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Journal Description

JMIR mHealth and uHealth (JMU, ISSN 2291-5222) is a sister journal of JMIR, the leading eHealth journal. JMIR mHealth and uHealth is indexed in PubMed, PubMed Central, and Science Citation Index Expanded (SCIE), and in June 2018 received an Impact Factor of 4.541, which ranks the journal #2 (behind JMIR) out of 25 journals in the medical informatics category indexed by the Science Citation Index Expanded (SCIE) by Thomson Reuters/Clarivate

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

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

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

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


Recent Articles:

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

    Mobile-Based Nutrition Counseling and Unconditional Cash Transfers for Improving Maternal and Child Nutrition in Bangladesh: Pilot Study


    Background: Inappropriate feeding practices, inadequate nutrition knowledge, and insufficient access to food are major risk factors for maternal and child undernutrition. There is evidence to suggest that the combination of cash transfer and nutrition education improves child growth. However, a cost-effective delivery platform is needed to achieve complete, population-wide coverage of these interventions. Objective: This study aimed to assess the feasibility, acceptability, and perceived appropriateness of an intervention package consisting of voice messaging, direct counseling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of a child’s life in a poor rural community in Bangladesh. Methods: We conducted a mixed-methods pilot study. We recruited 340 pregnant or recently delivered, lactating women from rural Bangladesh. The intervention consisted of an unconditional cash transfer combined with nutrition counseling, both delivered on a mobile platform. The participants received a mobile phone and BDT 787 per month (US $10). We used a voice messaging service to deliver nutrition-related messages. We provided additional nutrition counseling through a nutrition counselor from a call center. We carried out cross-sectional surveys at baseline and at the end of the study, focus group discussions, and in-depth interviews with participants and their family members. Results: Approximately 89% (245/275) of participants reported that they were able to operate the mobile phones without much trouble. Charging of the mobile handsets posed some challenges since only approximately 45% (124/275) households in our study had electricity at home. Approximately 26% (72/275) women reported they had charged their mobile phones at their neighbor’s house, while 34% (94/275) reported that they charged it at a marketplace. Less than 10% (22/275) of women reported difficulties understanding the voice messages or direct counseling through mobile phones, while only 3% (8/275) of women reported they had some problems withdrawing cash from the mobile bank agent. Approximately 87% (236/275) women reported spending the cash to purchase food for themselves and their children. Conclusions: The nature of our study precludes any conclusion about the effectiveness of the intervention package. However, the high coverage of our intervention and the positive feedback from the mothers were encouraging and support the feasibility, acceptability, and appropriateness of this program. Further research is needed to determine the efficacy and cost-effectiveness of mobile-based nutrition counseling and unconditional cash transfers in improving maternal and child nutrition in Bangladesh.

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

    Digital Food Records in Community-Based Interventions: Mixed-Methods Pilot Study


    Background: A pressing need exists to understand and optimize the use of dietary assessment tools that can be used in community-based participatory research (CBPR) interventions. A digital food record, which uses a mobile device to capture the dietary intake through text and photography inputs, is a particularly promising mobile assessment method. However, little is understood about the acceptability and feasibility of digital food records in CBPR and how to best tailor dietary assessment tools to the needs of a community. Objective: The objective of our study was to evaluate the acceptability and feasibility of digital food records among church-based populations in resource-limited wards of Washington, DC, USA, using a mixed-methods approach. Methods: This community-based pilot study was conducted as part of the Washington, DC Cardiovascular Health and Needs Assessment. Participants (n=17) received a mobile device (iPod Touch) to photodocument their dietary intake for a 3-day digital food record using a mobile app, FitNinja (Vibrent Health). The acceptability of the digital food record was explored through the thematic analysis of verbatim transcripts from a moderated focus group (n=8). In addition, the feasibility was evaluated by the percentage of participants complying with instructions (ie, capturing both before and after meal photos for at least 2 meals/day for 3 days). Results: Qualitative themes identified were related to (1) the feasibility and acceptability of the mobile device and app, including issues in recording the dietary information and difficulty with photodocumentation; (2) suggestions for additional support and training experiences; and (3) comparisons with other mobile apps. Overall, the participants accepted the digital food record by demonstrating satisfaction with the tool and intent to continue the use (eg, participants recorded an average of 5.2, SD 7, consecutive days). Furthermore, of the 17 participants, 15 photodocumented at least 1 meal during the study period and 3 fully complied with the digital food record instructions. Conclusions: This study demonstrated digital food records as an acceptable tool in CBPR and identified contributors and barriers to the feasibility of digital food records for future research. Engaging community members in the implementation of novel assessment methods allows for the tailoring of technology to the needs of the community and optimizing community-based interventions. Trial Registration: NCT01927783; (Archived by WebCite at

  • Improving linkage to HIV care via the SmartLink mobile phone app (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Improving Linkage to HIV Care Through Mobile Phone Apps: Randomized Controlled Trial


