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JMIR mHealth and uHealth

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


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 2017 received an impressive inaugural Impact Factor of 4.636, which ranks the journal #2 (behind JMIR) out of over 20 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: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Novel Method to Efficiently Create an mHealth App: Implementation of a Real-Time Electrocardiogram R Peak Detector


    Background: In parallel to the introduction of mobile communication devices with high computational power and internet connectivity, high-quality and low-cost health sensors have also become available. However, although the technology does exist, no clinical mobile system has been developed to monitor the R peaks from electrocardiogram recordings in real time with low false positive and low false negative detection. Implementation of a robust electrocardiogram R peak detector for various arrhythmogenic events has been hampered by the lack of an efficient design that will conserve battery power without reducing algorithm complexity or ease of implementation. Objective: Our goals in this paper are (1) to evaluate the suitability of the MATLAB Mobile platform for mHealth apps and whether it can run on any phone system, and (2) to embed in the MATLAB Mobile platform a real-time electrocardiogram R peak detector with low false positive and low false negative detection in the presence of the most frequent arrhythmia, atrial fibrillation. Methods: We implemented an innovative R peak detection algorithm that deals with motion artifacts, electrical drift, breathing oscillations, electrical spikes, and environmental noise by low-pass filtering. It also fixes the signal polarity and deals with premature beats by heuristic filtering. The algorithm was trained on the annotated non–atrial fibrillation MIT-BIH Arrhythmia Database and tested on the atrial fibrillation MIT-BIH Arrhythmia Database. Finally, the algorithm was implemented on mobile phones connected to a mobile electrocardiogram device using the MATLAB Mobile platform. Results: Our algorithm precisely detected the R peaks with a sensitivity of 99.7% and positive prediction of 99.4%. These results are superior to some state-of-the-art algorithms. The algorithm performs similarly on atrial fibrillation and non–atrial fibrillation patient data. Using MATLAB Mobile, we ran our algorithm in less than an hour on both the iOS and Android system. Our app can accurately analyze 1 minute of real-time electrocardiogram signals in less than 1 second on a mobile phone. Conclusions: Accurate real-time identification of heart rate on a beat-to-beat basis in the presence of noise and atrial fibrillation events using a mobile phone is feasible.

  • Man with type 2 diabetes using the self-management app. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Acceptability of an mHealth App Intervention for Persons With Type 2 Diabetes and its Associations With Initial Self-Management: Randomized Controlled Trial


    Background: Mobile health interventions are increasingly used in health care. The level of acceptability may indicate whether and how such digital solutions will be used. Objective: This study aimed to explore associations between the level of acceptability of a mobile diabetes app and initial ability of self-management for patients with type 2 diabetes. Methods: Participants with type 2 diabetes were recruited from primary health care settings to a 3-armed randomized controlled trial in the Norwegian study in the RENEWING HEALTH project. At the 1-year follow-up, 75 out of 101 participants from the intervention groups completed an acceptability questionnaire (The Service User Technology Acceptability Questionnaire). In the randomized controlled trial, the 2 intervention groups (n=101 in total) received a mobile phone with a diabetes diary app, and one of the groups received additional health counseling given by telephone calls from a diabetes specialist nurse (n=50). At baseline, we collected clinical variables from medical records, whereas demographic data and self-management (The Health Education Impact Questionnaire) measures were self-reported. Log data from the use of the app by self-monitoring were registered continuously. Associations between initial ability to self-manage at baseline and acceptability of the diabetes diary app after 1 year were analyzed using linear regression. Results: We found statistically significant associations between 5 of the 8 self-management domains and perceived benefit, one of the acceptability factors. However, when adjusting for age, gender, and frequency of use, only 1 domain, skill and technique acquisition, remained independently associated with perceived benefit. Frequency of use of the app was the factor that revealed the strongest association with the acceptability domain perceived benefit. Conclusions: Our findings indicate that persons with diabetes may accept the app, despite its perceived benefit being associated with only one of the 8 domains of their initial level of self-management. Trial Registration: NCT01315756; (Archived by WebCite at

  • Source: US Air Force; Copyright: Staff Sgt. Joshua Edwards; URL:; License: Public Domain (CC0).

    Reach and Acceptability of a Mobile Reminder Strategy and Facebook Group Intervention for Weight Management in Less Advantaged Adolescents: Insights From the...


