e-HealthExpert.org - Primum non nocere

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

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

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

Background: Integrating online weight-loss programs into the primary care setting could yield substantial public health benefit. Little is known about primary care providers’ perspectives on online weight-loss programs. Objective: To assess primary care providers’ perspectives on online weight-loss programs. Methods: We conducted focus group discussions with providers in family medicine, internal medicine, and combined internal medicine/pediatrics in Texas and Pennsylvania, USA. Open-ended questions addressed their experience with and attitudes toward online weight-loss programs; useful characteristics of existing online weight-loss programs; barriers to referring patients to online weight-loss programs; and preferred characteristics of an ideal online weight-loss program. Transcripts were analyzed with the grounded theory approach to identify major themes. Results: A total of 44 primary care providers participated in 9 focus groups. The mean age was 45 (SD 9) years. Providers had limited experience with structured online weight-loss programs and were uncertain about their safety and efficacy. They thought motivated, younger patients would be more likely than others to respond to an online weight-loss program. According to primary care providers, an ideal online weight-loss program would provide—at no cost to the patient—a structured curriculum addressing motivation, psychological issues, and problem solving; tools for tracking diet, exercise, and weight loss; and peer support monitored by experts. Primary care providers were interested in receiving reports about patients from the online weight-loss programs, but were concerned about the time required to review and act on the reports. Conclusions: Primary care providers have high expectations for how online weight-loss programs should deliver services to patients and fit into the clinical workflow. Efforts to integrate online weight-loss programs into the primary care setting should address efficacy and safety of online weight-loss programs in clinic-based populations; acceptable methods of sending reports to primary care providers about their patients’ progress; and elimination or reduction of costs to patients.

Background: Spouses and partners (“partners”) of women at-risk for (“previvors”) and surviving with hereditary breast/ovarian cancer are a primary source of support within their families. Yet, little is known about partners’ needs for psychoeducational intervention to enhance their cancer risk knowledge, coping, and support role functioning. Objective: To determine the type and range of need for psychoeducational intervention among partners of hereditary breast cancer previving and surviving women, and to understand the potential role of the Internet and other communication channels in meeting that need. Methods: We conducted a secondary data analysis on partners’ needs that were originally assessed via an online community-based organization devoted to hereditary breast cancer. Partners’ demographic characteristics, need for psychoeducation, and likelihood of using various communication channels were assessed along with other constructs. Analyses examined commonly-occurring clusters of likely intervention use and by communication channel. Results: Partners (n =143) endorsed a moderately high level of need for psychoeducation and did so across multiple content areas (e.g., role functioning, decision making, communication, intimacy). Factor analysis identified three commonly-preferred communication channels: 1) self-help materials, 2) online interactions, and 3) interpersonal interactions. A cluster analysis among these factors identified three groups of partners based on their likelihood of psychoeducational intervention use (low [18%], moderate [55%], and high [27%] users). In a covariate-adjusted MANOVA, moderate and high intervention users reported significantly greater need for psychoeducation compared to low users (F2,132 = 9.15, P < .001). Conclusions: A majority of assessed partners perceived a need for psychoeducational interventions surrounding hereditary breast cancer risk. Internet-based, interactive resources may be an efficient mechanism to reach large numbers of partners with tailored content. Research is warranted to inform the design and deployment of these resources to ensure quality and high impact, and ultimately to examine ways to integrate these resources into clinical care.

