%0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e10388 %T Connecting Home-Based Self-Monitoring of Blood Pressure Data Into Electronic Health Records for Hypertension Care: A Qualitative Inquiry With Primary Care Providers %A Rodriguez,Sarah %A Hwang,Kevin %A Wang,Jing %+ School of Nursing, The University of Texas Health Science Center at San Antonio, MSC 7851, 7703 Floyd Curl Drive, San Antonio, TX, 78229, United States, 1 210 450 8561, wangj1@uthscsa.edu %K patient-generated health data %K connected health %K remote monitoring %K electronic health record %K hypertension %K patient reported outcome %K self-measured blood pressure %K self-monitoring of blood pressure %D 2019 %7 23.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: There is a lack of research on how to best incorporate home-based self-measured blood pressure (SMBP) measurements, combined with other patient-generated health data (PGHD), into electronic health record (EHR) systems in a way that promotes primary care workflow without burdening the primary care team with irrelevant or superfluous data. Objective: The purpose of this study was to explore the perspectives of primary care providers in utilizing SMBP measurements and integrating SMBP data into the clinical workflow for the management of hypertension in the primary care setting. Methods: A total of 13 primary care physicians were interviewed in total; 5 in individual interviews and 8 in a focus group. The interview questions were centered on (1) the value of SMBP in hypertension care, (2) needs of viewing SMBP and desired visual display, (3) desired alert algorithm and critical values, (4) needs for other PGHD, and (5) workflow of primary care team in utilizing SMBP. The interviews were audiotaped and transcribed verbatim, and a thematic analysis was performed to extract overarching themes. Results: The primary care experience of the 13 providers ranged from 5 to 35 years. The following themes emerged from the individual and focus group interviews: (1) ways to utilize SMBP measurements in primary care, (2) preferred visual display of SMBP, (3) patient condition determines preferred scheduling of patient SMBP measurements and provider’s preferred frequency of viewing SMBP data, (4) effect of patient condition on alert parameters, (5) location to receive critical value alerts, (6) primary recipient of critical value alerts, and (7) the need of additional PGHD (eg, emotional stressors, food diary, and medication adherence) to provide context of SMBP values. Conclusions: The perspectives of primary care providers need to be incorporated into the design of a built-in interface in the EHR to incorporate SMBP and other PGHD. Future usability evaluation should be conducted with mock-up interfaces to solicit opinions on the optimal alert frequency and mechanism to best fit the workflow in the primary care setting. Future studies should examine how the utilization of a built-in interface that fully integrates SMBP measurements and PGHD into EHR systems can support patient self-management and thus, improve patient outcomes. %M 31124468 %R 10.2196/10388 %U http://formative.jmir.org/2019/2/e10388/ %U https://doi.org/10.2196/10388 %U http://www.ncbi.nlm.nih.gov/pubmed/31124468 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e10951 %T Digitizing a Face-to-Face Group Fatigue Management Program: Exploring the Views of People With Multiple Sclerosis and Health Care Professionals Via Consultation Groups and Interviews %A Thomas,Sarah %A Pulman,Andy %A Thomas,Peter %A Collard,Sarah %A Jiang,Nan %A Dogan,Huseyin %A Davies Smith,Angela %A Hourihan,Susan %A Roberts,Fiona %A Kersten,Paula %A Pretty,Keith %A Miller,Jessica K %A Stanley,Kirsty %A Gay,Marie-Claire %+ Bournemouth University Clinical Research Unit, Faculty of Health & Social Sciences, Bournemouth University, R506, Royal London House, Bournemouth,, United Kingdom, 44 1202961953, saraht@bournemouth.ac.uk %K multiple sclerosis %K fatigue %K telemedicine %K mobile health %K FACETS %K fatigue management %D 2019 %7 22.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Fatigue is one of the most common and debilitating symptoms of multiple sclerosis (MS) and is the main reason why people with MS stop working early. The MS Society in the United Kingdom funded a randomized controlled trial of FACETS—a face-to-face group-based fatigue management program for people with multiple sclerosis (pwMS)—developed by members of the research team. Given the favorable trial results and to help with implementation, the MS Society supported the design and printing of the FACETS manual and materials and the national delivery of FACETS training courses (designed by the research team) for health care professionals (HCPs). By 2015 more than 1500 pwMS had received the FACETS program, but it is not available in all areas and a face-to-face format may not be suitable for, or appeal to, everyone. For these reasons, the MS Society funded a consultation to explore an alternative Web-based model of service delivery. Objective: The aim of this study was to gather views about a Web-based model of service delivery from HCPs who had delivered FACETS and from pwMS who had attended FACETS. Methods: Telephone consultations were undertaken with FACETS-trained HCPs who had experience of delivering FACETS (n=8). Three face-to-face consultation groups were held with pwMS who had attended the FACETS program: London (n=4), Liverpool (n=4), and Bristol (n=7). The interviews and consultation groups were digitally recorded and transcribed. A thematic analysis was undertaken to identify key themes. Toward the end of the study, a roundtable meeting was held to discuss outcomes from the consultation with representatives from the MS Society, HCPs, and pwMS. Results: Key challenges and opportunities of designing and delivering an integrated Web-based version of FACETS and maintaining user engagement were identified across 7 themes (delivery, online delivery, design, group, engagement, interactivity, and HCP relationships). Particularly of interest were themes related to replicating the group dynamics and the lack of high-quality solutions that would support the FACETS’ weekly homework tasks and symptom monitoring and management. Conclusions: A minimum viable Web-based version of FACETS was suggested as the best starting point for a phased implementation, enabling a solution that could then be added to over time. It was also proposed that a separate study should look to create a free stand-alone digital toolkit focusing on the homework elements of FACETS. This study has commenced with a first version of the toolkit in development involving pwMS throughout the design and build stages to ensure a user-centered solution. %M 31120021 %R 10.2196/10951 %U http://formative.jmir.org/2019/2/e10951/ %U https://doi.org/10.2196/10951 %U http://www.ncbi.nlm.nih.gov/pubmed/31120021 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12635 %T Treatment Preferences for Internet-Based Cognitive Behavioral Therapy for Insomnia in Japan: Online Survey %A Sato,Daisuke %A Sutoh,Chihiro %A Seki,Yoichi %A Nagai,Eiichi %A Shimizu,Eiji %+ Department of Cognitive Behavioral Physiology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan, 81 43 226 2027, daisuke-sato@umin.ac.jp %K patient preference %K insomnia %K internet-based cognitive behavioral therapy %D 2019 %7 15.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: The internet has the potential to increase individuals’ access to cognitive behavioral therapy (CBT) for insomnia at low cost. However, treatment preferences regarding internet-based computerized CBT for insomnia have not been fully examined. Objective: The aim was to conduct an anonymous online survey to evaluate treatment preferences for insomnia among patients with insomnia and individuals without insomnia. Methods: We developed an online survey to recruit a total of 600 participants living in the Kanto district in Japan. There were three subgroups: 200 medicated individuals with insomnia, 200 unmedicated individuals with insomnia, and 200 individuals without insomnia. The survey asked questions about the severity of the respondent’s insomnia (using the Athens Insomnia Scale), the frequency of sleep medication use and the level of satisfaction with sleep medication use, the respondent’s knowledge of CBT, his or her preference for CBT for insomnia before drug therapy, preference for CBT versus drug therapy, and preference for internet-based CBT versus face-to-face CBT. Results: Of the 600 respondents, 47.7% (286/600) indicated that they received CBT before drug therapy, and 57.2% (343/600) preferred CBT for insomnia to drug therapy. In addition, 47.0% (282/600) preferred internet-based CBT for insomnia to face-to-face CBT. Although the respondents with insomnia who were taking an insomnia medication had a relatively lower preference for internet-based CBT (40.5%, 81/200), the respondents with insomnia who were not taking an insomnia medication had a relatively higher preference for internet-based CBT (55.5%, 111/200). Conclusions: The results of our online survey suggest that approximately half of the people queried preferred CBT for insomnia to drug therapy, and half of the respondents preferred internet-based CBT for insomnia to face-to-face CBT. %M 31094319 %R 10.2196/12635 %U http://formative.jmir.org/2019/2/e12635/ %U https://doi.org/10.2196/12635 %U http://www.ncbi.nlm.nih.gov/pubmed/31094319 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e13446 %T Internet-Based Cognitive Therapy for Social Anxiety Disorder in Hong Kong: Therapist Training and Dissemination Case Series %A Thew,Graham R %A Powell,Candice LYM %A Kwok,Amy PL %A Lissillour Chan,Mandy H %A Wild,Jennifer %A Warnock-Parkes,Emma %A Leung,Patrick WL %A Clark,David M %+ Department of Experimental Psychology, University of Oxford, The Old Rectory, Paradise Square, Oxford, OX1 1TW, United Kingdom, 44 01865 618600, graham.thew@psy.ox.ac.uk %K anxiety %K social phobia %K internet %K cognitive therapy %K clinical competence %K cross-cultural comparison %K Hong Kong %K benchmarking %K psychology, clinical %K mental health %D 2019 %7 15.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Guided internet-based psychological interventions show substantial promise for expanding access to evidence-based mental health care. However, this can only be achieved if results of tightly controlled studies from the treatment developers can also be achieved in other independent settings. This dissemination depends critically on developing efficient and effective ways to train professionals to deliver these interventions. Unfortunately, descriptions of therapist training and its evaluation are often limited or absent within dissemination studies. Objective: This study aimed to describe and evaluate a program of therapist training to deliver internet-based Cognitive Therapy for social anxiety disorder (iCT-SAD). As this treatment was developed in the United Kingdom and this study was conducted in Hong Kong with local therapists, an additional objective was to examine the feasibility, acceptability, and initial efficacy of iCT-SAD in this cultural context, based on data from a pilot case series. Methods: Training in iCT-SAD was provided to 3 therapists and included practice of the face-to-face format of therapy under clinical supervision, training workshops, and treating 6 patients with the iCT-SAD program. Training progress was evaluated using standardized and self-report measures and by reviewing patient outcomes. In addition, feedback from patients and therapists was sought regarding the feasibility and acceptability of the program. Results: The training program was effective at increasing therapists’ iCT-SAD knowledge and skills, resulting in levels of competence expected of a specialist Cognitive Behavioral Therapy practitioner. The 6 patients treated by the trainees all completed their treatment and achieved a mean pre- to posttreatment change of 53.8 points (SD 39.5) on the primary patient outcome measure, the Liebowitz Social Anxiety Scale. The within-group effect size (Cohen d) was 2.06 (95% CI 0.66-3.46). There was evidence to suggest that the patients’ clinical outcomes were sustained at 3-month follow-up. These clinical results are comparable to those achieved by UK patients treated by the developers of the internet program. Patient and therapist feedback did not identify any major cultural barriers to implementing iCT-SAD in Hong Kong; some modest language suggestions were made to assist understanding. Conclusions: The therapist training implemented here facilitated the successful dissemination of an effective UK-developed internet intervention to Hong Kong. The treatment appeared feasible and acceptable in this setting and showed highly promising initial efficacy. A randomized controlled trial is now required to examine this more robustly. As therapist training is critical to the successful dissemination of internet interventions, further research to develop, describe, and evaluate therapist training procedures is recommended. %M 31094320 %R 10.2196/13446 %U http://formative.jmir.org/2019/2/e13446/ %U https://doi.org/10.2196/13446 %U http://www.ncbi.nlm.nih.gov/pubmed/31094320 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 8 %N 2 %P e12664 %T EasyDetectDisease: An Android App for Early Symptom Detection and Prevention of Childhood Infectious Diseases %A Ponum,Mahvish %A Hasan,Osman %A Khan,Saadia %+ School of Electrical Engineering and Computer Science, National University of Sciences and Technology, Islamabad, Pakistan, Islamabad, 440000, Pakistan, 92 3067826262, mponum.msit15seecs@seecs.edu.pk %K infectious diseases %K mHealth %K causes of death %D 2019 %7 14.05.2019 %9 Original Paper %J Interact J Med Res %G English %X Background: Infectious diseases often lead to death among children under 5 years in many underdeveloped and developing countries. One of the main reasons behind this is an unawareness of disease symptoms among mothers and child caregivers. To overcome this, we propose the EasyDetectDisease mobile health app to educate mothers about the early symptoms of pediatric diseases and to provide them with practical advice for preventing the spread of such diseases in children under 5 years. The EasyDetectDisease app includes detailed knowledge of infectious diseases, including the corresponding symptoms, causes, incubation period, preventive measures, nutritional guidelines such as breastfeeding, video tutorials of child patients, and video guidelines by pediatric health experts to promote child health. It also provides information on the diagnosis of the infectious diseases based on symptoms. Objective: The objective of this study was to evaluate the usability (eg, ease of use, easy detection of disease, functionality, and navigation of interfaces) of the EasyDetectDisease app among mothers of children under 5 years of age. Methods: Two health sessions, held in Pakistan, were used to evaluate the usability of EasyDetectDisease by 30 mothers of children under 5 years. The app was evaluated based on various quantitative and qualitative measures. Results: The participating mothers confirmed that they were able to diagnose diseases accurately and that after following the instructions provided, their children recovered rapidly without any nutritional deficiency. All participating mothers showed an interest in using the EasyDetectDisease app if made available by governmental public health agencies, and they suggested its inclusion in all mobile phones as a built-in health app in the future. Conclusions: EasyDetectDisease was modified into a user-friendly app based on feedback collected during the usability sessions. All participants found it acceptable and easy to use, especially illiterate mothers. The EasyDetectDisease app proved to be a useful tool for child health care at home and for the treatment of infectious diseases and is expected to reduce the mortality rate of children under 5 years of age. %M 31094329 %R 10.2196/12664 %U http://www.i-jmr.org/2019/2/e12664/ %U https://doi.org/10.2196/12664 %U http://www.ncbi.nlm.nih.gov/pubmed/31094329 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e13882 %T Feasibility and Acceptability of Using a Mobile Phone App for Characterizing Auditory Verbal Hallucinations in Adolescents With Early-Onset Psychosis: Exploratory Study %A Smelror,Runar Elle %A Bless,Josef Johann %A Hugdahl,Kenneth %A Agartz,Ingrid %+ Department of Psychiatric Research, Diakonhjemmet Hospital, PO Box 85 Vinderen, Oslo, 0319, Norway, 47 95744029, runar.smelror@medisin.uio.no %K experience sampling method %K ecological momentary assessment %K schizophrenia %K mHealth %K health care technology %D 2019 %7 14.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Auditory verbal hallucinations (AVH) are the most frequent symptom in early-onset psychosis (EOP) and a risk factor for increased suicide attempts in adolescents. Increased knowledge of AVH characteristics can lead to better prediction of risk and precision of diagnosis and help identify individuals with AVH who need care. As 98% of Norwegian adolescents aged 12 to 16 years own a mobile phone, the use of mobile phone apps in symptom assessment and patient communication is a promising new tool. However, when introducing new technology to patients, their subjective experiences are crucial in identifying risks, further development, and potential integration into clinical care. Objective: The objective was to explore the feasibility and acceptability of a newly developed mobile phone app in adolescents with EOP by examining compliance with the app and user experiences. Indication of validity was explored by examining associations between AVH dimensions, which were correlated and analyzed. Methods: Three adolescents with EOP and active AVH were enrolled. Real-time AVH were logged on an iPod touch using the experience sampling method (ESM), for seven or more consecutive days. The app included five dimensions of AVH characteristics and was programmed with five daily notifications. Feasibility and acceptability were examined using the mean response rate of data sampling and by interviewing the participants. Validity was assessed by examining associations between the AVH dimensions using nonparametric correlation analysis and by visual inspection of temporal fluctuations of the AVH dimensions. Results: One participant was excluded from the statistical analyses but completed the interview and was included in the examination of acceptability. The sampling period of the two participants was mean 12 (SD 6) days with overall completed sampling rate of 74% (SD 30%), indicating adequate to high compliance with the procedure. The user experiences from the interviews clustered into four categories: (1) increased awareness, (2) personal privacy, (3) design and procedure, and (4) usefulness and clinical care. One participant experienced more commenting voices during the sampling period, and all three participants had concerns regarding personal privacy when using electronic devices in symptom assessment. The AVH dimensions of content, control, and influence showed moderate to strong significant correlations with all dimensions (P<.001). Days of data sampling showed weak to moderate correlations with localization (P<.001) and influence (P=.03). Visual inspection indicated that the app was able to capture fluctuations within and across days for all AVH dimensions. Conclusions: This study demonstrates the value of including patients’ experiences in the development and pilot-testing of new technology. Based on the small sample size, the use of mobile phones with ESM seems feasible for patients with EOP, but the acceptability of using apps should be considered. Further investigation with larger samples is warranted before definitive conclusions are made. %M 31094321 %R 10.2196/13882 %U http://formative.jmir.org/2019/2/e13882/ %U https://doi.org/10.2196/13882 %U http://www.ncbi.nlm.nih.gov/pubmed/31094321 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e12426 %T Design Choices and Trade-Offs in Health Care Blockchain Implementations: Systematic Review %A O'Donoghue,Odhran %A Vazirani,Anuraag A %A Brindley,David %A Meinert,Edward %+ Healthcare Translation Research Group, Department of Paediatrics, University of Oxford, Level 2, Children's Hospital, John Radcliffe Hospital, Oxford, OX3 9DU, United Kingdom, 44 7824446808, edward.meinert@paediatrics.ox.ac.uk %K blockchain %K interoperability %K distributed ledger technology %K scalability %K health information exchange %D 2019 %7 10.05.2019 %9 Review %J J Med Internet Res %G English %X Background: A blockchain is a list of records that uses cryptography to make stored data immutable; their use has recently been proposed for electronic medical record (EMR) systems. This paper details a systematic review of trade-offs in blockchain technologies that are relevant to EMRs. Trade-offs are defined as “a compromise between two desirable but incompatible features.” Objective: This review’s primary research question was: “What are the trade-offs involved in different blockchain designs that are relevant to the creation of blockchain-based electronic medical records systems?” Methods: Seven databases were systematically searched for relevant articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Papers published from January 1, 2017 to June 15, 2018 were selected. Quality assessments of papers were performed using the Risk Of Bias In Non-randomized Studies—of Interventions (ROBINS-I) tool and the Critical Assessment Skills Programme (CASP) tool. Database searches identified 2885 articles, of which 15 were ultimately included for analysis. Results: A total of 17 trade-offs were identified impacting the design, development, and implementation of blockchain systems; these trade-offs are organized into themes, including business, application, data, and technology architecture. Conclusions: The key findings concluded the following: (1) multiple trade-offs can be managed adaptively to improve EMR utility; (2) multiple trade-offs involve improving the security of blockchain systems at the cost of other features, meaning EMR efficacy highly depends on data protection standards; and (3) multiple trade-offs result in improved blockchain scalability. Consideration of these trade-offs will be important to the specific environment in which electronic medical records are being developed. This review also uses its findings to suggest useful design choices for a hypothetical National Health Service blockchain. International Registered Report Identifier (IRRID): RR2-10.2196/10994 %M 31094344 %R 10.2196/12426 %U https://www.jmir.org/2019/5/e12426/ %U https://doi.org/10.2196/12426 %U http://www.ncbi.nlm.nih.gov/pubmed/31094344 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e13324 %T Young Adults’ Engagement With a Self-Monitoring App for Vegetable Intake and the Impact of Social Media and Gamification: Feasibility Study %A Nour,Monica %A Chen,Juliana %A Allman-Farinelli,Margaret %+ School of Life and Environmental Sciences, Charles Perkins Centre, The University of Sydney, Level 4 EAST, Charles Perkins Centre D17 The University of Sydney, Camperdown, 2006, Australia, 61 403094095, mnou2973@uni.sydney.edu.au %K vegetables %K young adults %K mHealth %K social media %K experimental game %D 2019 %7 10.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Social media and gamification have been used in digital interventions for improving nutrition behaviors of young adults, but few studies measure engagement. Objective: This feasibility study aimed to explore user engagement with a 4-week smartphone program for improving vegetable intake. Methods: A goal setting and self-monitoring app was developed for feasibility testing. We assessed if additional components of gaming and/or social media support increased engagement. A 2 × 2 factorial study design was used with participants randomly allocated to each group. Engagement with the app (usage) was captured via inbuilt software, which recorded total days of app usage (duration) and the frequency of logging vegetable intake. Uptake of the social media (Facebook) content was measured by tracking views, likes, and comments on posts. Results: Out of the 110 potential participants who completed the prescreening questionnaire online, 97 were eligible (mean age 24.8 [SD 3.4]). In total, 49% (47/97) of participants were retained at 4 weeks. Attrition within the first week was the highest among users of the gamified app without social support (Facebook; P<.001). Over the intervention period, 64% (62/97) of participants logged into their app, with vegetable intake recorded on average for 11 out of 28 days. The frequency of recording decreased each week (mean 4 [SD 2] days in week 1 versus mean 2 [SD 2] days in week 4). No effects of gaming or social support on the frequency of recording vegetables or the duration of app engagement were found. However, regardless of the app type, the duration of app engagement was significantly associated with vegetable intake post intervention (P<.001). In total, 60% of Facebook posts were viewed by participants but engagement was limited to likes, with no comments or peer-to-peer interaction observed. Conclusions: As duration of usage was associated with vegetable intake, a deeper understanding of factors influencing engagement is needed. Dimensions such as personal attributes and the setting and context require further exploration in addition to content and delivery. %M 31094322 %R 10.2196/13324 %U http://formative.jmir.org/2019/2/e13324/ %U https://doi.org/10.2196/13324 %U http://www.ncbi.nlm.nih.gov/pubmed/31094322 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12132 %T An E-Learning Adaptation of an Evidence-Based Media Literacy Curriculum to Prevent Youth Substance Use in Community Groups: Development and Feasibility of REAL Media %A Ray,Anne E %A Greene,Kathryn %A Hecht,Michael L %A Barriage,Sarah C %A Miller-Day,Michelle %A Glenn,Shannon D %A Banerjee,Smita C %+ Department of Health Behavior, Society, and Policy, School of Public Health, Rutgers, The State University of New Jersey, 683 Hoes Lane West, Piscataway, NJ, 08854, United States, 1 732 235 5716, aer108@sph.rutgers.edu %K substance use %K prevention %K media literacy %K e-learning %K adaptation %D 2019 %7 09.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: There is a need for evidence-based substance use prevention efforts that target high school-aged youth that are easy to implement and suitable for dissemination in school and community groups. The Youth Message Development (YMD) program is a brief, four-lesson, in-person curriculum that aims to prevent youth substance use through the development of youth media literacy. Specifically, YMD aims to increase understanding of advertising reach and costs, along with the techniques used to sell products; develop counterarguing and critical thinking skills in response to advertisements; and facilitate application of these skills to the development of youth-generated antisubstance messages. Although YMD has demonstrated evidence of success, it is limited by its delivery method and focus on alcohol and smoking. Objective: Study objectives were two-fold: (1) to adapt the YMD curriculum to a self-paced, interactive, electronic-learning (e-learning) format and expand its content to cover alcohol, combustible cigarettes, e-cigarettes, smokeless tobacco, marijuana, and prescription drugs, and (2) to test the feasibility of the adapted curriculum in partnership with a national youth organization. Methods: An iterative process was employed in partnership with the 4-H youth development organization and a technology developer and consisted of six phases: (1) focus groups to guide adaptation, (2) adaptation to an e-learning format renamed REAL media, (3) pilot-testing of the REAL media prototype to determine feasibility and acceptability, (4) program revisions, (5) usability testing of the revised prototype, and (6) final revisions. Focus groups and pilot and usability testing were conducted with 4-H youth club members and adult club leaders. Results: Focus group feedback guided the build of an e-learning prototype of REAL media, which consisted of five online levels and interactive content guided by a mix of narration and on-screen text. Results of a pilot test of the prototype were neutral to positive, and the program was refined based on end-user feedback. An independent usability test indicated that youth 4-H members felt favorably about navigating REAL media, and they reported high self-efficacy in applying skills learned in the program. Additional refinements to the program were made based on their feedback. Conclusions: The iterative build process involving the end user from the outset yielded an overall successful technology-driven adaptation of an evidence-based curriculum. This should increase the likelihood of effectively impacting behavioral outcomes as well as uptake within community organizations. %M 31094328 %R 10.2196/12132 %U http://formative.jmir.org/2019/2/e12132/ %U https://doi.org/10.2196/12132 %U http://www.ncbi.nlm.nih.gov/pubmed/31094328 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11890 %T Barriers and Facilitators for Implementing a Decision Support System to Prevent and Treat Disease-Related Malnutrition in a Hospital Setting: Qualitative Study %A Paulsen,Mari Mohn %A Varsi,Cecilie %A Paur,Ingvild %A Tangvik,Randi Julie %A Andersen,Lene Frost %+ National Advisory Unit on Disease-related Malnutrition, Department of Cancer Medicine, Oslo University Hospital, Sognsvannsveien 20, Oslo, 0372, Norway, 47 22851103, m.m.paulsen@medisin.uio.no %K malnutrition %K implementation science %K eHealth %K qualitative research %K decision support systems, clinical %D 2019 %7 09.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Disease-related malnutrition is a challenge among hospitalized patients. Despite guidelines and recommendations for prevention and treatment, the condition continues to be prevalent. The MyFood system is a recently developed decision support system to prevent and treat disease-related malnutrition. Objective: To investigate the possible implementation of the MyFood system in clinical practice, the aims of the study were (1) to identify current practice, routines, barriers, and facilitators of nutritional care; (2) to identify potential barriers and facilitators for the use of MyFood; and (3) to identify the key aspects of an implementation plan. Methods: A qualitative study was performed among nurses, physicians, registered dietitians, and middle managers in 2 departments in a university hospital in Norway. Focus group discussions and semistructured interviews were used to collect data. The Consolidated Framework for Implementation Research (CFIR) was used to create the interview guide and analyze the results. The transcripts were analyzed using a thematic analysis. Results: A total of 27 health care professionals participated in the interviews and focus groups, including nurses (n=20), physicians (n=2), registered dietitians (n=2), and middle managers (n=3). The data were analyzed within 22 of the 39 CFIR constructs. Using the 5 CFIR domains as themes, we obtained the following results: (1) Intervention characteristics: MyFood was perceived to have a relative advantage of being more trustworthy, systematic, and motivational and providing increased awareness of nutritional treatment compared with the current practice. Its lack of communication with the existing digital systems was perceived as a potential barrier; (2) Outer settings: patients from different cultural backgrounds with language barriers and of older age were potential barriers for the use of the MyFood system; (3) Inner settings: no culture for specific routines or systems related to nutritional care existed in the departments. However, tension for change regarding screening for malnutrition risk, monitoring and nutritional treatment was highlighted in all categories of interviewees; (4) Characteristics of the individuals: positive attitudes toward MyFood were present among the majority of the interviewees, and they expressed self-efficacy toward the perceived use of MyFood; (5) Process: providing sufficient information to everyone in the department was highlighted as key to the success of the implementation. The involvement of opinion leaders, implementation leaders, and champions was also suggested for the implementation plan. Conclusions: This study identified several challenges in the nutritional care of hospitalized patients at risk of malnutrition and deviations from recommendations and guidelines. The MyFood system was perceived as being more precise, trustworthy, and motivational than the current practice. However, several potential barriers were identified. The assessment of the current situation and the identification of perceived barriers and facilitators will be used in planning an implementation and effect study, including the creation of an implementation plan. %M 31094333 %R 10.2196/11890 %U http://formative.jmir.org/2019/2/e11890/ %U https://doi.org/10.2196/11890 %U http://www.ncbi.nlm.nih.gov/pubmed/31094333 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11364 %T The Use of Smart Technology in an Online Community of Patients With Degenerative Cervical Myelopathy %A Mowforth,Oliver Daniel %A Davies,Benjamin Marshall %A Kotter,Mark Reinhard %+ Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge,, United Kingdom, 44 1223 763366, mrk25@cam.ac.uk %K spinal cord diseases %K cervical vertebrae %K spinal osteophytosis %K spondylosis %K biomedical technology %K chronic disease %K follow-up studies %D 2019 %7 09.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Degenerative cervical myelopathy (DCM) is a prevalent and progressively disabling neurological condition. Treatment is currently limited to surgery, the timing of which is not without controversy. New international guidelines recommend that all patients should undergo lifelong surveillance and those with moderate-to-severe or progressive disease should be offered surgery. Long-term surveillance will place substantial burden on health services and short clinic assessments may risk misrepresenting disease severity. The use of smart technology to monitor disease progression could provide an invaluable opportunity to lessen this burden and improve patient care. However, given the older demographic of DCM, the feasibility of smart technology use is unclear. Objective: The aim of this study was to investigate current usage of smart technology in patients with self-reported DCM to inform design of smart technology apps targeted at monitoring DCM disease progression. Methods: Google Analytics from the patient section of Myelopathy.org, an international DCM charity with a large online patient community, was analyzed over a 1-year period. A total of 15,761 sessions were analyzed. Results: In total, 39.6% (295/744) of visitors accessed the website using a desktop computer, 35.1% (261/744) using mobile, and 25.3% (188/744) using a tablet. Of the mobile and tablet visitors, 98.2% (441/449) utilized a touchscreen device. A total of 51.3% (141/275) of mobile and tablet visitors used iPhone Operating System (iOS) and 45.8% (126/275) used an Android operating system. Apple and Samsung were the most popular smart devices, utilized by 53.6% (241/449) and 25.8% (116/449) of visitors, respectively. The overall visitor age was representative of DCM trials. Smart technology was widely used by older visitors: 58.8% (113/192) of mobile visitors and 84.2% (96/114) of tablet visitors were aged 45 years or older. Conclusions: Smart technology is commonly used by DCM patients. DCM apps need to be iOS and Android compatible to be accessible to all patients. %M 31094330 %R 10.2196/11364 %U http://formative.jmir.org/2019/2/e11364/ %U https://doi.org/10.2196/11364 %U http://www.ncbi.nlm.nih.gov/pubmed/31094330 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12679 %T Feasibility of a Mobile Phone App to Promote Adherence to a Heart-Healthy Lifestyle: Single-Arm Study %A Lunde,Pernille %A Nilsson,Birgitta Blakstad %A Bergland,Astrid %A Bye,Asta %+ Department of Physiotherapy, Faculty of Health Sciences, Oslo Metropolitan University, P50, PB 4, St Olavs Plass, Oslo,, Norway, 47 48 06 35 37, plunde@oslomet.no %K mHealth %K eHealth %K mobile phone app %K cardiac rehabilitation %D 2019 %7 19.4.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Long-term maintenance of preventive activities is fundamental for achieving improved outcomes in cardiac rehabilitation (CR). Despite this, it has been shown to be a major challenge for many patients to follow recommendations and thereby adhere to a heart-healthy lifestyle. Mobile phone apps have been emphasized as potential tools to promote preventive activities after attendance in a CR program. Before commencing a trial to assess the potential effect of using an app to promote long-term adherence to preventive activities after attendance in CR, a study to assess if it is feasible to use an app is warranted. Objective: The goal of the research is to assess if it is feasible to use a mobile phone app for promoting and monitoring patients’ adherence to a heart-healthy lifestyle after CR. Methods: The study included an experimental, pre-post single-arm trial lasting for 12 weeks. All patients received access to an app aimed to guide individuals to change or maintain a heart-healthy lifestyle. During the study period, patients received weekly, individualized monitoring through the app, based on their own goals. Feasibility outcomes assessed were recruitment rate, adherence to the app, resource requirements, and efficacy regarding capability to detect a change in quality of life, health status, and perceived goal achievement as well as evaluating ceiling and floor effect in these outcomes. Criteria for success were preset to be able to evaluate whether the app was feasible to use in a potential future RCT. Results: In total, 71% (17/24) of the patients who completed CR were eligible for a potential RCT as well as for this study. All 14 patients included in the study used the app to promote preventive activities throughout the study. Satisfaction with the technology was high, and the patients found the technology-based follow-up intervention both useful and motivational. Ceiling effect was present in more than 20% of the patients in several domains of the questionnaires evaluating quality of life (36-Item Short Form Health Survey and COOP/WONCA functional health assessments) and health status (EQ-5D). Overall self-rated health status (EuroQol Visual Analog Scale) and perceived goal achievement were found to be outcomes able to detect a change. Conclusions: Individual follow-up through an app after attendance in CR is feasible. All patients used the app for preventive activities and found the app both useful and motivating. Several points of guidance from the patients in the study have been adopted and incorporated into the final design of the RCT now in the field. %M 31066684 %R 10.2196/12679 %U http://formative.jmir.org/2019/2/e12679/ %U https://doi.org/10.2196/12679 %U http://www.ncbi.nlm.nih.gov/pubmed/31066684 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12406 %T Considerations of Privacy and Confidentiality in Developing a Clinical Support Tool for Adolescent Tobacco Prevention: Qualitative Study %A Theis,Ryan P %A Malik,Ali M %A Thompson,Lindsay A %A Shenkman,Elizabeth A %A Pbert,Lori %A Salloum,Ramzi G %+ Institute for Child Health Policy, Department of Health Outcomes and Biomedical Informatics, University of Florida, 2004 Mowry Road, Suite 2252, Gainesville, FL, 32610, United States, 1 352 294 5973, rtheis@ufl.edu %K clinical decision support %K adolescent %K primary care %K tobacco use %K confidentiality %K implementation science %K qualitative research %D 2019 %7 28.4.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Electronic clinical support tools show promise for facilitating tobacco screening and counseling in adolescent well-care. However, the application of support tools in pediatric settings has not been thoroughly studied. Successfully implementing support tools in local settings requires an understanding of barriers and facilitators from the perspective of both patients and providers. Objective: This paper aimed to present the findings of a qualitative study conducted to inform the development and implementation of a support tool for adolescent tobacco screening and counseling in 3 pediatric clinics in North Florida. The primary objective of the study was to test and collect information needed to refine a tablet-based support tool with input from patients and providers in the study clinics. Methods: A tablet prototype was designed to collect information from adolescents on tobacco susceptibility and use before their well-care visit and to present tobacco prevention videos based on their responses. Information collected from adolescents by the support tool would be available to providers during the visit to facilitate and streamline tobacco use assessment and counseling components of well-care. Focus groups with providers and staff from 3 pediatric clinics (n=24) identified barriers and facilitators to implementation of the support tool. In-depth interviews with racially and ethnically diverse adolescent patients who screened as susceptible to tobacco use (n=16) focused on acceptability and usability of the tool. All focus groups and interviews were audio-recorded and transcribed for team-based coding using thematic analysis. Results: Privacy and confidentiality of information was a salient theme. Both groups expressed concerns that the tool’s audio and visual components would impede privacy and that parents may read their child’s responses or exert control over the process. Nearly all adolescents stated they would be comfortable with the option to complete the tool at home via a Web portal. Most adolescents stated they would feel comfortable discussing tobacco with their doctor. Adolescent interviews elicited 3 emergent themes that added context to perspectives on confidentiality and had practical implications for implementation: (1) purity: an expressed lack of concern for confidentiality among adolescents with no reported history of tobacco use; (2) steadfast honesty: a commitment to being honest with parents and providers about tobacco use, regardless of the situation; and (3) indifference: a perceived lack of relevance of confidentiality, based on the premise that others will “find out anyway” if adolescents are using tobacco. Conclusions: This study informed several modifications to the intervention to address confidentiality and introduce efficiency to well-care visits. The support tool was integrated into the electronic health record system used by the study clinics and modified to offer videos to all adolescents regardless of their tobacco use or susceptibility. Future studies will further test the acceptability of the intervention in practice. %M 31066687 %R 10.2196/12406 %U http://formative.jmir.org/2019/2/e12406/ %U https://doi.org/10.2196/12406 %U http://www.ncbi.nlm.nih.gov/pubmed/31066687 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 5 %P e13415 %T Web-Based Interventions to Improve Mental Health in Home Caregivers of People With Dementia: Meta-Analysis %A Zhao,Yinan %A Feng,Hui %A Hu,Mingyue %A Hu,Hengyu %A Li,Hui %A Ning,Hongting %A Chen,Huijing %A Liao,Lulu %A Peng,Linlin %+ Xiangya School of Nursing, Central South University, No 172 Tongzipo Road, Changsha,, China, 86 82650292, feng.hui@csu.edu.cn %K internet %K education %K mental health %K caregivers %K dementia %D 2019 %7 6.5.2019 %9 Review %J J Med Internet Res %G English %X Background: Dementia is a major cause of disability and dependency in older adults worldwide. It is often accompanied by general psychological distress, such as depression and anxiety symptoms, among caregivers of people with dementia (PwD). The physical and mental health of the caregiver is a prerequisite and a promise to help PwD continue to live as long and as well as possible. Web-based interventions can provide convenient and efficient support and an education tool to potentially reduce the negative outcomes associated with providing care. Objective: The aim of this study was to examine the effect of internet-based interventions on the mental health outcomes of family caregivers of PwD and to explore which components of the Web-based interventions play an important role. Methods: A comprehensive literature search was conducted in PubMed, Excerpta Medica dataBASE, PsycINFO, Cochrane Database, and the Cumulative Index to Nursing and Allied Health Literature using relevant terms such as Web-based and caregiver as keywords, covering all studies published before June 2018. A total of 2 reviewers independently reviewed all published abstracts, according to established inclusion and exclusion criteria. We extracted information about the participants, interventions, and results and reviewed article quality in terms of the randomized trial methods, using the approach recommended by the Cochrane Handbook for Systematic Reviews of Interventions. Results: A total of 815 caregivers participated in 6 studies, with 4 of the studies using depression as an outcome. The analysis found that depression scores dropped an average of 0.23 (95% CI −0.38 to −0.07; P<.01) after Web-based interventions. In 2 studies of caregivers who were experiencing anxiety symptoms, the average score for anxiety dropped by 0.32 points (95% CI −0.50 to −0.14; P<.01). However, in terms of coping, pain, and stress, the Web-based interventions showed a poor effect. On the whole, the addition of professional psychological support on the basis of education can improve caregivers’ mental health. Conclusions: Internet-based interventions were generally effective at reducing anxiety and depression in dementia caregivers, although negative results were found in some studies. As for burden and stress, further research is required. %M 31066680 %R 10.2196/13415 %U http://www.jmir.org/2019/5/e13415/ %U https://doi.org/10.2196/13415 %U http://www.ncbi.nlm.nih.gov/pubmed/31066680 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11958 %T The Implementation of an mHealth Intervention (ReZone) for the Self-Management of Overwhelming Feelings Among Young People %A Edridge,Chloe %A Deighton,Jessica %A Wolpert,Miranda %A Edbrooke-Childs,Julian %+ Anna Freud National Centre for Children and Families, 12 Maresfield Gardens, London, NW3 5SU, United Kingdom, 44 020 7433 6191, chloe.edridge@annafreud.org %K cluster trial %K behavioural difficulties %K schools %K mHealth, digital %K mental health %K mobile phone %D 2019 %7 02.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: The association between mental health difficulties and academic attainment is well established. There is increasing research on mobile health (mHealth) interventions to provide support for the mental health and education of young people. However, nonadoption and inadequate implementation of mHealth interventions are prevalent barriers to such trials. Objective: The aim of this study was to bridge this gap and examine the implementation of an mHealth intervention, ReZone, for young people in schools. Methods: Preliminary data for 79 students collected as part of a larger trial were analyzed. We additionally conducted postimplementation consultations with teachers. Results: ReZone was used 1043 times by 36 students in the intervention arm during the study period. Postimplementation teacher consultations provided data on implementation strategies, barriers, and facilitators. Conclusions: Implementation strategies, barriers, and facilitators for digital interventions need to be considered to limit nonadoption and inadequate implementation in larger trials. Important considerations involve tailoring the characteristics of the intervention to the requirements of the intended user group, the technology itself, and the organization in which it is implemented. Trial Registration: International Standard Randomised Controlled Trial Number: 13425994; http://www.isrctn.com/ISRCTN13425994 %M 31045499 %R 10.2196/11958 %U http://formative.jmir.org/2019/2/e11958/ %U https://doi.org/10.2196/11958 %U http://www.ncbi.nlm.nih.gov/pubmed/31045499 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11242 %T An Intervention to Increase Condom Use Among Users of Chlamydia Self-Sampling Websites (Wrapped): Intervention Mapping and Think-Aloud Study %A Newby,Katie %A Crutzen,Rik %A Brown,Katherine %A Bailey,Julia %A Saunders,John %A Szczepura,Ala %A Hunt,Jonny %A Alston,Tim %A Sadiq,S Tariq %A Das,Satyajit %+ Centre for Advances in Behavioural Science, Faculty of Health and Life Sciences, Coventry University, RC Building (4th Floor), Priory St, Coventry, CV1 5FB, United Kingdom, 44 02477 657459, k.newby@coventry.ac.uk %K sexually transmitted infection %K condoms %K sexual behavior %K young adult %K intervention development %K internet %K eHealth %K co-design %D 2019 %7 01.05.