JMIR Publications

JMIR mHealth and uHealth

Mobile and tablet apps, ubiquitous and pervasive computing, wearable computing and domotics for health.


Journal Description

JMIR mhealth and uhealth (mobile and ubiquitous health) (JMU, ISSN 2291-5222) is a spin-off journal of JMIR, the leading eHealth journal (Impact Factor 2015: 4.532). For JMIR mHealth and uHealth we are expecting the first impact factor in 2017 which will be at least 2.84. 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 is indexed in PubMed Central/PubMed, and Thomson Reuters' Science Citation Index Expanded (SCIE), and is expecting its first official impact factor in July 2017.

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:

  • Woman browsing page on mobile phone. Photo credit: tokyoform. Image Source: Flickr, URL: via Photopin, licensed under Creative Commons Attribution NonCommercial NoDerivs 2.0 Generic.

    Formative Evaluation of Participant Experience With Mobile eConsent in the App-Mediated Parkinson mPower Study: A Mixed Methods Study


    Background: To fully capitalize on the promise of mobile technology to enable scalable, participant-centered research, we must develop companion self-administered electronic informed consent (eConsent) processes. As we do so, we have an ethical obligation to ensure that core tenants of informed consent—informedness, comprehension, and voluntariness—are upheld. Furthermore, we should be wary of recapitulating the pitfalls of “traditional” informed consent processes. Objective: Our objective was to describe the essential qualities of participant experience, including delineation of common and novel themes relating to informed consent, with a self-administered, smartphone-based eConsent process. We sought to identify participant responses related to informedness, comprehension, and voluntariness as well as to capture any emergent themes relating to the informed consent process in an app-mediated research study. Methods: We performed qualitative thematic analysis of participant responses to a daily general prompt collected over a 6-month period within the Parkinson mPower app. We employed a combination of a priori and emergent codes for our analysis. A priori codes focused on the core concepts of informed consent; emergent codes were derived to capture additional themes relating to self-administered consent processes. We used self-reported demographic information from the study’s baseline survey to characterize study participants and respondents. Results: During the study period, 9846 people completed the eConsent process and enrolled in the Parkinson mPower study. In total, 2758 participants submitted 7483 comments; initial categorization identified a subset of 3875 germane responses submitted by 1678 distinct participants. Respondents were more likely to self-report a Parkinson disease diagnosis (30.21% vs 11.10%), be female (28.26% vs 20.18%), be older (42.89 years vs 34.47 years), and have completed more formal education (66.23% with a 4-year college degree or more education vs 55.77%) than all the mPower participants (P<.001 for all values). Within our qualitative analysis, 3 conceptual domains emerged. First, consistent with fully facilitated in-person informed consent settings, we observed a broad spectrum of comprehension of core research concepts following eConsent. Second, we identified new consent themes born out of the remote mobile research setting, for example the impact of the study design on the engagement of controls and the misconstruction of the open response field as a method for responsive communication with researchers, that bear consideration for inclusion within self-administered eConsent. Finally, our findings highlighted participants’ desire to be empowered as partners. Conclusions: Our study serves as a formative evaluation of participant experience with a self-administered informed consent process via a mobile app. Areas for future investigation include direct comparison of the efficacy of self-administered eConsent with facilitated informed consent processes, exploring the potential benefits and pitfalls of smartphone user behavioral habits on participant engagement in research, and developing best practices to increase informedness, comprehension, and voluntariness via participant coengagement in the research endeavor.

  • mHealth app. Photo credit: Thom Cochrane. Image source: Image is a derivative of

    Mixed-Methods Analysis of Factors Impacting Use of a Postoperative mHealth App


    Background: Limited communication and care coordination following discharge from hospitals may contribute to surgical complications. Smartphone apps offer a novel mechanism for communication and care coordination. However, factors which may affect patient app use in a postoperative, at-home setting are poorly understood. Objective: The objectives of this study were to (1) gauge interest in smartphone app use among patients after colorectal surgery and (2) better understand factors affecting patient app use in a postoperative, at-home setting. Methods: A prospective feasibility study was performed at a hospital that principally serves low socioeconomic status patients. After colorectal surgery, patients were enrolled and given a smartphone app, which uses previously validated content to provide symptom-based recommendations. Patients were instructed to use the app daily for 14 days after discharge. Demographics and usability data were collected at enrollment. Usability was measured with the System Usability Scale (SUS). At follow-up, the SUS was repeated and patients underwent a structured interview covering ease of use, willingness to use, and utility of use. Two members of the research team independently reviewed the field notes from follow-up interviews and extracted the most consistent themes. Chart and app log reviews identified clinical endpoints. Results: We screened 115 patients, enrolled 20 patients (17.4%), and completed follow-up interviews with 17 patients (85%). Reasons for nonenrollment included: failure to meet inclusion criteria (47/115, 40.9%), declined to participate (26/115, 22.6%), and other reasons (22/115, 19.1%). There was no difference in patient ratings between usability at first-use and after extended use, with SUS scores greater than the 95th percentile at both time points. Despite high usability ratings, 6/20 (30%) of patients never used the app at home after hospital discharge and 2/20 (10%) only used the app once. Interviews revealed three themes related to app use: (1) patient-related barriers could prevent use even though the app had high usability scores; (2) patients viewed the app as a second opinion, rather than a primary source of information; and (3) many patients viewed the app as an external burden. Conclusions: Use patterns in this study, and response rates after prompts to contact the operative team, suggest that apps need to be highly engaging to be adopted by patients. The growing penetration of smartphones and the proliferation of app-based interventions are unlikely to improve care coordination and communication, unless apps address the barriers and patient perceptions identified in this study. This study shows that high usability alone is not sufficient to motivate patients to use smartphone apps in the postoperative period.

