vishnu R %A Kalabin,Aleksandr %A Valdivieso,Sebastian C %A Murray-Ramcharan,Max %A Donaldson,Brian %+ Columbia University College of Physicians and Surgeons at Harlem Hospital, 506 Lenox Avenue, New York, NY, , United States, 1 2129391000 ext 1641, vishnu.mani@duke.edu %K SARS-CoV-2 %K COVID-19 %K pandemic %K New York City %K coronavirus outbreak %K American minority %K outbreak %K minority %K mortality %K patient %K characteristic %K mechanical ventilation %D 2020 %7 18.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the midst of the coronavirus disease pandemic, emerging clinical data across the world has equipped frontline health care workers, policy makers, and researchers to better understand and combat the illness. Objective: The aim of this study is to report the correlation of clinical and laboratory parameters with patients requiring mechanical ventilation and the mortality in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods: We did a review of patients with SARS-CoV-2 confirmed infection admitted and managed by our institution during the last month. Patients were grouped into intubated and nonintubated, and subgrouped to alive and deceased. A comprehensive analysis using the following parameters were performed: age, sex, ethnicity, BMI, comorbidities, inflammatory markers, laboratory values, cardiac and renal function, electrocardiogram (EKG), chest x-ray findings, temperature, treatment groups, and hospital-acquired patients with SARS-CoV-2. Results: A total of 184 patients were included in our study with ages ranging from 28-97 years (mean 64.72 years) and including 73 females (39.67%) and 111 males (60.33%) with a mean BMI of 29.10. We had 114 African Americans (61.96%), 58 Hispanics (31.52%), 11 Asians (5.98%), and 1 Caucasian (0.54%), with a mean of 1.70 comorbidities. Overall, the mortality rate was 17.39% (n=32), 16.30% (n=30) of our patients required mechanical ventilation, and 11.41% (n=21) had hospital-acquired SARS-CoV-2 infection. Pertinent and statistically significant results were found in the intubated versus nonintubated patients with confirmed SARS-CoV-2 for the following parameters: age (P=.01), BMI (P=.07), African American ethnicity (P<.001), Hispanic ethnicity (P=.02), diabetes mellitus (P=.001), creatinine (P=.29), blood urea nitrogen (BUN; P=.001), procalcitonin (P=.03), C-reactive protein (CRP; P=.007), lactate dehydrogenase (LDH; P=.001), glucose (P=.01), temperature (P=.004), bilateral pulmonary infiltrates in chest x-rays (P<.001), and bilateral patchy opacity (P=.02). The results between the living and deceased subgroups of patients with confirmed SARS-CoV-2 (linking to or against mortality) were BMI (P=.04), length of stay (P<.001), hypertension (P=.02), multiple comorbidity (P=.045), BUN (P=.04), and EKG findings with arrhythmias or blocks (P=.02). Conclusions: We arrived at the following conclusions based on a comprehensive review of our study group, data collection, and statistical analysis. Parameters that were strongly correlated with the need for mechanical ventilation were younger age group, overweight, Hispanic ethnicity, higher core body temperature, EKG findings with sinus tachycardia, and bilateral diffuse pulmonary infiltrates on the chest x-rays. Those intubated exhibited increased disease severity with significantly elevated levels of serum procalcitonin, CRP, LDH, mean glucose, creatinine, and BUN. Mortality was strongly correlated with BMI, African American ethnicity, hypertension, presence of multiple comorbidities (with a mean of 2.32), worsening renal function with acute kidney injury or acute chronic kidney injury, and EKG findings of arrhythmias and heart blocks. %M 32540837 %R 10.2196/20548 %U https://www.jmir.org/2020/9/e20548 %U https://doi.org/10.2196/20548 %U http://www.ncbi.nlm.nih.gov/pubmed/32540837 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20874 %T Use of Telemedicine for Chronic Liver Disease at a Single Care Center During the COVID-19 Pandemic: Prospective Observational Study %A Guarino,Maria %A Cossiga,Valentina %A Fiorentino,Andrea %A Pontillo,Giuseppina %A Morisco,Filomena %+ Gastroenterology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini, Naples, Italy, 39 0817464746, maria.guarino86@gmail.com %K telemedicine %K COVID-19 %K hepatology %K telehealth %K liver disease %K Italy %K hospital %K chronic disease %K liver %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 outbreak has overwhelmed and altered health care systems worldwide, with a substantial impact on patients with chronic diseases. The response strategy has involved implementing measures like social distancing, and care delivery modalities like telemedicine have been promoted to reduce the risk of transmission. Objective: The aim of this study was to analyze the benefits of using telemedicine services for patients with chronic liver disease (CLD) at a tertiary care center in Italy during the COVID-19–mandated lockdown. Methods: From March 9 to May 3, 2020, a prospective observational study was conducted in the Liver Unit of the University Hospital of Naples Federico II to evaluate the impact of (1) a fully implemented telemedicine program, partially restructured in response to COVID-19 to include video consultations; (2) extended hours of operation for helpline services; and (3) smart-working from home to facilitate follow-up visits for patients with CLD while adhering to social distancing regulations. Results: During the lockdown in Italy, almost 400 visits were conducted using telemedicine; only patients requiring urgent care were admitted to a non–COVID-19 ward of our hospital. Telemedicine services were implemented not only for follow-up visits but also to screen patients prior to hospital admission and to provide urgent evaluations during complications. Of the