TY - JOUR AU - Chen, Lichin AU - Chuang, Lee-Ming AU - Chang, Chia-Hsiun AU - Wang, Chiou-Shiang AU - Wang, I-Ching AU - Chung, Yufang AU - Peng, Hui-Yu AU - Chen, Hui-Chuen AU - Hsu, Yu-Ling AU - Lin, Yu-Sheng AU - Chen, Huang-Jen AU - Chang, Tieng-Chun AU - Jiang, Yi-Der AU - Lee, Hung-Chang AU - Tan, Ching-Ting AU - Chang, Hsin-Lu AU - Lai, Feipei PY - 2013/12/09 TI - Evaluating Self-Management Behaviors of Diabetic Patients in a Telehealthcare Program: Longitudinal Study Over 18 Months JO - J Med Internet Res SP - e266 VL - 15 IS - 12 KW - Internet KW - diabetes mellitus KW - telemedicine KW - self-care KW - online systems KW - personal health record KW - patient access to records N2 - Background: Self-management is an important skill for patients with diabetes, and it involves frequent monitoring of glucose levels and behavior modification. Techniques to enhance the behavior changes of diabetic patients have been developed, such as diabetes self-management education and telehealthcare. Although the patients are engaged in self-management activities, barriers to behavior changes remain and additional work is necessary to address the impact of electronic media and telehealthcare on patient self-care behaviors. Objective: The aims of this study were to (1) explore the behaviors of diabetic patients interacting with online applications, (2) determine the impact of a telehealthcare program among 7 self-care behaviors of the patients, and (3) determine the changes in glycosylated hemoglobin (HbA1c) levels. Methods: A telehealthcare program was conducted to assist the patients with 7 self-care activities. The telehealthcare program lasted for 18 months and included the use of a third-generation mobile telecommunications glucometer, an online diabetes self-management system, and a teleconsultant service. We analyzed the data of 59 patients who participated in the telehealthcare program and 103 who did not. The behavioral assessments and the HbA1c data were collected and statistically analyzed to determine whether the telehealthcare services had an impact on the patients. We divided the 18-month period into 3 6-month intervals and analyzed the parameters of patients assisted by the telehealthcare service at different time points. We also compared the results of those who were assisted by the telehealthcare service with those who were not. Results: There was a significant difference in monitoring blood glucose between the beginning and the end of the patient participation (P=.046) and between the overall period and the end of patient participation (P<.001). Five behaviors were significantly different between the intervention and control patients: being active (P<.001), healthy eating (P<.001), taking medication (P<.001), healthy coping (P=.02), and problem solving (P<.001). Monitoring of blood glucose was significantly different (P=.02) during the 6-12 month stage of patient participation between the intervention and control patients. A significant difference between the beginning and the 6-12 month stage of patient participation was observed for the mean value of HbA1c level (P=.02), and the differences between the overall HbA1c variability and the variability of each 6-month interval was also significant. Conclusions: Telehealthcare had a positive effect on diabetic patients. This study had enhanced blood glucose monitoring, and the patients in the program showed improvements in glycemic control. The self-care behaviors affect patient outcomes, and the changes of behavior require time to show the effects. UR - http://www.jmir.org/2013/12/e266/ UR - http://dx.doi.org/10.2196/jmir.2699 UR - http://www.ncbi.nlm.nih.gov/pubmed/24323283 ID - info:doi/10.2196/jmir.2699 ER - TY - JOUR AU - van Vugt, Michael AU - de Wit, Maartje AU - Cleijne, HJJ Wilmy AU - Snoek, J. Frank PY - 2013/12/13 TI - Use of Behavioral Change Techniques in Web-Based Self-Management Programs for Type 2 Diabetes Patients: Systematic Review JO - J Med Internet Res SP - e279 VL - 15 IS - 12 KW - Web-based KW - online KW - self-management KW - review KW - type 2 diabetes mellitus KW - behavioral change techniques N2 - Background: Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic metabolic disease characterized by hyperglycemia and cardiovascular risks. Without proper treatment, T2DM can lead to long-term complications. Diabetes self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs for T2DM patients can help to successfully improve patient health behaviors and health-related outcomes. Theories can help to specify key determinants of the target behaviors and behavior change strategies required to arrive at the desired health outcomes, which can then be translated into specific behavioral techniques or strategies that patients can learn to apply in their daily life. From previous reviews of a wide range of online diabetes self-management tools and programs, it appears that it is still unclear which behavioral change techniques (BCTs) are primarily used and are most effective when it comes to improving diabetes self-management behaviors and related health outcomes. Objective: We set out to identify which BCTs are being applied in online self-management programs for T2DM and whether there is indication of their effectiveness in relation to predefined health outcomes. Methods: Articles were systematically searched and screened on the mentioned use of 40 BCTs, which were then linked to reported statistically significant improvements in study outcomes. Results: We found 13 randomized controlled trials reporting on 8 online self-management interventions for T2DM. The BCTs used were feedback on performance, providing information on consequences of behavior, barrier identification/problem solving, and self-monitoring of behavior. These BCTs were also linked to positive outcomes for health behavior change, psychological well-being, or clinical parameters. Conclusions: A relatively small number of theory-based online self-management support programs for T2DM have been reported using only a select number of BCTs. The development of future online self-management interventions should be based on the use of theories and BCTs and should be reported accurately. UR - http://www.jmir.org/2013/12/e279/ UR - http://dx.doi.org/10.2196/jmir.2800 UR - http://www.ncbi.nlm.nih.gov/pubmed/24334230 ID - info:doi/10.2196/jmir.2800 ER - TY - JOUR AU - Bender, Lorene Jacqueline AU - Yue, Kwan Rossini Ying AU - To, Jason Matthew AU - Deacken, Laetitia AU - Jadad, R. Alejandro PY - 2013/12/23 TI - A Lot of Action, But Not in the Right Direction: Systematic Review and Content Analysis of Smartphone Applications for the Prevention, Detection, and Management of Cancer JO - J Med Internet Res SP - e287 VL - 15 IS - 12 KW - mobile KW - Internet KW - cancer KW - software applications KW - apps N2 - Background: Mobile phones have become nearly ubiquitous, offering a promising means to deliver health interventions. However, little is known about smartphone applications (apps) for cancer. Objective: The purpose of this study was to characterize the purpose and content of cancer-focused smartphone apps available for use by the general public and the evidence on their utility or effectiveness. Methods: We conducted a systematic review of the official application stores for the four major smartphone platforms: iPhone, Android, Nokia, and