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Journal Description

JMIR Formative Research (JFR) (a PubMed-indexed sister journal of J Med Internet Res (JMIR) and JMIR mHealth & uHealth, the leading eHealth and mHealth journals by impact factor) publishes peer-reviewed, openly accessible papers containing results from process evaluations, feasibility/pilot studies and other kinds of formative research and preliminary results. While the original focus was on the design of medical and health-related research and technology innovations, JFR publishes studies from all areas of medical and health research.

Formative research is research that occurs before a program is designed and implemented, or while a program is being conducted. Formative research can help

  • define and understand populations in need of a intervention or public health program
  • create programs that are specific to the needs of those populations
  • ensure programs are acceptable and feasible to users before launching
  • improve the relationship between users and agencies/research groups
  • demonstrate the feasibility, use, satisfaction with, or problems with a program before large-scale summative evaluation (looking at health outcomes)

Many funding agencies will expect some sort of pilot/feasibility/process evaluation before funding a larger study such as a Randomized Controlled Trial (RCT).

Formative research should be an integral part of developing programs or adapting programs, and should be used while the program is on-going to help refine and improve program activities. Thus, formative evaluation can and should also occur in form of a process evaluation alongside a summative evaluation such as a RCT.

This journal fills an important gap in the academic journals landscape, as it publishes sound and peer-reviewed formative research that is criticial for investigators to apply for further funding, but that is usually not published in outcomes-focussed medical journals aiming for impact and generalizability.

Summative evaluations of programs and apps/software that have undergone a thorough formative evaluation before launch have a better chance to be published in our high-impact flagship journals (JMIR mHealth, J Med Internet Res, JMIR Serious Games), thus we encourage authors to submit - as a first step - their formative evaluations in JMIR Formative Res (and their evaluation protocols in JMIR Res Protoc). 

JMIR Formative Res has been accepted for indexing in PubMed and PubMed Central.


Recent Articles:

  • Source: Flickr; Copyright: Matt Madd; URL:; License: Creative Commons Attribution (CC-BY).

    What Is Being Used and Who Is Using It: Barriers to the Adoption of Smartphone Patient Experience Surveys


    Background: Smartphones are positioned to transform the way health care services gather patient experience data through advanced mobile survey apps which we refer to as smart surveys. In comparison with traditional methods of survey data capture, smartphone sensing survey apps have the capacity to elicit multidimensional, in situ user experience data in real time with unprecedented detail, responsiveness, and accuracy. Objective: This study aimed to explore the context and circumstances under which patients are willing to use their smartphones to share data on their service experiences. Methods: We conducted in-person, semistructured interviews (N=24) with smartphone owners to capture their experiences, perceptions, and attitudes toward smart surveys. Results: Analysis examining perceived risk revealed a few barriers to use; however, major potential barriers to adoption were the identity of recipients, reliability of the communication channel, and potential for loss of agency. The results demonstrate that the classical dimensions of perceived risk raised minimal concerns for the use of smartphones to collect patient service experience feedback. However, trust in the doctor-patient relationship, the reliability of the communication channel, the altruistic motivation to contribute to health service quality for others, and the risk of losing information agency were identified as determinants in the patients’ adoption of smart surveys. Conclusions: On the basis of these findings, we provide recommendations for the design of smart surveys in practice and suggest a need for privacy design tools for voluntary, health-related technologies.

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

    The Learning Exchange, a Community Knowledge Commons for Learning Networks: Qualitative Evaluation to Test Acceptability, Feasibility, and Utility


    Background: Learning Networks are distributed learning health systems that enable collaboration at scale to improve health and health care. A key requirement for such networks is having a way to create and share information and knowledge in furtherance of the work of the community. Objective: We describe a Learning Exchange—a bespoke, scalable knowledge management and exchange platform initially built and tested for improving pediatric inflammatory bowel disease outcomes in the ImproveCareNow (ICN) Network—and assess evidence of its acceptability, feasibility, and utility in facilitating creation and sharing of information in furtherance of the work of the community and as a model for other communities. Methods: Acceptability was assessed via growth in active users and activity. Feasibility was measured in terms of the percentage of users with a log-in who became active users as well as user surveys and a case study. Utility was measured in terms of the type of work that the Learning Exchange facilitated for the community. Results: The ICNExchange has over 1000 users and supported sharing of resources across all care centers in ICN. Users reported that the Learning Exchange has facilitated their work and resulted in increased ability to find resources relevant to local information needs. Conclusions: The ICNExchange is acceptable, feasible, and useful as a knowledge management and exchange platform in service of the work of ICN. Experience with the ICNExchange suggests that the design principles are extensible to other chronic care Learning Networks.