nearly 1700 patients with CLD who attended a follow-up visit at our Liver Unit, none contracted COVID-19, and there was no need to alter treatment schedules. Conclusions: Telemedicine was a useful tool for following up patients with CLD and for reducing the impact of the COVID-19 pandemic. This system of health care delivery was appreciated by patients since it gave them the opportunity to be in contact with physicians while respecting social distancing rules. %M 32896833 %R 10.2196/20874 %U http://www.jmir.org/2020/9/e20874/ %U https://doi.org/10.2196/20874 %U http://www.ncbi.nlm.nih.gov/pubmed/32896833 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22181 %T Increased Internet Searches for Insomnia as an Indicator of Global Mental Health During the COVID-19 Pandemic: Multinational Longitudinal Study %A Lin,Yu-Hsuan %A Chiang,Ting-Wei %A Lin,Yu-Lun %+ Institute of Population Health Sciences, National Health Research Institutes, Room A3234, No 35 Keyan Road, Zhunan Town, Miaoli County, 35053, Taiwan, 1 886 37206166 ext 36383, yuhsuanlin@nhri.edu.tw %K internet search %K Google Trends %K infodemiology %K infoveillance %K COVID-19 %K insomnia %K mental health %D 2020 %7 21.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Real-time global mental health surveillance is urgently needed for tracking the long-term impact of the COVID-19 pandemic. Objective: This study aimed to use Google Trends data to investigate the impact of the pandemic on global mental health by analyzing three keywords indicative of mental distress: “insomnia,” “depression,” and “suicide.” Methods: We examined increases in search queries for 19 countries. Significant increases were defined as the actual daily search value (from March 20 to April 19, 2020) being higher than the 95% CIs of the forecast from the 3-month baseline via ARIMA (autoregressive integrated moving average) modeling. We examined the correlation between increases in COVID-19–related deaths and the number of days with significant increases in search volumes for insomnia, depression, and suicide across multiple nations. Results: The countries with the greatest increases in searches for insomnia were Iran, Spain, the United States, and Italy; these countries exhibited a significant increase in insomnia searches on more than 10 of the 31 days observed. The number of COVID-19–related deaths was positively correlated to the number of days with an increase in searches for insomnia in the 19 countries (ρ=0.64, P=.003). By contrast, there was no significant correlation between the number of deaths and increases in searches for depression (ρ=–0.12, P=.63) or suicide (ρ=–0.07, P=.79). Conclusions: Our analysis suggests that insomnia could be a part of routine mental health screening during the COVID-19 pandemic. %M 32924951 %R 10.2196/22181 %U http://www.jmir.org/2020/9/e22181/ %U https://doi.org/10.2196/22181 %U http://www.ncbi.nlm.nih.gov/pubmed/32924951 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20924 %T Dynamic Panel Estimate–Based Health Surveillance of SARS-CoV-2 Infection Rates to Inform Public Health Policy: Model Development and Validation %A Oehmke,James Francis %A Oehmke,Theresa B %A Singh,Lauren Nadya %A Post,Lori Ann %+ Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 420 E. Superior St, Chicago, IL, 60611, United States, 1 203 980 7107, lori.post@northwestern.edu %K COVID-19 %K models %K surveillance %K COVID-19 surveillance system %K dynamic panel data %K infectious disease modeling %K reopening America %K COVID-19 guidelines %K COVID-19 health policy %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: SARS-CoV-2, the novel coronavirus that causes COVID-19, is a global pandemic with higher mortality and morbidity than any other virus in the last 100 years. Without public health surveillance, policy makers cannot know where and how the disease is accelerating, decelerating, and shifting. Unfortunately, existing models of COVID-19 contagion rely on parameters such as the basic reproduction number and use static statistical methods that do not capture all the relevant dynamics needed for surveillance. Existing surveillance methods use data that are subject to significant measurement error and other contaminants. Objective: The aim of this study is to provide a proof of concept of the creation of surveillance metrics that correct for measurement error and data contamination to determine when it is safe to ease pandemic restrictions. We applied state-of-the-art statistical modeling to existing internet data to derive the best available estimates of the state-level dynamics of COVID-19 infection in the United States. Methods: Dynamic panel data (DPD) models were estimated with the Arellano-Bond estimator using the generalized method of moments. This statistical technique enables control of various deficiencies in a data set. The validity of the model and statistical technique was tested. Results: A Wald chi-square test of the explanatory power of the statistical approach indicated that it is valid (χ210=1489.84, P<.001), and a Sargan chi-square test indicated that the model identification is valid (χ2946=935.52, P=.59). The 7-day persistence rate for the week of June 27 to July 3 was 0.5188 (P<.001), meaning that every 10,000 new cases in the prior week were associated with 5188 cases 7 days later. For the week of July 4 to 10, the 7-day persistence rate increased by 0.2691 (P=.003), indicating that every 10,000 new cases in the prior week were associated with 7879 new cases 7 days later. Applied to the reported number of cases, these results indicate an increase of almost 100 additional new cases per day per state for the week of July 4-10. This signifies an increase in the reproduction parameter in the contagion models and corroborates the hypothesis that economic reopening