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Recent Articles in Journal of Medical Internet Research

Valenzuela JI, Arguello A, Cendales JG, Rizo CA
Web-based asynchronous teleconsulting for consumers in Colombia: a case study.
J Med Internet Res. 2007;9(4):e33.
BACKGROUND: Fourteen years after the reform to Colombia's health system, the promises of universality, improved equity, efficiency, and better quality of care have not materialized. Remote areas remain underserved and access to care very limited. Recognizing teleconsultation as an effective way to improve access to health care and health information, a noncommercial open-access Web-based application for teleconsultation called Doctor Chat was developed. OBJECTIVE: The objective was to report the experience of the Center for Virtual Education and Simulation eHealth (Centro de Educaci�n Virtual y Simulaci�n e-Salud) with open-access Web-based asynchronous teleconsultation for consumers in Colombia. METHODS: A teleconsultation service in Spanish was developed and implemented in 2006. Teleconsultation requests were classified on three axes: (1) the purpose of the query, (2) the specialty, and (3) the geographic area of the query. Content analysis was performed on the free-text queries submitted to Doctor Chat, and descriptive statistics were gathered for each of the data categories (name, email, city, country, age, and gender). RESULTS: From September 2006 to March 2007, there were 270 asynchronous teleconsultations documented from 102 (37.8%) men and 168 (62.2%) women. On average, 1.4 requests were received per day. By age group, the largest number of requests (n = 80; 30%) were from users 24-29 years, followed by users (n = 66; 24%) 18-23 years. Requests were mainly from Colombia (n = 204; 75.6%) but also from Spain (n = 17; 6.3%), Mexico (n = 11; 4.1%), and other countries. In Colombia, 137 requests (67.2%) originated in Bogot�, the nation's capital, 25 (12.4%) from other main cities of the country, 40 (19.7%) from intermediate cities, and 2 (0.7%) from remote areas. The purpose of the majority of requests was for information about symptoms, health-related problems, or diseases (n = 149; 55.2%) and medications/treatments (n = 70; 25.9%). By specialty, information was most requested for gynecology and obstetrics (n = 71; 26%), dermatology (n = 28; 10%), urology (n = 22; 8%), and gastroenterology (n = 18; 7%), with anesthesiology, critical care, physical medicine and rehabilitation, and pathology being the least requested (n = 0; 0%). Overall, sexual and reproductive health (n = 93; 34%) issues constituted the main query subject. The average time to deliver a response was 120 hours in 2006 and 59 hours in 2007. Only 19 out of 270 users (7%) completed a survey with comments and perceptions about the system, of which 18 out of 19 (95%) corresponded to positive perceptions and 1 out of 19 (5%) expressed dissatisfaction with the service. CONCLUSION: The implementation of a Web-based teleconsulting service in Colombia appeared to be an innovative way to improve access to health care and information in the community and encouraged open and explicit discussion. Extending the service to underserved areas could improve access to health services and health information and could potentially improve economic indicators such as waiting times for consultations and the rate of pregnancy among teenagers; however, cultural, infrastructural, and Internet connectivity barriers are to be solved before successful implementation can derive population-wide positive impacts. [Abstract/Link to Full Text]

Eysenbach G
Poverty, human development, and the role of eHealth.
J Med Internet Res. 2007;9(4):e34. [Abstract/Link to Full Text]

Masum H, Singer PA
A visual dashboard for moving health technologies from "lab to village".
J Med Internet Res. 2007;9(4):e32.
New technologies are an important way of addressing global health challenges and human development. However, the road for new technologies from "lab to village" is neither simple nor straightforward. Until recently, there has been no conceptual framework for analyzing and addressing the myriad forces and issues involved in moving health technologies from the lab to those who need them. Recently, based on empirical research, we published such a model. In this paper, we focus on extending the model into a dashboard and examine how this dashboard can be used to manage the information related to the path from lab to village. The next step will be for groups interested in global health, and even the public via the Internet, to use the tool to help guide technologies down this tricky path to improve global health and foster human development. [Abstract/Link to Full Text]

Kontos EZ, Bennett GG, Viswanath K
Barriers and facilitators to home computer and internet use among urban novice computer users of low socioeconomic position.
J Med Internet Res. 2007;9(4):e31.
BACKGROUND: Despite the increasing penetration of the Internet and amount of online health information, there are significant barriers that limit its widespread adoption as a source of health information. One is the "digital divide," with people of higher socioeconomic position (SEP) demonstrating greater access and usage compared to those from lower SEP groups. However, as the access gap narrows over time and more people use the Internet, a shift in research needs to occur to explore how one might improve Internet use as well as website design for a range of audiences. This is particularly important in the case of novice users who may not have the technical skills, experience, or social connections that could help them search for health information using the Internet. The focus of our research is to investigate the challenges in the implementation of a project to improve health information seeking among low SEP groups. The goal of the project is not to promote health information seeking as much as to understand the barriers and facilitators to computer and Internet use, beyond access, among members of lower SEP groups in an urban setting. OBJECTIVE: The purpose was to qualitatively describe participants' self-identified barriers and facilitators to computer and Internet use during a 1-year pilot study as well as the challenges encountered by the research team in the delivery of the intervention. METHODS: Between August and November 2005, 12 low-SEP urban individuals with no or limited computer and Internet experience were recruited through a snowball sampling. Each participant received a free computer system, broadband Internet access, monthly computer training courses, and technical support for 1 year as the intervention condition. Upon completion of the study, participants were offered the opportunity to complete an in-depth semistructured interview. Interviews were approximately 1 hour in length and were conducted by the project director. The interviews were held in the participants' homes and were tape recorded for accuracy. Nine of the 12 study participants completed the semistructured interviews. Members of the research team conducted a qualitative analysis based on the transcripts from the nine interviews using the crystallization/immersion method. RESULTS: Nine of the 12 participants completed the in-depth interview (75% overall response rate), with three men and six women agreeing to be interviewed. Major barriers to Internet use that were mentioned included time constraints and family conflict over computer usage. The monthly training classes and technical assistance components of the intervention surfaced as the most important facilitators to computer and Internet use. The concept of received social support from other study members, such as assistance with computer-related questions, also emerged as an important facilitator to overall computer usage. CONCLUSIONS: This pilot study offers important insights into the self-identified barriers and facilitators in computer and Internet use among urban low-SEP novice users as well as the challenges faced by the research team in implementing the intervention. [Abstract/Link to Full Text]