    Background: In HIV treatment program, gaps in the “cascade of care” where patients are lost between diagnosis, laboratory evaluation, treatment initiation, and retention in HIV care, is a well-described challenge. Growing access to internet-enabled mobile phones has led to an interest in using the technology to improve patient engagement with health care. Objective: The objectives of this trial were: (1) to assess whether a mobile phone–enabled app could provide HIV patients with laboratory test results, (2) to better understand the implementation of such an intervention, and (3) to determine app effectiveness in improving linkage to HIV care after diagnosis. Methods: We developed and tested an app through a randomized controlled trial carried out in several primary health care facilities in Johannesburg. Newly diagnosed HIV-positive patients were screened, recruited, and randomized into the trial as they were giving a blood sample for initial CD4 staging. Trial eligibility included ownership of a phone compatible with the app and access to the internet. Trial participants were followed for a minimum of eight months to determine linkage to HIV care indicated by an HIV-related laboratory test result. Results: The trial outcome results are being prepared for publication, but here we describe the significant operational and technological lessons provided by the implementation. Android was identified as the most suitable operating system for the app, due to Android functionality and communication characteristics. Android also had the most significant market share of all smartphone operating systems in South Africa. The app was successfully developed with laboratory results sent to personal smartphones. However, given the trial requirements and the app itself, only 10% of screened HIV patients successfully enrolled. We report on issues such as patient eligibility, app testing in a dynamic phone market, software installation and compatibility, safe identification of patients, linkage of laboratory results to patients lacking unique identifiers, and present lessons and potential solutions. Conclusions: The implementation challenges and lessons of this trial may assist future similar mHealth interventions to avoid some of the pitfalls. Ensuring sufficient expertise and understanding of the programmatic needs by the software developer, as well as in the implementation team, with adequate and rapid piloting within the target groups, could have led to better trial recruitment. However, the majority of screened patients were interested in the study, and the app was installed successfully in patients with suitable smartphones, suggesting that this may be a way to engage patients with their health care data in future. Trial Registration: NCT02756949; (Archived by WebCite at

  • Wearable activity tracker for patients with thyrotoxicosis. Source: Image created by the Authors; Copyright: Jae Hoon Moon; URL:; License: Creative Commons Attribution (CC-BY).

    Clinical Feasibility of Monitoring Resting Heart Rate Using a Wearable Activity Tracker in Patients With Thyrotoxicosis: Prospective Longitudinal...


    Background: Symptoms and signs of thyrotoxicosis are nonspecific and assessing its clinical status is difficult with conventional physical examinations and history taking. Increased heart rate (HR) is one of the easiest signs to quantify this, and current wearable devices can monitor HR. Objective: We assessed the association between thyroid function and resting HR measured by a wearable activity tracker (WD-rHR) and evaluated the clinical feasibility of using this method in patients with thyrotoxicosis. Methods: Thirty patients with thyrotoxicosis and 10 controls were included in the study. Participants were instructed to use the wearable activity tracker during the study period so that activity and HR data could be collected. The primary study outcomes were verification of changes in WD-rHR during thyrotoxicosis treatment and associations between WD-rHR and thyroid function. Linear and logistic model generalized estimating equation analyses were performed and the results were compared to conventionally obtained resting HR during clinic visits (on-site resting HR) and the Hyperthyroidism Symptom Scale. Results: WD-rHR was higher in thyrotoxic patients than in the control groups and decreased in association with improvement of thyrotoxicosis. A one standard deviation–increase of WD-rHR of about 11 beats per minute (bpm) was associated with the increase of serum free T4 levels (beta=.492, 95% CI 0.367-0.616, P<.001) and thyrotoxicosis risk (odds ratio [OR] 3.840, 95% CI 2.113-6.978, P<.001). Although the Hyperthyroidism Symptom Scale showed similar results with WD-rHR, a 1 SD-increase of on-site rHR (about 16 beats per minute) showed a relatively lower beta and OR (beta=.396, 95% CI 0.204-0.588, P<.001; OR 2.114, 95% CI 1.365-3.273, P<.001) compared with WD-rHR. Conclusions: Heart rate data measured by a wearable device showed reasonable predictability of thyroid function. This simple, easy-to-measure parameter is clinically feasible and has the potential to manage thyroid dysfunction. Trial Registration: NCT03009357; (Archived by WebCite at

  • Two Syrian women wait to collect a prescription at a health clinic in Lebanon's Bekaa Valley. Source: Flickr; Copyright: DFID - UK Department for International Development; URL:; License: Creative Commons Attribution (CC-BY).

