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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, Scopus, 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:

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

    Breast Cancer Survivors’ Experiences With an Activity Tracker Integrated Into a Supervised Exercise Program: Qualitative Study


    Background: There is growing evidence that physical activity is related to a better prognosis after a breast cancer diagnosis, whereas sedentary behavior is associated with worse outcomes. It is therefore important to stimulate physical activity and reduce sedentary time among patients with breast cancer. Activity trackers offer a new opportunity for interventions directed at stimulating physical activity behavior change. Objective: This study aimed to explore the experience of patients with breast cancer who used an activity tracker in addition to a supervised exercise intervention in the randomized UMBRELLA Fit trial. Methods: A total of 10 patients with breast cancer who completed cancer treatment participated in semistructured in-depth interviews about their experience with and suggestions for improvements for the Jawbone UP2 activity tracker. Results: The activity tracker motivated women to be physically active and created more awareness of their (sedentary) lifestyles. The women indicated that the automatically generated advice (received via the Jawbone UP app) lacked individualization and was not applicable to their personal situations (ie, having been treated for cancer). Furthermore, women felt that the daily step goal was one-dimensional, and they preferred to incorporate other physical activity goals. The activity tracker’s inability to measure strength exercises was a noted shortcoming. Finally, women valued personal feedback about the activity tracker from the physiotherapist. Conclusions: Wearing an activity tracker raised lifestyle awareness in patients with breast cancer. The women also reported additional needs not addressed by the system. Potential improvements include a more realistic total daily physical activity representation, personalized advice, and personalized goals.

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

    The Effectiveness and Safety of Utilizing Mobile Phone–Based Programs for Rehabilitation After Lumbar Spinal Surgery: Multicenter, Prospective Randomized...


    Background: Rehabilitation is crucial for postoperative patients with low back pain (LBP). However, the implementation of traditional clinic-based programs is limited in developing countries, such as China, because of the maldistribution of medical resources. Mobile phone–based programs may be a potential substitute for those who have no access to traditional rehabilitation. Objective: The aim of this study was to examine the efficacy of mobile phone–based rehabilitation systems in patients who underwent lumbar spinal surgery. Methods: Patients who accepted spinal surgeries were recruited and randomized into 2 groups of rehabilitation treatments: (1) a mobile phone–based eHealth (electronic health) program (EH) or (2) usual care treatment (UC). The primary outcomes were (1) function and pain status assessed by the Oswestry Disability Index (ODI) and (2) the visual analog scale (VAS). Secondary outcomes were (1) general mental health and (2) quality of life (Likert scales, EuroQol-5 Dimension health questionnaire, and 36-item Short-Form Health Survey). All the patients were assessed preoperatively and then at 3, 6, 12, and 24 months postoperatively. Results: A total of 168 of the 863 eligible patients were included and randomized in this study. Our analysis showed that the improvement of primary outcomes in the EH group was superior to the UC group at 24 months postoperatively (ODI mean 7.02, SD 3.10, P<.05; VAS mean 7.59, SD 3.42, P<.05). No significant difference of primary outcomes was found at other time points. A subgroup analysis showed that the improvements of the primary outcomes were more significant in those who completed 6 or more training sessions each week throughout the trial (the highest compliance group) compared with the UC group at 6 months (ODI mean 17.94, SD 5.24, P<.05; VAS mean 19.56, SD 5.27, P<.05), 12 months (ODI mean 13.39, SD 5.32, P<.05; VAS mean 14.35, SD 5.23, P<.05), and 24 months (ODI mean 18.80, SD 5.22, P<.05; VAS mean 21.56, SD 5.28, P<.05). Conclusions: This research demonstrated that a mobile phone–based telerehabilitation system is effective in self-managed rehabilitation for postoperative patients with LBP. The effectiveness of eHealth was more evident in participants with higher compliance. Future research should focus on improving patients’ compliance. Trial Registration: Chinese Clinical Trial Registry ChiCTR-TRC-13003314; (Archived by WebCite at

  • Source: Shutterstock; Copyright: Spectral-Design; URL:; License: Licensed by the authors.

