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Objectives: We aimed to study if smartphone applications could support the self-management of RA, while investigating engagement and potential negative psychological effects with app-use., Methods: App-based Education and GOal-setting in RA (AEGORA) was a multicentre randomised controlled trial with 2:1:1-allocation to usual care or two versions of an app-based self-management intervention for RA. The 16-week programme involved patient education, goal-setting, and remote monitoring of the Rheumatoid Arthritis Impact of Disease (RAID) instrument, either weekly or monthly depending on randomisation. The primary end point was improvement in the Arthritis Self-Efficacy Scale (ASES) after 16 weeks. Secondary endpoints included non-inferiority regarding the Pain Catastrophizing Scale (PCS) and superiority regarding patient-reported physical activity, sleep quality and RAID. App engagement and RAID-scores were analysed descriptively., Results: Overall, 122 patients were included: mean (SD) disease duration 12 (9) years, mean (SD) age 58(11), 68% female, mean (SD) DAS28-CRP 2.4(0.9). The intervention did not improve the ASES-score over usual care (β: 0.44, p= 0.87). Non-inferiority was established for the PCS (β -0.95 [95% CI -3.30 to + 1.40] favouring the intervention). Other predefined outcomes did not differ. App retention steadily declined to 43% by 16 weeks. Although the RAID remained stable over time overall, 35% of app users reported ≥1 episode of clinically relevant worsening over 16 weeks., Conclusion: This app-based self-management intervention was not superior to usual care regarding self-efficacy improvement. However, remote symptom monitoring provided valuable insight and did not increase pain catastrophising, alleviating concerns regarding the psychological impact of remote monitoring with apps., Trial Registration Number: clinicaltrials.gov, NCT05888181., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Chronic obstructive pulmonary disease (COPD) patients often have poor health literacy, leading to non-adherence to treatment and poor inhalation technique. Technological solutions can help manage COPD, but adherence tends to be low due to various factors., Objectives and Methods: We conducted a qualitative study to determine the needs of COPD patients and healthcare practitioners (HCPs) towards a mobile application and a web platform. We also aimed to identify potential barriers or facilitators to the use of such digital tools and their potential impact, and to assess the current state of collaboration between healthcare practitioners., Results: Our study found that COPD patients face difficulties in managing the disease and treatments, lack information and need easier contact with caregivers. Patients' needs include access to reliable information about COPD, its medical treatments and smoking cessation, help in maintaining good physical condition through adapted exercises, incentives and reminders, and crisis management protocols or a logbook. As patient needs can differ, it would be ideal if the mobile application could be customized. HCPs cite patient adherence, correct intake of the treatment, communication and lack of patient motivation as challenges. In particular, they would like to have access to information on patient follow-up and logbooks, as well as scientific documentation. They believe that interprofessional collaboration is essential for good patient care. However, lack of time is a major hurdle in optimizing this collaboration., Conclusion: Our study showed that most patients and HCPs view a technological platform positively to support the care of COPD patients and promote interprofessional collaboration., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Self-management of diabetes is extremely challenging and non-adherence is common. Health consequences are significant for those unable to adhere to the complex treatment regimen, which includes regular oral medication and/or insulin use, frequent blood sugar checks, strict dietary management, and regular physical activity. Mobile applications (apps) present a tremendous opportunity to help patients improve adherence to these behaviors. The availability of commercial diabetes self-management apps is increasing exponentially, making it difficult for patients and providers to stay informed about app options and benefits. Previous reviews have described commercial diabetes apps and their features and usability for patients with diabetes. A smaller number have reviewed the effectiveness of these apps in improving blood glucose as well as other aspects of diabetes management. The aim of this article is to update our 2016 review, summarize the results of new reviews, review outcomes of diabetes apps described in the literature, and offer recommendations for app features, effectiveness research, and marketing in apps for diabetes self-management. Although higher-quality research is needed, current reviews suggest that many diabetes apps are effective in lowering HbA1c. Recommendations for future research include reporting critical details such as patient demographics and intervention elements and designing studies to identify the most effective components of diabetes management apps. Furthermore, clearly labeling apps that have data supporting clinical efficacy in app stores would allow both providers and patients to easily identify apps that might be most beneficial. Future research should explore the use of apps for the prevention of diabetes in individuals diagnosed with prediabetes., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The full spectrum of side effects from COVID-19 vaccinations and infections, including milder symptoms or health effects that do not lead to health care visits, remains unknown. Person-centered self-reporting of symptoms may offer a solution. Monitoring patient-reported outcomes over time will vary in importance for different patients. Individuals have unique needs and preferences, in terms of both communication methods and how the collected information is used to support care., Objective: This study aims to describe how Symptoms, a system for person-centered self-reporting of symptoms and health-related quality of life, was utilized in investigating COVID-19 vaccine side effects. We illustrate this by presenting data from the Symptoms system in newly vaccinated individuals from the RECOVAC (Register-based large-scale national population study to monitor COVID-19 vaccination effectiveness and safety) study., Methods: During the COVID-19 pandemic, newly vaccinated individuals were identified as the ideal population to query for milder symptoms related to COVID-19 vaccinations and infections. To this end, we used posters in observation areas at 150 vaccination sites across the Västra Götaland region of Sweden, inviting newly vaccinated individuals to use a novel digital system, Symptoms. In the Symptoms system, users can track their symptoms, functioning, and quality of life as often as they wish, using evidence-based patient-reported outcome measures and short numeric rating scales. These scales cover a prespecified list of symptoms based on common COVID-19 symptoms and previously reported vaccine side effects. Participants could also use numeric rating scales for self-defined symptoms if their symptom was not included on the prespecified list., Results: A total of 731 people created user accounts and consented to share data for research between July 21, 2021, and September 27, 2022. The majority of users were female (444/731, 60.7%), with a median age of 38 (IQR 30-47) years. Most participants (498/702, 70.9%) did not report any of the comorbidities included in the questionnaire. Of the 731 participants, 563 (77.0%) reported experiencing 1 or more symptoms. The most common symptom was pain at the injection site (486/563, 86.3%), followed by fatigue (181/563, 32.1%) and headache (169/563, 30.0%). In total, 143 unique symptoms were reported. Of these, 29 were from the prespecified list, while the remaining 114 (79.7%) were self-defined entries in the symptom field. This suggests that the flexibility of the self-directed system-allowing individuals to decide which symptoms they consider worth tracking-may be an important feature., Conclusions: Self-reported symptoms in the Symptoms system appeared to align with previously observed post-COVID-19 vaccination symptoms. The system was relatively easy to use and successfully captured broad, longitudinal data. Its person-centered and self-directed design seemed crucial in capturing the full burden of symptoms experienced by users., (©Emelie Gustafson Hedov, Fredrik Nyberg, Stefan Gustafsson, Huiqi Li, Magnus Gisslén, Johan Sundström. Originally published in JMIR Formative Research (https://formative.jmir.org), 30.10.2024.)

Background: Social media is a powerful platform for disseminating health information, yet it is often riddled with misinformation. Further, few guidelines exist for producing reliable, peer-reviewed content. This study describes a framework for creating and disseminating evidence-based videos on polycystic ovary syndrome (PCOS) and thyroid conditions to improve health literacy and tackle misinformation., Objective: The study aims to evaluate the creation, dissemination, and impact of evidence-based, peer-reviewed short videos on PCOS and thyroid disorders across social media. It also explores the experiences of content creators and assesses audience engagement., Methods: This mixed methods prospective study was conducted between December 2022 and May 2023 and comprised five phases: (1) script generation, (2) video creation, (3) cross-platform publication, (4) process evaluation, and (5) impact evaluation. The SIMBA-CoMICs (Simulation via Instant Messaging for Bedside Application-Combined Medical Information Cines) initiative provides a structured process where medical concepts are simplified and converted to visually engaging videos. The initiative recruited medical students interested in making visually appealing and scientifically accurate videos for social media. The students were then guided to create video scripts based on frequently searched PCOS- and thyroid-related topics. Once experts confirmed the accuracy of the scripts, the medical students produced the videos. The videos were checked by clinical experts and experts with lived experience to ensure clarity and engagement. The SIMBA-CoMICs team then guided the students in editing these videos to fit platform requirements before posting them on TikTok, Instagram, YouTube, and Twitter. Engagement metrics were tracked over 2 months. Content creators were interviewed, and thematic analysis was performed to explore their experiences., Results: The 20 videos received 718 likes, 120 shares, and 54,686 views across all platforms, with TikTok (19,458 views) and Twitter (19,678 views) being the most popular. Engagement increased significantly, with follower growth ranging from 5% on Twitter to 89% on TikTok. Thematic analysis of interviews with 8 out of 38 participants revealed 4 key themes: views on social media, advice for using social media, reasons for participating, and reflections on the project. Content creators highlighted the advantages of social media, such as large outreach (12 references), convenience (10 references), and accessibility to opportunities (7 references). Participants appreciated the nonrestrictive participation criteria, convenience (8 references), and the ability to record from home using prewritten scripts (6 references). Further recommendations to improve the content creation experience included awareness of audience demographics (9 references), sharing content on multiple platforms (5 references), and collaborating with organizations (3 references)., Conclusions: This study demonstrates the effectiveness of the SIMBA CoMICs initiative in training medical students to create accurate medical information on PCOS and thyroid disorders for social media dissemination. The model offers a scalable solution to combat misinformation and improve health literacy., (©Maiar Elhariry, Kashish Malhotra, Kashish Goyal, Marco Bardus, SIMBA and CoMICs Team, Punith Kempegowda. Originally published in JMIR Medical Education (https://mededu.jmir.org), 30.10.2024.)

Background: Consumer technology is increasingly being adopted to support personal stress management, including by teachers. Multidisciplinary research has contributed some knowledge of design and features that can help detect and manage workplace stress. However, there is less understanding of what facilitates engagement with ubiquitous "off the shelf" technologies, particularly in a specific occupational setting. An understanding of features that facilitate or inhibit technology use, and the influences of contexts on the manner of interaction, could improve teachers' stress-management opportunities., Objective: The aim of the study was to investigate the interaction features that facilitated or inhibited engagement with 4 consumer technologies chosen by teachers for stress management, as well as the influence of the educational contexts on their engagement. We also examined how use of well-being technology could be better supported in the school., Methods: The choice of consumer technologies was categorized in a taxonomy for English secondary school teachers according to stress-management strategies and digital features. Due to the COVID-19 pandemic, we adapted the study so that working from home in the summer could be contrasted with being back in school. Thus, a longitudinal study intended for 6 weeks in the summer term (in 2020) was extended into the autumn term, lasting up to 27 weeks. Teachers chose to use either a Withings smartwatch or Wysa, Daylio, or Teacher Tapp apps. Two semistructured interviews and web-based surveys were conducted with 8 teachers in England in the summer term, and 6 (75%) of them took part in a third interview in the autumn term. Interviews were analyzed using reflexive thematic analysis informed by interpretive phenomenological analysis., Results: Technology elements and characteristics such as passive data collation, brevity of interaction, discreet appearance, reminders, and data visualization were described by teachers as facilitators. Lack of instructions and information on features, connectivity, extended interaction requirements, and nondifferentiation of activity and exercise data were described as barriers. Mesocontextual barriers to engagement were also reported, particularly when teachers were back on school premises, including temporal constraints, social stigma, and lack of private space to de-stress. Teachers had ideas for feature improvements and how educational leadership normalizing teachers' stress management with consumer technologies could benefit the school culture., Conclusions: Having preselected their stress-management strategies, teachers were able to harness design features to support themselves over an extended period. There could be an important role for digital interventions as part of teachers' stress management, which the school leadership would need to leverage to maximize their potential. The findings add to the holistic understanding of situated self-care and should inform developers' considerations for occupational digital stress support., (©Julia B Manning, Ann Blandford, Julian Edbrooke-Childs. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.10.2024.)

