Recent Articles:

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  Accident and Injury Prevention

  Jan 23, 2020

  Follow-Up Investigation on the Promotional Practices of Electric Scooter Companies: Content Analysis of Posts on Instagram and Twitter

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  Authors List:

  • Allison Dormanesh  
  • Anuja Majmundar  
  • Jon-Patrick Allem  

  Abstract:

  Background: Electric scooters (e-scooters) have become a popular mode of transportation in both the United States and Europe. In the wake of this popularity, e-scooters have changed the commuting experience in many metropolitan areas. Although e-scooters offer an efficient and economical way to travel short distances in traffic-congested areas, recent studies have raised concerns over their safety. Bird and Tier Mobility are 2 popular e-scooter companies in the United States and Europe, respectively. Both companies maintain active social media accounts with hundreds of posts and tens of thousands of followers. Recent studies have shown that consumer behavior may be influenced by the content posted to popular social media platforms, such as Instagram and Twitter. Objective: This study aimed to examine the official Instagram and Twitter accounts of Bird and Tier Mobility to determine whether these companies promote and demonstrate the use of safety gear in their posts to their consumers. Methods: Posts to Bird’s (n=287) and Tier Mobility’s (n=190) official Instagram accounts, as well as Bird’s (n=313) and Tier Mobility’s (n=67) official Twitter accounts, were collected from November 9, 2018, to October 7, 2019. Rules for coding content of posts were informed by previous research. Results: Among posts to Bird’s Instagram account, 69.3% (199/287) had a person visible with an e-scooter, 9.1% (26/287) contained persons wearing protective gear, and there were no mentions of protective gear in captions corresponding to the post. Among posts to Tier Mobility’s Instagram account, 84.7% (161/190) contained a person visible with an e-scooter, 36.3% (69/190) contained persons wearing protective gear, and 4.2% (8/190) of captions corresponding to posts mentioned protective gear. Among posts to Bird’s Twitter account, 71.9% (225/313) had an image, of which 44.0% (99/225) contained a person visible with an e-scooter and 15.1% (34/225) contained persons wearing protective gear. Among posts to Tier Mobility’s Twitter account, 78% (52/67) had an image, of which 52% (27/52) contained a person with an e-scooter and 21% (11/52) contained persons wearing protective gear. Conclusions: Findings show that modeling and promoting safety is rare on Bird’s and Tier Mobility’s official social media accounts, which may contribute to the normalization of unsafe riding practices. Social media platforms may offer a potential avenue for public health officials to intervene with rider safety campaigns for public education.

  • JMIR Public Health Surveill 2020;6(1):e16833

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  Infoveillance, Infodemiology and...

  Jan 15, 2020

  Perceptions and Sentiments About Electronic Cigarettes on Social Media Platforms: Systematic Review

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  Authors List:

  • Misol Kwon  
  • Eunhee Park  

  Abstract:

