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JMIR mHealth and uHealth

Mobile and tablet apps, ubiquitous and pervasive computing, wearable computing and domotics for health.


Journal Description

JMIR mHealth and uHealth (JMU, ISSN 2291-5222) is a sister journal of JMIR, the leading eHealth journal. JMIR mHealth and uHealth is indexed in PubMed, PubMed Central, and Science Citation Index Expanded (SCIE), and in June 2017 received an impressive inaugural Impact Factor of 4.636, which ranks the journal #2 (behind JMIR) out of over 20 journals in the medical informatics category indexed by the Science Citation Index Expanded (SCIE) by Thomson Reuters/Clarivate

The journal focusses on health and biomedical applications in mobile and tablet computing, pervasive and ubiquitous computing, wearable computing and domotics.

JMIR mHealth and uHealth publishes since 2013 and was the first mhealth journal in Pubmed. It publishes even faster and has a broader scope with including papers which are more technical or more formative/developmental than what would be published in the Journal of Medical Internet Research

JMIR mHealth and uHealth features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs.

JMIR mHealth and uHealth adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics.


Recent Articles:

  • Source: Freepik; Copyright: Freepik; URL:; License: Licensed by JMIR.

    Evaluating the Impact of Physical Activity Apps and Wearables: Interdisciplinary Review


    Background: Although many smartphone apps and wearables have been designed to improve physical activity, their rapidly evolving nature and complexity present challenges for evaluating their impact. Traditional methodologies, such as randomized controlled trials (RCTs), can be slow. To keep pace with rapid technological development, evaluations of mobile health technologies must be efficient. Rapid alternative research designs have been proposed, and efficient in-app data collection methods, including in-device sensors and device-generated logs, are available. Along with effectiveness, it is important to measure engagement (ie, users’ interaction and usage behavior) and acceptability (ie, users’ subjective perceptions and experiences) to help explain how and why apps and wearables work. Objectives: This study aimed to (1) explore the extent to which evaluations of physical activity apps and wearables: employ rapid research designs; assess engagement, acceptability, as well as effectiveness; use efficient data collection methods; and (2) describe which dimensions of engagement and acceptability are assessed. Method: An interdisciplinary scoping review using 8 databases from health and computing sciences. Included studies measured physical activity, and evaluated physical activity apps or wearables that provided sensor-based feedback. Results were analyzed using descriptive numerical summaries, chi-square testing, and qualitative thematic analysis. Results: A total of 1829 abstracts were screened, and 858 articles read in full. Of 111 included studies, 61 (55.0%) were published between 2015 and 2017. Most (55.0%, 61/111) were RCTs, and only 2 studies (1.8%) used rapid research designs: 1 single-case design and 1 multiphase optimization strategy. Other research designs included 23 (22.5%) repeated measures designs, 11 (9.9%) nonrandomized group designs, 10 (9.0%) case studies, and 4 (3.6%) observational studies. Less than one-third of the studies (32.0%, 35/111) investigated effectiveness, engagement, and acceptability together. To measure physical activity, most studies (90.1%, 101/111) employed sensors (either in-device [67.6%, 75/111] or external [23.4%, 26/111]). RCTs were more likely to employ external sensors (accelerometers: P=.005). Studies that assessed engagement (52.3%, 58/111) mostly used device-generated logs (91%, 53/58) to measure the frequency, depth, and length of engagement. Studies that assessed acceptability (57.7%, 64/111) most often used questionnaires (64%, 42/64) and/or qualitative methods (53%, 34/64) to explore appreciation, perceived effectiveness and usefulness, satisfaction, intention to continue use, and social acceptability. Some studies (14.4%, 16/111) assessed dimensions more closely related to usability (ie, burden of sensor wear and use, interface complexity, and perceived technical performance). Conclusions: The rapid increase of research into the impact of physical activity apps and wearables means that evaluation guidelines are urgently needed to promote efficiency through the use of rapid research designs, in-device sensors and user-logs to assess effectiveness, engagement, and acceptability. Screening articles was time-consuming because reporting across health and computing sciences lacked standardization. Reporting guidelines are therefore needed to facilitate the synthesis of evidence across disciplines.

  • The Carolinas Asthma Coach app (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Patient and Family Engagement in the Design of a Mobile Health Solution for Pediatric Asthma: Development and Feasibility Study


