JMIR Publications

JMIR mHealth and uHealth

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

JMIR's Thomson Reuter Impact Factor of 4.636 for 2016

Journal Description

JMIR mHealth and uHealth (JMU, ISSN 2291-5222) is a spin-off journal of JMIR, the leading eHealth journal (Impact Factor 2016: 5.175). JMIR mHealth and uHealth is indexed in PubMed, PubMed Central, and Science Citation Index Expanded (SCIE), and in June 2017 received a stunning inaugural Impact Factor of 4.636

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

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

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

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


Recent Articles:

  • Hardware setup and software UI of the reported system. Source: Image created by the Authors; Copyright: TerryDr Info Technology Co. Ltd; URL:; License: Creative Commons Attribution (CC-BY).

    Development of a Whole Slide Imaging System on Smartphones and Evaluation With Frozen Section Samples


    Background: The aim was to develop scalable Whole Slide Imaging (sWSI), a WSI system based on mainstream smartphones coupled with regular optical microscopes. This ultra-low-cost solution should offer diagnostic-ready imaging quality on par with standalone scanners, supporting both oil and dry objective lenses of different magnifications, and reasonably high throughput. These performance metrics should be evaluated by expert pathologists and match those of high-end scanners. Objective: The aim was to develop scalable Whole Slide Imaging (sWSI), a whole slide imaging system based on smartphones coupled with optical microscopes. This ultra-low-cost solution should offer diagnostic-ready imaging quality on par with standalone scanners, supporting both oil and dry object lens of different magnification. All performance metrics should be evaluated by expert pathologists and match those of high-end scanners. Methods: In the sWSI design, the digitization process is split asynchronously between light-weight clients on smartphones and powerful cloud servers. The client apps automatically capture FoVs at up to 12-megapixel resolution and process them in real-time to track the operation of users, then give instant feedback of guidance. The servers first restitch each pair of FoVs, then automatically correct the unknown nonlinear distortion introduced by the lens of the smartphone on the fly, based on pair-wise stitching, before finally combining all FoVs into one gigapixel VS for each scan. These VSs can be viewed using Internet browsers anywhere. In the evaluation experiment, 100 frozen section slides from patients randomly selected among in-patients of the participating hospital were scanned by both a high-end Leica scanner and sWSI. All VSs were examined by senior pathologists whose diagnoses were compared against those made using optical microscopy as ground truth to evaluate the image quality. Results: The sWSI system is developed for both Android and iPhone smartphones and is currently being offered to the public. The image quality is reliable and throughput is approximately 1 FoV per second, yielding a 15-by-15 mm slide under 20X object lens in approximately 30-35 minutes, with little training required for the operator. The expected cost for setup is approximately US $100 and scanning each slide costs between US $1 and $10, making sWSI highly cost-effective for infrequent or low-throughput usage. In the clinical evaluation of sample-wise diagnostic reliability, average accuracy scores achieved by sWSI-scan-based diagnoses were as follows: 0.78 for breast, 0.88 for uterine corpus, 0.68 for thyroid, and 0.50 for lung samples. The respective low-sensitivity rates were 0.05, 0.05, 0.13, and 0.25 while the respective low-specificity rates were 0.18, 0.08, 0.20, and 0.25. The participating pathologists agreed that the overall quality of sWSI was generally on par with that produced by high-end scanners, and did not affect diagnosis in most cases. Pathologists confirmed that sWSI is reliable enough for standard diagnoses of most tissue categories, while it can be used for quick screening of difficult cases. Conclusions: As an ultra-low-cost alternative to whole slide scanners, diagnosis-ready VS quality and robustness for commercial usage is achieved in the sWSI solution. Operated on main-stream smartphones installed on normal optical microscopes, sWSI readily offers affordable and reliable WSI to resource-limited or infrequent clinical users.

  • Students learning with mobile Augmented Reality blended learning environment (mARble). Source: The Authors; Copyright: Urs-Vito Albrecht; URL:; License: Creative Commons Attribution (CC-BY).

    Mobile Augmented Reality as a Feature for Self-Oriented, Blended Learning in Medicine: Randomized Controlled Trial