without applying best public health practices is associated with a resurgence of the pandemic. Conclusions: DPD models successfully correct for measurement error and data contamination and are useful to derive surveillance metrics. The opening of America involves two certainties: the country will be COVID-19–free only when there is an effective vaccine, and the “social” end of the pandemic will occur before the “medical” end. Therefore, improved surveillance metrics are needed to inform leaders of how to open sections of the United States more safely. DPD models can inform this reopening in combination with the extraction of COVID-19 data from existing websites. %M 32915762 %R 10.2196/20924 %U http://www.jmir.org/2020/9/e20924/ %U https://doi.org/10.2196/20924 %U http://www.ncbi.nlm.nih.gov/pubmed/32915762 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19992 %T Using Smartphones and Wearable Devices to Monitor Behavioral Changes During COVID-19 %A Sun,Shaoxiong %A Folarin,Amos A %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Cummins,Nicholas %A Matcham,Faith %A Dalla Costa,Gloria %A Simblett,Sara %A Leocani,Letizia %A Lamers,Femke %A Sørensen,Per Soelberg %A Buron,Mathias %A Zabalza,Ana %A Guerrero Pérez,Ana Isabel %A Penninx,Brenda WJH %A Siddi,Sara %A Haro,Josep Maria %A Myin-Germeys,Inez %A Rintala,Aki %A Wykes,Til %A Narayan,Vaibhav A %A Comi,Giancarlo %A Hotopf,Matthew %A Dobson,Richard JB %A , %+ The Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, PO Box 80 De Crespigny Park, Denmark Hill, London, SE58AF, United Kingdom, 44 02078480951, shaoxiong.sun@kcl.ac.uk %K mobile health %K COVID-19 %K behavioral monitoring %K smartphones %K wearable devices %K mobility %K phone use %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the absence of a vaccine or effective treatment for COVID-19, countries have adopted nonpharmaceutical interventions (NPIs) such as social distancing and full lockdown. An objective and quantitative means of passively monitoring the impact and response of these interventions at a local level is needed. Objective: We aim to explore the utility of the recently developed open-source mobile health platform Remote Assessment of Disease and Relapse (RADAR)–base as a toolbox to rapidly test the effect and response to NPIs intended to limit the spread of COVID-19. Methods: We analyzed data extracted from smartphone and wearable devices, and managed by the RADAR-base from 1062 participants recruited in Italy, Spain, Denmark, the United Kingdom, and the Netherlands. We derived nine features on a daily basis including time spent at home, maximum distance travelled from home, the maximum number of Bluetooth-enabled nearby devices (as a proxy for physical distancing), step count, average heart rate, sleep duration, bedtime, phone unlock duration, and social app use duration. We performed Kruskal-Wallis tests followed by post hoc Dunn tests to assess differences in these features among baseline, prelockdown, and during lockdown periods. We also studied behavioral differences by age, gender, BMI, and educational background. Results: We were able to quantify expected changes in time spent at home, distance travelled, and the number of nearby Bluetooth-enabled devices between prelockdown and during lockdown periods (P<.001 for all five countries). We saw reduced sociality as measured through mobility features and increased virtual sociality through phone use. People were more active on their phones (P<.001 for Italy, Spain, and the United Kingdom), spending more time using social media apps (P<.001 for Italy, Spain, the United Kingdom, and the Netherlands), particularly around major news events. Furthermore, participants had a lower heart rate (P<.001 for Italy and Spain; P=.02 for Denmark), went to bed later (P<.001 for Italy, Spain, the United Kingdom, and the Netherlands), and slept more (P<.001 for Italy, Spain, and the United Kingdom). We also found that young people had longer homestay than older people during the lockdown and fewer daily steps. Although there was no significant difference between the high and low BMI groups in time spent at home, the low BMI group walked more. Conclusions: RADAR-base, a freely deployable data collection platform leveraging data from wearables and mobile technologies, can be used to rapidly quantify and provide a holistic view of behavioral changes in response to public health interventions as a result of infectious outbreaks such as COVID-19. RADAR-base may be a viable approach to implementing an early warning system for passively assessing the local compliance to interventions in epidemics and pandemics, and could help countries ease out of lockdown. %M 32877352 %R 10.2196/19992 %U https://www.jmir.org/2020/9/e19992 %U https://doi.org/10.2196/19992 %U http://www.ncbi.nlm.nih.gov/pubmed/32877352 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22142 %T The Relation Between Official WhatsApp-Distributed COVID-19 News Exposure and Psychological Symptoms: Cross-Sectional Survey Study %A Liu,Jean C J %A Tong,Eddie M W %+ Yale-NUS College, 02-221, 16 College Avenue West, Singapore, 138527, Singapore, 65 66013694, jeanliu@yale-nus.edu.sg %K mental health %K social media %K pandemic %K depression %K anxiety %K stress %K COVID-19 %K app %K risk factor %K psychology %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In a global pandemic, digital technology offers innovative methods to disseminate public health messages. As an example, the messenger app WhatsApp was adopted by both the World Health Organization and government agencies to provide updates on the coronavirus disease (COVID-19). During a time when rumors and excessive news threaten psychological well-being, these services allow for rapid transmission of information and may boost resilience. Objective: