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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:

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

    The Remote Food Photography Method and SmartIntake App for the Assessment of Alcohol Use in Young Adults: Feasibility Study and Comparison to Standard...


    Background: Heavy drinking is prevalent among young adults and may contribute to obesity. However, measurement tools for assessing caloric intake from alcohol are limited and rely on self-report, which is prone to bias. Objective: The purpose of our study was to conduct feasibility testing of the Remote Food Photography Method and the SmartIntake app to assess alcohol use in young adults. Aims consisted of (1) quantifying the ability of SmartIntake to capture drinking behavior, (2) assessing app usability with the Computer System Usability Questionnaire (CSUQ), (3) conducting a qualitative interview, and (4) comparing preference, usage, and alcohol use estimates (calories, grams per drinking episode) between SmartIntake and online diet recalls that participants completed for a parent study. Methods: College students (N=15) who endorsed a pattern of heavy drinking were recruited from a parent study. Participants used SmartIntake to send photographs of all alcohol and food intake over a 3-day period and then completed a follow-up interview and the CSUQ. CSUQ items range from 1-7, with lower scores indicating greater usability. Total drinking occasions were determined by adding the number of drinking occasions captured by SmartIntake plus the number of drinking occasions participants reported that they missed capturing. Usage was defined by the number of days participants provided food/beverage photos through the app, or the number of diet recalls completed. Results: SmartIntake captured 87% (13/15) of total reported drinking occasions. Participants rated the app as highly usable in the CSUQ (mean 2.28, SD 1.23). Most participants (14/15, 93%) preferred using SmartIntake versus recalls, and usage was significantly higher with SmartIntake than recalls (42/45, 93% vs 35/45, 78%; P=.04). Triple the number of participants submitted alcohol reports with SmartIntake compared to the recalls (SmartIntake 9/15, 60% vs recalls 3/15, 20%; P=.06), and 60% (9/15) of participants reported drinking during the study. Conclusions: SmartIntake was acceptable to college students who drank heavily and captured most drinking occasions. Participants had higher usage of SmartIntake compared to recalls, suggesting SmartIntake may be well suited to measuring alcohol consumption in young adults. However, 40% (6/15) did not drink during the brief testing period and, although findings are promising, a longer trial is needed.

  • Source: Pexels; Copyright: Fabian Hurnaus; URL:; License: Public Domain (CC0).

    Health and Fitness Apps for Hands-Free Voice-Activated Assistants: Content Analysis


    Background: Hands-free voice-activated assistants and their associated devices have recently gained popularity with the release of commercial products, including Amazon Alexa and Google Assistant. Voice-activated assistants have many potential use cases in healthcare including education, health tracking and monitoring, and assistance with locating health providers. However, little is known about the types of health and fitness apps available for voice-activated assistants as it is an emerging market. Objective: This review aimed to examine the characteristics of health and fitness apps for commercially available, hands-free voice-activated assistants, including Amazon Alexa and Google Assistant. Methods: Amazon Alexa Skills Store and Google Assistant app were searched to find voice-activated assistant apps designated by vendors as health and fitness apps. Information was extracted for each app including name, description, vendor, vendor rating, user reviews and ratings, cost, developer and security policies, and the ability to pair with a smartphone app and website and device. Using a codebook, two reviewers independently coded each app using the vendor’s descriptions and the app name into one or more health and fitness, intended age group, and target audience categories. A third reviewer adjudicated coding disagreements until consensus was reached. Descriptive statistics were used to summarize app characteristics. Results: Overall, 309 apps were reviewed; health education apps (87) were the most commonly occurring, followed by fitness and training (72), nutrition (33), brain training and games (31), and health monitoring (25). Diet and calorie tracking apps were infrequent. Apps were mostly targeted towards adults and general audiences with few specifically geared towards patients, caregivers, or medical professionals. Most apps were free to enable or use and 18.1% (56/309) could be paired with a smartphone app and website and device; 30.7% (95/309) of vendors provided privacy policies; and 22.3% (69/309) provided terms of use. The majority (36/42, 85.7%) of Amazon Alexa apps were rated by the vendor as mature or guidance suggested, which were geared towards adults only. When there was a user rating available, apps had a wide range of ratings from 1 to 5 stars with a mean of 2.97. Google Assistant apps did not have user reviews available, whereas most of Amazon Alexa apps had at least 1-9 reviews available. Conclusions: The emerging market of health and fitness apps for voice-activated assistants is still nascent and mainly focused on health education and fitness. Voice-activated assistant apps had a wide range of content areas but many published in the health and fitness categories did not actually have a clear health or fitness focus. This may, in part, be due to Amazon and Google policies, which place restrictions on the delivery of care or direct recording of health data. As in the mobile app market, the content and functionalities may evolve to meet growing demands for self-monitoring and disease management.