    Background: Asthma is a highly prevalent, chronic disease with significant morbidity, cost, and disparities in health outcomes. While adherence to asthma treatment guidelines can improve symptoms and decrease exacerbations, most patients receive care that is not guideline-based. New approaches that incorporate shared decision-making (SDM) and health information technology (IT) are needed to positively impact asthma management. Despite the promise of health IT to improve efficiency and outcomes in health care, new IT solutions frequently suffer from a lack of widespread adoption and do not achieve desired results, as a consequence of not involving end-users in design. Objective: To describe a case study of a pediatric asthma SDM health IT solution’s development and demonstrate a methodology for engaging actual patients and families in IT development. Perspectives are shared from the vantage point of the research team and a parent of a child with asthma, who participated on the development team. Methods: We adapted user-centric design principles to engage actual users across three main development phases: project initiation, ideation, and usability testing. To facilitate the necessary level of user engagement, our approach included: (1) a Development Workgroup consisting of patients, caregivers, and providers who met regularly with the research team; and (2) “real-world users” consisting of patients, caregivers, and providers recruited from a variety of care locations, including safety-net clinics. Results: Using this methodology, we successful partnered with asthma patients and families to create an interactive, digital solution called Carolinas Asthma Coach. Carolinas Asthma Coach incorporates SDM principles to elicit patient information, including goals and preferences, and provides health-literate, tailored education with specific guideline-based recommendations for patients and their providers. Of the patients, caregivers, and providers surveyed, 100% (n=60) said they would recommend Carolinas Asthma Coach to a friend or colleague. Qualitative feedback from users provided support for the usability and engaging nature of the app. Conclusions: This project demonstrates the feasibility and benefits of deploying user-centric design methods that engage real patients and caregivers throughout the health IT design process.

  • Use of BEDSide Mobility at patient's bedside. Source: Image created by the authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    A Mobile App (BEDSide Mobility) to Support Nurses’ Tasks at the Patient's Bedside: Usability Study


    Background: The introduction of clinical information systems has increased the amount of clinical documentation. Although this documentation generally improves patient safety, it has become a time-consuming task for nurses, which limits their time with the patient. On the basis of a user-centered methodology, we have developed a mobile app named BEDSide Mobility to support nurses in their daily workflow and to facilitate documentation at the bedside. Objective: The aim of the study was to assess the usability of the BEDSide Mobility app in terms of the navigation and interaction design through usability testing. Methods: Nurses were asked to complete a scenario reflecting their daily work with patients. Their interactions with the app were captured with eye-tracking glasses and by using the think aloud protocol. After completing the tasks, participants filled out the system usability scale questionnaire. Descriptive statistics were used to summarize task completion rates and the users’ performance. Results: A total of 10 nurses (aged 21-50) participated in the study. Overall, they were satisfied with the navigation, layout, and interaction design of the app, with the exception of one user who was unfamiliar with smartphones. The problems identified were related to the ambiguity of some icons, the navigation logic, and design inconsistency. Conclusions: Besides the usability issues identified in the app, the participants’ results do indicate good usability, high acceptance, and high satisfaction with the developed app. However, the results must be taken with caution because of the poor ecological validity of the experimental setting.

  • Source:; Copyright: Amanda Mills; URL:; License: Public Domain (CC0).

    Quality of Publicly Available Physical Activity Apps: Review and Content Analysis


    Background: Within the new digital health landscape, the rise of health apps creates novel prospects for health promotion. The market is saturated with apps that aim to increase physical activity (PA). Despite the wide distribution and popularity of PA apps, there are limited data on their effectiveness, user experience, and safety of personal data. Objective: The purpose of this review and content analysis was to evaluate the quality of the most popular PA apps on the market using health care quality indicators. Methods: The top-ranked 400 free and paid apps from iTunes and Google Play stores were screened. Apps were included if the primary behavior targeted was PA, targeted users were adults, and the apps had stand-alone functionality. The apps were downloaded on mobile phones and assessed by 2 reviewers against the following quality assessment criteria: (1) users’ data privacy and security, (2) presence of behavior change techniques (BCTs) and quality of the development and evaluation processes, and (3) user ratings and usability. Results: Out of 400 apps, 156 met the inclusion criteria, of which 65 apps were randomly selected to be downloaded and assessed. Almost 30% apps (19/65) did not have privacy policy. Every app contained at least one BCT, with an average number of 7 and a maximum of 13 BCTs. All but one app had commercial affiliation, 12 consulted an expert, and none reported involving users in the app development. Only 12 of 65 apps had a peer-reviewed study connected to the app. User ratings were high, with only a quarter of the ratings falling below 4 stars. The median usability score was excellent—86.3 out of 100. Conclusions: Despite the popularity of PA apps available on the commercial market, there were substantial shortcomings in the areas of data safety and likelihood of effectiveness of the apps assessed. The limited quality of the apps may represent a missed opportunity for PA promotion.

  • GDm-health app. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Comparing the Efficacy of a Mobile Phone-Based Blood Glucose Management System With Standard Clinic Care in Women With Gestational Diabetes: Randomized...