    Popular Nutrition-Related Mobile Apps: An Agreement Assessment Against a UK Reference Method


    Background: Nutrition-related apps are commonly used to provide information about the user’s dietary intake, but limited research has been performed to assess how well their outputs agree with those from standard methods. Objective: The objective of our study was to evaluate the level of agreement of popular nutrition-related apps for the assessment of energy and available macronutrients and micronutrients against a UK reference method. Methods: We compared dietary analysis of 24-hour weighed food records (n=20) between 5 nutrition-related apps (Samsung Health, MyFitnessPal, FatSecret, Noom Coach, and Lose It!) and Dietplan6 (reference method), using app versions available in the United Kingdom. We compared estimates of energy, macronutrients (carbohydrate, protein, fat, saturated fat, and fiber), and micronutrients (sodium, calcium, iron, vitamin A, and vitamin C) using paired t tests and Wilcoxon signed-rank tests, correlation coefficients, and Bland-Altman plots. We obtained 24-hour weighed food records from 20 participants (15 female, 5 male participants; mean age 36.3 years; mean body mass index 22.9 kg/m2) from previous controlled studies conducted at the Hugh Sinclair Unit of Human Nutrition, University of Reading, Reading, UK. Participants had recorded their food consumption over a 24-hour period using standard protocols. Results: The difference in estimation of energy and saturated fat intake between Dietplan6 and the diet apps was not significant. Estimates of protein and sodium intake were significantly lower using Lose It! and FatSecret than using Dietplan6. Lose It! also gave significantly lower estimates for other reported outputs (carbohydrate, fat, fiber, and sodium) than did Dietplan6. Samsung Health and MyFitnessPal significantly underestimated calcium, iron, and vitamin C compared with Dietplan6, although there was no significant difference for vitamin A. We observed no other significant differences between Dietplan6 and the apps. Correlation coefficients ranged from r=–.12 for iron (Samsung Health vs Dietplan6) to r=.91 for protein (FatSecret vs Dietplan6). Noom Coach was limited to energy output, but it had a high correlation with Dietplan6 (r=.91). Samsung Health had the greatest variation of correlation, with energy at r=.79. Bland-Altman analysis revealed potential proportional bias for vitamin A. Conclusions: The findings suggest that the apps provide estimates of energy and saturated fat intake comparable with estimates by Dietplan6. With the exception of Lose It!, the apps also provided comparable estimates of carbohydrate, total fat, and fiber. FatSecret and Lose It! tended to underestimate protein and sodium. Estimates of micronutrient intake (calcium, iron, vitamin A, and vitamin C) by 2 apps (Samsung Health and MyFitnessPal) were inconsistent and less reliable. Lose It! was the app least comparable with Dietplan6. As the use and availability of apps grows, this study helps clinicians and researchers to make better-informed decisions about using these apps in research and practice.

  • A novel smartphone app: "CureApp Smoking Cessation". Source: iStock by Getty Images; Copyright: Sitthiphong; URL:; License: Licensed by the authors.

    Impact of a Novel Smartphone App (CureApp Smoking Cessation) on Nicotine Dependence: Prospective Single-Arm Interventional Pilot Study


    Background: Mobile apps have been considered to provide active and continuous support for smoking cessation. However, it is yet to be known whether a smoking cessation smartphone app improves long-term abstinence rates in nicotine-dependent patients. Objective: This study aimed to evaluate the long-term abstinence effect of a novel smartphone app, CureApp Smoking Cessation (CASC), in patients with nicotine dependence. Methods: In this prospective, interventional, multicenter, single-arm study, we provided the CASC app to all the participants, who used it daily for 24 weeks. The CASC app includes features to maximize the therapeutic effect of pharmacological therapies and counseling at outpatient clinics for smoking cessation. The primary endpoint was a continuous abstinence rate (CAR) from weeks 9 to 24, whereas secondary endpoints were CARs from weeks 9 to 12 and 9 to 52. Results: Of the 56 adult smokers recruited, 1 did not download the app; therefore, 55 participants constituted the full analysis sample. The CAR from weeks 9 to 24 was 64% (35/55, 95% CI 51%-76%), whereas the CARs from weeks 9 to 12 and 9 to 52 were 76% (42/55, 95% CI 65%-88%) and 58% (32/55, 95% CI 46%-71%), respectively. These CARs were better than the results of the national survey on outpatient clinics with regard to smoking cessation under the National Health Insurance Program and that of the varenicline phase 3 trial in Japan and the United States. There was only 1 participant who dropped out during the 12 weeks of the treatment period. This treatment decreased the scores related to withdrawal and craving symptoms. Conclusions: The addition of CASC to usual smoking cessation therapies resulted in high CARs, high patient retention rates, and improvement of cessation-related symptoms. The smartphone app CASC is a feasible and useful tool to help long-term continuous abstinence that can be combined with a standard smoking cessation treatment program.