  • A new T1DM (type 1 diabetes mellitus) management mobile app. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Exploration of Users’ Perspectives and Needs and Design of a Type 1 Diabetes Management Mobile App: Mixed-Methods Study


    Background: With the popularity of mobile phones, mobile apps have great potential for the management of diabetes, but the effectiveness of current diabetes apps for type 1 diabetes mellitus (T1DM) is poor. No study has explored the reasons for this deficiency from the users’ perspective. Objective: The aims of this study were to explore the perspectives and needs of T1DM patients and diabetes experts concerning a diabetes app and to design a new T1DM management mobile app. Methods: A mixed-methods design combining quantitative surveys and qualitative interviews was used to explore users’ needs and perspectives. Experts were surveyed at 2 diabetes conferences using paper questionnaires. T1DM patients were surveyed using Sojump (Changsha ran Xing InfoTech Ltd) on a network. We conducted semistructured, in-depth interviews with adult T1DM patients or parents of child patients who had ever used diabetes apps. The interviews were audio-recorded, transcribed, and coded for theme identification. Results: The expert response rate was 63.5% (127/200). The respondents thought that the reasons for app invalidity were that patients did not continue using the app (76.4%, 97/127), little guidance was received from health care professionals (HCPs; 73.2%, 93/127), diabetes education knowledge was unsystematic (52.8%, 67/127), and the app functions were incomplete (44.1%, 56/127). A total of 245 T1DM patient questionnaires were collected, of which 21.2% (52/245) of the respondents had used diabetes apps. The reasons for their reluctance to use an app were limited time (39%, 20/52), complicated operations (25%, 13/52), uselessness (25%, 13/52), and cost (25%, 13/52). Both the experts and patients thought that the most important functions of the app were patient-doctor communication and the availability of a diabetes diary. Two themes that were useful for app design were identified from the interviews: (1) problems with patients’ diabetes self-management and (2) problems with current apps. In addition, needs and suggestions for a diabetes app were obtained. Patient-doctor communication, diabetes diary, diabetes education, and peer support were all considered important by the patients, which informed the development of a prototype multifunctional app. Conclusions: Patient-doctor communication is the most important function of a diabetes app. Apps should be integrated with HCPs rather than stand-alone. We advocate that doctors follow up with their patients using a diabetes app. Our user-centered method explored comprehensively and deeply why the effectiveness of current diabetes apps for T1DM was poor and what T1DM patients needed for a diabetes app and provided meaningful guidance for app design.

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

    The Effectiveness of Near-Field Communication Integrated with a Mobile Electronic Medical Record System: Emergency Department Simulation Study


    Background: Improved medical practice efficiency has been demonstrated by physicians using mobile device (mobile phones, tablets) electronic medical record (EMR) systems. However, the quantitative effects of these systems have not been adequately measured. Objective: This study aimed to determine the effectiveness of near-field communication (NFC) integrated with a mobile EMR system regarding physician turnaround time in a hospital emergency department (ED). Methods: A simulation study was performed in a hospital ED. Twenty-five physicians working in the ED participated in 2 scenarios, using either a mobile device or personal computer (PC). Scenario A involved randomly locating designated patients in the ED. Scenario B consisted of accessing laboratory results of an ED patient at the bedside. After completing the scenarios, participants responded to 10 questions that were scored using a system usability scale (SUS). The primary metric was the turnaround time for each scenario. The secondary metric was the usability of the system, graded by the study participants. Results: Locating patients from the ED entrance took a mean of 93.0 seconds (SD 34.4) using the mobile scenario. In contrast, it only required a mean of 57.3 seconds (SD 10.5) using the PC scenario (P<.001). Searching for laboratory results of the patients at the bedside required a mean of only 25.2 seconds (SD 5.3) with the mobile scenario, and a mean of 61.5 seconds (SD 11.6) using the PC scenario (P<.001). Sensitivity analysis comparing only the time for login and accessing the relevant information also determined mobile devices to be significantly faster. The mean SUS score of NFC-mobile EMR was 71.90 points. Conclusions: NFC integrated with mobile EMR provided for a more efficient physician practice with good usability.

  • Forensic pathologist wears Google Glass and takes pictures in a hands-free manner. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Licensed by JMIR.

    Assessment of Google Glass for Photographic Documentation in Veterinary Forensic Pathology: Usability Study


    Background: Google Glass is a head-mounted device designed in the shape of a pair of eyeglasses equipped with a 5.0-megapixel integrated camera and capable of taking pictures with simple voice commands. Objective: The objective of our study was to determine whether Google Glass is fit for veterinary forensic pathology purposes. Methods: A total of 44 forensic necropsies of 2 different species (22 dogs and 22 cats) were performed by 2 pathologists; each pathologist conducted 11 necropsies of each species and, for each photographic acquisition, the images were taken with a Google Glass device and a Nikon D3200 digital single-lens reflex (DSLR) camera. The pictures were collected, divided into 3 groups (based on the external appearance of the animal, organs, and anatomical details), and evaluated by 5 forensic pathologists using a 5-point score system. The parameters assessed were overall color settings, region of interest, sharpness, and brightness. To evaluate the difference in mean duration between necropsies conduced with Google Glass and DSLR camera and to assess the battery consumption of the devices, an additional number of 16 necropsies were performed by the 2 pathologists. In these cases, Google Glass was used for photographic reports in 8 cases (4 dogs and 4 cats) and a Nikon D3200 reflex camera in the other 8 cases. Statistical evaluations were performed to assess the differences in ratings between the quality of the images taken with both devices. Results: The images taken with Google Glass received significantly lower ratings than those acquired with reflex camera for all 4 assessed parameters (P<.001). In particular, for the pictures of Groups A and B taken with Google Glass, the sum of frequency of ratings 5 (very good) and 4 (good) was between 50% and 77% for all 4 assessed parameters. The lowest ratings were observed for the pictures of Group C, with a sum of frequency of ratings 5 and 4 of 21.1% (342/1602) for region of interest, 26% (421/1602) for sharpness, 35.5% (575/1602) for overall color settings, and 61.4% (995/1602) for brightness. Furthermore, we found a significant reduction in the mean execution time for necropsy conduced with the Google Glass with respect to the reflex group (P<.001). However, Google Glass drained the battery very quickly. Conclusions: These findings suggest that Google Glass is usable in veterinary forensic pathology. In particular, the image quality of Groups A and B seemed adequate for forensic photographic documentation purposes, although the quality was lower than that with the reflex camera. However, in this step of development, the high frequency of poor ratings observed for the pictures of Group C suggest that the device is not suitable for taking pictures of small anatomical details or close-ups of the injuries.

