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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:

  • An mHealth intervention for improving cancer pain management. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An mHealth Pain Coping Skills Training Intervention for Hematopoietic Stem Cell Transplantation Patients: Development and Pilot Randomized Controlled Trial


    Background: Pain is a challenge for patients following hematopoietic stem cell transplantation (HCT). Objective: This study aimed to develop and test the feasibility, acceptability, and initial efficacy of a Web-based mobile pain coping skills training (mPCST) protocol designed to address the needs of HCT patients. Methods: Participants had undergone HCT and reported pain following transplant (N=68). To guide intervention development, qualitative data were collected from focus group participants (n=25) and participants who completed user testing (n=7). After their input was integrated into the mPCST intervention, a pilot randomized controlled trial (RCT, n=36) was conducted to examine the feasibility, acceptability, and initial efficacy of the intervention. Measures of acceptability, pain severity, pain disability, pain self-efficacy, fatigue, and physical disability (self-report and 2-min walk test [2MWT]) were collected. Results: Participants in the focus groups and user testing provided qualitative data that were used to iteratively refine the mPCST protocol. Focus group qualitative data included participants’ experiences with pain following transplant, perspectives on ways to cope with pain, and suggestions for pain management for other HCT patients. User testing participants provided feedback on the HCT protocol and information on the use of videoconferencing. The final version of the mPCST intervention was designed to bridge the intensive outpatient (1 in-person session) and home settings (5 videoconferencing sessions). A key component of the intervention was a website that provided personalized messages based on daily assessments of pain and activity. The website also provided intervention materials (ie, electronic handouts, short videos, and audio files). The intervention content included pain coping advice from other transplant patients and instructions on how to apply pain coping skills while engaging in meaningful and leisure activities. In the RCT phase of this research, HCT patients (n=36) were randomized to receive the mPCST intervention or to proceed with the treatment as usual. Results revealed that the mPCST participants completed an average of 5 out of 6 sessions. The participants reported that the intervention was highly acceptable (mean 3/4), and they found the sessions to be helpful (mean 8/10) and easy to understand (mean 7/7). The mPCST participants demonstrated significant improvements in pre- to post-treatment pain, self-efficacy (P=.03, d=0.61), and on the 2MWT (P=.03, d=0.66), whereas the patients in the treatment-as-usual group did not report any such improvements. Significant changes in pain disability and fatigue were found in both groups (multiple P<.02); the magnitudes of the effect sizes were larger for the mPCST group than for the control group (pain disability: d=0.79 vs 0.69; fatigue: d=0.94 vs 0.81). There were no significant changes in pain severity in either group. Conclusions: Using focus groups and user testing, we developed an mPCST protocol that was feasible, acceptable, and beneficial for HCT patients with pain. Trial Registration: NCT01984671; (Archived by WebCite at

  • Source: Pixabay; Copyright: Michal Jarmoluk; URL:; License: Public Domain (CC0).

    Medication Adherence Apps: Review and Content Analysis


    Background: Medication adherence is an expensive and damaging problem for patients and health care providers. Patients adhere to only 50% of drugs prescribed for chronic diseases in developed nations. Digital health has paved the way for innovative smartphone solutions to tackle this challenge. However, despite numerous apps available claiming to improve adherence, a thorough review of adherence apps has not been carried out to date. Objective: The aims of this study were to (1) review medication adherence apps available in app repositories in terms of their evidence base, medical professional involvement in development, and strategies used to facilitate behavior change and improve adherence and (2) provide a system of classification for these apps. Methods: In April 2015, relevant medication adherence apps were identified by searching the Apple App Store and the Google Play Store using a combination of relevant search terms. Data extracted included app store source, app price, documentation of health care professional (HCP) involvement during app development, and evidence base for each respective app. Free apps were downloaded to explore the strategies used to promote medication adherence. Testing involved a standardized medication regimen of three reminders over a 4-hour period. Nonadherence features designed to enhance user experience were also documented. Results: The app repository search identified a total of 5881 apps. Of these, 805 fulfilled the inclusion criteria initially and were tested. Furthermore, 681 apps were further analyzed for data extraction. Of these, 420 apps were free for testing, 58 were inaccessible and 203 required payment. Of the 420 free apps, 57 apps were developed with HCP involvement and an evidence base was identified in only 4 apps. Of the paid apps, 9 apps had HCP involvement, 1 app had a documented evidence base, and 1 app had both. In addition, 18 inaccessible apps were produced with HCP involvement, whereas 2 apps had a documented evidence base. The 420 free apps were further analyzed to identify strategies used to improve medication adherence. This identified three broad categories of adherence strategies, reminder, behavioral, and educational. A total of 250 apps utilized a single method, 149 apps used two methods, and only 22 apps utilized all three methods. Conclusions: To our knowledge, this is the first study to systematically review all available medication adherence apps on the two largest app repositories. The results demonstrate a concerning lack of HCP involvement in app development and evidence base of effectiveness. More collaboration is required between relevant stakeholders to ensure development of high quality and relevant adherence apps with well-powered and robust clinical trials investigating the effectiveness of these interventions. A sound evidence base will encourage the adoption of effective adherence apps, and thus improve patient welfare in the process.