    Background: Advantages of mobile Augmented Reality (mAR) application-based learning versus textbook-based learning were already shown in a previous study. However, it was unclear whether the augmented reality (AR) component was responsible for the success of the self-developed app or whether this was attributable to the novelty of using mobile technology for learning. Objective: The study’s aim was to test the hypothesis whether there is no difference in learning success between learners who employed the mobile AR component and those who learned without it to determine possible effects of mAR. Also, we were interested in potential emotional effects of using this technology. Methods: Forty-four medical students (male: 25, female: 19, mean age: 22.25 years, standard deviation [SD]: 3.33 years) participated in this study. Baseline emotional status was evaluated using the Profile of Mood States (POMS) questionnaire. Dermatological knowledge was ascertained using a single choice (SC) test (10 questions). The students were randomly assigned to learn 45 min with either a mobile learning method with mAR (group A) or without AR (group B). Afterwards, both groups were again asked to complete the previous questionnaires. AttrakDiff 2 questionnaires were used to evaluate the perceived usability as well as pragmatic and hedonic qualities. For capturing longer term effects, after 14 days, all participants were again asked to complete the SC questionnaire. All evaluations were anonymous, and descriptive statistics were calculated. For hypothesis testing, an unpaired signed-rank test was applied. Results: For the SC tests, there were only minor differences, with both groups gaining knowledge (average improvement group A: 3.59 [SD 1.48]; group B: 3.86 [SD 1.51]). Differences between both groups were statistically insignificant (exact Mann Whitney U, U=173.5; P=.10; r=.247). However, in the follow-up SC test after 14 days, group A had retained more knowledge (average decrease of the number of correct answers group A: 0.33 [SD 1.62]; group B: 1.14 [SD 1.30]). For both groups, descriptively, there were only small variations regarding emotional involvement, and learning experiences also differed little, with both groups rating the app similar for its stimulating effect. Conclusions: We were unable to show significant effects for mAR on the immediate learning success of the mobile learning setting. However, the similar level of stimulation being noted for both groups is inconsistent with the previous assumption of the success of mAR-based approach being solely attributable to the excitement of using mobile technology, independent of mAR; the mAR group showed some indications for a better long-term retention of knowledge. Further studies are needed to examine this aspect. Trial Registration: German Clinical Trials Register (DRKS): 00012980; navigationId=trial.HTML&TRIAL_ID=DRKS00012980 (Archived by WebCite at 6tCWoM2Jb).

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

    Effectiveness of SmartMoms, a Novel eHealth Intervention for Management of Gestational Weight Gain: Randomized Controlled Pilot Trial


    Background: Two-thirds of pregnant women exceed gestational weight gain (GWG) recommendations. Because excess GWG is associated with adverse outcomes for mother and child, development of scalable and cost-effective approaches to deliver intensive lifestyle programs during pregnancy is urgent. Objective: The aim of this study was to decrease the proportion of women who exceed the Institute of Medicine (IOM) 2009 GWG guidelines. Methods: In a parallel-arm randomized controlled trial, 54 pregnant women (age 18-40 years) who were overweight (n=25) or obese (n=29) were enrolled to test whether an intensive lifestyle intervention (called SmartMoms) decreased the proportion of women with excess GWG, defined as exceeding the 2009 IOM guidelines, compared to no intervention (usual care group). The SmartMoms intervention was delivered through mobile phone (remote group) or in a traditional in-person, clinic-based setting (in-person group), and included a personalized dietary intake prescription, self-monitoring weight against a personalized weight graph, activity tracking with a pedometer, receipt of health information, and continuous personalized feedback from counselors. Results: A significantly smaller proportion of women exceeded the IOM 2009 GWG guidelines in the SmartMoms intervention groups (in-person: 56%, 10/18; remote: 58%, 11/19) compared to usual care (85%, 11/13; P=.02). The remote intervention was a lower cost to participants (mean US $97, SD $6 vs mean US $347, SD $40 per participant; P<.001) and clinics (US $215 vs US $419 per participant) and with increased intervention adherence (76.5% vs 60.8%; P=.049). Conclusions: An intensive lifestyle intervention for GWG can be effectively delivered via a mobile phone, which is both cost-effective and scalable. Trial Registration: NCT01610752; (Archived by WebCite at

  • ORION smartphone app. Source: Image created by the Authors; Copyright: The Authors / Osaka Prefectural Government, NTT DATA KANSAI corporation; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Improvements in Patient Acceptance by Hospitals Following the Introduction of a Smartphone App for the Emergency Medical Service System: A Population-Based...


    Background: Recently, the number of ambulance dispatches has been increasing in Japan, and it is therefore difficult for hospitals to accept emergency patients smoothly and appropriately because of the limited hospital capacity. To facilitate the process of requesting patient transport and hospital acceptance, an emergency information system using information technology (IT) has been built and introduced in various communities. However, its effectiveness has not been thoroughly revealed. We introduced a smartphone app system in 2013 that enables emergency medical service (EMS) personnel to share information among themselves regarding on-scene ambulances and the hospital situation. Objective: The aim of this study was to assess the effects of introducing this smartphone app on the EMS system in Osaka City, Japan. Methods: This retrospective study analyzed the population-based ambulance records of Osaka Municipal Fire Department. The study period was 6 years, from January 1, 2010 to December 31, 2015. We enrolled emergency patients for whom on-scene EMS personnel conducted hospital selection. The main endpoint was the difficulty experienced in gaining hospital acceptance at the scene. The definition of difficulty was making ≥5 phone calls by EMS personnel at the scene to hospitals until a decision to transport was determined. The smartphone app was introduced in January 2013, and we compared the patients treated from 2010 to 2012 (control group) with those treated from 2013 to 2015 (smartphone app group) using an interrupted time-series analysis to assess the effects of introducing this smartphone app. Results: A total of 600,526 emergency patients for whom EMS personnel selected hospitals were eligible for our analysis. There were 300,131 emergency patients in the control group (50.00%, 300,313/600,526) from 2010 to 2012 and 300,395 emergency patients in the smartphone app group (50.00%, 300,395/600,526) from 2013 to 2015. The rate of difficulty in hospital acceptance was 14.19% (42,585/300,131) in the control group and 10.93% (32,819/300,395) in the smartphone app group. No change over time in the number of difficulties in hospital acceptance was found before the introduction of the smartphone app (regression coefficient: −2.43, 95% CI −5.49 to 0.64), but after its introduction, the number of difficulties in hospital acceptance gradually decreased by month (regression coefficient: −11.61, 95% CI −14.57 to −8.65). Conclusions: Sharing information between an ambulance and a hospital by using the smartphone app at the scene was associated with decreased difficulty in obtaining hospital acceptance. Our app and findings may be worth considering in other areas of the world where emergency medical information systems with IT are needed.