Patterson V, Swinfen P, Swinfen R, Azzo E, Taha H, Wootton R
Supporting hospital doctors in the Middle East by email telemedicine: something the industrialized world can do to help.
J Med Internet Res. 2007;9(4):e30.
BACKGROUND: Since 1999, the Swinfen Charitable Trust has operated an email referral system between doctors in the developing world and specialists in the industrialized world. Since 2001, it has expanded its operation into the Middle East, in particular Iraq, an area of considerable conflict. OBJECTIVES: The aim was to compare referral patterns to the Trust from the Middle East with those received from the rest of the developing world and to look for qualitative evidence of health gain. METHODS: We analyzed referrals to the Swinfen Charitable Trust between July 2004 and June 2007 and compared these by speciality with those received from elsewhere during the same 3-year period. We asked two referring doctors for their views of the process, and we analyzed the total Middle Eastern referrals made to a single specialty (neurology). RESULTS: Between July 2004 and June 2007, 283 referrals were received from four countries in the Middle East (Iraq, Afghanistan, Pakistan, Kuwait) and 500 cases were received from 22 other countries. The 283 cases resulted in 522 separate queries to specialists. The median time to specialist reply for the queries relating to the 283 Middle Eastern cases was 24.3 hours (interquartile range 6.1-63.3). There was a significant difference in case mix between the Middle East and the rest of the world (P < .001), with more obstetric referrals and fewer referrals in medical specialties and radiology. The referring doctors were helped greatly by the service. The neurologist was confident of the diagnosis in 20 of 26 referrals received (77%). Both referring doctors and the specialist were able to cite referred cases where management was improved as a result of the service. CONCLUSIONS: Email telemedicine can be used in areas of conflict such as the Middle East. Perhaps surprisingly, trauma referrals are not increased but obstetric referrals are. Supporting individual doctor-patient encounters in this way is therefore often beneficial and is easily expandable. As well as improving care for individuals, email telemedicine provides effective case-based learning for local doctors, leading to improved care for subsequent similar patients. [Abstract/Link to Full Text]

Fraser HS, Allen C, Bailey C, Douglas G, Shin S, Blaya J
Information systems for patient follow-up and chronic management of HIV and tuberculosis: a life-saving technology in resource-poor areas.
J Med Internet Res. 2007;9(4):e29.
BACKGROUND: The scale-up of treatment for HIV and multidrug-resistant tuberculosis (MDR-TB) in developing countries requires a long-term relationship with the patient, accurate and accessible records of each patient's history, and methods to track his/her progress. Recent studies have shown up to 24% loss to follow-up of HIV patients in Africa during treatment and many patients not being started on treatment at all. Some programs for prevention of maternal-child transmission have more than 80% loss to follow-up of babies born to HIV-positive mothers. These patients are at great risk of dying or developing drug resistance if their antiretroviral therapy is interrupted. Similar problems have been found in the scale-up of MDR-TB treatment. OBJECTIVES: The aim of the study was to assess the role of medical information systems in tracking patients with HIV or MDR-TB, ensuring they are promptly started on high quality care, and reducing loss to follow-up. METHODS: A literature search was conducted starting from a previous review and using Medline and Google Scholar. Due to the nature of this work and the relative lack of published articles to date, the authors also relied on personal knowledge and experience of systems in use and their own assessments of systems. RESULTS: Functionality for tracking patients and detecting those lost to follow-up is described in six HIV and MDR-TB treatment projects in Africa and Latin America. Preliminary data show benefits in tracking patients who have not been prescribed appropriate drugs, those who fail to return for follow-up, and those who do not have medications picked up for them by health care workers. There were also benefits seen in providing access to key laboratory data and in using this data to improve the timeliness and quality of care. Follow-up was typically achieved by a combination of reports from information systems along with teams of community health care workers. New technologies such as low-cost satellite Internet access, personal digital assistants, and cell phones are helping to expand the reach of these systems. CONCLUSIONS: Effective information systems in developing countries are a recent innovation but will need to play an increasing role in supporting and monitoring HIV and MDR-TB projects as they scale up from thousands to hundreds of thousands of patients. A particular focus should be placed on tracking patients from initial diagnosis to initiation of effective treatment and then monitoring them for treatment breaks or loss to follow-up. More quantitative evaluations need to be performed on the impact of electronic information systems on tracking patients. [Abstract/Link to Full Text]

Saul JE, Schillo BA, Evered S, Luxenberg MG, Kavanaugh A, Cobb N, An LC
Impact of a statewide Internet-based tobacco cessation intervention.
J Med Internet Res. 2007;9(3):e28.
BACKGROUND: An increasing number of people have access to the Internet, and more people are seeking tobacco cessation resources online every year. Despite the proliferation of various online interventions and their evident acceptance and reach, little research has addressed their impact in the real world. Typically, low response rates to Internet-based follow-up surveys generate unrepresentative samples and large confidence intervals when reporting results. OBJECTIVES: The aim of this study was to achieve a high response rate on follow-up evaluation in order to better determine the impact of an Internet-based tobacco cessation intervention provided to tobacco users in Minnesota, United States. METHODS: Participants included 607 men and women aged 18 and over residing in Minnesota who self-reported current tobacco use when registering for an Internet-based tobacco cessation program between February 2 and April 13, 2004. Participants were given access to an interactive website with features including social support, expert systems, proactive email, chat sessions, and online counselors. Mixed-mode follow-up (online survey with telephone survey for online nonrespondents) occurred 6 months after registration. RESULTS: Of the study participants, 77.6% (471/607) responded to the 6-month follow-up survey (39.4% online and 38.2% by telephone). Among respondents, 17.0% (80/471, 95% CI = 13.6%-20.4%) reported that they had not smoked in the past 7 days (observed rate). Assuming all nonrespondents were still smoking (missing=smoking rate), the quit rate was 13.2% (80/607, 95% CI = 10.5%-15.9%). CONCLUSIONS: This mixed-mode follow-up survey of an online smoking cessation program achieved a high response rate and provides a more accurate estimate of long-term cessation rates than has been previously reported. Quit rates for the Internet-based tobacco cessation program were higher than those expected for unassisted quit attempts and are comparable to other evidence-based behavioral interventions. The similarities between quit rates demonstrates that an Internet-based cessation program may have as great an impact as, and can have wider reach than, other cessation programs such as those delivered by telephone. With over 100000 people having visited the website and over 23000 having registered, a 6-month self-reported quit rate of 13.2% suggests that the quitplan.com program helped over 3000 Minnesotans remain tobacco free for at least 6 months. Results of this study suggest that an Internet-based cessation program is a useful tool in states' efforts to provide comprehensive cessation tools for smokers. [Abstract/Link to Full Text]