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

    Self-Directed Engagement with a Mobile App (Sinasprite) and Its Effects on Confidence in Coping Skills, Depression, and Anxiety: Retrospective Longitudinal...


    Background: Inadequacies in mental health care coverage remain an enormous problem in the United States. Barriers include scarcity of accessible mental health care professionals. Use of a mental health mobile app incorporating social cognitive theory may help improve confidence in coping skills and improve anxiety and depression. Sinasprite is a mobile app that recruited users via self-referral and clinician referral. Users completed questionnaires to obtain demographic and medical histories. At baseline and 6-week follow-up, users completed the Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder 7-Item (GAD-7), and the Coping Self-Efficacy Scale (CSE). It is unknown how self-directed use of a mobile app improves confidence in coping skills and its effects on self-reported depression and anxiety. Objective: The objective of this study was to evaluate the Sinasprite database to assess self-directed engagement and how use of this mobile app impacted self-reported confidence in coping skills and severity of depression and anxiety. Methods: This retrospective longitudinal study involved users recruited via clinician referral and self-referral through social media and news media. Questionnaires were used to record demographic, medical, and prescription medication histories. Mental health status was assessed via PHQ-8, GAD-7, and CSE questionnaires. A deidentified dataset reporting mobile app use data was provided to investigators. Individuals with verifiable usage data and at least one completed questionnaire at 6 weeks of use were included. Mann–Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman rho (ρ) test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed using Wilcoxon signed-rank test. A mixed-effects repeated-measures linear regression model assessed the main effects of time, concomitant counseling, and psychotropic prescription medication use on mental health status. Results: Thirty-four users were eligible for inclusion in the analysis. Users were predominantly female, white, married, and college educated. At baseline, 35% (12/34) of respondents reported the use of individual/group counseling, and 38% (19/34) reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. Statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (P<.001), GAD-7 (P=.002), and CSE (P<.001) questionnaire scores. A strong positive correlation between improvement in the GAD-7 and CSE questionnaire scores (ρ=.572, P=.001, n=28) was observed. The mixed-effects repeated-measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (P<.001), GAD-7 (P=.007), and CSE (P=.001). Conclusions: This 6-week retrospective study showed that self-directed use of the mobile app, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.

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

    Exploring Digital Health Use and Opinions of University Students: Field Survey Study


    Background: During university, students face some potentially serious health risks, and their lifestyle can have a direct effect on health and health behaviors later in life. Concurrently, university students are digital natives having easy access to the internet and new technologies. Digital health interventions offer promising new opportunities for health promotion, disease prevention, and care in this specific population. The description of the current use of and opinions on digital health among university students can inform future digital health strategies and interventions within university settings. Objective: The aim of this exploratory study was to report on university students’ use and opinions regarding information and communication technologies for health and well-being, taking into account sociodemographic and self-rated general and mental health correlates. Methods: This field survey was conducted from March to April 2017. An informed consent form and a paper questionnaire were given to students aged 18 to 24 years in 4 university campuses in Bordeaux, France. The survey was formulated in 3 sections: (1) sociodemographic characteristics and self-rated general and mental health, (2) information about the use of digital health, and (3) opinions about digital health. Data were analyzed using descriptive statistics and tests of independence. Results: A total of 59.8% (303/507 females) students completed the questionnaire. Concerning digital health use, 34.9% (174/498) had at least 1 health app mostly for physical activity (49.4%, 86/174) and general health monitoring (41.4%, 72/174,), but only 3.9% (20/507) of students had a wearable device. Almost all (94.8%, 450/476) had searched for Web-based health-related information at least once in the last 12 months. The most sought health-related topics were nutrition (68.1%, 324/476); pain and illnesses (64.5%, 307/476); and stress, anxiety, or depression (51.1%, 243/476). Although Wikipedia (79.7%, 357/448) and general health websites (349/448, 77.9%) were the most consulted sources, students considered institutional or official websites as the most credible sources (309/335, 92.2%). There were significant differences in digital health use by gender, field, and year of study. No statistically significant association was found between digital health use and self-rated general and mental health status. Concerning opinions on digital health, although 94.1% (475/505) of students estimated that today’s digital health cannot replace traditional health services and medical consultations, 44.6% (207/464) of students declared that this could be possible in the future, provided that digital health interventions are promoted by institutional or official entities. Conclusions: University students are largely using the internet for health information seeking, but using less mobile health apps and very few wearable devices. Our data suggest that digital health has the potential for improving health and well-being at the university, especially if digital health interventions take into account students’ profiles, interests, and needs.

  • Source: Pixabay; Copyright: LUM3N; URL:; License: Public Domain (CC0).

