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Journal Description

JMIR mHealth and uHealth (JMU, ISSN 2291-5222; Impact Factor 4.301) is a sister journal of JMIR, the leading eHealth journal. JMIR mHealth and uHealth is indexed in PubMed, PubMed Central, Scopus, MEDLINE and Science Citation Index Expanded (SCIE), and in June 2019 received an Impact Factor of 4.301, which ranks the journal #2 (behind JMIR) 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: Image created by the Authors; Copyright: Mengting Zhu; URL:; License: Public Domain (CC0).

    Mediators of Intervention Effects on Depressive Symptoms Among People Living With HIV: Secondary Analysis of a Mobile Health Randomized Controlled Trial...


    Background: Although several studies have investigated the effects of mobile health (mHealth) interventions on depression among people living with HIV, few studies have explored mediators of mHealth-based interventions to improve mental health in people living with HIV. Identifying influential mediators may enhance and refine effective components of mHealth interventions to improve mental health of people living with HIV. Objective: This study aimed to examine mediating factors of the effects of a mHealth intervention, Run4Love, designed to reduce depression among people living with HIV using 4 time-point measurement data. Methods: This study used data from a randomized controlled trial of a mHealth intervention among people living with HIV with elevated depressive symptoms in Guangzhou, China. A total of 300 patients were assigned to receive either the mHealth intervention (n=150) or a waitlist control group (n=150) through computer-generated block randomization. Depressive symptoms, coping, and HIV-related stigma were measured at baseline, 3-, 6-, and 9-month follow-ups. The latent growth curve model was used to examine the effects of the intervention on depressive symptoms via potential mediators. Mediating effects were estimated using bias-corrected 95% bootstrapped CIs (BCIs) with resampling of 5000. Results: Enhanced positive coping and reduced HIV-related stigma served as effective treatment mediators in the mHealth intervention. Specially, there was a significant indirect effect of the mHealth intervention on the slope of depressive symptoms via the slope of positive coping (beta=–2.86; 95% BCI –4.78 to –0.94). The indirect effect of the mHealth intervention on the slope of depressive symptoms via the slope of HIV-related stigma was also statistically significant (beta=–1.71; 95% BCI –3.03 to –0.40). These findings indicated that enhancement of positive coping and reduction of HIV-related stigma were important mediating factors of the mHealth intervention in reducing depression among people living with HIV. Conclusions: This study revealed the underlying mediators of a mHealth intervention to reduce depression among people living with HIV using latent growth curve model and 4 time-point longitudinal measurement data. The study results underscored the importance of improving positive coping skills and mitigating HIV-related stigma in mHealth interventions to reduce depression among people living with HIV.

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

    Impact of a Mobile App–Based Health Coaching and Behavior Change Program on Participant Engagement and Weight Status of Overweight and Obese Children:...


    Background: Effective treatment of obesity in children and adolescents traditionally requires frequent in-person contact, and it is often limited by low participant engagement. Mobile health tools may offer alternative models that enhance participant engagement. Objective: The aim of this study was to assess child engagement over time, with a mobile app–based health coaching and behavior change program for weight management, and to examine the association between engagement and change in weight status. Methods: This was a retrospective cohort study of user data from Kurbo, a commercial program that provides weekly individual coaching via video chat and supports self-monitoring of health behaviors through a mobile app. Study participants included users of Kurbo between March 2015 and March 2017, who were 5 to 18 years old and who were overweight or obese (body mass index; BMI ≥ 85th percentile or ≥ 95th percentile) at baseline. The primary outcome, engagement, was defined as the total number of health coaching sessions received. The secondary outcome was change in weight status, defined as the change in BMI as a percentage of the 95th percentile (%BMIp95). Analyses of outcome measures were compared across three initial commitment period groups: 4 weeks, 12 to 16 weeks, or 24 weeks. Multivariable linear regression models were constructed to adjust outcomes for the independent variables of sex, age group (5-11 years, 12-14 years, and 15-18 years), and commitment period. A sensitivity analysis was conducted, excluding a subset of participants involuntarily assigned to the 12- to 16-week commitment period by an employer or health plan. Results: A total of 1120 participants were included in analyses. At baseline, participants had a mean age of 12 years (SD 2.5), mean BMI percentile of 96.6 (SD 3.1), mean %BMIp95 of 114.5 (SD 16.5), and they were predominantly female 68.04% (762/1120). Participant distribution across commitment periods was 26.07% (292/1120) for 4 weeks, 61.61% (690/1120) for 12-16 weeks, and 12.32% (138/1120) for 24 weeks. The median coaching sessions (interquartile range) received were 8 (3-16) for the 4-week group, 9 (5-12) for the 12- to 16-week group, and 19 (11-25) for the 24-week group (P<.001). Adjusted for sex and age group, participants in the 4- and 12-week groups participated in –8.03 (95% CI –10.19 to –5.87) and –9.34 (95% CI –11.31 to –7.39) fewer coaching sessions, compared with those in the 24-week group (P<.001). Adjusted for commitment period, sex, and age group, the overall mean change in %BMIp95 was –0.21 (95% CI –0.25 to –0.17) per additional coaching session (P<.001). Conclusions: Among overweight and obese children using a mobile app–based health coaching and behavior change program, increased engagement was associated with longer voluntary commitment periods, and increased number of coaching sessions was associated with decreased weight status.

