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Journal Description

JMIR mHealth and uHealth (JMU, ISSN 2291-5222) is a sister journal of JMIR, the leading eHealth journal. JMIR mHealth and uHealth is indexed in PubMed, PubMed Central, Scopus, and Science Citation Index Expanded (SCIE), and in June 2018 received an Impact Factor of 4.541, which ranks the journal #2 (behind JMIR) out of 25 journals in the medical informatics category indexed by the Science Citation Index Expanded (SCIE) by Thomson Reuters/Clarivate

The journal focusses on health and biomedical applications in mobile and tablet computing, pervasive and ubiquitous computing, wearable computing and domotics.

JMIR mHealth and uHealth publishes since 2013 and was the first mhealth journal in Pubmed. It publishes even faster and has a broader scope with including papers which are more technical or more formative/developmental than what would be published in the Journal of Medical Internet Research

JMIR mHealth and uHealth features a rapid and thorough peer-review process, professional copyediting, professional production of PDF, XHTML, and XML proofs.

JMIR mHealth and uHealth adheres to the same quality standards as JMIR and all articles published here are also cross-listed in the Table of Contents of JMIR, the worlds' leading medical journal in health sciences / health services research and health informatics.

 

Recent Articles:

  • Source: Max Pixel; Copyright: Max Pixel; URL: https://www.maxpixel.net/Sleeping-Feet-Bed-Sleep-Technology-Comfortable-3493949; License: Public Domain (CC0).

    Smartphones as Sleep Duration Sensors: Validation of the iSenseSleep Algorithm

    Abstract:

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

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL: http://mhealth.jmir.org/2019/5/e13049/; License: Creative Commons Attribution (CC-BY).

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

    Abstract:

    Background: Young people aged 15 to 24 years account for one-third of new adult HIV infections. Controlling the HIV epidemic requires effective interventions targeted toward young people and their needs. Smartphone games offer a promising avenue for reaching this population with evidence-based HIV prevention interventions. It is crucial to the effectiveness of these interventions that they be acceptable and intrinsically motivating to adolescents as well as acceptable to their parents. Objective: Tumaini is a narrative-based smartphone game designed to help prevent HIV among young Africans aged 11 to 14 years by delaying first sex and increasing condom use at first sex. Following a 16-day feasibility study of Tumaini, we assessed the acceptability (1) of the intervention, where acceptability was operationalized as appeal, relevance, value, usability, and understandability, and (2) of this study and a planned future randomized controlled efficacy trial. Methods: During the randomized feasibility study (n=60) of Tumaini in western Kenya in spring 2017, 30 participants used the intervention on a study-provided smartphone. The app automatically logged participant interaction with the game in time-stamped log files. All 30 participants completed an Audio Computer-Assisted Self-Interview–based game experience survey, and 27 took part in 4 focus group discussions (FGDs) about the game’s appeal, relevance, value, usability, and understandability. Their parents (n=22) also participated in 4 FGDs about the acceptability of the intervention, of this study, and of a planned efficacy trial. Survey data were analyzed using SAS software (SAS Institute Inc); FGD transcripts were coded and analyzed in MAXQDA 12 (Verbi GmbH); and gameplay log files were analyzed using Microsoft Excel. Results: Adolescent participants’ survey responses indicated that Tumaini scored well with players on all indicators of acceptability (appeal, relevance, value, usability, and understandability). Focus group analyses aligned with these findings and emphasized a high degree of player engagement with the game, which was supported by log file analysis. Adolescent participants were eager for additional content, and parents were receptive to a longer study involving biomarkers, based on their positive experiences with this study. There is scope to improve communication with parents about their role in the intervention. As the game was tested in beta version, there is also scope to fine-tune some of the game mechanics to increase usability. Conclusions: This study shows the strong acceptability of an interactive smartphone-based game both to adolescents and their parents in western Kenya and that of the study methods used to pilot-test the intervention. It also suggests that longitudinal efficacy studies of this type of intervention, including those using biomarkers, have the potential to be acceptable among parents. Trial Registration: ClinicalTrials.gov NCT03054051; https://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW)

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL: http://mhealth.jmir.org/2019/5/e9232/; License: Creative Commons Attribution (CC-BY).

