%0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e17858 %T Adequate Management of Phosphorus in Patients Undergoing Hemodialysis Using a Dietary Smartphone App: Prospective Pilot Study %A Fakih El Khoury,Cosette %A Crutzen,Rik %A Schols,Jos MGA %A Halfens,Ruud JG %A Karavetian,Mirey %+ Department of Health Sciences, Zayed University, Academic city PO Box 19282, Dubai, United Arab Emirates, 971 562446865, kmirey@gmail.com %K renal diet %K mhealth %K dietary app %D 2021 %7 1.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The renal diet is complex and requires alterations of the diet and careful monitoring of various nutrients. Elevated serum phosphorus is common among patients undergoing hemodialysis, and it is associated with many complications. Smartphone technology could be used to support both dietitians and patients by providing a source of accessible and reliable information. Objective: The aim of this pilot is to assess the potential efficacy of an intervention using the educational and self-monitoring mobile app KELA.AE on the phosphorous management in hemodialysis patients. Results will be used to improve both the app and a planned, rigorous large-scale trial intended to assess app efficacy. Methods: This is a prospective pilot study performed at the hemodialysis unit of Al Qassimi Hospital (Emirate of Sharjah, United Arab Emirates). All patients were assessed for eligibility and, based on inclusion criteria, considered for enrollment. Participants met with a dietitian once a week and used the mobile app regularly for 2 weeks. Outcomes (knowledge, self-reported nonadherence, dietary intake, anthropometry, and biochemical data) were measured. This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT (Consolidated Standards of Reporting Trials) 2010 checklist for reporting pilot or feasibility trials. Results: Of 26 subjects, 23 successfully completed the pilot. Patient dietary knowledge about phosphorous management improved from 51.4% (SD 13.9) to 68.1% (SD 13.3) after intervention with a large effect size (d=1.22, 95% CI 0.59 to 1.85). Dietary protein intake increased from a mean of 0.9 g/kg (SD 0.3) per day to a mean of 1.3 g/kg (SD 0.5) per day with a large effect size (d=1.07, 95% CI 0.45 to 1.69). Phosphorus to protein ratio dropped from a mean of 18.4 mg/g protein to 13.5 mg/g protein with a large effect size (d=0.83, 95% CI 0.22 to 1.43). There was no evidence of change in phosphorous intake, self-reported nonadherence, and serum phosphorus. Conclusions: The findings of this prospective pilot reveal the potential efficacy of a smartphone app as a supportive nutrition education tool for phosphorus management in patients undergoing hemodialysis. This pilot study showed that the KELA.AE app has the potential to improve knowledge and dietary choices. A rigorous randomized controlled trial should be performed to evaluate the efficacy, assessing app use of a long-term intervention. %M 34061034 %R 10.2196/17858 %U https://formative.jmir.org/2021/6/e17858 %U https://doi.org/10.2196/17858 %U http://www.ncbi.nlm.nih.gov/pubmed/34061034 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e22970 %T Using a Mobile App–Based Video Recommender System of Patient Narratives to Prepare Women for Breast Cancer Surgery: Development and Usability Study Informed by Qualitative Data %A Ormel,Ilja %A Onu,Charles C %A Magalhaes,Mona %A Tang,Terence %A Hughes,John B %A Law,Susan %+ Department of Family Medicine, McGill University, 5858 Côte-des-Neiges Rd, Montréal, QC, H2T 1W1, Canada, 1 (514) 345 3511 ext 5060, ilja.ormel@mail.mcgill.ca %K qualitative research %K illness narratives %K experiential information %K breast cancer %K surgery %K tailored information %K recommender system %K patient information and communication %K mobile app %K mobile phone %D 2021 %7 2.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Women diagnosed with breast cancer are often bombarded with information. Such information overload can lead to misunderstandings and hamper women’s capacity for making informed decisions about their care. For women with breast cancer, this uncertainty is particularly severe in the period before surgery. Personalized narratives about others’ experiences can help patients better understand the disease course, the quality and type of care to be expected, the clinical decision-making processes, and the strategies for coping. Existing resources and eHealth apps rarely include experiential information, and no tools exist that tailor information for individual preferences and needs—offering the right information at the right time and in the right format. Combining high-quality experiential evidence with novel technical approaches may contribute to patient-centered solutions in this area. Objective: This study aims to design and seek preliminary feedback on a mobile app that will improve information access about surgery for patients with breast cancer, by drawing on a qualitative collection of personal narratives from a diverse sample of Canadian women and using video and audio recordings or audio recordings from the Canadian Health Experiences Research Network. Methods: In a previous study, we conducted in-depth interviews with 35 Canadian women and used video and audio recordings or audio recordings to collect stories about the lived experiences of breast cancer. The participants highlighted the need for more specific information between diagnosis and surgery that was relevant to their personal situations and preferences. They also wanted to learn from other women’s experiences. We worked with patients, clinicians, and informatics experts to develop a mobile app that provides access to tailored experiential information relevant to women’s personal situations and preferences. We completed focus groups and qualitative interviews, conducted a further analysis of the original qualitative data, designed novel software using artificial intelligence, and sought preliminary feedback from users on a new app via focus groups and a survey. Results: The secondary analysis of the breast cancer narratives revealed key themes and their interconnections relevant to the experience of surgery, including preparation, treatment decisions, aftercare, reconstruction, prostheses, lumpectomy and mastectomy, and complications. These themes informed the development of the structure and content of the app. We developed a recommender system within the app by using content matching (user and speaker profiles and user interests and video content) and collaborative filtering to identify clips marked as relevant by the user and by similar users. A 2-minute animated introductory video for users was developed. Pilot testing revealed generally positive responses regarding the content and value of this type of e-tool. Conclusions: Developing reliable, evidence-based tools and apps that are based on diverse collections of people’s experiences of illness offers a novel approach to help manage the plethora of information that women face after a diagnosis of breast cancer. %M 34076582 %R 10.2196/22970 %U https://formative.jmir.org/2021/6/e22970 %U https://doi.org/10.2196/22970 %U http://www.ncbi.nlm.nih.gov/pubmed/34076582 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e24937 %T Multicultural Adaptation of Mighty Girls for Widespread Dissemination: Pilot Study, App Development and Usability Testing, and Gauging Parent Support With Focus Groups %A Norris,Anne E %A Thalasinos,Roxana Delcampo %A Hecht,Michael L %+ REAL Prevention, LLC, 817 Kingsbridge Dr, Oviedo, FL, 32765, United States, 1 4074161727, anne@real-prevention.com %K implementation science %K mobile apps %K peer influence %K early intervention %K adolescent health %D 2021 %7 2.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Taking evidence-based interventions to scale is a challenge for prevention science. Mighty Girls is an evidence-based sexual health intervention program that combines classroom sessions with novel, cutting-edge technology (digital puppetry). The program was developed for 7th grade Latinas, but US school and community demographics rarely allow interventions targeting a single ethnic group. Additionally, digital puppetry is costly to scale up, and parent disapproval often prevents successful dissemination of adolescent sexual health programs. Intervening steps along the scaling-up pathway are needed to adapt the program prior to scaling up for dissemination. Objective: The aims of this study were to create a multicultural adaptation of the Mighty Girls program using a mobile app that is less costly to disseminate and is acceptable to parents of 7th grade girls. Methods: This study used a three-phase process to adapt Mighty Girls into Mighty Teens. All phases used purposive (nonprobability) sampling of low-income, multicultural, urban metropolitan groups (7th grade girls and their parents) within central Florida. Phase 1 involved two videotaped implementations of a multicultural adaptation of the classroom sessions, one involving focus groups (N=14) and the other serving as a single-group pretest-posttest pilot study (N=23). Phase 2 involved development of a narrative cell phone app prototype, which was subjected to usability testing (N=25). App usability and engagement were assessed qualitatively (observation, focus group, open-ended questions) and quantitatively. Phase 3 used focus groups to assess parent support for the program (N=6). Qualitative data were analyzed using descriptive content analysis. Quantitative data were analyzed using descriptive statistics and paired t tests. Results: Qualitative findings supported classroom sessions being multicultural, and identified simple changes to improve engagement and learning. Quantitative findings from the second classroom session implementation pilot study indicated a significant pre-post difference in intention to delay sexual intercourse (P=.04). App usability and appeal were supported by a System Usability Scale score of 76 (exceeding 68 per the industry standard) and 83% (20/24) of participants agreeing they would recommend the app to friends. Parents (mothers) expressed only positive regard for program goals, and classroom session and app activities. Conclusions: This study adapted Mighty Girls into an engaging, easier-to-disseminate, multicultural program, termed Mighty Teens, that uses a narrative-generating app to support behavior change, and is likely to be accepted by parents of 7th grade girls. This study also provides evidence of the preliminary effectiveness of Mighty Teens classroom sessions. The sampling method and sample size were appropriate for adaptation, but research involving a more representative US sample is needed to confirm multicultural fit, parent receptivity, and program effectiveness. Study implications include integrating app use throughout the classroom sessions to build narrative-generating skills across the program and increasing the number of narratives produced, which should in turn increase the program’s behavior change potency. %M 34076578 %R 10.2196/24937 %U https://formative.jmir.org/2021/6/e24937 %U https://doi.org/10.2196/24937 %U http://www.ncbi.nlm.nih.gov/pubmed/34076578 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e24509 %T Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre–Post Study %A Ho,Kendall %A Novak Lauscher,Helen %A Cordeiro,Jennifer %A Hawkins,Nathaniel %A Scheuermeyer,Frank %A Mitton,Craig %A Wong,Hubert %A McGavin,Colleen %A Ross,Dianne %A Apantaku,Glory %A Karim,Mohammad Ehsan %A Bhullar,Amrit %A Abu-Laban,Riyad %A Nixon,Suzanne %A Smith,Tyler %+ Digital Emergency Medicine, University of British Columbia, 818 West 10th Avenue, 2329 West Mall, Vancouver, BC, V6T 1Z4, Canada, 1 604 822 0327, kendall.ho@ubc.ca %K telemonitoring %K heart failure %K home health monitoring %K technology %K telehealth %K emergency care %K community care %K emergency department %K quality of life %K self-efficacy %D 2021 %7 3.