  • Source: Flickr; Copyright: Pan American Health Organization; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Toward Developing a Standardized Core Set of Outcome Measures in Mobile Health Interventions for Tuberculosis Management: Systematic Review


    Background: Tuberculosis (TB) management can be challenging in low- and middle-income countries (LMICs) not only because of its high burden but also the prolonged treatment period involving multiple drugs. With rapid development in mobile technology, mobile health (mHealth) interventions or using a mobile device for TB management has gained popularity. Despite the potential usefulness of mHealth interventions for TB, few studies have quantitatively synthesized evidence on its effectiveness, presumably because of variability in outcome measures reported in the literature. Objective: The aim of this systematic review was to evaluate the outcome measures reported in TB mHealth literature in LMICs. Methods: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched to identify mHealth intervention studies for TB (published up to May 2018) that reported any type of outcome measures. The extracted information included the study setting, types of mHealth technology used, target population, study design, and categories of outcome measures. Outcomes were classified into 13 categories including treatment outcome, adherence, process measure, perception, technical outcome, and so on. The qualitative synthesis of evidence focused on the categories of outcome measures reported by the type of mHealth interventions. Results: A total of 27 studies were included for the qualitative synthesis of evidence. The study designs varied widely, ranging from randomized controlled trials to economic evaluations. A total of 12 studies adopted short message service (SMS), whereas 5 studies used SMS in combination with additional technologies or mobile apps. The study populations were also diverse, including patients with TB, patients with TB/HIV, health care workers, and general patients attending a clinic. There was a wide range of variations in the definition of outcome measures across the studies. Among the diverse categories of outcome measures, treatment outcomes have been reported in 14 studies, but only 6 of them measured the outcome according to the standard TB treatment definitions by the World Health Organization. Conclusions: This critical evaluation of outcomes reported in mHealth studies for TB management suggests that substantial variability exists in reporting outcome measures. To overcome the challenges in evidence synthesis for mHealth interventions, this study can provide insights into the development of a core set of outcome measures by intervention type and study design.

  • Patients using Go-breath app. Source: Image created by the Authors; Copyright: Ji Yeong Soh; URL:; License: Creative Commons Attribution (CC-BY).

    A Mobile Phone–Based Self-Monitoring Tool for Perioperative Gastric Cancer Patients With Incentive Spirometer: Randomized Controlled Trial


    Background: An incentive spirometer (IS) is a medical device used to help patients improve the functioning of their lungs. It is provided to patients who have had any surgery that might jeopardize respiratory function. An incentive spirometer plays a key role in the prevention of postoperative complications, and the appropriate use of an IS is especially well known for the prevention of respiratory complications. However, IS utilization depends on the patient’s engagement, and information and communication technology (ICT) can help in this area. Objective: This study aimed to determine the effect of mobile ICT on the usage of an IS (Go-breath) app by postoperative patients after general anesthesia. Methods: For this study, we recruited patients from April to May 2018, who used the Go-breath app at a single tertiary hospital in South Korea. The patients were randomly classified into either a test or control group. The main function of the Go-breath app was to allow for self-reporting and frequency monitoring of IS use, deep breathing, and active coughing in real time. The Go-breath app was identical for both the test and control groups, except for the presence of the alarm function. The test group heard an alarm every 60 min from 9 am to 9 pm for 2 days. For the test group alone, a dashboard was established in the nurse’s station through which a nurse could rapidly assess the performance of multiple patients. To evaluate the number of performances per group, we constructed an incentive spirometer index (ISI). Results: A total of 44 patients were recruited, and 42 of them completed the study protocol. ISI in the test group was 20.2 points higher than that in the control group (113.5 points in the test group and 93.2 points in the control group, P=.22). The system usability scale generally showed almost the same score in the 2 groups (79.3 points in the test group and 79.4 points in the control group, P=.94). We observed that the performance rates of IS count, active coughing, and deep breathing were also higher in the test group but with no statistically significant difference between the groups. For the usefulness “yes or no” question, over 90% (38/42) of patients answered “yes” and wanted more functional options and information. Conclusions: The use of the Go-breath app resulted in considerable differences between the test group and control group but with no statistically significant differences. Trial Registration: NCT03569332; (Archived by WebCite at

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

    The Current State of Mobile Phone Apps for Monitoring Heart Rate, Heart Rate Variability, and Atrial Fibrillation: Narrative Review