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

    Longitudinal Validity and Reliability of Brief Smartphone Self-Monitoring of Diet, Stress, and Physical Activity in a Diverse Sample of Mothers


    Background: Multiple strategies can be used when self-monitoring diet, physical activity, and perceived stress, but no gold standards are available. Although self-monitoring is a core element of self-management and behavior change, the success of mHealth behavioral tools depends on their validity and reliability, which lack evidence. African American and Latina mothers in the United States are high-priority populations for apps that can be used for self-monitoring of diet, physical activity, and stress because the body mass index (BMI) of mothers typically increases for several years after childbirth and the risks of obesity and its’ sequelae diseases are elevated among minority populations. Objective: To examine the intermethod reliability and concurrent validity of smartphone-based self-monitoring via ecological momentary assessments (EMAs) and use of daily diaries for diet, stress, and physical activity compared with brief recall measures, anthropometric biomeasures, and bloodspot biomarkers. Methods: A purposive sample (n=42) of primarily African American (16/42, 39%) and Latina (18/42, 44%) mothers was assigned Android smartphones for using Ohmage apps to self-monitor diet, perceived stress, and physical activity over 6 months. Participants were assessed at 3- and 6-month follow-ups. Recall measures included brief food frequency screeners, physical activity assessments adapted from the National Health and Nutrition Examination Survey, and the nine-item psychological stress measure. Anthropometric biomeasures included BMI, body fat, waist circumference, and blood pressure. Bloodspot assays for Epstein–Barr virus and C-reactive protein were used as systemic load and stress biomarkers. EMAs and daily diary questions assessed perceived quality and quantity of meals, perceived stress levels, and moderate, vigorous, and light physical activity. Units of analysis were follow-up assessments (n=29 to n=45 depending on the domain) of the participants (n=29 with sufficient data for analyses). Correlations, R2 statistics, and multivariate linear regressions were used to assess the strength of associations between variables. Results: Almost all participants (39/42, 93%) completed the study. Intermethod reliability between smartphone-based EMAs and diary reports and their corresponding recall reports was highest for stress and diet; correlations ranged from .27 to .52 (P<.05). However, it was unexpectedly low for physical activity; no significant associations were observed. Concurrent validity was demonstrated for diet EMAs and diary reports on systolic blood pressure (r=−.32), C-reactive protein level (r=−.34), and moderate and vigorous physical activity recalls (r=.35 to.48), suggesting a covariation between healthy diet and physical activity behaviors. EMAs and diary reports on stress were not associated with Epstein–Barr virus and C-reactive protein level. Diary reports on moderate and vigorous physical activity were negatively associated with BMI and body fat (r=−.35 to −.44, P<.05). Conclusions: Brief smartphone-based EMA use may be valid and reliable for long-term self-monitoring of diet, stress, and physical activity. Lack of intermethod reliability for physical activity measures is consistent with prior research, warranting more research on the efficacy of smartphone-based self-monitoring of self-management and behavior change support.

  • Carrot Rewards app (montage). Source: Carrot Rewards; Copyright: Carrot Rewards; URL:; License: Licensed by JMIR.

    Evaluating the Carrot Rewards App, a Population-Level Incentive-Based Intervention Promoting Step Counts Across Two Canadian Provinces: Quasi-Experimental Study


