%0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e26559 %T Exploring Usage of COVID Coach, a Public Mental Health App Designed for the COVID-19 Pandemic: Evaluation of Analytics Data %A Jaworski,Beth K %A Taylor,Katherine %A Ramsey,Kelly M %A Heinz,Adrienne %A Steinmetz,Sarah %A Pagano,Ian %A Moraja,Giovanni %A Owen,Jason E %+ National Center for PTSD, Dissemination & Training Division, US Department of Veterans Affairs, 795 Willow Road, Menlo Park, CA, 94025, United States, 1 650 308 9437, beth.jaworski@va.gov %K COVID-19 %K coronavirus %K mobile app %K mHealth %K digital health %K mental health %K public mental health %K stress %K coping %K public health %K app %D 2021 %7 1.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 pandemic has significantly impacted mental health and well-being. Mobile mental health apps can be scalable and useful tools in large-scale disaster responses and are particularly promising for reaching vulnerable populations. COVID Coach is a free, evidence-informed mobile app designed specifically to provide tools and resources for addressing COVID-19–related stress. Objective: The purpose of this study was to characterize the overall usage of COVID Coach, explore retention and return usage, and assess whether the app was reaching individuals who may benefit from mental health resources. Methods: Anonymous usage data collected from COVID Coach between May 1, 2020, through October 31, 2020, were extracted and analyzed for this study. The sample included 49,287 unique user codes and 3,368,931 in-app events. Results: Usage of interactive tools for coping and stress management comprised the majority of key app events (n=325,691, 70.4%), and the majority of app users tried a tool for managing stress (n=28,009, 58.8%). COVID Coach was utilized for ≤3 days by 80.9% (n=34,611) of the sample whose first day of app use occurred within the 6-month observation window. Usage of the key content in COVID Coach predicted returning to the app for a second day. Among those who tried at least one coping tool on their first day of app use, 57.2% (n=11,444) returned for a second visit; whereas only 46.3% (n=10,546) of those who did not try a tool returned (P<.001). Symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) were prevalent among app users. For example, among app users who completed an anxiety assessment on their first day of app use (n=4870, 11.4% of users), 55.1% (n=2680) reported levels of anxiety that were moderate to severe, and 29.9% (n=1455) of scores fell into the severe symptom range. On average, those with moderate levels of depression on their first day of app use returned to the app for a greater number of days (mean 3.72 days) than those with minimal symptoms (mean 3.08 days; t1=3.01, P=.003). Individuals with significant PTSD symptoms on their first day of app use utilized the app for a significantly greater number of days (mean 3.79 days) than those with fewer symptoms (mean 3.13 days; t1=2.29, P=.02). Conclusions: As the mental health impacts of the pandemic continue to be widespread and increasing, digital health resources, such as apps like COVID Coach, are a scalable way to provide evidence-informed tools and resources. Future research is needed to better understand for whom and under what conditions the app is most helpful and how to increase and sustain engagement. %M 33606656 %R 10.2196/26559 %U https://www.jmir.org/2021/3/e26559 %U https://doi.org/10.2196/26559 %U http://www.ncbi.nlm.nih.gov/pubmed/33606656 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 3 %P e22571 %T A Fitness App for Monitoring Walking Behavior and Perception (Runkeeper): Mixed Methods Pilot Study %A Hollander,Justin B %A Folta,Sara C %A Graves,Erin Michelle %A Allen,Jennifer D %A Situ,Minyu %+ Department of Urban and Environmental Policy and Planning, School of Arts and Sciences, Tufts University, 97 Talbot Avenue, Medford, MA, 02155, United States, 1 6176273394, justin.hollander@tufts.edu %K physical activity %K smartphone %K mobile app %K sense of belongingness %K community cohesion %D 2021 %7 1.3.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Physical activity has a strong positive impact on both physical and mental health, and public health interventions often encourage walking as a means to promote physical activity. Social connectivity, such as that among spouses, families, friends, and colleagues, highly influences physical activity. Although technology-based interventions have some influence on human behavior, they have not been fully implemented and evaluated for their influence on walking through social connectivity. Objective: We aimed to pilot-test the organization of neighborhood walking clubs and use of a mobile app (Runkeeper) to encourage social connectedness and neighborhood cohesion, as well as to increase physical activity. Methods: We used a convenience sampling method to recruit 46 adults from an urban location in Greater Boston, Massachusetts. We assigned participants to teams based on their geographic location and neighborhood and required them to use the app (Runkeeper). Participants completed 2 self-administered web-based surveys before and after the intervention period. The surveys included standard measures to evaluate physical activity, social connectedness, perceived social support, and neighborhood cohesion (Buckner Neighborhood Cohesion Scale) before and after the intervention. Following the intervention, we randomly selected 14 participants to participate in postintervention, in-depth phone interviews to gain an understanding of their experiences. Results: This study was approved by the institutional review board in June 2018 and funded in January 2018. Recruitment started in May 2019 and lasted for 2 months. Data were collected from July 2019 to January 2020. In this study, Runkeeper was of limited feasibility as an app for measuring physical activity or promoting social connectedness. Data from the app recorded sparse and uneven walking behaviors among the participants. Qualitative interviews revealed that users experienced difficulties in using the settings and features of the app. In the questionnaire, there was no change between pre-post assessments in walking minutes (b=−.79; 95% CI −4.0 to 2.4; P=.63) or miles (b=−.07; 95% CI −0.15 to 0.01; P=.09). We observed a pre-post increase in social connectedness and a decrease in neighborhood cohesion. Both quantitative and qualitative results indicated that the psychosocial aspects of walking motivated the participants and helped them relieve stress. Interview results showed that participants felt a greater virtual connection in their assigned groups and enhanced connections with friends and family members. Conclusions: Our study found that Runkeeper created a virtual connection among walking group members and its data sharing and ranking motivated walking. Participants felt that walking improved their mental health, helped to relieve stress, and made them feel more connected with friends or family members. In future studies, it will be important to use an app that integrates with a wearable physical activity device. There is also a need to develop and test intervention components that might be more effective in fostering neighborhood cohesion. %M 33646132 %R 10.2196/22571 %U https://formative.jmir.org/2021/3/e22571 %U https://doi.org/10.2196/22571 %U http://www.ncbi.nlm.nih.gov/pubmed/33646132 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 3 %P e25289 %T Using Fitbit as an mHealth Intervention Tool to Promote Physical Activity: Potential Challenges and Solutions %A Balbim,Guilherme M %A Marques,Isabela G %A Marquez,David X %A Patel,Darshilmukesh %A Sharp,Lisa K %A Kitsiou,Spyros %A Nyenhuis,Sharmilee M %+ Department of Biomedical and Health Information Sciences, College of Applied Health Sciences, University of Illinois at Chicago, 1919 W Taylor St (MC 530), Chicago, IL, 60612, United States, 1 312 355 3519, skitsiou@uic.edu %K physical activity %K fitness trackers %K Fitbit %K smartphones %K interventional studies %K adults %K older adults %K wearable %K intervention %D 2021 %7 1.3.2021 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Consumer-based physical activity (PA) trackers, also known as wearables, are increasingly being used in research studies as intervention or measurement tools. One of the most popular and widely used brands of PA trackers is Fitbit. Since the release of the first Fitbit in 2009, hundreds of experimental studies have used Fitbit devices to facilitate PA self-monitoring and behavior change via goal setting and feedback tools. Fitbit’s ability to capture large volumes of PA and physiological data in real time creates enormous opportunities for researchers. At the same time, however, it introduces a number of challenges (eg, technological, operational, logistical), most of which are not sufficiently described in study publications. Currently, there are no technical reports, guidelines, nor other types of publications discussing some of these challenges and offering guidance to researchers on how to best incorporate Fitbit devices in their study design and intervention to achieve their research goals. As a result, researchers are often left alone to discover and address some of these issues during the study through “trial and error.” This paper aims to address this gap. Drawing on our cumulative experience of conducting multiple studies with various Fitbit PA trackers over the years, we present and discuss various key challenges associated with the use of Fitbit PA trackers in research studies. Difficulties with the use of Fitbit PA trackers are encountered throughout the entire research process. Challenges and solutions are categorized in 4 main categories: study preparation, intervention delivery, data collection and analysis, and study closeout. Subsequently, we describe a number of empirically tested strategies used in 4 of our interventional studies involving participants from a broad range of demographic characteristics, racial/ethnic backgrounds, and literacy levels. Researchers should be prepared to address challenges and issues in a timely fashion to ensure that the Fitbit effectively assists participants and researchers in achieving research and outcome goals. %M 33646135 %R 10.2196/25289 %U https://mhealth.jmir.org/2021/3/e25289 %U https://doi.org/10.2196/25289 %U http://www.ncbi.nlm.nih.gov/pubmed/33646135 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e18853 %T Rural Residents’ Perspectives on an mHealth or Personalized Health Coaching Intervention: Qualitative Study With Focus Groups and Key Informant Interviews %A Schoenberg,Nancy %A Dunfee,Madeline %A Yeager,Hannah %A Rutledge,Matthew %A Pfammatter,Angela %A Spring,Bonnie %+ Department of Behavior Science, University of Kentucky, 760 Press Avenue, 372 Healthy Kentucky Research Building, Lexington, KY, 40536, United States, 1 859 323 8175, nesch@uky.edu %K rural populations %K technology %K exercise %K diet %K community-based participatory research %K mobile phone %D 2021 %7 26.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Compared with national averages, rural Appalachians experience extremely elevated rates of premature morbidity and mortality. New opportunities, including approaches incorporating personal technology, may help improve lifestyles and overcome health inequities. Objective: This study aims to gather perspectives on whether a healthy lifestyle intervention, specifically an app originally designed for urban users, may be feasible and acceptable to rural residents. In addition to a smartphone app, this program—Make Better Choices 2—consists of personalized health coaching, accelerometer use, and financial incentives. Methods: We convened 4 focus groups and 16 key informant interviews with diverse community stakeholders to assess perspectives on this novel, evidence-based diet and physical activity intervention. Participants were shown a slide presentation and asked open-ended follow-up questions. The focus group and key informant interview sessions were audiotaped, transcribed, and subjected to thematic analysis. Results: We identified 3 main themes regarding Appalachian residents’ perspectives on this mobile health (mHealth) intervention: personal technology is feasible and desirable; challenges persist in implementing mHealth lifestyle interventions in Appalachian communities; and successful mHealth interventions should include personal connections, local coaches, and educational opportunities. Although viewed as feasible and acceptable overall, lack of healthy lifestyle awareness, habitual behavior, and financial constraints may challenge the success of mHealth lifestyle interventions in Appalachia. Finally, participants described several minor elements that require modification, including expanding the upper age inclusion, providing extra coaching on technology use, emphasizing personal and supportive connections, employing local coaches, and ensuring adequate educational content for the program. Conclusions: Blending new technologies, health coaching, and other features is not only acceptable but may be essential to reach vulnerable rural residents. %M 33635278 %R 10.2196/18853 %U https://formative.jmir.org/2021/2/e18853 %U https://doi.org/10.2196/18853 %U http://www.ncbi.nlm.nih.gov/pubmed/33635278 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e26557 %T A Multimodal Mobile Sleep Intervention for Young Adults Engaged in Risky Drinking: Protocol for a Randomized Controlled Trial %A Fucito,Lisa M %A Ash,Garrett I %A DeMartini,Kelly S %A Pittman,Brian %A Barnett,Nancy P %A Li,Chiang-Shan R %A Redeker,Nancy S %A O'Malley,Stephanie S %+ Department of Psychiatry, Yale University School of Medicine, 20 York Street, Fitkin Building, F619, New Haven, CT, 06510, United States, 1 2032001470, lisa.fucito@yale.edu %K sleep %K binge drinking %K young adults %K mHealth %K biosensor %K behavior therapy %K mobile phone %D 2021 %7 26.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: This paper describes the research protocol for a randomized controlled trial of a multimodal mobile sleep intervention for heavy-drinking young adults. Young adults report the highest rates of heavy, risky alcohol consumption and are a priority population for alcohol prevention and intervention efforts. Alcohol strategies that leverage other health concerns and use technology may offer an innovative solution. Poor sleep is common among young adults and is a risk factor for developing an alcohol use disorder. Moreover, young adults are interested in information to help them sleep better, and behavioral sleep interventions address alcohol use as a standard practice. Objective: The primary aim of this study is to assess the effectiveness of a 2-week multimodal mobile sleep intervention for reducing drinks consumed per week among heavy-drinking young adults. We will explore the effects on alcohol-related consequences, assessing quantitative and qualitative sleep characteristics as secondary aims. The study’s goals are to identify the optimal combination of sleep intervention components for improving drinking outcomes, the feasibility and acceptability of these components, and the potential mechanisms by which these components may promote alcohol behavior change. Methods: Young adults (aged 18-25 years) who report recent heavy drinking will be randomly assigned to one of three conditions: mobile sleep hygiene advice (n=30), mobile sleep hygiene advice and sleep and alcohol diary self-monitoring (n=30), or mobile sleep hygiene advice, sleep and alcohol diary self-monitoring, and sleep and alcohol data feedback (n=60). For the feedback component, participants will complete two web-based sessions with a health coach during which they will receive summaries of their sleep and alcohol data, and the potential association between them along with brief advice tailored to their data. All participants will wear sleep and alcohol biosensors daily for 2 weeks for objective assessments of these outcomes. Results: The study was funded by the National Institutes of Health in May 2018. Recruitment began in December 2018 and will be concluded in Spring 2021. As of February 4, 2021, we have enrolled 110 participants. Conclusions: Ultimately, this research could result in an efficacious, low-cost intervention with broad population reach through the use of technology. In addition, this intervention may substantially impact public health by reducing alcohol use disorder risk at a crucial developmental stage. Trial Registration: ClinicalTrials.gov NCT03658954; https://clinicaltrials.gov/ct2/show/NCT03658954 International Registered Report Identifier (IRRID): DERR1-10.2196/26557 %M 33635276 %R 10.2196/26557 %U https://www.researchprotocols.org/2021/2/e26557 %U https://doi.org/10.2196/26557 %U http://www.ncbi.nlm.nih.gov/pubmed/33635276 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e24165 %T Effects of COVID-19 Emergency Alert Text Messages on Practicing Preventive Behaviors: Cross-sectional Web-Based Survey in South Korea %A You,Myoungsoon %A Lee,Minjung %+ Department of Public Health Sciences, Graduate School of Public Health, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, 08826, Republic of Korea, 82 880 2773, msyou@snu.ac.kr %K COVID-19 %K coronavirus %K preventive behaviors %K text message %K mobile phone %K alert %K prevention %K behavior %K public health %K survey %D 2021 %7 25.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Sending emergency messages via mobile phone text messaging can be a promising communication tool to rapidly disseminate information and promote preventive behavior among the public during epidemic outbreaks. The battle to overcome COVID-19 is not yet over; thus, it is essential that the public practices preventive measures to prevent the spread of COVID-19. Objective: This study aimed to investigate the effectiveness of reading and obtaining information via emergency alert SMS text messages and their effects on the individual's practice of preventive behaviors during the early stages of the COVID-19 outbreak in South Korea. Methods: A cross-sectional web-based survey comprising 990 participants was conducted over 3 days (March 25-27, 2020). A multivariable logistic regression analysis revealed the sociodemographic factors that might influence the behavior of reading emergency alert text messages. A hierarchical linear regression model estimated the associations between reading emergency alert text messages for each precautionary behavior practiced against COVID-19. Additionally, the indirect effects of reading the text messages on each precautionary behavior via psychological factors (ie, perceived risk and response efficacy) were calculated. All data were weighted according to the 2019 Korea census data. Results: Overall, 49.2% (487/990) of the participants reported that they always read emergency alert text messages and visited the linked website to obtain more information. Factors such as female sex (odds ratio [OR] 1.68, 95% CI 1.28-2.21) and older age (30-39 years: OR 2.02, 95% CI 1.25-3.28; 40-49 years: OR 2.84, 95% CI 1.80-4.47; 50-59 years: OR 3.19, 95% CI 2.01-5.06; 60 years and above: OR 3.12, 95% CI 2.00-4.86 versus 18-29 years) were identified to be associated with a higher frequency of reading the text messages. Participants who always read the text messages practiced wearing facial masks (β=.074, P=.01) more frequently than those who did not. In terms of social distancing, participants who reported they always read the text messages avoided crowded places (β=.078, P=.01) and canceled or postponed social gatherings (β=.103, P<.001) more frequently than those who did not read the text messages. Furthermore, reading text messages directly and indirectly affected practicing precautionary behaviors, as the mediation effect of response efficacy between reading text messages and practicing preventive behaviors was significant. Conclusions: Our findings suggest that emergency alert text messages sent to individuals' mobile phones are timely and effective strategies for encouraging preventive behavior in public. Sending emergency alert text messages to provide the public with accurate and reliable information could be positively considered by the health authorities, which might reduce the negative impact of infodemics. %M 33544691 %R 10.2196/24165 %U https://www.jmir.org/2021/2/e24165 %U https://doi.org/10.2196/24165 %U http://www.ncbi.nlm.nih.gov/pubmed/33544691 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e17492 %T The Kurbo App: The Freemium Model and Developmental Behavior Concerns. Comment on “Impact of a Mobile App–Based Health Coaching and Behavior Change Program on Participant Engagement and Weight Status of Overweight and Obese Children: Retrospective Cohort Study” %A Vitolo,Marcia Regina %+ Federal University of Health Sciences of Porto Alegre, Rua Sarmento Leite 245, Porto Alegre, 90050170, Brazil, 55 1138651010, marciavitolo@hotmail.com %K childhood obesity %K intervention %K app %D 2021 %7 25.2.2021 %9 Letter to the Editor %J JMIR Mhealth Uhealth %G English %X %M 33629965 %R 10.2196/17492 %U https://mhealth.jmir.org/2021/2/e17492 %U https://doi.org/10.2196/17492 %U http://www.ncbi.nlm.nih.gov/pubmed/33629965 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e14179 %T Ecological Momentary Assessment Using Smartphones in Patients With Depression: Feasibility Study %A Maatoug,Redwan %A Peiffer-Smadja,Nathan %A Delval,Guillaume %A Brochu,Térence %A Pitrat,Benjamin %A Millet,Bruno %+ Sorbonne Université, AP-HP, Service de psychiatrie adulte de la Pitié-Salpêtrière, Institut du Cerveau, ICM, F-75013, 47-83 Boulevard de l'hôpital, Paris, 75013, France, 33 682476484, redwanmaatoug@gmail.com %K ecological momentary assessment %K depression %K smartphone %K feasibility study %K user experience %D 2021 %7 24.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Ecological momentary assessment (EMA) is a promising tool in the management of psychiatric disorders and particularly depression. It allows for a real-time evaluation of symptoms and an earlier detection of relapse or treatment efficacy. The generalization of the smartphone in the modern world offers a new, large-scale support for EMA. Objective: The main objective of this study was twofold: (1) to assess patients’ compliance with an EMA smartphone app defined by the number of EMAs completed, and (2) to estimate the external validity of the EMA using a correlation between self-esteem/guilt/mood variables and Hamilton Depression Rating Scale (HDRS) score. Methods: Eleven patients at the Pitié-Salpêtrière Hospital, Paris, France, were monitored for 28 days by means of a smartphone app. Every patient enrolled in the study had two types of assessment: (1) three outpatient consultations with a psychiatrist at three different time points (days 1, 15, and 28), and (2) real-time data collection using an EMA smartphone app with a single, fixed notification per day at 3 pm for 28 days. The results of the real-time data collected were reviewed during the three outpatient consultations by a psychiatrist using a dashboard that aggregated all of the patients’ data into a user-friendly format. Results: Of the 11 patients in the study, 6 patients attended the 3 outpatient consultations with the psychiatrist and completed the HDRS at each consultation. We found a positive correlation between the HDRS score and the variables of self-esteem, guilt, and mood (Spearman correlation coefficient 0.57). Seven patients completed the daily EMAs for 28 days or longer, with an average response rate to the EMAs of 62.5% (175/280). Furthermore, we observed a positive correlation between the number of responses to EMAs and the duration of follow-up (Spearman correlation coefficient 0.63). Conclusions: This preliminary study with a prolonged follow-up demonstrates significant patient compliance with the smartphone app. In addition, the self-assessments performed by patients seemed faithful to the standardized measurements performed by the psychiatrist. The results also suggest that for some patients it is more convenient to use the smartphone app than to attend outpatient consultations. %M 33625367 %R 10.2196/14179 %U https://formative.jmir.org/2021/2/e14179 %U https://doi.org/10.2196/14179 %U http://www.ncbi.nlm.nih.gov/pubmed/33625367 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e22877 %T Smoking Cessation Using Wearable Sensors: Protocol for a Microrandomized Trial %A Hernandez,Laura M %A Wetter,David W %A Kumar,Santosh %A Sutton,Steven K %A Vinci,Christine %+ Moffitt Cancer Center, 4115 E. Fowler Avenue, Tampa, FL, 33617, United States, 1 813 745 5421, Christine.Vinci@moffitt.org %K mHealth %K microrandomized trial %K smoking cessation %K mindfulness %K tobacco %K mobile phone %D 2021 %7 24.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cigarette smoking has numerous health consequences and is the leading cause of morbidity and mortality in the United States. Mindfulness has the ability to enhance resilience to stressors and can strengthen an individual’s ability to deal with discomfort, which may be particularly useful when managing withdrawal and craving to smoke. Objective: This study aims to evaluate feasibility results from an intervention that provides real-time, real-world mindfulness strategies to a sample of racially and ethnically diverse smokers making a quit attempt. Methods: This study uses a microrandomized trial design to deliver mindfulness-based strategies in real time to individuals attempting to quit smoking. Data will be collected via wearable sensors, a study smartphone, and questionnaires filled out during the in-person study visits. Results: Recruitment is complete, and data management is ongoing. Conclusions: The data collected during this feasibility trial will provide preliminary findings about whether mindfulness strategies delivered in real time are a useful quit smoking aid that warrants additional investigation. Trial Registration: Clinicaltrials.gov NCT03404596; https://clinicaltrials.gov/ct2/show/NCT03404596 International Registered Report Identifier (IRRID): DERR1-10.2196/22877 %M 33625366 %R 10.2196/22877 %U https://www.researchprotocols.org/2021/2/e22877 %U https://doi.org/10.2196/22877 %U http://www.ncbi.nlm.nih.gov/pubmed/33625366 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e17262 %T Evaluating a Mobile Phone–Delivered Text Message Reminder Intervention to Reduce Infant Vaccination Dropout in Arua, Uganda: Protocol for a Randomized Controlled Trial %A Ehlman,Daniel C %A Magoola,Joseph %A Tanifum,Patricia %A Wallace,Aaron S %A Behumbiize,Prosper %A Mayanja,Robert %A Luzze,Henry %A Yukich,Joshua %A Daniels,Danni %A Mugenyi,Kevin %A Baryarama,Fulgentius %A Ayebazibwe,Nicholas %A Conklin,Laura %+ Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, United States, 1 4046398224, dehlman@cdc.gov %K immunization %K vaccination %K reminder system %K mHealth %K short message service %K text messages %K cell phone %K mobile phone %K vaccination dropout %K vaccination timeliness %D 2021 %7 24.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Globally, suboptimal vaccine coverage is a public health concern. According to Uganda’s 2016 Demographic and Health Survey, only 49% of 12- to 23-month-old children received all recommended vaccinations by 12 months of age. Innovative ways are needed to increase coverage, reduce dropout, and increase awareness among caregivers to bring children for timely vaccination. Objective: This study evaluates a personalized, automated caregiver mobile phone–delivered text message reminder intervention to reduce the proportion of children who start but do not complete the vaccination series for children aged 12 months and younger in select health facilities in Arua district. Methods: A two-arm, multicenter, parallel group randomized controlled trial was conducted in four health facilities providing vaccination services in and around the town of Arua. Caregivers of children between 6 weeks and 6 months of age at the time of their first dose of pentavalent vaccine (Penta1; containing diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b antigens) were recruited and interviewed. All participants received the standard of care, defined as the health worker providing child vaccination home-based records to caregivers as available and providing verbal instruction of when to return for the next visit. At the end of each day, caregivers and their children were randomized by computer either to receive or not receive personalized, automated text message reminders for their subsequent vaccination visits according to the national schedule. Text message reminders for Penta2 were sent 2 days before, on the day of, and 2 days after the scheduled vaccination visit. Reminders for Penta3 and the measles-containing vaccine were sent on the scheduled day of vaccination and 5 and 7 days after the scheduled day. Study personnel conducted postintervention follow-up interviews with participants at the health facilities during the children’s measles-containing vaccine visit. In addition, focus group discussions were conducted to assess caregiver acceptability of the intervention, economic data were collected to evaluate the incremental costs and cost-effectiveness of the intervention, and health facility record review forms were completed to capture service delivery process indicators. Results: Of the 3485 screened participants, 1961 were enrolled from a sample size of 1962. Enrollment concluded in August 2016. Follow-up interviews of study participants, including data extraction from the children’s vaccination cards, data extraction from the health facility immunization registers, completion of the health facility record review forms, and focus group discussions were completed by December 2017. The results are expected to be released in 2021. Conclusions: Prompting health-seeking behavior with reminders has been shown to improve health intervention uptake. Mobile phone ownership continues to grow in Uganda, so their use in vaccination interventions such as this study is logical and should be evaluated with scientifically rigorous study designs. Trial Registration: ClinicalTrials.gov NCT04177485; https://clinicaltrials.gov/ct2/show/NCT04177485 International Registered Report Identifier (IRRID): DERR1-10.2196/17262 %M 33625372 %R 10.2196/17262 %U https://www.researchprotocols.org/2021/2/e17262 %U https://doi.org/10.2196/17262 %U http://www.ncbi.nlm.nih.gov/pubmed/33625372 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e20445 %T Effects of Smartphone-Based Stress Management on Improving Work Engagement Among Nurses in Vietnam: Secondary Analysis of a Three-Arm Randomized Controlled Trial %A Sasaki,Natsu %A Imamura,Kotaro %A Tran,Thuy Thi Thu %A Nguyen,Huong Thanh %A Kuribayashi,Kazuto %A Sakuraya,Asuka %A Bui,Thu Minh %A Nguyen,Quynh Thuy %A Nguyen,Nga Thi %A Nguyen,Giang Thi Huong %A Zhang,Melvyn Weibin %A Minas,Harry %A Sekiya,Yuki %A Watanabe,Kazuhiro %A Tsutsumi,Akizumi %A Shimazu,Akihito %A Kawakami,Norito %+ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, , Japan, 81 3 5841 3522, nkawakami@m.u-tokyo.ac.jp %K stress management %K mental health %K occupational health %K digital health %K workplace %K LMICs %K South-East Asia %K health care professionals %D 2021 %7 23.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Work engagement is important for employee well-being and work performance. However, no intervention study has investigated the effect of an eMental Health intervention on work engagement among workers in low- and middle-income countries (LMICs). Objective: The aim of the study was to examine the effects of a newly developed smartphone-based stress management program (ABC Stress Management) on improving work engagement among hospital nurses in Vietnam, an LMIC. Methods: Full-time registered nurses (n=949) were randomly assigned to one of 2 intervention groups or a control group. The intervention groups were a 6-week, 6-lesson program offering basic cognitive behavioral therapy (CBT-based stress management skills), provided in either free-choice (program A) or fixed order (program B). Work engagement was assessed at baseline and 3-month and 7-month follow-ups in each of the 3 groups. Results: The scores of work engagement in both intervention groups improved from baseline to 3-month follow-up, and then decreased at the 7-month follow-up, while the score steadily increased from baseline to 7-month follow-up in the control group. Program B showed a significant intervention effect on improving work engagement at the 3-month follow-up (P=.049) with a small effect size (Cohen d= 0.16; 95% CI 0.001 to 0.43]). Program A showed nonsignificant trend (d=0.13; 95% CI –0.014 to 0.41; P=.07) toward improved engagement at 3 months. Neither program achieved effectiveness at the 7-month follow-up. Conclusions: The study demonstrated that a fixed order (program B) delivery of a smartphone-based stress management program was effective in improving work engagement in nurses in Vietnam. However, the effect was small and only temporary. Further improvement of this program is required to achieve a greater effect size and more sustained, longer lasting impact on work engagement. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN000033139; tinyurl.com/55gxo253 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-025138 %M 33620328 %R 10.2196/20445 %U https://www.jmir.org/2021/2/e20445 %U https://doi.org/10.2196/20445 %U http://www.ncbi.nlm.nih.gov/pubmed/33620328 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e27109 %T A Digital Health Intervention (SweetGoals) for Young Adults With Type 1 Diabetes: Protocol for a Factorial Randomized Trial %A Stanger,Catherine %A Kowatsch,Tobias %A Xie,Haiyi %A Nahum-Shani,Inbal %A Lim-Liberty,Frances %A Anderson,Molly %A Santhanam,Prabhakaran %A Kaden,Sarah %A Rosenberg,Briana %+ Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, 46 Centerra Parkway, Lebanon, NH, , United States, 1 603 646 7023, Catherine.stanger@dartmouth.edu %K type 1 diabetes %K mhealth %K incentives %K health coaching %K young adults %D 2021 %7 23.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Many young adults with type 1 diabetes (T1D) struggle with the complex daily demands of adherence to their medical regimen and fail to achieve target range glycemic control. Few interventions, however, have been developed specifically for this age group. Objective: In this randomized trial, we will provide a mobile app (SweetGoals) to all participants as a “core” intervention. The app prompts participants to upload data from their diabetes devices weekly to a device-agnostic uploader (Glooko), automatically retrieves uploaded data, assesses daily and weekly self-management goals, and generates feedback messages about goal attainment. Further, the trial will test two unique intervention components: (1) incentives to promote consistent daily adherence to goals, and (2) web health coaching to teach effective problem solving focused on personalized barriers to self-management. We will use a novel digital direct-to-patient recruitment method and intervention delivery model that transcends the clinic. Methods: A 2x2 factorial randomized trial will be conducted with 300 young adults ages 19-25 with type 1 diabetes and (Hb)A1c ≥ 8.0%. All participants will receive the SweetGoals app that tracks and provides feedback about two adherence targets: (a) daily glucose monitoring; and (b) mealtime behaviors. Participants will be randomized to the factorial combination of incentives and health coaching. The intervention will last 6 months. The primary outcome will be reduction in A1c. Secondary outcomes include self-regulation mechanisms in longitudinal mediation models and engagement metrics as a predictor of outcomes. Participants will complete 6- and 12-month follow-up assessments. We hypothesize greater sustained A1c improvements in participants who receive coaching and who receive incentives compared to those who do not receive those components. Results: Data collection is expected to be complete by February 2025. Analyses of primary and secondary outcomes are expected by December 2025. Conclusions: Successful completion of these aims will support dissemination and effectiveness studies of this intervention that seeks to improve glycemic control in this high-risk and understudied population of young adults with T1D. Trial Registration: ClinicalTrials.gov NCT04646473; https://clinicaltrials.gov/ct2/show/NCT04646473 International Registered Report Identifier (IRRID): PRR1-10.2196/27109 %M 33620330 %R 10.2196/27109 %U https://www.researchprotocols.org/2021/2/e27109 %U https://doi.org/10.2196/27109 %U http://www.ncbi.nlm.nih.gov/pubmed/33620330 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e23612 %T Hybrid Ubiquitous Coaching With a Novel Combination of Mobile and Holographic Conversational Agents Targeting Adherence to Home Exercises: Four Design and Evaluation Studies %A Kowatsch,Tobias %A Lohse,Kim-Morgaine %A Erb,Valérie %A Schittenhelm,Leo %A Galliker,Helen %A Lehner,Rea %A Huang,Elaine M %+ Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, WEV-G, Weinbergstrasse 56/58, Zurich, 8092, Switzerland, 41 712247244, tkowatsch@ethz.ch %K ubiquitous coaching %K augmented reality %K health care %K treatment adherence %K design science research %K physiotherapy %K chronic back pain %K pain %K chronic pain %K exercise %K adherence %K treatment %K conversational agent %K smartphone %K mobile phone %D 2021 %7 22.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Effective treatments for various conditions such as obesity, cardiac heart diseases, or low back pain require not only personal on-site coaching sessions by health care experts but also a significant amount of home exercises. However, nonadherence to home exercises is still a serious problem as it leads to increased costs due to prolonged treatments. Objective: To improve adherence to home exercises, we propose, implement, and assess the novel coaching concept of hybrid ubiquitous coaching (HUC). In HUC, health care experts are complemented by a conversational agent (CA) that delivers psychoeducation and personalized motivational messages via a smartphone, as well as real-time exercise support, monitoring, and feedback in a hands-free augmented reality environment. Methods: We applied HUC to the field of physiotherapy and conducted 4 design-and-evaluate loops with an interdisciplinary team to assess how HUC is perceived by patients and physiotherapists and whether HUC leads to treatment adherence. A first version of HUC was evaluated by 35 physiotherapy patients in a lab setting to identify patients’ perceptions of HUC. In addition, 11 physiotherapists were interviewed about HUC and assessed whether the CA could help them build up a working alliance with their patients. A second version was then tested by 15 patients in a within-subject experiment to identify the ability of HUC to address adherence and to build a working alliance between the patient and the CA. Finally, a 4-week n-of-1 trial was conducted with 1 patient to show one experience with HUC in depth and thereby potentially reveal real-world benefits and challenges. Results: Patients perceived HUC to be useful, easy to use, and enjoyable, preferred it to state-of-the-art approaches, and expressed their intentions to use it. Moreover, patients built a working alliance with the CA. Physiotherapists saw a relative advantage of HUC compared to current approaches but initially did not see the potential in terms of a working alliance, which changed after seeing the results of HUC in the field. Qualitative feedback from patients indicated that they enjoyed doing the exercise with an augmented reality–based CA and understood better how to do the exercise correctly with HUC. Moreover, physiotherapists highlighted that HUC would be helpful to use in the therapy process. The longitudinal field study resulted in an adherence rate of 92% (11/12 sessions; 330/360 repetitions; 33/36 sets) and a substantial increase in exercise accuracy during the 4 weeks. Conclusions: The overall positive assessments from both patients and health care experts suggest that HUC is a promising tool to be applied in various disorders with a relevant set of home exercises. Future research, however, must implement a variety of exercises and test HUC with patients suffering from different disorders. %M 33461957 %R 10.2196/23612 %U https://www.jmir.org/2021/2/e23612 %U https://doi.org/10.2196/23612 %U http://www.ncbi.nlm.nih.gov/pubmed/33461957 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e23080 %T Effect of an mHealth Intervention on Hepatitis C Testing Uptake Among People With Opioid Use Disorder: Randomized Controlled Trial %A Hochstatter,Karli R %A Gustafson Sr,David H %A Landucci,Gina %A Pe-Romashko,Klaren %A Cody,Olivia %A Maus,Adam %A Shah,Dhavan V %A Westergaard,Ryan P %+ School of Social Work, Columbia University, 1255 Amsterdam Ave, New York, NY, 10027, United States, 1 9209600002, khochsta@medicine.wisc.edu %K intravenous injections %K mHealth %K hepatitis C virus %K opioid use disorder %K mobile phone %D 2021 %7 22.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The growing epidemic of opioid use disorder (OUD) and associated injection drug use has resulted in a surge of new hepatitis C virus (HCV) infections. Approximately half of the people with HCV infection are unaware of their HCV status. Improving HCV awareness and increasing screening among people with OUD are critical. Addiction-Comprehensive Health Enhancement Support System (A-CHESS) is an evidence-based, smartphone-delivered relapse prevention system that has been implemented among people with OUD who are receiving medications for addiction treatment (MAT) to improve long-term recovery. Objective: We incorporated HCV-related content and functionality into A-CHESS to characterize the HCV care continuum among people in early remission and receiving MAT for OUD and to determine whether incorporating such content and functionality into A-CHESS increases HCV testing. Methods: HCV intervention content, including dissemination of educational information, private messages tailored to individuals’ stage of HCV care, and a public discussion forum, was implemented into the A-CHESS platform. Between April 2016 and April 2020, 416 participants with OUD were enrolled in this study. Participants were randomly assigned to receive MAT alone (control arm) or MAT+A-CHESS (experimental arm). Quarterly telephone interviews were conducted from baseline to month 24 to assess risk behaviors and HCV testing history. Cox proportional hazards regression was used to assess whether participants who used A-CHESS were tested for HCV (either antibody [Ab] or RNA testing) at a higher rate than those in the control arm. To assess the effect of A-CHESS on subsets of participants at the highest risk for HCV, additional analyses were performed to examine the effect of the intervention among participants who injected drugs and shared injection equipment. Results: Overall, 44.2% (184/416) of the study participants were HCV Ab positive, 30.3% (126/416) were HCV Ab negative, and 25.5% (106/416) were considered untested at baseline. At month 24, there was no overall difference in HCV testing uptake between the intervention and control participants. However, among the subset of 109 participants who engaged in injection drug use, there was a slight trend toward increased HCV testing uptake among those who used A-CHESS (89% vs 85%; hazard ratio: 1.34; 95% CI 0.87-2.05; P=.18), and a stronger trend was observed when focusing on the subset of 32 participants who reported sharing injection equipment (87% vs 56%; hazard ratio: 2.92; 95% CI 0.959-8.86; P=.06). Conclusions: Incorporating HCV prevention and care information into A-CHESS may increase the uptake of HCV testing while preventing opioid relapse when implemented among populations who engage in high-risk behaviors such as sharing contaminated injection equipment. However, more studies that are powered to detect differences in HCV testing among high-risk groups are needed. Trial Registration: ClinicalTrials.gov NCT02712034; https://clinicaltrials.gov/ct2/show/NCT02712034 International Registered Report Identifier (IRRID): RR2-10.2196/12620 %M 33616545 %R 10.2196/23080 %U https://mhealth.jmir.org/2021/2/e23080 %U https://doi.org/10.2196/23080 %U http://www.ncbi.nlm.nih.gov/pubmed/33616545 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e23786 %T Effects of eHealth-Based Multiple Health Behavior Change Interventions on Physical Activity, Healthy Diet, and Weight in People With Noncommunicable Diseases: Systematic Review and Meta-analysis %A Duan,Yanping %A Shang,Borui %A Liang,Wei %A Du,Gaohui %A Yang,Min %A Rhodes,Ryan E %+ Department of Social Sciences, Hebei Sport University, 82 Xuefu Road, Shijiazhuang, 050041, China, 86 15383112089, borui_shang_pe@qq.com %K systematic review %K meta-analysis %K noncommunicable disease %K multiple health behavior change %K weight-related %K physical activity %K healthy diet %K eHealth %D 2021 %7 22.2.2021 %9 Review %J J Med Internet Res %G English %X Background: Noncommunicable diseases (NCDs) are associated with the burden of premature deaths and huge medical costs globally. There is an increasing number of studies combining a multiple health behavior change (MHBC) intervention paradigm with eHealth approaches to jointly promote weight-related health behaviors among people with NCD; yet, a comprehensive summary of these studies is lacking. Objective: This review aims to meta-analyze the effectiveness and systematically summarize the characteristics of the relevant intervention studies for improving the outcomes of physical activity, healthy diet, and weight among people with NCD. Methods: Following PRISMA guidelines, 4 electronic databases (PsycINFO, PubMed, Scopus, SPORTDiscus) were systematically searched to identify eligible articles based on a series of inclusion and exclusion criteria. Article selection, quality assessment, and data extraction were independently performed by 2 authors. The standardized mean difference (SMD) was calculated to evaluate the effectiveness of interventions for 3 intervention outcomes (physical activity, healthy diet, and weight), and subsequent subgroup analyses were performed for gender, age, intervention duration, channel, and theory. Calculations were conducted, and figures were produced in SPSS 22 and Review Manager 5.3. Results: Of the 664 original hits generated by the systematic searches, 15 eligible studies with moderate to high quality were included. No potential publication bias was detected using statistical analyses. Studies varied in intervention channel, intensity, and content. The meta-analysis revealed that the eHealth MHBC interventions significantly promoted physical activity (SMD 0.85, 95% CI 0.23 to 1.47, P=.008) and healthy diet (SMD 0.78, 95% CI 0.13 to 1.43, P=.02), but did not contribute to a healthy weight status (SMD –0.13, 95% CI= –0.47 to 0.20, P=.43) among people with NCDs, compared to the control conditions. Results from subgroup analysis indicated that theory-based interventions achieved greater effect than nontheory-based interventions in promoting physical activity, and interventions with traditional approaches (SMS, telephone) were more effective than those with modern internet-based approaches in promoting healthy diet. Conclusions: The results of this review indicates that eHealth MHBC interventions achieve preliminary success in promoting physical activity and healthy diet behaviors among people with NCD. Future studies could improve the intervention design to achieve better intervention effectiveness. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019118629; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=118629 %M 33616534 %R 10.2196/23786 %U https://www.jmir.org/2021/2/e23786 %U https://doi.org/10.2196/23786 %U http://www.ncbi.nlm.nih.gov/pubmed/33616534 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e22572 %T A Theory-Based mHealth Intervention (Getting Off) for Methamphetamine-Using Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial %A Reback,Cathy J %A Fletcher,Jesse B %A Mata,Raymond P %+ Friends Research Institution, Inc, 6910 Santa Monica Blvd, Los Angeles, CA, 90038, United States, 1 323 463 1601, rmata@friendsresearch.org %K HIV %K AIDS %K methamphetamine %K mHealth %K mobile app %K ART %K mobile phone %D 2021 %7 22.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Methamphetamine (meth) use among men who have sex with men (MSM) is associated with increased HIV prevalence and transmission and substandard advancement along the HIV prevention and care continuum. Given the growth of mobile health (mHealth) technologies, it is no longer necessary to limit meth treatment options to physical, brick-and-mortar sites, and administration using generic, nontailored content. Objective: In a 2-arm randomized controlled trial (RCT; N=300), we aim to evaluate the use of an mHealth intervention (Getting Off) to assess the impact and noninferiority of a cross-platform app (developed from a manualized meth treatment intervention) to help MSM reduce meth use and HIV sexual risk behaviors and improve their advancement along the HIV prevention and care continuum (HIV testing, pre-exposure prophylaxis uptake and persistence, and antiretroviral therapy uptake and adherence). Methods: Participants will be randomized into 2 arms: arm A, with immediate access to the app (immediate delivery: n=150), or arm B, with delayed access to the app after a 30-day period (delayed delivery: n=150). Participants in both arms will use the same Getting Off app and will have 30 days to complete the 24 sessions. Participants will be assessed at the 1-, 2- (delayed delivery arm only), 3-, 6-, and 9-month timepoints to determine observed treatment effects and will be compared with a historical matched sample of participants (n=~600) who received the brick-and-mortar group-based Getting Off intervention. Results: Recruitment began in January 2019 for phase 1, the formative phase. In January and February 2019, 4 focus groups (N=36) were formed to provide input on the adaptation of the group-based manual intervention to a mobile app. Data collection for phase 2, the RCT, is expected to be completed in January 2023. The final results are anticipated in April 2023. Conclusions: By creating a culturally responsive mobile app, Getting Off aims to reduce meth use and improve sexual health outcomes among meth-using MSM. The Getting Off app could have significant public health impact by greatly expanding access to effective, affordable, private, culturally competent, and highly scalable meth treatment for MSM. Trial Registration: Clinicaltrials.gov NCT03884946; https://clinicaltrials.gov/ct2/show/NCT03884946 International Registered Report Identifier (IRRID): DERR1-10.2196/22572 %M 33616547 %R 10.2196/22572 %U https://www.researchprotocols.org/2021/2/e22572 %U https://doi.org/10.2196/22572 %U http://www.ncbi.nlm.nih.gov/pubmed/33616547 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 2 %P e22277 %T Characteristics of the Users of Troubled Desire, a Web-Based Self-management App for Individuals With Sexual Interest in Children: Descriptive Analysis of Self-assessment Data %A Schuler,Miriam %A Gieseler,Hannes %A Schweder,Katharina W %A von Heyden,Maximilian %A Beier,Klaus M %+ Department of Health and Human Sciences, Institute of Sexology and Sexual Medicine, Charité-Universitätsmedizin Berlin, Charitépl 1, Berlin, 10117, Germany, 49 30 450 520 339, miriam.schuler@charite.de %K pedophilia %K hebephilia %K child sexual offenses %K child sexual abuse material %K web-based assessment %K web-based treatment %D 2021 %7 19.2.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite the high prevalence of child sexual offenses and the increasing amounts of available child sexual abuse material, there is a global shortage of preventive interventions focusing on individuals at risk of sexual offending. The web-based app Troubled Desire aims to address this shortage by offering self-assessments and self-management training modules in different languages to individuals with sexual interests in prepubescent and early pubescent children (ie, those with pedophilic and hebephiliac sexual interest, respectively). Objective: The aim of this study was to describe the characteristics of the users of the Troubled Desire app. Methods: The fully completed self-assessment data gathered within the first 30 months of this study from October 25, 2017 to April 25, 2020 were investigated. The main outcome measures were (1) sociodemographic information and (2) sexual interests and sexual behaviors of the users of Troubled Desire. Results: The self-assessment was completed by 4161 users. User accesses were mainly from Germany (2277/4161, 54.7%) and the United States (474/4161, 11.4%). Approximately 78.9% (3281/4161) of the users reported sexual interest in children; these users were significantly more likely to report distress and trouble owing to their sexual interest. Further, child sexual offenses and consumption of child sexual abuse material were significantly more common among users with sexual interest in children than among users with no sexual interest in children. Additionally, the majority of the offenses were not known to legal authorities. Conclusions: The Troubled Desire app is useful in reaching out to individuals with sexual interest in prepubescent and early pubescent children. However, future research is warranted to understand the prospective relevance of the Troubled Desire app in the prevention of child sexual offending. %M 33605895 %R 10.2196/22277 %U http://mental.jmir.org/2021/2/e22277/ %U https://doi.org/10.2196/22277 %U http://www.ncbi.nlm.nih.gov/pubmed/33605895 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e23180 %T Associations Between Digital Health Intervention Engagement, Physical Activity, and Sedentary Behavior: Systematic Review and Meta-analysis %A Mclaughlin,Matthew %A Delaney,Tessa %A Hall,Alix %A Byaruhanga,Judith %A Mackie,Paul %A Grady,Alice %A Reilly,Kathryn %A Campbell,Elizabeth %A Sutherland,Rachel %A Wiggers,John %A Wolfenden,Luke %+ School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, 2308, Australia, 61 02 4924 6477, Matthew.Mclaughlin1@health.nsw.gov.au %K engagement %K adherence %K digital health intervention %K digital behavior change intervention %K physical activity %K sedentary behavior %K mobile phone %D 2021 %7 19.2.2021 %9 Review %J J Med Internet Res %G English %X Background: The effectiveness of digital health interventions is commonly assumed to be related to the level of user engagement with the digital health intervention, including measures of both digital health intervention use and users’ subjective experience. However, little is known about the relationships between the measures of digital health intervention engagement and physical activity or sedentary behavior. Objective: This study aims to describe the direction and strength of the association between engagement with digital health interventions and physical activity or sedentary behavior in adults and explore whether the direction of association of digital health intervention engagement with physical activity or sedentary behavior varies with the type of engagement with the digital health intervention (ie, subjective experience, activities completed, time, and logins). Methods: Four databases were searched from inception to December 2019. Grey literature and reference lists of key systematic reviews and journals were also searched. Studies were eligible for inclusion if they examined a quantitative association between a measure of engagement with a digital health intervention targeting physical activity and a measure of physical activity or sedentary behavior in adults (aged ≥18 years). Studies that purposely sampled or recruited individuals on the basis of pre-existing health-related conditions were excluded. In addition, studies were excluded if the individual engaging with the digital health intervention was not the target of the physical activity intervention, the study had a non–digital health intervention component, or the digital health interventions targeted multiple health behaviors. A random effects meta-analysis and direction of association vote counting (for studies not included in meta-analysis) were used to address objective 1. Objective 2 used vote counting on the direction of the association. Results: Overall, 10,653 unique citations were identified and 375 full texts were reviewed. Of these, 19 studies (26 associations) were included in the review, with no studies reporting a measure of sedentary behavior. A meta-analysis of 11 studies indicated a small statistically significant positive association between digital health engagement (based on all usage measures) and physical activity (0.08, 95% CI 0.01-0.14, SD 0.11). Heterogeneity was high, with 77% of the variation in the point estimates explained by the between-study heterogeneity. Vote counting indicated that the relationship between physical activity and digital health intervention engagement was consistently positive for three measures: subjective experience measures (2 of 3 associations), activities completed (5 of 8 associations), and logins (6 of 10 associations). However, the direction of associations between physical activity and time-based measures of usage (time spent using the intervention) were mixed (2 of 5 associations supported the hypothesis, 2 were inconclusive, and 1 rejected the hypothesis). Conclusions: The findings indicate a weak but consistent positive association between engagement with a physical activity digital health intervention and physical activity outcomes. No studies have targeted sedentary behavior outcomes. The findings were consistent across most constructs of engagement; however, the associations were weak. %M 33605897 %R 10.2196/23180 %U http://www.jmir.org/2021/2/e23180/ %U https://doi.org/10.2196/23180 %U http://www.ncbi.nlm.nih.gov/pubmed/33605897 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 6 %N 1 %P e24030 %T Role of Digital Engagement in Diabetes Care Beyond Measurement: Retrospective Cohort Study %A Fundoiano-Hershcovitz,Yifat %A Hirsch,Abigail %A Dar,Sharon %A Feniger,Eitan %A Goldstein,Pavel %+ DarioHealth, Hatochen, 8, Caesarea, 3088900, Israel, 972 525296979, Yifat@mydario.com %K blood glucose %K mHealth %K diabetes %K self-management %K digital engagement %D 2021 %7 18.2.2021 %9 Original Paper %J JMIR Diabetes %G English %X Background: The use of remote data capture for monitoring blood glucose and supporting digital apps is becoming the norm in diabetes care. One common goal of such apps is to increase user awareness and engagement with their day-to-day health-related behaviors (digital engagement) in order to improve diabetes outcomes. However, we lack a deep understanding of the complicated association between digital engagement and diabetes outcomes. Objective: This study investigated the association between digital engagement (operationalized as tagging of behaviors alongside glucose measurements) and the monthly average blood glucose level in persons with type 2 diabetes during the first year of managing their diabetes with a digital chronic disease management platform. We hypothesize that during the first 6 months, blood glucose levels will drop faster and further in patients with increased digital engagement and that difference in outcomes will persist for the remainder of the year. Finally, we hypothesize that disaggregated between- and within-person variabilities in digital engagement will predict individual-level changes in blood glucose levels. Methods: This retrospective real-world analysis followed 998 people with type 2 diabetes who regularly tracked their blood glucose levels with the Dario digital therapeutics platform for chronic diseases. Subjects included “nontaggers” (users who rarely or never used app features to notice and track mealtime, food, exercise, mood, and location, n=585) and “taggers” (users who used these features, n=413) representing increased digital engagement. Within- and between-person variabilities in tagging behavior were disaggregated to reveal the association between tagging behavior and blood glucose levels. The associations between an individual’s tagging behavior in a given month and the monthly average blood glucose level in the following month were analyzed for quasicausal effects. A generalized mixed piecewise statistical framework was applied throughout. Results: Analysis revealed significant improvement in the monthly average blood glucose level during the first 6 months (t=−10.01, P<.001), which was maintained during the following 6 months (t=−1.54, P=.12). Moreover, taggers demonstrated a significantly steeper improvement in the initial period relative to nontaggers (t=2.15, P=.03). Additional findings included a within-user quasicausal nonlinear link between tagging behavior and glucose control improvement with a 1-month lag. More specifically, increased tagging behavior in any given month resulted in a 43% improvement in glucose levels in the next month up to a person-specific average in tagging intensity (t=−11.02, P<.001). Above that within-person mean level of digital engagement, glucose levels remained stable but did not show additional improvement with increased tagging (t=0.82, P=.41). When assessed alongside within-person effects, between-person changes in tagging behavior were not associated with changes in monthly average glucose levels (t=1.30, P=.20). Conclusions: This study sheds light on the source of the association between user engagement with a diabetes tracking app and the clinical condition, highlighting the importance of within-person changes versus between-person differences. Our findings underscore the need for and provide a basis for a personalized approach to digital health. %M 33599618 %R 10.2196/24030 %U http://diabetes.jmir.org/2021/1/e24030/ %U https://doi.org/10.2196/24030 %U http://www.ncbi.nlm.nih.gov/pubmed/33599618 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e20217 %T eHealth Intervention to Improve Health Habits in the Adolescent Population: Mixed Methods Study %A Benavides,Carmen %A Benítez-Andrades,José Alberto %A Marqués-Sánchez,Pilar %A Arias,Natalia %+ SALBIS Research Group, Department of Electric, Systems and Automatics Engineering, University of León, Campus de Vegazana s/n, León, Spain, 34 987293628, jbena@unileon.es %K adolescent behaviors %K BMI %K diet %K healthy habits %K intervention %K leader %K physical activity %K social network analysis %K adolescent %K social network %K behavior %D 2021 %7 18.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Technology has provided a new way of life for the adolescent population. Indeed, strategies aimed at improving health-related behaviors through digital platforms can offer promising results. However, since it has been shown that peers are capable of modifying behaviors related to food and physical exercise, it is important to study whether digital interventions based on peer influence are capable of improving the weight status of adolescents. Objective: The purpose of this study was to assess the effectiveness of an eHealth app in an adolescent population in terms of improvements in their age- and sex-adjusted BMI percentiles. Other goals of the study were to examine the social relationships of adolescents pre- and postintervention, and to identify the group leaders and study their profiles, eating and physical activity habits, and use of the web app. Methods: The BMI percentiles were calculated in accordance with the reference guidelines of the World Health Organization. Participants’ diets and levels of physical activity were assessed using the Mediterranean Diet Quality Index (KIDMED) questionnaire and the Physical Activity Questionnaire for Adolescents (PAQ-A), respectively. The variables related to social networks were analyzed using the social network analysis (SNA) methodology. In this respect, peer relationships that were considered reciprocal friendships were used to compute the “degree” measure, which was used as an indicative parameter of centrality. Results: The sample population comprised 210 individuals in the intervention group (IG) and 91 individuals in the control group (CG). A participation rate of 60.1% (301/501) was obtained. After checking for homogeneity between the IG and the CG, it was found that adolescents in the IG at BMI percentiles both below and above the 50th percentile (P50) modified their BMI to approach this reference value (with a significance of P<.001 among individuals with an initial BMI below the P50 and P=.04 for those with an initial BMI above the P50). The diet was also improved in the IG compared with the CG (P<.001). After verifying that the social network had increased postintervention, it was seen that the group leaders (according to the degree SNA measure) were also leaders in physical activity performed (P=.002) and use of the app. Conclusions: The eHealth app was able to modify behaviors related to P50 compliance and exert a positive influence in relation to diet and physical exercise. Digital interventions in the adolescent population, based on the improvement in behaviors related to healthy habits and optimizing the social network, can offer promising results that help in the fight against obesity. %M 33599616 %R 10.2196/20217 %U http://mhealth.jmir.org/2021/2/e20217/ %U https://doi.org/10.2196/20217 %U http://www.ncbi.nlm.nih.gov/pubmed/33599616 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e24607 %T Framework for the Design Engineering and Clinical Implementation and Evaluation of mHealth Apps for Sleep Disturbance: Systematic Review %A Aji,Melissa %A Gordon,Christopher %A Stratton,Elizabeth %A Calvo,Rafael A %A Bartlett,Delwyn %A Grunstein,Ronald %A Glozier,Nick %+ Brain and Mind Center, The University of Sydney, Level 5, Professor Marie Bashir Centre, Missenden Road, Camperdown, 2050, Australia, 61 29515 1596, nick.glozier@sydney.edu.au %K mobile applications %K sleep %K insomnia %K internet-based intervention %K mHealth %K mobile health %K systematic review %D 2021 %7 17.2.2021 %9 Review %J J Med Internet Res %G English %X Background: Mobile health (mHealth) apps offer a scalable option for treating sleep disturbances at a population level. However, there is a lack of clarity about the development and evaluation of evidence-based mHealth apps. Objective: The aim of this systematic review was to provide evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance. Methods: A systematic search of studies published from the inception of databases through February 2020 was conducted using 5 databases (MEDLINE, Embase, Cochrane Library, PsycINFO, and CINAHL). Results: A total of 6015 papers were identified using the search strategy. After screening, 15 papers were identified that examined the design engineering and clinical implementation and evaluation of 8 different mHealth apps for sleep disturbance. Most of these apps delivered cognitive behavioral therapy for insomnia (CBT-I, n=4) or modified CBT-I (n=2). Half of the apps (n=4) identified adopting user-centered design or multidisciplinary teams in their design approach. Only 3 papers described user and data privacy. End-user acceptability and engagement were the most frequently assessed implementation metrics. Only 1 app had available evidence assessing all 4 implementation metrics (ie, acceptability, engagement, usability, and adherence). Most apps were prototype versions (n=5), with few matured apps. A total of 6 apps had supporting papers that provided a quantitative evaluation of clinical outcomes, but only 1 app had a supporting, adequately powered randomized controlled trial. Conclusions: This is the first systematic review to synthesize and examine evidence for the design engineering and clinical implementation and evaluation of mHealth apps for sleep disturbance. The minimal number of apps with published evidence for design engineering and clinical implementation and evaluation contrasts starkly with the number of commercial sleep apps available. Moreover, there appears to be no standardization and consistency in the use of best practice design approaches and implementation assessments, along with very few rigorous efficacy evaluations. To facilitate the development of successful and evidence-based apps for sleep disturbance, we developed a high-level framework to guide researchers and app developers in the end-to-end process of app development and evaluation. %M 33595441 %R 10.2196/24607 %U http://www.jmir.org/2021/2/e24607/ %U https://doi.org/10.2196/24607 %U http://www.ncbi.nlm.nih.gov/pubmed/33595441 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e21432 %T Usage and Weekly Attrition in a Smartphone-Based Health Behavior Intervention for Adolescents: Pilot Randomized Controlled Trial %A Egilsson,Erlendur %A Bjarnason,Ragnar %A Njardvik,Urdur %+ Department of Psychology, University of Iceland, Sturlugata 1, Reykjavik, 101, Iceland, 354 6184805, erlendu@hi.is %K mHealth %K intervention %K adolescent %K attrition %K self-efficacy %K mental health %K physical activity %K young adult %K behavior %D 2021 %7 17.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The majority of adolescents own smartphones, although only 8% of them use health apps. Attrition rates from adolescent mobile health (mHealth) interventions for treating mental health problems such as anxiety and depression are an issue with a high degree of variation. Attrition in mHealth interventions targeting adolescent populations is frequently presented in a two-point fashion, from initiation of the intervention to the end of treatment, lacking more time-specific information on usage and times of attrition. Self-efficacy could provide an avenue to lower attrition rates, although a better understanding of the relationship between mental health factors and time-specific attrition rates is needed. Objective: The aims of this study were to obtain time-specific attrition rates among adolescents in an mHealth intervention, and to describe the intervention’s usage and feasibility in relation to adolescent self-efficacy levels, and emotional and physical health. Methods: A single-center randomized controlled public school pilot trial was undertaken with 41 adolescents. Outcome measures were assessed at baseline and after 6 weeks, while in-app activity and attrition rates were continually assessed throughout the intervention period. The primary outcome was attrition based on time and type of in-app health behavior usage, and feasibility of the mHealth app. Secondary outcome measures were self-efficacy levels, depressive and anxiety symptoms, as well as standardized BMI and sleep. Analyses of group mean variances with adjusted α levels through Bonferroni corrections were used to assess main outcome effects. Results: The attrition from initiation of the intervention to 6-week follow up was 35%. Attrition started in the third week of the intervention and was related to daily time of app usage (Rt=0.43, P<.001). The number of average weekly in-app health exercises completed decreased significantly from the first week of the intervention (mean 55.25, SD 10.96) to the next week (mean 13.63, SD 2.94). However, usage increased by 22% between week 2 and the last week of the intervention (mean 16.69, SD 8.37). Usability measures revealed satisfactory scores (mean 78.09, SD 9.82) without gender differences (P=.85). Self-reported daily physical activity increased by 19.61% in the intervention group but dropped by 26.21% among controls. Self-efficacy levels increased by 8.23% in the invention arm compared to a 3.03% decrease in the control group. Conclusions: This pilot study demonstrated the feasibility and usability of an mHealth intervention among adolescent participants. Indications were toward beneficial effects on physical and mental health that warrant further research. Focus on time-specific attrition measures alongside daily times of usage and ways to increase participants’ self-efficacy levels appear to be a promising avenue for research on mHealth interventions for adolescent populations with the aim to ultimately lower attrition rates. %M 33481750 %R 10.2196/21432 %U http://formative.jmir.org/2021/2/e21432/ %U https://doi.org/10.2196/21432 %U http://www.ncbi.nlm.nih.gov/pubmed/33481750 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e20700 %T Sociodemographic, Health and Lifestyle, Sampling, and Mental Health Determinants of 24-Hour Motor Activity Patterns: Observational Study %A Difrancesco,Sonia %A Riese,Harriëtte %A Merikangas,Kathleen R %A Shou,Haochang %A Zipunnikov,Vadim %A Antypa,Niki %A van Hemert,Albert M %A Schoevers,Robert A %A Penninx,Brenda W J H %A Lamers,Femke %+ Amsterdam Public Health Research Institute, Department of Psychiatry, Amsterdam UMC, Vrije Universiteit, Oldenaller 1, Amsterdam, 1078XL, Netherlands, 31 643193730, s.difrancesco@ggzingeest.nl %K actigraphy %K functional data analysis %K mental health %K well-being %K activity %D 2021 %7 17.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Analyzing actigraphy data using standard circadian parametric models and aggregated nonparametric indices may obscure temporal information that may be a hallmark of the circadian impairment in psychiatric disorders. Functional data analysis (FDA) may overcome such limitations by fully exploiting the richness of actigraphy data and revealing important relationships with mental health outcomes. To our knowledge, no studies have extensively used FDA to study the relationship between sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics and daily motor activity patterns assessed with actigraphy in a sample of individuals with and without depression/anxiety. Objective: We aimed to study the association between daily motor activity patterns assessed via actigraphy and (1) sociodemographic, health and lifestyle, and sampling factors, and (2) psychiatric clinical characteristics (ie, presence and severity of depression/anxiety disorders). Methods: We obtained 14-day continuous actigraphy data from 359 participants from the Netherlands Study of Depression and Anxiety with current (n=93), remitted (n=176), or no (n=90) depression/anxiety diagnosis, based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Associations between patterns of daily motor activity, quantified via functional principal component analysis (fPCA), and sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics were assessed using generalized estimating equation regressions. For exploratory purposes, function-on-scalar regression (FoSR) was applied to quantify the time-varying association of sociodemographic, health and lifestyle, sampling, and psychiatric clinical characteristics on daily motor activity. Results: Four components of daily activity patterns captured 77.4% of the variability in the data: overall daily activity level (fPCA1, 34.3% variability), early versus late morning activity (fPCA2, 16.5% variability), biphasic versus monophasic activity (fPCA3, 14.8% variability), and early versus late biphasic activity (fPCA4, 11.8% variability). A low overall daily activity level was associated with a number of sociodemographic, health and lifestyle, and psychopathology variables: older age (P<.001), higher education level (P=.005), higher BMI (P=.009), greater number of chronic diseases (P=.02), greater number of cigarettes smoked per day (P=.02), current depressive and/or anxiety disorders (P=.05), and greater severity of depressive symptoms (P<.001). A high overall daily activity level was associated with work/school days (P=.02) and summer (reference: winter; P=.03). Earlier morning activity was associated with older age (P=.02), having a partner (P=.009), work/school days (P<.001), and autumn and spring (reference: winter; P=.02 and P<.001, respectively). Monophasic activity was associated with older age (P=.005). Biphasic activity was associated with work/school days (P<.001) and summer (reference: winter; P<.001). Earlier biphasic activity was associated with older age (P=.005), work/school days (P<.001), and spring and summer (reference: winter; P<.001 and P=.005, respectively). In FoSR analyses, age, work/school days, and season were the main determinants having a time-varying association with daily motor activity (all P<.05). Conclusions: Features of daily motor activity extracted with fPCA reflect commonly studied factors such as the intensity of daily activity and preference for morningness/eveningness. The presence and severity of depression/anxiety disorders were found to be associated mainly with a lower overall activity pattern but not with the time of the activity. Age, work/school days, and season were the variables most strongly associated with patterns and time of activity, and thus future epidemiological studies on motor activity in depression/anxiety should take these variables into account. %M 33595445 %R 10.2196/20700 %U http://www.jmir.org/2021/2/e20700/ %U https://doi.org/10.2196/20700 %U http://www.ncbi.nlm.nih.gov/pubmed/33595445 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e18899 %T Addressing Care Continuity and Quality Challenges in the Management of Hypertension: Case Study of the Private Health Care Sector in Kenya %A Walcott-Bryant,Aisha %A Ogallo,William %A Remy,Sekou L %A Tryon,Katherine %A Shena,Winnie %A Bosker-Kibacha,Marloes %+ IBM Research Africa, Catholic University of Eastern Africa, Nairobi, , Kenya, 254 703023000, william.ogallo@ibm.com %K hypertension %K health information systems %K mobile phone %K private sector %K Kenya %D 2021 %7 17.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Hypertension is a major risk factor of cardiovascular disease and a leading cause of morbidity and mortality globally. In Kenya, the rise of hypertension strains an already stretched health care system that has traditionally focused on the management of infectious diseases. Health care provision in this country remains fragmented, and little is known about the role of health information technology in care coordination. Furthermore, there is a dearth of literature on the experiences, challenges, and solutions for improving the management of hypertension and other noncommunicable diseases in the Kenyan private health care sector. Objective: The aim of this study is to assess stakeholders’ perspectives on the challenges associated with the management of hypertension in the Kenyan private health care sector and to derive recommendations for the design and functionality of a digital health solution for addressing the care continuity and quality challenges in the management of hypertension. Methods: We conducted a qualitative case study. We collected data using in-depth interviews with 18 care providers and 8 business leads, and direct observations at 18 private health care institutions in Nairobi, Kenya. We analyzed the data thematically to identify the key challenges and recommendations for technology-enabled solutions to support the management of hypertension in the Kenyan private health sector. We subsequently used the generated insights to derive and describe the design and range of functions of a digital health wallet platform for enabling care quality and continuity. Results: The management of hypertension in the Kenyan private health care sector is characterized by challenges such as high cost of care, limited health care literacy, lack of self-management support, ineffective referral systems, inadequate care provider training, and inadequate regulation. Care providers lack the tools needed to understand their patients’ care histories and effectively coordinate efforts to deliver high-quality hypertension care. The proposed digital health platform was designed to support hypertension care coordination and continuity through clinical workflow orchestration, decision support, and patient-mediated data sharing with privacy preservation, auditability, and trust enabled by blockchain technology. Conclusions: The Kenyan private health care sector faces key challenges that require significant policy, organizational, and infrastructural changes to ensure care quality and continuity in the management of hypertension. Digital health data interoperability solutions are needed to improve hypertension care coordination in the sector. Additional studies should investigate how patients can control the sharing of their data while ensuring that care providers have a holistic view of the patient during any encounter. %M 33595446 %R 10.2196/18899 %U http://www.jmir.org/2021/2/e18899/ %U https://doi.org/10.2196/18899 %U http://www.ncbi.nlm.nih.gov/pubmed/33595446 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e20329 %T Induction of Efficacy Expectancies in an Ambulatory Smartphone-Based Digital Placebo Mental Health Intervention: Randomized Controlled Trial %A Stalujanis,Esther %A Neufeld,Joel %A Glaus Stalder,Martina %A Belardi,Angelo %A Tegethoff,Marion %A Meinlschmidt,Gunther %+ Department of Clinical Psychology and Cognitive Behavioral Therapy, International Psychoanalytic University Berlin, Stromstraße 1, Berlin, 10555, Germany, 49 30 300117 710, gunther.meinlschmidt@ipu-berlin.de %K digital placebo effect %K efficacy expectancies %K ecological momentary assessment %K mHealth %K mobile phone %K placebo effect %K randomized controlled trial %K smartphone-based intervention %D 2021 %7 17.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is certain evidence on the efficacy of smartphone-based mental health interventions. However, the mechanisms of action remain unclear. Placebo effects contribute to the efficacy of face-to-face mental health interventions and may also be a potential mechanism of action in smartphone-based interventions. Objective: This study aimed to investigate whether different types of efficacy expectancies as potential factors underlying placebo effects could be successfully induced in a smartphone-based digital placebo mental health intervention, ostensibly targeting mood and stress. Methods: We conducted a randomized, controlled, single-blinded, superiority trial with a multi-arm parallel design. Participants underwent an Android smartphone-based digital placebo mental health intervention for 20 days. We induced prospective efficacy expectancies via initial instructions on the purpose of the intervention and retrospective efficacy expectancies via feedback on the success of the intervention at days 1, 4, 7, 10, and 13. A total of 132 healthy participants were randomized to a prospective expectancy–only condition (n=33), a retrospective expectancy–only condition (n=33), a combined expectancy condition (n=34), or a control condition (n=32). As the endpoint, we assessed changes in efficacy expectancies with the Credibility Expectancy Questionnaire, before the intervention and on days 1, 7, 14, and 20. For statistical analyses, we used a random effects model for the intention-to-treat sample, with intervention day as time variable and condition as two factors: prospective expectancy (yes vs no) and retrospective expectancy (yes vs no), allowed to vary over participant and intervention day. Results: Credibility (β=−1.63; 95% CI −2.37 to −0.89; P<.001) and expectancy (β=−0.77; 95% CI −1.49 to −0.05; P=.04) decreased across the intervention days. For credibility and expectancy, we found significant three-way interactions: intervention day×prospective expectancy×retrospective expectancy (credibility: β=2.05; 95% CI 0.60-3.50; P=.006; expectancy: β=1.55; 95% CI 0.14-2.95; P=.03), suggesting that efficacy expectancies decreased least in the combined expectancy condition and the control condition. Conclusions: To our knowledge, this is the first empirical study investigating whether efficacy expectancies can be successfully induced in a specifically designed placebo smartphone-based mental health intervention. Our findings may pave the way to diminish or exploit digital placebo effects and help to improve the efficacy of digital mental health interventions. Trial Registration: Clinicaltrials.gov NCT02365220; https://clinicaltrials.gov/ct2/show/NCT02365220. %M 33594991 %R 10.2196/20329 %U http://mhealth.jmir.org/2021/2/e20329/ %U https://doi.org/10.2196/20329 %U http://www.ncbi.nlm.nih.gov/pubmed/33594991 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e18288 %T Acceptability of a Mobile Health Behavior Change Intervention for Cancer Survivors With Obesity or Overweight: Nested Mixed Methods Study Within a Randomized Controlled Trial %A Groarke,Jenny M %A Richmond,Janice %A Mc Sharry,Jenny %A Groarke,AnnMarie %A Harney,Owen M %A Kelly,Mary Grace %A Walsh,Jane C %+ Centre for Improving Health-Related Quality of Life, School of Psychology, Queen's University Belfast, 18-30 Malone Road, Belfast, BT71NN, United Kingdom, 44 28 90974886, j.groarke@qub.ac.uk %K mHealth %K self-management %K text messaging %K activity tracker %K exercise %K diet %K overweight %K obesity %K cancer survivors %K qualitative research %K mobile phone %D 2021 %7 16.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A significant proportion of cancer survivors have overweight or obesity. Although this has negative implications for health, weight management is not a standard component of oncology aftercare. Mobile health (mHealth) technology, in combination with behavior change techniques (BCTs), has the potential to support positive lifestyle changes. Few studies have been carried out with cancer survivors; therefore, the acceptability of these tools and techniques requires further investigation. Objective: The aim of this study is to examine the acceptability of a behavior change intervention using mHealth for cancer survivors with a BMI of 25 or more and to gather constructive feedback from participants. Methods: The intervention consisted of educational sessions and an 8-week physical activity goal setting intervention delivered using mobile technology (ie, Fitbit activity monitor plus SMS contact). In the context of a two-arm randomized controlled trial, semistructured interviews were conducted to assess the retrospective acceptability of the intervention from the perspective of the recipients. The theoretical framework for the acceptability of health care interventions was used to inform a topic guide. The interviews were transcribed and analyzed using thematic analysis. A quantitative survey was also conducted to determine the acceptability of the intervention. A total of 13 participants were interviewed, and 36 participants completed the quantitative survey. Results: The results strongly support the acceptability of the intervention. The majority of the survey respondents held a positive attitude toward the intervention (35/36, 97%). In qualitative reports, many of the intervention components were enjoyed and the mHealth components (ie, Fitbit and goal setting through text message contact) were rated especially positively. Responses were mixed as to whether the burden of participating in the intervention was high (6/36, 17%) or low (5/36, 14%). Participants perceived the intervention as having high efficacy in improving health and well-being (34/36, 94%). Most respondents said that they understood how the intervention works (35/36, 97%), and qualitative data show that participants’ understanding of the aim of the intervention was broader than weight management and focused more on moving on psychologically from cancer. Conclusions: On the basis of the coherence of responses with theorized aspects of intervention acceptability, we are confident that this intervention using mHealth and BCTs is acceptable to cancer survivors with obesity or overweight. Participants made several recommendations concerning the additional provision of social support. Future studies are needed to assess the feasibility of delivery in clinical practice and the acceptability of the intervention to those delivering the intervention. International Registered Report Identifier (IRRID): RR2-10.2196/13214 %M 33591290 %R 10.2196/18288 %U http://mhealth.jmir.org/2021/2/e18288/ %U https://doi.org/10.2196/18288 %U http://www.ncbi.nlm.nih.gov/pubmed/33591290 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e23912 %T mHealth Strategies Related to HIV Postexposure Prophylaxis Knowledge and Access: Systematic Literature Review, Technology Prospecting of Patent Databases, and Systematic Search on App Stores %A Queiroz,Artur Acelino Francisco Luz Nunes %A Mendes,Isabel Amélia Costa %A de Godoy,Simone %A Velez Lapão,Luís %A Dias,Sónia %+ Department of General and Specialized Nursing, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, R Prof Hélio Lourenço, 3900 - Vila Monte Alegre, Ribeirão Preto, 14040-902, Brazil, 55 16 3315 4321, arturqueiroz@usp.br %K HIV %K eHealth %K mHealth %K postexposure prophylaxis %K PEP %K prevention %K mobile phone %D 2021 %7 16.2.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Globally, the number of HIV cases continue to increase, despite the development of multiple prevention strategies. New cases of HIV have been reported disproportionately more in men who have sex with men and other vulnerable populations. Issues such as internalized and structural homophobia prevent these men from accessing prevention strategies such as postexposure prophylaxis (PEP). Mobile health (mHealth) interventions are known to be one of the newest and preferred options to enhance PEP knowledge and access. Objective: The aim of this study was to identify and analyze the mobile apps addressing PEP for HIV infections. Methods: We conducted a descriptive exploratory study in 3 sequential phases: systematic literature review, patent analysis, and systematic search of app stores. For the systematic review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines adapted for an integrative review in the databases of PubMed, Web of Knowledge, Scopus, Cochrane, Embase, Science Direct, Eric, Treasure, and CINAHL. The patent analysis was performed by exploring the databases of the Brazilian National Institute of Industrial Property, the United States Patent and Trademark Office, and the European Patent Office. For the systematic search, we analyzed mHealth apps related to HIV in 2 major app libraries, that is, Google Play Store and App Store. The apps were evaluated by name, characteristics, functions, and availability in iPhone operating system/Android phones. Results: We analyzed 22 studies, of which 2 were selected for the final stage. Both studies present the use of apps as mHealth strategies aimed at improving the sexual health of men who have sex with men, and they were classified as decision support systems. The search in the patent databases showed only 1 result, which was not related to the topic since it was a drug intervention. In the app libraries, 25 apps were found and analyzed, with 15 (60%) apps available for Android systems but only 3 (12%) addressing PEP. In general, the apps inform about HIV and HIV prevention and treatment, with the focus users being health care providers, people with HIV, or the general population, but they have only limited features available, that is, mainly text, images, and videos. The 3 apps exclusively focusing on PEP were created by researchers from Brazilian universities. Conclusions: Our review found no connection between the scientific studies, registered patents, and the available apps related to PEP; this finding indicates that these available apps do not have a theoretical or a methodological background in their creation. Thus, since the scientific knowledge on HIV is not translated into technological products, preventing the emergence of new infections, especially in the more vulnerable groups, is difficult. In the future, researchers and the community must work in synergy to create more mHealth tools aimed at PEP. %M 33591289 %R 10.2196/23912 %U http://mhealth.jmir.org/2021/2/e23912/ %U https://doi.org/10.2196/23912 %U http://www.ncbi.nlm.nih.gov/pubmed/33591289 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e25655 %T Development and Validation of Risk Scores for All-Cause Mortality for a Smartphone-Based “General Health Score” App: Prospective Cohort Study Using the UK Biobank %A Clift,Ashley K %A Le Lannou,Erwann %A Tighe,Christian P %A Shah,Sachin S %A Beatty,Matthew %A Hyvärinen,Arsi %A Lane,Stephen J %A Strauss,Tamir %A Dunn,Devin D %A Lu,Jiahe %A Aral,Mert %A Vahdat,Dan %A Ponzo,Sonia %A Plans,David %+ Huma Therapeutics, 13th Floor Millbank Tower, 21-24 Millbank, London, United Kingdom, 44 7527 016574, david.plans@huma.com %K C-Score %K mortality %K risk score %K smartphone %K health score %K medical informatics %K public health %K mobile health %K development %K validation %K app %K prospective %K cohort %K machine learning %D 2021 %7 16.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Given the established links between an individual’s behaviors and lifestyle factors and potentially adverse health outcomes, univariate or simple multivariate health metrics and scores have been developed to quantify general health at a given point in time and estimate risk of negative future outcomes. However, these health metrics may be challenging for widespread use and are unlikely to be successful at capturing the broader determinants of health in the general population. Hence, there is a need for a multidimensional yet widely employable and accessible way to obtain a comprehensive health metric. Objective: The objective of the study was to develop and validate a novel, easily interpretable, points-based health score (“C-Score”) derived from metrics measurable using smartphone components and iterations thereof that utilize statistical modeling and machine learning (ML) approaches. Methods: A literature review was conducted to identify relevant predictor variables for inclusion in the first iteration of a points-based model. This was followed by a prospective cohort study in a UK Biobank population for the purposes of validating the C-Score and developing and comparatively validating variations of the score using statistical and ML models to assess the balance between expediency and ease of interpretability and model complexity. Primary and secondary outcome measures were discrimination of a points-based score for all-cause mortality within 10 years (Harrell c-statistic) and discrimination and calibration of Cox proportional hazards models and ML models that incorporate C-Score values (or raw data inputs) and other predictors to predict the risk of all-cause mortality within 10 years. Results: The study cohort comprised 420,560 individuals. During a cohort follow-up of 4,526,452 person-years, there were 16,188 deaths from any cause (3.85%). The points-based model had good discrimination (c-statistic=0.66). There was a 31% relative reduction in risk of all-cause mortality per decile of increasing C-Score (hazard ratio of 0.69, 95% CI 0.663-0.675). A Cox model integrating age and C-Score had improved discrimination (8 percentage points; c-statistic=0.74) and good calibration. ML approaches did not offer improved discrimination over statistical modeling. Conclusions: The novel health metric (“C-Score”) has good predictive capabilities for all-cause mortality within 10 years. Embedding the C-Score within a smartphone app may represent a useful tool for democratized, individualized health risk prediction. A simple Cox model using C-Score and age balances parsimony and accuracy of risk predictions and could be used to produce absolute risk estimations for app users. %M 33591285 %R 10.2196/25655 %U http://mhealth.jmir.org/2021/2/e25655/ %U https://doi.org/10.2196/25655 %U http://www.ncbi.nlm.nih.gov/pubmed/33591285 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e24080 %T Effectiveness of Mobile Health–Based Exercise Interventions for Patients with Peripheral Artery Disease: Systematic Review and Meta-Analysis %A Kim,Mihui %A Kim,Changhwan %A Kim,Eunkyo %A Choi,Mona %+ College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 3341, monachoi@yuhs.ac %K peripheral artery disease %K mobile health %K exercise %K adherence %K meta-analysis %D 2021 %7 15.2.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Peripheral artery disease (PAD) affects over 236 million people worldwide, and exercise interventions are commonly used to alleviate symptoms of this condition. However, no previous systematic review has evaluated the effects of mobile health (mHealth)–based exercise interventions for patients with PAD. Objective: This study aimed to assess the effect of mHealth-based exercise interventions on walking performance, functional status, and quality of life in patients with PAD. Methods: A systematic review and meta-analysis were conducted. We searched in seven databases to identify randomized controlled trials of patients with PAD published in English up to December 4, 2020. Studies were included if patients participated in mHealth-based exercise interventions and were assessed for walking performance. We analyzed pooled effect size on walking performance, functional status, and quality of life based on the standardized mean differences between groups. Results: A total of seven studies were selected for the systematic review, and six studies were included in the meta-analysis. The duration of interventions in the included studies was 12 to 48 weeks. In the pooled analysis, when compared with the control groups, the mHealth-based exercise intervention groups were associated with significant improvements in pain-free walking (95% CI 0.13-0.88), maximal walking (95% CI 0.03-0.87), 6-minute walk test (6MWT) distance (95% CI 0.59-1.24), and walking distance (95% CI 0.02-0.49). However, benefits of the interventions on walking speed, stair-climbing ability, and quality of life were not observed. Conclusions: mHealth-based exercise interventions for patients with PAD were beneficial for improving pain-free walking, maximal walking, and 6MWT distance. We found that exercise interventions using mHealth are an important strategy for improving the exercise effectiveness and adherence rate of patients with PAD. Future studies should consider the use of various and suitable functions of mHealth that can increase the adherence rates and improve the effectiveness of exercise. %M 33587042 %R 10.2196/24080 %U http://mhealth.jmir.org/2021/2/e24080/ %U https://doi.org/10.2196/24080 %U http://www.ncbi.nlm.nih.gov/pubmed/33587042 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e25578 %T Durability of Abstinence After Completing a Comprehensive Digital Smoking Cessation Program Incorporating a Mobile App, Breath Sensor, and Coaching: Cohort Study %A Marler,Jennifer D %A Fujii,Craig A %A Galanko,Joseph A %A Balbierz,Daniel J %A Utley,David S %+ Carrot Inc., 1400A Seaport Blvd, Suite 501, Redwood City, CA, 94063, United States, 1 415 757 7696, marler@carrot.co %K smoking cessation %K digital health %K smartphone %K digital sensor %K carbon monoxide %K breath sensor %K biofeedback %K mobile apps %K health promotion %K app %D 2021 %7 15.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite decreasing prevalence over the last several decades, cigarette smoking remains the leading cause of preventable death and disease, underscoring the need for innovative, effective solutions. Pivot is a novel, inclusive smoking cessation program designed for smokers along the entire spectrum of readiness to quit. Pivot leverages proven methods and technological advancements, including a personal portable breath carbon monoxide sensor, smartphone app, and in-app text-based coaching. We previously reported outcomes from the end of active Pivot program participation in 319 adult smokers. Herein, we report longer-term follow up in this cohort. Objective: The aim of this study was to assess and report participant outcomes 3 months after completion of Pivot, including smoking behavior, quit rates, continuous abstinence rates and durability, and predictors of abstinence. Methods: This prospective remote cohort study included US-based cigarette smokers aged 18 to 65 years who smoked ≥5 cigarettes per day (CPD). Three months after completion of active participation in Pivot, final follow-up data were collected via an online questionnaire. Outcomes included smoking behavior (CPD and quit attempts), self-reported quit rates (7- and 30-day point prevalence abstinence [PPA]), and continuous abstinence rates (proportion who achieved uninterrupted abstinence) and duration. Exploratory regression analyses were performed to identify baseline characteristics associated with achievement of 7-day PPA, 30-day PPA, and continuous abstinence. Results: A total of 319 participants completed onboarding (intention-to-treat [ITT]); 288/319 participants (90.3%) completed follow up (completers) at a mean of 7.2 (SD 1.2) months after onboarding. At final follow up, CPD were reduced by 52.6% (SE 2.1; P<.001) among all 319 participants, and most completers (152/288, 52.8%) reduced their CPD by at least 50%. Overall, most completers (232/288, 80.6%) made at least one quit attempt. Quit rates increased after the end of Pivot; using ITT analyses, 35.4% (113/319) achieved 7-day PPA and 31.3% (100/319) achieved 30-day PPA at final follow up compared with 32.0% (102/319) and 27.6% (88/319), respectively, at the end of the Pivot program. Continuous abstinence was achieved in about a quarter of those who onboarded (76/319, 23.8%) and in most who reported 30-day PPA at the end of Pivot (76/88, 86.4%), with a mean abstinence duration of 5.8 (SD 0.6) months. In exploratory regression analyses, lower baseline CPD, more positive baseline attitudes reflecting higher self-efficacy (higher confidence to quit and lower perceived difficulty of quitting), and higher education were associated with achieving abstinence. Conclusions: This study provides the first longer-term outcomes of the Pivot smoking cessation program. At final follow up, quit rates increased and continuous abstinence was favorable; the majority who achieved abstinence at the end of Pivot sustained abstinence throughout follow up. Decreases in CPD persisted and most participants made a quit attempt. Overall, final follow-up outcomes were stable or improved when compared to previous outcomes from the end of the program. These findings validate earlier results, and suggest that Pivot is an effective and durable solution for smoking cessation. Trial Registration: ClinicalTrials.gov NCT03295643; https://clinicaltrials.gov/ct2/show/NCT03295643 %M 33482628 %R 10.2196/25578 %U http://www.jmir.org/2021/2/e25578/ %U https://doi.org/10.2196/25578 %U http://www.ncbi.nlm.nih.gov/pubmed/33482628 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e24703 %T Effectiveness of Smartphone-Based Cognitive Behavioral Therapy Among Patients With Major Depression: Systematic Review of Health Implications %A Hrynyschyn,Robert %A Dockweiler,Christoph %+ Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Health and Nursing Science, Campus Virchow Klinikum, Berlin, 13353, Germany, 49 30 450 529 124, robert.hrynyschyn@charite.de %K mobile health %K depression %K cognitive behavioral therapy %K systematic review %K mobile phone %D 2021 %7 10.2.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Depression is often associated with rapid changes in mood and quality of life that persist for a period of 2 weeks. Despite medical innovations, there are problems in the provision of care. Long waiting times for treatment and high recurrence rates of depression cause enormous costs for health care systems. At the same time, comprehensive limitations in physical, psychological, and social dimensions are observed for patients with depression, which significantly reduce their quality of life. In addition to patient-specific limitations, undersupply and inappropriate health care have been determined. For this reason, new forms of care are discussed. Smartphone-based therapy is considered to have great potential due to its reach and easy accessibility. Low socioeconomic groups, which are always difficult to reach for public health interventions, can now be accessed due to the high dispersion of smartphones. There is still little information about the impact and mechanisms of smartphone-based therapy on depression. In a systematic literature review, the health implications of smartphone-based therapy were presented in comparison with standard care. Objective: The objective of this review was to identify and summarize the existing evidence regarding smartphone-based cognitive behavioral therapy for patients with depression and to present the health implications of smartphone-based cognitive behavioral therapy of considered endpoints. Methods: A systematic literature review was conducted to identify relevant studies by means of inclusion and exclusion criteria. For this purpose, the PubMed and Psyndex databases were systematically searched using a search syntax. The endpoints of depressive symptoms, depression-related anxiety, self-efficacy or self-esteem, and quality of life were analyzed. Identified studies were evaluated for study quality and risk of bias. After applying the inclusion and exclusion criteria, 8 studies were identified. Results: The studies examined in this review reported contradictory results regarding the investigated endpoints. In addition, due to clinical and methodological heterogeneity, it was difficult to derive evident results. All included studies reported effects on depressive symptoms. The other investigated endpoints were only reported by isolated studies. Only 50% (4/8) of the studies reported effects on depression-related anxiety, self-efficacy or self-esteem, and quality of life. Conclusions: No clear implications of smartphone-based cognitive behavioral therapy could be established. Evidence for the treatment of depression using smartphone-based cognitive behavioral therapy is limited. Additional research projects are needed to demonstrate the effects of smartphone-based cognitive behavioral therapy in the context of evidence-based medicine and to enable its translation into standard care. Participatory technology development might help to address current problems in mobile health intervention studies. %M 33565989 %R 10.2196/24703 %U http://mhealth.jmir.org/2021/2/e24703/ %U https://doi.org/10.2196/24703 %U http://www.ncbi.nlm.nih.gov/pubmed/33565989 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e19210 %T An Innovative Wearable Device For Monitoring Continuous Body Surface Temperature (HEARThermo): Instrument Validation Study %A Yeh,Chun-Yin %A Chung,Yi-Ting %A Chuang,Kun-Ta %A Shu,Yu-Chen %A Kao,Hung-Yu %A Chen,Po-Lin %A Ko,Wen-Chien %A Ko,Nai-Ying %+ Department of Nursing, National Cheng Kung University, No 1, University Road, Tainan, 701, Taiwan, 886 6 2353535 ext 5838, nyko@mail.ncku.edu.tw %K body surface temperature %K wearable device %K validation %K continuous monitoring %D 2021 %7 10.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Variations in body temperature are highly informative during an illness. To date, there are not many adequate studies that have investigated the feasibility of a wearable wrist device for the continuous monitoring of body surface temperatures in humans. Objective: The objective of this study was to validate the performance of HEARThermo, an innovative wearable device, which was developed to continuously monitor the body surface temperature in humans. Methods: We implemented a multi-method research design in this study, which included 2 validation studies—one in the laboratory and one with human subjects. In validation study I, we evaluated the test-retest reliability of HEARThermo in the laboratory to measure the temperature and to correct the values recorded by each HEARThermo by using linear regression models. We conducted validation study II on human subjects who wore HEARThermo for the measurement of their body surface temperatures. Additionally, we compared the HEARThermo temperature recordings with those recorded by the infrared skin thermometer simultaneously. We used intraclass correlation coefficients (ICCs) and Bland-Altman plots to analyze the criterion validity and agreement between the 2 measurement tools. Results: A total of 66 participants (age range, 10-77 years) were recruited, and 152,881 completed data were analyzed in this study. The 2 validation studies in the laboratory and on human skin indicated that HEARThermo showed a good test-retest reliability (ICC 0.96-0.98) and adequate criterion validity with the infrared skin thermometer at room temperatures of 20°C-27.9°C (ICC 0.72, P<.001). The corrected measurement bias averaged –0.02°C, which was calibrated using a water bath ranging in temperature from 16°C to 40°C. The values of each HEARThermo improved by the regression models were not significantly different from the temperature of the water bath (P=.19). Bland-Altman plots showed no visualized systematic bias. HEARThermo had a bias of 1.51°C with a 95% limit of agreement between –1.34°C and 4.35°C. Conclusions: The findings of our study show the validation of HEARThermo for the continuous monitoring of body surface temperatures in humans. %M 33565990 %R 10.2196/19210 %U http://mhealth.jmir.org/2021/2/e19210/ %U https://doi.org/10.2196/19210 %U http://www.ncbi.nlm.nih.gov/pubmed/33565990 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e19430 %T App-Based Salt Reduction Intervention in School Children and Their Families (AppSalt) in China: Protocol for a Mixed Methods Process Evaluation %A Sun,Yuewen %A Luo,Rong %A Li,Yuan %A He,Feng J %A Tan,Monique %A MacGregor,Graham A %A Liu,Hueiming %A Zhang,Puhong %+ The George Institute for Global Health, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building No. 14 Liangmahe Nan Lu, Beijing, 100600, China, 86 10 8280 0177, zpuhong@georgeinstitute.org.cn %K mobile health %K mobile phone %K process evaluation %K salt reduction %K health education %D 2021 %7 10.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The app-based salt reduction intervention program in school children and their families (AppSalt) is a multicomponent mobile health (mHealth) intervention program, which involves multiple stakeholders, including students, parents, teachers, school heads, and local health and education authorities. The complexity of the AppSalt program highlights the need for process evaluation to investigate how the implementation will be achieved at different sites. Objective: This paper presents a process evaluation protocol of the AppSalt program, which aims to monitor the implementation of the program, explain its causal mechanisms, and provide evidence for scaling up the program nationwide. Methods: A mixed methods approach will be used to collect data relating to five process evaluation dimensions: fidelity, dose delivered, dose received, reach, and context. Quantitative data, including app use logs, activity logs, and routine monitoring data, will be collected alongside the intervention process to evaluate the quantity and quality of intervention activities. The quantitative data will be summarized as medians, means, and proportions as appropriate. Qualitative data will be collected through semistructured interviews of purposely selected intervention participants and key stakeholders from local health and education authorities. The thematic analysis technique will be used for analyzing the qualitative data with the support of NVivo 12. The qualitative data will be triangulated with the quantitative data during the interpretation phase to explain the 5 process evaluation dimensions. Results: The intervention activities of the AppSalt program were initiated at 27 primary schools in three cities since October 2018. We have completed the 1-year intervention of this program. The quantitative data for this study, including app use log, activity logs, and the routine monitoring data, were collected and organized during the intervention process. After completing the intervention, we conducted semistructured interviews with 32 students, 32 parents, 9 teachers, 9 school heads, and 8 stakeholders from local health and education departments. Data analysis is currently underway. Conclusions: Using mHealth technology for salt reduction among primary school students is an innovation in China. The findings of this study will help researchers understand the implementation of the AppSalt program and similar mHealth interventions in real-world settings. Furthermore, this process evaluation will be informative for other researchers and policy makers interested in replicating the AppSalt program and designing their salt reduction intervention. International Registered Report Identifier (IRRID): DERR1-10.2196/19430 %M 33565991 %R 10.2196/19430 %U http://www.researchprotocols.org/2021/2/e19430/ %U https://doi.org/10.2196/19430 %U http://www.ncbi.nlm.nih.gov/pubmed/33565991 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e23338 %T Efficiency of an mHealth App and Chest-Wearable Remote Exercise Monitoring Intervention in Patients With Type 2 Diabetes: A Prospective, Multicenter Randomized Controlled Trial %A Li,Jing %A Wei,Dong %A Liu,Shuyi %A Li,Mingxia %A Chen,Xi %A Chen,Li %A Wu,Yuelei %A Zhou,Wen %A Ouyang,Lingyun %A Tan,Cuixia %A Meng,Hongdao %A Tong,Nanwei %+ Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, 37 Guoxue Road, Wuhou District, Chengdu, 610041, China, 86 18980601196, tongnw@scu.edu.cn %K type 2 diabetes %K fitness app %K heart rate band %K exercise monitoring %K randomized controlled trial %K mobile phone %D 2021 %7 9.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Exercise has been recommended as a cornerstone for diabetes management. Supervised exercise is more efficient than unsupervised exercise but is less convenient and accessible. Objective: We aimed to determine the efficiency of exercise using a fitness app and heart rate band to remotely monitor patients with type 2 diabetes in comparison with that of traditional exercise. Methods: Patients with type 2 diabetes without severe complications or comorbidities were recruited to participate in this multicenter randomized controlled trial and were allocated to either the intervention or control group (1:1 ratio). Participants in both groups were asked to engage in moderate to vigorous physical activity for at least 150 minutes per week; each participant was prescribed individualized exercises. Participants in the intervention group were asked to follow exercise videos on the app and to wear a chest band; heart rate, exercise duration, and exercise intensity were recorded by the app. Participants in the control group self-reported exercise intensity and duration. Cardiopulmonary endurance, body composition, blood glucose level, and insulin level were assessed before and after a 3-month exercise program. Results: Of the 101 participants who were enrolled, the majority of them (85/101, 84.2%) completed the study. Both groups had similar baseline characteristics, with the exception that participants in the intervention group were slightly younger and less likely to have hypertension. Self-reported exercise duration was longer than app-recorded exercise duration (control: mean 214 minutes/week; intervention: mean 193 minutes/week); in addition, a higher proportion of participants in the control group (29/41, 71%) than in the intervention group (18/44, 41%) met the 150-minute target for moderate to vigorous physical activity. However, compared with the control group, the intervention group had a larger increase in cardiopulmonary endurance (mean difference –2.0 bpm [beats per minute] vs 1.0 bpm; P=.02) and a larger decrease in body fat percentage (mean difference –1.8% vs –0.8%; P=.01). There was no difference in hemoglobin A1c level reduction between the two groups, yet more participants in the intervention group stopped taking their antidiabetic drugs or had their dosages lowered by an endocrinologist, compared with those in the control group. There were no serious adverse events in either group. Conclusions: This was the first randomized controlled trial in China, to our knowledge, to test the efficiency of exercise using a fitness app and heart rate band to remotely monitor prescribed exercise in patients with type 2 diabetes. The findings of our study suggest that exercise programs may be more efficient if participants are remotely monitored with an app and heart rate band than if participants are not monitored. Trial Registration: Chinese Clinical Trial Register ChiCTR1800015963; http://www.chictr.org.cn/showprojen.aspx?proj=27080 %M 33560244 %R 10.2196/23338 %U https://mhealth.jmir.org/2021/2/e23338 %U https://doi.org/10.2196/23338 %U http://www.ncbi.nlm.nih.gov/pubmed/33560244 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e24177 %T Using a Commercially Available App for the Self-Management of Hypertension: Acceptance and Usability Study in Saudi Arabia %A Alessa,Tourkiah %A S Hawley,Mark %A Alsulamy,Nouf %A de Witte,Luc %+ Centre for Assistive Technology and Connected Healthcare, School of Health and Related Research, University of Sheffield, The Innovation Centre, 217 Portobello, Sheffield, S1 4DP, United Kingdom, 966 559346711, talessa1@sheffield.ac.uk %K mHealth %K mobile phone %K hypertension %K usability %K acceptance %K user satisfaction %D 2021 %7 9.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The use of smartphone apps to assist in the self-management of hypertension is becoming increasingly common, but few commercially available apps have the potential to be effective along with adequate security and privacy measures in place. In a previous study, we identified 5 apps that are potentially effective and safe, and based on the preferences of doctors and patients, one (Cora Health) was selected as the most suitable app for use in a Saudi context. However, there is currently no evidence of its usability and acceptance among potential users. Indeed, there has been little research into the usability and acceptance of hypertension apps in general, and less research considers this in the Gulf Region. Objective: This study aims to evaluate the acceptance and usability of the selected app in the Saudi context. Methods: This study used a mixed methods approach with 2 studies: a usability test involving patients in a controlled setting performing predefined tasks and a real-world usability study where patients used the app for 4 weeks. In the usability test, participants were asked to think aloud while performing the tasks, and an observer recorded the number of tasks they completed. At the end of the real-world pilot study, participants were interviewed, and the mHealth App Usability Questionnaire was completed. Descriptive statistics were used to analyze quantitative data, and thematic analysis was used to analyze qualitative data. Results: In total, 10 patients completed study 1. The study found that app usability was moderate and that participants needed some familiarization time before they could use the app proficiently. Some usability issues were revealed, related to app accessibility and navigation, and a few tasks remained uncompleted by most people. A total of 20 patients completed study 2, with a mean age of 51.6 (SD 11.7) years. Study 2 found that the app was generally acceptable and easy to use, with some similar usability issues identified. Participants stressed the importance of practice and training to use it more easily and proficiently. Participants had a good engagement level with 48% retention at the end of study 2, with most participants’ engagement being classed as meaningful. The most recorded data were blood pressure, followed by stress and medication, and the most accessed feature was viewing graphs of data trends. Conclusions: This study shows that a commercially available app can be usable and acceptable in the self-management of hypertension but also found a considerable number of possibilities for improvement, which needs to be considered in future app development. The results show that there is potential for a commercially available app to be used in large-scale studies of hypertension self-management if suggestions for improvements are addressed. %M 33560237 %R 10.2196/24177 %U http://mhealth.jmir.org/2021/2/e24177/ %U https://doi.org/10.2196/24177 %U http://www.ncbi.nlm.nih.gov/pubmed/33560237 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e12218 %T Effectiveness of Text Message Reminders on Adherence to Inhaled Therapy in Patients With Asthma: Prospective Multicenter Randomized Clinical Trial %A Almonacid,Carlos %A Melero,Carlos %A López Viña,Antolín %A Cisneros,Carolina %A Pérez de Llano,Luis %A Plaza,Vicente %A García-Rivero,Juan Luis %A Romero Falcón,Auxiliadora %A Ramos,Jacinto %A Bazús González,Teresa %A Andrés Prado,María %A Muriel,Alfonso %+ Department of Respiratory Medicine, Instituto Ramón y Cajal de Investigación Sanitaria, University of Alcala de Henares, Ctra. De Colmenar Viejo, km. 9,100, Madrid, , Spain, 34 655 534 475, caralmsan@gmail.com %K asthma %K adherence %K SMS %K control %K cell phone %K inhaler %K Smartinhaler %D 2021 %7 9.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Poor adherence to inhaled medication in asthma patients is of great concern. It is one of the main reasons for inadequate asthma control. Objective: The goal of the research was to determine if motivational messages using short message service (SMS, or text) improved adherence to inhaled medication in patients with asthma. Methods: A prospective multicenter randomized parallel-group clinical trial was conducted in 10 asthma clinics in Spain. Adherence was assessed with electronic monitors (Smartinhaler, Adherium Ltd) connected to inhalers. Patients in the SMS group received psychologist-developed motivational messages every 3 days for 6 months. Results: There were 53 patients in the SMS group and 88 patients in the control group. After 6 months, mean electronic adherence was 70% (SD 17%) in the intervention group and 69% (SD 17%) in the control group (P=.82). Significant differences between the study groups in morning and evening adherence to inhaled therapy, asthma control, exhaled nitric oxide levels, or improvement of lung functions were not observed. Conclusions: Motivational messages were not useful to improve adherence to inhaled asthma medication compared with usual care. %M 33560235 %R 10.2196/12218 %U http://formative.jmir.org/2021/2/e12218/ %U https://doi.org/10.2196/12218 %U http://www.ncbi.nlm.nih.gov/pubmed/33560235 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e20630 %T Five Lessons Learned From Randomized Controlled Trials on Mobile Health Interventions: Consensus Procedure on Practical Recommendations for Sustainable Research %A Pach,Daniel %A Rogge,Alizé A %A Wang,Jiani %A Witt,Claudia M %+ Institute for Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Luisenstraße 57, Berlin, 10117, Germany, daniel.pach@charite.de %K mHealth %K mobile apps %K pain %K behavior change techniques (BCTs) %K recommendations %D 2021 %7 8.2.2021 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Background: Clinical research on mobile health (mHealth) interventions is too slow in comparison to the rapid speed of technological advances, thereby impeding sustainable research and evidence-based implementation of mHealth interventions. Objective: We aimed to establish practical lessons from the experience of our working group, which might accelerate the development of future mHealth interventions and their evaluation by randomized controlled trials (RCTs). Methods: This paper is based on group and expert discussions, and focuses on the researchers’ perspectives after four RCTs on mHealth interventions for chronic pain. Results: The following five lessons are presented, which are based on practical application, increase of speed, and sustainability: (1) explore stakeholder opinions, (2) develop the mHealth app and trial simultaneously, (3) minimize complexity, (4) manage necessary resources, and (5) apply behavior change techniques. Conclusions: The five lessons developed may lead toward an agile research environment. Agility might be the key factor in the development and research process of a potentially sustainable and evidence-based mHealth intervention. %M 33555263 %R 10.2196/20630 %U https://mhealth.jmir.org/2021/2/e20630 %U https://doi.org/10.2196/20630 %U http://www.ncbi.nlm.nih.gov/pubmed/33555263 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e22802 %T Physiological Responses and User Feedback on a Gameful Breathing Training App: Within-Subject Experiment %A Lukic,Yanick Xavier %A Shih,Chen-Hsuan (Iris) %A Hernandez Reguera,Alvaro %A Cotti,Amanda %A Fleisch,Elgar %A Kowatsch,Tobias %+ Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Weinbergstrasse 56/58, Zurich, 8092, Switzerland, 41 446328638, ylukic@ethz.ch %K breathing training %K serious game %K biofeedback %K mobile health %K mHealth %K mobile phone %D 2021 %7 8.2.