Background: Although at the base of the pyramid-shaped organization of the Rwandan health system, community health workers (CHWs) are central to the community-based management of disease outbreaks., Objective: This mixed methods study aimed to explore the feasibility, acceptability, satisfaction, and challenges of a mobile health (mHealth) tool for community-based COVID-19 screening in Rwanda., Methods: Two urban (Gasabo and Nyarugenge) and 2 rural (Rusizi and Kirehe) districts in Rwanda participated in the project (smartphone app for COVID-19 screening). A mixed methods approach was used to inform the feasibility (awareness and expectation), acceptability (use and perceived benefits), satisfaction, and challenges of the mHealth intervention. At the end of the project, CHWs were asked to complete a quantitative questionnaire on the use of and satisfaction with the app. Then, in-depth interviews and focus group discussions were organized with CHWs. A content analysis was performed on the transcripts., Results: Overall, 383 CHWs were recruited and trained; 378 CHWs participated in the study. The mean age of CHWs was 36.7 (SD 6.6) to 45.3 (SD 9.9) years and most were women (237/378, 62.7%). More than 7000 people were registered with the use of the app and 20% were referred to a local COVID-19 testing facility. According to CHW reporting, the median number of people screened by each CHW ranged from 152 (IQR 70-276) for Nyarugenge to 24 (IQR 16-90) for Rusizi. COVID-19 positivity rates were higher in urban than rural districts: more than half of the CHWs in Gasabo reported a confirmed positive case versus only 2.4% for Kirehe and 15.4% for Rusizi. Despite the app being a novel tool, CHWs were well aware of the use of such a tool and had appropriate expectations. Acceptability and satisfaction were very high, with differences between urban and rural districts. Satisfaction was higher in Nyarugenge (72.8/100) and Gasabo (80.7/100) than in Kirehe (61.6/100) and Rusizi (64.5/100). More than 80% of the CHWs were willing to continue using the e-ASCov app, with the exception of CHWs in Kirehe (56.7%). The app was perceived as a tool to generate information on COVID-19, inform on the status of the pandemic, and help curb the spread of the pandemic in Rwanda. CHWs were satisfied with the app at all stages of its implementation in their districts., Conclusions: In this proof-of-concept study, a smartphone app for screening COVID-19 was useful as an mHealth tool to be used by CHWs, with the potential to increase health system efficiency in an epidemic context. The context should be analyzed for generalization on a country-wide scale, both in case of an epidemic and to take into account certain conditions at the community level. Information is needed on the conditions of generalization and transferability of this type of app to other health conditions so that CHWs can be given their full place in a pyramidal health system., (© Abdou Y Omorou, Pacifique Ndishimye, Bruno Hoen, Léon Mutesa, Prosper Karame, Ladislas Nshimiyimana, Simon Galmiche, Hassan Mugabo, Janvier Murayire, Muco Mugisha, Marie Michele Umulisa, Yvonne Uwera, Clarisse Musanagabanwa, Noella Bigirimana, Sabin Nsanzimana, Francis Guillemin, Jean-Paul Rwabihama. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org).)

Background: Neurodevelopmental disorders (NDs) are characterized by heterogeneity, complexity, and interactions among multiple domains with long-lasting effects in adulthood. Early and accurate identification of children at risk for NDs is crucial for timely intervention, yet many cases remain undiagnosed, leading to missed opportunities for effective interventions. Digital tools can help clinicians assist and identify NDs. The concept of using serious games to enhance health care has gained attention among a growing group of scientists, entrepreneurs, and clinicians., Objective: This study aims to explore the core principles of automated mobile detection of NDs in typically developing Greek children, using a serious game developed within the SmartSpeech project, designed to evaluate multiple developmental domains through principal component analysis (PCA)., Methods: A total of 229 typically developing children aged 4 to 12 years participated in the study. The recruitment process involved open calls through public and private health and educational institutions across Greece. Parents were thoroughly informed about the study's objectives and procedures, and written consent was obtained. Children engaged under the clinician's face-to-face supervision with the serious game "Apsou," which assesses 18 developmental domains, including speech, language, psychomotor, cognitive, psychoemotional, and hearing abilities. Data from the children's interactions were analyzed using PCA to identify key components and underlying principles of ND detection., Results: A sample of 229 typically developing preschoolers and early school-aged children played the Apsou mobile serious game for automated detection of NDs. Performing a PCA, the findings identified 5 main components accounting for about 80% of the data variability that potentially have significant prognostic implications for a safe diagnosis of NDs. Varimax rotation explained 61.44% of the total variance. The results underscore key theoretical principles crucial for the automated detection of NDs. These principles encompass communication skills, speech and language development, vocal processing, cognitive skills and sensory functions, and visual-spatial skills. These components align with the theoretical principles of child development and provide a robust framework for automated ND detection., Conclusions: The study highlights the feasibility and effectiveness of using serious games for early ND detection in children. The identified principal components offer valuable insights into critical developmental domains, paving the way for the development of advanced machine learning applications to support highly accurate predictions and classifications for automated screening, diagnosis, prognosis, or intervention planning in ND clinical decision-making. Future research should focus on validating these findings across diverse populations integrating additional features such as biometric data and longitudinal tracking to enhance the accuracy and reliability of automated detection systems., Trial Registration: ClinicalTrials.gov NCT06633874; https://clinicaltrials.gov/study/NCT06633874., International Registered Report Identifier (irrid): RR2-https://doi.org/10.3390/signals4020021., (©Eugenia I Toki, Victoria Zakopoulou, Giorgos Tatsis, Jenny Pange. Originally published in JMIR Formative Research (https://formative.jmir.org), 11.10.2024.)

Background: The use of mobile technologies to deliver behavioral health interventions, including smoking cessation support, has grown. Users' perceptions are important determinants of the adoption and use of new technologies. However, little is known about users' perceptions of mobile technologies as smoking cessation aids, particularly among disadvantaged individuals who smoke., Objective: This study aimed to examine the acceptance of mobile technologies for smoking cessation among young adults with low socioeconomic status who smoke., Methods: In total, 38 current cigarette smokers, 18 to 29 years old, who wanted to quit and did not have a 4-year college degree nor were enrolled in a 4-year college, participated in 12 semistructured digital focus groups. The moderation guide was guided by the Unified Theory of Acceptance and Use of Technology. Discussions were audio recorded, transcribed verbatim, and coded for the Unified Theory of Acceptance and Use of Technology constructs (ie, effort expectancy, facilitating conditions, performance expectancy, and social influence), sentiment (ie, negative, neutral, and positive), and purpose of using mobile technologies (ie, lifestyle and health management and smoking cessation) following a deductive thematic analysis approach., Results: Participants had positive experiences using mobile technologies for lifestyle and health management, primarily for fitness and dietary purposes. Salient themes were facilitating conditions of use (44/80, 55%), with prior experiences and costs subthemes, followed by perceived usefulness of mobile technologies in helping users attain health goals (22/80, 27.50%), which were generally positive. Ease of use (11/80, 13.75%) and social influences (3/80, 3.75%) were minimally discussed. Conversely, participants had limited awareness of smoking cessation uses of mobile technologies, which was the primary barrier under facilitating conditions discussed (33/51, 64.70%). Participants expressed skepticism about the usefulness of mobile technologies in helping them quit smoking (14/51, 27.45%). Effort expectancy was not discussed, given participants' limited prior use. Social influences on mobile technology use for smoking cessation were minimally discussed (4/51, 7.84%)., Conclusions: The use of mobile technologies for smoking cessation was unknown to young adults with low socioeconomic status who smoke. To reduce cigarette smoking and associated health disparities, increasing awareness and use of evidence-based mobile-based smoking cessation interventions are needed. Smoking cessation interventions should incorporate features perceived as useful and easy to use to capitalize on positive user experiences and the acceptability of mobile technologies for lifestyle and health management., (©Michael Wakeman, Lydia Tesfaye, Tim Gregory, Erin Leahy, Brandon Kendrick, Sherine El-Toukhy. Originally published in JMIR Formative Research (https://formative.jmir.org), 11.10.2024.)

Background: Digital, or eHealth, interventions are highly promising approaches to help adolescents improve their health behaviours and reduce their risk of chronic disease. However, they often have low uptake and retention. There is also a paucity of high-quality research into the predictors of eHealth engagement, and a lack of studies that have systematically evaluated existing engagement strategies in adolescent populations. This paper describes the protocol for a randomised controlled trial which primarily aims to assess the effectiveness of different strategies in increasing engagement with a healthy lifestyles app, Health4Life. Associations between the engagement strategies and improvements in adolescent health behaviours (healthy eating, physical activity, sleep, recreational screen time, smoking, alcohol use) will also be examined, along with potential predictors of adolescents' intentions to use health apps and their use of the Health4Life app., Methods: The current study will aim to recruit 336 adolescent and parent/guardian dyads (total sample N = 672) primarily through Australia wide online advertising. All adolescent participants will have access to the Health4Life app (a multiple health behaviour change, self-monitoring mobile app). The trial will employ a 2 4 factorial design, where participants will be randomly allocated to receive 1 of 16 different combinations of the four engagement strategies to be evaluated: text messages, access to a health coach, access to additional gamified app content, and provision of parent/guardian information resources. Adolescents and parents/guardians will both complete consent processes, baseline assessments, and a follow-up assessment after 3 months. All participants will also be invited to complete a qualitative interview shortly after follow-up. The primary outcome, app engagement, will be assessed via an App Engagement Index (Ei) using data collected in the Health4Life app and the Mobile App Rating Scale - User version., Discussion: This research will contribute significantly to building our understanding of the types of strategies that are most effective in increasing adolescents' engagement with health apps and which factors may predict adolescents' use of health apps., Trial Registration: The trial is registered at the Australian New Zealand Clinical Trials Registry (ACTRN12623000399695). Date registered: 19/04/2023., (© 2024. The Author(s).)

Background: Vaccination services are increasingly in demand by the public, and mobile apps are an effective tool to meet that demand. However, the characteristics and quality of these apps are unknown., Objective: Commonly used vaccination service apps on the market were surveyed with regard to quality, service content, and user experience to evaluate and guide users., Methods: The Qimai Data mobile app data analytics platform was used to search for common vaccination service apps by keyword, and the WeChat and Alipay platforms were searched for apps. The apps included in the study were independently evaluated by two reviewers using the Mobile Application Rating Scale, and the service content and user experience of the apps were analyzed. The intragroup correlation coefficient between raters was used to measure interrater reliability., Results: In the app stores of the four major Android platforms and the iOS app store, 1092 and 207 apps were found, respectively; 189 WeChat applets and 30 Alipay applets were also found. A total of 29 apps was ultimately included in this study according to the inclusion criteria, including 21 independent apps, 4 WeChat applets, and 4 Alipay applets. Significant differences were found between independent apps and applets in terms of the quality score (t 449.57 =-5.301; P<.001) and the subjective quality score (z=-4.753; P<.001). No significant differences were found between iOS and Android platforms in terms of the quality score (t 1404 =-2.55; P=.80) and the subjective quality score (z=-0.137; P=.89). There was good intragroup consistency among the raters., Conclusions: In this study, independent apps and nonindependent apps that rely on social and payment platforms for implementation were included in the vaccination services category. The overall quality of these apps was acceptable. Nonindependent running apps were found to have slightly lower scores and showed room for improvement, and scores for the participatory apps were found to be generally low overall., (©Chenchen Zhang, Xing Guo, Rui Zhu, Wenjie Hou, Lingmeng Wang, Fuzhi Wang, Li Zhang, Dan Luo. Originally published in the Online Journal of Public Health Informatics (https://ojphi.jmir.org/), 03.10.2024.)