    Background: The Carrot Rewards app was developed as part of an innovative public-private partnership to reward Canadians with loyalty points, exchangeable for retail goods, travel rewards, and groceries for engaging in healthy behaviors such as walking. Objective: This study examined whether a multicomponent intervention including goal setting, graded tasks, biofeedback, and very small incentives tied to daily step goal achievement (assessed by built-in smartphone accelerometers) could increase physical activity in two Canadian provinces, British Columbia (BC) and Newfoundland and Labrador (NL). Methods: This 12-week, quasi-experimental (single group pre-post) study included 78,882 participants; 44.39% (35,014/78,882) enrolled in the Carrot Rewards “Steps” walking program during the recruitment period (June 13–July 10, 2016). During the 2-week baseline (or “run-in”) period, we calculated participants’ mean steps per day. Thereafter, participants earned incentives in the form of loyalty points (worth Can $0.04 ) every day they reached their personalized daily step goal (ie, baseline mean+1000 steps=first daily step goal level). Participants earned additional points (Can $0.40) for meeting their step goal 10+ nonconsecutive times in a 14-day period (called a “Step Up Challenge”). Participants could earn up to Can $5.00 during the 12-week evaluation period. Upon meeting the 10-day contingency, participants could increase their daily goal by 500 steps, aiming to gradually increase the daily step number by 3000. Only participants with ≥5 valid days (days with step counts: 1000-40,000) during the baseline period were included in the analysis (n=32,229).The primary study outcome was mean steps per day (by week), analyzed using linear mixed-effects models. Results: The mean age of 32,229 participants with valid baseline data was 33.7 (SD 11.6) years; 66.11% (21,306/32,229) were female. The mean daily step count at baseline was 6511.22. Over half of users (16,336/32,229, 50.69%) were categorized as “physically inactive,” accumulating <5000 daily steps at baseline. Results from mixed-effects models revealed statistically significant increases in mean daily step counts when comparing baseline with each study week (P<.001). Compared with baseline, participants walked 115.70 more steps (95% CI 74.59 to 156.81; P<.001) at study week 12. BC and NL users classified as “high engagers” (app engagement above sample median; 15,511/32,229, 48.13%) walked 738.70 (95% CI 673.81 to 803.54; P<.001) and 346.00 (95% CI 239.26 to 452.74; P<.001) more steps, respectively. Physically inactive, high engagers (7022/32,229, 21.08%) averaged an increase of 1224.66 steps per day (95% CI 1160.69 to 1288.63; P<.001). Effect sizes were modest. Conclusions: Providing very small but immediate rewards for personalized daily step goal achievement as part of a multicomponent intervention increased daily step counts on a population scale, especially for physically inactive individuals and individuals who engaged more with the walking program. Positive effects in both BC and NL provide evidence of replicability.

  • Patient recording Activities of Daily Living using the Your Activities of Daily Living app (montage). Source: The Authors /; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    An mHealth App for Self-Management of Chronic Lower Back Pain (Limbr): Pilot Study


    Background: Although mobile health (mHealth) interventions can help improve outcomes among patients with chronic lower back pain (CLBP), many available mHealth apps offer content that is not evidence based. Limbr was designed to enhance self-management of CLBP by packaging self-directed rehabilitation tutorial videos, visual self-report tools, remote health coach support, and activity tracking into a suite of mobile phone apps, including Your Activities of Daily Living, an image-based tool for quantifying pain-related disability. Objective: The aim is to (1) describe patient engagement with the Limbr program, (2) describe patient-perceived utility of the Limbr program, and (3) assess the validity of the Your Activities of Daily Living module for quantifying functional status among patients with CLBP. Methods: This was a single-arm trial utilizing a convenience sample of 93 adult patients with discogenic back pain who visited a single physiatrist from January 2016 to February 2017. Eligible patients were enrolled in 3-month physical therapy program and received the Limbr mobile phone app suite for iOS or Android. The program included three daily visual self-reports to assess pain, activity level, and medication/coping mechanisms; rehabilitation video tutorials; passive activity-level measurement; and chat-based health coaching. Patient characteristics, patient engagement, and perceived utility were analyzed descriptively. Associations between participant characteristics and program interaction were analyzed using multiple linear regression. Associations between Your Activities of Daily Living and Oswestry Disability Index (ODI) assessments were examined using Pearson correlation and hierarchical linear modeling. Results: A total of 93 participants were enrolled; of these, 35 (38%) completed the program (age: mean 46, SD 16 years; female: 22/35, 63%). More than half of completers finished assessments at least every 3 days and 70% (19/27) used the rehabilitation component at least once a week. Among respondents to a Web-based feedback survey, 76% (16/21) found the daily notifications helped them remember to complete their exercises, 81% (17/21) found the system easy to use, and 62% (13/21) rated their overall experience good or excellent. Baseline Your Activities of Daily Living score was a significant predictor of baseline ODI score, with ODI increasing by 0.30 units for every 1-unit increase in Your Activities of Daily Living (P<.001). Similarly, hierarchical linear modeling analysis indicated that Your Activities of Daily Living daily assessment scores were significant predictors of ODI scores over the course of the study (P=.01). Conclusions: Engagement among participants who completed the Limbr program was high, and program utility was rated positively by most respondents. Your Activities of Daily Living was significantly associated with ODI scores, supporting the validity of this novel tool. Future studies should assess the effect of Limbr on clinical outcomes, evaluate its use among a wider patient sample, and explore strategies for reducing attrition. Trial Registration: NCT03040310; (Archived by WebCite at

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

    Text Messaging Interventions for Improvement in Physical Activity and Sedentary Behavior in Youth: Systematic Review