    Background: Mobile phone apps capable of monitoring arrhythmias and heart rate (HR) are increasingly used for screening, diagnosis, and monitoring of HR and rhythm disorders such as atrial fibrillation (AF). These apps involve either the use of (1) photoplethysmographic recording or (2) a handheld external electrocardiographic recording device attached to the mobile phone or wristband. Objective: This review seeks to explore the current state of mobile phone apps in cardiac rhythmology while highlighting shortcomings for further research. Methods: We conducted a narrative review of the use of mobile phone devices by searching PubMed and EMBASE from their inception to October 2018. Potentially relevant papers were then compared against a checklist for relevance and reviewed independently for inclusion, with focus on 4 allocated topics of (1) mobile phone monitoring, (2) AF, (3) HR, and (4) HR variability (HRV). Results: The findings of this narrative review suggest that there is a role for mobile phone apps in the diagnosis, monitoring, and screening for arrhythmias and HR. Photoplethysmography and handheld electrocardiograph recorders are the 2 main techniques adopted in monitoring HR, HRV, and AF. Conclusions: A number of studies have demonstrated high accuracy of a number of different mobile devices for the detection of AF. However, further studies are warranted to validate their use for large scale AF screening.

  • Source: Pexels; Copyright: Helena Lopes; URL:; License: Licensed by JMIR.

    Evaluating Mobile Health Apps for Customized Dietary Recording for Young Adults and Seniors: Randomized Controlled Trial


    Background: The role of individual-tailored dietary recording in mobile phone health apps has become increasingly important in management of self-health care and population-based preventive service. The development of such mobile apps for user-centered designing is still challengeable and requires further scientific evidence. Objective: This study aims to conduct a randomized trial to assess the accuracy and time efficiency of two prototypes for dietary recoding utilization related to the input method of food intake. Methods: We first present an innovative combinatorial concept for dietary recording to account for dish variation. One prototype was a self-chosen tab app that featured choosing each food ingredient to synthesize an individual dish, whereas the other was an autonomous exhaustive list app that provided one selection from a comprehensive list of dish items. The concept included commercially available choices that allowed users to more accurately account for their individual food selection. The two mobile apps were compared in a head-to-head parallel randomized trial evaluation. Young adults (n=70, aged 18-29) and older adults (n=35, aged 55-73) were recruited and randomized into two groups for accuracy and response time evaluation based on 12 types of food items in use of the developed self-chosen tab and autonomous exhaustive list apps, respectively. Results: For the trials based on the self-chosen tab (53 participants) and autonomous exhaustive list groups (52 participants), the two prototypes were found to be highly accurate (>98%). The self-chosen tab app was found to be more efficient, requiring significantly less time for input of 11 of 12 items (P<.05). The self-chosen tab users occasionally neglected to select food attributes, an issue which did not occur in the autonomous exhaustive list group. Conclusions: Our study contributes through the scientific evaluation of the transformation step into prototype development to demonstrate that a self-chosen tab app has potentially better opportunity in effectiveness and efficiency. The combinatorial concept offers potential for dietary recording and planning which can account for high food item variability. Our findings on prototype development of diversified dietary recordings provide design consideration and user interaction for related further app development and improvement. Trial Registration: ISRCTN Registry ISRCTN86142301; ISRCTN86142301 (Archived by WebCite at

  • Health Coaching with mHealth. Source: The Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Evaluating Motivational Interviewing and Habit Formation to Enhance the Effect of Activity Trackers on Healthy Adults’ Activity Levels: Randomized...


    Background: While widely used and endorsed, there is limited evidence supporting the benefits of activity trackers for increasing physical activity; these devices may be more effective when combined with additional strategies that promote sustained behavior change like motivational interviewing (MI) and habit development. Objective: This study aims to determine the utility of wearable activity trackers alone or in combination with these behavior change strategies for promoting improvements in active and sedentary behaviors. Methods: A sample of 91 adults (48/91 female, 53%) was randomized to receive a Fitbit Charge alone or in combination with MI and habit education for 12 weeks. Active and sedentary behaviors were assessed pre and post using research-grade activity monitors (ActiGraph and activPAL), and the development of habits surrounding the use of the trackers was assessed postintervention with the Self-Reported Habit Index. During the intervention, Fitbit wear time and activity levels were monitored with the activity trackers. Linear regression analyses were used to determine the influence of the trial on outcomes of physical activity and sedentary time. The influence of habits was examined using correlation coefficients relating habits of tracker use (wearing the tracker and checking data on the tracker and associated app) to Fitbit wear time and activity levels during the intervention and at follow-up. Results: Regression analyses revealed no significant differences by group in any of the primary outcomes (all P>.05). However, personal characteristics, including lower baseline activity levels (beta=–.49, P=.01) and lack of previous experience with pedometers (beta=–.23, P=.03) were predictive of greater improvements in moderate and vigorous physical activity. Furthermore, for individuals with higher activity levels at the baseline, MI and habit education were more effective for maintaining these activity levels when compared with receiving a Fitbit alone (eg, small increase of ~48 steps/day, d=0.01, vs large decrease of ~1830 steps/day, d=0.95). Finally, habit development was significantly related to steps/day during (r=.30, P=.004) and following the intervention (r=.27, P=.03). Conclusions: This study suggests that activity trackers may have beneficial effects on physical activity in healthy adults, but benefits vary based on individual factors. Furthermore, this study highlights the importance of habit development surrounding the wear and use of activity trackers and the associated software to promote increases in physical activity. Trial Registration: NCT03837366;