Background: Real-time surveillance is fundamental for effective control of disease outbreaks, but the official sentinel surveillance in Japan collects information related to disease activity only weekly and updates it with a 1-week time lag. Objective: To report on a prescription surveillance system using electronic records related to prescription drugs that was started in 2008 in Japan, and to evaluate the surveillance system for monitoring influenza activity during the 2009–2010 and 2010–2011 influenza seasons. Methods: We developed an automatic surveillance system using electronic records of prescription drug purchases collected from 5275 pharmacies through the application service provider’s medical claims service. We then applied the system to monitoring influenza activity during the 2009–2010 and 2010–2011 influenza seasons. The surveillance system collected information related to drugs and patients directly and automatically from the electronic prescription record system, and estimated the number of influenza cases based on the number of prescriptions of anti-influenza virus medication. Then it shared the information related to influenza activity through the Internet with the public on a daily basis. Results: During the 2009–2010 influenza season, the number of influenza patients estimated by the prescription surveillance system between the 28th week of 2009 and the 12th week of 2010 was 9,234,289. In the 2010–2011 influenza season, the number of influenza patients between the 36th week of 2010 and the 12th week of 2011 was 7,153,437. The estimated number of influenza cases was highly correlated with that predicted by the official sentinel surveillance (r = .992, P < .001 for 2009–2010; r = .972, P < .001 for 2010–2011), indicating that the prescription surveillance system produced a good approximation of activity patterns. Conclusions: Our prescription surveillance system presents great potential for monitoring influenza activity and for providing early detection of infectious disease outbreaks.

Background: Prostate cancer is the most common cancer affecting men in the United States. Management options for localized disease exist, yet an evidence-based criterion standard for treatment still has to emerge. Although 5-year survival rates approach 98%, all treatment options carry the possibility for significant side effects, such as erectile dysfunction and urinary incontinence. It is therefore recommended that patients be actively involved in the treatment decision process. We have developed an Internet/CD-ROM-based multimedia Prostate Interactive Educational System (PIES) to enhance patients’ treatment decision making. PIES virtually mirrors a health center to provide patients with information about prostate cancer and its treatment through an intuitive interface, using videos, animations, graphics, and texts. Objectives: (1) To examine the acceptability and feasibility of the PIES intervention and to report preliminary outcomes of the program in a pilot trial among patients with a new prostate cancer diagnosis, and (2) to explore the potential impact of tailoring PIES treatment information to participants’ information-seeking styles on study outcomes. Methods: Participants (n = 72) were patients with newly diagnosed localized prostate cancer who had not made a treatment decision. Patients were randomly assigned to 3 experimental conditions: (1) control condition (providing information through standard National Cancer Institute brochures; 26%), and PIES (2) with tailoring (43%) and (3) without tailoring to a patient’s information-seeking style (31%). Questionnaires were administrated before (t1) and immediately after the intervention (t2). Measurements include evaluation and acceptability of the PIES intervention, monitoring/blunting information-seeking style, psychological distress, and decision-related variables (eg, decisional confidence, feeling informed about prostate cancer and treatment, and treatment preference). Results: The PIES program was well accepted by patients and did not interfere with the clinical routine. About 79% of eligible patients (72/91) completed the pre- and post-PIES intervention assessments. Patients in the PIES groups compared with those in the control condition were significantly more likely to report higher levels of confidence in their treatment choices, higher levels of helpfulness of the information they received in making a treatment decision, and that the information they received was emotionally reassuring. Patients in the PIES groups compared with those in the control condition were significantly less likely to need more information about treatment options, were less anxious about their treatment choices, and thought the information they received was clear (P < .05). Tailoring PIES information to information-seeking style was not related to decision-making variables. Conclusions: This pilot study confirms that the implementation of PIES within a clinical practice is feasible and acceptable to patients with a recent diagnosis of prostate cancer. PIES improved key decision-making process variables and reduced the emotional impact of a difficult medical decision.

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

.

Background: Effectiveness of and engagement with website-delivered physical activity interventions is moderate at best. Increased exposure to Internet interventions is reported to increase their effectiveness; however, there is a lack of knowledge about which specific intervention elements are able to maintain website engagement. Objective: To prospectively study the associations of website engagement and exposure to intervention components for a publicly available physical activity website (10,000 Steps Australia). Methods: Between June and July 2006 a total of 348 members of 10,000 Steps completed a Web-based survey to collect demographic characteristics. Website engagement was subsequently assessed over a 2-year period and included engagement data on website components; individual challenges, team challenges, and virtual walking buddies; and indicators of website engagement (average steps logged, days logging steps, and active users). Results: On average participants logged steps on 169 (SD 228.25) days. Over a 2-year period this equated to an average of 1.6 logons per week. Binary logistic regression showed that individuals who participated in individual challenges were more likely to achieve an average of 10,000 steps per day (odds ratio [OR] = 2.80, 95% confidence interval [CI] 1.45–5.40), log steps on a higher than average number of days (OR = 6.81, 95% CI 2.87–13.31), and remain an active user (OR = 4.36, 95% CI 2.17–8.71). Additionally, those using virtual walking buddies (OR = 5.83, 95% CI 1.27–26.80) and of older age logged steps on a higher than average number of days. No significant associations were found for team challenges. Conclusions: Overall engagement with the 10,000 Steps website was high, and the results demonstrate the relative effectiveness of interactive components to enhance website engagement. However, only exposure to the interactive individual challenge feature was positively associated with all website engagement indicators. More research is needed to examine the influence of intervention components on website engagement, as well as the relationship between website engagement and physical activity change.