Many alcohol-industry-funded (AIF) organizations disseminate eHealth/mHealth tools that claim to assist users in making health decisions by monitoring alcohol consumption, e.g. blood alcohol calculators, AUDIT scores, consumption trackers. Previously, AIF materials were found to contain health misinformation that could increase consumption (dark nudges) or make healthy behaviour change more difficult (sludge). The accuracy and functionality of AIF tools have never been analysed, and given the history of AIF materials it is possible they contain misinformation and function as covert marketing channels to promote alcohol-industry-friendly narratives on the causes and possible solutions of alcohol-related harms. We evaluated the information accuracy and framing, behaviour change techniques (BCTs), and functions of AIF digital tools (n = 15, from the UK, Ireland, the USA, Canada, New Zealand, Australia; including Drinkaware, Drinkwise, Educ'alcool and others), compared to a non-industry-funded independent sample (n = 10). We identified misinformation and 'dark patterns' (interface design strategies for influencing users against their interest) throughout AIF tools; significantly fewer provided accurate feedback (33% vs 100%), and significantly more omitted information on cancer (67% vs 10%) and cardiovascular disease (80% vs 30%) and promoted industry-friendly narratives (47% vs 0%). AIF tools encouraged consumption through priming nudges (53%) and social norming (40%). AIF tools utilized fewer BCTs, provided users with more limited pre-set options (54%), and fewer drink choices (mean 24 vs 275). Their input structure often impeded their ability to provide guideline advice. We conclude that AIF tools contain pro-industry misinformation strategies and dark patterns that misinform users about their consumption and could 'nudge' them towards continuing to drink alcohol-characteristics of 'Dark Apps' designs., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

There is growing enthusiasm towards the role of smartphone app-based interventions in the management of insomnia and related sleep problems. A considerable number of apps designed to address insomnia have been developed in recent years, and randomized controlled trials (RCTs) have begun to explore their efficacy. We conducted a meta-analysis investigating the effectiveness of apps for insomnia and sleep disturbances. From 19 RCTs, we identified significant pooled effect sizes for the primary outcomes of self-reported insomnia (g = 0.60; 05 % CI = 0.44, 0.76; NNT = 4.8) and sleep disturbances (g = 0.70; 95 % CI = 0.58, 0.83; NNT = 4.1) in favour of apps over control conditions. These effects remained robust when restricting the analyses to trials that delivered a placebo control, received a lower risk of bias rating, and had a larger sample size. Significant pooled effects in favour of apps were also observed for secondary outcomes of night time awakenings (g = 0.56), total sleep time (g = 0.33), and sleep onset latency (g = 0.32), but non-significant effects emerged for daytime sleepiness, dysfunctional beliefs about sleep, sleep efficiency, sleep hygiene, and wake after sleep onset. The pooled dropout rate from app conditions was 13.1 % (95 % CI = 8.3, 20.0), which was significantly higher than control conditions (OR = 1.78, 95 % CI = 1.39, 2.28). Findings suggest that stand-alone app-based interventions can effectively address insomnia and sleep disturbances, and may play an important role in the management of these symptoms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Social participation is crucial for healthy aging, improving physical and mental health, cognitive function, and quality of life among older adults. However, social participation tends to decline with age due to factors like loss of social networks and health issues. Mobile health apps show promise in promoting healthy behaviors among older adults, but their effectiveness in increasing social participation remains understudied., Objective: This randomized controlled trial aimed to evaluate the efficacy of a mobile app called Encouragement of Social Participation (ESP, "Shakai Sanka no Susume;" Hitachi) in promoting social participation and physical activity among community-dwelling older adults., Methods: The study recruited 181 community-dwelling adults aged 60 years or older from 2 municipalities in Japan and through a web-based research panel. Participants were randomly assigned to either the intervention group (n=87), which used the ESP app for 12 weeks, or the control group (n=94), which used only Google Fit. The ESP app incorporated features such as self-monitoring of social participation, personalized feedback, gamification elements, and educational content. Primary outcomes were changes in social participation frequency over the previous 2 months and changes in step counts, measured at baseline and week 12. Secondary outcomes included changes in specific types of social activities and subjective well-being. Data were analyzed using analysis of covariance and linear mixed-effects models., Results: The intervention group showed a significantly greater increase in social participation frequency compared with the control group (adjusted difference 3.03; 95% CI 0.17-5.90; P=.04). Specifically, the intervention group demonstrated higher frequencies of participation in hobbies (adjusted difference: 0.82; 95% CI 0.01-1.63) and cultural clubs (adjusted difference 0.65; 95% CI 0.07-1.23) compared with the control group. However, there were no significant differences in weekly step counts between the groups. Subgroup analyses suggested potentially larger effects among participants who were older than 70 years, female, had lower educational attainment, and were recruited from community settings, although only females and the lower educational attainment subgroups demonstrated 95% CIs that did not encompass zero., Conclusions: The ESP mobile app effectively promoted social participation among community-dwelling older adults, particularly in hobbies and cultural club activities. However, it did not significantly impact physical activity levels as measured by step counts. These findings suggest that mobile apps can be valuable tools for encouraging social engagement in older populations, potentially contributing to healthy aging. Future research should focus on optimizing app features to maintain long-term engagement and exploring strategies to enhance physical activity alongside social participation., Trial Registration: University Medical Information Network Clinical Trial Registry UMIN000049045; https://center6.umin.ac.jp/cgi-open-bin/ctr&#95;e/ctr&#95;view.cgi?recptno=R000055781., (©Kenjiro Kawaguchi, Atsushi Nakagomi, Kazushige Ide, Katsunori Kondo. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 30.09.2024.)

Background: Despite the increased accessibility and availability of technology in recent years, equality and access to health-related technology remain limited to some demographics. In particular, patients who are older or from rural communities represent a large segment of people who are currently underusing mobile health (mHealth) solutions. System usability continues to hinder mHealth adoption among users with nontraditional digital literacy., Objective: This study aims to investigate if state-of-the-art mobile app interfaces from open-source libraries provide sufficient usability for rural patients with cancer, with minimal design changes and forgoing the co-design process., Methods: We developed Assuage (Network Reconnaissance Lab) as a research platform for any mHealth study. We conducted a pilot study using Assuage to assess the usability of 4 mobile user interfaces (UIs) based on open-source libraries from Apple's ResearchKit and CareKit. These UIs varied in complexity for reporting distress symptoms. Patients with cancer were recruited at the Markey Cancer Center, and all research procedures were conducted in person. Participants completed the distress assessment using a randomly selected UI in Assuage with little to no assistance. Data were collected on participant age, location, mobile app use, and familiarity with mHealth apps. Participants rated usability with the System Usability Scale (SUS), and usability issues were documented and compared. A one-way ANOVA was used to compare the effect of the UIs on the SUS scores., Results: We recruited 30 current or postsurgery patients with cancer for this pilot study. Most participants were aged >50 years (24/30, 80%), from rural areas (25/30, 83%), had up to a high school education (19/30, 63%), and were unfamiliar with mHealth apps (21/30, 70%). General mobile app use was split, with 43% (14/30) of the patients not regularly using mobile apps. The mean SUS score across the UIs was 75.8 (SD 22.2), with UI 3 and UI 4 achieving an SUS score ≥80, meeting the industry standard for good usability of 80. Critical usability issues were related to data input and navigation with touch devices, such as scale-format questions, vertical scrolling, and traversing multiple screens., Conclusions: The findings from this study show that most patients with cancer (20/30, 67%) who participated in this study rated the different interfaces of Assuage as above-average usability (SUS score >68). This suggests that Apple's ResearchKit and CareKit libraries can provide usable UIs for older and rural users with minimal interface alterations. When resources are limited, the design stage can be simplified by omitting the co-design process while preserving suitable usability for users with nontraditional technical proficiency. Usability comparable to industry standards can be achieved by considering heuristics for interface and electronic survey design, specifically how to segment and navigate surveys, present important interface elements, and signal gestural interactions., (©Alyssa Donawa, Christian Powell, Rong Wang, Ming-Yuan Chih, Reema Patel, Ralph Zinner, Eliah Aronoff-Spencer, Corey E Baker. Originally published in JMIR Formative Research (https://formative.jmir.org), 26.09.2024.)

Background: Digital peer support, defined as peer support delivered through technology such as smartphone apps, may be promising to promote activity in the form of step counts. Interactions among users have a positive impact on retention rates, and apps with social elements show significant improvements in daily step count. However, the feasibility of digital peer support in promoting physical activity (PA) is unknown; therefore, its effectiveness on step count and the clinical implications remain unconfirmed., Objective: This study aimed to assess the feasibility of digital peer support over a 3-month intervention period using the retention rate as the outcome. Moreover, changes in daily step count and physical measurements were compared between pre- and postintervention., Methods: The study design was a 3-month 1-arm intervention with participants from local government offices in Kanagawa, Japan. We used an available smartphone app, Minchalle, as the tool for the group intervention. Participants were required to report their daily step count to a maximum of 5 members composed exclusively of study participants. The primary outcome was the retention rate. Secondary outcomes included daily step count, the rate of achieving daily step goals, physical measurements, and lifestyle characteristics. Descriptive statistics and the Pearson coefficient were used to examine the relationship between goal achievement and step count, as well as changes in step count and various variables including physical measurements., Results: Of the 63 participants, 62 completed the intervention. The retention rate was 98% (62/63). The average daily step count during the intervention was 6993 (SD 2328) steps, an 1182-step increase compared with the count observed 1 week before the intervention began. The rate of achieving the daily step count during the intervention was 53.5% (SD 26.2%). There was a significant correlation (r=0.27, P=.05) between achieving daily step goals and increasing daily step count. Comparative analyses showed that changes in weight (68.56, SD 16.97 kg vs 67.30, SD 16.86 kg; P<.001), BMI (24.82, SD 4.80 kg/m 2 vs 24.35, SD 4.73 kg/m 2 ; P<.001), somatic fat rate (28.50%, SD 7.44% vs 26.58%, SD 7.90%; P=.005), systolic blood pressure (130.42, SD 17.92 mm Hg vs 122.00, SD 15.06 mm Hg; P<.001), and diastolic blood pressure (83.24, SD 13.27 mm Hg vs 77.92, SD 11.71 mm Hg; P=.002) were significantly different before and after the intervention. Similarly, the daily amount of PA significantly improved from 5.77 (SD 3.81) metabolic equivalent (MET)-hours per day to 9.85 (SD 7.84) MET-hours per day (P<.001)., Conclusions: This study demonstrated that digital peer support is feasible for maintaining a high retention rate and can, therefore, effectively promote PA. It can be a promising tool to improve daily step count, subjective PA, and clinical outcomes, such as weight and somatic fat rate., Trial Registration: UMIN Clinical Trials Registry UMIN000042520; https://tinyurl.com/46c4nm8z., (©Masumi Okamoto, Yoshinobu Saito, Sho Nakamura, Makoto Nagasawa, Megumi Shibuya, Go Nagasaka, Hiroto Narimatsu. Originally published in JMIR Formative Research (https://formative.jmir.org), 24.09.2024.)

Background: Germany has one of the oldest social security systems in the world. Population coverage has subsequently increased, reaching coverage of approximately 90% of the population in the statutory health insurance (SHI) system today. Before this background, Germany has been pioneering the integration of digital therapeutics (DTx) into its SHI system by the introduction of the Digital Healthcare Law (Digitale-Versorgung-Gesetz, DVG) in 2019. Thereby, patients became eligible for digital health applications (Digitale Gesundheitsanwendungen, DiGA), which are available upon prescription by qualified healthcare professionals., Challenge: As conventional healthcare delivery often lacks direct outcome measures as and is mostly still reimbursed on a fee-for-service basis, DiGA offer the opportunity to continuously provide individual outcome and performance data. They are, therefore, well-suited for a performance-based payment framework. While the DVG introduced the option for performance-based reimbursement components in 2019 already, the ongoing debate about the value of DiGA and to what extent they can contribute to the healthcare system has now been reflected in a 2023 health policy bill by the German Federal Ministry of Health, which aims to introduce a mandatory performance-based reimbursement component for DiGA., Proposal: In this light, we propose a framework for performance-based reimbursement of DiGA, involving an intervention-specific, performance-linked reimbursement framework with shared accountability between manufacturers and payers. The approach aims to align the often contradicting interests of the involved stakeholders to incentivize the delivery of high-value digital health care. Yet, the proposal also acknowledges the need for further research to establish a robust foundation for implementing such a framework., Competing Interests: LB receives a salary from Vivira Health Lab GmbH, a DiGA manufacturer. Yet, Vivira Health Lab GmbH did not have any influence on this article and did neither provide content, nor financial support to this work., (© The Author(s) 2024.)

Technology has the potential to address the unique needs of young stroke survivors. Despite this, little is known about the technological resources available to support young adults with stroke. This study aimed to identify and compile available technological resources that cater to the specific needs of young adults (18-30 years) with stroke in Australia. An environmental scan was conducted from December 2023 to March 2024. Sources included websites, app stores, rehabilitation centres, hospitals, organisations, technology developers, and healthcare professionals. Of the 114 resources identified, 11% were for re-training limb movement, 40% for speech rehabilitation, 20% for medication reminders, and 29% were social media posts offering peer mentoring and support. Most limb movement (75%) and medication reminder (87%) apps were free. However, most speech therapy apps (78%) had associated costs. Social media posts were hosted on Facebook (64%), Instagram (21%), TikTok (9%), YouTube (3%), and other websites (3%). Forty-six percent of the social media posts targeting young stroke survivors did not specify the age group. These resources were identified as available to young people with stroke. Although the resources found focused on young stroke survivors, it was difficult to ascertain the specific age group that was being targeted.