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

    Abstract:

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

  • “Rhythm App” can continuously and automatically record use patterns and sleep times over long periods, and therefore can be utilized for sleep and health monitoring. Source: The Authors; Copyright: The Authors; URL: https://mhealth.jmir.org/2019/5/e13421/; License: Creative Commons Attribution (CC-BY).

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

    Abstract:

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

  • Source: Image created by the Authors; Copyright: Corrie Health; URL: https://mhealth.jmir.org/2019/5/e14124; License: Creative Commons Attribution (CC-BY).

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

    Abstract:

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

  • Source: Freepik; Copyright: fanjianhua; URL: https://www.freepik.com/free-photo/shot-studio-young-asian-woman-play-mobile-phone-self-timer_1286605.htm; License: Licensed by JMIR.

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

    Abstract:

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

  • mPCAT usability testing in Kenya. Source: Image created by Authors; Copyright: The Authors; URL: http://mhealth.jmir.org/2019/5/e13963/; License: Creative Commons Attribution (CC-BY).

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

    Abstract:

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

  • Healthy lifestyles and Top Tips app. Source: The Authors / Shutterstock; Copyright: The Authors; URL: http://mhealth.jmir.org/2019/5/e12326/; License: Licensed by the authors.

    Development of the Top Tips Habit-Based Weight Loss App and Preliminary Indications of Its Usage, Effectiveness, and Acceptability: Mixed-Methods Pilot Study

    Abstract:

    Background: The Ten Top Tips (10TT) is an intervention based on the habit formation theory that promotes a set of weight management behaviors alongside advice about repetition in a consistent context. Overall, 3 studies have demonstrated that the 10TT can support individuals to lose weight when delivered in a leaflet format. Delivery of 10TT via new technology such as a mobile app could potentially improve its effectiveness and make it more convenient, appealing, and wide reaching. Objective: This study aimed to provide preliminary indications of the usage, effectiveness, and acceptability of an Android app of the 10TT intervention (Top Tips only app) and a second version including self-regulatory strategies for dealing with tempting foods (Top Tips plus app). Methods: The 3-month pilot randomized adults with overweight or obesity to (1) Top Tips only app, (2) Top Tips plus app, or (3) waiting list condition. Automated data from app users were collected. Validated questionnaires assessed self-regulatory skills, weight loss (kg), and behaviors at baseline and 3 months. Users’ feedback on their experience using the app was assessed using open questions. Results: A total of 81 participants took part in the pilot; 28 participants were randomized to the Top Tips only app, 27 to the Top Tips plus app, and 26 to the waiting list condition. On average, participants viewed a mean of 43.4 (SD 66.9) screens during a mean of 24.5 (SD 44.07) log-ins and used the app for 124.2 (SD 240.2) min over the 3-month period. Participants randomized to the Top Tips only app reported the greatest improvement in self-regulatory skills (mean 0.59, SD 1.0), weight loss (mean 4.5 kg, SD 5.2), and adherence to the target behaviors (mean 0.59, SD 0.49) compared with the Top Tips plus (meanself-regulation 0.15, SD 0.42; meanweight −1.9, SD 3.9; and meanbehaviors 0.29, SD 0.29) and waiting list condition (meanself-regulation −0.02, SD 0.29; meanweight −0.01, SD 0.51; and meanbehaviors 0.08, SD 0.38). Participants who reported the largest improvements, on average, viewed pages 2 to 3 times more, had 2 to 3 times more log-ins, logged their weight 2 to 3 times more, and achieved the tips more than those who reported smaller changes in these outcomes. According to users’ feedback, engagement with the app could be increased by making the app more interactive and allowing more tailoring. Conclusions: This study suggests that the Top Tips app could potentially be a useful intervention for promoting eating self-regulatory skills, weight loss, and weight management behaviors among adults with overweight or obesity. Future research should develop the app further based on user feedback and test it in larger sample sizes. Trial Registration: ISRCTN Registry ISRCTN10470937; http://www.isrctn.com/ISRCTN10470937 (Archived by Webcite at http://www.webcitation.org/76j6rQibI)

  • Source: iStock by Getty Images; Copyright: Wavebreakmedia; URL: https://www.istockphoto.com/ca/photo/pregnant-businesswoman-using-mobile-phone-gm665143374-121160855; License: Licensed by the authors.