    Background: Although information and communication technology interventions appear to be a promising means of reducing the health inequality gap in overweight and obesity prevention, research on information and communication technology interventions is lacking outside the Anglo-Saxon world. Objective: The aim of this study was to assess the reach and acceptability of 2 information and communication technology interventions delivered as part of a French nutritional program: an SMS text messaging (short message service, SMS) attendance-reminder for collective sessions strategy and a Facebook challenge group. Methods: This study sample comprised 262 socially less advantaged overweight adolescents aged between 13 and 18 years. The information and communication technology interventions were carried out during the 2013-2014 academic year in 33 French state-run schools. For the SMS attendance-reminder for collective sessions strategy, at the start of the academic year, adolescents were asked to give their mobile number. SMS attendance-reminders were sent shortly before each of the 5 collective sessions. For the Facebook challenge group, adolescents were invited to join a closed Facebook group in which challenges on physical activity and on diet were posted weekly. Process data and 2 sets of face-to-face interviews were also used to interpret participation rates and access to Facebook. Appreciation for both interventions was evaluated by a questionnaire at the end of the academic year. Results: Of the recruited adolescents, 79.0% (207/262) gave their mobile number, reflecting high access to a mobile phone. Giving a number was significantly more likely for girls (odds ratio [OR] 2.1, 95% CI 1.1-3.9; P=.02) and adolescents in a vocational or general high school as opposed to middle school (OR 1.0, 95% CI 0.4-2.7; OR 0.2, 95% CI 0.1-0.5; P<.001). Indicating a mobile number at the start of the year was not significantly associated with participation in collective sessions. Of the adolescents seen at the start-of-year face-to-face interviews, 78.1% (153/196) declared an interest in the Facebook challenge group, which implies having a Facebook account or being able to have access to one. However, only 21 adolescents went through the process of joining the group. Although there was satisfaction with the Facebook group among the participants, the low participation rate in the Facebook group does not allow conclusions to be drawn with confidence. Conclusions: The results are in line with the claim that using information and communication technologies in health programs is unlikely to widen health inequalities. However, in this population of French adolescents, mobile phone strategies seem more adapted to a high school context, and caution should be exercised with a younger audience. Although there is positive appreciation of the SMS attendance-reminders and a Facebook intervention is initially highly appealing to less advantaged adolescents, no evidence of impact could be demonstrated. These results highlight the difficulty in assessing the impact of specific interventions in complex health programs. Trial Registration: NCT01688453; (Archived by WebCite at

  • Filling the Wisepill Catridge. Source: Wisepill Technologies; Copyright: Wisepill Technologies; URL:; License: Creative Commons Attribution (CC-BY).

    Acceptability and Feasibility of Real-Time Antiretroviral Therapy Adherence Interventions in Rural Uganda: Mixed-Method Pilot Randomized Controlled Trial


    Background: Wireless electronic adherence monitors can detect antiretroviral therapy (ART) adherence lapses and trigger interventions in real time, thus potentially avoiding unnecessary HIV viremia. Evidence about the acceptability and feasibility of these monitors and associated interventions, however, is limited. Objective: The aim of this study was to assess the acceptability and feasibility of real-time adherence monitoring linked to text messaging (short message service, SMS) reminders and notifications to support adherence among individuals living with HIV who are taking ART in rural southwestern Uganda. Methods: Individuals living with HIV who were initiating ART were enrolled in a pilot randomized controlled trial and followed up for 9 months. Participants received a real-time adherence monitor and were randomized to one of the following study arms: (1) scheduled SMS, (2) SMS triggered by missed or delayed doses, or (3) no SMS. SMS notifications were also sent to 45 patient-identified social supporters for sustained adherence lapses in the scheduled SMS and triggered SMS arms. Study participants and social supporters participated in qualitative semistructured in-depth interviews on acceptability and feasibility of this technology. An inductive, content analytic approach, framed by the unified theory of acceptance and use of technology model, was used to analyze qualitative data. Quantitative feasibility data, including device functionality and SMS tracking data, were recorded based upon device metrics collected electronically and summarized descriptively. Results: A total of 63 participants participated in the study. Participants reported that real-time monitoring intervention linked to SMS reminders and notifications are generally acceptable; the predominant feedback was perceived utility—the intervention was beneficial in motivating and reminding patients to take medication, as well as enabling provision of social support. The intervention was found to be technically feasible, as data were obtained from most participants as expected most of the time. Potential challenges included the impact of the technology on confidentiality, shared phone ownership, usability skills, and availability of electricity. Conclusions: Real-time adherence monitoring integrated with SMS reminders and social support notifications is a generally acceptable (based primarily on perceived utility) and feasible intervention in a resource-limited country. Future efforts should focus on optimized device design, user training to overcome the challenges we encountered, cost effectiveness studies, as well as studying the monitoring aspect of the device without accompanying interventions. Trial Registration: NCT01957865; (Archived by WebCite at

  • Source: Burst; Copyright: Nicole De Khors; URL:; License: Licensed by the authors.

