JMIR Publications

JMIR mHealth and uHealth

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

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Journal Description

JMIR mhealth and uhealth (mobile and ubiquitous health) (JMU, ISSN 2291-5222) is a new spin-off journal of JMIR, the leading eHealth journal (Impact Factor 2015: 4.532). JMIR mHealth and uHealth has a projected impact factor (2015) of about 2.03. 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 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.
In addition to peer-reviewing paper submissions by researchers, JMIR mHealth and uHealth offers peer-review of medical apps itself (developers can submit an app for peer-review here).

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 is indexed in PubMed Central/PubMed, and Thomson Reuters' Science Citation Index Expanded (SCIE).

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:

  • User using Oiva mobile ACT app. Copyright VTT Technical Research Centre of Finland Ltd 2013.

    Usage and Dose Response of a Mobile Acceptance and Commitment Therapy App: Secondary Analysis of the Intervention Arm of a Randomized Controlled Trial

    Abstract:

    Background: Mobile phone apps offer a promising medium to deliver psychological interventions. A mobile app based on Acceptance and Commitment Therapy (ACT) was developed and studied in a randomized controlled trial (RCT). Objective: To study usage metrics of a mobile ACT intervention and dose-response relationship between usage and improvement in psychological flexibility. Methods: An RCT was conducted to investigate the effectiveness of different lifestyle interventions for overweight people with psychological stress. This paper presents a secondary analysis of the group that received an 8-week mobile ACT intervention. Most of the analyzed 74 participants were female (n=64, 86%). Their median age was 49.6 (interquartile range, IQR 45.4-55.3) years and their mean level of psychological flexibility, measured with the Acceptance and Action Questionnaire II, was 20.4 (95% confidence interval 18.3-22.5). Several usage metrics describing the intensity of use, usage of content, and ways of use were calculated. Linear regression analyses were performed to study the dose-response relationship between usage and the change in psychological flexibility and to identify the usage metrics with strongest association with improvement. Binary logistic regression analyses were further used to assess the role of usage metrics between those who showed improvement in psychological flexibility and those who did not. In addition, associations between usage and baseline participant characteristics were studied. Results: The median number of usage sessions was 21 (IQR 11.8-35), the number of usage days was 15 (IQR 9.0-24), and the number of usage weeks was 7.0 (IQR 4.0-8.0). The participants used the mobile app for a median duration of 4.7 (IQR 3.2-7.2) hours and performed a median of 63 (IQR 46-98) exercises. There was a dose-response relationship between usage and the change in psychological flexibility. The strongest associations with psychological flexibility (results adjusted with gender, age, and baseline psychological variables) were found for lower usage of Self as context related exercises (B=0.22, P=.001) and higher intensity of use, described by the number of usage sessions (B=−0.10, P=.01), usage days (B=−0.17, P=.008), and usage weeks (B=−0.73, P=.02), the number of exercises performed (B=−0.02, P=.03), and the total duration of use (B=−0.30, P=.04). Also, higher usage of Acceptance related exercises (B=−0.18, P=.04) was associated with improvement. Active usage was associated with female gender, older age, and not owning a smart mobile phone before the study. Conclusions: The results indicated that active usage of a mobile ACT intervention was associated with improved psychological flexibility. Usage metrics describing intensity of use as well as two metrics related to the usage of content were found to be most strongly associated with improvement. Trial Registration: ClinicalTrials.gov NCT01738256; https://clinicaltrials.gov/ct2/show/NCT01738256 (Archived by WebCite at http://www.webcitation.org/6iTePjPLL)

  • Image Source: Young people using their smartphones individually at a party., copyright Tomwsulcer,
https://en.wikipedia.org/wiki/Mobile_phone_overuse#/media/File:Young_people_texting_on_smartphones_using_thumbs.JPG,
Licensed under CC0 1.0 Universal (CC0 1.0) 
Public Domain Dedications https://creativecommons.org/publicdomain/zero/1.0/deed.en.

    The Era of Smartphones: Back to Our Biological Makeup?

    Abstract:

    Background: N/A Objective: N/A Methods: N/A Results: N/A Conclusions: N/A Clinical Trial: N/A

  • Image Source: By N I C O L A via FlickR, licensed under cc-by 2.0.