    Background: The use of text messages (short message service, SMS) to change physical activity and sedentary behavior in youth is of interest due to the need for novel, more effective intervention approaches. Previous reviews have examined a variety of technology-based interventions and their impact on different health behaviors, but evidence regarding the impact of just SMS on physical activity and sedentary behavior is lacking. Objective: The aim of this study was to assess the effectiveness and use of theory of SMS interventions for improving physical activity and sedentary behavior in youth. Methods: Authors systematically searched electronic databases from March to November 2017. Citations were sifted using additional reviewers, and a qualitative synthesis of eligible studies was conducted using piloted data extraction forms. To be eligible for inclusion, studies had to be of a randomized controlled or quasi-experimental design, incorporate SMS, involve adolescents between the ages of 10 and 19 years, and assess at least one physical activity or sedentary behavior outcome. Risk of bias was assessed using the Cochrane Collaboration’s Risk of Bias tool. Results: A total of 13 studies reporting 11 interventions were included in the qualitative analysis. Studies included interventions that were conducted in schools, online, or face-to-face. Studies were of high heterogeneity with regard to study duration, participant characteristics, intervention content, and outcome measures. Findings were equivocal with regard to intervention effectiveness for physical activity and sedentary behavior. Overall, 7 interventions resulted in an improvement for physical activity and 6 for sedentary behavior. All studies were judged to be of high risk of bias for at least 1 item. Conclusions: Some studies in this review showed promising results for using SMS to improve physical activity and sedentary behavior in youth. High heterogeneity of design and outcome measures precluded data pooling and conclusions as to which specific intervention elements are linked to increased effectiveness cannot be drawn. The authors propose incorporating the following elements in future studies: specific focus on desired health behavior; mixed-methods design; include long-term follow-up; include self-monitoring, goal setting, and feedback; combine SMS with a mobile app; and send 3 or more SMS text messages per week. More rigorous studies are needed to explore the relationship between intervention effectiveness and specific intervention components such as content and delivery.

  • The PARADE app collects rheumatoid arthritis symptoms from patients’ own phones (montage). Source: The Authors /; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Using a ResearchKit Smartphone App to Collect Rheumatoid Arthritis Symptoms From Real-World Participants: Feasibility Study


    Background: Using smartphones to enroll, obtain consent, and gather self-reported data from patients has the potential to enhance our understanding of disease burden and quantify physiological impact in the real world. It may also be possible to harness integral smartphone sensors to facilitate remote collection of clinically relevant data. Objective: We conducted the Patient Rheumatoid Arthritis Data From the Real World (PARADE) observational study using a customized ResearchKit app with a bring-your-own-device approach. Our objective was to assess the feasibility of using an entirely digital approach (social media and smartphone app) to conduct a real-world observational study of patients with rheumatoid arthritis. Methods: We conducted this observational study using a customized ResearchKit app with a bring-your-own-device approach. To recruit patients, the PARADE app, designed to guide patients through a series of tasks, was publicized via social media platforms and made available for patients in the United States to download from the Apple App Store. We collected patient-reported data, such as medical history, rheumatoid arthritis-related medications (past and present), and a range of patient-reported outcome measures. We included in the assessment a joint-pain map and a novel objective assessment of wrist range of movement, measured by the smartphone-embedded gyroscope and accelerometer. Results: Within 1 month of recruitment via social media campaigns, 399 participants self-enrolled, self-consented, and provided complete demographic data. Joint pain was the most frequently reported rheumatoid arthritis symptom to bother study participants (344/393, 87.5%). Severe patient-reported wrist pain appeared to be inversely linked with the range of wrist movement measured objectively by the app. At study entry, 292 of 399 participants (73.2%) indicated a preference for participating in a mobile app–based study. The number of participants in the study declined to 45 of 399 (11.3%) at week 12. Conclusions: Despite the declining number of participants over time, the combination of social media and smartphone app with sensor integration was a feasible and cost-effective approach for the collection of patient-reported data in rheumatoid arthritis. Integral sensors within smartphones can be harnessed to provide novel end points, and the novel wrist range of movement test warrants further clinical validation.

  • The InDEx app. Source: Image created by the Authors; Copyright: Daniel Leightley; URL:; License: Public Domain (CC0).

    A Smartphone App and Personalized Text Messaging Framework (InDEx) to Monitor and Reduce Alcohol Use in Ex-Serving Personnel: Development and Feasibility Study


    Background: Self-reported alcohol misuse remains high in armed forces personnel even after they have left service. More than 50% of ex-serving personnel meet the criteria for hazardous alcohol use; however, many fail to acknowledge that they have a problem. Previous research indicates that interventions delivered via smartphone apps are suitable in promoting self-monitoring of alcohol use, have a broad reach, and may be more cost-effective than other types of brief interventions. There is currently no such intervention specifically designed for the armed forces. Objective: This study sought to describe the development of a tailored smartphone app and personalized text messaging (short message service, SMS) framework and to test the usability and feasibility (measured and reported as user engagement) of this app in a hard-to-engage ex-serving population. Methods: App development used Agile methodology (an incremental, iterative approach used in software development) and was informed by behavior change theory, participant feedback, and focus groups. Participants were recruited between May 2017 and June 2017 from an existing United Kingdom longitudinal military health and well-being cohort study, prescreened for eligibility, and directed to download either Android or iOS versions of the ”Information about Drinking for Ex-serving personnel” (InDEx) app. Through the app, participants were asked to record alcohol consumption, complete a range of self-report measures, and set goals using implementation intentions (if-then plans). Alongside the app, participants received daily automated personalized text messages (SMS) corresponding to specific behavior change techniques with content informed by the health action process approach with the intended purpose of promoting the use of the drinks diary, suggesting alternative behaviors, and providing feedback on goals setting. Results: Invitations to take part in the study were sent to ex-serving personnel, 22.6% (31/137) of whom accepted and downloaded the app. Participants opened the InDEx app a median of 15.0 (interquartile range [IQR] 8.5-19.0) times during the 4 week period (28 days), received an average of 36.1 (SD 3.2) text messages (SMS), consumed alcohol on a median of 13.0 (IQR 11.0-15.0) days, and consumed a median of 5.6 (IQR 3.3-11.8) units per drinking day in the first week, which decreased to 4.7 (IQR 2.0-6.9) units by the last week and remained active for 4.0 (IQR 3.0-4.0) weeks. Conclusions: Personnel engaged and used the app regularly as demonstrated by the number of initializations, interactions, and time spent using InDEx. Future research is needed to evaluate the engagement with and efficacy of InDEx for the reduction of alcohol consumption and binge drinking in an armed forces population.