    Mindfulness-Based Symptom and Stress Management Apps for Adults With Chronic Lung Disease: Systematic Search in App Stores


    Background: Up to 70% of lung cancer survivors are affected by chronic obstructive pulmonary disease (COPD), a common, debilitating, comorbid disease. Lung cancer and COPD are both characterized by symptoms such as breathlessness, fatigue, and psychological distress. These distressing chronic symptoms are exacerbated by stress and detract from an individual’s quality of life. Objective: The aim of this study was to identify and evaluate evidence-based, commercially available apps for promoting mindfulness-based strategies among adults with a COPD or lung cancer history (ie, chronic lung disease). Methods: For this review, an interdisciplinary research team used 19 keyword combinations in the search engines of Google and iOS app stores in May 2017. Evaluations were conducted on the apps’ (1) content, (2) usability heuristics, (3) grade-level readability, and (4) cultural sensitivity. Results: The search resulted in 768 apps (508 in iOS and 260 in Google stores). A total of 9 apps met the inclusion criteria and received further evaluation. Only 1 app had below an eighth-grade reading level; the ninth one did not have enough text to calculate a readability score. None of the 9 apps met the cultural sensitivity evaluation criteria. Conclusions: This systematic review identified critical design flaws that may affect the ease of using the apps in this study. Few mobile apps promote mindfulness-based strategies among adults with chronic lung disease (ie, COPD or lung cancer or both), but those that exist, overall, do not meet the latest scientific evidence. Recommendations include more stringent regulation of health-related apps, use of evidence-based frameworks and participatory design processes, following evidence-based usability practices, use of culturally sensitive language and images, and ensuring that content is written in plain language.

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

    Health Care Professionals’ Attitudes Toward, and Experiences of Using, a Culture-Sensitive Smartphone App for Women with Gestational Diabetes Mellitus:...


    Background: The increasing prevalence of gestational diabetes mellitus (GDM) among women of different ethnic backgrounds provides new challenges for health care professionals, who often find it difficult to provide information about the management of this disease to such individuals. Mobile health (mHealth) may act as a useful tool for blood sugar control and care process enhancement. However, little is known about health care professionals’ experiences and attitudes toward the use of mHealth for women with GDM. Objective: The aim of this study was to explore how health care professionals perceived the provision of care to pregnant women who managed their GDM using the culture-sensitive Pregnant+ app in a randomized controlled trial. Methods: Individual interviews with 9 health care professionals providing care for women with GDM were conducted. Braun and Clark’s method of thematic content analysis inspired the analysis. This study included health care professionals who were primarily responsible for providing care to participants with GDM in the Pregnant+ randomized controlled trial at 5 diabetes outpatient clinics in Oslo, Norway. Results: Health care professionals perceived mHealth, particularly the Pregnant+ app, as an appropriate tool for the care of women with GDM, who were described as individuals comprising a heterogeneous, motivated group that could be easily approached with health-related information. Some participants reported challenges with respect to provision of advice to women with different food cultures. The advantages of the Pregnant+ app included provision of information that women could access at home, the information provided being perceived as trustworthy by health care professionals, the culture sensitivity of the app, and the convenience for women to register blood sugar levels. Technical problems, particularly those associated with the automatic transfer of blood glucose measurements, were identified as the main barrier to the use of the Pregnant+ app. Strict inclusion criteria and the inclusion of participants who could not speak Norwegian were the main challenges in the recruitment process for the randomized controlled trial. Conclusions: The findings of this study suggest that mHealth is a useful tool to enhance the care provided by health care professionals to women with GDM. Future mobile apps for the management of GDM should be developed by a trustworthy source and in cooperation with health care professionals. They should also be culture sensitive and should not exhibit technical problems.

  • Source: Flickr; Copyright: Ruby Victoria; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    mActive-Smoke: A Prospective Observational Study Using Mobile Health Tools to Assess the Association of Physical Activity With Smoking Urges


    Background: Evidence that physical activity can curb smoking urges is limited in scope to acute effects and largely reliant on retrospective self-reported measures. Mobile health technologies offer novel mechanisms for capturing real-time data of behaviors in the natural environment. Objective: This study aimed to explore this in a real-world longitudinal setting by leveraging mobile health tools to assess the association between objectively measured physical activity and concurrent smoking urges in a 12-week prospective observational study. Methods: We enrolled 60 active smokers (≥3 cigarettes per day) and recorded baseline demographics, physical activity, and smoking behaviors using a Web-based questionnaire. Step counts were measured continuously using the Fitbit Charge HR. Participants reported instantaneous smoking urges via text message using a Likert scale ranging from 1 to 9. On study completion, participants reported follow-up smoking behaviors in an online exit survey. Results: A total of 53 participants (aged 40 [SD 12] years, 57% [30/53] women, 49% [26/53] nonwhite) recorded at least 6 weeks of data and were thus included in the analysis. We recorded 15,365 urge messages throughout the study, with a mean of 290 (SD 62) messages per participant. Mean urge over the course of the study was positively associated with daily cigarette consumption at follow-up (Pearson r=.33; P=.02). No association existed between daily steps and mean daily urge (beta=−6.95×10−3 per 1000 steps; P=.30). Regression models of acute effects, however, did reveal modest inverse associations between steps within 30-, 60-, and 120-min time windows of a reported urge (beta=−.0191 per 100 steps, P<.001). Moreover, 6 individuals (approximately 10% of the study population) exhibited a stronger and consistent inverse association between steps and urge at both the day level (mean individualized beta=−.153 per 1000 steps) and 30-min level (mean individualized beta=−1.66 per 1000 steps). Conclusions: Although there was no association between objectively measured daily physical activity and concurrently self-reported smoking urges, there was a modest inverse relationship between recent step counts (30-120 min) and urge. Approximately 10% of the individuals appeared to have a stronger and consistent inverse association between physical activity and urge, a provocative finding warranting further study.