    Mobile Apps for Weight Management: A Scoping Review

    Abstract:

    Background: Obesity remains a major public health concern. Mobile apps for weight loss/management are found to be effective for improving health outcomes in adults and adolescents, and are pursued as a cost-effective and scalable intervention for combating overweight and obesity. In recent years, the commercial market for ‘weight loss apps’ has expanded at rapid pace, yet little is known regarding the evidence-based quality of these tools for weight control. Objective: To characterize the inclusion of evidence-based strategies, health care expert involvement, and scientific evaluation of commercial mobile apps for weight loss/management. Methods: An electronic search was conducted between July 2014 and July 2015 of the official app stores for four major mobile operating systems. Three raters independently identified apps with a stated goal of weight loss/management, as well as weight loss/management apps targeted to pediatric users. All discrepancies regarding selection were resolved through discussion with a fourth rater. Metadata from all included apps were abstracted into a standard assessment criteria form and the evidence-based strategies, health care expert involvement, and scientific evaluation of included apps was assessed. Evidence-based strategies included: self-monitoring, goal-setting, physical activity support, healthy eating support, weight and/or health assessment, personalized feedback, motivational strategies, and social support. Results: A total of 393 apps were included in this review. Self-monitoring was most common (139/393, 35.3%), followed by physical activity support (108/393, 27.5%), weight assessment (100/393, 25.4%), healthy eating support (91/393, 23.2%), goal-setting (84/393, 21.4%), motivational strategies (28/393, 7.1%), social support (21/393, 5.3%), and personalized feedback (7/393, 1.8%). Of apps, 0.8% (3/393) underwent scientific evaluation and 0.3% (1/393) reported health care expert involvement. No apps were comprehensive in the assessment criteria, with the majority of apps meeting less than two criteria. Conclusions: Commercial mobile apps for weight loss/management lack important evidence-based features, do not involve health care experts in their development process, and have not undergone rigorous scientific testing. This calls into question the validity of apps’ claims regarding their effectiveness and safety, at a time when the availability and growth in adoption of these tools is rapidly increasing. Collaborative efforts between developers, researchers, clinicians, and patients are needed to develop and test high-quality, evidence-based mobile apps for weight loss/management before they are widely disseminated in commercial markets.

  • Source: http://www.freepik.com/free-vector/mobile-phones-in-realistic-style_788452.htm#term=phone screen&page=1&position=12; CC licensed, Attribution: Freepik; modified with image from authors.

    Psychologist in a Pocket: Lexicon Development and Content Validation of a Mobile-Based App for Depression Screening

    Abstract:

    Background: Language reflects the state of one’s mental health and personal characteristics. It also reveals preoccupations with a particular schema, thus possibly providing insights into psychological conditions. Using text or lexical analysis in exploring depression, negative schemas and self-focusing tendencies may be depicted. As mobile technology has become highly integrated in daily routine, mobile devices have the capacity for ecological momentary assessment (EMA), specifically the experience sampling method (ESM), where behavior is captured in real-time or closer in time to experience in one’s natural environment. Extending mobile technology to psychological health could augment initial clinical assessment, particularly of mood disturbances, such as depression and analyze daily activities, such as language use in communication. Here, we present the process of lexicon generation and development and the initial validation of Psychologist in a Pocket (PiaP), a mobile app designed to screen signs of depression through text analysis. Objective: The main objectives of the study are (1) to generate and develop a depressive lexicon that can be used for screening text-input in mobile apps to be used in the PiaP; and (2) to conduct content validation as initial validation. Methods: The first phase of our research focused on lexicon development. Words related to depression and its symptoms based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and in the ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines classification systems were gathered from focus group discussions with Filipino college students, interviews with mental health professionals, and the review of established scales for depression and other related constructs. Results: The lexicon development phase yielded a database consisting of 13 categories based on the criteria depressive symptoms in the DSM-5 and ICD-10. For the draft of the depression lexicon for PiaP, we were able to gather 1762 main keywords and 9655 derivatives of main keywords. In addition, we compiled 823,869 spelling variations. Keywords included negatively-valenced words like “sad”, “unworthy”, or “tired” which are almost always accompanied by personal pronouns, such as “I”, “I’m” or “my” and in Filipino, “ako” or “ko”. For the content validation, only keywords with CVR equal to or more than 0.75 were included in the depression lexicon test-run version. The mean of all CVRs yielded a high overall CVI of 0.90. A total of 1498 main keywords, 8911 derivatives of main keywords, and 783,140 spelling variations, with a total of 793, 553 keywords now comprise the test-run version. Conclusions: The generation of the depression lexicon is relatively exhaustive. The breadth of keywords used in text analysis incorporates the characteristic expressions of depression and its related constructs by a particular culture and age group. A content-validated mobile health app, PiaP may help augment a more effective and early detection of depressive symptoms.

  • Source: https://pixabay.com/el/photos/tablet%20computer, CC0 Public Domain; modified using image from authors.