Woodall WG, Buller DB, Saba L, Zimmerman D, Waters E, Hines JM, Cutter GR, Starling R
Effect of emailed messages on return use of a nutrition education website and subsequent changes in dietary behavior.
J Med Internet Res. 2007;9(3):e27.
BACKGROUND: At-risk populations can be reached with Web-based disease prevention and behavior change programs. However, such eHealth applications on the Internet need to generate return usage to be effective. Limited evidence is available on how continued usage can be encouraged. OBJECTIVE: This analysis tested whether routine email notification about a nutrition education website promoted more use of the website. METHODS: Adults from six rural counties in Colorado and New Mexico, United States (n = 755) participating in a randomized trial and assigned to the intervention group (n = 380) received, over a period of 4 months, email messages alerting them to updates on the website, along with hyperlinks to new content. Update alerts were sent approximately every 5 weeks (each participant received up to 4 messages). Log-ons to the website were the primary outcome for this analysis. RESULTS: A total of 23.5% (86/366) of the participants responded to at least one email, and 51.2% (44/86) of these participants responded to half of the email messages by logging on to the website. Significantly more log-ons occurred on email notification days compared to all other days (OR = 3.71, 95% CI = 2.72-5.06). More log-ons also occurred just after the notification but declined each day thereafter (OR = 0.97, 95% CI = 0.96-0.98 one day further from mass email). Non-Hispanics (OR = 0.46, 95% CI = 0.26-0.84), older participants (OR = 1.04, 95% CI = 1.04-1.06), and those using the Internet most recently (OR = 0.62, 95% CI = 0.51-0.77) were more likely to log on. Responders to the messages had a more positive change in fruit and vegetable intake (mean change = +1.69) than nonresponders (+0.05), as measured with a food frequency assessment (adjusted Spearman partial correlation coefficient = 0.14, P = .049). Compared to nonresponders, responders were more likely to be non-Hispanic (P = .01), older (P < .001), and had used the Internet more recently (P < .001). CONCLUSIONS: Messages sent by email appeared to promote a modest short-lived increase in use of a disease prevention website by some adults. Those who responded to the messages by logging on to the website may have been influenced to improve their diet. [Abstract/Link to Full Text]

van den Berg MH, Schoones JW, Vliet Vlieland TP
Internet-based physical activity interventions: a systematic review of the literature.
J Med Internet Res. 2007;9(3):e26.
BACKGROUND: Nowadays people are extensively encouraged to become more physically active. The Internet has been brought forward as an effective tool to change physical activity behavior. However, little is known about the evidence regarding such Internet-based interventions. OBJECTIVE: The aim of the study was to systematically assess the methodological quality and the effectiveness of interventions designed to promote physical activity by means of the Internet as evaluated by randomized controlled trials. METHODS: A literature search was conducted up to July 2006 using the databases PubMed, Web of Science, EMBASE, PsycINFO, and Cochrane Library. Only randomized controlled trials describing the effectiveness of an Internet-based intervention, with the promotion of physical activity among adults being one of its major goals, were included. Data extracted included source and year of publication, country of origin, targeted health behaviors, participants' characteristics, characteristics of the intervention, and effectiveness data. In addition, the methodological quality was assessed. RESULTS: The literature search resulted in 10 eligible studies of which five met at least nine out of 13 general methodological criteria. The majority of the interventions were tailored to the characteristics of the participants and used interactive self-monitoring and feedback tools. Six studies used one or more theoretical models to compose the contents of the interventions. One study used an objective measure to assess the amount of physical activity (activity monitor), and six studies used multiple subjective measures of physical activity. Furthermore, half of the studies employed measures of physical fitness other than physical activity. In three studies, an Internet-based physical activity intervention was compared with a waiting list group. Of these three studies, two reported a significantly greater improvement in physical activity levels in the Internet-based intervention than in the control group. Seven studies compared two types of Internet-based physical activity interventions in which the main difference was either the intensity of contact between the participants and supervisors (4 studies) or the type of treatment procedures applied (3 studies). In one of these studies, a significant effect in favor of an intervention with more supervisor contact was seen. CONCLUSIONS: There is indicative evidence that Internet-based physical activity interventions are more effective than a waiting list strategy. The added value of specific components of Internet-based physical activity interventions such as increased supervisor contact, tailored information, or theoretical fidelity remains to be established. Methodological quality as well as the type of physical activity outcome measure varied, stressing the need for standardization of these measures. [Abstract/Link to Full Text]

Kongsved SM, Basnov M, Holm-Christensen K, Hjollund NH
Response rate and completeness of questionnaires: a randomized study of Internet versus paper-and-pencil versions.
J Med Internet Res. 2007;9(3):e25.
BACKGROUND: Research in quality of life traditionally relies on paper-and-pencil questionnaires. Easy access to the Internet has inspired a number of studies that use the Internet to collect questionnaire data. However, Internet-based data collection may differ from traditional methods with respect to response rate and data quality as well as the validity and reliability of the involved scales. OBJECTIVE: We used a randomized design to compare a paper-and-pencil questionnaire with an Internet version of the same questionnaire with respect to differences in response rate and completeness of data. METHODS: Women referred for mammography at a Danish public hospital from September 2004 to April 2005, aged less than 67 years and without a history of breast cancer, were eligible for the study. The women received the invitation to participate along with the usual letter from the Department of Radiology. A total of 533 women were invited to participate. They were randomized to receive either a paper questionnaire, with a prepaid return envelope, or a guideline on how to fill in the Internet-based version online. The questionnaire consisted of 17 pages with a total of 119 items, including the Short Form-36, Multidimensional Fatigue Inventory-20, Hospital Anxiety and Depression Scale, and questions regarding social status, education level, occupation, and access to the Internet. Nonrespondents received a postal reminder giving them the option of filling out the other version of the questionnaire. RESULTS: The response rate before the reminder was 17.9% for the Internet group compared to 73.2% for the paper-and-pencil group (risk difference 55.3%, P < .001). After the reminder, when the participant could chose between versions of the questionnaire, the total response rate for the Internet and paper-and-pencil group was 64.2% and 76.5%, respectively (risk difference 12.2%, P = .002). For the Internet version, 97.8% filled in a complete questionnaire without missing data, while 63.4% filled in a complete questionnaire for the paper-and-pencil version (risk difference 34.5%, P < .001). CONCLUSIONS: The Internet version of the questionnaire was superior with respect to completeness of data, but the response rate in this population of unselected patients was low. The general population has yet to become more familiar with the Internet before an online survey can be the first choice of researchers, although it is worthwhile considering within selected populations of patients as it saves resources and provides more complete answers. An Internet version may be combined with the traditional version of a questionnaire, and in follow-up studies of patients it may be more feasible to offer Internet versions. [Abstract/Link to Full Text]