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

    The Development of an Arabic Weight-Loss App Akser Waznk: Qualitative Results


    Background: Obesity and its related illnesses are a major health problem around the world. Saudi Arabia has one of the highest national obesity rates globally; however, it is not easy to intervene to prevent obesity and becoming overweight owing to Saudi Arabia’s cultural and social norms, and linguistic barriers. In recent years, there has been an exponential growth in the usage of smartphones and apps in Saudi Arabia. These could be used as a cost-effective tool to facilitate the delivery of behavior-modification interventions for obese and overweight people. There are a variety of health and fitness apps that claim to offer lifestyle-modification tools. However, these do not identify the motivational features required to overcome obesity, consider the evidence-based practices for weight management, or enhance the usability of apps by considering usability attributes. Objective: This study aimed to explore the opportunity and the need to develop an Arabic weight-loss app that provides localized content and addresses the issues with existing apps identified here. This study has explained the steps taken to design an Arabic weight-loss app that was developed to facilitate the adjustment of key nutritional and physical activities and behaviors, which considers the social and cultural norms of Saudi Arabia. Methods: Qualitative studies were conducted with 26 obese Saudi Arabians, who tested the level of usability of 2 weight-loss apps and then provided feedback and recommendations. The app Akser Waznk is an interactive, user-friendly app designed primarily for iPhones. It has several features intended to assist users to monitor and track their food consumption and physical activities. The app provides personalized diet and weight loss advice. Unique features such as Let’s Walk are designed to motivate users to walk more. An augmented reality function is implemented to provide information regarding fitness equipment, fruits, and vegetables. The app uses behavior-change techniques to increase activities and healthy behaviors and evidence-informed practices for weight-loss management. The Akser Waznk app considers user privacy and data security by applying a number of guidelines and procedures. Results: The development of the app took 26 months. In all, 7 experts (5 dietitians, and 2 physical activity professionals) evaluated the app’s contents. Moreover, 10 potential users (5 men and 5 women) tested the app’s level of usability, its features, and performance during a pilot study. They reported that the app’s design is interactive, and the motivational features are user-friendly. Conclusions: Mobile technology, such as mobile apps, has the potential to be an effective tool that facilitates the changing of unhealthy lifestyle behaviors within the Saudi community. To be successful, the target group, the usability, motivational features, and social and cultural norms must be considered.

  • The SecondEars consultation audio-recording app. Source: Image created by the Authors; Copyright: The Authors; URL:; License: Creative Commons Attribution + NoDerivatives (CC-BY-ND).

    Co-Design of a Consultation Audio-Recording Mobile App for People With Cancer: The SecondEars App


    Background: Many patients choose to audio-record their medical consultations so that they can relisten to them at home and share them with family. Consultation audio-recordings can improve patients’ recall and understanding of medical information and increase their involvement in decision making. A hospital-endorsed consultation audio-recording mobile app would provide patients with the permission and means to audio-record their consultations. The Theory of Planned Behavior provides a framework for understanding how patients can be encouraged to appropriately audio-record consultations. Objective: The aim of this study was to use a co-design process to develop a consultation audio-recording mobile app called SecondEars. Methods: App development began with stakeholder engagement, followed by a series of 6 co-design workshops and then user acceptance testing. Stakeholder engagement included advice from legal, information technology (IT), clinical and allied health leads; digital strategy; and medical records. he co-design workshops were attended by: patient consumers, members of the research team, IT staff, the app designers, clinicians, and staff from medical records. During workshops 1 to 4, the purpose and scope of the app were refined, possible pitfalls were addressed, and design features were discussed. The app designers then incorporated the results from these workshops to produce a wireframe mock-up of the proposed SecondEars app, which was presented for feedback at workshops 5 and 6. Results: The stakeholders identified 6 requirements for the app, including that it be patient driven, secure, clear in terms of legal responsibilities, linked to the patient’s medical record, and that it should require minimal upfront and ongoing resources. These requirements informed the scope of the co-design workshops. The workshops were attended by between 4 and 13 people. The workshop attendees developed a list of required features and suggestions for user interface design. The app developers used these requirements and recommendations to develop a prototype of the SecondEars app in iOS, which was then refined through user acceptance testing. Conclusions: The SecondEars app allows patients to have control and autonomy over audio-recording and sharing their consultations while maintaining privacy and safety for medical information and legal protection for clinicians. The app has been designed to have low upkeep and minimal impact on clinical processes. The SecondEars prototype is currently being tested with patients in a clinical setting.

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

    Consumption of Health-Related Content on Social Media Among Adolescent Girls: Mixed-Methods Pilot Study