  • Image Source: Javier Ignacio Acuña Ditzel via FlickR, licensed under Creative Commons BY 2.0.

    Latino Adults’ Perspectives on Treating Tobacco Use Via Social Media


    Background: Latinos are the largest minority group in the United States, and in California they outnumber non-Hispanic whites. Smoking cessation programs tailored for Latino culture, and this population’s specific smoking patterns, are needed. Online social networks for smoking cessation have high potential for Latinos, but have not been tested to date. Objective: Building a research program on social media apps for cancer prevention in diverse populations, this qualitative study assessed acceptability of tobacco treatment that was distributed via social media for Latino smokers. Methods: We conducted three focus groups with Latino adults who were former and current smokers recruited from Santa Clara County, California in 2015 (N=32). We assessed participants’ smoking histories, attempts to quit, social media exposure, and receptivity to a social media-based smoking cessation intervention. Audio transcripts were translated and coded for themes. Results: Participants reported factors driving their tobacco use and motivations to quit, and emphasized the importance of community and family in influencing their smoking initiation, cravings and triggers, attempts to quit, and abstinence. Participants valued the communal aspect of social media and suggested strategically tailoring groups based on key features (eg, age, gender, language preference). Participants reported preferring visual, educational, and motivational messages that were connected with existing services. Conclusions: Participants generally voiced acceptability of a social media-delivered intervention to help them quit smoking, viewed the intervention as well-equipped for catering to the strong community orientation of Latinos, and suggested that the platform was able to address variation within the population through strategic group creation. As a group member reflected, “Podemos hacerlo juntos” (We can do it together).

  • MyMealMate screenshots with overlay of smartphone recording food. Screenshots from MyMealMate website (University of Leeds). Overlay picture source:; copyright: CC0 Public Domain.

    Weight Loss Associated With Different Patterns of Self-Monitoring Using the Mobile Phone App My Meal Mate


    Background: Obesity is a major global public health issue due to its association with a number of serious chronic illnesses and its high economic burden to health care providers. Self-monitoring of diet has been consistently linked to weight loss. However, there is limited evidence about how frequently individuals need to monitor their diet for optimal weight loss. Objective: The aim of this paper is to describe app usage frequency and pattern in the mobile phone arm of a previously conducted randomized controlled trial. The relationship between frequency and pattern of electronic dietary self-monitoring and weight loss is also investigated. Methods: A randomized pilot trial comparing three methods of self-monitoring (mobile phone app, paper diary, Web-based) was previously conducted. Trial duration was 6 months. The mobile phone app My Meal Mate features an electronic food diary and encourages users to self-monitor their dietary intake. All food consumption data were automatically uploaded with a time and date stamp. Post hoc regression analysis of app usage patterns was undertaken in the My Meal Mate group (n=43; female: 77%, 33/43; white: 100%, 43/43; age: mean 41, SD 9 years; body mass index: mean 34, SD 4 kg/m2) to explore the relationship between frequency and pattern of electronic dietary self-monitoring and weight loss. Baseline characteristics of participants were also investigated to identify any potential predictors of dietary self-monitoring. Results: Regression analysis showed that those in the highest frequency-of-use category (recorded ≥129 days on the mobile phone app) had a −6.4 kg (95% CI −10.0 to −2.9) lower follow-up weight (adjusted for baseline weight) than those in the lowest frequency-of-use category (recorded ≤42 days; P<.001). Long-term intermittent monitoring over 6 months appeared to facilitate greater mean weight loss than other patterns of electronic self-monitoring (ie, monitoring over the short or moderate term and stopping and consistently monitoring over consecutive days). Participant characteristics such as age, baseline weight, sex, ethnicity, conscientiousness, and consideration of future consequences were not statistically associated with extent of self-monitoring. Conclusions: The results of this post hoc exploratory analysis indicate that duration and frequency of app use is associated with improved weight loss, but further research is required to identify whether there are participant characteristics that would reliably predict those who are most likely to regularly self-monitor their diet. Clinical Trial: NCT01744535; (Archived by WebCite at

  • Using the Philips Health Watch. Image sourced and copyright owned by Philips.