BlackBerry. Apps were included in the review if they were focused on cancer and available for use by the general public. This was complemented by a systematic review of literature from MEDLINE, Embase, and the Cochrane Library to identify evaluations of cancer-related smartphone apps. Results: A total of 295 apps from the smartphone app stores met the inclusion criteria. The majority of apps targeted breast cancer (46.8%, 138/295) or cancer in general (28.5%, 84/295). The reported app purpose was predominantly to raise awareness about cancer (32.2%, 95/295) or to provide educational information about cancer (26.4%, 78/295), followed by apps to support fundraising efforts (12.9%, 38/295), assist in early detection (11.5%, 34/295), promote a charitable organization (10.2%, 30/295), support disease management (3.7%, 11/295), cancer prevention (2.0%, 6/295), or social support (1.0%, 3/295). The majority of the apps did not describe their organizational affiliation (64.1%, 189/295). Apps affiliated with non-profit organizations were more likely to be free of cost (?21=16.3, P<.001) and have a fundraising or awareness purpose (?22=13.3, P=.001). The review of the health literature yielded 594 articles, none of which reported an evaluation of a cancer-focused smartphone application. Conclusions: There are hundreds of cancer-focused apps with the potential to enhance efforts to promote behavior change, to monitor a host of symptoms and physiological indicators of disease, and to provide real-time supportive interventions, conveniently and at low cost. However, there is a lack of evidence on their utility, effectiveness, and safety. Future efforts should focus on improving and consolidating the evidence base into a whitelist for public consumption. UR - http://www.jmir.org/2013/12/e287/ UR - http://dx.doi.org/10.2196/jmir.2661 UR - http://www.ncbi.nlm.nih.gov/pubmed/24366061 ID - info:doi/10.2196/jmir.2661 ER - TY - JOUR AU - Li, Ye AU - Wang, Wei AU - van Velthoven, Helena Michelle AU - Chen, Li AU - Car, Josip AU - Rudan, Igor AU - Zhang, Yanfeng AU - Wu, Qiong AU - Du, Xiaozhen AU - Scherpbier, W. Robert PY - 2013/12/04 TI - Text Messaging Data Collection for Monitoring an Infant Feeding Intervention Program in Rural China: Feasibility Study JO - J Med Internet Res SP - e269 VL - 15 IS - 12 KW - text messaging KW - data collection KW - program evaluation KW - child nutrition sciences N2 - Background: An effective data collection method is crucial for high quality monitoring of health interventions. The traditional face-to-face data collection method is labor intensive, expensive, and time consuming. With the rapid increase of mobile phone subscribers, text messaging has the potential to be used for evaluation of population health interventions in rural China. Objective: The objective of this study was to explore the feasibility of using text messaging as a data collection tool to monitor an infant feeding intervention program. Methods: Participants were caregivers of children aged 0 to 23 months in rural China who participated in an infant feeding health education program. We used the test-retest method. First, we collected data with a text messaging survey and then with a face-to-face survey for 2 periods of 3 days. We compared the response rate, data agreement, costs, and participants? acceptability of the two methods. Also, we interviewed participants to explore their reasons for not responding to the text messages and the reasons for disagreement in the two methods. In addition, we evaluated the most appropriate time during the day for sending text messages. Results: We included 258 participants; 99 (38.4%) participated in the text messaging survey and 177 (68.6%) in the face-to-face survey. Compared with the face-to-face survey, the text messaging survey had much lower response rates to at least one question (38.4% vs 68.6%) and to all 7 questions (27.9% vs 67.4%) with moderate data agreement (most kappa values between .5 and .75, the intraclass correlation coefficients between .53 to .72). Participants who took part in both surveys gave the same acceptability rating for both methods (median 4.0 for both on a 5-point scale, 1=disliked very much and 5=liked very much). The costs per questionnaire for the text messaging method were much lower than the costs for the face-to-face method: ¥19.7 (US $3.13) versus ¥33.9 (US $5.39) for all questionnaires, and ¥27.1 (US $4.31) versus ¥34.4 (US $5.47) for completed questionnaires. The main reasons for not replying were that participants did not receive text messages, they were too busy to reply, or they did not see text messages in time. The main reasons for disagreement in responses were that participants forgot their answers in the text messaging survey and that they changed their minds. We found that participants were more likely to reply to text messages immediately during 2 time periods: 8 AM to 3 PM and 8 PM to 9 PM. Conclusions: The text messaging method had reasonable data agreement and low cost, but a low response rate. Further research is needed to evaluate effectiveness of measures that can increase the response rate, especially in collecting longitudinal data by text messaging. UR - http://www.jmir.org/2013/12/e269/ UR - http://dx.doi.org/10.2196/jmir.2906 UR - http://www.ncbi.nlm.nih.gov/pubmed/24305514 ID - info:doi/10.2196/jmir.2906 ER - TY - JOUR AU - Sharifi, Mona AU - Dryden, M. Eileen AU - Horan, M. Christine AU - Price, Sarah AU - Marshall, Richard AU - Hacker, Karen AU - Finkelstein, A. Jonathan AU - Taveras, M. Elsie PY - 2013/12/06 TI - Leveraging Text Messaging and Mobile Technology to Support Pediatric Obesity-Related Behavior Change: A Qualitative Study Using Parent Focus Groups and Interviews JO - J Med Internet Res SP - e272 VL - 15 IS - 12 KW - child KW - obesity KW - overweight KW - health behavior KW - text messaging KW - telemedicine N2 - Background: Text messaging (short message service, SMS) is a widely accessible and potentially cost-effective medium for encouraging behavior change. Few studies have examined text messaging interventions to influence child health behaviors or explored parental perceptions of mobile technologies to support behavior change among children. Objective: Our aim was to examine parental acceptability and preferences for text messaging to support pediatric obesity-related behavior change. Methods: We conducted focus groups and follow-up interviews with parents of overweight and obese children, aged 6-12 years, seen for ?well-child? care in eastern Massachusetts. A professional moderator used a semistructured discussion guide and sample text messages to catalyze group discussions. Seven participants then received 3 weeks of text messages before a follow-up one-on-one telephone interview. All focus groups and interviews were recorded and transcribed verbatim. Using a framework analysis approach, we systematically coded and analyzed group and interview data to identify salient and convergent themes. Results: We reached thematic saturation after five focus groups and seven follow-up interviews with a total of 31 parents of diverse race/ethnicity and education levels. Parents were generally enthusiastic about receiving text messages to support healthy behaviors for their children and preferred them to paper or email communication because they are