In this study, we sought to accomplish the following: (1) assess well-being during the pandemic; (2) replicate prior findings linking exposure to COVID-19 news with psychological distress; and (3) examine whether subscription to an official WhatsApp channel can mitigate this risk. Methods: Across 8 weeks of the COVID-19 outbreak (March 7 to April 21, 2020), we conducted a survey of 1145 adults in Singapore. As the primary outcome measure, participants completed the Depression, Anxiety, and Stress Scale (DASS-21). As predictor variables, participants also answered questions pertaining to the following: (1) their exposure to COVID-19 news; (2) their use of the Singapore government’s WhatsApp channel; and (3) their demographics. Results: Within the sample, 7.9% of participants had severe or extremely severe symptoms on at least one DASS-21 subscale. Depression scores were associated with increased time spent receiving COVID-19 updates, whereas use of the official WhatsApp channel emerged as a protective factor (b=–0.07, t[863]=–2.04, P=.04). Similarly, increased anxiety scores were associated with increased exposure to both updates and rumors, but this risk was mitigated by trust in the government’s WhatsApp messages (b=–0.05, t[863]=–2.13, P=.03). Finally, although stress symptoms increased with the amount of time spent receiving updates, these symptoms were not significantly related to WhatsApp use. Conclusions: Our findings suggest that messenger apps may be an effective medium for disseminating pandemic-related information, allowing official agencies to reach a broad sector of the population rapidly. In turn, this use may promote public well-being amid an “infodemic.” Trial Registration: ClinicalTrials.gov NCT04305574; https://clinicaltrials.gov/ct2/show/NCT04305574 %M 32877349 %R 10.2196/22142 %U http://www.jmir.org/2020/9/e22142/ %U https://doi.org/10.2196/22142 %U http://www.ncbi.nlm.nih.gov/pubmed/32877349 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22767 %T Intergroup Contact, COVID-19 News Consumption, and the Moderating Role of Digital Media Trust on Prejudice Toward Asians in the United States: Cross-Sectional Study %A Tsai,Jiun-Yi %A Phua,Joe %A Pan,Shuya %A Yang,Chia-chen %+ School of Journalism and Communication, Renmin University of China, No. 59 Zhongguancun Street, Haidian District, Beijing, 100872, China, 86 10 62511081, shuya@ruc.edu.cn %K COVID-19 %K prejudice %K news exposure %K news trust %K infodemic %K media bias %K racism %K social media use %K intergroup contact %K regression %K moderation analysis %K cross-sectional survey %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The perceived threat of a contagious virus may lead people to be distrustful of immigrants and out-groups. Since the COVID-19 outbreak, the salient politicized discourses of blaming Chinese people for spreading the virus have fueled over 2000 reports of anti-Asian racial incidents and hate crimes in the United States. Objective: The study aims to investigate the relationships between news consumption, trust, intergroup contact, and prejudicial attitudes toward Asians and Asian Americans residing in the United States during the COVID-19 pandemic. We compare how traditional news, social media use, and biased news exposure cultivate racial attitudes, and the moderating role of media use and trust on prejudice against Asians is examined. Methods: A cross-sectional study was completed in May 2020. A total of 430 US adults (mean age 36.75, SD 11.49 years; n=258, 60% male) participated in an online survey through Amazon’s Mechanical Turk platform. Respondents answered questions related to traditional news exposure, social media use, perceived trust, and their top three news channels for staying informed about the novel coronavirus. In addition, intergroup contact and racial attitudes toward Asians were assessed. We performed hierarchical regression analyses to test the associations. Moderation effects were estimated using simple slopes testing with a 95% bootstrap confidence interval approach. Results: Participants who identified as conservatives (β=.08, P=.02), had a personal infection history (β=.10, P=.004), and interacted with Asian people frequently in their daily lives (β=.46, P<.001) reported more negative attitudes toward Asians after controlling for sociodemographic variables. Relying more on traditional news media (β=.08, P=.04) and higher levels of trust in social media (β=.13, P=.007) were positively associated with prejudice against Asians. In contrast, consuming news from left-leaning outlets (β=–.15, P=.001) and neutral outlets (β=–.13, P=.003) was linked to less prejudicial attitudes toward Asians. Among those who had high trust in social media, exposure had a negative relationship with prejudice. At high levels of trust in digital websites and apps, frequent use was related to less unfavorable attitudes toward Asians. Conclusions: Experiencing racial prejudice among the Asian population during a challenging pandemic can cause poor psychological outcomes and exacerbate health disparities. The results suggest that conservative ideology, personal infection history, frequency of intergroup contact, traditional news exposure, and trust in social media emerge as positive predictors of prejudice against Asians and Asian Americans, whereas people who get COVID-19 news from left-leaning and balanced outlets show less prejudice. For those who have more trust in social media and digital news, frequent use of these two sources is associated with lower levels of prejudice. Our findings highlight the need to reshape traditional news discourses and use social media and mobile news apps to develop credible messages for combating racial prejudice against Asians. %M 32924948 %R 10.2196/22767 %U http://www.jmir.org/2020/9/e22767/ %U