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Patients with heart failure (HF) can be affected by disabling symptoms and low quality of life. Furthermore, they may frequently need to visit the emergency department or be hospitalized due to their condition deteriorating. Home telemonitoring can play a role in tracking symptoms, reducing hospital visits, and improving quality of life. Objective: Our objective was to conduct a feasibility study of a home health monitoring (HHM) solution for patients with HF in British Columbia, Canada, to prepare for conducting a randomized controlled trial. Methods: Patients with HF were recruited from 3 urban hospitals and provided with HHM technology for 60 days of monitoring postdischarge. Participants were asked to monitor their weight, blood pressure, and heart rate and to answer symptomology questions via Bluetooth sensors and a tablet computer each day. A monitoring nurse received this data and monitored the patient’s condition. In our evaluation, the primary outcome was the combination of unscheduled emergency department revisits of discharged participants or death within 90 days. Secondary outcomes included 90-day hospital readmissions, patient quality of life (as measured by Veterans Rand 12-Item Health Survey and Kansas City Cardiomyopathy Scale), self-efficacy (as measured by European Heart Failure Self-Care Behaviour Scale 9), end-user experience, and health system cost-effectiveness including cost reduction and hospital bed capacity. In this feasibility study, we also tested the recruitment strategy, clinical protocols, evaluation framework, and data collection methods. Results: Seventy participants were enrolled into this trial. Participant engagement to monitoring was measured at 94% (N=70; ie, data submitted 56/60 days on average). Our evaluation framework allowed us to collect sound data, which also showed encouraging trends: a 79% reduction of emergency department revisits post monitoring, an 87% reduction in hospital readmissions, and a 60% reduction in the median hospital length of stay (n=36). Cost of hospitalization for participants decreased by 71%, and emergency department visit costs decreased by 58% (n=30). Overall health system costs for our participants showed a 56% reduction post monitoring (n=30). HF-specific quality of life (Kansas City Cardiomyopathy Scale) scores showed a significant increase of 101% (n=35) post monitoring (P<.001). General quality of life (Veterans Rand 12-Item Health Survey) improved by 19% (n=35) on the mental component score (P<.001) and 19% (n=35) on the physical component score (P=.02). Self-efficacy improved by 6% (n=35). Interviews with participants revealed that they were satisfied overall with the monitoring program and its usability, and participants reported being more engaged, educated, and involved in their self-management. Conclusions: Results from this small-sample feasibility study suggested that our HHM intervention can be beneficial in supporting patients post discharge. Additionally, key insights from the trial allowed us to refine our methods and procedures, such as shifting our recruitment methods to in-patient wards and increasing our scope of data collection. Although these findings are promising, a more rigorous trial design is required to test the true efficacy of the intervention. The results from this feasibility trial will inform our next step as we proceed with a randomized controlled trial across British Columbia. Trial Registration: ClinicalTrials.gov NCT03439384; https://clinicaltrials.gov/ct2/show/NCT03439384 %M 34081015 %R 10.2196/24509 %U https://formative.jmir.org/2021/6/e24509 %U https://doi.org/10.2196/24509 %U http://www.ncbi.nlm.nih.gov/pubmed/34081015 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e23118 %T Expanding the Reach of Research: Quantitative Evaluation of a Web-Based Approach for Remote Recruitment of People Who Hear Voices %A Buck,Benjamin %A Chander,Ayesha %A Brian,Rachel M %A Wang,Weichen %A Campbell,Andrew T %A Ben-Zeev,Dror %+ Behavioral Research in Technology and Engineering (BRiTE) Center, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 206 221 8518, buckbe@uw.edu %K digital health %K research procedures %K recruitment %K mobile phone %D 2021 %7 3.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Similar to other populations with highly stigmatized medical or psychiatric conditions, people who hear voices (ie, experience auditory verbal hallucinations [AVH]) are often difficult to identify and reach for research. Technology-assisted remote research strategies reduce barriers to research recruitment; however, few studies have reported on the efficiency and effectiveness of these approaches. Objective: This study introduces and evaluates the efficacy of technology-assisted remote research designed for people who experience AVH. Methods: Our group developed an integrated, automated and human complementary web-based recruitment and enrollment apparatus that incorporated Google Ads, web-based screening, identification verification, hybrid automation, and interaction with live staff. We examined the efficacy of that apparatus by examining the number of web-based advertisement impressions (ie, number of times the web-based advertisement was viewed); clicks on that advertisement; engagement with web-based research materials; and the extent to which it succeeded in representing a broad sample of individuals with AVH, assessed through the self-reported AVH symptom severity and demographic representativeness (relative to the US population) of the sample recruited. Results: Over an 18-month period, our Google Ads advertisement was viewed 872,496 times and clicked on 11,183 times. A total amount of US $4429.25 was spent on Google Ads, resulting in 772 individuals who experience AVH providing consent to participate in an entirely remote research study (US $0.40 per click on the advertisement and US $5.73 per consented participant) after verifying their phone number, passing a competency screening questionnaire, and providing consent. These participants reported high levels of AVH frequency (666/756, 88.1% daily or more), distress (689/755, 91.3%), and functional interference (697/755, 92.4%). They also represented a broad sample of diversity that mirrored the US population demographics. Approximately one-third (264/756, 34.9%) of the participants had never received treatment for their AVH and, therefore, were unlikely to be identified via traditional clinic-based research recruitment strategies. Conclusions: Web-based procedures allow for time saving, cost-efficient, and representative recruitment of individuals with AVH and can serve as a model for future studies focusing on hard-to-reach populations. %M 34081011 %R 10.2196/23118 %U https://formative.jmir.org/2021/6/e23118 %U https://doi.org/10.2196/23118 %U http://www.ncbi.nlm.nih.gov/pubmed/34081011 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25687 %T Racial Discrimination, Sedentary Time, and Physical Activity in African Americans: Quantitative Study Combining Ecological Momentary Assessment and Accelerometers %A Nam,Soohyun %A Jeon,Sangchoon %A Ash,Garrett %A Whittemore,Robin %A Vlahov,David %+ School of Nursing, Yale University, 400 West Campus Dr, West Haven, CT, 06516, United States, 1 203 737 2822, soohyun.nam@yale.edu %K racial discrimination %K physical activity %K ecological momentary assessment %K African American %K pilot study %K mobile phone %D 2021 %7 7.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: A growing number of studies indicate that exposure to social stress, such as perceived racial discrimination, may contribute to poor health, health behaviors, and health disparities. Increased physical activity (PA) may buffer the impact of social stress resulting from racial discrimination. However, to date, data on the relationship between racial discrimination and PA have been mixed. Part of the reason is that the effect of perceived racial discrimination on PA has primarily been examined in cross-sectional studies that captured retrospective measures of perceived racial discrimination associated with individuals’ current PA outcomes. The association between real-time perceived racial discrimination and PA among African Americans remains unclear. Objective: The purpose of this study is to examine the relationship among demographic, anthropometric and clinical, and psychological factors with lifetime racial discrimination and examine the within- and between-person associations between daily real-time racial discrimination and PA outcomes (total energy expenditure, sedentary time, and moderate-to-vigorous PA patterns) measured by ecological momentary assessment (EMA) and accelerometers in healthy African Americans. Methods: This pilot study used an intensive, observational, case-crossover design of African Americans (n=12) recruited from the community. After participants completed baseline surveys, they were asked to wear an accelerometer for 7 days to measure their PA levels. EMA was sent to participants 5 times per day for 7 days to assess daily real-time racial discrimination. Multilevel models were used to examine the within- and between-person associations of daily racial discrimination on PA. Results: More EMA-reported daily racial discrimination was associated with younger age (r=0.75; P=.02). Daily EMA-reported microaggression was associated with depressive symptoms (r=0.66; P=.05), past race-related events (r=0.82; P=.004), and lifetime discrimination (r=0.78; P=.01). In the within-person analyses, the day-level association of racial discrimination and sedentary time was significant (β=.30, SE 0.14; P=.03), indicating that on occasions when participants reported more racial discrimination than usual, more sedentary time was observed. Between-person associations of racial discrimination (β=−.30, SE 0.28; P=.29) or microaggression (β=−.34, SE 0.36; P=.34) with total energy expenditure were suggestive but inconclusive. Conclusions: Concurrent use of EMA and accelerometers is a feasible method to examine the relationship between racial discrimination and PA in real time. Examining daily processes at the within-person level has the potential to elucidate the mechanisms of which racial discrimination may have on health and health behaviors and to guide the development of personalized interventions for increasing PA in racial ethnic minorities. Future studies with a precision health approach, incorporating within- and between-person associations, are warranted to further elucidate the effects of racial discrimination and PA. International Registered Report Identifier (IRRID): RR2-10.1002/nur.22068 %M 34096870 %R 10.2196/25687 %U https://formative.jmir.org/2021/6/e25687 %U https://doi.org/10.2196/25687 %U http://www.ncbi.nlm.nih.gov/pubmed/34096870 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e28055 %T Multimodule Web-Based COVID-19 Anxiety and Stress Resilience Training (COAST): Single-Cohort Feasibility Study With First Responders %A Heyen,Janna Marie %A Weigl,Noé %A Müller,Mario %A Müller,Stefan %A Eberle,Urs %A Manoliu,Andrei %A Vetter,Stefan %A Brown,Adam D %A Berger,Thomas %A Kleim,Birgit %+ Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Lenggstrasse 31, PO Box 1931, Zürich, CH-8032, Switzerland, 41 (0)44 384 21 11, birgit.kleim@pukzh.ch %K anxiety %K COVID-19 %K electronic mental health %K feasibility %K first responder %K mental health %K mindfulness %K resilience %K self-efficacy %K sleep quality %K stress %K training %D 2021 %7 7.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Since the emergence of COVID-19, health care workers and first responders have been at a high risk for mental health symptoms owing to their exposure to the virus and increased work stress during the pandemic. Although interventions exist to address mental health issues following exposure to disasters, emergencies, and humanitarian crises, considerably less is known about web-based unguided interventions to help mitigate the negative impacts of such events. Additionally, in contexts in which emergencies reduce access to in-person care, remote forms of support are critical, yet there are limited studies on the use of such interventions. Evidence-based, easy-to-use, scalable interventions are direly needed for this population. Objective: This study aimed to develop and test the feasibility of an unguided electronic mental health program, COVID-19 Anxiety and Stress Resilience Training (COAST), tailored to first responders and health care personnel, based on scientific evidence and empirically based techniques. Methods: We developed COVID-19–specific training modules focusing on several domains that are previously reported as key to resilience and stress recovery: self-efficacy, mindfulness, sleep quality, and positive thinking. The program was made available to 702 first responders between May and August 2020, during the COVID-19 pandemic. Sociodemographic, work-, and COVID-19–related information was collected, and psychometric questionnaires were completed. We examined user acceptance and user activity, including module choice and participant feedback. Results: In total, 52 of 702 (7%) first responders to whom we reached out used the program at least once. COAST use was independent of age, sex, or baseline levels of self-efficacy, mindful awareness, sleep quality, and positive thinking (for all, P>.39). First responders who had tested positive and those who had been quarantined were more likely to engage in the program. A click count analysis per module showed that participants used the self-efficacy and mindfulness modules most often, with 382 and 122 clicks, respectively, over 15 weeks. Overall, first responders expressed satisfaction with the program. Conclusions: Engagement of first responders in the multimodule web-based COAST program was feasible and the first responder cohort expressed overall satisfaction with the program. Those in more difficult circumstances, including those in quarantine and those who tested positive, may be more likely to engage in such programs. Further controlled studies could pave the way for efficacy studies and the development of additional modules, including just-in-time interventions or blended interventions combining individual use of an unguided self-help intervention, such as COAST, with subsequent individual psychotherapy for those who continue to experience stress and psychological symptoms. %M 33999835 %R 10.2196/28055 %U https://formative.jmir.org/2021/6/e28055 %U https://doi.org/10.2196/28055 %U http://www.ncbi.nlm.nih.gov/pubmed/33999835 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e27280 %T Development of the 12-Item Social Media Disinformation Scale and its Association With Social Media Addiction and Mental Health Related to COVID-19 in Tunisia: Survey-Based Pilot Case Study %A Guelmami,Noomen %A Ben Khalifa,Maher %A Chalghaf,Nasr %A Kong,Jude Dzevela %A Amayra,Tannoubi %A Wu,Jianhong %A Azaiez,Fairouz %A Bragazzi,Nicola Luigi %+ Department of Mathematics and Statistics, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada, 1 2818392210, robertobragazzi@gmail.com %K COVID-19 pandemic %K media disinformation %K social media addiction %K mental health %K scale validation %D 2021 %7 9.