    Describing the Process of Adopting Nutrition and Fitness Apps: Behavior Stage Model Approach


    Background: Although mobile technologies such as smartphone apps are promising means for motivating people to adopt a healthier lifestyle (mHealth apps), previous studies have shown low adoption and continued use rates. Developing the means to address this issue requires further understanding of mHealth app nonusers and adoption processes. This study utilized a stage model approach based on the Precaution Adoption Process Model (PAPM), which proposes that people pass through qualitatively different motivational stages when adopting a behavior. Objective: To establish a better understanding of between-stage transitions during app adoption, this study aimed to investigate the adoption process of nutrition and fitness app usage, and the sociodemographic and behavioral characteristics and decision-making style preferences of people at different adoption stages. Methods: Participants (N=1236) were recruited onsite within the cohort study Konstanz Life Study. Use of mobile devices and nutrition and fitness apps, 5 behavior adoption stages of using nutrition and fitness apps, preference for intuition and deliberation in eating decision-making (E-PID), healthy eating style, sociodemographic variables, and body mass index (BMI) were assessed. Results: Analysis of the 5 behavior adoption stages showed that stage 1 (“unengaged”) was the most prevalent motivational stage for both nutrition and fitness app use, with half of the participants stating that they had never thought about using a nutrition app (52.41%, 533/1017), whereas less than one-third stated they had never thought about using a fitness app (29.25%, 301/1029). “Unengaged” nonusers (stage 1) showed a higher preference for an intuitive decision-making style when making eating decisions, whereas those who were already “acting” (stage 4) showed a greater preference for a deliberative decision-making style (F4,1012=21.83, P<.001). Furthermore, participants differed widely in their readiness to adopt nutrition and fitness apps, ranging from having “decided to” but not yet begun to act (stage 2; nutrition: 6.88%, 70/1017; fitness: 9.23%, 95/1029) to being “disengaged” following previous adoption (stage 5; nutrition: 13.77%, 140/1017; fitness: 15.06%, 155/1029). Conclusions: Using a behavior stage model approach to describe the process of adopting nutrition and fitness apps revealed motivational stage differences between nonusers (being “unengaged,” having “decided not to act,” having “decided to act,” and being “disengaged”), which might contribute to a better understanding of the process of adopting mHealth apps and thus inform the future development of digital interventions. This study highlights that new user groups might be better reached by apps designed to address a more intuitive decision-making style.

  • Effect view of the Sunface app. Source: Image created by the Authors; Copyright: Titus J Brinker; URL:; License: Creative Commons Attribution (CC-BY).

    A Skin Cancer Prevention Facial-Aging Mobile App for Secondary Schools in Brazil: Appearance-Focused Interventional Study


    Background: The incidence of melanoma is increasing faster than any other major cancer both in Brazil and worldwide. Southeast Brazil has especially high incidences of melanoma, and early detection is low. Exposure to ultraviolet (UV) radiation is a primary risk factor for developing melanoma. Increasing attractiveness is a major motivation among adolescents for tanning. A medical student-delivered intervention that takes advantage of the broad availability of mobile phones and adolescents’ interest in their appearance indicated effectiveness in a recent study from Germany. However, the effect in a high-UV index country with a high melanoma prevalence and the capability of medical students to implement such an intervention remain unknown. Objective: In this pilot study, our objective was to investigate the preliminary success and implementability of a photoaging intervention to prevent skin cancer in Brazilian adolescents. Methods: We implemented a free photoaging mobile phone app (Sunface) in 15 secondary school classes in southeast Brazil. Medical students “mirrored” the pupils’ altered 3-dimensional (3D) selfies reacting to touch on tablets via a projector in front of their whole grade accompanied by a brief discussion of means of UV protection. An anonymous questionnaire capturing sociodemographic data and risk factors for melanoma measured the perceptions of the intervention on 5-point Likert scales among 356 pupils of both sexes (13-19 years old; median age 16 years) in grades 8 to 12 of 2 secondary schools in Brazil. Results: We measured more than 90% agreement in both items that measured motivation to reduce UV exposure and only 5.6% disagreement: 322 (90.5%) agreed or strongly agreed that their 3D selfie motivated them to avoid using a tanning bed, and 321 (90.2%) that it motivated them to improve their sun protection; 20 pupils (5.6%) disagreed with both items. The perceived effect on motivation was higher in female pupils in both tanning bed avoidance (n=198, 92.6% agreement in females vs n=123, 87.2% agreement in males) and increased use of sun protection (n=197, 92.1% agreement in females vs n=123, 87.2% agreement in males) and independent of age or skin type. All medical students involved filled in a process evaluation revealing that they all perceived the intervention as effective and unproblematic, and that all pupils tried the app in their presence. Conclusions: The photoaging intervention was effective in changing behavioral predictors for UV protection in Brazilian adolescents. The predictors measured indicated an even higher prospective effectiveness in southeast Brazil than in Germany (>90% agreement in Brazil vs >60% agreement in Germany to both items that measured motivation to reduce UV exposure) in accordance with the theory of planned behavior. Medical students are capable of complete implementation. A randomized controlled trial measuring prospective effects in Brazil is planned as a result of this study.

  • Source: Shutterstock; Copyright: bokan; URL:; License: Licensed by the authors.