    Usability and Usefulness of a Mobile Health App for Pregnancy-Related Work Advice: Mixed-Methods Approach

    Abstract:

    Background: Pregnant women are often unaware of the potential risks that working conditions can cause to them and their unborn child. A mobile health (mHealth) app, the Pregnancy and Work (P and W) app, developed by a multidisciplinary team and based on an evidence-based guideline for occupational physicians, aims to provide advice on work adjustment during pregnancy. Objective: This study evaluates the usability of the mHealth P and W app and the perceived usefulness of the work advice, the main goal of the app, by potential end users. Methods: A total of 12 working pregnant women participated in think aloud usability sessions and performed 9 tasks. All think aloud sessions were recorded, transcribed, and coanalyzed. The usability problems were rated for their severity in accordance with Nielsen severity scale. The completion rates and time taken for completion of tasks were registered. In addition, participants were questioned on demographics and user characteristics and were asked to evaluate the value of the app by filling in the Intrinsic Motivation Inventory (IMI) score and the System Usability Scale (SUS) questionnaire. Results: In total, 82 usability problems with a severity ≥1 were identified, of which 40 had severity ≥3. The main usability problems concerned the interpretation of terminology used in the app’s questionnaires and difficulties in finding and understanding the work advice. Furthermore, 10 out of 12 participants were able to open the work advice page in the app. Only 7 out of these 10 participants understood and intended to follow the work advice. The overall mean IMI score was relatively high (5 out of 7), indicating that the participants did indeed value the use of the app. This IMI score corresponded to the overall mean SUS score (68 out of 100) and the mean grade given to the P and W app (7 out of 10). Conclusions: This think aloud usability study showed that the information provided in the P and W app was considered valuable by the end users, working pregnant women, and it meets their needs; however, usability issues severely impacted the perceived usefulness of the work advice given in the app.

  • Source: Image created by the Authors; Copyright: The Authors; URL: http://mhealth.jmir.org/2019/5/e13241/; License: Creative Commons Attribution (CC-BY).

    Social Inequity and Structural Barriers to Completion of Ecological Momentary Assessments for Young Men Who Have Sex With Men and Trans Women Living With HIV...

    Abstract:

    Background: Ecological momentary assessments (EMAs) administered via text messaging facilitate real-time data collection. With widespread cell phone access, EMAs are becoming more available to even the most disenfranchised communities, such as those living with HIV. However, structural barriers disproportionately burden young men who have sex with men (MSM) and trans women (TW) living with HIV and threaten participation in HIV research. Objective: We aim to identify structural barriers to completing EMA text surveys nested within a digital HIV care intervention for young MSM and TW living with HIV in San Francisco. Methods: A total of 10,800 EMA text messages were delivered daily over 90 days to 120 participants enrolled in the Health eNav intervention (2017-2018) at the San Francisco Department of Public Health. EMA surveys inquired about participants’ daily affect, sexual behaviors, substance use, and treatment adherence. Survey completion was calculated after 30, 60, and 90 days of follow-up. We described characteristics of nonstarters (those who provided less than four complete responses to the first seven EMA surveys) and analyzed structural correlates of days to first weeklong or more EMA survey noncompletion using multivariable Cox proportional hazards regression. Qualitative interviews were used to evaluate the acceptability of EMA surveys. Results: Participants completed 4384 of 10,800 (40.59%) EMA surveys. Completion of 70% or more of EMA surveys was attained by 56 of 120 participants (46.7%) at 30 days of follow-up, 40/120 (33.3%) at 60 days of follow-up, and 30/120 (25.0%) by the end of the 90-day study period. Twenty-eight participants (23.3%) were identified as nonstarters, and were more likely to be recently incarcerated (prevalence ratio [PR] 2.3, 95% CI 1.3-4.4), forego basic needs for HIV medications (PR 2.4, 95% CI 1.3-4.5), and be diagnosed with HIV in the last year (PR 2.2, 95% CI 1.1-4.1). Adjusting for nonstarters, young MSM and TW living in temporary/transitional housing (adjusted hazard ratio [aHR] 1.8, 95% CI 1.1-3.0), foregoing HIV medications to afford basic needs (aHR 1.7, 95% CI 1.1-2.7), and having less than a college education (aHR 3.5, 95% CI 1.4-9.0) had greater hazard of weeklong or more EMA survey noncompletion. Overall, there was high acceptability of the EMA surveys. Conclusions: Although access to and use of technology is increasingly ubiquitous, this analysis demonstrates persisting gaps in EMA completion by socioeconomic factors such as incarceration, education level, housing, and competing needs for young MSM and TW living with HIV in San Francisco. Moreover, those recently diagnosed with HIV were more likely to experience an immediate drop-off in completing EMA surveys. EMAs are feasible for individuals not experiencing social inequity and structural barriers. HIV prevention technologies addressing these barriers and leveraging similar methodology may prove effective for young MSM and TW living with HIV.

