Showing papers in "Journal of Medical Internet Research in 2012"

Persuasive System Design Does Matter: A Systematic Review of Adherence to Web-Based Interventions

Abstract: Background: Although web-based interventions for promoting health and health-related behavior can be effective, poor adherence is a common issue that needs to be addressed Technology as a means to communicate the content in web-based interventions has been neglected in research Indeed, technology is often seen as a black-box, a mere tool that has no effect or value and serves only as a vehicle to deliver intervention content In this paper we examine technology from a holistic perspective We see it as a vital and inseparable aspect of web-based interventions to help explain and understand adherence Objective: This study aims to review the literature on web-based health interventions to investigate whether intervention characteristics and persuasive design affect adherence to a web-based intervention Methods: We conducted a systematic review of studies into web-based health interventions Per intervention, intervention characteristics, persuasive technology elements and adherence were coded We performed a multiple regression analysis to investigate whether these variables could predict adherence Results: We included 101 articles on 83 interventions The typical web-based intervention is meant to be used once a week, is modular in set-up, is updated once a week, lasts for 10 weeks, includes interaction with the system and a counselor and peers on the web, includes some persuasive technology elements, and about 50% of the participants adhere to the intervention Regarding persuasive technology, we see that primary task support elements are most commonly employed (mean 29 out of a possible 70) Dialogue support and social support are less commonly employed (mean 15 and 12 out of a possible 70, respectively) When comparing the interventions of the different health care areas, we find significant differences in intended usage (p = 004), setup (p < 001), updates (p < 001), frequency of interaction with a counselor (p < 001), the system (p = 003) and peers (p = 017), duration (F = 6068, p = 004), adherence (F = 4833, p = 010) and the number of primary task support elements (F = 5631, p = 005) Our final regression model explained 55% of the variance in adherence In this model, a RCT study as opposed to an observational study, increased interaction with a counselor, more frequent intended usage, more frequent updates and more extensive employment of dialogue support significantly predicted better adherence Conclusions: Using intervention characteristics and persuasive technology elements, a substantial amount of variance in adherence can be explained Although there are differences between health care areas on intervention characteristics, health care area per se does not predict adherence Rather, the differences in technology and interaction predict adherence The results of this study can be used to make an informed decision about how to design a web-based intervention to which patients are more likely to adhere

Design of an mHealth App for the Self-management of Adolescent Type 1 Diabetes: A Pilot Study

Abstract: Background: The use of mHealth apps has shown improved health outcomes in adult populations with type 2 diabetes mellitus. However, this has not been shown in the adolescent type 1 population, despite their predisposition to the use of technology. We hypothesized that a more tailored approach and a strong adherence mechanism is needed for this group. Objective: To design, develop, and pilot an mHealth intervention for the management of type 1 diabetes in adolescents. Methods: We interviewed adolescents with type 1 diabetes and their family caregivers. Design principles were derived from a thematic analysis of the interviews. User-centered design was then used to develop the mobile app bant . In the 12-week evaluation phase, a pilot group of 20 adolescents aged 12–16 years, with a glycated hemoglobin (HbA 1c ) of between 8% and 10% was sampled. Each participant was supplied with the bant app running on an iPhone or iPod Touch and a LifeScan glucometer with a Bluetooth adapter for automated transfers to the app. The outcome measure was the average daily frequency of blood glucose measurement during the pilot compared with the preceding 12 weeks. Results: Thematic analysis findings were the role of data collecting rather than decision making ; the need for fast, discrete transactions ; overcoming decision inertia ; and the need for ad hoc information sharing . Design aspects of the resultant app emerged through the user-centered design process, including simple, automated transfer of glucometer readings; the use of a social community; and the concept of gamification, whereby routine behaviors and actions are rewarded in the form of iTunes music and apps. Blood glucose trend analysis was provided with immediate prompting of the participant to suggest both the cause and remedy of the adverse trend. The pilot evaluation showed that the daily average frequency of blood glucose measurement increased 50% (from 2.4 to 3.6 per day, P = .006, n = 12). A total of 161 rewards (average of 8 rewards each) were distributed to participants. Satisfaction was high, with 88% (14/16 participants) stating that they would continue to use the system. Demonstrating improvements in HbA 1c will require a properly powered study of sufficient duration. Conclusions: This mHealth diabetes app with the use of gamification incentives showed an improvement in the frequency of blood glucose monitoring in adolescents with type 1 diabetes. Extending this to improved health outcomes will require the incentives to be tied not only to frequency of blood glucose monitoring but also to patient actions and decision making based on those readings such that glycemic control can be improved. [J Med Internet Res 2012;14(3):e70]

The Smartphone in Medicine: A Review of Current and Potential Use Among Physicians and Students

Abstract: Background: Advancements in technology have always had major impacts in medicine. The smartphone is one of the most ubiquitous and dynamic trends in communication, in which one’s mobile phone can also be used for communicating via email, performing Internet searches, and using specific applications. The smartphone is one of the fastest growing sectors in the technology industry, and its impact in medicine has already been significant. Objective: To provide a comprehensive and up-to-date summary of the role of the smartphone in medicine by highlighting the ways in which it can enhance continuing medical education, patient care, and communication. We also examine the evidence base for this technology. Methods: We conducted a review of all published uses of the smartphone that could be applicable to the field of medicine and medical education with the exclusion of only surgical-related uses. Results: In the 60 studies that were identified, we found many uses for the smartphone in medicine; however, we also found that very few high-quality studies exist to help us understand how best to use this technology. Conclusions: While the smartphone’s role in medicine and education appears promising and exciting, more high-quality studies are needed to better understand the role it will have in this field. We recommend popular smartphone applications for physicians that are lacking in evidence and discuss future studies to support their use. [J Med Internet Res 2012;14(5):e128]

eHealth literacy: extending the digital divide to the realm of health information.

Abstract: Background: eHealth literacy is defined as the ability of people to use emerging information and communications technologies to improve or enable health and health care. Objective: The goal of this study was to explore whether literacy disparities are diminished or enhanced in the search for health information on the Internet. The study focused on (1) traditional digital divide variables, such as sociodemographic characteristics, digital access, and digital literacy, (2) information search processes, and (3) the outcomes of Internet use for health information purposes. Methods: We used a countrywide representative random-digital-dial telephone household survey of the Israeli adult population (18 years and older, N = 4286). We measured eHealth literacy; Internet access; digital literacy; sociodemographic factors; perceived health; presence of chronic diseases; as well as health information sources, content, search strategies, and evaluation criteria used by consumers. Results: Respondents who were highly eHealth literate tended to be younger and more educated than their less eHealth-literate counterparts. They were also more active consumers of all types of information on the Internet, used more search strategies, and scrutinized information more carefully than did the less eHealth-literate respondents. Finally, respondents who were highly eHealth literate gained more positive outcomes from the information search in terms of cognitive, instrumental (self-management of health care needs, health behaviors, and better use of health insurance), and interpersonal (interacting with their physician) gains. Conclusions: The present study documented differences between respondents high and low in eHealth literacy in terms of background attributes, information consumption, and outcomes of the information search. The association of eHealth literacy with background attributes indicates that the Internet reinforces existing social differences. The more comprehensive and sophisticated use of the Internet and the subsequent increased gains among the high eHealth literate create new inequalities in the domain of digital health information. There is a need to educate at-risk and needy groups (eg, chronically ill) and to design technology in a mode befitting more consumers.