    Variations in the Use of mHealth Tools: The VA Mobile Health Study

    Authors List:

    Abstract:

    Background: Mobile health (mHealth) technologies exhibit promise for offering patients and their caregivers point-of-need tools for health self-management. This research study involved the dissemination of iPads containing a suite of mHealth apps to family caregivers of veterans who receive care from the Veterans Affairs (VA) Health Administration and have serious physical or mental injuries. Objective: The goal of the study was to identify factors and characteristics of veterans and their family caregivers that predict the use of mHealth apps. Methods: Veteran/family caregiver dyads (N=882) enrolled in VA’s Comprehensive Assistance for Family Caregivers program were recruited to participate in an mHealth pilot program. Veterans and caregivers who participated and received an iPad agreed to have their use of the apps monitored and were asked to complete a survey assessing Caregiver Preparedness, Caregiver Traits, and Caregiver Zarit Burden Inventory baseline surveys. Results: Of the 882 dyads, 94.9% (837/882) of caregivers were women and 95.7% (844/882) of veteran recipients were men. Mean caregiver age was 40 (SD 10.2) years and mean veteran age was 39 (SD 9.15) years, and 39.8% (351/882) lived in rural locations. Most (89%, 788/882) of the caregivers were spouses. Overall, the most frequently used app was Summary of Care, followed by RX Refill, then Journal, Care4Caregivers, VA Pain Coach, and last, VA PTSD Coach. App use was significantly predicted by the caregiver being a spouse, increased caregiver computer skills, a rural living location, lower levels of caregiver preparedness, veteran mental health diagnosis (other than posttraumatic stress disorder), and veteran age. Conclusions: This mHealth Family Caregiver pilot project effectively establishes the VA’s first patient-facing mHealth apps that are integrated within the VA data system. Use varied considerably, and apps that were most used were those that assisted them in their caregiving responsibilities.

  • mHealth, http://pereira-azevedo.com/images/JMIR-mHealth.png. CC0 1.0 Universal (CC0 1.0) Public Domain Dedication.

    Expert Involvement Predicts mHealth App Downloads: Multivariate Regression Analysis of Urology Apps

    Abstract:

    Background: Urological mobile medical (mHealth) apps are gaining popularity with both clinicians and patients. mHealth is a rapidly evolving and heterogeneous field, with some urology apps being downloaded over 10,000 times and others not at all. The factors that contribute to medical app downloads have yet to be identified, including the hypothetical influence of expert involvement in app development. Objective: The objective of our study was to identify predictors of the number of urology app downloads. Methods: We reviewed urology apps available in the Google Play Store and collected publicly available data. Multivariate ordinal logistic regression evaluated the effect of publicly available app variables on the number of apps being downloaded. Results: Of 129 urology apps eligible for study, only 2 (1.6%) had >10,000 downloads, with half having ≤100 downloads and 4 (3.1%) having none at all. Apps developed with expert urologist involvement (P=.003), optional in-app purchases (P=.01), higher user rating (P<.001), and more user reviews (P<.001) were more likely to be installed. App cost was inversely related to the number of downloads (P<.001). Only data from the Google Play Store and the developers’ websites, but not other platforms, were publicly available for analysis, and the level and nature of expert involvement was not documented. Conclusions: The explicit participation of urologists in app development is likely to enhance its chances to have a higher number of downloads. This finding should help in the design of better apps and further promote urologist involvement in mHealth. Official certification processes are required to ensure app quality and user safety.

  • Image Source: Homeless Sign, copyright Steve Hardy,
https://www.flickr.com/photos/ruffryd/6909195096/,
Licensed under Creative Commons Attribution cc-by 2.0 https://creativecommons.org/licenses/by/2.0/.

    YTH StreetConnect: Development and Usability of a Mobile App for Homeless and Unstably Housed Youth

    Abstract:

    Background: Homeless and unstably housed (H/UH) youth are disproportionately affected by sexual health issues, including human immunodeficiency virus/sexually transmitted diseases, teen pregnancy, and dating violence, and are at a higher risk for poor mental health and underutilization of services. Research suggests that linking health care to H/UH adolescents might help improve their continuity of care, with most preferring to access health care information via the Internet. YTH StreetConnect is a dual-purpose mobile app that helps H/UH youth access health and vital services in Santa Clara County, CA, USA. We developed YTH StreetConnect PRO in parallel with the youth app as a companion tablet app for providers who serve H/UH youth. Objective: The objective of our study was to develop a mobile app to support H/UH youth and their providers in accessing health and vital resources, and to conduct usability and feasibility testing of the app among H/UH youth and technical consultants with local expertise in serving H/UH youth. Methods: Formative research included a literature review on H/UH youths’ mobile phone and Internet usage. In January 2015, we conducted interviews with medical and service providers of H/UH youth. Usability and feasibility testing were done with target audiences. Additionally, we conducted focus groups with youth regarding the app’s youth friendliness, accessibility, and usefulness. Results: H/UH youth and their providers noted the app’s functionality, youth friendliness, and resources. Usability testing proposed improvements to the app, including visual updates to the user interface, map icons, new underrepresented resource categories, and the addition of a peer rating system. Limitations included a small sample size among H/UH youth and providers and a single site for the study (Santa Clara County, CA), making the findings ungeneralizable to the US population. Conclusions: YTH StreetConnect is a promising way to increase service utilization, provide referral access, and share resources among H/UH youth and providers. Input from H/UH youth and providers offers insights on how to improve future models of YTH StreetConnect and similar programs that assist H/UH youth.

  • Source: https://www.flickr.com/photos/78428166@N00/3829063385; CC-BY2.0 Attribution: Tony Alter.

