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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:

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

    A Mobile Lifestyle Management Program (GlycoLeap) for People With Type 2 Diabetes: Single-Arm Feasibility Study


    Background: Singapore’s current prevalence of diabetes exceeds 13.6%. Although lifestyle modification can be effective for reducing the risks for complications of type 2 diabetes mellitus (T2DM), traditional lifestyle interventions are often difficult to administer in the primary care setting due to limited resources. Mobile health apps can address these limitations by offering low-cost, adaptable, and accessible platforms for disseminating lifestyle management interventions. Objective: Using the RE-AIM evaluation framework, this study assessed the potential effectiveness and feasibility of GlycoLeap, a mobile lifestyle management program for people with T2DM, as an add-on to standard care. Methods: This single-arm feasibility study recruited 100 patients with T2DM and glycated hemoglobin (HbA1c) levels of ≥7.5% from a single community health care facility in Singapore. All participants were given access to a 6-month mobile lifestyle management program, GlycoLeap, comprising online lessons and the Glyco mobile phone app with a health coaching feature. The GlycoLeap program was evaluated using 4 relevant dimensions of the RE-AIM framework: (1) reach (percentage who consented to participate out of all patients approached), (2) effectiveness (percentage point change in HbA1c [primary outcome] and weight loss [secondary outcome]), (3) implementation (program engagement as assessed by various participatory metrics), and (4) maintenance (postintervention user satisfaction surveys to predict the sustainability of GlycoLeap). Participants were assessed at baseline and at follow-up (≥12 weeks after starting the intervention). Results: A total of 785 patients were approached of whom 104 consented to participate, placing the reach at 13.2%. Four were excluded after eligibility screening, and 100 patients were recruited. Program engagement (implementation) started out high but decreased with time for all evaluated components. Self-reported survey data suggest that participants monitored their blood glucose on more days in the past week at follow-up compared to baseline (P<.001) and reported positive changes to their diet due to app engagement (P<.001) (implementation). Primary outcome data were available for 83 participants. Statistically significant improvements were observed for HbA1c (–1.3 percentage points, P<.001) with greater improvements for those who logged their weight more often (P=.007) (effectiveness). Participants also had a 2.3% reduction in baseline weight (P<.001) (effectiveness). User satisfaction was high with 74% (59/80) and 79% (63/80) of participants rating the app good or very good and claiming that they would probably or definitely recommend the app to others, respectively (maintenance). Conclusions: Although measures of program engagement decreased with time, clinically significant improvements in HbA1c were achieved with the potential for broader implementation. However, we cannot rule out that these improvements were due to factors unrelated to GlycoLeap. Therefore, we would recommend evaluating the effectiveness and cost effectiveness of GlycoLeap using a randomized controlled trial of at least 12 months. Trial Registration: NCT03091517; (Archived by WebCite at

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

    Using Mobile Health to Support Clinical Decision-Making to Improve Maternal and Neonatal Health Outcomes in Ghana: Insights of Frontline Health Worker...


    Background: Developing and maintaining resilient health systems in low-resource settings like Ghana requires innovative approaches that adapt technology to context to improve health outcomes. One such innovation was a mobile health (mHealth) clinical decision-making support system (mCDMSS) that utilized text messaging (short message service, SMS) of standard emergency maternal and neonatal protocols via an unstructured supplementary service data (USSD) on request of the health care providers. This mCDMSS was implemented in a cluster randomized controlled trial (CRCT) in the Eastern Region of Ghana. Objective: This study aimed to analyze the pattern of requests made to the USSD by health workers (HWs). We assessed the relationship between requests made to the USSD and types of maternal and neonatal morbidities reported in health facilities (HFs). Methods: For clusters in the intervention arm of the CRCT, all requests to the USSD during the 18-month intervention period were extracted from a remote server, and maternal and neonatal health outcomes of interest were obtained from the District Health Information System of Ghana. Chi-square and Fisher exact tests were used to compare the proportion and type of requests made to the USSD by cluster, facility type, and location; whether phones accessing the intervention were shared facility phones or individual-use phones (type-of-phone); or whether protocols were accessed during the day or at night (time-of-day). Trends in requests made were analyzed over 3 6-month periods. The relationship between requests made and the number of cases reported in HFs was assessed using Spearman correlation. Results: In total, 5329 requests from 72 (97%) participating HFs were made to the intervention. The average number of requests made per cluster was 667. Requests declined from the first to the third 6-month period (44.96% [2396/5329], 39.82% [2122/5329], and 15.22% [811/5329], respectively). Maternal conditions accounted for the majority of requests made (66.35% [3536/5329]). The most frequently accessed maternal conditions were postpartum hemorrhage (25.23% [892/3536]), other conditions (17.82% [630/3536]), and hypertension (16.49% [583/3536]), whereas the most frequently accessed neonatal conditions were prematurity (20.08% [360/1793]), sepsis (15.45% [277/1793]), and resuscitation (13.78% [247/1793]). Requests made to the mCDMSS varied significantly by cluster, type of request (maternal or neonatal), facility type and its location, type-of-phone, and time-of-day at 6-month interval (P<.001 for each variable). Trends in maternal and neonatal requests showed varying significance over each 6-month interval. Only asphyxia and sepsis cases showed significant correlations with the number of requests made (r=0.44 and r=0.79; P<.001 and P=.03, respectively). Conclusions: There were variations in the pattern of requests made to the mCDMSS over time. Detailed information regarding the use of the mCDMSS provides insight into the information needs of HWs for decision-making and an opportunity to focus support for HW training and ultimately improved maternal and neonatal health.

