JMIR Publications

JMIR mHealth and uHealth

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


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 2014: 3.4). 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 also the Thomson Reuters Emerging Sources Citation IndexESCI

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:

  • A training class of SMS text message-based disease reporting system at one commune health center. Image source and copyright: Institute of Population, Health and Development (PHAD), Hanoi, Vietnam.

    Perceptions of the Feasibility and Practicalities of Text Messaging-Based Infectious Disease Surveillance: A Questionnaire Survey


    Background: In Vietnam, infectious disease surveillance data are collected via a paper-based system through four government tiers leading to a large delay. Meanwhile, mobile phones are abundant and very popular in the country, and known to be a useful tool in health care worldwide. Therefore, there is a great potential for the development of a timely disease surveillance system through the use of mobile phone short message service (SMS) text messages. Objective: This study aims to explore insights about the feasibility and practicalities of the utilization of SMS text messaging-based interventions in disease-reporting systems by identifying potential challenges and barriers in the text messaging process and looking at lessons learned. Methods: An SMS text messaging-based disease tracking system was set up in Vietnam with patient reports texted by clinic staff. Two 6-month trials utilizing this disease tracking system were designed and implemented in two northern provinces of Vietnam to report two infectious diseases: diarrhea and influenza-like illness. A structured self-reported questionnaire was developed to measure the feasibility and practicalities of the system from the participants. On the completion of the second trial in 2013, participating health staff from 40 commune health centers in the two pilot provinces were asked to complete the survey (N=80). Results: Most participants were female (61%, 49/80) and nearly half (44%, 35/80) were heads of a commune health center. Approximately two-thirds (63%, 50/80) of participants retained the basic structure of the SMS text message report and there was a strong influence (OR 28.2, 95% CI 5.3-151.2) of those people on the time they spent texting the information. The majority (88%, 70/80) felt the information conveyed in the SMS text message report was not difficult to understand. Most (86%, 69/80) believed that they could report all 28 infectious diseases asked for by the Ministry of Health by using SMS text messaging. Conclusions: From a health center staff perspective, a disease-reporting system utilizing text messaging technology is easy to use and has great potential to be implemented and expanded nationwide. The survey showed positive perceptions and feedback from the participants and contributed to a promising practical solution to improve the surveillance system of infectious disease in Vietnam.

  • Source:, Copyright:dolgachov, License purchased by authors from

    User Preferences for Content, Features, and Style for an App to Reduce Harmful Drinking in Young Adults: Analysis of User Feedback in App Stores and Focus...


    Background: Electronic screening and brief intervention (eSBI) is effective in reducing weekly alcohol consumption when delivered by a computer. Mobile phone apps demonstrate promise in delivering eSBI; however, few have been designed with an evidence-based and user-informed approach. Objective: This study aims to explore from a user perspective, preferences for content, appearance, and operational features to inform the design of a mobile phone app for reducing quantity and frequency of drinking in young adults engaged in harmful drinking (18-30 year olds). Methods: Phase 1 included a review of user reviews of available mobile phone apps that support a reduction in alcohol consumption. Apps were identified on iTunes and Google Play and were categorized into alcohol reduction support, entertainment, blood alcohol content measurement (BAC), or other. eSBI apps with ≥18 user reviews were subject to a content analysis, which coded praise, criticism, and recommendations for app content, functionality, and esthetics. Phase 2 included four focus groups with young adults drinking at harmful levels and residing in South London to explore their views on existing eSBI apps and preferences for future content, functionality, and appearance. Detailed thematic analysis of the data was undertaken. Results: In Phase 1, of the 1584 apps extracted, 201 were categorized as alcohol reduction, 154 as BAC calculators, 509 as entertainment, and 720 as other. We classified 32 apps as eSBI apps. Four apps had ≥18 user reviews: Change for Life Drinks Tracker, Drinksmeter, Drinkaware, and Alcohol Units Calculator. The highest proportion of content praises were for information and feedback provided in the apps (12/27, 44%), followed by praise for the monitoring features (5/27, 19%). Many (8/12, 67%) criticisms were for the drinking diary; all of these were related to difficulty entering drinks. Over half (18/32, 56%) of functionality criticisms were descriptions of software bugs, and over half of those (10/18, 56%) were for app crashing or freezing. Drinksmeter and Alcohol Units Calculator were the most highly praised apps overall (23/57 and 22/57; 39% of praise overall). In Phase 2, two main themes were identified. The meaningfulness theme reflected how young adults thought apps needed to be tailored to the interests and values of their age group, particularly emphasizing content and feedback around broader health and well-being factors such as exercise, diet, and image. The community theme suggested that young adults want to be able to engage with other app users, both in groups of friends and with online users for motivation and support. Conclusions: Targeted and relevant information and feedback, in addition to easy-to-use monitoring tools, were found to be important features of a mobile phone app to support a reduction in drinking. Future app development should consider tailoring all app aspects to the needs of young adults, considering broader well-being monitoring tools and online community functions.

  • Image of generic medical app use.
Image source and copyright: Ying Liu, General Practice Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, China.

