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

    Enhanced Patient Education for Colonic Polyp and Adenoma Detection: Meta-Analysis of Randomized Controlled Trials


    Background: To improve patients’ comprehension of bowel preparation instructions before colonoscopy, enhanced patient education (EPE) such as cartoon pictures or other visual aids, phone calls, mobile apps, multimedia education and social media apps have been proposed. However, it is uncertain whether EPE can increase the detection rate of colonic polyps and adenomas. Objective: This meta-analysis aimed to evaluate the efficacy of EPE in detecting colonic polyps and adenomas. Methods: We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from their inception to June 2019 for the identification of trials comparing the EPE with standard patient education for outpatients undergoing colonoscopy. We used a random effects model to calculate summary estimates of the polyp detection rate (defined as the number of patients with at least one polyp divided by the total number of patients undergoing selective colonoscopy), adenoma detection rate (defined as the number of patients with at least one adenoma divided by the total number of patients undergoing selective colonoscopy), advanced adenoma detection rate (defined as the number of patients with at least one advanced adenoma divided by the total number of patients undergoing selective colonoscopy), sessile serrated adenoma detection rate (defined as the number of patients with at least one sessile serrated adenoma divided by the total number of patients undergoing selective colonoscopy), cancer detection rate (defined as the number of patients with at least one cancer divided by the total number of patients undergoing selective colonoscopy), or adenoma detection rate - plus (defined as the number of additional adenomas found after the first adenoma per colonoscopy). Moreover, we conducted trial sequential analysis (TSA) to determine the robustness of summary estimates of all primary outcomes. Results: We included 10 randomized controlled trials enrolling 4560 participants for analysis. The meta-analysis suggested that EPE was associated with an increased polyp detection rate (9 trials; 3781 participants; risk ratio [RR] 1.19, 95% CI 1.05-1.35; P<.05; I2=42%) and adenoma detection rate (5 trials; 2133 participants; RR 1.37, 95% CI 1.15-1.64; P<.001; I2=0%), which were established by TSA. Pooled result from the inverse-variance model illustrated an increase in the sessile serrated adenoma detection rate (3 trials; 1248 participants; odds ratio 1.76, 95% CI 1.22-2.53; P<.05; I2=0%). One trial suggested an increase in the adenoma detection rate - plus (RR 4.39, 95% CI 2.91-6.61; P<.001). Pooled estimates from 3 (1649 participants) and 2 trials (1375 participants) generated no evidence of statistical difference for the advanced adenoma detection rate and cancer detection rate, respectively. Conclusions: The current evidence indicates that EPE should be recommended to instruct bowel preparation in patients undergoing colonoscopy because it can increase the polyp detection rate, adenoma detection rate, and sessile serrated adenoma detection rate. However, further trials are warranted to determine the efficacy of EPE for advanced adenoma detection rate, adenoma detection rate - plus, and cancer detection rate because of limited data.

  • App prescription stand used in the study. Source: Image created by the authors; Copyright: Oyungerel Byambasuren; URL:; License: Creative Commons Attribution (CC-BY).

    mHealth App Prescription in Australian General Practice: Pre-Post Study


    Background: Evidence of effectiveness of mobile health (mHealth) apps as well as their usability as non-drug interventions in primary care are emerging around the globe. Objective: This study aimed to explore the feasibility of mHealth app prescription by general practitioners (GPs) and to evaluate the effectiveness of an implementation intervention to increase app prescription. Methods: A single-group, before-and-after study was conducted in Australian general practice. GPs were given prescription pads for 6 mHealth apps and reported the number of prescriptions dispensed for 4 months. After the reporting of month 2, a 2-minute video of one of the apps was randomly selected and sent to each GP. Data were collected through a prestudy questionnaire, monthly electronic reporting, and end-of-study interviews. The primary outcome was the number of app prescriptions (total, monthly, per GP, and per GP per fortnight). Secondary outcomes included confidence in prescribing apps (0-5 scale), the impact of the intervention video on subsequent prescription numbers, and acceptability of the interventions. Results: Of 40 GPs recruited, 39 commenced, and 36 completed the study. In total, 1324 app prescriptions were dispensed over 4 months. The median number of apps prescribed per GP was 30 (range 6-111 apps). The median number of apps prescribed per GP per fortnight increased from the pre-study level of 1.7 to 4.1. Confidence about prescribing apps doubled from a mean of 2 (not so confident) to 4 (very confident). App videos did not affect subsequent prescription rates substantially. Post-study interviews revealed that the intervention was highly acceptable. Conclusions: mHealth app prescription in general practice is feasible, and our implementation intervention was effective in increasing app prescription. GPs need more tailored education and training on the value of mHealth apps and knowledge of prescribable apps to be able to successfully change their prescribing habits to include apps. The future of sustainable and scalable app prescription requires a trustworthy electronic app repository of prescribable mHealth apps for GPs.

