@Article{info:doi/10.2196/66108, author="Choo, Jina and Noh, Songwhi and Shin, Yura", title="Evaluating Feasibility and Acceptability of the ``My HeartHELP'' Mobile App for Promoting Heart-Healthy Lifestyle Behaviors: Mixed Methods Study", journal="JMIR Form Res", year="2025", month="May", day="2", volume="9", pages="e66108", keywords="healthy lifestyle", keywords="primary prevention", keywords="cardiovascular diseases", keywords="community health nursing", keywords="mobile app", abstract="Background: Few mobile apps have strategies for self-monitoring multiple heart-healthy behaviors simultaneously, as well as automated and tailored feedback on individual behavioral outcomes for cardiovascular health. An app named ``My HeartHELP'' was developed for the general adult population to promote 6 heart-healthy lifestyle behaviors---physical activity, nonsedentary behaviors, healthy eating behaviors, nonsmoking, no alcohol binge drinking, and self-assessment of body weight. Three behavioral strategies were used: (1) text messaging the users for information on cardiovascular health, (2) self-monitoring of 6 heart-healthy behaviors to fill out the blanks of behavioral items, and (3) automated and tailored feedback messaging to users for behavioral outcomes obtained from self-monitoring. Objectives: This study aimed to evaluate the feasibility and acceptability of the ``My HeartHELP'' app. Methods: The participants were 29 community residents in Seoul, South Korea, who met at least 1 criterion of metabolic syndrome. To evaluate the feasibility, we assessed 3 records, which are as follows: First, the ``record for self-monitoring'' was determined as feasible if an average percentage for each of the 6 behaviors over 4 weeks was 75\% or higher based on percentages of participants who completed to record each of 6 heart-healthy behaviors. Second, the ``record for access to the app'' was determined as feasible if users accessed at least once a day on average per week. Third, ``records for behavioral changes'' over 4 weeks were collected via a self-reported questionnaire. To evaluate acceptability, we used an assessment tool comprising 12 items that included subscales for comprehensibility, ease, health benefits, technical completeness, overall satisfaction, and recommendation to others on a 5-point Likert scale. Acceptability was determined as acceptable if the average scores for the total scale and each subscale were 3.5 points or greater. Second, qualitative data were collected through 2 focus groups, each consisting of 14 or 15 participants. All data were collected in June and July 2022. Results: During the 4 weeks, 95.6\% (range: 85.8\%-97.4\%) of the participants adhered to more than 75\% of ``completion of daily self-monitoring of each heart-healthy behavior,'' having met the criterion. The participants accessed the app on average 1.8 (SD 1.70) times per day, meeting the criteria. Participants had positive behavioral changes in all 6 behaviors, of which nonsedentary behavior (10\%-28\%; $\chi$21=1.76; P<.001) and non--fast-food intake were especially statistically significant (72\%-93\%; $\chi$21=5.64; P=.03) over 4 weeks. Participants reported 3.8 points for a total score of acceptability and more than 3.5 points for all subscales, which met the criterion. Qualitative data obtained from focus groups indicated that automated and tailored feedback messages motivated participants to promote healthy lifestyles. Conclusions: The ``My HeartHELP'' app may be a feasible and acceptable mobile app to promote self-monitoring and possibly behavioral changes in heart-healthy lifestyle behaviors. ", doi="10.2196/66108", url="https://formative.jmir.org/2025/1/e66108" } @Article{info:doi/10.2196/64083, author="Huebner, Hanna and Wurmthaler, A. Lena and Goossens, Chlo{\"e} and Ernst, Mathias and Mocker, Alexander and Kr{\"u}ckel, Annika and Kallert, Maximilian and Geck, J{\"u}rgen and Limpert, Milena and Seitz, Katharina and Ruebner, Matthias and Kreis, Philipp and Heindl, Felix and H{\"o}rner, Manuel and Volz, Bernhard and Roth, Eduard and Hack, C. Carolin and Beckmann, W. Matthias and Uhrig, Sabrina and Fasching, A. Peter", title="A Digital Home-Based Health Care Center for Remote Monitoring of Side Effects During Breast Cancer Therapy: Prospective, Single-Arm, Monocentric Feasibility Study", journal="JMIR Cancer", year="2025", month="May", day="2", volume="11", pages="e64083", keywords="breast cancer", keywords="digital medicine", keywords="telehealth", keywords="remote monitoring", keywords="cyclin-dependent kinase 4/6 inhibitor", keywords="CDK4/6 inhibitor", keywords="mobile phone", abstract="Background: The introduction of oral anticancer therapies has, at least partially, shifted treatment from clinician-supervised hospital care to patient-managed home regimens. However, patients with breast cancer receiving oral cyclin-dependent kinase 4/6 inhibitor therapy still require regular hospital visits to monitor side effects. Telemonitoring has the potential to reduce hospital visits while maintaining quality care. Objective: This study aims to develop a digital home-based health care center (DHHC) for acquiring electrocardiograms (ECGs), white blood cell (WBC) counts, side effect photo documentation, and patient-reported quality of life (QoL) data. Methods: The DHHC was set up using an Apple Watch Series 6 (ECG measurements), a HemoCue WBC DIFF Analyzer (WBC counts), an iPhone SE (QoL assessments and photo documentation), a TP-Link M7350-4G Wi-Fi router, and a Raspberry Pi 4 Model B. A custom-built app stored and synchronized remotely collected data with the clinic. The feasibility and acceptance of the DHHC among patients with breast cancer undergoing cyclin-dependent kinase 4/6 inhibitor therapy were evaluated in a prospective, single-arm, monocentric study. Patients (n=76) monitored side effects---ECGs, WBC counts, photo documentation, and QoL---at 3 predefined time points: study inclusion (on-site), day 14 (remote), and day 28 (remote). After the study completion, patients completed a comprehensive questionnaire on user perception and feasibility. Adherence to scheduled visits, the success rate of the data transfer, user perception and feasibility, and the clinical relevance of remote measurements were evaluated. Results: Mean adherence to the planned remote visits was 63\% on day 14 and 37\% on day 28. ECG measurements were performed most frequently (day 14: 57/76, 75\%; day 28: 31/76, 41\%). The primary patient-reported reason for nonadherence was device malfunction. The expected versus the received data transfer per patient was as follows: ECGs: 3 versus 3.04 (SD 1.9); WBC counts: 3 versus 2.14 (SD 1.14); QoL questionnaires: 3 versus 2.5 (SD 1.14); and photo documentation: 6 versus 4.4 (SD 3.36). Among patients, 81\% (55/68) found ECG measurements easy, 82\% (55/67) found photo documentation easy, and 48\% (33/69) found WBC measurements easy. Additionally, 61\% (40/66) of patients felt comfortable with self-monitoring and 79\% (54/68) were willing to integrate remote monitoring into their future cancer care. Therapy-induced decreased neutrophil count was successfully detected (P<.001; mean baseline: 4.3, SD 2.2, {\texttimes}109/L; on-treatment: 1.8, SD 0.8, {\texttimes}109/L). All-grade neutropenia and corrected QT interval prolongations were detected in 80\% (55/68) and 2\% (1/42) of patients, respectively. Conclusions: Adherence to scheduled remote visits was moderate, with nonadherence primarily attributed to device-related complications, which may have also affected the success rate of data transfer. Overall, patients considered remote monitoring useful and feasible. The prevalence of reported adverse events was comparable to existing literature, suggesting clinical potential. This initial feasibility study highlights the potential of the DHHC. ", doi="10.2196/64083", url="https://cancer.jmir.org/2025/1/e64083" } @Article{info:doi/10.2196/65418, author="Tse, Chloe Trinity and Weiner, S. Lauren and Funkhouser, J. Carter and DeLuise, Danielle and Cullen, Colleen and Blumkin, Zachary and O'Brien, Casey and Auerbach, P. Randy and Allen, B. Nicholas", title="Acceptability and Usability of a Digital Behavioral Health Platform for Youth at Risk of Suicide: User-Centered Design Study With Patients, Practitioners, and Business Gatekeepers", journal="JMIR Form Res", year="2025", month="May", day="2", volume="9", pages="e65418", keywords="user-centered design", keywords="mobile sensing", keywords="behavior change", keywords="suicide prevention", keywords="digital health", keywords="mental health", abstract="Background: Youth suicide rates are climbing, underscoring the need to improve clinical care. Personal smartphones can provide an understanding of proximal risk factors associated with suicide and facilitate consistent contact between patients and practitioners to improve treatment engagement and effectiveness. The Vira digital behavior change platform (Vira) consists of a patient smartphone app and a web-based practitioner portal (Vira Pro) that integrates objective mobile sensing data with Health Insurance Portability and Accountability Act (HIPAA)--compliant communication tools. Through Vira, practitioners can continuously assess patients' real-world behavior and provide clinical tools to enhance treatment via just-in-time behavior change support. Objective: This study aimed to explore the acceptability and usability of the minimal viable product version of Vira through a user-centered design (UCD) approach and to identify barriers to implementing Vira in the context of an adolescent intensive outpatient program. Methods: Over 2 iterative phases, feedback was gathered from adolescent patients (n=16), mental health practitioners (n=11), and business gatekeepers (n=5). The mixed methods UCD approach included individual semistructured interviews (eg, perspectives on treatment and attitudes toward digital tools), surveys (eg, usability), and unmoderated user testing sessions (eg, user experience). Results: Overall, participants expressed optimism regarding Vira, particularly among adolescents, who showed high satisfaction with the app's interface and design. However, clinicians reported more mixed views, agreeing that it would be useful in treatment but also expressing concerns about the volume and displays of patient data in Vira Pro, workload management, and boundaries. Gatekeepers identified usability issues and implementation barriers related to electronic health records but also recognized Vira's potential to enhance treatment outcomes. Feedback from stakeholders informed several crucial changes to the platform, including adjustments to data-sharing protocols, user interface enhancements, and modifications to training methods. Conclusions: Vira has a high potential to improve patient engagement and improve clinical outcomes among high-risk youth. Iterative UCD and ongoing stakeholder engagement are essential for developing technology-based interventions that effectively meet the needs of diverse end users and align with clinical workflows. ", doi="10.2196/65418", url="https://formative.jmir.org/2025/1/e65418" } @Article{info:doi/10.2196/58427, author="Lincke, Lena and Martin-D{\"o}ring, Tim and Daunke, Andrea and Sadkowiak, Antonia and Nolkemper, Alexandra Daria and Sproeber-Kolb, Nina and Bienioschek, Stefanie and Reis, Olaf and K{\"o}lch, Michael", title="Integration of a Mental Health App (e-MICHI) Into a Blended Treatment of Depression in Adolescents: Single-Group, Naturalistic Feasibility Trial", journal="JMIR Form Res", year="2025", month="May", day="1", volume="9", pages="e58427", keywords="adolescents", keywords="major depressive disorder (MDD)", keywords="cognitive behavioral therapy (CBT)", keywords="digital health interventions (DHIs)", keywords="feasibility", keywords="adherence", keywords="outpatient setting", keywords="mobile application", keywords="accessibility", keywords="availability", keywords="efficacy", keywords="mobile phone", abstract="Background: Major depressive disorder is a common diagnosis among adolescents. Cognitive behavioral therapy is recommended as the first line of treatment. Digital health interventions, such as apps, could contribute to treatment. Advantages could be easy accessibility and availability, reduced time for face-to-face therapy, and the ability to intensify therapy by incorporating it into the patients' everyday lives. Challenges such as low adherence rates are common in digital health interventions. Therefore, they need to undergo rigorous testing for feasibility and effectiveness. Objective: An evaluated, cognitive behavioral therapy--based face-to-face therapy program for depression in adolescents was transformed into an app called e-MICHI. This study examined its feasibility and efficacy for use in blended therapy in outpatient settings. Methods: Adolescents aged 12 to 18 years with major depressive disorder receiving outpatient care were recruited from 2 university hospitals (n=36 included in analysis). The e-MICHI intervention combined daily app engagement over 6 weeks with 3 face-to-face sessions with a therapist. Feasibility was measured using various variables, including an adherence score (0=no or little patient engagement to 3=excellent engagement) and engagement rates (number of modules completed, number of messages sent by participants via the in-app messenger), satisfaction ratings from both participants and therapists, as well as participants' ratings of the usefulness of the antidepressant strategies covered in the app and the transfer of these strategies to everyday practice. Trends of efficacy were evaluated from multiple perspectives (participant self-rating, independent rater, or therapist), using the Beck Depression Inventory-II, the Children's Depression Rating Scale-Revised, and the Clinical Global Impressions-Severity Scale. Feasibility metrics were assessed by analyzing their central tendency and dispersion, efficacy data were analyzed using a repeated measures ANOVA. Results: e-MICHI was positively evaluated by both participants and therapists (participants: mean 7.3, SD 1.2 and therapists: mean 7.3, SD 1.1, on a scale from 0=bad to 10=excellent). Participants demonstrated high adherence rates (nearly 80\%, n=25, received a ``good'' or ``excellent'' adherence score) and showed overall good engagement (app modules completed [maximum 6]: mean 5.03, SD 1.27 and messages sent via messenger: mean 23, SD 22.1). Participants rated the psychoeducational content of the app as particularly useful and reported consistent practice of the e-MICHI strategies in everyday life. Use of the app was associated with a significant reduction of depressive symptoms (before app use vs 3-month follow-up, Beck Depression Inventory-II: mean ?6.76, SD 11.49, P=.01; Children's Depression Rating Scale-Revised: mean ?16.45, SD 16.76, P<.001; Clinical Global Impressions-Severity Scale: mean ?1.1, SD 1.24, P<.001). Conclusions: While acknowledging its limitations, such as the small number of participants and the limited validity concerning efficacy, this study confirms the feasibility of e-MICHI for treating adolescent depression in outpatient settings. Trial Registration: German Clinical Trial Register DRKS00022420; https://drks.de/search/en/trial/DRKS00022420/details ", doi="10.2196/58427", url="https://formative.jmir.org/2025/1/e58427" } @Article{info:doi/10.2196/66189, author="Li, Hui and Yao, Haiyang and Gao, Yuxiang and Luo, Hang and Cai, Changbin and Zhou, Zhou and Yuan, Muhan and Jiang, Wei", title="Identification of Major Bleeding Events in Postoperative Patients With Malignant Tumors in Chinese Electronic Medical Records: Algorithm Development and Validation", journal="JMIR Form Res", year="2025", month="May", day="1", volume="9", pages="e66189", keywords="machine learning", keywords="electronic medical record", keywords="postoperative patients with malignant tumors", keywords="postoperative bleeding", keywords="tumor surgery", keywords="abdominal", abstract="Background: Postoperative bleeding is a serious complication following abdominal tumor surgery, but it is often not clearly diagnosed and documented in clinical practice in China. Previous studies have relied on manual interpretation of medical records to determine the presence of postoperative bleeding in patients, which is time-consuming and laborious. More critically, this manual approach severely hinders the efficient analysis of large volumes of medical data, impeding in-depth research into the incidence patterns and risk factors of postoperative bleeding. It remains unclear whether machine learning can play a role in processing large volumes of medical text to identify postoperative bleeding effectively. Objective: This study aimed to develop a machine learning model tool for identifying postoperative patients with major bleeding based on the electronic medical record system. Methods: This study used data from the available information in the National Health and Medical Big Data (Eastern) Center in Jiangsu Province of China. We randomly selected the medical records of 2,000 patients who underwent in-hospital tumor resection surgery between January 2018 and December 2021 from the database. Physicians manually classified each note as present or absent for a major bleeding event during the postoperative hospital stay. Feature engineering involved bleeding expressions, high-frequency related expressions, and quantitative logical judgment, resulting in 270 features. Logistic regression (LR), K-nearest neighbor (KNN), and convolutional neural network (CNN) models were developed and trained using the 1600-note training set. The main outcomes were accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each model. Results: Major bleeding was present in 4.31\% (69/1600) of the training set and 4.75\% (19/400) of the test set. In the test set, the LR method achieved an accuracy of 0.8275, a sensitivity of 0.8947, a specificity of 0.8241, a PPV of 0.2024, an NPV of 0.9937, and an F1-score of 0.3301. The CNN method demonstrated an accuracy of 0.8900, sensitivity of 0.8421, specificity of 0.8924, PPV of 0.2807, NPV of 0.9913, and an F1-score of 0.4211. While the KNN method showed a high specificity of 0.9948 and an accuracy of 0.9575 in the test set, its sensitivity was notably low at 0.2105. The C-statistic for the LR method was 0.9018 and for the CNN method was 0.8830. Conclusions: Both the LR and CNN methods demonstrate good performance in identifying major bleeding in patients with postoperative malignant tumors from electronic medical records, exhibiting high sensitivity and specificity. Given the higher sensitivity of the LR method (89.47\%) and the higher specificity of the CNN method (89.24\%) in the test set, both models hold promise for practical application, depending on specific clinical priorities. ", doi="10.2196/66189", url="https://formative.jmir.org/2025/1/e66189" } @Article{info:doi/10.2196/59631, author="Waugh, Lim Mihyun and Mills, Tyler and Boltin, Nicholas and Wolf, Lauren and Parker, Patti and Horner, Ronnie and Wheeler II, L. Thomas and Goodwin, L. Richard and Moss, A. Melissa", title="Predicting Transvaginal Surgical Mesh Exposure Outcomes Using an Integrated Dataset of Blood Cytokine Levels and Medical Record Data: Machine Learning Approach", journal="JMIR Form Res", year="2025", month="May", day="1", volume="9", pages="e59631", keywords="cytokines", keywords="inflammatory response", keywords="medical record", keywords="pelvic organ prolapse", keywords="polypropylene mesh", keywords="supervised machine learning models", keywords="polypropylene", keywords="mesh surgery", keywords="surgical outcome", keywords="cost-efficiency", keywords="risk factor", keywords="efficacy", keywords="health care data", keywords="female", keywords="informed decision-making", keywords="patient care", keywords="digital health", abstract="Background: Transvaginal insertion of polypropylene mesh was extensively used in surgical procedures to treat pelvic organ prolapse (POP) due to its cost-efficiency and durability. However, studies have reported a high rate of complications, including mesh exposure through the vaginal wall. Developing predictive models via supervised machine learning holds promise in identifying risk factors associated with such complications, thereby facilitating better informed surgical decisions. Previous studies have demonstrated the efficacy of anticipating medical outcomes by employing supervised machine learning approaches that integrate patient health care data with laboratory findings. However, such an approach has not been adopted within the realm of POP mesh surgery. Objective: We examined the efficacy of supervised machine learning to predict mesh exposure following transvaginal POP surgery using 3 different datasets: (1) patient medical record data, (2) biomaterial-induced blood cytokine levels, and (3) the integration of both. Methods: Blood samples and medical record data were collected from 20 female patients who had prior surgical intervention for POP using transvaginal polypropylene mesh. Of these subjects, 10 had experienced mesh exposure through the vaginal wall following surgery, and 10 had not. Standardized medical record data, including vital signs, previous diagnoses, and social history, were acquired from patient records. In addition, cytokine levels in patient blood samples incubated with sterile polypropylene mesh were measured via multiplex assay. Datasets were created with patient medical record data alone, blood cytokine levels alone, and the integration of both data. The data were split into 70\% and 30\% for training and testing sets, respectively, for machine learning models that predicted the presence or absence of postsurgical mesh exposure. Results: Upon training the models with patient medical record data, systolic blood pressure, pulse pressure, and a history of alcohol usage emerged as the most significant factors for predicting mesh exposure. Conversely, when the models were trained solely on blood cytokine levels, interleukin (IL)-1$\beta$ and IL-12 p40 stood out as the most influential cytokines in predicting mesh exposure. Using the combined dataset, new factors emerged as the primary predictors of mesh exposure: IL-8, tumor necrosis factor-$\alpha$, and the presence of hemorrhoids. Remarkably, models trained on the integrated dataset demonstrated superior predictive capabilities with a prediction accuracy as high as 94\%, surpassing the predictive performance of individual datasets. Conclusions: Supervised machine learning models demonstrated improved prediction accuracy when trained using a composite dataset that combined patient medical record data and biomaterial-induced blood cytokine levels, surpassing the performance of models trained with either dataset in isolation. This result underscores the advantage of integrating health care data with blood biomarkers, presenting a promising avenue for predicting surgical outcomes in not only POP mesh procedures but also other surgeries involving biomaterials. Such an approach has the potential to enhance informed decision-making for both patients and surgeons, ultimately elevating the standard of patient care. ", doi="10.2196/59631", url="https://formative.jmir.org/2025/1/e59631" } @Article{info:doi/10.2196/63028, author="Biswas, Sawona and So, Joyce and Wallerstein, Robert and Gonzales, Ralph and Tout, Delphine and DeAngelis, Lisa and Rajkovic, Aleksandar", title="Assessing the Utilization of Electronic Consultations in Genetics: Seven-Year Retrospective Study", journal="JMIR Form Res", year="2025", month="Apr", day="30", volume="9", pages="e63028", keywords="genomic", keywords="e-Consult", keywords="genetic", keywords="utility", keywords="retrospective", keywords="assessment", keywords="effectiveness", keywords="electronic consultation", keywords="healthcare providers", keywords="genetic experts", keywords="university", keywords="consultations", keywords="e-Consult frameworks", keywords="accessibility", keywords="genetic testing", keywords="patient care", abstract="Background: Patient and health care provider access to genetic subspecialists is challenging owing to limited number of genetics experts across the United States. The University of California San Francisco (UCSF) Genetics electronic consultation (e-Consult) service was implemented along with the usual referral pathway to improve access to timely genetic expertise through robust asynchronous provider-to-provider communication. Objectives: This study examined the impact of the UCSF Genetics e-Consult service on patient access to genetics expertise. Methods: A retrospective chart review of 622 e-Consult requests was conducted. Data pertinent to e-Consult completion rates, provider response times, consultation content, and adherence to geneticist recommendations were abstracted. Results: From October 2016 to March 2024, the UCSF Genetics e-Consult service received a total of 622 consultation orders, with yearly volumes increasing from 34 in 2017 to 144 in 2023. A total of 360/622 (57.8\%) consultations were completed, of which 197/360 (54.6\%) were resolved without requiring a specialty care visit. Of the 262/622 (42.1\%) e-Consult orders declined by the geneticist reviewer, 184/262 (70.2\%) were scheduled for a synchronous genetics visit due to case complexity precluding an appropriate e-Consult response and 29.8\% (78/262) were recommended to be referred to a different and more appropriate specialty. Geneticists responded to 83.9\% (522/622) of e-Consults within 3 days, with most spending between 5 and 20 minutes on their e-Consult response. Nearly half of the genetics e-Consult requests (69/144; 47.9\%) came from primary care providers and pediatricians. Among the 144 e-Consult requests in 2023, 50.6\% (73/144) were about diagnostic queries, 17\% (25/144) were on symptom management, and 11\% (16/144) were about test interpretation. Provider adherence to geneticists' recommendations was observed in 84\% (116/144) of cases. Conclusions: The UCSF Genetics e-Consult service has demonstrated efficiency in providing timely genetic consultations, with a high rate of provider adherence to recommendations. These findings support the potential of e-Consult frameworks as a viable strategy for enhancing access to genetic health care services. ", doi="10.2196/63028", url="https://formative.jmir.org/2025/1/e63028" } @Article{info:doi/10.2196/66889, author="Brown, Christian Marsalis and Lin, Quincy Christopher and Jin, Christopher and Rohde, Matthew and Rocos, Brett and Belding, Jonathan and Woods, I. Barrett and Ackerman, J. Stacey", title="Effect of a Digital Health Exercise Program on the Intention for Spinal Surgery in Adult Spinal Deformity: Exploratory Cross-Sectional Survey", journal="JMIR Form Res", year="2025", month="Apr", day="29", volume="9", pages="e66889", keywords="adult spinal deformity", keywords="scoliosis", keywords="nonoperative management", keywords="spinal realignment therapy", keywords="digital health", keywords="program evaluation", abstract="Background: Adult spinal deformity (ASD) is a prevalent condition estimated at 38\%. Symptomatic ASD is associated with substantial health care costs. The role of nonoperative interventions in the management of ASD remains elusive. The National Scoliosis Clinic's (NSC) scoliosis realignment therapy (SRT) is a personalized digital health exercise program for the nonoperative management of ASD. Objective: This exploratory study had two objectives: (1) to evaluate the effect of the SRT program on users' intention of having spinal fusion; and (2) from a US payer perspective, to estimate the annual cost savings per 100,000 beneficiaries by averting spinal surgery. Methods: Individuals were enrolled in the SRT study from October 1, 2023 to September 1, 2024. Participants completed a web-based, cross-sectional survey about their history of prior scoliosis surgery and intent of having surgery before and after use of SRT (on a 4-point Likert scale, where 1 = ``No Intent for Surgery'' and 4 = ``High Intent for Surgery''). Intent for surgery before and after participation in SRT was compared using a nonparametric Wilcoxon signed-rank test for paired data. Annual cost savings per 100,000 beneficiaries by averting spinal fusions were estimated separately for commercial payers and Medicare using published literature and public data sources. Payer expenditures were inflation-adjusted to 2024 US dollars using the Hospital Services component of the Consumer Price Index. Results: A total of 62 NSC members (38.8\%) responded to the survey and were enrolled in the SRT program for an average (SD) of 17 (12) weeks. The mean (SD) age was 65.3 (13.5) years, and the majority were female (47/48, 98\%) and White (45/46, 98\%). Among the SRT users who did not have prior scoliosis surgery (n=56), 14\% (8/56) reported a decrease in intent for surgery (that is, a lower Likert score) with the use of SRT. The mean (SD) intent for surgery scores before compared to after SRT were 1.29 (0.53) and 1.14 (0.35), respectively (mean difference 0.15 [P=.006]). Participants with ``No Intent for Surgery'' pre- versus postuse of SRT (42/56 versus 48/56, respectively) corresponded to an absolute risk reduction of 11\% and a number needed to treat of 9 to avert one spinal fusion. Among the 6 participants who transitioned to ``No Intent'' for spinal surgery with the use of SRT, 3 were aged <65 years and 3 were ?65 years of age. The annual cost savings from averted spinal surgeries were estimated at US \$415,000 per 100,000 commercially-insured beneficiaries and US \$617,000 per 100,000 Medicare beneficiaries. Conclusions: SRT is a personalized, scoliosis-specific digital health exercise program with the potential for averting 1 spinal surgery for every 9 participants, resulting in a substantial reduction in payer expenditures while improving the quality of care for commercial payers and Medicare beneficiaries. ", doi="10.2196/66889", url="https://formative.jmir.org/2025/1/e66889" } @Article{info:doi/10.2196/56855, author="Tuot, Delphine and Crowley, Susan and Katz, Lois and Leung, Joseph and Alcantara-Cadillo, Delly and Ruser, Christopher and Talbot-Montgomery, Elizabeth and Vassalotti, Joseph", title="Impact of the Kidney Score Platform on Communication About and Patients' Engagement With Chronic Kidney Disease Health: Pre--Post Intervention Study", journal="JMIR Form Res", year="2025", month="Apr", day="29", volume="9", pages="e56855", keywords="chronic kidney disease", keywords="CKD", keywords="CKD communication", keywords="CKD knowledge", keywords="patient activation", keywords="kidney", keywords="kidney score platform", keywords="kidney health", keywords="United States", keywords="US", keywords="adult", keywords="aging", keywords="clinical practice", keywords="awareness campaign", keywords="health information", keywords="clinician", keywords="primary care", keywords="longitudinal intervention", keywords="web-based", keywords="mobile health", keywords="mHealth", abstract="Background: Chronic kidney disease (CKD) affects 14\% of the US adult population, yet patient knowledge about kidney disease and engagement in their kidney health is low despite many CKD education programs, awareness campaigns, and clinical practice guidelines. Objective: We aimed to examine the impact of the Kidney Score Platform (a patient-facing, risk-based online tool that provides interactive health information tailored to an individual's CKD risk plus an accompanying clinician-facing Clinical Practice Toolkit) on individual engagement with CKD health and CKD communication between clinicians and patients. Methods: We conducted a pre-post intervention study in which English-speaking veterans at risk for CKD in two primary care settings interacted with the Kidney Score platform's educational modules and their primary care clinicians were encouraged to review the Clinical Practice Toolkit. The impact of the Kidney Score on the Patient Activation Measure (the primary outcome), knowledge about CKD, and communication with their clinician about kidney health was determined with paired t tests. Multivariable linear and logistic models were used to determine whether changes in outcomes after versus before intervention were influenced by age, race or ethnicity, sex, and diabetes status, accounting for baseline values. Results: The study population (n=76) had a mean (SD) age of 64.4 (8.2) years, 88\% (67/76) was male, and 30.3\% (23/76) self-identified as African-American. Approximately 93\% (71/76) had hypertension, 36\% (27/76) had diabetes, and 9.2\% (7/76) had CKD according to the laboratory criteria but without an ICD-10 (International Classification of Diseases, 10th Edition) diagnosis. Patient interaction with the Kidney Score did not change the mean Patient Activation Measure (preintervention: 40.7\%, postintervention: 40.2\%, P=.23) but increased the mean CKD knowledge score (preintervention: 40.0\%, postintervention 51.1\%, P<.01), and changed the percentage of veterans who discussed CKD with their clinician (preintervention: 12.3\%, postintervention: 31.5\%, P<.01). Changes did not differ by age, sex, race, or diabetes status. Results were limited by the small sample size due to low recruitment and minimal clinician engagement with the Clinical Practice Toolkit during the COVID-19 pandemic. Conclusions: One-time web-based tailored education for patients can increase CKD knowledge and encourage conversations about kidney health. Increasing patient activation for CKD management may require multilevel, longitudinal interventions that facilitate ongoing conversations about kidney health between patients and clinician teams. ", doi="10.2196/56855", url="https://formative.jmir.org/2025/1/e56855" } @Article{info:doi/10.2196/59640, author="Minich, Matt and Kerr, Bradley and Moreno, Megan", title="Adolescent Emoji Use in Text-Based Messaging: Focus Group Study", journal="JMIR Form Res", year="2025", month="Apr", day="28", volume="9", pages="e59640", keywords="communication", keywords="text messaging", keywords="smartphones", keywords="emoji", keywords="focus groups", keywords="adolescent", keywords="teen", keywords="youth", keywords="teenagers", keywords="text", keywords="phone", keywords="messaging", keywords="text communication", keywords="emotion", abstract="Background: Adolescents increasingly communicate through text-based messaging platforms such as SMS and social media messaging. These are now the dominant platforms for communication between adolescents, and adolescents use them to obtain emotional support from parents and other adults. The absence of nonverbal cues can make it challenging to communicate emotions on these platforms, however, so users rely on emojis to communicate sentiment or imbue messages with emotional tone. While research has investigated the functions of emojis in adult communication, less is known about adolescent emoji use. Objective: This study sought to understand whether the pragmatic functions of adolescent emoji use resemble those of adults, and to gain insight into the semantic meanings of emojis sent by adolescents. Methods: Web-based focus groups were conducted with a convenience sample of adolescents, in which participants responded to questions about their use and interpretation of emojis and engaged in unstructured interactions with one another. Two trained coders analyzed transcripts using a constant comparative coding procedure to identify themes in the discussion. Results: A total of 6 focus groups were conducted with 31 adolescent participants (mean age 16.2, SD 1.5 years). Discussion in the groups generally fell into 4 themes: emojis as humorous or absurd, emokis as insincere or complex expressions of setiment, emojis as straightforward experssions of sentiment, and emojis as having context-dependent meanings. Across themes, participants often described important differences between their own emoji use and emoji use by adults. Conclusions: Adolescent focus group participants described patterns of emoji use that largely resembled those observed in studies of adults. Like adults, our adolescent participants described emojis' semantic meanings as being highly flexible and context-dependent. They also described both phatic and emotive functions of emoji use but described both functions in ways that differed from the patterns of emoji use described in adult samples. Adolescents described their phatic emoji use as absurd and described their emotive emoji use as most often sarcastic. These findings suggest that emoji use serves similar pragmatic functions for both adolescents and adults, but that adolescents see their emoji use as more complex than adult emoji use. This has important implications for adults who communicate with adolescents through text-based messaging and for researchers interested in adolescents' text-based communication. ", doi="10.2196/59640", url="https://formative.jmir.org/2025/1/e59640" } @Article{info:doi/10.2196/60612, author="Standaar, Lucille and Israel, Margje Adriana and van der Vaart, Rosalie and Keij, Brigitta and van Lenthe, J. Frank and Friele, Roland and Beenackers, A. Mari{\"e}lle and van Tuyl, Davida Lilian Huibertina", title="The Motivations of Citizens to Attend an eHealth Course in the Public Library: Qualitative Interview Study", journal="JMIR Form Res", year="2025", month="Apr", day="28", volume="9", pages="e60612", keywords="digital health", keywords="help-seeking behavior", keywords="socioeconomic factors", keywords="community health services", keywords="older people", keywords="eHealth", keywords="older adults", keywords="geriatric", keywords="support", keywords="eHealth literacy", keywords="interview", keywords="Netherlands", keywords="thematic data analysis", keywords="health literacy", keywords="mobile phone", abstract="Background: There is worldwide recognition of the potential increase of digital health inequity due to the increased digitalization of health care systems. Digital health skill development may prevent disparities in eHealth access and use. In the Dutch context, the public library has started to facilitate support in digital health skill development by offering public eHealth courses. Understanding the motivations of people to seek support may help to further develop this type of public service. Objective: This is a qualitative study on the motivations of citizens participating in an eHealth course offered by public libraries. The study aimed to explore why citizens were motivated to seek nonformal support for eHealth use. Methods: A total of 20 semistructured interviews with participants who participated in an eHealth course were conducted in 7 public libraries across the Netherlands. The interviews were conducted between April and June 2022. Purposive sampling took place in the public library during the eHealth course. The interviews covered participants' motivations, attitudes, and experiences with eHealth use and their motivations to seek help with eHealth use. Interviews were audio-recorded and transcribed. Themes were identified via a comprehensive thematic data analysis. Results: The participants were 51 to 82 years of age (average 73.5, SD 6.6 y) and 14 (70\%) participants were female. Three motivational themes were identified: (1) adapting to an increasingly digital society, (2) sense of urgency facilitated by prior experience in health care, and (3) a need for self-reliance and autonomy. Additionally, participants expressed a general desire for social contact and lifelong learning. A lack of adequate informal support by friends and family for digital skills and positive experiences with formal support from public libraries stimulated the participants to seek formal support for eHealth use. Conclusions: We show that the participants had a feeling of urgency that sparked their motivation to seek nonformal support in the public