    The Use of Mobile Phone and Medical Apps among General Practitioners in Hangzhou City, Eastern China


    Background: Mobile phones and mobile phone apps have expanded new forms of health professionals’ work. There are many studies on the use of mobile phone apps for different specialists. However, there are no studies on the current use of mobile phone apps among general practitioners (GPs). Objective: The objective of the study was to investigate the extent to which GPs own smartphones with apps and use them to aid their clinical activities. Methods: A questionnaire survey of GPs was undertaken in Hangzhou, Eastern China. Data probing GPs’ current use of medical apps in their clinical activities and factors influencing app use were collected and analyzed Results: 125 GPs participated in the survey. 90.4% of GPs owned a mobile phone, with 48.7% owning an iPhone and 47.8% owning an Android phone. Most mobile phone owners had 1-3 medical-related apps, with very few owning more than 4. There was no difference in number of apps between iPhone and Android owners (χ2=1.388, P=0.846). 36% of GPs reported using medical-related apps on a daily basis. The majority of doctors reported using apps to aid clinical activities less than 30 minutes per day. Conclusions: A high level of mobile phone ownership and usage among GPs was found in this study, but few people chose medical-related apps to support their clinical practice.

  • Source:, CC0 Licensed, public domain.

    Text Messaging-Based Interventions for Smoking Cessation: A Systematic Review and Meta-Analysis


    Background: Tobacco use is one of the leading preventable global health problems producing nearly 6 million smoking-related deaths per year. Interventions delivered via text messaging (short message service, SMS) may increase access to educational and support services that promote smoking cessation across diverse populations. Objective: The purpose of this meta-analysis is to (1) evaluate the efficacy of text messaging interventions on smoking outcomes, (2) determine the robustness of the evidence, and (3) identify moderators of intervention efficacy. Methods: Electronic bibliographic databases were searched for records with relevant key terms. Studies were included if they used a randomized controlled trial (RCT) to examine a text messaging intervention focusing on smoking cessation. Raters coded sample and design characteristics, and intervention content. Summary effect sizes, using random-effects models, were calculated and potential moderators were examined. Results: The meta-analysis included 20 manuscripts with 22 interventions (N=15,593; 8128 (54%) women; mean age=29) from 10 countries. Smokers who received a text messaging intervention were more likely to abstain from smoking relative to controls across a number of measures of smoking abstinence including 7-day point prevalence (odds ratio (OR)=1.38, 95% confidence interval (CI)=1.22, 1.55, k=16) and continuous abstinence (OR=1.63, 95% CI=1.19, 2.24, k=7). Text messaging interventions were also more successful in reducing cigarette consumption relative to controls (d+=0.14, 95% CI=0.05, 0.23, k=9). The effect size estimates were biased when participants who were lost to follow-up were excluded from the analyses. Cumulative meta-analysis using the 18 studies (k=19) measuring abstinence revealed that the benefits of using text message interventions were established only after only five RCTs (k=5) involving 8383 smokers (OR=1.39, 95% CI=1.15, 1.67, P<.001). The inclusion of the subsequent 13 RCTs (k=14) with 6870 smokers did not change the established efficacy of text message interventions for smoking abstinence (OR=1.37, 95% CI=1.25, 1.51, P<.001). Smoking abstinence rates were stronger when text messaging interventions (1) were conducted in Asia, North America, or Europe, (2) sampled fewer women, and (3) recruited participants via the Internet. Conclusions: The evidence for the efficacy of text messaging interventions to reduce smoking behavior is well-established. Using text messaging to support quitting behavior, and ultimately long-term smoking abstinence, should be a public health priority.

  • Female Entertainment Workers in Cambodia. Copyright: KHANA.

    Are Text Messages a Feasible and Acceptable Way to Reach Female Entertainment Workers in Cambodia with Health Messages? A Cross-Sectional Phone Survey


    Background: Despite great achievements in reducing the prevalence of HIV, eliminating new HIV infections remains a challenge in Cambodia. Entertainment venues such as restaurants, karaoke bars, beer gardens, cafes, pubs, and massage parlors are now considered important venues for HIV prevention efforts and other health outreach interventions. Objective: The purpose of this study was to explore phone use and texting practices of female entertainment workers (FEWs) in order to determine if text messaging is a feasible and acceptable way to link FEWs to health services. Methods: This cross-sectional phone survey was conducted in May 2015 with 97 FEWs aged 18–35 years and currently working at an entertainment venue in Phnom Penh. Results: Of the 96 respondents, 51% reported sending text messages daily; of them, 47% used Khmer script and 45% used Romanized Khmer. Younger FEWs were more likely to report daily texting (P<.001). Most FEWs (98%) in this study reported feeling comfortable receiving private health messages despite the fact that 39% were sharing their phone with others. Younger FEWs were less likely to share their phone with others (P=.02). Of all of the FEWs, 47% reported owning a smartphone, and younger women were more likely to own a smartphone than were older women (P=.08). Conclusions: The findings from this study support the development of mHealth interventions targeting high-risk groups in urban areas of Cambodia. Our data suggest that mHealth interventions using texting may be a feasible way of reaching FEWs in Phnom Penh.

  • Source and copyright: author Amr Jamal.