    Background: Consumption of health- and fitness-related social media content is a predominant behavior among teenage girls, which puts them at risk for consuming unreliable health-related information. Objective: This mixed-methods study (qualitative and quantitative) assessed health behavior attitudes and practices as well as social media use among adolescent girls. Additionally, similar practices and behaviors of adults who regularly interact with this population were studied. Methods: Girls aged 12-18 years were recruited to complete a 28-item survey and participate in a 45- to 60-minute focus group. Adults who regularly interact with adolescent girls, including parents, teachers, and healthcare professionals, were recruited from the local community and given a link to provide online consent and complete a survey. Results: A total of 27 adolescent girls participated in one of nine focus groups. Participants included 18 high school (age: mean 16.1 years; SD 1.3 years) and 9 middle school (age: mean 12.4 years; SD 0.7 years) girls. Eleven adults completed the online survey. Adolescents used social media to communicate and connect with friends, rather than as a source of health information. Although adolescents may see health-related content, most do not follow health-related pages or share such pages themselves, and fewer are actively searching for this information. Adolescents tend to trust information from familiar sources, and the participants reported that they do not follow official news accounts. Adults considered modeling and discussing healthy behaviors important and reportedly expected adolescents to see some level of health-related, especially fitness-related, content on social media. Conclusions: Education interventions are warranted for both adolescents and adults with whom adolescent girls regularly interact, in the areas of sedentary behavior to guide them to access reliable online health-related information and be judicious consumers of online health information.

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

    Using Exploratory Trials to Identify Relevant Contexts and Mechanisms in Complex Electronic Health Interventions: Evaluating the Electronic Patient-Reported...


    Background: Designing appropriate studies for evaluating complex interventions, such as electronic health solutions to support integrated care, remains a methodological challenge. With the many moving parts of complex interventions, it is not always clear how program activities are connected to anticipated and unanticipated outcomes. Exploratory trials can be used to uncover determinants (or mechanisms) to inform content theory that underpins complex interventions before designing a full evaluation plan. Objective: A multimethod exploratory trial of the electronic patient-reported outcome (ePRO) tool was conducted to uncover contexts, processes and outcome variables, and the mechanisms that link these variables before full-scale evaluation. ePRO is a mobile app and portal designed to support goal-oriented care in interdisciplinary primary health care practices (clinical-level integration). This paper offers evaluation findings and methodological insight on how to use exploratory trial data to identify relevant context, process, and outcome variables, as well as central (necessary to achieving outcomes) versus peripheral (less critical and potentially context dependent) mechanisms at play. Methods: The 4-month trial was conducted in 2 primary health care practices in Toronto, Canada. The patients were randomized into control and intervention groups and compared pre and post on quality of life and activation outcome measures. Semistructured interviews were conducted with providers and patients in the intervention group. Narrative analysis was used to uncover dominant mechanisms that inform the intervention’s content theory (how context and process variables are linked to outcomes). Results: Overall, 7 providers, 1 administrator, and 16 patients (7-control, 9-intervention) participated in the study. This study uncovered many complex and nuanced context, process, and outcome variables at play in the intervention. Narrative analysis of patient and provider interviews revealed dominant story lines that help to tease apart central and peripheral mechanisms driving the intervention. Provider and patient story lines centered around fitting the new intervention into everyday work and life of patients and providers and meaningfulness of the intervention. These themes were moderated by patient-provider relationships going into and throughout the intervention, their comfort with technology, and the research process. Conclusions: Identifying dominant story lines using narrative analysis helps to identify the most relevant context and process variables likely to influence study outcomes. Normalization process theory emerges as a useful theory to uncover underlying mechanisms because of its emphasis on the social production and normalization of technological, processual, and social aspects of work; all found to be critical to our intervention. The number of complex, overlapping influencing variables suggests that complex interventions such as ePRO require us to pay careful attention to central versus peripheral mechanisms that will influence study outcomes. The narrative methods presented here are shown to be useful in uncovering these mechanisms and help to guide subsequent larger evaluation studies.

  • Source: Pixabay; Copyright: younizealous; URL:; License: Public Domain (CC0).

    Using Mobile Technology to Improve Bone-Related Lifestyle Risk Factors in Young Women With Low Bone Mineral Density: Feasibility Randomized Controlled Trial


    Background: Poor bone health in adolescent and young adult females is a growing concern. Given the widespread use of mobile phones in this population, mobile health (mHealth) interventions may help improve health behaviors related to bone health in young women. Objective: The goal of the study was to determine the acceptability and feasibility of an mHealth intervention called Tap4Bone in improving health behaviors associated with the risk of osteoporosis in young women. Methods: The Tap4Bone mHealth intervention comprised the use of mobile phone apps, short messaging service (text messaging), and Web emails to encourage health behavior changes. The education group received osteoporosis prevention education leaflets. Changes in the bone health–related behaviors exercise, smoking, and calcium intake were assessed. User experiences and acceptance of the app were collected through focus group interviews. Results: A total of 35 (22 completed, mean age 23.1 [SD 1.8] years) were randomized to either the mobile phone (intervention n=18) or education (control n=17) group. Although there were trends toward improvement in calcium intake, sports activity, and smoking behaviors in the mHealth intervention group compared to the education group, these were not statistically significant. Conclusions: The Tap4Bone mHealth intervention was shown to be acceptable and feasible in subsets of the participants. The intervention should be improved upon using participant feedback to improve functionality. Findings from this study may aid in the development and modification of health care apps to reduce participant attrition.