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

    Exploring the Patterns of Use and Acceptability of Mobile Phones Among People Living With HIV to Improve Care and Treatment: Cross-Sectional Study in Three...


    Background: The use of mobile technology in health care (mobile health [mHealth]) could be an innovative way to improve health care, especially for increasing retention in HIV care and adherence to treatment. However, there is a scarcity of studies on mHealth among people living with HIV (PLHIV) in West and Central Africa. Objective: The aim of this study was to assess the acceptability of an mHealth intervention among PLHIV in three countries of West Africa. Methods: A cross-sectional study among PLHIV was conducted in 2017 in three francophone West African countries: Côte d’Ivoire, Burkina Faso, and Togo. PLHIV followed in the six preselected HIV treatment and care centers, completed a standardized questionnaire on mobile phone possession, acceptability of mobile phone for HIV care and treatment, preference of mobile phone services, and phone sharing. Descriptive statistics and logistic regression were used to describe variables and assess factors associated with mHealth acceptability. Results: A total of 1131 PLHIV—643 from Côte d’Ivoire, 239 from Togo, and 249 from Burkina Faso—participated in the study. Median age was 44 years, and 76.1% were women (n=861). Almost all participants owned a mobile phone (n=1107, 97.9%), and 12.6% (n=140) shared phones with a third party. Acceptability of mHealth was 98.8%, with the majority indicating their preference for both phone calls and text messages. Factors associated with mHealth acceptability were having a primary school education or no education (adjusted odds ratio=7.15, 95% CI 5.05-10.12; P<.001) and waiting over one hour before meeting a medical doctor on appointment day (adjusted odds ratio=1.84, 95% CI 1.30-2.62; P=.01). Conclusions: The use of mHealth in HIV treatment and care is highly acceptable among PLHIV and should be considered a viable tool to allow West and Central African countries to achieve the Joint United Nations Programme on HIV/AIDS 90-90-90 goals.

  • Source: Unsplash; Copyright: Michael Discenza; URL:; License: Licensed by JMIR.

    Making Sense of Negative Findings from Mobile Attention Bias Modification Interventions for Individuals with Addictive Disorders: Quantitative Feasibility Study


    Background: Advances in experimental psychology have led to a better understanding of unconscious, automatic processes that result in individuals relapsing into their substance-using habits. While some reviews have demonstrated the effectiveness of bias retraining of these unconscious biases, there have been other reviews that have highlighted that bias retraining is not always effective. Other studies have revealed there was no baseline biases among some participants. An examination of mobile bias retraining interventions has also revealed mixed results, with some reporting effectiveness and others null findings. A recent feasibility and acceptability study, done by the authors, revealed that 53% of participants have had no baseline biases and 21% of those with positive baseline biases did not have a positive change in magnitude following intervention. Objective: The aim of this paper was to explore potential variables (demographic and clinical) that could account for the negative baseline biases in the prior feasibility and acceptability study, and to discuss some of the factors that could account for the absence of baseline biases. We also explored potential reasons for why there was no reduction in the magnitude of attentional biases among individuals with baseline biases. Methods: Participants who were in the rehabilitation phase of their treatment were invited to participate. During the study they had to complete a set of baseline questionnaires, and on each day that they were on the ward they had to complete an attention bias assessment and modification task and rate their cravings using a visual analogue scale. Attention bias was deemed to be present if individuals had a positive score. Results: In our study, 53% (16/30) of individuals did not present with baseline attentional biases, and among those with positive baseline biases a total of 21% (3/14) of participants did not have a reduction in the overall magnitude of attentional biases. Chi-square analyses undertaken to compare the demographic characteristics of participants with and without baseline biases did not reveal any significant findings. However, with respect to clinical characteristics, those who had positive baseline biases had experimented with more substances. Conclusions: Our study is one of the first to have explored negative findings in attention bias modification interventions for individuals with addictive disorders. We postulate that several factors could account for the absence of baseline biases and there being no changes following bias retraining. Future research ought to take into consideration these factors.