  • Examples of apps downloaded for content analysis. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Limitations of Existing Dialysis Diet Apps in Promoting User Engagement and Patient Self-Management: Quantitative Content Analysis Study


    Background: With the unprecedented growth of mobile technology, a plethora of dialysis diet apps have been developed to promote patient dietary self-management. Nevertheless, the utility of such apps remains questionable. Objective: This study aimed to evaluate the content, features, and quality of commercial dialysis diet apps for adult dialysis patients. Methods: This study consisted of a quantitative content analysis of commercial dialysis diet apps downloaded from Google Play and the Apple App Store available in the Asian marketplace, searched for using the following keywords in English: dialysis diet and diet for kidney disease. Free and paid apps available in English that provide nutrition information for adult dialysis patients were included. Apps that were not relevant to the dialysis diet, not meant for patient self-management, or redundant were excluded. Apps were evaluated for language medium (subscore=1), credibility (subscore=1), food database (subscore=1), valuable features (subscore=12), health-behavior theory constructs (subscore=60), and technical quality (subscore=25). The relationships among the variables of interest were determined by Pearson correlation. Stepwise multiple linear regression analysis was performed to identify the features that contribute to greater technical quality of dialysis diet apps. Statistical significance was defined as P<.05. Results: A total of 22 out of 253 apps (8.7%) were eligible for evaluation. Based on a 100-point scale, the mean overall score of the apps was 31.30 (SD 14.28). Only 5% (1/22) of the apps offered relevant language options, and 46% (10/22) contained food databases. In addition, 54% (12/22) of the apps were not credible. The mean score for valuable features was 3.45 (SD 1.63) out of 12, in which general education (16/22, 73%), free download (15/22, 68%), and usability (13/22, 59%) were the three most popular features. However, the apps scored a mean of 13.41 (SD 11.56) out of 60 for health-behavior theory constructs. The overall app technical quality was considered poor, with a mean score of 2.70 (SD 0.41) out of 5. The scores of valuable features (r=.65, P=.001) and health-behavior theory constructs (r=.55, P=.009) were positively correlated with the overall technical quality of the commercial dialysis diet apps. Features such as free download (β=.43, P=.03) and usability (β=.41, P=.03) could significantly determine the functional quality of the apps. Health-behavior theory constructs such as self-monitoring could significantly predict both the subjective quality (β=.55, P=.008) and the engagement quality (β=.66, P=.001) of the apps, whereas the information quality domain could be determined by plan or orders (β=.48, P=.007) and knowledge (β=.45, P=.01). Conclusions: Although most of the available commercial dialysis diet apps are free and easy to use, they are subject to theory deficiency, limited language options, and a lack of food databases, credibility, tailored education, and overall technical quality.

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

    The Ubiquitous Cognitive Assessment Tool for Smartwatches: Design, Implementation, and Evaluation Study


    Background: Cognitive functioning plays a significant role in individuals’ mental health, since fluctuations in memory, attention, and executive functions influence their daily task performance. Existing digital cognitive assessment tools cannot be administered in the wild and their test sets are not brief enough to capture frequent fluctuations throughout the day. The ubiquitous availability of mobile and wearable devices may allow their incorporation into a suitable platform for real-world cognitive assessment. Objective: The aims of this study were threefold: (1) to evaluate a smartwatch-based tool for the assessment of cognitive performance, (2) to investigate the usability of this tool, and (3) to understand participants’ perceptions regarding the application of a smartwatch in cognitive assessment. Methods: We built the Ubiquitous Cognitive Assessment Tool (UbiCAT) on a smartwatch-based platform. UbiCAT implements three cognitive tests—an Arrow test, a Letter test, and a Color test—adapted from the two-choice reaction-time, N-back, and Stroop tests, respectively. These tests were designed together with domain experts. We evaluated the UbiCAT test measures against standard computer-based tests with 21 healthy adults by applying statistical analyses significant at the 95% level. Usability testing for each UbiCAT app was performed using the Mobile App Rating Scale (MARS) questionnaire. The NASA-TLX (Task Load Index) questionnaire was used to measure cognitive workload during the N-back test. Participants rated perceived discomfort of wearing a smartwatch during the tests using a 7-point Likert scale. Upon finishing the experiment, an interview was conducted with each participant. The interviews were transcribed and semantic analysis was performed to group the findings. Results: Pearson correlation analysis between the total correct responses obtained from the UbiCAT and the computer-based tests revealed a significant strong correlation (r=.78, P<.001). One-way analysis of variance (ANOVA) showed a significant effect of the N-back difficulty level on the participants' performance measures. The study also demonstrated usability ratings above 4 out of 5 in terms of aesthetics, functionality, and information. Low discomfort (<3 out of 7) was reported by our participants after using the UbiCAT. Seven themes were extracted from the transcripts of the interviews conducted with our participants. Conclusions: UbiCAT is a smartwatch-based tool that assesses three key cognitive domains. Usability ratings showed that participants were engaged with the UbiCAT tests and did not feel any discomfort. The majority of the participants were interested in using the UbiCAT, although some preferred computer-based tests, which might be due to the widespread use of personal computers. The UbiCAT can be administered in the wild with mentally ill patients to assess their attention, working memory, and executive function.

  • Source: Pexels; Copyright: Andrea Piacquadio; URL:; License: Licensed by JMIR.