  • Graphic of a mobile phone to illustrate sleep apps. Source: The Authors; Copyright: Julie W. McMahon, Senior Campus Designer, University of Illinois-Urbana Champaign; License: Licensed by the authors.

    Mobile Phone Interventions for Sleep Disorders and Sleep Quality: Systematic Review


    Background: Although mobile health technologies have been developed for interventions to improve sleep disorders and sleep quality, evidence of their effectiveness remains limited. Objective: A systematic literature review was performed to determine the effectiveness of mobile technology interventions for improving sleep disorders and sleep quality. Methods: Four electronic databases (EBSCOhost, PubMed/Medline, Scopus, and Web of Science) were searched for articles on mobile technology and sleep interventions published between January 1983 and December 2016. Studies were eligible for inclusion if they met the following criteria: (1) written in English, (2) adequate details on study design, (3) focus on sleep intervention research, (4) sleep index measurement outcome provided, and (5) publication in peer-reviewed journals. Results: An initial sample of 2679 English-language papers were retrieved from five electronic databases. After screening and review, 16 eligible studies were evaluated to examine the impact of mobile phone interventions on sleep disorders and sleep quality. These included one case study, three pre-post studies, and 12 randomized controlled trials. The studies were categorized as (1) conventional mobile phone support and (2) utilizing mobile phone apps. Based on the results of sleep outcome measurements, 88% (14/16) studies showed that mobile phone interventions have the capability to attenuate sleep disorders and to enhance sleep quality, regardless of intervention type. In addition, mobile phone intervention methods (either alternatively or as an auxiliary) provide better sleep solutions in comparison with other recognized treatments (eg, cognitive behavioral therapy for insomnia). Conclusions: We found evidence to support the use of mobile phone interventions to address sleep disorders and to improve sleep quality. Our findings suggest that mobile phone technologies can be effective for future sleep intervention research.

  • Consent from researchers app screen (montage). Source: ThemPower, Sage Bionetworks /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Consent Processes for Mobile App Mediated Research: Systematic Review


    Background: Since the launch of ResearchKit on the iOS platform in March 2015 and ResearchStack on the Android platform in June 2016, many academic and commercial institutions around the world have adapted these frameworks to develop mobile app-based research studies. These studies cover a wide variety of subject areas including melanoma, cardiomyopathy, and autism. Additionally, these app-based studies target a variety of participant populations, including children and pregnant women. Objective: The aim of this review was to document the variety of self-administered remote informed consent processes used in app-based research studies available between May and September 2016. Remote consent is defined as any consenting process with zero in-person steps, when a participant is able to join a study without ever seeing a member of the research team. This type of review has not been previously conducted. The research community would benefit from a rigorous interrogation of the types of consent taken as part of the seismic shift to entirely mobile meditated research studies. Methods: This review examines both the process of information giving and specific content shared, with special attention to data privacy, aggregation, and sharing. Results: Consistency across some elements of the app-based consent processes was found; for example, informing participants about how data will be curated from the phone. Variations in other elements were identified; for example, where specific information is shared and the level of detail disclosed. Additionally, several novel elements present in eConsent not typically seen in traditional consent for research were highlighted. Conclusions: This review advocates the importance of participant informedness in a novel and largely unregulated research setting.

  • Beat-to-beat analysis from R-R intervals (RRI) and peak-to-peak intervals (PPI). Source: Figure 3 from; Copyright: the authors; License: Creative Commons Attribution (CC-BY).