  Background: Electronic cigarettes (e-cigarettes) have been widely promoted on the internet, and subsequently, social media has been used as an important informative platform by e-cigarette users. Beliefs and knowledge expressed on social media platforms have largely influenced e-cigarette uptake, the decision to switch from conventional smoking to e-cigarette smoking, and positive and negative connotations associated with e-cigarettes. Despite this, there is a gap in our knowledge of people’s perceptions and sentiments on e-cigarettes as depicted on social media platforms. Objective: This study aimed to (1) provide an overview of studies examining the perceptions and sentiments associated with e-cigarettes on social media platforms and online discussion forums, (2) explore people’s perceptions of e-cigarette therein, and (3) examine the methodological limitations and gaps of the included studies. Methods: Searches in major electronic databases, including PubMed, Cumulative Index of Nursing and Allied Health Literature, EMBASE, Web of Science, and Communication and Mass Media Complete, were conducted using the following search terms: “electronic cigarette,” “electronic vaporizer,” “electronic nicotine,” and “electronic nicotine delivery systems” combined with “internet,” “social media,” and “internet use.” The studies were selected if they examined participants’ perceptions and sentiments of e-cigarettes on online forums or social media platforms during the 2007-2017 period. Results: A total of 21 articles were included. A total of 20 different social media platforms and online discussion forums were identified. A real-time snapshot and characteristics of sentiments, personal experience, and perceptions toward e-cigarettes on social media platforms and online forums were identified. Common topics regarding e-cigarettes included positive and negative health effects, testimony by current users, potential risks, benefits, regulations associated with e-cigarettes, and attitude toward them as smoking cessation aids. Conclusions: Although perceptions among social media users were mixed, there were more positive sentiments expressed than negative ones. This study particularly adds to our understanding of current trends in the popularity of and attitude toward e-cigarettes among social media users. In addition, this study identified conflicting perceptions about e-cigarettes among social media users. This suggests that accurate and up-to-date information on the benefits and risks of e-cigarettes needs to be disseminated to current and potential e-cigarette users via social media platforms, which can serve as important educational channels. Future research can explore the efficacy of social media–based interventions that deliver appropriate information (eg, general facts, benefits, and risks) about e-cigarettes. Clinical Trial: PROSPERO CRD42019121611; https://tinyurl.com/yfr27uxs

  • JMIR Public Health Surveill 2020;6(1):e13673

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  HIV/AIDS/STI Prevention and Care

  Jan 9, 2020

  Correlates of Successful Enrollment of Same-Sex Male Couples Into a Web-Based HIV Prevention Research Study: Cross-Sectional Study

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  Authors List:

  • Rob Stephenson  
  • Tanaka MD Chavanduka  
  • Stephen Sullivan  
  • Jason W Mitchell  

  Abstract:

  Background: The recognition of the role of primary partners in HIV transmission has led to a growth in dyadic-focused HIV prevention efforts. The increasing focus on male couples in HIV research has been paralleled by an increase in the development of interventions aimed at reducing HIV risk behaviors among male couples. The ability to accurately assess the efficacy of these interventions rests on the ability to successfully enroll couples into HIV prevention research. Objective: This study aimed to explore factors associated with successful dyadic engagement in Web-based HIV prevention research using recruitment and enrollment data from a large sample of same-sex male couples recruited online from the United States. Methods: Data came from a large convenience sample of same-sex male couples in the United States, who were recruited through social media venues for a Web-based, mixed method HIV prevention research study. The analysis examined the demographic factors associated with successful dyadic engagement in research, measured as both members of the dyad meeting eligibility criteria, consenting for the study, and completing all study processes. Results: Advertisements generated 221,258 impressions, resulting in 4589 clicks. Of the 4589 clicks, 3826 individuals were assessed for eligibility, of which 1076 individuals (538/1913, 28.12% couples) met eligibility criteria and were included in the study. Of the remaining 2740 ineligible participants, 1293/3826 (33.80%) were unlinked because their partner did not screen for eligibility, 48/2740 (1.75%) had incomplete partner data because at least one partner did not finish the survey, 22/2740 (0.80%) were ineligible because of 1 partner not meeting the eligibility criteria. Furthermore, 492/3826 (12.86%) individuals were fraudulent. The likelihood of being in a matched couple varied significantly by race and ethnicity, region, and relationship type. Men from the Midwest were less likely to have a partner who did not complete the survey. Men with college education and those who labeled their relationships as husband or other (vs boyfriend) were more likely to have a partner who did not complete the survey. Conclusions: The processes used allowed couples to independently progress through the stages necessary to enroll in the research study, while limiting opportunities for coercion, and resulted in a large sample with relative diversity in demographic characteristics. The results underscore the need for additional considerations when recruiting and enrolling, relative to improving the methods associated with these research processes.

  • JMIR Public Health Surveill 2020;6(1):e15078

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  Longitudinal and Cohort Studies in...