Increasing physical activity with mobile devices: a meta-analysis.

Abstract: Background: Regular physical activity has established physical and mental health benefits; however, merely one quarter of the U.S. adult population meets national physical activity recommendations. In an effort to engage individuals who do not meet these guidelines, researchers have utilized popular emerging technologies, including mobile devices (ie, personal digital assistants [PDAs], mobile phones). This study is the first to synthesize current research focused on the use of mobile devices for increasing physical activity. Objective: To conduct a meta-analysis of research utilizing mobile devices to influence physical activity behavior. The aims of this review were to: (1) examine the efficacy of mobile devices in the physical activity setting, (2) explore and discuss implementation of device features across studies, and (3) make recommendations for future intervention development. Methods: We searched electronic databases (PubMed, PsychINFO, SCOPUS) and identified publications through reference lists and requests to experts in the field of mobile health. Studies were included that provided original data and aimed to influence physical activity through dissemination or collection of intervention materials with a mobile device. Data were extracted to calculate effect sizes for individual studies, as were study descriptives. A random effects meta-analysis was conducted using the Comprehensive Meta-Analysis software suite. Study quality was assessed using the quality of execution portion of the Guide to Community Preventative Services data extraction form. Results: Four studies were of “good” quality and seven of “fair” quality. In total, 1351 individuals participated in 11 unique studies from which 18 effects were extracted and synthesized, yielding an overall weight mean effect size of g = 0.54 (95% CI = 0.17 to 0.91, P = .01). Conclusions: Research utilizing mobile devices is gaining in popularity, and this study suggests that this platform is an effective means for influencing physical activity behavior. Our focus must be on the best possible use of these tools to measure and understand behavior. Therefore, theoretically grounded behavior change interventions that recognize and act on the potential of smartphone technology could provide investigators with an effective tool for increasing physical activity. [J Med Internet Res 2012;14(6):e161]

Broad Reach and Targeted Recruitment Using Facebook for an Online Survey of Young Adult Substance Use

Abstract: Background: Studies of tobacco use and other health behaviors have reported great challenges in recruiting young adults. Social media is widely used by young adults in the United States and represents a potentially fast, affordable method of recruiting study participants for survey research. Objective: The present study examined Facebook as a mechanism to reach and survey young adults about tobacco and other substance use. Methods: Participants were cigarette users, age 18-25 years old, living throughout the United States and recruited through Facebook to complete a survey about tobacco and other substance use. Paid advertising using Facebook’s Ad program over 13 months from 2010 Feb 28 to 2011 Apr 4 targeted by age (18-25), location (United States or California), language (English), and tobacco- and/or marijuana-related keywords. Facebook approved all ads. Results: The campaign used 20 ads, which generated 28,683,151 impressions, yielding 14,808 clicks (0.7% of targeted Facebook members), at an overall cost of $6,628.24. The average cost per click on an ad was $0.45. The success of individual ads varied widely. There was a rise in both clicks and impressions as the campaign grew. However, the peak for clicks was 3 months before the peak for ad impressions. Of the 69,937,080 accounts for those age 18-25 in the United States, Facebook estimated that 2.8% (n = 1,980,240) were reached through tobacco and marijuana keywords. Our campaign yielded 5237 signed consents (35.4% of clicks), of which 3093 (59%) met criteria, and 1548 (50% of those who met criteria) completed the survey. The final cost per valid completed survey was $4.28. The majority of completed surveys came from whites (69%) and males (72%). The sample averaged 8.9 cigarettes per day (SD 7.5), 3.8 years of smoking (SD 2.9), with a median of 1 lifetime quit attempts; 48% did not intend to quit smoking in the next 6 months. Conclusions: Despite wide variety in the success of individual ads and potential concerns about sample representativeness, Facebook was a useful, cost-effective recruitment source for young-adult smokers to complete a survey about the use of tobacco and other substances. The current findings support Facebook as a viable recruitment option for assessment of health behavior in young adults.

Web-Based Recruiting for Health Research Using a Social Networking Site: An Exploratory Study

Abstract: BACKGROUND: Recruitment of young people for health research by traditional methods has become more expensive and challenging over recent decades. The Internet presents an opportunity for innovative recruitment modalities. OBJECTIVE: To assess the feasibility of recruiting young females using targeted advertising on the social networking site Facebook. METHODS: We placed an advertisement on Facebook from May to September 2010, inviting 16- to 25-year-old females from Victoria, Australia, to participate in a health study. Those who clicked on the advertisement were redirected to the study website and were able to express interest by submitting their contact details online. They were contacted by a researcher who assessed eligibility and invited them to complete a health-related survey, which they could do confidentially and securely either at the study site or remotely online. RESULTS: A total of 551 females responded to the advertisement, of whom 426 agreed to participate, with 278 completing the survey (139 at the study site and 139 remotely). Respondents' age distribution was representative of the target population, while 18- to 25-year-olds were more likely to be enrolled in the study and complete the survey than 16- to 17-year-olds (prevalence ratio=1.37, 95% confidence interval 1.05-1.78, P=.02). The broad geographic distribution (major city, inner regional, and outer regional/remote) and socioeconomic profile of participants matched the target population. Predictors of participation were older age, higher education level, and higher body mass index. Average cost in advertising fees per compliant participant was US $20, making this highly cost effective. CONCLUSIONS: Results demonstrate the potential of using modern information and communication technologies to engage young women in health research and penetrate into nonurban communities. The success of this method has implications for future medical and population research in this and other demographics.

The impact of electronic patient portals on patient care: a systematic review of controlled trials.

Abstract: Background: Modern information technology is changing and provides new challenges to health care. The emergence of the Internet and the electronic health record (EHR) has brought new opportunities for patients to play a more active role in his/her care. Although in many countries patients have the right to access their clinical information, access to clinical records electronically is not common. Patient portals consist of provider-tethered applications that allow patients to electronically access health information that are documented and managed by a health care institution. Although patient portals are already being implemented, it is still unclear in which ways these technologies can influence patient care. Objective: To systematically review the available evidence on the impact of electronic patient portals on patient care. Methods: A systematic search was conducted using PubMed and other sources to identify controlled experimental or quasi-experimental studies on the impact of patient portals that were published between 1990 and 2011. A total of 1,306 references from all the publication hits were screened, and 13 papers were retrieved for full text analysis. Results: We identified 5 papers presenting 4 distinct studies. There were no statistically significant changes between intervention and control group in the 2 randomized controlled trials investigating the effect of patient portals on health outcomes. Significant changes in the patient portal group, compared to a control group, could be observed for the following parameters: quicker decrease in office visit rates and slower increase in telephone contacts; increase in number of messages sent; changes of the medication regimen; and better adherence to treatment. Conclusions: The number of available controlled studies with regard to patient portals is low. Even when patient portals are often discussed as a way to empower patients and improve quality of care, there is insufficient evidence to support this assumption. [J Med Internet Res 2012;14(6):e162]

Understanding the Factors That Influence the Adoption and Meaningful Use of Social Media by Physicians to Share Medical Information