    Using Mobile Health to Enhance Outcomes of Noncommunicable Diseases Care in Rural Settings and Refugee Camps: Randomized Controlled Trial


    Background: Rural areas and refugee camps are characterized by poor access of patients to needed noncommunicable disease (NCD)–related health services, including diabetes and hypertension. Employing low-cost innovative eHealth interventions, such as mobile health (mHealth), may help improve NCDs prevention and control among disadvantaged populations. Objective: The aim of this study was to assess the effect of employing low-cost mHealth tools on the accessibility to health services and improvement of health indicators of individuals with NCDs in rural areas and refugee camps in Lebanon. Methods: This is a randomized controlled trial study in which centers were allocated randomly into control and intervention sites. The effect of an employed mHealth intervention is assessed through selected quality indicators examined in both control and intervention groups. Sixteen primary health care centers (eight controls, eight interventions) located in rural areas and Palestinian refugee camps across Lebanon were included in this study. Data on diabetic and hypertensive patients—1433 in the intervention group and 926 in the control group—was extracted from patient files in the pre and postintervention periods. The intervention entailed weekly short message service messages, including medical information, importance of compliance, and reminders of appointments or regular physician follow-up. Internationally established care indicators were utilized in this study. Descriptive analysis of baseline characteristics of participants, bivariate analysis, logistic and linear regression were conducted using SPSS (IBM Corp). Results: Bivariate analysis of quality indicators indicated that the intervention group had a significant increase in blood pressure control (P=.03), as well as a significant decrease in the mean systolic blood pressure (P=.02), mean glycated hemoglobin (HbA1c; P<.01), and in the proportion of HbA1c poor control (P=.02). Separate regression models controlling for age, gender, and setting showed a 28% increase in the odds of blood pressure control (P=.05) and a 38% decrease in the odds of HbA1c poor control (P=.04) among the intervention group in the posttest period. Females were at lower odds of HbA1c poor control (P=.01), and age was statistically associated with annual HbA1c testing (P<.01). Regression models for mean systolic blood pressure, mean diastolic blood pressure, and mean HbA1c showed that a mean decrease in HbA1c of 0.87% (P<.01) pretest to posttest period was observed among the intervention group. Patients in rural areas belonging to the intervention group had a lower HbA1c score as compared with those in refugee camps (P<.01). Conclusions: This study underlines the importance of employing integrative approaches of diseases prevention and control in which existing NCD programs in underserved communities (ie, rural and refugee camps settings) are coupled with innovative, low-cost approaches such as mHealth to provide an effective and amplified effect of traditional NCD-targeted care that can be reflected by improved NCD-related health indicators among the population. Trial Registration: NCT03580330; (Archived by WebCite at

  • Source: MaxPixel and Pixelbay; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An Assessment Framework for e-Mental Health Apps in Canada: Results of a Modified Delphi Process


    Background: The number of e-mental health apps is increasing rapidly. Studies have shown that the use of some apps is beneficial, whereas others are ineffective or do not meet users’ privacy expectations. Individuals and organizations that curate, recommend, host, use, or pay for apps have an interest in categorizing apps according to the consensus criteria of usability and effectiveness. Others have previously published recommendations for assessing health-related apps; however, the extent to which these recommendations can be generalized across different population groups (eg, culture, gender, and language) remains unclear. This study describes an attempt by Canadian stakeholders to develop an e-mental health assessment framework that responds to the unique needs of people living in Canada in an evidence-based manner. Objective: The objective of our study was to achieve consensus from a broad group of Canadian stakeholders on guiding principles and criteria for a framework to assess e-mental health apps in Canada. Methods: We developed an initial set of guiding principles and criteria from a rapid review and environmental scan of pre-existing app assessment frameworks. The initial list was refined through a two-round modified Delphi process. Participants (N=25) included app developers and users, health care providers, mental health advocates, people with lived experience of a mental health problem or mental illness, policy makers, and researchers. Consensus on each guideline or criterion was defined a priori as at least 70% agreement. The first round of voting was conducted electronically. Prior to Round 2 voting, in-person presentations from experts and a persona empathy mapping process were used to explore the perspectives of diverse stakeholders. Results: Of all respondents, 68% (17/25) in Round 1 and 100% (13/13) in Round 2 agreed that a framework for evaluating health apps is needed to help Canadian consumers identify high-quality apps. Consensus was reached on 9 guiding principles: evidence based, gender responsive, culturally appropriate, user centered, risk based, internationally aligned, enabling innovation, transparent and fair, and based on ethical norms. In addition, 15 informative and evaluative criteria were defined to assess the effectiveness, functionality, clinical applicability, interoperability, usability, transparency regarding security and privacy, security or privacy standards, supported platforms, targeted users, developers’ transparency, funding transparency, price, user desirability, user inclusion, and meaningful inclusion of a diverse range of communities. Conclusions: Canadian mental health stakeholders reached the consensus on a framework of 9 guiding principles and 15 criteria important in assessing e-mental health apps. What differentiates the Canadian framework from other scales is explicit attention to user inclusion at all stages of the development, gender responsiveness, and cultural appropriateness. Furthermore, an empathy mapping process markedly influenced the development of the framework. This framework may be used to inform future mental health policies and programs.