  Jan 8, 2020

  Medical Conditions Predictive of Self-Reported Poor Health: Retrospective Cohort Study

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  Authors List:

  • M Soledad Cepeda  
  • Jenna Reps  
  • David M Kern  
  • Paul Stang  

  Abstract:

  Background: Identifying the medical conditions that are associated with poor health is crucial to prioritize decisions for future research and organizing care. However, assessing the burden of disease in the general population is complex, lengthy, and expensive. Claims databases that include self-reported health status can be used to assess the impact of medical conditions on the health in a population. Objective: This study aimed to identify medical conditions that are highly predictive of poor health status using claims databases. Methods: To determine the medical conditions most highly predictive of poor health status, we used a retrospective cohort study using 2 US claims databases. Subjects were commercially insured patients. Health status was measured using a self-report health status response. All medical conditions were included in a least absolute shrinkage and selection operator regression model to assess which conditions were associated with poor versus excellent health. Results: A total of 1,186,871 subjects were included; 61.64% (731,587/1,186,871) reported having excellent or very good health. The leading medical conditions associated with poor health were cancer-related conditions, demyelinating disorders, diabetes, diabetic complications, psychiatric illnesses (mood disorders and schizophrenia), sleep disorders, seizures, male reproductive tract infections, chronic obstructive pulmonary disease, cardiomyopathy, dementia, and headaches. Conclusions: Understanding the impact of disease in a commercially insured population is critical to identify subjects who may be at risk for reduced productivity and job loss. Claims database studies can measure the impact of medical conditions on the health status in a population and to assess changes overtime and could limit the need to collect prospective collection of information, which is slow and expensive, to assess disease burden. Leading medical conditions associated with poor health in a commercially insured population were the ones associated with high burden of disease such as cancer-related conditions, demyelinating disorders, diabetes, diabetic complications, psychiatric illnesses (mood disorders and schizophrenia), infections, chronic obstructive pulmonary disease, cardiomyopathy, and dementia. However, sleep disorders, seizures, male reproductive tract infections, and headaches were also part of the leading medical conditions associated with poor health that had not been identified before as being associated with poor health and deserve more attention.

  • JMIR Public Health Surveill 2020;6(1):e13018

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  Prevention and Health Promotion

  Dec 20, 2019

  Perceptions and Experiences of Women Participating in a Digital Technology–Based Physical Activity Intervention (the mPED Trial): Qualitative Study

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  Authors List:

  • Teri Lindgren  
  • Julie Hooper  
  • Yoshimi Fukuoka  

  Abstract:

  Background: Despite the benefits of regular physical activity, women in every age group have lower activity levels than men, and few women meet the recommended levels of physical activity. Digital technologies have been useful in increasing physical activity during the course of an interventional study. However, sustaining that activity once the clinical trial was complete was a major challenge. Objective: This study aimed to describe the experiences and perspectives of physically inactive women who completed the mobile phone–based physical activity education (mPED), a randomized controlled trial, at 12 months. Methods: Of 210 women who were enrolled in the mPED trial, 203 completed a 12-month open-ended exit interview and survey through phone. The participants were asked about their physical activity levels; their digital technology use; what they learned from, liked, and would change about the trial; their motivations to keep active post-trial; and their advice for other women. Interviews were transcribed verbatim and thematically analyzed using the brief survey qualitative description. Descriptive statistics were used to describe the survey data with the significance level set at P<.05. Results: In the 12-month survey, a greater proportion of the participants in the intervention group, compared with the control group, reported that they regularly wore a pedometer or physical activity tracker (49.3%, 66/143 vs 26.1%, 18/69; P=.002) and engaged in brisk walking (54.5%, 73/134 vs 30.4%, 21/69; P=.001). The experiences and perceptions of physical activity of physically inactive women over time were embedded in a complex interplay of internal and external factors. A total of 6 interactive themes emerged as critical in supporting continued engagement in physical activity postintervention: tracking, technology versus personal touch, accountability, resources and environment, motivation, and habit formation. Technology allowed for self-tracking, which supported internal accountability. However, tracking by another person (personal touch) was needed for external accountability. Resources and environment underpinned the relationship among the themes of tracking, technology versus personal touch, accountability, motivation, and habit formation. Conclusions: Future research is needed to identify the best ways to harness this dynamic process in promoting and sustaining physical activity among inactive women. Digital technology is evolving at an exponential rate and provides new opportunities to transform research into new approaches to promote physical activity.