    Popular Mobile Phone Apps for Diet and Weight Loss: A Content Analysis

    Abstract:

    Background: A review of the literature has revealed that the rates of overweight and obesity have been increasing in Australia over the last two decades and that wellness mobile phone apps play a significant role in monitoring and managing individuals’ weight. Although mobile phone app markets (iTunes and Google Play) list thousands of mobile phone health apps, it is not always clear whether those apps are supported by credible sources. Likewise, despite the prevailing use of mobile phone apps to aid with weight management, the usability features of these apps are not well characterized. Objective: The research explored how usability taxonomy could inform the popularity of downloaded, socially focused wellness mobile phone apps, in particular weight loss and diet apps. The aim of the study was to investigate the Australian mobile phone app stores (iTunes and Google Play) in order to examine the usability features of the most popular (ie, most downloaded) wellness apps. Methods: The design of this study comprises 3 main stages: stage 1, identifying apps; stage 2, development of weight loss and diet evaluation framework; and stage 3, application of the evaluation framework. Each stage includes specific data collection, analysis tools, and techniques. Results: The study has resulted in the development of a justified evaluation framework for weight loss and diet mobile phone apps. Applying the evaluation framework to the identified apps has shown that the most downloaded iTunes and Google Play apps are not necessarily the most usable or effective. In addition, the research found that search algorithms for iTunes and Google Play are biased toward apps’ titles and keywords that do not accurately define the real functionality of the app. Moreover, the study has also analyzed the apps’ user reviews, which served as justification for the developed evaluation framework. Conclusions: The analysis has shown that ease of use, reminder, bar code scanning, motivation, usable for all, and synchronization are significant attributes that should be included in weight loss and diet mobile phone apps and ultimately in potential weight loss and diet evaluation frameworks.

  • Source: https://www.pexels.com/photo/medical-tablets-pharmacy-cure-56612 CC0 Public Domain; http://tinyurl.com/zhzvo8v CC0 Public Domain; http://tinyurl.com/jqpwv86 Public Domain; modified.

    An Evidence-Based Antimicrobial Stewardship Smartphone App for Hospital Outpatients: Survey-based Needs Assessment Among Patients

    Abstract:

    Background: Current advances in modern technology have enabled the development and utilization of electronic medical software apps for both mobile and desktop computing devices. A range of apps on a large variety of clinical conditions for patients and the public are available, but very few target antimicrobials or infections. Objective: We sought to explore the use of different antimicrobial information resources with a focus on electronic platforms, including apps for portable devices, by outpatients at two large, geographically distinct National Health Service (NHS) teaching hospital trusts in England. We wanted to determine whether there is demand for an evidence-based app for patients, to garner their perceptions around infections/antimicrobial prescribing, and to describe patients’ experiences of their interactions with health care professionals in relation to this topic. Methods: A cross-sectional survey design was used to investigate aspects of antimicrobial prescribing and electronic devices experienced by patients at four hospitals in London and a teaching hospital in the East of England. Results: A total of 99 surveys were completed and analyzed. A total of 82% (80/98) of respondents had recently been prescribed antimicrobials; 87% (85/98) of respondents were prescribed an antimicrobial by a hospital doctor or through their general practitioner (GP) in primary care. Respondents wanted information on the etiology (42/65, 65%) and prevention and/or management (32/65, 49%) of their infections, with the infections reported being upper and lower respiratory tract, urinary tract, oral, and skin and soft tissue infections. All patients (92/92, 100%) desired specific information on the antimicrobial prescribed. Approximately half (52/95, 55%) stated it was “fine” for doctors to use a mobile phone/tablet computer during the consultation while 13% (12/95) did not support the idea of doctors accessing health care information in this way. Although only 30% (27/89) of respondents reported on the use of health care apps, 95% (81/85) offered information regarding aspects of antimicrobials or infections that could be provided through a tailored app for patients. Analysis of the comments revealed the following main global themes: knowledge, technology, and patient experience. Conclusions: The majority of respondents in our study wanted to have specific etiological and/or infection management advice. All required antimicrobial-related information. Also, most supported the use of electronic resources of information, including apps, by their doctors. While a minority of people currently use health apps, many feel that apps could be used to provide additional support/information related to infections and appropriate use of antimicrobials. In addition, we found that there is a need for health care professionals to engage with patients and help address common misconceptions around the generation of antimicrobial resistance.

  • Team Support Features Would Render Wearable Devices an Effective Team Sports' Tool. 
WAT for teams. Sourced and copyright owned by authors Rebecca Cherng-Shiow Chang et al. Surface Pro 3, copyright Open Grid Scheduler / Grid Engine. Image retrieved from http://tinyurl.com/zrxrp3f. Licensed under Public Domain.