    Clinical Evaluation of the Measurement Performance of the Philips Health Watch: A Within-Person Comparative Study


    Background: Physical inactivity is an important modifiable risk factor for chronic diseases. A new wrist-worn heart rate and activity monitor has been developed for unobtrusive data collection to aid prevention and management of lifestyle-related chronic diseases by means of behavioral change programs. Objective: The objective of the study was to evaluate the performance of total energy expenditure and resting heart rate measures of the Philips health watch. Secondary objectives included the assessment of accuracy of other output parameters of the monitor: heart rate, respiration rate at rest, step count, and activity type recognition. Methods: A within-person comparative study was performed to assess the performance of the health watch against (medical) reference measures. Participants executed a protocol including 15 minutes of rest and various activities of daily life. A two one-sided tests approach was adopted for testing equivalence. In addition, error metrics such as mean error and mean absolute percentage error (MAPE) were calculated. Results: A total of 29 participants (14 males; mean age 41.2, SD 14.4, years; mean weight 77.2, SD 10.2, kg; mean height 1.8, SD 0.1, m; mean body mass index 25.1, SD 3.1, kg/m2) completed the 81-minute protocol. Their mean resting heart rate in beats per minute (bpm) was 64 (SD 7.3). With a mean error of −10 (SD 38.9) kcal and a MAPE of 10% (SD 8.7%), total energy expenditure estimation of the health watch was found to be within the 15% predefined equivalence margin in reference to a portable indirect calorimeter. Resting heart rate determined during a 15-minute rest protocol was found to be within a 10% equivalence margin in reference to a wearable electrocardiogram (ECG) monitor, with a mean deviation of 0 bpm and a maximum deviation of 3 bpm. Heart rate was within 10 bpm and 10% of the ECG monitor reference for 93% of the duration of the protocol. Step count estimates were on average 21 counts lower than a waist-mounted step counter over all walking activities combined, with a MAPE of 3.5% (SD 2.4%). Resting respiration rate was on average 0.7 (SD 1.1) breaths per minute lower than the reference measurement by the spirometer embedded in the indirect calorimeter during the 15-minute rest, resulting in a MAPE of 8.3% (SD 7.0%). Activity type recognition of walking, running, cycling, or other was overall 90% accurate in reference to the activities performed. Conclusions: The health watch can serve its medical purpose of measuring resting heart rate and total energy expenditure over time in an unobtrusive manner, thereby providing valuable data for the prevention and management of lifestyle-related chronic diseases. Trial Registration: Netherlands trial register NTR5552; (Archived by WebCite at

  • Text messaging to improve medication adherence. Image source: Image purchased by authors.

    Text Messaging to Improve Hypertension Medication Adherence in African Americans From Primary Care and Emergency Department Settings: Results From Two...


    Background: Hypertension (HTN) is an important problem in the United States, with an estimated 78 million Americans aged 20 years and older suffering from this condition. Health disparities related to HTN are common in the United States, with African Americans suffering from greater prevalence of the condition than whites, as well as greater severity, earlier onset, and more complications. Medication adherence is an important component of HTN management, but adherence is often poor, and simply forgetting to take medications is often cited as a reason. Mobile health (mHealth) strategies have the potential to be a low-cost and effective method for improving medication adherence that also has broad reach. Objective: Our goal was to determine the feasibility, acceptability, and preliminary clinical effectiveness of BPMED, an intervention designed to improve medication adherence among African Americans with uncontrolled HTN, through fully automated text messaging support. Methods: We conducted two parallel, unblinded randomized controlled pilot trials with African-American patients who had uncontrolled HTN, recruited from primary care and emergency department (ED) settings. In each trial, participants were randomized to receive either usual care or the BPMED intervention for one month. Data were collected in-person at baseline and one-month follow-up, assessing the effect on medication adherence, systolic and diastolic blood pressure (SBP and DBP), medication adherence self-efficacy, and participant satisfaction. Data for both randomized controlled pilot trials were analyzed separately and combined. Results: A total of 58 primary care and 65 ED participants were recruited with retention rates of 91% (53/58) and 88% (57/65), respectively. BPMED participants consistently showed numerically greater, yet nonsignificant, improvements in measures of medication adherence (mean change 0.9, SD 2.0 vs mean change 0.5, SD 1.5, P=.26), SBP (mean change –12.6, SD 24.0 vs mean change –11.3, SD 25.5 mm Hg, P=.78), and DBP (mean change –4.9, SD 13.1 mm Hg vs mean change –3.3, SD 14.3 mm Hg, P=.54). Control and BPMED participants had slight improvements to medication adherence self-efficacy (mean change 0.8, SD 9.8 vs mean change 0.7, SD 7.0) with no significant differences found between groups (P=.92). On linear regression analysis, baseline SBP was the only predictor of SBP change; participants with higher SBP at enrollment exhibited significantly greater improvements at one-month follow-up (β=–0.63, P<.001). In total, 94% (51/54) of BPMED participants agreed/strongly agreed that they were satisfied with the program, regardless of pilot setting. Conclusions: Use of text message reminders to improve medication adherence is a feasible and acceptable approach among African Americans with uncontrolled HTN. Although differences in actual medication adherence and blood pressure between BPMED and usual care controls were not significant, patterns of improvement in the BPMED condition suggest that text message medication reminders may have an effect and fully powered investigations with longer-term follow-up are warranted. Trial Registration: NCT01465217; (Archived by WebCite at

  • Fitbit. Image sourced and copyright owned by authors.