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Slow-paced breathing training (6 breaths per minute [BPM]) improves physiological and psychological well-being by inducing relaxation characterized by increased heart rate variability (HRV). However, classic breathing training has a limited target group, and retention rates are very low. Although a gameful approach may help overcome these challenges, it is crucial to enable breathing training in a scalable context (eg, smartphone only) and ensure that they remain effective. However, despite the health benefits, no validated mobile gameful breathing training featuring a biofeedback component based on breathing seems to exist. Objective: This study aims to describe the design choices and their implementation in a concrete mobile gameful breathing training app. Furthermore, it aims to deliver an initial validation of the efficacy of the resulting app. Methods: Previous work was used to derive informed design choices, which, in turn, were applied to build the gameful breathing training app Breeze. In a pretest (n=3), design weaknesses in Breeze were identified, and Breeze was adjusted accordingly. The app was then evaluated in a pilot study (n=16). To ascertain that the effectiveness was maintained, recordings of breathing rates and HRV-derived measures (eg, root mean square of the successive differences [RMSSDs]) were collected. We compared 3 stages: baseline, standard breathing training deployed on a smartphone, and Breeze. Results: Overall, 5 design choices were made: use of cool colors, natural settings, tightly incorporated game elements, game mechanics reflecting physiological measures, and a light narrative and progression model. Breeze was effective, as it resulted in a slow-paced breathing rate of 6 BPM, which, in turn, resulted in significantly increased HRV measures compared with baseline (P<.001 for RMSSD). In general, the app was perceived positively by the participants. However, some criticized the somewhat weaker clarity of the breathing instructions when compared with a standard breathing training app. Conclusions: The implemented breathing training app Breeze maintained its efficacy despite the use of game elements. Moreover, the app was positively perceived by participants although there was room for improvement. %M 33555264 %R 10.2196/22802 %U http://games.jmir.org/2021/1/e22802/ %U https://doi.org/10.2196/22802 %U http://www.ncbi.nlm.nih.gov/pubmed/33555264 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e18773 %T Digital Health Interventions for Cardiac Rehabilitation: Systematic Literature Review %A Wongvibulsin,Shannon %A Habeos,Evagelia E %A Huynh,Pauline P %A Xun,Helen %A Shan,Rongzi %A Porosnicu Rodriguez,Kori A %A Wang,Jane %A Gandapur,Yousuf K %A Osuji,Ngozi %A Shah,Lochan M %A Spaulding,Erin M %A Hung,George %A Knowles,Kellen %A Yang,William E %A Marvel,Francoise A %A Levin,Eleanor %A Maron,David J %A Gordon,Neil F %A Martin,Seth S %+ Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Carnegie 591, Baltimore, MD, 21287, United States, 1 410 502 0469, smart100@jhmi.edu %K cardiac rehabilitation %K telemedicine %K digital technologies %K mHealth %K mobile phone %D 2021 %7 8.2.2021 %9 Review %J J Med Internet Res %G English %X Background: Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite strong evidence supporting the benefits of cardiac rehabilitation (CR), over 80% of eligible patients do not participate in CR. Digital health technologies (ie, the delivery of care using the internet, wearable devices, and mobile apps) have the potential to address the challenges associated with traditional facility-based CR programs, but little is known about the comprehensiveness of these interventions to serve as digital approaches to CR. Overall, there is a lack of a systematic evaluation of the current literature on digital interventions for CR. Objective: The objective of this systematic literature review is to provide an in-depth analysis of the potential of digital health technologies to address the challenges associated with traditional CR. Through this review, we aim to summarize the current literature on digital interventions for CR, identify the key components of CR that have been successfully addressed through digital interventions, and describe the gaps in research that need to be addressed for sustainable and scalable digital CR interventions. Methods: Our strategy for identifying the primary literature pertaining to CR with digital solutions (defined as technology employed to deliver remote care beyond the use of the telephone) included a consultation with an expert in the field of digital CR and searches of the PubMed (MEDLINE), Embase, CINAHL, and Cochrane databases for original studies published from January 1990 to October 2018. Results: Our search returned 31 eligible studies, of which 22 were randomized controlled trials. The reviewed CR interventions primarily targeted physical activity counseling (31/31, 100%), baseline assessment (30/31, 97%), and exercise training (27/31, 87%). The most commonly used modalities were smartphones or mobile devices (20/31, 65%), web-based portals (18/31, 58%), and email-SMS (11/31, 35%). Approximately one-third of the studies addressed the CR core components of nutrition counseling, psychological management, and weight management. In contrast, less than a third of the studies addressed other CR core components, including the management of lipids, diabetes, smoking cessation, and blood pressure. Conclusions: Digital technologies have the potential to increase access and participation in CR by mitigating the challenges associated with traditional, facility-based CR. However, previously evaluated interventions primarily focused on physical activity counseling and exercise training. Thus, further research is required with more comprehensive CR interventions and long-term follow-up to understand the clinical impact of digital interventions. %M 33555259 %R 10.2196/18773 %U https://www.jmir.org/2021/2/e18773 %U https://doi.org/10.2196/18773 %U http://www.ncbi.nlm.nih.gov/pubmed/33555259 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e14378 %T A Brief Mobile-Augmented Suicide Prevention Intervention for People With Psychotic Disorders in Transition From Acute to Ongoing Care: Protocol for a Pilot Trial %A Depp,Colin %A Ehret,Blaire %A Villa,Jennifer %A Perivoliotis,Dimitri %A Granholm,Eric %+ Department of Psychiatry, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA, 92093-0603, United States, 1 858 822 4251, cdepp@ucsd.edu %K prevention %K mental health services %K psychosis %K technology %D 2021 %7 8.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: People with serious mental illnesses (SMIs) are at exceptionally high risk for lifetime suicidal ideation and behavior compared with the general population. The transition period between urgent evaluation and ongoing care could provide an important setting for brief suicide-specific interventions for SMIs. To address this concern, this trial, SafeTy and Recovery Therapy (START), involves a brief suicide-specific cognitive behavioral intervention for SMIs that is augmented with mobile phone interactions. Objective: The primary aim of this pilot trial is to evaluate the feasibility, acceptability, and preliminary effectiveness of the intervention. Methods: A 6-month pilot trial with 70 participants with a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, and current active suicidal ideation were randomized to START or START with mobile augmentation. START consists of 4 weekly sessions addressing early warning signs and triggers, symptoms influencing suicidal thinking, and social relationships. Recovery planning is followed by biweekly telephone coaching. START with mobile augmentation includes personalized automated cognitive behavioral therapy scripts that build from in-person content. Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of telephone coaching), and 24 weeks. In addition to providing point estimates of feasibility and acceptability, the primary outcome of the trial was the change in severity of suicidal ideation as measured with the Scale for Suicide Ideation (SSI) and secondary outcome included the rate of outpatient engagement. Results: The trial is ongoing. Feasibility and acceptability across conditions will be assessed using t tests or Mann-Whitney tests or chi-square tests. The reduction of SSI over time will be assessed using hierarchical linear models. Conclusions: The design considerations and results of this trial may be informative for adapted suicide prevention in psychotic disorders in applied community settings. Trial Registration: ClinicalTrials.gov NCT03198364; http://clinicaltrials.gov/ct2/show/NCT03198364 International Registered Report Identifier (IRRID): DERR1-10.2196/14378 %M 33555265 %R 10.2196/14378 %U https://www.researchprotocols.org/2021/2/e14378 %U https://doi.org/10.2196/14378 %U http://www.ncbi.nlm.nih.gov/pubmed/33555265 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e20464 %T Quantification of Smoking Characteristics Using Smartwatch Technology: Pilot Feasibility Study of New Technology %A Cole,Casey Anne %A Powers,Shannon %A Tomko,Rachel L %A Froeliger,Brett %A Valafar,Homayoun %+ Department of Computer Science and Engineering, University of South Carolina, 1400 Assembly Street, Columbia, SC, 29208, United States, 1 9372067968, coleca@email.sc.edu %K smartwatch %K CReSS %K smoking topography %K ASPIRE %K automated %K wearable technology %K wearable computing %K smoking %D 2021 %7 5.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: While there have been many technological advances in studying the neurobiological and clinical basis of tobacco use disorder and nicotine addiction, there have been relatively minor advances in technologies for monitoring, characterizing, and intervening to prevent smoking in real time. Better understanding of real-time smoking behavior can be helpful in numerous applications without the burden and recall bias associated with self-report. Objective: The goal of this study was to test the validity of using a smartwatch to advance the study of temporal patterns and characteristics of smoking in a controlled laboratory setting prior to its implementation in situ. Specifically, the aim was to compare smoking characteristics recorded by Automated Smoking PerceptIon and REcording (ASPIRE) on a smartwatch with the pocket Clinical Research Support System (CReSS) topography device, using video observation as the gold standard. Methods: Adult smokers (N=27) engaged in a video-recorded laboratory smoking task using the pocket CReSS while also wearing a Polar M600 smartwatch. In-house software, ASPIRE, was used to record accelerometer data to identify the duration of puffs and interpuff intervals (IPIs). The recorded sessions from CReSS and ASPIRE were manually annotated to assess smoking topography. Agreement between CReSS-recorded and ASPIRE-recorded smoking behavior was compared. Results: ASPIRE produced more consistent number of puffs and IPI durations relative to CReSS, when comparing both methods to visual puff count. In addition, CReSS recordings reported many implausible measurements in the order of milliseconds. After filtering implausible data recorded from CReSS, ASPIRE and CReSS produced consistent results for puff duration (R2=.79) and IPIs (R2=.73). Conclusions: Agreement between ASPIRE and other indicators of smoking characteristics was high, suggesting that the use of ASPIRE is a viable method of passively characterizing smoking behavior. Moreover, ASPIRE was more accurate than CReSS for measuring puffs and IPIs. Results from this study provide the foundation for future utilization of ASPIRE to passively and accurately monitor and quantify smoking behavior in situ. %M 33544083 %R 10.2196/20464 %U https://formative.jmir.org/2021/2/e20464 %U https://doi.org/10.2196/20464 %U http://www.ncbi.nlm.nih.gov/pubmed/33544083 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e21977 %T Effectiveness of a Mobile Health and Self-Management App for High-Risk Patients With Chronic Obstructive Pulmonary Disease in Daily Clinical Practice: Mixed Methods Evaluation Study %A Kooij,Laura %A Vos,Petra J E %A Dijkstra,Antoon %A van Harten,Wim H %+ Rijnstate Hospital, Wagnerlaan 55, Arnhem, 6815AD, Netherlands, 31 88 005 7544, WvanHarten@rijnstate.nl %K chronic obstructive pulmonary disease %K mHealth %K self-management %K mobile app %K mobile phone %D 2021 %7 4.2.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health and self-management interventions may positively affect behavioral change and reduce hospital admissions for patients with chronic obstructive pulmonary disease (COPD). However, not all patients qualify for these interventions, and systematic, comprehensive information on implementation- and compliance-related aspects of mobile self-management apps is lacking. Due to the tendency to target digital services to patients in stable phases of disease, it is especially relevant to focus on the use of these services in broad clinical practice for patients recently discharged from hospital. Objective: This study aims to evaluate the effects of a mobile health and self-management app in clinical practice for recently discharged patients with COPD on use of the app, self-management, expectations, and experiences (technology acceptance); patients’ and nurses’ satisfaction; and hospital readmissions. Methods: A prototype of the app was pilot tested with 6 patients with COPD. The COPD app consisted of an 8-week program including the Lung Attack Action Plan, education, medication overview, video consultation, and questionnaires (monitored by nurses). In the feasibility study, adult patients with physician-diagnosed COPD, access to a mobile device, and proficiency of the Dutch language were included from a large teaching hospital during hospital admission. Self-management (Partners in Health Scale), technology acceptance (Unified Theory Acceptance and Use of Technology model), and satisfaction were assessed using questionnaires at baseline, after 8 weeks, and 20 weeks. Use was assessed with log data, and readmission rates were extracted from the electronic medical record. Results: A total of 39 patients were included; 76.4% (133/174) of patients had to be excluded from participation, and 48.9% of those patients (65/133) were excluded because of lack of digital skills, access to a mobile device, or access to the internet. The COPD app was opened most often in the first week (median 6.0; IQR 3.5-10.0), but its use decreased over time. The self-management element knowledge and coping increased significantly over time (P=.04). The COPD app was rated on a scale of 1-10, with an average score by patients of 7.7 (SD 1.7) and by nurses of 6.3 (SD 1.2). Preliminary evidence about the readmission rate showed that 13% (5/39) of patients were readmitted within 30 days; 31% (12/39) of patients were readmitted within 20 weeks, compared with 14.1% (48/340) and 21.8% (74/340) in a preresearch cohort, respectively. Conclusions: The use of a mobile self-management app after hospital discharge seems to be feasible only for a small number of patients with COPD. Patients were satisfied with the service; however, use decreased over time, and only knowledge and coping changed significantly over time. Therefore, future research on digital self-management interventions in clinical practice should focus on including more difficult subgroups of target populations, a multidisciplinary approach, technology-related aspects (such as acceptability), and fine-tuning its adoption in clinical pathways. Trial Registration: Clinicaltrials.gov NCT04540562; https://clinicaltrials.gov/ct2/show/NCT04540562. %M 33538699 %R 10.2196/21977 %U http://mhealth.jmir.org/2021/2/e21977/ %U https://doi.org/10.2196/21977 %U http://www.ncbi.nlm.nih.gov/pubmed/33538699 %0 Journal Article %@ 2561-1011 %I JMIR Publications %V 5 %N 1 %P e18834 %T User Engagement With Smartphone Apps and Cardiovascular Disease Risk Factor Outcomes: Systematic Review %A Spaulding,Erin M %A Marvel,Francoise A %A Piasecki,Rebecca J %A Martin,Seth S %A Allen,Jerilyn K %+ Johns Hopkins University School of Nursing, 525 North Wolfe Street, Baltimore, MD, 21205, United States, 1 603 724 0604, espauld2@jhu.edu %K mHealth %K smartphone %K mobile phone %K engagement %K cardiovascular disease %K health behaviors %K risk factors %D 2021 %7 3.2.2021 %9 Review %J JMIR Cardio %G English %X Background: The use of mobile health (mHealth) interventions, including smartphone apps, for the prevention of cardiovascular disease (CVD) has demonstrated mixed results for obesity, hypercholesterolemia, diabetes, and hypertension management. A major factor attributing to the variation in mHealth study results may be mHealth user engagement. Objective: This systematic review aims to determine if user engagement with smartphone apps for the prevention and management of CVD is associated with improved CVD health behavior change and risk factor outcomes. Methods: We conducted a comprehensive search of PubMed, CINAHL, and Embase databases from 2007 to 2020. Studies were eligible if they assessed whether user engagement with a smartphone app used by an individual to manage his or her CVD risk factors was associated with the CVD health behavior change or risk factor outcomes. For eligible studies, data were extracted on study and sample characteristics, intervention description, app user engagement measures, and the relationship between app user engagement and the CVD risk factor outcomes. App user engagement was operationalized as general usage (eg, number of log-ins or usage days per week) or self-monitoring within the app (eg, total number of entries made in the app). The quality of the studies was assessed. Results: Of the 24 included studies, 17 used a randomized controlled trial design, 4 used a retrospective analysis, and 3 used a single-arm pre- and posttest design. Sample sizes ranged from 55 to 324,649 adults, with 19 studies recruiting participants from a community setting. Most of the studies assessed weight loss interventions, with 6 addressing additional CVD risk factors, including diabetes, sleep, stress, and alcohol consumption. Most of the studies that assessed the relationship between user engagement and reduction in weight (9/13, 69%), BMI (3/4, 75%), body fat percentage (1/2, 50%), waist circumference (2/3, 67%), and hemoglobin A1c (3/5, 60%) found statistically significant results, indicating that greater app user engagement was associated with better outcomes. Of 5 studies, 3 (60%) found a statistically significant relationship between higher user engagement and an increase in objectively measured physical activity. The studies assessing the relationship between user engagement and dietary and diabetes self-care behaviors, blood pressure, and lipid panel components did not find statistically significant results. Conclusions: Increased app user engagement for prevention and management of CVD may be associated with improved weight and BMI; however, only a few studies assessed other outcomes, limiting the evidence beyond this. Additional studies are needed to assess user engagement with smartphone apps targeting other important CVD risk factors, including dietary behaviors, hypercholesterolemia, diabetes, and hypertension. Further research is needed to assess mHealth user engagement in both inpatient and outpatient settings to determine the effect of integrating mHealth interventions into the existing clinical workflow and on CVD outcomes. %M 33533730 %R 10.2196/18834 %U http://cardio.jmir.org/2021/1/e18834/ %U https://doi.org/10.2196/18834 %U http://www.ncbi.nlm.nih.gov/pubmed/33533730 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e24382 %T Using Information Technology to Assess Patient Risk Factors in Primary Care Clinics: Pragmatic Evaluation %A Kosowan,Leanne %A Katz,Alan %A Halas,Gayle %A LaBine,Lisa %A Singer,Alexander %+ Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada, 1 204 789 3442, Alan.katz@umanitoba.ca %K risk factors %K information technology %K primary health care %K primary prevention %D 2021 %7 2.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Tobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review. Objective: This study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics. Methods: This is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation. Results: Clinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups. Conclusions: Clinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients’ context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care. %M 33528376 %R 10.2196/24382 %U https://formative.jmir.org/2021/2/e24382 %U https://doi.org/10.2196/24382 %U http://www.ncbi.nlm.nih.gov/pubmed/33528376 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e25443 %T mHealth-Supported Delivery of an Evidence-Based Family Home-Visiting Intervention in Sierra Leone: Protocol for a Pilot Randomized Controlled Trial %A Desrosiers,Alethea %A Schafer,Carolyn %A Esliker,Rebecca %A Jambai,Musu %A Betancourt,Theresa S %+ Boston College, School of Social Work, 140 Commonwealth Avenue, Chestnut Hill, MA, 01778, United States, 1 617 552 8398, alethea.desrosiers@bc.edu %K mHealth %K caregiver mental health %K family functioning %K early childhood development %K community health workers %D 2021 %7 2.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Past trauma and exposure to violence have been related to poor emotion regulation and household violence, which can have persistent mental health effects across generations. The Family Strengthening Intervention for Early Childhood Development (FSI-ECD/called Sugira Muryango in Rwanda) is an evidence-based behavioral home-visiting intervention to promote caregiver mental health, positive parenting practices, and early childhood development among families facing adversity. In Sierra Leone and other lower- and middle-income countries, mobile health (mHealth) technology has the potential to improve health care delivery and health outcomes. Objective: This study aims to (1) apply a user-centered design to develop and test mHealth tools to improve supervision and fidelity monitoring of community health workers (CHWs) delivering the FSI-ECD and (2) conduct a pilot randomized controlled trial of the FSI-ECD to assess feasibility, acceptability, and preliminary effects on caregiver mental health, emotion regulation, caregiving behaviors, and family violence in high-risk families with children aged 6-36 months in comparison with control families receiving standard care. Methods: We will recruit and enroll CHWs, supervisors, and families with a child aged 6-36 months from community health clinics in Sierra Leone. CHWs and supervisors will participate in 1 problem analysis focus group and 2 user interface/user experience cycles to provide feedback on mHealth tool prototypes. Families will be randomized to mHealth-supported FSI-ECD or standard maternal and child health services. We will collect quantitative data on caregiver mental health, emotion regulation, caregiving behaviors, and family functioning at baseline, postintervention, and 3-month follow up. We will use a mixed methods approach to explore feasibility and acceptability of mHealth tools and the FSI-ECD. Mixed effects linear modeling will assess FSI-ECD effects on caregiver outcomes. Cost-effectiveness analysis will estimate costs across FSI-ECD versus standard care. Results: Funding for this study was received from the National Institutes of Mental Health on August 17, 2020. Institutional Review Board approval was received on September 4, 2020. Data collection is projected to begin on December 15, 2020. Conclusions: This study will provide important data on the feasibility, acceptability, and preliminary efficacy of mHealth-supported delivery of an evidence-based family home-visiting intervention in a postconflict LMIC. Trial Registration: ClinicalTrials.gov NCT04481399; https://clinicaltrials.gov/ct2/show/NCT04481399. International Registered Report Identifier (IRRID): PRR1-10.2196/25443 %M 33528371 %R 10.2196/25443 %U https://www.researchprotocols.org/2021/2/e25443 %U https://doi.org/10.2196/25443 %U http://www.ncbi.nlm.nih.gov/pubmed/33528371 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e23389 %T The Use of Digital Platforms for Adults’ and Adolescents’ Physical Activity During the COVID-19 Pandemic (Our Life at Home): Survey Study %A Parker,Kate %A Uddin,Riaz %A Ridgers,Nicola D %A Brown,Helen %A Veitch,Jenny %A Salmon,Jo %A Timperio,Anna %A Sahlqvist,Shannon %A Cassar,Samuel %A Toffoletti,Kim %A Maddison,Ralph %A Arundell,Lauren %+ Institute for Physical Activity and Nutrition, Deakin University, 75 Pigdons Rd, Geelong, Australia, 61 92468094, k.parker@deakin.edu.au %K digital health %K moderate- to vigorous-intensity physical activity %K muscle-strengthening exercise %K online platforms %K COVID-19 %D 2021 %7 1.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Government responses to managing the COVID-19 pandemic may have impacted the way individuals were able to engage in physical activity. Digital platforms are a promising way to support physical activity levels and may have provided an alternative for people to maintain their activity while at home. Objective: This study aimed to examine associations between the use of digital platforms and adherence to the physical activity guidelines among Australian adults and adolescents during the COVID-19 stay-at-home restrictions in April and May 2020. Methods: A national online survey was distributed in May 2020. Participants included 1188 adults (mean age 37.4 years, SD 15.1; 980/1188, 82.5% female) and 963 adolescents (mean age 16.2 years, SD 1.2; 685/963, 71.1% female). Participants reported demographic characteristics, use of digital platforms for physical activity over the previous month, and adherence to moderate- to vigorous-intensity physical activity (MVPA) and muscle-strengthening exercise (MSE) guidelines. Multilevel logistic regression models examined differences in guideline adherence between those who used digital platforms (ie, users) to support their physical activity compared to those who did not (ie, nonusers). Results: Digital platforms include streaming services for exercise (eg, YouTube, Instagram, and Facebook); subscriber fitness programs, via an app or online (eg, Centr and MyFitnessPal); facilitated online live or recorded classes, via platforms such as Zoom (eg, dance, sport training, and fitness class); sport- or activity-specific apps designed by sporting organizations for participants to keep up their skills (eg, TeamBuildr); active electronic games (eg, Xbox Kinect); and/or online or digital training or racing platforms (eg, Zwift, FullGaz, and Rouvy). Overall, 39.5% (469/1188) of adults and 26.5% (255/963) of adolescents reported using digital platforms for physical activity. Among adults, MVPA (odds ratio [OR] 2.0, 95% CI 1.5-2.7), MSE (OR 3.3, 95% CI 2.5-4.5), and combined (OR 2.7, 95% CI 2.0-3.8) guideline adherence were higher among digital platform users relative to nonusers. Adolescents’ MVPA (OR 2.4, 95% CI 1.3-4.3), MSE (OR 3.1, 95% CI 2.1-4.4), and combined (OR 4.3, 95% CI 2.1-9.0) guideline adherence were also higher among users of digital platforms relative to nonusers. Conclusions: Digital platform users were more likely than nonusers to meet MVPA and MSE guidelines during the COVID-19 stay-at-home restrictions in April and May 2020. Digital platforms may play a critical role in helping to support physical activity engagement when access to facilities or opportunities for physical activity outside the home are restricted. %M 33481759 %R 10.2196/23389 %U https://www.jmir.org/2021/2/e23389 %U https://doi.org/10.2196/23389 %U http://www.ncbi.nlm.nih.gov/pubmed/33481759 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 2 %P e22601 %T Effects of Smartphone-Based Interventions on Physical Activity in Children and Adolescents: Systematic Review and Meta-analysis %A He,Zihao %A Wu,Hua %A Yu,Fengyu %A Fu,Jinmei %A Sun,Shunli %A Huang,Ting %A Wang,Runze %A Chen,Delong %A Zhao,Guanggao %A Quan,Minghui %+ School of Kinesiology, Shanghai University of Sport, No 399 Chang Hai Road, Shanghai, 200438, China, 86 021 65507367, quanminghui@163.com %K adolescents %K children %K mHealth %K physical activity %K smartphone %D 2021 %7 1.2.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: About 70% of children and adolescents worldwide do not meet the recommended level of physical activity (PA), which is closely associated with physical, psychological, and cognitive well-being. Nowadays, the use of technologies to change PA is of interest due to the need for novel, more effective intervention approaches. The previous meta-analyses have examined smartphone-based interventions and their impact on PA in adults, but evidence in children and adolescents still needs further research. Objective: This systematic review and meta-analysis aimed to determine the effectiveness of smartphone-based interventions for improving PA in children and adolescents. Methods: Five electronic databases (PubMed, Web of Science, OVID, Scopus, and the China National Knowledge Infrastructure) were searched up to June 29, 2020. Randomized controlled trials with a control group that examine the effect of smartphone interventions on PA among children and adolescents were included. Bias risks were assessed using the Cochrane collaboration tool. Meta-analysis was performed to assess the pooled effect on PA using a random effects model. Subgroup analyses were conducted to examine the potential modifying effects of different factors (eg, types of intervention, intervention duration, age, measurement, study quality). Results: A total of 9 studies were included in this review, including 4 mobile app interventions, 3 SMS text messaging interventions, and 2 app + SMS text messaging interventions. In general, the risk of bias of included studies was low. Compared with the control group, the use of smartphone intervention significantly improved PA (standardized mean difference [SMD] 0.44, 95% CI 0.11-0.77, P=.009), especially for total PA (TPA; weighted mean difference [WMD] 32.35, 95% CI 10.36-54.33, P=.004) and daily steps (WMD 1185, 95% CI 303-2068, P=.008), but not for moderate-to-vigorous PA (WMD 3.91, 95% CI –1.99 to 9.81, P=.19). High statistical heterogeneity was detected (I2=73.9%, P<.001) for PA. Meta-regression showed that duration (β=–.08, 95% CI –0.15 to –0.01, n=16) was a potential factor for high heterogeneity. The results of subgroup analyses indicated that app intervention (SMD 0.76, 95% CI 0.23-1.30, P=.005), children (SMD 0.64, 95% CI 0.10-1.18, P=.02), “≤8 weeks” (SMD 0.76, 95% CI 0.23-1.30, P=.005), objective measurement (SMD 0.50, 95% CI 0.09-0.91, P=.02), and low risk of bias (SMD 0.96, 95% CI 0.38-1.54, P=.001) can significantly improve PA. Conclusions: The evidence of meta-analysis shows that smartphone-based intervention may be a promising strategy to increase TPA and steps in children and adolescents. Currently, app intervention may be a more effective strategy among smartphone intervention technologies. To extend the promise of smartphone intervention, the future needs to design comparative trials among different smartphone technologies. Trial Registration: PROSPERO CRD42019148261; https://tinyurl.com/y5modsrd %M 33522980 %R 10.2196/22601 %U https://mhealth.jmir.org/2021/2/e22601 %U https://doi.org/10.2196/22601 %U http://www.ncbi.nlm.nih.gov/pubmed/33522980 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e21636 %T Factors Associated With Dropout of Participants in an App-Based Child Injury Prevention Study: Secondary Data Analysis of a Cluster Randomized Controlled Trial %A Li,Jie %A Ning,Peishan %A Cheng,Peixia %A Schwebel,David C %A Yang,Yang %A Wei,Xiang %A He,Jieyi %A Wang,Wanhui %A Li,Ruotong %A Hu,Guoqing %+ Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, 110 Xiangya Road, Changsha, 410078, China, 86 731 84805414, huguoqing009@gmail.com %K app-based intervention %K unintentional injury %K attrition %K influencing factors %D 2021 %7 29.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile health (mHealth) interventions offer great potential to reach large populations and improve public health. However, high attrition rates threaten evaluation and implementation of mHealth intervention studies. Objective: We explored factors associated with attrition of study participants in an mHealth randomized controlled trial (RCT) evaluating an intervention to reduce unintentional child injury risk in China. Methods: The cluster RCT compared two groups of an app-based intervention for caregivers of 3-6–year-old children (Bao Hu San). The intervention group received unintentional child injury and parenting education, whereas only parenting education was implemented in the control group. The trial included 2920 study participants in Changsha, China, and lasted 6 months. Data on participant engagement (using the app) were collected electronically throughout the 6-month period. Associations between participant attrition and demographic characteristics, and between attrition and intervention engagement were tested and quantified separately for the intervention and control groups using the adjusted odds ratio (aOR) based on generalized linear mixed models. Results: In total, 2920 caregivers from 20 eligible preschools participated, with 1510 in the intervention group and 1410 in the control group. The 6-month attrition rate differed significantly between the two groups (P<.001), at 28.9% (437/1510) in the intervention group and 35.7% (503/1410) in the control group. For the intervention group, the only significant predictor of attrition risk was participants who learned fewer knowledge segments (aOR 2.69, 95% CI 1.19-6.09). For the control group, significant predictors of attrition risk were lower monthly login frequency (aOR 1.48, 95% CI 1.00-2.18), learning fewer knowledge segments (aOR 1.70, 95% CI 1.02-2.81), and shorter learning durations during app engagement (aOR 2.39, 95% CI 1.11-5.15). Demographic characteristics were unrelated to attrition. Conclusions: Engagement in the app intervention was associated with participant attrition. Researchers and practitioners should consider how to best engage participants in app-based interventions to reduce attrition. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IOR-17010438; http://www.chictr.org.cn/showproj.aspx?proj=17376 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-018-5790-1 %M 33512318 %R 10.2196/21636 %U https://www.jmir.org/2021/1/e21636 %U https://doi.org/10.2196/21636 %U http://www.ncbi.nlm.nih.gov/pubmed/33512318 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e22723 %T Smartphone-Detected Ambient Speech and Self-Reported Measures of Anxiety and Depression: Exploratory Observational Study %A Di Matteo,Daniel %A Wang,Wendy %A Fotinos,Kathryn %A Lokuge,Sachinthya %A Yu,Julia %A Sternat,Tia %A Katzman,Martin A %A Rose,Jonathan %+ The Centre for Automation of Medicine, The Edward S Rogers Sr Department of Electrical and Computer Engineering, University of Toronto, DL Pratt Building, 6 King's College Road, Toronto, ON, M5S 3H5, Canada, 1 416 978 6992, dandm@ece.utoronto.ca %K mobile sensing %K passive sensing %K psychiatric assessment %K mood and anxiety disorders %K mobile apps %K linguistics %K speech recognition %K speech content %K lexical choice %D 2021 %7 29.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The ability to objectively measure the severity of depression and anxiety disorders in a passive manner could have a profound impact on the way in which these disorders are diagnosed, assessed, and treated. Existing studies have demonstrated links between both depression and anxiety and the linguistic properties of words that people use to communicate. Smartphones offer the ability to passively and continuously detect spoken words to monitor and analyze the linguistic properties of speech produced by the speaker and other sources of ambient speech in their environment. The linguistic properties of automatically detected and recognized speech may be used to build objective severity measures of depression and anxiety. Objective: The aim of this study was to determine if the linguistic properties of words passively detected from environmental audio recorded using a participant’s smartphone can be used to find correlates of symptom severity of social anxiety disorder, generalized anxiety disorder, depression, and general impairment. Methods: An Android app was designed to collect periodic audiorecordings of participants’ environments and to detect English words using automatic speech recognition. Participants were recruited into a 2-week observational study. The app was installed on the participants’ personal smartphones to record and analyze audio. The participants also completed self-report severity measures of social anxiety disorder, generalized anxiety disorder, depression, and functional impairment. Words detected from audiorecordings were categorized, and correlations were measured between words counts in each category and the 4 self-report measures to determine if any categories could serve as correlates of social anxiety disorder, generalized anxiety disorder, depression, or general impairment. Results: The participants were 112 adults who resided in Canada from a nonclinical population; 86 participants yielded sufficient data for analysis. Correlations between word counts in 67 word categories and each of the 4 self-report measures revealed a strong relationship between the usage rates of death-related words and depressive symptoms (r=0.41, P<.001). There were also interesting correlations between rates of word usage in the categories of reward-related words with depression (r=–0.22, P=.04) and generalized anxiety (r=–0.29, P=.007), and vision-related words with social anxiety (r=0.31, P=.003). Conclusions: In this study, words automatically recognized from environmental audio were shown to contain a number of potential associations with severity of depression and anxiety. This work suggests that sparsely sampled audio could provide relevant insight into individuals’ mental health. %M 33512325 %R 10.2196/22723 %U http://formative.jmir.org/2021/1/e22723/ %U https://doi.org/10.2196/22723 %U http://www.ncbi.nlm.nih.gov/pubmed/33512325 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 8 %N 1 %P e23796 %T The Use of Telehealth Technology to Support Health Coaching for Older Adults: Literature Review %A Markert,Carl %A Sasangohar,Farzan %A Mortazavi,Bobak J %A Fields,Sherecce %+ Department of Industrial and Systems Engineering, Texas A&M University, 3131 TAMU, College Station, TX, 77843, United States, 1 9794582337, sasangohar@tamu.edu %K telemedicine %K remote sensing technology %K health coaching %K decision support systems %K clinical %K older adults %D 2021 %7 29.1.2021 %9 Review %J JMIR Hum Factors %G English %X Background: Health coaching is an intervention process for driving behavior change through goal-setting, education, encouragement, and feedback on health-related behaviors. Telehealth systems that include health coaching and remote monitoring are making inroads in managing chronic conditions and may be especially suited for older populations. Objective: This literature review aimed to investigate the current status of health coaching interventions incorporating telehealth technology and the associated effectiveness of this intervention to deliver health care with an emphasis on older adults (aged 65 and older). Methods: A literature review was conducted to identify the research conducted on health coaching combined with remote monitoring for delivering health care to older adults. The Ovid MEDLINE and CINAHL databases were queried using a combination of relevant search terms (including middle aged, aged, older adult, elderly, health coaching, and wellness coaching). The search retrieved 196 papers published from January 2010 to September 2019 in English. Following a systematic review process, the titles and abstracts of the papers retrieved were screened for applicability to health coaching for older adults to define a subset for further review. Papers were excluded if the studied population did not include older adults. The full text of the 42 papers in this subset was then reviewed, and 13 papers related to health coaching combined with remote monitoring for older adults were included in this review. Results: Of the 13 studies reviewed, 10 found coaching supported by telehealth technology to provide effective outcomes. Effectiveness outcomes assessed in the studies included hospital admissions/re-admissions, mortality, hemoglobin A1c (HbA1c) level, body weight, blood pressure, physical activity level, fatigue, quality of life, and user acceptance of the coaching program and technology. Conclusions: Telehealth systems that include health coaching have been implemented in older populations as a viable intervention method for managing chronic conditions with mixed results. Health coaching combined with telehealth may be an effective solution for providing health care to older adults. However, health coaching is predominantly performed by human coaches with limited use of technology to augment or replace the human coach. The opportunity exists to expand health coaching to include automated coaching. %M 33512322 %R 10.2196/23796 %U http://humanfactors.jmir.org/2021/1/e23796/ %U https://doi.org/10.2196/23796 %U http://www.ncbi.nlm.nih.gov/pubmed/33512322 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e22041 %T A Relaxation App (HeartBot) for Stress and Emotional Well-Being Over a 21-Day Challenge: Randomized Survey Study %A Iyer,Laya %A Iyer,Ranjani B %A Kumar,Vetriliaa %+ Heartfulness Program for Schools, Heartfulness Institute, 24977 Glenda St, Novi, MI, 48375, United States, 1 2482559635, ranjani.heartfulness@gmail.com %K Heartfulness %K stress management %K iOS app %K social-emotional %K mental health %D 2021 %7 29.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: HeartBot is an app designed to enable people 14 years and older to use relaxation tools offered by Heartfulness Institute to deal with daily stress and anxiety in a healthy, productive manner. These tools have proven effective in stress management and mental wellness when administered in a controlled environment by a certified proctor. Objective: This study aimed to explore the app’s effectiveness and evaluate the implementation of the tools. Methods: In this study, 88 participants were recruited and randomly sorted into 2 groups, the HeartBot intervention group (n=46) and the waitlist control group (n=42). Pre- and postsurveys measured participants’ stress levels using the Perceived Stress Scale (PSS) and their social-emotional well-being using the EPOCH (Engagement, Perseverance, Optimism, Connectedness, and Happiness) Measure of Adolescent Well-Being before and after they used the app for 21 days for 30 minutes every day. Results: The study received institutional review board approval on August 18, 2019. Participant recruitment lasted from the approval date until September 30, 2019. The 21-day challenge started on October 1, 2019. Of the 135 people who signed up, 88 completed the study. There was a statistically significant difference in the mean PSS scores before and after the intervention (from 18.3 to 7.89; P<.001). The paired Wilcoxon rank sum test on the EPOCH scores indicated a significant difference in the medians of the total scores (W=411.5, P<.001). Conclusions: Evidence from this study shows that HeartBot is an effective app that can be used to manage stress and improve positive characteristics of emotional wellness. Future research and widespread usage of the app under this study are encouraged based on this preliminary evidence of its effectiveness. Trial Registration: ClinicalTrials.gov NCT04589520; https://clinicaltrials.gov/ct2/show/NCT04589520 %M 33455902 %R 10.2196/22041 %U http://formative.jmir.org/2021/1/e22041/ %U https://doi.org/10.2196/22041 %U http://www.ncbi.nlm.nih.gov/pubmed/33455902 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e21854 %T Examining the Relationship Between the Use of a Mobile Peer-Support App and Self-Injury Outcomes: Longitudinal Mixed Methods Study %A Kruzan,Kaylee Payne %A Whitlock,Janis %A Bazarova,Natalya N %+ Center for Behavioral Intervention Technologies, Northwestern University, 750 N Lake Shore Dr, 10th Fl, Chicago, IL, United States, 1 312 503 6585, kaylee.kruzan@northwestern.edu %K self-injury %K mobile apps %K peer support %K mHealth %D 2021 %7 28.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Many individuals who self-injure seek support and information through online communities and mobile peer-support apps. Although researchers have identified risks and benefits of participation, empirical work linking participation in these web-based spaces to self-injury behaviors and thoughts is limited. Objective: This study aims to investigate the relationship between behavioral and linguistic traces on a mobile peer support app and self-injury outcomes. Methods: Natural use data and web-based surveys (N=697) assessing self-injury outcomes were collected from 268 users (aged 13-38 years; median 19; 149/268, 55.6% female) of a mobile peer-support app for 4 months. Participants were identified as having posted self-injury content using an internal classifier. Natural log data was used to predict self-injury outcomes in a series of multilevel logistic and linear regressions. Results: Greater engagement on a mobile peer-support app was associated with a decreased likelihood of self-injury thoughts (odds ratio [OR] 0.25, 95% CI 0.09-0.73) and fewer intentions to self-injure (b=−0.37, SE 0.09), whereas posting triggering content was associated with an increased likelihood of engaging in behaviors (OR 5.37, 95% CI 1.25-23.05) and having self-injury thoughts (OR 17.87, 95% CI 1.64-194.15). Moreover, viewing triggering content was related to both a greater ability to resist (b=1.39, SE 0.66) and a greater intention to self-injure (b=1.50, SE 0.06). Conclusions: To our knowledge, this is the first study to connect naturally occurring log data to survey data assessing self-injury outcomes over time. This work provides empirical support for the relationship between participation in online forums and self-injury outcomes, and it articulates mechanisms contributing to this relationship. %M 33507154 %R 10.2196/21854 %U http://mental.jmir.org/2021/1/e21854/ %U https://doi.org/10.2196/21854 %U http://www.ncbi.nlm.nih.gov/pubmed/33507154 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e21926 %T Deep Learning–Based Multimodal Data Fusion: Case Study in Food Intake Episodes Detection Using Wearable Sensors %A Bahador,Nooshin %A Ferreira,Denzil %A Tamminen,Satu %A Kortelainen,Jukka %+ Faculty of Information Technology and Electrical Engineering, University of Oulu, Pentti Kaiteran katu 1, Oulu, FIN-90570, Finland, 358 417246274, nooshin.bahador@oulu.fi %K deep learning %K image processing %K data fusion %K covariance distribution %K food intake episode %K wearable sensors %D 2021 %7 28.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Multimodal wearable technologies have brought forward wide possibilities in human activity recognition, and more specifically personalized monitoring of eating habits. The emerging challenge now is the selection of most discriminative information from high-dimensional data collected from multiple sources. The available fusion algorithms with their complex structure are poorly adopted to the computationally constrained environment which requires integrating information directly at the source. As a result, more simple low-level fusion methods are needed. Objective: In the absence of a data combining process, the cost of directly applying high-dimensional raw data to a deep classifier would be computationally expensive with regard to the response time, energy consumption, and memory requirement. Taking this into account, we aimed to develop a data fusion technique in a computationally efficient way to achieve a more comprehensive insight of human activity dynamics in a lower dimension. The major objective was considering statistical dependency of multisensory data and exploring intermodality correlation patterns for different activities. Methods: In this technique, the information in time (regardless of the number of sources) is transformed into a 2D space that facilitates classification of eating episodes from others. This is based on a hypothesis that data captured by various sensors are statistically associated with each other and the covariance matrix of all these signals has a unique distribution correlated with each activity which can be encoded on a contour representation. These representations are then used as input of a deep model to learn specific patterns associated with specific activity. Results: In order to show the generalizability of the proposed fusion algorithm, 2 different scenarios were taken into account. These scenarios were different in terms of temporal segment size, type of activity, wearable device, subjects, and deep learning architecture. The first scenario used a data set in which a single participant performed a limited number of activities while wearing the Empatica E4 wristband. In the second scenario, a data set related to the activities of daily living was used where 10 different participants wore inertial measurement units while performing a more complex set of activities. The precision metric obtained from leave-one-subject-out cross-validation for the second scenario reached 0.803. The impact of missing data on performance degradation was also evaluated. Conclusions: To conclude, the proposed fusion technique provides the possibility of embedding joint variability information over different modalities in just a single 2D representation which results in obtaining a more global view of different aspects of daily human activities at hand, and yet preserving the desired performance level in activity recognition. %M 33507156 %R 10.2196/21926 %U http://mhealth.jmir.org/2021/1/e21926/ %U https://doi.org/10.2196/21926 %U http://www.ncbi.nlm.nih.gov/pubmed/33507156 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e23410 %T Effectiveness of Smartphone-Based Mindfulness Training on Maternal Perinatal Depression: Randomized Controlled Trial %A Sun,Yaoyao %A Li,Yanyan %A Wang,Juan %A Chen,Qingyi %A Bazzano,Alessandra N %A Cao,Fenglin %+ School of Nursing and Rehabilitation, Shandong University, 44 Wenhua Xi Road, Jinan, 250012, China, 86 053188382291, caofenglin2008@126.com %K mindfulness %K pregnancy %K perinatal care %K depression %K mHealth %K mobile health %K psychosocial intervention %D 2021 %7 27.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Despite potential for benefit, mindfulness remains an emergent area in perinatal mental health care, and evidence of smartphone-based mindfulness training for perinatal depression is especially limited. Objective: The objective of this study was to evaluate the effectiveness of a smartphone-based mindfulness training intervention during pregnancy on perinatal depression and other mental health problems with a randomized controlled design. Methods: Pregnant adult women who were potentially at risk of perinatal depression were recruited from an obstetrics clinic and randomized to a self-guided 8-week smartphone-based mindfulness training during pregnancy group or attention control group. Mental health indicators were surveyed over five time points through the postpartum period by online self-assessment. The assessor who collected the follow-up data was blind to the assignment. The primary outcome was depression as measured by symptoms, and secondary outcomes were anxiety, stress, affect, sleep, fatigue, memory, and fear. Results: A total of 168 participants were randomly allocated to the mindfulness training (n=84) or attention control (n=84) group. The overall dropout rate was 34.5%, and 52.4% of the participants completed the intervention. Mindfulness training participants reported significant improvement of depression (group × time interaction χ24=16.2, P=.003) and secondary outcomes (χ24=13.1, P=.01 for anxiety; χ24=8.4, P=.04 for positive affect) compared to attention control group participants. Medium between-group effect sizes were found on depression and positive affect at postintervention, and on anxiety in late pregnancy (Cohen d=0.47, –0.49, and 0.46, respectively). Mindfulness training participants reported a decreased risk of positive depressive symptom (Edinburgh Postnatal Depression Scale [EPDS] score>9) compared to attention control participants postintervention (odds ratio [OR] 0.391, 95% CI 0.164-0.930) and significantly higher depression symptom remission with different EPDS reduction scores from preintervention to postintervention (OR 3.471-27.986). Parity did not show a significant moderating effect; however, for nulliparous women, mindfulness training participants had significantly improved depression symptoms compared to nulliparous attention control group participants (group × time interaction χ24=18.1, P=.001). Conclusions: Smartphone-based mindfulness training is an effective intervention in improving maternal perinatal depression for those who are potentially at risk of perinatal depression in early pregnancy. Nulliparous women are a promising subgroup who may benefit more from mindfulness training. Trial Registration: Chinese Clinical Trial Registry ChiCTR1900028521; http://www.chictr.org.cn/showproj.aspx?proj=33474 %M 33502326 %R 10.2196/23410 %U http://www.jmir.org/2021/1/e23410/ %U https://doi.org/10.2196/23410 %U http://www.ncbi.nlm.nih.gov/pubmed/33502326 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e15369 %T A Smartphone App to Support Sedentary Behavior Change by Visualizing Personal Mobility Patterns and Action Planning (SedVis): Development and Pilot Study %A Wang,Yunlong %A König,Laura M. %A Reiterer,Harald %+ Department of Computer and Information Science, University of Konstanz, Universitätsstraße 10, Konstanz, 78457, Germany, 49 7531 88 3704, yunlong.wang@uni-konstanz.de %K sedentary behavior %K data visualization %K mobile app %K action planning %K human mobility patterns %K mobile phone %D 2021 %7 27.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Prolonged sedentary behavior is related to a number of risk factors for chronic diseases. Given the high prevalence of sedentary behavior in daily life, simple yet practical solutions for behavior change are needed to avoid detrimental health effects. Objective: The mobile app SedVis was developed based on the health action process approach. The app provides personal mobility pattern visualization (for both physical activity and sedentary behavior) and action planning for sedentary behavior change. The primary aim of the study is to investigate the effect of mobility pattern visualization on users’ action planning for changing their sedentary behavior. The secondary aim is to evaluate user engagement with the visualization and user experience of the app. Methods: A 3-week user study was conducted with 16 participants who had the motivation to reduce their sedentary behavior. Participants were allocated to either an active control group (n=8) or an intervention group (n=8). In the 1-week baseline period, none of the participants had access to the functions in the app. In the following 2-week intervention period, only the intervention group was given access to the visualizations, whereas both groups were asked to make action plans every day and reduce their sedentary behavior. Participants’ sedentary behavior was estimated based on the sensor data of their smartphones, and their action plans and interaction with the app were also recorded by the app. Participants’ intention to change their sedentary behavior and user experience of the app were assessed using questionnaires. Results: The data were analyzed using both traditional null hypothesis significance testing (NHST) and Bayesian statistics. The results suggested that the visualizations in SedVis had no effect on the participants’ action planning according to both the NHST and Bayesian statistics. The intervention involving visualizations and action planning in SedVis had a positive effect on reducing participants’ sedentary hours, with weak evidence according to Bayesian statistics (Bayes factor, BF+0=1.92; median 0.52; 95% CI 0.04-1.25), whereas no change in sedentary time was more likely in the active control condition (BF+0=0.28; median 0.18; 95% CI 0.01-0.64). Furthermore, Bayesian analysis weakly suggested that the more frequently the users checked the app, the more likely they were to reduce their sedentary behavior (BF−0=1.49; r=−0.50). Conclusions: Using a smartphone app to collect data on users’ mobility patterns and provide real-time feedback using visualizations may be a promising method to induce changes in sedentary behavior and may be more effective than action planning alone. Replications with larger samples are needed to confirm these findings. %M 33502322 %R 10.2196/15369 %U http://formative.jmir.org/2021/1/e15369/ %U https://doi.org/10.2196/15369 %U http://www.ncbi.nlm.nih.gov/pubmed/33502322 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e25456 %T It Is Time to REACT: Opportunities for Digital Mental Health Apps to Reduce Mental Health Disparities in Racially and Ethnically Minoritized Groups %A Friis-Healy,Elsa A %A Nagy,Gabriela A %A Kollins,Scott H %+ Department of Psychiatry and Behavioral Services, Duke University School of Medicine, 2608 Erwin Road, Durham, NC, 27705, United States, 1 919 681 0014, eaf23@duke.edu %K digital health %K app %K public mental health %K health disparities %K COVID-19 %K pandemic %K mental health %K disparity %K behavior %D 2021 %7 26.1.2021 %9 Viewpoint %J JMIR Ment Health %G English %X The behavioral health toll of the COVID-19 pandemic and systemic racism has directed increased attention to the potential of digital health as a way of improving access to and quality of behavioral health care. However, as the pandemic continues to widen health disparities in racially and ethnically minoritized groups, concerns arise around an increased reliance on digital health technologies exacerbating the digital divide and reinforcing rather than mitigating systemic health inequities in communities of color. As funding for digital mental health continues to surge, we offer five key recommendations on how the field can “REACT” to ensure the development of approaches that increase health equity by increasing real-world evidence, educating consumers and providers, utilizing adaptive interventions to optimize care, creating for diverse populations, and building trust. Recommendations highlight the need to take a strengths-based view when designing for racially and ethnically diverse populations and embracing the potential of digital approaches to address complex challenges. %M 33406050 %R 10.2196/25456 %U http://mental.jmir.org/2021/1/e25456/ %U https://doi.org/10.2196/25456 %U http://www.ncbi.nlm.nih.gov/pubmed/33406050 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e20314 %T Mobile Phone Use and Acceptability for the Delivery of Mental Health Information Among Perinatal Adolescents in Nigeria: Survey Study %A Kola,Lola %A Abiona,Dolapo %A Adefolarin,Adeyinka Olufolake %A Ben-Zeev,Dror %+ University of Ibadan, Department of Psychiatry, College of Medicine, WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Drug and Alcohol Abuse, Ibadan, , Nigeria, 234 8057943775, lola_kola2004@yahoo.com %K mHealth %K perinatal adolescent %K perinatal depression %K community %K low income %D 2021 %7 26.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: There are several barriers that may hamper adolescent mothers’ utilization of available health interventions for perinatal depression. Innovative treatment approaches are needed to increase adolescent mothers’ access to mental health care for improved maternal and child health outcomes. Mobile phones have the potential to serve as important conduits to mental health care in Africa. However, mobile phone use patterns and needs among young mothers in Nigeria are not well documented. Objective: This study sought to determine the prevalence of mobile phone use among perinatal adolescents and report patterns of use, as well as to assess the openness of young mothers to mobile health (mHealth) mental health interventions. Methods: We surveyed 260 adolescent mothers (ages 16-19 years) in their perinatal or postnatal periods of pregnancies in 33 primary health care clinics in Ibadan, Oyo State, Nigeria in 2020. Respondents were included if they were pregnant with a gestation age of greater than or equal to 4 weeks, or had babies (which they had birthed) that were younger than 12 months. Results: The total study sample consisted of 260 adolescent mothers with a mean age of 18.4 (SD 0.88) years. The majority of the respondents (233/260, 89.6%) owned mobile phones (eg, keypad, keypad and internet, smartphones); 22 (8.5%) of the 260 mothers had access to phones that belonged to relatives who lived in the same household, while 5 (1.9%) had access only to public paid phones. Only 23% (54/233) of phone owners (which is 20.5% of the total study population) had smartphones. On average, respondents reported first using mobile phones at 15.5 (SD 2.06) years old. The majority of respondents (222/260, 85.4%) reported using their phones for an average of 45 minutes daily for calls to family members. Facebook was the social media platform that was most often used among respondents who had phones with internet access (122/146 minutes per day, 83.4%). The majority of the sample responded as being “interested” and “very interested” in the use of mobile phones for preventive interventions (250/260, 96.2%) and treatment (243/260, 93.5%) information on mental illness such as depression and “hearing voices.” Half of the respondents (126/233, 50.4%) preferred to receive such information in the form of text messages. Conclusions: Findings from this study suggest that the vast majority of perinatal adolescents in Nigeria own and use mobile phones and that they are interested in leveraging these devices for prevention, treatment, and informational campaigns focused on mental health. The use of smartphones in this population is relatively low, and health intervention through text messages were favored by the women. %M 33496678 %R 10.2196/20314 %U http://mental.jmir.org/2021/1/e20314/ %U https://doi.org/10.2196/20314 %U http://www.ncbi.nlm.nih.gov/pubmed/33496678 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e24662 %T Association Between Care Utilization and Anxiety Outcomes in an On-Demand Mental Health System: Retrospective Observational Study %A Kunkle,Sarah %A Yip,Manny %A Hunt,Justin %A Ξ,Watson %A Udall,Dana %A Arean,Patricia %A Nierenberg,Andrew %A Naslund,John A %+ Ginger, 116 New Montgomery Street, San Francisco, CA, United States, 1 7175197355, sarah@ginger.io %K mental health %K digital health %K anxiety %K telehealth %K virtual care %K utilization %K outcome %K retrospective %K observational %D 2021 %7 26.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Anxiety is an extremely prevalent condition, and yet, it has received notably less attention than depression and other mental health conditions from a research, clinical, and public health perspective. The COVID-19 pandemic has only exacerbated growing concerns about the burden of anxiety due to the confluence of physical health risks, economic stressors, social isolation, and general disruption of daily activities. Objective: This study examines differences in anxiety outcomes by care modality (coaching, teletherapy and telepsychiatry, and combined care) within an on-demand mental health system. We also explore the association between levels of engagement within each care modality and odds of improvement in symptoms of anxiety. Methods: We conducted a retrospective observational study of individuals who accessed Ginger, an on-demand mental health system. Data were collected from 1611 Ginger members between January 1, 2018, and December 31, 2019. We used logistic regression to assess the association between care modality and improvement in anxiety symptoms. Within each modality, we assessed the association between level of engagement and improvement. Results: Of 1611 Ginger members, 761 (47.0%) experienced a decrease in anxiety symptoms, as measured by a change from a positive to a negative 2-item Generalized Anxiety Disorder (GAD-2) screen. Among members who still screened positive at follow-up (865/1611, 53%), a total of 192 members (11.9%) experienced a clinically significant score reduction in the full GAD-7 (ie, a score reduction of >5 points), even though their GAD-2 scores were still positive. All modalities showed increased odds of improvement compared to those who were not engaged with coaching or clinical services (“app-only”). Higher GAD-7 intake scores were also associated with decreased odds of improvement. Conclusions: This study found increased odds of anxiety improvement for all care modalities compared to those who did not engage in care, with larger effect sizes for higher utilization within all care modalities. Additionally, there is a promising observation that those engaged in combined care (teletherapy and text-based coaching) had the greatest odds of anxiety improvement. Future directions include more detailed classifications of utilization patterns and an exploration of explanations and solutions for lower-utilization members. %M 33496679 %R 10.2196/24662 %U http://formative.jmir.org/2021/1/e24662/ %U https://doi.org/10.2196/24662 %U http://www.ncbi.nlm.nih.gov/pubmed/33496679 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e24736 %T Examining a Digital Health Approach for Advancing Schizophrenia Illness Self-Management and Provider Engagement: Protocol for a Feasibility Trial %A Kidd,Sean %A McKenzie,Kwame %A Wang,Wei %A Agrawal,Sacha %A Voineskos,Aristotle %+ Department of Psychiatry, University of Toronto, CAMH, 1001 Queen Street West, 2-1, Toronto, ON, Canada, 1 647 239 1296, sean.kidd@camh.ca %K schizophrenia %K psychosis %K digital health %K mobile health %K smartphone %D 2021 %7 25.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: In schizophrenia spectrum populations, adherence to treatment is poor, community-based supports are limited, and efforts to foster illness self-management have had limited success. These challenges contribute to frequent, lengthy, and costly hospital readmissions and poor functional outcomes. Digital health strategies, in turn, hold considerable promise in the effort to address these problems. Objective: This feasibility trial will examine a digital health platform called App4Independence (A4i), which was designed to enhance illness self-management and treatment engagement for individuals with schizophrenia. Methods: Feasibility metrics in this single-blind, randomized trial include study recruitment and retention, rate of technology use, safety, and utility in clinical interactions. Other outcome metrics include symptomatology, treatment adherence, patient-provider alliance, and quality of life. In this trial, 160 study participants with schizophrenia spectrum diagnoses will be randomized to either treatment or control conditions, with pretest-posttest outcomes measured over a 6-month period. Results: This study was funded by the Canadian Institutes of Health Research in January 2020 and received Institutional Review Board approval on August 13, 2020. This study plans to begin recruiting in January 2021 and will be completed within 3 years. Data collection is projected to begin in January 2021. Conclusions: This research will provide critical information for the development of this new technology in the larger effort to address a key problem in the schizophrenia field—how to leverage technology to enhance illness self-management and care engagement in resource-limited service contexts. International Registered Report Identifier (IRRID): PRR1-10.2196/24736 %M 33492235 %R 10.2196/24736 %U http://www.researchprotocols.org/2021/1/e24736/ %U https://doi.org/10.2196/24736 %U http://www.ncbi.nlm.nih.gov/pubmed/33492235 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e21708 %T A Mobile App–Based Intervention Program for Nonprofessional Caregivers to Promote Positive Mental Health: Randomized Controlled Trial %A Ferré-Grau,Carme %A Raigal-Aran,Laia %A Lorca-Cabrera,Jael %A Lluch-Canut,Teresa %A Ferré-Bergadà,Maria %A Lleixá-Fortuño,Mar %A Puig-Llobet,Montserrat %A Miguel-Ruiz,Maria Dolores %A Albacar-Riobóo,Núria %+ Department of Nursing, Universitat Rovira i Virgili, 35, Catalunya Avenue, Tarragona, 43002, Spain, 34 977558000, laia.raigal@urv.cat %K clinical trial %K caregiver %K mobile phone app %K intervention program %K positive mental health %K mobile health %K health promotion %K randomized controlled trial %K nursing %K caregiving %K technology %D 2021 %7 22.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: While nonprofessional caregivers often experience a sense of fulfillment when they provide care, there is also a significant risk of emotional and physical burnout. Consequently, this can negatively affect both the caregiver and the person being cared for. Intervention programs can help empower nonprofessional caregivers of people with chronic diseases and develop solutions to decrease the physical and psychological consequences resulting from caregiving. However, most clinically tested intervention programs for nonprofessional caregivers require face-to-face training, and many caregivers encounter obstacles that hinder their participation in such programs. Consequently, it is necessary to design internet-based intervention programs for nonprofessional caregivers that address their needs and test the efficacy of the programs. Objective: The aim of this study was to evaluate the effectiveness of a smartphone app–based intervention program to increase positive mental health for nonprofessional caregivers. Methods: This study was a randomized controlled trial of 3 months’ duration. A total of 152 caregivers over 18 years of age with a minimum of 4 months’ experience as nonprofessional caregivers were recruited from primary health care institutions. Nonprofessional caregivers were randomized into two groups. In the intervention group, each caregiver installed a smartphone app and used it for 28 days. This app offered them daily activities that were based on 10 recommendations to promote positive mental health. The level of positive mental health, measured using the Positive Mental Health Questionnaire (PMHQ), and caregiver burden, measured using the 7-item short-form version of the Zarit Caregiver Burden Interview (ZBI-7), were the primary outcomes. Users’ satisfaction was also measured. Results: In all, 113 caregivers completed the study. After the first month of the intervention, only one factor of the PMHQ, F1–Personal satisfaction, showed a significant difference between the groups, but it was not clinically relevant (0.96; P=.03). However, the intervention group obtained a higher mean change for the overall PMHQ score (mean change between groups: 1.40; P=.24). The results after the third month of the intervention showed an increment of PMHQ scores. The mean difference of change in the PMHQ score showed a significant difference between the groups (11.43; P<.001; d=0.82). Significant changes were reported in 5 of the 6 factors, especially F5–Problem solving and self-actualization (5.69; P<.001; d=0.71), F2–Prosocial attitude (2.47; P<.001; d=1.18), and F3–Self-control (0.76; P=.03; d=0.50). The results of the ZBI-7 showed a decrease in caregiver burden in the intervention group, although the results were inconclusive. Approximately 93.9% (46/49) of the app users indicated that they would recommend the app to other caregivers and 56.3% (27/49) agreed that an extension of the program’s duration would be beneficial. Conclusions: The app-based intervention program analyzed in this study was effective in promoting positive mental health and decreasing the burden of caregivers and achieved a high range of user satisfaction. This study provides evidence that mobile phone app–based intervention programs may be useful tools for increasing nonprofessional caregivers’ well-being. The assessment of the effectiveness of intervention programs through clinical trials should be a focus to promote internet-based programs in health policies. Trial Registration: ISRCTN Registry ISRCTN14818443; http://www.isrctn.com/ISRCTN14818443 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-019-7264-5 %M 33480852 %R 10.2196/21708 %U http://mhealth.jmir.org/2021/1/e21708/ %U https://doi.org/10.2196/21708 %U http://www.ncbi.nlm.nih.gov/pubmed/33480852 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e25018 %T The Digital Marshmallow Test (DMT) Diagnostic and Monitoring Mobile Health App for Impulsive Behavior: Development and Validation Study %A Sobolev,Michael %A Vitale,Rachel %A Wen,Hongyi %A Kizer,James %A Leeman,Robert %A Pollak,J P %A Baumel,Amit %A Vadhan,Nehal P %A Estrin,Deborah %A Muench,Frederick %+ The Partnership to End Addiction, 485 Lexington Avenue, 3rd Floor, New York, NY, 10017, United States, 1 9175320623, fmuench@toendaddiction.org %K impulse control %K impulsivity %K self-regulation %K self-control %K mobile health %K mHealth %K ecological momentary assessment %K active task %K ResearchKit %D 2021 %7 22.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The classic Marshmallow Test, where children were offered a choice between one small but immediate reward (eg, one marshmallow) or a larger reward (eg, two marshmallows) if they waited for a period of time, instigated a wealth of research on the relationships among impulsive responding, self-regulation, and clinical and life outcomes. Impulsivity is a hallmark feature of self-regulation failures that lead to poor health decisions and outcomes, making understanding and treating impulsivity one of the most important constructs to tackle in building a culture of health. Despite a large literature base, impulsivity measurement remains difficult due to the multidimensional nature of the construct and limited methods of assessment in daily life. Mobile devices and the rise of mobile health (mHealth) have changed our ability to assess and intervene with individuals remotely, providing an avenue for ambulatory diagnostic testing and interventions. Longitudinal studies with mobile devices can further help to understand impulsive behaviors and variation in state impulsivity in daily life. Objective: The aim of this study was to develop and validate an impulsivity mHealth diagnostics and monitoring app called Digital Marshmallow Test (DMT) using both the Apple and Android platforms for widespread dissemination to researchers, clinicians, and the general public. Methods: The DMT app was developed using Apple’s ResearchKit (iOS) and Android’s ResearchStack open source frameworks for developing health research study apps. The DMT app consists of three main modules: self-report, ecological momentary assessment, and active behavioral and cognitive tasks. We conducted a study with a 21-day assessment period (N=116 participants) to validate the novel measures of the DMT app. Results: We used a semantic differential scale to develop self-report trait and momentary state measures of impulsivity as part of the DMT app. We identified three state factors (inefficient, thrill seeking, and intentional) that correlated highly with established measures of impulsivity. We further leveraged momentary semantic differential questions to examine intraindividual variability, the effect of daily life, and the contextual effect of mood on state impulsivity and daily impulsive behaviors. Our results indicated validation of the self-report sematic differential and related results, and of the mobile behavioral tasks, including the Balloon Analogue Risk Task and Go-No-Go task, with relatively low validity of the mobile Delay Discounting task. We discuss the design implications of these results to mHealth research. Conclusions: This study demonstrates the potential for assessing different facets of trait and state impulsivity during everyday life and in clinical settings using the DMT mobile app. The DMT app can be further used to enhance our understanding of the individual facets that underlie impulsive behaviors, as well as providing a promising avenue for digital interventions. Trial Registration: ClinicalTrials.gov NCT03006653; https://www.clinicaltrials.gov/ct2/show/NCT03006653 %M 33480854 %R 10.2196/25018 %U http://mhealth.jmir.org/2021/1/e25018/ %U https://doi.org/10.2196/25018 %U http://www.ncbi.nlm.nih.gov/pubmed/33480854 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 6 %N 1 %P e19088 %T Physical Activity Evaluation Using a Voice Recognition App: Development and Validation Study %A Namba,Hideyuki %+ Physical Education Lab., College of Science and Technology, Nihon University, 7-24-1 Narashinodai-Funabashi, Chiba, 274-8501, Japan, 81 47 469 5518, nanba.hideyuki@nihon-u.ac.jp %K voice recognition %K smartphone %K physical activity %K accelerometer %K application %D 2021 %7 21.1.2021 %9 Original Paper %J JMIR Biomed Eng %G English %X Background: Historically, the evaluation of physical activity has involved a variety of methods such as the use of questionnaires, accelerometers, behavior records, and global positioning systems, each according to the purpose of the evaluation. The use of web-based physical activity evaluation systems has been proposed as an easy method for collecting physical activity data. Voice recognition technology not only eliminates the need for questionnaires during physical activity evaluation but also enables users to record their behavior without physically touching electronic devices. The use of a web-based voice recognition system might be an effective way to record physical activity and behavior. Objective: The purpose of this study was to develop a physical activity evaluation app to record behavior using voice recognition technology and to examine the app’s validity by comparing data obtained using both the app and an accelerometer simultaneously. Methods: A total of 20 participants (14 men, 6 women; mean age 19.1 years, SD 0.9) wore a 3-axis accelerometer and inputted behavioral data into their smartphones for a period of 7 days. We developed a behavior-recording system with a voice recognition function using a voice recognition application programming interface. The exercise intensity was determined from the text data obtained by the voice recognition program. The measure of intensity was metabolic equivalents (METs). Results: From the voice input data of the participants, 601 text-converted data could be confirmed, of which 471 (78.4%) could be automatically converted into behavioral words. In the time-matched analysis, the mean daily METs values measured by the app and the accelerometer were 1.64 (SD 0.20) and 1.63 (SD 0.20), respectively, between which there was no significant difference (P=.57). There was a significant correlation between the average METs obtained from the voice recognition app and the accelerometer in the time-matched analysis (r=0.830, P<.001). In the Bland-Altman plot for METs measured by the voice recognition app as compared with METs measured by accelerometer, the mean difference between the two methods was very small (0.02 METs), with 95% limits of agreement from –0.26 to 0.22 METs between the two methods. Conclusions: The average METs value measured by the voice recognition app was consistent with that measured by the 3-axis accelerometer and, thus, the data gathered by the two measurement methods showed a high correlation. The voice recognition method also demonstrated the ability of the system to measure the physical activity of a large number of people at the same time with less burden on the participants. Although there were still issues regarding the improvement of automatic text data classification technology and user input compliance, this research proposes a new method for evaluating physical activity using voice recognition technology. %R 10.2196/19088 %U http://biomedeng.jmir.org/2021/1/e19088/ %U https://doi.org/10.2196/19088 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e23778 %T Comparing Effectiveness Between a Mobile App Program and Traditional Cognitive Behavior Therapy in Obsessive-Compulsive Disorder: Evaluation Study %A Hwang,Hyunchan %A Bae,Sujin %A Hong,Ji Sun %A Han,Doug Hyun %+ Department of Psychiatry, Chung-Ang University Hospital, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Republic of Korea, 82 262993132, hduk70@gmail.com %K obsessive-compulsive disorder %K exposure and response prevention %K cognitive behavior therapy %K cortico-striato-thalamo-cortical tract %K functional connectivity %K prevention %K cognitive %K mental illness %K behavior therapy %D 2021 %7 19.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: This study proposes a digital program for the treatment of mental illness that could increase motivation and improve learning outcomes for patients. Several studies have already applied this method by using an exposure and response prevention–inspired serious game to treat patients with obsessive-compulsive disorder (OCD). Objective: We hypothesized that a mobile cognitive behavior therapy (CBT) program would be as effective in treating OCD as traditional offline CBT. In addition, the treatment efficacy in response to mobile CBT for OCD might be associated with increased brain activity within the cortico-striato-thalamo-cortical (CSTC) tract. Methods: The digital CBT treatment program for OCD, OCfree, consists of 6 education sessions, 10 quests, and 7 casual games. Information was gathered from 27 patients with OCD (15 offline CBT and 12 OCfree CBT). During the 6-week intervention period, changes in clinical symptoms and brain function activity were analyzed. Results: There was no significant difference in the change in OCD symptoms and depressive symptoms between the two groups. However, the OCfree group showed greater improvement in anxiety symptoms compared to the offline CBT group. Both offline CBT and OCfree CBT increased the functional connectivity within the CSTC tract in all patients with OCD. However, CBT using OCfree showed greater changes in brain connectivity within the thalamus and insula, compared to offline CBT. Conclusions: OCfree, an OCD treatment app program, was effective in the treatment of drug-naïve patients with OCD. The treatment effects of OCfree are associated with increased brain connectivity within the CSTC tract. Multisensory stimulation by education, quests, and games in OCfree increases the activity within the thalamus and insula in patients with OCD. %M 33464208 %R 10.2196/23778 %U http://mental.jmir.org/2021/1/e23778/ %U https://doi.org/10.2196/23778 %U http://www.ncbi.nlm.nih.gov/pubmed/33464208 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 1 %P e16054 %T Electromyography-Driven Exergaming in Wheelchairs on a Mobile Platform: Bench and Pilot Testing of the WOW-Mobile Fitness System %A Enciso,James %A Variya,Dhruval %A Sunthonlap,James %A Sarmiento,Terrence %A Lee,Ka Mun %A Velasco,James %A Pebdani,Roxanna N %A de Leon,Ray D %A Dy,Christine %A Keslacy,Stefan %A Won,Deborah Soonmee %+ Department of Electrical and Computer Engineering, California State University, Los Angeles, 5151 State University Dr., Los Angeles, CA, 90032, United States, 1 323 343 5908, dwon@calstatela.edu %K exergaming %K gamercising %K mobile health %K wheelchair exercises %K wireless electromyography %K mobile phone %D 2021 %7 19.1.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Implementing exercises in the form of video games, otherwise known as exergaming, has gained recent attention as a way to combat health issues resulting from sedentary lifestyles. However, these exergaming apps have not been developed for exercises that can be performed in wheelchairs, and they tend to rely on whole-body movements. Objective: This study aims to develop a mobile phone app that implements electromyography (EMG)-driven exergaming, to test the feasibility of using this app to enable people in wheelchairs to perform exergames independently and flexibly in their own home, and to assess the perceived usefulness and usability of this mobile health system. Methods: We developed an Android mobile phone app (Workout on Wheels, WOW-Mobile) that senses upper limb muscle activity (EMG) from wireless body-worn sensors to drive 3 different video games that implement upper limb exercises designed for people in wheelchairs. Cloud server recordings of EMG enabled long-term monitoring and feedback as well as multiplayer gaming. Bench testing of data transmission and power consumption were tested. Pilot testing was conducted on 4 individuals with spinal cord injury. Each had a WOW-Mobile system at home for 8 weeks. We measured the minutes for which the app was used and the exergames were played, and we integrated EMG as a measure of energy expended. We also conducted a perceived usefulness and usability questionnaire. Results: Bench test results revealed that the app meets performance specifications to enable real-time gaming, cloud storage of data, and live cloud server transmission for multiplayer gaming. The EMG sampling rate of 64 samples per second, in combination with zero-loss data communication with the cloud server within a 10-m range, provided seamless control over the app exergames and allowed for offline data analysis. Each participant successfully used the WOW-Mobile system at home for 8 weeks, using the app for an average of 146 (range 89-267) minutes per week with the system, actively exergaming for an average of 53% of that time (39%-59%). Energy expenditure, as measured by integrated EMG, was found to be directly proportional to the time spent on the app (Pearson correlation coefficient, r=0.57-0.86, depending on the game). Of the 4 participants, 2 did not exercise regularly before the study; these 2 participants increased from reportedly exercising close to 0 minutes per week to exergaming 58 and 158 minutes on average using the WOW-Mobile fitness system. The perceived usefulness of WOW-Mobile in motivating participants to exercise averaged 4.5 on a 5-point Likert scale and averaged 5 for the 3 participants with thoracic level injuries. The mean overall ease of use score was 4.25 out of 5. Conclusions: Mobile app exergames driven by EMG have promising potential for encouraging and facilitating fitness for individuals in wheelchairs who have maintained arm and hand mobility. %M 33464221 %R 10.2196/16054 %U http://rehab.jmir.org/2021/1/e16054/ %U https://doi.org/10.2196/16054 %U http://www.ncbi.nlm.nih.gov/pubmed/33464221 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e16282 %T Unraveling Mobile Health Exercise Interventions for Adults: Scoping Review on the Implementations and Designs of Persuasive Strategies %A Sporrel,Karlijn %A Nibbeling,Nicky %A Wang,Shihan %A Ettema,Dick %A Simons,Monique %+ Faculty of Geosciences, Utrecht University, PO Box 80115, Princetonlaan 8a, Utrecht, 3584 CB, Netherlands, 31 642514287, k.sporrel@uu.nl %K mobile health %K physical activity %K goals %K feedback %K rewards %K reminder systems %K social support %K adult %D 2021 %7 18.1.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: It is unclear why some physical activity (PA) mobile health (mHealth) interventions successfully promote PA whereas others do not. One possible explanation is the variety in PA mHealth interventions—not only do interventions differ in the selection of persuasive strategies but also the design and implementation of persuasive strategies can vary. However, limited studies have examined the different designs and technical implementations of strategies or explored if they indeed influenced the effectiveness of the intervention. Objective: This scoping review sets out to explore the different technical implementations and design characteristics of common and likely most effective persuasive strategies, namely, goal setting, monitoring, reminders, rewards, sharing, and social comparison. Furthermore, this review aims to explore whether previous mHealth studies examined the influence of the different design characteristics and technical operationalizations of common persuasive strategies on the effectiveness of the intervention to persuade the user to engage in PA. Methods: An unsystematic snowball and gray literature search was performed to identify the literature that evaluated the persuasive strategies in experimental trials (eg, randomized controlled trial, pre-post test). Studies were included if they targeted adults, if they were (partly) delivered by a mobile system, if they reported PA outcomes, if they used an experimental trial, and when they specifically compared the effect of different designs or implementations of persuasive strategies. The study methods, implementations, and designs of persuasive strategies, and the study results were systematically extracted from the literature by the reviewers. Results: A total of 29 experimental trials were identified. We found a heterogeneity in how the strategies are being implemented and designed. Moreover, the findings indicated that the implementation and design of the strategy has an influence on the effectiveness of the PA intervention. For instance, the effectiveness of rewarding was shown to vary between types of rewards; rewarding goal achievement seems to be more effective than rewarding each step taken. Furthermore, studies comparing different ways of goal setting suggested that assigning a goal to users might appear to be more effective than letting the user set their own goal, similar to using adaptively tailored goals as opposed to static generic goals. This study further demonstrates that only a few studies have examined the influence of different technical implementations on PA behavior. Conclusions: The different implementations and designs of persuasive strategies in mHealth interventions should be critically considered when developing such interventions and before drawing conclusions on the effectiveness of the strategy as a whole. Future efforts are needed to examine which implementations and designs are most effective to improve the translation of theory-based persuasive strategies into practical delivery forms. %M 33459598 %R 10.2196/16282 %U http://mhealth.jmir.org/2021/1/e16282/ %U https://doi.org/10.2196/16282 %U http://www.ncbi.nlm.nih.gov/pubmed/33459598 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e20819 %T A Mindfulness-Based Brain-Computer Interface to Augment Mandala Coloring for Depression: Protocol for a Single-Case Experimental Design %A Daudén Roquet,Claudia %A Sas,Corina %+ School of Computing and Communications, Lancaster University, InfoLab21, Lancaster University, Lancaster, LA1 4WA, United Kingdom, 44 01524510321, c.daudenroquet1@lancaster.ac.uk %K brain-computer interface %K mental well-being %K depression %K mindfulness %K mandala coloring %D 2021 %7 18.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The regular practice of mindfulness has been shown to provide benefits for mental well-being and prevent depression relapse. Technology-mediated interventions can facilitate the uptake and sustained practice of mindfulness, yet the evaluation of interactive systems, such as brain-computer interfaces, has been little explored. Objective: The objective of this paper is to present an interactive mindfulness-based technology to improve mental well-being in people who have experienced depression. The system, Anima, is a brain-computer interface that augments mandala coloring by providing a generative color palette based on the unfolding mindfulness states during the practice. In addition, this paper outlines a multiple-baseline, single-case experimental design methodology to evaluate training effectiveness. Methods: Adult participants who have experienced depression in the past, have finished treatment within the last year, and can provide informed consent will be able to be recruited. The Anima system, consisting of 2 tablets and a nonintrusive mental activity headband, will be delivered to participants to use during the study. Measures include state and trait mindfulness, depression symptoms, mental well-being, and user experience, and these measures will be taken throughout the baseline, intervention, and monitoring phases. The data collection will take place in the form of a questionnaire before and after each mandala-coloring session and a semistructured interview every 2 weeks. Trial results will be analyzed using structured visual analysis, supplemented with statistical analysis appropriate to single-case methodology. Results: Study results will offer new insights into the deployment and evaluation of novel interactive brain-computer interfaces for mindfulness training in the context of mental health. Moreover, findings will validate the effectiveness of this training protocol to improve the mental well-being of people who have had depression. Participants will be recruited locally through the National Health Service. Conclusions: Evidence will assist in the design and evaluation of brain-computer interfaces and mindfulness technologies for mental well-being and the necessary services to support people who have experienced depression. International Registered Report Identifier (IRRID): PRR1-10.2196/20819 %M 33459604 %R 10.2196/20819 %U http://www.researchprotocols.org/2021/1/e20819/ %U https://doi.org/10.2196/20819 %U http://www.ncbi.nlm.nih.gov/pubmed/33459604 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e19506 %T Optimizing an Obesity Treatment Using the Multiphase Optimization Strategy Framework: Protocol for a Randomized Factorial Trial %A Bennett,Gary G %A Steinberg,Dori %A Bolton,Jamiyla %A Gallis,John A %A Treadway,Cayla %A Askew,Sandy %A Kay,Melissa C %A Pollak,Kathryn I %A Turner,Elizabeth L %+ Duke Global Health Institute, Duke University, 310 Trent Drive, Room 236, Durham, NC, 27708, United States, 1 9193954119, jamiyla.bolton@duke.edu %K text message %K digital health %K weight loss %K personalized %D 2021 %7 18.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Effective weight loss interventions exist, yet few can be scaled up for wide dissemination. Further, none has been fully delivered via text message. We used the multiphase optimization strategy (MOST) to develop multicomponent interventions that consist only of active components, those that have been experimentally determined to impact the chosen outcome. Objective: The goal of this study is to optimize a standalone text messaging obesity intervention, Charge, using the MOST framework to experimentally determine which text messaging components produce a meaningful contribution to weight change at 6 months. Methods: We designed a 6-month, weight loss texting intervention based on our interactive obesity treatment approach (iOTA). Participants are randomized to one of 32 experimental conditions to test which standalone text messaging intervention components produce a meaningful contribution to weight change at 6 months. Results: The project was funded in February 2017; enrollment began in January 2018 and data collection was completed in June 2019. Data analysis is in progress and first results are expected to be submitted for publication in 2021. Conclusions: Full factorial trials are particularly efficient in terms of cost and logistics when leveraged for standalone digital treatments. Accordingly, MOST has the potential to promote the rapid advancement of digital health treatments. Subject to positive findings, the intervention will be low cost, immediately scalable, and ready for dissemination. This will be of great potential use to the millions of Americans with obesity and the providers who treat them. Trial Registration: ClinicalTrials.gov NCT03254940; https://clinicaltrials.gov/ct2/show/NCT03254940 International Registered Report Identifier (IRRID): RR1-10.2196/19506 %M 33459600 %R 10.2196/19506 %U http://www.researchprotocols.org/2021/1/e19506/ %U https://doi.org/10.2196/19506 %U http://www.ncbi.nlm.nih.gov/pubmed/33459600 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e23771 %T Technology Enabled Clinical Care (TECC): Protocol for a Prospective Longitudinal Cohort Study of Smartphone-Augmented Mental Health Treatment %A Rauseo-Ricupero,Natali %A Torous,John %+ Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Rabb Building, Boston, MA, 02446, United States, 1 617 667 6700, jtorous@bidmc.harvard.edu %K mental health care %K access %K multi-language %K smartphone %K app %K quality improvement %K protocol %K mental health %K treatment %K acceptability %K efficacy %K COVID-19 %D 2021 %7 14.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Even before COVID-19, there has been an urgent need to expand access to and quality of mental health care. This paper introduces an 8-week treatment protocol to realize that vision—Technology Enabled Clinical Care (TECC). TECC offers innovation in clinical assessment, monitoring, and interventions for mental health. TECC uses the mindLAMP app to enable digital phenotyping, clinical communication, and smartphone-based exercises that will augment in-person or telehealth virtual visits. TECC exposes participants to an array of evidence-based treatments (cognitive behavioral therapy, dialectical behavior therapy, acceptance and commitment therapy) introduced through clinical sessions and then practiced through interactive activities provided through a smartphone app called mindLAMP. Objective: TECC will test the feasibility of providing technology-enabled mental health care within an outpatient clinic; explore the practicality for providing this care to individuals with limited English proficiency; and track anxiety, depression, and mood symptoms for participants to measure the effectiveness of the TECC design. Methods: The TECC study will assess the acceptability and efficacy of this care model in 50 participants as compared to an age- and gender-matched cohort of patients presenting with similar clinical severity of depression, anxiety, or psychotic symptoms. Participants will be recruited from clinics in the Metro Boston area. Aspects of TECC will be conducted in both Spanish and English to ensure wide access to care for multiple populations. Results: The results of the TECC study will be used to support or adapt this model of care and create training resources to ensure its dissemination. The study results will be posted on ClinicalTrials.gov, with primary outcomes related to changes in mood, anxiety, and stress, and secondary outcomes related to engagement, alliance, and satisfaction. Conclusions: TECC combines new digital mental health technology with updated clinical protocols and workflows designed to ensure patients can benefit from innovation in digital mental health. Supporting multiple languages, TECC is designed to ensure digital health equity and highlights how mobile health can bridge, not expand, gaps in care for underserved populations. International Registered Report Identifier (IRRID): PRR1-10.2196/23771 %M 33296869 %R 10.2196/23771 %U https://www.researchprotocols.org/2021/1/e23771 %U https://doi.org/10.2196/23771 %U http://www.ncbi.nlm.nih.gov/pubmed/33296869 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e24807 %T A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial %A Röhr,Susanne %A Jung,Franziska U %A Pabst,Alexander %A Grochtdreis,Thomas %A Dams,Judith %A Nagl,Michaela %A Renner,Anna %A Hoffmann,Rahel %A König,Hans-Helmut %A Kersting,Anette %A Riedel-Heller,Steffi G %+ Institute of Social Medicine, Occupational Health and Public Health, Medical Faculty, University of Leipzig, Philipp-Rosenthal-Strasse 55, Leipzig, Germany, 49 341 97 24568, susanne.roehr@medizin.uni-leipzig.de %K app %K cost-utility analysis %K mHealth %K posttraumatic stress %K PTSD %K quality-adjusted life years %K randomized controlled trial %K refugees %K stimga %K Syrian refugees %K usability %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress. Objective: The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. Methods: In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. Results: Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay. Conclusions: Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. Trial Registration: German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2110-y %M 33439140 %R 10.2196/24807 %U http://mhealth.jmir.org/2021/1/e24807/ %U https://doi.org/10.2196/24807 %U http://www.ncbi.nlm.nih.gov/pubmed/33439140 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e24467 %T The Human Factor in Automated Image-Based Nutrition Apps: Analysis of Common Mistakes Using the goFOOD Lite App %A Vasiloglou,Maria F %A van der Horst,Klazine %A Stathopoulou,Thomai %A Jaeggi,Michael P %A Tedde,Giulia S %A Lu,Ya %A Mougiakakou,Stavroula %+ ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, Bern, 3008, Switzerland, 41 6327592, stavroula.mougiakakou@artorg.unibe.ch %K mHealth %K dietary assessment %K smartphone %K apps %K human mistakes %K mobile phone %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Technological advancements have enabled nutrient estimation by smartphone apps such as goFOOD. This is an artificial intelligence–based smartphone system, which uses food images or video captured by the user as input and then translates these into estimates of nutrient content. The quality of the data is highly dependent on the images the user records. This can lead to a major loss of data and impaired quality. Instead of removing these data from the study, in-depth analysis is needed to explore common mistakes and to use them for further improvement of automated apps for nutrition assessment. Objective: The aim of this study is to analyze common mistakes made by participants using the goFOOD Lite app, a version of goFOOD, which was designed for food-logging, but without providing results to the users, to improve both the instructions provided and the automated functionalities of the app. Methods: The 48 study participants were given face-to-face instructions for goFOOD Lite and were asked to record 2 pictures (1 recording) before and 2 pictures (1 recording) after the daily consumption of each food or beverage, using a reference card as a fiducial marker. All pictures that were discarded for processing due to mistakes were analyzed to record the main mistakes made by users. Results: Of the 468 recordings of nonpackaged food items captured by the app, 60 (12.8%) had to be discarded due to errors in the capturing procedure. The principal problems were as follows: wrong fiducial marker or improper marker use (19 recordings), plate issues such as a noncompatible or nonvisible plate (8 recordings), a combination of various issues (17 recordings), and other reasons such as obstacles (hand) in front of the camera or matching recording pairs (16 recordings). Conclusions: No other study has focused on the principal problems in the use of automatic apps for assessing nutritional intake. This study shows that it is important to provide study participants with detailed instructions if high-quality data are to be obtained. Future developments could focus on making it easier to recognize food on various plates from its color or shape and on exploring alternatives to using fiducial markers. It is also essential for future studies to understand the training needed by the participants as well as to enhance the app’s user-friendliness and to develop automatic image checks based on participant feedback. %M 33439139 %R 10.2196/24467 %U http://mhealth.jmir.org/2021/1/e24467/ %U https://doi.org/10.2196/24467 %U http://www.ncbi.nlm.nih.gov/pubmed/33439139 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e21094 %T Feasibility, Usability, and Enjoyment of a Home-Based Exercise Program Delivered via an Exercise App for Musculoskeletal Health in Community-Dwelling Older Adults: Short-term Prospective Pilot Study %A Daly,Robin M %A Gianoudis,Jenny %A Hall,Travis %A Mundell,Niamh L %A Maddison,Ralph %+ Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, Melbourne, 3125, Australia, 61 392446040, rmdaly@deakin.edu.au %K home exercise %K multicomponent exercise %K mobile health %K musculoskeletal %K adherence %K usability %K older adults %K physical activity enjoyment %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Many older adults choose and prefer to exercise at home, but to attain the greatest benefits, the correct type and dose of exercise should be prescribed and adherence maintained. Advances in digital health technologies now provide the opportunity for exercise professionals to deliver and monitor personalized, evidence-based exercise programs to anyone at any time. Objective: The aim of this study was to evaluate the feasibility, usability, and enjoyment of a web-based exercise prescription app as a platform for exercise professionals to remotely deliver and monitor an individually tailored, home-based multicomponent exercise program (delivered through tablet computers) to older adults living independently in the community. Methods: This was an 8-week, prospective single-arm pilot study in 20 adults aged ≥65 years living independently in the community: 10 owned a tablet computer (tablet owners) and 10 did not own tablets (tablet nonowners). All participants were prescribed a home-based, muscle strengthening, weight-bearing impact and challenging balance/mobility program (3 days/week) using a commercial exercise prescription app on a tablet computer. Study endpoints were feasibility (retention, adherence, adverse events), usability (System Usability Scale), physical activity enjoyment (Physical Activity Enjoyment Scale), changes in lower extremity function (Short Physical Performance Battery [SPPB]), and level of physical activity (questionnaire). Process measures related to the participants' experiences and perceptions of the exercise program and web-based app were also included. Results: A total of 19 participants (mean age, 70 years) completed the study (19/20, 95%), and mean adherence to the exercise program was 84% (95% CI 70%-97%). There were 2 minor adverse events in 2 participants from 401 completed sessions. Mean weekly walking time increased by 78 minutes (95% CI 0-156, P=.049) and moderate-to-vigorous physical activity time by 41 minutes (95% CI –8 to 90, P=.09). For SPPB scores, there was a 0.3 point (95% CI –0.1 to 0.7, P=.17) modest sized (effect size, d=0.42) improvement after 8 weeks. Mean (SD) system usability was high (86 [10] with 100 best imaginable). There was no change in the overall physical activity enjoyment scores after 8 weeks, but participants reported that they enjoyed using the web-based exercise app and the exercise program (median score 4 on a 5-point Likert scale). For all measures, there were no differences between previous tablet owners and nonowners. Conclusions: This pilot feasibility study indicates that it is safe and feasible for community-dwelling older adults to participate in a home-based, multicomponent exercise program targeting musculoskeletal health and function that was delivered and monitored remotely by exercise professionals using a tablet-based exercise prescription app. %M 33439147 %R 10.2196/21094 %U http://mhealth.jmir.org/2021/1/e21094/ %U https://doi.org/10.2196/21094 %U http://www.ncbi.nlm.nih.gov/pubmed/33439147 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e19958 %T Mobile Apps for Dental Caries Prevention: Systematic Search and Quality Evaluation %A Chen,Rebecca %A Santo,Karla %A Wong,Grace %A Sohn,Woosung %A Spallek,Heiko %A Chow,Clara %A Irving,Michelle %+ Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, REN Building, Darcy Road, Westmead, 2145, Australia, 61 8890 3125, rebecca.chen@sydney.edu.au %K dental caries %K oral hygiene %K self-management %K mobile applications %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Dental caries is the most common multifactorial oral disease; it affects 60% to 90% of the global population. Dental caries is highly preventable through prevention behaviors aimed at improving oral hygiene, adequate fluoride usage, and dietary intake. Mobile apps have the potential to support patients with dental caries; however, little is known about the availability, target audience, quality, and features of these apps. Objective: This review aims to systematically examine dental caries prevention apps; to describe their content, availability, target audience, and features; and to assess their quality. Methods: We systematically identified and evaluated apps in a process paralleling a systematic review. This included a search strategy using search terms; an eligibility assessment using inclusion and exclusion criteria focused on accessibility and dental caries self-management behaviors, including oral hygiene, dietary intake, and fluoride usage; data extraction on app characteristics, including app store metrics; prevention behavior categorization; feature identification and description; a quality appraisal of all apps using the validated Mobile App Rating Scale (MARS) assessment tool; and data comparison and analysis. Results: Using our search strategy, we retrieved 562 apps from the Google Play Store and iTunes available in Australia. Of these, 7.1% (40/562) of the apps fit our eligibility criteria, of which 55% (22/40) targeted adults, 93% (37/40) were free to download, and 65% (26/40) were recently updated. Oral hygiene was the most common dental caries prevention behavior domain, addressed in 93% (37/40) of the apps, while dietary intake was addressed in 45% (18/40) of the apps and fluoride usage was addressed in 42% (17/40) of the apps. Overall, 50% (20/40) of the apps addressed only 1 behavior, and 38% (15/40) of the apps addressed all 3 behaviors. The mean MARS score was 2.9 (SD 0.7; range 1.8-4.4), with 45% (18/40) of the apps categorized as high quality, with a rating above 3.0 out of 5.0. We identified 21 distinctive features across all dental caries prevention behaviors; however, the top 5 most common features focused on oral hygiene. The highest-ranking app was the Brush DJ app, with an overall MARS score of 4.4 and with the highest number of features (n=13). We did not find any apps that adequately addressed dental caries prevention behaviors in very young children. Conclusions: Apps addressing dental caries prevention commonly focus on oral hygiene and target young adults; however, many are not of high quality. These apps use a range of features to support consumer engagement, and some of these features may be helpful for specific patient populations. However, it remains unclear how effective these apps are in improving dental caries outcomes, and further evaluation is required before they are widely recommended. %M 33439141 %R 10.2196/19958 %U http://mhealth.jmir.org/2021/1/e19958/ %U https://doi.org/10.2196/19958 %U http://www.ncbi.nlm.nih.gov/pubmed/33439141 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e22575 %T Participant Engagement in a Transmedia Storytelling Web-Based App Intervention for Mental Health of Latina Women: Qualitative Analysis %A Soderlund,Patricia D %A Martinez Hollingsworth,Adrienne S %A Heilemann,MarySue V %+ School of Nursing, University of California, Los Angeles, Factor Building, Box 6919, Los Angeles, CA, 90095-6919, United States, 1 310 206 4735, mheilema@sonnet.ucla.edu %K transmedia %K Latina %K mental health %K mobile applications %K internet %K depression %K anxiety %K storytelling %K mobile phone %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Stigma, fear, and lack of knowledge regarding treatment options or where to get help create delays for Latina women in accessing needed mental health help. Story-based media interventions hold appeal for Latina women. Thus, we drew upon the Social Cognitive Theory by Bandura to create an evidence-based, transmedia storytelling web-based app for mental health called Catalina: Confronting My Emotions to connect Latina women to a curated set of mental health resources. Understanding how Latina women perceive various aspects of the web-based app will help design future expansions. Objective: A previously published analysis led to the development of a category on how participants related to the lead character (Catalina) in the story line of the web-based app as a real person. However, the purpose of this analysis was to gain an understanding of participants’ experiences with the extension of the dramatic story line of the web-based app beyond Catalina to a Latina nurse-therapist character named Veronica, who was featured prominently in the app’s interactive content and bonus videos. Methods: Qualitative analyses were conducted with interview data from a community-based sample of 28 English-speaking Latina women aged between 21 and 50 years who scored above the threshold for anxiety (Generalized Anxiety Disorder-7) and/or depression (Patient Health Questionnaire-9) but were not suicidal at screening. Data were collected 72 hours after participants engaged with our transmedia storytelling web-based app for mental health. Grounded theory methodology guided the analysis and interpretation of data that had been collected telephonically, recorded, and transcribed with identifiers removed. Analyses included initial and focused coding using process codes (gerund form of verbs in codes focused on action), informed by symbolic interactionism, and the development of categories with properties through constant comparison, memo writing, and the use of charts and diagrams. Results: Our participants experienced a multiphase process that was most heavily related to Veronica, the Latina nurse-therapist character in our web-based app, who led them through a process to a place of action. We conceptualized this process as moving from passive viewer to active participant of a transmedia storytelling web-based app intervention. Overall, 3 new conceptual categories provided insight into women’s experiences, including encountering a trustworthy nurse-therapist character, taking in messages that dispel old beliefs, and preparing when and how to take action. Each category has nuanced properties that reflect participants’ experiences. Conclusions: Active engagement with our web-based app led our sample to successfully transition from the viewpoint of the observer to the viewpoint of the experiencer, moving from a passive position of watching to active engagement that involved imagining, thinking, reflecting, and acting. Careful development of dramatic material for health-related web-based apps using transmedia story extension and bonus videos needs to be based on input from the target group from the start of development through evaluation and testing. %M 33439137 %R 10.2196/22575 %U http://mental.jmir.org/2021/1/e22575/ %U https://doi.org/10.2196/22575 %U http://www.ncbi.nlm.nih.gov/pubmed/33439137 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 7 %N 1 %P e16785 %T Effects and Implementation of a Mindfulness and Relaxation App for Patients With Cancer: Mixed Methods Feasibility Study %A Mikolasek,Michael %A Witt,Claudia Margitta %A Barth,Jürgen %+ Institute for Complementary and Integrative Medicine, University Hospital Zurich and University of Zurich, Sonneggstrasse 6, Zurich, 8091, Switzerland, 41 44 255 51 49, michael.mikolasek@usz.ch %K mobile app %K mobile phone %K mindfulness %K relaxation %K cancer %K qualitative research %K implementation science %K mHealth %K evaluation study %K patient compliance %K patient participation %K patient preference %D 2021 %7 13.1.2021 %9 Original Paper %J JMIR Cancer %G English %X Background: Cancer diagnosis and cancer treatment can cause high levels of distress, which is often not sufficiently addressed in standard medical care. Therefore, a variety of supportive nonpharmacological treatments have been suggested to reduce distress in patients with cancer. However, not all patients use these interventions because of limited access or lack of awareness. To overcome these barriers, mobile health may be a promising way to deliver the respective supportive treatments. Objective: The aim of this study is to evaluate the effects and implementation of a mindfulness and relaxation app intervention for patients with cancer as well as patients’ adherence to such an intervention. Methods: In this observational feasibility study with a mixed methods approach, patients with cancer were recruited through the web and through hospitals in Switzerland. All enrolled patients received access to a mindfulness and relaxation app. Patients completed self-reported outcomes (general health, health-related quality of life, anxiety, depression, distress, mindfulness, and fear of progression) at baseline and at weeks 4, 10, and 20. The frequency of app exercise usage was gathered directly through the app to assess the adherence of patients. In addition, we conducted interviews with 5 health professionals for their thoughts on the implementation of the app intervention in standard medical care. We analyzed patients’ self-reported outcomes using linear mixed models (LMMs) and qualitative data with content analysis. Results: A total of 100 patients with cancer (74 female) with a mean age of 53.2 years (SD 11.6) participated in the study, of which 25 patients used the app regularly until week 20. LMM analyses revealed improvements in anxiety (P=.04), distress (P<.001), fatigue (P=.01), sleep disturbance (P=.02), quality of life (P=.03), and mindfulness (P<.001) over the course of 20 weeks. Further LMM analyses revealed a larger improvement in distress (P<.001), a moderate improvement in anxiety (P=.001), and a larger improvement in depression (P=.03) in patients with high levels of symptoms at baseline in the respective domains. The interviews revealed that the health professionals perceived the app as a helpful addition to standard care. They also made suggestions for improvements, which could facilitate the implementation of and adherence to such an app. Conclusions: This study indicates that a mindfulness and relaxation app for patients with cancer can be a feasible and effective way to deliver a self-care intervention, especially for highly distressed patients. Future studies should investigate if the appeal of the app can be increased with more content, and the effectiveness of such an intervention needs to be tested in a randomized controlled trial. %M 33439132 %R 10.2196/16785 %U https://cancer.jmir.org/2021/1/e16785 %U https://doi.org/10.2196/16785 %U http://www.ncbi.nlm.nih.gov/pubmed/33439132 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e24806 %T Wrist-Worn Activity Trackers in Laboratory and Free-Living Settings for Patients With Chronic Pain: Criterion Validity Study %A Sjöberg,Veronica %A Westergren,Jens %A Monnier,Andreas %A Lo Martire,Riccardo %A Hagströmer,Maria %A Äng,Björn Olov %A Vixner,Linda %+ School of Education, Health and Social Studies, Dalarna University, Högskolegatan 2, Falun, SE-791 88, Sweden, 46 23 77 87 57, vsj@du.se %K chronic pain %K energy expenditure %K heart rate %K physical activity %K step count %K validity %K wearable devices %K wearable %K pain %K rehabilitation %D 2021 %7 12.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Physical activity is evidently a crucial part of the rehabilitation process for patients with chronic pain. Modern wrist-worn activity tracking devices seemingly have a great potential to provide objective feedback and assist in the adoption of healthy physical activity behavior by supplying data of energy expenditure expressed as metabolic equivalent of task units (MET). However, no studies of any wrist-worn activity tracking devices’ have examined criterion validity in estimating energy expenditure, heart rate, or step count in patients with chronic pain. Objective: The aim was to determine the criterion validity of wrist-worn activity tracking devices for estimations of energy expenditure, heart rate, and step count in a controlled laboratory setting and free-living settings for patients with chronic pain. Methods: In this combined laboratory and field validation study, energy expenditure, heart rate, and step count were simultaneously estimated by a wrist-worn activity tracker (Fitbit Versa), indirect calorimetry (Jaeger Oxycon Pro), and a research-grade hip-worn accelerometer (ActiGraph GT3X) during treadmill walking at 3 speeds (3.0 km/h, 4.5 km/h, and 6.0 km/h) in the laboratory setting. Energy expenditure and step count were also estimated by the wrist-worn activity tracker in free-living settings for 72 hours. The criterion validity of each measure was determined using intraclass and Spearman correlation, Bland-Altman plots, and mean absolute percentage error. An analysis of variance was used to determine whether there were any significant systematic differences between estimations. Results: A total of 42 patients (age: 25-66 years; male: 10/42, 24%; female: 32/42, 76%), living with chronic pain (duration, in years: mean 9, SD 6.72) were included. At baseline, their mean pain intensity was 3.5 (SD 1.1) out of 6 (Multidimensional Pain Inventory, Swedish version). Results showed that the wrist-worn activity tracking device (Fitbit Versa) systematically overestimated energy expenditure when compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X). Poor agreement and poor correlation were shown between Fitbit Versa and both Jaeger Oxycon Pro and ActiGraph GT3X for estimated energy expenditure at all treadmill speeds. Estimations of heart rate demonstrated poor to fair agreement during laboratory-based treadmill walks. For step count, the wrist-worn devices showed fair agreement and fair correlation at most treadmill speeds. In free-living settings; however, the agreement for step count between the wrist-worn device and waist-worn accelerometer was good, and the correlation was excellent. Conclusions: The wrist-worn device systematically overestimated energy expenditure and showed poor agreement and correlation compared to the criterion standard (Jaeger Oxycon Pro) and the relative criterion standard (ActiGraph GT3X), which needs to be considered when used clinically. Step count measured with a wrist-worn device, however, seemed to be a valid estimation, suggesting that future guidelines could include such variables in this group with chronic pain. %M 33433391 %R 10.2196/24806 %U http://mhealth.jmir.org/2021/1/e24806/ %U https://doi.org/10.2196/24806 %U http://www.ncbi.nlm.nih.gov/pubmed/33433391 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e24333 %T Smartphone-Based Self-Reports of Depressive Symptoms Using the Remote Monitoring Application in Psychiatry (ReMAP): Interformat Validation Study %A Goltermann,Janik %A Emden,Daniel %A Leehr,Elisabeth Johanna %A Dohm,Katharina %A Redlich,Ronny %A Dannlowski,Udo %A Hahn,Tim %A Opel,Nils %+ Department of Psychiatry, University of Münster, Albert-Schweitzer-Campus 1, Münster, 48149, Germany, 49 251 8356610, n_opel01@uni-muenster.de %K mobile monitoring %K smartphone %K digital biomarkers %K digital phenotyping %K course of illness %K psychometric quality %K mood disorders %K depression %K affective disorders %K mobile phone %D 2021 %7 12.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Smartphone-based symptom monitoring has gained increased attention in psychiatric research as a cost-efficient tool for prospective and ecologically valid assessments based on participants’ self-reports. However, a meaningful interpretation of smartphone-based assessments requires knowledge about their psychometric properties, especially their validity. Objective: The goal of this study is to systematically investigate the validity of smartphone-administered assessments of self-reported affective symptoms using the Remote Monitoring Application in Psychiatry (ReMAP). Methods: The ReMAP app was distributed to 173 adult participants of ongoing, longitudinal psychiatric phenotyping studies, including healthy control participants, as well as patients with affective disorders and anxiety disorders; the mean age of the sample was 30.14 years (SD 11.92). The Beck Depression Inventory (BDI) and single-item mood and sleep information were assessed via the ReMAP app and validated with non–smartphone-based BDI scores and clinician-rated depression severity using the Hamilton Depression Rating Scale (HDRS). Results: We found overall high comparability between smartphone-based and non–smartphone-based BDI scores (intraclass correlation coefficient=0.921; P<.001). Smartphone-based BDI scores further correlated with non–smartphone-based HDRS ratings of depression severity in a subsample (r=0.783; P<.001; n=51). Higher agreement between smartphone-based and non–smartphone-based assessments was found among affective disorder patients as compared to healthy controls and anxiety disorder patients. Highly comparable agreement between delivery formats was found across age and gender groups. Similarly, smartphone-based single-item self-ratings of mood correlated with BDI sum scores (r=–0.538; P<.001; n=168), while smartphone-based single-item sleep duration correlated with the sleep item of the BDI (r=–0.310; P<.001; n=166). Conclusions: These findings demonstrate that smartphone-based monitoring of depressive symptoms via the ReMAP app provides valid assessments of depressive symptomatology and, therefore, represents a useful tool for prospective digital phenotyping in affective disorder patients in clinical and research applications. %M 33433392 %R 10.2196/24333 %U https://mental.jmir.org/2021/1/e24333 %U https://doi.org/10.2196/24333 %U http://www.ncbi.nlm.nih.gov/pubmed/33433392 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 1 %P e23699 %T The Effects of Downloading a Government-Issued COVID-19 Contact Tracing App on Psychological Distress During the Pandemic Among Employed Adults: Prospective Study %A Kawakami,Norito %A Sasaki,Natsu %A Kuroda,Reiko %A Tsuno,Kanami %A Imamura,Kotaro %+ Department of Mental Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan, 81 358413521, nkawakami@m.u-tokyo.ac.jp %K coronavirus disease %K digital contact tracing %K mental health %K working population %K longitudinal study %K COVID-19 %K contact tracing %K surveillance %K tracking %K anxiety %K distress %D 2021 %7 12.1.