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

    Improving Pacific Adolescents’ Physical Activity Toward International Recommendations: Exploratory Study of a Digital Education App Coupled With Activity...


    Background: The prevalence of overweight and obesity in children and adolescents has dramatically increased in the Pacific Island countries and territories over the last decade. Childhood overweight and obesity not only have short-term consequences but are also likely to lead to noncommunicable diseases in adulthood. A major factor contributing to the rising prevalence is an insufficient amount of daily moderate-to-vigorous physical activity (MVPA). In the Pacific region, less than 50% of children and adolescents meet the international recommendations of 11,000 steps and 60 min of MVPA per day. Although studies have shown the potential of digital technologies to change behaviors, none has been proposed to guide adolescents toward achieving these recommendations. Objective: The aims of this study were (1) to investigate whether a technology-based educational program that combines education, objective measures of physical activity (PA), and self-assessment of goal achievement would be well received by Pacific adolescents and help change their PA behaviors toward the international PA recommendations and (2) to create more insightful data analysis methods to better understand PA behavior change. Methods: A total of 24 adolescents, aged 12 to 14 years, participated in a 4-week program comprising 8 1-hour modules designed to develop health literacy and physical skills. This self-paced user-centered program was delivered via an app and provided health-related learning content as well as goal setting and self-assessment tasks. PA performed during the 4-week program was captured by an activity tracker to support learning and help the adolescents self-assess their achievements against personal goals. The data were analyzed using a consistency rate and daily behavior clustering to reveal any PA changes, particularly regarding adherence to international recommendations. Results: The consistency rate of daily steps revealed that the adolescents reached 11,000 steps per day 48% (approximately 3.4 days per week) of the time in the first week of the program, and this peaked at 59% (approximately 4.1 days per week) toward the end of the program. PA data showed an overall increase during the program, particularly in the less active adolescents, who increased their daily steps by 15% and ultimately reached 11,000 steps more frequently. The consistency of daily behavior clustering showed a 27% increase in adherence to international recommendations in the least active adolescents. Conclusions: Technology-supported educational programs that include self-monitored PA via activity trackers can be successfully delivered to adolescents in schools in remote Pacific areas. New data mining techniques enable innovative analyses of PA engagement based on the international recommendations.

  • Source:; Copyright: Mitchell Hollander; URL:; License: Licensed by JMIR.

    Lessons Learned: Recommendations For Implementing a Longitudinal Study Using Wearable and Environmental Sensors in a Health Care Organization


    Although traditional methods of data collection in naturalistic settings can shed light on constructs of interest to researchers, advances in sensor-based technology allow researchers to capture continuous physiological and behavioral data to provide a more comprehensive understanding of the constructs that are examined in a dynamic health care setting. This study gives examples for implementing technology-facilitated approaches and provides the following recommendations for conducting such longitudinal, sensor-based research, with both environmental and wearable sensors in a health care setting: pilot test sensors and software early and often; build trust with key stakeholders and with potential participants who may be wary of sensor-based data collection and concerned about privacy; generate excitement for novel, new technology during recruitment; monitor incoming sensor data to troubleshoot sensor issues; and consider the logistical constraints of sensor-based research. The study describes how these recommendations were successfully implemented by providing examples from a large-scale, longitudinal, sensor-based study of hospital employees at a large hospital in California. The knowledge gained from this study may be helpful to researchers interested in obtaining dynamic, longitudinal sensor data from both wearable and environmental sensors in a health care setting (eg, a hospital) to obtain a more comprehensive understanding of constructs of interest in an ecologically valid, secure, and efficient way.

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

    Analysis of the Implementation, User Perspectives, and Feedback From a Mobile Health Intervention for Individuals Living With Hypertension (DREAM-GLOBAL):...


