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1.  Confirmation Bias in Web-Based Search: A Randomized Online Study on the Effects of Expert Information and Social Tags on Information Search and Evaluation 
Background
The public typically believes psychotherapy to be more effective than pharmacotherapy for depression treatments. This is not consistent with current scientific evidence, which shows that both types of treatment are about equally effective.
Objective
The study investigates whether this bias towards psychotherapy guides online information search and whether the bias can be reduced by explicitly providing expert information (in a blog entry) and by providing tag clouds that implicitly reveal experts’ evaluations.
Methods
A total of 174 participants completed a fully automated Web-based study after we invited them via mailing lists. First, participants read two blog posts by experts that either challenged or supported the bias towards psychotherapy. Subsequently, participants searched for information about depression treatment in an online environment that provided more experts’ blog posts about the effectiveness of treatments based on alleged research findings. These blogs were organized in a tag cloud; both psychotherapy tags and pharmacotherapy tags were popular. We measured tag and blog post selection, efficacy ratings of the presented treatments, and participants’ treatment recommendation after information search.
Results
Participants demonstrated a clear bias towards psychotherapy (mean 4.53, SD 1.99) compared to pharmacotherapy (mean 2.73, SD 2.41; t 173=7.67, P<.001, d=0.81) when rating treatment efficacy prior to the experiment. Accordingly, participants exhibited biased information search and evaluation. This bias was significantly reduced, however, when participants were exposed to tag clouds with challenging popular tags. Participants facing popular tags challenging their bias (n=61) showed significantly less biased tag selection (F 2,168=10.61, P<.001, partial eta squared=0.112), blog post selection (F 2,168=6.55, P=.002, partial eta squared=0.072), and treatment efficacy ratings (F 2,168=8.48, P<.001, partial eta squared=0.092), compared to bias-supporting tag clouds (n=56) and balanced tag clouds (n=57). Challenging (n=93) explicit expert information as presented in blog posts, compared to supporting expert information (n=81), decreased the bias in information search with regard to blog post selection (F 1,168=4.32, P=.04, partial eta squared=0.025). No significant effects were found for treatment recommendation (Ps>.33).
Conclusions
We conclude that the psychotherapy bias is most effectively attenuated—and even eliminated—when popular tags implicitly point to blog posts that challenge the widespread view. Explicit expert information (in a blog entry) was less successful in reducing biased information search and evaluation. Since tag clouds have the potential to counter biased information processing, we recommend their insertion.
doi:10.2196/jmir.3044
PMCID: PMC3978552  PMID: 24670677
Web-based systems; prejudice; folksonomy; taxonomy; collaborative tagging; human information processing; psychotherapy; pharmacotherapy
2.  Characterizing Periodic Messaging Interventions Across Health Behaviors and Media: Systematic Review 
Background
Periodic prompts serve as tools for health behavior interventions to encourage and maintain behavior changes. Past literature reviews have examined periodic messages targeting specific behaviors (smoking, physical activity, diet, etc) or media (telephone, email, face-to-face, newsletter, etc) and have found them to be effective in impacting health behavior in the short term.
Objective
Our goal was to review the literature related to periodic messaging and prompts in order to explore typical characteristics, assess the role of prompt timing, identify common theoretical models used, and identify characteristics associated with the effectiveness of periodic prompts.
Methods
Electronic searches of PubMed, PsycINFO, CINAHL, and Web of Science were conducted in October 2012 and May 2013. Database search terms included variant terms for periods, prompts, interventions, media, and health behaviors.
Results
Forty-two of the 55 included research articles found that prompts resulted in significant positive behavioral outcomes for participants. Prompts were delivered via text messages, email, mailed communications, and in a few instances via phone. Generally, the provision of feedback and specific strategies to accomplish behavior change appears to be important for the success of periodic prompts. Rationale for prompt timing was rarely provided, although some studies did organize message content around days of the week or times perceived to be high risk for particular behaviors. Smoking cessation interventions tended to be organized around quit date. Among studies using theoretical models to inform their interventions, the transtheoretical model was most common.
Conclusions
Periodic messaging interventions yield positive results for short-term health behavior changes. Interventions including feedback and prompts that included strategies were more likely to report significantly positive outcomes. Work remains to better understand elements that make periodic prompts successful and whether they are effective in producing long-term outcomes.
doi:10.2196/jmir.2837
PMCID: PMC3978550  PMID: 24667840
prompts; periodic messaging; health behavior; review, systematic
3.  Web-Based Intervention in Mindfulness Meditation for Reducing Residual Depressive Symptoms and Relapse Prophylaxis: A Qualitative Study 
Background
Mindful Mood Balance (MMB) is a Web-based intervention designed to treat residual depressive symptoms and prevent relapse. MMB was designed to deliver the core concepts of mindfulness-based cognitive therapy (MBCT), a group treatment, which, despite its strong evidence base, faces a number of dissemination challenges.
Objective
The present study is a qualitative investigation of participants’ experiences with MMB.
Methods
Qualitative content analysis was conducted via 38 exit interviews with MMB participants. Study inclusion required a current PHQ-9 (Patient Health Questionnaire) score ≤12 and lifetime history ≥1 major depressive episode. Feedback was obtained on specific website components, program content, and administration as well as skills learned.
Results
Codes were assigned to interview responses and organized into four main themes: MBCT Web content, MBCT Web-based group process, home practice, and evidence of concept comprehension. Within these four areas, participants highlighted the advantages and obstacles of translating and delivering MBCT in a Web-based format. Adding increased support was suggested for troubleshooting session content as well as managing time challenges for completing home mindfulness practice. Participants endorsed developing affect regulation skills and identified several advantages to Web-based delivery including flexibility, reduced cost, and time commitment.
Conclusions
These findings support the viability of providing MBCT online and are consistent with prior qualitative accounts derived from in-person MBCT groups. While there is certainly room for innovation in the domains of program support and engagement, the high levels of participant satisfaction indicated that MMB can significantly increase access to evidence-based psychological treatments for sub-threshold symptoms of unipolar affective disorder.
doi:10.2196/jmir.3129
PMCID: PMC3978551  PMID: 24662625
mindfulness-based cognitive therapy; online depression; Web-based depression; Internet-based depression; depression relapse prevention; residual depression symptoms; online psychological treatment; qualitative methods
4.  Efficacy of a Web-Based Computer-Tailored Smoking Prevention Intervention for Dutch Adolescents: Randomized Controlled Trial 
Background
Preventing smoking initiation among adolescents is crucial to reducing tobacco-caused death and disease. This study focuses on the effectiveness of a Web-based computer-tailored smoking prevention intervention aimed at adolescents.