    Assessing the Influence of a Fitbit Physical Activity Monitor on the Exercise Practices of Emergency Medicine Residents: A Pilot Study


    Background: Targeted interventions have improved physical activity and wellness of medical residents. However, no exercise interventions have focused on emergency medicine residents. Objective: This study aimed to measure the effectiveness of a wearable device for tracking physical activity on the exercise habits and wellness of this population, while also measuring barriers to adoption and continued use. Methods: This pre-post cohort study enrolled 30 emergency medicine residents. Study duration was 6 months. Statistical comparisons were conducted for the primary end point and secondary exercise end points with nonparametric tests. Descriptive statistics were provided for subjective responses. Results: The physical activity tracker did not increase the overall self-reported median number of days of physical activity per week within this population: baseline 2.5 days (interquartile range, IQR, 1.9) versus 2.8 days (IQR 1.5) at 1 month (P=.36). There was a significant increase in physical activity from baseline to 1 month among residents with median weekly physical activity level below that recommended by the Centers for Disease Control and Prevention at study start, that is, 1.5 days (IQR 0.9) versus 2.4 days (IQR 1.2; P=.04), to 2.0 days (IQR 2.0; P=.04) at 6 months. More than half (60%, 18/30) of participants reported a benefit to their overall wellness, and 53% (16/30) reported a benefit to their physical activity. Overall continued use of the device was 67% (20/30) at 1 month and 33% (10/30) at 6 months. Conclusions: The wearable physical activity tracker did not change the overall physical activity levels among this population of emergency medicine residents. However, there was an improvement in physical activity among the residents with the lowest preintervention physical activity. Subjective improvements in overall wellness and physical activity were noted among the entire study population.

  • Examples of alcohol exposure videos. Image sourced and copyright owned by authors.

    A Smarter Pathway for Delivering Cue Exposure Therapy? The Design and Development of a Smartphone App Targeting Alcohol Use Disorder


    Background: Although the number of alcohol-related treatments in app stores is proliferating, none of them are based on a psychological framework and supported by empirical evidence. Cue exposure treatment (CET) with urge-specific coping skills (USCS) is often used in Danish treatment settings. It is an evidence-based psychological approach that focuses on promoting “confrontation with alcohol cues” as a means of reducing urges and the likelihood of relapse. Objective: The objective of this study was to describe the design and development of a CET-based smartphone app; an innovative delivery pathway for treating alcohol use disorder (AUD). Methods: The treatment is based on Monty and coworkers’ manual for CET with USCS (2002). It was created by a multidisciplinary team of psychiatrists, psychologists, programmers, and graphic designers as well as patients with AUD. A database was developed for the purpose of registering and monitoring training activities. A final version of the CET app and database was developed after several user tests. Results: The final version of the CET app includes an introduction, 4 sessions featuring USCS, 8 alcohol exposure videos promoting the use of one of the USCS, and a results component providing an overview of training activities and potential progress. Real-time urges are measured before, during, and after exposure to alcohol cues and are registered in the app together with other training activity variables. Data packages are continuously sent in encrypted form to an external database and will be merged with other data (in an internal database) in the future. Conclusions: The CET smartphone app is currently being tested at a large-scale, randomized controlled trial with the aim of clarifying whether it can be classified as an evidence-based treatment solution. The app has the potential to augment the reach of psychological treatment for AUD.

  • Smiling senior couple using smartphone. Image source: Image purchased by authors.

    Mobile Health Physical Activity Intervention Preferences in Cancer Survivors: A Qualitative Study


