JMIR mHealth and uHealth

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

TEXT2COPE: an mHealth pilot intervention for parents of overweight/obese preschool children

Background: Children are five times more likely to be overweight at the age of 12 years if they are overweight during the preschool period. Objective: The purpose of this research was to establish the feasibility, acceptability, and preliminary effects of a cognitive-behavioral intervention (TEXT2COPE) synergized with tailored mobile technology (mHealth) on the healthy lifestyle behaviors of parents of overweight and obese preschoolers delivered in a primary care setting. Methods: Fifteen preschool-parent dyads recruited through primary care clinics completed a manualized 7-week cognitive behavioral skills building intervention. Beck’s Cognitive Theory guided the TEXT2COPE intervention content and Fogg’s Behavior Model guided the implementation. The intervention employed via a combination of face-to-face clinic visits and ecological momentary interventions using text messaging. To enhance the intervention’s relevance to the family’s needs, parents dictated the wording of the text messaging and also were able to adapt the frequency and timing text message delivery throughout program implementation. Results: Self-reported findings indicate that the program is feasible and acceptable in this population. The intervention showed preliminary efficacy with significant improvements on parental knowledge about nutrition (P=.001) and physical activity (P=.012) for their children, parental beliefs (P=.001) towards healthy lifestyles, and parental behaviors (P=.040) towards engaging in healthy lifestyle choices for their children. Effect sizes were medium to large for all variables. The timing, frequency, and wording of the text messages were variable to the individual families, with 69% of parents (9/13) increasing the frequency of the tailored SMS from being sent once weekly to as many as five times a week. Conclusions: Utilizing a cognitive behavioral skills intervention with text messaging has great potential for supporting clinical care of overweight and obese preschool children and their families. Further exploration of the potential effects on health and behavioral outcomes is warranted.

2014-08-17

JMIR mHealth and uHealth (JMU) http://mhealth.jmir.org is now the first #mhealth journal listed in PubMed: http://www.ncbi.nlm.nih.gov/pubmed?term=%22JMIR+Mhealth+Uhealth%22[jour] and PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/journals/2531/ Please follow @JMedInternetRes on Twitter for JMU content updates and sign up for email alerts by creating a profile at http://mhealth.jmir.org/user/profile.

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Journal Description

JMIR mhealth and uhealth (mobile and ubiquitous health) (JMU, ISSN 2291-5222) is a new spin-off journal of JMIR, the leading eHealth journal (Impact Factor 2013: 4.7). 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).

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:

  • Image of the system of emergency medical services with tablet computers.

    An Effective Support System of Emergency Medical Services With Tablet Computers

    Abstract:

    Background: There were over 5,000,000 ambulance dispatches during 2010 in Japan, and the time for transportation has been increasing, it took over 37 minutes from dispatch to the hospitals. A way to reduce transportation time by ambulance is to shorten the time of searching for an appropriate facility/hospital during the prehospital phase. Although the information system of medical institutions and emergency medical service (EMS) was established in 2003 in Saga Prefecture, Japan, it has not been utilized efficiently. The Saga Prefectural Government renewed the previous system in an effort to make it the real-time support system that can efficiently manage emergency demand and acceptance for the first time in Japan in April 2011. Objective: The objective of this study was to evaluate if the new system promotes efficient emergency transportation for critically ill patients and provides valuable epidemiological data. Methods: The new system has provided both emergency personnel in the ambulance, or at the scene, and the medical staff in each hospital to be able to share up-to-date information about available hospitals by means of cloud computing. All 55 ambulances in Saga are equipped with tablet computers through third generation/long term evolution networks. When the emergency personnel arrive on the scene and discern the type of patient’s illness, they can search for an appropriate facility/hospital with their tablet computer based on the patient’s symptoms and available medical specialists. Data were collected prospectively over a three-year period from April 1, 2011 to March 31, 2013. Results: The transportation time by ambulance in Saga was shortened for the first time since the statistics were first kept in 1999; the mean time was 34.3 minutes in 2010 (based on administrative statistics) and 33.9 minutes (95% CI 33.6-34.1) in 2011. The ratio of transportation to the tertiary care facilities in Saga has decreased by 3.12% from the year before, 32.7% in 2010 (regional average) and 29.58% (9085/30,709) in 2011. The system entry completion rate by the emergency personnel was 100.00% (93,110/93,110) and by the medical staff was 46.11% (14,159/30,709) to 47.57% (14,639/30,772) over a three-year period. Finally, the new system reduced the operational costs by 40,000,000 yen (about $400,000 US dollars) a year. Conclusions: The transportation time by ambulance was shorter following the implementation of the tablet computer in the current support system of EMS in Saga Prefecture, Japan. The cloud computing reduced the cost of the EMS system.