  • Log2Lose. Source: iStock by Getty; Copyright: silverkblack; URL:; License: Licensed by the authors.

    Log2Lose: Development and Lessons Learned From a Mobile Technology Weight Loss Intervention


    Background: Providing financial incentives has gained popularity as a strategy to promote weight loss, but questions remain about how best to utilize them. A promising mobile health strategy provides users with near-real-time financial incentives based on both the process of weight loss (behavioral modification) and actual weight loss. To maximize the impact of this strategy, a methodology is needed to close the gap between the desired behavior and the financial incentive. Leveraging mobile health tools—such as mobile phone apps, cellular body weight scales that transmit data to physicians and researchers, and text messaging for instructions and encouragement—has the potential to close this gap. Objective: This study aimed to describe the development of an innovative technology-based solution and lessons learned from a feasibility trial—Log2Lose—that encouraged individuals to lose weight by providing near-real-time financial incentives for weight loss and/or dietary self-monitoring. Methods: We recruited participants (N=96) with a body mass index greater than or equal to 30 kg/m2 for a 24-week weight loss trial. Participants received a behavioral intervention of biweekly, in-person group sessions and were instructed to log a minimum number of daily calories in MyFitnessPal and to step on the BodyTrace cellular scale at least twice per week. In a 2×2 design, participants were randomized into 4 groups to receive financial incentives for the following: (group 1) weekly weight loss and dietary self-monitoring, (group 2) dietary self-monitoring only, (group 3) weekly weight loss only, or (group 4) no financial incentives. Diet and weight data from the devices were obtained through application programming interfaces. Each week, we applied algorithms to participants’ data to determine whether they qualified for a monetary incentive (groups 1-3). A text message notified these participants of whether they met weight loss and/or self-monitoring requirements to earn an incentive and the amount they earned or would have earned. The money was uploaded to a debit card. Results: Our custom-engineered software platform analyzed data from multiple sources, collated and processed the data to send appropriate text messages automatically, and informed study staff of the appropriate incentives. We present lessons learned from the development of the software system and challenges encountered with technology, data transmission, and participants (eg, lost connections or delayed communication). Conclusions: With consistent and constant validation checks and a robust beta test run, the process of analyzing data and determining eligibility for weekly incentives can be mostly automated. We were able to accomplish this project within an academic health system, which required significant security and privacy safeguards. Our success demonstrates how this methodology of automated feedback loops can provide health interventions via mobile technology. Trial Registration: NCT02691260;

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

    The MomConnect Nurses and Midwives Support Platform (NurseConnect): A Qualitative Process Evaluation


    Background: Over the past decade, mobile health has steadily increased in low-income and middle-income countries. However, few platforms have been able to sustainably scale up like the MomConnect program in South Africa. NurseConnect was created as a capacity building component of MomConnect, aimed at supporting nurses and midwives in maternal and child health. The National Department of Health has committed to expanding NurseConnect to all nurses across the country, and an evaluation of the current user experience was conducted to inform a successful scale up. Objective: This study aims to evaluate the perception and use of NurseConnect by nurses and midwives to produce feedback that can be used to optimize the user experience as the platform continues to scale up. Methods: We conducted focus group discussions and in-depth interviews with 110 nurses and midwives from 18 randomly selected health care facilities across South Africa. Questions focused on mobile phone use, access to medical information and their experience with NurseConnect registration, as well as the content and different platforms. Results: All participants had mobile phones and communication through calls and messaging was the main use in both personal and work settings. Of 110 participants, 108 (98.2%) had data-enabled phones, and the internet, Google, and apps (South African National Department of Health Guidelines, iTriage, were commonly used, especially to find information in the work setting. Of 110 participants, 62 (56.4%) were registered NurseConnect users and liked the message content, especially listeriosis and motivational messages, which created behavioral change in some instances. The mobisite and helpdesk, however, were underutilized because of a lack of information surrounding these platforms. Some participants did not trust medical information from websites and had more confidence in apps, while others associated a “helpdesk” with a call-in service, not a messaging one. Many of the unregistered participants had not heard of NurseConnect, and some cited data and time constraints as barriers to both registration and uptake. Conclusions: Mobile and smartphone penetration was very high, and participants often used their phone to find medical information. The NurseConnect messages were well-liked by all registered participants; however, the mobisite and helpdesk were underutilized owing to a lack of information and training around these platforms. Enhanced marketing and training initiatives that optimize existing social networks, as well as the provision of data and Wi-Fi, should be explored to ensure that registration improves, and that users are active across all platforms.

