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Journal Description

JMIR mHealth and uHealth (JMU, ISSN 2291-5222; Impact Factor 4.301) is a sister journal of JMIR, the leading eHealth journal. JMIR mHealth and uHealth is indexed in PubMed, PubMed Central, Scopus, MEDLINE and Science Citation Index Expanded (SCIE), and in June 2019 received an Impact Factor of 4.301, which ranks the journal #2 (behind JMIR) in the medical informatics category indexed by the Science Citation Index Expanded (SCIE) by Thomson Reuters/Clarivate

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

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

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

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


Recent Articles:

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

    Clustering Insomnia Patterns by Data From Wearable Devices: Algorithm Development and Validation Study


    Background: As societies become more complex, larger populations suffer from insomnia. In 2014, the US Centers for Disease Control and Prevention declared that sleep disorders should be dealt with as a public health epidemic. However, it is hard to provide adequate treatment for each insomnia sufferer, since various behavioral characteristics influence symptoms of insomnia collectively. Objective: We aim to develop a neural-net based unsupervised user clustering method towards insomnia sufferers in order to clarify the unique traits for each derived groups. Unlike the current diagnosis of insomnia that requires qualitative analysis from interview results, the classification of individuals with insomnia by using various information modalities from smart bands and neural-nets can provide better insight into insomnia treatments. Methods: This study, as part of the precision psychiatry initiative, is based on a smart band experiment conducted over 6 weeks on individuals with insomnia. During the experiment period, a total of 42 participants (19 male; average age 22.00 [SD 2.79]) from a large university wore smart bands 24/7, and 3 modalities were collected and examined: sleep patterns, daily activities, and personal demographics. We considered the consecutive daily information as a form of images, learned the latent variables of the images via a convolutional autoencoder (CAE), and clustered and labeled the input images based on the derived features. We then converted consecutive daily information into a sequence of the labels for each subject and finally clustered the people with insomnia based on their predominant labels. Results: Our method identified 5 new insomnia-activity clusters of participants that conventional methods have not recognized, and significant differences in sleep and behavioral characteristics were shown among groups (analysis of variance on rank: F4,37=2.36, P=.07 for the sleep_min feature; F4,37=9.05, P<.001 for sleep_efficiency; F4,37=8.16, P<.001 for active_calorie; F4,37=6.53, P<.001 for walks; and F4,37=3.51, P=.02 for stairs). Analyzing the consecutive data through a CAE and clustering could reveal intricate connections between insomnia and various everyday activity markers. Conclusions: Our research suggests that unsupervised learning allows health practitioners to devise precise and tailored interventions at the level of data-guided user clusters (ie, precision psychiatry), which could be a novel solution to treating insomnia and other mental disorders.

  • Health care provider using the PhotoExam app. Source: Mayo Foundation for Medical Education and Research; Copyright: Kirk D Wyatt; URL:; License: Fair use/fair dealings.

    Medical Videography Using a Mobile App: Retrospective Analysis


    Background: As mobile devices and apps grow in popularity, they are increasingly being used by health care providers to aid clinical care. At our institution, we developed and implemented a point-of-care clinical photography app that also permitted the capture of video recordings; however, the clinical findings it was used to capture and the outcomes that resulted following video recording were unclear. Objective: The study aimed to assess the use of a mobile clinical video recording app at our institution and its impact on clinical care. Methods: A single reviewer retrospectively reviewed video recordings captured between April 2016 and July 2017, associated metadata, and patient records. Results: We identified 362 video recordings that were eligible for inclusion. Most video recordings (54.1%; 190/351) were captured by attending physicians. Specialties recording a high number of video recordings included orthopedic surgery (33.7%; 122/362), neurology (21.3%; 77/362), and ophthalmology (15.2%; 55/362). Consent was clearly documented in the medical record in less than one-third (31.8%; 115/362) of the records. People other than the patient were incidentally captured in 29.6% (107/362) of video recordings. Although video recordings were infrequently referenced in notes corresponding to the clinical encounter (12.2%; 44/362), 7.7% (22/286) of patients were video recorded in subsequent clinical encounters, with 82% (18/22) of these corresponding to the same finding seen in the index video. Store-and-forward telemedicine was documented in clinical notes in only 2 cases (0.5%; 2/362). Videos appeared to be of acceptable quality for clinical purposes. Conclusions: Video recordings were captured in a variety of clinical settings. Documentation of consent was inconsistent, and other individuals were incidentally included in videos. Although clinical impact was not always clearly evident through retrospective review because of limited documentation, potential uses include documentation for future reference and store-and-forward telemedicine. Repeat video recordings of the same finding provide evidence of use to track the findings over time. Clinical video recordings have the potential to support clinical care; however, documentation of consent requires standardization.