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Young people aged 16-24 years are disproportionately affected by sexually transmitted infections (STIs). STIs can have serious health consequences for affected individuals and the estimated annual cost of treatment to the National Health Service is £620 million. Accordingly, the UK government has made reducing the rates of STIs among this group a priority. A missed opportunity to intervene to increase condom use is when young people obtain self-sampling kits for STIs via the internet. Objective: Our aim was to develop a theory-based tailored intervention to increase condom use for 16-24-years-olds accessing chlamydia self-sampling websites. Methods: The intervention, Wrapped, was developed using Intervention Mapping and was co-designed with young people. The following steps were performed: (1) identification of important determinants of condom use and evidence of their changeability using computer and digital interventions; (2) setting the intervention goal, performance objectives, and change objectives; (3) identification of Behavior Change Principles (BCPs) and practical strategies to target these determinants; and (4) development of intervention materials able to deliver the BCPs and practical strategies. Results: Users of existing chlamydia self-sampling websites are signposted to Wrapped after placing an order for a sampling kit. Salient barriers to condom use are identified by each user and relevant intervention components are allocated to target these. The components include the following: (1) a sample box of condoms, (2) an online condom distribution service, (3) a product for carrying condoms, (4) a condom demonstration video, (5) a series of videos on communication about condom use, and (6) erotic films of real couples discussing and demonstrating condom use. Conclusions: This intervention will be directed at young people who may be particularly receptive to messages and support for behavior change due to their testing status. %M 31042156 %R 10.2196/11242 %U http://formative.jmir.org/2019/2/e11242/ %U https://doi.org/10.2196/11242 %U http://www.ncbi.nlm.nih.gov/pubmed/31042156 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11586 %T Feasibility Randomized Controlled Trial of ImpulsePal: Smartphone App–Based Weight Management Intervention to Reduce Impulsive Eating in Overweight Adults %A van Beurden,Samantha B %A Smith,Jane R %A Lawrence,Natalia S %A Abraham,Charles %A Greaves,Colin J %+ College of Medicine and Health, University of Exeter, Smeall Building, Heavitree Road, Exeter, EX1 2LU, United Kingdom, 44 139272 ext 6440, s.b.vanbeurden@exeter.ac.uk %K weight loss %K mHealth %K digital behavior change %K obesity %K dual-process %D 2019 %7 30.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: ImpulsePal is a theory-driven (dual-process), evidence-informed, and person-centered smartphone app intervention designed to help people manage impulsive processes that prompt unhealthy eating to facilitate dietary change and weight loss. Objective: The aims of this study were to (1) assess the feasibility of trial procedures for evaluation of the ImpulsePal intervention, (2) estimate standard deviations of outcomes, and (3) assess usability of, and satisfaction with, ImpulsePal. Methods: We conducted an individually randomized parallel two-arm nonblinded feasibility trial. The eligibility criteria included being aged ≥16 years, having a body mass index of ≥25 kg/m2, and having access to an Android-based device. Weight was measured (as the proposed primary outcome for a full-scale trial) at baseline, 1 month, and 3 months of follow-up. Participants were randomized in a 2:1 allocation ratio to the ImpulsePal intervention or a waiting list control group. A nested action-research study allowed for data-driven refinement of the intervention across 2 cycles of feedback. Results: We screened 179 participants for eligibility, and 58 were randomized to the intervention group and 30 to the control group. Data were available for 74 (84%, 74/88) participants at 1 month and 67 (76%, 67/88) participants at 3 months. The intervention group (n=43) lost 1.03 kg (95% CI 0.33 to 1.74) more than controls (n=26) at 1 month and 1.01 kg (95% CI −0.45 to 2.47) more than controls (n=43 and n=24, respectively) at 3 months. Feedback suggested changes to intervention design were required to (1) improve receipt and understanding of instructions and (2) facilitate further engagement with the app and its strategies. Conclusions: The evaluation methods and delivery of the ImpulsePal app intervention are feasible, and the trial procedures, measures, and intervention are acceptable and satisfactory to the participants. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 14886370; http://www.isrctn.com/ISRCTN14886370 (Archived by WebCite at http://www.webcitation.org/76WcEpZ51) %M 31038464 %R 10.2196/11586 %U https://formative.jmir.org/2019/2/e11586/ %U https://doi.org/10.2196/11586 %U http://www.ncbi.nlm.nih.gov/pubmed/31038464 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12662 %T Smartphone-Based Meditation for Myeloproliferative Neoplasm Patients: Feasibility Study to Inform Future Trials %A Huberty,Jennifer %A Eckert,Ryan %A Larkey,Linda %A Kurka,Jonathan %A Rodríguez De Jesús,Sue A %A Yoo,Wonsuk %A Mesa,Ruben %+ College of Health Solutions, Arizona State University, 500 North 3rd St, Phoenix, AZ, 85004, United States, 1 402 301 1304, jhuberty@asu.edu %K mindfulness %K meditation %K smartphone %K mHealth %K cancer %K quality of life %D 2019 %7 29.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Myeloproliferative neoplasm (MPN) patients often report high symptom burden that persists despite the best available pharmacologic therapy. Meditation has gained popularity in recent decades as a way to manage cancer patient symptoms. Objective: The aim of this study was to examine the feasibility of 2 different consumer-based meditation smartphone apps in MPN patients and to examine the limited efficacy of smartphone-based meditation on symptoms compared with an educational control group. Methods: Patients (n=128) were recruited nationally through organizational partners and social media. Eligible and consented patients were enrolled into 1 of 4 groups, 2 of which received varying orders of 2 consumer-based apps (10% Happier and Calm) and 2 that received one of the apps alone for the second 4 weeks of the 8-week intervention after an educational control condition. Participants were asked to perform 10 min of meditation per day irrespective of the app and the order in which they received the apps. Feasibility outcomes were measured at weeks 5 and 9 with a Web-based survey. Feasibility outcomes were acceptability, demand, and limited efficacy for depression, anxiety, pain intensity, sleep disturbance, sexual function, quality of life, global health, and total symptom burden. Results: A total of 128 patients were enrolled across all 4 groups, with 73.4% (94/128) patients completing the intervention. Of the participants who completed the 10% Happier app, 61% (46/76) enjoyed it, 66% (50/76) were satisfied with the content, and 77% (59/76) would recommend to others. Of those who completed the Calm app, 83% (56/68) enjoyed it, 84% (57/68) were satisfied with the content, and 97% (66/68) would recommend to others. Of those who completed the educational control, 91% (56/61) read it, 87% (53/61) enjoyed it, and 71% (43/61) learned something. Participants who completed the 10% Happier app averaged 31 (SD 33) min/week; patients completing the Calm app averaged 71 (SD 74) min/week. 10% Happier app participants saw small effects on anxiety (P<.001 d=−0.43), depression (P=.02; d=−0.38), sleep disturbance (P=.01; d=−0.40), total symptom burden (P=.13; d=−0.27), and fatigue (P=.06; d=−0.30), and moderate effects on physical health (P<.001; d=0.52). Calm app participants saw small effects on anxiety (P=.29; d=−0.22), depression (P=.09; d=−0.29), sleep disturbance (P=.002; d=−0.47), physical health (P=.005; d=0.44), total symptom burden (P=.13; d=−0.27), and fatigue (P=.13; d=−0.27). Educational control participants (n=61) did not have effects on any patient-reported outcome except for a moderate effect on physical health (P<.001; d=0.77). Conclusions: Delivering meditation via the Calm app is feasible and scored higher in terms of feasibility when compared with the 10% Happier app. The Calm app will be used to implement a randomized controlled trial, testing the effects of meditation on symptom burden in MPNs. Trial Registration: ClinicalTrials.gov NCT03726944; https://clinicaltrials.gov/ct2/show/NCT03726944 (Archived by WebCite at http://www.webcitation.org/77MVdFJwM) %M 31033443 %R 10.2196/12662 %U http://formative.jmir.org/2019/2/e12662/ %U https://doi.org/10.2196/12662 %U http://www.ncbi.nlm.nih.gov/pubmed/31033443 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12982 %T An Adaptive Mobile Health System to Support Self-Management for Persons With Chronic Conditions and Disabilities: Usability and Feasibility Studies %A Setiawan,I Made Agus %A Zhou,Leming %A Alfikri,Zakiy %A Saptono,Andi %A Fairman,Andrea D %A Dicianno,Brad Edward %A Parmanto,Bambang %+ Department of Health Information Management, School of Health and Rehabilitation Sciences, University of Pittsburgh, 6025 Forbes Tower, Pittsburgh, PA, 15260, United States, 1 412 383 6649, parmanto@pitt.edu %K mHealth %K adaptive mHealth %K mobile apps %K telemedicine %K personalized medicine %K self-management %K self-care %K caregivers %K chronic disease %K persons with disabilities %D 2019 %7 25.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Persons with chronic conditions and disabilities (PwCCDs) are vulnerable to secondary complications. Many of these secondary complications are preventable with proactive self-management and proper support. To enhance PwCCDs' self-management skills and conveniently receive desired support, we have developed a mobile health (mHealth) system called iMHere. In 2 previous clinical trials, iMHere was successfully used to improve health outcomes of adult participants with spina bifida and spinal cord injury. To further expand use of iMHere among people with various types of disabilities and chronic diseases, the system needs to be more adaptive to address 3 unique challenges: 1) PwCCDs have very diverse needs with regards to self-management support, 2) PwCCDs’ self-management needs may change over time, and 3) it is a challenge to keep PwCCDs engaged and interested in long-term self-management. Objective: The aim of this study was to develop an adaptive mHealth system capable of supporting long-term self-management and adapting to the various needs and conditions of PwCCDs. Methods: A scalable and adaptive architecture was designed and implemented for the new version, iMHere 2.0. In this scalable architecture, a set of mobile app modules was created to provide various types of self-management support to PwCCDs with the ability to add more as needed. The adaptive architecture empowers PwCCDs with personally relevant app modules and allows clinicians to adapt these modules in response to PwCCDs’ evolving needs and conditions over time. Persuasive technologies, social support, and personalization features were integrated into iMHere 2.0 to engage and motivate PwCCDs and support long-term usage. Two initial studies were performed to evaluate the usability and feasibility of the iMHere 2.0 system. Results: The iMHere 2.0 system consists of cross-platform client and caregiver apps, a Web-based clinician portal, and a secure 2-way communication protocol for providing interactions among these 3 front-end components, all supported by a back-end server. The client and caregiver apps have 12 adaptive app modules to support various types of self-management tasks. The adaptive architecture makes it possible for PwCCDs to receive personalized app modules relevant to their conditions with or without support from various types of caregivers. The personalization and persuasive technologies in the architecture can be used to engage PwCCDs for long-term usage of the iMHere 2.0 system. Participants of the usability study were satisfied with the iMHere 2.0 client app. The feasibility evaluation revealed several practical issues to consider when implementing the system on a large scale. Conclusions: We developed an adaptive mHealth system as a novel method to support diverse needs in self-management for PwCCDs that can dynamically change over time. The usability of the client app is high, and it was feasible for PwCCDs to use in supporting personalized and evolving self-care needs. %M 31021324 %R 10.2196/12982 %U http://formative.jmir.org/2019/2/e12982/ %U https://doi.org/10.2196/12982 %U http://www.ncbi.nlm.nih.gov/pubmed/31021324 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11489 %T Measuring Free-Living Physical Activity With Three Commercially Available Activity Monitors for Telemonitoring Purposes: Validation Study %A Breteler,Martine JM %A Janssen,Joris H %A Spiering,Wilko %A Kalkman,Cor J %A van Solinge,Wouter W %A Dohmen,Daan AJ %+ Department of Anesthesiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, Utrecht,, Netherlands, 31 647396841, m.j.m.breteler@umcutrecht.nl %K activity trackers %K telemedicine %K exercise %D 2019 %7 24.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Remote monitoring of physical activity in patients with chronic conditions could be useful to offer care professionals real-time assessment of their patient’s daily activity pattern to adjust appropriate treatment. However, the validity of commercially available activity trackers that can be used for telemonitoring purposes is limited. Objective: The purpose of this study was to test usability and determine the validity of 3 consumer-level activity trackers as a measure of free-living activity. Methods: A usability evaluation (study 1) and validation study (study 2) were conducted. In study 1, 10 individuals wore one activity tracker for a period of 30 days and filled in a questionnaire on ease of use and wearability. In study 2, we validated three selected activity trackers (Apple Watch, Misfit Shine, and iHealth Edge) and a fourth pedometer (Yamax Digiwalker) against the reference standard (Actigraph GT3X) in 30 healthy participants for 72 hours. Outcome measures were 95% limits of agreement (LoA) and bias (Bland-Altman analysis). Furthermore, median absolute differences (MAD) were calculated. Correction for bias was estimated and validated using leave-one-out cross validation. Results: Usability evaluation of study 1 showed that iHealth Edge and Apple Watch were more comfortable to wear as compared with the Misfit Flash. Therefore, the Misfit Flash was replaced by Misfit Shine in study 2. During study 2, the total number of steps of the reference standard was 21,527 (interquartile range, IQR 17,475-24,809). Bias and LoA for number of steps from the Apple Watch and iHealth Edge were 968 (IQR −5478 to 7414) and 2021 (IQR −4994 to 9036) steps. For Misfit Shine and Yamax Digiwalker, bias was −1874 and 2004, both with wide LoA of (13,869 to 10,121) and (−10,932 to 14,940) steps, respectively. The Apple Watch noted the smallest MAD of 7.7% with the Actigraph, whereas the Yamax Digiwalker noted the highest MAD (20.3%). After leave-one-out cross validation, accuracy estimates of MAD of the iHealth Edge and Misfit Shine were within acceptable limits with 10.7% and 11.3%, respectively. Conclusions: Overall, the Apple Watch and iHealth Edge were positively evaluated after wearing. Validity varied widely between devices, with the Apple Watch being the most accurate and Yamax Digiwalker the least accurate for step count in free-living conditions. The iHealth Edge underestimates number of steps but can be considered reliable for activity monitoring after correction for bias. Misfit Shine overestimated number of steps and cannot be considered suitable for step count because of the low agreement. Future studies should focus on the added value of remotely monitoring activity patterns over time in chronic patients. %M 31017587 %R 10.2196/11489 %U http://formative.jmir.org/2019/2/e11489/ %U https://doi.org/10.2196/11489 %U http://www.ncbi.nlm.nih.gov/pubmed/31017587 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e12028 %T iCanCope PostOp: User-Centered Design of a Smartphone-Based App for Self-Management of Postoperative Pain in Children and Adolescents %A Birnie,Kathryn A %A Campbell,Fiona %A Nguyen,Cynthia %A Lalloo,Chitra %A Tsimicalis,Argerie %A Matava,Clyde %A Cafazzo,Joseph %A Stinson,Jennifer %+ Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, ON, M5G 0A4, Canada, 1 416 813 7654, kathryn.birnie@sickkids.ca %K postoperative pain %K smartphone %K mobile applications %K mHealth %K pain management %K self-management %K adolescent %D 2019 %7 22.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Moderate to severe postoperative pain in children is common. Increased pediatric day surgeries have shifted postoperative pain management predominantly to the home setting. Mobile health technology has the potential to overcome barriers to pain care by improving access to self-management resources. However, pain apps generally lack scientific evidence and are highly underutilized due to lack of involvement of end users in their development. Thus, an evidence-based pain self-management smartphone app that incorporates the needs and perspective of children and adolescents (end users) has potential to improve postoperative pain management. Objective: This paper aimed to describe how the principles of user-centered design were applied to the development of iCanCope PostOp, a smartphone-based pain self-management app for children and adolescents after surgery. Specifically, it presents 2 completed phases of the user-centered design process (concept generation and ideation) for the iCanCope PostOp app. Methods: Phase 1 was a multisite needs assessment from the perspective of 19 children and adolescents who had undergone various day surgeries, 19 parents, and 32 multidisciplinary health care providers. Children, adolescents, and parents completed individual semistructured interviews, and health care providers participated in focus groups. Data were summarized using qualitative content analysis. Phase 2 developed a pain care algorithm for the app using Delphi surveys and a 2-day in-person design workshop with 11 multidisciplinary pediatric postoperative pain experts and 2 people with lived experience with postoperative pain. Results: Phase 1 identified self-management challenges to postoperative pain management and recovery; limited available resources and reliance on medications as a predominant postoperative pain management strategy; and shared responsibility of postoperative pain care by children and adolescents, parents, and health care providers. Key app functions of tracking pain, pain self-management strategies, and goal setting were identified as priorities. Phase 2 led to the successful and efficient generation of a complete preliminary pain care algorithm for the iCanCope PostOp app, including clinically relevant inputs for feasible assessment and reassessment of pain and function (rest or sleep, movement or play, and mood or worry), as well as a catalog of pain management advice to be pushed to end users (psychological, physical, pharmacological, and education). Conclusions: The concept ideation and generation phases of the user-centered design approach were successfully completed for the iCanCope PostOp app. Next steps will include design finalization, app development (iOS or Android), evaluation through a randomized controlled trial, and subsequent implementation of the iCanCope PostOp app in clinical care. %M 31008704 %R 10.2196/12028 %U http://formative.jmir.org/2019/2/e12028/ %U https://doi.org/10.2196/12028 %U http://www.ncbi.nlm.nih.gov/pubmed/31008704 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e10880 %T AO Patient Outcomes Center: Design, Implementation, and Evaluation of a Software Application for the Collection of Patient-Reported Outcome Measures in Orthopedic Outpatient Clinics %A Rothrock,Nan E %A Bass,Michael %A Blumenthal,Andrea %A Gershon,Richard C %A Hanson,Beate %A Joeris,Alexander %A Kaat,Aaron %A Morrison,Suzanne %A O'Toole,Robert V %A Patel,Shalini %A Stover,Michael %A Weaver,Michael J %A White,Raymond %A Varela Diaz,Maria %A Vrahas,Mark S %+ Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 625 North Michigan Avenue, Suite 2700, Chicago, IL, 60611, United States, 1 312 503 3514, n-rothrock@northwestern.edu %K orthopedics %K patient reported outcome measures %K tablet computers %D 2019 %7 12.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Patient-reported outcomes are increasingly utilized in routine orthopedic clinical care. Computer adaptive tests (CATs) from the Patient-Reported Outcomes Measurement Information System (PROMIS) offer a brief and precise assessment that is well suited for collection within busy clinical environments. However, software apps that support the administration and scoring of CATs, provide immediate access to patient-reported outcome (PRO) scores, and minimize clinician burden are not widely available. Objective: Our objective was to design, implement, and test the feasibility and usability of a Web-based system for collecting CATs in orthopedic clinics. Methods: AO Patient Outcomes Center (AOPOC) was subjected to 2 rounds of testing. Alpha testing was conducted in 3 orthopedic clinics to evaluate ease of use and feasibility of integration in clinics. Patients completed an assessment of PROMIS CATs and a usability survey. Clinicians participated in a brief semistructured interview. Beta-phase testing evaluated system performance through load testing and usability of the updated version of AOPOC. In both rounds of testing, user satisfaction, bugs, change requests, and performance of PROMIS CATs were captured. Results: Patient feedback supported the ease of use in completing an assessment in AOPOC. Across both phases of testing, clinicians rated AOPOC as easy to use but noted difficulties in integrating a Web-based software application within their clinics. PROMIS CATs performed well; the default assessment of 2 CATs was completed quickly (mean 9.5 items) with a satisfactory range of measurement. Conclusion: AOPOC was demonstrated to be an easy-to-learn and easy-to-use software application for patients and clinicians that can be integrated into orthopedic clinical care. The workflow disruption in integrating any type of PRO collection must be addressed if patients’ voices are to be better integrated in clinical care. %M 30977735 %R 10.2196/10880 %U https://formative.jmir.org/2019/2/e10880/ %U https://doi.org/10.2196/10880 %U http://www.ncbi.nlm.nih.gov/pubmed/30977735 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e10990 %T Development of a Smartphone App for Informal Carers of People With Cancer: Processes and Learnings %A Heynsbergh,Natalie %A Heckel,Leila %A Botti,Mari %A O,Seung Chul %A Livingston,Patricia M %+ School of Nursing and Midwifery, Faculty of Health, Deakin University, Geelong,, Australia, 61 392446333, n.heynsbergh@deakin.edu.au %K cancer %K carer %K smartphone %K mobile applications %K technology %D 2019 %7 11.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: There are few support systems available to informal carers who provide care to cancer patients. Smartphone apps have the capacity to reach large audiences and can provide information and support at a time convenient to carers. Objective: The aim of this study was to design a smartphone app prototype for carers of adults with cancer. Methods: A multiple-method design was used to develop a smartphone app. Current and past carers of people with any type of cancer were recruited from a public hospital, a private hospital, and a carer organization, who participated in either a focus group or phone interview. Carers answered questions about items to include in an app to address supportive care needs identified. Using carers’ feedback, a smartphone app was designed and tested. Beta testing was conducted using a convenience sample of participants who completed scenarios to inform the app’s design, functionality, and usability. Scenarios were timed and marked as complete or incomplete. Participants completed a questionnaire about the usability of the app. Beta testing occurred in 2 stages—a paper-based version of the app and an app-based test using the participants’ preferred device. Alpha testing was completed internally to ensure the functionality of the app. Data were collected between May 2016 and August 2017. Results: A total of 33 carers participated in phone interviews and 12 in focus groups; their average age was 55 (SD 14) years, and 60% (27/45) were female. The majority of carers (76%, 25/33) had a positive attitude toward using smartphone apps. Carers noted that smartphone technology might improve their ability to seek information and support in managing their own health as well as the care needs of the person with cancer. Carers requested a variety of information and resources to be included in the app. Paper-based testing included the following: participants (N=10) were aged above 30 years (30%, 3/10), 30 to 49 years (30%, 3/10), and 50 years or above (40%, 4/10), and 60% (6/10) were male. Participants found the app user-friendly and pleasing in appearance. App-based testing included the following: participants (N=10) were aged above 30 years (20%, 2/10), 30 to 49 years (30%, 3/10), and 50 years or above (50%, 5/10), and 50% (5/10) were male. Participants reported the app to be user-friendly and easy to navigate. The majority (60%, 6/10) of participants were unable to create a shortcut icon to add the app to the home screen of their phone. Conclusions: Carers highlighted the needed information and support to assist them during the caring period; they also reported having a positive attitude toward smartphone apps. The Carer Guide App is currently undergoing a pilot study to further test usability among carers of people with 1 cancer type. %M 30973346 %R 10.2196/10990 %U http://formative.jmir.org/2019/2/e10990/ %U https://doi.org/10.2196/10990 %U http://www.ncbi.nlm.nih.gov/pubmed/30973346 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e9910 %T A Pilot Randomized Controlled Trial of a Digital Intervention Aimed at Improving Food Purchasing Behavior: The Front-of-Pack Food Labels Impact on Consumer Choice Study %A Harrington,Richard A %A Scarborough,Peter %A Hodgkins,Charo %A Raats,Monique M %A Cowburn,Gill %A Dean,Moira %A Doherty,Aiden %A Foster,Charlie %A Juszczak,Edmund %A Ni Mhurchu,Cliona %A Winstone,Naomi %A Shepherd,Richard %A Timotijevic,Lada %A Rayner,Mike %+ Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom, 44 1865289248, peter.scarborough@dph.ox.ac.uk %K diet %K randomized controlled trial %D 2019 %7 08.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Most food in the United Kingdom is purchased in supermarkets, and many of these purchases are routinely tracked through supermarket loyalty card data. Using such data may be an effective way to develop remote public health interventions and to measure objectively their effectiveness at changing food purchasing behavior. Objective: The Front-of-pack food Labels: Impact on Consumer Choice (FLICC) study is a pilot randomized controlled trial of a digital behavior change intervention. This pilot trial aimed to collect data on recruitment and retention rates and to provide estimates of effect sizes for the primary outcome (healthiness of ready meals and pizzas purchased) to inform a larger trial. Methods: The intervention consisted of a website where participants could access tailored feedback on previous purchases of ready meals and pizzas, set goals for behavior change, and model and practice the recommended healthy shopping behavior using traffic light labels. The control consisted of Web-based information on traffic light labeling. Participants were recruited via email from a list of loyalty card holders held by the participating supermarket. All food and drink purchases for the participants for the 6 months before recruitment, during the 6-week intervention period, and during a 12-week washout period were transferred to the research team by the participating supermarket. Healthiness of ready meals and pizzas was measured using a predeveloped scale based solely on the traffic light colors on the foods. Questionnaires were completed at recruitment, end of the intervention, and end of washout to estimate the effect of the intervention on variables that mediate behavior change (eg, belief and intention formation). Results: We recruited 496 participants from an initial email to 50,000 people. Only 3 people withdrew from the study, and purchase data were received for all other participants. A total of 208 participants completed all 3 questionnaires. There was no difference in the healthiness of purchased ready meals and pizzas between the intervention and control arms either during the intervention period (P=.32) or at washout (P=.59). Conclusions: Although the FLICC study did not find evidence of an impact of the intervention on food purchasing behavior, the unique methods used in this pilot trial are informative for future studies that plan to use supermarket loyalty card data in collaboration with supermarket partners. The experience of the trial showcases the possibilities and challenges associated with the use of loyalty card data in public health research. Trial Registration: ISRCTN Registry ISRCTN19316955; http://www.isrctn.com/ISRCTN19316955 (Archived by WebCite at http://www.webcitation.org/76IVZ9WjK) International Registered Report Identifier (IRRID): RR2-10.1186/s40814-015-0015-1 %M 30958277 %R 10.2196/formative.9910 %U http://formative.jmir.org/2019/2/e9910/ %U https://doi.org/10.2196/formative.9910 %U http://www.ncbi.nlm.nih.gov/pubmed/30958277 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11342 %T Developing a Data Dashboard Framework for Population Health Surveillance: Widening Access to Clinical Trial Findings %A Concannon,David %A Herbst,Kobus %A Manley,Ed %+ Centre for Advanced Spatial Analysis, University College London, Gower Street, London,, United Kingdom, 44 02031083884, ed.manley@ucl.ac.uk %K data visualization %K data dashboards %K health and demographic surveillance %K sub-Saharan Africa %K treatment as prevention %K clinical trials %K demographics %K real-time %K data literacy %D 2019 %7 04.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Population surveillance sites generate many datasets relevant to disease surveillance. However, there is a risk that these data are underutilized because of the volumes of data gathered and the lack of means to quickly disseminate analysis. Data visualization offers a means to quickly disseminate, understand, and interpret datasets, facilitating evidence-driven decision making through increased access to information. Objectives: This paper describes the development and evaluation of a framework for data dashboard design, to visualize datasets produced at a demographic health surveillance site. The aim of this research was to produce a comprehensive, reusable, and scalable dashboard design framework to fit the unique requirements of the context. Methods: The framework was developed and implemented at a demographic surveillance platform at the Africa Health Research Institute, in KwaZulu-Natal, South Africa. This context represents an exemplar implementation for the use of data dashboards within a population health-monitoring setting. Before the full launch, an evaluation study was undertaken to assess the effectiveness of the dashboard framework as a data communication and decision-making tool. The evaluation included a quantitative task evaluation to assess usability and a qualitative questionnaire exploring the attitudes to the use of dashboards. Results: The evaluation participants were drawn from a diverse group of users working at the site (n=20), comprising of community members, nurses, scientific and operational staff. Evaluation demonstrated high usability for the dashboard across user groups, with scientific and operational staff having minimal issues in completing tasks. There were notable differences in the efficiency of task completion among user groups, indicating varying familiarity with data visualization. The majority of users felt that the dashboards provided a clear understanding of the datasets presented and had a positive attitude to their increased use. Conclusions: Overall, this exploratory study indicates the viability of the data dashboard framework in communicating data trends within population surveillance setting. The usability differences among the user groups discovered during the evaluation demonstrate the need for the user-led design of dashboards in this context, addressing heterogeneous computer and visualization literacy present among the diverse potential users present in such settings. The questionnaire highlighted the enthusiasm for increased access to datasets from all stakeholders highlighting the potential of dashboards in this context. %M 30946016 %R 10.2196/11342 %U https://formative.jmir.org/2019/2/e11342/ %U https://doi.org/10.2196/11342 %U http://www.ncbi.nlm.nih.gov/pubmed/30946016 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e11397 %T Using Text Messaging, Social Media, and Interviews to Understand What Pregnant Youth Think About Weight Gain During Pregnancy %A DeJonckheere,Melissa %A Nichols,Lauren P %A Vydiswaran,VG Vinod %A Zhao,Xinyan %A Collins-Thompson,Kevyn %A Resnicow,Kenneth %A Chang,Tammy %+ Department of Family Medicine, University of Michigan, 1018 Fuller St, Ann Arbor, MI, 48104, United States, 1 (734) 998 7120, mjdejonckheere@gmail.com %K methods %K adolescents %K weight gain %K pregnancy %K text messaging %K social media %K natural language processing %D 2019 %7 01.04.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: The majority of pregnant youth gain more weight than recommended by the National Academy of Medicine guidelines. Excess weight gain during pregnancy increases the risk of dangerous complications during delivery, including operative delivery and stillbirth, and contributes to the risk of long-term obesity in both mother and child. Little is known regarding youth’s perceptions of and knowledge about weight gain during pregnancy. Objective: The aim of this study was to describe the feasibility and acceptability of 3 novel data collection and analysis strategies for use with youth (social media posts, text message surveys, and semistructured interviews) to explore their experiences during pregnancy. The mixed-methods analysis included natural language processing and thematic analysis. Methods: To demonstrate the feasibility and acceptability of this novel approach, we used descriptive statistics and thematic qualitative analysis to characterize participation and engagement in the study. Results: Recruitment of 54 pregnant women aged between 16 and 24 years occurred from April 2016 to September 2016. All participants completed at least 1 phase of the study. Semistructured interviews had the highest rate of completion, yet all 3 strategies were feasible and acceptable to pregnant youth. Conclusions: This study has described a novel youth-centered strategy of triangulating 3 sources of mixed-methods data to gain a deeper understanding of a health behavior phenomenon among an at-risk population of youth. %M 30932869 %R 10.2196/11397 %U https://formative.jmir.org/2019/2/e11397/ %U https://doi.org/10.2196/11397 %U http://www.ncbi.nlm.nih.gov/pubmed/30932869 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11600 %T Cultural Adaptation of a Scalable World Health Organization E-Mental Health Program for Overseas Filipino Workers %A Garabiles,Melissa R %A Harper Shehadeh,Melissa %A Hall,Brian J %+ Global and Community Mental Health Research Group, The University of Macau, E21-3040, Avenida da Universidade, Macau, 99908, China, 86 62899837, brianhall@um.edu.mo %K cultural adaptation %K migrant workers %K e-mental health %K overseas Filipino workers %D 2019 %7 29.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Electronic mental (e-mental) health interventions can address mental health needs of different populations. Cultural adaptation of these interventions is crucial to establish a better fit with the cultural group and to achieve better treatment outcomes. Objective: This study aimed to describe the cultural adaptation of the World Health Organization’s e-mental health program Step-by-Step for overseas Filipino workers. We used a framework which posits that cultural adaptation should enhance (1) relevance, wherein the cultural group can relate with the content; (2) acceptability, where the cultural group will not find any element offensive; (3) comprehensibility, where the program is understandable; and (4) completeness, wherein the adapted version covers the same concepts and constructs as the original program. We aimed to have English and Filipino and male and female versions. Methods: Overall, 3 experienced Filipino psychologists provided their perspectives on the program and how it might be adapted for overseas Filipino workers. We then adapted the program and obtained feedback from 28 overseas Filipino workers from diverse industries through focus group discussions. We conducted 7 and 9 focus group discussions with male and female participants, respectively. Per discussion, cognitive interviewing was used to probe for relevance, acceptability, comprehensibility, and completeness of illustrations and text. Participant feedback guided iterative program adaptations, which were again shown to participants for validation and improvement. Results: Several issues were raised by participants about the generic version of Step-by-Step. There were elements deemed irrelevant, like unfitting characters, lack of Filipino values, and unsuitable problems and activities. There were unacceptable components that were stigmatizing, political, inappropriate to context or subgroups, and too feminine for male users. Some elements were incomprehensible, unclear, or complicated. To address these issues, we made key adaptations. To enhance relevance, we adapted the narrative to match the experiences of overseas Filipino workers, incorporated Filipino values, and illustrated familiar problems and activities. To increase acceptability, our main characters were changed to wise elders rather than health professionals (reducing mental health and help-seeking stigma), political or unacceptable content was removed, and the program was made suitable for overseas Filipino workers from different sectors. To increase comprehension, we used English and Filipino languages, simplified the text to ease interpretation of abstract terms, and ensured that text and illustrations matched. We also used Taglish (ie, merged English and Filipino) when participants deemed pure Filipino translations sounded odd or incomprehensible. Finally, we retained the core elements and concepts included in the original Step-by-Step program to maintain completeness. Conclusions: This study showed the utility of a 4-point framework that focuses on acceptance, relevance, comprehensibility, and completeness in cultural adaptation. Moreover, we achieved a culturally appropriate adapted version of the Step-by-Step program for overseas Filipino workers. We discuss lessons learned in the process to guide future cultural adaptation projects of e-mental health interventions. %M 30924784 %R 10.2196/11600 %U https://formative.jmir.org/2019/1/e11600/ %U https://doi.org/10.2196/11600 %U http://www.ncbi.nlm.nih.gov/pubmed/30924784 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11300 %T Challenges in the Development of e-Quit worRx: An iPad App for Smoking Cessation Counseling and Shared Decision Making in Primary Care %A Doarn,Charles R %A Vonder Meulen,Mary Beth %A Pallerla,Harini %A Acquavita,Shauna P %A Regan,Saundra %A Elder,Nancy %A Tubb,Matthew R %+ Department of Family and Community Medicine, University of Cincinnati, 231 Albert Sabin Way, ML0582, Cincinnati, OH, 45267, United States, 1 5135586148, charles.doarn@uc.edu %K mobile health %K smoking cessation %K primary care %K decision aid %D 2019 %7 29.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Smoking is the leading preventable cause of morbidity and mortality in the United States, killing more than 450,000 Americans. Primary care physicians (PCPs) have a unique opportunity to discuss smoking cessation evidence in a way that enhances patient-initiated change and quit attempts. Patients today are better equipped with technology such as mobile devices than ever before. Objective: The aim of this study was to evaluate the challenges in developing a tablet-based, evidence-based smoking cessation app to optimize interaction for shared decision making between PCPs and their patients who smoke. Methods: A group of interprofessional experts developed content and a graphical user interface for the decision aid and reviewed these with several focus groups to determine acceptability and usability in a small population. Results: Using a storyboard methodology and subject matter experts, a mobile app, e-Quit worRx, was developed through an iterative process. This iterative process helped finalize the content and ergonomics of the app and provided valuable feedback from both patients and provider teams. Once the app was made available, other technical and programmatic challenges arose. Conclusions: Subject matter experts, although generally amenable to one another’s disciplines, are often challenged with effective interactions, including language, scope, clinical understanding, technology awareness, and expectations. The successful development of this app and its evaluation in a clinical setting highlighted those challenges and reinforced the need for effective communications and team building. %M 30924783 %R 10.2196/11300 %U https://formative.jmir.org/2019/1/e11300/ %U https://doi.org/10.2196/11300 %U http://www.ncbi.nlm.nih.gov/pubmed/30924783 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11374 %T Pregnant Users’ Perceptions of the Birth Plan Interface in the “My Prenatal Care” App: Observational Validation Study %A Moraes Carrilho,Juliana %A Oliveira,Isaias José Ramos %A Santos,Dimitri %A Osanan,Gabriel Costa %A Cruz-Correia,Ricardo João %A Reis,Zilma Silveira Nogueira %+ Informatics Center in Health, Universidade Federal de Minas Gerais, Faculty of Medicine, Av Professor Alfredo Balena, 190, Funcionários, Belo Horizonte, 30140070, Brazil, 55 31985177473, zilma.medicina@gmail.com %K birth plan %K perinatal care %K usability, mobile health %K mobile app %K pregnancy %K prenatal care %K mobile phone %D 2019 %7 28.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Birth plans are meant to be a declaration of the expectations and preferences of pregnant woman regarding childbirth. The My Prenatal Care app engages pregnant women in an educational intervention for a healthy pregnancy. We hypothesized that users’ positive perception of an in-app birth plan is a relevant step for establishing direct communication between pregnant women and the health care team, based on an online report available on the app. Objective: This study aimed to evaluate pregnant women’s perception about the communicability of birth-plan preparation using a mobile app. Methods: This was an observational, exploratory, descriptive study. The methodology was user centered, and both qualitative and quantitative approaches were employed. The tools of the communicability evaluation method were applied. Overall, 11 pregnant women evaluated their experience of using a birth-plan prototype interface. The evaluation was performed in a controlled environment, with authorized video recording. There were 8 task-oriented interactions proposed to evaluate interface communicability with users when using the Birth Plan menu. For evaluating perceptions and experiences, a survey with structured and open-ended questions in addition to the free expression of participants was conducted. The primary outcomes assessed were interface communicability and user’s perception of the Birth Plan prototype interface in the My Prenatal Care mobile app. Secondarily, we involved users in the prototyping phase of the interface to identify bottlenecks for making improvements in the app. Results: Regarding users’ performance in accomplishing previously prepared tasks, we found that 10 of 11 (91%) women were capable of completing at least 6 of 8 (75%) tasks. A positive relationship was found between the number of communicability problems and the success of completing the tasks. An analysis of the records revealed three communicability breakdowns related to the data entry, save, and scrollbar functions. The participants freely expressed suggestions for improvements such as for the save function and the process of sharing the birth-plan form upon completion. Conclusions: Users had a positive perception of the Birth Plan menu of the My Prenatal Care app. This user-centered validation enabled the identification of solutions for problems, resulting in improvements in the app. %M 30920372 %R 10.2196/11374 %U http://formative.jmir.org/2019/1/e11374/ %U https://doi.org/10.2196/11374 %U http://www.ncbi.nlm.nih.gov/pubmed/30920372 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e10731 %T The Development of VegEze: Smartphone App to Increase Vegetable Consumption in Australian Adults %A Hendrie,Gilly A %A James-Martin,Genevieve %A Williams,Gemma %A Brindal,Emily %A Whyte,Ben %A Crook,Anna %+ Health & Biosecurity, Commonwealth Scientific and Industrial Research Organisation, PO Box 10041, Adelaide, 5000, Australia, 61 88305 ext 0662, gilly.hendrie@csiro.au %K mHealth %K mobile applications %K vegetables %K adult %D 2019 %7 27.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Poor-quality dietary patterns are often characterized by inadequate consumption of fruits and vegetables. Changing dietary behavior is difficult, and although it is often clear what needs to change, how to enact change is more difficult. Smartphones have characteristics that may support the complexity of changing dietary behavior. Objective: This paper describes the iterative process of developing a theory-based smartphone app called VegEze that aimed to increase vegetable consumption. Methods: To upscale, reach target users, and create a user-friendly end product, a collaborative research-industry partnership was formed to build the app over a 20-week period. The Integrate, Design, Assess, and Share framework was used as a scientific basis to guide the development. The behavior change wheel was also used as a theoretical grounding in combination with other theory-based strategies, such as self-monitoring, social comparison, and gamification—which have all been shown to be successful in dietary change or digital health interventions. We conducted 1 consumer survey (N=1068), 1 usability testing session (N=11), and a pilot effectiveness and usability trial (N=283) to inform the design of the app. Results: The target behavior for the app was defined as having 3 different types of vegetables at dinner. The perceived achievability of this target behavior was high; 93% of respondents (993/1068 users) felt they were likely or very likely to be able to regularly achieve the behavior. App features that users wanted included the following: recipes and meal ideas (876/1068, 82% of users), functionality to track their intake (662/1068, 62%), and information on how to prepare vegetables (545/1068, 51%). On the basis of importance of self-monitoring as a behavior change technique (BCT) and its rating by users, the vegetable tracker was a core feature of the app and was designed to be quick and simple to use. Daily feedback messages for logging intake and communicating progress were designed to be engaging and fun, using friendly, positive language and emoji icons. Daily and weekly feedback on vegetable consumption was designed to be simple, informative, and reinforce monitoring. A creative team was engaged to assist in the branding of the app to ensure it had an identity that reflected the fun and simple nature of the underlying behavior. The app included 16 BCTs, most of which were from the goals and planning subsection of the BCT taxonomy. Conclusions: Combining a theoretical framework with an industry perspective and input resulted in an app that was developed in a timely manner while retaining its evidence-base. VegEze is an iOS app currently available in the App Store, and the overall impact of the VegEze app will be evaluated in an uncontrolled, quantitative study. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000481279; http://www.anzctr.org.au/TrialSearch.aspx?searchTxt=ACTRN12618000481279 (Archived by WebCite: at http://www.webcitation.org/769oG9EaA) %M 30916653 %R 10.2196/10731 %U http://formative.jmir.org/2019/1/e10731/ %U https://doi.org/10.2196/10731 %U http://www.ncbi.nlm.nih.gov/pubmed/30916653 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 6 %N 1 %P e11852 %T High-Fidelity Prototyping for Mobile Electronic Data Collection Forms Through Design and User Evaluation %A Mugisha,Alice %A Babic,Ankica %A Wakholi,Peter %A Tylleskär,Thorkild %+ Center for International Health, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21 Overlege Danielssens building, Bergen, 5020, Norway, 47 99884851, mugishaalice@gmail.com %K high-fidelity prototype %K group user testing %K mobile electronic data collection forms %K usability evaluation %D 2019 %7 22.03.2019 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Mobile data collection systems are often difficult to use for nontechnical or novice users. This can be attributed to the fact that developers of such tools do not adequately involve end users in the design and development of product features and functions, which often creates interaction challenges. Objective: The main objective of this study was to assess the guidelines for form design using high-fidelity prototypes developed based on end-user preferences. We also sought to investigate the association between the results from the System Usability Scale (SUS) and those from the Study Tailored Evaluation Questionnaire (STEQ) after the evaluation. In addition, we sought to recommend some practical guidelines for the implementation of the group testing approach particularly in low-resource settings during mobile form design. Methods: We developed a Web-based high-fidelity prototype using Axure RP 8. A total of 30 research assistants (RAs) evaluated this prototype in March 2018 by completing the given tasks during 1 common session. An STEQ comprising 13 affirmative statements and the commonly used and validated SUS were administered to evaluate the usability and user experience after interaction with the prototype. The STEQ evaluation was summarized using frequencies in an Excel sheet while the SUS scores were calculated based on whether the statement was positive (user selection minus 1) or negative (5 minus user selection). These were summed up and the score contributions multiplied by 2.5 to give the overall form usability from each participant. Results: Of the RAs, 80% (24/30) appreciated the form progress indication, found the form navigation easy, and were satisfied with the error messages. The results gave a SUS average score of 70.4 (SD 11.7), which is above the recommended average SUS score of 68, meaning that the usability of the prototype was above average. The scores from the STEQ, on the other hand, indicated a 70% (21/30) level of agreement with the affirmative evaluation statements. The results from the 2 instruments indicated a fair level of user satisfaction and a strong positive association as shown by the Pearson correlation value of .623 (P<.01). Conclusions: A high-fidelity prototype was used to give the users experience with a product they would likely use in their work. Group testing was done because of scarcity of resources such as costs and time involved especially in low-income countries. If embraced, this approach could help assess user needs of the diverse user groups. With proper preparation and the right infrastructure at an affordable cost, usability testing could lead to the development of highly usable forms. The study thus makes recommendations on the practical guidelines for the implementation of the group testing approach particularly in low-resource settings during mobile form design. %M 30900995 %R 10.2196/11852 %U http://humanfactors.jmir.org/2019/1/e11852/ %U https://doi.org/10.2196/11852 %U http://www.ncbi.nlm.nih.gov/pubmed/30900995 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11578 %T Development of PositiveLinks: A Mobile Phone App to Promote Linkage and Retention in Care for People With HIV %A Laurence,Colleen %A Wispelwey,Erin %A Flickinger,Tabor E %A Grabowski,Marika %A Waldman,Ava Lena %A Plews-Ogan,Erin %A Debolt,Claire %A Reynolds,George %A Cohn,Wendy %A Ingersoll,Karen %A Dillingham,Rebecca %+ Department of Medicine, University of Virginia School of Medicine, PO Box 801379, Charlottesville, VA, 22908, United States, 1 434 982 0103, Rd8v@hscmail.mcc.virginia.edu %K mHealth %K HIV %K treatment adherence and compliance %K retention in care %D 2019 %7 20.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Linkage to and retention in HIV care are challenging, especially in the Southeastern United States. The rise in mobile phone app use and the potential for an app to deliver just in time messaging provides a new opportunity to improve linkage and retention among people living with HIV (PLWH). Objective: This study aimed to develop an app to engage, link, and retain people in care. We evaluated the acceptability, feasibility, and impact of the app among users. Methods: App development was informed by principles of chronic disease self-management and formative interviews with PLWH. Once developed, the app was distributed among participants, and usability feedback was incorporated in subsequent iterations. We interviewed app users after 3 weeks to identify usability issues, need for training on the phone or app, and to assess acceptability. We tracked and analyzed usage of app features for the cohort over 2 years. Results: A total of 77 participants used the app during the pilot study. The query response rate for the first 2 years was 47.7%. Query response declined at a rate of 0.67% per month. The community message board was the most popular feature, and 77.9% (60/77) of users posted on the board at least once during the 2 years. Conclusions: The PositiveLinks app was feasible and acceptable among nonurban PLWH. High participation on the community message board suggests that social support from peers is important for people recently diagnosed with or returning to care for HIV. %M 30892269 %R 10.2196/11578 %U http://formative.jmir.org/2019/1/e11578/ %U https://doi.org/10.2196/11578 %U http://www.ncbi.nlm.nih.gov/pubmed/30892269 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e12489 %T An mHealth Assistive System “MyLung” to Empower Patients with Chronic Obstructive Pulmonary Disease: Design Science Research %A Alharbey,Riad %A Chatterjee,Samir %+ Information Systems and Technology, College of Computer Science and Engineering, University of Jeddah, Asfan 21959, Jeddah,, Saudi Arabia, 966 545593498, ralharbi@uj.edu.sa %K assistive technology %K patient empowerment %K chronic obstructive pulmonary disease %K design science research %D 2019 %7 19.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Chronic obstructive pulmonary disease (COPD) comprises a group of progressive diseases that deteriorate lung functions. When patients cannot breathe, nothing else in their lives matter. Breathlessness has negative implications on patients’ lives, which leads to physical and psychological limitations. Moreover, the lack of relevant and updated information about the causes and consequences of the disease can exacerbate the problems of health literacy, information accessibility, and medical adherence. Objective: The objective of this study is to design an innovative mobile health (mHealth) app system called “MyLung” that provides complete solutions in order to increase self-awareness and promote better self-care management. This system, an information technology artifact, includes three novel integrative modules: education, risk reduction, and monitoring. Methods: The utility and effectiveness of the assistive mobile-based technology were evaluated using a mixed-methods approach. The study combined quantitative and qualitative research methods to thoroughly understand how the assistive mobile-based technology can influence patients’ behavioral intention to change their lifestyle. Thirty patients were categorized into two groups (intervention group and control group). Results: The results from the quantitative analysis led to four follow-up interviews in the qualitative study. The results of the quantitative study provided significant evidence to show that the design of MyLung leads to a change in the awareness level, self-efficacy, and behavioral intention for patients with COPD. The t tests revealed a significant difference before and after using the mobile-based app with regard to the awareness level (mean 3.28 vs 4.56; t10=6.062; P<.001), self-efficacy (mean 3.11 vs 5.56; t10=2.96; P=.01), and behavioral intention (mean 2.91 vs 4.55; t10=3.212; P=.009). Independent sample t tests revealed significant differences between the intervention group and the control group in terms of the awareness level (mean 4.56 vs 3.31; t19=4.80; P<.001) and self-efficacy (mean 5.56 vs 3.66; t19=2.8; P<.01). Integration of findings from quantitative and qualitative studies reveled the impact of the design in a comprehensive manner. These inferences are referred to as “meta-inferences” in this study. Conclusions: We designed an innovative assistive mobile-based technology to empower patients with COPD, which helped increase awareness and engage patients in self-care management activities. The assistive technology aims to inform patients about the risk factors of COPD and to improve access to relevant information. Meta-inferences that emerge from the research outputs contribute to research into chronic management information systems by helping us gain a more complete understanding of the potential impacts of this proposed mobile-based design on patients with chronic disease. %M 30888329 %R 10.2196/12489 %U http://formative.jmir.org/2019/1/e12489/ %U https://doi.org/10.2196/12489 %U http://www.ncbi.nlm.nih.gov/pubmed/30888329 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11689 %T A Mobile App to Promote Adapted Exercise and Social Networking for People With Physical Disabilities: Usability Study %A Lai,Byron %A Wilroy,Jereme %A Young,Hui-Ju %A Howell,Jennifer %A Rimmer,James H %A Mehta,Tapan %A Thirumalai,Mohanraj %+ Department of Health Services Administration, University of Alabama at Birmingham, SHPB #590E, 1716 9th Avenue South, Birmingham, AL, 35233, United States, 1 2059347189, mohanraj@uab.edu %K exercise %K telehealth %K rehabilitation %K mHealth %D 2019 %7 19.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: People with physical disabilities (PWD) experience several unique challenges that prevent them from participating in onsite exercise programs. Although mobile apps can provide a ubiquitous channel for delivering convenient exercise services within the community, no exercise apps have been designed for people with disabilities who experience certain functional limitations. Objective: The aim of this study was to examine the usability of a mobile exercise app in PWD. Methods: A sequential explanatory mixed-method design was used to holistically test usability in 4 core areas: effectiveness (ie, ease of use), efficiency (ie, operation speed), perceived satisfaction, and usefulness. Participants completed 7 face-to-face usability tasks and 1 structured interview. Equipment included a computer tablet that came preinstalled with the exercise app. The app included exercise videos that focused on several components of fitness: aerobic capacity, muscular strength, functional strength or balance, and range of motion. The app contained 3 different versions of the exercise program: (1) a program for people with the ability to use the upper and lower limbs, (2) a seated program for people with the ability to use only upper limbs, and (3) a program designed for people with hemiparesis. The app also included educational resources in the form of infographics aimed at addressing key social cognitive theory constructs included social support, outcome expectancies, self-efficacy, and barriers or facilitators to exercising. Participant characteristics and quantitative usability data were descriptively reported. Qualitative data were analyzed using thematic analysis. Results: A total of 12 PWD tested the usability of the exercise app and completed 96% (69/72) of the usability tasks on the first attempt. Operation speed varied among users, which prompted the development team to make minor revisions to the app. Qualitative results demonstrated 3 overarching themes: facilitates exercise adoption, positive experiences of videos, and easy to learn. Participants noted that the app circumvented several barriers to exercise associated with leaving the home (eg, inclement weather conditions, exacerbations of health conditions or disability symptoms, difficulties with transportation, and social support). Conclusions: The mobile exercise app provided a simple platform that was effective, useful, and appreciated by PWD. Participants also perceived the app as easy to use and felt it was a valuable tool for assisting PWD to obtain regular exercise. Study findings also offered insight into the participants’ preferences for mobile exercise apps that can aid future research and development projects. Future exercise trials are needed to determine the true impact of mobile app technology on lifestyle physical activity in people with disabilities. Trial Registration: Clinicaltrials.gov NCT03024320; https://clinicaltrials.gov/ct2/show/NCT03024320 (Archived by WebCite at http://www.webcitation.org/75hNLgRFH). %M 30888325 %R 10.2196/11689 %U http://formative.jmir.org/2019/1/e11689/ %U https://doi.org/10.2196/11689 %U http://www.ncbi.nlm.nih.gov/pubmed/30888325 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e9922 %T What Is Being Used and Who Is Using It: Barriers to the Adoption of Smartphone Patient Experience Surveys %A Ng,Denise %A McMurray,Josephine %A Wallace,James %A Morita,Plinio %+ Business Technology Management, Lazaridis School of Business & Economics, Wilfrid Laurier University, 73 George Street, Brantford, ON, N3T3Y3, Canada, 1 5192427477, jmcmurray@wlu.ca %K quality of healthcare %K surveys and questionnaires %K patient satisfaction %K data collection %K smartphone %K mobile phone %K risk %K privacy %D 2019 %7 18.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Smartphones are positioned to transform the way health care services gather patient experience data through advanced mobile survey apps which we refer to as smart surveys. In comparison with traditional methods of survey data capture, smartphone sensing survey apps have the capacity to elicit multidimensional, in situ user experience data in real time with unprecedented detail, responsiveness, and accuracy. Objective: This study aimed to explore the context and circumstances under which patients are willing to use their smartphones to share data on their service experiences. Methods: We conducted in-person, semistructured interviews (N=24) with smartphone owners to capture their experiences, perceptions, and attitudes toward smart surveys. Results: Analysis examining perceived risk revealed a few barriers to use; however, major potential barriers to adoption were the identity of recipients, reliability of the communication channel, and potential for loss of agency. The results demonstrate that the classical dimensions of perceived risk raised minimal concerns for the use of smartphones to collect patient service experience feedback. However, trust in the doctor-patient relationship, the reliability of the communication channel, the altruistic motivation to contribute to health service quality for others, and the risk of losing information agency were identified as determinants in the patients’ adoption of smart surveys. Conclusions: On the basis of these findings, we provide recommendations for the design of smart surveys in practice and suggest a need for privacy design tools for voluntary, health-related technologies. %M 30882354 %R 10.2196/formative.9922 %U http://formative.jmir.org/2019/1/e9922/ %U https://doi.org/10.2196/formative.9922 %U http://www.ncbi.nlm.nih.gov/pubmed/30882354 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e9858 %T The Learning Exchange, a Community Knowledge Commons for Learning Networks: Qualitative Evaluation to Test Acceptability, Feasibility, and Utility %A McLinden,Daniel %A Myers,Sarah %A Seid,Michael %A Busch,Melida %A Davis,David %A Murphy,John %+ Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH,, United States, 1 513 803 0083, Michael.Seid@cchmc.org %K quality improvement %K knowledge management %K community networks %K intersectoral collaboration %K database management systems %K patient-centered care %D 2019 %7 14.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Learning Networks are distributed learning health systems that enable collaboration at scale to improve health and health care. A key requirement for such networks is having a way to create and share information and knowledge in furtherance of the work of the community. Objective: We describe a Learning Exchange—a bespoke, scalable knowledge management and exchange platform initially built and tested for improving pediatric inflammatory bowel disease outcomes in the ImproveCareNow (ICN) Network—and assess evidence of its acceptability, feasibility, and utility in facilitating creation and sharing of information in furtherance of the work of the community and as a model for other communities. Methods: Acceptability was assessed via growth in active users and activity. Feasibility was measured in terms of the percentage of users with a log-in who became active users as well as user surveys and a case study. Utility was measured in terms of the type of work that the Learning Exchange facilitated for the community. Results: The ICNExchange has over 1000 users and supported sharing of resources across all care centers in ICN. Users reported that the Learning Exchange has facilitated their work and resulted in increased ability to find resources relevant to local information needs. Conclusions: The ICNExchange is acceptable, feasible, and useful as a knowledge management and exchange platform in service of the work of ICN. Experience with the ICNExchange suggests that the design principles are extensible to other chronic care Learning Networks. %M 30869643 %R 10.2196/formative.9858 %U http://formative.jmir.org/2019/1/e9858/ %U https://doi.org/10.2196/formative.9858 %U http://www.ncbi.nlm.nih.gov/pubmed/30869643 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11785 %T The Development of an Arabic Weight-Loss App Akser Waznk: Qualitative Results %A Alturki,Ryan %A Gay,Valerie %+ School of Electrical and Data Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, 81 Broadway, Ultimo, Sydney, 2007, Australia, 61 410583330, ryan.m.alturki@student.uts.edu.au %K weight loss %K mobile app %K obesity %K physical activity %K smartphone %K mHealth %K motivation %D 2019 %7 14.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Obesity and its related illnesses are a major health problem around the world. Saudi Arabia has one of the highest national obesity rates globally; however, it is not easy to intervene to prevent obesity and becoming overweight owing to Saudi Arabia’s cultural and social norms, and linguistic barriers. In recent years, there has been an exponential growth in the usage of smartphones and apps in Saudi Arabia. These could be used as a cost-effective tool to facilitate the delivery of behavior-modification interventions for obese and overweight people. There are a variety of health and fitness apps that claim to offer lifestyle-modification tools. However, these do not identify the motivational features required to overcome obesity, consider the evidence-based practices for weight management, or enhance the usability of apps by considering usability attributes. Objective: This study aimed to explore the opportunity and the need to develop an Arabic weight-loss app that provides localized content and addresses the issues with existing apps identified here. This study has explained the steps taken to design an Arabic weight-loss app that was developed to facilitate the adjustment of key nutritional and physical activities and behaviors, which considers the social and cultural norms of Saudi Arabia. Methods: Qualitative studies were conducted with 26 obese Saudi Arabians, who tested the level of usability of 2 weight-loss apps and then provided feedback and recommendations. The app Akser Waznk is an interactive, user-friendly app designed primarily for iPhones. It has several features intended to assist users to monitor and track their food consumption and physical activities. The app provides personalized diet and weight loss advice. Unique features such as Let’s Walk are designed to motivate users to walk more. An augmented reality function is implemented to provide information regarding fitness equipment, fruits, and vegetables. The app uses behavior-change techniques to increase activities and healthy behaviors and evidence-informed practices for weight-loss management. The Akser Waznk app considers user privacy and data security by applying a number of guidelines and procedures. Results: The development of the app took 26 months. In all, 7 experts (5 dietitians, and 2 physical activity professionals) evaluated the app’s contents. Moreover, 10 potential users (5 men and 5 women) tested the app’s level of usability, its features, and performance during a pilot study. They reported that the app’s design is interactive, and the motivational features are user-friendly. Conclusions: Mobile technology, such as mobile apps, has the potential to be an effective tool that facilitates the changing of unhealthy lifestyle behaviors within the Saudi community. To be successful, the target group, the usability, motivational features, and social and cultural norms must be considered. %M 30869639 %R 10.2196/11785 %U http://formative.jmir.org/2019/1/e11785/ %U https://doi.org/10.2196/11785 %U http://www.ncbi.nlm.nih.gov/pubmed/30869639 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11111 %T Co-Design of a Consultation Audio-Recording Mobile App for People With Cancer: The SecondEars App %A Lipson-Smith,Ruby %A White,Fiona %A White,Alan %A Serong,Lesley %A Cooper,Guy %A Price-Bell,Georgia %A Hyatt,Amelia %+ Cancer Experiences Research, Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria, 3000, Australia, 61 3 8559 7837, amelia.hyatt@petermac.org %K referral and consultation %K adult %K humans %K cancer %K audiovisual aids %K mobile apps %K community-based participatory research %K health behavior %K psychological theory %D 2019 %7 12.03.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Many patients choose to audio-record their medical consultations so that they can relisten to them at home and share them with family. Consultation audio-recordings can improve patients’ recall and understanding of medical information and increase their involvement in decision making. A hospital-endorsed consultation audio-recording mobile app would provide patients with the permission and means to audio-record their consultations. The Theory of Planned Behavior provides a framework for understanding how patients can be encouraged to appropriately audio-record consultations. Objective: The aim of this study was to use a co-design process to develop a consultation audio-recording mobile app called SecondEars. Methods: App development began with stakeholder engagement, followed by a series of 6 co-design workshops and then user acceptance testing. Stakeholder engagement included advice from legal, information technology (IT), clinical and allied health leads; digital strategy; and medical records. he co-design workshops were attended by: patient consumers, members of the research team, IT staff, the app designers, clinicians, and staff from medical records. During workshops 1 to 4, the purpose and scope of the app were refined, possible pitfalls were addressed, and design features were discussed. The app designers then incorporated the results from these workshops to produce a wireframe mock-up of the proposed SecondEars app, which was presented for feedback at workshops 5 and 6. Results: The stakeholders identified 6 requirements for the app, including that it be patient driven, secure, clear in terms of legal responsibilities, linked to the patient’s medical record, and that it should require minimal upfront and ongoing resources. These requirements informed the scope of the co-design workshops. The workshops were attended by between 4 and 13 people. The workshop attendees developed a list of required features and suggestions for user interface design. The app developers used these requirements and recommendations to develop a prototype of the SecondEars app in iOS, which was then refined through user acceptance testing. Conclusions: The SecondEars app allows patients to have control and autonomy over audio-recording and sharing their consultations while maintaining privacy and safety for medical information and legal protection for clinicians. The app has been designed to have low upkeep and minimal impact on clinical processes. The SecondEars prototype is currently being tested with patients in a clinical setting. %M 30860487 %R 10.2196/11111 %U http://formative.jmir.org/2019/1/e11111/ %U https://doi.org/10.2196/11111 %U http://www.ncbi.nlm.nih.gov/pubmed/30860487 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11950 %T Using Exploratory Trials to Identify Relevant Contexts and Mechanisms in Complex Electronic Health Interventions: Evaluating the Electronic Patient-Reported Outcome Tool %A Steele Gray,Carolyn %A Gravesande,Janelle %A Hans,Parminder Kaur %A Nie,Jason X %A Sharpe,Sarah %A Loganathan,Mayura %A Lyons,Renee %A Cott,Cheryl %+ Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, 1 Bridgepoint Drive, Toronto, ON, M4M 2B5, Canada, 1 416 461 8252 ext 2908, Carolyn.SteeleGray@sinaihealthsystem.ca %K eHealth %K mHealth %K multiple chronic conditions %K clinical trial, phase III %K health care evaluation mechanisms %K quantitative evaluation %K qualitative evaluation %K narrative analysis %D 2019 %7 27.02.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Designing appropriate studies for evaluating complex interventions, such as electronic health solutions to support integrated care, remains a methodological challenge. With the many moving parts of complex interventions, it is not always clear how program activities are connected to anticipated and unanticipated outcomes. Exploratory trials can be used to uncover determinants (or mechanisms) to inform content theory that underpins complex interventions before designing a full evaluation plan. Objective: A multimethod exploratory trial of the electronic patient-reported outcome (ePRO) tool was conducted to uncover contexts, processes and outcome variables, and the mechanisms that link these variables before full-scale evaluation. ePRO is a mobile app and portal designed to support goal-oriented care in interdisciplinary primary health care practices (clinical-level integration). This paper offers evaluation findings and methodological insight on how to use exploratory trial data to identify relevant context, process, and outcome variables, as well as central (necessary to achieving outcomes) versus peripheral (less critical and potentially context dependent) mechanisms at play. Methods: The 4-month trial was conducted in 2 primary health care practices in Toronto, Canada. The patients were randomized into control and intervention groups and compared pre and post on quality of life and activation outcome measures. Semistructured interviews were conducted with providers and patients in the intervention group. Narrative analysis was used to uncover dominant mechanisms that inform the intervention’s content theory (how context and process variables are linked to outcomes). Results: Overall, 7 providers, 1 administrator, and 16 patients (7-control, 9-intervention) participated in the study. This study uncovered many complex and nuanced context, process, and outcome variables at play in the intervention. Narrative analysis of patient and provider interviews revealed dominant story lines that help to tease apart central and peripheral mechanisms driving the intervention. Provider and patient story lines centered around fitting the new intervention into everyday work and life of patients and providers and meaningfulness of the intervention. These themes were moderated by patient-provider relationships going into and throughout the intervention, their comfort with technology, and the research process. Conclusions: Identifying dominant story lines using narrative analysis helps to identify the most relevant context and process variables likely to influence study outcomes. Normalization process theory emerges as a useful theory to uncover underlying mechanisms because of its emphasis on the social production and normalization of technological, processual, and social aspects of work; all found to be critical to our intervention. The number of complex, overlapping influencing variables suggests that complex interventions such as ePRO require us to pay careful attention to central versus peripheral mechanisms that will influence study outcomes. The narrative methods presented here are shown to be useful in uncovering these mechanisms and help to guide subsequent larger evaluation studies. %M 30810532 %R 10.2196/11950 %U http://formative.jmir.org/2019/1/e11950/ %U https://doi.org/10.2196/11950 %U http://www.ncbi.nlm.nih.gov/pubmed/30810532 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e9435 %T Using Mobile Technology to Improve Bone-Related Lifestyle Risk Factors in Young Women With Low Bone Mineral Density: Feasibility Randomized Controlled Trial %A Subasinghe,Asvini Kokila %A Garland,Suzanne Marie %A Gorelik,Alexandra %A Tay,Ilona %A Wark,John Dennis %+ Infection and Immunity Theme, Murdoch Children's Research Institute, Level 7, Royal Women's Hospital, 20 Flemington Road, Parkville,, Australia, 61 03 8345 3692, asvini.subasinghe@gmail.com %K behavior therapy methods %K mobile phones %K health behavior %K primary prevention methods %K self-care methods %D 2019 %7 25.02.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Poor bone health in adolescent and young adult females is a growing concern. Given the widespread use of mobile phones in this population, mobile health (mHealth) interventions may help improve health behaviors related to bone health in young women. Objective: The goal of the study was to determine the acceptability and feasibility of an mHealth intervention called Tap4Bone in improving health behaviors associated with the risk of osteoporosis in young women. Methods: The Tap4Bone mHealth intervention comprised the use of mobile phone apps, short messaging service (text messaging), and Web emails to encourage health behavior changes. The education group received osteoporosis prevention education leaflets. Changes in the bone health–related behaviors exercise, smoking, and calcium intake were assessed. User experiences and acceptance of the app were collected through focus group interviews. Results: A total of 35 (22 completed, mean age 23.1 [SD 1.8] years) were randomized to either the mobile phone (intervention n=18) or education (control n=17) group. Although there were trends toward improvement in calcium intake, sports activity, and smoking behaviors in the mHealth intervention group compared to the education group, these were not statistically significant. Conclusions: The Tap4Bone mHealth intervention was shown to be acceptable and feasible in subsets of the participants. The intervention should be improved upon using participant feedback to improve functionality. Findings from this study may aid in the development and modification of health care apps to reduce participant attrition. %M 30801253 %R 10.2196/formative.9435 %U http://formative.jmir.org/2019/1/e9435/ %U https://doi.org/10.2196/formative.9435 %U http://www.ncbi.nlm.nih.gov/pubmed/30801253 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e10284 %T Digital Gaming for Nutritional Education: A Survey on Preferences, Motives, and Needs of Children and Adolescents %A Holzmann,Sophie Laura %A Dischl,Felicitas %A Schäfer,Hanna %A Groh,Georg %A Hauner,Hans %A Holzapfel,Christina %+ Institute for Nutritional Medicine, Else Kroener-Fresenius-Center for Nutritional Medicine, University Hospital “Klinikum rechts der Isar”, Technical University of Munich, Georg-Brauchle-Ring 62, 5th Floor, Munich, 80992, Germany, 49 89 289 249 23, christina.holzapfel@tum.de %K adolescents %K children %K communication %K motives %K mobile phone %K needs %K nutrition %K obesity %K overweight %K preferences %K serious games %K survey %D 2019 %7 13.02.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Use of novel information and communication technologies are frequently discussed as promising tools to prevent and treat overweight and obesity in children and adolescents. Objective: This survey aims to describe the preferences, motives, and needs of children and adolescents regarding nutrition and digital games. Methods: We conducted a survey in 6 secondary schools in the southern region of Germany using a 43-item questionnaire. Questions referred to preferences, motives, and needs of children and adolescents regarding nutrition and digital games. In addition, knowledge regarding nutrition was assessed with 4 questions. We collected self-reported sociodemographic and anthropometric data. Descriptive statistical analyses were performed using SPSS. Results: In total, 293 children and adolescents participated in the study, with ages 12-18 years (137 girls, 46.8%), weight 30.0-120.0 (mean 60.2 [SD 13.2]) kg, and height 1.4-2.0 (mean 1.7 [SD 0.1]) m. A total of 5.5% (16/290) correctly answered the 4 questions regarding nutrition knowledge. Study participants acquired digital nutritional information primarily from the internet (166/291, 57.0%) and television (97/291, 33.3%), while school education (161/291, 55.3%) and parents or other adults (209/291, 71.8%) were the most relevant nondigital information sources. Most participants (242/283, 85.5%) reported that they regularly play digital games. More than half (144/236, 61.0%) stated that they play digital games on a daily basis on their smartphones or tablets, and almost 70% (151/282, 66.5%) reported playing digital games for ≤30 minutes without any interruption. One-half of respondents (144/280, 51.4%) also stated that they were interested in receiving information about nutrition while playing digital games. Conclusions: This survey suggests that nutrition knowledge in children and adolescents might be deficient. Most children and adolescents play digital games and express interest in acquiring nutritional information during digital gameplay. A digital game with a focus on sound nutrition could be a potential educational tool for imparting nutrition knowledge and promoting healthier nutrition behaviors in children and adolescents. %M 30758290 %R 10.2196/10284 %U http://formative.jmir.org/2019/1/e10284/ %U https://doi.org/10.2196/10284 %U http://www.ncbi.nlm.nih.gov/pubmed/30758290 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e12528 %T A Digital Modality Decision Program for Patients With Advanced Chronic Kidney Disease %A Dubin,Ruth %A Rubinsky,Anna %+ San Francisco Veterans Affairs Medical Center, 4150 Clement Street, Box 111J, San Francisco, CA, 94121, United States, 1 5108474955, ruth.dubin@ucsf.edu %K chronic kidney disease %K end-stage renal disease %K online social networking %K patient education %K renal dialysis %D 2019 %7 06.02.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Patient education regarding end-stage renal disease (ESRD) has the potential to reduce adverse outcomes and increase the use of in-home renal replacement therapies. Objective: This study aimed to investigate whether an online, easily scalable education program can improve patient knowledge and facilitate decision making regarding renal replacement therapy options. Methods: We developed a 4-week online, digital educational program that included written information, short videos, and social networking features. Topics included kidney transplant, conservative management, peritoneal dialysis, in-home hemodialysis, and in-center hemodialysis. We recruited patients with advanced chronic kidney disease (stage IV and V) to enroll in the online program, and we evaluated the feasibility and potential impact of the digital program by conducting pre- and postintervention surveys in areas of knowledge, self-efficacy, and choice of ESRD care. Results: Of the 98 individuals found to be eligible for the study, 28 enrolled and signed the consent form and 25 completed the study. The average age of participants was 65 (SD 15) years, and the average estimated glomerular filtration rate was 21 (SD 6) ml/min/1.73 m2. Before the intervention, 32% of patients (8/25) were unable to make an ESRD treatment choice; after the intervention, all 25 participants made a choice. The proportion of persons who selected kidney transplant as the first choice increased from 48% (12/25) at intake to 84% (21/25) after program completion (P=.01). Among modality options, peritoneal dialysis increased as the first choice for 4/25 (16%) patients at intake to 13/25 (52%) after program completion (P=.004). We also observed significant increases in knowledge score (from 65 [SD 56] to 83 [SD 14]; P<.001) and self-efficacy score (from 3.7 [SD 0.7] to 4.3 [SD 0.5]; P<.001). Conclusions: Implementation of a digital ESRD education program is feasible and may facilitate patients’ decisions about renal replacement therapies. Larger studies are necessary to understand whether the program affects clinical outcomes. Trial Registration: ClinicalTrials.gov NCT02976220; https://clinicaltrials.gov/ct2/show/NCT02976220 %M 30724735 %R 10.2196/12528 %U http://formative.jmir.org/2019/1/e12528/ %U https://doi.org/10.2196/12528 %U http://www.ncbi.nlm.nih.gov/pubmed/30724735 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e12508 %T Impact of Food Preparation Video Exposure on Online Nutrition Education in Women, Infants, and Children (WIC) Program Participants: Retrospective Study %A Bensley,Robert J %A Brusk,John J %+ School of Interdisciplinary Health Programs, Western Michigan University, 2414 CHHS Building, 1903 W Michigan Avenue, Kalamazoo, MI, 49008, United States, 1 269 716 2301, bensley@wmich.edu %K internet %K online video %K WIC %K engagement %D 2019 %7 23.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The impact of integrating video into health education delivery has been extensively investigated; however, the effect of integrating video on a learner’s subsequent performance in an online educational setting is rarely reported. Results of the relationship between the learner’s online video viewing and subsequent progression toward health behavior change in a self-directed online educational session are lacking. Objective: This study aimed to determine the relationship between viewing a Health eKitchen online video and key engagement performance indicators associated with online nutrition education for women, infants, and children (WIC). Methods: This study involved a retrospective cohort of users grouped on the basis of whether Health eKitchen exposure occurred before or after completing a nutrition education lesson. A two-sample test for equality of proportions was performed to test the difference in the likelihood of progression between the groups overall and when stratified by lesson type, which was defined by whether the lesson focused on food preparation. Welch two-sample t tests were performed to test the difference in average link depth and duration of use between groups overall and stratified by lesson type. Logistic regression was conducted to validate the impact of video viewing prior to lesson completion while controlling for lesson type and factors known to be associated with WIC key performance indicators. Results: A greater stage of change progression was observed for both food preparation (χ2=12.6, P<.001) and non-food preparation (χ2=62.8, P<.001) lessons among early stage users who had viewed a Health eKitchen video before completing a lesson. Time spent viewing educational learning resource links within the lesson was also significantly longer for both food preparation (t=7.8, P<.001) and non-food preparation (t=2.5, P=.01) lessons. Logistic regression analysis corroborated these results while controlling for known confounding factors. The odds of user progression were nearly three times greater among those who viewed a Health eKitchen video prior to lesson completion (odds ratio=2.61; 95% CI=2.08-3.29). Type of lesson (food vs non-food preparation) was the strongest predictor of progression odds (odds ratio=3.12; 95% CI=2.47-3.95). Conclusions: User access to a Health eKitchen video prior to completion of an online educational session had a significant impact on achieving lesson goals, regardless of the food preparation focus. This observation suggests the potential benefit of providing an application-oriented video at the onset of online nutrition education lessons. %R 10.2196/12508 %U http://formative.jmir.org/2019/1/e12508/ %U https://doi.org/10.2196/12508 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 1 %P e10978 %T Design, Development, and Evaluation of an Injury Surveillance App for Cricket: Protocol and Qualitative Study %A Soomro,Najeebullah %A Chhaya,Meraj %A Soomro,Mariam %A Asif,Naukhez %A Saurman,Emily %A Lyle,David %A Sanders,Ross %+ Broken Hill University Department of Rural Health, University of Sydney, Corrindah Court, Broken Hill, 2880, Australia, 61 880801282, naj.soomro@sydney.edu.au %K cricket %K injury surveillance %K mobile app %K mobile phone %K TeamDoc %K mHealth %D 2019 %7 22.01.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Injury surveillance and workload monitoring are important aspects of professional sports, including cricket. However, at the community level, there is a dearth of accessible and intelligent surveillance tools. Mobile apps are an accessible tool for monitoring cricket-related injuries at all levels. Objective: The objective of this paper is to share the novel methods associated with the development of the free TeamDoc app and provide evidence from an evaluation of the user experience and perception of the app regarding its functionality, utility, and design. Methods: TeamDoc mobile app for Android and Apple smartphones was developed using 3 languages: C++, Qt Modeling Language, and JavaScript. For the server-side connectivity, Hypertext Preprocessor (PHP) was used as it is a commonly used cross-platform language. PHP includes components that interact with popular database management systems, allowing for secure interaction with databases on a server level. The app was evaluated by administrating a modified user version of the Mobile App Rating Scale (uMARS; maximum score: 5). Results: TeamDoc is the first complementary, standalone mobile app that records cricket injuries through a smartphone. It can also record cricketing workloads, which is a known risk factor for injury. The app can be used without the need for supplementary computer devices for synchronization. The uMARS scores showed user satisfaction (overall mean score 3.6 [SD 0.5]), which demonstrates its acceptability by cricketers. Conclusions: Electronic injury surveillance systems have been shown to improve data collection during competitive sports. Therefore, TeamDoc may assist in improving injury reporting and may also act as a monitoring system for coaching staff to adjust individual training workloads. The methods described in this paper provide a template for researchers to develop similar apps for other sports. %M 30668516 %R 10.2196/10978 %U http://mhealth.jmir.org/2019/1/e10978/ %U https://doi.org/10.2196/10978 %U http://www.ncbi.nlm.nih.gov/pubmed/30668516 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e11509 %T Feasibility of a Therapist-Supported, Mobile Phone–Delivered Online Intervention for Depression: Longitudinal Observational Study %A Goldin,Philippe R %A Lindholm,Riku %A Ranta,Kristian %A Hilgert,Outi %A Helteenvuori,Tiia %A Raevuori,Anu %+ Betty Irene Moore School of Nursing, University of California Davis, 4610 X Street, Sacramento, CA, 95817, United States, 1 4156769793, philippegoldin@gmail.com %K cognitive therapy %K depression %K digital health %K digital therapeutics %K mindfulness %K online intervention %D 2019 %7 22.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Depression is a very common condition that impairs functioning and is often untreated. More than 60% of the treatments for depressive disorder are administered in primary care settings by care providers who lack the time and expertise to treat depression. To address this issue, we developed Ascend, a therapist-supported, mobile phone–delivered 8-week intervention administered at the Meru Health Online Clinic in Finland. Objective: We conducted two pilot studies to examine the feasibility of the Ascend intervention, specifically, dropout rates, daily practice, weekly group chat use, and changes in depression symptoms. We also explored whether daily practice and weekly group chat use were associated with changes in depression symptoms. Methods: A total of 117 Finnish adults with elevated depressive symptoms enrolled in Ascend, a program that included daily cognitive behavioral and mindfulness meditation exercises delivered through a mobile phone app, anonymous group chat with other users, and chat/phone access to a licensed therapist. Eight weekly themes were delivered in a fixed, sequential format. Depression symptoms were measured at baseline, every second week during the intervention, immediately after the intervention, and 4 weeks after completion of the intervention. Data were analyzed using intent-to-treat repeated-measures analysis of variance and linear regression models. Results: For studies 1 and 2, we observed dropout rates of 27% and 15%, respectively, decreasing daily practice and group chat use, and decreased depression symptoms from baseline to immediately and 4 weeks after the intervention (P<.001). We found that both more daily practice and chat group use predicted the occurrence of fewer depressive symptoms at 4 weeks postintervention (Study 1: ∆R2=.38, P=.004 and ∆R2=.38, P=.002, respectively; Study 2: ∆R2=.16, P<.001 and ∆R2=.08, P=.002, respectively). Conclusions: This therapist-supported, mobile phone–delivered treatment for depression is feasible and associated with reduced depression symptoms. Design features that enhance daily practice and group chat use are areas of future investigation. Validation of these results using a controlled study design is needed to establish the evidence base for the Ascend intervention. %R 10.2196/11509 %U http://formative.jmir.org/2019/1/e11509/ %U https://doi.org/10.2196/11509 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e12227 %T Use of a Biofeedback Breathing App to Augment Poststress Physiological Recovery: Randomized Pilot Study %A Plans,David %A Morelli,Davide %A Sütterlin,Stefan %A Ollis,Lucie %A Derbyshire,Georgia %A Cropley,Mark %+ Faculty of Health and Medical Sciences, School of Psychology, University of Surrey, School of Psychology, Stag Hill, Guildford, GU2 7XH, United Kingdom, 44 01483686928, mark.cropley@surrey.ac.uk %K biofeedback %K breathing %K heart rate variability %K recovery %K rumination %K stress %D 2019 %7 11.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The speed of physiological recovery from stress may be a marker for cardiovascular disease risk. Stress management programs that incorporate guided breathing have been shown to moderate the stress response and augment recovery. Objective: The aim of this study was to examine the effectiveness of an app-based brief relaxation intervention (BioBase) for facilitating physiological recovery in individuals exposed to a brief psychological stressor. Methods: A total of 75 participants (44 women) completed a stressor speech task and were randomly assigned to one of three conditions: control, rumination, or an app-based relaxation breathing (BioBase) conditions. Heart rate variability (HRV) was assessed as a measure of autonomic function at baseline (6 min), during stress (6 min), and during recovery (6 min). Results: There was a significant increase in subjective stress following stress exposure, but the ratings returned to baseline after recovery in all three groups. In addition, there was a significant decrease in vagally mediated HRV in the poststress period. During recovery, the root mean square of successive differences (P<.001), the percentage of successive interbeat (RR) intervals that differ by >50 ms (pNN50; P<.001), and high-frequency (P<.02) HRV were significantly higher in the BioBase breathing condition than the rumination and control conditions. There was no difference in HRV values between the rumination and control conditions during recovery. Conclusions: App-based relaxed breathing interventions could be effective in reducing cardiovascular disease risk. These results provide additional utility of biofeedback breathing in augmenting physiological recovery from psychological stress. %M 30684437 %R 10.2196/12227 %U https://formative.jmir.org/2019/1/e12227/ %U https://doi.org/10.2196/12227 %U http://www.ncbi.nlm.nih.gov/pubmed/30684437 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e10246 %T Evaluation of a Mobile Device Survey System for Behavioral Risk Factors (SHAPE): App Development and Usability Study %A Oakley-Girvan,Ingrid %A Lavista,Juan M %A Miller,Yasamin %A Davis,Sharon %A Acle,Carlos %A Hancock,Jeffrey %A Nelson,Lorene M %+ Public Health Institute, 555 12th Street, 10th Floor, Oakland, CA,, United States, 1 4086562948, oakley@stanford.edu %K mobile phone %K demographic characteristics %K health surveys %K risk behaviors %K mobile apps %D 2019 %7 11.