Abstract: Background: Within the medical community there is persistent debate as to whether the information available through social media is trustworthy and valid, and whether physicians are ready to adopt these technologies and ultimately embrace them as a format for professional development and lifelong learning. Objective: To identify how physicians are using social media to share and exchange medical information with other physicians, and to identify the factors that influence physicians’ use of social media as a component of their lifelong learning and continuing professional development. Methods: We developed a survey instrument based on the Technology Acceptance Model, hypothesizing that technology usage is best predicted by a physician’s attitudes toward the technology, perceptions about the technology’s usefulness and ease of use, and individual factors such as personal innovativeness. The survey was distributed via email to a random sample of 1695 practicing oncologists and primary care physicians in the United States in March 2011. Responses from 485 physicians were analyzed (response rate 28.61%). Results: Overall, 117 of 485 (24.1%) of respondents used social media daily or many times daily to scan or explore medical information, whereas 69 of 485 (14.2%) contributed new information via social media on a daily basis. On a weekly basis or more, 296 of 485 (61.0%) scanned and 223 of 485 (46.0%) contributed. In terms of attitudes toward the use of social media, 279 of 485 respondents (57.5%) perceived social media to be beneficial, engaging, and a good way to get current, high-quality information. In terms of usefulness, 281 of 485 (57.9%) of respondents stated that social media enabled them to care for patients more effectively, and 291 of 485 (60.0%) stated it improved the quality of patient care they delivered. The main factors influencing a physician’s usage of social media to share medical knowledge with other physicians were perceived ease of use and usefulness. Respondents who had positive attitudes toward the use of social media were more likely to use social media and to share medical information with other physicians through social media. Neither age nor gender had a significant impact on adoption or usage of social media. Conclusions: Based on the results of this study, the use of social media applications may be seen as an efficient and effective method for physicians to keep up-to-date and to share newly acquired medical knowledge with other physicians within the medical community and to improve the quality of patient care. Future studies are needed to examine the impact of the meaningful use of social media on physicians’ knowledge, attitudes, skills, and behaviors in practice. [J Med Internet Res 2012;14(5):e117]

Development of a health information technology acceptance model using consumers' health behavior intention.

Abstract: Background: For effective health promotion using health information technology (HIT), it is mandatory that health consumers have the behavioral intention to measure, store, and manage their own health data. Understanding health consumers’ intention and behavior is needed to develop and implement effective and efficient strategies. Objective: To develop and verify the extended Technology Acceptance Model (TAM) in health care by describing health consumers’ behavioral intention of using HIT. Methods: This study used a cross-sectional descriptive correlational design. We extended TAM by adding more antecedents and mediating variables to enhance the model’s explanatory power and to make it more applicable to health consumers’ behavioral intention. Additional antecedents and mediating variables were added to the hypothetical model, based on their theoretical relevance, from the Health Belief Model and theory of planned behavior, along with the TAM. We undertook structural equation analysis to examine the specific nature of the relationship involved in understanding consumers’ use of HIT. Study participants were 728 members recruited from three Internet health portals in Korea. Data were collected by a Web-based survey using a structured self-administered questionnaire. Results: The overall fitness indices for the model developed in this study indicated an acceptable fit of the model. All path coefficients were statistically significant. This study showed that perceived threat, perceived usefulness, and perceived ease of use significantly affected health consumers’ attitude and behavioral intention. Health consumers’ health status, health belief and concerns, subjective norm, HIT characteristics, and HIT self-efficacy had a strong indirect impact on attitude and behavioral intention through the mediators of perceived threat, perceived usefulness, and perceived ease of use. Conclusions: An extended TAM in the HIT arena was found to be valid to describe health consumers’ behavioral intention. We categorized the concepts in the extended TAM into 3 domains: health zone, information zone, and technology zone.

Self-monitoring Using Mobile Phones in the Early Stages of Adolescent Depression: Randomized Controlled Trial

Abstract: Background: The stepped-care approach, where people with early symptoms of depression are stepped up from low-intensity interventions to higher-level interventions as needed, has the potential to assist many people with mild depressive symptoms. Self-monitoring techniques assist people to understand their mental health symptoms by increasing their emotional self-awareness (ESA) and can be easily distributed on mobile phones at low cost. Increasing ESA is an important first step in psychotherapy and has the potential to intervene before mild depressive symptoms progress to major depressive disorder. In this secondary analysis we examined a mobile phone self-monitoring tool used by young people experiencing mild or more depressive symptoms to investigate the relationships between self-monitoring, ESA, and depression. Objectives: We tested two main hypotheses: (1) people who monitored their mood, stress, and coping strategies would have increased ESA from pretest to 6-week follow-up compared with an attention comparison group, and (2) an increase in ESA would predict a decrease in depressive symptoms. Methods: We recruited patients aged 14 to 24 years from rural and metropolitan general practices. Eligible participants were identified as having mild or more mental health concerns by their general practitioner. Participants were randomly assigned to either the intervention group (where mood, stress, and daily activities were monitored) or the attention comparison group (where only daily activities were monitored), and both groups self-monitored for 2 to 4 weeks. Randomization was carried out electronically via random seed generation, by an in-house computer programmer; therefore, general practitioners, participants, and researchers were blinded to group allocation at randomization. Participants completed pretest, posttest, and 6-week follow-up measures of the Depression Anxiety Stress Scale and the ESA Scale. We estimated a parallel process latent growth curve model (LGCM) using Mplus to test the indirect effect of the intervention on depressive symptoms via the mediator ESA, and calculated 95% bias-corrected bootstrapping confidence intervals (CIs). Results: Of the 163 participants assessed for eligibility, 118 were randomly assigned and 114 were included in analyses (68 in the intervention group and 46 in the comparison group). A parallel process LGCM estimated the indirect effect of the intervention on depressive symptoms via ESA and was shown to be statistically significant based on the 95% bias-corrected bootstrapping CIs not containing zero (–6.366 to –0.029). The proportion of the maximum possible indirect effect estimated was κ2 =.54 (95% CI .426–.640). Conclusions: This study supported the hypothesis that self-monitoring increases ESA, which in turn decreases depressive symptoms for young people with mild or more depressive symptoms. Mobile phone self-monitoring programs are ideally suited to first-step intervention programs for depression in the stepped-care approach, particularly when ESA is targeted as a mediating factor. Trial Registration: ClinicalTrials.gov NCT00794222; http://clinicaltrials.gov/ct2/show/NCT00794222 (Archived by WebCite at http://www.webcitation.org/65lldW34k) [J Med Internet Res 2012;14(3):e67]

There’s an App for That: Content Analysis of Paid Health and Fitness Apps

Abstract: Background: The introduction of Apple’s iPhone provided a platform for developers to design third-party apps, which greatly expanded the functionality and utility of mobile devices for public health. Objective: This study provides an overview of the developers’ written descriptions of health and fitness apps and appraises each app’s potential for influencing behavior change. Methods: Data for this study came from a content analysis of health and fitness app descriptions available on iTunes during February 2011. The Health Education Curriculum Analysis Tool (HECAT) and the Precede-Proceed Model (PPM) were used as frameworks to guide the coding of 3336 paid apps. Results: Compared to apps with a cost less than US $0.99, apps exceeding US $0.99 were more likely to be scored as intending to promote health or prevent disease (92.55%, 1925/3336 vs 83.59%, 1411/3336; P <.001), to be credible or trustworthy (91.11%, 1895/3336 vs 86.14%, 1454/3349; P <.001), and more likely to be used personally or recommended to a health care client (72.93%, 1517/2644 vs 66.77%, 1127/2644; P <.001). Apps related to healthy eating, physical activity, and personal health and wellness were more common than apps for substance abuse, mental and emotional health, violence prevention and safety, and sexual and reproductive health. Reinforcing apps were less common than predisposing and enabling apps. Only 1.86% (62/3336) of apps included all 3 factors (ie, predisposing, enabling, and reinforcing). Conclusions: Development efforts could target public health behaviors for which few apps currently exist. Furthermore, practitioners should be cautious when promoting the use of apps as it appears most provide health-related information (predisposing) or make attempts at enabling behavior, with almost none including all theoretical factors recommended for behavior change. [J Med Internet Res 2012;14(3):e72]