    Mobile Apps for Mental Health Issues: Meta-Review of Meta-Analyses


    Background: Mental health apps have great potential to help people needing support to cope with distress or specific symptoms. In fact, there is an exponential increase in the number of mental health apps available on the internet, with less than 5% being actually studied. Objective: This study aimed to assess the quality of the available evidence regarding the use of mental health apps and to summarize the results obtained so far. Methods: Systematic reviews and meta-analyses were searched, specifically for mobile apps on mental health issues or symptoms, and rated using the Grading of Recommendations Assessment, Development and Evaluation system. Results: A total of 7 meta-analyses were carefully reviewed and rated. Although some meta-analyses looked at any mental health issue and analyzed the data together, these studies were of poorer quality and did not offer strong empirical support for the apps. Studies focusing specifically on anxiety symptoms or depressive symptoms were of moderate to high quality and generally had small to medium effect sizes. Similarly, the effects of apps on stress and quality of life tended to offer small to medium effects and were of moderate to high quality. Studies looking at stand-alone apps had smaller effect sizes but better empirical quality than studies looking at apps with guidance. The studies that included follow-ups mostly found a sustained impact of the app at an 11-week follow-up. Conclusions: This meta-review revealed that apps for anxiety and depression hold great promise with clear clinical advantages, either as stand-alone self-management or as adjunctive treatments. More meta-analyses and more quality studies are needed to recommend apps for other mental health issues or for specific populations.

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

    A Mobile Phone–Based Sexual and Reproductive Health Intervention for Female Sex Workers in Kenya: Development and Qualitative Study


    Background: Female sex workers (FSWs) have high rates of both unintended pregnancy and HIV, but few health promotion interventions address their contraceptive needs or other sexual and reproductive health and rights (SRHR) concerns. A broader approach integrates contraceptive promotion with HIV and sexually transmitted infection (STI) prevention and management, alcohol awareness, gender-based violence and rights, and health care utilization. The Women’s Health Intervention using SMS for Preventing Pregnancy (WHISPER) mobile phone intervention uses a participatory development approach and behavior change theory to address these high-priority concerns of FSWs in Mombasa, Kenya. Objective: This paper aimed to (1) describe the process of development of the WHISPER intervention, its theoretical framework, key content domains and strategies and (2) explore workshop participants’ responses to the proposed intervention, particularly with regard to message content, behavior change constructs, and feasibility and acceptability. Methods: The research team worked closely with FSWs in two phases of intervention development. First, we drafted content for three different types of messages based on a review of the literature and behavior change theories. Second, we piloted the intervention by conducting six workshops with 42 FSWs to test and refine message content and 12 interviews to assess the technical performance of the intervention. Workshop data were thematically analyzed using a mixed deductive and inductive approach. Results: The intervention framework specified six SRHR domains that were viewed as highly relevant by FSWs. Reactions to intervention content revealed that social cognitive strategies to improve knowledge, outcome expectations, skills, and self-efficacy resonated well with workshop participants. Participants found the content empowering, and most said they would share the messages with others. The refined intervention was a 12-month SMS program consisting of informational and motivational messages, role model stories portraying behavior change among FSWs, and on-demand contraceptive information. Conclusions: Our results highlight the need for health promotion interventions that incorporate broader components of SRHR, not only HIV prevention. Using a theory-based, participatory approach, we developed a digital health intervention that reflects the complex reality of FSWs’ lives and provides a feasible, acceptable approach for addressing SRHR concerns and needs. FSWs may benefit from health promotion interventions that provide relevant, actionable, and engaging content to support behavior change.

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

    Mobile Phone–Based Behavioral Interventions in Pregnancy to Promote Maternal and Fetal Health in High-Income Countries: Systematic Review


    Background: Chronic diseases have recently had an increasing effect on maternal-fetal health, especially in high-income countries. However, there remains a lack of discussion regarding health management with technological approaches, including mobile health (mHealth) interventions. Objective: This study aimed to systematically evaluate mHealth interventions used in pregnancy in high-income countries and their effects on maternal health behaviors and maternal-fetal health outcomes. Methods: This systematic review identified studies published between January 1, 2000, and November 30, 2018, in MEDLINE via PubMed, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and gray literature. Studies were eligible for inclusion if they included only pregnant women in high-income countries and evaluated stand-alone mobile phone interventions intended to promote healthy maternal beliefs, behaviors, and/or maternal-fetal health outcomes. Two researchers independently reviewed and categorized aspects of full-text articles, including source, study design, intervention and control, duration, participant age, attrition rate, main outcomes, and risk of bias. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and the study was registered in PROSPERO before initiation. Results: Of the 2225 records examined, 28 studies were included and categorized into 4 themes: (1) gestational weight gain, obesity and physical activity (n=9); (2) smoking cessation (n=9); (3) influenza vaccination (n=2); and (4) general prenatal health, preventive strategies, and miscellaneous topics (n=8). Reported sample sizes ranged from 16 to 5243 with a median of 91. Most studies were performed in the United States (18/28, 64%) and were randomized controlled trials (21/28, 75%). All participants in the included studies were pregnant at the time of study initiation. Overall, 14% (4/28) of studies showed association between intervention use and improved health outcomes; all 4 studies focused on healthy gestational weight. Among those, 3 studies showed intervention use was associated with less overall gestational weight gain. These 3 studies involved interventions with text messaging or an app in combination with another communication strategy (Facebook or email). Regarding smoking cessation, influenza vaccination, and miscellaneous topics, there was some evidence of positive effects on health behaviors and beliefs, but very limited correlation with improved health outcomes. Data and interventions were heterogeneous, precluding a meta-analysis. Conclusions: In high-income countries, utilization of mobile phone–based health behavior interventions in pregnancy demonstrates some correlation with positive beliefs, behaviors, and health outcomes. More effective interventions are multimodal in terms of features and tend to focus on healthy gestational weight gain.