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Risk factors, including limited exercise, poor sleep, smoking, and alcohol and drug use, if mitigated early, can improve long-term health. Risk prevalence has traditionally been measured using methods that now have diminished participation rates. With >75% of American citizens owning smartphones, new data collection methods using mobile apps can be evaluated. Objective: The objective of our study was to describe the development, implementation, and evaluation of a mobile device–based survey system for behavioral risk assessment. Specifically, we evaluated its feasibility, usability, acceptability, and validity. Methods: We enrolled 536 students from 3 Vermont State Colleges. Iterative mobile app development incorporated focus groups, extensive testing, and the following 4 app versions: iOS standard, iOS gamified, Android standard, and Android gamified. We aimed to capture survey data, paradata, and ambient data such as geolocation. Using 3 separate surveys, we asked a total of 27 questions that included demographic characteristics, behavioral health, and questions regarding the app’s usability and survey process. Results: Planned enrollment was exceeded in just a few days. There were 1392 “hits” to the landing page where the app could be downloaded. Excluding known project testers and others not part of the study population, 670 participants downloadeded the SHAPE app. Of those, 94.9% of participants (636/670) agreed to participate by providing in-app consent. Of the 636 who provided consent, 84.3% (536/636) were deemed eligible for the study. The majority of eligible respondents completed the initial survey (459/536, 85.6%), whereas 29.9% (160/536) completed the second survey and 28.5% (153/536) completed the third survey. The SHAPE survey obtained 414 participants on the behavioral risk items in survey 1, which is nearly double the 209 participants who completed the traditional Vermont College Health Survey in 2014. SHAPE survey responses were consistent with the traditionally collected Vermont College Health Survey data. Conclusions: This study provides data highlighting the potential for mobile apps to improve population-based health, including an assessment of recruitment methods, burden and response rapidity, and future adaptations. Although gamification and monetary rewards were relatively unimportant to this study population, item response theory may be technologically feasible to reduce individual survey burden. Additional data collected by smartphones, such as geolocation, could be important in additional analysis, such as neighborhood characteristics and their impact on behavioral risk factors. Mobile tools that offer rapid adaptation for specific populations may improve research data collection for primary prevention and could be used to improve engagement and health outcomes. %M 30684441 %R 10.2196/10246 %U https://formative.jmir.org/2019/1/e10246/ %U https://doi.org/10.2196/10246 %U http://www.ncbi.nlm.nih.gov/pubmed/30684441 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e12456 %T A Virtual Reality Food Court to Study Meal Choices in Youth: Design and Assessment of Usability %A Allman-Farinelli,Margaret %A Ijaz,Kiran %A Tran,Helen %A Pallotta,Hermes %A Ramos,Sidney %A Liu,Junya %A Wellard-Cole,Lyndal %A Calvo,Rafael A %+ Charles Perkins Centre, School of Life and Environmental Sciences, University of Sydney, Building D17, NSW, 2006, Australia, 61 0290367045, margaret.allmanfarinelli@sydney.edu.au %K virtual reality %K nutrition promotion %K food policy %K take-out food %K obesity %K young adults %D 2019 %7 09.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Regular consumption of take-out and fast foods with sugary drinks is associated with poor quality diets and higher prevalence of obesity. Among the settings where such food is consumed is the food court typically found in shopping malls prominent in many countries. Objective: The objective of this research was to develop a virtual reality food court that could be used to test food environmental interventions, such as taxation, and ultimately to facilitate the selection of healthier food choices. Methods: Fourteen food courts in Sydney, Australia were selected to include those in the city center and suburbs of high and low socioeconomic status. Researchers visited the courts to collect information on number and type of food outlets, all menu items for sale, cost of foods and beverages and sales promotions. This information was used to assemble 14 food outlets typically found in food courts, and representative menus were compiled. The UNITY gaming platform was used to design a virtual reality food court that could be used with HTC VIVE goggles. Participants navigated the virtual reality food court using the head-mounted display, keyboard, and mouse and selected a lunch meal, including food and beverage. A validated questionnaire on presence within the virtual reality food court and system usability was completed at the end of the session. The constructs for presence included a sense of control, sensory fidelity, realism, distraction, and involvement. Questions were rated on a scale from 1 (worst) through 7 (best) for each of 28 questions giving a maximum total score of 196. The systems usability scale (SUS) that gives a final score out of 100 was also assessed. Results: One hundred and sixty-two participants with a mean age of 22.5 (SD 3.1) years completed the survey. The mean score for total presence was 144 (SE 1.4) consisting of control: 62.1 (SE 0.8), realism: 17.5 (SE 0.2), involvement: 9.6 (SE 0.2), sensory fidelity: 34.9 (SE 0.4), and distraction: 24.0 (SE 0.3). The mean SUS was 69 (SE 1.1). Conclusions: Virtual reality shows promise as a tool to study food choice for test interventions to inform practice and policy. %M 30684440 %R 10.2196/12456 %U http://formative.jmir.org/2019/1/e12456/ %U https://doi.org/10.2196/12456 %U http://www.ncbi.nlm.nih.gov/pubmed/30684440 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e10944 %T Community Engagement in the Development of an mHealth-Enabled Physical Activity and Cardiovascular Health Intervention (Step It Up): Pilot Focus Group Study %A Ceasar,Joniqua Nashae %A Claudel,Sophie Elizabeth %A Andrews,Marcus R %A Tamura,Kosuke %A Mitchell,Valerie %A Brooks,Alyssa T %A Dodge,Tonya %A El-Toukhy,Sherine %A Farmer,Nicole %A Middleton,Kimberly %A Sabado-Liwag,Melanie %A Troncoso,Melissa %A Wallen,Gwenyth R %A Powell-Wiley,Tiffany M %+ National Heart, Lung, and Blood Institute, National Institutes of Health, Building 10-CRC, Room 5-5332, MSC 1454, 10 Center Drive, Bethesda, MD, 20892, United States, 1 301 594 3735, tiffany.powell-wiley@nih.gov %K cardiovascular health %K community-based participatory research %K health behaviors %K mHealth %K mobile phone %K physical activity %K qualitative data %D 2019 %7 04.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Community-based participatory research is an effective tool for improving health outcomes in minority communities. Few community-based participatory research studies have evaluated methods of optimizing smartphone apps for health technology-enabled interventions in African Americans. Objective: This study aimed to utilize focus groups (FGs) for gathering qualitative data to inform the development of an app that promotes physical activity (PA) among African American women in Washington, DC. Methods: We recruited a convenience sample of African American women (N=16, age range 51-74 years) from regions of Washington, DC metropolitan area with the highest burden of cardiovascular disease. Participants used an app created by the research team, which provided motivational messages through app push notifications and educational content to promote PA. Subsequently, participants engaged in semistructured FG interviews led by moderators who asked open-ended questions about participants’ experiences of using the app. FGs were audiorecorded and transcribed verbatim, with subsequent behavioral theory-driven thematic analysis. Key themes based on the Health Belief Model and emerging themes were identified from the transcripts. Three independent reviewers iteratively coded the transcripts until consensus was reached. Then, the final codebook was approved by a qualitative research expert. Results: In this study, 10 main themes emerged. Participants emphasized the need to improve the app by optimizing automation, increasing relatability (eg, photos that reflect target demographic), increasing educational material (eg, health information), and connecting with community resources (eg, cooking classes and exercise groups). Conclusions: Involving target users in the development of a culturally sensitive PA app is an essential step for creating an app that has a higher likelihood of acceptance and use in a technology-enabled intervention. This may decrease health disparities in cardiovascular diseases by more effectively increasing PA in a minority population. %M 30684422 %R 10.2196/10944 %U https://formative.jmir.org/2019/1/e10944/ %U https://doi.org/10.2196/10944 %U http://www.ncbi.nlm.nih.gov/pubmed/30684422 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e10858 %T Mobile Device Use Among Rural, Low-Income Families and the Feasibility of an App to Encourage Preschoolers’ Physical Activity: Qualitative Study %A McCloskey,Morgan L %A Thompson,Darcy A %A Chamberlin,Barbara %A Clark,Lauren %A Johnson,Susan L %A Bellows,Laura L %+ Department of Food Science and Human Nutrition, Colorado State University, 1571 Campus Delivery, Fort Collins, CO, 80523 1571, United States, 1 9704911305, laura.bellows@colostate.edu %K smartphone %K mobile apps %K families %K child, preschool %K physical activity %K rural population %K poverty %D 2018 %7 06.12.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: As mobile devices are becoming ubiquitous, technology-based interventions provide a promising strategy to positively influence health behaviors of families with young children. However, questions remain about the feasibility and acceptability of intervention delivery via mobile apps in low-income, rural settings and among families with preschoolers. Objective: The aims of this study were to understand the content and context of mobile device use for preschoolers; explore parent beliefs on this topic, including the acceptability of intervention delivery via mobile devices; and test a prototype of an app to encourage preschoolers’ physical activity with both parents and children. Methods: Parents (n=29) were recruited from 5 preschool centers in eastern, rural Colorado to complete a semistructured telephone interview regarding preschoolers’ mobile device use. A second sample of parents (n=31) was recruited from the same preschool centers to view the app prototype independently and provide feedback. A third sample of preschool children (n=24) was videotaped using the app in small groups to measure engagement and record their responses to the app. Results: Five key content areas emerged from the telephone interviews: (1) mobile devices are an important part of families’ everyday routines, and parents have parameters governing their use; (2) parents often use mobile devices as a tool for behavior management; (3) parents clearly distinguish between mobile device use for learning versus entertainment; (4) parents have an overarching desire for balance in regard to their child’s mobile device use; and (5) parents were generally supportive of the idea of using mobile apps for intervention delivery. From the app prototype testing with parents, participants reacted positively to the app and felt that it would be useful in a variety of situations. Testing with preschoolers showed the children were highly engaged with the app and a majority remained standing and/or actively moving through the entire length of the app. Conclusions: Mobile devices are already integrated into most families’ daily routines and appear to be an acceptable method of intervention delivery in low-income families in rural Colorado. The physical activity app represents an innovative way to reach these families and, with further improvements based on participant feedback, will provide children with a unique opportunity to practice key movement skills. %R 10.2196/10858 %U http://pediatrics.jmir.org/2018/2/e10858/ %U https://doi.org/10.2196/10858 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 12 %P e12077 %T The Internet of Things in Health Care in Oxford: Protocol for Proof-of-Concept Projects %A Meinert,Edward %A Van Velthoven,Michelle %A Brindley,David %A Alturkistani,Abrar %A Foley,Kimberley %A Rees,Sian %A Wells,Glenn %A de Pennington,Nick %+ Healthcare Translation Research Group, Department of Paediatrics, University of Oxford, Level 2, Children's Hospital, John Radcliffe, Oxford, OX3 9DU, United Kingdom, 44 7824446808, edward.meinert@paediatrics.ox.ac.uk %K Internet %K computer systems %K computing methodologies %K information systems %K information storage and retrieval %K dataset %K patient care %K health services %K Internet of Things %K Internet of Medical Things %D 2018 %7 04.12.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Demands on health services across are increasing because of the combined challenges of an expanding and aging population, alongside complex comorbidities that transcend the classical boundaries of modern health care. Continuing to provide and coordinate care in the current manner is not a viable route to sustain the improvements in health outcomes observed in recent history. To ensure that there continues to be improvement in patient care, prevention of disease, and reduced burden on health systems, it is essential that we adapt our models of delivery. Providers of health and social care are evolving to face these pressures by changing the way they think about the care system and, importantly, how to involve patients in the planning and delivery of services. Objective: The objective of this paper is to provide (1) an overview of the current state of Internet of Things (IoT) and key implementation considerations, (2) key use cases demonstrating technology capabilities, (3) an overview of the landscape for health care IoT use in Oxford, and (4) recommendations for promoting the IoT via collaborations between higher education institutions and industry proof-of-concept (PoC) projects. Methods: This study describes the PoC projects that will be created to explore cost-effectiveness, clinical efficacy, and user adoption of Internet of Medical Things systems. The projects will focus on 3 areas: (1) bring your own device integration, (2) chronic disease management, and (3) personal health records. Results: This study is funded by Research England’s Connecting Capability Fund. The study started in March 2018, and results are expected by the end of 2019. Conclusions: Embracing digital solutions to support the evolution and transformation of health services is essential. Importantly, this should not simply be undertaken by providers in isolation. It must embrace and exploit the advances being seen in the consumer devices, national rollout of high-speed broadband services, and the rapidly expanding medical device industry centered on mobile and wearable technologies. Oxford University Hospitals and its partner providers, patients, and stakeholders are building on their leading position as an exemplar site for digital maturity in the National Health Service to implement and evaluate technologies and solutions that will capitalize on the IoT. Although early in the application to health, the IoT and the potential it provides to make the patient a partner at the center of decisions about care represent an exciting opportunity. If achieved, a fully connected and interoperable health care environment will enable continuous acquisition and real-time analysis of patient data, offering unprecedented ability to monitor patients, manage disease, and potentially deliver early diagnosis. The clinical benefit of this is clear, but additional patient benefit and value will be gained from being able to provide expert care at home or close to home. International Registered Report Identifier (IRRID): DERR1-10.2196/12077 %M 30514695 %R 10.2196/12077 %U http://www.researchprotocols.org/2018/12/e12077/ %U https://doi.org/10.2196/12077 %U http://www.ncbi.nlm.nih.gov/pubmed/30514695 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e25 %T Behavior Change for Youth Drivers: Design and Development of a Smartphone-Based App (BackPocketDriver) %A Warren,Ian %A Meads,Andrew %A Whittaker,Robyn %A Dobson,Rosie %A Ameratunga,Shanthi %+ Department of Computer Science, University of Auckland, Science Centre Building, 38 Princess Street, Auckland, 1010, New Zealand, 64 9 373 7599 ext 88784, ian-w@cs.auckland.ac.nz %K smartphone %K public health %K telemedicine %K telemetry %D 2018 %7 26.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The over-representation of youth in road crash injury and fatality rates is a major public health issue globally. In New Zealand, youth drivers are most vulnerable in the restricted license period when they can drive without the requirement for supervision by an experienced adult. Behavioral change interventions delivered using mobile phone technology to young drivers could serve as a useful mechanism to develop safe driving skills, but this potential remains to be fully explored. Objective: This study aimed to apply behavioral change principles to design and develop a smartphone-based intervention with the aim of helping youth drivers to develop and hone safe driving skills. Methods: An iterative process was used to support development of the smartphone intervention. We reviewed behavioral change literature, identifying fundamental principles and exploring use of behavior change techniques (BCTs) in other areas of public health. We engaged with key stakeholders, including young drivers, government agencies, and relevant organizations. We also took into account technology adoption considerations when designing the app. Results: We developed BackPocketDriver (BPD), an Android smartphone app that uses in-built sensors to monitor and infer driver behavior. The app implements features that were identified during the design process and are traceable to BCTs and theory. A key feature is messaging, which is used to instruct, motivate, educate, and relay feedback to participants. In addition, messaging addresses attitudes and beliefs. Other features include journey feedback summaries, goal setting, achievements, and leaderboards. Conclusions: BPD’s design rests on a sound foundation of theory and evidence. With explicit links between theory and features, the app aims to be an effective intervention to change and improve youth driver behavior. The next phase of this study is to run a small pilot study to assess BPD’s effectiveness. %M 30684435 %R 10.2196/formative.9660 %U http://formative.jmir.org/2018/2/e25/ %U https://doi.org/10.2196/formative.9660 %U http://www.ncbi.nlm.nih.gov/pubmed/30684435 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e22 %T Assessing the Needs and Perspectives of Patients With Asthma and Chronic Obstructive Pulmonary Disease on Patient Web Portals: Focus Group Study %A Metting,Esther %A Schrage,Aaltje Jantine %A Kocks,Janwillem WH %A Sanderman,Robbert %A van der Molen,Thys %+ Groningen Research Institute for Asthma and COPD, Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 4, Groningen, 9713 AW, Netherlands, 31 6 2564 7087, e.i.metting@umcg.nl %K asthma %K chronic obstructive pulmonary disease %K health care %K health literacy %K internet %K electronic medical record %K self-management %D 2018 %7 22.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: As accessibility to the internet has increased in society, many health care organizations have developed patient Web portals (PWPs), which can provide a range of self-management options to improve patient access. However, the available evidence suggests that they are used inefficiently and do not benefit patients with low health literacy. Asthma and chronic obstructive pulmonary disease (COPD) are common chronic diseases that require ongoing self-management. Moreover, patients with COPD are typically older and have lower health literacy. Objective: This study aimed to obtain and present an overview of patients’ perspectives of PWPs to facilitate the development of a portal that better meets the needs of patients with asthma and COPD. Methods: We performed a focus group study using semistructured interviews in 3 patient groups from the north of the Netherlands who were recruited through the Dutch Lung Foundation. Each group met 3 times for 2 hours each at a 1-week interval. Data were analyzed with coding software, and patient descriptors were analyzed with nonparametric tests. The consolidated criteria for reporting qualitative research were followed when conducting the study. Results: We included 29 patients (16/29, 55% male; mean age 65 [SD 10] years) with COPD (n=14), asthma-COPD overlap (n=4), asthma (n=10), or other respiratory disease (n=1). There was a large variation in the internet experience; some patients hardly used the internet (4/29, 14%), whereas others used internet >3 times a week (23/29, 79%). In general, patients were positive about having access to a PWP, considering access to personal medical records as the most important option, though only after discussion with their physician. A medication overview was considered a useful option. We found that communication between health care professionals could be improved if patients could use the PWP to share information with their health care professionals. However, as participants were worried about the language and usability of portals, it was recommended that language should be adapted to the patient level. Another concern was that disease monitoring through Web-based questionnaire use would only be useful if the results were discussed with health care professionals. Conclusions: Participants were positive about PWPs and considered them a logical step. Today, most patients tend to be better educated and have internet access, while also being more assertive and better informed about their disease. A PWP could support these patients. Our participants also provided practical suggestions for implementation in current and future PWP developments. The next step will be to develop a portal based on these recommendations and assess whether it meets the needs of patients and health care providers. %M 30684436 %R 10.2196/formative.8822 %U http://formative.jmir.org/2018/2/e22/ %U https://doi.org/10.2196/formative.8822 %U http://www.ncbi.nlm.nih.gov/pubmed/30684436 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e24 %T The iPrevent Online Breast Cancer Risk Assessment and Risk Management Tool: Usability and Acceptability Testing %A Lo,Louisa L %A Collins,Ian M %A Bressel,Mathias %A Butow,Phyllis %A Emery,Jon %A Keogh,Louise %A Weideman,Prue %A Steel,Emma %A Hopper,John L %A Trainer,Alison H %A Mann,Gregory B %A Bickerstaffe,Adrian %A Antoniou,Antonis C %A Cuzick,Jack %A Phillips,Kelly-Anne %+ Department of Medical Oncology, Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett Street, Victoria, 8006, Australia, 61 3 85597860, Kelly.Phillips@petermac.org %K clinical decision support %K breast cancer %K BRCA1 gene %K BRCA2 gene %K risk %K preventive health %K screening %D 2018 %7 07.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: iPrevent estimates breast cancer (BC) risk and provides tailored risk management information. Objective: The objective of this study was to assess the usability and acceptability of the iPrevent prototype. Methods: Clinicians were eligible for participation in the study if they worked in primary care, breast surgery, or genetics clinics. Female patients aged 18-70 years with no personal cancer history were eligible. Clinicians were first familiarized with iPrevent using hypothetical paper-based cases and then actor scenarios; subsequently, they used iPrevent with their patients. Clinicians and patients completed the System Usability Scale (SUS) and an Acceptability questionnaire 2 weeks after using iPrevent; patients also completed measures of BC worry, anxiety, risk perception, and knowledge pre- and 2 weeks post-iPrevent. Data were summarized using descriptive statistics. Results: The SUS and Acceptability questionnaires were completed by 19 of 20 clinicians and 37 of 43 patients. Usability was above average (SUS score >68) for 68% (13/19) clinicians and 76% (28/37) patients. The amount of information provided by iPrevent was reported as “about right” by 89% (17/19) clinicians and 89% (33/37) patients and 95% (18/19) and 97% (36/37), respectively, would recommend iPrevent to others, although 53% (10/19) clinicians and 27% (10/37) patients found it too long. Exploratory analyses suggested that iPrevent could improve risk perception, decrease frequency of BC worry, and enhance BC prevention knowledge without changing state anxiety. Conclusions: The iPrevent prototype demonstrated good usability and acceptability. Because concerns about length could be an implementation barrier, data entry has been abbreviated in the publicly available version of iPrevent. %M 30684421 %R 10.2196/formative.9935 %U http://formative.jmir.org/2018/2/e24/ %U https://doi.org/10.2196/formative.9935 %U http://www.ncbi.nlm.nih.gov/pubmed/30684421 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e10945 %T Barriers and Opportunities for Using Wearable Devices to Increase Physical Activity Among Veterans: Pilot Study %A Kim,Rebecca H %A Patel,Mitesh S %+ Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA,, United States, 1 2678720364, rebecca.kim@uphs.upenn.edu %K veterans %K wearable devices %K connected health device %K physical activity %K mobile phone %D 2018 %7 06.11.2018 %9 Short Paper %J JMIR Formativ Res %G English %X Background: Few studies have examined the use of wearable devices among the veteran population. Objective: The objective of this study was to evaluate veterans’ perceptions of and experiences with wearable devices and identify the potential barriers and opportunities to using such devices to increase physical activity levels in this population. Methods: Veterans able to ambulate with or without assistance completed surveys about their mobile technology use and physical activity levels. They were then given the option of using a wearable device to monitor their activity levels. Follow-up telephone interviews were conducted after 2 months. Results: A total of 16 veterans were enrolled in this study, and all of them agreed to take home and use the wearable device to monitor their activity levels. At follow-up, 91% (10/11) veterans were still using the device daily. Veterans identified both opportunities and barriers for incorporating these devices into interventions to increase physical activity. Conclusions: Veterans engaged in using wearable devices at high rates. %M 30684414 %R 10.2196/10945 %U http://formative.jmir.org/2018/2/e10945/ %U https://doi.org/10.2196/10945 %U http://www.ncbi.nlm.nih.gov/pubmed/30684414 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e11062 %T Time Series Visualizations of Mobile Phone-Based Daily Diary Reports of Stress, Physical Activity, and Diet Quality in Mostly Ethnic Minority Mothers: Feasibility Study %A Comulada,W Scott %A Swendeman,Dallas %A Rezai,Roxana %A Ramanathan,Nithya %+ Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 10920 Wilshire Boulevard, Suite 350, Los Angeles, CA, 90024, United States, 1 3107948278, wcomulada@mednet.ucla.edu %K changepoint %K diet quality %K mobile phone %K moving average %K physical activity %K stress %K time series %D 2018 %7 05.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Health behavior patterns reported through daily diary data are important to understand and intervene upon at the individual level in N-of-1 trials and related study designs. There is often interest in relationships between multiple outcomes, such as stress and health behavior. However, analyses often utilize regressions that evaluate aggregate effects across individuals, and standard analyses target single outcomes. Objective: This paper aims to illustrate how individuals’ daily reports of stress and health behavior (time series) can be explored using visualization tools. Methods: Secondary analysis was conducted on 6 months of daily diary reports of stress and health behavior (physical activity and diet quality) from mostly ethnic minority mothers who pilot-tested a self-monitoring mobile health app. Time series with minimal missing data from 14 of the 44 mothers were analyzed. Correlations between stress and health behavior within each time series were reported as a preliminary step. Stress and health behavior time series patterns were visualized by plotting moving averages and time points where mean shifts in the data occurred (changepoints). Results: Median correlation was small and negative for associations of stress with physical activity (r=−.14) and diet quality (r=−.08). Moving averages and changepoints for stress and health behavior were aligned for some participants but not for others. A third subset of participants exhibited little variation in stress and health behavior reports. Conclusions: Median correlations in this study corroborate prior findings. In addition, time series visualizations highlighted variations in stress and health behavior across individuals and time points, which are difficult to capture through correlations and regression-based summary measures. %M 30684407 %R 10.2196/11062 %U https://formative.jmir.org/2018/2/e11062/ %U https://doi.org/10.2196/11062 %U http://www.ncbi.nlm.nih.gov/pubmed/30684407 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e11025 %T Web-Delivered Multimedia Training Materials for the Self-Collection of Dried Blood Spots: A Formative Project %A Allen,Alicia M %A Lundeen,Kim %A Murphy,Sharon E %A Spector,Logan %A Harlow,Bernard L %+ Department of Family & Community Medicine, College of Medicine, University of Arizona, Suite 300, 3950 South Country Club Road, Tucson, AZ, 85713, United States, 1 5206268157, aliciaallen@email.arizona.edu %K dried blood spot %K internet %K feasibility studies %D 2018 %7 05.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The use of dried blood spots (DBS) in biomedical research has been increasing as an objective measure for variables that are typically plagued by self-report, such as smoking status and medication adherence. The development of training materials for the self-collection of DBS that can be delivered through the Web would allow for broader use of this methodology. Objective: The objective of this study was to evaluate the acceptability and feasibility of the self-collection of DBS using newly developed multimedia training materials that were delivered through the Web. We also aimed to assess the usability of the collected DBS samples. Methods: We recruited participants through Facebook advertising for two distinct studies. The first study evaluated the acceptability of our newly developed DBS training materials, while the second assessed the implementation of this protocol into a larger Web-based study. Results: In the first study, participants (N=115) were aged, on average, 26.1 (SD 6.4) years. Training materials were acceptable (113/115, 98.2%, of participants were willing to collect DBS again) and produced usable samples (110/115, 95.7%, collected DBS were usable). In the second study, response rate was 25.0% (41/164), with responders being significantly younger than nonresponders (20.3 [SD 0.2] vs 22.0 [SD 0.4]; P<.001), and 92% (31/41) of collected DBS samples were usable by the laboratory. Conclusions: Overall, while the protocol is acceptable, feasible, and produced usable samples, additional work is needed to improve response rates. %M 30684406 %R 10.2196/11025 %U http://formative.jmir.org/2018/2/e11025/ %U https://doi.org/10.2196/11025 %U http://www.ncbi.nlm.nih.gov/pubmed/30684406 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e23 %T Using Cocreation in the Process of Designing a Smartphone App for Adolescents and Young Adults With Cancer: Prototype Development Study %A Elsbernd,Abbey %A Hjerming,Maiken %A Visler,Camilla %A Hjalgrim,Lisa Lyngsie %A Niemann,Carsten Utoft %A Boisen,Kirsten Arntz %A Jakobsen,Jens %A Pappot,Helle %+ Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, 2100, Denmark, 45 3545 8403, helle.pappot@regionh.dk %K adolescent and young adult %K cancer %K cocreation %K mHealth %K oncology %D 2018 %7 01.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Adolescent and young adult (AYA) oncology and hematology is a developing field of medicine, focusing on a population that faces many challenges throughout medical treatment and beyond. Mobile health (mHealth) interventions provide exciting new opportunities for improvement of health-related quality of life (HRQoL) in AYAs with cancer. Many smartphone apps are currently available for AYAs with cancer; however, for AYAs with cancer, very few apps have been designed with direct input from AYAs themselves or have demonstrated their effectiveness and benefit. Objective: The objective of this project was to develop the prototype of a smartphone app for AYAs with cancer through the process of cocreation, with the active input of AYAs who have received treatment for cancer directly impacting content and design. Methods: Patients were recruited from a population of Danish AYAs who had received treatment for cancer between the ages of 15 and 29 years. The cocreation process was completed over the course of 3 workshops and intermittent ad hoc meetings, where the recruited AYAs worked in coordination with 1 nurse, 1 doctor, and 2 representatives from a digital agency and app developer. During each workshop, participants prioritized their goals for the app. After new app content was developed, feedback was requested from the participants, and changes were made accordingly. This iterative process continued until consensus on final product features and design were achieved. Health care professionals provided minimal input and primarily performed observational roles in the workshops, with direct interaction limited to introducing the project and explaining measurement features of the app in development. Results: Three key features to be included in the prototype app were identified from the cocreation workshops: (1) a community forum; (2) an information library; and (3) a symptom and side-effect tracking tool. Bright, warm colors were selected for the app by the participating AYAs. The final prototype will be launched for pilot testing and implementation testing in February of 2018. Conclusions: The process of cocreation is a user-involved process that can create an end product that is useful and customized for the target population. This process, as such, is a beneficial process to utilize when addressing the specific needs of AYAs with cancer. The results of the here described app prototype will be evaluated in more detail in the near future. However, this description of the cocreation process in app development can be utilized for the creation of other mHealth interventions. %M 30684439 %R 10.2196/formative.9842 %U http://formative.jmir.org/2018/2/e23/ %U https://doi.org/10.2196/formative.9842 %U http://www.ncbi.nlm.nih.gov/pubmed/30684439 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e21 %T A Web-Based Interactive Tool to Reduce Childhood Obesity Risk in Urban Minority Youth: Usability Testing Study %A Verdaguer,Sandra %A Mateo,Katrina F %A Wyka,Katarzyna %A Dennis-Tiwary,Tracy A %A Leung,May May %+ School of Urban Public Health, Hunter College, The City University of New York, 2180 Third Avenue, New York, NY, 10035, United States, 1 212 396 7774, maymay.leung@hunter.cuny.edu %K usability testing %K interactive technology %K mHealth, childhood obesity %K minority %K health nutrition %K health education %D 2018 %7 01.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Childhood obesity is a serious public health issue among minority youth in the United States. Technology-enhanced approaches can be effective for promoting healthy behavior change. Objective: The purpose of this study was to test the usability of prototypes of a Web-based interactive tool promoting healthy dietary behaviors to reduce childhood obesity risk in urban minority youth. The Web-based tool comprised a manga-style comic with interactive features (eg, sound effects, clickable pop-ups), tailored messaging, and goal setting, and was optimized for use on tablet devices. Methods: Latino and black/African American children ages 9 to 13 years were recruited to participate in two rounds of usability testing. A modified think-aloud method was utilized. Self-reported surveys and field notes were collected. Audio recordings and field notes from usability testing sessions were systematically reviewed by extracting and coding user feedback as either positive comments or usability or negative issues. The quantitative data from self-reported questionnaires were analyzed using descriptive statistics. Results: Twelve children (four female; eight black/African American) with a mean age of 10.92 (SD 1.16) years participated. Testing highlighted overall positive experiences with the Web-based interactive tool, especially related to storyline, sound effects, and color schemes. Specific usability issues were classified into six themes: appearance, content, special effects, storyline, terminology, and navigation. Changes to the Web-based tool after round 1 included adding a navigation guide, making clickable icons more visible, improving graphic designs, and fixing programming errors. In round 2 of testing (after modifications to the Web-based tool were incorporated), many of the usability issues that were identified in round 1 did not emerge. Conclusions: Results of testing will inform further development and finalization of the tool, which will be tested using a two-group pilot randomized study, with the goal of reducing childhood obesity risk in minority, low-income youth. %M 30684417 %R 10.2196/formative.9747 %U http://formative.jmir.org/2018/2/e21/ %U https://doi.org/10.2196/formative.9747 %U http://www.ncbi.nlm.nih.gov/pubmed/30684417 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e10025 %T Linking Podcasts With Social Media to Promote Community Health and Medical Research: Feasibility Study %A Balls-Berry,Joyce %A Sinicrope,Pamela %A Valdez Soto,Miguel %A Brockman,Tabetha %A Bock,Martha %A Patten,Christi %+ Center for Clinical and Translational Science, Mayo Clinic, 200 First Street SW, Rochester, MN,, United States, 1 507 538 3755, ballsberry.joyce@mayo.edu %K biomedical research %K community health %K community and patient engagement in research %K podcast %K social media %D 2018 %7 24.10.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Linking podcasts with social media is a strategy to promote and disseminate health and health research information to the community without constraints of time, weather, and geography. Objective: To describe the process of creating a podcast library and promoting it on social media as a strategy for disseminating health and biomedical research topics to the community. Methods: We used a community and patient engagement in research approach for developing a process to use podcasts for dissemination of health and health research information. We have reported the aspects of audience reach, impressions, and engagement on social media through the number of downloads, shares, and reactions posted on SoundCloud, Twitter, and Facebook, among others. Results: In collaboration with our local community partner, we produced 45 podcasts focused on topics selected from a community health needs assessment with input from health researchers. Episodes lasted about 22 minutes and presented health-related projects, community events, and community resources, with most featured guests from Olmsted County (24/45, 53%). Health research was the most frequently discussed topic. Between February 2016 and June 2017, episodes were played 1843 times on SoundCloud and reached 1702 users on our Facebook page. Conclusions: This study demonstrated the process and feasibility of creating a content library of podcasts for disseminating health- and research-related information. Further examination is needed to determine the best methods to develop a sustainable social media plan that will further enhance dissemination (audience reach), knowledge acquisition, and communication of health topics. %M 30684430 %R 10.2196/10025 %U http://formative.jmir.org/2018/2/e10025/ %U https://doi.org/10.2196/10025 %U http://www.ncbi.nlm.nih.gov/pubmed/30684430 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e10257 %T Effects of Cold Stimulation on Cardiac-Vagal Activation in Healthy Participants: Randomized Controlled Trial %A Jungmann,Manuela %A Vencatachellum,Shervin %A Van Ryckeghem,Dimitri %A Vögele,Claus %+ Institute for Health and Behaviour, Faculty of Language and Literature, Humanities, Arts and Education, University of Luxembourg, Campus Belval, Maison des Sciences Humaines, 11, Porte des Sciences, Esch-sur-Alzette, 4366, Luxembourg, 352 4666449755, manuela.jungmann@uni.lu %K cold stimulation %K heart rate reduction %K lateral neck region %K diving reflex %K stress reduction %K wearable electronic devices %K thermode-based stimulation %K acute stress %K technology for stress relief %K vagus nerve stimulation %K psychological stress %D 2018 %7 09.10.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The experience of psychological stress has not yet been adequately tackled with digital technology by catering to healthy individuals who wish to reduce their acute stress levels. For the design of digitally mediated solutions, physiological mechanisms need to be investigated that have the potential to induce relaxation with the help of technology. Research has shown that physiological mechanisms embodied in the face and neck regions are effective for diminishing stress-related symptoms. Our study expands on these areas with the design for a wearable in mind. As this study charts new territory in research, it also is a first evaluation of the viability for a wearables concept to reduce stress. Objective: The objectives of this study were to assess whether (1) heart rate variability would increase and (2) heart rate would decrease during cold stimulation using a thermode device compared with a (nonstimulated) control condition. We expected effects in particular in the neck and cheek regions and less in the forearm area. Methods: The study was a fully randomized, within-participant design. Volunteer participants were seated in a laboratory chair and tested with cold stimulation on the right side of the body. A thermode was placed on the neck, cheek, and forearm. We recorded and subsequently analyzed participants’ electrocardiogram. The cold stimulation was applied in 16-second intervals over 4 trials per testing location. The control condition proceeded exactly like the cold condition, except we manipulated the temperature variable to remain at the baseline temperature. We measured heart rate as interbeat intervals in milliseconds and analyzed root mean square of successive differences to index heart rate variability. We analyzed data using a repeated-measures ANOVA (analysis of variance) approach with 2 repeated-measures factors: body location (neck, cheek, forearm) and condition (cold, control). Results: Data analysis of 61 participants (after exclusion of outliers) showed a main effect and an interaction effect for body location and for condition, for both heart rate and heart rate variability. The results demonstrate a pattern of cardiovascular reactivity to cold stimulation, suggesting an increase in cardiac-vagal activation. The effect was significant for cold stimulation in the lateral neck area. Conclusions: The results confirmed our main hypothesis that cold stimulation at the lateral neck region would result in higher heart rate variability and lower heart rate than in the control condition. This sets the stage for further investigations of stress reduction potential in the neck region by developing a wearable prototype that can be used for cold application. Future studies should include a stress condition, test for a range of temperatures and durations, and collect self-report data on perceived stress levels to advance findings. %M 30684416 %R 10.2196/10257 %U http://formative.jmir.org/2018/2/e10257/ %U https://doi.org/10.2196/10257 %U http://www.ncbi.nlm.nih.gov/pubmed/30684416 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e20 %T A Locally Developed Electronic Health Platform in Uganda: Development and Implementation of Stre@mline %A Liang,Li %A Wiens,Matthew O %A Lubega,Phaisal %A Spillman,Ian %A Mugisha,Samuel %+ Innovation Streams Limited, Plot 76/78 High Street, Mbarara La Grand Mall Room L2-03, Mbarara, PO Box 1340, Uganda, 256 704899935, samuel.gisha@gmail.com %K electronic health record %K locally developed technology %K appropriate technology %K eHealth in low-resource settings %D 2018 %7 24.9.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Electronic health records (EHRs) are especially important in low-resource settings due to their potential to address unique challenges such as a high number of patients requiring long-term treatments who are lost to follow-up, the frequent shortages of essential drugs, poor maintenance and storage of records, and inefficient clinical triaging. However, there is a lack of affordable and practical EHR solutions. Stre@mline is an EHR platform that has been locally developed by Ugandan clinicians and engineers in Southwestern Uganda. It is tailored to the specific context and needs of low-resource hospitals. It operates without internet access, incorporates locally relevant standards and key patient safety features, has a medication inventory management component, has local technical support available, and is economically sustainable without funding from international donors. Stre@mline is currently used by over 60,000 patients at 2 hospitals, with plans to expand across Uganda. Objective: The purpose of this article is to describe the key opportunities and challenges in EHR development in sub-Saharan Africa and to summarize the development and implementation of a “Made-for-Africa” EHR, Stre@mline, and how it has led to improved care for over 60,000 vulnerable patients in a rural region of Southwestern Uganda. Methods: A quantitative user survey consisting of a set of 33 questions on usability and performance was conducted at Kisiizi Hospital. Users responded to each question through a Likert scale with the values of strongly disagree, disagree, agree, and strongly agree. Through purposive sampling, 30 users were identified and 28 users completed the survey. Results: We found that users were generally very satisfied with the ease of use of Stre@mline, with 96% (27/28) finding it easy to learn and 100% (28/28) finding it easy to use. Users found that Stre@mline was helpful in improving both clinical efficiency and enhancing patient care. Conclusions: The partnership of local clinicians and developers is crucial to the design and adoption of user-centered technologies tailored to the specific needs of low-resource settings. The EHR described here could serve as a model for the development of future technologies suitable for developing countries. %M 30684419 %R 10.2196/formative.9658 %U http://formative.jmir.org/2018/2/e20/ %U https://doi.org/10.2196/formative.9658 %U http://www.ncbi.nlm.nih.gov/pubmed/30684419 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e10055 %T Adolescent Preferences and Design Recommendations for an Asthma Self-Management App: Mixed-Methods Study %A Roberts,Courtney %A Sage,Adam %A Geryk,Lorie %A Sleath,Betsy %A Carpenter,Delesha %+ Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Chapel Hill, NC, 27599, United States, 1 919 843 2278, carrinde@live.unc.edu %K asthma %K mHealth %K mobile app %K patient engagement %K self-management %K usability %D 2018 %7 13.09.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Approximately 10% of adolescents in the United States have asthma. Adolescents widely use apps on mobile phones and tablet technology for social networking and gaming purposes. Given the increase in recreational app use among adolescents, leveraging apps to support adolescent asthma disease management seems warranted. However, little empirical research has influenced asthma app development; adolescent users are seldom involved in the app design process. Objective: The aim of this mixed-methods study was to assess adolescent preferences and design recommendations for an asthma self-management app. Methods: A total of 20 adolescents with persistent asthma (aged 12-16 years) provided feedback on two asthma self-management apps during in-person semistructured interviews following their regularly scheduled asthma clinic visit and via telephone 1 week later. Interviews were audiorecorded, transcribed verbatim, analyzed using SPSS v24, and coded thematically using MAXQDA 11. Results: Regarding esthetics, app layout and perceived visual simplicity were important to facilitate initial app use. Adolescents were more likely to continually engage with apps that were deemed useful and met their informational needs. Adolescents also desired app features that fit within their existing paradigm or schema and included familiar components (eg, medication alerts that appear and sound like FaceTime notifications and games modeled after Quiz Up and Minecraft), as well as the ability to customize app components. They also suggested that apps include other features, such as an air quality tracker and voice command. Conclusions: Adolescents desire specific app characteristics including customization and tailoring to meet their asthma informational needs. Involving adolescents in early stages of app development is likely to result in an asthma app that meets their self-management needs and design preferences and ultimately the adoption and maintenance of positive asthma self-management behaviors. %M 30684424 %R 10.2196/10055 %U http://formative.jmir.org/2018/2/e10055/ %U https://doi.org/10.2196/10055 %U http://www.ncbi.nlm.nih.gov/pubmed/30684424 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e16 %T Improving Transitions of Care for Young Adults With Congenital Heart Disease: Mobile App Development Using Formative Research %A Lopez,Keila N %A O'Connor,Michael %A King,Jason %A Alexander,James %A Challman,Melissa %A Lovick,Donna K %A Goodly,Nicole %A Smith,Amelia %A Fawcett,Elliott %A Mulligan,Courtney %A Thompson,Debbe %A Fordis,Michael %+ Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, 6621 Fannin Street, MC 19-345, Houston, TX, 77030, United States, 1 832 826 5600, knlopez@bcm.edu %K adolescent health %K chronic disease %K transitions of care %K health disparities %K mobile health %K mHealth %K patient empowerment %K patient involvement %K self-efficacy %K user-centered design %D 2018 %7 11.09.