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

    Use of Mobile Health Apps and Wearable Technology to Assess Changes and Predict Pain During Treatment of Acute Pain in Sickle Cell Disease: Feasibility Study


    Background: Sickle cell disease (SCD) is an inherited red blood cell disorder affecting millions worldwide, and it results in many potential medical complications throughout the life course. The hallmark of SCD is pain. Many patients experience daily chronic pain as well as intermittent, unpredictable acute vaso-occlusive painful episodes called pain crises. These pain crises often require acute medical care through the day hospital or emergency department. Following presentation, a number of these patients are subsequently admitted with continued efforts of treatment focused on palliative pain control and hydration for management. Mitigating pain crises is challenging for both the patients and their providers, given the perceived unpredictability and subjective nature of pain. Objective: The objective of this study was to show the feasibility of using objective, physiologic measurements obtained from a wearable device during an acute pain crisis to predict patient-reported pain scores (in an app and to nursing staff) using machine learning techniques. Methods: For this feasibility study, we enrolled 27 adult patients presenting to the day hospital with acute pain. At the beginning of pain treatment, each participant was given a wearable device (Microsoft Band 2) that collected physiologic measurements. Pain scores from our mobile app, Technology Resources to Understand Pain Assessment in Patients with Pain, and those obtained by nursing staff were both used with wearable signals to complete time stamp matching and feature extraction and selection. Following this, we constructed regression and classification machine learning algorithms to build between-subject pain prediction models. Results: Patients were monitored for an average of 3.79 (SD 2.23) hours, with an average of 5826 (SD 2667) objective data values per patient. As expected, we found that pain scores and heart rate decreased for most patients during the course of their stay. Using the wearable sensor data and pain scores, we were able to create a regression model to predict subjective pain scores with a root mean square error of 1.430 and correlation between observations and predictions of 0.706. Furthermore, we verified the hypothesis that the regression model outperformed the classification model by comparing the performances of the support vector machines (SVM) and the SVM for regression. Conclusions: The Microsoft Band 2 allowed easy collection of objective, physiologic markers during an acute pain crisis in adults with SCD. Features can be extracted from these data signals and matched with pain scores. Machine learning models can then use these features to feasibly predict patient pain scores.

  • Milk formula advertising. Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    A Baby Formula Designed for Chinese Babies: Content Analysis of Milk Formula Advertisements on Chinese Parenting Apps


    Background: China is the largest market for infant formula. With the increasing use of smartphones, apps have become the latest tool used to promote milk formula. Formula manufacturers and distributors both have seized the popularity of apps as an avenue for marketing. Objective: This study aimed to identify and analyze milk formula ads featured on Chinese pregnancy and parenting apps, to build the first complete picture of app-based milk formula marketing techniques being used by milk formula brand variants on these apps, and to more fully understand the ad content that potentially undermines public health messaging about infant and young child feeding. Methods: We searched for free-to-download Chinese parenting apps in the 360 App Store, the biggest Android app store in China. The final sample consisted of 353 unique formula ads from the 79 apps that met the inclusion criteria. We developed a content analysis coding tool for categorizing the marketing techniques used in ads, which included a total of 22 coding options developed across 4 categories: emotional imagery, marketing elements, claims, and advertising disclosure. Results: The 353 milk formula ads were distributed across 31 companies, 44 brands, and 79 brand variants. Overall, 15 of 31 corporations were international with the remaining 16 being Chinese owned. An image of a natural pasture was the most commonly used emotional image among the brand variants (16/79). All variants included branding elements, and 75 variants linked directly to e-shops. Special price promotions were promoted by nearly half (n=39) of all variants. A total of 5 variants included a celebrity endorsement in their advertising. A total of 25 of the 79 variants made a product quality claim. Only 14 variants made a direct advertisement disclosure. Conclusions: The purpose of marketing messages is to widen the use of formula and normalize formula as an appropriate food for all infants and young children, rather than as a specialized food for those unable to breastfeed. Policy makers should take steps to establish an appropriate regulatory framework and provide detailed monitoring and enforcement to ensure that milk formula marketing practices do not undermine breastfeeding norms and behaviors.