  • the InDEx app in a pub setting. Source: Image created by the Authors; Copyright: Daniel Leightley; URL:; License: Creative Commons Attribution (CC-BY).

    A Qualitative Evaluation of the Acceptability of a Tailored Smartphone Alcohol Intervention for a Military Population: Information About Drinking for...


    Background: Alcohol consumption in the UK Armed Forces is higher than in the general population, and this pattern continues after leaving the service. Smartphone apps may be useful to increase ex-serving personnel’s awareness of their alcohol consumption, support self-monitoring, and prompt a change in behavior. Objective: The study aimed to explore the acceptability of Information about Drinking in Ex-serving personnel (InDEx), a tailored smartphone app, combined with personalized short message service (SMS) text messaging designed to target ex-serving personnel who meet the criteria for hazardous alcohol use. Methods: The InDEx intervention included 4 key modules: (1) assessment and normative feedback, (2) self-monitoring and feedback, (3) goal setting and review, and (4) personalized SMS text messaging. A semistructured telephone interview study was conducted with ex-serving personnel after using the app for a 28-day period. Interviews were used to explore the acceptability of app modules and its functionality and the perceived changes in participant’s drinking. Interview transcripts were analyzed using inductive thematic analysis. Results: Overall, 94% (29/31) participants who used InDEx agreed to take part in a telephone interview. Overall, 4 themes were identified: Credibility, Meeting their needs, Simplicity, and Helpful for ex-serving personnel. The importance of credibility, functionality, and meeting the individual needs of ex-serving personnel was emphasized. Acceptability and engagement with specific modules of the app and text messages were influenced by the following: (1) if they felt it provided credible information, (2) whether the content was appropriately personalized to them, (3) the ease of use, and (4) beliefs about their own drinking behaviors. Participants recommended that the app would be most suitable for personnel about to leave the Armed Forces. Conclusions: InDEx was an acceptable smartphone app for ex-serving personnel for monitoring alcohol consumption and in providing meaningful feedback to the individual. Pages that met the participant’s interests and provided real time personalized, credible feedback on their drinking and text messages tailored to participant’s interactions with the app were particularly favored.

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

    Who is Tracking Health on Mobile Devices: Behavioral Logfile Analysis in Hong Kong


    Background: Health apps on mobile devices provide an unprecedented opportunity for ordinary people to develop social connections revolving around health issues. With increasing penetration of mobile devices and well-recorded behavioral data on such devices, it is desirable to employ digital traces on mobile devices rather than self-reported measures to capture the behavioral patterns underlying the use of mobile health (mHealth) apps in a more direct and valid way. Objective: The objectives of this study were to (1) assess the demographic predictors of the adoption of mHealth apps; (2) investigate the temporal pattern underlying the use of mHealth apps; and (3) explore the impacts of demographic variables, temporal features, and app genres on the use of mHealth apps. Methods: Logfile data of mobile devices were collected from a representative panel of about 2500 users in Hong Kong. Users’ mHealth app activities were analyzed. We first conducted a binary logistic regression analysis to uncover demographic predictors of users’ adoption status. Then we utilized a multilevel negative binomial regression to examine the impacts of demographic characteristics, temporal features, and app genres on mHealth app use. Results: It was found that 27.5% of mobile device users in Hong Kong adopt at least one genre of mHealth app. Adopters of mHealth apps tend to be female and better educated. However, demographic characteristics did not showcase the predictive powers on the use of mHealth apps, except for the gender effect (Bfemale vs Bmale=–0.18; P=.006). The use of mHealth apps demonstrates a significant temporal pattern, which is found to be moderately active during daytime and intensifying at weekends and at night. Such temporal patterns in mHealth apps use are moderated by individuals’ demographic characteristics. Finally, demographic characteristics were also found to condition the use of different genres of mHealth apps. Conclusions: Our findings suggest the importance of dynamic perspective in understanding users’ mHealth app activities. mHealth app developers should consider more the demographic differences in temporal patterns of mHealth apps in the development of mHealth apps. Furthermore, our research also contributes to the promotion of mHealth apps by emphasizing the differences of usage needs for various groups of users.