Background: Axial spondyloarthritis (AS) is a chronic inflammatory rheumatic disease characterized by potentially disabling inflammation of the spine and adjacent joints. Regular exercise is a cornerstone of treatment. However, patients with AS currently have little support. YogiTherapy (MaD Lab) is an app developed to support patients with AS by providing instructions for yoga-based home exercise therapy., Objective: This study aimed to evaluate the usability and acceptance of the newly designed YogiTherapy app for patients with AS., Methods: Patients completed the User Version of the Mobile Application Rating Scale (uMARS) and net promoter score (NPS) questionnaires after the app introduction. Wilcoxon Mann-Whitney rank sum test, chi-square test for count data, and correlation analysis were conducted to examine the usability of the app, acceptance, and patient characteristics., Results: A total of 65 patients with AS (33, 51% female; age: mean 43.3, SD 13.6 years) were included in the study from May 2022 to June 2023. Subsequently, the data were analyzed. Usability was rated moderate, with a mean uMARS of 3.35 (SD 0.47) points on a scale from 0 to 5. The highest-rated uMARS dimension was information (mean 3.88, SD 0.63), followed by functionality (mean 3.84, SD 0.87). Females reported a significantly higher uMARS total score than males (mean 3.47, SD 0.48 vs mean 3.23, SD 0.45; P=.03, Vargha and Delaney A [VDA] 0.66, 95% CI 0.53-0.77). The mean average of the NPS was 6.23 (SD 2.64) points (on a scale from 0 to 10), based on 43% (26/65 nonpromoters, 42% (25/65) indifferent, and 15% (9/65) promoters. A total of 7% (5/65) of those surveyed did not answer the question. When applying the NPS formula, the result is -26%. The NPS showed a positive correlation with the usage of mobile apps (r=0.39; P=.02). uMARS functionality was significantly higher rated by patients younger than 41 years (mean 4.17, SD 0.55 vs mean 3.54, SD 1; P<.001; VDA 0.69, 95% CI 0.56-0.80). Patients considering mobile apps as useful reported higher uMARS (r=0.38, P=.02). The uMARS app quality mean score was correlated with the frequency of using apps (r=-0.21, P<.001)., Conclusions: The results revealed moderate acceptance and usability ratings, prompting further app improvement. Significant differences were observed between age and gender. Our results emphasize the need for further improvements in YogiTherapy., (©Lara Grube, Pascal Petit, Nicolas Vuillerme, Marlies Nitschke, Obioma Bertrand Nwosu, Johannes Knitza, Martin Krusche, Ann-Kristin Seifer, Bjoern M Eskofier, Georg Schett, Harriet Morf. Originally published in JMIR Formative Research (https://formative.jmir.org), 19.09.2024.)

Background: Work burden increases for physiotherapists in the primary health care sector as the prevalence of musculoskeletal disorders (MSDs) increases. Digital health technologies (DHTs) are proposed as a viable solution to secure the sustainability of the health care system and have shown promising results in a range of conditions. However, little is known about use of DHTs among physiotherapists in the primary health care sector in Norway., Objective: This study aimed to investigate the use of and attitudes toward DHTs among physiotherapists treating patients with MSDs in primary care, and potential facilitators or barriers for adopting DHTs in clinical practice., Methods: An author-developed web-based questionnaire was distributed to physiotherapists in all Norwegian municipalities in March 2023. The questionnaire included items regarding use of technologies, attitudes, suitability, and factors influencing adoption of DHT. Suitability and agreement on statements were scored on an 11-point numeric rating scale (0=very unsuitable or strongly disagree, 10=very suitable or strongly agree). Differences across employment sites and users versus nonusers of DHT were analyzed using the χ 2 test, Fisher exact test, Student t test, and Mann-Whitney U test., Results: Approximately 5000 physiotherapists were invited to participate, of which 6.8% (338) completed the questionnaire. A total of 46.2% (156/338) offered DHTs in their practice, of which 53.2% (83/156) used it on a weekly basis, mostly telephone consultations (105/156, 67.3%). A higher proportion of physiotherapists in private practice offered DHT compared with those employed by municipalities (95/170, 55.9% vs 61/168, 36.3%; P<.001). A majority (272/335, 81.2%) were positive about recommending DHTs to their patients. Suitability of DHTs in physiotherapy was rated an average of 6 (SD 2.1). Apps for smartphones or tablets were rated most suitable (mean rating 6.8, SD 2.4). The most frequently reported advantages were flexibility in how physiotherapy is offered (278/338, 82.3%) and reduced travel time for the patient (235/338, 70%). The highest rated disadvantages were limited scope for physical examination (252/338, 74.6%) and difficulty in building rapport with the patient (227/338, 67.2%). The main facilitators and barriers included a functioning (median rating 10, IQR 8-10) or lack of functioning (median rating 9, IQR 8-10) internet connection, respectively. Lack of training in DHTs was prominent regarding evaluation, diagnosing, and treatment (median rating 0, IQR 0-2), with minor, but significant, differences between nonusers and users (median rating 0, IQR 0-1 vs median rating 1, IQR 0-4); P<.001)., Conclusions: Physiotherapists in Norwegian primary care treating patients with MSDs are positive about using DHTs, and almost 50% (156/338) have adopted them in clinical practice. Concerns are related to lack of a physical examination and technical aspects. Training in the use of DHTs should be addressed in implementation processes., (©Lars Martinsen, Nina Østerås, Tuva Moseng, Anne Therese Tveter. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 16.09.2024.)

Traditional public health surveillance efforts are generally based on self-reported data. Although well validated, these methods may nevertheless be subjected to limitations such as biases, delays, and costs or logistical challenges. An alternative is the use of smart technologies (eg, smartphones and smartwatches) to complement self-report indicators. Having embedded sensors that provide zero-effort, passive, and continuous monitoring of health variables, these devices generate data that could be leveraged for cases in which the data are related to the same self-report metric of interest. However, some challenges must be considered when discussing the use of mobile health technologies for public health to ensure digital health equity, privacy, and best practices. This paper provides, through a review of major Canadian surveys and mobile health studies, an overview of research involving mobile data for public health, including a mapping of variables currently collected by public health surveys that could be complemented with self-report, challenges to technology adoption, and considerations on digital health equity, with a specific focus on the Canadian context. Population characteristics from major smart technology brands-Apple, Fitbit, and Samsung-and demographic barriers to the use of technology are provided. We conclude with public health implications and present our view that public health agencies and researchers should leverage mobile health data while being mindful of the current barriers and limitations to device use and access. In this manner, data ecosystems that leverage personal smart devices for public health can be put in place as appropriate, as we move toward a future in which barriers to technology adoption are decreasing., (©Pedro Elkind Velmovitsky, Merna Kirolos, Paulo Alencar, Scott Leatherdale, Donald Cowan, Plinio Pelegrini Morita. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 12.09.2024.)

Background: Adolescent and adult obesity continues to be a public health epidemic in the United States. Despite the popularity of mHealth apps with gamification among adolescents, there are insufficient studies to evaluate the efficacy of gamified mHealth apps and financial incentives to motivate sustained health behavior change in adolescents or their adult caregivers., Objective: This study aims to evaluate the effectiveness of gamification techniques and financial incentives used in the novel "CommitFit" mHealth app to motivate health behavior change and improve various mental and physical health metrics in adolescents and their caregivers., Methods: This study is a 3-month randomized controlled trial (RCT) with 30 adolescents (aged 13-15 years) and their adult caregivers (N=60). It evaluates "CommitFit," which uses gamification including points and leaderboards to motivate logging and achievement of self-selected health behavior goals (eg, more water, sleep, physical activity, fruits, or vegetables or fewer sugary beverages). The RCT had three arms, each with 10 dyads: (1) CommitFit-only users; (2) CommitFit$, where adolescents were paid US $0.05 for each point they earned; and (3) waitlist control. Intervention dyads used the app for 3 months and had the option to use it for the fourth month without prompts or extra financial incentives. User analytic software was used to evaluate the frequency of user logs and goal achievement. Monthly surveys evaluated self-reported change in the 5 CommitFit health behaviors. Changes in BMI and blood pressure were evaluated for all participants at 3 clinical visits. Mental health, gamification, and behavior economics surveys were completed during the clinical visits., Results: Recruitment began in August 2023 and was completed in 10 weeks. The research team successfully recruited and enrolled 30 dyads. Researchers emailed and called 89 caregivers on a physician-approved adolescent patient list, a 33% recruitment rate. Data collection and analysis will be conducted in the spring and summer of 2024. The results of this study are anticipated to be published between late 2024 and early 2025., Conclusions: This RCT will expand knowledge of the effectiveness of gamification techniques, financial incentives, and mHealth apps to motivate sustained health behavior change among adolescents and caregivers. These results may offer new opportunities to caregivers, health insurers, health care systems, and clinicians to motivate health behavior change in adolescents and caregivers, with the ultimate goal of preventing or reducing obesity and obesity-related diseases. Additional gamification, mental health surveys, and app user analytics included in the study may provide further insight into the characteristics of adolescents or caregivers who would benefit the most from using a gamified mHealth app like CommitFit., International Registered Report Identifier (irrid): DERR1-10.2196/63505., (©Amy Braddock, Parijat Ghosh, Emma Montgomery, Crystal Lim, Jaya Ghosh, Nicole Henry, Mihail Popescu, Kimberly Kimchi, Congyu Guo, K Taylor Bosworth, Richelle J Koopman. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 10.09.2024.)

Objective: This retrospective study (2020-2022) compared the usage patterns across international regions of an employer-provided digital mental health platform, which is available in native languages and offers both self-guided digital activities and one-on-one sessions., Methods: Routine data from the platform were analyzed by describing the demographic profile of 178,119 users from different geographical regions, their baseline mental health status and burnout levels, as well as patterns of engagement. Statistical analyses were conducted using logistic and ordered logit models to examine the association between cumulative engagement with the platform over time and baseline characteristics., Results: The platform had high engagement and satisfaction levels across regions and age groups. Female users were more engaged than males in both self-guided digital activities and one-on-one sessions. Older users and those from non-US regions were more engaged in self-guided digital activities, while younger users and those from the US were more engaged in one-on-one sessions. Symptoms of anxiety were also associated with engagement with one-on-one sessions., Conclusions: The study's findings provide valuable insights into the benefits of digital platforms in addressing mental health needs of employers from different regions. Future research should focus on exploring the specific factors that influence engagement with digital mental health platforms and how these platforms can be optimized and tailored to better serve diverse populations., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This study was funded by Modern Health, the developer and owner of the platform that was analyzed., (© The Author(s) 2024.)

The majority of Black women with hypertension in the United States have smartphones or tablets and use social media, and many use wearable activity trackers and health or wellness apps, digital tools that can be used to support lifestyle changes and medication adherence., (©Jolaade Kalinowski, Sandesh Bhusal, Sherry L Pagoto, Robert Newton Jr, Molly E Waring. Originally published in JMIR Cardio (https://cardio.jmir.org), 09.09.2024.)

Background: Disruptive behavior disorders are among the most common disorders of childhood, and evidence-based parenting programs are the first-line treatment. Digital microinterventions have been proposed as one possible means of supporting parenting style change by giving parents in-the-moment advice about how to respond to challenging behavior. Until now, no digital microintervention supporting evidence-based parenting skills programs has been evaluated., Objective: The aim of this study is to evaluate the subjective experience of parents using a digital microintervention to support evidence-based parenting skills, with particular attention to acceptability, usability, family relationships, and parents' values., Methods: We conducted serial interviews with 11 parents of 33 children before and after spending 3 weeks using an app including 3 digital microinterventions. Parents were recruited via local authorities in the Midlands region of the United Kingdom. Previous participation in a parenting program was an inclusion criterion. Interviews explored family composition; child behavior problems; and experience of using the mobile app, including barriers to use. Thematic analysis was conducted from a user-centered design perspective, and illustrative case vignettes were produced., Results: Many parents used the app in ways that helped them rather than strictly following the instructions they were given. Parents described a range of barriers to using the app including practical problems and failure to change child behavior. Parents and children responded in a variety of ways to the use of the phone, with many wholeheartedly embracing the convenience of technology. Case vignettes illustrate the uniqueness of each family's experience., Conclusions: Parents' use of a mobile app supporting evidence-based parenting skills is difficult to predict due to the unique challenges each family encounters. Many parents found it an acceptable and helpful addition to family life, but increased personalization is likely to be key to supporting parents. Future digital microintervention developers should keep in mind that parents are likely to use the app pragmatically rather than following instructions, may struggle to use a complex app under pressure, and are likely to hold complex feelings about parenting with an app., (© Nathan Hodson, Peter Woods, Juan Luque Solano, Charlotte Talbot, Domenico Giacco. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org).)