    Adolescents’ Perspectives on a Mobile App for Relationships: Cross-Sectional Survey


    Background: Adolescence can be a fertile time for relationship issues, with interpersonal conflict being a risk factor for poor mental health. Mobile app interventions may have a significant appeal to young people in assisting with relationship distress. However, currently available apps have not been formally evaluated. Youths’ perspectives on engaging with mobile technology to assist with relationships are also unknown. Objective: This study aimed to examine adolescents’ attitudes toward the concept of a mobile phone app for relationship help and support, and whether they would be likely to use such an intervention. Methods: A cross-sectional Web survey consisting of 42 questions, including 13 free responses, was delivered. The proposed app, including character vignettes, was presented, and participants were asked to indicate whether they had experienced the same relationship issues, whether their peers would relate to the issues, and how helpful they found the proposed advice. Participants were also asked to provide their own suggestions for help, which were analyzed using thematic analyses. Results: A total of 150 adolescents (aged 15 to 18) participated. Overall, 60.7% (91/150) were likely to use an app for relationship problems, and this was not associated with demographics or social support (all P values >.05). Likelihood of app usage was found to be influenced by perceived need for help, personal beliefs about app effectiveness, and whether the app is engaging and easy to use. Overall, adolescents were receptive of the proposed content with an average of 99.3% (149/150), rating the strategies provided as somewhat to very helpful. Conclusions: Adolescents were likely to use a mobile phone app for relationship support, and use was not influenced by gender, age, social support, or any other background characteristic. Instead, likely use was influenced by need, personal beliefs, usability, and the appropriateness of app content. App developers must address these factors if the app is to have a wide-scale uptake.

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

    Effect of Using an Indoor Air Quality Sensor on Perceptions of and Behaviors Toward Air Pollution (Pittsburgh Empowerment Library Study): Online Survey and...


    Background: Air quality affects us all and is a rapidly growing concern in the 21st century. We spend the majority of our lives indoors and can be exposed to a number of pollutants smaller than 2.5 microns (particulate matter, PM2.5) resulting in detrimental health effects. Indoor air quality sensors have the potential to provide people with the information they need to understand their risk and take steps to reduce their exposure. One such sensor is the Speck sensor developed at the Community Robotics, Education and Technology Empowerment Lab at Carnegie Mellon University. This sensor provides users with continuous real-time and historical PM2.5 information, a Web-based platform where people can track their PM2.5 levels over time and learn about ways to reduce their exposure, and a venue (blog post) for the user community to exchange information. Little is known about how the use of such monitors affects people’s knowledge, attitudes, and behaviors with respect to indoor air pollution. Objective: The aim of this study was to assess whether using the sensor changes what people know and do about indoor air pollution. Methods: We conducted 2 studies. In the first study, we recruited 276 Pittsburgh residents online and through local branches of the Carnegie Library of Pittsburgh, where the Speck sensor was made available by the researchers in the library catalog. Participants completed a 10- to 15-min survey on air pollution knowledge (its health impact, sources, and mitigation options), perceptions of indoor air quality, confidence in mitigation, current behaviors toward air quality, and personal empowerment and creativity in the spring and summer of 2016. In our second study, we surveyed 26 Pittsburgh residents in summer 2016 who checked out the Speck sensor for 3 weeks on the same measures assessed in the first study, with additional questions about the perception and use of the sensor. Follow-up interviews were conducted with a subset of those who used the Speck sensor. Results: A series of paired t tests found participants were significantly more knowledgeable (t25=−2.61, P=.02), reported having significantly better indoor air quality (t25=−5.20, P<.001), and felt more confident about knowing how to mitigate their risk (t25=−1.87, P=.07) after using the Speck sensor than before. McNemar test showed participants tended to take more action to reduce indoor air pollution after using the sensor (χ225=2.7, P=.10). Qualitative analysis suggested possible ripple effects of use, including encouraging family and friends to learn about indoor air pollution. Conclusions: Providing people with low- or no-cost portable indoor air quality monitors, with a supporting Web-based platform that offers information about how to reduce risk, can help people better express perceptions and adopt behaviors commensurate with the risks they face. Thus, thoughtfully designed and deployed personal sensing devices can help empower people to take steps to reduce their risk.

  • Source: Pixnio; Copyright: James Gathany, Judy Schmidt, USCDCP; URL:; License: Public Domain (CC0).

    Evaluation of a Mobile Phone–Based Intervention to Increase Parents’ Knowledge About the Measles-Mumps-Rubella Vaccination and Their Psychological...