    Mobile Phone Use Among Medical Residents: A Cross-Sectional Multicenter Survey in Saudi Arabia


    Background: Mobile phones have great potential for medical education, as they allow health care providers and students to access resources efficiently at the precise time at the point-of-care to help in informed decision making. Objective: The objective of the study was to evaluate the prevalence of mobile phone usage among medical residents and to explore their attitudes, perceptions, and the challenges they experience when using mobile phones in academic and clinical practice. Methods: A cross-sectional survey was conducted on all 133 residents in 17 different specialties across two large academic hospitals in Riyadh, Saudi Arabia. The Web-based validated questionnaire measured mobile phone platform preferences, and their uses in general and medical practice. The perception of confidentiality and safety impact of using mobile phones for communication and accessing patient’s data was also explored, alongside challenges of use and how residents learn to use their mobile phone. Results: With a response rate of 101/133 (75.9%) and mean age of 27.8 (SD 3.0) years, we found that 100/101 (99.0%) of participants were mobile phone users with mean duration of use of 5.12 (SD 2.4) years, and a range from 1 to 12 years. There was no significant difference in use between male and female respondents. A negative linear correlation was found between age and use duration (P=.004). The most common operating system used by participants was the iOS platform (55/101, 54.5%), with English the most commonly used language to operate residents’ mobile phones (96/100, 96.0%) despite their native language being Arabic. For communication outside medical practice, chatting applications such as WhatsApp matched phone calls as most commonly used tools (each 88/101, 87.1%). These were also the primary tools for medical communication, but used at a lower rate (each 65/101, 64.4%). In medical practice, drug (83/101, 82.2%) and medical (80/101, 79.2%) references and medical calculation applications (61/101, 60.4%) were the most commonly used. Short battery life (48/92, 52%) was the most common technical difficulty, and distraction at least on a weekly basis (54/92, 58%) was the most likely side effect of using a mobile phone in medical practice. Practically, all participants agreed with the idea of integrating medical staff mobile phones with the hospital information system. Most residents described themselves as self-learners, while half learned from peers, and a quarter learned from the Internet. Only 7/101 (6.9%) had received formal training on the medical use of mobile phones. Over half of residents thought it was safe to discuss patients over their personal, nonencrypted email. Conclusions: Mobile phone use among medical residents has become almost universal in academic and clinical settings. Thus, academic and health care institutions should support proper utilization of these devices in medical training and point-of-care decision making, while continuing to protect patient confidentiality.

  • Vegethon iPhone app. Source: Sarah et al. Copyright owned by Nutrition Studies group at the Stanford Prevention Research Center.

    Mobile Technology for Vegetable Consumption: A Randomized Controlled Pilot Study in Overweight Adults


    Background: Mobile apps present a potentially cost-effective tool for delivering behavior change interventions at scale, but no known studies have tested the efficacy of apps as a tool to specifically increase vegetable consumption among overweight adults. Objective: The purpose of this pilot study was to assess the initial efficacy and user acceptability of a theory-driven mobile app to increase vegetable consumption. Methods: A total of 17 overweight adults aged 42.0 (SD 7.3) years with a body mass index (BMI) of 32.0 (SD 3.5) kg/m2 were randomized to the use of Vegethon (a fully automated theory-driven mobile app enabling self-monitoring of vegetable consumption, goal setting, feedback, and social comparison) or a wait-listed control condition. All participants were recruited from an ongoing 12-month weight loss trial (parent trial). Researchers who performed data analysis were blinded to condition assignment. The primary outcome measure was daily vegetable consumption, assessed using an adapted version of the validated Harvard Food Frequency Questionnaire administered at baseline and 12 weeks after randomization. An analysis of covariance was used to assess differences in 12-week vegetable consumption between intervention and control conditions, controlling for baseline. App usability and satisfaction were measured via a 21-item post-intervention questionnaire. Results: Using intention-to-treat analyses, all enrolled participants (intervention: 8; control: 9) were analyzed. Of the 8 participants randomized to the intervention, 5 downloaded the app and logged their vegetable consumption a mean of 0.7 (SD 0.9) times per day, 2 downloaded the app but did not use it, and 1 never downloaded it. Consumption of vegetables was significantly greater among the intervention versus control condition at the end of the 12-week pilot study (adjusted mean difference: 7.4 servings; 95% CI 1.4-13.5; P=.02). Among secondary outcomes defined a priori, there was significantly greater consumption of green leafy vegetables, cruciferous vegetables, and dark yellow vegetables (adjusted mean difference: 2.6, 1.6, and 0.8 servings; 95% CI 0.1-5.0, 0.1-3.2, and 0.3-1.4; P=.04, P=.04, and P=.004, respectively). Participants reported positive experiences with the app, including strong agreement with the statements “I have found Vegethon easy to use” and “I would recommend Vegethon to a friend” (mean 4.6 (SD 0.6) and 4.2 (SD 0.8), respectively, (on a 5-point scale). Conclusions: Vegethon demonstrated initial efficacy and user acceptability. A mobile app intervention may be useful for increasing vegetable consumption among overweight adults. The small sample size prevented precise estimates of effect sizes. Given the improved health outcomes associated with increases in vegetable consumption, these findings indicate the need for larger, longer-term evaluations of Vegethon and similar technologies among overweight adults and other suitable target groups. Trial Registration: NCT01826591; (Archived by WebCite at

  • Authors holding a smartphone. Source and copyright owned by Emeku et al.