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

    Digital Gaming for Nutritional Education: A Survey on Preferences, Motives, and Needs of Children and Adolescents


    Background: Use of novel information and communication technologies are frequently discussed as promising tools to prevent and treat overweight and obesity in children and adolescents. Objective: This survey aims to describe the preferences, motives, and needs of children and adolescents regarding nutrition and digital games. Methods: We conducted a survey in 6 secondary schools in the southern region of Germany using a 43-item questionnaire. Questions referred to preferences, motives, and needs of children and adolescents regarding nutrition and digital games. In addition, knowledge regarding nutrition was assessed with 4 questions. We collected self-reported sociodemographic and anthropometric data. Descriptive statistical analyses were performed using SPSS. Results: In total, 293 children and adolescents participated in the study, with ages 12-18 years (137 girls, 46.8%), weight 30.0-120.0 (mean 60.2 [SD 13.2]) kg, and height 1.4-2.0 (mean 1.7 [SD 0.1]) m. A total of 5.5% (16/290) correctly answered the 4 questions regarding nutrition knowledge. Study participants acquired digital nutritional information primarily from the internet (166/291, 57.0%) and television (97/291, 33.3%), while school education (161/291, 55.3%) and parents or other adults (209/291, 71.8%) were the most relevant nondigital information sources. Most participants (242/283, 85.5%) reported that they regularly play digital games. More than half (144/236, 61.0%) stated that they play digital games on a daily basis on their smartphones or tablets, and almost 70% (151/282, 66.5%) reported playing digital games for ≤30 minutes without any interruption. One-half of respondents (144/280, 51.4%) also stated that they were interested in receiving information about nutrition while playing digital games. Conclusions: This survey suggests that nutrition knowledge in children and adolescents might be deficient. Most children and adolescents play digital games and express interest in acquiring nutritional information during digital gameplay. A digital game with a focus on sound nutrition could be a potential educational tool for imparting nutrition knowledge and promoting healthier nutrition behaviors in children and adolescents.

  • Patients and family members learn about chronic kidney disease. Source: Cricket Health; Copyright: Cricket Health; URL:; License: Licensed by JMIR.

    A Digital Modality Decision Program for Patients With Advanced Chronic Kidney Disease


    Background: Patient education regarding end-stage renal disease (ESRD) has the potential to reduce adverse outcomes and increase the use of in-home renal replacement therapies. Objective: This study aimed to investigate whether an online, easily scalable education program can improve patient knowledge and facilitate decision making regarding renal replacement therapy options. Methods: We developed a 4-week online, digital educational program that included written information, short videos, and social networking features. Topics included kidney transplant, conservative management, peritoneal dialysis, in-home hemodialysis, and in-center hemodialysis. We recruited patients with advanced chronic kidney disease (stage IV and V) to enroll in the online program, and we evaluated the feasibility and potential impact of the digital program by conducting pre- and postintervention surveys in areas of knowledge, self-efficacy, and choice of ESRD care. Results: Of the 98 individuals found to be eligible for the study, 28 enrolled and signed the consent form and 25 completed the study. The average age of participants was 65 (SD 15) years, and the average estimated glomerular filtration rate was 21 (SD 6) ml/min/1.73 m2. Before the intervention, 32% of patients (8/25) were unable to make an ESRD treatment choice; after the intervention, all 25 participants made a choice. The proportion of persons who selected kidney transplant as the first choice increased from 48% (12/25) at intake to 84% (21/25) after program completion (P=.01). Among modality options, peritoneal dialysis increased as the first choice for 4/25 (16%) patients at intake to 13/25 (52%) after program completion (P=.004). We also observed significant increases in knowledge score (from 65 [SD 56] to 83 [SD 14]; P<.001) and self-efficacy score (from 3.7 [SD 0.7] to 4.3 [SD 0.5]; P<.001). Conclusions: Implementation of a digital ESRD education program is feasible and may facilitate patients’ decisions about renal replacement therapies. Larger studies are necessary to understand whether the program affects clinical outcomes. Trial Registration: NCT02976220;

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

    Impact of Food Preparation Video Exposure on Online Nutrition Education in Women, Infants, and Children (WIC) Program Participants: Retrospective Study