brief and difficult to ignore. Participants anticipated high responsiveness to messaging endorsed by their child?s doctor and indicated they would appreciate messages 2-3 times/week or more as long as content remains relevant. Suggestions for maintaining message relevance included providing specific strategies for implementation and personalizing information. Most felt the negative features of text messaging (eg, limited message size) could be overcome by providing links within messages to other media including email or websites. Conclusions: Text messaging is a promising medium for supporting pediatric obesity-related behavior change. Parent perspectives could assist in the design of text-based interventions. Trial Registration: Clinicaltrials.gov NCT01565161; http://clinicaltrials.gov/show/NCT01565161 (Archived by WebCite at http://www.webcitation.org/6LSaqFyPP). UR - http://www.jmir.org/2013/12/e272/ UR - http://dx.doi.org/10.2196/jmir.2780 UR - http://www.ncbi.nlm.nih.gov/pubmed/24317406 ID - info:doi/10.2196/jmir.2780 ER - TY - JOUR AU - Buis, R. Lorraine AU - Hirzel, Lindsey AU - Turske, A. Scott AU - Des Jardins, R. Terrisca AU - Yarandi, Hossein AU - Bondurant, Patricia PY - 2013/12/19 TI - Use of a Text Message Program to Raise Type 2 Diabetes Risk Awareness and Promote Health Behavior Change (Part I): Assessment of Participant Reach and Adoption JO - J Med Internet Res SP - e281 VL - 15 IS - 12 KW - diabetes mellitus, type 2 KW - mobile health KW - cellular phone KW - text messaging KW - risk reduction behavior KW - program evaluation N2 - Background: There are an estimated 25.8 million American children and adults, equivalent to 8.3% of the US population, living with diabetes. Diabetes is particularly burdensome on minority populations. The use of mobile technologies for reaching broad populations is a promising approach, given its wide footprint and ability to deliver inexpensive personalized messages, to increase awareness of type 2 diabetes and promote behavior changes targeting risk factors associated with type 2 diabetes. As a part of the Beacon Community Cooperative Agreement Program, txt4health, a public-facing mobile health information service, was launched in 3 Beacon Communities: the Southeast Michigan Beacon Community in Detroit, MI, the Greater Cincinnati Beacon Community in Cincinnati, OH, and the Crescent City Beacon Community in New Orleans, LA. Txt4health is a mobile health information service designed to help people understand their risk for type 2 diabetes and become more informed about the steps they can take to lead healthy lives. Objective: The purpose of this investigation was to use the RE-AIM framework to document txt4health reach and adoption by focusing on enrollment and participant engagement in program pilots in Southeast Michigan and Greater Cincinnati. Methods: We conducted a retrospective records analysis of individual-level txt4health system data from participants in Southeast Michigan and Greater Cincinnati to determine participant usage of txt4health and engagement with the program. Results: Results from the retrospective records analysis revealed that 5570 participants initiated the 2-step enrollment process via 1 of 3 enrollment strategies: text message, website, or directly with Beacon staff who signed participants up via the website. In total, 33.00% (1838/5570) of participants completed the 2-step enrollment process and were fully enrolled in the program. All participants (100.00%, 1620/1620) who enrolled via text message completed the entire 2-step enrollment process versus 5.52% (218/3950) of participants who enrolled via website or a Beacon staff member. Of those who fully enrolled, 71.00% (1305/1838) completed the diabetes risk assessment and 74.27% (1365/1838) set an initial weight loss goal. Overall, 39.06% (718/1838) of participants completed all 14 weeks of the program and 56.26% (1034/1838) dropped out before completing all 14 weeks, with the bulk of dropouts occurring in the first 4 weeks. Length of participation varied greatly, ranging from 0-48.7 weeks (median 8.6, mean 15.8, SD 15.8). Wide variability of participant engagement in regards to weekly weight and physical activity was documented. Conclusions: Although broadly focused public health text message interventions may have the potential to reach large populations and show high levels of engagement among some users, the level of individual engagement among participants varies widely, suggesting that this type of approach may not be appropriate for all. UR - http://www.jmir.org/2013/12/e281/ UR - http://dx.doi.org/10.2196/jmir.2928 UR - http://www.ncbi.nlm.nih.gov/pubmed/24356329 ID - info:doi/10.2196/jmir.2928 ER - TY - JOUR AU - Buis, R. Lorraine AU - Hirzel, Lindsey AU - Turske, A. Scott AU - Des Jardins, R. Terrisca AU - Yarandi, Hossein AU - Bondurant, Patricia PY - 2013/12/19 TI - Use of a Text Message Program to Raise Type 2 Diabetes Risk Awareness and Promote Health Behavior Change (Part II): Assessment of Participants' Perceptions on Efficacy JO - J Med Internet Res SP - e282 VL - 15 IS - 12 KW - diabetes mellitus, type 2 KW - mobile health KW - cellular phone KW - text messaging KW - risk reduction behavior KW - program evaluation N2 - Background: Although there is great enthusiasm in both the public and private sector for the further development and use of large-scale consumer-facing public health applications for mobile platforms, little is known about user experience and satisfaction with this type of approach. As a part of the Beacon Community Cooperative Agreement Program, txt4health, a public-facing, mobile phone-based health information service targeting type 2 diabetes, was launched in 3 Beacon Communities: the Southeast Michigan Beacon Community in Detroit, MI, the Greater Cincinnati Beacon Community in Cincinnati, OH, and the Crescent City Beacon Community in New Orleans, LA. This program was marketed via large public health campaigns and drew many users within the respective communities. Objective: The purpose of this investigation was to use the RE-AIM framework to document txt4health efficacy by focusing on perceptions of satisfaction, usage, and behavior change among individuals who used txt4health in pilot studies in Southeast Michigan and Greater Cincinnati. Methods: We conducted a multimodal user survey with txt4health users recruited via text message through the program to understand participant perceptions of program use and satisfaction, as well as self-reported perceptions of behavior change as a result of using txt4health. Results: Txt4health users reported very high levels of program satisfaction, with 67.1% (108/161) reporting satisfaction scores of ?8 on a 10-point scale, with 10 equivalent to most satisfied (mean 8.2, SD 1.6). All survey participants agreed/strongly agreed that the messages included in txt4health were clear and easy to understand (100.0%, 160/160), and most found txt4health made them knowledgeable about their risk for type 2 diabetes (88.1%, 140/159) and made them conscious of their diet and physical activity (88.8%, 142/160). Most participants reported that txt4health helped them to make behavior changes related to diet; after having completed txt4health, most agreed/strongly agreed that they are more likely to replace sugary drinks, such as juice or soda, with water (78.0%, 124/159), have