    Background: DREAM-GLOBAL (Diagnosing hypertension—Engaging Action and Management in Getting Lower Blood Pressure in Indigenous and low- and middle-income countries) studied a SMS text messaging–based system for blood pressure measurement and hypertension management in Canadian Aboriginal and Tanzanian communities. The use of SMS text messages is an emerging point of interest in global health care initiatives because of their scalability, customizability, transferability, and cost-effectiveness. Objective: The study aim was to assess the effect on the difference in blood pressure reduction of active hypertension management messages or passive health behavior messages. The system was designed to be implemented in remote areas with wireless availability. This study described the implementation and evaluation of technical components, including quantitative data from the transmission of blood pressure measurements and qualitative data collected on the operational aspects of the system from participants, health care providers, and community leadership. Methods: The study was implemented in six remote Indigenous Canadian and two rural Tanzanian communities. Blood pressure readings were taken by a community health worker and transmitted to a mobile phone via Bluetooth, then by wireless to a programmed central server. From the server, the readings were sent to the participant’s own phone as well. Participants also received biweekly tailored SMS text messages on their phones. Quantitative data on blood pressure reading transmissions were collected from the study central server. Qualitative data were collected by surveys, focus groups, and key informant interviews of participants, health care providers, and health leadership. Results: In Canada, between February 2014 and February 2017, 2818 blood pressure readings from 243 patients were transmitted to the central server. In Tanzania, between October 2014 and August 2015, 1165 readings from 130 patients were transmitted to the central server. The use of Bluetooth technology enabled the secure, reliable transmission of information from participants to their health care provider. The timing and frequency were satisfactory to 137 of 187 (73.2%) of participants, supporting the process of sending weekly messages twice on Mondays and Thursdays at 11 am. A total of 97.0% (164/169) of the participants surveyed said they would recommend participation in the DREAM-GLOBAL program to a friend or relative with hypertension. Conclusions: In remote communities, the DREAM-GLOBAL study helped local health care providers deliver a blood pressure management program that enabled patients and community workers to feel connected. The technical components of the study were implemented as planned, and patients felt supported in their management through the SMS text messaging and mobile health program. Technological issues were solved with troubleshooting. Overall, the technical aspects of this research program enhanced clinical care and study evaluation and were well received by participants, health care workers, and community leadership. Clinical Trial: NCT02111226;

  • 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.

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  • Exploring Patients' Continuous Usage Intention of mHealth Services: An Elaboration Likelihood Perspective

    Date Submitted: Dec 5, 2019

    Open Peer Review Period: Dec 11, 2019 - Feb 11, 2020

    Background: With the increasingly rapid development of Web 2.0 technologies, the application of mobile healthcare in the field of health management has become popular. Accordingly, patients are able t...

    Background: With the increasingly rapid development of Web 2.0 technologies, the application of mobile healthcare in the field of health management has become popular. Accordingly, patients are able to access consulting services and effective health information online without temporal and geographical constraints. Objective: In this study, we drew on the Elaboration Likelihood Model (ELM) to investigate patients' continuous usage intention on mHealth services. In addition, we further examined which route (the central route or the peripheral route) has a stronger impact on a patient's usage of health management care. Methods: To meet these objectives, five hypotheses thus developed were empirically validated using a field survey to test the direct and indirect effects (via attitude) of the two routes on a continuous usage intention. Results: we found that patients perceived mHealth information quality and perceived mHealth system quality have a positive effect on their personal attitudes. Besides, the results reveal that social media influence had a positive effect on a patient’s attitude towards mHealth services. In particular, our findings suggest that a patient's health consciousness has a positive effect on the relationship between social media influence and attitude. Conclusions: This study contributes to the mHealth service literature by introducing the ELM as a referent theory for research, as well as by specifying the moderating role of health consciousness. For practitioners, this study introduces influence processes as policy tools that managers can employ to motivate the diffusion of mHealth services within their organizations.

  • Use of apps to promote childhood vaccination: a systematic review

    Date Submitted: Dec 10, 2019

    Open Peer Review Period: Dec 10, 2019 - Dec 20, 2019

    Background: Vaccination is a critical step to reducing child mortality; however, vaccination rates have declined in many countries in recent years. This decrease has been associated with an increase i...