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Congenital heart diseases (CHDs) are the most common type of birth defects. Improvements in CHD care have led to approximately 1.4 million survivors reaching adulthood. Successful transition and transfer from pediatric to adult care is crucial. Unfortunately, less than 30% of adolescents with CHD successfully transition to adult care; this number is lower for minority and lower socioeconomic status populations. Few CHD programs exist to facilitate successful transition. Objective: The goal of our study was to describe the formative research used to develop a prototype mobile app to facilitate transition to adult care for adolescents with CHD. Methods: A literature search about best practices in transition medicine for CHD was conducted to inform app development. Formative research with a diverse group of CHD adolescents and their parents was conducted to determine gaps and needs for CHD transition to adult care. As part of the interview, surveys assessing transition readiness and CHD knowledge were completed. Two adolescent CHD expert panels were convened to inform educational content and app design. Results: The literature review revealed 113 articles, of which 38 were studies on transition programs and attitudes and 3 identified best practices in transition specific to CHD. A total of 402 adolescents aged 15 to 22 years (median 16 years) participated in semistructured interviews. The group was racially and ethnically diverse (12.6% [51/402] African American and 37.8% [152/402] Latino) and 42.0% (169/402) female; 36.3% (146/402) received public insurance. Most adolescents (313/402, 76.7%) had moderate or severe CHD complexity and reported minimal CHD understanding (79.0% [275/348] of those aged 15 to 17 years and 61.1% [33/54] of those aged 18 to 22 years). Average initial transition readiness score was 50.9/100, meaning that transition readiness training was recommended. When participants with moderate to severe CHD (313/402, 77.9%) were asked about technology use, 94.2% (295/313) reported having access to a mobile phone. Interviews with parents revealed limited interactions with the pediatric cardiologist about transition-related topics: 79.4% (331/417) reported no discussions regarding future family planning, and 55.2% (230/417) reported the adolescent had not been screened for mental health concerns (depression, anxiety). Further, 66.4% (277/417) reported not understanding how health care changes as adolescents become adults. Adolescents in the expert panels (2 groups of 3 adolescents each) expressed interest in a CHD-specific tailored app consisting of quick access to specific educational questions (eg, “Can I exercise?”), a CHD story-blog forum, a mentorship platform, a question and answer space, and a checklist to facilitate transition. They expressed interest in using the app to schedule CHD clinic appointments and receive medication reminders. Based on this data, a prototype mobile app was created to assist in adolescent CHD transition. Conclusions: Formative research revealed that most adolescents with CHD had access to mobile phones, were not prepared for transition to adult care, and were interested in an app to facilitate transition to adult CHD care. Understanding adolescent and parent needs, interests, and concerns helped in the development of a mobile app with a broader, tailored approach for adolescents with CHD. %R 10.2196/formative.9963 %U http://formative.jmir.org/2018/2/e16/ %U https://doi.org/10.2196/formative.9963 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e18 %T Adapting a Behavioral Weight Loss Intervention for Delivery via Facebook: A Pilot Series Among Low-Income Postpartum Women %A Silfee,Valerie J %A Lopez-Cepero,Andrea %A Lemon,Stephenie C %A Estabrook,Barbara %A Nguyen,Oanh %A Wang,Monica L %A Rosal,Milagros C %+ Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, United States, 1 508 856 3173, Milagros.Rosal@umassmed.edu %K Facebook %K health disparities %K postpartum women %K social media %K weight loss %D 2018 %7 10.09.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Efforts to translate evidence-based weight loss interventions, such as the Diabetes Prevention Program (DPP), to low-income postpartum women have resulted in poor intervention attendance and high attrition. Strategies that improve engagement and retention in this population are needed to maximize the reach of evidence-based weight loss interventions. Objective: The objective of this study was to adapt a DPP-based weight loss intervention (Fresh Start) for Facebook delivery and to evaluate its feasibility among low-income postpartum women. Methods: This study comprised 3 single-group pilot studies where feasibility outcomes iteratively informed changes from one pilot to the next. We paralleled the in-person program for Facebook delivery by translating the protocol to a content library of Facebook posts with additional posts from lifestyle coaches. Low-income postpartum women were recruited from Women, Infants, and Children (WIC) clinics in Worcester, Massachusetts. Participants were enrolled into a 16-week weight loss intervention delivered via Facebook. During the first 8 weeks, Facebook intervention posts were delivered 2 times per day, with additional posts from coaches aiming to stimulate interaction among participants or respond to participants’ questions and challenges. For the following 8 weeks, posts were delivered once per day without additional coaching. Feasibility outcomes were engagement (defined by number of likes, comments, and posts measured throughout intervention delivery), acceptability, and retention (survey at follow-up and assessment completion rate, respectively). Changes in weight were also assessed at baseline and follow-up. Results: Pilot 1 had a retention rate of 89% (24/27), and on average, 62% (17/27) of women actively engaged with the group each week during the 8-week coached phase. Mean weight loss was 2.6 (SD 8.64) pounds, and 79% (19/27) would recommend the program to a friend. Pilot 2 had a retention rate of 83% (20/24), and on average, 55% (13/24) of women actively engaged with the group weekly during the 8-week coached phase. Mean weight loss was 2.5 (SD 9.23) pounds, and 80% (16/24) would recommend the program to a friend. Pilot 3 had a retention rate of 88% (14/16), and on average, 67% (11/16) of women actively engaged with the group weekly during the 8-week coached phase. Mean weight loss was 7.0 (SD 11.6) pounds, and 100% (16/16) would recommend the program to a friend. Conclusions: Our findings demonstrated that a Facebook-delivered intervention was acceptable and could be feasibly delivered to low-income postpartum women. Future research is needed to evaluate the efficacy of a Facebook-delivered weight loss intervention. %M 30684423 %R 10.2196/formative.9597 %U http://formative.jmir.org/2018/2/e18/ %U https://doi.org/10.2196/formative.9597 %U http://www.ncbi.nlm.nih.gov/pubmed/30684423 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e19 %T A Stress Management App Intervention for Cancer Survivors: Design, Development, and Usability Testing %A Børøsund,Elin %A Mirkovic,Jelena %A Clark,Matthew M %A Ehlers,Shawna L %A Andrykowski,Michael A %A Bergland,Anne %A Westeng,Marianne %A Solberg Nes,Lise %+ Center for Shared Decision Making and Collaborative Care Research, Division of Medicine, Oslo University Hospital, PO Box 4950 Nydalen, Oslo, 0424, Norway, 47 92667262, elin.borosund@rr-research.no %K stress management %K mindfulness %K cancer %K eHealth %K mHealth %K mobile apps %K development %K usability %K user-centered design %K mobile phones %D 2018 %7 06.09.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Distress is prevalent in cancer survivors. Stress management interventions can reduce distress and improve quality of life for cancer patients, but many people with cancer are unfortunately not offered or able to attend such in-person stress management interventions. Objective: The objective of this study was to develop an evidence-based stress management intervention for patients living with cancer that can be delivered electronically with wide reach and dissemination. This paper describes the design and development process of a technology-based stress management intervention for cancer survivors, including the exploration phase, intervention content development, iterative software development (including design, development, and formative evaluation of low- and high-level prototypes), and security and privacy considerations. Methods: Design and development processes were iterative and performed in close collaboration with key stakeholders (N=48). In the exploration phase, identifying needs and requirements for the intervention, 28 participants gave input, including male and female cancer survivors (n=11) representing a wide age range (31-81 years) and cancer diagnoses, healthcare providers (n=8) including psychosocial oncology experts, and eHealth experts (n=9) including information technology design and developers. To ensure user involvement in each phase various user-centered design and service design methods were included, such as interviews, usability testing, and think aloud processes. Overall, participants were involved usability testing in the software development and formative evaluation phase, including cancer survivors (n=6), healthy volunteers (n=7), health care providers (n=2), and eHealth experts (n=5). Intervention content was developed by stress management experts based on well-known cognitive behavioral stress management strategies and adjusted to electronic format through multiple iterations with stakeholders. Privacy and security issues were considered throughout. Results: The design and development process identified a variety of stakeholder requirements. Cancer survivors preferred stress management through a mobile app rather than through a personal computer (PC) and identified usefulness, easy access, user friendliness, use of easily understandable language, and many brief sections rather than longer ones as important components of the intervention. These requirements were also supported by recommendations from health care providers and eHealth experts. The final intervention was named StressProffen and the hospital Privacy and Security Protection Committee was part of the final intervention approval to also ensure anchoring in the hospital organization. Conclusions: Interventions, even evidence-based, have little impact if not actively used. This study illustrates how user-centered design and service design can be applied to identify and incorporate essential stakeholder aspects in the entire design and development process. In combination with evidence-based concepts, this process facilitated development of a stress management intervention truly designed for the end users, in this case, cancer survivors. Trial Registration: ClinicalTrials.gov NCT02939612; https://clinicaltrials.gov/ct2/show/NCT02939612 (Archived at WebCite at http://www.webcitation.org/71l9HcfcB) %M 30684438 %R 10.2196/formative.9954 %U http://formative.jmir.org/2018/2/e19/ %U https://doi.org/10.2196/formative.9954 %U http://www.ncbi.nlm.nih.gov/pubmed/30684438 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e11138 %T Conversation Within a Facebook Smoking Cessation Intervention Trial For Young Adults (Tobacco Status Project): Qualitative Analysis %A McKelvey,Karma %A Ramo,Danielle %+ Weill Institute for Neurosciences, Department of Psychiatry, University of California San Francisco, 401 Parnassus Avenue, San Francisco, CA, 94143, United States, 1 4154767695, danielle.ramo@ucsf.edu %K Facebook %K intervention %K qualitative analysis %K smoking cessation %K social media %K young adults %D 2018 %7 04.09.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Smoking cessation interventions delivered through social media have the potential to engage young people in behavior change. Objective: The aim of this study was to describe participant-posted messages in a Facebook smoking cessation intervention for young adults to discern support for behavior change. Methods: We qualitatively analyzed data from the treatment arm of a randomized trial testing the efficacy of the Tobacco Status Project Facebook intervention. Young adults (N=138) aged 18-25 years (female: 81/138, 58.7%; white: 101/138, 73.2%; mean age 21 years) were recruited using Facebook and placed into one of the 15 secret Facebook groups based on readiness-to-quit smoking. Messages posted to groups for 90 consecutive days were tailored to readiness-to-quit: Not Ready (46/138, 33.3%), Thinking (66/138, 47.8%), and Getting Ready (26/138, 18.8%). Groups were randomized to receive up to US $90 for posting or no incentive. Two independent coders conducted open coding of user posts. We considered content by readiness-to-quit group and incentive condition. Results: There were 4 dominant themes across all groups: coping skills, friends and family, motivation to quit, and benefits of quitting. The dominant themes in Not Ready groups were friends and family (incentive) and motivation to quit (no incentive), whereas coping skills was the dominant theme in Thinking and Getting Ready groups. The expression of themes varied by readiness-to-quit group but not by incentive condition. Conclusions: Intervention messages tailored to readiness-to-quit appear useful in eliciting the desired responses from young adult smokers, with limited influence by monetary incentive. Trial Registration: ClinicalTrials.gov NCT02207036; https://clinicaltrials.gov/ct2/show/NCT02207036 (Archived by WebCite at http://www.webcitation.org/722XAEAAz) %M 30684432 %R 10.2196/11138 %U http://formative.jmir.org/2018/2/e11138/ %U https://doi.org/10.2196/11138 %U http://www.ncbi.nlm.nih.gov/pubmed/30684432 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 8 %P e173 %T Assessing the Cross-Cultural Adaptation and Translation of a Text-Based Mobile Smoking Cessation Program in Samoa (TXTTaofiTapaa): Pilot Study %A McCool,Judith %A Tanielu,Helen %A Umali,Elaine %A Whittaker,Robyn %+ Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Private Bag 92019, Auckland, 1141, New Zealand, 64 09 373 7599 ext 82372, j.mccool@auckland.ac.nz %K mHealth %K mobile phone %K Pacific %K Samoa %K tobacco cessation %K text messages %D 2018 %7 31.08.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Samoa faces a persistently high prevalence of adult tobacco use and few existing cessation support services. Mobile phones are ubiquitous and generally affordable. Objective: This study aimed to adopt a text message (short message service, SMS) smoking cessation program designed in New Zealand (stop smoking with mobile phones, STOMP) for use in Samoa to assist national objectives in reducing the tobacco use. Methods: Using focus groups with smokers and ex-smokers, we explored the context for tobacco use and preferences for SMS text messages. Postintervention focus groups were held after participants received SMS text messages for 1 week. Frequent face-to-face meetings with the primary partner (Ministry of Health Samoa) and key stakeholders contributed to the adaptation process. Participatory feedback and collaboration from stakeholders became an integral part of the cultural adaptation and translation of the program. Furthermore, detailed document analyses were included as part of the formal evaluation of the initiative to explore the core determinants of success in adapting the program to the Samoan cultural context. Results: The SMS text messages evolved remarkably following an iterative process of consultation, in situ testing, revision, and retesting to arrive at an acceptable country-specific version of the mobile smoking cessation program. The SMS text messages retained in the final set were consistent with the theory of behavioral change but reflected both linguistic and cultural nuances appropriate for Samoa. Adapting messages required simultaneous multilevel processes, including complex high-level engagement, between the team and the stakeholders, along with crafting the precise content for (character limited) messages. Conclusions: Receiving cessation support messages through a mobile phone is promising and appears to be an acceptable and accessible mode of delivery for tobacco cessation, particularly in the absence of alternative support. Adapting a text-based program in Samoa requires fastidious attention to the nuances of culture, language, and sociopolitical structures in the country. %M 30170994 %R 10.2196/mhealth.9033 %U http://mhealth.jmir.org/2018/8/e173/ %U https://doi.org/10.2196/mhealth.9033 %U http://www.ncbi.nlm.nih.gov/pubmed/30170994 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e17 %T Assessing the Feasibility and Pre-Post Impact Evaluation of the Beta (Test) Version of the BeUpstanding Champion Toolkit in Reducing Workplace Sitting: Pilot Study %A Healy,Genevieve Nissa %A Eakin,Elizabeth G %A Winkler,Elisabeth AH %A Hadgraft,Nyssa %A Dunstan,David W %A Gilson,Nicholas D %A Goode,Ana D %+ School of Public Health, The University of Queensland, 266 Herston Road, Herston, Brisbane, 4006, Australia, 61 733655528, g.healy@uq.edu.au %K BeUpstanding Champion Toolkit %K implementation %K physical activity %K sedentary %K workplace sitting %D 2018 %7 28.08.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The Web-based, evidence-informed BeUpstanding Champion Toolkit was developed to provide employers (via a “train-the-champion approach”) with resources and support to help in reducing prolonged sitting in their own desk-based workplace. As part of a five-phase research-to-dissemination process, this study reports on the evaluation of the beta (test) version of this toolkit (Phase 2). Objective: The objective of our study was to evaluate (1) the implementation of the toolkit by workplace champions and (2) the impact of the toolkit on sitting (primary outcome), standing, and moving; use of activity-promoting strategies; knowledge and attitudes; and indicators of health and work performance. Methods: An implementation study using a pre-post design was conducted in 7 desk-based workplaces in Australia (September 2015 to May 2016), with work teams (one per workplace) purposively recruited to ensure representation across a range of sectors (white- or blue-collar), organizational sizes (small or medium or large), and locations (metropolitan or regional). All staff within participating teams were invited to participate in the relevant toolkit activities. Implementation outcomes (time commitment required by champions and toolkit activities completed) were collected from each champion via telephone interviews. Changes in impact outcomes, measured via a Web-based questionnaire completed by employees at baseline and 3 months postimplementation, were assessed using mixed models, correcting for clustering. Results: Champions reported a 30-60 minutes per week time commitment to the toolkit activities. All teams formed a wellbeing committee and sent the staff surveys at both time points; most champions held a staff consultation workshop (6/7), identified team-level strategies within that workshop (5/7), used the communication resources provided within the toolkit (emails, posters; 6/7), and completed the action plan (5/7). In total, 52% (315 of ≈600) employees participated in at least one survey and 97 (16%) participated in both. At follow-up, there was a significant (P<.05) reduction in self-reported workplace sitting time compared to baseline (−6.3%, 95% CI −10.1 to −2.5; n=85) equating to ≈30 minutes per workday. Significant benefits were also observed for the use of activity-promoting strategies, with small, nonsignificant changes observed for knowledge and attitudes and indicators of health and work performance. Conclusions: The beta version of the BeUpstanding Champion Toolkit was feasible to implement and effective in reducing self-reported workplace sitting across a broad range of desk-based workplaces. The next phase (Phase 3) will build on these findings to optimize the toolkit for wider-scale implementation and longer term evaluation. %M 30684420 %R 10.2196/formative.9343 %U http://formative.jmir.org/2018/2/e17/ %U https://doi.org/10.2196/formative.9343 %U http://www.ncbi.nlm.nih.gov/pubmed/30684420 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 3 %P e54 %T A Mobile App–Based Intervention for Depression: End-User and Expert Usability Testing Study %A Fuller-Tyszkiewicz,Matthew %A Richardson,Ben %A Klein,Britt %A Skouteris,Helen %A Christensen,Helen %A Austin,David %A Castle,David %A Mihalopoulos,Cathrine %A O'Donnell,Renee %A Arulkadacham,Lilani %A Shatte,Adrian %A Ware,Anna %+ School of Psychology, Deakin University, 1 Gheringhap Street, Geelong, 3220, Australia, 61 392517344, matthewf@deakin.edu.au %K depression %K eHealth %K mHealth %K young adult %D 2018 %7 23.08.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Despite the growing number of mental health apps available for smartphones, the perceived usability of these apps from the perspectives of end users or health care experts has rarely been reported. This information is vital, particularly for self-guided mHealth interventions, as perceptions of navigability and quality of content are likely to impact participant engagement and treatment compliance. Objective: The aim of this study was to conduct a usability evaluation of a personalized, self-guided, app-based intervention for depression. Methods: Participants were administered the System Usability Scale and open-ended questions as part of a semistructured interview. There were 15 participants equally divided into 3 groups: (1) individuals with clinical depression who were the target audience for the app, (2) mental health professionals, and (3) researchers who specialize in the area of eHealth interventions and/or depression research. Results: The end-user group rated the app highly, both in quantitative and qualitative assessments. The 2 expert groups highlighted the self-monitoring features and range of established psychological treatment options (such as behavioral activation and cognitive restructuring) but had concerns that the amount and layout of content may be difficult for end users to navigate in a self-directed fashion. The end-user data did not confirm these concerns. Conclusions: Encouraging participant engagement via self-monitoring and feedback, as well as personalized messaging, may be a viable way to maintain participation in self-guided interventions. Further evaluation is necessary to determine whether levels of engagement with these features enhance treatment effects. %M 30139722 %R 10.2196/mental.9445 %U http://mental.jmir.org/2018/3/e54/ %U https://doi.org/10.2196/mental.9445 %U http://www.ncbi.nlm.nih.gov/pubmed/30139722 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e10125 %T Game Plan: Development of a Web App Designed to Help Men Who Have Sex With Men Reduce Their HIV Risk and Alcohol Use %A Wray,Tyler %A Kahler,Christopher W %A Simpanen,Erik M %A Operario,Don %+ Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 S Main Street, Box G-S121-5, Providence, RI,, United States, 1 401 863 6659, tyler_wray@brown.edu %K alcohol %K HIV risk %K internet %K intervention %D 2018 %7 23.08.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Men who have sex with men (MSM) are at high risk for HIV, and alcohol use is a major risk factor for HIV infection. Internet-facilitated brief interventions have been shown to reduce alcohol use and HIV-risk behavior in other at-risk populations, but have so far incorporated limited content and have not been tested among MSM. Objective: This manuscript describes Game Plan, an interactive, tablet-optimized web application designed to help heavy drinking, high-risk MSM consider reducing their alcohol use and sexual risk behavior. In this paper, we discuss the rationale, goals, and flow for each of Game Plan’s components, which were modelled after common in-person and web-based brief motivational interventions for these behaviors. Methods: The development of Game Plan was informed by a thorough user-focused design research process that included (1) audits of existing interventions, (2) focus groups with stakeholders and (3) intended users (high-risk, heavy drinking MSM), and (4) usability testing. The aesthetic, features, and content of the app were designed iteratively throughout this process Results: The fully-functional Game Plan app provides (1) specific and personal feedback to users about their level of risk, (2) exercises to help prompt users to reflect on whether their current behavior aligns with other important life goals and values, and for those open to change, (3) exercises to help users understand factors that contribute to risk, and (4) a change planning module. In general, this flow was constructed to roughly align with the two phases described in early accounts of motivational interviewing (MI): (1) Content intended to elicit intrinsic motivation for change, and when/if sufficient motivation is present, (2) content intended to translate that motivation into specific goals and plans for change. This sequence first focuses on the user’s HIV risk behavior, followed by their alcohol use and the connection between the two. The app’s overall aesthetic (eg, branding, color palettes, icons/graphics) and its onboarding sequence was also designed to align with the “spirit” of MI by conveying respect for autonomy, open-mindedness (ie, avoiding judgment), and empathy. Conclusions: Should future research support its efficacy in facilitating behavior change, Game Plan could represent a wide-reaching and scalable tool that is well-suited for use in settings where delivering evidence-based, in-person interventions would be difficult or cost-prohibitive. %M 30684415 %R 10.2196/10125 %U http://formative.jmir.org/2018/2/e10125/ %U https://doi.org/10.2196/10125 %U http://www.ncbi.nlm.nih.gov/pubmed/30684415 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 8 %P e172 %T A Mobile App (iBeni) With a Neuropsychological Basis for Cognitive Stimulation for Elderly Adults: Pilot and Validation Study %A Martínez-Alcalá,Claudia I %A Rosales-Lagarde,Alejandra %A Hernández-Alonso,Esmeralda %A Melchor-Agustin,Roberto %A Rodriguez-Torres,Erika E %A Itzá-Ortiz,Benjamín A %+ Consejo Nacional de Ciencia y Tecnología, Av Insurgentes Sur 1582, Col Crédito Constructor, Del Benito Juárez, Ciudad de México, 03940, Mexico, 52 (771) 71 72 000 ext 4332, c_isabel_alcala@hotmail.com %K mobile application %K cognitive stimulation %K cognitive impairment %K older adults %K neuropsychological evaluation. %D 2018 %7 21.08.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Cognitive impairment is considered one of the most feared chronic conditions among the older adult population since its incidence is approximately twice more frequent than that of dementia. In Mexico, no studies or reports of older adults using technology for cognitive interventions have been published, given that institutions usually frame cognitive stimulation tasks in paper and pencil (ie, in the traditional manner). Objective: The objective of this study was to create and analyze the effect, viability, and impact of a mobile app for cognitive stimulation implemented among a group of elderly adults (over 60 years of age) from the state of Hidalgo in Mexico. Methods: This study was a nonprobabilistic pilot trial using convenience sampling. An intervention was implemented among a group of 22 older adults between 60 and 80 years of age over 12 weeks. Half of the older adults were stimulated with the mobile app (experimental group) and the other half followed the traditional paper and pencil training (control group). Assessments with the Mini-Mental State Examination (MMSE) and the Neuropsi, a neuropsychological test validated in Mexico, were done before and after both cognitive stimulations. Results: According to the analyzed data, 6/11 (55%) participants from the experimental group obtained better results in their cognitive skills, and 5 (45%) of the adults maintained their score, given that the participants were able to execute the exercises repetitively. Meanwhile, for the control group, only 3/11 (27%) participants obtained better results in the postevaluation. Significant values for results of the MMSE were obtained in the postevaluation for the experimental group compared to the control group, while results did not show significant differences in the Neuropsi. Regarding the validation of the app, all the participants evaluated its pertinence positively. Conclusions: The intervention data show that the experimental group obtained better results in the postevaluation given that the participants were able to execute the exercises repetitively. The control group could not accomplish this since they had to respond on the manual and no further attempts were provided. However, both groups increased their score in the neuropsychological evaluations. This suggests that a longer and more frequent intervention is required. Registered Report Identifier: RR1-10.2196/9603 %M 30131319 %R 10.2196/resprot.9603 %U http://www.researchprotocols.org/2018/8/e172/ %U https://doi.org/10.2196/resprot.9603 %U http://www.ncbi.nlm.nih.gov/pubmed/30131319 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e15 %T Electronic Swallowing Intervention Package to Support Swallowing Function in Patients With Head and Neck Cancer: Development and Feasibility Study %A Cowie,Julie %A Boa,Sally %A King,Emma %A Wells,Mary %A Cairns,David %+ Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Govan Mbeki Building, Cowcaddens Road, Glasgow, G4 0BA, United Kingdom, 44 141 331 8100, julie.cowie@gcu.ac.uk %K head and neck cancer %K eHealth %K self-management %K mHealth %K chemoradiotherapy %K mobile phones %D 2018 %7 17.08.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Many patients undergoing treatment for head and neck cancer (HNC) experience significant swallowing difficulties, and there is some evidence that swallowing exercises may improve outcomes, including quality of life. This feasibility study developed an evidence-based, practical Swallowing Intervention Package (SiP) for patients undergoing chemoradiotherapy (CRT) for HNC. As part of the study, an electronic version of SiP (e-SiP) was concurrently developed to support patients to self-manage during treatment. This paper reports on the e-SiP component of this work. Objective: The objective of our study was to develop and conduct a preliminary evaluation of an electronic support system (e-SiP) for patients undergoing CRT for HNC. Methods: The study was conducted using a recognized mHealth development and evaluation framework and involved health professionals and patients who were undergoing CRT for HNC. The scoping stage of e-SiP development investigated the potential usefulness of the app, exploring how e-SiP would look and feel and what content would be appropriate to provide. Patient and carer focus groups and a health professionals’ consensus day were used as means of data gathering around potential e-SiP content. A repeat focus group looked at an outline version of e-SiP and informed the next stage of its development with regard to refining the requirements for the tool. This was followed by further development and a testing stage of e-SiP that involved the coding of a prototype, which was then evaluated using a series of steering group meetings, semistructured interviews with both patients and health care professionals, and analysis of e-SiP log data. Results: Feedback from focus groups and health professional interviews was very positive, and it was felt e-SiP use would support and encourage patients in conducting their swallowing exercises. However, of the 10 patients who were offered e-SiP, only 2 opted to use it. For these patients, the aspects of the e-SiP app were considered useful, in particular, the ease of keeping a diary of exercises performed. Interviews with users and nonusers suggested significant barriers to its use. Most significantly, the lack of flexibility of the platform on which e-SiP could be accessed appeared a dominant factor in deterring e-SiP use. Conclusions: The results suggest that further research needs to be conducted around the implementation of e-SiP. This involves evaluating how e-SiP can be better integrated into usual care and through patient training and staff engagement, can be perceived as a beneficial tool to help support patients in conducting swallowing exercises. %R 10.2196/formative.9703 %U http://formative.jmir.org/2018/2/e15/ %U https://doi.org/10.2196/formative.9703 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e10411 %T Utilizing a Prototype Patient-Controlled Electronic Health Record in Germany: Qualitative Analysis of User-Reported Perceptions and Perspectives %A Poss-Doering,Regina %A Kunz,Aline %A Pohlmann,Sabrina %A Hofmann,Helene %A Kiel,Marion %A Winkler,Eva C %A Ose,Dominik %A Szecsenyi,Joachim %+ Department of General Practice and Health Services Research, University Hospital Heidelberg, Marsilius Arkaden, Tower West, 4th Floor, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 6221 56 ext 38643, regina.poss-doering@med.uni-heidelberg.de %K personal patient-controlled electronic health record %K eHealth %K nationwide implementation %K continuity of care %D 2018 %7 03.08.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Personal electronic health records (PHR) are considered instrumental in improving health care quality and efficiency, enhancing communication between all parties involved and strengthening the patient’s role. Technical architectures, data privacy, and applicability issues have been discussed for many years. Nevertheless, nationwide implementation of a PHR is still pending in Germany despite legal regulations provided by the eHealth Act passed in 2015. Within the information technology for patient-oriented care project funded by the Federal Ministry of Education and Research (2012-2017), a Web-based personal electronic health record prototype (PEPA) was developed enabling patient-controlled information exchange across different care settings. Gastrointestinal cancer patients and general practitioners utilized PEPA during a 3-month trial period. Both patients and physicians authorized by them could view PEPA content online and upload or download files. Objective: This paper aims to outline findings of the posttrial qualitative study carried out to evaluate user-reported experiences, perceptions, and perspectives, focusing on their interpretation of PEPA beyond technical usability and views on a future nationwide implementation. Methods: Data were collected through semistructured guide-based interviews with 11 patients and 3 physicians (N=14). Participants were asked to share experiences, views of perceived implications, and perspectives towards nationwide implementation. Further data were generated through free-text fields in a subsequent study-specific patient questionnaire and researcher’s notes. Data were pseudonymized, audiotaped, and transcribed verbatim. Content analysis was performed through the Framework Analysis approach. All qualitative data were systemized by using MAXQDA Analytics PRO 12 (Rel.12.3.1). Additionally, participant characteristics were analyzed descriptively using IBM SPSS Statistics Version 24. Results: Users interpreted PEPA as a central medium containing digital chronological health-related documentation that simplifies information sharing across care settings. While patients consider the implementation of PEPA in Germany in the near future, physicians are more hesitant. Both groups believe in PEPA’s concept, but share awareness of concerns about data privacy and older or impaired people’s abilities to manage online records. Patients perceive benefits for involvement in treatment processes and continuity of care but worry about financing and the implementation of functionally reduced versions. Physicians consider integration into primary systems critical for interoperability but anticipate technical challenges, as well as resistance from older patients and colleagues. They omit clear positioning regarding PEPA’s potential incremental value for health care organizations or the provider-patient relationship. Conclusions: Digitalization in German health care will continue to bring change, both organizational and in the physician-patient relationship. Patients endorse and expect a nationwide PEPA implementation, anticipating various benefits. Decision makers and providers need to contribute to closing modernization gaps by committing to new concepts and by invigorating transformed roles. %M 30684411 %R 10.2196/10411 %U http://formative.jmir.org/2018/2/e10411/ %U https://doi.org/10.2196/10411 %U http://www.ncbi.nlm.nih.gov/pubmed/30684411 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e14 %T Web-Based Tailored Intervention to Support Optimal Medication Adherence Among Kidney Transplant Recipients: Pilot Parallel-Group Randomized Controlled Trial %A Côté,José %A Fortin,Marie-Chantal %A Auger,Patricia %A Rouleau,Geneviève %A Dubois,Sylvie %A Boudreau,Nathalie %A Vaillant,Isabelle %A Gélinas-Lemay,Élisabeth %+ Research Centre of the Centre Hospitalier de l’Université de Montréal, 850 St-Denis, Tour St-Antoine, Door S01-128, Montreal, QC, H2X 0A9, Canada, 1 514 890 8000 ext 15536, jose.cote@umontreal.ca %K medication adherence %K transplant recipient %K self-management %K nursing %K Web-based tailored intervention %K randomized controlled trial %D 2018 %7 19.07.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Optimal immunosuppressive medication adherence is essential to graft survival. Transplant-TAVIE is a Web-based tailored intervention developed to promote this adherence. Objective: The objective of our study was to evaluate the Transplant-TAVIE intervention’s acceptability, feasibility, and preliminary efficacy. Methods: In a pilot, parallel-group, randomized controlled trial, we randomly assigned a convenience sample of 70 kidney transplant patients on immunosuppressive medication either to an experimental group (Transplant-TAVIE) or to a control group (existing websites). Kidney transplant recipients had to be older than 18 years, be taking immunosuppressant medication, and have access to the internet to participate in this study. Transplant-TAVIE was composed of three interactive Web-based sessions hosted by a virtual nurse. We documented user appreciation of and exposure to the intervention. Furthermore, we assessed medication adherence, medication self-efficacy, intake-related skills, and medication side effects at baseline and 3 and 6 months later. Analyses of variance were used to assess intergroup differences over time. Results: After baseline questionnaire completion, participants were randomly assigned either to Transplant-TAVIE (n=35) or to the websites (n=35) group. All participants had received their kidney graft <1 year to 32 years earlier (mean 6.8 years). Of the experimental group, 54% (19/35) completed the sessions of Transplant-TAVIE. Users found the intervention to be acceptable—33% were extremely satisfied (6/18), 39% were very satisfied (7/18), and 28% were satisfied (5/18). At baseline and over time, both experimental and control groups reported high medication adherence, high medication self-efficacy, and frequent use of skills related to medication intake. No intergroup differences emerged over time. Conclusions: The results of this study support the feasibility and acceptability of Transplant-TAVIE. It could constitute an accessible adjunct in support of existing specialized services. %M 30684400 %R 10.2196/formative.9707 %U http://formative.jmir.org/2018/2/e14/ %U https://doi.org/10.2196/formative.9707 %U http://www.ncbi.nlm.nih.gov/pubmed/30684400 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 7 %P e165 %T The Development of Complex Digital Health Solutions: Formative Evaluation Combining Different Methodologies %A Lee,Anne %A Sandvei,Marianne %A Asmussen,Hans Christian %A Skougaard,Marie %A Macdonald,Joanne %A Zavada,Jakub %A Bliddal,Henning %A Taylor,Peter C %A Gudbergsen,Henrik %+ Centre for Innovative Medical Technology, Odense University Hospital, Kloevervanget 8, Odense, 5000, Denmark, 45 21656406, anne.lee@rsyd.dk %K eHealth %K telemedicine %K stakeholder participation %K formative evaluation %K participatory design %K intervention theories %D 2018 %7 16.07.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: The development of digital health solutions for current health care settings requires an understanding of the complexities of the health care system, organizational setting, and stakeholder groups and of the underlying interplay between stakeholders and the technology. The digital health solution was founded on the basis of an information and communication technology platform and point-of-care devices enabling home-based monitoring of disease progression and treatment outcome for patients with rheumatoid arthritis (RA). Objective: The aim of this paper is to describe and discuss the applicability of an iterative evaluation process in guiding the development of a digital health solution as a technical and organizational entity in three different health care systems. Methods: The formative evaluation comprised the methodologies of contextual understanding, participatory design, and feasibility studies and included patients, healthcare professionals, and hardware and software developers. In total, the evaluation involved 45 patients and 25 health care professionals at 3 clinical sites in Europe. Results: The formative evaluation served as ongoing and relevant input to the development process of the digital health solution. Through initial field studies key stakeholder groups were identified and knowledge obtained about the different health care systems, the professional competencies involved in routine RA treatment, the clinics’ working procedures, and the use of communication technologies. A theory-based stakeholder evaluation achieved a multifaceted picture of the ideas and assumptions held by stakeholder groups at the three clinical sites, which also represented the diversity of three different language zones and cultures. Experiences and suggestions from the patients and health care professionals were sought through participatory design processes and real-life testing and actively used for adjusting the visual, conceptual, and practical design of the solution. The learnings captured through these activities aided in forming the solution and in developing a common understanding of the overall vision and aim of this solution. During this process, the 3 participating sites learned from each other’s feed-back with the ensuing multicultural inspiration. Moreover, these efforts also enabled the consortium to identify a ‘tipping point’ during a pilot study, revealing serious challenges and a need for further development of the solution. We achieved valuable learning during the evaluation activities, and the remaining challenges have been clarified more extensively than a single-site development would have discovered. The further obstacles have been defined as has the need to resolve these before designing and conducting a real-life clinical test to assess the outcome from a digital health solution for RA treatment. Conclusions: A formative evaluation process with ongoing involvement of stakeholder groups from 3 different cultures and countries have helped to inform and influence the development of a novel digital health solution, and provided constructive input and feedback enabling the consortium to control the development process. %M 30012548 %R 10.2196/resprot.9521 %U http://www.researchprotocols.org/2018/7/e165/ %U https://doi.org/10.2196/resprot.9521 %U http://www.ncbi.nlm.nih.gov/pubmed/30012548 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 3 %N 3 %P e10431 %T Design and Development of a Context-Aware Knowledge-Based Module for Identifying Relevant Information and Information Gaps in Patients With Type 1 Diabetes Self-Collected Health Data %A Giordanengo,Alain %A Øzturk,Pinar %A Hansen,Anne Helen %A Årsand,Eirik %A Grøttland,Astrid %A Hartvigsen,Gunnar %+ Norwegian Centre for E-health Research, University Hospital of North Norway, Postboks 35, Tromsø, 9038, Norway, 47 91715718, alain.giordanengo@ehealthresearch.no %K context aware %K knowledge-based system %K diabetes %K self-collected health data %K information gaps %D 2018 %7 11.07.2018 %9 Original Paper %J JMIR Diabetes %G English %X Background: Patients with diabetes use an increasing number of self-management tools in their daily life. However, health institutions rarely use the data generated by these services mainly due to (1) the lack of data reliability, and (2) medical workers spending too much time extracting relevant information from the vast amount of data produced. This work is part of the FullFlow project, which focuses on self-collected health data sharing directly between patients’ tools and EHRs. Objective: The main objective is to design and implement a prototype for extracting relevant information and documenting information gaps from self-collected health data by patients with type 1 diabetes using a context-aware approach. The module should permit (1) clinicians to assess the reliability of the data and to identify issues to discuss with their patients, and (2) patients to understand the implication their lifestyle has on their disease. Methods: The identification of context and the design of the system relied on (1) 2 workshops in which the main author participated, 1 patient with type 1 diabetes, and 1 clinician, and (2) a co-design session involving 5 patients with type 1 diabetes and 4 clinicians including 2 endocrinologists and 2 diabetes nurses. The software implementation followed a hybrid agile and waterfall approach. The testing relied on load, and black and white box methods. Results: We created a context-aware knowledge-based module able to (1) detect potential errors, and information gaps from the self-collected health data, (2) pinpoint relevant data and potential causes of noticeable medical events, and (3) recommend actions to follow to improve the reliability of the data issues and medical issues to be discussed with clinicians. The module uses a reasoning engine following a hypothesize-and-test strategy built on a knowledge base and using contextual information. The knowledge base contains hypotheses, rules, and plans we defined with the input of medical experts. We identified a large set of contextual information: emotional state (eg, preferences, mood) of patients and medical workers, their relationship, their metadata (eg, age, medical specialty), the time and location of usage of the system, patient-collected data (eg, blood glucose, basal-bolus insulin), patients’ goals and medical standards (eg, insulin sensitivity factor, in range values). Demonstrating the usage of the system revealed that (1) participants perceived the system as useful and relevant for consultation, and (2) the system uses less than 30 milliseconds to treat new cases. Conclusions: Using a knowledge-based system to identify anomalies concerning the reliability of patients’ self-collected health data to provide information on potential information gaps and to propose relevant medical subjects to discuss or actions to follow could ease the introduction of self-collected health data into consultation. Combining this reasoning engine and the system of the FullFlow project could improve the diagnostic process in health care. %M 30291097 %R 10.2196/10431 %U http://diabetes.jmir.org/2018/3/e10431/ %U https://doi.org/10.2196/10431 %U http://www.ncbi.nlm.nih.gov/pubmed/30291097 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e13 %T A Text Messaging Intervention (Txt4HappyKids) to Promote Fruit and Vegetable Intake Among Families With Young Children: Pilot Study %A Power,Julianne Mary %A Bersamin,Andrea %+ Center for Alaska Native Health Research, Institute of Arctic Biology, University of Alaska Fairbanks, 902 N Koyukuk Drive, PO Box 757000, Fairbanks, AK, 99775, United States, 1 907 474 6129, abersamin@alaska.edu %K fruits and vegetables %K nutrition education %K nutrition intervention %K young children %K text messaging %D 2018 %7 06.07.