    Background: There is mixed evidence on the effectiveness of vaccination-related interventions. A major limitation of most intervention studies is that they do not apply randomized controlled trials (RCTs), the method that, over the last 2 decades, has increasingly been considered as the only method to provide proof of the effectiveness of an intervention and, consequently, as the most important instrument in deciding whether to adopt an intervention or not. This study, however, holds that methods other than RCTs also can produce meaningful results. Objective: The aim of this study was to evaluate 2 mobile phone–based interventions aimed at increasing parents’ knowledge of the measles-mumps-rubella (MMR) vaccination (through elements of gamification) and their psychological empowerment (through the use of narratives), respectively. The 2 interventions were part of an RCT. Methods: We conducted 2 studies with the RCT participants: a Web-based survey aimed at assessing their rating of the tool regarding a number of qualities such as usability and usefulness (N=140), and qualitative telephonic interviews to explore participants’ experiences with the app (N=60). Results: The results of the survey showed that participants receiving the knowledge intervention (alone or together with the empowerment intervention) liked the app significantly better compared with the group that only received the empowerment intervention (F2,137=15.335; P<.001). Parents who were exposed to the empowerment intervention complained that they did not receive useful information but were only invited to make an informed, autonomous MMR vaccination decision. Conclusions: The results suggest that efforts to empower patients should always be accompanied by the provision of factual information. Using a narrative format that promotes parents’ identification can be an appropriate strategy, but it should be employed together with the presentation of more points of views and notions regarding, for instance, the risks and benefits of the vaccination at the same time. Trial Registration: International Standard Randomized Controlled Trial Number 30768813; ISRCTN30768813 (Archived by WebCite at

  • Source: Flickr; Copyright: Royal Opera House Covent Garden; URL:; License: Creative Commons Attribution (CC-BY).

    Using Google Glass in Surgical Settings: Systematic Review


    Background: In recent years, wearable devices have become increasingly attractive and the health care industry has been especially drawn to Google Glass because of its ability to serve as a head-mounted wearable device. The use of Google Glass in surgical settings is of particular interest due to the hands-free device potential to streamline workflow and maintain sterile conditions in an operating room environment. Objective: The aim is to conduct a systematic evaluation of the literature on the feasibility and acceptability of using Google Glass in surgical settings and to assess the potential benefits and limitations of its application. Methods: The literature was searched for articles published between January 2013 and May 2017. The search included the following databases: PubMed MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO (EBSCO), and IEEE Xplore. Two reviewers independently screened titles and abstracts and assessed full-text articles. Original research articles that evaluated the feasibility, usability, or acceptability of using Google Glass in surgical settings were included. This review was completed following the Preferred Reporting Results of Systematic Reviews and Meta-Analyses guidelines. Results: Of the 520 records obtained, 31 met all predefined criteria and were included in this review. Google Glass was used in various surgical specialties. Most studies were in the United States (23/31, 74%) and all were conducted in hospital settings: 29 in adult hospitals (29/31, 94%) and two in children’s hospitals (2/31, 7%). Sample sizes of participants who wore Google Glass ranged from 1 to 40. Of the 31 studies, 25 (81%) were conducted under real-time conditions or actual clinical care settings, whereas the other six (19%) were conducted under simulated environment. Twenty-six studies were pilot or feasibility studies (84%), three were case studies (10%), and two were randomized controlled trials (6%). The majority of studies examined the potential use of Google Glass as an intraoperative intervention (27/31, 87%), whereas others observed its potential use in preoperative (4/31, 13%) and postoperative settings (5/31, 16%). Google Glass was utilized as a videography and photography device (21/31, 68%), a vital sign monitor (6/31, 19%), a surgical navigation display (5/31, 16%), and as a videoconferencing tool to communicate with remote surgeons intraoperatively (5/31, 16%). Most studies reported moderate or high acceptability of using Google Glass in surgical settings. The main reported limitations of using Google Glass utilization were short battery life (8/31, 26%) and difficulty with hands-free features (5/31, 16%). Conclusions: There are promising feasibility and usability data of using Google Glass in surgical settings with particular benefits for surgical education and training. Despite existing technical limitations, Google Glass was generally well received and several studies in surgical settings acknowledged its potential for training, consultation, patient monitoring, and audiovisual recording.

  • Source: Keesler Air Force Base; Copyright: US Air Force (Holly Mansfield); URL:; License: Public Domain (CC0).

    More Stamina, a Gamified mHealth Solution for Persons with Multiple Sclerosis: Research Through Design