El Emam K, Neri E, Jonker E
An evaluation of personal health information remnants in second-hand personal computer disk drives.
J Med Internet Res. 2007;9(3):e24.
BACKGROUND: The public is concerned about the privacy of their health information, especially as more of it is collected, stored, and exchanged electronically. But we do not know the extent of leakage of personal health information (PHI) from data custodians. One form of data leakage is through computer equipment that is sold, donated, lost, or stolen from health care facilities or individuals who work at these facilities. Previous studies have shown that it is possible to get sensitive personal information (PI) from second-hand disk drives. However, there have been no studies investigating the leakage of PHI in this way. OBJECTIVES: The aim of the study was to determine the extent to which PHI can be obtained from second-hand computer disk drives. METHODS: A list of Canadian vendors selling second-hand computer equipment was constructed, and we systematically went through the shuffled list and attempted to purchase used disk drives from the vendors. Sixty functional disk drives were purchased and analyzed for data remnants containing PHI using computer forensic tools. RESULTS: It was possible to recover PI from 65% (95% CI: 52%-76%) of the drives. In total, 10% (95% CI: 5%-20%) had PHI on people other than the owner(s) of the drive, and 8% (95% CI: 7%-24%) had PHI on the owner(s) of the drive. Some of the PHI included very sensitive mental health information on a large number of people. CONCLUSIONS: There is a strong need for health care data custodians to either encrypt all computers that can hold PHI on their clients or patients, including those used by employees and subcontractors in their homes, or to ensure that their computers are destroyed rather than finding a second life in the used computer market. [Abstract/Link to Full Text]

Armstrong N, Hearnshaw H, Powell J, Dale J
Stakeholder perspectives on the development of a virtual clinic for diabetes care: qualitative study.
J Med Internet Res. 2007;9(3):e23.
BACKGROUND: The development of the Internet has created new opportunities for health care provision, including its use as a tool to aid the self-management of chronic conditions. We studied stakeholder reactions to an Internet-based "virtual clinic," which would allow people with diabetes to communicate with their health care providers, find information about their condition, and share information and support with other users. OBJECTIVE: The aim of the study was to present the results of a detailed consultation with a variety of stakeholder groups in order to identify what they regard as the desirable, important, and feasible characteristics of an Internet-based intervention to aid diabetes self-management. METHODS: Three focus groups were conducted with 12 people with type 1 diabetes who used insulin pumps. Participants were recruited through a local diabetes clinic. One-on-one interviews were conducted with 5 health care professionals from the same clinic (2 doctors, 2 nurses, 1 dietitian) and with 1 representative of an insulin pump company. We gathered patient consensus via email on the important and useful features of Internet-based systems used for other chronic conditions (asthma, epilepsy, myalgic encephalopathy, mental health problems). A workshop to gather expert consensus on the use of information technology to improve the care of young people with diabetes was organized. RESULTS: Stakeholder groups identified the following important characteristics of an Internet-based virtual clinic: being grounded on personal needs rather than only providing general information; having the facility to communicate with, and learn from, peers; providing information on the latest developments and news in diabetes; being quick and easy to use. This paper discusses these characteristics in light of a review of the relevant literature. The development of a virtual clinic for diabetes that embodies these principles, and that is based on self-efficacy theory, is described. CONCLUSIONS: Involvement of stakeholders is vital early in the development of a complex intervention. Stakeholders have clear and relevant views on what a virtual clinic system should provide, and these views can be captured and synthesized with relative ease. This work has led to the design of a system that is able to meet user needs and is currently being evaluated in a pilot study. [Abstract/Link to Full Text]

Ruland CM, Bakken S, R�islien J
Reliability and validity issues related to interactive tailored patient assessments: a case study.
J Med Internet Res. 2007;9(3):e22.
Recently there has been a proliferation of interactive tailored patient assessment (ITPA) tools. However, evidence of the reliability and validity of these instruments is often missing, which makes their value in research studies questionable. Because several of the common methods to evaluate instrument reliability and validity are not applicable to interactive tailored patient assessments, informatics researchers may benefit from some guidance on which methods of reliability and validity assessment they can appropriately use. This paper describes the main differences between interactive tailored patient assessments and assessment instruments based on psychometric, or classical test, theory; it summarizes the measurement techniques normally used to ascertain the validity and reliability of assessment instruments based on psychometric theory; it discusses which methods are appropriate for interactive tailored patient assessments and which are not; and finally, it illustrates the application of some of the feasible techniques with a case study that describes how the reliability and validity of the tailored symptom assessment instrument called Choice were evaluated. [Abstract/Link to Full Text]

Evans R, Elwyn G, Edwards A, Watson E, Austoker J, Grol R
Toward a model for field-testing patient decision-support technologies: a qualitative field-testing study.
J Med Internet Res. 2007;9(3):e21.
BACKGROUND: Field-testing is a quality assurance criterion in the development of patient decision-support technologies (PDSTs), as identified in the consensus statement of the International Patient Decision Aids Standards Collaboration. We incorporated field-testing into the development of a Web-based, prostate-specific antigen PDST called Prosdex, which was commissioned as part of the UK Prostate Cancer Risk Management Programme. OBJECTIVES: The aim of this study was to develop a model for the future field-testing of PDSTs, based on the field-testing of Prosdex. Our objectives were (1) to explore the reactions of men to evolving prototypes of Prosdex, (2) to assess the effect of these responses on the development process, and (3) to develop a model for field-testing PDSTs based on the responses and their effect on the development process. METHODS: Semistructured interviews were conducted with the men after they had viewed evolving prototypes of Prosdex in their homes. The men were grouped according to the prototype viewed. Men between 40 and 75 years of age were recruited from two family practices in different parts of Wales, United Kingdom. In the interviews, the men were asked for their views on Prosdex, both as a whole and in relation to specific sections such as the introduction and video clips. Comments and technical issues that arose during the viewings were noted and fed back to the developers in order to produce subsequent prototypes. RESULTS: A total of 27 men were interviewed, in five groups, according to the five prototypes of Prosdex that were developed. The two main themes from the interviews were the responses to the information provided in Prosdex and the responses to specific features of Prosdex. Within these themes, two of the most frequently encountered categories were detail of the information provided and balance between contrasting viewpoints. Criticisms were encountered, particularly with respect to navigation of the site. In addition, we found that participants made little use of the decision-making scale. The introduction of an interactive contents page to prototype 2 was the main change made to Prosdex as a result of the field-testing. Based on our findings, a model for the field-testing of PDSTs was developed, involving an exploratory field-testing stage between the planning stage and the development of the first prototype, and followed by the prototype field-testing stage, leading to the final PDST. CONCLUSIONS: In the field-testing of Prosdex, a Web-based prostate-specific antigen PDST, the responses of interviewed men were generally favorable. As a consequence of the responses, an interactive contents page was added to the site. We developed a model for the future field-testing of PDSTs, involving two stages: exploratory field-testing and prototype field-testing. [Abstract/Link to Full Text]