  • mSMART app (composite). Source: The Authors / Placeit; Copyright: Intelligent Automation, Incorporated; URL:; License: Licensed by JMIR.

    Smartphone-Based Contingency Management Intervention to Improve Pre-Exposure Prophylaxis Adherence: Pilot Trial


    Background: Pre-exposure prophylaxis (PrEP) provides a strong preventative benefit to individuals at risk for HIV. While PrEP adherence is highly correlated with its efficacy, adherence rates are variable both across and within persons. Objective: The objective of this study was to develop and pilot-test a smartphone-based intervention, known as mSMART, that targets PrEP adherence. mSMART provides contingency management in the form of monetary incentives for daily PrEP adherence based on a real-time adherence assessment using a camera-based medication event-monitoring tool as well as medication reminders, PrEP education, individualized behavioral strategies to address PrEP adherence barriers, and medication adherence feedback. Methods: This was a 4-week open-label, phase I trial in a community sample of young men who have sex with men already on PrEP (N=10). Results: Although adherence composite scores corresponding to PrEP biomarkers indicated that 90% (9/10) of the sample already had an acceptable baseline adherence in the protective range, by the end of the 4-week period, the scores improved for 30% (3/10) of the sample—adherence did not worsen for any participants. Participants reported mean PrEP adherence rates of 91% via daily entries in mSMART. At the end of the 4-week period, participants indicated acceptable ratings of satisfaction, usability, and willingness to recommend mSMART to others. There were no technical difficulties associated with smartphone compatibility, user misunderstandings about mSMART features that interfered with daily use, or study attrition. Conclusions: This study is the first to apply contingency management to PrEP adherence. Findings indicated that mSMART is feasible and acceptable. Such an adherence intervention administered via a user-friendly smartphone app can allow for widespread dissemination. Future efficacy trials are needed. Trial Registration: NCT02895893; (Accessed by Webcite at

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  • Investigating the Adoption of Mobile Health Services by Elderly Users from A Trust Transfer Perspective

    Date Submitted: Sep 20, 2018

    Open Peer Review Period: Sep 24, 2018 - Nov 19, 2018

    Background: Although elderly users comprise a major user group in the field of mHealth services, their adoption rate of mobile health services is relatively low compared to their use of offline health...

    Background: Although elderly users comprise a major user group in the field of mHealth services, their adoption rate of mobile health services is relatively low compared to their use of offline health services. Increasing the adoption rate of mHealth services among elderly users is considered beneficial to aging in place. Objective: Drawing upon the trust transfer theory, this study investigated declining physiological conditions and support from hospitals in an integrated framework to explain elderly users’ intentions to use mHealth services and empirically examine the trust transfer mechanism. Methods: A survey comprising 395 elderly users was conducted to validate our research model and hypotheses. Results: The results revealed that: (1) trust in offline health services positively influences trust in mHealth services; (2) declining physiological conditions strengthen the effect of trust in offline health services regarding trust in mHealth services; and (3) support from hospitals weakens the effect of trust in mHealth services on the intention to use. Conclusions: We concluded that the trust transfer mechanism is a viable means of building initial trust in mHealth services. In addition, declining physiological conditions and support from hospitals are important for investigating mHealth services adoption among elderly users.

  • A randomized controlled trial comparing the efficiency of a tailored smoking cessation intervention delivered by mobile text messaging versus email

    Date Submitted: Sep 20, 2018

    Open Peer Review Period: Sep 24, 2018 - Nov 19, 2018

    Background: A challenge for Internet-based smoking cessation interventions have been high dropout rates. Objective: To assess the efficiency of an Internet-based tailored smoking cessation interventio...