  • Source: Flickr; Copyright: Erik (HASH) Hersman; URL:; License: Creative Commons Attribution (CC-BY).

    Multistakeholder Perspectives on Maternal Text Messaging Intervention in Uganda: Qualitative Study


    Background: Despite continued interest in the use of mobile health for improving maternal health outcomes, there have been limited attempts to identify relevant program theories. Objectives: This study had two aims: first, to explicate the assumptions of program designers, which we call the program theory and second, to contrast this program theory with empirical data to gain a better understanding of mechanisms, facilitators, and barriers related to the program outcomes. Methods: To achieve the aforementioned objectives, we conducted a retrospective qualitative study of a text messaging (short message service) platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3), we elicited 3 main designers’ assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), as well as 6 focus group discussions with village health team members (n=50) who were all involved in the program. Results: Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for village health team members, mobile phone ownership, and health system factors should have been considered. Conclusions: Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories.

  • Woman using an mHealth meditation app for stress management. Source: Pixabay; Copyright: akiragiulia; URL:; License: Public Domain (CC0).

    Managing and Controlling Stress Using mHealth: Systematic Search in App Stores


    Background: Traditional stress management techniques have been proven insufficient to tackle the needs of today’s population. Computational-based techniques and now mobile health (mHealth) apps are showing promise to enable ease of use and access while educating end users on self-management. Objective: The main aim of this paper was to put forward a systematic review of mHealth apps for stress management. Methods: The scenario chosen for this study consists of a sample of the most relevant mHealth apps found on the British and Spanish online stores of the two main mobile operating systems: iOS and Android. The apps have been categorized and scored base on their impact, presence, number of results, language, and operating system. Results: A total of 433 different mobile apps for stress management was analyzed. Of these apps, 21.7% (94/433) belonged to the “relaxing music” category, 10.9% (47/433) were in the “draw and paint” category, 1.2% (5/433) belonged to the “heart rate control” category, and 1.2% (5/433) fell under “integral methodology.” Only 2.0% (8/433) of the apps qualified as high or medium interest while 98.0% were low interest. Furthermore, 2.0% (8/433) of the apps were available on both iOS and Android, and 98% of apps ran on only one platform (iOS or Android). Conclusions: There are many low-value apps available at the moment, but the analysis shows that they are adding new functionalities and becoming fully integrated self-management systems with extra capabilities such as professional assistance services and online support communities.

  • Source: Image created by the Authors; Copyright: Antonio Ascolese; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    User Needs in the Development of a Health App Ecosystem for Self-Management of Cystic Fibrosis: User-Centered Development Approach


    Background: Digital self-management in cystic fibrosis (CF) is foreseen as a means toward better understanding of the disease and its treatment and better adherence to the treatment. Mobile apps hold the potential to provide access to information, motivate, and strengthen compliance. However, to deliver high-quality apps, the development should be based on thorough knowledge about user needs. Empirical research on the user-centered development of mobile apps for health care is, however, still limited. Objective: The aim of this research is to develop and evaluate an app ecosystem for self-management in CF. It targets not only those directly affected by CF but also parents and health care professionals involved in the treatment. This paper covers the first step of the design process that aims to analyze the context and the user requirements. The primary research question is as follows: what digital support has the potential to usefully support persons with CF and their caregivers in the CF care? To answer this question, we address two preliminary questions: what important factors in everyday life affect the care of persons with CF? and how is the CF care delivered today and what are the limitations of CF care services? Methods: The overall research adopts a user-centered design approach in which future users are involved in the development process from the very beginning to ensure that the apps developed best suit the potential users. The research presented in the paper follows an interpretative case study research strategy seeking to understand the concerns and needs of persons with CF and their caregivers. Data were collected through semistructured qualitative interviews involving 74 participants in seven European countries and from internet forums. Results: The results of the analysis phase show a strong need for individuality of the digital support, as well as for its adaptability to different contexts. The paper presents the concerns and needs of the participants in the study and extracts a set of relevant features for a self-management app ecosystem. Education, enzyme dosage calculation, nutrition management, treatment organization, health diary, treatment follow-up, practical guidelines for treatment, communication with doctors, and communication with peers are foreseen as useful features. Conclusions: The results indicate the readiness for self-management in the CF care even in countries that provide well-functioning health care services for CF care. The large diversity of user requirements identified reflects the crucial role user integration plays in developing apps for a chronic condition such as CF. The need for personalization stemming from the individuality of the patients and the need for communication with health care professionals support the idea of an app ecosystem for the self-management of CF.