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: In recent years, online disinformation has increased. Fake news has been spreading about the COVID-19 pandemic. Since January 2020, the culprits and antidotes to disinformation have been digital media and social media. Objective: Our study aimed to develop and test the psychometric properties of the 12-item Social Media Disinformation Scale (SMDS-12), which assesses the consumption, confidence, and sharing of information related to COVID-19 by social media users. Methods: A total of 874 subjects were recruited over two phases: the exploratory phase group had a mean age of 28.39 years (SD 9.32) and the confirmatory phase group had a mean age of 32.84 years (SD 12.72). Participants completed the SMDS-12, the Internet Addiction Test, the COVID-19 Fear Scale, and the 10-item Perceived Stress Scale. The SMDS-12 was initially tested by exploratory factor analysis and was subsequently tested by confirmatory factor analysis. Results: The test supported the three-factor structure. In addition, no items were removed from the measurement scale, with three factors explaining up to 73.72% of the total variance, and the items had a lambda factor loading ranging from 0.73 to 0.85. Subsequently, confirmatory factor analysis confirmed the robustness of the measure by referring to a wide range of goodness-of-fit indices that met the recommended standards. The construct validity of the scale was supported by its convergent and discriminant validity. The reliability of the instrument examined by means of three internal consistency indices, and the corrected item-total correlation, demonstrated that the three dimensions of the instrument were reliable: Cronbach α values were .89, .88, and .88 for the consumption, confidence, and sharing subscales, respectively. The corrected item-total correlation ranged from 0.70 to 0.78. The correlation of the instrument’s dimensions with internet addiction and mental health factors showed positive associations. Conclusions: The SMDS-12 can be reliably utilized to measure the credibility of social media disinformation and can be adapted to measure the credibility of disinformation in other contexts. %M 34021742 %R 10.2196/27280 %U https://formative.jmir.org/2021/6/e27280 %U https://doi.org/10.2196/27280 %U http://www.ncbi.nlm.nih.gov/pubmed/34021742 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e23884 %T Perceptions of Endocrine Therapy in African-American Breast Cancer Survivors: Mixed Methods Study %A Donevant,Sara %A Heiney,Sue P %A Wineglass,Cassandra %A Schooley,Benjamin %A Singh,Akanksha %A Sheng,Jingxi %+ College of Nursing, University of South Carolina, 1601 Greene Street, Columbia, SC, 29208, United States, 1 803 777 7672, Donevant@mailbox.sc.edu %K mHealth %K breast cancer survivors %K medication adherence %K cultural considerations %K mobile health applications %D 2021 %7 11.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Although the incidence of breast cancer is lower in African-American women than in White women, African-American women have a decreased survival rate. The difference in survival rate may stem from poor endocrine therapy adherence, which increases breast cancer recurrence. Therefore, accessible and culturally sensitive interventions to increase endocrine therapy adherence are necessary. Objective: The purpose of this concurrent convergent mixed methods study was to provide further data to guide the development of the proposed culturally sensitive mHealth app, STORY+ for African-American women with breast cancer. Methods: We recruited 20 African-American women diagnosed with estrogen-positive breast cancer and currently prescribed endocrine therapy. We used a concurrent convergent data collection method to (1) assess the use of smartphones and computers related to health care and (2) identify foundational aspects to support endocrine therapy adherence for incorporation in a mobile health app. Results: Overwhelmingly, the participants preferred using smartphones to using computers for health care. Communicating with health care providers and pharmacies was the most frequent health care use of smartphones, followed by exercise tracking, and accessing the patient portal. We identified 4 aspects of adherence to endocrine therapy and smartphone use for incorporation in app development. The factors that emerged from the integrated qualitative and quantitative data were (1) willingness to use, (2) side effects, (3) social connection, and (4) beliefs about endocrine therapy. Conclusions: Further research is needed to develop a culturally sensitive app for African-American women with breast cancer to improve adherence to endocrine therapy. Our work strongly suggests that this population would use the app to connect with other African-American breast cancer survivors and manage endocrine therapy. %M 34114955 %R 10.2196/23884 %U https://formative.jmir.org/2021/6/e23884 %U https://doi.org/10.2196/23884 %U http://www.ncbi.nlm.nih.gov/pubmed/34114955 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e26417 %T A 5-Minute Cognitive Assessment for Safe Remote Use in Patients With COVID-19: Clinical Case Series %A Beresford,Thomas %A Ronan,Patrick J %A Hipp,Daniel %+ Laboratory for Clinical and Translational Research in Psychiatry, Rocky Mountain Regional VA Medical Center, (116), 1700 North Wheeling Street, Aurora, CO, 80045, United States, 1 7207237374, thomas.beresford@ucdenver.edu %K cognition %K COVID-19 %K safety %K remote use %K delirium %K brain injury, brain %K diagnosis %K assessment %K test %K telehealth %K telemedicine %D 2021 %7 14.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Early clinical experience during the COVID-19 pandemic has begun to elucidate that the disease can cause brain function changes that may result in compromised cognition both acutely and during variable recovery periods. Reports on cognitive assessment of patients with COVID-19 are often limited to orientation alone. Further assessment may seem to create an inappropriate burden for patients with acute COVID-19, which is characterized by fatigue and confusion, and may also compromise examiner safety. Objective: The aims of this study were to assess cognition in patients with COVID-19 as comprehensively as possible in a brief format, while observing safety precautions, and to establish a clear face value of the external validity of the assessment. Methods: We adapted a brief cognitive assessment, previously applied to liver transplant candidates and medical/surgical inpatients, for remote use in patients hospitalized for COVID-19 treatment. Collecting quality assurance data from telephone-administered assessments, this report presents a series of 6 COVID-19 case vignettes to illustrate the use of this 5-minute assessment in the diagnosis and treatment of brain effects. Primary medical teams referred the cases for neuropsychiatric consultation. Results: The age of the patients varied over four decades, and none of them were able to engage meaningfully with their surroundings on admission. On follow-up examination 6 to 10 days later, 4 of the 6 patients had recovered working memory, and only 1 had recovered calculation ability. Of the 6 patients, 2 were capable of complex judgment responses, while none of the cases completed frontal executive function testing in the normal range. Conclusions: Cognitive assessment in patients with COVID-19 using this remote examination reveals patterns of cognitive recovery that vary among cases and are far more complex than loss of orientation. In this series, testing of specific temporal, parietal, and frontal lobe functions suggests that calculation ability, judgment, and especially frontal executive functions may characterize the effects of COVID-19 on the brain. Used widely and serially, this examination method can potentially inform our understanding of the effects of COVID-19 on the brain and of healing from the virus. %M 34010137 %R 10.2196/26417 %U https://formative.jmir.org/2021/6/e26417 %U https://doi.org/10.2196/26417 %U http://www.ncbi.nlm.nih.gov/pubmed/34010137 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e24896 %T A Caregiver Digital Intervention to Support Shared Decision Making in Child and Adolescent Mental Health Services: Development Process and Stakeholder Involvement Analysis %A Liverpool,Shaun %A Edbrooke-Childs,Julian %+ Faculty of Health, Social Care & Medicine, Edge Hill University, St Helens Rd, Ormskirk, United Kingdom, 44 169 557 5171, shaun.liverpool.14@ucl.ac.uk %K digital health intervention %K caregivers %K parents %K child mental health %D 2021 %7 15.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Parents and caregivers are generally recognized by literature and the law as key to child and adolescent mental health decisions. Digital interventions are increasingly being used to support care and treatment in child and adolescent mental health services (CAMHS). However, evidence of the design and development process is generally not made available. Objective: In light of calls for more transparency, this paper aims to describe the development of an evidence-based, theoretically informed digital decision support intervention for parents and caregivers of young people accessing CAMHS. Methods: The intervention was developed in line with the UK Medical Research Council framework for developing complex interventions. The process incorporated the steps for developing patient decision aids, as follows: assessing need, assessing feasibility; defining objectives; identifying the framework of decision support; and selecting the methods, designs, and dissemination approach. We synthesized theory, research, international guidelines, and input from relevant stakeholders using an iterative design approach. Results: The development steps resulted in Power Up for Parents, a decision support intervention, with five key features (ie, decisions, goals, journey, support, and resources). The intervention aims to encourage discussion, allow parents to ask questions during sessions or seek further information between sessions, and allow service providers to tailor the shared decision-making process to accommodate the needs of the parent and child. Conclusions: We confirmed that it is possible to use input from end users—integrated with theory and evidence—to create digital interventions to be used in CAMHS. Key lessons with implications for practice, policy, and implementation science, along with preliminary findings, are presented. International Registered Report Identifier (IRRID): RR2-10.2196/14571 %M 34128821 %R 10.2196/24896 %U https://formative.jmir.org/2021/6/e24896 %U https://doi.org/10.2196/24896 %U http://www.ncbi.nlm.nih.gov/pubmed/34128821 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e26195 %T An mHealth Physical Activity Intervention for Latina Adolescents: Iterative Design of the Chicas Fuertes Study %A Larsen,Britta %A Greenstadt,Emily D %A Olesen,Brittany L %A Marcus,Bess H %A Godino,Job %A Zive,Michelle M %+ Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, 9500 Gilman Dr., San Diego, CA, United States, 1 8585348429, blarsen@ucsd.edu %K mobile health %K human-centered design %K qualitative research %K adolescent health %K health disparities %K mobile phone %D 2021 %7 15.