  • Woman running with fitness tracker. Source: Flickr; Copyright: Sangudo; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Automatic Identification of Physical Activity Type and Duration by Wearable Activity Trackers: A Validation Study


    Background: Activity trackers are now ubiquitous in certain populations, with potential applications for health promotion and monitoring and chronic disease management. Understanding the accuracy of this technology is critical to the appropriate and productive use of wearables in health research. Although other peer-reviewed validations have examined other features (eg, steps and heart rate), no published studies to date have addressed the accuracy of automatic activity type detection and duration accuracy in wearable trackers. Objective: The aim of this study was to examine the ability of 4 commercially available wearable activity trackers (Fitbits Flex 2, Fitbit Alta HR, Fitbit Charge 2, and Garmin Vívosmart HR), in a controlled setting, to correctly and automatically identify the type and duration of the physical activity being performed. Methods: A total of 8 activity types, including walking and running (on both a treadmill and outdoors), a run embedded in walking bouts, elliptical use, outdoor biking, and pool lap swimming, were tested by 28 to 34 healthy adult participants (69 total participants who participated in some to all activity types). Actual activity type and duration were recorded by study personnel and compared with tracker data using descriptive statistics and mean absolute percent error (MAPE). Results: The proportion of trials in which the activity type was correctly identified was 93% to 97% (depending on the tracker) for treadmill walking, 93% to 100% for treadmill running, 36% to 62% for treadmill running when preceded and followed by a walk, 97% to 100% for outdoor walking, 100% for outdoor running, 3% to 97% for using an elliptical, 44% to 97% for biking, and 87.5% for swimming. When activities were correctly identified, the MAPE of the detected duration versus the actual activity duration was between 7% and 7.9% for treadmill walking, 8.7% and 144.8% for treadmill running, 23.6% and 28.9% for treadmill running when preceded and followed by a walk, 4.9% and 11.8% for outdoor walking, 5.6% and 9.6% for outdoor running, 9.7% and 13% for using an elliptical, 9.5% and 17.7% for biking, and was 26.9% for swimming. Conclusions: In a controlled setting, wearable activity trackers provide accurate recognition of the type of some common physical activities, especially outdoor walking and running and walking on a treadmill. The accuracy of measurement of activity duration varied considerably by activity type and tracker model and was poor for complex sets of activity, such as a run embedded within 2 walking segments.

  • Source: Max Pixel; Copyright: Max Pixel; URL:; License: Public Domain (CC0).

    Smartphones as Sleep Duration Sensors: Validation of the iSenseSleep Algorithm


    Background: Smartphones are becoming increasingly ubiquitous every day; they are becoming more assimilated into our everyday life, being the last thing used before going to sleep and the first one after waking up. This strong correlation between our lifestyle choices and smartphone interaction patterns enables us to use them as sensors for sleep duration assessment to understand individuals’ lifestyle and sleep patterns. Objectives: The objective of this study was to estimate sleep duration based on the analysis of the users’ ON-OFF interaction with their smartphone alone using the iSenseSleep algorithm. Methods: We used smartwatch sleep assessment data as the ground truth. Results were acquired with 14 different subjects collecting smartwatch and smartphone interaction data for up to 6 months each. Results: Results showed that based on the smartphone ON-OFF patterns, individual’s sleep duration can be estimated with an average error of 7% (24/343) [SD 4% (17/343)] min of the total duration), enabling an estimate of sleep start and wake-up times as well as sleep deprivation patterns. Conclusions: It is possible to estimate sleep duration patterns using only data related to smartphone screen interaction.

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

    A Smartphone Game to Prevent HIV Among Young Africans (Tumaini): Assessing Intervention and Study Acceptability Among Adolescents and Their Parents in a...