A Changing Landscape of Physician Quality Reporting: Analysis of Patients’ Online Ratings of Their Physicians Over a 5-Year Period

Abstract: Background: Americans increasingly post and consult online physician rankings, yet we know little about this new phenomenon of public physician quality reporting. Physicians worry these rankings will become an outlet for disgruntled patients. Objective: To describe trends in patients’ online ratings over time, across specialties, to identify what physician characteristics influence online ratings, and to examine how the value of ratings reflects physician quality. Methods: We used data from RateMDs.com, which included over 386,000 national ratings from 2005 to 2010 and provided insight into the evolution of patients’ online ratings. We obtained physician demographic data from the US Department of Health and Human Services’ Area Resource File. Finally, we matched patients’ ratings with physician-level data from the Virginia Medical Board and examined the probability of being rated and resultant rating levels. Results: We estimate that 1 in 6 practicing US physicians received an online review by January 2010. Obstetrician/gynecologists were twice as likely to be rated (P < .001) as other physicians. Online reviews were generally quite positive (mean 3.93 on a scale of 1 to 5). Based on the Virginia physician population, long-time graduates were more likely to be rated, while physicians who graduated in recent years received higher average ratings (P < .001). Patients gave slightly higher ratings to board-certified physicians (P = .04), those who graduated from highly rated medical schools (P = .002), and those without malpractice claims (P = .1). Conclusion: Online physician rating is rapidly growing in popularity and becoming commonplace with no evidence that they are dominated by disgruntled patients. There exist statistically significant correlations between the value of ratings and physician experience, board certification, education, and malpractice claims, suggesting a positive correlation between online ratings and physician quality. However, the magnitude is small. The average number of ratings per physician is still low, and most rating variation reflects evaluations of punctuality and staff. Understanding whether they truly reflect better care and how they are used will be critically important. [J Med Internet Res 2012;14(1):e38]

Classification accuracies of physical activities using smartphone motion sensors.

Abstract: Background: Over the past few years, the world has witnessed an unprecedented growth in smartphone use. With sensors such as accelerometers and gyroscopes on board, smartphones have the potential to enhance our understanding of health behavior, in particular physical activity or the lack thereof. However, reliable and valid activity measurement using only a smartphone in situ has not been realized. Objective: To examine the validity of the iPod Touch (Apple, Inc.) and particularly to understand the value of using gyroscopes for classifying types of physical activity, with the goal of creating a measurement and feedback system that easily integrates into individuals’ daily living. Methods: We collected accelerometer and gyroscope data for 16 participants on 13 activities with an iPod Touch, a device that has essentially the same sensors and computing platform as an iPhone. The 13 activities were sitting, walking, jogging, and going upstairs and downstairs at different paces. We extracted time and frequency features, including mean and variance of acceleration and gyroscope on each axis, vector magnitude of acceleration, and fast Fourier transform magnitude for each axis of acceleration. Different classifiers were compared using the Waikato Environment for Knowledge Analysis (WEKA) toolkit, including C4.5 (J48) decision tree, multilayer perception, naive Bayes, logistic, k-nearest neighbor (kNN), and meta-algorithms such as boosting and bagging. The 10-fold cross-validation protocol was used. Results: Overall, the kNN classifier achieved the best accuracies: 52.3%–79.4% for up and down stair walking, 91.7% for jogging, 90.1%–94.1% for walking on a level ground, and 100% for sitting. A 2-second sliding window size with a 1-second overlap worked the best. Adding gyroscope measurements proved to be more beneficial than relying solely on accelerometer readings for all activities (with improvement ranging from 3.1% to 13.4%). Conclusions: Common categories of physical activity and sedentary behavior (walking, jogging, and sitting) can be recognized with high accuracies using both the accelerometer and gyroscope onboard the iPod touch or iPhone. This suggests the potential of developing just-in-time classification and feedback tools on smartphones. [J Med Internet Res 2012;14(5):e130]

Mobile Phone-Based Telemonitoring for Heart Failure Management: A Randomized Controlled Trial

Abstract: Background: Previous trials of telemonitoring for heart failure management have reported inconsistent results, largely due to diverse intervention and study designs. Mobile phones are becoming ubiquitous and economical, but the feasibility and efficacy of a mobile phone-based telemonitoring system have not been determined. Objective: The objective of this trial was to investigate the effects of a mobile phone-based telemonitoring system on heart failure management and outcomes. Methods: One hundred patients were recruited from a heart function clinic and randomized into telemonitoring and control groups. The telemonitoring group (N = 50) took daily weight and blood pressure readings and weekly single-lead ECGs, and answered daily symptom questions on a mobile phone over 6 months. Readings were automatically transmitted wirelessly to the mobile phone and then to data servers. Instructions were sent to the patients’ mobile phones and alerts to a cardiologist’s mobile phone as required. Results: Baseline questionnaires were completed and returned by 94 patients, and 84 patients returned post-study questionnaires. About 70% of telemonitoring patients completed at least 80% of their possible daily readings. The change in quality of life from baseline to post-study, as measured with the Minnesota Living with Heart Failure Questionnaire, was significantly greater for the telemonitoring group compared to the control group (P = .05). A between-group analysis also found greater post-study self-care maintenance (measured with the Self-Care of Heart Failure Index) for the telemonitoring group (P = .03). Brain natriuretic peptide (BNP) levels, self-care management, and left ventricular ejection fraction (LVEF) improved significantly for both groups from baseline to post-study, but did not show a between-group difference. However, a subgroup within-group analysis using the data from the 63 patients who had attended the heart function clinic for more than 6 months revealed the telemonitoring group had significant improvements from baseline to post-study in BNP (decreased by 150 pg/mL, P = .02), LVEF (increased by 7.4%, P = .005) and self-care maintenance (increased by 7 points, P = .05) and management (increased by 14 points, P = .03), while the control group did not. No differences were found between the telemonitoring and control groups in terms of hospitalization, mortality, or emergency department visits, but the trial was underpowered to detect differences in these metrics. Conclusions: Our findings provide evidence of improved quality of life through improved self-care and clinical management from a mobile phone-based telemonitoring system. The use of the mobile phone-based system had high adherence and was feasible for patients, including the elderly and those with no experience with mobile phones. Trial Registration: ClinicalTrials.gov NCT00778986 [J Med Internet Res 2012;14(1):e31]

Crowdsourced Health Research Studies: An Important Emerging Complement to Clinical Trials in the Public Health Research Ecosystem