In a recent JMIR article, El Emam, Moreau and Jonker highlight the importance of using strong passwords to protect personal health information in clinical trials [1]. An important implication that was not fully discussed is the potential problem people may have to create passwords that are complex but at the same time easy to remember. To address this problem we propose the PsychoPass methord, a simple way to create strong passwords which are easy to remember. This method relies on mental practice and is not an hardware or a software to download. The idea is that a password can be created, memorized and recalled by just thinking of an action sequence instead of a word or string of characters. To be more specific, the method consists of the following steps (see Figure 1 and 2): (1) begin with a letter on the keyboard; (2) memorize a sequence of actions (something like “the key on the left, then the upper one, then the one on the right”, and so on); (3) memorize the sequence (not the letters used); (4) create as many passwords as you want by remembering only the first letter and the sequence. Using different types of sequences it is possible generate thousands of different passwords. Using sequences' combination is possible to create an infinite number of passwords. Moreover the created passwords will be a nonsense sequence of letters, numbers and symbols, resilient to any attack. Furthermore the password communication among colleagues maybe done just by using the first letter and on the base of a common knowledge of the sequence (e.g., sequence 3, letter j). El Emam and Colleagues state that more sophisticated collaboration tools are required to allow file sharing without password sharing, and provide several recommendations to implement these practices. We think that more awareness and new practices among users may represent the correct way to implement security beyond the technological issues. In particular, future research needs to focus on the processes that make technology a powerful tool for security.

Background: Depression and diabetes are two highly prevalent and co-occurring health problems. Web-based, diabetes-specific cognitive behavioral therapy (CBT) depression treatment is effective in diabetes patients, and has the potential to be cost effective and to have large reach. A remaining question is whether the effectiveness differs between patients with seriously impaired mental health and patients with less severe mental health problems. Objective: To test whether the effectiveness of an eight-lesson Web-based, diabetes-specific CBT for depression, with minimal therapist support, differs in patients with or without diagnosed major depressive disorder (MDD), diagnosed anxiety disorder, or elevated diabetes-specific emotional distress (DM-distress). Methods: We used data of 255 patients with diabetes with elevated depression scores, who were recruited via an open access website for participation in a randomized controlled trial, conducted in 2008–2009, comparing a diabetes-specific, Web-based, therapist-supported CBT with a 12-week waiting-list control group. We performed secondary analyses on these data to study whether MDD or anxiety disorder (measured using a telephone-administered diagnostic interview) and elevated DM-distress (online self-reported) are effect modifiers in the treatment of depressive symptoms (online self-reported) with Web-based diabetes-specific CBT. Results: MDD, anxiety disorder, and elevated DM-distress were not significant effect modifiers in the treatment of self-assessed depressive symptoms with Web-based diabetes-specific CBT. Conclusions: This Web-based diabetes-specific CBT depression treatment is suitable for use in patients with severe mental health problems and those with a less severe clinical profile. ClinicalTrial: International Standard Randomized Controlled Trial Number (ISRCTN): 24874457; http://www.controlled-trials.com/ISRCTN24874457 (Archived by WebCite at http://www.webcitation.org/63hwdviYr)

An error in the CHERRIES statement has been corrected (J Med Internet Res 2004;6[3]:e34). In the original paper, in table 1, denominator and numerator were flipped in the recommendations on how response rates (view rate, participation rate, and completion rate) should be calculated. The view rate should be the ratio of unique survey visitors divided by unique site visitors. The participation rate should be the ratio of those who agreed to participate divided by unique first survey page visitors. The completion rate is the ratio of the number of people who finished the survey divided by those who agreed to participate. The corrections have been made in the table in both columns.