    Background: The impact of integrating video into health education delivery has been extensively investigated; however, the effect of integrating video on a learner’s subsequent performance in an online educational setting is rarely reported. Results of the relationship between the learner’s online video viewing and subsequent progression toward health behavior change in a self-directed online educational session are lacking. Objective: This study aimed to determine the relationship between viewing a Health eKitchen online video and key engagement performance indicators associated with online nutrition education for women, infants, and children (WIC). Methods: This study involved a retrospective cohort of users grouped on the basis of whether Health eKitchen exposure occurred before or after completing a nutrition education lesson. A two-sample test for equality of proportions was performed to test the difference in the likelihood of progression between the groups overall and when stratified by lesson type, which was defined by whether the lesson focused on food preparation. Welch two-sample t tests were performed to test the difference in average link depth and duration of use between groups overall and stratified by lesson type. Logistic regression was conducted to validate the impact of video viewing prior to lesson completion while controlling for lesson type and factors known to be associated with WIC key performance indicators. Results: A greater stage of change progression was observed for both food preparation (χ2=12.6, P<.001) and non-food preparation (χ2=62.8, P<.001) lessons among early stage users who had viewed a Health eKitchen video before completing a lesson. Time spent viewing educational learning resource links within the lesson was also significantly longer for both food preparation (t=7.8, P<.001) and non-food preparation (t=2.5, P=.01) lessons. Logistic regression analysis corroborated these results while controlling for known confounding factors. The odds of user progression were nearly three times greater among those who viewed a Health eKitchen video prior to lesson completion (odds ratio=2.61; 95% CI=2.08-3.29). Type of lesson (food vs non-food preparation) was the strongest predictor of progression odds (odds ratio=3.12; 95% CI=2.47-3.95). Conclusions: User access to a Health eKitchen video prior to completion of an online educational session had a significant impact on achieving lesson goals, regardless of the food preparation focus. This observation suggests the potential benefit of providing an application-oriented video at the onset of online nutrition education lessons.

  • Source: Shutterstock; Copyright: StudioByTheSea; URL:; License: Licensed by the authors.

    Feasibility of a Therapist-Supported, Mobile Phone–Delivered Online Intervention for Depression: Longitudinal Observational Study


    Background: Depression is a very common condition that impairs functioning and is often untreated. More than 60% of the treatments for depressive disorder are administered in primary care settings by care providers who lack the time and expertise to treat depression. To address this issue, we developed Ascend, a therapist-supported, mobile phone–delivered 8-week intervention administered at the Meru Health Online Clinic in Finland. Objective: We conducted two pilot studies to examine the feasibility of the Ascend intervention, specifically, dropout rates, daily practice, weekly group chat use, and changes in depression symptoms. We also explored whether daily practice and weekly group chat use were associated with changes in depression symptoms. Methods: A total of 117 Finnish adults with elevated depressive symptoms enrolled in Ascend, a program that included daily cognitive behavioral and mindfulness meditation exercises delivered through a mobile phone app, anonymous group chat with other users, and chat/phone access to a licensed therapist. Eight weekly themes were delivered in a fixed, sequential format. Depression symptoms were measured at baseline, every second week during the intervention, immediately after the intervention, and 4 weeks after completion of the intervention. Data were analyzed using intent-to-treat repeated-measures analysis of variance and linear regression models. Results: For studies 1 and 2, we observed dropout rates of 27% and 15%, respectively, decreasing daily practice and group chat use, and decreased depression symptoms from baseline to immediately and 4 weeks after the intervention (P<.001). We found that both more daily practice and chat group use predicted the occurrence of fewer depressive symptoms at 4 weeks postintervention (Study 1: ∆R2 =.38, P=.004 and ∆R2 =.38, P=.002, respectively; Study 2: ∆R2 =.16, P<.001 and ∆R2 =.08, P=.002, respectively). Conclusions: This therapist-supported, mobile phone–delivered treatment for depression is feasible and associated with reduced depression symptoms. Design features that enhance daily practice and group chat use are areas of future investigation. Validation of these results using a controlled study design is needed to establish the evidence base for the Ascend intervention.

  • BioBase app (montage). Source: App Store / Placeit; Copyright: JMIR Publications; URL:; License: Creative Commons Attribution (CC-BY).

    Use of a Biofeedback Breathing App to Augment Poststress Physiological Recovery: Randomized Pilot Study


    Background: The speed of physiological recovery from stress may be a marker for cardiovascular disease risk. Stress management programs that incorporate guided breathing have been shown to moderate the stress response and augment recovery. Objective: The aim of this study was to examine the effectiveness of an app-based brief relaxation intervention (BioBase) for facilitating physiological recovery in individuals exposed to a brief psychological stressor. Methods: A total of 75 participants (44 women) completed a stressor speech task and were randomly assigned to one of three conditions: control, rumination, or an app-based relaxation breathing (BioBase) conditions. Heart rate variability (HRV) was assessed as a measure of autonomic function at baseline (6 min), during stress (6 min), and during recovery (6 min). Results: There was a significant increase in subjective stress following stress exposure, but the ratings returned to baseline after recovery in all three groups. In addition, there was a significant decrease in vagally mediated HRV in the poststress period. During recovery, the root mean square of successive differences (P<.001), the percentage of successive interbeat (RR) intervals that differ by >50 ms (pNN50; P<.001), and high-frequency (P<.02) HRV were significantly higher in the BioBase breathing condition than the rumination and control conditions. There was no difference in HRV values between the rumination and control conditions during recovery. Conclusions: App-based relaxed breathing interventions could be effective in reducing cardiovascular disease risk. These results provide additional utility of biofeedback breathing in augmenting physiological recovery from psychological stress.