  • TB medication.

    Qualitative Evaluation of a Text Messaging Intervention to Support Patients With Active Tuberculosis: Implementation Considerations

    Abstract:

    Background: Tuberculosis (TB) remains a major global public health problem and mobile health (mHealth) interventions have been identified as a modality to improve TB outcomes. TextTB, an interactive text-based intervention to promote adherence with TB medication, was pilot-tested in Argentina with results supporting the implementation of trials at a larger scale. Objective: The objective of this research was to understand issues encountered during pilot-testing in order to inform future implementation in a larger-scale trial. Methods: A descriptive, observational qualitative design guided by a sociotechnical framework was used. The setting was a clinic within a public pulmonary-specialized hospital in Argentina. Data were collected through workflow observation over 115 days, text messages (n=2286), review of the study log, and stakeholder input. Emerging issues were categorized as organizational, human, technical, or sociotechnical considerations. Results: Issues related to the intervention included workflow issues (eg, human, training, security), technical challenges (eg, data errors, platform shortcomings), and message delivery issues (eg, unintentional sending of multiple messages, auto-confirmation problems). System/contextual issues included variable mobile network coverage, electrical and Internet outages, and medication shortages. Conclusions: Intervention challenges were largely manageable during pilot-testing, but need to be addressed systematically before proceeding with a larger-scale trial. Potential solutions are outlined. Findings may help others considering implementing an mHealth intervention to anticipate and mitigate certain challenges. Although some of the issues may be context dependent, other issues such as electrical/Internet outages and limited resources are not unique issues to our setting. Release of new software versions did not result in solutions for certain issues, as specific features used were removed. Therefore, other software options will need to be considered before expanding into a larger-scale endeavor. Improved automation of some features will be necessary, however, a goal will be to retain the intervention capability to be interactive, user friendly, and patient focused. Continued collaboration with stakeholders will be required to conduct further research and to understand how such an mHealth intervention can be effectively integrated into larger health systems.

  • (cc) Payne et al. CC-BY-SA-2.0, please cite as (http://mhealth.jmir.org/article/viewFile/3335/1/53684).

    Behavioral Functionality of Mobile Apps in Health Interventions: A Systematic Review of the Literature

    Abstract:

    Background: Several thousand mobile phone apps are available to download to mobile phones for health and fitness. Mobile phones may provide a unique means of administering health interventions to populations. Objective: The purpose of this systematic review was to systematically search and describe the literature on mobile apps used in health behavior interventions, describe the behavioral features and focus of health apps, and to evaluate the potential of apps to disseminate health behavior interventions. Methods: We conducted a review of the literature in September 2014 using key search terms in several relevant scientific journal databases. Only English articles pertaining to health interventions using mobile phone apps were included in the final sample. Results: The 24 studies identified for this review were primarily feasibility and pilot studies of mobile apps with small sample sizes. All studies were informed by behavioral theories or strategies, with self-monitoring as the most common construct. Acceptability of mobile phone apps was high among mobile phone users. Conclusions: The lack of large sample studies using mobile phone apps may signal a need for additional studies on the potential use of mobile apps to assist individuals in changing their health behaviors. Of these studies, there is early evidence that apps are well received by users. Based on available research, mobile apps may be considered a feasible and acceptable means of administering health interventions, but a greater number of studies and more rigorous research and evaluations are needed to determine efficacy and establish evidence for best practices.