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

    Development and Validation of a Multidisciplinary Mobile Care System for Patients With Advanced Gastrointestinal Cancer: Interventional Observation Study


    Background: Mobile health apps have emerged as supportive tools in the management of advanced cancers. However, only a few apps have self-monitoring features, and they are not standardized and validated. Objective: This study aimed to develop and validate a multidisciplinary mobile care system with self-monitoring features that can be useful for patients with advanced gastrointestinal cancer. Methods: The development of the multidisciplinary mobile health management system was divided into 3 steps. First, the service scope was set up, and the measurement tools were standardized. Second, the service flow of the mobile care system was organized. Third, the mobile app (Life Manager) was developed. The app was developed to achieve 3 major clinical goals: support for quality of life, nutrition, and rehabilitation. Three main functional themes were developed to achieve clinical goals: a to-do list, health education, and in-app chat. Thirteen clinically oriented measures were included: the modified Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events questionnaire, Scored Patient-Generated Subjective Global Assessment (PG-SGA), distress, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, International Physical Activity Questionnaire–Short Form, Low anterior resection syndrome score, satisfaction rate, etc. To validate the system, a prospective observational study was conducted. Patients with gastric cancer or colon cancer undergoing chemotherapy were recruited. We followed the subjects for 12 weeks, and selected clinical measures were taken online and offline. Results: After the development process, a multidisciplinary app, the Life Manager, was launched. For evaluation, 203 patients were recruited for the study, of whom 101 (49.8%) had gastric cancer, and 102 (50.2%) were receiving palliative care. Most patients were in their fifties (35.5%), and 128 (63.1%) were male. Overall, 176 subjects (86.7%) completed the study. Among subjects who dropped out, the most common reason was the change of patient’s clinical condition (51.9%). During the study period, subjects received multiple health education sessions. For the gastric cancer group, the “general gastric cancer education” was most frequently viewed (322 times), and for the colon cancer group, the “warming-up exercise” was most viewed (340 times). Of 13 measurements taken from subjects, 9 were taken offline (response rate: 52.0% to 90.1%), and 3 were taken online (response rate: 17.6% to 57.4%). The overall satisfaction rate among subjects was favorable and ranged from 3.93 (SD 0.88) to 4.01 (SD 0.87) on the 5-point Likert scale. Conclusions: A multidisciplinary mobile care system for patients with advanced gastrointestinal cancer was developed with clinically oriented measures. A prospective study was performed for its evaluation, which showed favorable satisfaction.

  • Proposed push notification sent to patient’s smartphone after app detects a potential hospital visit (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    “The Doctor Needs to Know”: Acceptability of Smartphone Location Tracking for Care Coordination


    Background: Care coordination can be highly challenging to carry out. When care is fragmented across health systems and providers, there is an increased likelihood of hospital readmissions and wasteful health care spending. During and after care transitions, smartphones have the potential to bolster information transfer and care coordination. However, little research has examined patients’ perceptions of using smartphones to coordinate care. Objective: This study’s primary objective was to explore patient acceptability of a smartphone app that could facilitate care coordination in a safety net setting. Our secondary objective was to identify how clinicians and other members of primary care teams could use this app to coordinate care. Methods: This qualitative study was conducted at a federally qualified health center in metropolitan Chicago, IL. We conducted four focus groups (two in English, two in Spanish) with high-risk adults who owned a smartphone and received services from an organizational care management program. We also conducted structured interviews with clinicians and a group interview with care managers. Focus groups elicited patients’ perceptions of a smartphone app designed to: (1) identify emergency department (ED) visits and inpatient stays using real-time location data; (2) send automated notifications (ie, alerts) to users’ phones, asking whether they were a patient in the hospital; and (3) send automated messages to primary care teams to notify them about patients’ confirmed ED visits and inpatient stays. Focus group transcripts were coded based on emergent themes. Clinicians and care managers were asked about messages they would like to receive from the app. Results: Five main themes emerged in patient focus group discussions. First, participants expressed a high degree of willingness to use the proposed app during inpatient stays. Second, participants expressed varying degrees of willingness to use the app during ED visits, particularly for low acuity ED visits. Third, participants stated their willingness to have their location tracked by the proposed app due to its perceived benefits. Fourth, the most frequently mentioned barriers to acceptability were inconveniences such as “false alarm” notifications and smartphone battery drainage. Finally, there was some tension between how to maximize usability without unnecessarily increasing user burden. Both clinicians and care managers expressed interest in receiving messages from the app at the time of hospital arrival and at discharge. Clinicians were particularly interested in conducting outreach during ED visits and inpatient stays, while care managers expressed more interest in coordinating postdischarge care. Conclusions: High-risk primary care patients in a safety net setting reported a willingness to utilize smartphone location tracking technology to facilitate care coordination. Further research is needed on the development and implementation of new smartphone-based approaches to care coordination.