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  • Pilot and Feasibility Test of a Mobile Health-Supported Intervention for Stopping Hypertension

    Date Submitted: Mar 12, 2019

    Open Peer Review Period: Mar 15, 2019 - May 10, 2019

    Background: The seminal Dietary Approaches to Stopping Hypertension (DASH) study demonstrated the effectiveness of diet to control hypertension, however, effective implementation and dissemination of...

    Background: The seminal Dietary Approaches to Stopping Hypertension (DASH) study demonstrated the effectiveness of diet to control hypertension, however, effective implementation and dissemination of its principles have been limited. Objective: We hypothesize that a smartphone version of the DASH diet that uses automatic data collection, social networks, and “in-the-moment” feedback will be an effective medium for the delivery of DASH. Methods: We conducted a single arm pilot study from August 2015 - August 2016 with a pre-post evaluation design to evaluate the feasibility and preliminary efficacy of a smartphone version of DASH incorporating human health-coaching. Results: Seventeen patients participated; they had a mean age of 59 years (SD 6) and 60% were women. Engagement was high: out of 90 days, the mean number of logged blood pressures was 63 (SD 46), recorded weights was 52 (SD 45), and recorded steps was 55 (SD 36). 73% of coaching phone calls were completed. The mean number of servings documented per patient for the dietary assessment was 709 (SD 541), and patients set a mean number of 5 (SD 2) goals. Mean systolic and diastolic blood pressure, heart rate, weight, body mass index; or steps did not significantly change over time. Conclusions: Successful lifestyle change interventions require substantial patient motivation, engagement, and access to experts. Our study was underpowered to evaluate for change in clinical outcomes; however, the high engagement of DASH mobile suggests that the “in-the-moment” delivery of DASH mobile may be a way to integrate and sustain behavioral change in HTN management. Future implementations of DASH can include integrated calendars, alarms, social networks, GPS or other smartphone tools to allow the delivery of behavioral feedback and education to the specific to the user’s behavior.

  • Young adults’ perceptions of using wearables, social media and other technologies to detect worsening mental health: A qualitative study

    Date Submitted: Mar 12, 2019

    Open Peer Review Period: Mar 15, 2019 - May 10, 2019

    Background: Technological interventions may help support and improve our mental health. Yet young peoples’ perspectives on using different technologies to detect deteriorating mental health in those...

    Background: Technological interventions may help support and improve our mental health. Yet young peoples’ perspectives on using different technologies to detect deteriorating mental health in those already diagnosed with a mental health condition is lacking. Objective: To explore the perspectives of young patients on the feasibility and acceptability of using wearables, social media and technologies to detect mental health deterioration Methods: The study was co-produced with young adults with past mental health difficulties. Semi-structured interviews were conducted with young adults with mental health difficulties and data was triangulated. Themes were finalised and presented in a thematic map. Results: Sixteen participants were interviewed (81% female). Wearables and mobile apps were considered acceptable and feasible to detect mental health deterioration in real-time if they could measure changes in sleep patterns, mood or activity levels as signs of deterioration. Getting help earlier was deemed essential particularly in reference to dissatisfaction with the current non-technological mental health services. However, patients identified issues to consider before implementation including viability, safeguarding and patient preference. Conclusions: Wearables and mobile apps could be viable technological options to help detect deterioration in young people to intervene early and avoid delay in accessing mental health services. However immediate action following detection is required for the patient to trust and use the intervention.

  • A New Tool for Public Health Opinion: Using Twitter Polls for Insight into Telemedicine

    Date Submitted: Mar 3, 2019

    Open Peer Review Period: Mar 5, 2019 - Apr 30, 2019

    Background: Telemedicine draws on information technologies in order to enable the delivery of clinical healthcare from distance [1,2]. Telemedicine has been utilised around the world and a recent Worl...