    Mobile Health Insurance System and Associated Costs: A Cross-Sectional Survey of Primary Health Centers in Abuja, Nigeria


    Background: Nigeria contributes only 2% to the world’s population, accounts for 10% of the global maternal death burden. Health care at primary health centers, the lowest level of public health care, is far below optimal in quality and grossly inadequate in coverage. Private primary health facilities attempt to fill this gap but at additional costs to the client. More than 65% Nigerians still pay out of pocket for health services. Meanwhile, the use of mobile phones and related services has risen geometrically in recent years in Nigeria, and their adoption into health care is an enterprise worth exploring. Objective: The purpose of this study was to document costs associated with a mobile technology–supported, community-based health insurance scheme. Methods: This analytic cross-sectional survey used a hybrid of mixed methods stakeholder interviews coupled with prototype throw-away software development to gather data from 50 public primary health facilities and 50 private primary care centers in Abuja, Nigeria. Data gathered documents costs relevant for a reliable and sustainable mobile-supported health insurance system. Clients and health workers were interviewed using structured questionnaires on services provided and cost of those services. Trained interviewers conducted the structured interviews, and 1 client and 1 health worker were interviewed per health facility. Clinic expenditure was analyzed to include personnel, fixed equipment, medical consumables, and operation costs. Key informant interviews included a midmanagement staff of a health-management organization, an officer-level staff member of a mobile network operator, and a mobile money agent. Results: All the 200 respondents indicated willingness to use the proposed system. Differences in the cost of services between public and private facilities were analyzed at 95% confidence level (P<.001). This indicates that average out-of-pocket cost of services at private health care facilities is significantly higher than at public primary health care facilities. Key informant interviews with a health management organizations and a telecom operator revealed high investment interests. Cost documentation analysis of income versus expenditure for the major maternal and child health service areas—antenatal care, routine immunization, and birth attendance for 1 year—showed that primary health facilities would still profit if technology-supported, health insurance schemes were adopted. Conclusions: This study demonstrates a case for the implementation of enrolment, encounter management, treatment verification, claims management and reimbursement using mobile technology for health insurance in Abuja, Nigeria. Available data show that the introduction of an electronic job aid improved efficiency. Although it is difficult to make a concrete statement on profitability of this venture but the interest of the health maintenance organizations and telecom experts in this endeavor provides a positive lead.

  • Source:, CC0 Licensed, Attribution: Maurizio Pesce; modified using image from authors.

    Smartphone Applications to Support Tuberculosis Prevention and Treatment: Review and Evaluation


    Background: Tuberculosis (TB) remains a major global health problem and is the leading killer due to a single infectious disease. Mobile health (mHealth)–based tools such as smartphone apps have been suggested as tools to support TB control efforts (eg, identification, contact tracing, case management including patient support). Objective: The purpose of this review was to identify and assess the functionalities of mobile apps focused on prevention and treatment of TB. Methods: We searched 3 online mobile app stores. Apps were included if they were focused on TB and were in English, Spanish, or Portuguese. For each included app, 11 functionalities were assessed (eg, inform, instruct, record), and searches were conducted to identify peer-review publications of rigorous testing of the available apps. Results: A total of 1332 potentially relevant apps were identified, with 24 meeting our inclusion criteria. All of the apps were free to download, but 7 required login and password and were developed for specific clinics, regional sites, or research studies. Targeted users were mainly clinicians (n=17); few (n=4) apps were patient focused. Most apps (n=17) had 4 or fewer functions out of 11 (range 1-6). The most common functionalities were inform and record (n=15). Although a number of apps were identified with various functionalities to support TB efforts, some had issues such as incorrect spelling and grammar, inconsistent responses to data entry, problems with crashing, or links to features that had no data. Of more concern, some apps provided potentially harmful information to patients, such as links to natural remedies for TB and natural healers. One-third of the apps (8/24) had not been updated for more than a year and may no longer be supported. Peer-reviewed publications were identified for only two of the included apps. In the gray literature (not found in the app stores), three TB-related apps were identified as in progress, being launched, or tested. Conclusions: Apps identified for TB prevention and treatment had minimal functionality, primarily targeted frontline health care workers, and focused on TB information (eg, general information, guidelines, and news) or data collection (eg, replace paper-based notification or tracking). Few apps were developed for use by patients and none were developed to support TB patient involvement and management in their care (eg, follow-up alerts/reminders, side effects monitoring) or improve interaction with their health care providers, limiting the potential of these apps to facilitate patient-centered care. Our evaluation shows that more refined work is needed to be done in the area of apps to support patients with active TB. Involving TB patients in treatment in the design of these apps is recommended.

  • Source and copyright: Emily Keeler/The Ohio State University College of Pharmacy, permission to use by authors.