https://doi.org/10.2196/22767 %U http://www.ncbi.nlm.nih.gov/pubmed/32924948 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e23565 %T Clinical Mortality in a Large COVID-19 Cohort: Observational Study %A Jarrett,Mark %A Schultz,Susanne %A Lyall,Julie %A Wang,Jason %A Stier,Lori %A De Geronimo,Marcella %A Nelson,Karen %+ Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, 500 Hofstra University, Hempstead, NY, 11549, United States, 1 5163216044, MJarrett@northwell.edu %K COVID-19 %K mortality %K respiratory failure %K hypoxemia %K observational %K review %K cohort %K ICU %K intensive care unit %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Northwell Health, an integrated health system in New York, has treated more than 15,000 inpatients with COVID-19 at the US epicenter of the SARS-CoV-2 pandemic. Objective: We describe the demographic characteristics of patients who died of COVID-19, observation of frequent rapid response team/cardiac arrest (RRT/CA) calls for non–intensive care unit (ICU) patients, and factors that contributed to RRT/CA calls. Methods: A team of registered nurses reviewed the medical records of inpatients who tested positive for SARS-CoV-2 via polymerase chain reaction before or on admission and who died between March 13 (first Northwell Health inpatient expiration) and April 30, 2020, at 15 Northwell Health hospitals. The findings for these patients were abstracted into a database and statistically analyzed. Results: Of 2634 patients who died of COVID-19, 1478 (56.1%) had oxygen saturation levels ≥90% on presentation and required no respiratory support. At least one RRT/CA was called on 1112/2634 patients (42.2%) at a non-ICU level of care. Before the RRT/CA call, the most recent oxygen saturation levels for 852/1112 (76.6%) of these non-ICU patients were at least 90%. At the time the RRT/CA was called, 479/1112 patients (43.1%) had an oxygen saturation of <80%. Conclusions: This study represents one of the largest reviewed cohorts of mortality that also captures data in nonstructured fields. Approximately 50% of deaths occurred at a non-ICU level of care despite admission to the appropriate care setting with normal staffing. The data imply a sudden, unexpected deterioration in respiratory status requiring RRT/CA in a large number of non-ICU patients. Patients admitted at a non-ICU level of care suffered rapid clinical deterioration, often with a sudden decrease in oxygen saturation. These patients could benefit from additional monitoring (eg, continuous central oxygenation saturation), although this approach warrants further study. %M 32930099 %R 10.2196/23565 %U http://www.jmir.org/2020/9/e23565/ %U https://doi.org/10.2196/23565 %U http://www.ncbi.nlm.nih.gov/pubmed/32930099 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19788 %T Understanding the Community Risk Perceptions of the COVID-19 Outbreak in South Korea: Infodemiology Study %A Husnayain,Atina %A Shim,Eunha %A Fuad,Anis %A Su,Emily Chia-Yu %+ Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, 172-1 Keelung Rd, Sec 2, Taipei, 106, Taiwan, 886 2 66382736 ext 1515, emilysu@tmu.edu.tw %K Google Trends %K risk %K perception %K communication %K COVID-19 %K South Korea %K outbreak %K infodemiology %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: South Korea is among the best-performing countries in tackling the coronavirus pandemic by using mass drive-through testing, face mask use, and extensive social distancing. However, understanding the patterns of risk perception could also facilitate effective risk communication to minimize the impacts of disease spread during this crisis. Objective: We attempt to explore patterns of community health risk perceptions of COVID-19 in South Korea using internet search data. Methods: Google Trends (GT) and NAVER relative search volumes (RSVs) data were collected using COVID-19–related terms in the Korean language and were retrieved according to time, gender, age groups, types of device, and location. Online queries were compared to the number of daily new COVID-19 cases and tests reported in the Kaggle open-access data set for the time period of December 5, 2019, to May 31, 2020. Time-lag correlations calculated by Spearman rank correlation coefficients were employed to assess whether correlations between new COVID-19 cases and internet searches were affected by time. We also constructed a prediction model of new COVID-19 cases using the number of COVID-19 cases, tests, and GT and NAVER RSVs in lag periods (of 1-3 days). Single and multiple regressions were employed using backward elimination and a variance inflation factor of <5. Results: The numbers of COVID-19–related queries in South Korea increased during local events including local transmission, approval of coronavirus test kits, implementation of coronavirus drive-through tests, a face mask shortage, and a widespread campaign for social distancing as well as during international events such as the announcement of a Public Health Emergency of International Concern by the World Health Organization. Online queries were also stronger in women (r=0.763-0.823; P<.001) and age groups ≤29 years (r=0.726-0.821; P<.001), 30-44 years (r=0.701-0.826; P<.001), and ≥50 years (r=0.706-0.725; P<.001). In terms of spatial distribution, internet search data were higher in affected areas. Moreover, greater correlations were found in mobile searches (r=0.704-0.804; P<.001) compared to those of desktop searches (r=0.705-0.717; P<.001), indicating changing behaviors in searching for online health information during the outbreak. These varied internet searches related to COVID-19 represented community health risk perceptions. In addition, as a country with a high number of coronavirus tests, results showed that adults perceived coronavirus test–related information