  • JMIR Public Health Surveill 2019;5(4):e13570

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  Theme Issue 2019: The Eastern...

  Dec 6, 2019

  The Acute Flaccid Paralysis (AFP) Surveillance System in Yemen, 2010-2015: Descriptive Study Based on Secondary Data Analysis

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  Authors List:

  • Khaled Abdullah Almoayed  
  • Ali Bin Break  
  • Mutahar Al-Qassimi  
  • Ali Assabri  
  • Yousef Khader  

  Abstract:

  Background: Acute flaccid paralysis (AFP) surveillance is an essential strategy for poliovirus eradication. Objective: This study aimed to evaluate the performance of the AFP surveillance system in Yemen from 2010 to 2015, identify components that require strengthening, and compare the indicators by year and governorates. Methods: This descriptive study was based on secondary analysis of AFP surveillance data reported during 2010-2015 from all Yemeni governorates. The World Health Organization (WHO) minimum performance standards were used to evaluate the performance of the AFP surveillance system. Results: A total of 3019 AFP cases were reported between January 2010 and December 2015. At the national level, AFP surveillance achieved WHO targets throughout the evaluating period for the nonpolio AFP rate of cases per 100,000 members of the population younger than 15 years of age, proportion of AFP cases reported within 7 days, proportion of AFP cases investigated within 48 hours of notification, proportion of AFP cases with two adequate stool specimens, and proportion of stool specimens from which nonpolio enterovirus was isolated. However, the proportion of specimens that arrived at the central level within 3 days of the first sample collection and the proportion of stool specimens with results sent from the reference laboratory within 28 days of receipt did not reach targets in 2011 and 2015, respectively. Conclusions: The AFP surveillance system in Yemen has met most of the WHO indicator levels. Nevertheless, the evaluation showed areas of weakness regarding the arrival of specimens at the central level within 3 days of the first sample collection and delays in processing of the results and submitting feedback by the laboratory. Therefore, there is a need to strengthen the follow-up of specimens submitted to the laboratory.

  • JMIR Public Health Surveill 2019;5(4):e14413

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  Equity and Digital Divide

  Dec 2, 2019

  Social Media Recruitment of Marginalized, Hard-to-Reach Populations: Development of Recruitment and Monitoring Guidelines

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  Authors List:

  • Jennifer Russomanno  
  • Joanne G Patterson  
  • Jennifer M Jabson Tree  

  Abstract:

  Background: Social media can be a useful strategy for recruiting hard-to-reach, stigmatized populations into research studies; however, it may also introduce risks for participant and research team exposure to negative comments. Currently, there is no published formal social media recruitment and monitoring guidelines that specifically address harm reduction for social media recruitment of marginalized populations. Objective: The purpose of this research study was to investigate the utility, successes, challenges, and positive and negative consequences of using targeted Facebook advertisements as a strategy to recruit transgender and gender nonconforming (TGNC) people into a research study. Methods: TGNC adults living in the Southeast Unites States were recruited via targeted Facebook advertisements over two cycles in April and June 2017. During cycle 1, researchers only used inclusion terms to recruit the target population. During cycle 2, the social media recruitment and monitoring protocol and inclusion and exclusion terms were used. Results: The cycle 1 advertisement reached 8518 people and had 188 reactions, comments, and shares but produced cyberbullying, including discriminatory comments from Facebook members. Cycle 2 reached fewer people (6976) and received 166 reactions, comments, and shares but produced mostly positive comments. Conclusions: Researchers must consider potential harms of using targeted Facebook advertisements to recruit hard-to-reach and stigmatized populations. To minimize harm to participants and research staff, researchers must preemptively implement detailed social media recruitment and monitoring guidelines for monitoring and responding to negative feedback on targeted Facebook advertisements.