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

    Continuous Digital Monitoring of Walking Speed in Frail Elderly Patients: Noninterventional Validation Study and Longitudinal Clinical Trial


    Background: Digital technologies and advanced analytics have drastically improved our ability to capture and interpret health-relevant data from patients. However, only limited data and results have been published that demonstrate accuracy in target indications, real-world feasibility, or the validity and value of these novel approaches. Objective: This study aimed to establish accuracy, feasibility, and validity of continuous digital monitoring of walking speed in frail, elderly patients with sarcopenia and to create an open source repository of raw, derived, and reference data as a resource for the community. Methods: Data described here were collected as a part of 2 clinical studies: an independent, noninterventional validation study and a phase 2b interventional clinical trial in older adults with sarcopenia. In both studies, participants were monitored by using a waist-worn inertial sensor. The cross-sectional, independent validation study collected data at a single site from 26 naturally slow-walking elderly subjects during a parcours course through the clinic, designed to simulate a real-world environment. In the phase 2b interventional clinical trial, 217 patients with sarcopenia were recruited across 32 sites globally, where patients were monitored over 25 weeks, both during and between visits. Results: We have demonstrated that our approach can capture in-clinic gait speed in frail slow-walking adults with a residual standard error of 0.08 m per second in the independent validation study and 0.08, 0.09, and 0.07 m per second for the 4 m walk test (4mWT), 6-min walk test (6MWT), and 400 m walk test (400mWT) standard gait speed assessments, respectively, in the interventional clinical trial. We demonstrated the feasibility of our approach by capturing 9668 patient-days of real-world data from 192 patients and 32 sites, as part of the interventional clinical trial. We derived inferred contextual information describing the length of a given walking bout and uncovered positive associations between the short 4mWT gait speed assessment and gait speed in bouts between 5 and 20 steps (correlation of 0.23) and longer 6MWT and 400mWT assessments with bouts of 80 to 640 steps (correlations of 0.48 and 0.59, respectively). Conclusions: This study showed, for the first time, accurate capture of real-world gait speed in slow-walking older adults with sarcopenia. We demonstrated the feasibility of long-term digital monitoring of mobility in geriatric populations, establishing that sufficient data can be collected to allow robust monitoring of gait behaviors outside the clinic, even in the absence of feedback or incentives. Using inferred context, we demonstrated the ecological validity of in-clinic gait assessments, describing positive associations between in-clinic performance and real-world walking behavior. We make all data available as an open source resource for the community, providing a basis for further study of the relationship between standardized physical performance assessment and real-world behavior and independence.

  • This is a lady using a smartphone App. Source: Flickr; Copyright: ACT Project Concordia; URL:; License: Creative Commons Attribution + Noncommercial (CC-BY-NC).

    Mobile Health Apps for Self-Management of Rheumatic and Musculoskeletal Diseases: Systematic Literature Review


