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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:

  • Mobile herbs (montage). Source: Pixabay; Copyright: kerdkanno; URL:; License: Licensed by JMIR.

    Social Media Users’ Perception of Telemedicine and mHealth in China: Exploratory Study


    Background: The use of telemedicine and mHealth has increased rapidly in the People’s Republic of China. While telemedicine and mHealth have great potential, wide adoption of this technology depends on how patients, health care providers, and other stakeholders in the Chinese health sector perceive and accept the technology. Objective: To explore this issue, we aimed to examine a social media platform with a dedicated focus on health information technology and informatics in China. Our goal is to utilize the findings to support further research. Methods: In this exploratory study, we selected a social media platform——to examine the perception of telemedicine and mHealth in China. We performed keyword analysis and analyzed the prevalence and term frequency–inverse document frequency of keywords in the selected social media platform; furthermore, we performed qualitative analysis. Results: We organized the most prominent 16 keywords from 571 threads into 8 themes: (1) Question versus Answer; (2) Hospital versus Clinic; (3) Market versus Company; (4) Doctor versus Nurse; (5) Family versus Patient; (6) iPad versus Tablet; (7) System versus App; and (8) Security versus Caregiving. Social media participants perceived not only significant opportunities associated with telemedicine and mHealth but also barriers to overcome to realize these opportunities. Conclusions: We identified interesting issues in this paper by studying a social media platform in China. Among other things, participants in the selected platform raised concerns about quality and costs associated with the provision of telemedicine and mHealth, despite the new technology’s great potential to address different issues in the Chinese health sector. The methods applied in this paper have some limitations, and the findings may not be generalizable. We have discussed directions for further research.

  • 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.

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    Open Peer Review Period: Sep 25, 2018 - Nov 20, 2018

    Background: Medication error reporting is one of the essential mechanisms to identify risky healthcare systems and practices that can lead to medication error. Unreported medication errors are real is...

    Background: Medication error reporting is one of the essential mechanisms to identify risky healthcare systems and practices that can lead to medication error. Unreported medication errors are real issue and one of the identified causes is burdensome medication error reporting system. Objective: The objective of this paper is to report usability testing of a mobile application(app) for reporting ME to report medication error anonymously. Methods: Quantitative and qualitative methods were employed involving 45 different testers (pharmacists, doctors and nurses) from a large tertiary hospital. Quantitative data was retrieved using task performance and rating of application and qualitative data was retrieved through focus group discussion (FGD). Three sessions, consisting of 15 testers each session; were conducted from January till March 2018. Results: Majority of testers were pharmacist 23/45 (51.1%), female 35/45 (77.8%) and mean age of testers were 36 [standard deviation (SD) 9]. A total of 135 complete reports were successfully submitted by the testers (3 reports per tester) and 88.9% of the reports were accurate. There was significant improvement in average System Usability Scale (SUS) in each sessions of development process (P<0.001) and average time to report medication error using the app not significantly different between each session (P=703) with an overall average time of 6.7 (SD=2.4). Testers found the app easy to use but doctors and nurses were unfamiliar with terms used especially medication process at which error occurred and type of error. Although, testers agreed that app can be used in the future for reporting but were apprehensive about security, validation and abuse of feedback featured in the app. Conclusions: Mobile application can be used to report medication error easily by various healthcare personnel and provide feedback on reporting. However, education on medication error reporting should be provide to doctors and nurses in Malaysia and security of app need to be established to boost reporting by this method. Clinical Trial: NMRR-15-1445-27125(IIR)

  • Effectiveness and feasibility of remote counselling by dietitians for overweight and obese adults: pilot study

    Date Submitted: Sep 21, 2018

    Open Peer Review Period: Sep 25, 2018 - Nov 20, 2018

    Background: To tackle the problem of obesity and related diseases in Switzerland cost-efficient, effective, innovative primary health care interventions for weight management are required. In this con...