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Only 3% of Latina teens meet the national physical activity (PA) guidelines, and these habits appear to persist into adulthood. Developing effective interventions to increase PA in Latina teens is necessary to prevent disease and reduce disparities. Mobile technologies may be especially appropriate for this population, but mobile health (mHealth) intervention content must be designed in collaboration with the target population. Objective: This study aims to develop an mHealth PA intervention for Latina adolescents using a multistage iterative process based on the principles of human-centered design and multiple iterations of the design phase of the IDEAS (Integrate, Design, Assess, Share) framework. Methods: On the basis of the feedback from a previous pilot study, the planned intervention included visual social media posts and text messaging, a commercial wearable tracker, and a primarily visual website. The development of the requested mHealth intervention components was accomplished through the following 2 phases: conducting focus groups with the target population and testing the usability of the final materials with a youth advisory board (YAB) comprising Latina adolescents. Participants for focus groups (N=50) were girls aged 13-18 years who could speak and read in English and who were recruited from local high schools and after-school programs serving a high proportion of Latinos. Facilitated discussions focused on experience with PA and social media apps and specific feedback on intervention material prototypes and possible names and logos. Viable products were designed based on their feedback and then tested for usability by the YAB. YAB members (n=4) were Latinas aged 13-18 years who were not regularly active and were recruited via word of mouth and selected through an application process. Results: The focus group discussions yielded the following findings: PA preferences included walking, running, and group fitness classes, whereas the least popular activities were running, swimming, and biking. Most participants (n=48, 96%) used some form of social media, with Instagram being the most favored. Participants preferred text messages to be sent no more than once per day, be personalized, and be positively worded. The focus group participants preferred an intervention directly targeting Latinas and social media posts that were brightly colored, included girls of all body types, and provided specific tips and information. Modified intervention materials were generally perceived favorably by the YAB members, who provided suggestions for further refinement, including the shortening of texts and the incorporation of some Spanish phrases. Conclusions: Latina teens were generally enthusiastic about an mHealth PA intervention, provided that the materials were targeted specifically to them and their preferences. Through multiple iterations of development and feedback from the target population, we gained insight into the needs of Latina teens and joined with industry partners to build a viable final product. %M 34128823 %R 10.2196/26195 %U https://formative.jmir.org/2021/6/e26195 %U https://doi.org/10.2196/26195 %U http://www.ncbi.nlm.nih.gov/pubmed/34128823 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25151 %T Comparing Two Commercially Available Diabetes Apps to Explore Challenges in User Engagement: Randomized Controlled Feasibility Study %A Maharaj,Alita %A Lim,David %A Murphy,Rinki %A Serlachius,Anna %+ Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, 22-30 Park Avenue, Grafton, Auckland, 1023, New Zealand, 64 9 923 3073, a.serlachius@auckland.ac.nz %K type 2 diabetes %K mobile apps %K diabetes %K self-management %K user engagement %K app %K mHealth %K randomized controlled trial %K intervention %K efficacy %D 2021 %7 16.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Diabetes apps represent a promising addition to face-to-face self-management interventions, which can be time and resource intensive. However, few randomized controlled trials have evaluated the efficacy of diabetes apps, in particular as a stand-alone intervention without additional clinical support. Objective: We used a feasibility randomized trial design to investigate differences in user engagement between 2 commercially available apps (free versions of Glucose Buddy and mySugr) over 2 weeks in adults with type 2 diabetes. Feasibility was assessed based on recruitment uptake, adherence to the diabetes apps, and follow-up rates. We also hypothesized that the diabetes app mySugr would demonstrate higher user engagement at follow-up due to its use of gamification. We also predicted higher user engagement would be associated with improved self-care behaviors and illness beliefs. Methods: Adults with type 2 diabetes attending outpatient diabetes clinics in Auckland were recruited and randomized (1:1 without blinding) to use either the Glucose Buddy or mySugr diabetes apps. User engagement, self-care behaviors, and illness beliefs were measured 2 weeks after baseline. Spearman rank correlations, Mann-Whitney tests, and Wilcoxon signed-rank tests were used to explore associations between the outcome measures and to investigate possible changes between and within groups. Six participants were interviewed to further explore acceptability and usability. Results: In total, 58 participants (29 per group) completed the 2-week follow-up, of whom only 38 reported using the apps (Glucose Buddy: n=20; mySugr: n=18). Both groups reported low engagement (Glucose Buddy: median 4 days; mySugr: median 6.5 days; P=.06; use for both groups: median 10 minutes). No changes were observed in self-care or illness beliefs in either group. Out of the self-care behaviors, only blood glucose testing was significantly associated with minutes of app use (P=.02). The interviews suggested that although both apps were deemed acceptable, they were generally viewed as time-consuming and too complicated to use. Conclusions: Low engagement with both Glucose Buddy and mySugr reflect the challenges associated with engaging users with diabetes apps. Due to low engagement and loss to follow-up, the changes in outcome measures should be interpreted with caution. The results highlight the need for more clinical support as well as involvement from end users and behavior change specialists in order to incorporate evidence-based behavior change techniques to motivate and provide value to users. Trial Registration: Australia New Zealand Clinical Trials Registry ACTRN12618000424202; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374671 %M 34132640 %R 10.2196/25151 %U https://formative.jmir.org/2021/6/e25151 %U https://doi.org/10.2196/25151 %U http://www.ncbi.nlm.nih.gov/pubmed/34132640 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e26452 %T Inpatient Telemedicine Implementation as an Infection Control Response to COVID-19: Qualitative Process Evaluation Study %A Safaeinili,Nadia %A Vilendrer,Stacie %A Williamson,Emma %A Zhao,Zicheng %A Brown-Johnson,Cati %A Asch,Steven M %A Shieh,Lisa %+ Department of Medicine, School of Medicine, Stanford University, 1265 Welch Rd x216, Stanford, CA, 94305, United States, 1 8053001922, nadiasaf@stanford.edu %K telemedicine %K inpatient %K COVID-19 %K qualitative %K RE-AIM %K infection control %K personal protective equipment %K implementation science %K quality improvement %D 2021 %7 16.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic created new challenges to delivering safe and effective health care while minimizing virus exposure among staff and patients without COVID-19. Health systems worldwide have moved quickly to implement telemedicine in diverse settings to reduce infection, but little is understood about how best to connect patients who are acutely ill with nearby clinical team members, even in the next room. Objective: To inform these efforts, this paper aims to provide an early example of inpatient telemedicine implementation and its perceived acceptability and effectiveness. Methods: Using purposive sampling, this study conducted 15 semistructured interviews with nurses (5/15, 33%), attending physicians (5/15, 33%), and resident physicians (5/15, 33%) on a single COVID-19 unit within Stanford Health Care to evaluate implementation outcomes and perceived effectiveness of inpatient telemedicine. Semistructured interview protocols and qualitative analysis were framed around the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework, and key themes were identified using a rapid analytic process and consensus approach. Results: All clinical team members reported wide reach of inpatient telemedicine, with some use for almost all patients with COVID-19. Inpatient telemedicine was perceived to be effective in reducing COVID-19 exposure and use of personal protective equipment (PPE) without significantly compromising quality of care. Physician workflows remained relatively stable, as most standard clinical activities were conducted via telemedicine following the initial intake examination, though resident physicians reported reduced educational opportunities given limited opportunities to conduct physical exams. Nurse workflows required significant adaptations to cover nonnursing duties, such as food delivery and facilitating technology connections for patients and physicians alike. Perceived patient impact included consistent care quality, with some considerations around privacy. Reported challenges included patient–clinical team communication and personal connection with the patient, perceptions of patient isolation, ongoing technical challenges, and certain aspects of the physical exam. Conclusions: Clinical team members reported inpatient telemedicine encounters to be acceptable and effective in reducing COVID-19 exposure and PPE use. Nurses adapted their workflows more than physicians in order to implement the new technology and bore a higher burden of in-person care and technical support. Recommendations for improved inpatient telemedicine use include information technology support and training, increased technical functionality, and remote access for the clinical team. %M 34033576 %R 10.2196/26452 %U https://formative.jmir.org/2021/6/e26452 %U https://doi.org/10.2196/26452 %U http://www.ncbi.nlm.nih.gov/pubmed/34033576 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e24659 %T Professionals’ and Students’ Perceived Needs for an Online Supportive Application for Reducing School Absence and Stimulating Reintegration: Concept Mapping Study %A Hoogsteder,Mariette H H %A Douma,Linda N %A Eskens,Charlotte G A %A Berendsen,Renske L %A Vanneste,Yvonne T M %A Schaafsma,Frederieke G %+ Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers (UMC), Vrije Universiteit Amsterdam, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 20 4445965, m.hoogsteder@amsterdamumc.nl %K medical absenteeism %K secondary education %K eHealth %K mHealth %K mobile health %K students %K schools, health occupations %K youth health physicians %K concept mapping %D 2021 %7 21.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: To limit students’ medical absenteeism and premature school dropout in the Netherlands, the Medical Advice for Sick-reported Students (MASS) intervention was developed to enhance collaboration between students, parents, school, and health care professionals. MASS reduces medical absenteeism. However, it does not yet optimally support professionals in monitoring students nor automatically stimulating students’ autonomy regarding their situation. Objective: This study aimed to identify professionals’ and students’ perceived need for an online supportive application to monitor and reduce absenteeism and stimulate student autonomy and school reintegration. Methods: Concept mapping sessions were held with professionals (n=23) and secondary school students (n=27) in group meetings or online to identify their perspectives and needs. Multidimensional scaling and hierarchical clustering were done with Ariadne 3.0 software. The resulting concept maps were reclustered and interpreted by 4 researchers. Results: Three heterogeneous groups of professionals generated 17 clusters (135 unique statements), with a mean importance rating ranging from 2.9 to 4.6 on a Likert scale with scores ranging from 1 to 5. Three heterogeneous groups of secondary school students generated 18 clusters (95 unique statements), with a mean importance rating ranging from 3.2 to 4.6. Professionals considered as most important the following: easily accessible contact with students; supporting, motivating, and rewarding students; monitoring absent students; providing information to students and their parents; exchanging information between professionals. Students considered as most important the following: better teacher-student communication and respect; communication between school professionals on the one hand and parents, other professionals, and students on the other hand; guidance in missed learning materials and tests. Students perceived an online format for support as the obvious option. Conclusions: Both professionals and students were positive about an online application to support students in dealing with medical absenteeism, especially considering the need for better and easily accessible contact between students and professionals. An eHealth or mobile health (mHealth) application addressing these aspects could stimulate student autonomy and have positive effects on medical absenteeism. %M 34152275 %R 10.2196/24659 %U https://formative.jmir.org/2021/6/e24659 %U https://doi.org/10.2196/24659 %U http://www.ncbi.nlm.nih.gov/pubmed/34152275 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e26505 %T Modeling the Implementation Context of a Telemedicine Service: Work Domain Analysis in a Surgical Setting %A Aminoff,Hedvig %A Meijer,Sebastiaan %A Arnelo,Urban %A Groth,Kristina %+ Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Teknikringen 42, Stockholm, 11428, Sweden, 46 734606075, hedvigam@kth.se %K telemedicine %K telementoring %K implementation context %K surgical guidance %K health technology %K usability %K work domain analysis %K cognitive work analysis %D 2021 %7 21.