  • Source: Pexels; Copyright: Andrea Piacquadio; URL:; License: Licensed by the authors.

    Content and Quality of Infant Feeding Smartphone Apps: Five-Year Update on a Systematic Search and Evaluation


    Background: Parents use apps to access information on child health, but there are no standards for providing evidence-based advice, support, and information. Well-developed apps that promote appropriate infant feeding and play can support healthy growth and development. A 2015 systematic assessment of smartphone apps in Australia about infant feeding and play found that most apps had minimal information, with poor readability and app quality. Objective: This study aimed to systematically evaluate the information and quality of smartphone apps providing information on breastfeeding, formula feeding, introducing solids, or infant play for consumers. Methods: The Google Play store and Apple App Store were searched for free and paid Android and iPhone Operating System (iOS) apps using keywords for infant feeding, breastfeeding, formula feeding, and tummy time. The apps were evaluated between September 2018 and January 2019 for information content based on Australian guidelines, app quality using the 5-point Mobile App Rating Scale, readability, and suitability of health information. Results: A total of 2196 unique apps were found and screened. Overall, 47 apps were evaluated, totaling 59 evaluations for apps across both the Android and iOS platforms. In all, 11 apps had affiliations to universities and health services as app developers, writers, or editors. Furthermore, 33 apps were commercially developed. The information contained within the apps was poor: 64% (38/59) of the evaluations found no or low coverage of information found in the Australian guidelines on infant feeding and activity, and 53% (31/59) of the evaluations found incomplete or incorrect information with regard to the depth of information provided. Subjective app assessment by health care practitioners on whether they would use, purchase, or recommend the app ranged from poor to acceptable (median 2.50). Objective assessment of the apps’ engagement, functionality, aesthetics, and information was scored as acceptable (median 3.63). The median readability score for the apps was at the American Grade 8 reading level. The suitability of health information was rated superior or adequate for content, reading demand, layout, and interaction with the readers. Conclusions: The quality of smartphone apps on infant feeding and activity was moderate based on the objective measurements of engagement, functionality, aesthetics, and information from a reliable source. The overall quality of information on infant feeding and activity was poor, indicated by low coverage of topics and incomplete or partially complete information. The key areas for improvement involved providing evidence-based information consistent with the Australian National Health and Medical Research Council’s Infant Feeding Guidelines. Apps supported and developed by health care professionals with adequate health service funding can ensure that parents are provided with credible and reliable resources.

  • Image is of the Hexoskin Smart Shirt, Hexoskin Smart recording device and mobile app. Source: The Authors; Copyright: Hamzeh Khundaqji; URL:; License: Creative Commons Attribution (CC-BY).

    Smart Shirts for Monitoring Physiological Parameters: Scoping Review


    Background: The recent trends of technological innovation and widescale digitization as potential solutions to challenges in health care, sports, and emergency service operations have led to the conception of smart textile technology. In health care, these smart textile systems present the potential to aid preventative medicine and early diagnosis through continuous, noninvasive tracking of physical and mental health while promoting proactive involvement of patients in their medical management. In areas such as sports and emergency response, the potential to provide comprehensive and simultaneous physiological insights across multiple body systems is promising. However, it is currently unclear what type of evidence exists surrounding the use of smart textiles for the monitoring of physiological outcome measures across different settings. Objective: This scoping review aimed to systematically survey the existing body of scientific literature surrounding smart textiles in their most prevalent form, the smart shirt, for monitoring physiological outcome measures. Methods: A total of 5 electronic bibliographic databases were systematically searched (Ovid Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Scopus, Cumulative Index to Nursing and Allied Health Literature, and SPORTDiscus). Publications from the inception of the database to June 24, 2019 were reviewed. Nonindexed literature relevant to this review was also systematically searched. The results were then collated, summarized, and reported. Results: Following the removal of duplicates, 7871 citations were identified. On the basis of title and abstract screening, 7632 citations were excluded, whereas 239 were retrieved and assessed for eligibility. Of these, 101 citations were included in the final analysis. Included studies were categorized into four themes: (1) prototype design, (2) validation, (3) observational, and (4) reviews. Among the 101 analyzed studies, prototype design was the most prevalent theme (50/101, 49.5%), followed by validation (29/101, 28.7%), observational studies (21/101, 20.8%), and reviews (1/101, 0.1%). Presented prototype designs ranged from those capable of monitoring one physiological metric to those capable of monitoring several simultaneously. In 29 validation studies, 16 distinct smart shirts were validated against reference technology under various conditions and work rates, including rest, submaximal exercise, and maximal exercise. The identified observational studies used smart shirts in clinical, healthy, and occupational populations for aims such as early diagnosis and stress detection. One scoping review was identified, investigating the use of smart shirts for electrocardiograph signal monitoring in cardiac patients. Conclusions: Although smart shirts have been found to be valid and reliable in the monitoring of specific physiological metrics, results were variable for others, demonstrating the need for further systematic validation. Analysis of the results has also demonstrated gaps in knowledge, such as a considerable lag of validation and observational studies in comparison with prototype design and limited investigation using smart shirts in pediatric, elite sports, and emergency service populations. Trial Registration:

  • Source: Pexels; Copyright: Daria Shevtsova; URL:; License: Licensed by the authors.