    Background: Although the increasing availability of mobile health (mHealth) apps may enable people with rheumatic and musculoskeletal diseases (RMDs) to better self-manage their health, there is a general lack of evidence on ways to ensure appropriate development and evaluation of apps. Objective: This study aimed to obtain an overview on existing mHealth apps for self-management in patients with RMDs, focusing on content and development methods. Methods: A search was performed up to December 2017 across 5 databases. For each publication relevant to an app for RMDs, information on the disease, purpose, content, and development strategies was extracted and qualitatively assessed. Results: Of 562 abstracts, 32 were included in the analysis. Of these 32 abstracts, 11 (34%) referred to an app linked to a connected device. Most of the apps targeted rheumatoid arthritis (11/32, 34%). The top three aspects addressed by the apps were pain (23/32, 71%), fatigue (15/32, 47%), and physical activity (15/32, 47%). The development process of the apps was described in 84% (27/32) of the articles and was of low to moderate quality in most of the cases. Despite most of the articles having been published within the past two years, only 5 apps were still commercially available at the time of our search. Moreover, only very few studies showed improvement of RMD outcome measures. Conclusions: The development process of most apps was of low or moderate quality in many studies. Owing to the increasing RMD patients’ willingness to use mHealth apps for self-management, optimal standards and quality assurance of new apps are mandatory.

  • Reading a book and interacting with medication information using the visualization app (montage). Source: The Authors / Placeit; Copyright: The Authors; URL:; License: Creative Commons Attribution (CC-BY).

    Improving Medication Information Presentation Through Interactive Visualization in Mobile Apps: Human Factors Design


    Background: Despite the detailed patient package inserts (PPIs) with prescription drugs that communicate crucial information about safety, there is a critical gap between patient understanding and the knowledge presented. As a result, patients may suffer from adverse events. We propose using human factors design methodologies such as hierarchical task analysis (HTA) and interactive visualization to bridge this gap. We hypothesize that an innovative mobile app employing human factors design with an interactive visualization can deliver PPI information aligned with patients’ information processing heuristics. Such an app may help patients gain an improved overall knowledge of medications. Objective: The objective of this study was to explore the feasibility of designing an interactive visualization-based mobile app using an HTA approach through a mobile prototype. Methods: Two pharmacists constructed the HTA for the drug risperidone. Later, the specific requirements of the design were translated using infographics. We transferred the wireframes of the prototype into an interactive user interface. Finally, a usability evaluation of the mobile health app was conducted. Results: A mobile app prototype using HTA and infographics was successfully created. We reiterated the design based on the specific recommendations from the usability evaluations. Conclusions: Using HTA methodology, we successfully created a mobile prototype for delivering PPI on the drug risperidone to patients. The hierarchical goals and subgoals were translated into a mobile prototype.

  • Tablet computer being used at home. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + Noncommercial + NoDerivatives (CC-BY-NC-ND).

    Mood Monitoring Over One Year for People With Chronic Obstructive Pulmonary Disease Using a Mobile Health System: Retrospective Analysis of a Randomized...


    Background: Comorbid anxiety and depression can add to the complexity of managing treatment for people living with chronic obstructive pulmonary disease (COPD). Monitoring mood has the potential to identify individuals who might benefit from additional support and treatment. Objective: We used data from the sElf-management anD support proGrammE (EDGE) trial to examine: (1) the extent to which the mood-monitoring components of a mobile health system for patients with COPD were used by participants; (2) the levels of anxiety and depression symptoms among study participants; (3) the extent to which videos providing advice about coping with low mood were viewed; and (4) the characteristics of participants with differing levels of mood and utilization of mood monitoring. Methods: A total of 107 men and women with a clinical diagnosis of COPD, aged ≥40 years old, were recruited to the intervention arm of the EDGE trial. Participants were invited to complete the Patient Health Questionnaire-8 and the Generalized Anxiety Disorder-7 test every four weeks using a tablet computer. Mood disturbance based on these measures was defined as a score ≥5 on either scale. Participants reporting a mood disturbance were automatically directed (signposted) to a stress or mood management video. Study outcomes included measures of health status, respiratory quality of life, and symptoms of anxiety and depression. Results: Overall, 94 (87.9%) participants completed the 12-month study. A total of 80 participants entered at least one response each month for at least ten months. On average, 16 participants (range 8-38 participants) entered ≥2 responses each month. Of all the participants, 47 (50%) gave responses indicating a mood disturbance. Participants with a mood disturbance score for both scales (n=47) compared with those without (n=20) had lower health status (P=.008), lower quality of life (P=.009), and greater anxiety (P<.001) and increased depression symptoms (P<.001). Videos were viewed by 64 (68%) people over 12 months. Of the 220 viewing visualizations, 70 (34.7%) began after being signposted. Participants signposted to the stress management video (100%; IQR 23.3-100%) watched a greater proportion of it compared to those not signposted (38.4%; IQR 16.0-68.1%; P=.03), whereas duration of viewing was not significantly different for the mood management video. Conclusions: Monitoring of anxiety and depression symptoms for people with COPD is feasible. More than half of trial participants reported scores indicating a mood disturbance during the study. Signposting participants to an advisory video when reporting increased symptoms of a mood disturbance resulted in a longer view-time for the stress management video. The opportunity to elicit measures of mood regularly as part of a health monitoring system could contribute to better care for people with COPD.