    Background: Treatment of hyperglycemia in women with gestational diabetes mellitus (GDM) is associated with improved maternal and neonatal outcomes and requires intensive clinical input. This is currently achieved by hospital clinic attendance every 2 to 4 weeks with limited opportunity for intervention between these visits. Objective: We conducted a randomized controlled trial to determine whether the use of a mobile phone-based real-time blood glucose management system to manage women with GDM remotely was as effective in controlling blood glucose as standard care through clinic attendance. Methods: Women with an abnormal oral glucose tolerance test before 34 completed weeks of gestation were individually randomized to a mobile phone-based blood glucose management solution (GDm-health, the intervention) or routine clinic care. The primary outcome was change in mean blood glucose in each group from recruitment to delivery, calculated with adjustments made for number of blood glucose measurements, proportion of preprandial and postprandial readings, baseline characteristics, and length of time in the study. Results: A total of 203 women were randomized. Blood glucose data were available for 98 intervention and 85 control women. There was no significant difference in rate of change of blood glucose (–0.16 mmol/L in the intervention and –0.14 mmol/L in the control group per 28 days, P=.78). Women using the intervention had higher satisfaction with care (P=.049). Preterm birth was less common in the intervention group (5/101, 5.0% vs 13/102, 12.7%; OR 0.36, 95% CI 0.12-1.01). There were fewer cesarean deliveries compared with vaginal deliveries in the intervention group (27/101, 26.7% vs 47/102, 46.1%, P=.005). Other glycemic, maternal, and neonatal outcomes were similar in both groups. The median time from recruitment to delivery was similar (intervention: 54 days; control: 49 days; P=.23). However, there were significantly more blood glucose readings in the intervention group (mean 3.80 [SD 1.80] and mean 2.63 [SD 1.71] readings per day in the intervention and control groups, respectively; P<.001). There was no significant difference in direct health care costs between the two groups, with a mean cost difference of the intervention group compared to control of –£1044 (95% CI –£2186 to £99). There were no unexpected adverse outcomes. Conclusions: Remote blood glucocse monitoring in women with GDM is safe. We demonstrated superior data capture using GDm-health. Although glycemic control and maternal and neonatal outcomes were similar, women preferred this model of care. Further studies are required to explore whether digital health solutions can promote desired self-management lifestyle behaviors and dietetic adherence, and influence maternal and neonatal outcomes. Digital blood glucose monitoring may provide a scalable, practical method to address the growing burden of GDM around the world. Trial Registration: NCT01916694; (Archived by WebCite at

  • An mHealth intervention for improving cancer pain management. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An mHealth Pain Coping Skills Training Intervention for Hematopoietic Stem Cell Transplantation Patients: Development and Pilot Randomized Controlled Trial


    Background: Pain is a challenge for patients following hematopoietic stem cell transplantation (HCT). Objective: This study aimed to develop and test the feasibility, acceptability, and initial efficacy of a Web-based mobile pain coping skills training (mPCST) protocol designed to address the needs of HCT patients. Methods: Participants had undergone HCT and reported pain following transplant (N=68). To guide intervention development, qualitative data were collected from focus group participants (n=25) and participants who completed user testing (n=7). After their input was integrated into the mPCST intervention, a pilot randomized controlled trial (RCT, n=36) was conducted to examine the feasibility, acceptability, and initial efficacy of the intervention. Measures of acceptability, pain severity, pain disability, pain self-efficacy, fatigue, and physical disability (self-report and 2-min walk test [2MWT]) were collected. Results: Participants in the focus groups and user testing provided qualitative data that were used to iteratively refine the mPCST protocol. Focus group qualitative data included participants’ experiences with pain following transplant, perspectives on ways to cope with pain, and suggestions for pain management for other HCT patients. User testing participants provided feedback on the HCT protocol and information on the use of videoconferencing. The final version of the mPCST intervention was designed to bridge the intensive outpatient (1 in-person session) and home settings (5 videoconferencing sessions). A key component of the intervention was a website that provided personalized messages based on daily assessments of pain and activity. The website also provided intervention materials (ie, electronic handouts, short videos, and audio files). The intervention content included pain coping advice from other transplant patients and instructions on how to apply pain coping skills while engaging in meaningful and leisure activities. In the RCT phase of this research, HCT patients (n=36) were randomized to receive the mPCST intervention or to proceed with the treatment as usual. Results revealed that the mPCST participants completed an average of 5 out of 6 sessions. The participants reported that the intervention was highly acceptable (mean 3/4), and they found the sessions to be helpful (mean 8/10) and easy to understand (mean 7/7). The mPCST participants demonstrated significant improvements in pre- to post-treatment pain, self-efficacy (P=.03, d=0.61), and on the 2MWT (P=.03, d=0.66), whereas the patients in the treatment-as-usual group did not report any such improvements. Significant changes in pain disability and fatigue were found in both groups (multiple P<.02); the magnitudes of the effect sizes were larger for the mPCST group than for the control group (pain disability: d=0.79 vs 0.69; fatigue: d=0.94 vs 0.81). There were no significant changes in pain severity in either group. Conclusions: Using focus groups and user testing, we developed an mPCST protocol that was feasible, acceptable, and beneficial for HCT patients with pain. Trial Registration: NCT01984671; (Archived by WebCite at

  • Source: Pixabay; Copyright: Michal Jarmoluk; URL:; License: Public Domain (CC0).