    Background: Vaccination is a critical step to reducing child mortality; however, vaccination rates have declined in many countries in recent years. This decrease has been associated with an increase in outbreaks of vaccine-preventable diseases. The potential for leveraging mobile platforms to promote vaccination coverage has been investigated in the development of numerous mobile apps. Whilst many are available for public use, there is little robust evaluation of these applications. Objective: This systematic review aims to assess the effectiveness of applications supporting childhood vaccinations in improving vaccination uptake, knowledge and decision-making as well as the usability and user perceptions of these applications. Methods: PubMed, Medline, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and ERIC databases were systematically searched for articles published between 2008 and 2019 which evaluated childhood vaccination apps. Two authors screened and selected studies according to the inclusion and exclusion criteria. Data were extracted and analysed and the studies were assessed for risk of bias. Results: Twenty-eight studies evaluating 25 applications met the inclusion criteria and were included in this analysis. Nine studies assessed vaccination uptake, of which four reported significant benefit (p<.001 or p=.028) of the implementation of the application. Similarly, 4/10 indicated significant (p≤.05) impact on knowledge and 4/8 on vaccination decision-making. Patient perceptions, usability and acceptability were generally positive. The quality of the included studies was found to be moderate to poor with many aspects of the methodology being unclear. Conclusions: There was little evidence to support the use of childhood vaccination apps on improving vaccination uptake, knowledge and/or decision-making. Further research is required to understand the dichotomous effects of vaccination information provision and the evaluation of these applications in larger, more robust studies. The methodology of studies must be reported more comprehensively to accurately assess the effectiveness of childhood vaccination applications and the risk of bias of studies.

  • Development and Evaluation of the MILK Text Message Program to Prevent Perceived Insufficient Milk and Improve Breastfeeding Outcomes: Retrospective Analysis of a Randomized Controlled Trial

    Date Submitted: Dec 6, 2019

    Open Peer Review Period: Dec 6, 2019 - Jan 31, 2020

    Background: Several recent trials have examined automated short message systems (SMS, i.e., ‘text messaging’) to provide remote breastfeeding support to mothers, but vary in terms of their design...

    Background: Several recent trials have examined automated short message systems (SMS, i.e., ‘text messaging’) to provide remote breastfeeding support to mothers, but vary in terms of their design features and outcomes examined. Objective: In this paper, we examine user engagement with and feedback on a theory-grounded SMS intervention intended to prevent perceived insufficient milk (PIM)—the single, leading modifiable cause of unintended breastfeeding reduction and cessation. Methods: We recruited 250 nulliparous women intending to breastfeed between 13-25 weeks of pregnancy in southwestern Pennsylvania. Women were randomly assigned with equal allocation to either a SMS intervention to prevent PIM and unintended breastfeeding reduction or cessation (A mobile, semi-automated text message-based intervention to prevent perceived low or insufficient milk supply, i.e., MILK; n=126) or a control group receiving general perinatal SMS-based support via the national, free Text4Baby system (n=124). Women in both groups received text messages 3-7 times per week from 25 weeks of pregnancy to 8 weeks postpartum. The MILK intervention incorporated several automated interactivity and personalization features (e.g., keyword texting for more detailed information on topics, branched response logic), as well as an option to receive one-on-one assistance from an on-call study lactation consultant. We examined participant interactions with the MILK system, including response rates to SMS queries. We also sought participant feedback on MILK content, delivery preferences, and overall satisfaction with the system via interviews and a remote survey at eight weeks postpartum. Results: Participants randomized to MILK (70% white, 68% college-educated) reported that MILK texts increased their breastfeeding confidence and helped them persevere through breastfeeding problems. Nine women (7%) elected to stop MILK messages and three (2%) opted to reduce message frequency during the course of the study. There were 46 texts through the MILK system for individualized assistance from the study lactation consultant (54% on weekends or after-hours). The most commonly texted keywords for more detailed information occurred in postpartum weeks 4-6 and addressed milk volume/intake and breastfeeding/sleep patterns. MILK participants stated a preference for anticipatory guidance on potential breastfeeding issues and less content addressing benefits of breastfeeding. Suggested improvements included extending messaging past eight weeks, providing access to messaging for partners, and tailoring content based on women’s pre-existing breastfeeding knowledge and unique breastfeeding trajectory. Conclusions: Prenatal and postpartum evidence-based breastfeeding support delivered via semi-automated SMS is a feasible and acceptable intervention for first-time mothers. To optimize engagement with digital breastfeeding interventions, enhanced customization features should be considered. Clinical Trial: NCT02724969, “A Mobile, Semi-automated Text Message-based Intervention to Prevent Perceived Low or Insufficient Milk Supply (MILK)”

  • 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.

  • 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.