as being more important than disease-related knowledge. Meanwhile, younger, and older age groups had different perceptions. Moreover, NAVER RSVs can potentially be used for health risk perception assessments and disease predictions. Adding COVID-19–related searches provided by NAVER could increase the performance of the model compared to that of the COVID-19 case–based model and potentially be used to predict epidemic curves. Conclusions: The use of both GT and NAVER RSVs to explore patterns of community health risk perceptions could be beneficial for targeting risk communication from several perspectives, including time, population characteristics, and location. %M 32931446 %R 10.2196/19788 %U http://www.jmir.org/2020/9/e19788/ %U https://doi.org/10.2196/19788 %U http://www.ncbi.nlm.nih.gov/pubmed/32931446 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22457 %T Self-Reported Compliance With Personal Preventive Measures Among Chinese Factory Workers at the Beginning of Work Resumption Following the COVID-19 Outbreak: Cross-Sectional Survey Study %A Pan,Yihang %A Fang,Yuan %A Xin,Meiqi %A Dong,Willa %A Zhou,Liemin %A Hou,Qinghua %A Li,Fanping %A Sun,Gang %A Zheng,Zilong %A Yuan,Jinqiu %A Wang,Zixin %A He,Yulong %+ Center for Digestive Disease, The Seventh Affiliated Hospital, Sun Yat-sen University, No. 628 Zhenyuan Road, Guangming (New) District, Shenzhen, 518107, China, 86 755 81206988, heyulong@mail.sysu.edu.cn %K COVID-19 %K work resumption, factory workers %K facemask wearing %K hand hygiene %K physical distancing %K prevention %K cross-sectional %K online %K survey %K compliance %D 2020 %7 29.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Maintaining compliance with personal preventive measures is important to achieve a balance of COVID-19 pandemic control and work resumption. Objective: The aim of this study was to investigate self-reported compliance with four personal measures to prevent COVID-19 among a sample of factory workers in Shenzhen, China, at the beginning of work resumption in China following the COVID-19 outbreak. These preventive measures included consistent wearing of face masks in public spaces (the workplace and other public settings); sanitizing hands using soap, liquid soap, or alcohol-based hand sanitizer after returning from public spaces or touching public installations and equipment; avoiding social and meal gatherings; and avoiding crowded places. Methods: The participants were adult factory workers who had resumed work in Shenzhen, China. A stratified two-stage cluster sampling design was used. We randomly selected 14 factories that had resumed work. All full-time employees aged ≥18 years who had resumed work in these factories were invited to complete a web-based survey. Out of 4158 workers who had resumed work in these factories, 3035 (73.0%) completed the web-based survey from March 1 to 14, 2020. Multilevel logistic regression models were fitted. Results: Among the 3035 participants, 2938 (96.8%) and 2996 (98.7%) reported always wearing a face mask in the workplace and in other public settings, respectively, in the past month. However, frequencies of self-reported sanitizing hands (2152/3035, 70.9%), avoiding social and meal gatherings (2225/3035, 73.3%), and avoiding crowded places (1997/3035, 65.8%) were relatively low. At the individual level, knowledge about COVID-19 (adjusted odds ratios [AORs] from 1.16, CI 1.10-1.24, to 1.29, CI 1.21-1.37), perceived risk (AORs from 0.58, CI 0.50-0.68, to 0.85, CI 0.72-0.99) and severity (AOR 1.05, CI 1.01-1.09, and AOR 1.07, CI 1.03-1.11) of COVID-19, perceived effectiveness of preventive measures by the individual (AORs from 1.05, CI 1.00-1.10, to 1.09, CI 1.04-1.13), organization (AOR 1.30, CI 1.20-1.41), and government (AORs from 1.14, CI 1.04-1.25, to 1.21, CI 1.02-1.42), perceived preparedness for a potential outbreak after work resumption (AORs from 1.10, CI 1.00-1.21, to 1.50, CI 1.36-1.64), and depressive symptoms (AORs from 0.93, CI 0.91-0.94, to 0.96, CI 0.92-0.99) were associated with self-reported compliance with at least one personal preventive measure. At the interpersonal level, exposure to COVID-19–specific information through official media channels (AOR 1.08, CI 1.04-1.11) and face-to-face communication (AOR 0.90, CI 0.83-0.98) were associated with self-reported sanitizing of hands. The number of preventive measures implemented in the workplace was positively associated with self-reported compliance with all four preventive measures (AORs from 1.30, CI 1.08-1.57, to 1.63, CI 1.45-1.84). Conclusions: Measures are needed to strengthen hand hygiene and physical distancing among factory workers to reduce transmission following work resumption. Future programs in workplaces should address these factors at multiple levels. %M 32924947 %R 10.2196/22457 %U http://www.jmir.org/2020/9/e22457/ %U https://doi.org/10.2196/22457 %U http://www.ncbi.nlm.nih.gov/pubmed/32924947 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21561 %T VA Video Connect for Clinical Care in Older Adults in a Rural State During the COVID-19 Pandemic: Cross-Sectional Study %A Padala,Kalpana P %A Wilson,Kerrie B %A Gauss,C Heath %A Stovall,Jessica D %A Padala,Prasad R %+ Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, United States, 1 501 257 2044, kalpana.padala@va.gov %K VA Video Connect %K older adults %K rural %K COVID-19 %K veterans %K telehealth %K elderly %K disparity %K veteran affairs %K capabillity %K cross-sectional %D 2020 %7 30.