  • This is a royalty free image by patrisyu (http://www.freedigitalphotos.net/images/businessman-holding-a-mobile-phone-photo-p234028).

    Analyzing the Mobile “Digital Divide”: Changing Determinants of Household Phone Ownership Over Time in Rural Bangladesh

    Abstract:

    Background: We had a unique opportunity to examine demographic determinants of household mobile phone ownership in rural Bangladesh using socioeconomic data collected as part of a multiyear longitudinal cohort study of married women of reproductive age. Objectives: This paper explores how the demographics of household mobile phone owners have changed over time in a representative population of rural Bangladesh. Methods: We present data collected between 2008 and 2011 on household mobile phone ownership and related characteristics including age, literacy, education, employment, electricity access, and household wealth among 35,306 individuals. Respondents were enrolled when found to be newly pregnant and contributed socioeconomic information once over the course of the time period serving as a “sample” of families within the population at that time. Univariate and multiple logistic regressions analyses were performed to identify the socioeconomic determinants of household phone ownership. Results: Across 3 fiscal years, we found that reported household ownership of at least 1 working mobile phone grew from 29.85% in the first fiscal year to 56.07% in the third fiscal year. Illiteracy, unavailability of electricity, and low quartiles of wealth were identified as overall demographic constraints to mobile phone ownership. However, over time, these barriers became less evident and equity gaps among demographic status began to dissipate as access to mobile technology became more democratized. We saw a high growth rate in ownership among households in lower economic standing (illiterate, without electricity, low and lowest wealth index), likely a result of competitive pricing and innovative service packages that improve access to mobile phones as the mobile phone market matures. In contrast, as market saturation is rapidly attained in the most privileged demographics (literate, secondary schooling, electricity, high wealth index), members of the lower wealth quartiles seem to be following suit, with more of an exponential growth. Conclusions: Upward trends in household mobile phone ownership in vulnerable populations over time underline the potential to leverage this increasingly ubiquitous infrastructure to extend health and finance services across social and economic strata.

  • Text-2-Quit. (cc) Bock et al. CC-BY-SA-2.0, please cite as (http://mhealth.jmir.org/article/viewFile/3779/1/46231).

    Translating Behavioral Interventions Onto mHealth Platforms: Developing Text Message Interventions for Smoking and Alcohol

    Abstract:

    The development of mHealth applications is often driven by the investigators and developers with relatively little input from the targeted population. User input is commonly limited to “like/dislike” post- intervention consumer satisfaction ratings or device or application specific user analytics such as usability. However, to produce successful mHealth applications with lasting effects on health behaviors it is crucial to obtain user input from the start of each project and throughout development. The aim of this tutorial is to illustrate how qualitative methods in an iterative process of development have been used in two separate behavior change interventions (targeting smoking and alcohol) delivered through mobile technologies (ie, text messaging). A series of focus groups were conducted to assist in translating a face-to-face smoking cessation intervention onto a text message (short message service, SMS) delivered format. Both focus groups and an advisory panel were used to shape the delivery and content of a text message delivered intervention for alcohol risk reduction. An in vivo method of constructing message content was used to develop text message content that was consistent with the notion of texting as “fingered speech”. Formative research conducted with the target population using a participatory framework led to important changes in our approach to intervention structure, content development, and delivery. Using qualitative methods and an iterative approach that blends consumer-driven and investigator-driven aims can produce paradigm-shifting, novel intervention applications that maximize the likelihood of use by the target audience and their potential impact on health behaviors.

  • Screenshot of text message.