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Downloading a COVID-19 contact tracing app may be effective in reducing users’ worry about COVID-19 and psychological distress. Objective: This 2.5-month prospective study aimed to investigate the association of downloading a COVID-19 contact tracing app, the COVID-19 Contact Confirming Application (COCOA), released by the Japanese government, with worry about COVID-19 and psychological distress in a sample of employed adults in Japan. Methods: A total of 996 full-time employed respondents to an online survey conducted May 22-26, 2020 (baseline), were invited to participate in a follow-up survey August 7-12, 2020 (follow-up). A high level of worrying about COVID-19 and high psychological distress were defined by baseline and follow-up scores on a single-item scale and the Kessler 6 (K6) scale, respectively. The app was released between the two surveys, on June 17. Participants were asked at follow-up if they downloaded the app. Results: A total of 902 (90.6%) of 996 baseline participants responded to the follow-up survey. Among them, 184 (20.4%) reported that they downloaded the app. Downloading of the contact tracing app was significantly negatively associated with psychological distress at follow-up after controlling for baseline variables, but not with worry about COVID-19. Conclusions: This study provides the first evidence that using a government-issued COVID-19 contact tracing app may be beneficial for the mental health of employed adults during the COVID-19 pandemic. %M 33347424 %R 10.2196/23699 %U http://mental.jmir.org/2021/1/e23699/ %U https://doi.org/10.2196/23699 %U http://www.ncbi.nlm.nih.gov/pubmed/33347424 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e21563 %T Effectiveness of Mobile Apps to Promote Health and Manage Disease: Systematic Review and Meta-analysis of Randomized Controlled Trials %A Iribarren,Sarah J %A Akande,Tokunbo O %A Kamp,Kendra J %A Barry,Dwight %A Kader,Yazan G %A Suelzer,Elizabeth %+ Department of Biobehavioral Nursing and Health Informatics, University of Washington, Health Science Building, T602C, Box 357266, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 2065435211, sjiribar@uw.edu %K systematic review %K mobile apps %K mobile phone %D 2021 %7 11.1.2021 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Interventions aimed at modifying behavior for promoting health and disease management are traditionally resource intensive and difficult to scale. Mobile health apps are being used for these purposes; however, their effects on health outcomes have been mixed. Objective: This study aims to summarize the evidence of rigorously evaluated health-related apps on health outcomes and explore the effects of features present in studies that reported a statistically significant difference in health outcomes. Methods: A literature search was conducted in 7 databases (MEDLINE, Scopus, PsycINFO, CINAHL, Global Index Medicus, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews). A total of 5 reviewers independently screened and extracted the study characteristics. We used a random-effects model to calculate the pooled effect size estimates for meta-analysis. Sensitivity analysis was conducted based on follow-up time, stand-alone app interventions, level of personalization, and pilot studies. Logistic regression was used to examine the structure of app features. Results: From the database searches, 8230 records were initially identified. Of these, 172 met the inclusion criteria. Studies were predominantly conducted in high-income countries (164/172, 94.3%). The majority had follow-up periods of 6 months or less (143/172, 83.1%). Over half of the interventions were delivered by a stand-alone app (106/172, 61.6%). Static/one-size-fits-all (97/172, 56.4%) was the most common level of personalization. Intervention frequency was daily or more frequent for the majority of the studies (123/172, 71.5%). A total of 156 studies involving 21,422 participants reported continuous health outcome data. The use of an app to modify behavior (either as a stand-alone or as part of a larger intervention) confers a slight/weak advantage over standard care in health interventions (standardized mean difference=0.38 [95% CI 0.31-0.45]; I2=80%), although heterogeneity was high. Conclusions: The evidence in the literature demonstrates a steady increase in the rigorous evaluation of apps aimed at modifying behavior to promote health and manage disease. Although the literature is growing, the evidence that apps can improve health outcomes is weak. This finding may reflect the need for improved methodological and evaluative approaches to the development and assessment of health care improvement apps. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42018106868; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=106868 %M 33427672 %R 10.2196/21563 %U https://mhealth.jmir.org/2021/1/e21563 %U https://doi.org/10.2196/21563 %U http://www.ncbi.nlm.nih.gov/pubmed/33427672 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e16490 %T Smartphone-Based Interventions and Internalizing Disorders in Youth: Systematic Review and Meta-analysis %A Buttazzoni,Adrian %A Brar,Keshbir %A Minaker,Leia %+ School of Planning, University of Waterloo, 200 University Avenue W, Waterloo, ON, N2L 3G1, Canada, 1 519 888 4567 ext 46564, anbuttazzoni@uwaterloo.ca %K mental health %K meta-analysis %K mobile phone %K smartphone %K systematic review %K youth %D 2021 %7 11.1.2021 %9 Review %J J Med Internet Res %G English %X Background: Mental health disorders in youth are a global issue that have important implications for the future quality of life and morbidity of affected individuals. In the context of public health initiatives, smartphone-based interventions have been suggested to hold the potential to be an effective strategy to reduce the symptoms of mental health disorders in youth; however, further evaluation is needed to confirm their effectiveness. This systematic review and meta-analysis documents and synthesizes existing research on smartphone-based interventions targeting internalizing disorders in youth populations. Objective: This study aims to synthesize existing research on smartphone-based interventions targeting internalizing disorders in youth populations. Methods: PubMed and SCOPUS were searched in 2019, and 4334 potentially relevant articles were found. A total of 12 studies were included in the final synthesis. We used the Hedges g meta-analysis approach and a random effects model for analysis. Results: The results of this review note that depression and anxiety are the most commonly targeted symptoms, and unlike other similar topics, most studies reviewed were linked to a proven treatment. The overall pooled effect from the meta-analysis showed small but significant effects (κ=12; N=1370; Hedges g=0.20; 95% CI 0.02-0.38) for interventions in reducing the symptoms of internalizing disorders. In total, 4 subgroup analyses examining specific symptoms and intervention styles found varied small significant and nonsignificant effects. Conclusions: Future research should focus on developing robust evaluative frameworks and examining interventions among more diverse populations and settings. More robust research is needed before smartphone-based interventions are scaled up and used at the population level to address youth internalizing disorders. %M 33427682 %R 10.2196/16490 %U http://www.jmir.org/2021/1/e16490/ %U https://doi.org/10.2196/16490 %U http://www.ncbi.nlm.nih.gov/pubmed/33427682 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e21727 %T Evaluation of Self-Care Activities and Quality of Life in Patients With Type 2 Diabetes Mellitus Treated With Metformin Using the 2D Matrix Code of Outer Drug Packages as Patient Identifier: Protocol for the DePRO Proof-of-Concept Observational Study %A Mueller,Christian %A Schauerte,Isabel %A Martin,Stephan %+ Pharmaceuticals Medicine, Pharmaceuticals, Medical Excellence & Innovation Management, Data Generation, Bayer Vital GmbH, Building K 56, 1D321, Leverkusen, 51368, Germany, 49 214 30 46587, christian.mueller4@bayer.com %K self-care activities %K quality of life %K type 2 diabetes mellitus %K patient-reported outcome measures %K digital observational study %K bring your own device %D 2021 %7 11.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Diabetes mellitus (DM) is one of the most common noncommunicable diseases. DM has a substantial negative impact on patients’ quality of life, which is measured using a variety of diabetes-specific measures covering multiple aspects of patients’ psychological state, behavior, and treatment satisfaction. A fully digital data collection system, including patient identification, would represent a substantial advance in how these patient-reported outcome (PRO) data are measured. Within the European Union, one way to identify patients without the involvement of health care professionals is to use the unique 2D matrix codes on the packaging of prescription medication—for example, metformin, the recommended initial treatment for patients with type 2 DM (T2DM). Objective: In the DePRO study we aim to (1) describe the self-care activities of patients with T2DM using metformin-containing medication; (2) describe the self-reported health status (eg, presence of diabetes complications and quality of life) of these patients; (3) describe associations between self-care activities and demographics and disease characteristics; and (4) assess the usability of the my ePRO app. Methods: DePRO is an observational, multicenter, cross-sectional, digital, patient-driven study conducted in Germany. Patients with a prescription for a metformin-containing medication will be given a postcard by their pharmacist, which will include a download link for the my ePRO app. In total, 12 diabetes-focused pharmacies, selected to represent urban and rural areas, will be recruited. Participants will use their own mobile device (bring your own device) to download the my ePRO app and access the DePRO study, for which they can register using the 2D matrix code on their medication. An electronic informed consent form will be displayed to the patients and only after giving consent will patients be able to complete the study questionnaires. The PRO instruments used in the study are the Summary of Diabetes Self-Care Activities Scale, the Diabetes Treatment Satisfaction Questionnaire, and the 5 level, 5-dimension EuroQol Questionnaire. Patients will also be asked to complete a questionnaire with items addressing demographics, patient characteristics, disease history, complications, and concomitant medications. Data will be transferred to the study database by the app upon completion of each questionnaire. Statistical analyses of primary and secondary endpoints will be exploratory and descriptive. Results: Enrollment began in June 2020. The estimated study completion date is December 31, 2020, and the planned sample size is 300 patients. Conclusions: The DePRO study uses completely digital data collection, including authentication of eligible patients and completion of the study questionnaires. Therefore, the design of the DePRO study represents a substantial advance in the evaluation of the digital capturing of PRO data. Trial Registration: ClinicalTrials.gov NCT04383041; https://clinicaltrials.gov/ct2/show/NCT04383041 International Registered Report Identifier (IRRID): PRR1-10.2196/21727 %M 33427685 %R 10.2196/21727 %U http://www.researchprotocols.org/2021/1/e21727/ %U https://doi.org/10.2196/21727 %U http://www.ncbi.nlm.nih.gov/pubmed/33427685 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e14864 %T Smartphone App (2kmFIT-App) for Measuring Cardiorespiratory Fitness: Validity and Reliability Study %A Muntaner-Mas,Adria %A Martinez-Nicolas,Antonio %A Quesada,Alberto %A Cadenas-Sanchez,Cristina %A Ortega,Francisco B %+ Department of Physical Education and Sports, Faculty of Education, University of Balearic Islands, Valldemossa Road, km 7.5, Palma, Spain, 34 971172875, adria.muntaner@uib.es %K exercise test %K mobile apps %K reproducibility of results %K physical fitness %K telemedicine %K cardiorespiratory fitness %D 2021 %7 8.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is strong evidence suggesting that higher levels of cardiorespiratory fitness (CRF) are associated with a healthier metabolic profile, and that CRF can serve as a powerful predictor of morbidity and mortality. In this context, a smartphone app based on the 2-km walk test (UKK test) would provide the possibility to assess CRF remotely in individuals geographically distributed around a country or continent, and even between continents, with minimal equipment and low costs. Objective: The overall aim of this study was to evaluate the validity and reliability of 2kmFIT-App developed for Android and iOS mobile operating systems to estimate maximum oxygen consumption (VO2max) as an indicator of CRF. The specific aims of the study were to determine the validity of 2kmFIT-App to track distance and calculate heart rate (HR). Methods: Twenty participants were included for field-testing validation and reliability analysis. The participants completed the UKK test twice using 2kmFIT-App. Distance and HR were measured with the app as well as with accurate methods, and VO2max was estimated using the UKK test equation. Results: The validity results showed the following mean differences (app minus criterion): distance (–70.40, SD 51.47 meters), time (–0.59, SD 0.45 minutes), HR (–16.75, SD 9.96 beats/minute), and VO2max (3.59, SD 2.01 ml/kg/min). There was moderate validity found for HR (intraclass correlation coefficient [ICC] 0.731, 95% CI –0.211 to 0.942) and good validity found for VO2max (ICC 0.878, 95% CI –0.125 to 0.972). The reliability results showed the following mean differences (retest minus test): app distance (25.99, SD 43.21 meters), app time (–0.15, SD 0.94 seconds), pace (–0.18, SD 0.33 min/km), app HR (–4.5, 13.44 beats/minute), and app VO2max (0.92, SD 3.04 ml/kg/min). There was good reliability for app HR (ICC 0.897, 95% CI 0.742-0.959) and excellent validity for app VO2max (ICC 0.932, 95% CI 0.830-0.973). All of these findings were observed when using the app with an Android operating system, whereas validity was poor when the app was used with iOS. Conclusions: This study shows that 2kmFIT-App is a new, scientifically valid and reliable tool able to objectively and remotely estimate CRF, HR, and distance with an Android but not iOS mobile operating system. However, certain limitations such as the time required by 2kmFIT-App to calculate HR or the temperature environment should be considered when using the app. %M 33416503 %R 10.2196/14864 %U http://mhealth.jmir.org/2021/1/e14864/ %U https://doi.org/10.2196/14864 %U http://www.ncbi.nlm.nih.gov/pubmed/33416503 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e23402 %T Usability and Preliminary Effectiveness of a Preoperative mHealth App for People Undergoing Major Surgery: Pilot Randomized Controlled Trial %A van der Velde,Miriam %A Valkenet,Karin %A Geleijn,Edwin %A Kruisselbrink,Marjoke %A Marsman,Marije %A Janssen,Liedewij MJ %A Ruurda,Jelle P %A van der Peet,Donald L %A Aarden,Jesse J %A Veenhof,Cindy %A van der Leeden,Marike %+ Innovation of Human Movement Care Research Group, HU University of Applied Sciences, Heidelberglaan 7, Utrecht, , Netherlands, 31 064 221 4251, miriam.vandervelde@hu.nl %K preoperative care %K smartphone %K mhealth %K risk behavior %K prehabilitation %K usability %D 2021 %7 7.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Major surgery is associated with negative postoperative outcomes such as complications and delayed or poor recovery. Multimodal prehabilitation can help to reduce the negative effects of major surgery. Offering prehabilitation by means of mobile health (mHealth) could be an effective new approach. Objective: The objectives of this pilot study were to (1) evaluate the usability of the Be Prepared mHealth app prototype for people undergoing major surgery, (2) explore whether the app was capable of bringing about a change in risk behaviors, and (3) estimate a preliminary effect of the app on functional recovery after major surgery. Methods: A mixed-methods pilot randomized controlled trial was conducted in two Dutch academic hospitals. In total, 86 people undergoing major surgery participated. Participants in the intervention group received access to the Be Prepared app, a smartphone app using behavior change techniques to address risk behavior prior to surgery. Both groups received care as usual. Usability (System Usability Scale), change in risk behaviors 3 days prior to surgery, and functional recovery 30 days after discharge from hospital (Patient-Reported Outcomes Measurement Information System physical functioning 8-item short form) were assessed using online questionnaires. Quantitative data were analyzed using descriptive statistics, chi-square tests, and multivariable linear regression. Semistructured interviews about the usability of the app were conducted with 12 participants in the intervention group. Thematic analysis was used to analyze qualitative data. Results: Seventy-nine people—40 in the intervention group and 39 in the control group—were available for further analysis. Participants had a median age of 61 (interquartile range 51.0-68.0) years. The System Usability Scale showed that patients considered the Be Prepared app to have acceptable usability (mean 68.2 [SD 18.4]). Interviews supported the usability of the app. The major point of improvement identified was further personalization of the app. Compared with the control group, the intervention group showed an increase in self-reported physical activity and muscle strengthening activities prior to surgery. Also, 2 of 2 frequent alcohol users in the intervention group versus 1 of 9 in the control group drank less alcohol in the run-up to surgery. No difference was found in change of smoking cessation. Between-group analysis showed no meaningful differences in functional recovery after correction for baseline values (β=–2.4 [95% CI –5.9 to 1.1]). Conclusions: The Be Prepared app prototype shows potential in terms of usability and changing risk behavior prior to major surgery. No preliminary effect of the app on functional recovery was found. Points of improvement have been identified with which the app and future research can be optimized. Trial Registration: Netherlands Trial Registry NL8623; https://www.trialregister.nl/trial/8623 %M 33410758 %R 10.2196/23402 %U http://mhealth.jmir.org/2021/1/e23402/ %U https://doi.org/10.2196/23402 %U http://www.ncbi.nlm.nih.gov/pubmed/33410758 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 4 %N 1 %P e24714 %T Digital Tools to Support Family-Based Weight Management for Children: Mixed Methods Pilot and Feasibility Study %A Staiano,Amanda E %A Shanley,Jenelle R %A Kihm,Holly %A Hawkins,Keely R %A Self-Brown,Shannon %A Höchsmann,Christoph %A Osborne,Melissa C %A LeBlanc,Monique M %A Apolzan,John W %A Martin,Corby K %+ Pennington Biomedical Research Center, 6400 Perkins Rd, Baton Rouge, LA, 70808, United States, 1 2257632729, amanda.staiano@pbrc.edu %K parent training %K weight loss %K telehealth %K obesity %K SafeCare %D 2021 %7 7.1.2021 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Family-based behavioral therapy is an efficacious approach to deliver weight management counseling to children and their parents. However, most families do not have access to in-person, evidence-based treatment. We previously developed and tested DRIVE (Developing Relationships that Include Values of Eating and Exercise), a home-based parent training program to maintain body weight among children at risk for obesity, with the intent to eventually disseminate it nationally alongside SafeCare, a parent support program that focuses on parent-child interactions. Currently the DRIVE program has only been tested independently of SafeCare. This study created the “mHealth DRIVE” program by further adapting DRIVE to incorporate digital and mobile health tools, including remotely delivered sessions, a wireless scale that enabled a child-tailored weight graph, and a pedometer. Telehealth delivery via mHealth platforms and other digital tools can improve program cost-effectiveness, deliver long-term care, and directly support both families and care providers. Objective: The objective of this study was to examine preliminary acceptability and effectiveness of the mHealth DRIVE program among children and parents who received it and among SafeCare providers who potentially could deliver it. Methods: Study 1 was a 13-week pilot study of a remotely delivered mHealth family-based weight management program. Satisfaction surveys were administered, and height and weight were measured pre- and post-study. Study 2 was a feasibility/acceptability survey administered to SafeCare providers. Results: Parental and child satisfaction (mean of 4.9/6.0 and 3.8/5.0, respectively) were high, and children’s (N=10) BMI z-scores significantly decreased (mean –0.14, SD 0.17; P=.025). Over 90% of SafeCare providers (N=74) indicated that SafeCare families would benefit from learning how to eat healthily and be more active, and 80% of providers reported that they and the families would benefit from digital tools to support child weight management. Conclusions: Pediatric mHealth weight management interventions show promise for effectiveness and acceptability by families and providers. Trial Registration: Clinicaltrials.gov NCT03297541, https://clinicaltrials.gov/ct2/show/NCT03297541. %M 33410760 %R 10.2196/24714 %U https://pediatrics.jmir.org/2021/1/e24714 %U https://doi.org/10.2196/24714 %U http://www.ncbi.nlm.nih.gov/pubmed/33410760 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e22184 %T Lifelog Data-Based Prediction Model of Digital Health Care App Customer Churn: Retrospective Observational Study %A Kwon,Hongwook %A Kim,Ho Heon %A An,Jaeil %A Lee,Jae-Ho %A Park,Yu Rang %+ Department of Biomedical Systems Informatics, College of Medicine, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 2493, yurangpark@yuhs.ac %K churn prediction %K digital health care %K life-log data %K topic modeling %K recurrent neural network %K deep learning interpretation %K attribution method %K integrated gradients %K digital health %K prediction %K model %K data %K app %K observational %K time-series %K neural network %D 2021 %7 6.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Customer churn is the rate at which customers stop doing business with an entity. In the field of digital health care, user churn prediction is important not only in terms of company revenue but also for improving the health of users. Churn prediction has been previously studied, but most studies applied time-invariant model structures and used structured data. However, additional unstructured data have become available; therefore, it has become essential to process daily time-series log data for churn predictions. Objective: We aimed to apply a recurrent neural network structure to accept time-series patterns using lifelog data and text message data to predict the churn of digital health care users. Methods: This study was based on the use data of a digital health care app that provides interactive messages with human coaches regarding food, exercise, and weight logs. Among the users in Korea who enrolled between January 1, 2017 and January 1, 2019, we defined churn users according to the following criteria: users who received a refund before the paid program ended and users who received a refund 7 days after the trial period. We used long short-term memory with a masking layer to receive sequence data with different lengths. We also performed topic modeling to vectorize text messages. To interpret the contributions of each variable to model predictions, we used integrated gradients, which is an attribution method. Results: A total of 1868 eligible users were included in this study. The final performance of churn prediction was an F1 score of 0.89; that score decreased by 0.12 when the data of the final week were excluded (F1 score 0.77). Additionally, when text data were included, the mean predicted performance increased by approximately 0.085 at every time point. Steps per day had the largest contribution (0.1085). Among the topic variables, poor habits (eg, drinking alcohol, overeating, and late-night eating) showed the largest contribution (0.0875). Conclusions: The model with a recurrent neural network architecture that used log data and message data demonstrated high performance for churn classification. Additionally, the analysis of the contribution of the variables is expected to help identify signs of user churn in advance and improve the adherence in digital health care. %M 33404511 %R 10.2196/22184 %U https://www.jmir.org/2021/1/e22184 %U https://doi.org/10.2196/22184 %U http://www.ncbi.nlm.nih.gov/pubmed/33404511 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e18686 %T Effects of Activity Tracker Use With Health Professional Support or Telephone Counseling on Maintenance of Physical Activity and Health Outcomes in Older Adults: Randomized Controlled Trial %A Brickwood,Katie-Jane %A Ahuja,Kiran D K %A Watson,Greig %A O'Brien,Jane A %A Williams,Andrew D %+ School of Health Sciences, College of Health and Medicine, University of Tasmania, Newnham Drive, Launceston, 7250, Australia, 61 0363245487, katiejane.brickwood@utas.edu.au %K physical activity %K fitness trackers %K telemedicine %K feedback %K older adults %K eHealth %K mobile phone %D 2021 %7 5.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite a range of efforts to increase physical activity participation in Australia, inactivity levels in older adults have remained high over recent decades, contributing to increased rates of chronic health conditions. Lifestyle interventions, including telephone counseling (TC), improve physical activity participation and associated health outcomes over the short term; however, ongoing feedback and support is required to maintain these changes. Newer technologies such as wearable activity trackers (ATs) may offer an alternative method for providing ongoing support. Objective: This study aims to investigate whether newer technologies such as wearable ATs assist in providing ongoing support to maintain physical activity levels and health outcomes. Methods: Older adults aged >60 years who had just completed a 12-week face-to-face individualized community exercise program in Tasmania, Australia, participated in the study. They were randomized to receive AT, TC, or usual care (UC). All groups received a home exercise program and an optional referral to a community-based exercise program. The AT group also received an AT and text message feedback from an accredited exercise physiologist (AEP). The TC group received phone calls from an AEP throughout the 12-month intervention. The primary outcome was daily steps measured by an ActivPAL (TM) accelerometer at baseline and at 3, 6, and 12 months. Secondary outcome measures included body composition, blood pressure, 10-time sit-to-stand (TTSTS) test, timed up and go test, and cardiorespiratory fitness. This trial was approved by the Tasmanian Health and Medical Human Research Ethics Committee (H0014713). Results: A total of 117 participants were randomized to the study (AT, n=37; TC, n=38; UC, n=42). At baseline, the participants (75/117, 64.1% female; mean age 72.4 years, SD 6.4) completed an average of 6136 steps (SD 2985) per day. Although there were no significant differences between groups, the TC and AT groups maintained daily step counts (mean difference [MD] −79 steps, 95% CI −823 to 663 steps; P=.81; and MD −588 steps, 95% CI −1359 to 182 steps; P=.09), and UC showed a reduction in daily steps (MD 981 steps, 95% CI −1668 to −294 steps; P=.003) during the 12-month period. Diastolic blood pressure was significantly higher after AT than after UC (MD 5.62 mm Hg, 95% CI 1.30 to 9.94 mm Hg; P=.01), and TTSTS was significantly slower on TC compared with UC (MD 2.36 seconds, 95% CI −0.14 to 4.87 seconds; P=.03). Conclusions: The use of an AT with AEP support or TC is effective at maintaining daily step count in older adults over a 12-month period, suggesting that wearable ATs are as effective as TC. Further research to investigate which option is more cost-effective would be beneficial. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12615001104549; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369118 %M 33399541 %R 10.2196/18686 %U https://mhealth.jmir.org/2021/1/e18686 %U https://doi.org/10.2196/18686 %U http://www.ncbi.nlm.nih.gov/pubmed/33399541 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 1 %P e25372 %T A Novel Artificial Intelligence-Powered Emotional Intelligence and Mindfulness App (Ajivar) for the College Student Population During the COVID-19 Pandemic: Quantitative Questionnaire Study %A Sturgill,Ronda %A Martinasek,Mary %A Schmidt,Trine %A Goyal,Raj %+ Department of Health Sciences and Human Performance, The University of Tampa, 401 West Kennedy Blvd, Box 30F, Tampa, FL, 33606, United States, 1 8132573445, rsturgill@ut.edu %K mindfulness %K COVID-19 %K college students %K emotional intelligence %D 2021 %7 5.1.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Emotional intelligence (EI) and mindfulness can impact the level of anxiety and depression that an individual experiences. These symptoms have been exacerbated among college students during the COVID-19 pandemic. Ajivar is an app that utilizes artificial intelligence (AI) and machine learning to deliver personalized mindfulness and EI training. Objective: The main objective of this research study was to determine the effectiveness of delivering an EI curriculum and mindfulness techniques using an AI conversation platform, Ajivar, to improve symptoms of anxiety and depression during this pandemic. Methods: A total of 99 subjects, aged 18 to 29 years, were recruited from a second-semester group of freshmen students. All participants completed the online TestWell Wellness Inventory at the start and end of the 14-week semester. The comparison group members (49/99, 49%) were given routine mental wellness instruction. The intervention group members (50/99, 51%) were required to complete Ajivar activities in addition to routine mental wellness instruction during the semester, which coincided with the onset of the COVID-19 pandemic. This group also completed assessments to evaluate for anxiety, using the 7-item Generalized Anxiety Disorder (GAD-7) scale, and depression, using the 9-item Patient Health Questionnaire (PHQ-9). Results: Study participants reported a mean age of 19.9 (SD 1.94) years; 27% (27/99) of the group were male and 60% (59/99) identified as Caucasian. No significant demographic differences existed between the comparison and intervention groups. Subjects in the intervention group interacted with Ajivar for a mean time of 1424 (SD 1168) minutes. There was a significant decrease in anxiety, as measured by the GAD-7: the mean score was 11.47 (SD 1.85) at the start of the study compared to 6.27 (SD 1.44) at the end (P<.001). There was a significant reduction in the symptoms of depression measured by the PHQ-9: the mean score was 10.69 (SD 2.04) at the start of the study compared to 6.69 (SD 2.41) at the end (P=.001). Both the intervention and comparison groups independently had significant improvements in the TestWell Wellness Inventory from pretest to posttest. The subgroups in the social awareness and spirituality inventories showed significant improvement in the intervention group. In a subgroup of participants (11/49, 22%) where the GAD-7 was available during the onset of the COVID-19 pandemic, there was an increase in anxiety from the start of the study (mean score 11.63, SD 2.16) to mid-March (ie, onset of the pandemic) (mean score 13.03, SD 1.48; P=.23), followed by a significant decrease at the end of the study period (mean score 5.9, SD 1.44; P=.001). Conclusions: It is possible to deliver EI and mindfulness training in a scalable way using the Ajivar app during the COVID-19 pandemic, resulting in improvements in anxiety, depression, and EI in the college student population. %M 33320822 %R 10.2196/25372 %U http://formative.jmir.org/2021/1/e25372/ %U https://doi.org/10.2196/25372 %U http://www.ncbi.nlm.nih.gov/pubmed/33320822 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 1 %P e25087 %T Adverse Childhood Experiences and Building Resilience With the JoyPop App: Evaluation Study %A MacIsaac,Angela %A Mushquash,Aislin R %A Mohammed,Shakira %A Grassia,Elizabeth %A Smith,Savanah %A Wekerle,Christine %+ Lakehead University, 955 Oliver Road, Thunder Bay, ON, , Canada, 1 8073438771, aislin.mushquash@lakeheadu.ca %K adverse childhood experiences %K resilience %K emotion regulation %K smartphone %K app %K childhood %K emotion %K mental health %K transition %K innovation %K intervention %D 2021 %7 4.1.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The effects of adverse childhood experiences (ACEs) on mental health, self-regulatory capacities, and overall resilience are well-known. Given such effects, ACEs may play a role in how individuals adjust to challenges later in life. Of interest in this study is the transition to university, a time of heightened stress when adapting to circumstances is required and when those with ACEs may need additional in-the-moment support to exercise resilience. A smartphone app may provide a worthwhile and readily accessible medium for a resilience intervention, provided behavioral outcomes are adequately evaluated. Objective: This study evaluates the impact of an innovative, smartphone app–based resilience intervention. The JoyPop app was designed to promote resilience through the use of self-regulatory skills such as emotion regulation and executive functioning. Among a sample of first-year undergraduate students, we explored whether use of the app would be associated with positive changes in resilience and related outcomes, and whether these benefits were influenced by level of childhood adversity. Methods: Participants (N=156) were requested to use the JoyPop app for 4 weeks, at least twice daily. Changes in resilience, emotion regulation, executive functioning, and depression were assessed after 2 and 4 weeks of app usage using multilevel modeling. Results: The sample of 156 participants included 123 females and 33 males, with a mean age of 19.02 years (SD 2.90). On average participants used the app on 20.43 of the possible 28 days (SD 7.14). App usage was associated with improvements in emotion regulation (χ21=44.46; P<.001), such that it improved by 0.25 points on the 18-point scale for each additional day of app usage, and symptoms of depression (χ21=25.12; P<.001), such that depression symptoms were reduced by .08 points on the 9-point scale with each additional day of app usage. An interaction between ACEs and days of app usage existed for emotion regulation, such that participants with more adversity evidenced a faster rate of change in emotion regulation (P=.02). Conclusions: Results highlight that daily incorporation of an app-based resilience intervention can help youth who have experienced adversity to improve emotion regulation skills and experience reductions in depression. The JoyPop app represents an important step forward in the integration of resilience intervention research with a technology-based medium that provides in-the-moment support. %M 33393908 %R 10.2196/25087 %U http://mhealth.jmir.org/2021/1/e25087/ %U https://doi.org/10.2196/25087 %U http://www.ncbi.nlm.nih.gov/pubmed/33393908 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e22201 %T Promotion of Physical Activity in Older People Using mHealth and eHealth Technologies: Rapid Review of Reviews %A McGarrigle,Lisa %A Todd,Chris %+ School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, United Kingdom, 44 1613067865, chris.todd@manchester.ac.uk %K physical activity %K mHealth %K eHealth %K app %K accelerometer %K pedometer %K technology %K COVID-19 %D 2020 %7 29.12.2020 %9 Review %J J Med Internet Res %G English %X Background: Older people are at increased risk of adverse health events because of reduced physical activity. There is concern that activity levels are further reduced in the context of the COVID-19 pandemic, as many older people are practicing physical and social distancing to minimize transmission. Mobile health (mHealth) and eHealth technologies may offer a means by which older people can engage in physical activity while physically distancing. Objective: The objective of this study was to assess the evidence for mHealth or eHealth technology in the promotion of physical activity among older people aged 50 years or older. Methods: We conducted a rapid review of reviews using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched for systematic reviews published in the English language in 3 electronic databases: MEDLINE, CINAHL Plus, and Scopus. Two reviewers used predefined inclusion criteria to select relevant reviews and extracted data on review characteristics and intervention effectiveness. Two independent raters assessed review quality using the AMSTAR-2 tool. Results: Titles and abstracts (n=472) were screened, and 14 full-text reviews were assessed for eligibility. Initially, we included 5 reviews but excluded 1 from the narrative as it was judged to be of critically low quality. Three reviews concluded that mHealth or eHealth interventions were effective in increasing physical activity. One review found that the evidence was inconclusive. Conclusions: There is low to moderate evidence that interventions delivered via mHealth or eHealth approaches may be effective in increasing physical activity in older adults in the short term. Components of successful interventions include self-monitoring, incorporation of theory and behavior change techniques, and social and professional support. %M 33372894 %R 10.2196/22201 %U http://www.jmir.org/2020/12/e22201/ %U https://doi.org/10.2196/22201 %U http://www.ncbi.nlm.nih.gov/pubmed/33372894 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e22090 %T Comparison of the Physical Activity Measured by a Consumer Wearable Activity Tracker and That Measured by Self-Report: Cross-Sectional Analysis of the Health eHeart Study %A Beagle,Alexander J %A Tison,Geoffrey H %A Aschbacher,Kirstin %A Olgin,Jeffrey E %A Marcus,Gregory M %A Pletcher,Mark J %+ Department of Medicine, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA, 94143, United States, 1 9098165831, alexanderjbeagle@gmail.com %K exercise %K body mass index %K overweight %K obesity %K fitness trackers %K self-report %K adult %K mHealth %K public health %K cardiovascular diseases %D 2020 %7 29.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Commercially acquired wearable activity trackers such as the Fitbit provide objective, accurate measurements of physically active time and step counts, but it is unclear whether these measurements are more clinically meaningful than self-reported physical activity. Objective: The aim of this study was to compare self-reported physical activity to Fitbit-measured step counts and then determine which is a stronger predictor of BMI by using data collected over the same period reflecting comparable physical activities. Methods: We performed a cross-sectional analysis of data collected by the Health eHeart Study, a large mobile health study of cardiovascular health and disease. Adults who linked commercially acquired Fitbits used in free-living conditions with the Health eHeart Study and completed an International Physical Activity Questionnaire (IPAQ) between 2013 and 2019 were enrolled (N=1498). Fitbit step counts were used to quantify time by activity intensity in a manner comparable to the IPAQ classifications of total active time and time spent being sedentary, walking, or doing moderate activities or vigorous activities. Fitbit steps per day were computed as a measure of the overall activity for exploratory comparisons with IPAQ-measured overall activity (metabolic equivalent of task [MET]-h/wk). Measurements of physical activity were directly compared by Spearman rank correlation. Strengths of associations with BMI for Fitbit versus IPAQ measurements were compared using multivariable robust regression in the subset of participants with BMI and covariates measured. Results: Correlations between synchronous paired measurements from Fitbits and the IPAQ ranged in strength from weak to moderate (0.09-0.48). In the subset with BMI and covariates measured (n=586), Fitbit-derived predictors were generally stronger predictors of BMI than self-reported predictors. For example, an additional hour of Fitbit-measured vigorous activity per week was associated with nearly a full point reduction in BMI (–0.84 kg/m2, 95% CI –1.35 to –0.32) in adjusted analyses, whereas the association between self-reported vigorous activity measured by IPAQ and BMI was substantially smaller in magnitude (–0.17 kg/m2, 95% CI –0.34 to –0.00; P<.001 versus Fitbit) and was dominated by the Fitbit-derived predictor when compared head-to-head in a single adjusted multivariable model. Similar patterns of associations with BMI, with Fitbit dominating self-report, were seen for moderate activity and total active time and in comparisons between overall Fitbit steps per day and IPAQ MET-h/wk on standardized scales. Conclusions: Fitbit-measured physical activity was more strongly associated with BMI than self-reported physical activity, particularly for moderate activity, vigorous activity, and summary measures of total activity. Consumer-marketed wearable activity trackers such as the Fitbit may be useful for measuring health-relevant physical activity in clinical practice and research. %M 33372896 %R 10.2196/22090 %U http://mhealth.jmir.org/2020/12/e22090/ %U https://doi.org/10.2196/22090 %U http://www.ncbi.nlm.nih.gov/pubmed/33372896 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e21733 %T Improving Heart Disease Risk Through Quality-Focused Diet Logging: Pre-Post Study of a Diet Quality Tracking App %A Kwon,Bum Chul %A VanDam,Courtland %A Chiuve,Stephanie E %A Choi,Hyung Wook %A Entler,Paul %A Tan,Pang-Ning %A Huh-Yoo,Jina %+ College of Computing and Informatics, Drexel University, 3675 Market St, Philadelphia, PA, 19104, United States, 1 2158952474, jinahuhyoo@drexel.edu %K mHealth %K diet monitoring %K diet tracking %K food tracking %K CVD %K heart disease risk %K health risk communication %K human-computer interaction %K user study %K mobile phone %D 2020 %7 23.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Diet-tracking mobile apps have gained increased interest from both academic and clinical fields. However, quantity-focused diet tracking (eg, calorie counting) can be time-consuming and tedious, leading to unsustained adoption. Diet quality—focusing on high-quality dietary patterns rather than quantifying diet into calories—has shown effectiveness in improving heart disease risk. The Healthy Heart Score (HHS) predicts 20-year cardiovascular risks based on the consumption of foods from quality-focused food categories, rather than detailed serving sizes. No studies have examined how mobile health (mHealth) apps focusing on diet quality can bring promising results in health outcomes and ease of adoption. Objective: This study aims to design a mobile app to support the HHS-informed quality-focused dietary approach by enabling users to log simplified diet quality and view its real-time impact on future heart disease risks. Users were asked to log food categories that are the main predictors of the HHS. We measured the app’s feasibility and efficacy in improving individuals’ clinical and behavioral factors that affect future heart disease risks and app use. Methods: We recruited 38 participants who were overweight or obese with high heart disease risk and who used the app for 5 weeks and measured weight, blood sugar, blood pressure, HHS, and diet score (DS)—the measurement for diet quality—at baseline and week 5 of the intervention. Results: Most participants (30/38, 79%) used the app every week and showed significant improvements in DS (baseline: mean 1.31, SD 1.14; week 5: mean 2.36, SD 2.48; 2-tailed t test t29=−2.85; P=.008) and HHS (baseline: mean 22.94, SD 18.86; week 4: mean 22.15, SD 18.58; t29=2.41; P=.02) at week 5, although only 10 participants (10/38, 26%) checked their HHS risk scores more than once. Other outcomes, including weight, blood sugar, and blood pressure, did not show significant changes. Conclusions: Our study showed that our logging tool significantly improved dietary choices. Participants were not interested in seeing the HHS and perceived logging diet categories irrelevant to improving the HHS as important. We discuss the complexities of addressing health risks and quantity- versus quality-based health monitoring and incorporating secondary behavior change goals that matter to users when designing mHealth apps. %M 33355537 %R 10.2196/21733 %U http://mhealth.jmir.org/2020/12/e21733/ %U https://doi.org/10.2196/21733 %U http://www.ncbi.nlm.nih.gov/pubmed/33355537 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 5 %N 4 %P e20888 %T Relationship Between Diabetes, Stress, and Self-Management to Inform Chronic Disease Product Development: Retrospective Cross-Sectional Study %A Yu,Jessica S %A Xu,Tong %A James,Roberta A %A Lu,Wei %A Hoffman,Julia E %+ Livongo Health, 150 W. Evelyn Ave, Mountain View, CA, 94041, United States, 1 866 435 5643, jessica.yu@livongo.com %K diabetes mellitus %K behavioral health %K mental health %K stress %K technology %D 2020 %7 23.12.2020 %9 Original Paper %J JMIR Diabetes %G English %X Background: Technology is rapidly advancing our understanding of how people with diabetes mellitus experience stress. Objective: The aim of this study was to explore the relationship between stress and sequelae of diabetes mellitus within a unique data set composed of adults enrolled in a digital diabetes management program, Livongo, in order to inform intervention and product development. Methods: Participants included 3263 adults under age 65 who were diagnosed with diabetes mellitus and had access to Livongo through their employer between June 2015 and August 2018. Data were collected at time of enrollment and 12 months thereafter, which included demographic information, glycemic control, presence of stress, diabetes distress, diabetes empowerment, behavioral health diagnosis, and utilization of behavioral health-related medication and services. Analysis of variance and chi-square tests compared variables across groups that were based on presence of stress and behavioral health diagnosis or utilization. Results: Fifty-five percent of participants (1808/3263) reported stress at the time of at least 1 blood glucose reading. Fifty-two percent of participants (940/1808) also received at least 1 behavioral health diagnosis or intervention. Compared to their peers, participants with stress reported greater diabetes distress, lower diabetes empowerment, greater insulin use, and poorer glycemic control. Participants with stress and a behavioral health diagnosis/utilization additionally had higher body mass index and duration of illness. Conclusions: Stress among people with diabetes mellitus is associated with reduced emotional and physical health. Digital products that focus on the whole person by offering both diabetes mellitus self-management tools and behavioral health skills and support can help improve disease-specific and psychosocial outcomes. %M 33355538 %R 10.2196/20888 %U http://diabetes.jmir.org/2020/4/e20888/ %U https://doi.org/10.2196/20888 %U http://www.ncbi.nlm.nih.gov/pubmed/33355538 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e18937 %T Interrelationships Between Patients’ Data Tracking Practices, Data Sharing Practices, and Health Literacy: Onsite Survey Study %A Luo,Yuhan %A Oh,Chi Young %A Jean,Beth St %A Choe,Eun Kyoung %+ College of Information Studies, University of Maryland, 4130 Campus Drive, Hornbake Library South, College Park, MD, , United States, 1 3014051085, choe@umd.edu %K consumer health informatics %K patient-generated health data %K self-tracking %K doctor-patient data sharing %K health literacy %K surveys and questionnaires %D 2020 %7 22.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although the use of patient-generated data (PGD) in the optimization of patient care shows great promise, little is known about whether patients who track their PGD necessarily share the data with their clinicians. Meanwhile, health literacy—an important construct that captures an individual’s ability to manage their health and to engage with their health care providers—has often been neglected in prior studies focused on PGD tracking and sharing. To leverage the full potential of PGD, it is necessary to bridge the gap between patients’ data tracking and data sharing practices by first understanding the interrelationships between these practices and the factors contributing to these practices. Objective: This study aims to systematically examine the interrelationships between PGD tracking practices, data sharing practices, and health literacy among individual patients. Methods: We surveyed 109 patients at the time they met with a clinician at a university health center, unlike prior research that often examined patients’ retrospective experience after some time had passed since their clinic visit. The survey consisted of 39 questions asking patients about their PGD tracking and sharing practices based on their current clinical encounter. The survey also contained questions related to the participants’ health literacy. All the participants completed the survey on a tablet device. The onsite survey study enabled us to collect ecologically valid data based on patients’ immediate experiences situated within their clinic visit. Results: We found no evidence that tracking PGD was related to self-reports of having sufficient information to manage one’s health; however, the number of data types participants tracked positively related to their self-assessed ability to actively engage with health care providers. Participants’ data tracking practices and their health literacy did not relate to their data sharing practices; however, their ability to engage with health care providers positively related to their willingness to share their data with clinicians in the future. Participants reported several benefits of, and barriers to, sharing their PGD with clinicians. Conclusions: Although tracking PGD could help patients better engage with health care providers, it may not provide patients with sufficient information to manage their health. The gaps between tracking and sharing PGD with health care providers call for efforts to inform patients of how their data relate to their health and to facilitate efficient clinician-patient communication. To realize the full potential of PGD and to promote individuals’ health literacy, empowering patients to effectively track and share their PGD is important—both technologies and health care providers can play important roles. %M 33350960 %R 10.2196/18937 %U http://www.jmir.org/2020/12/e18937/ %U https://doi.org/10.2196/18937 %U http://www.ncbi.nlm.nih.gov/pubmed/33350960 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 12 %P e20061 %T Integrating Key User Characteristics in User-Centered Design of Digital Support Systems for Seniors’ Physical Activity Interventions to Prevent Falls: Protocol for a Usability Study %A Revenäs,Åsa %A Johansson,Ann-Christin %A Ehn,Maria %+ Center for Clinical Research, Region Västmanland-Uppsala University, Hospital of Västmanland Västerås, Västerås Hospital, Entrance 29, Västerås, 72189, Sweden, 46 764959223, asa.revenas@regionvastmanland.se %K eHealth %K mobile health %K internet-based interventions %K physical activity %K exercise %K older adults %K gender %K user feedback %K user involvement %K user-centered design %D 2020 %7 21.12.2020 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The goal of user-centered design (UCD) is to understand the users’ perspective and to use that knowledge to shape more effective solutions. The UCD approach provides insight into users’ needs and requirements and thereby improves the design of the developed services. However, involving users in the development process does not guarantee that feedback from different subgroups of users will shape the development in ways that will make the solutions more useful for the entire target user population. Objective: The aim of this study was to describe a protocol for systematic analysis and prioritization of feedback from user subgroups in the usability testing of a digital motivation support for fall-preventive physical activity (PA) interventions in seniors (aged 65 years and older). This protocol can help researchers and developers to systematically exploit feedback from relevant user subgroups in UCD. Methods: Gender, PA level, and level of technology experience have been identified in the literature to influence users’ experience and use of digital support systems for fall-preventive PA interventions in seniors. These 3 key user characteristics were dichotomized and used to define 8 (ie, 23) possible user subgroups. The presented method enables systematic tracking of the user subgroups’ contributions in iterative development. The method comprises (1) compilation of difficulties and deficiencies in the digital applications identified in usability testing, (2) clustering of the identified difficulties and deficiencies, and (3) prioritization of deficiencies to be rectified. Tracking user subgroup representation in the user feedback ensures that the development process is prioritized according to the needs of different subgroups. Mainly qualitative data collection methods are used. Results: A protocol was developed to ensure that feedback from users representing all possible variants of 3 selected key user characteristics (gender, PA level, and level of technology experience) is considered in the iterative usability testing of a digital support for seniors’ PA. The method was applied in iterative usability testing of two digital applications during spring/summer 2018. Results from the study on the users’ experiences and the iterative modification of the digital applications are expected to be published during 2021. Conclusions: Methods for systematic collection, analysis, and prioritization of feedback from user subgroups might be particularly important in heterogenous user groups (eg, seniors). This study can contribute to identifying and improving the understanding of potential differences between user subgroups of seniors in their use and experiences of digital support for fall-preventive PA interventions. This knowledge may be relevant for developing digital support systems that are appropriate, useful, and attractive to users and for enabling the design of digital support systems that target specific user subgroups (ie, tailoring of the support). The protocol needs to be further used and investigated in order to validate its potential value. International Registered Report Identifier (IRRID): RR1-10.2196/20061 %M 33346732 %R 10.2196/20061 %U http://www.researchprotocols.org/2020/12/e20061/ %U https://doi.org/10.2196/20061 %U http://www.ncbi.nlm.nih.gov/pubmed/33346732 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e24268 %T Smartphone-Based Virtual Agents to Help Individuals With Sleep Concerns During COVID-19 Confinement: Feasibility Study %A Philip,Pierre %A Dupuy,Lucile %A Morin,Charles M %A de Sevin,Etienne %A Bioulac,Stéphanie %A Taillard,Jacques %A Serre,Fuschia %A Auriacombe,Marc %A Micoulaud-Franchi,Jean-Arthur %+ USR 3413 SANPSY, University of Bordeaux, Bordeaux, France, 33 557571100, lucile.dupuy@u-bordeaux.fr %K COVID-19 %K virtual agent %K sleep disorders %K technology acceptance %K agent %K sleep %K smartphone %K mobile phone %K eHealth %K feasibility %K stress %K app %K intervention %K behavior %D 2020 %7 18.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 crisis and consequent confinement restrictions have caused significant psychosocial stress and reports of sleep complaints, which require early management, have increased during recent months. To help individuals concerned about their sleep, we developed a smartphone-based app called KANOPEE that allows users to interact with a virtual agent dedicated to autonomous screening and delivering digital behavioral interventions. Objective: Our objective was to assess the feasibility of this app, in terms of inclusion rate, follow-up rate, perceived trust and acceptance of the virtual agent, and effects of the intervention program, in the context of COVID-19 confinement in France. Methods: The virtual agent is an artificial intelligence program using decision tree architecture and interacting through natural body motion and natural voice. A total of 2069 users aged 18 years and above downloaded the free app during the study period (April 22 to May 5, 2020). These users first completed a screening interview based on the Insomnia Severity Index (ISI) conducted by the virtual agent. If the users were positive for insomnia complaints (ISI score >14), they were eligible to join the 2-stage intervention program: (1) complete an electronic sleep diary for 1 week and (2) follow personalized sleep recommendations for 10 days. We collected and analyzed the following measures: sociodemographic information, ISI scores and sleep/wake schedules, and acceptance and trust of the agent. Results: Approximately 76% (1574/2069) of the app users completed the screening interview with the virtual agent. The virtual agent was well accepted by 27.4% (431/1574) of the users who answered the acceptance and trust questionnaires on its usability, satisfaction, benevolence, and credibility. Of the 773 screened users who reported sleep complaints (ISI score >14), 166 (21.5%) followed Step 1 of the intervention, and only 47 of those (28.3%) followed Step 2. Users who completed Step 1 found that their insomnia complaints (baseline mean ISI score 18.56, mean ISI score after Step 1 15.99; P<.001) and nocturnal sleep quality improved significantly after 1 week. Users who completed Step 2 also showed an improvement compared to the initial measures (baseline mean ISI score 18.87, mean ISI score after Step 2 14.68; P<.001). Users that were most severely affected (ISI score >21) did not respond to either intervention. Conclusions: These preliminary results suggest that the KANOPEE app is a promising solution to screen populations for sleep complaints and that it provides acceptable and practical behavioral advice for individuals reporting moderately severe insomnia. %M 33264099 %R 10.2196/24268 %U http://www.jmir.org/2020/12/e24268/ %U https://doi.org/10.2196/24268 %U http://www.ncbi.nlm.nih.gov/pubmed/33264099 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e19888 %T Evaluation of a Mobile App to Enhance Relational Awareness and Change During Cognitive Analytic Therapy: Mixed Methods Case Series %A Kellett,Stephen %A Easton,Katherine %A Cooper,Martin %A Millings,Abigail %A Simmonds-Buckley,Melanie %A Parry,Glenys %+ Sheffield Health & Social Care NHS Foundation Trust, University of Sheffield, 1 Vicar Lane, Sheffield, S1 2LT, United Kingdom, 44 114 222 6537, s.kellett@sheffield.ac.uk %K cognitive analytic therapy %K case series %K effectiveness %K outcome %K eHealth %K app %K awareness %K mHealth %K innovation %K therapy %D 2020 %7 18.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: There has been a lack of technological innovation regarding improving the delivery of integrative psychotherapies. This project sought to evaluate an app designed to replace previous paper-based methods supporting relational awareness and change during cognitive analytic therapy (CAT). Objective: We aimed to assess patients’ and therapists’ experience of using the technology (ie, the “CAT-App”) and to evaluate the relationship between app usage and clinical outcome. Methods: The design was a mixed methods case series. Patients completed the Clinical Outcomes in Routine Evaluation-Outcome Measure pre- and post-CAT. Mood data plus the frequency and effectiveness of relational awareness and change were collected via the app. Therapists and patients were interviewed about their experiences using the app. Results: Ten patients (treated by 3 therapists) were enrolled; seven completed treatment and 4 had a reliable improvement in their mental health. App usage and mood change did not differ according to clinical outcome, but there was a statistically significant difference in app usage between completers and dropouts. The qualitative themes described by the therapists were (1) the challenge of incorporating the technology into their clinical practice and (2) the barriers and benefits of the technology. Clients’ themes were (1) data protection, (2) motivation and engagement, and (3) restrictions versus flexibility. Conclusions: The CAT-App is capable of supporting relational awareness and change and is an upgrade on older, paper-based formats. Further clinical evaluation is required. %M 33337342 %R 10.2196/19888 %U http://mental.jmir.org/2020/12/e19888/ %U https://doi.org/10.2196/19888 %U http://www.ncbi.nlm.nih.gov/pubmed/33337342 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 8 %N 12 %P e20597 %T Missing-Data Handling Methods for Lifelogs-Based Wellness Index Estimation: Comparative Analysis With Panel Data %A Kim,Ki-Hun %A Kim,Kwang-Jae %+ Faculty of Industrial Design Engineering, Delft University of Technology, Landbergstraat 15, Delft, 2628 CE, Netherlands, 31 625244785, K.Kim-1@tudelft.nl %K lifelogs-based wellness index %K missing-data handling %K health behavior lifelogs %K panel data %K smart wellness service %D 2020 %7 17.12.2020 %9 Original Paper %J JMIR Med Inform %G English %X Background: A lifelogs-based wellness index (LWI) is a function for calculating wellness scores based on health behavior lifelogs (eg, daily walking steps and sleep times collected via a smartwatch). A wellness score intuitively shows the users of smart wellness services the overall condition of their health behaviors. LWI development includes estimation (ie, estimating coefficients in LWI with data). A panel data set comprising health behavior lifelogs allows LWI estimation to control for unobserved variables, thereby resulting in less bias. However, these data sets typically have missing data due to events that occur in daily life (eg, smart devices stop collecting data when batteries are depleted), which can introduce biases into LWI coefficients. Thus, the appropriate choice of method to handle missing data is important for reducing biases in LWI estimations with panel data. However, there is a lack of research in this area. Objective: This study aims to identify a suitable missing-data handling method for LWI estimation with panel data. Methods: Listwise deletion, mean imputation, expectation maximization–based multiple imputation, predictive-mean matching–based multiple imputation, k-nearest neighbors–based imputation, and low-rank approximation–based imputation were comparatively evaluated by simulating an existing case of LWI development. A panel data set comprising health behavior lifelogs of 41 college students over 4 weeks was transformed into a reference data set without any missing data. Then, 200 simulated data sets were generated by randomly introducing missing data at proportions from 1% to 80%. The missing-data handling methods were each applied to transform the simulated data sets into complete data sets, and coefficients in a linear LWI were estimated for each complete data set. For each proportion for each method, a bias measure was calculated by comparing the estimated coefficient values with values estimated from the reference data set. Results: Methods performed differently depending on the proportion of missing data. For 1% to 30% proportions, low-rank approximation–based imputation, predictive-mean matching–based multiple imputation, and expectation maximization–based multiple imputation were superior. For 31% to 60% proportions, low-rank approximation–based imputation and predictive-mean matching–based multiple imputation performed best. For over 60% proportions, only low-rank approximation–based imputation performed acceptably. Conclusions: Low-rank approximation–based imputation was the best of the 6 data-handling methods regardless of the proportion of missing data. This superiority is generalizable to other panel data sets comprising health behavior lifelogs given their verified low-rank nature, for which low-rank approximation–based imputation is known to perform effectively. This result will guide missing-data handling in reducing coefficient biases in new development cases of linear LWIs with panel data. %M 33331831 %R 10.2196/20597 %U http://medinform.jmir.org/2020/12/e20597/ %U https://doi.org/10.2196/20597 %U http://www.ncbi.nlm.nih.gov/pubmed/33331831 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e24693 %T Attitudes Toward Using COVID-19 mHealth Tools Among Adults With Chronic Health Conditions: Secondary Data Analysis of the COVID-19 Impact Survey %A Camacho-Rivera,Marlene %A Islam,Jessica Yasmine %A Rivera,Argelis %A Vidot,Denise Christina %+ Department of Community Health Sciences, State University of New York Downstate Health Sciences University, 450 Clarkson Avenue, MSC 43, Brooklyn, NY, 11203, United States, 1 7182704386, marlene.camacho-rivera@downstate.edu %K smartphone %K mHealth %K COVID-19 %K chronic health conditions %K health disparities %K chronic disease %K attitude %K perception %K data analysis %K contact tracing %K mobile app %K disparity %D 2020 %7 17.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Adults with chronic conditions are disproportionately burdened by COVID-19 morbidity and mortality. Although COVID-19 mobile health (mHealth) apps have emerged, research on attitudes toward using COVID-19 mHealth tools among those with chronic conditions is scarce. Objective: This study aimed to examine attitudes toward COVID-19, identify determinants of COVID-19 mHealth tool use across demographic and health-related characteristics, and evaluate associations between chronic health conditions and attitudes toward using COVID-19 mHealth tools (eg, mHealth or web-based methods for tracking COVID-19 exposures, symptoms, and recommendations). Methods: We used nationally representative data from the COVID-19 Impact Survey collected from April to June 2020 (n=10,760). Primary exposure was a history of chronic conditions, which were defined as self-reported diagnoses of cardiometabolic, respiratory, immune-related, and mental health conditions and overweight/obesity. Primary outcomes were attitudes toward COVID-19 mHealth tools, including the likelihood of using (1) a mobile phone app to track COVID-19 symptoms and receive recommendations; (2) a website to track COVID-19 symptoms, track location, and receive recommendations; and (3) an app using location data to track potential COVID-19 exposure. Outcome response options for COVID-19 mHealth tool use were extremely/very likely, moderately likely, or not too likely/not likely at all. Multinomial logistic regression was used to compare the likelihood of COVID-19 mHealth tool use between people with different chronic health conditions, with not too likely/not likely at all responses used as the reference category for each outcome. We evaluated the determinants of each COVID-19 mHealth intervention using Poisson regression. Results: Of the 10,760 respondents, 21.8% of respondents were extremely/very likely to use a mobile phone app or a website to track their COVID-19 symptoms and receive recommendations. Additionally, 24.1% of respondents were extremely/very likely to use a mobile phone app to track their location and receive push notifications about whether they have been exposed to COVID-19. After adjusting for age, race/ethnicity, sex, socioeconomic status, and residence, adults with mental health conditions were the most likely to report being extremely/very or moderately likely to use each mHealth intervention compared to those without such conditions. Adults with respiratory-related chronic diseases were extremely/very (conditional odds ratio 1.16, 95% CI 1.00-1.35) and moderately likely (conditional odds ratio 1.23, 95% CI 1.04-1.45) to use a mobile phone app to track their location and receive push notifications about whether they have been exposed to COVID-19. Conclusions: Our study demonstrates that attitudes toward using COVID-19 mHealth tools vary widely across modalities (eg, web-based method vs app) and chronic health conditions. These findings may inform the adoption of long-term engagement with COVID-19 apps, which is crucial for determining their potential in reducing disparities in COVID-19 morbidity and mortality among individuals with chronic health conditions. %M 33301415 %R 10.2196/24693 %U http://mhealth.jmir.org/2020/12/e24693/ %U https://doi.org/10.2196/24693 %U http://www.ncbi.nlm.nih.gov/pubmed/33301415 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 12 %P e17317 %T Mentoring Young African American Men and Transgender Women Who Have Sex With Men on Sexual Health: Formative Research for an HIV Mobile Health Intervention for Mentors %A Kaufman,Michelle R %A Casella,Albert %A Wiginton,John Mark %A Xu,Wenjian %A DuBois,David L %A Arrington-Sanders,Renata %A Simon,Jeannette %A Levine,Deb %+ Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 257, Baltimore, MD, 21205, United States, 1 4109552313, michellekaufman@jhu.edu %K mentoring %K HIV %K mobile app %K mHealth %K men who have sex with men %K transgender %K African Americans %D 2020 %7 17.12.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: African American men who have sex with men (MSM) and transgender women bear a disproportionate burden of HIV. Young MSM account for 75% of this burden for youth. When youths lack socially protective resources such as strong networks of adults, including parents, teachers, or community members, mentors may play a critical role in promoting health behaviors. This is especially true for youth at risk for HIV, such as African American youth with sexual and gender minority (SGM) identities. In the past decade, natural mentoring and mentoring programs have proliferated as a key prevention and intervention strategy to improve outcomes for young people at risk for poor academic, social, and health issues. Mentors appear to be able to facilitate health promotion among young SGM by modeling healthy behaviors; however, mentors’ knowledge and resource needs regarding sexual health topics including HIV are understudied, as is the potential role of mobile technology in enhancing mentoring relationships and the ability of mentors to learn about sensitive issues faced by youth. Objective: The aim of this study is to explore how mentoring plays a role in the sexual health of African American SGM youth and understand how mentoring relationships can be strengthened through mobile technology to promote youth HIV prevention behaviors. Methods: In-depth interviews were conducted with African American SGM youth mentees (n=17) and mentors (n=20) to such youths in 3 Mid-Atlantic cities. Mentee interviews focused on discussions regarding sexual health and HIV and how a mentor could broach such topics. Mentor interviews explored whether sexual health and HIV are currently mentoring topics, mentors’ knowledge and confidence in mentoring on these issues, and barriers to discussions. All participants were asked if a mobile app could help facilitate mentoring on sensitive health issues, particularly HIV and sexual health. Data were transcribed, coded, and analyzed for relevant themes. Results: Sexual health was a common topic in mentoring relationships, occurring more in natural mentorships than in mentoring program pairs. Mentors and mentees felt positive about such discussions. Mentors expressed having limited knowledge beyond condom use and HIV testing, and expressed a need for more complete resources. Both mentors and mentees had mixed comfort levels when discussing sexual health. Sufficient trust and shared lived experiences made discussions easier. Mentees have multifaceted needs; however, mentors stated that an app resource that provided self-training, resources, support from other mentors, and tips for better mentoring could prove beneficial. Conclusions: For the African American SGM community, access to natural mentors is crucial for young people to learn healthy behaviors. A mobile resource to assist mentors in confidently having discussions with mentees may be a promising way to promote healthy practices. %M 33331822 %R 10.2196/17317 %U https://formative.jmir.org/2020/12/e17317 %U https://doi.org/10.2196/17317 %U http://www.ncbi.nlm.nih.gov/pubmed/33331822 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e23734 %T Effects of a Mobile App Called Quittr, Which Utilizes Premium Currency and Games Features, on Improving Engagement With Smoking Cessation Intervention: Pilot Randomized Controlled Trial %A Bindoff,Ivan %A Ling,Tristan R %A Gee,Peter %A Geelan,Benjamin %A Ferguson,Stuart G %A Peterson,Gregory M %+ School of Pharmacy and Pharmacology, University of Tasmania, 1 Churchill Ave, Sandy Bay, 7005, Australia, 61 408528276, Ivan.Bindoff@utas.edu.au %K smoking %K cessation %K Quittr %K engagement %K retention %K churn %K cigarette %K mHealth %K game %D 2020 %7 14.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Numerous mobile health (mHealth) apps have been developed to support smokers attempting to quit smoking. Although these apps have been reported to be successful, only modest improvements in the quit rate have been measured. It has been proposed that efforts to improve user engagement and retention may improve the quit rate further. Owing to the high cost of smoking-related disease, it is considered worthwhile to pursue even small improvements. Objective: The aim of this study was to test a novel smartphone app that leverages premium currency strategies developed by the mobile games industry in an attempt to improve engagement and retention with a smoking cessation intervention. Methods: We designed and developed a smoking cessation app called “Quittr” in line with previously developed smoking cessation mHealth apps. In addition to this established framework, we added a stand-alone fully featured city-building clicker-style game called “Tappy Town,” and a premium virtual currency called “QuitCoins.” The user earns QuitCoins for using the app in a way that contributes positively toward their quit attempt, and they can redeem these coins in Tappy Town for bonuses. To establish whether these features improved engagement and retention, we ran a 5-month randomized controlled trial where the intervention group had the full app with the extra games features, while the control group had the standard app only. Recruitment was performed via web-based advertising. Participants (N=175) had no direct contact with the researchers or other support staff. Results: No significant differences in terms of engagement, retention, or smoking outcomes were found between the control and intervention groups. However, survey data indicated that the majority of the participants valued Tappy Town (10/17, 59%) and the QuitCoins rewards system (13/17, 77%). Usage data also suggested that Tappy Town was widely played and was generally appealing to users (mean total time spent in app, control group: 797 seconds vs intervention group: 3502 seconds, P<.001). Analysis of the results suggests that users in the intervention group may have been negatively affected by the aspects of the chosen design, and some theories were explored to explain this unexpected outcome. Conclusions: Although the novel features of the Quittr app failed to improve the key outcomes measured in this study, there were enough positive indications to warrant further exploration of the concept. Additional research will be required to identify and correct any design flaws that may have adversely affected our participants before a follow-up study can be completed. Trial Registration: Australian and New Zealand Clinical Trials Register ACTRN12617000491369; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372661&isReview=true %M 33315016 %R 10.2196/23734 %U http://games.jmir.org/2020/4/e23734/ %U https://doi.org/10.2196/23734 %U http://www.ncbi.nlm.nih.gov/pubmed/33315016 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e23369 %T Engagement With a Behavior Change App for Alcohol Reduction: Data Visualization for Longitudinal Observational Study %A Bell,Lauren %A Garnett,Claire %A Qian,Tianchen %A Perski,Olga %A Williamson,Elizabeth %A Potts,Henry WW %+ Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom, 44 02076368636, lauren.bell@lshtm.ac.uk %K mobile health %K behavior change %K apps %K digital health %K data visualizations %K engagement %K micro-randomized trial %K push notifications %K just-in-time adaptive interventions %D 2020 %7 11.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Behavior change apps can develop iteratively, where the app evolves into a complex, dynamic, or personalized intervention through cycles of research, development, and implementation. Understanding how existing users engage with an app (eg, frequency, amount, depth, and duration of use) can help guide further incremental improvements. We aim to explore how simple visualizations can provide a good understanding of temporal patterns of engagement, as usage data are often longitudinal and rich. Objective: This study aims to visualize behavioral engagement with Drink Less, a behavior change app to help reduce hazardous and harmful alcohol consumption in the general adult population of the United Kingdom. Methods: We explored behavioral engagement among 19,233 existing users of Drink Less. Users were included in the sample if they were from the United Kingdom; were 18 years or older; were interested in reducing their alcohol consumption; had a baseline Alcohol Use Disorders Identification Test score of 8 or above, indicative of excessive drinking; and had downloaded the app between May 17, 2017, and January 22, 2019 (615 days). Measures of when sessions begin, length of sessions, time to disengagement, and patterns of use were visualized with heat maps, timeline plots, k-modes clustering analyses, and Kaplan-Meier plots. Results: The daily 11 AM notification is strongly associated with a change in engagement in the following hour; reduction in behavioral engagement over time, with 50.00% (9617/19,233) of users disengaging (defined as no use for 7 or more consecutive days) 22 days after download; identification of 3 distinct trajectories of use, namely engagers (4651/19,233, 24.18% of users), slow disengagers (3679/19,233, 19.13% of users), and fast disengagers (10,903/19,233, 56.68% of users); and limited depth of engagement with 85.076% (7,095,348/8,340,005) of screen views occurring within the Self-monitoring and Feedback module. In addition, a peak of both frequency and amount of time spent per session was observed in the evenings. Conclusions: Visualizations play an important role in understanding engagement with behavior change apps. Here, we discuss how simple visualizations helped identify important patterns of engagement with Drink Less. Our visualizations of behavioral engagement suggest that the daily notification substantially impacts engagement. Furthermore, the visualizations suggest that a fixed notification policy can be effective for maintaining engagement for some users but ineffective for others. We conclude that optimizing the notification policy to target both effectiveness and engagement is a worthwhile investment. Our future goal is to both understand the causal effect of the notification on engagement and further optimize the notification policy within Drink Less by tailoring to contextual circumstances of individuals over time. Such tailoring will be informed from the findings of our micro-randomized trial (MRT), and these visualizations were useful in both gaining a better understanding of engagement and designing the MRT. %M 33306026 %R 10.2196/23369 %U http://www.jmir.org/2020/12/e23369/ %U https://doi.org/10.2196/23369 %U http://www.ncbi.nlm.nih.gov/pubmed/33306026 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e18513 %T Mobile Health Apps for Medical Emergencies: Systematic Review %A Plaza Roncero,Alejandro %A Marques,Gonçalo %A Sainz-De-Abajo,Beatriz %A Martín-Rodríguez,Francisco %A del Pozo Vegas,Carlos %A Garcia-Zapirain,Begonya %A de la Torre-Díez,Isabel %+ eVIDA Research Group, University of Deusto, Avda/ Universidades 24, Bilbao, 48007, Spain, 34 619967223, mbgarciazapi@deusto.es %K mobile health %K mHealth %K eHealth %K Android %K iOS %K medical emergencies %K mobile apps %D 2020 %7 11.12.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Mobile health apps are used to improve the quality of health care. These apps are changing the current scenario in health care, and their numbers are increasing. Objective: We wanted to perform an analysis of the current status of mobile health technologies and apps for medical emergencies. We aimed to synthesize the existing body of knowledge to provide relevant insights for this topic. Moreover, we wanted to identify common threads and gaps to support new challenging, interesting, and relevant research directions. Methods: We reviewed the main relevant papers and apps available in the literature. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was used in this review. The search criteria were adopted using systematic methods to select papers and apps. On one hand, a bibliographic review was carried out in different search databases to collect papers related to each application in the health emergency field using defined criteria. On the other hand, a review of mobile apps in two virtual storage platforms (Google Play Store and Apple App Store) was carried out. The Google Play Store and Apple App Store are related to the Android and iOS operating systems, respectively. Results: In the literature review, 28 papers in the field of medical emergency were included. These studies were collected and selected according to established criteria. Moreover, we proposed a taxonomy using six groups of applications. In total, 324 mobile apps were found, with 192 identified in the Google Play Store and 132 identified in the Apple App Store. Conclusions: We found that all apps in the Google Play Store were free, and 73 apps in the Apple App Store were paid, with the price ranging from US $0.89 to US $5.99. Moreover, 39% (11/28) of the included studies were related to warning systems for emergency services and 21% (6/28) were associated with disaster management apps. %M 33306037 %R 10.2196/18513 %U http://mhealth.jmir.org/2020/12/e18513/ %U https://doi.org/10.2196/18513 %U http://www.ncbi.nlm.nih.gov/pubmed/33306037 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e23157 %T Experiences, Attitudes, and Needs of Users of a Pregnancy and Parenting App (Baby Buddy) During the COVID-19 Pandemic: Mixed Methods Study %A Rhodes,Alexandra %A Kheireddine,Sara %A Smith,Andrea D %+ Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 20 7679 2000, alexandra.rhodes.15@ucl.ac.uk %K pregnancy %K parenting %K app %K COVID-19 %K pregnancy support %K postnatal support %K perinatal %K mental well-being %K physical well-being %K support %K well-being %K experience %K attitude %K needs %D 2020 %7 9.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The COVID-19 pandemic has impacted the lives of expectant parents and parents of young babies, with disruptions in health care provision and loss of social support. Objective: This study investigated the impact of the COVID-19 pandemic and its associated lockdown on this population through the lens of users of the UK National Health Service–approved pregnancy and parenting smartphone app, Baby Buddy. The study aims were threefold: to gain insights into the attitudes and experiences of expectant and recent parents (with babies under 24 weeks of age) during the COVID-19 pandemic; to investigate whether Baby Buddy is meeting users’ needs during this time; and to identify ways to revise the content of Baby Buddy to better support its users now and in future. Methods: A mixed methods study design combining a web-based survey with semistructured telephone interviews among Baby Buddy users in the United Kingdom was applied. Data were collected from April 15 to mid-June 2020, corresponding to weeks 4-13 of the lockdown in the United Kingdom. Results: A total of 436 expectant (n=244, 56.0%) and recent (n=192, 44.0%) parents responded to the web-based survey, of which 79.1% (n=345) were aged 25-39 years and 17.2% (n=75) spoke English as their second language. Of the 436 respondents, 88.5% (386/436) reported increased levels of anxiety around pregnancy, birth, and being a new parent, and 58.0% (253/436) were concerned about their emotional and mental health. Of the 244 pregnant respondents, 43.4% (n=106) were concerned about their physical health. Telephone interviews with 13 pregnant women and 19 recent parents revealed similarly increased levels of anxiety due to reduced health care provision and loss of support from friends and family. Although a minority of respondents identified some positive outcomes of lockdown, such as family bonding, many telephone interviewees reported feeling isolated, disregarded, and overwhelmed. Recent parents were particularly anxious about the impact of the lockdown on their baby’s development and socialization. Many interviewees were also concerned about their physical health as a consequence of both limited access to face-to-face medical appointments and their own poorer dietary and physical activity behaviors. Across both samples, 97.0% (423/436) of respondents reported that Baby Buddy was currently helping them, with many commenting that its role was even more important given the lack of face-to-face support from health care and parenting organizations. Greater speed in updating digital content to reflect changes due to the pandemic was suggested. Conclusions: The COVID-19 pandemic has created heightened anxiety and stress among expectant parents and those with a young baby, and for many, lockdown has had an adverse impact on their physical and mental well-being. With reductions in health care and social support, expectant and new parents are increasingly relying on web-based resources. As a free, evidence-based app, Baby Buddy is well positioned to meet this need. The app could support its users even more by actively directing them to the wealth of existing content relevant to their concerns and by adding content to give users the knowledge and confidence to meet new challenges. %M 33264100 %R 10.2196/23157 %U http://mhealth.jmir.org/2020/12/e23157/ %U https://doi.org/10.2196/23157 %U http://www.ncbi.nlm.nih.gov/pubmed/33264100 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e19991 %T A Mobile Social Networking App for Weight Management and Physical Activity Promotion: Results From an Experimental Mixed Methods Study %A Laranjo,Liliana %A Quiroz,Juan C %A Tong,Huong Ly %A Arevalo Bazalar,Maria %A Coiera,Enrico %+ Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera road, Sydney, 2113, Australia, 61 413461852, liliana.laranjo@mq.edu.au %K mobile apps %K fitness trackers %K exercise %K social networking %K body weight maintenance %K mobile phone %D 2020 %7 8.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Smartphone apps, fitness trackers, and online social networks have shown promise in weight management and physical activity interventions. However, there are knowledge gaps in identifying the most effective and engaging interventions and intervention features preferred by their users. Objective: This 6-month pilot study on a social networking mobile app connected to wireless weight and activity tracking devices has 2 main aims: to evaluate changes in BMI, weight, and physical activity levels in users from different BMI categories and to assess user perspectives on the intervention, particularly on social comparison and automated self-monitoring and feedback features. Methods: This was a mixed methods study involving a one-arm, pre-post quasi-experimental pilot with postintervention interviews and focus groups. Healthy young adults used a social networking mobile app intervention integrated with wireless tracking devices (a weight scale and a physical activity tracker) for 6 months. Quantitative results were analyzed separately for 2 groups—underweight-normal and overweight-obese BMI—using t tests and Wilcoxon sum rank, Wilcoxon signed rank, and chi-square tests. Weekly BMI change in participants was explored using linear mixed effects analysis. Interviews and focus groups were analyzed inductively using thematic analysis. Results: In total, 55 participants were recruited (mean age of 23.6, SD 4.6 years; 28 women) and 45 returned for the final session (n=45, 82% retention rate). There were no differences in BMI from baseline to postintervention (6 months) and between the 2 BMI groups. However, at 4 weeks, participants’ BMI decreased by 0.34 kg/m2 (P<.001), with a loss of 0.86 kg/m2 in the overweight-obese group (P=.01). Participants in the overweight-obese group used the app significantly less compared with individuals in the underweight-normal BMI group, as they mentioned negative feelings and demotivation from social comparison, particularly from upward comparison with fitter people. Participants in the underweight-normal BMI group were avid users of the app’s self-monitoring and feedback (P=.02) and social (P=.04) features compared with those in the overweight-obese group, and they significantly increased their daily step count over the 6-month study duration by an average of 2292 steps (95% CI 898-3370; P<.001). Most participants mentioned a desire for a more personalized intervention. Conclusions: This study shows the effects of different interventions on participants from higher and lower BMI groups and different perspectives regarding the intervention, particularly with respect to its social features. Participants in the overweight-obese group did not sustain a short-term decrease in their BMI and mentioned negative emotions from app use, while participants in the underweight-normal BMI group used the app more frequently and significantly increased their daily step count. These differences highlight the importance of intervention personalization. Future research should explore the role of personalized features to help overcome personal barriers and better match individual preferences and needs. %M 33289670 %R 10.2196/19991 %U http://www.jmir.org/2020/12/e19991/ %U https://doi.org/10.2196/19991 %U http://www.ncbi.nlm.nih.gov/pubmed/33289670 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e18439 %T A Mobile Phone–Based App for Use During Cognitive Behavioral Therapy for Adolescents With Anxiety (MindClimb): User-Centered Design and Usability Study %A Newton,Amanda %A Bagnell,Alexa %A Rosychuk,Rhonda %A Duguay,Janelle %A Wozney,Lori %A Huguet,Anna %A Henderson,Joanna %A Curran,Janet %+ Department of Psychiatry, Dalhousie University, PO Box 9700, 5850/5980 University Avenue, Halifax, NS, B3K 6R8, Canada, 1 902 470 8087, Alexa.Bagnell@iwk.nshealth.ca %K anxiety disorders %K mobile apps %K adolescents %K usability testing %K development %K design %K anxiety %D 2020 %7 8.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile device–based tools to help adolescents practice skills outside of cognitive behavioral therapy (CBT) sessions for treating an anxiety disorder may lead to greater treatment gains. Objective: This study aimed to develop, design, and test the acceptability, learnability, heuristics, and usability of MindClimb, a smartphone-based app for adolescents with anxiety to use between CBT sessions to plan and complete exposure activities using skills (cognitive, relaxation, exposure practice, and reward) learned in treatment. Methods: This 3-phase study took place from August 2015 to December 2018. In phase 1, the app was designed and developed in consultation with young people and CBT therapists to identify desired functions and content. Feedback was subjected to thematic analysis using a general inductive approach. In phase 2, we conducted 2 high-fidelity testing sessions using the think-aloud approach (acceptability, learnability, usability) and 10-item System Usability Scale with 10 adolescents receiving CBT. The high-fidelity MindClimb app was evaluated by 5 app developers based on Nielsen’s usability heuristics and 5-point severity ranking scale. In phase 3, a total of 8 adolescents and 3 therapists assessed the usability of MindClimb during CBT sessions by recording the frequency of skills practice, use of MindClimb features, satisfaction with the app, and barriers and facilitators to app use during treatment. Results: Feedback from phase 1 consultations indicated that the app should (1) be responsive to user needs and preferences, (2) be easy to use and navigate, (3) have relevant content to the practice of CBT for anxiety, and (4) be aesthetically appealing. Using this feedback as a guide, a fully functional app prototype for usability testing and heuristic evaluation was developed. In phase 2, think-aloud and usability data resulted in minor revisions to the app, including refinement of exposure activities. The average system usability score was 77 in both testing cycles, indicating acceptable usability. The heuristic evaluation by app developers identified only minor errors (eg, loading speed of app content, with a score of 1 on the severity ranking scale). In phase 3, adolescents considered app features for completing exposure (6.2/10) and relaxation (6.4/10) modestly helpful. Both adolescents (average score 11.3/15, SD 1.6) and therapists (average score 10.0/12, 2.6 SD) reported being satisfied with the app. Conclusions: The user-centered approach to developing and testing MindClimb resulted in a mobile health app that can be used by adolescents during CBT for anxiety. Evaluation of the use of this app in a clinical practice setting demonstrated that adolescents and therapists generally felt it was helpful for CBT practice outside of therapy sessions. Implementation studies with larger youth samples are necessary to evaluate how to optimize the use of technology in clinical care and examine the impact of the app plus CBT on clinical care processes and patient outcomes. %M 33289671 %R 10.2196/18439 %U https://mhealth.jmir.org/2020/12/e18439 %U https://doi.org/10.2196/18439 %U http://www.ncbi.nlm.nih.gov/pubmed/33289671 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e17536 %T Feasibility of a Digital Health Intervention to Improve Diet Quality Among Women With High Blood Pressure: Randomized Controlled Feasibility Trial %A Steinberg,Dori M %A Kay,Melissa C %A Svetkey,Laura P %A Askew,Sandy %A Christy,Jacob %A Burroughs,Jasmine %A Ahmed,Hira %A Bennett,Gary G %+ Duke University School of Nursing, 307 Trent Drive, DUMC 3322, Durham, NC, 27710, United States, 1 919 613 9439, dori.steinberg@duke.edu %K hypertension %K DASH dietary pattern %K digital health %K nutrition %K women’s health %K mHealth %D 2020 %7 7.12.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Over 100 million individuals have high blood pressure, and more than half of them are women. The Dietary Approaches to Stop Hypertension (DASH) dietary pattern is a proven lifestyle approach to lower blood pressure, yet population-level adherence is poor. Innovative strategies that promote DASH are needed. Objective: This paper aims to improve adherence to the DASH diet among women with hypertension or prehypertension. Methods: We conducted a 3-month randomized controlled feasibility trial comparing app-based diet tracking (active comparator) to app-based diet tracking plus feedback on DASH adherence via text message (intervention). The intervention platform extracted nutrient data from the app, compared it to DASH recommendations, and sent tailored feedback text messages. Outcomes included the number of days participants tracked their diet, changes in their DASH adherence score, and blood pressure. Results: The women (N=59) had a mean age of 49.9 (SD 11.9) years and were primarily non-Hispanic White (41/59, 69%) and college educated (49/59, 83%). The mean baseline DASH score was 2.3 (SD 1.3). At 3 months, the intervention and active comparator participants had similar mean days tracked per week (4.2, SD 2.1 days vs 4.6, SD 2.7 days; P=.54) and mean changes in their DASH score (0.8, 95% CI 0.2-1.5 vs 0.8, 95% CI 0.4-1.2; P=.75). Intervention participants had lower systolic (mean difference: –2.8 mmHg, 95% CI –1.8 to 7.4; P=.23) and diastolic (mean difference: –3.6 mmHg, 95% CI –0.2 to 7.3; P=.07) blood pressure compared with active comparator participants. Most intervention participants (23/29, 79%) said they would recommend the DASH Cloud intervention to a friend or family member. However, only 34% (10/59) indicated that the feedback text messages helped them reach their diet goals. Conclusions: A digital health intervention to improve DASH adherence is feasible and produces moderately high engagement among women with elevated blood pressure. The intervention did not enhance DASH adherence over diet tracking alone but resulted in greater reductions in blood pressure. Larger studies are needed to determine how digital health interventions can improve population-level adherence to DASH. Trial Registration: ClinicalTrials.gov NCT03215472; https://clinicaltrials.gov/ct2/show/study/NCT03215472 %M 33284116 %R 10.2196/17536 %U https://mhealth.jmir.org/2020/12/e17536 %U https://doi.org/10.2196/17536 %U http://www.ncbi.nlm.nih.gov/pubmed/33284116 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 12 %P e15602 %T Use of Different Food Image Recognition Platforms in Dietary Assessment: Comparison Study %A Van Asbroeck,Stephanie %A Matthys,Christophe %+ Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinology, KU Leuven, Herestraat 49, DIEET, Leuven, Belgium, 32 016 34 26 55, christophe.matthys@uzleuven.be %K image recognition %K dietary assessment %K automated food recognition %K accuracy %D 2020 %7 7.12.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: In the domain of dietary assessment, there has been an increasing amount of criticism of memory-based techniques such as food frequency questionnaires or 24 hour recalls. One alternative is logging pictures of consumed food followed by an automatic image recognition analysis that provides information on type and amount of food in the picture. However, it is currently unknown how well commercial image recognition platforms perform and whether they could indeed be used for dietary assessment. Objective: This is a comparative performance study of commercial image recognition platforms. Methods: A variety of foods and beverages were photographed in a range of standardized settings. All pictures (n=185) were uploaded to selected recognition platforms (n=7), and estimates were saved. Accuracy was determined along with totality of the estimate in the case of multiple component dishes. Results: Top 1 accuracies ranged from 63% for the application programming interface (API) of the Calorie Mama app to 9% for the Google Vision API. None of the platforms were capable of estimating the amount of food. These results demonstrate that certain platforms perform poorly while others perform decently. Conclusions: Important obstacles to the accurate estimation of food quantity need to be overcome before these commercial platforms can be used as a real alternative for traditional dietary assessment methods. %M 33284118 %R 10.2196/15602 %U https://formative.jmir.org/2020/12/e15602 %U https://doi.org/10.2196/15602 %U http://www.ncbi.nlm.nih.gov/pubmed/33284118 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 12 %P e22996 %T An Artificial Intelligence–Based, Personalized Smartphone App to Improve Childhood Immunization Coverage and Timelines Among Children in Pakistan: Protocol for a Randomized Controlled Trial %A Kazi,Abdul Momin %A Qazi,Saad Ahmed %A Khawaja,Sadori %A Ahsan,Nazia %A Ahmed,Rao Moueed %A Sameen,Fareeha %A Khan Mughal,Muhammad Ayub %A Saqib,Muhammad %A Ali,Sikander %A Kaleemuddin,Hussain %A Rauf,Yasir %A Raza,Mehreen %A Jamal,Saima %A Abbasi,Munir %A Stergioulas,Lampros K %+ Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800, Pakistan, 92 2134864232, momin.kazi@aku.edu %K artificial intelligence %K AI %K routine childhood immunization %K EPI %K LMICs %K mHealth %K Pakistan %K personalized messages %K routine immunization %K smartphone apps %K vaccine-preventable illnesses %D 2020 %7 4.12.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The immunization uptake rates in Pakistan are much lower than desired. Major reasons include lack of awareness, parental forgetfulness regarding schedules, and misinformation regarding vaccines. In light of the COVID-19 pandemic and distancing measures, routine childhood immunization (RCI) coverage has been adversely affected, as caregivers avoid tertiary care hospitals or primary health centers. Innovative and cost-effective measures must be taken to understand and deal with the issue of low immunization rates. However, only a few smartphone-based interventions have been carried out in low- and middle-income countries (LMICs) to improve RCI. Objective: The primary objectives of this study are to evaluate whether a personalized mobile app can improve children’s on-time visits at 10 and 14 weeks of age for RCI as compared with standard care and to determine whether an artificial intelligence model can be incorporated into the app. Secondary objectives are to determine the perceptions and attitudes of caregivers regarding childhood vaccinations and to understand the factors that might influence the effect of a mobile phone–based app on vaccination improvement. Methods: A mixed methods randomized controlled trial was designed with intervention and control arms. The study will be conducted at the Aga Khan University Hospital vaccination center. Caregivers of newborns or infants visiting the center for their children’s 6-week vaccination will be recruited. The intervention arm will have access to a smartphone app with text, voice, video, and pictorial messages regarding RCI. This app will be developed based on the findings of the pretrial qualitative component of the study, in addition to no-show study findings, which will explore caregivers’ perceptions about RCI and a mobile phone–based app in improving RCI coverage. Results: Pretrial qualitative in-depth interviews were conducted in February 2020. Enrollment of study participants for the randomized controlled trial is in process. Study exit interviews will be conducted at the 14-week immunization visits, provided the caregivers visit the immunization facility at that time, or over the phone when the children are 18 weeks of age. Conclusions: This study will generate useful insights into the feasibility, acceptability, and usability of an Android-based smartphone app for improving RCI in Pakistan and in LMICs. Trial Registration: ClinicalTrials.gov NCT04449107; https://clinicaltrials.gov/ct2/show/NCT04449107 International Registered Report Identifier (IRRID): DERR1-10.2196/22996 %M 33274726 %R 10.2196/22996 %U https://www.researchprotocols.org/2020/12/e22996 %U https://doi.org/10.2196/22996 %U http://www.ncbi.nlm.nih.gov/pubmed/33274726 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e22757 %T Web-Based Relaxation Intervention for Stress During Social Isolation: Randomized Controlled Trial %A Pizzoli,Silvia Francesca Maria %A Marzorati,Chiara %A Mazzoni,Davide %A Pravettoni,Gabriella %+ University of Milan, Department of Oncology and Hematology-Oncology, Via Festa del Perdono 7, Milan, 20122, Italy, 39 0294372099, silviafrancescamaria.pizzoli@ieo.it %K relaxation %K guided meditation %K web-based intervention %K social isolation %K intervention %K COVID-19 %K anxiety %K stress %K internet %D 2020 %7 3.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Relaxation practices might be helpful exercises for coping with anxiety and stressful sensations. They may be of particular utility when used in web-based interventions during periods of social isolation. Objective: This randomized study aimed to test whether web-based relaxation practices like natural sounds, deep respiration, and body scans can promote relaxation and a positive emotional state, and reduce psychomotor activation and preoccupation related to the COVID-19 pandemic. Methods: Participants were randomly assigned to one of three experimental conditions. Each condition was characterized by a single online session of a guided square breathing exercise, a guided body scan exercise, or natural sounds. The participants listened to one of the fully automated audio clips for 7 minutes and pre-post completed self-assessed scales on perceived relaxation, psychomotor activation, level of preoccupation associated with COVID-19, and emotional state. At the end of the session, qualitative reports on subjective experience were also collected. Results: Overall, 294 participants completed 75% of the survey and 240 completed the entire survey as well as one of three randomly assigned interventions. Perceived relaxation, psychomotor activation/stress, and preoccupation related to COVID-19 showed a positive improvement after participants listened to the audio clips. The same pattern was observed for the valence and perceived dominance of the emotional state. The square breathing and body scan exercises yielded superior results compared to natural sounds in lowering perceived stress. Conclusions: This study provides a novel insight that can guide the development of future low-cost web-based interventions to reduce preoccupation and stress in the general population. International Registered Report Identifier (IRRID): RR2-10.2196/19236 %M 33200990 %R 10.2196/22757 %U https://mental.jmir.org/2020/12/e22757 %U https://doi.org/10.2196/22757 %U http://www.ncbi.nlm.nih.gov/pubmed/33200990 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e23273 %T Effectiveness of WeChat for Improving Exclusive Breastfeeding in Huzhu County China: Randomized Controlled Trial %A Wu,Qiong %A Huang,Yiwen %A Liao,Zijun %A van Velthoven,Michelle Helena %A Wang,Wei %A Zhang,Yanfeng %+ Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China, 86 10 85695554, summyzh@126.com %K breastfeeding %K exclusive breastfeeding %K WeChat %K mHealth %K randomized controlled trial %D 2020 %7 3.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The benefits of breastfeeding for both infants and mothers have been well recognized. However, the exclusive breastfeeding rate in China is low and decreasing. Mobile technologies have rapidly developed; communication apps such as WeChat (one of the largest social networking platforms in China) are widely used and have the potential to conveniently improve health behaviors. Objective: This study aimed to assess the effectiveness of using WeChat to improve breastfeeding practices. Methods: This 2-arm randomized controlled trial was conducted among pregnant women from May 2019 to April 2020 in Huzhu County, Qinghai Province, China. Pregnant women were eligible to participate if they were aged 18 years or older, were 11 to 37 weeks pregnant with a singleton fetus, had no known illness that could limit breastfeeding after childbirth, used WeChat through their smartphone, and had access to the internet. A total of 344 pregnant women were recruited at baseline, with 170 in the intervention group and 174 in the control group. Women in the intervention group received breastfeeding knowledge and promotion information weekly through a WeChat official account from their third month of pregnancy to 6 months postpartum. The primary outcome of exclusive and predominant breastfeeding rate was measured 0-1 month, 2-3 months, and 4-5 months postpartum. Results: At 0-1 month postpartum, the exclusive breastfeeding rate was significantly higher in the intervention group than that in the control group (81.1% vs 63.3%; odds ratio [OR] 2.75, 95% CI 1.58-4.78; P<.001). Similarly, mothers in the intervention group were more likely to provide predominantly breast milk (OR 2.77, 95% CI 1.55-4.96; P<.001) and less likely to give dairy products to their children (OR 0.40, 95% CI 0.21-0.75; P=.005). There was no statistically significant difference for exclusive breastfeeding rate 2-3 months (P=.09) and 4-5 months postpartum (P=.27), though more children in the intervention group were exclusively breastfed than those in the control group 2-3 months postpartum (intervention: 111/152, 73.0%; control: 96/152, 63.2%) and 4-5 months postpartum(intervention: 50/108, 46.3%; control: 46/109, 42.2%). Conclusions: This study is the first effort to promote exclusive breastfeeding through WeChat in China, which proved to be an effective method of promoting exclusive breastfeeding in early life. WeChat health education can be used in addition to local breastfeeding promotion programs. Trial Registration: Chinese Clinical Trial Registry ChiCTR1800017364; http://www.chictr.org.cn/showproj.aspx?proj=29325 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-019-7676-2 %M 33270026 %R 10.2196/23273 %U https://www.jmir.org/2020/12/e23273 %U https://doi.org/10.2196/23273 %U http://www.ncbi.nlm.nih.gov/pubmed/33270026 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 6 %N 4 %P e18950 %T Outcomes of the Deployment of the Auto-Visual Acute Flaccid Paralysis Detection and Reporting (AVADAR) System for Strengthening Polio Surveillance in Africa From 2017 to 2018: Evaluation Study %A Ticha,Johnson Muluh %A Akpan,Godwin Ubong %A Paige,Lara MF %A Senouci,Kamel %A Stein,Andrew %A Briand,Patrick %A Tuma,Jude %A Oyaole,Daniel Rasheed %A Ngofa,Reuben %A Maleghemi,Sylvester %A Touray,Kebba %A Salihu,Abdullahi Ahmed %A Diallo,Mamadou %A Tegegne,Sisay Gashu %A Bello,Isah Mohammed %A Idris,Umar Kabo %A Maduka,Omosivie %A Manengu,Casimir %A Shuaib,Faisal %A Galway,Michael %A Mkanda,Pascal %+ World Health Organization Regional Office for Africa, Cite Du Djoue, Brazzaville, 500101, Congo, 242 055736476, akpang@who.int %K Auto-Visual Acute Flaccid Paralysis Detection and Reporting %K surveillance %K informants %K acute flaccid paralysis %K smartphones %K polio %D 2020 %7 2.12.2020 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: As we move toward a polio-free world, the challenge for the polio program is to create an unrelenting focus on smaller areas where the virus is still present, where children are being repeatedly missed, where immunity levels are low, and where surveillance is weak. Objective: This article aimed to describe a possible solution to address weak surveillance systems and document the outcomes of the deployment of the Auto-Visual Acute Flaccid Paralysis Detection and Reporting (AVADAR) project. Methods: This intervention was implemented in 99 targeted high-risk districts with concerns for silent polio circulation from eight countries in Africa between August 1, 2017, and July 31, 2018. A total of 6954 persons (5390 community informants and 1564 health workers) were trained and equipped with a smartphone on which the AVADAR app was configured to allow community informants to send alerts on suspected acute flaccid paralysis (AFP) and allow health worker to use electronic checklists for investigation of such alerts. The AVADAR and Open Data Kit ONA servers were at the center of the entire process. A dashboard system and coordination teams for monitoring and supervision were put in place at all levels. Results: Overall, 96.44% (24,142/25,032) of potential AFP case alerts were investigated by surveillance personnel, yielding 1414 true AFP cases. This number (n=1414) reported through AVADAR was higher than the 238 AFP cases expected during the study period in the AVADAR districts and the 491 true AFP cases reported by the traditional surveillance system. A total of 203 out of the 1414 true AFP cases reported were from special population settings, such as refugee camps and insecure areas. There was an improvement in reporting in silent health areas in all the countries using the AVADAR system. Finally, there were 23,473 reports for other diseases, such as measles, diarrhea, and cerebrospinal meningitis, using the AVADAR platform. Conclusions: This article demonstrates the added value of AVADAR to rapidly improve surveillance sensitivity. AVADAR is capable of supporting countries to improve surveillance sensitivity within a short interval before and beyond polio-free certification. %M 33263550 %R 10.2196/18950 %U http://publichealth.jmir.org/2020/4/e18950/ %U https://doi.org/10.2196/18950 %U http://www.ncbi.nlm.nih.gov/pubmed/33263550 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 12 %P e20325 %T Care Me Too, a Mobile App for Engaging Chinese Immigrant Caregivers in Self-Care: Qualitative Usability Study %A Liu,Mandong %A Jiang,Tongge %A Yu,Kexin %A Wu,Shinyi %A Jordan-Marsh,Maryalice %A Chi,Iris %+ Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 W 34th St, Los Angeles, CA, 90089, United States, 86 176 6259 0259, mandongl@usc.edu %K mHealth %K co-design %K usability %K acceptability %K immigrant %K caregiver %K mobile phone %D 2020 %7 2.12.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Caregiving and self-care are challenging for Chinese immigrants in the United States due to limited accessible support and resources. Few interventions exist to assist Chinese immigrant caregivers in better performing self-care. To address this gap in the literature, our team developed the Care Me Too app to engage Chinese immigrant caregivers in self-care and conducted a user experience test to assess its usability and acceptability. Objective: This paper aims to report the results of the app’s usability and acceptability testing with Chinese immigrant caregivers and to solicit participants’ feedback of the app design and functions. Methods: A total of 22 Mandarin-speaking Chinese caregivers participated in the study, which consisted of 2 parts: the in-lab testing and the 1-week at-home testing. In-depth face-to-face interviews and follow-up phone interviews were used to assess user experience of the app’s usability and acceptability and to solicit feedback for app design and functions. Directed content analysis was used to analyze the qualitative data. Results: Among the 22 participants, the average age was 60.5 (SD 8.1) years, ranging from 46 to 80 years; 17 (77%) participants were women and 14 (64%) had an associate degree or higher. Participants reported uniformly positive ratings of the usability and acceptability of the app and provided detailed suggestions for app improvement. We generated guidelines for mobile health (mHealth) app designs targeting immigrant caregivers, including weighing flexibility versus majority preferences, increasing text sizes, using colors effectively, providing engaging and playful visual designs and functions, simplifying navigation, simplifying the log-in process, improving access to and the content on the help document, designing functions to cater to the population’s context, and ensuring offline access. Conclusions: The main contribution of this study is the improved understanding of Chinese caregivers’ user experiences with a language-appropriate mHealth app for a population that lacks accessible caregiving and self-care resources and support. It is recommended that future researchers and app designers consider the proposed guidelines when developing mHealth apps for their population to enhance user experience and harness mHealth’s value. %M 33263552 %R 10.2196/20325 %U https://formative.jmir.org/2020/12/e20325 %U https://doi.org/10.2196/20325 %U http://www.ncbi.nlm.nih.gov/pubmed/33263552 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 12 %P e14296 %T Usage and Acceptability of the iBobbly App: Pilot Trial for Suicide Prevention in Aboriginal and Torres Strait Islander Youth %A Tighe,Joseph %A Shand,Fiona %A McKay,Kathy %A Mcalister,Taylor-Jai %A Mackinnon,Andrew %A Christensen,Helen %+ Black Dog Institute, Hospital Rd, Randwick, Sydney, Australia, 61 292824530, joetighe@hotmail.com %K mHealth %K suicide %K depression %K eHealth %K Indigenous %K Aboriginal %K First Nations %K mental health %K suicide ideation %K apps %D 2020 %7 1.12.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The proliferation of mental health apps purporting to target and improve psychological wellbeing is ever-growing and also concerning: Few apps have been rigorously evaluated, and, indeed, the safety of the vast majority of them has not been determined. Over 10,000 self-help apps exist but most are not used much after being downloaded. Gathering and analyzing usage data and the acceptability of apps are critical to inform consumers, researchers, and app developers. Objective: This paper presents pilot usage and acceptability data from the iBobbly suicide prevention app, an app distributed through a randomized controlled trial. Methods: Aboriginal and Torres Strait Islander participants from the Kimberley region of Western Australia completed a survey measuring their technology use in general (n=13), and data on their experiences with and views of the iBobbly app were also collected in semistructured interviews (n=13) and thematically analyzed. Finally, engagement with the app, such as the number of sessions completed and time spent on various acceptance-based therapeutic activities, was analyzed (n=18). Both groups were participants in the iBobbly app pilot randomized controlled trial (n=61) completed in 2015. Results: Regression analysis indicated that app use improved psychological outcomes, although only minimally, and effects were not significant. However, results of the thematic analysis indicated that the iBobbly app was deemed effective, acceptable, and culturally appropriate by those interviewed. Conclusions: There is a scarcity of randomized controlled trials and eHealth interventions in Indigenous communities, while extremely high rates of psychological distress and suicide persist. In this environment, studies that can add evidence from mixed-methods approaches are important. While the regression analysis in this study did not indicate a significant effect of app use on psychological wellbeing, this was predictable considering the small sample size (n=18) and typically brief app use. The results on engagement with the iBobbly app were however positive. This study showed that Indigenous youth are early and frequent users of technology in general, and they regarded the iBobbly app to be culturally safe and of therapeutic value. Qualitative analyses demonstrated that iBobbly app use was associated with self-reported improvements in psychological wellbeing, mental health literacy, and reductions in shame. Importantly, participants reported that they would recommend other similar apps if available to their peers. %M 33258782 %R 10.2196/14296 %U https://mental.jmir.org/2020/12/e14296 %U https://doi.org/10.2196/14296 %U http://www.ncbi.nlm.nih.gov/pubmed/33258782 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e23377 %T The Reach, Use, and Impact of a Free mHealth Mindfulness App in the General Population: Mobile Data Analysis %A Kozlov,Elissa %A Bantum,Erin %A Pagano,Ian %A Walser,Robyn %A Ramsey,Kelly %A Taylor,Katherine %A Jaworski,Beth %A Owen,Jason %+ Institute for Health, Health Policy and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ, 08901, United States, 1 9147153012, elissa.kozlov@rutgers.edu %K mHealth %K mindfulness %K mHealth psychotherapy %K mHealth mindfulness %K public health %K self-management %K mental health %D 2020 %7 27.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: As smartphones are now used by most Americans, it is increasingly possible for mental health mobile apps to be disseminated to the general public. However, little is known about how mobile mental health apps are used by the general population outside of a controlled research design. Objective: Our objective is to describe how the general population engages with Mindfulness Coach, an iOS- and Android-based app designed to deliver a mindfulness training course. Methods: Using anonymous download and analytics data, we characterized the reach, usage, retention, and impact of Mindfulness Coach. We included mobile analytics data from all unique downloads of Mindfulness Coach between August 1, 2018, and April 8, 2019 (N=104,067) as well as starred reviews from all Mindfulness Coach users who provided reviews of the app as of March 1, 2020. Mindfulness characteristics were measured by an in-app assessment using the Five-Facet Mindfulness Questionnaire–Short Form (FFMQ-SF). Results: Users engaged, on average, in 4.3 visits to the app (SD 8.8; median 2; 90th percentile 8) and associated with an average total of 49.2 interactions with the app (ie, clicks within the app) (SD 113.8; median 19; 90th percentile 105). Users spent an average of 16.2 minutes (SD 63.1) engaged with the app over the full study time period. There were strong linear effects of app engagement on total FFMQ-SF scores. For example, FFMQ-SF scores were associated with more time spent engaged with the app (R2=.23; P<.001). Mindfulness Coach has been reviewed in the Google Play Store 3415 times, with an average rating of 4.7 out of 5 stars, and over 2000 times in the Apple App Store, with an average rating of 4.8 out of 5 stars. Conclusions: These findings suggest that Mindfulness Coach has achieved substantial and sustained reach in the general population; however, it was used less frequently by many downloaders than researchers and designers intended. There was a subpopulation of users who engaged in the app regularly over an extended period of time, and there was a clear relationship between app use and improvements in mindfulness. To strengthen Mindfulness Coach’s public health impact, more research is needed to understand who is using the app and how, and to design strategies to increase user engagement in order for users to receive a larger dose of mindfulness treatment. %M 33245289 %R 10.2196/23377 %U http://mental.jmir.org/2020/11/e23377/ %U https://doi.org/10.2196/23377 %U http://www.ncbi.nlm.nih.gov/pubmed/33245289 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e18889 %T Self-Monitoring App Preferences for Sun Protection: Discrete Choice Experiment Survey Analysis %A Nittas,Vasileios %A Mütsch,Margot %A Braun,Julia %A Puhan,Milo Alan %+ Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Hirschengraben 84, Zurich, 8001, Switzerland, 41 44 63 44946, vasileios.nittas@uzh.ch %K preventive medicine %K mHealth %K telemedicine %K health informatics %K health economics %K preferences %K sun protection %D 2020 %7 27.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The availability and use of health apps continues to increase, revolutionizing the way mobile health interventions are delivered. Apps are increasingly used to prevent disease, improve well-being, and promote healthy behavior. On a similar rise is the incidence of skin cancers. Much of the underlying risk can be prevented through behavior change and adequate sun protection. Self-monitoring apps have the potential to facilitate prevention by measuring risk (eg, sun intensity) and encouraging protective behavior (eg, seeking shade). Objective: Our aim was to assess health care consumer preferences for sun protection with a self-monitoring app that tracks the duration and intensity of sun exposure and provides feedback on when and how to protect the skin. Methods: We conducted an unlabeled discrete choice experiment with 8 unique choice tasks, in which participants chose among 2 app alternatives, consisting of 5 preidentified 2-level attributes (self-monitoring method, privacy control, data sharing with health care provides, reminder customizability, and costs) that were the result of a multistep and multistakeholder qualitative approach. Participant preferences, and thus, the relative importance of attributes and their levels were estimated using conditional logit modeling. Analyses consisted of 200 usable surveys, yielding 3196 observations. Results: Our respondents strongly preferred automatic over manually operated self-monitoring (odds ratio [OR] 2.37, 95% CI 2.06-2.72) and no cost over a single payment of 3 Swiss francs (OR 1.72, 95% CI 1.49-1.99). They also preferred having over not having the option of sharing their data with a health care provider of their choice (OR 1.66, 95% CI 1.40-1.97), repeated over single user consents, whenever app data are shared with commercial thirds (OR 1.57, 95% CI 1.31-1.88), and customizable over noncustomizable reminders (OR 1.30, 95% CI 1.09-1.54). While most participants favored thorough privacy infrastructures, the attribute of privacy control was a relatively weak driver of app choice. The attribute of self-monitoring method significantly interacted with gender and perceived personal usefulness of health apps, suggesting that female gender and lower perceived usefulness are associated with relatively weaker preferences for automatic self-monitoring. Conclusions: Based on the preferences of our respondents, we found that the utility of a self-monitoring sun protection app can be increased if the app is simple and adjustable; requires minimal effort, time, or expense; and has an interoperable design and thorough privacy infrastructure. Similar features might be desirable for preventive health apps in other areas, paving the way for future discrete choice experiments. Nonetheless, to fully understand these preference dynamics, further qualitative or mixed method research on mobile self-monitoring-based sun protection and broader preventive mobile self-monitoring is required. International Registered Report Identifier (IRRID): RR2-10.2196/16087 %M 33245282 %R 10.2196/18889 %U http://www.jmir.org/2020/11/e18889/ %U https://doi.org/10.2196/18889 %U http://www.ncbi.nlm.nih.gov/pubmed/33245282 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e24718 %T Comparison of Mobile Health Technology Use for Self-Tracking Between Older Adults and the General Adult Population in Canada: Cross-Sectional Survey %A Jaana,Mirou %A Paré,Guy %+ Telfer School of Management, University of Ottawa, 55 Laurier Ave East, Ottawa, ON, K1N 6N5, Canada, 1 16135625800 ext 3400, jaana@telfer.uottawa.ca %K mobile health %K older adults %K self-tracking %K wearable technology %K smart devices %K mobile apps %K survey %K mobile phone %K seniors %K elderly %D 2020 %7 27.