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has accelerated the need for telehealth at home. Although the Department of Veterans Affairs is a leading provider of telehealth, disparities may exist in reaching older veterans living in rural areas. VA Video Connect (VVC) is a video conferencing app that enables veterans to connect with their health care provider via a secure and private session. Objective: The aim of this study was to examine the capability and willingness of older veterans to participate in a VVC visit during the COVID-19 pandemic. Methods: A cross-sectional study was conducted on older veterans (N=118) at the Central Arkansas Veterans Healthcare System. Participants were interviewed over the phone and responses to the following items were recorded: availability of internet, email, and an electronic device with a camera; veterans’ willingness to complete an appointment via a VVC visit; and availability of assistance from a caregiver for those who were unable to participate in a VVC visit alone. Results: Participants’ mean age was 72.6 (SD 8.3) years, 92% (n=108) were male, 69% (n=81) were Caucasian, 30% (n=35) were African Americans, and 36% (n=42) lived in a rural location. The majority reported having access to the internet (n=93, 77%) and email service (n=83, 70%), but only 56% (n=67) had a camera-equipped device. Overall, 53% (n=63) were willing and capable of participating in a VVC visit. The availability of internet access was significantly lower in rural compared to nonrural participants (P=.045) and in those with or less than a high school education compared to those who pursued higher education (P=.02). Willingness to participate in the VVC visit was significantly lower in rural compared to nonrural participants (P=.03). Of the participants who reported they were able and willing to partake in a VVC visit (n=54), 65% (n=35) opted for VVC and 35% (n=19) preferred a phone visit. In total, 77% (n=27) of the scheduled VVC visits were successful. Conclusions: Despite advances in technology, and willingness on the part of health care systems, there are some lingering issues with capability and willingness to participate in video telehealth visits, particularly among older adults residing in rural areas. %M 32936773 %R 10.2196/21561 %U http://www.jmir.org/2020/9/e21561/ %U https://doi.org/10.2196/21561 %U http://www.ncbi.nlm.nih.gov/pubmed/32936773 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e21915 %T Effects of the COVID-19 Pandemic on Obsessive-Compulsive Symptoms Among University Students: Prospective Cohort Survey Study %A Ji,Guangjun %A Wei,Wenjun %A Yue,Kai-Chen %A Li,Heng %A Shi,Li-Jing %A Ma,Jian-Dong %A He,Chen-Yang %A Zhou,Sheng-Sheng %A Zhao,Zongya %A Lou,Tao %A Cheng,Jie %A Yang,Shi-Chang %A Hu,Xian-Zhang %+ The Second Affiliated Hospital of Xinxiang Medical University, No 388, Jianshe Road, Muye District, Xinxiang City, 453002, China, 86 13938744850, huxianzhang@xxmu.edu.cn %K COVID-19 %K fear %K anxiety %K obsessive-compulsive disorder %K OCD %K Yale-Brown Obsessive-Compulsive Scale %K university student %K mental health %D 2020 %7 30.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic is associated with common mental health problems. However, evidence for the association between fear of COVID-19 and obsessive-compulsive disorder (OCD) is limited. Objective: This study aimed to examine if fear of negative events affects Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores in the context of a COVID-19–fear-invoking environment. Methods: All participants were medical university students and voluntarily completed three surveys via smartphone or computer. Survey 1 was conducted on February 8, 2020, following a 2-week-long quarantine period without classes; survey 2 was conducted on March 25, 2020, when participants had been taking online courses for 2 weeks; and survey 3 was conducted on April 28, 2020, when no new cases had been reported for 2 weeks. The surveys comprised the Y-BOCS and the Zung Self-Rating Anxiety Scale (SAS); additional items included questions on demographics (age, gender, only child vs siblings, enrollment year, major), knowledge of COVID-19, and level of fear pertaining to COVID-19. Results: In survey 1, 11.3% of participants (1519/13,478) scored ≥16 on the Y-BOCS (defined as possible OCD). In surveys 2 and 3, 3.6% (305/8162) and 3.5% (305/8511) of participants had scores indicative of possible OCD, respectively. The Y-BOCS score, anxiety level, quarantine level, and intensity of fear were significantly lower at surveys 2 and 3 than at survey 1 (P<.001 for all). Compared to those with a lower Y-BOCS score (<16), participants with possible OCD expressed greater intensity of fear and had higher SAS standard scores (P<.001). The regression linear analysis indicated that intensity of fear was positively correlated to the rate of possible OCD and the average total scores for the Y-BOCS in each survey (P<.001 for all). Multiple regressions showed that those with a higher intensity of fear, a higher anxiety level, of male gender, with sibling(s), and majoring in a nonmedicine discipline had a greater chance of having a higher Y-BOCS score in all surveys. These results were redemonstrated in the 5827 participants who completed both surveys 1 and 2 and in the 4006 participants who completed all three surveys. Furthermore, in matched participants, the Y-BOCS score was negatively correlated to changes in intensity of fear (r=0.74 for survey 2, P<.001; r=0.63 for survey 3, P=.006). Conclusions: Our findings indicate that fear of COVID-19 was associated with a greater Y-BOCS score, suggesting that an environment (COVID-19 pandemic) × psychology (fear and/or anxiety) interaction might be involved in OCD and that a fear of negative events might play a role in the etiology of OCD. %M 32931444 %R 10.2196/21915 %U http://www.jmir.org/2020/9/e21915/ %U https://doi.org/10.2196/21915 %U http://www.ncbi.nlm.nih.gov/pubmed/32931444 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18284 %T Comparison of a Mobile Health Electronic Visual Analog Scale App With a Traditional Paper Visual Analog