Objective
The intent of the study was to describe the intervention characteristics and to show the effectiveness and results of a randomized controlled trial. We hypothesized that the intervention would prevent smoking initiation among Dutch secondary school students aged 10-20 years and would have the largest smoking prevention effect among the age cohort of 14-16 years, as smoking uptake in that period is highest.
Methods
The intervention consisted of a questionnaire and fully automated computer-tailored feedback on intention to start smoking and motivational determinants. A total of 89 secondary schools were recruited via postal mail and randomized into either the computer-tailored intervention condition or the control condition. Participants had to complete a Web-based questionnaire at baseline and at 6-month follow-up. Data on smoking initiation were collected from 897 students from these schools. To identify intervention effects, multilevel logistic regression analyses were conducted using multiple imputation.
Results
Smoking initiation among students aged 10-20 years was borderline significantly lower in the experimental condition as compared to the control condition 6 months after baseline (OR 0.25, 95% CI 0.05-1.21, P=.09). Additional analyses of the data for the 14-16 year age group showed a significant effect, with 11.5% (24/209) of the students in the control condition reporting initiation compared to 5.7% (10/176) in the experimental condition (OR 0.22, 95% CI 0.05-1.02, P=.05). No moderation effects were found regarding gender and educational level.
Conclusions
The findings of this study suggest that computer-tailored smoking prevention programs are a promising way of preventing smoking initiation among adolescents for at least 6 months, in particular among the age cohort of 14-16 years. Further research is needed to focus on long-term effects.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 77864351; http://www.controlled-trials.com/ISRCTN77864351 (Archived by WebCite at http://www.webcitation.org/6BSLKSTm5).
doi:10.2196/jmir.2469
PMCID: PMC3978560  PMID: 24657434
computer tailoring; Web-based intervention; Internet; smoking prevention; smoking initiation; adolescents; randomized controlled trial
5.  Economic Evaluation of a Web-Based Tailored Lifestyle Intervention for Adults: Findings Regarding Cost-Effectiveness and Cost-Utility From a Randomized Controlled Trial 
Background
Different studies have reported the effectiveness of Web-based computer-tailored lifestyle interventions, but economic evaluations of these interventions are scarce.
Objective
The objective was to assess the cost-effectiveness and cost-utility of a sequential and a simultaneous Web-based computer-tailored lifestyle intervention for adults compared to a control group.
Methods
The economic evaluation, conducted from a societal perspective, was part of a 2-year randomized controlled trial including 3 study groups. All groups received personalized health risk appraisals based on the guidelines for physical activity, fruit intake, vegetable intake, alcohol consumption, and smoking. Additionally, respondents in the sequential condition received personal advice about one lifestyle behavior in the first year and a second behavior in the second year; respondents in the simultaneous condition received personal advice about all unhealthy behaviors in both years. During a period of 24 months, health care use, medication use, absenteeism from work, and quality of life (EQ-5D-3L) were assessed every 3 months using Web-based questionnaires. Demographics were assessed at baseline, and lifestyle behaviors were assessed at both baseline and after 24 months. Cost-effectiveness and cost-utility analyses were performed based on the outcome measures lifestyle factor (the number of guidelines respondents adhered to) and quality of life, respectively. We accounted for uncertainty by using bootstrapping techniques and sensitivity analyses.
Results
A total of 1733 respondents were included in the analyses. From a willingness to pay of €4594 per additional guideline met, the sequential intervention (n=552) was likely to be the most cost-effective, whereas from a willingness to pay of €10,850, the simultaneous intervention (n=517) was likely to be most cost-effective. The control condition (n=664) appeared to be preferred with regard to quality of life.
Conclusions
Both the sequential and the simultaneous lifestyle interventions were likely to be cost-effective when it concerned the lifestyle factor, whereas the control condition was when it concerned quality of life. However, there is no accepted cutoff point for the willingness to pay per gain in lifestyle behaviors, making it impossible to draw firm conclusions. Further economic evaluations of lifestyle interventions are needed.
Trial Registration
Dutch Trial Register NTR2168; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2168 (Archived by WebCite at http://www.webcitation.org/6MbUqttYB).
doi:10.2196/jmir.3159
PMCID: PMC3978559  PMID: 24650860
randomized controlled trial; economic evaluation; cost-effectiveness; cost-utility; lifestyle behaviors; Internet interventions; Web-based; computer-tailoring
6.  Stroke Experiences in Weblogs: A Feasibility Study of Sex Differences 
Background
Research on cerebral stroke symptoms using hospital records has reported that women experience more nontraditional symptoms of stroke (eg, mental status change, pain) than men do. This is an important issue because nontraditional symptoms may delay the decision to get medical assistance and increase the difficulty of correct diagnosis. In the present study, we investigate sex differences in the stroke experience as described in stories on weblogs.
Objective
The goal of this study was to investigate the feasibility of using the Internet as a source of data for basic research on stroke experiences.
Methods
Stroke experiences described in blogs were identified by using StoryUpgrade, a program that searches blog posts using a fictional prototype story. In this study, the prototype story was a description of a stroke experience. Retrieved stories coded by the researchers as relevant were used to update the search query and retrieve more stories using relevance feedback. Stories were coded for first- or third-person narrator, traditional and nontraditional patient symptoms, type of stroke, patient sex and age, delay before seeking medical assistance, and delay at hospital and in treatment.
Results
There were 191 relevant stroke stories of which 174 stories reported symptoms (52.3% female and 47.7% male patients). There were no sex differences for each traditional or nontraditional stroke symptom by chi-square analysis (all Ps>.05). Type of narrator, however, affected report of traditional and nontraditional symptoms. Female first-person narrators (ie, the patient) were more likely to report mental status change (56.3%, 27/48) than male first-person narrators (36.4%, 16/44), a marginally significant effect by logistic regression (P=.056), whereas reports of third-person narrators did not differ for women (27.9%, 12/43) and men (28.2%, 11/39) patients. There were more reports of at least 1 nontraditional symptom in the 92 first-person reports (44.6%, 41/92) than in the 82 third-person reports (25.6%, 21/82, P=.006). Ischemic or hemorrhagic stroke was reported in 67 and 29 stories, respectively. Nontraditional symptoms varied with stroke type with 1 or more nontraditional symptoms reported for 79.3% (23/29) of hemorrhagic stroke patients and 53.7% (36/67) of ischemic stroke patients (P=.001).