    Design and Multi-Country Validation of Text Messages for an mHealth Intervention for Primary Prevention of Progression to Hypertension in Latin America

    Abstract:

    Background: Mobile health (mHealth) has been posited to contribute to the reduction in health gaps and has shown fast and widespread growth in developing countries. This growth demands understanding of, and preparedness for, local cultural contexts. Objective: To describe the design and validation of text messages (short message service, SMS) that will be used for an mHealth behavioral change intervention to prevent hypertension in three Latin American countries: Argentina, Guatemala, and Peru. Methods: An initial set of 64 SMS text messages were designed to promote healthy lifestyles among individuals in different stages of behavior change, addressing four key domains: salt and sodium intake, fruit and vegetable intake, consumption of high fat and sugar foods, and physical activity. The 64 SMS text messages were organized into nine subsets for field validation. In each country 36 people were recruited, half of them being male. Of the participants, 4 per country evaluated each subset of SMS text messages, which contained between 6 and 8 SMS text messages regarding different key domains and stages of change. The understanding and appeal of each SMS text message was assessed using a 7-item questionnaire. The understanding and appeal ratings were used to reach a final set of 56 SMS text messages. Results: Overall, each of the 64 SMS text messages received a total of 12 evaluations (4 per country). The majority of evaluations—742 out of a total of 767 (96.7%) valid responses—revealed an adequate understanding of the key idea contained in the SMS text message. On a scale from 1 to 10, the average appeal score was 8.7 points, with a range of 4 to 10 points. Based on their low scores, 8 SMS text messages per country were discarded. Once the final set of 56 SMS text messages was established, and based on feedback obtained in the field, wording and content of some SMS text messages were improved. Of the final set, 9, 8, and 16 of the SMS text messages were improved based on participant evaluations from Argentina, Guatemala, and Peru, respectively. Most SMS text messages selected for the final set (49/56, 88%) were the same in all countries, except for small wording differences. Conclusions: The final set of SMS text messages produced had very high rates of understanding and appeal in three different Latin American countries. This study highlights the importance of developing and validating a package of simple, preventative SMS text messages, grounded in evidence and theory, across three different Latin American countries with active engagement of end users.

  • Finding a Depression App: A Review and Content Analysis of the
Depression App Marketplace.

    Finding a Depression App: A Review and Content Analysis of the Depression App Marketplace

    Abstract:

    Background: Depression is highly prevalent and causes considerable suffering and disease burden despite the existence of wide-ranging treatment options. Mobile phone apps offer the potential to help close this treatment gap by confronting key barriers to accessing support for depression. Objectives: Our goal was to identify and characterize the different types of mobile phone depression apps available in the marketplace. Methods: A search for depression apps was conducted on the app stores of the five major mobile phone platforms: Android, iPhone, BlackBerry, Nokia, and Windows. Apps were included if they focused on depression and were available to people who self-identify as having depression. Data were extracted from the app descriptions found in the app stores. Results: Of the 1054 apps identified by the search strategy, nearly one-quarter (23.0%, 243/1054) unique depression apps met the inclusion criteria. Over one-quarter (27.7%, 210/758) of the excluded apps failed to mention depression in the title or description. Two-thirds of the apps had as their main purpose providing therapeutic treatment (33.7%, 82/243) or psychoeducation (32.1%, 78/243). The other main purpose categories were medical assessment (16.9%, 41/243), symptom management (8.2%, 20/243), and supportive resources (1.6%, 4/243). A majority of the apps failed to sufficiently describe their organizational affiliation (65.0%, 158/243) and content source (61.7%, 150/243). There was a significant relationship (χ25=50.5, P<.001) between the main purpose of the app and the reporting of content source, with most medical assessment apps reporting their content source (80.5%, 33/41). A fifth of the apps featured an e-book (20.6%, 50/243), audio therapy (16.9%, 41/243), or screening (16.9%, 41/243) function. Most apps had a dynamic user interface (72.4%, 176/243) and used text as the main type of media (51.9%, 126/243), and over a third (14.4%, 35/243) incorporated more than one form of media. Conclusion: Without guidance, finding an appropriate depression app may be challenging, as the search results yielded non-depression–specific apps to depression apps at a 3:1 ratio. Inadequate reporting of organization affiliation and content source increases the difficulty of assessing the credibility and reliability of the app. While certification and vetting initiatives are underway, this study demonstrates the need for standardized reporting in app stores to help consumers select appropriate tools, particularly among those classified as medical devices.