Background: Older adults discharged from the emergency department (ED) face elevated risk of falls and functional decline. Smartphones might enable remote monitoring of mobility after ED discharge, yet their application in this context remains underexplored., Objective: This study aimed to assess the feasibility of having older adults provide weekly accelerometer data from an instrumented Timed Up-and-Go (TUG) test over an 11-week period after ED discharge., Methods: This single-center, prospective, observational, cohort study recruited patients aged 60 years and older from an academic ED. Participants downloaded the GaitMate app to their iPhones that recorded accelerometer data during 11 weekly at-home TUG tests. We measured adherence to TUG test completion, quality of transmitted accelerometer data, and participants' perceptions of the app's usability and safety., Results: Of the 617 approached patients, 149 (24.1%) consented to participate, and of these 149 participants, 9 (6%) dropped out. Overall, participants completed 55.6% (912/1639) of TUG tests. Data quality was optimal in 31.1% (508/1639) of TUG tests. At 3-month follow-up, 83.2% (99/119) of respondents found the app easy to use, and 95% (114/120) felt safe performing the tasks at home. Barriers to adherence included the need for assistance, technical issues with the app, and forgetfulness., Conclusions: The study demonstrates moderate adherence yet high usability and safety for the use of smartphone TUG tests to monitor mobility among older adults after ED discharge. Incomplete TUG test data were common, reflecting challenges in the collection of high-quality longitudinal mobility data in older adults. Identified barriers highlight the need for improvements in user engagement and technology design., (© Brian Suffoletto, David Kim, Caitlin Toth, Waverly Mayer, Sean Glaister, Chris Cinkowski, Nick Ashenburg, Michelle Lin, Michael Losak. Originally published in JMIR Aging (https://aging.jmir.org).)

Background: Controlling saturated fat and cholesterol intake is important for the prevention of cardiovascular diseases. Although the use of mobile diet-tracking apps has been increasing, the reliability of nutrition apps in tracking saturated fats and cholesterol across different nations remains underexplored., Objective: This study aimed to examine the reliability and consistency of nutrition apps focusing on saturated fat and cholesterol intake across different national contexts. The study focused on 3 key concerns: data omission, inconsistency (variability) of saturated fat and cholesterol values within an app, and the reliability of commercial apps across different national contexts., Methods: Nutrient data from 4 consumer-grade apps (COFIT, MyFitnessPal-Chinese, MyFitnessPal-English, and LoseIt!) and an academic app (Formosa FoodApp) were compared against 2 national reference databases (US Department of Agriculture [USDA]-Food and Nutrient Database for Dietary Studies [FNDDS] and Taiwan Food Composition Database [FCD]). Percentages of missing nutrients were recorded, and coefficients of variation were used to compute data inconsistencies. One-way ANOVAs were used to examine differences among apps, and paired 2-tailed t tests were used to compare the apps to national reference data. The reliability across different national contexts was investigated by comparing the Chinese and English versions of MyFitnessPal with the USDA-FNDDS and Taiwan FCD., Results: Across the 5 apps, 836 food codes from 42 items were analyzed. Four apps, including COFIT, MyFitnessPal-Chinese, MyFitnessPal-English, and LoseIt!, significantly underestimated saturated fats, with errors ranging from -13.8% to -40.3% (all P<.05). All apps underestimated cholesterol, with errors ranging from -26.3% to -60.3% (all P<.05). COFIT omitted 47% of saturated fat data, and MyFitnessPal-Chinese missed 62% of cholesterol data. The coefficients of variation of beef, chicken, and seafood ranged from 78% to 145%, from 74% to 112%, and from 97% to 124% across MyFitnessPal-Chinese, MyFitnessPal-English, and LoseIt!, respectively, indicating a high variability in saturated fats across different food groups. Similarly, cholesterol variability was consistently high in dairy (71%-118%) and prepackaged foods (84%-118%) across all selected apps. When examining the reliability of MyFitnessPal across different national contexts, errors in MyFitnessPal were consistent across different national FCDs (USDA-FNDSS and Taiwan FCD). Regardless of the FCDs used as a reference, these errors persisted to be statistically significant, indicating that the app's core database is the source of the problems rather than just mismatches or variances in external FCDs., Conclusions: The findings reveal substantial inaccuracies and inconsistencies in diet-tracking apps' reporting of saturated fats and cholesterol. These issues raise concerns for the effectiveness of using consumer-grade nutrition apps in cardiovascular disease prevention across different national contexts and within the apps themselves., (© Dang Khanh Ngan Ho, Wan-Chun Chiu, Jing-Wen Kao, Hsiang-Tung Tseng, Cheng-Yu Lin, Pin-Hsiang Huang, Yu-Ren Fang, Kuei-Hung Chen, Ting-Ying Su, Chia-Hui Yang, Chih-Yuan Yao, Hsiu-Yueh Su, Pin-Hui Wei, Jung-Su Chang. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org).)

Background: Wearable digital health technologies and mobile apps (personal digital health technologies [DHTs]) hold great promise for transforming health research and care. However, engagement in personal DHT research is poor., Objective: The objective of this paper is to describe how participant engagement techniques and different study designs affect participant adherence, retention, and overall engagement in research involving personal DHTs., Methods: Quantitative and qualitative analysis of engagement factors are reported across 6 unique personal DHT research studies that adopted aspects of a participant-centric design. Study populations included (1) frontline health care workers; (2) a conception, pregnant, and postpartum population; (3) individuals with Crohn disease; (4) individuals with pancreatic cancer; (5) individuals with central nervous system tumors; and (6) families with a Li-Fraumeni syndrome affected member. All included studies involved the use of a study smartphone app that collected both daily and intermittent passive and active tasks, as well as using multiple wearable devices including smartwatches, smart rings, and smart scales. All studies included a variety of participant-centric engagement strategies centered on working with participants as co-designers and regular check-in phone calls to provide support over study participation. Overall retention, probability of staying in the study, and median adherence to study activities are reported., Results: The median proportion of participants retained in the study across the 6 studies was 77.2% (IQR 72.6%-88%). The probability of staying in the study stayed above 80% for all studies during the first month of study participation and stayed above 50% for the entire active study period across all studies. Median adherence to study activities varied by study population. Severely ill cancer populations and postpartum mothers showed the lowest adherence to personal DHT research tasks, largely the result of physical, mental, and situational barriers. Except for the cancer and postpartum populations, median adherences for the Oura smart ring, Garmin, and Apple smartwatches were over 80% and 90%, respectively. Median adherence to the scheduled check-in calls was high across all but one cohort (50%, IQR 20%-75%: low-engagement cohort). Median adherence to study-related activities in this low-engagement cohort was lower than in all other included studies., Conclusions: Participant-centric engagement strategies aid in participant retention and maintain good adherence in some populations. Primary barriers to engagement were participant burden (task fatigue and inconvenience), physical, mental, and situational barriers (unable to complete tasks), and low perceived benefit (lack of understanding of the value of personal DHTs). More population-specific tailoring of personal DHT designs is needed so that these new tools can be perceived as personally valuable to the end user., (©Sarah M Goodday, Emma Karlin, Alexa Brooks, Carol Chapman, Christiana Harry, Nelly Lugo, Shannon Peabody, Shazia Rangwala, Ella Swanson, Jonell Tempero, Robin Yang, Daniel R Karlin, Ron Rabinowicz, David Malkin, Simon Travis, Alissa Walsh, Robert P Hirten, Bruce E Sands, Chetan Bettegowda, Matthias Holdhoff, Jessica Wollett, Kelly Szajna, Kallan Dirmeyer, Anna Dodd, Shawn Hutchinson, Stephanie Ramotar, Robert C Grant, Adrien Boch, Mackenzie Wildman, Stephen H Friend. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 03.09.2024.)

Background: The COVID-19 pandemic gave rise to countless user-facing mobile apps to help fight the pandemic ("COVID-19 mitigation apps"). These apps have been at the center of data privacy discussions because they collect, use, and even retain sensitive personal data from their users (eg, medical records and location data). The US government ended its COVID-19 emergency declaration in May 2023, marking a unique time to comprehensively investigate how data privacy impacted people's acceptance of various COVID-19 mitigation apps deployed throughout the pandemic., Objective: This research aims to provide insights into health data privacy regarding COVID-19 mitigation apps and policy recommendations for future deployment of public health mobile apps through the lens of data privacy. This research explores people's contextual acceptance of different types of COVID-19 mitigation apps by applying the privacy framework of contextual integrity. Specifically, this research seeks to identify the factors that impact people's acceptance of data sharing and data retention practices in various social contexts., Methods: A mixed methods web-based survey study was conducted by recruiting a simple US representative sample (N=674) on Prolific in February 2023. The survey includes a total of 60 vignette scenarios representing realistic social contexts that COVID-19 mitigation apps could be used. Each survey respondent answered questions about their acceptance of 10 randomly selected scenarios. Three contextual integrity parameters (attribute, recipient, and transmission principle) and respondents' basic demographics are controlled as independent variables. Regression analysis was performed to determine the factors impacting people's acceptance of initial data sharing and data retention practices via these apps. Qualitative data from the survey were analyzed to support the statistical results., Results: Many contextual integrity parameter values, pairwise combinations of contextual integrity parameter values, and some demographic features of respondents have a significant impact on their acceptance of using COVID-19 mitigation apps in various social contexts. Respondents' acceptance of data retention practices diverged from their acceptance of initial data sharing practices in some scenarios., Conclusions: This study showed that people's acceptance of using various COVID-19 mitigation apps depends on specific social contexts, including the type of data (attribute), the recipients of the data (recipient), and the purpose of data use (transmission principle). Such acceptance may differ between the initial data sharing and data retention practices, even in the same context. Study findings generated rich implications for future pandemic mitigation apps and the broader public health mobile apps regarding data privacy and deployment considerations., (©Yuanyuan Feng, Brad Stenger, Shikun Zhang. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 29.08.2024.)

Background: Understanding the causes and mechanisms underlying musculoskeletal pain is crucial for developing effective treatments and improving patient outcomes. Self-report measures, such as the Pain Drawing Scale, involve individuals rating their level of pain on a scale. In this technique, individuals color the area where they experience pain, and the resulting picture is rated based on the depicted pain intensity. Analyzing pain drawings (PDs) typically involves measuring the size of the pain region. There are several studies focusing on assessing the clinical use of PDs, and now, with the introduction of digital PDs, the usability and reliability of these platforms need validation. Comparative studies between traditional and digital PDs have shown good agreement and reliability. The evolution of PD acquisition over the last 2 decades mirrors the commercialization of digital technologies. However, the pen-on-paper approach seems to be more accepted by patients, but there is currently no standardized method for scanning PDs., Objective: The objective of this study was to evaluate the accuracy of PD analysis performed by a web platform using various digital scanners. The primary goal was to demonstrate that simple and affordable mobile devices can be used to acquire PDs without losing important information., Methods: Two sets of PDs were generated: one with the addition of 216 colored circles and another composed of various red shapes distributed randomly on a frontal view body chart of an adult male. These drawings were then printed in color on A4 sheets, including QR codes at the corners in order to allow automatic alignment, and subsequently scanned using different devices and apps. The scanners used were flatbed scanners of different sizes and prices (professional, portable flatbed, and home printer or scanner), smartphones with varying price ranges, and 6 virtual scanner apps. The acquisitions were made under normal light conditions by the same operator., Results: High-saturation colors, such as red, cyan, magenta, and yellow, were accurately identified by all devices. The percentage error for small, medium, and large pain spots was consistently below 20% for all devices, with smaller values associated with larger areas. In addition, a significant negative correlation was observed between the percentage of error and spot size (R=-0.237; P=.04). The proposed platform proved to be robust and reliable for acquiring paper PDs via a wide range of scanning devices., Conclusions: This study demonstrates that a web platform can accurately analyze PDs acquired through various digital scanners. The findings support the use of simple and cost-effective mobile devices for PD acquisition without compromising the quality of data. Standardizing the scanning process using the proposed platform can contribute to more efficient and consistent PD analysis in clinical and research settings., (© Corrado Cescon, Giuseppe Landolfi, Niko Bonomi, Marco Derboni, Vincenzo Giuffrida, Andrea Emilio Rizzoli, Paolo Maino, Eva Koetsier, Marco Barbero. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org).)