Conclusions
The results replicate previous findings based on hospital interview data supporting the reliability of findings from weblogs. New findings include the effect of first- versus third-person narrator on sex differences in the report of nontraditional symptoms. This result suggests that narrator is an important variable to be examined in future studies. A fragmentary data problem limits some conclusions because important information, such as age, was not consistently reported. Age trends strengthen the feasibility of using the Internet for stroke research because older adults have significantly increased their Internet use in recent years.
doi:10.2196/jmir.2838
PMCID: PMC3978549  PMID: 24647327
cerebral stroke; signs and symptoms; sex differences; Internet; blogging
7.  Smartphone Apps for Cardiopulmonary Resuscitation Training and Real Incident Support: A Mixed-Methods Evaluation Study 
Background
No systematic evaluation of smartphone/mobile apps for resuscitation training and real incident support is available to date. To provide medical, usability, and additional quality criteria for the development of apps, we conducted a mixed-methods sequential evaluation combining the perspective of medical experts and end-users.
Objective
The study aims to assess the quality of current mobile apps for cardiopulmonary resuscitation (CPR) training and real incident support from expert as well as end-user perspective.
Methods
Two independent medical experts evaluated the medical content of CPR apps from the Google Play store and the Apple App store. The evaluation was based on pre-defined minimum medical content requirements according to current Basic Life Support (BLS) guidelines. In a second phase, non-medical end-users tested usability and appeal of the apps that had at least met the minimum requirements. Usability was assessed with the System Usability Scale (SUS); appeal was measured with the self-developed ReactionDeck toolkit.
Results
Out of 61 apps, 46 were included in the experts’ evaluation. A consolidated list of 13 apps resulted for the following layperson evaluation. The interrater reliability was substantial (kappa=.61). Layperson end-users (n=14) had a high interrater reliability (intraclass correlation 1 [ICC1]=.83, P<.001, 95% CI 0.75-0.882 and ICC2=.79, P<.001, 95% CI 0.695-0.869). Their evaluation resulted in a list of 5 recommendable apps.
Conclusions
Although several apps for resuscitation training and real incident support are available, very few are designed according to current BLS guidelines and offer an acceptable level of usability and hedonic quality for laypersons. The results of this study are intended to optimize the development of CPR mobile apps. The app ranking supports the informed selection of mobile apps for training situations and CPR campaigns as well as for real incident support.
doi:10.2196/jmir.2951
PMCID: PMC3978555  PMID: 24647361
basic life support (BLS); cardiopulmonary resuscitation (CPR); external chest compression (ECC); smartphone apps; mobile phone; mobile health
8.  Do Email and Mobile Phone Prompts Stimulate Primary School Children to Reuse an Internet-Delivered Smoking Prevention Intervention? 
Background
Improving the use (eg, initial visit and revisits) of Internet-delivered interventions to promote healthy lifestyles such as non-smoking is one of the largest challenges in the field of eHealth. Prompts have shown to be effective in stimulating reuse of Internet-delivered interventions among adults and adolescents. However, evidence concerning effectiveness of prompts to promote reuse of a website among children is still scarce.
Objective
The aim of this study is to investigate (1) whether prompts are effective in promoting reuse of an intervention website containing information on smoking prevention for children, (2) whether the content of the prompt is associated with its effect in terms of reuse, and (3) whether there are differences between children who do or do not respond to prompts.
Methods
The sample of this cluster-randomized study consisted of 1124 children (aged 10-11 years) from 108 Dutch primary schools, who were assigned to the experimental group of an Internet-delivered smoking prevention intervention study. All participants completed a Web-based questionnaire on factors related to (non-)smoking. Schools were randomized to a no-prompt group (n=50) or a prompt group (n=58). All children could revisit the intervention website, but only the children in the prompt group received email and SMS prompts to revisit the website. Those prompt messages functioned as a teaser to stimulate reuse of the intervention website. Reuse of the website was objectively tracked by means of a server registration system. Repeated measures analysis of variance and linear regression analysis were performed to assess the effects of prompts on website reuse and to identify individual characteristics of participants who reuse the intervention website.
Results
Children in the prompt group reused the intervention website significantly more often compared to children in the no-prompt group (B=1.56, P<.001). Prompts announcing new animated videos (F 1,1122=9.33, P=.002) and games about (non-)smoking on the website (F 1,1122=8.28, P=.004) resulted in most reuse of the website. Within the prompt group, children with a low socioeconomic status (SES) reused the intervention website more often (B=2.19, P<.001) than children of high SES (B=0.93, P=.005).
Conclusions
Prompts can stimulate children to reuse an intervention website aimed at smoking prevention. Prompts showed, furthermore, to stimulate children of a low SES slightly more to reuse an intervention website, which is often a difficult target group in terms of stimulating participation. However, the number of revisits was quite low, which requires further study into how prompts can be optimized in terms of content and frequency to improve the number of revisits.
Trial Registration
Netherlands Trial Register Number: NTR3116; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3116 (Archived by WebCite at http://www.webcitation.org/6O0wQYuPI).
doi:10.2196/jmir.3069
PMCID: PMC3978553  PMID: 24642082
Internet; Internet-delivered intervention; prompts; primary school children; computer-tailoring
9.  Animated Randomness, Avatars, Movement, and Personalization in Risk Graphics 
Background
Risk communication involves conveying two inherently difficult concepts about the nature of risk: the underlying random distribution of outcomes and how a population-based proportion applies to an individual.
Objective
The objective of this study was to test whether 4 design factors in icon arrays—animated random dispersal of risk events, avatars to represent an individual, personalization (operationalized as choosing the avatar’s color), and a moving avatar—might help convey randomness and how a given risk applies to an individual, thereby better aligning risk perceptions with risk estimates.
Methods
A diverse sample of 3630 adults with no previous heart disease or stroke completed an online nested factorial experiment in which they entered personal health data into a risk calculator that estimated 10-year risk of cardiovascular disease based on a robust and validated model. We randomly assigned them to view their results in 1 of 10 risk graphics that used different combinations of the 4 design factors. We measured participants’ risk perceptions as our primary outcome, as well as behavioral intentions and recall of the risk estimate. We also assessed subjective numeracy, whether or not participants knew anyone who had died of cardiovascular causes, and whether or not they knew their blood pressure and cholesterol as potential moderators.
Results
Animated randomness was associated with better alignment between risk estimates and risk perceptions (F 1,3576=6.12, P=.01); however, it also led to lower scores on healthy lifestyle intentions (F 1,3572=11.1, P<.001). Using an avatar increased risk perceptions overall (F 1,3576=4.61, P=.03) and most significantly increased risk perceptions among those who did not know a particular person who had experienced the grave outcomes of cardiovascular disease (F 1,3576=5.88, P=.02). Using an avatar also better aligned actual risk estimates with intentions to see a doctor (F 1,3556=6.38, P=.01). No design factors had main effects on recall, but animated randomness was associated with better recall for those at lower risk and worse recall for those at higher risk (F 1,3544=7.06, P=.01).