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The burden of population aging and chronic conditions has been reported worldwide. Older adults, especially those with high needs, experience social isolation and have high rates of emergency visits and limited satisfaction with the care they receive. Mobile health (mHealth) technologies present opportunities to address these challenges. To date, limited information is available on Canadian older adults’ attitudes toward and use of mHealth technologies for self-tracking purposes—an area that is increasingly important and relevant during the COVID-19 era. Objective: This study presents contributions to an underresearched area on older adults and mHealth technology use. The aim of this study was to compare older adults’ use of mHealth technologies to that of the general adult population in Canada and to investigate the factors that affect their use. Methods: A cross-sectional survey on mHealth and digital self-tracking was conducted. A web-based questionnaire was administered to a national sample of 4109 Canadian residents who spoke either English or French. The survey instrument consisted of 3 sections assessing the following items: (1) demographic characteristics, health status, and comorbidities; (2) familiarity with and use of mHealth technologies (ie, mobile apps, consumer smart devices/wearables such as vital signs monitors, bathroom scales, fitness trackers, intelligent clothing); and (3) factors influencing the continued use of mHealth technologies. Results: Significant differences were observed between the older adults and the general adult population in the use of smart technologies and internet (P<.001). Approximately 47.4% (323/682) of the older adults in the community reported using smartphones and 49.8% (340/682) indicated using digital tablets. Only 19.6% (91/463) of the older adults using smartphones/digital tablets reported downloading mobile apps, and 12.3% (47/383) of the older adults who heard of smart devices/wearables indicated using them. The majority of the mobile apps downloaded by older adults was health-related; interestingly, their use was sustained over a longer period of time (P=.007) by the older adults compared to that by the general population. Approximately 62.7% (428/682) of the older adults reported tracking their health measures, but the majority did so manually. Older adults with one or more chronic conditions were mostly nontrackers (odds ratio 0.439 and 0.431 for traditional trackers and digital trackers, respectively). No significant differences were observed between the older adults and the general adult population with regard to satisfaction with mHealth technologies and their intention to continue using them. Conclusions: Leveraging mHealth technologies in partnership with health care providers and sharing of health/well-being data with health care professionals and family members remain very limited. A culture shift in the provision of care to older adults is deemed necessary to keep up with the development of mHealth technologies and the changing demographics and expectations of patients and their caregivers. %M 33104517 %R 10.2196/24718 %U http://mhealth.jmir.org/2020/11/e24718/ %U https://doi.org/10.2196/24718 %U http://www.ncbi.nlm.nih.gov/pubmed/33104517 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e21771 %T Effectiveness of an mHealth Intervention Combining a Smartphone App and Smart Band on Body Composition in an Overweight and Obese Population: Randomized Controlled Trial (EVIDENT 3 Study) %A Lugones-Sanchez,Cristina %A Sanchez-Calavera,Maria Antonia %A Repiso-Gento,Irene %A Adalia,Esther G %A Ramirez-Manent,J Ignacio %A Agudo-Conde,Cristina %A Rodriguez-Sanchez,Emiliano %A Gomez-Marcos,Manuel Angel %A Recio-Rodriguez,Jose I %A Garcia-Ortiz,Luis %A , %+ Institute of Biomedical Research of Salamanca (IBSAL), Primary Care Research Unit of Salamanca (APISAL), Health Service of Castilla y León (SACyL), Av. Portugal 83, 2nd Fl., Salamanca, 37005, Spain, 34 923 291100 ext 54750, crislugsa@gmail.com %K diet records %K mobile app %K telemedicine %K electric impedance %K obesity %K body fat distribution %K weight control %D 2020 %7 26.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) is currently among the supporting elements that may contribute to an improvement in health markers by helping people adopt healthier lifestyles. mHealth interventions have been widely reported to achieve greater weight loss than other approaches, but their effect on body composition remains unclear. Objective: This study aimed to assess the short-term (3 months) effectiveness of a mobile app and a smart band for losing weight and changing body composition in sedentary Spanish adults who are overweight or obese. Methods: A randomized controlled, multicenter clinical trial was conducted involving the participation of 440 subjects from primary care centers, with 231 subjects in the intervention group (IG; counselling with smartphone app and smart band) and 209 in the control group (CG; counselling only). Both groups were counselled about healthy diet and physical activity. For the 3-month intervention period, the IG was trained to use a smartphone app that involved self-monitoring and tailored feedback, as well as a smart band that recorded daily physical activity (Mi Band 2, Xiaomi). Body composition was measured using the InBody 230 bioimpedance device (InBody Co., Ltd), and physical activity was measured using the International Physical Activity Questionnaire. Results: The mHealth intervention produced a greater loss of body weight (–1.97 kg, 95% CI –2.39 to –1.54) relative to standard counselling at 3 months (–1.13 kg, 95% CI –1.56 to –0.69). Comparing groups, the IG achieved a weight loss of 0.84 kg more than the CG at 3 months. The IG showed a decrease in body fat mass (BFM; –1.84 kg, 95% CI –2.48 to –1.20), percentage of body fat (PBF; –1.22%, 95% CI –1.82% to 0.62%), and BMI (–0.77 kg/m2, 95% CI –0.96 to 0.57). No significant changes were observed in any of these parameters in men; among women, there was a significant decrease in BMI in the IG compared with the CG. When subjects were grouped according to baseline BMI, the overweight group experienced a change in BFM of –1.18 kg (95% CI –2.30 to –0.06) and BMI of –0.47 kg/m2 (95% CI –0.80 to –0.13), whereas the obese group only experienced a change in BMI of –0.53 kg/m2 (95% CI –0.86 to –0.19). When the data were analyzed according to physical activity, the moderate-vigorous physical activity group showed significant changes in BFM of –1.03 kg (95% CI –1.74 to –0.33), PBF of –0.76% (95% CI –1.32% to –0.20%), and BMI of –0.5 kg/m2 (95% CI –0.83 to –0.19). Conclusions: The results from this multicenter, randomized controlled clinical trial study show that compared with standard counselling alone, adding a self-reported app and a smart band obtained beneficial results in terms of weight loss and a reduction in BFM and PBF in female subjects with a BMI less than 30 kg/m2 and a moderate-vigorous physical activity level. Nevertheless, further studies are needed to ensure that this profile benefits more than others from this intervention and to investigate modifications of this intervention to achieve a global effect. Trial Registration: Clinicaltrials.gov NCT03175614; https://clinicaltrials.gov/ct2/show/NCT03175614. International Registered Report Identifier (IRRID): RR2-10.1097/MD.0000000000009633 %M 33242020 %R 10.2196/21771 %U http://mhealth.jmir.org/2020/11/e21771/ %U https://doi.org/10.2196/21771 %U http://www.ncbi.nlm.nih.gov/pubmed/33242020 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e18809 %T Evaluation of the MoMba Live Long Remote Smoking Detection System During and After Pregnancy: Development and Usability Study %A Valencia,Stephanie %A Callinan,Laura %A Shic,Frederick %A Smith,Megan %+ Department of Psychiatry, Yale University School of Medicine, 230 South Frontage Road, New Haven, CT, 06519, United States, 1 203 764 8655, megan.smith@yale.edu %K breath carbon monoxide %K contingency management %K smoking cessation %K pregnancy %K mobile-based sensor %K mobile phone %D 2020 %7 24.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The smoking relapse rate during the first 12 months after pregnancy is around 80% in the United States. Delivering remote smoking cessation interventions to women in the postpartum period can reduce the burden associated with frequent office visits and can enable remote communication and support. Developing reliable, remote, smoking measuring instruments is a crucial step in achieving this vision. Objective: The study presents the evaluation of the MoMba Live Long system, a smartphone-based breath carbon monoxide (CO) meter and a custom iOS smartphone app. We report on how our smoking detection system worked in a controlled office environment and in an out-of-office environment to examine its potential to deliver a remote contingency management intervention. Methods: In-office breath tests were completed using both the MoMba Live Long system and a commercial monitor, the piCO+ Smokerlyzer. In addition, each participant provided a urine test for smoking status validation through cotinine. We used in-office test data to verify the validity of the MoMba Live Long smoking detection system. We also collected out-of-office tests to assess how the system worked remotely and enabled user verification. Pregnant adult women in their second or third trimester participated in the study for a period of 12 weeks. This study was carried out in the United States. Results: Analyses of in-office tests included 143 breath tests contributed from 10 participants. CO readings between the MoMba Live Long system and the piCO+ were highly correlated (r=.94). In addition, the MoMba Live Long system accurately distinguished smokers from nonsmokers with a sensitivity of 0.91 and a specificity of 0.94 when the piCO+ was used as a gold standard, and a sensitivity of 0.81 and specificity of 1.0 when cotinine in urine was used to confirm smoking status. All participants indicated that the system was easy to use. Conclusions: Relatively inexpensive portable and internet-connected CO monitors can enable remote smoking status detection in a wide variety of nonclinical settings with reliable and valid measures comparable to a commercially available CO monitor. Trial Registration: ClinicalTrials.gov NCT02237898; https://clinicaltrials.gov/ct2/show/NCT02237898 %M 33231550 %R 10.2196/18809 %U https://mhealth.jmir.org/2020/11/e18809 %U https://doi.org/10.2196/18809 %U http://www.ncbi.nlm.nih.gov/pubmed/33231550 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e17156 %T Mobile Apps to Reduce Tobacco, Alcohol, and Illicit Drug Use: Systematic Review of the First Decade %A Staiger,Petra Karin %A O'Donnell,Renee %A Liknaitzky,Paul %A Bush,Rachel %A Milward,Joanna %+ School of Psychology, Deakin University, Faculty of Health, Locked Bag 20000, Geelong, 3220, Australia, 61 3 9244 6876, petra.staiger@deakin.edu.au %K smartphone app %K mobile phone %K mobile app %K problematic substance use %K addiction %K systematic review %K mHealth %K ecological momentary intervention %K alcohol %K tobacco %K smoking %K illicit drugs %D 2020 %7 24.11.2020 %9 Review %J J Med Internet Res %G English %X Background: Mobile apps for problematic substance use have the potential to bypass common barriers to treatment seeking. Ten years following the release of the first app targeting problematic tobacco, alcohol, and illicit drug use, their effectiveness, use, and acceptability remains unclear. Objective: This study aims to conduct a systematic literature review of trials evaluating mobile app interventions for problematic tobacco, alcohol, and illicit drug use. Methods: The review was conducted according to recommended guidelines. Relevant databases were searched, and articles were included if the mobile app study was a controlled intervention trial and reported alcohol, tobacco, or illicit drug consumption as outcomes. Results: A total of 20 studies met eligibility criteria across a range of substances: alcohol (n=11), tobacco (n=6), alcohol and tobacco (n=1), illicit drugs (n=1), and illicit drugs and alcohol (n=1). Samples included the general community, university students, and clinical patients. The analyzed intervention sample sizes ranged from 22 to 14,228, and content was considerably diverse, from simple stand-alone apps delivering self-monitoring or psychoeducation to multicomponent apps with interactive features and audio content, or used as adjuncts alongside face-to-face treatment. Intervention duration ranged from 1 to 35 weeks, with notifications ranging from none to multiple times per day. A total of 6 of the 20 app interventions reported significant reductions in substance use at post or follow-up compared with a comparison condition, with small to moderate effect sizes. Furthermore, two other app interventions reported significant reductions during the intervention but not at post treatment, and a third reported a significant interaction of two app intervention components. Conclusions: Although most app interventions were associated with reductions in problematic substance use, less than one-third were significantly better than the comparison conditions at post treatment. A total of 5 out of the 6 apps that reported intervention effects targeted alcohol (of those, one targeted alcohol and illicit drugs and another alcohol and tobacco) and 1 targeted tobacco. Moreover, 3 out of 6 apps included feedback (eg, personalized) and 2 had high risk of bias, 1 some risk, and 3 low risk. All 6 apps included interventions of 6 weeks or longer. Common study limitations were small sample sizes; risk of bias; lack of relevant details; and, in some cases, poorly balanced comparison conditions. Appropriately powered trials are required to understand which app interventions are most effective, length of engagement required, and subgroups most likely to benefit. In sum, evidence to date for the effectiveness of apps targeting problematic substance use is not compelling, although the heterogeneous comparison conditions and trial designs across studies limit the ability to compare efficacy between apps. We discuss potential approaches that can help ascertain whether the promise of mobile app interventions for problematic substance use can be fulfilled. %M 33231555 %R 10.2196/17156 %U http://www.jmir.org/2020/11/e17156/ %U https://doi.org/10.2196/17156 %U http://www.ncbi.nlm.nih.gov/pubmed/33231555 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e19570 %T Pre-Conception Interventions for Subfertile Couples Undergoing Assisted Reproductive Technology Treatment: Modeling Analysis %A Steegers-Theunissen,Régine %A Hoek,Annemieke %A Groen,Henk %A Bos,Annelies %A van den Dool,Grada %A Schoonenberg,Marieke %A Smeenk,Jesper %A Creutzberg,Eva %A Vecht,Loes %A Starmans,Luc %A Laven,Joop %+ Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Office EE-2271a, Dr.Molewaterplein 40, 3015 GD, Rotterdam, Netherlands, 31 107038255, r.steegers@erasmusmc.nl %K fertility, periconception, pregnancy chance, Smarter Pregnancy, cost-effectiveness, nutrition, obesity, IVF treatment %K mobile and web-based lifestyle apps %D 2020 %7 23.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Approximately 1 in 7 couples experience subfertility, many of whom have lifestyles that negatively affect fertility, such as poor nutrition, low physical activity, obesity, smoking, or alcohol consumption. Reducing lifestyle risk factors prior to pregnancy or assisted reproductive technology treatment contributes to the improvement of reproductive health, but cost-implications are unknown. Objective: The goal of this study was to evaluate reproductive, maternal pregnancy, and birth outcomes, as well as the costs of pre-conception lifestyle intervention programs in subfertile couples and obese women undergoing assisted reproductive technology. Methods: Using a hypothetical model based on quantitative parameters from published literature and expert opinion, we evaluated the following lifestyle intervention programs: (1) Smarter Pregnancy, an online tool; (2) LIFEstyle, which provides outpatient support for obese women; (3) concurrent use of both Smarter Pregnancy and LIFEstyle for obese women; (4) smoking cessation in men; and (5) a mindfulness mental health support program using group therapy sessions. The model population was based on data from the Netherlands. Results: All model-based analyses of the lifestyle interventions showed a reduction in the number of in vitro fertilization, intracytoplasmic sperm injection, or intrauterine insemination treatments required to achieve pregnancy and successful birth for couples in the Netherlands. Smarter Pregnancy was modeled to have the largest increase in spontaneous pregnancy rate (13.0%) and the largest absolute reduction in potential assisted reproductive technology treatments. Among obese subfertile women, LIFEstyle was modeled to show a reduction in the occurrence of gestational diabetes, maternal hypertensive pregnancy complications, and preterm births by 4.4%, 3.8%, and 3.0%, respectively, per couple. Modeled cost savings per couple per year were €41 (US $48.66), €360 (US $427.23), €513 (US $608.80), €586 (US $695.43), and €1163 (US $1380.18) for smoking cessation, mindfulness, Smarter Pregnancy, combined Smarter Pregnancy AND LIFEstyle, and LIFEstyle interventions, respectively. Conclusions: Although we modeled the potential impact on reproductive outcomes and costs of fertility treatment rather than collecting real-world data, our model suggests that of the lifestyle interventions for encouraging healthier behaviors, all are likely to be cost effective and appear to have positive effects on reproductive, maternal pregnancy, and birth outcomes. Further real-world data are required to determine the cost-effectiveness of pre-conception lifestyle interventions, including mobile apps and web-based tools that help improve lifestyle, and their effects on reproductive health. We believe that further implementation of the lifestyle app Smarter Pregnancy designed for subfertile couples seeking assistance to become pregnant is likely to be cost-effective and would allow reproductive health outcomes to be collected. %M 33226349 %R 10.2196/19570 %U https://mhealth.jmir.org/2020/11/e19570 %U https://doi.org/10.2196/19570 %U http://www.ncbi.nlm.nih.gov/pubmed/33226349 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e20820 %T Behavior Change Techniques in Wrist-Worn Wearables to Promote Physical Activity: Content Analysis %A Düking,Peter %A Tafler,Marie %A Wallmann-Sperlich,Birgit %A Sperlich,Billy %A Kleih,Sonja %+ Integrative and Experimental Exercise Science, Department of Sport Science, University of Würzburg, Würzburg, 97082, Germany, 49 931 31 84792, peterdueking@gmx.de %K cardiorespiratory fitness %K innovation %K smartwatch %K technology %K wearable %K eHealth %K mHealth %D 2020 %7 19.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Decreasing levels of physical activity (PA) increase the incidences of noncommunicable diseases, obesity, and mortality. To counteract these developments, interventions aiming to increase PA are urgently needed. Mobile health (mHealth) solutions such as wearable sensors (wearables) may assist with an improvement in PA. Objective: The aim of this study is to examine which behavior change techniques (BCTs) are incorporated in currently available commercial high-end wearables that target users’ PA behavior. Methods: The BCTs incorporated in 5 different high-end wearables (Apple Watch Series 3, Garmin Vívoactive 3, Fitbit Versa, Xiaomi Amazfit Stratos 2, and Polar M600) were assessed by 2 researchers using the BCT Taxonomy version 1 (BCTTv1). Effectiveness of the incorporated BCTs in promoting PA behavior was assessed by a content analysis of the existing literature. Results: The most common BCTs were goal setting (behavior), action planning, review behavior goal(s), discrepancy between current behavior and goal, feedback on behavior, self-monitoring of behavior, and biofeedback. Fitbit Versa, Garmin Vívoactive 3, Apple Watch Series 3, Polar M600, and Xiaomi Amazfit Stratos 2 incorporated 17, 16, 12, 11, and 11 BCTs, respectively, which are proven to effectively promote PA. Conclusions: Wearables employ different numbers and combinations of BCTs, which might impact their effectiveness in improving PA. To promote PA by employing wearables, we encourage researchers to develop a taxonomy specifically designed to assess BCTs incorporated in wearables. We also encourage manufacturers to customize BCTs based on the targeted populations. %M 33211023 %R 10.2196/20820 %U http://mhealth.jmir.org/2020/11/e20820/ %U https://doi.org/10.2196/20820 %U http://www.ncbi.nlm.nih.gov/pubmed/33211023 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e15717 %T Impact of Pediatric Mobile Game Play on Healthy Eating Behavior: Randomized Controlled Trial %A Kato-Lin,Yi-Chin %A Kumar,Uttara Bharath %A Sri Prakash,Bhargav %A Prakash,Bhairavi %A Varadan,Vasini %A Agnihotri,Sanjeeta %A Subramanyam,Nrutya %A Krishnatray,Pradeep %A Padman,Rema %+ The Heinz College of Information Systems and Public Policy, Carnegie Mellon University, 5000 Forbes Ave, Pittsburgh, PA, , United States, 1 412 268 2180, rpadman@cmu.edu %K pediatric obesity %K mobile games %K implicit learning %K healthy eating behavior evaluation %K game telemetry analysis %D 2020 %7 18.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Video and mobile games have been shown to have a positive impact on behavior change in children. However, the potential impact of game play patterns on outcomes of interest are yet to be understood, especially for games with implicit learning components. Objective: This study investigates the immediate impact of fooya!, a pediatric dietary mobile game with implicit learning components, on food choices. It also quantifies children’s heterogeneous game play patterns using game telemetry and determines the effects of these patterns on players’ food choices. Methods: We analyzed data from a randomized controlled trial (RCT) involving 104 children, aged 10 to 11 years, randomly assigned to the treatment group (played fooya!, a dietary mobile game developed by one of the authors) or the control group (played Uno, a board game without dietary education). Children played the game for 20 minutes each in two sessions. After playing the game in each session, the children were asked to choose 2 out of 6 food items (3 healthy and 3 unhealthy choices). The number of healthy choices in both sessions was used as the major outcome. We first compared the choice and identification of healthy foods between treatment and control groups using statistical tests. Next, using game telemetry, we determined the variability in game play patterns by quantifying game play measures and modeled the process of game playing at any level across all students as a Markov chain. Finally, correlation tests and regression models were used to establish the relationship between game play measures and actual food choices. Results: We saw a significant main effect of the mobile game on number of healthy foods actually chosen (treatment 2.48, control 1.10; P<.001; Cohen d=1.25) and identified (treatment 7.3, control 6.94; P=.048; Cohen d=.25). A large variation was observed in children’s game play patterns. Children played an average of 15 game levels in 2 sessions, with a range of 2 to 23 levels. The greatest variation was noted in the proportion of scoring activities that were highly rewarded, with an average of 0.17, ranging from 0.003 to 0.98. Healthy food choice was negatively associated with the number of unhealthy food facts that children read in the game (Kendall τ=–.32, P=.04), even after controlling for baseline food preference. Conclusions: A mobile video game embedded with implicit learning components showed a strong positive impact on children’s food choices immediately following the game. Game telemetry captured children’s different play patterns and was associated with behavioral outcomes. These results have implications for the design and use of mobile games as an intervention to improve health behaviors, such as the display of unhealthy food facts during game play. Longitudinal RCTs are needed to assess long-term impact. Trial Registration: ClinicalTrials.gov NCT04082195; https://clinicaltrials.gov/ct2/show/NCT04082195, registered retrospectively. %M 33206054 %R 10.2196/15717 %U http://mhealth.jmir.org/2020/11/e15717/ %U https://doi.org/10.2196/15717 %U http://www.ncbi.nlm.nih.gov/pubmed/33206054 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 11 %P e21450 %T A Cardiovascular Health and Wellness Mobile Health Intervention Among Church-Going African Americans: Formative Evaluation of the FAITH! App %A Brewer,LaPrincess C %A Kumbamu,Ashok %A Smith,Christina %A Jenkins,Sarah %A Jones,Clarence %A Hayes,Sharonne N %A Burke,Lora %A Cooper,Lisa A %A Patten,Christi A %+ Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, United States, 1 507 538 0325, brewer.laprincess@mayo.edu %K mobile health %K eHealth %K community-based participatory research %K health promotion %K African Americans %K mobile phone %D 2020 %7 17.11.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: In light of the scarcity of culturally tailored mobile health (mHealth) lifestyle interventions for African Americans, we designed and pilot tested the Fostering African-American Improvement in Total Health (FAITH!) App in a community-based participatory research partnership with African American churches to promote cardiovascular health and wellness in this population. Objective: This report presents the results of a formative evaluation of the FAITH! App from participants in an intervention pilot study. Methods: We included 2 semistructured focus groups (n=4 and n=5) to explore participants’ views on app functionality, utility, and satisfaction as well as its impact on healthy lifestyle change. Sessions were audio-recorded and transcribed verbatim, and qualitative data were analyzed by using general inductive analysis to generate themes. Results: In total, 6 overarching themes emerged among the 9 participants: overall impression, content usefulness, formatting, implementation, impact, and suggestions for improvement. Underpinning the themes was a high level of agreement that the intervention facilitated healthy behavioral change through cultural tailoring, multimedia education modules, and social networking. Suggestions for improvement were streamlining the app self-monitoring features, prompts to encourage app use, and personalization based on individuals’ cardiovascular risk. Conclusions: This formative evaluation found that the FAITH! App had high reported satisfaction and impact on the health-promoting behaviors of African Americans, thereby improving their overall cardiovascular health. Further development and testing of the app among African Americans is warranted. Trial Registration: ClinicalTrials.gov NCT03084822; https://clinicaltrials.gov/ct2/show/NCT03084822. %M 33200999 %R 10.2196/21450 %U http://formative.jmir.org/2020/11/e21450/ %U https://doi.org/10.2196/21450 %U http://www.ncbi.nlm.nih.gov/pubmed/33200999 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e20460 %T Engagement Features in Physical Activity Smartphone Apps: Focus Group Study With Sedentary People %A D'Addario,Marco %A Baretta,Dario %A Zanatta,Francesco %A Greco,Andrea %A Steca,Patrizia %+ Department of Psychology, University of Milan-Bicocca, Piazza dell'Ateneo Nuovo, 1, Milan, 20126, Italy, 39 3920317007, francesco.zanatta@unimib.it %K physical activity %K smartphone app %K engagement %K co-design %K thematic analysis %K mobile phone %D 2020 %7 16.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Engagement with physical activity mobile apps has been reported to be a core precondition for their effectiveness in digital behavior change interventions. However, to date, little attention has been paid to understanding the perspectives, needs, expectations, and experiences of potential users with physical activity mobile apps. Objective: The aim of this study was to investigate the features that are judged to be important for engagement with a physical activity mobile app and the reasons for their importance. Methods: A qualitative focus-group methodology with elements of co-design was adopted in this study. Participants reporting sedentary lifestyles and willingness to improve their physical activity behavior through mobile technology were recruited. The focus group sessions consisted of 13 participants (8 men and 5 women, mean [SD] age 41.9 [7.1] years). Two researchers conducted the data analysis independently by using the inductive thematic approach. Results: Four main themes emerged in relation to the research question and were named as follows: “physical activity participation motives,” “autonomy and self-regulation,” “need for relatedness,” and “smart.” Additionally, 2 subthemes originated from “physical activity participation motives” (ie, “medical guidance” and “weight loss and fitness for health”) and “smart” (ie, “action planning” and “adaptable and tailored”). Conclusions: Features enhancing autonomy and self-regulation and positively affecting health and physical well-being as well as the need for relatedness, adaptability, and flexibility should be considered as core elements in the engagement of potential users with physical activity mobile apps. The emerged findings may orient future research and interventions aiming to foster engagement of potential users with physical activity apps. %M 33196450 %R 10.2196/20460 %U http://mhealth.jmir.org/2020/11/e20460/ %U https://doi.org/10.2196/20460 %U http://www.ncbi.nlm.nih.gov/pubmed/33196450 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e18609 %T A Smartphone-Based Technique to Detect Dynamic User Preferences for Tailoring Behavioral Interventions: Observational Utility Study of Ecological Daily Needs Assessment %A Nicol,Ginger E %A Ricchio,Amanda R %A Metts,Christopher L %A Yingling,Michael D %A Ramsey,Alex T %A Schweiger,Julia A %A Miller,J Philip %A Lenze,Eric J %+ Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, 600 South Taylor Avenue, Suite 121, St. Louis, MO, 63110, United States, 1 314 362 5939, nicolg@wustl.edu %K mobile health %K telemedicine %K needs assessment %K healthy lifestyle %K ecological momentary assessment %K mobile applications %K behavior intervention %K behavior therapy %D 2020 %7 13.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health apps are promising vehicles for delivering scalable health behavior change interventions to populations that are otherwise difficult to reach and engage, such as young adults with psychiatric conditions. To improve uptake and sustain consumer engagement, mobile health interventions need to be responsive to individuals’ needs and preferences, which may change over time. We previously created an ecological daily needs assessment to capture microprocesses influencing user needs and preferences for mobile health treatment adaptation. Objective: The objective of our study was to test the utility of a needs assessment anchored within a mobile app to capture individualized, contextually relevant user needs and preferences within the framework of a weight management mobile health app. Methods: Participants with an iOS device could download the study app via the study website or links from social media. In this fully remote study, we screened, obtained informed consent from, and enrolled participants through the mobile app. The mobile health framework included daily health goal setting and self-monitoring, with up to 6 daily prompts to determine in-the-moment needs and preferences for mobile health–assisted health behavior change. Results: A total of 24 participants downloaded the app and provided e-consent (22 female; 2 male), with 23 participants responding to at least one prompt over 2 weeks. The mean length of engagement was 5.6 (SD 4.7) days, with a mean of 2.8 (1.1) responses per day. We observed individually dynamic needs and preferences, illustrating daily variability within and between individuals. Qualitative feedback indicated preferences for self-adapting features, simplified self-monitoring, and the ability to personalize app-generated message timing and content. Conclusions: The technique provided an individually dynamic and contextually relevant alternative and complement to traditional needs assessment for assessing individually dynamic user needs and preferences during treatment development or adaptation. The results of this utility study suggest the importance of personalization and learning algorithms for sustaining app engagement in young adults with psychiatric conditions. Further study in broader user populations is needed. %M 33055063 %R 10.2196/18609 %U http://mhealth.jmir.org/2020/11/e18609/ %U https://doi.org/10.2196/18609 %U http://www.ncbi.nlm.nih.gov/pubmed/33055063 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 2 %P e24536 %T Parents’ Perceptions of Their Children’s Engagement in a Consumer-Based Meditation Mobile App: Cross-Sectional Survey Study %A Puzia,Megan %A Laird,Breanne %A Green,Jeni %A Huberty,Jennifer %+ Behavioral Research and Analytics LLC, 154 S Street, Salt Lake City, UT, 84103, United States, 1 7046043782, meganpuzia@gmail.com %K mindfulness %K meditation %K children %K mental health %K sleep %K mHealth %D 2020 %7 13.11.2020 %9 Short Paper %J JMIR Pediatr Parent %G English %X Background: In the United States, nearly half (48%) of school-aged children experience sleep disturbance that results in less than the recommended sleep duration, which may negatively impact mental health and behavior. Mindfulness interventions may improve sleep and mental health in youth. However, there are gaps in the literature regarding how children (2-12 years) and adolescents (13-17 years) practice mindfulness and the extent to which they benefit from these practices. Objective: The purpose of this study was to determine parents’ perceptions of their children’s engagement with a consumer-based mindfulness meditation app and the extent to which they believe their children have benefitted from using the app, particularly with regard to sleep. Methods: This study is a secondary analysis of a cross-sectional survey in adult subscribers (N=11,108) to the mindfulness meditation mobile app Calm. Participants who indicated that they had a child or children younger than 18 years (2944/11,108) who used the Calm app were asked additional questions related to their perceptions of their children’s engagement with Calm. Descriptive statistics were used to assess children’s app engagement, and chi-square tests and binary logistic regression models were used to assess differences in children’s usage based on gender and age. Results: Among the survey respondents, approximately half of the parents (1537/2944, 52.21%) reported that their children used Calm. Children used Calm mostly for (1) sleep (1168/1537, 75.99%), (2) stress (491/1537, 31.95%), (3) depression or anxiety (430/1537, 27.98%), and (4) improvement of overall health (215/1537,13.99%). Older children were more likely to begin using Calm to reduce stress, depression, or anxiety, whereas younger children were more likely begin using Calm to improve sleep. Most children used Calm when lying down to go to bed (1113/1529, 72.79%). Children were most likely to use sleep stories at night (1144/1207, 94.78%), followed by music and soundscapes (749/1114, 67.24%), meditations (736/1120, 65.71%), and breathing exercises (610/1092, 55.86%). Nearly all parents believed that using sleep stories was helpful for their children’s sleep (1090/1128, 96.63%), and the majority of parents felt that the other components were also helpful for their children’s sleep (music and soundscapes [570/728, 78.30%], meditations [445/696, 63.94%], and breathing exercises [610/1092, 55.86%]). Conclusions: To our knowledge, this is the first study to explore parents’ perceptions of how their children or adolescents use a popular consumer-based mindfulness mobile app (ie, Calm). As the majority of children use the app for sleep, mindfulness meditation mobile apps should consider incorporating age-appropriate sleep content to meet the needs of this audience. More research is needed to confirm the feasibility and effectiveness of mindfulness meditation apps for improving sleep and mental health in children and adolescents. %M 33185564 %R 10.2196/24536 %U http://pediatrics.jmir.org/2020/2/e24536/ %U https://doi.org/10.2196/24536 %U http://www.ncbi.nlm.nih.gov/pubmed/33185564 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 11 %P e19508 %T Use of the Consumer-Based Meditation App Calm for Sleep Disturbances: Cross-Sectional Survey Study %A Huberty,Jennifer %A Puzia,Megan E %A Larkey,Linda %A Irwin,Michael R %A Vranceanu,Ana-Maria %+ College of Health Solutions, Arizona State University, 550 North 3rd St., Phoenix, AZ, 85004, United States, 1 602 827 2456, jennifer.huberty@asu.edu %K insomnia %K mental health %K mindfulness %K meditation %K mobile apps %K consumer behavior %K mobile phone %D 2020 %7 13.11.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Over 30% of Americans report regular sleep disturbance, and consumers are increasingly seeking strategies to improve sleep. Self-guided mindfulness mobile apps may help individuals improve their sleep. Despite the recent proliferation of sleep content within commercially available mindfulness apps, there is little research on how consumers are using these apps for sleep. Objective: We conducted a cross-sectional survey among subscribers to Calm, a popular, consumer-based, mindfulness-based meditation app, and described and compared how good sleepers, poor sleepers, and those with self-reported insomnia use the app for sleep. Methods: Participants who were paying subscribers of Calm and had used a sleep component of Calm in the last 90 days were invited to complete an investigator-developed survey that included questions about sleep disturbance and the use of Calm for sleep. Based on self-reports of sleep disturbances and of insomnia diagnosis, participants were categorized as “good sleepers,” “poor sleepers,” or “those with insomnia diagnosis.” Chi-square tests compared reasons for downloading the app and usage patterns across participants with and without sleep disturbance. Results: There was a total of 9868 survey respondents. Approximately 10% of participants (1008/9868, 10.21%) were good sleepers, 78% were poor sleepers (7565/9868, 77.66%), and 11% reported a diagnosis of insomnia (1039/9868, 10.53%). The sample was mostly White (8185/9797, 83.55%), non-Hispanic (8929/9423, 94.76%), and female (8166/9578, 85.26%). The most common reasons for sleep disturbances were racing thoughts (7084/8604, 82.33%), followed by stress or anxiety (6307/8604, 73.30%). Poor sleepers and those with insomnia were more likely than good sleepers to have downloaded Calm to improve sleep (χ22=1548.8, P<.001), reduce depression or anxiety (χ22=15.5, P<.001), or improve overall health (χ22=57.6, P<.001). Respondents with insomnia used Calm most often (mean 5.417 days/week, SD 1.936), followed by poor sleepers (mean 5.043 days/week, SD 2.027; F2=21.544, P<.001). The most common time to use Calm was while lying down to sleep (7607/9686, 78.54%), and bedtime use was more common among poor sleepers and those with insomnia (χ22=382.7, P<.001). Compared to good and poor sleepers, those with insomnia were more likely to use Calm after waking up at night (χ22=410.3, P<.001). Most participants tried to use Calm on a regular basis (5031/8597, 58.52%), but regular nighttime use was most common among those with insomnia (646/977, 66.1%), followed by poor sleepers (4040/6930, 58.30%; χ22=109.3, P<.001). Conclusions: Of the paying subscribers to Calm who have used one of the sleep components, approximately 90% have sleep difficulties, and 77% started using Calm primarily for sleep. These descriptive data point to areas of focus for continued refinement of app features and content, followed by prospective trials testing efficacy of consumer-based meditation mobile apps for improving sleep. %M 33185552 %R 10.2196/19508 %U http://formative.jmir.org/2020/11/e19508/ %U https://doi.org/10.2196/19508 %U http://www.ncbi.nlm.nih.gov/pubmed/33185552 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e17405 %T A Mobile Health Mindfulness Intervention for Women With Moderate to Moderately Severe Postpartum Depressive Symptoms: Feasibility Study %A Avalos,Lyndsay A %A Aghaee,Sara %A Kurtovich,Elaine %A Quesenberry Jr,Charles %A Nkemere,Linda %A McGinnis,MegAnn K %A Kubo,Ai %+ Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA, 94612, United States, 1 510 891 3426, Lyndsay.A.Avalos@kp.org %K depression %K postpartum %K health services, mental %K eHealth %K mental health %K internet-based intervention %K mindfulness %K behavioral intervention %K mobile phone %D 2020 %7 12.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Approximately 20% of women suffer from postpartum depression (PPD). Due to barriers such as limited access to care, half of the women with PPD do not receive treatment. Therefore, it is critical to identify effective and scalable interventions. Traditional mindfulness programs have been effective in reducing depressive symptoms, however access remains a barrier. A self-paced mobile health (mHealth) mindfulness program may fit the lifestyle of busy mothers who are unable to attend in-person classes. However, little is known regarding the feasibility or efficacy of mHealth mindfulness interventions in postpartum women with depressive symptoms. Objective: This study aims to assess the feasibility, acceptability, and preliminary efficacy of an mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms. Methods: We conducted a single-arm feasibility trial of an mHealth mindfulness intervention within Kaiser Permanente Northern California (KPNC), a large integrated health care system. Participants were identified through clinician referral and electronic health records via KPNC's universal perinatal depression screening program and recruited by the study team. Inclusion criteria included the following: English-speaking, up to 6 months postpartum with a Patient Health Questionnaire (PHQ-8) score of 10 to 19, and no regular mindfulness/meditation practice. Participants were asked to use a mindfulness app, Headspace, 10 to 20 min/day for 6 weeks. Baseline and postintervention surveys captured data on patient-reported outcomes (depression and stress symptoms, sleep quality, and mindfulness). Semistructured interviews captured acceptability. Retention and adherence were used to assess feasibility. Results: Of the 115 women who were contacted and met the eligibility criteria or declined participation before eligibility assessment, 27 (23%) were enrolled. In addition, 70% (19/27) completed the study. The mean age of participants was 31 years (SD 5.2), 30% (8/27) were non-Hispanic White, and, on average, participants were 12.3 weeks postpartum (SD 5.7). Of the women who completed the study, 100% (19/19) used the Headspace app at least once, and nearly half (9/19, 47%) used the app on ≥50% of the days during the 6-week intervention period. Of the 16 participants who completed the postintervention interview, 69% (11/16) reported that they were very or extremely satisfied with the app. Interviews indicated that women appreciated the variety of meditations and felt that the program led to reduced anxiety and improved sleep. Significant improvements in pre- and postintervention scores were observed for depressive symptoms (PHQ-8: −3.8, P=.004), perceived stress (10-item Perceived Stress Scale: −6.0, P=.005), and sleep quality (Pittsburgh Sleep Quality Index: −2.1, P=.02, indicating less sleep disturbance). Improvements in mindfulness were also significant (Five Facet Mindfulness Questionnaire-Short Form: 10.9, P=.01). Conclusions: An mHealth mindfulness intervention for postpartum women with moderate to moderately severe depressive symptoms is feasible and acceptable. An efficacy trial is warranted. %M 33180028 %R 10.2196/17405 %U https://mental.jmir.org/2020/11/e17405 %U https://doi.org/10.2196/17405 %U http://www.ncbi.nlm.nih.gov/pubmed/33180028 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e19836 %T Standalone Smartphone Cognitive Behavioral Therapy–Based Ecological Momentary Interventions to Increase Mental Health: Narrative Review %A Marciniak,Marta Anna %A Shanahan,Lilly %A Rohde,Judith %A Schulz,Ava %A Wackerhagen,Carolin %A Kobylińska,Dorota %A Tuescher,Oliver %A Binder,Harald %A Walter,Henrik %A Kalisch,Raffael %A Kleim,Birgit %+ University of Zurich, Psychiatric University Hospital, Lenggstrasse 31, Zurich, 8032, Switzerland, 41 44 384 23 51, birgit.kleim@uzh.ch %K mHealth %K mobile app %K ecological momentary intervention %K EMI %K cognitive behavioral therapy %K CBT %K COVID-19 %K mobile phone %K smartphone %D 2020 %7 12.11.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: A growing number of psychological interventions are delivered via smartphones with the aim of increasing the efficacy and effectiveness of these treatments and providing scalable access to interventions for improving mental health. Most of the scientifically tested apps are based on cognitive behavioral therapy (CBT) principles, which are considered the gold standard for the treatment of most mental health problems. Objective: This review investigates standalone smartphone-based ecological momentary interventions (EMIs) built on principles derived from CBT that aim to improve mental health. Methods: We searched the MEDLINE, PsycINFO, EMBASE, and PubMed databases for peer-reviewed studies published between January 1, 2007, and January 15, 2020. We included studies focusing on standalone app-based approaches to improve mental health and their feasibility, efficacy, or effectiveness. Both within- and between-group designs and studies with both healthy and clinical samples were included. Blended interventions, for example, app-based treatments in combination with psychotherapy, were not included. Selected studies were evaluated in terms of their design, that is, choice of the control condition, sample characteristics, EMI content, EMI delivery characteristics, feasibility, efficacy, and effectiveness. The latter was defined in terms of improvement in the primary outcomes used in the studies. Results: A total of 26 studies were selected. The results show that EMIs based on CBT principles can be successfully delivered, significantly increase well-being among users, and reduce mental health symptoms. Standalone EMIs were rated as helpful (mean 70.8%, SD 15.3; n=4 studies) and satisfying for users (mean 72.6%, SD 17.2; n=7 studies). Conclusions: Study quality was heterogeneous, and feasibility was often not reported in the reviewed studies, thus limiting the conclusions that can be drawn from the existing data. Together, the studies show that EMIs may help increase mental health and thus support individuals in their daily lives. Such EMIs provide readily available, scalable, and evidence-based mental health support. These characteristics appear crucial in the context of a global crisis such as the COVID-19 pandemic but may also help reduce personal and economic costs of mental health impairment beyond this situation or in the context of potential future pandemics. %M 33180027 %R 10.2196/19836 %U https://mhealth.jmir.org/2020/11/e19836 %U https://doi.org/10.2196/19836 %U http://www.ncbi.nlm.nih.gov/pubmed/33180027 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 11 %P e20534 %T Effects of a Collective Family-Based Mobile Health Intervention Called “SMARTFAMILY” on Promoting Physical Activity and Healthy Eating: Protocol for a Randomized Controlled Trial %A Wunsch,Kathrin %A Eckert,Tobias %A Fiedler,Janis %A Cleven,Laura %A Niermann,Christina %A Reiterer,Harald %A Renner,Britta %A Woll,Alexander %+ Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Engler-Bunte-Ring 15, Karlsruhe, 76131, Germany, 49 72160845431, kathrin.wunsch@kit.edu %K mobile app %K telemedicine %K behavior change %K health behavior %K family %K primary prevention %K exercise %K food and nutrition %K randomized controlled trial %K accelerometer %K wearable electronic devices %K social cognitive determinants %K just-in-time adaptive intervention %K digital intervention %K mobile phone %D 2020 %7 11.11.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Numerous smartphone apps are targeting physical activity and healthy eating, but empirical evidence on their effectiveness for initialization and maintenance of behavior change, especially in children and adolescents, is still limited. Objective: The aim of this study was to conceptualize a theory-based and evidence-based mHealth intervention called SMARTFAMILY (SF) that targets physical activity and healthy eating in a collective family-based setting. Subsequently, the app will be refined and re-evaluated to analyze additional effects of just-in-time adaptive interventions (JITAIs) and gamification features. Methods: A smartphone app based on behavior change theories and behavior change techniques was developed and implemented and will be evaluated with family members individually and cooperatively (SF trial). Existing evidence and gained results were used to refine and will be used to re-evaluate the app (SF2.0 trial). Both trials are cluster randomized controlled trials with 3 measurement occasions. The intervention group uses the app for 3 consecutive weeks, whereas the control group receives no treatment. Baseline measurements (T0) and postintervention measurements (T1) include physical activity (ie, self-reported and accelerometry) and healthy eating measurements (ie, self-reported fruit and vegetable intake) as the primary outcomes. The secondary outcomes (ie, self-reported) are intrinsic motivation, behavior-specific self-efficacy, and the family health climate, complemented by an intentional measure in SF2.0. Four weeks following T1, a follow-up assessment (T2) is completed by the participants, consisting of all questionnaire items to assess the stability of the intervention effects. Mixed-method analysis of covariance will be used to calculate the primary intervention effects (ie, physical activity, fruit and vegetable intake) while controlling for covariates, including family health climate, behavior-specific self-efficacy, and intrinsic motivation. Results: This study is funded by the German Federal Ministry of Education and Research and ethically approved by the Karlsruhe Institute of Technology. For both trials, it is hypothesized that the apps will positively influence physical activity and healthy eating in the whole family. Furthermore, SF2.0 is expected to produce stronger effects (ie, higher effect sizes) compared to SF. SF app development and piloting are completed. Data acquisition for the SF trial is terminated and discontinued due to the COVID-19 pandemic. SF2.0 app development and piloting are completed, while data acquisition is ongoing. Participant recruitment for the SF 2.0 trial started in February 2020. The results for SF are expected to be published in mid-2021, and the results of SF2.0 are expected to be published in mid-2022. Conclusions: In this study, it is hypothesized that targeting the whole family will facilitate behavior change at the individual level and the family level, as the implemented strategies address changes in daily family life. Furthermore, subsequent app development (SF2.0) with supplementary addition of motivation-enhancing features and a JITAI approach is expected to enhance positive intervention effects. Trial Registration: German Clinical Trials Register DRKS00010415; https://tinyurl.com/yyo87yyu International Registered Report Identifier (IRRID): DERR1-10.2196/20534 %M 33174849 %R 10.2196/20534 %U http://www.researchprotocols.org/2020/11/e20534/ %U https://doi.org/10.2196/20534 %U http://www.ncbi.nlm.nih.gov/pubmed/33174849 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e16517 %T Patient Perception of Mobile Phone Apps for the Care and Prevention of Sexually Transmitted Diseases: Cross-Sectional Study %A Jakob,Lena %A Steeb,Theresa %A Fiocco,Zeno %A Pumnea,Teodora %A Jakob,Sophia Nomi %A Wessely,Anja %A Rothenberger,Christoph Clemens %A Brinker,Titus Josef %A French,Lars Einar %A Berking,Carola %A Heppt,Markus Vincent %+ Department of Dermatology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Ulmenweg 18, Erlangen, 91054, Germany, 49 913185 ext 45810, markus.heppt@uk-erlangen.de %K sexually transmitted diseases %K sexually transmitted infection %K mobile phone apps %K health apps %D 2020 %7 10.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In the emerging era of digitalization and electronic health, various health-related apps have been launched, including apps for sexually transmitted diseases. Until now, little has been known about how patients perceive the value of such apps. Objective: To investigate patient’s attitudes and awareness toward sexually transmitted disease–related apps in an outpatient sexually transmitted disease clinic setting. Methods: A cross-sectional study was conducted at a dermatovenereological outpatient unit between April and July 2019. Patients completed a self-administered questionnaire on their perceptions of the popularity and usefulness of sexually transmitted disease–related apps. Descriptive analysis was performed with expression of categorical variables as frequencies and percentages. For continuous variables, the median, range, and interquartile range were indicated. Contingency tables and chi-square tests were used to investigate associations between sociodemographic data and items of the questionnaire. Results: A total of 226 patients were surveyed (heterosexual: 137/193, 71.0%; homosexual: 44/193, 22.8%; bisexual: 12/193, 6.2%); 11.9% (27/225) had previously used health-related apps. Nearly half of the patients (97/214, 45.3%) specifically considered sexually transmitted disease–related apps useful, 47.8% (100/209) voted that they could supplement or support the consultation of a physician. Interestingly, only 35.1% (74/211) preferred a printed patient brochure on sexually transmitted diseases over downloading and using an app, but 64.0% (134/209) would download a sexually transmitted disease–related app recommended by their physician. General information regarding sexually transmitted diseases (93/167, 55.7%), evaluation of skin diseases based on photos or videos (78/167, 53.3%), information on the prevention of sexually transmitted diseases (76/167, 45.5%), mediation of nearby contact points or test sites (74/167, 44.3%), anonymous medical advice (69/167, 41.3%), and calculation of the risk of having a sexually transmitted disease (63/167, 37.3%) were rated as the most important features. Men were more likely than women to find sexually transmitted disease–related apps useful in general (P=.04; χ2=6.28) and to pay for such apps (P=.01; χ2=9.19). Patients aged <40 years would rather download an app recommended by their physician (P=.03; χ2=7.23), whereas patients aged >40 years preferred reading a patient brochure on sexually transmitted diseases (P=.02; χ2=8.14). Conclusions: This study demonstrated high general interest in the use of sexually transmitted disease–related apps in this sample of dermatovenereological outpatients. In particular, young age and male sex were significantly associated with a positive perception, underlining the high potential of apps in the prevention and early recognition of sexually transmitted diseases in this group. Future studies are warranted to validate these findings in other populations. %M 33170133 %R 10.2196/16517 %U https://mhealth.jmir.org/2020/11/e16517 %U https://doi.org/10.2196/16517 %U http://www.ncbi.nlm.nih.gov/pubmed/33170133 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 11 %P e18067 %T Effectiveness of a Smartphone App (BioBase) for Reducing Anxiety and Increasing Mental Well-Being: Pilot Feasibility and Acceptability Study %A Kawadler,Jamie M %A Hemmings,Nicola Rose %A Ponzo,Sonia %A Morelli,Davide %A Bird,Geoffrey %A Plans,David %+ Huma Therapeutics Limited, 13th Floor Millbank Tower, 21-24 Millbank, , London, , United Kingdom, 44 7527016574, jamie@biobeats.com %K health and well-being %K health promotion %K organizational and leadership support %K workplace %D 2020 %7 10.11.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The prevalence of workplace-related stress and anxiety is high, resulting in stress-related physical and mental illness. Digital self-guided interventions aimed at key areas of workplace design may be able to provide remote anxiolytic effects. Objective: The aim of this feasibility study is to assess changes in anxiety and mental well-being after use of the BioBase programme, a mobile phone platform for psycho-educational modules, tools, and real-time feedback of physiological data. Methods: A 4-week observational study was carried out in 55 healthy adults who were screened for stress with the Depression Anxiety Stress Scale (DASS) Stress subscale. Participants completed anxiety (6-item State-Trait Anxiety Inventory [STAI]) and mental well-being (Warwick-Edinburgh Mental Well-being Scale [WEMWBS]) questionnaires at baseline and at 4 weeks. Feedback questionnaires were administered after 4 weeks. Results: After 4 weeks of using the programme and controlling for any effect of being paid to take part in the study, STAI significantly decreased (baseline mean 45.52 [SD 13.2]; 4-week mean 39.82 [SD 11.2]; t54=–3.51; P<.001; CI –8.88 to –2.52; Cohen d=0.96) and WEMWBS significantly increased (baseline mean 48.12 [SD 6.4]; 4-week mean 50.4 [SD 6.9]; t53=2.41; P=.019; CI 0.44-4.23; Cohen d=0.66). Further, higher baseline stress was significantly associated with a greater decrease in STAI (t53=–3.41; P=.001; CI –8.10 to –2.10; R2=0.180) and a greater increase in WEMWBS (t52=2.41; P=.019; CI 0.38-4.11, R2=0.101). On feedback, participants found the programme easy to use/navigate, with the content being acceptable and relevant to workplace-related stressors; 70% (21/30) of participants would recommend the programme to a friend. Conclusions: The BioBase programme is a potentially effective intervention in decreasing anxiety and increasing mental well-being, with larger changes in those with higher baseline levels of stress. %M 32969341 %R 10.2196/18067 %U https://formative.jmir.org/2020/11/e18067 %U https://doi.org/10.2196/18067 %U http://www.ncbi.nlm.nih.gov/pubmed/32969341 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 11 %P e19488 %T EatSmart, a Web-Based and Mobile Healthy Eating Intervention for Disadvantaged People With Type 2 Diabetes: Protocol for a Pilot Mixed Methods Intervention Study %A Karimi,Nazgol %A Crawford,David %A Opie,Rachelle %A Maddison,Ralph %A O’Connell,Stella %A Hamblin,Peter Shane %A Ng,Ashley Huixian %A Steele,Cheryl %A Rasmussen,Bodil %A Ball,Kylie %+ Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Building J, SENS, 221 Burwood Highway, Burwood, Melbourne, 3125, Australia, 61 410825300, Karimin@deakin.edu.au %K type 2 diabetes %K healthy eating %K diet %K low socioeconomic position %K self-management %K digitally delivered %K internet %K website %K mobile phone %K text message %D 2020 %7 6.11.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: People of low socioeconomic position (SEP) are disproportionately affected by type 2 diabetes (T2D), partly due to unhealthy eating patterns that contribute to inadequate disease self-management and prognosis. Digital technologies have the potential to provide a suitable medium to facilitate diabetes education, support self-management, and address some of the barriers to healthy eating, such as lack of nutritional knowledge or shopping or cooking skills, in this target group. Objective: This study aims to test the feasibility, appeal, and potential effectiveness of EatSmart, a 12-week, evidence-based, theoretically grounded, fully automated web-based and mobile-delivered healthy eating behavior change program to help disadvantaged people living with T2D to eat healthily on a budget and improve diabetes self-management. Methods: EatSmart is a mixed methods (quantitative and qualitative) pre-post design pilot study. Sixty socioeconomically disadvantaged people with T2D aged 18 to 75 years will be recruited. Participants will complete self-reported baseline assessments of their basic demographic and clinical data, dietary intake, dietary self-efficacy, and barriers to healthy eating. They will be provided with login access to the EatSmart web program, which includes six progressive skill-based modules covering healthy eating planning; smart food budgeting and shopping; time-saving meal strategies, healthy cooking methods, modifying recipes; and a final reinforcement and summary module. Over the 3-month intervention, participants will also receive 3 text messages weekly, encouraging them to review goals, continue to engage with different components of the EatSmart web program, and eat healthily. Participants will undertake follow-up assessments directly following the intervention 3 months post baseline and again after a 6-month postintervention follow-up period (9 months post baseline). Feasibility will be evaluated using the number of participants recruited and retained and objective indicators of engagement with the website. Program appeal and potential effects on primary and secondary outcomes will be assessed via the same surveys used at baseline, with additional questions asking about experience with and perceptions of the program. In-depth qualitative interviews will also be conducted 6 months post intervention to provide deeper insight into experiences with EatSmart and a more comprehensive description of the program’s appeal. Results: The EatSmart website has been developed, and all participants have viewed the modules as of May 2020. Results are expected to be submitted for publication in December 2020. Conclusions: This study will provide data to address the currently limited evidence regarding whether disadvantaged populations with T2D may benefit from digitally delivered behavior change programs that facilitate eating healthily on a budget. Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12619001111167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001111167 International Registered Report Identifier (IRRID): DERR1-10.2196/19488 %M 33155571 %R 10.2196/19488 %U https://www.researchprotocols.org/2020/11/e19488 %U https://doi.org/10.2196/19488 %U http://www.ncbi.nlm.nih.gov/pubmed/33155571 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e16632 %T Usability and Acceptability of a Mobile App to Help Emerging Adults Address their Friends' Substance Use (Harbor): Quantitative Study %A Bennett,Kyle Michael %A Clary,Kelly Lynn %A Smith,Douglas Cary %A Lee,Carol Ann %+ University of Illinois Urbana-Champaign, 1010 West Nevada Street, Urbana, IL, 61801, United States, 1 2177660755, kmbennet@illinois.edu %K young adults %K substance abuse %K peer influence %K mobile applications %K mobile phone %K community-based participatory research %K crowdsourcing %D 2020 %7 5.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Technology-assisted intervention and prevention strategies present opportunities for substance use–related research with emerging adults (EAs) and their peers. Emerging adulthood is a developmentally distinct period in which individuals between the ages of 18 and 29 years undergo unique emotional, cultural, developmental, and biological changes as they transition into adulthood. Crowdsourcing, or gathering feedback from a large group within web-based communities, offers researchers a unique and cost-effective way to obtain large amounts of information in a short period. Objective: This paper presents market feedback obtained via Amazon’s Mechanical Turk from EAs (N=458) on the acceptability and utility of brief intervention scripts for a smartphone app currently under development. The mobile app, Harbor, teaches friends of EAs with substance use problems effective and supportive strategies for helping their friend make changes in their substance use behavior. Methods: We examined feedback on the wording of the intervention scripts and estimated the market size of EAs who may use this app. Furthermore, we calculated correlations between script ratings and measures of personal risky drinking (ie, Alcohol Use Disorder Identification Test) and the participants’ use of confrontational, enabling, or supportive behaviors with an existing friend. Results: Approximately half of our sample (208/458, 45.4%) indicated that they had a close friend for whom they had concerns about their substance use, suggesting a potentially high demand for an app such as Harbor. Initial findings suggest that peers who engage in less enabling behaviors with friends who have a substance use problem exhibited lower risky drinking behaviors overall (r206=−0.501; P<.001). Concerning acceptability, 98.0% (449/458) of the sample rated the scripts’ dialogue as either somewhat, moderately, or extremely realistic (mean 3.92, SD 0.48) on 5-point Likert scale items. Finally, 95.4% (437/454) of respondents indicated that the scripts would be at least slightly helpful for training peers to help their friends with substance use issues. Finally, individuals who were better able to identify enabling language in enabling scripts self-reported fewer enabling behaviors toward their friend’s substance use (r206=−0.236; P=.001). Conclusions: There exists a demonstrated level of desirability and acceptability among EAs for a mobile app such as Harbor. EAs who wish to engage in more supportive behaviors with their friends who engage in substance use and who are amenable to assisting their friends with sobriety likely would use and benefit from this app. %M 33151158 %R 10.2196/16632 %U https://www.jmir.org/2020/11/e16632 %U https://doi.org/10.2196/16632 %U http://www.ncbi.nlm.nih.gov/pubmed/33151158 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e19159 %T Network Support Using Social Networking Services to Increase Exercise Adherence Among Korean-Chinese Middle-Aged Migrant Women: Mixed Methods Study %A Lee,Hyeyeon %A Lee,Hyeonkyeong %A Kim,Youlim %A Kim,Sookyung %A Lee,Young-Me %+ Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonse-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2228 3373, hlee39@yuhs.ac %K SNS %K social support %K network support %K exercise adherence %K social-cognitive factors %K text mining %D 2020 %7 5.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Social networking services (SNSs) are recognized to be a promising approach to easily deliver health interventions and to enhance social support for exercise adherence. However, the patterns and aspects of social support through SNSs have not been reported and their influence on other social-cognitive factors remains inconclusive. Objective: Our objective is to explore how social support delivered through SNSs impacts interactions among Korean-Chinese (KC) middle-aged women and to identify how this approach influences social-cognitive factors for exercise (eg, sense of community, self-efficacy for exercise, and social support for exercise). Methods: A mixed methods design was used. Text analysis of SNS messages and text mining using the Korean Natural Language Application (KoALA) were conducted. Social-cognitive factors (eg, sense of community, self-efficacy for exercise, and social support for exercise) were assessed at baseline and after 12 weeks using a structured questionnaire. A comparison of social-cognitive factors at baseline and at 12 weeks was conducted to identify any potential significant changes, using the Wilcoxon signed-rank test. Results: A total of 259 SNS messages were collected from 24 KC women, distributed among four chat groups, who participated in a 12-week walking intervention program between August and October 2018. The individual average frequency of chatting via the SNS was 10.79 (range 0-34) and the most frequent type of social support through the SNS was network support (172/259, 66.4%). The most common words extracted from the SNS were Health, Exercise, Participation, and We. Overall, the perceived levels of sense of community (P<.001) and social support for exercise (P=.002) were significantly increased at 12 weeks compared with baseline. Group 1 (P=.03) and Group 4 (P=.03), whose members demonstrated the highest frequency of network support, experienced a significant increase only in the level of sense of community. Conclusions: By integrating these data and conducting a mixed methods analysis, we observed that among the types of social support, network support was a key point for the promotion of social-cognitive factors in increasing exercise adherence. Therefore, network support through SNS-based interventions should be considered as a useful strategy to help vulnerable migrant populations make changes to exercise behaviors. %M 33151155 %R 10.2196/19159 %U https://mhealth.jmir.org/2020/11/e19159 %U https://doi.org/10.2196/19159 %U http://www.ncbi.nlm.nih.gov/pubmed/33151155 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e22878 %T Mobile App Strategy to Facilitate Human Papillomavirus Vaccination Among Young Men Who Have Sex With Men: Pilot Intervention Study %A Fontenot,Holly B %A White,Bradley Patrick %A Rosenberger,Joshua G %A Lacasse,Hailee %A Rutirasiri,Chokdee %A Mayer,Kenneth H %A Zimet,Gregory %+ School of Nursing and Dental Hygiene, University of Hawaii at Manoa, 2528 McCarthy Mall, Webster Hall 412, Honolulu, HI, 96822, United States, 1 808 956 4917, hbfont@hawaii.edu %K human papillomavirus %K men who have sex with men %K vaccination %K mobile health tool %K mHealth %D 2020 %7 4.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile app-based interventions have been identified as potential facilitators for vaccination among young men who have sex with men (MSM). Objective: This pilot study aimed to test the feasibility of a theoretically informed mobile health (mHealth) tool designed to reduce health disparities and facilitate human papillomavirus (HPV) vaccination among a sample of young MSM. Methods: The development of the mHealth tool was guided by previous research, implementation intention theory, and design thinking. We recruited MSM aged 18-26 years through a popular online dating app and linked participants to our mHealth tool, which provided HPV vaccine information and fostered access to care. Results: A total of 42 young MSM participated in this pilot study in Boston, Massachusetts. Participants reported variable HPV knowledge (ie, high knowledge of HPV risk factors and low knowledge of HPV-related cancer risks for men) and positive vaccine beliefs and attitudes. Of those who were either unvaccinated, not up to date, or did not report vaccine status, 23% (8/35) utilized the mHealth tool to obtain HPV vaccination. Participants primarily utilized the tool’s (1) educational components and (2) capabilities facilitating concrete vaccine action plans. Conclusions: We recruited an underserved at-risk population of youth via an online dating app for our mHealth intervention that resulted in in-person health care delivery. This study was limited by enrollment challenges, including low willingness to download the mHealth tool to mobile devices. %M 33146621 %R 10.2196/22878 %U https://www.jmir.org/2020/11/e22878 %U https://doi.org/10.2196/22878 %U http://www.ncbi.nlm.nih.gov/pubmed/33146621 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e20251 %T Engaging Unmotivated Smokers to Move Toward Quitting: Design of Motivational Interviewing–Based Chatbot Through Iterative Interactions %A Almusharraf,Fahad %A Rose,Jonathan %A Selby,Peter %+ The Edward S. Rogers Sr. Department of Electrical & Computer Engineering, Faculty of Applied Science & Engineering, University of Toronto, 10 King's College Road, Toronto, ON, M5S 3G4, Canada, 1 4169786992, jonathan.rose@ece.utoronto.ca %K smoking cessation %K motivational interviewing %K chatbot %K natural language processing %D 2020 %7 3.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: At any given time, most smokers in a population are ambivalent with no motivation to quit. Motivational interviewing (MI) is an evidence-based technique that aims to elicit change in ambivalent smokers. MI practitioners are scarce and expensive, and smokers are difficult to reach. Smokers are potentially reachable through the web, and if an automated chatbot could emulate an MI conversation, it could form the basis of a low-cost and scalable intervention motivating smokers to quit. Objective: The primary goal of this study is to design, train, and test an automated MI-based chatbot capable of eliciting reflection in a conversation with cigarette smokers. This study describes the process of collecting training data to improve the chatbot’s ability to generate MI-oriented responses, particularly reflections and summary statements. The secondary goal of this study is to observe the effects on participants through voluntary feedback given after completing a conversation with the chatbot. Methods: An interdisciplinary collaboration between an MI expert and experts in computer engineering and natural language processing (NLP) co-designed the conversation and algorithms underlying the chatbot. A sample of 121 adult cigarette smokers in 11 successive groups were recruited from a web-based platform for a single-arm prospective iterative design study. The chatbot was designed to stimulate reflections on the pros and cons of smoking using MI’s running head start technique. Participants were also asked to confirm the chatbot’s classification of their free-form responses to measure the classification accuracy of the underlying NLP models. Each group provided responses that were used to train the chatbot for the next group. Results: A total of 6568 responses from 121 participants in 11 successive groups over 14 weeks were received. From these responses, we were able to isolate 21 unique reasons for and against smoking and the relative frequency of each. The gradual collection of responses as inputs and smoking reasons as labels over the 11 iterations improved the F1 score of the classification within the chatbot from 0.63 in the first group to 0.82 in the final group. The mean time spent by each participant interacting with the chatbot was 21.3 (SD 14.0) min (minimum 6.4 and maximum 89.2). We also found that 34.7% (42/121) of participants enjoyed the interaction with the chatbot, and 8.3% (10/121) of participants noted explicit smoking cessation benefits from the conversation in voluntary feedback that did not solicit this explicitly. Conclusions: Recruiting ambivalent smokers through the web is a viable method to train a chatbot to increase accuracy in reflection and summary statements, the building blocks of MI. A new set of 21 smoking reasons (both for and against) has been identified. Initial feedback from smokers on the experience shows promise toward using it in an intervention. %M 33141095 %R 10.2196/20251 %U https://www.jmir.org/2020/11/e20251 %U https://doi.org/10.2196/20251 %U http://www.ncbi.nlm.nih.gov/pubmed/33141095 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e19869 %T A Mobile-Based Intervention for Dietary Behavior and Physical Activity Change in Individuals at High Risk for Type 2 Diabetes Mellitus: Randomized Controlled Trial %A Xu,Zidu %A Geng,Ji %A Zhang,Shuai %A Zhang,Kexin %A Yang,Lin %A Li,Jing %A Li,Jiao %+ School of Nursing, Peking Union Medical College, No 33, Badachu Road, Shijingshan District, Beijing, 100144, China, 86 1088771124, annelee13@126.com %K transtheoretical model %K type 2 diabetes mellitus %K high risk %K social media %K dietary behavior %K physical activity %D 2020 %7 3.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Intensive lifestyle modifications have proved effective in preventing type 2 diabetes mellitus (T2DM), yet the efficiency and effectiveness of these modifications need to be improved. Emerging social media interventions are considered useful in promoting these lifestyles; nevertheless, few studies have investigated the effectiveness of combining them with behavior theory. Objective: This study aims to examine the effectiveness of a 6-month mobile-based intervention (DHealthBar, a WeChat applet) combined with behavioral theory compared with a printed intervention in improving dietary behaviors, physical activity, and intention to change these behaviors among populations at high risk for T2DM. Methods: Participants aged 23 to 67 years were recruited offline in Beijing, China, and were randomized into the intervention group or the control group, which received educational content via DHealthBar or a printed handbook, respectively. Educational materials were culturally tailored recommendations on improving dietary behaviors, physical activity, and intention to change based on the transtheoretical model. Participants in the intervention arm received push notifications twice per week on WeChat and had access to the educational content for the 6-month study period. Participants in the control arm received the same intervention content through printed materials. The outcomes of participants’ behavior change, intention to change behavior, and anthropometric characteristics were collected via online measuring tools at baseline, 3 months, and 6 months. Results: In this study, 79 enrolled individuals completed baseline information collection (control: n=38 vs intervention: n=41), and 96% (76/79) completed the 6-month follow-up visit. Attrition rates did not differ significantly between the 2 groups (χ21=0.0, P=.61). Baseline equivalence was found. Participants in both groups reported a statistically significant decrease in energy intake at the 2 follow-up assessments compared with baseline (3 months, control: exp[β]=0.83, 95% CI 0.74-0.92 vs intervention: exp[β]=0.76, 95% CI 0.68-0.85; 6 months, control: exp[β]=0.87, 95% CI 0.78-0.96 vs intervention: exp[β]=0.57, 95% CI 0.51-0.64). At 6 months, a significantly larger decrease was observed in the intervention group in energy, fat, and carbohydrate intake, accompanied with a significantly larger increase in moderate-intensity physical activity compared with the control group (energy: exp[β]=0.66, 95% CI 0.56-0.77; fat: exp[β]=0.71, 95% CI 0.54-0.95; carbohydrates: exp[β]=0.83, 95% CI 0.66-1.03; moderate-intensity physical activity: exp[β]=2.05, 95% CI 1.23-3.44). After 6 months of the intervention, participants in the intervention group were more likely to be at higher stages of dietary behaviors (exp[β]=26.80, 95% CI 3.51-204.91) and physical activity (exp[β]=15.60, 95% CI 2.67-91.04) than the control group. Conclusions: DHealthBar was initially effective in improving dietary behavior, physical activity, and intention to change these behaviors among populations who were at high risk of developing T2DM, with significant differences in the changes of outcomes over the 6-month intervention period. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000032323; https://tinyurl.com/y4h8q4uf %M 33141092 %R 10.2196/19869 %U https://mhealth.jmir.org/2020/11/e19869 %U https://doi.org/10.2196/19869 %U http://www.ncbi.nlm.nih.gov/pubmed/33141092 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e15116 %T A Mobile App, KhunLook, to Support Thai Parents and Caregivers With Child Health Supervision: Development, Validation, and Acceptability Study %A Areemit,Rosawan %A Lumbiganon,Pagakrong %A Suphakunpinyo,Chanyut %A Jetsrisuparb,Arunee %A Sutra,Sumitr %A Sripanidkulchai,Kunwadee %+ Department of Computer Engineering, Faculty of Engineering, Chulalongkorn University, Phayatai Road, Wang Mai, Pathumwan, Bangkok, 10330, Thailand, 66 2 218 6998, kunwadee@cp.eng.chula.ac.th %K mobile app %K mHealth %K KhunLook %K child health supervision %K maternal and child health handbook %K feasibility %K acceptability %K Thailand %K mobile phone %D 2020 %7 30.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In Thailand, children born in government hospitals receive a maternal and child health handbook (MCHH). However, when a new MCHH edition is released, those with the previous editions do not have access to the updated information. A mobile app is an appealing platform to fill this gap. We developed a mobile app called “KhunLook” as an interactive electronic MCHH intended to assist parents in child health supervision. Objective: This study describes the user requirements and development of the KhunLook mobile app, validity of parents’ growth assessments, and parents’ evaluation of feasibility and acceptability of the app. Methods: Phase 1 was a qualitative study using individual interviews. The interview data were used to revise the prototype. In phase 2, parents were randomly assigned to assess their children’s growth with the app or the MCHH. The outcomes were compared to those of the physician’s assessment, and congruence was determined. In phase 3, parents evaluated the feasibility and acceptability of the app in comparison to the MCHH through a web-based survey. Results: Four health care providers and 8 parents participated in phase 1. Two themes were identified: (1) the mobile app potentially counters parents’ infrequent use of the MCHH with accuracy, attractiveness, convenience, and simplicity, and (2) health supervision needs to be standard, up-to-date, and understandable. KhunLook was publicly launched with a family page and 7 key features: growth and nutrition, development, immunizations, oral health, reminders for the next appointment, memories, and health advice. In phase 2, 56 parents participated in the growth parameter assessments; 34 were in the App group and 22 in the MCHH group. The outcomes of the growth parameter assessments between parents and physicians in both the App and MCHH groups were not significantly different. The congruence proportions were higher in the App group for weight and head circumference, but the differences were not statistically significant. In phase 3, 356 parents from all over Thailand participated in a web-based survey. Parents rated the app feasibility as “very easy to easy” to use at higher proportions than the MCHH in all health assessment domains (growth, development, and immunizations) and ease-of-use domains with statistical significance (P<.001). The KhunLook app received a significantly higher mean score (8.59/10) than the MCHH (7.6/10) (P<.001). Most parents (317/356, 89.0%) preferred the app over MCHH. Further, 93.5% (333/356) of the parents stated that they would continue to use the app and 96.9% (345/356) would recommend others to use it. Conclusions: KhunLook, a Thai mobile app for child health supervision, was developed, validated for growth assessments, and was well accepted for ease-of-use by parents. Further studies should be conducted with a large scale of users, and the impact of this app on health behaviors and health outcomes must be evaluated. %M 33124989 %R 10.2196/15116 %U http://mhealth.jmir.org/2020/10/e15116/ %U https://doi.org/10.2196/15116 %U http://www.ncbi.nlm.nih.gov/pubmed/33124989 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e21159 %T Primary Prevention of Cardiovascular Disease and Type 2 Diabetes Mellitus Using Mobile Health Technology: Systematic Review of the Literature %A Buss,Vera Helen %A Leesong,Stuart %A Barr,Margo %A Varnfield,Marlien %A Harris,Mark %+ Centre for Primary Health Care and Equity, University of New South Wales, Level 3, AGSM Building, UNSW Sydney, Sydney, 2052, Australia, 61 293851547, v.buss@student.unsw.edu.au %K systematic review %K mobile health %K telemedicine %K primary prevention %K cardiovascular diseases %K diabetes mellitus, type 2 %D 2020 %7 29.10.2020 %9 Review %J J Med Internet Res %G English %X Background: Digital technology is an opportunity for public health interventions to reach a large part of the population. Objective: This systematic literature review aimed to assess the effectiveness of mobile health–based interventions in reducing the risk of cardiovascular disease and type 2 diabetes mellitus. Methods: We conducted the systematic search in 7 electronic databases using a predefined search strategy. We included articles published between inception of the databases and March 2019 if they reported on the effectiveness of an intervention for prevention of cardiovascular disease or type 2 diabetes via mobile technology. One researcher performed the search, study selection, data extraction, and methodological quality assessment. The steps were validated by the other members of the research team Results: The search yielded 941 articles for cardiovascular disease, of which 3 met the inclusion criteria, and 732 for type 2 diabetes, of which 6 met the inclusion criteria. The methodological quality of the studies was low, with the main issue being nonblinding of participants. Of the selected studies, 4 used SMS text messaging, 1 used WhatsApp, and the remaining ones used specific smartphone apps. Weight loss and reduction in BMI were the most reported successful outcomes (reported in 4 studies). Conclusions: Evidence on the effectiveness of mobile health-based interventions in reducing the risk for cardiovascular disease and type 2 diabetes is low due to the quality of the studies and the small effects that were measured. This highlights the need for further high-quality research to investigate the potential of mobile health interventions. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019135405; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=135405 %M 33118936 %R 10.2196/21159 %U http://www.jmir.org/2020/10/e21159/ %U https://doi.org/10.2196/21159 %U http://www.ncbi.nlm.nih.gov/pubmed/33118936 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e20847 %T Relationship Between Patient Engagement and Depressive Symptoms Among People Living With HIV in a Mobile Health Intervention: Secondary Analysis of a Randomized Controlled Trial %A Zeng,Yu %A Guo,Yan %A Li,Linghua %A Hong,Y Alicia %A Li,Yiran %A Zhu,Mengting %A Zeng,Chengbo %A Zhang,Hanxi %A Cai,Weiping %A Liu,Cong %A Wu,Shaomin %A Chi,Peilian %A Monroe-Wise,Aliza %A Hao,Yuantao %A Ho,Rainbow Tin Hung %+ Department of Medical Statistics, School of Public Health, Sun Yat-sen University, No.74, 2nd Zhongshan Road, Guangzhou, 510000, China, 86 13501502582, guoy8@mail.sysu.edu.cn %K mHealth %K patient engagement %K latent growth curve model %K depressive symptoms %K HIV %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Associations between higher levels of patient engagement and better health outcomes have been found in face-to-face interventions; studies on such associations with mobile health (mHealth) interventions have been limited and the results are inconclusive. Objective: The objective of this study is to investigate the relationship between patient engagement in an mHealth intervention and depressive symptoms using repeated measures of both patient engagement and patient outcomes at 4 time points. Methods: Data were drawn from a randomized controlled trial (RCT) of an mHealth intervention aimed at reducing depressive symptoms among people living with HIV and elevated depressive symptoms. We examined the association between patient engagement and depressive symptoms in the intervention group (n=150) where participants received an adapted cognitive-behavioral stress management (CBSM) course and physical activity promotion on their WeChat social media app. Depressive symptoms were repeatedly measured using the Patient Health Questionnaire (PHQ-9) at baseline and 1 month, 2 months, and 3 months. Patient engagement was correspondingly measured by the completion rate, frequency of items completed, and time spent on the program at 1 month, 2 months, and 3 months. Latent growth curve models (LGCMs) were used to explore the relationship between patient engagement and depressive symptoms at multiple time points in the intervention. Results: The mean PHQ-9 scores were 10.2 (SD 4.5), 7.7 (SD 4.8), 6.5 (SD 4.7), and 6.7 (SD 4.1) at baseline, 1 month, 2 months, and 3 months, respectively. The mean completion rates were 50.6% (SD 31.8%), 51.5% (SD 32.2%), and 50.8% (SD 33.7%) at 1, 2, and 3 months, respectively; the average frequencies of items completed were 18.0 (SD 14.6), 32.6 (SD 24.8), and 47.5 (SD 37.2) at 1, 2, and 3 months, respectively, and the mean times spent on the program were 32.7 (SD 66.7), 65.4 (SD 120.8), and 96.4 (SD 180.4) minutes at 1, 2, and 3 months, respectively. LGCMs showed good model fit and indicated that a higher completion rate (β at 3 months=–2.184, P=.048) and a greater frequency of items completed (β at 3 months=–0.018, P=.04) were associated with fewer depressive symptoms at 3 months. Although not significant, similar trends were found in the abovementioned relationships at 1 and 2 months. There was no significant relationship between time spent on the program and depressive symptoms. Conclusions: This study revealed a positive association between patient engagement and health outcomes at 3 months of an mHealth intervention using LGCMs and repeated measures data. The results underscore the importance of improving patient engagement in mHealth interventions to improve patient-centered health outcomes. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://tinyurl.com/yxb64mef International Registered Report Identifier (IRRID): RR2-10.1186/s12889-018-5693-1 %M 33118956 %R 10.2196/20847 %U http://mhealth.jmir.org/2020/10/e20847/ %U https://doi.org/10.2196/20847 %U http://www.ncbi.nlm.nih.gov/pubmed/33118956 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e18653 %T Engagement, Acceptability, Usability, and Preliminary Efficacy of a Self-Monitoring Mobile Health Intervention to Reduce Sedentary Behavior in Belgian Older Adults: Mixed Methods Study %A Compernolle,Sofie %A Cardon,Greet %A van der Ploeg,Hidde P %A Van Nassau,Femke %A De Bourdeaudhuij,Ilse %A Jelsma,Judith J %A Brondeel,Ruben %A Van Dyck,Delfien %+ Department of Movement and Sport Sciences, Ghent University, Watersportlaan 2, Ghent, 9000, Belgium, 32 092646323, sofie.compernolle@ugent.be %K mHealth %K older adults %K self-monitoring %K perceptions %K engagement %K acceptability %K mixed methods %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although healthy aging can be stimulated by the reduction of sedentary behavior, few interventions are available for older adults. Previous studies suggest that self-monitoring might be a promising behavior change technique to reduce older adults’ sedentary behavior. However, little is known about older adults’ experiences with a self-monitoring–based intervention aimed at the reduction of sedentary behavior. Objective: The aim of this study is to evaluate engagement, acceptability, usability, and preliminary efficacy of a self-monitoring–based mHealth intervention developed to reduce older adults’ sedentary behavior. Methods: A mixed methods study was performed among 28 community-dwelling older adults living in Flanders, Belgium. The 3-week intervention consisted of general sedentary behavior information as well as visual and tactile feedback on participants’ sedentary behavior. Semistructured interviews were conducted to explore engagement with, and acceptability and usability of, the intervention. Sitting time was measured using the thigh-worn activPAL (PAL Technologies) accelerometer before and after the intervention. System usage data of the app were recorded. Quantitative data were analyzed using descriptive statistics and paired-samples t tests; qualitative data were thematically analyzed and presented using pen profiles. Results: Participants mainly reported positive feelings regarding the intervention, referring to it as motivating, surprising, and interesting. They commonly reported that the intervention changed their thinking (ie, they became more aware of their sedentary behavior) but not their actual behavior. There were mixed opinions on the kind of feedback (ie, tactile vs visual) that they preferred. The intervention was considered easy to use, and the design was described as clear. Some problems were noticed regarding attaching and wearing the self-monitoring device. System usage data showed that the median frequency of consulting the app widely differed among participants, ranging from 0 to 20 times a day. No significant reductions were found in objectively measured sitting time. Conclusions: Although the intervention was well perceived by the majority of older adults, no reductions in sitting time were found. Possible explanations for the lack of reductions might be the short intervention duration or the fact that only bringing the habitual sedentary behavior into conscious awareness might not be sufficient to achieve behavior change. Trial Registration: ClinicalTrials.gov NCT04003324; https://tinyurl.com/y2p4g8hx %M 33118951 %R 10.2196/18653 %U http://mhealth.jmir.org/2020/10/e18653/ %U https://doi.org/10.2196/18653 %U http://www.ncbi.nlm.nih.gov/pubmed/33118951 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e19503 %T Vaccipack, A Mobile App to Promote Human Papillomavirus Vaccine Uptake Among Adolescents Aged 11 to 14 Years: Development and Usability Study %A Teitelman,Anne M %A Gregory,Emily F %A Jayasinghe,Joshua %A Wermers,Zara %A Koo,Ja H %A Morone,Jennifer F %A Leri,Damien C %A Davis,Annet %A Feemster,Kristen A %+ University of Pennsylvania, School of Nursing, 418 Curie Blvd, Philadelphia, PA, 19104, United States, 1 2158981910, teitelm@nursing.upenn.edu %K cervical cancer %K prevention %K mobile health %K parents %K adolescent health %K vaccine %K human papillomavirus %D 2020 %7 29.10.2020 %9 Original Paper %J JMIR Nursing %G English %X Background: More than 90% of human papillomavirus (HPV)-related cancers could be prevented by widespread uptake of the HPV vaccine, yet vaccine use in the United States falls short of public health goals. Objective: The purpose of this study was to describe the development, acceptability, and intention to use the mobile app Vaccipack, which was designed to promote uptake and completion of the adolescent HPV vaccine series. Methods: Development of the mobile health (mHealth) content was based on the integrated behavioral model (IBM). The technology acceptance model (TAM) was used to guide the app usability evaluation. App design utilized an iterative process involving providers and potential users who were parents and adolescents. App features include a vaccine-tracking function, a discussion forum, and stories with embedded messages to promote intention to vaccinate. Parents and adolescents completed surveys before and after introducing the app in a pediatric primary care setting with low HPV vaccination rates. Results: Surveys were completed by 54 participants (20 adolescents aged 11 to 14 years and 34 parents). Notably, 75% (15/20) of adolescents and 88% (30/34) of parents intended to use the app in the next 2 weeks. Acceptability of the app was high among both groups: 88% (30/34) of parents and 75% (15/20) of adolescents indicated that Vaccipack was easy to use, and 82% (28/34) of parents and 85% (17/20) of adolescents perceived the app to be beneficial. Higher levels of app acceptability were found among parents with strong intentions to use the app (P=.09; 95% CI –2.15 to 0.15). Conclusions: mHealth technology, such as Vaccipack, may be an acceptable and nimble platform for providing information to parents and adolescents and advancing the uptake of important vaccines. %R 10.2196/19503 %U https://nursing.jmir.org/2020/1/e19503/ %U https://doi.org/10.2196/19503 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e17470 %T Patients’ Experiences of Using Smartphone Apps to Support Self-Management and Improve Medication Adherence in Hypertension: Qualitative Study %A McBride,Ciara M %A Morrissey,Eimear C %A Molloy,Gerard J %+ School of Psychology, National Univeristy of Ireland Galway, University Road, Galway, H91 TK33, Ireland, 353 91524411, mcbrideciara5@gmail.com %K hypertension %K self-management %K mobile applications %K feasibility %K usability %K medication adherence %K qualitative research %K digital technology %K mobile phone %D 2020 %7 28.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Worldwide, hypertension control rates remain suboptimal despite clinically effective antihypertensive drug therapy. Patient failure to take medication as prescribed (ie, nonadherence) is the most important factor contributing to poor control. Smartphone apps can facilitate the delivery of evidence-based behavior change techniques to improve adherence and may provide a scalable, usable, and feasible method to deliver self-management support. Objective: The aim of this study is to explore patients’ experiences of the usability and feasibility of smartphone apps to support self-management and improve medication adherence in hypertension. Methods: A qualitative descriptive study was conducted. A total of 11 people living with hypertension from the West of Ireland were sampled purposively and interviewed about their experience of using a self-management app for a 4-week period, which included two key functionalities: self-monitoring of blood pressure (BP) and medication reminders. Thematic analysis was carried out on the semistructured interview data. Results: Participants’ age ranged from 43 to 74 years (mean 62 years, SD 9.13). Three themes were identified: digital empowerment of self-management, human versus digital systems, and digital sustainability. Although patients’ experience of using the technology to self-monitor BP was one of empowerment, characterized by an enhanced insight and understanding into their condition, control, and personal responsibility, the reminder function was only feasible for patients who reported unintentional nonadherence to treatment. Patients experienced the app as a sustainable tool to support self-management and found it easy to use, including those with limited technological competence. Conclusions: The study’s findings provide new insights into the experience of using apps to support medication adherence in hypertension. Overall, the data support apps as a usable and feasible method to aid self-management of hypertension and highlight the need for personalized functionality, particularly with regard to medication adherence reminder strategies. The study’s findings challenge the perspective that the use of these technologies to support self-management can inevitably add to the burden of treatment experienced by patients. %M 33112251 %R 10.2196/17470 %U http://mhealth.jmir.org/2020/10/e17470/ %U https://doi.org/10.2196/17470 %U http://www.ncbi.nlm.nih.gov/pubmed/33112251 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e19844 %T Weight Management Apps in Saudi Arabia: Evaluation of Features and Quality %A Alshathri,Dalal M %A Alhumaimeedy,Abeer S %A Al-Hudhud,Ghada %A Alsaleh,Aseel %A Al-Musharaf,Sara %A Aljuraiban,Ghadeer S %+ Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Turki Alawwal, Riyadh , Saudi Arabia, 966 50 301 2345, galjuraiban@ksu.edu.sa %K mHealth %K eHealth %K smartphone %K obesity %K weight management %K mobile apps %K MARS %K six sigma %D 2020 %7 26.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Weight management apps may provide support and management options for individuals with overweight and obesity. Research on the quality of weight management mHealth apps among the Saudi population is insufficient despite frequent use. Objective: The aims of this study were to explore user perceptions of weight management apps, explore reasons for starting and stopping app use, appraise the quality of weight management apps available in the App Store, and compare the features currently available within the app market and those that are most desirable to weight management app users. Methods: A web-based survey consisted of 31 open and closed questions about sociodemographic information, general health questions, app use, app user perceptions, and discontinuation of app use. The quality of the weight management apps available on the App Store was assessed using the Mobile App Rating Scale and evidence-based strategies. We also used six sigma evaluations to ensure that the quality measured by the tools consistently meets customer expectations. Results: Data from the survey were analyzed. Of the respondents, 30.17% (324/1074) had used a weight management app, 18.16% (195/1074) used the apps and stopped, and 51.68% (555/1074) had never used a weight management app. Of apps mentioned, 23 met the inclusion criteria. The overall average Mobile App Rating Scale quality of apps was acceptable; 30% (7/23) received a quality mean score of 4 or higher (out of 5), and 30% (7/23) did not meet the acceptability score of 3 or higher. Evidence-based strategy results showed that feedback was not observed in any of the apps, and motivation strategy was observed in only 1 app. The sigma results of evidence-based strategies reflect that most of the apps fail to pass the mean. Conclusions: App users desired a feature that allows them to communicate with a specialist, which is a missing in the available free apps. Despite the large number and accessibility of weight management apps, the quality and features of most are variable. It can be concluded from six sigma results that passing the mean does not ensure that the quality is consistently distributed through all app quality properties and Mobile App Rating Scale and evidence-based strategies do not give developers an indication of the acceptance of their apps by mobile users. This finding stresses the importance of reevaluating the passing criterion, which is ≥50% for designing an effective app. %M 33104013 %R 10.2196/19844 %U http://mhealth.jmir.org/2020/10/e19844/ %U https://doi.org/10.2196/19844 %U http://www.ncbi.nlm.nih.gov/pubmed/33104013 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e17522 %T Mobile Social Network–Based Smoking Cessation Intervention for Chinese Male Smokers: Pilot Randomized Controlled Trial %A Chen,Jinsong %A Ho,Elsie %A Jiang,Yannan %A Whittaker,Robyn %A Yang,Tingzhong %A Bullen,Christopher %+ National Institute for Health Innovation, School of Population Health, University of Auckland, 22-30 Park Ave, Grafton, Auckland, 1023, New Zealand, 64 0220951065, jinsong.chen@auckland.ac.nz %K mHealth %K mobile smoking cessation %K social network-based intervention %K smoking cessation %K public health %K gamified health interventions %D 2020 %7 23.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Around 2 million Chinese people, mostly men, die annually from tobacco-related diseases; yet, fewer than 8% of Chinese smokers ever receive any smoking cessation support. Objective: This study aimed to test the preliminary effectiveness and feasibility for a mobile social network (WeChat)–based smoking cessation intervention (SCAMPI program) among Chinese male smokers. Methods: Chinese male smokers aged 25-44 years were recruited online from WeChat, the most widely used social media platform in China. Individuals using other smoking cessation interventions or who lacked capacity to provide online informed consent were excluded. Participants were randomly assigned (1:1) to intervention or control groups. Neither participants nor researchers were masked to assignment. The trial was fully online. All data were collected via WeChat. The intervention group received access to the full-version SCAMPI program, a Chinese-language smoking cessation program based on the Behaviour Change Wheel framework and relevant cessation guidelines. Specific intervention functions used in the program include: planning to help users make quitting plans, calculator to record quitting benefits, calendar to record progress, gamification to facilitate quitting, information about smoking harms, motivational messages to help users overcome urges, standardized tests for users to assess their levels of nicotine dependence and lung health, as well as a social platform to encourage social support between users. The control group had access to a static WeChat page of contacts for standard smoking cessation care. Both groups received incentive credit payments for participating. The primary outcome was 30-day biochemically verified smoking abstinence at 6 weeks after randomization, with missing data treated as not quitting. Secondary outcomes were other smoking status measures, reduction of cigarette consumption, study feasibility (recruitment and retention rate), and acceptability of and satisfaction with the program. Results: The program recorded 5736 visitors over a 13-day recruitment period. We recruited 80 participants who were randomly allocated to two arms (n=40 per arm). At 6 weeks, 36 of 40 (90%) intervention participants and 35 of 40 (88%) control participants provided complete self-reported data on their daily smoking status via WeChat. Biochemically verified smoking abstinence at 6 weeks was determined for 10 of 40 (25%) intervention participants and 2 of 40 (5%) control participants (RR=5, 95% CI 1.2-21.4, P=.03). In the intervention group, the calculator function, motivational messages, and health tests were underused (less than once per week per users). Participants rated their satisfaction with the intervention program as 4.56 out of 5.00. Conclusions: Our program is a novel, accessible, and acceptable smoking cessation intervention for Chinese male smokers. A future trial with a greater sample size and longer follow-up will identify if it is as effective as these preliminary data suggest. Trial Registration: ANZCTR registry, ACTRN12618001089224; https://tinyurl.com/y536n7sx International Registered Report Identifier (IRRID): RR2-18071 %M 33095184 %R 10.2196/17522 %U http://mhealth.jmir.org/2020/10/e17522/ %U https://doi.org/10.2196/17522 %U http://www.ncbi.nlm.nih.gov/pubmed/33095184 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e14322 %T Use of a Smartphone App to Increase Physical Activity Levels in Insufficiently Active Adults: Feasibility Sequential Multiple Assignment Randomized Trial (SMART) %A Gonze,Bárbara De Barros %A Padovani,Ricardo Da Costa %A Simoes,Maria Do Socorro %A Lauria,Vinicius %A Proença,Neli Leite %A Sperandio,Evandro Fornias %A Ostolin,Thatiane Lopes Valentim Di Paschoale %A Gomes,Grace Angélica De Oliveira %A Castro,Paula Costa %A Romiti,Marcello %A Gagliardi,Antonio %A Arantes,Rodolfo Leite %A Dourado,Victor Zuniga %+ Laboratory of Epidemiology and Human Movement (EPIMOV), Department of Human Movement Sciences, Federal University of São Paulo, Rua Silva Jardim 136, Vila Mathias, Santos, 11015-020, Brazil, 55 1332290203, victor.dourado@unifesp.br %K tailored messages %K gamification %K steps per day %D 2020 %7 23.10.2020 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The sequential multiple assignment randomized trial (SMART) design allows for changes in the intervention during the trial period. Despite its potential and feasibility for defining the best sequence of interventions, so far, it has not been utilized in a smartphone/gamified intervention for physical activity. Objective: We aimed to investigate the feasibility of the SMART design for assessing the effects of a smartphone app intervention to improve physical activity in adults. We also aimed to describe the participants’ perception regarding the protocol and the use of the app for physical activity qualitatively. Methods: We conducted a feasibility 24-week/two-stage SMART in which 18 insufficiently active participants (<10,000 steps/day) were first randomized to group 1 (smartphone app only), group 2 (smartphone app + tailored messages), and a control group (usual routine during the protocol). Participants were motivated to increase their step count by at least 2000 steps/day each week. Based on the 12-week intermediate outcome, responders continued the intervention and nonresponders were rerandomized to subsequent treatment, including a new group 3 (smartphone app + tailored messages + gamification) in which they were instructed to form groups to use several game elements available in the chosen app (Pacer). We considered responders as those with any positive slope in the linear relationship between weeks and steps per day at the end of the first stage of the intervention. We compared the accelerometer-based steps per day before and after the intervention, as well as the slopes of the app-based steps per day between the first and second stages of the intervention. Results: Twelve participants, including five controls, finished the intervention. We identified two responders in group 1. We did not observe relevant changes in the steps per day either throughout the intervention or compared with the control group. However, the rerandomization of five nonresponders led to a change in the slope of the steps per day (median −198 steps/day [IQR −279 to −103] to 20 steps/day [IQR −204 to 145]; P=.08). Finally, in three participants from group 2, we observed an increase in the number of steps per day up to the sixth week, followed by an inflection to baseline values or even lower (ie, a quadratic relationship). The qualitative analysis showed that participants’ reports could be classified into the following: (1) difficulty in managing the app and technology or problems with the device, (2) suitable response to the app, and (3) difficulties to achieve the goals. Conclusions: The SMART design was feasible and changed the behavior of steps per day after rerandomization. Rerandomization should be implemented earlier to take advantage of tailored messages. Additionally, difficulties with technology and realistic and individualized goals should be considered in interventions for physical activity using smartphones. Trial Registration: Brazilian Registry of Clinical Trials RBR-8xtc9c; http://www.ensaiosclinicos.gov.br/rg/RBR-8xtc9c/. %M 33094733 %R 10.2196/14322 %U https://www.researchprotocols.org/2020/10/e14322 %U https://doi.org/10.2196/14322 %U http://www.ncbi.nlm.nih.gov/pubmed/33094733 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e20982 %T Using mHealth to Provide Mobile App Users With Visualization of Health Checkup Data and Educational Videos on Lifestyle-Related Diseases: Methodological Framework for Content Development %A Aida,Azusa %A Svensson,Thomas %A Svensson,Akiko Kishi %A Urushiyama,Hirokazu %A Okushin,Kazuya %A Oguri,Gaku %A Kubota,Naoto %A Koike,Kazuhiko %A Nangaku,Masaomi %A Kadowaki,Takashi %A Yamauchi,Toshimasa %A Chung,Ung-Il %+ Precision Health, Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan, 81 3 5841 4737, akiko-kishi@umin.ac.jp %K apps %K educational videos %K health checkup %K lifestyle-related disease %K mHealth, prevention %K telehealth %K visualization %D 2020 %7 21.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The number of people with lifestyle-related diseases continues to increase worldwide. Improving lifestyle behavior with health literacy may be the key to address lifestyle-related diseases. The delivery of educational videos using mobile health (mHealth) services can replace the conventional way of educating individuals, and visualization can replace the provision of health checkup data. Objective: This paper aimed to describe the development of educational content for MIRAMED, a mobile app aimed at improving users’ lifestyle behaviors and health literacy for lifestyle-related diseases. Methods: All videos were based on a single unified framework to provide users with a consistent flow of information. The framework was later turned into a storyboard. The final video contents were created based on this storyboard and further discussions with leading experts and specialist physicians on effective communication with app users about lifestyle-related diseases. Results: The app uses visualization of personal health checkup data and educational videos on lifestyle-related diseases based on the current health guidelines, scientific evidence, and expert opinions of leading specialist physicians in the respective fields. A total of 8 videos were created for specific lifestyle-related diseases affecting 8 organs: (1) brain–cerebrovascular disorder, (2) eyes–diabetic retinopathy, (3) lungs–chronic obstructive pulmonary disease, (4) heart–ischemic heart disease, (5) liver–fatty liver, (6) kidneys–chronic kidney disease (diabetic kidney disease), (7) blood vessels–peripheral arterial disease, and (8) nerves–diabetic neuropathy. Conclusions: Providing enhanced mHealth education using novel digital technologies to visualize conventional health checkup data and lifestyle-related diseases is an innovative strategy. Future studies to evaluate the efficacy of the developed content are planned. %M 33084586 %R 10.2196/20982 %U http://mhealth.jmir.org/2020/10/e20982/ %U https://doi.org/10.2196/20982 %U http://www.ncbi.nlm.nih.gov/pubmed/33084586 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e18915 %T Feasibility and Acceptability of a Counseling- and mHealth-Based Physical Activity Intervention for Pregnant Women With Diabetes: The Fit for Two Pilot Study %A Larsen,Britta %A Micucci,Stephanie %A Hartman,Sheri J %A Ramos,Gladys %+ Department of Family Medicine & Public Health, University of California, San Diego, 9500 Gilman Dr, San Diego, CA, 92093-0725, United States, 1 8585348429, blarsen@ucsd.edu %K exercise %K behavioral medicine %K mHealth %K gestational diabetes %K type 2 diabetes %K mobile phone %D 2020 %7 21.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Diabetes during pregnancy poses serious health risks to both mother and child. Regular physical activity can reduce these risks, yet few clinic-based interventions of physical activity for pregnant women with diabetes have been attempted. Objective: The purpose of this single-arm pilot trial is to assess the feasibility and acceptability, and explore the potential efficacy of a counseling- and mobile health–based physical activity intervention for pregnant women with diabetes. Methods: Participants (N=17) who had type 2 or gestational diabetes, could read and speak in English or Spanish, and were between 10 and 27 weeks of gestation were recruited from the University of California San Diego Diabetes and Pregnancy Program. Participants engaged in a one-on-one counseling and goal-setting session immediately following a clinic visit with their physician. They were given a Fitbit and shown how to use the Fitbit app, including entering personalized step goals, and were encouraged to build up to 10,000 daily steps. Daily steps were recorded for 12 weeks, until they were 36 weeks’ gestation, or until 1 week before they gave birth, whichever came first. Feasibility was measured by recruitment, retention, and adherence, and acceptability was measured using consumer satisfaction questionnaires and follow-up interviews. Potential efficacy was explored by examining changes in daily steps over time. Results: The participants were primarily Hispanic (13/17, 76%), had public insurance (15/17, 88%), and had type 2 diabetes (12/17, 71%). Of the 17 patients who began the intervention, 76% (13/17) completed a follow-up visit, and 71% (12/17) continued wearing the Fitbit regularly after 8 weeks in the intervention. Adherence in wearing the Fitbit was relatively high, with a median wear adherence of 90% of days. The intervention was generally well accepted, with 85% (11/13) indicating that they were motivated to exercise more following the counseling session, 85% (11/13) indicating that the Fitbit helped increase their activity, and 92% (12/13) recommending the program overall. Mean daily steps increased from baseline (mean 6122, SD 2439) to week 3 (mean 6269, SD 2166) and then decreased through week 12 (mean 4191, SD 2228). Conclusions: High acceptability, retention, and adherence suggest that this may be a promising approach to delivering a simple, low-burden intervention in a clinical setting to a high-risk, underserved population. A randomized controlled trial is needed to determine whether this approach is effective in slowing the reduction in activity typically seen throughout pregnancy. Trial Registration: ClinicalTrials.gov NCT03302377; https://clinicaltrials.gov/ct2/show/NCT03302377 %M 33084584 %R 10.2196/18915 %U http://mhealth.jmir.org/2020/10/e18915/ %U https://doi.org/10.2196/18915 %U http://www.ncbi.nlm.nih.gov/pubmed/33084584 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e18237 %T Accuracy of Nutrient Calculations Using the Consumer-Focused Online App MyFitnessPal: Validation Study %A Evenepoel,Charlotte %A Clevers,Egbert %A Deroover,Lise %A Van Loo,Wendy %A Matthys,Christophe %A Verbeke,Kristin %+ Translational Research in Gastrointestinal Disorders, Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Herestraat 49, TARGID, O&N1, box 701, Leuven, 3000, Belgium, 32 16330150, kristin.verbeke@kuleuven.be %K dietary assessment %K MyFitnessPal %K Nubel %K nutrition %K online application %K diet %D 2020 %7 21.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital food registration via online platforms that are coupled to large food databases obviates the need for manual processing of dietary data. The reliability of such platforms depends on the quality of the associated food database. Objective: In this study, we validate the database of MyFitnessPal versus the Belgian food composition database, Nubel. Methods: After carefully given instructions, 50 participants used MyFitnessPal to each complete a 4-day dietary record 2 times (T1 and T2), with 1 month in between T1 and T2. Nutrient intake values were calculated either manually, using the food composition database Nubel, or automatically, using the database coupled to MyFitnessPal. First, nutrient values from T1 were used as a training set to develop an algorithm that defined upper limit values for energy intake, carbohydrates, fat, protein, fiber, sugar, cholesterol, and sodium. These limits were applied to the MyFitnessPal dataset extracted at T2 to remove extremely high and likely erroneous values. Original and cleaned T2 values were correlated with the Nubel calculated values. Bias was estimated using Bland-Altman plots. Finally, we simulated the impact of using MyFitnessPal for nutrient analysis instead of Nubel on the power of a study design that correlates nutrient intake to a chosen outcome variable. Results: Per food portion, the following upper limits were defined: 1500 kilocalories for total energy intake, 95 grams (g) for carbohydrates, 92 g for fat, 52 g for protein, 22 g for fiber, 70 g for sugar, 600 mg for cholesterol, and 3600 mg for sodium. Cleaning the dataset extracted at T2 resulted in a 2.8% rejection. Cleaned MyFitnessPal values demonstrated strong correlations with Nubel for energy intake (r=0.96), carbohydrates (r=0.90), fat (r=0.90), protein (r=0.90), fiber (r=0.80), and sugar (r=0.79), but weak correlations for cholesterol (ρ=0.51) and sodium (ρ=0.53); all P values were ≤.001. No bias was found between both methods, except for a fixed bias for fiber and a proportional bias for cholesterol. A 5-10% power loss should be taken into account when correlating energy intake and macronutrients obtained with MyFitnessPal to an outcome variable, compared to Nubel. Conclusions: Dietary analysis with MyFitnessPal is accurate and efficient for total energy intake, macronutrients, sugar, and fiber, but not for cholesterol and sodium. %M 33084583 %R 10.2196/18237 %U http://www.jmir.org/2020/10/e18237/ %U https://doi.org/10.2196/18237 %U http://www.ncbi.nlm.nih.gov/pubmed/33084583 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e21496 %T Smartphone App to Address Loneliness Among College Students: Pilot Randomized Controlled Trial %A Bruehlman-Senecal,Emma %A Hook,Cayce J %A Pfeifer,Jennifer H %A FitzGerald,Caroline %A Davis,Brittany %A Delucchi,Kevin L %A Haritatos,Jana %A Ramo,Danielle E %+ Hopelab, 100 California Street #1150, San Francisco, CA, 94111, United States, 1 415 728 8387, dramo@hopelab.org %K loneliness %K mental health %K smartphone app %K college %K app %K student %K young adult %K randomized controlled trial %K efficacy %K feasibility %K desirability %D 2020 %7 20.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Loneliness is a widespread and significant problem on college campuses. Prolonged loneliness in young adulthood is a risk factor for concurrent and future mental health problems and attrition, making college a critical time for support. Cognitive and behavioral interventions show promise for decreasing loneliness and can be widely disseminated through technology. Objective: This pilot randomized controlled trial was conducted to examine the initial efficacy, feasibility, and desirability of a smartphone app, Nod, designed to deliver cognitive and behavioral skill-building exercises to reduce loneliness during the transition to college. Methods: First-year college students (N=221, mean age 18.7 years, 59% female) were recruited online during incoming student orientation, and randomized to either receive immediate access to Nod (experimental group, n=100) or access after 4 weeks (control group, n=121). The app delivered skills via fully automated (1) “social challenges,” suggested activities designed to build social connections; (2) reflections, brief cognitive reframing exercises; and (3) student testimonials that encouraged a growth mindset toward social connection building. Main intention-to-treat analyses were used to compare the conditions on self-assessed loneliness, depressive symptoms, and other mental health and college adjustment outcomes at week 4, controlling for baseline values on those variables. Analyses were also performed to test the hypothesis that the treatment benefits would be particularly pronounced for participants with heightened psychological vulnerability at baseline (ie, higher baseline depressive symptoms and loneliness). Results: Retention was 97% at week 4, and participants viewed an average 36.7 pages of app content. There were no significant condition differences in loneliness at week 4 (F1, 211=0.05, P=.82; ηp2 <.001). However, there was a significant condition-by-baseline depression interaction to predict week-4 loneliness (F1,209=9.65, P=.002; ηp2 =.04). Simple slope analyses indicated that baseline depression positively predicted week-4 loneliness among control participants (r=0.30, t209=3.81, P<.001), but not among experimental participants (r=–0.09, t209=–0.84, P=.40), suggesting that Nod buffered participants with high baseline depression scores from experiencing heightened midquarter loneliness. Similarly, there were no significant condition differences in other week-4 outcomes. However, moderation by baseline vulnerability was found for week-4 depressive symptoms, sleep quality, and indices of college adjustment (eg, perceived social support and campus belonging). Conclusions: Although Nod exposure did not impact outcomes for the full sample, these results provide initial evidence of its benefit for vulnerable students. The results of this trial suggest that cognitive and behavioral skills delivered via a mobile app can buffer psychologically vulnerable college students against heightened loneliness and depressive symptoms, as well as other negative college adjustment outcomes. Future work will aim to improve upon app engagement, and to address loneliness among other key populations. Trial Registration: ClinicalTrials.gov NCT04164654; https://clinicaltrials.gov/ct2/show/NCT04164654 %M 33079071 %R 10.2196/21496 %U http://mental.jmir.org/2020/10/e21496/ %U https://doi.org/10.2196/21496 %U http://www.ncbi.nlm.nih.gov/pubmed/33079071 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e21759 %T The Effect of Smartphone App–Based Interventions for Patients With Hypertension: Systematic Review and Meta-Analysis %A Xu,Hongxuan %A Long,Huanyu %+ The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, No 1 DaHua Road, Dong Dan, Beijing, 100730, China, 86 13524791942, xueramber@gmail.com %K hypertension %K smartphone %K blood pressure %K mobile %K lifestyle %K adherence %K smartphone app %K medication adherence %D 2020 %7 19.10.