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  • Privacy of mHealth Systems: A national survey on user perspectives

    Date Submitted: May 21, 2018

    Open Peer Review Period: May 21, 2018 - Jul 16, 2018

    Background: Personal electronic health devices, such as fitness trackers, heart rate monitors, blood glucose meters, blood pressure monitors and stress level meters, and related smartphone-based healt...

    Background: Personal electronic health devices, such as fitness trackers, heart rate monitors, blood glucose meters, blood pressure monitors and stress level meters, and related smartphone-based health applications are increasing in usage and popularity. These Internet-based medical technologies, which this paper refers to as mHealth systems, may be prescribed by a healthcare professional or purchased over-the-counter and make it easier for an individual to collect, access and monitor information relevant to their own health and well-being. However, as with many Internet-based technologies, and especially so with sensitive, personal health information, privacy is a significant concern. Actual or a perceived risk of privacy intrusions may delay the wider adoption of mHealth systems and even generate mistrust that reduces their long-term effectiveness. This paper contributes to the understanding of users’ perspectives on information privacy in mHealth systems. Objective: To gain an understanding of current usage patterns and how important users perceive privacy, we have conducted a national survey in Australia. Understanding consumers’ preferences and expectations provide directions for developers, lawmakers and researchers in creating an improved mHealth ecosystem. Methods: As part of the National Social Survey by Population Research Laboratory of CQUniversity, participants who were 18 years or older were randomly selected from across Australia for telephone interviews. The participants were asked 10 questions about usage and privacy of mobile health systems. The collected data was tabulated, cleaned and analysed using SPSS and the resultant data set contained 1,225 cases with a total of 187 variables for each case. Results: The survey reveals users of mHealth systems have a strong desire for privacy, e.g. more than 80% rate privacy important or very important and more than 60% think no personal information should be released to developers. The survey also shows around 70% of users never or rarely review privacy policies, and that they perceive the significant potential impact of intrusions, including increased health insurance costs, embarrassment and financial loss. Conclusions: While the survey results show users desire privacy and have low trust of telecommunications and IT organisations, this conflicts with the technical design of mHealth systems: in many cases application developers, device manufacturers and telecommunication companies may have access to sensitive health information. The lack of standardization and guidelines for data processing by mHealth systems, as well as ineffectiveness of privacy policies, need to be addressed to avoid users’ confusion and potential invasions of privacy. Clinical Trial: This research is undertaken as part of our CQUniversity Population Research Grant Scheme (PRGS). NSS-2016 received approval by the Human Ethics Research Review Panel at CQUniversity before administration to the general public. Project: H14/09-203, NATIONAL SOCIAL SURVEY 2016.

  • Personalization in Physical Activity Interventions: A Systematic Review of the Literature

    Date Submitted: May 21, 2018

    Open Peer Review Period: May 21, 2018 - Jul 16, 2018

    Background: Fitness devices have spurred the development of applications that not only monitor physical activity (PA) but also aim to motivate users, through interventions, to increase their PA. Perso...

    Background: Fitness devices have spurred the development of applications that not only monitor physical activity (PA) but also aim to motivate users, through interventions, to increase their PA. Personalization in the interventions is essential as the target users are diverse with respect to their activity levels, requirements, preferences, and behavior. Objective: This review aims to: 1) identify different kinds of personalization in interventions for promoting PA; 2) identify user models used for providing personalization; and 3) identify gaps in the current literature and suggest future research directions. Methods: A systematic review was undertaken using the PRISMA guidelines. PsycINFO, PubMed and Web of Science databases were searched. The main inclusion criteria were: 1) studies that aimed to promote PA among target users as (at least one of) their objectives; 2) studies that had user personalization, with the intention of promoting PA (e.g., activity recommendations or motivational messages); 3) studies that described user models for personalization. Results: The literature search resulted in 28 eligible studies. Of these, 68% (19 studies) focused solely on increasing PA, while the remaining studies had other objectives, like healthcare (18%), weight loss (7%), rehabilitation (7%). The reviewed studies provide personalization in six categories related to recommendation and feedback: goal recommendation, activity recommendation, fitness partner recommendation, educational content, motivational content, and intervention timing. With respect to the mode of generation, interventions were found to be manual, semi-automated, or automatic. Of these, the automatic systems were either knowledge-based or data-driven or both. User models in the studies were constructed with parameters from five categories: PA profile, demographics, medical data, behavior change technique (BCT) parameters, and contextual information. Only 15 of the eligible studies evaluated the interventions and 67% of these 15 concluded that the interventions to increase PA are more effective when they are personalized. Conclusions: This systematic review investigates personalization of interventions, in the form of recommendations or feedback for increasing PA. Based on the review and gaps identified, research directions for improving the efficacy of personalized interventions are proposed. First, data-driven prediction techniques can facilitate effective personalization of automated and semi-automated interventions. Second, use of BCTs in automated interventions, and in combinations with PA guidelines, are yet to be explored and preliminary studies in this direction are promising. Third, systems with automated interventions also need to be suitably adapted to serve specific needs of patients with clinical conditions. Fourth, previous user models focus on single metric evaluations of PA instead of a, potentially more effective, holistic and multidimensional view. Fifth, with the widespread adoption of activity monitoring devices and smartphones, personalized and dynamic user models can be created using the available user data, including the user’s social profile. Finally, the long-term effects of such interventions need to be evaluated rigorously.