    Background: Young people aged 15 to 24 years account for one-third of new adult HIV infections. Controlling the HIV epidemic requires effective interventions targeted toward young people and their needs. Smartphone games offer a promising avenue for reaching this population with evidence-based HIV prevention interventions. It is crucial to the effectiveness of these interventions that they be acceptable and intrinsically motivating to adolescents as well as acceptable to their parents. Objective: Tumaini is a narrative-based smartphone game designed to help prevent HIV among young Africans aged 11 to 14 years by delaying first sex and increasing condom use at first sex. Following a 16-day feasibility study of Tumaini, we assessed the acceptability (1) of the intervention, where acceptability was operationalized as appeal, relevance, value, usability, and understandability, and (2) of this study and a planned future randomized controlled efficacy trial. Methods: During the randomized feasibility study (n=60) of Tumaini in western Kenya in spring 2017, 30 participants used the intervention on a study-provided smartphone. The app automatically logged participant interaction with the game in time-stamped log files. All 30 participants completed an Audio Computer-Assisted Self-Interview–based game experience survey, and 27 took part in 4 focus group discussions (FGDs) about the game’s appeal, relevance, value, usability, and understandability. Their parents (n=22) also participated in 4 FGDs about the acceptability of the intervention, of this study, and of a planned efficacy trial. Survey data were analyzed using SAS software (SAS Institute Inc); FGD transcripts were coded and analyzed in MAXQDA 12 (Verbi GmbH); and gameplay log files were analyzed using Microsoft Excel. Results: Adolescent participants’ survey responses indicated that Tumaini scored well with players on all indicators of acceptability (appeal, relevance, value, usability, and understandability). Focus group analyses aligned with these findings and emphasized a high degree of player engagement with the game, which was supported by log file analysis. Adolescent participants were eager for additional content, and parents were receptive to a longer study involving biomarkers, based on their positive experiences with this study. There is scope to improve communication with parents about their role in the intervention. As the game was tested in beta version, there is also scope to fine-tune some of the game mechanics to increase usability. Conclusions: This study shows the strong acceptability of an interactive smartphone-based game both to adolescents and their parents in western Kenya and that of the study methods used to pilot-test the intervention. It also suggests that longitudinal efficacy studies of this type of intervention, including those using biomarkers, have the potential to be acceptable among parents. Trial Registration: NCT03054051; (Archived by WebCite at

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

    A Focused Review of Smartphone Diet-Tracking Apps: Usability, Functionality, Coherence With Behavior Change Theory, and Comparative Validity of Nutrient...


    Background: Smartphone diet-tracking apps may help individuals lose weight, manage chronic conditions, and understand dietary patterns; however, the usabilities and functionalities of these apps have not been well studied. Objective: The aim of this study was to review the usability of current iPhone operating system (iOS) and Android diet-tracking apps, the degree to which app features align with behavior change constructs, and to assess variations between apps in nutrient coding. Methods: The top 7 diet-tracking apps were identified from the iOS iTunes and Android Play online stores, downloaded and used over a 2-week period. Each app was independently scored by researchers using the System Usability Scale (SUS), and features were compared with the domains in an integrated behavior change theory framework: the Theoretical Domains Framework. An estimated 3-day food diary was completed using each app, and food items were entered into the United States Department of Agriculture (USDA) Food Composition Databases to evaluate their differences in nutrient data against the USDA reference. Results: Of the apps that were reviewed, LifeSum had the highest average SUS score of 89.2, whereas MyDietCoach had the lowest SUS score of 46.7. Some variations in features were noted between Android and iOS versions of the same apps, mainly for MyDietCoach, which affected the SUS score. App features varied considerably, yet all of the apps had features consistent with Beliefs about Capabilities and thus have the potential to promote self-efficacy by helping individuals track their diet and progress toward goals. None of the apps allowed for tracking of emotional factors that may be associated with diet patterns. The presence of behavior change domain features tended to be weakly correlated with greater usability, with R2 ranging from 0 to .396. The exception to this was features related to the Reinforcement domain, which were correlated with less usability. Comparing the apps with the USDA reference for a 3-day diet, the average differences were 1.4% for calories, 1.0% for carbohydrates, 10.4% for protein, and −6.5% for fat. Conclusions: Almost all reviewed diet-tracking apps scored well with respect to usability, used a variety of behavior change constructs, and accurately coded calories and carbohydrates, allowing them to play a potential role in dietary intervention studies.

  • “Rhythm App” can continuously and automatically record use patterns and sleep times over long periods, and therefore can be utilized for sleep and health monitoring. Source: The Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Validation of the Mobile App–Recorded Circadian Rhythm by a Digital Footprint


    Background: Modern smartphone use is pervasive and could be an accessible method of evaluating the circadian rhythm and social jet lag via a mobile app. Objective: This study aimed to validate the app-recorded sleep time with daily self-reports by examining the consistency of total sleep time (TST), as well as the timing of sleep onset and wake time, and to validate the app-recorded circadian rhythm with the corresponding 30-day self-reported midpoint of sleep and the consistency of social jetlag. Methods: The mobile app, Rhythm, recorded parameters and these parameters were hypothesized to be used to infer a relative long-term pattern of the circadian rhythm. In total, 28 volunteers downloaded the app, and 30 days of automatically recorded data along with self-reported sleep measures were collected. Results: No significant difference was noted between app-recorded and self-reported midpoint of sleep time and between app-recorded and self-reported social jetlag. The overall correlation coefficient of app-recorded and self-reported midpoint of sleep time was .87. Conclusions: The circadian rhythm for 1 month, daily TST, and timing of sleep onset could be automatically calculated by the app and algorithm.