  • WelTel Health Care Provider managing software. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Health Care Provider Utilization and Cost of an mHealth Intervention in Vulnerable People Living With HIV in Vancouver, Canada: Prospective Study


    Background: Improving adherence to combined antiretroviral therapy (cART) can be challenging, especially among vulnerable populations living with HIV. Even where cART is available free of charge, social determinants of health act as barriers to optimal adherence rates. Patient-centered approaches exploiting mobile phone communications (mHealth) have been shown to improve adherence to cART and promote achievement of suppressed HIV plasma viral loads. However, data are scarce on the health care provider (HCP) time commitments and health care costs associated with such interventions. This knowledge is needed to inform policy and programmatic implementation. Objective: The purpose of this study was to approximate the resources required and to provide an estimate of the costs associated with running an mHealth intervention program to improve medication adherence in people living with HIV (PLWH). Methods: This prospective study of HCP utilization and costs was embedded within a repeated measures effectiveness study of the WelTel short-message service (SMS) mHealth program. The study included 85 vulnerable, nonadherent PLWH in Vancouver, Canada, and resulted in improved medication adherence and HIV plasma viral load among participants. Study participants were provided mobile phones with unlimited texting (where required) and received weekly bidirectional text messages to inquire on their status for one year. A clinic nurse triaged and managed participants' responses, immediately logging all patient interactions by topic, HCP involvement, and time dedicated to addressing issues raised by participants. Interaction costs were determined in Canadian dollars based on HCP type, median salary within our health authority, and their time utilized as part of the intervention. Results: Participant-identified problems within text responses included health-related, social, and logistical issues. Taken together, management of problems required a median of 43 minutes (interquartile range, IQR 17-99) of HCP time per participant per year, for a median yearly cost of Can $36.72 (IQR 15.50-81.60) per participant who responded with at least one problem. The clinic nurse who monitored the texts solved or managed 65% of these issues, and the remaining were referred to a variety of other HCPs. The total intervention costs, including mobile phones, plans, and staffing were a median Can $347.74/highly vulnerable participant per year for all participants or Can $383.18/highly vulnerable participant per year for those who responded with at least one problem. Conclusions: Bidirectional mHealth programs improve HIV care and treatment outcomes for PLWH. Knowledge about the HCP cost associated, here less than Can $50/year, provides stakeholders and decision makers with information relevant to determining the feasibility and sustainability of mHealth programs in a real-world setting. Trial Registration: NCT02603536; (Archived by WebCite at

  • A healthcare provider giving situational feedback. Source: iStock by Getty Images; Copyright: ChristopherBernard; URL:; License: Licensed by the authors.

    An mHealth Intervention for Persons with Diabetes Type 2 Based on Acceptance and Commitment Therapy Principles: Examining Treatment Fidelity


    Background: Web-based interventions are becoming an alternative of treatment aimed to support behavioral changes and several advantages over traditional treatments are reported. New ways of delivering an intervention may result in new challenges regarding monitoring of treatment fidelity (TF) which is essential to ensure internal and external validity. Despite the importance of the theme, only a few studies in this field are reported. Objective: To examine TF of a mobile phone delivered intervention based on Acceptance and Commitment Therapy (ACT) with electronic diaries and written situational feedback for persons with diabetes mellitus type 2, the recommendations from the Behavior Change Consortium (BCC) established by The National Institutes of Health (NHI) were applied. To analyze fidelity, they recommend 5 areas to be investigated (1) design of the study, (2) provider training, (3) delivery of treatment, (4) receipt of treatment, and (5) enactment of treatment. In the current study, these areas were examined based on the analysis of therapists’ adherence to the treatment protocol and participants’ and therapists’ experience with the intervention. Methods: To investigate the therapists’ adherence to the treatment protocol, a total of 251 written feedback text messages were divided into text segments. Qualitative thematic analyses were then performed to examine how ACT and other therapeutic processes were used in the feedback by the therapists. For the therapists’ and participants’ experience analysis, participants answered a self-reported questionnaire and participated in 2 interviews. The therapists continuously reported their experiences to the researcher responsible for the project. Results: The results show high adherence to the TF strategies 20/21 (95%) applicable items of the fidelity checklist recommended by NHI BCC were identified in the present study. Measured provider skill acquisition post-training was the only item absent in the fidelity checklist. The results also show high therapists’ adherence to the treatment protocol. All ACT processes (values, committed action, acceptance, contact with the present moment, self as context and cognitive defusion) were found in the coded text segments of the feedback in addition to communication and motivation strategies. For 336/730 (46%) of total possible text segments coded independently by 2 researchers, the interrater reliability measured by Cohen’s kappa was .85. The evaluation of participants’ and therapists’ experience with the intervention was generally positive. Conclusions: Based on the analyses of therapists’ adherence to the treatment protocol grounded by ACT-principles and participants’ and therapists’ experience with the intervention, the 5 areas of TF recommended by NHI BCC were analyzed indicating a high level of TF. These results ensure an appropriate level of internal and external validity of the study and reliable intervention results and facilitate a precise replication of this intervention concept. Web-based psychological interventions to support people with chronic conditions are becoming increasingly more common. This study supports the results from a previous study which indicated that ACT could be reliably delivered in a written web-based format. Trial Registration: NCT01297049; (Archived by WebCite at

  • A woman using a mobile app for medication and health management. Source: iStock by Getty Images; Copyright: AntonioGuillem; URL:; License: Licensed by the authors.