Conclusions
Animated randomness may help people better understand the random nature of risk. However, in the context of cardiovascular risk, such understanding may result in lower healthy lifestyle intentions. Therefore, whether or not to display randomness may depend on whether one’s goal is to persuade or to inform. Avatars show promise for helping people grasp how population-based statistics map to an individual case.
doi:10.2196/jmir.2895
PMCID: PMC3978557  PMID: 24642037
risk graphics; health communication; cardiovascular disease; animation; avatar; pictograph; icon array
10.  Web-Based Apps for Reflection: A Longitudinal Study With Hospital Staff 
Background
Reflection is an important cognitive process in workplace learning; however, it occurs only rarely on its own and therefore needs additional support.
Objective
In this study, we investigated the effect of software applications (apps) that aim to support reflection on hospital staff’s actual reflection behavior. In doing so, we also analyzed the relationship between reflection and the job satisfaction of health care professionals.
Methods
Reflective learning was introduced in the ward of a neurological hospital by providing apps that aimed to foster particular aspects of individual and collaborative reflection. Data were collected repeatedly: once before the introduction of the apps and again 2 years after the initial measure. We used a questionnaire with subjective ratings of reflection and job satisfaction. Response rates were 34.4% (167/485) for the first and 40.6% (210/517) for the second measure.
Results
Collaborative reflection was increased (P=.047) after the provision of the apps (2010: mean 2.84, SD 0.72; 2012: mean 3.06, SD 0.63) in contrast to a control group of other wards of the same hospital (2010: mean 2.68, SD 0.67; 2012: mean 2.63, SD 0.68). In addition, we revealed a positive correlation between collaborative reflection and job satisfaction (r=.61, P<.001).
Conclusions
The findings provide evidence for an effect of the apps on hospital employees’ reflection behavior. Apps that foster reflective learning can increase health care professionals’ reflection about work experiences and support them in discussing experiences in teams or with their supervisors. The relationship between collaborative reflection and job satisfaction suggests that opportunities for joint reflection on work experiences in a hospital have further impact over and above fostering reflective learning per se. We discuss the limitations of our study and provide suggestions for both future research and the development of Web-based apps.
doi:10.2196/jmir.3040
PMCID: PMC3979169  PMID: 24637405
computer applications software; mobile applications; learning; education, continuing; job satisfaction; hospitals; longitudinal studies; self report
11.  Tailored and Integrated Web-Based Tools for Improving Psychosocial Outcomes of Cancer Patients: The DoTTI Development Framework 
Background
Effective communication with cancer patients and their families about their disease, treatment options, and possible outcomes may improve psychosocial outcomes. However, traditional approaches to providing information to patients, including verbal information and written booklets, have a number of shortcomings centered on their limited ability to meet patient preferences and literacy levels. New-generation Web-based technologies offer an innovative and pragmatic solution for overcoming these limitations by providing a platform for interactive information seeking, information sharing, and user-centered tailoring.
Objective
The primary goal of this paper is to discuss the advantages of comprehensive and iterative Web-based technologies for health information provision and propose a four-phase framework for the development of Web-based information tools.
Methods
The proposed framework draws on our experience of constructing a Web-based information tool for hematological cancer patients and their families. The framework is based on principles for the development and evaluation of complex interventions and draws on the Agile methodology of software programming that emphasizes collaboration and iteration throughout the development process.
Results
The DoTTI framework provides a model for a comprehensive and iterative approach to the development of Web-based informational tools for patients. The process involves 4 phases of development: (1) Design and development, (2) Testing early iterations, (3) Testing for effectiveness, and (4) Integration and implementation. At each step, stakeholders (including researchers, clinicians, consumers, and programmers) are engaged in consultations to review progress, provide feedback on versions of the Web-based tool, and based on feedback, determine the appropriate next steps in development.
Conclusions
This 4-phase framework is evidence-informed and consumer-centered and could be applied widely to develop Web-based programs for a diverse range of diseases.
doi:10.2196/jmir.2849
PMCID: PMC3971205  PMID: 24641991
Internet; consumer health information; health literacy; medical informatics; neoplasms; communication
12.  The Use of Social Networking Sites for Public Health Practice and Research: A Systematic Review 
Background
Social networking sites (SNSs) have the potential to increase the reach and efficiency of essential public health services, such as surveillance, research, and communication.
Objective
The objective of this study was to conduct a systematic literature review to identify the use of SNSs for public health research and practice and to identify existing knowledge gaps.
Methods
We performed a systematic literature review of articles related to public health and SNSs using PubMed, EMBASE, and CINAHL to search for peer-reviewed publications describing the use of SNSs for public health research and practice. We also conducted manual searches of relevant publications. Each publication was independently reviewed by 2 researchers for inclusion and extracted relevant study data.
Results
A total of 73 articles met our inclusion criteria. Most articles (n=50) were published in the final 2 years covered by our search. In all, 58 articles were in the domain of public health research and 15 were in public health practice. Only 1 study was conducted in a low-income country. Most articles (63/73, 86%) described observational studies involving users or usages of SNSs; only 5 studies involved randomized controlled trials. A large proportion (43/73, 59%) of the identified studies included populations considered hard to reach, such as young individuals, adolescents, and individuals at risk of sexually transmitted diseases or alcohol and substance abuse. Few articles (2/73, 3%) described using the multidirectional communication potential of SNSs to engage study populations.
Conclusions
The number of publications about public health uses for SNSs has been steadily increasing in the past 5 years. With few exceptions, the literature largely consists of observational studies describing users and usages of SNSs regarding topics of public health interest. More studies that fully exploit the communication tools embedded in SNSs and study their potential to produce significant effects in the overall population’s health are needed.
doi:10.2196/jmir.2679
PMCID: PMC3971364  PMID: 24642014
public health informatics; public health; social network; health communication
13.  Considerations for Conducting Web-Based Survey Research With People Living With Human Immunodeficiency Virus Using a Community-Based Participatory Approach 
Background
Web or Internet-based surveys are increasingly popular in health survey research. However, the strengths and challenges of Web-based surveys with people living with human immunodeficiency virus (HIV) are unclear.
Objective
The aim of this article is to describe our experience piloting a cross-sectional, Web-based, self-administered survey with adults living with HIV using a community-based participatory research approach.
Methods
We piloted a Web-based survey that investigated disability and rehabilitation services use with a sample of adults living with HIV in Canada. Community organizations in five provinces emailed invitations to clients, followed by a thank you/reminder one week later. We obtained survey feedback in a structured phone interview with respondents. Participant responses were transcribed verbatim and analyzed using directed content analysis.
Results
Of 30 people living with HIV who accessed the survey link, 24/30 (80%) initiated and 16/30 (53%) completed the survey instrument. A total of 17 respondents participated in post-survey interviews. Participants described the survey instrument as comprehensive, suggesting content validity. The majority (13/17, 76%) felt instruction and item wording were clear and easy to understand, and found the software easy to navigate. Participants felt having a pop-up reminder directing them to missed items would be useful.