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

    Can Brief, Daily Training Using a Mobile App Help Change Maladaptive Beliefs? Crossover Randomized Controlled Trial


    Background: Obsessive-compulsive disorder (OCD) is a disabling condition with a wide variety of clinical presentations including contamination fears, fear of harm, and relationship-related obsessions. Cognitive behavioral models of OCD suggest that OC symptoms result from catastrophic misinterpretations of commonly occurring intrusive experiences and associated dysfunctional strategies used to manage them. OCD-related maladaptive beliefs including inflated responsibility, importance and control of thoughts, perfectionism, and intolerance for uncertainty increase the likelihood of such misinterpretations. Objective: Considering accumulating evidence suggesting that mobile health (mHealth) apps based on cognitive-behavioral principles may lead to significant reductions in psychopathological symptoms, we assessed the effectiveness of a novel cognitive training app (GGRO) designed to challenge OCD-related beliefs. Methods: A total of 97 students were randomized to groups undertaking immediate-use (iApp) or delayed use (dApp) of GGRO. All participants were requested to complete Web-based assessments, with questionnaires relating to maladaptive beliefs, mood, and OC symptoms at baseline (T1), 15 days from baseline (T2), and 30 days from baseline (T3). Participants in iApp group started using the app at baseline and continued using the app for 15 consecutive days. They were then requested to stop using the app until T3. Participants in the dApp group were requested to wait for 15 days and only then start using the app (crossover) for 15 consecutive days. Results: All participants used the app for a mean of 14.07 (SD 1.41) days with 2.94 levels per day. Consistent with previous findings, app use was associated with medium-large effect size reductions in both iApp (n=51) and dApp (n=46) groups. In the iApp group, all effects remained significant during the 15 days of follow-up. Analyses focusing on the first two assessment occasions revealed significant treatment × repeated measures interactions on maladaptive beliefs, several OC symptom measures, and self-esteem. Conclusions: This study provides further evidence for the efficacy of GGRO as a mobile-delivered training exercise that is useful for reducing OCD-related beliefs and symptoms. Trial Registration: NCT03571464; (Archived by WebCite at

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  • Derivation of breathing metrics from a photoplethysmograph at rest

    Date Submitted: Feb 18, 2019

    Open Peer Review Period: Feb 21, 2019 - Apr 18, 2019

    Background: Abstract—Recently, there has been an increased interest in monitoring health using wearable sensors technologies however, few have focused on breathing. The ability to monitor breathing...

    Background: Abstract—Recently, there has been an increased interest in monitoring health using wearable sensors technologies however, few have focused on breathing. The ability to monitor breathing metrics may have indications both for general health as well as respiratory conditions such as asthma, where long-term monitoring of lung function has shown promising utility. Objective: In this paper we characterise a Long Short-Term Memory (LSTM) architecture and predict measures of inter-breath intervals, respiratory rate and the inspiration:expiration ratio from a photoplethsymogram signal. Methods: A pulse oximeter was mounted to the left index finger of nine healthy subjects who breathed at controlled respiratory rates. A respiratory band was used to collect a reference signal as a comparison. Results: Over a 40 second window the LSTM model predicted breathing metrics with a bias and 95% confidence interval for inspiration time 0.03 s (-1.14, 1.20), expiration time 0.05 s (-1.07, 0.96), respiratory rate 0.12 (-1.5,1.75), inter-breath intervals (-1.29, 1.16) and the I:E ratio 0.00 (-.45, 0.46). Conclusions: A trained LSTM model shows acceptable accuracy for deriving breathing metrics, and could be useful for long-term breathing monitoring in health. Its utility in respiratory disease, e.g. asthma warrants further investigation. Clinical Trial: Sydney Local Health District Human Research Ethics Committee (#LNR/16/HAWKE99 ethics approval).

  • Development and Pilot Evaluation of a Behavioral Activation mHealth App for Smokers with Depression

    Date Submitted: Feb 15, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    Background: The integration of Behavioral Activation Treatment for Depression (BAT-D) into smoking cessation interventions is a promising approach to address depression as a barrier to quitting. Howev...