With the proliferation of wound assessment apps across various app stores and the increasing integration of artificial intelligence (AI) in healthcare apps, there is a growing need for a comprehensive evaluation system. Current apps lack sufficient evidence-based reliability, prompting the necessity for a systematic assessment. The objectives of this study are to evaluate the wound assessment and monitoring apps, identify limitations, and outline opportunities for future app development. An electronic search across two major app stores (Google Play store, and Apple App Store) was conducted and the selected apps were rated by three independent raters. A total of 170 apps were discovered, and 10 were selected for review based on a set of inclusion and exclusion criteria. By modifying existing scales, an app rating scale for wound assessment apps is created and used to evaluate the selected ten apps. Our rating scale evaluates apps' functionality and software quality characteristics. Most apps in the app stores, according to our evaluation, do not meet the overall requirements for wound monitoring and assessment. All the apps that we reviewed are focused on practitioners and doctors. According to our evaluation, the app ImitoWound got the highest mean score of 4.24. But this app has 7 criteria among our 11 functionalities criteria. Finally, we have recommended future opportunities to leverage advanced techniques, particularly those involving artificial intelligence, to enhance the functionality and efficacy of wound assessment apps. This research serves as a valuable resource for future developers and researchers seeking to enhance the design of wound assessment-based applications, encompassing improvements in both software quality and functionality., (© 2024. The Author(s).)

As digital phenotyping, the capture of active and passive data from consumer devices such as smartphones, becomes more common, the need to properly process the data and derive replicable features from it has become paramount. Cortex is an open-source data processing pipeline for digital phenotyping data, optimized for use with the mindLAMP apps, which is used by nearly 100 research teams across the world. Cortex is designed to help teams (1) assess digital phenotyping data quality in real time, (2) derive replicable clinical features from the data, and (3) enable easy-to-share data visualizations. Cortex offers many options to work with digital phenotyping data, although some common approaches are likely of value to all teams using it. This paper highlights the reasoning, code, and example steps necessary to fully work with digital phenotyping data in a streamlined manner. Covering how to work with the data, assess its quality, derive features, and visualize findings, this paper is designed to offer the reader the knowledge and skills to apply toward analyzing any digital phenotyping data set. More specifically, the paper will teach the reader the ins and outs of the Cortex Python package. This includes background information on its interaction with the mindLAMP platform, some basic commands to learn what data can be pulled and how, and more advanced use of the package mixed with basic Python with the goal of creating a correlation matrix. After the tutorial, different use cases of Cortex are discussed, along with limitations. Toward highlighting clinical applications, this paper also provides 3 easy ways to implement examples of Cortex use in real-world settings. By understanding how to work with digital phenotyping data and providing ready-to-deploy code with Cortex, the paper aims to show how the new field of digital phenotyping can be both accessible to all and rigorous in methodology., (©James Burns, Kelly Chen, Matthew Flathers, Danielle Currey, Natalia Macrynikola, Aditya Vaidyam, Carsten Langholm, Ian Barnett, Andrew (Jin Soo) Byun, Erlend Lane, John Torous. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 23.08.2024.)

Background: Assistive technology is becoming increasingly accessible and affordable for supporting people with dementia and their care partners living at home, with strong potential for technology-based prompting to assist with initiation and tracking of complex, multistep activities of daily living. However, there is limited direct comparison of different prompt features to guide optimal technology design., Objective: Across 3 experiments, we investigated the features of tablet-based prompts that best support people with dementia to complete activities of daily living at home, measuring prompt effectiveness and gaining feedback from people with dementia and their care partners about their experiences., Methods: Across experiments, we developed a specialized iPad app to enable data collection with people with dementia at home over an extended experimental period. In experiment 1, we varied the prompts in a 3 (visual type: text instruction, iconic image, and photographic image) × 3 (audio type: no sound, symbolic sound, and verbal instruction) experimental design using repeated measures across multiple testing sessions involving single-step activities. In experiment 2, we tested the most effective prompt breakdown for complex multistep tasks comparing 3 conditions (1-prompt, 3-prompt, and 7-prompt conditions). In experiment 3, we compared initiation and maintenance alerts that involved either an auditory tone or an auditory tone combined with a verbal instruction. Throughout, we asked people with dementia and their care partners to reflect on the usefulness of prompting technology in their everyday lives and what could be developed to better meet their needs., Results: First, our results showed that audible verbal instructions were more useful for task completion than either tone-based or visual prompts. Second, a more granular breakdown of tasks was generally more useful and increased independent use, but this varied across individuals. Third, while a voice or text maintenance alert enabled people with dementia to persist with a multistep task for longer when it was more frequent, task initiation still frequently required support from a care partner., Conclusions: These findings can help inform developers of assistive technology about the design features that promote the usefulness of home prompting systems for people with dementia as well as the preferences and insights of people with dementia and their care partners regarding assistive technology design., (©Madeleine Cannings, Ruth Brookman, Simon Parker, Leonard Hoon, Asuka Ono, Hiroaki Kawata, Hisashi Matsukawa, Celia B Harris. Originally published in JMIR Aging (https://aging.jmir.org), 23.08.2024.)

Background: Our prototype smoking cessation chatbot, Quin, provides evidence-based, personalized support delivered via a smartphone app to help people quit smoking. We developed Quin using a multiphase program of co-design research, part of which included focus group evaluation of Quin among stakeholders prior to clinical testing., Objective: This study aimed to gather and compare feedback on the user experience of the Quin prototype from end users and smoking cessation professionals (SCPs) via a beta testing process to inform ongoing chatbot iterations and refinements., Methods: Following active and passive recruitment, we conducted web-based focus groups with SCPs and end users from Queensland, Australia. Participants tested the app for 1-2 weeks prior to focus group discussion and could also log conversation feedback within the app. Focus groups of SCPs were completed first to review the breadth and accuracy of information, and feedback was prioritized and implemented as major updates using Agile processes prior to end user focus groups. We categorized logged in-app feedback using content analysis and thematically analyzed focus group transcripts., Results: In total, 6 focus groups were completed between August 2022 and June 2023; 3 for SCPs (n=9 participants) and 3 for end users (n=7 participants). Four SCPs had previously smoked, and most end users currently smoked cigarettes (n=5), and 2 had quit smoking. The mean duration of focus groups was 58 (SD 10.9; range 46-74) minutes. We identified four major themes from focus group feedback: (1) conversation design, (2) functionality, (3) relationality and anthropomorphism, and (4) role as a smoking cessation support tool. In response to SCPs' feedback, we made two major updates to Quin between cohorts: (1) improvements to conversation flow and (2) addition of the "Moments of Crisis" conversation tree. Participant feedback also informed 17 recommendations for future smoking cessation chatbot developments., Conclusions: Feedback from end users and SCPs highlighted the importance of chatbot functionality, as this underpinned Quin's conversation design and relationality. The ready accessibility of accurate cessation information and impartial support that Quin provided was recognized as a key benefit for end users, the latter of which contributed to a feeling of accountability to the chatbot. Findings will inform the ongoing development of a mature prototype for clinical testing., (©Hollie Bendotti, Sheleigh Lawler, David Ireland, Coral Gartner, Henry M Marshall. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 19.08.2024.)

Background: Malaria impacts nearly 250 million individuals annually. Specifically, Uganda has one of the highest burdens, with 13 million cases and nearly 20,000 deaths. Controlling the spread of malaria relies on vector surveillance, a system where collected mosquitos are analyzed for vector species' density in rural areas to plan interventions accordingly. However, this relies on trained entomologists known as vector control officers (VCOs) who identify species via microscopy. The global shortage of entomologists and this time-intensive process cause significant reporting delays. VectorCam is a low-cost artificial intelligence-based tool that identifies a mosquito's species, sex, and abdomen status with a picture and sends these results electronically from surveillance sites to decision makers, thereby deskilling the process to village health teams (VHTs)., Objective: This study evaluates the usability of the VectorCam system among VHTs by assessing its efficiency, effectiveness, and satisfaction., Methods: The VectorCam system has imaging hardware and a phone app designed to identify mosquito species. Two users are needed: (1) an imager to capture images of mosquitos using the app and (2) a loader to load and unload mosquitos from the hardware. Critical success tasks for both roles were identified, which VCOs used to train and certify VHTs. In the first testing phase (phase 1), a VCO and a VHT were paired to assume the role of an imager or a loader. Afterward, they swapped. In phase 2, two VHTs were paired, mimicking real use. The time taken to image each mosquito, critical errors, and System Usability Scale (SUS) scores were recorded for each participant., Results: Overall, 14 male and 6 female VHT members aged 20 to 70 years were recruited, of which 12 (60%) participants had smartphone use experience. The average throughput values for phases 1 and 2 for the imager were 70 (SD 30.3) seconds and 56.1 (SD 22.9) seconds per mosquito, respectively, indicating a decrease in the length of time for imaging a tray of mosquitos. The loader's average throughput values for phases 1 and 2 were 50.0 and 55.7 seconds per mosquito, respectively, indicating a slight increase in time. In terms of effectiveness, the imager had 8% (6/80) critical errors and the loader had 13% (10/80) critical errors in phase 1. In phase 2, the imager (for VHT pairs) had 14% (11/80) critical errors and the loader (for VHT pairs) had 12% (19/160) critical errors. The average SUS score of the system was 70.25, indicating positive usability. A Kruskal-Wallis analysis demonstrated no significant difference in SUS (H value) scores between genders or users with and without smartphone use experience., Conclusions: VectorCam is a usable system for deskilling the in-field identification of mosquito specimens in rural Uganda. Upcoming design updates will address the concerns of users and observers., (©Saisamhitha Dasari, Bhavya Gopinath, Carter James Gaulke, Sunny Mahendra Patel, Khalil K Merali, Aravind Sunil Kumar, Soumyadipta Acharya. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 16.08.2024.)

Background: Digital technology and gamified apps can be useful in the health care context. Gamification uses technology to influence users' actions and motivations through experiences that resemble games. Patient adherence to the enhanced recovery after surgery (ERAS) program is crucial for achieving early recovery after surgery and continuous monitoring is essential for obtaining good results., Objective: This study aimed to describe the development and validation of a mobile app for enhanced recovery after surgery (MobERAS), a gamified mobile health app for telemonitoring patients in the postoperative period based on the ERAS program, and to evaluate its functionality and usability and the experience of patients, health care professionals, and computer professionals with its use., Methods: We developed MobERAS for postoperative telemonitoring, with active participation of patients in the process, and offering availability of real-time information for the health team. The app development process included idealization, interdisciplinary team formation, potential needs assessment, and product deployment. Usability tests were conducted throughout the development process with improvements, technical adjustments, and updates. After finalization, comprehensive verification tests were performed. The parameters evaluated are those that can influence the length of hospital stay, such as nausea, vomiting, pain scales, return to normal gastrointestinal function, and thromboembolic events. MobERAS was designed to be downloaded by users on their phones, tablets, or other mobile devices and to provide postoperative data. The app has a GPS that monitors the patient's walking time and distance and is connected to a virtual database that stores the collected data., Results: Women undergoing medium and major gynecologic oncologic surgeries were included. We included 65 patients with an average age of 53.2 (SD 7.4, range 18-85) years. The time of use ranged from 23.4 to 70 hours (mean 45.1, SD 19.2 hours). Regarding adherence to the use of MobERAS, the mean fill rate was 56.3% (SD 12.1%, range 41.7%-100%), and ambulation data were obtained for 60 (92.3%) of the 65 patients. The researcher had access to the data filled out by the patients in real time. There was good acceptance of the use of MobERAS by the patients, with good evaluation of the app's usability. MobERAS was easy to use and considered attractive because of its gamified design. The app was rated as good or very good in all items by health care professionals (n=20) and professionals specializing in technological innovation (n=10)., Conclusions: MobERAS is easy to use, safe, well accepted by patients, and well evaluated by experts. It can be of great use in clinical surgical practice and an important tool for greater engagement of patients and health care professionals with the ERAS program., (©Aline Evangelista Santiago, Victor Pezzi Gazzinelli Cruz, Rafaela Souza Furtado, Eduardo Batista Cândido, Wladmir Cardoso Brandão, Agnaldo Lopes Silva Filho. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 14.08.2024.)