    Reciprocal Reinforcement Between Wearable Activity Trackers and Social Network Services in Influencing Physical Activity Behaviors

    Abstract:

    Background: Wearable activity trackers (WATs) are emerging consumer electronic devices designed to support physical activities (PAs), which are based on successful behavior change techniques focusing on goal-setting and frequent behavioral feedbacks. Despite their utility, data from both recent academic and market research have indicated high attrition rates of WAT users. Concurrently, evidence shows that social support (SS), delivered/obtained via social network services or sites (SNS), could increase adherence and engagement of PA intervention programs. To date, relatively few studies have looked at how WATs and SS may interact and affect PAs. Objective: The purpose of this study was to explore how these two Internet and mobile technologies, WATs and SNS, could work together to foster sustainable PA behavior changes and habits among middle-aged adults (40-60 years old) in Taiwan. Methods: We used purposive sampling of Executive MBA Students from National Taiwan University of Science and Technology to participate in our qualitative research. In-depth interviews and focus groups were conducted with a total of 15 participants, including 9 WAT users and 6 nonusers. Analysis of the collected materials was done inductively using the thematic approach with no preset categories. Two authors from different professional backgrounds independently annotated and coded the transcripts, and then discussed and debated until consensus was reached on the final themes. Results: The thematic analysis revealed six themes: (1) WATs provided more awareness than motivation in PA with goal-setting and progress monitoring, (2) SS, delivered/obtained via SNS, increased users’ adherence and engagement with WATs and vice versa, (3) a broad spectrum of configurations would be needed to deliver WATs with appropriately integrated SS functions, (4) WAT design, style, and appearance mattered even more than those of smartphones, as they are body-worn devices, (5) the user interfaces of WATs left a great deal to be desired, and (6) privacy concerns must be addressed before more mainstream consumers would consider adopting WATs. Conclusions: Participants perceived WATs as an awareness tool to understand one’s PA level. It is evident from our study that SS, derived from SNS and other pertinent vehicles such as the LINE social messaging application (similar to WhatsApp and WeChat), will increase the engagement and adherence of WAT usage. Combining WATs and SNS enables cost-effective, scalable PA intervention programs with end-to-end services and data analytics capabilities, to elevate WATs from one-size-fits-all consumer electronics to personalized PA assistants.

  • Image Source: 014/365 - day n nite, copyright Keirsten Marie,
http://tinyurl.com/j2y3usw, Licensed under Creative Commons Attribution cc-by 2.0 https://creativecommons.org/licenses/by/2.0/.

    Deriving Requirements for Pervasive Well-Being Technology From Work Stress and Intervention Theory: Framework and Case Study

    Abstract:

    Background: Stress in office environments is a big concern, often leading to burn-out. New technologies are emerging, such as easily available sensors, contextual reasoning, and electronic coaching (e-coaching) apps. In the Smart Reasoning for Well-being at Home and at Work (SWELL) project, we explore the potential of using such new pervasive technologies to provide support for the self-management of well-being, with a focus on individuals' stress-coping. Ideally, these new pervasive systems should be grounded in existing work stress and intervention theory. However, there is a large diversity of theories and they hardly provide explicit directions for technology design. Objective: The aim of this paper is to present a comprehensive and concise framework that can be used to design pervasive technologies that support knowledge workers to decrease stress. Methods: Based on a literature study we identify concepts relevant to well-being at work and select different work stress models to find causes of work stress that can be addressed. From a technical perspective, we then describe how sensors can be used to infer stress and the context in which it appears, and use intervention theory to further specify interventions that can be provided by means of pervasive technology. Results: The resulting general framework relates several relevant theories: we relate “engagement and burn-out” to “stress”, and describe how relevant aspects can be quantified by means of sensors. We also outline underlying causes of work stress and how these can be addressed with interventions, in particular utilizing new technologies integrating behavioral change theory. Based upon this framework we were able to derive requirements for our case study, the pervasive SWELL system, and we implemented two prototypes. Small-scale user studies proved the value of the derived technology-supported interventions. Conclusions: The presented framework can be used to systematically develop theory-based technology-supported interventions to address work stress. In the area of pervasive systems for well-being, we identified the following six key research challenges and opportunities: (1) performing multi-disciplinary research, (2) interpreting personal sensor data, (3) relating measurable aspects to burn-out, (4) combining strengths of human and technology, (5) privacy, and (6) ethics.

  • The Milk Man app. Image sourced and copyright owned by The authors.

    Theory-Based Design and Development of a Socially Connected, Gamified Mobile App for Men About Breastfeeding (Milk Man)

    Abstract:

    Background: Despite evidence of the benefits of breastfeeding, <15% of Australian babies are exclusively breastfed to the recommended 6 months. The support of the father is one of the most important factors in breastfeeding success, and targeting breastfeeding interventions to the father has been a successful strategy in previous research. Mobile technology offers unique opportunities to engage and reach populations to enhance health literacy and healthy behavior. Objective: The objective of our study was to use previous research, formative evaluation, and behavior change theory to develop the first evidence-based breastfeeding app targeted at men. We designed the app to provide men with social support and information aiming to increase the support men can offer their breastfeeding partners. Methods: We used social cognitive theory to design and develop the Milk Man app through stages of formative research, testing, and iteration. We held focus groups with new and expectant fathers (n=18), as well as health professionals (n=16), and used qualitative data to inform the design and development of the app. We tested a prototype with fathers (n=4) via a think-aloud study and the completion of the Mobile Application Rating Scale (MARS). Results: Fathers and health professionals provided input through the focus groups that informed the app development. The think-aloud walkthroughs identified 6 areas of functionality and usability to be addressed, including the addition of a tutorial, increased size of text and icons, and greater personalization. Testers rated the app highly, and the average MARS score for the app was 4.3 out of 5. Conclusions: To our knowledge, Milk Man is the first breastfeeding app targeted specifically at men. The development of Milk Man followed a best practice approach, including the involvement of a multidisciplinary team and grounding in behavior change theory. It tested well with end users during development. Milk Man is currently being trialed as part of the Parent Infant Feeding Initiative (ACTRN12614000605695).

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  • How best to obtain valid, verifiable data online from male couples? Lessons learned from an eHealth HIV prevention intervention for HIV-negative male couples

    Date Submitted: Jul 22, 2016

    Open Peer Review Period: Jul 25, 2016 - Sep 19, 2016

    Background: As interest increases in the development of eHealth HIV preventive interventions for gay male couples, web-based methods must also be developed to help increase the likelihood that couples...

    Background: As interest increases in the development of eHealth HIV preventive interventions for gay male couples, web-based methods must also be developed to help increase the likelihood that couples enrolled and data collected from them represent true, unique dyads. However, methods to recruit and collect reliable and valid data from both members of a couple (i.e., dyadic data) are lacking yet are crucial for uptake of novel sexual health and HIV prevention eHealth interventions. Methods to describe best practices to recruit male couples using targeted advertisements placed on Facebook are also lacking in the literature yet could also help in the uptake of referring male couples to new and novel eHealth, HIV preventive interventions. Objective: Experiences pertaining to recruitment and eligibility, enrollment data from two phases (formative, development phase and online randomized control trial) of an eHealth HIV prevention intervention for concordant HIV-negative male couples are used to describe challenges and lessons learned associated with: 1) recruiting male couples using targeted advertisements on Facebook; 2) validating that data came from two partners of the couple; and 3) verifying that the two partners of the couple are in a relationship with one another. Methods: The developmental phase refined the intervention via in-person focus groups whereas the pilot-testing phase included an online randomized control trial. For both phases, couples were recruited via Facebook advertisements targeting adult (e.g., >18) males interested in men, in a relationship, and had an interest in the LGBT community and/or gay news. Advertisements directed men to a study webpage and screener; once eligible, participants provided consent electronically. A partner referral system was embedded in the consenting process to recruit the relationship partner of the participant. Both men of the couple had to meet all eligibility criteria – individually and as a couple – before they could enroll into the study. Verification of couples’ relationships was assessed via the concurrence of pre-determined screener items from both partners, done manually in the developmental phase and electronically in the pilot-testing phase. A system of decision rules was developed to assess the validity that data came from two unique partners of a couple. Results: Several important lessons were learned from these experiences, resulting in recommendations for future eHealth studies involving male couples. Use of certain ‘interests’ and types of images (e.g., shirtless) in targeted Facebook advertisements should be avoided or used sparingly as these interests and types of images may generate adverse reactions from a broader audience. Development of a systematic approach with pre-determined criteria and parameters to verify male couples’ relationships is strongly recommended. Further, researchers are encouraged to develop a system of decision rules to detect and handle suspicious data (e.g., suspicious email addresses/names, multiple entries, same IP address used in multiple entries) to help validate the legitimacy of male couples’ relationships online. Conclusions: These lessons learned combined with recommendations for future studies aim to help enhance recruitment efforts and the validity and reliability of collecting dyadic data from male couples for novel, eHealth preventive interventions.

  • Evaluation of Diet Related Infographics on Pinterest for use of Behavior Change Theories; a content analysis

    Date Submitted: Jul 17, 2016

    Open Peer Review Period: Jul 20, 2016 - Sep 14, 2016

    Background: There is increasing interest in Pinterest as a method of disseminating health information, however it is unclear whether the health information promoted on Pinterest is evidence-based or p...