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Hypertension is a major cause of cardiovascular disease, which is the leading cause of premature death. People with hypertension who do not comply with recommended treatment strategies have a higher risk of heart attacks and strokes, leading to hospitalization and consequently greater health care costs. The smartphone, which is now ubiquitous, offers a convenient tool to aid in the treatment of hypertension through the use of apps targeting lifestyle management, and such app-based interventions have shown promising results. In particular, recent evidence has shown the feasibility, acceptability, and success of digital interventions in changing the behavior of people with chronic conditions. Objective: The aim of this study was to systematically compile available evidence to determine the overall effect of smartphone apps on blood pressure control, medication adherence, and lifestyle changes for people with hypertension. Methods: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines. Databases were searched to identify randomized controlled trials related to the influence of an app-based intervention in people with hypertension. Data extracted from the included studies were subjected to a meta-analysis to compare the effects of the smartphone app intervention to a control. Results: Eight studies with a total of 1657 participants fulfilled the inclusion criteria. Pooled analysis of 6 studies assessing systolic blood pressure showed a significant overall effect in favor of the smartphone intervention (weighted mean difference –2.28, 95% CI –3.90-0.66). Pooled analysis of studies assessing medication adherence demonstrated a significant effect (P<.001) in favor of the intervention group (standard mean difference 0.38, 95% CI 0.26-0.50) with low heterogeneity (I2=0%). No difference between groups was demonstrated with respect to physical activity. Conclusions: A smartphone intervention leads to a reduction in blood pressure and an increase in medication adherence for people with hypertension. Future research should focus on the effect of behavior coaching apps on medication adherence, lifestyle change, and blood pressure reduction. %M 33074161 %R 10.2196/21759 %U http://mhealth.jmir.org/2020/10/e21759/ %U https://doi.org/10.2196/21759 %U http://www.ncbi.nlm.nih.gov/pubmed/33074161 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e19280 %T Archetypes of Gamification: Analysis of mHealth Apps %A Schmidt-Kraepelin,Manuel %A Toussaint,Philipp A %A Thiebes,Scott %A Hamari,Juho %A Sunyaev,Ali %+ Department of Economics and Management, Karlsruhe Institute of Technology, Kaiserstraße 89, Karlsruhe, D-76133, Germany, 49 72160846037, sunyaev@kit.edu %K mHealth %K smartphones %K mobile phones %K gamification %K quantified-self %K exergames, persuasive technology %D 2020 %7 19.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Nowadays, numerous health-related mobile apps implement gamification in an attempt to draw on the motivational potential of video games and thereby increase user engagement or foster certain health behaviors. However, research on effective gamification is still in its infancy and researchers increasingly recognize methodological shortcomings of existing studies. What we actually know about the phenomenon today stems from fragmented pieces of knowledge, and a variety of different perspectives. Existing research primarily draws on conceptual knowledge that is gained from research prototypes, and isolated from industry best practices. We still lack knowledge on how gamification has been successfully designed and implemented within the industry and whether certain gamification approaches have shown to be particularly suitable for certain health behaviors. Objective: We address this lack of knowledge concerning best practices in the design and implementation of gamification for health-related mobile apps by identifying archetypes of gamification approaches that have emerged in pertinent health-related mobile apps and analyzing to what extent those gamification approaches are influenced by the underlying desired health-related outcomes. Methods: A 3-step research approach is employed. As a first step, a database of 143 pertinent gamified health-related mobile apps from the Apple App Store and Google Play Store is set up. Second, the gamification approach of each app within the database is classified based on an established taxonomy for gamification in health-related apps. Finally, a 2-step cluster analysis is conducted in order to identify archetypes of the most dominant gamification approaches in pertinent gamified health-related mobile apps. Results: Eight archetypes of gamification emerged from the analysis of health-related mobile apps: (1) competition and collaboration, (2) pursuing self-set goals without rewards, (3) episodical compliance tracking, (4) inherent gamification for external goals, (5) internal rewards for self-set goals, (6) continuous assistance through positive reinforcement, (7) positive and negative reinforcement without rewards, and (8) progressive gamification for health professionals. The results indicate a close relationship between the identified archetypes and the actual health behavior that is being targeted. Conclusions: By unveiling salient best practices and discussing their relationship to targeted health behaviors, this study contributes to a more profound understanding of gamification in mobile health. The results can serve as a foundation for future research that advances the knowledge on how gamification may positively influence health behavior change and guide practitioners in the design and development of highly motivating and effective health-related mobile health apps. %M 33074155 %R 10.2196/19280 %U https://mhealth.jmir.org/2020/10/e19280 %U https://doi.org/10.2196/19280 %U http://www.ncbi.nlm.nih.gov/pubmed/33074155 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e17881 %T Light-Induced Fluorescence-Based Device and Hybrid Mobile App for Oral Hygiene Management at Home: Development and Usability Study %A Kim,Jun-Min %A Lee,Woo Ram %A Kim,Jun-Ho %A Seo,Jong-Mo %A Im,Changkyun %+ Dental Life Science Research Institute, Seoul National University Dental Hospital, 601 Seoul National University Dental Hospital, 1 Gwanak-ro, Gwanak-Gu, Seoul, , Republic of Korea, 82 2 6747 6587, changkyun@snu.ac.kr %K dental plaque %K oral hygiene %K red fluorescence %K mobile health %K deep learning %K object detection %K instance segmentation %D 2020 %7 16.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Dental diseases can be prevented through the management of dental plaques. Dental plaque can be identified using the light-induced fluorescence (LIF) technique that emits light at 405 nm. The LIF technique is more convenient than the commercial technique using a disclosing agent, but the result may vary for each individual as it still requires visual identification. Objective: The objective of this study is to introduce and validate a deep learning–based oral hygiene monitoring system that makes it easy to identify dental plaques at home. Methods: We developed a LIF-based system consisting of a device that can visually identify dental plaques and a mobile app that displays the location and area of dental plaques on oral images. The mobile app is programmed to automatically determine the location and distribution of dental plaques using a deep learning–based algorithm and present the results to the user as time series data. The mobile app is also built with convergence of naive and web applications so that the algorithm is executed on a cloud server to efficiently distribute computing resources. Results: The location and distribution of users’ dental plaques could be identified via the hand-held LIF device or mobile app. The color correction filter in the device was developed using a color mixing technique. The mobile app was built as a hybrid app combining the functionalities of a native application and a web application. Through the scrollable WebView on the mobile app, changes in the time series of dental plaque could be confirmed. The algorithm for dental plaque detection was implemented to run on Amazon Web Services for object detection by single shot multibox detector and instance segmentation by Mask region-based convolutional neural network. Conclusions: This paper shows that the system can be used as a home oral care product for timely identification and management of dental plaques. In the future, it is expected that these products will significantly reduce the social costs associated with dental diseases. %M 33064097 %R 10.2196/17881 %U https://mhealth.jmir.org/2020/10/e17881 %U https://doi.org/10.2196/17881 %U http://www.ncbi.nlm.nih.gov/pubmed/33064097 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e19412 %T Exploring the Effects of a Brief Biofeedback Breathing Session Delivered Through the BioBase App in Facilitating Employee Stress Recovery: Randomized Experimental Study %A Chelidoni,Olga %A Plans,David %A Ponzo,Sonia %A Morelli,Davide %A Cropley,Mark %+ Faculty of Health and Medical Sciences, School of Psychology, University of Surrey, Stag Hill, Guildford, GU2 7XH, United Kingdom, 44 01483686928, mark.cropley@surrey.ac.uk %K breathing %K biofeedback %K smartphone %K heart rate variability %K recovery %K mindfulness %K stress %K mobile phone %D 2020 %7 15.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Recovery from stress is a predictive factor for cardiovascular health, and heart rate variability (HRV) is suggested to be an index of how well people physiologically recover from stress. Biofeedback and mindfulness interventions that include guided breathing have been shown to be effective in increasing HRV and facilitating stress recovery. Objective: This study aims to assess the effectiveness of a brief app-based breathing intervention (BioBase) in enhancing physiological recovery among employees who were induced to cognitive and emotional stress. Methods: In total, we recruited 75 full-time employees. Interbeat (RR) intervals were recorded continuously for 5 min at baseline and during cognitive and emotional stress induction. The session ended with a 5-min recovery period during which participants were randomly allocated into 3 conditions: app-based breathing (BioBase), mindfulness body scan, or control. Subjective tension was assessed at the end of each period. Results: Subjective tension significantly increased following stress induction. HRV significantly decreased following the stress period. In the recovery phase, the root mean square of successive RR interval differences (P=.002), the percentage of successive RR intervals that differed by >50 ms (P=.008), and high frequency (P=.01) were significantly higher in the BioBase breathing condition than in the mindfulness body scan and the control groups. Conclusions: Biofeedback breathing interventions digitally delivered through a commercially available app can be effective in facilitating stress recovery among employees. These findings contribute to the mobile health literature on the beneficial effects of brief app-based breathing interventions on employees’ cardiovascular health. %M 33055072 %R 10.2196/19412 %U http://mhealth.jmir.org/2020/10/e19412/ %U https://doi.org/10.2196/19412 %U http://www.ncbi.nlm.nih.gov/pubmed/33055072 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e19044 %T Rationale and Design of the Women’s Health And Daily Experiences Project: Protocol for an Ecological Momentary Assessment Study to Identify Real-Time Predictors of Midlife Women’s Physical Activity %A Arigo,Danielle %A Brown,Megan M %A Pasko,Kristen %A Ainsworth,Matthew Cole %A Travers,Laura %A Gupta,Adarsh %A Downs,Danielle Symons %A Smyth,Joshua M %+ Department of Psychology, Rowan University, 201 Mullica Hill Road, Robinson 116G, Robinson H109, Glassboro, NJ, 08028, United States, 1 8562564500 ext 53775, arigo@rowan.edu %K women's health %K midlife %K cardiovascular risk %K physical activity %K ecological momentary assessment %K mobile phone %D 2020 %7 15.10.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Midlife women are at an elevated risk for cardiovascular disease (CVD) and associated mortality. Those who have additional risk conditions such as obesity or hypertension report specific barriers to engaging in cardioprotective behaviors such as physical activity (PA). Considerable effort has been devoted to understanding PA determinants and designing interventions for midlife women, although with suboptimal success, as increasing PA could meaningfully attenuate CVD risk. An updated approach to understanding PA among midlife women could improve upon existing resources by focusing on novel psychosocial influences on PA in this population (ie, body satisfaction, social interactions, social comparisons, mood state) and within-person relations between these influences and PA in the natural environment. Objective: The overarching goal of Project WHADE (Women’s Health And Daily Experiences) is to use an ecological momentary assessment (EMA) approach to capture ecologically valid relations between midlife women’s psychosocial experiences and PA as they engage in their normal daily activities. The primary aim of the study is to identify within-person psychosocial predictors of variability in PA (ie, experiences associated with higher vs lower PA for a given individual). Methods: Midlife women (aged 40-60 years) with one or more additional risk markers for CVD (eg, hypertension) will be recruited from primary care clinics and the general community (target n=100). Eligible women will complete an initial survey and a face-to-face baseline session before engaging in a 10-day EMA protocol. Psychosocial experiences will be assessed using a brief self-report via a smartphone 5 times per day, and PA will be assessed throughout waking hours using a research-grade monitor. Participants will return for a brief exit interview at the end of 10 days. Multilevel models that address the nested structure of EMA data will be used to evaluate the study aims. Results: Recruitment and enrollment are ongoing, and a total of 75 women have completed the protocol to date. Data collection is expected to be completed in Fall 2020. Conclusions: Project WHADE is designed to identify naturally occurring psychosocial experiences that predict short-term variability in midlife women’s PA. As such, the results of this study should advance the current understanding of PA among midlife women by providing further insight into within-person psychosocial influences on PA in this group. In the future, this information could help inform the design of interventions for this population. International Registered Report Identifier (IRRID): DERR1-10.2196/19044 %M 33055065 %R 10.2196/19044 %U http://www.researchprotocols.org/2020/10/e19044/ %U https://doi.org/10.2196/19044 %U http://www.ncbi.nlm.nih.gov/pubmed/33055065 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e20720 %T Association Between Usage of an App to Redeem Prescribed Food Benefits and Redemption Behaviors Among the Special Supplemental Nutrition Program for Women, Infants, and Children Participants: Cross-Sectional Study %A Zhang,Qi %A Zhang,Junzhou %A Park,Kayoung %A Tang,Chuanyi %+ School of Community and Environmental Health, Old Dominion University, 3130 Health Sciences Building, Old Dominion University, Norfolk, VA, 23529, United States, 1 7576836870, qzhang@odu.edu %K mobile phone app %K WIC %K EBT %K benefit redemption %K mobile phone %D 2020 %7 14.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important food assistance programs in the United States, serving 6.4 million low-income, eligible women, infants, and children under 5 years of age in 2019. In the program, participants are prescribed a list of food benefits, which can be redeemed in WIC-authorized stores. However, there are multiple behavioral barriers in the program and the stores that prevent participants from redeeming the benefits fully. Objective: This study aims to examine the relationship between the use of a widely used mobile phone app, WICShopper, and the redemption of the prescribed food packages. Methods: WIC administrative data were obtained from West Virginia for the period January 2019 to January 2020 and included 30,440 WIC households that had received food benefits in that period. The redemption rates of 18 WIC food benefits were compared between app users and nonapp users, that is, those who never used the app in the study period. The use behaviors were defined for the app users, including the number of active use benefit cycles, active benefit cycle rates, number of active use days in the cycle, and proportion rates of daytime use. Panel linear regressions were applied to examine how the redemption rates were related to these behaviors over time. Results: App users consistently had higher average redemption rates than nonapp users; the difference ranged from 3.6% (4.8% relative) for infant formula to 14.3% (40.7% relative) for fish. After controlling for sociodemographics, the coefficients of app use were significantly positive for all benefit categories except for WIC-eligible nutritionals. More active cycles and active days in the cycle were significantly related to redemption rates for all categories, except for frozen juice (coefficient=−0.002, P=.09). Daytime app access was positively associated with redemption rates for most food benefits except only a few, such as infant formula (coefficient=−0.03, P<.001). Conclusions: Use of the WIC app was significantly related to higher redemption rates across food benefits, although the association varied across benefit categories. More active days were positively related to benefit redemptions across food categories, and the app’s daytime use was positively associated with the redemption of most benefit categories. These findings suggest that the WIC app can be an important tool for the promotion of benefit redemption among WIC participants. %M 33052133 %R 10.2196/20720 %U http://mhealth.jmir.org/2020/10/e20720/ %U https://doi.org/10.2196/20720 %U http://www.ncbi.nlm.nih.gov/pubmed/33052133 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e18545 %T App-Based Delivery of Clinical Emotional Freedom Techniques: Cross-Sectional Study of App User Self-Ratings %A Church,Dawson %A Stapleton,Peta %A Sabot,Debbie %+ School of Psychology, Faculty of Society & Design, Bond University, 14 University Drive, Robina, 4226, Australia, 61 755952515, dsabot@bond.edu.au %K anxiety %K stress %K meditation %K mobile health %K Emotional Freedom Techniques (EFT) %K mobile phone %D 2020 %7 14.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The burgeoning area of mobile health (mHealth) has experienced rapid growth in mobile apps designed to address mental health issues. Although abundant apps offer strategies for managing symptoms of anxiety and stress, information regarding their efficacy is scarce. Objective: This study aimed to assess the effect of an mHealth app on user self-ratings of psychological distress in a sample of 270,461 app users. The Tapping Solution App guides users through the therapeutic protocols of Clinical Emotional Freedom Techniques (EFT), an evidence-based psychophysiological intervention that combines acupressure with elements of cognitive and exposure therapies. Methods: App users provided self-ratings of emotional intensity before and after app sessions (termed “tapping meditations”) using an 11-point Subjective Units of Distress scale. App user data for 23 tapping meditations, which addressed psychological symptoms of anxiety and stress, were gathered between October 2018 and October 2019, totaling 380,034 completed app sessions. Results: Across 12 anxiety-tapping meditations, the difference in emotional intensity ratings from presession (mean 6.66, SD 0.25) to postsession (mean 3.75, SD 0.30) was statistically significant (P<.001; 95% CI −2.92 to −2.91). Across 11 stress-tapping meditations, a statistically significant difference was also found from presession (mean 6.91, SD 0.48) to postsession (mean 3.83, SD 0.54; P<.001; 95% CI −3.08 to −3.07). The results are consistent with the literature on the efficacy of Clinical EFT for anxiety and stress when offered in conventional therapeutic formats. Conclusions: The findings provide preliminary support for the effectiveness of the mHealth app in the immediate reduction of self-rated psychological distress. As an adjunct to professional mental health care, the app promises accessible and convenient therapeutic benefits. %M 32862128 %R 10.2196/18545 %U http://mhealth.jmir.org/2020/10/e18545/ %U https://doi.org/10.2196/18545 %U http://www.ncbi.nlm.nih.gov/pubmed/32862128 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e17377 %T Challenges in Acceptance and Compliance in Digital Health Assessments During Pregnancy: Prospective Cohort Study %A Brusniak,Katharina %A Arndt,Hannah Maria %A Feisst,Manuel %A Haßdenteufel,Kathrin %A Matthies,Lina Maria %A Deutsch,Thomas Maximilian %A Hudalla,Hannes %A Abele,Harald %A Wallwiener,Markus %A Wallwiener,Stephanie %+ Department of Gynecology and Obstetrics, University Hospital Heidelberg, Im Neuenheimer Feld 440, Heidelberg, 69120, Germany, 49 6221 5637551, Stephanie.Wallwiener@med.uni-heidelberg.de %K eHealth %K compliance %K pregnancy %K digital assessments %D 2020 %7 14.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pregnant women are increasingly using mobile apps to access health information during the antenatal period. Therefore, digital health solutions can potentially be used as monitoring instruments during pregnancy. However, a main factor of success is high user engagement. Objective: The aim of this study was to analyze engagement and factors influencing compliance in a longitudinal study targeting pregnant women using a digital health app with self-tracking. Methods: Digitally collected data concerning demographics, medical history, technical aspects, and mental health from 585 pregnant women were analyzed. Patients filling out ≥80% of items at every study visit were considered to be highly compliant. Factors associated with high compliance were identified using logistic regression. The effect of a change in mental and physical well-being on compliance was assessed using a one-sample t test. Results: Only 25% of patients could be considered compliant. Overall, 63% left at least one visit blank. Influential variables for higher engagement included higher education, higher income, private health insurance, nonsmoking, and German origin. There was no relationship between a change in the number of physical complaints or depressive symptoms and study dropout. Conclusions: Maintaining high engagement with digital monitoring devices over a long time remains challenging. As cultural and socioeconomic background factors had the strongest influence, more effort needs to be directed toward understanding the needs of patients from different demographic backgrounds to ensure high-quality care for all patients. More studies need to report on compliance to disclose potential demographic bias. %M 33052134 %R 10.2196/17377 %U https://mhealth.jmir.org/2020/10/e17377 %U https://doi.org/10.2196/17377 %U http://www.ncbi.nlm.nih.gov/pubmed/33052134 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e15430 %T Occurrence of and Reasons for “Missing Events” in Mobile Dietary Assessments: Results From Three Event-Based Ecological Momentary Assessment Studies %A Ziesemer,Katrin %A König,Laura Maria %A Boushey,Carol Jo %A Villinger,Karoline %A Wahl,Deborah Ronja %A Butscher,Simon %A Müller,Jens %A Reiterer,Harald %A Schupp,Harald Thomas %A Renner,Britta %+ Psychological Assessment & Health Psychology, Department of Psychology, University of Konstanz, PO Box 47, Konstanz, 78457, Germany, 49 7531884679, britta.renner@uni-konstanz.de %K dietary assessment %K diet records %K mobile phone %K mobile applications %K technology %K adherence %K compliance %K missing events %K Ecological Momentary Assessment %K mHealth %D 2020 %7 14.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Establishing a methodology for assessing nutritional behavior comprehensively and accurately poses a great challenge. Mobile technologies such as mobile image-based food recording apps enable eating events to be assessed in the moment in real time, thereby reducing memory biases inherent in retrospective food records. However, users might find it challenging to take images of the food they consume at every eating event over an extended period, which might lead to incomplete records of eating events (missing events). Objective: Analyzing data from 3 studies that used mobile image-based food recording apps and varied in their technical enrichment, this study aims to assess how often eating events (meals and snacks) were missed over a period of 8 days in a naturalistic setting by comparing the number of recorded events with the number of normative expected events, over time, and with recollections of missing events. Methods: Participants in 3 event-based Ecological Momentary Assessment (EMA) studies using mobile image-based dietary assessments were asked to record all eating events (study 1, N=38, 1070 eating events; study 2, N=35, 934 eating events; study 3, N=110, 3469 eating events). Study 1 used a basic app; study 2 included 1 fixed reminder and the possibility to add meals after the actual eating events occurred instead of in the moment (addendum); and study 3 included 2 fixed reminders, an addendum feature, and the option to record skipped meals. The number of recalled missed events and their reasons were assessed by semistructured interviews after the EMA period (studies 1 and 2) and daily questionnaires (study 3). Results: Overall, 183 participants reported 5473 eating events. Although the momentary adherence rate as indexed by a comparison with normative expected events was generally high across all 3 studies, a differential pattern of results emerged with a higher rate of logged meals in the more technically intensive study 3. Multilevel models for the logging trajectories of reported meals in all 3 studies showed a significant, albeit small, decline over time (b=−.11 to −.14, Ps<.001, pseudo-R²=0.04-0.06), mainly because of a drop in reported snacks between days 1 and 2. Intraclass coefficients indicated that 38% or less of the observed variance was because of individual differences. The most common reasons for missing events were competing activities and technical issues, whereas situational barriers were less important. Conclusions: Three different indicators (normative, time stability, and recalled missing events) consistently indicated missing events. However, given the intensive nature of diet EMA protocols, the effect sizes were rather small and the logging trajectories over time were remarkably stable. Moreover, the individual’s actual state and context seemed to exert a greater influence on adherence rates than stable individual differences, which emphasizes the need for a more nuanced understanding of the factors that affect momentary adherence. %M 33052123 %R 10.2196/15430 %U https://mhealth.jmir.org/2020/10/e15430 %U https://doi.org/10.2196/15430 %U http://www.ncbi.nlm.nih.gov/pubmed/33052123 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e23954 %T Fitbit-Based Interventions for Healthy Lifestyle Outcomes: Systematic Review and Meta-Analysis %A Ringeval,Mickael %A Wagner,Gerit %A Denford,James %A Paré,Guy %A Kitsiou,Spyros %+ Research Chair in Digital Health, HEC Montreal, 3000, Cote-Sainte-Catherine Road, Montreal, QC, H1Y3K9, Canada, 1 514 882 8672, guy.pare@hec.ca %K Fitbit %K wearables %K healthy lifestyle %K meta-analysis %K literature review %K fuzzy-set qualitative comparative analysis %D 2020 %7 12.10.2020 %9 Review %J J Med Internet Res %G English %X Background: Unhealthy behaviors, such as physical inactivity, sedentary lifestyle, and unhealthful eating, remain highly prevalent, posing formidable challenges in efforts to improve cardiovascular health. While traditional interventions to promote healthy lifestyles are both costly and effective, wearable trackers, especially Fitbit devices, can provide a low-cost alternative that may effectively help large numbers of individuals become more physically fit and thereby maintain a good health status. Objective: The objectives of this meta-analysis are (1) to assess the effectiveness of interventions that incorporate a Fitbit device for healthy lifestyle outcomes (eg, steps, moderate-to-vigorous physical activity, and weight) and (2) to identify which additional intervention components or study characteristics are the most effective at improving healthy lifestyle outcomes. Methods: A systematic review was conducted, searching the following databases from 2007 to 2019: MEDLINE, EMBASE, CINAHL, and CENTRAL (Cochrane). Studies were included if (1) they were randomized controlled trials, (2) the intervention involved the use of a Fitbit device, and (3) the reported outcomes were related to healthy lifestyles. The main outcome measures were related to physical activity, sedentary behavior, and weight. All the studies were assessed for risk of bias using Cochrane criteria. A random-effects meta-analysis was conducted to estimate the treatment effect of interventions that included a Fitbit device compared with a control group. We also conducted subgroup analysis and fuzzy-set qualitative comparative analysis (fsQCA) to further disentangle the effects of intervention components. Results: Our final sample comprised 41 articles reporting the results of 37 studies. For Fitbit-based interventions, we found a statistically significant increase in daily step count (mean difference [MD] 950.54, 95% CI 475.89-1425.18; P<.001) and moderate-to-vigorous physical activity (MD 6.16, 95% CI 2.80-9.51; P<.001), a significant decrease in weight (MD −1.48, 95% CI −2.81 to −0.14; P=.03), and a nonsignificant decrease in objectively assessed and self-reported sedentary behavior (MD −10.62, 95% CI −35.50 to 14.27; P=.40 and standardized MD −0.11, 95% CI −0.48 to 0.26; P=.56, respectively). In general, the included studies were at low risk for bias, except for performance bias. Subgroup analysis and fsQCA demonstrated that, in addition to the effects of the Fitbit devices, setting activity goals was the most important intervention component. Conclusions: The use of Fitbit devices in interventions has the potential to promote healthy lifestyles in terms of physical activity and weight. Fitbit devices may be useful to health professionals for patient monitoring and support. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019145450; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019145450 %M 33044175 %R 10.2196/23954 %U http://www.jmir.org/2020/10/e23954/ %U https://doi.org/10.2196/23954 %U http://www.ncbi.nlm.nih.gov/pubmed/33044175 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 10 %P e21075 %T Examining an App-Based Mental Health Self-Care Program, IntelliCare for College Students: Single-Arm Pilot Study %A Lattie,Emily %A Cohen,Katherine A %A Winquist,Nathan %A Mohr,David C %+ Department of Medical Social Sciences, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL, 60611, United States, 1 3125033741, emily.lattie@northwestern.edu %K mHealth %K college students %K depression %K anxiety %K mobile phone %D 2020 %7 10.10.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: In recent years, there has been an increase in symptoms of depression, anxiety, and other mental illnesses in college student populations alongside a steady rise in the demand for counseling services. Digital mental health programs, such as those delivered through mobile apps, can add to the array of available services but must be tested for usability and acceptability before implementation. Objective: This study aims to examine how students used IntelliCare for College Students over an 8-week period to examine the preliminary associations between app use and psychosocial targets and to gather user feedback about usability issues that need to be remedied before a larger implementation study. Methods: IntelliCare for College Students is an app-based platform that provides symptom assessments with personalized feedback, information about campus resources, lessons on mental health and wellness topics, and access to the suite of interactive skill–focused IntelliCare apps. A total of 20 students were recruited to participate in an 8-week study. To test for a broad range of potential users, we recruited a mixed sample of students with elevated symptoms of depression or anxiety and students without elevated symptoms. Participants completed psychosocial questionnaires at baseline, week 4, and week 8. Participants also completed user feedback interviews at weeks 4 and 8 in which they provided feedback on their experience using the app and suggestions for changes they would like to be made to the app. Results: Of the 20 students who downloaded the app, 19 completed the study, indicating a high rate of retention. Over the study period, participants completed an average of 5.85 (SD 2.1; range 1-8) symptom assessments. Significant improvements were observed in the Anxiety Literacy Questionnaire scores (Z=−2.006; P=.045) and in the frequency with which participants used both cognitive (Z=−2.091; P=.04) and behavioral (Z=−2.249; P=.03) coping skills. In the feedback interviews, we identified a high degree of usability with minor bugs in the app software, which were quickly fixed. Furthermore, in feedback interviews, we identified that users found the app to be convenient and appreciated the ability to use the program in short bursts of time. Conclusions: The findings indicate that the IntelliCare for College Students program was perceived as largely usable and engaging. Although the program demonstrated usability and preliminary benefits to students, further testing is needed to determine its clinical utility among college students. Trial Registration: ClinicalTrials.gov NCT04035577; https://clinicaltrials.gov/ct2/show/NCT04035577 %M 33037874 %R 10.2196/21075 %U http://mental.jmir.org/2020/10/e21075/ %U https://doi.org/10.2196/21075 %U http://www.ncbi.nlm.nih.gov/pubmed/33037874 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e15741 %T A Digital Companion, the Emma App, for Ecological Momentary Assessment and Prevention of Suicide: Quantitative Case Series Study %A Morgiève,Margot %A Genty,Catherine %A Azé,Jérôme %A Dubois,Jonathan %A Leboyer,Marion %A Vaiva,Guillaume %A Berrouiguet,Sofian %A Courtet,Philippe %+ Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU Montpellier, INSERM, Univ Montpellier, Neuropsychiatry: Epidemiological and Clinical Research, 371 Av. du Doyen Gaston Giraud, Montpellier, 34090, France, 33 609596532, margotmorgieve@yahoo.fr %K suicide %K ecological momentary assessment %K prediction %K prevention %K mobile health %K mHealth %K case reports %K ecological momentary intervention %D 2020 %7 9.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Many suicide risk factors have been identified, but traditional clinical methods do not allow for the accurate prediction of suicide behaviors. To face this challenge, emma, an app for ecological momentary assessment (EMA), ecological momentary intervention (EMI), and prediction of suicide risk in high-risk patients, was developed. Objective: The aim of this case report study was to describe how subjects at high risk of suicide use the emma app in real-world conditions. Methods: The Ecological Mental Momentary Assessment (EMMA) study is an ongoing, longitudinal, interventional, multicenter trial in which patients at high risk for suicide are recruited to test emma, an app designed to be used as a self-help tool for suicidal crisis management. Participants undergo clinical assessment at months 0, 1, 3, and 6 after inclusion, mainly to assess and characterize the presence of mental disorders and suicidal thoughts and behaviors. Patient recruitment is still ongoing. Some data from the first 14 participants who already completed the 6-month follow-up were selected for this case report study, which evaluated the following: (1) data collected by emma (ie, responses to EMAs), (2) metadata on emma use, (3) clinical data, and (4) qualitative assessment of the participants' experiences. Results: EMA completion rates were extremely heterogeneous with a sharp decrease over time. The completion rates of the weekly EMAs (25%-87%) were higher than those of the daily EMAs (0%-53%). Most patients (10/14, 71%) answered the EMA questionnaires spontaneously. Similarly, the use of the Safety Plan Modules was very heterogeneous (2-75 times). Specifically, 11 patients out of 14 (79%) used the Call Module (1-29 times), which was designed by our team to help them get in touch with health care professionals and/or relatives during a crisis. The diversity of patient profiles and use of the EMA and EMI modules proposed by emma were highlighted by three case reports. Conclusions: These preliminary results indicate that patients have different clinical and digital profiles and needs that require a highly scalable, interactive, and customizable app. They also suggest that it is possible and acceptable to collect longitudinal, fine-grained, contextualized data (ie, EMA) and to offer personalized intervention (ie, EMI) in real time to people at high risk of suicide. To become a complementary tool for suicide prevention, emma should be integrated into existing emergency procedures. Trial Registration: ClinicalTrials.gov NCT03410381; https://clinicaltrials.gov/ct2/show/NCT03410381 %M 33034567 %R 10.2196/15741 %U https://mhealth.jmir.org/2020/10/e15741 %U https://doi.org/10.2196/15741 %U http://www.ncbi.nlm.nih.gov/pubmed/33034567 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e17435 %T Effect of Smartphone-Based Lifestyle Coaching App on Community-Dwelling Population With Moderate Metabolic Abnormalities: Randomized Controlled Trial %A Cho,So Mi Jemma %A Lee,Jung Hyun %A Shim,Jee-Seon %A Yeom,Hyungseon %A Lee,Su Jin %A Jeon,Yong Woo %A Kim,Hyeon Chang %+ Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea, 82 2 2228 1873, hckim@yuhs.ac %K metabolic health %K health behavior %K lifestyle modification %K mobile health %D 2020 %7 9.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Metabolic disorders are established precursors to cardiovascular diseases, yet they can be readily prevented with sustained lifestyle modifications. Objective: We assessed the effectiveness of a smartphone-based weight management app on metabolic parameters in adults at high-risk, yet without physician diagnosis nor pharmacological treatment for metabolic syndrome, in a community setting. Methods: In this 3-arm parallel-group, single-blind, randomized controlled trial, we recruited participants aged 30 to 59 years with at least 2 conditions defined by the Third Report of the National Cholesterol Education Program expert panel (abdominal obesity, high blood pressure, high triglycerides, low high-density lipoprotein cholesterol, and high fasting glucose level). Participants were randomly assigned (1:1:1) by block randomization to either the nonuser group (control), the app-based diet and exercise self-logging group (app only), or the app-based self-logging and personalized coaching from professional dieticians and exercise coordinators group (app with personalized coaching). Assessments were performed at baseline, week 6, week 12, and week 24. The primary outcome was change in systolic blood pressure (between baseline and follow-up assessments). Secondary outcomes were changes in diastolic blood pressure, body weight, body fat mass, waist circumference, homeostatic model of assessment of insulin resistance, triglyceride level, and high-density lipoprotein cholesterol level between baseline and follow-up assessments. Analysis was performed using intention-to-treat. Results: Between October 28, 2017 and May 28, 2018, 160 participants participated in the baseline screening examination. Participants (129/160, 80.6%) who satisfied the eligibility criteria were assigned to control (n=41), app only (n=45), or app with personalized coaching (n=43) group. In each group, systolic blood pressure showed decreasing trends from baseline (control: mean –10.95, SD 2.09 mmHg; app only: mean –7.29, SD 1.83 mmHg; app with personalized coaching: mean –7.19, SD 1.66 mmHg), yet without significant difference among the groups (app only: P=.19; app with personalized coaching: P=.16). Instead, those in the app with personalized coaching group had greater body weight reductions (control: mean –0.12, SD 0.30 kg; app only: mean –0.35, SD 0.36 kg, P=.67; app with personalized coaching: mean –0.96, SD 0.37 kg; P=.08), specifically by body fat mass reduction (control: mean –0.13, SD 0.34 kg; app only: mean –0.64, SD 0.38 kg, P=.22; app with personalized coaching: mean –0.79, SD 0.38 kg; P=.08). Conclusions: Simultaneous diet and exercise self-logging and persistent lifestyle modification coaching were ineffective in lowering systolic blood pressure but effective in losing weight and reducing body fat mass. These results warrant future implementation studies of similar models of care on a broader scale in the context of primary prevention. Trial Registration: ClinicalTrials.gov NCT03300271; http://clinicaltrials.gov/ct2/show/NCT03300271 %M 33034564 %R 10.2196/17435 %U https://www.jmir.org/2020/10/e17435 %U https://doi.org/10.2196/17435 %U http://www.ncbi.nlm.nih.gov/pubmed/33034564 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e23716 %T Coping Skills Mobile App to Support the Emotional Well-Being of Young People During the COVID-19 Pandemic: Protocol for a Mixed Methods Study %A Serlachius,Anna %A Schache,Kiralee %A Boggiss,Anna %A Lim,David %A Wallace-Boyd,Kate %A Brenton-Peters,Jennifer %A Buttenshaw,Elise %A Chadd,Stephanie %A Cavadino,Alana %A Cao,Nicholas %A Morunga,Eva %A Thabrew,Hiran %+ Department of Psychological Medicine, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand, 64 09 923 3073, a.serlachius@auckland.ac.nz %K COVID-19 %K pandemic %K mental health %K mobile applications %K apps %K mHealth %K coping skills %K wellbeing %K adolescent %K young adult %K coping %D 2020 %7 8.10.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The COVID-19 pandemic is likely to increase anxiety and distress in young people worldwide. It is important to prioritize mental health during crisis events to mitigate the negative and often long-term effects of the crises on young people, families, and society. Mental health and well-being apps represent a scalable approach for improving psychological outcomes in young people and have potential to improve the equity of service access. Objective: The Whitu: 7 Ways in 7 Days well-being app was recently developed by our group to address the urgent need for innovative approaches to reach young New Zealanders who are struggling to cope with the COVID-19 pandemic. The aim of this study is twofold: to evaluate the acceptability of the prototype app and to examine the effectiveness of the refined app at improving mental and emotional well-being and reducing depression, anxiety, and stress in young people in New Zealand. Methods: A two-phase mixed methods study will be undertaken to achieve these aims. During the first phase, 20 young people aged 16-30 years (including those of Māori and Pacific ethnicity) will participate in a qualitative study to help refine the prototype app. During the second phase, 90 young people aged 16-30 years will participate in a randomized waitlist-controlled trial (RCT) to evaluate the efficacy of the refined Whitu app at 4 weeks and 3 months after baseline. Outcomes will be evaluated using validated web-based questionnaires at baseline, 4 weeks, and 3 months. Results: The study received ethics approval in May 2020, and recruitment for the focus groups commenced in June 2020. Recruitment for the RCT is expected to commence in October 2020. Participants for both study phases will be recruited via social media and web-based communities. Data collection for the RCT is expected to be completed by January 2021, and analyses are expected to be completed by March 2021. Linear mixed modelling will be used to determine between-group differences in psychological outcomes. Conclusions: There is an urgent need to develop culturally appropriate, scalable mental health interventions to address the psychological consequences of the COVID-19 pandemic. In this study, we will develop and test an evidence-based well-being app that, if effective, can be made available to all young people in New Zealand and internationally. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12620000516987); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379597. International Registered Report Identifier (IRRID): PRR1-10.2196/23716 %M 32991303 %R 10.2196/23716 %U https://www.researchprotocols.org/2020/10/e23716 %U https://doi.org/10.2196/23716 %U http://www.ncbi.nlm.nih.gov/pubmed/32991303 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e16911 %T Adoption of Mobile Health Apps in Dietetic Practice: Case Study of Diyetkolik %A Akdur,Gorkem %A Aydin,Mehmet Nafiz %A Akdur,Gizdem %+ Department of Management Information Systems, Kadir Has University, Kadir Has St., Cibali / Fatih, Istanbul, 34083, Turkey, 90 5360662866, gorkemakdur@gmail.com %K mHealth %K technology acceptance %K user acceptance %K mobile apps %K diet apps %K Technology Acceptance Model %K TAM %K dietetics %D 2020 %7 2.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Dietetics mobile health apps provide lifestyle tracking and support on demand. Mobile health has become a new trend for health service providers through which they have been shifting their services from clinical consultations to online apps. These apps usually offer basic features at no cost and charge a premium for advanced features. Although diet apps are now more common and have a larger user base, in general, there is a gap in literature addressing why users intend to use diet apps. We used Diyetkolik, Turkey’s most widely used online dietetics platform for 7 years, as a case study to understand the behavioral intentions of users. Objective: The aim of this study was to investigate the factors that influence the behavioral intentions of users to adopt and use mobile health apps. We used the Technology Acceptance Model and extended it by exploring other factors such as price-value, perceived risk, and trust factors in order to assess the technology acceptance of users. Methods: We conducted quantitative research on the Diyetkolik app users by using random sampling. Valid data samples gathered from 658 app users were analyzed statistically by applying structural equation modeling. Results: Statistical findings suggested that perceived usefulness (P<.001), perceived ease of use (P<.001), trust (P<.001), and price-value (P<.001) had significant relationships with behavioral intention to use. However, no relationship between perceived risk and behavioral intention was found (P=.99). Additionally, there was no statistical significance for age (P=.09), gender (P=.98), or previous app use experience (P=.14) on the intention to use the app. Conclusions: This research is an invaluable addition to Technology Acceptance Model literature. The results indicated that 2 external factors (trust and price-value) in addition to Technology Acceptance Model factors showed statistical relevance with behavioral intention to use and improved our understanding of user acceptance of a mobile health app. The third external factor (perceived risk) did not show any statistical relevance regarding behavioral intention to use. Most users of the Diyetkolik dietetics app were hesitant in purchasing dietitian services online. Users should be frequently reassured about the security of the platform and the authenticity of the platform’s dietitians to ensure that users’ interactions with the dietitians are based on trust for the platform and the brand. %M 33006566 %R 10.2196/16911 %U https://mhealth.jmir.org/2020/10/e16911 %U https://doi.org/10.2196/16911 %U http://www.ncbi.nlm.nih.gov/pubmed/33006566 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 10 %P e19860 %T Perceptions of Mobile Apps for Smoking Cessation Among Young People in Community Mental Health Care: Qualitative Study %A Gowarty,Minda A %A Kung,Nathan J %A Maher,Ashley E %A Longacre,Meghan R %A Brunette,Mary F %+ Departments of Internal Medicine and Community and Family Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, United States, 1 6036536868, minda.a.gowarty@hitchcock.org %K smoking cessation %K mHealth %K serious mental illness %K smartphone application %K digital health %K psychiatric illness %K tobacco treatment %D 2020 %7 2.10.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Young adults with serious mental illness are over twice as likely to have tobacco use disorder than those in the general population and are less likely to utilize proven treatment methods during quit attempts. However, little research has evaluated the efficacy of interventions for this group. Smartphone apps may be an underutilized tool for tobacco use disorder among young adults with serious mental illness. Objective: The aim of this study was to explore attitudes toward smoking cessation apps and preferences regarding app design in young adult smokers with serious mental illness. Methods: Five focus groups involving 25- to 35-year-old adults with serious mental illness receiving treatment at a community mental health center were conducted between May 2019 and August 2019. Three researchers independently coded transcripts and identified themes using thematic analysis. Results: Participants (n=22) were individuals who smoke daily: 10 (46%) self-identified as female, 18 (82%) self-identified as White, and 9 (41%) had psychotic disorders. Key themes that emerged included a general interest in using health apps; a desire for apps to provide ongoing motivation during a quit attempt via social support, progress tracking, and rewards; a desire for apps to provide distraction from smoking; concerns about app effectiveness due to a lack of external accountability; and concerns that apps could trigger cravings or smoking behavior by mentioning cigarettes or the act of smoking. Conclusions: Apps have the potential to support smoking cessation or reduction efforts among young adults with serious mental illness. However, they may require tailoring, optimization, and clinical support to effectively promote cessation in this population. %M 33006560 %R 10.2196/19860 %U https://formative.jmir.org/2020/10/e19860 %U https://doi.org/10.2196/19860 %U http://www.ncbi.nlm.nih.gov/pubmed/33006560 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e19720 %T Evaluating the Efficacy of a Mobile App (Drinks:Ration) and Personalized Text and Push Messaging to Reduce Alcohol Consumption in a Veteran Population: Protocol for a Randomized Controlled Trial %A Leightley,Daniel %A Rona,Roberto J %A Shearer,James %A Williamson,Charlotte %A Gunasinghe,Cerisse %A Simms,Amos %A Fear,Nicola T %A Goodwin,Laura %A Murphy,Dominic %+ King's College London, King's Centre for Military Health Research, 10 Cutcombe Road, London, SE5 9RJ, United Kingdom, 44 20 7848 5351, daniel.leightley@kcl.ac.uk %K alcohol misuse %K smartphone %K intervention %K SMS text messaging %K push notifications %D 2020 %7 2.10.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Alcohol misuse is higher in the UK Armed Forces than in the general population. Previous research has shown that interventions delivered via smartphones are efficacious in promoting self-monitoring of alcohol use, have utility in reducing alcohol consumption, and have a broad reach. Objective: This single-blinded randomized controlled trial (RCT) aims to assess the efficacy of a 28-day brief alcohol intervention delivered via a smartphone app (Drinks:Ration) in reducing weekly self-reported alcohol consumption between baseline and 3-month follow-up among veterans who drink at a hazardous or harmful level and receive or have received support for mental health symptoms in a clinical setting. Methods: In this two-arm, single-blinded RCT, a smartphone app that includes interactive features designed to enhance participants’ motivation and personalized messaging is compared with a smartphone app that provides only government guidance on alcohol consumption. The trial will be conducted in a veteran population that has sought help through Combat Stress, a UK veteran’s mental health charity. Recruitment, consent, and data collection will be carried out automatically through the Drinks:Ration platform. The primary outcome is the change in self-reported weekly alcohol consumption between baseline (day 0) and 3-month follow-up (day 84) as measured using the Time-Line Follow back for Alcohol Consumption. Secondary outcome measures include (1) change in the baseline to 3-month follow-up (day 84) Alcohol Use Disorder Identification Test score and (2) change in the baseline to 3-month follow-up (day 84) World Health Organization Quality of Life-BREF score to assess the quality of adjusted life years. Process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire. The primary and secondary outcomes will also be reassessed at the 6-month follow-up (day 168) to assess the longer-term benefits of the intervention, which will be reported as a secondary outcome. Results: The study will begin recruitment in October 2020 and is expected to require 12 months to complete. The study results will be published in 2022. Conclusions: This study assesses whether a smartphone app is efficacious in reducing self-reported alcohol consumption in a veteran population that has sought help through Combat Stress using personalized messaging and interactive features. This innovative approach, if successful, may provide a means to deliver a low-cost health promotion program that has the potential to reach large groups, in particular those who are geographically dispersed, such as military personnel. Trial Registration: ClinicalTrials.gov NCT04494594; https://clinicaltrials.gov/ct2/show/NCT04494594 International Registered Report Identifier (IRRID): PRR1-10.2196/19720 %M 33006569 %R 10.2196/19720 %U https://www.researchprotocols.org/2020/10/e19720 %U https://doi.org/10.2196/19720 %U http://www.ncbi.nlm.nih.gov/pubmed/33006569 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e16780 %T User Experiences of a Smartphone-Based Attentive Eating App and Their Association With Diet and Weight Loss Outcomes: Thematic and Exploratory Analyses From a Randomized Controlled Trial %A Whitelock,Victoria %A Kersbergen,Inge %A Higgs,Suzanne %A Aveyard,Paul %A Halford,Jason CG %A Robinson,Eric %+ Department of Psychological Sciences, University of Liverpool, Eleanor Rathbone Building, Bedford Street South, Liverpool, L69 7ZA, United Kingdom, 44 (0)151 794 1187, eric.robinson@liv.ac.uk %K attentive eating %K weight loss %K smartphone app %K eHealth %K mHealth %K food intake %K obesity %K overweight %K focused attention %K participant experience %D 2020 %7 2.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Short-term laboratory studies suggest that eating attentively can reduce food intake. However, in a recent randomized controlled trial we found no evidence that using an attentive eating smartphone app outside of the laboratory had an effect on energy intake or weight loss over 8 weeks. Objective: This research examined trial participants’ experiences of using an attentive eating smartphone app and whether app usage was associated with energy intake and weight loss outcomes over 8 weeks. Methods: We conducted thematic analysis of semistructured interviews (N=38) among participants in the attentive eating smartphone app group of the trial who completed the 8-week assessment. Linear regression models examined the associations between energy intake and weight loss outcomes at 8 weeks and app usage. Results: Participants reported several barriers and facilitators to using the smartphone app, including repetition of app content, social setting, motivation, and habitual use of the app. Participants believed that using the app had some beneficial effects on their eating behavior and diet. Exploratory analyses indicated that more frequent recording of eating episodes in the app was associated with lower body weight (B=–0.02, P=.004) and greater self-reported energy intake (B=5.98, P=.01) at 8 weeks, but not body fat percentage or taste-test energy intake. Total audio clip plays, gallery views, and percentage of food entries recorded using an image were not significantly associated with energy intake or weight. Conclusions: Frequent recording of eating episodes in a smartphone app was associated with greater weight loss. There are barriers and facilitators to frequent use of an attentive eating smartphone app that may be useful to address when designing dietary behavior change smartphone apps. Trial Registration: ClinicalTrials.gov NCT03602001; https://clinicaltrials.gov/ct2/show/NCT03602001; Open Science Framework DOI 10.17605/osf.io/btzhw; https://osf.io/btzhw/ %M 33006564 %R 10.2196/16780 %U https://mhealth.jmir.org/2020/10/e16780 %U https://doi.org/10.2196/16780 %U http://www.ncbi.nlm.nih.gov/pubmed/33006564 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 10 %P e21676 %T Development and Acceptability of a Method to Investigate Prescription Drug Misuse in Daily Life: Ecological Momentary Assessment Study %A Papp,Lauren M %A Barringer,Alexandra %A Blumenstock,Shari M %A Gu,Pamela %A Blaydes,Madison %A Lam,Jaime %A Kouros,Chrystyna D %+ Department of Human Development and Family Studies, University of Wisconsin-Madison, 1300 Linden Drive, Madison, WI, 53706, United States, 1 608 262 8611, papp@wisc.edu %K compliance %K ecological momentary assessment %K prescription drug misuse %K young adult %D 2020 %7 1.10.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Prescription drug misuse and abuse is an established public health challenge, and young adults are particularly affected. There is a striking lack of real-time, naturalistic data collection assessing intentions to misuse and other precipitating factors at the time of actual misuse, leaving the conditions under which individuals are most likely to misuse prescription medications unknown. Ecological momentary assessment (EMA) apps and protocols designed to capture this information would accelerate and expand the knowledge base and could directly contribute to prevention and treatment efforts. Objective: The objectives of this study are to describe the development and administration of a mobile app and the EMA protocol designed to collect real-time factors associated with college students’ prescription drug misuse intentions and behaviors in daily life; present completion rates, compliance, acceptability, and reactivity associated with the EMA protocol for participants who endorsed recent prescription drug misuse at screening (ie, risk group; n=300) and those who did not (ie, nonrisk group; n=55); and establish initial construct validity by linking the reports of misuse behaviors in daily life collected via the EMA app to prescription drug misuse reported on a standard survey. Methods: An EMA data collection app and protocol were designed specifically to capture hypothesized contextual factors along with prescription drug misuse intentions and behaviors in daily life. Using this protocol, young adult college students (N=352) completed signal- and event-contingent reports over a 28-day period. When the intention to misuse a prescription drug was endorsed, a brief follow-up prompt was sent 15 min later to collect participants’ indications of whether or not misuse had occurred. Results: Risk-group participants were significantly more likely than nonrisk counterparts to endorse any prescription drug misuse intentions in daily life (P<.001), to complete one or more follow-up reports (P<.001), and to endorse any prescription drug misuse behavior in daily life on the follow-ups (P<.001). Overall, participants demonstrated consistent engagement with the EMA procedures and returned an average of 74.5 (SD 23.82; range 10-122) reports. Participants in the risk and nonrisk groups did not differ in the number of reports they completed (P=.12), the number of their reporting days (P=.32), or their average completion rates (P=.14). The results indicated some evidence of reactivity to the momentary reporting procedure. Participants reported uniformly positive experiences and remained highly engaged throughout the reporting protocol and broader study. Conclusions: The novel EMA app and protocol provide an effective way to assess real-time factors associated with prescription drug misuse intentions and behaviors in daily life. The resulting investigations offer the potential to provide highly translatable information for research and prevention efforts. %M 32877351 %R 10.2196/21676 %U https://mhealth.jmir.org/2020/10/e21676 %U https://doi.org/10.2196/21676 %U http://www.ncbi.nlm.nih.gov/pubmed/32877351 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e18505 %T Excessive Smartphone Use and Self-Esteem Among Adults With Internet Gaming Disorder: Quantitative Survey Study %A Kim,Hyunmin %A Choi,In Young %A Kim,Dai-Jin %+ Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222 Banpo-daero, Seocho-gu, Seoul, Republic of Korea, 82 2258 7870, iychoi@catholic.ac.kr %K excessive smartphone use %K internet gaming disorder %K smartphone overuse %K self-esteem %K mental health %K gender difference %K Korean smartphone addiction proneness scale %K smartphone %K gaming %K young adult %K adult %K gender %D 2020 %7 29.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone overuse can harm individual health and well-being. Although several studies have explored the relationship between problematic or excessive smartphone use and mental health, much less is known about effects on self-esteem, which is essential in having a healthy life, among adults with mental health disorders, including internet gaming disorder. Furthermore, given that smartphone usage differs by gender, little is known about gender differences in the relationship between smartphone overuse and self-esteem. Objective: The objective of this study was to assess self-esteem among individuals with mental health disorders and explore the relationship with excessive smartphone use. Methods: Participants were selected based on their responses to the internet gaming disorder assessment, which includes 9 items developed based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria, from among a Korean cohort of smartphone users aged 20-40 years, resulting in a sample of 189 participants (men:120, women: 69). The Rosenberg self-esteem scale and the Korean smartphone addiction proneness scale were utilized to assess the outcome self-esteem with excessive smartphone use as the primary independent variable. Guided by the Bowlby attachment theory and prior studies, we selected several covariates. Generalized linear regression analyses, as well as subgroup analyses by gender, were performed. Results: Among adults with internet gaming disorder, the average Korean smartphone addiction proneness scale score was significantly higher in women than that in men (41.30 vs. 37.94; P=.001), and excessive smartphone use was significantly more prevalent in women than it was in men (30.43% vs. 20.83%; P=.02). Our findings from the generalized linear regression analyses indicated that an increase in Korean smartphone addiction proneness scale score had a negative relationship with self-esteem among those with internet gaming disorder (β=–0.18, P=.001). Furthermore, our interaction models showed that, among those with internet gaming disorder, more men than women had lower self-esteem associated with an increase in Korean smartphone addiction proneness scale score and a high degree of smartphone overuse (β=–0.19, P=.004; β=–3.73, P<.001). Conclusions: Excessive smartphone use was found to be adversely associated with self-esteem among young and middle-aged adults with internet gaming disorder; notably, more men than women were negatively influenced (regarding self-esteem) by smartphone overuse. Based on our findings, more efforts should be made to reduce excessive or problematic smartphone use by considering developing public health interventions or policy, particularly among those with mental health disorders such as internet gaming disorder. %M 32990637 %R 10.2196/18505 %U https://mhealth.jmir.org/2020/9/e18505 %U https://doi.org/10.2196/18505 %U http://www.ncbi.nlm.nih.gov/pubmed/32990637 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e22142 %T The Relation Between Official WhatsApp-Distributed COVID-19 News Exposure and Psychological Symptoms: Cross-Sectional Survey Study %A Liu,Jean C J %A Tong,Eddie M W %+ Yale-NUS College, 02-221, 16 College Avenue West, Singapore, 138527, Singapore, 65 66013694, jeanliu@yale-nus.edu.sg %K mental health %K social media %K pandemic %K depression %K anxiety %K stress %K COVID-19 %K app %K risk factor %K psychology %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In a global pandemic, digital technology offers innovative methods to disseminate public health messages. As an example, the messenger app WhatsApp was adopted by both the World Health Organization and government agencies to provide updates on the coronavirus disease (COVID-19). During a time when rumors and excessive news threaten psychological well-being, these services allow for rapid transmission of information and may boost resilience. Objective: In this study, we sought to accomplish the following: (1) assess well-being during the pandemic; (2) replicate prior findings linking exposure to COVID-19 news with psychological distress; and (3) examine whether subscription to an official WhatsApp channel can mitigate this risk. Methods: Across 8 weeks of the COVID-19 outbreak (March 7 to April 21, 2020), we conducted a survey of 1145 adults in Singapore. As the primary outcome measure, participants completed the Depression, Anxiety, and Stress Scale (DASS-21). As predictor variables, participants also answered questions pertaining to the following: (1) their exposure to COVID-19 news; (2) their use of the Singapore government’s WhatsApp channel; and (3) their demographics. Results: Within the sample, 7.9% of participants had severe or extremely severe symptoms on at least one DASS-21 subscale. Depression scores were associated with increased time spent receiving COVID-19 updates, whereas use of the official WhatsApp channel emerged as a protective factor (b=–0.07, t[863]=–2.04, P=.04). Similarly, increased anxiety scores were associated with increased exposure to both updates and rumors, but this risk was mitigated by trust in the government’s WhatsApp messages (b=–0.05, t[863]=–2.13, P=.03). Finally, although stress symptoms increased with the amount of time spent receiving updates, these symptoms were not significantly related to WhatsApp use. Conclusions: Our findings suggest that messenger apps may be an effective medium for disseminating pandemic-related information, allowing official agencies to reach a broad sector of the population rapidly. In turn, this use may promote public well-being amid an “infodemic.” Trial Registration: ClinicalTrials.gov NCT04305574; https://clinicaltrials.gov/ct2/show/NCT04305574 %M 32877349 %R 10.2196/22142 %U http://www.jmir.org/2020/9/e22142/ %U https://doi.org/10.2196/22142 %U http://www.ncbi.nlm.nih.gov/pubmed/32877349 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19992 %T Using Smartphones and Wearable Devices to Monitor Behavioral Changes During COVID-19 %A Sun,Shaoxiong %A Folarin,Amos A %A Ranjan,Yatharth %A Rashid,Zulqarnain %A Conde,Pauline %A Stewart,Callum %A Cummins,Nicholas %A Matcham,Faith %A Dalla Costa,Gloria %A Simblett,Sara %A Leocani,Letizia %A Lamers,Femke %A Sørensen,Per Soelberg %A Buron,Mathias %A Zabalza,Ana %A Guerrero Pérez,Ana Isabel %A Penninx,Brenda WJH %A Siddi,Sara %A Haro,Josep Maria %A Myin-Germeys,Inez %A Rintala,Aki %A Wykes,Til %A Narayan,Vaibhav A %A Comi,Giancarlo %A Hotopf,Matthew %A Dobson,Richard JB %A , %+ The Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Social Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, PO Box 80 De Crespigny Park, Denmark Hill, London, SE58AF, United Kingdom, 44 02078480951, shaoxiong.sun@kcl.ac.uk %K mobile health %K COVID-19 %K behavioral monitoring %K smartphones %K wearable devices %K mobility %K phone use %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the absence of a vaccine or effective treatment for COVID-19, countries have adopted nonpharmaceutical interventions (NPIs) such as social distancing and full lockdown. An objective and quantitative means of passively monitoring the impact and response of these interventions at a local level is needed. Objective: We aim to explore the utility of the recently developed open-source mobile health platform Remote Assessment of Disease and Relapse (RADAR)–base as a toolbox to rapidly test the effect and response to NPIs intended to limit the spread of COVID-19. Methods: We analyzed data extracted from smartphone and wearable devices, and managed by the RADAR-base from 1062 participants recruited in Italy, Spain, Denmark, the United Kingdom, and the Netherlands. We derived nine features on a daily basis including time spent at home, maximum distance travelled from home, the maximum number of Bluetooth-enabled nearby devices (as a proxy for physical distancing), step count, average heart rate, sleep duration, bedtime, phone unlock duration, and social app use duration. We performed Kruskal-Wallis tests followed by post hoc Dunn tests to assess differences in these features among baseline, prelockdown, and during lockdown periods. We also studied behavioral differences by age, gender, BMI, and educational background. Results: We were able to quantify expected changes in time spent at home, distance travelled, and the number of nearby Bluetooth-enabled devices between prelockdown and during lockdown periods (P<.001 for all five countries). We saw reduced sociality as measured through mobility features and increased virtual sociality through phone use. People were more active on their phones (P<.001 for Italy, Spain, and the United Kingdom), spending more time using social media apps (P<.001 for Italy, Spain, the United Kingdom, and the Netherlands), particularly around major news events. Furthermore, participants had a lower heart rate (P<.001 for Italy and Spain; P=.02 for Denmark), went to bed later (P<.001 for Italy, Spain, the United Kingdom, and the Netherlands), and slept more (P<.001 for Italy, Spain, and the United Kingdom). We also found that young people had longer homestay than older people during the lockdown and fewer daily steps. Although there was no significant difference between the high and low BMI groups in time spent at home, the low BMI group walked more. Conclusions: RADAR-base, a freely deployable data collection platform leveraging data from wearables and mobile technologies, can be used to rapidly quantify and provide a holistic view of behavioral changes in response to public health interventions as a result of infectious outbreaks such as COVID-19. RADAR-base may be a viable approach to implementing an early warning system for passively assessing the local compliance to interventions in epidemics and pandemics, and could help countries ease out of lockdown. %M 32877352 %R 10.2196/19992 %U https://www.jmir.org/2020/9/e19992 %U https://doi.org/10.2196/19992 %U http://www.ncbi.nlm.nih.gov/pubmed/32877352 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19716 %T Mobile Insight in Risk, Resilience, and Online Referral (MIRROR): Psychometric Evaluation of an Online Self-Help Test %A van Herpen,Merel Marjolein %A Boeschoten,Manon A %A te Brake,Hans %A van der Aa,Niels %A Olff,Miranda %+ ARQ Centre of Expertise for the Impact of Disasters and Crises, Nienoord 5, Diemen, , Netherlands, 31 610082023, m.van.herpen@impact.arq.org %K potentially traumatic events %K mobile mental health %K self-help %K online %K resilience %K posttraumatic stress disorder %D 2020 %7 25.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Most people who experience a potentially traumatic event (PTE) recover on their own. A small group of individuals develops psychological complaints, but this is often not detected in time or guidance to care is suboptimal. To identify these individuals and encourage them to seek help, a web-based self-help test called Mobile Insight in Risk, Resilience, and Online Referral (MIRROR) was developed. MIRROR takes an innovative approach since it integrates both negative and positive outcomes of PTEs and time since the event and provides direct feedback to the user. Objective: The goal of this study was to assess MIRROR’s use, examine its psychometric properties (factor structure, internal consistency, and convergent and divergent validity), and evaluate how well it classifies respondents into different outcome categories compared with reference measures. Methods: MIRROR was embedded in the website of Victim Support Netherlands so visitors could use it. We compared MIRROR’s outcomes to reference measures of PTSD symptoms (PTSD Checklist for DSM-5), depression, anxiety, stress (Depression Anxiety Stress Scale–21), psychological resilience (Resilience Evaluation Scale), and positive mental health (Mental Health Continuum Short Form). Results: In 6 months, 1112 respondents completed MIRROR, of whom 663 also completed the reference measures. Results showed good internal consistency (interitem correlations range .24 to .55, corrected item-total correlations range .30 to .54, and Cronbach alpha coefficient range .62 to .68), and convergent and divergent validity (Pearson correlations range –.259 to .665). Exploratory and confirmatory factor analyses (EFA+CFA) yielded a 2-factor model with good model fit (CFA model fit indices: χ219=107.8, P<.001, CFI=.965, TLI=.948, RMSEA=.065), conceptual meaning, and parsimony. MIRROR correctly classified respondents into different outcome categories compared with the reference measures. Conclusions: MIRROR is a valid and reliable self-help test to identify negative (PTSD complaints) and positive outcomes (psychosocial functioning and resilience) of PTEs. MIRROR is an easily accessible online tool that can help people who have experienced a PTE to timely identify psychological complaints and find appropriate support, a tool that might be highly needed in times like the coronavirus pandemic. %M 32975521 %R 10.2196/19716 %U http://www.jmir.org/2020/9/e19716/ %U https://doi.org/10.2196/19716 %U http://www.ncbi.nlm.nih.gov/pubmed/32975521 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e18491 %T Development and Evaluation of an Accelerometer-Based Protocol for Measuring Physical Activity Levels in Cancer Survivors: Development and Usability Study %A Crane,Tracy E %A Skiba,Meghan B %A Miller,Austin %A Garcia,David O %A Thomson,Cynthia A %+ Department of Biobehavioral Health Sciences, College of Nursing, University of Arizona, 1305 N Martin Ave, Tucson, AZ, 85721, United States, 1 5203310120, tecrane@email.arizona.edu %K wearable electronic devices %K physical activity %K cancer survivors %K activity trackers %K mobile phone %D 2020 %7 24.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The collection of self-reported physical activity using validated questionnaires has known bias and measurement error. Objective: Accelerometry, an objective measure of daily activity, increases the rigor and accuracy of physical activity measurements. Here, we describe the methodology and related protocols for accelerometry data collection and quality assurance using the Actigraph GT9X accelerometer data collection in a convenience sample of ovarian cancer survivors enrolled in GOG/NRG 0225, a 24-month randomized controlled trial of diet and physical activity intervention versus attention control. Methods: From July 2015 to December 2019, accelerometers were mailed on 1337 separate occasions to 580 study participants to wear at 4 time points (baseline, 6, 12, and 24 months) for 7 consecutive days. Study staff contacted participants via telephone to confirm their availability to wear the accelerometers and reviewed instructions and procedures regarding the return of the accelerometers and assisted with any technology concerns. Results: We evaluated factors associated with wear compliance, including activity tracking, use of a mobile app, and demographic characteristics with chi-square tests and logistic regression. Compliant data, defined as ≥4 consecutive days with ≥10 hours daily wear time, exceeded 90% at all study time points. Activity tracking, but no other characteristics, was significantly associated with compliant data at all time points (P<.001). This implementation of data collection through accelerometry provided highly compliant and usable activity data in women who recently completed treatment for ovarian cancer. Conclusions: The high compliance and data quality associated with this protocol suggest that it could be disseminated to support researchers who seek to collect robust objective activity data in cancer survivors residing in a wide geographic area. %M 32969828 %R 10.2196/18491 %U http://mhealth.jmir.org/2020/9/e18491/ %U https://doi.org/10.2196/18491 %U http://www.ncbi.nlm.nih.gov/pubmed/32969828 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e17685 %T Mobile Fitness and Weight Management Apps: Protocol for a Quality Evaluation %A Milne-Ives,Madison %A Lam,Ching %A van Velthoven,Michelle %A Meinert,Edward %+ Centre for Health Technology, Faculty of Health, University of Plymouth, 6 Kirkby Place, Plymouth, PL4 8AA, United Kingdom, 44 1752 600600, edward.meinert@plymouth.ac.uk %K mobile apps %K telemedicine %K smartphone %K exercise %K weight loss %K obesity %K physical fitness %K fitness trackers %D 2020 %7 24.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Obesity is a contributing factor for many noncommunicable diseases and a growing problem worldwide. Many mobile apps have been developed to help users improve their fitness and weight management behaviors. However, the speed at which apps are created and updated means that it is important to periodically assess their quality. Objective: The purpose of this study is to evaluate the quality of fitness and weight management mobile health apps using the Mobile Application Rating Scale (MARS). It will also describe the features of the included apps and compare the results to a previous evaluation conducted in 2015. Methods: Searches for “fitness,” “weight,” “exercise,” “physical activity,” “diet,” “eat*,” and “food” will be conducted in the Apple App Store and Google Play. Apps that have been updated over the past 5 years will be included. Two reviewers will rate the apps’ quality using the MARS objective and subjective quality subscales. Interrater reliability will also be assessed. Features included in high-quality apps will be assessed, and changes in quality, features, and behavior change techniques made during the past 5 years will be described. Results: The results will be included in the evaluation paper, which we aim to publish in 2020. Conclusions: This evaluation will assess the quality of currently available fitness and weight management apps. International Registered Report Identifier (IRRID): PRR1-10.2196/17685 %M 32969830 %R 10.2196/17685 %U http://www.researchprotocols.org/2020/9/e17685/ %U https://doi.org/10.2196/17685 %U http://www.ncbi.nlm.nih.gov/pubmed/32969830 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e16958 %T SMS Text Messages for Parents for the Prevention of Child Drowning in Bangladesh: Acceptability Study %A Hossain,Md Mosharaf %A Mani,Kulanthayan %A Mat Min,Ruhani %+ Safe Kids Malaysia and Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia, 60 0397692398, kulan@upm.edu.my %K acceptability %K SMS %K drowning %K parents %D 2020 %7 23.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In many cases, greater use is being made of mobile phone text messages as a means of communication between patients and health care providers in countries around the world. Objective: We studied the use of mobile phones and the factors related to the acceptability of text messages for parents for the prevention of child drowning in Bangladesh. Methods: From a randomized controlled trial involving 800 parents, 10% (80/800) were selected, and socioeconomic status, mobile phone use, and acceptability of SMS text messages for drowning prevention were measured. Participants with at least one child under 5 years of age were selected from rural areas in Rajshahi District in Bangladesh. Mobile phone–based SMS text messages were sent to the participants. Multivariate regression was used to determine the factors related to the acceptability of text messages for the prevention of child drowning in Bangladesh. Results: The acceptability of SMS text messages for the prevention of child drowning in Bangladesh was significantly lower among women (odds ratio [OR] 0.50, 95% CI 0.12-1.96, P=.02) than among men, lower for parents older than 30 years (OR 0.17, 95% CI 0.14-1.70, P=.01) compared to parents younger than 30 years, higher among parents who had an education (OR 1.63, 95% CI 1.11-5.80, P=.04) than among illiterate parents, and higher among parents with a monthly household income over 7000 Bangladeshi Taka (approximately US $82.54; OR 1.27, 95% CI 1.06-1.96, P=.05) than among parents whose monthly income was less than 7000 Bangladeshi Taka. Conclusions: The high percentage of mobile phone use and the acceptability of SMS text messages for parents for the prevention of child drowning are encouraging, in terms of identifying the best strategy for using such technologies, and deserve further evaluation. %M 32965224 %R 10.2196/16958 %U http://mhealth.jmir.org/2020/9/e16958/ %U https://doi.org/10.2196/16958 %U http://www.ncbi.nlm.nih.gov/pubmed/32965224 %0 Journal Article %@ 2561-9128 %I JMIR Publications %V 3 %N 2 %P e16639 %T Feasibility of Using a Single Heart Rate–Based Measure for Real-time Feedback in a Voluntary Deep Breathing App for Children: Data Collection and Algorithm Development %A Petersen,Christian L %A Görges,Matthias %A Todorova,Evgenia %A West,Nicholas C %A Newlove,Theresa %A Ansermino,J Mark %+ Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Rm V3-324, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada, 1 6048752000 ext 5616, mgorges@bcchr.ca %K pediatric pain %K respiratory sinus arrhythmia %K biofeedback %K pulse oximetry %K mobile health %K anxiety %K diaphragmatic breathing %K self-regulation %D 2020 %7 23.9.2020 %9 Original Paper %J JMIR Perioper Med %G English %X Background: Deep diaphragmatic breathing, also called belly breathing, is a popular behavioral intervention that helps children cope with anxiety, stress, and their experience of pain. Combining physiological monitoring with accessible mobile technology can motivate children to comply with this intervention through biofeedback and gaming. These innovative technologies have the potential to improve patient experience and compliance with strategies that reduce anxiety, change the experience of pain, and enhance self-regulation during distressing medical procedures. Objective: The aim of this paper was to describe a simple biofeedback method for quantifying breathing compliance in a mobile smartphone app. Methods: A smartphone app was developed that combined pulse oximetry with an animated protocol for paced deep breathing. We collected photoplethysmogram data during spontaneous and subsequently paced deep breathing in children. Two measures, synchronized respiratory sinus arrhythmia (RSAsync) and the corresponding relative synchronized inspiration/expiration heart rate ratio (HR-I:Esync), were extracted from the photoplethysmogram. Results: Data collected from 80 children aged 5-17 years showed a positive RSAsync effect in all participants during paced deep breathing, with a median (IQR; range) HR-I:Esync ratio of 1.26 (1.16-1.35; 1.01-1.60) during paced deep breathing compared to 0.98 (0.96-1.02; 0.82-1.18) during spontaneous breathing (median difference 0.25, 95% CI 0.23-0.30; P<.001). The measured HR-I:Esync values appeared to be independent of age. Conclusions: An HR-I:Esync level of 1.1 was identified as an age-independent threshold for programming the breathing pattern for optimal compliance in biofeedback. %M 33393917 %R 10.2196/16639 %U http://periop.jmir.org/2020/2/e16639/ %U https://doi.org/10.2196/16639 %U http://www.ncbi.nlm.nih.gov/pubmed/33393917 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19923 %T Determinants of Scale-up From a Small Pilot to a National Electronic Immunization Registry in Vietnam: Qualitative Evaluation %A Dang,Huyen %A Dao,Sang %A Carnahan,Emily %A Kawakyu,Nami %A Duong,Hong %A Nguyen,Trung %A Nguyen,Doan %A Nguyen,Linh %A Rivera,Maya %A Ngo,Tuan %A Werner,Laurie %A Nguyen,Nga %+ PATH, #1101, 11th Floor, Hanoi Towers, 49 Hai Bai Trung Street, Hoan Kiem District, Hanoi, , Vietnam, 84 24 3936 2216 ext 105, ntnguyen@path.org %K immunization %K immunization information system %K electronic immunization registry %K scale-up %K digital health intervention %K mHealth %K eHealth %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health innovations can improve health system performance, yet previous experience has shown that many innovations do not advance beyond the pilot stage to achieve scale. Vietnam’s National Immunization Information System (NIIS) began as a series of digital health pilots, first initiated in 2010, and was officially launched nationwide in 2017. The NIIS is one of the few examples of an electronic immunization registry (EIR) at national scale in low- and middle-income countries. Objective: The aim of this study was to understand the determinants of scale-up of the national EIR in Vietnam. Methods: This qualitative study explored the facilitators and barriers to national scale-up of the EIR in Vietnam. Qualitative data were collected from October to December 2019 through in-depth key informant interviews and desk review. The mHealth Assessment and Planning for Scale (MAPS) Toolkit guided the development of the study design, interview guides, and analytic framework. MAPS defines the key determinants of success, or the “axes of scale,” to be groundwork, partnerships, financial health, technology and architecture, operations, and monitoring and evaluation. Results: The partnership and operations axes were critical to the successful scale-up of the EIR in Vietnam, while the groundwork and monitoring and the evaluation axes were considered to be strong contributors in the success of all the other axes. The partnership model leveraged complementary strengths of the technical working group partners: the Ministry of Health General Department of Preventive Medicine, the National Expanded Program on Immunization, Viettel (the mobile network operator), and PATH. The operational approach to introducing the NIIS with lean, iterative, and integrated training and supervision was also a key facilitator to successful scale-up. The financial health, technology and architecture, and operations axes were identified as barriers to successful deployment and scale-up. Key barriers to scale-up included insufficient estimates of operational costs, unanticipated volume of data storage and transmission, lack of a national ID to support interoperability, and operational challenges among end users. Overall, the multiple phases of EIR deployment and scale-up from 2010 to 2017 allowed for continuous learning and improvement that strengthened all the axes and contributed to successful scale-up. Conclusions: The results highlight the importance of the measured, iterative approach that was taken to gradually expand a series of small pilots to nationwide scale. The findings from this study can be used to inform other countries considering, introducing, or in the process of scaling an EIR or other digital health innovations. %M 32960184 %R 10.2196/19923 %U http://www.jmir.org/2020/9/e19923/ %U https://doi.org/10.2196/19923 %U http://www.ncbi.nlm.nih.gov/pubmed/32960184 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e15307 %T Identifying Mobile Health Engagement Stages: Interviews and Observations for Developing Brief Message Content %A Burns,Kara %A Nicholas,Rebekah %A Beatson,Amanda %A Chamorro-Koc,Marianella %A Blackler,Alethea %A Gottlieb,Udo %+ School of Advertising, Marketing and Public Relations, QUT Business School, Queensland University of Technology, George St, Brisbane, QLD, 4000, Australia, 61 414294967, drkaraburns@gmail.com %K mobile health %K text messaging %K social media %K mobile phone %K health communication %D 2020 %7 22.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Interest in mobile health (mHealth) has increased recently, and research suggests that mHealth devices can enhance end-user engagement, especially when used in conjunction with brief message content. Objective: This research aims to explore the stages of engagement framework for mHealth devices and develop a method to generate brief message content to promote sustained user engagement. This study uses the framework by O’Brien and Toms as a point of departure, where engagement is defined as the uptake or the use of an mHealth device. The framework is a linear repeatable process, including point of engagement, period of engagement, disengagement, and re-engagement. Each stage is characterized by attributes related to a person’s technology experience. Although the literature has identified stages of engagement for health-related technology, few studies explore mHealth engagement. Furthermore, little research has determined a method for creating brief message content at each stage in this engagement journey. Methods: Interviews and observations from 19 participants who used mHealth technologies (apps, devices, or wellness websites) in a solo capacity were recruited for sample group 1. In sample group 2, interviews, and observations from 25 participants using mHealth technologies in a group capacity through the Global Corporate Challenge were used. These samples were investigated at 3 time points in both research contexts. The results underwent deductive-inductive thematic analysis for the engagement stages’ framework and attributes. Results: In addition to the 4 stages identified by O’Brien and Toms, 2 additional stages, self-management and limited engagement, were identified. Self-management captures where users had disengaged from their technology but were still engaged with their health activity. Limited engagement captures where group mHealth users had minimal interaction with their mHealth technology but continued to engage in a group fitness activity. The results revealed that mHealth engagement stages were nonlinear and embedded in a wider engagement context and that each stage was characterized by a combination of 49 attributes that could be organized into 8 themes. Themes documented the total user experience and included technology usability, technology features, technology aesthetics, use motivations, health awareness, goal setting, social support, and interruptions. Different themes were found to have more relevance at different engagement stages. Knowing themes and attributes at all engagement stages allows technology developers and health care professionals to generate relevant brief message content informed by a person-centered approach. Conclusions: This research extends an existing engagement stages framework and identifies attributes and themes relevant to mHealth technology users’ total user experience and incorporates concepts derived from health, business studies, and information systems literature. In addition, we offer a practical 5-step process based on a person-centered approach to develop mHealth technology brief message content for sustained engagement. %M 32960181 %R 10.2196/15307 %U http://www.jmir.org/2020/9/e15307/ %U https://doi.org/10.2196/15307 %U http://www.ncbi.nlm.nih.gov/pubmed/32960181 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e18106 %T Mobile-Enhanced Prevention Support Study for Men Who Have Sex With Men and Transgender Women Leaving Jail: Protocol for a Randomized Controlled Trial %A Edwards,Gabriel G %A Reback,Cathy J %A Cunningham,William E %A Hilliard,Charles L %A McWells,Charles %A Mukherjee,Sukrit %A Weiss,Robert E %A Harawa,Nina T %+ Department of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon Ave Suite 850, Los Angeles, CA, 90024, United States, 1 310 267 0609, gedwards@mednet.ucla.edu %K HIV %K MSM %K transgender women %K peer navigation %K jail %K substance use disorder %K eHealth %K PrEP %K sexually transmitted infections %K hepatitis C %K mobile phone %K smartphone %D 2020 %7 22.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Men who have sex with men (MSM) and transgender women, particularly those who have experienced criminal justice involvement, have particularly high HIV burdens, and a majority of those in jail have substance use disorders (SUDs). MSM and transgender women also experience elevated rates of incarceration. Once community re-entry occurs, individuals are in a critical period for addressing potential risks of HIV and sexually transmitted infection (STI) acquisition and negative sequelae of substance use. Further, the impact experienced by one’s social and sexual networks experienced at the time of detention and release have important health implications for MSM and transgender women. Objective: The purpose of this study is to test a new intervention—Mobile-Enhanced Prevention Support (MEPS)—that involves a GPS-based mobile app called GeoPassport (referred to as GeoPass in practice), incentives, and peer support for promoting HIV prevention, substance use treatment, and use of related services. Methods: A two-arm, unblinded, randomized controlled trial will seek to enroll 300 HIV-negative MSM and transgender women, aged 18-49 years, with SUDs, who are either in jail or have recently left jail. Participants will be enrolled by study staff and randomized to the MEPS intervention group or usual care group. The intervention group will receive customized wellness goals in addition to GeoPass, cash incentives, and the support of a trained peer mentor for 6 months. Data collection will consist of a baseline survey and three follow-up surveys at 3, 6, and 9 months postenrollment, either in person or by phone or videoconference when necessary. The primary outcomes include establishing a primary care provider; being prescribed and adhering to pre-exposure prophylaxis (PrEP) for HIV; screening for HIV, STIs, and hepatitis C virus; and engagement in recommended treatment for SUDs. Secondary outcomes include obtaining treatment for any identified infections and avoiding recidivism. Results: Enrollment began in November 2019 and study completion is expected in 2023. Conclusions: This study will advance our knowledge base on patient navigation and peer mentor interventions. Peer navigation services have been studied for the treatment of HIV, but less often in the context of HIV and STI prevention among sexual and gender minority populations at the time of re-entry into the community from jail. The MEPS study will examine the acceptability and feasibility of combining peer mentor services with a mobile app to facilitate service utilization and participant–peer mentor communication. MEPS will assess patterns of PrEP uptake and utilization in MSM and transgender women leaving jail. The study will provide heretofore unavailable data from persons leaving jail regarding HIV PrEP, STI screening, substance abuse treatment, and service utilization patterns and experiences, including geocoded data for those in the intervention arm. Trial Registration: ClinicalTrials.gov (NCT04036396); https://www.clinicaltrials.gov/ct2/show/NCT04036396 International Registered Report Identifier (IRRID): PRR1-10.2196/18106 %M 32959786 %R 10.2196/18106 %U http://www.researchprotocols.org/2020/9/e18106/ %U https://doi.org/10.2196/18106 %U http://www.ncbi.nlm.nih.gov/pubmed/32959786 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e20356 %T Social and Behavior Change Communication Interventions Delivered Face-to-Face and by a Mobile Phone to Strengthen Vaccination Uptake and Improve Child Health in Rural India: Randomized Pilot Study %A Johri,Mira %A Chandra,Dinesh %A Kone,Karna Georges %A Sylvestre,Marie-Pierre %A Mathur,Alok K %A Harper,Sam %A Nandi,Arijit %+ Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CRCHUM), 850, rue St-Denis, Montréal, QC, H2X0A9, Canada, 1 514 343 7318, mira.johri@umontreal.ca %K randomized controlled trial %K immunization programs %K child health %K mHealth %K health promotion %K health services accessibility %K implementation science %K pilot projects %K developing countries %K global health %D 2020 %7 21.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In resource-poor settings, lack of awareness and low demand for services constitute important barriers to expanding the coverage of effective interventions. In India, childhood immunization is a priority health strategy with suboptimal uptake. Objective: To assess study feasibility and key implementation outcomes for the Tika Vaani model, a new approach to educate and empower beneficiaries to improve immunization and child health. Methods: A cluster-randomized pilot trial with a 1:1 allocation ratio was conducted in rural Uttar Pradesh, India, from January to September 2018. Villages were randomly assigned to either the intervention or control group. In each participating village, surveyors conducted a complete enumeration to identify eligible households and requested participation before randomization. Interventions were designed through formative research using a social marketing approach and delivered over 3 months using strategies adapted to disadvantaged populations: (1) mobile health (mHealth): entertaining educational audio capsules (edutainment) and voice immunization reminders via mobile phone and (2) face-to-face: community mobilization activities, including 3 small group meetings offered to each participant. The control group received usual services. The main outcomes were prespecified criteria for feasibility of the main study (recruitment, randomization, retention, contamination, and adoption). Secondary endpoints tested equity of coverage and changes in intermediate outcomes. Statistical methods included descriptive statistics to assess feasibility, penalized logistic regression and ordered logistic regression to assess coverage, and generalized estimating equation models to assess changes in intermediate outcomes. Results: All villages consented to participate. Gaps in administrative data hampered recruitment; 14.0% (79/565) of recorded households were nonresident. Only 1.4% (8/565) of households did not consent. A total of 387 households (184 intervention and 203 control) with children aged 0 to 12 months in 26 villages (13 intervention and 13 control) were included and randomized. The end line survey occurred during the flood season; 17.6% (68/387) of the households were absent. Contamination was less than 1%. Participation in one or more interventions was 94.0% (173/184), 78.3% (144/184) for the face-to-face strategy, and 67.4% (124/184) for the mHealth strategy. Determinants including place of residence, mobile phone access, education, and female empowerment shaped intervention use; factors operated differently for face-to-face and mHealth strategies. For 11 of 13 intermediate outcomes, regression results showed significantly higher basic health knowledge among the intervention group, supporting hypothesized causal mechanisms. Conclusions: A future trial of a new intervention model is feasible. The interventions could strengthen the delivery of immunization and universal primary health care. Social and behavior change communication via mobile phones proved viable and contributed to standardization and scalability. Face-to-face interactions remain necessary to achieve equity and reach, suggesting the need for ongoing health system strengthening to accompany the introduction of communication technologies. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 44840759; https://doi.org/10.1186/ISRCTN44840759 %M 32955455 %R 10.2196/20356 %U http://mhealth.jmir.org/2020/9/e20356/ %U https://doi.org/10.2196/20356 %U http://www.ncbi.nlm.nih.gov/pubmed/32955455 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e18867 %T Breast Cancer Survivors’ Perspectives on Motivational and Personalization Strategies in Mobile App–Based Physical Activity Coaching Interventions: Qualitative Study %A Monteiro-Guerra,Francisco %A Signorelli,Gabriel Ruiz %A Rivera-Romero,Octavio %A Dorronzoro-Zubiete,Enrique %A Caulfield,Brian %+ Salumedia Tecnologías, Avda. República Argentina, nº 24 Edificio Torre de los Remedios, 5ª planta - módulo A, Seville, 41011, Spain, 34 672787858, francisco.guerra@ucdconnect.ie %K mHealth %K mobile app %K mobile phone %K coaching %K physical activity %K breast cancer %D 2020 %7 21.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite growing evidence supporting the vital benefits of physical activity (PA) for breast cancer survivors, the majority do not meet the recommended levels of activity. Mobile app–based PA coaching interventions might be a feasible strategy to facilitate adherence of breast cancer survivors to the PA guidelines. To engage these individuals, PA apps need to be specifically designed based on their needs and preferences and to provide targeted support and motivation. However, more information is needed to understand how these technologies can provide individual and relevant experiences that have the ability to increase PA adherence and retain the individual’s interest in the long term. Objective: The aim of this study is to explore insights from breast cancer survivors on motivational and personalization strategies to be used in PA coaching apps and interventions. Methods: A qualitative study was conducted, using individual semistructured interviews, with 14 breast cancer survivors. The moderator asked open-ended questions and made use of a slideshow presentation to elicit the participants’ perspectives on potential mobile app–based intervention features. Transcribed interviews were evaluated by 3 reviewers using thematic content analysis. Results: Participants (mean age 53.3, SD 8.7 years) were White women. In total, 57% (8/14) of the participants did not adhere to the PA guidelines. In general, participants had access to and were interested in using technology. The identified themes included (1) barriers to PA, (2) psychological mediators of PA motivation, (3) needs and suggestions for reinforcing motivation support, (4) personalization aspects of the PA coaching experience, and (5) technology trustworthiness. Motivational determinants included perceived control, confidence and perceived growth, and connectedness. Participants were interested in having a straightforward app for monitoring and goal setting, which would include a prescribed activity program and schedule, and positive communication. Opinions varied in terms of social and game-like system possibilities. In addition, they expressed a desire for a highly personalized coaching experience based on as much information collected from them as possible (eg, disease stage, physical limitations, preferences) to provide individualized progress information, dynamic adjustment of the training plan, and context-aware activity suggestions (eg, based on weather and location). Participants also wanted the app to be validated or backed by professionals and were willing to share their data in exchange for a more personalized experience. Conclusions: This work suggests the need to develop simple, guiding, encouraging, trustworthy, and personalized PA coaching apps. The findings are in line with behavioral and personalization theories and methods that can be used to inform intervention design decisions. This paper opens new possibilities for the design of personalized and motivating PA coaching app experiences for breast cancer survivors, which might ultimately facilitate the sustained adherence of these individuals to the recommended levels of activity. %M 32955446 %R 10.2196/18867 %U https://mhealth.jmir.org/2020/9/e18867 %U https://doi.org/10.2196/18867 %U http://www.ncbi.nlm.nih.gov/pubmed/32955446 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e17563 %T Implementing Facilitated Access to a Text Messaging, Smoking Cessation Intervention Among Swedish Patients Having Elective Surgery: Qualitative Study of Patients’ and Health Care Professionals’ Perspectives %A Thomas,Kristin %A Bendtsen,Marcus %A Linderoth,Catharina %A Bendtsen,Preben %+ Department of Health, Medicine and Caring Sciences, Linköping University, 58381, Linköping, , Sweden, 46 13282546, kristin.thomas@liu.se %K mHealth %K mobile health %K text messages %K health care %K smoking cessation %K patients with elective surgery %K implementation %D 2020 %7 18.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is strong evidence that short-term smoking cessation before surgery can reduce postoperative morbidity. There are, however, several structural problems in health care systems concerning how to implement smoking cessation interventions in routine practice for preoperative patients. Objective: This study aimed to analyze the implementation of a text messaging, smoking cessation intervention targeting patients having elective surgery. Implementation of facilitated access (ie, referral from practitioners) and the perceived usefulness among patients were investigated. Elective surgery is defined as scheduled, nonacute surgery. Methods: A qualitative study was carried out at two medium-sized hospitals in the south of Sweden. The implementation of facilitated access was investigated during a 12-month period from April 2018 to April 2019. Facilitated access was conceptualized as specialists recommending the text messaging intervention to patients having elective surgery. Implementation was explored in terms of perceptions about the intervention and behaviors associated with implementation; that is, how patients used the intervention and how specialists behaved in facilitating usage among patients. Two focus groups with smoking cessation specialists and 10 individual interviews with patients were carried out. Qualitative content analysis was used to analyze the data. Results: Two main categories were identified from the focus group data with smoking cessation specialists: implementation approach and perceptions about the intervention. The first category, implementation approach, referred to how specialists adapted their efforts to situational factors and to the needs and preferences of patients, and how building of trust with patients was prioritized. The second category, perceptions about the intervention, showed that specialists thought the content and structure of the text messaging intervention felt familiar and worked well as a complement to current practice. Two categories were identified from the patient interview data: incorporating new means of support from health care and determinants of use. The first category referred to how patients adopted and incorporated the intervention into their smoking cessation journey. Patients were receptive, shared the text messages with friends and family, humanized the text messages, and used the messages as a complement to other strategies to quit smoking. The second category, determinants of use, referred to aspects that influenced how and when patients used the intervention and included the following: timing of the intervention and text messages, motivation to change, and perceptions of the mobile phone medium. Conclusions: Smoking cessation specialists adopted an active role in implementing the intervention by adapting their approach and fitting the intervention into existing routines. Patients showed strong motivation to change and openness to incorporate the intervention into their behavior change journey; however, the timing of the intervention and messages were important in optimizing the support. A text messaging, smoking cessation intervention can be a valuable and feasible way to reach smoking patients having elective surgery. %M 32945772 %R 10.2196/17563 %U https://mhealth.jmir.org/2020/9/e17563 %U https://doi.org/10.2196/17563 %U http://www.ncbi.nlm.nih.gov/pubmed/32945772 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e19288 %T Promoting Health and Well-Being Through Mobile Health Technology (Roadmap 2.0) in Family Caregivers and Patients Undergoing Hematopoietic Stem Cell Transplantation: Protocol for the Development of a Mobile Randomized Controlled Trial %A Rozwadowski,Michelle %A Dittakavi,Manasa %A Mazzoli,Amanda %A Hassett,Afton L %A Braun,Thomas %A Barton,Debra L %A Carlozzi,Noelle %A Sen,Srijan %A Tewari,Muneesh %A Hanauer,David A %A Choi,Sung Won %+ Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States, 1 73461505707, sungchoi@med.umich.edu %K family caregivers %K mobile health app %K mHealth %K randomized controlled trial %K wearable wrist sensor %K hematopoietic stem cell transplantation %K HSCT %D 2020 %7 18.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cancer patients who undergo allogeneic hematopoietic stem cell transplantation are among the most medically fragile patient populations with extreme demands for caregivers. Indeed, with earlier hospital discharges, the demands placed on caregivers continue to intensify. Moreover, an increased number of allogeneic hematopoietic stem cell transplantations are being performed worldwide, and this expensive procedure has significant economic consequences. Thus, the health and well-being of family caregivers have attracted widespread attention. Mobile health technology has been shown to deliver flexible, and time- and cost-sparing interventions to support family caregivers across the care trajectory. Objective: This protocol aims to leverage technology to deliver a novel caregiver-facing mobile health intervention named Roadmap 2.0. We will evaluate the effectiveness of Roadmap 2.0 in family caregivers of patients undergoing hematopoietic stem cell transplantation. Methods: The Roadmap 2.0 intervention will consist of a mobile randomized trial comparing a positive psychology intervention arm with a control arm in family caregiver-patient dyads. The primary outcome will be caregiver health-related quality of life, as assessed by the PROMIS Global Health scale at day 120 post-transplant. Secondary outcomes will include other PROMIS caregiver- and patient-reported outcomes, including companionship, self-efficacy for managing symptoms, self-efficacy for managing daily activities, positive affect and well-being, sleep disturbance, depression, and anxiety. Semistructured qualitative interviews will be conducted among participants at the completion of the study. We will also measure objective physiological markers (eg, sleep, activity, heart rate) through wearable wrist sensors and health care utilization data through electronic health records. Results: We plan to enroll 166 family caregiver-patient dyads for the full data analysis. The study has received Institutional Review Board approval as well as Code Review and Information Assurance approval from our health information technology services. Owing to the COVID-19 pandemic, the study has been briefly put on hold. However, recruitment began in August 2020. We have converted all recruitment, enrollment, and onboarding processes to be conducted remotely through video telehealth. Consent will be obtained electronically through the Roadmap 2.0 app. Conclusions: This mobile randomized trial will determine if positive psychology-based activities delivered through mobile health technology can improve caregiver health-related quality of life over a 16-week study period. This study will provide additional data on the effects of wearable wrist sensors on caregiver and patient self-report outcomes. Trial Registration: ClinicalTrials.gov NCT04094844; https://www.clinicaltrials.gov/ct2/show/NCT04094844 International Registered Report Identifier (IRRID): PRR1-10.2196/19288 %M 32945777 %R 10.2196/19288 %U https://www.researchprotocols.org/2020/9/e19288 %U https://doi.org/10.2196/19288 %U http://www.ncbi.nlm.nih.gov/pubmed/32945777 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 9 %P e18071 %T A Mobile Social Network–Based Smoking Cessation Intervention for Chinese Male Smokers: Protocol for a Pilot Randomized Controlled Trial %A Chen,Jinsong %A Ho,Elsie %A Jiang,Yannan %A Whittaker,Robyn %A Yang,Tingzhong %A Bullen,Christopher %+ The National Institute for Health Innovation, The University of Auckland, 507, University of Auckland, 22-30 Park Ave, Grafton, Auckland, 1023, New Zealand, 64 093737599, jinsong.chen@auckland.ac.nz %K mHealth %K mobile phone %K smoking cessation %K public health %D 2020 %7 18.9.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Approximately 2 million Chinese people die annually from tobacco-related diseases, mostly men; yet, fewer than 8% of Chinese smokers ever receive any smoking cessation advice or support. A social network–based gamified smoking cessation intervention (SCAMPI: Smoking Cessation App for Chinese Male: Pilot Intervention) is designed to help Chinese male smokers to quit smoking. Objective: This paper aims to present the protocol of a study examining the preliminary effectiveness of SCAMPI by comparing the prolonged abstinence rate of a group of users with a comparator group during a 6-week follow-up period. Methods: A two-arm pilot randomized controlled trial was conducted to assess the preliminary effectiveness and acceptability of the SCAMPI program as a smoking cessation intervention. After initial web-based screening, the first 80 eligible individuals who had gone through the required registration process were registered as participants of the trial. Participants were randomly allocated to the intervention group (n=40) and the control group (n=40). Participants in the intervention group used the full version of the SCAMPI program, which is a Chinese smoking cessation program developed based on the Behavior Change Wheel framework and relevant smoking cessation and design guidelines with involvement of target users. The program delivers a range of smoking cessation approaches, including helping users to make quitting plans, calculator to record quitting benefits, calendar to record progress, gamification to facilitate quitting, providing information about smoking harms, motivational messages to help users overcome urges, providing standardized tests to users for assessing their levels of nicotine dependence and lung health, and providing a platform to encourage social support between users. Participants in the control group used the restricted version of the SCAMPI program (placebo app). Results: Recruitment for this project commenced in January 2019 and proceeded until March 2019. Follow-up data collection was commenced and completed by June 2019. The primary outcome measure of the study was the 30-day bio-verified smoking abstinence at the 6-week follow-up (self-reported data verified by the Nicotine Cotinine Saliva Test). The secondary outcome measures of the study included participants’ cigarette consumption reduction (compared baseline daily cigarette consumption with end-of-trial daily cigarette consumption), participants’ 7-day smoking abstinence at 4-week and 6-week follow-up (self-reported), participants’ 30-day smoking abstinence at 6-week follow-up (self-reported data only), and participants’ acceptability and satisfaction levels of using the SCAMPI program (measured by the Mobile App Rating Scale questionnaire). Conclusions: If the SCAMPI program is shown to be preliminary effective, the study will be rolled out to be a future trial with a larger sample size and longer follow-up (6 months) to identify if it is an effective social network–based tool to support Chinese male smokers to quit smoking. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618001089224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375381 International Registered Report Identifier (IRRID): RR1-10.2196/18071 %M 32945261 %R 10.2196/18071 %U http://www.researchprotocols.org/2020/9/e18071/ %U https://doi.org/10.2196/18071 %U http://www.ncbi.nlm.nih.gov/pubmed/32945261 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19627 %T Adherence of HIV Self-Testing Among Men Who Have Sex With Men in China: Longitudinal Study %A Yan,Xiangyu %A Su,Hexuan %A Zhang,Bo %A Li,Yongjie %A Zhang,Lingling %A Jia,Zhongwei %+ National Institute on Drug Dependence, Peking University, 38 Xueyuan Road, Haidian District, Beijing, , China, 86 10 82802457, urchinjj@163.com %K HIV self-testing %K adherence %K men who have sex with men %K HIV infection %K condom use %K mobile app %D 2020 %7 17.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The World Health Organization recommended HIV self-testing (HIVST) for individuals practicing unsafe sexual behaviors; however, the adherence to HIV testing has not been reported. Objective: In this study, we attempted to determine the adherence to HIVST among men who have sex with men (MSM), as well as the impact factors and potential effects of their adherence. Methods: We conducted a longitudinal study among MSM in Harbin, Heilongjiang province, China from July 1, 2017 to June 30, 2018. A mobile app system was used to provide the “Mailing rapid test reagent kit” for the HIVST service. The proportion of those who adhered to HIV testing every 3 months was calculated. Logistic regression was used to explore the impact factors related to adherence to HIVST. Rates of HIV infection between MSM who adhered to HIVST and those who did not were compared using Cox proportional hazards regression. Changes of condom use behaviors between the two groups were also compared using the chi-square test. Results: A total of 1315 MSM who received the HIVST service through the app were included in the study. Overall, 10% of the MSM adhered to HIVST, and the proportion of adhering tests was only 34.9%. Adherence of HIVST was associated with marital status (adjusted odds ratio [OR]unmarried vs married 2.31, 95% CI 1.13-4.71) and the number of HIV tests they received (adjusted OR3 times vs 2 times or below 3.36, 95% CI 2.01-5.63; adjusted OR4 times or above vs 2 times or below 7.30, 95% CI 4.67-11.42). Twenty HIV seroconversions were observed during 1-year follow up. The rate of HIV infection in the adherence group (17.10 per 100 person years, 95% CI 8.80-30.84) was significantly higher than that in the nonadherence group (4.80 per 100 person years, 95% CI 2.77-7.88; adjusted hazard ratio 3.33, 95% CI 1.35-8.20). Those who adhered to HIV testing were more likely to improve condom use behaviors, although the difference was not statistically significant. Conclusions: Regular HIV testing is necessary for early detection of HIV infection among MSM. Given the poor adherence, a new internet-based management paradigm for MSM is needed to raise their health awareness to optimize the implementation of HIVST. %M 32940619 %R 10.2196/19627 %U http://www.jmir.org/2020/9/e19627/ %U https://doi.org/10.2196/19627 %U http://www.ncbi.nlm.nih.gov/pubmed/32940619 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 7 %N 3 %P e17416 %T Embedding the Pillars of Quality in Health Information Technology Solutions Using “Integrated Patient Journey Mapping” (IPJM): Case Study %A McCarthy,Stephen %A O'Raghallaigh,Paidi %A Woodworth,Simon %A Lim,Yoke Yin %A Kenny,Louise C %A Adam,Frédéric %+ Department of Business Information Systems, Cork University Business School, University College Cork, Western Road, Cork, T12 K8AF, Ireland, 353 21 490 ext 3214, stephen.mccarthy@ucc.ie %K health information technology %K health care quality %K data analytics %K multidisciplinary research %K mobile phone %D 2020 %7 17.9.2020 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Health information technology (HIT) and associated data analytics offer significant opportunities for tackling some of the more complex challenges currently facing the health care sector. However, to deliver robust health care service improvements, it is essential that HIT solutions be designed by parallelly considering the 3 core pillars of health care quality: clinical effectiveness, patient safety, and patient experience. This requires multidisciplinary teams to design interventions that both adhere to medical protocols and achieve the tripartite goals of effectiveness, safety, and experience. Objective: In this paper, we present a design tool called Integrated Patient Journey Mapping (IPJM) that was developed to assist multidisciplinary teams in designing effective HIT solutions to address the 3 core pillars of health care quality. IPJM is intended to support the analysis of requirements as well as to promote empathy and the emergence of shared commitment and understanding among multidisciplinary teams. Methods: A 6-month, in-depth case study was conducted to derive findings on the use of IPJM during Learning to Evaluate Blood Pressure at Home (LEANBH), a connected health project that developed an HIT solution for the perinatal health context. Data were collected from over 700 hours of participant observations and 10 semistructured interviews. Results: The findings indicate that IPJM offered a constructive tool for multidisciplinary teams to work together in designing an HIT solution, through mapping the physical and emotional journey of patients for both the current service and the proposed connected health service. This allowed team members to consider the goals, tasks, constraints, and actors involved in the delivery of this journey and to capture requirements for the digital touchpoints of the connected health service. Conclusions: Overall, IPJM facilitates the design and implementation of complex HITs that require multidisciplinary participation. %M 32940610 %R 10.2196/17416 %U http://humanfactors.jmir.org/2020/3/e17416/ %U https://doi.org/10.2196/17416 %U http://www.ncbi.nlm.nih.gov/pubmed/32940610 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e21243 %T Testing Wearable UV Sensors to Improve Sun Protection in Young Adults at an Outdoor Festival: Field Study %A Horsham,Caitlin %A Antrobus,Jodie %A Olsen,Catherine M %A Ford,Helen %A Abernethy,David %A Hacker,Elke %+ School of Public Health and Social Work, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Brisbane, 4059, Australia, 61 731389674, elke.hacker@qut.edu.au %K melanoma %K health promotion %K public health %K preventive medicine %K sunlight %K sunburn %K adolescents %D 2020 %7 16.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Australia and New Zealand have the highest skin cancer incidence rates worldwide, and sun exposure is the main risk factor for developing skin cancer. Sun exposure during childhood and adolescence is a critical factor in developing skin cancer later in life. Objective: This study aims to test the effectiveness of wearable UV sensors to increase sun protection habits (SPH) and prevent sunburn in adolescents. Methods: During the weeklong school leavers outdoor festival (November 2019) at the Gold Coast, Australia, registered attendees aged 15-19 years were recruited into the field study. Participants were provided with a wearable UV sensor and free sunscreen. The primary outcome was sun exposure practices using the SPH index. Secondary outcomes were self-reported sunburns, sunscreen use, and satisfaction with the wearable UV sensor. Results: A total of 663 participants were enrolled in the study, and complete data were available for 188 participants (188/663, 28.4% response rate). Participants provided with a wearable UV sensor significantly improved their use of sunglasses (P=.004) and sunscreen use both on the face (P<.001) and on other parts of the body (P=.005). However, the use of long-sleeve shirts (P<.001) and the use of a hat (P<.001) decreased. During the study period, 31.4% (59/188) of the participants reported receiving one or more sunburns. Satisfaction with the wearable UV sensor was high, with 73.4% (138/188) of participants reporting the UV sensor was helpful to remind them to use sun protection. Conclusions: Devices that target health behaviors when outdoors, such as wearable UV sensors, may improve use of sunscreen and sunglasses in adolescents. %M 32936083 %R 10.2196/21243 %U http://mhealth.jmir.org/2020/9/e21243/ %U https://doi.org/10.2196/21243 %U http://www.ncbi.nlm.nih.gov/pubmed/32936083 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e18339 %T Mobile Phone Apps for Food Allergies or Intolerances in App Stores: Systematic Search and Quality Assessment Using the Mobile App Rating Scale (MARS) %A Mandracchia,Floriana %A Llauradó,Elisabet %A Tarro,Lucia %A Valls,Rosa Maria %A Solà,Rosa %+ Functional Nutrition, Oxidation, and Cardiovascular Diseases Group (NFOC-Salut), Healthy Environment Chair, Facultat de Medicina i Ciències de la Salut, Universitat Rovira i Virgili, C/Sant Llorenç, 21, Reus, Spain, 34 977758920, lucia.tarro@urv.cat %K food allergy %K food hypersensitivity %K food intolerance %K allergens %K mobile applications %K mobile health %K mHealth %K eHealth. %D 2020 %7 16.