    Effect of an mHealth Intervention Using a Pedometer App With Full In-Person Counseling on Body Composition of Overweight Adults: Randomized Controlled Weight...


    Background: In clinical practice, it is difficult to convey the benefits of sustained physical activity to adult patients with excess weight or obesity. For this purpose, a goal-setting walking prescription may be an effective strategy. Objective: This study aimed to determine the efficacy of the intervention of a pedometer app in setting a goal to reach 10,000 steps per day in adults. Methods: Overweight adults (n=98; mean body mass index 32.53 [SD 4.92] kg/m2) were randomized to one of two conditions (control or intervention). Both groups downloaded a pedometer app that recorded their daily step counts and were given a daily walking goal of 10,000 steps. Subjects participated in a 24-week in-person behavioral weight control program and were asked to monitor their daily levels using the pedometer app. Baseline data were recorded and followed up weekly. Only the intervention group had structured information delivery, a personalized physical activity prescription, and follow-up on number of steps per day. Results: The results show that regardless of sex or age, prescribing walking increased the number of steps per day by 4806 step on average (standardized β coefficient=–0.813, SE=427.586, t=–11.242, P<.001). Conclusions: These results could have implications for improving self-monitoring in overweight adults during periods of weight loss. Health professionals should analyze the implementation of tools that permit them to prescribe, follow up, and encourage the achievement of a goal of physical activity in overweight or obese patients. Trial Registration: NCT03845478;

  • Augmented reality rehabilitation of gait impairments. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Augmented Reality–Based Rehabilitation of Gait Impairments: Case Report


    Background: Gait and balance impairments are common in neurological diseases, including stroke, and negatively affect patients’ quality of life. Improving balance and gait are among the main goals of rehabilitation. Rehabilitation is mainly performed in clinics, which lack context specificity; therefore, training in the patient’s home environment is preferable. In the last decade, developed rehabilitation technologies such as virtual reality and augmented reality (AR) have enabled gait and balance training outside clinics. Here, we propose a new method for gait rehabilitation in persons who have had a stroke in which mobile AR technology and a sensor-based motion capture system are combined to provide fine-grained feedback on gait performance in real time. Objective: The aims of this study were (1) to investigate manipulation of the gait pattern of persons who have had a stroke based on virtual augmentation during overground walking compared to walking without AR performance feedback and (2) to investigate the usability of the AR system. Methods: We developed the ARISE (Augmented Reality for gait Impairments after StrokE) system, in which we combined a development version of HoloLens 2 smart glasses (Microsoft Corporation) with a sensor-based motion capture system. One patient with chronic minor gait impairment poststroke completed clinical gait assessments and an AR parkour course with patient-centered performance gait feedback. The movement kinematics during gait as well as the usability and safety of the system were evaluated. Results: The patient changed his gait pattern during AR parkour compared to the pattern observed during the clinical gait assessments. He recognized the virtual objects and ranked the usability of the ARISE system as excellent. In addition, the patient stated that the system would complement his standard gait therapy. Except for the symptom of exhilaration, no adverse events occurred. Conclusions: This project provided the first evidence of gait adaptation during overground walking based on real-time feedback through visual and auditory augmentation. The system has potential to provide gait and balance rehabilitation outside the clinic. This initial investigation of AR rehabilitation may aid the development and investigation of new gait and balance therapies.

  • Source: The Authors / Placeit; Copyright: The Authors / Placeit; URL:; License: Licensed by JMIR.

    A Questionnaire for Assessing User Satisfaction With Mobile Health Apps: Development Using Rasch Measurement Theory


    Background: Mobile health (mHealth) apps offer great opportunities to deliver large-scale, cost-efficient digital solutions for implementing lifestyle changes. Furthermore, many mHealth apps act as medical devices. Yet, there is little research on how to assess user satisfaction with an mHealth solution. Objective: This study presents the development of the mHealth Satisfaction Questionnaire and evaluates its measurement properties. Methods: Respondents who took part in the Health Integrator Study and were randomized to use the Health Integrator smartphone app for lifestyle changes (n=112), with and without additional telephone coaching, rated their satisfaction with the app using the new 14-item mHealth Satisfaction Questionnaire. The ratings were given on a 5-point Likert scale and measurement properties were evaluated using Rasch measurement theory (RMT). Results: Optimal scoring was reached when response options 2, 3, and 4 were collapsed, giving three response categories. After omitting two items that did not fit into the scale, fit residuals were within, or close to, the recommended range of ±2.5. There was no differential item functioning between intervention group, age group, or sex. The Person Separation Index was 0.79, indicating that the scale’s ability to discriminate correctly between person leniency was acceptable for group comparisons but not for individual evaluations. The scale did not meet the criterion of unidimensionality; 16.1% (18/112) of the respondents were outside the desired range of −1.96 to 1.96. In addition, several items showed local dependency and three underlying dimensions emerged: negative experiences, positive experiences, and lifestyle consequences of using the mHealth solution. Conclusions: In times where mHealth apps and digital solutions are given more attention, the mHealth Satisfaction Questionnaire provides a new possibility to measure user satisfaction to ensure usability and improve development of new apps. Our study is one of only a few cases where RMT has been used to evaluate the usability of such an instrument. There is, though, a need for further development of the mHealth Satisfaction Questionnaire, including the addition of more items and consideration of further response options. The mHealth Satisfaction Questionnaire should also be evaluated in a larger sample and with other mHealth apps and in other contexts. Trial Registration: NCT03579342;