library. Motivations to participate in the eHealth course stemmed from the need to adapt to the digital society, being a patient or a caregiver, or the need or wish to be independent from others. Participants of the study were mainly older female adults who had native language abilities, up-to-date digital devices, and time. It is likely that other populations experience similar feelings of urgency but have other support needs. Future research should explore the needs and attitudes of nonusers and other users of digital health toward seeking support in eHealth access and use. ", doi="10.2196/60612", url="https://formative.jmir.org/2025/1/e60612" } @Article{info:doi/10.2196/65801, author="Lai, Byron and Wright, Ashley and Hutchinson, Bailey and Bright, Larsen and Young, Raven and Davis, Drew and Malik, Ali Sultan and Rimmer, H. James and ", title="School-Based Virtual Reality Programming for Obtaining Moderate-Intensity Exercise Among Children With Disabilities: Pre-Post Feasibility Study", journal="JMIR Form Res", year="2025", month="Apr", day="25", volume="9", pages="e65801", keywords="disability", keywords="adapted physical activity", keywords="leisure-time exercise", keywords="exercise", keywords="telehealth", keywords="tele-exercise", keywords="cerebral palsy", keywords="pediatric rehabilitation", keywords="intellectual disability", keywords="developmental disability", keywords="child", keywords="high school", keywords="mobility", keywords="mobility disability", keywords="cardio", keywords="cardiorespiratory", keywords="cardiometabolic", keywords="feasibility", keywords="virtual reality", keywords="controlled trial", keywords="t test", keywords="VR", keywords="exergame", keywords="mixed method", abstract="Background: Children have busy daily schedules, making school an ideal setting for promoting health-enhancing exercise behavior. However, children with mobility disabilities have limited exercise options to improve their cardiorespiratory fitness and cardiometabolic health. Objective: This study aims to test the feasibility of implementing a virtual reality (VR) exercise program for children with mobility disabilities in a high school setting. Methods: A pre- to posttrial single-group design with a 6-week exercise intervention was conducted at a high school. The study aimed to enroll up to 12 students with a disability. Participants were given the option of exercising at home or school. The exercise prescription was three 25-minute sessions per week at a moderate intensity, using a head-mounted VR display. School exercise sessions were supervised by research staff. Home exercise sessions were performed autonomously. Several implementation metrics of feasibility were recorded, including exercise attendance, volume, adverse events or problems, and benefits related to health-related fitness (walking endurance and hand-grip strength). The study also included a qualitative evaluation of critical implementation factors and potential benefits for participants that were not included in the study measures. Outcomes were descriptively analyzed, and 2-tailed t tests were used as appropriate. Results: In total, 10 students enrolled in the program and 9 completed the study (mean age 17, SD 0.6 y). In total, 5 (56\%) participants exercised at school, and 4 (44\%) exercised at home; 1 participant dropped out prior to exercise. The mean attendance for all 9 completers was 61.1\% (11/18 sessions). The mean exercise minutes per week was 35.5 (SD 22) minutes. The mean move minutes per session was 17.7 (SD 11) minutes. The mean minutes per session was 18 (SD 1.4) minutes for school exercisers and 17 (SD 18) minutes for home exercisers, indicating variable responses from home exercisers. The mean rating of perceived exertion per exercise session was 4.3 (SD 2), indicating a moderate intensity that ranged from low to hard intensity. No adverse events or problems were identified. No improvements in walking endurance or hand-grip strength were observed. School exercisers achieved a higher attendance rate (83\%) than home exercisers (27\%; P<.001) and seemingly had a 2-fold increase in the volume of exercise achieved (school: mean 279, SD 55 min; 95\% CI 212?347; home: mean 131, SD 170 min; 95\% CI --140 to 401; P=.10). Qualitative themes relating to implementation factors and benefits to participant well-being were identified. Conclusions: This study identified factors to inform an optimal protocol for implementing a high school--based VR exercise program for children with disabilities. Study findings demonstrated that moderate exercise at school is feasible in VR, but simply providing children with VR exergaming technology at home, without coaching, will not successfully engage them in exercise. Trial Registration: ClinicalTrials.gov NCT05935982; https://clinicaltrials.gov/study/NCT05935982 ", doi="10.2196/65801", url="https://formative.jmir.org/2025/1/e65801" } @Article{info:doi/10.2196/37160, author="Arquembourg, Jocelyne and Glaser, Philippe and Roblot, France and Metzler, Isabelle and Gallant-Dewavrin, M{\'e}lanie and Nanguem, Feutze Hugues and Mebarki, Adel and Voillot, Pam{\'e}la and Sch{\"u}ck, St{\'e}phane", title="Discussions of Antibiotic Resistance on Social Media Platforms: Text Mining and Mixed Methods Content Analysis Study", journal="JMIR Form Res", year="2025", month="Apr", day="25", volume="9", pages="e37160", keywords="antibiotic ineffectiveness", keywords="antibiotic resistance", keywords="health-related quality of life", keywords="real-world", keywords="social media", keywords="quality of life", keywords="quantitative", keywords="qualitative", keywords="app", keywords="application", keywords="online", keywords="medical information", keywords="French", keywords="users", keywords="antibiotic", keywords="social media use", abstract="Background: With the increasing popularity of web 2.0 apps, social media has made it possible for individuals to post messages on antibiotic ineffectiveness. In such online conversations, patients discuss their quality of life (QoL). Social media have become key tools for finding and disseminating medical information. Objective: To identify the main themes of discussion, the difficulties encountered by patients with respect to antibiotic ineffectiveness and the impact on their QoL (physical, psychological, social, or financial). Methods: A noninterventional retrospective study was carried out by collecting social media posts in French language written by internet users mentioning their experience with antibiotics, and the impact of their ineffectiveness on their QoL. Messages posted between January 2014 and July 2020 were extracted from French-speaking publicly available online forums. Results: A total of 3773 messages were included in the analysis corpus after extraction and filtering. These messages were posted by 2335 individual web users, most of them being women around 35 years of age. Inefficacy of treatment options and the lack of information regarding the use of antibiotics were among the most discussed topics. QoL was discussed in 63\% of the 3773 messages posted. The most common is the physical impact (78\%). Patients discussed the persistence of symptoms and adverse effects. The second kind of impact is psychological (65\%), characterized by feelings of anxiety or despair about the situation. Conclusions: This social media analysis allowed us to identify a strong impact of the perceived ineffectiveness of antibiotic therapy on patients' daily life particularly in terms of physical and psychological consequences. These results provide health care experts information directly generated by patients regarding their own experiences. Social media studies constitute a complementary source of evidence that could be used to optimize messages to the public about appropriate use of antibiotics. ", doi="10.2196/37160", url="https://formative.jmir.org/2025/1/e37160" } @Article{info:doi/10.2196/57212, author="Elphinston, A. Rachel and Pager, Sue and Fatehi, Farhad and Sterling, Michele and Brown, Kelly and Gray, Paul and Hipper, Linda and Cahill, Lauren and Ziadni, Maisa and Worthy, Peter and Connor, P. Jason", title="Applying Patient and Health Professional Preferences in Co-Designing a Digital Brief Intervention to Reduce the Risk of Prescription Opioid--Related Harm Among Patients With Chronic Noncancer Pain: Qualitative Analysis", journal="JMIR Form Res", year="2025", month="Apr", day="25", volume="9", pages="e57212", keywords="chronic noncancer pain", keywords="CNCP", keywords="prescription opioid use", keywords="brief intervention", keywords="brief psychological intervention", keywords="co-design", keywords="patient partners", keywords="qualitative research", keywords="digital health", abstract="Background: Few personalized behavioral treatments are available to reduce the risk of prescription opioid--related harm among patients with chronic noncancer pain. Objective: We aimed to report on the second phase of the co-design of a digital brief intervention (BI) based on patient and health professional preferences. Methods: Eligible patients with chronic noncancer pain (n=18; 10 women; mean age 49.5, SD 6.91 y) from public hospital waitlists and health professionals (n=5; 2 women; mean age 40.2, SD 5.97 y) from pain and addiction clinics completed semistructured telephone interviews or participated in focus groups exploring BI preferences, needs, and considerations for implementation. Grounded theory was used to thematically analyze the data. Results: We identified 5 themes related to intervention content from patient reports: relevance of the biopsychosocial model and need for improved awareness and pain psychology education; nonpharmacological strategies and flexibility when applying coping skills training; opioid use reflection and education, with personalized medication and tapering plans; holistic and patient-inclusive assessment measures and feedback; and inclusion of holistic goals targeting comfort and happiness. Five themes related to the process and guiding principles were identified: therapist guided; engaging features; compassionate, responsive, person-centered care; a digital solution is exciting, maximizing reach; and educate and normalize system and policy challenges. Finally, 5 themes were reflected in the health professionals' reports: digital health use is rare but desired; digital health is useful for patient monitoring and accessing support; patient motivation is important; a digital BI app is likely beneficial and at multiple care points; and safe medication use and managing pain goals. The reported barriers from health professionals were intervention intensity, potential costs, and patient responsiveness; factors facilitating the implementation were the alignment of digital BIs with clinical models, a stepped-care approach, and feedback. Conclusions: This co-design study identified key content areas, guiding principles, enabling factors, and barriers from both patients and health professionals to guide the development of digital BIs. The knowledge gathered should inform future iterations of co-designing digital BIs for the population most at risk of the harmful effects of opioid medications. ", doi="10.2196/57212", url="https://formative.jmir.org/2025/1/e57212" } @Article{info:doi/10.2196/71676, author="Pack, Allison and Bailey, C. Stacy and O'Conor, Rachel and Velazquez, Evelyn and Wismer, Guisselle and Yeh, Fangyu and Curtis, M. Laura and Alcantara, Kenya and Wolf, S. Michael", title="A Portal-Based Intervention (PATTERN) Designed to Support Medication Use Among Older Adults: Feasibility and Acceptability Study", journal="JMIR Form Res", year="2025", month="Apr", day="24", volume="9", pages="e71676", keywords="older adults", keywords="multiple chronic conditions", keywords="polypharmacy", keywords="primary care", keywords="medication adherence", keywords="patient portal", abstract="Background: Poor medication adherence among older adults with multiple chronic conditions and polypharmacy is a public health concern stemming from distinct challenges. Prior interventions have largely used a one-size-fits-all approach or resource-intensive approaches inappropriate for busy primary care clinics. Objective: To address this, Phenotyping Adherence Through Technology-Enabled Reports and Navigation (PATTERN) was adapted from prior work. PATTERN is a portal-based intervention for monitoring self-reported medication adherence challenges among older adults in primary care. This study sought to implement and evaluate PATTERN's feasibility and acceptability. Methods: We conducted a patient randomized study with a posttest design. Primary care physicians at the participating health center were informed of the study, and approval was obtained to contact their patients. Patient eligibility included being aged 60 years or older, having prescription medications for ?8 chronic conditions, and an upcoming visit with a physician who had provided approval. Potentially eligible patients were identified using an electronic health record query, and a research coordinator phoned them to confirm eligibility, assess interest, obtain consent, and conduct enrollment. Randomization occurred following enrollment. Those randomized to PATTERN received a medication adherence assessment in their patient portal accounts several days ahead of their visit. The assessment identified whether a patient was experiencing a medication adherence challenge, and if so, the type (cognitive, psychological, medical, regimen-related, social, or economic). Identified challenges were sent to the patient's primary care physician. Assessment delivery several days ahead of a visit was thought to offer sufficient time for patients to complete it and clinicians to review any challenges. Approximately 2 weeks after visits, the coordinator recontacted participants to conduct posttest interviews. This ensured clinicians had sufficient time to respond to challenges during or after visits. Posttest interviews measured the self-reported use of the portal, demographic and health characteristics, and for those randomized to PATTERN, intervention satisfaction. Self-reported data were captured in REDCap and analyzed descriptively. Electronic health record data were also analyzed descriptively to objectively identify feasibility, that is, whether intervention arm participants completed the PATTERN assessment. Results: We enrolled 64 participants (32 received usual care, and 32 received intervention). Most were female (66\%, 42/64), not Hispanic or Latino (94\%, 60/64), and identified as White (58\%, 37/64). The average (SD) age was 75 (6.8) years. Most participants (80\%) self-reported using the patient portal ?12 times per year. However, electronic health record data revealed that less than half of all participants randomized to PATTERN (47\%, 15/32) completed the medication adherence assessment. Of those who remembered completing it, 60\% (3/5) were very satisfied with the experience and 20\% (1/5) were a little satisfied. Conclusions: PATTERN has the potential for use with older primary care patients experiencing multiple chronic conditions and polypharmacy. Yet, further adaptation is needed to ensure recipients access their patient portal accounts and complete assessments. Trial Registration: ClinicalTrials.Gov NCT05766423; https://clinicaltrials.gov/study/NCT05766423 ", doi="10.2196/71676", url="https://formative.jmir.org/2025/1/e71676" } @Article{info:doi/10.2196/64212, author="He, Xing and Bian, Jiang and Berlinski, Ariel and Guo, Yi and Simmons, Larry A. and Marshall, Alexandra S. and Greene, J. Carolyn and Brown, Hudson Rita and Turner, Jessica and Perry, T. Tamara", title="Mobile Health App for Adolescent Asthma Self-Management: Development and Usability Study of the Pulmonary Education and Knowledge Mobile Asthma Action Plan", journal="JMIR Form Res", year="2025", month="Apr", day="24", volume="9", pages="e64212", keywords="asthma self-management", keywords="mobile health", keywords="user-centered design", keywords="usability", keywords="adolescents", keywords="mobile phone", abstract="Background: Adolescents with asthma are vulnerable to poor asthma outcomes due to inadequate self-management skills and nonadherence to medications. Mobile health (mHealth) apps have shown promise in improving asthma control, medication adherence, and self-efficacy. However, existing mHealth asthma apps lack personalization and real-time feedback and are not tailored for at-risk adolescents. Objective: This study aimed to design, develop, and test a smartphone-based mHealth Asthma Action Plan for adolescents, called Pulmonary Education and Knowledge Mobile Asthma Action Plan (PEAK-mAAP), in preparation for a large-scale randomized controlled trial. Methods: We employed user-centered design principles to develop our app, leveraging our previous work and following guidelines from the National Heart, Lung, and Blood Institute. The app consists of a patient-facing mobile app and a provider-facing portal. A convenience sample of 13 adolescents (aged 12?20 years) was recruited from the Arkansas Children's Research Institute database or direct health care provider referrals. Participants underwent a task-based usability assessment followed by the System Usability Scale assessment to measure user satisfaction, interface effectiveness, and overall system usability. Results: PEAK-mAAP integrates 7 core modules supporting personalized asthma self-management, symptom monitoring, medication tracking, and real-time feedback. The mean System Usability Scale score was 83/100 (SD 5.54), indicating high user satisfaction and system usability. Notably, older adolescents (>17 years) reported higher usability scores (87.5) than younger users (77.5), suggesting potential age-related differences in app navigation and engagement. Conclusions: The results demonstrate that PEAK-mAAP is a feasible and user-friendly mHealth intervention for adolescent asthma self-management. While the high usability score reflects a positive user experience, some participants encountered initial usability challenges, highlighting the need for minor refinements and user training materials. The integration of personalized self-management tools and real-time feedback distinguishes PEAK-mAAP from existing asthma apps, addressing key barriers to adherence and engagement. Moving forward, an ongoing randomized controlled trial will assess its clinical effectiveness, long-term engagement, and impact on asthma outcomes, providing further insights into its potential as a scalable solution for adolescent asthma care. ", doi="10.2196/64212", url="https://formative.jmir.org/2025/1/e64212" } @Article{info:doi/10.2196/70855, author="Ding, Dan and Morris, Lindsey and Novario, Gina and Fairman, Andrea and Roehrich, Kacey and Foschi Walko, Palma and Boateng, Jessica", title="Mainstream Smart Home Technology--Based Intervention to Enhance Functional Independence in Individuals With Complex Physical Disabilities: Single-Group Pre-Post Feasibility Study", journal="JMIR Rehabil Assist Technol", year="2025", month="Apr", day="24", volume="12", pages="e70855", keywords="physical disabilities", keywords="smart home technology", keywords="assistive technology", keywords="assistive technology service delivery", keywords="functional independence", keywords="participation", keywords="occupational therapy", keywords="artificial intelligence", keywords="AI", abstract="Background: Mainstream smart home technologies (MSHTs), such as home automation devices and smart speakers, are becoming more powerful, affordable, and integrated into daily life. While not designed for individuals with disabilities, MSHT has the potential to serve as assistive technology to enhance their independence and participation. Objective: The study aims to describe a comprehensive MSHT-based intervention named ASSIST (Autonomy, Safety, and Social Integration via Smart Technologies) and evaluate its feasibility in enhancing the functional independence of individuals with complex physical disabilities. Methods: ASSIST is a time-limited intervention with a design based on the human activity assistive technology model, emphasizing client-centered goals and prioritizing individual needs. The intervention follows a structured assistive technology service delivery process that includes 2 assessment sessions to determine technology recommendations, installation and setup of the recommended technology, and up to 8 training sessions. An occupational therapist led the intervention, supported by a contractor and a technologist. Feasibility was evaluated through several measures: (1) the ASSIST Functional Performance Index, which quantifies the number of tasks transitioned from requiring assistance to independent completion and from higher levels of assistance or effort to lower levels; (2) pre- and postintervention measures of perceived task performance and satisfaction using a 10-point scale; (3) the number and types of tasks successfully addressed, along with the costs of devices and installation services; and (4) training effectiveness using the Goal Attainment Scale (GAS). Results: In total, 17 powered wheelchair users with complex physical disabilities completed the study with 100\% session attendance. Across participants, 127 tasks were addressed, with 2 to 10 tasks at an average cost of US \$3308 (SD US \$1192) per participant. Of these tasks, 95 (74.8\%) transitioned from requiring partial or complete assistance to independent completion, while 24 (18.9\%) either improved from requiring complete to partial assistance or, if originally performed independently, required reduced effort. Only 8 (6.3\%) tasks showed no changes. All training goals, except for 2, were achieved at or above the expected level, with a baseline average GAS score of 22.6 (SD 3.5) and a posttraining average GAS score of 77.2 (SD 4.5). Perceived task performance and satisfaction showed significant improvement, with performance score increasing from a baseline mean of 2.6 (SD 1.2) to 8.8 (SD 1.0; P<.001) and satisfaction score rising from an average of 2.9 (SD 1.3) to 9.0 (SD 0.9; P<.001). Conclusions: The ASSIST intervention demonstrated the immediate benefits of enhancing functional independence and satisfaction with MSHT among individuals with complex physical disabilities. While MSHT shows promise in addressing daily living needs at lower costs, barriers such as digital literacy, device setup, and caregiver involvement remain. Future work should focus on scalable models, caregiver engagement, and sustainable solutions for real-world implementation. ", doi="10.2196/70855", url="https://rehab.jmir.org/2025/1/e70855", url="http://www.ncbi.nlm.nih.gov/pubmed/40272873" } @Article{info:doi/10.2196/59477, author="Hollman, Heather and Sui, Wuyou and Zhang, Haowei and Rhodes, E. Ryan", title="A Mobile Health App Informed by the Multi-Process Action Control Framework to Promote Physical Activity Among Inactive Adults: Iterative Usability Study", journal="JMIR Form Res", year="2025", month="Apr", day="23", volume="9", pages="e59477", keywords="physical activity", keywords="mobile apps", keywords="mobile health", keywords="mHealth", keywords="usability study", keywords="inactive adults", keywords="smartphone", abstract="Background: Mobile health apps have high potential to address the widespread deficit in physical activity (PA); however, they have demonstrated greater impact on short-term PA compared to long-term PA. The multi-process action control (M-PAC) framework promotes sustained PA behavior by combining reflective (eg, attitudes) and regulatory (eg, planning and emotion regulation) constructs with reflexive (eg, habits and identity) constructs. Usability testing is important to determine the integrity of a mobile health app's intrinsic properties and suggestions for improvement before feasibility and efficacy testing. Objective: This study aimed to gather usability feedback from end users on a first and a second version of an M-PAC app prototype. Methods: First, 3 workshops and focus groups, with 5 adult participants per group, were conducted to obtain first impressions of the M-PAC app interface and the first 3 lessons. The findings informed several modifications to the app program (eg, added cards with reduced content) and its interface (eg, created a link placeholder image and added a forgot password feature). Subsequently, a single-group pilot usability study was conducted with 14 adults who were not meeting 150 minutes per week of moderate-to-vigorous PA. They used the updated M-PAC app for 2 weeks, participated in semistructured interviews, and completed the Mobile App Usability Questionnaire (MAUQ) to provide usability and acceptability feedback. The focus groups and interviews were recorded, transcribed, and analyzed with content analysis informed by usability heuristics. The MAUQ scores were analyzed descriptively. Results: Participants from the workshops and focus groups (mean age 30.40, SD9.49 years) expressed overall satisfaction with the app layout and content. The language was deemed appropriate; however, some terms (eg, self-efficacy) and acronyms (eg, frequency, intensity, time, and type) needed definitions. Participants provided several recommendations for the visual design (eg, more cards with less text). They experienced challenges in accessing and using the help module and viewing some images, and were unsure how to create or reset the password. Findings from the usability pilot study (mean age 41.38, SD12.92 years; mean moderate-to-vigorous PA 66.07, SD57.92 min/week) revealed overall satisfaction with the app layout (13/13, 100\%), content (10/13, 77\%), and language (7/11, 64\%). Suggestions included more enticing titles and additional and variable forms of content (eg, visual aids and videos). The app was easy to navigate (9/13, 69\%); however, some errors were identified, such as PA monitoring connection problems, broken links, and difficulties entering and modifying data. The mean MAUQ total and subscale scores were as follows: total=5.06 (SD1.20), usefulness=4.17 (SD1.31), ease of use=5.36 (SD1.27), and interface and satisfaction=5.52 (SD1.42). Conclusions: Overall, the M-PAC app was deemed usable and acceptable. The findings will inform the development of the minimum viable product, which will undergo subsequent feasibility testing. ", doi="10.2196/59477", url="https://formative.jmir.org/2025/1/e59477" } @Article{info:doi/10.2196/60854, author="Rudin, S. Robert and Santacroce, M. Leah and Ganguli, Ishani and Solomon, H. Daniel", title="Tailoring Rheumatoid Arthritis Visit Timing Based on mHealth App Data: Mixed Methods Assessment of Implementation and Usability", journal="JMIR Form Res", year="2025", month="Apr", day="21", volume="9", pages="e60854", keywords="mobile health", keywords="patient-reported outcomes", keywords="visit timing", keywords="visit frequency", keywords="rheumatoid arthritis", keywords="rheumatology", abstract="Background: Visits to medical subspecialists are common, with follow-up timing often based on heuristics rather than evidence. Unnecessary visits contribute to long wait times for new patients. Specialists could enhance visit timing and reduce frequency by systematically monitoring patients' symptoms between visits, especially for symptom-driven conditions like rheumatoid arthritis (RA). We previously designed an intervention using a mobile health (mHealth) app to collect patient-reported outcomes (PRO). One of several aims of the app was to assist rheumatologists in determining visit timing for patients with RA. The intervention did not reduce visit frequency. Objective: To explore possible reasons for the lack of association between the intervention and visit frequency, we describe app usage, assess usability, and identify barriers and facilitators for using between-visit PRO data to reduce visits when patients' symptoms are stable. Methods: We analyzed patients' use of the app by reporting adherence (percent of PRO questionnaires completed during the 12-month study) and retention (use in the last month of the study). To examine rheumatologists' experiences, we summarized views of the electronic health record (EHR)--embedded PRO dashboard and EHR inbox messages suggesting early or deferred visits. We assessed app usability using the interactive mHealth App Usability Questionnaire for Ease of Use and Usefulness for patients and the System Usability Scale for rheumatologists. We assessed rheumatologist-level effects of intervention usage using Kruskal-Wallis rank sum and equality of proportion tests. We identified barriers and facilitators through interviews and surveys. Results: The analysis included 150 patients with RA and their 11 rheumatologists. Patients answered a median of 53.3\% (IQR 34.1\%-69.2\%) of PRO questionnaires; this proportion varied by rheumatologist (range 40.7\%?67\%). Over half of the patients used the app during the final month of the study (56\%, range 51\%?65\%, by rheumatologists); the median number of months of use was 12 (IQR 9-12). Rheumatologists viewed the dashboard 78 times (17.6\% of 443 visits) with significant differences in viewing rates by rheumatologist (range 10\%?66\%; P<.01). There were 108 generated messages sent to rheumatologists suggesting a deferred visit (24.4\% of 443 visits) with significant differences in message counts received per visit by rheumatologist (range 10.8\%?22.6\%; P=.03). Rheumatologists' reported barriers to offering visit deferrals included already scheduling as far out as they were comfortable and rescheduling complexities for staff. Based on 39 patient interviews and 44 surveys, patients reported 2 main barriers to app usage: questionnaire frequency not being tailored to them and reduced motivation after not discussing PRO data with their rheumatologist. A total of 5 interviewed patients received the option to defer their visits, of which 3 elected to defer the appointment and 2 chose to keep it. Conclusions: While an mHealth app for reporting RA PROs was used frequently by patients, using these data to reduce the frequency of unneeded visits was not straightforward. Better engagement of clinicians may improve the use of PRO data. ", doi="10.2196/60854", url="https://formative.jmir.org/2025/1/e60854" } @Article{info:doi/10.2196/67855, author="Hoogendoorn, Petra and Shokralla, Mariam and Willemsen, Romy and Guldemond, Nick and Villalobos-Quesada, Mar{\'i}a", title="Compatibility of the CEN-ISO/TS 82304-2 Health App Assessment Framework With Catalan and Italian Health Authorities' Needs: Qualitative Interview Study", journal="JMIR Form Res", year="2025", month="Apr", day="21", volume="9", pages="e67855", keywords="assessment frameworks", keywords="mobile health", keywords="mHealth", keywords="health apps", keywords="wellness apps", keywords="digital transformation", keywords="Italy", keywords="Catalonia", keywords="diffusion of innovations", keywords="value proposition canvas", abstract="Background: Health authorities of European Union (EU) member states are increasingly working to integrate quality health apps into their health care systems. Given the current lack of unified EU assessment criteria, the European Commission initiated Technical Specification (TS) CEN-ISO 82304-2:2021---Health and wellness apps---Quality and reliability (hereinafter the ``TS'') to address the scattered EU landscape of assessment frameworks (AFs) for health apps. The adoption of an AF, such as the TS, falls within member state competence and is considered an uncertainty-reduction process. Evaluations by peers as well as ensuring the compatibility of the TS with the needs of health authorities can reduce uncertainty and mediate harmonization. Objective: This study aims to examine the compatibility of the TS with the needs of Catalan and Italian health authorities. Methods: Semistructured interviews were conducted with key informants from a regional (Catalonia in Spain) and national (Italy) health authority, and a thematic analysis was carried out. Main themes were established deductively, following the aspects defined by the value proposition canvas: (1) health authorities' needs (``gains,'' ``pains,'' and ``jobs'') and (2) the TS ``products and services'' and their distinct characteristics (``gain creators'' and ``pain relievers''). Subthemes were generated inductively. The compatibility of the needs with the TS was theoretically determined by the researchers. The results were visualized using the value proposition canvas. Two participant validation steps confirmed that the most relevant aspects of the predefined themes had been captured. Results: Despite the diversity of the 2 health authorities, subthemes were common and categorized into 9 gains, 9 pains, and 11 jobs. Key findings include the health authorities' perceived value of, and need for, integrating quality health apps and using an AF (gains), along with the related policy, implementation, and operational activities (jobs). The lack of enabling EU legislation and standardization, resulting in a need for the multiple authorities involved to consent, made achieving an AF challenging (pains). Nine products and services related to the TS and 17 distinct characteristics (eg, its multistakeholder evidence base) were found to be compatible with 3 gains (eg, stimulating the prescription and use of apps), 7 pains (eg, legislation and harmonization issues), and 6 jobs (eg, assessing apps). Indirect effects, 3 anticipated future services, and 1 anticipated gain creator and pain reliever increase this compatibility. Conclusions: Our results suggest that the health authorities share common fundamental needs, and that the TS is compatible with these needs. The identified needs and compatibility can potentially reduce peer authorities' uncertainties in adopting an AF in general and the TS in particular. More research is recommended to confirm and translate our results in other contexts and further fine-tune compatibility to achieve wide adoption of the TS and accelerate the uptake of health apps. ", doi="10.2196/67855", url="https://formative.jmir.org/2025/1/e67855" } @Article{info:doi/10.2196/58095, author="Benavent, Diego and Iniesta-Chamorro, M. Jose and Novella-Navarro, Marta and P{\'e}rez-Mart{\'i}nez, Miguel and Mart{\'i}nez-S{\'a}nchez, Nuria and Kaffati, M{\'o}nica and Ju{\'a}rez-Garc{\'i}a, Manuel and Molinari-P{\'e}rez, Marina and Gonz{\'a}lez-Torbay, Andrea and Guti{\'e}rrez, Mariana and L{\'o}pez-Juanes, Natalia and Navarro-Comp{\'a}n, Victoria and Monjo-Henry, Irene and Rodr{\'i}guez-Rosales, Germ{\'a}n and Bachiller, Javier and Calvo-Aranda, Enrique and Michelena, Xabier and Berbel-Arcob{\'e}, Laura and Balsa, Alejandro and and G{\'o}mez, J. Enrique and Plasencia-Rodr{\'i}guez, Chamaida", title="Digital Health Intervention for Patient Monitoring in Immune-Mediated Inflammatory Diseases: Cocreation and Feasibility Study of the IMIDoc Platform", journal="JMIR Hum Factors", year="2025", month="Apr", day="21", volume="12", pages="e58095", keywords="immune-mediated inflammatory diseases", keywords="cocreation", keywords="health care provider", keywords="digital health solution", keywords="inflammatory", keywords="inflammatory disease", keywords="monitoring", keywords="care model", keywords="patient care", keywords="development", keywords="app", keywords="user centered", keywords="patient monitoring", keywords="decision-making", keywords="user needs", abstract="Background: Immune-mediated inflammatory diseases, such as rheumatoid arthritis and spondyloarthritis, pose challenges due to recurrent flares and gaps in patient monitoring. Traditional health care models often fail to capture disease progression effectively. Objective: This study aimed to describes the structured cocreation of the IMIDoc platform, an interdisciplinary initiative aimed at improving patient monitoring, education, and health care provider decision-making. Methods: IMIDoc was cocreated through an interdisciplinary team involving clinical experts, biomedical engineers, and technical developers, using user-centered design principles. The development process included the identification of unmet clinical needs, user-centered app design, implementation of medication management features, patient data recording capabilities, and educational content. A 3-month feasibility and functionality testing was performed to evaluate the usability and technical performance of the apption. Results: During the feasibility testing, 111 entries were logged for the patient mobile app, comprising 76 errors identified and corrected, 16 improvements addressing functionality, usability, and performance, and 10 evolutionary suggestions. The professional interface received 45 entries, identifying 40 errors and 5 evolutionary suggestions. Ten iterative updates significantly enhanced the user interface intuitiveness and medication reminder functionality, aligning the solution closely with clinical workflows and user needs. Conclusions: The IMIDoc platform, developed by a multidisciplinary cocreation methodology, shows potential to improve the management of immune-mediated inflammatory diseases ithrough enhanced communication and monitoring. A multicenter clinical study with 360 patients across 5 Spanish hospitals will further evaluate its impact. Trial Registration: ClinicalTrials.gov NCT06273306; https://tinyurl.com/4t6ubcsf ", doi="10.2196/58095", url="https://humanfactors.jmir.org/2025/1/e58095" } @Article{info:doi/10.2196/68891, author="Seo, Woosuk and Li, Jiaqi and Zhang, Zhan and Zheng, Chuxuan and Singh, Hardeep and Pasupathy, Kalyan and Mahajan, Prashant and Park, Young Sun", title="Designing Health Care Provider--Centered Emergency Department Interventions: Participatory Design Study", journal="JMIR Form Res", year="2025", month="Apr", day="21", volume="9", pages="e68891", keywords="emergency departments", keywords="participatory design", keywords="health care providers", keywords="technology", keywords="interventions", keywords="artificial intelligence", abstract="Background: In the emergency department (ED), health care providers face extraordinary pressures in delivering accurate diagnoses and care, often working with fragmented or inaccessible patient histories while managing severe time constraints and constant interruptions. These challenges and pressures may lead to potential errors in the ED diagnostic process and risks to patient safety. With advances in technology, interventions have been developed to support ED providers in such pressured settings. However, these interventions may not align with the current practices of ED providers. To better design ED provider--centered interventions, identifying their needs in the diagnostic process is critical. Objective: This study aimed to identify ED providers' needs in the diagnostic process through participatory design sessions and to propose design guidelines for provider?centered technological interventions that support decision?making and reduce errors. Methods: We conducted a participatory design study with ED providers to validate their needs and identify considerations for designing ED provider--centered interventions to improve diagnostic safety. We used 9 technological intervention ideas as storyboards to address the study participants' needs. We had participants discuss the use cases of each intervention idea to assess their needs during the ED care process and facilitated co-design activities with the participants to improve the technological intervention designs. We audio- and video-recorded the design sessions. We then analyzed session transcripts, field notes, and design sketches. In total, we conducted 6 design sessions with 17 ED frontline providers. Results: Through design sessions with ED providers, we identified 4 key needs in the diagnostic process: information integration, patient prioritization, ED provider-patient communication, and care