    A Novel mHealth Approach for a Patient-Centered Medication and Health Management System in Taiwan: Pilot Study


    Background: Mobile health (mHealth) apps have recently demonstrated the potential to engage and empower people to improve their own health. Although the availability of health-related apps is increasing, their adoption rate in Taiwan is exceptionally low mainly due to the preponderance of Western culture-based app designs that are challenging for non-English-speaking individuals. To our knowledge, no mHealth app is available in Taiwan that is culturally tailored for Chinese-speaking users and that applies a patient-centered approach to self-manage medication and health. Objective: The purpose of this study was to design and deploy a culturally tailored mHealth system that could be easily integrated into current clinical practice and to evaluate how this mHealth system could support the continuity of patient care in Taiwan. Methods: An mHealth information system and a mobile app were designed. To promote the best patient experience, a Quick Response (QR) code system was developed to enable efficient registration of personal medication information through the mobile app. The app also supported notifications for drug utilization, refills, and symptom checks. Patients were encouraged to record medication use, symptoms, and self-assessments in the app during their treatment period. Evaluation of the novel mHealth system was conducted from August 1, 2016 to December 31, 2016 at MacKay Memorial Hospital, Taipei, Taiwan. Population data and app usage statistics were analyzed. Results: During the 5-month implementation period, a total of 25,909 users downloaded the app with an overall 7-day retention rate of 15.4% (SD 3.9). Young male adults (range 25-44 years) were the predominant user population. Patients’ feedback on app usability and design, QR code system as drug input method, medication reminders, and linking family or friends into care networks was generally positive. Physicians showed great interest in utilizing patient-generated data in their care process, and the positive medication adherence rate was the most highly valued component of this system. Conclusions: This pilot study demonstrated the value of a novel mHealth approach for individualized medication and health management in Taiwan. The mHealth system shows the potential to optimize personalized care into existing clinical services and may help hospitals and health authorities perform continuous quality improvement and policy development.

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

    Self-Management of Chronic Diseases Among Older Korean Adults: An mHealth Training, Protocol, and Feasibility Study


    Background: Most training programs for self-management of chronic diseases in Korea currently involve face-to-face interactions primarily in a health care setting. Therefore, older Koreans living in the community continue to seek other training opportunities for the management of chronic diseases. This has led to the development of new training methods, such as mobile health (mHealth) care, which are valuable in community centers and homes. Objective: This feasibility study (1) developed an mHealth training protocol to empower community-dwelling elderly individuals to manage their chronic diseases; (2) examined the feasibility of delivering this mHealth training protocol to elderly individuals through mobile tablets and applications (apps); and (3) discussed the contextual and methodological challenges associated with the development of this protocol. Methods: The mHealth training protocol was developed based on the eHealth Enhanced Chronic Care Model and comprised of four phases. Phase 1 included standardized technology (mobile tablets) training using guidebooks, demonstrations, and guided practice. Phase 2 included provision of standardized information about disease management that was obtained from governmental and professional health care organizations. Phase 3 included provision of training on the use of high-quality mHealth apps that were selected based on individual diagnoses. Phase 4 included encouraging the patients to practice using self-selected mHealth apps based on their individual needs. Quantitative descriptive statistics and qualitative content analyses of user evaluations were used to assess the feasibility and user acceptance of this protocol. Results: Of the 27 older adults included in this study, 25 completed all 4 weeks of the mHealth training. The attrition rate was 7% (2/27), and the reasons included time conflicts, emotional distress, and/or family discouragement. The men required little or no training for Phase 1, and in comparison with men, women seemed to depend more on the mHealth trainers in Phase 3. Gender, level of education, and previous experience of using smartphones were associated with the speed of learning, level of confidence, and overall competence. Conclusions: A tailored and personalized approach is required to develop mHealth training protocols for older adults. Self-management of chronic diseases via mHealth training requires careful consideration of the complex nature of human behavior, emotional responses, and familial influences. Therefore, integration of a theoretical, clinical, and technical approach is necessary for the successful development and implementation of an mHealth training program that targets older adults with chronic diseases in a community setting.

  • Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Learnability of a Configurator Empowering End Users to Create Mobile Data Collection Instruments: Usability Study


    Background: Many research domains still heavily rely on paper-based data collection procedures, despite numerous associated drawbacks. The QuestionSys framework is intended to empower researchers as well as clinicians without programming skills to develop their own smart mobile apps in order to collect data for their specific scenarios. Objective: In order to validate the feasibility of this model-driven, end-user programming approach, we conducted a study with 80 participants. Methods: Across 2 sessions (7 days between Session 1 and Session 2), participants had to model 10 data collection instruments (5 at each session) with the developed configurator component of the framework. In this context, performance measures like the time and operations needed as well as the resulting errors were evaluated. Participants were separated into two groups (ie, novices vs experts) based on prior knowledge in process modeling, which is one fundamental pillar of the QuestionSys framework. Results: Statistical analysis (t tests) revealed that novices showed significant learning effects for errors (P=.04), operations (P<.001), and time (P<.001) from the first to the last use of the configurator. Experts showed significant learning effects for operations (P=.001) and time (P<.001), but not for errors as the experts’ errors were already very low at the first modeling of the data collection instrument. Moreover, regarding the time and operations needed, novices got significantly better at the third modeling task than experts were at the first one (t tests; P<.001 for time and P=.002 for operations). Regarding errors, novices did not get significantly better at working with any of the 10 data collection instruments than experts were at the first modeling task, but novices’ error rates for all 5 data collection instruments at Session 2 were not significantly different anymore from those of experts at the first modeling task. After 7 days of not using the configurator (from Session 1 to Session 2), the experts’ learning effect at the end of Session 1 remained stable at the beginning of Session 2, but the novices’ learning effect at the end of Session 1 showed a significant decay at the beginning of Session 2 regarding time and operations (t tests; P<.001 for time and P=.03 for operations). Conclusions: In conclusion, novices were able to use the configurator properly and showed fast (but unstable) learning effects, resulting in their performances becoming as good as those of experts (which were already good) after having little experience with the configurator. Following this, researchers and clinicians can use the QuestionSys configurator to develop data collection apps for smart mobile devices on their own.