    Medication Adherence Apps: Review and Content Analysis


    Background: Medication adherence is an expensive and damaging problem for patients and health care providers. Patients adhere to only 50% of drugs prescribed for chronic diseases in developed nations. Digital health has paved the way for innovative smartphone solutions to tackle this challenge. However, despite numerous apps available claiming to improve adherence, a thorough review of adherence apps has not been carried out to date. Objective: The aims of this study were to (1) review medication adherence apps available in app repositories in terms of their evidence base, medical professional involvement in development, and strategies used to facilitate behavior change and improve adherence and (2) provide a system of classification for these apps. Methods: In April 2015, relevant medication adherence apps were identified by searching the Apple App Store and the Google Play Store using a combination of relevant search terms. Data extracted included app store source, app price, documentation of health care professional (HCP) involvement during app development, and evidence base for each respective app. Free apps were downloaded to explore the strategies used to promote medication adherence. Testing involved a standardized medication regimen of three reminders over a 4-hour period. Nonadherence features designed to enhance user experience were also documented. Results: The app repository search identified a total of 5881 apps. Of these, 805 fulfilled the inclusion criteria initially and were tested. Furthermore, 681 apps were further analyzed for data extraction. Of these, 420 apps were free for testing, 58 were inaccessible and 203 required payment. Of the 420 free apps, 57 apps were developed with HCP involvement and an evidence base was identified in only 4 apps. Of the paid apps, 9 apps had HCP involvement, 1 app had a documented evidence base, and 1 app had both. In addition, 18 inaccessible apps were produced with HCP involvement, whereas 2 apps had a documented evidence base. The 420 free apps were further analyzed to identify strategies used to improve medication adherence. This identified three broad categories of adherence strategies, reminder, behavioral, and educational. A total of 250 apps utilized a single method, 149 apps used two methods, and only 22 apps utilized all three methods. Conclusions: To our knowledge, this is the first study to systematically review all available medication adherence apps on the two largest app repositories. The results demonstrate a concerning lack of HCP involvement in app development and evidence base of effectiveness. More collaboration is required between relevant stakeholders to ensure development of high quality and relevant adherence apps with well-powered and robust clinical trials investigating the effectiveness of these interventions. A sound evidence base will encourage the adoption of effective adherence apps, and thus improve patient welfare in the process.

  • Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Self-Directed Engagement with a Mobile App (Sinasprite) and Its Effects on Confidence in Coping Skills, Depression, and Anxiety: Retrospective Longitudinal...


    Background: Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety. Objective: The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety. Methods: This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann–Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed using Wilcoxon signed-rank test. A mixed-effects repeated-measures linear regression model assessed the main effects of time, concomitant counseling, and psychotropic prescription medication use on mental health status. Results: Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (P<.001), GAD-7 (P=.002), and CSE (P<.001) questionnaire scores. A strong positive correlation between improvement in the GAD-7 and CSE questionnaire scores (ρ=.572, P=.001, n=28) was observed. The mixed-effects repeated-measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (P<.001), GAD-7 (P=.007), and CSE (P=.001). Conclusions: This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.

  • Source: rawpixel; Copyright: rawpixel; URL:; License: Licensed by JMIR.

    Exploring Digital Health Use and Opinions of University Students: Field Survey Study


    Background: During university, students face some potentially serious health risks, and their lifestyle can have a direct effect on health and health behaviors later in life. Concurrently, university students are digital natives having easy access to the internet and new technologies. Digital health interventions offer promising new opportunities for health promotion, disease prevention, and care in this specific population. The description of the current use of and opinions on digital health among university students can inform future digital health strategies and interventions within university settings. Objective: The aim of this exploratory study was to report on university students’ use and opinions regarding information and communication technologies for health and well-being, taking into account sociodemographic and self-rated general and mental health correlates. Methods: This field survey was conducted from March to April 2017. An informed consent form and a paper questionnaire were given to students aged 18 to 24 years in 4 university campuses in Bordeaux, France. The survey was formulated in 3 sections: (1) sociodemographic characteristics and self-rated general and mental health, (2) information about the use of digital health, and (3) opinions about digital health. Data were analyzed using descriptive statistics and tests of independence. Results: A total of 59.8% (303/507 females) students completed the questionnaire. Concerning digital health use, 34.9% (174/498) had at least 1 health app mostly for physical activity (49.4%, 86/174) and general health monitoring (41.4%, 72/174,), but only 3.9% (20/507) of students had a wearable device. Almost all (94.8%, 450/476) had searched for Web-based health-related information at least once in the last 12 months. The most sought health-related topics were nutrition (68.1%, 324/476); pain and illnesses (64.5%, 307/476); and stress, anxiety, or depression (51.1%, 243/476). Although Wikipedia (79.7%, 357/448) and general health websites (349/448, 77.9%) were the most consulted sources, students considered institutional or official websites as the most credible sources (309/335, 92.2%). There were significant differences in digital health use by gender, field, and year of study. No statistically significant association was found between digital health use and self-rated general and mental health status. Concerning opinions on digital health, although 94.1% (475/505) of students estimated that today’s digital health cannot replace traditional health services and medical consultations, 44.6% (207/464) of students declared that this could be possible in the future, provided that digital health interventions are promoted by institutional or official entities. Conclusions: University students are largely using the internet for health information seeking, but using less mobile health apps and very few wearable devices. Our data suggest that digital health has the potential for improving health and well-being at the university, especially if digital health interventions take into account students’ profiles, interests, and needs.

  • Source: Pixabay; Copyright: LUM3N; URL:; License: Public Domain (CC0).