  • Management of Anticoagulation in the Peri-Procedural Period: Uptake and Utilization of the MAPPP App

    Date Submitted: May 18, 2018

    Open Peer Review Period: May 19, 2018 - Jul 14, 2018

    Background: Anticoagulants are major contributors to preventable adverse drug events, and their optimal management in the peri-procedural period is particularly challenging. Traditional methods of dis...

    Background: Anticoagulants are major contributors to preventable adverse drug events, and their optimal management in the peri-procedural period is particularly challenging. Traditional methods of disseminating clinical guidelines and tools cannot keep pace with the rapid expansion of available therapeutic agents, approved indications for use, and published medical evidence, so a mobile application, Management of Anticoagulation in the Peri-Procedural Period (MAPPP), was developed and disseminated to provide clinicians with guidance reflecting the most current medical evidence. Objective: To assess the global, national, and state-level acquisition of a mobile app since its initial release and characterize individual episodes of use based on drug selection, procedural bleeding risk, and patient thromboembolic risk. Methods: Data was extracted from a mobile app usage tracker (Google Analytics) to characterize new users and completed episodes temporally (by calendar quarter) and geographically (globally, nationally, and in the targeted US state of New York) for the period from April 1, 2016, through September 30, 2017. Results: The app was acquired by 2,866 new users in the measurement period, and users completed nearly 10,000 individual episodes of use. Acquisition and utilization spanned 51 countries globally, predominantly in the United States and particularly in New York State. Warfarin and rivaroxaban were the most frequently selected drugs, and completed episodes most frequently included the selection of the high bleeding risk (49.06%) and high thromboembolic risk categories (45.17%). Conclusions: The MAPPP app is a successful means of disseminating current guidance on peri-procedural anticoagulant use, as indicated by broad global uptake and upward trends in utilization. Limitations in access to provider and patient-specific data preclude objective evaluation of the clinical impact of the app. An ongoing study incorporating app logic into electronic health record systems at participant health systems will provide a more definitive evaluation of the clinical impact of the app logic.

  • Are we delaying the inevitable? Maintaining lifestyle changes six months after the ‘Get Healthy, Stay Healthy’ extended contact intervention

    Date Submitted: May 17, 2018

    Open Peer Review Period: May 19, 2018 - Jul 14, 2018

    Background: Extended intervention contact after an initial, intensive intervention is becoming accepted as best practice in behavioral weight control interventions. What is not clear is whether extend...

    Background: Extended intervention contact after an initial, intensive intervention is becoming accepted as best practice in behavioral weight control interventions. What is not clear is whether extended contact mitigates weight regain in the longer-term, or whether it simply delays weight regain until after the extended intervention contact ceases. Objective: To evaluate maintenance following the Get Healthy, Stay Healthy (GHSH) extended contact intervention, by comparing: the intervention and control group averages at 12 months (the traditional comparison of maintained intervention effects); the intervention and control group averages over the first six months of non-contact (a novel approach which directly compares the relapse effects between groups over the same duration of time); and, the individual participant changes over the first six months of non-contact (to explore the extent to which the group average is reflective of directions of changes for individuals). Methods: Clients completing the Get Healthy Service (GHS) lifestyle telephone coaching program were randomised to receive extended contact via tailored text messages (GHSH, n=114) or standard care (no additional contact, n=114) and were assessed at baseline (following completion of GHS), six months (following completion of GHSH) and 12 months (no-contact maintenance follow-up). At all three assessments participants self-reported their body weight, waist circumference, physical activity (walking, moderate and vigorous sessions/week) and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks per day, takeaway meals per week; Fat, Fiber and Total indices from the Fat and Fiber Behavior Questionnaire). Moderate-vigorous physical activity (MVPA) was also assessed via accelerometry. Results: Retention over the 12-month trial was high (93%, 211/228). Participants had a mean (±standard deviation) age of 53.4±12.3 years and baseline BMI of 29.2±5.9 kg/m2. The between-group differences detected at 6 months were still present and statistically significant at 12 months for body weight (-1.33kg (-2.61, -0.05)) and accelerometer-assessed MVPA (24.9 minutes/week (5.8, 44.0)). None of the other outcomes were significantly favoured compared to the control group at 12 months. Changes over their first six months of non-contact for the GHSH group were significantly better than the control group in terms of accelerometer-measured MVPA and self-reported moderate activity (other differences between the groups were all non-significant). In addition to the maintenance seen in the group averages, most intervention participants had maintained their behavioral outcomes during the first six months of non-contact. Conclusions: The GHSH participants were better off relative to where they were initially, and relative to their counterparts not receiving extended contact in terms of MVPA. However, based on the between group difference in bodyweight over the first six months of non-contact, GHSH does appear to simply delay the ‘inevitable’ weight regain. However, this delay in weight regain, coupled with sustained improvements in MVPA, has public health benefit.