    Background: Multiple sclerosis (MS) is one of the world’s most common neurologic disorders. Fatigue is one of most common symptoms that persons with MS experience, having significant impact on their quality of life and limiting their activity levels. Self-management strategies are used to support them in the care of their health. Mobile health (mHealth) solutions are a way to offer persons with chronic conditions tools to successfully manage their symptoms and problems. Gamification is a current trend among mHealth apps used to create engaging user experiences and is suggested to be effective for behavioral change. To be effective, mHealth solutions need to be designed to specifically meet the intended audience needs. User-centered design (UCD) is a design philosophy that proposes placing end users’ needs and characteristics in the center of design and development, involving users early in the different phases of the software life cycle. There is a current gap in mHealth apps for persons with MS, which presents an interesting area to explore. Objective: The purpose of this study was to describe the design and evaluation process of a gamified mHealth solution for behavioral change in persons with MS using UCD. Methods: Building on previous work of our team where we identified needs, barriers, and facilitators for mHealth apps for persons with MS, we followed UCD to design and evaluate a mobile app prototype aimed to help persons with MS self-manage their fatigue. Design decisions were evidence-driven and guided by behavioral change models (BCM). Usability was assessed through inspection methods using Nielsen’s heuristic evaluation. Results: The mHealth solution More Stamina was designed. It is a task organization tool designed to help persons with MS manage their energy to minimize the impact of fatigue in their day-to-day life. The tool acts as a to-do list where users can input tasks in a simple manner and assign Stamina Credits, a representation of perceived effort, to the task to help energy management and energy profiling. The app also features personalization and positive feedback. The design process gave way to relevant lessons to the design of a gamified behavioral change mHealth app such as the importance of metaphors in concept design, negotiate requirements with the BCM constructs, and tailoring of gamified experiences among others. Several usability problems were discovered during heuristic evaluation and guided the iterative design of our solution. Conclusions: In this paper, we designed an app targeted for helping persons with MS in their fatigue management needs. We illustrate how UCD can help in designing mHealth apps and the benefits and challenges that designers might face when using this approach. This paper provides insight into the design process of gamified behavioral change mHealth apps and the negotiation process implied in it.

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

    Crush the Crave: Development and Formative Evaluation of a Smartphone App for Smoking Cessation


    Background: Emerging evidence supports the use of smartphone apps for smoking cessation, especially in young adults given their high smoking rates and high smartphone ownership rates. Although evaluative evidence is encouraging for supporting smoking cessation, there remains a paucity of research describing the design and development processes of mobile health (mHealth) interventions. Objective: The aim of this paper was to describe the process of developing Crush the Crave (CTC), an evidence-informed app to support smoking cessation in young adults, and the results of a formative evaluation of app usage behavior, as part of a broader program of research that seeks to establish the effectiveness of the CTC app. Methods: The Spiral Technology Action Research (STAR) 5-cycle model (listen, plan, do, act, and study) was employed to guide the development, implementation, and dissemination of CTC. The approach to development and formative evaluation included focus groups with young adult smokers (n=78) across 2 phases, analysis of the content of existing apps, 2 sessions with content experts, and Google Analytics to assess user behavior during a 12-month pilot. Results: LISTEN—focus groups revealed young adult smoker preferences of (1) positive reinforcement, (2) personalization, (3) social support, (4) quit support, (5) tracking the behavior, and (6) tracking quit benefits. PLAN—informed by evidence for smoking cessation, young adult preferences and an assessment of popular cessation apps, content experts produced a mind map and a storyboard describing app content and structure. DO—focus groups with young adult smokers provided feedback on the first version of the app with opinions on content and suggestions for improvement such as providing alerts and distractions from craving. ACT—refinements were made, and app content was organized using the 4 key design components informed by principles of persuasive technology for behavior change: credibility, task support, dialogue support, and social support. CTC was launched in April 2013 and piloted from the period July 2013 to June 2014 where 1987 Android users had 18,567 sessions, resulting in 59,384 page views and 89.58% (1780/1987) of users returning within the same day to use CTC. STUDY—a pragmatic randomized controlled trial of CTC was launched in August 2014 to demonstrate that including mHealth technology as a population-based intervention can help young adult smokers to quit. The results of this phase will be presented in a subsequent publication. Conclusions: CTC is one of the first smoking cessation apps designed to meet the needs of young adult smokers. The development was informed by the inclusion of young adults in the design and the systematic application of multiple stakeholder input, scientific evidence, and theory. The STAR model approach was followed from the beginning of intervention development, which should facilitate optimization of mHealth interventions in the future. Trial Registration: NCT01983150; (Archived by WebCite at

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

    Background: ScreenMen, a mobile web-app which aimed to improve health screening uptake in men was developed based on theories, evidence and needs. Objective: This study aimed to evaluate ScreenMen for...

    Background: ScreenMen, a mobile web-app which aimed to improve health screening uptake in men was developed based on theories, evidence and needs. Objective: This study aimed to evaluate ScreenMen for its utility and usability with men from the community. Methods: This study used a mixed-method approach. Healthy men who are working in a banking institution were recruited to participant in this study. They were purposively sampled according to job position, age, education level and screening status. Men were asked to use ScreenMen independently while the screen activities are being recorded. Once completed, retrospective think aloud with playback was conducted with men to obtain their feedback. They were asked to answer the System Usability Scale. Intention to undergo screening pre- and post- intervention were also measured. Qualitative data were analysed using a framework approach and followed by thematic analysis. For quantitative data obtained, the mean SUS score and change in intention to screening were calculated and analyses using McNemar test. Results: Twenty-four men participated in this study. Based on the qualitative data, men found ScreenMen useful as they could learn more about their health risks and screening. They found ScreenMen convenient to use and might trigger men to undergo screening. In terms of usability, men thought that ScreenMen was user-friendly and easy to understand. The key revision done on utility was the addition of a reminder function while for usability, the revisions done were in terms of attracting and gaining users trust; improving learnability; and making ScreenMen usable to all types of users. To attract men to use it, ScreenMen was introduced to users in terms of ‘improving health’ instead of ‘going for screening’. Another important revision made was emphasising the screening tests the users do not need instead of just informing them the screening tests they need. A ‘Quick Assessment Mode’ was also added for users with limited attention span. The quantitative data showed that eight (34.8%) out of 23 men planned to attend screening earlier than intended after using the ScreenMen. Out of 12 men who were in pre-contemplation stage, 4 (33.3%) changed to either contemplation or preparation stage after using ScreenMen. In terms of usability, the SUS score of 76.4 indicated that ScreenMen had good usability. Conclusions: This study showed that ScreenMen was acceptable to men in terms of its utility and usability. The preliminary data suggested that ScreenMen might increase men’s intention to undergo screening. This paper also presented key lessons learnt from the beta testing, which would useful for public health experts and researchers when developing a user-centered mobile web-app. Clinical Trial: Not applicable