  • Source: Wikimedia Commons; Copyright: Oakknollschool; URL: https://commons.wikimedia.org/wiki/File:Kindergarten_iPad.jpg; License: Creative Commons Attribution + ShareAlike (CC-BY-SA).

    Assessing the Quality of Mobile Apps Used by Occupational Therapists: Evaluation Using the User Version of the Mobile Application Rating Scale

    Abstract:

    Background: The continuous development of mobile apps has led to many health care professionals using them in clinical settings; however, little research is available to guide occupational therapists (OTs) in choosing quality apps for use in their respective clinical settings. Objective: The purpose of this study was to use the user version of the Mobile Application Rating Scale (uMARS) to evaluate the quality of the most frequently noted mobile health (mHealth) apps used by OTs and to demonstrate the utility of the uMARS to assess the quality of mHealth apps. Methods: A previous study surveying OTs’ use of apps in therapy compiled a list of apps frequently noted. A total of 25 of these apps were evaluated individually by 2 trained researchers using the uMARS, a simple, multidimensional analysis tool that can be reliably used to evaluate the quality of mHealth apps. Results: The top 10 apps had a total quality score of 4.3, or higher, out of 5 based on the mean scores of engagement, functionality, and aesthetics. Apps scored highest in functionality and lowest in engagement. Apps noted most frequently were not always high-quality apps; apps noted least frequently were not always low-quality apps. Conclusions: Determining the effectiveness of using apps in clinical settings must be built upon a foundation of the implementation of high-quality apps. Mobile apps should not be incorporated into clinical settings solely based on frequency of use. The uMARS should be considered as a useful tool for OTs, and other professionals, to determine app quality.

  • Source: The Authors / Placeit; Copyright: JMIR Publications; URL: http://mhealth.jmir.org/2019/4/e13555/; License: Creative Commons Attribution (CC-BY).

    Clinicians’ Role in the Adoption of an Oncology Decision Support App in Europe and Its Implications for Organizational Practices: Qualitative Case Study

    Abstract:

    Background: Despite the existence of adequate technological infrastructure and clearer policies, there are situations where users, mainly physicians, resist mobile health (mHealth) solutions. This is of particular concern, bearing in mind that several studies, both in developed and developing countries, showed that clinicians’ adoption is the most influential factor in such solutions’ success. Objective: The aim of this study was to focus on understanding clinicians’ roles in the adoption of an oncology decision support app, the factors impacting this adoption, and its implications for organizational and social practices. Methods: A qualitative case study of a decision support app in oncology, called ONCOassist, was conducted. The data were collected through 17 in-depth interviews with clinicians and nurses in the United Kingdom, Ireland, France, Italy, Spain, and Portugal. Results: This case demonstrates the affordances and constraints of mHealth technology at the workplace, its implications for the organization of work, and clinicians’ role in its constant development and adoption. The research findings confirmed that factors such as app operation and stability, ease of use, usefulness, cost, and portability play a major role in the adoption decision; however, other social factors such as endorsement, neutrality of the content, attitude toward technology, existing workload, and internal organizational politics are also reported as key determinants of clinicians’ adoption. Interoperability and cultural views of mobile usage at work are the key workflow disadvantages, whereas higher efficiency and performance, sharpened practice, and location flexibility are the main workflow advantages. Conclusions: Several organizational implications emerged, suggesting the need for some actions such as fostering a work culture that embraces new technologies and the creation of new digital roles for clinicians both on the hospitals or clinics and on the development sides but also more collaboration between health care organizations and digital health providers to enable electronic medical record integration and solving of any interoperability issues. From a theoretical perspective, we also suggest the addition of a fourth step to Leonardi’s methodological guidance that accounts for user engagement; embedding the users in the continuous design and development processes ensures the understanding of user-specific affordances that can then be made more obvious to other users and increase the potential of such tools to go beyond their technological features and have a higher impact on workflow and the organizing process.