minor error in the references section in the originally published version of the editorial by Eysenbach (J Med Internet Res 2011;13[4]:e123) on the relationship between citations and tweetations has been corrected; in addition, references being part of the dataset are no longer cited as “references”. The now corrected problem with the references was a formatting problem only and had no impact on the study findings. The originally published article stated correctly that all 55 articles published between issue 3/2009 and 2/2010 were included, but the cited references erroneously contained 12 additional references from issue 2/2009, which were not part of the analysis, for the reasons described in the article (sparse tweetations pre-issue 3/2009). In the corrected version we have not only removed these extra 12 references, but we also took the opportunity to move all other references of included articles into a new Multimedia Appendix 2, no longer citing them in the “References” section. We now refer to them in the paper by article ID (last 4-digits of the DOI), where we previously used in-text citations (Table 2 and Discussion). The original decision to cite them as references was made for the sake of convenience for our readers, to prevent them from having to look up the references in a separate file or by DOI. JMIR has no space limitations and prefers to cite references in the article rather than in an Appendix; for readers downloading a PDF file it is more convenient to have all references in a single file rather than having to download a separate Appendix. The decision to now move these references into a Multimedia Appendix was made after a reader pointed out that citing these articles may increase JMIR’s impact factor. Although none of the two peer-reviewers, both experts in scientometrics, were originally concerned about citing the included articles as references, and even though any potential additional impact factor points after the decimal point caused by the original editorial would have been neglible (after all, these articles are already highly cited: altogether, 638 times, according to Google Scholar), we wish to avoid any potential debate or uncertainty on what proportion of future JMIR impact factors were caused by this editorial, and have therefore decided to pre-emptively move these references into a separate file (Multimedia Appendix 2). The article correction was made on January 4, 2012, before submission to PubMed Central, Swets and other content aggregators and databases, and before indexing by Thomson Reuters. Having to remove references from a manuscript to preserve the validity of a journal-level impact metric is somewhat troubling, but if anything then this perhaps illustrates the limitations and tyranny of the impact factor, and why we should consider additional metrics.

Background: Web-based and mobile health interventions (also called “Internet interventions” or "eHealth/mHealth interventions") are tools or treatments, typically behaviorally based, that are operationalized and transformed for delivery via the Internet or mobile platforms. These include electronic tools for patients, informal caregivers, healthy consumers, and health care providers. The Consolidated Standards of Reporting Trials (CONSORT) statement was developed to improve the suboptimal reporting of randomized controlled trials (RCTs). While the CONSORT statement can be applied to provide broad guidance on how eHealth and mHealth trials should be reported, RCTs of web-based interventions pose very specific issues and challenges, in particular related to reporting sufficient details of the intervention to allow replication and theory-building. Objective: To develop a checklist, dubbed CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth), as an extension of the CONSORT statement that provides guidance for authors of eHealth and mHealth interventions. Methods: A literature review was conducted, followed by a survey among eHealth experts and a workshop. Results: A checklist instrument was constructed as an extension of the CONSORT statement. The instrument has been adopted by the Journal of Medical Internet Research (JMIR) and authors of eHealth RCTs are required to submit an electronic checklist explaining how they addressed each subitem. Conclusions: CONSORT-EHEALTH has the potential to improve reporting and provides a basis for evaluating the validity and applicability of eHealth trials. Subitems describing how the intervention should be reported can also be used for non-RCT evaluation reports. As part of the development process, an evaluation component is essential; therefore, feedback from authors will be solicited, and a before-after study will evaluate whether reporting has been improved.