    Enhancing Pharmacy Student Learning and Perceptions of Medical Apps


    Background: The use of mobile apps in health care is growing. Current and future practitioners must be equipped with the skills to navigate and utilize apps in patient care, yet few strategies exist for training health care professional students on the usage of apps. Objective: To characterize first-year pharmacy student use of medical apps, evaluate first-year pharmacy student's perception of skills in finding, evaluating, and using medical apps before and after a focused learning experience, and assess student satisfaction and areas for improvement regarding the learning experience. Methods: Students listened to a recorded, Web-based lecture on finding, evaluating, and using mobile apps in patient care. A 2-hour, interactive workshop was conducted during which students were led by an instructor through a discussion on strategies for finding and using apps in health care. The students practiced evaluating 6 different health care–related apps. Surveys were conducted before and after the focused learning experience to assess students' perceptions of medical apps and current use and perspectives on satisfaction with the learning experience and role of technology in health care. Results: This educational intervention is the first described formal, interactive method to educate student pharmacists on medical apps. With a 99% response rate, surveys conducted before and after the learning experience displayed perceived improvement in student skills related to finding (52/119, 44% before vs 114/120, 95% after), evaluating (18/119, 15% before vs 112/120, 93% after), and using medical apps in patient care (31/119, 26% before vs 108/120, 90% after) and the health sciences classroom (38/119, 32% before vs 104/120, 87% after). Students described satisfaction with the educational experience and agreed that it should be repeated in subsequent years (89/120, 74% agreed or strongly agreed). Most students surveyed possessed portable electronic devices (107/119, 90% mobile phone) and agreed with the concept of medical apps being an important part of the health care profession in the future (112/119, 94% before and 115/120, 96% after). Conclusions: Student pharmacists recognize the key role technology plays in the future of health care. A medical apps workshop was successful in improving student pharmacists' perceptions of ability to find, evaluate, and use medical apps.

  • Source:, CC0 Public domain; modified using image of Mobile App Development Guideline for Hospital Settings, source: the authors.

    A Mobile App Development Guideline for Hospital Settings: Maximizing the Use of and Minimizing the Security Risks of "Bring Your Own Devices" Policies


    Background: Hospitals today are introducing new mobile apps to improve patient care and workflow processes. Mobile device adoption by hospitals fits with present day technology behavior; however, requires a deeper look into hospital device policies and the impact on patients, staff, and technology development. Should hospitals spend thousands to millions of dollars to equip all personnel with a mobile device that is only used in a hospital environment? Allowing health care professionals to use personal mobile devices at work, known as bring-your-own-device (BYOD), has the potential to support both the hospital and its employees to deliver effective and efficient care. Objective: The objectives of this research were to create a mobile app development guideline for a BYOD hospital environment, apply the guideline to the development of an in-house mobile app called TaskList, pilot the TaskList app within Boston Children’s Hospital (BCH), and refine the guideline based on the app pilot. TaskList is an Apple operating system (iOS)-based app designed for medical residents to monitor, create, capture, and share daily collaborative tasks associated with patients. Methods: To create the BYOD guidelines, we developed TaskList that required the use of mobile devices among medical resident. The TaskList app was designed in four phases: (1) mobile app guideline development, (2) requirements gathering and developing of TaskList fitting the guideline, (3) deployment of TaskList using BYOD with end-users, and (4) refinement of the guideline based on the TaskList pilot. Phase 1 included understanding the existing hospital BYOD policies and conducting Web searches to find best practices in software development for a BYOD environment. Phase 1 also included gathering subject matter input from the Information Services Department (ISD) at BCH. Phase 2 involved the collaboration between the Innovation Acceleration Program at BCH, the ISD Department and the TaskList Clinical team in understanding what features should be built into the app. Phase 3 involved deployment of TaskList on a clinical floor at BCH. Lastly, Phase 4 gathered the lessons learned from the pilot to refine the guideline. Results: Fourteen practical recommendations were identified to create the BCH Mobile Application Development Guideline to safeguard custom applications in hospital BYOD settings. The recommendations were grouped into four categories: (1) authentication and authorization, (2) data management, (3) safeguarding app environment, and (4) remote enforcement. Following the guideline, the TaskList app was developed and then was piloted with an inpatient ward team. Conclusions: The Mobile Application Development guideline was created and used in the development of TaskList. The guideline is intended for use by developers when addressing integration with hospital information systems, deploying apps in BYOD health care settings, and meeting compliance standards, such as Health Insurance Portability and Accountability Act (HIPAA) regulations.

  • Image Source: https:, Copyright Syda Productions, CC-BY 2.0; license purchased by authors.

    Evaluating the Maintenance of Lifestyle Changes in a Randomized Controlled Trial of the ‘Get Healthy, Stay Healthy’ Program


    Background: Extending contact with participants after initial, intensive intervention may support maintenance of weight loss and related behaviors. Objective: This community-wide trial evaluated a text message (short message service, SMS)-delivered, extended contact intervention (‘Get Healthy, Stay Healthy’ (GHSH)), which followed on from a population-level, behavioral telephone coaching program. Methods: This study employed a parallel, randomized controlled trial: GHSH compared with no continued contact (standard practice). Participants (n=228) were recruited after completing a 6-month lifestyle telephone coaching program: mean age = 53.4 (standard deviation (SD)=12.3) years; 66.7% (152/228) female; mean body mass index (BMI) upon entering GHSH=29.5 kg/m2 (SD = 6.0). Participants received tailored text messages over a 6-month period. The message frequency, timing, and content of the messages was based on participant preference, ascertained during two tailoring telephone calls. Primary outcomes of body weight, waist circumference, physical activity (walking, moderate, and vigorous sessions/week), and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks per day, takeaway meals per week; fat, fiber and total indices from the Fat and Fiber Behavior Questionnaire) were assessed via self-report before (baseline) and after (6-months) extended contact (with moderate-vigorous physical activity (MVPA) also assessed via accelerometry). Results: Significant intervention effects, all favoring the intervention group, were observed at 6-months for change in weight (-1.35 kg, 95% confidence interval (CI): -2.24, -0.46, P=.003), weekly moderate physical activity sessions (0.56 sessions/week, 95% CI: 0.15, 0.96, P=.008) and accelerometer-assessed MVPA (24.16 minutes/week, 95% CI: 5.07, 43.25, P=.007). Waist circumference, other physical activity outcomes and dietary outcomes, did not differ significantly between groups. Conclusions: The GHSH extended care intervention led to significantly better anthropometric and physical activity outcomes than standard practice (no contact). This evidence is useful for scaling up the delivery of GHSH as standard practice following the population-level telephone coaching program.