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Increasing fruit and vegetable intake among low-income populations, especially children, is a priority for United States federal food assistance programs. With over 49 million federal food assistance program recipients, cost-effective and efficient methods are needed to effectively deliver nutrition education to such a large population. Objective: The objective of our study was to examine the preliminary efficacy and acceptability of a text messaging intervention, Txt4HappyKids, to promote fruit and vegetable intake among families with young children. Methods: The intervention was evaluated using a pre-post study design. Parents (N=72) in Alaska were recruited from venues that serve a predominantly low-income population to participate in an 11-week intervention based on social cognitive theory. Parents received two texts per week promoting child fruit and vegetable intake. Behaviors, self-efficacy, and attitudes related to fruit and vegetable intake were measured at baseline and postintervention. Perceived changes in behaviors and open-ended feedback were also collected postintervention. Results: Of all participants, 67.3% (72/107) completed the intervention. We found no changes in behavior (P=.26), self-efficacy (P=.43), or attitudes (P=.35) related to fruit and vegetable intake from pre- to postintervention. Completers reported that since their participation in Txt4HappyKids, 92% (66/72) served more fruits and vegetables to their child because they thought fruits and vegetables were beneficial, 86% (62/72) tried to follow a healthier diet, 85% (61/72) tried different ways of preparing fruits and vegetables, and 81% (58/72) were more aware of the foods their child consumes. Additionally, 79% (57/72) of completers thought that Txt4HappyKids was credible, 71% (51/72) found texts useful, and 82% (59/72) would recommend it to a friend. Conclusions: A text messaging intervention was not sufficient to increase fruit and vegetable intake among families with young children. However, parents felt positively impacted by Txt4HappyKids and were receptive to nutrition information, despite the absence of face-to-face contact. High satisfaction among completers indicates that text messaging may be an acceptable complement to budget-constrained nutrition programs. These findings are an important first step in developing larger multi-level interventions utilizing mobile technology; however, a more rigorous evaluation of the Txt4HappyKids intervention is warranted. %M 30684412 %R 10.2196/formative.8544 %U http://formative.jmir.org/2018/2/e13/ %U https://doi.org/10.2196/formative.8544 %U http://www.ncbi.nlm.nih.gov/pubmed/30684412 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e10457 %T An Online Hand Exercise Intervention for Adults With Rheumatoid Arthritis (mySARAH): Design, Development, and Usability Testing %A Srikesavan,Cynthia %A Williamson,Esther %A Cranston,Tim %A Hunter,John %A Adams,Jo %A Lamb,Sarah E %+ Rehabilitation Research in Oxford, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD, United Kingdom, 44 01865737907, cynthia.srikesavan@ndorms.ox.ac.uk %K rheumatoid arthritis %K hand joints %K exercise training %K web-based %D 2018 %7 27.06.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) program is a tailored, progressive 12-week exercise program for people with hand problems due to rheumatoid arthritis. The program was shown to be clinically and cost-effective in a large clinical trial and is recommended by the UK National Institute for Health and Care Excellence (NICE) guidelines for rheumatoid arthritis in adults. Objective: We have developed an online version of the SARAH program (mySARAH) to make the SARAH program widely accessible to people with rheumatoid arthritis. The purposes of this study were to develop mySARAH and to evaluate and address its usability issues. Methods: We developed mySARAH using a three-step process and gaining feedback from patient contributors. After initial development, mySARAH was tested in two iterative usability cycles in nine participants using a simplified think-aloud protocol and self-reported questionnaires. We also evaluated if participants executed the SARAH exercises correctly after watching the exercise videos included on the website. Results: A preliminary version of mySARAH consisting of six sessions over a 12-week period and delivered via text, exercise videos, images, exercise plan form, exercise calendar, and links to additional information on rheumatoid arthritis was developed. Five participants (1 male; 4 females; median age 64 years) and four participants (four females; median age 64.5 years) took part in the first and second usability testing cycles respectively. Usability issues identified from Cycle 1 such as having a navigation tutorial video and individualised feedback on pain levels were addressed prior to Cycle 2. The need for more instructions to complete the mySARAH patient forms was identified in Cycle 2 and was rectified. Self-reports from both cycles indicated that participants found the program useful and easy to use and were confident in performing the SARAH exercises themselves. Eight of the nine participants correctly demonstrated all the exercises. Conclusions: mySARAH is the first online hand exercise intervention for people with rheumatoid arthritis. We actively involved target users in the development and usability evaluation and ensured mySARAH met their needs and preferences. %M 29950288 %R 10.2196/10457 %U http://www.jmir.org/2018/6/e10457/ %U https://doi.org/10.2196/10457 %U http://www.ncbi.nlm.nih.gov/pubmed/29950288 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e12 %T Investigating Associations Between Changes in Mobile Phone Use and Emotions Using the Experience Sampling Method: Pilot Study %A Roggeveen,Suzanne %A van Os,Jim %A Bemelmans,Kelly %A van Poll,Mikal %A Lousberg,Richel %+ Department of Psychiatry and Psychology, Maastricht University, Vijverdalseweg 1, Maastricht,, Netherlands, 31 43 3884111, s.roggeveen@maastrichtuniversity.nl %K mobile phone %K experience sampling method %K emotions %K affect %K concentration %D 2018 %7 18.06.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The use of mobile phones has become, especially for young people, an integrated part of everyday life. Using the experience sampling method (ESM) may provide further insight on the association between mobile phone use and mental health. Objective: The objective of this study was to examine associations between mobile phone use and subtle changes in mental state. Methods: The ESM-based PsyMate app was installed on the mobile phones of 2 healthy 20-year-old participants. Over a period of 3 months, participants rated their mental states at 10 semirandom moments in the flow of daily life. Each assessment included present state emotions, environmental circumstances, and phone use. Results: Multilevel regression analyses indicated that an increase in mobile phone use was associated with a small increase in negative affect (particularly feeling bored and feeling lonely; P<.001) and small decreases in positive affect (P=.002) and concentration (P=.001). Treating the data as 2 separate N=1 studies revealed that the association with negative affect was present in both participants, whereas the associations with positive affect and concentration were evident in only 1 of the 2 participants. Conclusions: This pilot study suggests that mobile phone use may be associated with person-specific and group-level changes in emotional state. A larger study is required to study these associations, possible causality, and factors driving underlying heterogeneity in the pattern of associations. Trial registration: ClinicalTrials.gov NCT03221985; https://clinicaltrials.gov/ct2/show/NCT03221985 (archived by WebCite at http://www.webcitation.org/6zJnp61Wj) %M 30684428 %R 10.2196/formative.8499 %U http://formative.jmir.org/2018/1/e12/ %U https://doi.org/10.2196/formative.8499 %U http://www.ncbi.nlm.nih.gov/pubmed/30684428 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 6 %P e154 %T Development of a Tailored Intervention With Computerized Clinical Decision Support to Improve Quality of Care for Patients With Knee Osteoarthritis: Multi-Method Study %A Van de Velde,Stijn %A Kortteisto,Tiina %A Spitaels,David %A Jamtvedt,Gro %A Roshanov,Pavel %A Kunnamo,Ilkka %A Aertgeerts,Bert %A Vandvik,Per Olav %A Flottorp,Signe %+ Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 4404 Nydalen, Oslo, 0403, Norway, 47 46 40 04 75, stijn.vandevelde@med.kuleuven.be %K decision support systems, clinical %K practice guidelines as topic %K guideline adherence %K evidence-based medicine %K osteoarthritis, knee %K focus groups %D 2018 %7 11.06.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Clinical practice patterns greatly diverge from evidence-based recommendations to manage knee osteoarthritis conservatively before resorting to surgery. Objective: This study aimed to tailor a guideline-based computerized decision support (CDS) intervention that facilitates the conservative management of knee osteoarthritis. Methods: Experts with backgrounds in clinical medicine, research, implementation, or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to form the CDS algorithms. In 6 focus group sessions, 8 general practitioners and 22 patients from Norway, Belgium, and Finland discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. The focus group moderators used the GUideline Implementation with DEcision Support checklist, which we developed to support consideration of CDS success factors. Results: The experts prioritized 9 out of 22 recommendations for implementation. We formed the concept for 6 CDS algorithms to support implementation of these recommendations. The focus group suggested 59 unique factors that could affect the success of the presented CDS intervention. Five factors (out of the 59) were prioritized by focus group participants in every country, including the perceived potential to address the information needs of both patients and general practitioners; the credibility of CDS information; the timing of CDS for patients; and the need for personal dialogue about CDS between the general practitioner and the patient. Conclusions: The focus group participants supported the CDS intervention as a tool to improve the quality of care for patients with knee osteoarthritis through shared, evidence-based decision making. We aim to develop and implement the CDS based on these study results. Future research should address optimal ways to (1) provide patient-directed CDS, (2) enable more patient-specific CDS within the context of patient complexity, and (3) maintain user engagement with CDS over time. %M 29891466 %R 10.2196/resprot.9927 %U http://www.researchprotocols.org/2018/6/e154/ %U https://doi.org/10.2196/resprot.9927 %U http://www.ncbi.nlm.nih.gov/pubmed/29891466 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 6 %P e10525 %T A Digital Decision Support Tool to Enhance Decisional Capacity for Clinical Trial Consent: Design and Development %A Furberg,Robert D %A Ortiz,Alexa M %A Moultrie,Rebecca R %A Raspa,Melissa %A Wheeler,Anne C %A McCormack,Lauren A %A Bailey Jr,Donald B %+ Digital Health and Clinical Informatics, RTI International, 3040 E Cornwallis Road, Research Triangle Park, NC, 27709-2194, United States, 1 919 316 3726, rfurberg@rti.org %K decision support %K informed consent %K digital health %K intellectual disability %K fragile X syndrome %K telemedicine %D 2018 %7 06.06.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Challenges in the clinical and research consent process indicate the need to develop tailored, supportive interventions for all individuals, especially those with limited decisional capacity. We developed a tool to enhance shared decision making and the decisional capacity for individuals with fragile X syndrome engaged in the informed consent process for a clinical trial. Objective: We describe the design and development process of a tablet-based decision support tool. Methods: Our development process for the decision support tool employed a user-centered, feature-driven design approach. We began with an environmental scan to catalog relevant mobile apps, and we conducted interviews with people with a diagnosis of fragile X syndrome and clinicians at fragile X syndrome clinics. To develop content for the decision support tool, we extracted key concepts and elements from a real clinical trial consent form and rewrote it using plain-language principles. Results: We used iterative testing to continuously evaluate and revise the decision support tool content. The tool was finalized in 2016 and contained a series of vignettes, quiz questions, and a sorting activity. A randomized controlled trial was then conducted to compare the efficacy of the decision support tool with a standard verbal presentation of material that mimicked typical informed consent practice. Conclusions: The informed consent process is primed to leverage digital health resources that promote increased understanding and engagement of research participants in the consent and research process. The process and experiences we describe may provide a model for other digital health design and development initiatives seeking to create more interactive and accessible decision support resources. Trial Registration: ClinicalTrials.gov NCT02465931; https://www.clinicaltrials.gov/ct2/show/NCT02465931 (Archived by WebCite at http://www.webcitation.org/6zx2KY9YW) %R 10.2196/10525 %U http://www.researchprotocols.org/2018/6/e10525/ %U https://doi.org/10.2196/10525 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e10774 %T Developing Technology to Mobilize Personal Strengths in People with Chronic Illness: Positive Codesign Approach %A Mirkovic,Jelena %A Jessen,Stian %A Kristjansdottir,Olöf Birna %A Krogseth,Tonje %A Koricho,Absera Teshome %A Ruland,Cornelia M %+ Center for Shared Decision Making and Collaborative Care Research, Division of Medicine, Oslo University Hostipal, Box 4950 Nydalen, Oslo, 0424, Norway, 47 46343869, Jelena.Mirkovic@rr-research.no %K patient personal strengths %K participatory design %K codesign %K appreciative inquiry %K service design %K positive computing %K positive technology %K chronic disease %K eHealth %K mHealth %K patient requirements %K patient participation %D 2018 %7 05.06.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Emerging research from psychology and the bio-behavioral sciences recognizes the importance of supporting patients to mobilize their personal strengths to live well with chronic illness. Positive technology and positive computing could be used as underlying design approaches to guide design and development of new technology-based interventions for this user group that support mobilizing their personal strengths. Objective: A codesigning workshop was organized with the aim to explore user requirements and ideas for how technology can be used to help people with chronic illness activate their personal strengths in managing their everyday challenges. Methods: Thirty-five participants from diverse backgrounds (patients, health care providers, designers, software developers, and researchers) participated. The workshop combined principles of (1) participatory and service design to enable meaningful participation and collaboration of different stakeholders and (2) an appreciative inquiry methodology to shift participants’ attention to positive traits, values, and aspects that are meaningful and life-giving and stimulate participants’ creativity, engagement, and collaboration. Utilizing these principles, participants were engaged in group activities to develop ideas for strengths-supportive tools. Each group consisted of 3-8 participants with different backgrounds. All group work was analysed using thematic analyses. Results: Participants were highly engaged in all activities and reported a wide variety of requirements and ideas, including more than 150 personal strength examples, more than 100 everyday challenges that could be addressed by using personal strengths, and a wide range of functionality requirements (eg, social support, strength awareness and reflection, and coping strategies). 6 concepts for strength-supportive tools were created. These included the following: a mobile app to support a person to store, reflect on, and mobilize one’s strengths (Strengths treasure chest app); “empathy glasses” enabling a person to see a situation from another person’s perspective (Empathy Simulator); and a mobile app allowing a person to receive supportive messages from close people in a safe user-controlled environment (Cheering squad app). Suggested design elements for making the tools engaging included: metaphors (eg, trees, treasure island), visualization techniques (eg, dashboards, color coding), and multimedia (eg, graphics). Maintaining a positive focus throughout the tool was an important requirement, especially for feedback and framing of content. Conclusions: Combining participatory, service design, and appreciative inquiry methods were highly useful to engage participants in creating innovative ideas. Building on peoples’ core values and positive experiences empowered the participants to expand their horizons from addressing problems and symptoms, which is a very common approach in health care today, to focusing on their capacities and that which is possible, despite their chronic illness. The ideas and user requirements, combined with insights from relevant theories (eg, positive technology, self-management) and evidence from the related literature, are critical to guide the development of future more personalized and strengths-focused self-management tools. %M 30684404 %R 10.2196/10774 %U http://formative.jmir.org/2018/1/e10774/ %U https://doi.org/10.2196/10774 %U http://www.ncbi.nlm.nih.gov/pubmed/30684404 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e11 %T Feasibility of a Proactive Text Messaging Intervention for Smokers in Community Health Centers: Pilot Study %A Kruse,Gina %A Kelley,Jennifer HK %A Chase,Karen %A Rigotti,Nancy A %+ Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, United States, 1 6177243157, gkruse@partners.org %K smoking cessation %K primary health care %K text messaging %D 2018 %7 31.05.2018 %9 Short Paper %J JMIR Formativ Res %G English %X Background: Few smokers receive evidence-based cessation services during primary care visits. Objective: We aimed to assess the feasibility of a proactive text messaging program for primary care patients who smoke. Methods: We used electronic health records to identify smokers who had a mobile phone number listed from two community health centers in Massachusetts. Between March 2014 and June 2015, patients were screened by their primary care physician and then sent a proactive text message inviting them to enroll by texting back. Patients who opted in were asked about their readiness to quit. The text message program included messages from the QuitNowTXT library and novel content for smokers who were not ready to quit. Results: Among 949 eligible smokers, 88 (9.3%) enrolled after receiving a single proactive text message. Compared with those who did not enroll, enrollees were more often female (54/88, 61% vs 413/861, 48.0%, P=.02), but otherwise did not differ in age, race, insurance status, or comorbidities. In all, 28% (19/67) of enrollees reported they were not ready to quit in the next 30 days, 61% (41/67) were ready to quit, and 11% (7/67) already quit. The median time in the program was 9 days (interquartile range 2-32 days). Of current smokers, 25% (15/60) sent one or more keyword requests to the server. These did not differ by readiness to quit. Conclusions: A proactively delivered text messaging program targeting primary care patients who smoke was feasible and engaged both smokers ready to quit and those not ready to quit. This method shows promise as part of a population health model for addressing tobacco use outside of the primary care office. %R 10.2196/formative.9608 %U http://formative.jmir.org/2018/1/e11/ %U https://doi.org/10.2196/formative.9608 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e10 %T A Multimedia Support Skills Intervention for Female Partners of Male Smokeless Tobacco Users: Use and Perceived Acceptability %A Akers,Laura %A Andrews,Judy A %A Gordon,Judith S %+ Oregon Research Institute, 1776 Millrace Drive, Eugene, OR, 97403, United States, 1 541 484 2123, lauraa@ori.org %K tobacco cessation %K social support %K multimedia %K website design %K website development %K website use assessment %K usability testing %D 2018 %7 28.05.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: UCare is a new multimedia (website+booklet) intervention for women who want their male partner to quit their use of smokeless tobacco. The intervention is based on research showing that perceived partner responsiveness to social support is highest when the supporter conveys respect, understanding, and caring in their actions. The website included both didactic and interactive features, with optional video components, and special activities to help women develop empathy for nicotine addiction. The booklet reinforced the website content, encouraged women to use the website, and served both as a physical reminder of the intervention and a convenient way to share the information with her partner. Objective: The objective of this study was to describe the utilization and acceptability of a multimedia intervention among women seeking to support their partner in quitting smokeless tobacco. Lessons learned with respect to design considerations for online interventions are also summarized. Methods: We present the evaluation of the intervention components’ use and usefulness in a randomized trial. Results: In the randomized clinical trial, more than 250,000 visits were made to the website in a 2-year period, with the vast majority from mobile devices. Of the 552 women randomized to receive the intervention, 96.9% (535/552) visited the website at least once, and 30.8% (170/552) completed the core website component, “The Basics.” About half of the women (287/552) used the interactive “Take Notes” feature, and 37% (204/552) used the checklists. Few women used the post-Basics features. At 6 weeks, 40.7% (116/285) reported reading the printed and mailed booklet. Website and booklet use were uncorrelated. User ratings for the website and booklet were positive overall. Conclusions: Intervention website designers should consider that many users will access the program only once or twice, and many will not complete it. It is also important to distinguish between core and supplemental features and to consider whether the primary purpose is training or support. Furthermore, printed materials still have value. Trial Registration: ClinicalTrials.gov NCT01885221; https://clinicaltrials.gov/ct2/show/NCT01885221 (Archived by WebCite at http://www.webcitation.org/6zdIgGGtx) %R 10.2196/formative.9948 %U http://formative.jmir.org/2018/1/e10/ %U https://doi.org/10.2196/formative.9948 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e9 %T Developing a Self-Administered Decision Aid for Fecal Immunochemical Test–Based Colorectal Cancer Screening Tailored to Citizens With Lower Educational Attainment: Qualitative Study %A Gabel,Pernille %A Kirkegaard,Pia %A Larsen,Mette Bach %A Edwards,Adrian %A Andersen,Berit %+ Department of Public Health Programmes, Randers Regional Hospital, Central Denmark Region, Skovlyvej 15, Randers NØ, DK-8930, Denmark, 45 78420185, pergab@rm.dk %K colorectal neoplasms %K mass screening %K decision support techniques %K socioeconomic factors %K qualitative research %D 2018 %7 22.05.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Citizens with lower educational attainments (EA) take up colorectal cancer screening to a lesser degree, and more seldom read and understand conventional screening information than citizens with average EAs. The information needs of citizens with lower EA are diverse, however, with preferences ranging from wanting clear recommendations to seeking detailed information about screening. Decision aids have been developed to support citizens with lower EA in making informed decisions about colorectal cancer screening participation, but none embrace diverse information needs. Objective: The aim of this study was to develop a self-administered decision aid for participation in fecal immunochemical test–based colorectal cancer screening. The decision aid should be tailored to citizens with lower EA and should embrace diverse information needs. Methods: The Web-based decision aid was developed according to an international development framework, with specific steps for designing, alpha testing, peer reviewing, and beta testing the decision aid. In the design phase, a prototype of the decision aid was developed based on previous studies about the information needs of lower EA citizens and the International Patient Decision Aid Standards guidelines. Alpha testing was conducted using focus group interviews and email correspondence. Peer review was conducted using email correspondence. Both tests included both lower EA citizens and health care professionals. The beta testing was conducted using telephone interviews with citizens with lower EA. Data were analyzed using thematic analysis. Results: The developed decision aid presented information in steps, allowing citizens to read as much or as little as wanted. Values clarification questions were included after each section of information, and answers were summarized in a “choice-indicator” on the last page, guiding the citizens toward a decision about screening participation. Statistics were presented in both natural frequencies, absolute risk formats and graphically. The citizens easily and intuitively navigated around the final version of the decision aid and stated that they felt encouraged to think about the benefits and harms of colorectal cancer screening without being overloaded with information. They found the decision aid easy to understand and the text of suitable length. The health care professionals agreed with the citizens on most parts; however, concerns were raised about the length and readability of the text. Conclusions: We have developed a self-administered decision aid presenting information in steps. We involved both citizens and health care professionals to target the decision aid for citizens with lower EA. This decision aid represents a new way of communicating detailed information and may be able to enhance informed choices about colorectal cancer screening participation among citizens with lower EA. %M 30684402 %R 10.2196/formative.9696 %U http://formative.jmir.org/2018/1/e9/ %U https://doi.org/10.2196/formative.9696 %U http://www.ncbi.nlm.nih.gov/pubmed/30684402 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e10323 %T A Hybrid Web-Based and In-Person Self-Management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma: Feasibility and Acceptability of iPACT-E-Trauma %A Bérubé,Mélanie %A Gélinas,Céline %A Feeley,Nancy %A Martorella,Géraldine %A Côté,José %A Laflamme,G Yves %A Rouleau,Dominique M %A Choinière,Manon %+ Centre intégré universitaire du Nord-de-l’Île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, Trauma Program and Department of Nursing, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada, 1 514 338 2222 ext 2654, melanie.berube2@mail.mcgill.ca %K Acute pain %K chronic pain %K wound and injuries %K lower extremity %K self-care %K health promotion %K feasibility studies %K patient acceptance of health care %D 2018 %7 30.04.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: A transition from acute to chronic pain frequently occurs after major lower extremity trauma. While the risk factors for developing chronic pain in this population have been extensively studied, research findings on interventions aiming to prevent chronic pain in the trauma context are scarce. Therefore, we developed a hybrid, Web-based and in-person, self-management intervention to prevent acute to chronic pain transition after major lower extremity trauma (iPACT-E-Trauma). Objective: This study aimed to assess the feasibility and acceptability of iPACT-E-Trauma. Methods: Using a descriptive design, the intervention was initiated at a supra-regional level-1 trauma center. Twenty-eight patients ≥18 years old with major lower extremity trauma, presenting with moderate to high pain intensity 24 hours post-injury were recruited. Feasibility assessment was two-fold: 1) whether the intervention components could be provided as planned to ≥80% of participants and 2) whether ≥80% of participants could complete the intervention. The rates for both these variables were calculated. The E-Health Acceptability Questionnaire and the Treatment Acceptability and Preference Questionnaire were used to assess acceptability. Mean scores were computed to determine the intervention’s acceptability. Results: More than 80% of participants received the session components relevant to their condition. However, the Web pages for session 2, on the analgesics prescribed, were accessed by 71% of participants. Most sessions were delivered according to the established timeline for ≥80% of participants. Session 3 and in-person coaching meetings had to be provider earlier for ≥35% of participants. Session duration was 30 minutes or less on average, as initially planned. More than 80% of participants attended sessions and <20% did not apply self-management behaviors relevant to their condition, with the exception of deep breathing relaxation exercises which was not applied by 40% of them. Web and in-person sessions were assessed as very acceptable (mean scores ≥3 on a 0 to 4 descriptive scale) across nearly all acceptability attributes. Conclusions: Findings showed that the iPACT-E-Trauma intervention is feasible and was perceived as highly acceptable by participants. Further tailoring iPACT-E-Trauma to patient needs, providing more training time for relaxation techniques, and modifying the Web platform to improve its convenience could enhance the feasibility and acceptability of the intervention. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 91987302; http://www.controlled-trials.com/ISRCTN91987302 (Archived by WebCite at http://www.webcitation.org/6ynibjPHa) %M 30684418 %R 10.2196/10323 %U http://formative.jmir.org/2018/1/e10323/ %U https://doi.org/10.2196/10323 %U http://www.ncbi.nlm.nih.gov/pubmed/30684418 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e8 %T MedFit App, a Behavior-Changing, Theoretically Informed Mobile App for Patient Self-Management of Cardiovascular Disease: User-Centered Development %A Duff,Orlaith %A Walsh,Deirdre %A Malone,Shauna %A McDermott,Lauri %A Furlong,Brona %A O'Connor,Noel %A Moran,Kieran %A Woods,Catherine %+ School of Health and Human Performance, Dublin City University, Glasnevin,, Dublin, 9, Ireland, 353 17008011, kieran.moran@dcu.ie %K app development %K cardiac rehabilitation %K telemedicine %K exercise %K mHealth %K focus groups %K usability testing %D 2018 %7 27.04.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The MedFit app is designed to facilitate participation of people with cardiovascular disease (CVD) in an exercise-based rehabilitation program remotely. This paper details the development for the MedFit app. Objective: The aim of this research was to develop a behavior change, theoretically informed exercise rehabilitation mobile app for adults with CVD by following the early stages of the formative research: development and feasibility testing. Methods: Adhering to the mobile health (mHealth) development evaluation framework, the stages of the formative research process including (1) development and (2) feasibility were undertaken. The content and format of the MedFit app were developed based on (1) theory, (2) usability testing, and (3) content design. Results: A systematic review of the literature was undertaken to identify the most appropriate theories from which to develop the app. This led to the creation of the MedFit app. The app went through iterative rounds of usability focus group testing with adults with CVD to provide feedback on the app. This process was framed by the unified theory of acceptance and use of technology model. Feedback was then translated into feasible technical improvements to be executed through close collaboration with the technical team, who adapted and made modifications to the app based on this codesign process. Conclusions: The formative research process of the app development involved theoretical underpinning, usability testing, and content design. mHealth interventions may play a key role in the future of health care, potentially addressing the barriers to participation in cardiac rehabilitation. This work will provide guidance for future research aiming to develop mobile apps by incorporating a best practice framework for mHealth intervention development and a user-centered design approach. %M 30684426 %R 10.2196/formative.9550 %U http://formative.jmir.org/2018/1/e8/ %U https://doi.org/10.2196/formative.9550 %U http://www.ncbi.nlm.nih.gov/pubmed/30684426 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 2 %P e30 %T Worker Preferences for a Mental Health App Within Male-Dominated Industries: Participatory Study %A Peters,Dorian %A Deady,Mark %A Glozier,Nick %A Harvey,Samuel %A Calvo,Rafael A %+ Wellbeing Technology Lab, Faculty of Engineering and IT, University of Sydney, Bldg J03, Electrical Engineering, Sydney, 2006, Australia, 61 0289015604, dorian.peters@sydney.edu.au %K mental health %K mhealth %K mobile apps %K workplace %K men %K participatory design %D 2018 %7 25.04.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Men are less likely to seek help for mental health problems, possibly because of stigma imposed by cultural masculine norms. These tendencies may be amplified within male-dominated workplaces such as the emergency services or transport industries. Mobile apps present a promising way to provide access to mental health support. However, little is known about the kinds of mental health technologies men would be willing to engage with, and no app can be effective if the intended users do not engage with it. Objective: The goal of this participatory user research study was to explore the perceptions, preferences, and ideas of workers in male-dominated workplaces to define requirements for a mental health app that would be engaging and effective at improving psychological well-being. Methods: Workers from male-dominated workplaces in rural, suburban, and urban locations took part in an exploratory qualitative study involving participatory workshops designed to elicit their perspectives and preferences for mental health support and the design of an app for mental health. Participants generated a number of artifacts (including draft screen designs and promotional material) designed to reify their perceptions, tacit knowledge, and ideas. Results: A total of 60 workers aged between 26 and 65 years, 92% (55/60) male, from male-dominated workplaces in rural (16/60, 27%), suburban (14/60, 23%), and urban (30/60, 50%) locations participated in one of the 6 workshops, resulting in 49 unique feature ideas and 81 participant-generated artifacts. Thematic analysis resulted in a set of feature, language, and style preferences, as well as characteristics considered important by participants for a mental health app. The term “mental health” was highly stigmatized and disliked by participants. Tools including a mood tracker, self-assessment, and mood-fix tool were highly valued, and app characteristics such as brevity of interactions, minimal on-screen text, and a solutions-oriented approach were considered essential by participants. Some implementation strategies based on these findings are included in the discussion. Conclusions: Future mental health mobile phone apps targeting workers in male-dominated workplaces need to consider language use and preferred features, as well as balance the preferences of users with the demands of evidence-based intervention. In addition to informing the development of mental health apps for workers in male-dominated industries, these findings may also provide insights for mental health technologies, for men in general, and for others in high-stigma environments. %M 29695371 %R 10.2196/mental.8999 %U http://mental.jmir.org/2018/2/e30/ %U https://doi.org/10.2196/mental.8999 %U http://www.ncbi.nlm.nih.gov/pubmed/29695371 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 4 %P e78 %T A Website Supporting Sensitive Religious and Cultural Advance Care Planning (ACPTalk): Formative and Summative Evaluation %A Pereira-Salgado,Amanda %A Mader,Patrick %A O'Callaghan,Clare %A Boyd,Leanne %+ Centre for Nursing Research, Cabrini Institute, 154 Wattletree Road, Malvern, VIC, 3144, Australia, 61 395083436, apereira-salgado@cabrini.com.au %K advance care planning %K ehealth %K religion %K culture %K health personnel %D 2018 %7 16.04.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Advance care planning (ACP) promotes conversations about future health care needs, enacted if a person is incapable of making decisions at end-of-life that may be communicated through written documentation such as advance care directives. To meet the needs of multicultural and multifaith populations in Australia, an advance care planning website, ACPTalk, was funded to support health professionals in conducting conversations within diverse religious and cultural populations. ACPTalk aimed to provide religion-specific advance care planning content and complement existing resources. Objective: The purpose of this paper was to utilize the context, input, process, and product (CIPP) framework to conduct a formative and summative evaluation of ACPTalk. Methods: The CIPP framework was used, which revolves around 4 aspects of evaluation: context, input, process, and product. Context: health professionals’ solutions for the website were determined through thematic analysis of exploratory key stakeholder interviews. Included religions were determined through an environmental scan, Australian population statistics, and documentary analysis of project steering committee meeting minutes. Input: Project implementation and challenges were examined through documentary analysis of project protocols and meeting minutes. Process: To ensure religion-specific content was accurate and appropriate, a website prototype was built with content review and functionality testing by representatives from religious and cultural organizations and other interested health care organizations who completed a Web-based survey. Product: Website analytics were used to report utilization, and stakeholder perceptions were captured through interviews and a website survey. Results: Context: A total of 16 key stakeholder health professional (7 general practitioners, 2 primary health nurses, and 7 palliative care nurses) interviews were analyzed. Website solutions included religious and cultural information, communication ideas, legal information, downloadable content, and Web-based accessibility. Christian and non-Christian faiths were to be included in the religion-specific content. Input: Difficulties gaining consensus on religion-specific content were overcome by further state and national religious organizations providing feedback. Process: A total of 37 content reviewers included representatives of religious and cultural organizations (n=29), health care (n=5), and community organizations (n=3). The majority strongly agree or agree that the content used appropriate language and tone (92%, 34/37), would support health professionals (89%, 33/37), and was accurate (83%, 24/29). Product: Resource usage within the first 9 months was 12,957 page views in 4260 sessions; majority were (83.45%, 3555/4260) from Australia. A total of 107 Australian-based users completed the website survey; most felt information was accurate (77.6%, 83/107), easy to understand (82.2%, 88/107), useful (86.0%, 92/107), and appropriate (86.0%, 92/107). A total of 20 nurses (general practice n=10, palliative care n=8, and both disciplines n=2) participated in stakeholder interviews. Qualitative findings indicated overall positivity in relation to accessibility, functionality, usefulness, design, and increased knowledge of advance care planning. Recommended improvements included shortened content, a comparable website for patients and families, and multilingual translations. Conclusions: The CIPP framework was effectively applied to evaluate the development and end product of an advance care planning website.Although overall findings were positive, further advance care planning website development should consider the recommendations derived from this study. %M 29661749 %R 10.2196/resprot.8572 %U http://www.researchprotocols.org/2018/4/e78/ %U https://doi.org/10.2196/resprot.8572 %U http://www.ncbi.nlm.nih.gov/pubmed/29661749 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 4 %N 1 %P e7 %T Development of a Web-based Family Intervention for BRCA Carriers and Their Biological Relatives: Acceptability, Feasibility, and Usability Study %A Katapodi,Maria C %A Jung,Miyeon %A Schafenacker,Ann M %A Milliron,Kara J %A Mendelsohn-Victor,Kari E %A Merajver,Sofia D %A Northouse,Laurel L %+ Department of Public Health, Faculty of Medicine, University of Basel, Bernoullistrasse 28, Room 113, Basel, 4056, Switzerland, 41 79 109 5163, maria.katapodi@unibas.ch %K BRCA families %K family-based intervention study %K Web-based intervention study %K psycho-educational and skills-building intervention study %K communication and coping %K patient decision-aid %K genetic testing %D 2018 %7 13.04.2018 %9 Original Paper %J JMIR Cancer %G English %X Background: Carriers of breast cancer gene (BRCA) mutations are asked to communicate genetic test results to their biological relatives to increase awareness of cancer risk and promote use of genetic services. This process is highly variable from family to family. Interventions that support communication of genetic test results, coping, and offer decision support in families harboring a pathogenic variant may contribute to effective management of hereditary cancer. Objective: The aim of this paper was to describe the development of the Family Gene Toolkit, a Web-based intervention targeting BRCA carriers and untested blood relatives, designed to enhance coping, family communication, and decision making. Methods: We present findings from focus groups regarding intervention acceptability and participant satisfaction and from a pre-post pilot study with random allocation to a wait-listed control group regarding intervention feasibility and usability. Results: The Family Gene Toolkit was developed by a multidisciplinary team as a psycho-educational and skills-building intervention. It includes two live webinar sessions and a follow-up phone call guided by a certified genetic counselor and a master’s prepared oncology nurse. Each live webinar includes two modules (total four modules) presenting information about BRCA mutations, a decision aid for genetic testing, and two skill-building modules for effective coping and family communication. Participants in focus groups (n=11) were highly satisfied with the intervention, reporting it to be useful and describing clearly the important issues. From the 12 dyads recruited in the pre-post pilot study (response rate 12/52, 23%), completion rate was 71% (10/14) for intervention and 40% (4/10) for wait-listed control groups. Conclusions: Acceptability and satisfaction with the Family Gene Toolkit is high. On the basis of the findings from usability and feasibility testing, modifications on timing, delivery mode, and recruitment methods have been implemented. Trial Registration: ClinicalTrials.gov NCT02154633; https://clinicaltrials.gov/ct2/show/NCT02154633 (Archived by WebCite at http://www.webcitation.org/6yYNvLPjv) %M 29653920 %R 10.2196/cancer.9210 %U http://cancer.jmir.org/2018/1/e7/ %U https://doi.org/10.2196/cancer.9210 %U http://www.ncbi.nlm.nih.gov/pubmed/29653920 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 4 %P e61 %T Social Interaction Needs and Entertainment Approaches to Pregnancy Well-Being in mHealth Technology Design for Low-Income Transmigrant Women: Qualitative Codesign Study %A AlJaberi,Hana %+ Purdue Polytechnic Institute, Department of Computer Graphics Technology, Purdue University, 401 N Grant St, West Lafayette, IN, 47907, United States, 1 7654947505, aljaberi.hana@gmail.com %K mHealth %K mobile health %K participatory design %K pregnancy %K Caribbean %K immigrant women %D 2018 %7 13.04.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Low-income Caribbean transmigrant women face unique health challenges during pregnancy that set forth multidimensional implications for the design of mobile health (mHealth). Acknowledgment of the unique health needs of low-income Caribbean immigrant women in the United States and what that entails regarding technology design remains rarely examined in the literature of mHealth technologies. Objective: The goal of this study was to reveal the needs and gaps in mHealth interventions for pregnant immigrant women not yet realized in this field. These understandings reveal design opportunities for mHealth. Methods: The use of the qualitative participatory action research approach of codesign workshops in this study resulted in design solutions by the participants after reflecting on their earlier focus group discussions. The highlights are not the resulting designs per se but rather the inferences derived from the researcher reflecting on these designs. Results: The designs exposed two themes relevant to this paper. First, the participants desired the inclusion and rebuilding of social and organizational relationships in mHealth. The resulting designs formulate an understanding of the women’s health-related social support needs and how technology can facilitate them. Second, the participants wanted entertainment with an element of social participation incorporated in mHealth pregnancy management interventions. This brings attention to the role entertainment can add to the impact mHealth can deliver for pregnancy well-being. Conclusions: The study concluded with an examination of social and entertainment design implications that reveal pregnant immigrant women’s virtual health-related sharing habits, choice of sharing interaction scenarios during pregnancy (eg, local, long distance, one-way, two-way, and many-many), and choice of sharing media (eg, text, voice, and video). Additionally, the study revealed exclusions to social sharing capabilities in health technologies for these women. %M 29653919 %R 10.2196/mhealth.7708 %U http://mhealth.jmir.org/2018/4/e61/ %U https://doi.org/10.2196/mhealth.7708 %U http://www.ncbi.nlm.nih.gov/pubmed/29653919 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e7 %T User-Centered Design of a Mobile App for Weight and Health Management in Adolescents With Complex Health Needs: Qualitative Study %A Rivera,Jordan %A McPherson,Amy C %A Hamilton,Jill %A Birken,Catherine %A Coons,Michael %A Peters,Michelle %A Iyer,Sindoora %A George,Tessy %A Nguyen,Cynthia %A Stinson,Jennifer %+ The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G0A4, Canada, 1 416 813 7654 ext 304514, jennifer.stinson@sickkids.ca %K obesity %K weight loss %K adolescent %K mobile apps %D 2018 %7 04.04.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Growing research has been conducted into the deployment and evaluation of mobile technology interventions for weight management in adolescents. However, no work has yet been conducted toward the development of these technologies for adolescents with complex health needs receiving specialized tertiary-level health care. Objective: The aim of this study was to conduct a user-centered needs assessment of adolescents interested in weight management with complex health needs requiring specialized health care services, their parents, and health care providers (HCPs) to inform the design and development of a mobile app for weight and health management. Methods: A qualitative study design was employed. Participants were recruited from two tertiary health care centers. Separate audiotaped focus group interviews were conducted with adolescents aged 12 to 18 years, parents, and HCPs. Interviews were transcribed, and field notes were collected by research staff. Iterative simple content analysis was performed independently by 4 research team members using computer software NVivo (QSR International) 10.0. Results: A total of 19 adolescents, 16 parents, and 21 HCPs were interviewed. Qualitative analysis revealed seven major themes related to app functionality: healthy eating, social support, self-monitoring, communicating with HCPs, supporting mental health, gamification and incentives, and user interface (UI) design. Adolescents provided several ideas related to each feature, whereas parents’ views focused on assistance with meal planning and greater access to HCPs. HCPs viewed the app as a novel and more acceptable platform to connect remotely with adolescents than conventional methods. They also strongly endorsed the value of social support capabilities and the ability to connect with an HCP. Conclusions: This is the first study to conduct a qualitative needs assessment in adolescents receiving specialized health care services toward the design of a mobile app for weight and health management. Our results indicate that core components of the app should include tailored meal recommendations and assistance with meal planning, social networking for peer support, customized and convenient tracking, remote access to HCPs, features to support mental health, and an attractive and engaging UI. These findings will be used to develop and evaluate a mobile app targeting adolescents with complex health needs. %M 30684409 %R 10.2196/formative.8248 %U http://formative.jmir.org/2018/1/e7/ %U https://doi.org/10.2196/formative.8248 %U http://www.ncbi.nlm.nih.gov/pubmed/30684409 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e5 %T A Spiritually-Based Text Messaging Program to Increase Cervical Cancer Awareness Among African American Women: Design and Development of the CervixCheck Pilot Study %A Le,Daisy %A Aldoory,Linda %A Garza,Mary A %A Fryer,Craig S %A Sawyer,Robin %A Holt,Cheryl L %+ Department of Behavioral and Community Health, School of Public Health, University of Maryland, 1101H School of Public Health Building (255), College Park, MD, 20742, United States, 1 415 385 7330, drdaisyle@gmail.com %K short message service %K text messaging %K African Americans %K women’s health %K cervical cancer %K health status disparities %K pap test %K cancer screening %K health information technology %K spirituality %K community-based participatory research %D 2018 %7 29.03.