    Background: Cancer survivors are at an elevated risk for several negative health outcomes, but physical activity (PA) can decrease those risks. Unfortunately, adherence to PA recommendations among survivors is low. Fitness mobile apps have been shown to facilitate the adoption of PA in the general population, but there are limited apps specifically designed for cancer survivors. This population has unique needs and barriers to PA, and most existing PA apps do not address these issues. Moreover, incorporating user preferences has been identified as an important priority for technology-based PA interventions, but at present there is limited literature that serves to establish these preferences in cancer survivors. This is especially problematic given the high cost of app development and because the majority of downloaded apps fail to engage users over the long term. Objective: The aim of this study was to take a qualitative approach to provide practical insight regarding this population’s preferences for the features and messages of an app to increase PA. Methods: A total of 35 cancer survivors each attended 2 focus groups; a moderator presented slide shows on potential app features and messages and asked open-ended questions to elicit participant preferences. All sessions were audio recorded and transcribed verbatim. Three reviewers independently conducted thematic content analysis on all transcripts, then organized and consolidated findings to identify salient themes. Results: Participants (mean age 63.7, SD 10.8, years) were mostly female (24/35, 69%) and mostly white (25/35, 71%). Participants generally had access to technology and were receptive to engaging with an app to increase PA. Themes identified included preferences for (1) a casual, concise, and positive tone, (2) tools for personal goal attainment, (3) a prescription for PA, and (4) an experience that is tailored to the user. Participants reported wanting extensive background data collection with low data entry burden and to have a trustworthy source translate their personal data into individualized PA recommendations. They expressed a desire for app functions that could facilitate goal achievement and articulated a preference for a more private social experience. Finally, results indicated that PA goals might be best established in the context of personally held priorities and values. Conclusions: Many of the desired features identified are compatible with both empirically supported methods of behavior change and the relative strengths of an app as a delivery vehicle for behavioral intervention. Participating cancer survivors’ preferences contrasted with many current standard practices for mobile app development, including value-based rather than numeric goals, private socialization in small groups rather than sharing with broader social networks, and interpretation of PA data rather than merely providing numerical data. Taken together, these insights may help increase the acceptability of theory-based mHealth PA interventions in cancer survivors.

  • Mean engagement with mHealth intervention. Image sourced and copyright owned by authors.

    Analyzing mHealth Engagement: Joint Models for Intensively Collected User Engagement Data


    Background: Evaluating engagement with an intervention is a key component of understanding its efficacy. With an increasing interest in developing behavioral interventions in the mobile health (mHealth) space, appropriate methods for evaluating engagement in this context are necessary. Data collected to evaluate mHealth interventions are often collected much more frequently than those for clinic-based interventions. Additionally, missing data on engagement is closely linked to level of engagement resulting in the potential for informative missingness. Thus, models that can accommodate intensively collected data and can account for informative missingness are required for unbiased inference when analyzing engagement with an mHealth intervention. Objective: The objectives of this paper are to discuss the utility of the joint modeling approach in the analysis of longitudinal engagement data in mHealth research and to illustrate the application of this approach using data from an mHealth intervention designed to support illness management among people with schizophrenia. Methods: Engagement data from an evaluation of an mHealth intervention designed to support illness management among people with schizophrenia is analyzed. A joint model is applied to the longitudinal engagement outcome and time-to-dropout to allow unbiased inference on the engagement outcome. Results are compared to a naïve model that does not account for the relationship between dropout and engagement. Results: The joint model shows a strong relationship between engagement and reduced risk of dropout. Using the mHealth app 1 day more per week was associated with a 23% decreased risk of dropout (P<.001). The decline in engagement over time was steeper when the joint model was used in comparison with the naïve model. Conclusions: Naïve longitudinal models that do not account for informative missingness in mHealth data may produce biased results. Joint models provide a way to model intensively collected engagement outcomes while simultaneously accounting for the relationship between engagement and missing data in mHealth intervention research.

  • Tanning bed. Image source: dorianrochowski, Copyright: CC0 Public Domain.

    Design and Feasibility of a Text Messaging Intervention to Prevent Indoor Tanning Among Young Adult Women: A Pilot Study


    Background: Although skin cancer is largely preventable, it affects nearly 1 of 5 US adults. There is a need for research on how to optimally design persuasive public health indoor tanning prevention messages. Objective: The objective of our study was to examine whether framed messages on indoor tanning behavioral intentions delivered through short message service (SMS) text messaging would produce (1) positive responses to the messages, including message receptivity and emotional response; (2) indoor tanning efficacy beliefs, including response efficacy and self-efficacy; and (3) indoor tanning risk beliefs. Methods: We conducted a pilot study of indoor tanning prevention messages delivered via mobile phone text messaging in a sample of 21 young adult women who indoor tan. Participants completed baseline measures, were randomly assigned to receive gain-, loss-, or balanced-framed text messages, and completed postexposure outcome measures on indoor tanning cognitions and behaviors. Participants received daily mobile phone indoor tanning prevention text messages for 1 week and completed the same postexposure measures as at baseline. Results: Over the 1-week period there were trends or significant changes after receipt of the text messages, including increased perceived susceptibility (P<.001), response efficacy beliefs (P<.001), and message receptivity (P=.03). Ordinary least squares stepwise linear regression models showed an effect of text message exposure on self-efficacy to quit indoor tanning (t6=–2.475, P<.02). Ordinary least squares linear regression including all measured scales showed a marginal effect of SMS texts on self-efficacy (t20=1.905, P=.08). Participants endorsed highly favorable views toward the text messaging protocol. Conclusions: This study supports this use of mobile text messaging as an indoor tanning prevention strategy. Given the nature of skin cancer risk perceptions, the addition of multimedia messaging service is another area of potential innovation for disseminating indoor tanning prevention messages.