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

    Date Submitted: May 19, 2019

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

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

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

  • Evaluation of Mobile Apps Targeted to Patients with Spondyloarthritis for Disease Monitoring: Systematic App Review

    Date Submitted: May 17, 2019

    Open Peer Review Period: May 21, 2019 - Jul 16, 2019

    Background: There are many apps developed for patients with Spondyloarthritis in the market, but they are not objectively evaluated for their purposes and quality. Objective: To identify and evaluate...

    Background: There are many apps developed for patients with Spondyloarthritis in the market, but they are not objectively evaluated for their purposes and quality. Objective: To identify and evaluate existing publicly available, high-quality apps for monitoring Spondyloarthritis disease activity that use validated measurement instruments. Methods: We did a review of apps available on Apple App store and Google Play store based on a combination of keywords, inclusion and exclusion criteria. Validated disease activity measurement instruments were identified. Information regarding app characteristics, including the presence of validated disease activity measurement were extracted. The Mobile App Rating Scale (MARS) was used to review the apps for user experience. Results: A total of 1,253 apps were identified in the app stores, and five apps met the criteria and were further analyzed. Two apps (MySpA and GRAPPA App) contained some of the validated disease activity monitoring instruments for specific spondyloarthritis subtypes. These two apps are also rated “good” on the MARS (with total mean scores ≥ 4/5), while the other apps scored poorly in comparison. Conclusions: There are two high-quality spondyloarthritis disease activity monitoring apps publicly available, but they only target two spondyloarthritis subtypes- ankylosing spondylitis and psoriatic arthritis. There is a lack of high-quality apps that can measure disease activity for other spondyloarthritis subtypes, and no available app that consolidates all validated disease activity instruments across subtypes.

  • Development of the Families Moving Forward Connect Mobile Health Intervention for Fetal Alcohol Spectrum Disorders: Qualitative Evaluation of Design and Functionalities

    Date Submitted: May 17, 2019

    Open Peer Review Period: May 21, 2019 - Jul 16, 2019

    Background: Fetal alcohol spectrum disorders (FASD) affect approximately 2-5% of the U.S. population. However, most families are unable to access FASD-informed interventions. Barriers to care include...

    Background: Fetal alcohol spectrum disorders (FASD) affect approximately 2-5% of the U.S. population. However, most families are unable to access FASD-informed interventions. Barriers to care include lack of a knowledgeable and skilled workforce, and family-level barriers such as limited financial resources, inability to access childcare, and stigma. As a result, families often try peer-to-peer and self-help support strategies. However, they often take these strategies from disparate sources which have quite variable intervention quality and empirical support. Objective: This study represents an important step in systematic development and evaluation of a mobile health (mHealth) intervention (“app”) for caregivers raising children with FASD. Qualitative methodology was used to understand participant perspectives on app design and functionalities to inform further app development. Methods: The app, called “FMF Connect,” is derived from the scientifically-validated Families Moving Forward (FMF) Program, a clinician-delivered behavioral consultation intervention. FMF Connect is intended for caregiver self-delivery and includes five main components: 1) Learning Modules, 2) Family Forum, 3) Library, 4) Notebook, and 5) Dashboard. During the early development process, to optimize the app for the clinical population, focus group methods were used to solicit perspectives from diverse families on aspects such as interface design, ease of use, relevance of components and content, and perceived barriers and facilitators of use. A total of 25 caregivers participated in 7 focus groups across 5 U.S. cities. Data were analyzed thematically. Results: Focus group participants were generally enthusiastic about the app interface design and components. Four global positive impression themes emerged, including: 1) ease of access; 2) how the app guides and organizes information; 3) connection to other users and information; and 4) ability to share some content with others. Themes arose not only in discussions relating to positive app features, but also when participants were asked about motivators for app use. Participants related how these positive global themes could address some systems-level barriers, such as limited access to services, feeling isolated, and increased advocacy needs related to societal lack of FASD knowledge. Participants identified many positive features about individual app components and functionalities. They communicated potential barriers to use and raised important concerns and considerations relating to several app components. These included recognizability of the app based on the logo, balance of following the planned intervention sequence versus obtaining immediate answers, and privacy and dynamics within the Family Forum. Conclusions: FMF Connect is a promising novel intervention with potential to reach many families in need and reduce significant barriers to care, resulting in broader public health impact. Study findings will guide further app development both in terms of content and technological advances to optimize intervention effects. FMF Connect app development provides useful directions for other apps aimed at changing parenting practices.