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  • Factors impacting clinicians’ adoption of a clinical photo documentation app and its implications for clinical workflows and quality of care - A qualitative case study

    Date Submitted: May 25, 2020

    Open Peer Review Period: May 24, 2020 - Jul 19, 2020

    Background: Mobile health (mHealth) tools have shown promise in clinical photo and wound documentation for their potential to improve workflows, expand access to care, and improve the quality of patie...

    Background: Mobile health (mHealth) tools have shown promise in clinical photo and wound documentation for their potential to improve workflows, expand access to care, and improve the quality of patient care. However, some barriers to adoption persist. Objective: This research focuses on understanding the social, organizational, and technical factors impacting clinicians’ adoption of a clinical photo documentation mobile health app, and its implications for clinical workflows and quality of care. Methods: A qualitative case study of a clinical photo and wound documentation app, called imitoCam. The data were collected through 20 in-depth interviews with mHealth providers, clinicians, and medical informatics experts in 8 clinics and hospitals in Switzerland and Germany. Results: This case demonstrates that the use of mHealth in clinical photo and wound documentation provides numerous benefits such as time-saving and efficacy, better patient safety and quality of care, enhanced data security and validation, as well as better accessibility. Clinical workflow may also improve when the app is a good fit, resulting in better collaboration and transparency, streamlined daily work, clinician empowerment, and improved quality of care. Findings included important factors that may contribute to or hinder adoption. Factors may be related to the material nature of the tool such as the perceived usefulness, ease of use, interoperability, cost, or security of the app; or social, such as personal experience, attitudes, awareness, or culture. Organizational and policy barriers include the available clinical practice infrastructure, workload and resources, the complexity of the decision making, training, as well as ambiguity or lack of regulations. User engagement in the development and implementation process are vital contributors to the successful adoption of mHealth apps. Conclusions: The promising potential of mHealth in clinical photo and wound documentation is clear and may enhance clinical workflow and quality of care, but the factors impacting adoption go beyond the technical features of the tool itself to also embrace significant social and organizational elements. Technology providers, clinicians and decision makers should work together to carefully address any barriers in order to improve adoption and harness the potential of these tools. Clinical Trial: NA

  • Investigating Digital Cardiovascular Biomarker Responses to Transcutaneous Cervical Vagus Nerve Stimulation: State-Space Modeling, Prediction, and Simulation

    Date Submitted: May 20, 2020

    Open Peer Review Period: May 20, 2020 - Jul 15, 2020

    Background: Transcutaneous cervical vagus nerve stimulation (tcVNS) is a promising alternative to implantable stimulation of the vagus nerve. With demonstrated potential in myriad applications ranging...

    Background: Transcutaneous cervical vagus nerve stimulation (tcVNS) is a promising alternative to implantable stimulation of the vagus nerve. With demonstrated potential in myriad applications ranging from systemic inflammation reduction to traumatic stress attenuation, closed-loop tcVNS during periods of risk could improve treatment efficacy and reduce ineffective delivery. Objective: Accomplishing this, however, requires a deeper understanding of biomarker changes in time. We thus elucidate herein the dynamics of relevant cardiovascular biomarkers – extracted from wearable sensing modalities – in response to tcVNS. Methods: In 24 human subjects undergoing a randomized double-blind clinical protocol, electrocardiography (ECG) and photoplethysmography (PPG) were used to measure heart rate (HR) and PPG amplitude responses to tcVNS. Modeling these responses in state-space, we (1) compared the biomarkers in predictability and active vs. sham differentiation, (2) studied the latency between stimulation onset and measurable effects, and (3) visualized the true and model-simulated biomarker responses to tcVNS. Results: The models predict approximately 80% of the variability observed. Moreover, (1) we find that PPG amplitude demonstrates superiority to HR (P = .03) in both of the aforementioned comparisons, (2) a consistent delay of > 5 s is quantified between tcVNS onset and cardiovascular effects, and (3) dynamic characteristics differentiate responses to tcVNS from sham. Conclusions: This work furthers the state of the art by modeling pertinent biomarker responses to tcVNS. Through subsequent analysis, we observe three key findings with implications involving wearable sensing for bioelectronic medicine, the dominant mechanism of action for tcVNS-induced effects on cardiovascular physiology, and the existence of dynamic biomarker signatures that can be leveraged to titrate therapy in closed-loop. Clinical Trial: identifier NCT02992899

  • Sleep Validation of Commercially Available Smart Ring and Watch Against Medical-Grade Actigraphy in Everyday Settings

    Date Submitted: May 19, 2020

    Open Peer Review Period: May 19, 2020 - Jul 14, 2020

    Background: Assessment of sleep quality is essential to address poor sleep quality and understand the changes. Thanks to the advances in Internet-of-Things and wearable technologies, sleep monitoring...