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: A telemedicine service enabling remote surgical consultation had shown promising results. When the service was to be scaled up, it was unclear how contextual variations among different clinical sites could affect the clinical outcomes and implementation of the service. It is generally recognized that contextual factors and work system complexities affect the implementation and outcomes of telemedicine. However, it is methodologically challenging to account for context in complex health care settings. We conducted a work domain analysis (WDA), an engineering method for modeling and analyzing complex work environments, to investigate and represent contextual influences when a telemedicine service was to be scaled up to multiple hospitals. Objective: We wanted to systematically characterize the implementation contexts at the clinics participating in the scale-up process. Conducting a WDA would allow us to identify, in a systematic manner, the functional constraints that shape clinical work at the implementation sites and set the sites apart. The findings could then be valuable for informed implementation and assessment of the telemedicine service. Methods: We conducted observations and semistructured interviews with a variety of stakeholders. Thematic analysis was guided by concepts derived from the WDA framework. We identified objects, functions, priorities, and values that shape clinical procedures. An iterative “discovery and modeling” approach allowed us to first focus on one clinic and then readjust the scope as our understanding of the work systems deepened. Results: We characterized three sets of constraints (ie, facets) in the domain: the treatment facet, administrative facet (providing resources for procedures), and development facet (training, quality improvement, and research). The constraints included medical equipment affecting treatment options; administrative processes affecting access to staff and facilities; values and priorities affecting assessments during endoscopic retrograde cholangiopancreatography; and resources for conducting the procedure. Conclusions: The surgical work system is embedded in multiple sets of constraints that can be modeled as facets of the system. We found variations between the implementation sites that might interact negatively with the telemedicine service. However, there may be enough motivation and resources to overcome these initial disruptions given that values and priorities are shared across the sites. Contrasting the development facets at different sites highlighted the differences in resources for training and research. In some cases, this could indicate a risk that organizational demands for efficiency and effectiveness might be prioritized over the long-term outcomes provided by the telemedicine service, or a reduced willingness or ability to accept a service that is not yet fully developed or adapted. WDA proved effective in representing and analyzing these complex clinical contexts in the face of technological change. The models serve as examples of how to analyze and represent a complex sociotechnical context during telemedicine design, implementation, and assessment. %M 34152278 %R 10.2196/26505 %U https://formative.jmir.org/2021/6/e26505 %U https://doi.org/10.2196/26505 %U http://www.ncbi.nlm.nih.gov/pubmed/34152278 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e23293 %T Usability Analysis of a Health Sciences Digital Library by Medical Residents: Cross-sectional Survey %A Jamal,Amr %A Tharkar,Shabana %A Alenazi,Hanan %A Julaidan,Bedoor Saud %A Al Hindawi,Dania Ali %A AlAkeel,Norah Suleman %A AlNuhayer,Ola Mohammed %A AlDubaikhi,Raneem Hamoud %+ Evidence-Based Health Care & Knowledge Translation Research Chair, Department of Family and Community Medicine, College of Medicine, King Saud University, 3145, Riyadh, Saudi Arabia, 966 467000, amrjamal@ksu.edu.sa %K digital library usability %K medical education %K system usability scale %K medical residents %K Saudi Arabia %D 2021 %7 24.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The usability of a digital library depends on a myriad of factors ranging from the end users’ ability to website complexity. Although digital libraries provide instant access to online content, offering an efficient reference platform, their usability is highly variable. Objective: The aim of this study was to measure users’ perspectives and usability of the digital library of the Saudi Commission for Health Specialties (SCFHS). Methods: A web-based questionnaire survey was conducted using a validated System Usability Scale (SUS) containing 5 positive and 5 negative items on the usability of the digital library. The SUS standard cut-off score of 68 was considered for interpretation. Results: The overall mean SUS score of digital library usability was 52.9 (SD 15.2) with a grade “D” categorization, indicating low usability. The perceived measures of attributes of the 10 SUS items of findability, complexity, consistency, and confidence obtained below average scores. Only item 1 relating to perceived willingness to use the digital library frequently obtained a score above the targeted benchmark score (mean score 3.6). Higher SUS scores were associated with training (P=.02). Men felt the digital library to be more complex (P=.04) and board-certified physicians perceived a greater need for training on digital library use (P=.05). Only the UpToDate database was widely used (72/90, 80%). Conclusions: These findings demonstrate the low usability of the extensive facilities offered by the SCFHS digital library. It is pivotal to improve awareness of the availability of the digital library and popularize the databases. There is also a need for improved user training to enhance the accessibility and usability of the multiple databases. %M 34184992 %R 10.2196/23293 %U https://formative.jmir.org/2021/6/e23293/ %U https://doi.org/10.2196/23293 %U http://www.ncbi.nlm.nih.gov/pubmed/34184992 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e24353 %T Virtual Engagement in a Social Media Community of Mothers With Substance Use Disorders: Content Analysis %A Mazel,Shayna %A Zisman-Ilani,Yaara %A Hennig,Shannon %A Garnick,Deborah %A Nicholson,Joanne %+ Heller School for Social Policy and Management, Brandeis University, 415 South Street, Mailstop 035, Waltham, MA, 02454-9110, United States, 1 (781) 736 3820, mazel@brandeis.edu %K virtual engagement %K virtual community participation %K social media %K mental health %K opioids %K substance use %D 2021 %7 24.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Co-occurring substance use disorder is common among pregnant and parenting women with mental illness, but their engagement with and utilization of relevant services and treatment is low. Social media has the potential to convey benefits and facilitate engagement among this target group. Objective: This study aimed to explore the reach and engagement of specific social media posts among pregnant women and mothers with substance use disorders. Methods: Eighteen posts providing content related to substance use (cannabis, opioids, or alcohol), varying in type of content (informational or experiential) and target (policy-, practice-, or perception-related), were posted in a closed Facebook community page comprising over 33,000 pregnant women and mothers between May 2019 and October 2019. Results: The overall level of reach of these Facebook posts ranged from 453 to 3045 community members. Engagement levels, measured via the number of likes, comments, or posts shared, varied based on the type of post content (ie, informational or experiential). Conclusions: Participation in a virtual community via social media platforms can facilitate engagement among pregnant women and mothers with mental illness by communicating relevant information about substance use, as well as potentially promoting awareness of, access to, and engagement with treatment services. %M 34184993 %R 10.2196/24353 %U https://formative.jmir.org/2021/6/e24353/ %U https://doi.org/10.2196/24353 %U http://www.ncbi.nlm.nih.gov/pubmed/34184993 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25808 %T Effects of Mobile App–Based Intervention for Depression in Middle-Aged and Older Adults: Mixed Methods Feasibility Study %A Gould,Christine E %A Carlson,Chalise %A Ma,Flora %A Forman-Hoffman,Valerie %A Ranta,Kristian %A Kuhn,Eric %+ Geriatric Research, Education, and Clinical Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA, 94304, United States, 1 6504935000 ext 68899, cegould@stanford.edu %K aging %K depression %K digital health %K digital therapeutics %K mHealth %K mobile phone %D 2021 %7 29.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital mental health interventions may help middle-aged and older adults with depression overcome barriers to accessing traditional care, but few studies have investigated their use in this population. Objective: This pilot study examines the feasibility, acceptability, and potential efficacy of the Meru Health Program, an 8-week mobile app–delivered intervention. Methods: A total of 20 community-dwelling middle-aged and older adults (age: mean 61.7 years, SD 11.3) with elevated depressive symptoms participated in a single-arm pilot study investigating the Meru Health Program, an app-delivered intervention supported by remote therapists. The program primarily uses mindfulness and cognitive behavioral skills to target depressive symptoms. A semistructured interview was completed at the baseline to establish current psychiatric diagnoses. Depressive symptoms were measured using the Patient Health Questionnaire and Patient-Reported Outcomes Measurement Information System (PROMIS) depression measures. Anxiety symptoms were measured using the Generalized Anxiety Disorder Scale and the PROMIS Anxiety measure. User experience and acceptability were examined through surveys and qualitative interviews. Results: In total, 90% (18/20) of the participants completed the program, with 75% (15/20) completing at least 7 of the 8 introductory weekly lessons. On average, participants completed 60 minutes of practice and exchanged 5 messages with their therapists every week. The app was rated as helpful by 89% (17/19) participants. Significant decreases in depressive (P=.03) and anxiety symptom measures (P=.01) were found; 45% (9/20) of participants showed clinically significant improvement in either depressive symptoms or anxiety symptoms. Conclusions: The findings suggest that the commercially available Meru Health Program may be feasible, acceptable, and potentially beneficial to middle-aged and older adults. Although larger controlled trials are needed to demonstrate efficacy, these findings suggest that digital health interventions may benefit adults of all ages. %M 34185000 %R 10.2196/25808 %U https://formative.jmir.org/2021/6/e25808 %U https://doi.org/10.2196/25808 %U http://www.ncbi.nlm.nih.gov/pubmed/34185000 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e26030 %T Transforming Health and Resiliency Through Integration of Values-based Experiences: Implementation of an Electronic Evidence-based Whole Health Clinical Program %A Haun,Jolie N %A Paykel,Jacquelyn %A Melillo,Christine %+ Research Service, James A. Haley Veterans' Hospital, 8900 Grand Oak Circle, Tampa, FL, 33637, United States, 1 813 558 7622, JolieHaun@gmail.com %K virtual care %K group medical appointment %K complementary and integrative health %K veteran %K implementation %D 2021 %7 29.