coordination. We interpreted them as insights for designing technological interventions for ED patients. Hence, we discussed the design implications for technological interventions in four key areas: (1) enhancing ED provider--ED provider communication, (2) enhancing ED provider-patient communication, (3) optimizing the integration of advanced technology, and (4) unleashing the potential of artificial intelligence tools in the ED to improve diagnosis. This work offers evidence-based technology design suggestions for improving diagnostic processes. Conclusions: This study provides unique insights for designing technological interventions to support ED diagnostic processes. By inviting ED providers into the design process, we present unique insights into the diagnostic process and design considerations for designing novel technological interventions that meet ED providers' needs in the diagnostic process. International Registered Report Identifier (IRRID): RR2-10.2196/55357 ", doi="10.2196/68891", url="https://formative.jmir.org/2025/1/e68891" } @Article{info:doi/10.2196/66791, author="Ristow, Nele and Wilke, Annika and Skudlik, Christoph and John, Malte Swen and Ludewig, Michaela", title="User Experience of and Adherence to a Smartphone App to Maintain Behavior Change and Self-Management in Patients With Work-Related Skin Diseases: Multistep, Single-Arm Feasibility Study", journal="JMIR Form Res", year="2025", month="Apr", day="18", volume="9", pages="e66791", keywords="user experience", keywords="mobile health", keywords="mHealth", keywords="app", keywords="smartphone", keywords="complex intervention", keywords="Template for Intervention Description and Replication", keywords="behavior change techniques", keywords="behavior change", keywords="skin diseases", keywords="occupational dermatology", keywords="artificial intelligence", abstract="Background: Smartphone apps are a growing field supporting the prevention of chronic diseases. The user experience (UX) is an important predictor of app use and should be considered in mobile health research. Long-term skin protection behavior is important for those with work-related skin diseases. However, altering health behavior is complex and requires a high level of self-management. We developed a maintenance program consisting of the Mein Hautschutz im Alltag (MiA; ``My skin protection in everyday life'') app combined with an individual face-to-face goal-setting interview to support patients in the implementation of skin protection behavior after inpatient rehabilitation. Objective: The objectives of this paper are to (1) describe the intervention in a standardized manner; (2) evaluate the UX, subjective quality, and perceived impact of the MiA app; and (3) evaluate the adherence to the MiA app. Methods: We followed a user-centered and multistage iterative process in 2 steps that combined qualitative and quantitative data. The maintenance program was tested over 12 weeks after discharge from rehabilitation. The UX, subjective quality, and perceived impact were evaluated formatively based on the user version of the Mobile Application Rating Scale after 12 weeks (T2). Adherence was measured using the frequency of interactions with the app. Results: In total, 42 patients took part (with a dropout rate of n=18, 43\% at T2). The average age was 49.5 (SD 13.1) years, and 57\% (24/42) were male. We found high ratings for the UX, with an average score of 80.18 (SD 8.94) out of a theoretical maximum of 100, but there were a few exceptions in the usability and interaction with the app. The app was most frequently rated with 4 out of 5 stars (15/24, 65\%), which indicates a high subjective quality. Furthermore, the app seemed to influence important determinants to implement skin protection behavior. Adherence to skin protection tracking was higher over the study period than adherence to skin documentation and goal assessment. The number of adherent participants to skin protection tracking was higher in the skin care and skin cleansing categories (28/42, 67\% each) compared to the skin protection category (13/42, 31\%) on day 1 and decreased until day 84 in all dimensions (12/42, 29\% each for skin care and skin cleansing; 9/42, 21\% for skin protection). Conclusions: The results in terms of adherence met the expectations and were consistent with those of other studies evaluating the use of apps for chronic diseases. Interaction with the app could be increased using artificial intelligence to determine eczema severity via photos. It should be investigated which subgroups have difficulties with usability to individualize the support to a greater degree during onboarding. There is a need for further research regarding the effectiveness of the MiA app on skin protection behavior, quality of life, and eczema severity. ", doi="10.2196/66791", url="https://formative.jmir.org/2025/1/e66791" } @Article{info:doi/10.2196/65670, author="Weisman, Dan and Sugarman, Alanna and Huang, Ming Yue and Gelberg, Lillian and Ganz, A. Patricia and Comulada, Scott Warren", title="Development of a GPT-4--Powered Virtual Simulated Patient and Communication Training Platform for Medical Students to Practice Discussing Abnormal Mammogram Results With Patients: Multiphase Study", journal="JMIR Form Res", year="2025", month="Apr", day="17", volume="9", pages="e65670", keywords="standardized patient", keywords="virtual simulated patient", keywords="artificial intelligence", keywords="AI", keywords="large language model", keywords="LLM", keywords="GPT-4", keywords="agent", keywords="communication skills training", keywords="abnormal mammography results", keywords="biopsy", abstract="Background: Standardized patients (SPs) prepare medical students for difficult conversations with patients. Despite their value, SP-based simulation training is constrained by available resources and competing clinical demands. Researchers are turning to artificial intelligence and large language models, such as generative pretrained transformers, to create communication training that incorporates virtual simulated patients (VSPs). GPT-4 is a large language model advance allowing developers to design virtual simulation scenarios using text-based prompts instead of relying on branching path simulations with prescripted dialogue. These nascent developmental practices have not taken root in the literature to guide other researchers in developing their own simulations. Objective: This study aims to describe our developmental process and lessons learned for creating a GPT-4--driven VSP. We designed the VSP to help medical student learners rehearse discussing abnormal mammography results with a patient as a primary care physician (PCP). We aimed to assess GPT-4's ability to generate appropriate VSP responses to learners during spoken conversations and provide appropriate feedback on learner performance. Methods: A research team comprised of physicians, a medical student, an educator, an SP program director, a learning experience designer, and a health care researcher conducted the study. A formative phase with in-depth knowledge user interviews informed development, followed by a development phase to create the virtual training module. The team conducted interviews with 5 medical students, 5 PCPs, and 5 breast cancer survivors. They then developed a VSP using simulation authoring software and provided the GPT-4--enabled VSP with an initial prompt consisting of a scenario description, emotional state, and expectations for learner dialogue. It was iteratively refined through an agile design process involving repeated cycles of testing, documenting issues, and revising the prompt. As an exploratory feature, the simulation used GPT-4 to provide written feedback to learners about their performance communicating with the VSP and their adherence to guidelines for difficult conversations. Results: In-depth interviews helped establish the appropriate timing, mode of communication, and protocol for conversations between PCPs and patients during the breast cancer screening process. The scenario simulated a telephone call between a physician and patient to discuss the abnormal results of a diagnostic mammogram that that indicated a need for a biopsy. Preliminary testing was promising. The VSP asked sensible questions about their mammography results and responded to learner inquiries using a voice replete with appropriate emotional inflections. GPT-4 generated performance feedback that successfully identified strengths and areas for improvement using relevant quotes from the learner-VSP conversation, but it occasionally misidentified learner adherence to communication protocols. Conclusions: GPT-4 streamlined development and facilitated more dynamic, humanlike interactions between learners and the VSP compared to branching path simulations. For the next steps, we will pilot-test the VSP with medical students to evaluate its feasibility and acceptability. ", doi="10.2196/65670", url="https://formative.jmir.org/2025/1/e65670" } @Article{info:doi/10.2196/65185, author="Zeitlin, Anya and Mathenjwa, Thulile and Zuma, Thembelihle and Wyke, Sally and Matthews, Philippa and McGrath, Nuala and Seeley, Janet and Shahmanesh, Maryam and Blandford, Ann", title="Creating a Usable and Effective Digital Intervention to Support Men to Test for HIV and Link to Care in A Resource-Constrained Setting: Iterative Design Based on A Person-Based Approach and Human Computer Interaction Methods", journal="JMIR Form Res", year="2025", month="Apr", day="17", volume="9", pages="e65185", keywords="person-based approach", keywords="HIV", keywords="resource-constrained settings", keywords="digital intervention", keywords="user-centered design", keywords="behavior change techniques", keywords="digital health", abstract="Background: It is challenging to design usable and effective digital health interventions (DHIs). The person-based approach (PBA) has been proposed to incorporate users' perspectives for the design of DHIs. However, it does not explicitly describe the iterative stages of design and evaluation that are essential in moving from early planning to deployment. For this, we draw on methods from human computer interaction (HCI) that have been developed for various situations. Objective: This study aimed to reflect on the adaptation and synthesis of PBA and HCI approaches to developing DHIs. We present a case study applying both approaches to develop Empowering People through Informed Choices for HIV (EPIC-HIV1), a DHI designed for men living in rural KwaZulu-Natal, South Africa, intended to support them in making an informed choice about whether to take an HIV test and, if necessary, engage in care. Methods: We conducted a retrospective analysis of the documentation generated during the development of EPIC-HIV1 including findings about requirements, design representations, and the results of iterative rounds of testing. We developed an account of the process, the outcomes, and the strengths and limitations of the design and evaluation techniques applied. We also present the design of EPIC-HIV1 and summarize considerations when designing for hard-to-reach people in such settings. Results: The PBA was applied to deliver a first prototype. This helped identify key messages to convey and how to manage issues such as user privacy, but the resulting prototype was judged by the team not to be engaging for potential users, and it was unclear whether the design was inclusive of people with low digital or health literacy. We therefore introduced methods from HCI to iteratively test and refine the app. Working with local community representatives, we conducted four refinement cycles with 29 participants, adapting and retesting the app until no further changes were needed. Key changes included making it clearer what the consequences of selecting options in the app were and changing wording to minimize misconceptions (eg, that the app would test for HIV) while addressing common concerns about testing and emphasizing long-term benefits of engaging with care, if needed. Conclusions: Techniques for developing DHIs need to be situationally appropriate. The PBA enabled us to establish both empirical data and theory to design the content of EPIC-HIV1, but it did not directly inform interaction design to make the app usable and effective for the intended users; HCI techniques tailored to the setting enabled us to refine the app to be easy for men with little familiarity with digital technologies to use within the constraints of the setting. Iterative testing ensured the app was easy to use and that the intended clinical messages were communicated effectively. ", doi="10.2196/65185", url="https://formative.jmir.org/2025/1/e65185", url="http://www.ncbi.nlm.nih.gov/pubmed/40244652" } @Article{info:doi/10.2196/65986, author="Murray, M. Regan and Chiang, C. Shawn and Klassen, C. Ann and Manganello, A. Jennifer and Leader, E. Amy and Lo, Wen-Juo and Massey, M. Philip", title="Developing an Online Community Advisory Board (CAB) of Parents From Social Media to Co-Design an Human Papillomavirus Vaccine Intervention: Participatory Research Study", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e65986", keywords="online community advisory boards", keywords="community engagement", keywords="social media", keywords="digital health", keywords="digital health intervention", keywords="HPV vaccine", keywords="human papillomavirus", keywords="HPV", keywords="parent health", keywords="child health", abstract="Background: Social media health interventions have grown significantly in recent years. However, researchers are still developing innovative methods to meaningfully engage online communities to inform research activities. Little has been documented describing this approach of using online community advisory boards (CABs) to co-create health communication interventions on social media. Objective: This study describes the formation, engagement, and maintenance of an online CAB focused on co-creating a health education intervention for parents regarding the human papillomavirus (HPV) vaccine. The study provides guiding principles for public health researchers implementing such CABs in future digital health interventions. Methods: In May 2020, Twitter was used to recruit parents of children aged 9?14 years, who were active users of the platform and were interested in serving on a CAB focused on child health and online programs. The recruitment campaign included Twitter (rebranded as X in 2023) advertising tools (eg, ``interests'' and ``audience look-a-likes''). A total of 17 parents completed a screening survey and 6 completed a follow-up phone interview. Following phone interviews, 6 parents were invited to join the CAB, where they committed to a 1-year involvement. The CAB participated in eleven 1-hour online meetings in the first year, contributing to monthly feedback through participatory workbooks. Long-term engagement was sustained through icebreakers and casual online interactions, as well as providing real-time updates to demonstrate CAB feedback integration. An anonymous midterm evaluation was conducted at the end of the project's first year to assess processes and identify future growth opportunities. Results: A total of 6 parents (5 females and 1 male) with children aged 9-14 years from diverse racial and ethnic backgrounds (African American, South Asian American, and White) across 6 states in the United States, representing urban, suburban, and rural areas, agreed to serve as CAB members. All 6 CAB members committed to 1 year of service beginning in July 2020 with 4 extending their participation into a second year (August 2021-August 2022). The CAB provided expert insights and feedback to co-develop the intervention, including character development, narrative content creation, study recruitment, survey development, and intervention delivery. The midterm evaluation showed 100\% (6/6) satisfaction among CAB members, who valued the connections with other parents and their contribution to research. While all members felt confident discussing HPV, 83\% (5/6) suggested diversifying the group and increasing informal bonding to enhance engagement and inclusivity, especially for differing vaccination views. Conclusions: This study demonstrates that online CABs are a highly effective model for co-creating and informing online health communication interventions. The engagement of parents from diverse backgrounds and the structured use of online tools (eg, interactive workbooks) creates a constructive and thoughtful environment for incorporating parent contributions to research. This study highlights guiding principles to forming, engaging, and maintaining an online CAB to enhance health research and practice. ", doi="10.2196/65986", url="https://formative.jmir.org/2025/1/e65986" } @Article{info:doi/10.2196/67835, author="Sanjeewa, Ruvini and Iyer, Ravi and Apputhurai, Pragalathan and Wickramasinghe, Nilmini and Meyer, Denny", title="Machine Learning Approach to Identifying Empathy Using the Vocals of Mental Health Helpline Counselors: Algorithm Development and Validation", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e67835", keywords="vocal features", keywords="voice characteristics", keywords="empathy", keywords="mental health care", keywords="crisis helpline service", abstract="Background: This research study aimed to detect the vocal features immersed in empathic counselor speech using samples of calls to a mental health helpline service. Objective: This study aimed to produce an algorithm for the identification of empathy from these features, which could act as a training guide for counselors and conversational agents who need to transmit empathy in their vocals. Methods: Two annotators with a psychology background and English heritage provided empathy ratings for 57 calls involving female counselors, as well as multiple short call segments within each of these calls. These ratings were found to be well-correlated between the 2 raters in a sample of 6 common calls. Using vocal feature extraction from call segments and statistical variable selection methods, such as L1 penalized LASSO (Least Absolute Shrinkage and Selection Operator) and forward selection, a total of 14 significant vocal features were associated with empathic speech. Generalized additive mixed models (GAMM), binary logistics regression with splines, and random forest models were used to obtain an algorithm that differentiated between high- and low-empathy call segments. Results: The binary logistics regression model reported higher predictive accuracies of empathy (area under the curve [AUC]=0.617, 95\% CI 0.613?0.622) compared to the GAMM (AUC=0.605, 95\% CI 0.601?0.609) and the random forest model (AUC=0.600, 95\% CI 0.595?0.604). This difference was statistically significant, as evidenced by the nonoverlapping 95\% CIs obtained for AUC. The DeLong test further validated these results, showing a significant difference in the binary logistic model compared to the random forest (D=6.443, df=186283, P<.001) and GAMM (Z=5.846, P<.001). These findings confirm that the binary logistic regression model outperforms the other 2 models concerning predictive accuracy for empathy classification. Conclusions: This study suggests that the identification of empathy from vocal features alone is challenging, and further research involving multimodal models (eg, models incorporating facial expression, words used, and vocal features) are encouraged for detecting empathy in the future. This study has several limitations, including a relatively small sample of calls and only 2 empathy raters. Future research should focus on accommodating multiple raters with varied backgrounds to explore these effects on perceptions of empathy. Additionally, considering counselor vocals from larger, more heterogeneous populations, including mixed-gender samples, will allow an exploration of the factors influencing the level of empathy projected in counselor voices more generally. ", doi="10.2196/67835", url="https://formative.jmir.org/2025/1/e67835" } @Article{info:doi/10.2196/65555, author="Crocamo, Cristina and Cioni, Matteo Riccardo and Canestro, Aurelia and Nasti, Christian and Palpella, Dario and Piacenti, Susanna and Bartoccetti, Alessandra and Re, Martina and Simonetti, Valentina and Barattieri di San Pietro, Chiara and Bulgheroni, Maria and Bartoli, Francesco and Carr{\`a}, Giuseppe", title="Acoustic and Natural Language Markers for Bipolar Disorder: A Pilot, mHealth Cross-Sectional Study", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e65555", keywords="digital mental health", keywords="remote assessment", keywords="mHealth", keywords="speech", keywords="NLP", keywords="natural language processing", keywords="acoustic", keywords="symptom severity", keywords="machine learning", keywords="markers", keywords="mental health", keywords="bipolar disorders", keywords="app", keywords="applications", keywords="multimodal", keywords="mobile health", keywords="voice", keywords="vocal", keywords="bipolar", keywords="verbal", keywords="emotion", keywords="emotional", keywords="psychiatry", keywords="psychiatric", keywords="mental illness", abstract="Background: Monitoring symptoms of bipolar disorder (BD) is a challenge faced by mental health services. Speech patterns are crucial in assessing the current experiences, emotions, and thought patterns of people with BD. Natural language processing (NLP) and acoustic signal processing may support ongoing BD assessment within a mobile health (mHealth) framework. Objective: Using both acoustic and NLP-based features from the speech of people with BD, we built an app-based tool and tested its feasibility and performance to remotely assess the individual clinical status. Methods: We carried out a pilot, observational study, sampling adults diagnosed with BD from the caseload of the Nord Milano Mental Health Trust (Italy) to explore the relationship between selected speech features and symptom severity and to test their potential to remotely assess mental health status. Symptom severity assessment was based on clinician ratings, using the Young Mania Rating Scale (YMRS) and Montgomery-{\AA}sberg Depression Rating Scale (MADRS) for manic and depressive symptoms, respectively. Leveraging a digital health tool embedded in a mobile app, which records and processes speech, participants self-administered verbal performance tasks. Both NLP-based and acoustic features were extracted, testing associations with mood states and exploiting machine learning approaches based on random forest models. Results: We included 32 subjects (mean [SD] age 49.6 [14.3] years; 50\% [16/32] females) with a MADRS median (IQR) score of 13 (21) and a YMRS median (IQR) score of 5 (16). Participants freely managed the digital environment of the app, without perceiving it as intrusive and reporting an acceptable system usability level (average score 73.5, SD 19.7). Small-to-moderate correlations between speech features and symptom severity were uncovered, with sex-based differences in predictive capability. Higher latency time ($\rho$=0.152), increased silences ($\rho$=0.416), and vocal perturbations correlated with depressive symptomatology. Pressure of speech based on the mean intraword time ($\rho$=--0.343) and lower voice instability based on jitter-related parameters ($\rho$ ranging from --0.19 to --0.27) were detected for manic symptoms. However, a higher contribution of NLP-based and conversational features, rather than acoustic features, was uncovered, especially for predictive models for depressive symptom severity (NLP-based: R2=0.25, mean squared error [MSE]=110.07, mean absolute error [MAE]=8.17; acoustics: R2=0.11, MSE=133.75, MAE=8.86; combined: R2=0.16; MSE=118.53, MAE=8.68). Conclusions: Remotely collected speech patterns, including both linguistic and acoustic features, are associated with symptom severity levels and may help differentiate clinical conditions in individuals with BD during their mood state assessments. In the future, multimodal, smartphone-integrated digital ecological momentary assessments could serve as a powerful tool for clinical purposes, remotely complementing standard, in-person mental health evaluations. ", doi="10.2196/65555", url="https://formative.jmir.org/2025/1/e65555" } @Article{info:doi/10.2196/67885, author="Sidhu, Amrita and Shegog, Ross and Craig-Rushing, Stephanie and Trevino, Nicole and Singer, Michelle and Jessen, Cornelia and Gorman, Gwenda and Simpson, Sean and Peskin, Melissa and Hernandez, Belinda and Markham, Christine", title="Using the Healthy Native Youth Implementation Toolbox to Provide Web-Based Adolescent Health Promotion Decision Support to American Indian and Alaska Native Communities: Implementation Study", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e67885", keywords="implementation", keywords="culturally relevant program", keywords="evidence-based health promotion", keywords="user engagement", keywords="reach", keywords="decision support system", keywords="American Indian", keywords="Alaska", keywords="native communities", keywords="youth", keywords="adolescent", keywords="decision support", keywords="Alaska native", keywords="health inequities", keywords="sexual", keywords="reproductive", keywords="mental health", keywords="AI/AN", keywords="Tribal organization", keywords="Google Analytics", keywords="toolbox", abstract="Background: American Indian and Alaska Native (AI/AN) youth experience numerous health inequities, including those in sexual, reproductive, and mental health. Implementation of culturally relevant, age-appropriate evidence-based programs may mitigate these inequities. However, numerous barriers limit the adoption and implementation of evidence-based adolescent health promotion programs in AI/AN communities. Objective: This study examines user reach and engagement from 2022 to 2024 of web-based decision support (the Healthy Native Youth [HNY] website and the embedded HNY Implementation Toolbox), designed to increase the implementation of evidence-based adolescent health promotion programming in AI/AN communities. Methods: Promotional strategies were designed for optimal geographic reach to Tribal organizations, opinion leaders, federal decision makers, and funders. Promotional channels included grassroots, community, and professional networks. We used Google Analytics to examine the uptake of the HNY website and HNY Implementation Toolbox from January 2022 to January 2024. The Toolbox provides culturally relevant tools and templates to help users navigate through 5 phases of program adoption and implementation: Gather, Choose, Prepare, Implement, and Grow. User reach was estimated by demographic characteristics and geographic location; user engagement was estimated by visit frequency and duration, bounce rates, and frequency of page and tool access. Results: Over the study period, page views of the HNY website and HNY Toolbox increased 10-fold and 27-fold, respectively. Over the 2-year evaluation period since the Toolbox ``go live'' date, approximately 1 in 8 users of the HNY website visited the Toolbox. The majority of HNY website users were located in Washington (n=1515), California (n=1290), and Oregon (n=1019) and were aged between 18 and 24 (n=1559, 21.7\%) and 25?34 (n=1676, 23.29\%) years. Toolbox users were primarily located in California (n=1238), Washington (n=1142), and Oregon (n=986), mostly aged between 35 and 44 years (n=444, 35\%). Both website and Toolbox users were primarily female, who accessed the site and Toolbox via desktop computers. The most frequently accessed phase pages within the Implementation Toolbox were Gather, Choose, Implement, and Prepare, as supported by bounce rates and average time on page. The most viewed phase was the ``Gather'' phase, with 3278 views. The most frequently downloaded tools within the Toolbox were Gather: Community Needs and Resource Assessment, with 136 downloads. The phases and tools accessed may have differed based on the user's goal or stage of implementation. Conclusions: Findings indicate positive initial reach and engagement of the HNY website and HNY Implementation Toolbox among AI/AN educators that has consistently increased over the 2 years. The provision of web-based decision support that guides AI/AN users through the adoption, implementation, and maintenance of culturally relevant, age-appropriate, evidence-based adolescent health promotion programs in their communities may help increase the implementation of effective adolescent health promotion programs to ultimately increase health equity among AI/AN youth. ", doi="10.2196/67885", url="https://formative.jmir.org/2025/1/e67885" } @Article{info:doi/10.2196/56586, author="Tan, Orejana Josephine Rose and Neal, P. David and Vilmen, Maria and Boersma, Petra and Ettema, P. Teake and Gobbens, J. Robbert J. and Sikkes, M. Sietske A. and Dr{\"o}es, Rose-Marie", title="A Digital Photo Activity Intervention for Nursing Home Residents With Dementia and Their Carers: Mixed Methods Process Evaluation", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e56586", keywords="dementia", keywords="psychosocial interventions", keywords="nursing home", keywords="process evaluation", keywords="social interaction", keywords="photos", keywords="art", abstract="Background: Within the framework of a randomized controlled trial investigating the impact of a digital, psychosocial photo activity intervention for residents living with dementia in nursing homes and their informal and formal carers, a process evaluation was conducted to determine factors that affected the implementation of the intervention and potentially influenced the intervention outcomes. Objective: By tracing facilitators and barriers to implementation, the study also aimed to inform future implementation of the photo activity intervention. Methods: Following Medical Research Council guidance, mixed methods were used to investigate context, implementation, and mechanism-of-impact factors during the photo activity intervention via the Fotoscope web application versus a general conversation activity (control). Google Analytics was set up to gain insight into how the Fotoscope web application was used in practice. For quantitative data, descriptive statistics were calculated and differences between groups tested. For qualitative data, thematic analysis was performed. Results: In total, 163 semistructured interviews were conducted with residents (photo activity group: n=29, 17.8\%; control: n=29, 17.8\%), formal carers (photo activity group: n=23, 14.1\%; control: n=27, 16.6\%), and informal carers (photo activity group: n=28, 17.2\%; control: n=27, 16.6\%). Regarding contextual factors, a minority of formal carers in both groups (photo activity group: 4/18, 22\%; control: 9/24, 38\%) mentioned time and workload as barriers to implementing the intervention. Regarding implementation, 86\% (25/29) of the residents in the intervention group felt that the digital photo activity worked well on a tablet. Informal carers from both groups wanted more intervention updates from formal carers. The majority of formal carers from both groups were satisfied with how the training and activities were implemented. Regarding the mechanisms of impact, residents in the photo activity group (27/29, 93\%) felt significantly more positive about the conversations with their carer (U=533.0, z=2.865, r=0.39; P=.004). Formal carers in the photo activity group (20/23, 87\%) got to know the resident better (U=390.5, z=2.114, r=0.302; P=.04) compared to the formal carers in the control group (21/27, 78\%). Formal carers in the photo activity group (23/50, 46\%) gave a significantly higher rating to the digital photo activity as a way of getting to know the resident living with dementia better (median 9.00, IQR 7-9; U=419.0, z=2.169, r=0.307; P=.03) compared to formal carers in the control group (27/50, 54\%; median 8.00, IQR 6-8). Finally, the majority of formal carers in the photo activity group (14/18, 78\%) agreed that the Fotoscope app can be used as part of care activities in the nursing home. Conclusions: The work invested by formal carers in implementing the photo activity did not seem to differ greatly compared to implementing a general conversation activity, suggesting that the digital photo activity, as an easy-to-implement and enjoyable intervention, could be widely implemented and disseminated in nursing homes. International Registered Report Identifier (IRRID): RR2-https://doi.org/10.1186/s12877-021-02632-w ", doi="10.2196/56586", url="https://formative.jmir.org/2025/1/e56586" } @Article{info:doi/10.2196/69242, author="Brown, Marie Jacqueline and Rita, Nicholas and Franco-Arellano, Beatriz and LeSage, Ann and Arcand, Joanne", title="Evaluation of a Curriculum-Based Nutrition Education Intervention Protocol in Elementary Schools: Nonrandomized Feasibility Study", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e69242", keywords="nutrition education", keywords="serious games", keywords="children", keywords="food literacy", keywords="school nutrition intervention", keywords="feasibility", abstract="Background: Improving children's food literacy through school-based interventions can support developing healthy eating habits. However, teachers lack appropriate resources, time, and training to provide nutrition education in schools. Serious games, which are games designed for a purpose other than entertainment, have been demonstrated to improve children's food literacy and dietary intake and can address the barriers teachers face in providing nutrition education. Foodbot Factory (Arcand Lab) is a nutrition education intervention that is aligned with curricula and uses a serious game to provide nutrition education to students. Further evidence is needed to understand how serious games, including Foodbot Factory, can be researched in schools to support nutrition education. Objective: The objective of this study was to evaluate the feasibility of a research study protocol that implements the curriculum-based nutrition education intervention Foodbot Factory into a real-world classroom setting. The evaluation of the protocol included study processes, resources, and management feasibility outcomes, as well as a preliminary assessment of scientific outcomes relevant to the intervention. Methods: A nonrandomized study determined the feasibility of intervention implementation. Grade 4 and 4/5 classrooms were assigned to have nutrition education lessons for 5 days with either the Foodbot Factory or a control intervention. Outcomes were assessed in 4 feasibility domains of study processes (eg, recruitment and attrition rates), resources (eg, time taken to deliver the intervention), and management (eg, challenges with intervention delivery), and a preliminary assessment of scientific outcomes pertaining to the acceptability and impacts of the interventions. These outcomes were captured in semistructured field notes completed by study staff and a Nutrition Attitudes and Knowledge questionnaire and acceptability questionnaire completed by participants. Data were analyzed descriptively and using a paired t test to assess within-group changes in nutrition knowledge. Results: In total, 4 classrooms participated in the feasibility study, with varying recruitment rates for schools (3/20, 15\%), classrooms (4/4, 100\%), parents (54/102, 53\%), and children (49/54, 91\%). The time required to implement the research protocol, including data collection and lesson plans, was sufficient and management of the intervention implementation was overall successful. Some challenges were experienced with classroom management during data collection, specifically with electronic data collection. After the intervention, participants reported a positive affective experience (26/41, 63\%) and learning something new about healthy eating (31/41, 76\%). Participants in both study groups improved their nutrition knowledge, but the changes were not statistically significant. The Foodbot Factory group had a statistically significant improvement in their knowledge of vegetables and fruit (P=.04) and protein foods (P=.03). Conclusions: These findings indicate that the study protocol is feasible to implement and evaluate Foodbot Factory in a representative sample with select modifications to improve recruitment and data collection procedures. ", doi="10.2196/69242", url="https://formative.jmir.org/2025/1/e69242" } @Article{info:doi/10.2196/67637, author="Schmied, Emily and Hurtado, Lauren and Robinson, Ken W. and Simon-Arndt, M. Cynthia and Moyer III, Richard and Wilson, Leslie and Reed, Mark and Blakey, M. Shannon and Kan, Marni", title="Evaluating the Acceptability of a Brief Web-Based Alcohol Misuse Prevention Program Among US Military Cadets: Mixed Methods Formative Evaluation", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e67637", keywords="alcohol misuse prevention", keywords="digital interventions", keywords="formative research", keywords="military health", keywords="acceptability", keywords="alcohol prevention", keywords="US military", keywords="military", keywords="United States", keywords="formative evaluation", keywords="alcohol use", keywords="evidence-based prevention", keywords="alcohol intervention", keywords="mixed methods study", keywords="survey", keywords="alcohol use disorder", keywords="alcohol misuse", keywords="heavy drinker", keywords="educational web-based intervention", keywords="web-based intervention", abstract="Background: As alcohol misuse remains pervasive within the military, evidence-based prevention programs that are feasible to implement and appropriately tailored to meet the needs and norms of military personnel are critically needed. Further, programs that target future military leaders, such as trainees, recruits, and cadets, may be especially impactful. eCHECKUP TO GO is a web-based, evidence-based brief alcohol intervention designed to reduce alcohol misuse through education and personalized feedback that may be suitable for military trainees. However, because it was developed for civilian students, efforts to adapt the content for military settings are needed. Objective: This study aimed to evaluate the acceptability of a military version of eCHECKUP TO GO, tailored to include military-specific terminology and alcohol use statistics. Methods: US Air Force Academy cadets were recruited to participate in a single-arm, mixed methods study. Following the completion of eCHECKUP TO GO, participants completed a survey that assessed satisfaction with specific aspects of the user experience, including ease of use, design, and relevance of the information and personalized feedback (range: 1=strongly disagree to 7=strongly agree). A subset of cadets also participated in a focus group to expound on the survey responses. Results: Survey participants included 22 cadets (n=12, 55\% male; mean age 19.6, SD 1.8 years). In addition, 6 (27\%) cadets participated in the focus group. Participants were satisfied with the program overall (mean 5.8, SD 0.9) and gave the highest ratings to ease of use (mean 6.6, SD 0.7), site design (mean 6.5, SD 0.6), and site interactivity (mean 6.4, SD 1.0). Items pertaining to tailoring, relevance, and amount of content specific to cadets scored lowest (mean 5.8, SD 1.4; mean 5.6, SD 1.4; and mean 5.5, SD 1.5, respectively). Most (n=15, 68\%) participants said they would act upon the information they were provided. Focus group participants made suggestions for improved tailoring, such as increasing content on social aspects of drinking and military-specific risks of alcohol misuse (eg, Uniform Code of Military Justice violations). Conclusions: Although the acceptability of eCHECKUP TO GO was high, continued efforts are needed to ensure the content accurately reflects the experiences of cadets. Researchers who design military health promotion interventions need to