    Background: Telemedicine draws on information technologies in order to enable the delivery of clinical healthcare from distance [1,2]. Telemedicine has been utilised around the world and a recent World Health Organization survey found that 38% of the countries had some kind of telemedicine system and 30% had agencies that managed telemedicine services [1]. Telemedicine is particularly attractive in rural health areas as well as across long distances where it can be difficult to reach patients [2]. There have been positive and unsuccessful implementations of telemedicine around the world [3]. This has likely led members of the public to have views and opinion towards the technology. It is important to gain an understanding of perceptions towards telemedicine before implementing an order to ensure it is received positively. Twitter is a social networking platform which has 316 million month active users with 500 million tweets per day and its potential for real-time monitoring public health has been well documented [4]. Twitter has been used previously as a platform to disseminate guidelines and perform polls by the European Association of Urology [4,5]. However, there is a lack of empirical research which has critically examined the potential of Twitter polls for providing insight into public health. Twitter is a platform with a demographic which is college educated and where users are likely to be aware of new forms of technology. This makes examining opinions towards telemedicine an interesting case. One of the benefits of utilising Twitter polls is that it is possible to gain access to a large audience which can provide instant and real-time feedback. Moreover, Twitter polls are completely anonymised and it is not possible to learn the identify of a user completing a poll nor is it possible for one user to vote on more than one occasion. Our results will be of interest to health authorities, policy makers, and academics interested in tele-health. They are also likely to be of interest to health authorities around the world seeking low-cost real-time survey methods as well as researchers interested in a critical examination of Twitter polls. Objective: The overall objective of this study was to better understand opinions related to telemedicine on Twitter and to assess the potential of Twitter polls to validate and test survey questions. Methods: In this study, we devised two Twitter polls using questions from previous questionnaires to explore acceptance of telemedicine among Twitter users. We distributed the polls on one of the author’s Twitter timeline and asked the followers of the account to answer the poll and retweet it to reach a larger audience. The Twitter handle, which we used for this study “@jvalaball”, has more than 9 300 followers. Ethical approval was not required because Twitter polls are completely anonymised. Results: Our first Twitter poll was distributed in May 2016 and was ‘pinned’ on the top of the Twitter timeline used in the project for 7 days. By pinning a tweet it will permanently place it on the top of a Twitter users account such that any new visitor will see the tweet appear at the top of a user’s timeline. We used a question from the Telemedicine satisfaction questionnaire, a validated questionnaire developed by Yip et al. in 2002 [7]. The question posted is as followed: “I find telemedicine an acceptable way to receive health care services. Do you agree?” For the responses, only two answers were allowed which were, “yes” or “no”. Figure 1 below displays how the tweet was constructed as well as the responses retrieved by Twitter users. The poll was retweeted 51 times and had 6.698 impressions. It received a total of 108 votes, 90% of which were positive and 10% negative. The second poll was posted during November 2017, which was also pinned in the top of the timeline for 7 days. For this Twitter poll we used a question from the Physician questionnaire in the EU project Health Optimum [8] . The question posted as followed: “How do you rate the quality of care delivered by telemedicine when compared to the quality of traditional care?” Four answers were allowed: which were: “better”, “about the same”, “not as good” and “not sure”. The poll was retweeted 49 times and had 4 364 impressions. Figure 2 below provides insight into how the tweet was constructed as well as the responses retrieved by Twitter users. Overall, the poll received a total of 113 votes. 39% of the respondents stated that they rated the quality of care delivered by telemedicine not as good as traditional care, 19% found the quality of care about the same, 22% rated the quality of care as better and 20% were not sure about the level of care. Conclusions: Our study provided an overview of a novel experiment of using targeted Twitter polls to assess acceptance of telemedicine amongst Twitter users. We argue that this tool could be used to quickly perform surveys to assess the opinion of users regarding acceptance of telemedicine in order to obtain rapid feedback of new questionnaires before validating them. An advantage of using Twitter polls is that many can be created and disseminated in very little time as opposed to traditional questionnaire and surveys, which can become resource-heavy. One of the key benefits of utilising social media platforms such as Twitter is the very low cost when compared to traditional survey based methods. In certain departments with low-budgets Twitter could be used as a tool to gain initial public opinion feedback before a survey could be devised. The first poll showed an overwhelming support towards telemedicine as an acceptable way to receive health care services. In the second poll, which asked Twitter users to rate the quality of care delivered by telemedicine when compared to the quality of traditional care, the majority of users found that telemedicine was not as good as traditional care. This highlights how the design of a question can potentially influence the results of a survey. Our method could be used to conduct testing on survey questions and to compare the answers to ensure they are consistent. It must be noted that one of the limitations of using Twitter for gauging public opinion through the use of Twitter polls is that its users are not representative of the general population in terms of demographics [8]. However, a growing body of literature is noting the potential of social media data for providing unfiltered public opinion [9,10,11]. One of the potential strengthens of using social media data has been the ability to avoid the risk of interview bias [9]. Furthermore, due to the ability of social media to set agendas in mainstream media [12,13] it can be argued that it has become important to study content and public opinion held by social media users. Our study has demonstrated the potential of Twitter polls for gaining insight into public health topics such as telemedicine and for developing new light on how Twitter polls can be used to validate and test survey questions. Twitter polls could be utilised by health authorities to gain early real-time feedback on public views and opinion on a range of health issues not just limited to telemedicine. A key strength is the speed at which Twitter polls can be formulated as well as their low cost.

  • Human-Centered Design for Women’s Health Screening Tool Redevelopment: Participant Experiences

    Date Submitted: Mar 1, 2019

    Open Peer Review Period: Mar 4, 2019 - Apr 29, 2019

    Background: Human-Centered Design (HCD) is a formative innovation or design process that emphasizes stakeholder input. A growing body of literature examines the formative science of patient and commun...