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Although Hispanic women have the highest cervical cancer incidence rate, African American women account for a disproportionate burden of cervical cancer incidence and mortality when compared with non-Hispanic white women. Given that religion occupies an essential place in African American lives, delivering health messages through a popular communication delivery channel and framing them with important spiritual themes may allow for a more accessible and culturally appropriate approach to promoting cervical cancer educational content to African American women. Objective: The aim of this paper was to describe the design and development of the CervixCheck project, a spiritually based short message service (SMS) text messaging pilot intervention to increase cervical cancer awareness and Papanicolaou test screening intention among church-attending African American women aged 21 to 65 years. Methods: Through focus group interviews (n=15), formative research was conducted to explore facilitators, motivators, and barriers to cervical cancer screening. The interviews were also used to identify logistical factors that should be considered when developing the CervixCheck intervention. Culturally appropriate and spiritually grounded SMS text messages were developed based on the analysis of focus group data and the review of previous studies that incorporated technology into health behavior change interventions. After the CervixCheck intervention was developed, cognitive response interviews (n=8) were used to review the content of the SMS text messaging library, to ensure that the content was acceptable and understandable, particularly for church-attending African American women aged 21 to 65 years. Results: Design and development of the SMS text messages involved consideration of the content of the messages and technological specifications. Focus group participants overwhelmingly reported cell phone use and an interest in receiving spiritually based SMS text messages on cervical cancer prevention and early detection. Findings from the cognitive response interviews revealed that the content of the SMS text messaging library was acceptable and understandable with the target population. The revised SMS text messaging library currently includes 22 messages for delivery over 16 days, averaging 11 texts per week, with no more than two messages delivered per day. Initial usability testing also showed early feasibility. Conclusions: The design and development of the CervixCheck intervention provides important insight into what may be considered an overlooked minority population and missed opportunity in health information technology research. With increased internet penetration through the use of mobile phones, it is appropriate to investigate the viability of technology as a means to reach minority communities and to reduce health disparities. %M 30684433 %R 10.2196/formative.8112 %U http://formative.jmir.org/2018/1/e5/ %U https://doi.org/10.2196/formative.8112 %U http://www.ncbi.nlm.nih.gov/pubmed/30684433 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 1 %P e4 %T Development of an Exergame to Deliver a Sustained Dose of High-Intensity Training: Formative Pilot Randomized Trial %A McBain,Thomas %A Weston,Matthew %A Crawshaw,Paul %A Haighton,Catherine %A Spears,Iain %+ Academy of Sport and Physical Activity, Sheffield Hallam University, Collegiate Hall, Collegiate Crescent, Sheffield, S102BP, United Kingdom, 44 1142255805, t.mcbain@shu.ac.uk %K high-intensity interval training %K video games %K heart rate %K boxing %K metabolic syndrome %D 2018 %7 27.03.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sport science can play a critical role in reducing health inequalities. The inverse relationship between life expectancy, cardiorespiratory fitness, and socioeconomic status could be addressed by performing high-intensity training (HIT), delivered in a class salient and accessible approach. Commercially available exergames have shown encouraging compliance rates but are primarily designed for entertainment purposes rather than focusing on health-related outcomes. A serious game tailored toward delivering an exercise stimulus, while reducing the aversive protocols associated with HIT, could be beneficial to engage and improve health outcomes in socially deprived males. Objective: The aims of this study were to develop an exergame capable of delivering HIT and evaluate the effect on selected health outcomes in men recruited in regions of socioeconomic deprivation. Methods: We conducted an exploratory trial in our target population, and participants were allocated to intervention (n=14) or control groups (n=10) by third-party minimization. The intervention was a 6-week training program consisting of three sessions of exergaming per week. The sessions involved a structured warm-up, then brief intermittent repetitions in the form of boxing rounds (10 s, 20 s, and 30 s) against their peers with a work/rest ratio of 0.25. Results: Retention to the intervention was 87.5% (21/24). Over the duration of the intervention, session attendance was 67.5% (170/252); repetition mean and peak heart rates (% of maximal) and session ratings of perceived exertion (AU, arbitrary units) were 86.3 (5.4%), 89.9 (6.1%), and 7.5 (2.2 AU), respectively. The effect of the intervention, when compared with the control, was a likely small beneficial improvement in predicted maximum oxygen consumption (VO2 max, 3.0; 90% confidence limits ±2.6%). Effects on body mass, waist circumference, and blood pressure were either trivial or unclear. Conclusions: Over the 6-week intervention, the exergame delivered a consistent and sustained dose of HIT, with some beneficial effects on aerobic fitness in the target population. Trial Registration: ClinicalTrials.gov NCT03477773; https://clinicaltrials.gov/ct2/show/NCT03477773 (Archived by WebCite at http://www.webcitation.org/6yDLgVs35) %M 29588271 %R 10.2196/games.7758 %U http://games.jmir.org/2018/1/e4/ %U https://doi.org/10.2196/games.7758 %U http://www.ncbi.nlm.nih.gov/pubmed/29588271 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e6 %T Factors Affecting Patient Portal Use Among Low-Income Pregnant Women: Mixed-Methods Pilot Study %A Kim,Juhee %A Mathews,Holly %A Cortright,Lindsay M %A Zeng,Xiaoming %A Newton,Edward %+ Department of Public Health, Brody School of Medicine, East Carolina University, 1600 Moye Blvd, Lakeside Annex 7, Greenville, NC, 27858, United States, 1 252 744 5575, kimju@ecu.edu %K patient portals %K digital divide %K pregnancy %K poverty %K health literacy %D 2018 %7 22.03.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Patient portals offer patients personalized and secure Web access to their medical information and enable patients to manage their health care online. However, there is a lack of information about patient acceptance and use of patient portals among low-income pregnant women. Objective: This formative research aims to assess the potential of a patient portal, MyChart, for improving prenatal health care and pregnancy outcomes, and identify the barriers and facilitators of MyChart use among low-income pregnant women. Methods: A mixed-methods study was conducted with a convenience sample of 18 low-income pregnant women comprising low- and high-risk patients enrolled in a prenatal clinic in eastern North Carolina. MyChart use, patient demographics, and pregnancy information were collected by reviewing electronic medical charts. Health literacy was measured. Reported use and attitudes toward MyChart were collected using a semi-structured interview. Results: Although 39% (7/18) of participants interviewed signed up for MyChart, only 22% (4/18) of them became active users. Another 33% (6/18) had never heard of MyChart or was unsure of how to access it. Users primarily accessed test results and appointment schedules. The main facilitating factors for patient portal use were information and motivation from health care providers and concerns about pregnancy due to a history of miscarriage. Reported barriers were lack of educational resources, lack of care provider encouragement, and technical difficulties possibly exacerbated by low health literacy. Participants also suggested improvements for MyChart, especially the provision of discussion-based support for pregnant women. Conclusions: The one-time verbal introduction of MyChart does not meet current patients’ needs. Data reveal the need for more consistent patient education and support programs, tailored to patients’ previous pregnancy histories. The clinic also needs to facilitate better provider-patient communication about the importance of MyChart use. %M 30684413 %R 10.2196/formative.5322 %U http://formative.jmir.org/2018/1/e6/ %U https://doi.org/10.2196/formative.5322 %U http://www.ncbi.nlm.nih.gov/pubmed/30684413 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e21 %T A Web-Based Toolkit to Provide Evidence-Based Resources About Crystal Methamphetamine for the Australian Community: Collaborative Development of Cracks in the Ice %A Champion,Katrina Elizabeth %A Chapman,Cath %A Newton,Nicola Clare %A Brierley,Mary-Ellen %A Stapinski,Lexine %A Kay-Lambkin,Frances %A Nagle,Jack %A Teesson,Maree %+ National Health and Medical Research Council Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street, Randwick, Sydney, 2052, Australia, 61 293850333, k.champion@unsw.edu.au %K methamphetamine %K substance-related disorders %K internet %K preventive psychiatry %K health education %D 2018 %7 20.03.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: The use of crystal methamphetamine (ice) and the associated harms for individuals, families, and communities across Australia has been the subject of growing concern in recent years. The provision of easily accessible, evidence-based, and up-to-date information and resources about crystal methamphetamine for the community is a critical component of an effective public health response. Objective: This paper aims to describe the codevelopment process of the Web-based Cracks in the Ice Community Toolkit, which was developed to improve access to evidence-based information and resources about crystal methamphetamine for the Australian community. Methods: Development of the Cracks in the Ice Community Toolkit was conducted in collaboration with community members across Australia and with experts working in the addiction field. The iterative process involved the following: (1) consultation with end users, including community members, crystal methamphetamine users, families and friends of someone using crystal methamphetamine, health professionals, and teachers (n=451) via a cross-sectional Web-based survey to understand information needs; (2) content and Web development; and (3) user testing of a beta version of the Web-based toolkit among end users (n=41) and experts (n=10) to evaluate the toolkit’s acceptability, relevance, and appeal. Results: Initial end user consultation indicated that the most commonly endorsed reasons for visiting a website about crystal methamphetamine were “to get information for myself” (185/451, 41.0%) and “to find out how to help a friend or a family member” (136/451, 30.2%). Community consultation also revealed the need for simple information about crystal methamphetamine, including what it is, its effects, and when and where to seek help or support. Feedback on a beta version of the toolkit was positive in terms of content, readability, layout, look, and feel. Commonly identified areas for improvement related to increasing the level of engagement and personal connection, improving the ease of navigation, and balancing a “low prevalence of use, yet high impact” message. A total of 9138 users visited the website in the 3 months immediately post launch, and over 25,000 hard-copy Cracks in the Ice booklets and flyers were distributed across Australia. Of these resources, 60.93% (15,525/25,480) were distributed to relevant organizations and mailing list subscribers, and 39.07% (9955/25,480) were ordered directly by individuals, services, and community groups via the Cracks in the Ice website. Conclusions: The codevelopment process resulted in an engaging Web-based resource for the Australian community to access up-to-date and evidence-based resources about crystal methamphetamine. The Cracks in the Ice Community Toolkit provides much-needed information and support for individuals, families, and communities. %M 29559427 %R 10.2196/mental.8891 %U http://mental.jmir.org/2018/1/e21/ %U https://doi.org/10.2196/mental.8891 %U http://www.ncbi.nlm.nih.gov/pubmed/29559427 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e66 %T An mHealth Pain Coping Skills Training Intervention for Hematopoietic Stem Cell Transplantation Patients: Development and Pilot Randomized Controlled Trial %A Somers,Tamara J %A Kelleher,Sarah A %A Dorfman,Caroline S %A Shelby,Rebecca A %A Fisher,Hannah M %A Rowe Nichols,Krista %A Sullivan,Keith M %A Chao,Nelson J %A Samsa,Gregory P %A Abernethy,Amy P %A Keefe,Francis J %+ Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 2200 W Main St, Ste 340, Durham, NC, 27705, United States, 1 919 416 3408, tamara.somers@duke.edu %K stem cell transplantation %K hematopoietic stem cell %K cancer-related pain %K coping skills %D 2018 %7 19.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pain is a challenge for patients following hematopoietic stem cell transplantation (HCT). Objective: This study aimed to develop and test the feasibility, acceptability, and initial efficacy of a Web-based mobile pain coping skills training (mPCST) protocol designed to address the needs of HCT patients. Methods: Participants had undergone HCT and reported pain following transplant (N=68). To guide intervention development, qualitative data were collected from focus group participants (n=25) and participants who completed user testing (n=7). After their input was integrated into the mPCST intervention, a pilot randomized controlled trial (RCT, n=36) was conducted to examine the feasibility, acceptability, and initial efficacy of the intervention. Measures of acceptability, pain severity, pain disability, pain self-efficacy, fatigue, and physical disability (self-report and 2-min walk test [2MWT]) were collected. Results: Participants in the focus groups and user testing provided qualitative data that were used to iteratively refine the mPCST protocol. Focus group qualitative data included participants’ experiences with pain following transplant, perspectives on ways to cope with pain, and suggestions for pain management for other HCT patients. User testing participants provided feedback on the HCT protocol and information on the use of videoconferencing. The final version of the mPCST intervention was designed to bridge the intensive outpatient (1 in-person session) and home settings (5 videoconferencing sessions). A key component of the intervention was a website that provided personalized messages based on daily assessments of pain and activity. The website also provided intervention materials (ie, electronic handouts, short videos, and audio files). The intervention content included pain coping advice from other transplant patients and instructions on how to apply pain coping skills while engaging in meaningful and leisure activities. In the RCT phase of this research, HCT patients (n=36) were randomized to receive the mPCST intervention or to proceed with the treatment as usual. Results revealed that the mPCST participants completed an average of 5 out of 6 sessions. The participants reported that the intervention was highly acceptable (mean 3/4), and they found the sessions to be helpful (mean 8/10) and easy to understand (mean 7/7). The mPCST participants demonstrated significant improvements in pre- to post-treatment pain, self-efficacy (P=.03, d=0.61), and on the 2MWT (P=.03, d=0.66), whereas the patients in the treatment-as-usual group did not report any such improvements. Significant changes in pain disability and fatigue were found in both groups (multiple P<.02); the magnitudes of the effect sizes were larger for the mPCST group than for the control group (pain disability: d=0.79 vs 0.69; fatigue: d=0.94 vs 0.81). There were no significant changes in pain severity in either group. Conclusions: Using focus groups and user testing, we developed an mPCST protocol that was feasible, acceptable, and beneficial for HCT patients with pain. Trial Registration: ClinicalTrials.gov NCT01984671; https://clinicaltrials.gov/ct2/show/NCT01984671 (Archived by WebCite at http://www.webcitation.org/6xbpx3clZ) %M 29555620 %R 10.2196/mhealth.8565 %U http://mhealth.jmir.org/2018/3/e66/ %U https://doi.org/10.2196/mhealth.8565 %U http://www.ncbi.nlm.nih.gov/pubmed/29555620 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e4 %T A Web-Based Platform for People With Memory Problems and Their Caregivers (CAREGIVERSPRO-MMD): Mixed-Methods Evaluation of Usability %A Zafeiridi,Paraskevi %A Paulson,Kevin %A Dunn,Rosie %A Wolverson,Emma %A White,Caroline %A Thorpe,Jonathan Adrian %A Antomarini,Marco %A Cesaroni,Francesca %A Scocchera,Francesca %A Landrin-Dutot,Isabelle %A Malherbe,Laëtitia %A Lingiah,Hendi %A Bérard,Marie %A Gironès,Xavier %A Quintana,Maria %A Cortés,Ulises %A Barrué,Cristian %A Cortés,Atia %A Paliokas,Ioannis %A Votis,Konstantinos %A Tzovaras,Dimitrios %+ School of Engineering and Computer Science, University of Hull, Aire Building, Cottingham Road, Hull, HU67RX, United Kingdom, 44 01482464571 ext 4571, P.Zafeiridi@hull.ac.uk %K dementia %K technology %K social support %K caregivers %D 2018 %7 12.03.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The increasing number of people with dementia (PwD) drives research exploring Web-based support interventions to provide effective care for larger populations. In this concept, a Web-based platform (CAREGIVERSPRO-MMD, 620911) was designed to (1) improve the quality of life for PwD, (2) reduce caregiver burden, (3) reduce the financial costs for care, and (4) reduce administration time for health and social care professionals. Objective: The objective of this study was to evaluate the usability and usefulness of CAREGIVERSPRO-MMD platform for PwD or mild cognitive impairment (MCI), informal caregivers, and health and social care professionals with respect to a wider strategy followed by the project to enhance the user-centered approach. A secondary aim of the study was to collect recommendations to improve the platform before the future pilot study. Methods: A mixed methods design was employed for recruiting PwD or MCI (N=24), informal caregivers (N=24), and professionals (N=10). Participants were asked to rate their satisfaction, the perceived usefulness, and ease of use of each function of the platform. Qualitative questions about the improvement of the platform were asked when participants provided low scores for a function. Testing occurred at baseline and 1 week after participants used the platform. The dropout rate from baseline to the follow-up was approximately 10% (6/58). Results: After 1 week of platform use, the system was useful for 90% (20.75/23) of the caregivers and for 89% (5.36/6) of the professionals. When users responded to more than 1 question per platform function, the mean of satisfied users per function was calculated. These user groups also provided positive evaluations for the ease of use (caregivers: 82%, 18.75/23; professionals: 97%, 5.82/6) and their satisfaction with the platform (caregivers: 79%, 18.08/23; professionals: 73%, 4.36/6). Ratings from PwD were lower than the other groups for usefulness (57%, 13/23), ease of use (41%, 9.4/23), and overall satisfaction (47%, 11/23) with the platform (P<.05). Qualitative comments related to both improvements for functionality and the platform interface. Conclusions: Although caregivers and professionals were overall satisfied with the platform, further adaptations were recommended by PwD. This reiterates the importance of the involvement of end users in the development of Web-based interventions. Recommendations from users in this paper apply for the interface and functionality of a wider range of Web-based support interventions. %M 30684403 %R 10.2196/formative.9083 %U http://formative.jmir.org/2018/1/e4/ %U https://doi.org/10.2196/formative.9083 %U http://www.ncbi.nlm.nih.gov/pubmed/30684403 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e51 %T More Stamina, a Gamified mHealth Solution for Persons with Multiple Sclerosis: Research Through Design %A Giunti,Guido %A Mylonopoulou,Vasiliki %A Rivera Romero,Octavio %+ Salumedia Tecnologias, Avda. Republica Argentina nº 24, Edificio Torre de los Remedios 5ª planta modulo A, Sevilla, 41011, Spain, 34 717702622, drguidogiunti@gmail.com %K multiple sclerosis %K telemedicine %K fatigue %K mobile applications %K video games %K qualitative research %K exercise %K chronic disease %K user-computer interface %K software design %D 2018 %7 02.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Multiple sclerosis (MS) is one of the world’s most common neurologic disorders. Fatigue is one of most common symptoms that persons with MS experience, having significant impact on their quality of life and limiting their activity levels. Self-management strategies are used to support them in the care of their health. Mobile health (mHealth) solutions are a way to offer persons with chronic conditions tools to successfully manage their symptoms and problems. Gamification is a current trend among mHealth apps used to create engaging user experiences and is suggested to be effective for behavioral change. To be effective, mHealth solutions need to be designed to specifically meet the intended audience needs. User-centered design (UCD) is a design philosophy that proposes placing end users’ needs and characteristics in the center of design and development, involving users early in the different phases of the software life cycle. There is a current gap in mHealth apps for persons with MS, which presents an interesting area to explore. Objective: The purpose of this study was to describe the design and evaluation process of a gamified mHealth solution for behavioral change in persons with MS using UCD. Methods: Building on previous work of our team where we identified needs, barriers, and facilitators for mHealth apps for persons with MS, we followed UCD to design and evaluate a mobile app prototype aimed to help persons with MS self-manage their fatigue. Design decisions were evidence-driven and guided by behavioral change models (BCM). Usability was assessed through inspection methods using Nielsen’s heuristic evaluation. Results: The mHealth solution More Stamina was designed. It is a task organization tool designed to help persons with MS manage their energy to minimize the impact of fatigue in their day-to-day life. The tool acts as a to-do list where users can input tasks in a simple manner and assign Stamina Credits, a representation of perceived effort, to the task to help energy management and energy profiling. The app also features personalization and positive feedback. The design process gave way to relevant lessons to the design of a gamified behavioral change mHealth app such as the importance of metaphors in concept design, negotiate requirements with the BCM constructs, and tailoring of gamified experiences among others. Several usability problems were discovered during heuristic evaluation and guided the iterative design of our solution. Conclusions: In this paper, we designed an app targeted for helping persons with MS in their fatigue management needs. We illustrate how UCD can help in designing mHealth apps and the benefits and challenges that designers might face when using this approach. This paper provides insight into the design process of gamified behavioral change mHealth apps and the negotiation process implied in it. %M 29500159 %R 10.2196/mhealth.9437 %U http://mhealth.jmir.org/2018/3/e51/ %U https://doi.org/10.2196/mhealth.9437 %U http://www.ncbi.nlm.nih.gov/pubmed/29500159 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 3 %P e52 %T Crush the Crave: Development and Formative Evaluation of a Smartphone App for Smoking Cessation %A Baskerville,Neill B %A Struik,Laura L %A Dash,Darly %+ Propel Centre for Population Health Impact, Faculty of Applied Health Sciences, University of Waterloo, 200 University Ave West, Waterloo, ON, N2M 3G1, Canada, 1 519 888 4567 ext 35236, nbbaskerville@uwaterloo.ca %K mobile app %K smoking cessation %K young adult %K software design %K formative feedback %D 2018 %7 02.03.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Emerging evidence supports the use of smartphone apps for smoking cessation, especially in young adults given their high smoking rates and high smartphone ownership rates. Although evaluative evidence is encouraging for supporting smoking cessation, there remains a paucity of research describing the design and development processes of mobile health (mHealth) interventions. Objective: The aim of this paper was to describe the process of developing Crush the Crave (CTC), an evidence-informed app to support smoking cessation in young adults, and the results of a formative evaluation of app usage behavior, as part of a broader program of research that seeks to establish the effectiveness of the CTC app. Methods: The Spiral Technology Action Research (STAR) 5-cycle model (listen, plan, do, act, and study) was employed to guide the development, implementation, and dissemination of CTC. The approach to development and formative evaluation included focus groups with young adult smokers (n=78) across 2 phases, analysis of the content of existing apps, 2 sessions with content experts, and Google Analytics to assess user behavior during a 12-month pilot. Results: LISTEN—focus groups revealed young adult smoker preferences of (1) positive reinforcement, (2) personalization, (3) social support, (4) quit support, (5) tracking the behavior, and (6) tracking quit benefits. PLAN—informed by evidence for smoking cessation, young adult preferences and an assessment of popular cessation apps, content experts produced a mind map and a storyboard describing app content and structure. DO—focus groups with young adult smokers provided feedback on the first version of the app with opinions on content and suggestions for improvement such as providing alerts and distractions from craving. ACT—refinements were made, and app content was organized using the 4 key design components informed by principles of persuasive technology for behavior change: credibility, task support, dialogue support, and social support. CTC was launched in April 2013 and piloted from the period July 2013 to June 2014 where 1987 Android users had 18,567 sessions, resulting in 59,384 page views and 89.58% (1780/1987) of users returning within the same day to use CTC. STUDY—a pragmatic randomized controlled trial of CTC was launched in August 2014 to demonstrate that including mHealth technology as a population-based intervention can help young adult smokers to quit. The results of this phase will be presented in a subsequent publication. Conclusions: CTC is one of the first smoking cessation apps designed to meet the needs of young adult smokers. The development was informed by the inclusion of young adults in the design and the systematic application of multiple stakeholder input, scientific evidence, and theory. The STAR model approach was followed from the beginning of intervention development, which should facilitate optimization of mHealth interventions in the future. Trial Registration: ClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150 (Archived by WebCite at http://www.webcitation.org/6VGyc0W0i) %M 29500157 %R 10.2196/mhealth.9011 %U http://mhealth.jmir.org/2018/3/e52/ %U https://doi.org/10.2196/mhealth.9011 %U http://www.ncbi.nlm.nih.gov/pubmed/29500157 %0 Journal Article %@ 2562-0959 %I JMIR Publications %V 1 %N 1 %P e1 %T Acceptability and Feasibility of a Trial Testing Allocation to Sunscreen and a Smartphone App for Sun Protection: Discontinued Randomized Controlled Trial %A Rodrigues,Angela M %A Sniehotta,Falko F %A Birch-Machin,Mark A %A Olivier,Patrick %A Araújo-Soares,Vera %+ Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle, NE2 4AX, United Kingdom, 44 191 208 8974, angela.rodrigues@newcastle.ac.uk %K sunscreening agents %K sun protection factor %K smartphone %K mobile applications %K feasibility studies %K randomized controlled trial %K skin neoplasms %K melanoma %K skin aging %K holidays %K health promotion %K health behavior %D 2018 %7 27.02.2018 %9 Original Paper %J JMIR Dermatol %G English %X Background: Recreational sun exposure has been associated with melanoma prevalence, and tourism settings are of particular interest for skin cancer prevention. Effective, affordable, and geographically flexible interventions to promote sun protection are needed. Objective: The aim of this study was to describe the protocol for a definitive randomized controlled trial (RCT) evaluating a smartphone mobile intervention (mISkin app) promoting sun protection in holidaymakers and to assess the acceptability and feasibility of the mISkin app and associated trial procedures in an internal pilot study. Methods: Participants were recruited from the general community. Holidaymakers traveling abroad and owning a smartphone were enrolled in the internal pilot of a 2 (mISkin vs control) x 2 (sun protection factor [SPF] 15 vs SPF 30) RCT with a postholiday follow-up. The smartphone app is fully automated and entails a behavioral intervention to promote sun protection. It consisted of five components: skin assessment, educational videos, ultraviolet (UV) photos, gamification, and prompts for sun protection. Participants were also randomly allocated to receive sunscreen SPF 15 or SPF 30. Primary outcomes for the internal pilot study were acceptability and feasibility of trial procedures and intervention features. Secondary outcomes were collected at baseline and after holidays through face-to-face-assessments and included skin sun damage, sunscreen use (residual weight and application events), and sun protection practices (Web-based questionnaire). Results: From 142 registers of interest, 42 participants were randomized (76% [32/42] female; mean age 35.5 years). Outcome assessments were completed by all participants. Random allocation to SPF 15 versus SPF 30 was found not to be feasible in a definitive trial protocol. Of the 21 people allocated to the mISkin intervention, 19 (91%) installed the mISkin on their phones, and 18 (86%) used it at least once. Participants were satisfied with the mISkin app and made suggestions for further improvements. Due to difficulties with the random allocation to SPF and slow uptake, the trial was discontinued. Conclusions: The internal pilot study concluded that randomization to SPF was not feasible and that recruitment rate was slower than expected because of difficulties with gatekeeper engagement. Possible solutions to the problems identified are discussed. Further refinements to the mISkin app are needed before a definitive trial. Trial Registration: International Standard Randomized Controlled Trial Number ISRCTN63943558; http://www.isrctn.com/ISRCTN63943558 (Archived by WebCite at http://www.webcitation.org/6xOLvbab8) %R 10.2196/derma.8608 %U https://derma.jmir.org/2018/1/e1/ %U https://doi.org/10.2196/derma.8608 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 2 %P e45 %T Mobile App Delivery of the EORTC QLQ-C30 Questionnaire to Assess Health-Related Quality of Life in Oncological Patients: Usability Study %A Kessel,Kerstin A %A Vogel,Marco ME %A Alles,Anna %A Dobiasch,Sophie %A Fischer,Hanna %A Combs,Stephanie E %+ Department of Radiation Oncology, Technical University of Munich, Ismaninger Straße 22, Munich, 81675, Germany, 49 0894140 ext 4502, kerstin.kessel@tum.de %K radiation oncology %K healthcare surveys %K mobile applications %K mobile apps %K telemedicine %K health-related quality of life %K questionnaires %K oncology  %D 2018 %7 20.02.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile apps are evolving in the medical field. However, ongoing discussions have questioned whether such apps are really valuable and whether patients will accept their use in day-to-day clinical life. Therefore, we initiated a usability study in our department. Objective: We present our results of the first app prototype and patient testing of health-related quality of life (HRQoL) assessment in oncological patients. Methods: We developed an app prototype for the iOS operating system within eight months in three phases: conception, initial development, and pilot testing. For the HRQoL assessment, we chose to implement only the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 (QLQ-C30; German version 3). Usability testing was conducted for three months. Participation was voluntary and pseudonymized. After completion of the QLQ-C30 questionnaire using iPads provided by our department, we performed a short survey with 10 questions. This survey inquired about patients’ opinions regarding general aspects, including technical advances in medicine, mobile and app assistance during cancer treatment, and the app-specific functions (eg, interface and navigation). Results: After logging into the app, the user can choose between starting a questionnaire, reviewing answers (administrators only), and logging out. The questionnaire is displayed with the same information, questions, and answers as on the original QLQ-C30 sheet. No alterations in wording were made. Usability was tested with 81 patients; median age was 55 years. The median time for completing the HRQoL questionnaire on the iPad was 4.0 minutes. Of all participants, 84% (68/81) owned a mobile device. Similarly, 84% (68/81) of participants would prefer a mobile version of the HRQoL questionnaire instead of a paper-based version. Using the app in daily life during and after cancer treatment would be supported by 83% (67/81) of participants. In the prototype version of the app, data were stored on the device; in the future, 79% (64/81) of the patients would agree to transfer data via the Internet. Conclusions: Our usability test showed good results regarding attractiveness, operability, and understandability. Moreover, our results demonstrate a high overall acceptance of mobile apps and telemedicine in oncology. The HRQoL assessment via the app was accepted thoroughly by patients, and individuals are keen to use it in clinical routines, while data privacy and security must be ensured. %M 29463489 %R 10.2196/mhealth.9486 %U http://mhealth.jmir.org/2018/2/e45/ %U https://doi.org/10.2196/mhealth.9486 %U http://www.ncbi.nlm.nih.gov/pubmed/29463489 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 2 %P e54 %T Healthy Body Image Intervention Delivered to Young Women via Facebook Groups: Formative Study of Engagement and Acceptability %A Stapleton,Jerod L %A Manne,Sharon L %A Day,Ashley K %A Levonyan-Radloff,Kristine %A Pagoto,Sherry L %+ Rutgers Cancer Institute of New Jersey, Department of Medicine, Rutgers University, 195 Little Albany Street, New Brunswick, NJ, 08901, United States, 1 732 235 8112, staplejl@cinj.rutgers.edu %K body image %K dissonance-based intervention %K indoor tanning bed %K social media %K Facebook %K behavioral intervention %K prevention %D 2018 %7 20.02.2018 %9 Original Paper %J JMIR Res Protoc %G English %X Background: There is increasing interest in using social media sites such as Facebook to deliver health interventions so as to expose people to content while they are engaging in their usual social media habit. This formative intervention development study is novel in describing a preliminary test of using the secret group feature of Facebook to deliver a behavioral intervention targeting users of indoor tanning beds to reduce their risk of skin cancer. Intervention content was designed to challenge body image-related constructs associated with indoor tanning through the use of dissonance-inducing content. Objective: To evaluate engagement with and acceptability of using a secret Facebook group to deliver a healthy body image intervention to young women engaged in indoor tanning. Methods: Seventeen young women completed a baseline survey and joined a secret Facebook group with intervention content delivered via daily posts for 4 weeks. Engagement data was extracted and acceptability was measured via a follow-up survey. Results: The study had a high retention rate (94%, [16/17]). On average, posts were viewed by 91% of participants, liked by 35%, and commented on by 26%. The average comment rate was highest (65%) for posts that elicited comments by directly posing questions or discussion topics to the group. Average intervention acceptability ratings were highly positive and participants reported feeling connected to the group and its topic. Average rates of past 1-month indoor tanning reported following the intervention were lower than the baseline rate (P=.08, Cohen d=0.47). Conclusions: This study is novel in demonstrating participant engagement with and acceptability of using Facebook secret groups to deliver a dissonance-inducing intervention approach that utilizes group-based discussions related to body image. The study is also unique within the field of skin cancer prevention by demonstrating the potential value of delivering an indoor tanning intervention within an interactive social media format. The findings suggest that Facebook metrics of intervention post engagement (ie, likes and comments) may vary based on post types and that designing specifically labeled discussion posts may be helpful for soliciting engagement as well as challenging beliefs. %M 29463495 %R 10.2196/resprot.9429 %U http://www.researchprotocols.org/2018/2/e54/ %U https://doi.org/10.2196/resprot.9429 %U http://www.ncbi.nlm.nih.gov/pubmed/29463495 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 2 %P e44 %T A Smartphone App to Promote an Active Lifestyle in Lower-Educated Working Young Adults: Development, Usability, Acceptability, and Feasibility Study %A Simons,Dorien %A De Bourdeaudhuij,Ilse %A Clarys,Peter %A De Cocker,Katrien %A Vandelanotte,Corneel %A Deforche,Benedicte %+ Health Promotion and Education Unit, Department of Public Health, Ghent University, Corneel Heymanslaan 10, Ghent, 9000, Belgium, 32 498457442, dorien.simons@ugent.be %K mHealth %K young adult %K mobile applications %K physical activity %K active transport %K health promotion %D 2018 %7 20.02.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Physical activity (PA) levels are problematic in lower-educated working young adults (18-26 years). To promote PA, smartphone apps have great potential, but there is no evidence for their effectiveness in this population. To increase the likelihood that a newly developed app will be effective, formative research and user testing are required. Objective: The aim of this study was to describe the development, usability, acceptability, and feasibility of a new theory- and evidence-based smartphone app to promote an active lifestyle in lower-educated working young adults. Methods: The new app was developed by applying 4 steps. First, determinants important to promote an active lifestyle in this population were selected. Second, evidence-based behavior change techniques were selected to convert the determinants into practical applications. Third, a new smartphone app was developed. Fourth, volunteers (n=11, both lower and higher educated) tested the app on usability, and lower-educated working young adults (n=16) tested its acceptability and feasibility via (think aloud) interviews, a questionnaire, and Google Analytics. The app was accordingly adapted for the final version. Results: A new Android app, Active Coach, was developed that focused on knowledge, attitude, social support, and self-efficacy (based on outcomes from step 1), and that applied self-regulation techniques (based on outcomes from step 2). The app consists of a 9-week program with personal goals, practical tips, and scientific facts to encourage an active lifestyle. To ensure all-day and automatic self-monitoring of the activity behavior, the Active Coach app works in combination with a wearable activity tracker, the Fitbit Charge. Issues detected by the usability test (eg, text errors, wrong messages) were all fixed. The acceptability and feasibility test showed that participants found the app clear, understandable, and motivating, although some aspects needed to be more personal. Conclusions: By applying a stepwise, user-centered approach that regularly consulted the target group, the new app is adapted to their specific needs and preferences. The Active Coach app was overall positively evaluated by the lower-educated working young adults at the end of the development process. %M 29463491 %R 10.2196/mhealth.8287 %U http://mhealth.jmir.org/2018/2/e44/ %U https://doi.org/10.2196/mhealth.8287 %U http://www.ncbi.nlm.nih.gov/pubmed/29463491 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 1 %P e13 %T A Web-Based Psychoeducational Intervention for Adolescent Depression: Design and Development of MoodHwb %A Bevan Jones,Rhys %A Thapar,Anita %A Rice,Frances %A Beeching,Harriet %A Cichosz,Rachel %A Mars,Becky %A Smith,Daniel J %A Merry,Sally %A Stallard,Paul %A Jones,Ian %A Thapar,Ajay K %A Simpson,Sharon A %+ Division of Psychological Medicine and Clinical Neurosciences, Medical Research Council Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Hadyn Ellis Building, Maindy Rd, Cardiff, Wales, CF24 4HQ, United Kingdom, 44 02920688451, bevanjonesr1@cardiff.ac.uk %K adolescent %K depression %K internet %K education %K preventive psychiatry %K early medical intervention %D 2018 %7 15.02.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression is common in adolescence and leads to distress and impairment in individuals, families and carers. Treatment and prevention guidelines highlight the key role of information and evidence-based psychosocial interventions not only for individuals but also for their families and carers. Engaging young people in prevention and early intervention programs is a challenge, and early treatment and prevention of adolescent depression is a major public health concern. There has been growing interest in psychoeducational interventions to provide accurate information about health issues and to enhance and develop self-management skills. However, for adolescents with, or at high risk of depression, there is a lack of engaging Web-based psychoeducation programs that have been developed with user input and in line with research guidelines and targeted at both the individual and their family or carer. There are also few studies published on the process of development of Web-based psychoeducational interventions. Objective: The aim of this study was to describe the process underlying the design and development of MoodHwb (HwbHwyliau in Welsh): a Web-based psychoeducation multimedia program for young people with, or at high risk of, depression and their families, carers, friends, and professionals. Methods: The initial prototype was informed by (1) a systematic review of psychoeducational interventions for adolescent depression; (2) findings from semistructured interviews and focus groups conducted with adolescents (with depressive symptoms or at high risk), parents or carers, and professionals working with young people; and (3) workshops and discussions with a multimedia company and experts (in clinical, research, and multimedia work). Twelve interviews were completed (four each with young people, parents or carers, and professionals) and six focus groups (three with young people, one with parents and carers, one with professionals, and one with academics). Results: Key themes from the interviews and focus groups were: aims of the program, design and content issues, and integration and context of the program. The prototype was designed to be person-centered, multiplatform, engaging, interactive, and bilingual. It included mood-monitoring and goal-setting components and was available as a Web-based program and an app for mobile technologies. Conclusions: MoodHwb is a Web-based psychoeducational intervention developed for young people with, or at high risk of, depression and their families and carers. It was developed with user input using qualitative methods as well as user-centered design and educational and psychological theory. Further research is needed to evaluate the effectiveness of the program in a randomized controlled trial. If found to be effective, it could be implemented in health, education, youth and social services, and charities, to not only help young people but also families, carers, friends, and professionals involved in their care. %M 29449202 %R 10.2196/mental.8894 %U http://mental.jmir.org/2018/1/e13/ %U https://doi.org/10.2196/mental.8894 %U http://www.ncbi.nlm.nih.gov/pubmed/29449202 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e3 %T A Computer-Assisted Personal Interview App in Research Electronic Data Capture for Administering Time Trade-off Surveys (REDCap): Development and Pretest %A Oremus,Mark %A Sharafoddini,Anis %A Morgano,Gian Paolo %A Jin,Xuejing %A Xie,Feng %+ School of Public Health and Health Systems, University of Waterloo, 200 University Ave W, Waterloo, ON,, Canada, 1 519 888 4567 ext 35129, moremus@uwaterloo.ca %K computer-assisted personal interview %K health-related quality-of-life %K REDCap %K time trade-off %D 2018 %7 23.01.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The time trade-off (TTO) task is a method of eliciting health utility scores, which range from 0 (equivalent to death) to 1 (equivalent to perfect health). These scores numerically represent a person’s health-related quality of life. Software apps exist to administer the TTO task; however, most of these apps are poorly documented and unavailable to researchers. Objective: To fill the void, we developed an online app to administer the TTO task for a research study that is examining general public proxy health-related quality of life estimates for persons with Alzheimer’s disease. This manuscript describes the development and pretest of the app. Methods: We used Research Electronic Data Capture (REDCap) to build the TTO app. The app’s modular structure and REDCap’s object-oriented environment facilitated development. After the TTO app was built, we recruited a purposive sample of 11 members of the general public to pretest its functionality and ease of use. Results: Feedback from the pretest group was positive. Minor modifications included clarity enhancements, such as rearranging some paragraph text into bullet points, labeling the app to delineate different question sections, and revising or deleting text. We also added a research question to enable the identification of respondents who know someone with Alzheimer’s disease. Conclusions: We developed an online app to administer the TTO task. Other researchers may access and customize the app for their own research purposes. %M 30684429 %R 10.2196/formative.8202 %U http://formative.jmir.org/2018/1/e3/ %U https://doi.org/10.2196/formative.8202 %U http://www.ncbi.nlm.nih.gov/pubmed/30684429 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 1 %P e25 %T Young People’s, Parents’, and Professionals’ Views on Required Components of Mobile Apps to Support Self-Management of Juvenile Arthritis: Qualitative Study %A Waite-Jones,Jennifer M %A Majeed-Ariss,Rabiya %A Smith,Joanna %A Stones,Simon R %A Van Rooyen,Vanessa %A Swallow,Veronica %+ Faculty of Science, Charles Sturt University, Building 1293 Room 2, Bathurst,, Australia, 61 0419 490 431, v.m.swallow@leeds.ac.uk %K Adolescent %K young people %K juvenile arthritis %K mobile apps %K self-management %K qualitative research %D 2018 %7 19.01.