consider the varied contexts within the force and rigorously evaluate the acceptability of all content before implementation. ", doi="10.2196/67637", url="https://formative.jmir.org/2025/1/e67637" } @Article{info:doi/10.2196/67755, author="Li, Xiaoli and Liu, Xiaoyu and Yin, Cheng and Collins, Sandra and Alanazi, Eman", title="Impact of a Virtual Reality Video (``A Walk-Through Dementia'') on YouTube Users: Topic Modeling Analysis", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e67755", keywords="Alzheimer disease", keywords="Alzheimer disease and related dementias", keywords="ADRD", keywords="dementia", keywords="public awareness", keywords="text mining", keywords="older adult", keywords="health care student", keywords="training", keywords="health care professional", keywords="simulation", keywords="digital world", keywords="virtual environment", keywords="virtual tour", keywords="walk-through dementia", keywords="virtual reality", keywords="VR", keywords="VR video", keywords="VR application", keywords="topic modeling", keywords="YouTube", keywords="Bidirectional Encoder Representations from Transformers", keywords="BERT", keywords="social media comments", keywords="experiential learning tool", abstract="Background: Emerging research has highlighted the potential of virtual reality (VR) as a tool for training health care students and professionals in care skills for individuals with Alzheimer disease and related dementias (ADRD). However, there is limited research on the use of VR to engage the general public in raising awareness about ADRD. Objective: This research aimed to examine the impact of the VR video ``A Walk-Through Dementia'' on YouTube users by analyzing their posts. Methods: We collected 12,754 comments from the VR video series ``A Walk-Through Dementia,'' which simulates the everyday challenges faced by individuals with ADRD, providing viewers with an immersive experience of the condition. Topic modeling was conducted to gauge viewer opinions and reactions to the videos. A pretrained Bidirectional Encoder Representations from Transformers (BERT) model was used to transform the YouTube comments into high-dimensional vector embeddings, allowing for systematic identification and detailed analysis of the principal topics and their thematic structures within the dataset. Results: We identified the top 300 most frequent words in the dataset and categorized them into nouns, verbs, and adjectives or adverbs using a part-of-speech tagging model, fine-tuned for accurate tagging tasks. The topic modeling process identified eight8 initial topics based on the most frequent words. After manually reviewing the 8 topics and the content of the comments, we synthesized them into 5 themes. The predominant theme, represented in 2917 comments, centered on users' personal experiences with the impact of ADRD on patients and caregivers. The remaining themes were categorized into 4 main areas: positive reactions to the VR videos, challenges faced by individuals with ADRD, the role of caregivers, and learning from the VR videos. Conclusions: Using topic modeling, this study demonstrated that VR applications serve as engaging and experiential learning tools, offering the public a deeper understanding of life with ADRD. Future research should explore additional VR applications on social media, as they hold the potential to reach wider audiences and effectively disseminate knowledge about ADRD. ", doi="10.2196/67755", url="https://formative.jmir.org/2025/1/e67755" } @Article{info:doi/10.2196/68132, author="Sutori, Sara and Eliasson, Ther{\'e}se Emma and Mura, Francesca and Ortiz, Victor and Catrambonephd, Vincenzo and Hadlaczky, Gerg{\"o} and Todorov, Ivo and Alfeo, Luca Antonio and Cardi, Valentina and Cimino, A. Mario G. C. and Mioni, Giovanna and Raya, Alca{\~n}iz Mariano and Valenza, Gaetano and Carli, Vladimir and Gentili, Claudio", title="Acceptability, Usability, and Insights Into Cybersickness Levels of a Novel Virtual Reality Environment for the Evaluation of Depressive Symptoms: Exploratory Observational Study", journal="JMIR Form Res", year="2025", month="Apr", day="16", volume="9", pages="e68132", keywords="depression", keywords="virtual reality", keywords="assessment", keywords="acceptability", keywords="usability", keywords="cybersickness", abstract="Background: There is a clear need for enhanced mental health assessment, depressive symptom (DS) evaluation being no exception. A promising approach to this aim is using virtual reality (VR), which entails the potential of adding a wider set of assessment domains with enhanced ecological validity. However, whilst several studies have used VR for both diagnostic and treatment purposes, its acceptance, in particular how exposure to virtual environments affects populations with psychiatric conditions remains unknown. Objective: This study aims to report on the acceptability, usability, and cybersickness levels of a pilot VR environment designed for the purpose of differentiating between individuals with DSs. Methods: The exploratory study, conducted in Italy, included 50 healthy controls and 50 young adults with mild-to-moderate DSs (without the need for a formal diagnosis). The study used an observational design with approximately 30 minutes of VR exposure followed by a self-report questionnaire battery. The battery included a questionnaire based on the Theoretical Framework of Acceptability, the System Usability Scale as well as the Simulator Sickness Questionnaire. Results: Results indicate that the majority found VR acceptable for the purposes of mental health screening and treatment. However, for diagnostics, there was a clear preference for VR to be used by mental health professionals as a supplementary tool, as opposed to a stand-alone solution. In practice, following exposure to the pilot VR environment, generally, good levels of acceptability and usability were reported, but areas in need of improvement were identified (such as self-efficacy). Self-reported cybersickness levels were comparable to literature averages but were considerably higher among those with DSs. Conclusions: These findings raise questions about the potential interplay between underlying somatic symptoms of depression and VR-induced cybersickness and call for more attention from the scientific community both in terms of methodology as well as potential clinical and theoretical implications. Conclusively, user support indicates a potential for VR to aid mental health assessment, but further research is needed to understand how exposure to virtual environments might affect populations with varying severity and other forms of psychiatric symptoms. International Registered Report Identifier (IRRID): RR2-10.1186/ISRCTN16396369 ", doi="10.2196/68132", url="https://formative.jmir.org/2025/1/e68132" } @Article{info:doi/10.2196/68855, author="Feldman, G. Amy and Beaty, L. Brenda and Moore, L. Susan and Bull, Sheana and Wilson, Kumanan and Atkinson, M. Katherine and Bell, Cameron and Denize, M. Kathryn and Kempe, Allison", title="Feasibility, Acceptability, and Effectiveness of a Smartphone App to Increase Pretransplant Vaccine Rates: Usability Study", journal="JMIR Form Res", year="2025", month="Apr", day="15", volume="9", pages="e68855", keywords="mobile app", keywords="vaccines", keywords="immunizations", keywords="transplantation", keywords="children", keywords="beta test", keywords="mobile health", keywords="mHealth", abstract="Background: Vaccine-preventable infections result in significant morbidity, mortality, and costs in pediatric transplant recipients. Despite intensive medical care in the pretransplant period, less than 20\% of children are up to date for age-appropriate vaccines at the time of transplant. Mobile health apps have the potential to improve pretransplant vaccine rates. Objective: This paper aimed to perform phase 2 beta testing of the smartphone app, Immunize PediatricTransplant, to determine (1) if it was effective in achieving up-to-date vaccine status by the time of transplant in a cohort of children awaiting transplants and (2) if the app was feasible and acceptable to parent and transplant provider users. Methods: We recruited 25 dyads of parents and providers of a child awaiting a liver, kidney, or heart transplant at Children's Hospital Colorado, Ann and Robert H. Lurie Children's Hospital, and the Children's Hospital of Philadelphia. Parents and providers filled out an entry questionnaire before app use to gather baseline information. A research team member entered the child's vaccine records into the app. The parent and provider downloaded and used the app until the transplant to view vaccine records, read vaccine education, communicate with team members, and receive overdue vaccine reminders. After the transplant (or on April 1, 2024, the conclusion of the study), the parent and provider filled out an exit questionnaire to explore feasibility and acceptability of the app. The child's vaccine records were reviewed to determine if the child was up to date on vaccines at the time of transplant. Results: Twenty-five parent and provider dyads were enrolled; 56\% (14/25) had a child awaiting a liver transplant, 28\% (7/25) had a child awaiting a kidney transplant, and 16\% (4/25) had a child awaiting a heart transplant. At the conclusion of the study, 96\% (24/25) of the children were up to date on vaccines. Of the 36 parents and providers who filled out an exit questionnaire, 97\% (n=35) agreed or strongly agreed that they felt knowledgeable about pretransplant vaccine use and 86\% (n=31) agreed or strongly agreed that communication around vaccines was good after using the app. Further, 91\% (20/22) of parents and 79\% (11/14) of providers recommended the app to future parents and providers of transplant candidates. Parents and providers suggested that in the future the app should connect directly to the electronic medical record or state vaccine registries to obtain vaccine data. Conclusions: The overwhelming majority of children whose parents and providers used the Immunize PediatricTransplant app were up to date on vaccines at the time of transplant. The majority of app users felt the app was feasible and acceptable. In future iterations of the app and subsequent clinical trials, we will explore whether application programming interfaces might be used to extract vaccine data from the electronic medical record. If implemented broadly, this app has the potential to improve pretransplant vaccine rates, resulting in fewer posttransplant infections and improved posttransplant outcomes. ", doi="10.2196/68855", url="https://formative.jmir.org/2025/1/e68855" } @Article{info:doi/10.2196/66301, author="Coffield, Edward and Kausar, Khadeja", title="Evaluating User Engagement With a Real-Time, Text-Based Digital Mental Health Support App: Cross-Sectional, Retrospective Study", journal="JMIR Form Res", year="2025", month="Apr", day="14", volume="9", pages="e66301", keywords="mental health support", keywords="text", keywords="app", keywords="utilization", keywords="mobile", keywords="on demand", keywords="scheduled", keywords="mHealth", keywords="mobile health", keywords="student", keywords="university", keywords="college", keywords="mental health", keywords="employee", keywords="job", keywords="work", keywords="occupational health", keywords="counselor", keywords="counseling", keywords="usage", keywords="engagement", keywords="self-reported", abstract="Background: Approximately 20\% of US adults identify as having a mental illness. Structural and other barriers prevent many people from receiving mental health services. Digital mental health apps that provide 24-hour, real-time access to human support may improve access to mental health services. However, information is needed regarding how and why people engage with licensed counselors through a digital, real-time, text-based mental health support app in nonexperimental settings. Objective: This study aimed to evaluate how people engage with Counslr, a 24-hour, digital, mental health support app where users communicate in real time with human counselors through text messaging. Specifically, access patterns (eg, day of the week and time of session) and reasons for accessing the platform were examined. Furthermore, whether differences existed between session types (on-demand or scheduled) and membership types (education or noneducation) in regard to access patterns and why people accessed the platform were evaluated. Methods: The study population (users) consisted of students whose schools, universities, or colleges partnered with Counslr and employees whose organizations also partnered with Counslr. Users participated in text-based mental health support sessions. In these sessions, users engaged with licensed counselors through digital, text-based messaging in real time. Users could initiate an on-demand session or schedule a session 24 hours a day. User engagement patterns were evaluated through session length, session day, session time, and self-reported reasons for initiating the session. The data were stratified by membership type (education [students] or noneducation [employees]) and session type (on-demand or scheduled) to evaluate whether differences existed in usage patterns and self-reported reasons for initiating sessions by membership and session types. Results: Most students (178/283, 62.9\%) and employees (28/44, 63.6\%) accessed Counslr through on-demand sessions. The average and median session times were 40 (SD 15.3) and 45 minutes. On-demand sessions (37.9 minutes) were shorter (P=.001) than scheduled sessions (43.5 minutes). Most users (262/327, 80.1\%) accessed Counslr between 7 PM and 5 AM. The hours that users accessed Counslr did not statistically differ by membership type (P=.19) or session type (P=.10). Primary self-reported reasons for accessing Counslr were relationship reasons, depression, and anxiety; however, users initiated sessions for a variety of reasons. Statistically significant differences existed between membership and session types (P<.05) for some of the reasons why people initiated sessions. Conclusions: The novel findings of this study illustrate that real-time, digital mental health support apps, which offer people the opportunity to engage with licensed counselors outside of standard office hours for a variety of mental health conditions, may help address structural barriers to accessing mental health support services. Additional research is needed to evaluate the effectiveness of human-based apps such as Counslr and whether such apps can also address disparities in access to mental health support services among different demographic groups. ", doi="10.2196/66301", url="https://formative.jmir.org/2025/1/e66301" } @Article{info:doi/10.2196/65357, author="Keinert, Marie and Schindler-Gmelch, Lena and Rupp, Helene Lydia and Sadeghi, Misha and Richer, Robert and Capito, Klara and Eskofier, M. Bjoern and Berking, Matthias", title="The EmpkinS-EKSpression Reappraisal Training Augmented With Kinesthesia in Depression: One-Armed Feasibility Study", journal="JMIR Form Res", year="2025", month="Apr", day="14", volume="9", pages="e65357", keywords="depression", keywords="cognitive reappraisal", keywords="facial expression", keywords="kinesthesia", keywords="smartphone-based intervention", keywords="mobile phone", abstract="Background: Harboring dysfunctional depressogenic cognitions contributes to the development and maintenance of depression. A central goal of cognitive behavioral therapy (CBT) for depression is to invalidate such cognitions via cognitive reappraisal (CR). However, relatively low remission rates and high dropout rates in CBT demonstrate the need for further improvement. Potentially, the effects of CBT could be enhanced by addressing not only dysfunctional depressogenic cognitions but also body states associated with depression. This may be done, for example, by systematically pairing the invalidation of depressogenic cognitions with the performance of antidepressive kinesthesia. Objective: This study aimed to examine the feasibility and clinical potential of a smartphone-based cognitive restructuring task that required users to deliberately perform antidepressive kinesthesia in conjunction with the rejection of depressogenic statements and the affirmation of antidepressive statements. This feasibility study was conducted as a precursor to a large-scale randomized controlled trial. Methods: In total, 10 healthy participants engaged in a single 90-120-minute session of smartphone-based CR training. During the training, they completed 2 phases in which they were required to reject 20 depressogenic and affirm 20 antidepressive statements, respectively. Diagnostic assessments were conducted 1 week (T1) before and directly prior (T2) to the training, and again directly posttraining (T3) and at a 2-week follow-up posttraining (T4). Feasibility outcomes assessed at T3 included intervention safety recorded by study therapists, compliance, technical feasibility, usability assessed using the Short Version of the User Experience Questionnaire (UEQ-S), and acceptability assessed using the UEQ-S and self-developed items. Preliminary clinical potential was evaluated via single-item ratings of current depressed and positive mood assessed continuously during the training. Feasibility outcomes were analyzed descriptively, and clinical potential was examined using paired-sample t tests of pre and post ratings of mood at each training phase. Results: Overall, the results indicated that the training was safe, feasible, and usable (UEQ-S pragmatic quality scale: mean 1.45, SD 0.71). However, acceptance was limited (UEQ-S hedonic quality scale: mean 1.05, SD 0.79). While 80\% (8/10) of the participants were generally satisfied with the training, 80\% (8/10) would recommend it to a friend, 90\% (9/10) found it interesting, and 80\% (8/10) rated it as ``leading edge,'' 40\% (4/10) to 70\% (7/10) did not consider it particularly helpful and 50\% (5/10) found it repetitive. Preliminary results regarding clinical potential were promising, with significant increases in positive mood (rejection: Hedges g=0.63; affirmation: Hedges g=0.25), whereas changes in depressed mood were not significant. Conclusions: This study evaluated the feasibility and acceptability of a smartphone-based CR training augmented with validating and invalidating kinesthesia. This provided valuable insights for further optimizing the intervention for the subsequent randomized controlled trial, but also potential similar interventions. If future studies confirm their clinical potential, such interventions offer a promising approach to enhancing CBT for depression. Trial Registration: OSF Registries pw6ma; https://osf.io/pw6ma/ ", doi="10.2196/65357", url="https://formative.jmir.org/2025/1/e65357" } @Article{info:doi/10.2196/66509, author="Raspado, Olivier and Brack, Michel and Brack, Olivier and Vivancos, M{\'e}lanie and Esparcieux, Aur{\'e}lie and Cart-Tanneur, Emmanuelle and Aouifi, Abdellah", title="Oxidative Stress Markers and Prediction of Severity With a Machine Learning Approach in Hospitalized Patients With COVID-19 and Severe Lung Disease: Observational, Retrospective, Single-Center Feasibility Study", journal="JMIR Form Res", year="2025", month="Apr", day="11", volume="9", pages="e66509", keywords="oxidative stress", keywords="COVID-19", keywords="SARS-CoV-2", keywords="coronavirus", keywords="respiratory", keywords="infectious", keywords="pulmonary", keywords="respiration disorders", keywords="hospitalization", keywords="machine learning", keywords="ML", keywords="biomarker", keywords="lung", keywords="severity", keywords="prediction", abstract="Background: Serious pulmonary pathologies of infectious, viral, or bacterial origin are accompanied by inflammation and an increase in oxidative stress (OS). In these situations, biological measurements of OS are technically difficult to obtain, and their results are difficult to interpret. OS assays that do not require complex preanalytical methods, as well as machine learning methods for improving interpretation of the results, would be very useful tools for medical and care teams. Objective: We aimed to identify relevant OS biomarkers associated with the severity of hospitalized patients' condition and identify possible correlations between OS biomarkers and the clinical status of hospitalized patients with COVID-19 and severe lung disease at the time of hospital admission. Methods: All adult patients hospitalized with COVID-19 at the Infirmerie Protestante (Lyon, France) from February 9, 2022, to May 18, 2022, were included, regardless of the care service they used, during the respiratory infectious COVID-19 epidemic. We collected serous biomarkers from the patients (zinc [Zn], copper [Cu], Cu/Zn ratio, selenium, uric acid, high-sensitivity C-reactive protein [hs-CRP], oxidized low-density lipoprotein, glutathione peroxidase, glutathione reductase, and thiols), as well as demographic variables and comorbidities. A support vector machine (SVM) model was used to predict the severity of the patients' condition based on the collected data as a training set. Results: A total of 28 patients were included: 8 were asymptomatic at admission (grade 0), 14 had mild to moderate symptoms (grade 1) and 6 had severe to critical symptoms (grade 3). As the first outcome, we found that 3 biomarkers of OS were associated with severity (Zn, Cu/Zn ratio, and thiols), especially between grades 0 and 1 and between grades 0 and 2. As a second outcome, we found that the SVM model could predict the level of severity based on a biological analysis of the level of OS, with only 7\% misclassification on the training dataset. As an illustrative example, we simulated 3 different biological profiles (named A, B, and C) and submitted them to the SVM model. Profile B had significantly high Zn, low hs-CRP, a low Cu/Zn ratio, and high thiols, corresponding to grade 0. Profile C had low Zn, low selenium, high oxidized low-density lipoprotein, high glutathione peroxidase, a low Cu/Zn ratio, and low glutathione reductase, corresponding to grade 2. Conclusions: The level of severity of pulmonary damage in patients hospitalized with COVID-19 was predicted using an SVM model; moderate to severe symptoms in patients were associated with low Zn, low plasma thiol, increased hs-CRP, and an increased Cu/Zn ratio among a panel of 10 biomarkers of OS. Since this panel does not require a complex preanalytical method, it can be used and studied in other pathologies associated with OS, such as infectious pathologies or chronic diseases. ", doi="10.2196/66509", url="https://formative.jmir.org/2025/1/e66509" } @Article{info:doi/10.2196/65188, author="Fleszar-Pavlovic, E. Sara and Noriega Esquives, Blanca and Lovan, Padideh and Brito, E. Arianna and Sia, Marie Ann and Kauffman, Adelyn Mary and Lopes, Maria and Moreno, I. Patricia and Koru-Sengul, Tulay and Gong, Rui and Wang, Trent and Wieder, D. Eric and Rueda-Lara, Maria and Antoni, Michael and Komanduri, Krishna and Lesiuk, Teresa and Penedo, J. Frank", title="Development of an eHealth Mindfulness-Based Music Therapy Intervention for Adults Undergoing Allogeneic Hematopoietic Stem Cell Transplantation: Qualitative Study", journal="JMIR Form Res", year="2025", month="Apr", day="11", volume="9", pages="e65188", keywords="allogeneic stem cell transplantation", keywords="hematologic malignancy", keywords="bone marrow transplant", keywords="mindfulness-based music therapy", keywords="mindfulness", keywords="music therapy", keywords="eHealth", keywords="music therapy intervention", keywords="adult", keywords="adolescence", keywords="allogeneic", keywords="stem cell transplantation", keywords="stem cell", keywords="transplantation", keywords="qualitative study", keywords="treatment", keywords="hematologic cancers", keywords="psychological distress", keywords="side effects", keywords="mindfulness-based stress reduction", keywords="stress reduction", keywords="anxiety", keywords="depression", keywords="diagnosis", keywords="blood sample collection", keywords="eHealth tool", keywords="quality of life", keywords="cancer survivors", abstract="Background: Allogeneic hematopoietic stem cell transplantation (allo-SCT) is an effective treatment for various hematologic cancers, though it often results in severe side effects and psychological distress, which can negatively impact health outcomes. Integrative therapies like mindfulness-based stress reduction (MBSR), mindfulness meditation (MM), and music therapy (MT) yield promising results in enhancing both psychosocial outcomes (eg, reducing anxiety and depression) and physiological adaptation (eg, decreasing inflammation) in cancer patients. Objective: We developed and refined, using focus groups and environmental and field testing, an eHealth-delivered mindfulness-based music therapy (eMBMT) intervention aimed at improving health-related quality of life, symptom burden (ie, pain, fatigue, and sleep), disease activity (ie, chronic graft-versus-host disease, cytomegalovirus activation, and infections) and psychosocial (ie, depression, anxiety, and cancer-specific distress) and physiological adaptation (ie, inflammation and immune reconstitution) tailored to adults receiving allo-SCT. Methods: eMBMT intervention content is grounded in MT, MM, and MBSR, developed by a multidisciplinary team, and adapted for adults undergoing allo-SCT. eMBMT content was refined through focus groups and usability and field testing. Focus groups used a semistructured interview guide, while field testing used the ``think aloud'' method. Usability was evaluated using the 30-item Usefulness, Satisfaction, and Ease of Use (USE) questionnaire. Descriptive statistics analyzed the USE questionnaire and participant characteristics, while rapid qualitative analysis was applied to focus groups and field-testing sessions. Survivors eligible to participate in the focus groups and usability and field testing were adults (>18 years old) who received an allo-SCT (<36 months) for myelodysplastic syndrome, acute myeloid leukemia, or chronic myeloid leukemia, and were in remission for greater than 3 months. Results: During the focus groups, participants (n=11; mean age 43.6, SD 17.8 years) provided qualitative feedback highlighting the shock of diagnosis, challenges during hospitalization, and coping strategies posttreatment. The eMBMT platform received positive evaluations for usefulness (mean 6.47, SD 0.29), ease of use (mean 6.92, SD 0.60), and satisfaction (mean 6.16, SD 0.82). Key themes from field testing highlighted the significance of social support, hope, and maintaining an active lifestyle. Suggestions for improvement included incorporating more representative content, reducing text, enhancing guidance, offering diverse music options, and streamlining blood sample collection. Conclusions: The eMBMT intervention is a comprehensive, user-friendly eHealth tool tailored to the unique needs of allo-SCT patients. The positive feedback and identified areas for improvement underscore its potential to enhance well-being, symptom management, and overall quality of life for cancer survivors. A future pilot randomized controlled trial will further evaluate the feasibility, acceptability, and preliminary efficacy of the eMBMT intervention in improving health-related quality of life, symptom burden, disease activity, and psychosocial and physiological adaptation. Trial Registration: ClinicalTrials.gov NCT05968963; https://clinicaltrials.gov/study/NCT05968963 ", doi="10.2196/65188", url="https://formative.jmir.org/2025/1/e65188" } @Article{info:doi/10.2196/67275, author="Hutchison, G. Michael and Di Battista, P. Alex and Pyndiura, L. Kyla", title="Evaluating User Experience and Satisfaction in a Concussion Rehabilitation App: Usability Study", journal="JMIR Form Res", year="2025", month="Apr", day="11", volume="9", pages="e67275", keywords="mild traumatic brain injury", keywords="recovery", keywords="mHealth", keywords="app", keywords="digital health", keywords="smartphone", keywords="eHealth", keywords="digital", keywords="technology", keywords="usability", keywords="concussion rehabilitation", keywords="brain injury", keywords="rehabilitation protocols", keywords="evidence-based exercise", keywords="single-arm pilot study", keywords="home-based rehabilitation", keywords="user-friendly", keywords="questionnaire", keywords="telehealth", keywords="telemedicine", abstract="Background: Evidence-based guidelines support the use of structured exercise to facilitate concussion recovery. Despite the growing number of mobile health (mHealth) apps aimed at managing concussions, few focus on delivering exercise rehabilitation protocols. Therefore, a mobile app was developed to provide personalized rehabilitation programs based on evidence-based exercise principles designed to cater to individuals recovering from concussions. Objective: This study aimed to evaluate the usability and user experience of a mobile app designed to deliver an evidence-based rehabilitation program to individuals recovering from concussions. Methods: A two-week prospective single-arm pilot study was conducted among adults with a physician-diagnosed concussion. Participants engaged in home-based rehabilitation exercises through a mobile app. Usability was assessed using a combination of the mHealth App Usability Questionnaire (MAUQ) and five custom questions evaluating confidence in recommendations, exercise flow, clarity of voice commands, and usability of the exercise report feature. Following the two-week period, participants rated each question on a 7-point Likert scale ranging from ``strongly agree'' to ``strongly disagree''. Results: Twenty-six participants consented and were enrolled in the study, with 23 participants (82\%) completing all study components at the end of two weeks. The majority of participants were women, aged 26-38 years, and on average, approximately at three months postconcussion. Responses to both the MAUQ and custom questions were overwhelmingly positive. Overall, seven MAUQ questions received 100\% positive responses, with no single question scoring below 83\% positive responses. In the ``ease of use and satisfaction'' category, 100\% of users responded positively to questions on ease of learning, usability, interface likeness, and comfort in social settings, while 83\%-96\% (19-22) of users responded positively to the remaining four questions. In the ``system information arrangement'' category, 100\% (N=23) of users rated screen navigation, function usability, and health care service acceptability positively, with 87\%-96\% of users approving action acknowledgment, error recovery, and expected functions. Under the ``usefulness'' category, 96\% (n=22) of users found the app beneficial for health and well-being, and 91\% (n=21) users felt it effectively managed their health. For the five custom questions, 100\% (N=23) users responded positively to voice command clarity, exercise awareness, ease of following exercises, and report understandability, with a single unfavorable response noted for confidence in app recommendations. Conclusions: The findings of this study indicate that the mobile app is a user-friendly platform for delivering evidence-based exercise rehabilitation to individuals recovering from concussions. Positive user feedback, particularly in the areas of recommendation confidence, ease of exercise flow, and clarity of voice commands, highlights the app's potential to support concussion recovery. Future iterations of the app will aim to improve time efficiency and streamline error recovery processes to further enhance the user experience. ", doi="10.2196/67275", url="https://formative.jmir.org/2025/1/e67275" } @Article{info:doi/10.2196/63700, author="Havreng-Th{\'e}ry, Charlotte and Fouchard, Arnaud and Denis, Fabrice and Veyron, Jacques-Henri and Belmin, Jo{\"e}l", title="Cost-Effectiveness Analysis of a Machine Learning--Based eHealth System to Predict and Reduce Emergency Department Visits and Unscheduled Hospitalizations of Older People Living at Home: Retrospective Study", journal="JMIR Form Res", year="2025", month="Apr", day="11", volume="9", pages="e63700", keywords="monitoring", keywords="older adult", keywords="predictive tool", keywords="home care aide", keywords="emergency department visit", keywords="cost-effectiveness", keywords="artificial intelligence", keywords="electronic health", keywords="eHealth", keywords="emergency department", keywords="unscheduled hospitalization", keywords="aging", keywords="retrospective study", keywords="medico-economic", keywords="living at home", keywords="nursing home", keywords="emergency visit", keywords="Brittany", keywords="France", keywords="machine learning", keywords="remote monitoring", keywords="digital health", keywords="health informatics", abstract="Background: Dependent older people or those losing their autonomy are at risk of emergency hospitalization. Digital systems that monitor health remotely could be useful in reducing these visits by detecting worsening health conditions earlier. However, few studies have assessed the medico-economic impact of these systems, particularly for older people. Objective: The objective of this study was to compare the clinical and economic impacts of an eHealth device in real life compared with the usual monitoring of older people living at home. Methods: This study was a comparative, retrospective, and controlled trial on data collected between May 31, 2021, and May 31, 2022, in one health care and home nursing center located in Brittany, France. Participants had to be aged >75 years, living at home, and receiving assistance from the home care service for at least 1 month. We implemented among the intervention group an eHealth system that produces an alert for a high risk of emergency department visits or hospitalizations. After each home visit, the home care aides completed a questionnaire on participants' functional status using a smartphone app, and the information was processed in real time by a previously developed machine learning algorithm that identifies patients at risk of an emergency visit within 7 to 14 days. In the case of predicted risk, the eHealth system alerted a coordinating nurse who could then inform the family carer and the patient's nurses or general practitioner. Results: A total of 120 patients were included in the study, with 60 in the control group and 60 in the intervention group. Among the 726 visits from the intervention group that were not followed by an alert, only 4 (0.6\%) resulted in hospitalizations (P<.001), confirming the relevance of the system's alerts. Over the course of the study, 37 hospitalizations were recorded for 25 (20.8\%) of the 120 patients. Additionally, of the 120 patients, 9 (7.5\%) were admitted to a nursing home, and 7 (5.8\%) died. Patients in the intervention group (56/60, 93\%) remained at home significantly more often than those in the control group (48/60, 80\%; P=.03). The total cost of primary care and hospitalization during the study was {\texteuro}167,000 ({\texteuro}1=US \$1.09), with {\texteuro}108,000 (64.81\%) attributed to the intervention group (P=.20). Conclusions: This study presents encouraging results on the impact of a remote medical monitoring system for older adults, demonstrating a reduction in both emergency department visits and hospitalization costs. Trial Registration: ClinicalTrials.gov NCT05221697; https://clinicaltrials.gov/study/NCT05221697 ", doi="10.2196/63700", url="https://formative.jmir.org/2025/1/e63700", url="http://www.ncbi.nlm.nih.gov/pubmed/40215100" } @Article{info:doi/10.2196/63928, author="Shin, Jinyoung and Kweon, Jung Hyuk and Choi, Jaekyung", title="Assessment of Gait Parameters Using Wearable Sensors and Their Association With Muscle Mass, Strength, and Physical Performance in Korean Older Adults: Cross-Sectional Study", journal="JMIR Form Res", year="2025", month="Apr", day="10", volume="9", pages="e63928", keywords="gait analysis", keywords="sarcopenia", keywords="wearable electronic devices", keywords="muscle mass", keywords="physical performance", keywords="older adults", keywords="geriatric", keywords="cross-sectional study", keywords="outpatient clinic", keywords="Korea", keywords="mHealth", keywords="mobile health", abstract="Background: Gait speed indicates the onset or decline of physical performance in sarcopenia. However, real-time measurements of other gait parameters, such as step length, stride length, step width, and support time, are limited. The advent of wearable technology has facilitated the measurement of these parameters, necessitating further investigation into their potential applications. Objective: This study aimed to investigate the relationship between gait parameters measured using wearable sensors and muscle mass, strength, and physical performance in community-dwelling older adults. Methods: In a cross-sectional study of 91 participants aged ?65 years, gait parameters, such as step count, step length, cadence, single and double support times, vertical oscillation, and instantaneous vertical loading rate (IVLR), measured using a wireless earbud device, were analyzed on the basis of the appendicular skeletal muscle mass index (SMI), calf circumference, handgrip strength, 5-time chair stand test, short physical performance battery (SPPB), and the SARC-F (strength, assistance with walking, rise from a chair, climb stairs and fall frequency) questionnaire. This study was conducted from July 10 to November 1, 2023, at an outpatient clinic of a university hospital in Seoul, Korea. Multiple regression analysis was performed to investigate independent associations after adjusting for age, sex, BMI, and comorbidities. Results: Among 91 participants (45 men and 46 women; mean age 74.1 years for men and 73.6 years for women), gait speed and vertical oscillation showed negative associations with their performance in the 5-time chair stand test (P<.001) and SARC-F and positive associations with their performance in the SPPB (P<.001). Vertical oscillations were also associated with grip strength (P=.003). Single and double support times were associated with performance in the 5-time chair stand test and SPPB (P<.001). In addition, double support time was associated with SARC-F scores (P<.001). Gait speed, support time, vertical oscillation, and IVLR showed independent associations with performance in the 5-time chair stand test and SPPB (P<.001), both related to muscle strength or physical performance. Gait speed, double support time, and vertical oscillation all had significant associations with SARC-F scores. Conclusions: This study demonstrated a significant association between gait monitoring using wearable sensors and quantitative assessments of muscle strength and physical performance in older people. Furthermore, this study substantiated the extensive applicability of diverse gait parameters in predicting sarcopenia. ", doi="10.2196/63928", url="https://formative.jmir.org/2025/1/e63928" } @Article{info:doi/10.2196/67767, author="Chan, Fan-Ying and Ku, Yi-En and Lie, Wen-Nung and Chen, Hsiang-Yin", title="Web-Based Explainable Machine Learning-Based Drug Surveillance for Predicting Sunitinib- and Sorafenib-Associated Thyroid Dysfunction: Model Development and Validation Study", journal="JMIR Form Res", year="2025", month="Apr", day="10", volume="9", pages="e67767", keywords="thyroid dysfunction", keywords="machine learning", keywords="cancer", keywords="sunitinib", keywords="sorafenib", keywords="TKI", keywords="tyrosine kinase inhibitor", abstract="Background: Unlike one-snap data collection methods that only identify high-risk patients, machine learning models using time-series data can predict adverse events and aid in the timely management of cancer. Objective: This study aimed to develop and validate machine