  • Development and Usability Assessment of a Food Record App for Dietary Assessments among Older Adults with Type 2 Diabetes

    Date Submitted: May 19, 2019

    Open Peer Review Period: May 21, 2019 - May 27, 2019

    Background: More than one in four people in the United States aged 65 years and older have diabetes. For diabetes care, medical nutrition therapy (MNT) is recommended as a clinically effective interve...

    Background: More than one in four people in the United States aged 65 years and older have diabetes. For diabetes care, medical nutrition therapy (MNT) is recommended as a clinically effective intervention. Prior researchers have developed and validated dietary assessment methods using images of food items for improving the accuracy of self-reporting over traditional methods. Nevertheless, little is known about the usability of image-assisted dietary assessment methods for older adults with diabetes. Objective: The aims of this study were: a) to create a food record app for dietary assessments (FRADA) that would support image-assisted dietary assessments, and b) to evaluate the usability of FRADA for older adults with diabetes. Methods: For the development of FRADA, we identified design principles that address the needs of older adults and implemented three fundamental tasks required for image-assisted dietary assessments: capturing, viewing, and transmitting images of food based on the design principles. For the usability assessment of FRADA, older adults aged 65 to 80 (11 females and 3 males) were assigned to interact with FRADA in a lab-based setting. Participants’ opinions of FRADA and its usability were determined by a follow-up survey and interview. As an evaluation indicator of usability, the responses to the survey including an After-Scenario Questionnaire were analyzed. Qualitative data from the interviews confirmed the responses to the survey. Results: We developed a smartphone application that enables older adults with diabetes to capture, view, and transmit images of food items they consumed. The findings of this study showed that FRADA and its instructions for capturing, viewing, and transmitting images of food items were usable for older adults with diabetes. The survey showed that FRADA was easy to use, and study participants would consider using FRADA daily. The analysis of the qualitative data from interviews revealed multiple themes, such as the usability of FRADA, potential benefits and features of FRADA, and concerns of older adults with diabetes when interacting with FRADA. Conclusions: This study demonstrates in a lab-based setting, not only the usability of FRADA with older adults who have diabetes, but it also demonstrates potential opportunities using FRADA in real-life settings. The findings suggest implications for creating a smartphone application for an image-assisted dietary assessment. Future work still remains to evaluate the feasibility and validity of FRADA with multiple stakeholders involving older adults with diabetes and dietitians.

  • mHealth and Opportunities in Anti-Retroviral Adherence in HIV, A Diverse Group of Patients with Diverse and Unique Opportunities : A Narrative Review

    Date Submitted: May 16, 2019

    Open Peer Review Period: May 21, 2019 - Jul 16, 2019

    Background: Introduction: Antiretrovirals (ARVs) are key in the management of human immunodeficiency virus (HIV). While no cure exists, ARVs help patients live healthy lives and prevent transmission t...