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

    Opportunities and Pitfalls in Applying Emotion Recognition Software for Persons With a Visual Impairment: Simulated Real Life Conversations


    Background: A large part of the communication cues exchanged between persons is nonverbal. Persons with a visual impairment are often unable to perceive these cues, such as gestures or facial expression of emotions. In a previous study, we have determined that visually impaired persons can increase their ability to recognize facial expressions of emotions from validated pictures and videos by using an emotion recognition system that signals vibrotactile cues associated with one of the six basic emotions. Objective: The aim of this study was to determine whether the previously tested emotion recognition system worked equally well in realistic situations and under controlled laboratory conditions. Methods: The emotion recognition system consists of a camera mounted on spectacles, a tablet running facial emotion recognition software, and a waist belt with vibrotactile stimulators to provide haptic feedback representing Ekman’s six universal emotions. A total of 8 visually impaired persons (4 females and 4 males; mean age 46.75 years, age range 28-66 years) participated in two training sessions followed by one experimental session. During the experiment, participants engaged in two 15 minute conversations, in one of which they wore the emotion recognition system. To conclude the study, exit interviews were conducted to assess the experiences of the participants. Due to technical issues with the registration of the emotion recognition software, only 6 participants were included in the video analysis. Results: We found that participants were quickly able to learn, distinguish, and remember vibrotactile signals associated with the six emotions. A total of 4 participants felt that they were able to use the vibrotactile signals in the conversation. Moreover, 5 out of the 6 participants had no difficulties in keeping the camera focused on the conversation partner. The emotion recognition was very accurate in detecting happiness but performed unsatisfactorily in recognizing the other five universal emotions. Conclusions: The system requires some essential improvements in performance and wearability before it is ready to support visually impaired persons in their daily life interactions. Nevertheless, the participants saw potential in the system as an assistive technology, assuming their user requirements can be met.

  • Source: Unsplash; Copyright: Giang Vu; URL:; License: Licensed by JMIR.

    Assessment of a Mobile App by Adolescents and Young Adults With Cystic Fibrosis: Pilot Evaluation


    Background: Cystic fibrosis (CF) continues to be the most common life-limiting chronic pulmonary disease in adolescents and young adults. Treatment of CF demands a high treatment time investment to slow the progression of lung function decline, the most important contributor to morbidity and mortality. Adherence is challenging in CF due to the high treatment burden and the lack of immediate health consequences in case of nonadherence. Lung function decline is particularly pronounced in the transition phase between 12 and 24 years of age. The improvement of self-management and self-responsibility and independence from parents and desire for normalcy are conflicting aspects for many adolescents with CF, which influence adherence to the time-consuming pulmonary therapy. Mobile health (mHealth) care apps could help to support self-management and independence and thereby reconcile seemingly conflicting goals to improve adherence, quality of life, and ultimately CF life expectancy. Objective: This study aimed to (1) assess user behavior and satisfaction among adolescents and young adults with CF over an observation period of three months using an mHealth app; (2) identify areas of improvement for this mHealth app; and (3) compare overall and disease-specific satisfaction, lung function, and anthropometry before and after using the mHealth app. Methods: A total of 27 adolescents and young adults with CF (age range 12-24 years, mean age 16 years, SD 3 years; 14 females, 11 males) used a free mHealth app for three months of whom 25 provided questionnaire data for analysis at the end of the study. Data collection was carried out using questionnaires on usage characteristics and life satisfaction, and standardized assessment of lung function and anthropometry. Results: The use of the reminder function for medication declined from 70% (15/21) of the participants at week 4 to 65% (13/20) at week 8 of the observation period. At the end of the study, only 17% (4/23) of the participants wanted to continue using the app. Nevertheless, 56% (14/25) of participants saw the mobile app as a support for everyday life. Potential improvements targeting hedonistic qualities were identified to improve mHealth app adherence. Comparisons of satisfaction with different life aspects hinted at improvements or stabilization for the subitem respiration and the subitem lack of handicap by CF, suggesting that app use might stabilize certain CF-specific aspects of the weighted satisfaction with life. Lung function and anthropometry were not affected consistently. Conclusions: Most of the patients did not want to continue using the app after the study period. Only a few CF-specific aspects of weighted life satisfaction were possibly stabilized by the mHealth app; clinical parameters were not affected. Adaptation of the functions to adolescent-specific needs could improve the long-term use and thus positively affect the disease course.