  • JMIR Public Health Surveill 2019;5(4):e14886

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  Theme Issue 2019: The Eastern...

  Nov 19, 2019

  An Electronic Disease Early Warning System in Sana’a Governorate, Yemen: Evaluation Study

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  Authors List:

  • Mona Mayad  
  • Reema Alyusfi  
  • Ali Assabri  
  • Yousef Khader  

  Abstract:

  Background: Electronic Disease Early Warning System (eDEWS) is one of the effective programs in epidemiological surveillance. Objective: This study aimed to identify the strengths and weaknesses of eDEWS in Sana’a governorate, determine its usefulness, and assess its performance in terms of the system attributes, including simplicity, flexibility, data quality, acceptability, representativeness, timeliness, and stability. Methods: Updated guidelines on the evaluation of public health surveillance from the Center for Disease Control and Prevention (CDC) were used to evaluate the eDEWS in Sana’a governorate. Stakeholders from different levels were interviewed about the performance of the eDEWS. Results: The overall score for the usefulness of the eDEWS was good (mean=83%). The overall system performance was good (86%). The highest attribute score was 100% for representativeness and the lowest score was 70% for stability. The system simplicity and acceptability were good. Although the system representativeness and flexibility were excellent, the stability was average. System completeness and timeliness were 100%. Conclusions: In conclusion, eDEWS in Yemen is useful and met its main objective. The overall level of system performance was good.

  • JMIR Public Health Surveill 2019;5(4):e14295

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  Infoveillance, Infodemiology and...

  Nov 18, 2019

  Access to Primary Care and Internet Searches for Walk-In Clinics and Emergency Departments in Canada: Observational Study Using Google Trends and Population...

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  Authors List:

  • Joseph Ssendikaddiwa  
  • Ruth Lavergne  

  Abstract:

  Background: Access to primary care is a challenge for many Canadians. Models of primary care vary widely among provinces, including arrangements for same-day and after-hours access. Use of walk-in clinics and emergency departments (EDs) may also vary, but data sources that allow comparison are limited. Objective: We used Google Trends to examine the relative frequency of searches for walk-in clinics and EDs across provinces and over time in Canada. We correlated provincial relative search frequencies from Google Trends with survey responses about primary care access from the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries and the 2016 Canadian Community Health Survey. Methods: We developed search strategies to capture the range of terms used for walk-in clinics (eg, urgent care clinic and after-hours clinic) and EDs (eg, emergency room) across Canadian provinces. We used Google Trends to determine the frequencies of these terms relative to total search volume within each province from January 2011 to December 2018. We calculated correlation coefficients and 95% CIs between provincial Google Trends relative search frequencies and survey responses. Results: Relative search frequency of walk-in clinic searches increased steadily, doubling in most provinces between 2011 and 2018. Relative frequency of walk-in clinic searches was highest in the western provinces of British Columbia, Alberta, Saskatchewan, and Manitoba. At the provincial level, higher walk-in clinic relative search frequency was strongly positively correlated with the percentage of survey respondents who reported being able to get same- or next-day appointments to see a doctor or a nurse and inversely correlated with the percentage of respondents who reported going to ED for a condition that they thought could have been treated by providers at usual place of care. Relative search frequency for walk-in clinics was also inversely correlated with the percentage of respondents who reported having a regular medical provider. ED relative search frequencies were more stable over time, and we did not observe statistically significant correlation with survey data. Conclusions: Higher relative search frequency for walk-in clinics was positively correlated with the ability to get a same- or next-day appointment and inversely correlated with ED use for conditions treatable in the patient’s regular place of care and also with having a regular medical provider. Findings suggest that patient use of Web-based tools to search for more convenient or accessible care through walk-in clinics is increasing over time. Further research is needed to validate Google Trends data with administrative information on service use.