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Complementary and integrative health (CIH) is the foundation of the Department of Veterans Affairs (VA) Whole Health System program (WH), including Transforming Health and Resiliency through Integration of Values-based Experiences (THRIVE). The global COVID-19 pandemic prompted an urgent need to provide services such as THRIVE while following guidelines for social distancing. Objective: The objective of this paper was to describe the systematic implementation of THRIVE using an electronic delivery model. Methods: The study involved an observational clinical program implementation project using the RE-AIM framework to contextualize the implementation strategies and results, and then the implementation of an electronically delivered CIH group medical appointment program (eTHRIVE). Results: Clinical staff transitioned to 100% electronic delivery of the THRIVE curriculum using the new eTHRIVE delivery model. The current electronic delivery model, eTHRIVE, has effectively enrolled 10-12 veterans per cohort, with 8 cohorts, totaling 87 veterans to date. eTHRIVE attrition has been 6% (5/87) since initiation. Conclusions: The current climate of the VA WH programmatic initiative combined with the public health needs during a global pandemic prompted the move of THRIVE program into an electronic format to broaden scalability and reach. %M 34184996 %R 10.2196/26030 %U https://formative.jmir.org/2021/6/e26030 %U https://doi.org/10.2196/26030 %U http://www.ncbi.nlm.nih.gov/pubmed/34184996 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e22075 %T Advancing Mental Health and Psychological Support for Health Care Workers Using Digital Technologies and Platforms %A Ye,Jiancheng %+ Feinberg School of Medicine, Northwestern University, 633 N Saint Clair St, Chicago, IL, United States, 1 312 503 3690, jiancheng.ye@u.northwestern.edu %K mental health %K health care workers %K health informatics %K digital intervention %K health technology %K mobile health %K COVID-19 %D 2021 %7 30.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic is a global public health crisis that has not only endangered the lives of patients but also resulted in increased psychological issues among medical professionals, especially frontline health care workers. As the crisis caused by the pandemic shifts from acute to protracted, attention should be paid to the devastating impacts on health care workers’ mental health and social well-being. Digital technologies are being harnessed to support the responses to the pandemic, which provide opportunities to advance mental health and psychological support for health care workers. Objective: The aim of this study is to develop a framework to describe and organize the psychological and mental health issues that health care workers are facing during the COVID-19 pandemic. Based on the framework, this study also proposes interventions from digital health perspectives that health care workers can leverage during and after the pandemic. Methods: The psychological problems and mental health issues that health care workers have encountered during the COVID-19 pandemic were reviewed and analyzed based on the proposed MEET (Mental Health, Environment, Event, and Technology) framework, which also demonstrated the interactions among mental health, digital interventions, and social support. Results: Health care workers are facing increased risk of experiencing mental health issues due to the COVID-19 pandemic, including burnout, fear, worry, distress, pressure, anxiety, and depression. These negative emotional stressors may cause psychological problems for health care workers and affect their physical and mental health. Digital technologies and platforms are playing pivotal roles in mitigating psychological issues and providing effective support. The proposed framework enabled a better understanding of how to mitigate the psychological effects during the pandemic, recover from associated experiences, and provide comprehensive institutional and societal infrastructures for the well-being of health care workers. Conclusions: The COVID-19 pandemic presents unprecedented challenges due to its prolonged uncertainty, immediate threat to patient safety, and evolving professional demands. It is urgent to protect the mental health and strengthen the psychological resilience of health care workers. Given that the pandemic is expected to exist for a long time, caring for mental health has become a “new normal” that needs a strengthened multisector collaboration to facilitate support and reduce health disparities. The proposed MEET framework could provide structured guidelines for further studies on how technology interacts with mental and psychological health for different populations. %M 34106874 %R 10.2196/22075 %U https://formative.jmir.org/2021/6/e22075 %U https://doi.org/10.2196/22075 %U http://www.ncbi.nlm.nih.gov/pubmed/34106874 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e28952 %T A Web-Based Intervention to Increase Smokers’ Intentions to Participate in a Cessation Study Offered at the Point of Lung Screening: Factorial Randomized Trial %A Neil,Jordan M %A Chang,Yuchiao %A Goshe,Brett %A Rigotti,Nancy %A Gonzalez,Irina %A Hawari,Saif %A Ballini,Lauren %A Haas,Jennifer S %A Marotta,Caylin %A Wint,Amy %A Harris,Kim %A Crute,Sydney %A Flores,Efren %A Park,Elyse R %+ Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, 655 Research Parkway, 1404, Oklahoma City, OK, 73104, United States, 1 6034430743, jordan-neil@ouhsc.edu %K clinical trials recruitment %K digital outreach %K message design experiment %K smoking cessation %K lung cancer screening %K prospect theory %D 2021 %7 30.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Screen ASSIST is a cessation trial offered to current smokers at the point of lung cancer screening. Because of the unique position of promoting a prevention behavior (smoking cessation) within the context of a detection behavior (lung cancer screening), this study employed prospect theory to design and formatively evaluate a targeted recruitment video prior to trial launch. Objective: The aim of this study was to identify which message frames were most effective at promoting intent to participate in a smoking cessation study. Methods: Participants were recruited from a proprietary opt-in online panel company and randomized to a 2 (benefits of quitting vs risks of continuing to smoke at the time of lung screening; BvR) × 2 (gains of participating vs losses of not participating in a cessation study; GvL) message design experiment (N=314). The primary outcome was self-assessed intent to participate in a smoking cessation study. Message effectiveness and lung cancer risk perception measures were also collected. Analysis of variance examined the main effect of the 2 message factors and a least absolute shrinkage and selection operator (LASSO) approach identified predictors of intent to participate in a multivariable model. A mediation analysis was conducted to determine the direct and indirect effects of message factors on intent to participate in a cessation study. Results: A total of 296 participants completed the intervention. There were no significant differences in intent to participate in a smoking cessation study between message frames (P=.12 and P=.61). In the multivariable model, quit importance (P<.001), perceived message relevance (P<.001), and affective risk response (ie, worry about developing lung cancer; P<.001) were significant predictors of intent to participate. The benefits of quitting frame significantly increased affective risk response (Meanbenefits 2.60 vs Meanrisk 2.40; P=.03), which mediated the relationship between message frame and intent to participate (b=0.24; 95% CI 0.01-0.47; P=.03). Conclusions: This study provides theoretical and practical guidance on how to design and evaluate proactive recruitment messages for a cessation trial. Based on our findings, we conclude that heavy smokers are more responsive to recruitment messages that frame the benefits of quitting as it increased affective risk response, which predicted greater intention to participate in a smoking cessation study. %M 34255651 %R 10.2196/28952 %U https://formative.jmir.org/2021/6/e28952 %U https://doi.org/10.2196/28952 %U http://www.ncbi.nlm.nih.gov/pubmed/34255651 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e29365 %T Meaning in Life Among Patients With Chronic Pain and Suicidal Ideation: Mixed Methods Study %A Costanza,Alessandra %A Chytas,Vasileios %A Piguet,Valérie %A Luthy,Christophe %A Mazzola,Viridiana %A Bondolfi,Guido %A Cedraschi,Christine %+ Department of Psychiatry, Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, Geneva, 1211, Switzerland, 41 223795900, alessandra.costanza@unige.ch %K suicide %K suicidal behavior %K suicidal ideation %K suicide attempt %K chronic pain %K meaning in life %K protective factors %K risk factors %K mental health %D 2021 %7 4.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Patients with chronic pain have elevated risk of suicidal ideation and behavior, including suicide attempts and completed suicides. In most studies, associations between chronic pain and suicidal ideation/suicidal behavior are robust even after adjusting for the effect of sociodemographics and psychiatric comorbidity. However, to refine the risk profile of these patients, further exploration of other possible risk and protective factors is necessary. Objective: There is a common clinical observation that experiencing chronic pain often requires a revision of life goals and expectations, and hence, it impacts the existential domain including one’s perception of the meaning in life (MiL). This study aimed to characterize the main domains that constitute the personal MiL, including the “presence of” and “search for” constructs, in a group of patients with chronic pain and suicidal ideation. Methods: Seventy participants were enlisted by ongoing recruitment through a larger project anchored in daily clinical practice at the Multidisciplinary Pain Center of the Geneva University Hospitals. It was an observational mixed method study. Data were recorded through both validated quantitative questionnaires and qualitative open-ended questions. Results: The total sample consisted of 70 patients. Responses to questionnaires showed a depressive episode in 68 (97%) patients and anxious disorders in 25 (36%) patients. With a score threshold for positive MiL of 24, the mean score for the “presence of” construct was 20.13 (SD 8.23), and 63% (44/70) of respondents had a score <24. The mean score for the “search for” construct was lower at 18.14 (SD 8.64), and 70% (49/70) of respondents had a score <24. The “presence of” and “search for” constructs were significantly positively correlated (R=0.402; P=.001). An open question addressed the “presence of” construct by inviting the respondents to cite domains they consider as providing meaning in their life at the present time. All patients responded to this question, citing one or more domains. The three main dimensions that emerged from content analysis of this qualitative section were as follows: the domain of relationships, the domain of personal activities, and pain and its consequences on MiL. Conclusions: The study results provide insights into patients with chronic pain and suicidal ideation, including the domains that provide them with meaning in their lives and the impact of pain on these domains with regard to suicidal ideation. The main clinical implications concern both prevention and supportive/psychotherapeutic interventions. They are based on a narrative approach aiming to explore with the patients the content of their suffering and the MiL domains that they could identify to mitigate it, in order to restructure/reinforce these domains and thus possibly reduce suicidal ideation. Specifically, a focus on maintaining the domains of interpersonal relationships and personal activities can allow patients to ultimately escape the biopsychosocial vicious cycle of chronic pain–induced deep moral suffering. %M 34003136 %R 10.2196/29365 %U https://formative.jmir.org/2021/6/e29365 %U https://doi.org/10.2196/29365 %U http://www.ncbi.nlm.nih.gov/pubmed/34003136 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25083 %T Patients’ and Providers’ Needs and Preferences When Considering Fertility Preservation Before Cancer Treatment: Decision-Making Needs Assessment %A Hoffman,Aubri %A Crocker,Laura %A Mathur,Aakrati %A Holman,Deborah %A Weston,June %A Campbell,Sukhkamal %A Housten,Ashley %A Bradford,Andrea %A Agrawala,Shilpi %A Woodard,Terri L %+ Department of Gynecological Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Unit 1362, Houston, TX, 77030-4009, United States, 1 713 745 7591, tlwoodard@mdanderson.org %K cancer %K decision support techniques %K fertility preservation %K oncofertility %K oncology %K needs assessment %K patient decision aids %K patient needs %K shared decision making %D 2021 %7 7.