    Background: Introduction: Antiretrovirals (ARVs) are key in the management of human immunodeficiency virus (HIV). While no cure exists, ARVs help patients live healthy lives and prevent transmission to others. However, medication adherence to sometimes complex drug regiments is paramount to avoid the emergence of a drug-resistant virus. The goal of therapy is to reach an undetectable viral load. However, adherence is a common problem, stemming from such issues as mental health, chaotic home situations and busy work schedules. mHealth represents a new approach to improve medication adherence and multiple studies have been performed in this area. Objective: No current objective is listed in abstract. If needed can add the following: Objective: Our paper reviews the current implementations of mHealth in the management of HIV within different groups of patients. Methods: Methods: We used the PubMed database using various search terms to review the current implementations of mHealth in HIV care. Titles and abstracts were screened and 37 articles were fully reviewed. Results: Results: Upon a review of the literature, evidence was found for developing nations, intravenous and illicit drug users, and men who have sex with men. Conclusions: Discussion: There seems to be a role in developing nations; however, the optimal design of the interventions needs to be delineated. The evidence is less clear in other groups. Clinical Trial: Not Applicable

  • Examining the Accuracy of Optical Heart Rate Sensing Technology in Wearable Fitness Trackers for Young and Older Adults

    Date Submitted: May 14, 2019

    Open Peer Review Period: May 17, 2019 - Jul 12, 2019

    Background: Wearable fitness trackers are valuable tools that can record and enhance the physical activity of users. In recent years, the addition of photoplethysmography (PPG) devices, which employs...

    Background: Wearable fitness trackers are valuable tools that can record and enhance the physical activity of users. In recent years, the addition of photoplethysmography (PPG) devices, which employs the optical heart rate sensors that can display real-time heart rates, has become popular and is an important parameter for monitoring and controlling exercise intensity. Although studies have highlighted the practical benefits of using optical heart rate monitors, the accuracy of readouts these commercial devices generate has not been widely studied, especially for different age groups and for yellow-skin tone ethnicity. Objective: This study aimed to examine the feasibility of applying two wearable fitness trackers with PPG to monitor real-time heart rates during moderate exercises for young and older adults. Methods: A total of 20 young adults and 20 older adults were recruited to this study. All participants were asked to undergo a series of sedentary and moderate physical activities by using indoor aerobic exercise equipment. Polar H7 chest strap heart rate monitor was used as the criterion measure to the two fitness trackers, Xiaomi Mi Band 2 and Garmin Vivosmart HR+ in this study. The real-time second-by-second heart rate data from both devices were recorded through broadcast heart rate mode. To critically analyze the results, multiple statistical parameters, including the mean absolute percentage error (MAPE), Lin’s concordance correlation coefficient (CCC), intra-class correlation coefficient, Pearson’s product correlation coefficient, and Bland–Altman coefficient were determined to examine the performances of the devices. Results: Both test devices exhibited acceptable overall accuracy as heart rate sensors based on several statistical tests. Notably, the MAPE values were below 10% (the designated threshold) in both devices (GarminYoung = 3.77%; GarminSenior = 4.73%; XiaomiYoung = 7.69%; XiaomiSenior = 6.04%). The reliability test of CCC scores for Garmin was found to be 0.92 (Young) and 0.80 (Senior), whereas the CCC scores for Xiaomi were 0.76 (Young) and 0.73 (Senior). However, our results obtained using the Bland–Altman analysis indicated that both of the test optical devices averagely underestimated the heart rate. Most importantly, this study documented some unexpected extreme readings reported by these devices when used on certain paThis study revealed that commonly used optical heart rate sensors, such as Garmin vivosmart HR+ and Mi band 2 reported in the current study, generally produce accurate heart rate readings regardless of the age of the users. However, users should be cautious to rely entirely on these readings to indicate exercise intensities, as these devices have a tendency to produce erroneous extreme readings which might lead to the misjudgment of real-time exercise intensity. Future studies should, therefore, emphasize the occurrence rate of such errors, as this will likely benefit the development of improved models of heart rate sensors. rticipants. Conclusions: This study revealed that commonly used optical heart rate sensors, such as Garmin vivosmart HR+ and Mi band 2 reported in the current study, generally produce accurate heart rate readings regardless of the age of the users. However, users should be cautious to rely entirely on these readings to indicate exercise intensities, as these devices have a tendency to produce erroneous extreme readings which might lead to the misjudgment of real-time exercise intensity. Future studies should, therefore, emphasize the occurrence rate of such errors, as this will likely benefit the development of improved models of heart rate sensors.

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