learning models for sunitinib- and sorafenib-associated thyroid dysfunction using a time-series data collection approach. Methods: Time series data of patients first prescribed sunitinib or sorafenib were collected from a deidentified clinical research database. Logistic regression, random forest, adaptive Boosting, Light Gradient-Boosting Machine, and Gradient Boosting Decision Tree were used to develop the models. Prediction performances were compared using the accuracy, precision, recall, F1-score, area under the receiver operating characteristic curve, and area under the precision-recall curve. The optimal threshold for the best-performing model was selected based on the maximum F1-score. SHapley Additive exPlanations analysis was conducted to assess feature importance and contributions at both the cohort and patient levels. Results: The training cohort included 609 patients, while the temporal validation cohort had 198 patients. The Gradient Boosting Decision Tree model without resampling outperformed other models, with area under the precision-recall curve of 0.600, area under the receiver operating characteristic curve of 0.876, and F1-score of 0.583 after adjusting the threshold. The SHapley Additive exPlanations analysis identified higher cholesterol levels, longer summed days of medication use, and clear cell adenocarcinoma histology as the most important features. The final model was further integrated into a web-based application. Conclusions: This model can serve as an explainable adverse drug reaction surveillance system for predicting sunitinib- and sorafenib-associated thyroid dysfunction. ", doi="10.2196/67767", url="https://formative.jmir.org/2025/1/e67767" } @Article{info:doi/10.2196/58916, author="Francis, M. Jackson and Neti, S. Sitapriya and Polavarapu, Dhatri and Atem, Folefac and Xie, Luyu and Kapera, Olivia and Mathew, S. Matthew and Marroquin, Elisa and McAdams, Carrie and Schellinger, Jeffrey and Ngenge, Sophia and Kukreja, Sachin and Schneider, E. Benjamin and Almandoz, P. Jaime and Messiah, E. Sarah", title="Association of Social Media Recruitment and Depression Among Racially and Ethnically Diverse Metabolic and Bariatric Surgery Candidates: Prospective Cohort Study", journal="JMIR Form Res", year="2025", month="Apr", day="10", volume="9", pages="e58916", keywords="social media", keywords="social media recruitment", keywords="depression", keywords="depressed", keywords="major depressive disorder", keywords="MDD", keywords="depressive disorder", keywords="depressive", keywords="race", keywords="racial", keywords="racial differences", keywords="ethnic", keywords="ethnic differences", keywords="ethnicity", keywords="metabolic surgery", keywords="bariatric surgery", keywords="obesity", keywords="obese", keywords="online health", keywords="ethics", keywords="mental health", keywords="eHealth", keywords="internet", keywords="digital health", keywords="digital mental health", keywords="online interventions", keywords="public engagement", keywords="public health", abstract="Background: Due to the widespread use of social media and the internet in today's connected world, obesity and depression rates are increasing concurrently on a global scale. This study investigated the complex dynamics involving social media recruitment for scientific research, race, ethnicity, and depression among metabolic and bariatric surgery (MBS) candidates. Objective: This study aimed to determine (1) the association between social media recruitment and depression among MBS candidates and (2) racial and ethnic differences in social media recruitment engagement. Methods: The analysis included data from 380 adult MBS candidates enrolled in a prospective cohort study from July 2019 to December 2022. Race and ethnicity, recruitment method (social media: yes or no), and depression status were evaluated using $\chi$2 tests and logistic regression models. Age, sex, and ethnicity were adjusted in multivariable logistic regression models. Results: The mean age of the candidates was 47.35 (SD 11.6) years, ranging from 18 to 78 years. Participants recruited through social media (n=41, 38.32\%) were more likely to report past or current episodes of depression compared to nonsocial media--recruited participants (n=74, 27.11\%; P=.03), with a 67\% increased likelihood of depression (odds ratio [OR] 1.67, 95\% CI 1.04?2.68, P=.03). Further analysis showed that participants with a history of depression who were below the mean sample age were 2.26 times more likely to be recruited via social media (adjusted OR [aOR] 2.26, 95\% CI 1.03?4.95; P=.04) compared to those above the mean age. Hispanic (n=26, 38.81\%) and non-Hispanic White (n=53, 35.10\%) participants were significantly more likely to be recruited via social media than non-Hispanic Black (n=27, 18.37\%) participants (P<.001). After adjusting for covariates, non-Hispanic Black participants were 60\% less likely than non-Hispanic White participants to be recruited via social media (aOR 0.40, 95\% CI 0.22?0.71; P=.002). Conclusions: We found that individuals recruited through social media channels, especially younger participants, were more likely to report past or current episodes of depression compared to those recruited through nonsocial media. The study also showed that non-Hispanic Black individuals are less likely to engage in social media recruitment for scientific research versus other racial and ethnic groups. Future mental health--related studies should consider strategies to mitigate potential biases introduced by recruitment methods to ensure the validity and generalizability of research findings. ", doi="10.2196/58916", url="https://formative.jmir.org/2025/1/e58916" } @Article{info:doi/10.2196/63491, author="Louis, Lina-Estelle and Moussaoui, Sa{\"i}d and Ravoux, S{\'e}bastien and Milleville-Pennel, Isabelle", title="Encouraging the Voluntary Mobilization of Mental Resources by Manipulating Task Design: Explorative Study", journal="JMIR Form Res", year="2025", month="Apr", day="10", volume="9", pages="e63491", keywords="visual game-like elements", keywords="gamification", keywords="multiplicity of cognitive functions", keywords="cognitive tasks", keywords="perceived playfulness", keywords="mental workload", keywords="performance", keywords="cognitive training", keywords="aging", keywords="mental effort", keywords="cognitive function", keywords="cognitive skills", keywords="cognitive tests", abstract="Background: Cognitive training is increasingly being considered and proposed as a solution for several pathologies, particularly those associated with aging. However, trainees need to be willing to invest enough mental effort to succeed and make progress. Objective: In this study, we explore how gamification in a narrative context (ie, the addition of visual game-like elements [GLEs] embedded in real-world contexts) could contribute increase in perceived playfulness (PP) and voluntary mental effort allocated to a cognitive task. In such context, narrative elements and GLEs can be designed to align with a commonly relatable scenario (like simulating fishing or gardening activity) to ground the task in familiar, real-world contexts. We also consider if the supposed effect of GLEs on PP and voluntary mental effort could endure while manipulating an intrinsic variable of the task (ie, by increasing cognitive solicitation). Methods: In total, 20 participants (average age 33.6, SD 8.6 y) took part in 3 cognitive tasks proposed in a numerical format: a classic version of the Corsi test (Classic Corsi, a spatial memory task), a playful version of the Classic Corsi test (Playful Corsi), with added visual GLEs in a narrative context, and a playful version of the Classic Corsi test with added cognitive solicitation, that is, mental motor inhibition (Playful Corsi Multi). We assessed the impact of visual GLEs and cognitive solicitation on PP (1 question) and mental workload (MWL) using NASA-Task Load Index (NASA-TLX) and workload profile (WP) questionnaires. Results: Results showed that PP was not influenced by interface's playful characteristics (Classic Corsi [mean 62.4, SD 8.8] vs Playful Corsi [mean 66, SD 8.8]; W=77; P=.30) but decreased the time necessary to complete the task (Classic Corsi [mean 10.7, SD 2.1 s] vs Playful Corsi [mean 6.8, SD 1.6 s]; W=209; P<.001) as well as performance (Classic Corsi [mean 92.4, SD 9.1] vs Playful Corsi [mean 88.2, SD 11.3]; W=140.5; P=.02). So, possibly, visual GLEs could raise the stakes of the task slightly and implicitly encourage people to go a bit faster. Furthermore, visual GLEs increased MWL regarding attentional resources (assessed by WP: Classic Corsi [mean 52.4, SD 10.9] vs Playful Corsi [mean 65.8, SD 10.9]; W=27.5; P=.04), while manipulating cognitive solicitation impacted MWL when linked to task requirements (assessed by NASA-TLX: Playful Corsi [mean 54.2, SD 9.4] vs Playful Corsi Multi [mean 67.5, SD 9.4]; W=35.5; P=.01) without impacting the performance to the task (Playful Corsi [mean 83.8, SD 13.9] vs Playful Corsi Multi [mean 94, SD 5.5]; W=27; P=.007). Thus, working on the way cognitive functions are solicited would be wiser than adding visual GLEs to improve users' voluntary mental effort while preserving performance. Conclusion: These results offer valuable insights to improve users' experience during gamified cognitive tasks and serious games. ", doi="10.2196/63491", url="https://formative.jmir.org/2025/1/e63491" } @Article{info:doi/10.2196/65721, author="Wiesm{\"u}ller, Fabian and Prenner, Andreas and Ziegl, Andreas and El-Moazen, Gihan and Modre-Osprian, Robert and Baumgartner, Martin and Brodmann, Marianne and Seinost, Gerald and Silbernagel, G{\"u}nther and Schreier, G{\"u}nter and Hayn, Dieter", title="Support of Home-Based Structured Walking Training and Prediction of the 6-Minute Walk Test Distance in Patients With Peripheral Arterial Disease Based on Telehealth Data: Prospective Cohort Study", journal="JMIR Form Res", year="2025", month="Apr", day="10", volume="9", pages="e65721", keywords="mHealth", keywords="telehealth", keywords="peripheral arterial disease", keywords="home-based structured walking training", keywords="trend estimation", keywords="predictive modeling", keywords="continuous data", keywords="walking", keywords="walking training", keywords="prediction", keywords="prediction model", keywords="cardiovascular disease", keywords="stroke", keywords="heart failure", keywords="physical fitness", keywords="telehealth system", abstract="Background: Telehealth has been effective in managing cardiovascular diseases like stroke and heart failure and has shown promising results in managing patients with peripheral arterial disease. However, more work is needed to fully understand the effect of telehealth-based predictive modeling on the physical fitness of patients with peripheral arterial disease. Objective: For this work, data from the Keep Pace study were analyzed in depth to gain insights on temporal developments of patients' conditions and to develop models to predict the patients' total walking distance at the study end. This could help to determine patients who are likely to benefit from the telehealth program and to continuously provide estimations to the patients as a motivating factor. Methods: This work analyzes continuous patient-reported telehealth data, in combination with in-clinic data from 19 Fontaine stage II patients with peripheral arterial disease who underwent a 12-week telehealth-based walking program. This analysis granted insights into the increase of the total walking distance of the 6-minute walk tests (6MWT) as a measure for physical fitness, the steady decrease in the patients' pain, and the positive correlation between well-being and the total walking distance measured by the 6MWT. Results: This work analyzed trends of and correlations between continuous patient-generated data. Findings of this study include a significant decrease of the patients' pain sensation over time (P=.006), a low but highly significant correlation between pain sensation and steps taken on the same day (r=?0.11; P<.001) and the walking distance of the independently performed 6MWTs (r=?0.39; P<.001). Despite the reported pain, adherence to the 6MWT measurement protocol was high (85.53\%). Additionally, patients significantly improved their timed-up-and-go test times during the study (P=.002). Predicting the total walking distance at the study end measured by the 6MWT worked well at study baseline (root mean squared error of 30 meters; 7.04\% of the mean total walking distance at the study end of 425 meters) and continuously improved by adding further telehealth data. Future work should validate these findings in a larger cohort and in a prospective setting based on a clinical outcome. Conclusions: We conclude that the prototypical trend estimation has great potential for an integration in the telehealth system to be used in future work to provide tailored patient-specific advice based on these predictions. Continuous data from the telehealth system grant a deeper insight and a better understanding of the patients' status concerning well-being and level of pain as well as their current physical fitness level and the progress toward reaching set goals. Trial Registration: ClinicalTrials.gov Identifier: NCT05619835; https://tinyurl.com/mrxt7y9u ", doi="10.2196/65721", url="https://formative.jmir.org/2025/1/e65721" } @Article{info:doi/10.2196/67624, author="Coren, A. Morgan and Lindhiem, Oliver and Angus, R. Abby and Toevs, K. Emma and Radovic, Ana", title="Provider Perspectives on Implementing an Enhanced Digital Screening for Adolescent Depression and Suicidality: Qualitative Study", journal="JMIR Form Res", year="2025", month="Apr", day="10", volume="9", pages="e67624", keywords="depression", keywords="suicidality", keywords="adolescent mental health screening", keywords="primary care", keywords="digital tools", abstract="Background: With a growing adolescent mental health crisis, pediatric societies are increasingly recommending that primary care providers (PCPs) engage in mental health screening. While symptom-level screens identify symptoms, novel technology interventions can assist PCPs with providing additional point-of-care guidance to increase uptake for behavioral health services. Objective: In this study, we sought community PCP feedback on a web-based, digitally enhanced mental health screening tool for adolescents in primary care previously only evaluated in research studies to inform implementation in community settings. Methods: A total of 10 adolescent providers were recruited to trial the new screening tool and participate in structured interviews based on the Consolidated Framework for Implementation Research domains. Interviews were audio recorded, transcribed, and coded according to a prespecified codebook using a template analysis approach. Results: Providers identified improving mental health screening and treatment in pediatric primary care as a priority and agreed that a web-based digitally enhanced screening tool could help facilitate identification of and management of adolescent depression. Salient barriers identified were lack of electronic health record integration, time to administer screening, implications on clinic workflow, accessibility, and lack of transparency within health care organizations about the process of approving new technologies for clinical use. Providers made multiple suggestions to enhance implementation in community settings, such as incorporating customization options. Conclusions: Technology interventions can help address the need for improved behavioral health support in primary care settings. However, numerous barriers exist, complicating implementation of new technologies in real-world settings. ", doi="10.2196/67624", url="https://formative.jmir.org/2025/1/e67624" } @Article{info:doi/10.2196/64174, author="Laverdi{\`e}re, Roxanne and Jackson, L. Philip and Banville, Fr{\'e}d{\'e}ric", title="A New Mobile App to Train Attention Processes in People With Traumatic Brain Injury: Logical and Ecological Content Validation Study", journal="JMIR Form Res", year="2025", month="Apr", day="9", volume="9", pages="e64174", keywords="mobile app", keywords="attention training", keywords="cognitive remediation", keywords="mindfulness", keywords="psychometric properties", keywords="content validation", abstract="Background: Attention is at the base of more complex cognitive processes, and its deficits can significantly impact safety and health. Attention can be impaired by neurodevelopmental and acquired disorders. One validated theoretical model to explain attention processes and their deficits is the hierarchical model of Sohlberg and Mateer. This model guides intervention development to improve attention following an acquired disorder. Another way to stimulate attention functions is to engage in the daily practice of mindfulness, a multicomponent concept that can be explained by the theoretical model of Baer and colleagues. Mobile apps offer great potential for practicing mindfulness daily as they can easily be used during daily routines, thus facilitating transfer. Laverdi{\`e}re and colleagues have developed such a mobile app called Focusing, which is aimed at attention training using mindfulness-inspired attentional exercises. However, this app has not been scientifically validated. Objective: This research aims to analyze the logical content validity and ecological content validity of the Focusing app. Methods: Logical content validation was performed by 7 experts in neuropsychology and mindfulness. Using an online questionnaire, they determined whether the content of the attention training app exercises is representative of selected constructs, namely the theoretical model of attention by Sohlberg and Mateer and the theoretical model of mindfulness by Baer and colleagues. A focus group was subsequently held with the experts to discuss items that did not reach consensus in order to change or remove them. Ecological content validation was performed with 10 healthy adults. Participants had to explore all sections of the app and assess the usability, relevance, satisfaction, quality, attractiveness, and cognitive load associated with each section of the app, using online questionnaires. Results: Logical content validation results demonstrated a high content validity index (CVI) of the attention training app. Excellent scores (CVI ?0.78) in both the attention and mindfulness models were obtained for all exercises in the app, except 2 exercises. One of these exercises was subsequently modified to include expert feedback, and one was removed. Regarding ecological content validation, the results showed that workload, quality, user experience, satisfaction, and relevance of the app were adequate. The Mobile Application Rating Scale questionnaire showed an average quality rating between 3.75/5 (SD 0.41) (objective quality) and 3.65/5 (SD 0.36) (subjective quality), indicating acceptable quality. The?mean global?attractiveness rating from the AttrakDiff questionnaire was 2.36/3 (SD?0.57), which represents one of the strengths of the app.? Conclusions: Logical and ecological content validation showed that Focusing is theoretically valid, with a high level of agreement among experts and healthy participants. This tool can be tested to train attention processes after a neurological insult such as traumatic brain injury. ", doi="10.2196/64174", url="https://formative.jmir.org/2025/1/e64174", url="http://www.ncbi.nlm.nih.gov/pubmed/40202789" } @Article{info:doi/10.2196/69952, author="Holmqvist, Sophia and Kaplan, Marina and Chaturvedi, Riya and Shou, Haochang and Giovannetti, Tania", title="Longitudinal and Combined Smartwatch and Ecological Momentary Assessment in Racially Diverse Older Adults: Feasibility, Adherence, and Acceptability Study", journal="JMIR Hum Factors", year="2025", month="Apr", day="8", volume="12", pages="e69952", keywords="cognitive impairment", keywords="smartwatch", keywords="longitudinal monitoring", keywords="ecological momentary assessment", keywords="aging", abstract="Background: Due to the rising prevalence of Alzheimer disease and related dementias, easily deployable tools to quantify risk are needed. Smartphones and smartwatches enable unobtrusive and continuous monitoring, but there is limited information regarding the feasibility, adherence, and acceptability of digital data collection among racially diverse older adults. Objective: This paper examined the feasibility, adherence, and acceptability of a 4-week combined smartwatch monitoring and ecological momentary assessment (EMA) study in a racially diverse sample of older adults. Methods: A total of 44 older adults (aged ?55 y) with either mild cognitive impairment or healthy cognition completed an informed consent comprehension quiz, baseline cognitive testing, training regarding digital data collection, and questionnaires. Participants were instructed to wear a Garmin Vivosmart 4 smartwatch for 23 h/d for 4 weeks, sync 2 smartphone apps (Garmin and Labfront) daily, and complete a daily EMA survey with automated prompts for surveys and charging. Training time, smartwatch adherence (eg, wear time), daily EMA survey response rate, and performance on the consent quiz were quantified. Associations between feasibility and adherence metrics and participant factors were evaluated. Self-reported usability of the apps and smartwatch was collected at study end. Results: Consent comprehension quiz scores were high (mean 97.33\%, SD 6.86\% correct), and training sessions lasted on average 17.93 (SD 6.89) minutes. During the 4-week study, participants wore the smartwatch for an average of 21 h/d (SD 1.53) and showed an average response rate of 94\% (SD 9.58\%) to daily EMA surveys. In unadjusted bivariate analyses, age, race, and cognition were associated with feasibility and adherence measures, but only age and race remained significant in multivariate models. After accounting for all participant factors, older age was a significant predictor of longer training time, and Black race was a significant predictor of lower daily wear time. On the usability survey, all participants (45/45, 100\%) indicated willingness to participate in future smartwatch studies, >80\% (37/45) had a positive experience, and >90\% (41/45) were satisfied with smartphone app syncing. Conclusions: Smartwatch monitoring, requiring daily wear, smartphone syncing, and daily EMA survey completion, is highly feasible in older adults because adherence to daily wear and EMA surveys was high, as was general satisfaction on usability surveys. Although older participants may require more training on smartwatch and smartphone procedures and automated prompting during the study period, longitudinal monitoring with the Garmin Vivosmart 4 smartwatch and Labfront app is acceptable and feasible for collecting nearly continuous data in Black and White older adults, including those with mild cognitive impairment and those without. ", doi="10.2196/69952", url="https://humanfactors.jmir.org/2025/1/e69952" } @Article{info:doi/10.2196/59405, author="Par{\'e}s-Salom{\'o}n, Iris and Vaqu{\'e}-Crusellas, Cristina and Coffey, Alan and Loef, Bette and Proper, I. Karin and Se{\~n}{\'e}-Mir, M. Anna and Puig-Ribera, Anna and Dowd, P. Kieran and Bort-Roig, Judit", title="Development of Digital Strategies for Reducing Sedentary Behavior in a Hybrid Office Environment: Modified Delphi Study", journal="JMIR Hum Factors", year="2025", month="Apr", day="8", volume="12", pages="e59405", keywords="sedentary behavior", keywords="office work", keywords="home office", keywords="hybrid work", keywords="technology", keywords="Delphi", abstract="Background: Hybrid work is the new modus operandi for many office workers, leading to more sedentary behavior than office-only working. Given the potential of digital interventions to reduce sedentary behavior and the current lack of studies evaluating these interventions for home office settings, it is crucial to develop digital interventions for such contexts involving all stakeholders. Objective: This study aimed to reach expert consensus on the most feasible work strategies and the most usable digital elements as a delivery method to reduce sedentary behavior in the home office context. Methods: A modified Delphi study including 3 survey rounds and focus groups was conducted to achieve consensus. The first Delphi round consisted of two 9-point Likert scales for assessing the feasibility of work strategies and the potential usefulness of digital elements to deliver the strategies. The work strategies were identified and selected from a scoping review, a systematic review, and 2 qualitative studies involving managers and employees. The median and mean absolute deviation from the median for each item are reported. The second round involved 2 ranking lists with the highly feasible strategies and highly useful digital elements based on round 1 responses to order the list according to experts' preferences. The weighted average ranking for each item was calculated to determine the most highly ranked work strategies and digital elements. The third round encompassed work strategies with a weight above the median from round 2 to be matched with the most useful digital elements to implement each strategy. In total, 4 focus groups were additionally conducted to gain a greater understanding of the findings from the Delphi phase. Focus groups were analyzed using the principles of reflexive thematic analysis. Results: A total of 27 international experts in the field of occupational health participated in the first round, with response rates of 86\% (25/29) and 66\% (19/29) in rounds 2 and 3, respectively, and 52\% (15/29) in the focus groups. Consensus was achieved on 18 work strategies and 16 digital elements. Feedback on activity progress and goal achievement; creating an action plan; and standing while reading, answering phone calls, or conducting videoconferences were the most feasible work strategies, whereas wrist-based activity trackers, a combination of media, and app interfaces in smartphones were the most useful digital elements. Moreover, experts highlighted the requirement of combining multiple levels of strategies, such as social support, physical environment, and individual strategies, to enhance their implementation and effectiveness in reducing sedentary behavior when working from home. Conclusions: This expert consensus provided a foundation for developing digital interventions for sedentary behavior in home office workers. Ongoing interventions should enable the evaluation of feasible strategies delivered via useful digital elements in home office or hybrid contexts. ", doi="10.2196/59405", url="https://humanfactors.jmir.org/2025/1/e59405", url="http://www.ncbi.nlm.nih.gov/pubmed/40198908" } @Article{info:doi/10.2196/60531, author="Ho, Minh Nhat and Johnson, Catherine and Chidester, Autumn and Viera Corral, Ruby and Ramos, Jacundo and Garcia, Miguel and Gonuguntla, Rishi and Cote, Cyrena and Chandramohan, Divya and Lin, Hueylie and Taranova, Anna and Nijhawan, E. Ank and Kools, Susan and Ingersoll, Karen and Dillingham, Rebecca and Taylor, S. Barbara", title="Centering Youth Voice in the Adaptation of an mHealth Intervention for Young Adults With HIV in South Texas, United States: Human-Centered Design Approach", journal="JMIR Form Res", year="2025", month="Apr", day="8", volume="9", pages="e60531", keywords="HIV", keywords="implementation science", keywords="youth", keywords="mHealth", keywords="adherence", keywords="young", keywords="mobile health", keywords="mobile health intervention", keywords="AIDS", keywords="US", keywords="adult", keywords="self-efficacy", keywords="willingness", keywords="health outcomes", keywords="mHealth intervention", keywords="interview", keywords="human-centered design", keywords="acceptability", keywords="usability", keywords="mobile phone", abstract="Background: Young adults living with HIV are less likely to engage in care and achieve viral suppression, compared to other age groups. Young adults living with HIV also have a high degree of self-efficacy and willingness to adopt novel care modalities, including mobile health (mHealth) interventions. Interventions to increase care engagement could aid young adults living with HIV in overcoming structural and social barriers and leveraging youth assets to improve their health outcomes. Objective: The objective of the paper was to use an assets-based framework, positive youth development, and human-centered design principles to adapt an existing mHealth intervention, PositiveLinks (PL), to support care engagement for 18? to 29-year-olds with HIV. Methods: We conducted a formative evaluation including semistructured interviews with 14 young adults with HIV and focus groups with 26 stakeholders (providers, nurses, case managers, and clinic staff). Interviews covered barriers to care, provider communication, and concerns or suggestions about mHealth interventions. The research team used thematic analysis to review interview transcripts. In the second phase, human-centered design processes informed adaptation of the existing PL platform using data from real-time use suggestions of 3 young adults with HIV. Throughout the formative evaluation and adaptation, a Youth Advisory Board (YAB) provided input. Results: Young adults with HIV and stakeholders identified common elements of an mHealth intervention that would support care engagement including: the convenience of addressing needs through the app, online support groups to support interconnection, short videos or live chats with other young adults with HIV or providers, appointment and medication reminders, and medical information from a trustworthy source. Stakeholders also mentioned the need for youth empowerment. Concerns included worries about confidentiality, unintentional disclosures of status, urgent content in an unmoderated forum, and the impersonality of online platforms. Design suggestions from young adults with HIV included suggestions on appearance, new formatting for usability of the online support group, and prioritization of local content. Based on the feedback received, iterative changes were made to transform PL into Positive Links for Youth (PL4Y). Final votes on adaptations were made by the YAB. The overall appearance of the platform was changed, including logo, color, and font. The online support group was divided into 3 channels which support hashtags and content searches. The ``Resources'' and ``Frequently Asked Questions'' sections were condensed and revised to prioritize South Texas--specific content. Conclusions: Our assets-based framework supported young adults with HIV and stakeholder input in the transformation of an mHealth intervention to meet the needs of 18- to 29-year-olds in South Texas. The human-centered design approach allowed young adults with HIV to suggest specific changes to the intervention's design to support usability and acceptability. This adapted version, PL4Y, is now ready for pilot testing in the final phase of this implementation science project. ", doi="10.2196/60531", url="https://formative.jmir.org/2025/1/e60531" } @Article{info:doi/10.2196/72469, author="McAlister, Kelsey and Baez, Lara and Huberty, Jennifer and Kerppola, Marianna", title="Chatbot to Support the Mental Health Needs of Pregnant and Postpartum Women (Moment for Parents): Design and Pilot Study", journal="JMIR Form Res", year="2025", month="Apr", day="8", volume="9", pages="e72469", keywords="perinatal support", keywords="human-centered design", keywords="digital health", keywords="maternal health", keywords="chatbot", keywords="digital tool", abstract="Background: Maternal mental health disorders are prevalent, yet many individuals do not receive adequate support due to stigma, financial constraints, and limited access to care. Digital interventions, particularly chatbots, have the potential to provide scalable, low-cost support, but few are tailored specifically to the needs of perinatal individuals. Objective: This study aimed to (1) design and develop Moment for Parents, a tailored chatbot for perinatal mental health education and support, and (2) assess usability through engagement, usage patterns, and user experience. Methods: This study used a human-centered design to develop Moment for Parents, a rules-based chatbot to support pregnant and postpartum individuals. In phase 1, ethnographic interviews (n=43) explored user needs to inform chatbot development. In phase 2, a total of 108 pregnant and postpartum individuals were recruited to participate in a pilot test and had unrestricted access to the chatbot. Engagement was tracked over 8 months to assess usage patterns and re-engagement rates. After 1 month, participants completed a usability, relevance, and satisfaction survey, providing key insights for refining the chatbot. Results: Key themes that came from the ethnographic interviews in phase 1 included the need for trusted resources, emotional support, and better mental health guidance. These insights informed chatbot content, including mood-based exercises and coping strategies. Re-engagement was high (69/108, 63.9\%), meaning users who had stopped interacting for at least 1 week returned to the chatbot at least once. A large proportion (28/69, 40.6\%) re-engaged 3 or more times. Overall, 28/30 (93.3\%) found the chatbot relevant for them, though some noted repetitive content and limited response options. Conclusions: The Moment for Parents chatbot successfully engaged pregnant and postpartum individuals with higher-than-typical retention and re-engagement patterns. The findings underscore the importance of flexible, mood-based digital support tailored to perinatal needs. Future research should examine how intermittent chatbot use influences mental health outcomes and refine content delivery to enhance long-term engagement and effectiveness. ", doi="10.2196/72469", url="https://formative.jmir.org/2025/1/e72469" } @Article{info:doi/10.2196/60484, author="Maddah, Noha and Verma, Arpana and Ainsworth, John", title="Opportunities and Challenges Surrounding the Use of Wearable Sensor Bracelets for Infectious Disease Detection During Hajj: Qualitative Interview Study", journal="JMIR Form Res", year="2025", month="Apr", day="8", volume="9", pages="e60484", keywords="wearable sensor", keywords="unified theory of acceptance and use of technology", keywords="task-technology fit", keywords="hajj", keywords="presymptomatic detection", keywords="infectious diseases", keywords="artificial intelligence", abstract="Background: Wearable sensor bracelets have gained interest for their ability to detect symptomatic and presymptomatic infections through alterations in physiological indicators. Nevertheless, the use of these devices for public health surveillance among attendees of large-scale events such as hajj, the Islamic religious mass gathering held in Saudi Arabia, is currently in a nascent phase. Objective: This study aimed to explore hajj stakeholders' perspectives on the use of wearable sensor bracelets for disease detection. Methods: We conducted a qualitative, theoretically informed, interview-based study from March 2022 to October 2023 involving a diverse sample of hajj stakeholders, including technology experts, health care providers, and hajj service providers. The study was guided by the task-technology fit model and the unified theory of acceptance and use of technology to provide a comprehensive understanding of the factors influencing the acceptance and use of the technology. Semistructured in-depth interviews were used to capture perspectives on using wearable sensor bracelets for infectious disease detection during hajj. Thematic analysis of interview transcripts was conducted. Results: A total of 14 individuals were interviewed. In total, 4 main themes and 13 subthemes emerged from the study, highlighting crucial challenges, considerations, recommendations, and opportunities in the use of wearable sensor bracelets for the presymptomatic detection of infectious diseases during hajj. Implementing wearable sensor bracelets for disease detection during hajj faces obstacles from multiple perspectives, encompassing users, implementing stakeholders, and technological factors. Hajj stakeholders were concerned about the substantial financial and operational barriers. The motivation of implementing stakeholders and users is essential for the acceptance and uptake of devices during hajj. Successful integration of wearables into the hajj surveillance system depends on several factors, including infrastructure, device features, suitable use cases, training, and a smooth organizational integration process. Conclusions: This study provides valuable insights into the potential opportunities and challenges of adopting wearable sensor bracelets for disease detection during hajj. It offers essential factors to consider and important suggestions to enhance comprehension and ensure the effective implementation of this technology. ", doi="10.2196/60484", url="https://formative.jmir.org/2025/1/e60484" } @Article{info:doi/10.2196/66966, author="S{\o}rensen, Marie Nikita and Skaarnes, Helene and Mathiasen, Kim and Thastum, Mikael and Lomholt, Jeppesen Johanne", title="Developing an Internet-Based Cognitive Behavioral Therapy Intervention for Adolescents With Anxiety Disorders: Design, Usability, and Initial Evaluation of the CoolMinds Intervention", journal="JMIR Form Res", year="2025", month="Apr", day="8", volume="9", pages="e66966", keywords="user-centered design", keywords="digital treatment", keywords="digital mental health", keywords="internet-based", keywords="cognitive behavioral therapy", keywords="anxiety", keywords="adolescents", abstract="Background: Digital mental health interventions may help increase access to psychological treatment for adolescents with anxiety disorders. However, many clinical evaluations of digital treatments report low adherence and engagement and high dropout rates, which remain challenges when the interventions are implemented in routine care. Involving intended end users in the development process through user-centered design methods may help maximize user engagement and establish the validity of interventions for implementation. Objective: This study aimed to describe the methods used to develop a new internet-based cognitive behavioral therapy intervention, CoolMinds, within a user-centered design framework. Methods: The development of intervention content progressed in three iterative design phases: (1) identifying needs and design specifications, (2) designing and testing prototypes, and (3) running feasibility tests with end users. In phase 1, a total of 24 adolescents participated in a user involvement workshop exploring their preferences on graphic identity and communication styles as well as their help-seeking behavior. In phase 2, a total of 4 adolescents attended individual usability tests in which they were presented with a prototype of a psychoeducational session and asked to think aloud about their actions on the platform. In phase 3, a total of 7 families from the feasibility trial participated in a semistructured interview about their satisfaction with and initial impressions of the platform and intervention content while in treatment. Activities in all 3 phases were audio recorded, transcribed, and coded using thematic analysis and qualitative description design. The intervention was continuously revised after each phase based on the feedback. Results: In phase 1, adolescent feedback guided the look and feel of the intervention content (ie, color scheme, animation style, and communication style). Participants generally liked content that was relatable and age appropriate and felt motivating. Animations that resembled ``humans'' received more votes as adolescents could better ``identify'' themselves with them. Communication should preferably be ``supportive'' and feel ``like a friend'' talking to them. Statements including praise---such as ``You're well on your way. How are you today?''