  • Examples of the touch screen interface of the patient portal, including the visual analogue pain scale, an example of the QoR 9 question on postoperative nausea, and the visual analogue scale for fluid in the postoperative surgical drains.

    Using a Mobile App for Monitoring Post-Operative Quality of Recovery of Patients at Home: A Feasibility Study

    Abstract:

    Background: Mobile apps are being viewed as a new solution for post-operative monitoring of surgical patients. Mobile phone monitoring of patients in the post-operative period can allow expedited discharge and may allow early detection of complications. Objective: The objective of the current study was to assess the feasibility of using a mobile app for the monitoring of post-operative quality of recovery at home following surgery in an ambulatory setting. Methods: We enrolled 65 consecutive patients (n=33, breast reconstruction surgery; n=32, orthopedic surgery) and asked them to use a mobile phone daily to complete a validated quality of recovery scale (QoR-9) and take photographs of the surgical site for the first 30 days post-op. Surgeons were asked to review patient-entered data on each patient in their roster daily. A semistructured questionnaire was administered to patients and surgeons to assess satisfaction and feasibility of the mobile device. Results: All 65 patients completed the study. The mean number of logins was 23.9 (range 7-30) for the breast patients and 19.3 (range 5-30) for the orthopedic patients. The mean number of logins was higher in the first 14 days compared to the 15-30 days post-op for both breast patients (13.4 vs 10.5; P<.001) and for the orthopedic patients (13.4 vs 6.0; P<.001). The mean score for overall satisfaction with using the mobile device was 3.9 for breast patients and 3.7 for orthopedic patients (scored from 1 (poor) to 4 (excellent)). Surgeons reported on the easy-to-navigate design, the portability to monitor patients outside of hospital, and the ability of the technology to improve time efficiency. Conclusions: The use of mobile apps for monitoring the quality of recovery in post-operative patients at home was feasible and acceptable to patients and surgeons in the current study. Future large scale studies in varying patient populations are required.

  • Sahaay project logo.

    Implementation of a Confidential Helpline for Men Having Sex With Men in India

    Abstract:

    Background: In India, men who have sex with men (MSM) often face physical violence and harassment from police and the general society. Many MSM may not openly disclose their sexual identity, especially if they are married to women and have families. Due to pervasive stigma and discrimination, human immunodeficiency virus (HIV) prevention programs are unable to reach many MSM effectively. Objective: The objective of this paper was to describe the design, operations, and monitoring of the Sahaay helpline, a mHealth intervention for the MSM population of India. Methods: We established the “Sahaay” mHealth intervention in 2013; a MSM-dedicated helpline whose main goal was to increase access to comprehensive, community-based HIV prevention services and improve knowledge, attitudes, and behaviors of MSM towards HIV and sexually transmitted infections (STI) in three states of India (Chhattisgarh, Delhi, and Maharashtra). The helpline provided a 24x7 confidential and easy to use interactive voice response system (IVRS) to callers. IVRS function was monitored through an online dashboard of indicators. The system also provided real-time reporting on callers and services provided. Results: The helpline received more than 100,000 calls from 39,800 callers during the first nine months of operation. The helpline maintained an operational uptime of 99.81% (6450/6462 hours); and answered more than 81.33% (83,050/102,115) of all calls. More than three-fourths of the calls came between 9:00 am-12:00 pm. The most successful promotional activity was “interpersonal communication” (reported by 70.05%, 27,880/39,800, of the callers). Nearly three-fourths of the callers self-identified as MSM, including 17.05% (6786/39,800) as rural MSM and 5.03% (2001/39,800) as a married MSM. Most callers (93.10%, 37,055/39,800) requested information, while some (27.01%, 10,750/39,800) requested counseling on HIV/acquired immune deficiency syndrome (AIDS), STIs, and other health and nonhealth issues. There were 38.97% (15,509/39,800) of the callers that were provided contacts of different HIV/AIDS referral services. Many MSM clients reported increased self-esteem in dealing with their sexual identity and disclosing the same with their family and spouse; and an increase in HIV/AIDS risk-reduction behaviors like consistent condom use and HIV testing. Conclusions: National HIV/AIDS prevention interventions for MSM in India should consider scaling-up this helpline service across the country. The helpline may serve as an important mechanism for accessing hard-to-reach MSM, and thus improving HIV prevention programing.