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

    Evaluation of Heart Failure Apps to Promote Self-Care: Systematic App Search


    Background: Heart failure (HF) is a chronic disease that affects over 1% of Canadians and at least 26 million people worldwide. With the continued rise in disease prevalence and an aging population, HF-related costs are expected to create a significant economic burden. Many mobile health (mHealth) apps have been developed to help support patients’ self-care in the home setting, but it is unclear if they are suited to the needs or capabilities of older adults. Objective: This study aimed to identify HF apps and evaluate whether they met the criteria for optimal HF self-care. Methods: We conducted a systematic search of all apps available exclusively for HF self-care across Google Play and the App Store. We then evaluated the apps according to a list of 25 major functions pivotal to promoting HF self-care for older adults. Results: A total of 74 apps for HF self-care were identified, but only 21 apps were listed as being both HF and self-care specific. None of the apps had all 25 of the listed features for an adequate HF self-care app, and only 41% (31/74) apps had the key weight management feature present. HF Storylines received the highest functionality score (18/25, 72%). Conclusions: Our findings suggest that currently available apps are not adequate for use by older adults with HF. This highlights the need for mHealth apps to refine their development process so that user needs and capabilities are identified during the design stage to ensure the usability of the app.

  • Set up of the protocol test position to identify response time of the strikes. Source: Image created by the Authors; Copyright: Jader Sant' Ana; URL:; License: Creative Commons Attribution (CC-BY).

    Development of a Mobile Phone App for Measuring Striking Response Time in Combat Sports: Cross-Sectional Validation Study


    Background: TReaction is a mobile app developed to determine strike response time at low cost and with easy application in combat sports. However, the validity and accuracy of the response time obtained by the TReaction app has not yet been evaluated. Objective: This study aimed to test the validity and reliability of the TReaction app in measuring motor response time in combat sports. Methods: A total of two athletes performed 59 strikes to assess the response time upon visual stimulus using the TReaction app simultaneously with a high-speed camera. Accuracy of the measure was verified using a computer simulator programmed to discharge visual stimuli and obtain the response time. Pearson correlation, Student t test for dependent samples, and the Bland-Altman analysis were performed. Accuracy was verified using the intraclass correlation coefficient. Effect size (g) and the typical error of measurement (TEM) were calculated. The significance level was set at P<.05. Results: No significant difference (P=.56) was found between both systems. The methods presented a very strong correlation (r=0.993). The magnitude of differences was trivial (g<0.25), and TEM was 1.4%. These findings indicate a high accuracy between the computer screen and the mobile app measures to determine the beginning of the task and the response time. Conclusions: Our findings suggest that the TReaction app is a valid tool to evaluate the response time in combat sports athletes.

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

    Examining Mobile Technologies to Support Older Adults With Dementia Through the Lens of Personhood and Human Needs: Scoping Review


    Background: With the world’s rapidly growing older adult population, there is an increase in the number of people living with dementia. This growth leads to a strain on their caregivers and our health care system and to an increased attention on mitigating strain by using mobile technology to sustain the independence of people with dementia. However, less attention is given to whether these technologies meet the stated and unstated needs of people with dementia. Objective: The aim of this study was to provide an overview of the current research on mobile technologies for people with dementia, considering the current research through the lens of personhood and human needs, and to identify any gaps that represent research opportunities. Methods: We performed a systematic search in Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE), and the Cochrane Central Register of Controlled Trials (CENTRAL) in October 2018. We screened 5560 articles and identified 24 that met our inclusion and exclusion criteria. We then performed thematic analysis to organize the articles by the types of support mobile technologies provide and mapped those types of support to human needs to identify the gaps in support. Results: Articles described research on mobile technologies that support people with dementia to (1) perform daily activities, (2) maintain social interaction, (3) aid memory, (4) engage in leisure activities, (5) track location, and (6) monitor health. At least one type of support mapped to each human need, with most supporting lower-level needs such as physiological and safety needs. Little attention seems to be paid to personhood. Conclusions: Mobile technologies that support daily activities, relationships, memory, leisure activities, health, and safety can partially compensate for decreased function owing to dementia, but the human needs of people with dementia are often not adequately considered. Most technologies support basic physiological and safety needs, whereas many pay little attention to higher-level needs such as self-esteem and agency. Important research opportunities include using person-centered methods to develop technology to meet higher-level needs and to preserve personhood by incorporating human and psychological needs of people with dementia along with ethical considerations.

  • Source: Pixabay; Copyright: Confident Dental Care; URL:; License: Licensed by JMIR.

    An Interactive Parent-Targeted Text Messaging Intervention to Improve Oral Health in Children Attending Urban Pediatric Clinics: Feasibility Randomized...