    Background: Assessment of sleep quality is essential to address poor sleep quality and understand the changes. Thanks to the advances in Internet-of-Things and wearable technologies, sleep monitoring in free-living conditions has become feasible and practicable. Smart rings and smartwatches can be employed to perform mid- or long-term home-based sleep monitoring. However, the validity of such wearables should be investigated in terms of sleep parameters. Sleep validation studies are mostly limited to short-term laboratory tests. There is a need for a study to assess the sleep attributes of wearables in everyday settings, where the users engage in their daily routines. Objective: We evaluate the sleep parameters of Oura ring along with Samsung Gear Sport watch in comparison to a medically-approved actigraphy device in a mid-term everyday setting, where the users engage in their daily routines. Methods: We conduct home-based sleep monitoring in which the sleep parameters of forty-five healthy individuals (23 females and 22 males) are tracked for seven days. The total sleep time (TST), sleep efficiency (SE), and wake after sleep onset (WASO) of the ring and watch are assessed using the paired t-tests, Bland-Altman plots, and Pearson correlation. The parameters are also investigated, considering the gender of the participants as a dependent variable. Results: Our findings show that there are significant correlations between the TST (r=0.86,P<0.001), WASO (r=0.41,P<0.001), and SE (r=0.47,P<0.001) of the ring and actigraphy. In comparison of the watch with actigraphy, there is a significant correlation in TST (r=0.59, P<0.001). The mean differences of the TST, WASO, and SE of the ring and actigraphy are in the satisfactory ranges, although there are significant differences between the parameters (P<0.001). For the watch, the TST and SE mean differences are also in the satisfactory ranges, and the WASO is slightly higher than the range (31.27±35.15). However, the mean differences of the parameters between the watch and actigraphy are considerably higher than the ring. The watch also shows a significant difference between female and male groups in TST (P<0.001). Conclusions: Consequently, in a population sample of healthy adults, the sleep parameters of both Oura ring and Samsung watch have acceptable mean differences and indicate significant correlations with the actigraphy, but the ring outperforms the watch in terms of the non-staging sleep parameters.

  • Design and Usability Evaluation of Mobile Voice-added Food Reporting for the Elderly: Randomized Controlled Trial

    Date Submitted: May 19, 2020

    Open Peer Review Period: May 19, 2020 - Jul 14, 2020

    Background: Advances in voice technology have raised new possibilities for applications related to daily health maintenance. However, the usability of such technologies for older users remains unclear...

    Background: Advances in voice technology have raised new possibilities for applications related to daily health maintenance. However, the usability of such technologies for older users remains unclear and requires further investigation. Objective: We designed and evaluated two innovative mobile voice-added apps for food intake reporting, namely voice-only reporting (VOR) and voice-button reporting (VBR). Each app features a unique interactive procedure for reporting food intake. With VOR, users verbally report the main contents of each dish, while VBR provides both voice and existing touch screen inputs for food intake reporting. The relative usability of the two apps was assessed through the metrics of accuracy, efficiency, and user perception. Methods: The two mobile apps were compared in a head-to-head parallel randomized trial evaluation. A group of fifty-seven adults aged 60-90 (male=12; female=45) was recruited from a retirement community and randomized into two experimental groups, i.e., VOR (n=30) and VBR (n=27). Both groups were tested using the same set of seventeen food items including dishes and beverages selected and allocated to present distinct breakfast, lunch, and dinner meals. All participants used a 7-inch tablet computer for the test. The resulting data were analyzed to evaluate reporting accuracy and time efficiency, and system usability scale (SUS) was used to measure user perception. Results: For the eight error types identified in the experiment, the VBR group participants were significantly more error-prone, related to the tasks required in use of screen-touch buttons. The highest error rates in the VOR group were due to incomprehensible reporting speech (6.7%), while the highest error rates in the VBR group were related to failure to make required button taps (10.3%). The VOR group required significantly less time to complete food reporting. The overall subjective reaction of the two groups based on SUS surpassed the benchmark and were not significantly different. Conclusions: Experimental results show that VOR outperformed VBR, suggesting that voice-only food input reporting is preferable for elderly users. The voice-added apps offer a potential mechanism for the self-management of dietary intake tool by elderly users. Our study contributes an evidence-based evaluation of prototype design and selection under a user-centered design (UCD) model. The results provide a useful reference for selecting optimal user interaction design. Clinical Trial: International Standard Randomized Controlled Trial Registry ISRCTN36710750;

  • Social and behaviour change communication interventions delivered face-to-face and by mobile phone to strengthen vaccination uptake and improve child health in rural India: A randomised pilot study for a cluster randomised controlled trial

    Date Submitted: May 21, 2020

    Open Peer Review Period: May 17, 2020 - Jul 12, 2020

    Background: In resource-poor settings, lack of awareness and low demand for services constitute important barriers to expanding coverage of effective interventions. In India, childhood immunisation is...