  • Development of a UV index sensor-based portable device with the EUVB ratio of natural light

    Date Submitted: May 16, 2018

    Open Peer Review Period: May 18, 2018 - Jul 13, 2018

    Background: Ultraviolet (UV) rays are electromagnetic waves that account for about 5% of the solar light, and when overexposed, they pose malevolent effects on the human skin and health. However, with...

    Background: Ultraviolet (UV) rays are electromagnetic waves that account for about 5% of the solar light, and when overexposed, they pose malevolent effects on the human skin and health. However, with recent reports on the beneficial effects of some wavelength bands of UV rays, people’s interest in UV information has increased. This has resulted in requiring, not just simple information such as the amount of UV or UV index (UVI), but detailed UV information that directly affects health, such as EUVB(Erythemally weighted UVB). However, calculating EUVB, which can be done by applying the erythemal weighted function on the intensity value in wavelength, requires specialized optical measurement devices, which cannot be easily accessed by the general public; furthermore, public institutions UV information services do not offer EUVB information for individuals. Objective: Therefore, the present study proposes a UVI sensor-based portable device, with which the general public can have easy access to UV-related information. Methods: The proposed device comprises a UVI sensor that can measure the intensity of erythemal UV radiation, a BLE module that supports communication, and a MCU for key operations. In addition, it applies the ratio of EUVB by month/time, resulting from the actual analysis of natural light to calculate the EUVB and provides the amount of UVI and EUVB to check if they meet conditions required for outdoor activities through the device and smartphone applications. Results: The applicability of the proposed device was verified by the measurement performance comparison test with the standard device, a spectrometer (CAS 140 CT), which showed an average error of 0.06 for UVI and 0.0017 W/m2. Conclusions: The proposed device’s offering of UV-related information such as UVI and EUVB to user is expected to prevent potential damage due to the exposure to UV and to support healthy outdoor activities.

  • Original Paper: Informing Young Adults about the Risks of Using Electronic Cigarettes: A Pilot Study of an Informational Mobile Phone Text Messaging Program

    Date Submitted: May 15, 2018

    Open Peer Review Period: May 18, 2018 - Jul 13, 2018

    Background: Young adults are rapidly adopting electronic cigarette (e-cigarette) use. E-cigarettes’ popularity among young people can be attributed to heavy industry advertising and misleading healt...

    Background: Young adults are rapidly adopting electronic cigarette (e-cigarette) use. E-cigarettes’ popularity among young people can be attributed to heavy industry advertising and misleading health claims. Data indicate young e-cigarette users who never used conventional cigarettes are now progressing toward smoking combustible cigarettes. Literature documents the influence of text messaging as a delivery mode to support participants in behavioral interventions. Communicating e-cigarette risks via text messaging has not been tested. Objective: This pilot study assessed the impact of exposure to text messages on e-cigarette knowledge and risk perception outcomes. Methods: A 2-group randomized pretest and posttest study was conducted among young men and women recruited from vocational training programs. Personal phones were used to receive messages and 95 racially and ethnically diverse participants completed a pretest and posttest. Fifty percent were randomized to either receive gain- or loss-framed messages that integrated the latest scientific findings about e-cigarettes. All messages used wording suitable for audiences with low health literacy. Knowledge and risk perceptions about e-cigarettes and tobacco use were assessed pretest and posttest after message exposure. Results: The mean age of participants was 20.8 (SD = 1.7). At pretest, approximately 10.5% of the (n=10/95) participants were current e-cigarette users, and 27.4% (n=26/95) used a variety of tobacco products. Participants randomized to gain-framed messages reported a statistically significant higher risk perception for using e-cigarettes at posttest than those who received loss-framed messages (P = .018). After message exposure there was no change in use of e-cigarettes or other tobacco products. Conclusions: Young adults were informed that e-cigarette use may lead to addiction to nicotine and other consequences. Delivery of effective text messages such as those tested in this pilot can assist young consumers to evaluate and make decisions about e-cigarettes and other evolving tobacco products. Clinical Trial: This was a pilot study and not a clinical trial, thus the project was not registered.