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

    Technical Guidance for Clinicians Interested in Partnering With Engineers in Mobile Health Development and Evaluation


    The explosion of mobile health (mHealth) interventions has prompted significant investment and exploration that has extended past industry into academia. Although research in this space is emerging, it focuses on the clinical and population level impact across different populations. To realize the full potential of mHealth, an intimate understanding of how mHealth is being used by patients and potential differences in usage between various demographic groups must also be prioritized. In this viewpoint, we use our experiences in building an mHealth intervention that incorporates an iOS app, Bluetooth-enabled blood pressure cuff, and Apple Watch to share knowledge on (1) how user interaction data can be tracked in the context of health care privacy laws, (2) what is required for effective, nuanced communication between clinicians and engineers to design mHealth interventions that are patient-centered and have high clinical impact, and (3) how to handle and set up a process to handle user interaction data efficiently.

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

    Using Smartphone-Based Psychoeducation to Reduce Postnatal Depression Among First-Time Mothers: Randomized Controlled Trial


    Background: Smartphone-based psychoeducation interventions may be a low-cost, user-friendly alternative to resource-consuming, face-to-face antenatal classes to educate expectant mothers. Objective: This study aimed to empirically examine whether such an intervention would lead to reduced postnatal depression, anxiety, or stress and result in a better health-related quality of life. Methods: A single-blind randomized controlled trial was conducted in Hong Kong. All first-time expectant mothers with less than 24 weeks of gestation remaining and attending the antenatal clinic at a public hospital were included. Participants were assigned to the intervention group or the control group by drawing lots. The lots, presented in sealed opaque envelopes, were randomly designated as “intervention” or “control” by stratified randomization. The intervention, a psychoeducational mobile app, was provided in addition to the treatment as usual (TAU) services from the hospital. Follow up with participants took place at 4 weeks postpartum. The primary outcome was the difference in the levels of antenatal and postnatal depression, assessed by the Edinburgh Postnatal Depression Scale (EPDS). The intention-to-treat approach was employed in the analyses. Results: The final sample was 660 expectant mothers (nintervention=330 and ncontrol=330). The mean difference in EPDS scores between the two groups was −0.65 (95% CI −1.29 to 0.00; P=.049) after adjusting for confounding factors. Associations were found between participation in the intervention and reduced depression, and attendance in TAU classes and increased stress levels. Conclusions: The smartphone-based intervention plus TAU services was effective in reducing postnatal depression at 4 weeks postpartum compared with a control condition of TAU only, making this a cost-effective alternative to TAU education for expectant mothers. Limitations of the study included the short postpartum period after which the follow-up assessment was conducted and the inclusion of first-time mothers rather than all mothers. Trial Registration: HKU Clinical Trials Registry HKUCTR-2024; 34f62a2f6d594273a290491827206384

  • mPCAT usability testing in Kenya. Source: Image created by Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Development and Implementation of a Mobile Phone–Based Prevention of Mother-To-Child Transmission of HIV Cascade Analysis Tool: Usability and Feasibility...


    Background: Prevention of mother-to-child HIV transmission (PMTCT) care cascade failures drive pediatric HIV infections in sub-Saharan Africa. As nurses’ clinical and management role in PMTCT expand, decision-support tools for nurses are needed to facilitate identification of cascade inefficiencies and solutions. The mobile phone–based PMTCT cascade analysis tool (mPCAT) provides health facility staff a quick summary of the number of patients and percentage drop-off at each step of the PMCTC care cascade, as well as how many women-infant pairs would be retained if a step was optimized. Objective: The objective of this study was to understand and improve the mPCAT’s core usability factors and assess the health workers’ experience with using the mPCAT. Methods: Overall, 2 rounds of usability testing were conducted with health workers from 4 clinics and leading experts in maternal and child health in Kenya and Mozambique using videotaped think aloud assessment techniques. Semistructured group interviews gauged the understanding of mPCAT’s core usability factors, based on the Nielsen Usability Framework, followed by development of cognitive demand tables describing the needed mPCAT updates. Post adaptation, feasibility was assessed in 3 high volume clinics over 12 weeks. Participants completed a 5-point Likert questionnaire designed to measure ease of use, convenience of integration into work, and future intention to use the mPCAT. Focus group discussions with nurse participants at each facility and in-depth interviews with nurse managers were also conducted to assess the acceptability, use, and recommendations for adaptations of the mPCAT. Results: Usability testing with software engineers enabled real-time feedback to build a tool following empathic design principles. The revised mPCAT had improved navigation and simplified data entry interface, with only 1 data entry field per page. Improvements to the results page included a data visualization feature and the ability to share results through WhatsApp. Coding was simplified to enable future revisions by nontechnical staff—critical for context-specific adaptations for scale-up. Health care workers and facility managers found the tool easy to use (mean=4.3), used the tool very often (mean=4.1), and definitely intended to continue to use the tool (mean=4.8). Ease of use was the most common theme identified, with emphasis on how the tool readily informed system improvement decision making. Conclusions: The mPCAT was well accepted by frontline health workers and facility managers. The collaborative process between software developer and user led to the development of a more user-friendly, context-specific tool that could be easily integrated into routine clinical practice and workflow. The mPCAT gave frontline health workers and facility managers an immediate, direct, and tangible way to use their clinical documentation and routinely reported data for decision making for their own clinical practice and facility-level improvements.