---received the most votes (12 votes), whereas directive statements such as ``Tell us how your day has been?'' and ``How is practicing your steps going?'' received the least votes (2 and 0 votes, respectively). In phase 2, adolescents perceived the platform as intuitive and easy to navigate and the session content as easy to understand but lengthy. In phase 3, families were generally satisfied with the intervention content, emphasizing the helpfulness of graphic material to understand therapeutic content. Their feedback helped identify areas for further improvement, such as editing down the material and including more in-session breaks. Conclusions: Using user involvement practices in the development of interventions helps ensure continued alignment of the intervention with end-user needs and may help establish the validity of the intervention for implementation in routine care practice. ", doi="10.2196/66966", url="https://formative.jmir.org/2025/1/e66966" } @Article{info:doi/10.2196/65788, author="W{\"u}llner, Sarah and Hermenau, Katharin and Hecker, Tobias and Siniatchkin, Michael", title="The Use of Mobile Apps in Adolescent Psychotherapy: Assessment of Psychotherapists' Perspectives", journal="JMIR Form Res", year="2025", month="Apr", day="8", volume="9", pages="e65788", keywords="mental health app", keywords="psychotherapy", keywords="adolescent", keywords="mHealth", keywords="youth", keywords="feasibility", keywords="implementation", keywords="app features", keywords="barriers", keywords="drivers", abstract="Background: Therapy-accompanying mental health apps can play an important role in the psychotherapeutic treatment of adolescents. They can enhance adolescents' engagement and autonomy, provide immediate support in critical situations, and positively influence the therapeutic working alliance. Nevertheless, mental health apps are rarely used by psychotherapists. Furthermore, due to the limited or nonexistent use of apps in psychotherapy, little is known about the actual barriers and drivers affecting their integration into psychotherapists' daily routines. To better understand how mental health apps should be designed for practical use, it is essential to explore psychotherapists' perspectives on key app features and characteristics, as well as the factors influencing their integration into clinical practice. Objective: This study aims to analyze which app features and characteristics are essential for psychotherapists to use a mobile app in psychotherapy with adolescents and to identify the key drivers and barriers influencing the integration of a psychotherapeutic app from the psychotherapists' perspectives. Methods: We conducted 3 feasibility studies using Steps, a transdiagnostic, therapy-accompanying app for adolescents, across 3 different psychotherapeutic treatment contexts: inpatient treatment, treatment in psychiatric outpatient clinics, and outpatient treatment with psychotherapists in private practice. All studies followed a qualitative quasi-experimental design. Participants provided information on their age, occupation, years of work experience, media affinity, attitudes toward psychotherapeutic apps, perceived app quality and feasibility, and the implementation process of the therapy-accompanying app. Qualitative data were analyzed using deductive qualitative content analysis. A total of 40 mental health professionals participated across the 3 studies (study 1: n=18; study 2: n=13; study 3: n=9). Results: Study participation and app usage rates were low across all studies. Six core features for a transdiagnostic, therapy-accompanying app were identified: mood checks, library, reminders, goals and tasks, emergency kit, and questionnaires. Additionally, the integration of mental health apps into daily routines was influenced by various drivers and barriers. The most significant barriers included technological issues and practical constraints, such as limited time and resources. The most important driver was the perceived improvement in treatment quality. Conclusions: Overall, psychotherapists were generally open to using a therapy-accompanying mental health app. However, study participation and app usage remained low. As psychotherapists act as gatekeepers for patients' use of mental health apps, their needs should be prioritized in the development and implementation of such apps. Trial Registration: German Clinical Trials Register DRKS00031258; https://drks.de/search/en/trial/DRKS00031258/details ", doi="10.2196/65788", url="https://formative.jmir.org/2025/1/e65788" } @Article{info:doi/10.2196/68179, author="Rades, Dirk and K{\"u}ter, Jan-Dirk and von Staden, Michael and Al-Salool, Ahmed and Janssen, Stefan and Timke, Carmen and Duma, Nona Marciana and Bartscht, Tobias and Vesterg{\aa}rd Madsen, Christine and Kristiansen, Charlotte and Cremers, Florian", title="A Reminder App to Optimize Bladder Filling During Radiotherapy for Patients With Prostate Cancer (REFILL-PAC): Protocol for a Prospective Trial", journal="JMIR Res Protoc", year="2025", month="Apr", day="8", volume="14", pages="e68179", keywords="prostate cancer", keywords="external beam radiation therapy", keywords="radiation toxicity", keywords="bladder filling", keywords="mobile app", abstract="Background: Many patients with nonmetastatic prostate cancer receive radiotherapy, which may be associated with acute cystitis, particularly if the volume of the urinary bladder is small. Three studies showed bladder volumes <200 ml or <180 ml to be associated with increased urinary toxicity. Therefore, it is important to maintain bladder volumes greater than 200 ml during as many radiation fractions as possible. Several studies investigated drinking protocols, where patients were asked to drink a certain amount of water prior to radiotherapy sessions. This may require considerable discipline from the patients, who are predominantly older adults. Adherence to a drinking protocol may be facilitated by a mobile app that reminds patients to drink water prior to each radiation session. This study investigates the effect of such an app on bladder filling status in patients with prostate cancer undergoing external beam radiotherapy (EBRT) alone. Objective: The primary goal of this study is to evaluate the impact of an app that reminds patients irradiated for prostate cancer to drink 300 ml of water prior to each radiotherapy session on the number of fractions with bladder volumes <200 ml during the radiotherapy course. Methods: This ongoing phase 2 aims to recruit 28 patients treated with EBRT alone for nonmetastatic prostate cancer. Radiotherapy will be administered using normo-fractionation, with doses ranging from 70 to 80 Gy in 35 to 40 fractions of 2 Gy, preferably with volumetric-modulated arc therapy (VMAT). Treatment volumes include the prostate with or without the seminal vesicles. Results: Recruitment for this trial will start in March 2025 and is planned to be completed in October 2026. The study is scheduled to conclude in December 2026. Conclusions: This trial is the first to evaluate the impact of a reminder app on the number of radiotherapy fractions with bladder volumes <200 ml in patients undergoing irradiation for localized prostate cancer. Trial Registration: Clinicaltrials.gov NCT06653751; https://clinicaltrials.gov/show/NCT06653751 International Registered Report Identifier (IRRID): PRR1-10.2196/68179 ", doi="10.2196/68179", url="https://www.researchprotocols.org/2025/1/e68179" } @Article{info:doi/10.2196/59942, author="Biernetzky, A. Olga and Thyrian, Ren{\'e} Jochen and Boekholt, Melanie and Berndt, Matthias and Hoffmann, Wolfgang and Teipel, J. Stefan and Kilimann, Ingo", title="Identifying Unmet Needs of Informal Dementia Caregivers in Clinical Practice: User-Centered Development of a Digital Assessment Tool", journal="JMIR Aging", year="2025", month="Apr", day="7", volume="8", pages="e59942", keywords="unmet needs", keywords="assessment development", keywords="family caregivers of people with dementia", keywords="dementia", keywords="need", keywords="Alzheimer", keywords="self-guided", keywords="self-reported", keywords="caregiver", keywords="informal care", keywords="spousal care", keywords="interview", keywords="qualitative", keywords="thematic", keywords="usability", keywords="mHealth", keywords="tablet", keywords="self-completed", keywords="aging", keywords="patient care", keywords="health interventions", keywords="care giver", keywords="digital health", keywords="ehealth", keywords="digital assessment", keywords="memory", abstract="Background: Despite the increasing interventions to support family caregivers of people with dementia, service planning and delivery is still not effective. Objective: Our study aimed to develop a digitally-supported needs assessment tool for family caregivers of people with dementia that is feasible, time-efficient, understood by users, and can be self-completed in the primary care setting. Methods: The development of the unmet needs assessment tool was part of a cluster-randomized controlled trial examining the effectiveness of a digitally supported care management programme to reduce unmet needs of family caregivers of people with dementia (GAIN [Gesund Angeh{\"o}rige Pflegen]) and was conducted in 3 phases. Using an iterative participatory approach with informal caregivers, health care professionals including general practitioners, neurologists, psychologists, psychiatrists, nurses, and Alzheimer Society representatives, we developed a digital self-completion unmet needs assessment tool focusing on informal caregivers' biopsychosocial health und quality of life in connection to their caregiver responsibilities. Data were collected through group discussions, written feedback, protocols, think-aloud protocols, and interviews, and analyzed thematically. Results: Data from 27 caregivers, including caregivers of people with dementia (n=18), health care professionals (n=7), and Alzheimer Society representatives (n=2) were collected. Thematic analysis identified 2 main themes: content of the assessment tool and usability and handling of the digital tablet-based assessment tool. The feedback provided by the stakeholders led to new aspects and changes to make the tool comprehensive, easy to read, and easy to handle. The overall mean completion time was reduced from the initial 37 minutes to 18 minutes, which renders the assessment tool fit to be self-completed in waiting rooms of primary care practices or other settings. Conclusions: The input of the 3 stakeholder groups has supported the development of the assessment tool ensuring that all aspects considered important were covered and understood and the completion of the assessment procedure was time-efficient and practically feasible. Further validation of the assessment tool will be performed with the data generated as part of the GAIN trial. Trial Registration: ClinicalTrials.gov NCT04037501; https://clinicaltrials.gov/study/NCT04037501 ", doi="10.2196/59942", url="https://aging.jmir.org/2025/1/e59942" } @Article{info:doi/10.2196/67294, author="Jones, D. Caleb and Wasilko, Rachel and Zhang, Gehui and Stone, L. Katie and Gujral, Swathi and Rodakowski, Juleen and Smagula, F. Stephen", title="Detecting Sleep/Wake Rhythm Disruption Related to Cognition in Older Adults With and Without Mild Cognitive Impairment Using the myRhythmWatch Platform: Feasibility and Correlation Study", journal="JMIR Aging", year="2025", month="Apr", day="7", volume="8", pages="e67294", keywords="sleep", keywords="sleep/wake", keywords="circadian", keywords="activity pattern", keywords="dementia", keywords="cognition", keywords="mobile sensing", keywords="actigraphy", keywords="accelerometer", abstract="Background: Consumer wearable devices could, in theory, provide sufficient accelerometer data for measuring the 24-hour sleep/wake risk factors for dementia that have been identified in prior research. To our knowledge, no prior study in older adults has demonstrated the feasibility and acceptability of accessing sufficient consumer wearable accelerometer data to compute 24-hour sleep/wake rhythm measures. Objective: We aimed to establish the feasibility of characterizing 24-hour sleep/wake rhythm measures using accelerometer data gathered from the Apple Watch in older adults with and without mild cognitive impairment (MCI), and to examine correlations of these sleep/wake rhythm measures with neuropsychological test performance. Methods: Of the 40 adults enrolled (mean [SD] age 67.2 [8.4] years; 72.5\% female), 19 had MCI and 21 had no cognitive disorder (NCD). Participants were provided devices, oriented to the study software (myRhythmWatch or myRW), and asked to use the system for a week. The primary feasibility outcome was whether participants collected enough data to assess 24-hour sleep/wake rhythm measures (ie, ?3 valid continuous days). We extracted standard nonparametric and extended-cosine based sleep/wake rhythm metrics. Neuropsychological tests gauged immediate and delayed memory (Hopkins Verbal Learning Test) as well as processing speed and set-shifting (Oral Trails Parts A and B). Results: All participants meet the primary feasibility outcome of providing sufficient data (?3 valid days) for sleep/wake rhythm measures. The mean (SD) recording length was somewhat shorter in the MCI group at 6.6 (1.2) days compared with the NCD group at 7.2 (0.6) days. Later activity onset times were associated with worse delayed memory performance ($\beta$=?.28). More fragmented rhythms were associated with worse processing speed ($\beta$=.40). Conclusions: Using the Apple Watch-based myRW system to gather raw accelerometer data is feasible in older adults with and without MCI. Sleep/wake rhythms variables generated from this system correlated with cognitive function, suggesting future studies can use this approach to evaluate novel, scalable, risk factor characterization and targeted therapy approaches. ", doi="10.2196/67294", url="https://aging.jmir.org/2025/1/e67294" } @Article{info:doi/10.2196/62741, author="Mbeya-Munkhondya, E. Tiwonge and Meek, J. Caroline and Mphande, Mtisunge and Tembo, A. Tapiwa and Chitani, J. Mike and Jean-Baptiste, Milenka and Kumbuyo, Caroline and Vansia, Dhrutika and Simon, R. Katherine and Rutstein, E. Sarah and Mwapasa, Victor and Go, Vivian and Kim, H. Maria and Rosenberg, E. Nora", title="Anticipated Acceptability of Blended Learning Among Lay Health Care Workers in Malawi: Qualitative Analysis Guided by the Technology Acceptance Model", journal="JMIR Form Res", year="2025", month="Apr", day="7", volume="9", pages="e62741", keywords="blended learning", keywords="technology acceptance model", keywords="index case testing", keywords="acceptability", keywords="partner notification", keywords="contact tracing", abstract="Background: HIV index case testing (ICT) aims to identify people living with HIV and their contacts, engage them in HIV testing services, and link them to care. ICT implementation has faced challenges in Malawi due to limited counseling capacity among lay health care workers (HCWs). Enhancing capacity through centralized face-to-face training is logistically complex and expensive. A decentralized blended learning approach to HCW capacity-building, combining synchronous face-to-face and asynchronous digital modalities, may be an acceptable way to address this challenge. Objective: The objective of this analysis is to describe factors influencing HCW anticipated acceptability of blended learning using the Technology Acceptance Model (TAM). Methods: This formative qualitative study involved conducting 26 in-depth interviews with HCWs involved in the ICT program across 14 facilities in Machinga and Balaka, Malawi (November-December 2021). Results were analyzed thematically using TAM. Themes were grouped into factors affecting the 2 sets of TAM constructs: perceived usefulness and perceived ease of use. Results: A total of 2 factors influenced perceived usefulness. First, HCWs found the idea of self-guided digital learning appealing, as they believed it would allow for reinforcement, which would facilitate competence. They also articulated the need for opportunities to practice and receive feedback through face-to-face interactions in order to apply the digital components. In total, 5 factors influenced perceived ease of use. First, HCWs expressed a need for orientation to the digital technology given limited digital literacy. Second, they requested accessibility of devices provided by their employer, as many lacked personal devices. Third, they wished for adequate communication surrounding their training schedules, especially if they were going to be asynchronous. Fourth, they wished for support for logistical arrangements to avoid work interruptions. Finally, they wanted monetary compensation to motivate learning, a practice comparable with offsite trainings. Conclusions: A decentralized blended learning approach may be an acceptable method of enhancing ICT knowledge and skills among lay HCWs in Malawi, although a broad range of external factors need to be considered. Our next step is to integrate these findings into a blended learning package and examine perceived acceptability of the package in the context of a cluster randomized controlled trial. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2023-077706 ", doi="10.2196/62741", url="https://formative.jmir.org/2025/1/e62741" } @Article{info:doi/10.2196/70149, author="Ajayi, Toluwalase and Kueper, Jacqueline and Ariniello, Lauren and Ho, Diana and Delgado, Felipe and Beal, Matthew and Waalen, Jill and Baca Motes, Katie and Ramos, Edward", title="Digital Health Platform for Maternal Health: Design, Recruitment Strategies, and Lessons Learned From the PowerMom Observational Cohort Study", journal="JMIR Form Res", year="2025", month="Apr", day="7", volume="9", pages="e70149", keywords="maternal health research", keywords="digital health platforms", keywords="pregnancy monitoring", keywords="decentralized clinical trials", keywords="participant engagement", keywords="health disparities", abstract="Background: Maternal health research faces challenges in participant recruitment, retention, and data collection, particularly among underrepresented populations. Digital health platforms like PowerMom (Scripps Research) offer scalable solutions, enabling decentralized, real-world data collection. Using innovative recruitment and multimodal techniques, PowerMom engages diverse cohorts to gather longitudinal and episodic data during pregnancy and post partum. Objective: This study aimed to evaluate the design, implementation, and outcomes of the PowerMom research platform, with a focus on participant recruitment, engagement, and data collection across diverse populations. Secondary objectives included identifying challenges encountered during implementation and deriving lessons to inform future digital maternal health studies. Methods: Participants were recruited via digital advertisements, pregnancy apps, and the PowerMom Consortium of more than 15 local and national organizations. Data collection included self-reported surveys, wearable devices, and electronic health records. Anomaly detection measures were implemented to address fraudulent enrollment activity. Recruitment trends and descriptive statistics from survey data were analyzed to summarize participant characteristics, assess engagement metrics, and quantify missing data to identify gaps. Results: Overall, 5617 participants were enrolled from 2021 to 2024, with 69.8\% (n=3922) providing demographic data. Of these, 48.5\% (2723/5617) were younger than 35 years, 14\% (788/5617) identified as Hispanic or Latina, and 13.7\% (770/5617) identified as Black or African American. Geographic representation spanned all 50 US states, Puerto Rico, and Guam, with 58.3\% (3276/5617) residing in areas with moderate access to maternity care and 16.4\% (919/5617) in highly disadvantaged neighborhoods based on the Area Deprivation Index. Enrollment rates increased substantially over the study period, from 55 participants in late 2021 to 3310 in 2024, averaging 99.4 enrollments per week in 2024. Participants completed a total of 17,123 surveys, with 71.8\% (4033/5617) completing the Intake Survey and 12.4\% (697/5617) completing the Postpartum Survey. Wearable device data were shared by 1168 participants, providing more than 378,000 daily biometric measurements, including activity levels, sleep, and heart rate. Additionally, 96 participants connected their electronic health records, contributing 276 data points such as diagnoses, medications, and laboratory results. Among pregnancy-related characteristics, 28.1\% (1578/5617) enrolled during the first trimester, while 15.1\% (849/5617) reported information about the completion of their pregnancies during the study period. Among the 913 participants who shared delivery information, 56.1\% (n=512) had spontaneous vaginal deliveries and 17.9\% (n=163) underwent unplanned cesarean sections. Conclusions: The PowerMom platform demonstrates the feasibility of using digital tools to recruit and engage diverse populations in maternal health research. Its ability to integrate multimodal data sources showcases its potential to provide comprehensive maternal-fetal health insights. Challenges with data completeness and survey attrition underscore the need for sustained participant engagement strategies. These findings offer valuable lessons for scaling digital health platforms and addressing disparities in maternal health research. Trial Registration: ClinicalTrials.gov NCT03085875; https://clinicaltrials.gov/study/NCT03085875 ", doi="10.2196/70149", url="https://formative.jmir.org/2025/1/e70149" } @Article{info:doi/10.2196/70594, author="Balki, Eric", title="Are Dating App Algorithms Making Men Lonely and Does This Present a Public Health Concern?", journal="JMIR Form Res", year="2025", month="Apr", day="7", volume="9", pages="e70594", keywords="dating apps", keywords="mental health", keywords="men", keywords="algorithm", keywords="anxiety", keywords="depression", keywords="loneliness", doi="10.2196/70594", url="https://formative.jmir.org/2025/1/e70594" } @Article{info:doi/10.2196/64449, author="Gustafson Sr, H. David and Mares, Marie-Louise and Johnston, C. Darcie and Curtin, J. John and Pe-Romashko, Klaren and Landucci, Gina", title="Comparison of Smart Display Versus Laptop Platforms for an eHealth Intervention to Improve Functional Health for Older Adults With Multiple Chronic Conditions: Protocol for a Randomized Clinical Trial", journal="JMIR Res Protoc", year="2025", month="Apr", day="3", volume="14", pages="e64449", keywords="eHealth", keywords="aged", keywords="geriatrics", keywords="functional health", keywords="multiple chronic conditions", keywords="smart display", keywords="smart speaker", keywords="primary care", keywords="quality of life", abstract="Background: Maintaining functional health, or the ability to live independently, is a primary goal of individuals as they age, but most older adults develop chronic conditions that threaten this goal. Physical activity is a key aspect of self-care that can improve functional health, and digital interventions offering guidance on appropriate exercise can help. However, older adults with multiple morbidities may be unable to use a laptop or smartphone-based eHealth because poor vision, dexterity, mobility, or other physical challenges make typing or touch navigation difficult. A smart display platform---comprising a smart speaker plus a small visual screen---has the potential to remove these barriers because it is voice-activated. Objective: The study aims to compare usage patterns of an eHealth intervention for older adults when delivered via a voice-based smart display versus a typing-based laptop, and assess whether the smart display outperforms the laptop in improving functional health and its specific physical and mental aspects. Methods: A minimum of 356 adults aged 60 years and older with at least 5 chronic health conditions are to be recruited from primary care clinics and community organizations. Participants will be randomized 1:1 to 12 months of access to an evidence-based intervention, ElderTree, delivered on either a smart display or a touchscreen laptop, with a postintervention follow-up at 18 months. The primary outcome is differences between groups on a comprehensive measure of physical and mental functional health. Secondary outcomes are between-group differences in the subscales of functional health (eg, physical function and depression), as well as measures of health distress, loneliness, unscheduled health care, and falls. We will also examine mediators and moderators of the effects of ElderTree on both platforms. Participants will complete surveys at baseline, 6, 12, and 18 months, and ElderTree use data will be collected continuously during the intervention period in system logs. We will use linear mixed-effect models to evaluate outcomes over time, with treatment condition and time point as between-subjects factors. Separate analyses will be conducted for each outcome. Results: Recruitment began in July 2023 and was completed in May 2024, with 387 participants enrolled. The 12-month intervention period will end in May 2025; data collection will end in November 2025. Findings will be disseminated via peer-reviewed publications. Conclusions: Voice-activated digital health interventions have theoretical but untested advantages over typing-based technologies for older adults with physical limitations. As the population ages, and as multiple morbidities threaten the functional health of the majority of older adults, innovations in self-management are a matter of public health as well as individual quality of life. Trial Registration: ClinicalTrials.gov NCT05240534; https://clinicaltrials.gov/study/NCT05240534 International Registered Report Identifier (IRRID): DERR1-10.2196/64449 ", doi="10.2196/64449", url="https://www.researchprotocols.org/2025/1/e64449", url="http://www.ncbi.nlm.nih.gov/pubmed/40080672" } @Article{info:doi/10.2196/65412, author="Blomenkamp, Maja and Kiesel, Andrea and Baumeister, Harald and Lehr, Dirk and Unterrainer, Josef and Sander, B. Lasse and Spanhel, Kerstin", title="Assessing the Cultural Fit of a Digital Sleep Intervention for Refugees in Germany: Qualitative Study", journal="JMIR Form Res", year="2025", month="Apr", day="3", volume="9", pages="e65412", keywords="Ukraine", keywords="eHealth", keywords="sleep disturbances", keywords="low-threshold treatment", keywords="culturally sensitive treatment", keywords="refugee", keywords="digital sleep", keywords="Germany", keywords="digital intervention", keywords="interview", keywords="content analysis", keywords="qualitative study", keywords="mental burden", keywords="mental health care", keywords="electronic health", keywords="digital health", abstract="Background: Digital interventions have been suggested to facilitate access to mental health care for refugees, who experience structural, linguistic, and cultural barriers to mental health care. Sleep-e, a digital sleep intervention originally developed for German teachers, has been culturally adapted for refugees in Germany mainly coming from African and Middle East countries. With the increasing number of refugees from Ukraine and the associated diversity of cultural backgrounds among refugees in Germany, it is essential to assess whether existing digital interventions are culturally appropriate for this target group as well. Objective: The study aimed to investigate the perceived cultural appropriateness of Sleep-e in both its original and culturally adapted versions among refugees in Germany, hereby exploring and possibly contrasting the needs of refugees coming from Ukraine and other countries of origin. Methods: Overall, 13 refugees (6 from Ukraine, 23-66 years old; and 7 from other countries, 26-41 years old) participated in the study. Each participant went through parts of the original or culturally adapted version of the digital sleep intervention, with 5 participants going through both versions. A total of 17 semistructured interviews (11 for the adapted, 6 for the nonadapted intervention version) and 9 think-aloud sessions (6 for the adapted, 3 for the nonadapted intervention version) were conducted to assess cultural appropriateness, suggestions for adaptations, and perceived relevance. Data were transcribed, categorized, and analyzed using structured qualitative content analysis. Results: The findings showed key differences in the perceived appropriateness and identification between the 2 refugee groups and the 2 intervention versions. Ukrainian participants expressed positive (n=70) and negative (n=56) feedback on the adapted intervention version, which revealed identity conflicts, as the adapted intervention version was targeted at a refugee population with whom they could not fully identify (18 negative feedback quotes concerning the refugee example characters). Whereas they identified with the European context in the original version, they found the problems described less relevant to their experiences. In contrast, participating refugees from other countries found the culturally adapted version more comprehensible and culturally appropriate (55 positive and 5 negative feedback quotes). No significant usability issues were reported, but several participants highlighted the need for an individualization of the intervention content. Conclusions: Neither the original nor culturally adapted version of the digital sleep intervention fully met the needs of all refugee groups, highlighting the complexity of culturally adapting digital interventions for this population. Particularly, the identity conflict of participating Ukrainian refugees regarding the refugee context suggests that adaptation should go beyond regional considerations and consider the dynamics of social identity. These findings emphasize the relevance of including co-design processes with different refugee populations to ensure broad identification and, herewith, cultural appropriateness of digital interventions. Trial Registration: German Clinical Trials Register DRKS00036484; https://drks.de/search/de/trial/DRKS00036484 ", doi="10.2196/65412", url="https://formative.jmir.org/2025/1/e65412" } @Article{info:doi/10.2196/67997, author="Shourya, Shivesh and Liu, Jianfang and McInerney, Sophia and Casimir, Trinity and Kenniff, James and Kershaw, Trace and Batey, David and Schnall, Rebecca", title="A Remote Intervention Based on mHealth and Community Health Workers for Antiretroviral Therapy Adherence in People With HIV: Pilot Randomized Controlled Trial", journal="JMIR Form Res", year="2025", month="Apr", day="2", volume="9", pages="e67997", keywords="HIV", keywords="antiretroviral therapy adherence", keywords="ART", keywords="ART adherence", keywords="mobile health technology", keywords="mHealth technology", keywords="community health workers", keywords="CHWs", keywords="smart pill bottle", keywords="feasibility evaluation", keywords="mobile health technology acceptance model", abstract="Background: Despite the availability of antiretroviral therapy (ART), only 66\% of people with HIV in the United States achieve viral suppression, largely due to suboptimal ART adherence. Barriers such as limited access to care and forgetfulness impact adherence rates, which must be maintained at ?95\% to prevent viral load rebound. Combination interventions leveraging community health worker (CHW) support and mobile health (mHealth) technologies have the potential to overcome previously identified barriers and provide cost-effective support for improving adherence and viral suppression outcomes in people with HIV. Objective: This pilot study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of remote delivery of the Community Health Worker and mHealth to Improve Viral Suppression (CHAMPS) intervention, combining the WiseApp, CHW support, and the CleverCap smart pill bottle. A secondary aim was to gather participants' feedback on the usability of the app and pill bottle as well as to better understand their experiences with remote study procedures. Methods: This mixed methods pilot study involved 40 participants with HIV, who were randomly assigned to a control group (n=20, 50\%) or the CHAMPS intervention (n=20, 50\%) over 3 months. The intervention group participated in up to 12 sessions with CHWs and used the WiseApp, paired with a CleverCap smart pill bottle, to support ART adherence. Remote baseline and follow-up visits were conducted via Zoom and included surveys measuring adherence, self-efficacy, and usability (measured by Health Information Technology Usability Evaluation Scale [Health-ITUES] and Poststudy System Usability Questionnaire [PSSUQ]). Semistructured interviews explored participants' experiences with the intervention. Thematic analysis was used to identify key facilitators and barriers based on the Mobile Health Technology Acceptance Model. Results: Remote delivery of the CHAMPS intervention was feasible, with high usability ratings for both the WiseApp and CleverCap (overall scores on Health-ITUES: mean 4.35, SD 0.58 and PSSUQ: mean 2.04, SD 1.03). In the intervention group, there were nonsignificant improvements in self-reported adherence scores (P=.29) and in self-efficacy scores (P=.07). The adjusted odds ratio for achieving undetectable viral load in the intervention group compared to the control group was 3.01 (95\% CI --1.59 to 4.12), indicating a medium effect size in favor of the intervention. Overall study retention was 75\% (30/40), with higher retention in the control group. Participants valued the flexibility of remote study procedures, particularly Zoom-based study visits and mailed blood sample kits. Qualitative feedback highlighted the intervention's acceptability and ability to overcome logistical barriers. Conclusions: The remote CHAMPS pilot study demonstrated the feasibility and acceptability of combining mHealth tools with CHW support to promote medication adherence among people with HIV. While further optimization is needed to enhance its impact, this intervention shows potential for improving health outcomes in diverse underserved populations. Trial Registration: ClinicalTrials.gov NCT05938413; https://clinicaltrials.gov/study/NCT05938413 ", doi="10.2196/67997", url="https://formative.jmir.org/2025/1/e67997" } @Article{info:doi/10.2196/68242, author="Pereira, P. Ana and Janela, Dora and Areias, C. Anabela and Molinos, Maria and Tong, Xin and Bento, Virg{\'i}lio and Yanamadala, Vijay and Atherton, Jennesa and Dias Correia, Fernando and Costa, Fab{\'i}ola", title="Innovating Care for Postmenopausal Women Using a Digital Approach for Pelvic Floor Dysfunctions: Prospective Longitudinal Cohort Study", journal="JMIR Mhealth Uhealth", year="2025", month="Apr", day="2", volume="13", pages="e68242", keywords="women's health", keywords="pelvic floor muscle training", keywords="physical therapy", keywords="menopause", keywords="digital therapeutics", keywords="biofeedback", keywords="mobile phone", abstract="Background: The menopause transition is a significant life milestone that impacts quality of life and work performance. Among menopause-related conditions, pelvic floor dysfunctions (PFDs) affect ?40\%?50\% of postmenopausal women, including urinary or fecal incontinence, genito-pelvic pain, and pelvic organ prolapse. While pelvic floor muscle training (PFMT) is the primary treatment, access barriers leave many untreated, advocating for new care delivery models. Objective: This study aims to assess the outcomes of a digital pelvic program, combining PFMT and education, in postmenopausal women with PFDs. Methods: This prospective, longitudinal study evaluated engagement, safety, and clinical outcomes of a remote digital pelvic program among postmenopausal women (n=3051) with PFDs. Education and real-time biofeedback PFMT sessions were delivered through a mobile app. The intervention was asynchronously monitored and tailored by a physical therapist specializing in pelvic health. Clinical measures assessed pelvic floor symptoms and their impact on daily life (Pelvic Floor Impact Questionnaire--short form 7, Urinary Impact Questionnaire--short form 7, Colorectal-Anal Impact Questionnaire--short form 7, and Pelvic Organ Prolapse Impact Questionnaire--short form 7), mental health, and work productivity and activity impairment. Structural equation modeling and minimal clinically important change response rates were used for analysis. Results: The digital pelvic program had a high completion rate of 77.6\% (2367/3051), as well as a high engagement and satisfaction level (8.6 out of 10). The safety of the intervention was supported by the low number of adverse events reported (21/3051, 0.69\%). The overall impact of pelvic floor symptoms in participants' daily lives decreased significantly (?19.55 points, 95\% CI ?22.22 to ?16.88; P<.001; response rate of 59.5\%, 95\% CI 54.9\%-63.9\%), regardless of condition. Notably, nonwork-related activities and productivity impairment were reduced by around half at the intervention-end (?18.09, 95\% CI ?19.99 to ?16.20 and ?15.08, 95\% CI ?17.52 to ?12.64, respectively; P<.001). Mental health also improved, with 76.1\% (95\% CI 60.7\%-84.9\%; unadjusted: 97/149, 65.1\%) and 54.1\% (95\% CI 39\%-68.5\%; unadjusted: 70/155, 45.2\%) of participants with moderate to severe symptomatology achieving the minimal clinically important change for anxiety and depression, respectively. Recovery was generally not influenced by the higher baseline symptoms' burden in individuals with younger age, high BMI, social deprivation, and residence in urban areas, except for pelvic health symptoms where lower BMI levels (P=.02) and higher social deprivation (P=.04) were associated with a steeper recovery. Conclusions: This study demonstrates the feasibility, safety, and positive clinical outcomes of a fully remote digital pelvic program to significantly improve PFD symptoms, mental health, and work productivity in postmenopausal women while enhancing equitable access to personalized interventions that empower women to manage their condition and improve their quality of life. Trial Registration: ClinicalTrials.gov NCT05513417; https://clinicaltrials.gov/study/NCT05513417 ", doi="10.2196/68242", url="https://mhealth.jmir.org/2025/1/e68242" } @Article{info:doi/10.2196/69609, author="Adegboyega, Adebola and Wiggins, Amanda and Wuni, Abubakari and Ickes, Melinda", title="The Impact of a Human Papillomavirus Facebook-Based Intervention (\#HPVVaxTalks) Among Young Black (African American and Sub-Saharan African Immigrants) Adults: Pilot Pre- and Poststudy", journal="JMIR Form Res", year="2025", month="Apr", day="2", volume="9", pages="e69609", keywords="human papillomavirus vaccination", keywords="HPV vaccination", keywords="Facebook-based intervention", keywords="young Black adults", keywords="social media", abstract="Background: Despite the availability of prophylactic human papillomavirus (HPV) vaccines, uptake remains suboptimal among young Black adults. Social media is a platform for the dissemination of health information and can be used to promote HPV vaccination among young Black adults. Objective: This study aimed to assess the impact of a Facebook-based intervention (\#HPVVaxTalks), which consisted of 40 posts over 8 weeks in improving cognitive outcomes, reducing vaccine hesitancy, and increasing vaccine intention, and uptake among young Black adults aged 18-26 years. Methods: A pilot 1-group pre- and poststudy was conducted among 43 young Black adults who engaged in an 8-week Facebook intervention (\#HPVVaxTalks). \#HPVVaxTalks was developed in