a piece of fresh fruit instead of dessert (74.2%, 118/159), substitute a small salad for chips or fries when dining out (76.1%, 121/159), buy healthier foods when grocery shopping (79.7%, 126/158), and eat more grilled, baked, or broiled foods instead of fried (75.5%, 120/159). Conclusions: Results from this study suggest that participants in txt4health, a large-scale, public health?focused text message program targeting type 2 diabetes, have positive perceptions of the program and that participation has led to positive behavior change. UR - http://www.jmir.org/2013/12/e282/ UR - http://dx.doi.org/10.2196/jmir.2929 UR - http://www.ncbi.nlm.nih.gov/pubmed/24356359 ID - info:doi/10.2196/jmir.2929 ER - TY - JOUR AU - Harris, Marion Isobel AU - Roberts, Martine Lesley PY - 2013/12/20 TI - Exploring the Use and Effects of Deliberate Self-Harm Websites: An Internet-Based Study JO - J Med Internet Res SP - e285 VL - 15 IS - 12 KW - Internet KW - websites KW - deliberate self-harm KW - self-injury N2 - Background: In the United Kingdom, rates of deliberate self-harm (DSH) are rising. Alongside this, there has been an increase in the number of websites available with DSH content, and the Internet is known as a valuable resource for those who feel isolated by their condition(s). However, there is little and contradictory evidence available on the effects of using such websites. Further research is therefore required to examine the use and effects of DSH websites. Objective: Our objectives were to explore (1) the reasons people engage in the use of self-harm forums/websites, (2) the beliefs of users of self-harm forums regarding the role of such websites, (3) how the use of self-harm forums/websites modulates self-harm behaviors, and (4) other ways that self-harm forums affect the lives of individuals who use them. Methods: Data were collected by a questionnaire hosted on 20 websites with self-harm content. Participants were self-selected from users of these sites. Results were analyzed using descriptive statistics and simple thematic analysis. Results: In total, 329 responses were received with 91.8% (302/329) from female site users. The majority of participants (65.6%, 187/285) visited these sites at least twice per week, and most participants used the sites to find information (78.2%, 223/285) or participate in the forums (68.4%, 195/285). Positive effects of website use such as gaining help and support, isolation reduction, and a reduction in self-harm behaviors were reported by a large number of participants. However, smaller but important numbers reported negative effects including worsened self-harm, being triggered to self-harm, and additional negative physical and psychological effects. Conclusions: This is the first multisite study to explore DSH website use in depth. There are clear and important benefits to engaging in website use for many individuals; however, these are not experienced by all website users. Negative effects were experienced by moderate numbers following website use, and clinicians should consider the impact of a patient?s website use when consulting. UR - http://www.jmir.org/2013/12/e285/ UR - http://dx.doi.org/10.2196/jmir.2802 UR - http://www.ncbi.nlm.nih.gov/pubmed/24362563 ID - info:doi/10.2196/jmir.2802 ER - TY - JOUR AU - Bailey, V. Julia AU - Pavlou, Menelaos AU - Copas, Andrew AU - McCarthy, Ona AU - Carswell, Ken AU - Rait, Greta AU - Hart, Graham AU - Nazareth, Irwin AU - Free, Caroline AU - French, Rebecca AU - Murray, Elizabeth PY - 2013/12/11 TI - The Sexunzipped Trial: Optimizing the Design of Online Randomized Controlled Trials JO - J Med Internet Res SP - e278 VL - 15 IS - 12 KW - Internet KW - randomized controlled trials as topic KW - outcome assessment (health care) KW - sexual health KW - sexually transmitted diseases KW - behavioral research N2 - Background: Sexual health problems such as unwanted pregnancy and sexually transmitted infection are important public health concerns and there is huge potential for health promotion using digital interventions. Evaluations of digital interventions are increasingly conducted online. Trial administration and data collection online offers many advantages, but concerns remain over fraudulent registration to obtain compensation, the quality of self-reported data, and high attrition. Objective: This study addresses the feasibility of several dimensions of online trial design?recruitment, online consent, participant identity verification, randomization and concealment of allocation, online data collection, data quality, and retention at 3-month follow-up. Methods: Young people aged 16 to 20 years and resident in the United Kingdom were recruited to the ?Sexunzipped? online trial between November 2010 and March 2011 (n=2036). Participants filled in baseline demographic and sexual health questionnaires online and were randomized to the Sexunzipped interactive intervention website or to an information-only control website. Participants were also randomly allocated to a postal request (or no request) for a urine sample for genital chlamydia testing and receipt of a lower (£10/US$16) or higher (£20/US$32) value shopping voucher compensation for 3-month outcome data. Results: The majority of the 2006 valid participants (90.98%, 1825/2006) were aged between 18 and 20 years at enrolment, from all four countries in the United Kingdom. Most were white (89.98%, 1805/2006), most were in school or training (77.48%, 1545/1994), and 62.81% (1260/2006) of the sample were female. In total, 3.88% (79/2036) of registrations appeared to be invalid and another 4.00% (81/2006) of participants gave inconsistent responses within the questionnaire. The higher value compensation (£20/US$32) increased response rates by 6-10%, boosting retention at 3 months to 77.2% (166/215) for submission of online self-reported sexual health outcomes and 47.4% (118/249) for return of chlamydia urine samples by post. Conclusions: It was quick and efficient to recruit young people to this online trial. Our procedures for obtaining online consent, verifying participant identity, automated randomization, and concealment of allocation worked well. The optimal response rate for the online sexual health outcome measurement was comparable to face-to-face trials. Multiple methods of participant contact, requesting online data only, and higher value compensation increased trial retention at 3-month follow-up. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 55651027; http://www.controlled-trials.com/ISRCTN55651027 (Archived by WebCite at http://www.webcitation.org/6LbkxdPKf). UR - http://www.jmir.org/2013/12/e278/ UR - http://dx.doi.org/10.2196/jmir.2668 UR - http://www.ncbi.nlm.nih.gov/pubmed/24334216 ID - info:doi/10.2196/jmir.2668 ER - TY - JOUR AU - Shaffer, A. Victoria AU - Owens, Justin AU - Zikmund-Fisher, J. Brian PY - 2013/12/17 TI - The Effect of Patient Narratives on Information Search in a Web-Based Breast Cancer Decision Aid: An Eye-Tracking Study JO - J Med Internet Res SP - e273 VL - 15 IS - 12 KW - personal narratives KW - decision aids KW - eye tracking KW - breast cancer N2 - Background: Previous research has examined the impact of patient narratives on treatment choices, but to our knowledge, no study has examined the effect of narratives on information search. Further, no research has considered the relative impact of their format (text vs video) on health care decisions in a single study. Objective: Our goal was to examine the impact of video and text-based narratives on information search in a Web-based patient decision aid for early stage breast cancer. Methods: Fifty-six women were asked to imagine that they had been diagnosed with early stage breast cancer and needed to choose between two surgical treatments (lumpectomy with radiation or mastectomy). Participants were randomly assigned to view one of four versions of a Web decision aid. Two versions of the decision aid included videos of interviews with patients and physicians or videos of interviews with physicians only. To distinguish between the effect of narratives and the effect of videos, we created two text versions of the Web decision aid by replacing the patient and physician interviews with text transcripts of the videos. Participants could freely browse the Web decision aid until they developed a treatment preference. We recorded participants? eye movements using the Tobii 1750 eye-tracking system equipped with Tobii Studio software. A priori, we defined 24 areas of interest (AOIs) in the Web decision aid. These AOIs were either separate pages of the Web decision aid or sections within a single page covering different content. Results: We used multilevel modeling to examine the effect of narrative presence, narrative format, and their interaction on information search. There was a significant main effect of condition, P=.02; participants viewing decision aids with patient narratives spent more time searching for information than participants viewing the decision aids without narratives. The main effect of format was not significant, P=.10. However, there was a significant condition by format interaction on fixation duration, P<.001. When comparing the two video decision aids, participants viewing the narrative version spent more time searching for information than participants viewing the control version of the decision aid. In contrast, participants viewing the narrative version of the text decision aid spent less time searching for information than participants viewing the control version of the text decision aid. Further, narratives appear to have a global effect on information search; these effects were not limited to specific sections of the decision aid that contained topics discussed in the patient stories. Conclusions: The observed increase in fixation duration with video patient testimonials is consistent with the idea that the vividness of the video content could cause greater elaboration of the message, thereby encouraging greater information search. Conversely, because reading requires more effortful processing than watching, reading patient narratives may have decreased participant motivation to engage in more reading in the remaining sections of the Web decision aid. These findings suggest that the format of patient stories may be equally as important as their content in determining their effect on decision making. More research is needed to understand why differences in format result in fundamental differences in information search. UR - http://www.jmir.org/2013/12/e273/ UR - http://dx.doi.org/10.2196/jmir.2784 UR - http://www.ncbi.nlm.nih.gov/pubmed/24345424 ID - info:doi/10.2196/jmir.2784 ER - TY - JOUR AU - Jimbo, Masahito AU - Shultz, Garth Cameron AU - Nease, Eugene Donald AU - Fetters, Derwin Michael AU - Power, Debra AU - Ruffin IV, Thomas Mack PY - 2013/12/18 TI - Perceived Barriers and Facilitators of Using a Web-Based Interactive Decision Aid for Colorectal Cancer Screening in Community Practice Settings: Findings From Focus Groups With Primary Care Clinicians and Medical Office Staff JO - J Med Internet Res SP - e286 VL - 15 IS - 12 KW - colon cancer KW - colonoscopy KW - cancer screening KW - early detection of cancer KW - reminder systems KW - decision support techniques KW - focus groups KW - health information technology N2 - Background: Information is lacking about the capacity of those working in community practice settings to utilize health information technology for colorectal cancer screening. Objective: To address this gap we asked those working in community practice settings to share their perspectives about how the implementation of a Web-based patient-led decision aid might affect patient-clinician conversations about colorectal cancer screening and the day-to-day clinical workflow. Methods: Five focus groups in five community practice settings were conducted with 8 physicians, 1 physician assistant, and 18 clinic staff. Focus groups were organized using a semistructured discussion guide designed to identify factors that mediate and impede the use of a Web-based decision aid intended to clarify patient preferences for colorectal cancer screening and to trigger shared decision making during the clinical encounter. Results: All physicians, the physician assistant, and 8 of the 18 clinic staff were active participants in the focus groups. Clinician and staff participants from each setting reported a belief that the Web-based patient-led decision aid could be an informative and educational tool; in all but one setting participants reported a readiness to recommend the tool to patients. The exception related to clinicians from one clinic who described a preference for patients having fewer screening choices, noting that a colonoscopy was the preferred screening modality for patients in their clinic. Perceived barriers to utilizing the Web-based decision aid included patients? lack of Internet access or low computer literacy, and potential impediments to the clinics? daily workflow. Expanding patients? use of an online decision aid that is both easy to access and understand and that is utilized by patients outside of the office visit was described as a potentially efficient means for soliciting patients? screening preferences. Participants described that a system to link the online decision aid to a computerized reminder system could promote a better understanding of patients? screening preferences, though some expressed concern that such a system could be difficult to keep up and running. Conclusions: Community practice clinicians and staff perceived the Web-based decision aid technology as promising but raised questions as to how the technology and resultant information would be integrated into their daily practice workflow. Additional research investigating how to best implement online decision aids should be conducted prior to the widespread adoption of such technology so as to maximize the benefits of the technology while minimizing workflow disruptions. UR - http://www.jmir.org/2013/12/e286/ UR - http://dx.doi.org/10.2196/jmir.2914 UR - http://www.ncbi.nlm.nih.gov/pubmed/24351420 ID - info:doi/10.2196/jmir.2914 ER - TY - JOUR AU - Aalbers, Teun AU - Baars, E. Maria A. AU - Olde Rikkert, M. Marcel G. AU - Kessels, C. Roy P. PY - 2013/12/03 TI - Puzzling With Online Games (BAM-COG): Reliability, Validity, and Feasibility of an Online Self-Monitor for Cognitive Performance in Aging Adults JO - J Med Internet Res SP - e270 VL - 15 IS - 12 KW - cognitive testing KW - brain aging KW - games KW - validity KW - reliability KW - self-monitoring KW - Internet KW - eHealth N2 - Background: Online interventions are aiming increasingly at cognitive