    Background: The integration of Behavioral Activation Treatment for Depression (BAT-D) into smoking cessation interventions is a promising approach to address depression as a barrier to quitting. However, this approach has only been tested as a face-to-face intervention, which has low reach. Objective: The aims of the study were to develop a BAT-D mHealth app with high potential reach and determine its feasibility, acceptability, and preliminary effects on theory-based behavioral processes of behavioral activation and reduced depressive symptoms as well as smoking cessation. Methods: Following a user-centered design process consisting of competitive analysis, focus groups, and prototype testing, we conducted a single-arm pilot trial of Actify!—the BAT-D app for depressed smokers. Participants used SmokefreeTXT along with Actify to provide cessation content that had not yet been built into the app for this initial phase of pilot testing. Participants in the trial (n=17) were current, daily smokers with mild to moderate depressive symptoms. We examined process and cessation outcomes at 6 weeks post-enrollment for study completers (n=16; 94% retention). Results: Regarding acceptability, average number of logins per participant was 20 (SD=16), and 63% reported being satisfied overall with the app. Post-treatment interviews identified some usability challenges—e.g., high perceived burden of planning and scheduling values-based activities. There was a significant decrease in depressive symptoms from baseline to follow-up (mean change in PHQ-9 scores= -4.5, 95% CI: -7.7, -1.3; p=.01). Additionally, CO-confirmed, 7-day point prevalence abstinence (PPA) at 6-week follow-up was 31% (5/16), and the 30-day PPA was 19% (3/16). Conclusions: Results demonstrate strong engagement with Actify! and promising impact on theory-based change processes and cessation outcomes. Preliminary quit rates for this high-risk population of smokers compare favorably to both previous trials of smoking cessation apps for the general population (i.e., short-term, self-reported 30-day quit rates in the 8-18% range) as well as a previous trial of face-to-face BAT-D for depressed smokers (i.e., CO-confirmed, 7-day PPA rate of 17% at end of treatment).

  • Opportunities and pitfalls in applying emotion recognition software for persons with a visual impairment in real life applications.

    Date Submitted: Feb 15, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    Background: A large part of the communication cues exchanged between persons are nonverbal. Persons with a visual impairment (PVIs) are often unable to perceive these cues such as facial expressions o...

    Background: A large part of the communication cues exchanged between persons are nonverbal. Persons with a visual impairment (PVIs) are often unable to perceive these cues such as facial expressions of emotions. In a previous study we have determined that PVIs can increase their ability to recognize facial expressions of emotions from validated pictures and videos by using an emotion recognition system which signals vibrotactile cues associated to one of six basic emotions. Objective: In this study, we determined whether an emotion recognition system to support persons with a visual impairment (PVIs) worked as well in realistic situations as it did under controlled lab conditions. Methods: The emotion recognition system consists of a camera mounted on spectacles, a tablet running facial emotion recognition software, and a waist belt with vibrotactors to provide haptic feedback representing Ekman´s six universal emotions. Eight PVIs (four females, four males, mean age = 46.75, age range = 28-66) participated in two training sessions followed by one experimental session. During the experiment, participants engaged in two 15-minute conversations, in one of which they wore the emotion recognition system. To conclude the study, exit-interviews were conducted to assess the experiences of the participants. Due to technical issues with the registration of the emotion recognition software, only six participants were included in the video analysis. Results: We found that participants were quickly able to learn, distinguish, and remember vibrotactile signals associated with the six emotions. Four participants felt they were able to use the vibrotactile signals in the conversation. Five out of six participants had no difficulties in keeping the camera focused on the conversation partner. The emotion recognition was very accurate in detecting happiness but performed unsatisfactorily in recognizing the other five universal emotions. Conclusions: The system requires some essential improvements in performance and wearability before it is ready to support PVIs in their daily life interactions. Nevertheless, the participants saw potential in the system as an assistive technology, assuming their user requirements can be met.

  • Health Education on Mobile Devices: A Pilot Study of Human Presence and Mobile Technologies on College Students’ Sun Protection

    Date Submitted: Feb 15, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    Background: Health promotion and education programs are increasingly being adapted and developed for delivery via digital technologies. With this shift toward digital health approaches, it is importan...