Abstract: Background: Crowdsourced health research studies are the nexus of three contemporary trends: 1) citizen science (non-professionally trained individuals conducting science-related activities); 2) crowdsourcing (use of web-based technologies to recruit project participants); and 3) medicine 2.0 / health 2.0 (active participation of individuals in their health care particularly using web 2.0 technologies). Crowdsourced health research studies have arisen as a natural extension of the activities of health social networks (online health interest communities), and can be researcher-organized or participant-organized. In the last few years, professional researchers have been crowdsourcing cohorts from health social networks for the conduct of traditional studies. Participants have also begun to organize their own research studies through health social networks and health collaboration communities created especially for the purpose of self-experimentation and the investigation of health-related concerns. Objective: The objective of this analysis is to undertake a comprehensive narrative review of crowdsourced health research studies. This review will assess the status, impact, and prospects of crowdsourced health research studies. Methods: Crowdsourced health research studies were identified through a search of literature published from 2000 to 2011 and informal interviews conducted 2008-2011. Keyword terms related to crowdsourcing were sought in Medline/PubMed. Papers that presented results from human health studies that included crowdsourced populations were selected for inclusion. Crowdsourced health research studies not published in the scientific literature were identified by attending industry conferences and events, interviewing attendees, and reviewing related websites. Results: Participatory health is a growing area with individuals using health social networks, crowdsourced studies, smartphone health applications, and personal health records to achieve positive outcomes for a variety of health conditions. PatientsLikeMe and 23andMe are the leading operators of researcher-organized, crowdsourced health research studies. These operators have published findings in the areas of disease research, drug response, user experience in crowdsourced studies, and genetic association. Quantified Self, Genomera, and DIYgenomics are communities of participant-organized health research studies where individuals conduct self-experimentation and group studies. Crowdsourced health research studies have a diversity of intended outcomes and levels of scientific rigor. Conclusions: Participatory health initiatives are becoming part of the public health ecosystem and their rapid growth is facilitated by Internet and social networking influences. Large-scale parameter-stratified cohorts have potential to facilitate a next-generation understanding of disease and drug response. Not only is the large size of crowdsourced cohorts an asset to medical discovery, too is the near-immediate speed at which medical findings might be tested and applied. Participatory health initiatives are expanding the scope of medicine from a traditional focus on disease cure to a personalized preventive approach. Crowdsourced health research studies are a promising complement and extension to traditional clinical trials as a model for the conduct of health research. [J Med Internet Res 2012;14(2):e46]

The therapeutic relationship in e-therapy for mental health: a systematic review.

Abstract: Background: E-therapy is defined as a licensed mental health care professional providing mental health services via e-mail, video conferencing, virtual reality technology, chat technology, or any combination of these. The use of e-therapy has been rapidly expanding in the last two decades, with growing evidence suggesting that the provision of mental health services over the Internet is both clinically efficacious and cost effective. Yet there are still unanswered concerns about e-therapy, including whether it is possible to develop a successful therapeutic relationship over the Internet in the absence of nonverbal cues. Objective: Our objective in this study was to systematically review the therapeutic relationship in e-therapy. Methods: We searched PubMed, PsycINFO, and CINAHL through August 2011. Information on study methods and results was abstracted independently by the authors using a standardized form. Results: From the 840 reviewed studies, only 11 (1.3%) investigated the therapeutic relationship. The majority of the reviewed studies were focused on the therapeutic alliance—a central element of the therapeutic relationship. Although the results do not allow firm conclusions, they indicate that e-therapy seems to be at least equivalent to face-to-face therapy in terms of therapeutic alliance, and that there is a relationship between the therapeutic alliance and e-therapy outcome. Conclusions: Overall, the current literature on the role of therapeutic relationship in e-therapy is scant, and much more research is needed to understand the therapeutic relationship in online environments.

Improving adherence to antiretroviral therapy for youth living with HIV/AIDS: a pilot study using personalized, interactive, daily text message reminders

Abstract: Background: For youth living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), nonadherence to antiretroviral therapy (ART) can lead to poor health outcomes and significantly decreased life expectancy. Objective: To evaluate the feasability, acceptability, and preliminary efficacy of short message service (SMS) or text message reminders to improve adherence to ART for youth living with HIV/AIDS. Methods: We conducted this prospective pilot study using a pre–post design from 2009 to 2010 at a community-based health center providing clinical services to youth living with HIV/AIDS. Eligibility criteria included HIV-positive serostatus, age 14–29 years, use of a personal cell phone, English-speaking, and being on ART with documented poor adherence. During the 24-week study period, participants received personalized daily SMS reminders and a follow-up message 1 hour later assessing whether they took the medication, and asking participants to respond via text message with the number 1 if they took the medication and 2 if they did not. Outcome measures were feasibility, acceptability, and adherence. Self-reported adherence was determined using the visual analog scale (VAS) and AIDS Clinical Trial Group (ACTG) questionnaire 4-day recall. Viral load and CD4 cell count were followed as biomarkers of adherence and disease progression at 0, 12, and 24 weeks. Results: Participants (N = 25) were mean age 23 (range 14–29) years, 92% (n = 23) male, 60% (n = 15) black, and 84% (n = 21) infected through unprotected sex. Mean VAS scores significantly increased at 12 and 24 weeks in comparison with baseline (week 0: 74.7, week 12: 93.3, P < .001; week 24: 93.1, P < .001). ACTG questionnaire 4-day recall also improved (week 0: 2.33, week 12: 3.24, P = .002; week 24: 3.19, P = .005). There was no significant difference in CD4 cell count or viral load between baseline and 12- or 24-week follow-up, although there was a trend toward improvement of these biomarkers and a small to moderate standardized effect size (range of Cohen d: –0.51 to 0.22). Of 25 participants, 21 (84%) were retained, and 20 of the 21 (95%) participants who completed the study found the intervention helpful to avoid missing doses. Conclusions: In this pilot study, personalized, interactive, daily SMS reminders were feasible and acceptable, and they significantly improved self-reported adherence. Larger controlled studies are needed to determine the impact of this intervention on ART adherence and other related health outcomes for youth living with HIV/AIDS. [J Med Internet Res 2012;14(2):e51]

Short Message Service (SMS) Applications for Disease Prevention in Developing Countries

Abstract: Background: The last decade has witnessed unprecedented growth in the number of mobile phones in the developing world, thus linking millions of previously unconnected people. The ubiquity of mobile phones, which allow for short message service (SMS), provides new and innovative opportunities for disease prevention efforts. Objective: The aim of this review was to describe the characteristics and outcomes of SMS interventions for disease prevention in developing countries and provide recommendations for future work. Methods: A systematic search of peer-reviewed and gray literature was performed for papers published in English, French, and German before May 2011 that describe SMS applications for disease prevention in developing countries. Results: A total of 34 SMS applications were described, among which 5 had findings of an evaluation reported. The majority of SMS applications were pilot projects in various levels of sophistication; nearly all came from gray literature sources. Many applications were initiated by the project with modes of intervention varying between one-way or two-way communication, with or without incentives, and with educative games. Evaluated interventions were well accepted by the beneficiaries. The primary barriers identified were language, timing of messages, mobile network fluctuations, lack of financial incentives, data privacy, and mobile phone turnover. Conclusion: This review illustrates that while many SMS applications for disease prevention exist, few have been evaluated. The dearth of peer-reviewed studies and the limited evidence found in this systematic review highlight the need for high-quality efficacy studies examining behavioral, social, and economic outcomes of SMS applications and mobile phone interventions aimed to promote health in developing country contexts. [J Med Internet Res 2012;14(1):e3]

Internet-based interventions to promote mental health help-seeking in elite athletes: an exploratory randomized controlled trial

Abstract: The study was supported by a grant from the AIS. AG is supported by a joint scholarship from the AIS, the Brain and Mind Research Institute, Orygen, and The Australian National University. KG is supported by NHMRC Senior Research Fellowship No. 525413. HC is supported by NHMRC Senior Principal Research Fellowship No. 525411. AC is supported by NHMRC Early Career Fellowship 1013199. PB is supported by NHMRC Capacity Building Grant 418020.