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: As cancer treatments continue to improve, it is increasingly important that women of reproductive age have an opportunity to decide whether they want to undergo fertility preservation treatments to try to protect their ability to have a child after cancer. Clinical practice guidelines recommend that providers offer fertility counseling to all young women with cancer; however, as few as 12% of women recall discussing fertility preservation. The long-term goal of this program is to develop an interactive web-based patient decision aid to improve awareness, access, knowledge, and decision making for all young women with cancer. The International Patient Decision Aid Standards collaboration recommends a formal decision-making needs assessment to inform and guide the design of understandable, meaningful, and usable patient decision aid interventions. Objective: This study aims to assess providers’ and survivors’ fertility preservation decision-making experiences, unmet needs, and initial design preferences to inform the development of a web-based patient decision aid. Methods: Semistructured interviews and an ad hoc focus group assessed current decision-making experiences, unmet needs, and recommendations for a patient decision aid. Two researchers coded and analyzed the transcripts using NVivo (QSR International). A stakeholder advisory panel guided the study and interpretation of results. Results: A total of 51 participants participated in 46 interviews (18 providers and 28 survivors) and 1 ad hoc focus group (7 survivors). The primary themes included the importance of fertility decisions for survivorship, the existence of significant but potentially modifiable barriers to optimal decision making, and a strong support for developing a carefully designed patient decision aid website. Providers reported needing an intervention that could quickly raise awareness and facilitate timely referrals. Survivors reported needing understandable information and help with managing uncertainty, costs, and pressures. Design recommendations included providing tailored information (eg, by age and cancer type), optional interactive features, and multimedia delivery at multiple time points, preferably outside the consultation. Conclusions: Decision making about fertility preservation is an important step in providing high-quality comprehensive cancer care and a priority for many survivors’ optimal quality of life. Decision support interventions are needed to address gaps in care and help women quickly navigate toward an informed, values-congruent decision. Survivors and providers support developing a patient decision aid website to make information directly available to women outside of the consultation and to provide self-tailored content according to women’s clinical characteristics and their information-seeking and deliberative styles. %M 34096871 %R 10.2196/25083 %U https://formative.jmir.org/2021/6/e25083 %U https://doi.org/10.2196/25083 %U http://www.ncbi.nlm.nih.gov/pubmed/34096871 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25043 %T Exploring the Potential of Personalized Dietary Advice for Health Improvement in Motivated Individuals With Premetabolic Syndrome: Pretest-Posttest Study %A van der Haar,Sandra %A Hoevenaars,Femke P M %A van den Brink,Willem J %A van den Broek,Tim %A Timmer,Mariëlle %A Boorsma,André %A Doets,Esmée L %+ Wageningen Food & Biobased Research, Wageningen University & Research, Bornse Weilanden 9, Wageningen, 6708 WG, Netherlands, 31 0317 480171, sandra.vanderhaar@wur.nl %K personalized nutrition %K metabolic syndrome %K dietary behavior %K diet %K metabolic %K metabolic health %K dietary advice %K dietary feedback %K digital health %D 2021 %7 24.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Dietary quality plays an essential role in the prevention and management of metabolic syndrome (MetS). Objective: The aim of this pilot study is to organize personalized dietary advice in a real-life setting and to explore the effects on dietary intake, metabolic health, and perceived health. Methods: We followed a one-group pretest-posttest design and included 37 individuals at risk of MetS, who indicated motivation to change dietary behavior. For a period of 16 weeks, participants received personalized advice (t=0 and t=8) and feedback (t=0, t=4, t=8, t=12 and t=16) on dietary quality and metabolic health (ie, waist circumference, BMI, blood pressure, lipid profile, fasting glucose levels, and C-peptide). Personalized advice was generated in a two-stage process. In stage 1, an automated algorithm generated advice per food group, integrating data on individual dietary quality (Dutch Healthy Diet Index; total score 8-80) and metabolic health parameters. Stage 2 included a telephone consultation with a trained dietitian to define a personal dietary behavior change strategy and to discuss individual preferences. Dietary quality and metabolic health markers were assessed at t=0, t=8, and t=16. Self-perceived health was evaluated on 7-point Likert scales at t=0 and t=16. Results: At the end of the study period, dietary quality was significantly improved compared with the baseline (Dutch Healthy Diet Index +4.3; P<.001). In addition, lipid profile (triglycerides, P=.02; total cholesterol, P=.01; high-density lipoprotein, P<.001; and low-density lipoprotein, P<.001), BMI (P<.001), waist circumference (P=.01), and C-peptide (P=.01) were all significantly improved, whereas plasma glucose increased by 0.23 nmol/L (P=.04). In line with these results, self-perceived health scores were higher at t=16 weeks than at baseline (+0.67; P=.005). Conclusions: This exploratory study showed that personalized dietary advice resulted in positive effects on dietary behavior, metabolic health, and self-perceived health in motivated pre-MetS adults. The study was performed in a do-it-yourself setting, highlighting the potential of at-home health improvement through dietary changes. Trial Registration: ClinicalTrials.gov NCT04595669; https://clinicaltrials.gov/ct2/show/NCT04595669 %M 34185002 %R 10.2196/25043 %U https://formative.jmir.org/2021/6/e25043/ %U https://doi.org/10.2196/25043 %U http://www.ncbi.nlm.nih.gov/pubmed/34185002 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e20128 %T Tracking Stress, Mental Health, and Resilience Factors in Medical Students Before, During, and After a Stress-Inducing Exam Period: Protocol and Proof-of-Principle Analyses for the RESIST Cohort Study %A Fritz,Jessica %A Stochl,Jan %A Kievit,Rogier A %A van Harmelen,Anne-Laura %A Wilkinson,Paul O %+ Department of Psychiatry, University of Cambridge, Douglas House, 18B Trumpington Road, Cambridge, CB2 8AH, United Kingdom, 0044 1223 465253, jf585@cam.ac.uk %K exam stress %K perceived stress %K mental distress %K student mental health %K mental health resilience %K protective factors %K resilience factors %D 2021 %7 8.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Knowledge of mental distress and resilience factors over the time span from before to after a stressor is important to be able to leverage the most promising resilience factors and promote mental health at the right time. To shed light on this topic, we designed the RESIST (Resilience Study) study, in which we assessed medical students before, during, and after their yearly exam period. Exam time is generally a period of notable stress among medical students, and it has been suggested that exam time triggers mental distress. Objective: In this paper, we aim to describe the study protocol and to examine whether the exam period indeed induces higher perceived stress and mental distress. We also aim to explore whether perceived stress and mental distress coevolve in response to exams. Methods: RESIST is a cohort study in which exam stress functions as a within-subject natural stress manipulation. In this paper, we outline the sample (N=451), procedure, assessed measures (including demographics, perceived stress, mental distress, 13 resilience factors, and adversity), and ethical considerations. Moreover, we conducted a series of latent growth models and bivariate latent change score models to analyze perceived stress and mental distress changes over the 3 time points. Results: We found that perceived stress and mental distress increased from the time before the exams to the exam period and decreased after the exams to a lower level than before the exams. Our findings further suggest that higher mental distress before exams increased the risk of developing more perceived stress during exams. Higher perceived stress during exams, in turn, increased the risk of experiencing a less successful (or quick) recovery of mental distress after exams. Conclusions: As expected, the exam period caused a temporary increase in perceived stress and mental distress. Therefore, the RESIST study lends itself well to exploring resilience factors in response to naturally occurring exam stress. Such knowledge will eventually help researchers to find out which resilience factors lend themselves best as prevention targets and which lend themselves best as treatment targets for the mitigation of mental health problems that are triggered or accelerated by natural exam stress. The findings from the RESIST study may therefore inform student support services, mental health services, and resilience theory. %M 34100761 %R 10.2196/20128 %U https://formative.jmir.org/2021/6/e20128 %U https://doi.org/10.2196/20128 %U http://www.ncbi.nlm.nih.gov/pubmed/34100761 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e29122 %T The Development of a Digital Patient-Reported Outcome Measurement for Adults With Chronic Disease (The Parsley Symptom Index): Prospective Cohort Study %A Williams,Hants %A Steinberg,Sarah %A Berzin,Robin %+ School of Health Technology and Management, Stony Brook University, 101 Nicolls Rd, Stony Brook, NY, 11794, United States, 1 6502183789, hantsawilliams@gmail.com %K patient-reported outcomes %K PROMs %K chronic diseases %K symptom management %K Parsley Symptom Index %K Review of Symptoms %D 2021 %7 11.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The monitoring and management of chronic illness has always been a challenge. Patient-reported outcome measures (PROMs) can be powerful tools for monitoring symptoms and guiding treatment of chronic diseases, but the available PROM tools are either too broad or too disease specific for the needs of a primary care practice focused on longitudinal care. Objective: In this study we describe the development and preliminary validation of the Parsley Symptom Index (PSI). Methods: This prospective cohort study took place from January 5, 2018, to June 05, 2020, among a sample of 4621 adult patients at Parsley Health. After a review of literature, followed by binning and winnowing of potential items, a 45-item PROM that also served as a review of systems (ROS) was developed. The PSI was deployed and completed by patients via an online portal. Construct and face validity was performed by clinicians, tested on patients, and feasibility was measured by response rate, completion rate, and percentage of missing data. Results: The response rate for 12,175 collected PSIs was 93.72% (4331/4621) with a 100% item completion rate. A confirmatory factor analysis confirmed the model structure was satisfactory by a Comparative Fit Index of 0.943, Tucker–Lewis index of 0.938, and root mean square error of approximation of 0.028. Conclusions: A 45-item ROS-style PROM designed to capture chronic disease symptoms was developed, and preliminary validation suggests that the PSI can be deployed, completed, and helpful to both patients and clinicians. %M 33999007 %R 10.2196/29122 %U https://formative.jmir.org/2021/6/e29122 %U https://doi.org/10.2196/29122 %U http://www.ncbi.nlm.nih.gov/pubmed/33999007 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e27968 %T Using Emerging Telehealth Technology as a Future Model in Vietnam During the COVID-19 Pandemic: Practical Experience From Phutho General Hospital %A Nguyen,Ngoc Huy %A Nguyen,An Quang %A Ha,Van Thi Bich %A Duong,Phuong Xuan %A Nguyen,Thong Van %+ Department of Health, Phutho Province, Tran Phu Str, Viet Tri, 0084, Vietnam, 84 0985179888, ngochuynguyen8888@gmail.com %K telehealth %K telemedicine %K teleconsultation %K COVID-19 %K Vietnam %K digital health %K pandemic %D 2021 %7 22.6.2021 %9 Viewpoint %J JMIR Form Res %G English %X Telehealth has emerged as a model of modern technology for health care services in Vietnam during the COVID-19 pandemic. To actively prevent the outbreak of COVID-19 by using a national digital transformation program, the Vietnamese Ministry of Health launched project 2628/Quyet dinh-Bo y te, which approved a scheme for remote medical examinations and treatments for 2020 to 2025. The project aims to connect 1000 hospitals to strengthen the quality of medical services by using the expertise of central hospitals to support rural areas via provincial hospitals. Phutho General Hospital (PGH) is one of leading provincial hospitals that participated in and applied the early telehealth systems in Vietnam. By using telehealth systems, PGH can offer valuable support to doctors’ activities by streamlining and facilitating their work. Telehealth was demonstrated to be feasible, acceptable, and effective at PGH in Vietnam, and it resulted in considerable improvements in health care outcomes. The COVID-19 pandemic has facilitated the acceleration and enhancement of telehealth in Vietnam. The success of telehealth in Phutho may be a useful reference for other parts of the world. However, this telehealth system focuses on the connectivity among doctors rather than the connectivity between doctors and patients, which is an area that needs further assessment. %M 34078590 %R 10.2196/27968 %U https://formative.jmir.org/2021/6/e27968 %U https://doi.org/10.2196/27968 %U http://www.ncbi.nlm.nih.gov/pubmed/34078590 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e23630 %T Health Perceptions and Adopted Lifestyle Behaviors During the COVID-19 Pandemic: Cross-National Survey %A Manjunath,Nandi Krishnamurthy %A Majumdar,Vijaya %A Rozzi,Antonietta %A Huiru,Wang %A Mishra,Avinash %A Kimura,Keishin %A Nagarathna,Raghuram %A Nagendra,Hongasandra Ramarao %+ Swami Vivekananda Yoga Anusandhana Samsthana University, #19, Eknath Bhavan, Gavipuram Circle, KG Naga, Bengaluru, 560019, India, 91 08026995163, vijaya.majumdar@svyasa.edu.in %K health behavior %K self-report %K cross-national survey %K COVID-19 %K behavior %K perception %K lifestyle %K nutrition %K real-time %D 2021 %7 1.