Conclusions
Strengths of implementing the Web-based survey included: our community-based participatory approach, ease of software use, ability for respondents to complete the questionnaire on one’s own time at one’s own pace, opportunity to obtain geographic variation, and potential for respondent anonymity. Considerations for future survey implementation included: respondent burden and fatigue, the potentially sensitive nature of HIV Web-based research, data management and storage, challenges verifying informed consent, varying computer skills among respondents, and the burden on community organizations. Overall, results provide considerations for researchers conducting community-based participatory Web-based survey research with people living with HIV.
doi:10.2196/jmir.3064
PMCID: PMC3971118  PMID: 24642066
HIV infections; Internet; self-report; health surveys; questionnaires; community-based participatory research
14.  Implementing a Virtual Community of Practice for Family Physician Training: A Mixed-Methods Case Study 
Background
GP training in Australia can be professionally isolating, with trainees spread across large geographic areas, leading to problems with rural workforce retention. Virtual communities of practice (VCoPs) may provide a way of improving knowledge sharing and thus reducing professional isolation.
Objective
The goal of our study was to review the usefulness of a 7-step framework for implementing a VCoP for general practitioner (GP) training and then evaluated the usefulness of the resulting VCoP in facilitating knowledge sharing and reducing professional isolation.
Methods
The case was set in an Australian general practice training region involving 55 first-term trainees (GPT1s), from January to July 2012. ConnectGPR was a secure, online community site that included standard community options such as discussion forums, blogs, newsletter broadcasts, webchats, and photo sharing. A mixed-methods case study methodology was used. Results are presented and interpreted for each step of the VCoP 7-step framework and then in terms of the outcomes of knowledge sharing and overcoming isolation.
Results
Step 1, Facilitation: Regular, personal facilitation by a group of GP trainers with a co-ordinating facilitator was an important factor in the success of ConnectGPR. Step 2, Champion and Support: Leadership and stakeholder engagement were vital. Further benefits are possible if the site is recognized as contributing to training time. Step 3, Clear Goals: Clear goals of facilitating knowledge sharing and improving connectedness helped to keep the site discussions focused. Step 4, A Broad Church: The ConnectGPR community was too narrow, focusing only on first-term trainees (GPT1s). Ideally there should be more involvement of senior trainees, trainers, and specialists. Step 5, A Supportive Environment: Facilitators maintained community standards and encouraged participation. Step 6, Measurement Benchmarking and Feedback: Site activity was primarily driven by centrally generated newsletter feedback. Viewing comments by other participants helped users benchmark their own knowledge, particularly around applying guidelines. Step 7, Technology and Community: All the community tools were useful, but chat was limited and users suggested webinars in future. A larger user base and more training may also be helpful. Time is a common barrier. Trust can be built online, which may have benefit for trainees that cannot attend face-to-face workshops. Knowledge sharing and isolation outcomes: 28/34 (82%) of the eligible GPT1s enrolled on ConnectGPR. Trainees shared knowledge through online chat, forums, and shared photos. In terms of knowledge needs, GPT1s rated their need for cardiovascular knowledge more highly than supervisors. Isolation was a common theme among interview respondents, and ConnectGPR users felt more supported in their general practice (13/14, 92.9%).
Conclusions
The 7-step framework for implementation of an online community was useful. Overcoming isolation and improving connectedness through an online knowledge sharing community shows promise in GP training. Time and technology are barriers that may be overcome by training, technology, and valuable content. In a VCoP, trust can be built online. This has implications for course delivery, particularly in regional areas. VCoPs may also have a specific role assisting overseas trained doctors to interpret their medical knowledge in a new context.
doi:10.2196/jmir.3083
PMCID: PMC3967123  PMID: 24622292
community of practice; virtual community of practice; general practice; family physician; training; medical graduate; education; social media
15.  An Internet- and Mobile-Based Tailored Intervention to Enhance Maintenance of Physical Activity After Cardiac Rehabilitation: Short-Term Results of a Randomized Controlled Trial 
Background
An increase in physical activity for secondary prevention of cardiovascular disease and cardiac rehabilitation has multiple therapeutic benefits, including decreased mortality. Internet- and mobile-based interventions for physical activity have shown promising results in helping users increase or maintain their level of physical activity in general and specifically in secondary prevention of cardiovascular diseases and cardiac rehabilitation. One component related to the efficacy of these interventions is tailoring of the content to the individual.
Objective
Our trial assessed the effect of a longitudinally tailored Internet- and mobile-based intervention for physical activity as an extension of a face-to-face cardiac rehabilitation stay. We hypothesized that users of the tailored intervention would maintain their physical activity level better than users of the nontailored version.
Methods
The study population included adult participants of a cardiac rehabilitation program in Norway with home Internet access and a mobile phone. The participants were randomized in monthly clusters to a tailored or nontailored (control) intervention group. All participants had access to a website with information regarding cardiac rehabilitation, an online discussion forum, and an online activity calendar. Those using the tailored intervention received tailored content based on models of health behavior via the website and mobile fully automated text messages. The main outcome was self-reported level of physical activity, which was obtained using an online international physical activity questionnaire at baseline, at discharge, and at 1 month and 3 months after discharge from the cardiac rehabilitation program.
Results
Included in the study were 69 participants. One month after discharge, the tailored intervention group (n=10) had a higher median level of overall physical activity (median 2737.5, IQR 4200.2) than the control group (n=14, median 1650.0, IQR 2443.5), but the difference was not significant (Kolmogorov-Smirnov Z=0.823, P=.38, r=.17). At 3 months after discharge, the tailored intervention group (n=7) had a significantly higher median level of overall physical activity (median 5613.0, IQR 2828.0) than the control group (n=12, median 1356.0, IQR 2937.0; Kolmogorov-Smirnov Z=1.397, P=.02, r=.33). The median adherence was 45.0 (95% CI 0.0-169.8) days for the tailored group and 111.0 (95% CI 45.1-176.9) days for the control group; however, the difference was not significant (P=.39). There were no statistically significant differences between the 2 groups in stage of change, self-efficacy, social support, perceived tailoring, anxiety, or depression.
Conclusions
Because of the small sample size and the high attrition rate at the follow-up visits, we cannot make conclusions regarding the efficacy of our approach, but the results indicate that the tailored version of the intervention may have contributed to the long-term higher physical activity maintained after cardiac rehabilitation by participants receiving the tailored intervention compared with those receiving the nontailored intervention.