    Clinical Validation of Heart Rate Apps: Mixed-Methods Evaluation Study


    Background: Photoplethysmography (PPG) is a proven way to measure heart rate (HR). This technology is already available in smartphones, which allows measuring HR only by using the smartphone. Given the widespread availability of smartphones, this creates a scalable way to enable mobile HR monitoring. An essential precondition is that these technologies are as reliable and accurate as the current clinical (gold) standards. At this moment, there is no consensus on a gold standard method for the validation of HR apps. This results in different validation processes that do not always reflect the veracious outcome of comparison. Objective: The aim of this paper was to investigate and describe the necessary elements in validating and comparing HR apps versus standard technology. Methods: The FibriCheck (Qompium) app was used in two separate prospective nonrandomized studies. In the first study, the HR of the FibriCheck app was consecutively compared with 2 different Food and Drug Administration (FDA)-cleared HR devices: the Nonin oximeter and the AliveCor Mobile ECG. In the second study, a next step in validation was performed by comparing the beat-to-beat intervals of the FibriCheck app to a synchronized ECG recording. Results: In the first study, the HR (BPM, beats per minute) of 88 random subjects consecutively measured with the 3 devices showed a correlation coefficient of .834 between FibriCheck and Nonin, .88 between FibriCheck and AliveCor, and .897 between Nonin and AliveCor. A single way analysis of variance (ANOVA; P=.61 was executed to test the hypothesis that there were no significant differences between the HRs as measured by the 3 devices. In the second study, 20,298 (ms) R-R intervals (RRI)–peak-to-peak intervals (PPI) from 229 subjects were analyzed. This resulted in a positive correlation (rs=.993, root mean square deviation [RMSE]=23.04 ms, and normalized root mean square error [NRMSE]=0.012) between the PPI from FibriCheck and the RRI from the wearable ECG. There was no significant difference (P=.92) between these intervals. Conclusions: Our findings suggest that the most suitable method for the validation of an HR app is a simultaneous measurement of the HR by the smartphone app and an ECG system, compared on the basis of beat-to-beat analysis. This approach could lead to more correct assessments of the accuracy of HR apps.

  • Smarter Pregnancy, an mHealth platform to improve nutrition and lifestyle during the periconception period. Source: Peercode /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Opportunities of mHealth in Preconception Care: Preferences and Experiences of Patients and Health Care Providers and Other Involved Professionals


    Background: The importance of the preconception period and preconception care (PCC) are broadly acknowledged and the potential benefits regarding health promotion have been studied extensively. PCC provides the opportunity to identify, prevent, and treat modifiable and nonmodifiable risk factors to optimize the health of couples trying to become pregnant. The prevalence of modifiable and nonmodifiable risk factors in these couples is high, but the uptake of PCC remains low. Objective: The aim of this study is to identify the preferences and experiences of women and men (patients) trying to become pregnant and of health care providers and other involved professionals regarding mobile health (mHealth), in particular the coaching platform Smarter Pregnancy, and its potential role in PCC. Methods: Patients who participated in the Smarter Pregnancy randomized controlled trial (RCT) and health care providers and professionals also involved in PCC were invited to participate in a qualitative study. The barriers, benefits, and opportunities of big data collection by mHealth were discussed in focus group sessions, prompted with statements regarding PCC. Results: We composed five focus groups, consisting of 27 patients in total (23 women and 4 men), who participated in the RCT, and nine health care providers and other professionals. Of the patients, 67% (18/27) were familiar with the concept of PCC, but only 15% (4/27) received any form of PCC. A majority of 56% (combined percentages of statements 1 [n=18], 2 [n=11], and 3 [n=16]) of the patients believed in the benefit of receiving PCC, and all agreed that men should be involved in PCC as well. Patients did not have a problem using anonymized data obtained from mHealth tools for scientific purposes. Patients and health care providers and other professionals both acknowledged the lack of awareness regarding the importance of PCC and stated that mHealth provides several opportunities to support clinical PCC. Conclusions: Our findings substantiate previous studies addressing the low uptake of PCC due to unawareness or lack of perception of its relevance by couples who are trying to become pregnant. The positive judgment and experiences with mHealth, in particular Smarter Pregnancy, will stimulate future research and further development of effective and cost-effective personalized mHealth apps for patients, health care providers, and other professionals as an add-on to clinical PCC.

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

    Quantifying Human Movement Using the Movn Smartphone App: Validation and Field Study