    Background: To tackle the problem of obesity and related diseases in Switzerland cost-efficient, effective, innovative primary health care interventions for weight management are required. In this context Oviva has developed a scalable technology for dietitians to counsel overweight and obese patients via a smartphone-app. Objective: Evaluate the effectiveness and feasibility of dietitian’s weight loss counselling using a smartphone-app for patients with overweight/obesity. Methods: In this pre-post test pilot study, overweight and obese adults participated in a one-year behavioral intervention to lose weight through remote counselling by dietitians. The study started in April 2016 and finished in May 2018 in the German-speaking part of Switzerland. Participants received individual counselling through the app and the exchange with the dietitian had a focus on regular feedback on photo-based food-log, motivation and education. The contents were tailored the individual life style goal set. The pre-defined intensity of remote counselling decreased during the year. Group chat could be used. Following outcomes were examined: weight change (primary outcome), HBA1c; fasting glucose; fasting insulin, triglyceride, HDL-cholesterol, blood pressure, BMI, waist circumference, body fat, and by a self-administered questionnaire: physical activity, dietary assessment, health related quality of life. Changes are tested between the beginning and after 3 months / after 12 months as well as between the 3rd month and the 12th month. Results: 36 women and 7 men participated with a mean age of 40.6 years and 36 participants (30 completed the study. Results showed weight change in kilogram after the first 12 weeks (Phase I): median: -3.8kg (range -15, 2.4) p<.001; between week 12 and week 52 median -1.1kg (range -9.7, 7) p=.08 and throughout the entire intervention -4.9kg (range -21.9, 7.5) p<.001. Further the clinical parameters Body Mass Index, waist circumference, body fat, blood pressure also demonstrated significant positive results over one-year intervention. The analysis of the self-administered questionnaire showed less significant results. Certain eating habits showed positive significant effects (higher frequency of vegetable, fruit, breakfast consumption, lower frequency of alcohol, sweet, fat consumption). Conclusions: The present study has shown that in addition to the professional skills of RD a profession specific application like Oviva can provide effective support that meets the needs of the individual (registered dietitians and clients) on the long path of behavioral change and sustainable weight reduction. Clinical Trial: (NCT02694614)

  • Feasibility of Using Twitter to Detect Psychological Characteristics of Self-Identified Persons with Autism

    Date Submitted: Sep 24, 2018

    Open Peer Review Period: Sep 25, 2018 - Nov 20, 2018

    Background: More than 3.5 million Americans live with autism spectrum disorder (ASD). Major challenges persist in diagnosing ASD as no medical test to diagnose these disorders exist. Digital phenotypi...

    Background: More than 3.5 million Americans live with autism spectrum disorder (ASD). Major challenges persist in diagnosing ASD as no medical test to diagnose these disorders exist. Digital phenotyping holds promise to helping guide in the clinical diagnoses and screening of ASD. Objective: To explore the feasibility of using the online social media platform Twitter to detect psychological and behavioral characteristics of self-identified persons with autism. Methods: Data from Twitter was retrieved from 152 self-identified users with autism or ASD and 182 randomly selected control users from March 22, 2012 to July 20, 2017. A comparative textual analysis of tweets about repetitive and obsessive-compulsive behavioral characteristics typically associated with autism was conducted between groups. Common emotional characteristics of persons with autism such as fear, paranoia and anxiety were also examined between groups through textual analysis. Timing of tweets was compared between users with autism and control users to identify patterns in communication. Results: Users with autism/ASD posted a significantly higher frequency of tweets related to the specific repetitive behavior of counting compared to control users (P<.001). Textual analysis of obsessive-compulsive behavioral characteristics such as fixate, excessive, and concern were significantly higher among users with autism compared to the control group (P<.001). Emotional terms related to fear, paranoia and anxiety were also tweeted at a significantly higher rate among users with autism compared to control users (P<.001). Users with autism posted a smaller proportion of tweets during time intervals of 00:00–05:59 (P<.001), 06:00–11:59 (P<.001), and 18:00-23.59 (P<.001), and a greater proportion of tweets from 12:00-17:59 (P<.001) compared to control users. Conclusions: Social media may be a valuable resource for observing unique psychological characteristics of self-identified persons with autism. Collecting and analyzing data from these digital platforms may afford opportunities to identify characteristics of autism and assist in the diagnosis or verification of autism disorders. This study highlights the feasibility of leveraging digital data for gaining new insights about various health conditions.

  • 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.