Beckjord EB, Finney Rutten LJ, Squiers L, Arora NK, Volckmann L, Moser RP, Hesse BW
Use of the internet to communicate with health care providers in the United States: estimates from the 2003 and 2005 Health Information National Trends Surveys (HINTS).
J Med Internet Res. 2007;9(3):e20.
BACKGROUND: Despite substantial evidence that the public wants access to Internet-based communication with health care providers, online patient-provider communication remains relatively uncommon, and few studies have examined sociodemographic and health-related factors associated with the use of online communication with health care providers at a population level. OBJECTIVE: The aim of the study was to use nationally representative data to report on the prevalence of and changes in use of online patient-provider communication in 2003 and 2005 and to describe sociodemographic and health-related factors associated with its use. METHODS: Data for this study are from two iterations of the Health Information National Trends Survey (HINTS 2003, HINTS 2005). In both years, respondents were asked whether they had ever used email or the Internet to communicate with a doctor or a doctor's office. Adult Internet users in 2003 (n = 3982) and 2005 (n = 3244) were included in the present study. Multivariate logistic regression analysis was conducted to identify predictors for electronic communication with health care providers. RESULTS: In 2003, 7% of Internet users had communicated online with an health care provider; this prevalence significantly increased to 10% in 2005. In multivariate analyses, Internet users with more years of education, who lived in a metro area, who reported poorer health status or who had a personal history of cancer were more likely to have used online patient-provider communication. CONCLUSIONS: Despite wide diffusion of the Internet, online patient-provider communication remains uncommon but is slowly increasing. Policy-level changes are needed to maximize the availability and effectiveness of online patient-provider communication for health care consumers and health care providers. Internet access remains a significant barrier to online patient-provider communication. [Abstract/Link to Full Text]

Willinsky J, Quint-Rapoport M
How complementary and alternative medicine practitioners use PubMed.
J Med Internet Res. 2007;9(2):e19.
BACKGROUND: PubMed is the largest bibliographic index in the life sciences. It is freely available online and is used by professionals and the public to learn more about medical research. While primarily intended to serve researchers, PubMed provides an array of tools and services that can help a wider readership in the location, comprehension, evaluation, and utilization of medical research. OBJECTIVE: This study sought to establish the potential contributions made by a range of PubMed tools and services to the use of the database by complementary and alternative medicine practitioners. METHODS: In this study, 10 chiropractors, 7 registered massage therapists, and a homeopath (N = 18), 11 with prior research training and 7 without, were taken through a 2-hour introductory session with PubMed. The 10 PubMed tools and services considered in this study can be divided into three functions: (1) information retrieval (Boolean Search, Limits, Related Articles, Author Links, MeSH), (2) information access (Publisher Link, LinkOut, Bookshelf ), and (3) information management (History, Send To, Email Alert). Participants were introduced to between six and 10 of these tools and services. The participants were asked to provide feedback on the value of each tool or service in terms of their information needs, which was ranked as positive, positive with emphasis, negative, or indifferent. RESULTS: The participants in this study expressed an interest in the three types of PubMed tools and services (information retrieval, access, and management), with less well-regarded tools including MeSH Database and Bookshelf. In terms of their comprehension of the research, the tools and services led the participants to reflect on their understanding as well as their critical reading and use of the research. There was universal support among the participants for greater access to complete articles, beyond the approximately 15% that are currently open access. The abstracts provided by PubMed were felt to be necessary in selecting literature to read but entirely inadequate for both evaluating and learning from the research. Thus, the restrictions and fees the participants faced in accessing full-text articles were points of frustration. CONCLUSIONS: The study found strong indications of PubMed's potential value in the professional development of these complementary and alternative medicine practitioners in terms of engaging with and understanding research. It provides support for the various initiatives intended to increase access, including a recommendation that the National Library of Medicine tap into the published research that is being archived by authors in institutional archives and through other websites. [Abstract/Link to Full Text]

Singh PM, Wight CA, Sercinoglu O, Wilson DC, Boytsov A, Raizada MN
Language preferences on websites and in Google searches for human health and food information.
J Med Internet Res. 2007;9(2):e18.
BACKGROUND: While it is known that the majority of pages on the World Wide Web are in English, little is known about the preferred language of users searching for health information online. OBJECTIVES: (1) To help global and domestic publishers, for example health and food agencies, to determine the need for translation of online information from English into local languages. (2) To help these agencies determine which language(s) they should select when publishing information online in target nations and for target subpopulations within nations. METHODS: To estimate the percentage of Web publishers that translate their health and food websites, we measured the frequency at which domain names retrieved by Google overlap for language translations of the same health-related search term. To quantify language choice of searchers from different countries, Google provided estimates of the rate at which its search engine was queried in six languages relative to English for the terms "avian flu," "tuberculosis," "schizophrenia," and "maize" (corn) from January 2004 to April 2006. The estimate was based on a 20% sample of all Google queries from 227 nations. RESULTS: We estimate that 80%-90% of health- and food-related institutions do not translate their websites into multiple languages, even when the information concerns pandemic disease such as avian influenza. Although Internet users are often well-educated, there was a strong preference for searching for health and food information in the local language, rather than English. For "avian flu," we found that only 1% of searches in non-English-speaking nations were in English, whereas for "tuberculosis" or "schizophrenia," about 4%-40% of searches in non-English countries employed English. A subset of searches for health information presumably originating from immigrants occurred in their native tongue, not the language of the adopted country. However, Spanish-language online searches for "avian flu," "schizophrenia," and "maize/corn" in the United States occurred at only <1% of the English search rate, although the US online Hispanic population constitutes 12% of the total US online population. Sub-Saharan Africa and Bangladesh searches for health information occurred in unexpected languages, perhaps reflecting the presence of aid workers and the global migration of Internet users, respectively. In Latin America, indigenous-language search terms were often used rather than Spanish. CONCLUSIONS: (1) Based on the strong preference for searching the Internet for health information in the local language, indigenous language, or immigrant language of origin, global and domestic health and food agencies should continue their efforts to translate their institutional websites into more languages. (2) We have provided linguistic online search pattern data to help health and food agencies better select languages for targeted website publishing. [Abstract/Link to Full Text]