    Background: The use of embedded smartphone sensors offers opportunities to measure physical activity (PA) and human movement. Big data—which includes billions of digital traces—offers scientists a new lens to examine PA in fine-grained detail and allows us to track people’s geocoded movement patterns to determine their interaction with the environment. Objective: The objective of this study was to examine the validity of the Movn smartphone app (Moving Analytics) for collecting PA and human movement data. Methods: The criterion and convergent validity of the Movn smartphone app for estimating energy expenditure (EE) were assessed in both laboratory and free-living settings, compared with indirect calorimetry (criterion reference) and a stand-alone accelerometer that is commonly used in PA research (GT1m, ActiGraph Corp, convergent reference). A supporting cross-validation study assessed the consistency of activity data when collected across different smartphone devices. Global positioning system (GPS) and accelerometer data were integrated with geographical information software to demonstrate the feasibility of geospatial analysis of human movement. Results: A total of 21 participants contributed to linear regression analysis to estimate EE from Movn activity counts (standard error of estimation [SEE]=1.94 kcal/min). The equation was cross-validated in an independent sample (N=42, SEE=1.10 kcal/min). During laboratory-based treadmill exercise, EE from Movn was comparable to calorimetry (bias=0.36 [−0.07 to 0.78] kcal/min, t82=1.66, P=.10) but overestimated as compared with the ActiGraph accelerometer (bias=0.93 [0.58-1.29] kcal/min, t89=5.27, P<.001). The absolute magnitude of criterion biases increased as a function of locomotive speed (F1,4=7.54, P<.001) but was relatively consistent for the convergent comparison (F1,4=1.26, P<.29). Furthermore, 95% limits of agreement were consistent for criterion and convergent biases, and EE from Movn was strongly correlated with both reference measures (criterion r=.91, convergent r=.92, both P<.001). Movn overestimated EE during free-living activities (bias=1.00 [0.98-1.02] kcal/min, t6123=101.49, P<.001), and biases were larger during high-intensity activities (F3,6120=1550.51, P<.001). In addition, 95% limits of agreement for convergent biases were heterogeneous across free-living activity intensity levels, but Movn and ActiGraph measures were strongly correlated (r=.87, P<.001). Integration of GPS and accelerometer data within a geographic information system (GIS) enabled creation of individual temporospatial maps. Conclusions: The Movn smartphone app can provide valid passive measurement of EE and can enrich these data with contextualizing temporospatial information. Although enhanced understanding of geographic and temporal variation in human movement patterns could inform intervention development, it also presents challenges for data processing and analytics.

  • Spatial span test (montage). Source: The Authors / Dribbble; Copyright: Amir Hamdi; URL:; License: Creative Commons Attribution (CC-BY).

    Validation of a Smartphone-Based Approach to In Situ Cognitive Fatigue Assessment


    Background: Acquired Brain Injuries (ABIs) can result in multiple detrimental cognitive effects, such as reduced memory capability, concentration, and planning. These effects can lead to cognitive fatigue, which can exacerbate the symptoms of ABIs and hinder management and recovery. Assessing cognitive fatigue is difficult due to the largely subjective nature of the condition and existing assessment approaches. Traditional methods of assessment use self-assessment questionnaires delivered in a medical setting, but recent work has attempted to employ more objective cognitive tests as a way of evaluating cognitive fatigue. However, these tests are still predominantly delivered within a medical environment, limiting their utility and efficacy. Objective: The aim of this research was to investigate how cognitive fatigue can be accurately assessed in situ, during the quotidian activities of life. It was hypothesized that this assessment could be achieved through the use of mobile assistive technology to assess working memory, sustained attention, information processing speed, reaction time, and cognitive throughput. Methods: The study used a bespoke smartphone app to track daily cognitive performance, in order to assess potential levels of cognitive fatigue. Twenty-one participants with no prior reported brain injuries took place in a two-week study, resulting in 81 individual testing instances being collected. The smartphone app delivered three cognitive tests on a daily basis: (1) Spatial Span to measure visuospatial working memory; (2) Psychomotor Vigilance Task (PVT) to measure sustained attention, information processing speed, and reaction time; and (3) a Mental Arithmetic Test to measure cognitive throughput. A smartphone-optimized version of the Mental Fatigue Scale (MFS) self-assessment questionnaire was used as a baseline to assess the validity of the three cognitive tests, as the questionnaire has already been validated in multiple peer-reviewed studies. Results: The most highly correlated results were from the PVT, which showed a positive correlation with those from the prevalidated MFS, measuring 0.342 (P<.008). Scores from the cognitive tests were entered into a regression model and showed that only reaction time in the PVT was a significant predictor of fatigue (P=.016, F=2.682, 95% CI 9.0-84.2). Higher scores on the MFS were related to increases in reaction time during our mobile variant of the PVT. Conclusions: The results show that the PVT mobile cognitive test developed for this study could be used as a valid and reliable method for measuring cognitive fatigue in situ. This test would remove the subjectivity associated with established self-assessment approaches and the need for assessments to be performed in a medical setting. Based on our findings, future work could explore delivering a small set of tests with increased duration to further improve measurement reliability. Moreover, as the smartphone assessment tool can be used as part of everyday life, additional sources of data relating to physiological, psychological, and environmental context could be included within the analysis to improve the nature and precision of the assessment process.

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

    Developing and Evaluating JIApp: Acceptability and Usability of a Smartphone App System to Improve Self-Management in Young People With Juvenile Idiopathic...