  • JMIR Public Health Surveill 2019;5(4):e13130

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  Prevention and Health Promotion

  Nov 14, 2019

  Enhanced Safety Surveillance of Influenza Vaccines in General Practice, Winter 2015-16: Feasibility Study

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  Authors List:

  • Simon de Lusignan  
  • Ana Correa  
  • Gaël Dos Santos  
  • Nadia Meyer  
  • François Haguinet  
  • Rebecca Webb  
  • Christopher McGee  
  • Rachel Byford  
  • Ivelina Yonova  
  • Sameera Pathirannehelage  
  • Filipa Matos Ferreira  
  • Simon Jones  

  Abstract:

  Background: The European Medicines Agency (EMA) requires vaccine manufacturers to conduct enhanced real-time surveillance of seasonal influenza vaccination. The EMA has specified a list of adverse events of interest to be monitored. The EMA sets out 3 different ways to conduct such surveillance: (1) active surveillance, (2) enhanced passive surveillance, or (3) electronic health record data mining (EHR-DM). English general practice (GP) is a suitable setting to implement enhanced passive surveillance and EHR-DM. Objective: This study aimed to test the feasibility of conducting enhanced passive surveillance in GP using the yellow card scheme (adverse events of interest reporting cards) to determine if it has any advantages over EHR-DM alone. Methods: A total of 9 GPs in England participated, of which 3 tested the feasibility of enhanced passive surveillance and the other 6 EHR-DM alone. The 3 that tested EPS provided patients with yellow (adverse events) cards for patients to report any adverse events. Data were extracted from all 9 GPs’ EHRs between weeks 35 and 49 (08/24/2015 to 12/06/2015), the main period of influenza vaccination. We conducted weekly analysis and end-of-study analyses. Results: Our GPs were largely distributed across England with a registered population of 81,040. In the week 49 report, 15,863/81,040 people (19.57% of the registered practice population) were vaccinated. In the EPS practices, staff managed to hand out the cards to 61.25% (4150/6776) of the vaccinees, and of these cards, 1.98% (82/4150) were returned to the GP offices. Adverse events of interests were reported by 113 /7223 people (1.56%) in the enhanced passive surveillance practices, compared with 322/8640 people (3.73%) in the EHR-DM practices. Conclusions: Overall, we demonstrated that GPs EHR-DM was an appropriate method of enhanced surveillance. However, the use of yellow cards, in enhanced passive surveillance practices, did not enhance the collection of adverse events of interests as demonstrated in this study. Their return rate was poor, data entry from them was not straightforward, and there were issues with data reconciliation. We concluded that customized cards prespecifying the EMA’s adverse events of interests, combined with EHR-DM, were needed to maximize data collection.

  • JMIR Public Health Surveill 2019;5(4):e12016

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  Theme Issue 2019: The Eastern...

  Oct 29, 2019

  A Collaborative Initiative to Strengthen Sustainable Public Health Capacity for Polio Eradication and Routine Immunization Activities in the Eastern...