Cook RF, Billings DW, Hersch RK, Back AS, Hendrickson A
A field test of a web-based workplace health promotion program to improve dietary practices, reduce stress, and increase physical activity: randomized controlled trial.
J Med Internet Res. 2007;9(2):e17.
BACKGROUND: Most work sites engage in some form of health promotion programming designed to improve worker health and reduce health care costs. Although these programs have typically been delivered through combinations of seminars and print materials, workplace health promotion programs are increasingly being delivered through the Internet. OBJECTIVE: The purpose of this research was to evaluate the effectiveness of a Web-based multimedia health promotion program for the workplace, designed to improve dietary practices, reduce stress, and increase physical activity. METHODS: Using a randomized controlled trial design with pretest-posttest comparisons within each group, 419 employees of a human resources company were randomly assigned to the Web-based condition or to a condition that provided print materials on the same topics. All subjects were assessed at pretest and posttest through an online questionnaire containing multiple measures of health behavior and attitudes. The test period was 3 months. Questionnaire data were analyzed mainly by analysis of covariance and t tests. RESULTS: Retention rates were good for both groups-85% for the Web-based group and 87% for the print group. Subjects using the Web-based program performed significantly better than the print group on Attitudes Toward a Healthful Diet (F(1,415) = 7.104, P = .008) and Dietary Stage of Change (F(1,408) = 6.487, P = .01), but there were no significant group differences on the five other dietary measures. Both groups also showed improvement from pretest to posttest on most dietary measures, as indicated by significant t tests. Within the Web-based group, dosage analyses showed significant effects of the number of times the subject accessed the program on measures of Dietary Self-Efficacy (F(2,203) = 5.270, P = .003), Attitudes Toward a Healthful Diet (F(2,204) = 2.585, P = .045), and Dietary Stage of Change (F(2,200) = 4.627, P = .005). No significant differences were found between the two groups on measures of stress or physical activity, although t tests of pretest-posttest changes indicated that both groups improved on several of these measures. The Web-based group gave significantly higher ratings to the program materials than the print group on all health topics and in their overall evaluation (F(1,410) = 9.808, P = .002). CONCLUSIONS: The Web-based program was more effective than print materials in producing improvements in the areas of diet and nutrition but was not more effective in reducing stress or increasing physical activity. The higher ratings given to the Web-based program suggest that workers preferred it to the print materials. Both groups showed numerous pretest-posttest improvements in all health topics, although such improvements might be attributable in part to a Hawthorne effect. Results suggest that a multimedia Web-based program can be a promising means of delivering health promotion material to the workforce, particularly in the area of diet and nutrition. [Abstract/Link to Full Text]

Couper MP, Peytchev A, Strecher VJ, Rothert K, Anderson J
Following up nonrespondents to an online weight management intervention: randomized trial comparing mail versus telephone.
J Med Internet Res. 2007;9(2):e16.
BACKGROUND: Attrition, or dropout, is a problem faced by many online health interventions, potentially threatening the inferential value of online randomized controlled trials. OBJECTIVE: In the context of a randomized controlled trial of an online weight management intervention, where 85% of the baseline participants were lost to follow-up at the 12-month measurement, the objective was to examine the effect of nonresponse on key outcomes and explore ways to reduce attrition in follow-up surveys. METHODS: A sample of 700 non-respondents to the 12-month online follow-up survey was randomly assigned to a mail or telephone nonresponse follow-up survey. We examined response rates in the two groups, costs of follow-up, reasons for nonresponse, and mode effects. We ran several logistic regression models, predicting response or nonresponse to the 12-month online survey as well as predicting response or nonresponse to the follow-up survey. RESULTS: We analyzed 210 follow-up respondents in the mail and 170 in the telephone group. Response rates of 59% and 55% were obtained for the telephone and mail nonresponse follow-up surveys, respectively. A total of 197 respondents (51.8%) gave reasons related to technical issues or email as a means of communication, with older people more likely to give technical reasons for non-completion; 144 (37.9%) gave reasons related to the intervention or the survey itself. Mail follow-up was substantially cheaper: We estimate that the telephone survey cost about US $34 per sampled case, compared to US $15 for the mail survey. The telephone responses were subject to possible social desirability effects, with the telephone respondents reporting significantly greater weight loss than the mail respondents. The respondents to the nonresponse follow-up did not differ significantly from the 12-month online respondents on key outcome variables. CONCLUSIONS: Mail is an effective way to reduce attrition to online surveys, while telephone follow-up might lead to overestimating the weight loss for both the treatment and control groups. Nonresponse bias does not appear to be a significant factor in the conclusions drawn from the randomized controlled trial. [Abstract/Link to Full Text]

Pagliari C
Design and evaluation in eHealth: challenges and implications for an interdisciplinary field.
J Med Internet Res. 2007;9(2):e15.
Much has been written about insufficient user involvement in the design of eHealth applications, the lack of evidence demonstrating impact, and the difficulties these bring for adoption. Part of the problem lies in the differing languages, cultures, motives, and operational constraints of producers and evaluators of eHealth systems and services. This paper reflects on the benefits of and barriers to interdisciplinary collaboration in eHealth, focusing particularly on the relationship between software developers and health services researchers. It argues that the common pattern of silo or parallel working may be ameliorated by developing mutual awareness and respect for each others' methods, epistemologies, and contextual drivers and by recognizing and harnessing potential synergies. Similarities and differences between models and techniques used in both communities are highlighted in order to illustrate the potential for integrated approaches and the strengths of unique paradigms. By sharing information about our research approaches and seeking to actively collaborate in the process of design and evaluation, the aim of achieving technologies that are truly user-informed, fit for context, high quality, and of demonstrated value is more likely to be realized. This may involve embracing new ways of working jointly that are unfamiliar to the stakeholders involved and that challenge disciplinary conventions. It also has policy implications for agencies commissioning research and development in this area. [Abstract/Link to Full Text]

Leonard KJ, Sittig DF
Improving information technology adoption and implementation through the identification of appropriate benefits: creating IMPROVE-IT.
J Med Internet Res. 2007;9(2):e9.
This paper describes the objectives of a collaborative initiative that attempts to provide the evidence that increased information technology (IT) capabilities, availability, and use lead directly to improved clinical quality, safety, and effectiveness within the inpatient hospital setting. This collaborative network has defined specific measurement indicators in an attempt to examine the existence, timing, and level of improvements in health outcomes that can be derived from IT investment. These indicators are in three areas: (1) IT costs (which includes both initial and ongoing investment), (2) IT infusion (ie, system availability, adoption, and deployment), and (3) health performance (eg, clinical efficacy, efficiency, quality, and effectiveness). Herein, we outline the theoretical framework, the methodology employed to create the metrics, and the benefits that can be obtained. [Abstract/Link to Full Text]