    Background: Health promotion and education programs are increasingly being adapted and developed for delivery via digital technologies. With this shift toward digital health approaches, it is important to identify design strategies in health education and promotion programs that enhance participant engagement and promote behavior change. Objective: The objective of the current study was to examine the impact of a pilot mHealth educational intervention regarding skin cancer and sun protection perceptions among American college students. Methods: A sample of 136 college students aged 18 years or above participated in the current study in a lab setting, which examined the individual and combinatory effects of multiple dimensions of digital technologies on a health outcome in a 2 (interactivity: high vs. low) x 2 (human presence: absence vs. presence) x 2 (screen size: big screen vs. small screen) between-subjects design. Outcomes included attitudes toward the information, various dimensions of trust (affective trust focusing on personal bonds or feelings and cognitive trust related to judgments of the reliability of information), and intentions to use sun protection. Results: Generally, the presence of human characters in the health educational message demonstrates effectiveness, producing more favorable attitudes (p < .001), greater intentions to use sun protection (p = .001), as well as higher affective trust (p = .003). Further, delivering educational health messages on a large screen (i.e., iPad) was associated with greater heuristic processing (p = .04) and higher affective trust (p < .001), whereas messages on a small screen (i.e., iPhone) was associated with greater systematic processing (p = .02) and higher cognitive trust (p = .006). Interestingly, while interactivity did not lead to more favorable attitudes towards the message, it did lead to greater intentions to use sun protection (p = .04). Conclusions: This experimental study indicates that features of digital health intervention design can influence its impact on recipients. Effects on attitudes, trust, and behavioral intentions were found for conditions with human presence, highlighting the importance of including this feature in mHealth programs. This pilot study demonstrates the acceptability and feasibility of an mHealth educational intervention manipulating human presence and mobile technologies and promoting college students’ sun protection.

  • From collection of acceleration data to digital interventions in clinical settings

    Date Submitted: Feb 14, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    Present and evolving mobile and computer technologies together with wearable sensors have potential not only for promoting physical activity (PA) and reducing sedentary behavior (SB) but also facilita...

    Present and evolving mobile and computer technologies together with wearable sensors have potential not only for promoting physical activity (PA) and reducing sedentary behavior (SB) but also facilitating self-management of various diseases. Purpose of this narrative review was to evaluate clinical efficacy of digital interventions on various health outcomes on the basis of meta-analyses and reviews published on the topic. In addition, essential contents of digital interventions and accompanying PA and SB measurements were also discussed. In total, meta-analytic summary data from tens of thousands of patients representing all major non-communicable diseases were available. While the clinical utility of digital interventions is apparent, the quality of evidence was often low, treatment effects were small to moderate in general often not reaching statistical significance compared to the comparator treatment that is typically usual care. Apparently, several factors underlie these relatively poor outcomes, but the lack of considering personal factors and preferences when designing the contents of digital intervention may be the key issue. Future digital intervention trials should be adequately-powered, employ rigorous methods to assess long-term PA and SB 24/7, and utilize arguable personalized behaviour change techniques which are embedded in feasible mobile and sensor technology solutions.

  • Feasibility and acceptability of using wearable physiological monitors with suicidal adolescent inpatients

    Date Submitted: Feb 15, 2019

    Open Peer Review Period: Feb 19, 2019 - Apr 16, 2019

    Background: Wearable physiological monitoring devices enable the continuous measurement of human behavior and psychophysiology in the real world. Although such devices are promising, their availabilit...

    Background: Wearable physiological monitoring devices enable the continuous measurement of human behavior and psychophysiology in the real world. Although such devices are promising, their availability does not guarantee that participants will continuously wear and interact with them, especially during times of psychological distress. Wearable physiological monitoring devices enable the continuous measurement of human behavior and psychophysiology in the real world. Although such devices are promising, their availability does not guarantee that participants will continuously wear and interact with them, especially during times of psychological distress. Objective: The goal of this study was to evaluate the feasibility and acceptability of using a wearable behavioral and physiological monitor, the Empatica E4, to continuously assess a group of suicidal adolescent inpatients. Methods: Participants (n = 50 adolescent inpatients) were asked to wear an Empatica E4 on their wrist for the duration of their inpatient stay. In addition to assessing behavioral meta-data (e.g., hours worn per day) we also used qualitative interviews and self-report measures to assess participants’ experience of wearing the device. Results: Results supported the feasibility and acceptability of this approach. Participants wore the device for average for 18 hours a day and reported that despite sometimes finding the device uncomfortable, they did not mind wearing it. Many of the participants noted that the part of the study they enjoyed most was contributing to scientific understanding, especially if it could help people like them in the future. Conclusions: These findings provide promising support for using wearable monitors in clinical samples in future studies, especially if participants are invested in being part of a research study.