    Describing the Process of Adopting Nutrition and Fitness Apps: Behavior Stage Model Approach


    Background: Although mobile technologies such as smartphone apps are promising means for motivating people to adopt a healthier lifestyle (mHealth apps), previous studies have shown low adoption and continued use rates. Developing the means to address this issue requires further understanding of mHealth app nonusers and adoption processes. This study utilized a stage model approach based on the Precaution Adoption Process Model (PAPM), which proposes that people pass through qualitatively different motivational stages when adopting a behavior. Objective: To establish a better understanding of between-stage transitions during app adoption, this study aimed to investigate the adoption process of nutrition and fitness app usage, and the sociodemographic and behavioral characteristics and decision-making style preferences of people at different adoption stages. Methods: Participants (N=1236) were recruited onsite within the cohort study Konstanz Life Study. Use of mobile devices and nutrition and fitness apps, 5 behavior adoption stages of using nutrition and fitness apps, preference for intuition and deliberation in eating decision-making (E-PID), healthy eating style, sociodemographic variables, and body mass index (BMI) were assessed. Results: Analysis of the 5 behavior adoption stages showed that stage 1 (“unengaged”) was the most prevalent motivational stage for both nutrition and fitness app use, with half of the participants stating that they had never thought about using a nutrition app (52.41%, 533/1017), whereas less than one-third stated they had never thought about using a fitness app (29.25%, 301/1029). “Unengaged” nonusers (stage 1) showed a higher preference for an intuitive decision-making style when making eating decisions, whereas those who were already “acting” (stage 4) showed a greater preference for a deliberative decision-making style (F4,1012=21.83, P<.001). Furthermore, participants differed widely in their readiness to adopt nutrition and fitness apps, ranging from having “decided to” but not yet begun to act (stage 2; nutrition: 6.88%, 70/1017; fitness: 9.23%, 95/1029) to being “disengaged” following previous adoption (stage 5; nutrition: 13.77%, 140/1017; fitness: 15.06%, 155/1029). Conclusions: Using a behavior stage model approach to describe the process of adopting nutrition and fitness apps revealed motivational stage differences between nonusers (being “unengaged,” having “decided not to act,” having “decided to act,” and being “disengaged”), which might contribute to a better understanding of the process of adopting mHealth apps and thus inform the future development of digital interventions. This study highlights that new user groups might be better reached by apps designed to address a more intuitive decision-making style.

  • Effect view of the Sunface app. Source: Image created by the Authors; Copyright: Titus J Brinker; URL:; License: Creative Commons Attribution (CC-BY).

    A Skin Cancer Prevention Facial-Aging Mobile App for Secondary Schools in Brazil: Appearance-Focused Interventional Study


    Background: The incidence of melanoma is increasing faster than any other major cancer both in Brazil and worldwide. Southeast Brazil has especially high incidences of melanoma, and early detection is low. Exposure to ultraviolet (UV) radiation is a primary risk factor for developing melanoma. Increasing attractiveness is a major motivation among adolescents for tanning. A medical student-delivered intervention that takes advantage of the broad availability of mobile phones and adolescents’ interest in their appearance indicated effectiveness in a recent study from Germany. However, the effect in a high-UV index country with a high melanoma prevalence and the capability of medical students to implement such an intervention remain unknown. Objective: In this pilot study, our objective was to investigate the preliminary success and implementability of a photoaging intervention to prevent skin cancer in Brazilian adolescents. Methods: We implemented a free photoaging mobile phone app (Sunface) in 15 secondary school classes in southeast Brazil. Medical students “mirrored” the pupils’ altered 3-dimensional (3D) selfies reacting to touch on tablets via a projector in front of their whole grade accompanied by a brief discussion of means of UV protection. An anonymous questionnaire capturing sociodemographic data and risk factors for melanoma measured the perceptions of the intervention on 5-point Likert scales among 356 pupils of both sexes (13-19 years old; median age 16 years) in grades 8 to 12 of 2 secondary schools in Brazil. Results: We measured more than 90% agreement in both items that measured motivation to reduce UV exposure and only 5.6% disagreement: 322 (90.5%) agreed or strongly agreed that their 3D selfie motivated them to avoid using a tanning bed, and 321 (90.2%) that it motivated them to improve their sun protection; 20 pupils (5.6%) disagreed with both items. The perceived effect on motivation was higher in female pupils in both tanning bed avoidance (n=198, 92.6% agreement in females vs n=123, 87.2% agreement in males) and increased use of sun protection (n=197, 92.1% agreement in females vs n=123, 87.2% agreement in males) and independent of age or skin type. All medical students involved filled in a process evaluation revealing that they all perceived the intervention as effective and unproblematic, and that all pupils tried the app in their presence. Conclusions: The photoaging intervention was effective in changing behavioral predictors for UV protection in Brazilian adolescents. The predictors measured indicated an even higher prospective effectiveness in southeast Brazil than in Germany (>90% agreement in Brazil vs >60% agreement in Germany to both items that measured motivation to reduce UV exposure) in accordance with the theory of planned behavior. Medical students are capable of complete implementation. A randomized controlled trial measuring prospective effects in Brazil is planned as a result of this study.