Koru G, El Emam K, Neisa A, Umarji M
A survey of quality assurance practices in biomedical open source software projects.
J Med Internet Res. 2007;9(2):e8.
BACKGROUND: Open source (OS) software is continuously gaining recognition and use in the biomedical domain, for example, in health informatics and bioinformatics. OBJECTIVES: Given the mission critical nature of applications in this domain and their potential impact on patient safety, it is important to understand to what degree and how effectively biomedical OS developers perform standard quality assurance (QA) activities such as peer reviews and testing. This would allow the users of biomedical OS software to better understand the quality risks, if any, and the developers to identify process improvement opportunities to produce higher quality software. METHODS: A survey of developers working on biomedical OS projects was conducted to examine the QA activities that are performed. We took a descriptive approach to summarize the implementation of QA activities and then examined some of the factors that may be related to the implementation of such practices. RESULTS: Our descriptive results show that 63% (95% CI, 54-72) of projects did not include peer reviews in their development process, while 82% (95% CI, 75-89) did include testing. Approximately 74% (95% CI, 67-81) of developers did not have a background in computing, 80% (95% CI, 74-87) were paid for their contributions to the project, and 52% (95% CI, 43-60) had PhDs. A multivariate logistic regression model to predict the implementation of peer reviews was not significant (likelihood ratio test = 16.86, 9 df, P = .051) and neither was a model to predict the implementation of testing (likelihood ratio test = 3.34, 9 df, P = .95). CONCLUSIONS: Less attention is paid to peer review than testing. However, the former is a complementary, and necessary, QA practice rather than an alternative. Therefore, one can argue that there are quality risks, at least at this point in time, in transitioning biomedical OS software into any critical settings that may have operational, financial, or safety implications. Developers of biomedical OS applications should invest more effort in implementing systemic peer review practices throughout the development and maintenance processes. [Abstract/Link to Full Text]

Stepnowsky CJ, Palau JJ, Marler MR, Gifford AL
Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
J Med Internet Res. 2007;9(2):e14.
BACKGROUND: Obstructive sleep apnea (OSA) is a prevalent and serious medical condition characterized by repeated complete or partial obstructions of the upper airway during sleep and is prevalent in 2% to 4% of working middle-aged adults. Nasal continuous positive airway pressure (CPAP) is the gold-standard treatment for OSA. Because compliance rates with CPAP therapy are disappointingly low, effective interventions are needed to improve CPAP compliance among patients diagnosed with OSA. OBJECTIVE: The aim was to determine whether wireless telemonitoring of CPAP compliance and efficacy data, compared to usual clinical care, results in higher CPAP compliance and improved OSA outcomes. METHODS: 45 patients newly diagnosed with OSA were randomized to either telemonitored clinical care or usual clinical care and were followed for their first 2 months of treatment with CPAP therapy. CPAP therapists were not blinded to the participants' treatment group. RESULTS: 20 participants in each group received the designated intervention. Patients randomized to telemonitored clinical care used CPAP an average of 4.1 +/- 1.8 hours per night, while the usual clinical care patients averaged 2.8 +/- 2.2 hours per night (P = .07). Telemonitored patients used CPAP on 78% +/- 22% of the possible nights, while usual care patients used CPAP on 60% +/- 32% of the nights (P = .07). No statistically significant differences between the groups were found on measures of CPAP efficacy, including measures of mask leak and the Apnea-Hypopnea Index. Patients in the telemonitored group rated their likelihood to continue using CPAP significantly higher than the patients in the usual care group. Patients in both groups were highly satisfied with the care they received and rated themselves as "not concerned" that their CPAP data were being wirelessly monitored. CONCLUSIONS: Telemonitoring of CPAP compliance and efficacy data and rapid use of those data by the clinical sleep team to guide the collaborative (ie, patient and provider) management of CPAP treatment is as effective as usual care in improving compliance rates and outcomes in new CPAP users. This study was designed as a pilot-larger, well-powered studies are necessary to fully evaluate the clinical and economic efficacy of telemonitoring for this population. [Abstract/Link to Full Text]

Atkinson NL, Massett HA, Mylks C, Hanna B, Deering MJ, Hesse BW
User-centered research on breast cancer patient needs and preferences of an Internet-based clinical trial matching system.
J Med Internet Res. 2007;9(2):e13.
BACKGROUND: Internet-based clinical trial matching systems have the potential to streamline the search process for women with breast cancer seeking alternative treatments. A prototype system was developed to leverage the capabilities of a personal health record system for the purpose of identifying clinical trials. OBJECTIVE: This study examines how breast cancer patients perceive and interact with a preliminary version of an Internet-based clinical trial matching system, while taking into account the demands of diagnosis and treatment decision making. METHODS: Breast cancer patients participated in small group discussions and interacted with the prototype website in a two-phase qualitative research process. The first phase explored the experience of breast cancer patients (n = 8) with treatment decision making, initial responses to the idea of Internet-based clinical trial matching systems, and reactions to the prototype site. In the second phase, a different set of breast cancer patients (n = 7) reviewed revised website content and presentation and participated in a usability test in which they registered on the system and completed a personal health record to set up the matching process. RESULTS: Participants were initially skeptical of the prototype system because it emphasized registration, had a complicated registration process, and asked for complex medical information. Changing content and attending to usability guidelines improved the experience for women in the second phase of the research and enabled the identification of functionality and content issues, such as lack of clear information and directions on how to use the system. CONCLUSIONS: This study showed that women felt favorably about the idea of using the Internet to search for clinical trials but that such a system needed to meet their expectations for credibility and privacy and be sensitive to their situation. Developers can meet these expectations by conforming to established usability guidelines and testing improvements with breast cancer patients. Future research is needed to verify these findings and to continue to improve systems of this nature. [Abstract/Link to Full Text]

Meier A, Lyons EJ, Frydman G, Forlenza M, Rimer BK
How cancer survivors provide support on cancer-related Internet mailing lists.
J Med Internet Res. 2007;9(2):e12.
BACKGROUND: Internet mailing lists are an important and increasingly common way for cancer survivors to find information and support. Most studies of these mailing lists have investigated lists dedicated to one type of cancer, most often breast cancer. Little is known about whether the lessons learned from experiences with breast cancer lists apply to other cancers. OBJECTIVES: The aim of the study was to compare the structural characteristics of 10 Internet cancer-related mailing lists and identify the processes by which cancer survivors provide support. METHODS: We studied a systematic 9% sample of email messages sent over five months to 10 cancer mailing lists hosted by the Association of Cancer Online Resources (ACOR). Content analyses were used to compare the structural characteristics of the lists, including participation rates and members' identities as survivors or caregivers. We used thematic analyses to examine the types of support that list members provided through their message texts. RESULTS: Content analyses showed that characteristics of list members and subscriber participation rates varied across the lists. Thematic analyses revealed very little "off topic" discussion. Feedback from listowners indicated that they actively modeled appropriate communication on their lists and worked to keep discussions civil and focused. In all lists, members offered support much more frequently than they requested it; survivors were somewhat more likely than caregivers to offer rather than to ask for support. The most common topics in survivors' messages were about treatment information and how to communicate with health care providers. Although expressions of emotional support were less common than informational support, they appeared in all lists. Many messages that contained narratives of illness or treatment did not specifically ask for help but provided emotional support by reassuring listmates that they were not alone in their struggles with cancer. Survivors' explicit expressions of emotional support tended to be messages that encouraged active coping. Such messages also provided senders with opportunities to assume personally empowering "helper" roles that supported self-esteem. CONCLUSIONS: Many cancer survivors use the Internet to seek informational and emotional support. Across 10 lists for different cancers, informational support was the main communication style. Our finding of an emphasis on informational support is in contrast to most prior literature, which has focused on emotional support. We found the most common expressions of support were offers of technical information and explicit advice about how to communicate with health care providers. Topics and proportions of informational and emotional support differed across the lists. Our previous surveys of ACOR subscribers showed that they join the lists primarily to seek information; this qualitative study shows that they can and do find what they seek. They also find opportunities to play rewarding roles as support givers. [Abstract/Link to Full Text]