  • Smartphone. Image source: Author: JESHOOTS. Copyright: CC0 public domain.

    Smartphone Apps for Measuring Human Health and Climate Change Co-Benefits: A Comparison and Quality Rating of Available Apps


    Background: Climate change and the burden of noncommunicable diseases are major global challenges. Opportunities exist to investigate health and climate change co-benefits through a shift from motorized to active transport (walking and cycling) and a shift in dietary patterns away from a globalized diet to reduced consumption of meat and energy dense foods. Given the ubiquitous use and proliferation of smartphone apps, an opportunity exists to use this technology to capture individual travel and dietary behavior and the associated impact on the environment and health. Objective: The objective of the study is to identify, describe the features, and rate the quality of existing smartphone apps which capture personal travel and dietary behavior and simultaneously estimate the carbon cost and potential health consequences of these actions. Methods: The Google Play and Apple App Stores were searched between October 19 and November 6, 2015, and a secondary Google search using the apps filter was conducted between August 8 and September 18, 2016. Eligible apps were required to estimate the carbon cost of personal behaviors with the potential to include features to maximize health outcomes. The quality of included apps was assessed by 2 researchers using the Mobile Application Rating Scale (MARS). Results: Out of 7213 results, 40 apps were identified and rated. Multiple travel-related apps were identified, however no apps solely focused on the carbon impact or health consequences of dietary behavior. None of the rated apps provided sufficient information on the health consequences of travel and dietary behavior. Some apps included features to maximize participant engagement and encourage behavior change towards reduced greenhouse gas emissions. Most apps were rated as acceptable quality as determined by the MARS; 1 was of poor quality and 10 apps were of good quality. Interrater reliability of the 2 evaluators was excellent (ICC=0.94, 95% CI 0.87-0.97). Conclusions: Existing apps capturing travel and dietary behavior and the associated health and environmental impact are of mixed quality. Most apps do not include all desirable features or provide sufficient health information. Further research is needed to determine the potential of smartphone apps to evoke behavior change resulting in climate change and health co-benefits.

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  • Beta Testing of a Smartphone Application for WIC-Participating Families with Preschool-Aged Children

    Date Submitted: Feb 9, 2017

    Open Peer Review Period: Feb 9, 2017 - Apr 6, 2017

    Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the U.S. provides free supplemental healthy foods and nutrition education to limited-resource, nutritio...

    Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the U.S. provides free supplemental healthy foods and nutrition education to limited-resource, nutritionally at-risk mothers, infants, and children under age 5. Childhood obesity prevalence is higher among low-income preschool children participating in the WIC program compared to children in the general population in the U.S. The Children Eating Well (CHEW) smartphone application (“app”) was developed in English and Spanish for WIC-participating families with preschool-aged children as a home-based intervention to reinforce WIC nutrition education. Objective: This paper describes the development and beta testing of the CHEW smartphone app. The objective of beta testing was to test the CHEW app prototype with target users, focusing on usage, usability, and perceived benefits of the app. Methods: The goals of the CHEW app were to make the WIC shopping experience easier, maximize WIC benefit redemption, and improve parent snack feeding practices. The CHEW app prototype consisted of: (1) WIC shopping tools, including a barcode scanner and calculator tools for the cash value voucher for purchasing fruits and vegetables, and (2) nutrition education focused on healthy snacks and beverages, including a Yummy Snack Gallery and Healthy Snacking Tips. Mothers of 63 black and Hispanic WIC-participating children ages 2-4 tested the CHEW app prototype for three months and completed follow-up interviews. Results: Over three months, 81% reported using the WIC shopping tools, 68% used the snack gallery, 75% viewed the snacking tips, and 91% used at least one of these features. Indicators of usability, ranging from 1 (lowest) to 5 (highest), were rated moderately high to high (3.81-4.40) for the WIC shopping tools. Mothers of black children rated the helpfulness of the produce calculators lower than mothers of Hispanic children (3.86 vs. 4.53, P=.04). The WIC shopping tools scored high on most of the perceived benefits for targeted behaviors (4.10-4.51 on scale of 1 to 5), with the exception of helping them to spend more on the cash value voucher (3.57). Mothers who used the Yummy Snack Gallery and Healthy Snacking Tips consistently scored them high on all dimensions of usability (4.34-4.95), with relatively lower scores for perceived benefits (3.20-3.96). For the healthy snacking tips, seven of the eight perceived benefit items were lower for mothers of black children, ranging 3.17-3.73, compared to mothers of Hispanic children, ranging 4.30-4.68 (all P<.05). Conclusions: The prototype study successfully demonstrated feasibility of using the CHEW app prototype with mothers of WIC-enrolled black and Hispanic preschool-aged children, with moderate to high usability and perceived benefits for the three main components of the app. Future versions with enhanced shopping tools and expanded nutrition content should be implemented in WIC clinics to evaluate adoption and behavioral outcomes.