    Background: Effective preventive treatments for dental decay exist, but caries experience among preschoolers has not changed, with marked disparities in untreated decay. Despite near-universal use of SMS text messaging, there are no studies using text messages to improve the oral health of vulnerable children. Objective: This randomized controlled feasibility trial aimed to test the effects of oral health text messages (OHT) versus a control (child wellness text messages or CWT). OHT was hypothesized to outperform CWT on improving pediatric oral health behaviors and parent attitudes. Methods: Parents with a child aged <7 years were recruited at urban clinics during pediatric appointments (79% [41/52] below poverty line; 66% [36/55] black) and randomized to OHT (text messages on brushing, dental visits, bottle and sippy cups, healthy eating and sugary beverages, and fluoride) or CWT (text messages on reading, safety, physical activity and development, secondhand smoke, and stress) groups. Automated text messages based on Social Cognitive Theory were sent twice each day for 8-weeks. Groups were equivalent on the basis of the number of text messages sent, personalization, interactivity, and opportunity to earn electronic badges and unlock animated characters. Assessments were conducted at baseline and 8 weeks later. Data were analyzed with linear mixed–effects models. Results: A total of 55 participants were randomized (28 OHT and 27 CWT). Only one participant dropped out during the text message program and 47 (24 OHT and 23 CWT) completed follow up surveys. Response rates exceeded 68.78% (1040/1512) and overall program satisfaction was high (OHT mean 6.3; CWT mean 6.2; 1-7 scale range). Of the OHT group participants, 84% (21/25) would recommend the program to others. Overall program likeability scores were high (OHT mean 5.90; CWT mean 6.0; 1-7 scale range). Participants reported high perceived impact of the OHT program on brushing their child’s teeth, motivation to address their child's oral health, and knowledge of their child's oral health needs (mean 4.7, 4.6, and 4.6, respectively; 1-5 scale range). At follow up, compared with CWT, OHT group participants were more likely to brush their children’s teeth twice per day (odds ratio [OR] 1.37, 95% CI 0.28-6.50) and demonstrated improved attitudes regarding the use of fluoride (OR 3.82, 95% CI 0.9-16.8) and toward getting regular dental checkups for their child (OR 4.68, 95% CI 0.24-91.4). There were modest, but not significant, changes in motivation (F1,53=0.60; P=.45) and self–efficacy (F1,53=0.24; P=.63) to engage in oral health behaviors, favoring OHT (d=0.28 and d=0.16 for motivation and self–efficacy, respectively). Conclusions: The OHT program demonstrated feasibility was well utilized and appealing to the target population and showed promise for efficacy.

  • Source:; Copyright: Jordan Rowland; URL:; License: Licensed by JMIR.

    Iterative Adaptation of a Maternal Nutrition Videos mHealth Intervention Across Countries Using Human-Centered Design: Qualitative Study


    Background: Mobile health (mHealth) video interventions are often transferred across settings. Although the outcomes of these transferred interventions are frequently published, the process of adapting such videos is less described, particularly within and across lower-income contexts. This study fills a gap in the literature by outlining experiences and priorities adapting a suite of South African maternal nutrition videos to the context of rural Burkina Faso. Objective: The objective of this study was to determine the key components in adapting a suite of maternal nutrition mHealth videos across settings. Methods: Guided by the principles of human-centered design, this qualitative study included 10 focus group discussions, 30 in-depth interviews, and 30 observations. We first used focus group discussions to capture insights on local nutrition and impressions of the original (South African) videos. After making rapid adjustments based on these focus group discussions, we used additional methods (focus group discussions, in-depth interviews, and observations) to identify challenges, essential video refinements, and preferences in terms of content delivery. All data were collected in French or Dioula, recorded, transcribed, and translated as necessary into French before being thematically coded by two authors. Results: We propose a 3-pronged Video Adaptation Framework that places the aim of video adaptation at the center of a triangle framed by end recipients, health workers, and the environment. End recipients (here, pregnant or lactating mothers) directed us to (1) align the appearance, priorities, and practices of the video’s protagonist to those of Burkinabe women; (2) be mindful of local realities whether economic, health-related, or educational; and (3) identify and routinely reiterate key points throughout videos and via reminder cards. Health workers (here, Community Health Workers and Mentor Mothers delivering the videos) guided us to (1) improve technology training, (2) simplify language and images, and (3) increase the frequency of their engagements with end recipients. In terms of the environment, respondents guided us to localize climate, vegetation, diction, and how foods are depicted. Conclusions: Design research provided valuable insights in terms of developing a framework for video adaptation across settings, which other interventionists and scholars can use to guide adaptations of similar interventions.

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

    The Use of Smartphone-Based Triage to Reduce the Rate of Outpatient Error Registration: Cross-Sectional Study