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: There is growing evidence that supporting self-management of Juvenile Arthritis can benefit both patients and professionals. Young people with Juvenile Arthritis and their healthy peers increasingly use mobile technologies to access information and support in day-to-day life. Therefore, a user-led, rigorously developed and evaluated mobile app could be valuable for facilitating young people’s self-management of Juvenile Arthritis. Objective: The objective of this study was to seek the views of young people with Juvenile Arthritis, their parents or carers, and health care professionals (HCPs) as to what should be included in a mobile app to facilitate young people’s self-management of chronic Juvenile Arthritis. Methods: A qualitative approach was adopted with a purposeful sample of 9 young people aged 10-18 years with Juvenile Arthritis, 8 parents or carers, and 8 HCPs involved in their care. Data were gathered through semi-structured focus group and individual interviews with young people and their parents or carers and HCPs. Interview discussion was facilitated through demonstration of four existing health apps to explore participants’ views on strengths and limitations of these, barriers and facilitators to mobile app use, preferred designs, functionality, levels of interaction, and data sharing arrangements. Data were analyzed using the framework approach. Results: Analysis revealed three interlinked, overarching themes: (1) purpose, (2) components and content, and (3) social support. Despite some differences in emphasis on essential content, general agreement was found between young people with Juvenile Arthritis their parents or carers, and professionals that a mobile app to aid self-management would be useful. Underpinning the themes was a prerequisite that young people are enabled to feel a sense of ownership and control of the app, and that it be an interactive, engaging resource that offers developmentally appropriate information and reminders, as well as enabling them to monitor their symptoms and access social support. Conclusions: Findings justify and pave the way for a future feasibility study into the production and preliminary testing of such an app. This would consider issues such as compatibility with existing technologies, costs, age, and cross-gender appeal as well as resource implications. %M 29351898 %R 10.2196/mhealth.9179 %U http://mhealth.jmir.org/2018/1/e25/ %U https://doi.org/10.2196/mhealth.9179 %U http://www.ncbi.nlm.nih.gov/pubmed/29351898 %0 Journal Article %@ 2561-1011 %I JMIR Publications %V 2 %N 1 %P e2 %T Digital Health Innovation: A Toolkit to Navigate From Concept to Clinical Testing %A Marvel,Francoise Adeline %A Wang,Jane %A Martin,Seth Shay %+ Ciccarone Center for the Prevention of Heart Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 601 N. Caroline Street, 7th Floor, Baltimore, MD, 21287, United States, 1 4105020469, fmarvel1@jhmi.edu %K digital health innovation models %K mHealth %K innovation framework %K development of smartphone applications %K wearable technology %K healthcare transformation %D 2018 %7 18.01.2018 %9 Viewpoint %J JMIR Cardio %G English %X Digital health technologies such as smartphone apps, Web-based platforms, and wearable devices are rapidly emerging as promising interventions for acute and chronic disease management, particularly in the field of cardiovascular medicine. However, there is limited guidance on how to effectively develop and rigorously test digital health interventions (DHIs). Through our experience with innovating Corrie, a smartphone-based app paired with a smartwatch and blood pressure monitor for myocardial infarction recovery in the acute setting, we aim to provide a toolkit for navigating the digital health technology development and clinical testing processes. The toolkit consists of 6 steps: step one emphasizes concept generation by defining a specific clinical problem and the existing solutions aimed to address it; step two aims to recruit a multidisciplinary team within an academic institution; step three leverages technology accelerators and industry partnerships; step four develops the digital health technology with continuous feedback from patient and family end-users; step five solicits feedback from a diverse array of stakeholders; and step six performs a clinical study at a single site that, if successful, rapidly scales to multiple sites. DHI development is often a complex and vastly uncharted territory. By exploring the steps we took from concept to clinical testing with the first cardiology CareKit app, we hope to provide useful insights to teams that are starting out on their path to digital health innovation. We emphasize the central importance of embracing transdisciplinary work to move from silos to synergy. %R 10.2196/cardio.7586 %U http://cardio.jmir.org/2018/1/e2/ %U https://doi.org/10.2196/cardio.7586 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e6 %T Development of a Maternal, Newborn and Child mHealth Intervention in Thai Nguyen Province, Vietnam: Protocol for the mMom Project %A McBride,Bronwyn %A Nguyen,Liem Thanh %A Wiljer,David %A Vu,Nguyen C %A Nguyen,Cuong K %A O'Neil,John %+ Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A1S6, Canada, 1 778 782 5361, joneil@sfu.ca %K mobile health %K Vietnam %K maternal health %K reproductive health %K health equity %D 2018 %7 11.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Ethnic minority women (EMW) living in mountainous areas of northern Vietnam have disproportionately high infant and maternal mortality rates as a result of low maternal health knowledge, poverty, and remoteness from low-capacity health centers. Objective: The objective of this study was to describe the protocol for the development and evaluation of the mMom intervention, which is an integrated mobile health (mHealth) system designed to improve maternal and infant health knowledge, and behavior among women in remote areas of Thai Nguyen, Vietnam. Methods: This project featured the following four phases: (1) development of an mHealth platform integrated into the existing health management information system in partnership with the provincial health department; (2) ethnographic fieldwork and intervention content development; (3) intervention piloting and implementation; and (4) evaluation of the intervention’s impact on participants’ maternal health knowledge, behavior, and interactions with the health system. Results: The mMom project development process resulted in the following: (1) the successful development of the mMom system, including the mHealth platform hardware and integration, the intervention plan and content, and the monitoring and evaluation framework; (2) the piloting and implementation of the intervention as planned; and (3) the implementation of the monitoring and evaluation framework components. Conclusions: This protocol outlines the development of the mMom intervention and describes critical next steps in understanding the impact of the intervention on participants and the wider health system in Thai Nguyen province, Vietnam. %M 29326095 %R 10.2196/resprot.7912 %U http://www.researchprotocols.org/2018/1/e6/ %U https://doi.org/10.2196/resprot.7912 %U http://www.ncbi.nlm.nih.gov/pubmed/29326095 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 1 %P e11 %T Usage of an Exercise App in the Care for People With Osteoarthritis: User-Driven Exploratory Study %A Danbjørg,Dorthe Boe %A Villadsen,Allan %A Gill,Ester %A Rothmann,Mette Juel %A Clemensen,Jane %+ Centre for Innovative Medical Technology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Sdr Boulevard 29, Odense, 5000, Denmark, 45 26202186, dortheboe@gmail.com %K arthritis %K rehabilitation %K telemedicine %D 2018 %7 11.01.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Exercise has proven to reduce pain and increase quality of life among people living with osteoarthritis (OA). However, one major challenge is adherence to exercise once supervision ends. Objective: This study aimed to identify mental and physical barriers and motivational and social aspects of training at home, and to test or further develop an exercise app. Methods: The study was inspired from participatory design, engaging users in the research process. Data were collected through focus groups and workshops, and analyzed by systematic text condensation. Results: Three main themes were found: competition as motivation, training together, and barriers. The results revealed that the participants wanted to do their training and had knowledge on exercise and pain but found it hard to motivate themselves. They missed the observation, comments, and encouragement by the supervising physiotherapist as well as their peers. Ways to optimize the training app were identified during the workshops as participants shared their experience. Conclusions: This study concludes that the long-term continuation of exercising for patients with OA could be improved with the use of a technology tailored to users’ needs, including motivational and other behavioral factors. %M 29326092 %R 10.2196/mhealth.7734 %U https://mhealth.jmir.org/2018/1/e11/ %U https://doi.org/10.2196/mhealth.7734 %U http://www.ncbi.nlm.nih.gov/pubmed/29326092 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 1 %P e1 %T Developing Digital Facilitation of Assessments in the Absence of an Interpreter: Participatory Design and Feasibility Evaluation With Allied Health Groups %A Freyne,Jill %A Bradford,Dana %A Pocock,Courtney %A Silvera-Tawil,David %A Harrap,Karen %A Brinkmann,Sally %+ Australian eHealth Research Centre, Commonwealth Scientific and Industrial Research Organisation, Queensland Centre for Advanced Technologies, 1 Technology Court, Pullenvale, 4069, Australia, 61 733274404, dana.bradford@csiro.au %K mobile apps %K cultural diversity %K culturally appropriate technology %K cross-cultural care %K language barriers %K health care delivery %K ehealth allied health %D 2018 %7 09.01.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: To ensure appropriate and timely care, interpreters are often required to aid communication between clinicians and patients from non-English speaking backgrounds. In a hospital environment, where care is delivered 24 hours a day, interpreters are not always available. Subsequently, culturally and linguistically diverse (CALD) patients are sometimes unable to access timely assessment because of clinicians’ inability to communicate directly with them. Objective: The aim of this study was to design and evaluate CALD Assist, a tablet app to assist communication between patients and allied health clinicians in the absence of an interpreter. CALD Assist uses key phrases translated into common languages and uses pictorial, written, and voice-over prompts to facilitate communication during basic patient assessment. Methods: CALD Assist’s design, functionality, and content were determined through focus groups with clinicians and informed by interpreting and cultural services. An evaluation was conducted in a live trial phase on eight wards across 2 campuses of a hospital in Victoria, Australia. Results: A commercial grade CALD Assist mobile app for five disciplines within allied health was developed and evaluated. The app includes a total of 95 phrases in ten different languages to assist clinicians during their initial assessment. Evaluation results show that clinicians’ confidence in their assessment increased with use of the CALD Assist app: clinicians’ reports of “complete confidence” increased from 10% (3/30) to 42% (5/12), and assessment reports of “no confidence” decreased from 57% (17/30) to 17% (2/12). Average time required to complete an assessment with patients from non-English speaking backgrounds reduced from 42.0 to 15.6 min. Conclusions: Through the use of CALD Assist, clinician confidence in communicating with patients from non-English speaking backgrounds in the absence of an interpreter increased, providing patients from non-English speaking backgrounds with timely initial assessments and subsequent care in line with their English speaking peers. Additionally, the inclusion of images and video demonstrations in CALD Assist increased the ability to communicate with patients and overcome literacy-related barriers. Although a number of hurdles were faced, user uptake and satisfaction were positive, and the app is now available in the Apple App Store. %M 30684405 %R 10.2196/formative.8032 %U http://formative.jmir.org/2018/1/e1/ %U https://doi.org/10.2196/formative.8032 %U http://www.ncbi.nlm.nih.gov/pubmed/30684405 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 6 %N 1 %P e1 %T Stage-Based Mobile Intervention for Substance Use Disorders in Primary Care: Development and Test of Acceptability %A Levesque,Deborah %A Umanzor,Cindy %A de Aguiar,Emma %+ Pro-Change Behavior Systems, Inc, 1174 Kingstown Road, Suite 101, South Kingstown, RI, 02879, United States, 1 401 360 2975, dlevesque@prochange.com %K pilot projects %K substance use disorders %K primary care %K behavioral medicine %K expert system %D 2018 %7 02.01.2018 %9 Original Paper %J JMIR Med Inform %G English %X Background: In 2016, 21 million Americans aged 12 years and older needed treatment for a substance use disorder (SUD). However, only 10% to 11% of individuals requiring SUD treatment received it. Given their access to patients, primary care providers are in a unique position to perform universal Screening, Brief Intervention, and Referral to Treatment (SBIRT) to identify individuals at risk, fill gaps in services, and make referrals to specialty treatment when indicated. Major barriers to SBIRT include limited time among providers and low motivation to change among many patients. Objective: The objective of this study was to develop and test the acceptability of a prototype of a mobile-delivered substance use risk intervention (SURI) for primary care patients and a clinical dashboard for providers that can address major barriers to SBIRT for risky drug use. The SURI delivers screening and feedback on SUD risk via mobile tools to patients at home or in the waiting room; for patients at risk, it also delivers a brief intervention based on the transtheoretical model of behavior change (TTM) to facilitate progress through the stages of change for quitting the most problematic drug and for seeking treatment if indicated. The prototype also delivers 30 days of stage-matched text messages and 4 Web-based activities addressing key topics. For providers, the clinical dashboard summarizes the patient’s SUD risk scores and stage of change data, and provides stage-matched scripts to guide in-person sessions. Methods: A total of 4 providers from 2 federally qualified health centers (FQHCs) were recruited for the pilot test, and they in turn recruited 5 patients with a known SUD. Furthermore, 3 providers delivered dashboard-guided SBIRT sessions and completed a brief acceptability survey. A total of 4 patients completed a Web-based SURI session and in-person SBIRT session, accessed other program components, and completed 3 acceptability surveys over 30 days. Questions in the surveys were adapted from the National Cancer Institute’s Education Materials Review Form. Response options ranged from 1=strongly disagree to 5=strongly agree. The criterion for establishing acceptability was an overall rating of 4.0 or higher across items. Results: For providers, the overall mean acceptability rating was 4.4 (standard deviation [SD] 0.4). Notably, all providers gave a rating of 5.0 for the item, “The program can give me helpful information about my patient.” For patients, the overall mean acceptability rating was 4.5 (SD 0.3) for the mobile- and provider-delivered SBIRT sessions and 4.0 (SD 0.4) for the text messages and Web-based activities. One highly rated item was “The program could help me make some positive changes” (4.5). Conclusions: The SURI program and clinical dashboard, developed to reduce barriers to SBIRT in primary care, were well received by providers and patients. %M 29295811 %R 10.2196/medinform.7355 %U http://medinform.jmir.org/2018/1/e1/ %U https://doi.org/10.2196/medinform.7355 %U http://www.ncbi.nlm.nih.gov/pubmed/29295811 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 1 %N 1 %P e7 %T Identifying Asbestos-Containing Materials in Homes: Design and Development of the ACM Check Mobile Phone App %A Govorko,Matthew Hayden %A Fritschi,Lin %A White,James %A Reid,Alison %+ School of Public Health, Curtin University, GPO Box U1987, Bentley, Perth, 6845, Australia, 61 8 9266 1361, alison.reid@curtin.edu.au %K application development %K asbestos %K asbestos-containing materials %K mobile phones %K smartphone %K residential environment %K mobile applications %K environment and public health %D 2017 %7 14.12.2017 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Asbestos-containing materials (ACMs) can still be found in many homes in Australia and other countries. ACMs present a health risk when they are damaged or disturbed, such as during do-it-yourself home renovations. However, community members lack knowledge and awareness about asbestos identification and its safe management in residential settings. Objective: The objective of our study was to describe the process of developing a mobile phone app, ACM Check, that incorporates a questionnaire designed to identify and assess ACMs located in residential settings. Methods: A multidisciplinary team was involved in the formative development and creation of the mobile phone app. The formative development process comprised 6 steps: defining the scope of the app; conducting a comprehensive desktop review by searching online literature databases, as well as a wider online search for gray literature; drafting and revising the content, questionnaire, conditional branching rules, and scoring algorithms; obtaining expert input; manually pretesting the questionnaire; and formulating a final content document to be provided to the software development company. We then constructed ACM Check on the iOS platform for use in a validation study, and then updated the app, replicated it on Android, and released it to the public. Results: The ACM Check app identifies potential ACMs, prioritizes the materials based on their condition and likelihood of disturbance, and generates a summary report for each house assessed. Conclusions: ACM Check is an initiative to raise community members’ awareness of asbestos in the residential environment and also serves as a data collection tool for epidemiologic research. It can potentially be modified for implementation in other countries or used as the basis for the assessment of other occupational or environmental hazards. %M 30684427 %R 10.2196/formative.8370 %U http://formative.jmir.org/2017/1/e7/ %U https://doi.org/10.2196/formative.8370 %U http://www.ncbi.nlm.nih.gov/pubmed/30684427 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 4 %N 4 %P e30 %T An eHealth Application of Self-Reported Sports-Related Injuries and Illnesses in Paralympic Sport: Pilot Feasibility and Usability Study %A Fagher,Kristina %A Jacobsson,Jenny %A Dahlström,Örjan %A Timpka,Toomas %A Lexell,Jan %+ Rehabilitation Medicine Research Group, Department of Health Sciences, Lund University, PO Box 157, Lund,, Sweden, 46 46 222 1991, kristina.fagher@med.lu.se %K epidemiology %K feasibility studies %K sports medicine %K sports for persons with disabilities %K telemedicine %D 2017 %7 29.11.2017 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Sport participation is associated with a risk of sports-related injuries and illnesses, and Paralympic athletes’ additional medical issues can be a challenge to health care providers and medical staff. However, few prospective studies have assessed sports-related injuries and illnesses in Paralympic sport (SRIIPS) over time. Advances in mobile phone technology and networking systems offer novel opportunities to develop innovative eHealth applications for collection of athletes’ self-reports. Using eHealth applications for collection of self-reported SRIIPS is an unexplored area, and before initiation of full-scale research of SRIIPS, the feasibility and usability of such an approach needs to be ascertained. Objective: The aim of this study was to perform a 4-week pilot study and (1) evaluate the monitoring feasibility and system usability of a novel eHealth application for self-reported SRIIPS and (2) report preliminary data on SRIIPS. Methods: An eHealth application for routine collection of data from athletes was developed and adapted to Paralympic athletes. A 4-week pilot study was performed where Paralympic athletes (n=28) were asked to weekly self-report sport exposure, training load, general well-being, pain, sleep, anxiety, and possible SRIIPS. The data collection was followed by a poststudy use assessment survey. Quantitative data related to the system use (eg, completed self-reports, missing responses, and errors) were analyzed using descriptive statistics. The qualitative feasibility and usability data provided by the athletes were condensed and categorized using thematic analysis methods. Results: The weekly response rate was 95%. The athletes were of the opinion that the eHealth application was usable and feasible but stated that it was not fully adapted to Paralympic athletes and their impairments. For example, it was difficult to understand how a new injury or illness should be identified when the impairment was involved. More survey items related to the impairments were requested, as the athletes perceived that injuries and illnesses often occurred because of the impairment. Options for description of multifactorial incidents including an injury, an illness, and the impairment were also insufficient. Few technical issues were encountered, but athletes with visual impairment reported usability difficulties with the speech synthesizer. An incidence rate of 1.8 injuries and 1.7 illnesses per 100 hours of athlete exposure were recorded. The weekly pain prevalence was 56% and the impairment contributed to 20% of the reported incidents. Conclusions: The novel eHealth-based application for self-reported SRIIPS developed and tested in this pilot study was generally feasible and usable. With some adaptation to accommodate Paralympic athletes’ prerequisites and improved technical support for athletes with visual impairment, this application can be recommended for use in prospective studies of SRIIPS. Trial Registration: ClinicalTrials.gov NCT02788500; https://clinicaltrials.gov/ct2/show/NCT02788500 (Archived by WebCite at http://www.webcitation.org/6v56OqTeP) %M 29187343 %R 10.2196/humanfactors.8117 %U http://humanfactors.jmir.org/2017/4/e30/ %U https://doi.org/10.2196/humanfactors.8117 %U http://www.ncbi.nlm.nih.gov/pubmed/29187343 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 11 %P e230 %T An eHealth Intervention to Promote Physical Activity and Social Network of Single, Chronically Impaired Older Adults: Adaptation of an Existing Intervention Using Intervention Mapping %A Boekhout,Janet M %A Peels,Denise A %A Berendsen,Brenda AJ %A Bolman,Catherine AW %A Lechner,Lilian %+ Faculty of Psychology and Educational Science, Open University of the Netherlands, Postbus 2960, Valkenburgerweg 177, Heerlen, 6401 DL, Netherlands, 31 455762448, janet.boekhout@ou.nl %K exercise %K older adults %K single %K chronic disease %K eHealth %K social network %K Intervention Mapping %D 2017 %7 23.11.2017 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Especially for single older adults with chronic diseases, physical inactivity and a poor social network are regarded as serious threats to their health and independence. The Active Plus intervention is an automated computer-tailored eHealth intervention that has been proven effective to promote physical activity (PA) in the general population of adults older than 50 years. Objective: The aim of this study was to report on the methods and results of the systematic adaptation of Active Plus to the wishes and needs of the subgroup of single people older than 65 years who have one or more chronic diseases, as this specific target population may encounter specific challenges regarding PA and social network. Methods: The Intervention Mapping (IM) protocol was used to systematically adapt the existing intervention to optimally suit this specific target population. A literature study was performed, and quantitative as well as qualitative data were derived from health care professionals (by questionnaires, n=10) and the target population (by focus group interviews, n=14), which were then systematically integrated into the adapted intervention. Results: As the health problems and the targeted behavior are largely the same in the original and adapted intervention, the outcome of the needs assessment was that the performance objectives remained the same. As found in the literature study and in data derived from health professionals and focus groups, the relative importance and operationalization of the relevant psychosocial determinants related to these objectives are different from the original intervention, resulting in a refinement of the change objectives to optimally fit the specific target population. This refinement also resulted in changes in the practical applications, program components, intervention materials, and the evaluation and implementation strategy for the subgroup of single, chronically impaired older adults. Conclusions: This study demonstrates that the adaptation of an existing intervention is an intensive process in which adopting the IM protocol is an invaluable tool. The study provides a broad insight in adapting interventions aimed at single older adults with a chronic disease. It is concluded that even when the new target population is a sizable segment of the original target population, the adapted intervention still needs considerable changes to optimally fit the needs and situational differences of the narrower target population. %M 29170146 %R 10.2196/resprot.8093 %U http://www.researchprotocols.org/2017/11/e230/ %U https://doi.org/10.2196/resprot.8093 %U http://www.ncbi.nlm.nih.gov/pubmed/29170146 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 1 %N 1 %P e6 %T A Health Professional–Led Synchronous Discussion on Facebook: Descriptive Analysis of Users and Activities %A Grainger,Rebecca %A White,Bonnie %A Morton,Catherine %A Day,Karen %+ Rehabilitation Research and Teaching Unit, Department of Medicine, University of Otago Wellington, 23a Mein St, PO Box 7343, Wellington South, 6242, New Zealand, 64 43855541 ext 4031, rebecca.grainger@otago.ac.nz %K social media %K arthritis %K patient education %K patient engagement %D 2017 %7 22.11.2017 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Arthritis is a major cause of pain and disability. Arthritis New Zealand (Arthritis NZ) is a nongovernmental organization that provides advocacy, information, and advice and support services for people with arthritis in New Zealand. Since many people seek health information on the Web, Arthritis NZ has a webpage and a Facebook page. In addition to static content, Arthritis NZ provides synchronous discussions with an arthritis educator each week via Facebook. Objective: The aim of this study was to describe participation and structure of synchronous discussion with a health educator on a social media platform and the type of information and support provided to people with arthritis during discussions on this social media platform. Methods: Interpretive multimethods were used. Facebook Analytics were used to describe the users of the Arthritis NZ Facebook page and to provide descriptive summary statistics. Graphic analysis was used to summarize activity during a convenience sample of 10 arthritis educator–led synchronous discussions. Principles of thematic analysis were used to interpret transcripts of all comments from these 10 weekly arthritis educator–led discussions. Results: Users of the Arthritis NZ Facebook page were predominantly female (1437/1778, 80.82%), aged 18 to 54 years. Three major activities occurred during arthritis educator–led synchronous discussions: (1) seeking or giving support; (2) information enquiry; and (3) information sharing across a broad range of topic areas, largely related to symptoms and maintaining physical functioning. There was limited peer-to-peer interaction, with most threads consisting of two-comment exchanges between the users and arthritis educators. Conclusions: Arthritis educator–led discussions provided a forum for informational and emotional support for users. The facilitated discussion forum for people with arthritis on Facebook could be enhanced by encouraging increased user participation and increasing peer-to-peer interactions and further training of arthritis educators in facilitation of Web-based discussion. Future research should focus on addressing barriers to user participation and assessing the impact of arthritis educator facilitation training, with the latter leveraging the Action Research paradigm. %M 30684425 %R 10.2196/formative.7257 %U http://formative.jmir.org/2017/1/e6/ %U https://doi.org/10.2196/formative.7257 %U http://www.ncbi.nlm.nih.gov/pubmed/30684425 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 1 %N 1 %P e5 %T Implications for Training on Smartphone Medication Reminder App Use by Adults With Chronic Conditions: Pilot Study Applying the Technology Acceptance Model %A Park,Daniel Y %A Goering,Elizabeth M %A Head,Katharine J %A Bartlett Ellis,Rebecca J %+ Department of Communication Studies, Indiana University-Purdue University Indianapolis, 425 University Boulevard, Indianapolis, IN, 46202, United States, 1 317 278 3136, bgoering@iupui.edu %K chronic disease %K education of patients %K medication adherence %K mHealth %K mobile apps %K smartphone %D 2017 %7 10.11.2017 %9 Original Paper %J JMIR Formativ Res %G English %X Background: The majority of middle-aged to older patients with chronic conditions report forgetting to take medications as prescribed. The promotion of patients’ smartphone medication reminder app (SMRA) use shows promise as a feasible and cost-effective way to support their medication adherence. Providing training on SMRA use, guided by the technology acceptance model (TAM), could be a promising intervention to promote patients’ app use. Objective: The aim of this pilot study was to (1) assess the feasibility of an SMRA training session designed to increase patients’ intention to use the app through targeting perceived usefulness of app, perceived ease of app use, and positive subjective norm regarding app use and (2) understand the ways to improve the design and implementation of the training session in a hospital setting. Methods: A two-group design was employed. A total of 11 patients older than 40 years (median=58, SD=9.55) and taking 3 or more prescribed medications took part in the study on one of two different dates as participants in either the training group (n=5) or nontraining group (n=6). The training group received an approximately 2-hour intervention training session designed to target TAM variables regarding one popular SMRA, the Medisafe app. The nontraining group received an approximately 2-hour control training session where the participants individually explored Medisafe app features. Each training session was concluded with a one-time survey and a one-time focus group. Results: Mann-Whitney U tests revealed that the level of perceived ease of use (P=.13) and the level of intention to use an SMRA (P=.33) were higher in the training group (median=7.00, median=6.67, respectively) than in the nontraining group (median=6.25, median=5.83). However, the level of perceived usefulness (U=4.50, Z=−1.99, P=.05) and the level of positive subjective norm (P=.25) were lower in the training group (median=6.50, median=4.29) than in the nontraining group (median=6.92, median=4.50). Focus groups revealed the following participants’ perceptions of SMRA use in the real-world setting that the intervention training session would need to emphasize in targeting perceived usefulness and positive subjective norm: (1) the participants would find an SMRA to be useful if they thought the app could help address specific struggles in medication adherence in their lives and (2) the participants think that their family members (or health care providers) might view positively the participants’ SMRA use in primary care settings (or during routine medical checkups). Conclusions: Intervention training session, guided by TAM, appeared feasible in targeting patients’ perceived ease of use and, thereby, increasing intention to use an SMRA. Emphasizing the real-world utility of SMRA, the training session could better target patients’ perceived usefulness and positive subjective norm that are also important in increasing their intention to use the app. %M 30684397 %R 10.2196/formative.8027 %U http://formative.jmir.org/2017/1/e5/ %U https://doi.org/10.2196/formative.8027 %U http://www.ncbi.nlm.nih.gov/pubmed/30684397 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 1 %N 1 %P e4 %T Using mHealth to Support Postabortion Contraceptive Use: Results From a Feasibility Study in Urban Bangladesh %A Biswas,Kamal Kanti %A Hossain,Altaf %A Chowdhury,Rezwana %A Andersen,Kathryn %A Sultana,Sharmin %A Shahidullah,S M %A Pearson,Erin %+ Ipas, P.O. Box 9990, Chapel Hill, NC, 27515, United States, 919 967 7052, andersenk@Ipas.org %K mHealth %K Bangladesh %K contraceptive usage %K postabortion contraception %D 2017 %7 27.10.2017 %9 Original Paper %J JMIR Formativ Res %G English %X Background: As access to mobile technology improves in low- and middle-income countries, it becomes easier to provide information about sensitive issues, such as contraception and abortion. In Bangladesh, 97% of the population has access to a mobile signal, and the equity gap is closing in mobile phone ownership. Bangladesh has a high pregnancy termination rate and improving effective use of contraception after abortion is essential to reducing subsequent unwanted pregnancies. Objective: This study examines the feasibility and acceptability of implementing a short message service (SMS) text message-based mHealth intervention to support postabortion contraceptive use among abortion clients in Bangladesh, including women’s interest in the intervention, intervention preferences, and privacy concerns. Methods: This feasibility study was conducted in four urban, high abortion caseload facilities. Women enrolled in the study were randomized into an intervention (n=60) or control group (n=60) using block randomization. Women completed a baseline interview on the day of their abortion procedure and a follow-up interview 4 months later (retention rate: 89.1%, 107/120). Women in the intervention group received text message reminders to use their selected postabortion contraceptive methods and reminders to contact the facility if they had problems or concerns with their method. Women who did not select a method received weekly messages that they could visit the clinic if they would like to start a method. Women in the control group did not receive any messages. Results: Almost all women in the feasibility study reported using their mobile phones at least once per day (98.3%, 118/120) and 77.5% (93/120) used their phones for text messaging. In the intervention group, 87% (48/55) of women were using modern contraception at the 4-month follow-up, whereas 90% (47/52) were using contraception in the control group (P=.61). The intervention was not effective in increasing modern contraceptive use at follow-up, but 93% (51/55) of women reported at follow-up that the text reminders helped them use their method correctly and 76% (42/55) said they would sign up for this service again. Approximately half of the participants (53%, 29/55) said that someone they did not want to know about the text message reminders found out, mostly their husbands or children. Conclusions: In this small-scale feasibility study, text reminders did not increase postabortion contraceptive use. Despite the ineffectiveness of the text reminder intervention, implementation of a mHealth intervention among abortion clients in urban Bangladesh was feasible in that women were interested in receiving follow-up messages after their abortion and mobile phone use was common. Text messages may not be the best modality for a mHealth intervention due to relatively low baseline SMS text message use and privacy concerns. %M 30684398 %R 10.2196/formative.5151 %U http://formative.jmir.org/2017/1/e4/ %U https://doi.org/10.2196/formative.5151 %U http://www.ncbi.nlm.nih.gov/pubmed/30684398 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 1 %N 1 %P e3 %T Videoconferencing-Based Treatment of Alcohol Use Disorders: Analyses of Nonparticipation %A Tarp,Kristine %A Mejldal,Anna %A Nielsen,Anette Søgaard %+ Unit of Clinical Alcohol Research, Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 18, Indgang 220B, Odense C, 5000, Denmark, 45 6550 9359, ktarp@health.sdu.dk %K nonparticipation %K refusal to participate %K barriers %K treatment of alcohol use disorders %K alcoholism %K treatment refusal %K videoconferencing %K effectiveness %K treatment outcome %D 2017 %7 28.09.2017 %9 Original Paper %J JMIR Formativ Res %G English %X Background: We recently conducted a small randomized controlled trial (RCT) aiming to examine the effectiveness of videoconferencing-based treatment of alcohol use disorders in a real-life setting. The patient and participation rates were lower than anticipated. Objective: The objectives of our study were (1) to examine differences between participants and nonparticipants, and (2) to examine the characteristics of nonparticipants and their reported reasons for not participating. Methods: First, we analyzed nonparticipation through a comparative analysis of participants and nonparticipants using data from a clinical database, covering all patients starting treatment at the clinic. Second, on the basis of data from an anonymous questionnaire filled out by nonparticipants, we analyzed barriers to participating and the descriptive sociodemographics of nonparticipants who reported technical barriers versus those who did not. Results: Of 128 consecutive patients starting treatment during the study period, we found no significant differences between participants (n=71) and nonparticipants (n=51) according to sociodemographics, alcohol measures, and composite scores. Of 51 nonparticipants, 43 filled out the questionnaire with reasons for not participating. We derived 2 categories of barriers from the questionnaire: scientific barriers, which were barriers to the scientific study in general (n=6), and technical barriers, which were barriers to using a laptop or videoconferencing specifically (n=27). We found no significant differences in sociodemographics between nonparticipants who reported technical barriers to participating in the study and those who did not note technical barriers. A total of 13 patients elaborated on technical barriers, and 9 patients found videoconferencing impersonal, preferred personal contact, and would rather attend face-to-face treatment at the clinic. Conclusions: Patient barriers to participating in the RCT were mainly concerned with the technology. There were no significant differences between participants and nonparticipants, nor between nonparticipants who noted technical barriers to participating and those who did not. If a similar study is to be conducted or the solution is to be upscaled and implemented, attention should be given to the user friendliness of the technical equipment and the recruitment process, preparing the patients by emphasizing the information given to them about the technical equipment and its advantages. %M 30684431 %R 10.2196/formative.6715 %U http://formative.jmir.org/2017/1/e3/ %U https://doi.org/10.2196/formative.6715 %U http://www.ncbi.nlm.nih.gov/pubmed/30684431 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 1 %N 1 %P e2 %T A Novel Patient Engagement Platform Using Accessible Text Messages and Calls (Epharmix): Feasibility Study %A Som,Avik %A Patel,Kunjan %A Sink,Eric %A Peters,Robert Mattson %A Javaherian,Kavon %A Groenendyk,Jacob %A An,Tonya %A Xu,Zhuchen %A Polites,Gregory M %A Blanchard,Melvin %A Ross,Will %+ Department of Internal Medicine, Renal Division, Washington University School of Medicine, Box 8023, 660 South Euclid Avenue, St. Louis, MO,, United States, 1 314 362 6861, rossw@wustl.edu %K telemedicine %K mobile health %K eHealth %K telehealth %K mHealth innovations %K bioinformatics %K multiple chronic conditions %D 2017 %7 18.09.2017 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Patient noncompliance with therapy, treatments, and appointments represents a significant barrier to improving health care delivery and reducing the cost of care. One method to improve therapeutic adherence is to improve feedback loops in getting clinically acute events and issues to the relevant clinical providers as necessary (ranging from detecting hypoglycemic events for patients with diabetes to notifying the provider when patients are out of medications). Patients often don’t know which information should prompt a call to their physician and proactive checks by the clinics themselves can be very resource intensive. We hypothesized that a two-way SMS system combined with a platform web service for providers would enable both high patient engagement but also the ability to detect relevant clinical alerts. Objective: The objectives of this study are to develop a feasible two-way automated SMS/phone call + web service platform for patient-provider communication, and then study the feasibility and acceptability of the Epharmix platform. First, we report utilization rates over the course of the first 18 months of operation including total identified clinically significant events, and second, review results of patient user-satisfaction surveys for interventions for patients with diabetes, COPD, congestive heart failure, hypertension, surgical site infections, and breastfeeding difficulties. Methods: To test this question, we developed a web service + SMS/phone infrastructure (“Epharmix”). Utilization results were measured based on the total number of text messages or calls sent and received, with percentage engagement defined as a patient responding to a text message at least once in a given week, including the number of clinically significant alerts generated. User satisfaction surveys were sent once per month over the 18 months to measure satisfaction with the system, frequency and degree of communication. Descriptive statistics were used to describe the above information. Results: In total, 28,386 text messages and 24,017 calls were sent to 929 patients over 9 months. Patients responded to 80% to 90% of messages allowing the system to detect 1164 clinically significant events. Patients reported increased satisfaction and communication with their provider. Epharmix increased the number of patient-provider interactions to over 10 on average in any given month for patients with diabetes, COPD, congestive heart failure, hypertension, surgical site infections, and breastfeeding difficulties. Conclusions: Engaging high-risk patients remains a difficult process that may be improved through novel, digital health interventions. The Epharmix platform enables increased patient engagement with very low risk to improve clinical outcomes. We demonstrated that engagement among high-risk populations is possible when health care comes conveniently to where they are. %M 30684401 %R 10.2196/formative.7211 %U http://formative.jmir.org/2017/1/e2/ %U https://doi.org/10.2196/formative.7211 %U http://www.ncbi.nlm.nih.gov/pubmed/30684401 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 8 %P e161 %T Engaging Adolescents to Inform the Development of a Mobile Gaming App to Incentivize Physical Activity %A Pope,Lizzy %A Garnett,Bernice %A Dibble,Marguerite %+ University of Vermont, 533 Waterman Building, 85 South Prospect St, Burlington, VT, 05405, United States, 1 802 656 2187, bgarnett@uvm.edu %K adolescents %K qualitative research %K mHealth %K physical activity %D 2017 %7 29.08.2017 %9 Short Paper %J JMIR Res Protoc %G English %X Background: Involving youth in the development of a mobile game designed to increase physical activity may increase relevancy and adoption. Objective: To share the development process used to create a gaming app aimed at incentivizing physical activity in high school students. Methods: Five focus groups were conducted with high school students (N=50) to understand gaming behaviors. A subset of students from the focus groups chose to complete a Web-based survey (N=10). Four different versions of gaming artwork and concept design based on student input were pilot tested (N=35), and group consensus building determined the direction of the game. The 4 game versions differed in their artwork style and gaming concept with some requiring competition versus cooperation, or being more individual versus team based. Group consensus building meant that all artwork and game concept options were displayed at the front of a classroom. Students could then vote for their top artwork and concept choices by putting stickers on the top 1 or 2 artwork and concept options that they liked best. Once all votes were cast, investigators discussed the voting results with students, and brainstormed ways to incorporate popular aspects of the 3 “losing” artwork and game concepts into the winning ideas. Results: Focus group transcripts were analyzed for common themes. Artwork and gaming concept-voting data was tallied at the time of voting to share with students in real time. Focus groups and survey results revealed important themes for a successful gaming app: (1) competition, (2) balanced in-game rewards, (3) accessibility, and (4) aesthetic features. Consensus voting indicated the popularity of a collaborative competitive content design (35/66, 53%) and playful art (27/71, 38%). Conclusions: To ensure saliency and effectiveness of game-based physical activity interventions, youth need to be included in design and implementation. Furthermore, the unique preferences and social constructs of high school students need to be considered during intervention development. %M 28851676 %R 10.2196/resprot.8113 %U http://www.researchprotocols.org/2017/8/e161/ %U https://doi.org/10.2196/resprot.8113 %U http://www.ncbi.nlm.nih.gov/pubmed/28851676 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 1 %N 1 %P e1 %T The Impact of Participant Characteristics on Use and Satisfaction of a Web-Based Computer-Tailored Chronic Obstructive Pulmonary Disease Self-Management Intervention: A Process Evaluation %A Voncken-Brewster,Viola %A Amoureus,Mylène %A de Vries,Hein %A Nagykaldi,Zsolt %A Winkens,Bjorn %A van der Weijden,Trudy %A Tange,Huibert %+ Department of Family Medicine, Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht University, PO Box 616, Maastricht,, Netherlands, 31 43 388 2230, viola.voncken@maastrichtuniversity.nl %K Internet intervention %K computer tailoring %K application use %K participant characteristics %K COPD %K self-management %K behavior change %K process evaluation %D 2017 %7 21.08.2017 %9 Original Paper %J JMIR Formativ Res %G English %X Background: A randomized controlled trial (RCT) showed that a Web-based computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease (COPD) did not have a significant treatment effect. Process evaluation measures such as application use and satisfaction with the intervention can help understand these results. Objectives: The aim of this paper is to uncover reasons for suboptimal application use, evaluate satisfaction with the intervention, and investigate which participant characteristics predict application use and user satisfaction. Methods: Participants were recruited through 2 different channels: an online panel and general practice. The intervention group received the intervention, which consisted of 2 modules (smoking cessation and physical activity). The control group received no intervention. The study employed a mixed methods design. Quantitative and qualitative data were gathered assessing participant characteristics, application use, reasons for not using the application, and satisfaction with the intervention. Results: The RCT included 1325 participants. The proportion of individuals who participated was significantly higher in the online group (4072/6844, 59.5%) compared to the general practice group (43/335, 12.8%) (P<.001). Application use was low. Of all participants in the intervention group, 52.9% (348/658) initiated use of one or both modules, 36.0% (237/658) completed an intervention component (prolonged use), and 16.6% (109/658) revisited one of the modules after completing an intervention component (sustained use). Older age, established diagnosis of COPD, or experiencing breathlessness predicted sustained use. Participant satisfaction with the 2 modules was 6.7 (SD 1.6) on a scale from 0 to 10. The interviews revealed that a computer application was believed not to be sufficient and the help of a health care professional was necessary. Participants with a greater intention to change were more satisfied with the application. Conclusions: The application was not used sufficiently. Study materials should be further tailored to younger individuals, those at risk for COPD, and those who do not experience breathlessness in order to increase sustained use among them. Involvement of a health care professional could improve satisfaction with the intervention and potentially increase engagement with the intervention materials. However, to make this possible, recruitment in general practice needs to be improved. Recommendations are made for improving the study design, strengthening the intervention (eg, practice facilitation), and linking the computer application to interaction with a health care provider. %M 30684399 %R 10.2196//formative.6585 %U https://formative.jmir.org/2017/1/e1/ %U https://doi.org/10.2196//formative.6585 %U http://www.ncbi.nlm.nih.gov/pubmed/30684399