outcome measures but so far no easy and fast self-monitors for cognition have been validated or proven reliable and feasible. Objective: This study examines a new instrument called the Brain Aging Monitor?Cognitive Assessment Battery (BAM-COG) for its alternate forms reliability, face and content validity, and convergent and divergent validity. Also, reference values are provided. Methods: The BAM-COG consists of four easily accessible, short, yet challenging puzzle games that have been developed to measure working memory (?Conveyer Belt?), visuospatial short-term memory (?Sunshine?), episodic recognition memory (?Viewpoint?), and planning (?Papyrinth?). A total of 641 participants were recruited for this study. Of these, 397 adults, 40 years and older (mean 54.9, SD 9.6), were eligible for analysis. Study participants played all games three times with 14 days in between sets. Face and content validity were based on expert opinion. Alternate forms reliability (AFR) was measured by comparing scores on different versions of the BAM-COG and expressed with an intraclass correlation (ICC: two-way mixed; consistency at 95%). Convergent validity (CV) was provided by comparing BAM-COG scores to gold-standard paper-and-pencil and computer-assisted cognitive assessment. Divergent validity (DV) was measured by comparing BAM-COG scores to the National Adult Reading Test IQ (NART-IQ) estimate. Both CV and DV are expressed as Spearman rho correlation coefficients. Results: Three out of four games showed adequate results on AFR, CV, and DV measures. The games Conveyer Belt, Sunshine, and Papyrinth have AFR ICCs of .420, .426, and .645 respectively. Also, these games had good to very good CV correlations: rho=.577 (P=.001), rho=.669 (P<.001), and rho=.400 (P=.04), respectively. Last, as expected, DV correlations were low: rho=?.029 (P=.44), rho=?.029 (P=.45), and rho=?.134 (P=.28) respectively. The game Viewpoint provided less desirable results with an AFR ICC of .167, CV rho=.202 (P=.15), and DV rho=?.162 (P=.21). Conclusions: This study provides evidence for the use of the BAM-COG test battery as a feasible, reliable, and valid tool to monitor cognitive performance in healthy adults in an online setting. Three out of four games have good psychometric characteristics to measure working memory, visuospatial short-term memory, and planning capacity. UR - http://www.jmir.org/2013/12/e270/ UR - http://dx.doi.org/10.2196/jmir.2860 UR - http://www.ncbi.nlm.nih.gov/pubmed/24300212 ID - info:doi/10.2196/jmir.2860 ER - TY - JOUR AU - Brumen, Bostjan AU - Heri?ko, Marjan AU - Sev?nikar, Andrej AU - Zavr?nik, Jernej AU - Hölbl, Marko PY - 2013/12/16 TI - Outsourcing Medical Data Analyses: Can Technology Overcome Legal, Privacy, and Confidentiality Issues? JO - J Med Internet Res SP - e283 VL - 15 IS - 12 KW - confidentiality KW - patient data privacy KW - data protection KW - medical decision making KW - computer-assisted KW - data analysis N2 - Background: Medical data are gold mines for deriving the knowledge that could change the course of a single patient?s life or even the health of the entire population. A data analyst needs to have full access to relevant data, but full access may be denied by privacy and confidentiality of medical data legal regulations, especially when the data analyst is not affiliated with the data owner. Objective: Our first objective was to analyze the privacy and confidentiality issues and the associated regulations pertaining to medical data, and to identify technologies to properly address these issues. Our second objective was to develop a procedure to protect medical data in such a way that the outsourced analyst would be capable of doing analyses on protected data and the results would be comparable, if not the same, as if they had been done on the original data. Specifically, our hypothesis was there would not be a difference between the outsourced decision trees built on encrypted data and the ones built on original data. Methods: Using formal definitions, we developed an algorithm to protect medical data for outsourced analyses. The algorithm was applied to publicly available datasets (N=30) from the medical and life sciences fields. The analyses were performed on the original and the protected datasets and the results of the analyses were compared. Bootstrapped paired t tests for 2 dependent samples were used to test whether the mean differences in size, number of leaves, and the accuracy of the original and the encrypted decision trees were significantly different. Results: The decision trees built on encrypted data were virtually the same as those built on original data. Out of 30 datasets, 100% of the trees had identical accuracy. The size of a tree and the number of leaves was different only once (1/30, 3%, P=.19). Conclusions: The proposed algorithm encrypts a file with plain text medical data into an encrypted file with the data protected in such a way that external data analyses are still possible. The results show that the results of analyses on original and on protected data are identical or comparably similar. The approach addresses the privacy and confidentiality issues that arise with medical data and is adherent to strict legal rules in the United States and Europe regarding the processing of the medical data. UR - http://www.jmir.org/2013/12/e283/ UR - http://dx.doi.org/10.2196/jmir.2471 UR - http://www.ncbi.nlm.nih.gov/pubmed/24342053 ID - info:doi/10.2196/jmir.2471 ER - TY - JOUR AU - Lorimer, Karen AU - McDaid, Lisa PY - 2013/12/03 TI - Young Men?s Views Toward the Barriers and Facilitators of Internet-Based Chlamydia Trachomatis Screening: Qualitative Study JO - J Med Internet Res SP - e265 VL - 15 IS - 12 KW - qualitative research KW - adolescent male KW - socioeconomic status KW - chlamydia KW - sexually transmitted diseases KW - screening KW - Internet N2 - Background: There is a growing number of Internet-based approaches that offer young people screening for sexually transmitted infections. Objective: This paper explores young men?s views towards the barriers and facilitators of implementing an Internet-based screening approach. The study sought to consider ways in which the proposed intervention would reach and engage men across ages and socioeconomic backgrounds. Methods: This qualitative study included 15 focus groups with 60 heterosexual young men (aged 16-24 years) across central Scotland, drawn across age and socioeconomic backgrounds. Focus groups began by obtaining postcode data to allocate participants to a high/low deprivation category. Focus group discussions involved exploration of men?s knowledge of chlamydia, use of technology, and views toward Internet-based screening. Men were shown sample screening invitation letters, test kits, and existing screening websites to facilitate discussions. Transcripts from audio recordings were analyzed with "Framework Analysis". Results: Men?s Internet and technology use was heterogeneous in terms of individual practices, with greater use among older men (aged 20-24 years) than teenagers and some deprivation-related differences in use. We detail three themes related to barriers to successful implementation: acceptability, confidentiality and privacy concerns, and language, style, and content. These themes identify ways Internet-based screening approaches may fail to engage