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Food allergies and intolerances are increasing worldwide, and mobile phone apps could be a promising tool for self-management of these issues. Objective: This study aimed to systemically search and assess food allergy or intolerance apps in app stores using the multidimensional Mobile App Rating Scale (MARS) to rate the objective and subjective quality and to identify critical points for future improvements. Methods: This systematic search identified apps through the keywords “food allergy,” “food intolerance,” and “allergens” in English, Spanish, and Italian in the Apple App Store (iOS) and Google Play Store (Android). The inclusion criteria were a user star rating of ≥3 (of 5 stars) to limit the selection to the most highly rated apps; ≥1000 reviews as an indicator of reliability; and the most recent update performed up to 2017. Then, the apps were divided according to their purpose (searching for allergen-free “food products,” “restaurants,” or recipes in “meal planners”) and evaluated on a scale of 1 to 5 points using the MARS in terms of (1) app classification category with a descriptive aim; (2) app subjective and objective quality categories comprised of engagement, functionality, esthetics, and information sections (Medline was searched for eligible apps to check whether they had been tested in trials); and (3) an optional app-specific section. Furthermore, the output and input features were evaluated. Differences between MARS sections and between app purposes and correlations among MARS sections, star ratings, and numbers of reviews were evaluated. Results: Of the 1376 apps identified, 14 were included: 12 related to food allergies and intolerances that detect 2-16 food allergens and 2 related only to gluten intolerance. The mean (SD) MARS scores (maximum 5 points) were 3.8 (SD 0.4) for objective quality, highlighting whether any app had been tested in trials; 3.5 (SD 0.6) for subjective quality; and 3.6 (SD 0.7) for the app-specific section. Therefore, a rating ≥3 points indicated overall acceptable quality. From the between-section comparison, engagement (mean 3.5, SD 0.6) obtained significantly lower scores than functionality (mean 4.1, SD 0.6), esthetics (mean 4, SD 0.5), and information (mean 3.8, SD 0.4). However, when the apps were compared by purpose, critical points were identified: meal planner apps showed significantly higher engagement (mean 4.1, SD 0.4) than food product (mean 3.0, SD 0.6; P=.05) and restaurant (mean 3.2, SD 0.3; P=.02) apps. Conclusions: In this systematic search of food allergy or intolerance apps, acceptable MARS quality was identified, although the engagement section for food product and restaurant purpose apps should be improved and the included apps should be tested in trials. The critical points identified in this systematic search can help improve the innovativeness and applicability of future food allergy and intolerance apps. %M 32936078 %R 10.2196/18339 %U http://mhealth.jmir.org/2020/9/e18339/ %U https://doi.org/10.2196/18339 %U http://www.ncbi.nlm.nih.gov/pubmed/32936078 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e17977 %T Data Imputation and Body Weight Variability Calculation Using Linear and Nonlinear Methods in Data Collected From Digital Smart Scales: Simulation and Validation Study %A Turicchi,Jake %A O'Driscoll,Ruairi %A Finlayson,Graham %A Duarte,Cristiana %A Palmeira,A L %A Larsen,Sofus C %A Heitmann,Berit L %A Stubbs,R James %+ School of Psychology, The University of Leeds, 2 Lifton Place, Leeds, LS2 9JS, United Kingdom, 44 7718300764, psjt@leeds.ac.uk %K weight variability %K weight fluctuation %K weight cycling %K weight instability %K imputation %K validation %K digital tracking %K smart scales %K body weight %K energy balance %D 2020 %7 11.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Body weight variability (BWV) is common in the general population and may act as a risk factor for obesity or diseases. The correct identification of these patterns may have prognostic or predictive value in clinical and research settings. With advancements in technology allowing for the frequent collection of body weight data from electronic smart scales, new opportunities to analyze and identify patterns in body weight data are available. Objective: This study aims to compare multiple methods of data imputation and BWV calculation using linear and nonlinear approaches Methods: In total, 50 participants from an ongoing weight loss maintenance study (the NoHoW study) were selected to develop the procedure. We addressed the following aspects of data analysis: cleaning, imputation, detrending, and calculation of total and local BWV. To test imputation, missing data were simulated at random and using real patterns of missingness. A total of 10 imputation strategies were tested. Next, BWV was calculated using linear and nonlinear approaches, and the effects of missing data and data imputation on these estimates were investigated. Results: Body weight imputation using structural modeling with Kalman smoothing or an exponentially weighted moving average provided the best agreement with observed values (root mean square error range 0.62%-0.64%). Imputation performance decreased with missingness and was similar between random and nonrandom simulations. Errors in BWV estimations from missing simulated data sets were low (2%-7% with 80% missing data or a mean of 67, SD 40.1 available body weights) compared with that of imputation strategies where errors were significantly greater, varying by imputation method. Conclusions: The decision to impute body weight data depends on the purpose of the analysis. Directions for the best performing imputation methods are provided. For the purpose of estimating BWV, data imputation should not be conducted. Linear and nonlinear methods of estimating BWV provide reasonably accurate estimates under high proportions (80%) of missing data. %M 32915155 %R 10.2196/17977 %U http://mhealth.jmir.org/2020/9/e17977/ %U https://doi.org/10.2196/17977 %U http://www.ncbi.nlm.nih.gov/pubmed/32915155 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e17919 %T Design and Development of a Digital Weight Management Intervention (ToDAy): Qualitative Study %A Shoneye,Charlene L %A Mullan,Barbara %A Begley,Andrea %A Pollard,Christina M %A Jancey,Jonine %A Kerr,Deborah A %+ School of Public Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia, 61 61892664122, D.Kerr@curtin.edu.au %K obesity %K diet %K physical activity %K sedentary behavior %K digital behavioral interventions %K health behavior %K wearable activity monitor %K health %K mobile food record %K clinical trial %K focus group %K qualitative research %K mobile phone %D 2020 %7 9.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Tailored Diet and Activity (ToDAy) study aims to build on the campaign by adding a digital intervention with the potential to provide wide-reaching, cost-effective weight management support. Objective: The ToDAy study aims to build a tailored intervention using mobile technology to improve diet and physical activity behaviours in adults with overweight and obesity. The main objectives were to identify behavior change techniques for diet and physical activity (PA) change for weight loss and explore preferences for digital intervention features that would be effective in changing diet and PA behaviors. Methods: This qualitative study uses the principles of a person-based approach to intervention development; the behavioral intervention technology framework; and the capability, opportunity, motivation, and behavior (COM-B) framework. Focus groups and telephone interviews were conducted with 56 adults in Western Australia. Open-ended questions and example intervention features were used to explore the usability and acceptability of the self-monitoring tools, knowledge about effective weight-loss strategies, and acceptability of tailored feedback. Findings from the focus groups and interviews were analyzed using thematic analysis. Results: Qualitative findings revealed an awareness of key public health messages but a lack of confidence in how to perform these behaviors to help manage their weight. A total of 4 major themes were identified and mapped to the domains of the COM-B framework: (1) misinformation, (2) environmental support, (3) social norms, and (4) confidence. Conclusions: This study explores users’ capability, opportunity, and motivation to perform the target behaviors for weight loss. The findings suggested that a digital weight management intervention using a mobile food record and activity trackers to inform tailored feedback may be acceptable and feasible. Participants expressed a preference for simple expert advice, digital self-monitoring tools, and visual feedback. International Registered Report Identifier (IRRID): RR2-10.2196/12782 %M 32641284 %R 10.2196/17919 %U https://mhealth.jmir.org/2020/9/e17919 %U https://doi.org/10.2196/17919 %U http://www.ncbi.nlm.nih.gov/pubmed/32641284 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18253 %T Relationship Between Chronic Stress and Heart Rate Over Time Modulated by Gender in a Cohort of Office Workers: Cross-Sectional Study Using Wearable Technologies %A van Kraaij,Alex Wilhelmus Jacobus %A Schiavone,Giuseppina %A Lutin,Erika %A Claes,Stephan %A Van Hoof,Chris %+ OnePlanet Research Center, imec-the Netherlands, Bronland 10, Wageningen, 6708 WH, Netherlands, 31 404020400, alex.vankraaij@imec.nl %K chronic stress %K heart rate %K circadian rhythm %K gender %K age %K wearable device %D 2020 %7 9.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic stress is increasing in prevalence and is associated with several physical and mental disorders. Although it is proven that acute stress changes physiology, much less is known about the relationship between physiology and long-term stress. Continuous measurement of vital signs in daily life and chronic stress detection algorithms could serve this purpose. For this, it is paramount to model the effects of chronic stress on human physiology and include other cofounders, such as demographics, enabling the enrichment of a population-wide approach with individual variations. Objective: The main objectives of this study were to investigate the effect of chronic stress on heart rate (HR) over time while correcting for weekdays versus weekends and to test a possible modulation effect by gender and age in a healthy cohort. Methods: Throughout 2016 and 2017, healthy employees of technology companies were asked to participate in a 5-day observation stress study. They were required to wear two wearables, of which one included an electrocardiogram sensor. The derived HR was averaged per hour and served as an output for a mixed design model including a trigonometric fit over time with four harmonics (periods of 24, 12, 8, and 6 hours), gender, age, whether it was a workday or weekend day, and a chronic stress score derived from the Perceived Stress Scale (PSS) as predictors. Results: The study included 328 subjects, of which 142 were female and 186 were male participants, with a mean age of 38.9 (SD 10.2) years and a mean PSS score of 13.7 (SD 6.0). As main effects, gender (χ21=24.02, P<.001); the hour of the day (χ21=73.22, P<.001); the circadian harmonic (χ22=284.4, P<.001); and the harmonic over 12 hours (χ22=242.1, P<.001), over 8 hours (χ22=23.78, P<.001), and over 6 hours (χ22=82.96, P<.001) had a significant effect on HR. Two three-way interaction effects were found. The interaction of age, whether it was a workday or weekend day, and the circadian harmonic over time were significantly correlated with HR (χ22=7.13, P=.03), as well as the interaction of gender, PSS score, and the circadian harmonic over time (χ22=7.59, P=.02). Conclusions: The results show a relationship between HR and the three-way interaction of chronic stress, gender, and the circadian harmonic. The modulation by gender might be related to evolution-based energy utilization strategies, as suggested in related literature studies. More research, including daily cortisol assessment, longer recordings, and a wider population, should be performed to confirm this interpretation. This would enable the development of more complete and personalized models of chronic stress. %M 32902392 %R 10.2196/18253 %U http://www.jmir.org/2020/9/e18253/ %U https://doi.org/10.2196/18253 %U http://www.ncbi.nlm.nih.gov/pubmed/32902392 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e16953 %T Validity and Usability of a Smartphone Image-Based Dietary Assessment App Compared to 3-Day Food Diaries in Assessing Dietary Intake Among Canadian Adults: Randomized Controlled Trial %A Ji,Yuwei %A Plourde,Hugues %A Bouzo,Valerie %A Kilgour,Robert D %A Cohen,Tamara R %+ Faculty of Land and Food Systems, Food, Nutrition and Health, University of British Columbia, 218-2205 East Mall, Vancouver, BC, V6T 1Z4, Canada, 1 604 827 0362, tamara.cohen@ubc.ca %K mobile food record %K validity %K image-based dietary assessment %K healthy adults %K 3-day food diary %K diet %K application %K nutrition %K mHealth %K Canada %D 2020 %7 9.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Accurate dietary assessment is needed in studies that include analysis of nutritional intake. Image-based dietary assessment apps have gained in popularity for assessing diet, which may ease researcher and participant burden compared to traditional pen-to-paper methods. However, few studies report the validity of these apps for use in research. Keenoa is a smartphone image-based dietary assessment app that recognizes and identifies food items using artificial intelligence and permits real-time editing of food journals. Objective: This study aimed to assess the relative validity of an image-based dietary assessment app — Keenoa — against a 3-day food diary (3DFD) and to test its usability in a sample of healthy Canadian adults. Methods: We recruited 102 participants to complete two 3-day food records. For 2 weeks, on 2 non-consecutive days and 1 weekend day, in random order, participants completed a traditional pen-to-paper 3DFD and the Keenoa app. At the end of the study, participants completed the System Usability Scale. The nutrient analyses of the 3DFD and Keenoa data before (Keenoa-participant) and after they were reviewed by dietitians (Keenoa-dietitian) were analyzed using analysis of variance. Multiple tests, including the Pearson coefficient, cross-classification, kappa score, % difference, paired t test, and Bland-Altman test, were performed to analyze the validity of Keenoa (Keenoa-dietitian). Results: The study was completed by 72 subjects. Most variables were significantly different between Keenoa-participant and Keenoa-dietitian (P<.05) except for energy, protein, carbohydrates, fiber, vitamin B1, vitamin B12, vitamin C, vitamin D, and potassium. Significant differences in total energy, protein, carbohydrates, % fat, saturated fatty acids, iron, and potassium were found between the 3DFD and Keenoa-dietitian data (P<.05). The Pearson correlation coefficients between the Keenoa-dietitian and 3DFD ranged from .04 to .51. Differences between the mean intakes assessed by the 3DFD and Keenoa-dietitian were within 10% except for vitamin D (misclassification rate=33.8%). The majority of nutrients were within an acceptable range of agreement in the Bland-Altman analysis; no agreements were seen for total energy, protein, carbohydrates, fat (%), saturated fatty acids, iron, potassium, and sodium (P<.05). According to the System Usability Scale, 34.2% of the participants preferred using Keenoa, while 9.6% preferred the 3DFD. Conclusions: The Keenoa app provides acceptable relative validity for some nutrients compared to the 3DFD. However, the average intake of some nutrients, including energy, protein, carbohydrates, % fat, saturated fatty acids, and iron, differed from the average obtained using the 3DFD. These findings highlight the importance of verifying data entries of participants before proceeding with nutrient analysis. Overall, Keenoa showed better validity at the group level than the individual level, suggesting it can be used when focusing on the dietary intake of the general population. Further research is recommended with larger sample sizes and objective dietary assessment approaches. %M 32902389 %R 10.2196/16953 %U https://mhealth.jmir.org/2020/9/e16953 %U https://doi.org/10.2196/16953 %U http://www.ncbi.nlm.nih.gov/pubmed/32902389 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 7 %N 2 %P e18729 %T Usability and Acceptability of an App (SELFBACK) to Support Self-Management of Low Back Pain: Mixed Methods Study %A Nordstoga,Anne Lovise %A Bach,Kerstin %A Sani,Sadiq %A Wiratunga,Nirmalie %A Mork,Paul Jarle %A Villumsen,Morten %A Cooper,Kay %+ Department of Public Health and Nursing, Norwegian University of Science and Technology, Håkon Jarls gate 11, Trondheim, 7030, Norway, 47 99268260, anne.l.nordstoga@ntnu.no %K low back pain %K self-management %K physical activity %K exercise %K patient education %K smartphone %K mHealth %K eHealth %K digital health %K case-based reasoning %D 2020 %7 9.9.2020 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Self-management is the key recommendation for managing nonspecific low back pain (LBP). However, there are well-documented barriers to self-management; therefore, methods of facilitating adherence are required. Smartphone apps are increasingly being used to support self-management of long-term conditions such as LBP. Objective: The aim of this study was to assess the usability and acceptability of the SELFBACK smartphone app, designed to support and facilitate self-management of non-specific LBP. The app provides weekly self-management plans, comprising physical activity, strength and flexibility exercises, and patient education. The plans are tailored to the patient’s characteristics and symptom progress by using case-based reasoning methodology. Methods: The study was carried out in 2 stages using a mixed-methods approach. All participants undertook surveys, and semistructured telephone interviews were conducted with a subgroup of participants. Stage 1 assessed an app version with only the physical activity component and a web questionnaire that collects information necessary for tailoring the self-management plans. The physical activity component included monitoring of steps recorded by a wristband, goal setting, and a scheme for sending personalized, timely, and motivational notifications to the user’s smartphone. Findings from Stage 1 were used to refine the app and inform further development. Stage 2 investigated an app version that incorporated 3 self-management components (physical activity, exercises, and education). A total of 16 participants (age range 23-71 years) with ongoing or chronic nonspecific LBP were included in Stage 1, and 11 participants (age range 32-56 years) were included in Stage 2. Results: In Stage 1, 15 of 16 participants reported that the baseline questionnaire was easy to answer, and 84% (13/16) found the completion time to be acceptable. Overall, participants were positive about the usability of the physical activity component but only 31% (5/16) found the app functions to be well integrated. Of the participants, 90% (14/16) were satisfied with the notifications, and they were perceived as being personalized (12/16, 80%). In Stage 2, all participants reported that the web questionnaire was easy to answer and the completion time acceptable. The physical activity and exercise components were rated useful by 80% (8/10), while 60% (6/10) rated the educational component useful. Overall, participants were satisfied with the usability of the app; however, only 50% (5/10) found the functions to be well integrated, and 20% (2/10) found them to be inconsistent. Overall, 80% (8/10) of participants reported it to be useful for self-management. The interviews largely reinforced the survey findings in both stages. Conclusions: This study has demonstrated that participants considered the SELFBACK app to be acceptable and usable and that they thought it would be useful for supporting self-management of LBP. However, we identified some limitations and suggestions useful to guide further development of the SELFBACK app and other mobile health interventions. %M 32902393 %R 10.2196/18729 %U http://rehab.jmir.org/2020/2/e18729/ %U https://doi.org/10.2196/18729 %U http://www.ncbi.nlm.nih.gov/pubmed/32902393 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e18142 %T Neural Network–Based Algorithm for Adjusting Activity Targets to Sustain Exercise Engagement Among People Using Activity Trackers: Retrospective Observation and Algorithm Development Study %A Mohammadi,Ramin %A Atif,Mursal %A Centi,Amanda Jayne %A Agboola,Stephen %A Jethwani,Kamal %A Kvedar,Joseph %A Kamarthi,Sagar %+ Northeastern University, 360 Huntington Ave, Boston, MA, 02115, United States, 1 6173733070, sagar@coe.neu.edu %K activity tracker %K exercise engagement %K dynamic activity target %K neural network %K activity target prediction %K machine learning %D 2020 %7 8.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: It is well established that lack of physical activity is detrimental to the overall health of an individual. Modern-day activity trackers enable individuals to monitor their daily activities to meet and maintain targets. This is expected to promote activity encouraging behavior, but the benefits of activity trackers attenuate over time due to waning adherence. One of the key approaches to improving adherence to goals is to motivate individuals to improve on their historic performance metrics. Objective: The aim of this work was to build a machine learning model to predict an achievable weekly activity target by considering (1) patterns in the user’s activity tracker data in the previous week and (2) behavior and environment characteristics. By setting realistic goals, ones that are neither too easy nor too difficult to achieve, activity tracker users can be encouraged to continue to meet these goals, and at the same time, to find utility in their activity tracker. Methods: We built a neural network model that prescribes a weekly activity target for an individual that can be realistically achieved. The inputs to the model were user-specific personal, social, and environmental factors, daily step count from the previous 7 days, and an entropy measure that characterized the pattern of daily step count. Data for training and evaluating the machine learning model were collected over a duration of 9 weeks. Results: Of 30 individuals who were enrolled, data from 20 participants were used. The model predicted target daily count with a mean absolute error of 1545 (95% CI 1383-1706) steps for an 8-week period. Conclusions: Artificial intelligence applied to physical activity data combined with behavioral data can be used to set personalized goals in accordance with the individual’s level of activity and thereby improve adherence to a fitness tracker; this could be used to increase engagement with activity trackers. A follow-up prospective study is ongoing to determine the performance of the engagement algorithm. %M 32897235 %R 10.2196/18142 %U https://mhealth.jmir.org/2020/9/e18142 %U https://doi.org/10.2196/18142 %U http://www.ncbi.nlm.nih.gov/pubmed/32897235 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 9 %P e17646 %T Mobile Health App for Self-Learning on HIV Prevention Knowledge and Services Among a Young Indonesian Key Population: Cohort Study %A Garg,Priyanka Rani %A Uppal,Leena %A Mehra,Sunil %A Mehra,Devika %+ MAMTA Health Institute for Mother and Child, B-5, Greater Kailash Enclave-II, New Delhi, 110048, India, 91 11 29220210, leena@mamtahimc.org %K mHealth %K Indonesia %K HIV %K key populations %D 2020 %7 8.9.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Indonesia is the only country in the Asia Pacific region where the incidence of HIV is still on the rise, and its prevalence is extremely high among the key populations such as men who have sex with men, transgender women, and people who inject/use drugs. Mobile health (mHealth) apps provide an innovative platform for delivering tailored HIV prevention and care among these populations more efficiently than possible through the direct face-to-face approach. Objective: The aim of this study was to assess the role of a peer-customized mobile app based on the principle of self-learning for improving HIV prevention knowledge and access to health services among men who have sex with men, transgender women (known as Waria in Indonesia), and people who use drugs in Indonesia. Methods: A prospective intervention cohort study was conducted among the key populations in five provinces of Indonesia (Jakarata, West Java, East Java, Special Region of Yogyakarta, and Bali). The data were evaluated using a pre-post assessment survey conducted on a sample of 200 unique users, including 50 men who have sex with men and transgender women each, and 100 people who use drugs, with a follow-up response rate of 98% and 70%, respectively. An mHealth app named RUMAH SELA was developed and implemented among the key populations. Results: From baseline to the endpoint of the study, there was a significant increase in comprehensive HIV-related knowledge from 20% (10/49) to 60% (29/49), 22% (11/49) to 57% (28/49), and 49% (34/70) to 74% (52/70) among men who have sex with men (P=.004), transgender women (P<.001), and people who use drugs (P<.001), respectively. There was also a reduction in sexual activities without condom use from 22% (11/49) to 19% (9/49), 18% (9/49) to 12% (6/49), and 21% (15/70) to 10% (7/70) among men who have sex with men (P=.45), transgender women (P=.25), and people who use drugs (P<.001), respectively. There was an uptake of HIV testing by 31% (15/49) for men who have sex with men, 49% (24/49) for transgender women, and 26% (18/70) for people who use drugs after using the app. There was a reduction in injecting drugs with a used needle in drug users from 45/70 (78%) to 15/70 (26%). Measures of self-esteem increased among men who have sex with men (mean 26.4 vs mean 27.1), transgender women (mean 26.5 vs mean 27.8; P=.02), and people who use drugs (mean 24.0 vs mean 25.0). In addition, 27% (7/24) of men who have sex with men, 25% (4/15) of transgender women, and 11% (2/18) of drug users made an appointment for an HIV test through the app. The app was quite highly accepted by the key populations as nearly a quarter felt that they became more confident in discussing issues about sexuality, more than 80% found that the app provided sufficient knowledge about HIV, and more than half of the participants found the app to be user friendly. Conclusions: This one-of-a-kind mHealth intervention with an mHealth app as a self-learning tool is effective in increasing HIV-related knowledge and behavior, and access to services with strong acceptability by the community. There is a need to scale up such interventions for efficacy testing in a larger population to provide evidence for national-level mHealth programs addressing HIV. %M 32896831 %R 10.2196/17646 %U https://mhealth.jmir.org/2020/9/e17646 %U https://doi.org/10.2196/17646 %U http://www.ncbi.nlm.nih.gov/pubmed/32896831 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e20581 %T Digital Interventions for Screening and Treating Common Mental Disorders or Symptoms of Common Mental Illness in Adults: Systematic Review and Meta-analysis %A Sin,Jacqueline %A Galeazzi,Gian %A McGregor,Elicia %A Collom,Jennifer %A Taylor,Anna %A Barrett,Barbara %A Lawrence,Vanessa %A Henderson,Claire %+ School of Psychology and Clinical Language Sciences, University of Reading, Earley Gate, Whiteknights, Reading, RG6 6AL, United Kingdom, 44 7817027035, jacqueline.sin@reading.ac.uk %K eHealth %K mHealth %K psychiatric illness %K mental disorders %K common mental illness %K depression %K anxiety %K self-care %D 2020 %7 2.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Digital interventions targeting common mental disorders (CMDs) or symptoms of CMDs are growing rapidly and gaining popularity, probably in response to the increased prevalence of CMDs and better awareness of early help-seeking and self-care. However, no previous systematic reviews that focus on these novel interventions were found. Objective: This systematic review aims to scope entirely web-based interventions that provided screening and signposting for treatment, including self-management strategies, for people with CMDs or subthreshold symptoms. In addition, a meta-analysis was conducted to evaluate the effectiveness of these interventions for mental well-being and mental health outcomes. Methods: Ten electronic databases including MEDLINE, PsycINFO, and EMBASE were searched from January 1, 1999, to early April 2020. We included randomized controlled trials (RCTs) that evaluated a digital intervention (1) targeting adults with symptoms of CMDs, (2) providing both screening and signposting to other resources including self-care, and (3) delivered entirely through the internet. Intervention characteristics including target population, platform used, key design features, and outcome measure results were extracted and compared. Trial outcome results were included in a meta-analysis on the effectiveness of users’ well-being and mental health outcomes. We also rated the meta-analysis results with the Grading of Recommendations, Assessment, Development, and Evaluations approach to establish the quality of the evidence. Results: The electronic searches yielded 21 papers describing 16 discrete digital interventions. These interventions were investigated in 19 unique trials including 1 (5%) health economic study. Most studies were conducted in Australia and North America. The targeted populations varied from the general population to allied health professionals. All interventions offered algorithm-driven screening with measures to assess symptom levels and to assign treatment options including automatic web-based psychoeducation, self-care strategies, and signposting to existing services. A meta-analysis of usable trial data showed that digital interventions improved well-being (3 randomized controlled trials [RCTs]; n=1307; standardized mean difference [SMD] 0.40; 95% CI 0.29 to 0.51; I2=28%; fixed effect), symptoms of mental illness (6 RCTs; n=992; SMD −0.29; 95% CI −0.49 to −0.09; I2=51%; random effects), and work and social functioning (3 RCTs; n=795; SMD −0.16; 95% CI −0.30 to −0.02; I2=0%; fixed effect) compared with waitlist or attention control. However, some follow-up data failed to show any sustained effects beyond the post intervention time point. Data on mechanisms of change and cost-effectiveness were also lacking, precluding further analysis. Conclusions: Digital mental health interventions to assess and signpost people experiencing symptoms of CMDs appear to be acceptable to a sufficient number of people and appear to have enough evidence for effectiveness to warrant further study. We recommend that future studies incorporate economic analysis and process evaluation to assess the mechanisms of action and cost-effectiveness to aid scaling of the implementation. %M 32876577 %R 10.2196/20581 %U https://www.jmir.org/2020/9/e20581 %U https://doi.org/10.2196/20581 %U http://www.ncbi.nlm.nih.gov/pubmed/32876577 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19634 %T Weight Reduction Through a Digital Nutrition and Food Purchasing Platform Among Users With Obesity: Longitudinal Study %A Hu,Emily A %A Nguyen,Viet %A Langheier,Jason %A Shurney,Dexter %+ Zipongo, Inc, DBA Foodsmart, 600 California Street, 11th Floor, San Francisco, CA, 94108, United States, 1 415 604 4122, emily.hu@zipongo.com %K digital %K nutrition %K meal planning %K weight loss %K obese %K food environment %K food ordering %K food purchasing %K behavioral economics %K behavior change %K eating behavior %K mHealth %K app %D 2020 %7 2.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital nutrition apps that monitor or provide recommendations on diet have been found to be effective in behavior change and weight reduction among individuals with obesity. However, there is less evidence on how integration of personalized nutrition recommendations and changing the food purchasing environment through online meal planning and grocery delivery, meal kits, and grocery incentives impacts weight loss among individuals with obesity. Objective: The objective of this observational longitudinal study was to examine weight loss and predictors of weight loss among individuals with obesity who are users of a digital nutrition platform that integrates tools to provide nutrition recommendations and changes in the food purchasing environment grounded in behavioral theory. Methods: We included 8977 adults with obesity who used the digital Foodsmart platform, created by Zipongo, Inc, DBA Foodsmart between January 2013 and April 2020. We retrospectively analyzed user characteristics and their associations with weight loss. Participants reported age, gender, height, at least 2 measures of weight, and usual dietary intake. Healthy Diet Score, a score to measure overall diet quality, was calculated based on responses to a food frequency questionnaire. We used paired t tests to compare differences in baseline and final weights and baseline and final Healthy Diet Scores. We used univariate and multivariate logistic regression models to estimate odds ratios and 95% CI of achieving 5% weight loss by gender, age, baseline BMI, Healthy Diet Score, change in Healthy Diet Score, and duration of enrollment. We conducted stratified analyses to examine mean percent weight change by enrollment duration and gender, age, baseline BMI, and change in Healthy Diet Score. Results: Over a median (IQR) of 9.9 (0.03-54.7) months of enrollment, 59% of participants lost weight. Of the participants who used the Foodsmart platform for at least 24 months, 33.3% achieved 5% weight loss. In the fully adjusted logistic regression model, we found that baseline BMI (OR 1.02, 95% CI 1.02-1.03; P<.001), baseline Healthy Diet Score (OR 1.06, 95% CI 1.05-1.08; P<.001), greater change in Healthy Diet Score (OR 1.12, 95% CI 1.11-1.14; P<.001), and enrollment length (OR 1.28, 95% CI 1.23-1.32; P<.001) were all significantly associated with higher odds of achieving at least 5% weight loss. Conclusions: This study found that a digital app that provides personalized nutrition recommendations and change in one’s food purchasing environment appears to be successful in meaningfully reducing weight among individuals with obesity. %M 32792332 %R 10.2196/19634 %U http://www.jmir.org/2020/9/e19634/ %U https://doi.org/10.2196/19634 %U http://www.ncbi.nlm.nih.gov/pubmed/32792332 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18509 %T Clusters of Adolescent Physical Activity Tracker Patterns and Their Associations With Physical Activity Behaviors in Finland and Ireland: Cross-Sectional Study %A Ng,Kwok %A Kokko,Sami %A Tammelin,Tuija %A Kallio,Jouni %A Belton,Sarahjane %A O'Brien,Wesley %A Murphy,Marie %A Powell,Cormac %A Woods,Catherine %+ School of Educational Sciences and Psychology, University of Eastern Finland, PO Box 111, Joensuu, 80101, Finland, 358 504724051, kwok.ng@hbsc.org %K wearables %K children %K activity trackers %K active travel %K organised sport %K self-quantification %D 2020 %7 1.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity trackers (PATs) such as apps and wearable devices (eg, sports watches, heart rate monitors) are increasingly being used by young adolescents. Despite the potential of PATs to help monitor and improve moderate-to-vigorous physical activity (MVPA) behaviors, there is a lack of research that confirms an association between PAT ownership or use and physical activity behaviors at the population level. Objective: The purpose of this study was to examine the ownership and use of PATs in youth and their associations with physical activity behaviors, including daily MVPA, sports club membership, and active travel, in 2 nationally representative samples of young adolescent males and females in Finland and Ireland. Methods: Comparable data were gathered in the 2018 Finnish School-aged Physical Activity (F-SPA 2018, n=3311) and the 2018 Irish Children’s Sport Participation and Physical Activity (CSPPA 2018, n=4797) studies. A cluster analysis was performed to obtain the patterns of PAT ownership and usage by adolescents (age, 11-15 years). Four similar clusters were identified across Finnish and Irish adolescents: (1) no PATs, (2) PAT owners, (3) app users, and (4) wearable device users. Adjusted binary logistic regression analyses were used to evaluate how PAT clusters were associated with physical activity behaviors, including daily MVPA, membership of sports clubs, and active travel, after stratification by gender. Results: The proportion of app ownership among Finnish adolescents (2038/3311, 61.6%) was almost double that of their Irish counterparts (1738/4797, 36.2%). Despite these differences, the clustering patterns of PATs were similar between the 2 countries. App users were more likely to take part in daily MVPA (males, odds ratio [OR] 1.27, 95% CI 1.04-1.55; females, OR 1.49, 95% CI 1.20-1.85) and be members of sports clubs (males, OR 1.37, 95% CI 1.15-1.62; females, OR 1.25, 95% CI 1.07-1.50) compared to the no PATs cluster, after adjusting for country, age, family affluence, and disabilities. These associations, after the same adjustments, were even stronger for wearable device users to participate in daily MVPA (males, OR 1.83, 95% CI 1.49-2.23; females, OR 2.25, 95% CI 1.80-2.82) and be members of sports clubs (males, OR 1.88, 95% CI 1.55-2.88; females, OR 2.07, 95% CI 1.71-2.52). Significant associations were observed between male users of wearable devices and taking part in active travel behavior (OR 1.39, 95% CI 1.04-1.86). Conclusions: Although Finnish adolescents report more ownership of PATs than Irish adolescents, the patterns of use and ownership remain similar among the cohorts. The findings of our study show that physical activity behaviors were positively associated with wearable device users and app users. These findings were similar between males and females. Given the cross-sectional nature of this data, the relationship between using apps or wearable devices and enhancing physical activity behaviors requires further investigation. %M 32667894 %R 10.2196/18509 %U https://www.jmir.org/2020/9/e18509 %U https://doi.org/10.2196/18509 %U http://www.ncbi.nlm.nih.gov/pubmed/32667894 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17790 %T Effectiveness of Mobile Health Interventions Promoting Physical Activity and Lifestyle Interventions to Reduce Cardiovascular Risk Among Individuals With Metabolic Syndrome: Systematic Review and Meta-Analysis %A Sequi-Dominguez,Irene %A Alvarez-Bueno,Celia %A Martinez-Vizcaino,Vicente %A Fernandez-Rodriguez,Rubén %A del Saz Lara,Alicia %A Cavero-Redondo,Iván %+ Universidad de Castilla-La Mancha, Health and Social Research Center, Edificio Melchor Cano Campus Universitario de Cuenca, Camino de Pozuelo, s/n, Cuenca, 16071, Spain, 34 969 179 100 ext 4659, celia.alvarezbueno@uclm.es %K mobile health %K mobile technology %K telemedicine %K metabolic syndrome %K physical activity %K lifestyle intervention %K systematic review %K meta-analysis %D 2020 %7 31.8.2020 %9 Review %J J Med Internet Res %G English %X Background: Physical activity and lifestyle interventions, such as a healthy diet, have been proven to be effective approaches to manage metabolic syndrome. However, these interventions require great commitment from patients and clinicians owing to their economic costs, time consumption, and lack of immediate results. Objective: The aim of this systematic review and meta-analysis was to analyze the effect of mobile-based health interventions for reducing cardiometabolic risk through the promotion of physical activity and healthy lifestyle behaviors. Methods: PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and SPORTdiscus databases were searched for experimental studies evaluating cardiometabolic risk indicators among individuals with metabolic syndrome who were included in technology-assisted physical activity and lifestyle interventions. Effect sizes, pooled mean changes, and their respective 95% CIs were calculated using the DerSimonian and Laird method. Outcomes included the following clinical and biochemical parameters: body composition (waist circumference [WC] and BMI), blood pressure (systolic blood pressure [SBP] and diastolic blood pressure [DBP]), glucose tolerance (fasting plasma glucose [FPG] and glycated hemoglobin A1c [HbA1c]), and lipid profile (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol [HDL-C], and triglycerides). Results: A total of nine studies were included in the meta-analysis. Owing to the scarcity of studies, only pooled mean pre-post changes in the intervention groups were estimated. Significant mean changes were observed for BMI (−1.70 kg/m2, 95% CI −3.20 to −0.20; effect size: −0.46; P=.03), WC (−5.77 cm, 95% CI −9.76 to −1.77; effect size: −0.54; P=.005), SBP (−7.33 mmHg, 95% CI −13.25 to −1.42; effect size: −0.43; P=.02), DBP (−3.90 mmHg, 95% CI −7.70 to −0.11; effect size: −0.44; P=.04), FPG (−3.65 mg/dL, 95% CI −4.79 to −2.51; effect size: −0.39; P<.001), and HDL-C (4.19 mg/dL, 95% CI 2.43-5.95; effect size: 0.23; P<.001). Conclusions: Overall, mobile-based health interventions aimed at promoting physical activity and healthy lifestyle changes had a strong positive effect on cardiometabolic risk indicators among individuals with metabolic syndrome. Nevertheless, further research is required to compare this approach with usual care in order to support the incorporation of these technologies in health systems. Trial Registration: PROSPERO CRD42019125461; https://tinyurl.com/y3t4wog4. %M 32865503 %R 10.2196/17790 %U http://www.jmir.org/2020/8/e17790/ %U https://doi.org/10.2196/17790 %U http://www.ncbi.nlm.nih.gov/pubmed/32865503 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 5 %N 3 %P e21183 %T Technology-Assisted Self-Monitoring of Lifestyle Behaviors and Health Indicators in Diabetes: Qualitative Study %A Du,Yan %A Dennis,Brittany %A Rhodes,Shanae Lakel %A Sia,Michelle %A Ko,Jisook %A Jiwani,Rozmin %A Wang,Jing %+ Center on Smart and Connected Health Technologies, School of Nursing, University of Texas Health Science Center at San Antonio, 7739 Floyd Dr, San Antonio, TX, United States, 1 210 450 8561, wangj1@uthscsa.edu %K technology %K monitoring %K lifestyle %K diet %K exercise %K weight %K glucose %K diabetes management %D 2020 %7 28.8.2020 %9 Original Paper %J JMIR Diabetes %G English %X Background: Self-monitoring is key to successful behavior change in diabetes and obesity, and the use of traditional paper-based methods of self-monitoring may be time-consuming and burdensome. Objective: This study aimed to explore participant experiences while using technology-assisted self-monitoring of lifestyle behaviors and health indicators among overweight or obese adults with type 2 diabetes. Methods: Qualitative data collected from the intervention group of a 6-month, three-arm (control, paper diary, and technology-assisted self-monitoring groups) randomized clinical trial were analyzed. Study participants in the intervention group monitored their diet, exercise, and weight using the LoseIt! app, and their blood glucose levels using a glucometer and the Diabetes Connect app. Semistructured group discussions were conducted at 6 weeks (n=10) from the initiation of the behavioral lifestyle intervention and again at 6 months (n=9). All group interviews were audiotaped and transcribed verbatim. Using a combination of thematic and comparative analysis approaches, two trained professionals coded the transcriptions independently and then discussed and concluded common themes for the 6-week and 6-month discussions separately. Results: The sample (n=10), which primarily involved African American participants (n=7) and female participants (n=8), had a mean age of 59.4 years. The following eight themes emerged: (1) perceived benefits of technology-assisted self-monitoring; (2) perceived ease of use (eg, barriers: technical difficulties and lack of self-discipline; facilitators: help from family, friends, and the program); (3) use of technology-assisted self-monitoring; (4) facilitators of engaging in healthy lifestyle behaviors (eg, visualization and awareness of calorie input/expenditure); (5) positive lifestyle change; (6) barriers of engaging in healthy lifestyle behaviors (eg, event influence); (7) learning curve; and (8) monitored data sharing. The first six of these themes were shared between the 6-week and 6-month timepoints, but the codes within these themes were not all the same and differed slightly between the two timepoints. These differences provide insights into the evolution of participant thoughts and perceptions on using technology for self-monitoring and subsequent behavioral lifestyle changes while participating in lifestyle interventions. The findings from the 6-week and 6-month data helped to paint a picture of participant comfort and the integration of technology and knowledge overtime, and clarified participant attitudes, difficulties, behavioral processes, and modifications, as well as health indicators that were experienced throughout the study. Conclusions: Although there were some barriers, participants were able to identify various individual and external facilitators to adjust to and engage in technology-assisted self-monitoring, and it was concluded that the technology-assisted self-monitoring approach was beneficial, safe, and feasible to use for positive lifestyle change. These patient perspectives need to be considered in future research studies when investigating the effectiveness of using technology-assisted self-monitoring, as well as in clinical practice when recommending technology-assisted self-monitoring of lifestyle behaviors and health indicators to improve health outcomes. %M 32857056 %R 10.2196/21183 %U http://diabetes.jmir.org/2020/3/e21183/ %U https://doi.org/10.2196/21183 %U http://www.ncbi.nlm.nih.gov/pubmed/32857056 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e21784 %T Development of a Mobile Health Intervention with Personal Experiments for Smokers Who Are Ambivalent About Quitting: Formative Design and Testing %A Heffner,Jaimee L %A Catz,Sheryl L %A Klasnja,Predrag %A Tiffany,Brooks %A McClure,Jennifer B %+ Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101, United States, 1 206 287 2737, Jennifer.B.McClure@kp.org %K tobacco %K nicotine %K smoking %K cessation %K smartphone %K motivation %K mHealth %K intervention %K formative %K development %D 2020 %7 27.8.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: The majority of cigarette smokers want to quit someday but are not ready to commit to long-term abstinence. However, available smoking cessation treatments are not well-suited to meet the needs of these ambivalent smokers. Low-cost, high-reach mobile health (mHealth) interventions may be a cost-efficient means of offering assistance to ambivalent smokers, yet there are currently no evidence-based options available for this group. Objective: The aim of this study was to develop and preliminarily evaluate the core content for an mHealth program targeting adult smokers who are ambivalent about quitting. The core content consisted of a series of “personal experiments” similar to those tested as part of a counseling intervention in prior work, including brief cognitive or behavioral tasks designed to boost readiness for changing smoking behavior. Methods: We conducted individual user interviews (N=3) to refine program content, and then conducted a one-arm pilot study (N=25) to assess user receptivity and the potential impact of the experiments on motivation and self-efficacy to quit or reduce smoking. Results: In user interviews, participants liked the concept of the personal experiments. Participants in the pilot study found a medium-fidelity prototype to be highly acceptable. After watching a brief orientation video that explained how the program works, most participants (80%, 20/25) indicated that it sounded interesting, primarily because it did not require any commitment to quit. All participants (100%, 25/25) completed all 7 experiments, including a 24-hour quit attempt, although not all were able to refrain from smoking for a full day based on qualitative feedback on the experiment. The mean rating of usefulness of the overall program was 4.12 (SD 1.09) out of 5, and the average rating of the difficulty of the experiments was 2.16 (SD 1.18) out of 5. At the last assessment point, 92% (23/25) of the participants indicated that they were more interested in either quitting or cutting back than when they began the program, and 72% (18/25) said that if the program had included a free trial of nicotine replacement therapy, they would have used it to try to quit smoking. Conclusions: This formative work confirmed that ambivalent smokers are willing to use and will remain engaged with an mHealth intervention that employs the novel concept of personal experiments to enhance their motivation for and ability to quit smoking. The addition of action-oriented treatment (self-help and free nicotine replacement therapy, quitline referral) could further support users’ efforts to stop smoking and remain quit. %M 32852278 %R 10.2196/21784 %U http://formative.jmir.org/2020/8/e21784/ %U https://doi.org/10.2196/21784 %U http://www.ncbi.nlm.nih.gov/pubmed/32852278 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e21304 %T Digital Cognitive Behavior Therapy Intervention for Depression and Anxiety: Retrospective Study %A Venkatesan,Aarathi %A Rahimi,Lily %A Kaur,Manpreet %A Mosunic,Christopher %+ Vida Health, 100 Montgomery St, Ste 750, San Francisco, CA, 94104, United States, 1 (415) 989 1017, aarathi.venkatesan@vida.com %K depression %K anxiety %K CBT %K digital mental health intervention %K digital therapeutics %K cognitive behavioral therapy %K therapy %K digital health %K intervention %K mental health %D 2020 %7 26.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Digital mental health interventions offer a scalable solution that reduces barriers to seeking care for clinical depression and anxiety. Objective: We aimed to examine the effectiveness of a 12-week therapist supported, app-based cognitive behavioral therapy program in improving symptoms of depression and anxiety within 9 months. Methods: A total of 323 participants with mild to moderately severe depression or anxiety were enrolled in a 12-week digital cognitive behavior therapy program. The analysis was restricted to participants who provided at least one follow-up assessment after baseline. As a result, 146 participants (45.2%) were included in the analysis—74 (50.7%) participants completed assessments at 3 months, 31 participants (21.2%) completed assessments at 6 months, and 21 participants (14.4%) completed assessments at 9 months. The program included structured lessons and tools (ie, exercises and practices) as well as one-on-one weekly video counseling sessions with a licensed therapist for 12 weeks and monthly check-in sessions for 1 year. The clinically validated Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder Scale (GAD-7) were used to assess depression and anxiety, respectively. Linear mixed-effects modeling was employed to examine changes in depression and anxiety over time. Results: We observed a significant positive effect of program time on improvement in depression (β=–0.12, P<.001) and anxiety scores (β=–0.10, P<.001). At the end of the 12-week intervention, we observed an average reduction of 3.76 points (95% CI –4.76 to –2.76) in PHQ-8 scores. Further reductions in depression were seen at program month 6 (4.75-point reduction, 95% CI –6.61 to –2.88) and program month 9 (6.42-point reduction, 95% CI –8.66 to –6.55, P<.001). A similar pattern of improvement emerged for anxiety, with a 3.17-point reduction at the end of the 12-week intervention (95% CI –4.21 to –2.13). These improvements were maintained at program month 6 (4.87-point reduction, 95% CI –6.85 to –2.87) and program month 9 (5.19-point, 95% –6.85 to 4.81). In addition, greater program engagement during the first 12 weeks predicted a greater reduction in depression (β=–0.29, P<.001) Conclusions: The results suggest that digital interventions can support sustained and clinically meaningful improvements in depression and anxiety. Furthermore, it appears that strong initial digital mental health intervention engagement may facilitate this effect. However, the study was limited by postintervention participant attrition as well as the retrospective observational study design. %M 32845246 %R 10.2196/21304 %U http://mental.jmir.org/2020/8/e21304/ %U https://doi.org/10.2196/21304 %U http://www.ncbi.nlm.nih.gov/pubmed/32845246 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 2 %P e19269 %T Harnessing Phones to Target Pediatric Populations with Socially Complex Needs: Systematic Review %A Stiles-Shields,Colleen %A Potthoff,Lauren M %A Bounds,Dawn T %A Burns,Maureen T S %A Draxler,Janel M %A Otwell,Caitlin H %A Wolodiger,Emily D %A Westrick,Jennifer %A Karnik,Niranjan S %+ Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, 1645 W Jackson Blvd, Chicago, IL, 60612-3227, United States, 1 3129429998, colleen_stiles-shields@rush.edu %K underserved youth %K digital mental health %K mHealth %K telehealth %K health disparities %D 2020 %7 26.8.2020 %9 Review %J JMIR Pediatr Parent %G English %X Background: Mobile and smartphones are owned and accessed by many, making them a potentially optimal delivery mechanism to reach pediatric patients with socially complex needs (ie, pediatric populations who face overlapping adversities). Objective: To address the specialized needs of youth from such groups, this review synthesized the literature exploring the use of phone-based delivery to access pediatric populations with socially complex needs, targeting mental and behavioral health outcomes. The purpose of this synthesis was to provide recommendations for future research developing phone-based interventions for youth with socially complex needs. Methods: A trained medical librarian conducted the search strategy in the following databases: PubMed, Scopus, CINAHL, PsycINFO, Cochrane CENTRAL Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Studies targeting youth with socially complex needs were defined by recruiting samples that were primarily from traditionally underserved populations (ie, sex/gender minorities, racial/ethnic background, low socioeconomic status, rural/remote location, and sexual orientation). A systematic narrative framework was utilized and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed (registration number CRD42020141212). Results: A total of 14 studies met the inclusion criteria, with 3 depicting the use of phones to complete assessment and tracking goals and 11 to intervene on mental and behavioral health targets. Conclusions: The literature indicates important directions for future research, including (1) involving diverse and representative teens (ie, the likely users of the interventions), stakeholders, and clinical/research staff; (2) integrating evidence-based therapies with minority-focused theories; (3) harnessing mobile device capabilities; and (4) considering and assessing for potential costs in phones as delivery mechanisms. Trial Registration: PROSPERO CRD42020141212; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141212 %M 32845244 %R 10.2196/19269 %U http://pediatrics.jmir.org/2020/2/e19269/ %U https://doi.org/10.2196/19269 %U http://www.ncbi.nlm.nih.gov/pubmed/32845244 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 5 %N 1 %P e20921 %T Current Status and Future Challenges of Sleep Monitoring Systems: Systematic Review %A Pan,Qiang %A Brulin,Damien %A Campo,Eric %+ LAAS-CNRS, University of Toulouse, 7, avenue du Colonel Roche, Toulouse, 31400, France, 33 561 337 961, eric.campo@univ-tlse2.fr %K EEG %K ECG %K classification %K mobile phone %D 2020 %7 26.8.2020 %9 Review %J JMIR Biomed Eng %G English %X Background: Sleep is essential for human health. Considerable effort has been put into academic and industrial research and in the development of wireless body area networks for sleep monitoring in terms of nonintrusiveness, portability, and autonomy. With the help of rapid advances in smart sensing and communication technologies, various sleep monitoring systems (hereafter, sleep monitoring systems) have been developed with advantages such as being low cost, accessible, discreet, contactless, unmanned, and suitable for long-term monitoring. Objective: This paper aims to review current research in sleep monitoring to serve as a reference for researchers and to provide insights for future work. Specific selection criteria were chosen to include articles in which sleep monitoring systems or devices are covered. Methods: This review investigates the use of various common sensors in the hardware implementation of current sleep monitoring systems as well as the types of parameters collected, their position in the body, the possible description of sleep phases, and the advantages and drawbacks. In addition, the data processing algorithms and software used in different studies on sleep monitoring systems and their results are presented. This review was not only limited to the study of laboratory research but also investigated the various popular commercial products available for sleep monitoring, presenting their characteristics, advantages, and disadvantages. In particular, we categorized existing research on sleep monitoring systems based on how the sensor is used, including the number and type of sensors, and the preferred position in the body. In addition to focusing on a specific system, issues concerning sleep monitoring systems such as privacy, economic, and social impact are also included. Finally, we presented an original sleep monitoring system solution developed in our laboratory. Results: By retrieving a large number of articles and abstracts, we found that hotspot techniques such as big data, machine learning, artificial intelligence, and data mining have not been widely applied to the sleep monitoring research area. Accelerometers are the most commonly used sensor in sleep monitoring systems. Most commercial sleep monitoring products cannot provide performance evaluation based on gold standard polysomnography. Conclusions: Combining hotspot techniques such as big data, machine learning, artificial intelligence, and data mining with sleep monitoring may be a promising research approach and will attract more researchers in the future. Balancing user acceptance and monitoring performance is the biggest challenge in sleep monitoring system research. %R 10.2196/20921 %U http://biomedeng.jmir.org/2020/1/e20921/ %U https://doi.org/10.2196/20921 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e13637 %T Recruiting Student Health Coaches to Improve Digital Blood Pressure Management: Randomized Controlled Pilot Study %A Vasti,Elena %A Pletcher,Mark J %+ University of California, San Francisco School of Medicine, Stanford Internal Medicine Residency, 300 N Pasteur Dr s101, Stanford, CA, 94305, United States, 1 2094703263, ecvasti@stanford.edu %K mobile health %K hypertension %K coaching %K health-related behavior %K mobile phone %D 2020 %7 25.8.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Hypertension is a significant problem in the United States, affecting 1 in 3 adults aged above 18 years and is associated with a higher risk for cardiovascular disease and stroke. The prevalence of hypertension has increased in medically underserved areas (MUAs). Mobile health technologies, such as digital self-monitoring devices, have been shown to improve the management of chronic health conditions. However, patients from MUAs have reduced access to these devices because of limited resources and low health literacy. Health coaches and peer training programs are a potentially cost-effective solution for the shortage of physicians available to manage hypertension in MUAs. Activating young people as student health coaches (SHCs) is a promising strategy to improve community health. Objective: This pilot study aims to assess (1) the feasibility of training high school students as health technology coaches in MUAs and (2) whether the addition of SHCs to digital home monitoring improves the frequency of self-monitoring and overall blood pressure (BP) control. Methods: In total, 15 high school students completed 3-day health coach training. Patients who had a documented diagnosis of hypertension were randomly assigned to 1 of the 3 intervention arms. The QardioArm alone (Q) group was provided a QardioArm cuff only for convenience. The SHC alone (S) group was instructed to meet with a health coach for 30 min once a week for 5 weeks to create action plans for reducing BP. The student+QardioArm (S+Q) group received both interventions. Results: Participants (n=27) were randomly assigned to 3 groups in a ratio of 9:9:9. All 15 students completed training, of which 40% (6/15) of students completed all the 5 meetings with their assigned patient. Barriers to feasibility included transportation and patient response drop-off at the end of the study. Overall, 92% (11/12) of the students rated their experience as very good or higher and 69% (9/13) reported that this experience made them more likely to go into the medical field. There was a statistically significant difference in the frequency of cuff use (S+Q vs Q groups: 37 vs 17; P<.001). Participants in the S+Q group reported better BP control after the intervention compared with the other groups. The average BP at the end of the intervention was 145/84 (SD 9/18) mm Hg, 150/85 (SD 18/12) mm Hg, and 128/69 (SD 20/14) mm Hg in the Q, S, and S+Q groups, respectively. Conclusions: This pilot study demonstrates the feasibility of pairing technology with young student coaches, although challenges existed. The S+Q group used their cuff more than the Q group. Patients were more engaged in the S+Q group, reporting higher satisfaction with their SHC and better control of their BP. %M 32840489 %R 10.2196/13637 %U https://formative.jmir.org/2020/8/e13637 %U https://doi.org/10.2196/13637 %U http://www.ncbi.nlm.nih.gov/pubmed/32840489 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e17755 %T Mobile App Use for Insomnia Self-Management in Urban Community-Dwelling Older Korean Adults: Retrospective Intervention Study %A Chung,Kyungmi %A Kim,Seoyoung %A Lee,Eun %A Park,Jin Young %+ Department of Psychiatry, Yonsei University College of Medicine, Yongin Severance Hospital, Yonsei University Health System, Department of Psychiatry, Yongin Severance Hospital, 363, Dongbaekjukjeon-daero, Giheung-gu, Yongin, 16995, Republic of Korea, 82 2 2228 0972, empathy@yuhs.ac %K sleep hygiene %K cognitive behavioral therapy %K sleep initiation and maintenance disorders %K telemedicine %K mobile apps %K treatment adherence and compliance %K health education %K health services for the aged %K community mental health services %K health care quality, access, and evaluation %D 2020 %7 24.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: As an evidence-based psychotherapy for treating insomnia, cognitive behavioral therapy for insomnia (CBT-I), which helps people with sleep problems to change their unhelpful sleep-related beliefs and habits, has been well-established in older adults. Recently, the utilization of mobile CBT-I apps has been getting attention from mental health professionals and researchers; however, whether mobile CBT-I apps are usable among older users has yet to be determined. Objective: The aims of this study were to explore the relationships between subjective sleep quality and subjective memory complaints and depressive symptoms; to explore the relationship between perceived difficulty in mobile app use and usability of the mobile phone–based self-help CBT-I app, named MIND MORE, in urban community-dwelling Korean older adults; to compare changes in subjective sleep quality from pre-intervention to post-intervention, during which they used the mobile app over a 1-week intervention period; and evaluate adherence to the app. Methods: During the 2-hour training program delivered on 1 day titled “Overcoming insomnia without medication: How to use the ‘MIND MORE’ mobile app for systematic self-management of insomnia” (pre-intervention), 41 attendants were asked to gain hands-on experience with the app facilitated by therapists and volunteer workers. They were then asked to complete questionnaires on sociodemographic characteristics, subjective evaluation of mental health status (ie, depression, memory loss and impairment, and sleep problems), and app usability. For the 1-week home-based self-help CBT-I using the app (post-intervention), 9 of the 41 program attendants, who had already signed up for the pre-intervention, were guided to complete the given questionnaires on subjective evaluation of sleep quality after the 1-week intervention, specifically 8 days after the training program ended. Results: Due to missing data, 40 of 41 attendants were included in the data analysis. The main findings of this study were as follows. First, poor subjective sleep quality was associated with higher ratings of depressive symptoms (40/40; ρ=.60, P<.001) and memory complaints (40/40; ρ=.46, P=.003) at baseline. Second, significant improvements in subjective sleep quality from pre-intervention to post-intervention were observed in the older adults who used the MIND MORE app only for the 1-week intervention period (9/9; t8=3.74, P=.006). Third, apart from the program attendants who did not have a smartphone (2/40) or withdrew from their MIND MORE membership (3/40), those who attended the 1-day sleep education program adhered to the app from at least 2 weeks (13/35, 37%) to 8 weeks (2/35, 6%) without any further contact. Conclusions: This study provides empirical evidence that the newly developed MIND MORE app not only is usable among older users but also could improve subjective sleep quality after a 1-week self-help intervention period. %M 32831177 %R 10.2196/17755 %U http://mhealth.jmir.org/2020/8/e17755/ %U https://doi.org/10.2196/17755 %U http://www.ncbi.nlm.nih.gov/pubmed/32831177 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e18583 %T A Mobile Health Intervention for Adolescents Exposed to Secondhand Smoke: Pilot Feasibility and Efficacy Study %A Nardone,Natalie %A Giberson,Jeremy %A Prochaska,Judith J %A Jain,Shonul %A Benowitz,Neal L %+ Clinical Pharmacology Research Program, Division of Cardiology, Department of Medicine, University of California, Building 30, Room 3316, 1001 Potrero Ave, San Francisco, CA, 94110, United States, 1 628 206 8324, neal.benowitz@ucsf.edu %K secondhand smoke %K adolescents %K cotinine %K mHealth %K intervention %D 2020 %7 19.8.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Secondhand smoke (SHS) exposure in children and adolescents has adverse health effects. For adolescents of lower socioeconomic status (SES), exposure is widespread, evidenced in the measurement of urinary cotinine, a major metabolite of nicotine. Direct intervention with exposed children has been proposed as a novel method, yet there is minimal evidence of its efficacy. Combining this approach with a mobile health (mHealth) intervention may be more time and cost-effective and feasible for adolescent populations. Objective: In this pilot study, we assessed the feasibility and preliminary evidence of efficacy of a 30-day text message–based mHealth intervention targeted at reducing SHS exposure in adolescent populations of low SES. Methods: For the study, 14 nonsmoking and nonvaping participants between the ages of 12-21 years exposed to SHS were enrolled. The intervention consisted of a daily text message sent to the participants over the course of a month. Text message types included facts and information about SHS, behavioral methods for SHS avoidance, or true-or-false questions. Participants were asked to respond to each message within 24 hours as confirmation of receipt. Feasibility outcomes included completion of the 30-day intervention, receiving and responding to text messages, and feedback on the messages. Efficacy outcomes included a reduction in urinary cotinine, accuracy of true-or-false responses, and participants’ perceptions of effectiveness. Results: Of the 14 participants that were enrolled, 13 completed the intervention. Though not required, all participants had their own cell phones with unlimited text messaging plans. Of the total number of text messages sent to the 13 completers, 91% (372/407) of them received on-time responses. Participant feedback was generally positive, with most requesting more informational and true-or-false questions. In terms of efficacy, 54% (6/11) of participants reduced their cotinine levels (however, change for the group overall was not statistically significant (P=.33) and 45% (5/11) of participants increased their cotinine levels. Of the total number of true-or-false questions sent across all completers, 77% (56/73) were answered correctly. Participants’ ratings of message effectiveness averaged 85 on a scale of 100. Conclusions: In this pilot study, the intervention was feasible as the majority of participants had access to a cell phone, completed the study, and engaged by responding to the messages. The efficacy of the study requires further replication, as only half of the participants reduced their cotinine levels. However, participants answered the majority of true-or-false questions accurately and reported that the messages were helpful. %M 32812888 %R 10.2196/18583 %U http://formative.jmir.org/2020/8/e18583/ %U https://doi.org/10.2196/18583 %U http://www.ncbi.nlm.nih.gov/pubmed/32812888 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e21278 %T Personalized Approach Bias Modification Smartphone App (“SWIPE”) to Reduce Alcohol Use Among People Drinking at Hazardous or Harmful Levels: Protocol for an Open-Label Feasibility Study %A Manning,Victoria %A Piercy,Hugh %A Garfield,Joshua Benjamin Bernard %A Lubman,Dan Ian %+ Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Turning Point, 110 Church Street, Richmond, Victoria, 3121, Australia, 61 3 8413 8724, victoria.manning@monash.edu %K alcohol %K hazardous alcohol use %K alcohol use disorder %K approach bias modification %K cognitive bias modification %K smartphone app %K eHealth %K mobile phone app %K mHealth %K digital health %D 2020 %7 14.8.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Alcohol accounts for 5.1% of the global burden of disease and injury, and approximately 1 in 10 people worldwide develop an alcohol use disorder. Approach bias modification (ABM) is a computerized cognitive training intervention in which patients are trained to “avoid” alcohol-related images and “approach” neutral or positive images. ABM has been shown to reduce alcohol relapse rates when delivered in residential settings (eg, withdrawal management or rehabilitation). However, many people who drink at hazardous or harmful levels do not require residential treatment or choose not to access it (eg, owing to its cost, duration, inconvenience, or concerns about privacy). Smartphone app–delivered ABM could offer a free, convenient intervention to reduce cravings and consumption that is accessible regardless of time and place, and during periods when support is most needed. Importantly, an ABM app could also easily be personalized (eg, allowing participants to select personally relevant images as training stimuli) and gamified (eg, by rewarding participants for the speed and accuracy of responses) to encourage engagement and training completion. Objective: We aim to test the feasibility and acceptability of “SWIPE,” a gamified, personalized alcohol ABM smartphone app, assess its preliminary effectiveness, and explore in which populations the app shows the strongest indicators of effectiveness. Methods: We aim to recruit 500 people who drink alcohol at hazardous or harmful levels (Alcohol Use Disorders Identification Test score≥8) and who wish to reduce their drinking. Recruitment will be conducted through social media and websites. The participants’ intended alcohol use goal (reduction or abstinence), motivation to change their consumption, and confidence to change their consumption will be measured prior to training. Participants will be instructed to download the SWIPE app and complete at least 2 ABM sessions per week for 4 weeks. Recruitment and completion rates will be used to assess feasibility. Four weeks after downloading SWIPE, participants will be asked to rate SWIPE’s functionality, esthetics, and quality to assess acceptability. Alcohol consumption, craving, and dependence will be measured prior to commencing the first session of ABM and 4 weeks later to assess whether these variables change significantly over the course of ABM. Results: We expect to commence recruitment in August 2020 and complete data collection in March 2021. Conclusions: This will be the first study to test the feasibility, acceptability, and preliminary effectiveness of a personalized, gamified ABM intervention smartphone app for hazardous or harmful drinkers. Results will inform further improvements to the app, as well as the design of a statistically powered randomized controlled trial to test its efficacy relative to a control condition. Ultimately, we hope that SWIPE will extend the benefits of ABM to the millions of individuals who consume alcohol at hazardous levels and wish to reduce their use but cannot or choose not to access treatment. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000638932p; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000638932p International Registered Report Identifier (IRRID): PRR1-10.2196/21278 %M 32795989 %R 10.2196/21278 %U http://www.researchprotocols.org/2020/8/e21278/ %U https://doi.org/10.2196/21278 %U http://www.ncbi.nlm.nih.gov/pubmed/32795989 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e19624 %T App Technology to Support Physical Activity and Intake of Vitamins and Minerals After Bariatric Surgery (the PromMera Study): Protocol of a Randomized Controlled Clinical Trial %A Bonn,Stephanie Erika %A Hult,Mari %A Spetz,Kristina %A Löf,Marie %A Andersson,Ellen %A Wiren,Mikael %A Trolle Lagerros,Ylva %+ Clinical Epidemiology Division, Department of Medicine (Solna), Karolinska Institutet, Karolinska University Hospital, KEP T2:02, Stockholm, 171 76, Sweden, 46 851779173, stephanie.bonn@ki.se %K adults %K body composition %K exercise %K metabolic health %K obesity %K randomized controlled trial %K smartphones %K vitamin intake %K mobile phone %D 2020 %7 14.8.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: To optimize postoperative outcomes after bariatric surgery, lifestyle changes including increased physical activity are needed. Micronutrient deficiency after surgery is also common and daily supplementation is recommended. Objective: The aim of the PromMera study is to evaluate the effects of a 12-week smartphone app intervention on promotion of physical activity (primary outcome) and adherence to postsurgery vitamin and mineral supplementation, as well as on other lifestyle factors and overall health in patients undergoing bariatric surgery. Methods: The PromMera study is a two-arm, randomized controlled trial comprising patients undergoing bariatric surgery. Participants are randomized postsurgery 1:1 to either the intervention group (ie, use of the PromMera app for 12 weeks) or the control group receiving only standard care. Clinical and lifestyle variables are assessed pre- and postsurgery after 18 weeks (postintervention assessment), 6 months, 1 year, and 2 years. Assessments include body composition using Tanita or BOD POD analyzers, muscle function using handgrip, biomarkers in blood, and an extensive questionnaire on lifestyle factors. Physical activity is objectively measured using the ActiGraph wGT3X-BT triaxial accelerometer. Results: A total of 154 participants have been enrolled in the study. The last study participant was recruited in May 2019. Data collection will be complete in May 2021. Conclusions: Implementing lifestyle changes are crucial after bariatric surgery and new ways to reach patients and support such changes are needed. An app-based intervention is easily delivered at any time and can be a key factor in the adoption of healthier behavioral patterns in this rapidly growing group of patients. Trial Registration: ClinicalTrials.gov NCT03480464; https://clinicaltrials.gov/ct2/show/NCT03480464 International Registered Report Identifier (IRRID): DERR1-10.2196/19624 %M 32795990 %R 10.2196/19624 %U http://www.researchprotocols.org/2020/8/e19624/ %U https://doi.org/10.2196/19624 %U http://www.ncbi.nlm.nih.gov/pubmed/32795990 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17521 %T Understanding Time Series Patterns of Weight and Meal History Reports in Mobile Weight Loss Intervention Programs: Data-Driven Analysis %A Kim,Junetae %A Kam,Hye Jin %A Kim,Youngin %A Lee,Yura %A Lee,Jae-Ho %+ Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea, 82 3010 3350, rufiji@gmail.com %K weight loss %K self-reporting %K adherence %K mobile weight loss intervention %K diet %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mobile apps for weight loss provide users with convenient features for recording lifestyle and health indicators; they have been widely used for weight loss recently. Previous studies in this field generally focused on the relationship between the cumulative nature of self-reported data and the results in weight loss at the end of the diet period. Therefore, we conducted an in-depth study to explore the relationships between adherence to self-reporting and weight loss outcomes during the weight reduction process. Objective: We explored the relationship between adherence to self-reporting and weight loss outcomes during the time series weight reduction process with the following 3 research questions: “How does adherence to self-reporting of body weight and meal history change over time?”, “How do weight loss outcomes depend on weight changes over time?”, and “How does adherence to the weight loss intervention change over time by gender?” Methods: We analyzed self-reported data collected weekly for 16 weeks (January 2017 to March 2018) from 684 Korean men and women who participated in a mobile weight loss intervention program provided by a mobile diet app called Noom. Analysis of variance (ANOVA) and chi-squared tests were employed to determine whether the baseline characteristics among the groups of weight loss results were different. Based on the ANOVA results and slope analysis of the trend indicating participant behavior along the time axis, we explored the relationship between adherence to self-reporting and weight loss results. Results: Adherence to self-reporting levels decreased over time, as previous studies have found. BMI change patterns (ie, absolute BMI values and change in BMI values within a week) changed over time and were characterized in 3 time series periods. The relationships between the weight loss outcome and both meal history and self-reporting patterns were gender-dependent. There was no statistical association between adherence to self-reporting and weight loss outcomes in the male participants. Conclusions: Although mobile technology has increased the convenience of self-reporting when dieting, it should be noted that technology itself is not the essence of weight loss. The in-depth understanding of the relationship between adherence to self-reporting and weight loss outcome found in this study may contribute to the development of better weight loss interventions in mobile environments. %M 32780028 %R 10.2196/17521 %U https://www.jmir.org/2020/8/e17521 %U https://doi.org/10.2196/17521 %U http://www.ncbi.nlm.nih.gov/pubmed/32780028 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e15506 %T Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study %A Betthauser,Lisa M %A Stearns-Yoder,Kelly A %A McGarity,Suzanne %A Smith,Victoria %A Place,Skyler %A Brenner,Lisa A %+ Veterans Affairs, Rocky Mountain Mental Illness Research Education and Clinical Center, 1700 N Wheeling St, Aurora, CO, 80045, United States, 1 720 723 4867, lisa.betthauser@va.gov %K veterans %K mobile app %K smartphone %K mental health %K acceptability %K feasibility %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. Objective: Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. Methods: A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. Results: Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire–8, 79% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6%) reported concerns regarding personal privacy. Conclusions: Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide. %M 32779572 %R 10.2196/15506 %U https://www.jmir.org/2020/8/e15506 %U https://doi.org/10.2196/15506 %U http://www.ncbi.nlm.nih.gov/pubmed/32779572 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e16696 %T Effects of a Novel Contextual Just-In-Time Mobile App Intervention (LowSalt4Life) on Sodium Intake in Adults With Hypertension: Pilot Randomized Controlled Trial %A Dorsch,Michael P %A Cornellier,Maria L %A Poggi,Armella D %A Bilgen,Feriha %A Chen,Peiyu %A Wu,Cindy %A An,Lawrence C %A Hummel,Scott L %+ University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI, 48109, United States, 1 734 647 1452, mdorsch@med.umich.edu %K hypertension %K sodium intake %K geofencing %K mHealth %D 2020 %7 10.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: High dietary sodium intake is a significant public health problem in the United States. High sodium consumption is associated with high blood pressure and high risk of cardiovascular disease. Objective: The aim of this study was to evaluate the effect of a just-in-time adaptive mobile app intervention, namely, LowSalt4Life, on reducing sodium intake in adults with hypertension. Methods: In this study, 50 participants aged ≥18 years who were under treatment for hypertension were randomized (1:1, stratified by gender) into 2 groups, namely, the App group (LowSalt4Life intervention) and the No App group (usual dietary advice) in a single-center, prospective, open-label randomized controlled trial for 8 weeks. The primary endpoint was the change in the 24-hour urinary sodium excretion estimated from spot urine by using the Kawasaki equation, which was analyzed using unpaired two-sided t tests. Secondary outcomes included the change in the sodium intake measured by the food frequency questionnaire (FFQ), the 24-hour urinary sodium excretion, blood pressure levels, and the self-reported confidence in following a low-sodium diet. Results: From baseline to week 8, there was a significant reduction in the Kawasaki-estimated 24-hour urinary sodium excretion calculated from spot urine in the App group compared to that in the No App group (–462 [SD 1220] mg vs 381 [SD 1460] mg, respectively; P=.03). The change in the 24-hour urinary sodium excretion was –637 (SD 1524) mg in the App group and –322 (SD 1485) mg in the No App group (P=.47). The changes in the estimated sodium intake as measured by 24-hour dietary recall and by FFQ in the App group were –1537 (SD 2693) mg and –1553 (SD 1764) mg while those in the No App group were –233 (SD 2150) mg and –515 (SD 1081) mg, respectively (P=.07 and P=.01, respectively). The systolic blood pressure change from baseline to week 8 in the App group was –7.5 mmHg while that in the No App group was –0.7 mmHg (P=.12), but the self-confidence in following a low-sodium diet was not significantly different between the 2 groups. Conclusions: This study shows that a contextual just-in-time mobile app intervention resulted in a greater reduction in the dietary sodium intake in adults with hypertension than that in the control group over a 8-week period, as measured by the estimated 24-hour urinary sodium excretion from spot urine and FFQ. The intervention group did not show a significant difference from the control group in the self-confidence in following a low sodium diet and in the 24-hour urinary sodium excretion or dietary intake of sodium as measured by the 24-hour dietary recall. A larger clinical trial is warranted to further elucidate the effects of the LowSalt4Life intervention on sodium intake and blood pressure levels in adults with hypertension. Trial Registration: ClinicalTrials.gov NCT03099343; https://clinicaltrials.gov/ct2/show/NCT03099343 International Registered Report Identifier (IRRID): RR2-10.2196/11282 %M 32663139 %R 10.2196/16696 %U http://mhealth.jmir.org/2020/8/e16696/ %U https://doi.org/10.2196/16696 %U http://www.ncbi.nlm.nih.gov/pubmed/32663139 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e16797 %T Examining Responsiveness to an Incentive-Based Mobile Health App: Longitudinal Observational Study %A Brower,Jacob %A LaBarge,Monica C %A White,Lauren %A Mitchell,Marc S %+ Smith School of Business, Queen's University, 805 Johnson St, Kingston, ON, K7L2B6, Canada, 1 6132174726, jbrower@queensu.ca %K mHealth %K behavioral economics %K public health %K incentives %K mobile apps %K mobile phone %D 2020 %7 10.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The Carrot Rewards app was developed as part of a public-private partnership to reward Canadians with loyalty points for downloading the app, referring friends, completing educational health quizzes, and health-related behaviors with long-term objectives of increasing health knowledge and encouraging healthy behaviors. During the first 3 months after program rollout in British Columbia, a number of program design elements were adjusted, creating observed differences between groups of users with respect to the potential impact of program features on user engagement levels. Objective: This study examines the impact of reducing reward size over time and explored the influence of other program features such as quiz timing, health intervention content, and type of reward program on user engagement with a mobile health (mHealth) app. Methods: Participants in this longitudinal, nonexperimental observational study included British Columbia citizens who downloaded the app between March and July 2016. A regression methodology was used to examine the impact of changes to several program design features on quiz offer acceptance and engagement with this mHealth app. Results: Our results, based on the longitudinal app use of 54,917 users (mean age 35, SD 13.2 years; 65.03% [35,647/54,917] female), indicated that the key drivers of the likelihood of continued user engagement, in order of greatest to least impact, were (1) type of rewards earned by users (eg, movies [+355%; P<.001], air travel [+210%; P<.001], and grocery [+140%; P<.001] relative to gas), (2) time delay between early offers (−64%; P<.001), (3) the content of the health intervention (eg, healthy eating [−10%; P<.001] vs exercise [+20%, P<.001] relative to health risk assessments), and (4) changes in the number of points offered. Our results demonstrate that reducing the number of points associated with a particular quiz by 10% only led to a 1% decrease in the likelihood of offer response (P<.001) and that each of the other design features had larger impacts on participant retention than did changes in the number of points. Conclusions: The results of this study demonstrate that this program, built around the principles of behavioral economics in the form of the ongoing awarding of a small number of reward points instantly following the completion of health interventions, was able to drive significantly higher engagement levels than those demonstrated in previous literature exploring the intersection of mHealth apps and financial incentives. Previous studies have demonstrated the presence of incentive matters to user engagement; however, our results indicate that the number of points offered for these reward point–based health interventions is less important than other program design features such as the type of reward points being offered, the timing of intervention and reward offers, and the content of the health interventions in driving continued engagement by users. %M 32773371 %R 10.2196/16797 %U https://www.jmir.org/2020/8/e16797 %U https://doi.org/10.2196/16797 %U http://www.ncbi.nlm.nih.gov/pubmed/32773371 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e16239 %T #BlackBreastsMatter: Process Evaluation of Recruitment and Engagement of Pregnant African American Women for a Social Media Intervention Study to Increase Breastfeeding %A Dauphin,Cassy %A Clark,Nikia %A Cadzow,Renee %A Saad-Harfouche,Frances %A Rodriguez,Elisa %A Glaser,Kathryn %A Kiviniemi,Marc %A Keller,Maria %A Erwin,Deborah %+ Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, 14263, United States, 1 716 845 2927, deborah.erwin@roswellpark.org %K breastfeeding %K breast cancer education %K African American mothers %K Facebook %K mobile phone, social media %D 2020 %7 10.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In the United States, there are lower rates of breastfeeding among African American mothers, particularly those who are younger women. Recent epidemiological studies have shown a strong association of more aggressive types of breast cancer (estrogen receptor negative) among African American women, with a higher risk in African American women who did not breastfeed their children. Objective: This study aims to describe the process evaluation of recruitment and educational strategies to engage pregnant African American participants for a pilot study designed to determine whether social media messaging about breast cancer risk reduction through breastfeeding may positively influence breastfeeding rates. Methods: This pilot study is conducted in collaboration with a local Women, Infants, and Children (WIC) organization and hospital and prenatal clinics of a local health care network. To engage African American women to enroll in the study, several methods and monitoring processes were explored, including WIC electronic text-based messages sent out to all phones of current WIC recipients (referred to as e-blasts); keyword responses to texts from flyers and posters in local community-based organizations, hospitals, and prenatal clinics; keyword responses using electronic links posted in established Facebook groups; and snowball recruitment of other pregnant women by current participants through Facebook. Once enrolled, participants were randomized to 2 study conditions: (1) an intervention group receiving messages about breast cancer risk reduction and breastfeeding or (2) a control group receiving breastfeeding-only messages. Data were obtained through electronic monitoring, SurveyMonkey, qualitative responses on Facebook, focus groups, and interviews. Results: More than 3000 text messages were sent and received through WIC e-blasts and keyword responses from flyers. A total of 472 women were recruited through WIC e-blast, and 161 responded to flyers and contacts through the local health care network, community-based organizations, Facebook, and friend referrals. A total of 633 women were assessed for eligibility to participate in the study. A total of 288 pregnant African American women were enrolled, consented, and completed presurvey assessments (102.8% of the goal), and 22 participants attended focus groups or interviews reporting on their experiences with Facebook and the educational messages. Conclusions: This process evaluation suggests that using electronic, smartphone apps with social media holds promise for both recruitment and conduct of health education intervention studies for pregnant African American women. Providing messaging and resources through social media to reinforce and educate women about breastfeeding and potentially provide lactation support is intriguing. Convenience (for researchers and participants) is an attribute of social media for this demographic of women and worthy of further research as an educational tool. Trial Registration: ClinicalTrials.gov NCT03680235; https://clinicaltrials.gov/ct2/show/NCT03680235 %M 32773377 %R 10.2196/16239 %U https://www.jmir.org/2020/8/e16239 %U https://doi.org/10.2196/16239 %U http://www.ncbi.nlm.nih.gov/pubmed/32773377 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 8 %P e18347 %T Perceptions and Attitudes Toward a Mobile Phone App for Mental Health for College Students: Qualitative Focus Group Study %A Holtz,Bree E %A McCarroll,Alexis M %A Mitchell,Katharine M %+ Michigan State University, 404 Wilson Road, Room 309, East Lansing, MI, United States, 1 5178844537, bholtz@msu.edu %K mental health %K mobile phone %K mHealth %D 2020 %7 7.8.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Many college students who have mental health issues do not receive professional care for various reasons. Students who do not receive help often have both short- and long-term adverse health outcomes. Mobile apps for mental health services such as MySSP, a service provided to college students through their university, may help eliminate barriers to seeking mental health care and result in more positive outcomes for college students. Objective: This qualitative study aims to better understand college students’ perceptions and attitudes toward the adoption and use of a mobile phone app for mental health, MySSP, using the technology acceptance model (TAM). Methods: A series of nine focus groups were conducted with college students (N=30) between February and May 2019 at a large, public Midwestern university. The moderator’s guide was based on the TAM, and focus group sessions primarily focused on the use and knowledge of apps for mental health, specifically, MySSP. The focus group transcriptions were hand-coded to develop a set of themes that encompassed students’ perceptions and attitudes toward MySSP. Results: The analysis of the focus groups suggested the following themes: (1) existing awareness of the app, (2) perceived usefulness, (3) perceived ease of use, (4) attitudes toward apps for mental health and MySSP, and (5) social influence. Conclusions: The results of this study provide deeper insights into the perceptions of a mobile app for mental health among college students. Future research should explore the specific contexts in which an app for mental health will be most effective for college students. %M 32667892 %R 10.2196/18347 %U https://formative.jmir.org/2020/8/e18347 %U https://doi.org/10.2196/18347 %U http://www.ncbi.nlm.nih.gov/pubmed/32667892 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e20596 %T Mobile Health Apps That Help With COVID-19 Management: Scoping Review %A John Leon Singh,Hanson %A Couch,Danielle %A Yap,Kevin %+ Department of Public Health, School of Psychology and Public Health, La Trobe University, Health Sciences 2 Building, Melbourne, 3086, Australia, 61 3 9479 6068, kevinyap.ehealth@gmail.com %K COVID-19 %K mobile apps %K mHealth %K contact tracing %K symptom monitoring %K information provision %K mobile health %D 2020 %7 6.8.2020 %9 Review %J JMIR Nursing %G English %X Background: Mobile health (mHealth) apps have played an important role in mitigating the coronavirus disease (COVID-19) response. However, there is no resource that provides a holistic picture of the available mHealth apps that have been developed to combat this pandemic. Objective: Our aim is to scope the evidence base on apps that were developed in response to COVID-19. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews, literature searches were conducted on Google Search, Google Scholar, and PubMed using the country’s name as keywords and “coronavirus,” “COVID-19,” “nCOV19,” “contact tracing,” “information providing apps,” “symptom tracking,” “mobile apps,” “mobile applications,” “smartphone,” “mobile phone,” and “mHealth.” Countries most affected by COVID-19 and those that first rolled out COVID-19–related apps were included. Results: A total of 46 articles were reviewed from 19 countries, resulting in a total of 29 apps. Among them, 15 (52%) apps were on contact tracing, 7 (24%) apps on quarantine, 7 (24%) on symptom monitoring, and 1 (3%) on information provision. More than half (n=20, 69%) were from governmental sources, only 3 (10%) were from private organizations, and 3 (10%) from universities. There were 6 (21%) apps available on either Android or iOS, and 10 (34%) were available on both platforms. Bluetooth was used in 10 (34%) apps for collecting data, 12 (41%) apps used GPS, and 12 (41%) used other forms of data collection. Conclusions: This review identifies that the majority of COVID-19 apps were for contact tracing and symptom monitoring. However, these apps are effective only if taken up by the community. The sharing of good practices across different countries can enable governments to learn from each other and develop effective strategies to combat and manage this pandemic. %M 32897271 %R 10.2196/20596 %U https://nursing.jmir.org/2020/1/e20596/ %U https://doi.org/10.2196/20596 %U http://www.ncbi.nlm.nih.gov/pubmed/32897271 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e18370 %T Wearable Device Heart Rate and Activity Data in an Unsupervised Approach to Personalized Sleep Monitoring: Algorithm Validation %A Liu,Jiaxing %A Zhao,Yang %A Lai,Boya %A Wang,Hailiang %A Tsui,Kwok Leung %+ Centre for Systems Informatics Engineering, City University of Hong Kong, Tat Chee Avenue, Kowloon, 999077, China (Hong Kong), 852 34425792, yang.zhao@my.cityu.edu.hk %K sleep/wake identification %K hidden Markov model %K personalized health %K unsupervised learning %K sleep %K physical activity %K wearables %K heart rate %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The proliferation of wearable devices that collect activity and heart rate data has facilitated new ways to measure sleeping and waking durations unobtrusively and longitudinally. Most existing sleep/wake identification algorithms are based on activity only and are trained on expensive and laboriously annotated polysomnography (PSG). Heart rate can also be reflective of sleep/wake transitions, which has motivated its investigation herein in an unsupervised algorithm. Moreover, it is necessary to develop a personalized approach to deal with interindividual variance in sleep/wake patterns. Objective: We aimed to develop an unsupervised personalized sleep/wake identification algorithm using multifaceted data to explore the benefits of incorporating both heart rate and activity level in these types of algorithms and to compare this approach’s output with that of an existing commercial wearable device’s algorithms. Methods: In this study, a total of 14 community-dwelling older adults wore wearable devices (Fitbit Alta; Fitbit Inc) 24 hours a day and 7 days a week over period of 3 months during which their heart rate and activity data were collected. After preprocessing the data, a model was developed to distinguish sleep/wake states based on each individual’s data. We proposed the use of hidden Markov models and compared different modeling schemes. With the best model selected, sleep/wake patterns were characterized by estimated parameters in hidden Markov models, and sleep/wake states were identified. Results: When applying our proposed algorithm on a daily basis, we found there were significant differences in estimated parameters between weekday models and weekend models for some participants. Conclusions: Our unsupervised approach can be effectively implemented based on an individual’s multifaceted sleep-related data from a commercial wearable device. A personalized model is shown to be necessary given the interindividual variability in estimated parameters. %M 32755887 %R 10.2196/18370 %U https://mhealth.jmir.org/2020/8/e18370 %U https://doi.org/10.2196/18370 %U http://www.ncbi.nlm.nih.gov/pubmed/32755887 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e17699 %T Using Smart Bracelets to Assess Heart Rate Among Students During Physical Education Lessons: Feasibility, Reliability, and Validity Study %A Sun,Jiangang %A Liu,Yang %+ School of Physical Education and Sport Training, Shanghai University of Sport, 650 Qingyuanhuan Rd, Shanghai, 200438, China, 86 21 6550 7989, docliuyang@hotmail.com %K physical education %K heart rate %K validation %K feasibility %K reliability %K Fizzo %K Polar %K wrist-worn devices %K physical education lesson %K monitoring %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: An increasing number of wrist-worn wearables are being examined in the context of health care. However, studies of their use during physical education (PE) lessons remain scarce. Objective: We aim to examine the reliability and validity of the Fizzo Smart Bracelet (Fizzo) in measuring heart rate (HR) in the laboratory and during PE lessons. Methods: In Study 1, 11 healthy subjects (median age 22.0 years, IQR 3.75 years) twice completed a test that involved running on a treadmill at 6 km/h for 12 minutes and 12 km/h for 5 minutes. During the test, participants wore two Fizzo devices, one each on their left and right wrists, to measure their HR. At the same time, the Polar Team2 Pro (Polar), which is worn on the chest, was used as the standard. In Study 2, we went to 10 schools and measured the HR of 24 students (median age 14.0 years, IQR 2.0 years) during PE lessons. During the PE lessons, each student wore a Polar device on their chest and a Fizzo on their right wrist to measure HR data. At the end of the PE lessons, the students and their teachers completed a questionnaire where they assessed the feasibility of Fizzo. The measurements taken by the left wrist Fizzo and the right wrist Fizzo were compared to estimate reliability, while the Fizzo measurements were compared to the Polar measurements to estimate validity. To measure reliability, intraclass correlation coefficients (ICC), mean difference (MD), standard error of measurement (SEM), and mean absolute percentage errors (MAPE) were used. To measure validity, ICC, limits of agreement (LOA), and MAPE were calculated and Bland-Altman plots were constructed. Percentage values were used to estimate the feasibility of Fizzo. Results: The Fizzo showed excellent reliability and validity in the laboratory and moderate validity in a PE lesson setting. In Study 1, reliability was excellent (ICC>0.97; MD<0.7; SEM<0.56; MAPE<1.45%). The validity as determined by comparing the left wrist Fizzo and right wrist Fizzo was excellent (ICC>0.98; MAPE<1.85%). Bland-Altman plots showed a strong correlation between left wrist Fizzo measurements (bias=0.48, LOA=–3.94 to 4.89 beats per minute) and right wrist Fizzo measurements (bias=0.56, LOA=–4.60 to 5.72 beats per minute). In Study 2, the validity of the Fizzo was lower compared to that found in Study 1 but still moderate (ICC>0.70; MAPE<9.0%). The Fizzo showed broader LOA in the Bland-Altman plots during the PE lessons (bias=–2.60, LOA=–38.89 to 33.69 beats per minute). Most participants considered the Fizzo very comfortable and easy to put on. All teachers thought the Fizzo was helpful. Conclusions: When participants ran on a treadmill in the laboratory, both left and right wrist Fizzo measurements were accurate. The validity of the Fizzo was lower in PE lessons but still reached a moderate level. The Fizzo is feasible for use during PE lessons. %M 32663136 %R 10.2196/17699 %U http://mhealth.jmir.org/2020/8/e17699/ %U https://doi.org/10.2196/17699 %U http://www.ncbi.nlm.nih.gov/pubmed/32663136 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e19380 %T User Perception of a Smartphone App to Promote Physical Activity Through Active Transportation: Inductive Qualitative Content Analysis Within the Smart City Active Mobile Phone Intervention (SCAMPI) Study %A Lindqvist,Anna-Karin %A Rutberg,Stina %A Söderström,Emmie %A Ek,Anna %A Alexandrou,Christina %A Maddison,Ralph %A Löf,Marie %+ Division of Health, Medicine and Rehabilitation, Department of Health Sciences, Luleå University of Technology, Luleå, 971 87, Sweden, 46 0725390660, anna-karin.lindqvist@ltu.se %K behavior change %K smartphone intervention %K physical activity %K user perception %K active transportation %K mobile app %K inductive qualitative content analysis %K mobile health %K social cognitive theory %K mHealth %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Physical inactivity is globally recognized as a major risk factor for morbidity, particularly the incidence of noncommunicable diseases. Increasing physical activity (PA) is therefore a public health priority. Engaging in active transportation (AT) is a viable approach for promoting daily PA levels. Mobile health interventions enable the promotion of AT to a larger population. The Smart City Active Mobile Phone Intervention (SCAMPI) study was a randomized controlled trial designed to evaluate the ability of a behavior change program delivered via a smartphone app to motivate participants to increase their PA by engaging in AT. Objective: This qualitative study aims to examine the acceptance and user experience of the app promoting AT that was used in the SCAMPI trial (the TRavelVU Plus app). Methods: A total of 17 residents of Stockholm County (13 women; age range 25-61 years) who completed the 3-month app-based behavioral change program (delivered through the TRavelVU Plus app) in the SCAMPI randomized controlled trial during 2018 agreed to participate in a semistructured telephone-based interview. These participants were well representative of the whole intervention group (n=127) in terms of baseline characteristics such as age, sex, and area of residence. The interviews were audiorecorded, transcribed verbatim, and analyzed using an inductive qualitative content analysis. Results: The content analysis revealed 2 themes and 4 subcategories. The first theme, “main motivators: monitoring and messages,” highlighted that monitoring AT and being able to set weekly goals using the app were the primary motivators reported by study participants. The second theme, “acceptable but modifiable,” reflects that the app was well accepted and effectively encouraged many participants to use more AT. Nevertheless, there were functions in the app that require modification. For example, while the semiautomated travel tracking feature was appreciated, participants found it time-consuming and unreliable at times. Conclusions: This study contributes novel insight into adults’ experiences of using a mobile app to promote the use of AT. The results showed that the app was well accepted and that self-monitoring and goal setting were the main motivators to engage in more AT. The semiautomated tracking of AT was appreciated; however, it was also reported to be energy- and time-consuming when it failed to work. Thus, this feature should be improved going forward. Trial Registration: ClinicalTrials.gov NCT03086837; https://clinicaltrials.gov/ct2/show/NCT03086837 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-018-5658-4 %M 32755889 %R 10.2196/19380 %U https://mhealth.jmir.org/2020/8/e19380 %U https://doi.org/10.2196/19380 %U http://www.ncbi.nlm.nih.gov/pubmed/32755889 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e15156 %T Rams Have Heart, a Mobile App Tracking Activity and Fruit and Vegetable Consumption to Support the Cardiovascular Health of College Students: Development and Usability Study %A Krzyzanowski,Michelle C %A Kizakevich,Paul N %A Duren-Winfield,Vanessa %A Eckhoff,Randall %A Hampton,Joel %A Blackman Carr,Loneke T %A McCauley,Georgia %A Roberson,Kristina B %A Onsomu,Elijah O %A Williams,John %A Price,Amanda Alise %+ RTI International, 3040 Conwallis Rd, Research Triangle Park, NC, 27709, United States, 1 919 485 5648, mkrzyzanowski@rti.org %K exercise %K cardiovascular disease %K diary %K diet %K mHealth %K mobile phone %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With the increasing use of mobile devices to access the internet and as the main computing system of apps, there is a growing market for mobile health apps to provide self-care advice. Their effectiveness with regard to diet and fitness tracking, for example, needs to be examined. The majority of American adults fail to meet daily recommendations for healthy behavior. Testing user engagement with an app in a controlled environment can provide insight into what is effective and not effective in an app focused on improving diet and exercise. Objective: We developed Rams Have Heart, a mobile app, to support a cardiovascular disease (CVD) intervention course. The app tracks healthy behaviors, including fruit and vegetable consumption and physical activity, throughout the day. This paper aimed to present its functionality and evaluated adherence among the African American college student population. Methods: We developed the app using the Personal Health Informatics and Intervention Toolkit, a software framework. Rams Have Heart integrates self-reported health screening with health education, diary tracking, and user feedback modules to acquire data and assess progress. The parent study, conducted at a historically black college and university-designated institution in southeastern United States, consisted of a semester-long intervention administered as an academic course in the fall, for 3 consecutive years. Changes were made after the cohort 1 pilot study, so results only include cohorts 2 and 3, comprising a total of 115 students (n=55 intervention participants and n=54 control participants) aged from 17 to 24 years. Data collected over the study period were transferred using the secure Hypertext Transfer Protocol Secure protocol and stored in a secure Structured Query Language server database accessible only to authorized persons. SAS software was used to analyze the overall app usage and the specific results collected. Results: Of the 55 students in the intervention group, 27 (49%) students in cohort 2 and 25 (45%) in cohort 3 used the Rams Have Heart app at least once. Over the course of the fall semester, app participation dropped off gradually until exam week when most students no longer participated. The average fruit and vegetable intake increased slightly, and activity levels decreased over the study period. Conclusions: Rams Have Heart was developed to allow daily tracking of fruit and vegetable intake and physical activity to support a CVD risk intervention for a student demographic susceptible to obesity, heart disease, and type 2 diabetes. We conducted an analysis of app usage, function, and user results. Although a mobile app provides privacy and flexibility for user participation in a research study, Rams Have Heart did not improve compliance or user outcomes. Health-oriented research studies relying on apps in support of user goals need further evaluation. %M 32755883 %R 10.2196/15156 %U https://mhealth.jmir.org/2020/8/e15156 %U https://doi.org/10.2196/15156 %U http://www.ncbi.nlm.nih.gov/pubmed/32755883 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e19216 %T Effect of Adding Telephone-Based Brief Coaching to an mHealth App (Stay Strong) for Promoting Physical Activity Among Veterans: Randomized Controlled Trial %A Damschroder,Laura J %A Buis,Lorraine R %A McCant,Felicia A %A Kim,Hyungjin Myra %A Evans,Richard %A Oddone,Eugene Z %A Bastian,Lori A %A Hooks,Gwendolyn %A Kadri,Reema %A White-Clark,Courtney %A Richardson,Caroline R %A Gierisch,Jennifer M %+ Veterans Affairs Center for Clinical Management Research, Ann Arbor Healthcare System, 2215 Fuller Rd (152), Ann Arbor, MI, 48105, United States, 1 7348453603, laura.damschroder@va.gov %K exercise %K veterans %K smartphones %K wearable physical activity tracker %K behavior change %K mobile phone %K online %K app %K mobile app %K wearable %D 2020 %7 4.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone. Objective: The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching. Methods: Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation. Results: The average age of participants was 39.8 (SD 8.7) years, and 25.2% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0% (120/179) for Stay Strong and 61.8% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm. Conclusions: Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial’s 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up. Trial Registration: ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293 International Registered Report Identifier (IRRID): RR2-10.2196/12526 %M 32687474 %R 10.2196/19216 %U http://www.jmir.org/2020/8/e19216/ %U https://doi.org/10.2196/19216 %U http://www.ncbi.nlm.nih.gov/pubmed/32687474 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e15338 %T Monitoring Occupational Sitting, Standing, and Stepping in Office Employees With the W@W-App and the MetaWearC Sensor: Validation Study %A Bort-Roig,Judit %A Chirveches-Pérez,Emilia %A Garcia-Cuyàs,Francesc %A Dowd,Kieran P %A Puig-Ribera,Anna %+ Sport and Physical Activity Research Group, Centre for Health and Social Care Research, University of Vic-Central University of Catalonia, Miquel Martí i Pol, 1, Vic, 08500, Spain, 34 938863342, annam.puig@uvic.cat %K validity %K self-monitoring %K sedentary behavior %K physical activity %K smartphone %K mobile phone %K device-based measure %D 2020 %7 4.8.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Replacing occupational sitting time with active tasks has several proposed health benefits for office employees. Mobile phones and motion sensors can provide objective information in real time on occupational sitting behavior. However, the validity and feasibility of using mobile health (mHealth) devices to quantify and modify occupational sedentary time is unclear. Objective: The aim of this study is to validate the new Walk@Work-Application (W@W-App)—including an external motion sensor (MetaWearC) attached to the thigh—for measuring occupational sitting, standing, and stepping in free-living conditions against the activPAL3M, the current gold-standard, device-based measure for postural behaviors. Methods: In total, 20 office workers (16 [80%] females; mean age 39.5, SD 8.1 years) downloaded the W@W-App to their mobile phones, wore a MetaWearC sensor attached to their thigh using a tailored band, and wore the activPAL3M for 3-8 consecutive working hours. Differences between both measures were examined using paired-samples t tests and Wilcoxon signed-rank tests. Agreement between measures was examined using concordance correlation coefficients (CCCs), 95% CIs, Bland-Altman plots (mean bias, 95% limits of agreement [LoA]), and equivalence testing techniques. Results: The median recording time for the W@W-App+MetaWearC and the activPAL3M was 237.5 (SD 132.8) minutes and 240.0 (SD 127.5) minutes, respectively (P<.001). No significant differences between sitting (P=.53), standing (P=.12), and stepping times (P=.61) were identified. The CCC identified substantial agreement between both measures for sitting (CCC=0.98, 95% CI 0.96-0.99), moderate agreement for standing (CCC=0.93, 95% CI 0.81-0.97), and poor agreement for stepping (CCC=0.74, 95% CI 0.47-0.88). Bland-Altman plots indicated that sitting time (mean bias –1.66 minutes, 95% LoA –30.37 to 20.05) and standing time (mean bias –4.85 minutes, 95% LoA –31.31 to 21.62) were underreported. For stepping time, a positive mean bias of 1.15 minutes (95% LoA –15.11 to 17.41) was identified. Equivalence testing demonstrated that the estimates obtained from the W@W-App+MetaWearC and the activPAL3M were considered equivalent for all variables excluding stepping time. Conclusions: The W@W-App+MetaWearC is a low-cost tool with acceptable levels of accuracy that can objectively quantify occupational sitting, standing, stationary, and upright times in real time. Due to the availability of real-time feedback for users, this tool can positively influence occupational sitting behaviors in future interventions. Trial Registration: ClinicalTrials.gov NCT04092738; https://clinicaltrials.gov/ct2/show/NCT04092738 %M 32459625 %R 10.2196/15338 %U https://mhealth.jmir.org/2020/8/e15338 %U https://doi.org/10.2196/15338 %U http://www.ncbi.nlm.nih.gov/pubmed/32459625 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 8 %P e17281 %T Prescribing Behavior Change: Opportunities and Challenges for Clinicians to Embrace Digital and Mobile Health %A Agarwal,Anish %A Patel,Mitesh %+ Department of Emergency Medicine, University of Pennsylvania, Blockley Hall, Room 428, 423 Guardian Drive, Philadelphia, PA, 19146, United States, 1 610 304 2318, anish.agarwal@pennmedicine.upenn.edu %K digital health %K behavior change %K mobile health %K patient-centered data collection %D 2020 %7 4.8.2020 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Individual behaviors impact physical and mental health. Everyday behaviors such as physical activity, diet, sleep, and tobacco use have been associated with a range of acute and chronic medical conditions. Educating, motivating, and promoting sustained healthy behaviors can be challenging for clinical providers attempting to manage their patients’ health. The ubiquity and integration of mobile and digital health devices (eg, wearable step counters, smartphone-based apps) allow for individuals to generate and record enormous amounts of patient-generated health data. Research studies have begun to reveal how mobile and digital devices offer promise in motivating individual behavior change but they have not had consistent results. In this viewpoint, we discuss the potential synergy of digital health modalities and behavioral strategies as an approach for clinicians to prescribe, motivate, monitor, and sustain healthy behaviors. We discuss the strengths, challenges, and opportunities for the future of promoting health behaviors. %M 32749997 %R 10.2196/17281 %U https://mhealth.jmir.org/2020/8/e17281 %U https://doi.org/10.2196/17281 %U http://www.ncbi.nlm.nih.gov/pubmed/32749997 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16924 %T Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review %A Brigden,Amberly %A Anderson,Emma %A Linney,Catherine %A Morris,Richard %A Parslow,Roxanne %A Serafimova,Teona %A Smith,Lucie %A Briggs,Emily %A Loades,Maria %A Crawley,Esther %+ Centre for Academic Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, United Kingdom, 44 0117 42 83080, amberly.brigden@bristol.ac.uk %K mobile phone %K mHealth %K mobile health %K eHealth %K electronic health %K digital health %K behavior %K pediatrics %K chronic illness %K systematic review %D 2020 %7 31.7.2020 %9 Review %J J Med Internet Res %G English %X Background: The prevalence of chronic health conditions in childhood is increasing, and behavioral interventions can support the management of these conditions. Compared with face-to-face treatment, the use of digital interventions may be more cost-effective, appealing, and accessible, but there has been inadequate attention to their use with younger populations (children aged 5-12 years). Objective: This systematic review aims to (1) identify effective digital interventions, (2) report the characteristics of promising interventions, and (3) describe the user’s experience of the digital intervention. Methods: A total of 4 databases were searched (Excerpta Medica Database [EMBASE], PsycINFO, Medical Literature Analysis and Retrieval System Online [MEDLINE], and the Cochrane Library) between January 2014 and January 2019. The inclusion criteria for studies were as follows: (1) children aged between 5 and 12 years, (2) interventions for behavior change, (3) randomized controlled trials, (4) digital interventions, and (5) chronic health conditions. Two researchers independently double reviewed papers to assess eligibility, extract data, and assess quality. Results: Searches run in the databases identified 2643 papers. We identified 17 eligible interventions. The most promising interventions (having a beneficial effect and low risk of bias) were 3 targeting overweight or obesity, using exergaming or social media, and 2 for anxiety, using web-based cognitive behavioral therapy (CBT). Characteristics of promising interventions included gaming features, therapist support, and parental involvement. Most were purely behavioral interventions (rather than CBT or third wave), typically using the behavior change techniques (BCTs) feedback and monitoring, shaping knowledge, repetition and substitution, and reward. Three papers included qualitative data on the user’s experience. We developed the following themes: parental involvement, connection with a health professional is important for engagement, technological affordances and barriers, and child-centered design. Conclusions: Of the 17 eligible interventions, digital interventions for anxiety and overweight or obesity had the greatest promise. Using qualitative methods during digital intervention development and evaluation may lead to more meaningful, usable, feasible, and engaging interventions, especially for this underresearched younger population. The following characteristics could be considered when developing digital interventions for younger children: involvement of parents, gaming features, additional therapist support, behavioral (rather than cognitive) approaches, and particular BCTs (feedback and monitoring, shaping knowledge, repetition and substitution, and reward). This review suggests a model for improving the conceptualization and reporting of behavioral interventions involving children and parents. %M 32735227 %R 10.2196/16924 %U http://www.jmir.org/2020/7/e16924/ %U https://doi.org/10.2196/16924 %U http://www.ncbi.nlm.nih.gov/pubmed/32735227 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17857 %T An App for Classifying Personal Mental Illness at Workplace Using Fit Statistics and Convolutional Neural Networks: Survey-Based Quantitative Study %A Yan,Yu-Hua %A Chien,Tsair-Wei %A Yeh,Yu-Tsen %A Chou,Willy %A Hsing,Shu-Chen %+ Respiratory Therapy Unit, Chi Mei Medical Center, No 901, Chung Hwa Road, Yung Kung Dist, Tainan, 710, Taiwan, 886 +886937399106, rtlisa1965@gmail.com %K respiratory therapist %K ELMI app %K Rasch analysis %K convolutional neural network %K mental health %K mobile phone %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental illness (MI) is common among those who work in health care settings. Whether MI is related to employees’ mental status at work is yet to be determined. An MI app is developed and proposed to help employees assess their mental status in the hope of detecting MI at an earlier stage. Objective: This study aims to build a model using convolutional neural networks (CNNs) and fit statistics based on 2 aspects of measures and outfit mean square errors for the automatic detection and classification of personal MI at the workplace using the emotional labor and mental health (ELMH) questionnaire, so as to equip the staff in assessing and understanding their own mental status with an app on their mobile device. Methods: We recruited 352 respiratory therapists (RTs) working in Taiwan medical centers and regional hospitals to fill out the 44-item ELMH questionnaire in March 2019. The exploratory factor analysis (EFA), Rasch analysis, and CNN were used as unsupervised and supervised learnings for (1) dividing RTs into 4 classes (ie, MI, false MI, health, and false health) and (2) building an ELMH predictive model to estimate 108 parameters of the CNN model. We calculated the prediction accuracy rate and created an app for classifying MI for RTs at the workplace as a web-based assessment. Results: We observed that (1) 8 domains in ELMH were retained by EFA, (2) 4 types of mental health (n=6, 63, 265, and 18 located in 4 quadrants) were classified using the Rasch analysis, (3) the 44-item model yields a higher accuracy rate (0.92), and (4) an MI app available for RTs predicting MI was successfully developed and demonstrated in this study. Conclusions: The 44-item model with 108 parameters was estimated by using CNN to improve the accuracy of mental health for RTs. An MI app developed to help RTs self-detect work-related MI at an early stage should be made more available and viable in the future. %M 32735232 %R 10.2196/17857 %U https://mhealth.jmir.org/2020/7/e17857 %U https://doi.org/10.2196/17857 %U http://www.ncbi.nlm.nih.gov/pubmed/32735232 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16596 %T Effects of an mHealth Brisk Walking Intervention on Increasing Physical Activity in Older People With Cognitive Frailty: Pilot Randomized Controlled Trial %A Kwan,Rick YC %A Lee,Deborah %A Lee,Paul H %A Tse,Mimi %A Cheung,Daphne SK %A Thiamwong,Ladda %A Choi,Kup-Sze %+ Centre for Gerontological Nursing, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, Hong Kong (China), 852 27666546 ext 6546, rick.kwan@polyu.edu.hk %K cognitive frailty %K brisk walking %K smartphone %K moderate-to-vigorous physical activity %K older people %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Cognitive frailty is the coexistence of physical frailty and cognitive impairment and is an at-risk state for many adverse health outcomes. Moderate-to-vigorous physical activity (MVPA) is protective against the progression of cognitive frailty. Physical inactivity is common in older people, and brisk walking is a feasible form of physical activity that can enhance their MVPA. Mobile health (mHealth) employing persuasive technology has been successful in increasing the levels of physical activity in older people. However, its feasibility and effects on older people with cognitive frailty are unclear. Objective: We aimed to identify the issues related to the feasibility of an mHealth intervention and the trial (ie, recruitment, retention, participation, and compliance) and to examine the effects of the intervention on cognitive function, physical frailty, walking time, and MVPA. Methods: An open-label, parallel design, randomized controlled trial (RCT) was employed. The eligibility criteria for the participants were age ≥60 years, having cognitive frailty, and having physical inactivity. In the intervention group, participants received both conventional behavior change intervention and mHealth (ie, smartphone-assisted program using Samsung Health and WhatsApp) interventions. In the control group, participants received conventional behavior change intervention only. The outcomes included cognitive function, frailty, walking time, and MVPA. Permuted block randomization in 1:1 ratio was used. The feasibility issue was described in terms of participant recruitment, retention, participation, and compliance. Wilcoxon signed-rank test was used to test the within-group effects in both groups separately. Results: We recruited 99 participants; 33 eligible participants were randomized into either the intervention group (n=16) or the control (n=17) group. The median age was 71.0 years (IQR 9.0) and the majority of them were females (28/33, 85%). The recruitment rate was 33% (33/99), the participant retention rate was 91% (30/33), and the attendance rate of all the face-to-face sessions was 100% (33/33). The majority of the smartphone messages were read by the participants within 30 minutes (91/216, 42.1%). ActiGraph (58/66 days, 88%) and smartphone (54/56 days, 97%) wearing compliances were good. After the interventions, cognitive function improvement was significant in both the intervention (P=.003) and the control (P=.009) groups. The increase in frailty reduction (P=.005), walking time (P=.03), step count (P=.02), brisk walking time (P=.009), peak cadence (P=.003), and MVPA time (P=.02) were significant only in the intervention group. Conclusions: Our mHealth intervention is feasible for implementation in older people with cognitive impairment and is effective at enhancing compliance with the brisk walking training program delivered by the conventional behavior change interventions. We provide preliminary evidence that this mHealth intervention can increase MVPA time to an extent sufficient to yield clinical benefits (ie, reduction in cognitive frailty). A full-powered and assessor-blinded RCT should be employed in the future to warrant these effects. Trial Registration: HKU Clinical Trials Registry HKUCTR-2283; http://www.hkuctr.com/Study/Show/31df4708944944bd99e730d839db4756 %M 32735218 %R 10.2196/16596 %U https://mhealth.jmir.org/2020/7/e16596 %U https://doi.org/10.2196/16596 %U http://www.ncbi.nlm.nih.gov/pubmed/32735218 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e15418 %T Effectiveness of a Mobile App Intervention for Anxiety and Depression Symptoms in University Students: Randomized Controlled Trial %A McCloud,Tayla %A Jones,Rebecca %A Lewis,Gemma %A Bell,Vaughan %A Tsakanikos,Elias %+ Division of Psychiatry, University College London, 149 Tottenham Court Road, London, W1T 7NF, United Kingdom, 44 2031087765, t.mccloud@ucl.ac.uk %K anxiety %K depression %K cognitive behavioral therapy %K eHealth %K online intervention %K mobile apps %K randomized controlled trial %K mobile phone %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Depression and anxiety symptoms are common among university students, but many do not receive treatment. This is often because of lack of availability, reluctance to seek help, and not meeting the diagnostic criteria required to access services. Internet-based interventions, including smartphone apps, can overcome these issues. However, a large number of apps are available, each with little evidence of their effectiveness. Objective: This study aims to evaluate for the first time the effectiveness of a self-guided mobile app, Feel Stress Free, for the treatment of depression and anxiety symptoms in students. Methods: A web-based randomized controlled trial compared a cognitive behavioral therapy (CBT)–based mobile app Feel Stress Free with a wait-list control. University students self-identified as experiencing symptoms of anxiety or depression and were randomized to 6 weeks of intervention (n=84) or control (n=84), unblinded. The app is self-guided and incorporates behavioral relaxation activities, mood tracking and thought challenging, and minigames. Participants completed the Hospital Anxiety and Depression Scale online at baseline and every fortnight. Results: At week 6, the primary end point, there was evidence that the Feel Stress Free app reduced depression symptoms (mean difference −1.56; 95% CI −2.67 to −0.44; P=.006) but only very weak evidence that it reduced anxiety symptoms (mean difference −1.36; 95% CI −2.93 to 0.21; P=.09). At week 4, there was evidence to support the effectiveness of the intervention for anxiety symptoms (mean difference −1.94; 95% CI −3.11 to −0.77; P=.001) and, though weaker, depression symptoms (mean difference −1.08; 95% CI −2.12 to −0.04; P=.04). At week 6, 83% (34/41) of participants indicated that they were using the app weekly or more frequently. Conclusions: The Feel Stress Free app is a promising mobile intervention for treating symptoms of anxiety and depression in students and overcomes many of the barriers to traditional CBT. Further research is needed to establish its effectiveness at and beyond 6 weeks. Trial Registration: ClinicalTrials.gov NCT03032952; https://clinicaltrials.gov/ct2/show/NCT03032952 %M 32735221 %R 10.2196/15418 %U http://mhealth.jmir.org/2020/7/e15418/ %U https://doi.org/10.2196/15418 %U http://www.ncbi.nlm.nih.gov/pubmed/32735221 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e14013 %T Use of a Smartphone App for Weight Loss Versus a Paper-Based Dietary Diary in Overweight Adults: Randomized Controlled Trial %A Ahn,Jeong Sun %A Lee,Heejin %A Kim,Jiae %A Park,Haemin %A Kim,Dong Woo %A Lee,Jung Eun %+ Department of Food and Nutrition, College of Human Ecology, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea, 82 2 880 6834, jungelee@snu.ac.kr %K smartphone app %K mobile phone %K dietary self-monitoring %K randomized controlled trial %K weight loss %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) tools may be useful platforms for dietary monitoring and assessment. Objective: This study aims to evaluate the effectiveness of a mobile dietary self-monitoring app for weight loss versus a paper-based diary among adults with a BMI of 23 kg/m2 or above. Methods: A total of 33 men and 17 women aged 18-39 years participated in a 6-week randomized controlled trial. We randomly assigned participants to one of two groups: (1) a smartphone app group (n=25) or (2) a paper-based diary group (n=25). The smartphone app group recorded foods and dietary supplements that they consumed and received immediate dietary feedback using Well-D, a dietary self-monitoring app developed by our team. The paper-based diary group was instructed to record foods or supplements that they consumed using a self-recorded diary. The primary outcomes were weight, BMI, waist circumference, body fat mass, and skeletal muscle mass. We also examined changes in nutrient intake, including energy, carbohydrate, protein, fat, dietary fiber, vitamins, and minerals, using 3-day 24-hour recalls. Differences in changes between the two groups were analyzed using independent t tests or Wilcoxon Mann-Whitney tests. All of the data were analyzed using intent-to-treat analysis. Results: The mean number of days recorded was 18.5 (SD 14.1) for the app group and 15.5 (SD 10.1) for the paper-based diary group. The differences in changes in weight, BMI, and waist circumference were not significantly different between the app group and paper-based diary group (P=.33, .34, and .70, respectively). Similarly, changes in body fat mass or skeletal muscle mass did not differ between the two groups (P=.71 and .054, respectively). Although energy intake was reduced in both groups, there was no significant difference in changes in energy intake between the two groups (P=.98). Conclusions: There were no differences in changes in anthropometric measures and nutrient intake between the app group and the paper-based diary group. Both mobile dietary self-monitoring app and paper-based diary may be useful for improving anthropometric measures. Trial Registration: Clinical Research Information Service KCT0003170; https://cris.nih.go.kr/cris/search/search_result_st01_en.jsp?seq=11642<ype=&rtype= %M 32735225 %R 10.2196/14013 %U http://mhealth.jmir.org/2020/7/e14013/ %U https://doi.org/10.2196/14013 %U http://www.ncbi.nlm.nih.gov/pubmed/32735225 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17031 %T Effects of the e-Motivate4Change Program on Metabolic Syndrome in Young Adults Using Health Apps and Wearable Devices: Quasi-Experimental Study %A Lee,Ji-Soo %A Kang,Min-Ah %A Lee,Soo-Kyoung %+ Keimyung University, 1095 Dalgubeol-daero, Dalseo-Gu, Daegu, 42601, Republic of Korea, 82 53 258 7665, soo1005s@gmail.com %K metabolic syndrome %K telemedicine %K mobile apps %K preventive care %K wearable electronic devices %D 2020 %7 30.