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  • Exploratory Study of funding and commercialization strategies for sustainable adoption and scale-up of mHealth initiatives in the LMICs.

    Date Submitted: May 20, 2016

    Open Peer Review Period: May 25, 2016 - Jul 20, 2016

    Background: The new Sustainable Development Goals consist of 17 goals among which Universal Health Coverage (SDG3) and Partnerships for the Goals (SDG17) are two of the most relevant for our purposes....

    Background: The new Sustainable Development Goals consist of 17 goals among which Universal Health Coverage (SDG3) and Partnerships for the Goals (SDG17) are two of the most relevant for our purposes. (1) With rapid growth and daily innovations, Information and Communication Technology (ICT) has become the cornerstone of transforming global health care industry all around the world. Wide penetration of internet and mobile networks in many low and middle income countries (LMICs) has brought about new ideas and promises for better access, lower costs and higher quality of health services in remote areas. To make this promise come true, the ICT and global health industry along with a vast number of user and provider stakeholders have developed hundreds of transboundary mHealth ecosystems to leverage the provision and distribution of equitable health services operation, management and control through various mHealth initiatives. However, the lack of empirical evidence supporting the cost, performance and health outcomes of mHealth initiatives have impeded post pilot scale up, implementation and integration of mobile technologies in many health systems. On the same note, with limited financial and structural resources and without supporting empirical evidence the LMICs which are most likely to benefit from sustainable mHealth interventions, often do not manage to grab the attention of public and private partners to secure sustainable investments for scale up phase. Results of this study show that in agreement with the SDG17 and the comparative Net Utility equation, some elemental components for a successful business partnership, i.e.; “balance in value gain for the economic buyer and the funder”, “use of value capturing commercialization strategies with attention to stakeholders, Technology and contextual requirements, and “insurers’ contributions” need to get more concentrated attention before the sustainability of scale-up of mHealth projects can be achieved. Objective: This study is to show the necessity of ongoing market analyses to investigate the best practices for keeping mHealth initiatives sustainable for its adopters throughout its life cycle. Methods: The novel nature of our paper’s subject along with the authors’ concern to study a larger number of variables that could influence the paper’s suggested strategies, have encouraged us to use the Qualitative Exploratory Research method as the best way to address the new and undisclosed problems within the commercial scope of the mHealth industry. Results: The results of this exploratory review suggest that there are certain factors that may directly or indirectly contribute to an affordable and sustainable scale-up and adoption of mHealth initiatives especially within resource-poor contexts. Interestingly, some elemental components for a successful business partnership, i.e.; “balance in value gain for the economic buyer and the funder”, “use of value capturing commercialization strategies with attention to stakeholders, Technology and contextual requirements, and “insurers’ contributions” need to get more profound attention before the sustainability of scale-up mHealth projects could be achieved. Conclusions: Discussed as the “Technology, Context and Commercialization Triangle”, the study suggests that for mHealth projects to be sustainable, three main aspects need to be taken into consideration at the same time. The first two aspects, which have been more commonly discussed in the body of literature, are cultural norms and technical infrastructure. Designing systems that would strengthen and integrate with the pre-existing technologies would motivate LMICs’ health authorities to support new mHealth projects. Also for the LMICs to be receptive to mHealth technologies, the applications should agree with the community’s culture and believes. The third aspect however, is beyond the technical and contextual requirements and looks more carefully into mHealth projects financing and commercialization models. It seems that even in the LMICs, the era of one-way donor-receiver relationship in development projects is coming to its end and for the mHealth projects to experience sustainable scale-up phases, donor-receiver relationship should turn into more “gain” oriented business partnerships with variety of public and private investors. Choosing the right partner at different stages of the projects’ life cycle is one of the delicate moments of mHealth business which has failed to be thoroughly discussed in the context of academia and industry. This study shows that not all stages of mHealth projects’ life cycle would respond equally to a single donor-based financing model, but specific financing strategies and engagement with different types of investors, businesses and technical partners; i.e. “public, private, NGOs and foundations” at infancy, development and maturity stages of mHealth projects may increase the chances for more sustainable scale-up phases in resource-poor countries. Last but not least, similar to their movement in the developed countries, supportive financial systems such as health insurers should start to consider the LMICs’ population as a new segment. The authors suggest that further studies are needed to assess the relevance of these findings within the contextual realities that permeate the LMIC sphere.

  • The quality and accuracy of mobile applications to prevent driving after drinking alcohol

    Date Submitted: May 10, 2016

    Open Peer Review Period: May 16, 2016 - Jul 11, 2016

    Background: Driving after the consumption of alcohol represents a significant public health problem globally. Individual prevention countermeasures such as personalised mobile applications aimed at p...