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  • The effects of human behavior on tick exposure and the risk of Lyme disease: evaluation of the use and user demographic of The Tick App.

    Date Submitted: May 20, 2019

    Open Peer Review Period: May 23, 2019 - Jul 18, 2019

    Background: Mobile health technologies (mHealth) provide a unique opportunity to share and gather information about health and disease. In the context of public health, mHealth is particularly suited...

    Background: Mobile health technologies (mHealth) provide a unique opportunity to share and gather information about health and disease. In the context of public health, mHealth is particularly suited for patient education, disease self-management, and remote monitoring of patients. mHealth also takes advantage of smartphone features to turn them into research tools, with the potential to reach a larger section of the population in a cost-effective manner compared to traditional epidemiological methods. However, although mHealth apps have been widely implemented in chronic diseases and psychology, their potential use for vector-borne diseases research has not been yet fully exploited. Objective: In this study, we report on the development and implementation of a smartphone application, The Tick App, which is the first tick research-focused app in the United States. Methods: We used an iterative mixed-methods approach, including qualitative and quantitative methods, to develop and evaluate the implementation of The Tick App. This app was designed as a survey tool to collect data on human behaviors and movements associated with tick exposure, while simultaneously raising awareness among the general public by engaging users in tick identification and reporting. It consists of an enrollment survey to identify general risk factors; daily surveys to collect data on human activities and tick encounters (“Tick Diaries”); a survey to enter the details of tick encounters coupled with tick identification services (“Report a Tick”); and educational material. Results: Between May and September 2018, 1468 adult users enrolled, and approximately half were recurring users of the app. They were equally represented in gender and age, peaking at 37 and 55 years old. Most users owned a pet, did frequent outdoor activities (occupational, recreational and/or peridomestic) and lived in the Midwest and Northeast regions, increasing significantly in counties with high Lyme incidence or with recent increase in the number of reported cases in low incidence counties. Recurring users had a similar demographic profile to all users but participated in outdoor activities more frequently. The number of active users peaked in June and July, consistent with Ixodes scapularis nymphal activity. Although the “Tick Diary” was the most frequently used feature, the median number of submissions per user was 2 (IQR=1–11), falling short of the target of 15. The number of “Tick Diaries” submitted per user was higher for older age groups and in the Midwest, while the number of tick reports increased with the frequency of outdoor activities. Conclusions: This assessment allowed us to identify what fraction of the population used The Tick App which would allow us for a better interpretation of the external validity of the findings derived from the app-collected data, as well as to tailor the design of potential future tick prevention interventions to the users’ characteristics.

  • The Our Whole Lives Platform for Patients with Chronic Pain: an Open clinical trial

    Date Submitted: May 20, 2019

    Open Peer Review Period: May 23, 2019 - Jul 18, 2019

    Background: Chronic pain affects millions of Americans. Our Whole Lives; an electronic health toolkit for Chronic Pain (OWLCP) is a mind body chronic pain management platform that teaches self-managem...

    Background: Chronic pain affects millions of Americans. Our Whole Lives; an electronic health toolkit for Chronic Pain (OWLCP) is a mind body chronic pain management platform that teaches self-management strategies to reduce pain impact and pain medication use. Objective: The primary goal of this study was to evaluate the feasibility of OWLCP in reducing pain impact and pain associated outcomes. Methods: We conducted a pre-post clinical study (2 cohorts) to assess the feasibility of OWLCP usage among low-income patients with chronic pain. Outcome data, collected at baseline and 9 weeks, included: Patient-Reported Outcomes Measurement Information System (PROMIS-29), pain self-efficacy, and pain medication use. In the statistical analysis, we used descriptive statistics, logistic regression, linear regression, and qualitative methods. Results: Among the enrolled Forty-three participants, the average age was 50 years old, 91% female, 37% black, and 16% Hispanic. From baseline to follow-up, the PROMIS measures showed a reduction in depression (p=.02), pain interference (p=.003), and average pain impact score (p=0.007). Pain self-efficacy increased (p=.0001), while opioid use had a 13% reduction (p=0.03). Conclusions: The e-health chronic pain management platform OWLCP is a potential tool to reduce the impact of chronic pain for underserved patients.