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Social isolation measures are requisites to control viral spread during the COVID-19 pandemic. However, if these measures are implemented for a long period of time, they can result in adverse modification of people’s health perceptions and lifestyle behaviors. Objective: The aim of this cross-national survey was to address the lack of adequate real-time data on the public response to changes in lifestyle behavior during the crisis of the COVID-19 pandemic. Methods: A cross-national web-based survey was administered using Google Forms during the month of April 2020. The settings were China, Japan, Italy, and India. There were two primary outcomes: (1) response to the health scale, defined as perceived health status, a combined score of health-related survey items; and (2) adoption of healthy lifestyle choices, defined as the engagement of the respondent in any two of three healthy lifestyle choices (healthy eating habits, engagement in physical activity or exercise, and reduced substance use). Statistical associations were assessed with linear and logistic regression analyses. Results: We received 3371 responses; 1342 were from India (39.8%), 983 from China (29.2%), 669 from Italy (19.8%), and 377 (11.2%) from Japan. A differential countrywise response was observed toward perceived health status; the highest scores were obtained for Indian respondents (9.43, SD 2.43), and the lowest were obtained for Japanese respondents (6.81, SD 3.44). Similarly, countrywise differences in the magnitude of the influence of perceptions on health status were observed; perception of interpersonal relationships was most pronounced in the comparatively old Italian and Japanese respondents (β=.68 and .60, respectively), and the fear response was most pronounced in Chinese respondents (β=.71). Overall, 78.4% of the respondents adopted at least two healthy lifestyle choices amid the COVID-19 pandemic. Unlike health status, the influence of perception of interpersonal relationships on the adoption of lifestyle choices was not unanimous, and it was absent in the Italian respondents (odds ratio 1.93, 95% CI 0.65-5.79). The influence of perceived health status was a significant predictor of lifestyle change across all the countries, most prominently by approximately 6-fold in China and Italy. Conclusions: The overall consistent positive influence of increased interpersonal relationships on health perceptions and adopted lifestyle behaviors during the pandemic is the key real-time finding of the survey. Favorable behavioral changes should be bolstered through regular virtual interpersonal interactions, particularly in countries with an overall middle-aged or older population. Further, controlling the fear response of the public through counseling could also help improve health perceptions and lifestyle behavior. However, the observed human behavior needs to be viewed within the purview of cultural disparities, self-perceptions, demographic variances, and the influence of countrywise phase variations of the pandemic. The observations derived from a short lockdown period are preliminary, and real insight could only be obtained from a longer follow-up. %M 33900928 %R 10.2196/23630 %U https://formative.jmir.org/2021/6/e23630 %U https://doi.org/10.2196/23630 %U http://www.ncbi.nlm.nih.gov/pubmed/33900928 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e27185 %T Acceptability of Research and Health Care Visits During the COVID-19 Pandemic: Cross-sectional Survey Study %A Ross,Kathryn M %A Hong,Young-Rock %A Krukowski,Rebecca A %A Miller,Darci R %A Lemas,Dominick J %A Cardel,Michelle I %+ Department of Clinical and Health Psychology, College of Public Health and Health Professions, University of Florida, PO Box 10065, Gainesville, FL, 32610, United States, 1 3522948433, kmross@phhp.ufl.edu %K COVID-19 %K health care access %K telehealth %K research recruitment %K telemedicine %K belief %K access %K willingness %K cross-sectional %K survey %D 2021 %7 2.6.2021 %9 Short Paper %J JMIR Form Res %G English %X Background: The COVID-19 pandemic has had a widespread impact on attendance in biomedical research and health care visits. Objective: This study aimed to identify when and how American adults might feel comfortable about resuming in-person research and health care visits. Methods: Cross-sectional questionnaire data were collected from 135 adults (age: median 48 years; women: n=113, 83.7%; White participants: n=92, 68.2%) who were engaged in health-related research. Results: More than half of the respondents (65/122, 53.3%) felt that the COVID-19 pandemic positively affected their desire to participate in research. Although 73.6% (95/129) of respondents also indicated a willingness to attend in-person health care visits while Centers for Disease Control and Prevention (CDC) guidelines are implemented, 85.8% (109/127) indicated a willingness to attend in-person, outdoor visits, and 92.2% (118/128) reported a willingness to attend drive-through visits (with CDC guidelines implemented during both visit types). Videoconferencing was the most preferred format for intervention visits; however, adults over the age of 65 years preferred this format less than younger adults (P=.001). Conclusions: Researchers and clinicians should continue to provide opportunities for continuing the conduction of remote-based interventions while enforcing CDC guidelines during in-person visits. %M 34033577 %R 10.2196/27185 %U https://formative.jmir.org/2021/6/e27185 %U https://doi.org/10.2196/27185 %U http://www.ncbi.nlm.nih.gov/pubmed/34033577 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e25010 %T Potential Impact of a Paper About COVID-19 and Smoking on Twitter Users’ Attitudes Toward Smoking: Observational Study %A Tao,Chunliang %A Diaz,Destiny %A Xie,Zidian %A Chen,Long %A Li,Dongmei %A O’Connor,Richard %+ Department of Clinical and Translational Research, University of Rochester Medical Center, 265 Crittenden Boulevard CU 420708, Rochester, NY, 14642-0708, United States, 1 5852767285, Dongmei_Li@urmc.rochester.edu %K COVID-19 %K smoking %K Twitter %K infodemiology %K infodemic %K infoveillance %K impact %K attitude %K perception %K observational %K social media %K cross-sectional %K dissemination %K research %D 2021 %7 15.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: A cross-sectional study (Miyara et al, 2020) conducted by French researchers showed that the rate of current daily smoking was significantly lower in patients with COVID-19 than in the French general population, implying a potentially protective effect of smoking. Objective: We aimed to examine the dissemination of the Miyara et al study among Twitter users and whether a shift in their attitudes toward smoking occurred after its publication as preprint on April 21, 2020. Methods: Twitter posts were crawled between April 14 and May 4, 2020, by the Tweepy stream application programming interface, using a COVID-19–related keyword query. After filtering, the final 1929 tweets were classified into three groups: (1) tweets that were not related to the Miyara et al study before it was published, (2) tweets that were not related to Miyara et al study after it was published, and (3) tweets that were related to Miyara et al study after it was published. The attitudes toward smoking, as expressed in the tweets, were compared among the above three groups using multinomial logistic regression models in the statistical analysis software R (The R Foundation). Results: Temporal analysis showed a peak in the number of tweets discussing the results from the Miyara et al study right after its publication. Multinomial logistic regression models on sentiment scores showed that the proportion of negative attitudes toward smoking in tweets related to the Miyara et al study after it was published (17.07%) was significantly lower than the proportion in tweets that were not related to the Miyara et al study, either before (44/126, 34.9%; P<.001) or after the Miyara et al study was published (68/198, 34.3%; P<.001). Conclusions: The public’s attitude toward smoking shifted in a positive direction after the Miyara et al study found a lower incidence of COVID-19 cases among daily smokers. %M 33939624 %R 10.2196/25010 %U https://formative.jmir.org/2021/6/e25010 %U https://doi.org/10.2196/25010 %U http://www.ncbi.nlm.nih.gov/pubmed/33939624 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e28140 %T Teleconsultation in the Management of Elective Orthopedic and Spinal Conditions During the COVID-19 Pandemic: Prospective Cohort Study of Patient Experiences %A Melian,Christina %A Frampton,Christopher %A Wyatt,Michael Charles %A Kieser,David %+ Renaissance School of Medicine at Stony Brook University, 101 Nicolls Road, Health Sciences Center, Level 4, Stony Brook, NY, 11794-8434, United States, 1 631 444 2111, christina.melian@stonybrookmedicine.edu %K telemedicine %K patient satisfaction %K orthopedic surgery %K telehealth %K COVID-19 %K pandemic %D 2021 %7 15.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: The global adoption of teleconsultation has been expedited as a result of the COVID-19 pandemic. By allowing remote communication, teleconsultation may help limit the spread of the virus while maintaining the crucial patient-provider relationship. Objective: The aim of this study is to evaluate the value of teleconsultation compared to in-person visits in the management of elective orthopedic and spinal procedures. Methods: This was a prospective observational cohort study of 853 patients receiving orthopedic and spinal care at a private outpatient clinic in New Zealand. Patients were randomly divided into two groups: (1) patients receiving telephone consultation remotely, and (2) patients receiving in-person office consultations at the outpatient clinic. All patients received telephone consultations for 4 weeks during the mandated COVID-19 lockdown, followed by 4 weeks of telephone or in-person consultation. Patient preference, satisfaction, and duration of visit were recorded. Comparisons of patient preference between groups, visit type, sex, and location were performed using chi-square tests; similarly, satisfaction scores and visit durations were compared using a general linear model. Results: We report that 91% (353/388) of patients in the telephone group preferred teleconsultation over in-person office visits during the COVID-19 lockdown (P<.001). A combined-group analysis showed that 55.3% (446/807) of all patients preferred teleconsultation compared to 31.2% (252/807) who preferred in-person office visits (P<.001). Patients in the telephone group reported significantly higher satisfaction scores (mean 9.95, SD 0.04, 95% CI 9.87-10.03) compared to patients in the in-person group (mean 9.53, SE 0.04, 95% CI 9.45-9.62; P<.001). Additionally, in-person consultations were significantly longer in duration compared to telephone consultations, with a mean visit time of 6.70 (SE 0.18) minutes, 95% CI 6.32-7.02, compared to 5.10 (SE 0.17) minutes, 95% CI 4.73-5.42 (P<.001). Conclusions: Patients who use telephone consultations are more likely to prefer it over traditional, in-person visits in the future. This increased preference, coupled with higher patient satisfaction scores and shorter duration of visits, suggests that teleconsultation has a role in orthopedic surgery, which may even extend beyond the COVID-19 pandemic. %M 34048355 %R 10.2196/28140 %U https://formative.jmir.org/2021/6/e28140 %U https://doi.org/10.2196/28140 %U http://www.ncbi.nlm.nih.gov/pubmed/34048355