  • Source: Shutterstock; Copyright: bokan; URL:; License: Licensed by the authors.

    Adolescents’ Perspectives on a Mobile App for Relationships: Cross-Sectional Survey


    Background: Adolescence can be a fertile time for relationship issues, with interpersonal conflict being a risk factor for poor mental health. Mobile app interventions may have a significant appeal to young people in assisting with relationship distress. However, currently available apps have not been formally evaluated. Youths’ perspectives on engaging with mobile technology to assist with relationships are also unknown. Objective: This study aimed to examine adolescents’ attitudes toward the concept of a mobile phone app for relationship help and support, and whether they would be likely to use such an intervention. Methods: A cross-sectional Web survey consisting of 42 questions, including 13 free responses, was delivered. The proposed app, including character vignettes, was presented, and participants were asked to indicate whether they had experienced the same relationship issues, whether their peers would relate to the issues, and how helpful they found the proposed advice. Participants were also asked to provide their own suggestions for help, which were analyzed using thematic analyses. Results: A total of 150 adolescents (aged 15 to 18) participated. Overall, 60.7% (91/150) were likely to use an app for relationship problems, and this was not associated with demographics or social support (all P values >.05). Likelihood of app usage was found to be influenced by perceived need for help, personal beliefs about app effectiveness, and whether the app is engaging and easy to use. Overall, adolescents were receptive of the proposed content with an average of 99.3% (149/150), rating the strategies provided as somewhat to very helpful. Conclusions: Adolescents were likely to use a mobile phone app for relationship support, and use was not influenced by gender, age, social support, or any other background characteristic. Instead, likely use was influenced by need, personal beliefs, usability, and the appropriateness of app content. App developers must address these factors if the app is to have a wide-scale uptake.

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  • Reflection of Digital Health Technologies in Epidemiology Journals over the Past Decade: A Bibliographic Analysis

    Date Submitted: Mar 22, 2018

    Open Peer Review Period: Mar 22, 2018 - May 17, 2018

    Background: Digital health – mobile health, health information technology, wearable devices, telehealth, and personalized medicine – is an advancing phenomenon in the healthcare systems of modern...

    Background: Digital health – mobile health, health information technology, wearable devices, telehealth, and personalized medicine – is an advancing phenomenon in the healthcare systems of modern societies. Epidemiology has provided frameworks to support studies which utilize, evaluate, focus on, or benefit from digital health technologies in their methodology. Objective: Our study systematically evaluates the articles published by major epidemiology journals, with focus on or utilization of digital health technologies, to quantify their trends and visibility. Methods: All 27 PubMed-indexed, epidemiology journals were searched between 2006 and 2016, to find articles in English, in which the authors focused on, utilized, or discussed at least one digital health technology in the design, methodology, or conduct of their study. Additionally, a bibliometric analysis was conducted using the freely-available, Profiles Research Networking Software by the Harvard Clinical and Translational Science Center. Results: Out of 58,251 articles published on or using digital health technologies, 368 articles (0.63%) were published by 24 epidemiology journals (307 articles [0.53%] in the past decade), with ten-year average citation per article of 3.44. More than two-third (210 articles; 68.4%) were published by five major epidemiology journals, mainly by Pharmacoepidemiol Drug Saf, with 98 published articles (31.9%). Conclusions: The reflection of different digital health technologies in epidemiology journals increased dramatically over the past decade and Pharmacoepidemiol Drug Saf was the leading major epidemiology journal in this endeavor. For improving the share of epidemiology journals in publishing literature around digital health technologies, more regular bibliographic and bibliometric analyses would be needed.

  • Photography-based mobile assessment of alcohol use in young adults: Feasibility and comparison to standard assessment methodology

    Date Submitted: Mar 22, 2018

    Open Peer Review Period: Mar 22, 2018 - May 17, 2018

    Background: Heavy alcohol use is prevalent among young adults and may contribute to obesity. However, measurement tools for assessing caloric intake from alcohol are limited and rely on self-report, w...

    Background: Heavy alcohol use is prevalent among young adults and may contribute to obesity. However, measurement tools for assessing caloric intake from alcohol are limited and rely on self-report, which is prone to biases. Objective: The purpose of the pilot study was to conduct feasibility testing of SmartIntake®, a photo-based smartphone app, to assess alcohol use among young adults. Aims consisted of 1) quantifying the ability of SmartIntake® to capture drinking behavior; 2) assessing app usability with the Computer System Usability Questionnaire (CSUQ); 3) conducting a qualitative interview; and 4) comparing preference, compliance, and alcohol use estimates (calories, grams per drinking episode) between SmartIntake® and online diet recalls that participants completed for a parent study. Methods: College students (N=15) who endorsed a pattern of heavy drinking were recruited from a larger study examining the impact of drinking on weight. Participants used SmartIntake® to send photographs of all alcohol and food intake over a three-day period, and then completed a follow up interview and the CSUQ. CSUQ items range from 1-7, with lower scores indicating greater usability. Total number of drinking occasions was determined by adding the number of drinking occasions captured by SmartIntake® plus the number of drinking occasions participants reported that they missed capturing. Compliance was defined by the number of days participants provided food/beverage photo data through the app, or the number of diet recalls completed. Results: The SmartIntake® app captured 13 of 15 (87%) drinking occasions. Participants rated the app as highly usable in the CSUQ (M= 2.28). Most participants (93%) preferred using SmartIntake® vs. recalls and compliance was significantly higher with SmartIntake® than recalls (93% vs 78%; P= .04). Alcohol grams and calories per drinking occasion were not significantly different between the two methods (P values range .25-.99); however triple the number of participants submitted alcohol reports with SmartIntake® compared to the diet recalls (SmartIntake® 9/15 vs recalls 3/15; P=.06). Conclusions: SmartIntake® was well accepted by college students who drink heavily and captured most drinking occasions. Participants had higher compliance with SmartIntake® compared to diet recalls and triple the number of participants reported alcohol use with SmartIntake®, suggesting this method may be well suited to assessing alcohol use in young adults.