collaboration with a youth community advisory committee. Participants were actively recruited by research staff from community settings using flyers, and flyers were posted in public places in communities. Eligible participants were screened for eligibility and consented prior to study participation. Participants completed baseline surveys and were added to a Facebook page created for the study to receive intervention posts. Participants completed pre- and postdata on HPV knowledge, HPV vaccine knowledge, vaccine hesitancy, and vaccine uptake via REDCap (Research Electronic Data Capture) surveys distributed by email. Participants' satisfaction with the intervention was collected via individual interviews. Data were analyzed using 2-tailed paired t tests and repeated measures analysis Results: Overall, 32 of the 43 (74\%) participants completed the follow-up survey, and of the 23 participants who reported not having ever received the vaccine at baseline, 7 (30\%) reported receiving the vaccine at follow-up. Participants demonstrated significant improvements in HPV knowledge and receiving the vaccine at follow-up. Participants demonstrated significant improvements in HPV knowledge (pre: mean 7.3, SD 4.2 and post: mean 11.1, SD 4.3; P=.004) and HPV vaccine knowledge (pre: mean 2.8, SD 2.5 and post: mean 4.7, SD 2.2; P=.003) and reduction in vaccine hesitancy (pre: mean 28.3, SD 4.2 and post: mean 29.9, SD 3.6; P=.007) after the intervention. However, there were no significant changes in other outcomes. Feedback from open-ended questions and qualitative interviews highlighted participants' satisfaction with the intervention and its role in increasing HPV and HPV vaccine awareness. Conclusions: The findings from this study underscore the potential of social media platforms for health promotion among underrepresented populations and the importance of advocating for culturally appropriate interventions to improve HPV vaccination rates and reduce disparities. ", doi="10.2196/69609", url="https://formative.jmir.org/2025/1/e69609" } @Article{info:doi/10.2196/68249, author="Lattie, G. Emily and Beltzer, Miranda and Varra, Alethea and Chen, E. Connie and Lungu, Anita", title="Examining the Client Experience of Digital Tools in Blended Care Therapy: Qualitative Interview Study", journal="JMIR Form Res", year="2025", month="Apr", day="2", volume="9", pages="e68249", keywords="anxiety", keywords="depression", keywords="blended care therapy", keywords="mental health care", keywords="digital mental health", keywords="digital tools", keywords="qualitative interviews", keywords="Lyra Care Therapy", keywords="video lesson", keywords="symptom assessment", keywords="written exercise", keywords="thematic analysis", keywords="LCT model", keywords="therapeutic value", keywords="client experience", abstract="Background: Lyra Health's short-term blended care therapy model, Lyra Care Therapy (LCT), has demonstrated effectiveness at scale. In LCT, clients participate in synchronous telehealth sessions and asynchronous guided practice sessions, in which they are provided with digital tools to reinforce key concepts and skills. These digital tools include animated video lessons that use storytelling to show characters learning and implementing new skills from therapy, written psychoeducational materials, interactive exercises that prompt reflection and skills practice, symptom assessments, and messaging with therapists. Past research on LCT found that time spent in therapy sessions and viewing digital video lessons predicts improvements in depression and anxiety symptoms. Objective: This study aims to explore the client experience of LCT digital tools and to understand clients' perceived benefits and challenges of using digital tools while in LCT. Methods: In total, 12 ethnically and racially diverse adults (5 male, 6 female, and 1 pangender) who had graduated from LCT in the previous 4 months participated in semistructured interviews. Interviews focused on experiences with the digital components of LCT (ie, video lessons, symptom assessments, and written exercises). Transcripts were analyzed using thematic analytic methods to determine the benefits and challenges associated with components of the LCT model. Results: In total, 3 primary themes were generated through thematic analysis. These themes centered around supporting knowledge and skill development, the benefits and challenges associated with the range of digital tools, and the combination of flexibility and accountability promoting positive change. First, we summarize the ways in which guided practice sessions allow clients to develop additional knowledge and learn skills related to their mental health and well-being. Then, we describe how the range of digital tools included in LCT presents different benefits and challenges for clients. Finally, we discuss how flexibility inherent in having both synchronous and asynchronous sessions, along with the accountability from a provider, encourages clients to continue to practice skills related to their mental health and well-being. Conclusions: Results provide insights into the unique contributions of different components of the LCT model on therapeutic gains. While perceived time constraints and content preferences can impact engagement with digital tools, overall the digital tools were perceived as carrying significant value for participants in the LCT program. ", doi="10.2196/68249", url="https://formative.jmir.org/2025/1/e68249" } @Article{info:doi/10.2196/68149, author="Hong, Seojin and Choi, Hyun and Kweon, Hyosun", title="Medical Device Based on a Virtual Reality--Based Upper Limb Rehabilitation Software: Usability Evaluation Through Cognitive Walkthrough", journal="JMIR Form Res", year="2025", month="Apr", day="1", volume="9", pages="e68149", keywords="usability", keywords="cognitive walkthrough", keywords="virtual reality-based upper limb rehabilitation software", keywords="upper limb", keywords="limb rehabilitation", keywords="rehabilitation", keywords="therapist", keywords="virtual reality", keywords="VR", keywords="medical device", keywords="formative evaluation", keywords="quantitative", keywords="qualitative", keywords="occupational therapy", keywords="user safety", keywords="usability testing", keywords="software", keywords="risk factor", abstract="Background: The use of virtual reality (VR) technology in rehabilitation therapy has been growing, leading to the development of VR-based upper-limb rehabilitation softwares. To ensure the effective use of such software, usability evaluations are critical to enhance user satisfaction and identify potential usability issues. Objective: This study aims to evaluate the usability of a VR-based upper-limb rehabilitation software from the perspective of occupational therapists. Specifically, the study seeks to identify usability challenges and provide insights to improve user satisfaction. Methods: The VR-based upper-limb rehabilitation software was tailored for therapists to operate while delivering therapy to patients. Usability testing was conducted with occupational therapists from the Korean National Rehabilitation Center using cognitive walkthroughs and surveys. Participants performed tasks that simulated real clinical scenarios, including turning the device on, assisting patients with wearing the device, and shutting it down. Observers recorded user reactions during task performance, and participants completed surveys to assess the ease of use of the user interface. This mixed-methods approach provided qualitative insights into user difficulties and their root causes. Results: Usability evaluations were conducted with 6 participants. Cognitive walkthroughs revealed potential areas for improvement in the software, including (1) enhancements to the graphical user interface for ease of use, (2) refinements in the natural user interface, and (3) better user manuals for clearer product instructions. The ease-of-use score for the user interface averaged 1.58 on a 5-point scale (1=very easy to 5=very difficult). Conclusions: This study provides valuable insights into improving user satisfaction by focusing on the needs of occupational therapists who operate a VR-based rehabilitation software. Future research should explore software refinement and clinical efficacy to maximize the therapeutic potential of such technologies. ", doi="10.2196/68149", url="https://formative.jmir.org/2025/1/e68149" } @Article{info:doi/10.2196/65000, author="Shen, Yufei and Choto Olivier, Alicia and Yu, Han and Ito-Masui, Asami and Sakamoto, Ryota and Shimaoka, Motomu and Sano, Akane", title="Personalized Physician-Assisted Sleep Advice for Shift Workers: Algorithm Development and Validation Study", journal="JMIR Form Res", year="2025", month="Apr", day="1", volume="9", pages="e65000", keywords="cognitive behavioral therapy", keywords="CBT", keywords="health care workers", keywords="machine learning", keywords="medical safety", keywords="web-based intervention", keywords="app-based intervention", keywords="shift work", keywords="shift work sleep disorders", keywords="shift workers", keywords="sleep disorder", keywords="wearable sensors", keywords="well-being", abstract="Background: In the modern economy, shift work is prevalent in numerous occupations. However, it often disrupts workers' circadian rhythms and can result in shift work sleep disorder. Proper management of shift work sleep disorder involves comprehensive and patient-specific strategies, some of which are similar to cognitive behavioral therapy for insomnia. Objective: Our goal was to develop and evaluate machine learning algorithms that predict physicians' sleep advice using wearable and survey data. We developed a web- and app-based system to provide individualized sleep and behavior advice based on cognitive behavioral therapy for insomnia for shift workers. Methods: Data were collected for 5 weeks from shift workers (N=61) in the intensive care unit at 2 hospitals in Japan. The data comprised 3 modalities: Fitbit data, survey data, and sleep advice. After the first week of enrollment, physicians reviewed Fitbit and survey data to provide sleep advice and selected 1 to 5 messages from a list of 23 options. We handcrafted physiological and behavioral features from the raw data and identified clusters of participants with similar characteristics using hierarchical clustering. We explored 3 models (random forest, light gradient-boosting machine, and CatBoost) and 3 data-balancing approaches (no balancing, random oversampling, and synthetic minority oversampling technique) to predict selections for the 7 most frequent advice messages related to bedroom brightness, smartphone use, and nap and sleep duration. We tested our predictions under participant-dependent and participant-independent settings and analyzed the most important features for prediction using permutation importance and Shapley additive explanations. Results: We found that the clusters were distinguished by work shifts and behavioral patterns. For example, one cluster had days with low sleep duration and the lowest sleep quality when there was a day shift on the day before and a midnight shift on the current day. Our advice prediction models achieved a higher area under the precision-recall curve than the baseline in all settings. The performance differences were statistically significant (P<.001 for 13 tests and P=.003 for 1 test). Sensitivity ranged from 0.50 to 1.00, and specificity varied between 0.44 and 0.93 across all advice messages and dataset split settings. Feature importance analysis of our models found several important features that matched the corresponding advice messages sent. For instance, for message 7 (darken the bedroom when you go to bed), the models primarily examined the average brightness of the sleep environment to make predictions. Conclusions: Although our current system requires physician input, an accurate machine learning algorithm shows promise for automatic advice without compromising the trustworthiness of the selected recommendations. Despite its decent performance, the algorithm is currently limited to the 7 most popular messages. Further studies are needed to enable predictions for less frequent advice labels. ", doi="10.2196/65000", url="https://formative.jmir.org/2025/1/e65000" } @Article{info:doi/10.2196/63405, author="Spark, Jessica and Rowe, Elise and Alvarez-Jimenez, Mario and Bell, Imogen and Byrne, Linda and Dzafic, Ilvana and Ellinghaus, Carli and Lavoie, Suzie and Lum, Jarrad and McLean, Brooke and Thomas, Neil and Thompson, Andrew and Wadley, Greg and Whitford, Thomas and Wood, Stephen and Yuen, Pan Hok and Nelson, Barnaby", title="Integrating Virtual Reality, Neurofeedback, and Cognitive Behavioral Therapy for Auditory Verbal Hallucinations (Hybrid): Protocol of a Pilot, Unblinded, Single-Arm Interventional Study", journal="JMIR Res Protoc", year="2025", month="Apr", day="1", volume="14", pages="e63405", keywords="psychosis", keywords="first episode psychosis", keywords="schizophrenia", keywords="virtual reality", keywords="neurofeedback", keywords="EEG", keywords="auditory verbal hallucinations", keywords="voices", keywords="cognitive behavior therapy", keywords="youth mental health", keywords="pilot study", keywords="paracusias", keywords="paracusis", keywords="treatment", keywords="medication", keywords="psychotic disorder", keywords="efficacy", keywords="neuroscience", keywords="psychology", keywords="hybrid", keywords="adolescent", keywords="Australia", abstract="Background: Current treatments for schizophrenia and other psychotic disorders have limited efficacy, with high rates of nonresponse to ``gold standard'' treatments. New approaches are therefore urgently required. Objective: The aims of this pilot study are to investigate the feasibility, acceptability, safety, and usability of Hybrid treatment (primary aim); and to explore Hybrid's treatment efficacy and engagement of treatment targets (secondary aim). The primary aim will be assessed via face-to-face user experience surveys on a (self-assessed) 5-point Likert scale (and qualitative open-ended questions) examining: (1) acceptability, (2) helpfulness, (3) engagement, and (4) perceived safety. We will also examine consent and completion rates, and the number of sessions attended. Our threshold for moving on to efficacy trials will be at least 70\% of our participants to rate 3 and above (which corresponds to agree or strongly agree) that the intervention package was acceptable, feasible, and safe. The secondary aims will be assessed by observing whether individuals achieve self-directed modulation of high-$\beta$ neurophysiological activity (neural target) and progression upwards through the VR-based exposure hierarchy (psychological target), and by assessing symptom change scores. This study developed a new treatment approach for auditory verbal hallucinations, a major symptom of psychotic disorders, that integrates advances in psychological therapy (cognitive behavioral therapy for psychosis), technology (virtual reality, VR), and neuroscience (electroencephalography-based neurofeedback). Methods: Hybrid takes a ``symptom capture'' approach using individually tailored VR-based exposure exercises. Participants (N=10) will receive the intervention package weekly over 12 face-to-face sessions. Here, participants will be progressively exposed to symptom triggers and develop methods of downregulating neural activity associated with these symptoms (neurofeedback component) while concurrently receiving clinician-delivered cognitive behavioral therapy for psychosis. Results: As of February 2025, Hybrid has commenced (unblinded) recruitment activities from Orygen clinical services in Northwestern Melbourne, Australia. A total of 75 individuals have been approached and 64 individuals have been prescreened (41 individuals were deemed eligible, 15 individuals were ineligible, and 8 individuals declined or did not respond to contact attempts) and 5 individuals have been included in the study. Of the 5 individuals who have commenced the Hybrid treatment, 4 are actively engaged in the program and 1 individual has withdrawn. We expect recruitment to conclude in July 2025 and for the results to be published in 2026. Conclusions: The Hybrid study is piloting a novel approach that has the potential to address the shortcomings of current treatments for psychotic symptoms. If there is favorable evidence for the acceptability, feasibility, safety and usability of Hybrid, the study team will move on to efficacy trials. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12624000357550; https://tinyurl.com/24ey8hpy International Registered Report Identifier (IRRID): PRR1-10.2196/63405 ", doi="10.2196/63405", url="https://www.researchprotocols.org/2025/1/e63405" } @Article{info:doi/10.2196/63098, author="Liszio, Stefan and B{\"a}uerlein, Franziska and Hildebrand, Jens and van Nahl, Carolin and Masuch, Maic and Basu, Oliver", title="Cooperative Virtual Reality Gaming for Anxiety and Pain Reduction in Pediatric Patients and Their Caregivers During Painful Medical Procedures: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2025", month="Mar", day="31", volume="14", pages="e63098", keywords="virtual reality", keywords="extended reality", keywords="mixed reality", keywords="serious game", keywords="video game", keywords="pain", keywords="anxiety", keywords="stress", keywords="child", keywords="caregiver", keywords="patient experience", keywords="well-being", keywords="medical procedures", keywords="punctures", keywords="distraction", keywords="intervention", abstract="Background: The hospital experience is often marked by fear and pain, particularly for children undergoing medical procedures. Sedation is commonly used to alleviate patient anxiety, but it poses additional health risks. Caregivers, usually the parents, also experience emotional distress during the child's hospital stay, which can further exacerbate the child's anxiety and pain. While various interventions exist to ease patient distress, few consider the emotional well-being of caregivers. Objective: This study aims to explore the effectiveness of a cooperative virtual reality (VR) game as a novel nonpharmacological solution to reduce anxiety and pain for both pediatric patients and their caregivers during medical procedures. Specifically, we aim to investigate whether the VR game ``Sweet Dive VR'' (SDVR), designed for children aged between 6 and 12 years to play with 1 caregiver, can alleviate anxiety and pain during different types of needle punctures and Kirschner-wire removal. Methods: A prospective multicenter randomized clinical trial will be conducted. Eligible participants will be identified by scanning the hospital information system, and group allocation will follow stratified randomization. During the medical procedure, patients in the VR condition will play SDVR with a caregiver present, while patients in the control group will listen to a recording of gently crashing waves. Data collection will be carried out through self-reports of patients and caregivers using visual analog scales and questionnaires at 2 measurement time points: before and after the intervention. In addition, observation by the interviewers will occur during the intervention to capture emotional and pain reactions as well as interaction quality between patients and caregivers and smoothness of the procedure flow using a structured observation protocol. The measured variables will encompass patient affect and pain, caregiver affect, player experience, patient experience, and the flow of the procedure. Results: As of November 2024, we enrolled 39 patients and caregivers, 28 of whom completed the study. Data collection is still ongoing. Conclusions: Cooperative VR gaming, as exemplified by SDVR, emerges as a promising intervention to address anxiety and pain in pediatric patients while involving caregivers to support the emotional well-being of both parties. Our approach strives to foster positive shared experiences and to maintain trust between children and caregivers during emotionally challenging medical situations. Trial Registration: German Clinical Trial Register (DRKS) DRKS00033544; https://drks.de/search/en/trial/DRKS00033544 International Registered Report Identifier (IRRID): DERR1-10.2196/63098 ", doi="10.2196/63098", url="https://www.researchprotocols.org/2025/1/e63098" } @Article{info:doi/10.2196/62749, author="Iivanainen, Sanna and Arokoski, Reetta and Mentu, Santeri and Lang, Laura and Ekstr{\"o}m, Jussi and Virtanen, Henri and Kataja, Vesa and Koivunen, Pekka Jussi", title="Development of a Comprehensive Decision Support Tool for Chemotherapy-Cycle Prescribing: Initial Usability Study", journal="JMIR Form Res", year="2025", month="Mar", day="31", volume="9", pages="e62749", keywords="cancer", keywords="chemotherapy", keywords="ePRO", keywords="electronic patient-reported outcome", keywords="decision support system", abstract="Background: Chemotherapy cycle prescription is generally carried out through a multistep manual process that is prone to human error. Clinical decision support tools can provide patient-specific assessments that support clinical decisions, improve prescribing practices, and reduce medication errors. Objective: We hypothesized that a knowledge-based, patient-derived, evidence-directed decision support tool consisting of multiple modules focusing on the core duties preceding chemotherapy-cycle prescription could result in a more cost-effective and error-free approach and streamline the workflow. Methods: A 1-arm, multicenter, prospective clinical trial (``Follow-up of Cancer Patients Receiving Chemotherapy or Targeted Therapy by Electronic Patient Reported Outcomes-tool'' [ECHO] 7/2019-1/2021; NCT04081558) was initiated to investigate the tool. The most important inclusion criteria were the presence of colorectal cancer (CRC) treated with oxaliplatin-based chemotherapy, age ?18 years, Eastern Cooperative Oncology Group [ECOG] performance score of 0 to 2, and internet access. A decision support tool that included digital symptom monitoring, a laboratory value interface, and treatment schedule integration for semiautomated chemotherapy cycle prescribing was integrated into the care pathway. Performance was assessed by the percentage of chemotherapy cycles with sent and completed symptom questionnaires, while perceptions of health care professionals (HCPs) on the feasibility of the approach were collected through a 1-time semistructured interview. Results: The ECHO trial included 43 patients with CRC treated with doublet or triplet chemotherapy in an adjuvant or metastatic setting. Altogether, 843 electronic patient-reported outcome (ePRO) symptom questionnaires were completed. Of the 15 recorded symptoms, fatigue (n=446, 52.9\%) and peripheral neuropathy (n=429, 50.9\%) were reported most often, while 137 grade 3 to 4 symptoms were recorded, of which diarrhea (n=5, 4\%) and peripheral neuropathy (n=4, 3\%) were the most common. During the study, 339 chemotherapy cycles were prescribed, and for the 77\% (n=262) of new chemotherapy cycles, ePRO questionnaire data were available within preset limits (completed within 3 days prior to chemotherapy scheduling) while 65\% of the cycles (n=221) had symptom questionnaire grading at ?1\%, and 67\% of the cycles (n=228) had laboratory values in a preset range. The recommendations by the tool for a new chemotherapy cycle were tier 1 (green; meaning ``go'') in 145 (42.8\%) of the cycles, tier 2 (yellow; ``evaluate'') in 83 (25\%), and tier 3 (red; ``hold'') in 111 (32.7\%). HCPs (n=3) were interviewed with a questionnaire (comprising 8 questions), revealing that they most valued the improved workflow, faster patient evaluation, and direct messaging option. Conclusions: In this study, we investigated the feasibility of a decision support system for chemotherapy-cycle pre-evaluation and prescription that was developed for the prospective ECHO trial. The study showed that the functionalities of the investigated tool were feasible and that an automated approach to chemotherapy-cycle prescription was possible for nearly half of the cycles. Trial Registration: ClinicalTrials.gov NCT04081558; https://clinicaltrials.gov/study/NCT04081558 ", doi="10.2196/62749", url="https://formative.jmir.org/2025/1/e62749" } @Article{info:doi/10.2196/67545, author="Han, Areum and Oster, Robert and Yuen, Hon and Jenkins, Jeremy and Hawkins, Jessica and Edwards, Lauren", title="Videoconference-Delivered Acceptance and Commitment Therapy for Family Caregivers of People With Dementia: Pilot Randomized Controlled Trial", journal="JMIR Form Res", year="2025", month="Mar", day="31", volume="9", pages="e67545", keywords="acceptance and commitment therapy", keywords="Alzheimer disease", keywords="caregivers", keywords="dementia", keywords="depression", keywords="web-based intervention", keywords="quality of life", keywords="randomized controlled trial", keywords="stress", keywords="videoconferencing", abstract="Background: Family caregivers of individuals with dementia face significant mental health challenges. Acceptance and commitment therapy (ACT) has emerged as a promising intervention for improving these caregivers' mental health. While various delivery modes of ACT have been explored, there is a need for evidence on the efficacy of videoconference-delivered ACT programs for this population. Objective: This pilot randomized controlled trial, conducted in the United States, aims to assess the effects of a videoconference-delivered, therapist-guided ACT program on reducing depressive symptoms and improving other mental health outcomes among family caregivers with depression who give care to individuals with dementia, compared to a control group that received psychoeducation materials only. Methods: This 2-arm, parallel-group pilot randomized controlled trial randomly assigned 33 family caregivers to either a 10-week videoconference-delivered ACT program (n=16, 48\%) or a control group that received psychoeducation materials alone (n=17, 52\%). Depressive symptoms (primary outcome) were measured using the Patient Health Questionnaire-9. Secondary outcomes included anxiety, stress, psychological quality of life (QoL), caregiver burden, predeath grief, guilt, and ACT process measures. Outcomes were assessed in the pretest, posttest (10-12 weeks after pretest), and a 3-month follow-up (3 months after posttest, approximately 5-6 months after pretest). An intent-to-treat approach was used for all outcome analyses. Linear mixed-effects models for repeated measures were used to analyze outcomes. Results: The ACT group reported significantly greater improvements in stress (P=.043) and psychological QoL (P=.014) in the posttest compared to the control group. Within the ACT group, participants experienced a significant decrease in depressive symptoms, with a mean (SE) change of --6.09 (1.16) points (95\% CI --8.42 to --3.76; P<.001) in the posttest and --6.71 (1.45) points (95\% CI --9.63 to --3.81; P<.001) in the 3-month follow-up. These changes exceed the estimated minimal clinically important difference on the Patient Health Questionnaire-9. In addition, the ACT group reported significant improvements in anxiety, stress, psychological QoL, caregiver burden, predeath grief, guilt, values-driven action, and experiential avoidance at both posttest and 3-month follow-up. A sensitivity analysis, excluding 1 participant with near-outlier data, revealed statistically significant between-group differences in depressive symptoms at posttest (P=.037); stress at posttest (P<.001) and in 3-month follow-up (P=.001); psychological QoL at posttest (P<.001); caregiver burden at posttest (P=.003) and in 3-month follow-up (P=.003); predeath grief in 3-month follow-up (P=.031); and values-driven action at posttest (P=.032). Conclusions: The videoconference-delivered ACT program showed promise in improving mental health outcomes and ACT processes among family caregivers with depression who give care to individuals with dementia. Future studies should aim to replicate these findings with larger, more diverse caregiver populations and explore the long-term efficacy of videoconference-delivered ACT programs. Trial Registration: ClinicalTrials.gov NCT05043441; https://clinicaltrials.gov/study/NCT05043441 ", doi="10.2196/67545", url="https://formative.jmir.org/2025/1/e67545" } @Article{info:doi/10.2196/67047, author="Chauhan, Anshul and Goyal, Anju and Masih, Ritika and Kaur, Gagandeep and Kumar, Lakshay and Neha, ?. and Rastogi, Harsh and Kumar, Sonam and Singh, Lord Bidhi and Syal, Preeti and Gupta, Vishali and Vale, Luke and Duggal, Mona", title="Barriers and Determinants of Referral Adherence in AI-Enabled Diabetic Retinopathy Screening for Older Adults in Northern India During the COVID-19 Pandemic: Mixed Methods Pilot Study", journal="JMIR Form Res", year="2025", month="Mar", day="31", volume="9", pages="e67047", keywords="diabetic retinopathy", keywords="diabetes", keywords="gerontology", keywords="geriatric", keywords="old", keywords="aging", keywords="aged", keywords="artificial intelligence", keywords="retinopathy", keywords="retinal", keywords="referral", keywords="screening", keywords="optometry", keywords="ophthalmology", keywords="adherence", keywords="barriers", abstract="Background: Diabetic retinopathy (DR) is a leading cause of blindness globally. DR has increasingly affected both individuals and health care systems as the population ages. Objective: This study aims to explore factors and identify barriers associated with nonadherence to referral recommendations among older adult participants after DR screening (DRS) during the COVID-19 pandemic. Method: This paper presents findings from a pilot study on artificial intelligence--enabled DRS conducted in two districts in Punjab, India (Moga and Mohali) during the COVID-19 pandemic. The screenings were conducted from March to June 2022 at community health center Badhani Kalan in Moga and from March to June 2021 in community settings (homes) in Block Boothgarh, Mohali. Participants were referred to the district hospital for an ophthalmological review based on artificial intelligence--enabled screening. After 1 month, the participants were contacted by telephone to assess adherence to the referral recommendations. Participants who did not adhere to the referral were then interviewed alongside health care providers to understand the barriers explaining their nonadherence. Results: We aimed to recruit 346 and 600 older adult participants from 2 sites but enrolled 390. Key challenges included health facility closures due to COVID-19, low motivation among health personnel for recruitment, incomplete nonparticipation data, and high participant workloads. Approximately 45\% of the participants were male and 55\% female. Most participants (62.6\%) were between 60 and 69 years old, while 37.4\% were 70 or older, with a mean age of 67.2 (SD 6.2) years. In total, 159 participants (40.8\%) were referred, while 231 participants (59.2\%) were not. Only 23 (14.5\%) of those referred followed through and visited a health facility for ophthalmological review, while 136 (85.5\%) did not pursue further evaluation. Our analysis revealed no significant differences in the characteristics between adherent and nonadherent participants, suggesting that demographic and health factors alone do not predict adherence behavior in patients with DR. Interviews identified limited knowledge about DR, logistical challenges, financial constraints, and attitudinal barriers as the primary challenges. Conclusions: This study, conducted during the COVID-19 pandemic, showed suboptimal adherence to referral recommendations among older adult patients due to knowledge gaps, logistical challenges, and health system issues. Quantifying and understanding adherence factors are crucial for targeted interventions addressing barriers to referral recommendations after DRS. Integrating teleophthalmology into and strengthening infrastructure for artificial intelligence--enabled diabetic retinopathy screening to enhance access and outcomes. ", doi="10.2196/67047", url="https://formative.jmir.org/2025/1/e67047" } @Article{info:doi/10.2196/58542, author="Hylander, Johan and Gyllencreutz, Lina and Haney, Michael and Westman, Anton", title="Ambulance Commanders' Reluctance to Enter Road Tunnels in Simulated Incidents and the Effects of a Tunnel-Specific e-Learning Course on Decision-Making: Web-Based Randomized Controlled Trial", journal="JMIR Form Res", year="2025", month="Mar", day="28", volume="9", pages="e58542", keywords="e-learning", keywords="major incident", keywords="incident management", keywords="disaster medicine", keywords="road tunnels", abstract="Background: The optimal response to a major incident in a road tunnel involves efficient decision-making among the responding emergency services (fire and rescue services, police, and ambulances). The infrequent occurrence of road tunnel incidents may entail unfamiliarity with the tunnel environment and lead to uncertain and inefficient decision-making among emergency services commanders. Ambulance commanders have requested tunnel-specific learning materials to improve their preparedness. Objective: We aimed to assess decision-making among ambulance commanders in simulated road tunnel incidents after they had participated in a tunnel-specific e-learning course designed to support timely and correct decisions in this context. Methods: We conducted a web-based intervention study involving 20 participants from emergency medical services in Sweden who were randomly allocated to a test or control group. The control group (n=10, 50\%) received a lecture on general incident management, while the intervention group (n=10, 50\%) completed an e-learning course consisting of 5 modules focused on tunnel structure, safety, and collaboration in response. The participants took part in 2 simulation-based assessments for ambulance commander decision-making in major road tunnel incidents 1 month and 6 months after their allocated study intervention. In each simulation, the participants decided on the best course of action at 15 independent decision points, designed as multiple-choice questions. The primary outcome was the correct response to the question regarding how to appropriately enter the road tunnel. The secondary outcome measurements were correct or incorrect responses and the time taken to decide for each of the 15 decisions. Limited in-depth follow-up interviews were conducted with participants (n=5, 25\%), and collected data were analyzed using qualitative content analysis. Results: All 20 participants completed the first simulation, and 16 (80\%) completed the second. The main finding was that none (0/20, 0\%) of the participants correctly answered the question on entering the tunnel system in the 1-month assessment. There were no significant differences between the groups (P=.59; 2-sample test of proportions) in the second assessment. The e-learning course was not associated with more correct answers at the first assessment, including accounting for participant factors (mean difference between groups: --0.58 points, 95\% CI --1.88 to 0.73; P=.36). The e-learning course was also not associated with a shorter time to completion compared to the nonintervention group in either assessment. Interviews identified 3 categories linked to the main outcome: information (lack of), risk (limited knowledge and equipment), and mitigation (access to maps and aide-m{\'e}moire). Conclusions: Participation in a tunnel-specific e-learning course did not result in a measurable change in ambulance commanders' decision-making behavior during simulated road tunnel incidents. The observed hesitation to enter the road tunnel system may have several plausible causes, such as the lack of actionable intelligence and tunnel-specific plans. This novel approach to assessing commander decision-making may be transferable to other educational settings. ", doi="10.2196/58542", url="https://formative.jmir.org/2025/1/e58542" } @Article{info:doi/10.2196/69001, author="Razmjou, Helen and Denis, Suzanne and Robarts, Susan and Wainwright, Amy and Dickson, Patricia and Murnaghan, John", title="Convergent and Known-Groups Validity and Sensitivity to Change of the Virtual Performance Measure in Patients With Hip and Knee Osteoarthritis: Longitudinal Study", journal="JMIR Form Res", year="2025", month="Mar", day="28", volume="9", pages="e69001", keywords="virtual", keywords="video-based outcome", keywords="longitudinal validity", keywords="sensitivity to change", keywords="osteoarthritis", abstract="Background: Subsequent to the COVID-19 pandemic in 2020, a different approach to health care utilization was required to improve safety and efficiency. In the postpandemic era, virtual care and remote assessment of musculoskeletal conditions has become more common, and examining the accuracy of these remote encounters remains vital. In 2023, an innovative, video-based tool---the Virtual Performance Measure (VPM)---was introduced to assess the functional difficulties of patients with osteoarthritis of the knee joint. Further validation of this tool is warranted to expand its application longitudinally and in more diverse populations. Objective: This study examined the longitudinal validity of the VPM, a digitally based outcome tool, in patients with osteoarthritis of the hip and knee joints who had undergone arthroplasty. Methods: Patients completed a web-based survey after watching 40 videos that demonstrated 10 functional tasks with increasing difficulty, prior to and at approximately 3-5 months following surgery. The Lower Extremity Functional Scale (LEFS) was used as the reference measure. Longitudinal convergent and known-groups validity as well as sensitivity to change were assessed. Results: The data of 120 patients (n=80, 67\% female; mean age 67, SD 9 years; n=58, 48\% with hip osteoarthritis and n=62, 52\% with knee osteoarthritis) were examined. There was a statistically significant improvement in both LEFS (t119=16.04, P<.001) and VPM total scores (t119=13.92, P<.001) over time. The correlation between the postoperative LEFS and VPM scores was higher (r=0.66; P<.001) than the correlation between the change scores of these measures (r=0.51; P<.001). The area under the curve value for the VPM's ability to differentiate between urgent and nonurgent candidates for surgery was 0.71 (95\% CI 0.57-0.84). Sensitivity to change as measured by the standardized response mean was 1.27 (95\% CI 1.09-1.45), indicating good ability to detect change over time. Conclusions: The VPM demonstrated sufficient longitudinal convergent and known-groups validity as well as sensitivity to change in patients with hip and knee osteoarthritis following arthroplasty. This tool has a potential to improve the delivery of care by increasing access, reducing the frequency of in-person visits, and improving the overall efficiency of the health care system following a major surgery. ", doi="10.2196/69001", url="https://formative.jmir.org/2025/1/e69001" } @Article{info:doi/10.2196/60221, author="Waki, Kayo and Enomoto, Syunpei and Yamauchi, Toshimasa and Nangaku, Masaomi and Ohe, Kazuhiko", title="Personalized mHealth Intervention (StepAdd) for Increasing Physical Activity in Japanese Patients With Type 2 Diabetes: Secondary Analysis of Social Cognitive Theory Measurements of a Single-Arm Pilot Study", journal="JMIR Form Res", year="2025", month="Mar", day="28", volume="9", pages="e60221", keywords="social cognitive theory", keywords="mHealth", keywords="mobile health", keywords="behavior change", keywords="diabetes", keywords="diabetic", keywords="type 2 diabetes", keywords="walk", keywords="step", keywords="exercise", keywords="physical activity", keywords="walking", keywords="digital therapeutics", keywords="secondary