Using smartphone technology to monitor physical activity in the 10,000 Steps program: a matched case-control trial.

Abstract: Background: Website-delivered physical activity interventions are successful in producing short-term behavior change However, problems with engagement and retention of participants in these programs prevent long-term behavior change New ways of accessing online content (eg, via smartphones) may enhance engagement in these interventions, which in turn may improve the effectiveness of the programs Objective: To measure the potential of a newly developed smartphone application to improve health behaviors in existing members of a website-delivered physical activity program (10,000 Steps, Australia) The aims of the study were to (1) examine the effect of the smartphone application on self-monitoring and self-reported physical activity levels, (2) measure the perceived usefulness and usability of the application, and (3) examine the relationship between the perceived usefulness and usability of the application and its actual use Methods: All participants were existing members of the 10,000 Steps program We recruited the intervention group (n = 50) via email and instructed them to install the application on their smartphone and use it for 3 months Participants in this group were able to log their steps by using either the smartphone application or the 10,000 Steps website Following the study, the intervention group completed an online questionnaire assessing perceived usability and usefulness of the smartphone application We selected control group participants (n = 150), matched for age, gender, level of self-monitoring, preintervention physical activity level, and length of membership in the 10,000 Steps program, after the intervention was completed We collected website and smartphone usage statistics during the entire intervention period Results: Over the study period (90 days), the intervention group logged steps on an average of 62 days, compared with 41 days in the matched group Intervention participants used the application 7122% (2210/3103) of the time to log their steps Logistic regression analyses revealed that use of the application was associated with an increased likelihood to log steps daily during the intervention period compared with those not using the application (odds ratio 356, 95% confidence interval 172–739) Additionally, use of the application was associated with an increased likelihood to log greater than 10,000 steps on each entry (odds ratio 2064, 95% confidence interval 919–4639) Linear regression analysis revealed a nonsignificant relationship between perceived usability (r = 216, P = 21) and usefulness (r = 229, P = 17) of the application and frequency of logging steps in the intervention group Conclusion: Using a smartphone application as an additional delivery method to a website-delivered physical activity intervention may assist in maintaining participant engagement and behavior change However, due to study design limitations, these outcomes should be interpreted with caution More research, using larger samples and longer follow-up periods, is needed to replicate the findings of this study [J Med Internet Res 2012;14(2):e55]

Motivators and motivations to persist with online psychological interventions: a qualitative study of treatment completers.

Abstract: Background: Many users of Internet interventions do not persist with the full treatment program. As persistence may influence outcomes of such interventions, being able to maximize persistence is vital. However, while studies have begun to explore the predictors of dropout in Internet interventions, few have explored reasons why users persist with the programs, which may not just be the converse of the reasons for dropout. Objective: To answer the question of what influences persistence with online interventions. Methods: We interviewed participants in the Cardiovascular Risk E-couch Depression Outcome (CREDO), a trial evaluating the efficacy of an eHealth intervention (e-couch) in treating depressive symptoms in those with comorbid depression and cardiovascular risk factors. Interviews were semistructured in nature and were analyzed using a grounded theory approach. Interview numbers were curtailed (n = 12) after theoretical saturation. Results: All participants reported substantial barriers to completing the program including time constraints, competing priorities, anxiety about spending time on the computer, and perception of limited worth of the intervention. Participants who persisted with the trial reported intrinsic motivations such as personal values about task completion and sense of control, and recognized external motivators that aided the development of habits and identified personal benefits attributable to the program. Conclusions: Online interventions may benefit from content that enhances the intrinsic motivations such as a having sense of control and being able to identify with the program, and by increasing the relative value of the program in order to enhance persistence. Persistence within a trial setting appears modifiable through explicit messages regarding supporting others. In terms of motivators, the use of a hook to engage participants who are starting the intervention due to curiosity and the use of reminder systems to prompt participants may also improve persistence. The worth of such additions should be evaluated using adherence and outcomes metrics. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12610000085077; http://www.anzctr.org.au/ACTRN12610000085077.aspx (Archived by WebCite at http://www.webcitation.org/68MtyPO3w) [J Med Internet Res 2012;14(3):e91]

Effects of a Web-Based Intervention for Adults With Chronic Conditions on Patient Activation: Online Randomized Controlled Trial

Abstract: Background: With almost one-half of Americans projected to have at least one chronic condition before 2020, a vital role of the health care system is to develop informed, engaged individuals who are effective self-managers of their health. Self-management interventions (SMIs) delivered face-to-face or by telephone (traditional SMIs) are associated with improved self-management knowledge, skills, and self-efficacy, which are expressed by the composite construct of patient activation, a predictor of health outcomes. Web-based interventions to support self-management across the spectrum of chronic diseases have the potential to reach a broader population of patients for extended periods than do traditional SMIs. However, evidence of the effectiveness of Web-based interventions on patient activation is sparse. High-quality studies featuring controlled comparisons of patients with different chronic conditions are needed to explore the interaction of Web-based interventions and patient activation. Objective: To explore the effect of a Web-based intervention on the patient activation levels of patients with chronic health conditions, measured as attitudes toward knowledge, skills, and confidence in self-managing health. Methods: For this 12-week study, prospective participants were selected from the patient panel of a regional health care system in the United States. The 201 eligible participants were randomly assigned to two groups. Intervention group participants had access to MyHealth Online, a patient portal featuring interactive health applications accessible via the Internet. Control participants had access to a health education website featuring various topics. Patient activation was assessed pre- and posttest using the 13-item patient activation measure. Parametric statistical models (t test, analysis of variance, analysis of covariance) were applied to draw inferences. Results: The Web-based intervention demonstrated a positive and significant effect on the patient activation levels of participants in the intervention group. A significant difference in posttest patient activation scores was found between the two groups (F1,123 = 4.438, P = .04, r = .196). Patients starting at the most advanced development of patient activation (stage 4) in the intervention group did not demonstrate significant change compared with participants beginning at earlier stages. Conclusions: To our knowledge, this is the first study to measure change in patient activation when a Web-based intervention is used by patients living with different chronic conditions. Results suggest that Web-based interventions increase patient activation and have the potential to enhance the self-management capabilities of the growing population of chronically ill people. Activated patients are more likely to adhere to recommended health care practices, which in turn leads to improved health outcomes. Designing Web-based interventions to target a specific stage of patient activation may optimize their effectiveness. For Web-based interventions to reach their potential as a key component of chronic disease management, evidence is needed that this technology produces benefits for a sustained period among a diverse population. [J Med Internet Res 2012;14(1):e32]

Novel technologies for assessing dietary intake: evaluating the usability of a mobile telephone food record among adults and adolescents.