Trial Registration
ClinicalTrials.gov: NCT01223170; http://clinicaltrials.gov/show/NCT01223170 (Archived by WebCite at http://www.webcitation.org/6Nch4ldcL).
doi:10.2196/jmir.3132
PMCID: PMC3967125  PMID: 24618349
rehabilitation; cardiovascular diseases; exercise therapy; eHealth; telemedicine; Internet; cellular phone; self-management; physical activity; persuasive communication; health behavior
16.  Determinants of Follow-Up Participation in the Internet-Based European Influenza Surveillance Platform Influenzanet 
Background
“Influenzanet” is a network of Internet-based platforms aimed at collecting real-time data for influenza surveillance in several European countries. More than 30,000 European volunteers participate every year in the study, representing one of the largest existing Internet-based multicenter cohorts. Each week during the influenza season, participants are asked to report their symptoms (if any) along with a set of additional questions.
Objective
Focusing on the first influenza season of 2011-12, when the Influenzanet system was completely harmonized within a common framework in Sweden, the United Kingdom, the Netherlands, Belgium, France, Italy, and Portugal, we investigated the propensity of users to regularly come back to the platform to provide information about their health status. Our purpose was to investigate demographic and behavioral factors associated with participation in follow-up.
Methods
By means of a multilevel analysis, we evaluated the association between regular participation during the season and sociodemographic and behavioral characteristics as measured by a background questionnaire completed by participants on registration.
Results
We found that lower participation in follow-up was associated with lower educational status (odds ratio [OR] 0.80, 95% CI 0.75-0.85), smoking (OR 0.64, 95% CI 0.59-0.70), younger age (OR ranging from 0.30, 95% CI 0.26-0.33 to 0.70, 95% CI 0.64-0.77), not being vaccinated against seasonal influenza (OR 0.77, 95% CI 0.72-0.84), and living in a household with children (OR 0.69, 95% CI 0.65-0.74). Most of these results hold when single countries are analyzed separately.
Conclusions
Given the opportunistic enrollment of self-selected volunteers in the Influenzanet study, we have investigated how sociodemographic and behavioral characteristics may be associated with follow-up participation in the Influenzanet cohort. The study described in this paper shows that, overall, the most important determinants of participation are related to education and lifestyle: smoking, lower education level, younger age, people living with children, and people who have not been vaccinated against seasonal influenza tend to have a lower participation in follow-up. Despite the cross-country variation, the main findings are similar in the different national cohorts, and indeed the results are found to be valid also when performing a single-country analysis. Differences between countries do not seem to play a crucial role in determining the factors associated with participation in follow-up.
doi:10.2196/jmir.3010
PMCID: PMC3967126  PMID: 24613818
participatory surveillance; Internet; influenza
17.  Effectiveness of eHealth Interventions and Information Needs in Palliative Care: A Systematic Literature Review 
Background
One of the key components in palliative care is communication. eHealth technologies can be an effective way to support communications among participants in the process of palliative care. However, it is unclear to what extent information technology has been established in this field.
Objective
Our goal was to systematically identify studies and analyze the effectiveness of eHealth interventions in palliative care and the information needs of people involved in the palliative care process.
Methods
We conducted a systematic literature search using PubMed, Embase, and LILACS according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We collected and analyzed quantitative and qualitative data regarding effectiveness of eHealth interventions and users’ information needs in palliative care.
Results
Our search returned a total of 240 articles, 17 of which met our inclusion criteria. We found no randomized controlled trial studying the effects of eHealth interventions in palliative care. Studies tended to be observational, noncontrolled studies, and a few quasi-experimental studies. Overall there was great heterogeneity in the types of interventions and outcome assessments; some studies reported some improvement on quality of care, documentation effort, cost, and communications. The most frequently reported information need concerned pain management.
Conclusions
There is limited evidence around the effectiveness of eHealth interventions for palliative care patients, caregivers, and health care professionals. Focused research on information needs and high-quality clinical trials to assess their effectiveness are needed.
doi:10.2196/jmir.2812
PMCID: PMC3961802  PMID: 24610324
palliative Care; eHealth; systematic review
18.  Evaluating User Experiences of the Secure Messaging Tool on the Veterans Affairs’ Patient Portal System 
Background
The United States Department of Veterans Affairs has implemented an electronic asynchronous “Secure Messaging” tool within a Web-based patient portal (ie, My HealtheVet) to support patient-provider communication. This electronic resource promotes continuous and coordinated patient-centered care, but to date little research has evaluated patients’ experiences and preferences for using Secure Messaging.
Objective
The objectives of this mixed-methods study were to (1) characterize veterans’ experiences using Secure Messaging in the My HealtheVet portal over a 3-month period, including system usability, (2) identify barriers to and facilitators of use, and (3) describe strategies to support veterans’ use of Secure Messaging.
Methods
We recruited 33 veterans who had access to and had previously used the portal’s Secure Messaging tool. We used a combination of in-depth interviews, face-to-face user-testing, review of transmitted secure messages between veterans and staff, and telephone interviews three months following initial contact. We assessed participants’ computer and health literacy during initial and follow-up interviews. We used a content-analysis approach to identify dominant themes in the qualitative data. We compared inferences from each of the data sources (interviews, user-testing, and message review) to identify convergent and divergent data trends.
Results
The majority of veterans (27/33, 82%) reported being satisfied with Secure Messaging at initial interview; satisfaction ratings increased to 97% (31/32, 1 missing) during follow-up interviews. Veterans noted Secure Messaging to be useful for communicating with their primary care team to manage health care needs (eg, health-related questions, test requests and results, medication refills and questions, managing appointments). Four domains emerged from interviews: (1) perceived benefits of using Secure Messaging, (2) barriers to using Secure Messaging, (3) facilitators for using Secure Messaging, and (4) suggestions for improving Secure Messaging. Veterans identified and demonstrated impediments to successful system usage that can be addressed with education, skill building, and system modifications. Analysis of secure message content data provided insights to reasons for use that were not disclosed by participants during interviews, specifically sensitive health topics such as erectile dysfunction and sexually transmitted disease inquiries.
Conclusions
Veterans perceive Secure Messaging in the My HealtheVet patient portal as a useful tool for communicating with health care teams. However, to maximize sustained utilization of Secure Messaging, marketing, education, skill building, and system modifications are needed. Data from this study can inform a large-scale quantitative assessment of Secure Messaging users’ experiences in a representative sample to validate qualitative findings.
doi:10.2196/jmir.2976
PMCID: PMC3961805  PMID: 24610454
veterans; secure messaging; patient-provider communication; Department of Veterans Affairs; usability testing; mixed methods; patient-centered care
19.  Multimodal Guided Self-Help Exercise Program to Prevent Speech, Swallowing, and Shoulder Problems Among Head and Neck Cancer Patients: A Feasibility Study 
Background
During a 6-week course of (chemo)radiation many head and neck cancer patients have to endure radiotherapy-induced toxicity, negatively affecting patients’ quality of life. Pretreatment counseling combined with self-help exercises could be provided to inform patients and possibly prevent them from having speech, swallowing, and shoulder problems during and after treatment.