some men, such as by raising anxiety and failing to convey confidentiality. Men wanted screening websites to frame screening as a serious issue, rather than using humorous images and text. Participants were encouraged to reach a consensus within their groups on their broad design and style preferences for a screening website; this led to a set of common preferences that they believed were likely to engage men across age and deprivation groups and lead to greater screening uptake. Conclusions: The Internet provides opportunities for re-evaluating how we deliver sexual health promotion and engage young men in screening. Interventions using such technology should focus on uptake by age and socioeconomic background. Young people should be engaged as coproducers of intervention materials and websites to ensure messages and content are framed appropriately within a fast-changing environment. Doing so may go some way to addressing the overall lower levels of testing and screening among men compared with women. UR - http://www.jmir.org/2013/12/e265/ UR - http://dx.doi.org/10.2196/jmir.2628 UR - http://www.ncbi.nlm.nih.gov/pubmed/24300158 ID - info:doi/10.2196/jmir.2628 ER - TY - JOUR AU - Heyworth, Leonie AU - Clark, Justice AU - Marcello, B. Thomas AU - Paquin, M. Allison AU - Stewart, Max AU - Archambeault, Cliona AU - Simon, R. Steven PY - 2013/12/02 TI - Aligning Medication Reconciliation and Secure Messaging: Qualitative Study of Primary Care Providers? Perspectives JO - J Med Internet Res SP - e264 VL - 15 IS - 12 KW - medication reconciliation KW - secure messaging KW - secure email, primary care KW - provider experiences KW - health information technology (HIT) N2 - Background: Virtual (non-face-to-face) medication reconciliation strategies may reduce adverse drug events (ADEs) among vulnerable ambulatory patients. Understanding provider perspectives on the use of technology for medication reconciliation can inform the design of patient-centered solutions to improve ambulatory medication safety. Objective: The aim of the study was to describe primary care providers? experiences of ambulatory medication reconciliation and secure messaging (secure email between patients and providers), and to elicit perceptions of a virtual medication reconciliation system using secure messaging (SM). Methods: This was a qualitative study using semi-structured interviews. From January 2012 to May 2012, we conducted structured observations of primary care clinical activities and interviewed 15 primary care providers within a Veterans Affairs Healthcare System in Boston, Massachusetts (USA). We carried out content analysis informed by the grounded theory. Results: Of the 15 participating providers, 12 were female and 11 saw 10 or fewer patients in a typical workday. Experiences and perceptions elicited from providers during in-depth interviews were organized into 12 overarching themes: 4 themes for experiences with medication reconciliation, 3 themes for perceptions on how to improve ambulatory medication reconciliation, and 5 themes for experiences with SM. Providers generally recognized medication reconciliation as a valuable component of primary care delivery and all agreed that medication reconciliation following hospital discharge is a key priority. Most providers favored delegating the responsibility for medication reconciliation to another member of the staff, such as a nurse or a pharmacist. The 4 themes related to ambulatory medication reconciliation were (1) the approach to complex patients, (2) the effectiveness of medication reconciliation in preventing ADEs, (3) challenges to completing medication reconciliation, and (4) medication reconciliation during transitions of care. Specifically, providers emphasized the importance of medication reconciliation at the post-hospital visit. Providers indicated that assistance from a caregiver (eg, a family member) for medication reconciliation was helpful for complex or elderly patients and that patients? social or cognitive factors often made medication reconciliation challenging. Regarding providers? use of SM, about half reported using SM frequently, but all felt that it improved their clinical workflow and nearly all providers were enthusiastic about a virtual medication reconciliation system, such as one using SM. All providers thought that such a system could reduce ADEs. Conclusions: Although providers recognize the importance and value of ambulatory medication reconciliation, various factors make it difficult to execute this task effectively, particularly among complex or elderly patients and patients with complicated social circumstances. Many providers favor enlisting the support of pharmacists or nurses to perform medication reconciliation in the outpatient setting. In general, providers are enthusiastic about the prospect of using secure messaging for medication reconciliation, particularly during transitions of care, and believe a system of virtual medication reconciliation could reduce ADEs. UR - http://www.jmir.org/2013/12/e264/ UR - http://dx.doi.org/10.2196/jmir.2793 UR - http://www.ncbi.nlm.nih.gov/pubmed/24297865 ID - info:doi/10.2196/jmir.2793 ER - TY - JOUR AU - Nicholas, Angela AU - Bailey, V. Julia AU - Stevenson, Fiona AU - Murray, Elizabeth PY - 2013/12/12 TI - The Sexunzipped Trial: Young People?s Views of Participating in an Online Randomized Controlled Trial JO - J Med Internet Res SP - e276 VL - 15 IS - 12 KW - Internet KW - randomized controlled trials KW - qualitative research KW - outcome assessment (health care) KW - sexual health KW - chlamydia trachomatis N2 - Background: Incidence of sexually transmitted infections (STIs) among young people in the United Kingdom is increasing. The Internet can be a suitable medium for delivery of sexual health information and sexual health promotion, given its high usage among young people, its potential for creating a sense of anonymity, and ease of access. Online randomized controlled trials (RCTs) are increasingly being used to evaluate online interventions, but while there are many advantages to online methodologies, they can be associated with a number of problems, including poor engagement with online interventions, poor trial retention, and concerns about the validity of data collected through self-report online. We conducted an online feasibility trial that tested the effects of the Sexunzipped website for sexual health compared to an information-only website. This study reports on a qualitative evaluation of the trial procedures, describing participants? experiences and views of the Sexunzipped online trial including methods of recruitment, incentives, methods of contact, and sexual health outcome measurement. Objective: Our goal was to determine participants? views of the acceptability and validity of the online trial methodology used in the pilot RCT of the Sexunzipped intervention. Methods: We used three qualitative data sources to assess the acceptability and validity of the online pilot RCT methodology: (1) individual interviews with 22 participants from the pilot RCT, (2) 133 emails received by the trial coordinator from trial participants, and (3) 217 free-text comments from the baseline and follow-up questionnaires. Interviews were audio-recorded and transcribed verbatim. An iterative, thematic analysis of all three data sources was