    Background: In resource-poor settings, lack of awareness and low demand for services constitute important barriers to expanding coverage of effective interventions. In India, childhood immunisation is a priority health strategy with suboptimal uptake. Objective: To assess study feasibility and key implementation outcomes for the Tika Vaani model, a new approach to educate and empower beneficiaries to improve immunisation and child health. Methods: Cluster-randomised pilot trial with a 1:1 allocation ratio conducted in rural Uttar Pradesh, India from January to September, 2018. Villages were randomly assigned to either the intervention or control group. In each participating village, surveyors conducted a complete enumeration to identify all eligible households and requested participation in person prior to randomisation. Interventions were designed through formative research using a social marketing approach and delivered over a three-month period using strategies adapted to disadvantaged populations: (1) mHealth: entertaining educational audio capsules (edutainment) and voice immunisation reminders via mobile phone; (2) face-to-face: community mobilisation activities, including three small group meetings offered to each participant. The control group received usual services. The main outcomes were prespecified criteria for feasibility of the main study (recruitment, randomisation, retention, contamination, and adoption). Secondary endpoints tested equity of coverage and changes in intermediate outcomes. Statistical methods included descriptive statistics to assess feasibility, penalized maximum logistic regression and ordered logistic regression to assess coverage, and generalised estimating equations models to assess changes in intermediate outcomes. Results: All villages consented to participate. Gaps in administrative data hampered recruitment; 14% (79/565) of recorded households were non-resident. Only 1% (8/565) did not consent. 387 (184 intervention; 203 control) households with children ages 0 to 12 months in 26 (13 intervention: 13 control) villages were included and randomised. The end line survey occurred during flood season; 18% of (68/387) households were absent. Contamination was below 1%. Participation in one or more interventions was 94% (173/184) (82% (144/184) for the face-to-face strategy and 67% (124/184) for the mHealth strategy). Determinants including place of residence, mobile phone access, education and female empowerment shaped intervention use; factors operated differently for face-to-face and mHealth strategies. For 11 of 13 intermediate outcomes, regression results showed significantly higher basic health knowledge among the intervention group, supporting hypothesised causal mechanisms. Conclusions: A future trial of a new intervention model to improve immunisation uptake and child health is feasible. The interventions demonstrate the potential to strengthen delivery of immunization and universal primary health care. Social and behaviour change communication via mobile phone proved viable and contributed to standardisation and scalability. Face-to-face interactions remain necessary to achieve equity and reach, suggesting the need for ongoing health system strengthening to accompany introduction of communications technologies. Clinical Trial: ISRCTN44840759;

  • Feasibility and acceptability of a tablet-based, Engagement, Assessment, Support and Sign-posting (EASSi) tool used to facilitate and structure sexual wellbeing conversations in routine prostate cancer care: Mixed-methods evaluation

    Date Submitted: May 11, 2020

    Open Peer Review Period: May 11, 2020 - Jul 6, 2020

    Background: Background: Long-term side-effects associated with different prostate cancer treatment approaches are common. Sexual challenges are the most frequently occurring of these and can result i...

    Background: Background: Long-term side-effects associated with different prostate cancer treatment approaches are common. Sexual challenges are the most frequently occurring of these and can result in increased psychological morbidity. It is recognised that barriers to communication can make initiating discussions around sexual concerns in routine practice difficult. Healthcare professionals need to routinely initiate conversations, effectively engage with patients and assess needs in order to provide essential support. One proposed method which could support healthcare professionals to do this is use of prompts or structured frameworks to guide conversations. Objective: Objective: To assess feasibility, acceptability and satisfaction with a tablet-based, Engagement, Assessment, Support and Sign-posting (EASSi) tool designed to facilitate and structure sexual wellbeing discussions in routine prostate cancer care. Methods: Methods: Healthcare professionals (n=8) used the EASSi tool during 89 post-treatment appointments. Quantitative data were recorded based on programme usage and surveys completed by healthcare professionals and patients. Qualitative data exploring perceptions on use of the tool were gathered using semi-structured interviews with all healthcare professionals (n=8) and a sample of patients (n=10). Results: Results: Surveys were completed by healthcare professionals immediately following each appointment (n=89: 100%). Postal surveys were returned by 59 patients (66%). Healthcare professionals and patients reported that the tool helped facilitate discussions (91.1% and 82.4% respectively) and that information provided was relevant (92.1% and 84.6% respectively). Mean conversation duration was 6.01 minutes (SD: 2.91). Qualitative synthesis identified the tool’s ability to initiate and structure discussions, improve ‘depth’ of conversations, and normalise sexual concerns. Conclusions: Conclusion: The EASSi tool was appropriate and acceptable for use in practice and provided a flexible approach to facilitate routine, brief conversations and deliver essential sexual wellbeing support. Further work will be conducted evaluating the effectiveness of using the tablet-based tool in prostate cancer care settings. Clinical Trial: n/a