Background: Web 2.0 has improved interactions among peers on the Internet, especially for the many online patient communities that have emerged over the past decades. Online communities are said to be particularly beneficial peer support resources for patients with breast cancer. However, most studies of online patient communities have focused on those members who post actively (posters), even though there are many members who participate without posting (lurkers). In addition, little attention has been paid to the usage of online communities among non-English-speaking patients. Objective: The present study explored the differences in peer support received by lurkers and posters in online breast cancer communities. It also examined the effects of such support on both groups’ mental health. Methods: We conducted an exploratory, descriptive, cross-sectional, Web-based survey among members of four Japanese online breast cancer communities. In an online questionnaire, we asked questions regarding sociodemographics, disease-related characteristics, mental health, participation in online communities, and peer support received from those communities. Results: Of the 465 people who accessed the questionnaire, 253 completed it. Of the respondents, 113/220 (51.4%) were lurkers. There was no significant difference between lurkers and posters with regard to sociodemographic variables. About half of the posters had been given a diagnosis of breast cancer less than a year previously, which was a significantly shorter period than that of the lurkers (P = .02). The 5 support functions extracted by factor analysis were the same for both posters and lurkers. These were emotional support/helper therapy, emotional expression, conflict, advice, and insight/universality. When the support scores were calculated, insight/universality scored highest for both posters and lurkers, with scores that were not significantly different between the two groups. Among the 5 support scores, emotional support/helper therapy and emotional expression were significantly higher among posters. For posters, emotional support/helper therapy and advice were negatively correlated with the anxiety subscale of the Hospital Anxiety and Depression Scale. Emotional expression, advice, and insight/universality were negatively correlated with the anxiety subscale for lurkers. Conclusion: We found that posters felt they received more benefits from online communities than lurkers did, including emotional support, helping other patients, and expressing their emotions. Yet even lurkers were found to gain a certain amount of peer support through online communities, especially with regard to advice and insight/universality. The results demonstrate that participation in online communities—even as a lurker—may be beneficial to breast cancer patients’ mental health.

The impact and uptake of information and communication technologies that support health care are rather low. Current frameworks for eHealth development suffer from a lack of fitting infrastructures, inability to find funding, complications with scalability, and uncertainties regarding effectiveness and sustainability. These issues can be addressed by defining a better implementation strategy early in the development of eHealth technologies. A business model, and thus business modeling, help to determine such an implementation strategy by involving all important stakeholders in a value-driven dialogue on what the technology should accomplish. This idea also seems promising to eHealth, as it can contribute to the whole development of eHealth technology. We therefore suggest that business modeling can be used as an effective approach to supporting holistic development of eHealth technologies. The contribution of business modeling is elaborated in this paper through a literature review that covers the latest business model research, concepts from the latest eHealth and persuasive technology research, evaluation and insights from our prior eHealth research, as well as the review conducted in the first paper of this series. Business modeling focuses on generating a collaborative effort of value cocreation in which all stakeholders reflect on the value needs of the others. The resulting business model acts as the basis for implementation. The development of eHealth technology should focus more on the context by emphasizing what this technology should contribute in practice to the needs of all involved stakeholders. Incorporating the idea of business modeling helps to cocreate and formulate a set of critical success factors that will influence the sustainability and effectiveness of eHealth technology.

Background: Web-based interventions for problem drinking are effective but characterized by high rates of attrition. There is a need to better understand attrition rates in order to improve the completion rates and the success of Web-based treatment programs. Objective: The objectives of our study were to (1) examine attrition prevalence and pretreatment predictors of attrition in a sample of open-access users of a Web-based program for problem drinkers, and (2) to further explore attrition data from our randomized controlled trial (RCT) of the Web-based program. Methods: Attrition data from two groups of Dutch-speaking problem drinkers were collected: (1) open-access participants enrolled in the program in 2009 (n = 885), and (2) RCT participants (n = 156). Participants were classified as noncompleters if they did not complete all 12 treatment sessions (9 assignments and 3 assessments). In both samples we assessed prevalence of attrition and pretreatment predictors of treatment completion. Logistic regression analysis was used to explore predictors of treatment completion. In the RCT sample, we additionally measured reasons for noncompletion and participants’ suggestions to enhance treatment adherence. The qualitative data were analyzed using thematic analysis. Results: The open-access and RCT group differed significantly in the percentage of treatment completers (273/780, 35.0% vs 65/144, 45%, χ21 = 5.4, P = .02). Logistic regression analysis revealed a significant contribution of treatment readiness, gender, education level, age, baseline alcohol consumption, and readiness to change to predict treatment completion. The key reasons for noncompletion were personal reasons, dissatisfaction with the intervention, and satisfaction with their own improvement. The main suggestions for boosting strategies involved email notification and more flexibility in the intervention. Conclusions: The challenge of Web-based alcohol treatment programs no longer seems to be their effectiveness but keeping participants involved until the end of the treatment program. Further research should investigate whether the suggested strategies to improve adherence decrease attrition rates in Web-based interventions. If we can succeed in improving attrition rates, the success of Web-based alcohol interventions will also improve and, as a consequence, their public health impact will increase. Trial: International Standard Randomized Controlled Trial Number (ISRCTN): 39104853; http://www.controlled-trials.com/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/63IKDul1T)