  • NGT idea brainstorm.

    Using a Collaborative Research Approach to Develop an Interdisciplinary Research Agenda for the Study of Mobile Health Interventions for Older Adults

    Abstract:

    Background: Seniors with chronic diseases are often called on to self-manage their conditions. Mobile health (mHealth) tools may be a useful strategy to help seniors access health information at the point of decision-making, receive real-time feedback and coaching, and monitor health conditions. However, developing successful mHealth interventions for seniors presents many challenges. One of the key challenges is to ensure the scope of possible research questions includes the diverse views of seniors, experts and the stakeholder groups who support seniors as they manage chronic disease. Objective: Our primary objective was to present a case-study of a collaborative research approach to the development of an interdisciplinary research agenda. Our secondary objectives were to report on the results of a nominal group technique (NGT) approach used generate research questions and to assess the success of including non-academic researchers to enrich the scope, priority, and total number of possible research questions. Methods: We invited researchers and stakeholders to participate in a full day meeting that included rapid-style presentations by researchers, health care professionals, technology experts, patients and community groups followed by group discussions. An NGT was used to establish group consensus on the following question: In your opinion, what research needs to be done to better understand the effectiveness, usability and design of mobile health apps and devices for older adults? Results: Overall, the collaborative approach was a very successful strategy to bring together a diverse group of participants with the same end goal. The 32 participants generated 119 items in total. The top three research questions that emerged from the NGT were related to adoption, the need for high quality tools and the digital divide. Strong sub-themes included privacy and security, engagement and design. The NGT also helped us include the perspectives information from non-academic researchers that would not have been captured if the process had been limited to the research team. Conclusions: Developing ways for patients and other stakeholders to have a voice when it comes to developing patient awareness as related to mHealth may guide future research into engagement, ownership, usability and design. It is our intention that our paper be used and adapted by other researchers to engage small or vulnerable populations often excluded from mHealth research and design.

  • Google Glasses - image found on Google.

    Intelligent Glasses, Watches and Vests…Oh My! Rethinking the Meaning of “Harm” in the Age of Wearable Technologies

    Abstract:

    The widespread release and adoption of wearable devices will likely accelerate the “hybrid era”, already initiated by mobile digital devices, with progressively deeper levels of human-technology co-evolution and increasing blurring of our boundaries with machines. Questions about the potentially harmful nature of information and communication technologies have been asked before, since the introduction of the telephone, the Web, and more recently, mobile phones. Our capacity to answer them now is limited by outdated conceptual approaches to harm, mostly derived from drug evaluation; and by the slow and static nature of traditional research tools. In this article, we propose a re-conceptualizing of the meaning of “harm”, which builds on a global effort focused on health, adding flexibility and richness within a context that acknowledges the physical, mental, and social domains in which it can occur.

  • 3394_feature IMANGE.