Objective
Our goal was to investigate the feasibility of a multimodal guided self-help exercise program entitled Head Matters during (chemo)radiation in head and neck cancer patients.
Methods
Head and neck cancer patients treated with primary (chemo)radiation or after surgery were asked to perform Head Matters at home. This prophylactic exercise program, offered in three different formats, aims to reduce the risk of developing speech, swallowing, shoulder problems, and a stiff neck. Weekly coaching was provided by a speech and swallowing therapist. Patients filled out a diary to keep track of their exercise activity. To gain insight into possible barriers and facilitators to exercise adherence, reports of weekly coaching sessions were analyzed by 2 coders independently.
Results
Of 41 eligible patients, 34 patients were willing to participate (83% uptake). Of participating patients, 21 patients completed the program (64% adherence rate). The majority of participants (58%) had a moderate to high level of exercise performance. Exercise performance level was not significantly associated with age (P=.50), gender (P=.42), tumor subsite (P=1.00) or tumor stage (P=.20), treatment modality (P=.72), or Head Matters format (Web-based or paper) (P=1.00). Based on patients’ diaries and weekly coaching sessions, patients’ perceived barriers to exercise were a decreased physical condition, treatment-related barriers, emotional problems, lack of motivation, social barriers, and technical problems. Patients’ perceived facilitators included an increased physical condition, feeling motivated, and social and technical facilitators.
Conclusions
Head Matters, a multimodal guided self-help exercise program is feasible for head and neck cancer patients undergoing (chemo)radiation. Several barriers (decreased physical condition, treatment-related barriers) and facilitators (increased physical condition, feeling motivated) were identified providing directions for future studies. The next step is conducting a study investigating the (cost-)effectiveness of Head Matters on speech, swallowing, shoulder function, and quality of life.
doi:10.2196/jmir.2990
PMCID: PMC3961811  PMID: 24610383
eHealth; self-care; head and neck cancer; exercise; speech; swallowing; shoulder; surgery; radiotherapy; chemotherapy
20.  The New Health-Related Top-Level Domains Are Coming: Will Cureforcancer.health Go to the Highest Bidder? 
In 2012, the Internet Corporation for Assigned Names and Numbers (ICANN) opened a new round of applications for generic top-level domain (gTLD) names, receiving 1930 applications, of which at least 18 were related to health (eg, “.doctor”, “.health”, “.med”). The entry of new, commercial players applying to create health-related names reopens the debate on the role of international organizations, governments, non-governmental organizations, and other stakeholders regarding the safeguards and policies needed to protect consumers.
doi:10.2196/jmir.3358
PMCID: PMC3961804  PMID: 24598704
top-level domains; global community health; health information sources; quality health information
21.  Health Domains for Sale: The Need for Global Health Internet Governance 
A debate on Internet governance for health, or “eHealth governance”, is emerging with the impending award of a new dot-health (.health) generic top-level domain name (gTLD) along with a host of other health-related domains. This development is critical as it will shape the future of the health Internet, allowing largely unrestricted use of .health second-level domain names by future registrants, raising concerns about the potential for privacy, use and marketing of health-related information, credibility of online health content, and potential for Internet fraud and abuse. Yet, prospective .health gTLD applicants do not provide adequate safeguards for use of .health or related domains and have few or no ties to the global health community. If approved, one of these for-profit corporate applicants would effectively control the future of the .health address on the Internet with arguably no active oversight from important international public health stakeholders. This would represent a lost opportunity for the public health, medical, and broader health community in establishing a trusted, transparent and reliable source for health on the Internet. Countries, medical associations, civil society, and consumer advocates have objected to these applications on grounds that they do not meet the public interest. We argue that there is an immediate need for action to postpone awarding of the .health gTLD and other health-related gTLDs to address these concerns and ensure the appropriate development of sound eHealth governance rules, principles, and use. This would support the crucial need of ensuring access to quality and evidence-based sources of health information online, as well as establishing a safe and reliable space on the Internet for health. We believe, if properly governed, .health and other domains could represent such a promise in the future.
doi:10.2196/jmir.3276
PMCID: PMC3961808  PMID: 24598602
eHealth; global health governance; information technology; Internet; domain names
22.  Do Online Mental Health Services Improve Help-Seeking for Young People? A Systematic Review 
Background
Young people regularly use online services to seek help and look for information about mental health problems. Yet little is known about the effects that online services have on mental health and whether these services facilitate help-seeking in young people.
Objective
This systematic review investigates the effectiveness of online services in facilitating mental health help-seeking in young people.
Methods
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, literature searches were conducted in PubMed, PsycINFO, and the Cochrane library. Out of 608 publications identified, 18 studies fulfilled the inclusion criteria of investigating online mental health services and help-seeking in young people aged 14-25 years.
Results
Two qualitative, 12 cross-sectional, one quasi-experimental, and three randomized controlled trials (RCTs) were reviewed. There was no change in help-seeking behavior found in the RCTs, while the quasi-experimental study found a slight but significant increase in help-seeking. The cross-sectional studies reported that online services facilitated seeking help from a professional source for an average of 35% of users. The majority of the studies included small sample sizes and a high proportion of young women. Help-seeking was often a secondary outcome, with only 22% (4/18) of studies using adequate measures of help-seeking. The majority of studies identified in this review were of low quality and likely to be biased. Across all studies, young people regularly used and were generally satisfied with online mental health resources. Facilitators and barriers to help-seeking were also identified.
Conclusions
Few studies examine the effects of online services on mental health help-seeking. Further research is needed to determine whether online mental health services effectively facilitate help-seeking for young people.
doi:10.2196/jmir.3103
PMCID: PMC3961801  PMID: 24594922
adolescent; young adult; Internet; medical informatics; mental health; mental disorders; systematic review; information seeking behavior
23.  Supporting Self-Care for Families of Children With Eczema With a Web-Based Intervention Plus Health Care Professional Support: Pilot Randomized Controlled Trial 
Background
Childhood eczema, or childhood atopic dermatitis, causes significant distress to children and their families through sleep disturbance and itch. The main cause of treatment failure is nonuse of prescribed treatments.
Objective
The objective of this study was to develop and test a Web-based intervention to support families of children with eczema, and to explore whether support from a health care professional (HCP) is necessary to engage participants with the intervention.
Methods
We followed the PRECEDE-PROCEED model: regular emollient use was the target behavior we were seeking to promote and we identified potential techniques to influence this. LifeGuide software was used to write the intervention website. Carers of children with eczema were invited through primary care mail-out and randomized to 3 groups: (1) website only, (2) website plus HCP support, or (3) usual care. Patient-Oriented Eczema Measure (POEM) scores were measured online by carer report at baseline and at 12 weeks. Qualitative interviews were carried out with 13 HCPs (primarily practice nurses) and 26 participants to explore their experiences of taking part in the study.