    Background: Driving after the consumption of alcohol represents a significant public health problem globally. Individual prevention countermeasures such as personalised mobile applications aimed at preventing the behaviour are widespread but there is little research on their accuracy and evidence-base. There has been no known assessment investigating the quality of such apps. Objective: This study aimed to determine the quality and accuracy of apps for drink driving prevention by conducting a review and evaluation of relevant mobile apps. Methods: A systematic app search was conducted following PRISMA guidelines. App quality was assessed using the Mobile Application Rating Scale (MARS). Apps providing blood alcohol calculators (hereafter ‘calculators’) were reviewed against current alcohol advice for accuracy. Results: A total of 58 apps (30 iOS and 28 Android) were included in the final analysis. Drink driving prevention apps had significantly lower engagement and overall quality scores than alcohol management apps. Most calculators provided conservative BAC time until sober calculations. None of the apps had been evaluated to determine efficacy in changing either drinking or driving behaviours. Conclusions: This novel study demonstrates that drink driving prevention apps lack quality as a function of low engagement. This could be improved by increasing engagement features, such as gamification. Further research should examine the context and motivations for using apps to prevent driving after drinking in at-risk populations. Development of drink driving prevention apps should incorporate evidence based information and guidance, and this is lacking in current apps.

  • Beyond the RCT: a review of alternatives in mHealth clinical trial methods.

    Date Submitted: May 9, 2016

    Open Peer Review Period: May 13, 2016 - Jul 8, 2016

    Background: Randomized controlled trials (RCTs) have long been considered the primary research study design capable of eliciting causal relationships between health interventions and consequent outcom...

    Background: Randomized controlled trials (RCTs) have long been considered the primary research study design capable of eliciting causal relationships between health interventions and consequent outcomes. However, with a prolonged duration from recruitment to publication, high-cost trial implementation, and a rigid trial protocol, RCTs are perceived as an impractical evaluation methodology for most mHealth apps. Objective: Given the recent development of alternative evaluation methodologies and tools to automate mHealth research, we sought to determine the breadth of these methods and the extent that they were being used in clinical trials. Methods: We conducted a review of the registry to identify and examine current clinical trials involving mHealth apps and retrieved relevant trials registered between November 2014 and November 2015. Results: Of the 137 trials identified, 71 were found to meet inclusion criteria. The majority used an RCT trial design (77.5%; 55/71). Alternate designs included 3 one-shot case study designs (4.2%; 3/71), 2 one-group pretest posttest designs (2.8%;2/71), and 1 static-group comparison (1.4%; 1/71). Seventeen trials included a qualitative component to their methodology (23.9%). Complete trial data collection required 20 months on average to complete (M=20.75, SD=12.49). For trials with a total duration of two years or more (30.6%; 22/71), the average time from recruitment to complete data collection (M=35.45 months, SD=9.73) was two years longer than the average time required to collect primary data (M=10.68, SD=7.95). Trials had a moderate sample size of 115 participants. Two trials automated their data collection (2.9%) and seven trials collected data continuously (10.3%); on-site study implementation was heavily favoured (69/71, 97.1%). Frequent manual data collection extended trial duration, but automated continuous data collection did not. Academic sponsorship was the most common form of trial funding (73.2%; 52/71). Only seven trials had been completed at the time this retrospective review was conducted (9.9%; 7/71). Conclusions: mHealth evaluation methodology has not deviated from common methods, despite the need for more relevant and timely evaluations. There is a need for clinical evaluation to keep pace with the level of innovation of mHealth if it is to have meaningful impact in informing payers, providers, policy makers, and patients. Clinical Trial: n/a

  • Engaging Gatekeeper-stakeholders in Development of a Mobile Health Intervention to Improve Medication Adherence among African American and Pacific Islander Elderly Patients with Hypertension

    Date Submitted: Apr 25, 2016

    Open Peer Review Period: Apr 29, 2016 - Jun 24, 2016

    Background: Approximately 70 million people in the US have hypertension. While antihypertensive therapy can reduce the morbidity and mortality associated with hypertension, often patients do not take...

    Background: Approximately 70 million people in the US have hypertension. While antihypertensive therapy can reduce the morbidity and mortality associated with hypertension, often patients do not take their medication as prescribed. Objective: The goal of this study was to better understand issues affecting the acceptability and usability of mobile health technology (mHealth) to improve medication adherence for elderly African American (AA) and Native Hawaiian and Pacific Islander (NHPI) patients with hypertension. Methods: In-depth interviews were conducted with 20 Gatekeeper-stakeholders using targeted open-ended questions. Interviews were de-identified, transcribed, organized and coded manually by two independent coders. Analysis of patient interviews used largely a deductive approach because the targeted open-ended interview questions were designed to explore issues specific to the design and acceptability of a mHealth intervention for seniors. Results: A number of similar themes regarding elements of a successful intervention emerged from our two groups of AA and NHPI Gatekeeper-stakeholders. First was the need to teach participants both about the importance of adherence to antihypertensive medications; second, the use of smart/cell phones for messaging and patients need to be able to access ongoing technical support; third, messaging needs to be short and simple, but personalized, and to come from someone the participant trusts and with whom they have a connection. There were some differences between groups. For instance, there was a strong sentiment among AA that the church be involved and that the intervention begin with group workshops, while NHPI seemed to believe that the teaching could occur on a one-to-one basis with the health care provider. Conclusions: Information from our Gatekeeper-stakeholder (key informant) interviews suggests that the design of the mHealth intervention to improve adherence to antihypertensives among the elderly could be very similar between AAs and NHPIs. The main difference might be in the way in which the program is initiated (possibly through church-based workshops for AA and by individual providers for NHPIs). Another difference might be who sends the messages with AA wanting someone outside the health care system, but NHPI preferring a provider.