  • Implementing systematically collected user feedback to increase user retention in a mobile app for self-management of low back pain: A retrospective cohort study

    Date Submitted: Mar 15, 2018

    Open Peer Review Period: Mar 16, 2018 - Mar 28, 2018

    Background: Promising first results for Kaia, a mobile app digitalizing multidisciplinary rehabilitation for low back pain, were recently published. It remained unclear, whether the implementation of...

    Background: Promising first results for Kaia, a mobile app digitalizing multidisciplinary rehabilitation for low back pain, were recently published. It remained unclear, whether the implementation of user feedback in an updated version of this app led to desired effects in terms of increased app usage and clinical outcomes. Objective: To elucidate the effect on user retention and clinical outcomes of an updated version of the Kaia app where user feedback was included during development. Methods: User feedback of the initial app versions (0.x) was collected in a quality management system and systematically analyzed to define requirements of a new version. For the current study, the anonymized data of Kaia users was retrospectively analyzed and users subgrouped depending on the available version at the time of the signup (0.x vs.. 1.x). The effect on the duration of activity of users in the app, the number of completed exercises of each type of exercise and user reported pain levels were compared. Results: Overall, data of 1251 users fulfilled the inclusion criteria, of which 196 users signed up using version 0.x and 1055 users signed with version 1.x. There were significant differences in the demographic parameters for both groups. A log rank test showed no significant differences for the duration of activity in the app between groups (p= 0,307). Users signing up during availability of the 1.x version completed significantly more exercises of each type in the app (physical exercises 0.x 1.99 +/- 1.61 units/week vs. 1.x 3.15 +/-1.72 units/week; p<0.001; mindfulness exercises 0.x 1.36 +/-1.43 units/week vs. 1.x 2.42 +/- 1.82 units/week; p<0.001; educational content 0.x 1.51 +/- 1.42 units/week vs. 1.x 2.71 +/- 1.89 units/week; p<0.001). This translated into a stronger decrease in user-reported pain levels in versions 1.x (F-value 7.084, p-value = 0.008). Conclusions: Despite the limitations of retrospective cohort studies, the current study indicates, that the implementation of systematically collected user feedback during development of updated versions can contribute to improvements in terms of use frequency and potentially even clinical endpoints like pain level. The clinical efficiency of the Kaia app needs to be validated in prospective controlled trials to exclude bias.

  • How users experience and use an eHealth intervention based on self-regulation: a mixed-methods approach

    Date Submitted: Mar 14, 2018

    Open Peer Review Period: Mar 15, 2018 - May 10, 2018

    Background: EHealth interventions show stronger effects when informed by solid behaviour change theories. For example, self-regulation models supporting people in translating vague intentions to speci...

    Background: EHealth interventions show stronger effects when informed by solid behaviour change theories. For example, self-regulation models supporting people in translating vague intentions to specific actions have shown to be effective in altering health behaviours. Although these theories inform developers about which behaviour change techniques should be included, they provide limited information about how these techniques can be implemented in online interventions in an engaging way. Taking into account the high levels of attrition in eHealth, investigating users’ experience about the implementation of behaviour change techniques might be a fruitful avenue. Objective: We investigated how users experienced the implementation of self-regulation techniques in an online intervention targeting physical activity and sedentary behaviour in the general population. Methods: Twenty adults from the general population used the intervention for a period of five weeks. Users’ website data were explored and semi-structured interviews with each of the users were performed. A directed content analysis was performed using NVivo Software. Results: The techniques ‘providing feedback on performance’, ‘action planning’ and ‘prompting review of behavioural goals’ were appreciated by the users. However, the implementation of ‘barrier identification/problem solving’ appeared to frustrate users. This was also reflected by the users’ website data: many coping plans were of poor quality. Most users were well-aware of the benefits of adopting a more active way of living and stated not to have learned novel information. However, they appreciated the provided information as it reminded them about the importance of having an active lifestyle. Furthermore, prompting users to self-monitor their behavioural change was not stimulating enough to make users actually monitor their behaviour. Conclusions: Iteratively involving potential end-users offers guidance to optimally adapt the implementation of various behaviour change techniques to the target population. We recommend to create short interventions with a straightforward lay-out that support users in creating and evaluating specific plans for action.