  • 1 Deadly Step – evaluation of a novel, community-based chronic disease prevention and management program for Aboriginal people in New South Wales, Australia

    Date Submitted: May 20, 2019

    Open Peer Review Period: May 23, 2019 - Jul 18, 2019

    Background: Chronic diseases account for over 70% of health gaps between Aboriginal people and the rest of the Australian population. 1 Deadly Step is a community-based program that uses a sporting pl...

    Background: Chronic diseases account for over 70% of health gaps between Aboriginal people and the rest of the Australian population. 1 Deadly Step is a community-based program that uses a sporting platform and cultural ambassadors to improve chronic disease prevention and management in New South Wales (NSW). Objective: To evaluate the feasibility and acceptability of a community based chronic disease screening program for Aboriginal people. Methods: In 2015 the program was enhanced to include an iPad application for screening assessments, a results portal for nominated care providers, and a reporting portal for program administrators and implemented in nine NSW community events. A mixed methods evaluation comprising survey data, analytics obtained from iPad and web portal usage and key informant interviews was conducted. Results: 1046 people were screened between April 2015 and April 2016 (mean age 40.3 years, 61.2% female, 91.5% Aboriginal or Torres Strait Islander). High chronic disease rates were observed (22.1% participants at high cardiovascular disease (CVD) risk, 16.5% with diabetes, 17.3% with albuminuria). A minority at high risk of CVD (42.9%) and with diabetes (42.2%) were meeting guideline-recommended management goals. 297 participants completed surveys (response rate 37%) with 85% reporting satisfaction with event organisation and information gained, and 6% experiencing problems with certain screening activities. Twenty-one interviews were conducted. A strong local working group and processes that harnessed community social networks were key to implementation success. Although software enhancements facilitated screening and data management, some technical difficulties impeded smooth processing of information. Only 51.4% of participants had medical review recorded post-event with wide inter-site variability (10.5% - 85.6%). Factors associated with successful follow-up included clinic managers with overall program responsibility and availability of medical staff for immediate discussion of results on event day. The program was considered resource intensive to implement. Support from a central coordinating body and integration with existing operational processes was essential. Conclusions: 1 Deadly Step offers an effective and acceptable strategy to engage Aboriginal communities in chronic disease screening. High rates of risk factors and management gaps were encountered, including people with no prior knowledge of these issues. Strategies to improve linkage to primary care could enhance the program’s impact in reducing chronic disease burden. Clinical Trial: N/A

  • A Patient-centric Passive System for Patients’ Status Checking: Usable Design and Case Study

    Date Submitted: May 22, 2019

    Open Peer Review Period: May 23, 2019 - May 29, 2019

    Background: A hospital is an unfamiliar place to patients because of its style, atmosphere, and procedures. These hospital characteristics cause patients to lose their way in hospitals and become conf...

    Background: A hospital is an unfamiliar place to patients because of its style, atmosphere, and procedures. These hospital characteristics cause patients to lose their way in hospitals and become confused about responding to protocols, which slows down the procedural flows. Some additional IT infrastructure facilities and human resources may be needed to solve these problems. However, this solution needs high investment and cannot guarantee an accuracy of information sent to patients. To handle this limitation, EasyHos have been developed to help patients recognize their status during their stay in a hospital using all existing infrastructure and hospital's data and without changing existing hospital's process. Objective: The objective of this study is to provide a design of the EasyHos system and the case study in hospitals in Thailand. The design is usable and repeatable for small and medium sized hospitals where internet infrastructure is in place. Methods: The EasyHos system has been designed based on existing infrastructure, hospital's data and hospital's process. The main components include mobile devices, existing hospital's data, wireless communication network. The EasyHos system was deployed to two small- and medium-sized hospitals in Thailand. The experimental process was focused on solving the problem of unfamiliarity in the hospital. The criteria and pretest conditions regarding the unfamiliarity problem have been defined before the experiment. Results: The results are presented in terms of criteria, pretest conditions, posttest conditions in the Hospitals. The posttest conditions amplify the experimental result and the impact of the system on users, such as hospital nurse/staff and patients. For example, the number of patients who asked nurses/hospital staff decreased 83.3% while nurses/hospital staff have 5 minutes more to do their routine work each day. Additionally, another impact is that hospitals can create new information values from existing data, which now can be visible and valuable to patients. Conclusions: The hospitals’ unfamiliarity problem has been reduced by the EasyHos system. The system has eased the nurses/hospital staff members and patients while they are working or waiting in the hospital. The nurses/hospital staff members would have more time to do their routine works. The hospital can easily setup the EasyHos system while the implementation cost is low or near zero.