  • Source: Flickr; Copyright: Michal Shanny; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Association Between Self-Reported and Objective Activity Levels by Demographic Factors: Ecological Momentary Assessment Study in Children


    Background: To address the limitations of the retrospective self-reports of activity, such as its susceptibility to recall bias, researchers have shifted toward collecting real-time activity data on mobile devices via ecological momentary assessment (EMA). Although EMA is becoming increasingly common, it is not known how EMA self-reports of physical activity and sedentary behaviors relate to the objective measures of activity or whether there are factors that may influence the strength of association between these two measures. Understanding the relationship between EMA and accelerometry can optimize future instrument selection in studies assessing activity and health outcomes. Objective: The aim of this study was to examine the associations between EMA-reported sports or exercise using the accelerometer-measured moderate-to-vigorous physical activity (MVPA) and EMA-reported TV, videos, or video games with the accelerometer-measured sedentary time (ST) in children during matched 2-h windows and test potential moderators. Methods: Children (N=192; mean age 9.6 years; 94/192, 49.0% male; 104/192, 54.2% Hispanic; and 73/192, 38.0% overweight or obese) wore an accelerometer and completed up to 7 EMA prompts per day for 8 days during nonschool time, reporting on past 2-h sports or exercise and TV, videos, or video games. Multilevel models were used to assess the relationship between the accelerometer-measured ST and EMA-reported TV, videos, or video games. Given the zero-inflated distribution of MVPA, 2-part models were used assess the relationship between the accelerometer-measured MVPA and EMA-reported sports or exercise. Results: EMA-reported TV, videos, or video games were associated with a greater accelerometer-measured ST (beta=7.3, 95% CI 5.5 to 9.0, P<.001). This relationship was stronger in boys (beta=9.9, 95% CI 7.2 to 12.6, P<.001) than that in girls (beta=4.9, 95% CI 2.6 to 7.2, P≤.001). EMA-reported sports or exercise was associated with a greater accelerometer-measured MVPA (zero portion P<.001; positive portion P<.001). This relationship was stronger on weekends, in older children, and in non-Hispanic children (zero portion all P values<.001; positive portion all P values<.001). Conclusions: EMA reports highly relate to accelerometer measures. However, the differences in the strength of association depending on various demographic characteristics suggest that future research should use both EMA and accelerometers to measure activity to collect complementary activity data.

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  • Challenge to go: Systematic development of a theory-based and target group-adapted mobile app intervention to improve eating habits of adolescents and young adults

    Date Submitted: Jul 13, 2018

    Open Peer Review Period: Jul 16, 2018 - Sep 10, 2018

    Background: Due to the widespread use of smartphones, dietary mobile apps are promising tools for preventing diet-related non-communicable diseases early in life. But, most of currently available nutr...

    Background: Due to the widespread use of smartphones, dietary mobile apps are promising tools for preventing diet-related non-communicable diseases early in life. But, most of currently available nutrition apps lack scientific evaluation and user acceptance. Objective: The objective of the present study was the systematic design of a theory-driven and target group-adapted dietary mobile app concept to promote healthy eating habits with a focus on drinking habits as well as consumption of fruits and vegetables in adolescents and young adults, especially in deprived life situations. Methods: The design process was guided by the behaviour change wheel (BCW). The development process consisted of three stages. In stage 1, the target behavior was specified, and facilitators and barriers were identified. Furthermore, important insights into target group interests, needs and values in the field of nutrition and apps were revealed. To this end, two empirical studies were conducted with the target group. In stage 2, results of stage 1 were translated into behavior change techniques (BCTs) and finally into app functionalities and features. Consequently, in stage 3, the concept was evaluated and optimized through expert interviews. Results: Facilitators and barriers for achieving the target behavior were psychological capabilities (e.g. self-efficacy), reflective motivation (e.g. fitness), automatic motivation, social support, and physical opportunity (e.g. time). Target group interests, needs and values in the field of nutrition were translated into target group preferences for app usage, e.g. low usage effort, visual feedback or recipes. Education, training, incentives, persuasion, and enablement were identified as relevant interventions functions. Together with the target group preferences, these were translated via 14 BCTs, such as rewards, graded tasks or self-monitoring, into the app concept Challenge to go (C2go). The expert evaluation suggested changes of some app features for improving adherence, positive health effects and technical feasibility. The C2go concept consists of three worlds: (i) drinking, (ii) vegetable, and (iii) fruit world. In each world, the users are faced with challenges including feedbacks and a quiz. Tips were developed based on the health action process approach and help users to gain challenges and thereby achieve the target behavior. Challenges can be played alone or against someone in the community. Due to different activities, points can be collected, and levels can be achieved. Collected points open access to an infothek, where users can choose content that interest them. An avatar guides user through the app. Conclusions: C2go targets adolescents and young adults and aims to improve their fruit and vegetable consumption as well as drinking habits. It is a theory-driven and target group-adapted dietary mobile intervention concept that uses gamification and was systematically developed using the BCW.