    Background: Human-Centered Design (HCD) is a formative innovation or design process that emphasizes stakeholder input. A growing body of literature examines the formative science of patient and community engagement in health research yet little qualitative research to date examines how community members recruited to collaborate on designing health practice variations and delivery of care perceive and experience such a process. Objective: Examine perceptions of an HCD process as an engagement tool to inform delivery of care and practice innovation in women’s health screening. Methods: Data sources/study setting. Primary qualitative data collected at a medical education center/network of clinics, and in the surrounding community. Study Design. Qualitative study used opportunistic and purposive sampling recruiting participants from an earlier HCD process undertaken to redesign screening tools. Participants were purposively and sampled from among eligible participants who participated in the Human-Centered Design process to develop women’s health screening tools and who were community members and/or clinicians/clinical staff. There was no randomization, intervention, and no diagnostic or therapeutic procedures. Data collection/extraction methods. All eligible participants who agreed to participate were interviewed using a semi-structured, open-ended guide. Interviews were audio-recorded, transcribed, hand-coded, and analyzed using modified Grounded Theory. Results: Principal findings. Community members and clinicians reported divergent views of the HCD process; both groups valued the opportunity to participate. Some found the process easy to engage; others found it confusing or even embarrassing. Conclusions: Conclusions. Community members and clinicians valued being part of determining the best process for healthcare delivery and practice innovation or variation; concerns remained about access to and full participation in the process. Though a promising option and valuable process, the HCD process was not equally comfortable or accessible for all. Community engagement beyond the clinical team to developing practice variation is important but must be undertaken thoughtfully. Clinical Trial: n/a

  • Audience Response Systems and Missingness Trends: Can Interactive Polling Systems Be Used to Effectively Gather Sensitive Health Information from Youth?

    Date Submitted: Feb 22, 2019

    Open Peer Review Period: Feb 23, 2019 - Apr 20, 2019

    Background: The widespread availability and cost-effectiveness of new-wave, software-based Audience Response Systems (ARSs) has expanded the possibilities of collecting health data from hard-to-reach...

    Background: The widespread availability and cost-effectiveness of new-wave, software-based Audience Response Systems (ARSs) has expanded the possibilities of collecting health data from hard-to-reach populations, including youth. However, with all survey methods, biases in the data may exist because of participant nonresponse. Objective: Our goals were to: (1) examine the extent to which an ARS could be used to gather health information from youth within a large-group school setting, and (2) examine individual- and survey-level response biases stemming from this web-based data collection method. Methods: We used an ARS to delivered mental health survey to 3,418 youth at four high schools in the Midwestern U.S. The survey contained demographic questions, depression, anxiety, and suicidality screeners, and questions about their use of offline resources (e.g., parents, peers, and counselors) and online resources (i.e., telemental health technologies) when they faced stressful life situations. We then examined the response rates for each survey item, focusing on the individual- and survey-level characteristics that related to nonresponse. Results: Overall 80% of the youth participants answered more than half of the 38 survey questions; however, missingness analyses showed that there were some survey structure factors that led to higher rates of nonresponse (e.g., questions at end of survey, sensitive questions, and questions for which precise answers were difficult to provide), and there were also some personal characteristics that were associated with nonresponse (e.g., not identifying as either male or female, non-White ethnicity, and higher levels of depression). Specifically, a multivariate model showed that male students and students reporting “other” gender had significantly higher numbers of missed items compared to female students (B = .30 and B = .47, respectively, ps < .001). Similarly, non-White race (B = .39, p < .0001) and higher depression scores (B = .39, p < .0001) were positively related to the number of missing survey responses. Conclusions: Although our study showed that it is possible to gather sensitive mental health data from youth in large groups using ARSs, we also suggest that these nonresponse patterns need to be considered and controlled for when using ARSs for gathering population health data.

  • Pedal-assist Mountain Bikes: A Pilot Study Comparison of the Health Benefits, Perceptions, and Beliefs of Experienced Mountain Bikers

    Date Submitted: Feb 6, 2019

    Open Peer Review Period: Feb 11, 2019 - Apr 8, 2019

    The purpose of this study was to compare conventional mountain bicycle and electric pedal-assist mountain bicycle (eMTB) use. This was done by investigating two questions: 1) What proportion of health...

    The purpose of this study was to compare conventional mountain bicycle and electric pedal-assist mountain bicycle (eMTB) use. This was done by investigating two questions: 1) What proportion of health benefits are retained for an experienced mountain biker while using an eMTB when compared to a conventional mountain bike? and 2) What are the perceptions and beliefs of experienced mountain bikers toward eMTBs both before and after riding an eMTB? A convergent mixed-methods data collection approach was used in the study. Participants completed both a pre- and post-ride questionnaire, and data regarding heart rate was collected. Paired t-test statistics were calculated to compare beliefs of conventional mountain bikes and eMTBs, as well as to compare mean heart rate and speed between conventional mountain bike and eMTB use on the study loop. Heart rates from each ride were compared against the resting heart rate. Participants overwhelmingly perceived the potential impact of eMTB use to be positive on both pre- and post-eMTB ride questionnaires. Average heart rate during eMTB use was 93.6% of average heart rate during conventional mountain bike use. Therefore, eMTB use in this study retained a majority of the cardiovascular health benefits and exceeded established biometric thresholds for cardiovascular fitness. Despite the measured benefit, participants’ perceived exertion while riding the eMTB was low.