    Background: In many clinics, patients now have the option to make Web-based appointments but doing so according to their own judgment may lead to wrong registration and delayed medical services. We hypothesized that smartphone-based triage in outpatient services is superior to Web-based self-appointment registration guided by the medical staff. Objective: This study aimed to investigate smartphone-based triage in outpatient services compared with Web-based self-appointment registration and to provide a reference for improving outpatient care under appointment registration. Methods: The following parameters in Guangzhou Women and Children’s Medical Center were analyzed: wrong registration rate, the degree of patient satisfaction, outpatient visits 6 months before and after smartphone-based triage, queries after smartphone-based triage, number of successful registrations, inquiry content, and top 10 recommended diseases and top 10 recommended departments after queries. Results: Smartphone-based triage showed significant effects on average daily queries, which accounted for 16.15% (1956/12,112) to 29.46% (3643/12,366) of daily outpatient visits. The average daily successful registration after queries accounted for 56.14% (1101/1961) to 60.92% (1437/2359) of daily queries and 9.33% (1130/12,112) to 16.83% (2081/12,366) of daily outpatient visits. The wrong registration rate after smartphone-based triage was reduced from 0.68% (12,810/1,895,829) to 0.12% (2379/2,017,921) (P<.001), and the degree of patient satisfaction was improved. Monthly outpatient visits were increased by 0.98% (3192/325,710) to 13.09% (42,939/328,032) compared with the same period the preceding year (P=.02). Conclusions: Smartphone-based triage significantly reduces the wrong registration rate caused by patient Web-based appointment registration and improves the degree of patient satisfaction. Thus, it is worth promoting.

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

    A Model for Assessing Necessary Conditions for Rural Health Care’s Mobile Health Readiness: Qualitative Assessment of Clinician-Perceived Barriers


    Background: Mobile health (mHealth) technology dissemination has penetrated rural and urban areas alike. Yet, health care organization oversight and clinician adoption have not kept pace with patient use. mHealth could have a unique impact on health and quality of life for rural populations. If organizations are prepared to manage mHealth, clinicians may improve the quality of care for their patients, both rural and urban. However, many organizations are not yet prepared to prescribe or prohibit third-party mHealth technologies. Objective: This study explored organizational readiness for rural mHealth adoption, the use of patient-reported data by clinical care teams, and potential impact on improving rural health care delivery. Methods: Semistructured, open-ended interviews were used to investigate clinicians’ current practices, motivators, and perceived barriers to their use of mHealth technologies in rural settings. Results: A total of 13 clinicians were interviewed, and 53.8% (7/13) reported encouraging use of mHealth apps or wearable devices with rural patients. Perceived barriers to adoption were categorized into three primary themes: (1) personal (clinician), (2) patient, and (3) organizational. Organizational was most prominent, with subcodes of time, uniformity, and policy or direction. Thematic analysis revealed code-category linkages that identify the complex nature of a rural health care organization’s current climate from a clinician’s perspective. A thematic map was developed to visualize the flow from category to code. Identified linkages guided the development of a refined rural mHealth readiness model. Conclusions: Clinicians (including physicians) have limited time for continuing education, research, or exploration of emerging technologies. Clinicians are motivated to learn more, but they need guidance through organization-led directives. Rural health care institutions should consider investing in mHealth analysis, tool development, and formal recommendations of sanctioned tools for clinicians to use with patients.

  • Source: Unsplash; Copyright: Sara Kurfeß; URL:; License: Licensed by JMIR.

    Mental Health Apps in China: Analysis and Quality Assessment


    Background: Mental disorders have been a great burden on health care systems, affecting the quality of life of millions of people worldwide. Developing countries, including China, suffer from the double burden of both the increasing mental health issues in population and the deficiency in mental health care resources. The use of mobile health technologies, especially for mobile phone apps, can be a possible solution. Objective: This review aimed to describe the features and assess the quality of mental health apps in major mobile phone app markets in China and further discuss the priorities for mental health app development. Methods: Keywords including psychology, psychological health, psychological hygiene, psychological health service(s), mental, mental health, mental hygiene, mental health service(s), depression, and anxiety were searched in Chinese in 3 Android app markets (Baidu Mobile Assistant, Tencent MyApp, and 360 Mobile Assistant) and iOS App Store independently. Mental health apps were then selected according to established criteria for in-depth analysis and quality assessment by the Mobile App Rating Scale. Results: In total, 63 of 997 mental health apps were analyzed in depth, of which 78% (49/63) were developed by commercial entities for general population, 17% (11/63) were for patients or clients of specialized psychiatric hospitals or counseling agencies, 3% (2/63) were by government or local Centers for Disease Control and Prevention for general information, and 2% (1/63) for students of a university. Major built-in features of the apps included counseling services, mental health education, and self-assessment of mental health status by validated self-rating scales. The overall quality score of the MH apps was acceptable. Conclusions: Mental health apps are emerging in the area of mobile health in China. Popular mental health apps usually provide a synthetic platform organizing resources of information, knowledge, counseling services, self-tests, and management for the general population with mental health-related inquiries. The quality of the apps was rated as acceptable on average, suggesting some space for improvement. Official guidelines and regulations are urgently required for the field in the future.

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  • Mobile apps for health behaviour change in physical activity, diet, drug and alcohol use, and mental health: a systematic review

    Date Submitted: Nov 13, 2019

    Open Peer Review Period: Nov 13, 2019 - Nov 20, 2019

    Background: With a growing focus on patient interaction with health management, mobile apps are increasingly used to deliver behavioural health interventions. The large variation in these mobile healt...