    Background: Flare-ups in juvenile idiopathic arthritis (JIA) are characterized by joint pain and swelling and often accompanied with fatigue, negative emotions, and reduced participation in activities. To minimize the impact of JIA on the physical and psychosocial development and well-being of young people (YP), it is essential to regularly monitor disease activity and side effects, as well as to support self-management such as adherence to treatment plans and engagement in general health-promoting behaviors. Smartphone technology has the potential to engage YP with their health care through convenient self-monitoring and easy access to information. In addition, having a more accurate summary of self-reported fluctuations in symptoms, behaviors, and psychosocial problems can help both YP and health care professionals (HCPs) better understand the patient’s condition, identify barriers to self-management, and assess treatment effectiveness and additional health care needs. No comprehensive smartphone app has yet been developed in collaboration with YP with JIA, their parents, and HCPs involved in their care. Objectives: The objective of this study was to design, develop, and evaluate the acceptability and usability of JIApp, a self-management smartphone app system for YP with JIA and HCPs. Methods: We used a qualitative, user-centered design approach involving YP, parents, and HCPs from the rheumatology team. The study was conducted in three phases: (1) phase I focused on developing consensus on the features, content, and design of the app; (2) phase II was used for further refining and evaluating the app prototype; and (3) phase III focused on usability testing of the app. The interview transcripts were analyzed using qualitative content analysis. Results: A total of 29 YP (aged 10-23, median age 17) with JIA, 7 parents, and 21 HCPs were interviewed. Major themes identified as the ones that helped inform app development in phase I were: (1) remote monitoring of symptoms, well-being, and activities; (2) treatment adherence; and (3) education and support. During phase II, three more themes emerged that informed further refinement of the app prototype. These included (4) adapting a reward system to motivate end users for using the app; (5) design of the app interface; and (6) clinical practice integration. The usability testing during phase III demonstrated high rates of overall satisfaction and further affirmed the content validity of the app. Conclusions: We present the development and evaluation of a smartphone app to encourage self-management and engagement with health care for YP with JIA. The app was found to have high levels of acceptability and usability among YP and HCPs and has the potential to improve health care and outcomes for this age group. Future feasibility testing in a prospective study will firmly establish the reliability, efficacy, and cost-effectiveness of such an app intervention for patients with arthritis.

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

    Improving Patient-Centered Care for Young People in General Practice With a Codesigned Screening App: Mixed Methods Study


    Background: Despite experiencing a high prevalence and co-occurrence of mental health disorders and health-compromising behaviors, young people tend not to seek professional help for these concerns. However, they do regularly attend primary care, making primary care providers ideally situated to identify and discuss mental health and lifestyle issues as part of young people’s routine health care. Objective: The aim was to investigate whether using a codesigned health and lifestyle-screening app, Check Up GP, in general practice influenced young people’s assessment of the quality of their care (measures of patient-centered care and youth friendliness), and their disclosure of sensitive issues. In addition, this study aimed to explore young people’s acceptance and experience of using a screening app during regular health care. Methods: This was a mixed methods implementation study of Check Up GP with young people aged 14 to 25 years attending a general practice clinic in urban Melbourne, Australia. A 1-month treatment-as-usual group was compared to a 2-month intervention group in which young people and their general practitioners (GPs) used Check Up GP. Young people in both groups completed an exit survey immediately after their consultation about disclosure, patient-centered and youth-friendly care, and judgment. In addition, participants in the intervention group were surveyed about app acceptability and usability and their willingness to use it again. Semistructured interviews with participants in the intervention group expanded on themes covered in the survey. Results: The exit survey was completed by 30 young people in the treatment-as-usual group and 85 young people in the intervention group. Young people using Check Up GP reported greater disclosure of health issues (P<.001), and rated their GP higher in patient-centered care: communication and partnership (P=.01), personal relationship (P=.01), health promotion (P=.03), and interest in effect on life (P<.001). No differences were found on core indicators of youth-friendly care: trust, level of comfort, expectations met, and time to ask questions. In all, 86% (73/85) of young people felt the app was a “good idea” and only 1% (1/85) thought it a “bad idea.” Thematic analysis of qualitative interviews with 14 participants found that Check Up GP created scope to address unmet health needs and increased sense of preparedness, with use moderated by honesty, motivation, app content and functionality, and app administration. Conclusions: Integrating a health and lifestyle-screening app into face-to-face care can enrich young people’s experience of seeing their GP, create scope to identify and address unmet health needs, and increase patient-centered care. Further research is needed to investigate the effect of using a health and lifestyle-screening app in a diverse range of clinic types and settings, and with a diverse range of GPs and youth.

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    Open Peer Review Period: Sep 8, 2017 - Nov 3, 2017

    Background: Diabetes is a complex, demanding disease that requires the constant attention of patients. The burden of self-management, including different medication regimens, routine self-care activit...