  • A Path to Better-Quality Mobile Health Apps

    Date Submitted: Mar 14, 2018

    Open Peer Review Period: Mar 15, 2018 - May 10, 2018

    The rapid growth of mobile health applications has resulted in confusion among health care providers and the public about which products rely on evidence-based medicine. Only a small subset of mHealth...

    The rapid growth of mobile health applications has resulted in confusion among health care providers and the public about which products rely on evidence-based medicine. Only a small subset of mHealth apps are regulated by the US Food and Drug Administration. The system used to accredit and certify laboratory testing under the Clinical Laboratory Improvement Amendment, or CLIA, offers a potential model for ensuring basic standards of quality and safety for mHealth apps. With these products expanding into the realm of diagnosis and treatment, physicians and consumers are in a strong position to demand oversight that delivers safe and high-quality mHealth apps.

  • Electronic 12-Hour Dietary Recall (e-12HR): Comparison of a Mobile Phone App for Dietary Intake Assessment with a Food Frequency Questionnaire and Four Dietary Records.

    Date Submitted: Mar 14, 2018

    Open Peer Review Period: Mar 15, 2018 - May 10, 2018

    Background: One of the greatest challenges for nutritional epidemiology is improving upon traditional self-reporting methods for assessing usual dietary intake. Objective: Evaluating the relative vali...

    Background: One of the greatest challenges for nutritional epidemiology is improving upon traditional self-reporting methods for assessing usual dietary intake. Objective: Evaluating the relative validity of a new method known as the current-day dietary recall (current-day recall), based on a Smartphone app called 12-hour dietary recall (e-12HR), for determining the habitual intake of a series of key food/drink groups using a food frequency questionnaire (FFQ) and four dietary records (DRs) as reference methods. Methods: University students over the age of 18 recorded their consumption of certain groups of food/drink using e-12HR for 28 consecutive days. During this 28-day period, they also completed four DRs on randomly selected days. Once the monitoring period was finished, the subjects then completed a FFQ. A comparison was made between the different methods using the Spearman correlation coefficient (SCC), a cross-classification analysis, and weighted kappa (k). Results: A total of 87 participants completed the study (64% women, 56/87; 36% men, 31/87). e-12HR versus FFQ, for all food/drink groups: The average SCC was .70. Cross-classification analysis showed that the average percentage of individuals classified in the exact agreement category was 51.5%; exact agreement + adjacent was 91.8%; and no participant (0.0%) was classified in the extreme disagreement category. The average k was .51. e-12HR versus the four DRs, for all food/drink groups: The average SCC was .63. Cross-classification analysis showed that the average percentage of individuals classified in the exact agreement category was 47.1%; exact agreement + adjacent was 89.2%; and no participant (0.0%) was classified in the extreme disagreement category. The average k was .47. Conclusions: Current-day recall, based on the e-12HR app, is in good agreement with the two reference methods (FFQ & four DRs), demonstrating its potential usefulness for categorizing individuals according to the usual dietary intake of certain food/drink groups.

  • The implementation of an innovative hydration monitoring App in care home settings: a qualitative study

    Date Submitted: Mar 14, 2018

    Open Peer Review Period: Mar 14, 2018 - May 9, 2018

    Background: In response to significant concern regarding inadequate fluid intake recording in care homes, an innovative mobile hydration application was collaboratively developed. ‘Hydr8’ aimed t...

    Background: In response to significant concern regarding inadequate fluid intake recording in care homes, an innovative mobile hydration application was collaboratively developed. ‘Hydr8’ aimed to facilitate accurate recording and communication of residents’ fluid intake and ultimately increase care quality and patient safety. Objective: The aim of this study was to examine the implementation of Hydr8 in a sample of care homes within one area in England. Methods: Principles of Realist Evaluation and Action research were drawn upon throughout. Five care homes participated; three interview-only sites and two case-study sites, where interviews and observations were conducted at three time points. Twenty-eight staff participated including care staff, management, a registered nurse and administrative staff. Results: Findings suggest Hydr8 benefited practice: enhancing understanding of hydration and person-centred care, and improving staff communication. However, technical glitches hindered the seamless embedding of Hydr8 into everyday practice and enthusiasm for long-term use was dependent on resolution of issues. Difficulties often related to care home infrastructure, highlighting wider issues regarding the health and social care economy. Hydr8 also heightened perceptions of personal accountability and while managers viewed this as positive, some staff were apprehensive. However individuals were enthusiastic about the long-term use and potential of Hydr8. Conclusions: Utilising the findings from this study to further develop and adapt Hydr8 indicates the long-term use of Hydr8 as promising. Perceptions of Hydr8 were primarily positive, however, setbacks in its implementation and use created difficulties in normalising the solution into everyday practice. This study highlights the need for education relating to hydration practice and a change of infrastructure in care home settings in order to implement technical solutions and changes to care. Clinical Trial: n/a