    Background: With a growing focus on patient interaction with health management, mobile apps are increasingly used to deliver behavioural health interventions. The large variation in these mobile health apps - their target patient group, health behaviour, and behavioural change strategies - has resulted in a large but incohesive body of literature. Objective: The purpose of this systematic review was to assess the effectiveness of mobile apps at improving health behaviours and outcomes, and to examine the inclusion and effectiveness of Behaviour Change Techniques in mobile health apps. Methods: Medline, EMBASE, CINAHL, and Web of Science were systematically searched for articles published between 2014 and 2019 that evaluated mobile apps for health behaviour change. Two authors independently screened and selected studies according to the eligibility criteria. Data was extracted and risk of bias assessed by one reviewer and validated by a second reviewer. Results: 52 randomized controlled trials met the inclusion criteria and were included in analysis - 37 studies focused on physical activity, diet, or a combination of both, 11 on drug and alcohol use, and 4 on mental health. Participant perceptions were generally positive - only one app was rated as less helpful and satisfactory than the control - and the studies that measured engagement and usability found relatively high study completion rates (mean = 83.3%, n = 18) and ease of use ratings (3 significantly better than control, 9/15 rated >70%) . However, there was little evidence of changed behaviour or health outcomes. Conclusions: There was not strong evidence found to support the effectiveness of mobile apps at improving health behaviours or outcomes because few studies found significant differences between the app and control groups. Further research is needed to identify the behaviour change techniques that are most effective at promoting behaviour change. Improved reporting is necessary to accurately evaluate the mobile health app effectiveness and risk of bias.

  • Embodiment of Wearable Technology: A Qualitative Longitudinal Study

    Date Submitted: Nov 9, 2019

    Open Peer Review Period: Nov 9, 2019 - Jan 4, 2020

    Background: Current technology innovations such as wearables have caused surprising reactions and feelings of deep connection to the devices. Some researchers are calling mobile and wearable technolog...

    Background: Current technology innovations such as wearables have caused surprising reactions and feelings of deep connection to the devices. Some researchers are calling mobile and wearable technology a cognitive prosthesis, intrinsically connected to the individual as if it was part of the body, similar to a physical prosthesis. And while several studies have been done on the phenomenology of receiving and wearing a physical prosthesis, it is unknown whether similar subjective experiences arise with technology. Objective: In one of the first qualitative studies to track wearables in a longitudinal investigation; we explore whether a wearable can be embodied similarly to a physical prosthesis. We hoped to gain insight and compare the phases of embodiment (i.e.: initial adjustment to the prosthesis) but also the psychological responses (i.e.: accepting the prosthesis as part of their body) between wearables and limb prostheses. This approach allowed us to find out whether this pattern was part of a cyclical (i.e. periods of different usage intensity) or asymptotic (i.e. abandonment of the technology) pattern. Methods: We adapted a limb prosthesis methodological framework to be applied to wearables and conducted semi-structured interviews over a span of several months to assess if, how, and/or to what extent individuals come to embody wearables similarly to prosthetic devices. Twelve individuals wore fitness trackers for nine months, during which time interviews were conducted in three phases: after 3 months, after 6 months and at the end of the study after 9 months. A deductive thematic analysis based on Murray’s work was combined with an inductive approach in which new themes were discovered. Results: Overall the individuals experienced technology embodiment similarly to limb embodiment in terms of: adjustment, wearability, awareness, and body extension. Furthermore, we discovered two additional themes of engagement/reengagement and comparison to another device or person. Interestingly, many participants experienced a rarely reported phenomenon in longitudinal studies where the feedback from their device was counterintuitive to their own beliefs. This created a blurring of the self-perception and dilemma of ‘whom’ to believe, the machine or the self. Conclusions: There are many similarities between the embodiment of a limb prosthesis and a wearable. The large overlap between limb and wearable embodiment would suggest that insights from physical prostheses can be applied to wearables and vice versa. This is especially interesting as we are seeing the traditionally ‘dumb’ body prosthesis becoming smarter and thus a natural merging of technology and body. Participants experiencing a dilemma of whether to believe the device over their own instincts could imply evidence of technology reliance and decreased self-awareness.

  • SUpport for older adultS to STAy INdependent at home (SUSTAIN): a qualitative study for improving an online tool

    Date Submitted: Nov 8, 2019

    Open Peer Review Period: Nov 8, 2019 - Jan 3, 2020

    Background: Older adults desire to stay independent at home for as long as possible. We developed an interactive website that informed older adults and caregivers about ways to achieve this. In prepar...