    Background: Diabetes is a complex, demanding disease that requires the constant attention of patients. The burden of self-management, including different medication regimens, routine self-care activities, and provider visits, has an impact on patients’ emotional well-being. Diabetes distress and depression are two important components of emotional well-being that may negatively affect diabetes outcomes. Objective: To determine impact of a one-year mobile phone diabetes intervention (MDIS) cluster randomized clinical trial (RCT) on emotional well-being measured by diabetes distress and depression among adults with type 2 diabetes (T2D). Methods: 163 adults with less than well-controlled T2D were enrolled from community primary care practices. Primary care practices were cluster-randomized into either a usual care control group or intervention group. Intervention participants were given a mobile phone with coaching software including a web-portal to communicate with physicians/diabetes educators. A priori established secondary outcomes included distress measured by Diabetes Distress (DD) Scale (DDS); subscales measuring emotional burden (EB), interpersonal distress (ID), physician-related distress (PD), and regimen-related distress (RD); and depression, measured by Patient Health Questionnaire-9 (PHQ-9). Linear mixed models were used to calculate the effect of the intervention on diabetes distress levels over time both overall and separately by sex, and to determine if the intervention affected total DD, DD subscales, or depression. The impact of total DDS on changes in HbA1c was also studied. Results: There were no significant treatment group effects for DDS total (baseline P = .07, differences over time P = .38) or for depression (P = .06 over time). Significant declines in total DD were observed over the 12-month intervention period (P = .01). Regimen-related distress significantly decreased for all study participants (P < .001) but no significant change over time was observed for EB (P = .83), ID (P = .64), or PD (P = .73). Women in both the usual care and intervention groups were more likely to have higher overall DDS, EB, PD, and RD, but not ID. Women also reported higher baseline depression compared to men (P = .006). Overall, depression decreased over the treatment period (P =.007), but remained unaffected by group assignment (P =.06) or by sex (P = .97). Diabetes distress had no effect on the change in HbA1c (P = .91) over the treatment period. Conclusions: We found no definitive overall or sex-specific effect of the intervention on diabetes distress or depression; this study makes an important contribution to the understanding of mobile health interventions and the impact on emotional health. Our study verified previous work that although diabetes distress and depression are highly correlated, these measures are not evaluating the same construct. Mobile technology provides an opportunity to personalize, contextualize and intervene in the emotional well-being of persons with diabetes.

  • Development of Just-in-time Adaptive Intervention for Insomnia: Usability Study

    Date Submitted: Sep 5, 2017

    Open Peer Review Period: Sep 7, 2017 - Nov 2, 2017

    Background: Healthy sleep is a fundamental component of physical and brain health. Insomnia, however, is a prevalent sleep disorder that compromises functioning, productivity, and health. Therefore, d...

    Background: Healthy sleep is a fundamental component of physical and brain health. Insomnia, however, is a prevalent sleep disorder that compromises functioning, productivity, and health. Therefore, developing efficient treatment delivery methods for insomnia can have significant societal and personal health impacts. Cognitive behavioral therapy for insomnia (CBTI) is the recommended first-line treatment of insomnia but access is currently limited for patients, since treatment must occur in specialty sleep clinics, which suffer from an insufficient number of trained clinicians. Smartphone-based interventions offer a promising means for improving the delivery of CBTI. Furthermore, novel features such as real-time monitoring and assessment, personalization, dynamic adaptations of the intervention, and context awareness can enhance treatment personalization and effectiveness, and reduce associated costs. Ultimately, this “Just in Time Adaptive Intervention” (JITAI) for insomnia—an intervention approach that is acceptable to patients and clinicians, and is based on mobile health (mHealth) platform and tools—can significantly improve patient access and clinician delivery of evidence-based insomnia treatments. Objective: This study aims to develop and assess the usability of a JITAI application platform called iREST (“interactive Resilience Enhancing Sleep Tactics”) for use in behavioral insomnia interventions. iREST can be used by both patients and clinicians. Methods: The development of iREST was based on the interactive and incremental (IID) software development model. Requirement analysis was based on the case study’s description, workflow and needs, clinician inputs, and a previously conducted BBTI military study/implementation of the JITAI architecture. To evaluate the usability of the iREST mHealth tool, a pilot usability study was conducted. Additionally, this study explores the feasibility of using an off-the-shelf wearable device to supplement the subjective assessment of patient sleep patterns. Results: The iREST app was developed from the mobile logical architecture of JITAI. It consists of a cross-platform smartphone app, a clinician portal, and secure 2-way communications platform between the app and the portal. The usability study comprised 19 Active Duty Service Members (ADSM) and Veterans between the ages of 18 and 60. Descriptive statistics based on in-app questionnaires indicate that on average, 12 (mean=12.23, SD=8.96) unique devices accessed the clinician portal per day for more than two years, while the app was rated as “highly usable”, achieving a mean System Usability Score (SUS) score of 85.74 (SD =12.37), which translates to an adjective rating of “Excellent”. The participants also gave high scores on “ease of use and learnability” with an average score of 4.33 (SD=0.65) on a scale of 1 to 5. Conclusions: iREST provides a feasible platform for the implementation of JITAI in mHealth-based and remote intervention settings. The system was rated highly usable and its cross-platformness made it readily implemented within the heavily segregated smartphone market. The use of wearables to track sleep is promising; yet the accuracy of this technology needs further improvement. Ultimately, iREST demonstrates that mHealth-based JITAI is not only feasible, but also works effectively.