As the use of eHealth grows and diversifies globally, the concept of eHealth literacy – a foundational skill set that underpins the use of information and communication technologies (ICT) for health – becomes more important than ever to understand and advance. EHealth literacy draws our collective attention to the knowledge and complex skill set that is often taken for granted when people interact with technology to address information, focusing our attention on learning and usability issues from the clinical through to population health level. Just as the field of eHealth is dynamic and evolving, so too is the context where eHealth literacy is applied and understood. The original Lily Model of eHealth literacy and scale used to assess it were developed at a time when the first generation of web tools gained prominence before the rise of social media. The rapid shifts in the informational landscape created by Web 2.0 tools and environments suggests it might be time to revisit the concept of eHealth Literacy and consider what a second release might look like.

Background: Exercise is an effective intervention for the prevention of falls; however, some forms of exercises have been shown to be more effective than others. There is a need to identify effective and efficient methods for training health professionals in exercise prescription for falls prevention. Objective: The objective of our study was to compare two approaches for training clinicians in prescribing exercise to prevent falls. Methods: This study was a head-to-head randomized trial design. Participants were physiotherapists, occupational therapists, nurses, and exercise physiologists working in Victoria, Australia. Participants randomly assigned to one group received face-to-face traditional education using a 1-day seminar format with additional video and written support material. The other participants received Web-based delivery of the equivalent educational material over a 4-week period with remote tutor facilitation. Outcomes were measured across levels 1 to 3 of Kirkpatrick’s hierarchy of educational outcomes, including attendance, adherence, satisfaction, knowledge, and self-reported change in practice. Results: Of the 166 participants initially recruited, there was gradual attrition from randomization to participation in the trial (n = 67 Web-based, n = 68 face-to-face), to completion of the educational content (n = 44 Web-based, n = 50 face-to-face), to completion of the posteducation examinations (n = 43 Web-based, n = 49 face-to-face). Participant satisfaction was not significantly different between the intervention groups: mean (SD) satisfaction with content and relevance of course material was 25.73 (5.14) in the Web-based and 26.11 (5.41) in the face-to-face group; linear regression P = .75; and mean (SD) satisfaction with course facilitation and support was 11.61 (2.00) in the Web-based and 12.08 (1.54) in the face-to-face group; linear regression P = .25. Knowledge test results were comparable between the Web-based and face-to-face groups: median (interquartile range [IQR]) for the Web-based group was 90.00 (70.89–90.67) and for the face-to-face group was 80.56 (70.67–90.00); rank sum P = .07. The median (IQR) scores for the exercise assignment were also comparable: Web-based, 78.6 (68.5–85.1), and face-to-face, 78.6 (70.8–86.9); rank sum P = .61. No significant difference was identified in Kirkpatrick’s hierarchy domain change in practice: mean (SD) Web-based, 21.75 (4.40), and face-to-face, 21.88 (3.24); linear regression P = .89. Conclusion: Web-based and face-to-face approaches to the delivery of education to clinicians on the subject of exercise prescription for falls prevention produced equivalent results in all of the outcome domains. Practical considerations should arguably drive choice of delivery method, which may favor Web-based provision for its ability to overcome access issues for health professionals in regional and remote settings. Trial Registration: Australian New Zealand Clinical Trials Registry number: ACTRN12610000135011; http://www.anzctr.org.au/ACTRN12610000135011.aspx (Archived by WebCite at http://www.webcitation.org/63MicDjPV)