    Background: Older adults desire to stay independent at home for as long as possible. We developed an interactive website that informed older adults and caregivers about ways to achieve this. In preparation for scaling up, the website needed modifying to better meet the needs of its target population. Objective: We aimed to consult potential end-users (older adults and caregivers) about how to improve the interactive website to better inform older adults and caregivers about ways to stay independent at home. Methods: We conducted a qualitative descriptive study. Using multiple recruitment strategies, we enrolled a purposeful sample of older adults 65+ and caregivers of older adults struggling to stay independent at home. Older adults were eligible to participate if they were 65+ years old and cognitively capable of indicating their informed consent to participate. Formal or informal caregivers were eligible if they cared for an older adult struggling to remain independent at home. Both older adults and caregivers had to be available to consult the existing website before the interview. We conducted face-to-face or telephone interviews, in either English or French, which were audio-recorded and transcribed verbatim. Interviews were thematically analyzed. We collected three kinds of information: sociodemographic characteristics, other characteristics of participants (e.g. health, digital profile, perception of retirement homes), and experience of the website (factors facilitating their use of the website, barriers to its use, and proposals for its improvement). Results: We recruited 15 participants, including 5 older adults and 10 caregivers from eastern Canada (n=9), western Canada (n=4) and France (n=2). Most older adults (n=9) were women, around 75 years old, educated, and living at home. Most caregivers were women (n=6), around 57 years old, highly educated (n=10), and informal caregivers (n=9) taking care of a parent (n=8). Overall, participants found the website easy to navigate using a computer, reassuring, and useful for getting information. However, participants found barriers related to navigation, relevance, realism, understandability, comprehensiveness and accessibility. Their proposals for improvement included: a needs assessment section to direct users to support appropriate to their needs; information relevant to moving into residential care; a section for caregivers; distinction between state-provided and private support services; simpler language; expansion of content to be relevant to all of Canada; and video subtitles for the hearing-impaired. Conclusions: Users provided a wealth of information on the needs of older adults facing loss of autonomy and on what such a website could usefully provide. The request for less generic and more personalized information reflects the wide range of needs that eHealth innovations such as this need to address. After integrating the changes suggested, a scalability assessment could be performed to prepare it for expansion to more regions.

  • Mobile Health Applications in Peru: Why is a regulatory framework necessary?

    Date Submitted: Oct 23, 2019

    Open Peer Review Period: Oct 21, 2019 - Dec 16, 2019

    Background: Mobile applications have assumed a leading role in all the daily activities we carry out, but their application in the field of health remains controversial. Although many benefits are rep...

    Background: Mobile applications have assumed a leading role in all the daily activities we carry out, but their application in the field of health remains controversial. Although many benefits are reported, the level of evidence is not enough and an uncontrolled creation has led to serious problems as information quality and violations of data privacy. Objective: To make a review of the mobile health Apps created and uploaded in Peru, and make an analysis of the national regulatory framework that could be applied, placing special emphasis on solving the questions about why regulation is necessary Methods: Three reviews were carried out. First, we review the mHealth applications created and uploaded in Peru in the last 5 years recovered from scientific publications, news, government communications and from the virtual stores. The second review was carried out taking a sample of the most used mHealth applications in the Peruvian territory and evaluating the possible risks in security, privacy, medical evidence and reference of the information provided. Finally, in the third review we search for Peruvian regulatory aspects related to e-health that involve information technology that could be applied. Results: Search queries up to May 2019 located 66 mHealth applications developed and published in Perú. Of those, most were for administrative purposes or to provide information. 47% belonged to government agencies and some applications created by different agencies had the same or similar functions. Furthermore, no evidence was found on its effectiveness, quality or safety parameters. When we analyzed the 10 most used mHealth applications in Peru (regardless of the country of creation), we found violations of data security and doubts about the quality of the information provided. 60% did not mention the origin of the information they provided or if they had a health staff in their development team. This is important for some crucial calculations, such as fertile days. There is no specific regulatory framework for the development or use of mobile health applications in Perú, however, in recent years the country has regulated various aspects related to electronic health as the Law on the protection of personal data, the Law on medical devices and administrative Directives on standards and criteria on health information systems. Conclusions: There is a need for regulation of mobile health applications in Peru. Currently, there are regulations that apply to other aspects related to eHealth, but that based on experiences from other countries, could somehow also cover mobile applications. It is necessary to promote research studies on the evaluation and use of applications in Peru, in order to establish benefits and associated risks to start the path towards a specific regulatory framework.

  • Development and usability of app-based self-administrable clinical tests of physical function

    Date Submitted: Oct 9, 2019

    Open Peer Review Period: Oct 4, 2019 - Nov 29, 2019

    Background: Objective measures of physical function in older adults are widely used to predict health outcomes such as disability, institutionalization, and mortality. App-based clinical tests allow u...