    Background: A challenge for Internet-based smoking cessation interventions have been high dropout rates. Objective: To assess the efficiency of an Internet-based tailored smoking cessation intervention delivered by mobile phone text messages versus emails, in a real-world setting. Methods: An automated Randomized Controlled Trial of a multi component Norwegian Internet-based tailored smoking cessation intervention was conducted from May 2010-until October 2012. The RCT compared two different tailored message delivery formats. The participants were 4335 smokers, 16 years and older, recruited through an open, free governmental Internet site in Norway. We compared the text message (n=2188) with the email (n=2147) arm, using an intention-to-treat analysis. The main outome(s) were 7-days self-reported point-prevalence abstinence at 6 months post cessation. Results: The response rate was higher in the text message arm at 1 month (33.3% versus 29.8 %, P=.02) and at 3 months (25.8% versus 22.8%, P=.03). At 6 months there was no statistically significant difference in response rate P=.07. At 1 month, the reported quit rate was 19.1% in the text message - and 19.0 % in the email arm (OR 1.01; 95% CI’s .86-1.18) and at 6 months 11.5% in the text message and 11% in the email arm (OR 1.05; 95% CI’s .86-1.30). Conclusions: This large fully automated Randomized Controlled Trial shows, that 1 in 9 enrolled participants reported to have quit smoking at 6 months post cessation in both arms. Our study suggests that smoking cessation interventions delivered by mobile text messaging and emails may be equally successful at a population level. Clinical Trial: NCT011030427

  • A qualitative study to understand what patients want in a that helps them prepare for their colonoscopy appointments

    Date Submitted: Sep 17, 2018

    Open Peer Review Period: Sep 22, 2018 - Nov 17, 2018

    Background: Up to 11% of patients scheduled for colonoscopy do not keep their appointments and up to 33% of those attending their appointments have inadequately cleansed bowels that can lead to poor v...

    Background: Up to 11% of patients scheduled for colonoscopy do not keep their appointments and up to 33% of those attending their appointments have inadequately cleansed bowels that can lead to poor visualization of the colon and missed pathology. A smartphone application may be acceptable and far-reaching in improving patient adherence in the context of colonoscopy. Objective: To guide the development of colonAPPscopy, a smartphone application that supports colonoscopy attendance and preparation, we conducted focus groups to better understand user preferences for its content and features. Methods: Patients who had undergone outpatient colonoscopy in the prior 3 months and were aged 50-75, English- or French-speaking, and without inflammatory bowel disease or colorectal cancer participated in a focus group discussion at the McGill University Health Centre (Montreal, Canada). Discussions were 60-90 minutes, conducted by a trained facilitator using a standardized approach and audiotaped for analysis using the constant comparative approach. Participants discussed mobile health support tools they might use to help them carry out the colonoscopy, the informational content needed to support appointment adherence and bowel preparation, and the features that would make the mobile application easy to use. Results: Nine patients (2 women, 7 men) participated in 2 focus groups. Most participants accessed the internet for information related to colonoscopy and other health-related topics, but found some of the information not trustworthy, exaggerated and fear-inducing. Content areas identified for colonAPPscopy included: 1) instructions for the bowel preparation (laxative, diet, clear liquids), 2) medication restrictions, 3) appointment logistics, 4) communication with endoscopy staff, and 5) what to expect post-colonoscopy. Features for colonAPPscopy included: 1) reminders and alerts, 2) minimization of data input and 3) visual aids. The ability to tailor the smartphone application made it preferable to both paper and online instructions. Conclusions: Focus group participants identified novel content and features that had not been included in previous smartphone applications designed to support patient preparation for colonoscopy. These findings recognize the importance of including users in the development phase of building a smartphone application.

  • How CDCs can use WeChat official accounts for better health information dissemination in China: an analysis of factors affecting user engagement

    Date Submitted: Sep 19, 2018

    Open Peer Review Period: Sep 22, 2018 - Nov 17, 2018

    Background: Smart phones and mobile applications (apps) have become new channels and tools for information acquisition and exchange. In China, with the growing popularity of WeChat and WeChat official...

    Background: Smart phones and mobile applications (apps) have become new channels and tools for information acquisition and exchange. In China, with the growing popularity of WeChat and WeChat official accounts (WOAs), health promotion agencies have an opportunity to use them for successful information distribution and diffusion online. Objective: We aimed to explore the features frames of articles “pushed” by WOAs of Chinese provincial CDCs and to identify features that are associated with user engagement. Methods: We searched and subscribed to 28 WOAs of provincial CDCs, and considered all the articles that they pushed from January 1 to December 31, 2017 as research objects. We developed a features frame for each article and used a pre-designed questionnaire to record information on each article. Descriptive statistics were generated for six article features, and the Kruskal–Wallis test was used to compare the amount of reading and liking for each feature category. Two-category univariate logistic regression and multivariable logistic regression were conducted to explore associations between the features of the articles and user engagement, operationalized as reading level and liking level. Results: All provincial CDC WOAs provided a total of 5,976 articles in 2017. The median amount of reading was 551.5 and the median amount of liking was 10. For the amounts of reading and liking, there were statistically significant differences among the categories of six article features; the P values were all less than 0.001. Multivariable logistic regression analysis revealed that article content, article type, communication skills, the number of marketing elements, and article length were associated with reading level and liking level. However, title type was only associated with liking level. Conclusions: How social media can be used to best achieve health information dissemination and public health outcomes is a topic of much discussion and study in the public health community. Given the lack of related studies based on WeChat or official accounts, we conducted this study and found that article content, article type, communication skills, the number of marketing elements, article length and title type were associated with user engagement. Our study may provide public health and community leaders with insight into the diffusion of important health topics of concern.

  • Using a call centre to support self-administration of mifepristone and misoprostol in Bangladesh: a harm reduction approach

    Date Submitted: Sep 17, 2018

    Open Peer Review Period: Sep 21, 2018 - Nov 16, 2018

    Background: Annually there are approximately 25 million unsafe abortions, and this remains a leading cause of morbidity and maternal mortality. In settings where abortion is restricted, women are incr...