conducted to identify common themes related to the acceptability and feasibility of the online trial methodology. Results: Interview participants found the trial design, including online recruitment via Facebook, online registration, email communication with the researchers, and online completion of sexual health questionnaires to be highly acceptable and preferable to traditional methods. Incentives might assist in recruiting those who would not otherwise participate. Participants generally enjoyed taking part in sexual health research online and found the questionnaire itself thought-provoking. Completing the sexual health questionnaires online encouraged honesty in responding that might not be achieved with other methods. The majority of interview participants also thought that receiving and returning a urine sample for chlamydia testing via post was acceptable. Conclusions: These findings provide strong support for the use of online research methods for sexual health research, emphasizing the importance of careful planning and execution of all trial procedures including recruitment, respondent validation, trial related communication, and methods to maximize follow-up. Our findings suggest that sexual health outcome measurement might encourage reflection on current behavior, sometimes leading to behavior change. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 55651027; http://www.controlled-trials.com/isrctn/pf/55651027 (Archived by WebCite at http://www.webcitation.org/6LbkxdPKf). UR - http://www.jmir.org/2013/12/e276/ UR - http://dx.doi.org/10.2196/jmir.2647 UR - http://www.ncbi.nlm.nih.gov/pubmed/24334198 ID - info:doi/10.2196/jmir.2647 ER - TY - JOUR AU - Burns, Nicole Michelle AU - Montague, Enid AU - Mohr, C. David PY - 2013/12/05 TI - Initial Design of Culturally Informed Behavioral Intervention Technologies: Developing an mHealth Intervention for Young Sexual Minority Men With Generalized Anxiety Disorder and Major Depression JO - J Med Internet Res SP - e271 VL - 15 IS - 12 KW - mobile health KW - eHealth KW - cultural competency KW - minority health KW - male homosexuality KW - male adolescents KW - young adult KW - anxiety KW - depression N2 - Background: To our knowledge, there is no well-articulated process for the design of culturally informed behavioral intervention technologies. Objective: This paper describes the early stages of such a process, illustrated by the methodology for the ongoing development of a behavioral intervention technology targeting generalized anxiety disorder and major depression among young sexual minority men. Methods: We integrated instructional design for Internet behavioral intervention technologies with greater detail on information sources that can identify user needs in understudied populations, as well as advances in the understanding of technology-specific behavioral intervention technology dimensions that may need to be culturally tailored. Results: General psychological theory describing how to effect change in the clinical target is first integrated with theory describing potentially malleable factors that help explain the clinical problem within the population. Additional information sources are then used to (1) evaluate the theory, (2) identify population-specific factors that may affect users? ability to relate to and benefit from the behavioral intervention technology, and (3) establish specific skills, attitudes, knowledge, etc, required to change malleable factors posited in the theory. User needs result from synthesis of this information. Product requirements are then generated through application of the user needs to specific behavioral intervention technology dimensions (eg, technology platform). We provide examples of considerations relevant to each stage of this process and how they were applied. Conclusions: This process can guide the initial design of other culturally informed behavioral intervention technologies. This first attempt to create a systematic design process can spur development of guidelines for design of behavioral intervention technologies aimed to reduce health disparities. UR - http://www.jmir.org/2013/12/e271/ UR - http://dx.doi.org/10.2196/jmir.2826 UR - http://www.ncbi.nlm.nih.gov/pubmed/24311444 ID - info:doi/10.2196/jmir.2826 ER - TY - JOUR AU - Månsson, NT Kristoffer AU - Skagius Ruiz, Erica AU - Gervind, Elisabet AU - Dahlin, Mats AU - Andersson, Gerhard PY - 2013/12/10 TI - Development and Initial Evaluation of an Internet-Based Support System for Face-to-Face Cognitive Behavior Therapy: A Proof of Concept Study JO - J Med Internet Res SP - e280 VL - 15 IS - 12 KW - cognitive behavior therapy KW - Internet KW - anxiety KW - depression KW - Apple iPad N2 - Background: Evidence-based psychological treatments, such as cognitive behavior therapy (CBT), have been found to be effective in treating several anxiety and mood disorders. Nevertheless, issues regarding adherence are common, such as poor patient compliance on homework assignments and therapists? drifting from strictly evidence-based CBT. The development of Internet-delivered CBT (ICBT) has been intensive in the past decade and results show that guided ICBT can be as effective as face-to-face CBT but also indicate a need to integrate the two forms of CBT delivery. Objective: In this study, we developed and tested a new treatment format in which ICBT and face-to-face therapy were blended. We designed a support system accessible via the Internet (using a computer or an Apple iPad) for patients and therapists delivering CBT face-to-face. The support system included basic CBT components and a library of interventions gathered from existing ICBT manuals. Methods: The study involved 15 patients with mild to moderate anxiety or depression (or both). Eight therapists conducted the treatments. All participants were interviewed after the nine-week intervention. Further, patients provided self-reports on clinical measures pre- and post-trial, as well as at a 12-month follow-up. Results: A reduction was found in symptom scores across all measures. The reliable change index ranged from 60% to 87% for depression and anxiety. Large effect sizes (Cohen?s d) ranging from 1.62 (CI 95% 0.59-2.66) to 2.43 (CI 95% 1.12-3.74) were found. There were no missing data and no treatment dropouts. In addition, the results had been maintained at the 12-month follow-up. Qualitative interviews revealed that the users perceived the support system as beneficial. Conclusions: The results suggest that modern information technology can effectively blend with face-to-face treatments and be used to facilitate communication and structure in therapy, thus reducing therapist drift. UR - http://www.jmir.org/2013/12/e280/ UR - http://dx.doi.org/10.2196/jmir.3031 UR - http://www.ncbi.nlm.nih.gov/pubmed/24326065 ID - info:doi/10.2196/jmir.3031 ER - TY - JOUR AU - Albrecht, Urs-Vito PY - 2013/12/30 TI - Transparency of Health-Apps for Trust and Decision Making JO - J Med Internet Res SP - e277 VL - 15 IS - 12 KW - smartphone KW - technology KW - education KW - medicine KW - app KW - health care KW - Android KW - iPhone KW - BlackBerry KW - Windows Phone KW - mobile phone KW - standards UR - http://www.jmir.org/2013/12/e277/ UR - http://dx.doi.org/10.2196/jmir.2981 UR - http://www.ncbi.nlm.nih.gov/pubmed/24449711 ID - info:doi/10.2196/jmir.2981 ER -