  • Source:; Copyright: Luke Porter; URL:; License: Licensed by JMIR.

    Development of MyTeen Text Messaging Program to Support Parents of Adolescents: Qualitative Study


    Background: Parents play an important role in the lives of adolescents, and supporting and addressing the needs of families continue to be the focus of many researchers and policy makers. Mobile health interventions have great potential for supporting parents at a population level because of their broad reach and convenience. However, limited evidence exists for such interventions for parents of adolescents. This study reports on the formative work conducted with parents and/or primary caregivers to identify their needs and preferences for the development of MyTeen—an SMS text messaging program on promoting parental competence and mental health literacy for parents of adolescents (aged 10-15 years). Objective: The aim of this qualitative study was to explore parents and/or primary caregivers’ perspectives around youth well-being, parenting, and parenting support and their input on the development of MyTeen SMS text messaging parenting intervention. Methods: A total of 5 focus groups (n=45) were conducted with parents or primary caregivers of adolescents aged 10 to 15 years between October and December 2017 in New Zealand. A semistructured interview guideline and prompts were used. Data were audiotaped, transcribed, and analyzed using inductive thematic analysis. Results: Participants were concerned about youth mental health (ie, stigma and increasing demand on adolescents), and a number of parenting challenges (ie, social expectations, time, impact of technology, changes in family communication pattern, and recognizing and talking about mental health issues) were noted. Importantly, participants reported the lack of services and support available for families, and many were not aware of services for parents themselves. A number of recommendations were given on the style, content, and frequency of developing the text messaging program. Conclusions: Findings from this qualitative work informed the development of MyTeen, an SMS text messaging program designed to increase parental competence and improve mental health literacy for parents of adolescents.

  • A novel interactive mobile phone app for addressing low knowledge of the UK 5-a-day fruit and vegetable recommendations (montage). Source: The Authors / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    An Interactive Mobile Phone App (SMART 5-A-DAY) for Increasing Knowledge of and Adherence to Fruit and Vegetable Recommendations: Development and Pilot...