  • Applications for self-monitoring of gestational diabetes mellitus in pregnancy; part of the improvement of connected health in Europe

    Date Submitted: May 1, 2019

    Open Peer Review Period: May 22, 2019 - Jul 17, 2019

    Background: The rapid development of mobile application technology and personalized medicine also in Europe, stimulate the self-monitoring. Self-monitoring allows the patient to actively participate i...

    Background: The rapid development of mobile application technology and personalized medicine also in Europe, stimulate the self-monitoring. Self-monitoring allows the patient to actively participate in the treatment process, with a positive impact on the result of the treatment. Mobile applications thus offer a new way to promote healthy behaviors, such as healthy diet, physical activity and measurement of blood glucose levels in the care for women with gestational diabetes. However, there are many factors, which make significant barriers preventing wide use of mobile applications in general medical praxis. Objective: The main aim of this study is to evaluate the most commonly used mobile apps used to manage gestational diabetes and compare them to each other. Methods: This paper presents a study, which investigates the mobile applications that can potentially support controlling of the blood sugar in pregnant women. After a broad overview of mobile applications on the Google Play Store and iTunes, we found 90 mobile applications that fit our keywords search terms and our inclusion criteria. Among these 90 applications, only 4 were designed for the management of gestational diabetes and not diabetes in general. All 4 were downloaded and analysed. Among the rest 86 applications that were designed to manage diabetes in general we downloaded, evaluated and compared to each other 5 applications with the highest download rate. Results: The characteristics of the most commonly used applications were described. Differentiations between useful mobile applications were investigated. Conclusions: Applications can provide support for women to act on a certain issue by themselves without visiting an obstetrician. Although most of the applications were very useful, we suggested improvements. The greatest policy concerns of connected health are quality, privacy and safety of the gathered data.

  • Impact of a smartphone app to increase vegetable consumption and variety in adults: a large-scale community cohort study

    Date Submitted: May 19, 2019

    Open Peer Review Period: May 22, 2019 - Jul 17, 2019

    Background: Large scale initiatives to improve diet quality through increased vegetable consumption have had small to moderate success. Digital technologies have features which are appealing for healt...

    Background: Large scale initiatives to improve diet quality through increased vegetable consumption have had small to moderate success. Digital technologies have features which are appealing for health-related behavior change interventions, and may overcome some of the limitations associated with traditional delivery approaches. Objective: This study describes the implementation and evaluation of a smartphone app, called VegEze, that aimed to increase vegetable intake among Australian adults. Methods: To better capture the impact of this app in a real world setting the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework was utilized. An uncontrolled, quantitative cohort study was conducted with evaluation conducted after 21 and 90 days of the program. The app was placed in the Apple® App Store® and accompanied by television, radio and social media promotion. Evaluation surveys were embedded into the app using ResearchKit®. The primary outcomes were vegetable intake (serves per day) and vegetable variety (types per day). Psychological variables (attitudes, intentions, self-efficacy and action planning) and app usage were also assessed. Descriptive statistics and multiple linear regression were used to describe the impact of the app on vegetable intake, and determine the user characteristics associated with increased intake. Results: Data were available from 5062 participants who completed the baseline survey, 1224 who completed the 21 day survey and 273 who completed the 90 day survey. The sample resided all around Australia, were mostly female (84.3%) with a mean age of 48.2 years (SD=14.1). The mean increase in intake was 0.48 serves, from 3.06 serves at baseline to 3.54 serves at the end of the 21 day challenge (t(1223)=8.71, P<.001). Variety of vegetables also increased by 0.35 types per day (t(1123)=9.59, P<.001). Participants with the highest app usage increased their vegetable intake by 0.63 (SD=2.02) serves per day compared to 0.32 (SD=1.69) for those with the lowest app usage. Based on multiple linear regression gender, age, BMI; psychological variables of self-efficacy, attitudes, intentions and action planning specific to vegetables; baseline vegetable intake and active days of app usage accounted for 23.3% of the variance associated with change in intake (F(9,1208)=42.09, P<.001). Baseline vegetable intake was the strongest predictor of change in intake (β=-0.495, P<.001), with lower baseline intake associated with greater change in intake. Self-efficacy (β=0.116, P<.001), action planning (β=0.066, P=.017), BMI (β=0.070, P=.009) and app usage (β=0.081, P=.002) were all significant predictors of change in intake. Conclusions: The VegEze app was able to shift intake by half a serve in a large sample of Australian adults. Testing the app in a real world setting and embedded the consent process allowed for greater reach, and efficient and robust evaluation. App usage was associated with successful behavior change, but further work to improve engagement is warranted. Clinical Trial: CSIRO Health and Medical Human Research Ethics Committee (CHM HREC) Low Risk Review Panel (Proposal #13/2017). Australian New Zealand Clinical Trials Registry (ACTRN12618000481279).