analysis", keywords="personalization", keywords="coping", keywords="self-efficacy", abstract="Background: A 12-week pilot of the StepAdd mobile health (mHealth) behavior change intervention based on social cognitive theory (SCT) saw an 86.7\% increase in mean daily step counts among patients with type 2 diabetes. Due to the lack of exploration of theoretical implications in mHealth intervention studies, there is a need to understand the mechanism underlying the behavioral change to inform the future design of digital therapeutics. Objective: This study aimed to examine the SCT drivers underlying the mean increase in exercise among Japanese patients with type 2 diabetes who participated in the StepAdd intervention. Methods: This is a post hoc analysis of data collected in the single-arm pilot study of the 32 patients who completed the StepAdd intervention. The StepAdd app uses self-mastery and coping strategies to increase self-efficacy and thus increase walking. Self-mastery was measured by the goal completion (GC) rate, which is the percentage of days in which patients met these adapting goals. The use of coping strategies was measured by the strategy implementation (SI) rate, which is the percentage of days in which patients applied their selected coping strategies. We assessed correlations between GC, SI, and self-efficacy to increase walking via linear regression and analyzed relationships via structural equation modeling. Results: We found statistically significant support for the SCT approach, including a correlation coefficient ($\rho$) of 0.649 between step increase and GC rate (P<.001); a $\rho$ of 0.497 between the coping SI rate and self-efficacy increase (P=.004); a $\rho$ of 0.446 between GC rate and self-mastery increase (P=.01); and a $\rho$ of 0.355 between self-regulation increase and step increase (P=.046), giving us insight into why the behavior intervention succeeded. We also found significant correlations between self-efficacy for barriers and self-efficacy for task-specific behavior ($\rho$=0.358; P=.04), as well as self-regulation and self-efficacy for task-specific behavior ($\rho$=0.583; P<.001). However, a cross-lagged panel modeling analysis found no significant evidence that changes in self-efficacy preceded behavior changes in line with SCT. Conclusions: Self-mastery and coping strategies contributed to the walking behavior change in StepAdd, supporting the SCT model of behavior change. Future research is needed to better understand the causal pathways proposed by SCT. ", doi="10.2196/60221", url="https://formative.jmir.org/2025/1/e60221" } @Article{info:doi/10.2196/67861, author="Brown, Jeffrey and Mitchell, Zachary and Jiang, Albert Yu and Archdeacon, Ryan", title="Accuracy of Smartphone-Mediated Snore Detection in a Simulated Real-World Setting: Algorithm Development and Validation", journal="JMIR Form Res", year="2025", month="Mar", day="28", volume="9", pages="e67861", keywords="snore detection", keywords="snore tracking", keywords="machine learning", keywords="SleepWatch", keywords="Bodymatter", keywords="neural net", keywords="mobile device", keywords="smartphone", keywords="smartphone application", keywords="mobile health", keywords="sleep monitoring", keywords="sleep tracking", keywords="sleep apnea", abstract="Background: High-quality sleep is essential for both physical and mental well-being. Insufficient or poor-quality sleep is linked to numerous health issues, including cardiometabolic diseases, mental health disorders, and increased mortality. Snoring---a prevalent condition---can disrupt sleep and is associated with disease states, including coronary artery disease and obstructive sleep apnea. Objective: The SleepWatch smartphone app (Bodymatter, Inc) aims to monitor and improve sleep quality and has snore detection capabilities that were built through a machine-learning process trained on over 60,000 acoustic events. This study evaluated the accuracy of the SleepWatch snore detection algorithm in a simulated real-world setting. Methods: The snore detection algorithm was tested by using 36 simulated snoring audio files derived from 18 participants. Each file simulated a snoring index between 30 and 600 snores per hour. Additionally, 9 files with nonsnoring sounds were tested to evaluate the algorithm's capacity to avoid false positives. Sensitivity, specificity, and accuracy were calculated for each test, and results were compared by using Bland-Altman plots and Spearman correlation to assess the statistical association between detected and actual snores. Results: The SleepWatch algorithm showed an average sensitivity of 86.3\% (SD 16.6\%), an average specificity of 99.5\% (SD 10.8\%), and an average accuracy of 95.2\% (SD 5.6\%) across the snoring tests. The positive predictive value and negative predictive value were 98.9\% (SD 2.6\%) and 93.8\% (SD 14.4\%) respectively. The algorithm performed exceptionally well in avoiding false positives, with a specificity of 97.1\% (SD 3.5\%) for nonsnoring files. Inclusive of all snoring and nonsnore tests, the aggregated accuracy for all trials in this bench study was 95.6\% (SD 5.3\%). The Bland-Altman analysis indicated a mean bias of ?29.8 (SD 41.7) snores per hour, and the Spearman correlation analysis revealed a strong positive correlation (rs=0.974; P<.001) between detected and actual snore rates. Conclusions: The SleepWatch snore detection algorithm demonstrates high accuracy and compares favorably with other snore detection apps. Aside from its broader use in sleep monitoring, SleepWatch demonstrates potential as a tool for identifying individuals at risk for sleep-disordered breathing, including obstructive sleep apnea, on the basis of the snoring index. ", doi="10.2196/67861", url="https://formative.jmir.org/2025/1/e67861" } @Article{info:doi/10.2196/64384, author="Wittmar, Silke and Frankenstein, Tom and Timm, Vincent and Frei, Peter and Kurpiers, Nicolas and W{\"o}lwer, Stefan and Sch{\"a}fer, Meender Axel Georg", title="User Experience With a Personalized mHealth Service for Physical Activity Promotion in University Students: Mixed Methods Study", journal="JMIR Form Res", year="2025", month="Mar", day="28", volume="9", pages="e64384", keywords="usability testing", keywords="health promotion", keywords="exercise", keywords="smartphone app", keywords="mHealth", keywords="physical activity", keywords="user experience", keywords="user", keywords="university student", keywords="undergraduate", keywords="college", keywords="student", keywords="mixed methods", keywords="physical fitness", keywords="digital intervention", keywords="mobile health", keywords="promote", keywords="engagement", keywords="mobile phone", abstract="Background: Regular physical activity (PA) is known to offer substantial health benefits, including improved physical fitness, reduced risk of disease, enhanced psychological well-being, and better cognitive performance. Despite these benefits, many university students fail to meet recommended PA levels, risking long-term health consequences. Objective: This study evaluated the user experience (UX) of futur.move, a digital intervention aimed at promoting PA among university students. The service delivers personalized, evidence-based content to foster sustained engagement in PA. Methods: A mixed methods approach was used to evaluate the prototype of futur.move. UX assessments included on-site and online user tests, standardized questionnaires, and online focus groups. A total of 142 university students participated, with 23 joining additional focus groups. Each participant tested the service for 30 minutes. Quantitative data were collected using the User Experience Questionnaire and analyzed descriptively, followed by correlation analysis with variables such as PA level, age, gender, and experience with PA apps. Qualitative insights were gathered from transcribed focus group discussions and analyzed using content-structuring, qualitative content analysis. Quantitative findings were cross-validated with qualitative data. Results: The UX received positive ratings across 4 User Experience Questionnaire scales (range --3 to +3; higher numbers indicate positive UX): attractiveness (median 1.67, IQR 1.04-2.17), perspicuity (median 1.5, IQR 0.5-2), stimulation (median 1.5, IQR 1-2), and novelty (median 1.25, IQR 0.5-2). Weak correlations were found between adherence to World Health Organization guidelines for PA and the perspicuity subscale ($\eta$=0.232, P=.04), and between age and the perspicuity (Kendall $\tau$b=0.132, P=.03) and stimulation subscales (Kendall $\tau$b=0.144, P=.02), and a moderate correlation was found between gender and the novelty subscale ($\eta$=0.363, P=.004). Critical feedback from focus group discussions highlighted issues with manual data entry. Qualitative findings aligned with the quantitative results, emphasizing students' appreciation for the personalized, diverse content and social networking features of futur.move. Conclusions: futur.move demonstrates favorable UX and aligns with student needs, particularly through its personalized content and social features. Improvements should focus on reducing manual data entry and enhancing feature clarity, particularly for the features ``your condition'' and ``goal setting.'' While correlations between UX ratings and demographic variables were weak to moderate, they warrant further investigation to better address the diverse target audience. The feedback from the students serves as a basis for further adapting the service to their needs and expectations. Future work will involve coding an advanced prototype and conducting a longitudinal study to assess its impact on PA behavior and sustained engagement. ", doi="10.2196/64384", url="https://formative.jmir.org/2025/1/e64384" } @Article{info:doi/10.2196/65847, author="Tam, Chi Cheuk and Young, D. Sean and Harrison, Sayward and Li, Xiaoming and Litwin, H. Alain", title="Theory-Based Social Media Intervention for Nonmedical Use of Prescription Opioids in Young Adults: Protocol for a Randomized Controlled Trial", journal="JMIR Res Protoc", year="2025", month="Mar", day="26", volume="14", pages="e65847", keywords="nonmedical use of prescription opioids", keywords="opioid misuse", keywords="young adults", keywords="social media", keywords="psychosocial intervention", keywords="randomized controlled trial", keywords="mixed methods", abstract="Background: The nonmedical use of prescription opioids (NMUPO) in young adults in the United States is concerning and is robustly influenced by many psychosocial factors. Given the advantages of flexibility, wide coverage, and real-time responses and assessment, using social media appears to be a promising and innovative approach to delivering psychosocial intervention to young adults. However, few theory-based social media interventions are available for NMUPO targeting this at-risk population. Objective: Guided by the information-motivation-behavioral skills model, the proposed research aims to address critical gaps by theoretically exploring psychosocial content associated with NMUPO among young adults via formative assessment. These findings will then be used to develop and evaluate the feasibility and preliminary efficacy of a peer-led social media intervention to reduce NMUPO among young adults. Methods: The proposed study will comprise serial research activities. First, formative research will be conducted through semistructured interviews among 30 young adults engaged in NMUPO. Qualitative data will be synthesized using a pragmatic approach for identifying psychosocial content associated with NMUPO. Second, qualitative findings will be used for developing a peer-led social media intervention to reduce NMUPO among young adults by integrating promising psychotherapy principles and incorporating them with well-trained recovery coaches. Third, the social media intervention will be evaluated through a 12-week randomized controlled trial among 70 young adults (n=35, 50\% in the intervention group and control group) engaged in NMUPO via mixed methods, including pre- and postintervention surveys, social media paradata (eg, time-series reactions to posts) collection, and ecological momentary assessment during the intervention. The control group will not receive an intervention but will complete the pre- and postintervention surveys. The primary outcomes will be feasibility, usability, and acceptability, while the secondary outcomes will be psychosocial and behavioral measures, such as past--3-month NMUPO, intention, psychological distress, self-efficacy, resilience, and coping strategies. Results: The proposed study was funded in May 2024. Social media campaigns have received responses from a total of 379 individuals, with 24 (6.3\%) identified as eligible. As of February 10, 2025, we have completed formative interviews with 8 eligible participants. Conclusions: The proposed study will be one of the first efforts to develop and deliver a theory-based peer-led intervention on social media, incorporating empirical findings on the psychosocial mechanism of NMUPO. The findings of the proposed study will provide valuable insights into opioid risk reduction for young adults through an innovative approach. If the tested trial is found to be feasible, the proposed study will contribute to future scaled-up and fully powered psychosocial interventions among young adults and other key populations at risk for NMUPO. Trial Registration: ClincialTrials.gov NCT06469749; https://clinicaltrials.gov/study/NCT06469749 International Registered Report Identifier (IRRID): DERR1-10.2196/65847 ", doi="10.2196/65847", url="https://www.researchprotocols.org/2025/1/e65847" } @Article{info:doi/10.2196/59953, author="Gicquelais, E. Rachel and Conway, Caitlin and Vjorn, Olivia and Genz, Andrew and Kirk, Gregory and Westergaard, Ryan", title="Mobile Health Tool to Capture Social Determinants of Health and Their Impact on HIV Treatment Outcomes Among People Who Use Drugs: Pilot Feasibility Study", journal="JMIR Form Res", year="2025", month="Mar", day="26", volume="9", pages="e59953", keywords="HIV", keywords="drug use", keywords="social determinants of health", keywords="mobile health", keywords="mHealth", keywords="smartphone", abstract="Background: Active substance use, food or housing insecurity, and criminal legal system involvement can disrupt HIV care for people living with HIV and opioid use disorder (OUD). These social determinants of health are not routinely captured in clinical settings. Objective: We evaluated whether real-time reports of social and behavioral factors using a smartphone app could predict viral nonsuppression and missed care visits to inform future mobile health interventions. Methods: We enrolled 59 participants from the AIDS Linked to the Intravenous Experience (ALIVE) Study in Baltimore, Maryland, into a 12-month substudy between February 2017 and October 2018. Participants were eligible if they had OUD and had either a measured HIV RNA ?1000 copies/mL or a ?1-month lapse in antiretroviral therapy in the preceding 2 years. Participants received a smartphone and reported HIV medication adherence, drug use or injection, and several disruptive life events, including not having a place to sleep at night, skipping a meal due to lack of income, being stopped by police, being arrested, or experiencing violence on a weekly basis, through a survey on a mobile health app. We described weekly survey completion and investigated which factors were associated with viral nonsuppression (HIV RNA ?200 copies/mL) or a missed care visit using logistic regression with generalized estimating equations adjusted for age, gender, smartphone comfort, and drug use. Results: Participants were predominantly male (36/59, 61\%), Black (53/59, 90\%), and had a median of 53 years old. At baseline, 16\% (6/38) were virally unsuppressed. Participants completed an average of 23.3 (SD 16.3) total surveys and reported missing a dose of antiretroviral therapy, using or injecting drugs, or experiencing any disruptive life events on an average of 13.1 (SD 9.8) weekly surveys over 1 year. Reporting use of any drugs (adjusted odds ratio [aOR] 2.3, 95\% CI 1.4?3.7), injecting drugs (aOR 2.3, 95\% CI 1.3?3.9), and noncompletion of all surveys (aOR 1.6, 95\% CI 1.1?2.2) were associated with missing a scheduled care visit over the subsequent 30 days. Missing ?2 antiretroviral medication doses within 1 week was associated with HIV viral nonsuppression (aOR 3.7, 95\% CI: 1.2?11.1) in the subsequent 30 days. Conclusions: Mobile health apps can capture risk factors that predict viral nonsuppression and missed care visits among people living with HIV who have OUD. Using mobile health tools to detect sociobehavioral factors that occur prior to treatment disengagement may facilitate early intervention by health care teams. ", doi="10.2196/59953", url="https://formative.jmir.org/2025/1/e59953" } @Article{info:doi/10.2196/66763, author="Young, P. Nathan and Stern, I. Jennifer and Steel, J. Stephanie and Ebbert, O. Jon", title="Mobile App-Based Interactive Care Plan for Migraine: Survey Study of Usability and Improvement Opportunities", journal="JMIR Form Res", year="2025", month="Mar", day="26", volume="9", pages="e66763", keywords="migraine", keywords="remote monitoring", keywords="mobile app", keywords="mHealth", keywords="patient-reported outcomes", keywords="care plan", keywords="digital health", keywords="app", keywords="smartphone", keywords="eHealth", keywords="technology", keywords="survey study", keywords="headache", keywords="electronic health record", keywords="remote assessment", keywords="older adult", keywords="adult", keywords="electronic survey", keywords="pain", keywords="mobile phone", keywords="telehealth", keywords="telemedicine", abstract="Background: We implemented a novel mobile app-based Migraine Interactive Care Plan (MICP) integrated with our electronic health records (EHRs). The MICP facilitates remote assessment of adult patients with migraine, educational content delivery, and care team communication. Feasibility of the MICP was demonstrated in a pilot implementation study. Objective: We aimed to assess the preferences and satisfaction of patients with migraine users of a mobile app-based care plan integrated with the EHR. Methods: An electronic survey was administered to a single cohort of MICP users between December 6, 2021, and December 30, 2021. The survey assessed patient preferences for which data to track, frequency of tracking, and satisfaction with the MICP. Survey responses were compared between subsets determined by patient-reported headache frequency and treatment with and without botulinum toxin and calcitonin gene-related peptide (CGRP) antagonist therapy. The Wilcoxon rank-sum test was used for continuous variables and the $\chi$2 test or Fisher exact test for categorical variables. Results: The total sample size was 184 and the survey response rate was 30.4\% (56/184). No significant differences in age (P=.26) or sex (P=.19) between respondents and nonrespondents were observed. Respondent median age was 42 (range 20?72) years and 94.6\% (53/56) were female. Headache frequency was (1) 0 to 8 days (26/56, 46.4\%), (2) 9 to 14 days (12/56, 21.4\%), and (3) 15 or more days (18/56, 32.1\%). No difference was observed in any survey responses based on headache frequency or treatment. The majority of respondents preferred to track headache days weekly (30/56, 53.6\%) or daily (15/56, 26.8\%) and preferred to change the frequency of headache tracking reminders (42/56, 75\%). Respondents were somewhat or very interested in daily tracking personal observations in free text (41/52, 78.8\%), medication treatment (43/52, 82.7\%) and treatment response (39/56, 69.6\%), class of medication treatment (36/52, 69.2\%), severity of functional impairment (39/56, 69.6\%), type of functional impairment (35/53, 66\%), headache day (40/54, 74.1\%), and headache pain level on a scale of 1 to 10 (38/53, 71.7\%). Respondents agreed or strongly agreed that the education content was useful (31/51, 60.8\%) but lacked personalization (25/51, 49\%). Most respondents agreed or strongly agreed that they were satisfied with the MICP (38/50, 76\%) and that it helped them communicate with their care team (38/53, 71.7\%). Conclusions: Most MICP users were motivated to track headache frequency, medication treatment with response, functional impairment, and pain intensity. Opportunities to improve the MICP include (1) allowing patients to change the frequency of assessments and notifications; (2) recording personal observations or comments through free text, which may include headache triggers; (3) assessment of headache severity using a 1 to 10 pain scale; and (4) tailoring headache education based on frequency and severity (episodic vs chronic migraine). These observations may be useful to improve the usability of the MICP and similar EHR-integrated migraine care platforms that others may develop. ", doi="10.2196/66763", url="https://formative.jmir.org/2025/1/e66763" } @Article{info:doi/10.2196/64096, author="March, A. Christine and Naame, Elissa and Libman, Ingrid and Proulx, N. Chelsea and Siminerio, Linda and Miller, Elizabeth and Lyon, R. Aaron", title="School-Partnered Collaborative Care (SPACE) for Pediatric Type 1 Diabetes: Development and Usability Study of a Virtual Intervention With Multisystem Community Partners", journal="JMIR Diabetes", year="2025", month="Mar", day="26", volume="10", pages="e64096", keywords="type 1 diabetes", keywords="user-centered design", keywords="school health", keywords="collaborative care model", keywords="implementation research", keywords="pediatric", keywords="usability testing", keywords="virtual intervention", keywords="multisystem community partners", keywords="children", keywords="youth", keywords="diabetes management support", keywords="health system partners", keywords="psychosocial interventions", keywords="quantitative assessments", keywords="qualitative assessments", abstract="Background: School-partnered interventions may improve health outcomes for children with type 1 diabetes, though there is limited evidence to support their effectiveness and sustainability. Family, school, or health system factors may interfere with intervention usability and implementation. Objective: To identify and address potential implementation barriers during intervention development, we combined methods in user-centered design and implementation science to adapt an evidence-based psychosocial intervention, the collaborative care model, to a virtual school-partnered collaborative care (SPACE) model for type 1 diabetes between schools and diabetes medical teams. Methods: We recruited patient, family, school, and health system partners (n=20) to cocreate SPACE through iterative, web-based design sessions using a digital whiteboard (phase 1). User-centered design methods included independent and group activities for idea generation, visual voting, and structured critique of the evolving SPACE prototype. In phase 2, the prototype was evaluated with the usability evaluation for evidence-based psychosocial interventions methods. School nurses reviewed the prototype and tasks in cognitive walkthroughs and completed the Intervention Usability Scale (IUS). Two members of the research team independently identified and prioritized (1-3 rating) discrete usability concerns. We evaluated the relationship between prioritization and the percentage of nurses reporting each usability issue with Spearman correlation. Differences in IUS scores by school nurse characteristics were assessed with ANOVA. Results: In the design phase, the partners generated over 90 unique ideas for SPACE, prioritizing elements pertaining to intervention adaptability, team-based communication, and multidimensional outcome tracking. Following three iterations of prototype development, cognitive walkthroughs were completed with 10 school nurses (n=10, 100\% female; mean age 48.5, SD 9.5 years) representing different districts and years of experience. Nurses identified 16 discrete usability issues (each reported by 10\%-60\% of participants). Two issues receiving the highest priority (3.0): ability to access a virtual platform (n=3, 30\% of participants) and data-sharing mechanisms between nurses and providers (n=6, 60\% of participants). There was a moderate correlation between priority rating and the percentage of nurses reporting each issue ($\rho$=0.63; P=.01). Average IUS ratings (77.8, SD 11.1; 100-point scale) indicated appropriate usability. There was no difference in IUS ratings by school nurse experience (P=.54), student caseload (P=.12), number of schools covered (P=.90), or prior experience with type 1 diabetes (P=.83), suggesting that other factors may influence usability. The design team recommended strategies for SPACE implementation to overcome high-priority issues, including training users on videoconferencing applications, establishing secure forms for school data reporting, and sharing glucose data in real-time during SPACE meetings. Conclusions: Cross-sector interventions are complex, and perceived usability is a potential barrier to implementation. Using web-based cocreation methods with community partners promoted high-quality intervention design that is aligned with end-user priorities. Quantitative and qualitative assessments indicated appropriate degree of usability to move forward with pilot-testing. ", doi="10.2196/64096", url="https://diabetes.jmir.org/2025/1/e64096" } @Article{info:doi/10.2196/57468, author="Chen, T. Annie and Wang, C. Lexie and Johnny, Shana and Wong, H. Sharon and Chaliparambil, K. Rahul and Conway, Mike and Glass, E. Joseph", title="Stigma and Behavior Change Techniques in Substance Use Recovery: Qualitative Study of Social Media Narratives", journal="JMIR Form Res", year="2025", month="Mar", day="26", volume="9", pages="e57468", keywords="stigma", keywords="substance use", keywords="transtheoretical model", keywords="behavior change techniques", keywords="social media", abstract="Background: Existing literature shows that persons with substance use disorder (SUD) experience different stages of readiness to reduce or abstain from substance use, and tailoring intervention change strategies to these stages may facilitate recovery. Moreover, stigma may serve as a barrier to recovery by preventing persons with SUDs from seeking treatment. In recent years, the behavior change technique (BCT) taxonomy has increasingly become useful for identifying potential efficacious intervention components; however, prior literature has not addressed the extent to which these techniques may naturally be used to recover from substance use, and knowledge of this may be useful in the design of future interventions. Objective: We take a three-step approach to identifying strategies to facilitate substance use recovery: (1) characterizing the extent to which stages of change are expressed in social media data, (2) identifying BCTs used by persons at different stages of change, and (3) exploring the role that stigma plays in recovery journeys. Methods: We collected discussion posts from Reddit, a popular social networking site, and identified subreddits or discussion forums about 3 substances (alcohol, cannabis, and opioids). We then performed qualitative data analysis using a hybrid inductive-deductive method to identify the stages of change in social media authors' recovery journeys, the techniques that social media content authors used as they sought to quit substance use, and the role that stigma played in social media authors' recovery journeys. Results: We examined 748 posts pertaining to 3 substances: alcohol (n=316, 42.2\%), cannabis (n=335, 44.8\%), and opioids (n=135, 18\%). Social media content representing the different stages of change was observed, with the majority (472/748, 63.1\%) of narratives representing the action stage. In total, 11 categories of BCTs were identified. There were similarities in BCT use across precontemplation, contemplation, and preparation stages, with social support seeking and awareness of natural consequences being the most common. As people sought to quit or reduce their use of substances (action stage), we observed a variety of BCTs, such as the repetition and substitution of healthful behaviors and monitoring and receiving feedback on their own behavior. In the maintenance stage, reports of diverse BCTs continue to be frequent, but offers of social support also become more common than in previous stages. Stigma was present throughout all stages. We present 5 major themes pertaining to the manifestation of stigma. Conclusions: Patterns of BCT use and stigmatizing experiences are frequently discussed in social media, which can be leveraged to better understand the natural course of recovery from SUD and how interventions might facilitate recovery from substance use. It may be important to incorporate stigma reduction across all stages of the recovery journey. ", doi="10.2196/57468", url="https://formative.jmir.org/2025/1/e57468" } @Article{info:doi/10.2196/64266, author="Ackerhans, Sophia and Wehkamp, Kai and Petzina, Rainer and Dumitrescu, Daniel and Schultz, Carsten", title="Perceived Trust and Professional Identity Threat in AI-Based Clinical Decision Support Systems: Scenario-Based Experimental Study on AI Process Design Features", journal="JMIR Form Res", year="2025", month="Mar", day="26", volume="9", pages="e64266", keywords="artificial intelligence", keywords="clinical decision support systems", keywords="explainable artificial intelligence", keywords="professional identity threat", keywords="health care", keywords="physicians", keywords="perceptions", keywords="professional identity", abstract="Background: Artificial intelligence (AI)--based systems in medicine like clinical decision support systems (CDSSs) have shown promising results in health care, sometimes outperforming human specialists. However, the integration of AI may challenge medical professionals' identities and lead to limited trust in technology, resulting in health care professionals rejecting AI-based systems. Objective: This study aims to explore the impact of AI process design features on physicians' trust in the AI solution and on perceived threats to their professional identity. These design features involve the explainability of AI-based CDSS decision outcomes, the integration depth of the AI-generated advice into the clinical workflow, and the physician's accountability for the AI system-induced medical decisions. Methods: We conducted a 3-factorial web-based between-subject scenario-based experiment with 292 medical students in their medical training and experienced physicians across different specialties. The participants were presented with an AI-based CDSS for sepsis prediction and prevention for use in a hospital. Each participant was given a scenario in which the 3 design features of the AI-based CDSS were manipulated in a 2{\texttimes}2{\texttimes}2 factorial design. SPSS PROCESS (IBM Corp) macro was used for hypothesis testing. Results: The results suggest that the explainability of the AI-based CDSS was positively associated with both trust in the AI system ($\beta$=.508; P<.001) and professional identity threat perceptions ($\beta$=.351; P=.02). Trust in the AI system was found to be negatively related to professional identity threat perceptions ($\beta$=--.138; P=.047), indicating a partially mediated effect on professional identity threat through trust. Deep integration of AI-generated advice into the clinical workflow was positively associated with trust in the system ($\beta$=.262; P=.009). The accountability of the AI-based decisions, that is, the system required a signature, was found to be positively associated with professional identity threat perceptions among the respondents ($\beta$=.339; P=.004). Conclusions: Our research highlights the role of process design features of AI systems used in medicine in shaping professional identity perceptions, mediated through increased trust in AI. An explainable AI-based CDSS and an AI-generated system advice, which is deeply integrated into the clinical workflow, reinforce trust, thereby mitigating perceived professional identity threats. However, explainable AI and individual accountability of the system directly exacerbate threat perceptions. Our findings illustrate the complex nature of the behavioral patterns of AI in health care and have broader implications for supporting the implementation of AI-based CDSSs in a context where AI systems may impact professional identity. ", doi="10.2196/64266", url="https://formative.jmir.org/2025/1/e64266" } @Article{info:doi/10.2196/65114, author="Seel, Mariella and Mihalic, Alexander Julian and Froschauer, Mathias Stefan and Holzner, Bernhard and Meier, Jens and Gotterbarm, Tobias and Holzbauer, Matthias", title="Changes in Health Education Literacy After Structured Web-Based Education Versus Self-Directed Online Information Seeking in Patients Undergoing Carpal Tunnel Release Surgery: Nonrandomized, Controlled Study", journal="JMIR Form Res", year="2025", month="Mar", day="25", volume="9", pages="e65114", keywords="carpal tunnel release surgery", keywords="patient education", keywords="structured web-based education", keywords="online information", keywords="health education literacy", keywords="web-based", keywords="health education", keywords="information seeking", keywords="carpal tunnel release", keywords="carpal tunnel surgery", keywords="non-randomized", keywords="controlled study", keywords="self-management", keywords="perioperative", keywords="online health information", keywords="health literacy", keywords="day surgery", keywords="online search", keywords="carpal tunnel", keywords="carpal", abstract="Background: With advancements in anesthesiologic and surgical techniques, many surgeries are now performed as day-surgery procedures, requiring greater responsibilities for self-management from patients during the perioperative process. Online health information often lacks reliability and comprehensibility, posing risks for patients with low health literacy. Carpal tunnel release (CTR) surgery, a common day-surgery procedure, necessitates effective patient education for optimal recovery and self-management. Objective: This study introduces the CTS Academy, a web-based education program designed for patients undergoing CTR day surgery. The study aimed to evaluate the CTS Academy's impact on patients' health education literacy (HEL) compared with self-directed online information seeking. Methods: A scoping review on education programs focusing on the perioperative process of CTR was conducted before this study. In a nonrandomized controlled study, 60 patients scheduled for CTR were assigned to 2 groups based on the patients' preferences; the test group used the CTS Academy, while the control group performed self-directed online searches. HEL was assessed using the Health Education Literacy of Patients with chronic musculoskeletal diseases (HELP) questionnaire, focusing on patients's comprehension of medical information (COMPR), patients's ability to apply health-related information in an everyday life (APPLY), and patient's ability to communicate with health care professional (COMM). Secondary outcomes included content comprehensibility, patient preferences, platform usability, and clinical carpal tunnel syndrome (CTS)--related parameters. Results: In the scoping review, 17 studies could be identified and included for full-text analysis. Eighteen patients each were included in the test group (13 women and 5 men) and in the control group (11 women and 7 men). The average time spent in the study was 167 and 176 days for the test and control groups, respectively. The test group showed significant improvements in APPLY (mean 28, SD 7.99 vs mean 24, SD 5.14; P<.05) and COMM (mean 30, SD 10.52 vs mean 25, SD 6.01; P=.02) after using the CTS Academy in a longitudinal analysis. No significant changes were observed in the control group. In a comparison between groups, the test group had significantly higher APPLY scores at follow-up (mean 24, SD 5.14 vs mean 33, SD 14.78; P=.044) and fewer comprehension issues at baseline (mean 38, SD 16.60 vs mean 50, SD 19.00; P=.03). The CTS-related knowledge assessment yielded 92\% (66/72) versus 90\% (65/72) correct answers in the test and control groups, respectively. The test group rated the CTS Academy highly in usability (6.22 of 7.00 points) and utility (6.13 of 7.00 points). Preferences leaned toward using CTS Academy alongside doctor consultations (16/18, 89\%) and over self-directed searches (15/18, 84\%). No significant differences were found in CTS-related symptoms between groups. Conclusions: The CTS Academy effectively enhanced patients' HEL, especially in applying and communicating medical information. The platform's usability and utility were rated favorably, and patients preferred it over independent online information seeking. This suggests that structured, web-based education enhances patient self-management during the day surgery process. ", doi="10.2196/65114", url="https://formative.jmir.org/2025/1/e65114" } @Article{info:doi/10.2196/67293, author="Whittemore, Robin and Jeon, Sangchoon and Akyirem, Samuel and Chen, C. Helen N. and Lipson, Joanna and Minchala, Maritza and Wagner, Julie", title="Multilevel Intervention to Increase Patient Portal Use in Adults With Type 2 Diabetes Who Access Health Care at Community Health Centers: Single Arm, Pre-Post Pilot Study", journal="JMIR Form Res", year="2025", month="Mar", day="25", volume="9", pages="e67293", keywords="patient portal", keywords="mobile phone", keywords="diabetes", keywords="community health center", keywords="adults", keywords="diabetic", keywords="DM", keywords="diabetes mellitus", keywords="Type 2 diabetes", keywords="T2D", keywords="community health centers", keywords="CHCs", keywords="pilot study", keywords="feasibility", keywords="self-management", keywords="glycemic control", keywords="patient portals", keywords="social determinants of health", keywords="primary outcome", keywords="digital health", keywords="digital health literacy", keywords="health technology", keywords="health technologies", keywords="psychosocial", keywords="efficacy", abstract="Background: Diabetes self-management education and support (DSMS) delivered via patient portals significantly improves glycemic control. Yet, disparities in patient portal use persist. Community health centers (CHCs) deliver care to anyone who needs it, regardless of income or insurance status. Objective: This study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of a multilevel intervention to increase access and use of portals (MAP) among people with type 2 diabetes (T2D) receiving health care at CHCs. Methods: A within-subjects, pre-post design was used. Adults with T2D who were portal naive were recruited from 2 CHCs. After informed consent, participants met with a community health worker for referrals for social determinants of health, provision of a tablet with cell service, and individualized training on use of the tablet and portal. Next, a nurse met individually with participants to develop a DSMS plan and then communicated with patients via the portal at least twice weekly during the first 3 months and weekly for the latter 3 months. Data were collected at baseline, 3 months and 6 months. The primary outcome was patient activation and engagement with the portal. Secondary outcomes included technology attitudes, digital health literacy, health-related outcomes and psychosocial function. Results: In total, 26 patients were eligible, 23 received the intervention, and one was lost to follow up. The sample was predominately Latino or Hispanic (17/22, 77\%) and reported low income (19/22, 86\%< US \$40,000/year), low education (13/22, 59\%