  • Controlling Your "App"etite: How Diet and Nutrition-Related Mobile Applications Lead to Behavior Change

    Date Submitted: Jan 26, 2017

    Open Peer Review Period: Jan 26, 2017 - Mar 23, 2017

    Background: In recent years, obesity in America has become a serious public health crisis. While the problem of obesity is being addressed through a variety of strategies, the use of mobile applicatio...

    Background: In recent years, obesity in America has become a serious public health crisis. While the problem of obesity is being addressed through a variety of strategies, the use of mobile applications (apps) is a relatively new development that could prove useful in helping people to develop healthy dietary habits. While such apps might lead to healthy behavior change, especially when relevant behavior change theory constructs are integrated into them, the mechanisms by which those apps facilitate behavior change are largely unknown. Objective: The purpose of this study is to identify which behavior change mechanisms are associated with use of diet- and nutrition-related health apps and whether the use of diet- and nutrition-related apps is associated with health behavior change. Methods: A cross-sectional survey was administered to a total of 217 participants. Participants responded to questions on demographics, use of diet/nutrition app(s) in the past 6 months, engagement and likeability of app(s), and changes in the participant’s dietary behaviors. Regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior, after controlling for potential confounding variables. Results: The majority of study participants agreed or strongly agreed with statements regarding app use increasing their motivation to eat a healthy diet, improving their self-efficacy, and increasing their desire to set and achieve health diet goals. The majority of participants strongly agreed that using diet/nutrition apps led to changes in their behavior, namely increases in actual goal setting to eat a healthy diet (58.5%), increases in their frequency of eating healthy foods (57.6%), and increases in their consistency of eating healthy foods (54.4%). Participants also responded favorably to questions related to engagement and likability of diet/nutrition apps. A number of predictors were also positively associated with diet-related behavior change. Theory (p<.001), app engagement (p<.001), app use (p<.003), and education (p<.010) were all positively associated with behavior change. Conclusions: Study findings indicate that the use of diet/nutrition apps is associated with diet-related behavior change. Hence, diet- and nutrition-related apps that focus on improving motivation, desire, self-efficacy, attitudes, knowledge, and goal setting may be particularly useful. As the number of diet- and nutrition-related apps continues to grow, developers should consider integrating appropriate theoretical constructs for health behavior change into newly developed mobile apps.

  • Incorporation of a stress reducing mobile app in the care of patients with type 2 diabetes

    Date Submitted: Jan 25, 2017

    Open Peer Review Period: Jan 25, 2017 - Mar 22, 2017

    Background: Emotional stress has been shown to contribute to the onset, progression and control of type 2 diabetes (T2D). Stress management and biofeedback assisted relaxation have been shown to impro...

    Background: Emotional stress has been shown to contribute to the onset, progression and control of type 2 diabetes (T2D). Stress management and biofeedback assisted relaxation have been shown to improve glycemic control. Use of a mobile app for stress management may enhance the scalability of such an approach. Objective: The study was designed to assess the effect of using a mobile app of biofeedback assisted relaxation on weight, blood pressure and glycemic measures of patients with T2D. Methods: Adult patients with type 2 diabetes and inadequate glycemic control (HbA1c>7.5%) were recruited from the outpatient diabetes clinic. Baseline weight, blood pressure, HbA1c, fasting plasma glucose, triglycerides and 7-point self-monitoring of blood glucose were measured. Patients were provided with a stress reducing, biofeedback mobile app and instructed to use it three times a day. The mobile app - Serenita© - is an interactive relaxation app based on acquiring a photoplethysmography signal from the Smartphone's camera lens, where the user places his finger. The app collects information regarding the user's blood flow, heart rate and heart rate variability and provides real-time feedback and individualized breathing instructions in order to modulate the stress level. All clinical and biochemical measures were repeated at 8 and 16 weeks of the study. The primary outcome was changes in measures at 8 weeks. Results: Seven patients completed 8 weeks of the study, and four completed 16 weeks. At week 8 weight dropped by an average of 4.0±4.3 kg; systolic blood pressure by 8.6±18.6 mmHg; HbA1c by 1.3±1.6%; fasting plasma glucose by 4.3±4.2 mmol/l and serum triglycerides were unchanged. Conclusions: Stress reduction using a mobile app based on biofeedback has the potential of improving glycemic control, weight and blood pressure. Clinical Trial: 02691273

  • Usability of a culturally informed mHealth intervention for anxiety and depression: Feedback from young sexual minority men

    Date Submitted: Jan 24, 2017

    Open Peer Review Period: Jan 25, 2017 - Mar 22, 2017

    Background: To date, we are aware of no interventions for anxiety and depression developed as smartphone applications (apps) and tailored to young sexual minority men, a group especially at risk for a...