Background: It is difficult for families to navigate and access services for their children with autism. Barriers to service access are compounded among families from low-resourced backgrounds., Objective: The purpose of our study was to explore the development of an app to facilitate access to services among families of children with autism from low-resourced backgrounds. Our specific aims were to explore feedback from an advisory board about the app and to explore feedback from navigators about the app., Methods: Via a multistage codevelopment process, we elicited feedback from 5 key parties: the research team, a community organization, the app development team, the advisory board, and family navigators. Collectively, 36 individuals provided feedback about the development of the app via individual interviews, focus groups, observations, and surveys. The key features of the app included a dashboard showing the service needs of the family and related resources, a messaging feature between the family, the navigator, and the supervisor, and a fidelity checklist and evaluation feature., Results: The advisory board provided feedback about the app to increase its user-friendliness, include the ability to develop an action plan, improve the identification of needed services, and add information about service providers. Navigators suggested that the app should connect navigators to one another, have a clearer purpose for the notes section, and reflect an easier log-in process. Navigators also wanted training to role-play using the app. After participating in a role play using the app, navigators reported significantly more satisfaction with the app and greater usefulness (P<.001)., Conclusions: Our work sheds light on the importance of eliciting feedback from end users, especially users who are often overlooked by the research community and app developers. Further, it is important to elicit feedback in multiple ways to improve the app., (©Meghan Burke, Chak Li, Waifong Catherine Cheung, Adriana Kaori Terol, Amanda Johnston, Stephen M Schueller. Originally published in JMIR Formative Research (https://formative.jmir.org), 14.08.2024.)

Background: For a decade, despite results from many studies, telemedicine systems have suffered from a lack of recommendations for chronic heart failure (CHF) care because of variable study results. Another limitation is the hospital-based architecture of most telemedicine systems. Some systems use an algorithm based on daily weight, transcutaneous oxygen measurement, and heart rate to detect and treat acute heart failure (AHF) in patients with CHF as early on as possible., Objective: The aim of this study is to determine the efficacy of a telemonitoring system in detecting clinical destabilization in real-life settings (out-of-hospital management) without generating too many false positive alerts., Methods: All patients self-monitoring at home using the system after a congestive AHF event treated at a cardiology clinic in France between March 2020 and March 2021 with at least 75% compliance on daily measurements were included retrospectively. New-onset AHF was defined by the presence of at least 1 of the following criteria: transcutaneous oxygen saturation loss, defined as a transcutaneous oxygen measurement under 90%; rise of cardiac frequency above 110 beats per minute; weight gain of at least 2 kg; and symptoms of congestive AHF, described over the phone. An AHF alert was generated when the criteria reached our definition of new-onset acute congestive heart failure (HF)., Results: A total of 111 consecutive patients (n=70 men) with a median age of 76.60 (IQR 69.5-83.4) years receiving the telemonitoring system were included. Thirty-nine patients (35.1%) reached the HF warning level, and 28 patients (25%) had confirmed HF destabilization during follow-up. No patient had AHF without being detected by the telemonitoring system. Among incorrect AHF alerts (n=11), 5 patients (45%) had taken inaccurate measurements, 3 patients (27%) had supraventricular arrhythmia, 1 patient (9%) had a pulmonary bacterial infection, and 1 patient (9%) contracted COVID-19. A weight gain of at least 2 kg within 4 days was significantly associated with a correct AHF alert (P=.004), and a heart rate of more than 110 beats per minute was more significantly associated with an incorrect AHF alert (P=.007)., Conclusions: This single-center study highlighted the efficacy of the telemedicine system in detecting and quickly treating cardiac instability complicating the course of CHF by detecting new-onset AHF as well as supraventricular arrhythmia, thus helping cardiologists provide better follow-up to ambulatory patients., (©Jean Marie Urien, Emmanuelle Berthelot, Pierre Raphael, Thomas Moine, Marie Emilie Lopes, Patrick Assayag, Patrick Jourdain. Originally published in JMIR Cardio (https://cardio.jmir.org), 13.08.2024.)

Background: The NHS (National Health Service) COVID-19 app was a digital contact tracing app (DCTA) used in England in response to the COVID-19 pandemic. The aim of which was to limit the spread of COVID-19 by providing exposure alerts. At the time of the pandemic, questions were raised regarding the effectiveness and cost of the NHS COVID-19 app and whether DCTAs have a role in future pandemics., Objective: This study aims to explore key barriers to DCTAs in England during the COVID-19 pandemic., Methods: This is a qualitative study using semistructured video interviews conducted with professionals in public health, digital health, clinicians, health care law, and health executives who had an active role in the COVID-19 pandemic. These interviews aimed to explore the perspective of different experts involved in the pandemic response and gauge their opinions on the key barriers to DCTAs in England during the COVID-19 pandemic. The initial use of maximum variation sampling combined with a snowball sampling approach ensured diversity within the cohort of interviewees. Interview transcripts were then analyzed using Braun and Clarke's 6 steps for thematic analysis., Results: Key themes that acted as barriers to DCTAs were revealed by interviewees such as privacy concerns, poor communication, technological accessibility, digital literacy, and incorrect use of the NHS COVID-19 app. Interviewees believed that some of these issues stemmed from poor governmental communication and a lack of transparency regarding how the NHS COVID-19 app worked, resulting in decreased public trust. Moreover, interviewees highlighted that a lack of social support integration within the NHS COVID-19 app and delayed app notification period also contributed to the poor adoption rates., Conclusions: Qualitative findings from interviews highlighted barriers to the NHS COVID-19 app, which can be applied to DCTAs more widely and highlight some important implications for the future use of DCTAS. There was no consensus among interviewees as to whether the NHS COVID-19 app was a success; however, all interviewees provided recommendations for improvements in creating and implementing DCTAs in the future., (©Anna Palmer, Shaishab Sharma, Jayesh Nagpal, Victor Kimani, Florence Mai, Zara Ahmed. Originally published in JMIR Formative Research (https://formative.jmir.org), 12.08.2024.)

Background: Patient-reported outcomes are relevant in clinical practice showing patient benefits, supporting clinicians' decision-making, and contributing to the delivery of high standards of care. Digital monitoring of patient-reported outcomes is still rare. The Patient Benefit Index (PBI) measures benefits and goals from patients' views and may be relevant for regular documentation and shared decision-making., Objective: This study aimed to develop electronic versions of the PBI to examine their feasibility and acceptability in clinical practice for patients with psoriasis., Methods: We developed an app and a web version of the existing, valid PBI using focus groups and cognitive debriefings with patients before conducting a quantitative survey on its feasibility and acceptability. Conduction took part in an outpatient dermatology care unit in Germany. Descriptive and subgroup analyses were conducted., Results: A total of 139 patients completed the electronic PBIs (ePBIs) and took part in the survey. The ePBI was understandable (n=129-137, 92.8%-98.6%) and feasible, for example, easy to read (n=135, 97.1%) and simple to handle (n=137, 98.5%). Acceptability was also high, for example, patients can imagine using and discussing the ePBI data in practice (n=91, 65.5%) and documenting it regularly (n=88, 63.3%). They believe it could support treatment decisions (n=118, 84.9%) and improve communication with their physician (n=112, 81.3%). They can imagine filling in electronic questionnaires regularly (n=118, 84.9%), even preferring electronic over paper versions (n=113, 81.2%). Older and less educated people show less feasibility, but the latter expected the relationship with their physician to improve and would be more willing to invest time or effort., Conclusions: The app and web version of the PBI are usable and acceptable for patients offering comprehensive documentation and patient participation in practice. An implementation strategy should consider patients' needs, barriers, and facilitators but also physicians' attitudes and requirements from the health care system., (©Marina Otten, Vahid Djamei, Matthias Augustin. Originally published in JMIR Dermatology (http://derma.jmir.org), 09.08.2024.)

For artificial intelligence (AI) to support nutrition care, high quality and accuracy of its features within smartphone applications (apps) are essential. This study evaluated popular apps' features, quality, behaviour change potential, and comparative validity of dietary assessment via manual logging and AI. The top 200 free and paid nutrition-related apps from Australia's Apple App and Google Play stores were screened ( n = 800). Apps were assessed using MARS (quality) and ABACUS (behaviour change potential). Nutritional outputs from manual food logging and AI-enabled food-image recognition apps were compared with food records for Western, Asian, and Recommended diets. Among 18 apps, Noom scored highest on MARS (mean = 4.44) and ABACUS (21/21). From 16 manual food-logging apps, energy was overestimated for Western (mean: 1040 kJ) but underestimated for Asian (mean: -1520 kJ) diets. MyFitnessPal and Fastic had the highest accuracy (97% and 92%, respectively) out of seven AI-enabled food image recognition apps. Apps with more AI integration demonstrated better functionality, but automatic energy estimations from AI-enabled food image recognition were inaccurate. To enhance the integration of apps into nutrition care, collaborating with dietitians is essential for improving their credibility and comparative validity by expanding food databases. Moreover, training AI models are needed to improve AI-enabled food recognition, especially for mixed dishes and culturally diverse foods.

Purpose: The rising number of apps requires careful consideration in how these apps are being selected for students with extensive support needs in school-based settings. Current practices suggest that educational apps are being purchased without utilizing an evaluation tool to determine the quality or effectiveness of the apps. A systematic literature review was conducted to identify educational app evaluation tools for students with extensive support needs., Materials and Methods: A three-phase search process (electronic database search, journal hand-search, and ancestral search) was conducted using 14 keywords to maximize the number of articles. A two-step coding procedure was conducted to ensure articles met the four inclusion criteria. A 15 criteria checklist was used to evaluate the methodological rigor of accepted articles., Results: Findings focused on the type of app evaluation tools and their specific evaluation dimensions. A total of 107 articles were identified with 13 articles meeting the inclusion criteria. Stage 1 evaluated the methodological rigor of the app evaluation tools ( M  = 6.15, range 0.5 - 14). Stage 2 categorized the articles based on the type of evaluation tools (rubric = 5, rating scale = 6, checklist = 2). Stage 3 identified five evaluation dimensions (background, design features, usability, individualization, and overall impression)., Conclusions: There is a lack of empirically tested evaluation tools for communication and educational apps, making it difficult to recommend a valid app evaluation tool. Thus, barriers are likely to persist in the effective identification of apps for students with extensive support needs.

Men who have sex with men (MSM) are disproportionately affected by HIV. Given that over 70% of MSM meet sexual partners via dating apps, such apps may be an effective platform for promoting HIV pre-exposure prophylaxis (PrEP) use. We aimed to describe preferences among MSM for PrEP advertisements displayed on dating apps. We conducted individual in-depth interviews with 16 MSM recruited from a mobile sexual health unit in Boston, Massachusetts. Two focus groups were also held: one with mobile unit staff ( N  = 3) and one with mobile unit users ( N  = 3). Content analysis was used to identify themes related to advertisement content and integration with app use. Mean participant age was 28 (SD 6.8); 37% identified as White and 63% as Latinx. 21% of interviews were conducted in Spanish. Preferences were organized around four themes: (1) relevant and relatable advertisements, (2) expansion of target audiences to promote access, (3) concise and captivating advertisements, and (4) PrEP advertisements and services as options, not obligations. MSM are supportive of receiving information about PrEP on dating apps, but feel that existing advertisements require modification to better engage viewers. Dating apps may be an underutilized tool for increasing PrEP awareness and knowledge among MSM.

Background: A coordinated care system helps provide timely access to treatment for suspected acute stroke. In Northwestern Ontario (NWO), Canada, communities are widespread with several hospitals offering various diagnostic equipment and services. Thus, resources are limited, and health care providers must often transfer patients with stroke to different hospital locations to ensure the most appropriate care access within recommended time frames. However, health care providers frequently situated temporarily (locum) in NWO or providing care remotely from other areas of Ontario may lack sufficient information and experience in the region to access care for a patient with a time-sensitive condition. Suboptimal decision-making may lead to multiple transfers before definitive stroke care is obtained, resulting in poor outcomes and additional health care system costs., Objective: We aimed to develop a tool to inform and assist NWO health care providers in determining the best transfer options for patients with stroke to provide the most efficient care access. We aimed to develop an app using a comprehensive geomapping navigation and estimation system based on machine learning algorithms. This app uses key stroke-related timelines including the last time the patient was known to be well, patient location, treatment options, and imaging availability at different health care facilities., Methods: Using historical data (2008-2020), an accurate prediction model using machine learning methods was developed and incorporated into a mobile app. These data contained parameters regarding air (Ornge) and land medical transport (3 services), which were preprocessed and cleaned. For cases in which Ornge air services and land ambulance medical transport were both involved in a patient transport process, data were merged and time intervals of the transport journey were determined. The data were distributed for training (35%), testing (35%), and validation (30%) of the prediction model., Results: In total, 70,623 records were collected in the data set from Ornge and land medical transport services to develop a prediction model. Various learning models were analyzed; all learning models perform better than the simple average of all points in predicting output variables. The decision tree model provided more accurate results than the other models. The decision tree model performed remarkably well, with the values from testing, validation, and the model within a close range. This model was used to develop the "NWO Navigate Stroke" system. The system provides accurate results and demonstrates that a mobile app can be a significant tool for health care providers navigating stroke care in NWO, potentially impacting patient care and outcomes., Conclusions: The NWO Navigate Stroke system uses a data-driven, reliable, accurate prediction model while considering all variations and is simultaneously linked to all required acute stroke management pathways and tools. It was tested using historical data, and the next step will to involve usability testing with end users., (©Ayman Hassan, Rachid Benlamri, Trina Diner, Keli Cristofaro, Lucas Dillistone, Hajar Khallouki, Mahvareh Ahghari, Shalyn Littlefield, Rabail Siddiqui, Russell MacDonald, David W Savage. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.08.2024.)