    Background: There is increasing interest in Pinterest as a method of disseminating health information, however it is unclear whether the health information promoted on Pinterest is evidence-based or promotes behavior change. Objective: To determine the presence of Health Behavior Theory (HBT) constructs in pins found on Pinterest and to assess the relationship between various pin characteristics and the inclusion of HBT. Methods: A content analysis was conducted on pins collected from Pinterest identified with the search terms “nutrition infographic” and “healthy eating infographic.” The coding rubric included HBT constructs, pin characteristics, and visual communication tools. Each HBT construct was coded as present or not present (yes = 1/no = 0). A total theory score was calculated by summing the values for each of the 9 constructs (range 0 - 9). Adjusted regression analysis was used to identify factors associated with the inclusion of health behavior change theory in pins (P < .05). Results: The mean total theory score was 2.03 (SD = 1.2). Perceived benefits were present most often (72.03%), followed by behavioral capacity (51.68%) and perceived severity (33.47%). The construct that appeared the least was self-regulation/self-control (0.84%). Pin characteristics associated with the inclusion of HBT included a large amount of text (P=.01), photographs of real people (P = .001), cartoon pictures of food (P = .01) and the presence of references (P = .001). The number of repins (P = .04), likes (P = .01) and comments (P = .01) were positively associated with the inclusion of HBT. Conclusions: These findings suggest that current Pinterest infographics targeting healthy eating contain little HBT elements. Health professionals and organizations need to create and disseminate infographics that contain more elements of HBT to better influence healthy eating behavior. This may be accomplished by creating pins that utilize both text and images of people and food in order to portray elements of HBT and convey nutritional information.

  • Designing a mobile health application for patients with dysphagia following head and neck cancer

    Date Submitted: Jul 13, 2016

    Open Peer Review Period: Jul 16, 2016 - Sep 10, 2016

    Background: Adherence to swallowing rehabilitation exercises is important to develop and maintain functional improvement, yet more than half of head and neck cancer (HNC) patients report having diffic...

    Background: Adherence to swallowing rehabilitation exercises is important to develop and maintain functional improvement, yet more than half of head and neck cancer (HNC) patients report having difficulty adhering to prescribed regimens. Health applications (apps) with game elements have been used in other health domains to motivate and engage patients. Understanding the factors that impact adherence may allow for more effective gamified solutions. Objective: (1) Identify self-reported factors that influence adherence to conventional home therapy without a mobile device in HNC patients, and (2) identify appealing biofeedback designs that could be used in a health app. Methods: Ten (4 females) HNC patients (M = 60.1 years) with experience completing home-based rehabilitation programs were recruited. Thematic analysis of semi-structured interviews was used to answer the first objective. Convergent interviews were used to obtain reactions to biofeedback designs. Results: Facilitators and barriers of adherence to home therapy were described through six themes: patient perceptions on outcomes and progress; clinical appointments; cancer treatment; rehabilitation program; personal factors; and connection. App visuals that provide feedback on performance during swallowing exercises should retain the chief goals of biofeedback (e.g., immediate representation of effort relative to a goal). Simple, intuitive graphics were preferred over complex, abstract ones. Conclusions: Continued engagement with the app could be facilitated by tracking progress and by using visuals that build or create structures with each subsequent use.

  • Women’s Perceptions of Participation in an Extended Contact Text Message Weight Loss Intervention

    Date Submitted: Jul 7, 2016

    Open Peer Review Period: Jul 11, 2016 - Sep 5, 2016

    Background: Extending contact with participants after the end of an initial weight loss intervention has been shown to lead to maintained weight loss and related behavior change. Mobile phone text mes...

    Background: Extending contact with participants after the end of an initial weight loss intervention has been shown to lead to maintained weight loss and related behavior change. Mobile phone text messaging offers a low cost and efficacious method to deliver extended contact. In this rapidly developing area, formative work is required to understand user perspectives of text message technology. An extended contact intervention delivered by text messages following an initial telephone-delivered weight loss intervention in breast cancer survivors provided this opportunity. Objective: To qualitatively explore women’s perceptions of participation in an extended contact intervention using text messaging to support long-term weight loss, physical activity and dietary behavior change Methods: Following the end of an initial 6-month randomized controlled trial of a telephone-delivered weight loss intervention (versus usual care), participants received a 6-month extended contact intervention via tailored text messages. Participant perceptions of the different types of text messages, the content, tailoring, timing and frequency of the texts and the length of the intervention were assessed through semi-structured interviews conducted after the extended contact intervention. The interviews were transcribed verbatim and analysed with key themes identified. Results: Participants (n=27) were Caucasian with a mean age of 56.0 years (SD 12.0), mean BMI of 30.0kg/m2 (SD 4.2) and were a mean of 16.1 months (SD 3.1) post-diagnosis at study baseline. Participants perceived the texts to be useful behavioral prompts and felt the messages kept them accountable to their behavior change goals. The individual tailoring of the text content and schedules was a key to the acceptability of the messages, however some women preferred the support and real-time discussion via telephone (during the initial intervention) compared to the text messages (during the extended contact intervention). Conclusions: Text message support was perceived as acceptable for the majority of women as a way of extending intervention contact for weight loss and behavioral maintenance. Texts supported the maintenance of healthy behaviors established in the intervention phase and kept the women accountable to their goals. A combination of phone and text support was suggested as a more acceptable option for some of the women for an extended contact intervention. Clinical Trial: Not registered

  • How Accurate Is Your Activity Tracker? A Comparative Study of Step Counts in Low-Intensity Physical Activities

    Date Submitted: Jul 6, 2016

    Open Peer Review Period: Jul 8, 2016 - Sep 2, 2016

    Background: Tracking physical activity is crucial for monitoring individuals diagnosed with a range of chronic conditions including heart failure, diabetes, and cancer. One simple, yet effective, appr...