    Background: Fruit and vegetable consumption is important for health, but many individuals fail to consume adequate amounts for health benefits. Although many individuals are aware of current fruit and vegetable consumption recommendations, research suggests that adherence to these is hampered by low knowledge of the details of these recommendations. Objective: This paper reports the development and details of a pilot randomized controlled test of a novel interactive mobile phone app for addressing low knowledge of the UK 5-a-day fruit and vegetable recommendations. Methods: Requirements for the app were first defined by researchers and potential end users and prioritized using the MoSCoW (Must have, Should have, Could have, Won’t have) method. Second, a prototype mobile phone app was developed using an agile approach. Third, the prototype app was tested in a randomized controlled pilot trial for impacts on knowledge and intake of fruit and vegetables. Volunteers were randomized to either receive (n=50) or not receive the app (n=44) for 2 or 4 weeks, and fruit and vegetable knowledge, intake, and behavior were assessed at the beginning of the study and after 1 and 2 weeks or after 2 and 4 weeks, respectively. App usage and qualitative feedback were also investigated. All findings then informed the development of a final app. Results: Low knowledge of consumption recommendations centered around portion sizes and the need for variety, and an interactive mobile phone app was considered a suitable tool for improving this knowledge in a practical manner that would be available both at time of consumption and outside of these times. The pilot test revealed improved behavior after 2 weeks compared with baseline in volunteers who received the app, but improvements in knowledge on fruit and vegetable recommendations were found in both groups, and no improvements in fruit and vegetable intakes were found in formal measures. Patterns of app usage and qualitative feedback also suggested a number of modifications. The resultant final app incorporates several behavior change techniques (goal-setting, self-monitoring, and personalized feedback) as well as aiming to improve knowledge. Conclusions: A novel interactive mobile phone app was successfully developed based on requirements, and when tested in a pilot randomized controlled trial, this app was found to have some impacts on fruit and vegetable outcomes. Although benefits from the app were small, impacts will likely increase as a result of recent modifications. The final SMART 5-A-DAY app is available in the Google Play Store and now needs testing in the target population. Clinical Trial: NCT02779491;

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  • Efficacy of the Ascure Smoking Cessation Program: A Retrospective Study

    Date Submitted: Dec 5, 2019

    Open Peer Review Period: Dec 5, 2019 - Dec 16, 2019

    Background: Smoking cessation helps to extend a healthy life span and reduces medical expenses. However, the standard 12-week smoking cessation program in Japan has several notable problems. First, on...

    Background: Smoking cessation helps to extend a healthy life span and reduces medical expenses. However, the standard 12-week smoking cessation program in Japan has several notable problems. First, only 30% of the original participants complete this program. Second, participants may not choose to participate, unless they have health problems or a strong motivation to quit smoking. Third, the program does not assist patients in alleviating their psychological dependence on smoking. Objective: This study examined the efficacy of the 24-week ascure program that combines online mentoring, over-the-counter pharmacotherapy, and a smartphone app to address these problems. Methods: Using a retrospective study design, we investigated 177 adult smokers who were enrolled in the ascure smoking cessation program between August 2017 and August 2018. The primary outcomes were continuous abstinence rates (CARs) during weeks 9–12 and weeks 21–24. To confirm smoking status, we performed salivary cotinine testing at weeks 12 and 24. We also evaluated the program adherence rate. Finally, we exploratorily analyzed the factors associated with continuous abstinence at weeks 21–24 to thereby provide insights for assisting with long-term continuous abstinence. Results: The CARs for weeks 9–12 and weeks 21–24 were 48.6% (95% CI: 41.2–56.0%) and 47·5% (40.0–54.8%), respectively. Program adherence rates were relatively high throughout (72% at week 12 and 60% at week 24). In the analysis of the factors related to the CAR at weeks 21–24, the number of entries in the app’s digital diary and the number of educational videos watched during the first 12 weeks were significant factors. Conclusions: The ascure program achieved favorable CARs and participants showed reasonable adherence. Proactive usage of the smartphone app may help contribute to smoking cessation success in the long-term. Therefore, long-term support might help reduce returning to smoking, even after the completion of pharmacological therapy. Clinical Trial: All study procedures were reviewed and approved by the Kanazawa University Institutional Review Board.

  • Stunting Diagnostic and Awareness: Impact assessment study of sociodemographic factors of stunting among school-going children of Pakistan

    Date Submitted: Nov 26, 2019

    Open Peer Review Period: Nov 26, 2019 - Jan 21, 2020

    Background: Stunting is a major public health issue in most of developing countries. Although, its worldwide prevalence is decreasing slowly but the number of stunted children is still rising in Pakis...