Background: Demographic changes and a low birth rate have led to a workforce shortage in Japan. To address this issue, the government has promoted engagement of female employment. However, increased female employment can impact women's health. Using Internet of Things (IoT) and apps to manage women's health has gained attention, but few studies have focused on working women., Objective: This study aimed to clarify the current situation of working women and their use of IoT or apps to manage their health., Methods: A large-scale, nationwide internet survey was conducted among 10,000 female participants aged from 20 years to 64 years in Japan. Participants were recruited from a marketing research company's active survey panel of 5.24 million members. The survey included questions about health status, sociodemographic factors, psychological characteristics, and the use of IoT or apps for health management. We compared perceived health status and reasons for current IoT use using t tests and assessed participant characteristics that predicted IoT use using the C5.0 decision tree algorithm. Ethical approval was granted by St. Luke's International University., Results: Among participants, 14.6% (1455/10,000) currently used IoT or apps, 7% (695/10,000) used them previously, and 78.5% (7850/10,000) had never used them. Current users (42.7 years old) were older than past users (39.7 years old). Discrepancies were observed between participants' perceived health problems and the purpose for using IoT or apps, with 21.3% (2130/10,000) of all women reporting they experienced menstrual symptoms or disorders but only 3.5% (347/10,000) used IoT or apps to manage the same symptom. On the other hand, current users were more likely to use IoT or apps to manage nutrition-related problems such as underweight or obesity (405/1455, 27.8%). Device use was highest among current users, with 87.3% (1270/1455) using smartphones, 19.7% (287/1455) using smartwatches, and 13.3% (194/1455) using PCs. Decision tree analysis identified 6 clusters, the largest consisting of 81.6% (5323/6523) of non-IoT users who did not exercise regularly, while pregnant women were more likely to use IoT or apps., Conclusions: Our findings highlight the idea that woman with particular health problems (ie, menstrual symptoms or disorders and premenstrual syndrome) have lower use of IoT or apps, suggesting an unmet need for IoT and apps in specific areas., (©Kirio Sasayama, Etsuko Nishimura, Noyuri Yamaji, Erika Ota, Hisateru Tachimori, Ataru Igarashi, Naoko Arata, Daisuke Yoneoka, Eiko Saito. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 31.07.2024.)

Background: Individuals with Parkinson disease (PD) can improve their overall mobility and participation in daily activities as they engage in frequent exercise. Despite the need for individually tailored exercises, persons with PD often face barriers to accessing physical rehabilitation professionals who can provide them. Telerehabilitation (TR) may facilitate access to necessary and individually tailored rehabilitation for individuals with PD., Objective: The purpose of this study was to assess the feasibility of TR for individuals with PD and explore clinical outcomes compared to in-person care., Methods: This was a pilot randomized controlled trial conducted at 2 outpatient neurorehabilitation clinics with 3 study groups: clinic+TR, TR-only, and usual care (UC). TR was administered using a web-based application with a mobile app option. One-hour interventions were performed weekly for 4 weeks, in-person for the clinic+TR and UC groups and virtually for the TR-only group. Home exercises were provided on paper for the UC group and via the web-based platform for the clinic+TR and TR-only groups. Feasibility was assessed by recruitment and retention success and patient and therapist satisfaction, as rated in surveys. Clinical outcomes were explored using performance and patient-reported measures in between- and within-group analyses., Results: Of 389 patients screened, 68 (17.5%) met eligibility criteria, and 20 (29.4% of those eligible) were enrolled (clinic+TR, n=6; TR-only, n=6; and UC, n=8). One patient (TR-only) was withdrawn due to a non-study-related injurious fall. Regardless of group allocation, both patients and therapists generally rated the mode of care delivery as "good" or "very good" across all constructs assessed, including overall satisfaction and safety. In the analysis of all groups, there were no differences in clinical outcomes at the discharge visit. Within-group differences (from baseline to discharge) were also generally not significant except in the UC group (faster 5-time sit-to-stand time and higher mini balance evaluation systems test balance score) and clinic+TR group (higher mini balance evaluation systems test balance score)., Conclusions: High satisfaction amongst patients and clinicians regardless of group, combined with nonsignificant between-group differences in clinical outcomes, suggest that TR is feasible for individuals with PD in early-moderate stages. Future trials with a larger sample are necessary to test clinical effectiveness. As larger trials enroll patients with diverse characteristics (eg, in terms of age, disease progression, caregiver support, technology access and capacity, etc), they could begin to identify opportunities for matching patients to the optimal utilization of TR as part of the therapy episode., Trial Registration: ClinicalTrials.gov NCT06246747; https://clinicaltrials.gov/study/NCT06246747., (©Joshua K. Johnson, Jason K Longhurst, Michael Gevertzman, Corey Jefferson, Susan M Linder, Francois Bethoux, Mary Stilphen. Originally published in JMIR Formative Research (https://formative.jmir.org), 31.07.2024.)

Background: Blood glucose management around exercise is challenging for youth with type 1 diabetes (T1D). Previous research has indicated interventions including decision-support aids to better support youth to effectively contextualize blood glucose results and take appropriate action to optimize glucose levels during and after exercise. Mobile health (mHealth) apps help deliver health behavior interventions to youth with T1D, given the use of technology for glucose monitoring, insulin dosing, and carbohydrate counting., Objective: We aimed to develop a novel prototype mHealth app to support exercise management among youth with T1D, detail the application of a co-design process and design thinking principles to inform app design and development, and identify app content and functionality that youth with T1D need to meet their physical activity goals., Methods: A co-design approach with a user-centered design thinking framework was used to develop a prototype mHealth app "acT1ve" during the 18-month design process (March 2018 to September 2019). To better understand and respond to the challenges among youth with diabetes when physically active, 10 focus groups were conducted with youth aged 13-25 years with T1D and parents of youth with T1D. Thereafter, we conducted participatory design workshops with youth to identify key app features that would support individual needs when physically active. These features were incorporated into a wireframe, which was critically reviewed by participants. A beta version of "acT1ve" was built in iOS and android operating systems, which underwent critical review by end users, clinicians, researchers, experts in exercise and T1D, and app designers., Results: Sixty youth with T1D, 14 parents, 6 researchers, and 10 clinicians were engaged in the development of "acT1ve." acT1ve included key features identified by youth, which would support their individual needs when physically active. It provided advice on carbohydrates and insulin during exercise, information on hypoglycemia treatment, pre- and postexercise advice, and an educational food guide regarding exercise management. "acT1ve" contained an exercise advisor algorithm comprising 240 pathways developed by experts in diabetes and exercise research. Based on participant input during exercise, acT1ve provided personalized insulin and carbohydrate advice for exercise lasting up to 60 minutes. It also contains other features including an activity log, which displays a complete record of the end users' activities and associated exercise advice provided by the app's algorithm for later reference, and regular reminder notifications for end users to check or monitor their glucose levels., Conclusions: The co-design approach and the practical application of the user-centered design thinking framework were successfully applied in developing "acT1ve." The design thinking processes allowed youth with T1D to identify app features that would support them to be physically active, and particularly enabled the delivery of individualized advice. Furthermore, app development has been described in detail to help guide others embarking on a similar project., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001414101; https://tinyurl.com/mu9jvn2d., (©Vinutha B Shetty, Leanne Fried, Heather C Roby, Wayne H K Soon, Rebecca Nguyen, Arthur Ong, Mohinder Jaimangal, Jacinta Francis, Nirubasini Paramalingam, Donna Cross, Elizabeth Davis. Originally published in JMIR Diabetes (https://diabetes.jmir.org), 30.07.2024.)

Objective: With rising rates of mental health distress amongst youth during the COVID-19 pandemic, digital resources have been identified as a valuable tools for delivering support to young people. However, many of the websites and apps developed by professionals to support the youth do not take account of the importance young people place on exercising their own agency in managing their mental health. This article investigates how young people in Aotearoa New Zealand used digital resources to manage their mental health needs during the COVID-19 pandemic., Methods: The study gathered information from semi-structured interviews with 34 young people aged 16-22 years. The data was analysed using reflexive thematic analysis., Results: Six themes were identified including: searching for online information about mental health; evaluating digital mental health resources; controlling mood through online activity; looking for escape in the virtual world; staying connected online; and giving and receiving support., Conclusion: Young people's practices demonstrated their investment in their own agency, a general reluctance to engage with professional resources and recognition of the need to balance the risks and benefits of the informal strategies they preferred. Young people appeared sceptical of professionally-designed mental health resources and interventions and preferred to adapt and re-purpose the wide range of platforms and networks available in their informal digital worlds., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© The Author(s) 2024.)

Background: Sexual transmission among men who have sex with men (MSM) has become the major HIV transmission route. However, limited research has been conducted to investigate the association between transactional sex (TS) and HIV incidence in China., Objective: This study aims to investigate HIV incidence and distinguish sociodemographic and sexual behavioral risk factors associated with HIV incidence among MSM who engage in TS (MSM-TS) in China., Methods: We conducted a prospective cohort study using a WeChat-based platform to evaluate HIV incidence among Chinese MSM, including MSM-TS in Ningbo, recruited from July 2019 until June 2022. At each visit, participants completed a questionnaire and scheduled an appointment for HIV counseling and testing on the WeChat-based platform before undergoing offline HIV tests. HIV incidence density was calculated as the number of HIV seroconversions divided by person-years (PYs) of follow-up, and univariate and multivariate Cox proportional hazards regression was conducted to identify factors associated with HIV incidence., Results: A total of 932 participants contributed 630.9 PYs of follow-up, and 25 HIV seroconversions were observed during the study period, resulting in an estimated HIV incidence of 4.0 (95% CI 2.7-5.8) per 100 PYs. The HIV incidence among MSM-TS was 18.4 (95% CI 8.7-34.7) per 100 PYs, which was significantly higher than the incidence of 3.2 (95% CI 2.1-5.0) per 100 PYs among MSM who do not engage in TS. After adjusting for sociodemographic characteristics, factors associated with HIV acquisition were MSM-TS (adjusted hazard ratio [aHR] 3.93, 95% CI 1.29-11.93), having unprotected sex with men (aHR 10.35, 95% CI 2.25-47.69), and having multiple male sex partners (aHR 3.43, 95% CI 1.22-9.64) in the past 6 months., Conclusions: This study found a high incidence of HIV among MSM-TS in Ningbo, China. The risk factors associated with HIV incidence include TS, having unprotected sex with men, and having multiple male sex partners. These findings emphasize the need for developing targeted interventions and providing comprehensive medical care, HIV testing, and preexposure prophylaxis for MSM, particularly those who engage in TS., (©Hang Hong, Xiaojun Shi, Yuhui Liu, Wei Feng, Ting Fang, Chunlan Tang, Guozhang Xu. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org).)

Objective: Fitness technologies, such as smartphone applications and wearable tracking devices, have gained widespread popularity. This study had two main objectives: 1) to examine whether fitness technology use is associated with increased physical activity (PA) levels and 2) to investigate whether communication behaviors on social media mediated the association between fitness technology use and PA., Methods: Data were from the U.S. Health Information National Trends Survey 2022 ( N  = 6,252, weighted N  = 258,418,467). Weighted linear regressions were conducted to examine the associations between fitness technology usage, physical activities, and communication behaviors on social media. Mediations were tested using PROCESS macro, a path-analysis based tool., Results: Controlling for demographic and other known influences on PA, the findings revealed that users of fitness technology reported higher levels of both moderate PA ( β = .41, p  < 0.001) and strength training ( β = .29, p  < 0.001). Additionally, communication behaviors (i.e., sharing personal health information on social media and watching health-related videos on social media) mediated the relationship between fitness technology use and frequencies of strength training., Conclusion: The results underscored the potential of fitness technologies in enhancing PA levels through promoting communication behaviors on social media., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)