  • Engagement in an mHealth intervention is associated with weight loss

    Date Submitted: Mar 22, 2018

    Open Peer Review Period: Mar 22, 2018 - May 17, 2018

    Background: Mobile health (mHealth) technology provides innovative ways to deliver weight loss interventions. Understanding how engagement in mHealth interventions relates to weight change may help de...

    Background: Mobile health (mHealth) technology provides innovative ways to deliver weight loss interventions. Understanding how engagement in mHealth interventions relates to weight change may help develop more effective intervention strategies. Objective: To examine 1) patterns of participant engagement overall and in key intervention features within the interventions of the Cell Phone Intervention For You (CITY) clinical trial, 2) associations of engagement with weight change, and 3) characteristics of participants that are related to engagement. Methods: The CITY trial tested two 24-month behavioral weight loss interventions. One was delivered with a smartphone application (app) (Cell Phone; CP) that contained 24 features (weighing, tracking of diets, etc.) and included regular prompting by the app in pre-determined frequency and forms. The other intervention was delivered by a coach via monthly phone calls (Personal Coaching; PC) supplemented with limited app features (18 total) and without any prompting by the app. Engagement was assessed by calculating the percentage of days each app feature was used and the frequency of usage. Engagement was also examined across four weight change categories: gained (≥2%), stable (±2%), mild loss (≥2% to <5%), and greater loss (≥5%). Results: Data from 122 CP and 120 PC participants were analyzed. Usage of the app features was highest during month 1 for both groups; thereafter, usage dropped substantially and continuously until the end of the study. During the first six months, mean percentage of days any app feature was used was higher for the CP (74.2%, standard deviation [SD], 20.1) than for the PC group (48.9%, SD, 22.4). The CP group used the app features an average of 5.3 times/day [SD, 3.1], while the PC used them 1.7 times/day [SD, 1.2]. Similarly, when the self-weighing feature was examined alone, CP self-weighed more than PC (57.1% days [SD, 23.7] vs. 32.9% [23.3]). Further, percentage of days any app feature was used, number of app usages/day and percentage of days self-weighed all showed significant differences across the four weight categories for both CP and PC. Pearson correlation coefficients showed a negative linear association between weight change and percentage of days any app feature was used (CP: r=-0.213; PC: r=-0.319), number of app usages/day (CP:r=-0.264; PC:r=-0.308), and percentage of days self-weighed (CP:r=-0.297; PC:r=-0.354). Conclusions: Engagement in CITY intervention was associated with weight loss during the first six months. Nevertheless, engagement dropped substantially early on for most intervention features. Prompting may be helpful initially. More flexible and less-intrusive prompting strategies may be needed during different stages of an intervention to increase or sustain engagement. Future studies should explore the motivations for engagement and non-engagement in order to design effective intervention. Clinical Trial: NCT01092364

  • A systematic review to determine the existence, composition and quality of publically available smartphone apps about crystal methamphetamine (‘ice’)

    Date Submitted: Mar 19, 2018

    Open Peer Review Period: Mar 20, 2018 - May 15, 2018

    Background: Amid considerable community concern about prevalence and harms associated with crystal methamphetamine use, increased use of smartphones to access health information and a growing number o...

    Background: Amid considerable community concern about prevalence and harms associated with crystal methamphetamine use, increased use of smartphones to access health information and a growing number of available smartphone applications (‘apps’) related to crystal methamphetamine (ice), no previous reviews have examined content and quality of these apps. Objective: This present study aimed to systematically review existing apps in the iTunes and Google Play Stores to determine the existence, composition and quality of educational smartphone apps about methamphetamines, including ice. Methods: The iTunes and Google Play Stores were systematically searched in April 2017 for iOS Apple and Android apps, respectively. English-language apps that provided educational content or information about methamphetamine were eligible for inclusion. Eligible apps were downloaded and independently evaluated for quality by two reviewers using the Mobile Application Rating Scale (MARS). Results: A total of 2205 apps were initially identified, of which 18 were eligible and rated using the MARS. The mean MARS quality total score for all rated apps was 3.0 (SD = 0.6) indicating poor to acceptable quality. Overall mean scores were highest for functionality (x ̅=4.0; SD=0.5) and lowest for engagement (x ̅=2.3, SD=0.7). Conclusions: The present study demonstrated a shortage of high-quality educational and engaging smartphone apps specifically related to methamphetamine. The findings from this review highlight a need for further development of engaging and evidence-based apps that provide educational information about crystal methamphetamine.