    Background: Annually there are approximately 25 million unsafe abortions, and this remains a leading cause of morbidity and maternal mortality. In settings where abortion is restricted, women are increasingly able to self-manage abortions by purchasing abortion medications such as misoprostol and mifepristone from pharmacies or other drug sellers. Better availability of these drugs has been shown to be associated with reductions in complications from unsafe abortion. In Bangladesh abortion is restricted; however menstrual regulation (MR) was introduced in the 1970s as an interim method of preventing pregnancy. Pharmacy provision of medications for MR is widespread, but customers purchasing these drugs often do not have access to quality information on dosage and complications, which means a higher risk of side effects and complications developing. In 2010, Marie Stopes Bangladesh (MSB) established a call centre to reduce potential harm from self-administration of MR medications. The call centre number was advertised widely in pharmacies and on MR product packaging. Objective: This study aimed to assess call centre use over time and how this changed when a new MR product (combined mifepristone-misoprostol) was introduced to the market and started to advertise the call centre number in November 2014. Methods: We conducted a secondary analysis of routine data collected by call centre workers between July 2012-August 2016. We investigated reported types of caller, call reason and reported usage of MR products, before and after November 2014. We used interrupted time series analysis (ITS) to formally assess levels of change in caller characteristics and reason for calling. Results: Over the 4-year period 287,095 calls about MR were received and the numbers of users steadily increased over time. The most common callers were MR-users (23.5%), their husbands (23.0%), pharmacy workers (22.9%) and village doctors (19.5%). Most MR calls were about misoprostol (75.0%), but after November 2014 a growing proportion were about the mifepristone-misoprostol regimen. The most common reasons for calling were to obtain information about regimen (72.7%), side effects (72.5%), and to report side effects (17.4%). The ITS analyses showed that after November 2014, an increasing number of calls were from MR-users who had taken the complete regimen (P=0.023), who were calling to discuss reported side effects (P=0.006) and pain medication (P=0.013), and there were fewer calls asking about dosages (P<0.001). Conclusions: The high call volume suggests that this call centre intervention addressed an unmet demand for information about MR medications from both MR users and healthcare providers. Call centre interventions may improve the quality of information available to MR-users, by providing information directly, as well as to drug sellers, and thus helping to reduce harm from self-medication of MR drugs.

  • The Digital Education to LImit Salt in the Home (DELISH) Program improved salt-related knowledge, attitudes and behaviors in parents

    Date Submitted: Sep 17, 2018

    Open Peer Review Period: Sep 21, 2018 - Nov 16, 2018

    Background: Currently, Australian children and adults are eating too much salt, increasing their risk of cardiovascular-related conditions. Web-based programs provide an avenue to engage the parents o...

    Background: Currently, Australian children and adults are eating too much salt, increasing their risk of cardiovascular-related conditions. Web-based programs provide an avenue to engage the parents of primary schoolchildren in salt-specific messages which may positively impact on their own salt-related knowledge, attitudes and behaviors (KABs). Objective: The aim of this study was to determine whether parent’s salt-related KABs improved following participation in the Digital Education to LImit Salt in the Home (DELISH) web-based education program. Methods: The DELISH program was a 5-week home delivered web-based intervention targeting schoolchildren aged 7-10 years and their parents. This was a single arm study with a pre- and post-test design. Parents received weekly online educational newsletters and text messages. A study website hosted additional resources. Parents completed online pre- and post-program surveys assessing salt-related KABs. Upon completion of the program, all parents were also invited to complete an online evaluation survey. Changes in KABs outcomes were assessed using McNemar’s tests and paired t-tests. Results: Eighty parents commenced the program and 73 parents (mean age 41.0 (7.0) (SD) years, 86% females) completed both pre and post surveys. Overall, mean score for salt-related knowledge improved (+3.6±.41 (SE) points), mean behavior score also improved (+4.5±.61 points), indicating a higher frequency of engaging in behaviors to reduce salt in the diet and mean attitudes score decreased (-0.7±.19 points) representing lower importance of using salt to enhance the taste of food (all P<.001). Following participation, the proportion of parents aware of the daily salt intake recommendation increased from 40% to 74% (P<.001) and awareness of bread as the main source of salt increased from 58% to 95% (P<.001). The proportion of parents who agreed that salt should be used in cooking to enhance the flavor of food decreased from 30% to 11% (P=.002) and the proportion who agreed that sodium information displayed on food labels was difficult to understand decreased from 52% to 32% (P=.009). There was a reduction in the proportion of parents who reported adding salt during cooking (55% vs. 41%, P=.03) and at the table (32% vs. 18%, P=.002). Of the 16 parents who completed the evaluation survey, most parents (75%) enjoyed the program and all found the newsletters to be useful. Almost all parents (94%) agreed that the DELISH education program would be useful to other parents. Conclusions: The improvement in salt-related knowledge, attitudes and reported behaviors in the DELISH program indicates the potential for online technology, to effectively disseminate simple salt reduction education messages to families with primary school aged children. Future work should explore opportunities to integrate the program within the school setting to enable wider dissemination.