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The health behaviors of young adults lag behind those of other age groups, and active health management is needed to improve health behaviors and prevent chronic diseases. In addition, developing good lifestyle habits earlier in life could reduce the risk of metabolic syndrome (MetS) later on. Objective: The aim of this study is to investigate the effects of the e-Motivate4Change program, for which health apps and wearable devices were selected based on user needs. The program was developed for the prevention and management of MetS in young adults. Methods: This experimental study used a nonequivalent control group. In total, 59 students from 2 universities in Daegu, Korea participated in the study (experimental group n=30; control group n=29). Data were collected over 4 months, from June 1 to September 30, 2018. The experimental group received a 12-week e-Motivate4Change program intervention, and the control group received MetS education and booklets without the e-Motivate4Change program intervention. Results: After the program, the experimental group had significantly higher scores for health-related lifestyle (t=3.86; P<.001) and self-efficacy (t=6.00; P<.001) than did the control group. Concerning BMI, there were significant effects by group (F=1.01; P<.001) and for the group × time interaction (F=4.71; P=.034). Concerning cholesterol, there were significant main effects for group (F=4.32; P=.042) and time (F=9.73; P<.001). Conclusions: The e-Motivate4Change program effectively improved participants’ health-related lifestyle scores and self-efficacy, and significantly reduced their BMI and cholesterol levels. The program can be used to identify and prevent MetS among young adults. %M 32729838 %R 10.2196/17031 %U http://www.jmir.org/2020/7/e17031/ %U https://doi.org/10.2196/17031 %U http://www.ncbi.nlm.nih.gov/pubmed/32729838 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17571 %T Virtual Reality Smartphone-Based Intervention for Smoking Cessation: Pilot Randomized Controlled Trial on Initial Clinical Efficacy and Adherence %A Goldenhersch,Emilio %A Thrul,Johannes %A Ungaretti,Joaquín %A Rosencovich,Nicolas %A Waitman,Cristian %A Ceberio,Marcelo Rodriguez %+ Laboratorio de Investigación en Neurociencia y Ciencias Sociales, Universidad de Flores, Avenida Rivadavia 5741, Ciudad Autónoma de Buenos Aires, CP 1414, Argentina, 1 4808860102, emiliogolden@gmail.com %K smoking cessation %K nicotine dependence %K craving %K virtual reality %K mindfulness %K digital therapy %K mHealth %K mobile phone %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Obstacles to current tobacco cessation programs include limited access and adherence to effective interventions. Digital interventions offer a great opportunity to overcome these difficulties, yet virtual reality has not been used as a remote and self-administered tool to help increase adherence and effectiveness of digital interventions for tobacco cessation. Objective: This study aimed to evaluate participant adherence and smoking cessation outcomes in a pilot randomized controlled trial of the digital intervention Mindcotine (MindCotine Inc) using a self-administered treatment of virtual reality combined with mindfulness. Methods: A sample of 120 participants was recruited in the city of Buenos Aires, Argentina (mean age 43.20 years, SD 9.50; 57/120, 47.5% female). Participants were randomly assigned to a treatment group (TG), which received a self-assisted 21-day program based on virtual reality mindful exposure therapy (VR-MET) sessions, daily surveys, and online peer-to-peer support moderated by psychologists, or a control group (CG), which received the online version of the smoking cessation manual from the Argentine Ministry of Health. Follow-up assessments were conducted by online surveys at postintervention and 90-day follow-up. The primary outcome was self-reported abstinence at postintervention, with missing data assumed as still smoking. Secondary outcomes included sustained abstinence at 90-day follow-up, adherence to the program, and readiness to quit. Results: Follow-up rates at day 1 were 93% (56/60) for the TG and 100% (60/60) for the CG. At postintervention, the TG reported 23% (14/60) abstinence on that day compared with 5% (3/60) in the CG. This difference was statistically significant (χ21=8.3; P=.004). The TG reported sustained abstinence of 33% (20/60) at 90 days. Since only 20% (12/60) of participants in the CG completed the 90-day follow-up, we did not conduct a statistical comparison between groups at this follow-up time point. Among participants still smoking at postintervention, the TG was significantly more ready to quit compared to the CG (TG: mean 7.71, SD 0.13; CG: mean 7.16, SD 0.13; P=.005). A total of 41% (23/56) of participants completed the treatment in the time frame recommended by the program. Conclusions: Results provide initial support for participant adherence to and efficacy of Mindcotine and warrant testing the intervention in a fully powered randomized trial. However, feasibility of trial follow-up assessment procedures for control group participants needs to be improved. Further research is needed on the impact of VR-MET on long-term outcomes. Trial Registration: ISRCTN Registry ISRCTN50586181; http://www.isrctn.com/ISRCTN50586181 %M 32723722 %R 10.2196/17571 %U http://www.jmir.org/2020/7/e17571/ %U https://doi.org/10.2196/17571 %U http://www.ncbi.nlm.nih.gov/pubmed/32723722 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17914 %T Using Internet of Things to Reduce Office Workers’ Sedentary Behavior: Intervention Development Applying the Behavior Change Wheel and Human-Centered Design Approach %A Huang,Yitong %A Benford,Steve %A Price,Dominic %A Patel,Roma %A Li,Benqian %A Ivanov,Alex %A Blake,Holly %+ School of Media and Communication, Shanghai Jiaotong University, 800 Dongchuan Road, Shanghai, , China, 86 57782665881, huang.yitong@foxmail.com %K sedentary behavior %K workplace %K just-in-time adaptive intervention %K internet of things %D 2020 %7 29.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Sedentary behavior (SB) is associated with various adverse health outcomes. The prevalence of prolonged sitting at work among office workers makes a case for SB interventions to target this setting and population. Everyday mundane objects with embedded microelectronics and ubiquitous computing represent a novel mode of delivering health behavior change interventions enabled by internet of things (IoTs). However, little is known about how to develop interventions involving IoT technologies. Objective: This paper reports the design and development of an IoT-enabled SB intervention targeting office workers. Methods: The process was guided by the behavior change wheel (BCW), a systematic framework for theory-informed and evidence-based development of behavior change interventions, complemented by the human-centered design (HCD) approach. Intervention design was shaped by findings from a diary-probed interview study (n=20), a stakeholder design workshop (n=8), and a series of theoretical mapping and collaborative technical design activities. Results: The resulting intervention named WorkMyWay targets a reduction in office workers’ prolonged stationary behaviors at work and an increase in regular breaks by modifying behavioral determinants in 11 theoretical domains with 17 behavior change techniques. The delivery technology consists of a wearable activity tracker, a light-emitting diode reminder device attached to a vessel (ie, water bottle or cup), and a companion Android app connected to both devices over Bluetooth. The delivery plan consists of a 2-week baseline assessment, a 30-min face-to-face action planning session, and 6-week self-directed use of the delivery technology. Conclusions: This is the first study to demonstrate that it is possible to develop a complex IoT-enabled intervention by applying a combination of the BCW and HCD approaches. The next step is to assess the feasibility of WorkMyWay prior to testing intervention efficacy in a full-scale trial. The intervention mapping table that links individual intervention components with hypothesized mechanisms of action can serve as the basis for testing and clarifying theory-based mechanisms of action in future studies on WorkMyWay. %M 32723716 %R 10.2196/17914 %U http://mhealth.jmir.org/2020/7/e17914/ %U https://doi.org/10.2196/17914 %U http://www.ncbi.nlm.nih.gov/pubmed/32723716 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 3 %N 2 %P e18008 %T Inferring Destinations and Activity Types of Older Adults From GPS Data: Algorithm Development and Validation %A Bayat,Sayeh %A Naglie,Gary %A Rapoport,Mark J %A Stasiulis,Elaine %A Chikhaoui,Belkacem %A Mihailidis,Alex %+ Institute of Biomaterials and Biomedical Engineering, University of Toronto, 550 University Avenue, Toronto, ON, Canada, 1 416 597 3422 ext 7345, sayeh.bayat@mail.utoronto.ca %K outdoor mobility %K older adults %K GPS %K life space %K activity types %K machine learning %D 2020 %7 28.7.2020 %9 Original Paper %J JMIR Aging %G English %X Background: Outdoor mobility is an important aspect of older adults’ functional status. GPS has been used to create indicators reflecting the spatiotemporal dimensions of outdoor mobility for applications in health and aging. However, outdoor mobility is a multidimensional construct. There is, as of yet, no classification algorithm that groups and characterizes older adults’ outdoor mobility based on its semantic aspects (ie, mobility intentions and motivations) by integrating geographic and domain knowledge. Objective: This study assesses the feasibility of using GPS to determine semantic dimensions of older adults’ outdoor mobility, including destinations and activity types. Methods: A total of 5 healthy individuals, aged 65 years or older, carried a GPS device when traveling outside their homes for 4 weeks. The participants were also given a travel diary to record details of all excursions from their homes, including date, time, and destination information. We first designed and implemented an algorithm to extract destinations and infer activity types (eg, food, shopping, and sport) from the GPS data. We then evaluated the performance of the GPS-derived destination and activity information against the traditional diary method. Results: Our results detected the stop locations of older adults from their GPS data with an F1 score of 87%. On average, the extracted home locations were within a 40.18-meter (SD 1.18) distance of the actual home locations. For the activity-inference algorithm, our results reached an F1 score of 86% for all participants, suggesting a reasonable accuracy against the travel diary recordings. Our results also suggest that the activity inference’s accuracy measure differed by neighborhood characteristics (ie, Walk Score). Conclusions: We conclude that GPS technology is accurate for determining semantic dimensions of outdoor mobility. However, further improvements may be needed to develop a robust application of this system that can be adopted in clinical practice. %M 32720647 %R 10.2196/18008 %U http://aging.jmir.org/2020/2/e18008/ %U https://doi.org/10.2196/18008 %U http://www.ncbi.nlm.nih.gov/pubmed/32720647 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16783 %T The Cedar Project - Mobile Phone Use and Acceptability of Mobile Health Among Young Indigenous People Who Have Used Drugs in British Columbia, Canada: Mixed Methods Exploratory Study %A Jongbloed,Kate %A Pearce,Margo E %A Thomas,Vicky %A Sharma,Richa %A Pooyak,Sherri %A Demerais,Lou %A Lester,Richard T %A Schechter,Martin T %A Spittal,Patricia M %A , %+ School of Population and Public Health, Faculty of Medicine, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada, 1 604 875 2345 ext 5944, spittal@sm.hivnet.ubc.ca %K Indigenous %K mobile health %K mHealth %K text messaging %K substance use %K HIV/AIDS %D 2020 %7 27.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Indigenous leaders continue to be concerned about high rates of HIV and barriers to HIV treatment among young Indigenous people involved in substance use. Growing evidence suggests that using mobile phones for health (mHealth) may be a powerful way to support connection with health services, including HIV prevention and treatment. Objective: This study examined the patterns of mobile phone ownership and use among young Indigenous people who have used drugs living with or vulnerable to HIV and explored the acceptability of mHealth to support access to health care in this population. Methods: The Cedar Project is a cohort study involving young Indigenous people who have used drugs in Vancouver and Prince George, British Columbia. This mixed methods exploratory study involved 131 Cedar Project participants enrolled in our WelTel mHealth program. At enrollment, participants completed a questionnaire related to mobile phone use and interest in mHealth. Data were linked to Cedar Project questionnaires and serodata. We present comparative statistics (quantitative) and results of a rapid thematic analysis (qualitative) related to mobile phone patterns and interest in receiving mHealth. Results: Less than half of the participants (59/130; 45.4%) reported owning a phone. Among those with a phone, the majority owned a smartphone (46/59; 78%). Most participants with a phone reported having an unlimited texting plan (39/55; 71%), using the internet on their phone (44/59; 75%), and texting daily (44/55; 80%). A majority reported that using a mobile phone for health would be invaluable (120/130; 92.3%). There were no differences in mHealth acceptance between participants who owned a phone and those who did not (P>.99). All but one participant living with HIV felt using a mobile phone would be helpful for their health, while a small proportion of HIV-negative participants remained unsure (1.9% vs 11.7%; P=.047). In response to open-ended questions asking why using a mobile phone may be helpful for health, participants identified a diverse set of anticipated benefits: (1) connection for emotional, mental, and spiritual support, (2) connection to family, (3) staying in touch and/or being reachable, (4) overcoming current barriers to phone use, (5) convenience, privacy, and safety, and (6) access to health care and emergency services. Conclusions: We observed high acceptance and interest in using mobile phone technology for health despite low rates of personal mobile phone connectivity among young Indigenous people who have used drugs living with and vulnerable to HIV in British Columbia, Canada. Mobile phones were viewed as a way to support connections and relationships that are seen as critical to health and well-being among young Indigenous people in this study. Findings may be useful for health care providers preparing to scale up mHealth programs to support HIV prevention and treatment in this population. %M 32716311 %R 10.2196/16783 %U https://mhealth.jmir.org/2020/7/e16783 %U https://doi.org/10.2196/16783 %U http://www.ncbi.nlm.nih.gov/pubmed/32716311 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14223 %T An mHealth Intervention (ReZone) to Help Young People Self-Manage Overwhelming Feelings: Cluster-Randomized Controlled Trial %A Edridge,Chloe %A Wolpert,Miranda %A Deighton,Jessica %A Edbrooke-Childs,Julian %+ Clinical, Educational and Health Psychology, University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 020 7443 2218, Chloe.edridge@annafreud.org %K cluster trial %K behavioral difficulties %K schools %K mHealth %K digital %K mental health %D 2020 %7 27.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Mental health difficulties in young people are increasing, and there is a need for evidence on the effectiveness of digital interventions to increase opportunities for supporting mental health in young people. Such studies are complicated due to issues of implementation and adoption, outcome measurement, and appropriate study designs. Objective: The objective of this study was to examine the effectiveness of an mHealth intervention (ReZone) in reducing mental health difficulties in young people. Methods: The cluster-randomized controlled trial enrolled 409 participants aged 10-15 years, and classes were allocated to ReZone or management as usual. Self-reported questionnaires were completed at baseline and 3-month follow-up. Results: There were no significant differences between the ReZone condition and management as usual in the self-reported outcome measures. However, there were 3467 usage sessions, which corresponds to 16.9 times per student (total of 205 students) in classes allocated to ReZone. Conclusions: It is essential to publish studies that do not show significant differences, as these findings can still contribute to the literature, help in learning, and inform the direction of future work. The results reported in this paper could be due to a range of reasons, including whether ReZone has the scope to impact change or limitations related to the setting, context, and appropriateness of an RCT. The findings of this study suggest that ReZone was implemented and adopted. International Registered Report Identifier (IRRID): RR2-10.2196/resprot.7019 %M 32716299 %R 10.2196/14223 %U http://www.jmir.org/2020/7/e14223/ %U https://doi.org/10.2196/14223 %U http://www.ncbi.nlm.nih.gov/pubmed/32716299 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18437 %T A Community-Engaged Approach to Creating a Mobile HIV Prevention App for Black Women: Focus Group Study to Determine Preferences via Prototype Demos %A Chandler,Rasheeta %A Hernandez,Natalie %A Guillaume,Dominique %A Grandoit,Shanaika %A Branch-Ellis,Desiré %A Lightfoot,Marguerita %+ Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, Atlanta, GA, 30322, United States, 1 404 727 8164, r.d.chandler@emory.edu %K mHealth app %K mobile technology %K Black women %K HIV prevention %K reproductive health %K women’s health %D 2020 %7 24.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Black women are an important but relatively overlooked at-risk group in HIV prevention efforts. Although there is an aggregate decline of HIV diagnoses among women in the United States, there are persistent disparate rates of new HIV infections among Black women compared to any other cisgender female subgroup. Strategies to end the HIV epidemic—as outlined in the Ending the HIV Epidemic initiative—for all communities must consider HIV prevention messaging and message delivery mediums that are created with community input. Although mobile health (mHealth) is a popular platform for delivering HIV interventions, there are currently no mobile apps that consider cisgender Black women with the goal of promoting a comprehensive women’s reproductive health and HIV prevention lifestyle. Previous research recommends inclusion of the target population from project inception and iteratively throughout development, to promote use of the intervention. Objective: The purpose of this study is to understand cisgender Black women’s preferences for functionality, format, and design of a mobile HIV prevention app and to examine their willingness to use an app for HIV prevention. Methods: We conducted a series of four focus groups with 23 Black cisgender women. Focus groups included discussion and demonstration elements to address cisgender women’s general preference for apps, HIV prevention content that would be useful in an app, and preferred app features that would promote use of an HIV-centric app. During focus group discussions, participants were shown narrated, custom wireframes of HIV prevention app prototypes to demonstrate potential app function. Results: Findings indicated the presence of eight subthemes within the coding structure of three overall themes: (1) health content within the mobile app, (2) mobile app functionality, format, and design, and (3) other suggested features. Specifically, participants detailed preferred educational content, content distribution, app aesthetics, privacy considerations, and marketing of the app. Conclusions: Findings suggest that Black cisgender women preferred an app that integrated HIV prevention and optimal sexual health promotion. Participants provided a range of preferences for content integration and facilitators of app engagement with an HIV prevention app. Preferences centered on gender and cultural congruency of information and content, evidenced by visuals, language, and resources. Black cisgender women are viable consumers for a mobile app–based HIV prevention intervention. %M 32706723 %R 10.2196/18437 %U http://mhealth.jmir.org/2020/7/e18437/ %U https://doi.org/10.2196/18437 %U http://www.ncbi.nlm.nih.gov/pubmed/32706723 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e17541 %T Efficacy of a Smartphone App Intervention for Reducing Caregiver Stress: Randomized Controlled Trial %A Fuller-Tyszkiewicz,Matthew %A Richardson,Ben %A Little,Keriann %A Teague,Samantha %A Hartley-Clark,Linda %A Capic,Tanja %A Khor,Sarah %A Cummins,Robert A %A Olsson,Craig A %A Hutchinson,Delyse %+ Deakin University, 1 Gheringhap Street, Geelong, 3220, Australia, 61 3 9251 7344, matthewf@deakin.edu.au %K mHealth %K mobile phone %K caregiver %K psychological stress %K mental health %D 2020 %7 24.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Caregivers play a pivotal role in maintaining an economically viable health care system, yet they are characterized by low levels of psychological well-being and consistently report unmet needs for psychological support. Mobile app–based (mobile health [mHealth]) interventions present a novel approach to both reducing stress and improving well-being. Objective: This study aims to evaluate the effectiveness of a self-guided mobile app–based psychological intervention for people providing care to family or friends with a physical or mental disability. Methods: In a randomized, single-blind, controlled trial, 183 caregivers recruited through the web were randomly allocated to either an intervention (n=73) or active control (n=110) condition. The intervention app contained treatment modules combining daily self-monitoring with third-wave (mindfulness-based) cognitive-behavioral therapies, whereas the active control app contained only self-monitoring features. Both programs were completed over a 5-week period. It was hypothesized that intervention app exposure would be associated with decreases in depression, anxiety, and stress, and increases in well-being, self-esteem, optimism, primary and secondary control, and social support. Outcomes were assessed at baseline, postintervention, and 3-4 months postintervention. App quality was also assessed. Results: In total, 25% (18/73) of the intervention participants were lost to follow-up at 3 months, and 30.9% (34/110) of the participants from the wait-list control group dropped out before the postintervention survey. The intervention group experienced reductions in stress (b=−2.07; P=.04) and depressive symptoms (b=−1.36; P=.05) from baseline to postintervention. These changes were further enhanced from postintervention to follow-up, with the intervention group continuing to report lower levels of depression (b=−1.82; P=.03) and higher levels of emotional well-being (b=6.13; P<.001), optimism (b=0.78; P=.007), self-esteem (b=−0.84; P=.005), support from family (b=2.15; P=.001), support from significant others (b=2.66; P<.001), and subjective well-being (b=4.82; P<.001). On average, participants completed 2.5 (SD 1.05) out of 5 treatment modules. The overall quality of the app was also rated highly, with a mean score of 3.94 out of a maximum score of 5 (SD 0.58). Conclusions: This study demonstrates that mHealth psychological interventions are an effective treatment option for caregivers experiencing high levels of stress. Recommendations for improving mHealth interventions for caregivers include offering flexibility and customization in the treatment design. Trial Registration: Australian New Zealand Clinical Trial Registry ACTRN12616000996460; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371170 %M 32706716 %R 10.2196/17541 %U http://mental.jmir.org/2020/7/e17541/ %U https://doi.org/10.2196/17541 %U http://www.ncbi.nlm.nih.gov/pubmed/32706716 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17238 %T Worldwide Prevalence of Hearing Loss Among Smartphone Users: Cross-Sectional Study Using a Mobile-Based App %A Masalski,Marcin %A Morawski,Krzysztof %+ Department of Otolaryngology Head and Neck Surgery, Faculty of Medicine, Wroclaw Medical University, Wybrzeze Ludwika Pasteura 1, Wroclaw, 50-367, Poland, 48 515086252, marcin.masalski@pwr.edu.pl %K hearing loss %K epidemiology %K mobile-based %K hearing test %K pure-tone audiometry %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In addition to the aging process, risk factors for hearing loss in adults include, among others, exposure to noise, use of ototoxic drugs, genetics, and limited access to medical care. Differences in exposure to these factors are bound to be reflected in the prevalence of hearing loss. Assessment of hearing loss can easily be carried out on a large scale and at low cost using mobile apps. Objective: This study aimed to conduct a worldwide assessment of the differences in hearing loss prevalence between countries in a group of mobile device users. Methods: Hearing tests were conducted using the open-access Android-based mobile app Hearing Test. The app is available free of charge in the Google Play store, provided that consent to the use of the results for scientific purposes is given. This study included hearing tests carried out on device models supported by the app with bundled headphones in the set. Calibration factors for supported models were determined using the biological method. The tests consisted of self-determining the quietest audible tone in the frequency range from 250 Hz to 8 kHz by adjusting its intensity using the buttons. The ambient noise level was optionally monitored using a built-in microphone. Following the test, the user could compare his hearing threshold against age norms by providing his or her age. The user's location was identified based on the phone’s IP address. Results: From November 23, 2016 to November 22, 2019, 733,716 hearing tests were conducted on 236,716 mobile devices across 212 countries. After rejecting the tests that were incomplete, performed with disconnected headphones, not meeting the time criterion, repeated by the same user, or carried out regularly on one device, 116,733 of 733,716 tests (15.9%) were qualified for further analysis. The prevalence of hearing loss, defined as the average threshold at frequencies 0.5 kHz, 1 kHz, 2 kHz, and 4 kHz above 25 dB HL in the better ear, was calculated at 15.6% (95% CI 15.4-15.8). Statistically significant differences were found between countries (P<.001), with the highest prevalences for Bangladesh, Pakistan, and India (>28%) and the lowest prevalences for Taiwan, Finland, and South Korea (<11%). Conclusions: Hearing thresholds measured by means of mobile devices were congruent with the literature data on worldwide hearing loss prevalence. Uniform recruitment criteria simplify the comparison of the hearing loss prevalence across countries. Hearing testing on mobile devices may be a valid tool in epidemiological studies carried out on a large scale. %M 32706700 %R 10.2196/17238 %U http://www.jmir.org/2020/7/e17238/ %U https://doi.org/10.2196/17238 %U http://www.ncbi.nlm.nih.gov/pubmed/32706700 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e16380 %T Evaluation of a Blended Physical Activity Intervention for Older Adults: Mixed Methods Study %A Mehra,Sumit %A van den Helder,Jantine %A Visser,Bart %A Engelbert,Raoul H H %A Weijs,Peter J M %A Kröse,Ben J A %+ Applied Psychology, Faculty of Applied Social Sciences and Law, Amsterdam University of Applied Sciences, Wibautstraat 3b, Amsterdam, 1091 GH, Netherlands, 31 0621156956, s.mehra@hva.nl %K frail elderly %K aged %K activities of daily living %K exercise %K health behavior %K telemedicine %K mobile devices %K tablet computers %K usability testing %K evaluation %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity can prolong the ability of older adults to live independently. Home-based exercises can help achieve the recommended physical activity levels. A blended intervention was developed to support older adults in performing home-based exercises. A tablet and a personal coach were provided to facilitate the self-regulation of exercise behavior. Objective: In line with the Medical Research Council framework, this study aimed to carry out process evaluation of a blended intervention. The objectives were (1) to assess the long-term usability of the tablet adopted in the blended intervention and (2) to explore how the tablet, in conjunction with a personal coach, supported older adults in performing home-based exercises. Methods: The process evaluation was conducted with a mixed-methods approach. At baseline, older adults participating in the blended intervention were asked to fill out a questionnaire about their general experience with information and communication technology (ICT) devices and rate their own skill level. After 6 months, participants filled out the Usefulness, Satisfaction, and Ease of use (USE) questionnaire to assess the usefulness, satisfaction, and ease of use of the tablet. With a random selection of participants, in-depth interviews were held to explore how the tablet and coach supported the self-regulation. The interviews were double coded and analyzed with the directed content analysis method. Results: At baseline, 29% (65/224) of participants who started the intervention (mean age 72 years) filled out the ICT survey and 36% (37/103) of participants who used the tablet for 6 months (mean age 71 years) filled out the USE questionnaire. Furthermore, with 17% (18/103) of participants (mean age 73 years), follow-up interviews were held. The results of the baseline questionnaire showed that the large majority of participants already had experience with a tablet, used it regularly, and reported being skillful in operating ICT devices. After 6 months of use, the participants rated the usefulness, satisfaction, and ease of use of the tablet on average as 3.8, 4.2, and 4.1, respectively, on a 5-point scale. The analysis of the interviews showed that the participants felt that the tablet supported action planning, behavior execution, and self-monitoring. On the other hand, especially during the first few months, the personal coach added value during the goal setting, behavior execution, and evaluation phases of self-regulation. Conclusions: The results of the process evaluation showed that older adults who participated in the study were positive about the blended intervention that was designed to support them in performing home-based exercises. Participants reported that the tablet helped them to perform the exercises better, more frequently, and safely. It supported them in various phases of self-regulation. The availability of a personal coach was nevertheless crucial. To support physical activity in older adults, a blended approach is promising. %M 32459652 %R 10.2196/16380 %U http://www.jmir.org/2020/7/e16380/ %U https://doi.org/10.2196/16380 %U http://www.ncbi.nlm.nih.gov/pubmed/32459652 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e17075 %T Design, Recruitment, and Baseline Characteristics of a Virtual 1-Year Mental Health Study on Behavioral Data and Health Outcomes: Observational Study %A Kumar,Shefali %A Tran,Jennifer L A %A Ramirez,Ernesto %A Lee,Wei-Nchih %A Foschini,Luca %A Juusola,Jessie L %+ Evidation Health, 167 2nd Ave, San Mateo, CA, 94401, United States, 1 650 279 8855, jjuusola@evidation.com %K mental health %K anxiety %K depression %K behavioral data %D 2020 %7 23.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety greatly impact daily behaviors, such as sleep and activity levels. With the increasing use of activity tracking wearables among the general population, there has been a growing interest in how data collected from these devices can be used to further understand the severity and progression of mental health conditions. Objective: This virtual 1-year observational study was designed with the objective of creating a longitudinal data set combining self-reported health outcomes, health care utilization, and quality of life data with activity tracker and app-based behavioral data for individuals with depression and anxiety. We provide an overview of the study design, report on baseline health and behavioral characteristics of the study population, and provide initial insights into how behavioral characteristics differ between groups of individuals with varying levels of disease severity. Methods: Individuals who were existing members of an online health community (Achievement, Evidation Health Inc) and were 18 years or older who had self-reported a diagnosis of depression or anxiety were eligible to enroll in this virtual 1-year study. Participants agreed to connect wearable activity trackers that captured data related to physical activity and sleep behavior. Mental health outcomes such as the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Questionnaire (GAD-7), mental health hospitalizations, and medication use were captured with surveys completed at baseline and months 3, 6, 9, and 12. In this analysis, we report on baseline characteristics of the sample, including mental health disease severity and health care utilization. Additionally, we explore the relationship between passively collected behavioral data and baseline mental health status and health care utilization. Results: Of the 1304 participants enrolled in the study, 1277 individuals completed the baseline survey and 1068 individuals had sufficient activity tracker data. Mean age was 33 (SD 9) years, and the majority of the study population was female (77.2%, 994/1288) and identified as Caucasian (88.3%, 1137/1288). At baseline, 94.8% (1211/1277) of study participants reported experiencing depression or anxiety symptoms in the last year. This baseline analysis found that some passively tracked behavioral traits are associated with more severe forms of anxiety or depression. Individuals with depressive symptoms were less active than those with minimal depressive symptoms. Severe forms of depression were also significantly associated with inconsistent sleep patterns and more disordered sleep. Conclusions: These initial findings suggest that longitudinal behavioral and health outcomes data may be useful for developing digital measures of health for mental health symptom severity and progression. %M 32706712 %R 10.2196/17075 %U http://mental.jmir.org/2020/7/e17075/ %U https://doi.org/10.2196/17075 %U http://www.ncbi.nlm.nih.gov/pubmed/32706712 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17039 %T Use of Mobile Phone App Interventions to Promote Weight Loss: Meta-Analysis %A Islam,Md Mohaimenul %A Poly,Tahmina Nasrin %A Walther,Bruno Andres %A (Jack) Li,Yu-Chuan %+ Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan, 886 886 2 2736166, jaak88@gmail.com %K mobile app %K mHealth %K obesity %K physical activity %K weight gain prevention %D 2020 %7 22.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Obesity and lack of physical activity are major health risk factors for many life-threatening diseases, such as cardiovascular diseases, type 2 diabetes, and cancer. The use of mobile app interventions to promote weight loss and boost physical activity among children and adults is fascinating owing to the demand for cutting-edge and more efficient interventions. Previously published studies have examined different types of technology-based interventions and their impact on weight loss and increase in physical activity, but evidence regarding the impact of only a mobile phone app on weight loss and increase in physical activity is still lacking. Objective: The main objective of this study was to assess the efficacy of a mobile phone app intervention for reducing body weight and increasing physical activity among children and adults. Methods: PubMed, Google Scholar, Scopus, EMBASE, and the Web of Science electronic databases were searched for studies published between January 1, 2000, and April 30, 2019, without language restrictions. Two experts independently screened all the titles and abstracts to find the most appropriate studies. To be included, studies had to be either a randomized controlled trial or a case-control study that assessed a mobile phone app intervention with body weight loss and physical activity outcomes. The Cochrane Collaboration Risk of Bias tool was used to examine the risk of publication bias. Results: A total of 12 studies involving a mobile phone app intervention were included in this meta-analysis. Compared with the control group, the use of a mobile phone app was associated with significant changes in body weight (−1.07 kg, 95% CI −1.92 to −0.21, P=.01) and body mass index (−0.45 kg/m2, 95% CI −0.78 to −0.12, P=.008). Moreover, a nonsignificant increase in physical activity was observed (0.17, 95% CI −2.21 to 2.55, P=.88). Conclusions: The findings of this study demonstrate the promising and emerging efficacy of using mobile phone app interventions for weight loss. Future studies are needed to explore the long-term efficacy of mobile app interventions in larger samples. %M 32706724 %R 10.2196/17039 %U https://mhealth.jmir.org/2020/7/e17039 %U https://doi.org/10.2196/17039 %U http://www.ncbi.nlm.nih.gov/pubmed/32706724 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16971 %T A Mobile App to Rapidly Appraise the In-Store Food Environment: Reliability, Utility, and Construct Validity Study %A McMahon,Emma Joy %A Jaenke,Rachael %A Brimblecombe,Julie %+ Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Building Red 9, Casuarina campus, Ellengowan Drive, Darwin, 0810, Australia, 61 731694202, e.j.mcmahon@outlook.com %K mobile apps %K reliability and validity %K food %K diet %K environment and public health %D 2020 %7 22.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Consumer food environments are increasingly being recognized as influential determinants of food purchasing and subsequent intake and health. We developed a tool to enable efficient, but relatively comprehensive, appraisal of the in-store food environment. The Store Scout mobile app facilitates the evaluation of product (availability and range), placement (visibility, accessibility, proximity to high-traffic areas, and location relative to other products), price (price promotion), and promotion (displays and advertising) across 7 categories of food products, with appraisal given immediately as scores (0-100, where a higher score is more in line with best practice). Primary end users are public health nutritionists and nutritionists employed by store organizations; however, store managers and staff are also potential end users. Objective: This study aims to evaluate the reliability (interrater reliability and internal consistency), utility (distribution of scores), and construct validity (score by store type) of measurements using the Store Scout mobile app. Methods: The Store Scout mobile app was used independently by 2 surveyors to evaluate the store environment in 54 stores: 34 metropolitan stores (9 small and 11 large supermarkets, 10 convenience stores, and 4 petrol stations) in Brisbane, Australia, and 20 remote stores (19 small supermarkets and 1 petrol station) in Indigenous Australian communities in Northern Australia. The agreement between surveyors in the overall and category scores was evaluated using intraclass correlation coefficients (ICCs). Interrater reliability of measurement items was assessed using percentage agreement and the Gwet agreement coefficient (AC). Internal consistency was assessed by comparing the responses of items measuring similar aspects of the store environment. We examined the distribution of score values using boxplots and differences by store type using the Kruskal-Wallis test. Results: The median difference in the overall score between surveyors was 4.4 (range 0.0-11.1), with an ICC of 0.954 (95% CI 0.914-0.975). Most measurement items had very good (n=74/196, 37.8%) or good (n=81/196, 41.3%) interrater reliability using the Gwet AC. A minimal inconsistency of measurement was found. Overall scores ranged from 19.2 to 81.6. There was a significant difference in score by store type (P<.001). Large Brisbane supermarkets scored highest (median 77.4, range 53.2-81.6), whereas small Brisbane supermarkets (median 63.9, range 41.0-71.3) and small remote supermarkets (median 63.8, range 56.5-74.9) scored significantly higher than Brisbane petrol stations (median 33.1, range 19.2-37.8) and convenience stores (median 39.0, range 22.4-63.8). Conclusions: These findings suggest good reliability and internal consistency of food environment measurements using the Store Scout mobile app. We identified specific aspects that can be improved to further increase the reliability of this tool. We found a good distribution of score values and evidence that scoring could capture differences by store type in line with previous evidence, which gives an indication of construct validity. The Store Scout mobile app shows promise in its capability to measure and track the health-enabling characteristics of store environments. %M 32706683 %R 10.2196/16971 %U https://mhealth.jmir.org/2020/7/e16971 %U https://doi.org/10.2196/16971 %U http://www.ncbi.nlm.nih.gov/pubmed/32706683 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16899 %T Evaluation Criteria for Weight Management Apps: Validation Using a Modified Delphi Process %A Robles,Noemí %A Puigdomènech Puig,Elisa %A Gómez-Calderón,Corpus %A Saigí-Rubió,Francesc %A Cuatrecasas Cambra,Guillem %A Zamora,Alberto %A Moharra,Montse %A Paluzié,Guillermo %A Balfegó,Mariona %A Carrion,Carme %+ Agència de Qualitat i Avaluació Sanitàries de Catalunya, Carrer Roc Boronat 81-95, Barcelona, E08005, Spain, 34 93 5513476, epuigdomenech@gencat.cat %K mHealth %K technology assessment %K obesity %K overweight %K Delphi technique %K consensus %D 2020 %7 22.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The use of apps for weight management has increased over recent years; however, there is a lack of evidence regarding the efficacy and safety of these apps. The EVALAPPS project will develop and validate an assessment instrument to specifically assess the safety and efficacy of weight management apps. Objective: The aim of this study was to reach a consensus among stakeholders on a comprehensive set of criteria to guide development of the EVALAPPS assessment instrument. A modified Delphi process was used in order to verify the robustness of the criteria that had been identified through a literature review and to prioritize a set of the identified criteria. Methods: Stakeholders (n=31) were invited to participate in a 2-round Delphi process with 114 initial criteria that had been identified from the literature. In round 1, participants rated criteria according to relevance on a scale from 0 (“I suggest this criterion is excluded”) to 5 (“This criterion is extremely relevant”). A criterion was accepted if the median rating was 4 or higher and if the relative intraquartile range was equal to 0.67 or lower. In round 2, participants were asked about criteria that had been discarded in round 1. A prioritization strategy was used to identify crucial criteria according to (1) the importance attributed by participants (criteria with a mean rating of 4.00 or higher), (2) the level of consensus (criteria with a score of 4 or 5 by at least 80% of the participants). Results: The response rate was 83.9% (26/31) in round 1 and 90.3% (28/31) in round 2. A total of 107 out of 114 criteria (93.9%) were accepted by consensus—105 criteria in round 1 and 2 criteria in round 2. After prioritization, 53 criteria were deemed crucial. These related mainly to the dimensions of security and privacy (13/53, 24.5%) and usability (9/53, 17.0%), followed by activity data (5/53, 9.4%), clinical effectiveness (5/53, 9.4%), and reliability (5/53, 9.4%). Conclusions: Results confirmed the robustness of the criteria that were identified, with those relating to security and privacy being deemed most relevant by stakeholders. Additionally, a specific set of criteria based on health indicators (activity data, physical state data, and personal data) was also prioritized. %M 32706689 %R 10.2196/16899 %U http://mhealth.jmir.org/2020/7/e16899/ %U https://doi.org/10.2196/16899 %U http://www.ncbi.nlm.nih.gov/pubmed/32706689 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16405 %T Wearable Technology to Quantify the Nutritional Intake of Adults: Validation Study %A Dimitratos,Sarah M %A German,J Bruce %A Schaefer,Sara E %+ Foods for Health Institute, University of California, 2141 Robert Mondavi Institute, North Building, 1 Shields Ave, Davis, CA, 95616, United States, 1 530 574 0797, seschaefer@ucdavis.edu %K wearable technology %K mobile health %K mobile phone %K food intake %K validation study %D 2020 %7 22.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Wearable and mobile sensor technologies can be useful tools in precision nutrition research and practice, but few are reliable for obtaining accurate and precise measurements of diet and nutrition. Objective: This study aimed to assess the ability of wearable technology to monitor the nutritional intake of adult participants. This paper describes the development of a reference method to validate the wristband’s estimation of daily nutritional intake of 25 free-living study participants and to evaluate the accuracy (kcal/day) and practical utility of the technology. Methods: Participants were asked to use a nutrition tracking wristband and an accompanying mobile app consistently for two 14-day test periods. A reference method was developed to validate the estimation of daily nutritional intake of participants by the wristband. The research team collaborated with a university dining facility to prepare and serve calibrated study meals and record the energy and macronutrient intake of each participant. A continuous glucose monitoring system was used to measure adherence with dietary reporting protocols, but these findings are not reported. Bland-Altman tests were used to compare the reference and test method outputs (kcal/day). Results: A total of 304 input cases were collected of daily dietary intake of participants (kcal/day) measured by both reference and test methods. The Bland-Altman analysis had a mean bias of −105 kcal/day (SD 660), with 95% limits of agreement between −1400 and 1189. The regression equation of the plot was Y=−0.3401X+1963, which was significant (P<.001), indicating a tendency for the wristband to overestimate for lower calorie intake and underestimate for higher intake. Researchers observed transient signal loss from the sensor technology of the wristband to be a major source of error in computing dietary intake among participants. Conclusions: This study documents high variability in the accuracy and utility of a wristband sensor to track nutritional intake, highlighting the need for reliable, effective measurement tools to facilitate accurate, precision-based technologies for personal dietary guidance and intervention. %M 32706729 %R 10.2196/16405 %U https://mhealth.jmir.org/2020/7/e16405 %U https://doi.org/10.2196/16405 %U http://www.ncbi.nlm.nih.gov/pubmed/32706729 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e15948 %T Comparison of Geographic Information System and Subjective Assessments of Momentary Food Environments as Predictors of Food Intake: An Ecological Momentary Assessment Study %A Elliston,Katherine G %A Schüz,Benjamin %A Albion,Tim %A Ferguson,Stuart G %+ College of Health and Medicine, University of Tasmania, 17 Liverpool Street, Hobart, 7000, Australia, 61 362264259, katherine.elliston@utas.edu.au %K ecological momentary assessment %K mHealth %K geographic information systems %K food intake %K mobile phone %D 2020 %7 22.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: It has been observed that eating is influenced by the presence and availability of food. Being aware of the presence of food in the environment may enable mobile health (mHealth) apps to use geofencing techniques to determine the most appropriate time to proactively deliver interventions. To date, however, studies on eating typically rely on self-reports of environmental contexts, which may not be accurate or feasible for issuing mHealth interventions. Objective: This study aimed to compare the subjective and geographic information system (GIS) assessments of the momentary food environment to explore the feasibility of using GIS data to predict eating behavior and inform geofenced interventions. Methods: In total, 72 participants recorded their food intake in real-time for 14 days using an ecological momentary assessment approach. Participants logged their food intake and responded to approximately 5 randomly timed assessments each day. During each assessment, the participants reported the number and type of food outlets nearby. Their electronic diaries simultaneously recorded their GPS coordinates. The GPS data were later overlaid with a GIS map of food outlets to produce an objective count of the number of food outlets within 50 m of the participant. Results: Correlations between self-reported and GIS counts of food outlets within 50 m were only of a small size (r=0.17; P<.001). Logistic regression analyses revealed that the GIS count significantly predicted eating similar to the self-reported counts (area under the curve for the receiver operating characteristic curve [AUC-ROC] self-report=0.53, SE 0.00 versus AUC-ROC 50 m GIS=0.53, SE 0.00; P=.41). However, there was a significant difference between the GIS-derived and self-reported counts of food outlets and the self-reported type of food outlets (AUC-ROC self-reported outlet type=0.56, SE 0.01; P<.001). Conclusions: The subjective food environment appears to predict eating better than objectively measured food environments via GIS. mHealth apps may need to consider the type of food outlets rather than the raw number of outlets in an individual’s environment. %M 32706728 %R 10.2196/15948 %U https://mhealth.jmir.org/2020/7/e15948 %U https://doi.org/10.2196/15948 %U http://www.ncbi.nlm.nih.gov/pubmed/32706728 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e15576 %T Effectiveness of Wearable Trackers on Physical Activity in Healthy Adults: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A Tang,Matilda Swee Sun %A Moore,Katherine %A McGavigan,Andrew %A Clark,Robyn A %A Ganesan,Anand N %+ College of Medicine and Public Health, Flinders University, Level 5, Room 5E209 Flinders Medical Centre, Adelaide, Australia, 61 (08) 7221 8200, anand.ganesan@flinders.edu.au %K wearable activity tracker %K physical activity %K healthy adults %K randomized controlled trials %D 2020 %7 22.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Wearable trackers are an increasingly popular tool among healthy adults and are used to facilitate self-monitoring of physical activity. Objective: We aimed to systematically review the effectiveness of wearable trackers for improving physical activity and weight reduction among healthy adults. Methods: This review used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology and reporting criteria. English-language randomized controlled trials with more than 20 participants from MEDLINE, CINAHL, Cochrane Library, Web of Science, PubMed, and Scopus (2000-2017) were identified. Studies were eligible for inclusion if they reported an intervention group using wearable trackers, reporting steps per day, total moderate-to-vigorous physical activity, activity, physical activity, energy expenditure, and weight reduction. Results: Twelve eligible studies with a total of 1693 participants met the inclusion criteria. The weighted average age was 40.7 years (95% CI 31.1-50.3), with 64.4% women. The mean intervention duration was 21.4 weeks (95% CI 6.1-36.7). The usage of wearable trackers was associated with increased physical activity (standardized mean difference 0.449, 95% CI 0.10-0.80; P=.01). In the subgroup analyses, however, wearable trackers demonstrated no clear benefit for physical activity or weight reduction. Conclusions: These data suggest that the use of wearable trackers in healthy adults may be associated with modest short-term increases in physical activity. Further data are required to determine if a sustained benefit is associated with wearable tracker usage. %M 32706685 %R 10.2196/15576 %U http://mhealth.jmir.org/2020/7/e15576/ %U https://doi.org/10.2196/15576 %U http://www.ncbi.nlm.nih.gov/pubmed/32706685 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 7 %P e18068 %T Acceptability and Usability of the Mobile Digital Health App NoObesity for Families and Health Care Professionals: Protocol for a Feasibility Study %A Meinert,Edward %A Rahman,Em %A Potter,Alison %A Lawrence,Wendy %A Van Velthoven,Michelle %+ Digitally Enabled PrevenTative Health (DEPTH) Research Group, Department of Paediatrics, Univeristy of Oxford, John Radcliffe Hospital, Oxford, United Kingdom, 44 7824446808, e.meinert14@imperial.ac.uk %K mHealth %K mobile health %K digital health %K digital technology %K weight loss %K obesity %K overweight %K child health %K cell phone %K telecommunication %D 2020 %7 22.7.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Almost a quarter or more than a fifth of children in the United Kingdom are overweight or obese by the time they start school. The UK Department of Health and Social Care’s national policy for combating childhood obesity has critical outcomes centered on sugar and caloric consumption reduction. Health Education England has developed two digital apps for families with children up to 15 years and for their associated health care professionals to provide a digital learning resource and tool aimed at encouraging healthy lifestyles to prevent obesity. Objective: This feasibility study assesses the usability and acceptability of Health Education England’s NoObesity app for undertaking activities to improve families’ diet and physical activity. The purpose of the study is to evaluate the app’s influence on self-efficacy and goal setting and to determine what can be learnt to improve its design for future studies, if there is evidence of adoption and sustainability. Methods: The study population will include 20 to 40 families and their linked health care professionals. Considering issues related to digital access associated with socioeconomic status and the impact on information technology use, study recruitment will be regionally focused in a low socioeconomic status area. The study will last for 9 months (3-month intervention period and 6-month follow-up). The evaluations of feasibility, acceptability, and usability will be conducted using the following scales and theoretical frameworks: (1) system usability scale; (2) Reach Effectiveness Adoption Implementation Maintenance framework; (3) Bandura model of health promotion; and (4) Nonadoption, Abandonment, and Challenges to the Scale-up, Spread, and Suitability framework. App use will be captured and quantitatively analyzed for net use patterns (eg, number of screens viewed, number of logins, cumulative minutes using the app, number of plans made, and number of times goals met) and to triangulate qualitative feedback from study participants. Results: This study was funded in March 2019 by Health Education England and received University of Oxford Medical Sciences Interdivisional Research Ethics Committee approval on January 31, 2020 (R62092/RE001). At manuscript submission, study recruitment is pending, and expected results will be published in 2021. Conclusions: This study will provide evidence on the NoObesity app’s influence on self-efficacy and goal-setting and determine what can be learnt to improve its design for future studies, if there is evidence of adoption and sustainability. International Registered Report Identifier (IRRID): PRR1-10.2196/18068 %M 32706703 %R 10.2196/18068 %U http://www.researchprotocols.org/2020/7/e18068/ %U https://doi.org/10.2196/18068 %U http://www.ncbi.nlm.nih.gov/pubmed/32706703 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e19364 %T A Novel Educational Control Group Mobile App for Meditation Interventions: Single-Group Feasibility Trial %A Huberty,Jennifer %A Eckert,Ryan %A Puzia,Megan %A Laird,Breanne %A Larkey,Linda %A Mesa,Ruben %+ College of Health Solutions, Arizona State University, 500 North 3rd Street, Phoenix, AZ, 85004, United States, 1 402 301 1304, jhuberty@asu.edu %K feasibility %K smartphone %K mHealth %K digital health %K cancer %K beta test %D 2020 %7 21.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Smartphone ownership is becoming ubiquitous among US adults, making the delivery of health interventions via a mobile app (ie, mobile health [mHealth]) attractive to many researchers and clinicians. Meditation interventions have become popular and have been delivered to study participants via mobile apps to improve a range of health outcomes in both healthy adults and those with chronic diseases. However, these meditation mHealth interventions have been limited by a lack of high-quality control groups. More specifically, these studies have lacked consistency in their use of active, time-matched, and attention-matched control groups. Objective: The purpose of this study is to beta test a novel health education podcast control condition delivered via a smartphone app that would be a strong comparator to be used in future studies of app-based meditation interventions. Methods: Patients with myeloproliferative neoplasm (MPN) cancer were recruited nationally. Upon enrollment, participants were informed to download the investigator-developed health education podcast app onto their mobile phone and listen to ~60 min/week of cancer-related educational podcasts for 12 weeks. The benchmarks for feasibility included ≥70% of participants completing ≥70% of the prescribed 60 min/week of podcasts, ≥70% of participants reporting that they were satisfied with the intervention, and ≥70% of participants reporting that they enjoyed the health education podcasts. Results: A total of 96 patients with MPN were enrolled in the study; however, 19 never began the intervention. Of the 77 patients who participated in the intervention, 39 completed the entire study (ie, sustained participation through the follow-up period). Participation averaged 103.2 (SD 29.5) min/week. For 83.3% (10/12) of the weeks, at least 70% of participants completed at least 70% of their total prescribed use. Almost half of participants reported that they enjoyed the health education podcasts (19/39, 48.7%) and were satisfied with the intervention (17/39, 43.6%). There were no significant changes in cancer-related outcomes from baseline to postintervention. Conclusions: A 12-week, health education podcast mobile app was demanded but not accepted in a sample of patients with cancer. Using the mobile app was not associated with significant changes in cancer-related symptoms. Based on findings from this study, a health education podcast mobile app may be a feasible option as a time- and attention-matched control group for efficacy trials with more extensive formative research for the content of the podcasts and its acceptability by the specific population. Trial Registration: ClinicalTrials.gov NCT03907774; https://clinicaltrials.gov/ct2/show/NCT03907774 %M 32706719 %R 10.2196/19364 %U http://formative.jmir.org/2020/7/e19364/ %U https://doi.org/10.2196/19364 %U http://www.ncbi.nlm.nih.gov/pubmed/32706719 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18495 %T Smartphone Apps Targeting Physical Activity in People With Rheumatoid Arthritis: Systematic Quality Appraisal and Content Analysis %A Bearne,Lindsay M %A Sekhon,Mandeep %A Grainger,Rebecca %A La,Anthony %A Shamali,Mehrdad %A Amirova,Aliya %A Godfrey,Emma L %A White,Claire M %+ Department of Population Health Sciences, School of Population Health and Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, 2nd Floor, Addison House, Guy's Campus, London, SE1 1UL, United Kingdom, 44 02078486283, lindsay.bearne@kcl.ac.uk %K rheumatoid arthritis %K physical activity %K exercise %K mobile applications %K behavior change techniques %K mobile phone %D 2020 %7 21.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Rheumatoid arthritis (RA) is a disabling, inflammatory joint condition affecting 0.5%-1% of the global population. Physical activity (PA) and exercise are recommended for people with RA, but uptake and adherence tend to be low. Smartphone apps could assist people with RA to achieve PA recommendations. However, it is not known whether high quality, evidence-informed PA apps that include behavior change techniques (BCTs) previously identified as effective for PA adherence are available for people with RA. Objective: This study aims to systematically identify apps that include goals to facilitate PA for adults with RA and assess app quality and content for the inclusion of relevant BCTs against recommendations for cardiorespiratory, resistance, flexibility, and neuromotor PA and exercise. Methods: A systematic search of the Apple App Store and Google Play Store in the United Kingdom was conducted to identify English language apps that promote PA for adults with RA. Two researchers independently assessed app quality (mobile app rating scale [MARS]; range 0-5) and content (BCT Taxonomy version 1, World Health Organization, the American College of Sports Medicine, and the European League against Rheumatism recommendations for PA). The completeness of reporting of PA prescription was evaluated using a modified version of the Consensus on Exercise Reporting Template (CERT; range 0-14). Results: A total of 14,047 apps were identified. Following deduplication, 2737 apps were screened for eligibility; 6 apps were downloaded (2 on the Apple App Store and 4 on the Google Play Store), yielding 4 unique apps. App quality varied (MARS score 2.25-4.17). Only 1 app was congruent with all aspects of the PA recommendations. All apps completely or partially recommended flexibility and resistance exercises, 3 apps completely or partially advised some form of neuromotor exercise, but only 2 offered full or partial guidance on cardiorespiratory exercise. Completeness of exercise reporting was mixed (CERT scores 7-14 points) and 3-7 BCTs were identified. Two BCTs were common to all apps (information about health consequences and instruction on how to perform behavior). Higher quality apps included a greater number of BCTs and were more closely aligned to PA guidance. No published trials evaluating the effect of the included apps were identified. Conclusions: This review identifies 4 PA apps of mixed quality and content for use by people with RA. Higher quality apps were more closely aligned to PA guidance and included a greater number of BCTs. One high-quality app (Rheumatoid Arthritis Information Support and Education) included 7 BCTs and was fully aligned with PA and exercise guidance. The effect of apps on PA adherence should be established before implementation. %M 32706727 %R 10.2196/18495 %U http://mhealth.jmir.org/2020/7/e18495/ %U https://doi.org/10.2196/18495 %U http://www.ncbi.nlm.nih.gov/pubmed/32706727 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e15331 %T Usability of Wearable Devices With a Novel Cardiac Force Index for Estimating the Dynamic Cardiac Function: Observational Study %A Hsiao,Po-Jen %A Chiu,Chih-Chien %A Lin,Ke-Hsin %A Hu,Fu-Kang %A Tsai,Pei-Jan %A Wu,Chun-Ting %A Pang,Yuan-Kai %A Lin,Yu %A Kuo,Ming-Hao %A Chen,Kang-Hua %A Wu,Yi-Syuan %A Wu,Hao-Yi %A Chang,Ya-Ting %A Chang,Yu-Tien %A Cheng,Chia-Shiang %A Chuu,Chih-Pin %A Lin,Fu-Huang %A Chang,Chi-Wen %A Li,Yuan-Kuei %A Chan,Jenq-Shyong %A Chu,Chi-Ming %+ Division of Biostatistics and Medical Informatics, Department of Epidemiology, School of Public Health, National Defense Medical Center, Neihu 114, Taipei, Taiwan, 1 886 2 87923100, chuchiming@web.de %K cardiac force %K running %K acceleration %K physical activity %K heart rate %D 2020 %7 21.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Long-distance running can be a form of stress to the heart. Technological improvements combined with the public’s gradual turn toward mobile health (mHealth), self-health, and exercise effectiveness have resulted in the widespread use of wearable exercise products. The monitoring of dynamic cardiac function changes during running and running performance should be further studied. Objective: We investigated the relationship between dynamic cardiac function changes and finish time for 3000-meter runs. Using a wearable device based on a novel cardiac force index (CFI), we explored potential correlations among 3000-meter runners with stronger and weaker cardiac functions during running. Methods: This study used the American product BioHarness 3.0 (Zephyr Technology Corporation), which can measure basic physiological parameters including heart rate, respiratory rate, temperature, maximum oxygen consumption, and activity. We investigated the correlations among new physiological parameters, including CFI = weight * activity / heart rate, cardiac force ratio (CFR) = CFI of running / CFI of walking, and finish times for 3000-meter runs. Results: The results showed that waist circumference, smoking, and CFI were the significant factors for qualifying in the 3000-meter run. The prediction model was as follows: ln (3000 meters running performance pass probability / fail results probability) = –2.702 – 0.096 × [waist circumference] – 1.827 × [smoke] + 0.020 × [ACi7]. If smoking and the ACi7 were controlled, contestants with a larger waist circumference tended to fail the qualification based on the formula above. If waist circumference and ACi7 were controlled, smokers tended to fail more often than nonsmokers. Finally, we investigated a new calculation method for monitoring cardiac status during exercise that uses the CFI of walking for the runner as a reference to obtain the ratio between the cardiac force of exercise and that of walking (CFR) to provide a standard for determining if the heart is capable of exercise. A relationship is documented between the CFR and the performance of 3000-meter runs in a healthy 22-year-old person. During the running period, data are obtained while participant slowly runs 3000 meters, and the relationship between the CFR and time is plotted. The runner’s CFR varies with changes in activity. Since the runner’s acceleration increases, the CFR quickly increases to an explosive peak, indicating the runner’s explosive power. At this period, the CFI revealed a 3-fold increase (CFR=3) in a strong heart. After a time lapse, the CFR is approximately 2.5 during an endurance period until finishing the 3000-meter run. Similar correlation is found in a runner with a weak heart, with the CFR at the beginning period being 4 and approximately 2.5 thereafter. Conclusions: In conclusion, the study results suggested that measuring the real-time CFR changes could be used in a prediction model for 3000-meter running performance. %M 32706725 %R 10.2196/15331 %U https://mhealth.jmir.org/2020/7/e15331 %U https://doi.org/10.2196/15331 %U http://www.ncbi.nlm.nih.gov/pubmed/32706725 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e14778 %T Formative Evaluation of a Smartphone App for Monitoring Daily Meal Distribution and Food Selection in Adolescents: Acceptability and Usability Study %A Langlet,Billy %A Maramis,Christos %A Diou,Christos %A Maglaveras,Nikolaos %A Fagerberg,Petter %A Heimeier,Rachel %A Lekka,Irini %A Delopoulos,Anastasios %A Ioakimidis,Ioannis %+ The Innovative Use of Mobile Phones to Promote Physical Activity and Nutrition Across the Lifespan Research Group, Department of Biosciences and Nutrition, Karolinska Institutet, Blickagången 16, Huddinge, , Sweden, 46 08 524 810 95, billy.langlet@ki.se %K mHealth %K eHealth %K dietary behavior %K lifestyle behavioral monitoring %K lifestyle interventions %K obesity %K mobile phone %K smartphone %K weight management %K overweight %D 2020 %7 21.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Obesity interventions face the problem of weight regain after treatment as a result of low compliance. Mobile health (mHealth) technologies could potentially increase compliance and aid both health care providers and patients. Objective: This study aimed to evaluate the acceptability and usability and define system constraints of an mHealth system used to monitor dietary habits of adolescents in real life, as a first step in the development of a self-monitoring and lifestyle management system against adolescent obesity. Methods: We recruited 26 students from a high school in Stockholm, Sweden. After a 30-minute information meeting and 5-minute individual instruction on how to use an mHealth system (smartphone with app and two external sensors), participants used it for 2-3 weeks to objectively collect dietary habits. The app and sensors were used by the participants, without supervision, to record as many main meals and snacks as possible in real life. Feasibility was assessed following the “mHealth evidence reporting and assessment checklist,” and usability was assessed by questionnaires. Compliance was estimated based on system use, where a registration frequency of 3 main meals (breakfast, lunch, and dinner) per day for the period of the experiment, constituted 100% compliance. Results: Participants included in the analysis had a mean age of 16.8 years (SD 0.7 years) and BMI of 21.9 kg/m2 (SD 4.1 kg/m2). Due to deviations from study instructions, 2 participants were excluded from the analysis. During the study, 6 participants required additional information on system use. The system received a ‘Good’ grade (77.1 of 100 points) on the System Usability Scale, with most participants reporting that they were comfortable using the smartphone app. Participants expressed a willingness to use the app mostly at home, but also at school; most of their improvement suggestions concerned design choices for the app. Of all main meals, the registration frequency increased from 70% the first week to 76% the second week. Participants reported that 40% of the registered meals were home-prepared, while 34% of the reported drinks contained sugar. On average, breakfasts took place at 8:30 AM (from 5:00 AM to 2:00 PM), lunches took place at 12:15 PM (from 10:15 AM to 6:15 PM), and dinners took place at 7:30 PM (from 3:00 PM to 11:45 PM). When comparing meal occurrence during weekdays vs weekends, breakfasts and lunches were eaten 3 hours later during weekends, while dinner timing was unaffected. Conclusions: From an infrastructural and functional perspective, system use was feasible in the current context. The smartphone app appears to have high acceptability and usability in high school students, which are the intended end-users. The system appears promising as a relatively low-effort method to provide real-life dietary habit measurements associated with overweight and obesity risk. %M 32706684 %R 10.2196/14778 %U http://mhealth.jmir.org/2020/7/e14778/ %U https://doi.org/10.2196/14778 %U http://www.ncbi.nlm.nih.gov/pubmed/32706684 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18012 %T Mobile Personal Health Care System for Noninvasive, Pervasive, and Continuous Blood Pressure Monitoring: Development and Usability Study %A Mena,Luis J %A Félix,Vanessa G %A Ostos,Rodolfo %A González,Armando J %A Martínez-Peláez,Rafael %A Melgarejo,Jesus D %A Maestre,Gladys E %+ Academic Unit of Computing, Master Program in Applied Sciences, Universidad Politecnica de Sinaloa, Carretera Municipal Libre Mazatlan-Higueras Km. 3, Mazatlan, 82199, Mexico, 52 6691800695 ext 140, lmena@upsin.edu.mx %K mHealth %K photoplethysmography %K blood pressure monitoring %K hypertension %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-based blood pressure (BP) monitoring using photoplethysmography (PPG) technology has emerged as a promising approach to empower users with self-monitoring for effective diagnosis and control of hypertension. Objective: This study aimed to develop a mobile personal health care system for noninvasive, pervasive, and continuous estimation of BP level and variability, which is user friendly for elderly people. Methods: The proposed approach was integrated by a self-designed cuffless, calibration-free, wireless, and wearable PPG-only sensor and a native purposely designed smartphone app using multilayer perceptron machine learning techniques from raw signals. We performed a development and usability study with three older adults (mean age 61.3 years, SD 1.5 years; 66% women) to test the usability and accuracy of the smartphone-based BP monitor. Results: The employed artificial neural network model had good average accuracy (>90%) and very strong correlation (>0.90) (P<.001) for predicting the reference BP values of our validation sample (n=150). Bland-Altman plots showed that most of the errors for BP prediction were less than 10 mmHg. However, according to the Association for the Advancement of Medical Instrumentation and British Hypertension Society standards, only diastolic blood pressure prediction met the clinically accepted accuracy thresholds. Conclusions: With further development and validation, the proposed system could provide a cost-effective strategy to improve the quality and coverage of health care, particularly in rural zones, areas lacking physicians, and areas with solitary elderly populations. %M 32459642 %R 10.2196/18012 %U https://mhealth.jmir.org/2020/7/e18012 %U https://doi.org/10.2196/18012 %U http://www.ncbi.nlm.nih.gov/pubmed/32459642 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17665 %T The Effect of Women’s Differential Access to Messages on Their Adoption of Mobile Health Services and Pregnancy Behavior in Bangladesh: Retrospective Cross-Sectional Study %A Alam,Mafruha %A Banwell,Cathy %A Lokuge,Kamalini %+ Australian National University, 62 Mills Road, National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, ACT, 2601, Australia, 61 6125 5602, mafruha.alam@gmail.com %K mHealth %K inequality %K access %K pregnancy %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Text or voice messages have been used as a popular method for improving women’s knowledge on birth preparedness and newborn health care practices worldwide. The Aponjon service in Bangladesh provides twice-weekly messages to female subscribers about their pregnancy and newborn care on mobile phones that they own or share with family members. It is important to understand whether women’s singular access to a phone affects their service satisfaction and the adoption of health messages before deploying such interventions in resource-limited settings. Objective: This study aims to evaluate the effect of women’s singular and shared access to mobile phone messages on their service utilization and perceived behavioral change around birth preparedness and pregnancy care. Methods: In 2014, Aponjon conducted a retrospective cross-sectional survey of 459 female subscribers who received text or voice messages during their pregnancy by themselves (n=253) or with family members (n=206). We performed multivariable regression analyses to investigate the association between pregnant women’s differential access to messages and other socioeconomic factors and outcomes of service satisfaction, ability to recall service short code, ability to identify danger signs of pregnancy, preference for skilled delivery, arrangement of a blood donor for delivery and pregnancy complications, maternal nutrition, use of potable drinking water, and washing hands with soap for hygiene. Results: In the multivariable analysis, women who had singular access to messages had higher odds of reporting high satisfaction (odds ratio [OR] 1.72, 95% CI 1.12-2.63; P=.01), recalling the service short code (OR 2.88, 95% CI 1.90-4.36; P<.001), consuming nutritious food 5 times a day (OR 1.58, 95% CI 1.04-2.40; P=.03), and following the instructions of Aponjon on drinking potable water (OR 1.90, 95% CI 1.17-3.09; P=.01) than women who shared access with family members. Women’s differential access to messages did not affect their knowledge of danger signs and preparedness around delivery. Adolescent women and women aged 20-24 years had lower odds of planning safe deliveries than older women (aged≥25 years). Secondary education was statistically significantly associated with women’s ability to recall the short code and pregnancy danger signs, plan safe delivery, and select blood donors for emergencies. Higher family income was associated with women’s satisfaction, recognition of danger signs, and arrangement of blood donors and nutritious diet. Women who received more than 4 antenatal care visits had higher odds of liking the service, preferring skilled delivery, recalling danger signs, and consuming nutritious food. Conclusions: The capacity of women to independently access mobile phone messages can improve their adoption of mobile health services and some pregnancy health care practices. A holistic approach and equitable support are required to improve access to resources and knowledge of delivery preparedness among low-literate and younger women in low-income households. %M 32706694 %R 10.2196/17665 %U https://mhealth.jmir.org/2020/7/e17665 %U https://doi.org/10.2196/17665 %U http://www.ncbi.nlm.nih.gov/pubmed/32706694 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17535 %T Feasibility and Acceptability of an Adapted Mobile Phone Message Program and Changes in Maternal and Newborn Health Knowledge in Four Provinces of Afghanistan: Single-Group Pre-Post Assessment Study %A Lebrun,Victoria %A Dulli,Lisa %A Alami,Sayed Omar %A Sidiqi,Arzoo %A Sultani,Ahmad Shah %A Rastagar,Sayed Haroon %A Halimzai,Iftikhar %A Ahmadzai,Sharif %A Todd,Catherine S %+ Global Health, Population, and Nutrition, FHI 360, 359 Blackwell St #200, Durham, NC, 27701, United States, 1 9195447040 ext 11640, vlebrun@fhi360.org %K Afghanistan %K mobile apps %K pregnant women %K maternal health %K newborn health %K social and behavior change %K mHealth %K voice message %K SMS %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile phone apps for health promotion have expanded in many low- and middle-income countries. Afghanistan, with high maternal and newborn morbidity and mortality rates, a fragile health infrastructure, and high levels of mobile phone ownership, is an ideal setting to examine the utility of such programs. We adapted messages of the Mobile Alliance for Maternal Action (MAMA) program, which was designed to promote healthy behaviors during pregnancy and a newborn’s first year of life, to the Afghan context. We then piloted and assessed the program in the provinces of Kabul, Herat, Kandahar, and Balkh. Objective: The aim of this study was to assess the feasibility and acceptability of the MAMA pilot program, and to examine changes in reported maternal, newborn, and child health (MNCH) knowledge and attitudes among participants from baseline to follow up. Methods: We conducted a single-group study with data collected within 10 weeks of enrollment, and data collection was repeated approximately 6 months later. Data were collected through face-to-face interviews using structured questionnaires. Eligible participants included pregnant women who had registered to receive fully automated mobile health messages and their husbands. Assessment questionnaires queried sociodemographic details; knowledge, attitudes, and health care-seeking practices; and intervention experience and acceptability at follow up. The number of messages received by a given phone number was extracted from the program database. We descriptively analyzed the feasibility and acceptability data and compared the change in MNCH knowledge between baseline and follow-up measures using the McNemar Chi square test. Results: Overall, 895 women were enrolled in the MAMA program. Data from 453/625 women (72.5% of the pretest sample) who received voice (n=302) or text (n=151) messages, and 276/427 men (64.6% of the pretest sample) who received voice (n=185) or text (n=91) messages contributing data at both time points were analyzed. At follow up, 699/729 (95.9%) participants were still enrolled in the MAMA program; voice message and SMS text messaging subscribers received 43 and 69 messages on average over the 6-month period, respectively. Participants who were voice message subscribers and female participants more commonly reported missing messages compared with the text message subscribers and men; predominant reasons for missed messages were the subscribers being busy with chores or not having their shared phone with them. Over 90% of men and women reported experiencing benefits from the program, mainly increased knowledge, and 226/453 (49.9%) of the female participants reported referring someone else to the program. Most of the participants (377/453, 83.2% women and 258/276, 93.5% men) believed it was beneficial to include husbands in the program. Joint decision making regarding maternal and child health care increased overall. The proportions of participants with correct knowledge significantly increased for all but one MNCH measure at follow up. Conclusions: This assessment indicates that the pilot MAMA program is feasible and acceptable in the Afghan context. Further research should be conducted to determine whether program participation leads to improved MNCH knowledge, health practices, and health service utilization in this fragile setting prior to larger scale up. %M 32706690 %R 10.2196/17535 %U https://mhealth.jmir.org/2020/7/e17535 %U https://doi.org/10.2196/17535 %U http://www.ncbi.nlm.nih.gov/pubmed/32706690 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17552 %T A Personalized Physical Activity Coaching App for Breast Cancer Survivors: Design Process and Early Prototype Testing %A Monteiro-Guerra,Francisco %A Signorelli,Gabriel Ruiz %A Tadas,Shreya %A Dorronzoro Zubiete,Enrique %A Rivera Romero,Octavio %A Fernandez-Luque,Luis %A Caulfield,Brian %+ Salumedia Tecnologias, Salumedia Tecnologías S.L.U., Avda. República Argentina, nº 24 Edificio Torre de los Remedios, 5ª planta módulo A, Seville, 41011, Spain, 34 656930901, luis@salumedia.com %K user-centered design %K physical activity %K coaching %K behavior change %K mobile app %K mobile phone %K breast cancer %K usability %D 2020 %7 15.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Existing evidence supports the many benefits of physical activity (PA) in breast cancer survival. However, few breast cancer survivors adhere to the recommended levels of activity. A PA coaching app that provides personalized feedback, guidance, and motivation to the user might have the potential to engage these individuals in a more active lifestyle, in line with the general recommendations. To develop a successful tool, it is important to involve the end users in the design process and to make theoretically grounded design decisions. Objective: This study aimed to execute the design process and early prototype evaluation of a personalized PA coaching app for posttreatment breast cancer survivors. In particular, the study explored a design combining behavioral theory and tailored coaching strategies. Methods: The design process was led by a multidisciplinary team, including technical and health professionals, and involved input from a total of 22 survivors. The process comprised 3 stages. In stage 1, the literature was reviewed and 14 patients were interviewed to understand the needs and considerations of the target population toward PA apps. In stage 2, the global use case for the tool was defined, the features were ideated and refined based on theory, and a digital interactive prototype was created. In stage 3, the prototype went through usability testing with 8 patients and was subjected to quality and behavior change potential evaluations by 2 human-computer interaction experts. Results: The design process has led to the conceptualization of a personalized coaching app for walking activities that addresses the needs of breast cancer survivors. The main features of the tool include a training plan and schedule, adaptive goal setting, real-time feedback and motivation during walking sessions, activity status through the day, activity history, weekly summary reports, and activity challenges. The system was designed to measure users’ cadence during walking, use this measure to infer their training zone, and provide real-time coaching to control the intensity of the walking sessions. The outcomes from user testing and expert evaluation of the digital prototype were very positive, with scores from the system usability scale, mobile app rating scale, and app behavior change scale of 95 out of 100, 4.6 out of 5, and 15 out of 21, respectively. Conclusions: Implementing a user-centered design approach for the development and early evaluation of an app brings essential considerations to tailor the solution to the user’s needs and context. In addition, informing the design on behavioral and tailored coaching theories supports the conceptualization of the PA coaching system. This is critical for optimizing the usability, acceptability, and long-term effectiveness of the tool. After successful early in-laboratory testing, the app will be developed and evaluated in a pilot study in a real-world setting. %M 32673271 %R 10.2196/17552 %U https://mhealth.jmir.org/2020/7/e17552 %U https://doi.org/10.2196/17552 %U http://www.ncbi.nlm.nih.gov/pubmed/32673271 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18255 %T Exclusively Digital Health Interventions Targeting Diet, Physical Activity, and Weight Gain in Pregnant Women: Systematic Review and Meta-Analysis %A Rhodes,Alexandra %A Smith,Andrea D %A Chadwick,Paul %A Croker,Helen %A Llewellyn,Clare H %+ University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom, 44 207679 1720, alexandra.rhodes.15@ucl.ac.uk %K gestational weight gain %K digital interventions %K behavior change techniques %K user engagement %K smartphone %K mobile phone %D 2020 %7 10.7.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Interventions to promote a healthy diet, physical activity, and weight management during pregnancy are increasingly embracing digital technologies. Although some interventions have combined digital with interpersonal (face-to-face or telephone) delivery, others have relied exclusively on digital delivery. Exclusively digital interventions have the advantages of greater cost-effectiveness and broader reach and as such can be a valuable resource for health care providers. Objective: This systematic review aims to focus on exclusively digital interventions to determine their effectiveness, identify behavior change techniques (BCTs), and investigate user engagement. Methods: A total of 6 databases (Medical Literature Analysis and Retrieval System Online [MEDLINE], Excerpta Medica dataBASE [EMBASE], PsycINFO, Cumulated Index to Nursing and Allied Health Literature [CINAHL] Plus, Web of Science, and ProQuest) were searched for randomized controlled trials or pilot control trials of exclusively digital interventions to encourage healthy eating, physical activity, or appropriate weight gain during pregnancy. The outcome measures were gestational weight gain (GWG) and changes in physical activity and dietary behaviors. Study quality was assessed using the Cochrane Risk of Bias tool 2.0. Where possible, pooled effect sizes were calculated using a random effects meta-analysis. Results: In total, 11 studies met the inclusion criteria. The risk of bias was mostly high (n=5) or moderate (n=3). Of the 11 studies, 6 reported on GWG as the primary outcome, 4 of which also measured changes in physical activity and dietary behaviors, and 5 studies focused either on dietary behaviors only (n=2) or physical activity only (n=3). The meta-analyses showed no significant benefit of interventions on total GWG for either intention-to-treat data (−0.28 kg; 95% CI −1.43 to 0.87) or per-protocol data (−0.65 kg; 95% CI −1.98 to 0.67). Substantial heterogeneity in outcome measures of change in dietary behaviors and physical activity precluded further meta-analyses. BCT coding identified 7 BCTs that were common to all effective interventions. Effective interventions averaged over twice as many BCTs from the goals and planning, and feedback and monitoring domains as ineffective interventions. Data from the 6 studies reporting on user engagement indicated a positive association between high engagement with key BCTs and greater intervention effectiveness. Interventions using proactive messaging and feedback appeared to have higher levels of engagement. Conclusions: In contrast to interpersonal interventions, there is little evidence of the effectiveness of exclusively digital interventions to encourage a healthy diet, physical activity, or weight management during pregnancy. In this review, effective interventions used proactive messaging, such as reminders to engage in BCTs, feedback on progress, or tips, suggesting that interactivity may drive engagement and lead to greater effectiveness. Given the benefits of cost and reach of digital interventions, further research is needed to understand how to use advancing technologies to enhance user engagement and improve effectiveness. %M 32673251 %R 10.2196/18255 %U https://mhealth.jmir.org/2020/7/e18255 %U https://doi.org/10.2196/18255 %U http://www.ncbi.nlm.nih.gov/pubmed/32673251 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17558 %T A Physical Activity and Diet Program Delivered by Artificially Intelligent Virtual Health Coach: Proof-of-Concept Study %A Maher,Carol Ann %A Davis,Courtney Rose %A Curtis,Rachel Grace %A Short,Camille Elizabeth %A Murphy,Karen Joy %+ Alliance for Research in Exercise, Nutrition and Activity, Allied Health and Human Performance, University of South Australia, GPO Box 2471, Adelaide, 5001, Australia, 61 883022315, carol.maher@unisa.edu.au %K virtual assistant %K chatbot %K Mediterranean diet %K physical activity %K lifestyle %D 2020 %7 10.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Poor diet and physical inactivity are leading modifiable causes of death and disease. Advances in artificial intelligence technology present tantalizing opportunities for creating virtual health coaches capable of providing personalized support at scale. Objective: This proof of concept study aimed to test the feasibility (recruitment and retention) and preliminary efficacy of physical activity and Mediterranean-style dietary intervention (MedLiPal) delivered via artificially intelligent virtual health coach. Methods: This 12-week single-arm pre-post study took place in Adelaide, Australia, from March to August 2019. Participants were inactive community-dwelling adults aged 45 to 75 years, recruited through news stories, social media posts, and flyers. The program included access to an artificially intelligent chatbot, Paola, who guided participants through a computer-based individualized introductory session, weekly check-ins, and goal setting, and was available 24/7 to answer questions. Participants used a Garmin Vivofit4 tracker to monitor daily steps, a website with educational materials and recipes, and a printed diet and activity log sheet. Primary outcomes included feasibility (based on recruitment and retention) and preliminary efficacy for changing physical activity and diet. Secondary outcomes were body composition (based on height, weight, and waist circumference) and blood pressure. Results: Over 4 weeks, 99 potential participants registered expressions of interest, with 81 of those screened meeting eligibility criteria. Participants completed a mean of 109.8 (95% CI 1.9-217.7) more minutes of physical activity at week 12 compared with baseline. Mediterranean diet scores increased from a mean of 3.8 out of 14 at baseline, to 9.6 at 12 weeks (mean improvement 5.7 points, 95% CI 4.2-7.3). After 12 weeks, participants lost an average 1.3 kg (95% CI –0.1 to –2.5 kg) and 2.1 cm from their waist circumference (95% CI –3.5 to –0.7 cm). There were no significant changes in blood pressure. Feasibility was excellent in terms of recruitment, retention (90% at 12 weeks), and safety (no adverse events). Conclusions: An artificially intelligent virtual assistant-led lifestyle-modification intervention was feasible and achieved measurable improvements in physical activity, diet, and body composition at 12 weeks. Future research examining artificially intelligent interventions at scale, and for other health purposes, is warranted. %M 32673246 %R 10.2196/17558 %U https://mhealth.jmir.org/2020/7/e17558 %U https://doi.org/10.2196/17558 %U http://www.ncbi.nlm.nih.gov/pubmed/32673246 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 2 %P e17044 %T High School Students’ Preferences and Design Recommendations for a Mobile Phone–Based Intervention to Improve Psychological Well-Being: Mixed Methods Study %A Müssener,Ulrika %A Thomas,Kristin %A Bendtsen,Preben %A Bendtsen,Marcus %+ Department of Medical and Health Sciences, Linköping University, Sandbäcksgatan 1, Linköping, 58183, Sweden, 46 732702426, ulrika.mussener@liu.se %K mental health %K stress %K high school students %K intervention %K mHealth %D 2020 %7 9.7.2020 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Young adults’ mental health is characterized by relatively high rates of stress and anxiety and low levels of help-seeking behavior. Mobile health (mHealth) interventions could offer a cost-effective and readily available avenue to provide personalized support to young adults. More research needs to be directed at the development of mHealth interventions targeting youths specifically, as well as at determining how to reach young people and how to effectively intervene to improve psychological well-being. Objective: The objective was to gather perceptions from high school students to inform the development of a prototype mHealth intervention aiming to promote psychological well-being. Methods: A mixed methods design was used to (1) investigate high school students’ perceptions about stress and its consequences in daily life, as well as their ability to cope with stress, and (2) explore their preferences and design recommendations for an mHealth intervention to improve psychological well-being. Students from two high schools in the southeast of Sweden were invited to take part in the study. Recruitment of high school students was completed over a 6-week period, between October 25 and December 7, 2018. Recruitment entailed inviting students to complete a stress test (ie, screening and feedback) on their mobile phones. After completing the stress test, all participants were invited to complete a follow-up questionnaire and take part in telephone interviews. Results: A total of 149 high school students completed the stress test, of which 68 completed the questionnaire. There were 67 free-text comments distributed across the items. The majority of participants (55/68, 81%) stated that they coped with stress better or in the same way after engaging in the stress test, due to time management, dialogue with others, and self-refection. A total of 4 out of 68 participants (6%)—3 female students (75%) and 1 male student (25%)—took part in telephone interviews. Three main themes were identified from the interview data: perceptions about stress, design features, and intervention features. Conclusions: Stress was described by the students as a condition caused by high demands set by oneself and the social environment that impacted their physical health, personal relationships, school performance, and emotional well-being. Participants claimed that mHealth interventions need to be clearly tailored to a young age group, be evidence based, and offer varied types of support, such as information about stress, exercises to help organize tasks, self-assessment, coping tools, and recommendations of other useful websites, literature, blogs, self-help books, or role models. Mobile phones seemed to be a feasible and acceptable platform for the delivery of an intervention. %M 32673268 %R 10.2196/17044 %U https://pediatrics.jmir.org/2020/2/e17044 %U https://doi.org/10.2196/17044 %U http://www.ncbi.nlm.nih.gov/pubmed/32673268 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 7 %P e16699 %T Preventing Cardiovascular Disease Among Urban African Americans With a Mobile Health App (the MOYO App): Protocol for a Usability Study %A Taylor Jr,Herman A %A Francis,Sherilyn %A Evans,Chad Ray %A Harvey,Marques %A Newton,Brittney A %A Jones,Camara P %A Akintobi,Tabia Henry %A Clifford,Gari %+ Cardiovascular Research Institute, Morehouse School of Medicine, 720 West View Drive, Atlanta, GA, United States, 1 404 752 1978, htaylor@msm.edu %K African Americans %K mHealth %K community-based participatory research %K agile design %K cardiovascular %D 2020 %7 9.7.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cardiovascular disease (CVD) disparities are a particularly devastating manifestation of health inequity. Despite advancements in prevention and treatment, CVD is still the leading cause of death in the United States. Additionally, research indicates that African American (AA) and other ethnic-minority populations are affected by CVD at earlier ages than white Americans. Given that AAs are the fastest-growing population of smartphone owners and users, mobile health (mHealth) technologies offer the unparalleled potential to prevent or improve self-management of chronic disease among this population. Objective: To address the unmet need for culturally tailored primordial prevention CVD–focused mHealth interventions, the MOYO app was cocreated with the involvement of young people from this priority community. The overall project aims to develop and evaluate the effectiveness of a novel smartphone app designed to reduce CVD risk factors among urban-AAs, 18-29 years of age. Methods: The theoretical underpinning will combine the principles of community-based participatory research and the agile software development framework. The primary outcome goals of the study will be to determine the usability, acceptability, and functionality of the MOYO app, and to build a cloud-based data collection infrastructure suitable for digital epidemiology in a disparity population. Changes in health-related parameters over a 24-week period as determined by both passive (eg, physical activity levels, sleep duration, social networking) and active (eg, use of mood measures, surveys, uploading pictures of meals and blood pressure readings) measures will be the secondary outcome. Participants will be recruited from a majority AA “large city” school district, 2 historically black colleges or universities, and 1 urban undergraduate college. Following baseline screening for inclusion (administered in person), participants will receive the beta version of the MOYO app. Participants will be monitored during a 24-week pilot period. Analyses of varying data including social network dynamics, standard metrics of activity, percentage of time away from a given radius of home, circadian rhythm metrics, and proxies for sleep will be performed. Together with external variables (eg, weather, pollution, and socioeconomic indicators such as food access), these metrics will be used to train machine-learning frameworks to regress them on the self-reported quality of life indicators. Results: This 5-year study (2015-2020) is currently in the implementation phase. We believe that MOYO can build upon findings of classical epidemiology and longitudinal studies like the Jackson Heart Study by adding greater granularity to our knowledge of the exposures and behaviors that affect health and disease, and creating a channel for outreach capable of launching interventions, clinical trials, and enhancements of health literacy. Conclusions: The results of this pilot will provide valuable information about community cocreation of mHealth programs, efficacious design features, and essential infrastructure for digital epidemiology among young AA adults. International Registered Report Identifier (IRRID): DERR1-10.2196/16699 %M 32673258 %R 10.2196/16699 %U https://www.researchprotocols.org/2020/7/e16699 %U https://doi.org/10.2196/16699 %U http://www.ncbi.nlm.nih.gov/pubmed/32673258 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18543 %T Improving the Quality of Antenatal Care Using Mobile Health in Madagascar: Five-Year Cross-Sectional Study %A Benski,Anne Caroline %A Schmidt,Nicole C %A Viviano,Manuela %A Stancanelli,Giovanna %A Soaroby,Adelia %A Reich,Michael R %+ Takemi Program in International Health, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, United States, 1 787397261, cbenski@hsph.harvard.edu %K mobile health %K maternal health %K antenatal care %K quality of care %K mobile phone %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite many efforts, maternal mortality remains a major burden in most developing countries. Mobile health (mHealth) has the potential to improve access to obstetric care through apps that help patients and providers. Objective: This study aimed to use mHealth to provide antenatal care (ANC) to 1446 pregnant women in a rural area in Madagascar and evaluate the quality of ANC provided by an mHealth system designed to change the behaviors of providers and patients. Methods: We included 1446 women who attended ANC visits in rural Madagascar from 2015 to 2019 using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). This cross-sectional study used data from different participants, with information collected over several years, to analyze the outputs related to the quality of ANC over time. Specifically, we examined the timing of the first ANC visit, the relationship between the visit duration and the risk factors among pregnant women, and the number of ANC visits per woman. Results: Following the implementation of the mHealth system in 2015, we observed that women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years (P<.001). In 2019, fewer women attended their first ANC visit in the third trimester (57/277, 20.6%) than in 2015 (147/343, 42.9%). There were statistically significant associations between the ANC visit durations and the risk factors, including age (>35 years; 25.0 min, 95% CI 24.0-25.9), educational level (longer visit for women with lower than primary education and for women who attended university and shorter for women with primary school–level education; 40.7 min, 95% CI 30.2-51.3 and 25.3 min, 95% CI 24.4-26.3 vs 23.3 min, 95% CI 22.9-23.8; P=.001), experience of domestic violence during pregnancy, gravidity, parity, infectious diseases (HIV, malaria, and syphilis), and level of anemia. Statistically significant associations were observed for all quality indicator variables. We observed a statistically significant increase in the number of ANC visits per woman over time from 2015 to 2017; the number of ANC visits per woman then became stable after the third year of implementing the PANDA mHealth system. Conclusions: This study shows the potential of an mHealth system to improve the quality of ANC, change provider behavior by standardizing ANC visits, and change patient behavior by increasing the willingness to return for subsequent visits and encouraging ANC attendance early in pregnancy. As this is an exploratory study, further studies are necessary to better understand how mHealth can change behavior and identify the conditions required for behavioral changes to persist over time. %M 32673263 %R 10.2196/18543 %U https://mhealth.jmir.org/2020/7/e18543 %U https://doi.org/10.2196/18543 %U http://www.ncbi.nlm.nih.gov/pubmed/32673263 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17842 %T Mobile Delivery of the Diabetes Prevention Program in People With Prediabetes: Randomized Controlled Trial %A Toro-Ramos,Tatiana %A Michaelides,Andreas %A Anton,Maria %A Karim,Zulekha %A Kang-Oh,Leah %A Argyrou,Charalambos %A Loukaidou,Elisavet %A Charitou,Marina M %A Sze,Wilson %A Miller,Joshua D %+ Noom, Inc, 229 W 28th St, New York, NY, , United States, 1 5168087328, andreas@noom.com %K prediabetes %K body weight %K mHealth %K mobile app %K mobile phone %K randomized controlled trial %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Centers for Disease Control and Prevention (CDC) diabetes prevention program (DPP) has formed the foundation for Type 2 Diabetes Mellitus (T2DM) prevention efforts and lifestyle change modifications in multiple care settings. To our knowledge, no randomized controlled trial has verified the efficacy of a fully mobile version of CDC’s diabetes prevention program (DPP). Objective: This study aimed to investigate the long-term weight loss and glycemic efficacy of a mobile-delivered DPP compared with a control group receiving usual medical care. Methods: Adults with prediabetes (N=202) were recruited from a clinic and randomized to either a mobile-delivered, coach-guided DPP (Noom) or a control group that received regular medical care including a paper-based DPP curriculum and no formal intervention. The intervention group learned how to use the Noom program, how to interact with their coach, and the importance of maintaining motivation. They had access to an interactive coach-to-participant interface and group messaging, daily challenges for behavior change, DPP-based education articles, food logging, and automated feedback. Primary outcomes included changes in weight and hemoglobin A1c (HbA1c) levels at 6 and 12 months, respectively. Exploratory secondary outcomes included program engagement as a predictor of changes in weight and HbA1c levels. Results: A total of 202 participants were recruited and randomized into the intervention (n=101) or control group (n=99). In the intention-to-treat (ITT) analyses, changes in the participants’ weight and BMI were significantly different at 6 months between the intervention and control groups, but there was no difference in HbA1c levels (mean difference 0.004%, SE 0.05; P=.94). Weight and BMI were lower in the intervention group by −2.64 kg (SE 0.71; P<.001) and −0.99 kg/m2 (SE 0.29; P=.001), respectively. These differences persisted at 12 months. However, in the analyses that did not involve ITT, program completers achieved a significant weight loss of 5.6% (SE 0.81; P<.001) at 6 months, maintaining 4.7% (SE 0.88; P<.001) of their weight loss at 12 months. The control group lost −0.15% at 6 months (SE 0.64; P=.85) and gained 0.33% (SE 0.70; P=.63) at 12 months. Those randomized to the intervention group who did not start the program had no meaningful weight or HbA1c level change, similar to the control group. At 1 year, the intervention group showed a 0.23% reduction in HbA1c levels; those who completed the intervention showed a 0.28% reduction. Those assigned to the control group had a 0.16% reduction in HbA1c levels. Conclusions: This novel mobile-delivered DPP achieved significant weight loss reductions for up to 1 year compared with usual care. This type of intervention reduces the risk of overt diabetes without the added barriers of in-person interventions. Trial Registration: ClinicalTrials.gov NCT03865342; https://clinicaltrials.gov/ct2/show/NCT03865342 %M 32459631 %R 10.2196/17842 %U https://mhealth.jmir.org/2020/7/e17842 %U https://doi.org/10.2196/17842 %U http://www.ncbi.nlm.nih.gov/pubmed/32459631 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16365 %T The Effects of Gamification and Oral Self-Care on Oral Hygiene in Children: Systematic Search in App Stores and Evaluation of Apps %A Fijačko,Nino %A Gosak,Lucija %A Cilar,Leona %A Novšak,Alenka %A Creber,Ruth Masterson %A Skok,Pavel %A Štiglic,Gregor %+ Faculty of Health Sciences, University of Maribor, Žitna 15, Maribor, Slovenia, 386 23004764, nino.fijacko@um.si %K mobile health %K oral health care %K gamification %K mobile store %K evidence-based dentistry %K behavior change technique %K Mobile Application Rating Scale user version %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Poor oral hygiene is a great public health problem worldwide. Oral health care education is a public health priority as the maintenance of oral hygiene is integral to overall health. Maintaining optimal oral hygiene among children is challenging and can be supported by using relevant motivational approaches. Objective: The primary aim of this study was to identify mobile smartphone apps that include gamification features focused on motivating children to learn, perform, and maintain optimal oral hygiene. Methods: We searched six online app stores using four search terms (“oral hygiene game,” “oral hygiene gamification,” “oral hygiene brush game,” and “oral hygiene brush gamification”). We identified gamification features, identified whether apps were consistent with evidence-based dentistry, performed a quality appraisal with the Mobile App Rating Scale user version (uMARS), and quantified behavior scores (Behavior Change score, uMARS score, and Coventry, Aberdeen, and London-Refined [CALO-RE] score) using three different instruments that measure behavior change. Results: Of 612 potentially relevant apps included in the analysis, 17 met the inclusion criteria. On average, apps included 6.87 (SD 4.18) out of 31 possible gamification features. The most frequently used gamification features were time pressure (16/17, 94%), virtual characters (14/17, 82%), and fantasy (13/17, 76%). The most common oral hygiene evidence-based recommendation was brushing time (2-3 minutes), which was identified in 94% (16/17) of apps. The overall mean uMARS score for app quality was high (4.30, SD 0.36), with good mean subjective quality (3.79, SD 0.71) and perceived impact (3.58, SD 0.44). Sufficient behavior change techniques based on three taxonomies were detected in each app. Conclusions: The majority of the analyzed oral hygiene apps included gamification features and behavior change techniques to perform and maintain oral hygiene in children. Overall, the apps contained some educational content consistent with evidence-based dentistry and high-quality background for oral self-care in children; however, there is scope for improvement. %M 32673235 %R 10.2196/16365 %U https://mhealth.jmir.org/2020/7/e16365 %U https://doi.org/10.2196/16365 %U http://www.ncbi.nlm.nih.gov/pubmed/32673235 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 7 %P e16341 %T Engagement and Clinical Improvement Among Older Adult Primary Care Patients Using a Mobile Intervention for Depression and Anxiety: Case Studies %A Orr,L Casey %A Graham,Andrea K %A Mohr,David C %A Greene,Carolyn J %+ Center for Health Services Research, Psychiatric Research Institute, University of Arkansas for Medical Sciences, 4301 W Markham #554, Little Rock, AR, 72205, United States, 1 5015512880, lcorr@ualr.edu %K mobile health %K older adults %K depression %K anxiety %K primary care %K smartphone %K mobile phone %K text messaging %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Technology-based mental health interventions are an increasingly attractive option for expanding access to mental health services within the primary care system. Older adults are among the groups that could potentially benefit from the growing ubiquity of technology-based mental health interventions; however, older adults are perceived to be averse to using technology and have reported barriers to use. Objective: The aim of this paper is to present a case study of 3 participants from a clinical trial evaluating IntelliCare, an evidence-based mobile intervention for depression and anxiety, among adults recruited from primary care clinics. Our report of these 3 participants, who were aged 60 years or older, focuses on their engagement with the IntelliCare service (ie, app use, coach communication) and clinical changes in depression or anxiety symptoms over the intervention period. Methods: The 3 case study participants were offered IntelliCare with coaching for 8 weeks. The intervention consisted of 5 treatment intervention apps that support a variety of psychological skills, a Hub app that contained psychoeducational content and administered weekly assessments, and coaching for encouragement, accountability, and technical assistance as needed. The 3 case study participants were selected to reflect the overall demographics of participants within the trial and because their interactions with IntelliCare provided a good illustration of varied experiences regarding engagement with the intervention. Results: The 3 participants’ unique experiences with the intervention are described. Despite potential barriers and experiencing some technical glitches, the participants showed proficient ability to use the apps, high levels of participation through frequent app use and coach interaction, and decreased depression and anxiety scores. At the end of the 8-week intervention, each of these 3 participants expressed great enthusiasm for the benefit of this program through feedback to their coach, and they each identified a number of ways they had seen improvements in themselves. Conclusions: These 3 cases provide examples of older individuals who engaged with and benefitted from the IntelliCare service. Although the results from these 3 cases may not generalize to others, they provide an important, informed perspective of the experiences that can contribute to our understanding of how older adults use and overcome barriers to mental health technologies. The findings also contribute toward the ultimate goal of ensuring that the IntelliCare intervention is appropriate for individuals of all ages. %M 32673236 %R 10.2196/16341 %U https://mental.jmir.org/2020/7/e16341 %U https://doi.org/10.2196/16341 %U http://www.ncbi.nlm.nih.gov/pubmed/32673236 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17183 %T Effect of a Health System–Sponsored Mobile App on Perinatal Health Behaviors: Retrospective Cohort Study %A Cawley,Caroline %A Buckenmeyer,Hannelore %A Jellison,Trina %A Rinaldi,Joseph B %A Vartanian,Keri B %+ Center for Outcomes Research and Education, Providence Portland Medical Center, 5251 NE Glisan Street, Portland, OR, 97213, United States, 1 503 215 2594, Keri.Vartanian@providence.org %K mobile health %K perinatal health %K health behaviors %D 2020 %7 6.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pregnancy mobile apps are becoming increasingly popular, with parents-to-be seeking information related to their pregnancy and their baby through mobile technology. This increase raises the need for prenatal apps with evidence-based content that is personalized and reliable. Previous studies have looked at whether prenatal apps impact health and behavior outcomes among pregnant and postpartum individuals; however, research has been limited. Objective: The primary objective of this study is to assess whether the use of a health system–sponsored mobile app—Circle by Providence—aimed at providing personalized and reliable health information on pregnancy, postpartum recovery, and infant care is associated with improved health outcomes and increased healthy behaviors and knowledge among users. Methods: This observational study compared app users and app nonusers using a self-reported survey and electronic medical records. The study took place over 18 months and was conducted at Providence St. Joseph Health in Portland, Oregon. The sample included patients who received prenatal care at one of seven Providence clinics and had a live birth at a Providence hospital. Recruitment occurred on a rolling basis and only those who completed the survey were included. Survey respondents were separated into app users and app nonusers, and survey responses and clinical outcomes were compared across groups using univariate and adjusted multivariate logistic regression. Results: A total of 567 participants were enrolled in the study—167 in the app user group and 400 in the nonuser group. We found statistically significant differences between the two groups for certain behavior outcomes: subjects who used the app had 75% greater odds of breastfeeding beyond 6 months postpartum (P=.012), were less likely to miss prenatal appointments (P=.046), and were 50% more likely to exercise 3 or more times a week during pregnancy (P=.04). There were no differences in nutritional measures, including whether they took prenatal vitamins, ate 5 fruits or vegetables a day, or drank caffeine. We found no differences in many of the infant care outcomes; however, there was an increase in awareness of “purple crying.” Finally, there were no significant differences in measured clinical health outcomes, including cesarean births, length of hospital stays (in minutes), low birth weight infants, preterm births, small-for-gestational-age births, large-for-gestational-age births, and neonatal intensive care unit stays. Conclusions: The use of the Circle app, which provides access to personalized and evidence-based health information, was associated with an increase in certain healthy behaviors and health knowledge, although there was no impact on clinical health outcomes. More research is needed to determine the impact of mobile prenatal apps on healthy pregnancies, clinical health outcomes, and infant care. %M 32628123 %R 10.2196/17183 %U https://mhealth.jmir.org/2020/7/e17183 %U https://doi.org/10.2196/17183 %U http://www.ncbi.nlm.nih.gov/pubmed/32628123 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 7 %P e17159 %T Effectiveness of Using Mental Health Mobile Apps as Digital Antidepressants for Reducing Anxiety and Depression: Protocol for a Multiple Baseline Across-Individuals Design %A Marshall,Jamie M %A Dunstan,Debra A %A Bartik,Warren %+ School of Psychology, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia, 61 2 6773 3012, jmarsh21@une.edu.au %K mHealth %K eHealth %K mobile apps %K mobile phone %K anxiety %K depression %K single-case study %D 2020 %7 5.7.