  • Investigating the Perceptions of Care Coordinators on Using Behavior Theory-Based Mobile Health Technology with Medicaid Populations: A Grounded Theory Study

    Date Submitted: Apr 20, 2016

    Open Peer Review Period: Apr 22, 2016 - Jun 17, 2016

    Background: Medicaid populations are less engaged in their healthcare than the rest of the population, translating to worse health outcomes and increased healthcare costs. Since theory-based mobile he...

    Background: Medicaid populations are less engaged in their healthcare than the rest of the population, translating to worse health outcomes and increased healthcare costs. Since theory-based mobile health (mHealth) interventions have been shown to increase patient engagement, mobile phones may be an optimal strategy to reach this population. There is a deep disconnect between developers of mHealth technology and health behavior researchers, so there is a lack of data on what components of theory-based mHealth increase patient engagement. Objective: This study aims to address this gap between academia and practice by conducting research using the health behavior-theory based patient-provider text-messaging platform, Sense Health, which integrates Transtheoretical Model and Stages of Change (TTM), Social Cognitive Theory (SCT), Supportive Accountability, and Motivational Interviewing. Methods: Interviews based in grounded-theory methodology were conducted with 10 care managers to triangulate the findings of internal user activity data and to further understand perceptions of the relationship between mHealth and patient engagement. Results: The interviews with care managers yield a grounded theory model including four intertwined relationships revolving around patient engagement: between Sense Health, client-care manager relationships, and communication; Sense Health, literacy, and access to care; support, Sense Health, and communication; and Sense Health, patient accountability, and patient motivation. Conclusions: Sense Health features tied to health behavior theory appear to be effective in improving patient engagement. Two-way communication (Supportive Accountability), trusted relationships (Supportive Accountability, SCT), personalized messages (TTM), and patient input (TTM, SCT, Motivational Interviewing) appeared as the most relevant components in achieving desired outcomes. Additionally, reminder messages were noted as especially useful in making Medicaid patients accountable, and in turn engaging them in their health and healthcare. These findings expose how this theory-centered platform drives engagement, allowing Sense Health, and future mHealth interventions that aim to improvement patient engagement in Medicaid populations, to improve their technology. Clinical Trial: Columbia University Medical Center Institutional Review Board (IRB-AAAQ5254)

  • SMS-Based Intervention Targeting Alcohol Consumption Among University Students: Findings from a Formative Development Study

    Date Submitted: Apr 12, 2016

    Open Peer Review Period: Apr 12, 2016 - Jun 7, 2016

    Background: Drinking of alcohol among university students is a global phenomenon with heavy episodic drinking being accepted despite several potential negative consequences. Half of all young adults i...

    Background: Drinking of alcohol among university students is a global phenomenon with heavy episodic drinking being accepted despite several potential negative consequences. Half of all young adults in Sweden attend university making the health and well-being of this group a public health concern. There is emerging evidence that text messaging (SMS) interventions are effective to promote behaviour change among students. However, it is still unclear how effectiveness can be optimized through intervention design or how user interest and adherence can be maximised. Objective: To develop an SMS-based intervention targeting alcohol drinking among university students using formative research. Methods: A formative research design was used including an iterative revision process based on input from end users and experts. Data were collected via focus groups (n=7) with students and a panel evaluation involving students (n=15) and experts (n=5). Student participants were recruited from five universities in Sweden. A semi-structured interview guide was used in the focus groups and included questions on alcohol culture, message content and intervention format. The panel evaluation asked participants to rate to what degree preliminary messages were understandable, usable and had a good tone on a scale from 1 to 4 (1 = very low degree; 4 = very high degree). Participants could also write their own comments for each message. Qualitative data were analysed using qualitative descriptive analysis. Quantitative data were analysed using descriptive statistics. The SMS messages and the intervention format were revised continuously, in parallel with data collection. A behaviour change technique analysis was conducted on the final version of the program. Results: The focus group data showed that, overall, students were positive towards the SMS intervention. Messages that were neutral, motivated, clear and tangible engaged students. Students expressed that they preferred short, concise messages and confirmed that a 6-week intervention was an appropriate duration. However, there was limited consensus regarding SMS frequency, personalization of messages and timing. Overall, messages scored high on understanding (3.86, SD 0.43), usability (3.70, SD 0.61) and tone (3.78, SD 0.53). Participants added comments to 67 of 70 messages, including suggestions for change in wording, order of messages, and feedback on why a message was unclear or needed major revision. Comments also included positive feedback that confirmed the value of the messages. Twenty-three behaviour change techniques, aimed at, for example, addressing self-regulatory skills, were identified in the final program. Conclusions: The formative research design was valuable and resulted in significant changes to the intervention. All the original SMS messages were changed and new messages were added. The findings showed that, overall, students were positive towards receiving support through SMS and that neutral, motivated, clear and tangible messages promoted engagement. However, limited consensus was found on the timing, frequency and tailoring of messages.