    Background: Tracking physical activity is crucial for monitoring individuals diagnosed with a range of chronic conditions including heart failure, diabetes, and cancer. One simple, yet effective, approach to monitor the amount of daily physical activity that individuals perform is to count the number of steps taken throughout a day. Several commercially available activity trackers have been tested for reliability and validity in many research studies in various exercise activities such as walking and running at a wide range of speeds. However, there have been only a few studies within healthcare research. Currently, there exists a gap in our knowledge regarding the performance of these trackers facing low intensity activities. In this study, we evaluate the reliability of the Fitbit step counters during a number of moderate and light everyday physical activities, and we investigate whether or not using the trackers on different body locations affect their performance. Objective: This paper answers the four following questions: (1) which activities are certain motion sensor based trackers more accurate at monitoring? (2) to what extent does body location affect step counting accuracy? (3) for each activity, which particular body location results in the best step counting performance? (4) how does the intensity of certain physical activities and the physical characteristics of the users affect the performance of activity trackers in counting steps? Methods: We recruited 15 healthy young adults (aged 21-33) to perform six physical activities while wearing three Fitbits (i.e., Zip, One, and Flex) on different body locations (i.e., chest, pocket, and wrist). These activities include walking at 1.5, 3, and 4.5 mph, walking with a shopping cart, walking with aid of a walker, and eating while sitting. We compared the number of steps counted by each tracker with the ground truth (video recorded during the experiments). Results: Our results show that these trackers are most accurate in the treadmill experiment with an average margin of error of five steps per minute from the actual step counts. On the other hand, in the walker experiment, the average error over the three body locations is significantly higher than the other activities, which demonstrates the poor performance of the activity trackers in detecting movements in slow and abnormal walking patterns. However, there was no significant difference between the step counts of the trackers in the treadmill and shopping cart experiments and the ground truth. The wrist-band tracker, Flex, counted several steps when eating (p < .01), showing that the Flex is inaccurate when encountering vigorous stationary tasks. Looking at different locations, pants pocket is the most promising location to capture steps in high intensity PAs, while wrist is the best choice to wear the activity tracker on in lower intensity PAs. Conclusions: Accelerometer-based activity monitoring devices such as Fitbit trackers are most accurate in exercise activities, such as walking on treadmill, and least accurate in lower intensity activities, which has a significantly different pattern from the normal gait, such as walking with walking aids. Compared to the wrist-band and pocket trackers, the activity tracker on the chest is superior in tracking more intense physical activities (e.g., walking on treadmill), but oversensitive in light activities such as walking with a walker and eating. These results demonstrate that the body location significantly affects the accuracy of the trackers. This result demonstrates the need for activity recognition algorithms to consider the locations of trackers and intensity of activities.

  • Efficacy of mobile applications to support the care of patients with diabetes mellitus: systematic review and meta-analysis

    Date Submitted: Jul 4, 2016

    Open Peer Review Period: Jul 7, 2016 - Sep 1, 2016

    Background: Diabetes Mellitus (DM) is a chronic disease that is considered a global public health problem. Education and self-monitoring by diabetic patients help to optimize and make possible a satis...

    Background: Diabetes Mellitus (DM) is a chronic disease that is considered a global public health problem. Education and self-monitoring by diabetic patients help to optimize and make possible a satisfactory metabolic control enabling improved management and reduced morbidity and mortality. The global growth in the use of mobile phones makes them a powerful platform to help provide tailored health, delivered conveniently to patients through health applications (apps). Objective: Evaluate the efficacy of mobile apps through a systematic review and meta-analysis to assist diabetes mellitus patients in treatment. Methods: We conducted searches in the electronic databases MEDLINE (Pubmed), CENTRAL/ Cochrane Register of Controlled Trials and LILACS, manual search in references of publications included, systematic reviews, specialized journals and gray literature. We considered eligible randomized controlled trials (RCTs) conducted after 2008 with participants of all ages, diabetes mellitus patients and users of apps to help manage the disease. The meta-analysis of glycated hemoglobin (HbA1c) was performed in Review Manager Software 5.3. Results: The literature search identified 1036 publications. From these, 10 studies were included that evaluated 980 patients. In four RCTs, there were a statistical significant reduction (P < 0.03) of HbA1c at the end of studies in the intervention group. The HbA1c data were evaluated by meta-analysis with the following results (MD = - .42; CI: - .60, - .25; P < .11; I² = 34%).The evaluation favored the treatment in patients who used apps without significant heterogeneity. Conclusions: The use of apps by diabetic patients could help improve the control of HbA1c. In addition, the apps seem to strengthen the perception of self-care contributing better information and health education to patients. Patients also become more self-confident to deal with their diabetes, mainly, by reducing fear of not knowing how to deal with potential hypoglycemic episodes that may occur.

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