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: The use of mental health mobile apps to treat anxiety and depression is widespread and growing. Several reviews have found that most of these apps do not have published evidence for their effectiveness, and existing research has primarily been undertaken by individuals and institutions that have an association with the app being tested. Another reason for the lack of research is that the execution of the traditional randomized controlled trial is time prohibitive in this profit-driven industry. Consequently, there have been calls for different methodologies to be considered. One such methodology is the single-case design, of which, to the best of our knowledge, no peer-reviewed published example with mental health apps for anxiety and/or depression could be located. Objective: The aim of this study is to examine the effectiveness of 5 apps (Destressify, MoodMission, Smiling Mind, MindShift, and SuperBetter) in reducing symptoms of anxiety and/or depression. These apps were selected because they are publicly available, free to download, and have published evidence of efficacy. Methods: A multiple baseline across-individuals design will be employed. A total of 50 participants will be recruited (10 for each app) who will provide baseline data for 20 days. The sequential introduction of an intervention phase will commence once baseline readings have indicated stability in the measures of participants’ mental health and will proceed for 10 weeks. Postintervention measurements will continue for a further 20 days. Participants will be required to provide daily subjective units of distress (SUDS) ratings via SMS text messages and will complete other measures at 5 different time points, including at 6-month follow-up. SUDS data will be examined via a time series analysis across the experimental phases. Individual analyses of outcome measures will be conducted to detect clinically significant changes in symptoms using the statistical approach proposed by Jacobson and Truax. Participants will rate their app on several domains at the end of the intervention. Results: Participant recruitment commenced in January 2020. The postintervention phase will be completed by June 2020. Data analysis will commence after this. A write-up for publication is expected to be completed after the follow-up phase is finalized in January 2021. Conclusions: If the apps prove to be effective as hypothesized, this will provide collateral evidence of their efficacy. It could also provide the benefits of (1) improved access to mental health services for people in rural areas, lower socioeconomic groups, and children and adolescents and (2) improved capacity to enhance face-to-face therapy through digital homework tasks that can be shared instantly with a therapist. It is also anticipated that this methodology could be used for other mental health apps to bolster the independent evidence base for this mode of treatment. International Registered Report Identifier (IRRID): PRR1-10.2196/17159 %M 32623368 %R 10.2196/17159 %U https://www.researchprotocols.org/2020/7/e17159 %U https://doi.org/10.2196/17159 %U http://www.ncbi.nlm.nih.gov/pubmed/32623368 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e16159 %T Maintaining Physical Activity Level Through Team-Based Walking With a Mobile Health Intervention: Cross-Sectional Observational Study %A Hamamatsu,Yuri %A Ide,Hiroo %A Kakinuma,Michiru %A Furui,Yuji %+ Institute for Future Initiatives, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan, 81 3 5841 0934　, ide@ifi.u-tokyo.ac.jp %K mHealth %K physical activity %K walking %K team-based %K smartphone app %D 2020 %7 3.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The health conditions of Japanese salespersons may be adversely affected by their lifestyle. Face-to-face or on-site health interventions are not convenient for salespersons because of their tendency for out-of-office sales. Previous studies showed that mobile health (mHealth) interventions (compared to usual practice) have great potential to promote physical activity. For Japanese salespersons, mHealth can offer additional convenience to change their physical activity habits because they can access the mHealth contents anytime and anywhere. However, the specific elements that are most important to maintain physical activity levels using an mHealth approach remain unclear. Objective: We aimed to identify elements that account for both a high average physical activity level and can help to prevent a decrease in physical activity during a 9-week intervention period. Methods: Salespersons were recruited from 11 Japanese companies. A team-based walking intervention was held from October to December 2018 (for a total of 9 weeks), during which the walking step data were recorded by smartphone apps. Average walking steps of each participant during the intervention and the difference in walking steps between the initial and the final week were respectively used as dependent variables. The effects of team characteristics (ie, frequency of communication with team members and team size) and behavioral characteristics (ie, number of days with recorded steps on the apps) on the average walking steps, and the difference in walking steps between the initial and the final week were estimated using multiple and multilevel regression analyses. Results: Of the 416 participants, walking step data of 203 participants who completed postintervention assessments were included in the analyses. Multiple regression analysis of the average walking steps showed that the number of days with recorded steps was positively correlated with the log-transformed average walking steps (β=.01, P<.001). Multilevel analysis of the average walking steps considering the company level estimated that the intraclass correlation coefficient was 37%. This means that belonging to the same company largely affected an individual’s average walking steps. Multiple regression analysis of the difference in walking steps showed that communication with team members once or twice a week correlated with preventing a decrease in walking steps from the initial to the final week (β=1539.4, P=.03), and being on a larger team correlated with a decrease in walking steps from the initial to the final week (β=–328.4, P=.01). Conclusions: This study showed that the elements accounting for high average walking steps and those preventing the decrease in walking steps from the initial to the final week differed. Behavioral characteristics correlated positively with average walking steps. Team characteristics (ie, regular communication and a smaller team size) significantly correlated with preventing a decrease in walking steps. %M 32618576 %R 10.2196/16159 %U https://mhealth.jmir.org/2020/7/e16159 %U https://doi.org/10.2196/16159 %U http://www.ncbi.nlm.nih.gov/pubmed/32618576 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e18391 %T Designing for the Co-Use of Consumer Health Technology in Self-Management of Adolescent Overweight and Obesity: Mixed Methods Qualitative Study %A LeRouge,Cynthia M %A Hah,Hyeyoung %A Deckard,Gloria J %A Jiang,Haoqiang %+ Department of Information Systems and Business Analytics, Florida International University, 11200 SW 8th Street, Miami, FL, 33199, United States, 1 3147090624, clerouge@fiu.edu %K consumer health technologies %K obesity care model %K chronic care model %K UTAUT %K qualitative research %K overweight %K mobile phone %K adolescent %K couse %K social support %K obesity %K social influence %K consumer health informatics %D 2020 %7 29.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Overweight and obesity in adolescents has reached epidemic proportions in the United States. Consumer health technology (CHT) can serve as a behavioral and social support tool for the management of overweight in adolescence. Recognizing CHT as a social support tool during design enables input from multiple stakeholders who engage in shared co-use to reinforce and empower adolescents in their self-management efforts. Objective: This study aimed to explore design requirements and enabling factors for the use of CHT as a social support tool for patients (as primary users) and parents and health care providers (as co-users). Our model incorporates key components of the unified theory of acceptance and use of technology (UTAUT) within the framework of the obesity care model (OCM) by recognizing patient self-management as the central process with the influence of their care support network on CHT use and outcomes. Methods: This study was part of a larger two-staged usability study combining focus group, semistructured interviews, and usability walkthroughs of CHT mockups from adolescents (BMI in the 85th-99th percentile range), parents, and physicians. In phase 1, 48 adolescents between the ages of 12 and 17 years, 10 of their parents, and 6 health care providers participated in identifying design requirements and enabling factors for the use of a potential CHT. In phase 2, 70 adolescents and 10 health care providers evaluated the CHT mockups and indicated enabling factors and willingness to use the proposed CHT. Results: Our qualitative analysis identified adolescents’ intention for the use of CHT in alignment with UTAUT elements of performance expectancy, effort expectancy, and facilitating conditions. Our reconceptualization of social influence identified the expectations and envisioned roles of parents and health care providers as co-users and influencing factors on the co-use of CHT in managing overweight in adolescence. Parents were expected to monitor, to provide guidance and motivation, and to suggest modifications in daily habits, for example, recipes and meals, whereas health care providers were expected to encourage and monitor progress in a clinical setting. These expected roles and co-use patterns were congruent among all 3 stakeholders; the co-use of CHT was desired to be minimally invasive for parents and health care providers and controlled by the adolescents. Conclusions: Our study integrates and extends the perspectives of 2 seminal models to explore design features and social influence roles for the successful user-centered design of CHT for weight self-management in adolescents. Although the co-users (ie, adolescents, parents, health care providers) suggested differing features consistent with their roles, role definitions were congruent. All users recognized the adolescent as the primary user with differential, supportive use from parents and health care providers. This multistakeholder approach can guide successful CHT design that reinforces the collective perspective of self-management. %M 32597788 %R 10.2196/18391 %U http://mhealth.jmir.org/2020/6/e18391/ %U https://doi.org/10.2196/18391 %U http://www.ncbi.nlm.nih.gov/pubmed/32597788 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e19213 %T Physical Activity With Tailored mHealth Support for Individuals With Intellectual Disabilities: Protocol for a Randomized Controlled Trial %A Michalsen,Henriette %A Wangberg,Silje Camilla %A Hartvigsen,Gunnar %A Jaccheri,Letizia %A Muzny,Miroslav %A Henriksen,André %A Olsen,Monica Isabel %A Thrane,Gyrd %A Jahnsen,Reidun Birgitta %A Pettersen,Gunn %A Arntzen,Cathrine %A Anke,Audny %+ Department of Rehabilitation, University Hospital of North Norway, Hansine Hansens vei 67, Tromsø, 9038, Norway, 47 41500304, henriette.michalsen@uit.no %K intellectual disability %K physical activity %K technology %K mHealth %K mobile phone %K goal attainment %K social support %K self-efficacy %D 2020 %7 29.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Individuals with intellectual disabilities (IDs) have lower levels of physical activity (PA) and greater barriers for participation in fitness activities compared with members of the general population. As increased PA has positive effects on cardiovascular and psychosocial health, it is exceedingly important to identify effective interventions for use in everyday settings. Mobile health (mHealth) methods such as motion sensor games (exergames) and smartphone reminders for PA have been explored and found to be promising in individuals with IDs. Objective: The purpose of this study is to examine the effectiveness of an individually tailored PA program with motivational mHealth support on daily levels of PA in youth and adults with IDs. Methods: The trial uses a randomized controlled design comprising 30 intervention participants and 30 control group participants, aged 16 to 60 years, with sedentary lifestyles or low PA levels. While the controls will receive standard care, the intervention aims to increase the level of PA, measured as steps per day, as the primary outcome. Secondary outcome variables are body mass index, blood pressure, physical performance, social support for PA, self-efficacy in a PA setting, behavior problems, and goal attainment. The intervention involves the delivery of tailored mHealth support, using smartphones or tablets to create structure with focus on the communicative abilities of individual participants. Rewards and feedback are provided in order to motivate individuals to increase participation in PA. Participants in the intervention group, their close relatives, and care staff will be invited to participate in a preintervention goal-setting meeting, where goal attainment scaling will be used to select the participants’ PA goals for the intervention period. All participants will be assessed at baseline, at 3 months, and at 6 months. Results: Enrollment was planned to start in April 2020 but will be delayed due to the pandemic situation. The main contribution of this paper is a detailed plan to run our study, which will produce new knowledge about tailored mHealth to support PA in individuals with intellectual disabilities. Conclusions: We expect the new intervention to perform better than standard care in terms of improved PA, improved self-efficacy, and social support for activities. Technology offers new opportunities to promote healthy behaviors. The results of the study will determine the effectiveness and sustainability of a tailored mHealth support intervention to increase PA in youth and adults with IDs. Trial Registration: ClinicalTrials.gov NCT04079439; https://clinicaltrials.gov/ct2/show/NCT04079439 International Registered Report Identifier (IRRID): PRR1-10.2196/19213 %M 32437328 %R 10.2196/19213 %U http://www.researchprotocols.org/2020/6/e19213/ %U https://doi.org/10.2196/19213 %U http://www.ncbi.nlm.nih.gov/pubmed/32437328 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e18996 %T Stratification of Individual Symptoms of Contact Lens–Associated Dry Eye Using the iPhone App DryEyeRhythm: Crowdsourced Cross-Sectional Study %A Inomata,Takenori %A Nakamura,Masahiro %A Iwagami,Masao %A Midorikawa-Inomata,Akie %A Sung,Jaemyoung %A Fujimoto,Keiichi %A Okumura,Yuichi %A Eguchi,Atsuko %A Iwata,Nanami %A Miura,Maria %A Fujio,Kenta %A Nagino,Ken %A Hori,Satoshi %A Tsubota,Kazuo %A Dana,Reza %A Murakami,Akira %+ Department of Ophthalmology, Juntendo University Faculty of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan, 81 3 3813 3111, tinoma@juntendo.ac.jp %K contact lens-associated dry eye %K mobile health %K ResearchKit %K smartphone app %K DryEyeRhythm %K subjective symptoms %K risk factors %K dry eye %K stratification %K mobile phone %D 2020 %7 26.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Discontinuation of contact lens use is mainly caused by contact lens–associated dry eye. It is crucial to delineate contact lens–associated dry eye's multifaceted nature to tailor treatment to each patient’s individual needs for future personalized medicine. Objective: This paper aims to quantify and stratify individual subjective symptoms of contact lens–associated dry eye and clarify its risk factors for future personalized medicine using the smartphone app DryEyeRhythm (Juntendo University). Methods: This cross-sectional study included iPhone (Apple Inc) users in Japan who downloaded DryEyeRhythm. DryEyeRhythm was used to collect medical big data related to contact lens–associated dry eye between November 2016 and January 2018. The main outcome measure was the incidence of contact lens–associated dry eye. Univariate and multivariate adjusted odds ratios of risk factors for contact lens–associated dry eye were determined by logistic regression analyses. The t-distributed Stochastic Neighbor Embedding algorithm was used to depict the stratification of subjective symptoms of contact lens–associated dry eye. Results: The records of 4454 individuals (median age 27.9 years, SD 12.6), including 2972 female participants (66.73%), who completed all surveys were included in this study. Among the included participants, 1844 (41.40%) were using contact lenses, and among those who used contact lenses, 1447 (78.47%) had contact lens–associated dry eye. Multivariate adjusted odds ratios of risk factors for contact lens–associated dry eye were as follows: younger age, 0.98 (95% CI 0.96-0.99); female sex, 1.53 (95% CI 1.05-2.24); hay fever, 1.38 (95% CI 1.10-1.74); mental illness other than depression or schizophrenia, 2.51 (95% CI 1.13-5.57); past diagnosis of dry eye, 2.21 (95% CI 1.63-2.99); extended screen exposure time >8 hours, 1.61 (95% CI 1.13-2.28); and smoking, 2.07 (95% CI 1.49-2.88). The t-distributed Stochastic Neighbor Embedding analysis visualized and stratified 14 groups based on the subjective symptoms of contact lens–associated dry eye. Conclusions: This study identified and stratified individuals with contact lens–associated dry eye and its risk factors. Data on subjective symptoms of contact lens–associated dry eye could be used for prospective prevention of contact lens–associated dry eye progression. %M 32589162 %R 10.2196/18996 %U http://www.jmir.org/2020/6/e18996/ %U https://doi.org/10.2196/18996 %U http://www.ncbi.nlm.nih.gov/pubmed/32589162 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e15563 %T The Adaptive Behavioral Components (ABC) Model for Planning Longitudinal Behavioral Technology-Based Health Interventions: A Theoretical Framework %A Young,Sean D %+ Institute for Prediction Technology, Department of Informatics, University of California, Irvine, Bren School of Information and Computer Science, Irvine, CA, 92617-4022, United States, 1 650 223 5448, syoung5@hs.uci.edu %K health behavior %K risk behavior %K behavioral medicine %K public health informatics %K consumer health informatics %K psychological theory %D 2020 %7 26.6.2020 %9 Viewpoint %J J Med Internet Res %G English %X A growing number of interventions incorporate digital and social technologies (eg, social media, mobile phone apps, and wearable devices) into their design for behavior change. However, because of a number of factors, including changing trends in the use of technology over time, results on the efficacy of these interventions have been mixed. An updated framework is needed to help researchers better plan behavioral technology interventions by anticipating the needed resources and potential changes in trends that may affect interventions over time. Focusing on the domain of health interventions as a use case, we present the Adaptive Behavioral Components (ABC) model for technology-based behavioral interventions. ABC is composed of five components: basic behavior change; intervention, or problem-focused characteristics; population, social, and behavioral characteristics; individual-level and personality characteristics; and technology characteristics. ABC was designed with the goals of (1) guiding high-level development for digital technology–based interventions; (2) helping interventionists consider, plan for, and adapt to potential barriers that may arise during longitudinal interventions; and (3) providing a framework to potentially help increase the consistency of findings among digital technology intervention studies. We describe the planning of an HIV prevention intervention as a case study for how to implement ABC into intervention design. Using the ABC model to plan future interventions might help to improve the design of and adherence to longitudinal behavior change intervention protocols; allow these interventions to adapt, anticipate, and prepare for changes that may arise over time; and help to potentially improve intervention behavior change outcomes. Additional research is needed on the influence of each of ABC’s components to help improve intervention design and implementation. %M 32589152 %R 10.2196/15563 %U https://www.jmir.org/2020/6/e15563 %U https://doi.org/10.2196/15563 %U http://www.ncbi.nlm.nih.gov/pubmed/32589152 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e15951 %T Evaluation of the Tobbstop Mobile App for Smoking Cessation: Cluster Randomized Controlled Clinical Trial %A Pallejà-Millán,Meritxell %A Rey-Reñones,Cristina %A Barrera Uriarte,Maria Luisa %A Granado-Font,Esther %A Basora,Josep %A Flores-Mateo,Gemma %A Duch,Jordi %+ Institut Català de la Salut, Unitat de Suport a la Recerca Camp de Tarragona, C/ Camí de Riudoms, 53, Reus, 43202, Spain, 34 977778515 ext 405, crey.tgn.ics@gencat.cat %K tobacco smoking %K tobacco use cessation %K mobile application %K primary public health %K clinical trial %K mobile phone %D 2020 %7 26.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile apps provide an accessible way to test new health-related methodologies. Tobacco is still the primary preventable cause of death in industrialized countries, constituting an important public health issue. New technologies provide novel opportunities that are effective in the cessation of smoking tobacco. Objective: This paper aims to evaluate the efficacy and usage of a mobile app for assisting adult smokers to quit smoking. Methods: We conducted a cluster randomized clinical trial. We included smokers older than 18 years who were motivated to stop smoking and used a mobile phone compatible with our mobile app. We carried out follow-up visits at 15, 30, and 45 days, and at 2, 3, 6, and 12 months. Participants of the intervention group had access to the Tobbstop mobile app designed by the research team. The primary outcomes were continuous smoking abstinence at 3 and 12 months. Results: A total of 773 participants were included in the trial, of which 602 (77.9%) began the study on their D-Day. Of participants in the intervention group, 34.15% (97/284) did not use the app. The continuous abstention level was significantly larger in the intervention group participants who used the app than in those who did not use the app at both 3 months (72/187, 38.5% vs 13/97, 13.4%; P<.001) and 12 months (39/187, 20.9% vs 8/97, 8.25%; P=.01). Participants in the intervention group who used the app regularly and correctly had a higher probability of not being smokers at 12 months (OR 7.20, 95% CI 2.14-24.20; P=.001) than the participants of the CG. Conclusions: Regular use of an app for smoking cessation is effective in comparison with standard clinical practice. Trial Registration: Clinicaltrials.gov NCT01734421; https://clinicaltrials.gov/ct2/show/NCT01734421 %M 32589153 %R 10.2196/15951 %U http://mhealth.jmir.org/2020/6/e15951/ %U https://doi.org/10.2196/15951 %U http://www.ncbi.nlm.nih.gov/pubmed/32589153 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e15942 %T Surveying the Role of Analytics in Evaluating Digital Mental Health Interventions for Transition-Aged Youth: Scoping Review %A Lo,Brian %A Shi,Jenny %A Hollenberg,Elisa %A Abi-Jaoudé,Alexxa %A Johnson,Andrew %A Wiljer,David %+ Education, Technology and Innovation, University Health Network, 3-RFE-441, 190 Elizabeth Street, Toronto, ON, M5G 2C4, Canada, 1 4163404800 ext 6322, David.Wiljer@uhn.ca %K user engagement %K mobile apps %K mHealth %K telemedicine %K mental health %K adolescent %K data analytics %D 2020 %7 25.6.2020 %9 Review %J JMIR Ment Health %G English %X Background: Consumer-facing digital health interventions provide a promising avenue to bridge gaps in mental health care delivery. To evaluate these interventions, understanding how the target population uses a solution is critical to the overall validity and reliability of the evaluation. As a result, usage data (analytics) can provide a proxy for evaluating the engagement of a solution. However, there is paucity of guidance on how usage data or analytics should be used to assess and evaluate digital mental health interventions. Objective: This review aimed to examine how usage data are collected and analyzed in evaluations of mental health mobile apps for transition-aged youth (15-29 years). Methods: A scoping review was conducted using the Arksey and O’Malley framework. A systematic search was conducted on 5 journal databases using keywords related to usage and engagement, mental health apps, and evaluation. A total of 1784 papers from 2008 to 2019 were identified and screened to ensure that they included analytics and evaluated a mental health app for transition-aged youth. After full-text screening, 49 papers were included in the analysis. Results: Of the 49 papers included in the analysis, 40 unique digital mental health innovations were evaluated, and about 80% (39/49) of the papers were published over the past 6 years. About 80% involved a randomized controlled trial and evaluated apps with information delivery features. There were heterogeneous findings in the concept that analytics was ascribed to, with the top 3 being engagement, adherence, and acceptability. There was also a significant spread in the number of metrics collected by each study, with 35% (17/49) of the papers collecting only 1 metric and 29% (14/49) collecting 4 or more analytic metrics. The number of modules completed, the session duration, and the number of log ins were the most common usage metrics collected. Conclusions: This review of current literature identified significant variability and heterogeneity in using analytics to evaluate digital mental health interventions for transition-aged youth. The large proportion of publications from the last 6 years suggests that user analytics is increasingly being integrated into the evaluation of these apps. Numerous gaps related to selecting appropriate and relevant metrics and defining successful or high levels of engagement have been identified for future exploration. Although long-term use or adoption is an important precursor to realizing the expected benefits of an app, few studies have examined this issue. Researchers would benefit from clarification and guidance on how to measure and analyze app usage in terms of evaluating digital mental health interventions for transition-aged youth. Given the established role of adoption in the success of health information technologies, understanding how to abstract and analyze user adoption for consumer digital mental health apps is also an emerging priority. %M 32348261 %R 10.2196/15942 %U https://mental.jmir.org/2020/6/e15942 %U https://doi.org/10.2196/15942 %U http://www.ncbi.nlm.nih.gov/pubmed/32348261 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17109 %T Menstrual Cycle Length and Patterns in a Global Cohort of Women Using a Mobile Phone App: Retrospective Cohort Study %A Grieger,Jessica A %A Norman,Robert J %+ Robinson Research Institute, University of Adelaide, North Terrace, Adelaide, 5000, Australia, 61 88137697, jessica.grieger@adelaide.edu.au %K body mass index %K follicular phase %K fertility %K luteal phase %K menstrual cycle %K mobile application %K internet %K ovulation %K mobile phone %D 2020 %7 24.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is increasing information characterizing menstrual cycle length in women, but less information is available on the potential differences across lifestyle variables. Objective: This study aimed to describe differences in menstrual cycle length, variability, and menstrual phase across women of different ages and BMI among a global cohort of Flo app users. We have also reported on demographic and lifestyle characteristics across median cycle lengths. Methods: The analysis was run based on the aggregated anonymized dataset from a menstrual cycle tracker and ovulation calendar that covers all phases of the reproductive cycle. Self-reported information is documented, including demographics, menstrual flow and cycle length, ovulation information, and reproductive health and diseases. Data from women aged ≥18 years and who had logged at least three cycles (ie, 2 completed cycles and 1 current cycle) in the Flo app were included (1,579,819 women). Results: Of the 1.5 million users, approximately half (638,683/1,579,819, 40.42%) were aged between 18 and 24 years. Just over half of those reporting BMIs were in the normal range (18.5-24.9 kg/m2; 202,420/356,598, 56.76%) and one-third were overweight or obese (>25 kg/m2; 120,983/356,598, 33.93%). A total of 16.32% (257,889/1,579,819) of women had a 28-day median cycle length. There was a higher percentage of women aged ≥40 years who had a 27-day median cycle length than those aged between 18 and 24 years (22,294/120,612, 18.48% vs 60,870/637,601, 9.55%), but a lower percentage with a 29-day median cycle length (10,572/120,612, 8.77% vs 79,626/637,601, 12.49%). There were a higher number of cycles with short luteal phases in younger women, whereas women aged ≥40 years had a higher number of cycles with longer luteal phases. Median menstrual cycle length and the length of the follicular and luteal phases were not remarkably different with increasing BMI, except for the heaviest women at a BMI of ≥50 kg/m2. Conclusions: On a global scale, we have provided extensive evidence on the characteristics of women and their menstrual cycle length and patterns across different age and BMI groups. This information is necessary to support updates of current clinical guidelines around menstrual cycle length and patterns for clinical use in fertility programs. %M 32442161 %R 10.2196/17109 %U http://www.jmir.org/2020/6/e17109/ %U https://doi.org/10.2196/17109 %U http://www.ncbi.nlm.nih.gov/pubmed/32442161 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e17118 %T Accuracy of Distance Recordings in Eight Positioning-Enabled Sport Watches: Instrument Validation Study %A Gilgen-Ammann,Rahel %A Schweizer,Theresa %A Wyss,Thomas %+ Swiss Federal Institute of Sport Magglingen, Hauptstrasse 247, Magglingen/Macolin, , Switzerland, 41 584676321, rahel.gilgen@baspo.admin.ch %K geographic information systems %K GPS measurement error %K sports %K geographic locations %K monitoring physical training %K movement analysis %D 2020 %7 24.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Elite athletes and recreational runners rely on the accuracy of global navigation satellite system (GNSS)–enabled sport watches to monitor and regulate training activities. However, there is a lack of scientific evidence regarding the accuracy of such sport watches. Objective: The aim was to investigate the accuracy of the recorded distances obtained by eight commercially available sport watches by Apple, Coros, Garmin, Polar, and Suunto when assessed in different areas and at different speeds. Furthermore, potential parameters that affect the measurement quality were evaluated. Methods: Altogether, 3 × 12 measurements in urban, forest, and track and field areas were obtained while walking, running, and cycling under various outdoor conditions. Results: The selected reference distances ranged from 404.0 m to 4296.9 m. For all the measurement areas combined, the recorded systematic errors (±limits of agreements) ranged between 3.7 (±195.6) m and –101.0 (±231.3) m, and the mean absolute percentage errors ranged from 3.2% to 6.1%. Only the GNSS receivers from Polar showed overall errors <5%. Generally, the recorded distances were significantly underestimated (all P values <.04) and less accurate in the urban and forest areas, whereas they were overestimated but with good accuracy in 75% (6/8) of the sport watches in the track and field area. Furthermore, the data assessed during running showed significantly higher error rates in most devices compared with the walking and cycling activities. Conclusions: The recorded distances might be underestimated by up to 9%. However, the use of all investigated sport watches can be recommended, especially for distance recordings in open areas. %M 32396865 %R 10.2196/17118 %U http://mhealth.jmir.org/2020/6/e17118/ %U https://doi.org/10.2196/17118 %U http://www.ncbi.nlm.nih.gov/pubmed/32396865 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16429 %T A Pantheoretical Framework to Optimize Adherence to Healthy Lifestyle Behaviors and Medication Adherence: The Use of Personalized Approaches to Overcome Barriers and Optimize Facilitators to Achieve Adherence %A Seixas,Azizi %A Connors,Colleen %A Chung,Alicia %A Donley,Tiffany %A Jean-Louis,Girardin %+ NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, , United States, 1 9728490862, azizi.seixas@nyumc.org %K adherence %K mHealth %K management %K chronic diseases %K prevention %K technology %D 2020 %7 24.6.2020 %9 Viewpoint %J JMIR Mhealth Uhealth %G English %X Patient nonadherence to healthy lifestyle behaviors and medical treatments (like medication adherence) accounts for a significant portion of chronic disease burden. Despite the plethora of behavioral interventions to overcome key modifiable/nonmodifiable barriers and enable facilitators to adherence, short- and long-term adherence to healthy lifestyle behaviors and medical treatments is still poor. To optimize adherence, we aimed to provide a novel mobile health solution steeped in precision and personalized population health and a pantheoretical approach that increases the likelihood of adherence. We have described the stages of a pantheoretical approach utilizing tailoring, clustering/profiling, personalizing, and optimizing interventions/strategies to obtain adherence and highlight the minimal engineering needed to build such a solution. %M 32579121 %R 10.2196/16429 %U https://mhealth.jmir.org/2020/6/e16429 %U https://doi.org/10.2196/16429 %U http://www.ncbi.nlm.nih.gov/pubmed/32579121 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e19292 %T Closing the Psychological Treatment Gap During the COVID-19 Pandemic With a Supportive Text Messaging Program: Protocol for Implementation and Evaluation %A Agyapong,Vincent Israel Opoku %A Hrabok,Marianne %A Vuong,Wesley %A Gusnowski,April %A Shalaby,Reham %A Mrklas,Kelly %A Li,Daniel %A Urichuk,Liana %A Snaterse,Mark %A Surood,Shireen %A Cao,Bo %A Li,Xin-Min %A Greiner,Russ %A Greenshaw,Andrew James %+ Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, 1E1 Walter Mackenzie Health Sciences Centre, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada, 1 7807144315, agyapong@ualberta.ca %K COVID-19 %K Text4Hope %K mobile phones %K text %K anxiety %K depression %K stress %K pandemic %K e-mental health %D 2020 %7 22.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Coronavirus disease (COVID-19) has spread globally with far-reaching, significant, and unprecedented impacts on health and everyday life. Threats to mental health, psychological safety, and well-being are now emerging, increasing the impact of this virus on world health. Providing support for these challenges is difficult because of the high number of people requiring support in the context of a need to maintain physical distancing. This protocol describes the use of SMS text messaging (Text4Hope) as a convenient, cost-effective, and accessible population-level mental health intervention. This program is evidence-based, with prior research supporting good outcomes and high user satisfaction. Objective: The project goal is to implement a program of daily supportive SMS text messaging (Text4Hope) to reduce distress related to the COVID-19 crisis, initially among Canadians. The prevalence of stress, anxiety, and depressive symptoms; the demographic correlates of the same; and the outcomes of the Text4Hope intervention in mitigating distress will be evaluated. Methods: Self-administered anonymous online questionnaires will be used to assess stress (Perceived Stress Scale), anxiety (Generalized Anxiety Disorder-7 scale [GAD-7]), and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]). Data will be collected at baseline (onset of SMS text messaging), the program midpoint (6 weeks), and the program endpoint (12 weeks). Results: Data analysis will include parametric and nonparametric techniques, focusing on primary outcomes (ie, stress, anxiety, and depressive symptoms) and metrics of use, including the number of subscribers and user satisfaction. Given the large size of the data set, machine learning and data mining methods will also be used. Conclusions: This COVID-19 project will provide key information regarding prevalence rates of stress, anxiety, and depressive symptoms during the pandemic; demographic correlates of distress; and outcome data related to this scalable population-level intervention. Information from this study will be valuable for practitioners and useful for informing policy and decision making regarding psychological interventions during the pandemic. International Registered Report Identifier (IRRID): DERR1-10.2196/19292 %M 32501805 %R 10.2196/19292 %U http://www.researchprotocols.org/2020/6/e19292/ %U https://doi.org/10.2196/19292 %U http://www.ncbi.nlm.nih.gov/pubmed/32501805 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e15619 %T Rethinking the Use of Mobile Apps for Dietary Assessment in Medical Research %A Khazen,Wael %A Jeanne,Jean-François %A Demaretz,Laëtitia %A Schäfer,Florent %A Fagherazzi,Guy %+ Innovation Science and Nutrition, Danone Nutricia Research, RD 128 Avenue de la Vauve, Palaiseau, 91767, France, 33 622256853, florent.schafer@danone.com %K diet %K dietary assessment %K epidemiology %K clinical research %K mobile diet app %K academic apps %K consumer-grade apps %D 2020 %7 18.6.2020 %9 Viewpoint %J J Med Internet Res %G English %X Food intake and usual dietary intake are among the key determinants of health to be assessed in medical research and important confounding factors to be accounted for in clinical studies. Although various methods are available for gathering dietary data, those based on innovative technologies are particularly promising. With combined cost-effectiveness and ease of use, it is safe to assume that mobile technologies can now optimize tracking of eating occasions and dietary behaviors. Yet, choosing a dietary assessment tool that meets research objectives and data quality standards remains challenging. In this paper, we describe the purposes of collecting dietary data in medical research and outline the main considerations for using mobile dietary assessment tools based on participant and researcher expectations. %M 32554383 %R 10.2196/15619 %U https://www.jmir.org/2020/6/e15619 %U https://doi.org/10.2196/15619 %U http://www.ncbi.nlm.nih.gov/pubmed/32554383 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16350 %T Optimizing Smartphone-Delivered Cognitive Behavioral Therapy for Body Dysmorphic Disorder Using Passive Smartphone Data: Initial Insights From an Open Pilot Trial %A Weingarden,Hilary %A Matic,Aleksandar %A Calleja,Roger Garriga %A Greenberg,Jennifer L %A Harrison,Oliver %A Wilhelm,Sabine %+ Massachusetts General Hospital/Harvard Medical School, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States, 1 6176436206, hilary_weingarden@mgh.harvard.edu %K body dysmorphic disorder %K cognitive behavioral therapy %K mobile health %K mobile phone %K patient engagement %D 2020 %7 18.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-delivered cognitive behavioral therapy (CBT) is becoming more common, but research on the topic remains in its infancy. Little is known about how people typically engage with smartphone CBT or which engagement and mobility patterns may optimize treatment. Passive smartphone data offer a unique opportunity to gain insight into these knowledge gaps. Objective: This study aimed to examine passive smartphone data across a pilot course of smartphone CBT for body dysmorphic disorder (BDD), a psychiatric illness characterized by a preoccupation with a perceived defect in physical appearance, to inform hypothesis generation and the design of subsequent, larger trials. Methods: A total of 10 adults with primary diagnoses of BDD were recruited nationally and completed telehealth clinician assessments with a reliable evaluator. In a 12-week open pilot trial of smartphone CBT, we initially characterized natural patterns of engagement with the treatment and tested how engagement and mobility patterns across treatment corresponded with treatment response. Results: Most participants interacted briefly and frequently with smartphone-delivered treatment. More frequent app usage (r=–0.57), as opposed to greater usage duration (r=–0.084), correlated strongly with response. GPS-detected time at home, a potential digital marker of avoidance, decreased across treatment and correlated moderately with BDD severity (r=0.49). Conclusions: The sample was small in this pilot study; thus, results should be used to inform the hypotheses and design of subsequent trials. The results provide initial evidence that frequent (even if brief) practice of CBT skills may optimize response to smartphone CBT and that mobility patterns may serve as useful passive markers of symptom severity. This is one of the first studies to examine the value that passively collected sensor data may contribute to understanding and optimizing users’ response to smartphone CBT. With further validation, the results can inform how to enhance smartphone CBT design. %M 32554382 %R 10.2196/16350 %U http://mhealth.jmir.org/2020/6/e16350/ %U https://doi.org/10.2196/16350 %U http://www.ncbi.nlm.nih.gov/pubmed/32554382 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e20185 %T Mental Health and Behavior of College Students During the Early Phases of the COVID-19 Pandemic: Longitudinal Smartphone and Ecological Momentary Assessment Study %A Huckins,Jeremy F %A daSilva,Alex W %A Wang,Weichen %A Hedlund,Elin %A Rogers,Courtney %A Nepal,Subigya K %A Wu,Jialing %A Obuchi,Mikio %A Murphy,Eilis I %A Meyer,Meghan L %A Wagner,Dylan D %A Holtzheimer,Paul E %A Campbell,Andrew T %+ Department of Psychological and Brain Science, Dartmouth College, HB6207, Hanover, NH, 03755, United States, 1 508 657 4825, jeremy.f.huckins@dartmouth.edu %K COVID-19 %K depression %K anxiety %K mobile sensing %K sedentary %K phone usage %K mental health %K behavior %K pandemic %K app %D 2020 %7 17.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The vast majority of people worldwide have been impacted by coronavirus disease (COVID-19). In addition to the millions of individuals who have been infected with the disease, billions of individuals have been asked or required by local and national governments to change their behavioral patterns. Previous research on epidemics or traumatic events suggests that this can lead to profound behavioral and mental health changes; however, researchers are rarely able to track these changes with frequent, near-real-time sampling or compare their findings to previous years of data for the same individuals. Objective: By combining mobile phone sensing and self-reported mental health data among college students who have been participating in a longitudinal study for the past 2 years, we sought to answer two overarching questions. First, have the behaviors and mental health of the participants changed in response to the COVID-19 pandemic compared to previous time periods? Second, are these behavior and mental health changes associated with the relative news coverage of COVID-19 in the US media? Methods: Behaviors such as the number of locations visited, distance traveled, duration of phone usage, number of phone unlocks, sleep duration, and sedentary time were measured using the StudentLife smartphone sensing app. Depression and anxiety were assessed using weekly self-reported ecological momentary assessments of the Patient Health Questionnaire-4. The participants were 217 undergraduate students, with 178 (82.0%) students providing data during the Winter 2020 term. Differences in behaviors and self-reported mental health collected during the Winter 2020 term compared to previous terms in the same cohort were modeled using mixed linear models. Results: During the first academic term impacted by COVID-19 (Winter 2020), individuals were more sedentary and reported increased anxiety and depression symptoms (P<.001) relative to previous academic terms and subsequent academic breaks. Interactions between the Winter 2020 term and the week of the academic term (linear and quadratic) were significant. In a mixed linear model, phone usage, number of locations visited, and week of the term were strongly associated with increased amount of COVID-19–related news. When mental health metrics (eg, depression and anxiety) were added to the previous measures (week of term, number of locations visited, and phone usage), both anxiety (P<.001) and depression (P=.03) were significantly associated with COVID-19–related news. Conclusions: Compared with prior academic terms, individuals in the Winter 2020 term were more sedentary, anxious, and depressed. A wide variety of behaviors, including increased phone usage, decreased physical activity, and fewer locations visited, were associated with fluctuations in COVID-19 news reporting. While this large-scale shift in mental health and behavior is unsurprising, its characterization is particularly important to help guide the development of methods to reduce the impact of future catastrophic events on the mental health of the population. %M 32519963 %R 10.2196/20185 %U http://www.jmir.org/2020/6/e20185/ %U https://doi.org/10.2196/20185 %U http://www.ncbi.nlm.nih.gov/pubmed/32519963 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 6 %P e18890 %T Adherence of the #Here4U App – Military Version to Criteria for the Development of Rigorous Mental Health Apps %A Linden,Brooke %A Tam-Seto,Linna %A Stuart,Heather %+ Health Services and Policy Research Institute, Queen's University, 21 Arch Street, Kingston, ON, K7L 3L3, Canada, 1 613 533 6387, brooke.linden@queensu.ca %K mental health services %K telemedicine %K mHealth %K chatbot %K e-solutions %K Canadian Armed Forces %K military health %K mobile phone %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Over the past several years, the emergence of mobile mental health apps has increased as a potential solution for populations who may face logistical and social barriers to traditional service delivery, including individuals connected to the military. Objective: The goal of the #Here4U App – Military Version is to provide evidence-informed mental health support to members of Canada’s military community, leveraging artificial intelligence in the form of IBM Canada’s Watson Assistant to carry on unique text-based conversations with users, identify presenting mental health concerns, and refer users to self-help resources or recommend professional health care where appropriate. Methods: As the availability and use of mental health apps has increased, so too has the list of recommendations and guidelines for efficacious development. We describe the development and testing conducted between 2018 and 2020 and assess the quality of the #Here4U App against 16 criteria for rigorous mental health app development, as identified by Bakker and colleagues in 2016. Results: The #Here4U App – Military Version met the majority of Bakker and colleagues’ criteria, with those unmet considered not applicable to this particular product or out of scope for research conducted to date. Notably, a formal evaluation of the efficacy of the app is a major priority moving forward. Conclusions: The #Here4U App – Military Version is a promising new mental health e-solution for members of the Canadian Armed Forces community, filling many of the gaps left by traditional service delivery. %M 32554374 %R 10.2196/18890 %U https://formative.jmir.org/2020/6/e18890 %U https://doi.org/10.2196/18890 %U http://www.ncbi.nlm.nih.gov/pubmed/32554374 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 6 %P e16072 %T Low-Burden Mobile Monitoring, Intervention, and Real-Time Analysis Using the Wear-IT Framework: Example and Usability Study %A Brick,Timothy R %A Mundie,James %A Weaver,Jonathan %A Fraleigh,Robert %A Oravecz,Zita %+ Department of Human Development and Family Studies, Real-Time Science Laboratory, The Pennsylvania State University, 115 HHD Building, University Park, PA, , United States, 1 8148654868, tbrick@psu.edu %K smartphone apps %K ecological momentary assessment %K real-time analysis %K behavior change %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Mobile health (mHealth) methods often rely on active input from participants, for example, in the form of self-report questionnaires delivered via web or smartphone, to measure health and behavioral indicators and deliver interventions in everyday life settings. For short-term studies or interventions, these techniques are deployed intensively, causing nontrivial participant burden. For cases where the goal is long-term maintenance, limited infrastructure exists to balance information needs with participant constraints. Yet, the increasing precision of passive sensors such as wearable physiology monitors, smartphone-based location history, and internet-of-things devices, in combination with statistical feature selection and adaptive interventions, have begun to make such things possible. Objective: In this paper, we introduced Wear-IT, a smartphone app and cloud framework intended to begin addressing current limitations by allowing researchers to leverage commodity electronics and real-time decision making to optimize the amount of useful data collected while minimizing participant burden. Methods: The Wear-IT framework uses real-time decision making to find more optimal tradeoffs between the utility of data collected and the burden placed on participants. Wear-IT integrates a variety of consumer-grade sensors and provides adaptive, personalized, and low-burden monitoring and intervention. Proof of concept examples are illustrated using artificial data. The results of qualitative interviews with users are provided. Results: Participants provided positive feedback about the ease of use of studies conducted using the Wear-IT framework. Users expressed positivity about their overall experience with the framework and its utility for balancing burden and excitement about future studies that real-time processing will enable. Conclusions: The Wear-IT framework uses a combination of passive monitoring, real-time processing, and adaptive assessment and intervention to provide a balance between high-quality data collection and low participant burden. The framework presents an opportunity to deploy adaptive assessment and intervention designs that use real-time processing and provides a platform to study and overcome the challenges of long-term mHealth intervention. %M 32554373 %R 10.2196/16072 %U https://formative.jmir.org/2020/6/e16072 %U https://doi.org/10.2196/16072 %U http://www.ncbi.nlm.nih.gov/pubmed/32554373 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e14266 %T The Quality of Mobile Apps Used for the Identification of Pressure Ulcers in Adults: Systematic Survey and Review of Apps in App Stores %A Koepp,Janine %A Baron,Miriam Viviane %A Hernandes Martins,Paulo Ricardo %A Brandenburg,Cristine %A Kira,Ariane Tieko Frare %A Trindade,Vanessa Devens %A Ley Dominguez,Luis Manuel %A Carneiro,Marcelo %A Frozza,Rejane %A Possuelo,Lia Gonçalves %A De Mello Pinto,Marcus Vinicius %A Mahlmann Kipper,Liane %A Pinheiro da Costa,Bartira Ercília %+ University of Santa Cruz do Sul, Avenida Independência, 2293 - Block 35, Santa Cruz do Sul, 96816-501, Brazil, 55 51 99806 2275, janinekoepp@yahoo.com.br %K software %K portable app %K mobile app %K pressure sore %K decubitus ulcer %K wounds and injuries %D 2020 %7 16.6.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: The increasing global use of smartphones has contributed to the growing use of apps for various health conditions, showing promising results. Through mobile apps, it is possible to perform chronological and iconographic follow-up of wounds, such as pressure ulcers, using a simple and practical tool. However, numerous surveys have pointed out issues related to the functionality, design, safety, and veracity of app information. Objective: The objective of this study was to perform a systematic review of published studies regarding mobile apps and a systematic survey in app stores looking for apps developed to identify, evaluate, treat, and/or prevent pressure ulcers in adults, and to evaluate those apps based on software quality characteristics. Methods: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The main bibliographic databases were searched between January 1, 2007 and October 15, 2018, and an app survey was performed in app stores. The selected studies were evaluated according to software quality characteristics by the International Organization for Standardization/International Electrotechnical Commission (ie, ISO/IEC 25010:2011) that involve functionality, efficiency, compatibility, usability, reliability, safety, maintenance, and portability. Results: The search in databases and web-based app stores returned a total of 2075 studies. After removal of duplicates and screening of titles and abstracts, 48 complete articles were evaluated for eligibility, and among these, six were included for qualitative synthesis. Conclusions: In this review, it was observed that all studies involved the initial phase of app development or improvement, and therefore, the apps still need to be evaluated using different software quality characteristics, so that in the future, a gold standard can be approached. Therefore, the prescription of an app for the identification, evaluation, treatment, and/or prevention of pressure ulcers in adults is currently limited. However, the evaluated studies provided important insights for future research. It is of utmost importance that future surveys develop apps jointly with users, using collaborative and cocreative processes and assess patients in real-world situations across different service settings, and they should consider different ethnicities, so that apps are useful to end users, such as patients, family members, health professionals, and students, in the health area. In addition, it is necessary for studies to describe the methodological course of app development in a clear and objective way in order to ensure reproducibility of the study and to offer inputs to allow future research to approach the development of ideal apps that are geared to positively impact the health of end users. Trial Registration: PROSPERO CRD42018114137; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=114137 %M 32470916 %R 10.2196/14266 %U http://mhealth.jmir.org/2020/6/e14266/ %U https://doi.org/10.2196/14266 %U http://www.ncbi.nlm.nih.gov/pubmed/32470916 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16720 %T A Mobile App Adopting an Identity Focus to Promote Physical Activity (MoveDaily): Iterative Design Study %A Hooglugt,Floris %A Ludden,Geke D S %+ Department of Design, Production and Management, University of Twente, Drienerlolaan 5, Enschede, 7522NB, Netherlands, 31 534892920, g.d.s.ludden@utwente.nl %K research through design %K physical activity %K habits %K identity %K behavior change %K mHealth %K design %D 2020 %7 15.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Web-based and mobile interventions to influence physical activity behavior have had limited effects on sustained behavior change. One reason may be that the interventions aim to change largely habitual behavior. Following an identity-oriented approach could be a successful strategy to behavior change because people are committed to behave in line with their self-perception of identity. Objective: In this paper, we take a closer look at the role of motivation in long-term adherence to lifestyle interventions. The paper outlines a method for web-based or mobile intervention development that allows exploration of integrating behavior change theory into the design process. We will describe the development of a mobile app that allows people to be self-determined and to value and self-regulate physical activity by adopting an identity-oriented approach. Methods: This paper describes a Research through Design (RtD) process in which design activities are carried out as part of the knowledge-generating process. Two RtD phases were completed, followed by a conceptual design phase. In the first RtD phase, 8 participants used diary cards to study initial attitudes toward starting with small changes in physical activity. In the second RtD phase, 26 participants used a web-based app to study changes in physical activity. We used an adapted version of the Self-Report Habit Index (SRHI) to evaluate individuals’ perceptions of a particular behavior with respect to the three facets of a habit. The conceptual design phase consolidated the results from first two RtD phases into a design of a mobile app that combines an identity approach with gamification principles. The conceptual design was evaluated in a user-experience study with 4 participants. Results: In the first RtD phase, we found that interacting daily with diary cards and reflecting on physical activity patterns is a promising strategy but works better through a digital medium. In the second RtD phase, SHRI ratings from all participants generally increased each week. In the conceptual design phase, we found that the concept of the mobile app was positively evaluated by participants. However, participants mentioned that terms such as “identity” do not resonate with them and that scenarios could be simpler. Conclusions: This paper provides deeper insights into designing for electronic health (eHealth) interventions and services and suggests a new way that motivation can be shaped by the design of an intervention and adherence to physical activity. To the best of our knowledge, this was the first iterative design study in which the effects of adopting an identity approach to both motivation and physical activity were included and observed. Initial promising results were found for using a web-based intervention where habits and identification with the personal importance of a behavior were repetitively triggered. %M 32538795 %R 10.2196/16720 %U http://mhealth.jmir.org/2020/6/e16720/ %U https://doi.org/10.2196/16720 %U http://www.ncbi.nlm.nih.gov/pubmed/32538795 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e14116 %T Continuous Measurement of Reconnaissance Marines in Training With Custom Smartphone App and Watch: Observational Cohort Study %A Saxon,Leslie %A DiPaula,Brooks %A Fox,Glenn R %A Ebert,Rebecca %A Duhaime,Josiah %A Nocera,Luciano %A Tran,Luan %A Sobhani,Mona %+ University of Southern California, Center for Body Computing, Keck School of Medicine, 12015 East Waterfront Drive, Playa Vista, CA, 90094, United States, 1 310 448 5373, saxon@usc.edu %K military %K marines %K wearable devices %K wearable technology %K smartphone %K mobile app %D 2020 %7 15.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Specialized training for elite US military units is associated with high attrition due to intense psychological and physical demands. The need to graduate more service members without degrading performance standards necessitates the identification of factors to predict success or failure in targeted training interventions. Objective: The aim of this study was to continuously quantify the mental and physical status of trainees of an elite military unit to identify novel predictors of success in training. Methods: A total of 3 consecutive classes of a specialized training course were provided with an Apple iPhone, Watch, and specially designed mobile app. Baseline personality assessments and continuous daily measures of mental status, physical pain, heart rate, activity, sleep, hydration, and nutrition were collected from the app and Watch data. Results: A total of 115 trainees enrolled and completed the study (100% male; age: mean 22 years, SD 4 years) and 64 (55.7%) successfully graduated. Most training withdrawals (27/115, 23.5%) occurred by day 7 (mean 5.5 days, SD 3.4 days; range 1-22 days). Extraversion, positive affect personality traits, and daily psychological profiles were associated with course completion; key psychological factors could predict withdrawals 1-2 days in advance (P=.009). Conclusions: Gathering accurate and continuous mental and physical status data during elite military training is possible with early predictors of withdrawal providing an opportunity for intervention. %M 32348252 %R 10.2196/14116 %U https://mhealth.jmir.org/2020/6/e14116 %U https://doi.org/10.2196/14116 %U http://www.ncbi.nlm.nih.gov/pubmed/32348252 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e17756 %T A Mobile Game (Safe City) Designed to Promote Children’s Safety Knowledge and Behaviors: Protocol for a Randomized Controlled Trial %A Wong,Rosa S %A Tung,Keith TS %A Wong,Hiu Tung %A Ho,Frederick KW %A Wong,Hing Sang %A Fu,King-Wa %A Pong,Ting Chuen %A Chan,Ko Ling %A Chow,Chun Bong %A Ip,Patrick %+ Department of Paediatrics & Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong, China (Hong Kong), 852 2255 4090, patricip@hku.hk %K serious game %K safety training %K mobile game %K mobile phone %K injury prevention %K randomized controlled trial %K game-based intervention %D 2020 %7 12.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Children have high levels of curiosity and eagerness to explore. This makes them more vulnerable to danger and hazards, and they thus have a higher risk of injury. Safety education such as teaching safety rules and tips is vital to prevent children from injuries. Although game-based approaches have the potential to capture children’s attention and sustain their interest in learning, whether these new instructional approaches are more effective than traditional approaches in delivering safety messages to children remains uncertain. Objective: The aim of this study is to test the effectiveness of a game-based intervention in promoting safety knowledge and behaviors among Hong Kong school children in Grades 4-6. It will also examine the potential effect of the game-based intervention on these children’s functioning and psychosocial difficulties. Methods: This study comprises the development of a city-based role-playing game Safe City, where players are immersed as safety inspectors to prevent dangerous situations and promote safety behavior in a virtual city environment. The usability and acceptability tests will be conducted with children in Grades 4-6 who will trial the gameplay on a mobile phone. Adjustments will be made based on their feedback. A 4-week randomized controlled trial with children studying in Grades 4-6 in Hong Kong elementary schools will be conducted to assess the effectiveness of the Safe City game–based intervention. In this trial, 504 children will play Safe City, and 504 children will receive traditional instructional materials (electronic and printed safety information). The evaluation will be conducted using both child self-report and parent proxy-report data. Specifically, child safety knowledge and behaviors will be assessed by a questionnaire involving items on knowledge and behaviors, respectively, for home safety, road safety, and sport-related safety; child functioning will be assessed by PedsQL Generic Core Scales; and psychosocial difficulties will be assessed by the Strength and Difficulties Questionnaire. These questionnaires will be administered at 3 time points: before, 1 month, and 3 months after the intervention. Game usage statistics will also be reviewed. Results: This project was funded in September 2019. The design and development of the Safe City game are currently under way. Recruitment and data collection will begin from September 2020 and will continue up to March 1, 2021. Full analysis will be conducted after the end of the data collection period. Conclusions: If the Safe City game is found to be an effective tool to deliver safety education, it could be used to promote safety in children in the community and upgraded to incorporate more health-related topics to support education and empowerment for the larger public. Trial Registration: ClinicalTrials.gov NCT04096196; https://clinicaltrials.gov/ct2/show/NCT04096196 International Registered Report Identifier (IRRID): PRR1-10.2196/17756 %M 32530436 %R 10.2196/17756 %U http://www.researchprotocols.org/2020/6/e17756/ %U https://doi.org/10.2196/17756 %U http://www.ncbi.nlm.nih.gov/pubmed/32530436 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e19494 %T Influence of the SARS-CoV-2 Outbreak on the Uptake of a Popular Smoking Cessation App in UK Smokers: Interrupted Time Series Analysis %A Perski,Olga %A Herbeć,Aleksandra %A Shahab,Lion %A Brown,Jamie %+ Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom, 44 020 7679 1258, olga.perski@ucl.ac.uk %K SARS-CoV-2 %K COVID-19 %K smoking cessation %K mobile health %K smartphone app %K time series analysis %K smoking %K public health %K app %D 2020 %7 11.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak may motivate smokers to attempt to stop in greater numbers. However, given the temporary closure of UK stop smoking services and vape shops, smokers attempting to quit may instead seek out mobile health support, such as smartphone apps. Objective: We examined, using an interrupted time series approach, whether the SARS-CoV-2 outbreak has been associated with a step change or increasing trend in UK downloads of an otherwise popular smoking cessation app, Smoke Free. Methods: Data were from daily and nondaily adult smokers in the United Kingdom who had downloaded the Smoke Free app between January 1, 2020, and March 31, 2020 (primary analysis), and January 1, 2019, and March 31, 2020 (secondary analysis). The outcome variable was the number of downloads aggregated at the 12-hourly (primary analysis) or daily level (secondary analysis). The explanatory variable was the start of the SARS-CoV-2 outbreak, operationalized as March 1, 2020 (primary analysis), and January 15, 2020 (secondary analysis). Generalized additive mixed models adjusted for relevant covariates were fitted. Results: Data were collected on 45,105 (primary analysis) and 119,881 (secondary analysis) users. In both analyses, there was no evidence for a step change or increasing trend in downloads attributable to the start of the SARS-CoV-2 outbreak. Calculation of Bayes factors (BFs) indicated that the data for the primary analysis favored the null hypothesis compared with large associations (for level, BF=0.25; for slope, BF=0.26) but were insensitive to the detection of small associations (for level, BF=0.78; for slope, BF=1.35). Conclusions: In the United Kingdom, between January 1, 2020, and March 31, 2020, and between January 1, 2019, and March 31, 2020, there was no evidence that the SARS-CoV-2 outbreak has been associated with a large step change or increasing trend in downloads of a popular smoking cessation app. Findings on the association of the SARS-CoV-2 outbreak with a small step change or increasing trend were inconclusive. %M 32463375 %R 10.2196/19494 %U http://mhealth.jmir.org/2020/6/e19494/ %U https://doi.org/10.2196/19494 %U http://www.ncbi.nlm.nih.gov/pubmed/32463375 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e18014 %T Health Gain, Cost Impacts, and Cost-Effectiveness of a Mass Media Campaign to Promote Smartphone Apps for Physical Activity: Modeling Study %A Mizdrak,Anja %A Telfer,Kendra %A Direito,Artur %A Cobiac,Linda J %A Blakely,Tony %A Cleghorn,Christine L %A Wilson,Nick %+ Department of Public Health, University of Otago Wellington, Department of Public Health, 23 Mein Street, Newtown, Wellington, 6021, New Zealand, 64 49186192, anja.mizdrak@otago.ac.nz %K physical activity %K mHealth %K mobile health %K smartphone apps %K modeling %K mass media campaigns %D 2020 %7 11.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Physical activity smartphone apps are a promising strategy to increase population physical activity, but it is unclear whether government mass media campaigns to promote these apps would be a cost-effective use of public funds. Objective: We aimed to estimate the health impacts, costs, and cost-effectiveness of a one-off national mass media campaign to promote the use of physical activity apps. Methods: We used an established multistate life table model to estimate the lifetime health gains (in quality-adjusted life years [QALYs]) that would accrue if New Zealand adults were exposed to a one-off national mass media campaign to promote physical activity app use, with a 1-year impact on physical activity, compared to business-as-usual. A health-system perspective was used to assess cost-effectiveness. and a 3% discount rate was applied to future health gains and health system costs. Results: The modeled intervention resulted in 28 QALYs (95% uncertainty interval [UI] 8-72) gained at a cost of NZ $81,000/QALY (2018 US $59,500; 95% UI 17,000-345,000), over the remaining life course of the 2011 New Zealand population. The intervention had a low probability (20%) of being cost-effective at a cost-effectiveness threshold of NZ $45,000 (US $32,900) per QALY. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions around the maintenance of physical activity behaviors beyond the duration of the intervention. Conclusions: A mass media campaign to promote smartphone apps for physical activity is unlikely to generate much health gain or be cost-effective at the population level. Other investments to promote physical activity, particularly those that result in sustained behavior change, are likely to have greater health impacts. %M 32525493 %R 10.2196/18014 %U http://mhealth.jmir.org/2020/6/e18014/ %U https://doi.org/10.2196/18014 %U http://www.ncbi.nlm.nih.gov/pubmed/32525493 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 6 %P e14913 %T Mobile App Integration Into Dialectical Behavior Therapy for Persons With Borderline Personality Disorder: Qualitative and Quantitative Study %A Austin,Stephen F %A Jansen,Jens Einar %A Petersen,Charlotte Juul %A Jensen,Rasmus %A Simonsen,Erik %+ Department of Psychiatric Research, Region Zealand Psychiatry, Faelledvej 6, Slagelse, 4200, Denmark, 45 5853 6000, stfa@regionsjaelland.dk %K dialectical behavior therapy %K mobile application %K blended intervention %K mHealth %K app %D 2020 %7 11.6.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: The advancement of and access to technology such as smartphones has implications for psychotherapeutic health care and how interventions for a range of mental health disorders are provided. Objective: The objective of this study was to describe the experiences of participants while using a mobile phone app that was designed to enhance and support dialectical behavior therapy for personality disorders. Methods: A combination of in-depth interviews and questionnaires were used to capture the experiences of participants who used the app while undergoing dialectical behavior therapy treatment. A mixed methods approach was used; qualitative data from the interviews were analyzed using thematic analysis and were combined with quantitative data from the questionnaires. Results: Participants (N=24) who were receiving dialectical behavior therapy used the trial app. Participants (n=20) completed an evaluation questionnaire and a subset of this group (n=8) participated in semistructured interviews. Major themes that were identified from the interviews were (1) an overall positive experience of using the app—participants perceived that the app facilitated access and implementation of dialectical behavior therapy strategies (to regulate mood and behavior in challenging situations)—and (2) that the app provided a common source of information for patient and therapist interactions—app-based interactions were perceived to facilitate therapeutic alliance. Qualitative themes from the interviews were largely congruent with the quantitative responses from the questionnaires. Conclusions: Participants welcomed the integration of technology as a supplement to clinical treatment. The app was perceived to facilitate and support many of the therapeutic techniques associated with dialectical behavior therapy treatment. The incorporation of technology into psychotherapeutic interventions may facilitate the transfer of knowledge and strategies that are learned in therapy to use in real-world settings thereby promoting recovery from mental health problems. %M 32525488 %R 10.2196/14913 %U http://mental.jmir.org/2020/6/e14913/ %U https://doi.org/10.2196/14913 %U http://www.ncbi.nlm.nih.gov/pubmed/32525488 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e16506 %T The Model of Gamification Principles for Digital Health Interventions: Evaluation of Validity and Potential Utility %A Floryan,Mark %A Chow,Philip I %A Schueller,Stephen M %A Ritterband,Lee M %+ Department of Computer Science, University of Virginia, 85 Engineer's Way, Charlottesville, VA, 22904, United States, 1 4342433087, mrf8t@virginia.edu %K gamification %K internet interventions %K eHealth %K mHealth %K digital health %D 2020 %7 10.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Although gamification continues to be a popular approach to increase engagement, motivation, and adherence to behavioral interventions, empirical studies have rarely focused on this topic. There is a need to empirically evaluate gamification models to increase the understanding of how to integrate gamification into interventions. Objective: The model of gamification principles for digital health interventions proposes a set of five independent yet interrelated gamification principles. This study aimed to examine the validity and reliability of this model to inform its use in Web- and mobile-based apps. Methods: A total of 17 digital health interventions were selected from a curated website of mobile- and Web-based apps (PsyberGuide), which makes independent and unbiased ratings on various metrics. A total of 133 independent raters trained in gamification evaluation techniques were instructed to evaluate the apps and rate the degree to which gamification principles are present. Multiple ratings (n≥20) were collected for each of the five gamification principles within each app. Existing measures, including the PsyberGuide credibility score, mobile app rating scale (MARS), and the app store rating of each app were collected, and their relationship with the gamification principle scores was investigated. Results: Apps varied widely in the degree of gamification implemented (ie, the mean gamification rating ranged from 0.17≤m≤4.65 out of 5). Inter-rater reliability of gamification scores for each app was acceptable (κ≥0.5). There was no significant correlation between any of the five gamification principles and the PsyberGuide credibility score (P≥.49 in all cases). Three gamification principles (supporting player archetypes, feedback, and visibility) were significantly correlated with the MARS score, whereas three principles (meaningful purpose, meaningful choice, and supporting player archetypes) were significantly correlated with the app store rating. One gamification principle was statistically significant with both the MARS and the app store rating (supporting player archetypes). Conclusions: Overall, the results support the validity and potential utility of the model of gamification principles for digital health interventions. As expected, there was some overlap between several gamification principles and existing app measures (eg, MARS). However, the results indicate that the gamification principles are not redundant with existing measures and highlight the potential utility of a 5-factor gamification model structure in digital behavioral health interventions. These gamification principles may be used to improve user experience and enhance engagement with digital health programs. %M 32519965 %R 10.2196/16506 %U https://www.jmir.org/2020/6/e16506 %U https://doi.org/10.2196/16506 %U http://www.ncbi.nlm.nih.gov/pubmed/32519965 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e17450 %T Developing Empirical Decision Points to Improve the Timing of Adaptive Digital Health Physical Activity Interventions in Youth: Survival Analysis %A Ortega,Adrian %A Cushing,Christopher C %+ Schiefelbusch Life Span Institute, University of Kansas, 1000 Sunnyside Avenue, Lawrence, KS, United States, 1 7858640713, christopher.cushing@ku.edu %K telemedicine %K exercise %K physical activity %K adolescent %D 2020 %7 10.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Current digital health interventions primarily use interventionist-defined rules to guide the timing of intervention delivery. As new temporally dense data sets become available, it is possible to make decisions about the intervention timing empirically. Objective: This study aimed to explore the timing of physical activity among youth to inform decision points (eg, timing of support) for future digital physical activity interventions. Methods: This study comprised 113 adolescents aged between 13 and 18 years (mean age 14.64, SD 1.48 years) who wore an accelerometer for 20 days. Multilevel survival analyses were used to estimate the most likely time of day (via odds ratios and hazard probabilities) when adolescents accumulated their average physical activity. The interacting effects of physical activity timing and moderating variables were calculated by entering predictors, such as gender, sports participation, and school day, into the model as main effects and tested for interactions with the time of day to determine conditional main effects of these predictors. Results: On average, the likelihood that a participant would accumulate a typical amount of moderate-to-vigorous physical activity increased and peaked between 6 PM and 8 PM before decreasing sharply after 9 PM. Hazard and survival probabilities suggest that optimal decision points for digital physical activity programs could occur between 5 PM and 8 PM. Conclusions: Overall, the findings of this study support the idea that the timing of physical activity can be empirically identified and that these markers may be useful as intervention triggers. %M 32519967 %R 10.2196/17450 %U https://mhealth.jmir.org/2020/6/e17450 %U https://doi.org/10.2196/17450 %U http://www.ncbi.nlm.nih.gov/pubmed/32519967 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16721 %T The Mediating Role of Organizational Reputation and Trust in the Intention to Use Wearable Health Devices: Cross-Country Study %A Adebesin,Funmi %A Mwalugha,Revingstone %+ Department of Informatics, University of Pretoria, Corner of Lynwood and Roper Street, Hatfield, Pretoria, 0083, South Africa, 27 0124205667, funmi.adebesin@up.ac.za %K fitness trackers %K intention %K Kenya %K physical activity %K privacy %K South Africa %K trust %K regression analysis %D 2020 %7 9.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The use of consumer wearable health devices for fitness tracking has seen an upward trend across the globe. Previous studies have shown that trust is an important factor in the adoption and use of new technologies. However, little is known about the influence of organizational reputation and trust on the intention to use wearable health devices. Objective: This study aimed to investigate the mediating role of organizational reputation and trust in the intention to use wearable health devices and to examine the extent to which the country of residence influenced the effect of organizational reputation on consumers’ trust in and intention to use wearable health devices. Methods: We conducted a cross-country survey with participants from Kenya and South Africa using a Google Forms questionnaire derived from previously validated items. A series of mediation regression analyses were carried out using the PROCESS macro with the bootstrap CI procedure. A one-way, between-group multivariate analysis of variance (MANOVA) was also used to determine the key factors that distinguish Kenyans and South Africans in their intention to use wearable health devices. Results: A total of 232 questionnaire responses were collected. The results revealed that organizational reputation significantly mediates the relationship between trust propensity and trust, with an indirect effect of 0.22 (95% CI 0.143-0.309). Organizational reputation also plays a significant direct role in the intention to use a wearable health device, with a direct effect of 0.32 (95% CI 0.175-0.483). This role is regardless of participants’ country of residence. Furthermore, there is a significant mediating effect of trust on the relationship between trust propensity and the intention to use a wearable health device, with an indirect effect of 0.26 (95% CI 0.172-0.349); between perceived security and the intention to use a wearable health device, with an indirect effect of 0.36 (95% CI 0.255-0.461); and between perceived privacy and the intention to use a wearable health device, with an indirect effect of 0.42 (95% CI 0.282-0.557). The MANOVA test shows statistically significant differences in all variables for both groups, with the exception of organizational reputation where there is no significant difference between the two cohorts. Conclusions: Organizational reputation has a significant direct influence on participants’ trust in and the intention to use a wearable health device irrespective of their country of residence. Even in the presence of perceived security and perceived privacy, trust has a significant mediating effect on the intention to use a wearable health device. %M 32348260 %R 10.2196/16721 %U http://mhealth.jmir.org/2020/6/e16721/ %U https://doi.org/10.2196/16721 %U http://www.ncbi.nlm.nih.gov/pubmed/32348260 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e16059 %T Experiences of African American Breast Cancer Survivors Using Digital Scales and Activity Trackers in a Weight Gain Prevention Intervention: Qualitative Study %A Power,Julianne M %A Tate,Deborah F %A Valle,Carmina G %+ Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 302 Rosenau Hall, CB #7440, 135 Dauer Drive, Chapel Hill, NC, 27514, United States, 1 9199665852 ext 2, julma@live.unc.edu %K African American %K cancer survivors %K digital tools %K weight gain prevention %K qualitative %D 2020 %7 8.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The use of digital tools to promote daily self-weighing and daily activity tracking may be a promising strategy for weight control among African American breast cancer survivors (AABCS). There have been no studies exploring the acceptability and feasibility of using digital tools for weight control or qualitative studies characterizing perceptions of daily self-weighing and daily activity tracking among AABCS. Objective: This study aimed to explore the subjective experiences of daily self-weighing and daily activity tracking using digital tools, including wireless scales and activity trackers, in a sample of AABCS participating in two technology-based weight gain prevention interventions over 6 months. Methods: Semistructured interviews (N=21) were conducted in person or over the phone, were audio recorded, and then transcribed verbatim. Each transcript was read to identify key themes and develop a codebook. Each transcript was coded using Atlas.ti software, and code outputs were used to identify overarching themes and patterns in the data. Results: On average, participants were 52.6 (SD 8.3) years of age, with obesity at baseline (BMI 33.1 kg/m2, SD 5.9), and weighed on 123.4 (SD 48.0) days out of the 168 days (73.5%) in the study period. Women tended to attribute their weight gain to cancer treatment and framed program benefits in terms of improved quality of life and perceptions of prolonging their survival following treatment. Using the smart scale for daily self-weighing was viewed as the tool by which participants could control their weight and improve their health and well-being posttreatment. The activity tracker increased awareness of physical activity and motivated participants to be more active. Conclusions: Participants reported positive experiences and benefits from daily self-weighing and daily activity tracking. Findings suggest that daily self-weighing and daily activity tracking using digital tools are well-received, acceptable, and feasible intervention strategies for AABCS in the context of posttreatment weight management. %M 32510461 %R 10.2196/16059 %U https://mhealth.jmir.org/2020/6/e16059 %U https://doi.org/10.2196/16059 %U http://www.ncbi.nlm.nih.gov/pubmed/32510461 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e18531 %T Effectiveness of a 3-Month Mobile Phone–Based Behavior Change Program on Active Transportation and Physical Activity in Adults: Randomized Controlled Trial %A Ek,Anna %A Alexandrou,Christina %A Söderström,Emmie %A Bergman,Patrick %A Delisle Nyström,Christine %A Direito,Artur %A Eriksson,Ulf %A Henriksson,Pontus %A Maddison,Ralph %A Trolle Lagerros,Ylva %A Bendtsen,Marcus %A Löf,Marie %+ Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, 581 83, Sweden, 46 73 656 9338, marie.lof@liu.se %K behavior change %K mobile phone intervention %K physical activity %K active transportation %K mobile phone app %K smartphone app %D 2020 %7 8.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Active transportation (AT; ie, walking and cycling as a mode for transportation) has been associated with decreased morbidity and mortality; however, low-cost and scalable intervention programs are lacking. Objective: The goal of the research was to determine the effectiveness of a 3-month behavior change program delivered via a mobile phone app to promote AT (TravelVu Plus) on time spent in moderate-to-vigorous physical activity (MVPA). Methods: For this 2-arm parallel randomized controlled trial, we recruited a population-based sample of 254 adults from Stockholm County who were aged 20 to 65 years and had access to a smartphone. On completion of 1-week baseline measures, the 254 participants were randomized to either the control or intervention group (1:1 ratio). Both groups had access to the standard TravelVu app (Trivector AB) for monitoring their AT for 6 months. The intervention group also received a 3-month behavior change program to promote AT (TravelVu Plus app). Assessors of outcomes were blinded to group allocation. Outcomes were objectively measured MVPA at 3 (primary) and 6 months. Secondary outcomes were AT, attitudes toward AT, and health-related quality of life at 3 and 6 months. Results: No effect on MVPA was observed after 3 months (P=.29); however, at 6 months the intervention group had a greater improvement in MVPA than the controls (6.05 minutes per day [95% CI 0.36 to 11.74; P=.04]). A Bayesian analyses showed that there was a 98% probability that the intervention had any effect at 6 months, and a 63% probability that this effect was >5 minute MVPA per day. Conclusions: No effect on MVPA immediately after the intervention period (at 3 months) was observed; however, there was a delayed effect on MVPA (6 minutes per day) at 6 months, which corresponds to approximately 30% of the weekly MVPA recommendation. Our findings suggest that a behavior change program promoting AT delivered via an app may have a relevant effect on PA. Trial Registration: ClinicalTrials.gov NCT03086837; https://clinicaltrials.gov/ct2/show/NCT03086837 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-018-5658-4 %M 32510462 %R 10.2196/18531 %U https://mhealth.jmir.org/2020/6/e18531 %U https://doi.org/10.2196/18531 %U http://www.ncbi.nlm.nih.gov/pubmed/32510462 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 6 %P e18098 %T A Clinical Trial to Increase Self-Monitoring of Physical Activity and Eating Behaviors Among Adolescents: Protocol for the ImPACT Feasibility Study %A Moore,Justin B %A Dilley,Joshua R %A Singletary,Camelia R %A Skelton,Joseph A %A Miller Jr,David P %A Heboyan,Vahé %A De Leo,Gianluca %A Turner-McGrievy,Gabrielle %A McGrievy,Matthew %A Ip,Edward H %+ Department of Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, 525 Vine St, Winston-Salem, NC, 27101, United States, 1 336 716 3702, jusmoore@wakehealth.edu %K physical activity %K obesity %K adolescence %K adult %K therapy, family %K mobile phone %D 2020 %7 5.6.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Severe obesity among youths (BMI for age≥120th percentile) has been steadily increasing. The home environment and parental behavioral modeling are two of the strongest predictors of child weight loss during weight loss interventions, which highlights that a family-based treatment approach is warranted. This strategy has been successful in our existing evidence-based pediatric weight management program, Brenner Families in Training (Brenner FIT). However, this program relies on face-to-face encounters, which are limited by the time constraints of the families enrolled in treatment. Objective: This study aims to refine and test a tailored suite of mobile health (mHealth) components to augment an existing evidence-based pediatric weight management program. Methods: Study outcomes will include acceptability from a patient and clinical staff perspective, feasibility, and economic costs relative to the established weight management protocol alone (ie, Brenner FIT vs Brenner FIT + mHealth [Brenner mFIT]). The Brenner mFIT intervention will consist of 6 mHealth components designed to increase patient and caregiver exposure to Brenner FIT programmatic content including the following: (1) a mobile-enabled website, (2) dietary and physical activity tracking, (3) caregiver podcasts (n=12), (4) animated videos (n=6) for adolescent patients, (5) interactive messaging, and (6) in-person tailored clinical feedback provided based on a web-based dashboard. For the study, 80 youths with obesity (aged 13-18 years) and caregiver dyads will be randomized to Brenner FIT or Brenner mFIT. All participants will complete baseline measures before randomization and at 3- and 6-month follow-up points. Results: This study was approved by the Institutional Review Board in July 2019, funded in August 2019, and will commence enrollment in April 2020. The results of the study are expected to be published in the fall/winter of 2021. Conclusions: The results of this study will be used to inform a large-scale implementation-effectiveness clinical trial. International Registered Report Identifier (IRRID): PRR1-10.2196/18098 %M 32348291 %R 10.2196/18098 %U https://www.researchprotocols.org/2020/6/e18098 %U https://doi.org/10.2196/18098 %U http://www.ncbi.nlm.nih.gov/pubmed/32348291 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e15752 %T Technologies for Opioid Use Disorder Management: Mobile App Search and Scoping Review %A Nuamah,Joseph %A Mehta,Ranjana %A Sasangohar,Farzan %+ Department of Industrial and Systems Engineering, Texas A&M University, 3131 TAMU, College Station, TX, 77843, United States, 1 9794582337, sasangohar@tamu.edu %K mHealth %K apps %K wearable sensors %K substance abuse disorder %K mobile phone %D 2020 %7 5.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Advances in technology engender the investigation of technological solutions to opioid use disorder (OUD). However, in comparison to chronic disease management, the application of mobile health (mHealth) to OUD has been limited. Objective: The overarching aim of our research was to design OUD management technologies that utilize wearable sensors to provide continuous monitoring capabilities. The objectives of this study were to (1) document the currently available opioid-related mHealth apps, (2) review past and existing technology solutions that address OUD, and (3) discuss opportunities for technological withdrawal management solutions. Methods: We used a two-phase parallel search approach: (1) an app search to determine the availability of opioid-related mHealth apps and (2) a scoping review of relevant literature to identify relevant technologies and mHealth apps used to address OUD. Results: The app search revealed a steady rise in app development, with most apps being clinician-facing. Most of the apps were designed to aid in opioid dose conversion. Despite the availability of these apps, the scoping review found no study that investigated the efficacy of mHealth apps to address OUD. Conclusions: Our findings highlight a general gap in technological solutions of OUD management and the potential for mHealth apps and wearable sensors to address OUD. %M 32501273 %R 10.2196/15752 %U https://mhealth.jmir.org/2020/6/e15752 %U https://doi.org/10.2196/15752 %U http://www.ncbi.nlm.nih.gov/pubmed/32501273 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17152 %T Associations Between Commercial App Use and Physical Activity: Cross-Sectional Study %A Petersen,Jasmine Maria %A Kemps,Eva %A Lewis,Lucy K %A Prichard,Ivanka %+ SHAPE Research Centre, Flinders University, GPO Box 2100, Adelaide, Australia, 61 8 82013713, jasmine.petersen@flinders.edu.au %K physical activity %K mobile applications %K social networking %D 2020 %7 3.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In today’s society, commercial physical activity apps (eg, Fitbit and Strava) are ubiquitous and hold considerable potential to increase physical activity behavior. Many commercial physical activity apps incorporate social components, in particular app-specific communities (allowing users to interact with other app users) or the capacity to connect to existing social networking platforms (eg, Facebook or Instagram). There is a growing need to gain greater insights into whether commercial physical activity apps and specific components of these apps (social components) are beneficial in facilitating physical activity. Objective: This study aimed to examine the relationship between the use of commercial physical activity apps and engagement in physical activity. The social components of commercial physical activity apps (app-specific communities and existing social networking platforms) were also explored. This involved isolating specific features (eg, sharing, providing, and receiving encouragement, comparisons, and competitions) of app-specific communities and existing social networking platforms that were most valuable in facilitating physical activity. Methods: A cross-sectional web-based survey was conducted. Participants were 1432 adults (mean age 34.1 years, 1256/1432, 88.00% female) who completed measures assessing physical activity, the use of commercial physical activity apps, and engagement with app-specific communities and existing social networking platforms. Results: Overall, 53.14% (761/1432) of the sample reported engaging with a commercial physical activity app. The most commonly used apps were Fitbit (171/761, 22.5%), Strava (130/761, 17.1%), and Garmin (102/761, 13.4%). The use of physical activity apps was significantly associated with physical activity. Notably, the use of app-specific communities and existing social networking platforms facilitated significantly greater engagement in physical activity. The features of app-specific communities that were most beneficial in promoting engagement in physical activity were providing encouragement to a partner, receiving encouragement from close friends and family, and engaging in competitions with members of public app-specific communities. In relation to existing social networking platforms, sharing physical activity posts predicted engagement in physical activity. Conclusions: The findings indicate that app-specific communities and existing social networking platforms are components of apps that are fundamental in facilitating physical activity. They further suggest that commercial physical activity apps afford high population level reach and hold great potential to promote engagement in physical activity, an important public health consideration. %M 32490836 %R 10.2196/17152 %U https://www.jmir.org/2020/6/e17152 %U https://doi.org/10.2196/17152 %U http://www.ncbi.nlm.nih.gov/pubmed/32490836 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e15943 %T Feasibility and Acceptability of a Mobile Mindfulness Meditation Intervention Among Women: Intervention Study %A Rung,Ariane Lisann %A Oral,Evrim %A Berghammer,Lara %A Peters,Edward S %+ Epidemiology Program, School of Public Health, Louisiana State University Health Sciences Center New Orleans, 2020 Gravier Street, 3rd Floor, New Orleans, LA, 70112, United States, 1 504 568 5709, abedim@lsuhsc.edu %K mindfulness %K mobile phone %K depressive symptoms %K women %K Louisiana %D 2020 %7 2.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Traditional mindfulness-based stress reduction programs are resource intensive for providers and time- and cost-intensive for participants, but the use of mobile technologies may be particularly convenient and cost-effective for populations that are busy, less affluent, or geographically distant from skilled providers. Women in southern Louisiana live in a vulnerable, disaster-prone region and are highly stressed, making a mobile program particularly suited to this population. Objective: This study aimed to (1) assess the feasibility and acceptability of a mobile mindfulness app in real-world conditions in a pilot study of a community sample of women residing in southern Louisiana, (2) describe predictors of app usage, and (3) assess the effect of the app on secondary health outcomes. Methods: Women were recruited from an oil spill study on health. A total of 236 women completed a baseline survey, were offered the mobile mindfulness program, and completed a follow-up survey. Subjects were asked to download and use the app for at least 30 days for 10 min. All study procedures were completed on the web. Primary outcomes were feasibility and acceptability of the app and characteristics of app utilization. Secondary outcomes included mindfulness, depression, perceived stress, sleep quality, physical activity, BMI, and healthy eating. Results: Overall, 74.2% (236/318) of subjects completed the follow-up survey, and 13.5% (43/318) used the app. The main barrier to app usage was lack of time, cited by 37% (16/43) of users and 48.7% (94/193) of nonusers of the app. Women who chose to use the app were more highly educated (16/43, 63% had a college education vs 65/193, 33.7% of nonparticipants; P<.001), had higher incomes (23/43, 58% had incomes >US $50,000 per year vs 77/193, 43.0% of nonparticipants), and were employed (34/43, 79% vs 122/193, 63.2% of nonparticipants; P=.047). Those who engaged with the app did so at high levels, with 72% (31/43) of participants self-reporting the completion of some or all sessions and 74% (32/43) reporting high levels of satisfaction with the app. Participation with the app had a beneficial impact on depression (odds ratio [OR] 0.3, 95% CI 0.11-0.81), sleep quality (OR 0.1, 95% CI 0.02-0.96), sleep duration (OR 0.3, 95% CI 0.07-0.86), sleep latency (OR 0.3, 95% CI 0.11-0.81), and physical activity (2.8 95% CI 1.0-7.8), but mindfulness scores did not change from baseline to follow-up. Conclusions: The Headspace mobile mindfulness app was easy and cost-effective to implement and acceptable to those who participated, but few women elected to try it. The unique characteristics of this southern Louisiana population suggest that more intense promotion of the benefits of mindfulness training is needed, perhaps in conjunction with some therapist or researcher support. Several short-term benefits of the app were identified, particularly for depression and sleep. %M 32442147 %R 10.2196/15943 %U https://mhealth.jmir.org/2020/6/e15943 %U https://doi.org/10.2196/15943 %U http://www.ncbi.nlm.nih.gov/pubmed/32442147 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 6 %P e13808 %T Limitations of Existing Dialysis Diet Apps in Promoting User Engagement and Patient Self-Management: Quantitative Content Analysis Study %A Lim,Jun-Hao %A Lim,Cordelia-Kheng-May %A Ibrahim,Imliya %A Syahrul,Jazlina %A Mohamed Zabil,Mohd Hazli %A Zakaria,Nor Fadhlina %A Daud,Zulfitri Azuan Mat %+ Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM Serdang, Serdang, 43400, Malaysia, 60 397692431, zulfitri@upm.edu.my %K renal apps %K nutrition %K dialysis %K self-management %K mHealth %D 2020 %7 1.6.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: With the unprecedented growth of mobile technology, a plethora of dialysis diet apps have been developed to promote patient dietary self-management. Nevertheless, the utility of such apps remains questionable. Objective: This study aimed to evaluate the content, features, and quality of commercial dialysis diet apps for adult dialysis patients. Methods: This study consisted of a quantitative content analysis of commercial dialysis diet apps downloaded from Google Play and the Apple App Store available in the Asian marketplace, searched for using the following keywords in English: dialysis diet and diet for kidney disease. Free and paid apps available in English that provide nutrition information for adult dialysis patients were included. Apps that were not relevant to the dialysis diet, not meant for patient self-management, or redundant were excluded. Apps were evaluated for language medium (subscore=1), credibility (subscore=1), food database (subscore=1), valuable features (subscore=12), health-behavior theory constructs (subscore=60), and technical quality (subscore=25). The relationships among the variables of interest were determined by Pearson correlation. Stepwise multiple linear regression analysis was performed to identify the features that contribute to greater technical quality of dialysis diet apps. Statistical significance was defined as P<.05. Results: A total of 22 out of 253 apps (8.7%) were eligible for evaluation. Based on a 100-point scale, the mean overall score of the apps was 31.30 (SD 14.28). Only 5% (1/22) of the apps offered relevant language options, and 46% (10/22) contained food databases. In addition, 54% (12/22) of the apps were not credible. The mean score for valuable features was 3.45 (SD 1.63) out of 12, in which general education (16/22, 73%), free download (15/22, 68%), and usability (13/22, 59%) were the three most popular features. However, the apps scored a mean of 13.41 (SD 11.56) out of 60 for health-behavior theory constructs. The overall app technical quality was considered poor, with a mean score of 2.70 (SD 0.41) out of 5. The scores of valuable features (r=.65, P=.001) and health-behavior theory constructs (r=.55, P=.009) were positively correlated with the overall technical quality of the commercial dialysis diet apps. Features such as free download (β=.43, P=.03) and usability (β=.41, P=.03) could significantly determine the functional quality of the apps. Health-behavior theory constructs such as self-monitoring could significantly predict both the subjective quality (β=.55, P=.008) and the engagement quality (β=.66, P=.001) of the apps, whereas the information quality domain could be determined by plan or orders (β=.48, P=.007) and knowledge (β=.45, P=.01). Conclusions: Although most of the available commercial dialysis diet apps are free and easy to use, they are subject to theory deficiency, limited language options, and a lack of food databases, credibility, tailored education, and overall technical quality. %M 32478665 %R 10.2196/13808 %U https://mhealth.jmir.org/2020/6/e13808 %U https://doi.org/10.2196/13808 %U http://www.ncbi.nlm.nih.gov/pubmed/32478665 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e17572 %T Influences on the Uptake of and Engagement With Health and Well-Being Smartphone Apps: Systematic Review %A Szinay,Dorothy %A Jones,Andy %A Chadborn,Tim %A Brown,Jamie %A Naughton,Felix %+ School of Health Sciences, University of East Anglia, Norwich Research Park, Norwich, NR47TJ, United Kingdom, 44 1603593064 ext 3064, d.szinay@uea.ac.uk %K mHealth %K health app %K engagement %K uptake %K systematic review %K COM-B %K TDF %K digital health %K mobile phone %K smartphone %K smartphone app %D 2020 %7 29.5.2020 %9 Review %J J Med Internet Res %G English %X Background: The public health impact of health and well-being digital interventions is dependent upon sufficient real-world uptake and engagement. Uptake is currently largely dependent on popularity indicators (eg, ranking and user ratings on app stores), which may not correspond with effectiveness, and rapid disengagement is common. Therefore, there is an urgent need to identify factors that influence uptake and engagement with health and well-being apps to inform new approaches that promote the effective use of such tools. Objective: This review aimed to understand what is known about influences on the uptake of and engagement with health and well-being smartphone apps among adults. Methods: We conducted a systematic review of quantitative, qualitative, and mixed methods studies. Studies conducted on adults were included if they focused on health and well-being smartphone apps reporting on uptake and engagement behavior. Studies identified through a systematic search in Medical Literature Analysis and Retrieval System Online, or MEDLARS Online (MEDLINE), EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Scopus, Cochrane library databases, DataBase systems and Logic Programming (DBLP), and Association for Computing Machinery (ACM) Digital library were screened, with a proportion screened independently by 2 authors. Data synthesis and interpretation were undertaken using a deductive iterative process. External validity checking was undertaken by an independent researcher. A narrative synthesis of the findings was structured around the components of the capability, opportunity, motivation, behavior change model and the theoretical domains framework (TDF). Results: Of the 7640 identified studies, 41 were included in the review. Factors related to uptake (U), engagement (E), or both (B) were identified. Under capability, the main factors identified were app literacy skills (B), app awareness (U), available user guidance (B), health information (E), statistical information on progress (E), well-designed reminders (E), features to reduce cognitive load (E), and self-monitoring features (E). Availability at low cost (U), positive tone, and personalization (E) were identified as physical opportunity factors, whereas recommendations for health and well-being apps (U), embedded health professional support (E), and social networking (E) possibilities were social opportunity factors. Finally, the motivation factors included positive feedback (E), available rewards (E), goal setting (E), and the perceived utility of the app (E). Conclusions: Across a wide range of populations and behaviors, 26 factors relating to capability, opportunity, and motivation appear to influence the uptake of and engagement with health and well-being smartphone apps. Our recommendations may help app developers, health app portal developers, and policy makers in the optimization of health and well-being apps. %M 32348255 %R 10.2196/17572 %U http://www.jmir.org/2020/5/e17572/ %U https://doi.org/10.2196/17572 %U http://www.ncbi.nlm.nih.gov/pubmed/32348255 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17458 %T Mobile Apps for Mental Health Issues: Meta-Review of Meta-Analyses %A Lecomte,Tania %A Potvin,Stéphane %A Corbière,Marc %A Guay,Stéphane %A Samson,Crystal %A Cloutier,Briana %A Francoeur,Audrey %A Pennou,Antoine %A Khazaal,Yasser %+ Department of Psychology, University of Montreal, 90 rue Vincent d'Indy, Bur C-358, CP 6128, Succ Centre-Ville, Montreal, QC, H3C 3J7, Canada, 1 343 6274, tania.lecomte@umontreal.ca %K apps %K mental health %K depression %K anxiety %K review %K meta %D 2020 %7 29.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mental health apps have great potential to help people needing support to cope with distress or specific symptoms. In fact, there is an exponential increase in the number of mental health apps available on the internet, with less than 5% being actually studied. Objective: This study aimed to assess the quality of the available evidence regarding the use of mental health apps and to summarize the results obtained so far. Methods: Systematic reviews and meta-analyses were searched, specifically for mobile apps on mental health issues or symptoms, and rated using the Grading of Recommendations Assessment, Development and Evaluation system. Results: A total of 7 meta-analyses were carefully reviewed and rated. Although some meta-analyses looked at any mental health issue and analyzed the data together, these studies were of poorer quality and did not offer strong empirical support for the apps. Studies focusing specifically on anxiety symptoms or depressive symptoms were of moderate to high quality and generally had small to medium effect sizes. Similarly, the effects of apps on stress and quality of life tended to offer small to medium effects and were of moderate to high quality. Studies looking at stand-alone apps had smaller effect sizes but better empirical quality than studies looking at apps with guidance. The studies that included follow-ups mostly found a sustained impact of the app at an 11-week follow-up. Conclusions: This meta-review revealed that apps for anxiety and depression hold great promise with clear clinical advantages, either as stand-alone self-management or as adjunctive treatments. More meta-analyses and more quality studies are needed to recommend apps for other mental health issues or for specific populations. %M 32348289 %R 10.2196/17458 %U https://mhealth.jmir.org/2020/5/e17458 %U https://doi.org/10.2196/17458 %U http://www.ncbi.nlm.nih.gov/pubmed/32348289 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 6 %N 2 %P e16303 %T Ambiguity in Communicating Intensity of Physical Activity: Survey Study %A Kim,Hyeoneui %A Kim,Jaemin %A Taira,Ricky %+ School of Nursing, Duke University, 307 Trent Drive, Durham, NC, 27710, United States, 1 919 684 7534, hyeoneui.kim@duke.edu %K exercise %K health communication %K exercise intensity %D 2020 %7 28.5.2020 %9 Original Paper %J JMIR Public Health Surveill %G English %X Background: Communicating physical activity information with sufficient details, such as activity type, frequency, duration, and intensity, is vital to accurately delineate the attributes of physical activity that bring positive health impact. Unlike frequency and duration, intensity is a subjective concept that can be interpreted differently by people depending on demographics, health status, physical fitness, and exercise habits. However, activity intensity is often communicated using general degree modifiers, degree of physical exertion, and physical activity examples, which are the expressions that people may interpret differently. Lack of clarity in communicating the intensity level of physical activity is a potential barrier to an accurate assessment of exercise effect and effective imparting of exercise recommendations. Objective: This study aimed to assess the variations in people’s perceptions and interpretations of commonly used intensity descriptions of physical activities and to identify factors that may contribute to these variations. Methods: A Web-based survey with a 25-item questionnaire was conducted using Amazon Mechanical Turk, targeting adults residing in the United States. The questionnaire included questions on participants’ demographics, exercise habits, overall perceived health status, and perceived intensity of 10 physical activity examples. The survey responses were analyzed using the R statistical package. Results: The analyses included 498 responses. The majority of respondents were females (276/498, 55.4%) and whites (399/498, 79.9%). Numeric ratings of physical exertion after exercise were relatively well associated with the 3 general degree descriptors of exercise intensity: light, moderate, and vigorous. However, there was no clear association between the intensity expressed with those degree descriptors and the degree of physical exertion the participants reported to have experienced after exercise. Intensity ratings of various examples of physical activity differed significantly according to respondents’ characteristics. Regression analyses showed that those who reported good health or considered regular exercise was important for their health tended to rate the intensity levels of the activity examples significantly higher than their counterparts. The respondents’ age and race (white vs nonwhite) were not significant predictors of the intensity rating. Conclusions: This survey showed significant variations in how people perceive and interpret the intensity levels of physical activities described with general severity modifiers, degrees of physical exertion, and physical activity examples. Considering that these are among the most widely used methods of communicating physical activity intensity in current practice, a possible miscommunication in assessing and promoting physical activity seems to be a real concern. We need to adopt a method that represents activity intensity in a quantifiable manner to avoid unintended miscommunication. %M 32348256 %R 10.2196/16303 %U http://publichealth.jmir.org/2020/2/e16303/ %U https://doi.org/10.2196/16303 %U http://www.ncbi.nlm.nih.gov/pubmed/32348256 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e15111 %T Mobile Phone–Based Behavioral Interventions in Pregnancy to Promote Maternal and Fetal Health in High-Income Countries: Systematic Review %A Hussain,Tasmeen %A Smith,Patricia %A Yee,Lynn M %+ Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 E. Superior Street, #5-2145, Chicago, IL, United States, 1 312 472 4685, lynn.yee@northwestern.edu %K mHealth %K mobile health %K pregnancy %K smartphone %K text messaging %K mobile applications %K software %K chronic disease %K health behavior %D 2020 %7 28.5.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Chronic diseases have recently had an increasing effect on maternal-fetal health, especially in high-income countries. However, there remains a lack of discussion regarding health management with technological approaches, including mobile health (mHealth) interventions. Objective: This study aimed to systematically evaluate mHealth interventions used in pregnancy in high-income countries and their effects on maternal health behaviors and maternal-fetal health outcomes. Methods: This systematic review identified studies published between January 1, 2000, and November 30, 2018, in MEDLINE via PubMed, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and gray literature. Studies were eligible for inclusion if they included only pregnant women in high-income countries and evaluated stand-alone mobile phone interventions intended to promote healthy maternal beliefs, behaviors, and/or maternal-fetal health outcomes. Two researchers independently reviewed and categorized aspects of full-text articles, including source, study design, intervention and control, duration, participant age, attrition rate, main outcomes, and risk of bias. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and the study was registered in PROSPERO before initiation. Results: Of the 2225 records examined, 28 studies were included and categorized into 4 themes: (1) gestational weight gain, obesity and physical activity (n=9); (2) smoking cessation (n=9); (3) influenza vaccination (n=2); and (4) general prenatal health, preventive strategies, and miscellaneous topics (n=8). Reported sample sizes ranged from 16 to 5243 with a median of 91. Most studies were performed in the United States (18/28, 64%) and were randomized controlled trials (21/28, 75%). All participants in the included studies were pregnant at the time of study initiation. Overall, 14% (4/28) of studies showed association between intervention use and improved health outcomes; all 4 studies focused on healthy gestational weight. Among those, 3 studies showed intervention use was associated with less overall gestational weight gain. These 3 studies involved interventions with text messaging or an app in combination with another communication strategy (Facebook or email). Regarding smoking cessation, influenza vaccination, and miscellaneous topics, there was some evidence of positive effects on health behaviors and beliefs, but very limited correlation with improved health outcomes. Data and interventions were heterogeneous, precluding a meta-analysis. Conclusions: In high-income countries, utilization of mobile phone–based health behavior interventions in pregnancy demonstrates some correlation with positive beliefs, behaviors, and health outcomes. More effective interventions are multimodal in terms of features and tend to focus on healthy gestational weight gain. %M 32463373 %R 10.2196/15111 %U https://mhealth.jmir.org/2020/5/e15111 %U https://doi.org/10.2196/15111 %U http://www.ncbi.nlm.nih.gov/pubmed/32463373 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17300 %T Content and Quality of Infant Feeding Smartphone Apps: Five-Year Update on a Systematic Search and Evaluation %A Cheng,Heilok %A Tutt,Alison %A Llewellyn,Catherine %A Size,Donna %A Jones,Jennifer %A Taki,Sarah %A Rossiter,Chris %A Denney-Wilson,Elizabeth %+ Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, 88 Mallett Street, Camperdown, 2050, Australia, 61 1800793864, jessica.cheng@sydney.edu.au %K breast feeding %K bottle feeding %K infant food %K readability %K consumer health information %K breastfeeding %K mobile apps %K smartphones %D 2020 %7 27.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Parents use apps to access information on child health, but there are no standards for providing evidence-based advice, support, and information. Well-developed apps that promote appropriate infant feeding and play can support healthy growth and development. A 2015 systematic assessment of smartphone apps in Australia about infant feeding and play found that most apps had minimal information, with poor readability and app quality. Objective: This study aimed to systematically evaluate the information and quality of smartphone apps providing information on breastfeeding, formula feeding, introducing solids, or infant play for consumers. Methods: The Google Play store and Apple App Store were searched for free and paid Android and iPhone Operating System (iOS) apps using keywords for infant feeding, breastfeeding, formula feeding, and tummy time. The apps were evaluated between September 2018 and January 2019 for information content based on Australian guidelines, app quality using the 5-point Mobile App Rating Scale, readability, and suitability of health information. Results: A total of 2196 unique apps were found and screened. Overall, 47 apps were evaluated, totaling 59 evaluations for apps across both the Android and iOS platforms. In all, 11 apps had affiliations to universities and health services as app developers, writers, or editors. Furthermore, 33 apps were commercially developed. The information contained within the apps was poor: 64% (38/59) of the evaluations found no or low coverage of information found in the Australian guidelines on infant feeding and activity, and 53% (31/59) of the evaluations found incomplete or incorrect information with regard to the depth of information provided. Subjective app assessment by health care practitioners on whether they would use, purchase, or recommend the app ranged from poor to acceptable (median 2.50). Objective assessment of the apps’ engagement, functionality, aesthetics, and information was scored as acceptable (median 3.63). The median readability score for the apps was at the American Grade 8 reading level. The suitability of health information was rated superior or adequate for content, reading demand, layout, and interaction with the readers. Conclusions: The quality of smartphone apps on infant feeding and activity was moderate based on the objective measurements of engagement, functionality, aesthetics, and information from a reliable source. The overall quality of information on infant feeding and activity was poor, indicated by low coverage of topics and incomplete or partially complete information. The key areas for improvement involved providing evidence-based information consistent with the Australian National Health and Medical Research Council’s Infant Feeding Guidelines. Apps supported and developed by health care professionals with adequate health service funding can ensure that parents are provided with credible and reliable resources. %M 32459187 %R 10.2196/17300 %U http://mhealth.jmir.org/2020/5/e17300/ %U https://doi.org/10.2196/17300 %U http://www.ncbi.nlm.nih.gov/pubmed/32459187 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e16999 %T Effect of an mHealth Intervention Using a Pedometer App With Full In-Person Counseling on Body Composition of Overweight Adults: Randomized Controlled Weight Loss Trial %A Hernández-Reyes,Alberto %A Cámara-Martos,Fernando %A Molina-Luque,Rafael %A Moreno-Rojas,Rafael %+ Universidad de Córdoba, Darwin Building, Annex, Campus de Rabanales, Córdoba, 14014, Spain, 34 687376563, z52heloa@uco.es %K pedometer %K physical activity %K exercise prescription %K diet %K health behavior %D 2020 %7 27.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In clinical practice, it is difficult to convey the benefits of sustained physical activity to adult patients with excess weight or obesity. For this purpose, a goal-setting walking prescription may be an effective strategy. Objective: This study aimed to determine the efficacy of the intervention of a pedometer app in setting a goal to reach 10,000 steps per day in adults. Methods: Overweight adults (n=98; mean body mass index 32.53 [SD 4.92] kg/m2) were randomized to one of two conditions (control or intervention). Both groups downloaded a pedometer app that recorded their daily step counts and were given a daily walking goal of 10,000 steps. Subjects participated in a 24-week in-person behavioral weight control program and were asked to monitor their daily levels using the pedometer app. Baseline data were recorded and followed up weekly. Only the intervention group had structured information delivery, a personalized physical activity prescription, and follow-up on number of steps per day. Results: The results show that regardless of sex or age, prescribing walking increased the number of steps per day by 4806 step on average (standardized β coefficient=–0.813, SE=427.586, t=–11.242, P<.001). Conclusions: These results could have implications for improving self-monitoring in overweight adults during periods of weight loss. Health professionals should analyze the implementation of tools that permit them to prescribe, follow up, and encourage the achievement of a goal of physical activity in overweight or obese patients. Trial Registration: ClinicalTrials.gov NCT03845478; https://clinicaltrials.gov/ct2/show/NCT03845478 %M 32348263 %R 10.2196/16999 %U http://mhealth.jmir.org/2020/5/e16999/ %U https://doi.org/10.2196/16999 %U http://www.ncbi.nlm.nih.gov/pubmed/32348263 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e15849 %T Effectiveness of Text Message Interventions for Weight Management in Adolescents: Systematic Review %A Partridge,Stephanie Ruth %A Raeside,Rebecca %A Singleton,Anna %A Hyun,Karice %A Redfern,Julie %+ The University of Sydney, Westmead Applied Research Centre, Faculty of Medicine and Health, Department of General Practice, Acacia House, Westmead Hospital, Sydney, 2145, Australia, 61 288908187, stephanie.partridge@sydney.edu.au %K adolescent %K text message %K obesity %K overweight %K prevention %K mHealth %D 2020 %7 26.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The incidence of obesity among adolescents is increasing. Text messages are a primary communication form for adolescents and potentially a scalable strategy for delivering population health interventions. Objective: This study aimed to determine the effectiveness of text message interventions in reducing BMI in adolescents and describe characteristics that are common to effective interventions. Methods: This systematic review included randomized controlled trials of text message lifestyle interventions involving adolescents aged 10 to 19 years with outcomes focused on obesity prevention or management. Primary outcome was objective or self-report change in BMI. Results: In total, 4362 records were identified, and 215 full-text articles were assessed for eligibility. A total of 8 unique studies were identified, including 767 participants, mean age 14.3 (SD 0.9) years, BMI 29.7 (SD 1.6) kg/m2 and 53.1% (407/767) female (31/101, 30.7%-172/172, 100.0%). All interven