  • Utility and Usability Testing of A Mobile Web-App (ScreenMen) to Improve Health Screening Uptake in Men

    Date Submitted: Mar 19, 2018

    Open Peer Review Period: Mar 19, 2018 - May 14, 2018

    Background: ScreenMen, a mobile web-app which aimed to improve health screening uptake in men was developed based on theories, evidence and needs. Objective: This study aimed to evaluate ScreenMen for...

    Background: ScreenMen, a mobile web-app which aimed to improve health screening uptake in men was developed based on theories, evidence and needs. Objective: This study aimed to evaluate ScreenMen for its utility and usability with men from the community. Methods: This study used a mixed-method approach. Healthy men who are working in a banking institution were recruited to participant in this study. They were purposively sampled according to job position, age, education level and screening status. Men were asked to use ScreenMen independently while the screen activities are being recorded. Once completed, retrospective think aloud with playback was conducted with men to obtain their feedback. They were asked to answer the System Usability Scale. Intention to undergo screening pre- and post- intervention were also measured. Qualitative data were analysed using a framework approach and followed by thematic analysis. For quantitative data obtained, the mean SUS score and change in intention to screening were calculated and analyses using McNemar test. Results: Twenty-four men participated in this study. Based on the qualitative data, men found ScreenMen useful as they could learn more about their health risks and screening. They found ScreenMen convenient to use and might trigger men to undergo screening. In terms of usability, men thought that ScreenMen was user-friendly and easy to understand. The key revision done on utility was the addition of a reminder function while for usability, the revisions done were in terms of attracting and gaining users trust; improving learnability; and making ScreenMen usable to all types of users. To attract men to use it, ScreenMen was introduced to users in terms of ‘improving health’ instead of ‘going for screening’. Another important revision made was emphasising the screening tests the users do not need instead of just informing them the screening tests they need. A ‘Quick Assessment Mode’ was also added for users with limited attention span. The quantitative data showed that eight (34.8%) out of 23 men planned to attend screening earlier than intended after using the ScreenMen. Out of 12 men who were in pre-contemplation stage, 4 (33.3%) changed to either contemplation or preparation stage after using ScreenMen. In terms of usability, the SUS score of 76.4 indicated that ScreenMen had good usability. Conclusions: This study showed that ScreenMen was acceptable to men in terms of its utility and usability. The preliminary data suggested that ScreenMen might increase men’s intention to undergo screening. This paper also presented key lessons learnt from the beta testing, which would useful for public health experts and researchers when developing a user-centered mobile web-app. Clinical Trial: Not applicable

  • Implementing systematically collected user feedback to increase user retention in a mobile app for self-management of low back pain: A retrospective cohort study

    Date Submitted: Mar 15, 2018

    Open Peer Review Period: Mar 16, 2018 - Mar 28, 2018

    Background: Promising first results for Kaia, a mobile app digitalizing multidisciplinary rehabilitation for low back pain, were recently published. It remained unclear, whether the implementation of...

    Background: Promising first results for Kaia, a mobile app digitalizing multidisciplinary rehabilitation for low back pain, were recently published. It remained unclear, whether the implementation of user feedback in an updated version of this app led to desired effects in terms of increased app usage and clinical outcomes. Objective: To elucidate the effect on user retention and clinical outcomes of an updated version of the Kaia app where user feedback was included during development. Methods: User feedback of the initial app versions (0.x) was collected in a quality management system and systematically analyzed to define requirements of a new version. For the current study, the anonymized data of Kaia users was retrospectively analyzed and users subgrouped depending on the available version at the time of the signup (0.x vs.. 1.x). The effect on the duration of activity of users in the app, the number of completed exercises of each type of exercise and user reported pain levels were compared. Results: Overall, data of 1251 users fulfilled the inclusion criteria, of which 196 users signed up using version 0.x and 1055 users signed with version 1.x. There were significant differences in the demographic parameters for both groups. A log rank test showed no significant differences for the duration of activity in the app between groups (p= 0,307). Users signing up during availability of the 1.x version completed significantly more exercises of each type in the app (physical exercises 0.x 1.99 +/- 1.61 units/week vs. 1.x 3.15 +/-1.72 units/week; p<0.001; mindfulness exercises 0.x 1.36 +/-1.43 units/week vs. 1.x 2.42 +/- 1.82 units/week; p<0.001; educational content 0.x 1.51 +/- 1.42 units/week vs. 1.x 2.71 +/- 1.89 units/week; p<0.001). This translated into a stronger decrease in user-reported pain levels in versions 1.x (F-value 7.084, p-value = 0.008). Conclusions: Despite the limitations of retrospective cohort studies, the current study indicates, that the implementation of systematically collected user feedback during development of updated versions can contribute to improvements in terms of use frequency and potentially even clinical endpoints like pain level. The clinical efficiency of the Kaia app needs to be validated in prospective controlled trials to exclude bias.