  • Using the algorithm of betweenness centrality in social network analysis to identify the influential author who published papers in JMIR mHealth and uHealth: A Bibliometric Analysis

    Date Submitted: Jul 11, 2018

    Open Peer Review Period: Jul 15, 2018 - Sep 9, 2018

    Background: Many papers investigating author collaboration might have biases because some different authors with the same name exist. However, no study has dealt with the matter of duplicate names in...

    Background: Many papers investigating author collaboration might have biases because some different authors with the same name exist. However, no study has dealt with the matter of duplicate names in bibliometric data. Although betweenness centrality (BC) is one of the most popular degrees of density in social network analysis (SNA), few have applied the BC algorithm to interpret a network’s characteristics. Objective: This study aimed to apply the BC algorithm to examine possible identical names in a network and report the author collaboration characteristics for a journal related to international mobile health research. Methods: We obtained 676 abstracts from Medline based on the keywords of “JMIR mHealth and uHealth” (Journal) on June 30, 2018. The author names, countries/areas, and author-defined keywords were recorded. The BCs were calculated for the following: (1) the countries/areas distributed for the first author in geography, (2) the author clusters dispersed on Google Maps, and (3) the keywords dispersed for the cluster with the most productive author on a dashboard. Pajek software was performed to yield the BC for each entity (or say node). The submission and acceptance days of articles submitted to a journal were compared using two-way ANOVA to examine the differences among authors’ areas over the years. Results: We found that the top two countries with the highest BC were the USA and the UK. The most productive authors with seven papers were Urs-Vito Albrecht (Germany) and Sherif M. Badawy (the USA). The most influential author Ralph Maddison (Australia) earned the highest BC in the authoring network. The keyword of mHealth, as expected, gained the highest BC in the keyword network. All visual representations were successfully displayed on Google Maps. No difference in submission and acceptance days of articles submitted to JMIR mHealth and uHealth was found among continents (F=0.08, df=5, p=0.99) or over the years (F=0.56, df=3, p=0.64). Conclusions: SNA provides deep insight into the patterns of international author collaborations for JMIR mHealth and uHealth. The results on Google Maps are novel and unique as knowledge concept maps for understanding the feature of a specific journal. The research approach using the BC to identify the same author names can be applied to other bibliometric analyses in the future. Clinical Trial: Not available

  • Remote monitoring and discordant values: A qualitative study of low-income immigrant elders in the U.S.

    Date Submitted: Jul 11, 2018

    Open Peer Review Period: Jul 15, 2018 - Sep 9, 2018

    Background: Remote monitoring technologies are positioned to mitigate the problem of a dwindling care workforce and disparities in access to care for the growing elder immigrant population in the Unit...

    Background: Remote monitoring technologies are positioned to mitigate the problem of a dwindling care workforce and disparities in access to care for the growing elder immigrant population in the United States. To achieve these ends, designers and providers need to understand how these supports can be best provided in the context of various socio-cultural environments that shape older adults’ expectations and care relationships, yet few studies have examined how the same remote monitoring technologies may produce difference effects and uses depending on what population is using them in a particular context. Objective: We examine the experiences of low-income and immigrant senior housing residents with a sensor-based passive monitoring system. We are interested in adoption and discontinuation decisions and use over time, rather than projected acceptance or preferences. The senior housing organization had been offering the QuietCare sensor system to its residents for six years at the time of study. Our research question is “Do cultural differences influence use of this remote monitoring technology, and how?” The study does not draw generalizable conclusions about how cultural groups interact with a given technology, but rather, it examines how values are made visible in elder care technology interactions. Methods: The sample population is 49 senior housing residents, family emergency contacts, and social work staff who are responsible for using the QuietCare sensor-based monitoring system in six large senior housing independent living apartment buildings. Interviews were conducted in English and Korean with these participants who collectively had immigrated to the U.S. from ten different countries. Results: The most significant differences in adoption and use of QuietCare were observed between Russian-speaking and Asian residents. None of the more than 200 Russian-speaking residents accepted the remote monitoring system, which social workers attributed to the desire for hands-on care and the expectation that care should be provided to them based on sociopolitical norms of publically provided services. Asian elders accepted the intervention social workers offered largely to appease them, but unlike their U.S.-born counterparts, they adopted reluctantly without hope that it would ameliorate their situation. Asian immigrants discontinued use at the highest rate of all residents and intergenerational family cultural conflict contributed to this termination. Conclusions: This research into the interactions of culturally diverse people with the same monitoring technology reveals the significant role that social values and context play in shaping how people and families interact with and experience elder care interventions. If technology-based care services are to reach their full potential, it will be important to identify the ways cultural values produce different uses and responses to technologies intended to help older adults live independently.