    Background: Stunting is a major public health issue in most of developing countries. Although, its worldwide prevalence is decreasing slowly but the number of stunted children is still rising in Pakistan. Stunting is highly associated with several long-term consequences, including higher rate of mortality and morbidity, deficient cognitive growth, school performance, learning capacity, work capacity and work productivity. To prevent stunting, we proposed Stunting Diagnostic and Education app. This app includes detailed knowledge of stunting and it’s all forms, symptoms, causes, video tutorials and guidelines by the Pediatricians and Nutritionists. Objective: The aim and objective of this study is to assess the prevalence of stunting in school-going children in Multan District of Punjab Pakistan and to analyze the risk factors associated with stunting in children under and over 5 age. This study presents Stunting Diagnostic and Education app to prevent the stunting in children under 5 age and children over 5 age (where required). Methods: A cross-sectional study has been conducted in schools of Multan District, Pakistan for the period of January 2019 to June 2019. Sample data of 1420 children, aged 4 to 18 years using three age groups, were analyzed by using SPSS version 21.0 to assess the prevalence of stunting and to analyze the main factors associated with it. Chi square test was applied in comparison with rural and urban participants and p-value <0.05 was considered as significant. This study includes distribution of sociodemographic characteristics, parental education, working status of mothers, dietary patterns of school going children and prevalence of stunting in school going children. After getting study results, Stunting Diagnostic and Education app was developed according to the instructions of child experts and nutritionists. Results: 354 (24.93%) participants were stunted out of 1420, 11.9 % children were obese and 63.17% children were normal. Out of 354 stunted children, higher ratio of stunting was found in the age group of 8-11 years children with 51.98 percentage. 37.85% stunted children were found in the age group of 4-7 years and 10.17% stunting was found in the age group of 12-18 years children. It was observed in the study that male children were highly stunted than female with 57.91 % and 42.09% respectively. Children living in rural areas were more stunted affected as compared to the children living in urban society with percentage 58.76 and 41.24 respectively. Conclusions: Our study concluded that 24.93% children were stunted, out of which, age group of 8-11 years children were highly stunted. The study showed that the literacy of mother or caregiver had high impact on children’s health. Therefore, Stunting Diagnostic and Education app was developed to educate mothers to prevent stunting.

  • Analysis of secure apps for daily clinical use as a German orthopaedic surgeon - searching for the "needle in a haystack"

    Date Submitted: Nov 16, 2019

    Open Peer Review Period: Nov 16, 2019 - Jan 11, 2020

    Background: Benefits of adequate smartphone and app implementation in the fields of orthopaedic surgery are undeniable and offer enormous opportunities for future challenges in public health. But the...

    Background: Benefits of adequate smartphone and app implementation in the fields of orthopaedic surgery are undeniable and offer enormous opportunities for future challenges in public health. But the number of available apps in the two major app stores remains unclear for use in daily clinical routine as a German orthopaedic surgeon. Objective: The objective was to gain evidence regarding quantity and quality of available apps in the two major app stores for the intended use. Methods: We conducted a systematic, keyword-based app store screening to gain evidence concerning quantity and quality of commercially available apps. Apps that met the inclusion criteria were evaluated using the “app-synopsis – checklist for users” and the German Mobile App Rating Scale with regard to secure use, trustworthiness and quality. Results: The investigation revealed serious shortcomings regarding legal and medical aspects in the majority of apps. Most apps turned out useless and unsuitable for the clinical field of application (99.84%, 4242/4249). Finally, seven trustworthy and high-quality apps (0.16%, 7/4249) were identified offering secure usage in orthopaedic daily clinical routine. These apps mainly focused on education (5/7). None of these was CE certified. Moreover, all apps lack evidence of a beneficial effect demonstrated in studies. Conclusions: Gained data suggest that the number of trustworthy and high-quality apps on offer is extremely low. Nowadays, finding appropriate apps in the fast-moving, complex, dynamic and rudimentarily controlled app stores is most challenging. Promising approaches, e.g. systematic app store screenings, app rating developments, reviews or app-libraries and the creation of consistent standards have been established. But future efforts are required not only to transfer knowledge but also to ensure safety of these innovative Mobile Health applications in daily clinical practice.

  • Embodiment of Wearable Technology: A Qualitative Longitudinal Study

    Date Submitted: Nov 9, 2019

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

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

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

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

    Date Submitted: Nov 8, 2019

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

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

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

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

    Date Submitted: Oct 23, 2019

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

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

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