Abstract: Background: The development of a mobile telephone food record has the potential to ameliorate much of the burden associated with current methods of dietary assessment. When using the mobile telephone food record, respondents capture an image of their foods and beverages before and after eating. Methods of image analysis and volume estimation allow for automatic identification and volume estimation of foods. To obtain a suitable image, all foods and beverages and a fiducial marker must be included in the image. Objective: To evaluate a defined set of skills among adolescents and adults when using the mobile telephone food record to capture images and to compare the perceptions and preferences between adults and adolescents regarding their use of the mobile telephone food record. Methods: We recruited 135 volunteers (78 adolescents, 57 adults) to use the mobile telephone food record for one or two meals under controlled conditions. Volunteers received instruction for using the mobile telephone food record prior to their first meal, captured images of foods and beverages before and after eating, and participated in a feedback session. We used chi-square for comparisons of the set of skills, preferences, and perceptions between the adults and adolescents, and McNemar test for comparisons within the adolescents and adults. Results: Adults were more likely than adolescents to include all foods and beverages in the before and after images, but both age groups had difficulty including the entire fiducial marker. Compared with adolescents, significantly more adults had to capture more than one image before (38% vs 58%, P = .03) and after (25% vs 50%, P = .008) meal session 1 to obtain a suitable image. Despite being less efficient when using the mobile telephone food record, adults were more likely than adolescents to perceive remembering to capture images as easy (P < .001). Conclusions: A majority of both age groups were able to follow the defined set of skills; however, adults were less efficient when using the mobile telephone food record. Additional interactive training will likely be necessary for all users to provide extra practice in capturing images before entering a free-living situation. These results will inform age-specific development of the mobile telephone food record that may translate to a more accurate method of dietary assessment. [J Med Internet Res 2012;14(2):e58]

Issues in mHealth: Findings From Key Informant Interviews

Abstract: Background: mHealth is enjoying considerable interest and private investment in the United States. A small but growing body of evidence indicates some promise in supporting healthy behavior change and self-management of long-term conditions. The unique benefits mobile phones bring to health initiatives, such as direct access to health information regardless of time or location, may create specific issues for the implementation of such initiatives. Other issues may be shared with general health information technology developments. Objective: To determine the important issues facing the implementation of mHealth from the perspective of those within the US health system and those working in mHealth in the United States. Methods: Semistructured interviews were conducted with 27 key informants from across the health and mHealth sectors in the United States. Interviewees were approached directly following an environmental scan of mHealth in the United States or recommendation by those working in mHealth. Results: The most common issues were privacy and data security, funding, a lack of good examples of the efficacy and cost effectiveness of mHealth in practice, and the need for more high-quality research. The issues are outlined and categorized according to the environment within which they predominantly occur: policy and regulatory environments; the wireless industry; the health system; existing mHealth practice; and research. Conclusions: Many of these issues could be addressed by making the most of the current US health reform environment, developing a strategic and coordinated approach, and seeking to improve mHealth practice. [J Med Internet Res 2012;14(5):e129]

Disseminating self-help: positive psychology exercises in an online trial.

Abstract: Background: The recent growth of positive psychology has led to a proliferation in exercises to increase positive thoughts, behaviors, and emotions. Preliminary evidence suggests that these exercises hold promise as an approach for reducing depressive symptoms. These exercises are typically researched in isolation as single exercises. The current study examined the acceptability of several multi-exercise packages using online dissemination. Objective: The purpose of this study was to investigate methods of dissemination that could increase the acceptability and effectiveness of positive psychology exercises. To achieve this goal, we compared the use of positive psychology exercises when delivered in packages of 2, 4, or 6 exercises. Methods: Self-help–seeking participants enrolled in this study by visiting an online research portal. Consenting participants were randomly assigned to receive 2, 4, or 6 positive psychology exercises (or assessments only) over a 6-week period. These exercises drew from the content of group positive psychotherapy. Participants visited an automated website that distributed exercise instructions, provided email reminders, and contained the baseline and follow-up assessments. Following each exercise, participants rated their enjoyment of the exercise, answered how often they had used each technique, and completed outcome measures. Results: In total, 1364 individuals consented to participate. Attrition rates across the 2-, 4-, and 6-exercise conditions were similar at 55.5% (181/326), 55.8% (203/364), and 52.7% (168/319) respectively but were significantly greater than the attrition rate of 42.5% (151/355) for the control condition (χ 2 3 = 16.40, P < .001). Participants in the 6-exercise condition were significant more likely than participants in the 4-exercise condition to use both the third (F 1,312 = 5.61, P = .02) and fourth (F 1,313 = 6.03, P = .02) exercises. For 5 of the 6 exercises, enjoyment was related to continued use of the exercise at 6-week follow-up (r’s = .12 to .39). All conditions produced significant reductions in depressive symptoms (F1,656 = 94.71, P < .001); however, a significant condition by time interaction (F 3,656 = 4.77, P = .003) indicated that this reduction was larger in the groups that received 2 or 4 exercises compared with the 6-exercise or control condition. Conclusion: Increasing the number of exercises presented to participants increased the use of the techniques and did not increase dropout. Participants may be more likely to use these skills when presented with a variety of options. Increasing the number of exercises delivered to participants produced a curvilinear relationship with those in the 2- and 4-exercise conditions reporting larger decreases in depressive symptoms than participants in the 6-exercise or control conditions. Although research generally offers a single exercise to test isolate effects, this study supports that studying variability in dissemination can produce important findings.

An internet-based virtual coach to promote physical activity adherence in overweight adults: randomized controlled trial.

Abstract: Background: Addressing the obesity epidemic requires the development of effective, scalable interventions. Pedometers and Web-based programs are beneficial in increasing activity levels but might be enhanced by the addition of nonhuman coaching. Objectives: We hypothesized that a virtual coach would increase activity levels, via step count, in overweight or obese individuals beyond the effect observed using a pedometer and website alone. Methods: We recruited 70 participants with a body mass index (BMI) between 25 and 35 kg/m2 from the Boston metropolitan area. Participants were assigned to one of two study arms and asked to wear a pedometer and access a website to view step counts. Intervention participants also met with a virtual coach, an automated, animated computer agent that ran on their home computers, set goals, and provided personalized feedback. Data were collected and analyzed in 2008. The primary outcome measure was change in activity level (percentage change in step count) over the 12-week study, split into four 3-week time periods. Major secondary outcomes were change in BMI and participants’ satisfaction. Results: The mean age of participants was 42 years; the majority of participants were female (59/70, 84%), white (53/70, 76%), and college educated (68/70, 97%). Of the initial 70 participants, 62 completed the study. Step counts were maintained in intervention participants but declined in controls. The percentage change in step count between those in the intervention and control arms, from the start to the end, did not reach the threshold for significance (2.9% vs –12.8% respectively, P = .07). However, repeated measures analysis showed a significant difference when comparing percentage changes in step counts between control and intervention participants over all time points (analysis of variance, P = .02). There were no significant changes in secondary outcome measures. Conclusions: The virtual coach was beneficial in maintaining activity level. The long-term benefits and additional applications of this technology warrant further study. Trial Registration: ClinicalTrials.gov NCT00792207; http://clinicaltrials.gov/ct2/show/NCT00792207 (Archived by WebCite at http://www.webcitation.org/63sm9mXUD) [J Med Internet Res 2012;14(1):e1]