Results
A total of 143 carers were recruited through 31 practices. We found a decrease of ≥2 in follow-up compared with baseline POEM score in 23 of 42 (55%) participants in the website only group, 16 of 49 (33%) in the usual care group, and 18 of 47 (38%) in the website plus HCP group. Website use data showed that 75 of 93 (81%) participants allocated to the website groups completed the core modules, but less than half used other key components (videos: 35%; regular text reminders: 39%). There were no consistent differences in website use between the website only or the website plus HCP groups. Qualitative feedback showed that most HCPs had initial concerns about providing support for eczema self-care because this was not a condition that they felt expert in. However, HCPs reported productive consultations and that they found it helpful to use the website in consultations, while observing that some participants seemed to need more support than others. Qualitative interviews with participants suggested that HCP support was valued highly only by a minority, generally those who were less confident in their management of eczema or less confident using the Internet.
Conclusions
Our pilot trial demonstrated the potential for greater improvements in POEM scores in both website intervention groups and that a full-scale trial is feasible. Such a trial would quantify the effectiveness and cost-effectiveness of this intervention to determine whether it should be widely promoted to families of children with newly diagnosed eczema. In this study population, HCP support was not strongly valued by participants and did not lead to better outcomes or website use than use of the Web-based intervention alone.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 98560867; http://www.controlled-trials.com/ISRCTN98560867 (Archived by WebCite at http://www.webcitation.org/6NcxvMtgN).
doi:10.2196/jmir.3035
PMCID: PMC3961807  PMID: 24594972
child; primary care; randomized controlled trial; eczema; Internet; self-care
24.  Comparison of Text and Video Computer-Tailored Interventions for Smoking Cessation: Randomized Controlled Trial 
Background
A wide range of effective smoking cessation interventions have been developed to help smokers to quit. Smoking rates remain high, especially among people with a lower level of education. Multiple tailoring adapted to the individual’s readiness to quit and the use of visual messaging may increase smoking cessation.
Objective
The results of video and text computer tailoring were compared with the results of a control condition. Main effects and differential effects for subgroups with different educational levels and different levels of readiness to quit were assessed.
Methods
During a blind randomized controlled trial, smokers willing to quit within 6 months were assigned to a video computer tailoring group with video messages (n=670), a text computer tailoring group with text messages (n=708), or to a control condition with short generic text advice (n=721). After 6 months, effects on 7-day point prevalence abstinence and prolonged abstinence were assessed using logistic regression analyses. Analyses were conducted in 2 samples: (1) respondents (as randomly assigned) who filled in the baseline questionnaire and completed the first session of the program, and (2) a subsample of sample 1, excluding respondents who did not adhere to at least one further intervention session. In primary analyses, we used a negative scenario in which respondents lost to follow-up were classified as smokers. Complete case analysis and multiple imputation analyses were considered as secondary analyses.
Results
In sample 1, the negative scenario analyses revealed that video computer tailoring was more effective in increasing 7-day point prevalence abstinence than the control condition (OR 1.45, 95% CI 1.09-1.94, P=.01). Video computer tailoring also resulted in significantly higher prolonged abstinence rates than controls among smokers with a low (ready to quit within 4-6 months) readiness to quit (OR 5.13, 95% CI 1.76-14.92, P=.003). Analyses of sample 2 showed similar results, although text computer tailoring was also more effective than control in realizing 7-day point prevalence abstinence. No differential effects were found for level of education. Complete case analyses and multiple imputation yielded similar results.
Conclusions
In all analyses, video computer tailoring was effective in realizing smoking cessation. Furthermore, video computer tailoring was especially successful for smokers with a low readiness to quit smoking. Text computer tailoring was only effective for sample 2. Results suggest that video-based messages with personalized feedback adapted to the smoker’s motivation to quit might be effective in increasing abstinence rates for smokers with diverse educational levels.
Trial Registration
Netherlands Trial Register: NTR3102; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3102 (Archived by WebCite at http://www.webcitation.org/6NS8xhzUV).
doi:10.2196/jmir.3016
PMCID: PMC3961744  PMID: 24589938
smoking cessation; multiple computer tailoring; delivery strategy; educational level; text messages; video messages
25.  An Innovative Smartphone-Based Otorhinoendoscope and Its Application in Mobile Health and Teleotolaryngology 
Background
The traditional otorhinoendoscope is widely used in the diagnosis of a variety of ear and nose diseases, but only one doctor can use it at a time. It is also very difficult to share observations from one doctor with another doctor. With advances in electronic health technology, the extended potential application of smartphones to support medical practice or mobile health has grown steadily.
Objective
The first phase of the study discussed how smartphones may be used for otorhinoscopic imaging and image management via an innovative adaptor. The second phase of the study was to evaluate the diagnostic capability of the smartphone-based otorhinoendoscope, as compared to the traditional otorhinoendoscope, and its application in mobile health and teleotolaryngology.
Methods
We designed a unique adaptor to connect the otorhinoendoscope and smartphone in order to perform smartphone-based otorhinoendoscopy. The main aim was to transform the smartphone into an otorhinoendoscope. We devised a method that would allow us to use the smartphone’s camera to capture otorhinoscopic images. Using a freely available Web-based real-time communication application platform and the 3G (or WIFI) network, the smartphone-based otorhinoendoscope could synchronize the smartphone-based otorhinoscopic image with smartphones, tablet PCs, computer notebooks, or personal computers.
Results
We investigated the feasibility of telemedicine using a smartphone, tablet PC, and computer notebook. Six types of clinical otorhinoscopic images were acquired via the smartphone-based otorhinoendoscope from six patients, which were examined in this study. Three teleconsultants (doctors A, B, and C) reviewed the six types of clinical otorhinoscopic images and made a telediagnosis. When compared to the face-to-face diagnosis, which was made in-person via a traditional otorhinoendoscope, the three teleconsultants obtained scores of a correct primary telediagnosis 83% (5/6), 100% (6/6), and 100% (6/6) of the time, respectively. When the clinical data were provided, the three teleconsultants obtained a correct secondary telediagnosis score of 100% (6/6), 100% (6/6), and 100% (6/6) of the time, respectively.
Conclusions
The use of previously available technologies in the absence of any additional expensive devices could significantly increase the quality of diagnostics while lowering extraneous costs. Furthermore, this could also increase the connectivity between most isolated family doctors and remote referral centers.
doi:10.2196/jmir.2959
PMCID: PMC3961810  PMID: 24590187
otorhinoendoscope; smartphone; mobile health; teleotolaryngology; telediagnosis

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