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  Authors List:

  • Magid Al Gunaid  
  • Faris Lami  
  • Najwa Jarour  

  Abstract:

  The many challenges in the Eastern Mediterranean region put the involved countries at risk of polio transmission and affect their ability to meet progress targets in eliminating vaccine-preventable diseases. The Global Health Development (GHD) and Eastern Mediterranean Public Health Network (EMPHNET) are working together on the project “Strengthening sustainable public health capacity in the Eastern Mediterranean region for polio eradication and routine immunization activities” with an overall goal of improving routine immunization, eradicating poliovirus, and controlling/eliminating or eradicating other vaccine-preventable diseases in the Eastern Mediterranean region. The aim of this manuscript is to describe the project and the achievements of GHD/EMPHNET over the last 3 years (2016-2018) to build effective surveillance and immunization systems in the Eastern Mediterranean region through the development of a sustainable and competent public health system to eradicate polio and control/eliminate vaccine-preventable diseases. This project assists the targeted Eastern Mediterranean region countries to build effective surveillance and immunization systems in an effort to expand their capacities to eradicate polio and control/eliminate other vaccine-preventable diseases. The project is streamlined with the Global Polio Eradication Initiative, the Centers for Disease Control and Prevention’s Strategic Framework for Global Immunization 2016-2020, and the Polio Eradication and Endgame Strategic Plan 2013-2018. The project also supports the Global Health Security Agenda by focusing on efforts to accelerate progress toward a world safe and secure from infectious disease threats. Project activities were designed to respond to countries’ needs and assist them in building their institutional and workforce capacity to effectively plan, implement, and evaluate activities to eradicate polio and strengthen routine immunization activities. The project activities covered a set of areas including surveillance of acute flaccid paralysis and other vaccine-preventable diseases, family and community engagement, workforce capacity building, improvement of data quality, management and use of information systems, use of polio assets to control/eliminate other vaccine-preventable diseases, support of countries to develop national strategies, piloting of innovative initiatives, program evaluation and accountability, and immunization strengthening. The project adopts the Global Polio Eradication Initiative strategies for assisting countries to strengthen routine immunization services, maintain highly sensitive acute flaccid paralysis surveillance, and sustain polio eradication functions.

  • JMIR Public Health Surveill 2019;5(4):e14664

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  Health Care Quality and Health...

  Oct 28, 2019

  Perception of the Progressing Digitization and Transformation of the German Health Care System Among Experts and the Public: Mixed Methods Study

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  Authors List:

  • Arne Hansen  
  • Maximilian Herrmann  
  • Jan P Ehlers  
  • Thomas Mondritzki  
  • Kai Oliver Hensel  
  • Hubert Truebel  
  • Philip Boehme  

  Abstract:

  Background: Health care systems worldwide are struggling to keep rising costs at bay with only modest outcome improvement among many diseases. Digitization with technologies like Artificial Intelligence or Machine Learning algorithms might address this. Although digital technologies have been successfully applied in clinical studies the effect on the overall health care system so far was limited. The regulatory ecosystem or data privacy might be responsible, but other reasons may also predominate. Objective: We analyzed how the digitization of the German health care market is currently perceived among different stakeholders and investigated reasons for its slow adaption. Methods: This was a mixed methods study split into a qualitative Part A using the conceptual approach of the Grounded Theory and a quantitative Part B using the Delphi method. For Part A we interviewed experts in the health care system and converted the results into 17 hypotheses. The Delphi method consisted of an online survey which was sent to the participants via email and was available for three months. For the assessment of the 17 hypotheses, the participants were given a six-point Likert scale. The participants were grouped into patients, physicians, and providers of services within the German health care market. Results: There was a strong alignment of opinions on the hypotheses between experts (N=21) and survey participants (N=733), with 70.5% overall agreement on 12/17 hypotheses. Physicians demonstrated the lowest level of agreement with the expert panel at 88% (15/17) disagreement, with the hypotheses “H8: Digitization in the health care system will free up jobs,” and “H6: Digitization in the health care system will empower the patients,” perceived to be in profound disagreement (P=.036 and P<.001, respectively). Conclusions: Despite the firm agreement among participants and experts regarding the impact of digitization on the health care system, physicians demonstrated a more negative attitude. We assume that this might be a factor contributing to the slow adoption of digitization in practice. Physicians might be struggling with changing power structures, so future measures to transform the market should involve them to a larger degree.

  • JMIR Public Health Surveill 2019;5(4):e14689

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