MEMO—A Mobile Phone Depression Prevention Intervention for Adolescents: Development Process and Postprogram Findings on Acceptability From a Randomized Controlled Trial

Abstract: Background: Prevention of the onset of depression in adolescence may prevent social dysfunction, teenage pregnancy, substance abuse, suicide, and mental health conditions in adulthood. New technologies allow delivery of prevention programs scalable to large and disparate populations. Objective: To develop and test the novel mobile phone delivery of a depression prevention intervention for adolescents. We describe the development of the intervention and the results of participants’ self-reported satisfaction with the intervention. Methods: The intervention was developed from 15 key messages derived from cognitive behavioral therapy (CBT). The program was fully automated and delivered in 2 mobile phone messages/day for 9 weeks, with a mixture of text, video, and cartoon messages and a mobile website. Delivery modalities were guided by social cognitive theory and marketing principles. The intervention was compared with an attention control program of the same number and types of messages on different topics. A double-blind randomized controlled trial was undertaken in high schools in Auckland, New Zealand, from June 2009 to April 2011. Results: A total of 1348 students (13–17 years of age) volunteered to participate at group sessions in schools, and 855 were eventually randomly assigned to groups. Of these, 835 (97.7%) self-completed follow-up questionnaires at postprogram interviews on satisfaction, perceived usefulness, and adherence to the intervention. Over three-quarters of participants viewed at least half of the messages and 90.7% (379/418) in the intervention group reported they would refer the program to a friend. Intervention group participants said the intervention helped them to be more positive (279/418, 66.7%) and to get rid of negative thoughts (210/418, 50.2%)—significantly higher than proportions in the control group. Conclusions: Key messages from CBT can be delivered by mobile phone, and young people report that these are helpful. Change in clinician-rated depression symptom scores from baseline to 12 months, yet to be completed, will provide evidence on the effectiveness of the intervention. If proven effective, this form of delivery may be useful in many countries lacking widespread mental health services but with extensive mobile phone coverage. ClinicalTrial: Australia New Zealand Clinical Trials Registry (ACTRN): 12609000405213; http://www.anzctr.org.au/trial_view.aspx?ID=83667 (Archived by WebCite at http://www.webcitation.org/64aueRqOb) [J Med Internet Res 2012;14(1):e13]

Using Internet Search Engines to Obtain Medical Information: A Comparative Study

Abstract: Background: The Internet has become one of the most important means to obtain health and medical information. It is often the first step in checking for basic information about a disease and its treatment. The search results are often useful to general users. Various search engines such as Google, Yahoo!, Bing, and Ask.com can play an important role in obtaining medical information for both medical professionals and lay people. However, the usability and effectiveness of various search engines for medical information have not been comprehensively compared and evaluated. Objective: To compare major Internet search engines in their usability of obtaining medical and health information. Methods: We applied usability testing as a software engineering technique and a standard industry practice to compare the four major search engines (Google, Yahoo!, Bing, and Ask.com) in obtaining health and medical information. For this purpose, we searched the keyword breast cancer in Google, Yahoo!, Bing, and Ask.com and saved the results of the top 200 links from each search engine. We combined nonredundant links from the four search engines and gave them to volunteer users in an alphabetical order. The volunteer users evaluated the websites and scored each website from 0 to 10 (lowest to highest) based on the usefulness of the content relevant to breast cancer. A medical expert identified six well-known websites related to breast cancer in advance as standards. We also used five keywords associated with breast cancer defined in the latest release of Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) and analyzed their occurrence in the websites. Results: Each search engine provided rich information related to breast cancer in the search results. All six standard websites were among the top 30 in search results of all four search engines. Google had the best search validity (in terms of whether a website could be opened), followed by Bing, Ask.com, and Yahoo!. The search results highly overlapped between the search engines, and the overlap between any two search engines was about half or more. On the other hand, each search engine emphasized various types of content differently. In terms of user satisfaction analysis, volunteer users scored Bing the highest for its usefulness, followed by Yahoo!, Google, and Ask.com. Conclusions: Google, Yahoo!, Bing, and Ask.com are by and large effective search engines for helping lay users get health and medical information. Nevertheless, the current ranking methods have some pitfalls and there is room for improvement to help users get more accurate and useful information. We suggest that search engine users explore multiple search engines to search different types of health information and medical knowledge for their own needs and get a professional consultation if necessary. [J Med Internet Res 2012;14(3):e74]

Effectiveness of a Web-Based Cognitive-Behavioral Tool to Improve Mental Well-Being in the General Population: Randomized Controlled Trial

Abstract: Background: Interventions to promote mental well-being can bring benefits to the individual and to society. The Internet can facilitate the large-scale and low-cost delivery of individually targeted health promoting interventions. Objective: To evaluate the effectiveness of a self-directed Internet-delivered cognitive-behavioral skills training tool in improving mental well-being in a population sample. Methods: This was a randomized trial with a waiting-list control. Using advertisements on a national health portal and through its mailing list, we recruited 3070 participants aged 18 or over, resident in England, and willing to give their email address and access a fully automated Web-based intervention. The intervention (MoodGYM) consisted of 5 interactive modules that teach cognitive-behavioral principles. Participants in the intervention arm received weekly email reminders to access the intervention. The control group received access to the intervention after the trial was completed and received no specific intervention or email reminders. Outcomes were assessed by using self-completion questionnaires. The primary outcome was mental well-being measured with the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes were Center for Epidemiologic Studies Depression scale (CES-D) depression scores, Generalized Anxiety Disorder 7-item scale (GAD-7) anxiety scores, EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) quality of life scores, physical activity, and health service use. All outcomes were measured at baseline, and at 6- and 12-week follow-ups. Results: A total of 1529 (49.80%) participants completed final follow-up at 12 weeks. Retention was 73.11% (1123/1536) in the control arm and 26.47% (406/1534) in the intervention arm. No relationship between baseline measures and withdrawal could be established. The analysis of WEMWBS mental well-being scores using a linear mixed model for repeated measures showed no difference between intervention and control group at baseline (difference –0.124 points, 95% CI –0.814 to 0.566), and significant improvements for the intervention group at 6 weeks (2.542 points, 95% CI 1.693-3.390) and at 12 weeks (2.876 points, 95% CI 1.933-3.819). The model showed a highly significant ( P <.001) intervention by time interaction effect. There were also significant improvements in self-rated scores of depression and anxiety. Given the high level of attrition, a sensitivity analysis with imputed missing values was undertaken that also showed a significant positive effect of the intervention. Conclusions: Participants allocated to the intervention arm had an average increase of approximately 3 points on the WEMWBS scale compared to no increase for participants in the control group. Three points on this scale is approximately one-third of a standard deviation. In a low-cost automated intervention designed to shift the population distribution of mental well-being, a small difference per individual could yield a major benefit in population terms. In common with other Web-based interventions, there were high rates of attrition. Further work is needed to improve acceptability, to evaluate against placebo effect, and to disaggregate the effect on mental well-being from the effect on depression and anxiety. Trial Registration: International Standard Randomised Controlled Trial Number Register ISRCTN 48134476; http://www.controlled-trials.com/ISRCTN48134476 (Archived by WebCite® at http://www.webcitation.org/6DFgW2p3Q) [J Med Internet Res 2013;15(1):e2]