    Background: To date, we are aware of no interventions for anxiety and depression developed as smartphone applications (apps) and tailored to young sexual minority men, a group especially at risk for anxiety and depression. We developed TODAY!, a culturally informed smartphone intervention for young men who are attracted to men and who have clinically significant symptoms of anxiety and/or depression. The core of the intervention consists of daily psychoeducation informed by transdiagnostic cognitive-behavioral therapy and a set of tools to facilitate putting these concepts into action, with regular mood ratings that result in tailored feedback (e.g. tips for current distress, visualizations of mood by context). Objective: We conducted usability testing to understand how young sexual minority men interact with the app, to inform later stages of intervention development. Methods: Participants (n = 9) were young sexual minority men aged 18-20 (M = 19.00, SD = 0.71; 44% Black, 44% White, 11.1% Latino), who endorsed at least mild depression and anxiety symptoms. Participants were recruited via flyers, emails to college LGBT organizations, online advertisements, another researcher’s database of sexual minority youth interested in research participation, and word of mouth. During recorded interviews, participants were asked to think out loud while interacting with the TODAY! app on a smartphone. Feedback identified from these recordings and from associated field notes were subjected to analysis. To aid interpretation of results, methods and results are reported according to the consolidated criteria for reporting qualitative research (COREQ). Results: Thematic analysis of usability feedback revealed six broad recurring themes: 1) Functionality (e.g., highlight new material when available); 2) Personalization (e.g., more tailored feedback); 3) Presentation (e.g., keep content brief); 4) Aesthetics, (e.g., use brighter colors); 5) LGBT/Youth Content (e.g., add content about coming out); and 6) Barriers to Use (e.g., perceiving psychoeducation as homework). Conclusions: Feedback from usability testing was vital to understanding what young sexual minority men desire from a smartphone intervention for anxiety and depression and was used to inform the ongoing development of such an intervention.

  • Design of Mobile Health Tools to Promote Goal Achievement in Self-Management Tasks

    Date Submitted: Jan 20, 2017

    Open Peer Review Period: Jan 21, 2017 - Mar 18, 2017

    Background: Goal setting within rehabilitation is a common practice ultimately geared toward helping patients make functional progress. Objective: The purposes of this study were to design a basic goa...

    Background: Goal setting within rehabilitation is a common practice ultimately geared toward helping patients make functional progress. Objective: The purposes of this study were to design a basic goal setting module within a mobile health system and to determine what functionality could be added to this goal setting module to support the complex goal setting routines desired by patients. Methods: A total of 750 goals were analyzed from patients with spina bifida and spinal cord injury enrolled in a wellness program. Results: A goal setting module was successfully developed. Checklists, data tracking and fact finding tools were identified as three functionalities that could be added to existing mobile health systems to support goal setting and achievement. Additional lessons learned provide a detailed list of recommendations for software development. Conclusions: Goals commonly set by individuals with disabilities can be supported by innovative mobile health tools.

  • Semantic location from mobile phones: Going beyond GPS

    Date Submitted: Jan 10, 2017

    Open Peer Review Period: Jan 16, 2017 - Mar 13, 2017

    Background: Is someone at home, at their friend’s place, at a restaurant, or enjoying the great outdoors? Knowing the semantic location matters for delivering medical interventions, recommendations,...

    Background: Is someone at home, at their friend’s place, at a restaurant, or enjoying the great outdoors? Knowing the semantic location matters for delivering medical interventions, recommendations, and other context-aware services. This knowledge is particularly useful in mental healthcare for monitoring the behavioral indicators of mood states and improving treatment delivery. Local search-and-discovery services such as Foursquare can be used to detect semantic locations based on GPS coordinates, but GPS alone is often inaccurate. Smartphones can also sense other signals, such as movement, light, and sound, and using these signals promises to lead to a better estimation of the semantic location. Objective: To examine the ability of smartphone sensors in estimating semantic locations, and to evaluate the relationship between semantic location visit patterns and mental health. Methods: 208 participants across the United States were asked to log the type of locations they visited daily, including home and work, for a period of 6 weeks, while their phone sensor data was recorded. Based on the sensor data and Foursquare queries, we trained models to predict these logged locations, and evaluated their prediction accuracy on participants not seen by the model. We also evaluated the relationship between the amount of time spent in each semantic location and depression and anxiety, assessed at the baseline, in the middle, and at the end of the study. Results: While Foursquare queries detected the true semantic locations with an average area under the curve (AUC) of 0.60, using phone sensor data increased the AUC to 0.72. When we used Foursquare and sensor data together, the AUC further increased to 0.78. We found a few significant relationships between the time spent in certain locations and depression and anxiety, although these relationships were not consistent. Conclusions: The accuracy of location services such as Foursquare can significantly benefit from using phone sensor data besides their location databases. Our results suggest that the nature of the places we go to explains only a small part of the variance of anxiety and depression.