  • Development of a mobile sleep-management learning system for improving students’ sleeping habits via integrating a self-regulated learning strategy

    Date Submitted: Jul 11, 2018

    Open Peer Review Period: Jul 15, 2018 - Sep 9, 2018

    Insomnia can significantly affect students’ learning performance. Researchers have indicated the importance and challenge of coping with insomnia using non-drug treatments, such as the cognitive beh...

    Insomnia can significantly affect students’ learning performance. Researchers have indicated the importance and challenge of coping with insomnia using non-drug treatments, such as the cognitive behavioral therapy for insomnia (CBT-I). However, it is easy for the traditional CBT-I to be interrupted owing to the overly lengthy period of sleep therapy. Self-regulated learning (SRL) strategies are known to be an effective approach for helping students improve their time management as well as their ability to set learning goals and adopt learning strategies. Therefore, in this study, a mobile sleep-management learning system integrated with self-regulated learning strategies and cognitive behavioral therapy is proposed. With the assistance of this proposed approach, students are able to plan their daily life by setting goals, applying strategies, monitoring their life habits process, and modifying strategies to cultivate good learning and healthy lifestyle habits. A total of 18 undergraduate students from a university in northern Taiwan participated in the 2-week experiment of using this sleep-management system. The experimental results showed that the proposed approach was useful and easy for the students to use. The number of students with insomnia also significantly decreased; that is, the proposed approach could help the students improve their sleep quality and cultivate better sleeping habits, which is important for them to enhance their learning efficiency.

  • Customizing of types of technologies used by T1D patients for diabetes treatment: exemplification made by set of case series

    Date Submitted: Jul 10, 2018

    Open Peer Review Period: Jul 15, 2018 - Sep 9, 2018

    Background: Despite the fact there are many wearable and mobile medical devices that enable patients to better self-manage their diabetes, not many patients are aware of all the options they have. In...

    Background: Despite the fact there are many wearable and mobile medical devices that enable patients to better self-manage their diabetes, not many patients are aware of all the options they have. In addition, there are those, who are not fully satisfied with the devices they use and, besides that, they often do not use them effectively. Objective: Deeper understanding of patients’ needs and abilities can help to both tailor a given device for a particular group of patients and assemble sets and types of devices that best comply with the needs of the patients. Methods: 6 specific patients (3 men and 3 women), who have been using the Diani telemedicine system for at least 3 months up to 4 years, were properly instructed by a technology educator in how to operate each of the system components. Before starting to use the system and during the monitoring phase, the patients took interviews with a doctor and the educator about their daily regimen, technology capabilities, life preferences and similar topics. The technology educator was also tracking patterns of handling the devices 1) by observation while educating the patients on how to use them, and 2) via the Diani web application during the monitoring phase. Informed consent was signed and obtained from each of the patients included. Results: Each of the presented case study describes how a given patient is handling the system and its particular parts based on his/her lifestyle, level of education, manners in diabetes management, personality type and other factors. At the conclusion of each case study, the best composition of devices for patients with similar personal description is suggested. Conclusions: Except for the input information we get about a patient, it is obvious that there is a substantial need for proper education of both patients and healthcare providers. We believe this article can provide a relevant guidance on how to help particular patients choose the best technology that is likely to fit them the most, based on specific patient information we are able to obtain from them.

  • Believing is Seeing: A proof-of-concept study on using mobile Virtual Reality to boost the effects of Interpretation Bias Modification for anxiety

    Date Submitted: Jul 10, 2018

    Open Peer Review Period: Jul 15, 2018 - Sep 9, 2018

    Background: Cognitive Bias Modification of Interpretations (CBM-I) is a computerized intervention designed to change negatively biased interpretations of ambiguous information, which underlie and rein...

    Background: Cognitive Bias Modification of Interpretations (CBM-I) is a computerized intervention designed to change negatively biased interpretations of ambiguous information, which underlie and reinforce anxiety. The repetitive and monotonous features of CBM-I can negatively impact on training adherence and learning processes. Objective: This proof-of-concept study examined whether performing a CBM-I training using mobile Virtual Reality technology (VR-CBM-I) improves training experience and effectiveness. Methods: Forty-two students high in trait anxiety completed one session of either VR-CBM-I or standard CBM-I training for performance anxiety. Participants’ feelings of immersion and presence, emotional reactivity, and changes in interpretation bias and state anxiety were assessed. Results: The VR-CBM-I resulted in greater feelings of presence and immersion in the training scenarios and outperformed the standard training in effects on state anxiety and emotional reactivity. Both training-varieties successfully increased the endorsement of positive interpretations and decreased negative ones. In addition, changes in the emotional outcomes were correlated with greater feelings of immersion. Conclusions: Our findings hold promise for the further investigation of VR as a tool to boost the effects of CMB-I trainings for highly anxious individuals.