Glasgow RE, Nelson CC, Kearney KA, Reid R, Ritzwoller DP, Strecher VJ, Couper MP, Green B, Wildenhaus K
Reach, engagement, and retention in an Internet-based weight loss program in a multi-site randomized controlled trial.
J Med Internet Res. 2007;9(2):e11.
BACKGROUND: Research increasingly supports the conclusion that well-designed programs delivered over the Internet can produce significant weight loss compared to randomized controlled conditions. Much less is known about four important issues addressed in this study: (1) which recruitment methods produce higher eHealth participation rates, (2) which patient characteristics are related to enrollment, (3) which characteristics are related to level of user engagement in the program, and (4) which characteristics are related to continued participation in project assessments. METHODS: We recruited overweight members of three health maintenance organizations (HMOs) to participate in an entirely Internet-mediated weight loss program developed by HealthMedia, Inc. Two different recruitment methods were used: personal letters from prevention directors in each HMO, and general notices in member newsletters. The personal letters were sent to members diagnosed with diabetes or heart disease and, in one HMO, to a general membership sample in a particular geographic location. Data were collected in the context of a 2x2 randomized controlled trial, with participants assigned to receive or not receive a goal setting intervention and a nutrition education intervention in addition to the basic program. RESULTS: A total of 2311 members enrolled. Bivariate analyses on aggregate data revealed that personalized mailings produced higher enrollment rates than member newsletters and that members with diabetes or heart disease were more likely to enroll than those without these diagnoses. In addition, males, those over age 60, smokers, and those estimated to have higher medical expenses were less likely to enroll (all P < .001). Males and those in the combined intervention were less likely to engage initially, or to continue to be engaged with their Web program, than other participants. In terms of retention, multiple logistic regressions revealed that enrollees under age 60 (P < .001) and those with higher baseline self-efficacy were less likely to participate in the 12-month follow-up (P = .03), but with these exceptions, those participating were very similar to those not participating in the follow-up. CONCLUSIONS: A single personalized mailing increases enrollment in Internet-based weight loss. eHealth programs offer great potential for recruiting large numbers of participants, but they may not reach those at highest risk. Patient characteristics related to each of these important factors may be different, and more comprehensive analyses of determinants of enrollment, engagement, and retention in eHealth programs are needed. [Abstract/Link to Full Text]

Linke S, Murray E, Butler C, Wallace P
Internet-based interactive health intervention for the promotion of sensible drinking: patterns of use and potential impact on members of the general public.
J Med Internet Res. 2007;9(2):e10.
BACKGROUND: Heavy drinking is responsible for major health and social problems. Brief interventions have been shown to be effective, but there have been difficulties in reaching those who might benefit from them. Pilot studies have indicated that a Web-based intervention is likely to be acceptable to heavy drinkers and may produce some health benefits. However, there are few data on how many people might use such a program, the patterns of use, and potential benefits. OBJECTIVES: The aim was to examine the demographic characteristics of users of a free, Web-based, 6-week intervention for heavy drinkers and to describe the methods by which users identified the site, the pattern of site use and attrition, the characteristics associated with completing the program, and the self-reported impact on alcohol-related outcomes. METHODS: Cohort study. Visitors to the Web site were offered screening with the Fast Alcohol Screening Test, and those scoring above the cutoff for risky drinking were invited to register with the program. Demographic information was collected routinely at registration, and questionnaires were completed at the end of weeks 1 and 6. The outcome measures assessed dependency (Short Alcohol Dependency Data Questionnaire), harms (modified Alcohol Problems Questionnaire), and mental health (Clinical Outcomes in Routine Evaluation-Outcome Measure). RESULTS: The records of 10,000 users were analyzed. The mean age was 37.4 years, 51.1% were female, 37.5% were single, and 42.4% lived with children. The majority were White British, lived in the United Kingdom, and reported occupations from the higher socioeconomic strata. Over 70% connected to the Down Your Drink (Down Your Drink) site from another Internet-based resource, whereas only 5.8% heard about the site from a health or other professional. Much of the Web site use (40%) was outside normal working hours. Attrition from the program was high, with only 16.5% of registrants completing the whole 6 weeks. For those who completed the program, and the final outcome measures, measures of dependency, alcohol-related problems, and mental health symptoms were all reduced at week 6. CONCLUSIONS: The Web-based intervention was highly used, and those who stayed with the program showed significant reductions in self-reported indicators of dependency, alcohol-related problems, and mental health symptoms; however, this association cannot be assumed to be causal. Programs of this type may have the potential to reach large numbers of heavy drinkers who might not otherwise seek help. There are significant methodological challenges and further research is needed to fully evaluate such interventions. [Abstract/Link to Full Text]

Gustafson DH
A good death.
J Med Internet Res. 2007;9(1):e6.
The Institute of Medicine defines a good death a "one that is free from avoidable death and suffering for patients, families and caregivers in general accordance with the patients' and families' wishes." The current system creates barriers to reducing the stress and suffering that accompany a patient's end of life. Data and eHealth technology, if it were more accessible, could help patients, families, and caregivers to cope with end of life issues. [Abstract/Link to Full Text]

Keselman A, Tse T, Crowell J, Browne A, Ngo L, Zeng Q
Assessing consumer health vocabulary familiarity: an exploratory study.
J Med Internet Res. 2007;9(1):e5.
BACKGROUND: Accurate assessment of the difficulty of consumer health texts is a prerequisite for improving readability. General purpose readability formulas based primarily on word length are not well suited for the health domain, where short technical terms may be unfamiliar to consumers. To address this need, we previously developed a regression model for predicting "average familiarity" with consumer health vocabulary (CHV) terms. OBJECTIVE: The primary goal was to evaluate the ability of the CHV term familiarity model to predict (1) surface-level familiarity of health-related terms and (2) understanding of the underlying meaning (concept familiarity) among actual consumers. Secondary goals involved exploring the effect of demographic factors (eg, health literacy) on surface-level and concept-level familiarity and describing the relationship between the two levels of familiarity. METHODS: Survey instruments for assessing surface-level famil