    Background: Objective measures of physical function in older adults are widely used to predict health outcomes such as disability, institutionalization, and mortality. App-based clinical tests allow users to assess their own physical function and have objective tracking of changes over time by use of their smartphones. We developed three smartphone apps with instrumented versions of the ‘Timed Up and Go’ (Self-TUG), ‘Standing tandem’ (Self-Tandem) and ‘Five times sit-to-stand’ (Self-STS), respectively. Results from these tests can potentially guide interventions remotely, and provide more detailed prognostic information about the participants’ physical performance for the users themselves and for therapists and other health care personnel. Objective: Develop and test the usability of three smartphone app-based self-tests of physical function using an iterative design. Methods: The apps were tested in three iterations; the first and second in a lab-setting, and the third in a separate home-based study. Participants were healthy adults between 60 to 80 years of age. Assessors observed while participants self-administered the tests without any guidance. Errors were recorded and usability problems defined. Problems were addressed in each subsequent iteration. Perceived usability in the home-based setting was assessed by use of the System Usability Scale (SUS), the User Experience Questionnaire (UEQ) and semistructured interviews. Results: Seven usability problems were identified in the first iteration, where 22% and 27.5% were able to correctly perform the Self-TUG and the Self-Tandem, respectively. In the second iteration, errors caused by the problems identified in the first iteration was drastically reduced, where 83.1% and 75.8% of the participants correctly performed the Self-TUG and Self-Tandem, respectively. A first version of Self-STS was also tested in this iteration, with a completion rate of 30.1%. For the third usability test, the seven usability problems initially identified were further improved. Testing the apps in a home-setting gave rise to some new usability problems, and for Self-TUG and Self-STS, the rate of correctly performed trials was slightly reduced from the second version, while for Self-Tandem it increased. Mean score on the SUS was 77.63 ± 16.1, and 80-95% of the participants reported the highest or second highest positive rating on all items in the UEQ. Conclusions: The study results suggest that the apps have the potential to be offered as a solution for self-testing of physical function in seniors in an non-supervised home-based setting. The participants reported a high degree of ease of use. Evaluating the usability in a home-setting allowed us to identify new usability problems that could affect the validity of the tests. These usability issues are not easily found in the lab-setting, indicating that if possible, app usability should be evaluated in both settings. Before being made available to end-users, the apps require further improvements and validation.

  • A pantheoretical framework to optimize adherence to healthy lifestyle behaviors and medication adherence: The use of personalized approaches to overcome barriers and optimize facilitators to achieve adherence

    Date Submitted: Sep 27, 2019

    Open Peer Review Period: Sep 27, 2019 - Nov 22, 2019

    Background: Poor adherence to primary prevention and management of chronic health conditions (such as lifestyle health behaviors and medications) has significant economic and health consequences, resu...

    Background: Poor adherence to primary prevention and management of chronic health conditions (such as lifestyle health behaviors and medications) has significant economic and health consequences, resulting in greater healthcare expenditures, multiple morbidities, and deaths. The burgeoning use of mobile technology to deliver health, lifestyle and wellness interventions has shown initial signs of improving adherence to primary prevention and management of chronic health conditions. However, the full potential of achieving optimized levels of adherence are thwarted by a wide range of sociodemographic, psychosocial, behavioral, and system-level barriers and the lack of a personalized medicine and a precision population health approach—approaches that understands disease and health and provides just-in-time, adaptive, and just-enough interventions based on biological/individual (e.g. genes, biomarkers, circadian profile), lifestyle/behavioral (diet, physical activity, sleep and stress management), and environmental/contextual (household, neighborhood, and cultural) factors. Objective: The purpose of this paper is to explore: 1) modifiable and non-modifiable barriers and facilitators of adherence to primary prevention and management of chronic health conditions, especially in mHealth solutions; 2) a personalized medicine and precision population health framework that overcomes barriers and accentuates facilitations to adherence in primary prevention and management solutions of chronic health conditions; and 3) how to implement a personalized medicine and precision population health approach in mHealth/digital health solutions. Methods: Through a careful review of the literature via several public databases such as PubMed and Google Scholar (years 2017-2019), we identified and describe key barriers and facilitators to adherence to primary prevention and management strategies in chronic health conditions. To overcome these challenges, we provide a novel mHealth solution steeped in precision and personalized population health and pantheoretical approach that increase the likelihood of adherence. We describe the stages of a pantheoretical approach focuses on tailoring, clustering/profiling, personalizing and optimizing interventions/strategies to obtain adherence and highlight minimal engineering needed to build such a solution. Results: Addressing modifiable determinants such as social support, health literacy, user motivation, emotional status, cognition (memory and information processing), and healthcare systems may provide better opportunities to effect behavior change and long-term adherence to health behaviors. We further argue that a mobile health solution may be a viable approach to address modifiable barriers and optimize adherence, while taking into consideration non-modifiable factors, which serve to tailor, cluster/profile, personalize and optimize interventions/strategies to obtain adherence, the pantheoretical approach. Conclusions: Although mHealth solutions can be ideal for successful achievement and maintenance of adherence behaviors, they can also exacerbate barriers and thus compromise adherence.