  • Combining fitness trackers with motivational interviewing and mutual support to increase physical activity in adolescent/parent dyads

    Date Submitted: Sep 5, 2017

    Open Peer Review Period: Sep 7, 2017 - Nov 2, 2017

    Background: An essential component of any effective adolescent weight management program is physical activity (PA). The growing field of health technology provides potential solutions for addressing c...

    Background: An essential component of any effective adolescent weight management program is physical activity (PA). The growing field of health technology provides potential solutions for addressing chronic health issues and lifestyle change, such as adolescent obesity. Activity trackers, used in conjunction with smart phone apps, can engage, motivate, and foster support, among users while simultaneously providing feedback on their PA progress. Objective: To evaluate the effect of a 10 week pilot study utilizing smartphone-enabled activity tracker data to tailor motivation, goal setting on physical activity (PA) for overweight/obese adolescents and their parents. Methods: Eligible adolescents, ages 13-16 with BMI >85th percentile, and one of their parents were queried as to behaviors, barriers to change, perceptions about exercise and health pre- and post-intervention. We captured daily step count and active minutes via fitness trackers. Staff made phone calls to dyads at weeks 1, 2, 4, 8 post enrollment to set daily personalized step count/active minutes goals based upon their prior data, age specific Center for Disease Control and Prevention (CDC) goals. Dyad correlations were evaluated using the non-parametric Spearman rank order correlations. Results: 9 parent adolescent dyads were enrolled. Mean adolescent age was 15 years (range 14-16) (4 female/5 male); mean parent age was 47 years (range 36-66). On average, adolescents met their personalized daily step count goals 35% (11-62%) of the days they wore their trackers; parents did so 40% (3-68%) of the days they wore their tracker. Adolescents met their active minute goals 56% (27-85%) of the days they wore their tracker; parents did 83% (52-97%) of the days. Parent and adolescent success was strongly correlated: step count r=0.36, P=.001, active minutes r=0.30, P=.007. Parental age was inversely correlated with step count success (r=-0.78, P=.01). Conclusions: Our findings that parent-adolescent dyads have highly correlated physical activity success rates suggest that further investment in family-centered weight management strategies merit consideration by policy makers, insurers, and health care providers.

  • SAMUV: the development of a digital app for teaching about Multiple-Victim Accidents

    Date Submitted: Sep 1, 2017

    Open Peer Review Period: Sep 2, 2017 - Oct 28, 2017

    Background: Multiple-Victim Accidents involve accidents with more than five seriously-ill victims and which are attended by SAMU service in Brazil. So, continuing education for team that works in thi...

    Background: Multiple-Victim Accidents involve accidents with more than five seriously-ill victims and which are attended by SAMU service in Brazil. So, continuing education for team that works in this service is important. Objective: To develop a mobile educational app focusing on decision-making in relation to multiple-victim accidents, for use in continuing education with professionals of the Urgent Medical Aid Service (SAMU, in Portuguese). Methods: An applied methodological study on technological production, undertaken between July and December 2016, following the stages of specification of requirements with the SAMU emergency care providers of a city in the Brazilian state of Paraná bordering Paraguay and Argentina, and the project and implementation based on the software development life cycle theory. The app was designed for the android platform and was written in the HTML 5 markup language. The study complied with ethical requirements. Results: The requirements specifications phase made it possible to carry out the paper prototyping with 17 SAMU professionals, thus allowing these staff members to participate in the app’s planning. The project and implementation phase realized the projections developed in the previous phase, with the construction of pages addressing theoretical topics on definitions of the various terms used in attending multiple-victim accidents, how the attendance functions, signs used to warn people of hazards, methods for triaging victims, each professional’s role during the attendance, frequently-asked questions, an interactive quiz, and a tab providing information on the app’s technical characteristics and the sources referenced in the texts. Conclusions: The theory used guided all the stages of the app’s development. It is necessary for other interactive and innovative strategies to be adopted in teaching urgent and emergency care, to encourage learning in the process of continuing education.

  • Digital blind-spots: the role of symptom severity and user experience in digital intervention adherence.

    Date Submitted: Aug 25, 2017

    Open Peer Review Period: Aug 30, 2017 - Oct 25, 2017

    A recent systematic review by Killikelly and colleagues suggested a number of factors which may affect adherence to digital interventions for individuals with psychosis. While the review outlined some...

    A recent systematic review by Killikelly and colleagues suggested a number of factors which may affect adherence to digital interventions for individuals with psychosis. While the review outlined some crucial points from the research it drew early conclusions into the role that symptom severity may play in study drop-outs, and didn't discuss the potential role user experience may play in keeping user attention. This commentary discusses these points and suggests the necessity for research into the visual design of apps.