    Knowledge, Attitudes, and Practices Regarding Avian Influenza A (H7N9) Among Mobile Phone Users: A Survey in Zhejiang Province, China

    Abstract:

    Background: Understanding people’s knowledge, attitudes, and practices (KAP) regarding a new infectious disease is crucial to the prevention and control of it. Human infection with avian influenza A (H7N9) was first identified on March 31, 2013 in China. Out of the total number of 134 cases confirmed from March to September 2013 in China, Zhejiang Province saw the greatest number (46 cases). Objective: This study employed a mobile Internet survey to assess KAP regarding H7N9 among mobile phone users in Zhejiang Province. This study intended to examine KAP by region and the association between sociodemographic variables and KAP. Methods: An anonymous questionnaire was designed by Zhejiang Provincial Center for Disease Control and Prevention (CDC). A cross-sectional survey was executed through a mobile Internet application platform of China Unicom in 5 regions in Zhejiang Province. Stratified and clustered sampling methods were applied and mobile phone users were invited to participate in the study voluntarily. Results: A total of 9582 eligible mobile phone users participated in the survey with a response rate of 1.92% (9582/5,000,000). A total of 9105 valid responses (95.02%) were included for statistical analysis. Generally, more than three-quarters of the participants had some basic knowledge of H7N9 and held the attitude recommended by the Zhejiang CDC toward eating cooked poultry (77.55%, 7061/9105) and visiting a hospital at the occurrence of symptoms (78.51%, 7148/9105). Approximately half of the participants worried about contracting H7N9, and took preventive practices recommended by the Zhejiang CDC. But only 14.29% (1301/9105) of participants kept eating cooked poultry as usual. Although worry about H7N9 infection did not differ by region, Hangzhou saw the largest proportion of participants with knowledge of H7N9, which was probably because Hangzhou had the greatest number of H7N9 cases. KAP varied by some sociodemographic variables. Female participants were more likely to know about symptoms of H7N9 (OR 1.32, 95% CI 1.08-1.61), to worry about contracting it (OR 1.15, 95% CI 1.04-1.27), and to report their lives being influenced by it (OR 1.27, 95% CI 1.15-1.41). They were also more likely to take the recommended precautions. Male participants and younger participants were less likely to comply with advocated protective practices. Conclusions: The results suggest that health education should be customized depending on sociodemographic variables to achieve more effective behavioral outcomes.

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  • TEXT2COPE: an mHealth pilot intervention for parents of overweight/obese preschool children

    Date Submitted: Mar 4, 2015

    Open Peer Review Period: Mar 5, 2015 - Apr 30, 2015

    Background: Children are five times more likely to be overweight at the age of 12 years if they are overweight during the preschool period. Objective: The purpose of this research was to establish the...

    Background: Children are five times more likely to be overweight at the age of 12 years if they are overweight during the preschool period. Objective: The purpose of this research was to establish the feasibility, acceptability, and preliminary effects of a cognitive-behavioral intervention (TEXT2COPE) synergized with tailored mobile technology (mHealth) on the healthy lifestyle behaviors of parents of overweight and obese preschoolers delivered in a primary care setting. Methods: Fifteen preschool-parent dyads recruited through primary care clinics completed a manualized 7-week cognitive behavioral skills building intervention. Beck’s Cognitive Theory guided the TEXT2COPE intervention content and Fogg’s Behavior Model guided the implementation. The intervention employed via a combination of face-to-face clinic visits and ecological momentary interventions using text messaging. To enhance the intervention’s relevance to the family’s needs, parents dictated the wording of the text messaging and also were able to adapt the frequency and timing text message delivery throughout program implementation. Results: Self-reported findings indicate that the program is feasible and acceptable in this population. The intervention showed preliminary efficacy with significant improvements on parental knowledge about nutrition (P=.001) and physical activity (P=.012) for their children, parental beliefs (P=.001) towards healthy lifestyles, and parental behaviors (P=.040) towards engaging in healthy lifestyle choices for their children. Effect sizes were medium to large for all variables. The timing, frequency, and wording of the text messages were variable to the individual families, with 69% of parents (9/13) increasing the frequency of the tailored SMS from being sent once weekly to as many as five times a week. Conclusions: Utilizing a cognitive behavioral skills intervention with text messaging has great potential for supporting clinical care of overweight and obese preschool children and their families. Further exploration of the potential effects on health and behavioral outcomes is warranted.