Scale for Pain Evaluation: Cross-Sectional Observational Study %A Turnbull,Alexandra %A Sculley,Dean %A Escalona-Marfil,Carles %A Riu-Gispert,Lluís %A Ruiz-Moreno,Jorge %A Gironès,Xavier %A Coda,Andrea %+ School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Health Precinct, BE154, PO Box 127, Ourimbah, 2258, Australia, 61 0243484507, andrea.coda@newcastle.edu.au %K pain %K mobile app %K mHealth %K digital health %K electronic visual analog scale %K visual analog scale %K symptom %K eHealth %K reliability %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Accurate quantification of pain in a clinical setting is vital. The use of an electronic pain scale enables data to be collected, analyzed, and utilized much faster compared with traditional paper-based scales. The advancement of smart technology in pediatric and adult pain evaluation may offer opportunities to introduce easy-to-use and reliable pain assessment methods within different clinical settings. If promptly introduced within different pediatric and adult pain clinic services, validated and easily accessible mobile health pain apps may lead to early pain detection, promoting improvement in patient’s quality of life and leading to potentially less time off from school or work. Objective: This cross-sectional observational study aimed to investigate the interchangeability of an electronic visual analog scale (eVAS) app with a traditional paper visual analog scale (pVAS) among Australian children, adolescents, and adults for pain evaluation. Methods: Healthy participants (age range 10-75 years) were recruited from a sporting club and a secondary school in Melbourne (Australia). The data collection process involved application of pressure (8.5 kg/cm2) from a Wagner Force Dial FDK 20 to the midpoint of the thumb. The pressure was applied twice with a 5-minute interval. At each pressure application, participants were asked to randomly record their pain perception using the “eVAS” accessible via the “Interactive Clinics” app and the traditional pVAS. Statistical analysis was conducted to determine intermethod and intramethod reliabilities. Results: Overall, 109 healthy participants were recruited. Adults (mean age 42.43 years, SD 14.50 years) had excellent reliability, with an intraclass correlation coefficient (ICC) of 0.94 (95% CI 0.91-0.96). Children and adolescents (mean age 13.91 years, SD 2.89 years) had moderate-to-good intermethod and intramethod reliabilities, with an ICC of 0.80 (95% CI 0.70-0.87) and average ICC of 0.80 (95% CI 0.69-0.87), respectively. Conclusions: The eVAS app appears to be interchangeable compared with the traditional pVAS among children, adolescents, and adults. This pain evaluation method may offer new opportunities to introduce user-friendly and validated pain assessment apps for patients, clinicians, and allied health professionals. %M 32940621 %R 10.2196/18284 %U http://www.jmir.org/2020/9/e18284/ %U https://doi.org/10.2196/18284 %U http://www.ncbi.nlm.nih.gov/pubmed/32940621 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18431 %T Investigating the Accessibility of Voice Assistants With Impaired Users: Mixed Methods Study %A Masina,Fabio %A Orso,Valeria %A Pluchino,Patrik %A Dainese,Giulia %A Volpato,Stefania %A Nelini,Cristian %A Mapelli,Daniela %A Spagnolli,Anna %A Gamberini,Luciano %+ Human Inspired Technologies Research Center, University of Padova, Via Luzzatti, 4, Padova, Italy, 39 049 827 5796, luciano.gamberini@unipd.it %K voice assistants %K accessibility %K cognitive functions %K disability %K ambient assisted living %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Voice assistants allow users to control appliances and functions of a smart home by simply uttering a few words. Such systems hold the potential to significantly help users with motor and cognitive disabilities who currently depend on their caregiver even for basic needs (eg, opening a door). The research on voice assistants is mainly dedicated to able-bodied users, and studies evaluating the accessibility of such systems are still sparse and fail to account for the participants’ actual motor, linguistic, and cognitive abilities. Objective: The aim of this work is to investigate whether cognitive and/or linguistic functions could predict user performance in operating an off-the-shelf voice assistant (Google Home). Methods: A group of users with disabilities (n=16) was invited to a living laboratory and asked to interact with the system. Besides collecting data on their performance and experience with the system, their cognitive and linguistic skills were assessed using standardized inventories. The identification of predictors (cognitive and/or linguistic) capable of accounting for an efficient interaction with the voice assistant was investigated by performing multiple linear regression models. The best model was identified by adopting a selection strategy based on the Akaike information criterion (AIC). Results: For users with disabilities, the effectiveness of interacting with a voice assistant is predicted by the Mini-Mental State Examination (MMSE) and the Robertson Dysarthria Profile (specifically, the ability to repeat sentences), as the best model shows (AIC=130.11). Conclusions: Users with motor, linguistic, and cognitive impairments can effectively interact with voice assistants, given specific levels of residual cognitive and linguistic skills. More specifically, our paper advances practical indicators to predict the level of accessibility of speech-based interactive systems. Finally, accessibility design guidelines are introduced based on the performance results observed in users with disabilities. %M 32975525 %R 10.2196/18431 %U http://www.jmir.org/2020/9/e18431/ %U https://doi.org/10.2196/18431 %U http://www.ncbi.nlm.nih.gov/pubmed/32975525