  • Qualitative evaluation of a mobile phone application aimed at improving iron intake in premenopausal women.

    Date Submitted: Feb 1, 2015

    Open Peer Review Period: Feb 2, 2015 - Mar 30, 2015

    Background: Low iron intakes can lead to iron deficiency (ID) which can result in impaired health effects and can lead to iron deficiency anemia (IDA). Premenopausal women are at increased risk of ID...

    Background: Low iron intakes can lead to iron deficiency (ID) which can result in impaired health effects and can lead to iron deficiency anemia (IDA). Premenopausal women are at increased risk of ID due to blood loss via menstruation, low dietary iron intake and high gestational requirements. A smartphone application (app) utilizing successful strategies of behavior change such as goal setting, monitoring, feedback, and knowledge was developed with the aim to increase bioavailable iron intake in premenopausal women. Involving users in the development of a health app is necessary to increase usability, functionality and to ensure content acceptability. Objective: Evaluate the content, usability and acceptability of a smartphone app designed to improve intake of bioavailable dietary iron. Methods: Women aged 18-50 years with an Android smartphone were invited to participate. After a two-week trial period, semi-structured focus groups with participants were conducted. Focus group discussions were audio recorded and analyzed via an inductive open-coding method using the qualitative analysis software NVivo 10. Themes were identified and frequency of code occurrence was calculated. Background demographics of participants was recorded. Results: Four focus groups (n=26) were conducted (age range=19-36 years, mean=24.7, SD=5.2). Two themes about the app’s functionality were identified (numerical occurrence in brackets): interface and design (134), and technology issues/usability (86). Four themes about the app’s components were identified: goal tracker (121), facts (78), photo diary (40) and games (46); these themes were then categorized into the behavior change strategies of knowledge, self-efficacy and planning, goals, feedback and self-monitoring. A number of suggestions were provided, particularly in regards to improving the interface and design of the app. Conclusions: This research indicates that participants are willing to use an app utilizing behavior change strategies to try and increase intake of bioavailable iron. Suggestions from participants will aid the ongoing development of the app, adding to the usability and functionality of the app; potentially leading to an increased acceptability.

  • Case Report: Carpal Tunnel Syndrome in the Digital Era - Are Electronic Health Records and Wrist Pedometers Potentially Synergistic Risk Factors?

    Date Submitted: Jan 28, 2015

    Open Peer Review Period: Jan 29, 2015 - Mar 26, 2015

    A 53-year-old right-handed healthy male health care professional presented with 2.5 months of numbness and tingling in the left median nerve distribution, consistent with carpal tunnel syndrome. Six w...

    A 53-year-old right-handed healthy male health care professional presented with 2.5 months of numbness and tingling in the left median nerve distribution, consistent with carpal tunnel syndrome. Six weeks before symptom onset, his hand use for keyboarding had increased because of the implementation of an electronic health record system and he began wearing a circumferential left-wrist electronic pedometer. The increased repetitive finger flexor motion, altered wrist flexion/extension angle while typing, and mild circumferential compression of the flexor tendons and median nerve likely led to his symptoms. He had no upper extremity clubbing, cyanosis, or edema but had mild bilateral thumb carpometacarpal joint arthritis with minimal osteophytes and slight subluxation. Although his symptoms improved after eliminating the wrist pedometer and using a wrist splint for proper ergonomics, it is premature to state that wearing an electronic wrist pedometer will cause carpal tunnel syndrome. We recommend several precautions for wrist pedometer use.